MENINGOCOCCAL INFECTION Meningococcal infection [grech, meninx, meningos meninx + kokkos grain, stone (fruit); an infection] — the infectious disease with the drop mechanism of transfer of the activator which is characterized by local damage of a mucous membrane of a nasopharynx, generalization in the form of a specific septicaemia and an inflammation of a soft meninx.
M and. can be localized and generalized. The localized forms; a meningokokkonositelstvo, an acute nasopharyngitis, the isolated meningococcal pneumonia. Generalized forms: a meningococcemia (acute and chronic), a spotted fever (epidemic cerebrospinal meningitis), a meningococcal encephalomeningitis, the mixed form (a meningococcemia + meningitis), a meningococcal endocarditis, meningococcal arthritis (synovitis) or polyarthritis, a meningococcal iridocyclitis.
- 1 History
- 2 Etiology
- 3 The epidemiology
- 4 The pathogeny
- 5 Pathological anatomy
- 6 Immunity
- 7 A clinical picture
- 8 Complications
- 10 Treatment
- 11 Prevention
- 12 Features of a meningococcal infection at children
- 13 Tables
Clinic of acute meningitis, apparently, was known still to doctors of antiquity. However isolation of various forms meningitis (see) occurred relatively recently. The first descriptions a wedge, pictures of meningitis T. Villizy and T. Sydenham belong to 17 century. Practically studying of epidemic meningitis begins since 1805 when G. Vieusseux gave the authentic description of a disease at the outbreak of meningitis in Geneva. After this there were numerous works about epidemics of meningitis arising in Europe (France, Italy, Spain, etc.) and America. In Russia epidemic meningitis is for the first time noted in 1863 in the Kaluga province and in 1866 in Moscow. In the same years the disease is described in Asia, Africa, Australia.
Allocation of epidemic cerebrospinal meningitis in an independent nozol, a form happened after opening by A.Weichselbaum in 1887, its activator — gram-negative a diplococcus. At the end of 19 century the meningococcemia as a special form M. was described and., and at the beginning of 20 century messages on a meningococcal nasopharyngitis appeared. In 1965 the XIX World assembly of health care at the eighth review of the international classification of diseases entered the new name of a disease «a meningococcal infection».
Geographical distribution and statistics. At first 20 century M. and. was registered on all continents. The first and second world wars brought to epid, to rise in incidence in Europe, the USA and in other territories. In the 50th almost around the world there occurred recession of incidence. Since the beginning of the 60th increase in incidence of generalized forms M. is noted and. in the countries of Europe, Africa, in Canada.
M.'s incidence and. in Europe and in the USA makes from 1 to 12 people on 100 000 population. In Africa the indicator of incidence continues to remain very high: in Ghana (1948) — 268,3 on 100 000 inhabitants, in Nigeria (1962) — 62,5, in Niger (1962) — 536.
Generalized forms M. and. are characterized by a high lethality. Before use of causal treatment 50 — 60% of the diseased died; administration of antimeningococcal immune serum lowered this indicator by 2 — 3 times, and use of streptocides and antibiotics — by 5 — 6 times. In the majority of the countries the lethality is registered within 10%. The greatest lethality is noted at early age, especially till 1 year; with increase in age it decreases, but among persons 60 years are more senior about a half of the diseased dies.
Activator M. and. meningokokk — Neisseria meningitidis (Albert et Ghon 1903, Murray 1929) — has almost correct round form; its sizes from 0,6 to 1,0 microns. It is well painted by aniline dyes, gramotritsatelen. In smears of cerebrospinal liquid and blood of the patient, blood of an experimental animal of a cell are located parno; their surfaces turned to each other are slightly flattened; the capsule is outside noticeable. At cultivation on mediums the capsule is lost. The submicroscopy reveals on a surface of cells of svezhevydelenny strains of an eyelash (pili, fimbrias). Capsules and cilia play a role of factors of virulence: the first promote resistance of meningokokk to phagocytosis, the second — to their attachment to an epithelium. The three-layered cell wall of a microbe consists of proteins, glycoproteins, lipids and a lipopolisakharid. The last is endotoxin of a meningokokk and comes to the environment from a surface of cells.
Meningokokk is not mobile, the dispute does not form, is a little steady against external influences, however the increased air humidity (80 — 90%), availability of protective colloids (a secret of mucous membranes, saliva) promote preservation of its viability. Direct sunshine, temperature lower than 22 °, lead of drying to bystry death of a microbe. Under the influence of disinfectants in the form of solutions of phenol (1%), chloroamine (0,01%), hydrogen peroxide (0,1%) meningokokk perishes in 2 — 3 min.; it is sensitive to penicillin and its derivatives, levomycetinum, erythromycin; its sensitivity to tetracycline and streptocides considerably decreased; it is steady against Ristomycinum, lincomycin and Vancomycinum. Under the influence of penicillin, antibodies, a complement and other factors breaking rigidity of a cell wall of bacteria there occurs L-transformation of a meningokokk.
From exoenzymes the hyaluronidase and a neuraminidase providing penetration of the activator from the place of primary localization in intercellular spaces are found in a meningokokk. As well as all Neisseria (see), meningokokk possesses a catalase. Is an aerobe, splits glucose and a maltose to - t without formation of gas, does not reduce nitrates. Meningokokk is whimsical to culture conditions and does not grow in the first generation on simple mediums. Wednesdays shall contain a large amount of amino acids (amine nitrogen of 1,5 g/l), and also not identified growth factors which are in blood serum of mammals, exudates and egg yolk. An optimum of pH — 7,2 — 7,4. Stimulation of growth requires the increased humidity in the atmosphere, and during the use not enough full-fledged environments — another 5 — 10% of carbon dioxide gas.
Surface layers of a cell and the capsule contain a large amount of polysaccharide, to-rogo are a part aminosugar and sialine to - you. The composition of polysaccharides is not identical at different strains of meningokokk on the basis of what the last are subdivided into antigenic versions — serogroups of A, B, C, D, X, Y, Z and not identified strains. In 1976 the research group of WHO suggested to allocate two more serogroups — 29E and W 135. In groups B, C and Y described serotypes (serovars) differing on proteinaceous antigens to-rye match at representatives of different serogroups and a gonokokk; the general for the sake of appearances N. meningitidis antigen is not emitted yet. Lipopolisakharidny antigens of a cell wall are heterogeneous at different strains though they are close among themselves and other neysseriya. At dissociation of cultures at R-mutants of a meningokokk the capsule and surface group-specific antigens therefore the factors having serol come to light disappear. relationship with other representatives of neysseriya.
the Person (the patient or the bacillicarrier) is the only source of an infection. Most of the persons who caught meningokokky practically has no wedge, manifestations; approximately at 0,1 — 1,8 there is a picture of an acute nasopharyngitis and only individuals have a generalized form of a disease: spotted fever, meningococcemia, etc. The number of clinically explicit forms is direct reflection of prevalence hidden therefore indicators of incidence of generalized forms M. and. practically point to degree of a prevalence of the population meningokokky. Observations show that from 100 to 20 000 bacillicarriers are the share of one diseased with a generalized form. These ratios depend on age, a susceptibility of individuals, virulence of the circulating strain of the activator.
The mechanism of transmission of infection — aerogenic; the activator is transferred with droplets of slime at cough, sneezing, a conversation. Infection is promoted by density of people, close contact between them, napr, at schools, kindergartens, hostels, barracks and so forth. A sick generalized form is the most important source of an infection. Epid, the importance of the patient with a meningococcal nasopharyngitis is 2 — 3 times lower, but also is rather high; the healthy carrier of activators has smaller value as a source of an infection.
Duration of a meningokokkonositelstvo usually does not exceed 2 — 3 weeks, sometimes proceeds to 6 weeks. There are data and on longer carriage, especially in the presence hron, inflammatory conditions of a nasopharynx.
Transfer of activators happens only at close and long communication with the infected person that is explained by extreme instability of a meningokokk out of a human body. Infection of the healthy person is almost possible when the distance between it and the patient or the carrier does not exceed 0,5 m; the risk of infection increases in process of prolongation of communication. Infection not only an aerogenic way, but also through the objects contaminated by saliva is possible.
