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Teal L, Sheller B, Susarla HK. Pediatric Odontogenic Infections. Oral Maxillofac Surg Clin North Am 2024; 36:391-399. [PMID: 38777729 DOI: 10.1016/j.coms.2024.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
Odontogenic infections are a broad group of head and neck conditions that arise from the teeth and surrounding periodontium. These largely preventable infections disproportionately affect members of ethnic and racial minorities and low-income/uninsured groups, and result in significant costs to our health care system. Left untreated, odontogenic infections can spread to deep spaces of the head and neck and can result in life-threatening complications. The mainstay of treatment includes timely treatment of the affected teeth. These infections are a global public health concern that could be diminished with improved access to routine dental care.
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Affiliation(s)
- Lindsey Teal
- Division of Plastic Surgery, Department of Surgery, University of Washington Medical Center, 325 9th Avenue, Seattle, WA 98013, USA
| | - Barbara Sheller
- Department of Dentistry, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA 98105, USA
| | - Harlyn K Susarla
- Department of Dentistry, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA 98105, USA.
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Katoumas K, Mitsopoulos G. Vacuum-assisted closure of a tissue deficit of the submental area in a patient with a necrotizing soft tissue odontogenic infection. Oral Surg Oral Med Oral Pathol Oral Radiol 2024; 137:e119-e124. [PMID: 38155007 DOI: 10.1016/j.oooo.2023.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Revised: 10/16/2023] [Accepted: 10/24/2023] [Indexed: 12/30/2023]
Abstract
Odontogenic infections can rarely progress to necrotizing soft tissue infections. Cervical necrotizing fasciitis (CNF) is a rare but fulminant infection that spreads along the fascial planes, including connective tissue, muscle, and subcutaneous fat, and is typified by necrosis of the skin and other adjacent tissues. This article aims to present the treatment of a patient with submental skin and soft tissue necrosis due to an odontogenic infection and the subsequent management of the tissue deficit with a vacuum-assisted closure (VAC) system. The patient presented with extensive skin necrosis in the submental area and was immediately hospitalized, and management of the odontogenic infection was performed. When the patients' infection had been sufficiently controlled, a wound VAC device was placed in the deficit. The VAC device was removed after 12 days, and the patient was discharged. In conclusion, VAC can be used to manage tissue deficits with good aesthetic results.
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Affiliation(s)
- Konstantinos Katoumas
- Department of Oral & Maxillofacial Surgery, General Hospital of Athens "Evaggelismos" and Dental School of the National and Kapodistrian University of Athens, Athens, Greece.
| | - Georgios Mitsopoulos
- Department of Oral & Maxillofacial Surgery, 401 General Military Hospital of Athens, Athens, Greece
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Hematologic and inflammatory parameters for determining severity of odontogenic infections at admission: a retrospective study. BMC Infect Dis 2022; 22:931. [PMID: 36503406 PMCID: PMC9743669 DOI: 10.1186/s12879-022-07934-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 12/07/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Severe odontogenic infections in the head and neck region, especially necrotizing soft tissue infection (NSTI) and deep neck abscess, are potentially fatal due to their delayed diagnosis and treatment. Clinically, it is often difficult to distinguish NSTI and deep neck abscess in its early stage from cellulitis, and the decision to perform contrast-enhanced computed tomography imaging for detection is often a challenge. This retrospective case-control study aimed to examine the utility of routine blood tests as an adjunctive diagnostic tool for NSTI in the head and neck region and deep neck abscesses. METHODS Patients with severe odontogenic infections in the head and neck region that required hospitalization were classified into four groups. At admission, hematologic and inflammatory parameters were calculated according to the blood test results. In addition, a decision tree analysis was performed to detect NSTI and deep neck abscesses. RESULTS There were 271 patients, 45.4% in Group I (cellulitis), 22.5% in Group II (cellulitis with shallow abscess formation), 27.3% in Group III (deep neck abscess), and 4.8% in Group IV (NSTI). All hematologic and inflammatory parameters were higher in Groups III and IV. The Laboratory Risk Indicator for Necrotizing Fasciitis score, with a cut-off value of 6 and C-reactive protein (CRP) + the neutrophil-to-lymphocyte ratio (NLR), with a cut-off of 27, were remarkably useful for the exclusion diagnosis for Group IV. The decision tree analysis showed that the systemic immune-inflammation index (SII) of ≥ 282 or < 282 but with a CRP + NLR of ≥ 25 suggests Group III + IV and the classification accuracy was 89.3%. CONCLUSIONS Hematologic and inflammatory parameters calculated using routine blood tests can be helpful as an adjunctive diagnostic tool in the early diagnosis of potentially fatal odontogenic infections. An SII of ≥ 282 or < 282 but with a CRP + NLR of ≥ 25 can be useful in the decision-making for performing contrast-enhanced computed tomography imaging.
