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.

Gas gangrene in an illicit drug user. a. One and half hours after his admission in the emergency department. b. X-ray of the affected limb revealing gas in soft tissues.

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.

Figure 2
Surgical treatment of gas gangrene with preservation of the affected limb. a. Intraoperative figure showing necrosis of significant proportions of biceps brachii and the flexors of the forearm. b. Approximating sutures after broad resection of necrotic tissues of arm and forearm. c. Postoperative day 50: Healing with granulation of the tissue. d. Four months postoperatively: Restoration of skin deficits with the use of free skin flaps.

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 3rd 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.

Author

1Department of Orthopaedic Traumatology, University Hospital of Heraklion, Voutes, Heraklion, 71100, Greece2Department of General Surgery, University Hospital of Heraklion, Voutes, Heraklion, 71100, Greece3Alexander S. Onassis Public Benefit Foundation, Voutes, Heraklion, 71100, GreeceCorresponding author.#Contributed equally.John Aggelidakis: moc.oohay@sikadilegga.sinnaig; Konstantinos Lasithiotakis: rg.yregruscirtaireg@sikatoihtisal; Anastasia Topalidou: moc.liamg@uodilapota; John Koutroumpas: rg.oohay@sapmuortuokj; Georgios Kouvidis: moc.oohay@oegsidivuok; Paulos Katonis: rg.oohay@htisalsatswk

References
  • Bryant AE, Stevens DL. Clostridial myonecrosis: new insights in pathogenesis and management. Curr Infect Dis Rep. 2010;12(5):383–91. doi: 10.1007/s11908-010-0127-y. [PubMed] [CrossRef] [Google Scholar]
  • Bryan C. Gangrene bug killed 35 heroin users. WJM. 2000;173:82–83. doi: 10.1136/ewjm.173.2.82. [CrossRef] [Google Scholar]
  • Stevens. In: Cecil Textbook of Medicine. 21. L Goldman, JC Bennett, editor. chapter 334. Philadelphia: WB Saunders; 2000. Clostridial Myonecrosis and other Clostridial Diseases; pp. 1668–1673. [Google Scholar]
  • Kershaw CJ, Bulstrode CJ. Gas gangrene in a diabetic after intramuscular injection. Postgrad Med J. 1988;64:812–3. doi: 10.1136/pgmj.64.756.812. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
  • Lanting B, Athwal GS, Naudie DD. Spontaneous Clostridium perfringens myonecrosis of the shoulder: a case report. Clin Orthop Relat Res. 2007;461:20–4. [PubMed] [Google Scholar]
  • Ferraù S, Sallusti R, Lozano Valdes A, Gonzales C, Jónsson M, Gunnlaugsson G, Gullo A. HBO and gas gangrene. A case report. Minerva Anestesiol. 2001;67:745–9. [PubMed] [Google Scholar]
  • Hoffman S, Katz JF, Jacobson JH. Salvage of a lower limb after gas gangrene. Bull N Y Acad Med. 1971;47:40–9. [PMC free article] [PubMed] [Google Scholar]
  • Basow, DS, editor. Pentazocine: Drug information. Waltham, MA; 2011. No authors listed. In: UpToDate 19.1, [Google Scholar]
  • Assadian O, Assadian A, Senekowitsch C, Makristathis A, Hagmüller G. Gas gangrene due to Clostridium perfringens in two injecting drug users in Vienna, Austria. Wien Klin Wochenschr. 2004;116:264–7. doi: 10.1007/BF03041058. [PubMed] [CrossRef] [Google Scholar]
  • Gibson M, Avgerinos D, Llaguna O, Sheth D. Myonecrosis secondary to Clostridium Septicum in a patient with occult colon malignancy: a case report. Cases Journal. 2008;1:300. doi: 10.1186/1757-1626-1-300. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
  • Larson CM, Bubrick MP, Jacobs DM, West MA. Malignancy, mortality, and medicosurgical management of Clostridium septicum infection. Surgery. 1995;118:592–7. doi: 10.1016/S0039-6060(05)80023-6. discussion 597-8. [PubMed] [CrossRef] [Google Scholar]
  • Clay A, Behnia M. A 55-Year-Old Man With Fever, Renal Failure, and Hip Pain. Chest. 2001;119:281–284. doi: 10.1378/chest.119.1.281. [PubMed] [CrossRef] [Google Scholar]
  • Sudarsky LA, Laschinger JC, Coppa GF, Spencer FC. Improved results from a standardized approach in treating patients with necrotizing fasciitis. Ann Surg. 1987;206:661–5. [PMC free article] [PubMed] [Google Scholar]
  • Fernandez RJ, Gluck JL. Clostridium septicum gas gangrene of the gluteus maximus and an ascending colon malignant tumor. A case report. Clin Orthop Relat Res. 1994;308:178–82. [PubMed] [Google Scholar]
  • Heck R. In: Campbell’s Operative Orthopedics. 11. Canale ST, Beaty JH, editor. Vol. 1. Pensylvania: Mosby, Elsevier; 2008. General Principles of Amputations; pp. 562–566. [Google Scholar]
  • Smith D. In: Current diagnosis and treatment in orthopedics. 3. Skinner H, editor. New York: Lange Medical Books/Mc Graw-Hill; 2003. Amputations; pp. 638–654. [Google Scholar]
  • Lehner PJ, Powell H. Gas gangrene. BMJ. 1991;303:240–2. doi: 10.1136/bmj.303.6796.240. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
  • Mercer N, Davies DM. Gas gangrene. BMJ. 1991;303:854–5. [PMC free article] [PubMed] [Google Scholar]
  • Stevens DL, Bisno AL, Chambers HF, Everett ED, Dellinger P, Goldstein EJ, Gorbach SL, Hirschmann JV, Kaplan EL, Montoya JG, Wade JC. Practice guidelines for the diagnosis and management of skin and soft-tissue infections. CID. 2005;41:1373–406. doi: 10.1086/497143. [PubMed] [CrossRef] [Google Scholar]
  • Norrby-Teglund A, Muller MP, McGeer A, Gan BS, Guru V, Bohnen J, Thulin P, Low DE. Successful management of severe group A streptococcal soft tissue infections using an aggressive medical regimen including intravenous polyspecific immunoglobulin together with a conservative surgical approach. Scand J Infect Dis. 2005;37:166–72. [PubMed] [Google Scholar]
  • Tibbles PM, Edelsberg JS. Hyperbaric-oxygen therapy. N Engl J Med. 1996;334:1642. doi: 10.1056/NEJM199606203342506. [PubMed] [CrossRef] [Google Scholar]
  • Demello FJ, Haglin JJ, Hitchcock CR. Comparative study of experimental Clostridium perfringens infection in dogs treated with antibiotics, surgery, and hyperbaric oxygen. Surgery. 1973;73:936. [PubMed] [Google Scholar]
  • Lorea P, Baeten Y, Chahidi N, Franck D, Moermans JP. A severe complication of muscle transfer: clostridial myonecrosis. Ann Chir Plast Esthet. 2004;49:32–5. doi: 10.1016/j.anplas.2003.12.010. [PubMed] [CrossRef] [Google Scholar]
  • McNae J. An unusual case of Clostridium welchii infection. J Bone Joint Surg Br. 1966;48:512–3. [PubMed] [Google Scholar]
Share it