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36
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Cellulitis in Special Areas
Orbital Cellulitis
Cellulitis in orbit causes proptosis, leading to impair ment of
ocular movements and blindness.
It can spread through ophthalmic veins into cavernous sinus
causing cavernous sinus thrombosis.
It requires admis sion and immediate aggressive treatment
with higher generation antibiotics (Penicillins, cephalosporins).
SRB's Manual of Surgery
Fig. 1.90: Dangerous area of face—area of upper lip and lower part
of nose. Infection from this area spreads through deep facial vein →
pterygoid plexus → communicating vein → cavernous sinus causing
its life-threatening thrombosis.
Fig. 1.91: Severe cellulitis face involving nose, eyelids and facial skin.
It can cause septicaemia, cavernous sinus thrombosis or intracranial
spread of infection. This area is called as dangerous zone in face. It
needs hospitalisation for treatment.
Ludwig’s Angina (Wilhelm Frederick von Ludwig in
1836)
It is a rapidly progressive polymicrobial cellulitis of the
sublingual and submandibular spaces involving the floor of
the mouth and suprahyoid area on both sides of the neck.
Commonest cause is dental infection of 2nd or 3rd molar teeth
precipitated by tooth extraction; other causes are submandibular sialadenitis, trauma, peritonsillar abscess, upper
respiratory infection, interventions like endotracheal intubation.
Predisposing factors are—diabetes mellitus, chemotherapy,
oral cancer, alcohol, neutropenia.
Commonest organisms are—Streptococcus viridians, Staph-
ylococcus aureus and anaerobes. Gram-negative organisms
can also be involved.
Cellulitis may extend into the pharyngomaxillary space,
retropharynx, and superior mediastinum.
Diffuse painful swelling with woody brawny induration of the
mouth and anterior neck is seen. Swelling is non-fluctuant
but with redness and tenderness. Bilateral submandibular
oedema with marked tenderness on palpation at suprahyoid
area with bull’s neck appearance.
Toxic features like fever, tachycardia, tachypnoea is common.
Difficulty in speech, earache, drooling of saliva and putrid
halitosis.
Involvement of connective tissues, muscles and fascial
spaces but not glandular structures.
Spread via fascial planes in continuity not by lymphatics; no
lymph node enlargement.
Oedema of the tongue with pushing against palate (eleva-
tion) upwards and backwards causing airway obstruction,
dysphagia and odynophagia.
Stridor, respiratory distress and cyanosis may develop due
to oedema of tongue and larynx.
Investigations—CT scan or MRI is useful to identify airway
block, fluid collection and presence of gas. Ultrasound neck is
simpler method to identify same. Total count, blood sugar, chest
X-ray and often blood gas analysis (in severe cases) is done.
Differential diagnoses are—angioneurotic oedema, sublingual
haematoma, sialadenitis, lymphadenitis.
Complications
¾
Laryngeal oedema can occur due to spread of inflammation
to glottis submucosa via stylohyoid tunnel. It may require
emergency tracheostomy to maintain the respiration.
¾
Mediastinitis due to spread of infection into medi-
astinum; aspiration pneumonia.
¾
Septicaemia.
¾
Spread of infection into the parapharyngeal space leads
to thrombosis of the internal jugular vein which may
extend above into the sigmoid sinus which may be fatal.
¾
Mortality is less than 5% unlike in olden days.
Treatment:
¾
Antibiotics (intravenous) like penicillins, piperazillin, tazobactam, clindamycin, metronidazole should be started at
the earliest.
¾
If patient is in respiratory distress, tracheostomy is
required as a life saving procedure.
¾
Whenever distress is severe surgical decompression
is required. Submental horizontal incision is placed;
mylohyoid muscles are cut (both sides); wound may be
closed with a loose sutures with a drain or kept open with
a dressing cover until oedema and sepsis subsides and
later secondary suturing can be done.
¾
Initial steroid therapy (dexamethasone) may be beneficial
and is often used to reduce oedema even though it is
controversial.
