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Mediastinitis and septicaemia see page Oedema of the glottis due to spread of the cellulitis via a 3. Toxaemia and septicaemia: Streptococcal toxic shock tunnel occupied by stylohyoid to submucosa of the glottis. Cellulitis can precipitate ketoacidosis in a patient who has diabetes mellitus. Anaerobes also play a common. Tender, painful lymph nodes in the groin are major role Key Box 2.
Rubor-redness: It is due to inflammation resulting in hyperaemia. Pyogenic abscess: It is the commonest form of an abscess. It can be subcutaneous, deep or can occur within the viscera 3. Dolor-pain: An abscess is extremely tender. In this chapter, pyogenic abscess 4. Tumour-swelling: It consists of pus. It is tensely cystic refers to soft tissue abscess. Pyaemic abscess: Occurs due to circulation of pyaemic 5.
Loss of function: The function of the part is impaired, due emboli in the blood pyaemia. Cold abscess: Usually refers to tubercular abscess due to 6. Fluctuation: It can be elicited. However, in a deep-seated involvement of either lymph nodes or spine.
It can also be due to haematogenous spread from a skin, gut, oral cavity. However, deep-seated abscess such distant focus such as tonsillitis or caries tooth. Pyogenic as breast abscess may cause much tissue destruction before abscess can also be due to cellulitis. Pathological events are summarised in Fig. The pus which comes out is collected infiltrated with leukocytes and bacteria.
It is called pyogenic and sent for culture and sensitivity. A sinus forceps or a membrane. Fresh oozing of the pus is an Symptoms indication of completion of the procedure.
The abscess The patient feels ill and complains of throbbing pain at the cavity is irrigated with saline or mild antiseptic agents such site. Throbbing pain is indicative of pus and is due to pressure as iodine solution or hydrogen peroxide. Hydrogen peroxide on the nerve endings by the pus.
Fever, with or without chills acts by liberating nascent oxygen. Calor-heat: The affected part is warmer due to local rise the slough. The cavity, if large, may need to be packed in temperature. Permeability Reticuloendothelial response Bacteriology. Exudation of protein Macrophages and polymorphs Release of toxins and enzymes. Fibrin formation Release of lysosomal enzymes Tissue destruction. Roller gauze packing prevents fibrosis, resulting in thickening of the abscess wall.
Clinically the premature closure of the skin, thereby facilitating the this may result in a hard lump. With appropriate antibiotics etc. Antibioma in the breast may mimic carcinoma of the breast.
Dosage: mg, 6th hourly for days. This method is pyaemia. It is the systemic effect of sepsis. It commonly followed where an abscess is situated in the vicinity of occurs in diabetics and patients receiving chemotherapy and important anatomical structures such as vessels or nerves radiotherapy. Pyaemic abscess is characterised by following Table 2.
Hence, it is called nonreactive abscess to differentiate it from pyogenic abscess. This is treated by multiple incisions Relationship of nerves or vessels with an over the abscess site and drainage like a pyogenic abscess abscess with antibiotic cover. Usually, it is due to tuberculosis, e. Ruptured aneurysm can present as subcutaneous abscess mycosis and madura foot also produce abscesses which are with pain, redness and local rise of temperature.
There may 'cold' in nature Key Box 2. In this chapter, cold abscess be leukocytosis also. Ruptured vertebral ariery aneurysm due to tubercular lymphadenitis in the neck is discussed. It is more common in children the pus gets partially sterilised. Antibiotics also produce and women, more common in Asians and Pacific islanders.
Organisms directly penetrate Sibson's fascia suprapleural membrane and can cause enlargement of 0 supraclavicular node. Multiple sites may be involved. Stage of cold abscess Figs 2.
Clinical features of cold disease. Stage of lymphadenitis Fig. Treatment of cold abscess Figs 2. Differential diagnosis Branchial cyst can be confused for cold abscess in the anterior B triangle. Branchial cyst is of longer duration and patients with cold abscess may have other lymph nodes in the neck. Figs 2. Stage of collar stud abscess Figs 2. It is treated like a cold abscess.
Stage of sinus Fig. Summary of the management of various stages of tuberculous lymphadenitis. Stage Investigations Treatment. It is gold standard. AFB is usually negative. It is a hair follicle infection Caseating type: Most common type seen in young adults.
After about days, softening occurs in the centre Atrophic type: Seen in elderly patients. Lymphoid tissue and a pustule develops which bursts spontaneously undergoes degeneration. Glands are small with early caseation. Necrosis of subcutaneous tissues produces a greenish slough. Skin overlying the boil also undergoes Treatment Table 2. Hence, boil is included under acute infective After confirming the diagnosis antituberculous treatment is gangrene.
Pain tuberculosis is also due to dense adherence of skin to the perichondrium there is no subcutaneous tissue. Diabetes, if present, is treated. It giving rise to a cribriform appearance Fig. Skin of these sites is coarse 1. Worsening of the diabetic status resulting in diabetic and has poor vascularity. Pathology 2. Extensive necrosis of skin overlying carbuncle. Hence, it is included under acute infective gangrene. The initial lesion is similar to a boil in the form of hair follicle 3.
Septicaemia, toxaemia. Since majority of patients are diabetics, infection takes a virulent course and results in Treatment Key Box 2. Most strains of Staphylococcal aureus sieve-like openings. This appearance is described as are sensitive to cloxacillin, flucloxacillin, erythromycin and cribriform appearance which is pathognomonic of carbuncle.
