AA Kornbluth

B Lanting

BS Abella

DB Wall

DC Elliot

Engelbert Schröpfer

L Boenicke

M Barza

M Flores-Diaz

MP Burke

PK Goon

PM Tibbles

Stephan Rauthe

Thomas Meyer

VK Panchbhav

WM Tang

ZC Jacob

English

PubMed

Crossref

Diagnosis and misdiagnosis of necrotizing soft tissue infections: three case reports

Springer - Publisher Connector

BioMed CentralCases Journal
ssOpen AcceCase Report
Diagnosis and misdiagnosis of necrotizing soft tissue infections: 
three case reports
Engelbert Schröpfer*1, Stephan Rauthe2 and Thomas Meyer1
Address: 1Department of General-, Visceral-, Vascular- and Transplant-Surgery, Julius-Maximilians-University of Würzburg, Würzburg, Germany 
and 2Department of Pathology, Julius-Maximilians-University of Würzburg, Würzburg, Germany
Email: Engelbert Schröpfer* - Schroepfer_e@chirurgie.uni-wuerzburg.de; Stephan Rauthe - Rauthe_S@klinik.uni-wuerzburg.de; 
Thomas Meyer - Meyer_T@chirurgie.uni-wuerzburg.de
* Corresponding author    
Abstract
Background: Today, gas gangrene is rare, but still many of the patients die, despite having received
timely treatment.
Case presentation: This report highlights the cases of three different patients, who were
transferred to our surgical department in 2006. The first patient (Patient_A), with the suspected
diagnosis "femoral hematoma", a second patient (Patient_B) because of an "acute abdomen" and
the third patient (Patient_C) with suspected gas gangrene of the right leg.
Conclusion: The first two cases demonstrate gas gangrene should always be kept in mind,
especially in high-risk-patients. Though, the third case shows that severe consequences because of
a precipitate diagnosis can be avoided by careful evaluation.
Background
Anaerobic infections by exotoxin-producing Clostridium
perfringens are rare [1]. Due to systemic progression of the
infection gas gangrene still remains life-threatening when
detected late. We report on three cases of necrotizing soft
tissue infections (NSTI). The first two patients suffering
from NSTI were admitted to our hospital with different
provisional diagnoses, one with compartment syndrome,
the second with appendicitis. Despite immediate treat-
ment both patients died within 24 hours after admittance
to our hospital. The third patient was free of NSTI,
although evincing all typical symptoms of gas gangrene.
Case presentation
First case
The first case reports on a 47-year-old man suffering from
myelodysplastic syndrome for several years. Furthermore,
he had inguinal and scrotal ulcerations, refractory to all
previous treatments since 2002. Before admission to our
university hospital with the suspected diagnosis of com-
partment syndrome, he was first admitted to a smaller
hospital with a deep venous thrombosis of the right leg.
Upon arrival in our hospital the patient was already in
shock. On examination his right leg was edematous and
discoloured with crepitus on deep palpation (Fig. 1).
According to the accompanying documents these symp-
toms had existed for two days. Due to the provisional
diagnosis of NSTI the patient was immediately taken to
the operating room after initial cardiovascular stabiliza-
tion in our intensive care unit. Broad-spectrum antibiotics
were administered prior to operation. After hemipelvec-
tomy (Fig. 2) a massive spreading of the NSTI, including
necrosis of the psoas muscle, was detectable. Therefore no
further surgical debulking of the infected tissue was possi-
Published: 20 October 2008
Cases Journal 2008, 1:252 doi:10.1186/1757-1626-1-252
Received: 25 June 2008
Accepted: 20 October 2008
This article is available from: http://www.casesjournal.com/content/1/1/252
© 2008 Schröpfer et al; licensee BioMed Central Ltd. 
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), 
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 4
(page number not for citation purposes)
Cases Journal 2008, 1:252 http://www.casesjournal.com/content/1/1/252ble. Despite intensive therapy the patient died eight hours
after admission to our hospital.
The provisional diagnosis of gas gangrene caused by
clostridium perfringens was confirmed by microbiologi-
cal and pathological findings of the tissue obtained dur-
ing surgery (Fig. 3, Fig. 4).
Second case
The second patient, a 73-year-old man suffering from nau-
sea, emesis and diarrhoea was admitted to our hospital for
further treatment with the diagnosis acute appendicitis.
