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144
Manipal Manual of Surgery
• In severe cases, a small plastic catheter should be
introduced into the synovial bursa and should exit
by a counter-incision in the palm for antibiotic
irrigation.
• Postoperatively, appropriate antibiotics should be
given for about 2 weeks.
• The hand should be in an elevated position to reduce
oedema.
Complications
1. Stiffness of the fingers
. Suppurating arthritis of the joints
2
3. Osteomyelitis
4. Loss of tendon, digit
5. Spread of infection to space of Parona. It is the space
deep to the flexor profundus and superficial to the
pronator quadratus in the lower end of the forearm.
Patients present with swelling of the forearm along
with gross oedema of the hand. In addition to the
treatment mentioned above, a separate incision may
have to be given in the lower forearm for better
drainage of pus.
GENERAL PRINCIPLES OF
HAND INFECTION MANA
GEMENT
• Early diagnosis and splinting.
• Early proper drainage
• Proper incision—preferably a crease incision
• Elevation of the hand to reduce oedema
• Pus culture and sensitivity
• Cloxacillin 500 mg 6th hourly and metronidazole
400 mg 8th hourly for 7–10 days. Higher antibiotics
such as cephalosporins may have to be given.
• Physiotherapy to decrease stiffness of the fingers.
• Tetanus prophylaxis in high-risk patients.
Recommended Antibiotics
Staphylococcus aureus: First generation cephalosporins.
Anaerobics/Escherichia coli: Clindamycin or β-lactamase
inhibitors, amoxicillin clavulanate potassium.
Herpetic Whitlow: Antivirals.
Position of Hand Functions (Fig. 24.17)
The hand is held as if holding a cup/glass, with the
thumb in alignment with the forearm.
• Extension at wrist: 25°
• Flexion at metacarpophalangeal joint: 60°
• Flexion at interphalangeal joint: 10°
Section II • General Surgery
• Flexion at distal interphalangeal joint: 5°
Fig. 24.17: Position of functions
OTHER HAND INFECTIONS
1. Compound palmar ganglion (see page 314).
2. Barber’s pilonidal sinus (interdigital): It occurs due
to repeated clipping by barbers.
3. Orf virus infections: It is also called ecthyma
contagiosum, highly contagious pustular dermatitis
due to parapoxvirus infection. It is endemic in sheep
and goat herds worldwide. It is transmitted by direct
contact. Lesions cannot only occur in hands but also
in lips, ear nostrils, etc. Typically, it appears as an
ulcerated nodule which is red in colour. It is selflimiting course, may take 1 to 2 months.
4. Milker’s nodes: A viral disease transmitted by
handling a cow’s udder. Milker’s nodules (pseudo
cowpox) are harmless skin lesions most commonly
seen in persons whose occupation regularly brings
them into close contact with cattle. Lesions are
multiple swellings with central ulceration. Like any
other hand infections, there is oedema of the hands.
Treatment is symptomatic.
5. Human bites: Common organism is Staphylococcus.
The wound is explored, and proper treatment is
given.
6. Atypical mycobacterial infections: It affects tendon
sheaths resulting in swelling, stiffness, pain, and
redness. Fever can also be a feature. Diagnosis is by
exploration and excision of the infected tendon sheath
lining. Histopathological examination should include
not only to look for granulomas but also gene expert
for Rifampicin resistance. Mycobacterium marinum is
the common cause.
FOOT INFECTIONS
MYCETOMA PEDIS
Also called Madura Foot or Maduramycosis.
Hand, Foot Infections and Tendon Transfer
Definition: Mycetoma is a chronic, progressive and
suppurative subcutaneous granulomatous infection
characterized by painless swelling and draining sinus
tracts, and purulent discharge. This type of process of
swelling or becoming tumorous like phenomenon is
described as tumefaction.
Types
. Bacterial mycetoma: It is due to Nocardia madurae or
1
Actinomyces. These organisms are normally present
in the soil.
2. Fungal mycetoma: It is caused by Madurella mycetoma, etc.
Etiopathogenesis
• Male farmers between the 20 and 40 years of age are
affected. Foot is the commonest site. Rarely it may
involve the hands, back, or shoulders.
