HAY FEVER

From Big Medical Encyclopedia

HAY FEVER (leptospirosis) — the acute infectious disease from group of zoonoz caused by leptospira with preferential damage of kidneys and a liver, a cardiovascular and nervous system.

The diseases which were earlier defined separately depending on a serotype (serological option — a serovar) leptospir, are considered as a wedge, options of one nosological form. Differences in a wedge, a picture of various options L., in particular icteric and anicteric, preferential consist in the nature of changes of pigmental exchange; the pathogenetic essence of process remains uniform.

History and geographical distribution

Klin, description of a severe form of L. it is for the first time given by Veyl (A. Weil, 1886) and N. P. Vasilyev (1888). Etiology of L. it was established by A. Inada's works et al. (1915), Hübner, Reuters (H. Hubner, N. to Reiter, 1915), P. U flax a gutta and Fromm (W. Fromme, 1915). The found microorganism at first received several names — Spirochaeta icterohaemorrhagiae, S. nodosa, S. icterogenes, etc., and then Leptospira interrogans. In the subsequent Ido (Y. I do) et al. (1918), S. I. Tarasov (1928) and others it was shown that L. can proceed also in the anicteric forms caused by different serotypes leptospir. In 1938 I. Tersky and M. V. Zemskov proved that the icterohemoglobinuria of cattle is L.

Till 60th 20 century described two forms L.: icteric (Vasilyev's disease — Veylya, ikterogemorragichesky L.) and anicteric (water, mowing fevers, etc.).

L. treats eurysynusic inf. to the diseases registered on all continents (apprx. 70 countries). People are ill L. more often in yuzh. the countries, especially in low and wet areas with hot and tropical climate,

the Official accounting of incidence of people of L. in many countries it is not conducted or only severe forms of a disease proceeding with jaundice are considered. In this regard indicators of incidence of L. among people in various countries fluctuate in considerable limits.

Etiology

Activator L. — the leptospira — belongs to this. To Spirochaetaceae, sort Leptospira. This sort contains one pathogenic look — Leptospira interrogans (Stimson, 1907) Wehyon, 1926, divided into 18 serogroups and numerous serotypes. In addition to pathogenic leptospir, in the nature there are also saprophytic leptospira.

Fig. 1. Diffraction pattern of a leptospira (habit view); X 8000.
Fig. 2. Diffraction pattern of a leptospira (fragment): 1 — axial filament; 2 — protoplasm with a cover; x 30 000

Leptospira represents a long shtoporoobrazny cell (length of 10 — 15 microns, to dia. 0,2 — 0,25 microns) from the ends bent in the form of hooks has the axial filament twisted with protoplasm, it is covered with a thin unstructured cover (fig. 1 and 2). For leptospir the difficult and vigorous movement, most often rotation around the long axis is characteristic. Cultivation leptospir is successfully conducted at t ° 28 ° on various liquid mediums which are usually containing

3 — 5% of rabbit serum. Methods of cultivation leptospir and on dense mediums are developed. The culture leptospir, grown on 4 — the 5th day in a liquid medium, does not change its color and can be found only during the viewing of a drop of the environment in a dark field of sight of a microscope. Leptospira are among microorganisms, unstable to adverse environmental factors. It is long survive in water and the decaying organic material (to 2 — 3 weeks), on foodstuff — several days.

Epidemiology

Owners leptospir are various look animals, representatives of four classes of vertebrata — mammals, amphibiouses, reptiles and birds. The person as a source of contagiums practically does not matter. Distinguish two types of the centers of L. — natural and antropourgichesky, each of to-rykh has the epidemiological and epizootological features.

The natural centers meet ranging from 67 °C. highway to 40 ° SL in uninhabited places, in the crude stations (floodplains of the rivers, lowlands, swamps, the crude woods, etc.) which grew with the grassy vegetation forming a food supply for animals — owners leptospir. A source of activators in the natural centers are mammals of groups of rodents, insectivorous, ascigerous, artiodactyl and predatory, to a lesser extent reptiles, Amphibia and birds. Rodents from this have the greatest value. homyakoobrazny (voles, muskrats, hamsters, etc.) and mysheobrazny (mice, rats). Infectiousness of L. these little wild beasts in various centers depends on their number, age, season, relief, etc. fluctuates from several percent to 50 — 60% and above. High infectiousness of L. in a number of the European and domestic natural centers it is revealed at voles (a vole housekeeper, an ordinary vole, the Far East vole, etc.).

