course material

1. Capstone assignment on Clostridium Perfringens Associates degree in
Medical Technology
Capstone assignment onClostridium Perfringens Associates degree in Medical
Technology Univ Case History:96-year-old female was admitted to the hospital with
complaint of generalized weakness and diarrhea. She described persistent diarrhea without
blood for two weeks as well as fever, body ache and chills. Patients’ past history revealed
she was relatively healthy with a previous history of cholesterol management with
medication and medications for back pain. Blood Pressure on arrival was within normal
limits. Initial lab work was ordered at 17:37 and the CBC revealed an elevated white blood
cell count of 13.4 (4.8-10.8%) with a differential that showed an elevated neutrophil count
of 82.4% (45.0- 75.0%), 16.0 % lymphocytes (15.0-45.0%), 0.8% monocytes (1.0-10.0%),
0.4% eosinophils (0.0-5.0%), and 0.4% basophils (0.0-3.0%). Her CBC also showed a slightly
decreased red blood cell count of 4.09 mill/cmm (4.20-5.40 mill/cmm) with a hemoglobin
and hematocrit within normal limits. Red blood cell indices were also normal. CMP revealed
elevated total bilirubin 1.5 mg/dl (0.10-1.20 mg/dl), alkaline phosphatase 145 IU/L (39-
136 IU/L), AST 182 IU/L (8-46 IU/L), and elevated ALT 262 (12-78 IU/L). The patient had
an elevated heart rate and temperature of 101.5 degrees Fahrenheit indicating a positive
sepsis screen although her Lactic acid was within normal limits at 1.3 mmol/L (0.4-2.0
mmol/L). Patient was started on the broad-spectrum antibiotics Fortaz. Blood cultures
were collected.The following morning labs were collected and received into the laboratory
at 03:00. After centrifugation the tech noticed the tubes did not appear as though they had
been spun. With further investigation the tech realized the patient’s specimens were grossly
hemolyzed. The patients CBC now indicated a variety of suspect flags and system flags.
There was a rapid change from the previous evenings CBC results. The following are
comparison tables showing the initial CBC results with the first morning results:Table 1:
Initial evening results. Red values indicate abnormal results.Table 2: Morning CBC results
indicating sudden change in patient condition. Red values indicate abnormal
results. TestResultWBC36.1RBC2.34HGB5.1HCT10.7MCV45.7MCH21.8MCHC47.7RDW27.5
PLT59Neutrophil78.5Lymphocyte18.4Monocyte2.4Eosinophil0.5 TestResultWBC13.4RBC4.
09HGB12.7HCT38.2MCV93MCH31.1MCHC33.3RDW14.2PLT197Neutrophil82.4Lymphocyt
e16.0Monocyte0.8Eosinophil0.4Reference Range4.8-10.8 (10^3/uL) 4.20-5.40
(10^6/uL)Reference Range4.8-10.8 (10^3/uL) 4.20-5.40 (10^6/uL) 12.0-16.0 (g/dL) 36.0-
47.0 (%)81-99 (fL) 27.0-33.0 (pg) 32.0-36.0 (g/dL) 11.6-15.6 (%) 150-400 (10^3/uL) 45.0-

2. 75.0 (%) 15.0-45.0 (%) 1.0-10.0 (%) 0.0-5.0 (%)0.0-3.0 (%) 12.0-16.0 36.0-47.081-99
(fL) 27.0-33.0 32.0-36.0 11.6-15.6150-400 (10^3/uL) 45.0-75.0 (%) 15.0-45.0 (%) 1.0-10.0
(%) 0.0-5.0 (%)0.0-3.0 (%)(g/dL) (%) (pg) (g/dL) (%) Basophil
0.4Basophil0.2 A slide review was done, and massive intravascular hemolysis was
observed. The peripheral smear showed a severe decrease in RBCs, with the presence of
spherocytosis, toxic vacuolization, polychromasia with basophilic stippling, immature RBCs,
erythrophagocytosis, and immature neutrophils. Images of the patient’s peripheral smear
are shown below. The house supervisor was notified of these results. Later than morning,
the patient’s blood cultures alarmed indicating growth in the anaerobic bottles. A
preliminary gram stain revealed large gram-positive bacilli. Anaerobic culture results
revealed the organism as Clostridium perfringens.Following this exercise, the reader will be
able to describeMicrobiology chemical natureStudent Learning Outcome (SLO) Following
this exercise, the reader will be able to compile an accurate diagnosis and
treatmentClostridium perfringens by its Following this exercise, the reader will be able to
