CHICKEN POX (varicella) — the acute infectious disease which is followed by fervescence and papulo-vesicular rash on skin and mucous membranes. Strikes children aged up to 10 years more often.
For century of the lake it is for the first time described in 16 century by ital. doctors Vidius and Ingrassia (V. Vidius, 1500 — 1569; G. F. Ingrassia, 1510 — 1580) under the name «cristalli». The term «varicella» was introduced for the first time by Vogel in 1772; it allocated
V. to the lake in the independent nosological unit independent of natural smallpox (variola). In 1911 Mr. H. Aragao for the first time opened the activator B. of the lake, having found in contents of vesicles of the patient small educations — elementary little bodies.
The activator B. of the lake — DNA-viruliferous (Varicella-virus). It belongs to group of viruses of herpes (see. Herpes viruses ). On properties we will not distinguish a virus from the causative agent of the surrounding herpes (herpes zoster). Virion of a virus B. of the lake has the oval form and the sizes 150 — 200 nanometers. It is unstable to external influences. Its long preservation is possible only in certain conditions at very low temperatures (— 65 ° below). The virus does not breed in chicken germs and nepatogenen for laboratory animals. He breeds and can be supported in passages primary and intertwined cultures of cells of the person and monkeys (in the last replication of a virus happens less intensively). The development cycle of a virus occurs in a kernel and cytoplasm of the infected cells. Its accumulation happens in cellular substrate (fig. 1), only an insignificant part of a virus can be found in culture medium. The cytopathic effect caused by it — focal type with slow distribution on the periphery of the centers due to contact infection of the next cells. In the struck cells (cultures and elements of papulo-vesicular rash of patients) eosinophilic intranuclear inclusions form. Huge multinucleate cells which kernels also contain inclusions can be formed.
the Source of an infection — sick V. of the lake (from the 10th day of an incubation interval to the 5th day from the moment of emergence of the last elements of rash) and sometimes — patients with the surrounding herpes [according to I. Czubkowska, 1972, before drying of vesicles]. Transmission of infection happens in the airborne way; cases of transplacental infection are described. A susceptibility of children to V. of the lake very high, excepting the first months of life. Recurrent diseases are exclusively rare. V.'s incidence of the lake in big cities is observed constantly, from time to time (hl. obr. in winter and spring months) giving epid, rises. At emergence epid, flashes in institutions for children of early age (a day nursery, kindergartens etc.) are surprised, as a rule, all or almost all children who were earlier not ill V. the lake
Kartina of pathological opening of the islands who died of V. differs in a variety depending on existence or lack of consecutive infection. In case of joined (owing to skin having combed) consecutive infection the changes characteristic of septic process are observed. The pathoanatomical picture during the opening of the islands who died of generalized V. was described by H. Schleussing in 1927 at 2 premature children, Johnson (N. of N. Johnson) in 1940 at the 7-month-old child, V. N. Vertsner and T.E. Ivanovskaya in 1954 at the child of 1 year. In 1960 T.E. Ivanovskaya, S. D. Nosov with soavt, and in 1963 N. Vertsner described visceral defeats at V. of the lake.
In 1944 Oppengeymer (E. N of Oppenheimer) and in 1947 Lyukkezi (R. of F. Lucchesi) with soavt, published these openings of the islands who died of inborn generalized V., and J. Waring in 1942, W. D. Claudy in 1947, L. Frank in 1950 — from V. of the lake at adults.
At V. islands are surprised integuments, mucous membranes, internals and a brain. Formation of varicellous bubbles in skin begins with vacuolation and a diskompleksation of an aculeiform layer of epidermis. Gradually epithelial cells are exposed to balloon dystrophy before full death. Existence of intranuclear and intra cytoplasmic eosinophilic cytoplasmic inclusions in the changed cells of epidermis is characteristic. In an aculeiform layer the hyperplasia leading to formation of multinuclear syncytial cellular forms is observed. The last is especially expressed during the formation of large bubbles. Necroses of cells of epidermis and accumulation of an interintercellular lymph lead to formation of intra epidermal bubbles. The derma is edematous, in certain cases in it hemorrhages and small increase in monocytic cells in perivascular fabric are observed. Involution of bubbles happens by a resorption of liquid to formation of a dry crust. Various stages of development and the sizes of bubbles cause the polymorphism of skin eruption characteristic of V. of the lake (tsvetn. fig. 1 — 3). At a severe form of V. of the lake formation of very large bubbles which as if stiffened at one stage of development is observed. Formation of erosion and sores on visible mucous membranes is observed also at V. by the lake without a lethal outcome. In V.'s cases of the lake with a lethal outcome of an erosion and sore are described on mucous membranes of a digestive tract, a trachea, a renal pelvis, a bladder, an urethra, a neck of uterus. The rotundity of a form, existence of a hemorrhagic belt, the sizes corresponding to elements of skin rashes is macroscopically noted. Microscopically — considerable hypostasis of a submucosal layer, hemorrhage and in uncomplicated cases lack of inflammatory infiltration. On a conjunctiva of an eye and a mucous membrane of an urethra it is possible to observe formation of the vesicles preceding erosion with balloon dystrophy of an epithelium. From internals the liver, kidneys, lungs are surprised more often; more rare — a spleen, marrow, bark of adrenal glands, a pancreas, a thymus gland.
