Asian Cardiovasc Thorac Ann 2007;15:e12-e13
© 2007 Asia Publishing EXchange Ltd
Non-Clostridial Gas Gangrene of the Neck and Mediastinum
Saulat Fatimi, MD,
Sadaf Sheikh, MBBS,
Majid Shafiq, MBBS,
Zaman Shah, MBBS
The Aga Khan University Hospital, Karachi, Pakistan
For reprint information contact: Sadaf Sheikh, MD, Tel: 92 21 486 4876, Fax: 92 21 493 0051, Email: sheikh.sadaf{at}gmail.com, Juma Building, Aga Khan University, Stadium Road, Karachi, Pakistan
 |
ABSTRACT
|
|---|
Herein we report a case of gas gangrene of the neck and mediastinum in a poorly managed Type II diabetic with concomitant chronic renal failure and a recent history of mucormycosis. Despite the burden of co-morbidities and the gravity of the illness, the patient was successfully treated and remained free of complications in the long term.
|
INTRODUCTION
|
|---|
Although gas gangrene is common enough to have been well described in the literature, the neck and mediastinum regions remain infrequent sites for such infection.1 Furthermore, the causative organism is seldom any other than Clostridium perfringens.2 Here we report one case to the contrary.
|
CASE REPORT
|
|---|
A 51-year-old lady, known to be suffering from Type II diabetes mellitus (DM), hypertension, and chronic renal failure was admitted to the hospital with complaints of pus-filled, tender swellings over the right wrist and the left elbow, together with a high grade fever. An incision and drainage of these abscesses was promptly performed. Blood, urine, and pus specimens were sent for culture and sensitivity and the patient was empirically started on intravenous Meropenem, Amikacin, Vancomycin, and Clindamycin.
On the third day of hospitalization, the patient complained of progressively worsening pain in the neck and chest along with dysphagia. Examination revealed a tender, diffuse swelling of the neck. Crepitus was positive. Computed tomography (CT) scan revealed a necrotic right sternocleidomastoid (SCM) muscle containing gas shadows (Figure 1
) that were extending into the superior mediastinum, in addition to erosions of the right clavicle and the manubrium (Figure 2). A diagnosis of gas gangrene of the neck plus mediastinitis was made. Radical debridement of the right SCM, medial half of the right clavicle, the manubrium, and anterior cortex of the mid-sternum was carried out. A feeding gastrostomy was created at the same time. The chest was closed in two layers after inserting two Penrose and one suction drain. Postoperatively, the patient was placed on a ventilator and successfully extubated after three days.
View larger version (144K):
[in this window]
[in a new window]
|
Figure 2. In this section, the manubrium is seen to be largely eroded; gas shadows are seen in the right region of the superior mediastinum.
|
|
Culture of the pus revealed Ps. aeruginosa and K. pneumoniae. Blood culture revealed K. pneumoniae, while urine culture grew Pseudomonas and E. coli. No anerobes were seen to grow in any of the cultures. On the basis of these reports, Clindamycin and Vancomycin were discontinued. The other antibiotics were continued for three weeks. The patient was transferred from the intensive care unit one week after surgery, and remained in the general ward for another two weeks.
The patient was followed up as an out-patient regularly for the next six months, and did not develop any new infections during that period.
|
DISCUSSION
|
|---|
Muscular infections usually occur in areas of the body that have been compromised or injured by a foreign body, trauma, ischemia, injection of illicit drug, malignancy, or surgery.2 Since the local bacterial flora is often responsible for these infections, anatomic sites that are subject to fecal or oral contamination are particularly at risk.1 Infectious myositis caused by bacteria can invade from contiguous sites such as skin and subcutaneous abscesses and ulcers or through hematogenous spread. However, primary muscle abscesses have also occurred in the apparent absence of a predisposing site of infection.3 The neck and mediastinum are not known to be commonly involved, especially in the absence of the afore-mentioned predisposing factors. Additionally, myositis has been seen to occur largely among patients with systemic pathologies such as immunosuppressive states and hematological illnesses.4 Our patient could be considered to be at a slightly higher risk than normal because of her uncontrolled diabetes.
The causative organism in gas gangrene is Clostridium perfringens in 80–95% of cases. However, other Clostridial species and other microbes such as E. coli have also been isolated.3 In our case, culture of the pus only grew Ps. aeruginosa and K. pneumoniae.
Gas gangrene can rapidly progress to serious morbidity and even mortality, and prompt, extensive surgery is clearly indicated.1 Management of non-clostridial gas gangrene of the neck is a challenge not just for the thoracic surgeon, but additionally for the infectious disease physician. For the surgeon, proximity of the great vessels and other sensitive structures makes for a high-risk surgery. For the physician, prompt but accurate institution of empirical therapy while waiting for the bacterial culture reports is no less than a decent challenge. Notably, many clinicians (including us) are unconvinced about the worth of hyperbaric oxygen therapy (while the possibility of clostridial infection still remains) due to inconclusive research findings.5 However, Sugihara et al 6 have recently recommended its use in tandem with antibiotics for soft tissue infections.
In light of our case, as well as review of the current literature, we conclude that gas gangrene of the neck needs to be diagnosed quickly and managed aggressively for desirable results to follow. Management pitfalls include a low index of suspicion, undue reliance on conservative management and hence, undue delay in proceeding to surgery.
|
REFERENCES
|
|---|
- Patel SR, Olenginski TP, Perruquet JL, Harrington TM. Pyomyositis: clinical features and predisposing conditions. J Rheumatol 1997;24:1734–8.[Medline]
- Hsueh PR, Hsiue TR, Hsieh WC. Pyomyositis in intravenous drug abusers: report of a unique case and review of the literature. Clin Infect Dis 1996;22:858–60.[Medline]
- Levin MJ, Gardner P, Waldvogel FA. An unusual infection due to staphylococcus aureus. N Engl J Med 1971;284:196–8.[Medline]
- Christin L, Sarosi GA. Pyomyositis in North America: case reports and review. Clin Infect Dis 1992;15:668–77.[Medline]
- Wang C, Schwaitzberg S, Berliner E, Zarin DA, Lau J. Hyperbaric oxygen for treating wounds: a systematic review of the literature. Arch Surg 2003;138:272–80.[Abstract/Free Full Text]
- Sugihara A, Watanabe H, Oohashi M, Kato N, Murakami H, Tsukazaki S, et al. The effect of hyperbaric oxygen therapy on the bout of treatment for soft tissue infections. J Infect 2004;48:330–3.[Medline]
TOP
ABSTRACT
INTRODUCTION