list the 6 different Major types of Clostridium perfringens based on toxins plan for a patient
with Clostridium perfringens Following this exercise, the reader will be able to evaluate
transmission of Clostridium perfringens Following this exercise, the reader will be able to
classify the complications that can occur from a Clostridium perfringens
infection. DiscussionClostridium perfringens was first discovered in 1892 by George Nuttall
and William Welch which is why it was originally named Clostridium welchii. Clostridium
perfringens is an anaerobic, Gram-positive, rod-shaped, encapsulated pathogenic bacterium
of the genus Clostridium. Clostridium perfringens is typically found in the soil, raw meat
and poultry, in the intestines of certain animals, but is also often found as part of the
intestinal normal flora and sometimes in the vaginal flora. Clostridium perfringens is one of
the most common causes of food poisoning in the United States and infections due to C.
perfringens can lead to types of tissue necrosis, septicemia and diseases such as
enterocolitis and gas gangrene. Immunosuppression, malignancy and diabetes are the most
common risk factors for developing complications induced by C. perfringens. The most
common vehicle for transmission isundercooked beef, followed by poultry since clostridium
perfringens is not transmitted from person to person; it is not as contagious as other
clostridium species like clostridium difficile.Clostridium perfringens has 6 major different
toxins that cause all types of infections and diseases. [١] The major toxins involved in
diseases are alpha (CPA), beta (CPB), epsilon (ETX), iota (ITX), enterotoxin (CPE), and
necrotic B-like (NetB) toxins. While the alpha toxin and enterotoxin are known to cause
human disease each of the toxins can lead to a different pathology in humans and animals.
All types of Clostridium perfringens produce alpha toxin which has been reported to
hydrolyze phospholipids in red blood cell membranes, leading to massive hemolysis and
severe tissue hypoxia due to the failure of oxygen transport function restricting blood flow
towards the area of infection producing an anaerobic environment essential for the
proliferation of the bacteria. Alpha toxin causes food poisoning and the disease gas
gangrene, which is the most common infection with Clostridium perfringens, it affects deep
muscle tissue where gas is released causing tissue death and can be very life-threatening.
Beta toxin is responsible for the disease [٢] Pigbel which is a form of acute,segmental,

3. necrotizing enteritis presenting as a common and life-threatening disease among the people
of the highlands of Papua New Guinea. The epsilon toxin plays an important role in the
disease enterotoxemia in sheep and goats and recently has been associated with
development of Multiple sclerosis in humans as they have been shown to have antibodies to
the epsilon toxin of Clostridium perfringens. The iota toxin and its enzymatic activity
destroys normal cell functions and is responsible for diseases in animals implicated in some
diarrheic outbreaks among calves and lambs. Enterotoxin produced by Clostridium
perfringens is responsible for causing the gastrointestinal symptoms of several food- and
nonfood-borne human gastrointestinal diseases. NetB is a pore-forming toxin identified in
avian necrotic enteritis but so far has not been linked to pathogenicity in humans. Diagnosis
of Clostridium perfringens is somewhat difficult as it is not a routine test for clinical
laboratories and needs to be specially ordered by the physician if they suspect it to be the
cause of infection. Physicians will notice that the patient presents with hemolysis increased
levels of indirect bilirubin, LDH and anemia are indications for further testing but if gross
hemolysis is noticed immediate action needs to be taken as that could lead to death.
