Non-traumatic Clostridial myonecrosis.

GAS GANGRENE is defined as an invasive anaerobic infection of muscle, which is characterised by massive tissue death and by variable degrees of gas production. It is caused by the following organisms of the Clostridial group: C. perfringens (welchii), C. novyi (oedematiens), C. septicum (feseri), C. fallax, C. bifermentans and C. histolyticum. There are numerous other strains within this group but the above mentioned are the only strains capable of producing gas gangrene without any other organism being present (MacLennan 1962). Gas gangrene can also be caused by anaerobic streptococci. In almost all cases these organisms gain entry via a wound that has been contaminated by soil, faeces or foreign body. Non-traumatic gas gangrene is a much rarer phenomenon and of nine reported cases there has been only one survival of three weeks, the others dying within the first forty-eight hours (Marty and Filler 1969). In these cases there has been no visible external portal of entry and almost all the patients were more susceptible to disease by being either diabetic or on cytotoxic agents. In this case the patient was an elderly man who was neither diabetic nor receiving cancer chemotherapy. He had an adenocarcinoma of the caecum and presented as gas gangrene. CASE REPORT The patient was a thin elderly male of seventy-four years of age who was brought to Lagan Valley Hospital because of severe pain in his left thigh. He was so ill that he was unable to give a history but his wife was able to give a clear account of his illness. He had had no previous hospital admissions but one year earlier he had attended as an out-patient for investigation of abdominal pain, and had a barium meal carried out which was normal. Six months later he began to complain of upper left abdominal pain, loss of appetite, weight loss and constipation. He had had diarrhoea for four days prior to admission and the day before admission his abdominal pain had increased and he had vomited. The pain radiated into the left thigh which was discoloured, being dusky-blue in colour. On examination he was pale and had a normal temperature, the pulse rate was 84 per minute in sinus rhythm and the blood pressure was 130/80 mm. Hg. There was no evidence of heart failure. There was generalised tenderness over the abdomen and this was maximal in the right iliac fossa. Guarding and rebound tenderness were also present. A rectal examination revealed only faeces. Femoral pulses were good, no leg oedema was present and joint movements were normal, The left thigh was swollen, bruised and tender. He lay with the leg semi-flexed and abducted and on palpation the thigh was crepitant throughout its medial aspect. A diagnosis of gas gangrene was made and the patient prepared for laparotomy. The only laboratory data of significance was an Astrup of pH of 7.10 and a base excess of-17.5.