• Enterovirus and coronavirus infection in children symptoms

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    Enterovirus infection is a viral disease caused by a group of intestinal ECHO and Coxsackie viruses and is characterized by a variety of clinical manifestations, among which the leading place is occupied by intoxication, fever, diarrhea, myalgia and nervous system damage.

    Etiology. The causative agents of acute enterovirus diseases are non-poliomyelitis picornaviruses( family Picomaviridae, genus Enterovinis).There are 24 types of Coxsackie A virus and 6 types of Coxsackie B. Coxsacki viruses A and B differ in pathogenicity for mice. Group A viruses are highly virulent for newborn mice, cause severe myositis of skeletal musculature and death. Group B viruses cause less severe myositis, but at the same time cause damage to the nervous system, sometimes the pancreas, other internal organs. All types of group B and some types of group A are able to multiply in the culture of human embryonic cells, monkey kidneys, other cultures, exerting a pronounced cytopathogenic effect.

    In addition to 30 types of Coxsackie A and B viruses, 32 types of ECHO viruses and 4 types of enteroviruses( type 68-71) are well-cultivated in the culture of kidney cells of monkeys, types 68 and 69 are causative agents of intestinal diseases, type 70 is a causative agent of acute hemorrhagicconjunctivitis. Most serotypes of Coxsackie and ECHO viruses can cause disease in humans.

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    Coxsackie viruses are represented by two groups: the Coxsackie A group, which includes 23 serovariants( A1-A22, 4), and the Coxsackie group B, including six serovariants( B1-B6).Coxsackie viruses A and B cause a person to have lyomyelitis-like diseases, in 20-40% of patients under the age of 20, the infection is complicated by myocarditis. There is some connection between the serovariant of the virus and the nature of the clinical manifestations of the infection. Thus, the Coxsacki virus A16 causes damage to the mucous membrane of the mouth, paresis of the limbs, Coxsacki A24 - acute hemorrhagic conjunctivitis, Coxsaki from B1 to B5 - pericarditis, myocarditis and fulminant encephalomyocarditis. For the diagnosis of Coxsackie infection, serological methods are used - RSK, RTGA and neutralization reaction.
    The general properties of this group of viruses are small sizes of virus particles, 15-35 nm, magnesium ions have a stabilizing effect on them, are resistant to 70% alcohol, 5% lysine, to freezing. They are inactivated with 0.3% formalin solution, chlorine containing preparations with a chlorine content of 0.3-0.5 g / l, with heating at 56 ° C and above, with drying and ultraviolet irradiation. ECHO viruses are stable in the external environment, for a long time they remain viable in wastewater, in swimming pools, in open reservoirs, in milk, on vegetables, in faeces. The only owner and source of Coxsackie A and B viruses is a human.

    Sources of enterovirus infection are patients and virus carriers. An important role in the spread of infection is played by erased forms of the disease, as well as convalescent viruses that release feces into the environment for a long time. In the incidence of enterovirus infection, summer-autumn seasonality is clearly discernible. It should be noted that enteroviruses are significantly stable in the environment, for a long time they are found in sewage, swimming pool water, open water bodies, as well as in milk, bread and other food products.

    Children from 3 to 10 years old, mostly visiting children's institutions, are most often ill. Enterovirus infection in children's groups often occurs in the form of epidemic outbreaks, which have much in common with acute respiratory-viral diseases.

    Infection occurs by fecal-oral or airborne droplets. The probability of transmission is transplacental, which can lead to congenital malformations.

    The entrance gates of enterovirus infection are epithelial cells and lymphoid formations of the upper respiratory tract and intestines, where the viruses multiply. The further development of the pathological process depends on the tropism of the virus to certain organs, on the state of cellular and humoral immunity. Penetration of enterovirus through the blood-brain barrier can lead to the development of acute serous meningitis or encephalitis. In other variants, the virus predominantly affects skeletal muscles with characteristic waxy necrosis and the breakdown of muscle fibers, a pattern of acute myositis is observed. Possible primary damage to the myocardium( myocarditis), the mucous membrane of the oropharynx( herpetic angina), skin integuments( enterovirus exanthema) and other infection localization. Often, the virus tropism manifests itself to many organs and systems, which leads to the development of combined forms.

    The leading clinical syndromes distinguish the following clinical forms of the disease, presented in the classification proposed by N.I.Nisevich and VFUchaykin( 1990):

    II.By the severity of the process:

    III.In the course of the disease: acute, prolonged with relapses and exacerbations.

    IV.By the nature of complications: otitis media, pneumonia, mixed infection.