An eurysynusic carriage of a meningokokk, on the one hand, and a low susceptibility of people to the activator, with another, the main epidemiol define, M.'s lines and. Frequency of rises in incidence with the big intervals reaching 20 — 30 years is characteristic of it. Increase in incidence of generalized forms arises usually against the background of a wide spread occurance of a bacteriocarrier (see. Carriage of contagiums and invasion ). During the periods epid, rise incidence increases in tens of times in comparison with years of wellbeing. The largest epid, rises in incidence are caused meningokokky serogroups And. Rises in incidence are explained by increase in susceptible persons, is preferential at the expense of been born after the previous epidemic; recessions result thanks to increase in an immune layer from latent immunization in process of distribution of a bacteriocarrier among the population of this territory. Duration of the periods of wellbeing is explained by rather slow accumulation of the number of sources of an infection sufficient for emergence of epidemic. A low susceptibility of the person to M. and. allows to consider an indicator of incidence 2,0 on 100 000 population close to epidemic. In big cities at high incidence the number of carriers among the population can reach 6 — 8%. Decrease in number of carriers occurs later, than decrease in number of patients. In breaks between epid, rises incidence has sporadic character. However the carriage remains and makes about 0,5%.
Immunol, origins of rises in incidence and its recessions is confirmed by age structure of the diseased. As in years epid, rises, and in the years of recessions of 50% of diseases of generalized forms falls on children under 5 years; 20% — on children at the age of 6 — 14 years. In process of increase in age of people indicators of incidence decrease, but the frequency of a carriage increases. A little increased incidence in an age group of 15 — 20 years is explained by intensive communication of persons of this age in schools, hostels, barracks. In these conditions first of all the persons which arrived from the remote areas, earlier not contacting to the activator get sick. The most struck with M. and. usually appear the closed groups of small children (a day nursery, kindergartens) and persons of youthful age (the students and pupils living in hostels, soldiers).
At a drift of a disease on territories where it was not registered earlier (the countries of tropical Africa, the remote districts of the North, the hardly accessible mountain districts of Asia), generalized forms strike equally all age; recession of epidemic happens slowly, without reaching the level of sporadic incidence.
M.'s incidence and. it is subject to seasonal fluctuations that is connected with change of intensity of communication of people during the different periods of year. In years epid, rise seasonality is expressed more, than in the period of sporadic incidence.
In the countries of a temperate climate annual rise in incidence begins in November — December and reaches a maximum in March - — May. Increase in number of carriers begins in the first autumn months, i.e. in the period of an intensification of communication of people in educational institutions, service premises, on transport. In the countries yuzh. hemispheres seasonal rise is expressed in August — September. In the countries of Africa located to the north of the equator, seasonal rise falls on December — May, i.e. on a season of dry winds. The population escapes from sandy dust in huts where the possibility of transfer of the activator sharply raises.
Incidence of generalized forms among urban population is higher, than in rural areas that easily is explained by more intensive and close communication of people in the cities. Dependence M.'s distribution y. from intensity communication of people made it the satellite of the processes connected with mass migration of the population and growth of big cities.
The rare ochagovost of an infection is explained by a low individual susceptibility to generalized forms.
Recurrent diseases in the same families and collectives meet seldom. They arise only at a large number not of immune persons (the small children or people who arrived from the remote rural areas). In the family centers and collectives of the closed type recurrent diseases are described by these forms in 3,3 — 18% of cases; in the period of epidemic the frequency of repeated cases in the centers is higher, than at sporadic incidence.
At a drift of an infection in the closed collectives the carriage covers almost all his members within 2 — 3 months. To establish the exact threshold of prevalence of a carriage in collective indicating probability of emergence of diseases, difficult; this threshold depends on many conditions of communication of people. Long-term observations show, however, that diseases of generalized forms usually arise in the presence in collective not less than 10 — 20% of carriers.
In most cases meningokokk on a mucous membrane of a nasopharynx does not cause either noticeable disturbances of the state of health, or its local inflammation. Only in 10 — 15% of cases hit of meningokokk on a mucous membrane of a nose, a throat, and is possible, and bronchial tubes leads to development of an inflammation.
A way of distribution of the activator in an organism — hematogenous.
Bacteremia is followed by massive disintegration of meningokokk — toxaemia (see), the disease playing a large role in a pathogeny.
The reasons leading to generalization of process up to the end are not found out. The previous disturbances of a condition of an organism caused virus, a thicket influenzal, by an infection, jump of climatic conditions, an injury, etc. are important. Generalizations of process develops against the background of disturbance immunol, the status of an organism what points the decrease in the IgM and IgG level observed in the first days of a disease to.
In M.'s pathogeny and. the combination of processes of septic and toxic character to allergic reactions plays a role. Often already at a direct bacterioscopy of blood smears find meningokokk, usually fagotsitirovanny neutrophilic leukocytes. Majority of defeats (meningitis, otitis, labyrinthitis, arthritis, pericardis, uveitis, etc.) the early period of a disease it is caused by primary and septic process. Toxicosis more svoystven meningococcemias, but is observed also at patients with meningitis. The toxins which are formed as a result of death of meningokokk lead to defeat of vessels of a microcirculator bed, in to-rykh plasmorrhagias, fibrinoid necroses of a wall, fibrinous blood clots develop. The toxaemia is followed by stimulation of sympaticoadrenal system with development of the generalized vasoconstriction (which is replaced by dilatation), disturbance of the microcirculation leading along with oppression of oxidation-reduction processes to development of fabric hypoxias (see) and acidosis (see), to disturbances of transmembrane processes and fibrillation.
These processes lead finally to heavy damage and funkts, to disturbances of vitals, first of all a brain, kidneys, adrenal glands, a liver. At patients with a meningococcemia the circulatory unefficiency is connected also with falling of sokratitelny ability of a myocardium and disturbance of a vascular tone.
At a heavy current of a meningococcemia signs of hypocoagulation at the expense of thrombocytopenia and a prothrombinopenia prevail. At meningitis and a medium-weight current of a meningococcemia the tendency to hypercoagulation is more often noted. However hemorrhagic rashes, hemorrhages and bleedings at M. and. are generally connected not with pathology of coagulant system of blood, and with damage of vessels. In cases of shock disturbance of coagulability of blood with development of an afibrinogenemiya is observed that is followed by the raised bleeding. Aggregation of uniform elements of blood, change of their volume and form is at the same time observed. For generalized forms M. and. the hypopotassemia and increase in content of potassium in erythrocytes, disturbance of oxidation-reduction processes, a metabolic acidosis of blood and cerebrospinal liquid, activation of anaerobic glycolysis, disturbance of metabolism of the catecholamines, glucocorticoid hormones, a histamine and serotonin which are also playing a part in shifts of a hemodynamics and homeostasis are characteristic.
Speed of development and extensiveness of the defeats arising literally during the first hours diseases, a hemorrhagic syndrome, heart attacks of adrenal glands of hemorrhage in mucous membranes pull together a pathogeny of a fulminant meningococcemia with Sanarelli's phenomenon — Shvarttsmana (see. Shvarttsmana phenomenon ), to-rogo the nonspecific sensitization is the cornerstone. However immunoallergic party of a pathogeny of M. and. it is studied not enough. Connect with an allergic component also arthritis, myocarditis, a pericardis.
In most cases meningokokk gets into a meninx, and then the wedge, and patomorfol, a picture of meningitis or encephalomeningitis develops. At the same time the wedge, a picture of a disease is defined by all-brain, meningeal, focal symptoms of damage of a brain and internals. Inflammatory infiltration can extend to an ependyma of ventricles (ependimatit), on vaginas of cranial and spinal nerves (infiltrative neuritis), through a threshold of a snail on a snail (labyrinthitis). Inflammatory infiltration of tissue of brain meets around side and the third ventricles (periventrikulyarny encephalitis), konveksitalny departments of a cerebral cortex, in the field of basal and trunk formations of a cerebellum (encephalitis) more often, is more rare than a spinal cord (myelitis). But generally changes in a brain in the early period of a disease are connected with frustration of a hemodynamics and toxic damage of a brain, in later terms — with the crushing extra cerebral defeats which are followed by receipt in a blood stream not only toxins of bacteria, but also a number of the active endogenous agents (e.g., a histamine) which are released at damage of cells and fabrics, a hypoxia, disturbances of a homeostasis. Hemorrhages in a meninx and substance of a brain are frequent.
