Enterovirus infections - Causes, symptoms and treatment. MF.
The high incidence of enterovirus infections is recorded annually in Russia and other countries. The epidemiological situation of 2013 in Russia is still fresh in the memory of the population. According to the chief state sanitary doctor of Russia, G.G.Onishchenko incidence in 2013 exceeded the same indicator of the previous year more than 2 times. The anxiety of the situation is aggravated by the fact that most often the children's age group suffers, that is, the most vulnerable and immunologically vulnerable part of the population.
From the clinical point of view, a variety of forms of the disease attract attention, which are often "masked" for traditional respiratory infections, which makes it difficult to diagnose early enterovirus infections and timely medical care. The possibility of developing severe forms of the disease with the development of meningitis and encephalitis attracts our attention precisely to the early diagnosis and timely hospitalization in the hospital.
So,
Enterovirus infections is a group of human infectious diseases( anthroponosis) caused by enteroviruses( non-poliomyelitis), having spring-summer-autumn seasonality, affecting mainly children's population and characterized by fever, tonsils, central nervous system, gastrointestinal tract,skin manifestations and damage to other organs and systems.
Pathogens is a group of non-poliomyelitis enteroviruses Coxsackie A( 24 serovars), Coxsackie B( 6 serovars), ECHO( 34 serovars) and unclassifiable human enteroviruses of 68-72 serotypes. These are RNA-containing viruses that are fairly stable in the external environment. Resistant to low temperatures, can withstand freezing and thawing. At room temperature can remain viable for 15 days. At boiling die instantly. Destructive to them are chlorine-containing solutions, solutions of hydrogen peroxide, manganese potassium, ultraviolet irradiation.
Enteroviruses
Reasons for the spread of enterovirus infections
The source of infection of is patients with clinically pronounced form of the disease, asymptomatic forms of the disease, carriers of viruses. Infected sources of infection are nasopharyngeal mucus, bowel movements, spinal fluid. Since already in the incubation period( the period from the moment of infection until the appearance of the first symptoms of the disease) there is a multiplication and accumulation of the virus in the mucous membrane of the oropharynx and the gastrointestinal tract, the patient isolates the virus in a small amount already at this stage. The maximum release of the virus is noted in the first days of the disease. The term of the infectious period can last 3-6 weeks, rarely longer. An important role in the spread of infection is played by asymptomatic carriers, whose frequency of occurrence does not exceed 45%( more often children of early age), and convalescents( convalescent), which often continue to secrete viruses.
There are two infection mechanisms - fecal-oral and aerogenic, the leading one being fecal-oral. The main transmission routes are water( during bathing in reservoirs infected with enteroviruses) and alimentary( eating contaminated water, dirty vegetables and fruits, milk and other products).Viruses can be transmitted through household items( toys, towels), dirty hands. Another way of transmission is airborne( the secretion of viruses with nasopharyngeal mucus during coughing, sneezing, talking).We remind you that the risk group is people who are in direct contact with the source of infection( for sneezing and coughing, this is an aerosol cloud 3 meters in diameter).Possible and transplacental transmission of infection from the mother to the fetus( in the case of a pregnant woman with a clinically expressed form of the disease).
The susceptibility of the population to enterovirus infections is high. Possible family outbreaks and outbreaks in organized children's groups. Groups at risk of infection are persons immunologically compromised, that is, individuals with reduced resistance to the organism - children, people of advanced age, persons with chronic diseases. After the transferred disease, a stable immunity to a certain type of virus is formed, which is often cross( that is, immediately to several serotypes of enteroviruses).
Symptoms of enterovirus infections
Short path of enterovirus in the human body: the entrance gates of infection are the mucous membranes of the nasopharynx and digestive tract, where the enteroviruses settle and accumulate, which coincides in time with the incubation period( from 2x10 days, usually 3-4 days).Then the viruses lymphogenically penetrate into the lymph nodes, close to the entrance gates( regional), which coincides with the onset of the disease - 1-2 days( the patient may have pharyngitis, diarrhea).Further, the viruses penetrate into the blood and are hematogenously spread by various organs and systems( primary viremia) - from the 3rd day of the disease. Clinically characterized by many syndromes, depending on the tropism( the preferred system or organ) of a particular enterovirus. Possible secondary viremia( repeated release of the virus into the blood), which is clinically accompanied by a second wave of fever.
