35-year-old male intravenous drug user diagnosed with gas gangrene.
A 35-year-old male patient presented to the emergency with right upper limb pain and a 24-hour history of swelling. He had a history of chronic intravenous drug use and was diagnosed with gas gangrene of the limb.
On examination, the patient’s temperature was 39°C, respiratory rate of 25 breaths per minute, heart rate 120 beats per minute and blood pressure 141/76 mmHg. Clinical examination showed severe oedema of the upper limb, erythema, blistering and crepitus of the arm. Motor and sensory function of the limb was not impaired. Radial and ulnar artery could be palpated. The patient’s past medical history included a diagnosis of hepatitis C.
The patient also reported of intramuscular injections of saline, a common practice among intravenous drug users to provoke pain for recovery after drug induced coma. An X-ray was performed which showed gas in the soft tissues, consistent with the diagnosis of gas gangrene.
The patient was immediately started on empirical broad spectrum antibiotics, piperacillin/tazobactam, clindamycin and vancomycin in usual dosages. The soft tissue swelling medially expanded from the forearm to the neck within one hour. The patient’s general condition worsened with severe pain and hoarseness. He was intubated because of a compromised airway. He was shifted to the operating room within two hours of his admission. And underwent a fasciotomy of the arm and forearm because of threatening compartment syndrome. The infected areas were debrided and drained. In addition, a broad resection of the necrotic tissues of the arm and forearm was done.
The patient remained intubated and in septic shock in the intensive care unit. The first day after the procedure, he developed acute renal failure because of myoglobinuria and required hemodialysis. On the second day, his platelet count dropped, however, gradually increased the following day. The wound was surgically debrided on a daily basis and on the 10th day his general condition gradually improved.
He was discharged on the 30th day and was referred for limb physiotherapy. Skin defects were restored using free skin grafts from the femoral region 4 months after surgery. At this time, he could extend his elbow and shoulder against gravity with minimal movement of the wrist and fingers.
References
Limb salvage after gas gangrene: a case report and review of the literature https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3182882/