The most frequent proximate cause of death of patients with meningitis and an encephalomeningitis is swelling and wet brain (see. Swelled also swelling of a brain ).
The hypertensia which — is often met, but not the only reaction of a brain to toxi-infectious influence. Certain authors pay attention to the falling of intracranial pressure observed in an onset of the illness at a number of patients with purulent meningitis. In genesis of cerebral hypotension the main role is played by the neurometastasis ad nervos leading to heavy pathology of a water salt metabolism. A cerebral collapse — the main pathogenetic issue in emergence of a serious early complication of meningitis — subdural an exudate, limited accumulation of exudate. Generalized forms M. and. often are followed by emergence on 2 — the 4th day of a disease of herpetic bubbles. Virusol, and serol, researches, confirm the frequency of herpetic superinfection at sick M. and. Disturbances of trunk functions of a brain, atelectases, stagnation and hemorrhages in pulmonary fabric promote development in sick M. and. pneumonia.
At microscopic examination of a mucous membrane of a nasopharynx and subordinate clauses (okolonosovy, T.) bosoms the picture of an acute or subacute inflammation comes to light. In case of overcoming meningokokky an immune barrier of a nasopharynx there can come meningococcal bacteremia.
The wedge, picture, pathophysiological and morphological changes at a meningococcemia correspond to bacterial shock with the expressed trombogemorragichesky syndrome (see. Hemorrhagic diathesis ). The main changes develop in a microcircular bed where the plasmorrhagia, a hyperemia are observed, staz, fibrinous blood clots and a fibrinoid necrosis of walls of vessels are found. Morfol, changes of skin, mucous membranes, a brain and internals at a meningococcemia are characterized by the expressed hypostasis, existence of hemorrhages and the multiple small centers of a necrosis (tsvetn. fig. 1), infiltrirovanny leukocytes. Multiple hemorrhages in skin (a hemorrhagic purpura), bilateral massive hemorrhages in adrenal glands with development of acute adrenal insufficiency are especially characteristic of a meningococcemia (tsvetn. fig. 6) — Waterhouse's syndrome — Frideriksena (see. Adrenal glands ) and acute hypostasis of a brain. In kidneys dystrophic and necrotic changes of an epithelium of tubules are found, quite often there is thrombosis of glomerular circulatory capillaries (tsvetn. fig. 2), can develop a symmetric cortical necrosis of kidneys. Morfol, the picture is supplemented by dystrophic changes, hemorrhages and focal necroses of a liver and myocardium, and also hypostasis and hemorrhages of lungs.
The meningococcemia can end with typical sepsis (see) with suppurative focuses, characteristic of it, in internals and serous covers: purulent uveitis, pyelonephritis, peritonitis, arthritises, etc.
The spotted fever represents a serous or purulent inflammation of a soft cover of a head and spinal cord. Macroscopically in the 1st days of a disease the firm meninx is strained and cyanotic, soft — is edematous, hyperemic. Tissue of a brain is full-blooded, side ventricles contain slightly rather turbid liquid, their ependyma is dimmy, sometimes with dot hemorrhages. In these terms at microscopic examination find a focal serous inflammation of covers of a brain and an ependyma. In inflammatory infiltrate along with granulocytes lymphocytes and macrophages are visible; at the same time in cytoplasm of granulocytes it is possible to reveal gram-negative diplococcuses (meningokokk), and in macrophages — nuclear splinters of neutrophilic leukocytes. More rough changes are noted in the cover covering the basis of a brain.
On the 2nd days inflammatory changes of a soft meninx become more noticeable.
On the course of a furrow of a corpus collosum, lateral (silviyevy) and other deep furrows of hemispheres, and also on a lower surface of hemispheres, the brain (varoliyev) bridge, a cerebellum and a myelencephalon the muddy jellylike grayish-yellow exudate filling subarachnoid space clearly is visible. For the 3rd days exudate can turn yellow, get thick even more, accepting purulent character (tsvetn. fig. 5). The same exudate fills side and the third ventricles, a gleam to-rykh is considerably expanded. Crinkles of a brain are flattened, furrows are maleficiated, in the substance of a brain which bulked up and swelled there are multiple hemorrhages. Inflammatory changes in covers of a spinal cord usually appear later on 1 — 2 day. At gistol, a research the picture of a fibrinopurulent pia-arachnitis and an ependimatit is noted. Granulotsitarny infiltration of a meninx becomes very dense, later in infiltrate lymphocytes and macrophages prevail, and exudate is exposed to enzymatic disintegration and a resorption. The described dynamics morfol, changes in a meninx can change and be interrupted in any phase, especially at vigorous treatment by antibiotics.
Changes in substance of a brain are connected by hl. obr. with the sharp disorders of blood circulation and cerebrospinal liquid coming owing to acute inflammatory hypostasis, a plethora of its covers and textures, blockade of outflow tracts of cerebrospinal liquid. During the swelling and wet brain (see Hypostasis and swelling of a brain) there is heavy cerebral hypertensia. After this there can come infringement of its caudal departments in a big occipital opening with development of the expressed trunk symptomatology. Microscopically in substance of a brain at the same time it is possible to observe hypostasis, multiple hemorrhages, and also dystrophy and a necrosis of separate neurons. Inflammatory infiltrates in tissue of a brain are changeable and meet around side and the third ventricles more often. Such periventrikulyarny encephalitis is a direct consequence of a purulent ependimatit. In other departments of a head and spinal cord inflammatory changes meet even less often.
Purulent exudate can spread from subarachnoid space to vaginas of cranial and spinal nerves, causing the corresponding radiculoneurites.
A heavy complication of meningitis is purulent damage of an inner ear. Meningococcal average otitises often occur at children and without meningitis, being in these cases a consequence of spread of an infection from a nasopharynx.
At a spotted fever there can be a pneumonia developing usually on 3 — the 4th day of a disease against the background of atelectases, a plethora and hemorrhages in pulmonary fabric; she is called by autoflory, is more often staphylococcus, a pneumococcus or a streptococcus.
Pathoanatomical diagnosis of M. and. includes a bakterioskopichesky research of smears prints, first of all from a meninx and an ependyma of ventricles, even at absence in them macroscopic signs of an inflammation, from a mucous membrane of almonds and a nasal part of a throat, from the centers of a necrosis and hemorrhages in skin and in internals.
Transfer of antibodies from immunizirovanny mother to a fruit occurs in the transplacental way, but these antibodies are noted approximately in half of cases and are found only within 2 — 5 months after the birth of the child. At children with an agammaglobulinemia the high susceptibility to M. is observed and.
In the course of M. and. in blood serum there is an accumulation of specific antibodies (bactericidal, agglutinins, etc.). In protection of an organism bactericidal antibodies have the greatest value. Bactericidal activity of blood serum is higher at adults and low at children, especially aged from 6 months up to 2 years.
Postinfectious immunity at generalized forms M. and. has sufficient tension what the rarity of recurrent diseases and palindromias testifies to. At early stages of a disease of an antibody have the makroglobulinovy nature with a sedimentation constant 19S, and on later — the mikroglobulinovy nature (7S). The significant role in protective effect is played by antibodies to serotipovy proteinaceous antigens of the activator, and not just to polysaccharide of a meningokokk. It is shown that at patients with a generalized form M. and. in a heat * diseases the absolute relative decrease in contents in a pla of T lymphocytes correlating with weight of a disease is noted. The maintenance of V-lymphocytes at patients with various forms M. and. raises to the 2nd week of a disease.
It is specified that at nek-ry allergic displays of a disease (usually on 6 — the 9th day) the cell-bound immune complexes consisting of antigen of the activator and antibodies, specific to it, can play a role.
A clinical picture
On a current each form M. and. (except a meningokokkonositelstvo) can be easy, moderately severe, heavy and extremely heavy.
The incubation interval is more often than 6 — 7 days, minimum — 12 hours, maximum up to 20 days.
If on a mucous membrane of a nasopharynx temporarily is found meningokokk, then in most cases the state of health considerably is not broken, but nevertheless there is an immune response.