Macroscopically in fabrics of bodies the numerous small necroses with a hemorrhagic corbel corresponding to sypny elements of skin are visible; only their sizes are more uniform (tsvetn. fig. 4 and 5).
Microscopically on the periphery of the centers inflammatory reaction is absent. The exception is represented by lungs where on the periphery of necroses hypostasis and pneumonia of catarral and desquamative type with existence in infiltrate of preferential mononuclear elements is observed. Necroses have no certain topographical localization (e.g., in a liver they are scattered both in the center, and on the periphery of a segment). In an epithelium of a liver, bronchial tubes, tracheas and in an alveolar epithelium of lungs are found lakes, typical for V., intranuclear and intra cytoplasmic inclusions (Johnson). At the children having an acute leukosis treated hormones and 6 Mercaptopurinum, V.'s accession by the lake can lead to development of heavy hepatitis with a diskompleksation of cells and an outcome in an acute massive necrosis of a liver (fig. 2). Encephalitis at children of advanced age and at adults is described. At the same time pathoanatomical changes are localized in white matter, are similar with clumsy and postvaccinal. Perivascular (perivenous) demyelination and circulator disturbances are characteristic: hypostasis, hemorrhages, secondary dystrophic and necrobiotic changes of nervous tissue.
A clinical picture
the Incubation interval of V. of the lake from 10 to 21st day (the thicket is 14 days old). The prodromal phenomena (subfebrile temperature, indisposition) are expressed poorly, often at all are absent. The rash of the so-called prodromal rash (resh) having scarlatiniform is sometimes observed korepodobny character is more rare. Often resh appears already in the presence of typical varicellous rash. Emergence of varicellous rash happens without any certain order; it appears on a face, a pilar part of the head, a trunk and extremities and often is followed by an itch. Unlike natural smallpox, varicellous rash «does not give preference to the person at all does not spare a stomach» (N. F. Filatov). Elements of rash have in the beginning character of small makulo-papules which very quickly turn into vesicles. Some papules dry up, without reaching a stage of a bubble. Varicellous vesicles have various size (from the sizes of a pin head to a small pea) and a round or oval form. They are located superficially on the neinfiltrirovanny basis, their wall is strained, brilliant, contents are transparent; in an environment the narrow border of a hyperemia is found. Umbilicate cave-in are noted only on separate elements. At a puncture the bubble owing to the one-seclusion is emptied from contents. Vesicles quickly (in 1 — 2 — 3 day) dry up; the flat brown crusts disappearing in 1 — 3 week are formed. There is no hem left, as a rule. As the rash of a varicellous dieback happens not at the same time, and to intervals in 1 — 2 day, rash gains polymorphic character: at the same time on the same limited site of skin there are elements in different stages of development — small knots, bubbles, crusts (tsvetn, the tab., Art. 168, fig. 1 — 3).
At a considerable part of patients the rash is observed also on mucous membranes (a mouth, a nasopharynx, a throat, generative organs etc.) where bubbles quickly turn into surface erosions with a yellowish-gray bottom. The rash usually is followed by rise in temperature to 38 °, is more rare to more high level. At severe forms high fever (t ° 39 — 40 °) and the expressed intoxication is noted. Each new attack of a rash is followed by new rise in temperature and deterioration in the general state: the sleep is interrupted, appetite falls, irritability, a capriciousness appears. All these phenomena are stronger expressed at plentiful rash. On 3 — the 5th day if new rashes do not develop, temperature decreases and the general condition of the patient improves. From blood in the period of a rash the small leukopenia, a neutropenia, a relative lymphocytosis is observed.
