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Necrotizing fasciitis: case series and review of the literature on clinical and medico-legal diagnostic challenges

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Abstract

Necrotizing fasciitis (NF) is a life-threatening infection of soft tissues spreading along the fasciae to the surrounding musculature, subcutaneous fat and overlying skin areas that can rapidly lead to septic shock and death. Due to the pandemic increase of medical malpractice lawsuits, above all in Western countries, the forensic pathologist is frequently asked to investigate post-mortem cases of NF in order to determine the cause of death and to identify any related negligence and/or medical error. Herein, we review the medical literature dealing with cases of NF in a post-mortem setting, present a case series of seven NF fatalities and discuss the main ante-mortem and post-mortem diagnostic challenges of both clinical and forensic interests. In particular, we address the following issues: (1) origin of soft tissue infections, (2) micro-organisms involved, (3) time of progression of the infection to NF, (4) clinical and histological staging of NF and (5) pros and cons of clinical and laboratory scores, specific forensic issues related to the reconstruction of the ideal medical conduct and the evaluation of the causal value/link of any eventual medical error.

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Authors and Affiliations

  1. Department of Medical and Surgical Sciences (DIMEC), Institute of Legal Medicine, University of Bologna, Bologna, Italy

    Paolo Fais

  2. Department of Legal and Occupational Medicine, Toxicology and Public Health, University-Hospital of Padova, Via Falloppio 50, 35128, Padova, Italy

    Alessia Viero, Guido Viel, Renzo Giordano, Giovanni Cecchetto & Massimo Montisci

  3. Department of Public Health and Community Medicine, Unit of Forensic Medicine, University of Verona, P.le L.A. Scuro 10, Verona, Italy

    Dario Raniero

  4. Emergency Department, Rovigo Hospital, ULSS 5 “Polesana”, Rovigo, Italy

    Stefano Kusstatscher

  5. Institute of Radiology, Department of Medicine (DiMED), University-Hospital Padova, Via Giustiniani 2, 35128, Padova, Italy

    Chiara Giraudo

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  1. Paolo Fais
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  2. Alessia Viero
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  3. Guido Viel
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  4. Renzo Giordano
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  9. Massimo Montisci
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Correspondence to Guido Viel.

Additional information

Paolo Fais and Alessia Viero have equally contributed to the manuscript and should be both considered first authors. They are both Members of the International Academy of Legal Medicine (IALM); Alessia Viero is less than 35 years-old and belongs to the IALM Youth Section.

Electronic supplementary material

Fig. 1 – Electronic Source 1

Histological pattern of necrotizing fasciitis characterized by: interstitial oedema (A, EE 100×), necrosis (B, EE 100×), haemorrhagic infiltration (C, EE 400×), and bacterial colonies (C, EE 400× - D, EE 200× – E, Giemsa 200×) along the subcutaneous fasciae. The inflammatory reaction is minimal or absent in the subcutaneous fat tissues (F, EE 200×). (GIF 422 kb)

High resolution image (TIFF 7423 kb)

Table A - Electronic Source 2

Literature data from internationally published papers dealing with post-mortem cases of NF investigated through (at least) an autopsy with or without histology and/or microbiology analyses are here summarized. For each included manuscript, the classification used by the Journal (paper type), the number of cases investigated (cases), the type of histology (histopathology) and microbiological investigations (microbiology) performed are presented. The last column reports the time frame (in hours) between medical consultation/hospital admission and death. (DOCX 38 kb)

Table B - Electronic Source 3

Literature data on the diagnostic efficiency of LRINEC. For each included manuscript, first author, year of publication, number of investigated cases, type of investigation, cut-off used for the LRINEC score, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and area under the curve (AUC) are reported. (DOCX 29 kb)

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Fais, P., Viero, A., Viel, G. et al. Necrotizing fasciitis: case series and review of the literature on clinical and medico-legal diagnostic challenges. Int J Legal Med 132, 1357–1366 (2018). https://doi.org/10.1007/s00414-018-1838-0

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