Clostridium perfringens can be diagnosed or confirmed by detection of the bacteria and/or
toxin in a stool culture or by PCR methods, stool studies will also include WBCs, ova, and
parasites to help rule out other etiologies.The Alpha toxin produced by Clostridium
perfringens is the most lethal of the toxins and can cause intravascular hemolysis in
patients if untreated. Intravascular hemolysis is the rupture or lysis of RBC within the
circulation in vivo (in a living system). When the membrane of erythrocytes rupture, they
release their hemoglobin into the plasma and will cause visible discoloration of plasma
causing it to appear red or pink, as we seen in the case study. There was a rapid change in
the patient blood results from the initial blood draw until the 3:00am draw as the
deterioration of the body systems is fast and we see that with the red blood cell (RBC) /
hemoglobin (Hb) discrepancy and by the hemolysis, in the presence of infection should
prompt the physicians to consider clostridium perfringens septicemia to act quickly to
provide appropriate treatment because of the severity of the disease. The patient in the case
study had a peripheral smear done which was indicative of intravascular hemolysis as it
showed adecrease in mature RBCs and an increase with immature RBCs with toxic
vacuolization, also a great indicator of an infection in the blood. Clostridium perfringens can
also lead to sepsis in your blood which is a life-threatening complication of an infection,
chemicals released in the bloodstream to fight the infection trigger inflammation
throughout the body and not only fight the infection but can trigger a response throughout
the body causing inflammation and changes that can damage multiple organ systems. Sepsis
has symptoms that include fever, difficulty breathing, low blood pressure, and a fast heart
rate which is how our patient presented in the case study. Clostridium perfringens
septicemia is rare due to CPA-mediated destruction of red blood cells but typically proves
rapidly fatal in this situation early antibiotic treatment would be essential. Our Patient had
Blood cultures done to confirm a blood infection and the next morning it grew Clostridium
perfringens. Once the organism is identified we can now proceed with treatment although
the patient was started on broad spectrum antibiotics, we can now narrow the antibiotics to
what is needed. Infection with C perfringens is probably the most serious condition, and

4. treatment should be started as soon as suspicion arises. You treat C. perfringens by
managing any complications until it passes, dehydration caused by diarrhea and vomiting is
the most common complication.[٣] C. perfringens strains are generally sensitive to a variety
of antibiotics, such as penicillins, cephalosporins, carbapenems, clindamycin, metronidazole
and vancomycin. Benzylpenicillin has been listed as the first choice.However, there is
experimental data indicating that clindamycin and metronidazole, among others, may
reduce alpha toxin activity more rapidly. You can prevent Clostridium perfringens food
poisoning by cooling and storing foods correctly, use a clean meat thermometer to
determine whether foods are cooked to a safe temperature, and finally When in doubt,
throw it out and never take the chance with your body.Case conclusion:This patient
presented with persistent GI symptoms. She did have some indicators of sepsis, but the
severity was not apparent. Her Lactic acid results on arrival were within normal limits and
her initial CBC was relatively unremarkable with the presence of neutrophilia and slightly
anemia. In time span of less than 12 hours the patient’s condition deteriorated rapidly. The
C. perfringens bacteria rapidly proliferated causing massive intravascular hemolysis which
lead to the patient’s death only a few hours after her specimens were received in the lab the
lab the morning after her arrival. Unfortunately, because of the patient’s age an autopsy was
not performed, and the exact source of the Clostridium perfringens infection was not
determined. Because of her GI symptoms, it is hypothesized that the patient suffered from
enteritis for a couple of weeks and eventually the bacteria caused a perforation in her bowel
that led to large numbers of bacteria entering her blood stream. This large amount of
bacteria produced high amount of toxins that caused severe and rapid damage to her RBCs
and the patient was unable to recover. Clostridium perfringens produces many different
toxins that enhance the virulence of this organism depending on the type and source of the
infection. It is important to understand the way this organism causes disease and how to
recognize this organism so that rapid detection and prompt treatment can prevent
deterioration of patient condition to the point where treatment is ineffective. REFENCES1.
Navarro, Mauricio A et al. “Mechanisms of Action and Cell Death Associated with
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29681209; PMCID: PMC6439943 en and for how long is a
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