Gas gangrene with Clostridium septicum in a neutropenic patient

Abstract

Gas gangrene is a rare presentation of a necrotizing fasciitis, caused by Clostridium perfringens, C. septicum and other clostridial species. With its rapid progression it is a potentially life-threatening infection, that poses as a challenge in the clinical management requiring an interdisciplinary approach.Here we present a 62-year-old woman, who developed neutropenic fever while undergoing chemotherapy for triple negative breast cancer. She presented with a high fever, reporting little pain in her left thigh accompanied by redness and induration locally. Subsequently the patient developed pain and redness of the back of the left hand. The initial findings suggested cellulitis and immediate empiric treatment with intravenous meropenem was started. Despite the antibiotic treatment the patient rapidly developed septic shock along with progression of the local infection. Emergency surgical debridement revealed extensive necrosis of the soft tissues including extensive myonecrosis of the thigh. On the left hand an extensive debridement was performed, the left lower limb could not be preserved and exarticulation of the left hip was required. Microbiologically C. septicum was isolated in different samples, confirming gas gangrene. As there was no local entry portal on the skin, hematogenous seeding from intestinal translocation in this neutropenic patient was suspected. The empiric antibiotic treatment was tailored to intravenous penicillin and complemented with clindamycin for toxin inhibition. Following radical debridement and antibiotic treatment, the patient could be stabilized. After repetitive debridement wound closure was achieved and the patient was discharged for rehabilitation. Antibiotic treatment was continued for four weeks.This rare case of gas gangrene in a neutropenic patient shows the complexity in the diagnostic and therapeutic management of necrotizing soft tissue infections in immunocompromised patients. It particularly highlights the importance of an interdisciplinary management with fast recognition of the disease and rapid, if needed radical, surgical debridement as well as tailored antibiotic treatment for a successful outcome.

Fig. 1

Clinical presentation of the left thigh upon the patient’s entry into the operating room. Purplish patches present with palpable crepitus along the entire thigh extending down to the knee

Fig. 2

Preoperative computed tomography images. A, B: Extended presence of gas inclusion in the anteromedial muscle group of the left thigh. C, D: Intraluminal gas in the venous system shown here in the V. cava inf. as well as the right ventricle

Fig. 3

Intraoperative condition. Presence of widespread necrotic tissue involving subcutaneous tissue, muscular fascia, and muscles of the left thigh

Fig. 4

Left lower limb amputated. Necrotic soft tissues visible proximally

Fig. 5

Biopsy of the fascia of the thigh. A: Necrotic soft tissue with abundant interspersed rod bacteria (blue, HE 600x). B: Abundant Gram-positive rod bacteria (Gram stain, 600x)