From rodents in the natural center strains leptospir, belonging to various serogroups, napr are allocated, in the European part of the USSR find preferential strains from serogroups of Grippotyphosa, Pomona, Hebdomadis, Icterohaemorrhagiae, Canicola, etc. Many researchers claim that there is a communication between serotypes leptospir and species of rodents — their carriers. So, from a field mouse allocate leptospira from a serogroup of Pomona, from a vole housekeeper more often — from serogroups of Grippotyphosa, and from rats — from a serogroup of Icterohaemorrhagiae.

Infectiousness of rodents and other animals in the natural centers of L. it is presented in the table.

The Leptospirozny infection at rodents proceeds in hron, a form with formation of a carriage and long leptospirouriya. According to V. V. Ananyin and E. V. Karasyova (1961), a leptospira, concentrating in kidneys of rodents, can be allocated with urine within 188 days. Infection of rodents in the center is possible during the eating of the plants contaminated by urine of a sick animal through the infected water and at sexual contact.

Infection of L. people in the natural centers occurs through the water of open reservoirs (during the work in water, bathing, washing of linen, etc.) infected with animals — leptospironositel. Leptospira can get into a human body both through skin, and through mucous membranes, including a mucous membrane of intestines. Usual places of infection are the temporary reservoirs appearing after floods of the rivers, swamps, ponds, streams and small small rivers with drift of water.

The role of blood-sicking arthropods in transfer of activators from a sick rodent to the person is denied, however there are messages on allocation leptospir from the ticks removed from sick animals or who are brought together in the natural center of L.

Among the diseased in the natural centers the persons which are carrying out various pages prevail - x. works (haymaking, cleaning of vegetables, etc.). The disease can have mass character and strike hundreds and even thousands of people. Especially big epidemics of L. are described in the past among the people working in the natural centers after heavy rains and floods of the rivers.

The disease has the expressed seasonality (June — August). In the tropical countries disease of people of L. in the natural centers it is connected with work on plantations of rubber, a sugarcane, rice, etc. Reasons to believe are had that on formation of the natural centers of L. physical influences. - chemical composition of water and the soil. In areas where water has acidity or the increased content of mineral salts, L. it was not observed.

The Antropourgichesky centers meet in rural areas and in the cities. The rural antropourgichesky centers are connected with existence of L. preferential among page - x. animals (large and small cattle, pigs, horses, etc.), and also dogs and rats. Cattle and pigs have the greatest value as a source of activators. Epizooty of L. among page - x. animals are described in many countries of the world and, according to the Soviet authors, these animals in 90 — 95% serve as a cause of illness of people. At cattle of L. the wedge, signs can proceed as asymptomatically, and with pronounced: high temperature, diarrhea, emergence of jaundice and haemoglobinuria, damage of skin and mucous membranes. The disease at animals is characterized by decrease in a yield of milk of milk, mass abortions, a high lethality, especially among young growth. The had animals can remain leptospironositel up to 3 — 5 months. The carriage of leptospira occurs among healthy animals to 3%. According to the Soviet researchers, at sick animals antibodies to the following serogroups leptospir come to light: Hebdomadis (64%), Pomona (12%), Tarassovi (9%), Grippotyphosa (4%), Icterohaemorrhagiae (2%), Canicola (1%) and to other serogroups (8%). Character a wedge, diseases is not caused by a serotype of a leptospira.

L. at pigs it is described almost in all countries of Europe, North and South America, Asia and in Australia. The prevalence of pigs in nek-ry areas can reach 50 — 60%. The wedge, symptoms of a disease at them are shown in the form of temperature increase, numerous hemorrhages on mucous and serous membranes, jaundices, necroses of sites of skin, etc. At pregnant animals in 20 — 50% abortions are observed. In most cases, however, L. at pigs proceeds in the latent form or in a look hron, process. Asymptomatic forms in nek-ry farms can be noted almost at 100% of pigs. A part of the had animals remains leptospironositel (till 1 year), the carriage of leptospira can be observed also at healthy pigs. Strains leptospir, allocated from pigs, in the majority belong to serogroups of Pomona and Tarassovi. Sheep, goats, horses, buffalo s have smaller value as a source of causative agents of leptospirosis. The role of birds in preservation and spread of a leptospirozny infection in the rural center is definitely not established, but, probably, it is small. Transfer of activators L. at page - x. animals occurs through the water and a forage (including underfoot on pastures) contaminated by urine of sick animals or healthy leptospironositel. Leptospira get into an organism of an animal through a mucous membrane of a mouth and intestines or through integuments (bathing). It is possible that transfer leptospir at animals happens sexually since pathogenic leptospira were repeatedly allocated both from seed plants, and from sperm. Infection of people in the rural center of L. perhaps all the year round, but mass diseases are registered more often in the summer in the form of the flashes of water type connected with bathing or use for drink and economic domestic needs of water of open reservoirs. These centers of L. are characteristic for yuzh. districts where water of open reservoirs is widely used by the population for bathing and economic needs, sometimes and for drink. In hot time of day animals (especially cattle) stand hours in water of the small uncomfortable ponds, small rivers etc., contaminating them the allocations. Also not disinfected drain waters near the located livestock farms can be the cause of pollution of such reservoirs. Flashes of L., connected with water, in the rural centers are usually characterized by emergence in a short time term of a large number of the diseased and sharp recession of incidence after carrying out protivoepid, actions. Smaller value in the rural centers of L. has food infection (through milk) and infection at patient care with animals or at slaughter and cutting of carcasses of these animals. L. professional character it is established among employees of the meat-processing plants, pig-tenders, milkmaids, grooms and other workers occupied with page - x. animals. To a certain risk of infection of L. also the personnel of fur farms are exposed (silver-black and red foxes, etc.). Diseases of L. these animals are repeatedly described as in the USSR, and abroad.

