• Users Online: 2054
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 


 
 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 16  |  Issue : 1  |  Page : 186-188

Gas gangrene in a closed pelvic injury


Department of Orthopedics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Wardha, Maharashtra, India

Date of Submission07-Jul-2020
Date of Decision03-Nov-2020
Date of Acceptance01-Dec-2020
Date of Web Publication29-Jul-2021

Correspondence Address:
Dr. Antariksh Waghmare
J N Medical College, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-4534.322620

Rights and Permissions
  Abstract 


Gas gangrene in a closed pelvic injury is very rare phenomenon and we could not find many reported cases in the literature. Radiographs are not enough for diagnosis and computed tomography (CT) is not widely available yet in primary health center. Basic management includes surgical debridement with incision and drainage of necrotic tissue of the involved area, antibiotic therapy, and surgical intensive care. Delay of the surgical debridement for >12 h is associated with higher overall morbidity. The aerobic and anaerobic bacteria with the indigenous commensal of the pelvis results in the production of exotoxins that leads to severe rapid tissue necrosis and the synthesis of insoluble gases characteristic of subcutaneous emphysema or Fournier's gangrene. Although gas gangrene is often diagnosed clinically, emergency CT can support in early diagnosis with accurate assessment of the disease extent. CT not only helps evaluate the pelvic bony structures but also helps assess the spread of disease in the abdomen and pelvis. The mainstay of the management includes surgical debridement with incision and drainage of necrotic tissue of involved area, antibiotic therapy, and surgical intensive care. Early diagnosis remains the mainstay of the treatment of Gas gangrene. It is important to diagnose these life-threatening conditions and treat them as early as possible. Due to the rarity of such events and the unavailability of gold standard diagnostic and treatment modalities, it is very difficult to prevent the mortality for such patients. There is a need for a better treatment plan to diagnose and manage such patients urgently and not to miss the initial phase of disease progression which is critical for saving the life of the patient.

Keywords: Gas gangrene, pelvic injury, trauma


How to cite this article:
Waghmare A, Shrivastava S, Date S, Bukhari R, Nair A, Deo N. Gas gangrene in a closed pelvic injury. J Datta Meghe Inst Med Sci Univ 2021;16:186-8

How to cite this URL:
Waghmare A, Shrivastava S, Date S, Bukhari R, Nair A, Deo N. Gas gangrene in a closed pelvic injury. J Datta Meghe Inst Med Sci Univ [serial online] 2021 [cited 2021 Sep 23];16:186-8. Available from: http://www.journaldmims.com/text.asp?2021/16/1/186/322620




  Introduction Top


Gas gangrene in a closed pelvic injury is a very rare phenomenon and we could not find many reported cases in the literature. High-velocity trauma causing gas gangrene is reported in the perineum and limbs, but most of them are open injuries accompanied with fractures. Gas gangrene with necrotizing fasciitis of the perineum and abdomen is reported with a very rapid progression, systemic toxemia with a high mortality rate.[1],[2] Radiographs are not enough for diagnosis and computed tomography (CT) is not widely available yet in the primary health center. Basic management includes surgical debridement with incision and drainage of necrotic tissue of the involved area, antibiotic therapy, and surgical intensive care.[1],[3],[4] Rapid progression of the pathology and involvement of the whole compartment with overwhelming sepsis is associated with a significant mortality rate reported as 16% in metaanalysis of Eke.[1] Delay of the surgical debridement for >12 h is associated with higher overall morbidity.[5]


  Case Report Top


A 35-year-old female with a history of 3 days old road traffic accidents, was presented to the emergency department with severe pain in the pelvis and abdomen region which was increasing for 24 h. Her initial vitals were notable for the temperature of 39°C, respiratory rate of 25 breaths per minute, heart rate of 100 beats per minute, and blood pressure of 134/76 mmHg. She gave a history of high-velocity trauma 3 days back following which the patient went to private hospital and was diagnosed with closed pelvic fracture with no wound over pelvis or abdomen. She was conservatively managed with fluid management and traction to both lower limbs for immobilizing her pelvis. Her pain could not be controlled even with IV analgesics so the patient was sent to higher center for management.

Her blood counts showed a white blood cell count of 11,300, hemoglobin 5.9, and platelet count 1.53. Her C-reactive protein was elevated and liver enzymes were higher than normal limits. Her electrolyte and coagulation profiles were within the normal limits. Culture report showed growth of non fermenters polymicrobes.

