Introduction Immunosuppression after transplantation increases the risk of infections. Clostridium (C) bacteremia and spontaneous gas gangrene of solid organs is rare, almost exclusively seen in immunocompromised patients, and associated with high mortality. Here we present a case of rapidly progressive and ultimately fatal C. perfringens septicemia following heart transplantation (HT). Case Report A 62-year-old female with stage D non-ischemic cardiomyopathy underwent uncomplicated HT. The patient's immunosuppression included tacrolimus, mycophenolate mofetil and prednisone. Her post-operative course was notable for multiple infections requiring immunotherapy adjustment. In the weeks after HT, she had serial echocardiograms showing normal graft function and negative biopsies. Her course was notable for severe constipation and a CT scan demonstrated large stool burden and rectal wall thickening consistent with stercoral colitis. She was started on an aggressive bowel regimen and underwent manual disimpaction. 11 weeks after HT, she became acutely delirious and short of breath, with rapidly progressive shock and ultimately suffered a pulseless electrical arrest. She was emergently cannulated to veno-arterial ECMO. Despite ongoing resuscitation, she developed cardiac standstill and was pronounced dead. Post-mortem, blood cultures resulted with C. perfringens. Autopsy revealed the presence of C. perfringens in the myocardium with extensive necrosis, hemorrhage and gram-positive rods in the absence of inflammation (Figure). C perfringens was also noted in the large intestine. Summary We report here a case of severe Clostridium perfringens bacteremia from gut translocation, leading to myonecrosis of the cardiac allograft and death. This complication emphasizes the importance of constipation management post HT.

ObjectivesThe ‘hypervirulent’ variant of Klebsiella pneumoniae (hvKp) is a predominant cause of community-acquired pyogenic liver abscess in Asia, and is an emerging pathogen in Western countries. hvKp infections have demonstrated ‘metastatic’ dissemination in immunocompetent hosts, an unusual mode of infection associated with severe complications. Two cases alerted us to the possible presence of hvKp at our hospital, both involving elderly Hispanic males who presented with recurrent fever, bacteraemia, epigastric pain and liver abscesses/phlegmon, thus prompting an assessment of hvKp prevalence.MethodsA surveillance of K. pneumoniae blood, body fluid and wound isolates was conducted using real-time PCR to detect virulence-associated genes (uni-rmpA, iucA and peg344). Positive isolates were further characterized by wzi gene sequencing to determine capsular types (K-type) and by multilocus sequence typing and pulsed-field gel electrophoresis to determine strain relatedness.ResultsFour-hundred and sixty-three K. pneumoniae isolates, derived from 412 blood, 21 body fluids and 30 abdominal wound specimens, were screened over a 3-year period. Isolates included 98 multidrug-resistant strains. Eighteen isolates from 17 patients, including two from the index patient, screened positive for all three virulence genes. Sixteen of 18 positive isolates had K-types associated with hvKp, and isolates from different patients were unrelated strains, indicating likely community acquisition. Of 13 patients with significant morbidity, five died; eight patients had co-existing hepatobiliary disease, and six had diabetes mellitus.ConclusionsMultiple strains of hvKp are emerging in New York City and are associated with high mortality relative to multidrug-resistant and classical Klebsiella infections. Co-existing hepatobiliary disease appears to be a potential risk factor for these infections.