The city antropourgichesky centers are connected with L. at gray (R. norvegicus) and black (R. rattus) rats, and also at dogs. The Leptospirozny infection at rats proceeds latentno with the subsequent sedimentation leptospir in kidneys and their allocation to the environment with urine more often.

During the studying of infectiousness of rats of a leptospirama it is revealed that in Paris in 1920 it made 10%, in London in 1922 — 30%, in New York in 1922 — 17,2%, in Warsaw in 1923 — 20%, in Leningrad in 1936 — 6,2%, in Vienna in 1937 — 39,5%, in Lisbon in 1943 — 35,7%, in Moscow in 1941 — 1,3%, in Amsterdam in 1965 — 30,4%. In most cases the leptospira allocated from rats belong to a serogroup of Icterohaemorrhagiae. Incidence of people of L. usually sporadic also does not reflect intensity of an epizooty among rats in the cities. Only considerable disturbances dignity. wellbeing of the city can cause a mass disease of L. population. The flash of L can be an example of it. in Leningrad, arisen in 1942 in severe days of blockade. Nek-roye value as source of L. in the city center dogs can have. The Leptospirozny epizooty among dogs is described in the 30th in Holland, and then and in other countries (Denmark, England, Spain, Germany, GDR, Hungary, the USA, Australia, Japan, etc.). The strains allocated from dogs leptospir belonged preferential to a serogroup of Canicola. Value of cats as source of L., probably, it is insignificant.

The pathogeny

the Activator gets into a human body through a mucous membrane of intestines, a conjunctiva, skin, without causing inflammatory changes on site of implementation. Even imperceptible damages, skin scratches, attritions can become infection atriums. In 5 — 30 min. after an invasion of a leptospira the blood flow and a lymph brings in the bodies rich with reticuloendothelial fabric, hl. obr. to a liver, kidneys, a spleen where they quickly breed and again come to blood. To 3 — to the 5th day of a disease the leptospiremiya reaches full development that is shown by intoxication, a hyperthermia. During generalization of a leptospira can be found in blood and cerebrospinal liquid where they get, having broken a blood-brain barrier. Along with the strengthened reproduction of the activator there is a process of destruction of microbic bodies, release of biologically active agents of an endogenous origin. Accumulation in blood of decomposition products leptospir leads to a sensitization of an organism, emergence of giperergichesky reactions. The major pathogenetic factor is defeat of circulatory capillaries. Increase them permeability (see) it is clinically shown by a hemorrhagic syndrome, in an origin to-rogo great value have thrombocytopenia (see) and decrease in coagulability of blood (see. Coagulant system of blood ). Inflammatory process in hepatocytes quite often is followed by an icteric syndrome (see. Jaundice ).

In the course of a disease in blood specific antibodies are shown, under influence to-rykh a leptospira disappear from blood by the end of the 1st week of a disease. In late terms there is an intensive accumulation leptospir in kidneys and their allocation to urine. Damage of gyrose tubules of kidneys leads to disturbance of an uropoiesis, up to anuries (see) and uraemias (see).

Pathological anatomy. On opening usually find jaundice, displays of hemorrhagic diathesis and dystrophic changes in parenchymatous bodies. The endothelium of capillaries giperplazirutsya, develops fatty infiltration of its cytoplasm with the subsequent desquamation. Puffiness, a thickening is quite often observed, fibrinoid swelling of nek-ry arteries and veins is more rare. Inflammatory changes of vessels are absent. Owing to a capillaropathy and the subsequent thrombosis of larger vessels there are multiple hemorrhages in kidneys, lungs, an endocardium, an epicardium, mucous membranes went. - kish. a path, and also in integuments and a conjunctiva. Massive hemorrhages in vitals are less often observed that can be one of causes of death at any stage of a disease, including early terms. Also pneumonic centers are observed. Massive hemorrhages in both adrenal glands can become a proximate cause of death.

