Overview Infection with Clostridium septicum is only found in 1% of these cases and is typically related to trauma or cancer. While the presence of diffuse subcutaneous gas is an important clinical sign, air within the femoral vessels correlates with extensive soft tissue destruction. This process must be treated with wide excision of necrotic tissue and intravenous antibiotics. This article reviews the course of a patient without significant co-morbidities who developed C. septicum infection one week after stepping on a nail. This is important as C. septicum is one of a few Clostridial species that will cause myonecrosis and carries a higher mortality rate.
Gas Gangrene
Michael J Feldman, MD,1 Mark Prosciak, MD,1 Zahra Maleki, MD,2 and Stephen M Milner, MD1
Johns Hopkins Burn Center1 and Department of Pathology,2 Johns Hopkins University, Baltimore, Maryland.
Contact: Michael J Feldman, MD E-mail
This e-mail address is being protected from spambots. You need JavaScript enabled to view it
.
|
Citation: Feldman MJ, Prosciak M, Maleki Z, and Milner SM. Gas Gangrene. J Surg Radiol. 2010 Oct 1;1(2).
Received June 18, 2010. Accepted July 21, 2010. Epub August 5, 2010. Copyright: © 2010 Surgisphere Corporation. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. |
Contents - Introduction- Discussion - Disclosures - References |
Introduction
Gas gangrene is an infectious process due to the production of a toxin by a species of Clostridial bacteria. These toxins result in the destruction of soft tissue which creates gas within the subcutaneous plane.1,2 Patients with this disease are critically ill and require urgent excision of the necrotic tissue. While most cases are due to infection with Clostridium perfringens, we describe a patient who was infected with Clostridium septicum. A description of the case follows, with particular emphasis on radiologic findings that indicate extensive soft tissue destruction.Case Report
A 52 year-old male with a history of depression presented to the emergency department with severe pain in his right thigh. He recalled stepping on a nail prior to his arrival but was unable to recall his name, date, or current location. His family informed us that he had stepped on a nail one week before these events while he was walking outside. The patient had extracted the nail himself and had not sought medical care at the time. Further examination revealed crepitus overlying his right thigh. A CT scan of the lower extremity showed diffuse subcutaneous air throughout the thigh as well as air within the femoral vein (Figure 1). A diagnosis of gas gangrene was made.
Figure 1. Lower extremity CT on initial presentation showed extensive subcutaneous air in the right thigh (arrowheads) as well as air within the right femoral vein (arrow).
Initial laboratory values were as follows: WBC 2220/mm3, Hgb 12.6 g/dL, creatinine 1.4 mg/dL, albumin 1.6 g/dL and platelets 266 K/mm3.
Intraoperatively he was found to have extensive necrotic muscle in all thigh compartments, thrombosed vessels, and diffuse gas tracking along the entire femur. His leg was deemed non-salvageable and a right hip disarticulation was performed. He required full ventilatory and hemodynamic support postoperatively. The following day, further debridement of necrotic muscle was performed. He was subsequently able to be weaned from the vasopressors and extubated five days later. He was discharged to a subacute care facility after one month. The hip disarticulation site required a skin graft for closure two months after admission. While his skin graft healed in several weeks, he is still undergoing therapy in a rehabilitation facility three months following his arrival to the emergency room. The long-term treatment plan includes fitting for prosthesis.
Cultures of the wound grew out Clostridium septicum, which has been responsible for 1% of cases of gas gangrene.3 Histology was consistent with extensive muscle necrosis and an invasive gram positive bacilli infection (Figure 2).
Figure 2. Section of muscle showing numerous gram positive bacilli surrounding the disintegrating muscle bundles (Brown & HOPPS stain, magnification X600).
Discussion
These cases are typically associated with trauma or cancer.3 This particular species of Clostridium causes tissue necrosis by formation of toxins that disrupt the cell membrane.2 Identifying the type of Clostridial bacterium helps predict mortality as rates for C. septicum approach 63% in adults versus 11% in those infected with C. perfringens.4 There is no clinical difference between an infection with these two Clostridial species. Most patients present with nonspecific findings such as fever, leukocytosis, and pain.4 A number of cases of C. septicum infection have been reported in patients with hepatic metastases (gastrointestinal primary),2 as fasciitis of the foot in a patient with adenocarcinoma of the colon,3 spontaneous aortic dissection from C. septicum aortitis,5 as well as a splenic abscess in a diabetic patient.5
Infection with C. septicum carries a high mortality rate especially if not recognized early within its course.6 The mortality is even greater with involvement of the femoral vessels. This process was described by Assadian et al. (2004), with intravenous drug abusers and C. perfringens infection. Involvement of the femoral vessels implies extensive infection beyond the expected myonecrosis typically seen with gas gangrene.7 Treatment options include a combination of wide surgical excision of the infected tissue and systemic antibiotics.
These infections most likely present with pain out of proportion to the examination and altered mental status. The presence of crepitus can be a late finding so that absence of this sign should not sway one from pursuing this diagnosis.
Disclosures
The authors have no disclosures or conflicts of interest related to this manuscript.
References
- Martí de Gracia M, Gutiérrez FG, Martínez M, Dueñas VP. Subcutaneous emphysema: diagnostic clue in the emergency room. Emerg Radiol. 2009 Sep; 16(5):343-8. Epub 2009 Jan 30. CrossRef PubMed
- Saleh N, Sohail MR, Hashmey RH, Al Kaabi M. Clostridium septicum infection of hepatic metastases following alcohol injection: a case report. Cases J. 2009 Dec 31; 2:9408. CrossRef PubMed
- Shade V, Roukis TS, Haque MM. Clostridium septicum necrotizing fasciitis of the forefoot secondary to adenocarcinoma of the colon: case report and review of the literature. J Foot Ankle Surg. 2010 Mar-Apr; 49(2):159.e1-8.
- Myers G, Ngoi SS, Cennerazzo W, Harris L, DeCosse JJ. Clostridial septicemia in an urban hospital. Surg Gynecol Obstet. 1992; 174: 291- 296. PubMed
- Yang Z, Reilly SD. Clostridium septicum aortitis causing aortic dissection in a 22-year-old man. Tex Heart Inst J. 2009; 36(4):334-6. PubMed
- Imamura M, Shimomura K, Watanabe A, Negishi M, Akuzawa M, Takahashi M, Proks P, Shimomura Y. Sepsis and gas-forming splenic abscess by Clostridium septicum in a patient with type 2 diabetes. J Diabetes Complications. 2009 Mar 12: 1-3.
- Assadian O, Assadian A, Senekowitsch C, Markistathis A, Hagmüller G. Gas gangrene due to Clostridium perfringens in two injecting drug users in Vienna, Austria. Wien Klin Wochenschr. 2004 Apr 30; 116(7-8):264-7. CrossRef PubMed
| < Prev | Next > |
|---|
