Phlegmon is a purulent process in adipose tissue that does not have clear boundaries and is prone to spreading to surrounding tissues. The causative agent is most often Staphylococcus aureus. Phlegmon is manifested by general malaise and intoxication, a significant increase in body temperature, sharp soreness during movements and palpation of the affected area. The superficial phlegmon is characterized by the probing of a dense infiltrate, which, gradually softening, turns into a pus-filled cavity. The diagnosis is established on the basis of the clinical picture. Treatment of phlegmon is carried out by opening and draining it, using proteolytic enzymes and wound healing ointments.
Phlegmon is a spilled purulent, less often putrefactive inflammation in the fatty tissue. Its characteristic feature is the lack of clear boundaries. Phlegmon can spread rapidly through cellular spaces, passing to muscles, tendons, bones and other structures. It can be both an independent disease and a complication of other purulent processes (sepsis, abscess, carbuncle). Dental surgeons are engaged in the treatment of phlegmon in the facial area. Treatment of phlegmon in the trunk and extremities is the responsibility of purulent surgeons. Treatment of secondary phlegmon, developed against the background of a fracture or wound of soft tissues, is carried out by traumatologists.
The direct cause of the purulent process in the vast majority of cases are pathogenic microorganisms that penetrate into the cellular spaces directly through a wound or abrasion or through lymphatic or blood vessels. Most often, phlegmon develops under the influence of Staphylococcus aureus, the second most common is streptococcus.
The occurrence of phlegmon may be caused by other microorganisms. For example, in young children, phlegmon is sometimes provoked by a hemophilic bacterium. When a dog or cat is bitten, Pasturella multocida penetrates into the tissues, which can cause phlegmon with a very short incubation period (4-24 hours). And as a result of an injury received while working with poultry, pigs, marine fish or shellfish, the cause of phlegmon may be the bacterium Erysipelothrix rhusiopathiae.
Most often, bacteria enter the subcutaneous tissue through damaged skin or mucous membranes. In addition, infectious agents can enter the cellular space hematogenically or lymphogenically from some source of infection (for example, with tonsillitis, furunculosis, caries). Contact spread of inflammation is also possible with the breakthrough of a purulent focus (for example, an abscess or carbuncle). In some cases, phlegmon can be caused not by pathogens, but by chemicals. Thus, the development of purulent inflammation in the subcutaneous tissue is possible when gasoline, kerosene, turpentine, etc. are injected under the skin.
The likelihood of phlegmon increases with a decrease in the protective functions of the body, which may be due to exhaustion, immunodeficiency conditions (HIV infection), chronic diseases (diabetes mellitus, blood diseases, tuberculosis) or chronic intoxication (alcoholism, drug addiction). With all these conditions, there is a more severe course and rapid spread of phlegmon, which is due to the inability of the body to resist infection. The probability of infection, the peculiarities of the course of phlegmon and sensitivity to drugs are also determined by the type and strain of the microorganism.
The nature and features of the phlegmon development are determined by the peculiarities of the vital activity of the bacterium that caused the purulent process. So, streptococci and staphylococci cause purulent inflammation. And when infected with putrefactive streptococcus, vulgar proteus and E. coli, putrefactive phlegmon occurs.
The most severe forms of phlegmon develop as a result of the vital activity of obligate anaerobes – bacteria that multiply in the absence of oxygen. Such microorganisms include non-spore-forming (bacteroids, peptostreptococci, peptococci) and spore-forming anaerobes (clostridia), which are characterized by extreme aggressiveness, high rate of tissue destruction and a tendency to rapid spread of inflammation. The chronic form of phlegmon (woody phlegmon) is caused by low-virulent strains of microorganisms such as Diphtheria bacillus, Staphylococcus, paratyphoid bacillus, pneumococcus, etc.
Phlegmon can be primary (resulting from the direct introduction of microorganisms) or secondary (developed during the transition of inflammation from surrounding tissues), acute or chronic, superficial or deep, progressive or delimited. Depending on the nature of tissue destruction in purulent surgery, serous, purulent, necrotic and putrefactive forms of phlegmon are isolated. Taking into account the localization, the phlegmons are divided into subcutaneous, intermuscular, subfascial, retroperitoneal, inter-organ, mediastinal fiber phlegmons, neck, hand, foot phlegmons.
