Initially the patient complains of severe pain in the infected area. There is swelling and color changes from pale to red, to bronze and finally blackish green, the hallmark of necrosis. Large blisters are formed, containing gas bubbles which can be seen or felt under the skin. Exudates from the wound smell of putrifaction. The patient sweats a lot and becomes agitated and anxious. There is vomiting, rapid heart rate and breathing, and jaundice, caused by bacterial exotoxins. 

The patient is initially alert and becomes lethargic as the disease progresses. Hypotension and hypovolemia lead to shock, then, coma, and kidney failure. Without treatment, patients die within 48 hours. Probably due to delay in treatment, one out of eight people with limb involvement and two out of three people with trunk involvement succumb. Most patients with posttraumatic gas gangrene have had a history of skin or soft tissue injury or open fractures. Patients with postoperative gas gangrene recall having undergone surgery. On the other hand, spontaneous gas gangrene has been reported from patients with occult malignancy and no apparent exposure to infections with clostridia. 

The first symptom of gas gangrene is pain that gradually worsens, accompanied by heaviness of the affected extremity, low-grade fever and mental apathy.  Other signs and symptoms include tenderness, swelling, massive edema, crepitus, tachycardia, skin discoloration with hemorrhagic blebs and bullae, and fruity odor.  

• Gangrene

  gas) 040.0 Cellulitis (diffuse) (with lymphangitis) (see also Abscess) 682.9 anaerobic (see also Gas gangrene) 040.0 Edema, edematous 782.3 malignant (see also Gangrene, gas) 040.0 Gangrene, gangrenous (anemia) (artery) (cellulitis) (dermatitis) (dry [icd9data.com]

  Recently, cases of spontaneous or nontraumatic gas gangrene have been reported in both adults and children. We report a case of nontraumatic gas gangrene involving both the lower extremities simultaneously. [ncbi.nlm.nih.gov]

  Not all wounds contaminated with clostridia develop gas gangrene; the myonecrosis seems to only develop when sufficient devitalized tissue is present to support anaerobic metabolism. [2] Traumatic gas gangrene and surgical gas gangrene occur through direct [emedicine.medscape.com]

• Swelling

  Watch for signs of infection (such as redness, pain, drainage, or swelling around a wound). See your provider promptly if these occur. [nlm.nih.gov]

  The authors report a clinical case of gas gangrene in a rare anatomic location in a 79-year-old woman, admitted because 3 days earlier she had developed a painful swelling with erythematous cutis in her right iliac fossa and suffered from a seriously [ncbi.nlm.nih.gov]

  Several enzymes produced by the pathogen, including collagenase and hyal-uronidase, break down macromolecules in the dead tissues to smaller ones, thereby promoting swelling. [alpfmedical.info]

• Fever

  […] report a clinical case of gas gangrene in a rare anatomic location in a 79-year-old woman, admitted because 3 days earlier she had developed a painful swelling with erythematous cutis in her right iliac fossa and suffered from a seriously increasing fever [ncbi.nlm.nih.gov]

  In severe cases, a child can have bloody diarrhea, fever, and a swollen or enlarged abdomen that is tender to the touch. [deadlydeceit.com]

• Wound Infection

  Gas gangrene results from dirty lacerated wounds infected by anaerobic bacteria, especially species of Clostridium. [medical-dictionary.thefreedictionary.com]

  Wound Infections I I © The McGraw-Hill Microbiology, A Human Companies, 2003 Perspective, Fourth Edition 27.3 Diseases Due to Anaerobic Bacterial Wound Infections 703 Table 27.5 Gas Gangrene (Clostridial Myonecrosis) © Clostridium perfringens spores enter [alpfmedical.info]

  We hypothesize that sugars, which have been used throughout history to prevent wound infection, may represent a nutritional signal against gas gangrene development. [ncbi.nlm.nih.gov]

  […] noun Rapidly spreading gangrene occurring in dirty wounds infected by bacteria that give off a foul-smelling gas. [en.oxforddictionaries.com]

  Tofte RW, Cunningham BL: Aeromonas hydrophila wound infection of the hand initially presenting as clostridial myonecrosis. J Hand Surg 1983; 8:333-335. 17. [healio.com]

• Rigor

  Nonetheless the most important act remains the early, complete, rational and rigorous debridement of the wounds. Far from being an obsolete attitude, this is one of humility, wisdom ... and with future prospects. [ncbi.nlm.nih.gov]

  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. [cochrane.org]

