{"paper_id":"3a068c23-3a96-4c0e-96b5-5e2f55a90738","body_text":"Gas gangrene is a rare and deadly infection that progresses very rapidly. Although it is usually caused by traumatic injury, it can also occur after surgery [ 1 – 5 ]. While the timing of symptom onset varies among cases, it occurred at least 24 h after surgery in previous reports. Here, we report a case of gas gangrene in which the clinical symptoms of sepsis appeared 16 h after urologic surgery. Although primary care was effective in this case, the patient died 38 days after the surgery. To our knowledge, this case represents the most acute onset of postoperative gas gangrene ever reported.\n\nA 65-year-old woman was diagnosed with bladder cancer 6 years earlier, for which she had undergone transurethral resection six times. Oophorectomy for a right ovarian cyst and total hysterectomy for endometriosis had been performed under general anesthesia at the ages of 30 and 35 years, respectively. During the current surgery, she underwent radical cystectomy with creation of an ileal conduit and removal of pelvic lymph nodes. Her past history of multiple laparotomies resulted in intestinal adhesions and massive intraoperative bleeding. The total blood loss during surgery was 5340 ml. She received 1200 ml of autologous blood transfusion, and subsequent transfusion of 560 ml of red cell concentrates and 1200 ml of fresh-frozen plasma in the operation room. The surgical time was 6 h and 49 min. Administration of the antibiotic isepamicin (ISP: 200 mg) was started to treat a fever of 40 °C immediately after moving her to the ward. However, she developed a shock state 16 h after the operation (Fig.  1 ). Her systolic blood pressure decreased to approximately 70 mmHg and urine output was less than 25 ml/h. Infusions of Ringer’s solution, albumin preparations, immunoglobulins, and vasopressors were started because we suspected septic shock. Administration of imipenem/cilastatin sodium (IPM/CS: 500 mg) was added to ISP because we thought that more intensive empiric antimicrobial therapy was necessary. Two days after the operation, she was transferred to the intensive care unit (ICU) because of deterioration in her respiratory and circulatory condition. Soon after moving her to the ICU, a subcutaneous hemorrhage-like skin rash appeared and extended rapidly over her left side (Fig.  2 a). On admission to the ICU, blood tests indicated severe metabolic acidosis, liver and renal dysfunction, and signs of disseminated intravascular coagulation (DIC) (Table  1 ). Her APACHE II (Acute physiology and chronic health evaluation) and SOFA (Sequential organ failure assessment) scores at this time were 24 and 14, respectively. An X-ray examination and computed tomography (CT), which was performed on postoperative day 2, indicated uninterrupted massive emphysematous tissue from her left chest to lower abdomen (Fig.  2 b, c). Suspecting necrotizing fasciitis or gas gangrene, we performed emergency fasciotomy. Subsequently, multidisciplinary treatment, including mechanical ventilation, hyperbaric oxygen therapy (HBOT), polymyxin B-immobilized fiber column direct hemoperfusion (PMX-DHP), and continuous hemodiafiltration (CHDF), was started. Antibiotic therapy was changed to clindamycin (CLDM: 900 mg), vancomycin (VCM: 1000 mg), and IPM/CS (Fig.  3 ). Gram-positive bacilli, but not Gram-negative bacteria, were detected by microscopic examination of blister fluid aspirated from the skin rash. Moreover, a culture test detected  Clostridium perfringens  ( C. perfringens ) in a wound abscess that was removed during the emergency fasciotomy. Based on these observations, she was diagnosed with gas gangrene. HBOT was performed on the first and second ICU days. We had to abandon plans for a second fasciotomy because the area that required treatment was too large. CHDF was continued through her ICU stay, although PMX-DMP was performed only once on the first ICU day. Her APACHE II and SOFA scores continued to be flat during the first 2 weeks, indicating that the initial treatment prevented further clinical deterioration (Fig.  3 ). However, she suffered from secondary infection from the 3rd week onward due to infection with multiple pathogenic bacteria, including  Candida albicans  and  Pseudomonas aeruginosa , as shown in Table  2 . Finally, she died of sepsis 38 days after the operation in spite of prompt diagnosis and intensive therapy for the gas gangrene. Fig. 1 Vital signs of the patient on the day of and after the surgery. The  black  and  brown  lines indicate systolic and diastolic blood pressure, respectively.  