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Neal TW, Schlieve T. Complications of Severe Odontogenic Infections: A Review. BIOLOGY 2022; 11:biology11121784. [PMID: 36552293 PMCID: PMC9775288 DOI: 10.3390/biology11121784] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 12/03/2022] [Accepted: 12/05/2022] [Indexed: 12/13/2022]
Abstract
Severe odontogenic infections are routinely treated with little associated morbidity and mortality. Improvements in surgical techniques, antibiotic treatments, and imaging modalities have made associated complications exceedingly rare. A number of complications have been described in the literature including airway obstruction, descending necrotizing mediastinitis, orbital abscess, septic cavernous sinus thrombosis, cerebral abscess, sepsis, necrotizing fasciitis, and Lemierre's syndrome. The purpose of this article is to discuss the pathophysiology of severe odontogenic infections and the risk factors associated with the development of complications. Given the morbidity and mortality of these conditions, it is important to review the clinical features of each and the diagnostic tools that aid in early recognition.
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Crowe CS, Yu JL, Yesantharao P, Keys K, Kennedy SA. Predictors of Mortality and Amputation in Patients With Necrotizing Soft Tissue Infections of the Upper Extremity. J Hand Surg Am 2022; 47:629-638. [PMID: 35537969 DOI: 10.1016/j.jhsa.2022.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 12/23/2021] [Accepted: 02/09/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE Necrotizing soft tissue infection (NSTI) of the upper extremity is characterized by rapid progression, local tissue necrosis, systemic toxicity, and a high mortality rate. The negative consequences of debridement are balanced against preservation of life and limb. The primary objective of this study was to identify predictors of mortality in upper extremity NSTI. Secondary objectives were to identify predictors of amputation, final defect size, length of stay, and readmission within 30 days. METHODS An institutional registry for patients with NSTI was retrospectively queried from a single tertiary center covering a large referral population. Data on confirmed upper extremity NSTI were used to determine patient characteristics, infection data, and operative factors. Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) and Quick Sequential Organ Failure Assessment (qSOFA) scores were calculated from primary data to provide a measure of clinical severity. Bivariate screening identifying possible predictors of mortality and multivariable regression was performed to control for confounding. Similar analyses were performed for amputation, final defect size, and readmission within 30 days. RESULTS A total of 99 patients met the study criteria. In-hospital mortality occurred in 12 patients, and amputation was performed in 7 patients. Etiology, causative organism, and clinical severity scores were variable. Logistic regression showed mortality to be independently predicted by vasopressor dependency outside of operative anesthesia. The relatively low number of case events, limited sample size, and multiple comparisons limited the evaluation of lesser predictor variables. The LRINEC score did not strongly predict amputation or death in this series. CONCLUSIONS Necrotizing soft tissue infection of the upper extremity carries risk of mortality and amputation, and effective treatment requires prompt recognition, early goal-directed resuscitation, and early debridement. The strongest independent predictor of in-hospital mortality was vasopressor dependence outside operative anesthesia. The LRINEC score did not strongly predict death or amputation in upper extremity NSTI. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic IV.
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Affiliation(s)
- Christopher S Crowe
- Division of Plastic Surgery, Department of Surgery, University of Washington, Seattle, WA
| | - Jenny L Yu
- Division of Plastic Surgery, Department of Surgery, University of Washington, Seattle, WA
| | - Pooja Yesantharao
- Division of Plastic and Reconstructive Surgery, Stanford University, Stanford, CA
| | - Kari Keys
- Division of Plastic Surgery, Department of Surgery, University of Washington, Seattle, WA
| | - Stephen A Kennedy
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, WA.
