Chronic Infections

Acknowledgment:

Govind Narain Malaviya was the main contributor to the section on leprosy. He was a leader in surgery for Hansen disease in the world and has now retired. I am thankful to Dr. Malaviya for his great contribution to this chapter and dedicate the leprosy section to his legacy.

General Principles

Chronic infections of the hand and upper extremity can be caused by a variety of agents: viruses, bacteria, mycobacteria, fungi, Prototheca , protozoa, parasites, and insects ( Table 3.1 ). An infection may be superficial and affect the skin or nails, or it may affect subcutaneous tissue, or it may be deep and affect the nerves, tenosynovium, joints, and bone. Chronic lesions of the hand, both superficial and deep, have a nonspecific presentation and early biopsy and cultures facilitate diagnosis. Early suspicion and diagnosis of a chronic infection is the mainstay of all ensuing treatment principles and is the primary message of this chapter.

TABLE 3.1

Etiology, Diagnosis, and Treatment of Chronic Infections of the Hand and Upper Extremity

	Organism	Predilection	Diagnosis	Chemotherapy
Bacteria	Actinobacillus actinomycetemcomitans	TS	Actinobacillosis	Ampicillin
	Actinomyces israelii	S, SC, J, B	Actinomycosis	Penicillin
	Bartonella henselae and Bartonella quintana	S	Bacillary angiomatosis/CSD	ERY
	Francisella tularensis	S	Tularemia	Streptomycin
	Nocardia species	S, SC, B	Mycetoma (actinomycetoma)	As per C&S
	Treponema pallidum	S, SC	Syphilis	Penicillin
	Treponema pertenue	S	Yaws	Penicillin
	Bacillus anthracis	S	Anthrax	Doxycycline
	Brucella	B, J	Brucellosis	RFM, TC
Fungi	Aspergillus	S, SC	Aspergillosis	AB, fluconazole
	Blastomyces dermatitidis	TS, B	Blastomycosis	AB, KTC
	Candida albicans	S, TS	Candidiasis	AB
	Coccidioides immitis	TS, J	Coccidioidomycosis	AB, miconazole
	Cryptococcus neoformans	TS	Cryptococcosis	AB
	Exophiala jeanselmei	Deep abscess	Chromohyphomycosis	None
	Histoplasma capsulatum	TS, J	Histoplasmosis	AB, KTC
	Madurella mycetomatis	S, SC	Mycetoma (eumycetoma)	As per C&S
	Rhizopus arrhizus	SC	Mucormycosis	AB
	Sporothrix schenckii	S, SC	Sporotrichosis	KTC, SSKI, AB
Mycobacterium leprae	M. leprae	N	Hansen disease	D, RFM, CFZ, ETH
Tuberculous mycobacteria	M. tuberculosis	S, TS, J, B	Typical tuberculosis	INH, RFM, ETH, PZA
Tuberculous mycobacteria	M. bovis	TS	Typical tuberculosis	INH, RFM, ETH, PZA
Nontuberculous mycobacteria	M. asiaticum	TS	Atypical tuberculosis	TC, CLAR
	M. avium (MAC or MAI)	SC, TS, J, B	Atypical tuberculosis	AZI, CLAR, ETH, RFB
	M. chelonae	TS	Atypical tuberculosis	AMK, ERY
	M. fortuitum	Deep abscess	Atypical tuberculosis	INH, RFM, MIN
	M. haemophilum	J	Atypical tuberculosis
	M. kansasii	S, TS, J, B	Atypical tuberculosis	INH, RFM
	M. marinum	S, TS, J, B	Atypical tuberculosis	RFM, TC, MIN, AMK
	M. malmoense	TS, J	Atypical tuberculosis	INH, RFM, ETH, PZA
	M. szulgai	TS, BU	Atypical tuberculosis	INH, RFM, ETH, PZA
	M. terrae	S, SC, T, J	Atypical tuberculosis	ETH, CYCLO
Parasites (worms)	Gnathostoma spinigerum	SC	Gnathostomiasis	None
Parasites (worms)	Onchocerca volvulus	TS	Onchocerciasis	None
Prototheca	Prototheca wickerhamii	S, TS	Protothecosis	AB, TC
Protozoa	Leishmania	S	Leishmaniasis	Antimony, AB
Mites	Sarcoptes scabiei	S	Scabies	Permethrin cream
Viruses	HIV	CD4 lymphocyte	AIDS	NRTI/PI
	HPV	S (epidermis)	Warts (verruca vulgaris)	Topical salicylic acid
	Herpes simplex virus	S	Herpetic whitlow	Acyclovir
	Orf (paravaccinia) virus	S	Orf/milker’s nodule	Cidofovir, imiquimod, idoxuridine cream

B , Bone; BU , bursa; C&S , culture and sensitivity; CSD , cat-scratch disease; J , joint; MAC , Mycobacterium avium complex; MAI , Mycobacterium avium-intracellulare ; N , nerve; S , skin; SC , subcutaneous; TS , tenosynovium.

Chemotherapeutic drugs are abbreviated as follows: AB , amphotericin B; AMK , amikacin; AZI , azithromycin; CFZ , clofazimine; CHL , chloromycetin; CLAR , clarithromycin; CYCLO , cycloserine; D , dapsone; ERY , erythromycin; ETH , ethambutol; GNT , gentamicin; INH , isoniazid; KTC , ketoconazole; MIN , minocycline; NRTI , nucleoside reverse transcriptase inhibitor; PI , protease inhibitor; PZA , pyrazinamide; RFB , rifabutin (Mycobutin); RFM , rifampin (Rifadin); SSKI , supersaturated solution of potassium iodide; Sulfa , sulfonamides; TC , tetracycline.

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