Pathophysiology

There have been seven Clostridium species identified as causing gas gangrene. Clostridium perfringens is attributed to 80 to 95 percent of cases, with C. septicum being the second most common etiology.2 The clostridial organisms are large, gram-positive, spore-forming anaerobic bacilli normally found in the soil, gastrointestinal tract, and female genitourinary tract. They produce several exotoxins that are responsible for the cellular destruction as well as the rapid progression and systemic toxicity of the disease. Bacteremia is rare. Secondary toxic effects may be caused by the release of myoglobin, creatine phosphokinase (CPK), and potassium from tissue breakdown.

There are two potential mechanisms for infection with clostridial organisms. The first and most common is through direct inoculation from an open wound. Similar to tetanus, clostridial species thrive best in contaminated wounds with crushed or ischemic edges that tend to offer a favorable anaerobic environment. The second mechanism for infection is via hematogenous spread. Nearly all these patients are relatively immunocompromised from some form of underlying disease such as diabetes mellitus, peripheral vascular disease, alcoholism, drug abuse, or hematologic or gastrointestinal malignancies. Almost a third of these cases of "spontaneous gas gangrene" are caused by C. septicum, with an even higher incidence in cases related to malignancies.

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