A case of Clostridium septicum spontaneous gas gangrene

Case Reports

CJEM 2007;9(2):133-135

Abstract

Résumé

Case History

An 84-year-old diabetic man with a history of penicillin allergy was seen in the emergency department (ED) with a 12-hour history of urinary frequency. He denied dysuria, fever or chills, but he had noted pain in his right thigh. His medical history included coronary artery disease and atrial fibrillation. There was a prior history of a gastrointestinal hemorrhage while on anticoagulation therapy. A colonoscopy at that time had revealed pandiverticulitis; however, the cecum was not visualized.

On initial examination the patient was in no distress and his vital signs were temperature 37.5°C, pulse 66 beats/ min, respiratory rate 16 breaths /min and blood pressure (BP) 129/63 mm Hg. There was no costovertebral angle or abdominal tenderness. Examination of the testes and prostate was unremarkable. The right hip had a normal range of motion with no skin erythema. The urinanalysis showed hematuria but no pyuria. The white blood cell count (WBC) was 19.5 × 10⁹/L, the hemoglobin was 86 g/L and the serum creatinine was 172 mmol/L (NR = 44-123).

The history of urinary frequency with hematuria and leukocytosis suggested a possible prostatitis and a dose of oral ciprofloxacin 500 mg was given. However, there was some uncertainty surrounding the diagnosis and the complaint of thigh pain was still unexplained, so the patient was kept for overnight observation. Reassessment, performed 2 hours later, indicated an area of erythema over the inner right thigh with some small blister formation. By that time, the patient was in severe pain and a repeat WBC was 25.9 × 10⁹/L with an elevated creatine kinase of 700 IU/L (NR = 20-180). His BP had dropped to 100/60 mm Hg with a pulse of 110 beats/min. He did not have a fever. His serum lactate was elevated at 12.8 mmol/L (N = 0.6-2.4).

The diagnosis was changed to necrotizing fasciitis and the patient was started on intravenous (IV) cefazolin, clindamycin and gatifloxacin. A surgical consultation was obtained and the patient was taken to the operating room 8.5 hours after having arrived in the ED. Incisions were made in the thigh and a foul smelling thin exudate was obtained. The underlying muscles were necrotic and a decision was made to perform a disarticulation of the right leg at the hip. Only the anaerobic culture was positive and grew Clostridium (C.) septicum. The initial urine culture grew Acinetobacter baumannii. The patient was given a total of 12 days of combined cefazolin and clindamycin, which was stopped when there was no evidence of residual clostridial infection on clinical and radiologic exam. Almost 3 weeks after undergoing surgery, the patient had a sudden deterioration in his pre-existing cardiac condition and he died. An autopsy was not performed.

Discussion

Life-threatening skin and soft-tissue infections (SSTIs) are infrequent and difficult to diagnose on initial presentation. A useful classification of SSTI uses the presence or absence of gas in the soft tissues (Table 1). Gas can be found either clinically (crepitus) or radiologically, but is usually a later manifestation, often seen when the patient is in shock. Among the gas-forming SSTIs, the pathogens most frequently responsible, either alone or in combination, are Clostridia, other anaerobes and coliforms. Clostridial myonecrosis, or gas gangrene, is the result of infection by exotoxin producing bacteria that invade muscle tissue and result in tissue necrosis and gas production.1 Clostridia thrive in an anaerobic environment such as the large intestine. Most cases result from the contamination of an open wound by fecal flora, but infection has been reported postpartum,2 after septic abortions or with illicit IV drug use. C. perfringens accounts for 80%-95% of cases that are associated with an open wound.

Spontaneous or nontraumatic gas gangrene is a rare entity and is almost exclusively caused by C. septicum,3-9 which is aerotolerant and capable of infecting non-devitalized tissue.8 The pathogenesis is a hematogenous spread from an intestinal focus, and the portal of entry is believed to be mucosal ulceration or perforation of the gastrointestinal tract.4 Bowel pathology, such as carcinoma, diverticulitis, infarction, enterocolitis and volvulus, has been reported.8 In one study of patients with C. septicum infection, 50% were found to have a primary malignancy, 75% of which were colonic; and of those, 40% were cecal.10 Although this patient was not proven to harbour a colonic malignancy, he was anemic with a history of occult lower gastrointestinal bleeding. Previous colonoscopy had been incomplete, with failure to visualize the cecum.

Seeding tends to involve an extremity, but may involve more than one area.11 Diabetes or atherosclerotic peripheral vascular disease may result in relative tissue hypoxia sufficient for colonization once seeded. Then a multitude of bacterial toxins overwhelms the host defenses and initiates a cycle of tissue destruction, local ischemia, bacterial proliferation and toxin production.5

The incubation period is short, ranging from 6 hours to 3 days with an abrupt onset of illness heralded by rapidly increasing pain. The patient appears toxic with fever and possible delirium. Initial examination of the skin may be relatively unimpressive and the clinician must be vigilant to maintain a high index of suspicion. At onset, the skin may appear edematous and tender, and then blebs or bullae develop containing a thin, dark fluid. The underlying skin becomes necrotic and changes to a purplish-black colour. Samples of material taken from the infected area will show a paucity of leukocytes and the presence of gram-positive rods on gram stain. C. septicum can be distinguished from C. perfringens on gram stain. Both organisms produce toxins that inhibit leukocyte migration and function, and can rapidly cause shock.1

Therapy for gas gangrene involves early and aggressive surgical exploration to establish the diagnosis and to remove devitalized tissue, and amputation is often required. Concurrent antibiotic therapy is critical and should be instituted immediately. The recommended regimen includes high dose IV penicillin, 18-24 million units/day in divided doses, and IV clindamycin.12 Clindamycin is believed to prevent toxin release and has been shown to be more efficacious than penicillin in an animal model.13 Mixed infections are not uncommon so an agent active against gram-negative organisms should also be added until the final bacteriology results are known. The benefit of hyperbaric oxygen therapy in gas gangrene has not been established, but it may play a role as an adjunct to surgical debridement under certain circumstances.

The mortality rate for spontaneous gas gangrene remains high, ranging from 67%-100%, and most patients die on the first day of illness.8 This patient appeared to have survived his C. septicum infection only to die 3 weeks later from unknown causes. The rapid institution of antibiotics and the extensive debridement he underwent were important factors in his short-term survival.

Conclusion

For successful treatment, it is critical that the emergency physician recognize the disease early in its course. The presence of severe localized pain with or without fever and leukocytosis should raise concern as the characteristic skin changes may not be initially apparent. Current treatment involves high-dose, broad-spectrum antimicrobial therapy combined with timely surgical intervention.

References

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