Infectious Diseases: Boils, Carbuncles, Cellulitis, Erysipelas, and Ludwig's Angina
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- Ludwig's angina is a rapidly progressive polymicrobial cellulitis of the sublingual and submandibular spaces, involving the floor of the mouth and suprahyoid area of the neck bilaterally. - It is commonly caused by dental infections and presents with diffuse painful swelling and woody induration of the mouth and anterior neck, which can lead to airway obstruction if not treated promptly with antibiotics and potentially tracheostomy. - Complications include laryngeal edema, mediastinitis, sepsis and spread of infection to deep spaces which can become life-threatening.
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Infectious Diseases: Boils, Carbuncles, Cellulitis, Erysipelas, and Ludwig's Angina
- 1. en love da Homoeopathy INFECTIOUS DISEASES
- 2. en love da Homoeopathy BOILS OR FURUNCLE
- 4. BOILS OR FURUNCLE DEFINITION • It is an acute staphylococcal infection of a hair follicle with perifolliculitis which usually proceeds to suppuration & central necrosis • Oftenboil open on its own & subsides (S. aureus infection) BOIL
- 5. • Furuncle in external auditory canal is very painful , because of rich cutaneous nerves • Here skinis adherent to perichondrium Blind healed dull boil • Boils often heals spontaneously • &suppurationwill not occur in suchboil • It is often called as blind healeddull boil Blind healed dull boil
- 6. COMMONSITES • Axilla • Groin • Areola • Umblicus • Scalp • Chest • Perineum • Boil is common over back, neck, Thigh & forearmeventhoughit can occur anywhere Boil in axilla
- 7. • Boil in eyelashfollicle is called as stye • Boil can occur in perianal regionwhich ca lead into abscess& fistula • Boil can lead into hidradenitis ,commonin axilla & pubic region • Boil can cause cellulitis of local area • Overlying skinundergoes necrosis • But during healing Re- epithelializationoccurs . Hidradenitis
- 8. CLINICALFEATURES • Boil subsides spontaneously with the support of suitable antibiotics – often requires incision& drainage • Regional Enlarged tender Lymph nodes may be palpable due to secondary infection • Redness • Swelling • Warmsensation • Fever • Pain- Throbbing • Lymph nodes Enlargement • Constitutional symptoms • Systemic features are not common unlessit is multiple/recurrent /severe or in diabetics & immunosuppressed • Multiple/Recurrent boils is common in diabetics
- 9. TREATMENT • Antibiotics given if boil is not resolving sponataneously- • Cloxacillin • Amoxycillin • Rarely Drainageof boil is needed in severe persistent Form Drainage of Boil
- 10. COMPLICATIONS • Cellulitis • Lymphadenitis • Hidradenitis (infectionof group of hair follicle ) • Boil in dangerous zone in the face ,can cause cavernous sinus thrombosis Cellulitis Acute Cervical Lymphadenitis
- 11. REFERENCE 1. SRB's Manual of Surgery by SriramBhat M 2. A Manual on Clinical Surgeryby Das 3. A Concise textbookof Surgeryby Das
- 12. en love da Homoeopathy CARBUNCLE
- 13. CARBUNCLE
- 14. CARBUNCLE DEFINITION • Word meaning of carbuncle is charcoal. • It is an infective gangrene of skinand subcutaneous tissue. • Staphylococcus aureus is the mainculprit.
- 15. COMMONSITES • Common site of occurrence is napeof the neck & back. • Shoulder • Cheek • Hand • Forearm. • It is commonin diabetics & after 40 years of age. • It is common in males. PATHOLOGY Infection ↓ Followedby developmentof Small Vesicles ↓ Sieve like patternin the skin ↓ Skin becomes Red , indurated withdischarge of pus ↓ All vesicles Fused together & forma Central necrotic ulcer
- 16. Pathology of Carbuncle ↓ Surrounded by vesicles & it lookslike a RosetteAppearance ↓ Followedby – The skinbecome Black due to blockage of cutaneous vessels ↓ Then diseases spread to adjacentarea veryrapidly ↓ Patient becomes toxic
- 17. . ↓ In Carbuncle – A groupof Hair follicles are involved & it looks likea clusters of furuncles CLINICALFEATURES • Pain– Throbbing • Swelling • Redness • Vesicles • Ulcer • Rosette Appearance • Gangrene INVESTIGATION • Urine sugar • Urine ketone bodies • Blood sugar. • Discharge for C/S.
