Full text of DOI:10.1177/021849230201000223

Gas Gangrene in Atherosclerosis Obliterans
CASE STUDY
Niimi
Gas Gangrene in Patient With
Atherosclerosis Obliterans
Masanori Niimi, MD, Yosifumi Ikeda, MD,
Shigenao Kan, MD, Hiroshi Takami, MD
JAPAN
First Department of Surgery
Teikyo University School of Medicine
Tokyo, Japan
ABSTRACT
Clostridia are the main cause of nontraumatic spontaneous gas gangrene. Poor
blood flow due to arterial occlusion exacerbates the anaerobic condition. Fulminant
gas gangrene in a 54-year-old man with atherosclerosis obliterans was treated by
revascularization of the iliac artery using endarterectomy, and his gangrenous
lower leg was amputated. However, he died from renal failure.
(Asian Cardiovasc Thorac Ann 2002;10:178–80)
INTRODUCTION
minute, and axillary temperature of 38.4°C. There was
dry gangrene of the left lower leg which was cold and
cyanotic, there was crepitation in the left upper leg, and
crepitation and lymphadenopathy in the left inguinal
region. The left femoral artery was not palpable.
Laboratory tests on admission revealed a white blood cell
count of 28,800/mm3 with 93% blasts; a hemoglobin
Gas gangrene is still a life-threatening condition. The
spore-forming anaerobic gram-positive bacilli Clostridia
are the main cause of nontraumatic spontaneous gas
gangrene. Poor blood flow due to arterial occlusion
increases the anaerobic condition of the legs and prevents
antibiotics reaching the site of infection. However, there
are few reports of gas gangrene due to arterial occlusion.1 level of 96 g·L–1; and a serum creatinine concentration of
A rare case of fulminant gas gangrene due to Clostridium 7.6 mg·L–1. Computed tomography demonstrated multiple
perfringens in a patient with atherosclerosis obliterans is bullae in the left thigh and pelvic region (Figure 1).
described.
Angiography showed complete occlusion of the left iliac
and femoral arteries including the deep femoral artery
(Figure 2). Because of the foul smell and crepitation,
CASE REPORT
A 54-year-old man with atherosclerosis obliterans, diabetes Clostridium infection was strongly suspected. Therefore,
mellitus, and mitral valve stenosis with arterial fibrillation multiple antibiotics (piperacillin, imipenem, and cilastatin)
refused medical treatment for 6 months. Four months were administered intravenously. Blood culture revealed
prior to admission, he noticed pain at rest in his left leg,
and his toe became necrotic. The dry necrosis extended
up his left leg. Seven days before admission, he developed
fever, chills, and pain in the left thigh. On the morning
of admission, a neighbor noticed an extremely foul smell
from his house and called an ambulance. His blood
Clostridium perfringens and Enterococcus faecalis. As
the anaerobic condition of the left thigh was considered
to be aggravating the severity of infection and preventing
antibiotics from reaching the infection site in sufficient
concentrations, surgery was undertaken.
pressure was 80/50 mm Hg, his pulse rate was 138 beats Under general anesthesia, the left leg was amputated
per minute, with a respiratory rate of 32 breaths per above the knee. Endarterectomy of the left common and
For reprint information contact:
Masanori Niimi, MD Tel: 81 3 3964 1228 Fax: 81 3 3962 2128 email: mniimi@med.teikyo-u.ac.jp
First Department of Surgery, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo 173-8605, Japan.
A
SIAN
C
ARDIOVASCULAR & THORACIC
A
NNALS
178
2002, VOL. 10, NO. 2
Downloaded from aan.sagepub.com at Freie Universitaet Berlin on May 3, 2015

