Gas Gangrene

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     A 12-year-old boy with acute myelogenous leukemia that had been diagnosed two months earlier presented to a hospital with fever and leg pain. He had received intravenous cytarabine two weeks earlier. He was pancytopenic, with a total leukocyte count of 1900 per cubic millimeter, a hemoglobin level of 6.8 g per deciliter, and a platelet count of 24,000 per cubic millimeter. The absolute granulocyte count was 190 per cubic millimeter. He was afebrile and had painful, ecchymotic areas on his legs that progressed with marked swelling during the next few hours. He was treated with ceftazidime and analgesics and was transferred to our institution. Shortly after admission he went into shock and was transferred to the intensive care unit. Crepitus was noted in both legs, and radiographs of the legs were obtained. The radiographs of the right leg (Panels A and B) showed a feathery pattern of extensive gas formation in the subcutaneous tissues, along the fascial planes, and between major muscle bundles. A diagnosis of gas gangrene was made, and intravenous fluids, vasopressor agents, penicillin G, clindamycin, and meropenem were given to the patient preoperatively. Examination of a needle aspirate from an ecchymotic area showed gram-positive bacilli. Both legs were amputated. The patient was also treated with hyperbaric oxygen, but after three episodes of cardiac arrest he died approximately 24 hours after admission. Permission for an autopsy was refused. Blood cultures grew Clostridium septicum. Histologic examination of the amputated legs showed necrotizing fasciitis with hemorrhage, edema, and focal myonecrosis. Gram-positive bacilli were seen on special stains.

    Stephen M. Schexnayder, M.D.

    Sarah G. Klein, M.D.

    University of Arkansas for Medical Sciences

    Little Rock, AR 72205

    http://www.100md.com/html/DirDu/2006/11/29/30/40/94.htm