Non-mechanical traumatic gas gangrene: forgotten but not gone

Introduction

Gas gangrene (GG) is a rare but life-threatening infection that is most often associated with recent surgery or skeletal muscle trauma. ¹ Traumatic injury accounts for about 70% of GG cases, and about 80% of these are caused by Clostridium perfringens. ² Other pathogens include C. septicum, C. novyi, C. histolyticum, C. bifermentans, C. tertium and C. fallax. Occasionally, GG can occur at remote sites, with seeding from a gastrointestinal source in the site of the malignancy. ³ We report a case of GG following an intramuscular injection in a non-diabetic HIV seronegative man who died 60 hours after receiving an intramuscular injection. The case occurred in rural India and stresses the need for hand washing and sterile precautions even when performing simple procedures such as intramuscular injections. This is a very significant, and yet often neglected, occurrence in the rural regions of developing countries.

Case history

A 40-year-old previously healthy man who had no co-morbidity was brought to the emergency department of a referral hospital in South India with pain and swelling of the upper right arm and blisters. He had received an intramuscular injection of vitamin B-complex in the right shoulder region two days earlier from a primary care physician based in a rural area. He had developed severe pain at the injection site after three hours, followed by chills with rigor.

Due to the unbearable pain and increasing size of the swelling, he was admitted to the referral hospital with a diagnosis of injection abscess. On examination he was revealed to be toxic and febrile with altered sensorium. His systolic blood pressure was 60 mm Hg but the diastolic cycle was not recordable. His central pulse was feeble. The entire arm was mottled and indurated with multiple blisters around the elbow (Figure 1). The arm and forearm were tense, tender and erythematous with palpable subcutaneous crepitus extending along the entire volar aspect of the limb with foul smelling bubbles discharging from the puncture site on digital pressure. The plain radiograph of the arm (Figure 2) revealed the presence of gas under the skin and between the muscular fibres, which was characteristic of GG. He had: a leukocyte count of 15,000/uL with 90% neutrophils; C-reactive protein 28 mg/dL; total creatinine kinase 3,098 IU/L; serum creatinine 2.3 mg/dL; blood glucose 116 mg/dL; and haemoglobin 12.1 g/dL. His HIV status was negative. Arterial blood gas revealed pH 7.13, PaO2 94 mmHg, PaCO2 32 mmHg and HCO3 10 mEq/L, suggestive of metabolic acidosis.

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Figure 1

Tense, tender right upper arm with brownish discoloration extending well into the axilla and forearm. Blister formation at the elbow is evident. Crepitation was present on palpation of the arm

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Figure 2

Plain X-ray of the right upper arm showing gas formation in the muscle plane extending into the axilla and forearm

The Gram stain of the discharge from the lesion showed Gram-positive rods and a few inflammatory cells. The discharge specimen was sent for culture. Resuscitative therapy was started with intravenous fluids, a combination of penicillin and clindamycin and vasopressors were added. Surgical consultation was sought for the immediate debridement of the devitalized tissue. Despite these measures, he became unresponsive 45 minutes after arrival. Cardiopulmonary resuscitation was initiated as per standard protocol but was in vain. The rhythm in the monitor continued to show asystole, and the patient was pronounced dead 1.5 hours after his arrival at the emergency department.

Although his blood culture was negative, C. perfringens was grown from the ante mortem specimen taken from the lesions with typical saccharolytic reaction. There was no indication of gastrointestinal malignancies.

Discussion

GG is a life threatening muscle infection caused by Clostridium species. Progressive invasion and the destruction of healthy muscle tissue (spreading myonecrosis) is the hallmark of this infection. ² It can spread as fast as 2 cm/h and cause multiorgan failure and death within 12 hours. Although wound contamination with clostridial spores or vegetative organisms occurs frequently, in the absence of devitalized tissue it does not necessarily lead to infection. In one study, 30–80% of open traumatic wounds were contaminated with clostridial species. ² Other important features of GG include: muscle swelling; severe pain; crepitus and sepsis with hypotension; leucocytosis; multiorgan dysfunction; elevated creatinine kinase; and disseminated intravascular hemolysis. ³ Also, a few inflammatory cells in the smear are indicative of cytolysis induced by toxins produced by the organisms. ⁴ This widespread infection is facilitated by a lack of fibrous attachments. The radiographs of the affected area will demonstrate the presence of subcutaneous gas within and between muscle fibres, as in this case. ⁵

The occurrence of GG after intramuscular injections has previously been reported. ^6,7 In this case, the exact cause for the development of GG was not discovered. The pathogens could have been carried from the needle, syringe, contamination of injection fluid, the patient's own skin or from the hands of the person administering the injection. This emphasizes the importance of host and local factors for the development of GG. Simple hand washing and sterile precautions could have prevented this death.

Conclusion

This case emphasizes the importance of hand washing and sterile precautions even when performing simple procedures such as intramuscular injections. Although the use of sterile gloves would be ideal before such procedures, their supply in rural areas is often limited and care-givers often have to resort to hand washing as an alternative method. Dr William Osler rightly said, ‘soap, water and common sense are the best disinfectants’. Ignoring the significance of such a simple but vital step before performing any procedure is bound to cause problems including grave ones such as GG.