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Gynecologic Clostridial Toxic Shock in Women of Reproductive Age

  • Urinary Tract Infections (Jack D. Sobel, Section Editor)
  • Published:
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Abstract

Clostridial toxic shock, caused by Clostridium sordellii or Clostridium perfringens, is a rare and largely fatal syndrome among reproductive-aged women with genital tract infection, and may occur following various pregnancy outcomes or without pregnancy. Clinicians should be aware of common clinical features of this very rapidly-progressing syndrome including abdominal pain, tachycardia, hypotension, third-space fluid accumulations, hemoconcentration, and marked leukemoid response, often with lack of fever. In this review, we summarize known cases through mid-2011 and information on clinical presentation, diagnosis, treatment, and results of recent investigations regarding pathogenesis, including germination, toxins, and host response that may have important implications for development of preventive or therapeutic interventions.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. Bagge E, Persson M, Johansson K-E. Diversity of spore-forming bacteria in cattle manure, slaughterhouse waste and samples from biogas plants. J App Micro. 2010;109:1549–65.

    CAS  Google Scholar 

  2. Hammill HA. Normal vaginal flora in relation to vaginitis. Obstet Gynecol Clin North Am. 1989;16(2):329–36.

    PubMed  CAS  Google Scholar 

  3. Gorbach SL, Menda KB, Thadepalli H, Keith L. Anaerobic microflora of the cervix in healthy women. Am J Obstet Gynecol. 1973;117(8):1053–5.

    PubMed  CAS  Google Scholar 

  4. Ohm MJ, Galask RP. Bacterial flora ofthe cervix from 100 prehysterectomy patients. Am J Obstet Gynecol. 1975;122:683–7.

    PubMed  CAS  Google Scholar 

  5. Shannon C, Veatch M, Chong E, et al. Vaginal and rectal clostridial colonization among women of reproductive age in the United States [abstract p95]. Presented at the Reproductive Health 2010 Annual Meeting. Chicago, IL; September 22-25, 2010. Abstract published in Contraception 2010; 82:214.

  6. Sordellii A. Un anaerobic agent de gangrene gazeuse. Compt Rend Soc Biol. 1922;87:838–40.

    Google Scholar 

  7. Lewis CJ, Naylor RD. Sudden death in sheep associated with Clostridium sordellii. Vet Rec. 1998;142:417–21.

    Article  PubMed  CAS  Google Scholar 

  8. Smith LP, McLean AP, Maughan GB. Clostridium welchii septicotoxemia: a review and report of 3 cases. Am J Obstet Gynecol. 1971;110(1):135–49.

    PubMed  CAS  Google Scholar 

  9. • Ho CS, Bhatnagar J, Cohen AL, et al.: Undiagnosed cases of fatal Clostridium-associated toxic shock in Californian women of childbearing age. Am J Obstet Gynecol 2009, 201:459.e1-7. Population-based retrospective study provides evidence that CSTS is cause of death for approximately 1 in 200 of women of reproductive age, and demonstrates C. perfringens may cause clinical course and pathologic findings similar to C. sordellii.

    Article  Google Scholar 

  10. Barrett JP, Whiteside JL, Boardman L. Fatal clostridial sepsis after spontaneous abortion. Ob Gyn. 2002;99(5)part 2:899-901.

    Google Scholar 

  11. Hamoda H, Chamberlain PF. Clostridium welchii infection following amniocentesis: a case report and review of the literature. Prenat Diagn. 2002;22:783–5.

    Article  PubMed  CAS  Google Scholar 

  12. Fischer M, Bhatnagar J, Guarner J, et al. Fatal toxic shock syndrome associated with Clostridium sordellii after medical abortion. N Engl J Med. 2005;353:2352–60.

    Article  PubMed  CAS  Google Scholar 

  13. Cohen AL, Bhatnagar J, Reagan S, et al. Toxic shock associated with Clostridium sordellii and Clostridium perfringens after medical and spontaneous abortion. Obstet Gynecol. 2007;110:1027–33.

