Furunculosis.Chronic recurrent furunculosis - Causes, Symptoms and Treatment .MF .

Currently, there is a tendency to an increase in chronic bacterial and viral diseases, which are characterized by continuously relapsing course and low efficiency of antibiotic and symptomatic therapy.One such disease is chronic recurrent furunculosis.Furuncle develops as a result of acute purulent necrotic inflammation of the hair follicle and the surrounding tissues.As a rule, the boil is a complication osteofollikulita staphylococcal etiology.Boils may occur as single or multiple (the so-called furunculosis).

In case of recurrence diagnosed chronic recurrent furunculosis furunculosis.Usually, it is characterized by frequent relapses, long, indolent relapses, tolerant of antibacterial therapy.Depending on the number of boils, the prevalence and severity of the inflammatory process is classified by severity with abrasions.

Severe boils: disseminated, multiple, continuous recurrent small pockets of weak local inflammatory response, no palpable or slightly determines the regional lymph nodes.Severe boi

ls accompanied by symptoms of intoxication: weakness, headache, decreased performance, increased body temperature, sweating.

moderate furunkuleza- single or multiple large boils that occur with violent inflammatory reaction, with relapses from 1 to 3 times a year.Sometimes it is accompanied by an increase in regional lymph nodes, lymphangitis, short-term fever and minor signs of intoxication.

mild furunkuleza- single boils, accompanied by a moderate inflammatory reaction, relapse of 1 to 2 times a year, well palpable regional lymph nodes, without the phenomena of intoxication.

Most often, patients suffering from boils, receiving treatment for surgeons, in the best case at the outpatient stage they performed blood tests for sugar, autohemotherapy, some appointed and immunomodulating medications without first conducting a survey and in most cases they do not get a positive result from holdingtherapy.The purpose of this article - to share experience of the management of patients with chronic furunculosis.

Causes boils

main etiological factor of chronic boils considered Staphylococcus aureus, which is found, according to various estimates, in 60-97% of cases.Less abrasions caused by other microorganisms - Staphylococcus epidermidis (earlier considered nonpathogenic), Streptococcus groups A and B, and other types of bacteria.Described outbreak of disease of the lower extremities boils in 110 patients, who were patients of the same pedicure salon.The causative agent of the outbreak was Mycobacterium fortuitium, wherein the microorganism has been identified in the foot bath used in the salon.In most cases, HRF from purulent foci sown antibiotic-resistant strains of Staphylococcus aureus.According to NM Kalinina, St.aureus in 89.5% of cases resistant to penicillin and ampicillin, 18.7% - and is resistant to erythromycin in 93% sensitive to cloxacillin, cephalexin and cotrimoxazole.In recent years there has been widely spread of methicillin-resistant strains of this organism (up to 25% of patients).According to foreign literature, the presence on the skin or nasal mucosa pathogenic strain St.aureus is considered an important factor in disease progression.

Chronic furunculosis is complex and still insufficiently studied pathogenesis.It was found that the debut and further recurrence of the disease are caused by a number of endogenous and exogenous factors, among which the most important are considered to be a violation of the barrier function of the skin, gastrointestinal tract pathology, endocrine and urinary systems, the presence of chronic foci of infection of various localization.According to the data of our research, chronic infection of various localization lesions detected in 75-99,7% of patients with chronic furunculosis.The most common lesions of chronic upper respiratory tract infections (chronic tonsillitis, chronic sinusitis, chronic pharyngitis), intestinal dysbiosis with increasing content of coccoid forms.

Patients with chronic furunculosis gastrointestinal pathology (chronic gastroduodenitis, erosive bulbit, chronic cholecystitis) is defined in 48-91,7% of cases.In 39.7% of patients diagnosed pathology of the endocrine system, provided impaired carbohydrate metabolism, hormone-producing function of the thyroid and gonads.In 39.2% of patients with persistently current furunculosis has latent sensitization, 4.2% - the clinical manifestations of sensitization to allergens from house dust, pollen of trees and grasses, at 11.1% - increased concentration of serum IgE.

Thus, for the majority of patients with boils characterized by continuously relapsing course of the disease (41.3%) with severe and moderate severity of abrasions (88%) and long-term acute (14 to 21 days - 39.3%).In 99.7% of patients had chronic foci of infection of various localization.In 39.2% of cases determined latent sensitization to various allergens.The main causative agent is St.aureus.

