Necrotizing fasciitis with fatal outcome: a report of two cases

High-throughput 16S rDNA sequencing assisting in the detection of bacterial pathogen candidates: a fatal case of necrotizing fasciitis in a child

Postmortem detection of pathogens in infectious deaths is quite important for diagnosing the cause of death and public health. However, it is difficult to detect possible bacterial pathogens in forensic practice using conventional methods like bacterial culture, especially in cases with putrefaction and antibiotic treatment. We report a fatal case caused by necrotizing fasciitis due to bacterial infection. An 8-year-old girl was found dead during sleep 4 days after a minor trauma to her left knee. The gross autopsy suggested that bacterial soft tissue infection might be the cause of death, and the microscopic examination confirmed the diagnosis. The slight putrefaction found at gross autopsy might interfere through postmortem bacterial translocation and reproduction with bacterial culture. High-throughput 16S rDNA sequencing was employed to identify possible pathogens. Bacterial DNA sequencing results suggested Streptococcus pyogenes and Staphylococcus, typical pathogens of necrotizing fasciitis in the tissue. 16S rDNA sequencing might thus be a useful tool for accurate detection of pathogens in forensic practice.

Medico-legal importance of necrotizing fasciitis

Despite the rarity of necrotizing fasciitis (NF), it is a relatively common cause of death in many lawsuits. Families seek financial compensation or legal charges against those they believe to be involved in the death, usually physicians who did not identify the infection soon enough. This paper explores six cases in forensic pathology practice where NF posed a unique medico-legal dilemma.

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

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.

The Shock of Strep: Rapid Deaths Due to Group a Streptococcus

Streptococcus pyogenes, also known as group A beta-hemolytic strep, is a Gram positive coccus responsible for several million infections every year. The types of infections vary widely from pharyngitis to myositis, but all can advance to severe life threatening invasive disease. Of those infected, approximately 1100 to 1600 people die each year due to invasive disease. Why certain individuals contract severe infections is not known, but many strains of Streptococcus pyogenes are known to produce toxins and superantigens. Invasive Streptococcus pyogenes infections have been shown to cause significant morbidity and rapid mortality. In many cases, patients expire before full antemortem testing can be performed, causing physicians and families to look to forensic pathologists for answers. Understanding the pathogenesis of invasive group A strep infections, relevant gross and microscopic findings, and proper culturing techniques is critical for forensic pathologists to diagnosis this condition and assist in the education and protection of the communities they serve.

Strategies for Reducing Fatal Complications in Liposuction

BACKGROUND

Liposuction has become one of the most common cosmetic surgical procedures, and severe complications secondary to this procedure have also increased significantly. That is why we carry out a research work to know the most frequent severe complications reported in the scientific literature to indicate criteria for prevention.

METHODS

English-language scientific publications about liposuction and its complications were analyzed using the PubMed.gov, from the beginning of PubMed's history through June 10, 2017. Five terms were used to define liposuction and its complications: "liposuction," "liposuction AND complications," liposuction AND major complications," "liposuction AND complications AND death," and "liposuction AND death." The quantities of results for the 5 phrases were analyzed, along with their contents.

RESULTS

One thousand sixty-three results were obtained from 1973 through June 10, 2017 for the phrase "Liposuction and Complications" in humans; for "Liposuction and Major Complications," 153 articles were found; for "Liposuction and Deaths," 89 articles were found; and 42 articles were obtained with the terms "Liposuction and Major Complications and Deaths." After final depuration, all those that were not specific to severe liposuction complications were eliminated, leaving a total of 39 articles that were included in our study. Five problems proved to be the most serious complications when performing liposuction: Thromboembolic disease, fat embolism, pulmonary edema, lidocaine intoxication, and intraabdominal visceral lesion.

CONCLUSIONS

The 5 most important complications that can cause death in liposuction are easily preventable using simple measures and proper safety protocols that are described in this work.

Bromine, bear-claw scratch fasciotomies, and the Eagle effect: management of group A streptococcal necrotising fasciitis and its association with trauma

Necrotising fasciitis is a rare, but potentially fatal, soft-tissue infection. Historical depictions of the disease have been described since classical times and were mainly recorded in wartime reports of battle injuries. Although several different species of bacteria can cause necrotising fasciitis, perhaps the most widely known is group A streptococcus (GAS). Infection control, early surgical debridement, and antibiotic therapy are now the central tenets of the clinical management of necrotising fasciitis; these treatment approaches all originate from those used in wars in the past 150 years. We review reports from the 19th century, early 20th century, and mid-20th century onwards to show how the management of necrotising fasciitis has progressed in parallel with prevailing scientific thought and medical practice. Historically, necrotising fasciitis has often, but not exclusively, been associated with penetrating trauma. However, along with a worldwide increase in invasive GAS disease, recent reports have cited cases of necrotising fasciitis following non-combat-related injuries or in the absence of antecedent events. We also investigate the specific association between GAS necrotising fasciitis and trauma. In the 21st century, molecular biology has improved our understanding of GAS pathogenesis, but has not yet affected attributable mortality.

An autopsy case of a homeless person with unilateral lower extremity edema

We present an autopsy case of a homeless person showing remarkable unilateral lower extremity edema, which was strongly associated with the cause of death. A 55-year-old homeless man without any past medical history was found dead in a flophouse. External examination showed evidence of malnourishment and remarkable swelling of the right, lower extremity. Putrefactive discoloration in the same area was evident at the time of autopsy (approximately 30h post-mortem). The autopsy revealed focal pneumonia in the right lower lobe, dehydration and chronic pancreatitis. Dissection of the edematous extremity revealed massive abscess formation in the subcutaneous tissue and superficial fascia around the right knee joint. Histopathological findings were compatible with necrotizing fasciitis and blood chemistry results showed an elevation of HbA1c (6.3%). The cause of death is considered to be necrotizing fasciitis and secondary pneumonia/dehydration. This case suggests that necrotizing fasciitis should be differentiated during postmortem diagnosis, especially in cases showing lower extremity edema with early putrefactive changes. In addition, forensic pathologists should closely examine a lower extremity of such cases to detect a true cause of death, even if other pathological findings which can be a cause of death, such as pneumonia and dehydration, are observed in major internal organs.