Avazashvili D., Nonikashvili Z., Kopadze T., Sharipashvili G.
Tbilisi First City Hospital, Department of Vascular Surgery and Urgent Microsurgery
Intact human skin harbors vast amounts of bacteria, presented over skin surface or in the hair follicles. Although normal skin has characters that protects it from infective nature of some pathogens. These are: stratum corneum which is particularly impermeable for microorganisms, and waxy interstitial substance – complex mixture of lipids, which connects cells of stratum granulosum and prevents skin.
Skin infections usually develop in case of trauma, overhydration or inflammatory skin infections destroy its protective barrier. Organisms that cause skin infections can be part of skin normal flora, nearest mucosal flora or egsogenouslly derived from humans, environment or polluted objects.
It is considered that erysipelas is caused by β-haemolytic Streptococcus from group A. Clinical course of erysipelas can be with fever and chills.
Erysipelas is acute, rapidly spreading infection of the skin and subcutaneous tissues, characterized by fever and general intoxication. Its morphologic elements havewell demarcated serpiginous borders which mainly develop with involvement of superficial dermal layers in pathologic processes. Superficial layers of skin are erythematous, swollen and indurate sometimes with vesicle and pustule formation and rarely withlymphangitis andlymphadenitis.
Without treatment seriouscomplications like: fasciitis, myositis , subcutaneous abscess and septicopyemia.
Today treatment of erysipelas is actual therapeutic problem caused by high disease prevalence, chronization of acute forms and retention of disease’s residual symptoms causing long-term debilitation and sometimes even permanent disability (1, 2).
Of particular interest is erysipelas that develops in patients with lower extremity varicose veins. In such cases acute dermal inflammation can become cause of pulmonary embolism or chronic venous insufficiency leading to elephantiasis (3, 4).
Sources and Methods:
The article is based on data of 2006-2007 years, about treatment methods concearning erysipelas that developed during presence of varicose veins.
43 patients were under observation, patients’ age varied between 45-70 years, 72.04% were women and 27.96% were men. 36 Patients (83.72%) had primary erysipelas and 7 (16.28%) had recurrence. In addition to varicose veins other co-morbidities that the patients had were: Diabetes -13 patients, 29 patients (67.44%) were obeseand 9 (20.43%) patients had fungal infection. Considering above data most of the patients had more than one co-morbidity that by itself was additional risk factor.
Among provocating factors of the disease it is important to mention the microtraumas of the skin surface that often develop at the locations of varicose nodules including at the venous ulcers, over cooling and prior viral infections. 11(25.58%) patients from the study group were not able to state clear precipitating factors of their disease.
Erythematous local forms of erysipelas were predominating - 35 (81.39%) of patients. Erythematous and bullous forms were reported in 8 (18.61%) patients. Haemorrhagic and necrosis forms were not reported. In every case local inflammatory process was in the lower extremities. Clinical form of the disease onset was typical in each case. Every patient complained of chills, fever (38-39C), malaise, headache and myalgia during initial acute stage of the disease. Lately most patients 23 (53.49%) developed regional painful lymphadenitis, with soreness in the lesion areas.
Among observed complications it is important to mention that 5 (11.62%) patients developed lower extremity subcutaneous ascending thrombophlebitis. No surgical treatment was conducted in these cases.
Every patient was given complex medication therapy:
- Combined medication of Penicillin group Bactamed (Ampicillin/Sulbactam) with the following dosing regimen: 1.5g x 3 per 24 hours IM. Intravenous route of medication delivery wasn’t reviewed because of no clinical necessity in this group ofthe patients.
- NSAID (Nimesulide– 1 sachet 2-3 times per 24 hours after meals).
- Antihistamine medication: Acrivastine- 8 mg x 2 per day.
- Vitamins A, C and E
- In case of varico-thrombophlebitis anticoagulation medications were added: low molecular Heparin (calcium nadroparin) in therapeutic doses under strict INR monitoring.
- Also venotonic and angioprotecting agents were added: Venodiol (Hesperidine and Diosmine containedmedication) one tablet x 2 per 24 hour.
- In case of bulla opening for erosive surface treatment antiseptic topical agents were used (Hydrogen peroxide, Dioxidine).
After the conducted treatment cure was achieved in all 43 patients. In case of erythematous forms of Erysipelas swelling was gone in 6-7 days, and for Bullous and erythematous forms it took 7-10 days. Normalizaion of the body temperature was achieved in 4-5 days, pain syndrome – in 6-7 days, hyperemia – in 7-10 days. Ascending thrombophlebitis as a complication of erysipelas was cured in 15-18 days. Every case of thrombophlebitis complication was linked to the patients’ delayed attention and later doctor visits.
Laboratory tests (ESR and Leukocytosis) normalization was achieved in 8-10 days of treatment. After cessation of acute inflammation in 3-5 week period local lymphatic oedema formation was observed in 12 (27.9%) patients, 7 of these had recurrent forms.
After intensive use of venotonic and enzymatic medications with lower limb elastic bandage compressions, oedema cessation was achieved in 9 (75%) patients of the group.
The results achieved note that erysipelas formed in the presence of varicose veins can be effectively treated with inclusion of Bactamed in the complex treatment regimen.
This medication contains irreversible β-lactamase inhibitor - Sulbactam. Prescription of this medication is pathogenetically rational because causative agent of erysipelas is β-hemolytic Streptococcus from group A that cause induction of β-lactamases.
It is also obvious that in such patient group timely diagnosis and evaluation of inflammatory processes at the early stage of the disease can avoid such serious complications as ascending varico-thromboplebitis and chronic venous and lymphatic insufficiency development.
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