Local manifestations and signs of progression
The development of a purulent focus goes through two main stages, which are easily distinguished by palpation. In the infiltrative phase, the physician detects a dense and sharply painful formation. When the process transitions into the purulent phase (abscess formation stage), the tissue softens, and the characteristic sign of fluctuation appears—a sensation of fluid shifting (rippling) under the fingers.
If the infection is not localized, visible markers of its spread appear:
- Lymphangitis — red streaks on the skin along the lymphatic pathways.
- Lymphadenitis — painful induration of regional lymph nodes.
- Thrombophlebitis — the appearance of dense cord-like strands over superficial veins.
It is important to remember that the increase in local inflammatory changes always entails an intensification of the body's general intoxication. Patients often adopt a forced position: lying on the affected side, since turning to the healthy side increases pain and shortness of breath due to mediastinal shift.
General body response and intoxication syndrome
The severity of general symptoms depends on the size of the focus, its location, and the body's reactivity (in hyperergic reactions, changes are sharp; in weak reactions, they are barely noticeable). The patient's appearance can be quite characteristic: an earthy skin tone, sharp facial features (facies hippocratica), dry tongue with a dense gray or brown coating.
Key manifestations of endogenous toxicosis include:
- Central nervous system: from mild euphoria or lethargy to the development of intoxication delirium, psychosis, and loss of consciousness.
- Hemodynamics: persistent tachycardia, which in severe cases exceeds 130 beats per minute, and progressive decrease in blood pressure.
- Respiratory system: pronounced shortness of breath (more than 30 respiratory movements per minute).
- Excretory system: a decrease in urine output (oliguria) up to acute renal failure with anuria.
Rigors are frequently observed, followed by a hectic temperature spike and profuse sweating. Gastrointestinal function is impaired: appetite disappears, constipation occurs, and signs of hepatosplenomegaly (enlargement of the liver and spleen, jaundice of the sclera) develop.
Laboratory and instrumental diagnostics
Laboratory tests clearly reflect the severity of the purulent-destructive process:
- Clinical blood count: pronounced leukocytosis with a left shift (increase in band neutrophils, appearance of immature forms). Anemia rapidly develops (hemoglobin and erythrocytes drop) due to intoxication. ESR increases sharply and remains high for a long time.
- Biochemistry: pronounced dysproteinemia is observed—albumins decrease, while globulin fractions increase. In severe cases, total protein drops to 50–60 g/L. Acidosis develops.
- Urinalysis: low specific gravity, appearance of protein (proteinuria), casts, leukocytes, and bacteria.
- Microbiology: blood, pus, urine, and exudate cultures are performed to identify the pathogen and select antibiotic therapy.
The problem of "masked forms"
The classic picture of surgical infection is less common today due to the widespread use of antibiotics before hospitalization. Self-medication masks ("smooths out") symptoms: the patient may lack a high temperature, leukocytosis remains within normal limits, and the phenomena of toxicosis are mildly expressed.
Such a "neglected" course is especially dangerous for deeply located foci (for example, in purulent appendicitis, peritonitis, gallbladder empyema). Hidden inflammation greatly complicates diagnosis and requires comprehensive instrumental examination.
Diagnostic criteria and differentiation from sepsis
Diagnosis is based on identifying a discrepancy between local manifestations and the patient's severe general condition. Suspicion of process generalization arises if, after surgical opening and adequate drainage of the abscess, the condition does not improve.
Fundamental difference from sepsis: upon elimination of the primary purulent focus, the phenomena of endogenous toxicosis completely disappear (provided that irreversible changes have not yet formed in the organs).
The "SCISSORS" rule in diagnostics: if the pulse curve creeps up (tachycardia) and the temperature curve stays put or drops—look for severe purulent intoxication masking as apparent well-being.
Class and exam questions
How to distinguish the infiltration stage from abscess formation by palpation?
During infiltration, a dense and painful formation is palpated, while upon transition to the purulent phase, the focus softens and the fluctuation sign appears (a sensation of fluid shifting under the fingers).
What does the appearance of red streaks on the skin near a purulent wound indicate?
This is a classic sign of lymphangitis—inflammation of the lymphatic vessels. It indicates the progression and spread of infection beyond the primary focus.
How does severe purulent intoxication fundamentally differ from sepsis?
In purulent intoxication, radical elimination of the primary focus (opening, drainage) leads to the relief of toxicosis symptoms, whereas in true sepsis, the infectious process sustains itself.
What else to study on this topic
- Features of the course of severe septicopyemia and the development of toxic myocarditis
- Differential diagnosis of purulent pericarditis and left-sided exudative pleurisy
- Metastasis of purulent infection to the lungs and development of abscessing pneumonia
- Changes in the blood coagulation system and the risk of bleeding in endogenous toxicosis
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Other topics from the section "CHAPTER 11. SURGICAL INFECTION (PURULENT-INFLAMMATORY DISEASES)"
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