Gas gangrene

Is There a Place for Hyperbaric Oxygen Therapy?

Hyperbaric oxygen therapy (HBOT) involves treating patients by providing 100% oxygen through inhalation while inside a treatment pressurized chamber. The oxygen acts as a drug and the hyperbaric chamber as the dosing device. The effect of hyperbaric hyperoxia is dose dependent and, therefore, treatment depth and duration are important when considering its use. HBOT can either be the primary method of treatment or used adjunctively to medications or surgical techniques. The underpinning physiology is to bring oxygen-rich plasma to hypoxic tissue, preventing reperfusion injury, strengthening immune responsiveness, and encouraging new collagen deposition as well as endothelial cell formation.

Treating infections with ionizing radiation: a historical perspective and emerging techniques

Background

Widespread use and misuse of antibiotics have led to a dramatic increase in the emergence of antibiotic resistant bacteria, while the discovery and development of new antibiotics is declining. This has made certain implant-associated infections such as periprosthetic joint infections, where a biofilm is formed, very difficult to treat. Alternative treatment modalities are needed to treat these types of infections in the future. One candidate that has been used extensively in the past, is the use of ionizing radiation. This review aims to provide a historical overview and future perspective of radiation therapy in infectious diseases with a focus on orthopedic infections.

Methods

A systematic search strategy was designed to select studies that used radiation as treatment for bacterial or fungal infections. A total of 216 potentially relevant full-text publications were independently reviewed, of which 182 focused on external radiation and 34 on internal radiation. Due to the large number of studies, several topics were chosen. The main advantages, disadvantages, limitations, and implications of radiation treatment for infections were discussed.

Results

In the pre-antibiotic era, high mortality rates were seen in different infections such as pneumonia, gas gangrene and otitis media. In some cases, external radiation therapy decreased the mortality significantly but long-term follow-up of the patients was often not performed so long term radiation effects, as well as potential increased risk of malignancies could not be investigated. Internal radiation using alpha and beta emitting radionuclides show great promise in treating fungal and bacterial infections when combined with selective targeting through antibodies, thus minimizing possible collateral damage to healthy tissue.

Conclusion

The novel prospects of radiation treatment strategies against planktonic and biofilm-related microbial infections seem feasible and are worth investigating further. However, potential risks involving radiation treatment must be considered in each individual patient.

Uterine Sarcoma Presenting with Sepsis from Clostridium perfringens Endometritis in a Postmenopausal Woman

Clostridium perfringens is an anaerobic gram positive rod that is found in normal vaginal and cervical flora in 1-10% of healthy women. Uterine infection with Clostridium perfringens is seen rarely but is often related to underlying uterine pathology and can progress quickly to sepsis. Early recognition of sepsis, prompt treatment with antibiotics, and source control with surgical management allow for optimal chance of recovery. We present a case of a postmenopausal woman who presented with sepsis, vaginal bleeding, and back pain who was found to have Clostridium perfringens infection in the setting of undifferentiated uterine sarcoma.

Is There an Association Between Hyperbaric Oxygen Therapy and Improved Outcome of Deep Chemical Peeling? A Randomized Pilot Clinical Study

Background

Phenol chemical peeling (PCP) treatment is associated with prolonged recovery and sustained adverse events. Hyperbaric oxygen therapy (HBOT) is known to accelerate wound healing. The purpose of the current study was to evaluate the effect of HBOT on PCP recovery period and adverse events.

Methods

This is a pilot randomized controlled clinical study. Women following PCP underwent 5 consecutive daily HBOT sessions, compared with PCP alone. Pain, pruritus, erythema, crusting, scaling, and edema were daily evaluated up to 28 days following PCP. Photographs taken on days 14 and 35 following PCP were assessed. Confidence to appear in public was assessed 14 days following PCP.

Results

Eight participants equally assigned to HBOT and control groups. Lower severity scores for erythema, scaling, and pruritus were documented in the HBOT group (mean difference 1.19, P = .006; .84, P = .04; and 2.19, P = .001, respectively). Photographic assessment severity score was higher for skin tightness, edema, erythema, crusting, and scaling in the control group on day 14 post PCP (P < .05) and for erythema on day 35 post PCP (P < .05). Epithelialization percentage was higher in the HBOT group on day 14 post PCP compared with controls (98.5% ± 1% vs 94.2% ± 1%; P = .021). The HBOT group scored higher in confidence to appear in public (20.8 ± 1.7 vs 14.5 ± 1.3; P = .029).

Conclusion

Hyperbaric oxygen therapy following PCP is associated with faster recovery as assessed by both patients and caregivers. So far, HBOT was mainly used in the treatment of problematic or chronic wounds. Our study suggests expanding the indications in which hyperbaric oxygen treatment is applicable and recommended.

