myonecrosis can present in a myriad of ways depending on the infected tissue site. Patients may present with chest pain, severe arm pain and non-specific symptoms of malaise and nausea.11–13
Non-traumatic gas gangrene is usually associated with gastrointestinal, intra-abdominal and haematological malignancies.14
There have been only two previous cases occurring in patients with lung cancer, one patient with non-small cell lung cancer following combined modality therapy5
and a second patient with small cell lung cancer receiving etoposide chemotherapy.4
There are no published reports of gemcitabine and carboplatin associated with C septicum
infection. Although our patient was not neutropenic, the chemotherapy may have altered functionality of immune cells, contributing to C septicum
’s access to the bloodstream. C septicum
is unique in respect to other clostridial group members. It is relatively aerotolerant, allowing multiplication in healthy muscle tissue, unlike Clostridium perfringens
which requires tissue devoid of oxygen.15
This is almost certainly why C septicum
is overwhelmingly found in non-traumatic scenarios.16
Unlike C perfringens
which is a gut commensal, in humans C septicum
is an opportunistic infection suggesting the need for relative immunosuppresion as a prerequisite for its presence.12
Fulminant myonecrosis induced by C Septicum
relies on the production of a haemolytic, necrotising α-toxin which inhibits neutrophil recruitment to the infected region. This is reflected in histological tissue samples which are shown to be deficient in number and functionality of neutrophils.17
α-Toxin contributes to septic shock by increasing capillary permeability.18
Treatment has to consider the patient's premorbid condition. The mainstays remain surgical debridement with broad spectrum intravenous antibiotics. There is little evidence to support the use of hyperbaric oxygen therapy. Its role is probably limited in C Septicum
infection as the organism is not fully dependent on an anaerobic environment.19
However, in theory it could help prevent further bacterial spread through the muscle and allow smaller resection margins.1 20
In many cases related to malignancy, major surgery may not be appropriate and therefore a palliative approach, focusing on pain control should be initiated as soon as the diagnosis is made. Both primary and secondary care physicians need to be aware of non-traumatic gas gangrene despite its rarity. Our case illustrates that potentially all cancer patients are susceptible to opportunistic infections such as C Septicum
. This diagnosis should be considered in patients with known malignancy and inexplicable pain and palpation for crepitus is vital. More rapid diagnosis may allow more aggressive surgical management or rapid institution of good symptom control in the last hours of life.
- Malignancy of all types potentially renders patients susceptible to opportunistic infections such as Clostridium septicum.
- Non-traumatic gas gangrene should be considered in patients with known malignancy with unexplainable pain symptoms in both primary and secondary care settings.
- More rapid diagnosis may improve survival or at least allow faster initiation of palliative care in the last hours of life
- When examining the patient it is important to consider palpating for crepitus in the area of severe pain.
- Survivors of non-traumatic gas gangrene should undergo investigation of the gastrointestinal tract to exclude an underlying gastrointestinal malignancy if a malignancy is not already known.