ERYSIPELAS
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Erysipelas is (Greek-red skin, Ignis sacer, holy fire, St
Anthony fire) an acute spreading inflammation of the upper
(outer) dermis and superficial lymphatics; it has got typical
skin rash presenting on legs, toes, face and fingers due to
acute infection by beta haemolytic Streptococcus pyogenes,
presenting as raised well demarcated skin rash (rash is due
to exotoxin). It is more superficial than cellulitis. In olden
days, it was more common in face, now it is common in legs.
Infection occurs through a minor trauma. It affects all races;
more common in females. There will be always cutaneous
lymphangitis with development of rose pink rash with cutaneous lymphatic oedema. Vesicles which form eventually will
rupture to cause serous discharge.
Sites: Orbit, face and ear lobule—most common; Hands and
scrotum; Umbilicus in infants;
Decubitus ulcer of lower limb
(legs and feet are now becoming more common site).
Features
Toxaemia is always a feature.
Rash is fast spreading and blanches on pressure. It is raised
with sharp margin.
Redness becomes brown and later yellow with vesicles.
Discharge is serous (In cellulitis discharge is purulent).
In the face and orbit it causes severe oedema.
Milian’s ear sign is a clinical sign used to differentiate erysipelas
from cellulitis wherein ear lobule is spared. Skin of ear lobule
is adherent to the subcutaneous tissue and so cellulitis cannot
occur. Erysipelas being a cutaneous condition can spread into
the ear lobule (Gaston Milian—dermatologist Paris, 1945).
Tender, regional lymph nodes are usually palpable.
Differential diagnoses—herpes zoster, angioneurotic
oedema, contact dermatitis.
Complications
¾
Septicaemia, localized cutaneous and subcutaneous
gangrene are dangerous problems.
¾
Abscess, pneumonia, meningitis may develop.
¾
Lymphoedema of face or eyelid or limbs (when involved)
can occur due to lymphatic fibrosis.
¾
Glomerulonephritis (not rheumatic fever), septic arthritis,
necrotizing fasciitis, can occur occasionally.
¾
Recurrence rate is 20%. It causes disfiguring sequelae.
Treatment: Antibiotics like penicillins, clindamycin, erythro-
mycin, roxithromycin given. Recurrent erysipelas may require
injection benzathine penicillin (long-term penicillin) monthly
for 2 years.
LYMPHANGITIS
It is an acute nonsuppurative infection and spreading inflamma-
tion of lymphatics of skin and subcutaneous tissues due to beta
haemolytic streptococci, staphylococci, clostridial organisms.
It is commonly associated with cellulitis. Erysipelas is a type
of lymphangitis.
In endemic areas, filariasis is the most common cause (coastal
India). It is caused by Wuchereria bancrofti. It is transmitted
through bites of Culex mosquito. Microfilaria reaches the
lymph node forming adult worm which blocks the lymph node
causing obstruction, fibrosis and lymphangitis.
Usually lymphangitis due to bacterial infection occurs following
a small trauma. Rapidly affected area develops warmness and
redness.
Features
Streaky redness which is spreading is typical. On pressure
area blanches; on release redness reappears.
Oedema of the part, palpable tender regional lymph nodes are
obvious.
Fever, tachycardia, features of toxaemia.
Groin lymph nodes are enlarged and tender in lower limb
lymphangitis. In upper limb, as lymphatics are mainly located
on the dorsum of hand, oedema and redness develops on
the dorsum. Infection in thumb and index finger causes
palpable tender axillary nodes; in little and ring finger causes
first tender palpable epitrochlear nodes to appear; infection
in middle finger causes first deltopectoral nodes to enlarge.
Regional lymph nodes (only) may eventually suppurate to
form an abscess.
Toxaemia, septicaemia may occur. Rapidity may be more in
diabetics and immunosuppressed.
Chronic lymphangitis occurs due to repeated attacks of acute
recurrent lymphangitis leading into acquired lymphoedema.
37
CHAPTER 1D General Surgery: Infectious Diseases
ERYSIPELOID DISEASE
B
x Also called as ‘Fish handler’s disease
x Occurs following any cuts or scratches
x It has features of both erysipelas and cellulitis
x It is self-limiting with relatively mild symptoms.
