Phlegmon – the purulent process in fatty cellulose which does not have a clear boundary and inclined to distribution on surrounding fabrics. The activator most often is golden staphylococcus. Phlegmon can have primary and secondary character. It is shown by a general malaise and intoxication, substantial increase of body temperature, sharp morbidity at the movements and a palpation of the struck area. Superficial phlegmon is characterized by probing of dense infiltrate which, being gradually softened, turns into the cavity filled with pus. Treatment of phlegmon is carried out by its opening and drainage, use of proteolytic enzymes and wound healing ointments.
Phlegmon – poured purulent, is more rare a putrefactive inflammation in fatty cellulose. Its characteristic is lack of a clear boundary. Phlegmon can quickly extend on kletchatochny spaces, passing to muscles, sinews, bones and other structures. Can be both an independent disease, and a complication of other purulent processes (sepsis, abscess, an anthrax). Most often phlegmon is caused by golden staphylococcus. In most cases proceeds sharply, however there are also chronic options of a disease.
Classification of phlegmons
Phlegmon can be primary (resulted from direct introduction of microorganisms) or secondary (developed upon transition of an inflammation from surrounding fabrics), sharp or chronic, superficial or deep, progressing or delimited. Depending on the nature of destruction of fabrics allocate a serous, purulent, necrotic and putrefactive form of phlegmon. Taking into account localization of phlegmon phlegmons of cellulose of a sredosteniye, phlegmon of a neck, a brush, foot are subdivided on hypodermic, intermuscular, podfastsialny, zabryushinny, interorgan.
If the purulent inflammation develops in kletchatochny spaces around any body, its name is formed of the Latin name of an inflammation of this body and the couple prefix meaning "near" or "around". Examples: the cellulose inflammation around a kidney – paranephrite, a cellulose inflammation around a rectum – paraproktit, a cellulose inflammation in a small pelvis (near a uterus) – a parametritis, etc. At a rapid current phlegmon can be beyond one anatomic area and extend to next, occupying at the same time, for example, the area of buttocks, a hip and a crotch or a brush and a forearm.
Causative agents of phlegmon
In most cases pathogenic microorganisms which get into kletchatochny spaces directly through a wound or a graze or on lymphatic or blood vessels are an immediate cause of phlegmon. Most often phlegmon develops under the influence of golden staphylococcus, the second place on prevalence is taken by a streptococcus.
Developing of phlegmon can be caused also by other microorganisms. So, for example, at children of younger age phlegmon is sometimes provoked by a hemophilic bacterium. At a sting of a dog or cat Pasturella multocida which can cause phlegmon with very short incubatory period (4-24 hours) gets into fabrics. And as a result of the wound got in operating time with poultry, pigs, sea fishes or mollusks, Erysipelothrix rhusiopathiae bacterium can become the reason of phlegmon.
Character and features of development of phlegmon are defined by features of activity of the bacterium which caused purulent process. So, streptococci and staphylococcus cause a purulent inflammation. And at infection with a putrefactive streptococcus, putrefactive phlegmon arises vulgar Proteus and colibacillus.
The most severe forms of phlegmon develop as a result of activity of obligate anaerobe bacterias – bacteria which breed for lack of oxygen. Are among such microorganisms nesporoobrazuyushchy (bakteroida, peptostreptokokk, peptokokk) and sporoobrazuyushchy anaerobe bacterias (klostridiya) which are characterized by extreme aggression, high speed of destruction of fabrics and a tendency to bystry distribution of an inflammation. The chronic form of phlegmon (ligneous phlegmon) is caused by low-virulent strains of such microorganisms as a diphtheritic stick, staphylococcus, a paratyphus stick, a pneumococcus, etc.
Reasons of development of phlegmon
Most often bacteria get into hypodermic cellulose through the damaged integuments or mucous membranes. Besides, causative agents of an infection can get to kletchatochny space in the hematogenic or limfogenny way from some center of an infection (for example, at tonsillitis, a furunkuleza, caries). Also contact distribution of an inflammation at break of the purulent center is possible (for example, abscess or an anthrax). In some cases phlegmon can be caused not by pathogenic microorganisms, but chemicals. So, development of a purulent inflammation in hypodermic cellulose is possible at introduction under skin of gasoline, kerosene, turpentine, etc.