- 18. TREATMENT • Control of diabetes • Antibiotics like • Penicillins • cephalosporins • Drainage is done by a cruciate incision and debridementof all dead tissues is done. • Excision is done later Drainage of Carbuncle
- 19. • Once wound granulates well, skingrafting may be required. • Renal Carbuncle is an entity whichoccurs in kidney due to infection, forming localizedinfective mass lesion Renal Carbuncle
- 20. REFERENCE 1. SRB's Manual of Surgery by SriramBhat M 2. A Manual on Clinical Surgeryby Das 3. A Concise textbookof Surgeryby Das
- 21. en love da Homoeopathy CELLULITIS
- 22. CELLULITIS
- 23. INFECTIOUS DISEASES- CELLULITIS DEFINITION • It is a spreading infectionof subcutaneous &Fascial planes • Oedema gives rise to soft pitting, whileif pus is present ,indurationcan alwaysbe felt • Infectionmay followa small scratch or woundor incisionor insect/snake/scorpionbite CELLULITIS
- 24. TYPES • superficial • Deep COMMON • Diabetes • Immunosuppressed people • old age • Face • Lower limb • Upper limb & scrotumwherein subcutaneous tissue is lax CAUSES • streptococcus pyogenes &other gram+veorganisms • Releaseof streptokinase& Hyaluronidase cause spread of infection • Oftengram -ve organisms like • Klebsiella • Pseudomonas • E.coli are also involved (usually Gram-ve Organisms cause secondary infection)
- 25. SEQUALE • Infectioncan get localizedto formpyogenic abscess • Infectioncan spread to cause • Bacteremia • Septicaemia • Pyaemia • Ofteninfection can lead to local gangrene • Extensive necrosis of skin& subcutaneous tissue – Nectrotising fasciitis Nectrotising fasciitis
- 26. CLINICALFEATURES • Fever, • Toxicity( tachycardia, tachypnoea, hypotension) • Swelling is diffuse &spreading in nature • Pain& Tenderness • Red, shiny area with stretchedwarmskin • Cellulitis will progress rapidly in diabetic &immunosuppressed individuals • Tender regional lymph nodes may be palpable whichsignifyseverity of the infection • No edge, • No pus • No fluctuation • No limit
- 27. INVESTIGATION • TBC-decreases –tobe done • Liver function test • Blood urea & serum creatinine in severe cases • Blood sugar estimation • Urine test for ketone total count raises • Differential count • plateletbodies • Glycosalated haemoglobin estimation • Deep VeinThrombosis (DVT) – may mimic, so Doppler &Ultrasound of soft tissues may require
- 28. Cellulitis covered with PARAFFIN GAUZE TREATMENT • Elevationof the limb to reduce oedema so as to increasethe circulation & Bandaging • Antibiotics • Penicillins • Cephalosporins • Dressing • glycerine dressing is used (often used) • glycerine - magnesium sulphate dressing
- 29. WOUND DRESSING • Glycerine dressing - reduces the oedema becauseof its hygroscopic action , • Patient withsepticemia • shouldbe treatedwith higher antibiotics • critical care with fluid management • along withmaintaining adequateurine output or catheterization is required
- 30. ORBITAL CELLULITIS CELLULITISIN SPECIAL AREAS • Orbital cellulitis • Cellulitis in orbit causes proptosis • leads to impairment of ocular movements • Blindness- spread through ophthalmic veins ↓ cavernous sinus ↓ cavernous sinus thrombosis
- 31. REFERENCE 1. SRB's Manual of Surgery by SriramBhat M 2. A Manual on Clinical Surgeryby Das 3. A Concise textbookof Surgeryby Das
- 32. en love da Homoeopathy ERYSIPELAS
- 33. ERYSIPELAS
- 34. ERYSIPELAS DEFINITION • Erysipelasis an acute spreading inflammationof the upper(outer)dermis & Superficial lymphatics • It has got typical skinash presenting on legs, toes, face & fingers due to acute infection • by the beta haemolytic streptococcus pyogens, ERYSIPELAS