Figs. 1.92: Typical ear lobule infection after ear prick for ear stud.
Hope puts our feet on the path when our eyes cannot see it.
38
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Protein exudation causes fibrin deposition and formation of
pyogenic membrane.
Macrophages and polymorphs release lysosomal enzymes
which cause liquefaction of tissues leading into pus formation.
Toxins and enzymes released causes tissue destruction and
pus formation.
A1
A2
SRB's Manual of Surgery
B
Figs. 1.93A and B: (A1) Lymphangitis of upper limb; (A2) Blanching
is seen immediately after pressure; (B) Typical red streaks in an upper
limb lymphangitis.
Management: Blood count, platelet count, renal and liver
function tests, peripheral smear and blood culture—are
needed investigations; Antibiotics like penicillin, cloxacillin
are started; Elevation, rest, glycerine magnesium sulphate
dressing done; Management of toxaemia or septicaemia with
critical care is done.
Fig. 1.95: Pyogenic abscess—parts.
Mode of infection: Direct; Haematogenous; Lymphatics;
extension from adjacent tissues
Bacteria causing abscess: Staphylococcus aureus;
Streptococcus pyogenes; Gram-negative bacteria (E. coli,
Pseudomonas, Klebsiella); Anaerobes.
FACTORS PRECIPITATING ABSCESS FORMATION
B
x General condition of the patient: Nutrition, anaemia, age of the
patient
x Associated diseases: Diabetes, HIV, immunosup pression
x Type and virulence of the organisms
x Trauma, haematoma, road traffic accidents.
Fig. 1.94: Lymphangitis of one leg. Note the typical streaky
redness compare to normal side.
ABSCESS
TYPES
B
x Pyogenic abscess
x Pyaemic abscess
x Metastatic abscess
x Cold abscess due to chronic infection like tuber culosis.
Pyogenic Abscess
It is a localised collection of pus in a cavity lined by granulation tissue, covered by pyogenic membrane. It contains pus in
loculi. Pus contains dead WBC’s, multiplying bacteria, toxins
and necrotic material.
Clinical features:
¾
Fever often with chills and rigors.
¾
Localised swelling which is smooth, soft and fluctuant
with visible (pointing) pus.
¾
Throbbing pain and pointing tenderness and Brawny
induration around.
Fig. 1.96: Abscess in the face. Note the localisation and redness.
Fig. 1.97: Abscess in the nape of the neck—suboccipital region.
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Note the redness and visible pus. Patient is diabetic.
¾
Redness and warmth with restricted movement around
a joint.
¾
Rubor (redness); dolor (pain); calor (warmness); tumour
(swelling) and functiolaesa (loss of localised and adjacent
tissue/joint function) are quiet obvious.
(Commonly cellulitis occurs first which eventually gets localised
to form an abscess.)
C
Fig. 1.98C
Figs. 1.98A to C: Pyogenic abscess in different locations in neck
(child), abdominal wall and thigh; note the swelling and redness.
Visible (pointing) pus, tenderness, fluctuation are the features
of formed abscess.
Cellulitis Pyogenic abscess
•
Diffused—no edge • Well-localised with
clear edge
• Pus not formed—nonsuppurative initially
• Not fluctuant • Fluctuant
• Spreading—SIRS can occur
• Blood culture may be
negative
• Never incise; if done danger
of bacteraemia.
elevation, dressing—are
treatment
Antibiotics,
• Formed pus
• Culture of pus is usually
positive
•
Drainage is essential
39
CHAPTER 1D General Surgery: Infectious Diseases
Sites of abscess
¾
A
External sites: Fingers, hand, dental, tonsillar, oral, neck,
axilla, breast, abdominal wall, ischiorectal, peroneal, perianal, gluteal, thigh, foot. In places like gluteal region and
thigh it is deeply situated with brawny induration.
¾
Internal sites:
–
Abdominal: Subphrenic, pelvic, paracolic, amebic/
pyogenic liver abscess, splenic/pancreatic abscesses.
