A 24-year-old immunocompetent woman was admitted to the emergency department (ED) in a state of coma. The patient had liposuction done in her bilateral lower limbs two days ago, but the specific procedure done remains unknown. After her operation, the patient went shopping and had some street food. The patient then went home with no complications.
In the evening, the patient had swelling and pain in her right lower limb. She was given analgesic treatment, but it did not have any significant symptomatic relief.
Twelve hours after her operation, the patient visited the local hospital and was given tramadol for analgesia. But she still had no symptomatic relief, reporting persistent bilateral swelling, pain, and a poor spirit.
Sixteen hours after her operation, the patient visited a plastic and reconstructive surgery clinic and was administered analgesic and cooling treatment. At that time, the patient’s body temperature was 39.0 ℃. The patient was found to have scattered ecchymosis on her bilateral lower limbs with blisters.
Twenty-two hours after her operation, the patient visited the ED of Shenzhen Hospital with a body temperature of 37.1 °C, bilateral limb swelling, extensive ecchymoses on her lower abdomen and bilateral thighs, local crepitus, blisters, weak pulses on her femoral artery and dorsalis pedis, and high skin tension. Then patient accepted emergency CT and was started on cefamandole + ornidazole (anti-infective), intramuscular tetanus anti-toxin, fluid replacement, and dopamine to raise her blood pressure.
Twenty-eight hours after her operation, the patient became unconscious with an SpO2 of 87%. She was given an endotracheal intubation with a ventilator to assist her respiration. The patient’s vital signs improved to an SpO2 of 100% and a heart rate (HR) of 139 bpm with regular blood pressure monitoring. For further diagnosis and treatment, the patient’s families contacted an ambulance and the patient was sent to the ED of Guangzhou Overseas Hospital.
Thirty-one hours after her operation, the patient arrived at the ED of Guangzhou Chinese Overseas Hospital. Physical examination revealed unconsciousness, bilateral round pupils of equal size with a diameter of 6 mm, no light reflex disappeared, 71/33 mmHg BP (with dopamine support), a HR of 133 bpm, and an SpO2 of 70% with endotracheal intubation to assist respiration. Doctors in the ER started her on dopamine to maintain blood pressure. She was then admitted to Guangzhou Chinese Overseas Hospital with the following diagnosis: “(1) Finding the cause of lower limb infection accompanied by soft tissue infection; (2) Infectious shock; (3) Postoperative status after bilateral lower limb liposuction.”
Physical examination after admission revealed that she had extensive ecchymoses on her abdomen, waist, buttock, perineum, and bilateral lower limbs with blood blisters (Fig. 1). Bloody exudates were observed in areas with skin damage. Her bilateral lower limbs were highly swollen, especially in the right lower limb, in which the skin tension was high with local crepitus. A weak carotid artery pulse was palpable, but her peripheral artery pulses were unpalpable. Both her pupils were round and of equal size at a diameter of 5.0 mm, but she had no light reflex. She had an HR of 143 bpm with regular rhythm. Muscle tone in her bilateral upper limbs was at level 2, but no limb movements were observed in her bilateral lower limbs. No pathological reflexes were observed.
Her blood panel showed High sensitivity C-reactive protein (HsCRP) at 197.23 mg/L, white blood cell (WBC) at 18.18 × 109/L, monocyte percentage (MONO%) at 1.3%, eosinophil percentage (EOS%) at 0.1%, neutrophil (NEU#) at 9.82 × 109/L, lymphocyte (LYM#) at 8.05 × 109/L, red blood cell (RBC) at 2.13 × 1012/L, hemoglobin (HGB) at 37 g/L, hematocrit (HCT) at 11.3%, mean corpuscular volume (MCV) at 53.2 fL, mean corpuscular hemoglobin (MCH) at 17.6 pg, and red blood cell distribution width (RDW-CV) at 33.2%. Her coagulation functions showed an activated partial thromboplastin times (APTTs) of 110.1 s, a prothrombin time (PT) of 45.8 s, an international normalized ratio (INR) of 4.84, a fibrinogen degradation product (FDP) of 43.72 μg/mL, and a d-dimer (DD) of 8600 ng/mL. Finally, her myocardial infarction examination showed a creatine kinase-MB (CK-MB) of 118.0 ng/mL, a high sensitivity troponin-1 (HSTNI) of 0.669 ng/mL, and a brain natriuretic peptide (BNP) of 35,000 pg/mL (Additional file 1).
The patient was unstable, had multiple organ dysfunction (MODS), was in a coma, and had weak spontaneous respiration. Her left pupil diameter was 6.0 mm while the right pupil diameter was 5.0 mm. The patient was intubated and was persistently hooked to a ventilator. She patient had circulatory failure and was therefore given high-dose noradrenaline (54 mg), high doses of intravenous blood products (RBC 11U, plasma 3000 mL, albumin 200 mL, and fibrinogen 2 g), volume expanders, and fluid replacement to rescue her symptoms. However, her BP still fluctuated greatly with the patient reaching critical condition.
At 2:00 pm on the day of admission, the patient underwent debridement surgery and vacuum drainage in the Orthopedics Department. During the operation, doctors found a large amount of subcutaneous, red, and foul-smelling effusion, which was sent for bacterial culture. Necrotic and devitalized fat tissues were removed. The infection was mostly located outside the muscle (Fig. 2). However, the patient’s BP still could not be lifted even after giving her multiple vasopressors in large doses.
At 6:40 pm on the day of admission, her BP dropped to 58/20 mmHg, HR dropped to 86 bpm, her left pupil diameter remained at 6.0 mm, and her right pupil diameter increased to 5.5 mm. She still had no light reflex, and there were large amounts of exudates in her wounds.
The patient was given a 500 mL dextran injection to expand her volume, adrenaline to increase BP, and intravenous RBC and plasma. At 7:00 pm, the patient’s BP rose to 72/23 mmHg with an HR of 100 bpm. Succinyl gelatin injection, dextran, and albumin were given to her for volume expansion. Despite these efforts, her BP continued to decrease. Bacterial examination revealed positive results for C. perfringens. According to the bacterial examination, the antibiotic regimen was adjusted to given imipenem and cilastatin sodium 1 g Q12h, penicillin 800 × 105iu Q8h and linezolid 600 mg Q12h.
At 8:28 pm,she still had no light reflex. What’s worse ,She no longer had palpable pulses, and her electrocardiograph monitoring showed a horizontal line. The patient had absence of spontaneous respiration and was declared to have clinical death.
The patient’s family agreed to have the patient undergo a postmortem examination. The recorded cause of death were as follows: (1) Extensive soft tissue infection (C. perfringens infection) and (2) Multiple organ dysfunction syndrome (DIC, kidney, liver, circulation, respiration, central nervous system). The recorded diagnosis of death were as follows: (1) Gas gangrene (C. perfringens infection), (2) Infectious shock, (3) Multiple organ dysfunction syndrome (DIC, kidney, liver, circulation, respiration, central nervous system), and (4) Postoperative liposuction in the bilateral lower limbs.