Primary abdominal gas gangrene: a report of two autopsy cases

Primary hepatic gas gangrene is a form of primary abdominal gas gangrene. The condition is caused by Clostridium perfringens, other clostridia, and non-clostridia bacterial species producing gas. Unlike classical gas gangrene or myonecrosis, the disease develops without a wound or a port of entry. Instead, gas-producing bacteria in the gastrointestinal tract colonize an underlying pathological process with foci of necrosis, producing excessive gas and spreading hematogenously to other organs. Herein we present two autopsy cases of primary hepatic gas gangrene diagnosed on autopsy, with the gross and histological changes that can be considered specific for this rare condition. Both patients had severe underlying liver disease-prone for this entity development. The gross changes in the cases are postmortem subcutaneous emphysema, skin bullae with pooled blood, pneumothorax, pneumoabdomen, abundant gas in the circulatory system, porous structure of the internal organs (tissue gas bubbles), and advanced tissue lysis, not corresponding to the post mortem time. Histology showed optically empty areas of varying size in the internal organs, which weave the structure of the organs and rod-shaped bacteria with scarcity or complete absence of inflammatory reaction.

Clostridium perfringens α and ß recombinant toxoids in equine immunization / Toxóides recombinantes α e ß de Clostridium perfringens na imunização de equinos

Clostridium perfringens is considered one of the main causative agents of superacute enterocolitis, usually fatal in the equine species, due to the action of the ß toxin, and is responsible for causing severe myonecrosis, by the action of the α toxin. The great importance of this agent in the equine economy is due to high mortality and lack of vaccines, which are the main form of prevention, which guarantee the immunization of this animal species. The aim of this study was to evaluate three different concentrations (100, 200 and 400µg) of C. perfringens α and ß recombinant toxoids in equine immunization and to compare with a group vaccinated with a commercial toxoid. The commercial vaccine was not able to stimulate an immune response and the recombinant vaccine was able to induce satisfactory humoral immune response in vaccinated horses, proving to be an alternative prophylactic for C. perfringens infection.(AU)

Clostridium perfringens é considerado um dos principais agentes causadores de enterocolites superagudas, geralmente fatais na espécie equina, devido à ação da toxina ß, além de ser responsável por causar quadros graves de mionecrose, pela ação da toxina α. A grande importância desses agentes na equinocultura, deve-se a elevada mortalidade e a inexistência de vacinas, principal forma de prevenção, que garantam a imunização dessa espécie animal. O objetivo deste trabalho foi avaliar três diferentes concentrações (100, 200 e 400µg) dos toxóides recombinantes α e ß de C. perfringens na imunização de equinos, bem como comparar com um grupo vacinado com um toxóide comercial. A vacina comercial não se mostrou capaz de estimular uma resposta imune e a vacina recombinante foi capaz de induzir resposta imune humoral satisfatória em equinos vacinados, provando ser uma alternativa profilática para infecção por C. Perfringens.(AU)

Clostridial diseases diagnosed in cattle from the South of Rio Grande do Sul, Brazil. A forty-year survey (1978-2018) and a brief review of the literature / Clostridioses diagnosticadas em bovinos no sul do Rio Grande do Sul. Uma pesquisa de quarenta anos (1978-2018) e breve revisão da literatura

Clostridial diseases are important causes of livestock losses in the southern Rio Grande do Sul. Since 1978 annual surveys conducted at the "Laboratório Regional de Diagnóstico" of the "Universidade Federal de Pelotas" (LRD-UFPel) have shown that clostridial diseases represent 10.40% of the bacterial diseases diagnosed in cattle and 1.65% of all diseases diagnosis in cattle over a 40-year period. The purpose of this study is to review the clinical, epidemiological and pathological aspects of the clostridial diseases diagnosed in cattle from January 1978 to December 2018 at the LRD-UFPel in the hopes that it will constitute a useful guide for field veterinary practitioners and interested farmers. We assessed and review the necropsy protocols of 6,736 cattle; these necropsies were performed either by LRD-UFPel faculty or by field veterinary practitioners; 111 outbreaks (1.65%) were diagnosed as clostridial disease, distributed as follows: 35 outbreaks of tetanus, 34 of blackleg, 23 of bacillary hemoglobinuria, 11 of malignant edema (gas gangrene), and eight of botulism. Approximately 904, from a total of 42,480 cattle at risk, died in these outbreaks.(AU)