- 35. • presenting as raised well demarcated skinrash (rash is due to exotoxin) • there will always be cutaneous lymphangitis withdevelopmentof rose pink rash withcutaneous lymphatic oedema • Vesicles whichform eventually will rupture to cause serous discharge CAUSATIVEORGANISM • beta haemolytic streptococcus pyogens SITE • Orbit • Face • ear lobule – most common • Hands &Scrotum • Umbilicus in infants • Decubitus ulcer of lower limb (legs &feet are now becoming more commonsite)
- 36. CLINICALFEATURES • Toxaemia is alwaysa feature. • Rash is fast spreading and blanches of pressure. • Rash is raisedwithsharp margin. • Redness becomes brown &later yellowwith vesicles • Discharge is serous (in cellulitis discharge is purulent) ERYSIPELAS
- 37. • In the face & orbit it causes severe oedema • Millian’s ear sign is a clinical signused to differentiate erysipelasfromcellulitis cannot occur • Erysipelasbeing a cutaneous conditioncan spread into ear lobule • Tender • Regional lymph nodes are usually palpable Millian’s ear sign
- 38. DIFFERENTIAL DIAGNOSIS • Herpes zoster • Angioneurotic oedema • Contact dermatitis COMPLICATION • Septicemia, • localizedcutaneous • subcutaneous gangrene • Abscess • Pneumonia • Meningitis • Lymphoedema of face or eyelid or limbs (when involved) can occur due to lymphatics fibrosis Angioneurotic Oedema
- 39. • Glomerulonephriis(not rheumaticfever), • septic arthritis • Nectrotising fasciitis,can occur occasionally RECURRENCE • Recurrence rate is 20% • It causes disfiguring sequelae TREATMENT • Penicillins • Clindamycin • Erythromycin • Recurrent erysipelas may require injection benzathine penicillin (long termpenicillin) monthlyor 2 years
- 40. REFERENCE 1. SRB's Manual of Surgery by SriramBhat M 2. A Manual on Clinical Surgeryby Das 3. A Concise textbookof Surgeryby Das
- 41. en love da Homoeopathy LUDWIG’S ANGINA
- 42. LUDWIG’S ANGINA
- 43. LUDWIG’SANGINA DEFINITION • Rapidlyprogressive polymicrobial cellulitis of the sublingual & submandibular spaces involving the floor of the mouth& suprahyoidarea on both sidesof the neck LUDWIG’s ANGINA
- 44. CAUSE • Commonest causeis the dental infection of 2nd or 3rd molarteeth precipitatedby tooth extraction • submandibular sialadenitis • Trauma • Peritonsillar abscess • Upper respiratorytract infection, • Interventions by endotracheal intubation PREDISPOSINGFACTORS • Diabetes Mellitus • Chemotherapy • Oral cancer, • OH, • Neutropenia COMMONESTORGANISM • Streptococcus viridians • Staphylococcus aureus • & anerobes • Gramnegative organsims are also involved
- 45. EXTENSION • Cellulitis may extend into the pharyngo-maxillary space, • Retro-pharynx • Superior mediastinum CLINICALFEATURES • Diffuse painful swelling with woodybrawnyindurationof the mouth&anterior neck • Swelling is non- fluctuant but with redness &tenderness • Bilateral submandibular oedema withmarked tenderness on palpationat suprahyoid area withbull’s neck appearance Bull Neck Appearance
- 46. • Toxic features like • Tachypnoea, • Tachycardia • Fever is common • Difficulty in speech, • Earache • Drooling of saliva & putrid halitosis • Involvement of connective tissues, muscles and fascial spaces but not glandular structures • odemaof tongue withpushing against palate(elevation) upwards and backwards causing airwayobstruction • Dysphagia & odynophagia • Stridor • Respiratorydistress • Cyanosis may developdue to oedema of tongue & larynx