Closed circles  and  open squares  indicate body temperature and heart rate, respectively.  DOA  dopamine hydrochloride Fig. 2 Images of the patient.  a  A diffuse skin rash developed over the  left side  of her trunk 2 days after the surgery.  b  Abdominal X-ray taken immediately after ICU admission showed soft tissue swelling with the density of air on the left abdominal wall ( arrows ).  c  Computed tomography of the abdomen taken 2 days after the surgery showed subcutaneous emphysema over the  left side  of the trunk ( arrows ).  d  Enhanced computed tomography of the abdomen taken 1 day after the surgery. The  rectangle  indicates the area shown in  e .  e  The  arrows  indicate air-densities between the subcutaneous fat tissue and muscle layer in the vicinity of the left drainage tube Table 1 Results of blood tests performed immediately after ICU admission Blood count  Hct (%) 28.5  Hb (g/dl) 9.2  WBC (/μl) 7500  Plt (/μl) 7.1 × 10 4 \n Blood coagulation tests  PT (%) 37  APTT (s) 59.3  Fibrinogen (mg/dl) 385  FDP (μg/ml) 47.3   d -dimer (μg/ml) 39.1  TAT (ng/ml) 36.1  PIC (μg/ml) 1.3 Biochemical tests  T-bil (mg/dl) 6.2  AST (IU/l) 376  ALT (IU/l) 41  LDH (IU/l) 3067  BUN (mg/dl) 49  Cr (mg/dl) 2.23  CRP (mg/dl) 24.24 Blood gas analysis  pH 7.265  pCO 2 \n 14.3  pO 2  (FM 8L) 91.7  HCO 3 \n −  (mmol/l) 10.5  BE (mmol/l) −20.6 \n Hct  hematocrit,  Hb  hemoglobin,  WBC  white blood cells,  Plt  platelets,  PT  prothrombin time,  APTT  activated partial thromboplastin time,  FDP  fibrin/fibrinogen degradation products,  TAT  thrombin-antithrombin complex,  PIC  plasmin-α2 plasmin inhibitor complex,  T-bil  total bilirubin,  AST  aspartate aminotransferase,  ALT  alanine aminotransferase,  LDH  lactate dehydrogenase,  BUN  blood urea nitrogen,  Cr  creatinine,  CRP  C-reactive protein,  pCO \n 2  carbon dioxide partial pressure,  pO \n 2  oxygen partial pressure,  BE  base excess Fig. 3 The clinical course of the patient.  FOM  fosfomycin,  ISP  isepamicin,  IPM/CS  imipenem/cilastatin,  CLDM  clindamycin,  VCM  vancomycin,  FCZ  fluconazole,  CPFX  ciprofloxacin,  MEPM  meropenem,  CAZ  ceftazidime,  HBOT  hyperbaric oxygen therapy,  HD  hemodialysis,  CHDF  continuous hemodiafiltration,  APACHE  acute physiology and chronic health evaluation,  SOFA  sequential organ failure assessment Table 2 List of the bacteria that were isolated and results of antimicrobial susceptibility testing Species Bacteria count Sampling site Date of collection Reporting date Antimicrobial susceptibility testing Susceptible Intermediate Resistant \n Clostridium perfringens \n 2+ Closed abscess POD2 POD6 ABPC, ABPC/SBT, CMZ, FMOX, IPM, MINO LVFX CLDM Small number Drain POD2 POD9 ABPC/SBT, IPM, MINO ABPC, CMZ, FMOX, LVFX CLDM \n Pseudomonas aeruginosa \n 3+ Debris POD14 POD17 PIPC, CPZ, CAZ, CZOP, CFS, CFPM, MEPM, AZT, S/C, TOB, AMK, LVFX, CPFX IPM, GM FOM 3+ Open abscess POD24 POD28 \n Pseudomonas aeruginosa  with metallo-β-lactamase 3+ Open abscess POD33 POD38 PIPC, CAZ, CZOP, S/C, TOB, AMK CPZ, CFS, CFPM, GM IPM, MEPM, AZT, LVFX, CPFX, FOM \n Candida albicans \n 2+ Debris POD14 POD17 N/A N/A N/A 2+ Open abscess POD24 POD28 N/A N/A N/A \n Staphylococcus epidermidis \n N/A CV catheter POD8 POD15 VCM, TEIC, LZD N/A PCG, ABPC, MPIPC, CEZ, CTM, CPR, FMOX, IPM, GM, EM, CLDM, LVFX, ST, FOM N/A Venous blood, CV catheter POD14 POD17 VCM, TEIC N/A PCG, ABPC, MPIPC, CEZ, CTM, CPR, FMOX, IPM, GM, EM, CLDM, LVFX, ST, FOM \n Stenotrophomonas maltophilia \n 3+ Open abscess POD24 POD28 MINO, ST LVFX CAZ 3+ Open abscess POD33 POD38 MINO, ST N/A CAZ, LVFX \n Enterococcus casseliflavus \n 3+ Open abscess POD33 POD38 VCM, TEIC, LZD N/A LVFX, ABPC, PCG, EM \n POD  