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Key Features

Essentials of Diagnosis

  • Contamination of a wound with soil or feces

  • Massive edema, skin discoloration, bleb formation, and pain in an area of trauma

  • Serosanguineous exudate from wound

  • Crepitation of subcutaneous tissue

  • Rapid progression of signs and symptoms

  • Clostridia cultured or seen on stained smears

General Considerations

  • Gas gangrene (clostridial myonecrosis)

    • Defined as a necrotizing infection that follows trauma or surgery

    • Caused by several anaerobic, gram-positive, spore-forming bacilli of the genus Clostridium

      • Spores are found in soil, feces, and vaginal secretions

      • In devitalized tissue, the spores germinate into vegetative bacilli that proliferate and produce toxins, causing thrombosis, hemolysis, and tissue necrosis

  • C perfringens, the species causing approximately 80% of cases of gas gangrene, produces at least eight toxins

  • Extremities, abdomen, and uterus are areas involved most often

  • Clostridium septicum may also cause myonecrosis and causes septicemia in patients with neutropenia

  • Nonclostridial infections with gas formation can mimic clostridial infections and are more common

  • Neutropenia is a risk factor for this severe infection

Clinical Findings

Symptoms and Signs

  • Sudden onset, often 1 day after trauma or surgery (mean, 3–4 days) but can be delayed up to 20 days

  • Pain and swelling usually are intense

  • Skin around the wound becomes discolored (pale, red, or purple), with hemorrhagic bullae, serosanguineous exudate, and crepitus

  • Absence of crepitus does not rule out the diagnosis

  • Systemic illness appears early and progresses rapidly to intravascular hemolysis, jaundice, shock, toxic delirium, and renal failure

Differential Diagnosis

  • Gangrene and cellulitis caused by other organisms and clostridial cellulitis (not myonecrosis) must be distinguished

  • Necrotizing fasciitis may resemble gas gangrene


Laboratory Findings

  • Isolation of the organism requires anaerobic cultures

  • The wound exudate, soft tissue, muscle and blood can be cultured

  • Gram-stained smears may demonstrate many gram-positive rods and few inflammatory cells


  • Radiographs may demonstrate gas in tissues, but this is a late finding

Diagnostic Procedures

  • Direct visualization of the muscle at surgery may be necessary to diagnose gas gangrene

  • Early, the muscle is pale and edematous and does not contract normally

  • Later, the muscle may be frankly gangrenous



  • Penicillin G (300,000–400,000 units/kg/d intravenously in six divided doses) should be given

  • Clindamycin, metronidazole, meropenem, and ertapenem are alternatives for penicillin-allergic patients

  • Some experts recommend a combination of penicillin and clindamycin; clindamycin may inhibit toxin production


  • Should be prompt and extensive, with removal of all necrotic tissue

  • Compartment syndromes

    • Can occur even if there are few cutaneous findings

    • Compartment pressures should be checked in ...

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