Hemipelvectomy for Clostridium septicum necrotizing soft tissue infection with extensive pelvic organ destruction: a...

Clostridium septicum is a highly virulent, gas-forming, anaerobic Gram-positive bacillus known to cause rapidly progressive necrotizing soft tissue infection that is often associated with gastrointestinal malignancy or immunocompromised states. Mortality remains extremely high, with many patients dying within the first 24 h of onset. Although aggressive surgical debridement is the cornerstone of treatment, cases requiring hemipelvectomy are exceedingly rare, and postoperative management of exposed pelvic organs has not been described in the relevant literature.

A 73-year-old woman with ascending colon cancer developed sudden severe left leg pain and paralysis, and computed tomography revealed extensive gas from the left thigh to the pelvis. Upon arrival at our tertiary center, she was in septic shock with gas rapidly progressing to the high retroperitoneum. Emergent hip disarticulation was performed, and Clostridium septicum was isolated. Despite early source control, ongoing toxin-mediated necrosis extending beyond the limits of limb amputation necessitated left hemipelvectomy on Day 4. Following radical debridement, postoperative management became extremely challenging because multiple pelvic organs were exposed, with necrosis of the bladder and perforation of ureter, rectum and vaginal wall. Serial debridement and staged repairs were required over a prolonged course. Granulation of the pelvic wound gradually progressed, allowing split-thickness skin grafting on Day 88, after which wound healing stabilized. She was ultimately stable enough to return to the referring hospital on Day 187.

This is an extremely rare case of Clostridium septicum necrotizing soft tissue infection requiring hemipelvectomy, demonstrating that aggressive and timely radical debridement can be life-saving, even in cases with massive pelvic involvement. Furthermore, we present the first documented example of stepwise management of exposed pelvic organs after hemipelvectomy performed for necrotizing soft tissue infection, providing valuable insights for clinicians facing similar catastrophic presentations.