In heart diffusion small-drop obesity of muscle fibers is observed, interstitial meets less often myocarditis (see), followed by expansion of cardial cavities and smoothing of its top.

The liver is surprised from the very beginning of a disease, in 26 — 80% of cases it is increased. Massive and focal necroses are absent, there is a necrosis of separate cells. Proteinaceous and fatty dystrophy of hepatocytes, a diskompleksation of frame structures, and also adjournment of bilious pigments in cells of a liver and a nek-swarm expansion of the bilious courses is noted.

Rather the strengthened reproduction of hepatocytes is early observed that is expressed in emergence of two - and multinucleate cells, especially in the centers of segments. Filling around sinusoidal spaces (perisinusoidalny spaces of Disse) by serous and hemorrhagic exudate and proliferation of kupferovsky cells is described. The phenomena of an erythrophagocytosis and moderate reactive processes on the course of a fibrous cover (the glissonovy capsule) are treated as reaction to destruction of erythrocytes. There is a bystry increase in blood of the pigments which are processed into bilious pigments.

Increase in a spleen is defined in x / z cases. Its weight can reach 400 — 500 g, i.e. by 2 — 3 times to exceed usual. Microscopically find many plasmocytes in a red pulp, neutrophils, observe the phenomenon of an eritrofagiya and «gemoglobinovy drops» in an endothelium of vessels; hemorrhages meet. In follicles of a spleen — a hyperplasia of cells of a reticuloendothelium. Similar changes are described also in regional limf, nodes, preferential mesenteric.

Fig. 3. Microdrug of tissue of kidney at a hay fever: melkoochagovy kruglokletochny infiltrates in an interstitium of a kidney (are specified by shooters); X200.

Damages of kidneys at L. most often reveal in late terms of a disease. At this time leptospira begin to be removed with urine. On opening of a kidney icteric are considerably increased in sizes, flabby, on a section. Hemorrhages in marrow and pararenal cellulose can meet. Histologically the picture of a nephrosis prevails, up to a necrosis of an epithelium of gyrose tubules. Balls are surprised less, than tubules. In a gleam of tubules leptospira can be found. Along with the phenomena of a nephrosis melkoochagovy kruglokletochny infiltrates in an interstitium of a kidney (fig. 3) are possible.

As a rule, the c is surprised. the N of page, at the same time is observed hypostasis of a soft meninx and tissue of a brain, sometimes focal hemorrhages, dystrophic changes of nervous cells with the centers of loss, demyelination of nervous trunks with lymphoid infiltrates on the course of nervous bunches. Necrobiotic ochazhka in substance of a brain contact thrombosis of small vessels.

Hemorrhages in cross-striped, especially gastrocnemius muscles, a coagulative necrosis, vacuolation, disintegration of separate muscle fibers, cellular infiltrates are noted.

For identification leptospir in fabrics it is possible to recommend coloring across Levaditi (see. Levaditi method ).

Immunity

After the postponed disease forms strong and life-long immunity. The leading role in protection of an organism belongs to factors of humoral immunity. The possibility of the recurrent disease caused by other serotypes leptospir is not excluded.

The clinical picture

the Clinical picture differs in considerable variety — from a short-term feverish state to extremely severe forms which are coming to an end with a lethal outcome. The incubation interval of 3 — 20 days, is more often than 6 — 14 days.

Only gradual development of L is occasionally observed. in the form of an indisposition, weakness. In the majority of cases the disease begins sharply. Patients call not only day, but also hour of suddenly begun disease. Usually among full health there is a chilling soon passing into the tremendous fever which is replaced by heat. Temperature increases to 38 — 40 °, has remittiruyushchy character, sticks to 5 — 8 days, and then decreases critically or as the accelerated lysis. A recurrence is possible — approximately in 7 — 8 days after the end of the feverish period temperature increases again and the symptoms of a disease which were usually less expressed in comparison with the first wave repeat. 2 — 3 recurrence were in some cases observed. In process of development of a leptospiremiya intoxication accrues: appetite disappears, there are nausea and vomiting, a headache, the nonsense, a loss of consciousness are sometimes possible. The sharp weakness adjoining on prostration develops. Often patients remain in a bed in a condition of an immovability because of the expressed muscular pains. Especially pains in gastrocnemius muscles of such intensity disturb that patients hardly move, hardly keeping standing. Only in some cases muscular pains can be absent. Quite often there are pains in a stomach connected with damage of belly muscles. Afterwards mialgiya is replaced by long muscular weakness.

