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114
Manipal Manual of Surgery
• Tuberculous lymphadenitis presents as a gradually
increasing painless swelling of one or more lymph
nodes and lasts from a few weeks to a few months.
Multiple sites may be involved.
• Systemic symptoms such as chills, fever, weight loss,
fatigue, and night sweats are common, especially in those
with extensive disease. Seen in about 40% of patients.
• In tuberculosis, interleukin-1(IL-1) and interleukin-6
(IL-6) are released, resulting in high-grade fever.
However, this effect is somewhat counteracted by
cortisol levels (which are also increased), resulting
in low-grade fever.
Stages of Tuberculous (TB) Lymphadenitis
1. Stage of L
ymphadenitis (Fig. 22.5)
• Common in young adults between 20 and 30 years
of age.
• Upper anterior deep cervical nodes are enlarged.
• Nontender, discrete, mobile, firm lymph nodes are
palpable.
2. Stage of Periadenitis/Stage of Matting (Fig. 22.6)
• Results due to capsular involvement
• Nodes move together—matting
• Firm, nontender
• Matting is pathognomonic of tuberculosis
• Other rare causes of matting are chronic lympha-
denitis and anaplastic variety of lymphoma.
3. Stage of Cold Abscess (Figs 22.7–22.11)
It occurs due to caseating necrosis of the lymph nodes,
which results in a fluctuant swelling in the neck. Clinical
features of a cold abscess in the neck are:
• No local rise of temperature, tenderness, or redness
Fig. 22.7: Cold abscess in the midline above suprasternal
notch—another common site
Fig. 22.5: TB lymphadenitis—discrete nodes
Section II • General Surgery
Fig. 22.6: TB lymphadenitis—matted nodes Fig. 22.9: Cold abscess in the second intercostal space
Fig. 22.8: TB lymphadenitis—cold abscess
Acute Infections, Sinuses, Fistula and Surgical Site Infections
Fig. 22.10: Cold abscess of the right sternoclavicular joint
115
Fig. 22.12A and B: Nondependent aspiration
4. Stage of Collar Stud Abscess (Figs 22.13 and 22.14)
It results when a cold abscess deep to the deep fascia
ruptures through the deep fascia and forms another
swelling, which is fluctuant, in the subcutaneous plane.
Cross fluctuation test may be positive. It is treated like
a cold abscess.
Fig. 22.11: Cold abscess in the paravertebral region secondary
to tuberculosis of spine
• Soft, cystic, fluctuant, transillumination—negative
swelling.
• It becomes less prominent on sternocleidomastoid
contraction test, indicating that it is deep to the deep
fascia.
Multiple, matted, mobile lymph nodes are characteristic of
tuberculosis.
Differential Diagnosis
Branchial cyst may be confused for cold abscess in the
anterior triangle. Cold abscess is of a shorter duration
and may present with
other lymph nodes in the neck.
Branchial cyst, being a congenital swelling, is of a longer
duration.
Treatment of Cold Abscess (Figs 22.12A and B)
• Nondependent aspiration using a wide bore needle
to avoid a persistent sinus.
• A wide bore needle is preferred because the caseous
material is thick.
• Incision and drainage should not be done as it causes
persistent tuberculous sinus.
• Antituberculous treatment is administered.
Fig. 22.13: Collar stud abscess
Fig. 22.14: Collar stud abscess
5. Stage of Sinus (Fig. 22.15)
• A sinus is a blind tract leading from the surface down
into the tissues.
• It occurs when a collar stud abscess ruptures through
the skin.
• In India, tubercular sinus is the most common sinus
in the neck.
Section II • General Surgery
116
Fig. 22.15: Multiple tubercular sinuses in the neck and in front
of the ear
Manipal Manual of Surgery
• It is common in young females. There may be
multiple sinuses.
• Tubercular sinuses have a wide opening.
• The sinus resembles an ulcer with an undermined
edge.
• There is no induration.
• Surrounding skin is hyperpigmented and sometimes
bluish in colour.
• A group of lymph nodes is usually palpable under-
neath the sinus.
Tuberculosis of Intrathoracic Nodes
• Occurs is about 25% of all TB lymphadenitis cases.
• Pressure on the bronchus gives rise to atelectasis and
lung infection.
• Pressure on the oesophagus causes dysphagia and
oesophagotracheal fistula (Fig. 22.16).
• Retroperitoneal nodes may give rise to chylous ascites
and chyluria.
