Clinical Case presentation Gas Gangrene

Dr Vishal Kulkarni MBBS MD (Microbiology)

Case history

50 years old, male patient came in casualty department with

the history of road traffic accident 2 days ago with c/o-

Multiple open wounds and swelling on right leg since 2 days.

Pain and heaviness in right leg since 2 days.

Fever since 1 day

Lightheadness since 1 day

H/O present Illness:

Patient was apparently alright 2 days back when he had road traffic accident

while travelling on his bike to his village. He fell from his bike on ground.

He had no immediate complain except mild pain and multiple open wounds

on right leg. The wounds were contaminated with soil and blood.

He had local treatment in a primary health centre from which he referred to

our hospital.

He was having swelling, involving right leg, progressing gradually with

black discoloration since 2 days.

He had pain in right leg which was sudden in onset, worsening gradually.

He also had low grade fever which was insidious in onset, progressed gradually.

He also had been complaining lightheadness & disorientation along with drowsiness and fatigue.

No h/o of any spasms, convulsions No H/o TB, DM, HTN, Asthma etc

Past History:-

No h/o similar complains in past.

Family History:-No significant family history is present.

General Examination:-

Patient was drowsy, and not oriented with time, place and person.

Temp: 99.4 degree F. Pulse- 120 / min Regular, all peripheral pulses felt. R/R- 22/ min BP- 90/70 No H/O cynosis, clubbing ,lymphadenopathy.

Local examination-Inspection- 7—8 multiple open wounds on right leg, varying in

size and shape, oozing out serosanguinous discharge, few were ulcerated with bronze discoloration of surrounding skin.

Few wounds involving muscles tissues which were necrosed

Oedematous swelling over right leg.

Palpation- Warmth ++ Tenderness ++ Crepitus +++

Systemic examination- CVS- NAD RS- NAD CNS- NAD

Differential diagnosis

Clostridium perfringens Clostridium septicum Clostridium novyi Clostridium tetani E. coli Proteus Staphylococci Anaerobic streptococci

Lab.diagnosis:

Sample Collection- Films from muscles at the edge of affected area Tissue in necrotic area Exudates from part from where infection appears to be most

active. Collected with capillary pipette or swab Transported to laboratory immediately

Gram stain- Scanty pus cells. Large number of regularly shaped, Gram positive bacilli

without spores

Emergency Treatment-

Surgery along with prophylactic antibiotics were advised

Metronidazole & Gentamicin IV before surgery (8 hrly x

24 hrs)

All damaged tissues were removed promptly

Uncompromised excision of all damaged parts was done.

Culture-

Aerobic culture-

Mac conkey- 4-5 LFF colonies

BA- 5-6 large gray moist colonies.

Anaerobic culture RCM broth were inoculated Media turned pink on incubation Incubated and subcultured on BA after 24-48 hrs Haemolysis positive on BA with large grey moist colonies.

Naegler reaction- Positive

IMViC-

1. (++--)

2. (-+--)

TSI-

1. A/A without gas

2. A/A with H₂S

Reverse CAMP test- Positive

Diagnosis-

Based on above findings diagnosis is likely to be a case of Gas

gangrene caused by infection of Clostridium perfringens.

Post-operative treatment-

Post-op care was taken.

Metronidazole and gentamicin was continued for another

48 hours.