Lakes vary abundance of rash and weight of the general manifestations at V. Along with the rudimentary form which is shown a rash of single papules and vesicles in the absence of fever severe forms with very plentiful rash, a hyperthermia and the expressed symptoms of intoxication occur (more often at adults).
The big rarity is represented by cases of specific varitsellezny damages of internals (small ochazhka of a necrosis): lungs, liver, spleen, kidneys, etc. Such generalized V. of the lake occurs at sharply weakened subjects, sometimes after the previous long hormonal therapy and use of immunodepressants.
Even less often such malignant forms B. of the lake as gangrenous and hemorrhagic meet. At the gangrenous form arising at the exhausted sick children, especially in the conditions of bad leaving as a result of accession of consecutive infection, on site bubbles necrotic strupa at which falling away deep ulcers with a dirty necrotic bottom and the abrupt or subdug edges are bared are formed; the current is long, are frequent is purulent - septic complications.
The hemorrhagic form occurs also at sharply weakened children. On observations of a number of authors, this form quite often develops at the children receiving corticosteroids to infection or in an incubation interval. On 2 — the 3rd day of a rash contents of vesicles accept hemorrhagic character; there are hemorrhages in skin and mucous membranes, nasal bleedings, a hematemesis. These three forms of a disease can lead to a lethal outcome.
Complications at V. lakes are rare. At emergence of vesicular rash on a mucous membrane of a throat the picture of laryngitis, sometimes with the phenomena of a stenosis of respiratory tracts (a varicellous croup) develops. Accessions of consecutive infection can result a violent streptoderma (varicella bullosa), abscesses, phlegmon, an ugly face, stomatitis, otitis, lymphadenitis, pneumonia, sepsis and very seldom arthritis, a glomerulonephritis, myocarditis, encephalitis, encephalomyelitis. Primary pneumonia arises in the first days of a disease usually in the presence of a plentiful skin rash. The consecutive bacterial infection joins. General serious condition, high temperature; short wind, cyanosis, cough, sometimes with a bloody phlegm. Radiological in lungs multiple ochazhka are found. At V.'s disease of the lake of women at the end of pregnancy premature births and a still birth are possible; at mortinatus small ochazhka of a necrosis in internals are found. Authentic instructions for V.'s role the lake in development of embryopathies is not published.
The diagnosis and the differential diagnosis
Usually the diagnosis does not represent difficulties. Difficulties arise at suspicion of natural smallpox. The initial stage at natural smallpox is followed by substantial increase of temperature and severe pains in a sacrum; unlike V. of the lake, the rash is followed by decrease, but not rise in temperature. Elements of rash at natural smallpox have considerable density and are located in the thickness of skin on the infiltrirovanny basis; pockmarks are multichamber, are not fallen down at a puncture, have umbilicate impression. On this or that limited site of skin all elements, unlike V. lakes, are in one stage of development (monomorphism). Data epidemiol, the anamnesis and laboratory researches are of great importance for differential diagnosis.
Impetigo differs from V. in the lake preferential localization on a face, hands, flabbiness of bubbles with bystry disturbance of their integrity and the subsequent formation of purulent crusts.
At a strophulus, unlike V. the lake, elements of rash have big density, hl are localized. obr. on a waist, buttocks, an extensor surface of extremities are also followed by a severe itch; temperature increase is not observed. Current long.
With V.'s scarlet fever of the lake it can be mixed in case of a rash of prodromal scarlatiniform rash. Usually there is a thought of simultaneous development of that and other disease. Scarlet fever can be excluded in the absence of quinsy, typical changes of language and pallor of a nasolabial triangle. In some cases specification of the diagnosis requires observation within 1 — 2 days.
In laboratory diagnosis use morphological and serological methods, and also allocation of the activator. Morfol. methods include detection of a virus (Aragan's little body) in painted (e.g., silvering according to Morozov) smears of vesicular liquid at light microscopy. Much more effective is use for the same purpose of a submicroscopy. In this case identification of virions from group of herpes, characteristic of viruses, allows to confirm with morphology in combination with clinical and other data V.'s diagnosis about and to exclude the diseases caused by viruses of smallpox group. The main serological method is reaction of binding complement (see), to-ruyu use as for identification of varicellous antigen (in the presence of serum of convalescents of V. of the lake, shingles or hyperimmune serum of animals), and the specific antibodies appearing in serum of the patient on 4 — the 5th day after a rash. Isolation of the activator B. of the lake (from skin defeats of patients or bodies of the dead) is carried out in cellular cultures (the most sensitive the culture of cells of a thyroid gland of the person is). Detection of a virus in cellular cultures is possible also by means of a method of fluorescent antibodies (see. Immunofluorescence ).