• Barefoot walking, which results in repeated minor
trauma, implants the organisms within the subcutaneous tissue.
• Ultimate result is chronic granulomatous lesions of
the foot involving the skin and subcutaneous tissues.
• The disease also involves deeper structures like
bones, resulting in osteomyelitis.
• Gross thickening of the subcutaneous tissue results
in characteristic convexity (flattening) of the instep
of the foot (Fig. 24.18).
Clinical Features
• It starts as a pale, painless, single nodule. Later,
multiple nodules develop and rupture, resulting in
multiple sinuses.
• Chronic suppuration, multiple sinuses, and sulphur
granules in the discharge are also characteristic of
mycetoma pedis.
Diagnosis
• Sulphur granules in the discharge: Actinomycotic
grains typically have Gram-negative centers with
145
Fig. 24.19: Plain radiograph of the foot showing extensive
rarefaction of the bones
fine, branched Gram-positive filaments. In cases of
eumycetomas, a mass of Gram-negative septate
hyphae embedded in intercellular cement with wider
filaments are found.
• Plain radiograph of the foot (Fig. 24.19) may show
soft tissue shadow, lytic lesions, periosteal reactions
and sclerosis.
• CT/MRI: Dot in a circle sign is characteristic of
mycetoma pedis. Done for assessment of bone and
soft tissue involvement.
• FNAC: It can be taken when there is a mass like lesion.
It can show the characteristic histopathologic changes
such as polymorphous inflammatory cells intermixed
with grains, neutrophils, lymphocytes, plasma cells,
histiocytes, macrophages, and foreign body giant cells.
• Biopsy is important to determine the causative
organism.
Treatment
• Broad-spectrum antibiotics to treat secondary
infection along with dapsone (drug of choice)
100 mg twice daily. Treatment may have to be
continued for 1–2 years.
• Fungal mycetoma may not respond to antibiotics and
may be treated with ketoconazole.
• A combination of trimethoprim/sulfamethoxazole
and rifampicin may also be tried.
• Amputation may be necessary in refractory cases to
get rid of a deformed, diseased limb.
Fig. 24.18: Flattening of the foot (Courtesy: Prof Madakatti, Head,
Department of Surgery, Karnataka Institute of Medical Sciences,
Hubli, Karnataka)
Mucocutaneous Splendore-Hoeppli Phenomenon
• It refers to the accumulation of eosinophilic material
(asteroid-like) around microorganisms, known as
‘asteroid bodies.’
• Fungal and bacterial infections may give rise to this
(e.g. actinomycosis, candidiasis, etc.)
• This phenomenon results due to a localised immuno-
logical response to an antigen–antibody precipitate.
Section II • General Surgery
146
Manipal Manual of Surgery
INGROWN TOENAIL (ONYCHOCRYPTOSIS)
• It is also described as an embedded toenail. The exact
aetiology is not clear. However, a few patients have
a family history of this condition. Excessive trimming
of the nail may result in an ingrown toenail.
• As the nail grows inside, some degree of infection
sets in, resulting in the development of granulation
tissue which starts pouting. The condition is painful,
disturbing, and unsightly.
Treatment
• Conservative: Dressing with antiseptic agents such
as iodine. Copper sulphate may be applied to treat extra
granulation tissue. Appropriate antibiotics are given.
• Surgical: Under local anaesthesia, a portion of the
involved nail up to the base is removed, followed by
application of phenol to the growing point of the
nailbed at its base. It takes about 10–15 days for
complete healing.
• Zadik’ s or Fowler’ s operation: The principle of this
radical procedure is to expose the lateral spike and
germinal matrix. This is achieved by incising the skin
over the lateral margin and root of the nail.
MISCELLANEOUS
Pyogenic Granuloma (Fig. 24.20)
• It is not a true granuloma, but a
capillary haemangioma
• It is due to trauma, not infec-
tion (pyogenic is a misnomer)
• It is smooth, red, and lobulated
• It may be painful
• It bleeds due to minor trauma
• In fingers, persistent irritation
may result in excessive
granulation tissue
• It may also occur in the oral
cavity
Fig. 24.20: Pyogenic
granuloma
• It is also known as ‘pregnancy tumour’ .
