Gas Gangrene Clinical Presentation

  • Author: Hoi Ho, MD; Chief Editor: Burke A Cunha, MD   more...
 
Updated: Aug 16, 2011
 

History

The history in patients with gas gangrene depends on the precipitating factors of the infection. Most patients with posttraumatic gas gangrene have sustained serious injury to the skin or soft tissues or have experienced open fractures. Patients with postoperative gas gangrene have frequently undergone recent surgery of the GI or biliary tract. In contrast, the history is usually unremarkable in patients with occult malignancy–associated spontaneous gas gangrene.

  • A sudden onset of pain is usually the first symptom of gas gangrene. The pain gradually worsens but spreads only as the underlying infection spreads.
  • Some patients report a feeling of heaviness in the affected extremity.
  • A low-grade fever and apathetic mental status may develop.
Next

Physical

  • Local swelling and a serosanguineous exudate appear soon after the onset of pain.
    • The skin characteristically turns to a bronze color, then progresses to a blue-black color with skin blebs and hemorrhagic bullae.
    • Within hours, the entire region may become markedly edematous.
    • The wound may be nonodorous or may have a sweet mousy odor.
    • Crepitus follows gas production; at times, crepitus may not be detected with palpation owing to brawny edema.
    • Pain and tenderness to palpation disproportionate to wound appearance are common findings.
  • Tachycardia disproportionate to body temperature is common, and the patient may report a feeling of impending doom.
  • Late signs of gas gangrene include hypotension, renal failure, and a paradoxical heightening of mental acuity.

In summary, the typical signs and symptoms of gas gangrene include severe pain and tenderness, local swelling to massive edema, skin discoloration with hemorrhagic blebs and bullae, nonodorous or sweet odor, crepitus, fever, relative tachycardia, and altered mental status.

Previous
Next

Causes

Gas gangrene can be classified as posttraumatic, postoperative, or spontaneous.

  • Posttraumatic gas gangrene accounts for 60% of all gas gangrene cases.
    • Most of these cases involve automobile collisions.
    • Other complications of trauma arise from crush injuries, compound fractures, gunshot wounds, thermal or electrical burns, and frostbite.
    • Farm or industrial injuries contaminated with soil are especially prone to developing gas gangrene.
    • Intramuscular or subcutaneous injections with insulin, epinephrine, quinine, heroin or cocaine are rare antecedent events leading to gas gangrene.A patient developed gas gangrene after injecting cA patient developed gas gangrene after injecting cocaine. Clostridium septicum was isolated in both blood and wound cultures.
  • Postoperative clostridial infections follow cases of colon resection; ruptured appendix; bowel perforation; and biliary or other GI surgery, including laparoscopic cholecystectomy and colonoscopy. It has also been reported following liposuction procedures.[17] Septic back-street abortions are the main cause of uterine gas gangrene.
  • Spontaneous gas gangrene without external wound or injury occurs frequently in patients who have serious underlying conditions.
    • Colorectal adenocarcinoma is the most prevalent risk factor in this group. Hematologic malignancy is also a major premorbid condition.
    • In children, neutropenia, either induced by chemotherapy or cyclic in nature, represents the single most important risk factor for spontaneous C septicum infections.
    • The remaining cases are associated with diabetes or neutropenic colitis. In many cases, no predisposing condition can be found.
    • Although C perfringens and C septicum infections are commonly reported, C septicum infection predominates. Patients with C septicum infections have overt or occult malignancies approximately 5 times more often than patients with other clostridial infections. In a large series of nontraumatic C septicum myonecrosis, malignant tumors were identified in 92% of patients; of these, 58% had colonic adenocarcinomas.[12, 19]
Previous
Proceed to Differential Diagnoses
 
 
Contributor Information and Disclosures
Author

Hoi Ho, MD  Associate Dean for Faculty Affairs and Development, Professor, Department of Internal Medicine, Director, Center for Advanced Teaching and Assessment in Clinical Simulation (ATACS), Paul L Foster School of Medicine, Texas Tech University Health Sciences Center; Consulting Physician, University Medical Center

Hoi Ho, MD is a member of the following medical societies: Alpha Omega Alpha, American Association for the Advancement of Science, American College of Forensic Examiners, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Coauthor(s)

Juan B Figueroa-Casas, MD  Associate Professor, Division of Pulmonary and Critical Care Medicine, Texas Tech University Health Sciences Center at El Paso

Disclosure: Nothing to disclose.

David G Maxfield  Texas Tech University Health Sciences Center, Paul L Foster School of Medicine

David G Maxfield, is a member of the following medical societies: American College of Physicians, Congress of Neurological Surgeons, and Texas Medical Association

Disclosure: Nothing to disclose.

