An Unusual Case of Gas Gangrene in Intravenous Heroin Addict
Keywords:Intravenous addicts, Gas gangrene, Forensic medicine, Autopsy
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.
Plum Analytics Artifact Widget Block
Hanganu B, Neagu M, Manoilescu I, Velnic A, Ioan B. Gas gangrene: Case presentation and literature data. J Surg. 2017;13(4):139-142. https://doi.org/10.7438/1584-9341-13-4-7
Crum-Cianflone NF. Bacterial, fungal, parasitic, and viral myositis. Clin Microbiol Rev. 2008;21(3):473-94. https://doi.org/10.1128/cmr.00001-08 PMid:18625683
Debata N, Chander Y, Singh L, Ohri V, Singh G, Nesargi S, et al. Investigation of a case of clostridial myonecrosis. Med J Armed Forces India. 1998;54(1):55-6. https://doi.org/10.1016/s0377-1237(17)30412-4 PMid:28775416
Leiblein M, Wagner N, Adam EH, Frank J, Marzi I, Nau C. Clostridial gas gangrene-a rare but deadly infection: Case series and comparison to other necrotizing soft tissue infections. Orthop Surg. 2020;12(6):1733-47. https://doi.org/10.1111/os.12804 PMid:33015993
Leikin JB, Paloucek FP. Clostridium perfringens poisoning. In: Poisoning and Toxicology Handbook. 4th ed. New York: Informa; 2008. p. 892-3.
Mishra S, Singh S, Gupta S. Necrotizing soft tissue infections: Surgeon’s prospective. Int J Inflam. 2013;2013:609628. PMid:24455410
Wurcel AG, Merchant EA, Clark RP, Stone DR. Emerging and underrecognized complications of illicit drug use. Clin Infect Dis. 2015;61(12):1840-9. https://doi.org/10.1093/cid/civ689 PMid:26270683
Aggelidakis J, Lasithiotakis K, Topalidou A, Koutroumpas J, Kouvidis G, Katonis P. Limb salvage after gas gangrene: A case report and review of the literature. World J Emerg Surg. 2011;6:28. https://doi.org/10.1186/1749-7922-6-28 PMid:21846405
Tsokos M, Schalinski S, Paulsen F, Sperhake J, Püschel K, Sobottka I. Pathology of fatal traumatic and nontraumatic clostridial gas gangrene: A histopathological, immunohistochemical, and ultrastructural study of six autopsy cases. Int J Legal Med. 2008;122(1):35-41. https://doi.org/10.1007/s00414-007-0163-9 PMid:17370083
Bryan C. Gangrene bug killed 35 heroin users. West J Med. 2000;173(2):82-3. PMid:10924416
Heras-Garcia L, Rico-Pecero J. Necrotizing fasciitis at a distance in a drug user. MOJ Orthop Rheumatol. 2018;10(3):315-6. https://doi.org/10.15406/mojor.2018.10.00418
Mittapalli D, Velineni R, Rae N, Howd A, Suttie S. Necrotizing soft tissue infections in intravenous drug users: A vascular surgical emergency. Eur J Vasc Endovasc Surg. 2015;49(5):593-9. https://doi.org/10.1016/j.ejvs.2015.02.002 PMid:25805328
Lehner P, Powell H. Gas gangrene. BMJ. 1991;303(6796):240-2. https://doi.org/10.1136/bmj.303.6796.240 PMid:1884064
Georgiadis G, Bessias N, Pavlidis P, Pomoni M, Batakis N, Lazarides M. Infected false aneurysms of the limbs secondary to chronic intravenous drug abuse: Analysis of perioperative considerations and operative outcomes. Surg Today. 2007;37(10):837-44. https://doi.org/10.1007/s00595-006-3495-z PMid:17879032
Liu F, Xue S, Zhang Y, Yang J, Hu J, Li D, et al. Clostridium perfringens sepsis in three patients with acute leukemia and review of the literature. Int J Hematol. 2021;113(4):508-17. https://doi.org/10.1007/s12185-020-03060-z PMid:33387294
Peters J, Iacobelli J, Ryan E. Recurrent necrotizing fasciitis: A case report of fulminant and sub-acute necrotizing fasciitis in a diabetic patient. Cureus. 2020;12(12):e12153. https://doi.org/10.7759/cureus.12153 PMid:33489565
Al-Qurayshi Z, Nichols RL, Killackey MT, Kandil E. Mortality risk in necrotizing fasciitis: National prevalence, trend, and burden. Surg Infect (Larchmt). 2020;21(10):840-52. https://doi.org/10.1089/sur.2019.277 PMid:32196411
Harvey PW, Purnell GV. Fatal case of gas gangrene associated with intramuscular injections. Br Med J. 1968;1(5594):744-6. https://doi.org/10.1136/bmj.1.5594.744 PMid:5641440
Rogers PJ, Lewis BM, Odak M, Bucher J. Spontaneous necrotizing fasciitis. Cureus. 2020;12(12):e11880. https://doi.org/10.7759/cureus.11880 PMid:33415033
Wu YE, Baras A, Cornish T, Riedel S, Burton EC. Fatal spontaneous clostridium septicum gas gangrene: A possible association with iatrogenic gastric acid suppression. Arch Pathol Lab Med. 2014;138(6):837-41. https://doi.org/10.5858/arpa.2013-0104-cr PMid:24878026
Kumar D, Cortes-Penfield NW, El-Haddad H, Musher DM. Bowel perforation resulting in necrotizing soft-tissue infection of the abdomen, flank, and lower extremities. Surg Infect (Larchmt). 2018;19(5):467-72. https://doi.org/10.1089/sur.2018.022 PMid:29893614
Lee H, Cho S, Lee D, Ko Y, Hyun J, Kim B, et al. A fatal spontaneous gas gangrene due to Clostridium perfringens during neutropenia of allogeneic stem cell transplantation: Case report and literature review. Infect Chemother. 2014;46(3):199- 203. https://doi.org/10.3947/ic.2014.46.3.199 PMid:25298910
El Sayad M, Chikate A, Ramesh B. Gas gangrene presenting with back pain. Case Reports. 2014;2014:bcr2013010241. https://doi.org/10.1136/bcr-2013-010241 PMid:24811103
Levi N, Rørdam P, Jensen L, Schroeder T. Femoral pseudoaneurysms in drug addicts. Eur J Vasc Endovasc Surg. 1997;13(4):361-2. https://doi.org/10.1016/s1078-5884(97)80076-7 PMid:9133986
How to Cite
Copyright (c) 2021 Snežana Pavlekić, Dragan Ječmenica, Đorđe Alempijević (Author)
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
All rights reserved.