Clostridioses são doenças produzidas por alguma das espécies do gênero Clostridium e são importantes causas de perdas pecuárias no sul do Rio Grande do Sul. Pesquisas anuais realizadas no Laboratório Regional de Diagnóstico da Faculdade de Veterinária da Universidade Federal de Pelotas (LRD-UFPel) desde 1978 demonstraram que as clostridioses representaram 11,1% das doenças bacterianas diagnosticadas em bovinos e 1,65% de todos os diagnósticos de doenças em bovinos ao longo de 40 anos. O objetivo deste estudo é revisar os aspectos clínicos, epidemiológicos e patológicos das clostridioses diagnosticadas de janeiro de 1978 a dezembro de 2018, pelo LRD/UFPel com a intenção de que esse trabalho possa servir de guia útil para os veterinários de campo e fazendeiros interessados. Foram avaliados e revisados os protocolos de necropsia de 6.736 bovinos; essas necropsias foram realizadas pelo pessoal do LRD/UFPel ou por veterinários de campo. Cento e quatro (1,16%) casos foram diagnosticados como clostridioses, distribuídos da seguinte forma: 35 surtos de tétano, 34 de carbúnculo sintomático, 23 de hemoglobinúria bacilar, 11 de edema maligno (gangrena gasosa) e oito de botulismo. Aproximadamente 904, de um total de 42.480 bovinos sob-risco, morreram nesses surtos.(AU)

Infección mortal por Clostridium perfringens con hemólisis tras quimioterapia en un adolescente / A fatal Clostridium perfringens infection with hemolysis after chemotherapy in an adolescent

La gangrena gaseosa, o mionecrosis clostridial, es una de las enfermedades infecciosas más graves, y se caracteriza por la rápida y progresiva destrucción de los tejidos blandos profundos y la producción de gas dentro de los tejidos. Presentamos un caso de gangrena gaseosa espontánea mortal causada por Clostridium perfringens en un paciente con leucemia linfocítica aguda durante la fase de quimioterapia de inducción de la remisión.

Gas gangrene, clostridial myonecrosis, is one of the most serious infectious diseases, characterized by rapidly progressive destruction of deep soft tissues and production of gas within the tissues. We presented a case of fatal spontaneous gas gangrene due to Clostridium perfringens in a patient with acute lymphoblastic leukemia during remission induction chemotherapy phase.

Gangrena gaseosa / Gangrène gazeuse / Gas gangrene

Se presenta un paciente masculino de 29 años, mestizo, recluso, quien 7 días antes de haber sido remitido al servicio de urgencias del Hospital Universitario Amalia Simoni se había inoculado, en autoagresión, heces fecales en la pierna y el muslo derechos. Refirió dolor y presentaba gran toma del estado general. A la exploración física se constató aumento de volumen generalizado del miembro inferior derecho, con zonas de eritema marcado que alternaban con áreas de necrosis que incluso afectaban el abdomen bajo, aumento de la temperatura local; a la palpación, dolor intenso con amplia zona de crepitación subcutánea, además de bulas de contenido serohemático, pútrido, de olor fétido. La radiografía reveló aumento marcado de la opacidad de las partes blandas, bandas de gas a nivel del tejido celular subcutáneo y presencia de numerosas bulas sin toma ósea. Se decidió tratamiento quirúrgico multidisciplinario que incluyó la desarticulación en guillotina del miembro inferior derecho a nivel de la cadera y toilette amplia, medidas de soporte vital, y la combinación de clindamicina, vancomicina y meronem. La gangrena gaseosa es una infección fulminante de los tejidos blandos con una mortalidad elevada; la sospecha diagnóstica y el entendimiento de la fisiopatología mejoran el pronóstico. El soporte vital, el equilibrio del medio interno, el uso de antimicrobianos de amplio espectro y un tratamiento quirúrgico agresivo, disminuyen la mortalidad(AU)

