A rare cause of pneumoperitoneum due to clostridium perfringens in a cirrhotic patient.

INTRODUCTION: Abdominal gas gangrene caused by Clostridium perfringens is a rare differential diagnosis to pneumoperitoneum caused by bowel perforation. There are only a handful of case reports on this topic. PATIENTS AND METHODS: We present the case of a 58 year old cirrhotic patient who represented to our ER after complicated surgery for retroperitoneal liposarcoma. On admission he complained of abdominal pain and mild fever. Due to leukocytosis and CRP a CT scan was performed which showed extensive free air. The patient was taken to the OR for suspected bowel perforation. No perforation could be identified after extensive search and lavage. RESULTS: Twelve hours after surgery microbiology reported extensive growth of clostridium perfringens in the cultures drawn from ascites. The patient was successfully treated with antibiotics and discharged home soon after. CONCLUSION: Gas gangrene is a rare differential diagnosis to bowel perforation. Most reported cases are from cirrhotic patients. If no perforation can be identified in the OR postoperative antibiotics should cover clostridium perfringens.

Atraumatic Clostridium septicum myonecrosis presenting as upper limb ischaemia in a patient with undiagnosed bowel cancer.

Necrotising infections remain challenging to surgeons, both in diagnosis and management. Timely recognition and treatment remain vital. We report a presentation of limb ischaemia with no apparent precipitating factors, in a systemically stable patient, due to atraumatic Clostridium septicum myonecrosis. This article demonstrates the use of rapid cross-sectional imaging in finding an undiagnosed bowel cancer as a basis for this type of infection. Rapid cross-sectional imaging may be utilised where there is doubt about the underlying pathology of upper limb ischaemia. Patients whose cultures grow Clostridium septicum must be investigated for malignancy.

Fournier's Gangrene With Subcutaneous Emphysema of the Thigh Caused by Air Inflow Associated With a Rectovaginal Fistula: A Case Report of Pseudo-gas Gangrene.

INTRODUCTION: Rectovaginal fistulas (RVFs) are abnormal connections between the rectum and vagina. CASE REPORT: A 61-year-old female patient was admitted to the authors' hospital with swelling, extending from the left thigh to the left lower abdomen and crepitus. An axial computed tomography scan showed air in the soft tissue of the left thigh, left buttock, perineal region, and left lower abdomen. Gas gangrene was suspected. Accordingly, the patient was administered meropenem, clindamycin, and vancomycin and underwent emergency debridement. An intraoperative examination revealed necrotizing fasciitis in the left buttock but no inflammatory signs in the thigh. On postoperative day 8, fecal matter was discharged from the patient's vagina, and an RVF was detected by colon fiberscopy. The patient underwent resurfacing surgery with a free skin graft, and a colon stoma was fashioned 15 days after the primary surgery. The patient was discharged on day 14 following surgery with wound healing. CONCLUSION: The existence of free air in subcutaneous tissue combined with an infection, particularly in the extremities, is generally suggestive of gas gangrene. In the present case, subcutaneous gas was not caused by gas gangrene but rather by air inflow from an RVF. Appropriate treatment of the RVF was necessary to avoid the exacerbation of Fournier's gangrene and prevent necrosis spreading to the thigh.

Epinephrine Auto-Injection After Allergic Reaction Leading to Gas Gangrene of the Leg.

BACKGROUND Clostridial myonecrosis, also known as gas gangrene, is a highly lethal necrotizing soft tissue infection. While commonly associated with trauma, clostridial myonecrosis may be the result of parenteral injection of medications. Epinephrine is the most commonly reported medication leading to gas gangrene. CASE REPORT A 60-year-old man presented to the Emergency Department (ED) with "the worst pain in his life" to the right thigh near the site at which he auto-injected epinephrine after multiple bee stings 10-11 h prior to arrival. Initial heart rate was 112 beats/min but all other vital signs were unremarkable at presentation. Due to extreme pain, a computed tomography (CT) scan was ordered, revealing prominent gas within the anterior compartment of the right thigh, mostly involving the vastus lateralis and rectus femoris, suggesting necrotizing fasciitis. Antimicrobials were initiated immediately and the patient was taken for surgical debridement within 70 min after obtaining the CT results. Clostridium perfringens was cultured from the patient's tissue. After several surgical debridement's, appropriate antimicrobial therapy, supportive care, and wound care, the patient's limb remained intact and he was discharged after 11 days. CONCLUSIONS With millions of epinephrine auto-injectors prescribed yearly in the United States, awareness of clostridial gas gangrene following epinephrine auto-injection for the provider may help guide decision-making in patients presenting with extreme pain, redness, or swelling near the injection site after epinephrine injection.

Necrotizing Soft Tissue Infections.