If purulent inflammation develops in the cellular spaces around an organ, its name is formed from the Latin name of the inflammation of this organ and the prefix “para”, meaning “about” or “around”. Examples: inflammation of the fiber around the kidney – paranephritis, inflammation of the fiber around the rectum – paraproctitis, inflammation of the fiber in the pelvic region (near the uterus) – parametritis, etc. With a rapid flow of phlegmon, it can go beyond one anatomical area and spread to neighboring ones, capturing simultaneously, for example, the buttocks, thigh and perineum, or the hand and forearm.
For an acute process, a quick start is typical with an increase in temperature to 39-40 °With and above, symptoms of general intoxication, thirst, sharp weakness, chills and headache. With superficial phlegmon, swelling and redness appear in the affected area. The affected limb increases in volume, an increase in regional lymph nodes is determined.
In the process of palpation of the phlegmon, a sharply painful, motionless, hot to the touch formation without clear boundaries is revealed. The skin above it is glossy. Movements are painful, the pain also increases with a change in body position, so patients try to move as little as possible. Subsequently, a softening area appears in the area of inflammation – a cavity filled with pus. Pus can either break out with the formation of a fistula, or spread to neighboring tissues, causing their inflammation and destruction.
Deep phlegmon is characterized by the earlier appearance and more pronounced general symptoms – hyperthermia, weakness, thirst, chills. There is a rapid deterioration of the condition, possible shortness of breath, decreased blood pressure, frequent weak pulse, headache, decreased urination, cyanosis of the extremities and jaundice of the skin.
Regardless of the location (deep or superficial), acute phlegmon progresses rapidly, capturing all new areas of adipose tissue, as well as anatomical formations located nearby, and is accompanied by severe intoxication. There are five forms of acute phlegmon.
- Serous phlegmon. Develops at the initial stage. Serous inflammation prevails: exudate accumulates in the area of the affected area, adipose tissue cells are infiltrated by leukocytes. The fiber acquires a gelatinous appearance and is impregnated with a watery cloudy liquid. The boundary between diseased and healthy tissues is practically not pronounced. Subsequently, the serous form can turn into purulent or putrefactive.
- Purulent phlegmon. Histolysis is observed (melting of tissues with the formation of pus), resulting in a cloudy, whitish, yellow or green exudate. Due to the melting of tissues in this form of phlegmon, the formation of ulcers, fistulas and cavities is often observed. With an unfavorable course of purulent phlegmon, inflammation spreads to neighboring tissues (muscles, bones, tendons), which are involved in the purulent process and also undergo destruction. Pus spreads through “natural cases” – subfascial spaces and tendon sheaths. The muscles acquire a dirty gray color, are soaked with pus and do not bleed.
- Putrid phlegmon. It is characterized by the destruction of tissues with the formation of gases with an unpleasant odor. Tissues with such a phlegmon acquire a dirty brown or dark green color, become slippery, loose and collapse, turning into a semi-liquid smearing mass. Putrefactive decay of tissues causes severe intoxication.
- Necrotic phlegmon. It is characterized by the formation of foci of necrosis, which subsequently either melt or are rejected, leaving behind a wound surface. With a favorable course of phlegmon, the area of inflammation is limited from the surrounding healthy tissues by the leukocyte shaft, and later by the granulation barrier. The inflammation is localized, abscesses form in place of the phlegmon, which are either opened independently or drained surgically.
- Anaerobic phlegmon. There is a widespread serous inflammatory process with the appearance of extensive areas of necrosis and the release of gas bubbles from the tissues. The fabrics are dark gray, with a fetid smell. During palpation, crepitation (soft crunch) is determined due to the presence of gas. The tissues around the focus of inflammation acquire a “boiled” appearance, there is no redness.
Chronic phlegmon can develop with low virulence of microorganisms and high resistance of the patient’s body. Accompanied by the appearance of a very dense, woody infiltrate. The skin over the area of inflammation is cyanotic.