• Jaundice

  […] fever Moderate to severe pain around a skin injury Pale skin color, later becoming dusky and changing to dark red or purple Swelling that worsens around a skin injury Sweating Vesicle formation, combining into large blisters Yellow color to the skin (jaundice [nlm.nih.gov]

  If left untreated, many complications may arise from gas gangrene, including the following: Tissue damage Jaundice Liver damage Kidney failure Shock Delirium Sepsis (where the infection spreads to other parts of the body) Coma Death It’s important that [belmarrahealth.com]

  Potential complications include: permanent tissue damage jaundice liver damage kidney failure shock widespread infection coma death The sooner gas gangrene is treated, the better the outcome. [healthline.com]

  In some people, the skin turns yellow, indicating jaundice. These effects are caused by toxins produced by the bacteria. Typically, people remain alert until late in the illness, when dangerously low blood pressure (shock) and coma develop. [merckmanuals.com]

• Tachycardia

  Postoperatively he did well, until he developed tachycardia, profound hypotension, and coffee ground emesis on postoperative day 3. Despite resuscitative measures, he arrested and expired. [ncbi.nlm.nih.gov]

  → red-purple → black skin discoloration and overlying bullae Sweet, foul-smelling, or nonodorous discharge produced by anaerobic metabolic products Crepitus Systemic toxicity Can progress to systemic infection within a few hours Early signs: fever, tachycardia [amboss.com]

  Symptoms include: Air under the skin ( subcutaneous emphysema ) Blisters filled with brown-red fluid Drainage from the tissues, foul-smelling brown-red or bloody fluid ( serosanguineous discharge) Increased heart rate ( tachycardia ) Moderate to high [nlm.nih.gov]

  Her heart rate may increase (tachycardia), along with rapid breathing, sweating, paleness, and fever. [healthychildren.org]

  […] as 6/24 Symptoms History muscle penetrating injury Earliest & most sensitive symptom is pain Pain/ heaviness out of proportion to injury or procedure Initially alert & anxious Later fearful of death Signs General Pale & sweaty Moderate fever Marked tachycardia [orthofracs.com]

• Hypertension

  In this paper we present a case of fulminant, endogenous gas gangrene in a 58-year old diabetic female with arterial hypertension and atherosclerosis, following uneventful laparoscopic cholecystectomy. [ncbi.nlm.nih.gov]

• Blister

  Large blisters often form. Gas bubbles may be visible within the blister or may be felt under the skin, usually after the infection progresses. Fluids draining from the wound smell rotten (putrid). [merckmanuals.com]

  Symptoms include: Air under the skin ( subcutaneous emphysema ) Blisters filled with brown-red fluid Drainage from the tissues, foul-smelling brown-red or bloody fluid ( serosanguineous discharge) Increased heart rate ( tachycardia ) Moderate to high [nlm.nih.gov]

  By noon a blister had formed in this area and by 5:00 p.m. the blister was 8 cm with crepitance in left calf. Xray revealed large amount of gas in left lower extremity, left lower abdominal wall of pelvis. [archive.rubicon-foundation.org]

• Subcutaneous Crepitus

  Physical exam demonstrated an erythematous and edematous left foot with subcutaneous crepitus along the plantar surface. Plain film x-rays of the left foot demonstrated gas pockets in the soft tissue and acute osteomyelitis (Figure 1). [ncbi.nlm.nih.gov]

• Muscle Swelling

  The hallmarks of this disease are rapid onset of myonecrosis with muscle swelling, severe pain, gas production, and sepsis. [1, 2, 3] Pathophysiology Clostridium species are gram-positive, spore-forming, anaerobic rods normally found in soil and the gastrointestinal [emedicine.medscape.com]

• Myalgia

  Myalgias. Anorexia. Gas gangrene pattern recognition For traumatic gas gangrene : Pain (often out of proportion to skin findings). Skin discoloration (initially pale, then bronze, then purple or red). Tense skin. [clinicaladvisor.com]

• Suggestibility

  The clinical course and chest computed radiography and thoracoscopy findings suggested that her condition resulted from a relatively rare esophageal injury after she accidentally ingested a fish bone. [ncbi.nlm.nih.gov]

  A study by Mendez et al suggests that sugar may inhibit the production of alpha and theta toxins that trigger the gas. [3] Clostridium perfringens, previously known as Clostridium welchii, is the most common cause of clostridial gas gangrene (80-90% of [emedicine.medscape.com]

• Kidney Failure

  failure, coma, and finally death. [nlm.nih.gov]