- 47. SPREAD • Spreadvia fascial planes in continuitynot by lymphatics • no lymh node enlargement INVESTIGATIONS • CT scan/ MRI – • To identify airway block, • fluid collection • presence of gas • Ultrasoundneck • Total count, Blood sugar • Chest X-Ray • Blood gas analysis(In severe cases) is done DIFFERENTIAL DIAGNOSIS • Angioneuroticoedema • SublingualHaematoma • Sialadenitis • Lymphadenitis Silaladenitis
- 48. COMPLICATION • Laryngeal oedema • due to spread of inflammationto glottis submucosa via stylohyoidtunnel. • may require an emergency tracheostomyto maintainthe respiration • Mediastinitis • due to spread of infectioninto mediastinum MEDIASTINITIS LARYNGEAL OEDEMA
- 49. • aspirationpneumonia • Septicemia • Spreadof infectioninto the para pharyngeal space ↓ Thrombosis of the internal jugular vein ↓ may extend above intosigmoid sinus ↓ fatal & Mortality is less than5% TREATMENT • Antibiotics – intravenously can be given • If the patient is in the respiratory distress – tracheostomyis the life- saving procedure REFERENCE 1. SRB's Manual of Surgery by SriramBhat M 2. A Manual on Clinical Surgeryby Das 3. A Concise textbookof Surgeryby Das
- 50. en love da Homoeopathy PYAEMIC ABSCESS
- 51. PYAEMIC ABSCESS
- 52. PYAEMICABSCESS DEFINITION • 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. Pyaemic Abscess in kidney
- 53. • This may lead to multi organdysfunction syndrome (MODS) • It may endanger life if not treatedproperly CAUSES • Urinary infection( Most common) • Biliary Tract infection • Lower respiratorytract infection • Abdominal sepsis of any cause • Sepsis incaseof • Diabetics • immunosuppressed • HIV • SteroidTherapy CLINICALFEATURES • Fever withChills & Rigor • Jaundice • Oliguria • Drowsiness • Hypotension • Peripheral Circulatory Collapse • Coma with MODS
- 54. INVESTIGAION • Total leucocyte count • Plateletcount • C- Reactive protein • Pus, Blood, Urine Culture depending on need • Blood Urea , Serum Creatinine • Liver Functiontest, • Prothrombintime • Chest X –Ray • USGabdomen • CT chest/Abdomen/Brain as needed
- 55. • Arterial blood gas analysis if needed • Monitoring Vital parameters • Antibiotics • IV fluids- Maintenance of Urine Output • Blood & Plasma transfusion • Nasal Oxygen • Ventilator Support • monitoring of pulmonary function Ventilator support
- 56. en love da Homoeopathy PYOGENIC ABSCESS
- 57. PYOGENIC ABSCESS
- 58. ABSCESS DEFINITION • An Abscessis a circumscribedarea of inflammationor an abnormal cavity that cntains pus if matured TYPES • Pyogenicabscess • Pyaemic Abscess • Metastatic abscess • Cold abscessdue to chronic infectionlike tuberculosis PYOGENICABSCESS DEFINITION • It is localized collection of pus in a cavity lined by granulationtissue, covered by pyogenic membrane • It contains pus in loculi
- 59. CAUSES Modeof infection • Direct • Haematogenous • Lymphatics • Extension fromadjacent tissues CAUSATIVEORGANISM • Staphylococcus aureus • Strepococcus pyogens • Gramnegative Bacteria • E.Coli, • Pseudomonas, • Klebsiella • Anaerobes
- 60. PATHOLOGY Pus ↓ contains dead WBC’s multiplying bacteria, toxins & necrotic material ↓ Proteinexudationoccurs ↓ It causes fibrindeposition ↓ &formation of pyogenic membrane ↓ Macrophages &Polymorphs release lysosomal enzymes ↓ whichcauseliquefaction of tissues ↓ leads to pus formation ↓ Toxins & enzymes released causes tissue destruction & pus formation