TENDON TRANSFER
1,2
Tendon transfer surgeries are a highly useful form of
reconstruction wherein the actions of lost or weakened
neuromuscular action are supplemented or substituted
by redirecting the action of other intact and relatively
expendable musculo-tendinous units. Thus, certain
actions and abilities that are deemed more important
are reconstructed at the expense of others.
Several of these procedures have been described,
Section II • General Surgery
developed, and popularized by Indian surgeons such
as Paul Brand, Srinivasan, Fritchie, Antia among others.
The surgical techniques and principles of tendon
transfer underwent a lot of development under these
illustrious surgeons especially for the treatment of nerve
palsy from Hansen’s disease which used to be endemic
to certain parts of our country.
All tendon transfer surgeries follow certain principles
which are paramount to the success of these highly
sophisticated and technically demanding procedures.
They require accurate realignment of the direction of
force of the transferred musculotendinous unit as well
preservation of transferred elements with minimal
damage to the donor tissue. Success of the procedure
also requires that both the surgeon and the patient
understand the functional and aesthetic goals along
with the limitations and expectations of surgery.
The basic principles of tendon transfer are as follows:
1. Supple joints prior to transfer: Prior to the procedure,
the joint that the tendon transfer will move must be
supple and have maximum x range of motion when
moved passively.
2. Soft tissue equilibrium: The tissues through which
the tendon transfer is negotiated must be healthy and
free of any edema, inflammation or scar. These may
hinder tendo-muscular glide and optimal wound
healing following tendon transfer.
3. Donor of adequate excursion: The maximum linear
movement of the transferred Musculo-Tendinous
Unit (MTU) or its change in length on contracting or
relaxing should be adequate to achieve the desired
hand movement. The MTU chosen for transfer
should ideally have an excursion similar that of the
tendon which it is replacing.
4. Donor of adequate strength: The MTU to be transferred
must be strong enough to achieve the desired
movement, but at the same time, should not be too
strong. A donor MTU that is too weak will have
inadequate movement and function, while a donor
that is too strong will result in imbalanced movement
and inappropriate posture at rest. Thus, MTU chosen
for transfer should ideally have strength similar that
of the tendon which it is replacing.
5. Expendable donor: Use of a potential donor MTU
for transfer, may result in some degree of weakness,
loss of movement, or imbalance. These must not be
more debilitating than the function it is replacing.
Further, the choice of the donor MTU should
preferably be those which have other MTUs that
serve a since purpose or perform similar actions.
6. Straight line of pull: Tendon transfers are most
effective if the MTU provides straight line of pull.
Direction changes diminish the force that the
transferred MTU is able to exert on its insertion.
Hand, Foot Infections and Tendon Transfer
147
However, change of direction may be required in a
few cases and utilize pulleys to bring about this
directional change.
7. Synergy: Muscle groups (finger flexors or wrist
extensors) usually work together to perform a
function or movement. MTU utilized for transfer
must be synergistic to the function it is replacing with
rare exceptions. Thus, extensors are not used to
replace flexor actions and vice versa.
8. Single function per transfer: It is ideal to attempt
achieving just single function out of a single MTU
1. Which of the following statements are false regarding
paronychia?
A. It is caused by a fungal infection
B. It is a deep infection
C. It is the most common hand infection
D. Infection spreads beneath the eponychium
2. The following are true for terminal pulp space
infection except:
A. It is called ‘felon’
B
. It may cause digital arterial thrombosis
C. Osteomyelitis of the distal phalanx will not occur
due to extensive collaterals
D. Pyogenic arthritis may occur
3. The following are true for deep palmar abscess except:
A. It is an infection of the midpalmar space
B. Interphalangeal joint movements are very painful
C. Metacarpophalangeal joint movements are very
painful
D. It communicates with the anterior compartment
of the forearm
transfer. Every transfer will result in compromised
strength and movement. There is an inherent
tendency to lose at least one grade of power (MRC
grade) when a tendon transfer is performed.
REFERENCES
1. Tendon Transfers Part I: Principles of Transfer and Transfers for
Radial Nerve Palsy. Douglas M. Sammer, MD1 and Kevin C. Chung,
MD, MS2.
