SAPROPYRA EPIDEMIC (synonym typhus exanthematicus) — the epidemic infectious disease which is characterized by a cyclic current with fever, a specific dieback, damage of the central nervous system and blood vessels.
Now sporadic cases of S. of t meet more often. aa., Brill's diseases differing in easier current and received the name (see below).
- 1 History
- 2 Geographical distribution
- 3 The etiology
- 4 The epidemiology
- 5 A pathogeny
- 6 The pathological anatomy
- 7 Immunity
- 8 The clinical picture
- 9 Differential diagnosis
- 10 Treatment
- 11 The forecast
- 12 Prevention
- 13 Features of epidemiology and prevention of an epidemic sapropyra in troops
- 14 The disease Shaved
S. of t. aa. it is known from an extreme antiquity. Consider that the general disease observed in 430 — 425 BC and described by Thucydides was S.'s epidemic of t. aa. T, similar to S. aa. diseases were described by Kiprian from Carthage in 253.
First scientific description of S. of t. aa. under the name of petekhialny fever it is given in 16 century by J. Frakastoro observing epidemic of this disease in the French troops in 1525 — 1530. However to the middle of 19 century of epidemic of S. of t. aa. quite often mixed up with epidemics of belly N returnable typhus. In an independent nosological form C. of t. aa. V. Grizin-eera was allocated thanks to S. P. Botkin (1868) works, Gerhard (W. W. Gerhard, 1837) (see t. 25, additional materials). Inf. S.'s nature of t. aa. and existence of the activator in blood of the patient were convincingly proved in 1876 by the Russian doctor O. O. Mochutkoyesky in heroic experience of autoinfection by the blood taken from sick S. to t. aa. On S.'s communication t. aa. with pediculosis in 1841 the Russian medical officer I. A. Pribyl for the first time specified, to-ry wrote that the disease became infectious with the advent of pediculosis at prisoners of war, and «the infection increased with multiplication of louses». Probability of transfer of S. of t. aa. «by means of the insects sucking blood» the Russian doctor G. of N Minkh noted in 1878. To the same conclusion on the basis epidemiol. data came and N. F. Gamaley in 1908 the Fr. researcher Sh. Nikoll in 1909 in experiences on monkeys showed that S.'s carrier of t. aa. the louse is.
Researches on detection of the activator C. of t. aa. G. Rikkets and Wilder conducted in 1909 — 1910 (R. M of Wilder) in Mexico N in 1913 — 1914 the Czech researcher S. Provachek. G. Rikkets and S. Prova-chek, having caught during the carrying out an experiment, t died from S. aa. The Brazilian scientist of E. Roche-Lim in 1916, working in Hamburg tropical in-those, completed G. Rikkets and S. Provachek's work; it allocated the activator C. of t. aa., having given it the name — Provachek's rickettsia.
In the past all wars were followed by S. t. aa. Usually from S.'s epidemics of t. aa. troops sustained the losses much exceeding fighting losses. So, in the Russian-Turkish war of 1768 — 1774 in the Russian troops from S. of t. aa. died apprx. 44 thousand people, and died from weapon apprx. 35 thousand. Napoleonic troops carried S. to t. aa. across all Europe; in Germany in 1813 — 1814 S. of t. aa. 2 — 3 million people had.
World War I led to high rise in incidence of S. of t. aa. in a number of the states. E.g., in Serbia in 1915 died from S. of t. aa. St. 150 thousand persons. During Civil war and foreign intervention and in the next years (1918 — 1922) in the territory of the USSR, according to various researchers, S. of t. aa. had from 7 to 20 million persons.
World War II was also followed by high incidence of S. of t. aa. in many countries. So, from S.'s epidemics of t. aa. in 1942 — 1944 the countries Sowing were damaged. Africa. Then with S.'s troops of t. aa. got into Italy (epidemic in Naples), struck Poland, Germany, Romania, etc., widely extended in Iran and Iraq. S.'s epidemics of t. aa. were observed also in the territory of the USSR, temporarily occupied by nemetsko-fa-shistsky troops. So, at release from occupation of the Velikiye Luki district among the population 5205 patients, and in the territory of Nevelsky and neighboring districts — 5806 were revealed. S.'s incidence of t. aa. raised also in the rear districts of the USSR a little that was connected with evacuation of big mass of the population from the western districts of the country on V., with density of the evacuated people living quite often in the rooms which are not adapted for housing (nearly 70% of patients were necessary on evacuated), however the disease was not widely adopted.
the Causative agent of a typhus is Provachek's rickettsia — Rickettsia proAvazekii da Ro-cha-Lima, 1916, belonging to the sort Rickettsia this. Rickettsiaceae. Rickettsiae of a gramotritsatelna, 0,3 in size — 0,6 X 0,8 — 2,0 microns (sometimes to 4,0 microns). Unlike other types of rickettsiae (see) at Provachek's rickettsiae at cultivation polymorphism is observed — they take the form of cocci and sticks (see fig. 1 to St. Rickettsiae, t. 22, Art. 292). Provachek's rickettsiae during the coloring across Gimza or across Zdrodovsko-m (modification of coloring of Makkia-vello) of red color are also well visible in a light microscope; their ultrastructure (see fig. 2 to St. Rickettsiae, t. 22, Art. 292) is similar to the submicroscopic organization of gram-negative bacteria. Provachek's rickettsiae transverse binary fission, time of generation breed at optimal conditions apprx. the 12th hour.
Provachek's rickettsiae contain proteins, carbohydrates, lipids, phospholipids, RNA, DNA; in a cell wall are found muramovy and diaminopimelic to - you, sugar, aminosugar, 17 amino acids. Provachek's rickettsiae, being intracellular parasites, are located in cytoplasm. They well breed in a vitellicle of a chicken embryo and on various cellular cultures; in culture of fibroblasts of a chicken embryo form «plaques». Availability of very labile toxin is characteristic of Provachek's rickettsia. They are sensitive to action of high temperature, humidity, many chemical substances. At the same time they can is long to remain at a low temperature in proteinaceous substrates, and also in the dried-up look. Special value has a possibility of long preservation of rickettsiae in dry excrements of the infected louses. Provachek's rickettsiae are sensitive to action of a number of antibiotics (levomycetinum, tetracyclines, erythromycin, rifampicin). From a lab. animals are most susceptible to Provachek's rickettsiae cotton rats and Guinea pigs (at all ways of infection), white mice are highly sensitive to intranasal infection.
the Only source of an infection is the sick person, to-ry remains a source of infection during 20 — 21 in the afternoon, i.e. the last two days of an incubation, all feverish period (up to 17 days) and the first two days of an apirekeiya. Till last two days of an incubation interval and from the day before yesterday apirekeiya of activators C. of t. aa. in blood of the patient, as a rule, do not find.
