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Massive haemolysis because of Clostridium perfringes liver abscess in a patient on peritoneal dialysis

A 65-year-old man with diabetes, ischaemic heart disease and renal failure, who was on continuous ambulatory peritoneal dialysis, presented with fever and blood stained peritoneal fluid (top). Biochemical screening, automated blood count and cross-match all failed because of gross haemolysis. A blood count and film showed complete absence of red cells, a white cell count of 25 · 10/l and a normal platelet count. Examination of peritoneal fluid showed no red cells. Bed-side monitoring showed a haemoglobin level of 6Æ2 g/dl (HaemoCue AB, Derbyshire, UK). The fever subsided with broad-spectrum antibiotics. Haemodialysis was used to remove metabolic wastes (bottom left, arrowhead) and hourly intermittent peritoneal dialysis (IPD) was used to remove haemoglobin (bottom left, arrow). Transfusion of group O unmatched blood was guided by HaemoCue, which resulted in a steady decrease in haemoglobinaemia and increase in haematocrit (top, arrows). Clostridium perfringes liver abscess was later confirmed (bottom right), but the patient died of sudden asystole on day 3. Massive haemolysis because of clostridial haemolysin is a rare occurrence since the advent of penicillin, and most patients die rapidly because of septic shock and renal shutdown. Our patient, already on dialysis, appeared relatively unaffected by the ‘toxins’ released by massive corpuscular rupture. It also appeared that haemoglobin solution was effective in oxygen delivery, at least in the short-term. Antibiotic treatment promptly stopped ongoing toxin release and haemolysis, and exchange transfusion was unlikely to be of additional benefit. However, haemodialysis appeared to be less effective than IPD for removing haemoglobin products in this clinical situation.