Gas gangrene due toClostridium perfringens in two injecting drug users in Vienna, Austria

Abstract

We describe two cases of severe myonecrotic infections caused by Clostridium perfringens in injecting drug users (IDUs) in Vienna, Austria. Clostridial myonecrosis, or gas gangrene, is a clostridial infection primarily of muscle tissue. C. perfringens is isolated in 90% of these infections. Other clostridial species isolated are C. novyi, C. septicum, C. histolyticum, C. fallax, and C. bifermentans. Classically, clostridial myonecrosis has an acute presentation and a fulminant clinical course. It is diagnosed mainly on a clinical basis. The infection may be so rapidly progressive that any delay in recognition or treatment may be fatal. The onset is sudden, often within 4 to 6 hours after an injury. An early clinical finding is sudden severe pain in the area of infection. Swelling and edema in the area of infection is pronounced. At surgery, the infected muscle is dark-red to black, is noncontractile, and does not bleed when cut. Crepitus, although not prominent, is sometimes detected. We were able to demonstrate spores that were morphologically indistinguishable from spores of C. perfringens in a drug sample obtained from case 2. General practitioners and accident and emergency staff should be aware of the possibility of C. perfringens infection in IDUs, especially if injection into soft tissue is suspected.

Limb salvage after gas gangrene: a case report and review of the literature

“…Moreover, repeating trauma of soft tissue resulting from peculiar practices among illicit drug users, as the intramuscular injections with normal saline in our case, introduce organisms directly into deep tissue and create an anaerobic environment that is ideal for the proliferation of Clostridia. Such anaerobic environment also results from crash type injury, contaminated open fractures and retained foreign material and is associated with C.perfrigens gas gangrene [3,5,7,9]. Spontaneous gas gangrene of the limbs is due to C. septicum in the vast majority of cases.…”

“…Improved techniques currently allow for revascularization of limbs that previously would have been unsalvageable. Revascularization is not without risk, however [9,15]. Attempts to salvage a severely compromised limb may lead to metabolic overload and secondary organ failure.…”

Neuromuscular and Central Nervous System Manifestations of Clostridium perfringens Infections

“…Myonecrosis may occur spontaneously after trauma or after surgery, affects children and adults, and is much more frequent than CNS affection [51]. Myonecrosis presents with an acute onset, 4-6 h after injury, and takes a fulminate course [80]. Patients complain about severe pain accompanied by non-painful swelling and edema in the region of the infection, brawny discoloration of the skin with bullae formation and muscle necrosis, tachycardia, hypotension, and acute renal failure [48,50].…”

“…One of the most frequent manifestations of a C. perfringens infection is myonecrosis or gas gangrene, a primary infection of the skeletal muscle with C. perfringens [80,81]. Myonecrosis may occur spontaneously after trauma or after surgery, affects children and adults, and is much more frequent than CNS affection [51].…”

“…Patients complain about severe pain accompanied by non-painful swelling and edema in the region of the infection, brawny discoloration of the skin with bullae formation and muscle necrosis, tachycardia, hypotension, and acute renal failure [48,50]. At surgery the infected muscle is dark-red to black, noncontractile, occasionally crepitates, and does not bleed when cut [80]. Rarely, myonecrosis may result from repeated intramuscular injections over several years [82].…”