• HIV infection and lymph node TB (Key Box 22.4).
Section II • General Surgery
Fig. 22.16: Large mediastinal lymph nodes
Key Box 22.4
HIV Infection and Lymph Node Tuberculosis
It is more common than lymphoma and sarcoma
Patients are male and older
Multiple sites are more commonly affected
Disseminated disease (virulent) may be seen
Nodes can be tender
Weight loss is more common
TB-IRIS: Tuberculosis associated Immune Reconstitution
Inflammatory Syndrome. This is seen in patients with
tubercular lymphadenitis on retroviral therapy. It
manifests as deterioration of a treated infection or as a
new presentation of a previously subclinical infection.
Thus, lymph nodes may persist or may become bigger.
• It occurs due to an antigenic response caused by the
bactericidal action of antitubercular drugs.
• It needs only reassurance and anti-inflammatory drugs.
• A short course of steroids may be needed if pressure
symptoms are present.
• However, if lymph nodes do not respond and are
increasing, a biopsy should be done to rule out
lymphoma.
Investigations
TB lymphadenitis is most commonly diagnosed by
histopathology. Other investigations used for diagnosis
are acid-fast bacilli (AFB) smear or Ziehl-Neelsen (ZN)
staining and culture of lymph node material.
Collection of sample/material for examination
may
be done by either:
1. Fine needle aspiration, or
2. Excisional lymph node biopsy.
1. Fine needle aspiration (FNA): It is considered as the
first line of evaluation of suspected tuberculous
lymphadenopathy. FNA had good sensitivity and
specificity (77% and 93%, respectively). Materials
obtained should be tested for:
AFB smear microscopy (ZN staining or fluore-
a.
scence microscopy)
b. Mycobacterial culture with drug susceptibility testing
c. Cytology
d. Nucleic acid amplification testing (Xpert MTB/RIF)
and line probe assays.
2. Excisional biopsy: This allows for a larger sample to
be collected and has a higher diagnostic yield than
FNA. Because a sinus tract may form if an incisional
biopsy is performed, excisional biopsy is preferred.
Materials obtained should be tested for:
AFB smear microscopy (ZN staining or fluore-
a.
scence microscopy)
Acute Infections, Sinuses, Fistula and Surgical Site Infections
117
b. Mycobacterial culture with drug susceptibility
testing
c. Histology: TB may be confirmed if epithelioid cell
granulomas and caseation are seen. The chance of
diagnosing TB is increased if multinucleated cells
are present. In patients living with HIV, these
typical granulomas are usually not found, as T cells
(which are essential for their formation) are
affected.
d. Nucleic acid amplification testing (Xpert MTB/RIF)
and line probe assays.
• Histopathology findings of caseating granulo-
mas, Langhans giant cells and foreign body giant
cells are suggestive of TB.
• Nucleic acid amplification testing (NAAT)—CB-
NAAT (cartridge-based NAAT)/Xpert MTB/RIF
helps in both the
tion of rifampicin resistance. NAAT identifies the
complex nucleic acid of Mycobacterium tuber-
culosis but cannot assess the viability of the
bacteria. It cannot be used for monitoring the
response to the treatment as it identifies the
complex nucleic acid of dead Mycobacterium
tuberculosis bacilli as well.
• Line probe assays are molecular tests which
make use of PCR to evaluate drug susceptibility
to isoniazid, rifampicin, aminoglycosides, and
fluoroquinolones.
• Mycobacterial culture is the gold standard for
diagnosis. It also helps in performing drug
susceptibility testing (DST) on MTB complex
growth, which may be used for decision making
by the treating physician/surgeon.
• Tuberculin skin test (Mantoux test) is a delayed
type hypersensitivity reaction to antigens of
Mycobacterium tuberculosis. The reagent used is
protein purified derivative (PPD) which is injected
intradermally. The induration is measured
between 48 and 72 hours. An induration >10 mm
is considered to be reactive and is suggestive of
M. tuberculosis infection. However, it does not
indicate active disease. A 5–9 mm induration is
an intermediate response and may be attributed
to BCG vaccination, M. tuberculosis, or atypical
mycobacterial infections. An induration <4 mm
is considered negative.
• Interferon-gamma release assays (IGRAs) may
be used in place of Mantoux test for diagnosing
TB infection.