post-operative days,  ABPC  ampicillin,  ABPC/SBT  ampicillin/sulbactam,  CMZ  cefmetazole,  FMOX  flomoxef,  IPM  imipenem,  MINO  minocycline,  PIPC  piperacillin,  CPZ  cefoperazone,  CAZ  ceftazidime,  CZOP  cefozopran,  CFS  cefsulodin,  CFPM  cefepime,  MEPM  meropenem,  AZT  aztreonam,  S/C  sulbactam/cefoperazone,  TOB  tobramycin,  AMK  amikacin,  LVFX  levofloxacin,  VCM  vancomycin,  TEIC  teicoplanin,  LZD  linezolid,  ST  sulfamethoxazole–trimethoprim,  GM  gentamicin,  CLDM  clindamycin,  FOM  fosfomycin,  CPFX  ciprofloxacin,  PCG  benzylpenicillin,  MPIPC  oxacillin,  CEZ  cephazolin,  CTM  cefotiam,  CPR  cefpirome,  EM  erythromycin\nVital signs of the patient on the day of and after the surgery. The  black  and  brown  lines indicate systolic and diastolic blood pressure, respectively.  Closed circles  and  open squares  indicate body temperature and heart rate, respectively.  DOA  dopamine hydrochloride\nImages of the patient.  a  A diffuse skin rash developed over the  left side  of her trunk 2 days after the surgery.  b  Abdominal X-ray taken immediately after ICU admission showed soft tissue swelling with the density of air on the left abdominal wall ( arrows ).  c  Computed tomography of the abdomen taken 2 days after the surgery showed subcutaneous emphysema over the  left side  of the trunk ( arrows ).  d  Enhanced computed tomography of the abdomen taken 1 day after the surgery. The  rectangle  indicates the area shown in  e .  e  The  arrows  indicate air-densities between the subcutaneous fat tissue and muscle layer in the vicinity of the left drainage tube\nResults of blood tests performed immediately after ICU admission\nHct  hematocrit,  Hb  hemoglobin,  WBC  white blood cells,  Plt  platelets,  PT  prothrombin time,  APTT  activated partial thromboplastin time,  FDP  fibrin/fibrinogen degradation products,  TAT  thrombin-antithrombin complex,  PIC  plasmin-α2 plasmin inhibitor complex,  T-bil  total bilirubin,  AST  aspartate aminotransferase,  ALT  alanine aminotransferase,  LDH  lactate dehydrogenase,  BUN  blood urea nitrogen,  Cr  creatinine,  CRP  C-reactive protein,  pCO \n 2  carbon dioxide partial pressure,  pO \n 2  oxygen partial pressure,  BE  base excess\nThe clinical course of the patient.  FOM  fosfomycin,  ISP  isepamicin,  IPM/CS  imipenem/cilastatin,  CLDM  clindamycin,  VCM  vancomycin,  FCZ  fluconazole,  CPFX  ciprofloxacin,  MEPM  meropenem,  CAZ  ceftazidime,  HBOT  hyperbaric oxygen therapy,  HD  hemodialysis,  CHDF  continuous hemodiafiltration,  APACHE  acute physiology and chronic health evaluation,  SOFA  sequential organ failure assessment\nList of the bacteria that were isolated and results of antimicrobial susceptibility testing\nPOD  post-operative days,  ABPC  ampicillin,  ABPC/SBT  ampicillin/sulbactam,  CMZ  cefmetazole,  FMOX  flomoxef,  IPM  imipenem,  MINO  minocycline,  PIPC  piperacillin,  CPZ  cefoperazone,  CAZ  ceftazidime,  CZOP  cefozopran,  CFS  cefsulodin,  CFPM  cefepime,  MEPM  meropenem,  AZT  aztreonam,  S/C  sulbactam/cefoperazone,  TOB  tobramycin,  AMK  amikacin,  LVFX  levofloxacin,  VCM  vancomycin,  TEIC  teicoplanin,  LZD  linezolid,  ST  sulfamethoxazole–trimethoprim,  GM  gentamicin,  CLDM  clindamycin,  FOM  fosfomycin,  CPFX  ciprofloxacin,  PCG  benzylpenicillin,  MPIPC  oxacillin,  CEZ  cephazolin,  CTM  cefotiam,  CPR  cefpirome,  EM  erythromycin\n\nHere, we report a fatal case of postoperative gas gangrene with very acute onset and rapid progression of the symptoms. This case report especially focuses on the risk factors, cause of infection, and treatment methods of postoperative gas gangrene.\nGas gangrene used to be frequent during war times, being related to weapon injuries [ 6 ]. In modern clinical practice, the various causes of gas gangrene have included “sterile” operations, intravenous infusion, intramuscular injection, and criminal abortion, etc. [ 7 ]. Even if a patient does not have any evident infectious causes, recent abdominal surgical intervention can also contribute to gas gangrene formation. Indeed, several cases of gas gangrene with  C. perfringens  after abdominal surgery have been recently reported [ 2 ,  3 ]. The onset of symptoms in these cases was 2 weeks and 2 days after the operation, respectively. To our knowledge, our case represents the most acute onset of postoperative gas gangrene with  C. perfringens  ever reported.