International Journal of Legal Medicine

, Volume 122, Issue 1, pp 35–41

Pathology of fatal traumatic and nontraumatic clostridial gas gangrene: a histopathological, immunohistochemical, and ultrastructural study of six autopsy cases

  • Michael Tsokos
  • Sarah Schalinski
  • Friedrich Paulsen
  • Jan P. Sperhake
  • Klaus Püschel
  • Ingo Sobottka
Original Article


We prospectively investigated six fatal cases of clostridial gas gangrene using autopsy, histology, immunohistochemistry, microbiology, and scanning electron microscopy. The causative pathogen was Clostridium perfringens in four cases, C. sordellii in one case, and a mixed infection with both C. perfringens and C. sordellii in one case. According to the previous medical history and autopsy findings, clostridial infection was related to trauma in three cases. Characterized by extensive tissue necrosis and total absence of an accompanying leukocyte infiltration and tissue inflammatory response, the histopathological picture of clostridial gas gangrene is distinctly different from other bacterial infections. In medicolegal casework, the proof of the source of infection and the portal of entry of the responsible pathogen is not always an easy task, especially in the absence of trauma.


Gas gangrene Clostridial myonecrosis Clostridium perfringens Autopsy Forensic pathology 


  1. 1.
    Abella BS, Kuchinic P, Hiraoka T, Howes DS (2003) Atraumatic clostridial myonecrosis: case report and literature review. J Emerg Med 24:401–405PubMedCrossRefGoogle Scholar
  2. 2.
    Awad MM, Ellemor DM, Boyd RL, Emmins JJ, Rood JI (2001) Synergistic effects of alpha-toxin and perfringolysin O in Clostridium perfringens-mediated gas gangrene. Infect Immun 69:7904–7910PubMedCrossRefGoogle Scholar
  3. 3.
    Bryant AE (2003) Biology and pathogenesis of thrombosis and procoagulant activity in invasive infections caused by group A streptococci and Clostridium perfringens. Clin Microbiol Rev 16:451–462PubMedCrossRefGoogle Scholar
  4. 4.
    Bryant AE, Bayer CR, Aldape MJ, Wallace RJ, Titball RW, Stevens DL (2006) Clostridium perfringens phospholipase C-induced platelet/leukocyte interactions impede neutrophil diapedesis. J Med Microbiol 55:495–504PubMedCrossRefGoogle Scholar
  5. 5.
    Burke MP, Opeskin K (1999) Nontraumatic clostridial myonecrosis. Am J Forensic Med Pathol 20:158–162PubMedCrossRefGoogle Scholar
  6. 6.
    Caplan ES, Kluge RM (1976) Gas gangrene: review of 34 cases. Arch Intern Med 136:788–791PubMedCrossRefGoogle Scholar
  7. 7.
    Chetta SG, Weber MJ, Nelson CL (1982) Non-traumatic clostridial myonecrosis: report of two cases. J Bone Joint Surg Am 64:456–457PubMedGoogle Scholar
  8. 8.
    Delbridge MS, Turton EPL, Kester RC (2005) Spontaneous fulminant gas gangrene. Emerg Med J 22:520–521PubMedCrossRefGoogle Scholar
  9. 9.
    Fineschi V, Riezzo I, Centini F et al (2007) Sudden cardiac death during anabolic steroid abuse: morphologic and toxicologic findings in two fatal cases of bodybuilders. Int J Legal Med 121:48–53PubMedCrossRefGoogle Scholar
  10. 10.
    Hausmann R, Albert F, Geißdörfer W, Betz P (2004) Clostridium fallax associated with sudden death in a 16-year-old boy. J Med Microbiol 53:581–583PubMedCrossRefGoogle Scholar
  11. 11.
    Ikegami T, Kido A, Shimokawa H, Ishida T (2004) Primary gas gangrene of the pancreas: report of a case. Surg Today 34:80–81PubMedCrossRefGoogle Scholar
  12. 12.
