Undiagnosed cases of fatal Clostridium-associated toxic shock in Californian women of childbearing age

Article Outline

• Abstract
• Materials and Methods
  • Retrospective death certificate review
  • Laboratory investigation
• Results
• Comment
• Conclusion
• Acknowledgments
• References
• Copyright

Objective

In 2005, 4 Clostridium sordellii-associated toxic shock fatalities were reported in young Californian women after medical abortions. The true incidence of this rare disease is unknown, and a population-based study has never been performed. Additional clostridia-associated deaths were sought to describe associated clinical characteristics.

Study Design

Population-based death certificate review and a clinical case definition for clostridial-associated toxic shock identified women with likelihood of dying from a Clostridium infection. Formalin-fixed autopsy tissues underwent immunohistochemical and polymerase chain reaction assays.

Results

Thirty-eight women were suspected of having C sordellii-associated death. Five tested positive for Clostridium species: 3 for Clostridium perfringens, 1 for C sordellii, and 1 for both. Deaths occurred after the medical procedures for cervical dysplasia (n = 2), surgical abortion (n = 1), stillborn delivery (n = 1), and term live birth (n = 1). None had a medical abortion.

Conclusion

C sordellii and C perfringens are associated with undiagnosed catastrophic infectious gynecologic illnesses among women of childbearing age.

Key words: Clostridium perfringens, Clostridium sordellii, medical abortion, mifepristone, toxic shock

Clostridium sordellii is a ubiquitous gram-positive anaerobe found in soil. It causes enteritis and enterotoxemia in sheep and cattle¹ and is an infrequent human pathogen that is difficult to culture and easily missed. Rarely, it has been linked to cases of cellulitis, myonecrosis, and endometritis in humans.¹, ², ³, ⁴, ⁵, ⁶, ⁷ Bacteremia and sepsis are rare, occurring mainly in persons who are immunosuppressed.⁶

In December 2005, the deaths from C sordellii-associated toxic shock (CSTS) of 4 young Californian women after medically induced abortions were reported.⁸ As with other published cases of CSTS, these shared a rapidly lethal clinical course, with marked refractory hypotension, leukemoid reaction with a white blood cell count greater than 50,000 cells/μL, hemoconcentration with a hematocrit greater than 50%, and profound capillary leak syndrome with fluid sequestration and edema formation. These 4 women received a common regimen of 200 mg of oral mifepristone and 800 μg of vaginal misoprostol. Bacteriologic cultures of blood and cervix were all negative, and diagnosis was made only by immunohistochemistry (IHC) and polymerase chain reaction (PCR) assays performed on formalin-fixed tissues. C sordellii diagnosis was also confirmed by sequencing of PCR products. Before this report, C sordellii had been linked to 1 death from gynecologic infection not associated with pregnancy and 9 parturient deaths: 8 postpartum and 1 after a medical abortion.¹, ², ³, ⁴, ⁵, ⁶, ⁷ With increased surveillance that followed this report, 5 additional CSTS-associated deaths were found: 2 after second-trimester spontaneous abortions,⁹ 1 caused by postpartum perineal infection of a laceration,¹⁰ 1 after medical abortion, and 1 nonfatal case after spontaneous abortion.¹¹ Two of these women had mixed infections with postmortem cultures growing C sordellii along with Clostridium perfringens⁹ or other mixed anaerobic flora.¹⁰ Another fatality caused by Clostridium endometritus was reported in a recent Cuban study, which evaluated medical abortion with 400 μg vs 800 μg misoprostol.¹² The true number of C sordellii-related deaths among young women may be underestimated because of the limitations of diagnostic methods.

Clostridium species, such as Clostridium difficile, have emerged as a more virulent pathogen in recent years,¹³, ¹⁴ and reports of fatal C sordellii infections raise concerns of increasing pathogenicity of clostridial organisms. However, the increase in published case reports of Clostridium-associated toxic shock could be an artifact of new diagnostic capability and increased clinical suspicion. We initiated an epidemiologic investigation to find undetected CSTS deaths among women within the same time frame and locale as the 4 original reported cases from California.

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Materials and Methods 

Retrospective death certificate review 

Clinical characteristics common to other published cases of fatal C sordellii infection determined the case definition for CSTS.¹, ², ³, ⁴, ⁵, ⁶, ⁷, ⁸, ¹⁰, ¹¹, ¹⁵, ¹⁶ A case was defined as a previously healthy woman aged 15-44 years with an acute fatal illness that included at least 1 finding from each of these groups: (1) leukemoid reaction, hemoconcentration, or hypotension; (2) focal gastrointestinal or gynecologic symptoms; and (3) pleural, pericardial, or peritoneal effusions.

