GENERALIZED CLOSTRIDIAL INFECTION WITH RH ABDOMYOLYSIS AFTER CHOLECYSTECTOMY

We report a rare case of spontaneously developing generalised gas gang rene with massive rhabdomyolysis after a cholecystectomy and drainage of a hepatic abscess. On preoperative physical examination the patient appeared severely ill and was icteric and oliguric. Laboratory evalua tion showed signs of systemic inflammation, elevated lactate levels, e vidence of disseminated intravascular coagulation (DIC), and increased levels of serum creatine kinase (CK) activity. Abdominal ultrasound a nd endoscopic retrograde cholangiography showed a gallbladder perforat ion and a hepatic abscess. Cholecystectomy and drainage of the abscess was performed immediately and without technical problems. After posto perative admission to the intensive care unit, the patient showed evid ence of generalised myonecrosis with subcutaneous gas formation and ac ute renal failure. Initially, there were few other signs of systemic t oxicity; the patient was not hypotensive and the pulmonary gas exchang e was normal. Within hours diffuse swelling of his right leg developed with cutaneous gangrene and a compartment syndrome. After fasciectomy and extensive surgical debridement, uncontrollable bleeding due to DI C developed from the fasciectomy site, which finally required exarticu lation of the leg at the hip joint. At this point, multiple organ fail ure including severe adult respiratory distress syndrome was present. Two days after cholecystectomy, the patient died from hypoxic cardioci rculatory failure. Clostridium perfringens was repeatedly isolated fro m the wounds. Besides gas gangrene, the differential diagnosis of such infections includes localised clostridial cellulitis, nonclostridial anaerobic cellulitis caused by mixed aerobes and anaerobes, and type I or type II necrotising fasciitis. Patients with systemic necrotising infections should be treated with broad-spectrum antimicrobial regimen s (penicillin G, 3rd generation cephalosporins, clindamycin, and amino glycosides). An otherwise unexplained elevation of serum CK activity i n the presence of acute cholecystitis may suggest haematologic spread of an aggressive myolytic agent and the beginning of myonecrosis. This should prompt immediate surgical exploration after establishing broad -spectrum antibiotic coverage. The role of hyperbaric oxygen treatment in this situation remains to be established. If hyperbaric oxygen is to be employed, it should neither delay surgical exploration nor jeopa rdise the patient with the hazards of an interhospital transport.