Here’s a clinical case to test your knowledge of nasty infections, courtesy one of the μgnome’s gneighbours.
- A 65 year old woman, with
- sudden onset of severe left thigh pain
- currently receiving chemotherapy for breast cancer
- she appears unwell
- is febrile (T 38.9oC)
- the left anteromedial thigh is swollen and warm, but not erythematous
- Plain X-ray is normal, and a ultrasound scan demonstrates only subcutaneous oedema.
- Blood tests show neutropaenia (0.46) and an elevated CRP (110mg/L).
2 hours later, the skin over the thigh has become brown and indurated, there is palpable crepitation under the skin, and she has developed pain and swelling of the right calf.
- What is the diagnosis?
- What is the treatment?
Selected CT views (RM)
kindly provided by Dr Ronan Murray, Perth, WA.
1 Endogenous clostridial myonecrosis of the left thigh and right gastrocnemius muscle.
- This is a rare condition that occurs in patients with neutropaenic enterocolitis, or those with known or occult malignancy, particularly colonic malignancy.
- The most common causes are Clostridium septicum and C. perfringens.
- Clostridium perfringens was cultured form both from blood and from muscle tissue
2 The treatment of choice is unknown, but usually includes a combination of
- early and aggressive surgical debridement
- anti-clostridial antimicrobial therapy (usually various combinations of penicillin + metronidazole + clindamycin)
- hyperbaric oxygen therapy
- and organ support.
Clostridial myonecrosis is a medical and surgical emergency with close to 100% mortality.