Clostridial Hepatic Gas Gangrene with Massive Intravascular Haemolysis and Acute Renal Failure: A Case Report and Literature Review

Clostridial hepatic gas gangrene is a rare but highly fatal disease. We report a complicated case of clostridial hepatic gas gangrene, presented with short history of fever, followed by severe back pain and systemic hypertension. Urgent contrast computed tomogram (CT) thorax and abdomen was performed to rule out aortic dissection. Instead, a gas-forming lesion was found in the liver, with multiple areas of hepatic venous gas. Also, CT showed poor renal contrast excretion, indicating acute renal failure. Unexpectedly, the patient developed cardiac arrest shortly after imaging and succumbed despite active resuscitation. Repeated biochemical tests showed gross hemolysis. Autopsy revealed generalised autolytic changes in internal organs with abundance of Gram positive bacilli. The overall picture was compatible with clostridial hepatic gas gangrene, with massive intravascular haemolysis and acute renal failure. Upon literature review, the importance of early diagnosis and aggressive management is highlighted.

Clostridium septicum: An Unusual Link to a Lower Gastrointestinal Bleed

Clostridium septicum is a highly virulent pathogen which is associated with colorectal malignancy, hematological malignancy, immunosuppression, diabetes mellitus and cyclical neutropenia. Presentation may include disseminated clostridial infection in the form of septicemia, gas gangrene, and mycotic aortic aneurysms. We report the case of a 62-year-old female presenting with necrotizing fasciitis of her left thigh and subsequently developing rectal bleeding. While she was being treated with empiric antibiotics, her blood culture was found to be positive for C. septicum. We would like to highlight the importance of early colorectal cancer screening in minimizing the occurrence of undetected tumors which provide an optimal growth environment for C. septicum, leading to localized and/or remote infection.

Analytic Reviews : Hyperbaric Oxygen Therapy

The physiological effects of hyperbaric oxygen extend beyond the elevation of oxygen concentration in body tissues, and clinical data is available to support its use in more than gas bubble diseases. Hyperbaric medicine is discussed within the context of its recognized mecha nisms of action. The experimental data and clinical ex perience for hyperbaric oxygen therapy are reviewed for the following conditions: clostridial myonecrosis, necrotizing soft-tissue infections, chronic refractory os teomyelitis, radiation necrosis, refractory cutaneous ul cerations, compromised skin grafts and flaps, crush in jury and acute peripheral ischemia, carbon monoxide poisoning, arterial gas embolism, decompression sick ness, and thermal burns. Risks associated with hyper baric oxygen therapy are discussed, and cost analysis data are noted for specific conditions.

Interventions for treating gas gangrene

BACKGROUND

Gas gangrene is a rapidly progressive and severe disease that results from bacterial infection, usually as the result of an injury; it has a high incidence of amputation and a poor prognosis. It requires early diagnosis and comprehensive treatments, which may involve immediate wound debridement, antibiotic treatment, hyperbaric oxygen therapy, Chinese herbal medicine, systemic support, and other interventions. The efficacy and safety of many of the available therapies have not been confirmed.

OBJECTIVES

To evaluate the efficacy and safety of potential interventions in the treatment of gas gangrene compared with alternative interventions or no interventions.

SEARCH METHODS

In March 2015 we searched: The Cochrane Wounds Group Specialized Register, The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), Ovid MEDLINE, Ovid EMBASE, EBSCO CINAHL, Science Citation Index, the China Biological Medicine Database (CBM-disc), the China National Knowledge Infrastructure (CNKI), and the Chinese scientific periodical database of VIP INFORMATION (VIP) for relevant trials. We also searched reference lists of all identified trials and relevant reviews and four trials registries for eligible research. There were no restrictions with respect to language, date of publication or study setting.

SELECTION CRITERIA

We selected randomized controlled trials (RCTs) and quasi-RCTs that compared one treatment for gas gangrene with another treatment, or with no treatment.

DATA COLLECTION AND ANALYSIS

Independently, two review authors selected potentially eligible studies by reviewing their titles, abstracts and full-texts. The two review authors extracted data using a pre-designed extraction form and assessed the risk of bias of each included study. Any disagreement in this process was solved by the third reviewer via consensus. We could not perform a meta-analysis due to the small number of studies included in the review and the substantial clinical heterogeneity between them, so we produced a narrative review instead.

