Fatal necrotizing fasciitis caused by a toothpick injury

Clinical Parameters and Challenges of Managing Cervicofacial Necrotizing Fasciitis in a Sub-Saharan Tertiary Hospital

INTRODUCTION

Necrotizing fasciitis is a severe soft tissue infection. In our environment, patients presenting with this infection are usually financially incapacitated and, therefore, their management can be challenging. This paper aimed to document the pattern and challenges encountered in the management of cervicofacial necrotizing fasciitis (CNF) in the University College Hospital, Ibadan.

MATERIALS AND METHODS

Information such as biodata, site of infection, systemic conditions, widest span of defect, management provided, hospital stay, and outcome of management was prospectively collected on all patients with CNF who presented at the Department of Oral and Maxillofacial Surgery between January 2007 and December 2013. The patients were managed according to a devised protocol of antibiotic therapy, serial debridement and honey dressings.

RESULTS

Twenty-four cases of CNF were seen. There were 9 males and 15 females while 70.9% of the patients belonged to the low socioeconomic class. The mean span of wound defect was 12.2 (±8.844) cm. The mean hospital stay was 27.8 (±23.1) days, and scar formation was the most common complication encountered.

CONCLUSION

Our study represents the largest series of CNF from a Nigerian health facility presently. The management of necrotizing fascitis in the maxillofacial region poses a significant challenge to both the surgeon and the patient. However, the mortality rate of CNF in our center appears comparatively low.

Toothpick puncture injuries of the foot in children

We reviewed the medical records of five children seen between January 1997 and September 2003 for toothpick puncture injuries of the foot. Failure to visualize retained toothpicks by plain radiographs delayed early removal. Patients subsequently developed recurrent foot cellulitis, complicated by foot osteomyelitis in three cases. Ultrasound, computed tomography or magnetic resonance imaging detected the toothpicks. These imaging tools should be considered for initial evaluation of these patients.

Necrotizing fasciitis: a 10-year retrospective study of cases in a single university hospital in Oman

OBJECTIVE

(1) To study the clinical profile of all cases of necrotizing fasciitis (NF) diagnosed in a university hospital in Oman. (2) To evolve a strategy for early diagnosis.

PATIENTS AND METHODS

The inpatient records of the Sultan Qaboos University hospital from 1990-99 were searched for the words "fasciitis", "necrosis" or "gangrene" and cases of NF (defined as a soft tissue infection characterized by widespread necrosis of the subcutaneous tissues confirmed at surgery or pathology or both) were selected and analyzed. Cases with necrosis due to other obvious causes were excluded.

RESULTS

Of the seven cases of NF (hospital incidence-8.4/10(5)), there were three post-operative, three spontaneous and one post-traumatic. Sites involved: upper limb (1), lower limb (2), abdomen (2), gluteal (1), and breasts (1). The median age was 50 years (range 21-85) and the male:female ratio was 4:3. All patients had local pain out of proportion to the signs and six had fever. Hypotension, liver or kidney dysfunction or coagulopathy were seen in four and a drop in haemoglobin was seen in six. In none was NF even considered by the referring or admitting physician, diagnosis being delayed by 2-10 days. In four cases a diagnostic incision under local anesthesia revealed the correct diagnosis. At surgery, extensive fascial and fat necrosis were seen in all, but only two had myonecrosis. The commonest isolate was beta-hemolytic group D streptococcus (4/7). Blood and tissue were positive for beta-hemolytic group A streptococci in one fatal case. Mean hospital stay was 54.5 days (11-134), mean surgical procedures were 2.3 per case, two required ICU admission with one death.

CONCLUSION

NF is a rare but serious bacterial disease that is often incorrectly diagnosed. Unexplained severe local pain, deep tenderness without impressive local signs, fall in haemoglobin, organ system dysfunction and constitutional upsets were regular features. A high index of suspicion and immediate direct inspection of the fascia facilitates an early diagnosis.

Necrotizing fasciitis of odontogenic origin in Ibadan, Nigeria

We reviewed eight patients with necrotizing fasciitis of odontogenic origin. There were three women and five men, mean age 58 (range 46-72), and none had any associated medical condition such as diabetes. All cases had symptoms of toothache for a mean duration of 34 days (range 26-42) before they sought treatment. Infection originated in the molar teeth region, and initially presented as an odontogenic or periodontal abscess. The clinical features of necrotizing fasciitis became apparent only after the superficial fascia had been invaded. The transient unusually reddish hue for a dark skin might be explained by the fact the deep fascia and muscles were affected before the superficial fascia and skin. Necrosis of the skin began in the submandibular region and progressed downwards. The necrotic area was less than the extent of infection. Antimicrobial treatment, debridement, and fasciotomy improved healing. Delay before appropriate treatment had an adverse affect on outcome, and one patient died.

Necrotizing fasciitis: reports of three fatal cases simulating and resulting from assaults

Necrotizing fasciitis is a progressive, potentially fatal, rapid, necrotizing infection of the subcutaneous tissues and fascia often caused by a mixture of organisms or by infection with group A Streptococcus pyogenes with or without Staphylococcus aureus. Three cases are presented that have been encountered in forensic pathologic practice. Two cases presented after assaults, and the third simulated an assault and burglary. The history, scene, and pathologic findings are presented with a brief review of the literature.

Bacterial and protozoal infections

The oral cavity is a common site for manifestations of systemic microbial diseases. Oral lesions may be typical of those seen elsewhere on the body, or the lesions may be modified by the local environment. The ease of examination within the oral cavity, however, and any site-specific features facilitates diagnosis of the systemic condition.