Introduction
This topic covers two chronic specific infections that a surgeon may meet: tuberculosis (TB), where surgery is an adjunct to long-term chemotherapy, and actinomycosis, a rare chronic suppurative infection that is treated mainly with prolonged antibiotics plus surgical drainage. Both are granulomatous or suppurative processes that mimic malignancy and must be distinguished from other chronic lesions.
Tuberculosis: general aspects
Tuberculosis is caused by Mycobacterium tuberculosis, an acid-fast bacillus spread mainly by airborne droplets. Primary infection is usually contained by granulomas (tubercles with caseous necrosis). Disease develops when the infection reactivates or spreads haematogenously or lymphatically, most often to the lungs, lymph nodes, bones and joints, urinary tract, genital organs, and abdomen. Key pathogenic features for the exam are the caseous necrosis, the formation of cold abscesses without inflammatory signs, and the tendency to chronic sinus formation.
Indications for surgery in tuberculosis
Surgery is never the first-line treatment of TB. It is indicated when chemotherapy alone cannot control the disease or when a complication requires it:
- Diagnosis in doubt, when histological confirmation is needed
- Failure of medical therapy, or drug-resistant disease with a persistent cavity
- Massive or recurrent haemoptysis not controlled conservatively
- Bronchopleural fistula, empyema or a localised destroyed lung
- Spinal instability, neurological deficit or large paravertebral abscess
- Intestinal obstruction, perforation or fistula from abdominal TB