MAIN RESULTS

We included two RCTs with a total of 90 participants. Both RCTs assessed the effect of interventions on the 'cure rate' of gas gangrene; 'cure rate' was defined differently in each study, and differently to the way we defined it in this review.One trial compared the addition of Chinese herbs to standard treatment (debridement and antibiotic treatment; 26 participants) against standard treatment alone (20 participants). At the end of the trial the estimated risk ratio (RR) of 3.08 (95% confidence intervals (CI) 1.00 to 9.46) favoured Chinese herbs. The other trial compared standard treatment (debridement and antibiotic treatment) plus topical hyperbaric oxygen therapy (HBOT; 21 participants) with standard treatment plus systemic HBOT (23 participants). There was no evidence of difference between the two groups; RR of 1.10 (95% CI 0.25 to 4.84). For both comparisons the GRADE assessment was very low quality evidence due to risk of bias and imprecision so further trials are needed to confirm these results.Neither trial reported on this review's primary outcomes of quality of life, and amputation and death due to gas gangrene, or on adverse events. Trials that addressed other therapies such as immediate debridement, antibiotic treatment, systemic support, and other possible treatments were not available.

AUTHORS' CONCLUSIONS

Re-analysis of the cure rate based on the definition used in our review did not show beneficial effects of additional use of Chinese herbs or topical HBOT on treating gas gangrene. The absence of robust evidence meant we could not determine which interventions are safe and effective for treating gas gangrene. Further rigorous RCTs with appropriate randomisation, allocation concealment and blinding, which focus on cornerstone treatments and the most important clinical outcomes, are required to provide useful evidence in this area.

A case of nontraumatic gas gangrene in a common marmoset (Callithrix jacchus)

The common marmoset is widely used in neuroscience and regenerative medicine research. However, information concerning common marmoset disorders, particularly infectious diseases, is scarce. Here, we report a case of a female common marmoset that died suddenly due to gas gangrene. The animal presented with gaseous abdominal distention at postmortem, and Clostridium perfringens type A was isolated from several tissues. Vacuoles, a Gram-positive bacteremia and intravascular hemolysis were observed microscopically in the muscles, liver and lungs. On the basis of these findings, we diagnosed nontraumatic gas gangrene caused by Clostridium perfringens type A in this common marmoset.

Vertebral osteomyelitis and epidural abscess caused by gas gangrene presenting with complete paraplegia: a case report

Introduction

Gas gangrene is most often caused by Clostridium perfringens infection. Gas gangrene is a medical emergency that develops suddenly. The mortality rate is higher with trunk involvement than with involvement of the extremities, which carries a better prognosis. With respect to vertebral involvement, there are few reports in the literature. The purpose of this paper is to report a very rare case of vertebral osteomyelitis caused by gas gangrene.

Case presentation

A 78-year-old Japanese woman with diabetes mellitus was admitted to our hospital with the chief complaints of back pain, dysuria, and complete paralysis of both legs. A computed tomography scan showed soft tissue swelling anterolaterally at intervertebral disc level T11/12 and a gas-containing epidural abscess that compressed her spinal cord. Cultures later grew Clostridium perfringens and Escherichia coli. Hemilaminectomy was done from T10 to T12, and an epidural abscess was removed. She went on to have fusion surgery 6 weeks after the initial operation and subsequently experienced complete pain relief. She was discharged 2 months later, at which time she was able to walk with a cane. Examination 18 months after surgery showed normal gait without a cane.

Conclusions

Discitis caused by gas gangrene infection was successfully treated by immediate debridement and subsequent fusion surgery.

Clostridium perfringens septicemia in a long-beaked common dolphin Delphinus capensis: an etiology of gas bubble accumulation in cetaceans

An adult female long-beaked common dolphin Delphinus capensis live-stranded in La Jolla, California, USA, on July 30, 2012 and subsequently died on the beach. Computed tomography and magnetic resonance imaging revealed gas bubble accumulation in the vasculature, organ parenchyma, mandibular fat pads, and subdermal sheath as well as a gas-filled cavity within the liver, mild caudal abdominal effusion, and fluid in the uterus. Gross examination confirmed these findings and also identified mild ulcerations on the palate, ventral skin, and flukes, uterine necrosis, and multifocal parenchymal cavitations in the brain. Histological review demonstrated necrosis and round clear spaces interpreted as gas bubbles with associated bacterial rods within the brain, liver, spleen, and lymph nodes. Anaerobic cultures of the lung, spleen, liver, bone marrow, and abdominal fluid yielded Clostridium perfringens, which was further identified as type A via a multiplex PCR assay. The gas composition of sampled bubbles was typical of putrefaction gases, which is consistent with the by-products of C. perfringens, a gas-producing bacterium. Gas bubble formation in marine mammals due to barotrauma, and peri- or postmortem off-gassing of supersaturated tissues and blood has been previously described. This case study concluded that a systemic infection of C. perfringens likely resulted in production of gas and toxins, causing tissue necrosis.

