Gangrene
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Gangrene is a type of tissue death caused by a lack of blood supply. Symptoms may include a change in skin color to red or black, numbness, swelling, pain, skin breakdown, and coolness. The feet and hands are most commonly affected. If the gangrene is caused by an infectious agent, it may present with a
fever Fever or pyrexia in humans is a symptom of an anti-infection defense mechanism that appears with Human body temperature, body temperature exceeding the normal range caused by an increase in the body's temperature Human body temperature#Fever, s ...
or
sepsis Sepsis is a potentially life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs. This initial stage of sepsis is followed by suppression of the immune system. Common signs and s ...
. Risk factors include
diabetes Diabetes mellitus, commonly known as diabetes, is a group of common endocrine diseases characterized by sustained high blood sugar levels. Diabetes is due to either the pancreas not producing enough of the hormone insulin, or the cells of th ...
,
peripheral arterial disease Peripheral artery disease (PAD) is a vascular disorder that causes abnormal narrowing of arteries other than those that supply the heart or brain. PAD can happen in any blood vessel, but it is more common in the legs than the arms. When narr ...
,
smoking Smoking is a practice in which a substance is combusted, and the resulting smoke is typically inhaled to be tasted and absorbed into the bloodstream of a person. Most commonly, the substance used is the dried leaves of the tobacco plant, whi ...
,
major trauma Major trauma is any injury that has the potential to cause prolonged disability or death. There are many causes of major trauma, blunt and penetrating, including falls, motor vehicle collisions, stabbing wounds, and gunshot wounds. Dependi ...
,
alcoholism Alcoholism is the continued drinking of alcohol despite it causing problems. Some definitions require evidence of dependence and withdrawal. Problematic use of alcohol has been mentioned in the earliest historical records. The World He ...
,
HIV/AIDS The HIV, human immunodeficiency virus (HIV) is a retrovirus that attacks the immune system. Without treatment, it can lead to a spectrum of conditions including acquired immunodeficiency syndrome (AIDS). It is a Preventive healthcare, pr ...
,
frostbite Frostbite is a skin injury that occurs when someone is exposed to extremely low temperatures, causing the freezing of the skin or other tissues, commonly affecting the fingers, toes, nose, ears, cheeks and chin areas. Most often, frostbite occ ...
,
influenza Influenza, commonly known as the flu, is an infectious disease caused by influenza viruses. Symptoms range from mild to severe and often include fever, runny nose, sore throat, muscle pain, headache, coughing, and fatigue. These sympto ...
,
dengue fever Dengue fever is a mosquito-borne disease caused by dengue virus, prevalent in tropical and subtropical areas. Asymptomatic infections are uncommon, mild cases happen frequently; if symptoms appear, they typically begin 3 to 14 days after i ...
,
malaria Malaria is a Mosquito-borne disease, mosquito-borne infectious disease that affects vertebrates and ''Anopheles'' mosquitoes. Human malaria causes Signs and symptoms, symptoms that typically include fever, Fatigue (medical), fatigue, vomitin ...
,
chickenpox Chickenpox, also known as varicella ( ), is a highly contagious disease caused by varicella zoster virus (VZV), a member of the herpesvirus family. The disease results in a characteristic skin rash that forms small, itchy blisters, which ...
, plague,
hypernatremia Hypernatremia, also spelled hypernatraemia, is a high concentration of sodium in the blood. Early symptoms may include a strong feeling of thirst, weakness, nausea, and loss of appetite. Severe symptoms include confusion, muscle twitching, and ...
, radiation injuries,
meningococcal disease Meningococcal disease is a serious infection caused by ''Neisseria meningitidis'', also known as meningococcus, a gram negative diplococcus. Meningococcal disease includes meningitis, meningococcal septicemia, or a combination of both, which c ...
, Group B streptococcal infection and Raynaud's syndrome. It can be classified as dry gangrene, wet gangrene, gas gangrene, internal gangrene, and
necrotizing fasciitis Necrotizing fasciitis (NF), also known as flesh-eating disease, is an infection that kills the body's soft tissue. It is a serious disease that begins and spreads quickly. Symptoms include red or purple or black skin, swelling, severe pain, fever ...
. The diagnosis of gangrene is based on symptoms and supported by tests such as
medical imaging Medical imaging is the technique and process of imaging the interior of a body for clinical analysis and medical intervention, as well as visual representation of the function of some organs or tissues (physiology). Medical imaging seeks to revea ...
. Treatment may involve surgery to remove the dead tissue,
antibiotics An antibiotic is a type of antimicrobial substance active against bacteria. It is the most important type of antibacterial agent for fighting pathogenic bacteria, bacterial infections, and antibiotic medications are widely used in the therapy ...
to treat any infection, and efforts to address the underlying cause. Surgical efforts may include debridement,
amputation Amputation is the removal of a Limb (anatomy), limb or other body part by Physical trauma, trauma, medical illness, or surgery. As a surgical measure, it is used to control pain or a disease process in the affected limb, such as cancer, malign ...
, or the use of maggot therapy. Efforts to treat the underlying cause may include bypass surgery or
angioplasty Angioplasty, also known as balloon angioplasty and percutaneous transluminal angioplasty, is a minimally invasive procedure, minimally invasive endovascular surgery, endovascular Medical procedure, procedure used to widen narrowed or obstructe ...
. In certain cases,
hyperbaric oxygen therapy Hyperbaric medicine is medical treatment in which an increase in barometric pressure of typically air or oxygen is used. The immediate effects include reducing the size of gas emboli and raising the partial pressures of the gases present. Initial ...
may be useful. How commonly the condition occurs is unknown.


