Purulent-resorptive fever is a pathological process that occurs during secondary wound healing. The main symptoms are local complications (purulent congestion, abscesses, phlegmons), fever and general intoxication manifestations. With a prolonged course, traumatic exhaustion develops, a fatal outcome occurs. Diagnosis of the disease is based on anamnesis data, clinical symptoms, detection of pyogenic flora. Treatment is aimed at stopping the entry of wound toxins into the blood, which is usually achieved by surgical excision, pathogenetic and symptomatic treatment, and the appointment of antibiotics.
50.8 Other specified fever
Purulent-resorptive fever is a local complication accompanied by a general reaction of the body adequate to changes in the area of injury. In fact, this process serves as a prerequisite for the development of sepsis. The importance of pathology for clinical infectology and medicine is to reduce mortality. Up to 5% of fever cases are caused by abdominal wounds and suppuration of various localization against the background of post-wound dysfunction of the central nervous and endocrine systems.
There are no specific pathogens. The causes of purulent-resorptive fever include the sorption effect of microorganisms, their excreted waste products, toxins, absorption of exudate from tissue detritus, pro-inflammatory and protective factors of the body. Wound infection is most often introduced from the environment (soil, clothing, shell fragments, bullets), skin, but bacteria can also enter the wound endogenously (hemato- or lymphogenic) from chronic inflammatory foci – the oral cavity, digestive, urinary, reproductive and other systems.
The main risk factors are extensive, multiple and deep wounds, burn disease, prolonged compression syndrome (crash syndrome). Prognostically unfavorable signs are sluggish healing, pronounced edema, abundant exudate and simultaneous absence or insufficient drainage of the wound, a large area of necrotic tissues, the presence of systemic immune deficiency of any etiology, diabetes mellitus, gastrointestinal pathologies.
According to modern concepts, purulent-resorptive fever can be equated with systemic inflammatory response syndrome (SIRS), the pathogenesis of which is based on the activation of all components of the cytokine network. In parallel, the cascade proteolysis of blood plasma is suppressed and the synthesis of anti-inflammatory interleukins-10, 13 is inhibited. Tissue breakdown products accumulate and are absorbed into the bloodstream, spreading by hematogenic and lymphogenic pathways.
The main difference between this infectious pathology and sepsis is the morphological restriction of local necrotic processes by the formation of a demarcation shaft. Due to local edema, the trophism of damaged tissues worsens, histologically dystrophic and necrotic changes are detected. Hypoxia is especially dangerous for phospholipid membranes and intracellular structures: mitochondria, lysosomes, cytoskeleton due to their swelling, decay, release of enzymes and activation of apoptosis.
For the course of nosology, the correspondence of local symptoms and general intoxication complaints is typical. Pathology should be suspected with a prolonged fever of more than 37.5 ° C, throbbing pain, swelling, redness in the wound area. There may be a grayish plaque, crusts, bleeding during dressing or active movement. Marked weakness, drowsiness, decreased performance, deterioration of appetite and sleep are characteristic. Patients with purulent-resorptive fever are worried about chills, headaches, nausea, stool breakdowns, weight loss.
Important for the identification and prediction of the condition is a triad of clinical symptoms: body temperature, respiratory rate and heart rate. It is urgently necessary to seek medical help if a patient with a wound has severe shortness of breath, tachycardia of more than 90 beats per minute, a temperature above 38 ° C or below 36 ° C in the presence of local wound inflammatory symptoms, as well as impaired consciousness, a decrease in the amount of urine excreted, the appearance of spot hemorrhages on the skin and mucous membranes.
The most common complication of purulent-resorptive fever in the absence of treatment is sepsis with the likely development of such a life-threatening condition as septic shock. Long-term consequences include traumatic exhaustion with the formation of cachexia, chronic dystrophic processes in internal organs: heart attacks, lung abscesses, nephritis, ulcerative necrotic colitis, hepatitis, amyloidosis of the spleen. The development of adrenal and pancreatic insufficiency, hypothyroidism is likely.
Detection of purulent-resorptive fever is carried out with the participation of an infectious disease specialist and a surgeon. Specialists of other medical profiles are involved in the examination according to indications. It is necessary to carefully collect information about the cause, prescription and nature of the injury, the amount of surgical assistance provided. The basic laboratory and instrumental diagnostic signs of the pathological process are:
- Physical data. The edges of the wound are edematous, granulations bleed easily, grayish, without marginal epithelization, there is a dense fibrinous plaque. On palpation, the wound surface is sharply painful, often with fluctuation, sometimes crepitation is detected. Exudate of various colors, often fetid. Internal organs are usually without pathology; with a prolonged course, cachexia, skeletal muscle atrophy, hepatomegaly and splenomegaly are formed.
