1. Adjunctive hyperbaric oxygen therapy for the treatment of Clostridium perfringens-associated liver abscess and septic shock complicated by hemolytic anemia. LT Stephen Hughes, MD

2. Financial Relationship Disclosure I have no relevant financial relationships with any commercial supporters

3. The Case HPI: 68 yo M w/ pmh of chronic cholecystitis/cholelithiasis now 3 days s/p laparoscopic cholecystectomy presenting to the ER w/ hematuria, jaundice, diarrhea and back pain w/ continued RUQ pain. PMH/PSH: CAD, HLD, OSA,GI ulcers. Cholecystectomy 26Mar14 (3 days prior)

4. ICU Admission Physical Exam and Labs PE: – Gen: NAD, Intubated/sedated – ABD: S, Distended. Lap Chole incisions w/o erythema/induration/purulen ce – Skin: Jaundiced to bilat thighs LABS – WBC: 38.6 Hg 5.8  9.6 – Cr: 4.17 – Tbili: 15.8 (Ind 12.1) – Lactate: 4.3 – LDH: 3550, Haptoglobin: 52 U/A:

5. Imaging

6. Clostridium perfringens Ubiquitous, gram pos. spore forming rod Obligate anaerobe Synergistic α (Phospholipase C) and θ (Perfringolysin O) toxins

7. Clostridial Sepsis Simon, T. et. al, Journal of Intensive Care Medicine 2013 Mortality: 74% Median time to death of 9.6 hours TREATMENT Penicillin 3-4 million units IV q4h Clindamycin 600mg IV q6h Surgical Debridement Adjunctive Hyperbaric Oxygen

8. Adjunctive Hyperbaric Oxygen Therapy (HBOT) Historically used in treatment of Gas Gangrene Prior to this case, has been used 4 times for Clostridial septicemia. 0% Mortality in patients treated with HBOT in addition to standard therapies. http://longbeachhyperbaricmedicine.com/files/HBO_chamber_1.JPG

9. Back to the Case The pt was treated with 8 sessions of HBOT Course was complicated only by otic barotrauma The pt was discharged 2 ½ weeks following admission on OPAT and 3x/week hemodialysis Continues to improve despite the historically poor prognosis of this virulent condition.

10. Special Thanks/ Additional Authors CDR Ryan Maves, MD 1 Elizabeth Middleton, MD 2,3 Jonathan Stabile, DO 3,4 Matthew Hegewald, MD 2,3 James Orme, MD 2,3 1 Naval Medical Center, San Diego, CA 2 University of Utah School of Medicine, Salt Lake City, UT 3 Intermountain Medical Center, Murray, UT 4 Duke University School of Medicine, Durham, NC

11. References Simon, T., Bradley, J., Jones, A., & Carino, G. (2013). Massive Intravascular Hemolysis From Clostridium perfringens Septicemia: A Review. Journal of Intensive Care Medicine, 00(0), 1-7. Ng, H., Lam, S., Shum, H., & Yan, W. (2010). Clostridium perfringen liver abscess with massive haemolysis. Hong Kong Med J, 16(4), 310-312. Fauci, A., et al (2008). Harrison's principles of internal medicine (17th ed., pp. 903-907). New York: McGraw-Hill Medical.

12. Questions?