  Potential complications include: permanent tissue damage jaundice liver damage kidney failure shock widespread infection coma death The sooner gas gangrene is treated, the better the outcome. [healthline.com]

  If untreated, her condition can get worse and lead to a lowering of blood pressure to dangerous levels (hypotension), kidney failure, an impairment of her mental status, and shock. [healthychildren.org]

  Kidney failure and death rapidly follow. Without treatment, death occurs in 100% of infected people, usually within 48 hours. Even with treatment, about one in four people die. [merckmanuals.com]

• Confusion

  The authors also discuss the confusion surrounding the definition of gas gangrene. [ncbi.nlm.nih.gov]

  HyperbaricLink Commentary Clostridium perfringens is not to be confused with antibiotic-resistant Clostridium difficile (C. diff), an increasingly common source of healthcare-associated infections (HAIs). Gas gangrene does not involve C. diff. [hyperbariclink.com]

  Gas gangrene must not be confused with poison gases, phosgene or mustard gas, or even with trench foot. [kumc.edu]

  The fulminant course described in this report proceeded from a painful but alert patient to a confused and potentially moribund patient within less than two hours following hospital admission. [healio.com]

  This has led to some confusion, since NSTIs have a similar pathologic basis underlying their development, and require similar treatment modalities irrespective of the body part on which they are located. [clinicaladvisor.com]

The diagnosis of gas gangrene relies heavily on a thorough physical examination, assessment of symptoms, history of possible exposure to Clostridium, and rapid progression of disease.  Hence, prompt diagnosis and treatment is critical as any further delay can be potentially fatal. X-rays are used to visualize gas bubbles in muscle tissue, while computed tomography (CT) or magnetic resonance imaging (MRI) can detect areas of dead muscle tissue. Gas bubbles may also be found in other anaerobic infections. Microscopic examination and culture of exudate from the wound should confirm the presence of clostridia.

Persons harboring clostridia do not necessarily have gas gangrene. Biopsy of muscle can reveal pathologic changes to establish the diagnosis of clostridial myonecrosis. Radiographs can show the disposition of gas bubbles in the intramuscular fascial planes and muscles. Extraluminal gas in intra-abdominal clostridial gas gangrene is readily evaluated with CT scanning. A recent study using the new-generation CT scanners reported 100% sensitivity in detecting necrotizing soft tissue infections; however, the study did not include patients taken to surgery prior to CT scanning and not all clinically suspected cases were examined [12]. MRI is only 80-90% efficient in detecting necrotizing soft tissue infection; specificity is likewise limited and the technic is time consuming [13].

Gas gangrene should be treated as a medical emergency. The patient's survival depends on immediate recognition of gas gangrene and aggressive treatment with antibiotics with debridement [14]. Any delay in diagnosis and treatment is tantamount to a death sentence. Records show that 20% of patients with limb involvement require amputation. Treatment with hyperbaric oxygen is recommended if available. Any patient with clostridial gas gangrene should be considered critically ill and should be confined in the ICU with provision for telemetry and pulse oximetry. In any case, surgical removal of necrotic tissue and anti-tetanustherapy are equally important. Fluid and electrolyte balance should be maintained. Traditionally, penicillin G in dosages of 10-24 million U/d was the drug of choice. Recent studies show that protein synthesis inhibitors (e.g., clindamycin, chloramphenicol, tetracycline) are more efficacious in interrupting the production of clostridial exotoxins and the clinical course of the disease. 

Gas gangrene is 100% fatal without treatment within 24 hours from onset of symptoms [5]. With treatment, the overall mortality rate is reduced from 20 to 30% [1] [10] [11]. The risk is higher when the trunk is involved (50%) than with the extremities (24%) which presents a better prognosis [1]. Prompt diagnosis and surgical intervention are important in the management of gas gangrene as these two factors will determine the outcome of treatment. Prognosis of gas gangrene is good when the incubation period is shorter than 30 hours, with limb rather than trunk involvement, and when there are no underlying medical conditions or complications (e.g., ARDS, DIC, shock, renal failure). On account of the varied predisposing factors spontaneous gas gangrene is more difficult to manage that the two other forms of gas gangrene. Gas gangrene is an infectious disease entity with highly fatal consequences. On the average, mortality rates vary widely, 25% in recent studies and nearly 100% in spontaneous gas gangrene when treatment is delayed. Recovery can be expected with patients who survive the initial critical hours.  Shock when it occurs does not portend well because of complications and irreversible damage to the body's vital functions. 