Gas gangrene presenting with back pain

A 61-year-old Caucasian man (previously fit and well) presented to the emergency department with 2 days of non-traumatic, non-radiating lower back pain. He was admitted to our department having been provisionally diagnosed with discitis. Later that night, while being reassessed, a skin lesion on his thigh appeared and gas could be palpated. The patient was then taken immediately to theatre and a radical surgical debridement was performed. The organism that grew from tissue samples was Clostridium septicum, which when identified is an indication to exclude colonic neoplasms. The patient managed to preserve his limb on this occasion, however, he underwent a right hemicolectomy for what proved to be a colonic tumour at a later date.

Necrotizing Soft Tissue Infections: Surgeon's Prospective

Necrotizing soft tissue infections (NSTIs) are fulminant infections of any layer of the soft tissue compartment associated with widespread necrosis and systemic toxicity. Delay in diagnosing and treating these infections increases the risk of mortality. Early and aggressive surgical debridement with support for the failing organs significantly improves the survival. Although there are different forms of NSTIs like Fournier's gangrene or clostridial myonecrosis, the most important fact is that they share common pathophysiology and principles of treatment. The current paper summarizes the pathophysiology, clinical features, the diagnostic workup required and the treatment principles to manage these cases.

Diagnosis of gas gangrene: does a discrepancy exist between the published data and practice

The Infectious Disease Society of America has defined gas gangrene as an infection caused by Clostridium species. However, in many clinical settings, soft tissue infections that produce subcutaneous gas have been diagnosed as gas gangrene without identification of the presence of Clostridium species. Instead, the diagnosis was based on clinical and radiographic findings. A chart review was performed of 25 consecutive patients treated at the Atlantic Health System for infections of the lower extremity that were diagnosed as gas gangrene. Wound cultures from the 25 patients grew 31 different species of bacteria. The most prevalent organism was Staphylococcus aureus, which accounted for 17 of 31 (54.84%) different organisms identified and 19.77% of 86 separate aerobic or anaerobic cultures. The most prevalent genus was Streptococcus, which accounted for 20 (64.52%) of the organisms identified and 23.26% of the cultures. The most prevalent anaerobic genus was Peptostreptococcus, which accounted for 8 (25.81%) of the organisms identified and 9.3% of the cultures. None of the cultures grew Clostridium species. These findings showed that gas-forming soft tissue infections of the lower extremity, commonly diagnosed as gas gangrene, are rarely caused by Clostridium species.

[Benign subcutaneous emphysema after nail penetration. Case report and important differential diagnoses]

Crepitus under the skin after penetrating injuries: harmless benign subcutaneous emphysema or life-threatening infection with gas-producing bacteria (gas gangrene because of Clostridium perfringens, crepitating cellulitis because of anaerobic Streptococcus or other coliforme bacteria)? We report a case of a 74-year-old male who developed massive crepitation of the left upper extremity and the lateral thoracic wall and mediastinal emphysema after sustaining a laceration of the left thumb and forefinger from a nail. Because there was the suspicion of gas gangrene we performed generous skin incisions of the ventral and dorsal part of the hand, the forearm and upper arm and open wound treatment. A triple antibiotic therapy was initiated. Due to fast regression of the subcutaneous emphysema and the mediastinal emphysema, continuing lack of symptoms, negative smear test results from the beginning and low infection parameters in the blood all wounds could be closed 9 days after primary surgery. The suspicion of gas gangrene was not confirmed so the diagnosis of benign subcutaneous emphysema was made.

Necrotizing soft-tissue infections

OBJECTIVE

To provide a contemporary review of the diagnosis and management of necrotizing soft-tissue infections.

DATA SOURCES

Scientific literature and internet sources.

STUDY SELECTION

Major articles of importance in this area.

CONCLUSIONS

The mortality for necrotizing soft-tissue infections appears to be decreasing, possibly due to improved recognition and earlier delivery of more effective therapy. Establishing a diagnosis and initiating treatment as soon as possible provides the best opportunity for a good outcome.

Correction of Hypoxia, a Critical Element for Wound Bed Preparation Guidelines: TIMEO2 Principle of Wound Bed Preparation

Wound bed preparation is an organized approach to create an optimal environment for wound healing by the use of the most cost-effective therapeutic options. It has become an essential part of wound management and seeks to use the latest findings from molecular and cellular research to maximize the benefits of today's advanced wound care products. The international advisory panel on wound bed preparation met in 2002 to develop a systemic approach to wound management. These principles of this approach are referred to by the mnemonic TIME, which stands for the management of nonviable or deficient tissue (T), infection or inflammation (I), prolonged moisture imbalance (M), and nonadvancing or undermined epidermal edge (E). One critical element of pathophysiology, understanding of the hypoxic nature of the wound and correction of hypoxia as a critical element of wound bed preparation, is not covered. This article proposes to add correction of hypoxia to the TIME principle (TIMEO2 principle) based on the evidence. The evidence that will support the reason and the need for modification of the wound bed preparation protocol is discussed.