A carrier of contagiums at S. of t. aa. the clothes louse (Pediculus vestimenti) serves. Head and pubic louses (Pediculus capitis and Phthirus pubis) can also transfer the activator, but their Epi-demiol. the role in comparison with a clothes louse is insignificant (see the Louse). S.'s rickettsiae of t. aa. the louse catches at a krovososaniye on the patient; capable to transfer the activator it becomes only on 5 — the 6th day, is more rare — on 9 — the 10th day. At this time there is an accumulation of the activator' and its implementation in an epithelium of an intestinal wall of a louse. Once having caught, the louse is capable to transfer the activator until the end of the life (lives up to 45 — 46 days). Insects of rickettsiae do not transfer to the posterity.
Activators C. of t. aa., breeding and collecting in a large number in epithelial cells of a gut of a louse, break off these cells and are allocated in a gleam of her intestines. Including in sialadens and in the sucking device, rickettsiae do not contain in other parts of a body of a louse. Infection of the person S. of t. aa. occurs as follows. When the infected louse pierces skin of the person and begins to suck blood, her intestines are gradually filled krovyo and at the same time there is an act of defecation, at Krom excrements with a large number of rickettsiae are emitted for the surface of skin of the person. The sting of a louse is followed by an itch. The person, combing the place of a sting, rubs infectious material in the formed grazes.
Thus, emergence and S.'s distribution of t. aa. it is always connected with the pediculosis (see the Louse) accompanying deterioration a dignity. conditions of these or those groups of the population. Page of t. aa. in the past quite often was called military, hungry, prison typhus. These names say that the greatest distribution of S. of t. aa. received during wars, hunger and other social shocks when financial position of the people worsened, population shift amplified, the lack of linen was observed, washed, etc.
To S. of t. aa. people of all age are susceptible. In the conditions of spread of a disease workers of transport, personnel of baths, laundries, disinfectors are most subject to risk of infection. In the past the increased incidence among medical staff was observed. Implementation in practice of sanitary cleaning of patients, disinsections of things of the patient and a dignity. transport reduced this danger.
The expressed S.'s seasonality of t. aa. for middle latitudes (February — April) is defined by increase in contacts among the population due to density in dwellings in cold season.
Provachek's Rickettsiae, getting to blood of the person, quickly get into cells of an endothelium of blood vessels where breed and allocate endotoksinony under the influence of endotoxin endothelial cells bulk up, there is their desquamation and destruction. Rickettsiae come to blood again, part of them perishes, releasing endotoxin, and the others get into cells of an endothelium of vessels again. Such process without seen a wedge, manifestations continues until there occurs sufficient quantitative saturation of an organism rickettsiae and their endotoxin. The last has vazodilatatsionny effect, especially in system of small vessels — capillaries, precapillaries, arterioles, venules, in to-rykh microcirculation is broken (see) up to formation of a paralytic hyperemia and delay of a blood flow. As a result of it the conditions promoting development of hyaline blood clots in places of parasitizing of rickettsiae where there was a destruction of an endothelium of vessels, to the subsequent education in bodies and fabrics of a specific granuloma (see) are created. Such changes in vessels come to light with 6 — the 8th day of a disease practically in all bodies and fabrics, but most of all they are expressed in a brain, in skin, conjunctivas of eyeglobes, adrenal glands, a myocardium, kidneys. The known role in S.'s pathogeny of t. aa. plays also an allergic component, but its essence is not clear yet. In the course of a disease there comes the specific immune reorganization of an organism leading as a result to recovery. Rickettsiae can be found in bodies and fabrics in the last days of an incubation, during all feverish period and in the first days of an apirekeiya. In an organism of patients the activator can is long to remain also after clinical recovery, this phenomenon is still insufficiently studied.
Involution morfol. changes begins from the 18-20th day from an onset of the illness and comes to the end generally by the end of the 4th week, and sometimes later.
The pathological anatomy
Pathological anatomy of a sapropyra is studied by hl. obr. domestic researchers And. V. Davydovsky, A. P. Avtsyny, Sh. I. Kri-nitsky, etc. On skin it is possible to find signs of rash in the form of not clearly konturirovanny spots and points of pink, brownish, red color. More resistant sign is conjunctival rash (see Kiari — Avtsyna a symptom). Serous meningitis (see), a plethora of tissue of brain, a considerable plethora and increase in mass of lungs (by 2 — 4 times), increase in the sizes of a spleen by 2 — 3 times is noted. At gistol. a research find the characteristic defeat of blood vessels of capillary type which received the name of an endothrombovasculitis with swelling and destruction of an endothelium, exfoliating of its cells in a gleam of a vessel and formation of pristenochny or occlusive blood clot (see). These changes are followed by proliferation of adventitious histiocytes, to the Crimea not numerous neutrophils and lymphoid elements are added that along with a focal hyperemia of capillaries is the cornerstone of formation of a typhous roseola. Deepening of destructive changes in vessels, emigration of erythrocytes characterize transformation of a roseola into a typhous petechia. Similar changes can be found in various bodies and systems.
In a brain (see) the typhous small knots for the first time described by L. V. Popov (1875) are found in the varoliyevy bridge (the bridge of a brain, T.), legs of a brain, cerebral cortex, basal kernels, thalamuses (visual hillocks), cerebellum, hypothalamus, back share of a hypophysis. As a rule, there are no typhous small knots in white matter of cerebral hemispheres. Typhous small knots in tissue of a brain are constructed of cells of a microglia, to the Crimea segmentoyaderny leukocytes (fig. 1) are, as a rule, added. Important diagnostic value has accumulation of typhous small knots in a myelencephalon, in a chdstnost in the field of its lower olive kernels. Quantity of such small knots in c. the N of page depends generally on duration of the feverish period. In case of death on 2 — the 4th week of a disease they are found in 100%. At had typhous small knots regress. The histologic changes remaining during later periods of a disease can be a diagnostic character transferred in last S. t. aa.
