Clostridial Gas Gangrene Clinical Presentation

  • Author: Don R Revis Jr, MD; Chief Editor: John Geibel, MD, DSc, MA   more...
 
Updated: Nov 28, 2011
 

History

Obtaining a thorough medical history is important. It helps the physician identify risk factors that may affect the progression of the disease and the prognosis.

  • Pain
    • Increasing pain after surgery or trauma
    • Out of proportion to physical findings
    • Sudden onset
    • May be severe
  • Prior trauma
  • Prior surgery, including abortions
  • Diabetes mellitus
  • Peripheral vascular disease
  • Alcoholism
  • Drug abuse
  • Advanced age
  • Chronic debilitating disease(s)
  • Immunocompromised state
    • Steroid use
    • Malnutrition
    • Malignancy
    • Acquired immunodeficiency syndrome (AIDS)
Next

Physical

Perform a thorough physical examination before focusing on the involved body part.

  • Vital signs - May indicate systemic toxicity and include no or low-grade fever, tachycardia (relative tachycardia), tachypnea, hypotension, or hypoxia
  • Edema bullae
  • Erythema with purplish black discoloration
  • Extreme tenderness
  • Brownish skin discoloration (bronzing, brawny) with bullae
  • Profuse, "dish-watery," serous drainage from ruptured bullae
  • Discharge - May have a peculiar, "mousy," sweet odor
  • Minimal crepitant bullae
  • Crepitant tissue - May extend well beyond any skin discoloration, edema, or bleb formation
  • Mental status - Paradoxically, may be depressed early during the disease course; sensorium then may clear as the disease progresses and the patient is near death
Previous
Next

Causes

The disease process must include tissue inoculation and a low oxygen tension environment. More than 50% of cases are preceded by trauma.[2, 3] Other cases occur spontaneously or in patients after operative procedures.

  • Trauma
    • Compound fractures
    • Foreign bodies
    • Frostbite
    • Thermal or electrical burns
    • Subcutaneous or intravenous injection of medications or illicit drugs
    • Pressure sores
    • Motor vehicle crashes
  • Postoperative
    • Gastrointestinal tract surgery
    • Genitourinary tract surgery
    • Abortion
    • Amputation
    • Tourniquets, casts, bandages, or dressings applied too tightly
  • Spontaneous
    • This also is known as nontraumatic, idiopathic, or metastatic gas gangrene.
    • It most often is mixed infection caused by C septicum, C perfringens, and C novyi. Several series report a mortality rate that approaches 100%.
    • The gastrointestinal tract is the source of organisms. The organisms escape the bowel by translocation, enter the bloodstream, and seed distant sites where they can cause gas gangrene. This process may also result in a more localized infection that involves the viscera or intra-abdominal compartment.
    • Approximately 80% of patients without trauma have an overt or occult malignancy. Of these, approximately 40% are hematologic malignancies and an additional 34% are colorectal.[4] Survival from this process should initiate a search for an occult malignancy if none has been documented previously in patients without trauma.
Previous
Proceed to Workup
 
 
Contributor Information and Disclosures
Author

Don R Revis Jr, MD  Consulting Staff, Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Florida College of Medicine

Don R Revis Jr, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Society for Aesthetic Plastic Surgery, and American Society of Plastic Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

Fred A Lopez, MD  Associate Professor and Vice Chair, Department of Medicine, Assistant Dean for Student Affairs, Louisiana State University School of Medicine

Fred A Lopez, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, Infectious Diseases Society of America, and Louisiana State Medical Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Charles V Sanders, MD  Edgar Hull Professor and Chairman, Department of Internal Medicine, Professor of Microbiology, Immunology and Parasitology, Louisiana State University School of Medicine at New Orleans; Medical Director, Medicine Hospital Center, Charity Hospital and Medical Center of Louisiana at New Orleans; Consulting Staff, Ochsner Medical Center

Charles V Sanders, MD is a member of the following medical societies: Alliance for the Prudent Use of Antibiotics, Alpha Omega Alpha, American Association for the Advancement of Science, American Association of University Professors, American Clinical and Climatological Association, American College of Physician Executives, American College of Physicians, American Federation for Medical Research, American Foundation for AIDS Research, American Geriatrics Society, American Lung Association, American Medical Association, American Society for Microbiology, American Thoracic Society, American Venereal Disease Association, Association for Professionals in Infection Control and Epidemiology, Association of American Medical Colleges, Association of American Physicians, Association of Professors of Medicine, Infectious Disease Society for Obstetrics and Gynecology, Infectious Diseases Society of America, Louisiana State Medical Society, Orleans Parish Medical Society, Royal Society of Medicine, Sigma Xi, Society of General Internal Medicine, Southeastern Clinical Club, Southern Medical Association, Southern Society for Clinical Investigation, and Southwestern Association of Clinical Microbiology

