Clostridium perfringens Bacteraemia following Normal Vaginal Delivery

Clostridial uterine infections and bacteraemia are of a rare occurrence, especially in the absence of risk factors. However, when encountered, they can carry significant morbidity and mortality rates. We present a rare case of C. perfringens bacteraemia in the immediate postpartum period of a noncomplicated vaginal delivery. Prompt diagnosis and early initiation of treatment were imperative for ensuring a safe recovery of the patient. Despite the fact that bacteraemia caused by C. perfringens is an infrequent event in the uneventful postpartum phase, maintaining vigilance for the potential occurrence of such an event allows for early detection and timely administration of antibiotics and resuscitative measures.


Introduction
Clostridium perfringens, an anaerobic, nonmotile, Grampositive, spore-forming bacillus, is an integral component of the gastrointestinal and genitourinary fora, known for its pathogenicity.Tis bacillus is notorious for releasing various exotoxins with remarkable enteroinvasive properties [1].Te clinical spectrum associated with Clostridium perfringens infections is broad, ranging from cellulitis, necrotising fasciitis, and myonecrosis to acute hemolysis [2].
Bacteraemia stemming from C. perfringens is relatively infrequent in hospital settings, with reported incidences ranging from 0.04 to 2% [1,3].Te clinical manifestations often lack specifcity, resulting in delayed diagnoses and treatment initiation.Cases of bacteraemia are primarily linked to compromised immunity, such as in cancer and immunosuppressed patients [3].A noteworthy association has been proposed between C. perfringens bacteraemia and gastrointestinal tract malignancies [3,4].Despite the source of bacteraemia, documented cases exhibit an elevated mortality rate, reaching 15.2% [1].
Pregnancy-related C. perfringens infections are associated with uterine instrumentation, caesarean sections, and abortions.Te presence of a leiomyoma in the context of an abortion appears to heighten the risk of soft tissue clostridial infections [5].Regardless of predisposing factors, Clostridial uterine infections and bacteraemia carry signifcant morbidity and mortality rates.Terefore, prompt diagnosis and early initiation of treatment are imperative for ensuring a safe recovery [5].
In the realm of our discourse, we bring forth a distinctive case, elucidating an occurrence of Clostridium perfringens bacteraemia within the immediate postpartum period following a vaginal delivery, characterised by the absence of discernible underlying risk factors or predisposing medical conditions.Tis singular case serves as a poignant reminder of the intricate and often unpredictable nature of C. perfringens infections, urging a comprehensive understanding of the diverse clinical manifestations and potential risk factors associated with this pathogen.Te scarcity of instances featuring C. perfringens bacteraemia in the absence of identifable risk factors underscores the need for meticulous investigation into the nuanced dynamics of this infection.
In conclusion, the singular case presented here serves as a microcosm of the broader challenges and opportunities in understanding and managing C. perfringens infections.As the landscape of medical research continues to evolve, the synergy between clinical observations and scientifc inquiry remains paramount in guiding clinicians towards more efective strategies for the diagnosis, management, and prevention of Clostridium perfringens infections.

Case Description
A 40-year-old woman presented with chills, fever, and abdominal pain forty hours following an uncomplicated vaginal delivery.Her antenatal course transpired without any noteworthy events, culminating in a vaginal delivery at 38 + 3 weeks of gestation.Te frst stage of labour unfolded smoothly over 13 hours, marked by the artifcial rupture of membranes at the 11th hour, resulting in clear amniotic fuid.Te subsequent second stage, lasting 2 hours, encountered a solitary episode of low-grade (38 degrees Celsius), which spontaneously resolved.Te noninstrumental vaginal delivery yielded a live-born male singleton weighing 3,245 grams, with Apgar scores of 9 and 9 at 1 and 5 minutes, respectively.Following a midline seconddegree laceration, primarily repaired, the placenta was spontaneously and completely delivered.
Te patient's medical history included a hepatitis B carrier state with consistently negative viral loads during pregnancy and a past surgical history featuring inguinal hernia repair.Notably, she had experienced frst-trimester recurrent pregnancy loss and recurrent implantation failure, achieving pregnancy after thirteen unsuccessful in vitro fertilization (IVF) attempts.
Upon presentation, vital signs revealed a temperature of 38.90 °C and tachycardia peaking at 101 bpm, with overall hemodynamic stability.Physical examination was unremarkable except for signifcant tenderness at the perineal repair site.Relevant laboratory testing indicated a white blood cell count of 16,700 cells/mm 3 (83% polymorphonuclear cells) and positive urine leucocyte esterase, prompting the initiation of ceftriaxone for a presumed urinary tract infection.
Eight hours postcollection, blood cultures revealed the presence of C. perfringens.Consequently, the antibiotic regimen was adjusted to Tazocin (piperacillin/tazobactam) 4.5 grams intravenously every 6 hours and metronidazole 500 mg every 8 hours.Abdominopelvic computed tomography showed no evidence of intraabdominal tumours, perineal fasciitis, or collections.Following fve days of antibiotic treatment, her symptoms resolved completely, leading to her discharge home on amoxicillin/clavulanic acid and metronidazole.A week after discharge, during a clinic follow-up, all signs and symptoms had resolved completely, refecting the successful resolution of the C. perfringens infection.Tis case underscores the necessity for detailed exploration of clinical scenarios, especially in the context of atypical presentations, contributing to a broader understanding of the complexities surrounding Clostridium perfringens infections and guiding efective clinical management strategies.

