PNEUMOCYSTOSIS (pneumocystosis; synonym plazmokletochny pneumonia) — the disease caused by pneumocysts, which is found preferential at children and characterized by intersticial, plazmotsellyulyarny pneumonia.
For the first time the activator P. — Pneumocystis carinii — is described in 1909 by Shagasom (S. Chagas) who incorrectly counted it as a stage of development of a trypanosome. In 1912 in Paris Delanoe and Delanoe (R. of Delanoe, M. of Delanoe) found a parasite in easy rats and proved his specific independence. In the subsequent Pneumocystis carinii it was found in easy different animals (rats, mice, dogs, cats, rabbits, pigs) and the person. In 1952 O. Yirovets and J. Vanek proved that it is the causative agent of intersticial pneumonia at the premature and weakened children.
The etiology and a pathogeny
the Activator P. — R. of carinii — most of researchers carries to type protozoa (see) — Protozoa though the systematic provision and the nature of pneumocysts are not found out yet. A lot of things pull together them with protozoa of a class of Sporozoa, but the opinion on their vegetable nature and belonging to the lowest fungi of the sort Candida was expressed. Pneumocystis given about the protozoan nature are represented nevertheless by more convincing.
Parasites have rounded shape, 2 — 3 microns long, from 1,5 to 2 microns wide. The activator is well painted across Romanovsky — to Gimza (see. Romanovsky — Gimza a method ). The kernel concluded in the unstructured cover consisting of glikozaminoglikan is located in the center or is excentric.
Parasites breed by halving under a cover then also the mucous sphere pereshnurovyvatsya on two spheres.
After a number of divisions there comes the stage of a sporogony. Its process consists that the parasitic little body increases, filling almost all mucous membrane, and turns into a sporoblast. The kernel also increases and consistently is divided into 2, 4 and 8 kernels. The sporogony comes to an end with formation of a cyst, in a cut there are 8 oval or pear-shaped dispute of 1 in size — 2 microns everyone.
In the drawing the scheme of a development cycle and morphology of separate stages of Pneumocystis carinii, according to Frenkel is submitted (J.К. Frenkel, 1976).
The item is one of the reasons of an acute disease of lungs at children of early age, at premature, weakened owing to other diseases of various etiology, at the children accepting corticosteroids and immunodepressants; sometimes is the reason of pulmonary pathology at the adults suffering hron, diseases of blood, oncological diseases and treated from corticosteroids and immunodepressants and at the patients who transferred organ transplantation. At the expressed decrease in resilience to R.'s infection of carinii causes a generalized disease.
Inflammatory infiltration of interalveolar partitions leads to disturbance of gas exchange, filling of alveoluses with foamy weight, reduces the respiratory surface of lungs, causes oxygen insufficiency of various degree of manifestation and weight of a state.
people and animals — patients and carriers of activators can be P.'s Source. The main way of transfer of activators — airborne, however is possible also transplacental. Carriers of pneumocysts among employees of child care facilities are especially dangerous, from them the weakened and premature children susceptible to the Item can get sick. In view of the fact that P. is found in many house and wildings, some researchers draw a conclusion about a natural ochagovost
of P. P. is eurysynusic. Epidemics are described in 17 countries, and sporadic cases — in 30 countries of Europe, Asia, Africa, America. In Europe P. meets in the form of epidemic flashes, in America only sporadic cases are noted. In the USSR pneumocystic pneumonia is registered generally in Moscow, Leningrad, Kharkiv, Tajikistan and Estonia.