The type of the patient is characteristic: the bright hyperemia and puffiness of the person, the expressed injection of vessels of scleras, are possible massive hemorrhages under a conjunctiva. In early terms rozeolezno-papular or punctate scarlatiniform ephemeral rash develops. In hard cases it gains petekhialny character. Herpetic rashes on lips, at wings of a nose, an enantem of a mucous membrane of a pharynx are frequent. At the height of a disease hemorrhagic manifestations are possible: persistent nasal bleedings (see), a hematemesis (see. Hematemesis ), melena (see), hamaturia (see); on places of subcutaneous injections, intravenous injections there are traces in the form of extensive bruises.

In lungs sometimes there are catarral phenomena of the nonspecific nature. Cough, the pneumorrhagia connected with the increased vascular permeability is observed. Borders of heart within norm, muting of tones, emergence of systolic noise in a top is noted. Pulse is more often slowed down, sometimes tachycardia, arrhythmia. The tendency to development of hypotension due to decrease in hl is defined. obr. diastolic pressure. In hard cases the collapses, the following one by one accepting long character are possible.

With 3 — the 4th day of a disease emergence is possible jaundices (see). It quickly accrues, sometimes literally for several hours, and soon skin gets intensive and saffron-yellow coloring. Degree of an ikterichnost to a certain extent corresponds to weight of disease. By the time of developing of jaundice the sizes of the liver acting on 2 — 3 cm from under a costal arch as dense painful edge considerably increase. The liver remains increased throughout all feverish period and in more remote terms even in the conditions of the developing hepatargy.

From the first days of a disease so demonstrative symptoms of defeat of c are observed. N of page that nek-ry authors allocate a meningeal form L. There is a sharp headache, persistent sleeplessness, block or a hyperexcitability. Quite often nevrol, the symptomatology is limited meningism (see), but at a heavy current serous meningitis can develop (see). In these cases the stiff neck, positive Kernig's signs and Brudzinsky, unstable patol, the reflexes disappearing from survey to survey come to light. At a puncture cerebrospinal liquid follows frequent drops — transparent, sometimes xanthochromatic, opalescent. The disease proceeds as lymphocytic meningitis with the expressed proteinaceous and cellular dissociation.

In some cases, usually in the presence of the meningeal phenomena, mental disorders can develop (see. Infectious psychoses ); more stoutly they are investigated at anicteric forms. Their beginning is followed by disturbance of a rhythm of a dream, the suppressed mood is observed. Further there comes stupefaction on delirious type, but there can be also amental states. At patients hallucinations are observed, they state the sketchy crazy ideas of prosecution, are excited, auditory hallucinations prevail over visual and olfactory, the nonsense sometimes has the prof. character. With normalization of temperature consciousness clears up and the state emotional giperesteticheskoy weaknesses is established. In a wedge, a picture the suppressed mood attracts attention, a cut can reach degree of the expressed depression. Patients complain of easing of memory, development of a syndrome of Korsakov is described (see. Korsakovsky syndrome ). Duration of a state emotional giperesteticheskoy weaknesses of 3 — 6 weeks.

Mental disorders at L. in the majority have a favorable current: patients in 4 — 6 months after hospitalization usually are returned to former activity.

In development of a disease into the forefront symptoms of damage of kidneys act. Considerably decreases diuresis (see), in urine appear protein, cylinders, the azotemia accrues. During this period the ABP raises. Disturbance of glomerular filtering and a canalicular reabsorption leads to an anury (see). Gradual increase of a diuresis marks a change towards involution of a disease. The oliguria is replaced by a polyuria, the health improves, there is an appetite, the headache abates, jaundice decreases, but weakness as one of signs of a postinfectious adynamy remains for a long time. The general duration of a disease makes apprx. 4 weeks.

Heavy current of L. characterize three main signs: anury, hepatargy (see) and hemorrhage. However these terrible symptoms are expressed not always. In most cases the disease proceeds in a medium-weight and easy form with the short-term fever moderated by intoxication, small muscular pains. Increase in a liver is not followed by jaundice, changes of kidneys come down to quickly passing albuminuria and a cylindruria, funkts, tests of a liver and kidneys are a little broken, the diuresis remains normal.

Complications

damage of heart is Quite often observed. Elektrokardiograficheski of change in a look myocarditis (see), endocarditis (see) come to light more often than it was supposed earlier. In the period of the beginning reconvalescence development is possible polyneuritis (see), the numbness of fingers of hands which is followed by feeling, decrease in sensitivity. Gradually these phenomena pass. Sometimes there are irites, iridocyclites (see), uveites (see). According to M. M. Sakharova (1968), an outcome of eye complications favorable, but in 4,5% of cases they ended with a cataract, and in 1,8% — a partial atrophy of an optic nerve. Falloff of body resistance can lead to development of pneumonia, otitis, purulent parotitis.