However, methicillin-resistant Staphylococcal aureus MRSA bacteria are resistant to the drugs mentioned above. They are sensitive only to expensive drug vancomycin which has to be given intravenously. It can be left open to the exterior or saline dressings may be applied to reduce oedema. Complete resolution may take place within days. Surgery is required when there is pus. Cruciate incision is preferred because of multiple abscesses and extensive subcutaneous necrosis.
Edges of the skin flap are excised, pus is drained, loculi are broken down, slough is excised, and cavity is irrigated with antiseptic agents. Like pyogenic Figs 2. Some cases require split skin grafting Sites Foot, hand, thigh, etc. Causes 1. Foreign bodies: These are the most common causes for chronic abscess. Typical history of a recurrent swelling discharging pus is present. Wooden pieces impacted in the thigh or in the foot are common. Synthetic mesh used in repair of hernias getting infected is another example.
Dead tissue: As it occurs in diabetic patients. Pilonidal sinus: This condition gives rise to recurrent abscesses. Typical history of pain and swelling which ruptures followed by spontaneous recovery is present. Chronic disease: Tuberculosis is one of the causes.
Causative organism is Streptococcus pyogenes. Precipitating factors are malnourishment, chronic diseases, etc. Thus, children A year-old female presented with swelling of the left thigh and old people are commonly affected.
There were no signs of inflammation. At surgery, thick-walled, localised very rapidly resulting in toxaemia. Sites: Face, eyelids, abscess withfleshy tissue was removed. Thefinal report was scrotum and in infants, the umbilicus. There was no evidence of tuberculosis anywhere in the Clinical features body.
Detailed investigations could not reveal and has a consistency of button hole. This is described as Milian's ear sign positive. This sign is used It is a spreading, destructive, invasive infection of skin and to differentiate cellulitis of face from facial erysipelas. In soft tissues including deep fascia with relative sparing of cellulitis of face, pinna does not get involved because of muscle.
Common sites Complications It is common in lower extremities. Other sites are genitalia, l. Toxaemia and septicaemia groin, lower abdomen. In these places it is comparable or 2. Gangrene of skin and subcutaneous tissue similar to gangrene and is called Meleney's gangrene. Other 3. Lymphoedema of face and eyelids due to lymphatic sites are the lower extremities. It is also called type II necrotising fasciitis.
Risk factors for type I necrotising fasciitis Key Box 2. There were no precipitating ment and intensive care, he factors. Diagnosis Full thickness biopsy taken at bedside can give full diagnosis. Watery pus dishwater liquid is also a characteristic. Treatment Early, aggressive treatment includes supportive and surgical treatment. Vancomycin with carbapenem may be required urgently.
Pathogenesis See Key Box 2. Pain over the part oedema fever jaundice are common. Summary-Key Box 2. Colony of microorganisms increases in intensive care unit In surgical wards, discharging wounds, infected urine, patients on previous antibiotic therapy, preoperative faeces, sputum are all sources of nosocomial infection. Environment: This is from the operating room. OT attire and drapes: Scrub suits, caps, masks, double soap or chlorhexidine is recommended.
Preoperative hair gloves and dedicated footwear are used as barriers. Life of removal clipping should be done immediately before an a sterile glove is 3 hours. It should be changed if surgery lasts for more than 3 hours.
Some examples are: Wearing - Osteomyelitis: Gives rise to sinus discharging pus with gloves before any procedure, cleaning the patients abdomen with or without bony spicules Figs 2. It discharges cheesy material. Skin aseptic precautions.
It is lined with granulation tissue. Congenital sinus: Preauricular sinus, post-amicular sinus infiltrating the skin Fig. Presence of foreign body 2. Persistent infection 3. Distal obstruction as in enterocutaneous fistula 4.
Absence of rest 5. Epithelialisation of the track 6. Malignancy 7. Nondependent drainage, inadequate drainage 8. Dense fibrosis 9.
Irradiation Specific causes-tuberculosis, actinomycosis. Observe that the Fig. ESR may be increased as in tuberculosis. Increased total count suggests infection. Management Key Box 2. Initially, it was thought to be due to infection.
A gauze piece was found and removed. The wound healed well. Please note: Details regarding individual fistula and sinus have been discussed in their respective chapters. We had a sixty-year-old man who had a small sinus in the loin discharging wateryfluid.
Inflammatory Syndrome. This is seen in patients with tubercular lymphadenitis on retroviral therapy. It manifests as deterioration of a treated infection or new presentation of previously subclinical infection. Thus lymph node may persist or may become bigger. Treatment of cold abscess is: 6.
Following are true for carbuncle except: A. Excision A. Nape of the neck is the commonest site B. Cribriform appearance is diagnostic B. Incision and drainage C.
Abscesses are not communicating with each other C. Marsupialisation D. Staphylococcus is the commonest organism D. Nondependent aspiration 7. Following are true for erysipelas except: 2. Tubercular sinuses in the neck-following are true A. Rose pink rash is common except: B. Cuticular lymphangitis is an important component A. Usually multiple C. Pinna never gets affected in facial erysipelas B.
Edge is bluish in colour D. It is caused by Streptococcus pyogenes C. Induration is very characteristic D. Jugulo-digastric nodes are commonly affected 8. Muscles are spared in which condition? Gas gangrene B. Necrotising fasciitis 3. The ideal treatment of carbuncle is: C. Pyomyositis D. Acute embolic gangrene A. Drainage B. Incision and drainage 9. Following are features of necrotising fasciitis C. You may send an email to madxperts [at] gmail.
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