Gas Gangrene Workup

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

Laboratory Studies

  • Rapidly developing hemolytic anemia with an increased lactate dehydrogenase (LDH) level is common in patients with gas gangrene.
  • Despite serious infection, white blood cell counts may not show leukocytosis. However, in patients with toxic shock syndrome due to C sordellii or C septicum, the CBC count may show hemoconcentration and extreme leukocytosis.
  • A Gram stain of the exudate or infected tissues reveals "box-car," large gram-positive bacilli without neutrophils. One study reported the usefulness and good sensitivity of Gram stain (86%) in the diagnosis of clostridial gas gangrene in survivors of Wenchuan earthquake.[20]
  • Less than 1% of blood cultures in patients with gas gangrene grow clostridial species.
  • The chemistry profile may show significant metabolic abnormalities (metabolic acidosis and renal failure) frequently associated with tissue injuries and hypotension.
Next

Imaging Studies

  • Radiography can help delineate the typical feathering pattern of gas in soft tissue; however, gas may not be present in patients with gas gangrene. Conversely, the simple presence of gas in soft tissue does not confirm the diagnosis of gas gangrene.Gas feathering in the arm soft tissue of a patientGas feathering in the arm soft tissue of a patient with gas gangrene. Extension of gas gangrene to the chest wall despitExtension of gas gangrene to the chest wall despite initial debridement.
  • CT scanning is also helpful, especially in abdominal cases of gas gangrene. A recent study with the new-generation CT scanners reported 100% sensitivity to detect necrotizing soft tissue infections; however, it excluded patients taken to surgery prior to CT scanning and did not explore surgically all clinically suspected cases .[21]
  • Studies on MRI to detect necrotizing soft tissue infection have reported lower sensitivity (80-90%) and limited specificity. In addition, MRI is time consuming and not always available.[22]
  • Ultrasound, although attractive as rapid bedside test, has not been well studied in this clinical scenario. In a cadaveric model of soft tissue gas, it showed excellent sensitivity in detecting gas and its localization.[23]
Previous
Next

Other Tests

  • Rapid detection of alpha-toxin or sialidases (ie, neuraminidases) in infected tissues through enzyme-linked immunosorbent assay (ELISA) is not widely available but represents a potential diagnostic tool. ELISA can provide results in as little as 2 hours when the test is applied to wound exudate, tissue samples, or serum.
  • Although not widely available for clinical practice, in vitro amplification of the alpha-toxin or DNA by polymerase chain reaction (PCR) has been used to isolate clostridial species.
Previous
Next

Procedures

  • Surgical exploration confirms the diagnosis of myonecrosis. Affected muscle appears pale and shows no contractile function when incised or electrically stimulated.
  • Under local anesthesia, bedside biopsy with immediate frozen section can be performed to provide early and accurate diagnosis of gas gangrene. Although advocated by some authors for early diagnosis of necrotizing fascitis,[24] others question bedside biopsy for its practical application and potential delay of appropriate surgical exploration in the operating room.[25]
  • Because adjunctive diagnostic studies are time consuming and have limited utility for the diagnosis of necrotizing soft tissue infections, it is important to emphasize the invaluable role of the direct examination of the involved tissues in the operating room in making the diagnosis.
  • Due to the potentially high mortality and morbidity associated with delays in treatment, the threshold for operative exploration should be very low if the diagnosis is under consideration.[25]
  • Patients with gas gangrene frequently develop massive hemolysis, shock, acute respiratory distress syndrome (ARDS), and renal failure, which often require invasive procedures (eg, right-sided heart catheterization, mechanical ventilation, hemodialysis).
Previous
Next

Histologic Findings

Histopathologic findings in gas gangrene consist of widespread myonecrosis, destruction of other connective tissues, and a paucity of neutrophils in the infected area. Leukocyte aggregates are found in the border regions.

Previous
Proceed to Treatment & Management
 
 
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.