A feature of enterovirus infections is the variety of clinical forms, that is, even within a single outbreak, completely different symptoms of the disease can be recorded. Clinical forms of enterovirus infections can be generalized into two large groups: typical and atypical( unusual and rare).
Typical forms:
1. Gerpangina
2. Enterovirus exanthema
3. Serous meningitis
4. Epidemic myalgia
Atypical forms:
1. Minor disease( 3 day fever)
2. Respiratory( catarrhal) form
3. Enterovirus diarrhea
4. Enfefalitic form
5. Polio-like( spinal) form
6. Encephalomyocarditis of newborns
7. Epidemic hemorrhagic conjunctivitis
8. Uveitis
9. Nephritis
10. Pancreatitis
11. Inapparant form( subclinical, impotencemtm)
Gerpangina is one of the most frequent forms of enterovirus infection. Coxsackie A viruses( types 2,3,4,6,7,10) and Coxsackie B( type 3) are caused. Characteristic of the presence of 2 syndromes - infectious-toxic( ITS) and catarrhal. The beginning is acute. ITS is manifested by fever up to 39-400, symptoms of intoxication - weakness, headache, nausea, however, well-being can remain satisfactory. The fever lasts 2-5 days. Catarrhal syndrome appears at the end of 1x-2h days - redness of the arch, tongue, posterior pharyngeal wall. Within 2 days of the onset of the disease, grayish white elements( papules) appear on the tonsils and arcs up to 2 mm in diameter, the number of which varies from 4-5 to 20. The papules soon become bubbles 5 mm in diameter, which soon burst, leaving afterself-erosion( 2-3 day sickness), covered with a grayish coating with a reddish aureole around the periphery. Erosions heal without a trace in 4-6 days. The peculiarity of catarrhal syndrome with enteroviral herpagnine is absence or weak manifestation of pain syndrome. The pain in the throat can appear only at the stage of erosion formation.
Gerpangin can be confused with other tonsillitis, in which most often against a high temperature there is a pronounced pain in the throat, difficulty in swallowing food, and also characteristic changes in the oropharynx.
When to call a doctor: the appearance of heat with a relatively satisfactory state of health, which is poorly docked;the appearance of changes in the oropharynx without pain in the throat. Diagnosis of this form can only a doctor( infectious disease specialist, pediatrician, therapist).Self-diagnosis and treatment in herpangina can lead to the occurrence of relapse( re-illness), as well as the appearance of another more severe form of the disease( serous meningitis).
Gerpangina
Enterovirus exanthema ( Boston or epidemic exanthema).It is caused by ECHO viruses( types 4, 5, 9, 12, 16, 18) and Coxsackie( A-9, A-16, B-3).It is characterized by a sharp onset, the appearance of a high temperature up to 390 and symptoms of intoxication( weakness, muscle pains, headaches, sore throat).After 1-2 days, there is a rash on the trunk, kinechnosti, face and feet. By nature, it can be koreal, rubella-like, scarlish-like and petechial. Accordingly, it can be a small-spotty rash, small-spotted, spotted-papular. In some cases, the emergence of a syndrome of meningism( headache, vomiting, photophobia, the impossibility of tilting and turning the head), as well as the combination of this form with serous meningitis.
When to call a doctor: high fever and the appearance of a rash;the occurrence of repeated vomiting on the background of high temperature. Determine the nature of the rash and appoint the right treatment can only the doctor.
Enterovirus exanthema
Serous meningitis is one of the most common forms of enterovirus infection. It is caused by Coxsackie viruses( A-2, 4, 7, 9), Coxsackie B( types 1-5), ECHO( types 4, 6, 9, 11, 16, 30).
Meningitis begins sharply with the appearance of chills, increasing to 39-40 °( very rarely t remains normal), symptoms of intoxication appear. A few hours or by the end of the day there is a rapidly increasing diffuse headache of a bursting nature. In most patients, nausea, multiple vomiting, and hyperemia of the face and motor excitement, increased sensitivity to all kinds of irritants are added a little later. During the first 12-24 hours from the onset of the meningitis, a detailed picture of meningeal and cerebral syndromes is formed. Meningeal symptoms appear and quickly grow: stiff neck muscles, Kernig symptom, Brudzinsky, etc. Patients are characterized by a "meningeal posture" or "pose of a leper dog".Consciousness is first saved, and then replaced by a state of stunnedness, stopper, coma.
