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Medical literature offers no clear treatment guidelines when performing amputations for gangrene of the forefoot despite a high percentage that suffer poor outcome due to infection. Gas gangrene and wet gangrene are often preceded by dry stable gangrene. This is a retrospective review of consecutive patients who underwent forefoot amputation and bone biopsy as treatment of forefoot gangrene by a single surgeon. Procedures performed included digital, ray, or transmetatarsal amputation with bone biopsy sent for both culture and histopathologic evaluation. One hundred patients (35 females, 65 males) met inclusion criteria. Mean follow-up was 9.6 months. Mean age was 63.5 years old. Forty-six out of 100 (46%) had elective amputation while 54/100 (54%) were emergent for acute infection. Vascular intervention was performed in 52/100 (52%). Seventy-eight out of 100 (78%) had histopathologic diagnosis of acute osteomyelitis while 82/100 (82%) had positive bone culture. Patients with acute infection had worse outcomes, with higher rates of more proximal amputation and delayed wound healing. We found that 79.7% of patients who underwent forefoot amputation due to gangrene had underlying osteomyelitis. We also found that those with acute infection during the time of amputation had poorer postamputation outcomes such as delayed wound healing, revision surgery, and high rates of more proximal amputation. Therefore, it may imply that earlier amputation of stable gangrene prior to becoming acutely infected may decrease the occurrence of osteomyelitis and avoid some of the preventable postamputation complications. Further studies are warranted.

BACKGROUND: Gas gangrene is a clostridium infection primarily of muscle tissue, most commonly caused by C. perfringens. Clinical diagnosis is usually made by local inspection of the wound: the infected tissue shows characteristic signs of tissue inflammation with blistered changes. The disease can starts suddenly, 4-6 hours after the injury, but most commonly the incubation period lasts 2-4 days. Without proper medical intervention, death occurs in 4-24 hours after the development of the first symptoms, but even with timely and adequate therapy, the lethality is very high (around 12%). Due to its fulminant course, in all cases with fatal outcomes, a forensic autopsy is an obligatory procedure. However, discovering the entrance gate and source of infection is not an easy task, especially in the absence of a traumatic injury. CASE PRESENTATION: Male, 27 years old, an intravenous heroin addict for about 10 years, injured his left leg in a traffic accident. He only visited the doctor after 5 days. Upon examination, it was determined that there were no externally visible injuries and no fracture, and he was given a splint immobilization for an ankle luxation. Twelve days after the accident (or 7 days after the immobilization) his mother found him unconscious. CONCLUSION: From medicolegal aspects, it’s important to have in mind even the less frequent paths of infection, in order to give an expert professional opinion on origin and cause of death.

Clostridial myonecrosis or gas gangrene (myonecrosis) and tetanus are relatively rare nowadays, but they are still considered serious conditions associated with poor prognosis and high mortality. Life-threatening infections caused by Clostridium species have been known and studied for centuries, as they differed from other infections in terms of typical clinical manifestations, challenges of therapy and prevention. The aim of the study was to analyse the global incidence of gas gangrene and tetanus and challenges of prevention and treatment of these diseases. The review of up-to-date scientific literature demonstrated that gas gangrene continues to be a problem due to its rapid progression and challenging treatment. There are two main forms of the disease—traumatic and spontaneous. Traumatic gas gangrene is usually caused by C. perfringens, C. septicum, C. novyi (oedematiens), or C. histolyticum. Its incidence increases dramatically during wars, natural disasters, and other calamities. The literature review demonstrated that over the past 40 years there has been a rise in the frequency of spontaneous gas gangrene caused by C. septicum in people with compromised immune systems, in injecting drug users, and in women during various gynecological procedures and during normal delivery. Despite the effectiveness of the tetanus immunisation programme, the infection remains widespread in countries with insufficient vaccination coverage. The risk of tetanus in developed countries is high among elderly unvaccinated or partially vaccinated people, among injecting drug users, and vaccine refusers. The paper describes some clinical cases of gas gangrene and tetanus which demonstrate problems associated with challenging diagnosis and treatment, low awareness among primary healthcare personnel about mechanisms of anaerobic infection development, and anti-vaccination movement.

Purpose: Intratumorally injected Clostridium novyi-NT (nontoxic; lacking the alpha toxin), an attenuated strain of C. novyi, replicates within hypoxic tumor regions resulting in tumor-confined cell lysis and inflammatory response in animals, which warrants clinical investigation. Patients and Methods: This first-in-human study (NCT01924689) enrolled patients with injectable, treatment-refractory solid tumors to receive a single intratumoral injection of C. novyi-NT across 6 dose cohorts (1 × 104 to 3 × 106 spores, 3+3 dose-escalation design) to determine dose-limiting toxicities (DLT), and the maximum tolerated dose. Results: Among 24 patients, a single intratumoral injection of C. novyi-NT led to bacterial spores germination and the resultant lysis of injected tumor masses in 10 patients (42%) across all doses. The cohort 5 dose (1 × 106 spores) was defined as the maximum tolerated dose; DLTs were grade 4 sepsis (n = 2) and grade 4 gas gangrene (n = 1), all occurring in three patients with injected tumors >8 cm. Other treatment-related grade ≥3 toxicities included pathologic fracture (n = 1), limb abscess (n = 1), soft-tissue infection (n = 1), respiratory insufficiency (n = 1), and rash (n = 1), which occurred across four patients. Of 22 evaluable patients, nine (41%) had a decrease in size of the injected tumor and 19 (86%) had stable disease as the best overall response in injected and noninjected lesions combined. C. novyi-NT injection elicited a transient systemic cytokine response and enhanced systemic tumor-specific T-cell responses. Conclusions: Single intratumoral injection of C. novyi-NT is feasible. Toxicities can be significant but manageable. Signals of antitumor activity and the host immune response support additional studies of C. novyi-NT in humans.