Disclosure: Baxter International and Johnson & Johnson Royalty Other

Eleftherios Mylonakis, MD  Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital

Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Chief Editor

John Geibel, MD, DSc, MA  Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director, Surgical Research, Department of Surgery, Yale-New Haven Hospital

John Geibel, MD, DSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, and Society for Surgery of the Alimentary Tract

Disclosure: AMGEN Royalty Consulting; ARdelyx Ownership interest Board membership

References

  1. Méndez MB, Goñi A, Ramirez W, Grau RR. Sugar inhibits the production of the toxins that trigger clostridial gas gangrene. Microb Pathog. Nov 4 2011;[Medline].

  2. Oncel S, Arsoy ES. Rapidly developing gas gangrene due to a simple puncture wound. Pediatr Emerg Care. Jun 2010;26(6):434-5. [Medline].

  3. Chen E, Deng L, Liu Z, Zhu X, Chen X, Tang H. Management of gas gangrene in Wenchuan earthquake victims. J Huazhong Univ Sci Technolog Med Sci. Feb 2011;31(1):83-7. [Medline].

  4. San Ildefonso A, Maruri I, Facal C, Casal E. Clostridium septicum infection associated with perforation of colon diverticulum. Rev Esp Enferm Dig. Jun 2002;94(6):361-6. [Medline].

  5. Burke MP, Opeskin K. Nontraumatic clostridial myonecrosis. Am J Forensic Med Pathol. Jun 1999;20(2):158-62. [Medline].

  6. Ellemor DM, Baird RN, Awad MM, Boyd RL, Rood JI, Emmins JJ. Use of genetically manipulated strains of Clostridium perfringens reveals that both alpha-toxin and theta-toxin are required for vascular leukostasis to occur in experimental gas gangrene. Infect Immun. Sep 1999;67(9):4902-7. [Medline].

  7. Feingold DS. Gangrenous and crepitant cellulitis. J Am Acad Dermatol. Mar 1982;6(3):289-99. [Medline].

  8. Hart GB, Lamb RC, Strauss MB. Gas gangrene. J Trauma. Nov 1983;23(11):991-1000. [Medline].

  9. Hatheway CL. Toxigenic clostridia. Clin Microbiol Rev. Jan 1990;3(1):66-98. [Medline].

  10. Hirn M. Hyperbaric oxygen in the treatment of gas gangrene and perineal necrotizing fasciitis. A clinical and experimental study. Eur J Surg Suppl. 1993;1-36. [Medline].

  11. Korhonen K, Klossner J, Hirn M, Niinikoski J. Management of clostridial gas gangrene and the role of hyperbaric oxygen. Ann Chir Gynaecol. 1999;88(2):139-42. [Medline].

  12. Larson CM, Bubrick MP, Jacobs DM, West MA. Malignancy, mortality, and medicosurgical management of Clostridium septicum infection. Surgery. Oct 1995;118(4):592-7; discussion 597-8. [Medline].

  13. McDonel JL. Clostridium perfringens toxins (type A, B, C, D, E). Pharmacol Ther. 1980;10(3):617-55. [Medline].

  14. Present DA, Meislin R, Shaffer B. Gas gangrene. A review. Orthop Rev. Apr 1990;19(4):333-41. [Medline].

  15. Rood JI, Cole ST. Molecular genetics and pathogenesis of Clostridium perfringens. Microbiol Rev. Dec 1991;55(4):621-48. [Medline].

  16. Samlaska CP, Maggio KL. Subcutaneous emphysema. Adv Dermatol. 1996;11:117-51; discussion 152. [Medline].

  17. Stephens MB. Gas gangrene: potential for hyperbaric oxygen therapy. Postgrad Med. Apr 1996;99(4):217-20, 224. [Medline].

  18. Stevens DL, Tweten RK, Awad MM, et al. Clostridial gas gangrene: evidence that alpha and theta toxins differentially modulate the immune response and induce acute tissue necrosis. J Infect Dis. Jul 1997;176(1):189-95. [Medline].

  19. Valentine EG. Nontraumatic gas gangrene. Ann Emerg Med. Jul 1997;30(1):109-11. [Medline].

  20. Weinstein L, Barza MA. Gas gangrene. N Engl J Med. Nov 22 1973;289(21):1129-31. [Medline].

 
Previous
Next
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.