Gas gangrene is most often caused by a bacterium called Clostridium perfringens. It also can be caused by group A streptococcus, Staphylococcus aureus, and Vibrio vulnificus.

Clostridial species are present in water, soil, dust, and intestines of man and various animals [1] [2] [3]. C. perfringens is subdivided into 5 distinct types - A, B, C, D, and E. Of these subgroups, type A is associated with most human infections. C. perfringens is aerotolerant or partially tolerant of aerobic conditions. It is fast-growing with a generation time of 8 to 10 minutes and produces abundant gas under optimal conditions.

There are three types of gas gangrene namely: posttraumatic, postoperative and spontaneous [4]. Posttraumatic gas gangrene is seen in 60% of all cases, resulting from motor vehicle accidents, gunshot wounds, compound fractures, electrical or thermal burns, and farm or industrial injuries (due to contact with contaminated soil). Other risk factors, probably not so rare in this day and age, are intramuscular or subcutaneous injections of drugs and narcotics. 

Risk factors for postoperative clostridial infections are colon resection, biliary and other GI surgery, ruptured appendix, bowel perforation, colonoscopy and laparoscopic cholecystectomy.

Spontaneous clostridial myonecrosis constitutes 16% of cases of gas gangrene [4]. Of these, 60% is due to C. perfringens and 30% to C. septicum [5] [6]. Susceptibility to spontaneous gas gangrene is likely to occur in patients with clinically serious conditions such as colorectal adenocarcinoma, hematologic malignancy, frost bite, atherosclerosis, diabetes, or neutropenic colitis. Children with neutropenia, whether induced by chemotherapy or pathophysiologic, are particularly prone to C. septicum infections. Still many spontaneous gangrene cases have no detectable predisposing condition. 

Gas gangrene has a short incubation period and is potentially fatal under any circumstance. Certain injuries are very conducive sites for the development of the causative organisms: deep wounds, traumatized tissues; venipuncture or intramuscular injection with contaminated needles;  open wounds and fractures that are contaminated with soil or excrements.

Clostridium species occur everywhere and have a wide range of ecological niche in soil or cultivated land. The density of bacterial population in the soil correlates proportionately with the incidence of posttraumatic gas gangrene  This type of gas gangrene occurs in 60% of cases, most of which are the result of vehicular accidents [7] and various traumatic injuries. There is no comprehensive epidemiological data on gas gangrene. Morbidity and mortality is not gender related. With age, if at all, it is usually among the elderly or those with physical handicaps or concomitant ailments. Prevalence is also most likely to be higher in countries or areas lacking access to adequate and proper health care.

Clostridia species are ubiquitous and widely distributed in the soil, especially in cultivated land. The density of clostridia in the soil is a contributing factor in the development of trauma-related gas gangrene. Gas gangrene can be classified as posttraumatic, postoperative, or spontaneous. Posttraumatic gas gangrene accounts for 60% of the overall incidence; most cases involve automobile collisions [7]. Gas gangrene has no specific sexual predilection, and the sex of the individual does not affect the outcome. Although age is not a prognostic factor in gas gangrene, advanced age and comorbid conditions are associated with a higher likelihood of mortality. Although no published data exist, prevalence is most likely higher in countries other than the United States because of lack of access to health care in other parts of the world.

Clostridium organisms are saprophytic and widely distributed in soil and dust. Bacteria have been isolated from mucous membranes, GI tract, female genital tract, skin and the perineum. Although clostridia are obligate anaerobes some species can tolerate aerobic conditions (aerotolerant). Low oxygen tension is required for growth and production of exotoxins which are soluble proteins. The kappa-toxin produced by C perfringens is a collagenase which destroys blood vessels and connective tissue. Other clostridial toxins are deoxyribonuclease and hyaluronidase. 

In posttraumatic or postoperative gangrene lesions are initially contaminated by clostridial spores, which need to germinate. Conditions in the wound itself, that is, damaged tissue, provide the necessary enzymes and low redox potential for the germination of bacterial spores. In experimental laboratory animals, the presence of foreign materials, premature wound closure, and devitalized muscle have been shown to accelerate bacterial proliferation, gas and toxin-production.    

The typical incubation period of gas gangrene is less than 24 hours, but duration of one hour to 6 weeks have been observed. Progressive tissue destruction results from rapid bacterial growth and the effects of exotoxins. The pathogenesis of gas gangrene includes necrosis of muscle and subcutaneous fat, thrombosis of blood vessels and edema which altogether compromise blood supply to the affected organ.

