International Journal of Legal Medicine

, Volume 132, Issue 5, pp 1357–1366 | Cite as

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

  • Paolo Fais
  • Alessia Viero
  • Guido VielEmail author
  • Renzo Giordano
  • Dario Raniero
  • Stefano Kusstatscher
  • Chiara Giraudo
  • Giovanni Cecchetto
  • Massimo Montisci
Original Article


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.


Forensic pathology Clinical forensic medicine Necrotizing fasciitis Medical malpractice LRINEC score 

Supplementary material

414_2018_1838_Fig1_ESM.gif (423 kb)
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)

414_2018_1838_MOESM1_ESM.tiff (7.2 mb)
High resolution image (TIFF 7423 kb)
414_2018_1838_MOESM2_ESM.docx (39 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)
414_2018_1838_MOESM3_ESM.docx (29 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)


  1. 1.
    Wilson B (1952) Necrotizing fasciitis. Am Surg 18:416–431PubMedGoogle Scholar
  2. 2.
    Descamps V, Aitken J, Lee MG (1994) Hippocrates on necrotising fasciitis. Lancet 344:556CrossRefPubMedGoogle Scholar
  3. 3.
    Roje Z, Matic D, Librenjak D, Dokuzovic S, Varvodic J (2011) Necrotizing fasciitis: literature review of contemporary strategies for diagnosing and management with three case reports: torso, abdominal wall, upper and lower limbs. World J Emerg Surg 6:46CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Morgan MS (2010) Diagnosis and management of necrotising fasciitis: a multiparametric approach. J Hosp Infect 75:249–257CrossRefPubMedGoogle Scholar
  5. 5.
    Murphy G, Markeson D, Choa R, Armstrong A (2013) Raised serum lactate: a marker of necrotizing fasciitis? J Plast Reconstr Aesthet Surg 66:1712–1716CrossRefPubMedGoogle Scholar
  6. 6.
    Wong CH, Khin LW, Heng KS, Tan KC, Low CO (2004) The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections. Crit Care Med 32:1535–1541CrossRefPubMedGoogle Scholar
  7. 7.
    Wall DB, Klein SR, Black S, de Virgilio C (2000) A simple model to help distinguish necrotizing fasciitis from nonnecrotizing soft tissue infection. J Am Coll Surg 191:227–231CrossRefPubMedGoogle Scholar
  8. 8.
    Ferrara SD (2013) Medical malpractice and legal medicine. Int J Legal Med 127(3):541–543CrossRefPubMedGoogle Scholar
  9. 9.
    Ferrara SD, Baccino E, Bajanowski T et al (2013) Malpractice and medical liability. European Guidelines on Methods of Ascertainment and Criteria of Evaluation. Int J Legal Med 127:545–557CrossRefPubMedGoogle Scholar
  10. 10.
    Rutty GN, Busuttil A (2000) Necrotizing fasciitis: reports of three fatal cases simulating and resulting from assaults. Am J Forensic Med Pathol 21:151–154CrossRefPubMedGoogle Scholar
  11. 11.
    Callister ME, Wall RA (2001) Descending necrotizing mediastinitis caused by group a streptococcus (serotype M1T1). Scand J Infect Dis 33:771–772CrossRefPubMedGoogle Scholar
  12. 12.
    Francque SM, Van Laer C, Struyf N, Vermeulen P, Corthouts B, Jorens PG (2001) Perforating oesophageal carcinoma presenting as necrotizing fasciitis of the neck. Eur J Gastroenterol Hepatol 13:1261–1264CrossRefPubMedGoogle Scholar
  13. 13.
    McGuigan CC, Penrice GM, Gruer L et al (2002) Lethal outbreak of infection with Clostridium novyi type A and other spore-forming organisms in Scottish injecting drug users. J Med Microbiol 51:971–977CrossRefPubMedGoogle Scholar
  14. 14.
    Finn SP, Leen E, English L, O'Briain DS (2003) Autopsy findings in an outbreak of severe systemic illness in heroin users following injection site inflammation: an effect of Clostridium novyi exotoxin? Arch Pathol Lab Med 127:1465–1470PubMedGoogle Scholar
  15. 15.