Intravascular haemolysis and septicaemia due to Clostridium perfringens liver abscess

Intravascular haemolysis is a rare but serious complication of Clostridium perfringens sepsis. The outcome is usually fatal unless treatment is started early. We describe a case of survival after haemolysis and multiple organ failure in the setting of a ruptured liver abscess and sepsis caused by C. perfringens in an immunocompetent 58-year-old male.

Bacterial, fungal, parasitic, and viral myositis

Infectious myositis may be caused by a broad range of bacterial, fungal, parasitic, and viral agents. Infectious myositis is overall uncommon given the relative resistance of the musculature to infection. For example, inciting events, including trauma, surgery, or the presence of foreign bodies or devitalized tissue, are often present in cases of bacterial myositis. Bacterial causes are categorized by clinical presentation, anatomic location, and causative organisms into the categories of pyomyositis, psoas abscess, Staphylococcus aureus myositis, group A streptococcal necrotizing myositis, group B streptococcal myositis, clostridial gas gangrene, and nonclostridial myositis. Fungal myositis is rare and usually occurs among immunocompromised hosts. Parasitic myositis is most commonly a result of trichinosis or cystericercosis, but other protozoa or helminths may be involved. A parasitic cause of myositis is suggested by the travel history and presence of eosinophilia. Viruses may cause diffuse muscle involvement with clinical manifestations, such as benign acute myositis (most commonly due to influenza virus), pleurodynia (coxsackievirus B), acute rhabdomyolysis, or an immune-mediated polymyositis. The diagnosis of myositis is suggested by the clinical picture and radiologic imaging, and the etiologic agent is confirmed by microbiologic or serologic testing. Therapy is based on the clinical presentation and the underlying pathogen.

A rare trifocal presentation of Clostridium septicum myonecrosis

Gas gangrene or clostridial myonecrosis is a rare, life threatening infection of the muscle that is typically associated with recent surgery or trauma. It usually affects older individuals who suffer from vascular insufficiency or who are immunocompromised. The typical pathogen is Clostridium perfringens. Atraumatic gas gangrene caused by Clostridium septicum is less common and has a unique association with colon cancer. This condition aggressively spreads through the muscular tissue and often culminates in septic shock. Fatality occurs within 48 hours if left untreated yet, despite emergent treatment the mortality rate is >50% without any comorbidities. Given the propensity to occur in the extremities the orthopedic surgeon must be familiar with its presentation, diagnosis, and treatment. This article presents a case of a 16-year-old girl who presented to the emergency room with an 18-hour history of malaise and progressive right arm discomfort and swelling. The identification and emergent treatment of necrotizing soft tissue infections is important and often falls on the orthopedic surgeon, especially when isolated to the extremities. Subtle initial presentation and rapid progression of the infection are classic findings of necrotizing soft tissue infections, particularly with clostridial myonecrosis and necrotizing fasciitis. Clostridium myonecrosis is a rare orthopedic condition with high mortality. Early diagnosis and debridement is imperative. A team approach to managing these patients postoperatively is necessary. The use of hyperbaric oxygen can be considered, however, it may not be readily available and its use is unproven in human studies. Due to its high mortality, one should err on the side of more aggressive resective/ablative surgery.

Fournier's gangrene progressing from the buttocks to the scrotum following a perianal abscess

We describe a case of gas-producing infection following a perianal abscess. A 61-year-old man was admitted to our hospital complaining of perineal pain and was found to have a perianal abscess. He was diabetic but had not received treatment for the disease. Although the perianal abscess was drained and antibiotic treatment started, severe swelling of the scrotum, with crepitation, redness, and partial necrosis progressed rapidly. Computed tomography revealed subcutaneous gas formation in the scrotum. A culture study revealed Clostridium, Enterococcus, and numerous other types of bacteria. The patient was diagnosed with Fournier's gangrene caused by infection with Clostridium in combination with other species of bacteria. The infection was refractory to drainage and antibiotic therapy. Thus, repeated extensive debridement of all necrotic tissue in the scrotum was required until healthy granulation was present in the wound. Our case shows that, in patients with Fournier's gangrene caused by infection with Clostridium in combination with other species of bacteria, the mainstay of treatment should be open drainage and aggressive surgical debridement of all necrotic tissue, followed by broad-spectrum antibiotic therapy.

