eMedicine Specialties > Emergency Medicine > Infectious Diseases

Gas Gangrene: Differential Diagnoses & Workup

Author: Anil Shukla, MD, Staff Physician, Harvard Affiliated Emergency Medicine Residency, Beth Israel Deaconess Medical Center
Coauthor(s): Carlo L Rosen, MD, Assistant Professor of Medicine, Harvard Medical School; Program Director, Department of Emergency Medicine, Beth Israel Deaconess Medical Center/ Harvard Affiliated Emergency Medicine Residency program; Jason K Wong, MD, Staff Physician, Department of Emergency Medicine, Jefferson Regional Medical Center
Contributor Information and Disclosures

Updated: Jun 22, 2009

Differential Diagnoses

CBRNE - Anthrax Infection
Pyomyositis (muscle abscess)
Cellulitis
Rhabdomyolysis
Deep Venous Thrombosis and Thrombophlebitis
Streptococcal (pyogenes) myositis
necrotizing cellulitis
Vibrio Vulnificus Infection
Necrotizing Fasciitis

Other Problems to Be Considered

Other causes of necrotizing myositis (group A streptococci, polymicrobial aerobic-anaerobic flora, and nonclostridial anaerobes)1,2,3
Cutaneous anthrax
Vaccinia vaccination
Acute gout
Septic arthritis
Familial Mediterranean fever
Fixed drug reaction
Pyoderma gangrenosa
Sweet syndrome
Wells syndrome
Carcinoma erysipeloids
Pyomyositis
Water-borne skin infections (Vibrio vulnificus, Aeromonas hydrophila, Mycobacterium marinum)
Other causes of soft tissue gas (eg, pneumomediastinum, pneumothorax, fractured larynx, fractured trachea)

Workup

Laboratory Studies

Lab studies include the following:1,2,3,13

  • Gram stain and culture of bullae fluid: Clostridia species are known to be large, gram-positive rods (boxcar appearance); however, the organisms may appear gram variable in Gram stains from tissue samples. The presence of gram-positive or gram variable rods with few white blood cells is indicative of clostridial etiology, whereas the presence of many white cells is more suggestive of a mixed bacterial infection. Although this information can be helpful, simple superficial wound swabs should not be obtained. Microorganisms that colonize the skin surface often do not contribute to the underlying infection.
  • Complete blood count: CBC may reveal anemia, thrombocytopenia, and evidence of intravascular hemolysis on smear. 
  • Electrolyte level: Hyperkalemia can result from cell breakdown. Hypocalcemia may result from subcutaneous fat necrosis.
  • Renal panel: Kidney dysfunction may occur secondary to hypotension, hemoglobinuria, and myoglobinuria or direct toxin effect.
  • Coagulation panel: Coagulopathy and thrombocytopenia can result.
  • Liver function tests: Hyperbilirubinemia and liver dysfunction may result from release of toxins.
  • Arterial blood gas determination: Gas gangrene can cause metabolic acidosis with significant lactic acidosis secondary to tissue death and ischemia.
  • Myoglobin level: Myoglobinemia and myoglobinuria can result from cellular breakdown.
  • Blood cultures: This may help narrow antibiotic coverage.

Imaging Studies

  • Gas in the soft tissues is neither sensitive nor specific for gas gangrene. Many different bacteria, trauma, and visceral perforation can cause soft tissue gas. Plain radiographs or ultrasonography can be used to look for the presence of gas.
  • Computed tomography or magnetic resonance imaging can help to evaluate the depth of soft tissue inflammation.

Other Tests

  • Once Clostridia are isolated from culture, identification of the lecithinase function of alpha toxin may be elicited by inoculating blood agar with the isolated bacteria. A double area of hemolysis will develop around the colonies, demonstrating the presence of lecithinase. Inoculation of the colonies with anti-toxin will halt the hemolysis. 

Procedures

  • Tissue biopsy with culture and Gram stain is the criterion standard in helping make the diagnosis of gas gangrene.

More on Gas Gangrene

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

References

  1. Trott AT. Skin and Soft-tissue Infections. In: Wolfson AB, et al, eds. Harwood-Nuss' Clinical Practice of Emergency Medicine. 4th ed. Lippincott Williams & Wilkins; 2005:715-717.

  2. Folstad SG. Soft tissue infections. In: Tintinalli JE, et al, eds. Emergency Medicine: A Comprehensive Study Guide. 6th ed. McGraw Hill; 2004:979-986.

