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 Table of Contents  
Year : 2022  |  Volume : 2  |  Issue : 2  |  Page : 540-542

Sino-orbital gas gangrene – A guest unknown

Department of Ophthalmology, Grant Government Medical College and Sir JJ Group of Hospitals, Mumbai, Maharashtra, India

Date of Submission27-Sep-2021
Date of Acceptance10-Jan-2022
Date of Web Publication13-Apr-2022

Correspondence Address:
Sumeet Lahane
JJ Hospital, Byculla, Mumbai 400 008, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_2514_21

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Orbital cellulitis is a dreaded entity that can lead to an array of complications from visual loss to cavernous sinus involvement. Paranasal sinus (PNS) infection and trauma are the most common etiology. We report a case series of three patients who were victims of landslide and developed orbital cellulitis. Facial edema, proptosis, central retinal artery occlusion and hyperdense foci in the orbit, and PNS with proven growth of Clostridium perfringes were the common features in all these patients. Natural calamity leading to this fulminant infection led to mortality of all three patients. This is the first case series of sino-orbital gas gangrene in victims of heavy rainfall causing landslide.

Keywords: Case Series, central retinal artery occlusion, Clostridium perfringes, orbital gas gangrene

How to cite this article:
Lahane S, Gujar T, Vaishya A, Prajapati D, Dembla S, Parekh R, Lahane T. Sino-orbital gas gangrene – A guest unknown. Indian J Ophthalmol Case Rep 2022;2:540-2

How to cite this URL:
Lahane S, Gujar T, Vaishya A, Prajapati D, Dembla S, Parekh R, Lahane T. Sino-orbital gas gangrene – A guest unknown. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 May 24];2:540-2. Available from: https://www.ijoreports.in/text.asp?2022/2/2/540/342959

Clostridium perfringes gas gangrene is a dreaded infection that is usually seen in deep contaminated wounds. It is a gram-positive organism, which is an obligate anaerobe found in soil and bowel flora. It may result in death due to the effects of potent exotoxins like lecithinase, phospholipase, neuraminidase, collagenase, and DNAase.[1] It is a highly lethal infection of bone and soft tissue and is synonymous with myonecrosis, characterized by rapidly progressive gangrene of the injured tissue along with the production of foul-smelling gas and characteristic crepitus.[2]

Orbital infection due to clostridia is scarcely reported. Single case reports of C. perfringes endophthalmitis, panophthalmitis, and orbital involvement post-trauma have been documented. Our encounter with these three patients of gas gangrene victims of landslide injury showed the fulminant course of infection which caused rapid loss of vision and eventually led to death despite all measures taken to contain the infection.

  Case Reports Top

A 25-year-old male (Case 1) and a 41-year-old female (Case 2) and her 21-year-old daughter (Case 3) were brought to casualty along with 16 patients as victims of landslide due to heavy rains.

Case 1

A 25-year-old male presented with bilateral lower limb multiple exposed fractures with foul-smelling pus discharge and subcutaneous crepitus suggestive of gas gangrene, for which he underwent bilateral lower limb above-knee amputation. He was started on benzylpenicillin G, clindamycin, and amikacin and confirmed on culture with microbiology as gram-positive anaerobic bacilli suggestive of Clostridium species. There was no evidence of fungal growth in culture. He was referred for ophthalmic opinion on postoperative day 4 with complaints of facial edema and difficulty in eye opening. On examination, he had no perception of light in the left eye (LE) with proptosis, chemosis, total ophthalmoplegia, semi-dilated pupil with central retinal artery occlusion (CRAO) and normal right eye (RE) [Figure 1]a. There was no obvious crepitus felt on palpation. There was no facial wound noted from the primary injury. Computed tomography (CT) scan of brain, orbit, and paranasal sinus (PNS) was normal on day 1 of hospital admission [Figure 1]b. Repeat CT on day 5 showed dramatic changes as air fluid levels in maxilla, calcific foci (600–800 HU) in sinuses, and near-complete opacification of sphenoid sinus with adjacent bony walls suggestive of demineralization. Extraconal fat stranding along with air foci suggestive of orbital cellulitis and pneumo-orbit was also seen [Figure 1]c. He underwent immediate debridement of PNS, which confirmed Clostridium infection of sino-orbital region. Despite aggressive management, he succumbed to septicemia and multiorgan involvement.
Figure 1: (a) Clinical picture of patient Case 1 showing facial edema with LE orbital cellulitis, severe chemosis, ecchymosis, and dilated pupil. (b) Day of admission CT scan of same patient, which is within normal limits. (c) CT of same patient on day 5 showing heterogenous dense opacification of bilateral maxillary sinus and pneumo orbit. CT = computed tomography, LE = left eye

