eMedicine Specialties > Infectious Diseases > Skin and Soft-Tissue Infections

Clostridial Gas Gangrene: Differential Diagnoses & Workup

Author: Don R Revis Jr, MD, Consulting Staff, Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Florida College of Medicine
Contributor Information and Disclosures

Updated: Jun 23, 2008

Differential Diagnoses

Other Problems to Be Considered

Anaerobic (nonclostridial) cellulitis and/or myositis
Bacterial synergistic gangrene
Nonclostridial necrotizing fasciitis
Nonclostridial infections involving muscle (Peptostreptococcus species, Streptococcus pyogenes, Staphylococcus aureus, Vibrio vulnificus)
Pyomyositis
Rhabdomyolysis
Synergistic necrotizing cellulitis

Workup

Laboratory Studies

  • The white blood cell count may be normal or elevated. Immature forms are usually increased.
  • Elevated liver function test results may indicate progressive hepatic dysfunction.
  • Elevated blood urea nitrogen and creatinine may indicate azotemia, renal insufficiency, or renal failure.
  • Myonecrosis may elevate serum aldolase, potassium, lactate dehydrogenase, and creatine phosphokinase levels.
  • Profound anemia may result from severe intravascular hemolysis.
  • Arterial blood gas determinations and chemistry panel analysis may reveal metabolic acidosis.
  • Disseminated intravascular coagulation may result from exotoxin release.
  • A Gram stain of the wound discharge reveals gram-positive rods and an absence of polymorphonuclear cells. Other organisms are also present in up to 75% of cases. This test is essential for rapid diagnosis.
  • An assay for sialidases (neuraminidase) produced by clostridia also may be performed on serum and wound discharge. These tests provide rapid (<2 h) confirmation of Gram stain results.

Imaging Studies

  • Radiographs reveal fine gas bubbles within the soft tissues, dissecting into the intramuscular fascial planes and muscles. Other necrotizing soft tissue infections produce abundant gas, in contrast to the paucity of gas of clostridial gas gangrene.
  • Intra-abdominal clostridial gas gangrene is evaluated most readily with CT scanning, which demonstrates extraluminal gas.

Other Tests

  • Blood and bullous fluid cultures reveal clostridia but take at least 48 hours to perform. They are not useful because the delay almost certainly results in death.

Histologic Findings

Histologic analysis reveals necrotic muscle, clostridia, and a minimal inflammatory infiltrate.

More on Clostridial Gas Gangrene

Overview: Clostridial Gas Gangrene
Differential Diagnoses & Workup: Clostridial Gas Gangrene
Treatment & Medication: Clostridial Gas Gangrene
Follow-up: Clostridial Gas Gangrene
References
[ CLOSE WINDOW ]

References

  1. 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].

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

  3. 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].

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

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

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

  7. 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].

  8. 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].

  9. 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].

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

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

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

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

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

  15. 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].

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

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

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

clostridial gas gangrene, Clostridium gas gangrene, clostridial myonecrosis, myonecrosis, gangrene, soft tissue infection, Clostridium, Clostridium perfringens, C perfringens, Clostridium welchii, C welchii, Clostridium novyi, C novyi, Clostridium septicum, C septicum, Clostridium histolyticum, C histolyticum, Clostridium bifermentans, C bifermentans, Clostridium fallax, C fallax, battlefield injury, war wound, clostridia, compound fracture, frost bite, frostbite, bed sores, bedsores, pressure sores, burns, burn injury

[ CLOSE WINDOW ]

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.

Medical Editor

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.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

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: Nothing to disclose.

CME Editor

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 Chairman, Professor, Department of Surgery, Section of Gastrointestinal Medicine and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of 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 Other; AstraZeneca Grant/research funds Other

RELATED EMEDICINE ARTICLES
 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
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.