Lorenzo B Aragon, MD  Associate Professor, Department of Family Medicine, Paul L Foster Texas Tech University Health Sciences Center; Medical Director, Ambrosio Guillen Texas State Veterans Home

Lorenzo B Aragon, MD is a member of the following medical societies: American Academy of Family Physicians, American Medical Directors Association, Society of Teachers of Family Medicine, and Texas Medical Association

Disclosure: Nothing to disclose.

Enes Kanlic, MD  Professor, Department of Orthopedic Surgery, Texas Tech University Health Science Center

Disclosure: Stryker Honoraria Speaking and teaching

Specialty Editor Board

Pranatharthi Haran Chandrasekar, MBBS, MD  Professor, Department of Internal Medicine, Director of Infectious Disease Fellowship, Harper Hospital, Wayne State University School of Medicine

Pranatharthi Haran Chandrasekar, MBBS, MD is a member of the following medical societies: American College of Physicians and Infectious Diseases Society of America

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

Burke A Cunha, MD  Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital

Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous coauthors Jeffrey P Nelson, MD; Miguel Angel Pena-Ruiz, MD; and Karl C Bentley, MS, to the development and writing of this article.

References

  1. Chapnick EK, Abter EI. Necrotizing soft-tissue infections. Infect Dis Clin North Am. Dec 1996;10(4):835-55. [Medline].

  2. Gawande A. Casualties of war--military care for the wounded from Iraq and Afghanistan. N Engl J Med. Dec 9 2004;351(24):2471-5. [Medline].

  3. Murray CK, Hsu JR, Solomkin JS, Keeling JJ, Andersen RC, Ficke JR. Prevention and management of infections associated with combat-related extremity injuries. J Trauma. Mar 2008;64(3 Suppl):S239-51. [Medline].

  4. U.S. casualty status. Department of Defense, 2004. Available at http://www.defenselink.mil/news/casualty.pdf.

  5. Wang Y, Hao P, Lu B, Yu H, Huang W, Hou H, et al. Causes of infection after earthquake, China, 2008. Emerg Infect Dis. Jun 2010;16(6):974-5. [Medline]. [Full Text].

  6. De A, Varaiya A, Mathur M, Bhesania A. Bacteriological studies of gas gangrene and related infections. Indian J Med Microbiol. Jul-Sep 2003;21(3):202-4. [Medline]. [Full Text].

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

  8. Nichols RL, Smith JW. Anaerobes from a surgical perspective. Clin Infect Dis. May 1994;18 Suppl 4:S280-6. [Medline].

  9. Knapp O, Maier E, Mkaddem SB, Benz R, Bens M, Chenal A, et al. Clostridium septicum alpha-toxin forms pores and induces rapid cell necrosis. Toxicon. Jan 2010;55(1):61-72. [Medline].

  10. Oda M, Kihara A, Yoshioka H, Saito Y, Watanabe N, Uoo K. Effect of erythromycin on biological activities induced by clostridium perfringens alpha-toxin. J Pharmacol Exp Ther. Dec 2008;327(3):934-40. [Medline].

  11. Ohtani K, Hirakawa H, Tashiro K, Yoshizawa S, Kuhara S, Shimizu T. Identification of a two-component VirR/VirS regulon in Clostridium perfringens. Anaerobe. Jun 2010;16(3):258-64. [Medline].

  12. Stevens DL, Musher DM, Watson DA, et al. Spontaneous, nontraumatic gangrene due to Clostridium septicum. Rev Infect Dis. Mar-Apr 1990;12(2):286-96. [Medline].

  13. Brown PW, Kinman PB. Gas gangrene in a metropolitan community. J Bone Joint Surg [Am]. Oct 1974;56(7):1445-51. [Medline].

  14. Barnham M, Weightman N. Clostridium septicum infection and hemolytic uremic syndrome. Emerg Infect Dis. Apr-Jun 1998;4(2):321-4. [Medline]. [Full Text].

  15. Fischer M, Bhatnagar J, Guarner J, Reagan S, Hacker JK, Van Meter SH, et al. Fatal toxic shock syndrome associated with Clostridium sordellii after medical abortion. N Engl J Med. Dec 1 2005;353(22):2352-60. [Medline].

  16. McGuigan CC, Penrice GM, Gruer L, Ahmed S, Goldberg D, Black M. Lethal outbreak of infection with Clostridium novyi type A and other spore-forming organisms in Scottish injecting drug users. J Med Microbiol. Nov 2002;51(11):971-7. [Medline].