Necrotizing soft tissue infections occur after traumatic injuries, minor skin lesions, nonpenetrating injuries, natural childbirth, and in postsurgical and immunocompromised patients. Infections can be severe, rapidly progressive, and life threatening. Survivors often endure multiple surgeries and prolonged hospitalization and rehabilitation. Despite subtle nuances that may distinguish one entity from another, clinical approaches to diagnosis and treatment are highly similar. This review describes the clinical and laboratory features of necrotizing soft tissue infections and addresses recommended diagnostic and treatment modalities. It discusses the impact of delays in surgical debridement, antibiotic use, and resuscitation on mortality, and summarizes key pathogenic mechanisms.

Clostridial Gas Gangrene - A Rare but Deadly Infection: Case series and Comparison to Other Necrotizing Soft Tissue Infections.

OBJECTIVE: Clostridial gas gangrene (GG) or clostridial myonecrosis is a very rare but life-threatening necrotizing soft tissue infection (NSTI) caused by anaerobic, spore-forming, and gas-producing clostridium subspecies. It is the most rapidly spreading and lethal infection in humans, also affecting muscle tissue. The high mortality, of up to 100%, in clostridial GG is mediated by potent bacterial exotoxins. Necrotizing fasciitis (NF) is an important differential diagnosis, most often caused by group A streptococci, primarily not affecting musculature but the subcutaneous tissue and fascia. In the early stages of the infection, it is difficult to distinguish between GG and NF. Therefore, we compare both infection types, identify relevant differences in initial clinical presentation and later course, and present the results of our patients in a retrospective review. METHODS: Patients diagnosed with GG from 2008 to 2018 in our level one trauma center were identified. Their charts were reviewed retrospectively and data analyzed in terms of demographic information, microbiological and histological results, therapeutic course, outcome, and mortality rates. The laboratory risk indicator for NF (LRINEC) score was applied on the first blood work acquired. Results were compared to those of a second group diagnosed with NF. RESULTS: Five patients with GG and nine patients with NF were included in the present study. Patients with GG had a mortality rate of 80% compared to 0% in patients with NF. In eight patients with NF, affected limbs could be salvaged; one NF underwent amputation. LRINEC did not show significant differences between the groups; however, C-reactive protein was significantly increased (P = 0.009) and hemoglobin (Hb) was significantly decreased (P = 0.02) in patients with GG. Interleukin-6 and procalcitonin levels did not show significant difference. Patients with GG were older (70.2 vs 50 years). Of the isolated bacteria, 86% were sensitive to the initial calculated antibiotic treatment with ampicillin-sulbactam or imipenem plus metronidazole plus clindamycin. CONCLUSION: Both GG and NF need full-scale surgical, antibiotic, and intensive care treatment, especially within the first days. Among patients with NSTI, those with clostridial GG have a significantly increased mortality risk due to early septic shock caused by clostridial toxins. In the initial stages, clinical differences are hardly detectable. Immediate surgical debridement is the key to successful therapy for NSTI and needs to be performed as early as possible. However, patients should be treated in a center with an experienced interdisciplinary intensive care team based on a predetermined treatment plan.

A Middle-Aged Woman With Hematochezia, Hypotension, and Leg Cramps.

CASE PRESENTATION: A 57-year-old woman with a history of mantle cell lymphoma presented to the ED with complaints of vomiting, bleeding per rectum, and leg cramps, that started 6 h prior to her arrival. She had received chemotherapy a week prior. Her leg cramps were not associated with pain or swelling of the legs; she also denied any trauma to the legs. She did complain of mild lower abdominal pain at presentation. Review of systems was negative for fever, chills, diarrhea, chest pain, and dizziness. She denied using alcohol or nonsteroidal anti-inflammatory drugs. The patient was tachycardic with a systolic BP (SBP) of 85 mm Hg and was administered 1-L normal saline, with improvement in her SBP to 90 mm Hg. The hematocrit level was 24%, the WBC count was 0.3 × 109/L, and the platelet count was 6 × 109/L in the ED. On arrival in the ICU, she was noted to have an SBP of 70 mm Hg. Resuscitation with IV fluids was initiated, followed by transfusion of packed RBCs and platelets, based on the blood counts. Despite aggressive fluid resuscitation and improvement in her hemoglobin, the patient remained persistently hypotensive. The diagnosis of underlying septic shock because of neutropenia was considered; the patient was started on vasopressors and empirical broad-spectrum antibiotics, with improvement in her BP. After this, the patient was sent to radiology for a CT scan of the abdomen and pelvis with contrast to evaluate for mesenteric infarction, enteric or colonic bleeding, and the need for arterial embolization.