The dissemination of infection through the lymphatic and blood vessels can cause the development of thrombophlebitis, lymphangitis and lymphadenitis. In some patients, erysipelas or sepsis is detected. Secondary purulent congestion may occur. Phlegmon of the face can be complicated by purulent meningitis. When the process spreads to nearby soft tissue and bone structures, purulent arthritis, osteomyelitis, tendovaginitis can develop, with pleural lesions – purulent pleurisy, etc. One of the most dangerous complications of phlegmon is purulent arteritis – inflammation of the arterial wall with its subsequent melting and massive arterial bleeding.
This disease is life-threatening and requires emergency hospitalization. In the course of treatment, a strict rule applies: in the presence of pus, its evacuation is necessary, therefore, the main therapeutic measure is surgical intervention – opening and drainage of the purulent focus. An exception to the general rule is the initial stage of phlegmon (before the formation of the infiltrate). In this case, the operation is not performed. Patients are prescribed thermal procedures (sollux, heating pads, warming compresses), UHF therapy or compresses with yellow mercury ointment (Dubrovin bandage). Simultaneous use of UHF and mercury ointment is contraindicated.
The presence of high temperature and formed infiltrate is an indication for surgical treatment of phlegmon even in the absence of obvious fluctuation in the lesion. Opening and drainage of the inflammatory area allows to reduce tissue tension, improve tissue metabolism and create conditions for the evacuation of inflammatory fluid. Surgical intervention is performed under general anesthesia. The autopsy of the phlegmon is carried out by a wide incision. At the same time, in order to ensure a good outflow of pus, not only superficial, but also deep tissues are widely dissected. After the discharge of purulent fluid, the cavity is washed and drained with rubber graduates, tubes or half-tubes.
Bandages with hypertonic solution or water-soluble ointments containing antibiotics are applied to the wound. Ointments based on vaseline lanolin and fat (syntomycin emulsion, Vishnevsky ointment, neomycin, tetracycline ointments, etc.) are not shown in the early stages, because they hinder the outflow of wound contents. In order to accelerate the rejection of dead areas, special necrolytic agents are used – proteolytic enzymes (proteases, chymotrypsin, trypsin) or ointments containing enzymes.
After cleansing the wound cavity, ointment dressings are used. Troxevazine and methyluracil ointment are used to stimulate regeneration, fat–based ointments are used to protect granulation tissue from damage, and water–soluble ointments are used to prevent re-infection. In the phase of epithelization and scarring, rosehip and sea buckthorn oil are applied. With long-term non-healing wounds and extensive defects, dermoplasty is performed.
Simultaneously with local treatment, conservative therapy is carried out, aimed at increasing the body’s defenses, fighting infection and intoxication. The patient is prescribed bed rest. The affected area is given an elevated position if possible. Painkillers are usually administered intramuscularly. All patients must undergo antibiotic therapy. Drugs are selected taking into account the sensitivity of the pathogen. With anaerobic phlegmon, anti-gangrenous serums are used intramuscularly or subcutaneously.
To regulate the acid-base state of the blood and neutralize toxins, a solution of urotropin is injected intravenously, and a solution of calcium chloride is used to improve vascular tone. To improve the nutrition of the heart muscle, glucose solution is used intravenously. If necessary, drugs that normalize the activity of the cardiovascular system (caffeine, etc.) are used. They prescribe copious drinking, intravenous infusion therapy, vitamin therapy, general tonic agents and immunomodulatory drugs. Antibiotic therapy is continued until the acute inflammation is eliminated.
Prognosis and prevention
The prognosis is determined by the extent of the lesion, the nature of the purulent process, the general state of the patient’s health and the time of initiation of treatment. With late treatment, the development of complications may be fatal. After recovery, rough scarring is often observed, external defects are possible, and the function of the affected segment is impaired. Prevention of phlegmon consists in the prevention of injuries, treatment of wounds and abrasions, timely treatment of foci of infection (carious teeth, boils, pyoderma, etc.). If the first signs of inflammation and the slightest suspicion of phlegmon occur, you should immediately consult a doctor.