    Article  PubMed  CAS  Google Scholar 

  14. Rørbye C, Petersen IS, Nilas L. Postpartum Clostridium sordellii infection associated with fatal toxic shock syndrome. Acta Obstet Gynecol Scand. 2000;79(12):1134–5.

    PubMed  Google Scholar 

  15. Hogan SF, Ireland K. Fatal acute spontaneous endometritis resulting from Clostridium sordelli. Am J Clin Pathol. 1989;91(1):104–6.

    PubMed  CAS  Google Scholar 

  16. Sinave C, Le Templier G, Blouin D, et al. Toxic shock syndrome due to Clostridium sordellii: a dramatic postpartum and postabortion disease. Clin Infect Dis. 2002;35(11):1441–3.

    Article  PubMed  Google Scholar 

  17. Zane SB, Berg CJ. Deaths from Clostridium sordellii after medical abortion. N Engl J Med. 2006;354(15):1646–7. author reply 1647.

    CAS  Google Scholar 

  18. McGregor JA, Soper DE, Lovell G, Todd JK. Maternal deaths associated with Clostridium sordellii infection. Am J Obstet Gynecol. 1989;161(4):987–95.

    PubMed  CAS  Google Scholar 

  19. Bitti A, Mastrantonio P, Spigaglia P, et al. A fatal postpartum Clostridium sordellii associated toxic shock syndrome. J Clin Pathol. 1997;50(3):259–60.

    Article  PubMed  CAS  Google Scholar 

  20. Soper DE. Clostridial myonecrosis arising from an episiotomy. Obstet Gynecol. 1986;68(3 Suppl):26S–8S.

    PubMed  CAS  Google Scholar 

  21. Sosolik RC, Savage BA, Vaccarello L. Clostridium sordellii toxic shock syndrome: a case report and review of the literature. Infect Dis Obstet Gynecol. 1996;4(1):31–5.

    Article  PubMed  CAS  Google Scholar 

  22. Golde S, Ledger WJ. Necrotizing fasciitis in postpartum patients. A report of four cases. Obstet Gynecol. 1977;50(6):670–3.

    PubMed  CAS  Google Scholar 

  23. • Aldape MJ, Bryant AE, Stevens DL. Clostridium sordellii infection: epidemiology, clinical findings, and current perspectives on diagnosis and treatment. Clin Infect Dis. 2006;43:1436-46. Provides extensive background and summary of information on C. sordellii disease for clinicans, clinical pathologists, and researchers.

    Article  PubMed  CAS  Google Scholar 

  24. Kimura AC, Higa JI, Levin RM, et al. Outbreak of necrotizing fasciitis due to Clostridium sordellii among Black-Tar heroin users. Clin Infect Dis. 2004;38(9):e87–91.

    Article  PubMed  Google Scholar 

  25. Voth D, Martinez O, Ballard J. Variations in lethal toxin and cholesterol-dependent cytolysin production correspond to the differences in cytotoxicity among strains of Clostridium sordellii. FEMS Microbiol Lett. 2006;259:295–302.

    Article  PubMed  CAS  Google Scholar 

  26. Ramirez N, Abel-Santos E. Requirements for germination of Clostridium sordellii spores in vitro. J Bacteriol. 2010;192:418–25.

    Article  PubMed  CAS  Google Scholar 

  27. • Liggins M, Ramirez N, Magnuson N, Abel-Santos E. Progesterone analogs influence germination of clostridium sordellii and Clostridium difficile spores in vitro. J Bacteriol. 2011;193(11):2776–83. Provides detailed information on the influence of specific sterane compounds on germination of C. sordellii.

    Article  PubMed  CAS  Google Scholar 

  28. • Genth H, Just I. Functional implications of lethal toxin-catalysed glucosylation of (H/K/N)Ras and Rac1 in Clostridium sordellii-associated disease. Eur J Cell Biol. 2010, Dec 4 [Epub ahead of print]. This is an extensive and nicely presented review of the effect of TcsL.

  29. Kachman MT, Hurley MC, Thiele T, et al. Comparative analysis of the extracellular proteomes of two Clostridium sordellii strains exhibiting contrasting virulence. Anaerobe. 2010;16:454–60.

