A 68-year-old man with a history of hypertension and chronic obstructive pulmonary disease (COPD) presented to the emergency department with right hip pain and fever of 4 days’ duration. He was unable to bear weight on the right lower extremity and there was limited range of motion of the right hip secondary to pain. Vital signs were blood pressure, 136/85 mm Hg; pulse, 129 beats/min; temperature, 38°C (100.4°F); respiratory rate, 23/min; and oxygen saturation, 96% on room air.
The patient’s medications were fluticasone propionate/salmeterol, 250/50 µg, inhalation powder, twice daily; tiotropium bromide, 18 µg, inhalation powder, once daily; hydrochlorothiazide, 25 mg once daily; and prednisone, 5 mg daily. He had been hospitalized frequently during the past year for COPD exacerbations and multiple tapered-dose regimens of prednisone had been prescribed. The most recent course had been initiated 5 weeks before his current presentation and he had been taking the 5-mg daily dose for the past week.
Physical examination revealed an obese male in mild distress and diaphoresis. Abdominal examination revealed a soft and obese abdomen, normoactive bowel sounds, and no tenderness to palpation. Examination of the right hip found limited passive and active range of motion in all directions secondary to pain. Hip swelling and erythema were not present. Laboratory testing was significant for a white blood cell count of 18.5 x 103/µL, with 11% bands; erythrocyte sedimentation rate of 105 mm/h; and C-reactive protein level of 56 mg/dL. Blood and urine cultures were negative.
Figure 1. Sagittal image
A CT scan of the abdomen and pelvis revealed multiple foci of gas throughout the right femoral head (Figures 1 and 2, black arrows); gas extending along the right iliacus muscle (Figures 1 and 2, dashed white arrows) and an air-fluid level within the gallbladder lumen (Figure 1, solid white arrow) with peripheral gas in the wall (Figure 3, solid white arrow). Culture of the hip bone was positive for Clostridium perfringens and confirmed a diagnosis of emphysematous cholecystitis (EC) caused by C perfringens with spread to the right hip.
Figure 2. Coronal image
Figure 3. Coronal image
Treatment with IV piperacillin/tazobactam was started. He underwent emergent right hip debridement and subsequent laparoscopic cholecystectomy. When cultures from the hip bone returned positive for C perfringens, antibiotic treatment was switched to IV clindamycin and continued for a total of 6 weeks. Gallbladder pathology was consistent with gangrenous cholecystitis and showed evidence of rod-shaped organisms (Figure 4). Gram stain of gallbladder tissue revealed boxcar–shaped, gram-positive rods. Four surgical debridements of the right hip were required during a 2-week period. Repeated hip bone cultures obtained 1 month after diagnosis were negative for infection. He was discharged after 37 days to a rehabilitation facility.
The patient’s ongoing use of prednisone to treat COPD exacerbations had most likely compromised his immunity, which, in turn, increased his risk for infection with gas-forming organisms and led to a blunted pro-inflammatory response.
Although their clinical efficacy is unclear and they may cause serious adverse effects, systemic glucocorticoids are a standard treatment for patients hospitalized with exacerbations of COPD.1 Use of these agents leads to early modest improvments in spirometric parameters and marginal reductions in length of hospital stay.1 Resarch has found that a 2-week course of oral prednisolone is as effective as longer courses for exacerbations.1