UGLY FACE

From Big Medical Encyclopedia

UGLY FACE (erysipelas) the infectious disease which is characterized by a focal serous or serous and hemorrhagic inflammation of skin (mucous membranes), fever and intoxication.

The river was well-known to doctors of ancient India, Hippocrates, K. Galen. In 19 century of A. Trusso, and later N. I. Pirogov, I. Zemmeljveys, etc. considered R. as an infectious disease, is frequent as a wound fever.

The etiology

the Activator P, is Streptococcus pyogenes — a hemolitic streptococcus of group A (see. Streptococci ). For the first time it was allocated at an ugly face by V. V. Lukom-sky (1874 — 1876) and T. Billroth (1874). Feleyzen (F. Fehleisen, 1882) found a streptococcus in sites of an erysipelatous inflammation, in limf, vessels, hypodermic cellulose and surface layers of skin. These data were confirmed by R. Koch. On I. I. Mechnikov's observations, the greatest accumulations of a streptococcus often are located in a peripheral zone of an affected area. But if earlier the streptococcus was constantly found in sites of an erysipelatous inflammation of skin, then now it became a rarity that is caused, according to E. A. Galperin (1960), intensive use of antibiotics.

Etiol. the role of a streptococcus in R.'s emergence is experimentally confirmed by Feleyzen, Krom managed to cause a disease in rabbits. infecting them with the cultures of a streptococcus which are marked out from R. Zamecheno's patients also that R. often precede such acute streptococcal infections as, e.g. quinsy (see). Recurrent R. of the person and the heads is usually connected with existence of the centers of a persistent streptococcal infection — sinusitis, rhinitises. Streptococci of the same type are found in sick R. in slime of a pharynx and on an affected area of skin.

At sick R. usually from the first days of a disease the high level of anti-toxic immunity and a specific sensitization — a giperchuvstvptelnost of the slowed-down type is noted (see. Allergy ) to antigens of a streptococcus. According to V. L. Cherkasov (1963) and M. N. Smirnova (1971), at the beginning of a disease also raised antiserum capacities to extracellular products and enzymes of a streptococcus are observed. At the same time use of Bicillinum for the prevention of a recurrence of R. gives reliable effect, as well as at other streptococcal infections.

Etiol. the role in R.'s development of streptococci of group A is confirmed constantly and their increase at primary and repeated R. is long the observed raised antiserum capacities to O-streptolysin and enzymes of a streptococcus (hyaluronidase, Streptokinasa), and also; frequent detection at sick R. of antigens of a streptococcus in urine and blood (and treatment by penicillin leads to their disappearance); the raised antiserum capacities to polysaccharide of a streptococcus of group A (A-polysaccharide) at primary and repeated R.'s patients since the 2nd week of a disease, and at recurrent R.'s patients — from the first days and preservation of antibodies at one level for a long time; an orientation of these antibodies to the determinant of A-polysaccharide specific to streptococci of group A.

At the same time the streptococci belonging to the same types of group A can cause not only R., but also others patol. processes. At streptococcal infections development of this or that disease depends, apparently, not on features of the activator, and on character of an immune response on various antigens, infection atriums and other conditions defining reaction of an organism to a streptococcus. At the same time the possibility of existence of special streptococci of group A is not excluded — activators P.

Epidemiology

R. is observed in the form of sporadic cases, is widespread everywhere. According to M. G. Raskovalov (1970, 1973), R.'s incidence makes 12 — 20 on 10 thousand population.

A source of a contagium are patients with various streptococcal infections, and in particular R., and also carriers of streptococci. Activators are transferred in the basic through the hands contaminated by a streptococcus, linen, clothes, etc., also the airborne way of transfer is not excluded. Disease malokontagiozno. The general and local predisposition of an organism to this disease is of great importance. Nek-ry researchers are inclined to carry R. (in particular, recuring) to autoinfection when infection occurs in the endogenous way. It is noticed that more often R. arises at the people having persistent streptococcal infections, and infection occurs by lymphogenous and hematogenous dissimination of a streptococcus and, more rare, its direct penetration into skin and mucous membranes at microtraumas, cracks, attritions, etc.

the Pathogeny

For development of an erysipelatous inflammation happens not enough implementation of a streptococcus in skin or mucous membranes. There is a number of the associated diseases and factors promoting R. Eto's development, first of all, the centers of a persistent streptococcal infection, disturbance of venous and arterial circulation and a lymphokinesis, various diseases of skin, overcooling, overfatigue, etc. In a course of a disease factors cellular and humoral are of great importance immunity (see). So, decrease in immunity, a condition of hypersensitivity of the slowed-down type to a hemolitic streptococcus, reduction of activity of factors of nonspecific resistance lead to emergence of an erysipelatous inflammation.