Breast gangrene is rare in surgical practice. Its aetiology is variable and multifactorial. Debridement and appropriate antibiotic treatment are the mainstay of management. Two such cases presented one early and the other desperately late. We report these two cases to emphasise the potential fatality of this condition.

As the trend to look beautiful is growing, so does the number of patients seeking reconstructive and aesthetic facial surgery, which leads to the rapid development of this field. To date, there exists a large number of techniques to eliminate a scar deformity, but none of them guarantees the optimal cosmetic effect. The purpose of the study. The study aims to search for and analyze scientific sources related to the prevention of pathological scars in Ukraine and the world. Materials and methods of research. To study the research materials, the bibliosemantic and analytical methods have been applied to process literature data, as well as research materials posted on the Internet. Skin is the largest human organ whose total surface area ranges from 1.7 to 2.6 m2 and can vary depending on height and weight. It acts as the main protective barrier from the environment. Violation of this barrier after injury, burns, or surgical resection can lead to chronic wounds and scars that affect patients physically and emotionally. Therefore, a better understanding of the cellular and molecular mechanisms underlying wound healing can potentially improve the lives of such people, as well as stimulate the development of new prevention and treatment methods. All wounds, except for surgical ones, are initially considered to be infected. Microorganisms get into the wound along with the damaging object, soil, pieces of clothing, air, and during hand touching. Once in the wound, microorganisms can cause suppuration and complications such as erysipelas. The most dangerous way for the microorganisms to enter the wound is in the absence of air which can cause anaerobic infection (gas gangrene). Another dangerous wound complication is a tetanus infection. For its prevention, all contaminated wounds (especially, by soil) should be treated with anti-tetanus toxoid or anti-tetanus serum. Thus, wound healing is one of the most difficult processes in the human body. It includes spatial and temporal synchronization of different cell types with different roles in the phases of hemostasis, inflammation, growth, reepithelialization, and remodeling. With the development of technology, it became possible to detect the phenotypic and functional heterogeneity of cell types. Discovering the role of each of these cell types and their interaction with each other is important for understanding the mechanisms of wound regeneration. The scar (Cicatrix) is a secondary morphological element of the skin, which is formed when it is damaged, and especially when the reticular dermis is damaged. Laser therapy is used to prevent scarring, but the evidence for the effectiveness of laser treatment of surgical and hypertrophic scars, as well as keloids is somewhat insufficient, but generally suggests promising results. Multiple studies report a significant scar thickness improvement when applying the right program. Conclusion. Based on the bibliosemantic and analytical methods applied to process literature data, we believe that the study of intra- and postoperative prevention of pathological scars at different stages of their formation remains a topical issue and needs further study.

Background: The United States is in the midst of an opioid crisis. Injection drug use is a major risk factor for necrotizing soft tissue infections (NSTI) by introducing bacteria into the soft tissues. Repetitive infection and atypical pathogens may be tangible manifestations of the opioid crisis. Methods: We describe recidivism in two cases of NSTI involving opioid abuse and atypical pathogens at a single institution and review pertinent international literature. Results: Repetitive NSTI is rare. Patients with chronic injection drug use, however, may be at particular risk of repetitive NSTI and infections with atypical organisms. Conclusions: Care providers must have a heightened awareness of infections with atypical pathogens and risk of repetitive infection in patients with injection drug use. Aggressive surgical management and antibiotic coverage tailored to culture and susceptibility data are necessary for a successful short-term outcome. A successful long-term outcome mandates identification and management of co-existent behavioral health issues.

Clostridium species are gram-positive, spore-forming, anaerobic rods normally found in the soil and gastrointestinal tract of humans and animals. Spontaneous sepsis due to C. perfringens is not caused by injury, which sets it apart from the classical gas gangrene that typically follows trauma. Spontaneous C. perfringens sepsis often develops as a rapidly progressive intravascular hemolysis and metabolic acidosis, with high mortality rates of over 70% with standard intensive care. In such cases, alpha toxin secreted by C. perfringens is considered the main toxin responsible for intravascular hemolysis, disseminated intravascular coagulopathy, and multiple organ failure. Theta-toxin causes a cytokine cascade, which results in peripheral vasodilation similar to that seen in septic shock. For C. perfringens infections, antibiotics, such as high-dose penicillin, and surgical drainage as early as possible are the principal treatments of choice. However, considering the current mortality rate of sepsis, outcomes have not improved with the current standard treatment for C. perfringens infections. Monoclonal antibody against theta toxin in combination with gas gangrene antitoxin presents a promising therapeutic option.