    Article  PubMed  CAS  Google Scholar 

  30. • Hao Y, Senn T, Opp JS, et al. Lethal toxin is a critical determinant of rapid mortality in rodent models of Clostridium sordellii endometritis. Anaerobe. 2010;16:55–60. Seminal study of a C. sordellii clinical isolate in animal models of infection, verification of the major role of TcsL in causing refractory toxic shock in in vivo studies that removed TcsL or blocked its function, and in vitro evidence correlating the presence of virulence factors with clinical features of infection.

    Article  Google Scholar 

  31. • Carter GP, Awad MM, Hao Y, et al. TcsL is an essential virulence factor in Clostridium sordellii ATCC 9714. Infect Immun. 2011;79:1025–32. Developed methods for the introduction of plasmids into C. sordellii and successfully used these techniques to inactivate the tcsL gene in a reference strain. The mutant strain was used to demonstrate that TcsL is an essential virulence factor and also contributes to edema seen during uterine infection. Molecular tools and methodologies developed in this work make it possible to use molecular approaches to explore the role of conjectural C. sordellii virulence factors in disease.

    Article  PubMed  CAS  Google Scholar 

  32. • Geny B, Khun H, Fitting C et al. Clostridium sordellii lethal toxin kills mice by inducing a major increase in lung vascular permeability. Am J Pathol. 2007;170:1003-17. Very elegant study of the pathology in an experimental mouse model with nice correlation with clinical presentation and pathogenic mechanisms.

    Article  PubMed  CAS  Google Scholar 

  33. Aldape MJ, Bryant AE, Katahira EJ, et al. Innate immune recognition of, and response to, Clostridium sordellii. Anaerobe. 2010;16:125–30.

    Article  PubMed  CAS  Google Scholar 

  34. Thelen T, Hao Y, Medeiros AI, et al. The class A scavenger receptor, macrophage receptor with collagenous structure, is the major phagocytic receptor for Clostridium sordellii expressed by human decidual macrophages. J Immunol. 2010;185:4328–35.

    Article  PubMed  CAS  Google Scholar 

  35. Wagner A, Russell C, Ponterio JM, Pessolano JC. Ruptured tuboovarian abscess and septic shock with Clostridium perfringens in a postmenopausal woman: a case report. J Reprod Med. 2009;54(10):652–4.

    PubMed  Google Scholar 

  36. Tsokos M, Schalinski S, Paulsen F, et al. Pathology of fatal traumatic and nontraumatic clostridial gas gangrene: a histopathological, immunohistochemical, and ultrastructural study of six autopsy cases. Int J Legal Med. 2008;122:35–41.

    Article  PubMed  Google Scholar 

  37. Valour F, Boisset S, Lebras L, et al. Clostridium sordellii brain abscess diagnosed by 16S rRNA gene sequencing. J Clin Microbiol. 2010;48:3443–4.

    Article  PubMed  CAS  Google Scholar 

  38. Foroulis CN, Gerogianni I, Kouritas VK, et al. Direct detection of Clostridium sordellii in pleural fluid of a patient with pneumonic empyema by a broad-range 16S rRNA PCR. Scand J Infect Dis. 2007;39:617–9.

    Article  PubMed  CAS  Google Scholar 

  39. Davenport OW, Olsen DE. Pathologic physiology and treatment of postabortal Clostridium welchii sepsis. Am J Obstet Gyne. 1960;80:512–5.

    CAS  Google Scholar 

  40. O’Neill RT, Schwarz RH. Clostridial organisms in septic abortions: report of 7 cases. Obstet Gynecol. 1970;35:458–61.

    PubMed  Google Scholar 

  41. De Alverez RR, Wolter DF. Management of postabortal sepsis and acute renal failure due to Clostridium welchii. Obstet Gyn. 1958;11:280–9.

    Google Scholar 

  42. Pritchard JA, Whalley PJ. Abortion complicated by Clostridium perjringens infection. Am J Obstet Gynecol. 1971;111:484–92.

