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- 1. Madura Foot This is a chronic granulomatous disease commonly affecting the foot with extensive granulation tissue formation and bone destruction. The disease is common in the tropics and occurs through a prick in barefoot walkers in 90% of cases. Etiology: The causative microorganisms for this infection are various fungi or actinomycetes found in road dust. Clinical Manifestation: Firm, painless, pale nodule appears initially followed by others Vesicles surrounding the nodules which later burst and form sinuses Watery discharge, which may contain granules appearing yellow, red or black color Flattening of the convexity of inner foot Deep spread to bones subcutaneous plane leading to secondary infection.
- 2. Treatment: Sulphonamides and Dapson (prolonged course) Broad spectrum antibiotics for secondary infection Amputation if severe and disfiguring infection. Necrotizing fasciitis This is an acute invasive infection of the subcutaneous tissue and fascia characterized by vascular thrombosis, which leads to tissue necrosis. The skin is secondarily affected. It is idiopathic in origin but minor wounds, ulcers and surgical wounds are believed to be initiating factors. The condition is described as "Meleneys synergistic gangrene" if it occurs over the abdominal wall and Fourniers gangrene if in the scrotum and perineal area.
- 3. Cont. Mixed pathogens of the following microorganisms are usually cultured. Streptococci Staphylococci Gram negative bacteria Anaerobes and Clostridia Clinical Features: Sudden onset of localized pain Rapidly spreading inflammation Bacteriology:
- 4. Cont. Spread along chemic fascial planes Hemorrhagic bulla and edema Skin devascularization +/- Crepitations +/- Muscle necrosis Systemic signs of toxemi Management: Broad spectrum combined antibiotics Gentamycin or Ceftriaxone for coverage of aerobic organisms and
- 5. Cont. Cloxacilline or chloramphenicol or Metronidazole for coverage of anaerobic organisms Circulatory support with intravenous fluid as much as required and transfusion of cross matched blood when necessary Surgery soon as possible. The following surgical procedures may be required: - Debridement and excision of all dead tissue - Multiple incisions for drainage - Repeated wound inspection - Skin graft may be needed later if extensive skin involved.
- 6. CLOSTRIDIAL INFECTIONS : Tetanus. Tetanus is a non-invasive infection caused by anaerobic micro-organisms which requires favorable wounds like abortions, lacerations, injections, open fractures, burns, deep contused wounds with dead tissues and foreign body... It can practically be eliminated by tetanus vaccine immunization if properly initiated and maintained. Etiology: Clostridium tetani, a gram-positive rod found in soil and manure is the causative agent. It require anaerobic environment for growth, invasion and elaboration of toxin, tetano-spasmin for its dramatic virulence.
- 7. Cont. Clinical Features: - Can be latent with healed and forgotten wounds - - Local or generalized weakness - Stiffness or cramping pain on the back, neck and abdomen - - Difficult of chewing and swallowing - - Tonic muscles spasms - - Sardonic smile as evidence of onset of tonic spasm - - Severe pain and opisothonus due to reflex convulsion of all muscles - - Progressive difficulty of respiration - - Fever, tachycardia, cyanosis - - Respiratory failure and death due to repeated cyanotic convulsive attacks.
- 8. Cont. Treatment: - Meticulous surgical excision of the wound regardless of immunization state to eliminate the bacterial infection and the dead contaminated tissue - - Isolation, quietness and comfort - Sedation with chlorpromazine up to 200mg IM/day barbiturates or diazepam 50mgIV under close follow-up and observation for central signs of drug over dose - - Antibiotics: crystalline penicillin is the drug of choice for parenteral medication. Tetracycline can be an alternative antibiotic for oral therapy. - - Intensive nursing care - Naso-gastric tube for feeding to maintain protein balance - - Immunization - Respiratory support and consider tracheostomy if spasms becomes frequent leading to cyanosis - - Human antitetanus globulin if available to neutralize circulating toxin - - Active immunization with 0.5 ml of tetanus toxoid if the patient is not immunized or the wound is tetanus prone
- 9. Cont. Prevention: Prevention of clinical tetanus depends on adequate immunization of the population and careful surgical management of all traumatic wounds, even those which appear to be minor. Patients with grossly contaminated wounds and no or unclear history of immunization should receive an intramuscular antitoxin therapy. Active immunization with tetanus toxoid should also be started.
- 10. Gas Gangrene Gas Gangrene Gas gangrene is another clostridia associated with soft tissue infection (Clostridial myonecrosis). It is a rare but devastating infection characterized by muscle necrosis and systemic toxicity due to the elaboration and release of toxins. It usually follows wounding with trauma or surgery and requires factors contributing to tissue hypoxia like foreign bodies, vascular insufficiency or occurs as a complication of amputation. Etiology: Clostridium perfringens is responsible for over 80% of cases. More than one species can be isolated or polymicrobial infection with other microorganisms can occur.
- 11. Cont. Clinical features: It is characterized by fulminant local and systemic manifestations. Patients may appear normal at early state. Clinical features include: - Sudden and persistent severe pain at wound site. - Localized tense edema, pallor and tenderness - Gas noted on palpation or radiographs - Progressive brownish discoloration of skin and hemorrhagic bullae formation - Dirty brown discharge with offensive, sweetish odor - Severe systemic manifestations including fever, tachycardia, hemolytic anemia, hypotension, renal failure and finally death - Grams stain from the discharge can be diagnostic
- 12. Cont. Management: Surgery is most important component Extensive, wide excision of involved muscles Amputation of an extremity may be needed. Antibiotics: high dose penicillin is the preferred drug Supportive measures including - Intravenous infusions - Blood transfusions - - Close monitoring and follow up