EC is a rare condition that is the result of infection with C perfringens and other gas-producing organisms, including Escherichia coli, Bacteroides fragilis, and Klebsiella species. Obstruction of the cystic duct with gallstones and ischemic changes in the cystic artery related to arteriosclerosis, hypertension, and diabetes have been suggested as causes of infection with gas-forming organisms in the gallbladder wall.2 EC commonly presents in men with a mean age of 59 years, in patients with type 2 diabetes mellitus, and in patients with biliary stones.3 Patients typically present with fever, right upper quadrant abdominal pain, nausea, and vomiting. Our patient was atypical, presenting with no abdominal pain or peritoneal signs, no biliary stones, and no history of type 2 diabetes mellitus. He was only mildly febrile and tachycardic.
EC evolves to gangrenous cholecystitis in 75% of cases and, once gangrenous cholecystitis is present, perforation of the gallbladder is inevitable.3 Untreated EC may also progress to soft tissue gangrene caused by hematogenous spread of microorganisms to muscles.4 The disorder can result in septic shock and carries a mortality rate of 15% to 25%.5
In this case, hematogenous spread of C perfringens resulted in gas along the right iliacus muscle and in the right hip. EC should be included in the differential diagnosis when an unknown source of infection with gas-producing organisms is present despite the absence of abdominal symptoms. Prompt diagnosis of EC is critical and the standard treatment is emergent cholecystectomy, either open or laparoscopic. If cholecystectomy is contraindicated, percutaneous cholecystectomy and broad-spectrum antibiotics is an alternative treatment.
Treatment of septic hip from gas-forming agents consists of antibiotics, surgical debridement, and supportive measures. Prompt debridement of affected tissue is mandatory to improve survival, preserve limbs, and prevent complications.6 Patients may require multiple surgical debridements over the course of several days. Antibiotic agents with excellent in vitro activity against C perfringens include clindamycin(Drug information on clindamycin), metronidazole(Drug information on metronidazole), and penicillin.6,7
1. Wedzicha JA. Oral corticosteroids for exacerbations of chronic obstructive pulmonary disease. Thorax. 2000;55(Suppl 1):S23-S27.
2. Kanehiro T, Tsumura H, Ichikawa T, et al. Patient with perforation caused by emphysematous cholecystitis who showed flare on the skin of the right dorsal lumbar region and intraperitoneal free gas. J Hepatobiliary Pancreat Surg. 2008;15:204-208.
3. Garcia-Sancho Tellez L, Rodriguez-Montes JA, Fernandez de Lis S, Garcia-Sancho Martin L. Acute emphysematous cholecystitis. Report of 20 cases. Hepatogastroenterology. 1999;46:2144-2148.
4. Safioleas M, Stamatakos M, Kanakis M, et al. Soft tissue gas gangrene: a severe complication of emphysematous cholecystitis. Tohoku J Exp Med. 2007;213:323-328.
5. Mentzer RM Jr, Golden GT, Chandler JG, Horsley JS 3rd. A comparative appraisal of emphysematous cholecystitis. Am J Surg. 1975;129:10-15.
6. Lorber B. Gas gangrene and other Clostridium-associated diseases. In: Mandell GL, Bennett JE, Dolin R, eds. Principles and Practice of Infectious Diseases. 6th ed. Philadelphia: Churchill Livingstone; 2005:2828.
7. Stevens DL, Maier KA, Laine BM, Mitten JE. Comparison of clindamycin, rifampin, tetracycline(Drug information on tetracycline), metronidazole, and penicillin for efficacy in prevention of experimental gas gangrene due to Clostridium perfringens. J Infect Dis. 1987;155:220.