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Haykal S, Hadzimustafic N, Ghazarian D, Musgrave M. Three Ds for diagnosing necrotizing fasciitis by front-line clinicians. J Plast Reconstr Aesthet Surg 2023; 84:37-46. [PMID: 37320950 DOI: 10.1016/j.bjps.2023.05.020] [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] [Received: 08/23/2022] [Revised: 04/01/2023] [Accepted: 05/15/2023] [Indexed: 06/17/2023]
Abstract
INTRODUCTION Necrotizing fasciitis (NF) is a life-threatening infection and a surgical emergency. Not all clinicians have the experience or resources to detect NF in its early stages. OBJECTIVE To develop a diagnostic algorithm for primary care and emergency physicians to identify patients with possible NF, including an initial approach to triaging such individuals. METHODS Medline was searched to identify studies of validated algorithms for NF diagnosis and/or cohort or case series providing clinical and diagnostic features of NF. Candidate algorithms were validated via application to 3 published cases of initially misdiagnosed NF. We retrospectively reviewed NF cases between 2011 and 2022 at our center to validate our algorithm. RESULTS The search yielded 540 articles; 109 were included following a review of abstracts. No published validated diagnostic algorithm was identified. Using the reported clinical and diagnostic features of NF, we generated an algorithm of the "3Ds" of NF: Disproportionate pain, Dermatological findings, and Disorganized physiology. A larger number of Ds indicated a greater level of suspicion for NF and prioritization for urgent surgical consultation. In 3 published cases of missed NF, the 3Ds algorithm successfully identified all as having possible NF. On reviewing our cases, we identified 56 patients with NF during an 11 year period. 66% of whom had the 3Ds at their initial presentation. DISCUSSION The 3Ds algorithm, a simple and easy-to-remember tool can be easily applied in a primary or emergency care setting, and may improve the early diagnosis of NF. Retrospective analysis of NF cases allows for validation of this algorithm. However, this algorithm requires prospective validation.
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Affiliation(s)
- Siba Haykal
- Division of Plastic and Reconstructive Surgery, University Health Network, Toronto General Hospital, Department of Surgery, University of Toronto, Canada.
| | | | - Danny Ghazarian
- Department of Pathology, University Health Network, Toronto General Hospital, University of Toronto, Canada
| | - Melinda Musgrave
- Division of Plastic and Reconstructive Surgery, St. Michael's Hospital, Department of Surgery, University of Toronto, Canada
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Kim MJ, Shin SH, Park JY. Medicolegal implications from litigations involving necrotizing fasciitis. Ann Surg Treat Res 2020; 99:131-137. [PMID: 32908844 PMCID: PMC7463042 DOI: 10.4174/astr.2020.99.3.131] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 06/04/2020] [Accepted: 06/25/2020] [Indexed: 11/30/2022] Open
Abstract
PURPOSE Necrotizing fasciitis (NF) is one of the most severe healthcare-associated infections. Early diagnosis of NF is difficult because of nonspecific signs and symptoms in the early stage. NF often presents with risks of medicolegal disputes. This study aimed to provide baseline data on the general characteristics of medical accidents involving NF, features of NF, and typical court opinions regarding medical malpractice in Korea. METHODS In this study, 25 cases of medical malpractice litigation involving NF sentenced between 1998 and 2018 were analyzed with respect to 3 variables: medical accident, NF, and breach of duty. RESULTS The department of colorectal surgery was most frequently involved in litigation cases (40.0%), and colorectal surgery was the most frequent procedure before the diagnosis of NF (40.0%). The most common sites were the upper and lower extremities. The courts agreed that there was typically improper monitoring after treatment, frequently related to NF. CONCLUSION These litigation cases imply that physicians cannot be blamed for the failure to prevent NF. The timely recognition and management of NF might be considered as one of the main factors for deciding malpractice in court. Therefore, surgeons, especially in the department of colorectal surgery, should pay attention to changes in the patient's status after surgery. Surgeons need to learn from medical accidents, as it is important for risk management, preventing the occurrence of similar cases, and improving the quality of healthcare services. We report the medicolegal implications from medical lawsuits involving NF.