The diagnosis

the Diagnosis is established on the basis epidemiol, the anamnesis, a wedge, pictures and results a lab. researches. At poll of the patient it is necessary to obtain perhaps more complete information about the conditions of the environment, circumstances preceding a disease. Quite often it is possible to establish that the diseased by the nature of the prof. of activity (page - x. workers, personnel of meat-processing plants, fur farms, the workers servicing the sewerage, faces which are engaged in cleaning of the inhabited places) adjoined to rodents, in particular to rats. In some cases it is possible to establish that the first symptoms of L. appeared in 7 — 12 days after swimming in the shallow-water rivers, reservoirs with landlocked water. Value epidemiol is big. the anamnesis in recognition of the group diseases connected with field pages - x. works. From here such synonyms of L., as meadow, water, mowing fever that emphasizes value of the prof. of a factor, the geographical landscape inherent in this natural and focal disease (see. Natural ochagovost ).

At assessment a wedge, data such signs as the acute beginning with a fever and a hyperthermia, gastrocnemius muscle pains, a headache, the expressed injection of vessels of scleras, rash, herpes, nasal bleedings, increase in the sizes of a liver, jaundice, an oliguria, patol, elements in urine, Meningeal symptoms are considered. Kliniko-epidemiol. data are the sufficient basis to suspect L.

Laboratory researches facilitate diagnosis. From the first days increase in quantity of leukocytes up to 20 — 30 thousand with the expressed neutrophylic shift to the left, sometimes to young and myelocytes is noted. The disease is heavier, the leukocytosis is higher and the more the neutrophylic shift is expressed. The quantity of eosinophils almost always decreases, plasmocytes appear. ROE differs in big constancy: it accelerates to 40 — 60 mm an hour and even exceeds these indicators. The hypochromia anemia reaching the greatest degree in the period of recovery develops. Considerably the hemoglobin content decreases, coagulability of blood is slowed down that is confirmed by koagulogrammy. In process of development of an icteric syndrome the content of bilirubin in blood increases to 15 mg of % and above at the expense of a straight line and to a lesser extent indirect fraction. Activity of enzymes, in particular aminotransferases, is moderately increased or remains within normal amounts that speaks about existence inflammatory more (but not necrotic) process in a liver. Diagnostically an important sign is increase in level of residual nitrogen to 60 mg of % and higher rates (see. residual nitrogen ); level of urea and creatinine increases. In urine find protein (0,33 per milles and above), erythrocytes, cells of a renal epithelium, cylinders — hyaline and granular, wax-like are more rare.

Laboratory the diagnosis is confirmed by allocation leptospir from blood, cerebrospinal liquid, urine of the patient, detection of specific antibodies (agglutinins, lysines, etc.) and infection lab. animals.

For receiving a hemoculture leptospir the blood of the patient (8 — 10 ml) taken to 4 — the 5th day of a disease, is sowed on 0,5 — 1,0 ml in test tubes with a liquid medium, to-rye are located in the thermostat (at t ° 28 °) and are periodically looked through. Receiving a hemoculture confirms the diagnosis. In the period of reconvalescence it is recommended to carry out microscopy and crops on liquid mediums of sterilely collected urine.

Great value at establishment of the diagnosis of L. have data serol, researches; the greatest distribution was gained by reaction of micro agglutination (see. Agglutination ). Due to the high specificity of reaction for this purpose recommend to use the reference driagnostikuma prepared from strains leptospir various serogroups — Icterohaemorrhagiae, Javanica, Celledoni, Canicola, Ballum, Pyrogenes, Cynopteri, Autumnalis, Australis, Pomona, Grippotyphosa, Hebdomadis, Bataviae, Tarassovi, Panama, Shermani, etc. Reaction of microagglutination is put in 4 — 6 drops of mix of culture leptospir and the studied serum and considered in a dark field of sight of a microscope after a 2-hour incubation of mix at t ° 37 °. At the same time formation of the agglomerates consisting from live whole or partially lizirovanny leptospir is observed. At low cultivations of serum also a full lysis leptospir can be observed. Cultivation of serum is considered positive reaction, at Krom not less than 50% leptospir are agglutinated. At a single research reaction of microagglutination is considered positive from a caption 1: 100 and above. In doubtful cases repeated statement of reaction (in 7 — 10 days) for the purpose of identification of increase of a caption of agglutinins is recommended. The diagnostic caption of agglutinins appears at the sick person on the 2nd week, in the subsequent it can reach high figures (1: 100 000 and above) it is also long to remain. It allows to recommend reaction of microagglutination and for retrospective diagnosis of L. leptospir apply reaction of adsorption of agglutinins as Castellani's reaction to typification of the allocated strains (see. Castellani method ).