The contributing factors
The probability of developing of phlegmon increases at decrease in protective functions of an organism which can be caused by exhaustion, immunodeficiency (HIV infection), chronic diseases (diabetes, blood diseases, tuberculosis) or chronic intoxications (alcoholism, drug addiction). At all listed states heavier course and bystry spread of phlegmon is observed that is caused by impossibility of an organism to resist to an infection. The probability of infection, feature of a course of phlegmon and sensitivity to medicines are also caused by a look and a strain of a microorganism.
Quick start with temperature increase to 39-40 °C and above, symptoms of the general intoxication, thirst, sharp weakness, a fever and a headache is characteristic of sharp phlegmons. At superficial phlegmon in a zone of defeat hypostasis and redness develops. The affected extremity increases in volume, increase in regionarny lymph nodes is defined. In the course of a palpation of phlegmon education sharply painful, motionless, hot to the touch without clear boundary comes to light. Skin over it shines. The movements are painful, pain also amplifies at change of position of a body therefore patients try to move as little as possible. In the subsequent in the field of an inflammation there is a site of a softening – the cavity filled with pus. Pus can or break outside with formation of fistula, or extend to the next fabrics, causing their inflammation and destruction.
Emergence and brighter expressiveness of the general symptoms – a hyperthermia, weakness, thirst, a fever is characteristic of deep phlegmons earlier. Bystry deterioration in a state is noted, short wind, a lowering of arterial pressure, a frequent low pulse, a headache, reduction of a mocheotdeleniye, cyanosis of extremities and yellowness of integuments is possible.
The majority of kinds of a disease proceeds sharply and quite often has malignant character. Pathology quickly progresses, occupying all new sites of fatty cellulose, and also nearby anatomic educations, and is followed by heavy intoxication. Allocate five forms of sharp phlegmon.
- Serous phlegmon. Develops at the initial stage. The serous inflammation prevails: in the field of an affected area exudate accumulates, cells of fatty cellulose infiltrirutsya by leukocytes. Cellulose takes a jellylike form and becomes impregnated with watery muddy liquid. The border between sick and healthy fabrics is almost not expressed. In the subsequent the serous form can pass in purulent or into putrefactive.
- Purulent phlegmon. It is observed (fusion of fabrics with formation of pus) therefore muddy, whitish, yellow or green exudate is formed. Because of fusion of fabrics at this form of phlegmon formation of ulcers, fistulas and cavities is often observed. At the adverse course of purulent phlegmon the inflammation extends to the next fabrics (muscles, bones, sinews) which are involved in purulent process and also are exposed to destruction. Pus spreads on "natural cases" - to podfastsialny spaces and tendinous vaginas. Muscles get rather dirty-gray coloring, become impregnated with pus and do not bleed.
- Putrefactive phlegmon. It is characterized by destruction of fabrics with formation of gases with an unpleasant smell. Fabrics at such phlegmon get dirty-brown or dark green coloring, become slippery, friable and collapse, turning into the semi-fluid smeared weight. Putrefactive disintegration of fabrics causes heavy intoxication.
- Necrotic phlegmon. Formation of the centers of a necrosis which in the subsequent either melt is characteristic, or are torn away, leaving behind a wound surface. At the favorable course of phlegmon the area of an inflammation is limited from surrounding healthy fabrics to a leykotsitarny shaft, and further – a granulyatsionny barrier. The inflammation is localized, on the place of phlegmon abscesses which either are opened independently are formed, or drained in the operational way.
- Anaerobic phlegmon. Widespread serous inflammatory process with emergence of extensive sites of a necrosis and allocation of fabrics of vials of gas is observed. Fabrics dark gray, with a fetid smell. At a palpation the krepitation (a soft crunch) caused by gas availability is defined. Fabrics around the center of an inflammation take a "boiled" form, reddening is absent.
Chronic phlegmon can develop at low virulence of microorganisms and high resilience of an organism of the patient. Is followed by emergence of very dense, ligneous infiltrate. Integuments over area of an inflammation cyanotic.
