Fulminant leukemoid reaction due to postpartum Clostridium sordellii infection
A 22 year old female presented in the emergency department with complaints of fatigue, malaise, dizziness, shortness of breath, and abdominal distension for the last 5 days. She had a full-term normal vaginal home delivery 10 days back and the baby expired 6 days after the birth. There was no history of fever, abdominal pain, or post partum hemorrhage.\nOn examination pulse was 110/min, blood pressure was 80/60 mmHg. Pallor, icterus, cyanosis, clubbing, lymphadenopathy were absent. Pitting edema was present in both lower limbs.\nRespiratory system revealed bilateral pleural effusion, evident by absent breath sounds, and stony dullness on the bilateral lower axillary area. Abdominal examination revealed ascites with no hepatosplenomegaly. CNS and CVS were normal. On gynecological examination Labia majora were edematous and vaginal mucosa was congested and friable. There was no evidence of bleeding or foul smelling lochia. On bimanual examination, uterus was tender, bilateral fornices were nonpalpable and nontender.\nOn laboratory examination Hb 11.6 gm/dL, hematocrit 35%, and total leukocyte count of 64,030/m3 with polymorph 83%, lymphocyte 4%, and promyelocyte 13%, ESR 58 mm, general blood picture was normocytic normochromic. CRP was >150 mg/L. Renal and Liver Function Test and blood sugar were normal. HIV and HbsAg were nonreactive. On ultrasound there was fluid collection in peritoneal cavity and mild hepatomegaly. On ascitic fluid examinations, total cell count were 3200/mm3 with 60% RBC, 37% lymphocyte, and 3% polymorphs. On Gram staining gram positive rods were present and culture was positive for clostridia; differentiation of clostridium species could not be done due to unavailability of laboratory facility for different clostridia subspecies. Ascitic fluid AFB staining was negative, pleural fluid was exudative in nature and culture was sterile for gram staining and AFB. Blood culture was negative. Urine culture showed E. coli.\nPatient was shifted in intensive care unit and administered fluid vasopressors, fresh frozen plasma, and intravenous antibiotic (piperacillin/tazobactam, gentamicin, and clindamycin). Patient gradually improved and her vitals became stable. Her TLC fall to 6200/mm3 gradually over 3 weeks. Patient improved clinically and was discharged.