  17. Lehnhardt M, Homann HH, Daigeler A, Hauser J, Palka P, Steinau HU. Major and lethal complications of liposuction: a review of 72 cases in Germany between 1998 and 2002. Plast Reconstr Surg. Jun 2008;121(6):396e-403e. [Medline].

  18. Stevens DL, Bisno AL, Chambers HF, Everett ED, Dellinger P, Goldstein EJ. Practice guidelines for the diagnosis and management of skin and soft-tissue infections. Clin Infect Dis. Nov 15 2005;41(10):1373-406. [Medline].

  19. 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].

  20. 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].

  21. Zacharias N, Velmahos GC, Salama A, Alam HB, de Moya M, King DR. Diagnosis of necrotizing soft tissue infections by computed tomography. Arch Surg. May 2010;145(5):452-5. [Medline].

  22. Hopkins KL, Li KC, Bergman G. Gadolinium-DTPA-enhanced magnetic resonance imaging of musculoskeletal infectious processes. Skeletal Radiol. Jul 1995;24(5):325-30. [Medline].

  23. Butcher CH, Dooley RW, Levitov AB. Detection of subcutaneous and intramuscular air with sonography: a sensitive and specific modality. J Ultrasound Med. Jun 2011;30(6):791-5. [Medline].

  24. Majeski J, Majeski E. Necrotizing fasciitis: improved survival with early recognition by tissue biopsy and aggressive surgical treatment. South Med J. Nov 1997;90(11):1065-8. [Medline].

  25. Ustin JS, Malangoni MA. Necrotizing soft tissue infections. Crit Care Med. Apr 28 2011;[Medline].

  26. Stevens DL, Maier KA, Laine BM, Mitten JE. Comparison of clindamycin, rifampin, tetracycline, metronidazole, and penicillin for efficacy in prevention of experimental gas gangrene due to Clostridium perfringens. J Infect Dis. Feb 1987;155(2):220-8. [Medline].

  27. Aldridge KE, Ashcraft D, Cambre K, Pierson CL, Jenkins SG, Rosenblatt JE. Multicenter survey of the changing in vitro antimicrobial susceptibilities of clinical isolates of Bacteroides fragilis group, Prevotella, Fusobacterium, Porphyromonas, and Peptostreptococcus species. Antimicrob Agents Chemother. Apr 2001;45(4):1238-43. [Medline].

  28. Khanna N. Clindamycin-resistant Clostridium perfringens cellulitis. J Tissue Viability. Aug 2008;17(3):95-7. [Medline].

  29. Bernard GR, Vincent JL, Laterre PF, LaRosa SP, Dhainaut JF, Lopez-Rodriguez A. Efficacy and safety of recombinant human activated protein C for severe sepsis. N Engl J Med. Mar 8 2001;344(10):699-709. [Medline].

  30. [Best Evidence] Abraham E, Laterre PF, Garg R, Levy H, Talwar D, Trzaskoma BL. Drotrecogin alfa (activated) for adults with severe sepsis and a low risk of death. N Engl J Med. Sep 29 2005;353(13):1332-41. [Medline].

  31. Stevens DL, Bryant AE, Adams K, Mader JT. Evaluation of therapy with hyperbaric oxygen for experimental infection with Clostridium perfringens. Clin Infect Dis. Aug 1993;17(2):231-7. [Medline].

  32. Brown DR, Davis NL, Lepawsky M, et al. A multicenter review of the treatment of major truncal necrotizing infections with and without hyperbaric oxygen therapy. Am J Surg. May 1994;167(5):485-9. [Medline].

  33. George ME, Rueth NM, Skarda DE, Chipman JG, Quickel RR, Beilman GJ. Hyperbaric oxygen does not improve outcome in patients with necrotizing soft tissue infection. Surg Infect (Larchmt). Feb 2009;10(1):21-8. [Medline].

  34. Tibbles PM, Edelsberg JS. Hyperbaric-oxygen therapy. N Engl J Med. Jun 20 1996;334(25):1642-8. [Medline].

  35. Stevens DL, Troyer BE, Merrick DT, et al. Lethal effects and cardiovascular effects of purified alpha- and theta- toxins from Clostridium perfringens. J Infect Dis. Feb 1988;157(2):272-9. [Medline].

 
Previous
Next
 
A patient developed gas gangrene after injecting cocaine. Clostridium septicum was isolated in both blood and wound cultures.
Gas feathering in the arm soft tissue of a patient with gas gangrene.
Extension of gas gangrene to the chest wall despite initial debridement.
 
 
 
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.