Gas gangrene of the leg with tissue necrosis

Case contributed by Dr Domenico Nicoletti

Presentation

Diabetic with fever, pain and swollen left calf. Two weeks earlier, foot injury with a dirty nail. On physical examination, crepitus and skin sloughing was noted on the left calf. The blood tests showed significantly raised inflammatory markers with a white cell count of 22.2 × 109/L an C-reactive protein of 345 mg/L. Within two hours since his admission, the patient underwent leg fasciotomy due to compartment syndrome and broad surgical debridement and drainage of the infected areas.

Patient Data

Age: 65 years
Gender: Male

CT left leg with contrast

CT

Fluid collections and gas with ring enhancement located in the posterior, lateral and anterior lodges of the leg with extension to the malleolar region, without vascular involvement. There is a fasciotomy with two anterolateral incisions. The bone is normal.

 

The general condition of the patient worsened with severe left lower limb pain and he was intubated due to a threatened airway. After three days, amputation of the limb above the knee was performed. Blood cultures grew Clostridium perfrigens.

Operative report

Atherosclerosis of the native arteries of the limbs with gangrene. Sepsis.

Left femur after above ­knee amputation.

Case Discussion

Gas formation within the soft tissue is a manifestation of infection. Gas gangrene is a bacterial infection caused by several clostridial species associated with high morbidity and mortality. The infection usually follows open contaminated wounds with concomitant vascular compromise. Another form of clostridial infection is anaerobic cellulitis where the gas is confined to the subcutaneous and superficial fascial layers. Diabetes mellitus, steroid treatment, and immunodeficiency states including HIV infection are predisposing factors. Amputation is usually necessary to control infection and prevent death. 

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