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Soledad Holanda Peña" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Elena" "apellidos" => "Cuenca Fito" "email" => array:1 [ 0 => "ecuencafito@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Elsa" "apellidos" => "Ots Ruiz" ] 2 => array:2 [ "nombre" => "M. Soledad" "apellidos" => "Holanda Peña" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Medicina Intensiva, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Gangrena gaseosa espontánea por <span class="elsevierStyleItalic">Clostridium septicum</span> en paciente neutropénica" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Clostridial myonecrosis, also known as gas gangrene, is a rare, rapidly progressive, life-threatening muscle infection caused by <span class="elsevierStyleItalic">Clostridium</span> sp. Gas gangrene has three presentations: traumatic, which is the most frequent one and caused by <span class="elsevierStyleItalic">C. perfringens;</span> spontaneous, which is caused by <span class="elsevierStyleItalic">C. septicum</span> or <span class="elsevierStyleItalic">C. tertium;</span> and gynecological, caused by <span class="elsevierStyleItalic">C. sordellii.</span><a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In this paper we describe the case of a 40-year-old, pregnant woman in her 17th week of gestation and with a history of idiopathic chronic neutropenia due to myeloid maturation arrest. The patient visited the Emergency Department due to experiencing pain in her right calf muscle. A Doppler ultrasound was performed, ruling out deep vein thrombosis (DVT). Forty-eight hours later, she returned complaining of increased pain and new-onset erythematous, purple lesions. A physical examination revealed muscle and tendon exposure along the entire posteromedial aspect of her limb, with palpable pedal and femoral pulses. The most remarkable findings of her vital signs assessment was hypotension (systolic blood pressure [SBP] of 95 mmHg and diastolic blood pressure [DBP] of 50 mmHg) and tachycardia at 100 bpm.</p><p id="par0015" class="elsevierStylePara elsevierViewall">A second Doppler ultrasound was performed, identifying data suggestive of necrotizing fascitis. Blood work revealed leukopenia (1.1 × 10<span class="elsevierStyleSup">3</span> µl), neutropenia (0.4 × 10<span class="elsevierStyleSup">3</span> µl), thrombocytopenia (144 × 10<span class="elsevierStyleSup">3</span> µl), coagulation alterations (prothrombin time 59%), increased muscle enzyme levels (creatine phosphokinase [CPK] 14,043 IU/L, lactate dehydrogenase [LDH] 358 IU/L, and glutamic oxaloacetic transaminase [GOT] 261 IU/L), and increased levels of acute phase reactants (C-reactive protein [CRP] >30.4 mg/dl and procalcitonin [PCT] 12.5 ng/mL). Emergency surgery was performed, detecting gas bubbles and muscle pallor during the procedure, owing to which a fasciotomy and debridement were carried out. Antibiotic therapy with penicillin G and clindamycin was subsequently started, and the patient was referred to our clinic.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Despite this treatment, her condition evolved poorly in the form of progression of the erythema throughout her leg and shock figures. A new surgical check-up was performed, observing a devitalized foot and posterior compartments, with vascular thrombosis and imperceptible distal pulses. Given these findings, a supracondylar amputation was carried out. Because her postoperative evolution was torpid, she had to undergo three subsequent surgical check-ups and receive seven sessions of hyperbaric oxygen therapy. Muscle cultures revealed isolates of <span class="elsevierStyleItalic">C. septicum</span>.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Spontaneous gas gangrene tends to arise from an abdominal port with subsequent hematogenous spread toward the muscles. It is usually observed in patients with a previously known or unknown gastrointestinal disease, such as colon adenocarcinoma, diverticulitis, ileitis, abdominocentesis, abdominal surgery, necrotizing enterocolitis, or abdominal radiotherapy. However, an abdominal disease is not essential for bacterial entry and dissemination to occur, as this type of infection can be found in patients with hematological risk factors, such as neutropenia (cyclic or chronic), lymphoproliferative disorders, or previous chemotherapy cycles. Although the most frequently isolated microorganism in cases of spontaneous gangrene is <span class="elsevierStyleItalic">C. septicum, C. tertium</span> has also been identified in some cases.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The relationship between <span class="elsevierStyleItalic">C. septicum</span> and malignant diseases has been known for several years. In a 1989 review including 162 patients with a <span class="elsevierStyleItalic">C. septicum</span> infection, 40% had some type of hematological disease and 34% had a colon neoplasm, in which case inflammation and tissue necrosis that favor intestinal bleeding occur. On the one hand, the low oxygen concentration favors the proliferation of the microorganism and, on the other, the bleeding facilitates its entry into the blood stream.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In the case of spontaneous gas gangrene where there is not always a history of recent trauma, its associated symptoms may be confused with muscle pain secondary to contractures or deep vein thrombosis. Thus, a high suspicion rate and the conduct of imaging tests (computed tomography [CT] and magnetic resonance imaging [MRI]) revealing images of gas within the tissues are required to reach an early diagnosis.</p><p id="par0040" class="elsevierStylePara elsevierViewall">There is no doubt that, in the case of this disease, a surgical examination must be performed within the first 24 h. In fact, some studies described increased survival rates with very early surgical interventions (within the first 6 h).<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The usefulness of hyperbaric therapy is controversial, as no studies performed to date have proven that it is clearly beneficial.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> In the case described in this paper, we tried to complete these sessions prior to the intervention considering its usefulness in better delimiting the necrotic tissue and facilitating the surgical procedure. Despite its potential usefulness, surgical debridement should not be delayed, as this procedure, together with a 10- to 14-day course of antibiotic therapy with penicillin G and clindamycin, is the preferred approach for this condition.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Progression of gas gangrene is life-threatening, with an associated mortality rate of 70-100% in different case series, especially in patients with immunosuppression, neoplasms, or neutropenia.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Cuenca Fito E, Ots Ruiz E, Holanda Peña MS. Gangrena gaseosa espontánea por <span class="elsevierStyleItalic">Clostridium septicum</span> en paciente neutropénica. Med Clin (Barc). 2021;157:e337–e338.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cellulitis, necrotizing fasciitis, and subcutaneous tissue infections" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M.S. Pasternack" 1 => "M.N. Swartz" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "LibroEditado" => array:6 [ "editores" => "J.E.Bennett, R.Dolin, M.J.Blaser" "titulo" => "Mandell, Douglas, and Bennett’s Principles and practice of infectious diseases" "paginaInicial" => "1194" "paginaFinal" => "1215" "edicion" => "8th ed." 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Stevens" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s11908-010-0127-y" "Revista" => array:6 [ "tituloSerie" => "Curr Infect Dis Rep" "fecha" => "2010" "volumen" => "12" "paginaInicial" => "383" "paginaFinal" => "391" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21308521" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000015700000011/v1_202112030828/S2387020621006380/v1_202112030828/en/main.assets" "Apartado" => array:4 [ "identificador" => "43309" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000015700000011/v1_202112030828/S2387020621006380/v1_202112030828/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020621006380?idApp=UINPBA00004N" ]
