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 Table of Contents  
Year : 2022  |  Volume : 34  |  Issue : 3  |  Page : 366-368

A rare case report of cervicofacial necrotizing fasciitis: The flesh-eating bacteria syndrome

1 Department of Oral Medicine and Radiology, Dr. D.Y. Patil Dental College and Hospital, Dr. D.Y. Patil Dental College and Hospital, Pune, Maharashtra, India
2 Department of Public Health Dentistry, Dr. D.Y. Patil Dental College and Hospital, Dr. D.Y. Patil Dental College and Hospital, Pune, Maharashtra, India

Date of Submission18-Dec-2021
Date of Decision14-Jul-2022
Date of Acceptance17-Jul-2022
Date of Web Publication26-Sep-2022

Correspondence Address:
Shrutika Ravindra Sonawane
Department of Oral Medicine and Radiology, Dr. D. Y. Patil Dental College and Hospital, Pimpri, Pune - 411 018, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiaomr.jiaomr_345_21

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Cervicofacial necrotizing fasciitis is a fatal infection of the orofacial region that spreads rapidly through the subcutaneous tissues and fascia causing extensive necrosis and gas formation. Due to high morbidity and mortality rates, accurate diagnosis and immediate treatment are of utmost importance to avoid the devastating complications associated with it. This case report is of a 55-year-old male, reported with suppuration in the left aspect of the neck. Due to acute, aggressive, and rapidly progressive character of the infection, this report was written to create awareness about such a fatal infection and highlight the importance of accurate diagnosis and prompt treatment.

Keywords: Cervicofacial necrotizing fasciitis, extraction, fascial planes, odontogenic infection

How to cite this article:
Sonawane SR, Sawane HB, Pasalkar LH, Sarma A. A rare case report of cervicofacial necrotizing fasciitis: The flesh-eating bacteria syndrome. J Indian Acad Oral Med Radiol 2022;34:366-8

How to cite this URL:
Sonawane SR, Sawane HB, Pasalkar LH, Sarma A. A rare case report of cervicofacial necrotizing fasciitis: The flesh-eating bacteria syndrome. J Indian Acad Oral Med Radiol [serial online] 2022 [cited 2022 Dec 10];34:366-8. Available from: http://www.jiaomr.in/text.asp?2022/34/3/366/356965

   Introduction Top

Cervicofacial necrotizing fasciitis (CNF) is a fatal “flesh-eating” infection involving the subcutaneous adipose tissue and fascial planes of the orofacial region.[1] Recent Watson Health datasets showed an increasing annual incidence of 28,500 cases in 2018. The estimated annual incidences in the United States in 2018 were 10.3 per 100,000 persons.[2],[3] A study by Gunaratne et al.[4] demonstrated a drastic increase in the incidence of NF from merely 14.36% to 41% worldwide. In the initial stages, it can be misdiagnosed with more frequent acute inflammatory lesions of the orofacial region. This condition has high morbidity and mortality rate, and hence accurate diagnosis and prompt management are crucial.[5]

   Case Report Top

Chief complaint: A 55-year-old male patient reported to the Oral Medicine department complaining of pus discharge from the left side of the neck for four days [Figure 1].
Figure 1: Partial necrosis and suppuration in the left lateral aspect of the neck

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Timeline of History: [Table 1]
Table 1: Timeline of history

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Medical history was non-contributory.

Clinical examination: Generalized weakness, malaise, fever, difficulty in breathing. Extra-oral examination: Diffuse, tender, erythematous swelling over the lower left side of the face, superiorly 1 cm below the lateral aspect of the left earlobe till the left mid-sternocleidomastoid (SCM) region; anterio-posteriorly from midline till the posterior aspect of the mastoid head of the SCM muscle. The borders were ischemic and erythematous. The surface was soft and purulent with raised temperature. A healing socket of 28 was noted with mild trismus.

Provisional diagnosis: CNF. Suppurative osteomyelitis and Noma as differential diagnosis.



  • Hemoglobin level (11.60 gm/dl)
  • Leukocytosis
  • Thrombocytosis (623000/μl)
  • Red blood cell count (2.70 × 106/μl),
  • Sodium levels (134 mml/l)
  • C-reactive protein 202.96 mg/l.

Culture sensitivity: Presence of Escherichia coli, Streptococci mutans, and Staphylococci aureus.

Radiological: Coronal and axial computerized tomography scans showed diffuse thickening of parotid-masseteric fascia and investing layer of deep fascia: fasciitis, abnormal attenuation of buccal fat pad; cellulitis, enhancement and thickening of the masseter muscle and masseteric space; and myositis, fluid collections and air accumulation along the fascial planes and neck compartments [Figure 2].
Figure 2: Axial and coronal CT scan with signs of NF

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Final diagnosis: Cervicofacial necrotizing fasciitis.

Treatment: The patient was immediately started on IV Augmentin 1.2 gm, IV Metronidazole 100 ml, IV Dynapar 75 mg (1cc aq in 100 ml NS), IV Pan 40, Betadine mouthwash, and fluids. The area was debrided, foul-smelling necrotic fascia was removed, and fresh bleeding bed was obtained [Figure 3]a. A split-thickness skin graft was sutured on the defect.
Figure 3: (a) Fresh bleeding bed after removal of necrotic tissues (b) Graft healing 14 days post-operation

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Prognosis: Prognosis was good [Figure 3]b.