    Abella BS, Kuchinic P, Hiraoka T, Howes DS (2003) Atraumatic Clostridial myonecrosis: case report and literature review. J Emerg Med 24:401–405CrossRefPubMedGoogle Scholar
  16. 16.
    Porter CJ, Simcock JW, MacKinnon CA (2005) Necrotising fasciitis and cellulitis after traditional Samoan tattooing: case reports. J Inf Secur 50:149–152Google Scholar
  17. 17.
    Muldrew KL, Simpson JF, Stratton CW, Tang YW (2005) Molecular diagnosis of necrotizing fasciitis by 16S rRNA gene sequencing and superantigen gene detection. J Mol Diagn 7(5):641–645CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Yang Z, Lavelle JC, Reilly SD (2006) A 51-year-old man with acute dyspnea and leg swelling. Lab Med 37:611–612CrossRefGoogle Scholar
  19. 19.
    Matsubara K, Mikamo H, Numa M, Yamamoto G, Kusano H, Takamine Y (2006) Three fatal cases of invasive serotype VI group B streptococcal infection. J Inf Secur 53:e139–e142Google Scholar
  20. 20.
    Hidalgo-Carballal A, Suarez-Mier MP (2006) Sudden unexpected death in a child with varicella caused by necrotizing fasciitis and streptococcal toxic shock syndrome. Am J Forensic Med Pathol 27:93–96CrossRefPubMedGoogle Scholar
  21. 21.
    Batalis NI, Caplan MJ, Schandl CA (2007) Acute deaths in nonpregnant adults due to invasive streptococcal infections. Am J Forensic Med Pathol 28:63–68CrossRefPubMedGoogle Scholar
  22. 22.
    Muldrew KL, Miller RR, Kressin M, Tang YW, Stratton C (2007) Necrotizing fasciitis from Vibrio vulnificus in a patient with undiagnosed hepatitis and cirrhosis. J Clin Microbiol 45:1058–1062CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Dunbar NM, Harruff RC (2007) Necrotizing fasciitis: manifestations, microbiology and connection with black tar heroin. J Forensic Sci 52:920–923CrossRefPubMedGoogle Scholar
  24. 24.
    Sugimoto T, Nakazawa J, Yomoda M et al (2007) Necrotizing fasciitis resulting from Escherichia coli in a patient with chronic rheumatoid arthritis. APLAR J Rheumatol 10:57–59CrossRefGoogle Scholar
  25. 25.
    Christensen RD, Pysher TJ, Christensen SS (2007) Case report: perianal necrotizing fasciitis in a near-term neonate. J Perinatol 27:390–391CrossRefPubMedGoogle Scholar
  26. 26.
    Bono G, Argo A, Zerbo S, Triolo V, Procaccianti P (2008) Cervical necrotizing fasciitis and descending necrotizing mediastinitis in a patient affected by neglected peritonsillar abscess: a case of medical negligence. J Forensic Legal Med 15:391–394CrossRefGoogle Scholar
  27. 27.
    Tajiri T, Tate G, Akita H, Ohike N, Masunaga A, Kunimura T, Mitsuya T, Morohoshi T (2008) Autopsy cases of fulminant-type bacterial infection with necrotizing fasciitis: group A (beta) hemolytic Streptococcus pyogenes versus Vibrio vulnificus infection. Pathol Int 58:196–202CrossRefPubMedGoogle Scholar
  28. 28.
    Akamine M, Miyagi K, Uchihara T, Azuma M, Yara S, Higa F, Haranaga S, Tateyama M, Matsuzaki A, Nakayama T, Fujita J (2008) Necrotizing fasciitis caused by Pseudomonas aeruginosa. Intern Med 47(6):553–556CrossRefPubMedGoogle Scholar
  29. 29.
    Tajiri T, Tate G, Miura K, Masuda S, Ohike N, Kunimura T, Mitsuya T, Morohoshi T (2008) Sudden death caused by fulminant bacterial infection: background and pathogenesis of Japanese adult cases. Intern Med 47:1499–1504CrossRefPubMedGoogle Scholar
  30. 30.
    Loughnan BA, Grover M, Nielsen PB (2010) Maternal death due to extended spectrum beta-lactamase-producing E. coli: a warning for the future? Int J Obstet Anesth 19:327–330CrossRefPubMedGoogle Scholar
  31. 31.
    Sugiyama T, Kobayashi T, Nagao K, Hatada T, Wada H, Sagawa N (2010) Group A streptococcal toxic shock syndrome with extremely aggressive course in the third trimester. J Obstet Gynaecol Res 36:852–855CrossRefPubMedGoogle Scholar