    PubMed  CAS  Google Scholar 

  43. Decker WH, Hall W. Treatment of abortions infected with Clostridium welchii. Am J Obstet GynecoI. 1966;95:394–9.

    CAS  Google Scholar 

  44. Meites E, Zane SB, Gould C. Fatal Clostridium sordellii infections after medical abortions. N Engl J Med. 2010;363:1382–3.

    Article  PubMed  CAS  Google Scholar 

  45. Reis T, Chaves C, Soares A et al. A Clostridium sordellii fatal toxic shock syndrome post-medical-abortion in Portugal [abstract 124927]. Presented at the 21st European Congress of Clinical Microbiology and Infectious Diseases. Milan, Italy; May 7-10, 2011. Available at http://registration.akm.ch/einsicht.php?XNABSTRACT_ID=124927&XNSPRACHE_ID=2&XNKONGRESS_ID=136&XNMASKEN_ID=900. Accessed May 2011.

  46. Aronoff DM, Ballard J. Clostridium sordellii toxic shock syndrome. Lancet Infect Dis. 2009;9:281-90.

    Article  Google Scholar 

  47. Dylewski J, Wiesenfeld H, Latour A. Postpartum uterine infection with Clostridium perfringens. Rev Inf Dis. 1989;11(3):470–3.

    Article  CAS  Google Scholar 

  48. Aronoff DM, Thelen T, Walk ST, et al. Pseudo-outbreak of Clostridium sordellii infection following probable cross-contamination in a hospital clinical microbiology laboratory. Infect Control Hosp Epidemiol. 2010;31:640–2.

    Article  PubMed  Google Scholar 

  49. Stevens DL, Bryant AE, Berger A, von Eichel-Streiber C. Clostridium. In: Versalovic J, editor. American Society of Microbiology Manual of Clinical Microbiology. 10th ed. Washington: ASM Press; 2010.

    Google Scholar 

  50. Bryant AE, Stevens DL. Clostridial myonecrosis: new insights in pathogenesis and management. Curr Infect Dis Rep. 2010;12:383–91.

    Article  PubMed  Google Scholar 

  51. Abougergi MS, Broor A, Cui W, Jaar BG. Intravenous immunoglobulin for the treatment of severe Clostridium difficile colitis: an observational study and review of the literature. J Hosp Med. 2010;5(1):E1–9.

    Article  PubMed  Google Scholar 

  52. McPherson S, Rees CJ, Ellis R, et al. Intravenous immunoglobulin for the treatment of severe, refractory, and recurrent Clostridium difficile diarrhea. Dis Colon Rectum. 2006;49(5):640–5.

    Article  PubMed  Google Scholar 

  53. Lowy I, Molrine DC, Leav BA, et al. Treatment with monoclonal antibodies against Clostridium difficile toxins. N Engl J Med. 2010;362(3):197–205.

    Article  PubMed  CAS  Google Scholar 

  54. Schulz F, Just I, Genth H. Prevention of Clostridium sordellii lethal toxin-induced apoptotic cell death by tauroursodeoxycholic acid. Biochemistry. 2009;48(38):9002–10.

    Article  PubMed  CAS  Google Scholar 

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Acknowledgement

The findings and conclusions in this paper are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

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No potential conflicts of interest relevant to this article were reported.

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Authors and Affiliations

  1. Division of Reproductive Health, Centers for Disease Control and Prevention, 4770 Buford Hwy, NE, Mailstop K-23, Atlanta, GA, 30341, USA

    Suzanne Zane

  2. Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Emory University Hospital, Room C179C, 1364 Clifton Road, NE, Atlanta, GA, 30322, USA

    Jeannette Guarner

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  1. Suzanne Zane
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Correspondence to Suzanne Zane.

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Zane, S., Guarner, J. Gynecologic Clostridial Toxic Shock in Women of Reproductive Age. Curr Infect Dis Rep 13, 561–570 (2011). https://doi.org/10.1007/s11908-011-0207-7

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  • DOI: https://doi.org/10.1007/s11908-011-0207-7

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