Emergent Treatment of Gas Gangrene Clinical Presentation

Updated: Oct 21, 2016
  • Author: Xiao Wang, MD; Chief Editor: Jeter (Jay) Pritchard Taylor, III, MD  more...
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Presentation

History

History of gas gangrene is discussed below. [1, 2]

Infection usually results from deep trauma or surgery, although minor procedures, such as intramuscular injection, have been associated with gas gangrene.

The incubation period is usually less than 24 hours but has been described to be anywhere from 7 hours to 6 weeks. When symptoms start, clinical deterioration can occur within hours.

Muscle swelling and severe pain are prominent features. The pain is often out of proportion to physical findings, reflective of the hypoxic state of the muscle tissue, and is key to distinguishing gas gangrene from simple or anaerobic cellulitis.

Systemic toxicity may cause altered mental status, and the progression to toxemia and shock can be rapid.

History of wound contamination with freshwater and seawater should prompt consideration for other causative organisms of necrotizing soft tissue infections, such as Vibrio vulnificus and Aeromonas hydrophila, which have different preferred first-line antibiotic coverage. [10, 11]

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Physical

Physical findings of gas gangrene are discussed below. [1, 2, 3, 12, 13, 10, 11, 14] :

Vital signs

Unusually, fever is not a prominent feature of infection and may only be low grade throughout the clinical course. The degree of systemic involvement may produce a spectrum of changes from tachycardia through outright septic shock including hypotension and diaphoresis.

Visual inspection

Initially, the skin may be normal or have mild-to-cellulitic–appearing erythema. Overtime, it typically progresses through a yellowing or bronzing to bulla formation to patches of green/blue/grey/black necrosis. However, discoloration and bullae formation are only present in 20-40% of initial examinations and necrosis is much less frequent. Serosanguineous drainage may be present, described classically as either extremely foul smelling, having a mousy or slightly sweet odor. [15, 10, 11]

Palpation and tissue examination

Most notable is extreme pain of the affected area with or without movement and with palpation. The pain may be out of proportion to the extent of the overlying skin changes. Pain out of proportion to examination may be the only early warning sign distinguishing the necrotizing soft tissue infection from a more benign illness and is present in more than 97% of cases. [11]

Crepitus may be present in 12-25% of cases, but a lack of crepitus on examination does not exclude clostridial myonecrosis. The presence of crepitus is also not specific, as a more common and benign clostridial soft tissue infection, anaerobic cellulitis, may also present with crepitus. [11]

Tense edema may occur and is proportional to the extent of underlying necrosis.

Crepitus, significant discoloration, and tissue tenseness are typically signs of later, more advanced infection and should not be relied upon to diagnose gas gangrene. [11]

Vascular examination

Distal pulses may be normal or diminished depending on the extent of local tissue damage or the presence of compartment syndrome.

Neurologic examination

Decreased pain or anesthesia at the site of infection can indicate that cutaneous nerve endings are being destroyed and that the disease is advanced.

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Causes

Risk factors for gas gangrene include the following [8, 16, 17, 18, 19, 15, 10, 14] :

  • Battlefield Injury
  • Burns
  • Chronic alcoholism (See the image below.)
    Left lower extremity in a 56-year-old patient with Left lower extremity in a 56-year-old patient with alcoholism who was found comatose after binge drinking. Surgical drainage was performed to treat the pyomyositis-related, large, non–foul-smelling (sweetish) bullae. Gram staining showed the presence of gram-positive rods. Cultures revealed Clostridium perfringens. The diagnosis was clostridial myonecrosis.
  • Corticosteroid use
  • Gastrointestinal malignancy
  • HIV/AIDS
  • Hypoalbuminemia
  • Intravenous drug abuse (See the image below.)
    A patient developed gas gangrene after injecting c A patient developed gas gangrene after injecting cocaine. Clostridium septicum was isolated in both blood and wound cultures.
  • Malnutrition
  • Mass casualty
  • Obesity
  • Open fractures
  • Surgery
  • Trauma
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