Clostridial Myonecrosis
A Case Presentation and Discussion of
Hyperbaric Oxygen Therapy

A 60 year-old insulin dependent diabetic was admitted to our hospital with a deep plantar abscess of the left foot. She reported having nausea, fever, and chills for twenty-four hours prior to admission. At the time of admission, her temperature was 102.9 and her white blood cell count was over 14,000. The foot was malodorous and the patient was experiencing tenderness in the posterior leg, calf, ankle, and foot. The patient’s skin was warm to touch.

Jay Lieberman, DPM, FACFAS
by Jay Lieberman
DPM, FACFAS, Director of
Podiatric Medical Education,
Northwest Medical Center
A dose of Clindamycin was given after two sets of blood cultures (no growth). X rays demonstrated gas in the soft tissue of the plantar aspect of the foot. An MRI indicated a deep space abscess.

 

Patient’s Medical History:
Diabetes Mellitus with Charcot Arthropathy
Hypertension
Atherosclerotic Heart Disease
End Stage Renal Disease

Medications:
1. Humulin 70/30
2. Prevachol
3. Clonidine
4. Norvasc

Allergies:
Aspirin

Salient Lower Extremity Physical Examination

Palpable Dorsalis Pedis and Posterior Tibial pulses. Capillary refill was less than 3 seconds bilaterally. Deep tendon reflexes were absent. Vibratory sensation was absent. The patient could not discern a 5.07gm Semmes-Weinstein Filament.  She was virtually insensate.

Clinically the patient demonstrated a 3cm X 2cm necrotic fluctuance along the plantar aspect of the foot. Very foul smelling purulence was emanating from a small defect.

Upon admission, the patient was started on Unasyn 3gm, intravenously q24h and Levaquin 250mg intravenously qod.

The following relevant levels were ascertained from her laboratory testing:
   Glucose 299
   Creatinine 3.9
   BUN  28
   Albumin  2.7

Surgical Procedure:


The patient was brought to surgery later that evening for Incision and Drainage of the abscess. She was given Vancomycin 1gm intravenously, preoperatively.

A 5cm lazy S incision was made in the plantar aspect of the foot. Large amounts of foul smelling purulence were expressed from the wound. The margins of the wound were necrotic and therefore, the lazy S incision was modified into an elliptical incision 4cm wide by 5 cm long. The fascial ligament was also necrotic and therefore it was excised as well. In the first muscle layer, numerous pockets of liquifactive necrosis were encountered.

Aerobic, Anaerobic, Fungal, and Acid Fast cultures were obtained, as well as a stat gram stain. No tracking was appreciated. The wound was pulse lavaged with a Polymyxin/Bacitracin solution. Cultures revealed a mixed infection, which included clostridium perfringens. The patient was referred for Hyperbaric Oxygen Treatments.


Chamber photographs courtesy of
The Center for Wound Care and
Hyperbaric Medicine at Boca Raton
Community Hospital.

Discussion

Jeffrey Niezgoda, MD, offers an in-depth discussion of this topic in his PRESENT lecture “Introduction to Hyperbaric Oxygen Therapy.”  Paul Glusman, DO, goes into even more depth in his lecture "Hyperbaric Oxygen Therapy and the Diabetic Lower Extremity Wound"

The bacteria, Clostridum Perfringens is an anaerobic Gram+ rod which is unable to grow in the presence of free oxygen. It produces an exotoxin, which is particularly lethal to skeletal muscle. Certainly, the introduction of Hyperbaric Oxygen has significant antimicrobial activity against this very dangerous organism. It will also salvage marginal tissue and help the body repair  sizeable defects.

Dr. Niezgoda defines Hyperbaric Oxygen Therapy as “inhaled 100% oxygen in an enclosed systemic pressurized environment.” The goal of HBO2 therapy is to hyper-oxygenate all hemoglobin binding sites thereby helping to meet the increased metabolic demands needed to augment wound healing.

Why is oxygen so important for wound healing?

  1. All phases of wound healing are oxygen dependent

  2. Promotion of angiogenesis is oxygen dependent

  3. Tissue oxygen tensions above 30mmHg are needed for collagen synthesis

  4. O2 is bacteriostatic and bacteriocidal. HBO2 is particularly beneficial to the patient with osteomyelitis

Gas gangrene is one of the many emergent indications for Hyperbaric Oxygen Therapy. Other routine indications include:

  1. Compromised wounds

  2. Osteomyelitis

  3. Soft tissue radionecrosis

  4. Compromised flaps and grafts

  5. Burns

  6. Brown Recluse Spider bites

Despite a very large plantar defect, this wound eventually developed sufficient granulation tissue to allow for skin grafting.

 

With the benefits of Hyperbaric Oxygen Therapy brought to bear in the treatment of this patient, she went on to have a successful outcome.