Main symptoms of this form M. and. the headache, pain and feeling of irritation in a throat, a congestion of a nose, cold with are scanty separated mucopurulent character, sometimes bloody, dry cough. The back wall of a throat is hyperemic, edematous, is frequent with imposings of slime. The bilateral injection of vessels of scleras and a hyperemia of conjunctivas is often observed. In hard cases dizziness, sometimes vomiting, symptoms are noted meningism (see), neurangiosis. Body temperature can remain normal, but increases to 37,5 — 38 ° more often, and in more hard cases above. Duration of fever, as a rule, makes 2 — 3, 5 — 7 days are rare. In the same terms the phenomena of a nasopharyngitis abate. With 2 — the 3rd day the hyperplasia limf, follicles of a mucous membrane of a stomatopharynx develops.
Gemogramma at patients meningococcal a nasopharyngitis either remains normal, or is characterized by a tendency to a leukocytosis with a deviation to the left. ROE accelerates a little. The nasopharyngitis quite often precedes development of generalized forms of a disease.
a Number of researchers acknowledges the possibility of primary isolated focal or lobar meningococcal pneumonia proceeding without meningitis and a meningococcemia. Its main signs — a large number of a phlegm, a heavy current, frequent pleurisy, the long period of recovery.
the Meningococcemia is characterized by the acute beginning, fever, usually intermittent) pl of constant type, skin rashes on 1 — the 2nd day of a disease. In uncured cases fever at a meningococcemia has more often intermittent character, but the temperature curve does not differ in special constancy. During 1 — 2 days of a disease temperature happens high (39 — 41 °), further it can be constant type, gektichesky, occasionally subfebrile, at shock — normal or subnormal.
From the first day of a disease the expressed intoxication attracts attention: pallor, vasculomotor lability, dryness of integuments, coated tongue, polydipsia. Appetite is absent.
The main wedge, the symptom allowing to distinguish a meningococcemia — characteristic hemorrhagic rash (tsvetn. fig. 3). In an early stage of a disease, a thicket on a trunk and the lower extremities, korepodobny rash can develop. It quickly disappears and usually within several hours is replaced by typical rash in the form of irregular shape of asterisks of various size (averages in size have in dia. 3 — 7 mm), dense to the touch and slightly acting over a surface kozhn. Elements of hemorrhages at the same patient happen various size — from punctulate petechias to the extensive hemorrhages which are observed in hard cases. Quite often hemorrhagic rash is combined from a rozeolezny pla rozeolezno-papular. Since the rash occurs not at the same time, various elements of rash have various coloring and brightness. The most characteristic localization of rash are the trunk, buttocks, hips, shins, hands, eyelids. The enantema on a transitional fold of a conjunctiva and hemorrhage in scleras is often observed. Rash on a face is observed less often and usually at severe forms of a disease. In scrapings from elements of rash, blood smears sometimes it is possible to find meningokokk in not treated patients with antibiotics. At involution of rash rozeolezny and rozeolezno-papular elements quickly disappear, without leaving marks, and small hemorrhages are pigmented. On site hemorrhages, considerable on the area, necroses are quite often formed (tsvetn. fig. 4) with the subsequent rejection of necrotic sites and formation of defects. Also cases of a necrosis of finger-tips, feet, auricles, a nose (fig. 1 and 2) meet. Nasal bleedings, hemorrhages in mucous membranes, etc. are possible.
Arthritises and polyarthritises (both serous, and purulent) are observed at 5 — 8% of patients with a meningococcemia. The inflammation of a choroid of an eyeglobe (a metastatic ophthalmia) is in some cases possible — iridotsiklokhorioidit, more often only uveitis (see), usually unilateral. Also such defeats as an aortitis, pneumonia, pleurisy, etc. are described.
Quite often at patients dullness of cordial tones, change of a heart rhythm, tachycardia, decrease in the ABP, faints, a collapse and other signs of disturbance of a hemodynamics is noted, degree of manifestation to-rykh correlates with weight of disease. Significantly sokratitelny ability of a myocardium suffers. Development meningococcal mio-, endo-and perikardit is possible.
In some cases develops hepatolienal syndrome (see), and the liver and a spleen remain soft in this connection are not always accurately palpated. Damage of kidneys at patients with a meningococcemia — is preferential funkts, character. However at a heavy current of a meningococcemia these changes have character of focal glomerulonephritis (see) what the proteinuria, a microhematuria, a leukocyturia, reduction in the rate of glomerular filtering indicates. In many respects pathology of internals is explained by hemorrhages in them.
The metabolic acidosis, an arterial anoxemia, a venous hyperoxia and a hypocapny are characteristic of a meningococcemia. The quantity of nedookislenny products in blood at certain patients by 3 — 4 times exceeds norm. Content of ammonia at a heavy current in blood twice, in cerebrospinal liquid — is 6 times higher than norm. At most of patients in the acute period of a disease decrease in level of potassium in plasma is observed. Shortening of a calcium clotting time of plasma, increase in a thrombotest and concentration of fibrinogen, decrease in fibrinolitic activity of blood is characteristic of a moderately severe meningococcemia. Gemogramma at patients with a meningococcemia is characterized by usually high leukocytosis (20 000 — 40 000 in 1 mkl), neutrophylic shift to young, and sometimes and to myelocytes, an aneosinophilia, acceleration of ROE. Decrease in quantity of leukocytes, especially during the first hours diseases, is a bad predictive sign.
The leading sign in klinich. to a picture of extremely severe, fulminant form of a meningococcemia infectious and toxic shock with disturbance of microcirculation, with development of so-called kapillyarotrofichesky insufficiency is. The disease begins violently with rise in temperature and a fever, a headache, vomiting. Spasms, the dispeptic phenomena are frequent. Already during the first hours diseases there is plentiful hemorrhagic rash, the ABP normal or raised, but tachycardia and moderate cyanosis clearly come to light. The disease quickly progresses. Rash becomes more and more plentiful, extensive hemorrhages develop. Patients are pale, complain of a burdensome cryesthesia. There is vomiting, is frequent with blood. Nasal bleedings, hemorrhages in internals are possible. The ABP progressively falls. Pulse is frequent, almost inaudible, soon it ceases to be probed. Cyanosis amplifies. On extremities, and then and on a trunk crimson and cyanotic spots appear. An asthma accrues. Patients periodically fall into an unconscious state, there is a motive excitement, quite often spasms, and then the progressing prostration with a loss of consciousness. In a terminal phase edematization and swelling of a brain with its shift is possible (see. Dislocation of a brain ). A meningeal syndrome (see. Meningitis ) it is, as a rule, sharply expressed. The body temperature in the beginning increased falls quite often to subnormal figures.
Sharp shifts in coagulant system of blood are observed. Possibly, in the beginning there is a short-term giperkoagulyatorny phase of a trombogemorragichesky syndrome (see. Hemorrhagic diathesis ). Then in case of shock develops hypo - or the afibrinogenemiya, the expressed thrombocytopenia which are followed by bleeding. Aggregation of uniform elements of blood, change of their volume and a form is at the same time observed. In case of recovery on 3 — 4 days often develop again tendency to hypercoagulation (fibrinosis).
The hyperleukocytosis, the increased maintenance of unripe forms of neutrocytes is typical. At a bacterioscopy of a blood smear the diplococcuses located in cytoplasm of leukocytes and vnekletochno often are found.
Signs are sharply expressed respiratory insufficiency (see). Funkts, researches allow to reveal deep disturbances of a hemodynamics, decrease in sokratitelny ability of a myocardium, disturbance of oxygenation of blood at the expense of pulmonary shunts, falloff of a renal blood-groove and glomerular filtering up to an anury. Development of a symmetric cortical necrosis is possible. The anoxemia along with microcirculator disturbances and disturbances of gas exchange in fabrics leads to a fabric anoxia, acidosis. In blood the noncompensated metabolic acidosis, an anoxemia, a hypocapny is found, at development of an acute renal failure — hyperpotassemia (see).
Rare option M. and. the meningococcemia with is subacute and hron, a current. The disease proceeds with periodic rises in temperature, emergence on skin of rozeolezno-papular and hemorrhagic rash, sometimes is followed by arthritises. Fever of the wrong type or remittiruyushchy from several days to 1 — 2 month. Then there occurs remission. Hron, a meningococcemia pathogenetic is often connected with an endocarditis.