Often, these symptoms are accompanied by other symptoms of enterovirus infection - myalgia, rash on the body, myocardial damage, oropharynx. Duration of fever and meningeal syndrome up to 7 days with timely treatment. Sometimes there is a second wave of fever.
Analysis of cerebrospinal fluid: flows under pressure, clear, cytosis 200-300 cells in 1 μl, neutrophils up to 50%, lymphocytes prevail more often.
When to call a doctor: high fever, severe headache, repeated vomiting, neck pain, inability to bend it - all these symptoms for immediate contact with a doctor. In young children - high fever, constant crying and anxiety of the child - an occasion for an urgent call to a doctor. Meningitis requires urgent medical interventions in a hospital.
Epidemic myalgia. Caused by Coxsackie viruses( types 1-5), Coxsackie A-9, ECHO( types 1,6,9).The beginning is acute. Symptoms include infectious-toxic syndrome and myalgia syndrome. Against the background of high temperature and symptoms of intoxication, muscle pains( myalgia) appear. Localization - abdominal muscles, lower parts of the thorax, back, limbs. The peculiarity of myalgias is their paroxysm, seizures last for 5-10 minutes and are repeated in 20-30-60 minutes. In 50% of patients, a second wave of fever is observed. Often there are other symptoms of enterovirus infection( rash, oropharynx, lymph nodes).The average duration is 7-8 days, sometimes a second wave with repeated attacks.
When to call a doctor: fever and paroxysmal pain in the muscles. This form is difficult to diagnose, often differentiation is carried out with myocarditis, pleurisy, acute abdomen and other conditions.
"Minor disease" ( 3-day fever, "summer flu") can be caused by all types of enteroviruses. Short-term( 1-3 days) and mild severity( moderate temperature, weakness, myalgia, dizziness) characterize this form of the disease. Often disguised as ARVI.The correct diagnosis is usually established only with an outbreak of enterovirus infection.
Respiratory( catarrhal) form of enterovirus infection is caused by many types of enteroviruses. Symptoms are similar to ARI of another etiology - the temperature is combined with upper respiratory tract infection( pharyngitis, laryngitis).Caution in diagnosis requires young children who have the syndrome of "false croup"( barking cough, difficulty breathing), which appears, as a rule, at night.
Enterovirus diarrhea ( viral gastroenteritis) occurs in both children's and adult age groups. Against the background of high fever( 38-390) there is a loose stool from 2 to 10 times a day, abdominal pain, general malaise, nausea, vomiting. The fever lasts an average of a week. Stool disorder may be the only sign of the disease.
The enfefalitic form of enterovirus infection of is infrequent. Light forms are manifested only by malaise, unexpressed headaches and difficult to diagnose. Heavy forms can be accompanied by convulsive syndrome, impaired consciousness, lesion of individual cranial nerves.
The poliomyelitis-like( spinal) form of is manifested by paresis and paralysis, but it is easier in nature than poliomyelitis with rapid recovery of motor functions.
Neonatal encephalomyocarditis is caused by Coxsackie viruses( types 2-5).Characterized by severe course and high lethality( up to 80%).Against the background of high fever the child becomes drowsy, refuses to eat, there is a convulsive syndrome, cyanosis of the skin, heart failure.
Epidemic hemorrhagic conjunctivitis causes enterovirus serotype 70. It begins with acute damage to one eye, then the second eye is affected. The patient has lachrymation, a fear of light, a foreign body sensation in the eyes. When examining hemorrhage in the conjunctiva, edema of the eyelids, muco-purulent discharge.
Hemorrhagic conjunctivitis
The cases of enteroviral myocarditis and pericarditis, uveitis, nephritis, pancreatitis are also described.
Complications of enterovirus infections
Complications of enterovirus infections are associated mainly with the damage to the nervous system. One of the dangerous complications is cerebral edema with the danger of a wedge syndrome( cardiac and pulmonary arrest).This complication is possible with severe forms of infections, as well as with late seeking medical help.
