Phlegmon

Phlegmon
Classification and external resources
ICD-10	Xxx.x
ICD-9-CM	xxx

Phlegmon is a spreading diffuse inflammatory process with formation of purulent exudate (pus). This is the result of acute purulent inflammation which may be related to bacterial infection, however the term 'phlegmon' mostly refers to a walled-off inflammatory mass without bacterial infection, one that may be palpable on physical examination.

An example would be phlegmon of diverticulitis. In this case a patient would present to the emergency department with left lower-quadrant abdominal tenderness, and the diagnosis of sigmoid diverticulitis would be high on the differential diagnosis, yet the best test to confirm it would be CT scan.^[1]

Another example, phlegmon affecting the spine, is known as spondylodiscitis and is associated with endplate destruction and loss of disc height. In adults, the bone marrow is affected first, while in children, the disease starts in the disc itself and spreads rapidly to the adjacent vertebral bodies. Phlegmon in the spine can be a diffuse enhancement, or localized abscess, (peripheral enhancement) in the epidural, subligamentous or paraspinous spaces. Under MRI examination, phlegmon will show dark with T1, and high signal (bright) with T2.

Signs and symptom

Systemic features of infection such as increased body temperature (up to 38-40 °C), general fatigue, chills, sweatings, headache, loss of appetite).

Inflammatory signs – dolor (localized pain), calor (increase local tissue temperature), rubor (skin redness/hyperemia), tumor (either clear or non-clear bordered tissue swelling), functio laesa (diminish affected function).

NB: severity of patient condition with phlegmons is directly proportional to the degree of intoxication level i.e. the more severe the condition, the higher the degree of intoxication level.

A noninfectious occurrence of phlegmon can be found in the acute pancreatitis of Systemic Lupus Erythematosus. The immunosuppressive aspects of this disease and the immunosuppressive medications used to treat it blunt each of the signs of infection.^[2]

Cause

Commonly by bacteria – streptococci, spore and non-spore forming anaerobes, etc.

Factors affecting the development of phlegmons are virulence of bacteria and immunity strength.

Classifications

1. By clinical course:
   • acute
   • subacute
2. By severity of condition:
   • mild
   • average
   • severe (with spreading to other location(s))
3. By location:
   • Superficial
     • cutaneous
     • subcutaneous
     • interstitial tissue
     • intramuscular
   • Deep
     • mediastinal
     • retroperitoneal
4. By etiology:
   • single
   • mix (e.g.:spore and non-spore forming anaerobes)
5. By pathogenesis:
   • per continuitatem (through neighbouring tissues)
   • hematogenous (through non-valvular veins like venous plexus of face e.g.: v. pterygoideus plexus → inflammation of veins (phlebitis) → thrombus formation in veins → embolization of thrombus into sinus venousus systems)
   • odontogenous
6. By exudative character:
   • purulent phlegmon
   • purulent-hemorrhagic phlegmon
   • putrefactive phlegmon
7. By presence of complications:
   • with complications (disturbance of mastication, ingestion, speech, cardiovascular and respiratory system, peritonitis, lymphadenitis, loss of conscious if very severe, etc.)
   • without complication

Diagnostics

1. Complaints and clinical appearances
2. Anamnesis
3. Visual and Palpations
4. Blood test – leukocytosis (up to 10-12×10⁹ /L), decrease or absence eosinophils level, shift of white count differential to the left (neutrophilia), increase ESR (up to 35–40 mm/h).
5. Urine test – presence of bacteria in urine, increase urinary leucocyte counts.
6. X-ray test
7. Ultrasound test

Treatments

The main goal of treatment is to remove the cause of the phlegmonous process in order to achieve effective treatment and prevention of recidives.

If the patient's condition is mild and signs of inflammatory process are present without signs of infiltrates, then conservative treatment with antibiotics is sufficient.

If the patient's condition is severe, however, immediate operation is usually necessary with application of drainage system. All of these are done under general anaesthesia. During operation, the cavity or place of phlegmonous process are washed with antiseptic, antibiotic solutions and proteolyic ferments.

In post-operative period, patients are treated with intravenous antibiotics, haemosorbtion, vitaminotherapy. Additionally, the use of i/v or i/m antistaphylococci γ-globulin or anatoxin can be taken as immunotherapy.

During operation of phlegmon dissection at any location, it is important:

1. to avoid spreading of pus during operation;
2. to take into account the cosmetic value of the operating site, especially when treating phlegmmonous process of the face; and
3. to avoid damaging nerves.

See also

• Cellulitis

References

1. Sabiston textbook of surgery board review, 7th edition. Chapter 44 colon and rectum, question 3
2. Lalani TA, Kanne JP. “Imaging Findings in Systemic Lupus Erythematosus.” RadioGraphics, July 2004. 24,1069-1086. PMID 15256629.