2. Green’s Operative Hand Surgery, 2-Volume Set, 8th Edition.
6. The following are true for acute suppurating tenosynovitis except:
A. Finger is fixed and flexed
B
. Interphalangeal joint movements are not painful
C. Metacarpophalangeal joint movements may be
painful
D. Kanavel’s sign may be positive
7. The characteristic feature of mycetoma pedis is:
A. The disease affects bones
. It starts as a pale, painless, single nodule
B
C. It causes extensive rarefaction of the bone
D. There is convexity of the instep of the foot
8. The following are clinical features of mycetoma pedis
except:
A. Crepitus
. Multiple sinuses
B
C. Gross thickening of the subcutaneous tissues
D. Chronic nature
4. Kanavel’s sign is:
A. Tenderness over the pulp space
. Tenderness over the midpalmar space
B
C. Tenderness over the radial bursa
D. Tenderness over the ulnar bursa
5. Space of Parona refers to:
A. Space deep to the palmar aponeurosis
B
. Space deep to the flexor digitorum superficialis
C. Space deep to the flexor profundus
D. Space deep to the flexor carpi ulnaris
9. Pyogenic granuloma is due to:
A. Bacterial infection B. Viral infection
C. Fungal infection
D. Trauma
10. The following are principles of hand infection management except:
A. Hand should be elevated
. Early splinting
B
C. Tetanus prophylaxis in high-risk patient
D. Pencillin is the drug of choice
Answers
1. B 2. C 3. B 4. D 5. C 6. B 7. D 8. A 9. D 10. D
Section II • General Surgery
25
Chronic Infectious Disease
Actinomycosis
Leprosy
Deformities in leprosy
SU6.1: Define and describe the aetiology and patho-
genesis of surgical infections.
INTRODUCTION
Actinomycosis, leprosy, syphilis, and AIDS are the
chronic diseases discussed in this chapter. Actinomycosis is a rare disease, leprosy and syphilis of more
interest to dermatologists, and AIDS is an interesting
topic to all clinicians. Hence, only relevant aspects of
each of these diseases, as far as general surgeons are
concerned, will be discussed here.
ACTINOMYCOSIS
Mycetoma are of two types. Eumycetoma is caused by
fungi and actinomycosis is caused by bacteria. It predominantly occurs in the mycetoma belt that lies between
the latitudes 15°S and 30°N, comprising countries such
as Sudan, Somalia, India, Argentina, Mexico, etc.
Actinomycosis is caused by Actinomyces israelii, an
anaerobic, gram-positive, branching, filamentous
organism (ray fungus). It is normally present in the oral
cavity, tonsillar crypts, and dental cavities. They become
pathogenic in the presence of trauma. Other species
include A. neuri and A. neyeri.
Three types of actinomycosis which are of interest
to general surgeons are discussed here.
FACIOCERVICAL ACTINOMYCOSIS (50%)
• It is the most common manifestation of actinomycosis.
• It is common in patients with poor oral hygiene, bad
caries tooth, etc.
Syphilis
AIDS
• Diabetes mellitus, immunosuppression, local tissue
damage secondary to radiation and neoplasia may
precipitate actinomycosis.
• There is subacute or chronic inflammation for many
months to years and a lumpy jaw (Key Box 25.1).
• Eventually, the cheek, mandible, jaws, and salivary
glands are involved, resulting in suppuration. The
most common site is the mandible.
Key Box 25.1
Differential Diagnosis
Jaw tumour
Osteomyelitis of jaw
Malignancy of oral cavity
Clinical Features
Two patterns are identified:
1. Chronic slowly progressive inflammation resulting
in an indurated mass.
• Extensive (marked) induration of the lower jaw
(mandible) and gums give the consistency of bone.
• Multiple subcutaneous nodules over bluish skin
covering the jaw.
• The nodules rupture, resulting in multiple dis-
charging sinuses.
• The discharge contains sulphur granules which
contain gram-positive mycelia surrounded by
gram-negative clubs.
. Less commonly, it may present as an acute suppurative
2
infection with rapid progression to abscess formation.