A case of a 29-year convict mestizo male patient is presented here. This patient is referred to the emergency department of Traumatology at Amalia Simoni University Hospital, seven days after having self-inoculated with stool in his right leg and thigh as self-harm. The patient complained of pain and his general was very poor. Physical examination revealed generalized increase in volume of the right lower limb, with marked erythema areas alternating with areas of necrosis that were even affecting the lower abdomen; increased local temperature, tenderness, pain with subcutaneous crepitus in wide area were found, as well as bulls serohematic bulls, putrid, foul-smelling. Radiography reveals marked increase in opacity of the soft tissues, bands of gas at the level of subcutaneous tissue and the presence of numerous bulls without bone involvement. Multidisciplinary surgical treatment was decided including the guillotine disarticulation of the right leg to hip level and wide toilette, life support, and the combination of clindamycin, vancomycin, and meronem. Gas gangrene is a fulminant soft tissue infection with high mortality; the suspected diagnosis and understanding of the pathophysiology improve prognosis. Life support, balance the internal environment, the use of broad-spectrum antimicrobials and aggressive surgical treatment, reduce mortality(AU)

Un patient âgé de 29 ans, métis, reclus, référé au service d'urgences à l'hôpital universitaire "Amalia Simoni" dû à une automutilation (inoculation de selle dans la jambe et la cuisse droites), est présenté. Il a exprimé une douleur et une sensation de mal-être. Dans l'examen physique, on a pu constater une inflammation du membre inférieur droit; des zones érythémateuses très marquées alternant avec des zones nécrosées, même arrivant à l'abdomen bas; une augmentation de la température locale; une douleur violente avec une zone de crépitements à la palpation, et des bulles à contenu séro-hématique, putréfié et fétide. La radiographie a révélé une augmentation significative de l'opacité des parties molles, des bandes gazeuses au niveau du tissu cellulaire sous-cutané, et une présence de nombreuses bulles sans prise osseuse. On a décidé un traitement chirurgical pluridisciplinaire consistant à une désarticulation en guillotine du membre inférieur droit au niveau de la hanche et un curettage profond; des soins intensifs, et une combinaison de clindamycine, vancomycine et méropénème. La gangrène gazeuse est une infection fulminante des tissus mous avec un taux de mortalité très haut. Le diagnostic suspecté et la compréhension de la physiopathologie améliorent le pronostic. Les soins intensifs, l'équilibre du milieu intérieur, l'emploi d'antimicrobiens à large spectre et un traitement chirurgical agressif font réduire le taux de mortalité(AU)

Gas Gangrene Caused by Streptococcus anginosus / 대한내과학회지

Gas gangrene, a subset of necrotizing myositis, is a bacterial infection that produces gas in tissues in gangrene. It is usually caused by Clostridium species, most commonly Clostridium perfringens. Streptococcus anginosus is a rare cause of gas gangrene, with very few cases reported. We report a rare case of traumatic gas gangrene caused by S. anginosus in a 57-year-old female with diabetes after being stabbed with scissors.

Novel application of vacuum sealing drainage with continuous irrigation of potassium permanganate for managing infective wounds of gas gangrene / 华中科技大学学报（医学）（英德文版）

Traumatic gas gangrene is a fatal infection mainly caused by Clostridium perfringens. It is a challenge to manage gas gangrene in open wounds and control infection after debridement or amputation. The aim of the present study was to use vacuum sealing drainage (VSD) with continuous irrigation of potassium permanganate to manage infective wounds of gas gangrene and observe its clinical efficacy. A total of 48 patients with open traumatic gas gangrene infection were included in this study. Amputations were done for 27 patients, and limb salvage procedures were performed for the others. After amputation or aggressive debridement, the VSD system, including polyvinyl alcohol (PVA) foam dressing and polyurethane (PU) film, with continuous irrigation of 1:5000 potassium permanganate solutions, was applied to the wounds. During the follow-up, all the patients healed without recurrence within 8-18 months. There were four complications. Cardiac arrest during amputation surgery occurred in one patient who suffered from severe septic shock. Emergent resuscitation was performed and the patient returned to stable condition. One patient suffered from mixed infection of Staphylococcal aureus, and a second-stage debridement was performed. One patient suffered from severe pain of the limb after the debridement. Exploratory operation was done and the possible reason was trauma of a local peripheral nerve. Three cases of crush syndrome had dialysis treatment for concomitant renal failure. In conclusion, VSD can convert open wound to closed wound, and evacuate necrotic tissues. Furthermore, potassium permanganate solutions help eliminate anaerobic microenvironment and achieve good therapeutic effect on gas gangrene and mixed infection. VSD with continuous irrigation of potassium permanganate is a novel, simple and feasible alternative for severe traumatic open wounds with gas gangrene infection.