Etymology

The
etymology Etymology ( ) is the study of the origin and evolution of words—including their constituent units of sound and meaning—across time. In the 21st century a subfield within linguistics, etymology has become a more rigorously scientific study. ...
of gangrene derives from the
Latin Latin ( or ) is a classical language belonging to the Italic languages, Italic branch of the Indo-European languages. Latin was originally spoken by the Latins (Italic tribe), Latins in Latium (now known as Lazio), the lower Tiber area aroun ...
word and from the
Greek Greek may refer to: Anything of, from, or related to Greece, a country in Southern Europe: *Greeks, an ethnic group *Greek language, a branch of the Indo-European language family **Proto-Greek language, the assumed last common ancestor of all kno ...
''gangraina'' (γάγγραινα), which means "
putrefaction Putrefaction is the fifth stage of death, following pallor mortis, livor mortis, algor mortis, and rigor mortis. This process references the breaking down of a body of an animal Post-mortem interval, post-mortem. In broad terms, it can be view ...
of tissues".


Signs and symptoms

Symptoms may include a change in skin color to red or black, numbness, pain, skin breakdown, and coolness. The feet and hands are most commonly involved.


Causes

Gangrene is caused by a critically insufficient blood supply (e.g., peripheral vascular disease) or infection. It is associated with
diabetes Diabetes mellitus, commonly known as diabetes, is a group of common endocrine diseases characterized by sustained high blood sugar levels. Diabetes is due to either the pancreas not producing enough of the hormone insulin, or the cells of th ...
and long-term tobacco smoking.


Dry gangrene

Dry gangrene is a form of
coagulative necrosis Coagulative necrosis is a type of accidental cell death typically caused by ischemia or infarction. In coagulative necrosis, the architectures of dead tissue are preserved for at least a couple of days. It is believed that the injury denatures stru ...
that develops in
ischemic Ischemia or ischaemia is a restriction in blood supply to any tissue, muscle group, or organ of the body, causing a shortage of oxygen that is needed for cellular metabolism (to keep tissue alive). Ischemia is generally caused by problems ...
tissue, where the blood supply is inadequate to keep tissue viable. It is not a disease itself, but a symptom of other diseases. The term ''dry'' is used only when referring to a limb or to the gut (in other locations, this same type of necrosis is called an infarction, such as
myocardial infarction A myocardial infarction (MI), commonly known as a heart attack, occurs when Ischemia, blood flow decreases or stops in one of the coronary arteries of the heart, causing infarction (tissue death) to the heart muscle. The most common symptom ...
). Dry gangrene is often due to
peripheral artery disease Peripheral artery disease (PAD) is a vascular disorder that causes abnormal narrowing of arteries other than those that supply the heart or brain. PAD can happen in any blood vessel, but it is more common in the legs than the arms. When narr ...
, but can be due to acute limb ischemia. As a result, people with atherosclerosis, high cholesterol, diabetes and smokers commonly have dry gangrene. The limited oxygen in the ischemic limb limits
putrefaction Putrefaction is the fifth stage of death, following pallor mortis, livor mortis, algor mortis, and rigor mortis. This process references the breaking down of a body of an animal Post-mortem interval, post-mortem. In broad terms, it can be view ...
and bacteria fail to survive. The affected part is dry, shrunken, and dark reddish-black. The line of separation usually brings about complete separation, with eventual falling off of the gangrenous tissue if it is not removed surgically, a process called autoamputation. Dry gangrene is the result of chronic
ischemia Ischemia or ischaemia is a restriction in blood supply to any tissue, muscle group, or organ of the body, causing a shortage of oxygen that is needed for cellular metabolism (to keep tissue alive). Ischemia is generally caused by problems ...
without
infection An infection is the invasion of tissue (biology), tissues by pathogens, their multiplication, and the reaction of host (biology), host tissues to the infectious agent and the toxins they produce. An infectious disease, also known as a transmis ...
. If ischemia is detected early, when ischemic wounds rather than gangrene are present, the process can be treated by
revascularization In medical and surgical therapy, revascularization is the restoration of perfusion to a body part or organ that has had ischemia. It is typically accomplished by surgical means. Vascular bypass and angioplasty are the two primary means of r ...
(via vascular bypass or angioplasty). However, once gangrene has developed, the affected tissues are not salvageable. Because dry gangrene is not accompanied by infection, it is not as emergent as gas gangrene or wet gangrene, both of which have a risk of sepsis. Over time, dry gangrene may develop into wet gangrene if an infection develops in the dead tissues.
Diabetes mellitus Diabetes mellitus, commonly known as diabetes, is a group of common endocrine diseases characterized by sustained hyperglycemia, high blood sugar levels. Diabetes is due to either the pancreas not producing enough of the hormone insulin, or th ...
is a risk factor for peripheral vascular disease, thus for dry gangrene, but also a risk factor for wet gangrene, particularly in patients with poorly controlled blood sugar levels, as elevated serum glucose creates a favorable environment for bacterial infection.