This causes pain, trismus, dyspnoea, and dysphagia.
• Lymph nodes are not involved. It spreads mainly
by direct extension.
148
Chronic Infectious Disease
149
• Triad of actinomycosis: Subcutaneous mass,
multiple sinuses, and seropurulent discharge.
ACTINOMYCOSIS OF THE THORAX AND LUNG (30%)
• It is common in children, and is caused by inhalation
of ray fungus.
• Over a period of years, it produces actinomycosis of
the lung with involvement of the pleura. Later, it also
involves the chest wall, resulting in multiple discharging sinuses.
• There may be associated empyema and it may easily
spread to the liver.
ACTINOMYCOSIS OF THE RIGHT ILIAC FOSSA AND
LIVER (ABDOMINAL A
CTINOMYCOSIS—20%)
• It commonly occurs after surgery when there is
mucosal injury or discontinuity (e.g. after appendicec-
tomy, after perforation of hollow viscus, neoplasia).
• The organisms which are normally present in the gut
slowly migrate into the pericaecal tissue, then into
the soft tissue and subcutaneous tissue, and produce
subacute or chronic low-grade inflammation.
• No compromise of the bowel lumen.
• Once the portal venous radical gets involved, it
spreads to the liver.
Clinical Features
• History of appendicectomy is present in almost all cases.
• 3–6 months later, fever and a swelling in the right
iliac fossa appear.
• On examination, there is an indurated, nodular, and
fixed mass in the right iliac fossa.
• Late stages produce multiple discharging sinuses,
sometimes discharging faecal matter and sulphur
granules. Unlike tuberculosis, the lymph nodes are
not enlarged.
Differential Diagnosis
• Carcinoma caecum, Crohn’s ileocolitis, pericolic
abscess, etc.
Management of Actinomycosis in General
• It is a low-grade chronic disease and is difficult to
eradicate.
• Inj. crystalline penicillin 10 lakh units once a day for
6 months–1 year. Tetracycline and lincomycin are
alternatives. Amoxycillin 500 mg thrice daily may
have to be given for 2–6 months.
• Sinuses in the jaw may have to be excised.
• Osteomyelitis has to be curetted out.
• Actinomycosis of the right iliac fossa may require a
right hemicolectomy. Surgery is not easy. Often, there
is extensive necrosis and abscess formation. Malignancy
cannot be ruled out. If possible, resect. Otherwise,
excise the fistulae, drain the abscesses, and administer
IV antibiotics.
LEPROSY (HANSEN’S DISEASE)
• Leprosy is caused by Mycobacterium leprae, an acid-
fast bacillus. Poverty, poor hygiene, and population
(overcrowding) facilitate its spread.
• The disease is contracted in childhood or adolescence,
but manifests after a latent period of 2–5 years.
• Nasal secretions are the main source of infection but
active ulcers and sweat also contain lepra bacilli.
• Leprosy predominantly affects the skin, upper respira
tory tract (nasal cavity), and nerves. Thus, characteristic lesions of leprosy include an anaesthetic patch
of skin, or hypopigmented macule, thickened nerves,
a deformed leonine face, and a collapsed nasal bridge.
Types (Table 25.1)
1. Tuberculoid leprosy: It occurs in patients with good
immunity/strong tissue response.
2. Lepromatous leprosy: It occurs in patients with poor
immunity/poor tissue response.
3. Borderline leprosy: It may be borderline lepromatous
or borderline tuberculoid leprosy, depending on the
immune response.
-
Table 25.1 Comparison of tuberculoid leprosy with lepromatous leprosy
Tuberculoid leprosy Lepromatous leprosy
1. Cell-mediated immunity Strong Low
2. Histology Giant cells, epithelioid cells, histiocytes, Bacilli distending the macrophages—‘GLOBI’.
lymphocytes are present. Bacilli are a few. Plenty of bacilli invading nerves, adnexa, sweat
glands, etc.
3. Clinical Localised. Anaesthetic, hypopigmented, Generalised. Erythematous multiple macular
raised skin patch. Early nerve damage, rashes. Nerve involvement is usually not seen.
nerve thickening is a characteristic feature. Leonine facies, collapse of the bridge of the
Involvement of face and nose is not seen. nose are characteristic.
