Clinical case presentation. gas gangrene

Gas gangrene, Clostrodium perfringens, Clinical case presentation

1. Clinical Case presentation Gas Gangrene Dr Vishal Kulkarni MBBS MD (Microbiology)

2. Case history 50 years old, male patient came in casualty department with the history of road traffic accident 2 days ago with c/o- Multiple open wounds and swelling on right leg since 2 days. Pain and heaviness in right leg since 2 days. Fever since 1 day Lightheadness since 1 day

3. H/O present Illness : Patient was apparently alright 2 days back when he had road traffic accident while travelling on his bike to his village. He fell from his bike on ground. He had no immediate complain except mild pain and multiple open wounds on right leg. The wounds were contaminated with soil and blood . He had local treatment in a primary health centre from which he referred to our hospital. He was having swelling, involving right leg, progressing gradually with black discoloration since 2 days.

4. He had pain in right leg which was sudden in onset, worsening gradually. He also had low grade fever which was insidious in onset, progressed gradually. He also had been complaining lightheadness & disorientation along with drowsiness and fatigue. No h/o of any spasms, convulsions No H/o TB, DM, HTN, Asthma etc

5. Past History:- No h/o similar complains in past. Family History:- No significant family history is present.

6. General Examination:- Patient was drowsy, and not oriented with time, place and person. Temp: 99.4 degree F. Pulse- 120 / min Regular, all peripheral pulses felt. R/R- 22 / min BP- 90/70 No H/O cynosis , clubbing , lymphadenopathy .

7. Local examination- Inspection- 7—8 multiple open wounds on right leg, varying in size and shape, oozing out serosanguinous discharge, few were ulcerated with bronze discoloration of surrounding skin. Few wounds involving muscles tissues which were necrosed Oedematous swelling over right leg.

8. Palpation- Warmth ++ Tenderness ++ Crepitus +++ Systemic examination- CVS- NAD RS- NAD CNS- NAD

9. Differential diagnosis Clostridium perfringens Clostridium septicum Clostridium novyi Clostridium tetani E. coli Proteus Staphylococci Anaerobic streptococci

10. Lab.diagnosis : Sample Collection- Films from muscles at the edge of affected area Tissue in necrotic area Exudates from part from where infection appears to be most active. Collected with capillary pipette or swab Transported to laboratory immediately

11. Gram stain- Scanty pus cells. Large number of regularly shaped, Gram positive bacilli without spores

12. Emergency Treatment- Surgery along with prophylactic antibiotics were advised Metronidazole & Gentamicin IV before surgery (8 hrly x 24 hrs) All damaged tissues were removed promptly Uncompromised excision of all damaged parts was done.

13. Culture- Aerobic culture- Mac conkey - 4-5 LFF colonies BA- 5-6 large gray moist colonies.

14. Anaerobic culture RCM broth were inoculated Media turned pink on incubation Incubated and subcultured on BA after 24-48 hrs Haemolysis positive on BA with large grey moist colonies.

15. Naegler reaction- Positive

16. IMViC - ( ++ --) (- + --) TSI- A/A without gas A/A with H ₂S Reverse CAMP test - Positive

17. Diagnosis- Based on above findings diagnosis is likely to be a case of Gas gangrene caused by infection of Clostridium perfringens .

18. Post-operative treatment- Post-op care was taken. Metronidazole and gentamicin was continued for another 48 hours.