In c. the N of page is marked out, as a rule, a hyperemia and staza (it is frequent with formation of hyaline blood clots in capillaries of gray matter), perivascular (hl. obr. perivenous) couplings from plasmocytes, diffusion and focal proliferation of a microglia. This patogistologichesky complex (staza, characteristic typhous small knots in gray matter of a brain, especially in a myelencephalon, couplings from plasmocytes around small veins, proliferation of macrophages in a soft cover of a brain) grants the right to consider that each case of S. of t. aa. is followed by encephalitis (see Encephalitis), expressiveness to-rogo widely varies. It should be noted that as opposed to the specified vascular and intersticial changes in c. N of page crushing alterativny defeat of nervous cells and nerve fibrils for a typical current of S. of t. aa. it is not characteristic.
In sympathetic and to a lesser extent in a parasympathetic nervous system at S. of t. aa. the intersticial ganglionitis with nodulation and infiltrates, proliferation of capsular cells is observed. Heavy destructive ganglionites and specific neuritis meet as an exception.
Characteristic sign of S. of t. aa. is as well the intersticial myocarditis (see) which is shown focal more rare diffusion infiltration of a stroma of a myocardium plasmocytes in combination with big or smaller formation of typhous small knots and weak changes of cardiomyocytes (fig. 2).
Also typhous intersticial orchitis (fig. 3) and intersticial nephrite is noted (see), to-rye can be focal and diffusion. Defeat of renal balls is shown by hl. obr. hyaline thrombosis (sometimes with a necrosis of separate loops) and much more rare a focal glomerulonephritis (see).
At bad care of an oral cavity at the patients who are in prostration are observed purulent parotitis (see) and an inflammation of submaxillary gland (see). Occasionally small infiltrates, small knots and defeats of vessels of a stomach meet. The sizes of a liver are increased, its parenchyma is a little changed.
The mucous membrane of respiratory tracts is usually full-blooded. Natural increase in mass of lungs and their cerise color are caused by hl. obr. deposition of blood in a small circle of blood circulation. The fluid lungs is possible. In muscles of a throat at microscopic examination the specific intersticial miositis is observed. Are rather rare a perichondritis (see) and phlegmon of a throat (see). Very frequent complication is pneumonia (usually lobulyarny, but occasionally and lobar).
A peculiar form of defeat of larger vessels is represented by sectoral and the circular necroses of a wall of arteries which are followed by the phenomena of a plasmorrhagia (see) and perivascular proliferata are more rare. They meet not earlier than the 3rd week of a disease, but can be observed later. Occasionally they can be the cause of heavy local hemodynamic frustration — the encephalomalacia which is followed by paralyzes (see Paralyses, paresis), aphasia (see), a wedge, a picture of a cross myelitis (see), etc. The same changes in arteries of a retina can cause a blindness (see). Obviously, they are the cornerstone enough rare accidental hemorrhages in a brain at convalescents. These late destructive changes of large arterial trunks connect with a hyper sensitization of an organism. Intersticial infiltrates can be observed in a wall of an aorta and in a muscular coat of large veins. In closed glands (a hypophysis, adrenal glands, a thyroid gland) it is possible to find characteristic typhous small knots and focal infiltrates.
In a spleen (see) reveal sharply expressed proliferation of histiocytes and plasmocytes, desquamation of their and larger macrophagic elements, and also accumulation of segmentoyaderny leukocytes, moderate deposits of a haemo-si dogwood. In cytoplasm of macrophages and endothelial cells find the azurophilic granularity morphologically indistinguishable from rickettsiae. In marrow (see) also note proliferation of basphilic histiocytes and formation of specific perivascular small knots is more rare.
Inf. process at S. of t. aa. is followed by development of durable and long immunity. Recurrent diseases are rare. In P.F. Zdrodovsky's works with sotr. (1972) it is shown that immunity at S. to t. aa. arises soon after infection. During the feverish period the immunitas non sterilisans, i.e. develops in the presence of a microbe, and after the postponed disease, according to many researchers, sterile, remaining is long (up to 40 years). A number of researchers — K. N. Tokarevich, G. S. Mosing, V. M. Kolotov, R. A. Pshenichny with sotr., Sh. Nikolau and N. Constantinesco allow a possibility of long experience of rickettsiae in an organism of the transferred S. of t. aa. person. Taking into account it K. N. Tokarevich and G. S. Mosing considered S. which arose later of t. aa. immunity as unsterile. Active immunization by the vaccine prepared from culture of rickettsiae of Provachek is possible (see below Prevention).
The clinical picture
the Incubation interval fluctuates from 5 to 25 days, 10 — 12 days are more often. Distinguish easy, medium-weight, heavy and very heavy disease.
At the most typical medium-weight current of S. of t. aa., observed at 60 — 65% of patients, the disease begins with temperature increase, emergence of feeling of heat, dizziness and a headache, weakness, easy chilling and perspiration, an ache in all body, thirst and loss of appetite. All these signs quickly accrue, especially the headache, edges from the first days becomes painful. There are sleeplessness, muscle and joints pain, perceptions escalate, irritability and the concern sometimes passing into a condition of euphoria and excitement are noted; the condition of block is possible. The expressed hyperemia of the person and conjunctivas — «red eyes on a red face», a dermahemia of a neck and an upper part of a trunk, an easy amimia, puffiness of the person, moderate cyanosis of lips is observed. Skin to the touch hot, the increased humidity; symptoms of a pinch and a plait positive (see Konchalovsky • — Rumpelya — Leede a symptom). Sometimes there is herpes on lips (see Herpes).
From the 3rd day of a disease it is possible to find Kiari's symptom — Avtsyna — the rash which is located on transitional folds of a conjunctiva i.e. in the field of top and bottom a fornix conjunctiva, in the form of single petechias, and Rosenberg's symptom — Vinokurova — Lendorffa — an enantema on a soft palate. The spleen increases that comes to light a brace bit-torno, and later and palpatorno. A moderate asthma, moderate tachycardia and a priglushennost of cardiac sounds, hypotension are noted (see). The tremor of language can be observed (Govorov's symptom — Godelye), quite often his deviation (deviation), is poorly expressed the general tremor (see Trembling). The nonsense can be observed (see).