Wet gangrene

Wet, or infected, gangrene is characterized by thriving bacteria and has a poor
prognosis Prognosis ( Greek: πρόγνωσις "fore-knowing, foreseeing"; : prognoses) is a medical term for predicting the likelihood or expected development of a disease, including whether the signs and symptoms will improve or worsen (and how quickly) ...
(compared to dry gangrene) due to sepsis resulting from the free communication between infected fluid and circulatory fluid. In wet gangrene, the tissue is infected by saprogenic microorganisms (''
Clostridium perfringens ''Clostridium perfringens'' (formerly known as ''C. welchii'', or ''Bacillus welchii'') is a Gram-positive, bacillus (rod-shaped), anaerobic, spore-forming pathogenic bacterium of the genus '' Clostridium''. ''C. perfringens'' is ever-present ...
'' or '' Bacillus fusiformis'', for example), which cause tissue to swell and emit a foul odor. Wet gangrene usually develops rapidly due to blockage of venous (mainly) or arterial blood flow. The affected part is saturated with stagnant blood, which promotes the rapid growth of bacteria. The toxic products formed by bacteria are absorbed, causing systemic manifestation of sepsis and finally death. The affected part is edematous, soft, putrid, rotten, and dark. Because of the high mortality associated with infected gangrene (about 80% without treatment and 20% with treatment), an emergency salvage amputation, such as a guillotine amputation, is often needed to limit systemic effects of the infection. Such an amputation can be converted to a formal amputation, such as a below- or above-knee amputation.


Gas gangrene

Gas gangrene is a bacterial infection that produces gas within tissues. It can be caused by '' Clostridium'', most commonly alpha toxin-producing ''C. perfringens'', or various nonclostridial species. Infection spreads rapidly as the gases produced by the bacteria expand and infiltrate healthy tissue in the vicinity. Because of its ability to quickly spread to surrounding tissues, gas gangrene should be treated as a
medical emergency A medical emergency is an acute injury or illness that poses an immediate risk to a person's life or long-term health, sometimes referred to as a situation risking "life or limb". These emergencies may require assistance from another, qualified ...
. Gas gangrene is caused by bacterial exotoxin-producing clostridial species, which are mostly found in soil, and other anaerobes such as ''
Bacteroides ''Bacteroides'' is a genus of Gram-negative, obligate anaerobic bacteria. ''Bacteroides'' species are non endospore–forming bacilli, and may be either motile or nonmotile, depending on the species. The DNA base composition is 40–48% GC. Un ...
'' and anaerobic streptococci. These environmental bacteria may enter the muscle through a wound and subsequently proliferate in necrotic tissue and secrete powerful toxins that destroy nearby tissue, generating gas at the same time. A gas composition of 5.9% hydrogen, 3.4% carbon dioxide, 74.5% nitrogen, and 16.1% oxygen was reported in one clinical case. Gas gangrene can cause necrosis, gas production, and sepsis. Progression to toxemia and shock is often very rapid.