• Imaging:
Chest X-ray should be done in all patients
a.
suspected with lymph node tuberculosis, as
diagnosis of TB and in detec-
lungs are the portal of entry for bacilli. It may
show features suggestive of active pulmonary
tuberculosis or apical fibrosis suggesting
previous exposure to tuberculosis. Positive
chest radiograph abnormalities are more
commonly seen in patients living with HIV.
b. HRCT scan of the thorax or abdomen may be
done if mediastinal or abdominal lymphadenopathy is suspected.
c. Ultrasound scanning of the suspected
anatomical site may be done to confirm the
lymph node swelling, abscess and also helps
in guided FNA.
d. EBUS (endobronchial ultrasound) helps in
localising the mediastinal lymph node and in
guiding transbronchial needle aspiration
(FNA) of mediastinal lymph nodes (mediastinoscopy or CT-guided FNA/biopsy are
preferred if mediastinal lymph nodes are not
accessible through EBUS).
Definitions of Diagnosis (INDEX TB Guidelines)
Bacteriologically Confirmed LNTB Cases
Lymph Node TB)
(
A patient with symptoms and signs of LNTB who has
at least one of the following:
• Positive microscopy for AFB on examination of
lymph node fluid or tissue
• Positive culture of Mycobacterium tuberculosis from
lymph node fluid or tissue
• Positive validated PCR-based test (such as Xpert
MTB/RIF)
Clinically Diagnosed LNTB Case
A presumptive LNTB patient who undergoes diagnostic
testing and has all of the following:
• Negative microscopy, negative culture, and negative
PCR-based tests
• No other diagnosis to explain the clinical features
• Strongly suggestive evidence of LNTB by radio-
logical findings, histopathological findings, or clinical
course
TREATMENT
Antitubercular drugs are the cornerstone of treatment
for LNTB.
Isoniazid (H), rifampicin (R), pyrazinamide (Z),
ethambutol (E) and streptomycin (S) are the 1st line
antitubercular drugs and are very important in treating
drug-sensitive tuberculosis.
Section II • General Surgery
118
Manipal Manual of Surgery
Regimen
IP (intensive phase) of 2 months of HRZE followed by
CP (continuation phase) of 4 months of HRE in new
cases (patients without a history of previous exposure
to ATT).
TREATMENT OF DRUG-RESISTANT CASES
MDR-resistance to Rifampicin and Isoniazid
• IP (intensive phase): 6–9 months of kanamycin,
levofloxacin, pyrazinamide (Z), ethambutol (E),
cycloserine, and ethionamide.
• CP (continuation phase): 18 months of levofloxacin,
ethambutol (E), cycloserine, and ethionamide.
• If sensitive to isoniazid and resistant to rifampicin,
isoniazid can be added to the above regimen in both
phases.
• If resistant to isoniazid and sensitive to rifampicin
(isoniazid monoresistance), treat with:
IP: 3–6 months of kanamycin, levofloxacin,
–
rifampicin (R), pyrazinamide (Z), ethambutol (E).
– CP: 6 months of levofloxacin, rifampicin (R),
pyrazinamide (Z), ethambutol (E).
– Individual monoresistance should be treated
according to drug sensitivity testing results.
HIV CO-INFECTION
In India, the most common opportunistic infection
related to HIV is tuberculosis. Patients with latent
tuberculosis are more prone to develop tuberculosis in
their lifetime, if they become infected with HIV. Extrapulmonary tuberculosis is more common in patients
living with HIV (PLHIV) than in non-HIV infected
patients. HIV has been accepted by WHO as a defining
criteria for clinical stage 4 disease diagnosis. Tuberculous lymphadenopathy often suggests disseminated
tuberculosis in PLHIV. In PLHIV, lymph node enlargement is usually symmetrical and multiple. Significant
mycobacterial load is often reported in PLHIV. Chest
X-ray findings of pulmonary tuberculosis are a common
association with tuberculous lymphadenitis in PLHIV.
Response to treatment with antitubercular treatment is
similar to HIV negative patients; however, recurrence
and death are higher in PLHIV.
Incidence of Different Lymph Node Sites Involved
The cervical group of lymph nodes is the most common
group of lymph nodes involved (63.3%), followed by
the mediastinal lymph nodes (26.7%) and the axillary
lymph nodes (8.3%).
Cervical and mediastinal lymph nodes together
constitute around 70% of the cases of TBLN. Axillary,
Section II • General Surgery
mesenteric, hepatic, periportal, and inguinal lymph
nodes constitute the rest. In descending order, the
incidence of involvement of lymph nodes are cervical
(64.9%), axillary (27%), and mediastinal (8%) nodes.
