|Necrotizing fasciitis .......Gas Gangrene.....continued|
The next case involves a 61 year old insulin dependent diabetic male with a six month history of weight loss, anemia and stools (+) for occult blood.The individual presented to the Emergency department with a swollen , extremely tender (L) arm.The day prior to presentation he volunteered a history of nausea , vomiting and diarrhea.The night prior he suffered a mild blunt trauma to his (L) elbow which in the past had been swollen with olecranon bursitis.During the night the pain became more severe and he presented to the emergency for assessment.He was discharged home on oral antibiotics only to return within 8 hours with increasing pain and swelling with a decreased range of movement in the hand.On examination crepitus was felt around the elbow progressing towards the axilla.The presence of gas was confirmed by X-ray.The man was immediately started on intravenous Clindamycin,Penicillin and Merem.
slide A & B
Surgical consultation was obtained . The man was found to be hypotensive, lethargic and slightly confused.Pain was steadily increasing with the swelling and a brawny induration.Crepitus was now in the axilla.The range of motion to the hand was decreased with tingling. After resuscitation the patient was brought to the OR and given the benefit of dorsal and volar fasciotomies to the forearm with a carpel tunnel release and olecranon bursectomy . All non viable tissue was debrided.Gram stain showed evidence of gram (+) rods.The eventual culture established a growth of Clostridium septicum
slide C& D &E & F
Within 24 hours the patient was brought back for a second look.The muscle necrosis was more extensive.Crepitus now had advanced over the anterior chest wall and the exposed muscle was more serous and boggy.A shoulder disarticulation then ensued.The patient survived and was discharged 3 weeks later
slide G& H
On the admission CXR ,the patient was noted to have a lung mass and in view of the anemia a CT was done of the abdomen and chest.The lung findings proved benign but in the abdomen a large gas filled mass was detected.The patient refused any further in hospital investigation and was discharge.He was subsequently readmitted 3 weeks later with a complete large bowel obstruction and taken to surgery where he underwent a subtotal colectomy , distal gastrectomy and ileostomy for a locally invasive and advanced carcinoma of the transverse colon(DukesC lesion)
Fortunately gas gangrene due to clostridial sepsis is now less prevalent.Clostridium perfringens still remains the most common variant but Clostridiium septicum does cause one third of the atraumatic cases.It has the ability of attacking normal viable tissue.It must be remembered that these gram(+) bacilli(spore formers) cause their rapid tissue destruction by their production of exotoxin.
Penicillin and Clindamycin are still the major antibiotics used.
However, surgical debridement is the mainstay of all therapy.The use of hyperbaric oxygen is also beneficial but may not be readily available.Interestingly enough as in many toxic states , there is some form of immune compromise and in clostridial sepsis a correlation with an underlying GI malignacy may be present .
The web reference is taken from www.emedicine.com and is a very complete and thorough overview which I recommend for a better understanding of this problem