Proteus question

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Had a patient with gas on x ray. Took repeat x ray 8 hours later, no change in gas. Gas was located at ulcer site of foot, and several cm proximal to ulcer site. No crepitus, no fluctuance. WBC 7. No fever. Clinically the foot didn't look like your typical gas patient. Pt. may be immunocompromised from DM, hep C, etc. Local wound swab grew Proteus Mirabilis, which also grew in blood culture. Infectious Disease says not all gas on x ray is emergent, that Proteus can grow gas, but it isn't toxic like C. Perfringens.

I've never heard this before, always assumed that any gas on X ray was emergency surgery. Any thoughts? Thanks.

Originally Posted by Creflo

Infectious Disease says not all gas on x ray is emergent, that Proteus can grow gas, but it isn't toxic like C. Perfringens.

I've never heard this before, always assumed that any gas on X ray was emergency surgery. Any thoughts? Thanks.

Perhaps from a retrospective/academic standpoint the statement by ID is correct, however nonclostridial gas is rare and for the reasons you mentioned (delays in symptomology, diagnosis and treatment) can be very deadly if left untreated (1). I've encountered 2 recent instances where patients with plantar ulcers showed what appeared to be "gas" on XR, which actually turned out to be localized air pockets. You are absolutely correct that gas on XR, especially in the diabetic and/or vascular compromised limb is emergent and you'd be hard pressed to find a surgeon who would tell you otherwise.

1. Takahira N, et al. Treatment outcome of nonclostridial gas gangrene at a Level 1 trauma center. J Orthop Trauma. 2002 Jan;16(1):12-7.

I also once saw nongangrenous emphysema during an inpatient consult. Like your patient, the vitals and labs were unremarkable. The resident and attending did perform a bedside I&D and found just air and took a culture. This shocked me because I had assumed all gas required surgery. I was close: all gas gangrene requires surgery, but not all gas is gangrene.

The resident acted like it was an uncommon occurrence, but not exceedingly rare. Labs and especially normal vitals will tip you off to fairly benign gas.

Originally Posted by GSRaw

Perhaps from a retrospective/academic standpoint the statement by ID is correct, however nonclostridial gas is rare and for the reasons you mentioned (delays in symptomology, diagnosis and treatment) can be very deadly if left untreated (1). I've encountered 2 recent instances where patients with plantar ulcers showed what appeared to be "gas" on XR, which actually turned out to be localized air pockets. You are absolutely correct that gas on XR, especially in the diabetic and/or vascular compromised limb is emergent and you'd be hard pressed to find a surgeon who would tell you otherwise.

1. Takahira N, et al. Treatment outcome of nonclostridial gas gangrene at a Level 1 trauma center. J Orthop Trauma. 2002 Jan;16(1):12-7.

I'd say I deal with nonclostridial gas more often than not. Usually staph or strep.

Originally Posted by densmore22

I'd say I deal with nonclostridial gas more often than not. Usually staph or strep.

Me, too. I added the citation to clarify the rarity in reported literature. Indeed there were other case studies on NCG specifically in diabetic lower limbs.