    The incubation period of enterovirus infection ranges from 1 to 10 days. The clinical picture of enterovirus infection is characterized by general symptoms in the form of fever from subfebrile to febrile figures of varying duration( from 1 to 10 days), headache, repeated vomiting, and decreased appetite. Frequent manifestations of the disease are mild catarrhal symptoms( hyperemia of the mucous membrane of the oropharynx, injection of sclera, marginal conjunctivitis).As a rule, there are signs of cardiovascular insufficiency - tachycardia, muffled heart tones, transient changes on the ECG.Sometimes there is an increase in the size of the liver and lymph nodes.

    In addition to general clinical symptoms, each clinical form of the disease has its own characteristic features. Thus, with "herpetic angina," the leading signs are local signs of damage to the mucous membrane of the anterior arch, tongue, hard palate, posterior pharyngeal wall in the form of whitish-gray papules that turn into bubbles surrounded by a red halo within a day. Eruptions last for several days, leaving behind a superficial erosion. The course of the disease and the prognosis for this form of enterovirus infection are favorable.

    For epidemic myalgia( pleurodynia, Bornholm disease) is characterized by an acute, sudden onset of fever to febrile figures, headache and severe pain in the muscles of the chest, abdomen and diaphragm, making breathing difficult, especially deep breath. Pain paroxysmal, usually lasts 10-30 minutes. Sometimes the pain is localized in the epigastric region, around the navel or in the ileum, or it is combined with pain in the limbs, having a migrating character. The duration of this syndrome varies from 3 to 14 days. The outcome is favorable.

    Serous enterovirus meningitis begins acutely, with a rise in body temperature to 38-39 ° C, the onset of headache, headache, repeated vomiting, and sometimes catarrhal symptoms. From the first day of the disease, meningeal syndrome is detected: positive stiff neck muscles, symptoms of Kernig, Brudzinsky upper and lower.

    Babies have a bulging and pulsation of a large fontanel. In the clinical picture, the leading is hydrocephalic-hypertensive syndrome. Some patients have fast-paced focal symptoms due to edema of the brain. The study of cerebrospinal fluid reveals a mild cytosis of lymphocytic character, a slight increase in the level of protein. Enterovirus meningitis proceeds wavy, but the outcome is favorable.

    Symptomatic of enteroviral encephalitis consists of general infectious and cerebral symptoms: high body temperature, impaired consciousness, headache, drowsiness or agitation, vomiting, convulsions. Depending on the topic of brain damage( stem, cerebellar, hemispheric) develops the corresponding symptomatology. Thus, the stem symptoms are manifested by the lesion of the glossopharyngeal, wandering and sublingual nerves, speech disorders, swallowing. With a higher level of lesion of the trunk, strabismus, ptosis takes place. Sometimes the process is combined with a lesion of the spinal cord in the form of flaccid paresis or paralysis of the muscles of the trunk and extremities. With the development of meningo-encephalitis, meningeal symptoms attach. With this form of enterovirus infection, vegetative disorders are possible. The course of the disease, as a rule, is very difficult, a lethal outcome is possible.

    Enterovirus encephalomyocarditis in infants is a rare but very severe form of the disease. It occurs most often in the form of outbreaks in maternity hospitals. The child becomes infected from the mother or from the staff. The incubation period is from 1 to 7 days. Initial manifestations of the disease are characterized by the appearance of lethargy, anorexia, regurgitation, followed by the addition of fever to febrile figures, tachypnea, tachycardia, acute cardiovascular insufficiency, cyanosis and cerebral symptoms. The child dies on the 2-3 day from the onset of the disease. When pathoanatomical research, dilated heart cavities, inflammatory necrotic changes in the myocardium, diffuse or focal encephalitis, often serous meningitis.

    Enterovirus myocarditis is also a rather rare form of the disease. It is characterized by complaints of rapid fatigue, weakness, sometimes unpleasant sensations in the heart. In objective research, cardiac enlargement, tachycardia, subdued cardiac tones, diffuse or focal changes in the myocardium on the ECG are detected. This form has a benign course.

    Intestinal form of enterovirus infection is most common in children of the first year of life. The disease begins sharply with an increase in body temperature to 38-39 ° C, the occurrence of vomiting, abdominal pain, frequent, profuse, watery stools, sometimes with a slight admixture of mucus. Symptoms of intoxication are poorly expressed. The duration of the disease does not exceed 10-14 days, it is often combined with catarrhal symptoms and has a benign course.

    Acute enteroviral hepatitis is rare and resembles an atypical, jaundiced form of viral hepatitis A. Clinical manifestations of this form of the disease are characterized by moderately expressed catarrhal symptoms, body temperature, possible myalgia and enlargement of the liver, revealed by objective examination. Functional liver tests vary slightly. There is a rapid positive dynamics of symptoms.

