Necrotizing soft tissue infections (NSTI) are identified  by the presence of toxin-producing bacteria, extensive  tissue destruction, and fulminant inflammatory progression, that  leads  to development of  sepsis, multi-organ failure and also  death in untreated patients[1]. On the basis the microbial agents involved, there are two types of NSTI. Type 1 which is a polymicrobial infection while type II infection is  monomicrobial infection primarily caused by Streptococcus pyogenes resulting in necrotising fasciitis [1–3] . NSTI can involve any layer of the soft tissue, but the characteristic feature of necrotizing fasciitis (NF) is extensive necrosis of the fascia and the overlaying subcutaneous and skin tissue. However, in Clostridial myonecrosis,  additionally to the above layers  , muscles are also affected  in the advanced stages of the infection[4,5].  Clostridial gas gangrene (GG) or clostridial myonecrosis  is  a life-threatening soft tissue infection  caused by anaerobic, spore-forming clostridium subspecies subsequent to  traumatic injury but can  occur spontaneously, frequently with the background of abdominal pathology or malignancy[6] .

The most common microbe   that cause these infections are Clostridium perfringens, Clostridium septicum, and Clostridium histolyticum. C. septicum is the most common cause of spontaneous gas gangrene in patients with  G.I. abnormalities, like colon cancer whereas  C. perfringens and C. histolyticum are frequently  associated with post-traumatic infections.[7,8].  Recently, an unusual pathogen ,  Clostridium sordellii,  has been described to cause fatal shock syndrome and gas gangrene of the uterus after medical abortion with oral mifepristone and vaginal misoprostol, septic abortions and deep tissue infection after childbirth.[9-11]

Clinically, in the early stage of infection  NF and clostridial GG have similar clinical presentation which is difficult to diagnose clinically. If the early diagnosis of Clostridial GG is missed, the infection often shows a dramatic course resulting in increased mortality. Therefore, the purpose of this study is, to differentiate  clostridial GG (myonecrosis) from other necrotizing soft tissue infections by Microbiological investigation , to identify the etiology of gas gangrene and to evaluate the standard treatment and its outcome . 

MATERIAL & METHODS:

Afters Ethics approval,  the study was carried at  a tertiary care hospital.

Patient Data:   All patients diagnosed with clostridial GG over a period of 12 months, between 1 January 2023 and 30 December 2024, in our institution were identified and included in the study. All patients’ medical records  were reviewed retrospectively. Diagnosis was based on clinical, microbiological, radiological, and intraoperative findings, as well as on histopathology results.  All patients underwent surgery interventions, microbiological as well as histopathological samples were collected intraoperatively and send to Microbiology laboratory for confirmation. Patients were analysed retrospectively in terms of demographic and social information (gender, age, and comorbidities). Isolated pathogens and corresponding treatment were reviewed. The way of admission, clinical presentation, the course of infection and treatment was investigated in terms of anatomical site, etiology, and medical outcome in terms of survival, organ and limb salvage, were evaluated.

Table:1 Demographic data, co – morbidies, admission, clinical features, microbiological findings, treatment and outcome

RESULTS:

Demographic data:  Between January 2023 to Dec 2024, seven patients were diagnosed and treated for Clostridial GG in our hospital. Four of them were male and three female, the median age was 35 years. (Table:1)

Comorbidities: Among the patient with GG, two had a medical history of diabetes mellitus.

Location and etiology:  Gas gangrene appeared in one patient in the pelvic region following septic abortion by quack. In two patients, infection started in the lower extremities following trauma. One patient developed GG in the gluteal region following drug injection at the site while the other developed GG in the pubic region subsequently to pubic hair removal. Two infections occurred in the upper extremities following trauma. (Table:1)

Clinical findings : At the time of admission, all the patients with GG had local skin symptoms including emphysema, blackish discoloration of skin, foul smelling discharge, swelling and pain. (Table:1)

Microbiology and Histopathology: In all patients, samples were taken in every surgical interventions for microbiological investigation.  In all patients with GG, clostridia could be identified as causative agent.  In 4 cases, C. perfringens was found.  C. septicum was found in two cases.  C. histolyticum was found in one case. (Table:1)

Therapy and critical care management: Patients were transferred or self-initiated presentation to the emergency department of our hospital.  Out of these 7 patients, five required intensive care. Immediate treatment after admission included an algorithm-based therapy according to the recommendations of the Surviving Sepsis Campaign for septic shock [12].

