CHRONIC SPECIFIC SURGICAL INFECTION

The chronic specific surgical infection is caused by specific agents and has a vague clinical course. Surgical tuberculosis, actinomycosis, bone-joint syphilis, lepra, brucellosis, tularemia, leishmaniosis belong to the chronic specific surgical infection. All these diseases are characterized by development of specific granulomas.

SURGICAL TUBERCULOSIS

Tuberculosis of joints and bones, tuberculosis of lymph nodes, serous cavities, intestines, urine and genitals tracts, and also some forms of pulmonary tuberculosis belong to the group of surgical tuberculosis. At treatment of these forms the surgical method is applied.

Aetiology and pathogenesis. The agent of tuberculosis is Bacillus tuberculosis.

Infection occurs through respiratory ways by the air-drop way, through the digestive tract by the infected meat-milk products, by swallowing sputum (self-infection), through the damaged skin, mucous, ulcers, decubitus, infected placenta.

Specific granuloma (tubercular tubercle) forms as the result of infecting, in which a specific caseosis (curdle) necrosis takes place in future. Tubercular tubercles join and form a tubercular focus, in which caseous disintegration of tissue occurs or salts of calcium deposit and the connecting tissue grows. If resistance of an organism is high, incapsulating of the focus takes place. With low resistance of an organism the Bacillus tuberculosis can spread by contactic, lymphatic, haematogenic ways. The lymph nodes are the basic barrier on the way of infection spreading. There are huge packages of the lymph nodes. Haematogenic way of the tubercular process generalization results in formation of the secondary foci in the distant organs and tissues, which is typical for surgical tuberculosis.

Tuberculosis of Bones and Joints

Aged people suffer from tuberculosis of bones and joints, mostly with injury to the thoraco-lumbar part of the spinal cord, hip and knee joints.

Patho-anatomic picture. The bone tuberculosis is characterized by occurrence of a specific osteomyelitis (osteitis), a high degree of a sensitization and allergization of the patient. Metaphysis and epiphysis of the tubular bones with caseous disintegration of tissue are mostly affected. The cavities with soft sequestrations form in the bone (a piece of melting sugar), and inflammation reaction takes place in the surrounding tissues.

The primary osteitis (pre-arthritis form) and the secondary arthritis (arthritis form) with the involvement of joint cavity are distinguished in the bone tuberculosis.

With tubercular damage to vertebrae (tubercular spondylitis) the spongy substance of vertebrae is subject to fast caseous necrotic disintegration with formation of cold abscess. A destroyed vertebra covers the underlaying one, and the hump forms. The cold abscess can spread down to inguinal region and appears as protuberance and swelling in the inguinal region, in the region of the upper third of the anterior surface of the hip. The skin colour above is usual, local temperature is normal. At the abscess puncture Micobacteria Tuberculosis are revealed in its contents.

With tuberculosis of joints the process involves the adjoining spongy layer of the bone. Synovial, fungous bone forms of an articulate tuberculosis are distinguished.

The synovial form is characterized by increased exudation from the synovial membranes of the joint which can resolve completely or fibrin deposit takes place, that results in restriction of movements in a joint.

The fungous form arises at growth of granulation tissue from the synovial membranes, which fills the joint cavity, grows into the joint’s capsule, surrounding tissue, the bone. The joint enlarges. The skin above it is pale, thin. The joint’s slit narrows.

The bone form of surgical tuberculosis appears as primary osteitis against a background of reactive inflammation of the joint of the infiltrative character and is accompanied with increasing contracture, development of fistulae, pathological dislocations, secondary infection.

Clinical picture. With surgical tuberculosis local symptoms are observed: pains, restriction of function, deformation of the injured extremities or infringement of bearing, atrophy of muscles, which appear long time after the moment of infecting and depend on reactivity of an organism, age of the patient, localization of the focus.

The pain is the result of irritation of the nerve endings with inflammatory infiltration, or toxic influence. The pain is constant or alternating, increases at loading on the zone of damage.

Restriction of function of the injured extremity or the vertebral column are observed at the initial stage of development of surgical tuberculosis as sparing of the injured extremity or the vertebral column at tubercular spondylitis. The compelled position of the extremity leads to steady articulate contractions.

Restriction of function, intoxication result in the infringement of nerve trophism: muscular atrophy develop, sclerosis of the skin and subcutaneous tissue, oedema. The skin fold with the subcutaneous tissue on the side of injury is thicker (the Alexandrov’s symptom).

Deformation in the injured extremity, changes of joint’s contours appear in later terms.

The liquid accumulation in the joint manifests itself as fluctuation (balloting of the patella of the injury knee joint).The joint is spindle-shaped pale, thin skin. In neglected cases fistulae can burst, from which liquid, pus, flakes of fibrin, products of caseous disintegration of tissue, fine bone sequestrations discharge.