Besides abdominal pain, a physical examination demon-
strated haematoma of the right shoulder. Computer tom-
ography of the abdomen revealed a cecal tumor with
hepatic and splenic metastasis. In addition, a progression
of the haematoma with crepitus on palpation appeared
(Fig. 5). A provisional diagnosis of NSTI was made and
the patient was immediately taken to the operation room
for forequarter amputation of the right arm. Due to pro-
gression of necrosis, nearly all pectoral, spinal and scapu-
lar muscles were resected. Although the perioperative
antibiotic treatment with penicillin was intensified by the
addition of clindamycin and ceftriaxone in the intensive
care unit, a further progression of necrosis could be
observed. The patient died in the intensive care unit 14
hours after admission. Pathologic findings confirmed the
diagnosis clostridial infection.
Third case
The third case reports on a 68-year-old patient, admitted
to our department because of "gas gangrene of the right
leg". Medical history revealed leucocytoclastic vasculitis
and diabetic foot ulcer on the right side sine six months.
Two days before debridement of the ulcer was performed
by a local GP. Physical examination demonstrated crepi-
Pathologic findings of the muscle tissueFigure 3
Pathologic findings of the muscle tissue. Postoperative 
pathologic findings of the muscle tissue obtained during surgi-
cal removal. Hämatoxylin-Eosin-stain, zoom 100×. Infected 
tissue with gas-inclusion between the muscle-fibres can be 
seen. 
Preoperative photography of the first patientFigur  1
Preoperative photography of the first patient. First 
patient on the intensive ward before hemipelvectomy: The 
right thigh is swollen, edemous and discoloured. An impres-
sive crepitus is already palpable. At this juncture the patient 
is in shock.
Photography during operation after hemipelvectomy on the righ  side with view f the acet bulumFigure 2
Photography during operation after hemipelvectomy 
on the right side with view of the acetabulum. View on 
the acetabulum and the pelvic muscles after hemipelvectomy 
was performed. Necrosis has already spread into the psoas 
muscle, therefore surgical resection of the necrotic tissue is 
not possible any more. Afterwards bandage of the open 
wound is performed and the patient is transmitted to inten-
sive care unit for further treatment.Page 2 of 4
(page number not for citation purposes)
Cases Journal 2008, 1:252 http://www.casesjournal.com/content/1/1/252tation of the lower right leg and right thigh. Inflammatory
parameters in laboratory findings were slightly increased
(leucocytes 11.600/μl [5.000–10.000/μl], CRP 2.52 mg/
dl [0–0.5 mg/dl]). X-ray imaging revealed intramuscular
and subcutaneous gas (Fig. 6). The patient was immedi-
ately taken to the operation room for superficial skin inci-
sion of the medial lower leg. Both, the subcutaneous and
the muscle tissue were raised by gas. The entire tissue
appeared healthy and no necrosis could be observed.
Biopsy of the muscle was taken and immediately sent to
the microbiology department. Fasciotomy of the medial
and lateral lower leg and the lateral thigh was performed.
Microbiologic findings of the muscle tissue revealed no
bacterial growth. The patient was admitted to our inten-
sive care unit for antibiotic treatment and hourly wound
monitoring. Further observation showed healthy muscle
tissue and normal white blood cell count. Therefore we
performed secondary suture of the fasciotomy wounds
and surgical treatment of the foot ulcer. The patient was
discharged from the intensive care unit three days after
admission.
X-Ray Images of the right lower leg of patient threeFigure 6
X-Ray Images of the right lower leg of patient three. 
X-Ray Images in the anteroposterior and lateral projection of 
the right lower leg and ankle joint of the third patient: Free 
gas in the subcutaneous and in the muscle tissue can be seen. 
According to these images, the surgeon in charge of another 
hospital admitted the patient to our department with the 
provisional diagnosis "gas gangrene of the right leg" for ampu-
tation and intensive care monitoring.
Pathologic findings of the muscle tissueFigure 4
Pathologic findings of the muscle tissue. Postoperative 
pathologic findings of the muscle tissue obtained during surgi-
cal removal. Gram-stain, Zoom 1000×. Identification of 
