Chronic Infectious Disease Types Notes

Chronic Infectious Disease

Actinomycosis, leprosy, syphilis, and AIDS are the chronic diseases discussed in this chapter. Actinomycosis is a rare disease, leprosy is more interesting to skin specialists, and AIDS is interesting to all clinicians. Hence, the only relevant aspects of each of these diseases as far as general surgeons are concerned are being discussed here.

Actinomycosis

Actinomycosis is caused by Actinomyces israelii, an anaerobic, gram-positive branching filamentous organism (ray fungus). Normally present in the oral cavity, tonsillar crypts and dental cavities, they become pathogenic in the presence of trauma.

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Types Of Actinomycosis

Facio-Cervical Actinomycosis

• It is common in patients with poor oral hygiene, bad caries teeth, etc.
• The organisms produce a subacute or chronic inflammation for many months to years and produce a lumpy jaw.
• Eventually, the cheek, mandible, jaws, and salivary glands are involved, resulting in suppuration.

Actinomycosis Clinical Features

• Extensive induration of the lower jaw (mandible) and gums gives consistency of bone.
• Multiple subcutaneous nodules over bluish-coloured skin of the jaw.
• The nodules rupture, resulting in multiple discharging sinuses.
• The discharge contains sulphur granules which are gram-positive mycelia surrounded by gram-negative clubs.
• Lymph nodes are not involved.

Actinomycosis Of Thorax And Lung

• It is common in children, caused by inhalation of a ray fungus, through the diaphragm.
• Over years, it produces actinomycosis of the lung with the involvement of the pleura. Later it involves the chest wall, resulting in multiple discharging sinuses.
• There may be associated empyema and can easily spread to the liver.

Actinomycosis Of The Right Iliac Fossa And Liver

• It commonly occurs after surgery when there is mucosal injury, discontinuity, etc. Example: After appendicectomy.
• The organs that are normally present in the gut slowly migrate into periapical tissue, then into the soft tissue, and subcutaneous tissue, and produce subacute or chronic low-grade inflammation.
• No compromise with the bowel lumen.
• Once the portal venous radical gets involved, spread to the liver occurs.

Actinomycosis Of The Right Iliac Fossa And Liver Clinical Features

• The history of appendicectomy is present in almost all cases.
• 3–6 months later, a swelling appears in the right iliac fossa and is associated with fever. Fever is probably due to pyaemia.
• On examination, there is a mass in the right iliac fossa which is indurated, nodular and fixed.
• Late stages produce multiple discharges, sometimes fecal matter and sulphur granules. Unlike tuberculosis, the lymph nodes are not enlarged.

Differential Diagnosis

Carcinoma caecum, Crohn’s ileocolitis, pericolic abscess, etc.

Treatment Of Actinomycosis In General

• It is a low-grade chronic disease, difficult to eradicate.
• Inj. crystalline penicillin—10 lakh units once a day for 6–12 months. Tetracycline and lincomycin are the other alternatives.
• Sinuses in the jaw may have to be excised and osteomyelitis has to be curetted out.
• Actinomycosis of the right iliac fossa may need a right hemicolectomy.

Leprosy (Hansen’s Disease)

• Leprosy is caused by Mycobacterium leprae, an acid-fast bacillus. Poverty, poor hygiene and population (overcrowding) facilitate the spread of the disease.
• The disease is contracted in childhood or adolescence, but it 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 skin, upper respiratory tract (nasal cavity) and nerves. Thus, characteristic lesions of leprosy include an anaesthetic patch of skin, thickened nerves, a deformed leonine face and a collapsed nose.

Leprosy Types

1. Tuberculoid leprosy: It occurs in patients with good immunity with strong tissue response.
2. Lepromatous leprosy: It occurs in patients with poor immunity with poor tissue response.
3. Borderline leprosy: It can be borderline lepromatous or borderline tuberculoid leprosy depending upon the immune response.

Leprosy Treatment

1. Lepromatous and borderline lepromatous leprosy (Multibacillary disease)

• • A 3-drug regimen is the most ideal treatment

2. Tuberculoid and borderline tuberculoid leprosy (Paucibacillary disease)

Deformities In Leprosy

Primary deformity

It occurs directly due to the disease.

Face: It is involved in lepromatous leprosy and it is described as leonine fades with multiple nodules over the face, pigmentation, loss of a lateral portion of the eyebrows (Madarosis), the collapse of the bridge of the nose due to the destruction of nasal cartilages (warm and moist area) and paralysis of the facial nerve.

Leprosy Disease

Hands: Involvement of ulnar nerve at the elbow and median nerve at wrist giving 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.

Leprosy And Nerve Abscess

• Most commonly seen in paucibacillary tubercular leprosy
• The most common nerve involved is the ulnar nerve
• Most commonly, Mycobacterium leprae inhabits the Schwann cell
• Mostly granuloma formation occurs, and a few cases of abscesses occur
• Mostly it occurs when immunity is high

Correction of deformity of the face by:

Plastic reconstruction

1. A prosthesis to correct the nose
2. Lateral tarsorrhaphy, to prevent exposure to keratitis.
3. Temporalis muscle flap to the upper eyelid to prevent exposure to keratitis.

Correction Of Deformity Of The Hand And Foot

• The claw hand can be corrected by the extensor carpi radialis brevis muscle (Paul Brand’s procedure).
• Otherwise, flexor digitorum profundus can be used (Bunnell’s procedure).
• Foot drop can be corrected by using the tibialis posterior muscle tendon transfer (Ober’s and Barr’s procedure).

Leprosy Disease

Secondary Deformity

Because of the involvement of the nerves, sensations are impaired or lost. As a result of this, ulcers on the fingers, a deep penetrating, perforating ulcer over the sole, and even auto amputation of toes can occur.