The general symptoms in the initial stage of the disease are vague: subfebrile temperature, weakness, anemia. Secondary infection joins, development of purulent complications is accompanied with deterioration of general condition, raising of the temperature and ESR, strong pains, leukocytosis. In the remote period organs and systems are involved (amyloidosis of the parenchymatous organs), miliary tuberculosis, steady deformations of joints and vertebral column can develop with shortening of the extremities, breaching of the bearing, appearing of paresis and paralyses.

Diagnosis and differential diagnosis. Various radiological exams (fluorography, X-ray, computer tomography, ultrasonotomography), bacteriological exam of the secretions, the specific Mantoux test play an important role while establishing the diagnosis.

Surgical tuberculosis should be differed from nonspecific osteomyelitis, syphilis of bones and joints, bone tumours, infectious (gonorrhoea, typhus, scarlatina, influenza), posttraumatic, rheumatic, endocrine arthritises.

Treatment. In treatment of surgical tuberculosis early diagnosis has great value.

The surgical tuberculosis is treated in the specialized antitubercular hospitals, sanatoria, clinics. Medical actions are divided into general and local.

The general treatment is directed at increase of organism resistance, its immunobiologic properties and activation of regenerative processes. Full-value feeding, fresh air, solar radiation (heliotherapy), labour therapy, physiotherapy exercises, application of preparations of blood, chemotherapeutic means have special value.

Antibacterial therapy of the surgical tuberculosis consists in prescription pf canamycin, streptomycin, para-aminosalicylic acid (PAS), phthivasid, rifadin, ethambutol, bepask, tubasid, salusid. The dosage and treatment mode are established for each individual case. Local therapy consists in conservative and operative actions.

Conservative local treatment consists in revealing bones and joints, maintenance of rest due to immobilization by the method of extension, applying the plaster bandages which they change each 4–6 weeks with stage redressation. At tubercular spondylitis the patient is placed in a plaster bed for 1–2 years, with the subsequent application of a plaster corset or special plastic clamps. In the post arthritic period physiotherapy is prescribed, with the presence of fistulae — laser therapy.

Puncture and opening of an abscess, joint resections, amputations, bone-joint plasty, orthopaedic operations are applied.

Punctures are used with the diagnostic and medical purpose, watching for that the needle was entered from up to down, and after the injection the channel closed and fistula didn’t appear.

Lancing of abscess is combined with necroectomy and removal of infiltrated soft tissue with the subsequent washing a cavity by rifadin, PASA.

Bone resections are carried out after abatement of the active tubercular process. Operation is completed by plasty of the bones and joints with the use of allotransplantats, endoprosthesis. Amputation is indicated with full disintegration of bones and joints with the threat of sepsis development.

Tubercular Lymphadenitis

The tuberculosis of lymph nodes belongs to rather often manifestation of tubercular damage of an organism, both primary and secondary. It is caused by pathogenetic mechanisms of the disease development.

With tuberculosis of bronchial lymph nodes infection occurs by the air way, mesenteric lymph nodes — through the digestive organs, cervical lymph nodes — by the lymphatic or haematogenic way, through the mucous membrane. Feature of a tuberculosis of lymph nodes is plurality of their damage with conglomerates formation.

Clinical picture. The disease has chronic course with rather satisfactory general condition, subfebrile temperature. The disease is of a season type — in the summer the lymph nodes decrease, in the winter — increase. With damage of the cervical lymph nodes, necrosis in the injured nodes with plural fistulae, through which white-grey pus and grains of the necrotic mass discharge, can be observed. The anemia, accelerated ESR, leukocytosis, lymphacytosis are revealed in the blood analyses.

The differential diagnosis is necessary to carry out with banal lymphadenitis, actinomycosis, lymphagranulomatosis, lymphasarcoma, cancer metastasises to the lymph nodes of the neck. Specific tests for a tuberculosis, puncture biopsy play an important role in diagnosis.

All standard techniques of the tubercular process treatment mentioned above are used for the tubercular lymphadenitis treatment.

Surgical treatment is indicated with complications caused by tubercular lymphadenitis. At compression of the vital blood vessels, nerves, respiratory ways with enlarged lymph nodes exterpation of the lymph nodes conglomerate are made with application of the specific antibacterial preparations in the pre- and postoperative period.

ACTINOMYCOSIS

Actinomycosis is the chronic specific infectious disease, characterised by development of dense infiltrations in which specific druzen are found out.

Aetiology and pathogenesis. The causative agents of the disease are special fungi Actinomyces israeli, Gr+ microorganisms from the group of Fungi imperfecti, and also Actinomices naestundii and Arachnia propionica. These agents are met in stalks of cereal cultures, other plants and are widely spread in the nature. While inhaling the dust containing in these fungi, gets to the lungs, with the saliva — to the gastrointestinal tract.