    For enterovirus infection occurring with exanthema, the acute onset of the disease with elevated body temperature, the appearance of catarrhal symptoms, sometimes diarrhea, abdominal pain. Simultaneously, with a drop in temperature, there is an abundant pink patchy-papy-eyed rash on the skin of the face, trunk, limbs, which lasts 12 72 hours and disappears without leaving pigmentation. The disease resembles rubella, from which it is distinguished by the absence of an increase in the occipital and posterior lymph nodes.

    Catarrhal form of enterovirus infection occurs as an acute respiratory-viral disease( acute onset, rise in body temperature to 37.5-38 ° C, the onset of a runny nose, cough, less often conjunctivitis, hyperemia of the mucous oropharynx).Sometimes an increase in regional lymph nodes, liver and spleen is added. Symptoms of intoxication are not very pronounced. The disease proceeds, as a rule, easily, without complications. Duration 5-7 days. This form of enterovirus infection is often called "summer flu".

    Enterovirus fever is the most common form of enterovirus infection. It is characterized by an increase in body temperature from sub-febrile to febrile digits for 2-3 days to 2-3 weeks with mild catarrhal symptoms and a slight increase in lymph nodes( polyadeny).The disease can take a long time and wave.

    Paralytic form of enterovirus infection is more common in young children. The disease begins against the background of normal body temperature and relative well-being with the appearance of gait disturbance, weakness in the legs, hands( limp pareses, paralysis).With objective examination, a decrease in muscle tone, tendon reflexes on the side of the lesion is revealed. Rarely is there an isolated lesion of the facial nerve along the peripheral type. The disease proceeds easily, usually leaving no residual effects.

    The diagnosis of enterovirus infection is based on the following criteria:

    Differential diagnosis of enterovirus infection presents certain difficulties due to the variety of clinical forms and the wide spread of enterovirus among the population.

    Depending on the clinical symptoms of enterovirus infection, the following leading syndromes are distinguished for differential diagnosis:

    1. Catarrhal syndrome, which must be differentiated from SARS of another etiology.

    2. Syndrome of flaccid paralysis - with poliomyelitis and neuropathies.

    3. Syndrome of exanthema - with diseases( infectious and non-infectious genesis), accompanied by exanthems.

    4. Syndrome of CNS damage( meningitis, meningoencephalitis, encephalitis) - with meningococcal, other purulent and serous meningitis and encephalitis, coma, tumors and other brain lesions.5. Syndrome of diarrhea - with acute diarrhea due to other viruses( rotaviruses, adenoviruses), opportunistic microbes( E. coli, Klebsiella, vulgar proteus, Staphylococcus aureus), as well as with atypical forms of shigellosis and salmonellosis.

    6. Hepatomegaly syndrome - with anicteric forms of hepatitis of other etiology.

    7. Myalgia syndrome - depending on the topic of the pain syndrome, the following diseases should be excluded:

    16. Infectious diseases in children

    For confirmation, the results of the histological examination are necessary.

    The diagnosis of enterovirus infection can be confirmed by a virological study of flushing from the nasopharynx, fecal masses, cerebrospinal fluid during the first days of the disease by direct and indirect immunofluorescence. Of decisive importance in the diagnosis is serological examination in paired sera( neutralization reaction, RSK, RTGA).Increasing the titer of specific antibodies more than 4 times in the dynamics of the disease is a confirmation of the diagnosis of enterovirus infection.

    A promising area for laboratory diagnosis of enterovirus infection is a direct method for detecting the virus by polymerase chain reaction( PCR).Compared with serological and virological diagnostic methods, PCR has several advantages:

    Coronavirus infection is an acute infectious disease of the viral nature, characterized by catarrhal phenomena with a predominant nose injury, possible gastrointestinal tract damage and mild intoxication. At the same time, the development of severe acute respiratory syndrome( SARS, Severe Acute Respiratory Syndrome, SARS, "SARS") is possible. This is a new infectious disease that first arose in November 2002 in Southern China and spread to the territories of 29 countries in Europe, Asia, North and South America, Africa and Australia. Officially reported on 8422 patients and more than 900 died from SARS.

    The causative agent of coronavirus infection is the RNA-containing virus. The diameter of the virions is from 75 to 160 nm. The outer shell has shoots in the form of petals. The virion contains one molecule of infective single-stranded RNA, which is the most stable of all known viral RNAs. Viruses are destroyed under the influence of ether, chloroform, detergents, but are stable in the external environment, they are well tolerated by low temperatures and drying. At the same time, at a temperature of 56 ° C, they perish in 10-15 minutes, at a temperature of 37 ° C - after 10 hours.

