Anaerobic infections by exotoxin-producing Clostridium perfringens are rare [1]. Due to systemic progression of the infection gas gangrene still remains life-threatening when detected late. We report on three cases of necrotizing soft tissue infections (NSTI). The first two patients suffering from NSTI were admitted to our hospital with different provisional diagnoses, one with compartment syndrome, the second with appendicitis. Despite immediate treatment both patients died within 24 hours after admittance to our hospital. The third patient was free of NSTI, although evincing all typical symptoms of gas gangrene.

Clostridium perfringens is an aerotolerant spore-forming, gram-positive bacterium found in soil and the intestinal tract of humans and other vertebrates [2, 3]. Proliferation of Clostridium perfringens requires changing normal environmental conditions to an anaerobic milieu. Such conditions can be caused by earlier widespread destruction of soft tissue, yet clostridial gas gangrene can also be found without a prior trauma [4]. Different risk factors, e.g. diabetes, malignancy, immunodeficiency and vascular diseases are known. Due to the growing number of diabetics and the elderly, NSTI, especially in absence of trauma, may become more important in the future.

All three patients suffered from at least one risk factor, none of them remembering a recent trauma. However, possible entry points for bacteria can be identified in patient one and three. In case one and two NSTI should have been considered as a differential diagnosis from the beginning. Due to the association of NSTI with large and contaminated wounds, the wrong diagnosis was made initially. As surgical sanitation of the infection is essential in NSTI, early diagnosis is the most important factor for survival [5].

A review of the English literature by Lanting et al. revealed three cases of spontaneous gas gangrene of the shoulder [6]. The primary diseases in these cases were diabetes with peptic ulcer disease, diabetes and ischemic heart disease and radiation colitis [7–9]. A strong relation between gastrointestinal malignancies and NSTI was shown by Kornbluth et al. [10], therefore colonoscopy is recommended for all patients with spontaneous clostridium infection [11].

The third case demonstrates the necessity of comparing radiological, clinical and intraoperative findings. According to literature, 79.2% of the patients with NSTI were in shock and all patients were suffering from enormous pain at the wound site [12]. Patients with a white blood-cell-count ≤ 15.400/μl have only a 1% chance of developing NSTI [13]. The number of white blood-cells in the third patient was slightly increased; no pain or signs of shock could be observed. In order to be able to inspect the muscle tissue, we decided on surgical treatment. After incision, muscle tissue could be observed and a biopsy was taken. Due to microbiological findings clostridial infection could be excluded. Detection of free gas in the tissue is not an indisputable indicator for bacterial infection. Therefore, a precise comparison between clinical and radiological findings is required before a decision on radical surgical treatment is made. Through fasciotomy a sufficient wound control in the first days after admission was possible.

In patients suffering from NSTI, early diagnosis is essential for sufficient treatment and survival [14]. Although NSTI is well known, it was not considered in the first two cases due to absence of trauma. Despite all efforts, both patients died because surgical resection of the necrotic tissue was not possible. Nether less, free gas in the tissue and crepitus are not necessarily caused by NSTI and the diagnosis is not always straightforward [15].

Written consent for publication was obtained from the relatives in case 1 and 2 and from the patient in case 3