Antibiotic treatment was most often started with imipenem, clindamycin, and metronidazole Additional supportive care, such as nutritional support and high dose therapy with Vitamin C (6 g per day), was carried out in all patients. Surgical treatment included multiple and extensive debridement and amputation. (Table:1)

Mortality, Outcome, and Complications: Of the seven patients with GG, four died (mortality 57.14%) of multi-organ failure.  Three patients survived (20%), however, the affected limb  amputation was done and the patient was transferred into rehabilitation after 13 days of intensive care treatment. (Table:1)

DISCUSSION:

Gas gangrene is mostly considered as a disease linked with war or other mass casualty conditions.  The etiological agent of gas gangrene can be grouped into following different types: clostridial myonecrosis, clostridial cellulitis, non clostridial lesions imitating as  gas gangrene. Clostridial myonecrosis is the ideal term to represent the clinical syndrome of true gas gangrene [13]. Identifying the type of Clostridium aids to predict mortality. With Cl. septicum , it is approximately 63% and 11% with Cl. welchii. [14] but there is no difference in the clinical findings between these two clostridial species infections.  Gas gangrene following IM injections is uncommon. Cases of myonecrosis have been reported following IM administration of adrenaline[15,16] and vitamin B12[17]. In our case, the source of clostridium could be the needle, syringe, contaminated injection fluid or the patients own skin flora. It should be kept in mind  that even routine procedures like administration of IM injections can lead to dreaded complication like GG , therefore, all aseptic precautions should be prevent it.  The setup of  CSSD in  hospitals  and the introduction of use of disposable sterilized syringes have significantly reduced the infections but has not abolished the risk of infection that can be introduced by injections[15].

The basic principal to effective treatment for gas gangrene comprises of prompt recognition of the diagnosis and commencement of multiple therapy including supportive measures, antimicrobial therapy, and timely surgical intervention. Despite this, in a majority  of cases of C. perfringens induced gas gangrene, radical amputation still remains the best choice of treatment [18]. If not controlled, it will always lead to systemic toxemia, hypotension, shock, multiorgan failure, and even death [19]. Hyperbaric oxygen therapy is suggested by some experts but is controversial because its effectiveness has not yet been well-known. Out of five patients only two survived as they received anti gas gangrene serum along with other treatment measures. For the other five patients anti gas gangrene serum was not available in the hospital even when it’s a life saving measure. Probable reason for this is the anti gas gangrene serum  is not included in the list of national emergency drug where other antisera like antisnake venom, anti tetanus serum, anti diphtheria serum are included.

CONCLUSIONS:

Based on the case presented in the paper and our review of the literature on gas gangrene , following points should be highlighted.

• Our emergency clinicians should be aware of this severe and potentially lethal infectious disease and should not delay treatment  to save the patient’s life.
• Strict aseptic techniques should be observed for even the most minor procedureas Clostridial spores are ubiquitous and can reside in hospital environments, possibly on surgeons’ hands, patients’ skin, topical application, and so on.
• Once gas gangrene is diagnosed, careful and adequate debridement should be started immediately with admistration of antigas gangrene serum    is  still the basis of treatment, along with antibiotics and all other supportive treatments.
• We recommend that anti gas gangrene serum should be included in the national list of emergency drug (NLED) in immunoglobulin and antisera section. A separate portal should be made by all medical colleges for the availability of antisera and should be updated weekly so can be shared when needed. Antisera should be purchased as per the prevalence of the disease in that area.