A Fatal Spontaneous Gas Gangrene due to Clostridium perfringens during Neutropenia of Allogeneic Stem Cell Transplantation: Case Report and Literature Review

Most cases of gas gangrene caused by Clostridium species begin with trauma-related injuries but in rare cases, spontaneous gas gangrene (SGG) can occur when patients have conditions such as advanced malignancy, diabetes, or immunosuppression. Clostridium perfringens, a rare cause of SGG, exists as normal flora of skin and intestines of human. Adequate antibiotics with surgical debridement of infected tissue is the only curative therapeutic management. Mortality rate among adults is reported range of 67-100% and majority of deaths are occurred within 24 hours of onset. We experienced a case of SGG on the trunk, buttock and thigh in a neutropenic patient with acute lymphoblastic leukemia. His clinical course was rapid and fatal during pre-engraftment neutropenic period of allogeneic stem cell transplantation.

Infecção fulminante por Clostridium septicum: relato de caso / Fulminant Clostridium septicum infection: case report

As infecções de tecidos moles causadas por espécies de Clostridium têm sido descritos na literatura por centenas de anos. A gangrena gasosa por Clostridium continua sendo uma importante causa de morbidade e mortalidade no mundo. O objetivo deste estudo foi relatar um caso de paciente com diagnóstico de síndrome mielodisplásica, submetida à curetagem uterina e evoluindo com gangrena gasosa espontânea, 10 horas após a cirurgia.Paciente do sexo feminino, 26 anos, com história de dor em terço distal de membros inferiores, irradiando para região de fossa poplítea, com piora à palpação e movimentação dos membros, acompanhada de aumento da temperatura e volume local. Negava febre, hiperemia ou trauma local, evoluindo para choque séptico. Angiotomografia das extremidades e pelve revelou a presença de gás permeando os feixes musculares da coxa e da perna, bilateralmente. A combinação da história e exame clínico,ao estudo radiológico confirmou o diagnóstico sindrômico de gangrena gasosa espontânea. Apesar de elevado índice de suspeição melhorar os resultados clínicos, tais infecções progridem tão rapidamente que o óbito pode preceder o diagnóstico,não obstante, o reconhecimento precoce e tratamento agressivo,incluindo drenagem aberta ou percutânea. Antibióticos parenterais contra Clostrídios devem ser prontamente iniciados, bem como medidas de suporte clínico.

The soft tissue infections caused by Clostridium species have been described in the literature for hundreds of years. The gas gangrene due to Clostridium remains an important cause of morbidity and mortality worldwide. The aim of this study was to report a patient diagnosed with myelodysplastic syndrome who underwent curettage, evolving with spontaneous gas gangrene, 10 hours after surgery. Female patient, 26 years, with pain in the distal third of the lower limbs, radiating to the popliteal fossa region, which worsened on palpation and movement of limbs, and accompanied by an increase in temperature and local volume. She denied fever, redness or local trauma, and progressed to septic shock. Angiotomography of the extremities and pelvis revealed the presence of gas permeating the muscle bundles of the thigh and leg bilaterally. The combination of history and clinical examination and radiological examination confirmed the syndromic diagnosis of Spontaneous Gas Gangrene. Although a high index of suspicion may improve clinical outcomes, such infections progress so rapidly that death usually precedes the diagnosis. However, early recognition and aggressive treatment, including open or percutaneous drainage and parenteral antibiotics against Clostridia should be promptly initiated, along with clinical support.

Gangrena gaseosa de la mama / Gas gangrene of the breast

La gangrena gaseosa de la mama es una enfermedad rara y potencialmente mortal descrita como consecuencia de un traumatismo, por complicaciones infecciosas de la cirugía o por una trombosis venosa. También se ha relacionado ocasionalmente con otras causas tales como la diabetes mellitus, el envenenamiento con monóxido de carbono o la cirugía plástica. Presentamos un caso de gangrena gaseosa de mama en una mujer diabética de 74 años. Esta rara infección representa una emergencia médico-quirúrgica(AU)