TBLN may involve single or multiple sites. When all
TB lymphadenopathies are analysed, the incidence is
as follows: Only cervical nodes (63.6%), cervical +
axillary + inguinal nodes (15.1%), only hilar nodes (6%),
only inguinal nodes (3%), axillary + inguinal nodes (3%)
and axillary + abdominal + hilar lymph nodes (3%).
Role of Surgery in Tuberculous Lymphadenitis
• Biopsy: Lymph node biopsy, wedge biopsy from the
edge of the sinus.
• Aspiration: Non-dependent aspiration of cold
abscess and pus should be sent for AFB staining,
Ziehl-Neelsen (ZN) staining.
• Excision of lymph nodes if they persist in spite of
antitubercular treatment.
• Excision of sinus wall along with the tract.
OTHER SPECIAL TYPES OF PYOGENIC INFECTIONS
BOIL (Key Boxes 22.5 and 22.6)
• This is also called a furuncle. It is a hair follicle infec-
tion caused by Staphylococcus aureus or a secondary
infection of a sebaceous cyst.
• It starts with a painful indurated swelling with
surrounding oedema. After about 1–2 days, softening
occurs in the centre and a pustule develops which
bursts spontaneously and discharges pus. Necrosis
of subcutaneous tissues produces a greenish slough.
Skin overlying the boil also undergoes necrosis.
Hence, boil is included under acute infective
gangrene.
Key Box 22.5
Precipitating Factors Common Locations
Scratching Face and back of the neck
Diabetes Axilla
Poor immunity Gluteal region
Key Box 22.6
Facts about a Boil
Dangerous boil : On the skin of face
Tender boil : External auditory
Sweet boil : Diabetic patients
Boil likes : Oily skin
Blind boil or dull boil : Subsides without suppuration
Acute Infections, Sinuses, Fistula and Surgical Site Infections
119
• Furuncle of the external auditory meatus is a very
painful condition because of the rich nerve supply of
the skin. Pain is also due to the dense adherence of
the skin to the perichondrium (there is no subcutaneous tissue).
Treatment of Boil
Incision and drainage with excision of slough. Antibiotic
cloxacillin is given. Diabetes, if present, is treated.
Complications of Boil
• Necrosis of the skin.
• Pyaemic abscess and septicaemia.
• Cavernous sinus thrombosis due to a boil on the face
or a stye on the eyelid.
CARBUNCLE (Figs 22.17A and B)
• Name is derived from Latin: Carbunculus, a small
coal.
• This is an infective gangrene of the subcutaneous
tissue caused by Staphylococcus aureus (Key Box
It commonly occurs in diabetic patients
22.7).
Patients with poor immunity or those undergoing
radiotherapy may also develop carbuncle.
• Sites: Nape of the neck is the most common site,
followed by the back and shoulder region. The skin
of these sites is coarse and has poor vascularity.
• Carbuncle can also occur in kidney.
Pathology
The initial lesion is similar to a boil in the form of a hair
follicle infection with perifolliculitis. Since the majority
of patients are diabetic, infection takes a virulent course
and results in subcutaneous fat
necrosis, giving rise to
multiple abscesses. These abscesses are intercommunicat-
ing and open to the exterior by multiple sieve-like
openings. This appearance is described as cribriform
appearance which is pathognomonic of a carbuncle.
Clinical Features
• Typically, the patient is a diabetic.
• Severe pain and swelling in the nape of the neck.
• Constitutional symptoms, such as fever with chills
and rigors, are severe.
• Surface is red and angry-looking like red hot coal.
• Surrounding area is indurated.
• Later, skin over the centre of carbuncle softens and
peripheral satellite vesicles appear, which rupture
and discharge pus,
giving rise to a cribriform appea-
rance (Fig. 22.17A).
• The end result is the development of a large crateri-
form ulcer with central slough.
Complications
1. Worsening of diabetic status, resulting in diabetic
ketoacidosis.
. Extensive necrosis of the skin overlying the carbuncle.
2
Hence, it is included under acute infective gangrene.
