Early diagnosis and treatment are essential in this life-threatening disorder. Familiarity with the disease and its clinical features is important to avoid overlooking the subtle early signs of its presentation. Any patient presenting with pain out of proportion to physical findings, with or without low-grade fever, and significant tachycardia, with or without a cutaneous injury, should be carefully evaluated for possible clostridial infection. Crepitus detectable on physical examination may be a later finding, and its absence does not rule out the diagnosis. Plain radiographs of the affected area may reveal gas within the involved muscle and surrounding soft tissue. A Gram stain of exudate or tissue showing gram-positive rods with a relative lack of leukocytes is considered diagnostic. Surgical exploration is also helpful in the diagnosis. In the early stages, the muscles are edematous and pale but still bleed when cut; in later stages, the muscles lose contractility and on dissection appear beefy red without bleeding and gas bubbles may be evident between the tissues.
The differential diagnosis of clostridial myonecrosis must encompass other gas-forming infections, including necrotizing fasciitis, streptococcal myositis, acute streptococcal hemolytic gangrene, crepitant cellulitis, and synergistic necrotizing cellulitis. The crepitance should be differentiated from other causes of subcutaneous emphysema such as pneumothorax, pneumomediastinum, and fractured larynx or trachea. The edema and pallor, with loss of distal pulses, seen in an affected extremity should be differentiated from vascular thrombosis conditions such as phlegmasia cerulea dolens.
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