Background Clostridium septicum is an anaerobic, motile, spore-forming, toxin-producing gram-positive bacillus that can lead to rapidly progressive gas gangrene due to the release of alpha toxin. Aortic aneurysm secondary to C. septicum infection is a rare condition with 60 cases reported in the literature; however, we have recently treated several patients with the condition in our large tertiary care and aortic center. Methods Blood and tissue culture results collected between January 2005 and January 2018 and maintained in the microbiology laboratory database at the Cleveland Clinic were reviewed to identify those with C. septicum reported. Each was reviewed to determine radiographic or histopathologic correlation with aortic disease. Results Seven cases of C. septicum aortitis were reviewed. Underlying malignant disease was found in four cases and a history of remote malignant disease in one case. The most common location for infection was the infrarenal abdominal aorta. Vascular surgery had previously been performed in three of the cases. Five of the seven patients underwent operative repair. All patients were treated with β-lactam antibiotics. The two patients who did not undergo an operation died, which is consistent with the 100% mortality described in the literature. Of the five patients who underwent an operation, there was only one documented survivor and one was lost to follow-up. Conclusions In the largest reported case series, only a small percentage of patients with C. septicum-infected aortic aneurysms survived >1 year. In the patients described, those who did not receive an operation had 100% mortality. Earlier recognition and prompt operation with appropriate antimicrobial therapy are needed to improve the outcome of patients diagnosed with this rare infection.

Recently, postmortem imaging is sometimes used as an alternative to conventional autopsy. However, there are few case reports of postmortem imaging of dialysis patients. Here, we report a fatal case of gas gangrene involving a 76-year-old man who underwent dialysis. He died suddenly before a diagnosis could be established. Immediately after his death, postmortem computed tomography (PMCT) revealed gas accumulation in his right upper extremity and ascending aorta. Gas gangrene progresses rapidly and may sometimes result in sudden death before it is diagnosed. In this case, PMCT findings were useful to diagnose gas gangrene. Intravascular gas is a common finding on PMCT and is generally caused by cardiopulmonary resuscitation and decomposition. However, the detection of gas in the ascending aorta by PMCT was not described previously. Moreover, Gram stain and culture of the exudate showed anaerobic Gram-positive bacilli which suggested that the gas generation in the blood was caused by Clostridia species. To the best our knowledge, this is the first report of a dialysis patient whose cause of death was determined as gas gangrene using PMCT.

Gas gangrene is the term used to describe necrotizing skin and soft tissue infection by gas forming organisms. In the modern era, this type of infection is rarely seen outside theatres of war. Patients often present in sepsis, shock or organ dysfunction. Without prompt therapy, gas gangrene has high mortality therefore early diagnosis and swift initiation of antibiotic therapy forms the cornerstone of management. Radical surgical therapy is usually required.

Necrotizing soft tissue infection of the breast is an extremely rare event in routine surgical practice. It is the most aggressive form of soft tissue infection and a real surgical emergency. It is associated with a high risk of mortality if not diagnosed promptly. A Literature search has revealed only a few such cases. The exact etiology is variable and very often multifactorial. Early recognition and prompt surgical treatment along with broad-spectrum antibiotic therapy are of paramount importance to prevent mortality. In this report, we present the first case of necrotizing fasciitis of the breast following an insect bite in the literature, in a 57-year-old diabetic patient with a delayed presentation that required a life-saving mastectomy.

The maternal death rate remains unacceptably high worldwide, predominantly in areas of poor access to quality health services. According to the WHO, in 2017, 810 women died from preventable causes related to pregnancy and childbirth. Causes of maternal death are plenty, including previous morbidity and unexpected causes. Among the latter are infectious disease-related deaths. Herein, we describe a case of a 29-year-old woman at 37 weeks’ gestation who presented with right upper quadrant pain, which was initially considered to be pregnancy-related. However, she collapsed shortly after the hospital admission. The physical examination revealed severe hypovolemic shock due to a large amount of intraperitoneal free fluid. The patient was immediately rushed into an emergency cesarean section followed by exploratory laparotomy, which demonstrated a large intra-abdominal hemorrhage. The patient and her fetus died in the operating room. An autopsy revealed acute gangrenous cholecystitis along with abundant rod-shaped bacteria within the mucosa and vessels of the gallbladder, gas gangrene and rupture of the spleen, and signs of shock. Clostridium perfringens (CP) was isolated in the culture of a splenic sample. Although CP is a well-known and dreadful infectious etiological agent, catastrophic cases still happen. The acquaintance of this infection by the caregivers is crucial for the early diagnosis and treatment. This is a quite unique way to provide a dismal chance of survival in sepsis cases by this agent.

Background: Necrotizing soft tissue infections (NSTIs) are rapidly progressing, life-threatening diseases associated with substantial morbidity and mortality, especially in patients 65 years or older. We aimed to evaluate clinical factors associated with mortality and discharge disposition after NSTIs in elderly patients. Patients and Methods: Retrospective data were obtained from the 2007-2017 American College of Surgeons-National Surgical Quality (ACS-NSQIP) database. Patients aged 65 years or older with a post-operative diagnosis of an NSTI (defined as gas gangrene, necrotizing fasciitis, or Fournier gangrene) were included. Univariable and multivariable analyses were performed to identify independent clinical and demographic factors associated with mortality and with discharge disposition. Results: A total of 1,460 patients were included. Median age was 71 years, 43% were females. Overall, 30-day mortality was 18.5% and 30-day morbidity was 63.6%. The most important predictors of mortality included pre-operative septic shock (odds ratio [OR], 6.36; 95% confidence interval [CI], 3.61-11.18), pre-operative dialysis dependence (OR, 2.99; 95% CI, 1.77-5.05), coagulopathy (international normalized ratio [INR], >1.5, OR, 2.25; 95% CI, 1.51-3.37), hepatobiliary disease (bilirubin >1.0 mg/dL; OR, 2.05; 95% CI, 1.38-3.04) and aged 80 years or older (OR, 3.36; 95% CI, 2.08-5.44). Patients without any of these risk factors had a mortality of 7.3%. Predictors of discharge to inpatient rehabilitation or skilled care included age 80 years or older (OR, 2.49; 95% CI, 1.44-4.30), American Society of Anesthesiologists (ASA) ≥3 (OR, 2.05; 95% CI, 1.03-4.05)] and amputation as opposed to debridement (OR, 2.53; 95% CI,1.48-4.32). Conclusions: We identified several pre-operative clinical factors that were associated with increased post-operative mortality and discharge to post-acute care. The next steps should focus on determining if optimization of modifiable predictors would improve mortality.