Gas gangrene of the breast is a rare and potentially lethal disease following trauma, as a result of infectious complications from surgery or venous thrombosis. Other rare etiologies, such as diabetes mellitus, carbon monoxide poisoning, and plastic surgery, have also been reported as related to this illness. A case of gas gangrene of the breast found in a 74-year-old diabetic woman was presented in this paper. This rare infection is a medical and surgical emergency situation(AU)

Subcutaneous Emphysema of Lower Extremity after Knee Arthroscopy / 대한정형외과학회잡지

Subcutaneous emphysema of lower extremity is a rare disease entity. Crepitation and swelling on physical examination and gas on radiographs raise the concern of infection due to the presence of gas gangrene forming organisms. Therefore, delay of diagnosis and appropriate management can be a major predisposing factor for sepsis and further associated high mortality. We experienced a rare case of subcutaneous emphysema of the right lower extremity after knee arthroscopy; life-threatening infection was ruled out by physical examination and laboratory testing. The patient recovered uneventfully with conservative management. Therefore, we report on this case with a review of current literature.

Comprehensive treatment for gas gangrene of the limbs in earthquakes / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Mortality rates for patients with gas gangrene from trauma or surgery are as high as 25%, but they increase to 50%-80% for patients injured in natural hazards. Early diagnosis and treatment are essential for these patients.</p><p><b>METHODS</b>We retrospectively analyzed the clinical characteristics and therapeutic results of 19 patients with gas gangrene of the limbs, who were injured in the May 2008 earthquake in the Wenchuan district of China's Sichuan province and treated in our hospital, to seek how to best diagnose and treat earthquake-induced gas gangrene.</p><p><b>RESULTS</b>Of 226 patients with limbs open injuries sustained during the earthquake, 53 patients underwent smear analysis of wound exudates and gas gangrene was diagnosed in 19 patients. The average elapsed time from injury to arrival at the hospital was 72 hours, from injury to definitive diagnosis was 4.3 days, and from diagnosis to conversion of negative findings on wound smear analysis to positive findings was 12.7 days. Anaerobic cultures were also obtained before wound closure. The average elapsed time from completion of surgery to recovery of normal vital signs was 6.3 days. Of the 19 patients, 16 were treated with open amputation, two with closed amputation, and 1 with successful limb salvage; 18 patients were successfully treated and one died.</p><p><b>CONCLUSIONS</b>In earthquakes, rapid, accurate screening and isolation are essential to successful treatment of gas gangrene and helpful in preventing nosocomial diffusion. Early and thorough debridement, open amputation, and active supportive treatment can produce satisfactory therapeutic results.</p>

Mionecrosis por clostridio: una enfermedad de todos los tiempos / Mionecrosis due to clostridium: a disease of all times

Se realizó una revisión bibliográfica exhaustiva sobre la gangrena gaseosa, con el fin de profundizar en los principales aspectos fisiopatológicos, microbiológicos, clínicos, de diagnóstico y terapéuticos de la mionecrosis por clostridio, dadas su prevalencia e incidencia elevadas, tanto en tiempos de paz como de guerra. Se ofrecen las consideraciones actuales sobre la evaluación de las principales complicaciones y cómo proceder para eliminarlas

A detailed literature survey on the gas phlegmone was carried out, aiming at deepening in the main pathophysiological, microbiological, clinical, diagnostic and therapeutical aspects of the mionecrosis due to clostridium, given its high prevalence and incidence either in peace times or in war times. The current considerations on the evaluation of the main complications and what to do to eliminate them are given

Endogenous gas gangrene after laparoscopic cholecystectomy / Gangrena Gaseosa endógena tras la colecistectomía laparoscópica

Clostridial gas gangrene of the abdominal wall is rare, and it is usually associated with organ perforation, immunosuppression or gastrointestinal malignancies. In this paper, we present a case of fulminant, endogenous gas gangrene in a 58-year old diabetic female with arterial hypertension and atherosclerosis, following uneventful laparoscopic cholecystectomy. She developed gas gangrene of the abdominal wall 12-hours after cholecystectomy and died 24-hours after the onset of the first symptoms, in spite oftreatment.

La gangrena gaseosa clostridial de la pared abdominal es rara, y normalmente se halla asociada con la perforación de órganos, inmunosupresión o malignidades gastrointestinales. En este trabajo, se presenta un caso de gangrena gaseosa endógena fulminante en una mujer diabética de 58 años con hipertensión arterial y ateroesclerosis, tras una colecistectomía laparoscópica sin incidentes. Doce horas después de la colecistectomía, la mujer desarrolló una gangrena gaseosa de la pared abdominal, y murió 24 horas después del comienzo de los primeros síntomas, a pesar del tratamiento.