3. Septicaemia, toxaemia.
Fig. 22.17A and B: (A) Carbuncle of the back of neck—
common site, sieve-like appearance, (B) after excision of the
carbuncle—wound heals within 2 to 3 weeks. Some cases require
split skin grafting
Key Box 22.7
Staphylococcal Infections of Surgical Importance
Boil Parotitis
Carbuncle Osteomyelitis
Breast abscess
Treatment (Key Box 22.8)
Key Box 22.8
Summary of Carbuncle
Caused by Cocci
Abscesses Communicating
Red hot like Coal
Appearance Cribriform, Crateriform ulcer
Gangrene Cutaneous (subcutaneous)
Drug of choice Cloxacillin
Diabetes Control
Incision Cruciate Observe 8 Cs
Treatment of carbuncle is excision.
• Control diabetes, preferably with injectable insulin.
• Appropriate parenteral antibiotics are given till
complete resolution occurs. Most strains of Staphylo-
coccus aureus are sensitive to cloxacillin, flucloxacillin,
Section II • General Surgery
120
Fig. 22.18: Carbuncle with central slough. A cruciate incision
should be given followed by excision
Manipal Manual of Surgery
• When it occurs over the face, it involves the pinna
because erysipelas is basically a cuticular lymph-
angitis. This is described as Milian’s ear sign
positive, which is used to differentiate cellulitis of
the face from facial erysipelas. In cellulitis of face,
the pinna does not get involved because of the close
adherence of the skin and cartilage.
Complications
1. Toxaemia and septicaemia
. Gangrene of the skin and subcutaneous tissue
2
3. Lymphoedema of face and eyelids due to lymphatic
obstruction and fibrosis
erythromycin, and some cephalosporins. However,
methicillin-resistant Staphylococcus aureus (MRSA)
bacteria are resistant to these drugs. They are sensitive only to the expensive drug vancomycin, which
has to be given intravenously.
• Improve general health of the patient.
• If the carbuncle does not show any softening or shows
evidence of healing, it is not incised
and may be left
open to the exterior. Alternatively, saline dressings
may be applied to reduce oedema. Complete resolution may take place within 10–15 days.
• Surgery is required when there is pus (Fig. 22.18). A
cruciate incision is preferred because of the multiple
abscesses and extensive subcutaneous necrosis. Edges
of the skin flap are excised, the pus is drained, loculi
are broken down, slough is excised, and the cavity is
irrigated with antiseptic agents. Like pyogenic abscess,
wound heals with granulation tissue from the depth.
ERYSIPELAS
• It is an acute inflammation of the skin and sub-
cutaneous tissue associated with severe lymphangitis.
The causative organism is Streptococcus pyogenes. The
precipitating factors are malnourishment, chronic
diseases, etc. Thus, children and old people are
commonly affected.
• Infection sets in after a small scratch or abrasion and
spreads very rapidly, resulting in toxaemia. Sites:
Face, eyelids, scrotum, and in infants, the umbilicus.
Clinical Features
• Rose-pink rash with a raised edge (on palpation) and
a button hole consistency.
• Vesicles appear later and rarely become pustular.
• Oedema of the eyelids or scrotum, depending on the
site.
• Features of toxaemia
Section II • General Surgery
Treatment
Injection crystalline penicillin 10 lakh units 6th hourly
IM/IV for 5–10 days.
CHRONIC ABSCESS
It occurs when the initial infective process or cause is
not fully identified and properly treated.
Sites
Foot, hand, thigh, etc.
Causes
. Foreign bodies: These are the most common causes
1
chronic abscess. There is a typical history of a
of a
recurrent swelling discharging pus. Wooden pieces
impacted in the thigh or in the foot are common.
Infection of the synthetic mesh used in hernial repair
is another example.
2. Dead tissue: As it occurs in diabetic patients.
3. Pilonidal sinus: This condition gives rise to recurrent
abscesses. There is a typical history of pain and a
swelling that ruptures and is followed by spontaneous recovery. However, the sinus persists.
4. Chronic disease: Tuberculosis is one of the causes.
All features of cold abscess may be present but in an
unusual location.
A 40-year-old female presented with swelling of the left
thigh of 8 months duration. There were no signs of
inflammation. FNAC was inconclusive. During surgery, a
localised abscess with a thick wall and fleshy tissue was
removed. The final report was tubercular abscess.
There was no evidence of tuberculosis anywhere in the
body. Tuberculosis may present in different forms, as seen
in this case. Detailed investigations were unable to reveal
any evidence of pulmonary tuberculosis.
Acute Infections, Sinuses, Fistula and Surgical Site Infections
NECROTISING FASCIITIS
It is a spreading, destructive, invasive infection of the
skin and soft tissues, which includes the deep fascia,
but relatively spares muscle.
