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Gas Gangrene Workup

  • Author: Hoi Ho, MD; Chief Editor: Burke A Cunha, MD  more...
 
Updated: Nov 05, 2015
 

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.[22]

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.

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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. See the images below.

Gas feathering in the arm soft tissue of a patient Gas feathering in the arm soft tissue of a patient with gas gangrene.
Extension of gas gangrene to the chest wall despit Extension 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 .[23]

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.[24]

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.[25]

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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.

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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,[26] others question bedside biopsy for its practical application and potential delay of appropriate surgical exploration in the operating room.[27]

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.[27]

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).

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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.

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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 Institute, American College of Physicians, American Society for Microbiology, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Coauthor(s)

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

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, AMDA - The Society for Post-Acute and Long-Term Care Medicine, Society of Teachers of Family Medicine, Texas Medical Association

Disclosure: Nothing to disclose.

Juan B Figueroa-Casas, MD Associate Professor, Division of Pulmonary and Critical Care Medicine, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine

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, Texas Medical Association, Congress of Neurological Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

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

Disclosure: Received royalty from Baxter International for other.

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, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Additional Contributors

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

Pranatharthi Haran Chandrasekar, MBBS, MD is a member of the following medical societies: American College of Physicians, American Society for Microbiology, International Immunocompromised Host Society, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference 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.

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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.
 
 
 
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