The American Journal of Forensic Medicine and Pathology

22(2):177179, 2001.

2001 Lippincott Williams & Wilkins, Inc., Philadelphia

Acute Necrotizing Bacterial Tonsillitis

With Clostridium perfringens
John E. Gerber, M.D.

Clostridia species are gram-positive, anaerobic,

spore-forming bacilli with a wide distribution in
nature. These bacteria can cause disease by invading tissues and can arise from exogenous or endogenous sources or from the secretion of toxins by
the bacteria. Clostridium perfringens causes food
poisoning but is also frequently implicated in postoperative infections, especially meningitis, subdural
empyema, and neonatal necrotizing enterocolitis.
Whether from food poisoning or postoperative infection, C. perfringens causes acute illness with severe pain and the rapid development of hypotension
and shock (1,2).
This article presents a case study of a 9-month old
infant with acute necrotizing tonsillitis caused by C.
perfringens. Such a case has not been previously reported in the literature. Acute tonsillitis due to C.
perfringens is reportedly rare but may be more common if the oropharyngeal tissues in the neonate and
infant 1 year of age or less are routinely sampled.

Bacterial infection with Clostridium perfringens in children less than 2 years of age is frequently associated
with meningitis, necrotizing gastrointestinal infection,
and postoperative infections. However, a review of the
literature reveals no reports of these bacteria infecting
the tonsils. A 9-month old black female was found unresponsive at the baby-sitters and was rushed to the hospital. Shortly after admission to the emergency department death was pronounced. An autopsy performed on
this otherwise healthy infant revealed shock and acute
necrotizing bacterial tonsillitis. The initial report of this
infants death was questionable sudden infant death syndrome and questionable smothering. Postmortem cerebrospinal fluid, blood, and lung cultures grew pure
colonies of C. perfringens. The necrotizing tonsil revealed no significant gross lesions. Microscopically,
large numbers of gram-positive rods were easily recognized and were compatible with C. perfringens. Because
the oropharynx is a common portal of entry for infectious agents, it is essential to sample tissues of
Waldeyers ring and especially the tonsils to find infectious diseases that may become systemic.
Key Words: Bacterial tonsillitisClostridium perfringensSudden infant death syndrome.

CASE REPORT
KG was a 9-month old infant who had a pattern
of sleeping through the night. She had up-to-date
immunizations, was eating and drinking normally,
and was developmentally on target. The child had
no history of any illnesses, including vomiting, diarrhea, bloody stools, or respiratory illness.
KGs mother was scheduled to work two shifts
and took KG to her sister for care during this time.
She left KG at this home at 07:30 on the day in
question and returned 16 hours later.
KGs mother entered the home and found her sister asleep on a sofa, with KG between her sister
and the back of the sofa. The mother saw that the
child was blue and unresponsive and immediately
called 911. Emergency medical technicians found
the child pulseless and in asystole; however, with
resuscitation a pulse was regained.

Manuscript received March 22, 2000; accepted August 21,

2000.
From Forensic Medical, Metropolitan Davidson County,
Nashville, Tennessee, U.S.A.
Presented at the National Association of Medical Examiners,
Minneapolis, Minnesota, October 16, 1999.
Address correspondence to John E. Gerber, M.D., Forensic
Medical, 84 Hermitage Avenue, Nashville, TN 37210, U.S.A.

177

178

J. E. GERBER

KG was taken to Vanderbilt University Childrens Hospital, where her temperature was 95.6 F.
She was admitted and, despite optimal intensive
care, was pronounced dead about 18 hours after
911 was dialed.
Following the death of KG, a pediatrician at Vanderbilt Medical Center called the Medical Examiners office and notified the staff of a death that
was presumed to be caused by positional asphyxia.
Postmortem Examination
Postmortem examination revealed marked plethora with mottling of the skin. There was also
anasarca. The well-developed 9-month old had no
congenital anomalies and no external or internal
trauma. In addition, there were no petechial hemorrhages. However, internally there were bilateral
pleural effusions of port wine liquid with 100 cc in
each pleural cavity as well as 275 cc of similar fluid
in the peritoneal cavity. There was a gray duskiness
to the maroon appearance of all the organs. In addition, there was generalized lymphadenopathy.
Pink liquid was in the small and large intestine, and
reddish mucus was in the rectum. There was also
marked cerebral edema, with a brain weight of 810
g (normal, 750 g). Microbiologic postmortem cultures of blood, cerebrospinal fluid, and lung all
grew pure colonies of C. perfringens bacteria.
Microscopically there was fulminant pulmonary
edema as well as an exudate of red cells into the
alveolar spaces. A minimal inflammatory infiltrate
was also present. A section of tonsil revealed a