At V. of the lake proceeding without complications necessary is only a gigabyte. keeping of the patient, prevention of consecutive infection. Bathtubs with weak solution of potassium permanganate, respect for purity of hands of the patient are recommended. For acceleration of drying of a vesicle grease 1 — 2% with solution of potassium permanganate, 1% spirit of tetraethyl-diamino-triphenyl-carbohydride sulfate, apply indifferent ointments. The oral cavity should be rinsed periodically weak disinfecting solution.
At development of purulent complications apply antibiotics. At the weakened patients at a prolonged sluggish reparation carry out the stimulating therapy: injection of plasma, gamma-globulin, blood and so forth. Treatment of neurologic complications (encephalitis, meningoentsefalit) and pneumonia is carried out by the general rules of treatment of these diseases. The issue of use of hormonal therapy by various authors is resolved is contradictory. Special observations [Kotova, Bradachova (A. Kottova, M. of Bradacova), 1964] showed that kortikoida are valuable addition to the therapeutic complex used at meningoentsefalita.
V. of the lake, as a rule, comes to an end with an absolute recovery. Deaths are exclusively rare — 0,01 — 0,05% [E. Tyzzer], are caused, as a rule, by the joined consecutive, septic infection; are less often observed at V. by the lake with generalization. Cases of death from V. by the lake at patients with an acute leukosis, treated hormones and cytostatics are described. Century of the lake worsens the course of many infectious diseases (whooping cough, scarlet fever, flu, etc.). promoting development of complications; it can activate chronically proceeding infections (dysentery, tuberculosis).
At detection of a case of sick V. of the lake is subject to isolation (in house conditions); isolation stops 5 days later from the moment of the last rash. In the conditions of hospital department of the patient it is isolated in boxing. Early isolation of the first patient can be effective in epidemiol, the relation. After isolation of the patient airing of the room is made. Disinfection is excessive.
The children of babyhood (up to 3 years) who were in contact with sick V. of the lake and not being ill before this infection are isolated from the 10th to the 21st day, beginning from the moment of contact. For the purpose of a seroimmunity intramuscular administration of gamma-globulin (3 — 6 ml) is recommended to the children contacting to the patient. According to a number of clinical physicians, this method reduces incidence and softens disease in cases if it nevertheless develops. There are instructions on successful use of a live vaccine from the attenuirovanny (weakened) virus strain of V. of the lake (V. I. Iovlev et al.).
Bibliography: Vertsner V. N. Chicken pox, M., 1963, bibliogr.; At r in and the p E. B. Chicken pox, Mnogotomn, the management on mikr., wedge, and epid, infekts. diseases, under the editorship of H. N. Zhukova-Verezh-nikova, t. 8, page 472, M., 1966; Zhdanov B. M and Gaydamovich of S. Ya. Virusologiya, page 449, M., 1966, bibliogr.; Ivanovskaya T. E. Chicken pox, Mnogotomn, the management on a stalemate. annate., under the editorship of A. I. Strukov, t. I, page 142, M., 1960, bibliogr.; Laboratory diagnosis of viral and rickettsial diseases, under the editorship of E. Lennet and N. Schmidt, the lane with English, page 596, M., 1974; S. D Noses. Chicken pox, Mnogotomn, the management on pediat., under the editorship of Yu. F. Dombrovskaya, t. 5, page 440, M., 1963, bibliogr.; The general and private epidemiology, under the editorship of I. I. Elkin, t. 2, page 99, M., 1973; With t at to with G. G. Chicken pox, M., 1958, bibliogr.; D. S footer. Diseases of a nervous system at children, page 169, M., 1965; In r u n e 1 1 P. And. Varicella-zoster infections in pregnancy, J. Amer. med. Ass., v. 199, p. 315, 1967; Krugman S., Goodrich Ch. H. a. Word R. Primary varicella pneumonia, New Engl. J. Med., v. 257, p. 843, 1957; Meurisse E. Laboratory studies on the varicella-zoster virus, J. med. Microbiol., v. 2, p. 317, 1969.
C. D. Nosov; T. E. Ivanovskaya (stalemate. An.), S. S. Marennikova (etiol., lab.diagnostika).