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Case 2

A 41-year-old female presented with fracture of right lower and left upper limb, for which she underwent primary repair. On postoperative day 4, ophthalmic reference was done in view of facial and orbital edema. She had no perception of light in LE with orbital cellulitis and complete ophthalmoplegia [Figure 2]a. CRAO was noted on fundus examination of LE, while RE was normal. Her CT scan features were on similar lines as case 1, as she had normal brain–orbit CT scan on day 1 of admission and day 5 CT, suggestive of bilateral maxillary sinus and LE orbital involvement [Figure 2]b, [Figure 2]c. She underwent sinus debridement and intensive care admission. In contrary to case 1, she initially was not diagnosed as a case of gas gangrene and received benzylpenicillin infusion systemically after confirmation of gram-positive bacilli post sinus surgery. Sequalae of rapid development of gangrene and septicemia led to her death.
Figure 2: (a) Clinical picture of patient Case 2 showing LE orbital cellulitis and complete ophthalmoplegia. (b) Day of admission CT scan of the same patient, which is within normal limits. (c) CT of the same patient on day 5 showing heterogenous dense opacification of left maxillary sinus. CT = computed tomography, LE = left eye

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Case 3

A 21-year-old female (daughter of case 2) presented with bilateral lower limb injury and was operated for debridement on day 1 of hospital admission. She followed similar course as case 2 and developed orbital symptoms on day 4. She survived longest among the three patients and died on day 25 due to septicemia and lower limb gangrene [Figure 3]a,[Figure 3]b,[Figure 3]c.
Figure 3: (a) Clinical picture of patient Case 3 showing facial edema with LE orbital cellulitis and ecchymosis. (b) Day of admission CT scan of the same patient, which is within normal limits. (c) CT of the same patient on day 5 showing heterogenous dense opacification of sinuses and pneumo orbit. CT = computed tomography, LE = left eye

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  Discussion Top

Clostridium myonecrosis or gas gangrene is a fulminant and swiftly spreading lethal infection, typically manifesting with foul-smelling gas and crepitus at sites of traumatic or surgical wounds, with limbs being the most common site.[3]

Bhargava et al.,[4] in their review, mentioned 61 cases of ophthalmic gas gangrene with the common feature of etiology being penetrating trauma and the outcome being loss of eye or vision. Leavelle et al. postulated about ophthalmic gas gangrene as infection post globe perforation with loss of vision, evisceration or enucleation, and uneventful recovery post-surgery.[11]

Very few cases of ocular gas gangrene conclud in eye salvage, Crock et al reported one such case of uniocular visual improvement.[1] Abu el Asrar et al.,[8] Wiles et al.[9] reported vision salvage post vitrectomy in case of gas gangrene endophthalmitis. Our case series had orbital involvement rather than intraocular infection, which, as described by Rosenblum et al.,[5] is a case of sinus gas gangrene with radiological features of sinus opacification and calcification, with bone demineralization.