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Affiliation(s)
- Min Ji Kim
- Department of Medical Law and Ethics, Graduate School, Yonsei University, Seoul, Korea
- Korea Medical Dispute Mediation and Arbitration Agency, Seoul, Korea
| | - Su Hwan Shin
- Department of Medical Law and Ethics, Graduate School, Yonsei University, Seoul, Korea
- Blue Urology Clinic, Seoul, Korea
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Arruda JA, Figueiredo E, Álvares P, Silva L, Silva L, Caubi A, Silveira M, Sobral AP. Cervical Necrotizing Fasciitis Caused by Dental Extraction. Case Rep Dent 2016; 2016:1674153. [PMID: 27375905 PMCID: PMC4916313 DOI: 10.1155/2016/1674153] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 05/16/2016] [Indexed: 11/18/2022] Open
Abstract
Cervical necrotizing fasciitis is an unusual infection characterized by necrosis of the subcutaneous tissue and fascial layers. Risk factors for the development of necrotizing fasciitis include diabetes mellitus, chronic renal disease, peripheral vascular disease, malnutrition, advanced age, obesity, alcohol abuse, intravenous drug use, surgery, and ischemic ulcers. This report presents a case of necrotizing fasciitis in the cervical area caused by dental extraction in a 73-year-old woman. Cervical necrotizing fasciitis in geriatric patient is rare, and even when establishing the diagnosis and having it timely treated, the patient can suffer irreversible damage or even death. Clinical manifestations in the head and neck usually have an acute onset characterized by severe pain, swelling, redness, erythema, presence of necrotic tissue, and in severe cases obstruction of the upper airways. Therefore, the presentation of this clinical case can serve as guidance to dentists as a precaution to maintain an aseptic chain and be aware of the clinical condition of older patients and the systemic conditions that may increase the risk of infections.
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Affiliation(s)
- José Alcides Arruda
- Faculdade de Odontologia de Pernambuco, Universidade de Pernambuco, Avenida General Newton Cavalcante, 1650 Aldeia dos Camarás, 54753-020 Camaragibe, PE, Brazil
| | - Eugênia Figueiredo
- Hospital da Restauração, Avenida Governador Agamenon Magalhães, S/N, Derby, 52010-040 Recife, PE, Brazil
| | - Pâmella Álvares
- Faculdade de Odontologia de Pernambuco, Universidade de Pernambuco, Avenida General Newton Cavalcante, 1650 Aldeia dos Camarás, 54753-020 Camaragibe, PE, Brazil
| | - Luciano Silva
- Faculdade de Odontologia de Pernambuco, Universidade de Pernambuco, Avenida General Newton Cavalcante, 1650 Aldeia dos Camarás, 54753-020 Camaragibe, PE, Brazil
| | - Leorik Silva
- Universidade Federal do Rio Grande do Norte, Campus Universitário Lagoa Nova, P.O. Box 1524, 59078-970 Natal, RN, Brazil
| | - Antônio Caubi
- Faculdade de Odontologia de Pernambuco, Universidade de Pernambuco, Avenida General Newton Cavalcante, 1650 Aldeia dos Camarás, 54753-020 Camaragibe, PE, Brazil
| | - Marcia Silveira
- Faculdade de Odontologia de Pernambuco, Universidade de Pernambuco, Avenida General Newton Cavalcante, 1650 Aldeia dos Camarás, 54753-020 Camaragibe, PE, Brazil
| | - Ana Paula Sobral
- Faculdade de Odontologia de Pernambuco, Universidade de Pernambuco, Avenida General Newton Cavalcante, 1650 Aldeia dos Camarás, 54753-020 Camaragibe, PE, Brazil
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Muldrew KL, Simpson JF, Stratton CW, Tang YW. Molecular diagnosis of necrotizing fasciitis by 16S rRNA gene sequencing and superantigen gene detection. J Mol Diagn 2006; 7:641-5. [PMID: 16258164 PMCID: PMC1867552 DOI: 10.1016/s1525-1578(10)60599-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
We report the use of molecular techniques in the diagnosis of a case of culture-negative necrotizing fasciitis occurring in a 32-year-old female with no significant past medical history and who died within 36 hours of admission. Paraffin-embedded tissue sections from the popliteal fossa region obtained at autopsy showed hemorrhage, necrosis, and mild inflammation by hematoxylin and eosin staining. Tissue gram stain showed numerous gram-positive organisms arranged in clusters. The sequences of the first 500 bp of bacterial 16S rRNA gene amplified from the lesion were identical to a Lancefield group A beta-hemolytic Streptococcus pyogenes. Streptococcal pyrogenic exotoxin A and B superantigen genes were detected and an emm type 1 was determined by polymerase chain reaction and sequencing from the lesion. This confirmed the etiology of the patient's rapid deterioration with multisystem organ failure.