Objective: Describe patients developing subcutaneous edema after knee arthroscopy. Methods: Personally encountered reported case plus searches using PubMed, Scopus, Web of Science of “subcutaneous edema” and “arthroscopy”. Results: Of 11 cases, 4 could be traced to mishaps during the arthroscopic procedure and two others to non-healing wounds. Edema ranged from chest wall to ankle, and usually appeared several days after arthroscopy. Patients appeared well and did not motivate treatment for gas gangrene, except in one case that underwent fasciotomy and another an arthrotomy. Recovery was complete within 2 days to 3 weeks, with no residual effect on the operated knee. Reported subcutaneous edema follows shoulder arthroscopy more often than knee arthroscopy, and can also complicate arthroscopy of hip and elbow. Conclusion: Subcutaneous edema is a rare dramatic complication of knee arthroscopy with a benign outcome.

Background Gas gangrene is usually manifested as myonecrosis and subcutaneous gas accumulation, but rarely manifested as arterial occlusion or pneumatosis in the right ventricle and the pulmonary artery. Case presentation We report a case of gas gangrene caused by Clostridium septicum. The patient developed gas gangrene after being pecked by a chicken but turned for the better following antibiotic treatment and debriment. Imaging test revealed a rare occlusion of the right femoral artery and pneumatosis in the right ventricle and the main pulmonary artery. Conclusions In the presence of gas gangrene, special care must be taken to prevent against the formation of circulatory air embolism. The gas gangrene-induced gangrene in the limb of this patient might be attributed to the combined action of infection and arterial occlusion. MDT (Multidisciplinary team)-Green Channel mode is conductive to treatment success of gas gangrene.

Primary hepatic gas gangrene is a form of primary abdominal gas gangrene. The condition is caused by Clostridium perfringens, other clostridia, and non-clostridia bacterial species producing gas. Unlike classical gas gangrene or myonecrosis, the disease develops without a wound or a port of entry. Instead, gas-producing bacteria in the gastrointestinal tract colonize an underlying pathological process with foci of necrosis, producing excessive gas and spreading hematogenously to other organs. Herein we present two autopsy cases of primary hepatic gas gangrene diagnosed on autopsy, with the gross and histological changes that can be considered specific for this rare condition. Both patients had severe underlying liver disease-prone for this entity development. The gross changes in the cases are postmortem subcutaneous emphysema, skin bullae with pooled blood, pneumothorax, pneumoabdomen, abundant gas in the circulatory system, porous structure of the internal organs (tissue gas bubbles), and advanced tissue lysis, not corresponding to the post mortem time. Histology showed optically empty areas of varying size in the internal organs, which weave the structure of the organs and rod-shaped bacteria with scarcity or complete absence of inflammatory reaction.

Pancreatic necrosis infection (PNI) accounts for about 20–40 % of severe acute pancreatitis. PNI caused by anaerobic bacteria is unusual but when they present,Clostridium perfringensis the microorganism most commonly involved. We present a 60-year-old patient with a previous history of SARS-CoV-2, diagnosed with acute pancreatitis. During the hospitalisation he developedClostridium perfringensbacteraemia. A CT-scan showed pancreatic gas gangrene and a surgical necrosectomy was performed.Clostridium perfringenswas isolated in cultures of the pancreatic tissue and collections. The patient’s clinical status improved after surgery and the appropriate medical therapy. He was discharged 76 days after admission. Nowadays, the ‘step-up approach’ is an accepted therapeutic tool in treatment of pancreatic necrosis and peripancreatic fluid collections. However, most authors suggest thatClostridum perfringensinfection requires a more aggressive approach due to the high mortality associated to clostridial infection.

Gas gangrene of the uterus is rarely seen in the present era of modern medicine. It is a fulminant infection caused by clostridium perfringens and is associated with a very high mortality rate [1]. Most cases of gas gangrene of the uterus reported in literature are associated with gynecological malignancy, septic abortion, and prolonged rupture of membranes during pregnancy [2]. The present study reports the case of an 18-year-old nulliparous woman with 3 months of amenorrhea who underwent dilatation and evacuation (D&E) at a government facility due to incomplete abortion. The patient had expelled the fetus at home and was taken to the facility because of persistent bleeding after completion of the abortion process. The patient was otherwise healthy and had no history of fever. The patient's next of kin provided informed written consent for the publication of this study.

Abdominal gas gangrene caused by Clostridium perfringens is a rare differential diagnosis to pneumoperitoneum caused by bowel perforation. There are only a handful of case reports on this topic.We present the case of a 58 year old cirrhotic patient who represented to our ER after complicated surgery for retroperitoneal liposarcoma. On admission he complained of abdominal pain and mild fever. Due to leukocytosis and CRP a CT scan was performed which showed extensive free air. The patient was taken to the OR for suspected bowel perforation. No perforation could be identified after extensive search and lavage.Twelve hours after surgery microbiology reported extensive growth of clostridium perfringens in the cultures drawn from ascites. The patient was successfully treated with antibiotics and discharged home soon after.Gas gangrene is a rare differential diagnosis to bowel perforation. Most reported cases are from cirrhotic patients. If no perforation can be identified in the OR postoperative antibiotics should cover clostridium perfringens.

