Clostridial myositis and myonecrosis is an acute, rapidly progressive infection of the soft tissues commonly known as “gas gangrene.” The infection is caused by one of several bacteria in the group known as “clostridium.” While over 150 species of clostridium have been identified, only a few commonly cause gas gangrene. The infection typically spreads from a discrete focus of clostridium within the body. The original source can actually be within the body, as clostridium normally live in the gastrointestinal tract. Alternatively, the infection can originate outside the body, such as when infection results from contamination of wounds during trauma (e.g. motor vehicle accidents).
Gas gangrene infection is severe and can advance quickly. Besides replicating and migrating, the organisms which cause gas gangrene produce poisons known as exotoxins. Exotoxins are capable of liquefying adjacent tissue and inhibiting local defense mechanisms which might normally contain a less virulent infection. As such, the advancing infection of gas gangrene may simply destroy healthy tissue in its path and spread over the course of hours.
Clostridium bacteria are “anaerobic,” meaning that they prefer low oxygen concentrations to grow. If clostridium are exposed to high amounts of oxygen, their replication, migration, and exotoxin production can be inhibited. This is the rationale for the use of hyperbaric oxygen in the treatment of gas gangrene. Repeated treatment in the hyperbaric chamber has the potential to slow the progress of the infection while the two primary therapies, antibiotics and surgical resection of infected tissue, control it.
The advantages of hyperbaric oxygen treatment in gas gangrene are two-fold. First, it may be life-saving because exotoxin production is rapidly halted and less heroic surgery may be needed in gravely ill patients. Second, it may be limb and tissue-saving, possibly preventing limb amputation that might otherwise be necessary.
1. Bakker DJ. Clostridial myonecrosis. In Davis JC, Hunt TK, eds. Problem Wounds: The Role of Oxygen. New York: Elsevier, 1988:153-172.
2. Hirn M. Hyperbaric oxygen in the treatment of gas gangrene and perineal necrotizing fasciitis: A clinical and experimental study. Eur J Surg 1993;570(Suppl):9-36.
3. Hyperbaric Oxygen Therapy Committee. Clostridial myositis and myonecrosis (gas gangrene). In: Hampson NB, ed. Hyperbaric Oxygen Therapy: 1999 Committee Report. Kensington, MD: Undersea and Hyperbaric Medical Society, 1999:13-16.
4. Stevens DL, Bryant AE, Adams K, Mader JT. Evaluation of therapy with hyperbaric oxygen for experimental infection with Clostridium perfringens. Clin Infect Dis 1993;17:231-237.
Other references on Clostridal Myositis and Myonecrosis (Gas Gangrene)
- Bakker DJ: Clostridial myonecrosis. In Problem Wounds, The Role of Oxygen, Eds. Davis JC and Hunt TK 1988:153-172, Elsevier Publishing Co., New York.
A comprehensive review article from the institution that has pioneered the medical and surgical management of gas gangrene over the past four decades. This reported case series involving bacterially-proven clostridium perfringens gas gangrene is the largest in the world,. The report demonstrates that early application of HBO therapy:
- is limb- and tissue-saving
- clarifies the demarcation.
- Van Unnik AJM: Inhibition of toxin production in Clostridium perfringens in vitro by hyperbaric oxygen. Antonie Van Leeuwenhoek 1965;31:181-186.
An historically important in-vitro study that demonstrated the critical role that Alfa-toxin plays in the pathophysiology of Clostridium perfringens (gas gangrene) infections. Further, HBO therapy inhibited production of this toxin.
- Kaye D: Effect of hyperbaric oxygen on Clostridia in vitro and in vivo. Proc Soc Exp Biol Med 1967;124:360-366.
A second early study that confirmed the bactericidal properties of HBO therapy in gas gangrene. HBO was protective, resulting in decreased mortality.
- Hart GB, Lamb RC, Strauss MB: Gas gangrene: I. A collective review. The Journal of Trauma 1983;23(11):991-1000.
This two-part report initially provides a 20-year literature review of gas gangrene, indicating that "a combined therapy approach with early recognition, surgical intervention, appropriate antibiotics, and hyperbaric oxygen (HBO) provides optimal care". The second part summarizes the outcomes of a large clinical series, supporting the earlier contention that the addition of HBO therapy to standard surgical and antibiotic regimes optimizes survival.
- Demello FJ, Haglin JJ, Hitchcock CR: Comparative study of experimental Clostridium perfringens infection in dogs treated with antibiotics, surgery, and hyperbaric oxygen. Surgery 1973;73(6):936-941.
A comparative study of gas gangrene treated with various combinations of surgery, antibiotics and hyperbaric oxygen. Maximum effectiveness (95% survival) was achieved when all three modalities were combined.
- Hirn M: Hyperbaric oxygen in the treatment of gas gangrene and perineal necrotizing fasciitis. Eur J Surg 1993;(570):1-36.
A monograph; it describes both an experimental model and a clinical series. The animal model resulted in statistically significant improvement in survival (13% vs. 38%) when HBO therapy was combined with surgical debridement. Clinically, HBO reduced mortality through multifactional mechanisms, which the author describes in detail.
Hirn M, Niinikoski J, Lehtonen OP: Effect of hyperbaric oxygen and surgery on experimental gas gangrene. Eur Surg Res 1992;24:356-362.
An experimental model of Clostridial gas gangrene that reflects modern day medical and surgical management practices