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Kim DH, Kim SW, Hwang SH. Application of the laboratory risk indicator for necrotizing fasciitis score to the head and neck: a systematic review and meta-analysis. ANZ J Surg 2022; 92:1631-1637. [PMID: 35014152 DOI: 10.1111/ans.17459] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 12/19/2021] [Accepted: 12/21/2021] [Indexed: 01/26/2023]
Abstract
BACKGROUND Recent studies have attempted to verify the predictive capability of the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) for cervical necrotizing fasciitis (CNF). METHODS The two authors independently reviewed six databases (PubMed, Cochrane, Embase, Web of Science, SCOPUS and Google Scholar databases were searched). Seven cohort studies were included in the analysis. Sensitivity and specificity were determined by extracting items from binary classification from each paper. The diagnostic accuracy of the included studies was evaluated using QUADAS ver. 2. RESULTS The diagnostic odds ratio (OR) of LRINEC for CNF with the cutoff value of 6 was 13.9952 (95% CI, 3.8537; 50.8255, I2 = 76.7%). The area under the SROC curve was 0.842, suggesting acceptable diagnostic accuracy. The correlation between sensitivity and false positive rate was 0.055, indicating that it was not heterogeneous. The sensitivity, specificity, and negative predictive values were 0.7503 ([0.4637; 0.9126], I2 = 79.1%), 0.8455 ([0.7084; 0.9250], I2 = 96.0%) and 0.9829 ([0.9089; 0.9970], I2 = 93.7%), respectively. In the comparison of subgroups according to a LRINEC score (6-8, and), the cutoff value of 6 showed moderate sensitivity (75%) and high specificity (85%) and greater diagnostic power than other cutoff values. CONCLUSIONS LRINEC is a useful adjunctive tool for predicting CNF in patients with a soft tissue infection. In addition, a more accurate diagnosis is possible by using the LRINEC score with a cutoff value of 6.
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Affiliation(s)
- Do Hyun Kim
- Department of Otolaryngology-Head and Neck Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Sung Won Kim
- Department of Otolaryngology-Head and Neck Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Se Hwan Hwang
- Department of Otolaryngology-Head and Neck Surgery, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
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Bègue L, Schlund M, Raoul G, Ferri J, Lauwers L, Nicot R. Biological factors predicting the length of hospital stay in odontogenic cellulitis. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2021; 123:303-308. [PMID: 34260983 DOI: 10.1016/j.jormas.2021.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/27/2021] [Accepted: 07/08/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The purpose of this study was to assess whether common biological factors are correlated with a longer hospital stay. STUDY DESIGN All patients having odontogenic cellulitis, treated from January 2019 to December 2019 at Lille University Hospital, and requiring surgical drainage under general anesthesia, were included, retrospectively. Data, such as length of hospital stay and biological factors, namely, C-reactive protein (CRP) level, Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score, and bacterial samples were collected. RESULTS Significant moderate-strong correlations were found between postoperative length of stay and patients' LRINEC score (rs = 0.556) and presurgical CRP level (rs = 0.579). There was a significant moderate correlation between postoperative length of stay and presurgical procalcitonin level (rs = 0.451), and a weak correlation between postoperative length of stay and presurgical white blood cell count (rs = 0.282). Linear regression verified CRP as an independent predictor of length of hospital stay, showing a significant linear relationship between them (p < 0.0001). A significant regression equation was found (F(1,65) = 27.089; p = 0.0001), with an R2 of 0.294. CONCLUSION In this study, CRP was the key biological predictor of length of hospital stay. STATEMENT OF CLINICAL RELEVANCE The ability to predict length of hospital stay and identify patients requiring intensive care management, using simple and inexpensive biological parameters (such as CRP), will enable more cost-effective care and efficient hospital bed management.
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Affiliation(s)
- Louis Bègue
- University Lille, Department of Oral and Maxillofacial Surgery, CHU Lille, F-59000 Lille, France
| | - Matthias Schlund
- University Lille, Department of Oral and Maxillofacial Surgery, CHU Lille, INSERM U 1008, Controlled Drug Delivery Systems and Biomaterials, F-59000 Lille, France
| | - Gwénaël Raoul
- University Lille, Department of Oral and Maxillofacial Surgery, CHU Lille, INSERM U 1008, Controlled Drug Delivery Systems and Biomaterials, F-59000 Lille, France
| | - Joël Ferri
- University Lille, Department of Oral and Maxillofacial Surgery, CHU Lille, INSERM U 1008, Controlled Drug Delivery Systems and Biomaterials, F-59000 Lille, France
| | - Ludovic Lauwers
- University Lille, Department of Oral and Maxillofacial Surgery, CHU Lille, F-59000 Lille, France
| | - Romain Nicot
- University Lille, Department of Oral and Maxillofacial Surgery, CHU Lille, INSERM U 1008, Controlled Drug Delivery Systems and Biomaterials, F-59000 Lille, France.
