A 52-Year-Old Diabetic Man with Poor Dental Hygiene, Right Dental Abscess, and Parapharyngeal Abscess with Gas Gangrene Due to Infection, Presenting with Septic Shock and Multiorgan Failure, Who Recovered After Surgical Neck Debridement

Background

Gas gangrene is a very rare and life-threatening necrotizing soft-tissue infection that is rapidly progressive and most common in the extremities [1]. Gas gangrene of the head and neck is a very rare condition and an unusual case of non-clostridial gas-forming neck abscess, caused by Klebsiella pneumoniae. Klebsiella pneumoniae is a gram-negative, encapsulated, rod-shaped bacterium. It is found in the normal flora of the mouth, skin, and intestines and has become an important pathogen. The most common infection outside the hospital is pneumonia, while gas gangrene is a rare condition. Sepsis and septic shock can follow entry of the bacteria into the blood [2].

This report is of a diabetic man with poor dental hygiene, a right dental abscess, and parapharyngeal abscess with gas gangrene due to Klebsiella pneumoniae infection, presenting with septic shock and multiorgan failure, who recovered after surgical neck debridement.

Case Report

A 52-year-old diabetic man passed out on a curbside and was brought in by basic ambulance service within 10 minutes. He presented with painful swelling of the right-side neck for a week that associated with spiking fever, confusion, dyspnea, and stridor. On presentation, his blood pressure was 90/60 mmHg, heart rate was 140 beats per minute, temperature was 40°C, and respiratory rate was 36 breaths per minute. On examination, there was right preauricular, submandibular, and supraclavicular swelling with crepitus, and multiple dental caries were found. He was intubated.

Moreover, he was confused, with abnormal laboratory findings of multiorgan involvement, metabolic acidosis (Table 1), and gastrointestinal bleeding. The patient had severe sepsis that led to multiorgan dysfunction syndrome with an acute physiology and chronic health evaluation (APACHE) II Score of 41.

Emergency contrast-enhanced computed tomography showed the loculated collection with internal emphysema, 12.6×8.7×6.8 cm from the right masticator space, right parotid space, right paralaryngeal space, with swelling of the right para- and retropharyngeal soft tissue (Figure 1). Dense infiltration and pleural effusion at visualized upper lobes were noted. Intravenous amoxicillin-clavulanic acid was started as empiric antibiotic. Three hours after arriving at the hospital, neck exploration was performed for drainage. Necrotic tissue and foul-smelling pus were debrided and drained. Gram stain showed gram-negative bacilli. Necrotic tissue, pus, and blood culture showed Klebsiella pneumoniae. Anaerobic culture was not performed. The antibiotic susceptibility testing showed resistance only to ampicillin and amoxicillin-clavulanic acid. The intravenous amoxicillin-clavulanic acid was changed to intravenous meropenem because of the recommendation of infectious diseases doctors based on the severity of multiorgan failure and comorbidities of the patient. It was given on extended infusion.

After 3 days, his acidosis was improved. He remained on intravenous meropenem 1 g every 12 hours for 14 days and the wound was frequently debrided and irrigated with povidone-iodine solution in normal saline every 2 days until the infection subsided after 1 week. He was successfully extubated on the ninth day. Finally, normal physiologic functions of the failing organ system were restored.

Discussion

The most common (80–95%) organism causing gas gangrene is Clostridium perfringens. However, other microbes have also been isolated, such as Escherichia coli [5]. In the present case, pus culture showed Klebsiella pneumoniae, which is a very rare gas-forming abscess. On reviewing the literature, the rare cases of non-clostridial infection showed reported Klebsiella pneumoniae in pus and blood culture [1,5,6], and Prevotella buccae and Eggerthella species in pus culture [2]. Fatimi et al reported a woman with diabetes mellitus who was diagnosed with gas gangrene of the neck with mediastinitis; culture of pus revealed Klebsiella pneumoniae and Pseudomonas aeruginosa, but the blood culture revealed only Klebsiella pneumoniae. Anaerobes were not seen to grow in any culture. She had no symptom of multiorgan dysfunction syndrome. Postoperatively, she was successfully extubated after 3 days [5].

Gas gangrene of neck spaces have been reported as a result of acute pharyngolaryngeal inflammation (46%), odontogenic causes (27%), trauma (8%), and unknown etiology (19%) [3,4]. Our patient had an odontogenic infection with concomitant diabetes mellitus that led to gas gangrene, severe sepsis, and multiorgan dysfunction syndrome. He did not have a history of pharyngolaryngeal inflammation or trauma. Vaidya et al reported a 52-year-old man with diabetes mellitus and dental caries who was diagnosed with gas gangrene of the neck, but he had no symptom of multiorgan dysfunction syndrome [1]. Gamoh et al reported a case of gas gangrene originating from dental caries, but without a history of diabetes mellitus and no multiorgan dysfunction syndrome [7].

Gas gangrene can rapidly progress, leading to severe morbidity and high mortality. It needs to be diagnosed early and aggressive debridement is indicated [1]. Kawagoe et al reported a death from cervical gas gangrene after tooth extraction of a mandibular third molar [8]. Many serious complications have been reported, such as bilateral septic cavernous sinus thrombosis following masticator and parapharyngeal space abscess [9] and orbital abscess with gas gangrene [10]. Our patient could be considered at higher risk than normal because of his diabetes that caused severe sepsis and multiple organ failure. However, rapid diagnosis and emergency aggressive drainage can reduce serious morbidity. The present patient was brought in by basic ambulance service within 10 minutes and the drainage was performed within 3 hours after arriving at the hospital. His multiorgan dysfunction syndrome gradually improved when his infection subsided.

Conclusions

We presented a rare case of Klebsiella pneumoniae infection causing gas gangrene in the deep neck spaces, leading to septic shock and multiorgan failure, who recovered after surgical neck debridement. This is a fatal condition that requires active emergency treatment with hemodynamic supports, appropriate antibiotics, aggressive drainage, and debridement of necrotic tissue.