    There are three serotypes of coronaviruses. The first and second serotypes cause diseases in mammals, the third - in Birds. The coronavirus of SARS refers to the first serotype, but differs from the rest of the viruses in the composition of the genome by 50-60%.This virus has a tropism for alveolitis and resistance in the external environment( it persists for 24 hours).

    Epidemiology. The source of infection is a person who is sick with coronavirus. The disease is transmitted by airborne droplets. At the same time, the possibility of a fecal-oral route is possible, since coronaviruses are secreted from the intestine.

    An increase in the incidence of this infection is usually observed in the winter-winter period.

    SARS is anthropozoonosis. The source of infection are special varieties of raccoons, ferrets and badgers, as well as humans. The virus is released together with mucus of the respiratory tract, urine, feces, tear fluid. Transmission ways - airborne, airborne, possibly fecal-oral. The virus has a high volatility. Children rarely suffer from SARS and carry it in mild form, which is associated with a wide spread of coronavirus infection in children and the presence of cross immunity.

    Pathogenesis. The entrance gates are the mucosa of the upper respiratory tract, in which serous inflammation develops. Later, there is viremia, as a result of which the virus is disseminated throughout the body. SARS is characterized by the defeat of alveolocytes, development of interstitial alveolar edema, the appearance of hyaline membranes, cytological atypia of cells, rapid attachment of secondary bacterial and fungal microflora. The outcome of inflammation in some patients is pulmonary fibrosis.

    The incidence of acute respiratory infections caused by coronaviruses is 4.2 to 9.4%.In this case, the upper respiratory tract is usually affected. However, in children with a burdened premorbid background, it is possible to involve bronchi and lungs in the pathological process.

    In addition to respiratory organs, coronaviruses can cause damage to the gastrointestinal tract and central nervous system. Thus, HECV-24 and HECV-25 viruses were isolated from the intestines of children with clinical manifestations of acute gastroenteritis. In addition, there are numerous reports of the isolation of coronaviruses from the brain of patients with multiple sclerosis.

    Usually, the infection occurs as a mild disease with signs of upper respiratory tract infection. The main symptom of the disease is profuse rhinitis, accompanied by a moderately expressed general infectious symptomatology. Body temperature remains normal. Along with rhinitis, cough, occasional pain in the chest, wheezing in the lungs can be observed.

    The literature describes the outbreaks in which coronavirus infection manifested itself only by a short-term diarrheal syndrome. The disease proceeded according to the type of acute gastroenteritis and was accompanied by recovery.

    The incubation period of SARS is 3-10 days. When transferring from person to person, it is shortened, when transferred from an animal - it lengthens to 7-10 days.

    During the SARS, three stages can be distinguished.

    In children, SARS proceeds more easily than in adults. The duration of fever is reduced to 3-10 days, pneumonia - up to 15-18 days.

    Clinical and laboratory criteria for the development of bacterial complications:

    The main principle of therapy is an early start considering the age of the child, its premorbid background, the expected causative agent and severity of the disease, localization of the process, and the presence of complications.

    Treatment of patients is predominantly performed on an outpatient basis. Hospitalization is subject to patients with severe forms, children of early age with moderate forms and an unfavorable premorbid background, patients with complicated course of the disease, according to epidemiological and social indications, due to the lack of the effect of outpatient treatment for 48-72 hours.

    Etiotropic therapy consists of the appointment of drugs that have virucidal activity, interferons, inducers of interferonogenesis, immunoglobulins.

    WHO recommendations on the use of antivirals:

    A. Antiviral drugs

    1. Drugs with virucidal activity:

    2. Protein channel blockers M2, amantine derivatives:

    3. Other broad spectrum antiviral drugs:

    4. Interferons with universalantiviral properties, suppress the replication of RNA, DNA, stimulate simultaneously the immunological reactions of the body:

    5. Interferonogenesis inductors with the ability to stimulate the formationMaintenance of its own, mainly alpha-interferon:

    B. Antibacterial agents.

    In the treatment of uncomplicated forms of influenza and other acute respiratory viral infections in children, there is no need to prescribe antibacterial and sulfanilamide preparations, since their administration only contributes to the development of various adverse reactions, including allergic reactions. Irrational use of antibiotics leads to the death of normal intestinal, cutaneous and respiratory microflora, to the selection of antibiotic-resistant opportunistic microorganisms, the growth of fungi, the formation of secondary immunodeficiency. Up to 25-60% of patients with ARVI receive antibiotics from the first day of the disease unreasonably.