Risk factors are given in Key Box 22.9.
Key Box 22.9
Necrotising Fasciitis—Risk Factors
Diabetes mellitus, malnutrition
Obesity, corticosteroids
Immune deficiency
Common Sites
It is common in the lower extremities. Other sites are
the genitalia, groin, and lower abdomen. In these places,
it is comparable or similar to gangrene and is called
Meleney’s gangrene.
121
Types and Microorganisms
• Type I necrotising fasciitis : Polymicrobial: It is due
to a synergistic combination of anaerobes and coliforms or nongroup A streptococci— Very often, there
is no history of injury when it occurs in the lower limbs.
• Type II necrotising fasciitis (Key Box 22.10): Mono-
microbial: It is due to group A β-haemolytic streptococci.
This has been referred to as flesh eating disease.
• Type III necrotising fasciitis: Gas gangrene due to
clostridium (Chapter 3).
• Type IV necrotising fasciitis (others): Fungal
(candida) and vibrio species-marine organisms.
Pathogenesis:
• Numerous cytokines, such as IL-1, IL-6, and TNF-α, are
released due to inflammation caused by M proteins,
which are produced by Streptococci.
• Streptococci also produce exotoxins, which destroy
neutrophils. This results in the growth of bacteria,
which in turn destroy the tissues.
Clinical Features
• Sudden pain in the affected area with gross swelling
of the limbs (Figs 22.19–22.21).
Key Box 22.10
Specific Features of Type II Necrotising Fasciitis
Caused by Streptococcus pyogenes
Occur in young healthy people
Minor abrasions, laceration may be a precipitating factor
Severe systemic illness with multiorgan failure—
streptococcal toxic shock syndrome
Fig. 22.19: Type II necrotising
fasciitis in a healthy man. In
spite of debridement and
intensive care, he died of
multiorgan failure
Fig. 22.21: Observe the skin changes in necrotising fasciitis
Fig. 22.20: This patient presen-
ted with features of cellulitis with
renal failure. There were no precipitating factors. After debridement, recovery was complete
• The part is swollen, red, erythematous, and
oedematous with skip lesions of skin necrosis and
ulceration.
• Skin changes: Bronze hue, brawny induration, blebs,
or crepitus are other important features. Very soon,
skin patches and a dusky blue colour, followed by
blebs and bullae appear.
• Thrombosis of the nutrient artery results in
gangrene. Interestingly, muscles are spared.
• High degree fever, jaundice, and renal failure may
occur soon in untreated cases.
Section II • General Surgery
122
Manipal Manual of Surgery
Diagnosis
• Early diagnosis may be made by a scoring system
proposed by Wong et al., which considers white cell
count, CRP (C-reactive protein), haemoglobin, sodium,
creatinine, and glucose levels. This system is called
the Laboratory Risk Indicator of Necrotising
Fasciitis—LRINEC.
• Full thickness biopsy taken at bedside may give the
full diagnosis. Watery pus (dishwater liquid) is also
characteristic.
• A high index of suspicion is required to diagnose
necrotising fasciitis. When in doubt, one can do
exploratory fasciotomy. Lack of resistance between
normally adherent fascia to blunt dissection is
diagnostic of necrotising fasciitis.
• The finger test is a bedside procedure done under
local anaesthesia. A 2-cm incision is made and
deepened to the deep fascia, at which level gentle
probing with the index finger is applied. The presence
of dishwater liquid and a lack of resistance are
characteristic of necrotising fasciitis.
Treatment
Early, aggressive management with supportive and
surgical treatment.
• Supportive treatment includes hospitalisation,
adequate hydration, treatment of hypotension and
broad-spectrum antibiotics.
• First and second generation cephalosporins are used
to treat Staphylococcus aureus. However, in cases of
resistant cases due to MRSA (methicillin resistant
Staphylococcus aureus) vancomycin with carbapenem
may be urgently required. Surgery should be performed
as early as possible. Severe pain, colour changes in
the skin, and drowsiness are indicators of sepsis. In
such cases, do not wait for all reports and perform
debridement on an emergency basis. This involves
wide excision and generous debridement, followed
by skin grafting after a few days or weeks. Debridement may have to be repeated till healthy tissue is
encountered. Do not hesitate to amputate if the
patient’s life is in danger, because in a few patients,
that is the only life-saving measure.