Spotted fever (synonym: cerebrospinal epidemic meningitis, epidemic spotted fever). The disease usually begins sharply with a tremendous fever, rough rise in temperature to 38 — 40 °. The general state sharply worsens. In several hours appears and quickly the meningeal symptomatology — muscle tension of a nape, a Kernig's sign, Brudzinsky, Giyen, Edelmann's symptoms, etc. progresses. At elderly people the onset of the illness can be less acute, temperature subfebrile, Meningeal symptoms appear on 3 — the 4th day of a disease.
The general hyperesthesia p a hyperacusia is characteristic. The hyperemia of the person, motive concern is observed. Disorders of consciousness and mental disturbances appear on 2 more often — the 4th day of a disease. However they can dominate in a wedge, a picture from the first hours of a disease. Excitement, nonsense, hallucinations or, on the contrary, block, an adynamia, a sopor, in hard cases — a coma is possible. Quite often, especially at children's age, there are general and focal kloniko-tonic spasms, sometimes hyperkinesias. Strengthening or oppression of tendon and periosteal jerks, an anizorefleksiya is in most cases observed, appear patol, Babinski's reflexes, Gordon, Oppengeym, etc. From cranial nerves II, III, VI, VII and VIII couples are surprised more often. Development purulent is possible labyrinthitis (see) and the retrolabyrinth defeats leading to decrease or a full hearing loss. Much less often the optic neuritis meets. At a number of patients focal nevrol. the symptomatology is result of hypostasis and brain swelling. In these cases it quickly regresses. At others it results from encephalitis or hematencephalons.
Fever at meningitis of the wrong type, in hard cases deep disturbances of thermal control with development hypo - or a hyperthermia are possible. On 3 — the 4th day of a disease often joins a herpes infection: rashes can
be plentiful and have various localization, their emergence often is followed by new is increased it temperatures and deterioration in the general state. A moderate asthma is observed. At children of early age and elderly pneumonia often joins. Pulse labilen, with bent to tachycardia, but also bradycardia is possible. The ABP tends to increase. Cardiac sounds are muffled. The ECG indicates dystrophic changes of a myocardium. Language is laid over, dry. The chair and an urination are often detained. Changes in cerebrospinal liquid (tab. 1) are characteristic.
Cases belong to rare options of a current of a spotted fever, at to-rykh cerebrospinal liquid remains transparent or slightly opalescent. The moderate pleocytosis with dominance of lymphocytes is noted (but always with the increased maintenance of neutrophils!) and increase in protein content. Meningeal symptoms are poorly expressed. More often the similar course of meningitis is observed at timely begun and rationally carried out treatment. Detection of meningokokk in these cases is difficult. In blood the moderate leukocytosis with neutrophylic shift is noted. In nek-ry cases of a spotted fever cerebrospinal liquid and during all disease can be left serous without treatment.
In blood at patients with purulent meningitis the considerable leukocytosis (from 12 000 to 30 000 and more), hl is observed. obr. at the expense of polinuklear; eosinophils, as a rule, are absent, ROE is accelerated; moderate hypochromia anemia is sometimes noted.
The meningococcal encephalomeningitis is characterized from the first days of a disease by disturbance of consciousness, spasms, the paralyzes and paresis which early are shown. The meningeal phenomena at the same time can be expressed poorly. During sick M.' treatment and. endolumbar introduction of antibiotics often observed an encephalomeningitis with a syndrome of an ependimatit (ventrikulit). Clinically ependimatit it is characterized generally by symptoms encephalitis (see) with the nek-ry specific features caused by localization of process. Drowsiness, the permanent or progressing disorders of consciousness — a coma or a sopor (apprx. 80%), very high muscular rigidity, sometimes with development of an opisthotonos, a spasm are observed. Along with it the symptoms indicating increase in intracranial pressure accrue: a severe headache, babies have a protrusion and tension of a big fontanel with discrepancy in later terms of seams of a skull, developments of stagnation in an optic disk, often vomiting, a hyperesthesia. Cerebrospinal liquid protein content increases sometimes to very high figures, quite often liquid gets xanthochromatic coloring. In cases of development of an ependimatit in early terms of a disease the wedge, a picture from the very beginning has character of an encephalomeningitis, the syndrome of an ependimatit at the same time masks the meningeal phenomena. The diagnosis of an ependimatit in these cases quite often is established only on section.
At meningitis and an encephalomeningitis allocate options of a current with a syndrome of a vklineniye of a brain, development of cerebral hypotension.
The mixed form — a combination of a meningococcemia to meningitis when in one cases symptoms of meningitis prevail, and in others — a meningococcemia.
Meningococcal endocarditis proceeds it is long and is rather favorable. Short wind, cyanosis are possible; in lungs wet rattles, the weakened breath are quite often listened dry, and sometimes. Can be followed by periodic rises in temperature, an enanthesis, swelling of joints.
Meningococcal arthritis (synovitis), polyarthritis more often happens serous. Quite often also interphalangeal joints of a brush, sometimes large joints are surprised metacarpophalangeal. Patients complain of joint pains, restriction of movements, the dermahemia over them, fluctuation, increase in volume is possible. Puffiness and a hyperemia in joints disappear at treatment within 2 — 4 days, morbidity — during 3 — days. Recovery of function of joints full.
The meningococcal iridocyclitis
Around a meningococcal embolism in vessels of a retina or a uveal path is formed the inflammatory center with fibrinoznognoyny infiltration in a vitreous. The first sign of an iridotsiklokhorioidit — bystry decrease in sight, a cut can reach per day a total blindness. The iris is sharoobrazno stuck out forward, the anterior chamber is small. The pupil is narrowed, sometimes irregular shape. The iris gains rusty color. Intraocular pressure is lowered. Then the atrophy with reduction of the size of an eyeglobe develops. The purulent panophthalmia with necrotic disintegration of an eye is in rare instances observed (see. Panophthalmia ). Iridocyclitis (see) almost always leads to a blindness, and only at an early intensive penicillin therapy sight manages to be kept. Iridotsiklokhoriodit as well as arthritises, develops at patients with a meningococcemia more often, but occasionally can be isolated.
Distinguish the specific complications of the early and late period of disease i.e. connected with a pathogeny of L. S. and nonspecific complications. Specific complications of the early period of a disease — toxi-infectious shock, an acute renal failure, went. - kish. and uterine bleeding, parenchymatous and subarachnoidal hemorrhage, mioendoperikardit, acute swelling and wet brain with a syndrome of a vklineniye, cerebral hypotension, the epileptic status, a fluid lungs, ependimatit, a labyrinthitis, paralyzes and paresis, etc.; specific complications of the late period of a disease — necroses, hormonal dysfunction, paralyzes and paresis, epilepsy, hydrocephaly, etc.
Nonspecific complications: otitis, herpes, pyelonephritis, pneumonia, etc.
the Diagnosis make the Diagnosis on the basis a wedge., epidemiol, and lab. researches.
From anamnestic data the greatest attention is paid to an onset of the illness — suddenness, emergence among full health or soon after an easy and short-term nasopharyngitis.
The acute onset of the illness, high temperature of a body, sharp headache, disturbances of mental activity, vomiting, a hyperesthesia, the Meningeal symptom complex, characteristic meningokokkemichesky rash allow to diagnose clinically M. and. In conditions epid, flashes the diagnosis comes easy. In sporadic cases to make the correct diagnosis to M. and. more difficultly. Are of great importance for diagnosis a lab. researches.
At symptoms of meningitis make the analysis cerebrospinal liquid (see), blood (see), slime from a back wall of a throat. Material shall be sowed immediately on the freshly cooked, warmed-up to t ° 37 ° mediums or is brought to laboratory in not cooled state. The drop of a deposit sterilely of the taken cerebrospinal liquid is sowed in a Petri dish with the nutrient agar containing 20% of normal serum or 5% of a defibrinated blood of a horse, a bull, a ram. One more drop is used for preparation of two smears on glass, one of to-rykh is painted across Gram, another — fuchsin or methylene blue. Other cerebrospinal liquid is filled in in a test tube from 5 ml of a semi-fluid agar for enrichment from where in 1 days, and then once a week within a month do crops on dense circles of the same structure, as for direct crops. Express diagnosis is possible on the basis of detection of a specific antigen in cerebrospinal liquid or blood in reactions of the passer immunoelectrophoresis (see) with group precipitant antiserums, and also radioimmunol. by method or enzimoimmunol. by method (REMA).
