Currently there is a trend towards an increase in chronic bacterial and viral diseases, which are characterized by multiple recurrences and low efficiency of antibacterial and symptomatic therapy. One such disease is chronic recurrent furunculosis. A boil develops as a result of acute purulent-necrotic inflammation of the hair follicle and the surrounding tissues. Generally, the boil is a complication of osteo folliculitis staphylococcal etiology. Boils can occur as single or multiple (called boils).
In case of recurrence of boils diagnosed chronic recurrent furunculosis. Typically, it is characterized by frequent relapses, a long, slow exacerbations, tolerant of antibacterial therapy. Depending on the number of boils, the prevalence and severity of the inflammatory process with abrasions classified by severity.
Severe furunculosis: metastatic, multiple, continuously recurrent small lesions with mild local inflammatory reaction, not or slightly palpable as determined by the regional lymph nodes. Severe furunculosis is accompanied by symptoms of intoxication: weakness, headache, decreased performance, increased body temperature, sweating.
The average severity of boils— single or multiple boils large size, flowing with a rapid inflammatory response, relapses from 1 to 3 times a year. Sometimes accompanied by an increase in regional lymph nodes, limpaphayom, short-term fever and minor signs of intoxication.
Easy severity of boils— single boils, accompanied by a moderate inflammatory reaction, with relapses from 1 to 2 times a year, well palpable regional lymph nodes, without any symptoms of intoxication.
Most often patients suffering from furunculosis, receive treatment from surgeons at best outpatient im a blood analysis on sugar, autohemotherapy, some prescribed and immunomodulating drugs without the preliminary examination, and in most cases they do not receive a positive outcome from the therapy. The purpose of our article is to share the experience of patients with chronic furunculosis.
Causes of boils (recurrent furunculosis)
The main etiological factor of chronic furunculosis is considered to be Staphylococcus aureus, which occurs, according to various sources, 60-97% of cases. Less acne is caused by other microorganisms of the epidermis Staphylococcus (previously considered apatogennye), streptococci of groups A and b and other types of bacteria. Described outbreak furunculosis of the lower extremities in 110 patients who were patients of the same pedicure salon. The causative agent of this outbreak was Mycobacterium fortuitium, and this microorganism was found in the baths for the feet, used in the salon. In most cases HRF from purulent foci are sown antibiotic-resistant strains of Staphylococcus aureus. According to N. M. Kalinina St. aureus in 89.5% of cases resistant to penicillin and ampicillin, at 18.7% were resistant to erythromycin and in 93% of cases sensitive to cloxacillin, cephalexin and cotrimoxazole. In recent years there has been fairly wide spread of methicillin-resistant strains of this microorganism (up to 25% of patients). According to foreign literature, the presence of skin or on the mucous membrane of the nose pathogenic strain St. aureus is considered an important factor in the development of the disease.
Chronic furunculosis is a complex and still poorly understood pathogenesis. It is established that the debut and further recurrence of the disease is due to a number of endo – and exogenous factors, among which the most important ones are the violation of the barrier function of the skin, pathology of the gastrointestinal tract, endocrine and urinary systems, the presence of foci of chronic infections of various localization. According to research, chronic infections of various localization detected in 75-99,7% of patients with chronic furunculosis. Most common chronic infections of ENT-organs (chronic tonsillitis, chronic sinusitis, chronic pharyngitis), intestinal dysbiosis with increased content of coccal forms.
In patients with chronic furunculosis pathology of the gastrointestinal tract (chronic gastroduodenitis, erosive bulbit, chronic cholecystitis) is defined in 48-91,7% of cases. I 39,7% of patients diagnosed pathology of endocrine system metabolic disorders of carbohydrates, the hormone producing thyroid and gonads. In 39.2% of patients with persistently current furunculosis has latent sensitization, 4.2% were clinical manifestations of sensitization to allergens of house dust, pollen of trees and grasses, in 11.1% — increased concentration of serum IgE.
Thus, for most patients with furunculosis characterized by multiple recurrences of the disease (41,3%) in severe and moderate severity of boils (88%) and prolonged exacerbation (14 to 21 days to 39.3%). In 99.7% of patients revealed chronic infections of various localization. In 39.2% of cases were determined latent sensitization to various allergens. The main causative agent is St. aureus.
In the occurrence and development of chronic furunculosis, along with the characteristics of the pathogen, pathogenic, virulent and invasive properties, presence of comorbidity, a big role for the disruption of normal functioning and interaction of various parts of the immune system. The immune system is designed to provide the biological identity of the organism and, as a result, the protective contact with infectious, genetically foreign agents, for various reasons, may fail, resulting in inadequate protection of the body from germs and is manifested in increased infectious morbidity.