A case report of iatrogenic gas gangrene post colonoscopy successfully treated with conservative management- is surgery always necessary?

BACKGROUND: Colonoscopy is a routine procedure in diagnosis and treatment of colonic disease. While generally regarded as a safe procedure, potentially fatal complications can occur. Gas gangrene is one such complication, with very high mortality. There are few cases of gas gangrene occurring after colonoscopy, making it one of the rarer complications of this procedure. There have been no previously reported cases of a patient surviving such an infection and the optimal treatment strategy is contentious. This report describes a case of intramural gas gangrene of the colon, treated conservatively with antibiotic therapy in which the patient survived with full recovery. CASE PRESENTATION: A 71-year-old, previously healthy male presented 6 h post apparently uncomplicated colonoscopic polypectomy with rigors, nausea, vomiting and right upper quadrant pain. At presentation he was febrile at 40.1 °C but hemodynamically stable. Abdominal computed tomography revealed substantial colonic thickening and several focal intramural gas bubbles (pneumatosis intestinalis) surrounding the polypectomy site. Within 24 h post procedure he became hypotensive and was admitted to ICU in frank septic shock requiring inotropes, and with demonstrable septic myocardial depression. Bloods showed multi-organ derangement with leukocytosis, lactic acidosis, haemolytic anaemia and hyperbilirubinemia. A diagnosis of presumed Clostridial gas gangrene was made, and treatment was initiated with benzylpenicillin, clindamycin, metronidazole and vancomycin. After 4 days in ICU he was stepped down, and discharged after a further 10 days with no surgical or endoscopic interventions. At three-month review he reported being back to full health. CONCLUSIONS: This case demonstrates that gas gangrene infection is a possible complication of colonoscopic polypectomy. This is a cause of rapid deterioration in post-colonoscopy patients and has been misdiagnosed as colonic perforation in previously reported cases of retroperitoneal gas gangrene. Such misdiagnosis delays antibiotic therapy, which likely plays a role in the high mortality of this condition. Early diagnosis and initiation of antibiotic therapy with benzylpenicillin and clindamycin as seen in this case is essential for patient survival. While surgery is typically performed, non-operative management of pneumatosis intestinalis, and potentially gas gangrene is becoming more common and was utilized effectively in this patient.

Clostridium septicum-infected aortic aneurysm or graft is a deadly diagnosis.

BACKGROUND: Clostridium septicum is an anaerobic, motile, spore-forming, toxin-producing gram-positive bacillus that can lead to rapidly progressive gas gangrene due to the release of alpha toxin. Aortic aneurysm secondary to C. septicum infection is a rare condition with 60 cases reported in the literature; however, we have recently treated several patients with the condition in our large tertiary care and aortic center. METHODS: Blood and tissue culture results collected between January 2005 and January 2018 and maintained in the microbiology laboratory database at the Cleveland Clinic were reviewed to identify those with C. septicum reported. Each was reviewed to determine radiographic or histopathologic correlation with aortic disease. RESULTS: Seven cases of C. septicum aortitis were reviewed. Underlying malignant disease was found in four cases and a history of remote malignant disease in one case. The most common location for infection was the infrarenal abdominal aorta. Vascular surgery had previously been performed in three of the cases. Five of the seven patients underwent operative repair. All patients were treated with ß-lactam antibiotics. The two patients who did not undergo an operation died, which is consistent with the 100% mortality described in the literature. Of the five patients who underwent an operation, there was only one documented survivor and one was lost to follow-up. CONCLUSIONS: In the largest reported case series, only a small percentage of patients with C. septicum-infected aortic aneurysms survived >1 year. In the patients described, those who did not receive an operation had 100% mortality. Earlier recognition and prompt operation with appropriate antimicrobial therapy are needed to improve the outcome of patients diagnosed with this rare infection.

[Vascularised Fibula and Tendon Transfer in the Comprehensive Treatment of Forearm Fracture with Gas Gangrene Complication]. / Vaskularizovaná fibula a slachový transfer v komplexnej liecbe otvorenej zlomeniny predlaktia komplikovanej plynnou snetou.

Vascularized bone grafting was for the first time described in the 1970s. It has become a crucial component in the reconstruction of long bone defects and non-unions in a poorly vascularised environment. Although the vascularized bone is well described for the lower extremity and mandibular reconstructions, it started to be used for the upper extremity bone defects only recently. This publication presents a case of a young man with an open fracture of both the forearm bones. The treatment of the injury has been complicated with anaerobic gas gangrene of the forearm. This resulted in a non-union, radius shortening and necrosis of both the thumb extensors and flexors muscles. Once the acute infection was managed, the patient received a two-step treatment provided jointly by orthopaedic and plastic surgeons at the University Hospital in Bratislava. At the first stage auto transplantation of the vascularized fibula into the defect of radius was performed, with radial artery and radial veins being the recipient vessels. One year later, a tendon transfer was made in order to reconstruct the extension and flexion of the thumb. Donor tendons were the following: extensor indicis proprius and flexor digitorum superficialis for ring finger. The result of the reconstruction is the full incorporation of the fibular transplant (6 months after the primary operation) and the excellent range of motion of the hand and wrist. Thanks to the tendon transfer the function of the thumb, including the opposition, was achieved two months after the secondary surgery. Key words: defect of radius, tendon transfer, anaerobic infection, gas necrosis, microsurgery.