On 4 — the 6th day of a disease appears characteristic plentiful rozeolezno-petekhialny rash on skin of side surfaces of a breast, a stomach, the flexion surfaces of upper extremities. Elements of rash seldom happen more than 3 mm in the diameter. Sometimes rash develops on palms and is very rare on a face. Roseolas and petechias at S. of t. aa. seem flat and indistinct, deckle-edged since are located usually vnut-rikozhno. At use of a plait dot petechias (see) on a forearm it is possible to find from the 3rd day of a disease. Sometimes roseolas tower over skin and exclusively seldom turn into papules. Elements of rash within 3 — 5 days have pink, bright red or a little cyanochroic coloring, then roseolas turn pale, and petechias become pigmented. In 7 — 9 days from the beginning of a rash rash disappears, leaving for a short time indistinct pigmentation. New rashes at S. of t. aa., as a rule, does not happen. Rash usually plentiful, seldom happens scanty and absolutely seldom is absent completely.
With the advent of rash become more expressed a symptom of a pinch, conjunctival rash and an enantema, and also disturbances from c. N of page. Considerably the ABP goes down, tachycardia amplifies, dullness of cardiac sounds and expansion of its borders is noted; elektrokardiografichesk are registered the changes testimonial of development of myocarditis. Weakness, the heads-yaya pain and sleeplessness accrue. It is possible, especially at night, a peculiar typhous delirium with hallucinations, nonsense, excitement, concern, fussiness are characteristic. Sometimes patients jump from a bed, try to run. There are symptoms of defeat of a meninx: poorly expressed muscle tensions of a nape, Kernig's signs — Brudzinsky (see Ker-niga a symptom, Meningitis) at ma-loizmenenny cerebrospinal liquid (the cytosis does not exceed 100 cells in 1 mkl). Many patients have more accurate symptoms of defeat of cranial nerves (cranial, T.), in particular there is a smoothness of nasolabial folds, can be observed decrease in hearing, moyo-and polyneurites, a moderate hyperesthesia of skin.
Appetite at the patient is reduced or absolutely is absent, thirst disturbs. Language dry, is laid over by a serogryazny plaque, to-ry often accepts brown coloring (fuligi-nozny language); quite often on it cracks appear. The liver and a spleen at most of patients are increased, locks, a meteorism are noted. There can be an oliguria, or the urination occurs drops at the crowded bladder (inconscience with overflow). Changes in urine are insignificant, in the form of a feverish albuminuria. Temperature by 5th day of a disease reaches the maximum figures (39 — 40 ° above) and keeps to 12 — the 14th day of a disease with the subsequent normalization within 2 — 3 days.
Recovery begins with fall of temperature and decrease in intoxication. Puffiness of the person and its hyperemia decrease. There is an interest in surrounding, the dream and appetite improve, the mocheotdeleniye amplifies. To 3 — to the 5th day of standard temperature the sizes of a liver and spleen come to norm. Cardiac sounds become clearer and the ABP is normalized. However at patients the considerable adynamia and weakness are still noted, the hyperesthesia of skin remains. The absolute recovery comes approximately in a month after normalization of temperature.
Easy current of S. of t. aa. it is usually peculiar to persons of young age. The phenomena of the general intoxication in, these cases are insignificant, temperature usually does not exceed 38 °, consciousness is not changed, block is sometimes noted. The nonsense, is observed only at certain patients. The headache and sleeplessness are expressed. Rozeolezny rash prevails, petechias are not numerous. The liver and a spleen increase approximately at a third of patients. The hyperemia and puffiness of the person, a hyperemia of conjunctivas, Kiari's symptom — Avtsyna, Govorov — Godelye are more constant. The feverish period lasts on average 9 days.
At a heavy current of S. of t. aa., a cut occurs at 15 — 20% of patients, more snowballing of vascular and brain symptoms owing to the expressed intoxication is observed. Pulse is frequent, to 140 beats per minute, arrhythmia is frequent, systolic the ABP decreases to 70 — 80 mm. Cardiac sounds deaf. The Crocq's disease is expressed. The tachypnea is observed (see), disturbance of a rhythm 'breath as biotovsky (see Biotovsky breath) or Cheyna — Stokes is possible (see Cheyn — Stokes breath). Changes in c are especially considerable. N of page. Early there are mental disorders, sharp excitement, deliriums which are quickly replaced by block. Signs of defeat of a meninx and a trembling syndrome up to emergence of spasms are expressed (see), are observed disturbance of swallowing (see the Dysphagy), a dysarthtia (see). Temperature reaches 41 — 42 °. Rash preferential pe-tekhialny with possible considerable hemorrhages that is a terrible sign. Conjunctival rash is expressed. The highest manifestation of a heavy current of S. of t. aa. the deep coma is (see), in this state patients often perish.
As very severe form so-called fulminant typhus — typhus siderans when owing to heavy intoxication there were changes in adrenal glands was described and patients perished in a condition of toxi-infectious shock (see). Heavy and very heavy current is most often observed at elderly people.
Atypical forms of a disease meet, at' to-rykh a separate wedge, S.'s signs of t. aa. are absent or are unsharply expressed.
S. children have a t. aa. proceeds much easier and recovery nastu7 sings quicker. Intoxication, defeat of cardiovascular system and c. N of page at children are less expressed, than at vzrsly. The disease begins also less sharply. At the beginning of a disease moderate general intoxication with the weak headache, the catarral phenomena moderated by changes from bodies of blood circulation at a part of patients — dysfunction of intestines is usually observed. Fever happens constant, remittiruyushchy and wrong; duration of the feverish period is no more than 11 — 13 days. At the majority on 4 — the 5th day of a disease appears rash, is preferential rozeolezno-petekhi-alnaya; apprx. 20% of children transfer S. of t. aa. without rash. The loss of consciousness, nonsense, hallucinations, the general excitement are not frequent and if happen, then are expressed more weakly, than at adults. The liver and a spleen increase no more than at 40% of patients.
At most of children of S. of t. aa. proceeds benign, less often — in the form of moderately severe and almost never — it is heavy. A lethality at S. of t. aa. at children was almost not registered. The period' reconvalescences proceeds more favorably N quicker, than at adults.