4. Prognosis Good Not good
Section II • General Surgery
150
Manipal Manual of Surgery
Diagnosis of Leprosy
1. Skin biopsy: A full-thickness biopsy is taken from
the most active margin of the most active lesion and
subjected to acid-fast staining. Skin smears may be
taken from ears, elbows, and knees.
2. PCR: Polymerase chain reaction is used to detect
M. leprae DNA.
Note: No other blood test is available.
Treatment
. Lepromatous and borderline lepromatous leprosy
1
(multibacillary disease)
• 3-drug regimen is the most ideal treatment.
Dapsone 100 mg/day
Clofazimine 50 mg/day
Rifampicin 600 mg once
monthly, supervised.
Clofazimine 300 mg once
For a minimum
period of 2 years.
Skin smear should
be negative.
monthly, supervised.
2. Tuberculoid and borderline tuberculoid leprosy
(paucibacillary disease)
• Dapsone 100 mg daily
• Rifampicin 600 mg once
a month, supervised.
For a period
of 6 months.
Fig. 25.2: Autoamputation of the toes in a case of leprosy
Leonine
facies,
collapse of
the bridge
of the nose
are a few
other
features of
lepromatous
leprosy
DEFORMITIES IN LEPROSY
I. P
rimary Deformity (Figs 25.1 to 25.3)
They occur directly due to the disease.
• Face: It is involved in lepromatous leprosy and is
described as ‘leonine facies’ with multiple nodules
over the face, pigmentation, loss of the lateral portion
of the eyebrows (madarosis), collapse of the nasal
bridge due to destruction of nasal cartilages (warm
and moist area), and paralysis of the facial nerve.
• Hands: Involvement of the ulnar nerve at the elbow
and median nerve at the wrist gives rise to claw hand.
• Foot: The posterior tibial nerve is involved at the
ankle leading to clawing of the toes. Foot drop occurs
when the lateral popliteal nerve below the knee joint
is involved.
Fig. 25.3: Observe deformed ear
MS exam case, KMC, Manipal (2004)
A 28-year-old lady complained of swelling in the posterior
triangle of 8 months duration. The swelling was tender, a
bit irregular, and had restricted mobility. 3 candidates
offered nonspecific lymphadenitis as a diagnosis. Only
one candidate thought of a nerve abscess. The clue was
a thickened nerve above. It was a case of Hansen’s
disease (Fig. 25.4).
Fig. 25.1: Observe small muscle wasting in both the hands
Section II • General Surgery
Fig. 25.4: Nerve abscess and thickened postauricular nerve
Chronic Infectious Disease
151
Ulnar Nerve Abscess (Key Box 25.2, Fig. 25.5) and
Small Muscle Atrophy in the Hand (Fig. 25.6)
Key Box 25.2
Ulnar Nerve Abscess
May be a part of pure neuritic leprosy.
Presents as oval fluctuant swelling on the medial side
of arm.
Granuloma is common. Progression to abscess occurs
in tuberculoid leprosy.
Schwann cell is affected. Slowly whole endoneurial
zone is occupied by endothelial cells.
High resolution ultrasound can demonstrate echotexture
of masses.
MRI—with the post-gadolinium T
W sequence—
1
peripheral rim enhancement with central necrosis.
Treatment: Incision, drainage, excision of granulo-
matous mass followed by treatment for leprosy.
Fig. 25.5: Ulnar nerve abscess
Correction of Facial Deformities by
Plastic Reconstruction
1. Prosthesis to correct the nose.
. Lateral tarsorrhaphy to prevent exposure keratitis.
2
3. Temporalis muscle flap for the upper eyelid to
prevent exposure keratitis.
Correction of Hand and Foot Deformities
• Claw hand may be corrected using the extensor carpi
radialis brevis (Paul Brand’s procedure). Otherwise,
the flexor digitorum superficialis may be used
(Bunnell’s procedure).
• Foot drop may be corrected by using a tibialis poste-
rior tendon transfer (Ober’s and Barr’s procedure).