At suspicion on a meningococcemia from a vein take 5 — 10 ml of blood, to-ruyu immediately sow in a bottle from 50 ml of a semi-fluid agar, incubate at t ° 37 ° during 7 days with daily crops on lamellar environments.
In the first days of a meningococcemia of the activator it is possible to see at a bacterioscopy of the painted thick drop of the blood taken from a finger (see. Thick drop ). The bacterioscopy and crops can subject a droplet of the exudate which acted on a surface of the scarified rash; scraping should be taken from fresh elements of rash, it is better on the periphery of elements. Results of a bakterioskopichesky research of material regard as approximate. For confirmation of the diagnosis the result of allocation and identification of pure growth of a meningokokk is considered final.
At suspicion on a meningococcal nasopharyngitis or a bacteriocarrier slime from a back wall of a throat is taken the sterile cotton plug strengthened on the aluminum delay bent at an angle 120 ° to dia. 2 — 3 mm (language is wrung out by means of the sterile pallet from top to bottom). Crops is made immediately on the serumal agar containing 5 mkg/ml of lincomycin for suppression of the accompanying gram-positive flora and on the similar environment without antibiotic. At impossibility to sow material directly on dense environments it is possible to ship tampons in the test tubes containing the warmed-up broth with antibiotics (Ristomycinum, lincomycin) and to bring to laboratory in 3 — 5 hours at a temperature not lower than 22 ° then to do crops on a serumal agar without antibiotic.
Grown on a serumal agar after crops of cerebrospinal liquid, blood, slime of colony of a meningokokk are colourless, and on a blood agar — creamy color, semi-spherical shape with flattening, to dia, from 0,5 to 1,5 mm, wet, merging with each other. In case of growth of pure growth start its identification on the same day; in the presence of other microflora the suspicious colony is oversown in a test tube with a slanted serumal agar and studied in 20 — 22 hours of an incubation at t ° 37 °. Morfol, properties, negative coloring across Gram and positive oksidazny reaction (a pinkness of colonies during the drawing 1% of solution of a paradiethylphenylenediamine muriatic) allow to refer culture to the sort Neisseria.
Identification of a type of a meningokokk is made on the basis of features of colonies, lack of a pigment, inability to grow in the first generation on nutrient agar without serum of a pla of blood. Additional data can be received at crops on Wednesdays with glucose, a maltose, sucrose, levulose, fructose and the indicator indicating splitting of the first two carbohydrates to - t. The cultures identified as meningokokk subdivide into serogroups by means of an agglutination test across Nobl (see. Noblya reaction ) or microprecipitations in an agar.
For serol, diagnoses apply reaction of RPGA with erythrocytes, sensibilized group-specific polysaccharides (see. Hemagglutination ). At patients with generalized forms and nasopharyngites of an antibody appear no later than the 5th day of a disease; at generalized forms — in credits 80 — 5120, at a nasopharyngitis — in credits 20 — 640. After release from the activator there occurs bystry decrease in an antiserum capacity. Antibodies to some serogroups in credits 20 — 80 can be found in the persons who are not infected meningokokky that is explained by broad circulation of a meningokokk among the population in the form of an asymptomatic carriage.
Differential diagnosis carry out taking into account a wedge, forms of a disease. So, the nasopharyngitis is differentiated with acute respiratory viral diseases (see), an aggravation hron, inflammatory processes of a nasopharynx — tonsillitis (see), rhinitis (see) and pansinusites (see. Paranasal sinuses ). Specification of the diagnosis and differentiation of a spotted fever from other diseases proceeding with a meningeal syndrome is promoted by a research of cerebrospinal liquid (see). Nek-ry indicators of results of a research of cerebrospinal liquid at a meningism, a spotted fever, serous meningitis of a virus and bacterial etiology and subarachnoidal hemorrhage are given in table 1.
As the purulent inflammation of a meninx can be caused by various bacterial flora (pneumococci, a hemophilic stick of Afanasyev — Pfeyffera, stafilokokka, streptococci, fungi and many other microorganisms), the differential diagnosis of various groups of purulent meningitis is difficult and is frequent without bacterial. researches it is impossible. At the same time it is necessary to consider that treatment by antibiotics even in insufficient therapeutic doses, carried out on an outpatient basis, leads to bystry disappearance of activators from cerebrospinal liquid in this connection the percent bacteriological of not confirmed meningitis grows from year to year.
At specification of the diagnosis detailed somatic inspection of the patient is necessary for identification of primary suppurative focus (otitis, a pansinusitis, pneumonia, bronchiectasias of lungs, purulent processes on skin or in other bodies).
The meningococcemia also often is the reason of diagnostic mistakes. The most important differential diagnostic characters of a meningococcemia are given in table 2.
Treatment shall be complex and be based on the careful analysis of a condition of the diseased. Along with etiotropic means apply pathogenetic therapy, edges in many cases of meningitis and a meningococcemia has character of acute management and only thanks to its timely carrying out it is possible to save life of the patient.
At an acute nasopharyngitis rinsings of a nasopharynx by warm solutions boric to - you (2%), potassium permanganate (0,05 — 0,1%), Furacilin (0,02%) are shown. For reduction of dryness dig in in Nov a liquid paraffin, enteritsid, to-ry possesses also antimicrobic action. In cases of the expressed fever, intoxications appoint penicillin, levomycetinum or rifampicin within 3 — 5 days.
At generalized forms M. and. appoint one of the antibiotics stated above or sulfanamide drugs. At the same time not only degree of order to an antibiotic of meningokokk, but also ability of drug to get through a blood-brain barrier is considered. Endolyumbalno antibiotics at this form of meningitis in a wedge, practice do not apply because of a possibility of development of complications.
Treatment is begun as soon as possible since every day, and quite often even hour has crucial importance. Penicillin is appointed at the rate of 200 000 — 300 000 PIECES to 1 kg of mass of the patient a day. If treatment is begun later 3 — the 4th day of a disease and already the phenomena of an ependimatit, an encephalomeningitis, especially periventrikulyarny divorced, the dose increases to 500 000 — 1 000 000 PIECES. The drug is administered intramusculary with an interval of 4 hours. The first dose — 4 000 000 — 6 000 000 PIECES of sodium salt benzylpenicillinic to - you can be entered intravenously (kapelno). Further administration of penicillin in a vascular bed shall be carried out continuously. Duration of treatment usually 5 — 8 days. If at the control puncture made before drug withdrawal in cerebrospinal liquid more than 100 cells in 1 mkl are noted a cytosis or the considerable maintenance of neutrocytes, treatment is recommended to continue 2 — 4 more days. The combination of penicillin to other antibiotics or streptocides does not increase efficiency of treatment and therefore it is reasonable only in the presence of bacterial superinfections (pneumonia, a pyelitis, etc.).
Are highly effective at M. and. semi-synthetic Penicillin (ampicillin, Oxacillinum, Methicillinum, etc.), tetracycline, tsefalosporinovy antibiotics, levomycetinum. However, considering later normalization of cerebrospinal liquid at their use, they are shown in the absence of effect of a penicillin therapy. Levomycetinum sodium succinate apply in a daily dose 50 — 100 mg/kg within 6 — 8 days. It is shown in cases of infectious and toxic shock since at purpose of this drug by 3 times less than against the background of a penicillin therapy, strengthening of endotoxic reactions is observed. Tetracycline is entered intramusculary on 25 mg/kg a day.
For treatment of patients with moderately severe forms use sulfanamide drugs of the prolonged action, napr, sulfamonometoksinony it is appointed by the adult inside in tablets on 2 g by 2 times in the first day and on 2 g once a day in the next days. Course of treatment of 7 — 10 days. Thanks to convenience of use sulfanamide drugs are perspective in the centers of high incidence.
For fight against toxicosis enter enough liquid taking into account electrolytic balance (plentiful drink, intravenous administration of solution of Ringer, glucose, Neocompensanum, Haemodesum, plasma transfusion). At the same time carry out dehydration by use of diuretics (Mannitolum, lasixum, Diacarbum, Uregitum).