Complications Page of t. aa. — a collapse (see), pneumonia (see), myocarditis (see), thrombophlebitises (see), fibrinferments (see), thromboembolisms, disturbances of cerebral circulation (see the Stroke, the Thromboembolism), a myocardial infarction (see), later psychoses, a consecutive purulent infection — - otitises (see), parotitis (see), a pyelitis (see Pyelonephritis), etc. At children of a complication are rare.
Diagnosis is based on epidemiol. data (pediculosis, contact with sick S. of t. aa.), characteristic wedge, picture and data lab. researches, positive takes to-rykh can be received not earlier than 6 — the 7th day of a disease.
At S. of t. aa. at the height of a disease in blood insignificant decrease in quantity of erythrocytes, thrombocytopenia, a moderate leukocytosis with a neutrocytosis and band shift (it is noted already in an initial stage), the eosinopenia, a lymphopenia, emergence of plasmocytes accelerated by ROE are observed.
Laboratory diagnosis is carried out generally by definition in blood serum of antibodies to Provachek's rickettsiae. The main serol. reactions (see. Serological researches) in a lab.
to S.'s diagnosis t. aa.: RSK — reaction of binding complement (see), RNGA — reaction of indirect hemagglutination (see. Hemagglutination ), an agglutination test (see Agglutination), a method of an immunofluorescence (see. Immunofluorescence ).
RSK is one of the most common for recognition of a typhous infection both clinically expressed cases, and the erased forms. With its help also retrospective detection of the infection postponed in the past since fixators to Provachek's rickettsiae remain up to 10 years and more is possible. Fixators are found usually with 5 — the 7th day of a disease in 50 — 60%, and from the 10th day — in 100% of patients with a sapropyra. The maximum antiserum capacities (1:320 — 1:5120) are registered on 2 — the 3rd week of a disease. The diagnostic caption at single definition should be considered 1:160. More reliable is definition of antibodies in dynamics (in 5 — 7 days after the previous research). For retrospective diagnosis of S. of t. aa. a diagnostic caption is 1:10 — 1:20. The modification of RSK offered P. Fiset, allowing to put it with small amounts of ingredients was widely adopted.
RNGA is highly sensitive test. For statement of this reaction use the let-out erythrocyte diagnostts-godfather. RNGA gives the chance to diagnose fresh cases of a sapropyra, it is positive in most cases S. of t. aa.; the maximum antiserum capacities (1:6400 — 1:12800) are registered on 2 — the 3rd week of a disease, a diagnostic caption at single definition — 1:1000. The most reliable is definition of antibodies in dynamics.
The agglutination test is the simplest, but is applied seldom since is less sensitive, than RSK and RNGA; diagnostic caption of reaction 1:160. It is highly sensitive at use of the antigen received from the rickettsiae which are grown up in louses (Veygl's reaction).
For detection of antibodies against rickettsiae the indirect luminescent serological method can be used.
S. of t. aa. differentiate with Brill's disease (see below), flu (see), pneumonia (see), meningitis (see), hemorrhagic fevers (see), a typhoid (see) and paratyphus (see), a North Asian tick-borne rickettsiosis (see), a drug disease (see), a trichinosis (see), various eritema (see. Erythema ).
For a differential diagnog flow down S. of t. aa. with Brill's disease data of the anamnesis are important (for Brill's disease — a recurrent disease); it is necessary to consider that Brill's disease can arise against the background of epidemic wellbeing. Differential diagnosis of S. of t. aa. and diseases Brilla is based on the provision, known in immunology, on formation of various classes of immunoglobulins as a result of primary and repeated diseases and antigenic incentives interfaced to them, a cut in principle is applicable to these zabrleva-niya. At S. of t. aa. there is a formation at first of IgM (198 antibodies), and then IgG (78 antibodies), at Brill's disease — bystry formation only of IgG (78 antibodies). As IgM is more labile, it manages to be destroyed, natsr. applying a number of the reducing substances (2 mercaptoethanol, cysteine, etc.). If at a research of blood serum of the patient such processing leads to decrease in an antiserum capacity, by 4 — 8 times and more, it is possible to assume that in blood serum was in the main IgM, to-ry then collapsed; if the caption of serum was left without changes, it is possible to assume existence of IgG. It should be noted that at S.'s differentiation t. aa. and Brill's disease should not be based only on serological methods; it is necessary to consider all complex a wedge, and epidemiol. indicators (e.g., S.'s disease of t. aa. in the past).
Most often at the beginning of S.'s disease of t. aa. it is diagnosed as flu. However flu differs from S. in t. aa. more acute beginning (the patient calls not only day, but also hour of an onset of the illness), sharp weakness in the first day of a disease, constant plentiful perspiration, lack of puffiness and an amimia of the person and Govorov's symptom — Godelye. The headache is localized usually in a forehead, superciliary arches and temporal areas, easily is removed analgetics, during the pressing on eyeballs and at the movement pain arises them; rash, increase in a liver and spleen are not characteristic of flu. At pneumonia there are no rash, a hepatolienal syndrome, Kiari's symptom — Avtsyna, and also symptoms of defeat of kernels of cranial nerves.
Meningitis of various etiology differs from S. in t. aa. existence of the expressed meningeal syndrome (muscle tension of a nape, positive Kernig's signs and Brudzinsky, etc.). Decisive in diagnosis the analysis of cerebrospinal liquid can be (see).
At hemorrhagic fevers, especially with a renal syndrome, the hyperemia of the person and conjunctivas is more expressed, rash has character of not plentiful dot hemorrhages, is more often on side surfaces of a trunk and in axillary areas; vomiting and a hiccups, a back pain and a stomach are usual; thirst and an oliguria, sharply positive symptom of Pasternatsky are typical (see Pasternatsky a symptom). The hyperglobulia, the normal or accelerated ROE, substantial increase of residual nitrogen and urea of blood, hamaturia, albuminuria, cylindruria are characteristic.
Pallor of the person, an adynamia and slackness are characteristic of a typhoid and paratyphus. Language is thickened, laid over, with prints of teeth at the edges and on a tip. Bradycardia with a dicrotism of pulse is often noted. The meteorism and rumbling in the right ileal area, later increase in a liver and spleen are usual. Rash is scanty rozeolez-ny, develops not earlier than the 8th day of a disease on a breast, a stomach and side surfaces of a trunk. In blood a leukopenia with an eosinopenia, band shift with a relative lymphocytosis, thrombocytopenia.
