Clinical Picture
Non-traumatic gas gangrene due to Clostridium sporogenes
Lancet Infect Dis 2020; 20: 754
Department of Medical
Microbiology (R Kanaujia MD,
A Angrup MD, Prof P Ray MD),
Department of General Surgery
(Prof D Dahiya MS, A R Banda
MS), Post Graduate Institute of
Medical Education and
Research, Chandigarh, India
Correspondence to:
Dr Archana Angrup, Department
of Medical Microbiology,
Post Graduate Institute of
Medical Education and Research,
Chandigarh 160012, India
archanaangrup@yahoo.com
A B
Figure: Gas gangrene with discoloration of skin and blebs
(A) Whole leg view and (B) and sole of the foot.
754
Rimjhim Kanaujia, Divya Dahiya, Ashwin Rao Banda, Pallab Ray, Archana Angrup
A farmer aged 25 years presented at a primary health
centre in Tarantaran (India) with fever, pain in the left leg,
and a non-healing, rapidly advancing, painful ulcerating
wound on his left foot, which he had had for the previous
2 weeks. He had a long-standing history of bilateral lower-
limb elephantiasis that progressed over the past 8 years.
For the latest complaints, he received empirical antibiotics
for 2 weeks, with no improvement. He was referred to the
Postgraduate Institute of Medical Education and Research
(Chandigarh, India) on suspicion of necro­tising fasciitis.
On admission, the patient had toxic symptoms such as
high-grade fever (38·9°C) and tachycardia. On examination
of the left leg and foot, the skin was violet and gunmetal
grey, the flexor tendons were exposed, and blebs with a
musty smell were present (figure). Pulses of the popliteal
artery and the anterior and posterior tibial arteries were
not detectable, and subcutaneous crepitus could be felt
over the entire leg. The patient had a white blood cell count
of 14 × 10⁹ cells per L, platelet count of 237 × 10⁹ cells per L,
and concentrations of haemoglobin of 10·1 g/dL, of
sodium of 141 mmol/L, of potassium of 3·6 mmol/L, of
urea of 26 mg/dL, and of creatinine of 0·6 mg/dL. His pro­
thrombin index was 65%. Radiological investigation of the
leg unveiled multiple intramuscular air pockets. Bilateral
lower-limb Doppler ultrasound revealed normal blood
flow in the anterior and posterior tibial arteries.
The patient was empirically started on augmentin
1·25 mg and clindamycin 600 mg every 8 h, for presumed
gas gangrene. The patient was given intravenous fluids
and transfused fresh frozen plasma. In view of his critical
condition, he unerwent emergency surgical debridement.
Multiple pus pockets were found during the operation.
The wound was debrided extensively until a healthy
muscle layer was reached; approximately 15–20 kg of
necrotic tissue were removed. The debrided tissue was
sent for aerobic and anaerobic culturing.
Gram staining of necrotic tissue showed thick Gram-
positive bacilli, with no polymorphs. A presumptive
diagnosis of gas gangrene was made. After 48 h of
incubation, the culture plates ino­culated with tissue and
incubated anaerobically (Anoxomat system, MART
Micro­biology BV, Drachten, Netherlands) were opened
and revealed small, white spreading haemolytic colonies
sensitive to metronidazole. Gram staining of the colonies
revealed thick Gram-positive bacilli with subterminal
spores. The colonies were con­ firmed as Clostridium
sporogenes by matrix-assisted laser desorption/ionisation-
time of flight mass spectro­metry (Microflex LT Biotyper
Instrument Bruker Daltonics, Bremen, Germany) with a
score of 2·0. The patient was continued on the above
mentioned intravenous antibiotics and growth of healthy
granulation tissue was observed after the debridement
operation.
Clostridial myonecrosis, or gas gangrene, is a rapidly
pro­gressive life-threatening infection of skeletal muscle
caused by clostridia (mainly C perfringens, C novyi,
C septicum, and C sporogenes). It usually starts manifesting
24–72 h after traumatic injuries or as secondary infection
in tissues with decreased oxygen tension (eg, elephantiasis
or crush injuries). Patients present with excruciating pain
at the site and, on palpation and radiological investigations,
crepitus and gas accu­ mulation can be observed. Dis­
colouration of skin and presence of blebs with the sero­
sanguineous discharge and musty smell are characteristic
symptoms. Gram staining of the discharge usually reveals
Gram-positive bacilli but no spores, as Clostridium species
do not form spores within the tissue. The α toxin secreted
by this group of clostridia destroys neutrophils, hence
neutrophil counts are low. This toxin leads to profound
ischaemia and the lesions do not bleed, unlike other soft
tissue infections where the inflammatory process increases
blood flow and hence bleeding.
Rapid diagnosis and prompt therapeutic intervention are
crucial for management of clostridial myonecrosis. For
extre­mities, amputation or extensive debridement is
appropriate. Penicillin remains the antibiotic of choice.
Other drugs, including metronidazole, clindamycin, and
carbapenems are also effective.
Contributors
RK and AA did microbiological investigations and drafted the manuscript.
DD and ARB assisted in taking clinical history. PR did the final edit of of the
manuscript. Written consent for publication was obtained from the patient.
Declaration of interests
We declare no competing interests.
© 2020 Elsevier Ltd. All rights reserved.
www.thelancet.com/infection Vol 20 June 2020