The occurrence and development of chronic boils, along with the features of the pathogen, its pathogenic, virulent and invasive properties, the presence of comorbidity, a large role is played by disruption of the normal functioning and interaction of different parts of the immune system.The immune system, designed to ensure the biological individuality of the body and, as a result, performs a protective function in contact with infectious, genetically alien agents, for various reasons, may fail, leading to a disruption of the body's protection against germs and is manifested in the increased incidence of infectious diseases.

immune defense against bacterial pathogens-includes two interrelated components - congenital (wearing mostly nonspecific) and adaptive (characterized by high specificity to foreign antigens) immunity.The causative agent of furunculosis in contact with the skin cause a "cascade" of defense reactions.

In chronic abrasions are detected violations of almost all parts of the immune system.According to N. H. Setdikova, 71.1% of patients had boils violation phagocytic immunity, which was reflected in a decrease in intracellular bactericidal neutrophil defects formation of reactive oxygen species.Defects leading to disruption of migration of granulocytes, can lead to chronic bacterial infections that demonstrated in the work Kalkman et al in 2002 g. defects in phagocyte utilization pathogens may be due to different reasons, and have serious consequences (for example, NADPH oxidase defectIt leads to incomplete phagocytosis and the development of appropriate severe clinical picture).

Low levels of serum iron, perhaps may contribute to the loss of efficiency of oxidative killing of pathogens by neutrophils.Several authors showed a reduction in the total number of T-lymphocytes in peripheral blood.As a rule, in patients with HRF reduced number of CD4-lymphocytes (in 20-50% of patients), and increased the number of CD8-lymphocytes (y 14-60,4% of patients).
In 26-35% of patients with chronic furunculosis, reduces the number of B-lymphocytes.In assessing the components of humoral immunity in patients with furunculosis identified various disimmunoglobulinemii.The most common reduction in levels of IgG and IgM.A decrease in the affinity of antibodies in patients with HRF, the correlation between the frequency of occurrence of the defect, the stage and severity of the disease.The severity of the disorders in laboratory parameters correlate with the severity of clinical manifestations of boils.

From the foregoing it follows that patients with HRF change the immune status are varied: from 42.9% observed changes in lymphocyte subpopulations, at 71.1% - phagocytic and 59.5% - humoral immune system.Depending on the severity of the changes in the indicators of the immune status of patients with HRF can be divided into three groups: light weight, medium and heavy currents, which correlates with the clinical course of the disease.In less severe boils, most patients (70%) of the immune status indicators are within normal limits.In moderate and severe changes are detected predominantly phagocytic and humoral immune system.

Diagnosis of chronic recurrent boils

Based on the above pathogenetic features boils diagnostic algorithm should include the identification of foci of chronic infection, diagnosis, comorbidities, evaluation of laboratory parameters of the immune system.

mandatory laboratory testing for symptoms of boils:

biochemical analysis of blood (total protein, protein fractions, total bilirubin, urea, creatinine, transaminase - AST, ALT);
blood test for hepatitis B and C;
crop contents boil on flora and sensitivity to antibiotics;
glycemic profile;
immunological examination (phagocytic index, spontaneous and induced chemiluminescence (CL), the stimulation index (SI) of luminol chemiluminescence LZHL) bactericidal of neutrophils, immunoglobulins A, M, G, affinity immunoglobulins);
bacteriological examination of faeces;
feces analysis on helminth eggs;
crop from fauces on flora and mushrooms.

Additional laboratory testing for symptoms of boils:

determine the level of thyroid hormones (T3, T4, TSH, antibodies to TG);
determine the level of sex hormones (estradiol, prolactin, progesterone);
blood cultures for sterility three times;
urine culture (by prescription);
crop of bile (if indicated);
definition of basal secretion;
immunological examination (a subpopulation of T-lymphocytes, B-lymphocytes);
total IgE.

Instrumental methods of examination for symptoms of boils:

gastroscopy with definition of basal secretion;
ultrasound of the abdomen;
thyroid ultrasound (if indicated);
ultrasound of female genital mutilation (if indicated);
duodenal intubation;
respiratory function;
chest X-ray;
radiography of the paranasal sinuses.

Specialist consultations for symptoms of boils: otolaryngologist, gynecologist, endocrinologist, surgeon, urologist.