Macroscopically lungs look air, with the centers of violent emphysema. The visceral pleura at the same time is a little thickened, quite often there are spotty hemorrhages. Owing to a rupture of emphysematous bubbles can develop pneumomediastinum (see), pheumothorax (see). On a section tissue of lungs grayish and cyanotic, discharge viscous, scanty. A mucous membrane of a throat, a trachea and large bronchial tubes pale, in a gleam of respiratory tracts foamy contents. At gistol, a research in a gleam of alveoluses, and sometimes in interalveolar partitions the large number of pneumocysts and proteinaceous masses rich with immunoglobulins, in alveoluses, around the breaking-up conglomerates of a parasite — macrophages, neutrophilic leukocytes, erythrocytes, fibrin is found. Stroma of lungs, walls of small bronchial tubes and Interalveolar partitions utolsh; ena, infiltrirovana various cellular elements with dominance of plasmatic and lymphoid cells. In cytoplasm of cells of an epithelium of a mucous membrane of bronchial tubes macrophages with pneumocysts are found.
A clinical picture
the Incubation interval, according to most of researchers, on average 30 — 40 days, the shortest 7 — 10 days, the most long — to 26 weeks. The disease develops gradually and there pass three stages. The first lasts from several days to several weeks and is characterized by emergence uchash; unlimited breath, an asthma, cyanosis of a nasolabial triangle at suction and shout. The child refuses a breast, does not put on weight. Excrements can be liquid, do not change more often. Temperature — normal or subfebrile, at accession of a consecutive bacterial infection raised.
In the second stage of P. the wedge, a picture is characterized by a triad of symptoms: cyanosis, short wind, tachypnea. On 3 — the 4th week of a disease dry persuasive cough develops. Perkutorno is defined the expressed bandbox sound, increase in the lower bounds of lungs, mezhreberye are considerably expanded. Breath is not changed, weakened or hardish, in juxtaspinal areas single small-bubbling rattles are defined. Respiratory progresses acidosis (see).
The rupture of lobulyarny swellings and formation of pheumothorax is possible. Supplements heavy metabolic frustration respiratory eksikoz (see. Dehydration of an organism ). Massive damage of lungs leads to development of a pulmonary heart (see. Pulmonary heart ), the spleen and a liver increase.
In the third stage the state improves. An asthma decreases, cough disappears. The bandbox sound defined perkutorno disappears, the borders of heart before blocked emfi-zematozno by the increased lungs are defined more accurately. Rattles are not listened by Auskultativno. The phenomena of recurrent laryngitis or a persistent asthmatic syndrome occur at a part of patients. At all stages of P. in blood the lymphocytosis and a monocytosis is possible. In an acute stage the neutrophylic leukocytosis is sometimes observed; in uncomplicated cases — ROE is not changed, prp accession of consecutive infection accelerated.
P.'s current can be wavy: the periods of improvement are replaced by strengthening of an asthma, cough and other symptoms. Duration of a disease in uncomplicated cases of 4 — 8 weeks. P.'s complication secondary pneumonia leads to change clinical and rentgenol, pictures (see. Pneumonia ).
the Diagnosis is based on data of the anamnesis, an epidemiological situation, a wedge, a picture, detection of pneumocysts in slime from upper respiratory tracts, increase of an antiserum capacity, characteristic radiological data.
In slime of upper respiratory tracts the activator is found by the end of the 2nd week after the beginning of a disease. From a phlegm prepare smears, fix and paint across Romanovsky — to Gimza, Gomori, Masson, etc.
From immunol, methods for P.'s diagnosis use reaction of binding complement (see). Specificity and sensitivity of reaction is studied insufficiently. The most sensitive is reaction immunofluorescence (see) with the antigen purified of fabric cells. Data on specificity and sensitivity of reaction of an immunofluorescence are contradictory. Positively the big percent of healthy faces reacts. The intracutaneous test gives nonspecific reactions more often.
At P. the picture allowing to suspect the Item with a high probability is observed peculiar rentgenol. At the beginning of development of a respiratory syndrome find consolidation of a root of lungs of weak intensity. In the second stage, according to V. F. Baklanova (1980), the set of focal shadows, heterogeneous on the intensity, so-called wadded lungs appears. The formed atelectases not always manage to be revealed. Consolidation of a costal pleura and pleura of interlobar surfaces of a lung is possible. In the third stage of a disease in process of disappearance of the condensed and emphysematous sites the vozdukho-nosnost of pulmonary fabric is recovered also in rentgenol, in the forefront consolidation of intersticial fabric is visible to a picture. The strengthened pulmonary drawing can remain within several months.