Gas gangrene (GG) remains a life-threatening and deadly disease. Early recognition together with daily surgical debridement remains the mainstay of therapy. We sought to describe a fatal case of necrotizing soft tissue infection, which was a gas gagrene in this case. This case was remarkable as two main sites were infected simultaneously in geographical zones very far from each other making dissemination between both sites almost impossible. The other particularity was the fact that the infection was caused at the same time by four different bacteria that is atypical in GG similar to that in streptoccocal necrotizing fasciitis where one bacteria is the causative agent (Clostridium perfringens for GG and group A streptococcus for necrotizing fasciitis).

Purpose: Emphysematous cholecystitis (EC) is an uncommon, severe variant of acute cholecystitis caused by gasforming bacteria - most often Clostridium perfringens and Escherichia coli. We present a deceptive case of EC associated with retroperitoneal gas gangrene and emphysematous pancreatitis. Case report: An 86-year-old, overweight woman was admitted to the emergency department with non-specific abdominal symptoms. Admission laboratory tests showed elevated diastase levels indicating acute pancreatitis. Computed tomography (CT) demonstrated a substantial amount of gas in the retroperitoneum and peritoneal cavity, which raised a suspicion of duodenal perforation. Primary diagnosis was not confirmed during emergency laparotomy, which revealed a gangrenous gallbladder adjacent to the duodenum and surrounded by purulent fluid. The final diagnosis established after laparotomy and rereading of CT scans was that of emphysematous cholecystitis associated with gangrenous pancreatitis and retroperitoneal gangrene. After surgery, the patient was transferred to the intensive care unit in septic shock. Shortly after, the second laparotomy was undertaken on suspicion of internal bleeding. During surgery, the patient experienced cardiac arrest and died despite immediate resuscitation. Conclusions: Emphysematous cholecystitis may be associated with a spread of infection both to the peritoneal cavity and retroperitoneum and result in a substantial amount of gas in those anatomic compartments. The knowledge of this rare complication may be helpful in establishing a correct diagnosis.

Background Even though gas gangrene caused by Clostridium septicum in goats is mentioned in the classical textbooks, we have not managed to find any case description in the literature. Case presentation Clinical signs resembling gas gangrene such as subcutaneous bloating, edema and crepitation were detected at various body parts of nine pregnant animals at the ages of 2–3 years on a hair goat farm (n = 170) located in Bingol province, Eastern Turkey. Five of these suspected animals with severe clinical symptoms died within 2 days. Various samples such as internal organs, edematous skin and edema fluid collected from dead and live animals were analyzed for the presence of clostridial agents by histopathological and microbiological methods. As a result of macroscopic and microscopic examination, lesions of gas gangrene were detected. The suspected isolates were identified and confirmed as C. septicum by bacteriological and molecular methods. Conclusion The present study was the first to report identification of C. septicum as primary agent in the gas gangrene of goats.

We herein review and analyze the diagnosis, treatment, and outcome of a severe infection caused by a human bite. A 68-year-old man was bitten on the forearm by a 3-year-old child. Rapid progression of infection, severe local and systemic poisoning, and diverse clinical manifestations were observed at presentation. Based on the medical history, physical signs, imaging examinations (X-ray films, color Doppler ultrasound, and computed tomography), laboratory examinations, and multidisciplinary consultation, the patient was diagnosed with gas gangrene or gas gangrene-like changes. Twenty-four hours after the injury, an emergency amputation was performed (open amputation with wound closure after 1 week). After the operation, the patient was sent to the intensive care unit for isolation and further anti-infection and anti-shock treatments. His condition gradually improved after treatment and he was discharged without further complications. Bacteriological and pathological examinations indicated Aeromonas hydrophila infection leading to extensive necrotizing fasciitis of the limb and severe systemic poisoning. In addition, pre-existing myelodysplastic syndrome progressing to acute myeloid leukemia was identified as a possible predisposing factor. Human bites can cause serious infections requiring timely treatment, particularly in patients with predisposing comorbidities.

Gas gangrene is infectious disease caused by Clostridium perfringens infection. We are presenting extremely rare case of gluteal clostridial myonecrosis after intramuscular injection of diclofenac in immunocompromised young patient on a long-standing corticosteroid therapy presented with sepsis and initially absent clinical signs of severe anaerobic infection. After delayed diagnosis, she was treated with aggressive surgical removal of necrosed tissue and targeted antibiotic therapy which led to a rapid improvement allowing application of a negative- pressure wound therapy device with favorable outcome. This report shows the importance of timely diagnosis with pitfalls of imaging. It confirms that surgical debridement along with specific antibiotic therapy is the mainstay of treatment, but also promotes negative-pressure wound therapy which has proved convenient for accelerated closure of large incisions with tissue loss without any adverse effects or the need for complex recon-structive procedures.

Background: Blackleg and malignant edema are acute clostridialinfections primarily affecting cattle. The objectives of this study were toidentify i) animal-related factors influencing the occurrence and ii)prognostic pathological findings supporting the differentiation of fatalblackleg and malignant edema cases in the cattle population from 1998to 2018 in Styria, Austria.Methods: Two binomial logistic models were applied to analyse theresearch questions. Additionally, cross-validations were performed toestimate the accuracy of the predictive models.Results: Model results show that animal-related factors (i.e. age,geographical discovery location of dead cattle, vaccination status)significantly influence the occurrence of blackleg when compared tomalignant edema. Pathological findings are similar for both diseases.Conclusions: Model results reveal that using animal-related factors has abetter accuracy to predict the fatal cases caused by both pathogens.Thus, the authors recommend not to rely on pathological findings aspredictive factors in the differentiation between blackleg and malignantedema in cattle.

