A previously healthy, non-diabetic, 82 year old man was admitted to York District Hospital complaining of pain and swelling of the right arm. He attributed this to a trivial injury sustained to his arm on a supermarket shelf earlier that day. At approximately 6 30 pm on the same day his wife noticed what appeared to be a bruise over the upper arm with small areas of blistering. He was admitted to York District Hospital later that evening by which time the entire right upper limb had become tense and swollen upto the level of the neck; the skin was dusky purple and cyanosed, and there were a number of haemorrhagic bullae.

On examination he appeared pale and distressed but was alert and cooperative. Inspection of the upper limb revealed diffuse crepitus and absent distal pulses, both on palpation and Doppler. Vital signs were as follows: pulse 100 per minute, blood pressure (BP) 100/60 mm Hg, temperature 36.7 °C. Abnormal laboratory results included low plasma sodium levels (127 mmol/l; hyponatraemia), raised urea and creatinine (7.3 mmol/l and 186 μmol/l, respectively) and raised plasma glucose level (24.6 mmol/l; hyperglycaemia). A chest x ray confirmed the presence of diffuse surgical emphysema (fig 1).

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Figure 1

 Chest x ray: note the diffuse surgical emphysema over the chest wall.

The patient was catheterised and given 1.5 g cefuroxime, 500 mg metronidazole, and 600 mg benzylpenicillin; in addition he received opiate analgesia and 1 l of succinylated gelatin (Gelofusine; B Braun Medical, UK).

Early next morning he was transferred to St James University Hospital. On arrival at 8 15 am he remained afebrile and was still cardiovascularly stable. However, it was clear that he had deteriorated severely—he was confused, agitated, and tachypnoeic. The blistering and discoloration had spread across his chest wall, neck, back, and abdomen. His vital signs at this point were as follows: urine output 30 ml/h, pulse 100 per minute, BP 120/70 mm Hg and temperature 36 °C. Additional laboratory results demonstrated metabolic acidosis (HCO₃⁻ 16.3 mmol/l and pH 7.28).

We sought advice about management of the patient from both a microbiologist and a plastic surgeon, but it was deemed that radical debridement would be of little use at this stage and any treatment would be palliative. At 9 am he was intubated and ventilated and an internal jugular central line inserted. He was given 100 ml 20% mannitol, 50 ml 8.4% HCO₃⁻ and 1 l 0.9% NaCl; in addition we carried out multiple fasciotomies in an attempt to improve circulation in the upper limb (fig 2).

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Figure 2

 Areas of dusky discoloration and haemorrhagic bullae can be seen. Note also the fasciotomy incisions and the marker line on the chest indicating the rapidity of the spreading infection.

The patient had a cardiac arrest at 9 30 am and was successfully revived, but unfortunately he had a second arrest and resuscitation was unsuccessful. He was declared dead at 10 50 am.

A diagnosis of arterial vascular occlusion secondary to gas gangrene was made which was confirmed by post mortem. Microbiological examination revealed Gram-positive bacilli and culture demonstrated profuse C. septicum infection. The post mortem declared the cause of death to be acute myocardial ischaemia, but a major contributing factor was the gross infection of the upper limb; an additional finding was a small caecal carcinoma with a 4 cm metastatic deposit in the right lobe of the liver.

DISCUSSION

Gas gangrene is a condition of rapidly developing and spreading infection mediated by toxins released by the bacteria Clostridium spp. It is most often associated with traumatic injuries. C. perfringens is the commonest species, followed by C. novyi. C. septicum is relatively uncommon, and it is estimated to be the cause of only 1.3% of all clostridial infections.^1–3C. septicum represents a novel subtype among clostridial species, with several notable differences. It is able to cause devastating tissue necrosis in the absence of prior trauma,^1,3–6 and is able to present distant from the presumed portal of entry resulting in metastatic myonecrosis.^4,5

Clostridial infections are believed to have a greater prevalence among individuals who have malignant disease.^1,4–6 Larson et al, in a series of 241 patients with clostridial infection, found 10% had an associated malignancy.⁵ However, when C. septicum infections were considered alone the incidence of associated malignancy was 52.6%.⁶ In a further study of patients with C. septicum infection, conducted between 1966 and 1993, 50% had a primary malignancy, 75% of which were colonic, of these 40% were caecal.⁵

Few patients presenting with C. septicum infection have a history of prior trauma.^1,4–6 Several papers have suggested that mucosal ulceration of the tumour surface and haematogenous invasion allow a portal of entry for the bacteria, thus explaining the low incidence of antecedent trauma.^7–9 The theory of mucosal ulceration as the portal of entry is supported by the case reported by Abella et al in which a patient with radiation colitis had spontaneous C. septicum gas gangrene.¹

Our case illustrates the fulminant nature of gas gangrene and although it is an uncommon diagnosis, it is essential that the management be initiated early. This should include aggressive resuscitation, early antibiotics, hyperbaric oxygen therapy (although this has never been subjected to a controlled trial and unless it is readily available it would seem to present a potentially fatal delay), and radical surgical debridement.