Infection lab. animals (biological test) it is made intraperitoneally or subcutaneously by material from the sick person — blood (to 4 — the 5th day of a disease), cerebrospinal liquid or urine (in the period of reconvalescence). Hamsters, young Guinea pigs and rabbits suckers are most sensitive to leptospira. The Guinea pig at infection with her virulent strain leptospir gets sick in several days with temperature increase, falling of weight and emergence of jaundice. On opening icteric coloring of all fabrics, necrotic ochazhka in a liver and dot hemorrhages is observed (especially in lungs and adrenal glands). At animals detection leptospir in exudate of an abdominal cavity already on 2 — after its infection is possible the 3rd day that the lab is by the earliest method. to mean L. Sleduyet's diagnoses that only nek-paradise a part of svezhevydelenny strains leptospir causes a disease of animals. Leptospira of serogroups of Icterohaemorrhagiae, Bataviae, Pomona concern to them first of all. A big part pathogenic for the person leptospir does not cause a disease in animals.

The differential diagnosis

Difficulties in diagnosis arise owing to false interpretation such a wedge, signs as fever, jaundice (see), abdominal pains, Meningeal signs, hemorrhagic manifestations, an acute renal failure when separate symptoms mistakenly are accepted to an estimated disease. In these cases of L. it is necessary to delimit from flu (see), a viral hepatitis (see. viral hepatitis ), typhoid (see), paratyphus (see), holetsistopankreatita (see), serous meningitis (see), hemorrhagic nephrosonephritis (see) and others nozol, the forms similar on the symptomatology.

Treatment

Considering staging inf. process and profound changes in an organism from the first hours of a disease, attach great value to early hospitalization of the patient. Along with corrective actions on the activator methods of pathogenetic therapy are applied. Perhaps earlier protivoleptospirozny gamma-globulin and antibiotics are appointed. A single dose of gamma-globulin for adult 5 — 10 ml, for children at the age of 8 — 13 years — 3 ml intramusculary within 3 — 4 days; in total on a course of treatment respectively 20 — 30 and 10 ml. Along with the first days of a disease throughout all feverish period antibiotics are appointed, it is desirable with preliminary definition of sensitivity.

For the purpose of desintoxication intravenous drop injections of isotonic solution of glucose and low-molecular blood-substituting liquids — Haemodesum, reopoliglyukin are appointed; in cases of bleeding — a gluconate of calcium, Haemophobinum, Vikasolum, hemotransfusion and plasmas.

The amplifying jaundice with the phenomena of a liver failure (a hepatargy, nausea and vomiting) is a reason for intravenous administration of Prednisolonum on 15 — 30 mg and higher doses with the subsequent decrease in process of improvement of a condition of the patient, and according to special indications and hemosorptions . For fight against acidosis recommend intravenous injections of 3 — 4% of solution of Natrii hydrocarbonas on 50 — 100 ml, an oxygenotherapy. At a collapse appoint the means recovering the volume of the circulating blood, raising a vascular tone — a phenylephine hydrochloride, ephedrine, Phethanolum, noradrenaline and cardiac glycosides (strophanthin, etc.).

During the definition to lay down. tactics it is necessary to consider dynamics hepato-renal syndrome (see) to control funkts, a condition of kidneys and a liver. At the developing oliguria appoint 20% solution of a mannitol (1 g to 1 kg of weight), diuretics (furosemide, lasixum, veroshpiron). For improvement of a renal blood-groove and strengthening of a diuresis intravenously enter 10 ml of 2,4% of solution of an Euphyllinum under control of the ABP. If the applied means do not give effect and the resistant anury develops, use of an artificial kidney is shown (see. Hemodialysis ), quite often giving the next wedge, effect. In the presence of mental disorders appoint psychotropic drugs.

The forecast

the Forecast remains heavy at the accruing intoxication, insufficiency of kidneys and a liver, development of cordial weakness. The outcome of the disease in many respects depends from premorbidal states, terms of hospitalization and to lay down. tactics at various stages of a disease. The most frequent causes of death — uraemia, a collapse, a hepatic coma, bleeding. The lethality considerably fluctuates and continues to remain quite high, and not only among elderly people with the burdened anamnesis, but also with persons of young age. In cases of an easy and moderately severe current the forecast favorable.

Prevention

Prevention depends on character epid, the center and consists of a complex of administrative, veterinary and sanitary and medical actions.