Necrotizing soft tissue infections occur after traumatic injuries, minor skin lesions, nonpenetrating injuries, natural childbirth, and in postsurgical and immunocompromised patients. Infections can be severe, rapidly progressive, and life threatening. Survivors often endure multiple surgeries and prolonged hospitalization and rehabilitation. Despite subtle nuances that may distinguish one entity from another, clinical approaches to diagnosis and treatment are highly similar. This review describes the clinical and laboratory features of necrotizing soft tissue infections and addresses recommended diagnostic and treatment modalities. It discusses the impact of delays in surgical debridement, antibiotic use, and resuscitation on mortality, and summarizes key pathogenic mechanisms.

Spontaneous emphysematous splenitis is a life-threatening condition reported rarely in humans; however, published reports in dogs are currently lacking. The aim of this multicentric, retrospective, case series design study was to describe radiographic and ultrasonographic imaging findings in Golden Retriever dogs diagnosed with spontaneous emphysematous splenitis. A total of three dogs were sampled. All dogs had a history of lethargy, diarrhea, and weight loss. Radiographic findings in all dogs included a mass effect with focal or multifocal coalescing "vesicular-like" gas pattern in the splenic region and focal loss of serosal detail. Ultrasonographic findings in all dogs included focal or multifocal irregularly shaped, hypoechoic areas containing a mixture of hyperechoic fluid and gas within the splenic parenchyma, hyperechoic abdominal free fluid, and generalized hyperechoic mesenteric fat without evidence of splenic torsion. Pneumoperitoneum was detected ultrasonographically and radiographically in two dogs. All three dogs underwent splenectomy and splenic torsion was definitively ruled out at surgery. One dog died three days after surgery, whereas the other two dogs recovered uneventfully. Culture of the splenic tissue and free abdominal fluid was positive for Clostridium spp. in all three cases. Findings supported inclusion of spontaneous emphysematous splenitis and septic peritonitis as differential diagnoses for dogs with this combination of clinical and imaging characteristics.

Background: Previous estimates of the incidence of necrotizing soft tissue infections (NSTI) in the United States have substantial limitations and underestimate its occurrence. Improvements in hosp...

Background Widespread use and misuse of antibiotics have led to a dramatic increase in the emergence of antibiotic resistant bacteria, while the discovery and development of new antibiotics is declining. This has made certain implant-associated infections such as periprosthetic joint infections, where a biofilm is formed, very difficult to treat. Alternative treatment modalities are needed to treat these types of infections in the future. One candidate that has been used extensively in the past, is the use of ionizing radiation. This review aims to provide a historical overview and future perspective of radiation therapy in infectious diseases with a focus on orthopedic infections. Methods A systematic search strategy was designed to select studies that used radiation as treatment for bacterial or fungal infections. A total of 216 potentially relevant full-text publications were independently reviewed, of which 182 focused on external radiation and 34 on internal radiation. Due to the large number of studies, several topics were chosen. The main advantages, disadvantages, limitations, and implications of radiation treatment for infections were discussed. Results In the pre-antibiotic era, high mortality rates were seen in different infections such as pneumonia, gas gangrene and otitis media. In some cases, external radiation therapy decreased the mortality significantly but long-term follow-up of the patients was often not performed so long term radiation effects, as well as potential increased risk of malignancies could not be investigated. Internal radiation using alpha and beta emitting radionuclides show great promise in treating fungal and bacterial infections when combined with selective targeting through antibodies, thus minimizing possible collateral damage to healthy tissue. Conclusion The novel prospects of radiation treatment strategies against planktonic and biofilm-related microbial infections seem feasible and are worth investigating further. However, potential risks involving radiation treatment must be considered in each individual patient.

Background Colonoscopy is a routine procedure in diagnosis and treatment of colonic disease. While generally regarded as a safe procedure, potentially fatal complications can occur. Gas gangrene is one such complication, with very high mortality. There are few cases of gas gangrene occurring after colonoscopy, making it one of the rarer complications of this procedure. There have been no previously reported cases of a patient surviving such an infection and the optimal treatment strategy is contentious. This report describes a case of intramural gas gangrene of the colon, treated conservatively with antibiotic therapy in which the patient survived with full recovery. Case presentation A 71-year-old, previously healthy male presented 6 h post apparently uncomplicated colonoscopic polypectomy with rigors, nausea, vomiting and right upper quadrant pain. At presentation he was febrile at 40.1 °C but hemodynamically stable. Abdominal computed tomography revealed substantial colonic thickening and several focal intramural gas bubbles (pneumatosis intestinalis) surrounding the polypectomy site. Within 24 h post procedure he became hypotensive and was admitted to ICU in frank septic shock requiring inotropes, and with demonstrable septic myocardial depression. Bloods showed multi-organ derangement with leukocytosis, lactic acidosis, haemolytic anaemia and hyperbilirubinemia. A diagnosis of presumed Clostridial gas gangrene was made, and treatment was initiated with benzylpenicillin, clindamycin, metronidazole and vancomycin. After 4 days in ICU he was stepped down, and discharged after a further 10 days with no surgical or endoscopic interventions. At three-month review he reported being back to full health. Conclusions This case demonstrates that gas gangrene infection is a possible complication of colonoscopic polypectomy. This is a cause of rapid deterioration in post-colonoscopy patients and has been misdiagnosed as colonic perforation in previously reported cases of retroperitoneal gas gangrene. Such misdiagnosis delays antibiotic therapy, which likely plays a role in the high mortality of this condition. Early diagnosis and initiation of antibiotic therapy with benzylpenicillin and clindamycin as seen in this case is essential for patient survival. While surgery is typically performed, non-operative management of pneumatosis intestinalis, and potentially gas gangrene is becoming more common and was utilized effectively in this patient.