At the fulminant meningococcemia proceeding with shock, treatment is begun with intravenous (a venipuncture, venesection), and sometimes intra arterial injection of liquids: Ringer's solution, kvartasola, reopoliglyukin, Haemodesum, 5% of solution of glucose, plasma, albumine; the most reasonable ratio of crystalloid and colloidal solutions 3:1. It is necessary to add to the first portion of perfused liquid (500 — 1000 ml) (taking into account age and degree of a collapse) from 50 to 500 mg of a hydrocortisone, from 90 to 300 mg of Prednisolonum, heart glucosides, cocarboxylase, ATP. The daily dose of a hydrocortisone can reach 50 mg/kg, Prednisolonum — 1 — 5 mg/kg depending on weight of shock. In the absence of a peripheric pulse and the ABP solution is struyno entered in the beginning, then, after emergence of pulse, kapelno.
After removal of patients from shock for perfusion use liquids with the smaller maintenance of corticosteroids. Their quantity and rate of administering constantly korrigirut depending on pulse rate and the ABP level, and also results biochemical, blood analyses. Measurement of these indicators is repeated by each 30 min. Intravenous administration of drugs shall be long. It can be stopped only after permanent stabilization of a condition of cardiovascular activity. For fight against a hypoxia appoint an oxygenotherapy.
After removal of the patient from a collapse corticosteroids (a cortisone or a hydrocortisone) enter intramusculary: to children of school age — - 100 — 200 mg, preschool — 50 — 100 mg. Injections repeat each 4 — 6 hour. At repeated introductions the dose under control of the ABP is reduced by 2 — 4 times, then gradually reduced; in 2 — 7 days treatment is finished. For maintenance of electrolytic balance enter also cortexone acetate on 0,5 — 2 mg 2 times a day.
At the same time recommend to appoint also high doses ascorbic to - you.
The severe forms of purulent meningitis proceeding with sharp intoxication are also the indication to steroid therapy. Hormones appoint 0,5 — 1 mg/kg in a dose, and carry out treatment to disappearance of toxicosis.
For the prevention of an acute renal failure at normalization of a hemodynamics kapelno enter 50 — 100 ml of 0,25% of solution of novocaine with the subsequent use of Mannitolum.
Correction of acidosis is reached by use of 4% of solution of sodium bicarbonate or solution of sodium acetate. At heavy acidosis only a half of a dose of solution is entered in the beginning, and other — it is consecutive according to indicators of an acid-base state. For correction hypopotassemias (see) administration of drugs of potassium (potassium chloride, Pananginum) is shown. For improvement of activity of cardiovascular system administration of the corresponding drugs is shown.
Therapy of acute hypostasis and brain swelling is carried out in a complex and adequately by degrees of manifestation of wet brain. The basis of therapy is made by desintoxication, dehydration, an oxygenotherapy, fight against a hypoxia of a brain, respiratory frustration. According to indications carry out anticonvulsant treatment. Suction of slime from respiratory tracts, overseeing by their passability is of great importance (retraction of language and an epiglottis is possible).
In fight against a vklineniye of a brain solution of Mannitolum at the rate of 1 — 3 g/kg is most effective 20%. For strengthening of dehydration it is reasonable to enter mix of Mannitolum and urea. However urea is contraindicated at sharply expressed hemorrhagic phenomena and damage of kidneys. Osmotic diuretics need to be combined with lasixum, Uregitum and other diuretics, and also intravenous administration of an Euphyllinum. Along with dehydrational therapy (see) carry out intensive disintoxication therapy (see), eliminate, and warn dehydration of an organism even better and timely korrigirut disturbances of water and electrolytic and acid-base balance.
The oxygenotherapy has huge value. If breath is not enough (frequency of dykhaniye is 2,5 — 3 times higher than norm, persistent cyanosis, a hypoxia, not korrigiruyemy an oksigenization), are necessary an intubation or tracheostomies (see) using hardware breath by oxygen air mixture (see. Artificial respiration ). However at the same time patients often have further a pneumonia that makes heavier a current of a basic disease and demands additional to lay down. actions — prescriptions of antibiotics of a broad spectrum of activity (intramusculary and endotracheal careful sanitation of a bronchial tree.
At cerebral hypotension dehydration is contraindicated or it should be combined with the strengthened intravenous administration of isoelectrolytic solutions. Also intraventricular or endolumbar administration of isotonic solution of sodium chloride is reasonable. The last procedure is shown also in cases when dehydrational therapy at patients with a syndrome of a vklineniye of a brain does not give effect. With a low intracranial pressure into the spinal canal enter depending on age 5 — 20 ml fiziol, solution.
For prevention and treatment of spasms, and also at motive excitement use lytic mix (Promedolum, aminazine or Tisercinum, Dimedrol or Pipolphenum), to-ruyu enter intramusculary 3 — 4 times a day. Also phenobarbital, Chlorali hydras in enemas and if there is no bystry effect — thiopental of sodium or hexenal in a dose of 10 — 15 mg/kg are recommended. The most expressed anticonvulsant effect gives intravenous and intramuscular administration of Seduxenum (50 — 100 mg a day for adults).
The large role is played also by symptomatic therapy. Apply cold to reduction of a headache — a cranial hypothermia, the cut is the elementary form a rubber bubble with ice; appoint pyramidon with analginum, drugs, aminazine.
Usually at inf. patients it is artificial it is inexpedient to reduce body temperature. However at the hyperthermia reaching at rectal measurement 41,5 — 42 °, especially at spasms artificial cooling is shown (see. Hypothermia artificial ).
Good nutrition is a necessary condition of recovery. In the fever adult patient spends a day about 2500 — 3000 kcal, to-rye and shall be compensated by food with the increased protein content — to 120 — 150 g, and water to 40 — 45 ml on 1 kg a day. If the patient is in coma or because of paralysis cannot swallow, it should be fed via the probe entered in Nov or a mouth (see. artificial nutrition ). At the phenomena of an acute renal failure limit protein in food taking into account clearance of urea.
Forecast at timely treatment it is in most cases favorable. Such crushing organic lesions as hydrocephaly, dementia and an oligophrenia, an amaurosis, became a rarity. Are noted preferential funkts. disturbances of psychological activity (asthenic syndrome, delay of rate of mental development). The residual phenomena meet more often and happen more expressed at persons, treatment to-rykh was begun in late terms of a disease.
Carrying out measures for M.'s prevention and. in mezhepid. the period presents considerable difficulties. As it was specified, the number of carriers during this period is small also a lab. inspection of the population for the purpose of identification of carriers at all bulkiness and complexity is ineffective. Only two actions should be carried to real and reasonable: early identification in child care facilities (kindergartens, schools, nursing homes, orphanages, technical training college, etc.) children with nasopharyngites and other diseases, suspicious on M. and.; isolation of such children from collective, overseeing by them at home with daily visit of the doctor.
The strict complex of events is held in epid, the center (at sick M.'s identification and.). Persons, at to-rykh the disease of a meningococcemia, meningococcal is established by meningitis or a nasopharyngitis, are immediately hospitalized in specialized departments or boxes. At a forced delay with hospitalization of the patient place in the isolation center of kindergarten, a day nursery.
Immediately inform on the arisen disease SES (public health department). The extract of convalescents is made after double (at an interval of 1 — 2 day) a lab. inspections with a negative take. As material of a research serves the mucous discharge of a nasopharynx. Inspection begin only after disappearance a wedge, the phenomena and not earlier than in 72 hours upon termination of treatment. In children's collectives convalescents are allowed after single a lab. the examination with a negative take conducted not earlier than in 10 days after an extract from-tsy. All patients who transferred M. and., there have to be under observation of the regional psychoneurologist not less than 2 years.
Family members or children's collective where sick M. is revealed and., and other persons contacting to the patient are inspected on a carriage of a meningokokk.
Behind the persons contacting to sick M. and., medical observation within 10 days is established. At the same time surely make daily thermometry and survey of a nasopharynx. From families where there was M.'s disease and., children are not admitted to child care facilities before the termination by bacterial, inspections, and at establishment of a carriage — before the end of sanitation. In child care facilities where M.'s disease is stated and., new children are not accepted within 10 days from the moment of isolation of the last diseased.