II. Secondary Deformities
Because of nerve involvement, sensations are impaired
or lost. As a result, ulcers on the fingers, a deep, penetrating, perforating ulcer over sole of the foot, or even
autoamputation of the toes may occur.
Treatment of Secondary Deformities
Nonhealing ulcer over the sole of foot is corrected with
application of a POP (plaster of Paris) posterior slab off
loading or nonweight-bearing cast. It takes off the
pressure to help the ulcer heal. If the calcaneus is involved
due to osteomyelitis, the bone has to be curetted out,
followed by the application of regular dressings.
Fig. 25.6: Small muscles atrophy in the hand
A 33-year-old male presented to the outpatient department
with inability to use his right hand for the last 6 months.
He said he could not work or hold objects. Examination
revealed small muscle atrophy, especially of the
hypothenar and interossei muscles. A 2 cm ‘skin ulcer’
was also noticed. On careful questioning, he said he
also had loss of sensation. Further examination revealed a
4-cm × 3-cm, firm, oval swelling on the medial side of
his right arm, with some amount of fluctuation.
What is the diagnosis?
Ulnar nerve abscess (cold) secondary to leprosy. This is a
case of pure neuritic leprosy with nerve abscess, an uncommon manifestation of M. leprae. No other peripheral
nerve was involved.
SYPHILIS: FRENCH DISEASE, GREAT POX
• This is a sexually transmitted disease caused by
Treponema pallidum. It is a delicate spiral organism
(spirochaete).
• Syphilis is infective only in its early stage. Early
lesions are predominantly situated in moist areas,
such as the genitalia and oral cavity.
Clinical Presentation
Key Box 25.3 describes congenital syphilis
Early syphilis
I.
II. Late syphilis
Key Box 25.3
Congenital Syphilis
Early
Snuffles (rhinitis), epiphysitis, periostitis, osteochondritis.
Late
Hutchinson’s triad
– Interstitial keratitis
– 8th nerve deafness
– Hutchinson’s teeth
Section II • General Surgery
152
Manipal Manual of Surgery
I. Early Syphilis
1. Primary syphilis: Classically, a genital chancre
occurs in the penis or vulva after 3–4 weeks of sexual
exposure.
• The chancre is a shallow, indurated, painless ulcer
called Hunterian chancre (Fig. 25.7). Associated
inguinal nodes, which are shotty, multiple, and
nontender clinch the diagnosis.
• Extragenital chancres may occur over the lips,
tongue, nipple, etc. They produce large enlargement of the corresponding lymph nodes. Chancres
in the rectum and perianal region are common in
homosexuals. They are painful and resemble anal
fissures.
Investigations
Serological tests for syphilis
Nonspecific: VDRL, Kahn, Meinicke, Wasserman
A.
B. Specific treponemal antigen tests
• CFT—complement fixation test
• TPHA—TP haemagglutination test
• TPI—TP immobilisation test
• FTA-Abs—fluorescent treponema antibody
absorption test
• Demonstration of Treponema pallidum in the
clear exudate of the lesion by dark field microscopy confirms the diagnosis.
2. Secondary syphilis: It appears after 6–12 weeks of
spirochaetaemia.
• It is characterised by bilateral, symmetrical, coppery
red rashes which are generalised. The rash is
macular or papular, but never vesicular. Papules on
moist sites such as the vulva and perineum enlarge
to form condylomata lata—fleshy wart-like growths.
• Small superficial ulcers in the mouth join to form
snail track ulcers.
• Generalised lymphadenopathy involving the
epitrochlear and occipital nodes may occur.
• Moth-eaten alopecia, iritis, bone and joint pains.
3. Latent syphilis: If secondary syphilis is not treated,
it will develop into latent syphilis. There are no signs,
but serum tests are positive.
II. Late Syphilis
It is also called tertiary syphilis. It basically affects vessels
causing inflammatory reactions and the end result is as
follows: ‘Endarteritis obliterans’ !
tissue necrosis ! ulcers
or fibrosis.
This stage develops after 5–15 years of primary
syphilis. It causes neurosyphilis and cardiovascular
syphilis (aortitis).