In our case series, all three patients developed orbital cellulitis with sudden onset visual loss, which on fundoscopic finding was due to CRAO [Table 1]. Cannistra et al.[6] noted CRAO in a case of endogenous clostridial bacteremia, which they hypothesized was because of clostridial seeding with exotoxins leading to vessels' thrombosis. The pathogenesis behind this phenomenon can be explained by the action of phospholipase-C–induced activation of gpIIbIIIa, which mediates vascular occlusion and myonecrosis in clostridial gas gangrene.[7]
Table 1: Clinical and radiological description of cases

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In addition, we also noted that none of our patients had any trauma to the face on presentation and developed the symptoms of orbital gas gangrene later, which is in contradiction to Leavelle's postulates. We would like to suggest the hypothesis of the entry of causative organism via airway to the sinuses, and hence to orbits.

The treatment modalities include surgical intervention with evisceration, enucleation, or exenteration, as well as sensitive antimicrobial therapy, specifically with penicillin. Few cases of endophthalmitis following penetrating globe injury were operated for vitrectomy and reported eye and vision salvage.[8],[9] Fielden et al.[10] and others have recommended adjuvant hyperbaric oxygen therapy (HBOT) as a treatment measure to reduce the morbidity and mortality.

In contradiction to cases reported in literature, our cases were victims of landslide without facial trauma. Also, presentation of orbital gas gangrene was delayed compared to other cases. Injury and septicemia in our cases were so severe that none of the patients could survive.

  Conclusion Top

In trauma department, disaster protocols are of utmost importance to manage mass casualties. Early imaging modalities of brain, orbit, and a multidisciplinary approach of all specialities including surgery, ophthalmology, orthopedics, pathology, and microbiology can definitely help to reduce morbidity and mortality.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Crock GW, Heriot WJ, Janakiraman P, Weiner JM. Gas gangrene infection of the eyes and orbits. Br J Ophthalmol 1985;69:143-8.  Back to cited text no. 1
Buboltz JB, Murphy-Lavoie HM. Gas Gangrene. [Updated 2021 Jul 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537030/.  Back to cited text no. 2
Gas Gangrene (Clostridial Myonecrosis): Background, Pathophysiology, Epidemiology. 2021. Available from: https://emedicine.medscape.com/article/217943-overview. [Last accessed on 2021 Sep 12].  Back to cited text no. 3
Bhargava SK, Chopdar A. Gas gangrene panophthalmitis. Br J Ophthalmol 1971;55:136-8.  Back to cited text no. 4
Rosenblum BN, Gutwein M, Bartell MF. Sphenoid sinusitis caused by clostridium perfringens. Otolaryngol Head Neck Surg 2001;125:101-2.  Back to cited text no. 5
Cannistra AJ, Albert DM, Frambach DA, Dreher RJ, Roberts L. Sudden visual loss associated with clostridial bacteraemia. Br J Ophthalmol 1988;72:380-5.  Back to cited text no. 6
Bryant AE, Chen RY, Nagata Y, Wang Y, Lee CH, Finegold S, et al. Clostridial gas gangrene. II. Phospholipase C-induced activation of platelet gpIIbIIIa mediates vascular occlusion and myonecrosis in Clostridium perfringens gas gangrene. J Infect Dis 2000;182:808-15.  Back to cited text no. 7
Wiles SB, Ide CH. Clostridium perfringens endophthalmitis. Am J Ophthalmol 1991;111:654-6.  Back to cited text no. 8
Abu el-Asrar AM, Tabbara KF. Clostridium perfringens endophthalmitis. Doc Ophthalmol Adv Ophthalmol 1994;87:177-82.  Back to cited text no. 9
Fielden MP, Martinovic E, Ells AL. Hyperbaric oxygen therapy in the treatment of orbital gas gangrene. J AAPOS 2002;6:252-4.  Back to cited text no. 10
Leavelle RB. Gas gangrene panophthalmitis; review of the literature; report of new cases. AMA Arch Ophthalmol. 1955 May;53(5):634-42  Back to cited text no. 11


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1]


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