Highlights • Atraumatic Clostridium septicum infection is seen in metastatic breast cancer. • Rapid identification and aggressive treatment atypical of clostridial species is required. • Atraumatic infection may require debridement beyond visible necrosis., Clostridium septicum is an anaerobic, gram-positive bacillus known to cause myonecrosis, also known as gas gangrene, a life-threatening necrotizing soft tissue infection. Though it accounts for just 1 % of all infections attributable to Clostridia spp., C. septicum is a highly virulent and aggressive pathogen. Classic presentations of infection include bacteremia resulting in shock, myonecrosis, and vascular seeding. C. septicum-associated gas gangrene most commonly occurs in the setting of traumatic injury, but has also been reported in patients with colorectal malignancy, immunosuppression, neutropenia, and exceedingly rare in association with breast cancer. We report the case of a 56-year-old female patient with stage IV mixed lobar and ductal breast carcinoma with metastasis to the bone and liver, who presented with spontaneous C. septicum myonecrosis of the right hand. No prior traumatic injury was noted. Following amputation of the right forearm, antibiotic treatment, and multiorgan support, the patient passed following transition to palliative care. We hope to increase awareness of this relatively uncommon, though potentially deadly pathogen, as well as to discuss treatment options in patients infected with C. septicum.

Gas gangrene is a necrotizing infection of subcutaneous tissue and muscle that affects mainly ruminants and horses, but also other domestic and wild mammals. Clostridium chauvoei, C. septicum, C. novyi type A, C. perfringens type A, and C. sordellii are the etiologic agents of this disease, acting singly or in combination. Although a presumptive diagnosis of gas gangrene can be established based on clinical history, clinical signs, and gross and microscopic changes, identification of the clostridia involved is required for confirmatory diagnosis. Gross and microscopic lesions are, however, highly suggestive of the disease. Although the disease has a worldwide distribution and can cause significant economic losses, the literature is limited mostly to case reports. Thus, we have reviewed the current knowledge of gas gangrene in mammals.

Enteric disease in horses may be caused by a variety of microorganisms, including several clostridial species. Paeniclostridium sordellii (previously Clostridium sordellii) has been frequently associated with gas gangrene in humans and several animal species, including horses. However, its role in enteric diseases of animals has not been fully determined. We describe herein 7 cases of enteric disease in horses associated with P. sordellii infection. Grossly, the small and/or large intestines were necrotic, hemorrhagic, and edematous. Microscopically, there was severe mucosal necrosis and hemorrhage of the small and/or large intestine of all horses. P. sordellii was isolated and/or demonstrated by immunohistochemistry and/or PCR in the intestine of all horses. All other known causes of enteric disease in horses were ruled out in these 7 cases. P. sordellii should be considered among the differential diagnoses in cases of enteric disease in horses.

Highlights • Though Parvimonas micra is not generally regarded as virulent, it may cause fulminant infection in people with weak immune system. • The diagnosis of P. micra infection is sometimes missed because of its slow growth during culturing. Molecular methods may be helpful for identification. • Our patient died due to disseminated infection. The organism was later identified as P. micra using 16S ribosomal RNA sequencing., An 83-year-old man visited an orthopedic hospital for his lower back pain. A compression fracture was noted in his second lumbar vertebra. He had taken pain medication for approximately five weeks, but the pain had worsened and he was unable to walk by himself. He was transferred to our hospital and diagnosed with lumbar spondylodiscitis, an iliopsoas abscess, gas gangrene of his left lower limb, and left massive pleural effusion. He was admitted to the intensive care unit. We drained the abscess and pleural effusion, provided continuous hemodiafiltration under ventilator control, and administered intravenous antibiotics. However, he died from sepsis and multiple organ failure three days following admission. Several days after his death, gram-positive cocci were identified in blood culture, pus from the abscess, and pleural exudate; although the causative organism could not be identified. Two weeks subsequent to his death, 16S ribosomal RNA gene sequencing identified Parvimonas micra in specimens taken from his body.