Neurosyphilis includes general paresis and tabes
dorsalis involving the posterior column and dorsal
roots. It presents with sensory atonia, lancinating pain,
and Argyll Robertson pupils.
A lesser form is a benign lesion called gumma. Gumma
is a syphilitic hypersensitivity reaction comprising a
granuloma with central necrosis and sloughing.
Clinical Features of Gumma
• Typically, it is a subcutaneous swelling.
• Affects the midline of the body (e.g. posterior one-
third of the tongue, sternum, sternoclavicular joint).
• Edges are punched out if the gumma ulcerates.
• Floor contains wash leather slough.
• On healing, it leaves a silvery, tissue paper scar (thin
scar).
Gumma may also involve the bone, testis, and liver (ovary is
not involved).
Treatment
1. Primary and secondary syphilis are treated by Inj.
procaine penicillin 2.4 MU in 1 ml stat. Doxycycline
100 mg BID is given for 21 days. Tetracycline 500 mg
QID is also given.
2. In tertiary/latent syphilis: Inj. procaine penicillin
2.4 MU IM once a week for 3 weeks.
3. In late syphilis: Treatment is continued for 21 days.
With the current effective treatment of syphilis, it is
highly unusual to find late cases now.
Section II • General Surgery
Fig. 25.7: Genital chancres
AIDS AND THE GENERAL SURGEON
• Acquired Immunodeficiency Syndrome (AIDS) is
the end stage of a progressive state of immunodeficiency.
Causative organism: Human immunodeficiency virus
(HIV).
Chronic Infectious Disease
153
• The details regarding the aetiopathogenesis and
immunology of AIDS are discussed in medicine
books. Topics of surgical interest are discussed
below.
Prophylactic Measures to be adopted by Surgeons
(Healthcare W
orkers) while Treating AIDS Patients
(Universal Precautions) (Key Box 25.4)
I. In the Outpatient Department (OPD)
1
• Wear gloves
when examining any patient with an
open wound.
• Wear gloves during proctoscopy or sigmoidoscopy.
• Use hand gloves and eye protection during flexible
endoscopy.
• Use disposable instruments.
• Clean reusable instruments such as endoscopes with
soap and water, and immerse them in glutaraldehyde.
• Do not perform any surgical procedure involving
sharp instruments in the OPD.
Key Box 25.4
Summary of Universal Precautions to be taken in OT
Face mask to be worn
Avoid splashing on body: Be slow
Cover feet and legs: Shoe covers, boot
Extra glove: Double glove
Meticulous technique: Haemostasis, gentleness
Allow only required people
Spectacles: Protects from splash
Kidney tray: Use it to transfer sharps
Remember as FACE MASK
II. In the Operation Theatre
• Operating table is covered with a single sheet of
polythene.
• The number of theatre personnel is reduced to mini-
mum.
• Staff with abrasions or lacerations on their hands are
not allowed inside the theatre.
• Staff who enter the theatre must wear shoe covers,
gloves, disposable and water-resistant gowns, and
eye protection.
• Double gloves and eye protection by staff directly
involved in the operation (surgeon, assistant, scrub
nurse) (Figs 25.8 to 25.10).
• Surgical technique:
. Avoid ‘sharps’ and needlestick injuries
1
2. Preferably use scissors or diathermy instead of a
scalpel
3. Use skin clips rather than skin sutures
4. Proper autoclaving after the surgery
5. In the event of needlestick injury, allow the part to
bleed and wash thoroughly under tap water.
6. AZT—zidovudine, lamivudine and indinavir
should be given to health workers following
exposure of susceptible areas to infected material
from AIDS patients.
RANGE OF SURGERY IN HIV-POSITIVE PATIENTS
. Anorectal disease is the most frequent reason for
I
surgical treatment in HIV-positive patients. This is
common in homosexuals, in whom AIDS is also
common. They have been grouped together as
“AIDS anus syndrome.” Anorectal disease may be
classified into:
Fig. 25.8: Protection of feet Fig. 25.9: Eye protection
1
Gloves were introduced by William Halsted to protect his nurse’s hands from the harmful effects of carbolic acid (the nurse became his wife).
Fig. 25.10: Double glove
Section II • General Surgery