• Type II cases (streptococcal): High dose penicillins
with clindamycin is the treatment of choice.
Clindamycin has a special effect as it is a potent
suppressor of bacterial toxin synthesis.
• Intravenous immunoglobulin (IVIG) has recently
been described as a reasonable and desirable option
Section II • General Surgery
for neutralizing streptococcal toxins.
ACUTE PYOMYOSITIS
Definition
Pyomyositis refers to a localised area of suppuration
within striated muscle. It occurs after trauma (Key
Box 22.11).
Key Box 22.11
Pathogenesis of Acute Pyomyositis
Trauma
(Striated muscles are rich in iron)
Release of iron
Profuse growth of bacteria
Intramuscular abscess
Spreading infection
Septicaemia
Clinical Features
• Classically, the quadriceps, gluteus, and shoulder and
upper arm muscles are affected. Pain over the part,
oedema, fever, and jaundice are common. Tenderness,
induration, and muscle spasms
are characteristic.
• Renal failure follows soon.
Investigations
• Sonographic-guided aspiration of pus followed by
culture
• CT and MRI are ideal to determine the spread of the
infection.
• Creatine kinase may go up to 50,000–2,00,000 units/L
during the acute phase because of rhabdomyolysis.
Treatment
• Early diagnosis and early aggressive treatment
• Antibiotics
• Exploration—for diagnosis and treatment
• Wide excision of muscles and compartmental excision
until viable tissues become visible (Figs 22.22 and 22.23).
Summary—Key Box 22.12.
NOSOCOMIAL INFECTIONS
• An acquired infection from the hospital is known as
a nosocomial infection.
• Infection may occur from the patient’s own
organisms (self-infection) or from external organisms.
Acute Infections, Sinuses, Fistula and Surgical Site Infections
Fig. 22.22: Extensive pyomyositis affecting muscles of the back
123
associated with systemic inflammatory response
syndrome (SIRS), it is called sepsis, and if it is associated
with organ failure and requires inotropes, it is called
severe sepsis. More details are given under septic shock
(page 65).
When to Suspect SSIs?
• A postoperative patient with elevated temperature,
tachycardia, tachypnoea, and an elevated white blood
cell (WBC) count.
• The wound shows signs of inflammation such as
rubor, colour, dolor, and tumour (swelling). These
are the part of SIRS (systemic inflammatory response
syndrome).
• Wound is tender with discharge.
• Microorganisms are identified in blood, pus, or urine.
• SIRS may be caused by variety of diseases, such as
pancreatitis, polytrauma, malignancies, transfusion
reactions, as well as infection.
• SIRS caused by an infection is known as sepsis. SIRS
is mediated by the production of proinflammatory
mediators, such as lipopolysaccharides (endotoxin)
derived from gram-negative organisms and peptidoglycans from gram-positive organisms.
Fig. 22.23: Healing after 2 weeks
Key Box 22.12
Pyomyositis
Trauma
Transient bacteraemia
Tropical countries
Thigh muscles are affected
Tender intramuscular abscess
Tenderness, temperature, toxicity
Total renal failure—rhabdomyolysis
Treatment—early aggressive exploration and excision
Observe 8 Ts
• Surgical site infections (SSIs) are the third most
frequently reported nosocomial infection, after
pneumonia and catheter-related infections (including
urinary tract infection).
SURGICAL SITE INFECTIONS (SSIs)
Definition
SSIs refer to infections of the tissues, organs, or spaces
that have been exposed during invasive surgical
procedures. They may be superficial, such as redness
of a postoperative wound or a swollen local part. When
PIRO Classification Scheme
Predisposition: Advancing age or immunosuppression
that may affect survival.
Insult (infection): It depends on the infecting organism
or location of the disease.
Response: It refers to the development of SIRS, shock,
elevated C-reactive protein, etc.
Organ dysfunction: Failure or dysfunction of organ
(s).
Clinical Features
• Superficial SSI: The wound is tender, erythematous,
and oedematous.
• Deep incisional SSI: Tenderness extends, and
crepitus, vesicles, and/or bullae may be present.
• Intra-cavitary SSI: This depends on the system
involved. A classical example is paralytic ileus
continuing in abdominal infections.
Common Sources of Infections
Major surgical site infections present with systemic
manifestations, whereas minor surgical site infections
present with suture site discharge only.
In surgical wards, discharging wounds, infected
urine, faeces, and sputum are sources of nosocomial
infections.
Section II • General Surgery