4 days after a patient received a gunshot wound to the soft tissues of middle third of the thigh, his condition suddenly began deteriorating. There are complaints of bursting pain in the wound; pain has been increasing during the last 12 hours. Edema of skin and hypodermic tissue quickly grows. Body temperature is 38,2°C, heart rate is 102/min. The wound edges gape, are dull in color; the muscles, viable as of day before, now protrude into the wound, look boiled, are dull in color, have dirty-gray coating, and fall apart when held with forceps. What infection has developed in the wound?

Answer options

1. Anaerobic
2. Aerobic gram-positive
3. Diphtheria of the wound
4. Putrid
5. Aerobic gram-negative

Explanation

This infection is particularly relevant to military and trauma surgery. Patients who are immunocompromised, diabetic, or have the malignant disease are at greater risk, particularly if they have wounds containing necrotic or foreign material, resulting in anaerobic conditions. Military wounds provide an ideal environment as the kinetic energy of high-velocity missiles or shrapnel causes extensive tissue damage. The cavitation which follows the passage of a missile through the tissues causes a «sucking» entry wound, leaving clothing and environmental soiling in the wound in addition to revascularized tissue. Anaerobic wound infections are associated with severe local wound pain and crepitus (gas in the tissues, which may also be visible on plain radiographs – gas gangrene). The wound produces a thin, brown, sweet-smelling exudate, in which Gram staining will reveal bacteria. Edema and spreading gangrene follow the release of collagenase, hyaluronidase, other proteases, and alpha-toxin. Early systemic complications with circulatory collapse and organ failure follow if prompt action is not taken. Bailey & Love’s short practice of surgery. – 27th edition. – P. 49.