It is impossible to exclude also the individual predisposition of an organism to the activator P. as which is genetically caused, and secondary, appeared as a result of a repeated sensitization of an organism to a hemolitic streptococcus.

A. I. Kortev and S. A. Kortev (1980) consider that in R.'s pathogeny undoubted value has emergence of autoallergens (see. Autoallergy ), in response to a cut are developed autoantibodies (see), capable to destroy healthy cells and thus to turn protective function of an organism into an autoaggression.

Development, generally in a derma, a serous or serous and hemorrhagic inflammation is characteristic of R. At the same time along with a large amount of the toxins and enzymes which are waste products and disintegration of streptococci and causing the phenomena of toxicosis and fever the produced many biologically active agents, especially get to a circulatory bed histamine (see). At a hyper histaminemia and decrease in processes of an inactivation of a histamine hemorrhagic forms P. and permanent disturbance of a lymphokinesis develop.

Microbic and allergic factors at an erysipelatous inflammation affect various links gipotalamo - pituitary and adrenal system that is the reason of glucocorticoid insufficiency. And it, in turn, aggravates a condition of an allergy of the slowed-down type to a hemolitic streptococcus. The described phenomena lead to weakening of processes of an inactivation of biologically active agents, permeability of fabric barriers increases.

Immunity after the postponed disease, as well as in most cases at streptococcal infections, does not arise. And it is the reason of repeated and recurrent forms P.

== Pathological anatomy == too On skin (is more rare on a mucous membrane of an oral cavity, a nose) sharply hyperemic center appears, to-ry quickly turns into the painful, red, dense, accurately delimited by the edges raised in the form of the roller erysipelatous plaque having gear outlines. Microscopically at an erythematic form P. the serous inflammation of a derma, preferential its reticular (mesh) layer and the subject cellulose is found. Serous exudate contains neutrophilic leukocytes and impurity of lymphocytes. The expressed plethora, hemorrhages, a lymphostasis, a vein thrombosis, hypostasis of fabrics are observed. Walls of vessels of an infiltrirovana granular leucocytes (granulocytes). Collagenic and elastic fibers bulk up. By means of coloring by Romanovsky's methods — Gimza and Gram it is possible to reveal the streptococci sometimes accumulating in fabrics and capillaries of the struck zone. In epidermis over this site desquamation and unsharp is noted parakeratosis (see).

At a significant amount of transparent-yellow serous exudate (see), accumulating under epidermis, bubbles of different size are formed. Sometimes exudate grows turbid owing to plentiful accumulation in it of neutrophilic leukocytes, bubbles turn into pustules. Exudate can have hemorrhagic character, sometimes with impurity of fibrin.

The recurrent R. which is repeatedly arising on the same site of skin leads to a sclerosis of a derma, hypodermic cellulose, disturbance of a lymphokinesis and the subsequent development elephantiasis (see).

At R. mucous membranes of bubbles are not formed, fabric is full-blooded, with the centers of a necrosis, is edematous.

In internals there can be dystrophic changes, a hyperplasia of a pulp of a spleen.

A clinical picture

On classification of R. offered by V. L. Cherkasov (1977) depending on the nature of local manifestations allocate erythematic, erythematic and hemorrhagic, erythematic and violent and violent and hemorrhagic forms P. On weight of a current distinguish easy, medium-weight and heavy R.; on the nature of prevalence of local manifestations — localized, wandering, metastatic (the centers of an inflammation remote from each other) R.; on primacy or frequency of development of process — primary, repeated (arising 2 years later and more after the previous disease), recuring (differing in continuous localization of local process and arising during the period from several days to 1 — 2 years after the previous disease).

Recurrent R. is more often (especially at persons of advanced and senile age) proceeds atypically — without the phenomena of the expressed intoxication, with the short period of fever. Preferential lower extremities while at primary R. process is localized, as a rule, on a face are surprised.

