伴有Clostridium septicum的气性坏疽在中性粒细胞减少患者中的表现

气性坏疽是坏死性筋膜炎的一种少见表现，由Clostridium perfringens、C. septicum及其他梭状芽孢杆菌属细菌引起。由于其快速进展，具有潜在危及生命的感染特性，在临床管理中构成挑战，需多学科合作。本案例报告一名62岁女性患者，在接受三阴性乳腺癌化疗期间出现中性粒细胞减少性发热。患者表现为左大腿高热，伴有局部红肿和硬结，但疼痛较轻。随后患者出现左手背部疼痛和红肿。初步诊断为蜂窝织炎，立即给予静脉注射美洛西林进行经验性治疗。尽管抗生素治疗，患者迅速发展为败血性休克，并伴有局部感染加重。急诊手术清创显示软组织广泛坏死，包括大腿肌肉坏死。左手也进行了大面积清创，左下肢无法保留，需截除左髋关节。微生物学检测在多个标本中分离出C. septicum，确认气性坏疽。由于皮肤未见明显的局部入口，疑为肠道转移引起的血源性播散。经验性抗生素调整为静脉青霉素，并联合克林霉素以抑制毒素。经过彻底清创和抗生素治疗后，患者得以稳定。经过多次清创后实现伤口闭合，患者出院接受康复治疗。抗生素治疗持续四周。该罕见的中性粒细胞减少患者气性坏疽病例，显示免疫功能低下患者在坏死性软组织感染的诊断与治疗中具有复杂性，强调快速识别疾病、及时进行必要的激进手术清创以及个体化抗生素治疗的重要性，以取得良好预后。

Gas gangrene is a rare presentation of a necrotizing fasciitis, caused by Clostridium perfringens, C. septicum and other clostridial species. With its rapid progression it is a potentially life-threatening infection, that poses as a challenge in the clinical management requiring an interdisciplinary approach.Here we present a 62-year-old woman, who developed neutropenic fever while undergoing chemotherapy for triple negative breast cancer. She presented with a high fever, reporting little pain in her left thigh accompanied by redness and induration locally. Subsequently the patient developed pain and redness of the back of the left hand. The initial findings suggested cellulitis and immediate empiric treatment with intravenous meropenem was started. Despite the antibiotic treatment the patient rapidly developed septic shock along with progression of the local infection. Emergency surgical debridement revealed extensive necrosis of the soft tissues including extensive myonecrosis of the thigh. On the left hand an extensive debridement was performed, the left lower limb could not be preserved and exarticulation of the left hip was required. Microbiologically C. septicum was isolated in different samples, confirming gas gangrene. As there was no local entry portal on the skin, hematogenous seeding from intestinal translocation in this neutropenic patient was suspected. The empiric antibiotic treatment was tailored to intravenous penicillin and complemented with clindamycin for toxin inhibition. Following radical debridement and antibiotic treatment, the patient could be stabilized. After repetitive debridement wound closure was achieved and the patient was discharged for rehabilitation. Antibiotic treatment was continued for four weeks.This rare case of gas gangrene in a neutropenic patient shows the complexity in the diagnostic and therapeutic management of necrotizing soft tissue infections in immunocompromised patients. It particularly highlights the importance of an interdisciplinary management with fast recognition of the disease and rapid, if needed radical, surgical debridement as well as tailored antibiotic treatment for a successful outcome.