Furunculosis. Chronic recurrent furunculosis - Causes, symptoms and treatment. MF.

Currently, there is a tendency to increase chronic bacterial and viral diseases, which are characterized by continuously recurrent course and low effectiveness of antibacterial and symptomatic therapy. One of these diseases is chronic recurrent furunculosis. The furuncle develops as a result of acute purulent-necrotic inflammation of the hair follicle and surrounding tissues. As a rule, a furuncle is a complication of staphylococcal osteophiliculitis. Furuncles can occur either singly or multiply( the so-called furunculosis).

In case of recurrence of furunculosis, chronic recurrent furunculosis is diagnosed. As a rule, it is characterized by frequent relapses, prolonged, sluggish exacerbations, tolerant to ongoing antibiotic therapy. Depending on the number of boils, the prevalence and severity of the inflammatory process with furunculosis is classified by severity.

Severe degree of furunculosis: disseminated, multiple, continuously recurring small foci with weak local inflammatory response, not palpable or slightly defined regional lymph nodes. The severe course of furunculosis is accompanied by symptoms of general intoxication: weakness, headache, decreased efficiency, increased body temperature, sweating.

Medium severity of furunculosis - single or multiple boils of large size, flowing with a violent inflammatory reaction, with relapses from 1 to 3 times a year. Sometimes accompanied by an increase in regional lymph nodes, lymphangitis, a short-term increase in body temperature and minor signs of intoxication.

Easy severity of furunculosis - single furuncles, accompanied by a mild inflammatory reaction, with relapses from 1 to 2 times a year, well palpable regional lymph nodes, without intoxication.

Most often, patients suffering from furunculosis receive treatment from surgeons; at best, at an outpatient stage, they undergo blood sugar testing, autohemotherapy, some prescribe and immunomodulating drugs without a preliminary examination, and in most cases they do not get a positive result from the therapy. The purpose of our article is to share the experience of managing patients with chronic furunculosis.

Causes of furunculosis

The main etiological factor of chronic furunculosis is Staphylococcus aureus, which, according to various sources, occurs in 60-97% of cases. Less often furunculosis is caused by other microorganisms - epidermal staphylococcus( previously considered to be apatogenic), streptococci of groups A and B and other types of bacteria. An outbreak of furunculosis of lower extremities in 110 patients who were patients of the same pedicure salon is described. The causative agent of this outbreak was Mycobacterium fortuitium, and this microorganism was detected in the footbaths used in the salon. In most cases, CRF from purulent foci are sown antibiotic resistant strains of Staphylococcus aureus. According to NM Kalinina, St.aureus in 89.5% of cases is resistant to penicillin and ampicillin, in 18.7% - is resistant to erythromycin and in 93% of cases it is sensitive to cloxacillin, cephalexin and cotrimoxazole. In recent years there has been a fairly wide spread of methicillin-resistant strains of this microorganism( up to 25% of patients).According to foreign literature, the presence on the skin or mucous membrane of the pathogenic strain St.aureus is considered an important factor in the development of the disease.

Chronic furunculosis has a complex and still poorly understood pathogenesis. It is established that the debut and the further recurrence of the disease are caused by a number of endo- and exogenous factors, among which the most significant are the violation of the barrier function of the skin, the pathology of the gastrointestinal tract, endocrine and urinary systems, the presence of foci of chronic infection of different localization. According to the data of our studies, the centers of chronic infection of different localization are revealed in 75-99,7% of patients suffering from chronic furunculosis. The most common foci of chronic infection of the ENT organs( chronic tonsillitis, chronic sinusitis, chronic pharyngitis), intestinal dysbacteriosis with an increase in the content of coccal forms.

In patients with chronic furunculosis, the pathology of the gastrointestinal tract( chronic gastroduodenitis, erosive bulbitis, chronic cholecystitis) is defined in 48-91.7% of cases. In 39.7% of patients, the pathology of the endocrine system is diagnosed, which is represented by disorders in the metabolism of carbohydrates, the hormone-producing function of the thyroid and sex glands. In 39.2% of patients with persistent current furunculosis there is latent sensitization, 4.2% - clinical manifestations of sensitization to house dust allergens, pollen of trees and grasses, 11.1% have an increased concentration of serum IgE.Thus, for the majority of patients with furunculosis, the recurring course of the disease( 41.3%) with a severe and moderate severity of the course of furunculosis( 88%) and prolonged exacerbations( from 14 to 21 days - 39.3%) are characteristic. In 99.7% of patients, chronic foci of infection of different localization were identified. In 39.2% of cases latent sensitization to various allergens was determined. The main causative agent is St.aureus.