In the natural centers where diseases of people are connected preferential with work in the infected reservoirs or with use of the infected water for economic domestic needs, it is necessary to prevent first of all contacts of these people with the infected water (providing the persons working in the center, waterproof footwear and rubber gloves, prohibition on bathing, use for drink and domestic needs disinfected by boiling or chlorination of water etc.). Along with it vaccination of the persons working in the natural center is reasonable (see. Immunization ). In the USSR for this purpose A. A. Varfolomeyeva and G. N. Kovalsky (1953) offered the corpuscular vaccine containing several serotypes leptospir. Vaccination carry out twice subcutaneously, in a dose of 2 and 2,5 ml at an interval of 7 — 10 days and in 1 year once a revaccination (2 ml).

In the natural centers carrying out deratization works is recommended (see. Deratization ). However a radical action for elimination of the natural center are meliorative works. Drainage of swamps, meadows, floodplains of the rivers leads to disappearance of marsh vegetation (a food supply of hygrophilous rodents) and falloff of number of rodents — the main carriers of a leptospirozny infection in the natural centers.

In the antropourgichesky rural centers where the main source of a leptospirozny infection are pages - x. animals, early detection of sick animals, their isolation and treatment, improvement of unsuccessful farms, observance of quarantine measures, specific prevention etc. is carried out. Workers of livestock production are provided with overalls and footwear. Special places for bathing and a watering place of the cattle, for bathing of people are allocated. One of effective protivoepid. actions at the water outbreak of leptospirosis prohibition of bathing and use of water from the open reservoir which served as the reason of infection of people is. Water both for drink, and for the economic and household purposes is used only after disinfecting. In unsuccessful on L. settlements inoculations are carried out.

In the antropourgichesky city centers the main thing in fight against L. deratization and protection of foodstuff and water from pollution is their rats. Considering a rarity of L., in usual conditions of an inoculation against L. in the cities are not carried out.

In all centers of L. patients are hospitalized on a wedge, to indications. Allocations of the hospitalized patients disinfect, as at intestinal infections. Among the population the dignity is carried out. - a gleam, work (about measures of prevention of L.).

Table. Infectiousness of separate species of rodents and other animals of a leptospirama in various years in some natural centers

Bibliography: Ananyin V. V. and Karasyov E. V. Natural ochagovost of leptospirosis, M., 1961, bibliogr.; Bashenin V. A. A new epidemic disease of the Moscow province — «water fever», the Gigabyte. and epid., No. 3, page 34, 1928; Bern-sovsky E. P., etc. Leptospirosis, Kiev, 1978, bibliogr.; Brenmans. M. Mental changes at anicteric a hay fever, Zhurn, a neuropath, and psikhiat., t. 57, appendix, page 62, 1957; Kiktenko V. S. Leptospirosis of the person, M., 1954; Leptospirosis of people and animals, under the editorship of V. V. Ananyin, M., 1971; Mitchenko I. K., Pletnev V. M. and With l about about d I would be a N yu to M. I. Some clinical features of leptospirosis, Doctor, business, No. 6, page 138, 1971; Pupkev and ch-D and and m and N of Ya. S. O of t clinical forms and clinical classification of leptospirozny diseases, Klin, medical, t. 48, No. 5, page 102, 1970; The Guide to infectious diseases, under the editorship of V. I. Pokrovsky and K. M. Loban, page 158, M., 1977; Sakharova M. M. Diseases of eyes at water fever, Grozny, 1968; Modern problems of studying of leptospirosis, the Report of the group of experts of WHO, the lane with English, M., 1968; Tersky V. I. and To about to about in and I. L. Leptospiroznye's N of a disease of people, M. 1964, bibliogr.; T about to and r e in and the p K. H. Leptospirosis, L., 1957; Works of the 4th All-Union conference on leptospirosis of the person and animals, M., 1967; At r Goma in B. L., etc. To differential diagnosis of a disease of Vasilyev — Veylya, the Doctor, business, No. 9, page 137, 1 976; And e-an Y. M of The pathologic anatomy and pathogenesis of fatal human leptospirosis (Weil’s disease), Amer. J. Path., v. 40, p. 393, 1962; Bergey’s manual of determinative bacteriology, ed. by R. E. Buchanan a. N. E. Gibbons, Baltimore, 1975, bibliogr.; Leptospiren und Leptospirosen, hrsg. v. J. Kathe u. H. Mochmann, Bd 1 — 2, Jena, 1967, Bibliogr.; Schiitz J., To 1 e i n e H. Page u. L and u f H. Septischer Verlauf einer Leptospirosis vom Serotyp grippotyphosa (Feldfieber), Z. arztl. Fort-bild, Bd 70, S. 939, 1976.


B. S. Kiktenko, B. L. Ugryumov; H. A. Maksimovich (stalemate. An.), D. S. Ozeretskovsky (psikhiat.).

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