Dissemination of an infection on lymphatic and blood vessels can become the reason of development of thrombophlebitis, a limfangit and lymphadenitis. At some patients the erysipelatous inflammation or sepsis comes to light. Emergence of secondary purulent zatek is possible. Phlegmon of the person can be complicated by purulent meningitis. At distribution of process on nearby myagkotkanny and bone structures purulent arthritis, osteomyelitis can develop, tendovaginit, at damage of a pleura – purulent pleurisy etc. One of the most dangerous complications of phlegmon is purulent arteritis – an inflammation of an arterial wall with its subsequent fusion and massive arterial bleeding.
Treatment of phlegmon
Phlegmon – a serious, life-threatening illness at which obligatory hospitalization is required. In the course of treatment the strict rule works: in the presence of pus its evacuation therefore the main medical action is surgical intervention – opening and drainage of the purulent center is necessary. An exception of the general rule is the initial stage of phlegmon (before infiltrate formation). In this case operation is not performed. To patients appoint thermal procedures (, the hot-water bottles warming compresses), UVCh-therapy or compresses with yellow mercury ointment (a bandage across Dubrovin). Simultaneous use of UVCh and mercury ointment is contraindicated.
Existence of high temperature and the created infiltrate is the indication to expeditious treatment of phlegmon even in the absence of obvious fluctuation in the defeat center. Opening and drainage of area of an inflammation allows to reduce tension of fabrics, to improve fabric exchange and to create conditions for evacuation of inflammatory liquid. Surgical intervention is carried out under the general anesthesia. Opening of phlegmon is carried out by a wide section. At the same time, to provide good outflow of pus, widely cut not only surface, but also deep fabrics. After an otkhozhdeniye of purulent liquid the cavity is washed out and drained rubber graduates, tubes or semi-tubes.
Apply bandages with the hypertensive solution or water-soluble ointments containing antibiotics a wound. Ointments on a vazelinlanolinovy and fatty basis (a sintomitsinovy emulsion, Vishnevsky's ointment, neomitsinovy, tetracycline ointments and so forth) at early stages are not shown as they complicate outflow of wound contents. To accelerate rejection of the become lifeless sites, apply special nekrolitichesky means – proteolytic enzymes (proteases, chymotrypsin, trypsin) or ointments with the content of enzymes.
After clarification of a wound cavity use mazevy bandages. To stimulation of regeneration apply troksevazinovy and metiluratsilovy ointment, to protection of granulyatsionny fabric against damage – ointment on a fatty basis, to prevention of repeated infection – water-soluble ointments. In a phase of an epitelization and scarring apply shipovnikovy and sea-buckthorn oil. At it is long not healing wounds and extensive defects carry out to thermoplastic.
Along with local treatment the conservative therapy directed to increase in protective forces of an organism, fight against an infection and intoxication is carried out. To the patient appoint a bed rest. The affected area is whenever possible given sublime situation. Anesthetics usually enter intramuscularly. Carry surely out by all patient antibiotic treatment. Medicines select taking into account sensitivity of the activator. At anaerobic phlegmons intramuscularly or hypodermically apply antigangrenous serums.
For regulation of an acid-base condition of blood and neutralization of toxins intravenously enter urotropin solution, for improvement of a tone of vessels – solution of chloride calcium. Apply glucose solution to improvement of food of a cardiac muscle intravenously. If necessary apply the medicines normalizing activity of cardiovascular system (caffeine etc.). Appoint the plentiful drink, intravenous infusional therapy, vitamin therapy all-strengthening means and immunomodulatory medicines. Antibiotic treatment is continued up to elimination of an acute inflammation.
Prevention of phlegmon
Prevention of phlegmon consists in the prevention of injuries, processing of wounds and grazes, timely treatment of the centers of an infection (carious teeth, furuncles, a piodermiya and so forth). At emergence of the first signs of an inflammation and the slightest suspicion of phlegmon it is necessary to see a doctor immediately. In a face surgeons-stomatologists are engaged in treatment of phlegmons. Treatment of phlegmons in a trunk and extremities is under authority of surgeons. Treatment of the secondary phlegmons which developed against the background of a change or a wound of soft fabrics is performed by traumatologists.