During a disease allocate 3 main periods: incubatory, erysipelatous inflammation, recovery. The incubation interval lasts from several hours to 3 — 5 days. Sometimes the course of a disease is preceded by a prodromal stage, but usually the disease begins sharply. Symptoms of intoxication — a headache, a fever, the general weakness prevail, body temperature increases to 39 — 40 °, nausea and vomiting are less often noted. Local manifestations arise along with symptoms of intoxication or several hours later, and sometimes and days after the beginning of a disease.

Fig. 1. A face of the patient at an erythematic form of an ugly face: sharp hypostasis, the dermahemia symmetrized in the form of wings of a butterfly with accurate outlines. Fig. 2. Sick erythematic form of an ugly face of an auricle: skin of an auricle is sharply edematous also a giperemprovana. Fig. 3. Person sick violent and hemorrhagic form of an ugly face: the numerous violent elements on skin of a forehead, a nose, cheeks and a chin containing hemorrhagic exudate. Fig. 4. Foot and a distal part of a shin at an erythematic form of an ugly face: a cutaneous dropsy and a hyperemia with a clear boundary. Fig. 5. Foot and a distal part of a shin at an erythematic and violent form of the ugly face complicated by a necrosis of skin: foot is edematous, epidermis on a big extent otsloyen, under it dark nekrotizirovanny sites of a derma are visible. Fig. 6. A distal part of a shin and stop at a recurrent erythematic ugly face: hypostasis, local hyperemia and infiltration of skin. Fig. 7. Distal department of a shin and a part of foot at a recurrent erythematic and violent ugly face: hypostasis and a dermahemia with the opened violent elements and otsloyenny epidermis. Fig. 8. Shin at the recurrent ugly face complicated by a lymphostasis, a necrosis of skin and hypodermic cellulose: the shin is increased in volume, her skin moderately of a giperemprovan, with a cyanotic shade, an infiltrirovana; the ulcer is visible irregular shape with it is purulent - necrotic imposings. Fig. 9. A hand at the recurrent ugly face complicated by a lymphostasis: the forearm and a brush are sharply increased in volume; a moderate dermahemia without clear boundary.

Accurately delimited hyperemia of an affected area of skin, hypostasis and infiltration is characteristic of an erythematic form P. (tsvetn. fig. 1, 2, 4, 6). Skin in the center of an inflammation hot to the touch, is strained, painful. Borders of the center have an appearance of teeth, tongues of flame.

At an erythematic and violent form P. against the background of an erythema in terms from several hours to 3 — 5 days there are bubbles (bulls) containing transparent, light serous liquid (tsvetn. fig. 5,7).

The erythematic and hemorrhagic form P. is characterized by emergence of hemorrhages against the background of an erythema, a fibrinous and hemorrhagic exudate of N of a bubble. Existence of bubbles is characteristic of a violent and hemorrhagic form P. (tsvetn. fig. 3).

At the uncomplicated course of a disease local manifestations of R. regress more slowly, than all-toxic. At an erythematic form the inflammation is stopped on 5 — the 7th day of a disease, and at erythematic and violent — on 10 — the 12th and later. After the postponed R. there are such residual phenomena as a peeling, pigmentation and pastosity of skin, formation of crusts on site of the disappeared bubbles.

On a face at an erythematic form P. the redness appears in a nose more often and is followed by hypostasis, an itch and burning, sometimes small pains. Reddening extends usually symmetrically in the form of wings of a butterfly (tsvetn. fig. 1). During the pressing by a finger the redness completely does not disappear. Regions of the hyperemic site are valikoobrazno raised and have scalloped outlines. In several hours, and sometimes in 1 — 2 day after the beginning of a disease painful increase regional limf, nodes appears. Inflammatory process can capture all person, extend to a pilar part of the head, a nape or a neck. At timely treatment hypostasis gradually disappears, the person takes a usual form. Abscesses (in the thickness of a century) or big accumulations of pus under skin of a pilar part of the head are in rare instances formed that sometimes leads to amotio of skin from the subject fabrics. If suppuration extends to hypodermic cellulose, development of phlegmon is possible. At a considerable tension of soft tissues, especially at the weakened patients and persons of senile age, gangrene can develop.

The erysipelatous inflammation usually passes to a trunk from the neighboring areas, often consistently occupies different sites of skin (the wandering, or migrating R.), can extend on all trunk. In this case the disease proceeds is longer and it is heavier.