  32. 32.
    Radovan K, Ilic G, Antovic A, Banovic LK, Miroslav M, Marina D (2011) Rapidly fatal necrotizing fasciitis: report of three cases. Rom J Legal Med 19:95–100Google Scholar
  33. 33.
    Heinze S, Puschel K, Tsokos M (2011) Necrotizing fasciitis with fatal outcome: a report of two cases. Forensic Sci Med Pathol 7:278–282CrossRefPubMedGoogle Scholar
  34. 34.
    Iwata K, Arinuma Y, Nakayama H, Nogi S, Futami H, Takaoka H, Hashimoto A, Shimada K, Komiya A, Matsui T, Saito I, Tohma S (2011) An autopsy case of necrotizing fasciitis with rapidly progressive purpura caused by hemolytic streptococcal infection in a patient with rheumatoid arthritis. Mod Rheumatol 21:669–672CrossRefPubMedGoogle Scholar
  35. 35.
    Reinders JSK, Schuurman JP, de Vries JPPM, Biemond-Moeniralam HS, Vlaminckx BJM, Wille J (2011) Severe necrotizing soft tissue disease. Netherlands. J Crit Care 15:212–217CrossRefGoogle Scholar
  36. 36.
    van der Oord BM, Hol C, Manten B (2011) An exceptional case of streptococcal toxic shock syndrome. Netherlands. J Crit Care 15:27–29Google Scholar
  37. 37.
    Reisman JS, Weinberg A, Ponte C, Kradin R (2012) Monomicrobial Pseudomonas necrotizing fasciitis: a case of infection by two strains and a review of 37 cases in the literature. Scand J Infect Dis 44:216–221CrossRefPubMedGoogle Scholar
  38. 38.
    Kiratisin P, Leelaporn A, Sangruchi T (2012) Vibrio vulnificus septicemia in Thailand: a 12-year case series and report of two fatal massive rhabdomyolysis cases. Asian. Biomedicine 6:495–502Google Scholar
  39. 39.
    Tajiri T, Tate G, Masunaga A, Mitsuya T, Miura K, Masuda S, Kunimura T, Morohoshi T (2012) Autopsy cases of fulminant bacterial infection in adults: clinical onset depends on the virulence of bacteria and patient immune status. J Infect Chemother 18:637–645CrossRefPubMedGoogle Scholar
  40. 40.
    Suzuki H, Hikiji W, Shigeta A, Fukunaga T (2013) An autopsy case of a homeless person with unilateral lower extremity edema. Leg Med (Tokyo) 15:209–212CrossRefGoogle Scholar
  41. 41.
    Cope TE, Cope W, Beaumont DM (2013) A case of necrotising fasciitis caused by Serratia marsescens: extreme age as functional immunosuppression? Age Ageing 42:266–268CrossRefPubMedGoogle Scholar
  42. 42.
    Fernando DM, Kaluarachchi CI, Ratnatunga CN (2013) Necrotizing fasciitis and death following an insect bite. Am J Forensic Med Pathol 34:234–236CrossRefPubMedGoogle Scholar
  43. 43.
    Hourmozdi JJ, Hawley DA, Hadi CM, Tahir B, Seupaul RA (2014) Streptococcal necrotizing myositis: a case report and clinical review. J Emerg Med 46:436–442CrossRefPubMedGoogle Scholar
  44. 44.
    Wu YE, Baras A, Cornish T, Riedel S, Burton EC (2014) Fatal spontaneous Clostridium septicum gas gangrene: a possible association with iatrogenic gastric acid suppression. Arch Pathol Lab Med 138:837–841CrossRefPubMedGoogle Scholar
  45. 45.
    Vongpaisarnsin K, Tansrisawad N, Hoonwijit U, Jongsakul T (2015) Pseudomonas aeruginosa septicemia causes death following liposuction with allogenic fat transfer and gluteal augmentation. Int J Legal Med 129:815–818CrossRefPubMedGoogle Scholar
  46. 46.
    Yonekura S, Kodama M, Murano S, Kishi H, Toyoda A (2016) Richter's type of incarcerated obturator hernia that presented with a deep femoral abscess: an autopsy case report. Am J Case Rep 17:830–833CrossRefPubMedPubMedCentralGoogle Scholar
  47. 47.
    Rellinger EJ, Craig BT, Craig-Owens LD, Pacheco MC, Chung DH, Danko ME (2016) Clostridium sordellii necrotizing omphalitis: a case report and literature review. J Pediatr Surg Case Rep 10:35–38CrossRefGoogle Scholar
  48. 48.