At the North Asian tick-borne rickettsiosis which is found in the Regions of Siberia and the Far East, differentiation is based on existence at most of patients with a tick-borne rickettsiosis of primary affect representing dense infiltrate of brown or brown color is more often to 1,5 cm in the diameter with a possible necrosis in the center; regional lymphadenitis, to-ry develops almost along with primary affect; the rozeolezno-papular bright rash on all body developing on 2 — the 4th day of a disease.
The allergic dieback (see Rashes) arising at treatment by streptocides and antibiotics of patients with various ostrolikhoradochny diseases (flu, pneumonia etc.) quite often mixes up with S. of t. aa., especially at emergence of rash on 4 — the 5th day from an onset of the illness. Elements of rash at the same time are more often than exudative character, sometimes rozeolez-but-papular, act over skin, are very plentiful on all body parts, but it is more on an extensor surface of joints and tend to merge. The lymphadenopathy is noted. The spleen is usually increased.
For a wedge, pictures of a trichinosis are characteristic a face edema and a century («odutlovatka»), a headache and pain in all groups of muscles at the movement and at their palpation, moderate conjunctivitis, sometimes a chemosis of an eyeglobe, morbidity at the movement of eyes. Rash is plentiful, can be rozeolezny, rozeolezno-papular, urtikarny and even pe-tekhialny. Increase of rash is possible. The hypereosinophilia is typical. In the anamnesis — the instruction on consumption of insufficiently thermally processed pork and quite often group disease.
Various an erythema — exudative and mnogoformny — t differ from S. aa. the fact that rash at them covers all body and the person. Erie-tematozno-exudative elements of usually large sizes also often merge. Nodes and a spleen increase peripheral limf. Perspiration, a fever, joint pains are expressed. Symmetry of an arrangement of rash is characteristic of a mnogoformny erythema. After its blossom fading the peeling is noted.
the Most effective remedies are drugs of a tetracycline row (tetracycline, Oxytetracyclinum, doxycycline — semi-synthetic derivative Oxytetracyclinum of the prolonged action, Sigmamycinum, Oletetrinum), and also levomycetinum (hlorotsid, chloramphenicol). Tetracycline drugs the adult appoint 0,3 — 0,4 g, and levomycetinum — on 0,5 g 4 times a day till 2nd day of standard temperature (to children antibiotics are appointed according to age). It is possible to enter tetracyclines (tetracycline, Oxytetracyclinum, Sigmamycinum, etc.) intramusculary or intravenously on 250 mg 2 times a day at very heavy and heavy disease. Doxycycline is appointed also inside in the 1st days on 0,1 g by each 12 hours, in the next days — on 0,1 g of 1 times a day. At treatment by antibiotics temperature is normalized through 1V2 — 2 of days. At treatment of heavy and very severe forms of S. of t. aa. the intensive care with use of steroid hormones is carried out. Along with it also pathogenetic therapy, in particular use cordial and vascular, especially pressor, means (camphor, Cordiaminum, caffeine, noradrenaline, ephedrine, Hypertensinum, a phenylephine hydrochloride), according to indications — Korglykonum and strophanthin is necessary. In case of the expressed excitement or a delirium appoint bromides, barbiturates, Chlorali hydras, aminazine, Droperidolum, diazepam (Seduxenum).
Treatment by antibiotics considerably reduced number of the complications which are especially connected with secondary microflora. The arising complications of other sort demand treatment according to their character, napr, anticoagulants at fibrinferments and thromboembolisms. All types of treatment shall be combined with the corresponding diet at the height of a disease, absolute rest of the patient to 5 — the 6th day of standard temperature and careful care of it. With 7 — the 8th day of standard temperature patients can allow to go. For the 12th day of the patient write out on condition of the normal period of reconvalescence.
the Lethality in the past in separate epidemics reached 80%, now thanks to an antibioticotherapia the lethality sharply decreased and makes less than 1%.
Growth of material and cultural level of the population and after this disappearance of pediculosis was excluded by a possibility of circulation of the activator and an epidemic distributional pattern of S. of t. aa. in our country.
The found separate cases of a disease of Brill demand holding unrelenting preventive actions as this form of a disease in the epidemic relation does not differ from S. in t. aa. First of all daily prevention of pediculosis is necessary. In the presence of epidemic indications perform regular inspections of children at schools and preschool institutions, the patients arriving in to lay down. institutions. At detection of pediculosis carry out cleansing (see). Importance in prevention of pediculosis, and consequently, and S. of t. aa. has a dignity. education, promotion of measures for the prevention of pediculosis and S. of t. e *
In fight against the arisen diseases the leading place belongs to early identification and sick S.' isolation of t. aa., elimination of pediculosis at them, and also isolation of persons with suspicion of a disease. As the caught louse becomes capable to transfer rickettsiae to people only on 5 — the 6th day, identification and hospitalization (isolation) of the patient, his sanitary cleaning no later than the 5th day from an onset of the illness exclude a possibility of the new diseases connected with this patient. In epid. the center «household bypasses» allow to provide early identification of in the fever patients, among to-rykh also sick S. can appear t. aa. With the same purpose within 25 days medical observation (with daily thermometry) for the persons communicating with sick S. of t is conducted. aa.
The second important action in epid. the center elimination of pediculosis is. The hospitalized patient is exposed to obligatory sanitary cleaning, all persons adjoining to it, bedding and things to-rymi the patient, and the room where he lived used.
Specific prevention has auxiliary value. Veygl (R. Weigl, 1924) developed a method of production of a vaccine from contents of the intestines of the infected louses processed 0,5% by solution of phenol. A. V. Pshenichnov and B. M. Ry-her in 1943 used as a vaccine a formalinizirovan-ny suspension from the pounded larvae of the louses infected with rickettsiae of Pro-vacheka. In 1940. Coke (H. R. Dried) suggested to prepare a vaccine from Provachek's rickettsiae which are saved up in vitelline sacks of chicken embryos.