Treatment of chronic recurrent boils

The treatment of patients with chronic recurrent furunculosis is determined by the stage of disease, concomitant diseases and immunological disorders.In the acute stage boils require local therapy in the form of boils treatment antiseptic solutions, antibacterial ointments, hypertonic solution;in the case of localization of boils in the head and neck, or the presence of multiple boils - antimicrobial therapy based on susceptibility.At any stage of the disease must be corrected revealed pathology (sanitation foci of chronic infection, the treatment of gastrointestinal diseases, endocrine disorders, and so on. D.).

In identifying patients with furunculosis latent sensitization, or in the presence of clinical manifestations of allergy must be between pollinatsii add to treatment antihistamines, assign hypoallergenic diet, carry out surgery with hormonal and premedication with antihistamines.

Recently, in the treatment of patients with chronic furunculosis are increasingly using drugs that have a corrective effect on the immune system.Indications to the appointment of immunomodulators according to the dominant type of disturbances of the immune status and extent of disease.Thus, in the acute stage of chronic boils recommended the use of these immunomodulators.

When there is a change of phagocytic immunity expedient appointment polyoxidonium 6-12 mg intramuscularly for 6-12 days.
By reducing the affinity of immunoglobulins - galavit number of 100 mg intramuscularly 15.
By reducing the level of B-lymphocytes violation CD4 / CD8 ratio is shown to decrease the use mielopida 3 mg over 5 days intramuscularly.
By reducing the level of IgG against the backdrop of a severe exacerbation boils in the clinical application of inefficiency galavita used immunoglobulin preparations for intravenous administration (Octagam, gabriglobin, Intraglobin).
In remission is possible to assign the following immunomodulators.

polioksidony 6-12 mg intramuscularly within 6-12 days - when there are changes of phagocytic immunity.
Likopid 10 mg orally for 10 days - in the presence of defects in the formation of reactive oxygen species.
Galavit 100 mg intramuscularly number 15 - with a decrease in the affinity of antibodies.
Application licopid advisable also at low intensity, continuously recurrent abrasions.When persistent recurrence HRF on the background of changes in humoral immunity shows the assignment of immunoglobulin preparations for intravenous administration (Octagam, gabriglobin, Intraglobin).In some cases, it is advisable to use a combination of immunomodulatory drugs (for example, at an exacerbation boils polyoxidonium possible appointment in the future, the detection of the defect affinity immunoglobulin added galavit and so. D.).

Despite the significant progress made in the field of clinical immunology, effective treatment of chronic boils is quite a challenge.In this regard it requires further study pathogenetic features of the disease, as well as the development of new approaches to the treatment of chronic furunculosis.

There is an ongoing search for new immunomodulatory drugs capable of exerting a positive influence on the course of the inflammatory process with abrasions.Clinical trials of new domestic immunomodulators, such as Seram, Neogene.Ceram is a synthetic analog of the endogenous immunoregulatory peptide - MYELOPEPTIDE-3 (MT-3).Seram was used in the complex treatment of patients with boils in the acute stage, and in the 5 mg intramuscularly number 5 remission.After drug treatment were observed normal levels of B-lymphocytes, and reduction of CD8-lymphocytes.There was a significant prolongation of disease remission (up to 12 months 30% of patients).

Neogen is a synthetic tripeptide composed of L-amino acid residues izoletsitina, tryptophan and glutamine.Neogen used in the complex therapy, conducted by patients with chronic furunculosis.Intramuscular injections of the drug were conducted Neogene to 1 ml of 0.01% solution of 1 times a day every day, the course - 10 injections.

Application of the Neogene in the treatment of patients with chronic furunculosis on the stage of disease remission is accurate normalization of initially modified immunological parameters (relative and absolute lymphocyte count, the relative number of CD3 +, CD8 +, CD19 +, CD16 + lymphocytes, the absorptive capacity of the monocytes towards St. aureus)and increased rates of spontaneous chemiluminescence and affinity of anti-DAO antibodies amount of HLA-DR + lymphocytes, and thus allows to extend the period of remission of the disease compared to the control group.

Thus, from the foregoing that the chronic furunculosis occurs under the influence of a complex set of etiological and pathogenetic factors and can not be considered only as a local inflammation.Patients with chronic furunculosis necessary to conduct a comprehensive survey to identify possible foci of chronic infection, which are the source of septicemia and, if not elimination of microbes in the blood as a result of reduction in immunological reactivity lead to the occurrence of boils.