    Wang TL, Hung CR (2004) Role of tissue oxygen saturation monitoring in diagnosing necrotizing fasciitis of the lower limbs. Ann Emerg Med 44:222–228CrossRefPubMedGoogle Scholar
  49. 49.
    Wong CH, Wang YS (2005) The diagnosis of necrotizing fasciitis. Curr Opin Infect Dis 18:101–106CrossRefPubMedGoogle Scholar
  50. 50.
    Wong CH (2005) Tissue oxygen saturation monitoring in diagnosing necrotizing fasciitis of the lower limb: a valuable tool but only for a select few. Ann Emerg Med 45:461–462 author reply 2-3CrossRefPubMedGoogle Scholar
  51. 51.
    Wong CH, Khin LW (2005) Clinical relevance of the LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score for assessment of early necrotizing fasciitis. Crit Care Med 33:1677CrossRefPubMedGoogle Scholar
  52. 52.
    Wang TL (2005) In reply. Ann Emerg Med 45:462–463CrossRefGoogle Scholar
  53. 53.
    Su YC, Chen HW, Hong YC, Chen CT, Hsiao CT, Chen IC (2008) Laboratory risk indicator for necrotizing fasciitis score and the outcomes. ANZ J Surg 78:968–972CrossRefPubMedGoogle Scholar
  54. 54.
    Thomas AJ, Meyer TK (2012) Retrospective evaluation of laboratory-based diagnostic tools for cervical necrotizing fasciitis. Laryngoscope 122:2683–2687CrossRefPubMedGoogle Scholar
  55. 55.
    Liao CI, Lee Y-K, Su Y-C, Chuang C-H, Wong C-H (2012) Validation of the laboratory risk indicator for necrotizing fasciitis (LRINEC) score for early diagnosis of necrotizing fasciitis. Tzu Chi Med J 24:73–76CrossRefGoogle Scholar
  56. 56.
    Chao WN, Tsai SJ, Tsai CF, Su CH, Chan KS, Lee YT, Ueng KC, Lin DB, Chen CC, Chen SC (2012) The Laboratory Risk Indicator for Necrotizing Fasciitis score for discernment of necrotizing fasciitis originated from Vibrio vulnificus infections. J Trauma Acute Care Surg 73:1576–1582CrossRefPubMedGoogle Scholar
  57. 57.
    Swain RA, Hatcher JC, Azadian BS, Soni N, De Souza B (2013) A five-year review of necrotising fasciitis in a tertiary referral unit. Ann R Coll Surg Engl 95:57–60CrossRefPubMedPubMedCentralGoogle Scholar
  58. 58.
    Bozkurt O, Sen V, Demir O, Esen A (2015) Evaluation of the utility of different scoring systems (FGSI, LRINEC and NLR) in the management of Fournier's gangrene. Int Urol Nephrol 47:243–248CrossRefPubMedGoogle Scholar
  59. 59.
    Hodgins N, Damkat-Thomas L, Shamsian N, Yew P, Lewis H, Khan K (2015) Analysis of the increasing prevalence of necrotising fasciitis referrals to a regional plastic surgery unit: a retrospective case series. J Plast Reconstr Aesthet Surg 68:304–311CrossRefPubMedGoogle Scholar
  60. 60.
    Sandner A, Moritz S, Unverzagt S, Plontke SK, Metz D (2015) Cervical necrotizing fasciitis—the value of the laboratory risk indicator for necrotizing fasciitis score as an indicative parameter. J Oral Maxillofac Surg 73:2319–2333CrossRefPubMedGoogle Scholar
  61. 61.
    Borschitz T, Schlicht S, Siegel E, Hanke E, von Stebut E (2015) Improvement of a clinical score for necrotizing fasciitis: ‘pain out of proportion’ and high CRP levels aid the diagnosis. PLoS One 10:e0132775CrossRefPubMedPubMedCentralGoogle Scholar
  62. 62.
    Kincius M, Telksnys T, Trumbeckas D, Jievaltas M, Milonas D (2016) Evaluation of LRINEC scale feasibility for predicting outcomes of Fournier gangrene. Surg Infect 17:448–453CrossRefGoogle Scholar
  63. 63.
    Putnam LR, Richards MK, Sandvall BK, Hopper RA, Waldhausen JH, Harting MT (2016) Laboratory evaluation for pediatric patients with suspected necrotizing soft tissue infections: a case-control study. J Pediatr Surg 51:1022–1025CrossRefPubMedGoogle Scholar
  64. 64.
    Burner E, Henderson SO, Burke G, Nakashioya J, Hoffman JR (2016) Inadequate sensitivity of laboratory risk indicator to rule out necrotizing fasciitis in the emergency department. West J Emerg Med 17:333–336CrossRefPubMedPubMedCentralGoogle Scholar
