Case Study Of Patient With Gas Gangrene

Clostridium perfringens gas gangrene at a wrist intravenous line insertion

Catherine Determann1 and Craig Andrew Walker2

1Department of Anaesthetics & Critical Care, NHS Lothian, Edinburgh, Midlothian, UK

2Department of Emergency Medicine, NHS Lothian, Edinburgh, Midlothian, UK

Correspondence to Dr Catherine Determann, moc.liamg@nnamretedenirehtac

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Copyright 2013 BMJ Publishing Group Ltd

Case Report

This article has been cited by other articles in PMC.

Abstract

A patient admitted to the intensive care unit for management of hypotension following a multiple medications overdose subsequently deteriorated rapidly with sepsis. A cannula site was noted to be bruised, swollen and erythematous and the X-ray demonstrated gas sitting within the tissues surrounding the metacarpal bones. The patient was referred to the orthopaedic surgeons and quickly taken for debridement of the affected area and fasciotomies of the forearm. Microbiological investigation confirmed Clostridium perfringens to be present in multiple fluid samples taken from the affected site.

Background

This is the first described case of sepsis as a result of gas gangrene from a cannula site. Gas gangrene is described as having a 5–18% associated mortality rate1 depending on the stage of presentation and associated comorbidities. The key to survival without significant morbidity is early recognition with prompt surgical debridement, broad spectrum antibiotic therapy and physiological support.

Case presentation

A 74-year-old woman was assessed in the emergency department having taken a multiple medicines overdose of Lisinopril, Verapamil and Nicorandil. She reported having consumed around 40 tablets in total, but was unable to report what dose of each medication she had taken. She was known to have a history of depression and had taken one previous medicine overdose 15 years prior to this presentation and described having taken the overdose intentionally on impulse due to stressful family circumstances at home.

At the time of assessment the patient was hypotensive with systolic blood pressure (BP) of 60 mm Hg, had an ischaemic appearance of her ECG with ST segment depression in the chest leads V3–V6 and was intermittently aggressive towards the emergency department staff. A 20 G venous cannula was inserted into the dorsum of the right hand and dressed with a Tegaderm cannula dressing. This was completed under aseptic technique; the skin site for cannulation was identified as being entirely healthy and prepared by cleaning with 2% chlorhexidine and the emergency department staff completed the task while wearing non-sterile gloves. Despite intravenous fluid resuscitation and a total of 30 mLs of intravenous 10% calcium gluconate, the patient had persisting hypotension and oliguria with urine output of around 5 mL/h. Serum creatine was over 50% of the patient's baseline at 175 µmol/L confirming an acute kidney injury as per RIFLE classification. Blood gas analysis revealed a raised lactate of 4.4 mmol/L and a metabolic acidosis with hydrogen ions of 74 nmol/L. The patient was admitted to the high dependency unit for treatment of ongoing hypotension with inotropic support and invasive cardiovascular monitoring. The patient's condition stabilised quickly with an infusion of norepinephrine 8 mg%, and cardiac index was not measured. Troponin-T level at 12 h following admission was not raised.

Over the following 2 days steady progress had been made in weaning from cardiovascular support until, at 48 h after her initial presentation, the patient had a sudden episode of bradycardia and hypotension. ECG demonstrated a sinus rhythm with a rate of 35 bpm and some depression of the ST segments in the lateral chest leads. Arterial blood gas analysis demonstrated type I respiratory failure with a significant and worsening metabolic acidosis (PaO2 8.21 nmol/L, PaCO2 3.37 kPa, H+ 91.2 nmol/L, base excess (BE) −10.2 mmol/L, HCO3− 17.3 mEq/L).

She received further boluses of 10% calcium gluconate and fluid challenges, but became increasingly agitated and difficult to manage with a rapidly increasing norepinephrine requirement and worsening physiological parameters. She was transferred to the intensive care unit where she was sedated, intubated and ventilated.

Investigations

At this time, the patient's white cell count increased from 10.5×10 to 15.6×10/L (with a predominance of neutrophils) and she developed a fever of 38.8 °C. It was noted that her right hand was bruised and swollen, with some superficial blisters and crepitus developing over the dorsal aspect at the site of the cannula which had been inserted in the emergency department. The cannula was removed and swabs of fluid from blisters at the site were sent for analysis, along with peripheral blood, urine and sputum cultures. The patient was started on intravenous vancomycin and clindamycin to cover a suspected group A streptococcal infection. X-rays of the right hand revealed gas within the tissues surrounding the metacarpal bones (figure 1).

Figure 1

X-ray of the right hand demonstrating gas within the tissues surrounding the metacarpal bones.

