Acute post-surgical bilateral orbital gas-producing infection — a case report and literature review

Abstract

The presence of visible gas on radiography, computed tomography (CT), or magnetic resonance imaging (MRI) is associated with various pathological conditions, ranging from severe infections caused by gas-producing organisms to cutaneous and subcutaneous tissue disruption that allows an interface with the air [1]. A high index of suspicion surrounds the finding of gas because of the virulence of conditions such as gas gangrene and necrotizing fasciitis [1–12]. Gas dissecting into the orbital soft tissues as a result of bacterial activity is a rapidly progressive, extremely serious, life-threatening ophthalmological emergency [1–12]. Gas gangrene (myonecrosis) and necrotizing fasciitis can cause necrosis of tissues and systemic shock with multiorgan failure, sometimes within a matter of hours [1–3, 13]. It is well known that the usual causative organisms in gas-producing infection from a contaminated wound are clostridial species: Clostridium perfringens accounts for the majority of cases (over 80 %), while most other cases are caused by other Clostridium species [1–3]. Clostridial infection is always associated with necrosis, and very often associated with poor functional and anatomical outcome [1–4]. However, a variety of other non-clostridial organisms, both aerobes and anaerobes, may also produce infections in which gas is demonstrable: Escherichia coli, Proteus species, Pseudomonas aeruginosa, Bacteroides, Klebsiela pneumoniae, Prevotella species, Staphylococcus aureus, Peptostreptococcus species, Fusobacterium species, and Streptococcus pyogenes are only the species reported most often in the literature [2]. Non-clostridial infections may take various forms, which lead to difficulties in making accurate and prompt diagnoses and are also related to the confusion between gas gangrene and various (bacterial and nonbacterial) lesions that simulate gas gangrene. Aside from the fact that non-clostridial organisms usually involve subcutaneous tissues, they may also involve muscle and simulate clostridial myonecrosis [2, 3]. However, non-clostridial gas infections accompanied by gangrene are not very common, even in immunosuppressed individuals [2, 3]. Since the initial report by Chiari (1893), which concerned a non-clostridial gas-forming infection due to a colon bacillus in the gangrenous lower limb of a diabetic patient [4], fewer than 40 cases of non-clostridial gas-forming infections have been described. Only four such cases have been described in the orbit [5–7, 12], and these are quite different from the present case. With regard to the pathogenesis of gas bubbles of clostridial or non-clostridial etiology, they are liberated by the bacterial fermentation of glucose [4]. In addition, impaired microcirculation may also contribute to gas formation [3, 4]. It is also necessary to mention the benign, non-infectious presence of gas in the orbit, which is known as orbital emphysema. Orbital emphysema is a well-known entity that can arise from nose-blowing, tumor presentation, or after fractures of the orbital floor, and may be self-induced in psychiatric patients [15]. There are no research contracts or any kind of financial support (grants) for this study. No authors have any conflicts of interest.