Outcome of brain abscess by Clostridium perfringens

OBJECTIVE

Despite the aggressive infection of soft tissue caused by Clostridium perfringens (gas gangrene-necrotizing fasciitis), a brain abscess with this bacteria treated by early surgical excision, debridement of necrotic tissue, and antibiotic coverage may be expected to have a good recovery. Long-term follow-up has not been well established in this group of patients. We report this case to show the outcome at 3 years post surgical and antibiotic treatment for C. perfringens brain abscess and stress the need for urgent intervention to achieve good outcome. We also present a literature review of Clostridial brain abscesses since the 1960s.

CLINICAL PRESENTATION

A 53-year-old man was brought to the emergency room after having a witnessed seizure status postassault 3 days before admission. On presentation, he was febrile, disoriented, lethargic, and demonstrated right upper extremity weakness. A computed tomographic scan of the head showed a left frontoparietal depressed cranial fracture complicated with gas and intraparenchymal air fluid level cavity.

INTERVENTION

Emergent surgery for debridement and excision of necrotic tissue was performed. Empiric intravenous antibiotic therapy was started and penicillin G was added for 6 weeks after C. perfringens was demonstrated.

CONCLUSION

Despite the severe infection and effect of C. perfringens in soft tissues in the brain, it appears that emergent surgical debridement and antibiotic coverage will yield an excellent outcome for these patients.

[Gas gangrene of the abdominal wall due to underlying GI pathology: seven cases]

OBJECTIVE

Gas gangrene of the abdominal wall is a rare clinical occurrence with high rates of morbidity and mortality. The primary source of the infection is often unknown. To analyze the primary underlying intestinal etiologies and diagnostic approaches of gas gangrene of the abdominal wall, and to highlight specific treatment problems, particularly that of constructing a colostomy exteriorized through a massively infected abdominal wall.

PATIENTS AND METHODS

Seven cases of abdominal wall gas gangrene due to a gastrointestinal etiology were identified. (Cases arising from proctologic sources or related to recent abdominal surgery were excluded.) During the same period, 39 other patients presenting with abdominal wall gangrene from non-intestinal sources were treated.

RESULTS

The etiologies were: perforated sigmoid diverticulitis (n=2), perforated appendicitis (n=1), acute pancreatitis with associated cecal perforation (n=1), and perforated colorectal cancer (n=3). Four of the seven patients died despite treatment (mortality of 57%).

CONCLUSION

The clinical presentations of these seven cases demonstrate that a GI source must be suspected whenever a patient presents with abdominal wall gas gangrene, even when there are no specific GI symptoms. Imaging, particularly with CT scan, is essential both to visualize the extent of tissue necrosis and to reveal underlying primary GI pathology. This optimizes the surgical approach both by allowing for complete debridement and drainage of infected tissue, and by focussing the intervention on correction of the underlying primary GI source of infection.

Civilian gas gangrene: a clinical challenge

Gas gangrene due to clostridia infections is commonly seen in war injuries and is much less commonly seen in civilian life. When such problems do occur, they present a challenge to the surgeon due to the associated high morbidity and mortality associated. A case is presented where a patient developed gas gangrene in a limb consequent to trauma that had been treated surgically. It is vital to make a correct diagnosis at the earliest to limit disease progression and to avoid complications.

Microbiology and management of soft tissue and muscle infections

This review summarizes the microbiological aspects and management of soft tissue and muscle infections. The infections presented are: impetigo, folliculitis, furunculosis and carbuncles, cellulitis, erysipelas, infectious gangrene (includes necrotizing fasciitis or streptococcal gangrene, gas gangrene or clostridium myonecrosis, anaerobic cellulites, progressive bacterial synergistic gangrene, synergistic necrotizing cellulitis or perineal phlegmon, gangrenous balanitis, and gangrenous cellulitis in the immunocompromised patient), secondary bacterial infections complication skin lesions, diabetic and other chronic superficial skin ulcers and subcutaneous abscesses and myositis. These infections often occur in body sites or in those that have been compromised or injured by foreign body, trauma, ischemia, malignancy or surgery. In addition to Group A streptococci and Staphylococcus aureus, the indigenous aerobic and anaerobic cutaneous and mucous membranes local microflora usually is responsible for polymicrobial infections. These infections may occasionally lead to serious potentially life-threatening local and systemic complications. The infections can progress rapidly and early recognition and proper medical and surgical management is the cornerstone of therapy.