In the emergence and development of chronic furunculosis, along with the characteristics of the pathogen, its pathogenic, virulent and invasive properties, the presence of concomitant pathology, a major role is assigned to violations of the normal functioning and interaction of various parts of the immune system. The immune system, designed to ensure the biological individuality of the body and, as a consequence, fulfills a protective function in contact with infectious, genetically alien agents, can for various reasons lead to failure, which leads to a violation of the body's protection from microbes and manifests itself in an increased infectious morbidity.

Immune protection against pathogen bacteria includes two interrelated components - congenital( predominantly nonspecific) and adaptive( characterized by high specificity for foreign antigens) immunity. The causative agent of furunculosis upon entering the skin causes a "cascade" of protective reactions.

With chronic furunculosis, violations of virtually all parts of the immune system are detected. According to N. Kh. Setdikova, 71.1% of patients with furunculosis had violations of phagocytic immunity, which was reflected in a decrease in intracellular bactericidal activity of neutrophils, defects in the formation of active forms of oxygen. Defects leading to a disruption in the migration of granulocytes can lead to chronic bacterial infections, as demonstrated by Kalkman and co-authors in 2002. Defects in the utilization of pathogens within phagocytes can be due to various causes and have severe consequences( for example, the defect of NADPH oxidaseleads to unfinished phagocytosis and the development of a corresponding severe clinical picture).

Low serum iron levels may possibly cause a decrease in the effectiveness of the oxidative killing of pathogenic microorganisms by neutrophils. A number of authors showed a decrease in the total number of peripheral blood T-lymphocytes. As a rule, in patients with CRF, the number of CD4-lymphocytes( in 20-50% of patients) is decreased and the number of CD8-lymphocytes is increased( in 14-60.4% of patients).
In 26-35% of patients suffering from chronic furunculosis, the number of B-lymphocytes decreases. When assessing the components of humoral immunity in patients with furunculosis, various dissymunoglobulinemia are detected. The most common decrease in levels of IgG and IgM.There was a decrease in the affinity of immunoglobulins in patients with CRF, and a correlation was found between the incidence of this defect, the stage and severity of the disease. The severity of violations of laboratory indicators correlates with the severity of clinical manifestations of furunculosis.

It follows from the above that the changes in the immune status indices in patients with CRF are of a varied nature: 42.9% have a change in the subpopulation composition of lymphocytes, 71.1% have phagocytic and 59.5% have a humoral immune system. Depending on the severity of changes in the immune status of patients, CRP can be divided into three groups: mild, moderate and severe, which correlates with the clinical course of the disease. With a slight course of furunculosis in most patients( 70%), the immune status is within normal limits. With an average and severe degree, changes in the phagocytic and humoral parts of the immune system are mainly detected.

Diagnosis of chronic recurrent furunculosis

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

Mandatory laboratory examination for symptoms of furunculosis:

clinical blood test;
general urinalysis;
biochemical blood test( total protein, protein fractions, total bilirubin, urea, creatinine, transaminases - AST, ALT);
RW, HIV;
blood test for hepatitis B and C;
sowing the contents of the boil to the flora and sensitivity to antibiotics;
glycemic profile;
immunological examination( phagocytic index, spontaneous and induced chemiluminescence( CL), stimulation index( IC) of luminol-dependent chemiluminescence of LZHL), bactericidal neutrophils, immunoglobulins A, M, G, immunoglobulin affinity);
bacteriological study of faeces;
analysis of feces for eggs of worms;
sowing from throat to flora and mushrooms.

Additional laboratory test for symptoms of furunculosis:

determination of the level of thyroid hormones( T3, T4, TTG, AT to TG);
determination of the level of sex hormones( estradiol, prolactin, progesterone);
blood culture for sterility three times;
urine culture( according to indications);
bile seeding( according to indications);
determination of basal secretion;
immunological examination( subpopulations of T-lymphocytes, B-lymphocytes);
total IgE.

Instrumental examination methods for symptoms of furunculosis:

gastroscopy with determination of basal secretion;
ultrasound of the abdominal cavity;
ultrasound of the thyroid gland( according to indications);
ultrasound of female genital organs( according to indications);
duodenal sounding;
function of external respiration;
ECG;
chest radiography;
radiography of the paranasal sinuses.

Consultations of specialists with symptoms of furunculosis: otolaryngologist, gynecologist, endocrinologist, surgeon, urologist.

Treatment of chronic recurrent furunculosis

Tactics of treatment of patients with chronic recurrent furunculosis are determined by the stage of the disease, concomitant pathology and immunological disorders. In the acute stage of furunculosis, local therapy is required in the form of furuncles treatment with antiseptic solutions, antibacterial ointments, hypertonic solution;in the case of localization of boils in the head and neck or the presence of multiple furuncles - the conduct of antibiotic therapy, taking into account the sensitivity of the pathogen. In any stage of the disease, correction of the revealed pathology( sanation of foci of chronic infection, treatment of pathology of the gastrointestinal tract, endocrine pathology, etc.) is necessary.