–
Others: Perinephric/retroperitoneal/lung/brain/
retropharyngeal abscesses.
B
Figs. 1.98A and B
Fig. 1.99: Abscess face with erythema after trauma.
Happy is he who has no serious consequences of his erroneous diagnosis to regret.—Fredrick H Marsh
40
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Investigations:
¾
Total count is increased; Urine sugar and blood sugar is
done to rule out diabetes
¾
USG of the part or abdomen or other region is done when
required; Chest X-ray is done in case of lung abscess;
Gallium isotope scan is very useful; CT scan or MRI is
done in cases of brain and thoracic abscess;
¾
Investigations, relevant to specific types are done: Liver
tion tests, PO2 and PCO2 estimation, blood culture.
func
SRB's Manual of Surgery
Fig. 1.101: Multiple abscesses in neck, chin, face. It is common in
HIV, diabetes and immunosuppressed.
Differential diagnosis
¾
Aneurysm: Especially in popliteal, femoral and axillary
regions. So before draining the abscess, presence of
pus is confirmed by aspirating with a needle. It should
be remembered that thrombosed aneurysm may not be
pulsatile but can be warm, soft and tender.
¾
Soft tissue tumours: Sarcomas may be smooth, soft
and warmer.
¾
Haematoma.
¾
Cold abscess.
Fig. 1.100: Abscess in plantar aspect of foot. Note the visible pus.
COMPLICATIONS OF AN ABSCESS
B
x Bacteraemia, septicaemia, and pyaemia
x Multiple abscess formation
x Metastatic abscess
x Destruction of tissues
x Antibioma formation (common in breast abscess). Once abscess
forms, thick fibrous tissue develops around abscess cavity because
of antibiotics. Cavity contains sterile pus as thick flaques. It is
nontender, localised, smooth, hard swelling which may mimic
carcinoma (in breast—carcinoma breast). It should be differentiated clinically from carcinoma (it is not progressive whereas carcinoma is progressively increasing). FNAC is essential to differentiate.
Antibioma should be excised
x Sinus and fistula formation
x Large abscess may erode into adjacent vessels and can cause life-
threatening torrential haemorrhage, e.g. as in pancreatic abscess
x Abscess in head and neck region can cause laryngeal oedema,
stridor and dysphagia
x Specific complications of internal abscess:
– Brain abscess can cause intracranial hyper tension, epilepsy,
neurological deficit.
– Liver abscess can cause hepatic failure, rupture, jaundice.
– Lung abscess can lead to bronchopleural fistula or septi-
caemia or respiratory failure or ARDS.
Fig. 1.102: Typical cold abscess and tuberculous sinus in the neck. It
does not show signs of acute inflammation. It should be drained (under
cover of antituberculous drugs) through nondependent incision and
incision should be closed without placing a drain.
Treatment of an abscess
ABSCESS SHOULD BE FORMED BEFORE DRAINING.
B
EXCEPTIONS FOR THIS RULE ARE:
x Parotid abscess
x Breast abscess
x Axillary abscess
Note:
x Thigh abscess
x Ischiorectal abscess
• Pus anywhere will come to surface; pus anywhere should be drained.
• “Pus is like the truth—you have to let it out.”—Gareth Morris-Stiff
• Features of a formed abscess are—visible pus; pointing tenderness;
fluctuation; excruciating pain.
Differences between pyogenic abscess and cold abscess
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T
Pyogenic abscess Cold abscess
a. Red, warm, tender, with signs of acute inflammation a. No signs of acute inflammation
b. Pyogenic bacteria are nonspecific organisms
(Streptococcus, Staphylococcus)
c. For drainage, dependent incision is used c. Nondependent incision is used
d. Suturing of the wound is not done d. Wound is sutured
Drain is placed e. Drain is not placed (otherwise sinus will form
e.
b. Tuberculous bacteria
which is difficult to treat)
Procedure
Hilton’s method of draining an abscess.
Initially broad-spectrum antibiotics are started (depen ding
on severity, extent and site of the abscess).