gram-positive, rod-shaped, anaerobic, spore-forming bacteria 
in the infected muscle tissue. The result is highly compatible 
to an infection with clostridium perfringens.
Preoperative photography of the second patientFigur  5
Preoperative photography of the second patient. Ery-
thema of the right shoulder of patient two before operation. 
At this juncture crepitus is palpable in the subcutaneous tis-
sue of the shoulder and the upper arm. In comparison, the 
erythema shows a massive progressionPage 3 of 4
(page number not for citation purposes)
Cases Journal 2008, 1:252 http://www.casesjournal.com/content/1/1/252Discussion
Clostridium perfringens is an aerotolerant spore-forming,
gram-positive bacterium found in soil and the intestinal
tract of humans and other vertebrates [2,3]. Proliferation
of Clostridium perfringens requires changing normal
environmental conditions to an anaerobic milieu. Such
conditions can be caused by earlier widespread destruc-
tion of soft tissue, yet clostridial gas gangrene can also be
found without a prior trauma [4]. Different risk factors,
e.g. diabetes, malignancy, immunodeficiency and vascu-
lar diseases are known. Due to the growing number of dia-
betics and the elderly, NSTI, especially in absence of
trauma, may become more important in the future.
All three patients suffered from at least one risk factor,
none of them remembering a recent trauma. However,
possible entry points for bacteria can be identified in
patient one and three. In case one and two NSTI should
have been considered as a differential diagnosis from the
beginning. Due to the association of NSTI with large and
contaminated wounds, the wrong diagnosis was made
initially. As surgical sanitation of the infection is essential
in NSTI, early diagnosis is the most important factor for
survival [5].
A review of the English literature by Lanting et al. revealed
three cases of spontaneous gas gangrene of the shoulder
[6]. The primary diseases in these cases were diabetes with
peptic ulcer disease, diabetes and ischemic heart disease
and radiation colitis [7-9]. A strong relation between gas-
trointestinal malignancies and NSTI was shown by Korn-
bluth et al. [10], therefore colonoscopy is recommended
for all patients with spontaneous clostridium infection
[11].
The third case demonstrates the necessity of comparing
radiological, clinical and intraoperative findings. Accord-
ing to literature, 79.2% of the patients with NSTI were in
shock and all patients were suffering from enormous pain
at the wound site [12]. Patients with a white blood-cell-
count ≤ 15.400/μl have only a 1% chance of developing
NSTI [13]. The number of white blood-cells in the third
patient was slightly increased; no pain or signs of shock
could be observed. In order to be able to inspect the mus-
cle tissue, we decided on surgical treatment. After incision,
muscle tissue could be observed and a biopsy was taken.
Due to microbiological findings clostridial infection
could be excluded. Detection of free gas in the tissue is not
an indisputable indicator for bacterial infection. There-
fore, a precise comparison between clinical and radiolog-
ical findings is required before a decision on radical
surgical treatment is made. Through fasciotomy a suffi-
cient wound control in the first days after admission was
possible.
Conclusion
In patients suffering from NSTI, early diagnosis is essential
for sufficient treatment and survival [14]. Although NSTI
is well known, it was not considered in the first two cases
due to absence of trauma. Despite all efforts, both patients
died because surgical resection of the necrotic tissue was
not possible. Nether less, free gas in the tissue and crepitus
are not necessarily caused by NSTI and the diagnosis is not
always straightforward [15].
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
ES analyzed the data and drafted the manuscript and was
the main coordinator. SR carried out the immunohisto-
chemical staining. TM participated in editorial support.
Consent
Written consent for publication was obtained from the
relatives in case 1 and 2 and from the patient in case 3
Acknowledgements
We thank Mrs. L. Stevenson-Knebel for technical assistance.
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Diagnosis and misdiagnosis of necrotizing soft tissue infections: three case reports

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