Infection and musculoskeletal conditions: Infectious myositis

Infectious myositis, an infection of the skeletal muscle(s), is uncommon. This clinical entity may be caused by viral, bacterial, fungal, and parasitic pathogens. Viral etiologies typically cause diffuse myalgias and/or myositis, whereas bacteria and fungi usually lead to a local myositis which may be associated with sites compromised by trauma or surgery and are more common among immunocompromised patients. Localized collections within the muscles are referred to as pyomyositis. Other pyogenic causes of myositis include gas gangrene, group A streptococcal myonecrosis, and other types of non-clostridial myonecrosis. Early recognition and treatment of these conditions are necessary as they may rapidly become life-threatening.

Fournier's gangrene: a retrospective clinical study on forty-one patients

BACKGROUND

Fournier's gangrene, first described by Dr Jean Alfred Fournier in 1883, still has a high mortality rate. The prognosis and outcome of such patients were analysed.

METHODS

Forty-one patients with Fournier's gangrene were reviewed on the parameters of age, sex, aetiological agents, predisposing factors, treatment modalities and outcomes.

RESULTS

Although early intervention and careful treatment was carried out, nine of 41 patients (21.9%) died as a result of complications of septicemia. Among the treatment modalities, there were extensive debridement, drainage, excisions of the skin and fascia, colostomy procedure, extensive antibiotic treatment and hyperbaric oxygen therapy. Although a combination of different treatment modalities were used, the mortality rate was 21.9%.

CONCLUSIONS

Fournier's gangrene is still a severe disease. Today, hyperbaric oxygen treatment is very effective in the treatment of this disease.

The hospital costs of treating necrotizing fasciitis

BACKGROUND

Management of necrotizing fasciitis places significant demands upon hospital and medical resources. A successful management usually requires extensive surgical intervention and an adjunct hyperbaric oxygen treatment. The cost impact on the health care system has not been well characterized. We have, therefore, analysed the cost of treating this disease at an Australian tertiary referral hospital with extensive case experience and well-developed financial costing systems and have compared this with the current casemix-based government funding arrangements applying in Victoria, Australia.

METHODS

Data was extracted from the medical records of 92 sequential patients treated by the Alfred Hospital (Melbourne, Australia) during the four financial years 2000-04. Clinical costing data and government funding data was provided by the hospital's Finance Departments.

RESULTS

The total Alfred Hospital in-patient costs for treating the patients was $5,935,545 with a mean cost per patient of $64,517 (range, $1025 to $514,889). The total casemix-based funding allocation derived from treating these patients was calculated at $3,208,664 with the per patient mean $34,887 (range, $1331 to $387,168). This analysis does not include allowance for non-Alfred Hospital costs such as those incurred by the ambulance service, referring hospitals, for rehabilitation or as a result of the burden of residual disability.

CONCLUSIONS

This study has confirmed that a significant economic burden is involved in treating necrotizing fasciitis. There is a substantial difference between the hospital costs and government funding for treating these patients in the Australian setting.

Manifestations of cutaneous diabetic microangiopathy

The etiologies of a variety of skin conditions associated with diabetes have not been fully explained. One possible etiological factor is diabetic microangiopathy, which is known to affect the eyes and kidneys in patients with diabetes. There are many mechanisms by which diabetes may cause microangiopathy. These include excess sorbitol formation, increased glycation end products, oxidative damage, and protein kinase C overactivity. All of these processes occur in the skin, and the existence of a cutaneous diabetic microangiopathy has been well demonstrated. These microangiopathic changes are associated with abnormalities of skin perfusion. Because the skin plays a thermoregulatory role, there is significant capillary redundancy in normal skin. In diabetic patients, loss of capillaries is associated with a decrease in perfusion reserve. This lost reserve is demonstrable under stressed conditions, such as thermal stimulation. The associated failure of microvascular perfusion to meet the requirements of skin metabolism may result in diverse skin lesions in patients with diabetes. Many skin conditions peculiar to diabetes are fairly rare. Necrobiosis lipoidica diabeticorum (NLD) and diabetic bullae occur very infrequently as compared with diabetic retinopathy and nephropathy. Conversely, there is a correlation between diabetic microvascular disease and NLD. This correlation also exists with more common skin conditions, such as diabetic dermopathy. This relationship suggests that diabetic microangiopathy may contribute to these conditions even if it is not primarily causal. Clinically, the major significance of diabetic cutaneous microangiopathy is seen in skin ulceration which is very common and has a major impact on diabetic patients. Many factors contribute to the development of diabetic foot ulcers. Neuropathy, decreased large vessel perfusion, increased susceptibility to infection, and altered biomechanics all play a role, but there is no doubt that inadequate small blood vessel perfusion is a major cause of the inability to heal small wounds that eventually results in ulcer formation. The accessibility of skin capillaries makes cutaneous diabetic microangiopathy an attractive model for research on the evolution of microvascular disease in diabetic patients.