Treatment

Surgical debridement of the right hand was performed with fasciotomies of the dorsal compartment of the forearm the same day. Microscopy and Gram stain demonstrated Gram-positive bacilli, thought to be Clostridium, and the patient remained on vancomycin and clindamycin while sensitivities were awaited.

During the course of 48 h following her surgical debridement and the start of antibiotic therapy the patient significantly improved. Multiple samples of fluid from the right hand were growing large numbers of C perfringens sensitive to clindamycin and vancomycin. She was weaned from both cardiovascular and respiratory support and successfully extubated. At this time the patient was referred to the plastic surgical team for negative pressure dressings and a plan for later skin grafting to her right hand wound.

Outcome and follow-up

Prior to discharge the patient underwent psychiatric review. She was found to have taken an impulsive overdose of her medications, demonstrated significant remorse and was regarded as being at low risk for taking future overdoses.

Since her admission to the intensive care unit, the patient has undergone further debridement and skin grafting of her dorsal right hand wound under local anaesthetic. The wound continues to gradually increase in size with a sloughy area at the base and the plastic surgery team currently plan to continue conservative management with regular review.

Discussion

The finding of gas gangrene at a venous cannula site has not previously been reported. In this case it was established as a cause of sepsis in a rapidly deteriorating patient who was then quickly referred for surgical debridement and source control.

Previous case reports of C perfringens causing gas gangrene and septicaemia associated with indwelling arterial catheters exist, but when appropriate aseptic techniques are followed Clostridium species is an exceptionally unusual pathogen to isolate.2 This suggests that in order for even the most pathogenic species to cause infection the environment must be optimised.3 Hyperbaric oxygen therapy has been shown to inhibit C perfringens toxin production in vitro4 and, as such, hypoxaemia is likely to contribute to bacterial cell growth in patients developing early infection.

Despite improved investigation, advanced monitoring techniques and new antibiotics, Clostridium species continue to result in significant morbidity and mortality.1 Complete early debridement of clostridia cellulitis and myositis is vital,5 and delay in diagnosis is a critical determinant of clinical outcome.

Our patient received prompt diagnosis and surgical debridement within just hours of deterioration requiring intubation and ventilation. The hypoxaemia which may have contributed to the growth of C perfringens was recognised and managed promptly. The principles of management of Clostridium are well known; early and aggressive surgical debridements with broad spectrum antibiotic therapy, close monitoring and physiological support. These can easily be forgotten as the disease is uncommon. Nevertheless, awareness of this potentially life-threatening and limb-threatening disease is important as a differential cause of a rapidly deteriorating patient with a cannula site infection.

Learning points

  • All indwelling venous and arterial catheters should be inserted in an aseptic and antiseptic manner.

  • If an unexpected deterioration occurs, all intravascular lines should be examined and promptly removed if possible.

  • Consider gas gangrene as a cause of rapidly worsening cellulitis/necrotising fasciitis, particularly in the presence of hypoxaemia.

  • Early referral for urgent surgical debridement is of critical importance in this instance.

Footnotes

Competing interests: None.

Patient consent: Obtained.

Provenance and peer review: Not commissioned; externally peer reviewed.

References

1. Hart G, Lamb RC, Strauss MB. Gas gangrene: I. A collective review. J Trauma Inj Infect Crit Care 1983;2013:991

2. Banks DC, Cawdrey HM, Yates DB, et al. Infection from intravenous catheters. Lancet 1970:2013:443–5. [PubMed]

3. Rose HD. Gas gangrene and Clostridium perfringens septicemia associated with the use of an indwelling radial artery catheter. CMAJ 1979;2013:1595–6 [PMC free article][PubMed]

4. Brummelkamp WH, Boerema I, Hoogendijk JL. Treatment of clostridial infections with hyperbaric oxygen drenching; a report on 26 cases. Lancet 1963;2013:235–8 [PubMed]

5. Wiuis AT. Clostridia of wound infection. CMAJ 1969;2013:1564–5

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  • Chapnick EK, Abter EI. Necrotizing soft-tissue infections. Infect Dis Clin North Am. 1996 Dec. 10(4):835-55. [Medline].

  • Gawande A. Casualties of war--military care for the wounded from Iraq and Afghanistan. N Engl J Med. 2004 Dec 9. 351(24):2471-5. [Medline].

  • Murray CK, Hsu JR, Solomkin JS, Keeling JJ, Andersen RC, Ficke JR. Prevention and management of infections associated with combat-related extremity injuries. J Trauma. 2008 Mar. 64(3 Suppl):S239-51. [Medline].

  • U.S. casualty status. Department of Defense, 2004. Available at http://www.defenselink.mil/news/casualty.pdf.

  • Wang Y, Hao P, Lu B, Yu H, Huang W, Hou H, et al. Causes of infection after earthquake, China, 2008. Emerg Infect Dis. 2010 Jun. 16(6):974-5. [Medline]. [Full Text].