Immune defense against bacteria-pathogens includes two interrelated components — innate (which are mostly nonspecific) and adaptive (characterized by high specificity for foreign antigens) to the immune system. The causative agent of furunculosis when injected into the skin causes a cascade of defense reactions.
In chronic furunculosis identify violations of almost all parts of the immune system. According to N. H. Sitdikova, 71.1% of patients with furunculosis had impaired phagocytic immunity, which was reflected in the decrease in intracellular bactericidal activity of neutrophils, the defects in the formation of reactive oxygen species. Defects leading to impaired migration of granulocytes, can lead to chronic bacterial infections, as demonstrated in their work Kalkman and co-authors in 2002. Defects recycling of pathogens inside the phagocytes can be caused different causes and can have serious consequences (for example, a defect of NADPH oxidase leads to incomplete phagocytosis and the development of appropriate severe clinical picture).
Low serum iron may may worsen the efficiency of oxidative killing of pathogens by neutrophils. Several authors showed a reduction in the total number of T-lymphocytes in the peripheral blood. As a rule, patients HRF reduced number of CD4-lymphocytes (in 20-50% of patients) and increased the number of CD8-lymphocytes (14-60,4% of patients).
In 26-35% of patients with chronic furunculosis, decreases the number of b-lymphocytes. When evaluating components of humoral immunity in patients with furunculosis revealed a variety of disimmunoglobulinemia. Most often there are lower levels of IgG and IgM. Decreased affinity of immunoglobulins in patients HRF, and correlation between the frequency of occurrence of this defect, stage and severity of disease. Severity of changes in laboratory parameters correlated with the severity of clinical symptoms of furunculosis.
From the above it follows that the changes of immune status in patients HRF are diverse in nature: 42.9% of the observed change in the subpopulation composition of lymphocytes, 71.1% of phagocytic and 59.5 per cent — of the humoral component of the immune system. Depending on the severity of the changes in the immune status of patients HRV can be divided into three groups: mild, moderate and severe, which correlates with the clinical course of the disease. For minor abrasions in the majority of patients (70%) indicators of immune status are within normal limits. When moderate-to-severe primarily revealed changes in phagocytic and humoral links of the immune system.
Diagnosis of chronic recurrent boils
Based on the above pathogenetic features of boils diagnostic algorithm should include the identification of foci of chronic infection, diagnosis, comorbidities, assessment of laboratory parameters of the immune system.
Mandatory laboratory research when symptoms of boils:
- clinical analysis of blood;
- blood chemistry (total protein, protein fractions, total bilirubin, urea, creatinine, transaminases AST, ALT);
- RW, HIV;
- a blood test for the presence of hepatitis b and C;
- sowing the contents boil on flora and sensitivity to antibiotics;
- glycemic profile;
- immunological examination (phagocytic index, spontaneous and induced chemiluminescence (CL), stimulation index (IP) luminol-dependent chemiluminescence LSHL), the bactericidal action of neutrophils, immunoglobulins A, M, G, affinity immunoglobulin);
- bacteriological examination of faeces;
- the analysis of a feces on eggs of worms;
- culture from the throat flora and fungi.
Additional laboratory research when symptoms of boils:
- determining the level of hormones thyroid (T3,T4, TSH, antibodies to TG);
- determining the level of sex hormones (estradiol, prolactin, progesterone);
- blood cultures for sterility triple;
- the urine culture (if indicated);
- seeding bile (according to indications);
- definition of basal secretion;
- immunological examination (subpopulations of T-lymphocytes, b-lymphocytes);
- total IgE.
Instrumental methods of examination for symptoms of boils:
- gastroscopy with the definition of basal secretion;
- Ultrasound examination of abdominal cavity;
- Thyroid ultrasound (if indicated);
- Ultrasound of female genital mutilation (indication);
- duodenal intubation;
- of respiratory function;
- roentgenography of organs of a thorax;
- radiography of the paranasal sinuses.
Expert advice on symptoms of boils: otolaryngologist, gynecologist, endocrinologist, surgeon, urologist.
Treatment of chronic recurrent boils
Tactics of treatment of patients with chronic recurrent furunculosis is determined by the stage of disease, concomitant diseases and immunological disorders. In the acute stage of boils requires local therapy in the treatment of boils antiseptic solution, antibiotic ointments, hypertonic solution; in the case of localization of boils in the head and neck or the presence of multiple furuncles — antibiotic therapy based on susceptibility. In any stage of the disease the necessary correction of the revealed pathology (sanitation foci of chronic infection, the treatment of gastrointestinal pathology, endocrine pathology, etc.).
