Septicaemia (Bacterial

Sepsis) and TB
Lymphadenitis
Prepared by:
Dr. Zacharia J.Z. Toyi
Learning Objectives
By the end of this session, students are expected to be able to:
Describe aetiology septicaemia and tuberculous lymphadenitis
Discuss clinical features of septicaemia and tuberculous
lymphadenitis
Describe management of septicaemia and tuberculous lymphadenitis
Definition, Aetiology, Pathophysiology and
Epidemiology of Septicemia
Introduction
Septicemia is defined as presence of microbes or their toxins in
blood. It refers to the active multiplication of bacteria in the
bloodstream usually with the production of severe systemic
symptoms such as fever and hypotension.
Bacteraemia is the presence of bacteria in blood, as evidenced by
positive blood cultures.
Septicemia has an extremely high mortality and demand immediate
attention.
Sepsis is a clinical term used to describe symptomatic bacteremia,
with or without organ dysfunction.
Sustained bacteremia, in contrast to transient bacteremia, may result
in a sustained febrile response that may be associated with organ
dysfunction.
Pathophysiology
The pathophysiology of sepsis is complex and results from the effects
of circulating bacterial products, mediated by cytokine release,
caused by sustained bacteremia.
Cytokines, previously termed endotoxins, are responsible for the
clinically observable effects of the bacteremia in the host.
Impaired pulmonary, hepatic, or renal function may result from
excessive cytokine release during the septic process.
Epidemiology
Sepsis is a common cause of mortality and morbidity worldwide.
The prognosis of sepsis depends on the underlying status and host
defenses, prompt and adequate surgical drainage of abscesses, relief
of any obstruction of the intestinal or urinary tract, and appropriate
and early empiric antimicrobial therapy with the drug spectrum
appropriate to the presumed septic source.
Sepsis does not appear to have a racial or sex predisposition.
Elderly men are more likely to develop urosepsis due to benign
urinary tract obstruction caused by prostatic hypertrophy.
Aetiology
Sepsis or septic shock may be associated with the direct introduction
of microbes into the bloodstream via intravenous infusion (e.g.,
intravenous line, other device-associated infections).
An intra-abdominal or pelvic structure may be perforated,
compromised, or ruptured.
Bacteremia due to bacteruria (urosepsis) may complicate cystitis in
compromised hosts
Intrarenal infection (pyelonephritis), renal abscess (intrarenal or
extrarenal), acute prostatitis, or prostatic abscess may cause urosepsis
in immunocompetent hosts.
Sepsis may be caused by overwhelming pneumococcal infection in
patients with impaired or absent splenic function.
Meningococcemia from a respiratory source may also result in sepsis,
with or without associated meningitis.
 Causes of Septicaemia in a Previously
Healthy Adult
Site of Origin Usual Pathogen(s)

Skin Staphylococcal aureus and other gram

positive cocci

Urinary Tract Escherichia coli and other aerobic gram

negative rods

Respiratory tract Streptococcal pneumoniae

Gallbladder or bowel Streptococcus faecalis, E. coli, other gram

negative rods and Bacteroides fragilis

Pelvic organs Neissseria gonorrheae and anaerobes

 Causes of Septicaemia in Hospitalized
Patients
Clinical Problem Usual Pathogens

Urinary catheter Escherichia coli, Klebsiella spp, Proteus spp.

Intravenous catheter Staphylococcua aureus and Staphococcus

epidermidis, Klebsiella spp, Pseudomonas
spp, Candida albicans
Peritoneal catheter Staphylococcus epidemidis

Post -surgery: wound infection Staphylococcus aureus, E. coli, anerobes

(depending on the site)