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Affiliation(s)
- Kenneth L Muldrew
- Molecular Infectious Disease Laboratory, Vanderbilt University Hospital, 4605 TVC, Nashville, TN 37232-5310, USA
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Mulla ZD. Group A streptococcal necrotizing fasciitis: reducing the risk of unwarranted litigation. Am J Emerg Med 2005; 23:578-9. [PMID: 16032643 DOI: 10.1016/j.ajem.2004.12.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Costa IMC, Cabral ALSV, Pontes SSD, Amorim JFD. Fasciíte necrosante: revisão com enfoque nos aspectos dermatológicos. An Bras Dermatol 2004. [DOI: 10.1590/s0365-05962004000200010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Fasciíte necrosante é infecção bacteriana destrutiva e rapidamente progressiva do tecido subcutâneo e fáscia superficial, associada a altos índices de morbimortalidade, se não tiver tratamento precoce. Recentemente, inúmeros casos publicados têm demonstrado aumento na freqüência e gravidade dessa infecção, particularmente causada pelo Streptococcus do grupo A (GAS) e que acomete até mesmo pessoas jovens e saudáveis. Classifica-se em tipo I, quando causada por flora mista de anaeróbios e outras bactérias, e tipo II, quando causada pelo GAS isolado ou associado ao Staphylococcus aureus. Os fatores predisponentes incluem: doenças crônicas e malignas, abuso de álcool, uso de drogas endovenosas, lesões da pele como varicela, úlceras crônicas, psoríase, cirurgia, traumas abertos e fechados, entre outros. Clinicamente destacam-se: a dor intensa, o edema grave, a rápida progressão e a resposta pobre à antibioticoterapia. É necessário um alto índice de suspeição para o diagnóstico clínico, que é confirmado à intervenção cirúrgica, com a evidência de necrose da fáscia superficial. Os exames radiológicos são úteis, e o diagnóstico diferencial deve ser feito principalmente com celulite em seu estágio inicial. O tratamento, que deve ser precoce, é feito com antibióticos de amplo espectro, debridamento cirúrgico agressivo e medidas de suporte clínico e nutricional.
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Abstract
Necrotizing skin and soft tissue infections are caused by many different bacteria, are frequently polymicrobial, and may have a deceptively innocent early clinical presentation. Clostridial and nonclostridial necrotizing infections are frequently similar in their early presentation. The initial presentation of these infections can be insidious, which results in delay in diagnosis and the start of therapy. The clinician must use sound medical principles of clinical history and meticulous examination in each patient, combined with constant suspicion, to establish a timely diagnosis. This group of infectious diseases is associated with frequent morbidity and significant mortality rates, which increase with any delay in the diagnosis and the initiation of medical and surgical therapy. Also associated with these necrotizing infections is an excessive index of litigation. This review is intended as a guide for the clinician in making an early diagnosis of any necrotizing skin and soft tissue infection and initiating effective medical and surgical therapy.
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Affiliation(s)
- James A Majeski
- Surgical Services, Charleston Veterans Affairs Hospital, Charleston, SC, USA.
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