Typhoid fever and Brill's disease - Causes, symptoms and treatment. MF.

Typhus( historical, European, lousy, cosmopolitan, hungry, military, prison military fever, Brill's disease - all synonymous with typhus) is an acute anthroponic disease with a transmissive transmission mechanism caused by Rickettsia of Provachek, characterized by a cyclic course with predominant cardiovascular andnervous systems and rosaolous rashes on the skin, these symptoms flow to the background of a typical fever.

This disease has always been associated with socio-economic decline, wars, resettlement, etc. The term "typhus" was introduced by Hippocrates and means in translation from Greek - "smoke", "fog", "obscuration of consciousness" and used to refer to all states accompanied by confusion of consciousness.

Causes of infection with typhus

Like all rickettsiosis, typhus is very contagious and the patient becomes contagious from the time of rickettsia in the blood( last 2-3 days of the incubation period) and maintaining contagiousness throughout the febrile period, and after 7-8 daysfrom the normalization of temperature. The main carrier of rickettsia is the head, pubic and louse. Combing the skin in places of bite of lice, a person rubs their feces containing rickettsia - this is how the infection occurs.

Symptoms of typhus

Like all infectious diseases, typhus has periods of infection( incubation, initial, peak period and reconvalescence).

Incubation period

The incubation period is the time from the onset of the introduction of the pathogen, to the first signs of the disease. It lasts from 6 to 25 days, but on average 12-14 days. During this period, rickettsia, which got into the body through damaged skin( scratches, clefts, cracks, etc.), appear in the blood after 15 minutes, then penetrate into the endothelial cell( vascular cage), affecting mainly small vessels( capillaries, precapillaries,arthritis and venules), where intensive reproduction and accumulation inside these cells occurs. This leads to further cell death as a result of swelling and desquamation. Death causes the release of rickettsias and some of them die, and some damage the vascular cells( new ones) again, and cell death occurs again, followed by the release of rickettsia in even greater numbers, and as soon as the amount reaches a certain concentration, the initial symptoms of the disease appear - the period of clinicalmanifestations.

But the damaging effect on blood vessels is exerted not only by the pathogens themselves, but also by the toxin, which exerts paralytic expansion and increases the permeability of the vascular wall with the development of diffuse hyperemia. In the future, a destructive-proliferative vasculitis is formed, that is, a functional shift is formed with a violation of nutrition and gas exchange, hemodynamic disorders and water-electrolyte balance. In turn, the violation of permeability leads to a violation of the protein ratio in organs and tissues - it is diagnosed by a decrease in the total protein in the blood and a systemic metabolic disorder, which forms a vicious circle, since the disturbed metabolism directly and indirectly damages the vascular endothelium, releasing rickettsia.

Initial period of clinical manifestations of typhus

The initial period of clinical manifestations is considered from the time of fever to the development of the rash, this period lasts 4-5 days. The onset is acute, with a rise in temperature in the first 2 days to its maximum values, general toxication symptoms join in the form of a decrease in appetite, hypodynamia, general malaise, anxiety, irritability, refusal to eat, and on the third and fourth day of the disease specific manifestations can be detected.

At the forefront hemodynamic disorders( from the cardiovascular system):

• characteristic appearance of the patient in the form of puffiness and hyperemia of the face, as well as conjunctiva( injection of sclera vessels);
• the appearance of point petechiae on the mucous membranes of the soft palate, tongue and anterior palatine arch;
• positive symptom pinch - after a slight tweaking on the skin remain hemorrhages;
• decreased diastolic blood pressure due to impaired venous return, and then a fall in systemic blood pressure;
• Acute myocarditis with a lesion of the conductor system, which is manifested by a feeling of palpitations and irregular heartbeats, pains of a different nature and intensity;
• Reddening of the skin of the face, neck, upper body and mucous membranes of the conjunctiva / sclera / soft and hard palate - due to paralytic vascular damage by toxin and affecting the upper and middle cervical sympathetic nodes.
• Moderate, and then pronounced tachycardia - is the result of compensatory response to the deposition of blood and vasodilation.

Symptoms on the part of the central nervous system are often recorded motor disorders, and their specificity depends on the site of the lesion:

• Govorov-Godelie symptom( difficulty in protruding tongue from the tongue), and / or deviation of the tongue( tongue deflection when protruding from the middleline) - this occurs when the medulla oblongata is affected;
• meningeal signs - due to destructive changes there is a specific non-disseminated disseminated meningoencephalitis;
• in case of defeat of the striapolar system - a mask-like face, a consequence of hypomymia or amy- mia;
• with encephalitis - violation of articulation( dysarthria), swallowing( dysphagia), mild nystagmus, sudden violation of breathing, falling blood pressure, rhythmic small trembling of the tongue / lips / fingers. If changes from the side of the central nervous system are registered already from the first days of the disease - it is diagnosed unfavorably.