Niimi
Gas Gangrene in Atherosclerosis Obliterans
external iliac arteries was performed using patches of and female genitourinary tracts, and the skin. Clostridial
superficial femoral vein. The left thigh was revascularized. infections have been associated with traumatic wounds
Subsequently, active bleeding was detected from arteries and surgical procedures.1,2 Although early diagnosis is
at the edge of the amputation site; it was controlled by most important to save patients with gas gangrene,
ligation of these vessels. Multiple skin incisions and fulminant gas gangrene was established in our patient
fasciotomies of the thigh and pelvic region were performed when he was admitted. It was not clear when or where
to facilitate aerobic conditions. A foul-smelling purulent he acquired the Clostridium perfringens infection. The
discharge was detected from the amputation site and the mortality rate from sepsis secondary to Clostridium
fasciotomies. Therefore, subcutaneous tissue and the perfringens ranges from 70% to 100%.3 The treatment
muscles of the upper thigh and pelvis were sterilized with of choice for Clostridium perfringens bacteremia is
povidone-iodine solution, resulting in cessation of the intravenous penicillin G in doses of 10 to 24 million units
foul smell. However, the patient died due to renal failure daily.3 Most treatment recommendations are based on
one day after the operation.
animal models and retrospective studies of patients with
gas gangrene caused by Clostridium perfringens, in which
a combination of penicillin and clindamycin was more
effective than penicillin alone in suppressing toxin
synthesis.4 In-vitro studies have also shown chloram-
phenicol to be effective against all species of Clostridia.
Clostridial infection is often associated with other bacterial
infections, thus broad-spectrum antibiotic coverage
(piperacillin, imipenem, and cilastatin) was used in this
patient. Recently, a new therapeutic strategy using a
glycoprotein GPIIb-IIIa antagonist has been reported.5
DISCUSSION
Clostridia are found in soil, and they are constituents of
the normal flora of the human gastrointestinal, biliary,
Surgical debridement of all involved gangrenous tissue is
crucial in preventing progression of infection and sub-
sequent exotoxin production. In this patient, the infected
site could not be completely amputated as the region of
gas and purulent discharge came up to the pelvis. A
prosthetic graft could not be used because of the septic
condition of the reconstruction site. The revascularization
was successful because cyanosis subsided and active
bleeding from the edge of amputation was detected after
reconstruction. The cause of the renal failure was unclear.
One possibility was rhabdomyolysis after revasculari-
zation.Another possibility was exotoxin from Clostridium
perfringens.6 A rare possibility was the use of povidone-
iodine solution for sterilization of the infection site.7
Figure 1. Selected images from computed tomography of the lower
abdomen and the left thigh, showing edematous tissue with crepitation
and multiple bullae.
An alternative treatment option for this patient might
have been hyperbaric oxygen after fasciotomy of the
upper leg and the lower abdomen. It has been reported
that hyperbaric oxygen therapy improves phagocyte-
mediated bacterial killing, suppresses toxin formation,
and helps create a bacteriostatic environment. The addition
of hyperbaric oxygen therapy has clearly improved the
survival of patients with gas gangrene, although random-
ized prospective studies of this therapy have not yet been
undertaken.8 However, in view of the severe arterial
occlusion, complete recovery of the anaerobic site might
not have been achieved, even after fasciotomy and hyper-
baric oxygen treatment. Therefore, we believed that our
choice of reconstruction of the iliac artery was reasonable.
REFERENCES
1. Kahn O, Wagner W, Bessman AN. Mortality of diabetic
patients treated surgically for lower limb infection and or
gangrene. Diabetes 1974;23:287–92.
Figure 2. Arteriogram showing complete occlusion of the left iliac,
superficial femoral, and deep femoral arteries.
2002, VOL. 10, N
O
. 2
179
ASIAN CARDIOVASCULAR & THORACIC ANNALS
Downloaded from aan.sagepub.com at Freie Universitaet Berlin on May 3, 2015

Gas Gangrene in Atherosclerosis Obliterans
Niimi
2. Rechner PM, Agger WA, Mruz K, Cogbill TH. Clinical
features of clostridial bacteremia: a review from a rural
area. Clin Infect Dis 2001;33:349–53.
6. Slotki IN, MacIver JE, Mallick NP, Palmer HM. Acute
intravascular hemolysis with minimal renal impairment in
Clostridium perfringens infection. Clin Nephrol 1976;6:
451–2.
3. Marty AT, Filler RM. Recovery from non-traumatic
localised gas gangrene and clostridial septicaemia. Lancet
1969;2(7611):79–81.
7. Campistol JM, Abad C, Nogue S, Bertran A. Acute renal
failure in a patient treated by continuous povidone-iodine
mediastinal irrigation. J Cardiovasc Surg (Torino) 1988;
29:410–2.
4. Bartlett JG, Sutter VL, Finegold SM. Treatment of
anaerobic infections with lincomycin and clindamycin. N
Engl J Med 1972;287:1006–10.
8. Korhonen K, Klossner J, Hirn M, Niinikoski J.
Management of clostridial gas gangrene and the role of
hyperbaric oxygen. Ann Chir Gynaecol 1999;88:139–42.
5. BryantAE, Chen RY, NagataY, Wang Y, Lee CH, Finegold
S, et al. Clostridial gas gangrene. II. Phospholipase
C-induced activation of platelet GPIIb-IIIa mediates
vascular occlusion and myonecrosis in Clostridium
perfringens gas gangrene. J Infect Dis 2000;182:808–15.
A
SIAN
C
ARDIOVASCULAR & THORACIC
A
NNALS
180
2002, VOL. 10, NO. 2
Downloaded from aan.sagepub.com at Freie Universitaet Berlin on May 3, 2015