[Necrotizing fascitis in a 47-year old diabetic man: case report]

Necrotizing fasciitis is one of the rare complications of misdiagnosed appendicitis with the mortality rate of over 25%.We report a 47-year old diabetic man admitted with necrotizing fasciitis of flank and abdominal wall secondary to acute appendicitis. The patient, with primary diagnosis of gas gangrene and necrotizing fasciitis, underwent surgical operation and after 3 months, elective appendectomy was performed. After that, he was discharged in good conditions

A brain abscess caused by Porphyromonas gingivalis / 대한내과학회지

Porphyromonas gingivalis is a gram-negative, anaerobic, rod-shaped bacterium originally classified within the Bacteroides genus, and a major etiological agent in the initiation and progression of severe periodontal disease. P. gingivalis has occasionally been involved in otitis media, lung abscesses, gas gangrene, appendicitis, sinusitis, paranasal mucocele, peri-tonsillar abscesses, pleura-pulmonary infections, and thoracic empyema. We report the case of a 44-year-old male who presented with a brain abscess in which the organism, presumably originated from his poor dentition. He was successfully treated with surgical drainage and antibiotics.

A brain abscess caused by Porphyromonas gingivalis / 대한내과학회지

Porphyromonas gingivalis is a gram-negative, anaerobic, rod-shaped bacterium originally classified within the Bacteroides genus, and a major etiological agent in the initiation and progression of severe periodontal disease. P. gingivalis has occasionally been involved in otitis media, lung abscesses, gas gangrene, appendicitis, sinusitis, paranasal mucocele, peri-tonsillar abscesses, pleura-pulmonary infections, and thoracic empyema. We report the case of a 44-year-old male who presented with a brain abscess in which the organism, presumably originated from his poor dentition. He was successfully treated with surgical drainage and antibiotics.

Cardiac arrest that developed during anesthetic induction in a patient with abdominal gas gangrene: A case report / 대한마취과학회지

We report here on a fatal case of abdominal gas gangrene. Two days after gastrectomy, a 56-year-old man presented with intractable abdominal pain and fever of a sudden onset, which quickly progressed over several hours to septic shock. Despite of the unexplained gas collections in the abdominal muscle, fascia, and subcutaneous layers on computed tomography scan, its clinical significance was overlooked. Emergency laparotomy was initially scheduled because of concern that there may have been a perforated viscus. At the time of monitoring for the anesthesia, we noticed marbled skin discoloration and the subcutaneous emphysema had spread on his flank. Shortly after the initial suspicion of gas gangrene, cardiac arrest developed during the arterial line cannulation. Despite prompt resuscitation measures, including the administration of catecholamines and the application of extracoporeal membrane oxygenation, he eventually died. Anesthesiologists need to understand this fulminant disease because extensive debridement under general anesthesia is essential for the treatment of abdominal gas gangrene.

Deep Infection Caused by Gas-Forming Bacteria after Total Hip Arthroplasty

A deep infection after total hip arthroplasty is a very severe complication that occurs in about 1~2% of the patients. The major cause of this infection is Staphylococcus aureus in the early stage and Staphylococcus epidermidis in the late stage A nontraumatic gas-forming infection is rare and difficult to diagnose because of its slower clinical course than that of gas gangrene. Therefore, it has a high mortality rate due to delayed treatment. There have been no reports on gas-forming infection by Escherichia coli after total hip arthroplasty. We report here on a patient who was treated by open arthrotomy and the patient expired due to a Escherichia coli, gas-forming infection after undergoing total hip arthroplasty.

A case of gas gangrene caused by Streptococcus constellatus / 대한내과학회지

Gas gangrene is usually caused by clostridial species; non-clostridial gas gangrene is infrequently reported. S. constellatus belongs to the Streptococcus milleri group, which are considered part of the normal flora and frequently associated with abscess formation. We report a rare case of spontaneous gas gangrene caused by S. constellatus. An 86-year-old man was admitted with gas gangrene of the left hip. He was treated with surgical debridement of the necrotic tissue, and antibiotic therapy, and had a satisfactory clinical course.