Limb salvage after gas gangrene

Case report:

A 35-year-old Caucasian man with a history of chronic intravenous drug use presented to the emergency department with right upper limb pain and swelling lasting 24 hours. His initial vital signs were notable for temperature of 39°C, respiratory rate of 25 breaths per minute, heart rate of 120 beat per minute and blood pressure of 141/76 mmHg. He was distressed and on clinical examination severe edema of the upper limb, erythema, blistering of the arm and crepitus over the shoulder and arm was noted [Figure ​1a]. At this time, motor and sensory function of the limb was not impaired and pulses of the radial and ulna artery could be palpated. His past medical history consisted of a diagnosis of hepatitis C. Intramuscular injections with normal saline in the shoulder were also reported. This is a practice among illicit drug users used to provoke pain for recovery after drug induced coma.

Blood counts showed a white blood cell count of 10.7 K/μL (normal range 3.5-10.0 K/μL) (88.6% neutrophils, 6.9%lymphocytes, 0.1%monocytes), hemoglobulin 13.6 g/dl (normal range 14-18 g/dl), platelet count 161 K/μL (normal range 150-450 K/μL). His creatinine phosphokinase was elevated at 3594 IU/L (normal range 40-148 U/L), c-reactive protein was elevated at 7.29 mg/dl (normal range < 1 mg/dl) and SGOT/SGPT were two times above higher normal limits. His electrolytes and coagulation profile were within normal limits.

An X-ray of the affected limb revealed gas in soft tissues suggestive of gas gangrene [Figure 1b]. Empirical broad spectrum antibiotic treatment was immediately initiated consisting of piperacillin/tazobactam, clindamycin and vancomycin in usual dosages. Within one hour swelling of soft tissues was expanded to the forearm and neck medially [Figure 2a]. The general condition of the patient was worsening with severe pain and hoarseness and he was intubated due to threatened airway. Within two hours since his admission, the patient was guided to the operating theater and underwent arm and forearm fasciotomy due to threatening compartment syndrome and broad surgical debridement and drainage of the infected areas. A Henry type anterior shoulder incision was used from the anterior deltoid muscle to the forearm with division of the transverse carpal ligament.

Extended subcutaneous emphysema was noted, with foul smelling areas of necrosis in most of biceps brachii and the flexors of the forearm. Broad resection of necrotic tissues of arm and forearm was done. Thorough mechanical irrigation of the affected area was performed using normal saline, hypertonic solutions and the Stryker irrigation-suction device. Approximating tension sutures were used and the wound was let to be healed by third intention [Figure ​2b]. Subsequently the patient was transferred to the intensive care unit. Cultures of tissue specimens obtained intraoperatively revealed Staphylococcus epidermidis, Clostridium perfringens and Staphylococcus aureus.

Postoperatively the patient remained in the intensive care unit intubated and in septic shock. The first postoperative day he developed acute renal failure attributed to myoglobinuria requiring hemodialysis. The second postoperative day his platelet count was decreased to 45Κ/μL and increased gradually the following days. According to the results of antibiogram meropenem 1 gr 12 hourly was administered the 3^rd postoperative day. Daily surgical debridement with resection of additional necrotic tissue was performed in the intensive care unit. His temperature returned to normal on postoperative day 10 and his general condition was gradually improved thereafter. He was discharged from the intensive care unit on postoperative day 30. In the orthopedic ward he remained afebrile and his wound was progressively healing with granulation of the tissue and regression of the foci of necrotic infection [Figure ​2c]. Blood supply of the limb was adequate. However, significant motor and sensor neural deficits of the radial and ulnar nerve were noted. Limb physiotherapy was administered on daily basis. Four months postoperatively, skin deficits were restored with the use of free skin grafts from the femoral region [Figure 2d]. At this time flexure and extension of the elbow and shoulder against gravity was possible along with minimal active movement of the wrist and fingers.