- Laboratory tests. Blood test is characterized by leukocytosis with a pronounced shift of the formula to the left, moderate anemia, acceleration of ESR. During biochemical and immunological examination, hypoproteinemia, hypoalbuminemia, significant acidosis, an increase in the level of interleukin-6, TNF-alpha are recorded. In the general analysis of urine – proteinuria, increased sediment density, leukocyturia.
- Identification of infectious agents. Microscopy of wound or fistula discharge is mandatory, sowing on nutrient media. If actinomycosis is suspected, a biopsy of the wound edges, a scraping of granulations, an allergic test with actinolysate, a serological examination – a Borde-Zhang reaction. To exclude the septic process, blood is seeded three times for hemoculture and sterility, the level of procalcitonin, presepsin, proadrenomedullin, troponin is studied.
- Instrumental techniques. Chest x-ray is recommended in order to exclude tuberculous lesions; examination of bones and joints by radiation methods is performed depending on the localization of damage and the depth of inflammatory and necrotic changes. Ultrasound of the musculoskeletal system, soft tissues is prescribed, if available, the area of the postoperative suture.
Differential diagnosis is carried out with actinomycosis (confirmed by laboratory), resorptive-toxic fever, which occurs with closed injuries, does not cause a long-term increase in body temperature and pronounced local inflammatory changes. Sepsis of any genesis is not characterized by an improvement in the patient’s condition during the rehabilitation of the focus of infection, the primary focus is often not determined or does not cause significant subjective complaints.
Treatment of purulent-resorptive fever
Patients are urgently hospitalized in a surgical hospital. Up to 5-7 days of normal body temperature, strict bed rest is prescribed, bedsores and hypostatic pneumonia are prevented. A high-protein fortified diet is recommended, an increase in water load (in the absence of contraindications), preferably with the use of means to correct electrolyte imbalance and acidosis (oral, etc.). If necessary, patients are transferred to the intensive care unit.
The management of patients with symptoms of purulent-resorptive fever has much in common with the treatment of septic patients. The main goals of conservative therapy after the rehabilitation of the primary focus are the fight against the causative agent of the local inflammatory process, proportionate oxygenation, reduction of the systemic inflammatory effect of the body and prevention of the development of a septic response. The following tactics of therapeutic support are most often used:
- Etiotropic treatment. Broad-spectrum antibiotics are prescribed, since bacterial agents are most often the cause of infection. In the first line – penicillins, fluoroquinolones, metronidazole, linezolid, vancomycin and their combinations. The effectiveness of the selected drug is evaluated no earlier than 48-72 hours from the start of administration.
- Pathogenetic agents. Massive infusion detoxification with hydroxyethylene starches, crystalloids, the introduction of albumin solutions, freshly frozen plasma is carried out. Extracorporeal detoxification is used less often: plasmapheresis, hemofiltration, dialysis. The use of NSAIDs is justified, less often – glucocorticosteroids.
- Symptomatic therapy. According to the indications, antipyretic, analgesic, vasoactive, microcirculation-improving agents, anticoagulants, diuretics are prescribed. The effectiveness of hyperbaric oxygenation in the anaerobic etiology of the process is reported. In the presence of hyperglycemia, the administration of adequate doses of insulin has a proven effect on survival.
Nutritional support is important in order to prevent exhaustion against the background of hypercatabolism and hypermetabolism, characteristic symptoms of systemic inflammation. For the relief of systemic coagulation disorders in severe fever, the administration of activated protein C is recommended. Intravenous use of combined immunoglobulin preparations with a proven effect of enhancing the action of beta-lactam antibiotics, limiting the effect of proinflammatory cytokines is possible. Patients with symptoms of wound fever should receive tetanus prophylaxis.
It is the main method of treatment. The volume of surgical intervention depends on the extent of the lesion, possibly limited excision of wound edges, necrectomy, arthrotomy, joint resection, limb amputation. It is mandatory to inspect the wound canal for swelling and purulent pockets, install drains with active aspiration, washing with antiseptic solutions, regular dressings with water-based antibacterial ointments. After healing with a widespread lesion, various types of dermoplasty are performed.
In case of extensive and deep necrotic changes in the wound, sequential excision with regular dressings, the use of sorption dressings, proteolytic enzymes, washing with a pulsating jet of oxygen-saturated antiseptic is recommended. Instead of drainage tubes, the use of loose tamponade of the infected cavity is allowed. Secondary sutures are applied only after complete cleansing of the infected surface, with good granulation development.
Prognosis and prevention
The prognosis with timely detection and treatment is favorable, the mortality rate is lower than with sepsis. Prevention of purulent-resorptive fever consists in the correct tactics of primary surgical treatment of wounds, detection, opening and drainage of purulent wound complications, rational antibiotic therapy, early skin grafting for burn disease. Qualitative sanitization of foci of chronic infection in the body, drug compensation of metabolic diseases, immune deficiency is considered important.