Background : Malignant edema is one of the terms used to designate severe necrotizing syndromes in soft tissues by Clostridium spp . which are potentially fatal in farm animals. These species are responsible for myonecrosis, belonging to the group of histotoxic clostridia, and may also culminate in toxemia with the worsening of the lesions. These clostridia and their spores require a gateway such as wounds on mucous membranes or skin, which may occur due to shear, tail cut, injuries during delivery, castration or injections by contaminated needles. This report aims to describe the clinical-pathological findings of a case of malignant edema caused by C. perfringens type A in an equine. Case : A female equine, undefined breed, used as traction animal, had a history of abdominal pain. According to the requisitioning veterinary, the tutor reused needles for medication. On palpation, a compact mass was noticed in the pelvic flexure, as well as edema on the region of head and neck with crackling areas. After surgical intervention for compactation correction, the animal did not show anesthetic recovery and was submited to euthanasia. Tissue samples were collected, fixed in 10% buffered formalin solution, routinely processed for histopathology and stained with hematoxylin and eosin and Gram stain. Samples of serous-sanguineous edema fluid and fragments of the abdominal muscles and neck were collected. The samples were kept under refrigeration and sent for microbiological culture. Necropsy showed the subcutaneous region of the pectoral was markedly gelatinous and yellowish (edema) and subcutaneous emphysema characterized by accumulation of serous-sanguineous fluid and gas bubbles. In microscopy, we verified fibrous-haemorrhagic, emphysematous, suppurative and diffuse superficial histiocytic necrotizing cellulitis and myositis. Gram-positive bacillary aggregates were observed in spleen and subcutaneous sections. Colony suggestive of Clostridium perfringens were submitted to PCR for confirmation of identity followed by genotyping . Lastly, C. perfringens type A was isolated from the muscle fragments and serosanguinolent liquid collected. Discussion : In the present study, the diagnosis of malignant edema caused by Clostridium perfringens type A in an equine was confirmed by the clinical-pathological findings added to the isolation and genotyping of the agent from fragments of injured muscle. Although C. perfringens has been reported in cases of clostridial myositis in horses in the United States, in Brazil there are only reports of sporadic cases associated with C. septicum, C. novyi and C. chauvoei in this species. In histotoxic cases by C. perfringens , alpha toxin is known to be the main virulence factor involved, causing destruction of the phospholipid membrane of erythrocytes, endothelial cells, leukocytes and muscle fibers. As consequence, there is an increase in the vascular permeability of capillaries and, with the spread of the infection, there is production of inflammatory edema with serosanguineous exudate and gas. Typically, anatomopathological findings are characterized by increased volume of the affected region associated with edema with bloody fluid and rancid odor, gas bubbles in the subcutaneous tissue, and fasciae associated or not with necrotic myositis. It is assumed that a contaminated needle injection, performed during the treatment of colic symptoms on the property has been the gateway to infection. The clinical course of clostridial infection in horses is considered acute, ranging from 24 to 48 h. In this case, was observed the animal with signs of cervical and pectoral edema still in the property, a day before euthanasia. This is the first study to confirm Clostridium perfringens as a cause of gas gangrene in horses in Brazil.

Este artículo se encuentra disponible en la siguiente URL: https://journals.sagepub.com/doi/pdf/10.1177/1040638719877844 This is the pre-peer reviewed version of the following article: Sacco, S. C., Ortega, J., Navarro, M. A., Fresneda, K. C., Anderson, M., Woods, L. W., Moore, J., & Uzal, F. A. (2020). Clostridium sordellii-associated gas gangrene in 8 horses, 1998-2019. Journal of Veterinary Diagnostic Investigation, vol. 32, i. 2 (01 mar.), pp. 246?251, which has been published in final form at https://doi.org/10.1177/1040638719877844 Este es el pre-print del siguiente artículo: Sacco, S. C., Ortega, J., Navarro, M. A., Fresneda, K. C., Anderson, M., Woods, L. W., Moore, J., & Uzal, F. A. (2020). Clostridium sordellii-associated gas gangrene in 8 horses, 1998-2019. Journal of Veterinary Diagnostic Investigation, vol. 32, i. 2 (01 mar.), pp. 246?251, que se ha publicado de forma definitiva en https://doi.org/10.1177/1040638719877844 En este artículo de investigación también participan: Joaquín Ortega, Mauricio A. Navarro, Karina C. Fresneda, Mark Anderson, Leslie W. Woods, Janet Moore y Francisco A. Uzal. Gas gangrene occurs in several animal species, and it is caused by one or more clostridial species. In horses, the disease is most often caused by Clostidium perfringens type A. Although Clostridium sordellii has been associated with gas gangrene in ruminants and humans, cases of the disease associated with this microorganism have not been described in horses. We report 8 cases of gas gangrene by C. sordellii in horses. These cases were characterized by myonecrosis and cellulitis, associated with systemic changes suggestive of toxic shock. The diagnosis was confirmed by gross and microscopic changes combined with anaerobic culture, fluorescent antibody test, immunohistochemistry and/or PCR. The predisposing factor in these cases was an injection or a traumatic skin injury. C. sordellii should be considered as a possible etiologic agent in cases of gas gangrene in horses.

Clostridium septicum is a highly pathogenic microbe that causes gas gangrene in humans, and is the principal cause of spontaneous gas gangrene in patients with gastrointestinal maladies, including adenocarcinoma of the colon. Despite modern approaches to manage C. septicum infection, morbidity and mortality remain high (>60%). At present, no objective in-vivo data exist supporting the current antibiotic treatment recommendations for C. septicum infection. Utilizing an established murine model of clostridial myonecrosis, this study investigated the efficacy of standard antibiotics for anaerobic Gram-positive soft tissue infections (penicillin, clindamycin, tetracycline and vancomycin) in treating C. septicum gas gangrene. Following intramuscular challenge with 1 × 106 colony-forming units of C. septicum, antibiotics were administered by intraperitoneal injection every 4 h for a total of four doses. At 30 h, all animals in all treatment groups survived the C. septicum challenge, compared with no survivors in the untreated controls (100% mortality by 10 h). However, by 60 h, mice treated with vancomycin exhibited 40% mortality, with no mortality observed in any other antibiotic treatment group. Microbroth dilution minimum inhibitory concentration analyses for three strains of C. septicum also demonstrated high susceptibility to penicillin, clindamycin and tetracycline, but considerably lower susceptibility to vancomycin. This study suggests that penicillin, clindamycin and tetracycline are suitable alternatives for the treatment of C. septicum infection in humans.