When detecting patients with furunculosis latent sensitization or in the presence of clinical manifestations of allergy, it is necessary during the pollination period to add antihistamines to the treatment, prescribe a hypoallergenic diet, and perform surgical intervention with premedication with hormonal and antihistamine drugs.

Recently, in the complex therapy of patients with chronic furunculosis, drugs that have a corrective effect on the immune system are increasingly being used. Developed indications for the appointment of immunomodulators, depending on the dominant type of immune status disorders and the degree of disease. So, in the stage of exacerbation of chronic furunculosis, the following immunomodulators are recommended.

In the presence of changes in the phagocytic link of immunity, it is advisable to administer polyoxidonium at 6-12 mg intramuscularly for 6-12 days.
With a decrease in the affinity of immunoglobulins - galavit 100 mg No. 15 intramuscularly.
With lowering of B-lymphocyte count, violation of the CD4 / CD8 ratio towards the decrease, the use of myelopid 3 mg for 5 days intramuscularly is indicated.
When the level of IgG is reduced against a background of severe exacerbation of furunculosis, immunological globulin preparations are used for intravenous administration( octagam, gabriglobin, intraglobin).
During the remission period, the following immunomodulators can be administered.

Polyoxidonium 6-12 mg intramuscularly for 6-12 days - in the presence of changes in the phagocytic link of immunity.
Likopid 10 mg for 10 days orally - in the presence of defects in the formation of reactive oxygen species.
Galavit 100 mg No. 15 intramuscularly - with a decrease in the affinity of immunoglobulins.
The use of lycopase is also advisable with slow, continuously recurring furunculosis. With persistent recurrence of CRF against the background of changes in the humoral link of immunity, the appointment of immunoglobulin preparations for intravenous administration( octagam, gabriglobin, intraglobin) is indicated. In some cases, the combined use of immunomodulating drugs is advisable( for example, with aggravation of furunculosis, the administration of polyoxidonium is possible, in the future, if a defect in the affinity of immunoglobulins is detected, galavite is added, etc.).

Despite significant progress in the field of clinical immunology, the effective management of chronic furunculosis remains a challenge. In connection with this, further study of the pathogenetic features of this disease is required, as well as the development of new approaches to the treatment of chronic furunculosis.

At present, the search for new immunomodulating drugs that can have a positive effect on the course of the inflammatory process in the course of furunculosis continues. Clinical trials of new domestic immunomodulators, such as seramyl, Neogene, are conducted. Seramil is a synthetic analogue of the endogenous immunoregulatory peptide - myelopeptide-3( MP-3).Seramil was used as a part of complex treatment of patients with furunculosis both at the stage of exacerbation and in the remission stage of 5 mg No. 5 intramuscularly. After treatment, the drug was normalized B-lymphocyte levels, as well as a decrease in the level of CD8-lymphocytes. A significant lengthening of the remission period of the disease was revealed( up to 12 months in 30% of patients).

Neogene is a synthetic tripeptide consisting of L-amino acid residues of isoleucine, glutamine and tryptophan. Neogene was used as part of complex therapy conducted by a patient with chronic furunculosis. Intramuscular injections of the Neogene preparation were carried out on 1 ml of 0.01% solution once a day daily, the course - 10 injections.

The use of neogen in the complex therapy of patients with chronic furunculosis at the stage of remission of the disease causes a significant normalization of the initially changed immunological parameters( relative and absolute number of lymphocytes, relative amounts of CD3 +, CD8 +, CD19 +, CD16 + lymphocytes, monocyte absorbance relative to St. aureus) andan increase in the indices of spontaneous CL and the affinity of anti-OAD antibodies, the amount of HLA-DR + lymphocytes, and consequently, allows to prolong the period of remission of the disease in comparisonwith a control group.

Thus, it follows from the foregoing that chronic furunculosis proceeds under the influence of a complex complex of etiological and pathogenetic factors and it can not be considered only as a local inflammation. Patients with chronic furunculosis should conduct a comprehensive examination in order to identify possible foci of chronic infection, which are the source of septicemia, and when the elimination of microbes in the blood as a result of a decrease in the immunological reactivity of the body lead to the emergence of furuncles.

Since the appointment of immunocorrecting drugs may cause an exacerbation of the underlying disease, we believe that the treatment of patients must begin with the rehabilitation of identified foci of infection. The question of the appointment of immunocorrecting drugs should be addressed individually, taking into account the stage of the disease, the presence of concomitant pathology and the type of immunological defect. If the patient is sensitized to different allergens, the treatment of furunculosis should be performed against the background of anti-allergic therapy.