Recurrent diseases in a family or in the closed collective — the phenomenon rather rare. However in collective where there was a disease, a large number of carriers of a meningokokk usually forms. And it is known that increase of number of carriers, as a rule, involves flash (epidemic) of M. and. Therefore identification of carriers of a meningokokk in an environment of the patient and their sanitation gain the extreme importance.
At detection in collective of St. 10% of carriers of a meningokokk all children repeatedly bacteriological are inspected in 7 — 10 days and so before elimination of a carriage in collective. The carriers revealed in child care facilities isolate at home or in hospital and allow in collectives after double bacteriological inspection with a negative take.
At the carriage proceeding ev. 3 weeks, appoint a course of sanitation antibiotics of a broad spectrum of activity (erythromycin or ampicillin). Erythromycin is appointed the adult on 0,25 g, and ampicillin — on 0,5 g 4 times a day for 4 days, to children — according to age.
The revealed adult carriers of a meningokokk discharge of work in child care facilities before release from the carriage confirmed double bacterial, inspection with a negative take.
Measures of restraint of ways of transmission of infection are very important. Decrease in density of accommodation of children is effective: arrangement of beds at distance not less than 1 m, reduction of number of groups, use for bedrooms of other rooms. These quite available measures, considering low resistance of a meningokokk, sharply reduce a possibility of distribution of M. and. in collective. Are recommended also long stay of children and teenagers in the fresh air (walks, games in a garden), cancellation of visits of cinema and theaters. At the big outbreak of a meningococcal infection collective temporarily gets out of hand.
The room where there is a patient, needs to be aired, made regularly in it wet cleaning with use of chlorine-containing drugs, UF-radiation of air; ware of the patient should be boiled. The persons who are looking after sick M. and., shall wear gauze masks.
Specific prevention. In the 70th in the USA the meningococcal chemical vaccine on the basis of group-specific polysaccharides A and C is developed. According to WHO data, the vaccine was rather effective. Vaccination of 25 — 40% of the contingent of people sharply reduces number of diseases of generalized forms M. and. Vaccination is shown at the beginning of epidemic raising of a meningococcal infection.
Features of a meningococcal infection at children
M. and. meets most often aged up to 5 years. M.'s cases are described and., postponed vnutriutrobno, at the same time children are born with hydrocephaly. The opinion on family predisposition to M. is expressed and., to what repeated cases of children from one family testify. Anomalies of development and a disease of a brain are also considered as the contributing factors to M. and.
Clinical manifestations meningococcal infection at children, as well as at adults, are very various.
Clinically the meningokokkonositelstvo, a meningococcal nasopharyngitis and a meningococcemia at children are characterized a cinciput by symptoms, as at adults. The meningococcemia is followed by hemorrhagic rash, sometimes formation of hemorrhages and necroses; it occurs at children of early age more often than at adults and children of advanced age. Apprx. 2/3 cases of generalized forms M. and. at children it is the share of the mixed forms (a meningococcemia + meningitis), the isolated forms of a meningococcemia meet seldom.
The spotted fever at children of chest age has a number of features: it proceeds usually at weak expressiveness or total absence of a meningeal syndrome against the background of clear all-toxic or all-infectious symptoms. The disease at them begins sharply, violently, suddenly. Initial symptoms often are vomiting, excitement, concern of the child, a fever, temperature increase. The loss of consciousness and spasms happen quite often first symptoms of a disease. Meningeal symptoms (muscle tension of a nape, a Kernig's sign, Brudzinsky's symptom) at the same time can be hardly expressed or absolutely are absent. The full complex of the expressed meningeal symptoms at children of chest age almost never happens that extremely complicates early diagnosis of a disease. It is necessary to pay, however, attention to protrusion and tension of a big fontanel, and also to the general hyperesthesia.
Diagnosis of a spotted fever at newborn children is especially difficult, at to-rykh the Meningeal phenomena are, as a rule, not expressed. Therefore such general symptoms as temperature increase, concern of the child, crying, shout, a bad dream, failure from a breast, sometimes vomiting, a tremor of hands, a hyperesthesia, shall be the basis for carrying out spinal puncture (see), by results the cut quite often is also diagnosed meningitis.
Children of the first year have lives more often than at the senior children, also such forms as a meningococcal encephalomeningitis meet the expressed focal phenomena and ependimatit. However the severe forms of an ependimatit which are followed by occlusion, a cachexia and development of hydrocephaly are observed very seldom.
In sporadic cases M.'s diagnosis and. at children of early age it is especially difficult since many inf. diseases at children (pneumonia, acute respiratory viral diseases, intestinal infections, etc.) are followed by vomiting, spasms and meningeal symptoms; at the same time at newborns and children of the first year of life at the expressed meningitis can not be meningeal symptoms.
Diagnosis to meningococcemia in typical cases when there is characteristic star-shaped hemorrhagic rash and other displays of a disease, does not present difficulties. Sometimes hemorrhagic rash at a meningococcemia is taken for a hemorrhagic vasculitis (see. Shenleyna-Genokh disease ) or a Werlhof's disease (see. Werlhof's disease ). Damage of joints is accepted for sepsis (see) or epiphyseal osteomyelitis (see).
In the presence of spotty, dot or rozeolezny rash the meningococcemia should be differentiated with other inf. the diseases which are followed by ekzantema (see. Measles , Rubella , Scarlet fever etc.). The hypertoxical form of a meningococcemia should be differentiated with sepsis.
Principles treatments at a meningococcal infection the same, as at adults.
All children, patients with both a generalized form, and a nasopharyngitis, and also carriers of a meningokokk, are isolated from collective.
Patients are surely hospitalized.
At the children who transferred M. and., timely and correctly treated, heavy organic pathology from c does not come to light. N of page. Only disturbances of psychological activity funkts, character (an asthenic syndrome) come to light.
Such children need long dispensary observation at the psychoneurologist and the corresponding treatment.
Preventive inoculations to children. the transferred L. S., are not carried out during 1 year. For the prevention of generalized forms M. and. to the children of preschool age (age from 6 months to 7 years) communicating with patients with a generalized form M. and., it is necessary to enter normal human immunoglobulin (protivokorevy gamma-globulin) — once 3 ml no later than the 7th day after isolation of the patient (it is desirable as soon as possible).
Table 1. Some indicators of cerebrospinal liquid are normal, at a meningism, various forms of meningitis and subarachnoidal hemorrhage
Table 2. DIFFERENTIAL and DIAGNOSTIC DISTINCTIONS of the MENINGOCOCCEMIA, FLU,' the WERLHOF'S DISEASE, the HEMORRHAGIC VASCULITIS (according to V. I. Pokrovsky and Yu. Ya. Vengerov, 1977)
Bibliography: Fight against cerebrospinal meningitis, It is gray. tekhn. dokl. WHO of L 588, Geneva, WHO, 1978; In and shch e of N to about M. A. and M and to with * both m of e of c of V. G. Meningit and an encephalomeningitis of a meningococcal etiology, Kiev, 1980; Dyomina A. A., etc. Immunological structure of the population against a meningokokk, * Zhurn, mikr., epid, and immun., No. 10, page 24, * 1979; The Pokrovsk V. I., F and in about r about in and L. A. and Kostyukov H. H. Meningococcal infection, M., 1976; X about d and e in Sh. of X. and With about to about l about in and I. A. Meningococcal infection, Tashkent, 1978; Bergey’s manual of determinative bacteriology, ed. by R. E. Buchanan a. N. E. Gibbons, Baltimore, 1975, bibliogr.; Gotschlich E. C., Liu T. Y. a. A r t e n s t e i n M. S. Human immunity to the meningococcus. III. Preparation and immunochemical properties of the group A, group B and group With meningococcal polysaccharides, J. exp. Med., v (j-129, p. 1349, 1969; Griffiss J. M. a. ArtensteinM. S. The ecology of the genus Neisseria, Mt Sinai J. Med., v. 43, p. 746, 1976.
V. I. Pokrovsky; H. H. Kostyukova (etiol., epid., lab., diagn.), A. M. Nesvetov (stalemate. An.), N. I. Nisevich (ped.).