Gas production is presumed to be the result of fermentation of glucose. Analysis of C septicum spontaneous gas gangrene shows the following components: 74.5% nitrogen; 16.1% oxygen; 5.9% hydrogen; and 3.4% carbon dioxide. Carbon dioxide and hydrogen sulfide insinuate into muscle bellies and fascial planes. These biochemical events accompany the course of infection and its sequelae [8]. Meanwhile exotoxins may cause severe systemic hemolysis, depress hemoglobin levels, and with hypotension, may lead to acute tubular necrosis, renal failure and finally, shock.  C. perfringens gas gangrene is terminally fatal following the attack on damaged muscle (myonecrosis), progressive destruction of adjacent viable tissue, hypovolemia and shock. The main extracellular and highly potent toxins produced by this organism are α phospholipase C (PLC) and θ perfringolysin O (PFO). PLC is the major lethal factor in C. perfringens gas gangrene [9]. Exotoxins produced by clostridia are soluble tissue-necrotizng enzymes (antigens). These are hyaluronidase, lecithinase, collagenase, fibrinolysin, hemagglutinin, and hemolysin. At least 17 of these identifiable exotoxins are used for distinguishing subtypes of C. perfringens (i.e., type A to type E). 

• Do not suture wounds from collision injury or open fractures with torn muscle and soil contaminants.       
• Instruct volunteers and health care providers on the potential danger of gas gangrene and tetanus in patients rescued from natural disasters and accidents, and the importance of emergency procedures when possible or seeking professional help for prompt and adequate treatment.
• Wounds should be cleaned thoroughly by removing foreign materials, soil, and necrotic tissue from the wounds.
• Administer antibiotics intravenously to surgery patients to prevent postoperative infection.
• There is no vaccine against clostridial infection.
• Avoid exposing open wound on hands and feet to contamination with soil .

Gas gangrene is a life-threatening necrotizing infection of skeletal muscles caused by several species of pathogenic bacteria. The most prominent among these is Clostridium perfringens, hence, the term clostridial myonecrosis. Although other clostridial species, Group A Streptococcus, Staphylococcus aureus, and Vibrio vunificus are associated with gas gangrene, much of the knowledge of the disease is attributed to C. perfringens. So far as known, C. perfringens gas gangrene is the most rapidly insidious and potentially fatal complication following surgery or traumatic injury from accidents. Toxins and gases are produced in the infected tissue, causing progressive destruction of healthy muscle within 6-8 hours. Clostridial myonecrosis is a medical emergency because of the short incubation period. Without prompt medical intervention, death can ensue in 48 hours. 

Diagnosis is through examination of open wounds, bacterial culture and microscopy, and imaging studies to visualize the presence of gas in lesions. Antibiotic treatment and debridement of infected wounds are standard procedures; amputation of a gangrenous limb if it cannot be deferred.

The causative agents of gas gangrene abound in the environment, therefore, the prevalence is high in places with poor sanitation and hygienic practices; if not the latter, contact with contaminated soil as in farming, and wounds sustained in battle. Prevention is straight forward knowing where and how to avoid infection.

Gas gangrene is a potentially fatal infection with Clostridium perfringens, a bacterial species naturally found in our environment. It can infect or contaminate wounds sustained from accidents, natural disasters, and surgical procedures. Clostridium destroys muscle tissue, produces gas and toxins, causing pain, other systemic disorders, and at its worst, death.
Other bacterial species may cause gas gangrene, but the signs and symptoms, course of infection, and treatment are essentially the same as in C. perfringens infection. Gas gangrene is preventable if diagnosed and treated immediately that is, with 24 hours or less. It is a medical emergency. Treatment is with high doses of antibiotics, such as penicillin, clindamycin, and more recently developed antibiotics, especially protein synthesis inhibitors. Wounds should be thoroughly cleaned by surgically removing foreign material, soil, dead and infected tissue. Studies have shown that about 20% of patient with gas gangrene in a limb have undergone amputation. Treatment with hyperbaric oxygen is recommended if available.
Since the bacteria grow and produces gas and toxins within hours any further delay in treatment is tantamount to a death sentence. These factors determine the course of the disease.
Recovery from gas gangrene is better with limb rather than with trunk involvement, and if there are no other concomitant disease or complications such as shock, disseminated intravascular coagulation, acute respiratory disease syndrome, or renal failure.
On account of varied predisposing factors, spontaneous gas gangrene is more difficult to manage than posttruamatic and postoperative gas gangrene.

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