Conflict of Interest: Nil

Acknowledgement: Nil

REFERENCES:

1. Tessier JM, Sanders J, Sartelli M, et al. Necrotizing soft tissue infections: a focused review of pathophysiology, diagnosis, operative management, antimicrobial therapy, and Pediatrics. Surg Infect (Larchmt), 2020, 21: 81–93.
2. Miller LG, Perdreau-Remington F, Rieg G, et al. Necrotizing fasciitis caused by community-associated methicillin-resistant Staphylococcus aureus in Los Angeles. N Engl J Med, 2005, 352: 1445–1453.
3. Sarani B, Strong M, Pascual J, Schwab CW. Necrotizing fasciitis: current concepts and review of the literature. J Am Coll Surg, 2009, 208: 279–288.
4. Fisher JR, Conway MJ, Takeshita RT, Sandoval MR. Necrotizing fasciitis. Importance of roentgenographic studies for soft-tissue gas. JAMA, 1979, 241: 803–806.
5. Tilkorn DJ, Citak M, Fehmer T, et al. Characteristics and differences in necrotizing fasciitis and gas forming myonecrosis: a series of 36 patients. Scand J Surg, 2012, 101: 51–55.
6. Yang Z, Hu J, Qu Y, et al. Interventions for treating gas gangrene. Cochrane Database Syst Rev, 2015, 10(12): CD010577.
7. Huang YY, Lin CW, Yang HM, Hung SY, Chen IW. Survival and associated risk factors in patients with diabetes and amputations caused by infectious foot gangrene. J Foot Ankle Res. 2018;11:1. [ PMC5755273] [ PMC free article: PubMed: 29312468]
8. Perkins TA, Bieniek JM, Sumfest JM. Solitary Candida albicans Infection Causing Fournier Gangrene andReview of Fungal Etiologies. Rev Urol. 2014;16(2):95-8. [ PMC free article: PMC4080857] [Pubmed:25009452]
9. Takehara M. [Host Defense against Bacterial Infection and Bacterial Toxin-induced Impairment of Innate Immunity]. Yakugaku Zasshi. 2018;138(10):1249-1253. [ PubMed: 30270267]
10. Dempsey A. Serious infection associated with induced abortion in the United States. Clin Obstet Gynecol. 2012 Dec;55(4):888-92. [ PubMed: 23090457]
11. Stevens DL, Bryant AE. Necrotizing Soft-Tissue Infections. N Engl J Med. 2017 Dec 07;377(23):2253-2265. [P ubMed: 29211672]
12. Levy MM, Evans LE, Rhodes A. The surviving sepsis campaign bundle: 2018 update. Crit Care Med, 2018, 46: 997–1000.
13. WeinsteinandM.A.Barza,“Gasgangrene,”TheNewEngland Journal of Medicine, vol. 289, no. 21, pp. 1129–1131, 1973.
14. Feldman MJ, Prosciak M, Maleki Z, Milner SM. Gas gangrene. J Surg Radiol 2010;1:100‑1. Feldman MJ, Prosciak M, Maleki Z, Milner SM. Gas gangrene. J Surg Radiol 2010;1:100‑1
15. Harvey PW, Purnell GV. Fatal case of gas gangrene associated with intramuscular injection. Br Med J 1968;1:744‑6.
16. Van Hook R, Vandevelde AG. Gas gangrene after intramuscular injection of epinephrine: Report of a fatal case. Ann Intern Med 1975;83:669‑70.
17. Peerapur BV, Mantur BG, Uppin BC, Patil AV. Gas gangrene following intramuscular injection of vitamin B‑Complex: Report of a fatal case. Indian J Med Microbiol 2002;20:169.
18. L. Stevens and A. E. Bryant, “The role of clostridial toxins in the pathogenesis of gas gangrene,” Clinical Infectious Diseases, vol.35,no.1,pp.S93–S100,2002.
19. D. L. Stevens, “The pathogenesis of clostridial myonecrosis,” International Journal of Medical Microbiology,vol.290,no.4-5, pp. 497–502, 2000