Under general anaesthesia or regional block anaesthesia,*
after cleaning and draping, abscess is aspirated and presence
of pus is confirmed.
Skin is incised adequately, in the line parallel to the neuro-
vascular bundle in the most dependent position.
Next, pyogenic membrane is opened using Sinus forceps**
and all loculi are broken up. Abscess cavity is cleared of pus
and washed with saline.
A drain (either gauze drain or corrugated rubber drain) is
placed.
Wound is not closed. Wound is allowed to granulate and heal.
Pus is sent for culture and sensitivity.
Biopsy should be done in suspected tuberculosis or malignancy.
Sometimes secondary suturing or skin grafting is req uired.
Antibiotics are continued.
Treating the cause is important.
Fig. 1.10 4 : Abdominal wall abscess being aspirated. Note the aspirated
pus in the syringe. Abscess should be aspirated prior to drainage.
Note:
• Counter-incision is placed in breast abscess which is placed in upper
quadrant.
• Incision should be deeper while draining pus in radial and ulnar bursae,
palmar spaces and tenosy novitis.
• Problems in drainage: Improper drainage, bleeding, residual abscess
or sinus formation.
41
CHAPTER 1D General Surgery: Infectious Diseases
A
Fig. 1.103: Scrotal abscess, which is well-localised and ready for
drainage. Patient has undergone surgery for hernia earlier.
* As the pus is acidic local anaesthetic agent will not act and hence it is not used.
** Sinus forceps do not have lock and has got serrations in the tip. It is called as sinus forceps because it was initially designed and used to
pack sinuses.
B
Figs. 1.105A and B
Joseph Lister is father of modern surgery and started antiseptic surgery in 1912.
42
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C
SRB's Manual of Surgery
D
E
F
Figs. 1.105C to F
Figs. 1.105A to F: Technique of incision and drainage of a pyogenic
abscess. Abscess should be aspirated first to get pus; No. 11 blade is
used to incise; using sinus forceps pyogenic membrane is opened; pus
is collected for culture; loculi are broken using sinus forceps and little
finger; cavity is irrigated with normal saline (ideal); cavity is packed
with roller gauze; wound is not sutured.
A B
Figs. 1.106A and B: (A)Incision for draining an abscess by Hilton’s
method. Note the longitudinal incision; (B) Abscess with loculi and
breaking of loculi using finger for drainage.
Fig. 1.107: Different instruments required for incision and
drainage of an abscess.
METASTATIC AND PYAEMIC ABSCESS
Metastatic abscess
It is an abscess which occurs as a spread from other abscess.
For example, lung abscess causing metastatic abscess in the
brain (common example).
Presentation here is of features of focus abscess and of
metastatic abscess (localised features).
Pyaemic abscess
It is from any infective focus which need not be always from
an abscess (from cellulitis or skin infections, etc.) causing
pyaemic emboli leading into multiple abscess in different places
like brain, kidneys, liver, etc.
Presentation here, is mainly of systemic features involving
multiple organs with toxicity.
These emboli contain bulk of multiplying organisms often
derived from infective thrombus or vegetations. Focus may be
an abscess, cellulitis, skin infection, acute osteomyelitis, and
acute bacterial endocarditis. Acute appendicitis with severe
sepsis can cause infective pyaemia in liver called as pyelphle-
bitis or portal pyaemia.
Pyaemic abscess are multiple, deeper, beneath the fascia or in
the internal organs. When it is on the surface, it is less tender
without any clear signs of inflammation.
Pyaemic abscess carries high mortality with SIRS and MODS.
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Management:
¾
Evaluation for focus of infection, pus for culture, blood
culture (three samples), antibiotics, critical care, systemic
therapy, drainage of surface abscesses.