The river of a mammary gland can arise as a complication mastitis (see). At the same time gangrene of tissue of mammary gland sometimes develops, and the subsequent scarring can lead to disturbance of its function.

At R. of a scrotum and a penis sometimes there comes the necrosis of fabrics, as a result to-rogo testicles can be naked, but then quickly become covered by granulations (the necrosis does not extend to fabric of a small egg). The subsequent long scarring leads to an atrophy of testicles.

On female generative organs and a crotch the erythematic form P. with quite expressed hypostasis is most often observed.

On extremities all forms P meet. More often than in other areas, the disease is complicated by phlegmon. On upper extremities the ugly face develops quite often against the background of the lymphostasis caused by the postponed radical mastectomy.

The erysipelatous inflammation of mucous membranes (is more often than a pharynx) usually arises initially, but sometimes process passes from the next fabrics. On a mucous membrane of a pharynx the intensive redness and sharply expressed phenomena come to light quinsies (see), sometimes followed by bulging, a necrosis and retropharyngeal abscess (see). From a mucous membrane of an oral cavity the erysipelatous inflammation can extend to face skin. At primary damage of a mucous membrane of a nose can develop rhinitis (see), proceeding with severe pains, high temperature, cervical lymphadenitis (see). The mucous membrane of a throat most often is surprised for the second time though in some cases erysipelatous laryngitis (see) can be primary. Danger of this defeat consists in a possibility of development of quickly accruing hypostasis throats (see).

Complications meet in 4 — 8% of cases. The erysipelatous inflammation can be complicated by development abscess (see), phlegmons (see), ulcers and necrosis of skin (tsvetn. fig. 5,8), suppurations of contents of bubbles, thrombophlebitis.

At persons of senile age and the weakened patients heavy pneumonia, a septic state can develop (see. Sepsis ).

Owing to obstruction and an obliteration limf, vessels there come disturbances of a lymph drainage (tsvetn. fig. 8,9) also arises lymphostasis (see). Growth of connecting fabric in hypodermic cellulose leads in elephantiasis. The lymphostasis and elephantiasis considerably meet at recurrent R. more often (on a nek-eye to data in 30% of cases) while at primary p repeated — in 7,3 and 5% of cases respectively.

The diagnosis

the Diagnosis is usually made on the basis of yielded the anamnesis and results of an objective research.

Specific lab. diagnostic methods are not developed. For the purpose of detection of a streptococcal infection definition of antibodies to O-streptolysin and hyaluronidase can be used.

Differential diagnosis is carried out with various eritema and dermatitis. Spots at an infectious erythema (see. Erythema infectious ) are painless and, as a rule, appear on extensor surfaces of extremities. Temperature increase at the same time insignificant or at all is absent.

Sites of defeat at R. shine, are painful, dense to the touch, the redness is not interrupted by sites of healthy skin and does not disappear during the pressing. regions of the hyperemic site of skin are sharply delimited from healthy skin and raised in the form of the roller that does not happen at eritema.

Acute eczema (see), followed by redness of the person, R. reminds, but at eczema process is taken from the very beginning by all person, redness imperceptibly, without sharp borders passes to healthy skin.

It is also necessary to differentiate an erysipelatous inflammation with abscess and phlegmon, phlebitis (see), thrombophlebitis (see - shingles (see. Herpes ), a nodular periarteritis (see. Periarteritis nodular ), erizipeloidy (see), skin form malignant anthrax (see).

Treatment

Treatment depends on a form of a disease, degree of intoxication and the nature of local manifestations.

In a complex to lay down. actions at R. takes the leading place anti-bnotikoterapiya. At primary and repeated R. with success apply penicillin (in a dose of 3 000 000 — 4 000 000 PIECES a day), ampicillin (2 — 3 g a day), tetracycline (to 1,5 g a day), Oletetrinum or Tetraolenum (to 2 g a day). Sick with recurrent R. appoint erythromycin, Oleandomycinum, Tetraolenum, lincomycin, and in nek-ry cases and antibiotics of group of cephalosporins. If R.'s recurrence arises often or the long course of a disease is noted, carry out a repeated course of treatment, surely changing an antibiotic. At the same time use semi-synthetic penicillin — Oxacillinum, Methicillinum, ampicillin. At intolerance of antibiotics good to lay down. drugs of a nitrofuran row or the combined drugs give effect (Bactrimum, bisepto l).