- 61. PRECIPITATINGFACTORS • General condition of the patient • Nutrition • Anaemia • Age of the patient • Associateddiseases • Diabetes • HIV • Immunosup pression • Types & Virulence of the organisms • Trauma • Hematoma • Road TrafficAccidents CLINICALFACTORS • Fever oftenchills & Rigors • Localized Swelling whichis smooth, soft, & fluctuant • Viable (pointing) pus • Throbbing pain • pointing Tenderness • Brawny induration around
- 62. • Redness & warmthwith restrictedmovement arounda joint • Rubor (redness) • dolar ( pain) • calor(warmness) • Tumor (swelling) and functionlesa(lossof localized&adjacent tissue/ jointFunction) are quiet obvious • Commonly cellulitis occurs first which eventually gets localized to forman abscess
- 63. COMMONSITES Site of abscess External sites • Fingers & hand • Thigh– here it is deeply situatedwithbrawny induration • Ischiorectal & perianal region • Abdominal wall • Dental abscess • Tonsillar abscess • Other abscessin the oral cavity Dental abscess Bilateral tonsillar abscess
- 64. Internal sites • Internal abscess • Abdominal • Sub-phrenic • Pelvic • Paracolic • AmoebicLiver Abscess • Pyogenicabscess of liver • Splenic abscess • PancreaticAbscess • PerinephricAbscess • Retroperitoneal Abscess • Lung Abscess • BrainAbscess • Retropharyngeal Abscess LUNG ABSCESS
- 65. INVESTIGATIONS • Total countis increased • Urine • Sugar • Blood sugar is done to rule out diabetes • USGof the part or abdomen/other regionis donewhen Required • Chest X-ray in case of lung abscess • Galliumisotope scanis very useful LUNG ABSCESS
- 66. COMPLICATION • Bacteriaemia • Septicaemia • Pyaemia • Multiple abscess formation • Metastatic Abscess • Destruction of tissues • Once abscessforms ,Thickfibrous tissue develops aroundabscess cavity because of antibiotics • Cavitycontains sterile pus as Thick Plaques • It is non – tender, localizedsmooth, hard swelling which may mimiccarcinoma
- 67. • Large abscess may erode into adjacent vessels & cause life –threatening torrential haemorrhage • Eg., as in pancreatic abscess • Brainabscess – intracranial hypertension, epilepsy, neurological deficit • Liver Abscess- cause hepaticfailure, rupture jaundice • Lung Abscess – Bronchopleural fistula or septicemia, or respiratory failureor AIDS
- 68. DIFFERENTIAL DIAGNOSIS • Aneurysm • especiallyin poplitelal • Femoral • & axillaryregions • Thrombosedaneurysm may be warm, soft & tender • Soft issues tumors : sarcomasmay be smooth,soft, & warme • Haematoma • Cold Abscess
- 69. TREATMENT • Abscessshould be formed before draining , • except ParotidAbscess • Breast Abscess • Axillary Abscess • ThighAbscess • Ischiorectal Abscess • Initially broad spectrum antibiotics are started (depending uponseverity, extent & site of the abscess) Hilton’s method of draining an abscess Under general anaesthesia or regional blockanaesthesia ↓ after cleaning & draping ↓ Abscessis aspiratedand presence of pus is confirmed ↓ Skin is incisedadequately, in the line parallel to neurovascular bundle in the most dependent position
- 70. ↓ Next pyogenicmembrane is openedusing sinus Forceps & all loculi are broken up ↓ Abscesscavity is cleared of pus & washed withsaline ↓ A drain( either gauze drain or corrugatedrubber drain) is placed ↓ Wound is not closed. woundis allowed to granulate & heal ↓ Pus is sent for culture & sensitivity ↓ Biopsy should be donein case of suspectedmalignancy ↓ Sometimes secondary suturing or skingrafting is required ↓ Treating the cause is important
- 71. INCISION & DRAINAGE OF PUS FROM ABSCESS
- 72. REFERENCE 1. SRB's Manual of Surgery by SriramBhat M 2. A Manual on Clinical Surgeryby Das 3. A Concise textbookof Surgeryby Das
- 73. A Special Thanks To A Very Special Doctor