BACTERAEMIA
It is the presence of bacteria (live) in the blood circulation (sepsis
is the host response to bacteria). It may be primary wherein
bacteria are introduced directly into the blood by drug abuse
injections, venous catheters or secondary wherein bacteria
enter blood through some other infection focus like pneumonia,
urinary infection, etc. Bacteraemia may be transient or intermit-
tent or persistent. In transient type, bacteria is present in the
circulation for only minutes to few hours and gets cleared like
in small procedures and instrumentation. In intermittent type,
periodic bacteraemia occur—seen in pneumonia or abscess,
etc. Persistent type is continuous presence of bacteria in blood
often seen in infected heart valve or central line or vessel graft
or prosthesis etc. Bacteraemia can be Gram positive or Gram
negative. It is more often seen in meningitis, typhoid, brucellosis, etc. Risk factors are HIV, diabetes, transplant, dialysis and
immunosuppression. Two blood cultures taken from two sepa-
rate sites of the body if show same bacteria it is confirmed as
bacteraemia. Condition is treated by effective antibiotic therapy.
SEPTICAEMIA
It is the presence of overwhelming and multiplying bacteria in the
blood with toxins causing SIRS (systemic inflammatory response
syndrome) or MODS (multiorgan dysfunction syndrome) which
later may progress into multiple system organ failure (MSOF).
Actually, sepsis which means body’s response to infection eventually causing damage to its own organs. Sepsis is SIRS with
infection. Severe sepsis is sepsis syndrome with MO
Even though two or more of SIRS criteria (Refer
Shock) are used to diagnose sepsis, currently other scoring systems
are used (2016). SOFA score [Sequential (sepsis related) organ
failure assessment] is ideal using six parameters respiratory, neurological, cardiovascular, liver, coagulation and renal systems; each
having 0,1,2,3,4 scores. Quick SOFA score (qSOFA score) is also
used based on 3 parameters—low blood pressure <100 mm Hg;
increased respiratory rate >22/minute; altered mentation—GCS <13.
Septicaemia can be Gram positive or Gram negative. Gram-
positive septicaemia is due to staphylococci, streptococci,
pneumococci, etc. infection. It is common in children, old age,
diabetes and after splenectomy (OPSI—overwhelming postsplenectomy infection). Gram-negative septicaemia is common
in acute abdomen like peritonitis, abscess, biliary, pancreatic,
gastrointestinal or urinary infections, infected woundsand postoperative sepsis. It is commonly seen in malnourished, old age,
immunosuppressed people and diabetics. Common bacteria are
E. coli, Klebsiella, Pseudomonas, Proteus, etc. Gram-negative
septicaemia causes endotoxic shock. Initial reversible warm
stage presents with fever, chills and rigors which are due to
DS or MSOF.
Chapter 1G—
pyrogenic response; eventual irreversible cold stage develops
wherein patient goes for complications like—AR
DS; renal, liver
and multiorgan failure; disseminated intravascular coagulation
DIC); bone marrow suppression (thrombocytopenia).
(
Evaluation of septicaemia is done using clinical assessment;
blood parameters (haematocrit, liver and renal function tests,
coagulation profile, electrolyte estimation, arterial blood gas
analysis, C-reactive protein); culture of urine/pus/discharge/bile/
blood; chest X-ray; imaging as per need.
Treatment: Fluid therapy, antibiotics, monitoring (heart rate,
respiration, oxygen saturation, urine output (may need to pass
Foley’s catheter), oxygen supplementation, fresh frozen plasma, or
fresh blood transfusion, critical care with ventilator support, electrolyte management. CVP line, parenteral nutrition, management
complications (like haemodialysis for renal failure, tracheostomy).
COMPLICATIONS OF SEPTICAEMIA
B
x Disseminated intravascular coagulation (DIC)
x ARDS
x Liver dysfunction
x Renal failure
x Bone marrow suppression—thrombocytopaenia
x Multiorgan failure
PYAEMIA
Presence of multiplying bacteria in blood as emboli which
spread and lodge in different organs in the body like liver, lungs,
kidneys, spleen, brain causing pyaemic abscess. This may lead
to multiorgan dysfunction syndrome (MODS). It may endanger
life if not treated properly.
Clinical features
¾
Fever with chills and rigors, Jaundice, oliguria, drowsiness
¾
Hypotension, peripheral circulatory collapse and later
coma with MO
Note: Causes, evaluation and treatment of pyaemia is like septicaemia
above.