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Sideris G, Sapountzi M, Malamas V, Papadimitriou N, Maragkoudakis P, Delides A. Early detecting cervical necrotizing fasciitis from deep neck infections: a study of 550 patients. Eur Arch Otorhinolaryngol 2021; 278:4587-4592. [PMID: 33559743 DOI: 10.1007/s00405-021-06653-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 01/27/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE The aim of this retrospective review study is to evaluate Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score as an indicative parameter in early detecting cervical necrotizing fasciitis (CNF) from deep neck infections (DNI). METHODS We reviewed 12 cases of CNF and 538 cases of non-necrotizing deep neck infection hospitalized in our hospital over the last decade. Cervical necrotizing fasciitis was histologically confirmed. RESULTS Using an LRINEC score of 6 as a cutoff sensitivity was calculated at 100% (95% CI 99.9-100) and specificity 72.5% (95% CI 72.4-72.6). Negative predicted value (NPV) was 100% and positive predicted value (PPV) was 7.5%. C-reactive protein (CRP), white blood count (WBC), and glucose (Glu) levels have a higher correlation. Haemoglobin (Hb), sodium (Na), and creatinine (Cr) do not seem to have a big impact in our study. CONCLUSION LRINEC score proves to be a useful "rule-out" tool that works on the safe side with high sensitivity and poor specificity. WBC, CRP, and Glu seem to be the most significant variables of the LRINEC score. Hb, Na, and Cr make the score safer. Decision for surgery must be based on medical history, clinical symptoms and signs, imaging findings, and laboratory tests and not according to the LRINEC score itself.
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Affiliation(s)
- Giorgos Sideris
- 2nd Otolaryngology Department, School of Medicine, "Attikon" University Hospital, National and Kapodistrian University of Athens, Rimini 1, Chaidari, 124 62, Athens, Greece.
| | - Marilia Sapountzi
- 2nd Otolaryngology Department, School of Medicine, "Attikon" University Hospital, National and Kapodistrian University of Athens, Rimini 1, Chaidari, 124 62, Athens, Greece
| | - Vangelis Malamas
- Department of Informatics, University of Piraeus, Piraeus, Greece
| | - Nikolaos Papadimitriou
- 2nd Otolaryngology Department, School of Medicine, "Attikon" University Hospital, National and Kapodistrian University of Athens, Rimini 1, Chaidari, 124 62, Athens, Greece
| | - Pavlos Maragkoudakis
- 2nd Otolaryngology Department, School of Medicine, "Attikon" University Hospital, National and Kapodistrian University of Athens, Rimini 1, Chaidari, 124 62, Athens, Greece
| | - Alexander Delides
- 2nd Otolaryngology Department, School of Medicine, "Attikon" University Hospital, National and Kapodistrian University of Athens, Rimini 1, Chaidari, 124 62, Athens, Greece
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Necrotizing Soft Tissue Infection: Diagnostic Accuracy of Physical Examination, Imaging, and LRINEC Score: A Systematic Review and Meta-Analysis. Ann Surg 2019; 269:58-65. [PMID: 29672405 DOI: 10.1097/sla.0000000000002774] [Citation(s) in RCA: 142] [Impact Index Per Article: 28.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE We sought to summarize accuracy of physical examination, imaging, and Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score in diagnosis of necrotizing soft tissue infection (NSTI) in adults with a soft tissue infection clinically concerning for NSTI. SUMMARY OF BACKGROUND DATA NSTI is a life-threatening diagnosis. Delay to diagnosis and surgical management is associated with increased mortality. METHODS We searched 6 databases from inception through November 2017. We included English-language studies reporting diagnostic accuracy of testing or LRINEC Score. Outcome was NSTI confirmed by surgery or histopathology. Two reviewers screened all citations and extracted data independently. Summary measures were obtained from the Hierarchical Summary Receiver Operating Characteristic model. RESULTS From 2,290 citations, we included 23 studies (n = 5982). Of physical examination signs, pooled sensitivity and specificity for fever was 46.0% and 77.0% respectively, for hemorrhagic bullae 25.2% and 95.8%, and for hypotension 21.0% and 97.7%. Computed tomography (CT) had sensitivity of 88.5% and specificity of 93.3%, while plain radiography had sensitivity of 48.9% and specificity of 94.0%. Finally, LRINEC ≥ 6 had sensitivity of 68.2% and specificity of 84.8%, while LRINEC ≥ 8 had sensitivity of 40.8% and specificity of 94.9%. CONCLUSIONS Absence of any 1 physical examination feature (eg, fever or hypotension) is not sufficient to rule-out NSTI. CT is superior to plain radiography. LRINEC had poor sensitivity, and should not be used to rule-out NSTI. Given the poor sensitivity of these tests, a high clinical suspicion warrants early surgical consultation for definitive diagnosis and management.