An obstetrician/gynecologist expert in International Classification of Diseases (ICD) review of maternal fatalities assisted in compiling a set of 12 ICD-10 codes that would select primary causes of death consistent with CSTS. California state mortality datasets from 2000-2003 were queried to identify women who died at ages 15-44 years with these ICD-10 codes listed as the primary cause of death. Additional variables included age, date of death, and hospital admission. Death certificates, autopsy reports, and medical records were reviewed for the subset that underwent autopsy. Investigators extracted history, exposures, physical findings, and laboratory results. Formalin-fixed tissue blocks of affected organs were requested from medical examiners and pathologists. Because this investigation was a public health response, approval through institutional review boards and consent of next of kin were not required.

Laboratory investigation 

Formalin-fixed tissue blocks from autopsy and surgical specimens were sent to CDC, where IHC assays using antibodies against Clostridium species, Staphylococcus aureus, group A Streptococcus, and Neisseria species were performed.⁸ DNA was extracted from formalin-fixed tissues by using the QIAamp DNA Mini kit (QIAGEN, Valencia, CA) after the tissue extraction protocol. DNA was evaluated by broad-range eubacterial 16S rDNA PCR, C sordellii-specific PCR assays targeting the cytotoxin L (C sordellii lethal toxin [TcsL]) and C sordellii phospholipase C (Csp) genes,⁸ and C perfringens-specific PCR assay targeting the alpha toxin (cpa) gene.¹⁷ Amplified PCR products were separated on 1.8% agarose gel, extracted from the gel by using QIAquick gel extraction kit (QIAGEN) and directly sequenced on a CEQ 2000 XL sequencer (Beckman Coulter, Fullerton, CA). A search for homologies to known sequences was performed with the Basic Local Alignment Search Tool (BLAST) at http://www.ncbi.nim.nih.gov/blast/.

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Results 

There were 1115 deaths among women aged 15-44 years between 2000-2003. We determined that 38 of these women had death certificate ICD-10 diagnoses highly suspicious for CSTS (Table 1). To assess possible coinfections with Clostridium species, decedents diagnosed with other bacterial infections were not excluded. Fourteen women met the case definition, but 3 women did not have autopsy reports or tissues available, and 24 were excluded because of factors such as underlying immunocompromised condition, noninfectious cause of death, or falling outside the case definition for CSTS (Table 2 and Figure).

TABLE 1. Number of study subjects with primary cause of death ICD-10 codes highly suspicious for Clostridium sordellii-associated toxic shock (n = 38)

ICD-10, International Classification of Disease, 10th revision; PID, pelvic inflammatory disease.

Ho. Undiagnosed cases of fatal Clostridium-associated toxic shock. Am J Obstet Gynecol 2009.

TABLE 2. Diagnoses of excluded cases

DVT, deep venous thrombosis; ICD, International Classification of Diseases.

Ho. Undiagnosed cases of fatal Clostridium-associated toxic shock. Am J Obstet Gynecol 2009.

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• FIGURE. 

  Flowchart

• CA, California; CSTS, C sordellii toxic shock; ICD-10, International Classification of Diseases, 10; IHC, immunohistochemistry; PCR, polymerase chain reaction.

• Ho. Undiagnosed cases of fatal Clostridium-associated toxic shock. Am J Obstet Gynecol 2009.

Of the remaining 11 women, tissues from 5 women were positive for Clostridium species by molecular testing: 3 for C perfringens, 1 for C sordellii, and 1 for both C perfringens and C sordellii (Table 3). Evidence of infection with multiple pathogens was identified in an additional case: Clostridium species and group A Streptococcus were identified by IHC on the surface of the episiotomy wound/perineum. Because the 16S ribosomal RNA gene sequences amplified from tissues showed 99% identity with Fusobacterium nucleatum, infection from Clostridium species was not deemed to be the cause of this death. IHC and PCR assays were negative for the remaining 5 women, including 3 who had other bacterial pathogens listed as their cause of death.

TABLE 3. Characteristics of study subjects with positive molecular assays for Clostridium

IDPB, infectious disease pathology branch; IHC, immunohistochemical assay; N/A, not applicable; N/R, not recorded; PCR, polymerase chain reaction.