Non-infective subcutaneous emphysema of the hand secondary to a minor webspace injury

Subcutaneous emphysema in the hand is commonly associated with infection or high-pressure injection injuries, with other non-infectious causes being reported as rarities in the literature. We describe an unusual case of minor injury to the first webspace resulting in significant subcutaneous emphysema.

Clostridium perfringens: insight into virulence evolution and population structure

Clostridium perfringens is an important pathogen in veterinary and medical fields. Diseases caused by this organism are in many cases life threatening or fatal. At the same time, it is part of the ecological community of the intestinal tract of man and animals. Virulence in this species is not fully understood and it does seem that there is erratic distribution of the toxin/enzyme genes within C. perfringens population. We used the recently developed multiple-locus variable-number tandem repeat analysis (MLVA) scheme to investigate the evolution of virulence and population structure of this species. Analysis of the phylogenetic signal indicates that acquisition of the major toxin genes as well as other plasmid-borne toxin genes is a recent evolutionary event and their maintenance is essentially a function of the selective advantage they confer in certain niches under different conditions. In addition, it indicates the ability of virulent strains to cause disease in different host species. More interestingly, there is evidence that certain normal flora strains are virulent when they gain access to a different host species. Analysis of the population structure indicates that recombination events are the major tool that shapes the population and this panmixia is interrupted by frequent clonal expansion that mostly corresponds to disease processes. The signature of positive selection was detected in alpha toxin gene, suggesting the possibility of adaptive alleles on the other chromosomally encoded determinants. Finally, C. perfringens proved to have a dynamic population and availability of more genome sequences and use of comparative proteomics and animal modeling would provide more insight into the virulence of this organism.

Musculoskeletal infections in children

Serious musculoskeletal infections in children include osteomyelitis, septic arthritis, pyomyositis, and necrotizing fasciitis. The epidemiology, pathophysiology, and microbiology of each of these infections are reviewed. Specific diagnostic studies and management strategies are discussed. Prompt recognition and treatment is emphasized to prevent potential long-term sequelae.

Fulminant massive gas gangrene caused by Clostridium perfringens

Clostridium perfringens (C.P) gas gangrene is one of the most fulminant infectious diseases. We encountered fulminant massive gas gangrene in a 56- year-old man with alcoholic liver cirrhosis. The patient died 14 hours after diagnosis of gas gangrene (54 hours after admission). Dramatic changes in abdominal CT imaging revealed development of a massive volume of gas in the intra-portal vein, retroperitoneum and abdominal subcutaneous tissue within 24 hours. We also proved C.P infection by immunohistological staining, leading to a diagnosis of C.P gas gangrene.

Rapid infectious killers

Central to the practice of emergency medicine is the ability to identify patients in whom immediate intervention is needed to prevent long-term morbidity and mortality. This article has highlighted some of the characteristics of several infectious diseases that may become fatal quickly if not treated quickly and appropriately by physicians. Bacterial meningitis,necrotizing soft tissue infections, invasive gram-negative disease, pneumo-coccal pneumonia, and West Nile encephalitis all require prompt recognition and treatment by emergency care providers.

Gas gangrene pyaemia with myocardial abscess formation--fatal outcome from a rare infection nowadays

We report a case of sudden death after gas gangrene. A 67-year-old male patient with diabetes mellitus and chronic renal failure (on haemodialysis three times a week) presented in the surgical emergency department with a severe swelling and crepitation in the right groin. No signs of trauma were present-except for a well-healed, 1-year-old scar after femoro-popliteal bypass surgery. Two days earlier, he had presented to the internal medicine department with epigastric pain and had left against medical advice. On readmission the patient was initially conscious and in a stable cardiopulmonary condition but developed sudden cardiocirculatory failure and underwent resuscitation. Despite all resuscitation measures, including the administration of high doses of catecholamines and the treatment of hyperkalemia, the patient died. Autopsy revealed septicaemia with rod-shaped gram-positive bacteria, typical of Clostridium perfringens, evidenced by multiple areas of myonecrosis. Abscess formation was found in the myocardium. Clostridial gas gangrene is a rare clinical condition. Unless immediate diagnosis and adequate therapy measures are taken, the outcome and chances for survival are poor as demonstrated by this case.

Clostridium infection in a knee extensor mechanism allograft: case report and review

An unusual case of Clostridium perfringens infection after an allograft reconstruction of an extensor mechanism in a multiply revised total knee arthroplasty is reported. The case occurred in an elderly patient with an underlying bleeding dyscrasia who had previously undergone two revision total knee arthroplasties. The patient was treated by open irrigation, debridement, removal of allograft and prosthesis, intravenous antibiotics, and implantation of an antibiotic impregnated cement spacer utilizing an intramedullary rod.