Treatment of Secondary Deformity

Non-healing ulcer over the sole is corrected by applying a POP (Plaster of Paris) posterior slab. It takes off the pressure and thus the ulcer heals. If calcaneus is involved due to osteomyelitis, the bone has to be cured followed by regular dressings.

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 stages. Early lesions are predominantly situated in moist areas like the genitalia and oral cavity.

Syphilis, French Disease, Great Pox, Clinical Presentation

1. Early syphilis
2. Late syphilis.

Congenital Syphilis

Early

• Snuffles (rhinitis), epiphysitis, periostitis, osteochondritis.

Late

• Hutchinson’S Triad
• Interstitial keratitis
• 8th nerve deafness
• Hutchinson’s teeth

Early Syphilis

1. Primary syphilis: Classically, a genital chancre occurs in the penis or vulva after 3–4 weeks of sexual exposure. This chancre is shallow, indurated, painless, and called a Hunterian chancre.

• Associated inguinal nodes which are shotty, multiple, and non-tender, clinch the diagnosis.
• Extragenital chancres can occur in the lips, tongue, nipple, etc. They produce a large enlargement of the corresponding lymph nodes. Chancres in the rectum and perianal region are common in homosexuals. They are painful, resemble anal fissures.

Early Syphilis Investigations

Serological tests for syphilis

Leprosy Disease

1. Non-specific: VDRL, Kahn, Meinicke, Wasserman.
2. Specific treponemal antigen tests:

• CFT—Complement fixation test
• TPHA—T.P. haemagglutination test
• TPI – T.P. immobilization test
• FTA—Abs—Fluorescent treponema antibody absorption test.
• Demonstration of Treponema pallidum in the clear exudate from 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, never vesicular. Papules on moist sites like the vulva and perineum enlarge to form condylomata lata—flexy wartlike growths.
• Small superficial ulcers in the mouth join to form snail-track ulcers.
• Generalised lymphadenopathy involving epitrochlear and occipital nodes can occur.
• Moth-eaten alopecia, iritis, bone and joint pains.

Latent Syphilis: If secondary syphilis is not treated, it will develop into latent syphilis.

There are no signs but serum tests are positive.

Late Syphilis

• It is also called tertiary syphilis. It affects vessels causing inflammatory reactions and the 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. A lesser form, a benign lesion is called GUMMA. Gumma is a syphilitic hypersensitivity reaction consisting of granuloma with central necrosis and sloughing.

Clinical Features Of Gumma

• Typically it is a subcutaneous swelling.
• Affects the midline of the body, for example, the posterior ⅓ tongue, sternum, over the sternoclavicular joint.
• Edges are punched out when the gumma ulcerates.
• The floor contains washed leather slough.
• On healing, it leaves a silvery, tissue paper scar (thin scar).

Early Syphilis Treatment

1. Primary and secondary syphilis are treated by injection of procaine penicillin 10 lakh units I.M. × 14 days.
2. 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.

Aids And Prophylactic Measures

• Acquired immunodeficiency syndrome (AIDS) is the end stage of a progressive state of immunodeficiency.
  Causative organism: Human Immunodeficiency Virus (HIV).
• The details regarding the etiopathogenesis and immunology of AIDS are discussed in medicine books. Topics of the surgeon’s interest are discussed below.
• Prophylactic measures to be adopted by surgeons (Health care workers) while treating AIDS Patients (Universal Precautions)
• In the outpatient department (OPD)
• For any patient with an open wound, gloves are worn when examining a patient.
• During proctoscopy or sigmoidoscopy, gloves should be worn.
• Hand gloves and eye protection during flexible endoscopy.
• Use disposable instruments
• Re-usable instruments like endoscopes are cleaned in soap and water and immersed in glutaraldehyde.
• No surgical procedure involving sharp instruments is performed in the OPD.

Leprosy Disease

In the Operating Room

• The operating table is covered with a single sheet of polythene.
• The number of theatre personnel is reduced to a minimum.

1 Gloves were introduced by William Halstead to protect his nurse’s hands from the harmful effects of carbolic acid. (The nurse became his wife.)

• The Staff with abrasions or lacerations on their hands are not allowed inside the theatre. Staff who enter the theatre wear shoes, gloves, disposable, water-resistant gowns and eye protection.
• Double gloves and eye protection—by Staff directly involved with the operation (Surgeon, Assistant, Scrub nurse).
• Surgical technique:

1. Avoid sharp injury
2. Prefer scissors or diathermy, to the scalpel
3. Use skin clips
4. Avoid ‘needlestick’ injuries
5. Proper autoclaving at the end of surgery
6. AZT — Zidovudine, Lamivudine and Indinavir should be given to health workers following exposure of susceptible areas to infected material from AIDS patients.

Common Oral Cavity Diseases In AIDS Patients

1. Fungal infections: Candidiasis, histoplasmosis
2. Viral infections: Herpes simplex virus infections, human papillomavirus infections, Epstein Barr virus infections and cytomegalovirus infections
3. Bacterial infections: Mycobacterial infections
4. Life-threatening malignancies: Kaposi’s sarcoma, Non-Hodgkin’s Lymphoma
5. Oral ulcers: Aphthous ulcers,
6. Gingival and Periodontal disease: Gingivitis, erythema
7. Sialosis: Salivary gland enlargement and atelectasis

Common Precautions To Be Taken In AIDS Patients

1. Wear double gloves, facemasks and eye protection,
2. Sterilize all drills and other dental instruments for every patient,
3. Items that cannot be sterilized are discarded
4. After treating each patient visit, gloves are discarded, and hands are washed.