In tissues fungi form druzen in the center of which the interwaved threads are visible, which pass in the mace-shaped endings in the external zone. Under favorable conditions druzen merge in uniform dense infiltration.

Clinical picture. Like in any infectious disease, actinomycosis has the incubatory period, which lasts from several weeks to several months. More often the infiltrations are located in the region of the lower jaw, the neck, are subject for disintegration with formation of plural fistulae from which pus with an impurity of druzen discharge. The skin around the fistulae becomes dark blue, purple.

In case of injury of the lungs perifocal pneumonia, lungs abscesses, secondary bronchoectasis develop in their lower lobes. The process can pass to the wall of the thorax, the diaphragm with formation of intercostal fistulae.

Among the organs of the abdomenal cavity the blind gut is mostly affected. The formation of induration in the right ileac region reminds the appendicular infiltration and soon the fistula forms on the anterior abdominal wall.

Differential diagnosis. Actinomycosis should be differed from tubercular lymphadenitis, malignant and benign tumours. For establishment of the diagnosis the intracutaneous tests and serologic reactions with actinolysate are carried out. The pus is investigated for presence of druzen.

Treatment. Treatment of actinomycosis should be complex and long-term. Antibiotics, iodide preparations, X-ray, transfusion of blood components, specific actinolysate are applied. The actinolysate is entered intracutaneously or intramuscularly according to the method of G. R. Suteyev and D. I. Asnin two times a week after the scheme starting with 0.5 ml, increasing the doze by 0.1 ml up to 2.0 ml (20–25 injections for the course, which can be repeated in 2– 3 months. Surgical removal of dense infiltration is made if it is possible.

SYPHILIS

Syphilis is a venereal disease caused by pale spirochete (treponema pallidum) of spining forms, the sizes of 5–15 microns, facultative anaerobe.

Infection is transmitted basically by the sexual way. The direct way of infection through the skin injury, blood and its components transfusion and indirect one (household) are possible.

Getting in an organism of the person, treponemas settle in the regional lymph nodes.

Diagnosis of syphilis is carried out by microscopic way and serologic method — the Wassermann’s reaction.

Syphilis is characterized by staged course.

In 5–8 days after infectioning the primary syphilis declares itself by formation of the hard chancre (inflammatory response of the mucosa or the skin on inoculation of spirochetes), exudation, infiltration with lymphocytes and macrophages of the injured site, proliferation of the connective tissue, necrosis of the epithelium, regional lymph nodes enlargement. Hard chancre, or the primary syphilis, spontaneously disappears in 2 weeks without a trace. Lymphadenitis disappears in a month.

The second period of the disease (secondary syphilis) comes in 1.5–2 months. The secondary syphilis is the manifectation by general damage of an organism and declares itself by weakness, fever, headache, general lymphadenopathy, pains in the whole body, enlargement of tonsils, local syphilides — rashes on the skin, mucous membrane of the mouth, vagina, conjunctiva. The wide condylomas and indurative keratosis form around the genital organs and anus as a result of chronic irritation by discharge.

The tertiary syphilis is consequence of secondary syphilis and develops in 3–4 years after it, sometimes — later. The morphological substratum of the tertiary syphilis is formation of gumma, in the internal organs. Gumma is the proliferative-necrotic form of the limited inflammation as granuloma, caused by spirochaetemia. Syphilitic gummas are subject to disintegration. The necrosis of superficial gummas causes formation of deep ulcers, which will penetrate into the thickness of soft tissues and bones with danger of development of secondary infection, formation of deep necrosises, which after healing leave rough cicatrices, which deform the skin surface. The flat and tubular bones are damaged causing periostitis, osteitis, osteomyelitis in the tertiary period of syphilis.

The syphilitic periostitis is accompanied by significant osteoblastic periostic reaction of locally limited type with formation of painful nodes in the periosteum and deformation of the bones. The osteitis is accompanied by focused destruction of the bones with formation of small sequestered and significant periosteal reaction.

The syphilitic osteomyelitis is characterized by focused necrosis, sequestration of bones, acute osteoblastic periostic reaction with its ossification and calcification, obliteration of the bone medullary cannel, and the bone (for example the shin bones) looks like a deformed formation. It is enaburation of the bones.

Clinically tertiary syphilis of bones manifests itself by night pains in the bones, insignificant infringement of function of extremities, loss of sensitivity.

The differential diagnosis should be made with bone tuberculosis, chronic osteomyelitis, malignant osteosarcomas.Treatment of syphilis is specific: antibiotics, in particular preparations of penicillin. Destructive changes in bones are treated by the surgical way with application of various plastic orthopaedic operations.