LAUSR

A 45-year-old non-diabetic woman receiving hyper-CVAD (hyperfractionated cyclophosphamide, vincristine, doxorubicin, and dexamethasone) chemotherapy for suspected high-grade transformation of follicular lymphoma presented to the emergency department with febrile neutropenia and left flank pain radiating down the left leg that was not responsive to high-dose morphine. Laboratory findings were profound neutropenia (neutrophil count 0.0 × 109/L), thrombocytopenia (platelet count 17 × 109/L), and elevated CRP (13.22 mg/dL). Computed tomography of the abdomen and pelvis showed extensive abnormal gas around the left ilium causing its destruction, with necrosis of adjacent gluteal muscles, and gas extending into the left sacrum, pubic ramus and right inferior epigastric vein (Fig. 1). The patient deteriorated rapidly with septic shock and died 10 h later despite broad-spectrum intravenous antibiotics and inotropic support in the intensive care unit. Blood cultures later grew Clostridium septicum, as well as Staphylococcus aureus and Gram-variable bacilli. C. septicum is a Gram-positive, anaerobic bacillus responsible for atraumatic myonecrosis (also known as gas gangrene). It is associated with colon adenocarcinoma, immunosuppression, diabetes mellitus, cyclical or congenital neutropenia and peripheral vascular disease [1]. Possible contributing factors in this case were profound immune suppression, multiple prior lines of chemotherapy, colonic mucositis or infiltration of the bowel wall by lymphoma. Management of myonecrosis includes surgical debridement or in some cases amputation, support in intensive care, antibiotics and hyperbaric oxygen treatment. Prognosis is poor and, as this case highlights, can often be quickly fatal despite intervention.