Discussion
C. perfringens, an anaerobic bacterium previously known as Clostridium welchii, has been sporadically isolated from vaginal and cervical fuids in seemingly healthy and asymptomatic women [6].While generally benign, this anaerobic bacterium can, in rare instances, precipitate postpartum bacteraemia, presenting a diagnostic challenge due to its infrequency.Smith et al. reported recovering C. perfringens from 10 to 27% of genital tract cultures in aborting women, with sepsis manifesting in less than 1% of the cases [7].Te exploration of C. perfringens has seen notable advancements in the recent past, contributing valuable insights into its epidemiology, pathogenic mechanisms, and diagnostic approaches.
In our presented case, the patient had a midline seconddegree laceration.Second-degree lacerations are limited to the vaginal wall and do not reach the rectal cavity, hence less likely to predispose to bacterial crossover from the rectal space to vaginal and or uterine space.Te absence of identifable risk factors for C. perfringens bacteraemia led to a positive response to broad-spectrum antibiotics and appropriate resuscitative measures.Clinical manifestations arise from the release of twelve exotoxins, with alpha toxin, responsible for platelet aggregation, reduced blood fow, and soft tissue necrosis, identifed as the most crucial.Timely administration of antibiotic therapy, resuscitative measures, and surgical intervention, involving the resection of afected tissues, are critical in preventing life-threatening complications [8].
Lopez-Fabal et al. place emphasis on its more frequent occurrence in patients with compromised immunity, often associated with malignancies, diabetes mellitus, and advanced age [3].In some instances, Clostridium bacteraemia may serve as the revealing event of underlying diseases, as reported by a Spanish group in a fatal case where postmortem analysis unveiled an undiagnosed colorectal neoplasm [9].Coincidental diagnoses of gynaecologic malignancies, including undiferentiated uterine sarcoma and uterine endometrial adenocarcinoma, have also been reported [10].Importantly, our patient showed no evidence of any gastrointestinal disorders.Te patient did have a history of recurrent pregnancy losses as well as recurrent implantation failure.It is not clear whether C. perfringens colonisation predisposes to adverse reproductive and antenatal outcomes as to the best of our knowledge, there are no published data on the topic.Tere is a rising evidence highlighting the efect of the endometrial microbiome on the fertility potential and reproductive outcomes, yet C. perfringens was not found as one of the culprits [11].
Te literature on postpartum C. perfringens-induced bacteraemia cases in previously healthy patients is somewhat limited, making risk factors in obstetrical patients elusive.Possible contributors could include the presence of leiomyoma, uterine instrumentation, caesarean section, 2 Case Reports in Infectious Diseases abortion, prolonged labour, and traumatic delivery [5].Typically, treatment involves broad-spectrum antibiotics with intravenous hydration, and surgical debridement is considered if no clinical improvement is documented.In summary, C. perfringens bacteraemia during the postpartum period, though rare, demands vigilant consideration.As exemplifed in our case report, diagnosis and management are paramount, with blood cultures forming a crucial diagnostic tool for patients presenting with postdelivery fever and sepsis.Te intricate interplay between this pathogen and obstetrical risk factors necessitates ongoing research and clinical vigilance.Understanding the diverse clinical scenarios associated with C. perfringens infections is essential for optimising therapeutic strategies and preventive measures.

Conclusion
Bacteraemia caused by C. perfringens is an infrequent event in the uneventful postpartum phase.Maintaining vigilance for the potential occurrence of such an event allows for early detection and timely administration of antibiotics and resuscitative measures.Patients exhibiting postdelivery fever and sepsis in addition to blood culture analysis should undergo computerised tomography, which proves to be a suitable method for screening necrotising and gangrenous processes, along with detecting potential abdominopelvic malignancies.