  • Wang Y, Lu B, Hao P, Yan MN, Dai KR. Comprehensive treatment for gas gangrene of the limbs in earthquakes. Chin Med J (Engl). 2013 Oct. 126(20):3833-9. [Medline].

  • De A, Varaiya A, Mathur M, Bhesania A. Bacteriological studies of gas gangrene and related infections. Indian J Med Microbiol. 2003 Jul-Sep. 21(3):202-4. [Medline]. [Full Text].

  • Hart GB, Lamb RC, Strauss MB. Gas gangrene. J Trauma. 1983 Nov. 23(11):991-1000. [Medline].

  • Nichols RL, Smith JW. Anaerobes from a surgical perspective. Clin Infect Dis. 1994 May. 18 Suppl 4:S280-6. [Medline].

  • Knapp O, Maier E, Mkaddem SB, Benz R, Bens M, Chenal A, et al. Clostridium septicum alpha-toxin forms pores and induces rapid cell necrosis. Toxicon. 2010 Jan. 55(1):61-72. [Medline].

  • Oda M, Kihara A, Yoshioka H, Saito Y, Watanabe N, Uoo K. Effect of erythromycin on biological activities induced by clostridium perfringens alpha-toxin. J Pharmacol Exp Ther. 2008 Dec. 327(3):934-40. [Medline].

  • Ohtani K, Hirakawa H, Tashiro K, Yoshizawa S, Kuhara S, Shimizu T. Identification of a two-component VirR/VirS regulon in Clostridium perfringens. Anaerobe. 2010 Jun. 16(3):258-64. [Medline].

  • Stevens DL, Musher DM, Watson DA, et al. Spontaneous, nontraumatic gangrene due to Clostridium septicum. Rev Infect Dis. 1990 Mar-Apr. 12(2):286-96. [Medline].

  • Brown PW, Kinman PB. Gas gangrene in a metropolitan community. J Bone Joint Surg [Am]. 1974 Oct. 56(7):1445-51. [Medline].

  • Barnham M, Weightman N. Clostridium septicum infection and hemolytic uremic syndrome. Emerg Infect Dis. 1998 Apr-Jun. 4(2):321-4. [Medline]. [Full Text].

  • Fischer M, Bhatnagar J, Guarner J, Reagan S, Hacker JK, Van Meter SH, et al. Fatal toxic shock syndrome associated with Clostridium sordellii after medical abortion. N Engl J Med. 2005 Dec 1. 353(22):2352-60. [Medline].

  • McGuigan CC, Penrice GM, Gruer L, Ahmed S, Goldberg D, Black M. Lethal outbreak of infection with Clostridium novyi type A and other spore-forming organisms in Scottish injecting drug users. J Med Microbiol. 2002 Nov. 51(11):971-7. [Medline].

  • Lehnhardt M, Homann HH, Daigeler A, Hauser J, Palka P, Steinau HU. Major and lethal complications of liposuction: a review of 72 cases in Germany between 1998 and 2002. Plast Reconstr Surg. 2008 Jun. 121(6):396e-403e. [Medline].

  • Stevens DL, Bisno AL, Chambers HF, Everett ED, Dellinger P, Goldstein EJ. Practice guidelines for the diagnosis and management of skin and soft-tissue infections. Clin Infect Dis. 2005 Nov 15. 41(10):1373-406. [Medline].

  • Takazawa K, Otsuka H, Nakagawa Y, Inokuchi S. Clinical Features of Non-clostridial Gas Gangrene and Risk Factors for In-hospital Mortality. Tokai J Exp Clin Med. 2015 Sep 20. 40 (3):124-9. [Medline].

  • Bryant CS, Perry L, Shah JP, Kumar S, Deppe G. Life-Threatening Clostridial Sepsis in a Postmenopausal Patient with Degenerating Uterine Leiomyoma. Hindawi-Case Reports in Medicine. Available at http://dx.doi.org/10.1155/2010/541959. 2010; Accessed: 2017.

  • Larson CM, Bubrick MP, Jacobs DM, West MA. Malignancy, mortality, and medicosurgical management of Clostridium septicum infection. Surgery. 1995 Oct. 118(4):592-7; discussion 597-8. [Medline].

  • Chen E, Deng L, Liu Z, Zhu X, Chen X, Tang H. Management of gas gangrene in Wenchuan earthquake victims. J Huazhong Univ Sci Technolog Med Sci. 2011 Feb. 31(1):83-7. [Medline].

  • Zacharias N, Velmahos GC, Salama A, Alam HB, de Moya M, King DR. Diagnosis of necrotizing soft tissue infections by computed tomography. Arch Surg. 2010 May. 145(5):452-5. [Medline].