Other types

*
Necrotizing fasciitis Necrotizing fasciitis (NF), also known as flesh-eating disease, is an infection that kills the body's soft tissue. It is a serious disease that begins and spreads quickly. Symptoms include red or purple or black skin, swelling, severe pain, fever ...
is a rare infection that spreads deep into the body along tissue planes. It is categorized into four subtypes, with the first two being the most common. Type 1 requires an infection with an anaerobe and a species in the Enterobacteriaceae family, while type 2 is characterized by infection with ''
Streptococcus pyogenes ''Streptococcus pyogenes'' is a species of Gram-positive, aerotolerant bacteria in the genus '' Streptococcus''. These bacteria are extracellular, and made up of non-motile and non-sporing cocci (round cells) that tend to link in chains. They ...
'', a Gram-positive cocci bacteria, and thus is also known as hemolytic streptococcal gangrene. * Noma is a gangrene of the face most often found in Africa, Southeast Asia and South America. * Fournier gangrene is a type of necrotizing fasciitis that usually affects the genitals and groin. * Venous limb gangrene may be caused by Heparin-induced thrombocytopenia and
thrombosis Thrombosis () is the formation of a Thrombus, blood clot inside a blood vessel, obstructing the flow of blood through the circulatory system. When a blood vessel (a vein or an artery) is injured, the body uses platelets (thrombocytes) and fib ...
. * Severe mesenteric ischemia may result in gangrene of the
small intestine The small intestine or small bowel is an organ (anatomy), organ in the human gastrointestinal tract, gastrointestinal tract where most of the #Absorption, absorption of nutrients from food takes place. It lies between the stomach and large intes ...
. * Severe ischemic colitis may result in gangrene of the
large intestine The large intestine, also known as the large bowel, is the last part of the gastrointestinal tract and of the Digestion, digestive system in tetrapods. Water is absorbed here and the remaining waste material is stored in the rectum as feces befor ...
.


Treatment

Treatment varies based on the severity and type of gangrene.


Lifestyle

Exercises such as walking and massage therapy may be tried.


Medication

Medications may include pain management, medications that promote circulation in the
circulatory system In vertebrates, the circulatory system is a system of organs that includes the heart, blood vessels, and blood which is circulated throughout the body. It includes the cardiovascular system, or vascular system, that consists of the heart ...
and antibiotics. Since gangrene is associated with periodic pain caused by too little blood flow, pain management is important so patients can continue doing exercises that promote circulation. Pain management medications can include opioids and opioid-like analgesics. Since gangrene is a result of
ischemia Ischemia or ischaemia is a restriction in blood supply to any tissue, muscle group, or organ of the body, causing a shortage of oxygen that is needed for cellular metabolism (to keep tissue alive). Ischemia is generally caused by problems ...
, circulatory system management is important. These medications can include antiplatelet drug,
anticoagulant An anticoagulant, commonly known as a blood thinner, is a chemical substance that prevents or reduces the coagulation of blood, prolonging the clotting time. Some occur naturally in blood-eating animals, such as leeches and mosquitoes, which ...
, and fibrinolytics. As infection is often associated with gangrene,
antibiotics An antibiotic is a type of antimicrobial substance active against bacteria. It is the most important type of antibacterial agent for fighting pathogenic bacteria, bacterial infections, and antibiotic medications are widely used in the therapy ...
are often a critical component of its treatment. The life-threatening nature of gangrene requires treatment with intravenous antibiotics in an inpatient setting. Antibiotics alone are not effective because they may not penetrate infected tissues sufficiently.


Surgery

Surgical removal of all dead tissue, however, is the mainstay of treatment for gangrene. Often, gangrene is associated with underlying infection, thus the gangrenous tissue must be debrided to hinder the spread of the associated infection. The extent of surgical debridement needed depends on the extent of the gangrene and may be limited to the removal of a finger, toe, or ear, but in severe cases may involve a limb amputation. Dead tissue alone does not require debridement, and in some cases, such as dry gangrene, the affected part falls off (autoamputates), making surgical removal unnecessary. Waiting for autoamputation, however, may cause health complications as well as decreased quality of life. After the gangrene is treated with debridement and antibiotics, the underlying cause can be treated. In the case of gangrene due to critical limb ischemia, revascularization can be performed to treat the underlying peripheral underlateral artery disease. Ischemic disease of the legs is the most common reason for amputations. In about a quarter of these cases, the other side requires amputation in the next three years. Angioplasty should be considered if severe blockage in lower leg vessels ( tibial and peroneal artery) leads to gangrene.