Ho. Undiagnosed cases of fatal Clostridium-associated toxic shock. Am J Obstet Gynecol 2009.

Ages ranged from 32-41 years for the 5 women with molecular evidence of Clostridium species infection (cases 1-5). Two women had undergone a medical procedure for cervical dysplasia (1 by laser therapy and 1 by conization); 1 had an abortion that used cervical dilatation with laminaria, followed by curettage; 1 woman had a stillborn delivery; and 1 woman delivered an infant 4 days earlier. The time interval from their precipitating event to the onset of symptoms varied, with both acute and delayed presentations (median 4 days; range, immediately to 2 weeks). The time interval from hospital admission to death ranged from 6 hours to 2 days. One woman died before hospital admission; 2 weeks had elapsed from the time of her abortion until her death. Two of the women had a history of methamphetamine abuse.

Because of rapidly deteriorating conditions, patient clinical and laboratory information was not always available. The available clinical characteristics, nonetheless, were consistent with other reports of CSTS: tachycardia, hypotension, edema formation, hemoconcentration, leukemoid reaction, and the absence of fever. For those with available medical history, all had abdominal pain, but none had vomiting, diarrhea, or rash. Available laboratory results showed a marked leukemoid response (white blood cell count range, 70.2-131.2 [×10³/μL]) and hemoconcentration (hematocrit range, 56.9-59.7[%]). Hospital cultures of blood, peritoneal, and cervical specimens from 3 of the women were all negative.

The histopathology examination for the 5 Clostridium-positive women showed inflammation with either a cervical or uterine (endometrium or myometrium) focus. All had evidence of severe hemorrhage, and 3 of the 5 women had diffuse necrosis. There was no evidence of gas production in any of the cases.

Between 2000-2003, an average of 16.5 million women (range, 15,995,796-16,910,486) aged 14-44 years were living in California.¹⁸ Including the 4 California women who were reported previously⁸ and the 2 women found to have C sordellii infection in this investigation, this gives an estimated incidence of 0.036 episodes of CSTS per 100,000 persons. The proportion of deaths caused by CSTS is 0.54% or 5.4 per 1000 deaths for women who died in this age group during this 4-year span.

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Comment 

Although an exceedingly uncommon cause of death in the general population, CSTS is a relatively common cause of death among young women; our investigation found that approximately 1 in 200 deaths in women of childbearing age in California is due to CSTS. In our study, 3 of 5 cases of CSTS, normally attributed to C sordellii, were actually C perfringens. All Clostridium-positive cases shared clinical characteristics consistent with past cases of CSTS. Many of the symptoms unique to CSTS—the toxic shock presentation, edema formation, hemoconcentration, and leukemoid reaction—are attributable to the highly potent large clostridial toxins: lethal toxin (LT) and hemorrhagic toxin (HT) from C sordellii and alpha toxin from C perfringens.¹⁷, ¹⁹, ²⁰, ²¹ The cytopathic effects of C sordellii are enhanced in acidic environments, such as the vagina.²² Two of the women were not pregnant but had undergone recent instrumentation of the cervix. Women selected through our death certificate query were older (median age, 40 years) than women described in previously published similar cases of clostridial infection. In contrast to previously published reports, we observed a wider range of time between symptom onset and death, and none of the women in this investigation had nausea or vomiting when they sought medical attention. In 10 of 16 previously published accounts of women with CSTS, gastrointestinal symptoms of nausea and vomiting were reported.

Deaths from CSTS are sudden and catastrophic, and laboratory data and tissue are usually either negative or unavailable. Microbial isolates were not available for further characterization. Our investigation yielded a high proportion of clostridial infections among the 11 cases examined. This is important, because negative microbial cultures in this toxin-mediated disease are common; thus, ascertaining the true clinical spectrum of this disease is difficult. Differences in virulence factors or strains that might determine pathogenicity could not be examined. The presence of toxins such as sordellilysin (SDL), a cholesterol-dependent cytolysin, has been found to be associated with a less lethal strain of C sordellii than in cases with lethal toxin.²³ Future studies aimed at delineating the clinical and microbiologic factors that characterize fatal CSTS are needed to improve diagnosis and treatment for this fatal disease.