    Antibacterial drugs can be divided into two groups:

    Patients with focal infections in the oral and nasopharyngeal can be recommended to assign the first group of drugs with local, anti-inflammatory and antimicrobial effects( hexoral, tantalum verde, bioparox, septothete, falimint, IRS-19, imudon, lysobact).

    Absolute indications for the administration of systemic antibiotics inwards or parenterally are complications of acute respiratory viral infection of bacterial etiology( pneumonia, sinusitis, otitis media, exacerbation of chronic bronchitis, bacterial angina, urinary tract infections) or respiratory diseases of non-viral origin( chlamydia, mycoplasmosis).However, it is not always possible to solve the problem of the nature of infection at the patient's bedside. Even with the use of special survey methods, it is possible to identify the cause of the disease in no more than 50-60% of patients. Therefore, systemic antibiotics are prescribed not only to patients with obvious bacterial and viral-bacterial ARI, but also to patients with severe forms of acute respiratory viral infection( toxicosis II-III degree, obstructive bronchitis, bronchiolitis, stenosing laryngitis, etc.), patients at risk( infants, chronic foci of infection, an unfavorable premorbid background, etc.), in the absence of the effect of the therapy for three days.

    Antibiotic therapy is initially inevitably empirical. Selecting the patient empirically antibacterial drug, the doctor must take into account a number of factors:

    The starting antibacterial drug must first of all be active against the leading pathogens of respiratory tract infections( pneumococcus, hemophilic rod, moraxella cataris, Staphylococcus aureus, pathogenic streptococci).If suspected of chlamydial or mycoplasmal etiology of the disease, macrolides are prescribed. Antibacterial preparations of the first choice( aminopenicillins, cephalosporins of the 1 st generation) are prescribed in the absence of grounds to think about drug resistance and community-acquired process;preparations of the second choice( cephalosporins of the third generation) - with probable stability of the pathogen, nosocomial process;preparations of the reserve( cephalosporins of the 4th generation, carbopines) - marked multidrug resistance, as a rule, nosocomial pathogen. It is widely believed that after a laboratory determination of the pathogen, a mandatory correction with the appointment of a pathogen-directed antibiotic is necessary. However, with a clear clinical efficacy of the empirically prescribed drug, it is advisable to continue treatment with them. If there is no effect, after 48-72 hours of antibiotic therapy( a decrease in temperature below 38 ° C, a decrease in the amount of intoxication, a positive dynamics in the outbreak), the drug is changed, preferably taking into account the results of the additional examination. The duration of the entire course of antibiotic therapy is determined by positive clinical and laboratory dynamics. To prevent side effects of antibiotics, their use should be combined with probiotics.

    1. Control of hyperthermia

    Indications for decreasing temperature are:

    Paracetamol preparations( "Cefekon D", "Tylenol", "Efferalgan", "Fervex for children") are the safest antipyretic for children. If it is necessary to obtain an analgesic and anti-inflammatory effect, non-steroidal anti-inflammatory drugs( naiZ, nurofen, ibuprofen) are indicated. Do not forget the physical methods of cooling. Homeopathic preparations "Antigrippin", "Agri", "Ocilococcinum", "Aflubin", "Anafezgan" proved to be very useful.

    2. Antitussive therapy is performed taking into account the nature and mechanism of coughing:

    3. For the purpose of arresting rhinitis, it is recommended to rinse the nasal passages with mineral water, the drug "Aqua Maris", isotonic sodium chloride solution, followed by instillation with swelling of the mucous membrane and serous release of the following preparations: "Tanasnos", "Naphtizin", "Nazol", "Galazolin", etc. With a thick detachable it is recommended to wash with subsequent instillation in the nasal passages of procorgol, miramistin, polidex, fromoffs, vibrocil.

    4. Local antiseptic drugs used to treat acute respiratory infections:

    Children with severe disease, rapid progression and generalization of the process, development of neurotoxicosis, DIC syndrome, infectious-toxic shock, acute renal failure, stenosis of the larynx, bronchoobstructivesyndrome. This category of patients is subject to urgent hospitalization in the children's intensive care unit or in the intensive care unit. The main therapeutic measures should be directed to the therapy of toxicosis, the restoration of the functions of vital organs and systems, the elimination of metabolic disorders.

    In the period of convalescence the child is observed by a district pediatrician for 1 month, according to the indications, he is consulted by an ENT doctor, an immunologist, an infectious disease specialist. The appointment of vitamins, plant adaptogens, local immunomodulating medications( IRS-19, imudon, bronchomunal, ribomunil) is indicated, and, if necessary, sanation of chronic foci of infection.