Nontraumatic clostridial myonecrosis: an infectious disease emergency

A 64-year-old man presented with a history of four days of lower abdominal pain and 12 hours of cutaneous discoloration, bullae formation, and swelling of the soft tissues of abdominal wall and right thigh. Myonecrosis of abdominal wall and an adenocarcinoma of the cecum were found at operation. Cultures of blood and fluid from the bullae yielded Clostridium septicum. Nontraumatic clostridial myonecrosis is a fulminant, usually fatal disease that is most often the result of bacteremia from an occult gastrointestinal lesion. Ulceration of the colon or terminal ileum is the most common predisposing condition, and is usually due to gastrointestinal or hematological malignancy. Patients often present with nonspecific complaints, including pain at the affected site and fever. The disease progresses rapidly to include bronze discoloration, edema, and hemorrhagic bullous lesions of the skin, subcutaneous emphysema, and myonecrosis. Presumptive diagnosis often can be made by Gram stain of the bullous fluid that reveals gram-positive bacilli and a paucity of leukocytes. Favorable outcome depends on prompt institution of appropriate antimicrobial therapy and surgical debridement of involved soft tissues, as well as correction of the underlying disorder. This disease should be considered to be a medical-surgical emergency.