The importance in pathogenetic treatment of R. is attached to corticosteroids, to-rye are shown first of all to patients of youthful and middle age at recurrent R. with frequent aggravations and formation of a lymphostasis. The course dose of Prednisolonum makes 350 — 400 mg. It is necessary to avoid purpose of steroid hormones at abscesses and the phenomena of a necrosis, they are contraindicated and to patients of advanced age.

In a complex to lay down. actions at an ugly face usually include also hyposensibilizing means, biogenic stimulators (e.g., Prodigiosanum), autohemotherapy (see. To vitamins of group P. At hemorrhagic displays of a disease high doses ascorbic to - you, a routine are effective.

Broad application is found by physiotherapeutic methods of treatment of R., as in the acute period (UF-radiation, UVCh), and in the period of a rekov-valestsention (an electrophoresis of a lidaza, calcium chloride, radonic bathtubs, applications of ozokerite).

Topical treatment of R. has auxiliary value. In a stage of the acute phenomena it is not recommended to apply salve dressings. At an erythematic and violent form P. it is possible to be limited to opening of bubbles (without deleting otsloyenny epidermis) and imposing of a bandage with solutions of Furacilin or Rivanolum. At emergence of extensive erosion on site of bubbles apply bandages with polimiksinovy, sintomitsinovy, tetracycline ointments. Resort to operational treatment only in cases of development of abscesses, phlegmons, necroses; at the expressed hypostases sometimes make relief incisions.

In the subsequent, after recovery, the processes promoting R.'s emergence (chronic venous insufficiency, a lymphostasis, fungal infections of skin, the centers of a persistent streptococcal infection) are subject to obligatory treatment.

Forecast and Prevention

Forecast in most cases favorable. The lethality makes 0,2 — 0,5% p, as a rule, is caused by various complications. Repeatedly recurrent R. quite often leads to the progressing lymphostasis, and then elephantiasis, owing to a cut often there comes disability.

Prevention includes the actions directed to the prevention of transmission of infection from painful to surrounding persons. In medical institution isolation of patients is shown.

For prevention of a recurrence of R. it is necessary to recommend to the patient to preserve earlier affected areas of skin against impact of wind, a hot air, etc. The bitsillinoprofilaktika of a recurrence of R. is effective, as the indication to a cut serve a frequent recurrence, the considerable residual phenomena after the postponed primary and repeated R.

Rekomenduyetsya dispensary observation for the patients who transferred R. and suffering from her recurrence.

Mental disorders at an ugly face

Mental disorders at R. meet seldom and belong to to infectious psychoses (see). Emergence and their character depend on features of a current of R., expressiveness of local and somatic manifestations, and also localization of process. More often mental disturbances develop at an erysipelatous inflammation of the person and a pilar part of the head. The gipnagogichesky delirium is among the most typical mental disorders (see. Delirious syndrome ). At heavier, long current of an ugly face development is possible amental syndrome (see), the short-term hypomaniacal state with euphoria can precede Krom (see. Maniacal syndromes ). Psychoses have tranzitorny character. In process of improvement of a somatic state, before an absolute recovery, they can give way to the phenomena emotional giperesteticheskoy weaknesses (see. Symptomatic psychoses ). Hypochiondrial and depressive frustration sometimes join this symptomatology.

Mental disturbances at R. need to be differentiated with other mental diseases (schizophrenia, maniac-depressive psychosis), manifestation or an aggravation to-rykh can be provoked by an infection.

Treatment of psychoses at R., in addition to the actions directed to fight against a basic disease shall include use of sedatives, neuroleptics, nootropic means (nootropil, Aminalonum, Encephabolum), and also fortifying therapy.

The ugly face

the Ugly face at children occurs at children seldom. Aged about one year it proceeds heavier, than at children of more advanced age. The erythematic form of a disease is more often observed. Localization of process can be the most various. At girls the crotch, external genitals and buttocks quite often are surprised. Newborns entrance infection atriums can have a navel. At the same time the front abdominal wall is surprised. R.'s treatment at children same, as well as at adults. Forecast, as a rule, favorable.



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V. A. Ivanov, A.S. Yermolov; I. M. Lyampert (etiol.), V. L. Belyanin (stalemate. An.), M. A. Tsivilno (psikhiat.).

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