Treatment is developed insufficiently. From specific means pentamidine (the antagonist folic to - you), in a dose of 4 mg/kg a day within 8 — 14 days is most effective (pneumocysts disappear from slime for the 6th day). However use of pentamidine can often cause a complication, napr, hypodermic hemorrhages, hypotonia, an azotemia, a glucosuria, an oliguria, megaloblastny anemia. For elimination of by-effects use folic to - that in a dose of 6 mkg a day. Apply also furasolidone, Trichopolum (metronidazole) with aminokhpnoly (a course 10 — 14 days). At accession of a bacterial infection appoint antibiotics. Carry out infusional therapy: enter gamma-globulin, Haemodesum, isotonic solution, plasma, blood; at anorexia glucose, albumine, alvezin and other means of parenteral food are shown.
The forecast and Prevention
the Forecast at the weakened children with inborn immunodeficient and states (see. Immunological insufficiency ) adverse. Death comes from asphyxia, sometimes owing to accession of a bacterial infection, a thicket staphylococcal, or generalized cytomegalies (see).
Prevention. Sick and suspicious on P. isolate to boxes. Service of children and contents same, as at other inf. pulmonary diseases. For patients constant and long observation is made. The medical staff should be inspected on a carriage of pneumocysts and at positive reaction not to allow to work with children. Patients and the weakened children shall not contact to animals who can be carriers of pneumocysts.
Bibliography: Andreyev I., etc. Differential diagnosis of the major symptoms of children's diseases, the lane with bolg., page 250, etc., Plovdiv, 1977; Baklanova V. F. and In frets of kina of M. I. The management but radiodiagnosis of diseases of a respiratory organs at children, L., 1978; Kerpel-Fronius E. Pediatrics, the lane with Wenger., page 413, Budapest, 1977; Matveev M. P., etc. A pneumocystosis at children, Pediatrics, No. 2, page 56, 1979; P I would be c of e in and V. A., etc. Pneumocystosis (distribution, sources and ways of transfer), in the same place, No. 6, page 30, 1974; Tsinzerling And. Century and M. V. O Ne-zhentsev to a nnevmotsistoza of easy children of early age, Arkh. patol., t. 32, No. I, page 21, 1970; D e 1 and n about yo R. of Sur les rapports des kystes de Carini du pou-mon des rats avec le Trypanosoma lewisi, C. R. Acad. Sci. (Paris), t. 155, p. 658, 1912; Frenkel J. K. Pneumocystis jiroveci n. sp. from man, Nat. Cancer Inst. Monograph., v. 43, p. 13, 1976; Geormaneanu M., Gherghi-na S. §i Cernatescu I. Pneumonia alveolo-interstitiala cu Pneumocystis ca-rinii, Rev. Pediat. Obstet. Ginec. (Buc.), V. 25, p. 55, 1976; Jirovec O. u. V a n e k J. Zur Morphologie der Pneumocystis carinii und zur Pathogenese der Pneumocystis-Pneumonie, Zbl. allg. Path. path. Anat., Bd 92, S. 424, 1954; Lip son A., Marshall W. C. a. Hayward A. R. Treatment ot pneu-mocystis carinii pneumonia in children, Arch. Dis. Childh., v. 52, p. 314, 1977; Pathology of tropical and extraordinary diseases, ed. by Ch. H. Binford a. D.H. Connor, V. 1, p. 303, Washington, 1976; Proceedings of the Symposium on pneumocys-tis carinii infection, Washington, 1976; V a V r a J. K u cera K. Pneumocystis carinii Delanoe, J. Protozool., V. 17, p. 463, 1970; Walzer P. D. a. o. Pneumocystis carinii pneumonia in the United States, Ann. intern. Med., v. 80, p. 83, 1974.
H. A. Tyurin; D.N. Zasukhin, M. I. Shaykhutdinov (etiol.).