  65. 65.
    Tan JH, Koh BT, Hong CC et al (2016) A comparison of necrotising fasciitis in diabetics and non-diabetics: a review of 127 patients. Bone Joint J 98-B:1563–1568CrossRefPubMedGoogle Scholar
  66. 66.
    Bechar J, Sepehripour S, Hardwicke J, Filobbos G (2017) Laboratory risk indicator for necrotising fasciitis (LRINEC) score for the assessment of early necrotising fasciitis: a systematic review of the literature. Ann R Coll Surg Engl 99:341–346CrossRefPubMedPubMedCentralGoogle Scholar
  67. 67.
    Neeki MM, Dong F, Au C, Toy J, Khoshab N, Lee C, Kwong E, Yuen H, Lee J, Ayvazian A, Lux P, Borger R (2017) Evaluating the laboratory risk indicator to differentiate cellulitis from necrotizing fasciitis in the emergency department. West J Emerg Med 18:684–689CrossRefPubMedPubMedCentralGoogle Scholar
  68. 68.
    Narasimhan V, Ooi G, Weidlich S, Carson P (2017) Laboratory Risk Indicator for Necrotizing Fasciitis score for early diagnosis of necrotizing fasciitis in Darwin. ANZ J Surg 87:1062CrossRefPubMedGoogle Scholar
  69. 69.
    Zemplenyi K, Lopez B, Sardesai M, Dillon JK (2017) Can progression of odontogenic infections to cervical necrotizing soft tissue infections be predicted? Int J Oral Maxillofac Surg 46:181–188CrossRefPubMedGoogle Scholar
  70. 70.
    El-Menyar A, Asim M, Mudali IN, Mekkodathil A, Latifi R, Al-Thani H (2017) The laboratory risk indicator for necrotizing fasciitis (LRINEC) scoring: the diagnostic and potential prognostic role. Scand J Trauma Resusc Emerg Med 25:28CrossRefPubMedPubMedCentralGoogle Scholar
  71. 71.
    Poeze M, Greve JWM, Ramsay G (1996) Necrotizing Fasciitis. In: Vincent J-L (ed) Yearbook of intensive care and emergency medicine. Springer, Berlin, pp 533–541CrossRefGoogle Scholar
  72. 72.
    Chaudhry AA, Baker KS, Gould ES, Gupta R (2015) Necrotizing fasciitis and its mimics: what radiologists need to know. Am J Roentgenol 204:128–139CrossRefGoogle Scholar
  73. 73.
    Fugitt JB, Puckett ML, Quigley MM, Kerr SM (2004) Necrotizing fasciitis. Radiographics 24:1472–1476CrossRefPubMedGoogle Scholar
  74. 74.
    Malghem J, Lecouvet FE, Omoumi P, Maldague BE, Vande Berg BC (2013) Necrotizing fasciitis: contribution and limitations of diagnostic imaging. Joint Bone Spine 80:146–154CrossRefPubMedGoogle Scholar
  75. 75.
    Hayeri MR, Ziai P, Shehata ML, Teytelboym OM, Huang BK (2016) Soft-tissue infections and their imaging mimics: from cellulitis to necrotizing fasciitis. Radiographics 36:1888–1910CrossRefPubMedGoogle Scholar
  76. 76.
    Patterson JW (2013) Infectious diseases, including infestations and parasitic diseases. In: Patterson JW (ed) Practical skin pathology: a diagnostic approach. Elservier Saunders, Philadelphia, pp 251–314Google Scholar
  77. 77.
    Ferrara SD, Baccino E, Boscolo-Berto R et al (2016) Padova charter on personal injury and damage under civil-tort law : medico-legal guidelines on methods of ascertainment and criteria of evaluation. Int J Legal Med 130:1–12CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Medical and Surgical Sciences (DIMEC), Institute of Legal MedicineUniversity of BolognaBolognaItaly
  2. 2.Department of Legal and Occupational Medicine, Toxicology and Public HealthUniversity-Hospital of PadovaPadovaItaly
  3. 3.Department of Public Health and Community Medicine, Unit of Forensic MedicineUniversity of VeronaVeronaItaly
  4. 4.Emergency DepartmentRovigo Hospital, ULSS 5 “Polesana”RovigoItaly
  5. 5.Institute of Radiology, Department of Medicine (DiMED)University-Hospital PadovaPadovaItaly

Personalised recommendations