   Discussion Top

“Necrotizing fasciitis” coined by Dr. Wilson in 1952[6] is a disease of soft tissues and fascia which is sudden in onset and spreads rapidly. It is synonymized as a “flesh-eating” disease as it causes extensive necrosis of tissues.[7] The primary etiological cause for CNF is odontogenic infection which may further fulminate to the mediastinum. Other important predisposing factors are underlying systemic causes or an immunocompromised state.

Pathogenesis of this disease

It is divided into Type I, II, III, and IV NF.[8] Type II is a monomicrobial disease; Group A streptococcus is the commonest microbe, followed by methicillin-resistant staphylococcus aureus.[8] The primary etiological cause is an odontogenic infection.[9]

In a case series of four cases by Adewale AO et al.,[10] none of the patients had underlying systemic conditions and the infection was purely due to an odontogenic cause. The classic triad of reduced host immunity, increased microbial virulence, and predisposing factors [Table 2] are important for the development of this infection. In a retrospective study by Cheng CN et al.,[11] 165 cases diagnosed with NF were collected, out of which 84 patients were diabetic and the overall case fatality rate was 29.7%. In a retrospective study by Misiakos EP et al.,[12] out of 62 patients diagnosed with NF, 25 patients had diabetes mellitus and 17.74% were obese.
Table 2: Predisposing factors

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Patients presenting with cardinal signs like fever, pain out of proportion, dishwater pus discharge, and bluish-black discoloration of skin suspicion about this fatal infection should be raised and immediate investigations should be ordered but without delay in surgical debridement.

This fatal infection can be misdiagnosed as other similar soft tissue infections (SSTI) such as impetigo, erysipelas, purulent SSTI, cellulitis, pyomyositis, toxic shock syndrome.

Surgical debridement and broad-spectrum antibiotics remain the mainstay of the treatment. Retardation of fluid collection in the wound site should be achieved as it can serve as a hub for microbial growth. Hyperbaric oxygen along with surgical debridement reduces the mortality rate by 50%.[13]

   Conclusion Top

CNF is a rapidly spreading fulminating infection mainly caused by odontogenic infections. Because of low incidence and vague early clinical findings, diagnosis of CNF can be challenging. Principle management remains a broad antibiotic coverage with aggressive surgical debridement. Hence, immediate attention, early diagnosis, and prompt treatment are necessary to reduce both morbidity and mortality.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Sadasivan J, Maroju N, Balasubramaniam A. Necrotizing fasciitis. Indian J Plast Surg 2013;46:472-8.  Back to cited text no. 1
[PUBMED]  [Full text]  
Trent JT, Kirsner RS. Diagnosing necrotizing fasciitis. Adv Skin Wound Care 2002;15:135-8.  Back to cited text no. 2
May AK, Talisa VB, Wilfret DA, Eileen Bulger, Dankner W, Bernard A, et al. Estimating the impact of necrotizing soft tissue infections in the United States: Incidence and re-admissions. Surg Infect 2021;22:509-15.  Back to cited text no. 3
Gunaratne DA, Tseros EA, Hasan Z, Kudpaje AS, Suruliraj A, Smith MC, et al. Cervical necrotizing fasciitis: Systematic review and analysis of 1235 reported cases from the literature. Head Neck 2018;40:2094-2102.  Back to cited text no. 4
Maria A, Rajnikanth K. Cervical necrotizing fasciitis caused by dental infection: A review and case report. Natl J Maxillofac Surg 2010;1:135-8.  Back to cited text no. 5
[PUBMED]  [Full text]  
Wilson B. Necrotizing fasciitis. Am Surg 1952;18:416-31.  Back to cited text no. 6
Paz Maya S, Dualde Beltrán D, Lemercier P, Leiva-Salinas C. Necrotizing fasciitis: An urgent diagnosis. Skeletal Radiol 2014;43:577-89.  Back to cited text no. 7
Stevens DL, Bryant AE. Necrotizing soft-tissue infections. N Engl J Med 2017;377:2253-65.  Back to cited text no. 8
Nouraei SA, Hodgson EL, Malata CM. Cervicofacial necrotising fasciitis: Management with neck dissection and topical negative pressure. J Wound Care 2003;12:147-9.  Back to cited text no. 9
Adewale AO, Olamide OT, Yussuf SA, Stephen IO. Cervicofacial necrotizing fasciitis in patients with no underlying medical conditions: A review of four cases seen in twelve months at a Nigerian tertiary hospital. Iran J Med Sci 2018;43:653-8.  Back to cited text no. 10
Cheng NC, Tai HC, Chang SC, Chang CH, Lai HS. Necrotizing fasciitis in patients with diabetes mellitus: Clinical characteristics and risk factors for mortality. BMC Infect Dis 2015;15:417-25.  Back to cited text no. 11
Misiakos EP, Bagias G, Papadopoulos I, Danias N, Patapis P, Machairas N, et al. Early diagnosis and surgical treatment for necrotizing fasciitis: A multicenter study. Front Surg 2017;4:1-7.  Back to cited text no. 12
Hakkarainen TW, Kopari NM, Pham TN, Evans HL. Necrotizing soft tissue infections: Review and current concepts in treatment, systems of care, and outcomes. Curr Probl Surg 2014;51:344-62.  Back to cited text no. 13


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2]


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