A rare trifocal presentation of Clostridium septicum myonecrosis

Gas gangrene or clostridial myonecrosis is a rare, life threatening infection of the muscle that is typically associated with recent surgery or trauma. It usually affects older individuals who suffer from vascular insufficiency or who are immunocompromised. The typical pathogen is Clostridium perfringens. Atraumatic gas gangrene caused by Clostridium septicum is less common and has a unique association with colon cancer. This condition aggressively spreads through the muscular tissue and often culminates in septic shock. Fatality occurs within 48 hours if left untreated yet, despite emergent treatment the mortality rate is >50% without any comorbidities. Given the propensity to occur in the extremities the orthopedic surgeon must be familiar with its presentation, diagnosis, and treatment. This article presents a case of a 16-year-old girl who presented to the emergency room with an 18-hour history of malaise and progressive right arm discomfort and swelling. The identification and emergent treatment of necrotizing soft tissue infections is important and often falls on the orthopedic surgeon, especially when isolated to the extremities. Subtle initial presentation and rapid progression of the infection are classic findings of necrotizing soft tissue infections, particularly with clostridial myonecrosis and necrotizing fasciitis. Clostridium myonecrosis is a rare orthopedic condition with high mortality. Early diagnosis and debridement is imperative. A team approach to managing these patients postoperatively is necessary. The use of hyperbaric oxygen can be considered, however, it may not be readily available and its use is unproven in human studies. Due to its high mortality, one should err on the side of more aggressive resective/ablative surgery.