[Low-titer cold agglutinin disease following Salmonella gastroenteritis].

We encountered a patient with cold agglutinin disease (CAD) that worsened after Salmonella gastroenteritis. A 52-year-old male complained pain in the left fingers with cyanosis and was admitted in a local hospital. After treatment for ischemia, he demonstrated diarrhea with fever. Because of progressive anemia, he was referred to our hospital. Salmonella gastroenteritis was diagnosed based on the results of microbiological examination. Severe hemolysis was noted at admission, and Coombs test was positive (IgG-, C3d+). Cold agglutinin titer was elevated (x256). There were no findings of malignancy or infection demonstrating CA. A diagnosis of CAD with Salmonella gastroenteritis was made. Because spherocytosis was noted during admission, we measured the mean channel fluorescence (MCF) of eosin-5-maleimide (EMA) in erythrocytes from patients. MCF of EMA of the patient's erythrocytes was similar to that of normal subjects. Therefore, we concluded that coexisting hereditary spherocytosis was unlikely. We also examined the in vitro hemolytic effect of Salmonella infection on his blood and on blood from normal subjects. Treatment with Salmonella enteritidis isolated from this patient was found to induce hemolysis in the patient's blood, but not in blood from a normal subject. Moreover, treatment with Salmonella increased the titer of cold agglutinin in vitro. These data suggested that Salmonella infection might worsen hemolysis in CAD.

Clinical and epidemiological features of Clostridium perfringens bacteremia: a review of 18 cases over 8 year-period in a tertiary care center in metropolitan Tokyo area in Japan.

OBJECTIVE: Clostridial sepsis has a very poor prognosis, owing to the life-threatening combination of shock and acute massive hemolysis. No papers have described the clinical features of clostridial sepsis cases in Japan. Therefore, we retrospectively examined the clinical features of patients with systemic inflammatory response syndrome (SIRS) from whose blood cultures Clostridium perfringens was isolated. SUBJECTS AND MATERIALS: Blood samples were obtained from SIRS patients and cultured between January 1, 2001 and June 30, 2009. The samples were retrospectively reviewed, and 18 samples were positive for C. perfringens. The medical records of these 18 patients were reviewed for age, gender, underlying disease, past illnesses, results of physical and laboratory testing, and radiographic data. RESULTS: All patients were diagnosed with SIRS. Fifteen patients (83.3%) were >65 years old -mean age, 75±2 years (range, 59-88 years). There were more men (13) than women (5). The blood cultures were obtained from patients in various wards: tertiary care center (8), emergency room (5), surgical ward (4), and medical ward (1). Hepatobiliary tract diseases such as gallbladder stones and hepatic carcinoma were the most frequent underlying diseases (8). Five patients died, resulting in an overall mortality rate at 30 days of 27%. In the non-survival group, patients presented with septic shock (4) and gas-forming infection (2), and with significantly lower fibrinogen levels than those in the survival group. Septic shock at initial presentation was significantly associated with 30-day mortality for C. perfringens infection. DISCUSSION AND CONCLUSION: There were no specific characteristics among clinical features of C. perfringens infection accompanied with SIRS. This may indicate that, in emergency rooms, diagnosing and initiating appropriate treatment for C. perfringens infection may be considerably difficult. It is important to be especially vigilant in identifying patients with C. perfringens infection underlying SIRS, and accompanied by shock.