M. K. Krontovskaya with sotr. and M. M. Mayevsky with sotr. developed and in 1941 offered a method of production of a pulmonary vaccine like Durant — Fat. White mice were the best producers. Rickettsiae collected in the easy infected mice; lungs crushed in the corresponding way, processed formalin. Then rickettsiae took centrifuging. Krontov-skaya's vaccine — Mayevsky was applied during the Great Patriotic War both in troops, and among the population. According to most of the specialists studying immunological efficacy it reduces incidence and weight of disease at vaccinated. At immunization of the population incidence at vaccinated was about 2,5 — 3 times lower, than among not vaccinated. Now in the USSR for specific prevention of S. of t. aa. the dry chemical typhous vaccine representing the purified concentrated immunogene substance of a surface antigen of rickettsiae of Provachek is produced (see Immunization, the table). Inoculations are only carried out by this vaccine on epid. to indications in cases when ordinary actions for elimination of the centers of S. of t are difficult feasible. aa. Also inoculations are shown to the medical personnel working in the conditions of S.'s epidemics of t. aa.
Features of epidemiology and prevention of an epidemic sapropyra in troops
In last S. of t. aa. called «military typhus» since S.'s epidemics of t. aa. always accompanied wars, made devastations among the population and struck troops, putting the whole connections and armies out of action. Massive epidemics it are noted in troops of a number of the countries of Europe in 18 — 19 centuries. High incidence of S. of t. aa. took place and in the Russian army. So, Kutuzov's army during prosecution of Napoleonic troops in 1812 incurred t from S. aa. big losses. In the Crimean war, by data T. E. Boldyreva, from November, 1853 to November, 1855 only in the southern (Russian) army 29 411 people got sick with «typhus», from them died the 6929th persons. In the Russian-Turkish war of 1877 — 1878 in the Danube and Caucasian armies 36 656 people got sick, from them died 12 071 persons. S.'s incidence of t was high. aa. and during the Russian-Japanese war of 1904 — 1905 (5,0 — 5,3 on 1000 people of staff), and in the years of civil war it reached 130,67 on 1000 people of staff (1919). In post-war years of peaceful construction S.'s incidence of t. aa. in Red Army it was almost liquidated.
In 1941 — 1945 in the territory occupied by fascist army, S. in t. aa. was widely adopted among local population. Fascist command not only did not carry out any measures of fight against S. of t. aa., but intentionally concentrated sick S. t. aa. in settlements on the way of alleged approach of the Soviet troops, creating threat of a drift and S.'s distribution of t. aa. among our troops. Thanks to accurately organized anti-epidemic actions (see System of anti-epidemic providing Armed Forces) in troops it was succeeded to keep epidemic wellbeing while the army of invaders sustained considerable losses from S. of t. aa.
Owing to specific conditions of accommodation of staff of troops in field army (density, possible temporary interruptions in bath-and-laundry service, etc.) conditions for distribution of S. brought in troops of t are created. aa. Therefore in system of anti-epidemic providing troops, both in peace, and in wartime, the complex of the preventive actions directed to prevention of a drift of S. of t is provided. aa. in troops and the prevention of pediculosis: observance of authorized requirements of personal and public hygiene; weekly washing in a bath with change of linen; regular medical examinations of staff, isolation and full cleansing (see) the persons with the revealed pediculosis and also contacting to them; medical control of the arriving replenishment and returned from business trips, issues, their sanitary cleaning, and if necessary a karantinization for 14 days (see the Quarantine, a karantinization); control for a dignity. a condition of staff and vehicles during the transportations on., to water and automobile means of communication, timely sanitary cleaning along the line; in wartime — prevention of contact with local population in case of placement or conducting combat operations in the territory, unsuccessful according to S. of t. aa. Timely information about epid. to a situation the dignity is reached by continuous carrying out. - epid. investigations (see. Medical investigation, Sanitary and epidemiologic observation). At explicit threat of a drift of S. of t. aa. in troops the staff is exposed to immunization.
At identification regarding sick S. of t. aa. it should be isolated, carried out immediately sanitary cleaning, and also disinsection of regimentals, linen, bedding of the patient and transport, he was brought to Krom (see Disinsection). Patients in wartime are evacuated in inf. hospital (see. Infectious field mobile hospital). Evacuation should be carried out on a dignity. transport, to-ry later delivery of the patient in hospital it has to be disinfected. The staff which had contact with the patient is obliged to undergo full sanitary cleaning, behind it observation with daily thermometry is established. For establishment of a source of infection for the purpose of acceptance of radical measures for the termination of further distribution of S. of t. aa. it is necessary to carry out a dignity. - epid. inspection (see. Epidemiological inspection).
The disease Shaved
Brill's Disease (a synonym: a repeated sapropyra, a recurrent sapropyra, Brill's disease — Tsinsse-ra) — the acute cyclic infectious disease which is shown in many years at the persons who had S. in t. aa. It is characterized by a sporadichnost of diseases in the absence of pediculosis, easier, than at S. in t. aa., current and typical clinical simitomokomplek-catfish.
For the first time acute inf. the disease of not clear nature reminding a sapropyra was observed by Brill (N. E. Brill) in 1898 and 1910 in New York. After it also other researchers described, to-rye especially emphasized lack of communication with a source of an infection and pediculosis among persons from an environment of the patient. In 1934 Tsinsser made a hypothesis that this disease is a recurrence of S. postponed many years ago of t. aa. owing to activation of the rickettsiae of Provachek which remained in an abeyance in body tissues. Later Price (W. The N of Price, 1955) allocated two strains of rickettsiae of Provachek from limf, nodes of two dead who transferred S. of t. aa. in 20 years prior to death. In the subsequent Sh. Ni- the kolaa and Konstantinesko (N. Constanti-nesco, 1965) was reported about allocation by more than 20 strains of rickettsiae of Provachek from the persons who had various cardiovascular diseases and had before S. t. aa. The hypothesis of an endogenous origin of a disease Brilla was supported in our country by P.F. Zdrodovsky, G. S. Mosing, K. N. Tokarevich, etc. At the same time L. V. Gromashev-sky, M. N. Solovyov, I. I. Elkin, etc. considered that cases of a recurrent disease of S. of t. aa. are connected with reinfection of the persons who transferred S. of t. aa. in the past, but lost immunity to it.
In the conditions of a pediculosis patients with Brill's disease can be a source of diseases of S. of t. aa.