Burns Gram positive cocci, Pseudomonas spp,

Candida albicans

Immunocompromised patient Any of the above

Cardinal Features of Severe Septicemia
Fever
Rigors
Hypotension

Less Specific Features

Headache
Lethargy
Nervousness
Change in conscious level
Pulmonary oedema and adult respiratory distress syndrome
Disseminated intravascular coagulation (DIC)
Differential diagnosis
Refer session 16, figure 3
Investigations and Treatment of
Septicaemia
Very limited investigations can be done at the primary health care
facilities (dispensary & health centre) and therefore patients
suspected of having septicaemia should be referred to hospitals.
Laboratory Studies
Blood cultures
Blood cultures should be obtained in all patients upon admission to
demonstrate the organism responsible for infection.
Negative blood culture results are also necessary to include
pseudosepsis in the differential diagnoses.
Complete blood count (CBC) count is usually not helpful because of the
numerous conditions that mimic sepsis (e.g. pseudosepsis) and that
manifest as leukocytosis
Urine Gram stain, urinalysis, and urine culture if urosepsis is suspected.
Imaging Studies
Chest Radiography
Is important to rule out pneumonia and diagnose other causes of pulmonary
infiltrates.
Ultra-sonography
Abdominal ultrasonography may be performed if biliary tract obstruction is
suspected based on the clinical presentation.
Sonograms in patients with cholecystitis may show a thickened gallbladder wall or
biliary calculi with dilatation of the common bile duct. Stones in the biliary tract
are visible in patients with cholangitis, but the common bile duct is dilated.
Abdominal ultrasonography is suboptimal for the detection of abscesses or
perforated hollow organs.
Treatment
Few things can be done at the dispensary and health centre to
patients with septicaemia. Patients should be referred to hospital
immediately after resuscitation.
At dispensary or health centre, the following can be done before
referral.
I/V fluids, I/V Antibioctics (broad spectrum when available), Anti-
pyretics and monitoring of vital signs.
Manual provion of respiratory support (when in need)
Antimicrobial Therapy
Appropriate antimicrobial therapy depends on adequate coverage of
the resident flora of the organ system presumed to be the source of
the septic process.
Combination therapeutic agents include clindamycin or
metronidazole plus levofloxacin, or an aminoglycoside.
Complications
Peritonitis may result in abscesses, which may subsequently need to be
drained
Inadequate correction of intra-abdominal perforation or drainage
procedures may result in a continuance or relapse of the patient's septic
condition
Cardiopulmonary complications-septic shock
Renal complications-oliguria, azotaemia, proteinuria
Coagulopathy
Neurologic complications-polyneuropathy
Prognosis
The prognosis in most patients is good, except in those with intra-
abdominal or pelvic abscesses due to organ perforation.
The underlying physiologic condition of the host is the primary
determinant of outcome.
Early and appropriate empiric antimicrobial therapy and surgical
intervention are critical in decreasing mortality and morbidity.
 Introduction, Types and Aetiology of
Tuberculosis
Introduction
Tuberculosis is granulomatous disease of the lungs, although in up to
one-third of cases other organs are involved.
Is caused by bacteria belonging to the Mycobacterium tuberculosis
complex.
Types of Tuberculosis
Pulmonary
Extrapulmonary TB
Aetiology of Tuberculosis
The acid fast bacilli Mycobacterium tuberculosis
Other mycobacteria that may produce disease indistinguishable from
that include
Mycobacterium bovis
Mycobacterium kansasii
Mycobacterium avium
Mycobacterium intracellulae
 Definition and Epidemiology of TB
Lymphadenitis
TB Lymphadenitis: Is the inflammation and/or enlargement of a
lymph node in response to local, or generalized TB infections.
TB lymphadenitis may affect a single node or a localized group of
nodes (regional adenopathy) and may be unilateral or bilateral.
Epidemiology
TB lymphadenitis is the commonest presentation of extrapulmonary
tuberculosis (being documented in more than 25% of cases).
Lymph-node disease is particularly frequent among HIV-infected
patients.
Children and women seem to be especially susceptible.
 Clinical Features, Differential Diagnosis,
Investigations and Treatment of Lymphadenitis
Clinical Features
Lymph-node tuberculosis presents as painless swelling of the lymph
nodes most commonly at cervical and supraclavicular sites.
Lymph nodes are usually discrete in early disease but later become
matted together.
May be inflamed and have a fistulous tract draining caseous material
Systemic symptoms are usually limited to HIV-infected patients, and
concomitant lung disease may or may not be present. Others features
include
Sore throat
Cough
Fever
Night sweats
Fatigue
Weight loss
Investigations
Specific investigations are done at hospital level and some of the
capable health centres that can perform ZN stain as follows.
ZN stain of the aspirate (after fine-needle aspiration)
Acid fast bacilli (AFB) are seen in up to 50% of cases
Cultures of the aspirates are positive for AFB in 70 to 80%
Surgical biopsy for histologic examination shows granulomatous
lesions
In HIV-infected patients, granulomatous changes are usually not seen
CXR should be done to rule Pulmonary involvement
Other investigations that can be done include
FBP, ESR
Sputum for AFB (if there is history of Productive cough)
HIV test
Differential Diagnosis
Non-Hodgkin Lymphoma
Hodgkin Lymphoma
PGL (persistent generalized lymphadenopathy) in HIV positive
patients
Acute or Chronic Lymphocytic leukaemia
Rheumatoid arthritis
Treatment
Normally, TB lymphadenitis is treated as Tuberculosis Category III
(sputum negative & less severe extrapulmonary TB). The treatment
may be initiated at hospital following diagnosis and patient may
return to continue with treatment even at dispensary or health centre
where anti-TB drugs are available.
The National guideline for management of Tuberculosis and leprosy
should always be referred for proper treatment.