  3. Meislin HW, Guisto JA. Soft tissue infections. In: Marx JA, et al, eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. 5th ed. Mosby-Year Book; 2002:1944-1955.

  4. Stevens DL. The pathogenesis of clostridial myonecrosis. Int J Med Microbiol. Oct 2000;290(4-5):497-502. [Medline].

  5. Brook I. Recovery of anaerobic bacteria from wounds after lawn-mower injuries. Pediatr Emerg Care. Feb 2005;21(2):109-10. [Medline].

  6. Headley AJ. Necrotizing soft tissue infections: a primary care review. Am Fam Physician. Jul 15 2003;68(2):323-8. [Medline].

  7. Bryant AE. Biology and pathogenesis of thrombosis and procoagulant activity in invasive infections caused by group A streptococci and Clostridium perfringens. Clin Microbiol Rev. Jul 2003;16(3):451-62. [Medline].

  8. Miller LG, Perdreau-Remington F, Rieg G, et al. Necrotizing fasciitis caused by community-associated methicillin-resistant Staphylococcus aureus in Los Angeles. N Engl J Med. Apr 7 2005;352(14):1445-53. [Medline].

  9. Fridkin SK, Hageman JC, Morrison M, et al. Methicillin-resistant Staphylococcus aureus disease in three communities. N Engl J Med. Apr 7 2005;352(14):1436-44. [Medline].

  10. Anesti E, Brooks P, Majumder S. Images in emergency medicine. Gas gangrene. Ann Emerg Med. Jul 2007;50(1):14, 33. [Medline].

  11. Arteta-Bulos R, Karim SM. Images in clinical medicine. Nontraumatic Clostridium septicum myonecrosis. N Engl J Med. Oct 21 2004;351(17):e15. [Medline].

  12. Frazee BW, Lynn J, Charlebois ED, Lambert L, Lowery D, Perdreau-Remington F. High prevalence of methicillin-resistant Staphylococcus aureus in emergency department skin and soft tissue infections. Ann Emerg Med. Mar 2005;45(3):311-20. [Medline].

  13. Schneider DJ, Reid JS. Images in clinical medicine. Gas gangrene associated with occult cancer. N Engl J Med. Nov 30 2000;343(22):1615. [Medline].

  14. Swartz MN. Clinical practice. Cellulitis. N Engl J Med. Feb 26 2004;350(9):904-12. [Medline].

  15. Wang C, Schwaitzberg S, Berliner E, Zarin DA, Lau J. Hyperbaric oxygen for treating wounds: a systematic review of the literature. Arch Surg. Mar 2003;138(3):272-9; discussion 280. [Medline].

  16. Smith-Slatas CL, Bourque M, Salazar JC. Clostridium septicum infections in children: a case report and review of the literature. Pediatrics. Apr 2006;117(4):e796-805. [Medline].

  17. Temple AM, Thomas NJ. Gas gangrene secondary to Clostridium perfringens in pediatric oncology patients. Pediatr Emerg Care. Jul 2004;20(7):457-9. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

gas gangrene , Clostridium perfringens, C perfringens, Clostridium septicum, C septicum, clostridial myonecrosis, tissue infection, clostridial infection of tissues, emphysematous gangrene, gangrenous emphysema, progressive emphysematous necrosis, gas production, sepsis, myonecrosis, necrotizing myositis, muscle swelling, colon cancer, diabetic peripheral vascular disease, chronic immunosuppression

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Anil Shukla, MD, Staff Physician, Harvard Affiliated Emergency Medicine Residency, Beth Israel Deaconess Medical Center
Disclosure: Nothing to disclose.

Coauthor(s)

Carlo L Rosen, MD, Assistant Professor of Medicine, Harvard Medical School; Program Director, Department of Emergency Medicine, Beth Israel Deaconess Medical Center/ Harvard Affiliated Emergency Medicine Residency program
Carlo L Rosen, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Jason K Wong, MD, Staff Physician, Department of Emergency Medicine, Jefferson Regional Medical Center
Jason K Wong, MD is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

Medical Editor

Michelle Ervin, MD, Chair, Department of Emergency Medicine, Howard University Hospital
Michelle Ervin, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, National Medical Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

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

Managing Editor

Barry J Sheridan, DO, Chief, Department of Emergency Medical Services, Brooke Army Medical Center
Barry J Sheridan, DO is a member of the following medical societies: American Academy of Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

RELATED MEDSCAPE ARTICLES
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.