Characterization of two glycosyl hydrolases, putative prophage endolysins, that target Clostridium perfringens.

Clostridium perfringens, a spore-forming anaerobic bacterium, causes food poisoning and gas gangrene in humans and is an agent of necrotizing enteritis in poultry, swine and cattle. Endolysins are peptidoglycan hydrolases from bacteriophage that degrade the bacterial host cell wall causing lysis and thus harbor antimicrobial therapy potential. The genes for the PlyCP10 and PlyCP41 endolysins were found in prophage regions of the genomes from C. perfringens strains Cp10 and Cp41, respectively. The gene for PlyCP10 encodes a protein of 351 amino acids, while the gene for PlyCP41 encodes a protein of 335 amino acids. Both proteins harbor predicted glycosyl hydrolase domains. Recombinant PlyCP10 and PlyCP41 were expressed in E. coli with C-terminal His-tags, purified by nickel chromatography and characterized in vitro. PlyCP10 activity was greatest at pH 6.0, and between 50 and 100 mM NaCl. PlyCP41 activity was greatest between pH 6.5 and 7.0, and at 50 mM NaCl, with retention of activity as high as 600 mM NaCl. PlyCP10 lost most of its activity above 42°C, whereas PlyCP41 survived at 50°C for 30 min and still retained >60% activity. Both enzymes had lytic activity against 75 C. perfringens strains (isolates from poultry, swine and cattle) suggesting therapeutic potential.

Use of Viable Cryopreserved Umbilical Tissue for Soft Tissue Defects in Patients With Gas Gangrene: A Case Series.

INTRODUCTION: Gas gangrene is a rapidly progressive bacterial infection leading to necrosis that usually develops as a result of trauma or postoperative complications. This condition requires early diagnosis with immediate surgical intervention. With a poor prognosis, a high incidence of amputation, and comorbidities such as diabetes and peripheral vascular disease, patients with gas gangrene are put at further risk for surgical complications. OBJECTIVE: This case series reports the clinical outcomes of using a commercially available viable cryopreserved umbilical tissue (vCUT) in the surgical management of 10 patients (9 males, 1 female) with acute lower extremity gas gangrene. MATERIALS AND METHODS: All 10 patients had aggressive debridement and irrigation, followed by an intraoperative application of vCUT to cover the large, complex wounds with exposed bone, tendon, and soft tissue, which was fenestrated and sutured to the surrounding skin edges. RESULTS: The average wound size following debridement was 45.9 cm2 (range, 8 cm2-105 cm2). Average percent area reduction of the wounds at 4 weeks post-vCUT application was 68.4% (range, 49%-99.5%). The average length of hospital stay was 9 days (range, 2-16 days), and postdischarge patients were treated with negative pressure wound therapy and standard of care (nonadherent dressing, dry gauze, and mild compression) until wound closure was achieved (average, 3.3 months [range, 1.25-4.5 months]). With a 1-time application of vCUT, all patients reached complete wound closure with decreased time to closure, fewer complications, and a shorter duration of hospitalization as compared with traditional inpatient management of gas gangrene (incision and drainage with staged procedures). CONCLUSIONS: The positive clinical outcomes indicate that vCUT may be an effective aid as an intraoperative application to cover wounds following aggressive debridement in the presence of gas gangrene.

Spontaneous C. septicum gas gangrene: A literature review.

As the infectious disease paradigm undergoes a subtle shift, unusual infections associated with malignancy and immunosuppression are being increasingly reported. Spontaneous or non-traumatic Clostridium septicum infection is one such unusual infection which has gained prominence. This article aims to understand the pathophysiology, clinical manifestations and current trends in diagnosing and treating this rare but deadly infection. To understand the multifactorial causation of this infection a review of published cases of spontaneous C. septicum gas gangrene was performed and a total of 94 such cases were identified. Several factors were analyzed for each case: age, infection location and underlying illness, presenting signs and symptoms, neutropenia, gross pathology of the colon, antibiotic use, surgical intervention, and survival. A known or occult malignancy was present in 71% patients and an overall mortality of 67% was observed.