On the part of the respiratory system:

• rhinitis is manifested by nasal congestion and abundant discharge;• laryngitis and tracheobronchitis - hoarse voice, sore throat, dry cough.

From the side of the urinary system: pain in the lower back and a decrease in the amount of urine being separated;With an additional examination - a positive symptom of Pasternatsky( pain in the lumbar region with effleurage).Violation of urination of central genesis, rather than peripheral.

On the part of the digestive tract, impairments of peristalsis are observed in the form of spastic or atonic constipation and flatulence.

The period of swelling of typhus

The swelling period lasts 4-10 days and is considered from the moment of rash appearance to the normalization of temperature.

Features of rash with typhus

The first place of localization - in the area of ​​the clavicle, lateral surfaces of the trunk, in the axillae - then the rash spreads to the abdomen, chest, hips and limbs.

The rash is truly polymorphic, i.e. on the same part of the body, the different nature of the rash is revealed - roseola and petechiae are pale red, their sizes are from 1-10 mm, the boundaries are clear, but sometimes the jagged edges are observed. First, roseoles are formed( they can disappear for a while, and then reappear for a while), and after 2-3 days they turn into petechiae due to rupture of the walls of small vessels. But the roseola can end its existence without turning into petechia, and gradually turning pale they become yellow, and then completely disappear - this occurs on the 4th day from the beginning of their appearance. Petechia also disappear on the 4th day, becoming bluish-violet, then yellowish, leaving pigmentation for 5 days( sometimes more).

From the side of the central nervous system: severe painful headache, symptoms of the initial period is increasing, signs of damage to the peripheral nervous system appear: neuritis, neuralgia, polyradiculoneuritis, plexitis. But most often polyradiculitis, which manifests itself in the form of pain syndrome with pressure on the course of the corresponding nerves and muscles. Also trophic changes of tissues are frequent - quickly formed bedsores, trophic ulcers, catarrhal-ulcerous changes on the mucous membrane of the larynx, etc. Most often there are neuritis of the ulnar, axillary, humerus, peroneal, and sciatic nerves. The defeat of the auditory nerve can lead to a one-sided loss of hearing, and with damage to the nuclei of the auditory nerve - complete deafness. When the vestibular apparatus is affected, dizziness, spontaneous nystagmus, is observed. Changes in the form of pupil deformation, pupillary reflex reflexes, anisocoria - speak of a lesion of the optic nerve. During this period, pathological reflexes( Gordon, Oppenheim, Marinescu-Radovici) and general tremor appear.

The defeat of the autonomic nervous system is characterized by a frequent change of completely opposite signs due to the phasic response of rickettsial intoxication, and this manifests itself in the following: excitation is quickly replaced by inhibition, hyperemia of the face - pallor, tachycardia - bradycardia( pulse then frequent, then weak), and t. Features of the temperature curve - rises in the first days to 39-40 ° C, and on days 4-5 and 9-10 starts to decrease for several hours, and then again returns to its original position, and only on day 14 it goes on a slow but constant decline.

From the side of the urinary system - the defeat of the central genesis is manifested by a delay in urination or involuntary urination.

On the part of the digestive system - hepatosplenomegaly( enlarged liver and spleen), with jaundice of palmar and plantar surfaces, but not due to a violation of pigmental metabolism, but because of carotene, therefore the skin and sclera remain unchanged, and urobilin with bile pigments is notare determined.

Stage of convalescence

The stage of reconvalescence is a clinical recovery lasting 2-3 weeks. This stage begins with a slow but steady decrease in temperature on Day 14 from the onset of the disease. In addition to the temperature drop, all the symptoms come to naught.

Depending on rickettsiaemia and toxemia, the degree of severity of the disease will depend: mild, moderate, severe and abortive.

Diagnosis of typhus

1.General clinical methods of investigation:

- changes in UAC are dependent on the severity of the disease course, but leukopenia with lymphocytosis remains unchanged( but leukocytosis is possible in the middle of the disease), giant granulocytes, Türk cells appear,moderately increased ESR( 20-30 mm / h), by the end of the febrile period - anemia with poikilocytosis.
- the color changes and density increase( 1030 and more), aluinuria and cylindruria occur in the OAMS and the hematuria
at the height of the fever period. - The analysis of the cerebrospinal fluid shows only the lymphocyte cytosis
. - Biochemical methods of investigation indicate only the severity of intoxication in the form of metabolic acidosis, residual nitrogen and creatinine, a change in the sugar level is possible in any direction( both decrease and increase), a decrease in the total amount of protein, the albumin and globule ratios are violatednew in favor of the latter.

