Myonecrosis, clostridial A48.0

Author: Prof. Dr. med. Peter Altmeyer

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Last updated on: 29.10.2020

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Synonym(s)

Clostridial myonecrosis; Clostridium cellulitis; Clostridium myositis; Gas fire; Gas Gangrene; Gas oedema; Gas phlegmons; Klostridal myonecrosis

Definition
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Specific infectious muscle disease.

Pathogen
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  • Mainly Clostridium perfringens, more rarely Clostridium novii, C. histolyticum, C. septicum, C. sporogenes, C. bifermentans, C. putrificum and Gram-positive anaerobic cocci.
  • Clostridia are anaerobic, Gram-positive, spore-forming, rod-shaped bacteria of the family Clostridiaceae. They occur ubiquitously in nature and can also be found in the human intestinal tract. The spores are ubiquitous in the soil.
  • Notice! Clostridium perfringens may also be involved in purulent, non-gas-forming infections.

Classification
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According to tartar there are 3 different diseases:
  • Syndrome of "simple contamination": caused by Clostridium sporogenes, bifermentans, putrificum and Gram-positive cocci.
  • "Anaerobic cellulitis.
  • Anaerobic clostridial myonecrosis (" gas gangrene").

Occurrence/Epidemiology
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Worldwide spread. Infections are more common among war wounded.

Clinical features
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  • Incubation time: 12-96 hours.
  • "Simple Contamination": green-blackish, superficial wound coating and moderately increased inflammatory parameters with little impairment of the general condition.
  • Anaerobic cellulitis: subcutaneous gas inclusions, usually originating from a dirty-smelly wound, limited exclusively to the subcutaneous tissue.
  • Anaerobic, clostridial myonecrosis: gas gangrene infection, affected is the striated musculature, ballooned swelling of the muscles of the extremity with palpable emphysema (crepitations), severe local pain, reduced general condition with cold sweat and cerebral dysfunction. There is hardly any pus (since Clostridium perfringens has a cytolytic effect). Leukopenia often occurs. Mostly the extremities are affected, more rarely pleural and pulmonary involvement (haemorrhagic infarction), in the late stages haemolysis, icterus, death by renal failure.

Diagnosis
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  • In the x-ray: characteristic feathering of the musculature.
  • Histology of the peripheral musculature: microscopy after Gram staining.

Differential diagnosis
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necrotizing fasciitis; gas formation in wounds caused by pathogens such as E.coli, Bacteroides, Klebsiella, Proteus.

Therapy
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  • Wound debridement, possibly amputation of the extremity.
  • Hyperbaric oxygen therapy: 3 treatments within the first 24 hours after diagnosis at 300 kPa for 90 minutes followed by a decompression phase (Boerema scheme). In the following days 2 hyperbaric treatments/day. Hyperbaric oxygen therapy can only be used for patients with intensive care if intensive medical care is also possible inside the pressure chamber.

Internal therapy
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  • Antibiotics in high doses, 1st choice Benzylpenicillin (e.g. Penicillin GrĂ¼nenthal) 20-40 million IU/day distributed over 4-6 ED as short infusion in combination with Metronidazol (e.g. Clont), adults: 2-3 times 500 mg/day i.v., children: 20 mg/kg bw/day i.v. or p.o. distributed over 3 ED.
  • Alternatively: cefotaxime (e.g. claforan) 2-3 times/day 2 g i.v. (max. 4 times/day 3 g) in combination with metronidazole (e.g. Clont), adults: 2-3 times/day 500 mg/day i.v., children: 20 mg/kg bw/day i.v. or p.o. distributed over 3 ED.
  • In case of penicillin allergy: Imipenem (e.g. Zienam): adults: 3-4 times 0.5-1.0 g/day i.v., infants: 60 mg/kg bw/day distributed over 4 ED. Alternatively: erythromycin (erythrocin i.v.), adults 2 g/day i.v. in 4 ED, children 20-30 mg/kg bw/day i.v. in 4 ED. Alternatively linezolid (cyvoxide): adults 2 times/day 600 mg i.v.

Progression/forecast
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  • Syndrome of "simple contamination": good prognosis.
  • "Anaerobic cellulitis: good prognosis.
  • Anaerobic clostridial myonecrosis ("gas gangrene"): high mortality.

Literature
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  1. Brook I (2007) Microbiology and management of soft tissue and muscle infections. Int J Surg 15 ahead of print
  2. Parasca I, Damian L, Albu A (2006) Infectious muscle disease. Rome J Internal Med 44: 131-141

Disclaimer

Please ask your physician for a reliable diagnosis. This website is only meant as a reference.

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Last updated on: 29.10.2020