In identifying patients with furunculosis latent sensitization or the presence of clinical manifestations of Allergy is necessary during the period of pollination to add to the treatment of antihistamines, to appoint a hypoallergenic diet, to carry out surgery premedication with steroid and antihistamines.
Recently in the complex therapy of patients with chronic furunculosis increasingly using drugs that have a corrective effect on the immune system. Indications for the prescription of immunomodulators depending on the dominant type of violations of the immune status and the extent of the disease. Thus, in the acute stage of chronic furunculosis recommended usage the following immunomodulators.
When there are changes phagocytic immunity appropriate designation of polyoxidonium on 6-12 mg intramuscularly for 6-12 days.
By reducing the affinity of immunoglobulins – Galavit 100 mg № 15 intramuscularly.
By reducing the level of b-lymphocytes, the violation of the ratio of CD4/CD8 decrease shows the use of mielopid 3 mg for 5 days intramuscularly.
By reducing the level of IgG against the backdrop of severe acute furunculosis, a failure in clinical application of Galavit used preparations of intravenous immunoglobulin (Octagam, gabrilove, Intraglobin).
During remission the following immunomodulators.
Polyoxidonium 6-12 mg intramuscularly within 6 to 12 days in the presence of changes of phagocytic immunity.
Licopid 10 mg for 10 days oral in the presence of defects in the formation of reactive oxygen species.
Galavit 100 mg number intramuscularly 15 – while reducing the affinity of immunoglobulins.
The administration of licopid it is also appropriate in low, continuously recurrent furunculosis. When persistent recurrence HRF on the background of changes of humoral immunity shows the prescription of intravenous immunoglobulin (Octagam, gabrilove, Intraglobin). In some cases, it is appropriate that the combined use of immunomodulatory drugs (eg, exacerbation of boils the appointment of polyoxidonium in the future, in case of any defects affinity of immunoglobulins, Galavit is added, etc.).
Despite considerable achievements in the field of clinical immunology, effective treatment of chronic furunculosis remains a challenge. In this regard, further study of pathogenetic features of this disease and develop new approaches to the treatment of chronic furunculosis.
In an ongoing search for new immunomodulatory drugs, which can have a positive impact on the course of inflammatory process with abrasions. Carry out clinical trials of new domestic immunomodulators, such as ceramic, the Neogene. Caramel is a synthetic analogue of endogenous immunoregulatory peptide — mielopeptide-3 (MP-3). Ceramic was applied in complex treatment of patients with furunculosis in the acute stage and in remission 5 mg No. 5 intramuscularly. After drug treatment showed normalization of the level of b-lymphocytes and a decrease in the level CD8-lymphocytes. Significant prolongation of remission of the disease (up to 12 months in 30% of patients).
The Neogene is a synthetic Tripeptide consisting of L-amino acid residue isolectin, glutamine and tryptophan. The Neogene was used as part of integrated therapies to patients with chronic furunculosis. Intramuscular injections of the Neogene was carried out on 1 ml of 0.01% solution of 1 times a day, every day, a course of 10 injections.
The use of the Neogene in the complex therapy of patients with chronic furunculosis in remission of the disease causes a reliable normalization of the initially modified immunological parameters (relative and absolute number of lymphocytes relative number of CD3+, CD8+, CD19+, CD16+lymphocytes, absorption capacity of monocytes to St. aureus) and the increase of spontaneous CL and affinity anti-ASPM antibody, the number of HLA-DR+-lymphocytes, and therefore allows to extend the period of remission compared to the control group.
Thus, it follows from the foregoing that the chronic furunculosis occurs under the influence of a complex set of etiological and pathogenetic factors and should not be regarded only as local inflammation. Patients with chronic furunculosis is necessary to conduct a comprehensive survey to identify possible foci of chronic infection, which are the source of septicemia and in violation of elimination of microbes in the blood by reducing the immunological reactivity of the organism lead to the occurrence of boils.
Since the purpose of immunokorrigiruyuschy drugs can cause exacerbation of the underlying disease, we believe that treatment of patients should start with the rehabilitation of the identified foci of infection. The appointment immunokorrigiruyuschy drugs should be treated individually, taking into account the stage of disease, presence of comorbidity and the type of immune defect. In identifying the patient sensitization to various allergens treatment of furunculosis should be carried out on the background of anti-allergic therapy.