2. Additional diagnostic methods are the monitoring of a separate organ system: ECG study in dynamics, ultrasound, EEG, lung radiography, consultation of other specialists - all according to the indications.

3. Specific Diagnosis - Serological Test Methods:

The Weil-Felix reaction helps to identify antibodies to Procatch's rickettsia, this is one of the leading reactions, but its main disadvantages are late diagnosis( at the end of the second week) and cross-sensitivity to other rickettsia.

RSK( complement fixation reaction) is a specific, highly sensitive diagnostic method, it also helps to detect antibodies, but from the 5th-7th day of the disease( in 60% of patients), and for 2 weeks of the disease - in 100%.

RNGA( indirect haemagglutination reaction) is a reaction that gives a qualitative and quantitative determination of antigens and antibodies. It becomes positive already from 3-4 days of the disease.

ELISA( Enzyme Immunoassay) - allows to determine specific antibodies of class G and M, so if IgM is determined - they say about fresh infections, if an increase in IgG is determined - they say about Brill's disease( it will be described below), but if IgG remain in high ranges indifferent terms - this indicates a transferred disease.

Treating typhus

Treatment consists of observing bed rest, complete rest and sparing diet, etiotropic, pathogenetic and symptomatic therapy is also prescribed. Etiotropic treatment - preparations of tetracycline series( tetracycline, metacycline, aureomycin, chlorotetracycline, terramycin, oletetrin, oxytetracycline, morphocycline, doxycycline).But even drugs from the same group can have varying degrees of effectiveness, so the approach in the appointment should be differentiated. Most often the drug of choice is doxycycline, because on its background the temperature drop comes already on day 3, and the severity of typhoid status also decreases.

Antibiotic therapy is prescribed throughout the febrile period and 3 more days after the normalization of temperature. If there is intolerance to tetracyclines, you can use reserve drugs - levomitsetin, rifampicin, erythromycin.

Pathogenetic treatment aims to reduce intoxication and eliminate cardiovascular and nervous system disorders. So adrenaline, caffeine, norepinephrine and epinephrine are used to prevent the decrease in the arterial pressure, but these drugs are only in the intensive care units, so patients are necessarily hospitalized so that with the progressive drop in pressure, the above mentioned drugs should be urgently applied.

Because of the damaging effect of histamine, antihistamines such as tavegil, diazolin, etc. are prescribed. When developing thrombophlebitis and thrombosis appoint anticoagulants from the first days of the disease, and often the drug of choice is heparin.

Symptomatic treatment is prescribed depending on the prevailing symptoms.

The discharge is carried out no earlier than 12 days from the normalization of temperature and with a positive dynamics from the laboratory diagnosis. Complications of typhus

Complications are associated with vascular disorders leading to collapse, thrombosis, thrombophlebitis, thromboembolism and, as a consequence, bedsore, gangrene, ischemic strokes, hemiplegia and hemiparesis, intestinal bleeding. Regardless of the degree of blood supply, frequent attachment of secondary infections.

Brill's disease

This disease occurs only in people who have recovered from typhus, ie as a result of endogenous relapses, so the symptoms are identical to typhus, but proceed in a more mild form. Relapses are recorded even after 20-30 years.

Unlike typhus, there is no correlation between individual cases of the disease, there is no participation of carriers( lice), there is no seasonality, it is not possible to determine the duration of the incubation period, since it is an endogenous relapse, ie the causative agent is in the patient's body for a long time,but in a latent state.

There are no "incisions" in the temperature curve, in contrast to the typhoid temperature curve, which is characterized by sharp daily temperature drops 2-3 times for the entire feverish period lasting an average of 14 days. Less formed granulomas in the vessels of the brain. The duration of the febrile period is reduced by 2 times and lasts not 12-15 days, but 6-12

. The disease is much easier and the methods of diagnosis are the same, but the Weil-Felix reaction remains negative, therefore the diagnosis should always be carried out in conjunction with other serological reactions(RSA, RSK, RNGA, IFA)

Prevention of typhus

Nonspecific prevention consists in isolating the patient and conducting disinfestation in the foci of infection, and contacting persons should daily measure their temperature within 25days and with its increase urgently to address to the doctor.

Specific prophylaxis is the use of a chemical typosotype vaccine - it is a purified antigen from Rickettsia Provacek( subcutaneously 0.5 ml once).In the foci of typhus, emergency chemoprophylaxis is carried out by administering doxycycline 0.1 g once a day, or rifampicin 0.3 g 2 times a day, or tetracycline 0.5 g 3 times in knocking - these drugs are used for 10 days.

Other rickettsiosis for clinical manifestations, complications and treatment are identical to typhus, but there are some features discussed in the relevant articles.

Therapist doctor Shabanova I.Е.