necrotizing process with destruction of tonsillar tissue and many rod-shaped structures in the parenchyma. Red cells, neutrophils, and mononuclear inflammatory cells were also present (Fig. 1). A Gram
stain revealed innumerable gram-positive rods, consistent with clostridial organisms (Fig. 2).
DISCUSSION
Clostridial bacterial infections or gas gangrene
complications are well known as complications from
trauma or surgical procedures. They have been associated with casualties of war, motor vehicle accidents, and industrial trauma and in association with
neurosurgery, abdominal surgery, or intravenous
drug abuse. However, nontraumatic clostridial infection is less commonly associated with specific
underlying disease processes, such as gastrointestinal and hematologic malignancies, peripheral vascular diseases, and diabetes mellitus, as well as immunodeficiency diseases (3).
A variety of toxins are released from clostridial
species. At least 17 toxins are produced from C. perfringens, the most important of which is an alpha
toxin, a lecithinase called phospholipase C, which
causes the following: lysis of cell membranes, acute
renal failure, and disseminated intravascular coagulation. Furthermore, a hyaluronidase called muroxin
is synthesized and directly acts on connective tissue
to facilitate the spread of infection (1).
Bacterial infection with C. perfringens in children less than 2 years is frequently associated with

FIG. 1. Low-power (10)

of tonsil with acute necrotizing process.

Am J Forensic Med Pathol, Vol. 22, No. 2, June 2001

ACUTE NECROTIZING BACTERIAL TONSILLITIS

179

FIG. 2. High-power (40)

of tonsil with neutrophils
and rod-shaped bacteria.

meningitis, necrotizing gastrointestinal infection,

and postoperative infections. However, a review of
the literature reveals no reports of these bacteria infecting the tonsils (4,5). This could possibly represent the fact that many general and forensic pathologists do not routinely sample tissue from
Waldeyers ring in the oropharynx, which includes
the tonsils. During the autopsy in the case under
discussion, the tonsils revealed no gross evidence
of necrosis. It was only because it is this pathologists routine procedure to sample Waldeyers ring
in all unexplained infant deaths that C. perfringens
was found.
C. perfringens can easily incubate in spoiled
food in a home setting, and a child could quite simply get access to such food or be fed food that is
beginning to spoil (6,7). This bacterium could effortlessly enter via the oropharynx, which is the
presumed route of entry in the case under discussion. Because the oropharynx is a common portal
of entry for infectious agents, it is essential to sample tissues of Waldeyers ring and especially the
tonsils to find infectious diseases that may become
systemic. It could also be another way to be more
specific in identifying childhood diseases that could
be either grouped in the sudden infant death syndrome or others of unknown etiology (8,9).
When a hospital or forensic pathologist is presented with a sudden unexpected infant death, rou-

tine sampling of lymphoid tissue from the oropharynx is highly recommended.

Acknowledgments: The author thanks Sherry Lewis
and Diane Eigsti-Gerber for reviewing and editing this
article.

REFERENCES
1. Fmigold SM, George WL. Miscellaneous clostridial infections. In Balows A, Hausler WJ, Lennette EH. Laboratory
diagnosis of infectious diseases, vol 1. New York: SpringerVerlag, 1988:193201.
2. Burke MP, Opeskin K. Nontraumatic clostridial myonecrosis. Am J Forensic Med Pathol 1999;20:15862.
3. Caya JG, Truant AL. Clostridial bacteremia in the non-infant pediatric population: a report of two cases and review
of the literature. Pediatr Infect Dis J 1999;18:2918.
4. Brook I. Clostridial infection in children. J Med Microbiol
1995;42:7882.
5. Ahtonen P, Lehtonen OP, Kero P, et al. Clostridium perfringens in stool, intra-partum antibiotics and gastrointestinal
signs in a neonatal intensive care unit. Acta Paediatr 1994;
83:38990.
6. Meer RR, Songer JG, Park DL. Human disease associated
with Clostridium perfringens enterotoxin. Rev Environ Contam Toxicol 1997;150:7594.
7. Lindsay JA. Clostridium perfringens type A enterotoxin
(CPE): more than just explosive diarrhea. Crit Rev Microbiol 1996;22:25777.
8. Murrell TJ, Murrell WG, Lindsay JA. Sudden infant death
syndrome (SIDS): are common bacterial toxins responsible,
and do they have a vaccine potential? Vaccine 1994;12:
3658.
9. Murrell WG, Stewart BJ, ONeil C, et al. Enterotoxigenic
bacteria in the sudden infant death syndrome. J Med Microbiol 1993;39:11427.

Am J Forensic Med Pathol, Vol. 22, No. 2, June 2001