DS
BOIL (Furuncle)
It is an acute staphylococcal infection of a hair follicle with
perifolliculitis which usually proceeds to sup
central necrosis.
Often boil opens on its own and subsides (S. aureus infection).
Furuncle in external auditary canal is very painful because of
rich cutaneous nerves. Here skin is adherent to perichondrium.
Boil often heals spontaneously; suppuration will not occur in
such boil; it is often called as blind healed dull boil.
Boil is common over back, neck, thigh, and forearm even
though it can occur anywhere. Boil in eyelash follicle is
called as sty (stye). Boil can occur in perianal region which
can lead into abscess and fistula. Boil can lead into hidrad-
enitis, which is common in axilla and pubic region. Boil
can cause cellulitis of local area. Overlying skin undergoes
necrosis. But during healing re-epithelialisation occurs.
puration and
43
CHAPTER 1D General Surgery: Infectious Diseases
“Never let the sun set or rise on an undrained abscess”— Royal Whitmann
44
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Boil commonly subsides spontaneously often with the
support of suitable antibiotics; occasionally it requires inci-
sion and drainage. Regional enlarged tender lymph nodes
may be palpable due to secondary infection.
Systemic features are not common unless it is multiple/
recurrent/severe or in diabetics and immunosuppressed.
Multiple/recurrent boils are common in diabetics.
HURLEY STAGING SYSTEM IN HIDRADENITIS
B
SUPPURATIVA
Stage I: Abscess formation, single or multiple, without sinus tracts
or scarring.
Stage II: Single or multiple, widely separated, recurrent abscesses
with sinus tract formation or scarring.
Stage III: Diffuse or near diffuse involvement or multiple interconnected sinus tracts and abscesses across the entire area.
Note: The Sartorius Hidradenitis Suppurative Scoring is made by
counting involved regions, nodules and sinus tracts.
SRB's Manual of Surgery
Fig. 1.108: Furuncle/boil are infection of hair follicle with
perifolliculitis due to Staphylococcus aureus.
Treatment
¾
Antibiotics given if boil is not resolving spontaneously—
cloxacillin/amoxycillin.
¾
Rarely drainage of boil is needed in severe persistent
form.
Complications
¾
Cellulitis, lymphadenitis.
¾
Hidradenitis (Infection of group of hair follicles).
¾
Boil in dangerous zone in the face, can cause cavernous
sinus thrombosis.
A
HIDRADENITIS SUPPURATIVA
It is a, chronic scarring inflammatory acne like disease of the
skin bearing apocrine sweat glands. Apocrine sweat glands
are coiled glands which open into the hair follicles.
Hidradenitis suppurativa is also known as ‘acne inversa’.
It occurs commonly in women of menstruating age group;
smoking is the important aetiological factor. It may be associ-
ated with acne, pilonidal sinus or Crohn’s disease.
Aetiology
¾
Smoking, obesity, poor hygiene, polycystic ovarian disease.
¾
Diabetes mellitus, steroid therapy.
¾
Genetic causes: It is associated with chromosome 15q24q25. Multiple members of the family may be affected. It may
be associated with pyoderma gangrenosum, acne (PASH
syndrome) or/and pyogenic arthritis (PAPASH syndrome).
Note:
• Lesion is usually sterile; bacterial infection supervenes in deep abscesses
and sinus tracks. Staphylococcus aureus and Propionibacterium acnes
are the common bacteria.
• Sites of apocrine sweat glands: Axilla, groin, areola, umbilicus, scalp,
chest and perineum.
• Hidradenitis suppurativa in the anal region rarely my turn into squamous
cell carcinoma.
B
Figs. 1.109A and B: Hidradenitis suppurativa. It is chronic infection
of apocrine sweat glands of the skin. It is common in axilla (Courtesy:
Dr Achaleshwar Dayal, MS, Itarsi, MP).