Other

Hyperbaric oxygen therapy Hyperbaric medicine is medical treatment in which an increase in barometric pressure of typically air or oxygen is used. The immediate effects include reducing the size of gas emboli and raising the partial pressures of the gases present. Initial ...
treatment is used to treat gas gangrene. It increases pressure and oxygen content to allow blood to carry more oxygen to inhibit anaerobic organism growth and reproduction. Regenerative medical treatments and stem-cell therapies have successfully altered gangrene and ulcer prognosis.


History

As early as 1028,
flies Flies are insects of the Order (biology), order Diptera, the name being derived from the Ancient Greek, Greek δι- ''di-'' "two", and πτερόν ''pteron'' "wing". Insects of this order use only a single pair of wings to fly, the hindwin ...
and
maggot A maggot is the larva of a fly (order Diptera); it is applied in particular to the larvae of Brachycera flies, such as houseflies, cheese flies, hoverflies, and blowflies, rather than larvae of the Nematocera, such as mosquitoes and cr ...
s were commonly used to treat chronic wounds or
ulcers An ulcer is a discontinuity or break in a bodily membrane that impedes normal function of the affected organ. According to Robbins's pathology, "ulcer is the breach of the continuity of skin, epithelium or mucous membrane caused by sloughing ...
to prevent or arrest necrotic spread, as some species of maggots consume only dead flesh, leaving nearby living tissue unaffected. This practice largely died out after the introduction of antibiotics to the range of treatments for wounds. In recent times, however, maggot therapy has regained some credibility and is sometimes employed with great
efficacy Efficacy is the ability to perform a task to a satisfactory or expected degree. The word comes from the same roots as '' effectiveness'', and it has often been used synonymously, although in pharmacology a distinction is now often made betwee ...
in cases of chronic tissue necrosis. The French Baroque composer
Jean-Baptiste Lully Jean-Baptiste Lully ( – 22 March 1687) was a French composer, dancer and instrumentalist of Italian birth, who is considered a master of the French Baroque music style. Best known for his operas, he spent most of his life working in the court o ...
contracted gangrene in January 1687 when, while conducting a performance of his ''
Te Deum The ( or , ; from its incipit, ) is a Latin Christian hymn traditionally ascribed to a date before AD 500, but perhaps with antecedents that place it much earlier. It is central to the Ambrosian hymnal, which spread throughout the Latin ...
'', he stabbed his own toe with his pointed staff (which was used as a baton). The disease spread to his leg, but the composer refused to have his toe amputated, which eventually led to his death in March of that year. French King
Louis XIV LouisXIV (Louis-Dieudonné; 5 September 16381 September 1715), also known as Louis the Great () or the Sun King (), was King of France from 1643 until his death in 1715. His verified reign of 72 years and 110 days is the List of longest-reign ...
died of gangrene in his leg on 1 September 1715, four days prior to his 77th birthday.
Sebald Justinus Brugmans Sebald Justinus Brugmans (24 March 1763, Franeker – 22 July 1819, Leiden) was a Dutch people, Dutch botanist and physician. He was the son of naturalist Anton Brugmans (1732–1789). Brugmans studied philosophy, mathematics and physics at the ...
, Professor at Leyden University, from 1795 on Director of the Medical Bureau of the Batavian Republic, and inspector-general of the French Imperial Military Health-Service in 1811, became a leading expert in the fight against hospital-gangrene and its prevention. He wrote a treatise on gangrene in 1814 in which he meticulously analyzed and explained the causes of this dreadful disease, which he was convinced was contagious. He completed his entry with a thorough evaluation of all possible and well experienced sanitary regulations. His work was very well received and was instrumental in convincing most later authors that gangrene was a contagious disease. John M. Trombold wrote: "Middleton Goldsmith, a surgeon in the Union Army during the American Civil War, meticulously studied hospital gangrene and developed a revolutionary treatment regimen. The cumulative Civil War hospital gangrene mortality was 45%. Goldsmith's method, which he applied to over 330 cases, yielded a mortality under 3%." Goldsmith advocated the use of debridement and topical and injected bromide solutions on infected wounds to reduce the incidence and virulence of "poisoned miasma". Copies of his book were issued to Union surgeons to encourage the use of his methods.


References


External links

* {{Authority control Health effects of tobacco Symptoms and signs: Vascular Necrosis Causes of amputation Wikipedia medicine articles ready to translate Causes of death