The patient was admitted to the orthopedic department where X-ray pelvis and CT pelvis were suggestive of Type C2 fracture of the pelvis [Figure 1] according to tiles classification with extensive musculocutaneous emphysema in the abdomen and pelvic region. The patient was immediately started on empirical broad-spectrum antibiotics consisting of meropenem, pipracillintazobactum and ceftraixonesulbactum, amoxicillin clavulate, and gentamycin on usual dosage along with immobilization of the pelvis with skin traction. In 48 h, the patient's general condition showed no improvement. She developed a high-grade fever with excruciating pain in the abdomen and pelvic region with distension of the abdomen. She also developed a blister over the abdomen with a foul-smelling discharge through her vagina. A repeat X-ray abdomen and CT showed a major gas shadow in the pelvic and abdomen region [Figure 2] with bilateral pleural effusion and a partial collapse of the lung.
Figure 1: Three-dimensional reconstruction view of computed tomography showing fracture pelvic bone

Click here to view
Figure 2: Radiograph showing gas shadows in the abdomen and pelvic region

Click here to view


The patient was taken into surgery and debridement of the abdomen and pelvic region was done accompanying with the department of general surgery. Broad resection of the soft tissue was done and thorough irrigation of the affected area was performed using normal saline. Dead necrotic tissue was found during the debridement and maximum possible tissue was tried and removed during the surgery. Approximating sutures were used and wound was let to be healed by secondary intention. The patient was kept on ionotropic supports for the next 48 h in the intensive care unit. The patient's general condition did not improve. Second, debridement was planned and performed, but the patient did not recover and died after intubation and failing resuscitation attempts.


  Discussion Top


Gas gangrene with necrotizing fasciitis of the perineum and abdomen is a very rare phenomenon, but it shows a very rapid progression, systemic toxemia with a high mortality rate.[1],[2] Fournier's gangrene is defined as a synergistic, polymicrobial necrotizing fasciitis of the perineal and genital region. The aerobic and anaerobic bacteria with the indigenous commensal of the pelvis results in the production of exotoxins that leads to severe rapid tissue necrosis and the synthesis of insoluble gases characteristic of subcutaneous emphysema or Fournier's gangrene.,[1],[2],[3],[6],[7]

Out of proportion pain is the most common complaint and among the first sign with bullae and bluish skin discoloration supporting the diagnosis of gas gangrene. The triad of pain, tachycardia out of proportion to fever, and crepitus are highly suggestive of clostridial myonecrosis. Clinical examination reveals crepitus in 19%–64% of the patients.[4] Systemic findings may include leukocytosis, dehydration, tachycardia, thrombocytopenia, anemia, and hyperglycemia.[4],[6],[8]

Although gas gangrene is often diagnosed clinically, emergency CT can support in early diagnosis with accurate assessment of the disease extent. CT not only helps evaluate the pelvic bony structures but also helps assess the spread of disease in the abdomen and pelvis.[4],[9] Findings at CT include subcutaneous emphysema, asymmetric fascial thickening, abscess formation, and fluid collection.

The mainstay of the management includes surgical debridement with incision and drainage of necrotic tissue of the involved area, antibiotic therapy, and surgical intensive care.[1],[3],[4] Early diagnosis and aggressive management are demanded. Rapid progression and overwhelming sepsis are associated with a significant mortality rate reported as 16% in meta analysis of Eke.[1] Delay of the operation for more than 12 h is associated with higher overall morbidity.[5]

Adjuvant hyperbaric oxygen therapy has been shown to increase survival in studies, suppressing alpha toxins of clostridium, enhance leukocyte killing activity, enhance the destruction of anaerobic bacteria, and tissue repair is improved in poorly vascularized tissue.[1],[10],[11],[12] Hyperbaric oxygen therapy has shown decrease in the number of debridement procedures, shortening hospital stay, and helps in wound healing. It increases tissue oxygenation to a very high level which in turn inhibits and kills all of the anaerobic bacteria while suppressing the proliferation of aerobic bacteria.[4],[8],[11],[12],[13],[14],[15],[16]


  Conclusion Top


Early diagnosis remains the mainstay of the treatment of Gas gangrene. It is important to diagnose these life-threatening conditions and treat them as early as possible. Reluctance of major surgical debridement without specific diagnostic investigations and delay in onset of symptoms leads to the rapid spread of the gas gangrene which is often deadly. Keeping in mind the possibility of such conditions even in closed trauma due to high-velocity injury in the abdomen and pelvis is very important. Further studies need to be done in this area to figure out more advanced modalities of treatment as massive surgical debridement is not realistic to perform in the abdomen and pelvis region. Major vascular structures and vital organs make it very difficult to operate in this region. Lack of definitive diagnostic test makes this a further complicated entity as CT abdomen and pelvis is not performed routinely in many hospitals. Furthermore, symptoms and signs are masked under routine fracture signs and take up a valuable golden period of management which is very important for preventing the morbidity and mortality of the patients. Due to the rarity of such events and the unavailability of gold standard diagnostic and treatment modalities, it is very difficult to prevent the mortality for such patients. There is a need for a better treatment plan to diagnose and manage such patients urgently and not to miss the initial phase of disease progression which is critical for saving the life of the patient.