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Gore MR. Odontogenic necrotizing fasciitis: a systematic review of the literature. BMC EAR, NOSE, AND THROAT DISORDERS 2018; 18:14. [PMID: 30127662 PMCID: PMC6094465 DOI: 10.1186/s12901-018-0059-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 07/11/2018] [Indexed: 02/03/2023]
Abstract
Background While odontogenic soft tissue infections of the head and neck are common, progression to necrotizing fasciitis is relatively rare. Necrotizing fasciitis is a potentially life-threatening and rapidly progressive soft tissue infection that can lead to significant skin and soft tissue loss, mediastinitis, vascular thrombosis or rupture, limb loss, organ failure, and death. Methods A PubMed literature search was conducted for case reports and case series on odontogenic necrotizing fasciitis. Individual patient data was analyzed and compiled and demographic, treatment, microbiology, and mortality data were extracted. Fisher’s exact test was used to examine the relationship between death from odontogenic necrotizing fasciitis and diabetes mellitus (DM) and human immunodeficiency virus (HIV) positivity. Results A total of 58 studies totaling 164 patients were identified. Thirty-three patients had DM and 3 were HIV +. All patients underwent aggressive surgical debridement and treatment with IV antibiotics. Twenty patients were also treated with hyperbaric oxygen. There were 16 deaths reported, for a mortality rate of 9.8%. The mortality rate among patients with DM was 30.3 and 0% among HIV positive patients. There was a statistically significant increase in the mortality rate in DM patients with odontogenic necrotizing fasciitis (p = 0.0001, odds ratio for death 9.1). Conclusions Necrotizing fasciitis arising from odontogenic infection is a rapidly progressive and life-threatening illness. Prompt recognition of the infection, aggressive and often serial surgical debridement, and aggressive broad-spectrum antibiotics are necessary to prevent serious morbidity and mortality. Patients with diabetes mellitus are at a significantly increased risk of death from odontogenic necrotizing fasciitis.
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Fais P, Viero A, Viel G, Giordano R, Raniero D, Kusstatscher S, Giraudo C, Cecchetto G, Montisci M. Necrotizing fasciitis: case series and review of the literature on clinical and medico-legal diagnostic challenges. Int J Legal Med 2018; 132:1357-1366. [PMID: 29627916 DOI: 10.1007/s00414-018-1838-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 03/27/2018] [Indexed: 12/19/2022]
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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Affiliation(s)
- Paolo Fais
- Department of Medical and Surgical Sciences (DIMEC), Institute of Legal Medicine, University of Bologna, Bologna, Italy
| | - Alessia Viero
- Department of Legal and Occupational Medicine, Toxicology and Public Health, University-Hospital of Padova, Via Falloppio 50, 35128, Padova, Italy
| | - Guido Viel
- Department of Legal and Occupational Medicine, Toxicology and Public Health, University-Hospital of Padova, Via Falloppio 50, 35128, Padova, Italy.
| | - Renzo Giordano
- Department of Legal and Occupational Medicine, Toxicology and Public Health, University-Hospital of Padova, Via Falloppio 50, 35128, Padova, Italy
| | - Dario Raniero
- Department of Public Health and Community Medicine, Unit of Forensic Medicine, University of Verona, P.le L.A. Scuro 10, Verona, Italy
| | | | - Chiara Giraudo
- Institute of Radiology, Department of Medicine (DiMED), University-Hospital Padova, Via Giustiniani 2, 35128, Padova, Italy
| | - Giovanni Cecchetto
- Department of Legal and Occupational Medicine, Toxicology and Public Health, University-Hospital of Padova, Via Falloppio 50, 35128, Padova, Italy
| | - Massimo Montisci
- Department of Legal and Occupational Medicine, Toxicology and Public Health, University-Hospital of Padova, Via Falloppio 50, 35128, Padova, Italy
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