Other complications include the development of "false croup" in the respiratory form in young children, as well as the attachment of a secondary bacterial infection with the development of pneumonia and other bacterial foci. In rare cases of hemorrhagic keratoconjunctivitis and uveitis, development of cataract and blindness is possible.
Diagnosis of enterovirus infections
1. Preliminary diagnosis is made by the doctor when examining the patient on the basis of suspicious symptoms after a differential diagnosis. The epidemiological situation with possible development of family and group outbreaks of the disease is taken into account.
2. The final diagnosis is made only after laboratory confirmation of the diagnosis. Indication for examination is determined only by the doctor.
Individuals who have one or more of the following clinical symptoms / syndromes are subject to an examination for enterovirus infections:
- focal neurological symptoms;
- meningeal symptoms;
- septicemia of neonates of non-bacterial nature;
- exanthema of the oral cavity and extremities;
- herpangina, aphthous stomatitis;
- myocarditis;
- hemorrhagic conjunctivitis;
- uveitis;
- myalgia;
- others( including respiratory syndrome, gastroenteritis, exanthema in case of group morbidity in a children's organized group).
For the study, a swab from the oropharynx / nasopharynx, a smear of detached ulcers in herpangina, fecal samples, spinal fluid, conjunctivable discharge, a smear of vesicles, blood, organ biopsy( sterile types of clinical material), autopsy material( non-sterile types of clinical materialmaterial).
Taking a certain type of material for laboratory research is carried out taking into account the clinical picture of the disease.
Timing of material intake: nasopharyngeal washings are taken in the first 3-4 days of the disease;two samples of feces in the first 7 days of the disease with an interval of 24-48 hours;the blood is taken twice - the first sample as soon as possible from the onset of the disease, the second one at 3-4 weeks of illness;In parallel, blood is taken to isolate the virus;spinal fluid is withdrawn for the first time days of illness in aseptic( sterile) conditions.
The main methods of laboratory confirmation of EVI are: - virological method( virus isolation);- polymerase chain reaction( PCR)( detection of RNA virus);serological methods( detection of antibodies in paired sera);molecular biological methods( for the determination of serotypes of enteroviruses).
1) Virus isolation: virological method( in cell culture or in animals) and detection of enterovirus RNA by PCR.Isolation of the virus on media requires more time, gives the most unequivocal answer to the question of the etiology of the disease. PCR is more sensitive, faster, and allows detection of viruses that do not multiply in the cell culture. PCR is used in the study of cerebrospinal fluid and materials from the upper respiratory tract. It should be borne in mind that the detection of enteroviruses in faeces is possible in healthy virus carriers, and therefore mandatory confirmation by serological reactions is required.
2) Detection of specific antibodies by reactions: RCC, RTGA, gel precipitation reaction, neutralization reaction with paired sera. Diagnosis is an increase in antibody titer in paired sera 4 and more times.
3) Molecular biological methods allow serotyping of the material on the 2-3 day of the study.
Treatment of enterovirus infections
Basic therapy( correct treatment regimen, rational therapeutic diet, use of a complex of vitamins).
Mode for enterovirus infection
Hospitalization is carried out selectively according to clinical indications, taking into account the possibility of treating patients at home. Treatment of mild forms of enterovirus infection in children and light, medium-heavy forms in adults is carried out at home, and such patients, as is known most. An indispensable condition is adherence to bed rest for the entire febrile period, and also to the elimination of complications.
The diet is aimed at increasing immunity, reducing intoxication, rapid resolution of the inflammatory process, sparing the organs of the CCC and digestive systems, kidney function, preventing the possible effects of drugs. The diet is differentiated depending on the patient's condition and the stage of the disease.
• To increase immunological reactivity, a physiologically complete diet with a sufficient amount of protein and an increased content of vitamins A, C, and B group is prescribed.
• To reduce intoxication, a sufficient amount of liquid is indicated( preferably black currant, dogrose, chokeberry, lemon).
• All products are appointed in a warm form, avoiding sharp, fatty, fried, salted, pickled dishes.