Consent

Essential verbal and informed written consent were obtained from the patient and her relatives.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Eke N. Fournier's Gangrene: A review of 1726 cases. Br J Surg 2000;87:718-28.  Back to cited text no. 1
    
2.
Mercer N, Davis DM. Gas gangrene. BMJ 1991;303:854-5.  Back to cited text no. 2
    
3.
Paty R, Smith AD, Gangrene PR. Fourniers gangrene. Urologic Clinics of North America 1992;19:149-62.  Back to cited text no. 3
    
4.
Cullen IM, Larkin JO, Moore M, Fitzgeral E, O'Ríordáin M, Rogers E. Fournier's Gangrene _Findings on Computed Tomography. ScientificWorldJournal 2007;7:1839-41.  Back to cited text no. 4
    
5.
Sudarsky LA, Laschinger JC, Coppa GF, Spencer FC. Improved results from a standardized approach in treating patients with necrotizing fasciitis. Ann Surg 1987;206:661-5.  Back to cited text no. 5
    
6.
Lehner PJ, Powell H. Gas gangrene. overwhelming infection responsive to surgical and medical treatment. BMJ: British Medical Journal 1991;303:240.  Back to cited text no. 6
    
7.
Wolf CT, Wolf SJ. Fournier gangrene. West J Emerg Med 2010;11:101-2.  Back to cited text no. 7
    
8.
Aggelidakis J, Lasithiotakis K, Topalidou A, Koutroumpas J, Kouvidis G, Katonis P. Limb Salvage after gas gangrene: A case report and review of the literature. World J Emerg Surg 2011;6:28.  Back to cited text no. 8
    
9.
Levenson RB, Singh AK, Novelline RA. Fournier gangrene: Role of imaging. Radiographics 2008;28:519-28.  Back to cited text no. 9
    
10.
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.  Back to cited text no. 10
    
11.
Hirn M. Hyperbaric oxygen in the treatment of gas gangrene and perineal necrotizing fasciitis. A clinical and experimental study. Eur J Surg Suppl 1993;(570):1-36.  Back to cited text no. 11
    
12.
Korhonen K. Hyperbaric oxygen therapy in acute necrotizing infections with a special reference to the effects on tissue gas tensions. Ann Chir Gynaecol Supp 2000;214:7-36.  Back to cited text no. 12
    
13.
Acharya N, Agrawal M, Singh P, Fating T. The Effect of Antenatal and Postnatal Pelvic Floor Muscle Training on the Risk of Developing Pelvic Floor Dysfunction-a Cohort Study. Int J Cur Res Rev 2020;12:13-5. Available from: https://doi.org/10.31782/IJCRR.2020.SP71. [Last accessed on 2020 Mar 18].  Back to cited text no. 13
    
14.
Khan K, Dhaniwala N, Chitriv YU. Outcome Analysis of Pelvic Fractures in Tertiary Care Health Centre. Eur J Molecular Clin Med 2020;7:1856-9.  Back to cited text no. 14
    
15.
James SL, Castle CD, Dingels ZV, Fox JT, Hamilton EB, Liu Z, et al. Estimating Global Injuries Morbidity and Mortality: Methods and Data Used in the Global Burden of Disease 2017 Study. Injury Prevention 2020;26:I125-53. Available from: https://doi.org/10.1136/injuryprev-2019-043531.[Last accessed on 2020 Mar 18].  Back to cited text no. 15
    
16.
Abbafati C, Machado DB, Cislaghi B, Salman OM, Karanikolos McKee M, et al. Global Burden of 369 Diseases and Injuries in 204 Countries and Territories, 1990–2019: A Systematic Analysis for the Global Burden of Disease Study 2019. The Lancet 2020;396:1204-22. Available from: https://doi.org/10.1016/S0140-6736(20)30925-9. [Last accessed on 2020 Mar 18].  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Case Report
Discussion
Conclusion
References
Article Figures

 Article Access Statistics
    Viewed204    
    Printed24    
    Emailed0    
    PDF Downloaded16    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]