A pathogeny and pathological anatomy at Brill's disease the same, as at S. of t. aa., but rickettsial intoxication is relatively less expressed.
Durable and long immunity develops.
Brill's disease begins sharply, with feeling of heat, sometimes with easy chilling, weaknesses, a headache, sleeplessness, loss of appetite, temperature increase. These phenomena progress during the first 2 — 3 days. In the first days a headache almost always strong, sleeplessness resistant. To 4 — to the 5th day of a disease temperature reaches 38 — 40 °. The average duration of the feverish period of 8 — 10 days, decrease in temperature occurs usually within two days. From the first days of a disease usually against the background of feverish excitement the hyperemia and puffiness of the person, a hyperemia of conjunctivas, gloss of eyes, a dermahemia of a neck and an upper third of a trunk, moderate cyanosis come to light. lips, a positive symptom of a pinch, elements of conjunctival rash (Kiari's symptom — Avtsyna), enantema on slightly hyperemic mucous membrane of a soft palate (Rosenberg's symptom — Vinokurova — Lendorffa). On 4 — the 6th, and sometimes on 7 — the 8th day of a disease at most of patients appears plentiful rozeolezno-petekhialny rash with localization on a breast, side surfaces of a trunk, a back, the flexion surfaces of hands. It remains within 5 — 7 days then completely disappears. Approximately at a third of patients only rozeolezny or rozeolez-but-papular rash is observed, rash can sometimes be absent. An asthma is possible, but usually breath corresponds to temperature, as well as pulse. Tachycardia is noted no more than at 25% of patients, also bradycardia quite often takes place. Hypotension is more constant. Cardiac sounds are muffled, sometimes considerably, systolic noise can be listened. Elektrokardiograficheski symptoms of diffusion myocarditis come to light. The language which is laid over, dry. The liver and a spleen are moderately increased at most of patients. The oliguria, an insignificant albuminuria and occasionally an inconscience with overflow is possible. The characteristic symptomatology connected with defeat of c is diverse. N of page. The headache and sleeplessness are so painful, as well as at classical S. of t. aa. Euphoria is almost also expressed.
Serious mental violations are observed seldom, but excitement or block, a moderate snopodobny delirium, sometimes depersonalization, motive excitement are in a varying degree noted often. The general tremor (trembling of lips and extremities, especially fingers of hands, an insignificant dysarthtia), an easy smoothness of nasolabial folds, deviation of language, Govorov's symptom — Godelye, symptoms of a meningism is possible. One or several of these symptoms, are more often Govorov's symptom — Godelye and a hyperesthesia of skin, appear already on 3 — the 4th day of a disease. Neuritis of an acoustical nerve is quite often noted. Usually the disease happens moderately severe or proceeds easily; the heavy current occurs seldom, as a rule, at elderly persons. Changes of blood are not characteristic.
Reconvalescence begins with 10 — the 12th day of a disease and proceeds quicker, than at S. of t. aa. Cardiovascular activity is recovered to 5 — to the 7th day of standard temperature, and only at nek-ry patients in later terms postinfectious myocarditis is observed. Recovery of functions and. the N of page comes to 15 — to the 17th day of standard temperature. The sizes of a liver and spleen are normalized to 3 — to the 4th day of the period of reconvalescence. The extract of patients is allowed after normalization of temperature on 11 — the 12th day.
Complications, the diagnosis, the differential diagnosis and treatment the same, as at S. of t. aa.
The forecast is usually favorable. Rare lethal outcomes are caused by development of thromboses, thromboembolisms, a collapse, myocardial infarction, pneumonia.
During the developing of a disease of Brill the events directed to the prevention of spread of an epidemic typhus are held.
See also Rickettsioses .
Bibliography: A. I. O apricots of pathological anatomy of a sapropyra, Owls. medical, JN» 23-24, page 8, 1941; And in - c y A. P. Gistopatologiya's N of rickettsial intoxication, Arkh. patol., t. 8, No. 5-6, page 107, 1946; About l and N e in and the p E. M. Reaction of indirect hemagglutination with protective antigen of rickettsiae Pro-vatseka, Shurn. mikr., epid. and immun., No. 8, page 58, 1981, bibliogr.; Gromashevs to and y JI. B. Private epidemiology, page 413, M., 1947; it, About the nature of a modern sapropyra and P.F. Zdrodovsky's «audit», Zhurn. mikr., epid. and immun., No. 6, page 139, 1961; Davydovsky I. V. Pathological anatomy and pathology of a sapropyra, t. 1 — 2, M., 1921 — 1922; 3 d r odovskiyp. T. both about l and N e in and the p E. M. The doctrine about rickettsiae and rickettsioses, M., 1 972; Infectious diseases of the person in the USSR, under the editorship of P. N. Burgasov, page 21, M., 1968; The Mullet To. M. Sapropyra, M., 1960, bibliogr.; it, the Major rickettsioses, page 31, 121, L., 1980; Experience of the Soviet medicine in the Great Patriotic War of 1941 — 1945, t. 32, M., 1955; Anti-epidemic protection of troops, under the editorship of A. I. Burnazyan, page 71, M., 1944; Encyclopaedic dictionary of military medicine, t. 5, Art. 406, M., 1948; Brill N. E. An acute infectious disease of unknown origin, Amer. J. med. Sci., v. 139, p. 484, 1910; Popov V. L. a. Ignatovich V. F. Electron microscopy of surface structures of Rickettsia prowazekii stained with ruthenium red, Acta virol. (Praha), v. 20, p. 424, 1976; Prowazek S. Aetiologische Untersu-chungen iiber den Flecktyphus in Serbien 1913 und Hamburg 1914, Beitr. klin. Infek-tionsur. Wurzb., Bd 4, S. 5, 1914 — 1916; S i 1 v e r m a n n D. J. a. o. External layers of Rickettsia prowazekii and Rickettsia riekettsii, occurence of a slime layer, Infect. Immun., v. 22, p. 233, 1978; Tropical medicine, ed. by G. H. Hunter a. o., p. 95, Philadelphia a. o., 1976.
K. M. Loban; A. P. Avtsyn (stalemate. An.), V. I. Agafonov (soldier.), I. I. Elkin, V. M. Rozhdestvensky (epid., prevention), N. G. Kekcheeva (etiol., lab. diagnosis).