  • Hopkins KL, Li KC, Bergman G. Gadolinium-DTPA-enhanced magnetic resonance imaging of musculoskeletal infectious processes. Skeletal Radiol. 1995 Jul. 24(5):325-30. [Medline].

  • Butcher CH, Dooley RW, Levitov AB. Detection of subcutaneous and intramuscular air with sonography: a sensitive and specific modality. J Ultrasound Med. 2011 Jun. 30(6):791-5. [Medline].

  • Majeski J, Majeski E. Necrotizing fasciitis: improved survival with early recognition by tissue biopsy and aggressive surgical treatment. South Med J. 1997 Nov. 90(11):1065-8. [Medline].

  • Ustin JS, Malangoni MA. Necrotizing soft tissue infections. Crit Care Med. 2011 Apr 28. [Medline].

  • Wong CH, Khin LW, Heng KS, Tan KC, Low CO. The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections. Crit Care Med. 2004 Jul. 32 (7):1535-41. [Medline].

  • Anaya DA, Bulger EM, Kwon YS, Kao LS, Evans H, Nathens AB. Predicting death in necrotizing soft tissue infections: a clinical score. Surg Infect (Larchmt). 2009 Dec. 10 (6):517-22. [Medline].

  • Stevens DL, Maier KA, Laine BM, Mitten JE. Comparison of clindamycin, rifampin, tetracycline, metronidazole, and penicillin for efficacy in prevention of experimental gas gangrene due to Clostridium perfringens. J Infect Dis. 1987 Feb. 155(2):220-8. [Medline].

  • Aldridge KE, Ashcraft D, Cambre K, Pierson CL, Jenkins SG, Rosenblatt JE. Multicenter survey of the changing in vitro antimicrobial susceptibilities of clinical isolates of Bacteroides fragilis group, Prevotella, Fusobacterium, Porphyromonas, and Peptostreptococcus species. Antimicrob Agents Chemother. 2001 Apr. 45(4):1238-43. [Medline].

  • Khanna N. Clindamycin-resistant Clostridium perfringens cellulitis. J Tissue Viability. 2008 Aug. 17(3):95-7. [Medline].

  • Bernard GR, Vincent JL, Laterre PF, LaRosa SP, Dhainaut JF, Lopez-Rodriguez A. Efficacy and safety of recombinant human activated protein C for severe sepsis. N Engl J Med. 2001 Mar 8. 344(10):699-709. [Medline].

  • Abraham E, Laterre PF, Garg R, Levy H, Talwar D, Trzaskoma BL. Drotrecogin alfa (activated) for adults with severe sepsis and a low risk of death. N Engl J Med. 2005 Sep 29. 353(13):1332-41. [Medline].

  • Stevens DL, Bryant AE, Adams K, Mader JT. Evaluation of therapy with hyperbaric oxygen for experimental infection with Clostridium perfringens. Clin Infect Dis. 1993 Aug. 17(2):231-7. [Medline].

  • Brown DR, Davis NL, Lepawsky M, et al. A multicenter review of the treatment of major truncal necrotizing infections with and without hyperbaric oxygen therapy. Am J Surg. 1994 May. 167(5):485-9. [Medline].

  • George ME, Rueth NM, Skarda DE, Chipman JG, Quickel RR, Beilman GJ. Hyperbaric oxygen does not improve outcome in patients with necrotizing soft tissue infection. Surg Infect (Larchmt). 2009 Feb. 10(1):21-8. [Medline].

  • Shaw JJ, Psoinos C, Emhoff TA, Shah SA, Santry HP. Not just full of hot air: hyperbaric oxygen therapy increases survival in cases of necrotizing soft tissue infections. Surg Infect (Larchmt). 2014 Jun. 15 (3):328-35. [Medline].

  • Tibbles PM, Edelsberg JS. Hyperbaric-oxygen therapy. N Engl J Med. 1996 Jun 20. 334(25):1642-8. [Medline].

  • Manning-Giest B, Rimawi BH. Severe Infections in Obstetrics and Gynecology: How Early Surgical Intervention Save Lives. J Clin Gynecol Obstet. 2016 Mar. 5:1-16. [Full Text].

  • Monturiol-Gross L, Flores-Díaz M, Campos-Rodríguez D, Mora R, Rodríguez-Vega M, Marks DL, et al. Internalization of Clostridium perfringens a-toxin leads to ERK activation and is involved on its cytotoxic effect. Cell Microbiol. 2013 Nov 18. [Medline].

  • [Guideline] Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014 Jul 15. 59 (2):e10-52. [Medline].

  • Determann C, Walker CA. Clostridium perfringens gas gangrene at a wrist intravenous line insertion. BMJ Case Rep. 2013 Oct 9. 2013:[Medline].

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