Etiotropic treatment( antiviral chemotherapeutic and biological agents)
Etiotropic therapy includes antiviral drugs, which include:
1) interferons( influinon, antiviral, immunomodulatory, viferon suppress virus reproduction, immunostimulating effect).
2) inducers of interferon( amixin, lavomax, which have a pronounced immunomodulatory effect, tsikloferon, improving the immune status of the patient, promoting the production of interferons in the body, which has anti-inflammatory, antiviral effect, anaferon children and adults - the immunomodulator, stimulates both humoral( general) and cellular( local) immunity, aflubin - a complex homeopathic preparation with immunomodulatory, antiviral, antipyretic action.).
Pathogenetic intensive care( correction of protective functions of the body)
In hospital, severe forms of enterovirus infections are prescribed detoxification treatment, with meningitis and meningoencephalitis - dehydration therapy with forced diuresis( diuretics) under strict control of laboratory changes in water-salt metabolism. When the heart is affected - cardioprotectors, the brain - means that improve blood supply and rheological properties of blood. This section of therapy is possible only in a hospital.
Pathogenetic and symptomatic therapy( antipyretics, analgesics, anti-inflammatory, antihistamines, intestinal adsorbents, vasoconstrictor for the nose)
1. Antipyretics( nurofen, panadol to children, teraflu, koldreks, fervex, effer langan to adults) in order to reduce fever and improve overall health.
2. Anti-inflammatory therapy and analgesics - ibuprofen, paracetamol, ketorol - relieve pain syndrome, in particular with myalgia.
3. Antihistamines - diazolin, suprastin, claritin, zodak, zirtek and drugie - to reduce the general toxic and allergic reaction of the body.
4. Adsorbents( activated carbon, white coal, smectite, polyphepam, enterosgel) - for binding of toxins and viral particles in the intestine.
5. With pronounced rhinitis, drops in the nose are recommended: nasol, nasal advans - convenience in the form, nazivin, aquamaris, tizin.
6. When attaching a secondary bacterial infection, antibacterial agents that are prescribed prophylactically in certain categories of patients( persons with chronic bacterial foci).And the drug, and the dose, and the course is selected by a strictly treating doctor. Self-targeting and treatment threatens to add unpleasant complications.
7. Probiotics in case of development of enteritis( bifiform, yogulact, bifistim, bifidum forte, etc.) in order to activate normal microflora and fight enterovirus infection in the lesion.
8. Intensification of treatment with herpangin and respiratory form is prescribed IRS-19, immunon, immunal in order to maintain local immunity and prevent sufficiently rapid bacterial contamination.
5) distracting and topical therapy includes steam inhalations with a solution of soda, solutions of herbs - sage, chamomile( which is important for catarrhal form and herpangina);irrigation of the pharynx with disinfectant solutions in order to avoid bacterial contamination of the lesion site;anti-inflammatory drops in the eyes with conjunctivitis.
Treatment of children and pregnant women should be done only by a doctor who will accurately determine both the group of drugs and the dosages required in this age group and at this time of pregnancy.
Self-medication with enterovirus infection is undesirable, as the symptoms of the disease( as can be easily seen) are nonspecific, that is, they occur in many diseases. Therefore, it is easy for a person without special education to mix up viral and bacterial contamination, and, accordingly, to be treated not in the right direction.
The dispensary observation is established individually. On average, the recovery period for infection lasts from 1 to 3 months. During this period, the ill should not be supercooled, observe a healthy diet without excess, drink vitamins, restore immunity. After the transferred forms with defeat of heart and nervous system the dispensary observation during 6-12 months is necessary with attraction to the supervision of the cardiologist, the neuropathologist. After suffering meningitis during the year, it is undesirable to fly, change the climate, and be vaccinated.
Prevention of enterovirus infections
Prevention of enterovirus infections is reduced to activities in the outbreak of enterovirus infection. The patient is isolated either at home or in the hospital. Contact is observed for 14 days. There is no vaccination for this infection. For the purpose of non-specific prophylaxis, it is possible to administer influenza in drops and normal human immunoglobulin intramuscularly. It is necessary to regularly conduct hygienic education of children and adolescents( washing hands after the toilet and before eating, hygiene, washing vegetables and fruits before meals, do not swallow water while swimming in open water).
The doctor infektsionist Bykova N.I.