Clostridium Sacroiliitis (Gas Gangrene) Following Sacroiliac Joint Injection – Case Report and Review of the Literature

Abstract

An 80-year-old woman presented with chronic lumbosacral pain since her laminectomy and instrumentation 10 years ago. Examination was consistent with left sacroiliitis, and the patient underwent an elective left sacroiliac joint injection. Two days following her procedure she fell and landed on her left hip and on the next day, she presented to the emergency room with acutely worsening left gluteal pain. On evaluation in the emergency department, she was found to be suffering from a fever, headache, nausea, vomiting, and dysuria. A computed tomography (CT) scan was performed and this showed extensive foci of gas throughout the posterior aspect of the left iliopsoas muscle, sacrum, and ileum surrounding the left sacroiliac joint. The patient underwent emergent surgical debridement. The microbiology report of blood culture revealed clostridium perfringens, while her pathology showed necrosis and acute inflammation of fibroadipose tissue, skeletal muscle, and fat. The patient’s hospital course resulted in multi-organ failure and the family elected for comfort care measures only. Unfortunately, she passed away 36 hours later. Septic arthritis is a potential catastrophic complication following intra-articular steroid therapy. The cause of the septic joint can be multifactorial but is likely caused by one of the following processes: direct inoculation of bacteria by the injection, hematogenous seeding of the percutaneous injection tract, or due to activation of a quiescent infection by the injected steroid. Clostridial spores are very resistant to standard aseptic skin preparations, including chlorhexidine and betadine solutions. The only effective methods to eliminate the spores is to heat them at a temperature greater than 100 degrees Celsius for 10 minutes or with use of a 10% potassium hydroxide (KOH) solution. We hypothesize that clostridium spores were present on the patient’s skin from previous stool soiling, and that these were introduced directly into the soft tissue by needle trauma. Rare complications such as this one are scarcely reported in the literature and thus it becomes difficult to adequately identify risk factors or to formulate strategies to improve practice management. Key words: Lower back pain, sacroiliitis, sacroiliac joint injection, clostridium perfringens, gas gangrene

Radiological Insights into Sacroiliitis: A Narrative Review

“…It typically presents unilaterally and often includes symptoms like a high or low-grade fever and intense, persistent pain originating from the affected sacroiliac joint [ 22 , 23 ]. Proposed factors that may increase the risk of pyogenic sacroiliitis encompass intravenous drug use, infections, especially those originating from skin tissues and infective endocarditis, as well as pregnancy [ 22 , 28 ]. Additionally, there have been documented cases of Clostridium sacroiliitis with gas gangrene occurring after SIJ injections [ 28 ].…”

Complications following diagnostic and therapeutic sacroiliac joint region injections in horses: A study describing clinicians' experiences

“…Clostridial myositis was described in a horse following diagnostic anaesthesia of the SI joint region 7 and has been documented in the human literature. 23 This complication was not mentioned by any of the clinicians participating in the current study.…”

A Rare Case of Septic Knee Arthritis Caused by Clostridium perfringens in a Patient With Colostomy

“…Proper surveillance of C. perfringens infections is vital as the endotoxin produced by the bacteria acts as a lecithinase and can lead to gas gangrene. While not commonly seen in association with joint infections, contiguous myonecrosis has been reported [ 14 ]. Associated osteomyelitis requiring joint resection was reported from another clostridial species [ 15 ].…”