Polymicrobial Emphysematous Hepatitis With Clindamycin-Resistant Clostridium Perfringens in a Patient With Pancreatic Cancer

Emphysematous hepatitis (EH) is a fulminant, gas-forming infection of the liver parenchyma, radiologically defined by diffuse intraparenchymal gas without abscess formation. Mortality exceeds 70%. A 61-year-old man with metastatic pancreatic adenocarcinoma and biliary stents presented with encephalopathy, hypotension, tachycardia, and lactic acidosis (14 mmol/L). CT revealed intraparenchymal hepatic gas within necrotic metastases, consistent with EH, with pneumoperitoneum. A chest radiograph demonstrated free subdiaphragmatic air. Percutaneous cholangiography confirmed intrahepatic duct narrowing, and postkissing stent deployment demonstrated restored ductal configuration. MRCP showed recurrent porta hepatis mass with intrahepatic biliary dilatation. Blood cultures grew <i>Clostridium perfringens</i> (resistant to clindamycin), <i>Escherichia coli</i>, and <i>Enterococcus faecium</i>. This polymicrobial profile is typical of EH in biliary obstruction, and rare clindamycin resistance in <i>Clostridium perfringens</i> has implications for empiric therapy. Broad-spectrum antibiotics were commenced. However, given presentation, polymicrobial sepsis, portal vein occlusion, and advanced malignancy, surgical options were not feasible. Care was transitioned to comfort measures, and the patient died the following day. This case highlights polymicrobial EH with <i>C. perfringens</i> clindamycin resistance. It underscores the importance of rapid recognition, empiric toxin-active therapy, and early goals-of-care discussions in patients with advanced malignancy.