    Karger B, Fechner G (2006) Sudden death due to giant cell coronary arteritis. Int J Legal Med 120:377–379PubMedCrossRefGoogle Scholar
  13. 13.
    Keogh G, Unsworth I, Vowels M, Kern IB (1994) Spontaneous Clostridium septicum myonecrosis in congenital neutropenia. Aust N Z J Surg 64:574–575PubMedGoogle Scholar
  14. 14.
    Leung FW, Serota AI, Mulligan ME, George WL, Finegold SM (1981) Nontraumatic clostridial myonecrosis: an infectious disease emergency. Ann Emerg Med 10:312–314PubMedCrossRefGoogle Scholar
  15. 15.
    Levy P, Boudet MJ, Perniceni T et al (1999) Spontaneous gas gangrene of the pancreas caused by Clostridium perfringrens. Gastroenterol Clin Biol 23:1248–1250PubMedGoogle Scholar
  16. 16.
    Roberts FJ (1998) Procurement, interpretation, and value of postmortem cultures. Eur J Clin Microbiol Infect Dis 17:821–827PubMedCrossRefGoogle Scholar
  17. 17.
    Sakai K, Takatsu A, Shigeta A, Abe S, Ikegami M, Takagi K (2007) Sudden death due to undiagnosed acute promyelocytic leukemia: a case report. Int J Legal Med (in press) DOI:10.007/s00414-006-0106-x
  18. 18.
    Sasaki T, Nanjo H, Takahashi M, Sugiyama T, Ono I, Masuda H (2000) Non-traumatic gas gangrene in the abdomen: report of six autopsy cases. Gastroenterology 35:382–390CrossRefGoogle Scholar
  19. 19.
    Siemann M, Koch-Dörfler M, Rabenhorst G (2000) Clostridium difficile-associated diseases. The clinical courses of 18 fatal cases. Intensive Care Med 26:416–421PubMedCrossRefGoogle Scholar
  20. 20.
    Smith-Slatas CL, Bourque M, Salazar JC (2006) Clostridium septicum infections in children : a case report and review of the literature. Pediatrics 117:e796–e805PubMedCrossRefGoogle Scholar
  21. 21.
    Soper DE (1986) Clostridial myonecrosis arising from an episiotomy. Obstet Gynecol 68(3 Suppl):26S–28SPubMedGoogle Scholar
  22. 22.
    Stevens DL, Bryant AE (2002) The role of clostridial toxins in the pathogenesis of gas gangrene. Clin Infect Dis 35(Suppl 1):S93–S100PubMedCrossRefGoogle Scholar
  23. 23.
    Stevens DL, Musher DM, Watson DA et al (1990) Spontaneous, nontraumatic gangrene due to Clostridium septicum. Rev Infect Dis 12:286–296PubMedGoogle Scholar
  24. 24.
    Takahira N, Shindo M, Tanaka K, Soma K, Ohwada T, Itoman M (2002) Treatment outcome of nonclostridial gas gangrene at a level 1 trauma center. J Orthop Trauma 16:12–17PubMedCrossRefGoogle Scholar
  25. 25.
    Thys JP, Ectors P, Noel P (1980) Non-traumatic clostridial myositis: an unusual feature of brain death. Postgrad Med J 56:501–503PubMedCrossRefGoogle Scholar
  26. 26.
    Tsokos M, Herbst H (2005) Black oesophagus: a rare disorder with potentially fatal outcome. A forensic pathological approach based on five autopsy cases. Int J Legal Med 119:146–152PubMedCrossRefGoogle Scholar
  27. 27.
    Valentine EG (1997) Nontraumatic gas gangrene. Ann Emerg Med 30:109–111PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2007

Authors and Affiliations

  • Michael Tsokos
    • 1
  • Sarah Schalinski
    • 1
  • Friedrich Paulsen
    • 2
  • Jan P. Sperhake
    • 3
  • Klaus Püschel
    • 3
  • Ingo Sobottka
    • 4
  1. 1.Institute of Legal Medicine and Forensic SciencesCharité—Universitätsmedizin BerlinBerlinGermany
  2. 2.Department of Anatomy and Cell BiologyMartin Luther University of Halle-WittenbergHalle (Saale)Germany
  3. 3.Institute of Legal MedicineUniversity Hospital Hamburg-EppendorfHamburgGermany
  4. 4.Institute of Infectious MedicineUniversity Hospital Hamburg-EppendorfHamburgGermany

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