Reports of fatal CSTS and endometritis subsequent to receiving the medical abortion regimen of oral mifepristone and intravaginal misoprostol have raised questions regarding the safety of this regimen. In 2005, the report of 4 Californian women with fatal CSTS was followed shortly by a public health advisory from the Food and Drug Administration regarding this medical abortion regimen. In addition, Planned Parenthood of America has changed their regimen to the use of oral instead of intravaginal misoprostol. The possible association of medically induced abortion with fatal C sordellii infection is difficult to assess without a background estimate of the true incidence rate of CSTS among young women. Whether the recent cases of fatal CSTS resulted from the mifepristone-misoprostol regimen for medically induced abortion or were incidentally diagnosed by enhanced molecular-based testing has been the subject of much discussion.²⁴, ²⁵, ²⁶, ²⁷, ²⁸, ²⁹ Hypotheses supporting an association between medical abortion and CSTS are based on mifepristone's antagonistic effects on both glucocorticoid and progesterone receptors. Interference with the glucocorticoid-mediated stress response could compromise normal physiologic compensatory mechanisms in the setting of septic shock, resulting in cardiovascular collapse and death.²² However, women who have not undergone medically induced abortion have died of obstetric or gynecologic CSTS,¹, ³, ⁵, ⁷, ³⁰ and in 1 case, a fatal gynecologic infection occurred in the absence of pregnancy or pharmacologic intervention.² Our investigation discovered fatal CSTS in 2 young women, neither of whom had been recently pregnant or undergone medical abortion but who had undergone medical procedures to the cervix (laser therapy [case 2] and conization [case 3]). This suggests that pregnancy and pharmacologic modulation of the host's immune response are not the sole determinants of fatal C sordellii and C perfringens infections. In each, circumstances allowed the passage of anaerobic pathogens into the uterus, an environment likely to be supportive of Clostridium replication and toxin production.

This retrospective review probably underestimates the true prevalence of fatal infections from Clostridium species and C sordellii in particular. Undiagnosed cases of fatal CSTS in women may not have had the selected ICD-10 codes listed as the primary cause of death, autopsies performed, or tissues or hospital records available for evaluation. Also, the CSTS case definition we devised was based on symptoms from published C sordellii fatalities,¹, ², ³, ⁴, ⁵, ⁶, ⁷, ⁸, ¹⁰, ¹¹, ¹², ¹⁶ which could have excluded other deaths caused by CSTS. Finally, this investigation would not have detected any patients with nonlethal CSTS who were hospitalized but survived. Cohen et al¹¹ report 1 nonfatal obstetric infection with a C sordellii strain that lacked the lethal toxin gene, but the vast majority of reported cases have been fatal.

This retrospective death certificate review targeted women in the same geographic region, age, and time frame as the 4 young women who died after receiving medical abortion.⁸ Our search revealed previously undiagnosed cases of fatal clostridial infections, including fatal C perfringens infections in peripartum women with CSTS-like illnesses. C sordellii or C perfringens infection should be suspected in afebrile women who are postpartum, had a recent abortion, or had recent surgical procedures on the cervix, with negative bacterial cultures and rapidly deteriorating condition. This constellation of findings should alert clinicians toward CSTS as a possible diagnosis. Although CSTS has been almost uniformly fatal to date, the treatment of choice is aggressive physiologic support, surgical debridement with removal of the necrotic tissue, and appropriate anaerobic antibiotic coverage. Hopefully, earlier institution of specific treatment can save lives.

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Conclusion 

A rare disease, the diagnosis of CSTS often goes undetected. Our retrospective study shows that C sordellii and C perfringens are associated with undiagnosed catastrophic infectious gynecologic illnesses among women of childbearing age who are either peripartum or have had recent cervical instrumentation. These cases did not include any women who received medically induced abortion with mifepristone or misoprostol, but the clinical spectrum of our CSTS cases was consistent with cases in previously published reports. Indeed, we suspect that treatments or conditions that allow passage of anaerobic bacterium into the uterus are important risk factors for catastrophic clostridial infections in women.

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Acknowledgments 

We thank Dr Cynthia Berg, Maternal and Infant Branch, CDC, for her advice regarding ICD-10 codes; Dr Michael Curtis, Chief, Office of Surveillance, Epidemiology and Program Evaluation Section, Maternal, Child and Adolescent Health Branch, California Department of Public Health, for executing the mortality datasets queries; Kristina Smith, Chief of the Office of Vital Records for providing death certificates; and Lindy Liu for her administrative and surveillance activity expertise. We also are grateful to the many county medical examiners and pathologists who provided tissue specimens and were integral to this investigation.

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