Pathogenesis
Obstruction of duct of apocrine sweat gland by keratin
↓
Dilatation of the duct of gland
↓
Infection and abscess formation
↓
Involvement of subcutaneous tissue and adjacent apocrine glands
↓
Fibrosis, scarring, sinus formation
↓
Spread to surrounding tissues
Features
¾
Common in females 4 : 1.
¾
The most common site is axilla. Often it is bilateral.
¾
Multiple discharging sinuses, with nodules in the skin
which is tender.
¾
Induration due to fibrosis.
Investigation: Discharge study—culture/sensitivity and AFB.;
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Biopsy to rule out tuberculosis or malignancy.
Differential diagnosis:
¾
Tuberculous sinus.
¾
Malignancy (squamous cell carcinoma of skin).
¾
Lymph node mass in the region which are in deeper
plane.
Treatment
¾
Topical clindamycin 1%; topical resorcinol 15% cream.
¾
Oral antibiotics like clindamycin, erythromycin, doxycycline—needs longer course.
¾
Infliximab, retinoids (isotretinoin 0.25–0.4 mg/kg) may
be used in severe cases.
¾
Wide excision (radical excision) of the involved area with
skin grafting.
¾
Antiandrogen therapy in females using oral estrogen or
oral contraceptives or spironolactone or cyproterone
acetate or finasteride.
¾
Ablative laser (CO2 or erbium YAG) therapy is an alternate
therapy often used.
CARBUNCLE (Word meaning of carbuncle is charcoal)
It is an infective gangrene of skin and subcutaneous tissue.
Staphylococcus aureus is the main culprit.
Common site of occurrence is nape of the neck and back.
Skin in this area is thick. Condition also can occur in shoulder,
cheek, hand, forearm.
It is common in diabetics and after forty years of age.
It is common in males.
Infection
Development of small vesicles
Red indurated skin with discharging pus
Many fuse together to form a central necrotic ulcer (ash-grey slough)
with peripheral fresh vesicle looking like a “rosette” (cribriform)
Skin becomes black due to blockage of cutaneous vessels
Disease spreads to adjacent skin rapidly
Patient is toxic and in diabetics they are ketotic
↓
↓
Sieve like pattern
↓
↓
↓
↓
Fig. 1.110: Carbuncle in the nape of the neck—typical site. Note the
wide area of involvement and dark area—charcoal like. Ash-grey slough
is specific.
POTT’S PUFFY TUMOUR
It is a misnomer. It is not a tumour.
It is formation of diffuse external swelling in the scalp due to
subperiosteal pus formation (abscess) and scalp oedema.
It originates commonly in frontal region and may extend into
other regions.
There is acute osteomyelitis of frontal bone.
Causes
¾
Chronic frontal sinusitis which eventually sup purates and
extends into subperiosteal region.
¾
Trauma—subperiosteal haematoma.
¾
Chronic suppurative otitis media.
Features
Pain and boggy swelling in frontal region which is warm,
tender.
Toxicity and drowsiness.
Pitting scalp oedema is typical.
Investigations:
¾
Total leucocyte count—increased. ESR—raised.
¾
X-ray skull. CT scan.
Differential diagnosis: Secondaries in the skull or brain.
45
CHAPTER 1D General Surgery: Infectious Diseases
In carbuncle, group of hair follicles are involved. Carbuncle
is cluster of furuncles connected subcutaneously, causing
deeper suppuration and scarring.
Investigations: Urine sugar and urine ketone bodies; Blood
sugar; Discharge for C/S.
Treatment
¾
Control of diabetes is essential using insulin.
¾
Antibiotics like penicillins, cephalosporins or depending
on C/S is given.
¾
Drainage is done by a cruciate incision and debridement
of all dead tissues is done. Excision is done later.
¾
Once wound granulates well, skin grafting may be required.
Note: Renal Carbuncle is an entity which occurs in kidney due to infection,
forming localized infective mass lesion.
Age or youth is not a matter of chronology. we are as young or old as we feel—Sarvapalli Radhakrishnan
Fig. 1.111: Pott’s Puffy tumour. Note the swelling over the frontal
region and eyelid.
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