\nIt is well known that both the existence of cancer cells and exposure to anesthetic agents can suppress the immune system, which in turn increases the risk of surgical site infection [ 8 ]. In addition, gas gangrene occurs more frequently in diabetics, alcoholics, immunosuppressed patients, IV drug users, and patients with peripheral vascular disease [ 9 ]. The risk of postoperative infection in our case may have been increased by the long operation and massive blood transfusion [ 8 ]. However, the patient had a past history of exposure to neither anticancer nor immunosuppressive agents. Moreover, she did not have any preexisting co-morbidities other than hyperthyroidism. Hence, she was not considered to have a particularly high risk for development of postoperative gas gangrene. Thus, the cause of fulminant infection with  C. perfringens  in this patient with no remarkable risk factors is unknown. Molecular typing of toxins and enzymes involved in the virulence of  C. perfringens  seems to be a powerful tool to clarify this issue. However, we did not assess the toxins and enzymes, which is a limitation of this case report.\nWe hypothesized that the source of infection in this case might have been the ileum used for bladder reconstruction. Urinary diversion via the bowel might contribute to contamination by bowel microbes [ 10 ]. In general, two conditions are necessary for the onset of gas gangrene: (1) the presence of clostridial spores, and (2) an area of tissue hypoperfusion caused by circulatory failure in a local area or by extensive soft tissue damage and necrotic muscle tissue. The occurrence of clostridial species in feces is not rare, a large number of clostridia having been found to be present in normal human feces (10 6 –10 9 /g feces) [ 7 ]. In particular,  C. perfringens  was reportedly detected in 33 % of healthy Japanese adults, and at a concentration of at least 10 3 /g feces [ 11 ]. These indicate that endogenous clostridial spores that probably existed in her ileum may have spread into the surgical wound. Abdominal enhanced CT images obtained 1 day after the operation (Fig.  2 d, e) showed the presence of air-densities between the subcutaneous fat tissue and muscle layer in the vicinity of the drainage tubes. These CT images support our hypothesis that the drainage tube might have been the source of the  C. perfringens  infection.\nUrgent surgical exploration and debridement of devitalized tissue are crucial for the treatment of gas gangrene. In addition, aggressive antibiotic treatment is also important. The first choice of antibiotics for Clostridium is penicillin [ 12 ]. However, we could not use penicillin because she had developed hypersensitivity responses to penicillin with shock at the age of approximately 20 years. Hence, we used IPM/CS and CLDM, which are considered the second choice for Clostridium. It was recently reported that CLDM resistant  C. perfringens  species are on the increase [ 1 ]. In this case, CLDM resistant  C. perfringens  was detected in the wound abscess. Therefore, we had to discontinue use of CLDM. Although  C. perfringens  was abolished by our intensive therapy, multidrug-resistant  Pseudomonas aeruginosa  caused multi-organ failure and, ultimately, death. Similar to what has been seen in many cases of severe sepsis, the secondary infection was likely due to a combination of neutropenia and an adverse reaction to broad spectrum antibiotics.\nDespite remarkable progress of multidisciplinary therapeutic methods, including extensive surgical debridement, antibiotic coverage and HBOT, the morbidity and mortality rates of gas gangrene are still very high (up to 57 %) [ 13 ,  14 ]. Given this high mortality rate of gas gangrene, physicians should be aware that any patient could possibly develop gas gangrene after an operation.","source_license":"CC-BY-4.0","license_restricted":false}