SCARLET FEVER

From Big Medical Encyclopedia

SCARLET FEVER (ital. scarlattina, from late armor. scarlatum bright red color) — the acute infectious disease caused by a beta and hemolitic toxicogenic streptococcus of group A, which is characterized by a feverish state, the general intoxication, quinsy and a punctate rash.

For the first time the wedge, a picture of a disease were described by T. Sydenham in 1675

the Aetiology

Activators C. toxicogenic and virulent hemolitic streptococci of group A are (see. Streptococci ). For many years S.'s etiology was a subject of a discussion. In 1900 Baginsky and Sommerfeld (A. Wa-ginsky, P. Sommerfeld) established frequent presence of a streptococcus at a pharynx of patients with scarlet fever. In 1905 I. G. Savchenko discovered streptococcal scarlatinal erythrogene toxin, the anti-toxic serum giving therapeutic effect was prepared for them. In 1906 by N. Gabrichevsky it was shown that at introduction to children for immunization of the streptococcal vaccine containing toxin their scarlatinoids were observed — the phenomena similar to symptoms of primary period of scarlet fever.

The streptococcal theory of an etiology of S. was confirmed by researches of spouses Dick (G. F. Dick, G. N of Dick, 1938), established in attempt of immunization that high doses of the erythrogene toxin produced by scarlatinal streptococci cause the symptoms characteristic of primary period of Page in the persons who were not ill S. At intradermal introduction of small doses of toxin there is a local inflammatory reaction (reaction Is wild). With immunity to S. reaction Is wild negative since toxin is neutralized by specific antibodies.

An obstacle for recognition of a streptococcus the activator C. was the fact that at some other diseases of a streptococcal etiology the same types of a streptococcus are allocated, as at S., and the toxins received from these cultures do not differ on the properties. The virus etiology of S. was assumed, edges it was disproved by virologic and immunological researches.

The new evidence of the streptococcal theory of emergence of S. was obtained as a result of numerous epidemiological, micro-biol. and immunol. the researches conducted at S. and other diseases of a streptococcal etiology and also in the course of studying of properties of erythrogene toxin and the mechanism of its action. At the same time it was established that streptococci of group A, as a rule, are found in sick S.' pharynx at the beginning of a disease; planting by a streptococcus of a pharynx at sick S. in hundreds times more, than at healthy carriers; in blood and sick S.' urine streptococcal antigens constantly come to light, to-rye disappear at treatment by penicillin; after the postponed S., as a rule, there is an increase of antibodies to antigens and enzymes of a streptococcus. Parallelism between S.'s distribution and a streptococcal infection in a pharynx at children in children's collectives is observed.

S.'s originality in comparison with other streptococcal infections is explained by the fact that at S. the toxicosis caused by erit-rogenny toxin develops. As the proof of it serves emergence in nek-ry cases of scarlatinoids at administration of high cleaning drugs of erythrogene toxin for the purpose of immunization, emergence of symptoms and morfol. the changes characteristic of S., at the rabbits reacting to toxin at intravenous administration of high doses of toxin by it and also more high level of toxigenicity of the streptococci allocated from sick S. Besides, at S. is observed high sensitivity to erythrogene toxin at the beginning of a disease; at quinsies and other diseases of a streptococcal etiology, on the contrary, the high level of anti-toxic immunity is from the very beginning noted.

S.'s incidence is in a feedforward with degree of order to erythrogene toxin. As a result of use of a titratsion-ny method (reaction Is wild with different doses of toxin) it is established that incidence значительно^ is higher at the children reacting to small doses of toxin (x / 10 than a skin dose), and is practically absent at the persons which are not reacting to 10 skin doses. The direct proof of dependence of incidence of S. on the level of anti-toxic immunity is decrease in incidence of S. after immunization by the purified toxin. Nek-ry researchers found positive skin reactions after the postponed S. that is explained by use of the crude erythrogene toxin containing impurity of the thermostable fraction which is allergen. Also negative reactions of Dick at the beginning of a disease of Page are described. This phenomenon is not connected with existence of anti-toxic immunity, and depends on the areactivity to toxin arising at toxicosis. Rather strong and life-long immunity after the postponed S. and lack of that at other streptococcal infections do not contradict the streptococcal nature of Page. Anti-toxic immunity important at S. is strong and long while the antimicrobic immunity playing the main role at other streptococcal infections, as we know, is type-specific and in connection with existence of a large number of types of a streptococcus cannot interfere with emergence of recurrent diseases.

Infection with toxicogenic streptococci not always causes S.'s development, despite the lack of anti-toxic immunity. This results from the fact that S.'s emergence requires not only existence of toxicogenic streptococci and lack of anti-toxic immunity, but also lack of antimicrobic immunity to this type of a streptococcus and hl. obr. high virulence of cultures of a streptococcus. Justification of this situation is what at S., as a rule, is found by the virulent cultures of a streptococcus containing M-substance (see. Streptococci ). The majority of the marked-out cultures at carriers of a streptococcus, and also at convalescents, do not contain M-substance, i.e. are avirulent.

The epidemiology

the Source of infection at S. is the patient or the bacillicarrier. Contagiums get to the environment with a secret of a mucous membrane of a pharynx and nasopharynx at cough, sneezing, a conversation; they can contain also in separated various open suppurative focuses (at otitis, sinusitis, purulent lymphadenitis, etc.). An important role in S.'s epidemiology is played by patients with the erased forms with is incomplete or poorly expressed a wedge, manifestations. In the epidemiological relation S. proceeding in the form of usual quinsy with lack of such important symptom as rash is of great importance. The hidden («mute») immunization of healthy children, i.e. increase of immunity at them testifies to an epidemiological role of bacillicarriers during epidemic. The healthy carriage is short-term, contageousness of bacillicarriers in comparison with patients is much lower.

Transfer of contagiums happens hl. obr. in the airborne way. Infection through various objects is of secondary importance. The rare outbreaks of a disease at infection through milk and dairy products are described.

Children aged from 2 up to 7 years are most susceptible to S., after 15 years S. meets seldom that is explained by acquisition of specific immunity after the postponed disease in clinically expressed or erased form, and also after a bacteriocarrier.

Page — an eurysynusic disease. Incidence is higher in the countries with moderately frigid and humid climate, it increases in the fall, in the winter, in the spring and decreases in the summer.

The wavy current of epidemics is noted: periodic rises in incidence repeat in 4 — 6 years. The incidence of S. for the last decades significantly did not change. According to B. N. Dodonova (1974, 1978), considerably decreased intensity of periodic rises in incidence. Along with it * lungs and the erased forms meet more often, and the number of severe forms and complications was sharply reduced. The lethality, in the past high, in a crust, time is reduced to the 100-th shares of percent, and in nek-ry places — to zero that is a consequence of increase in efficiency of treatment of scarlet fever and first of all uses of antibiotics.

The pathogeny

Entrance gate for the activator C. is a mucous membrane of a pharynx and a throat. Occasionally the contagium can get through the injured skin or a mucous membrane of generative organs (ekstrabukkalny, or ex-trafaringealnaya, a form). According to A. A. Koltypin's proposal distinguish three main components of a pathogeny — toxic, infectious (septic) and allergic, closely connected among themselves. Takg considered earlier that vospalitelnonekrotichesky changes in the place of implementation of a contagium are caused by direct action of a streptococcus, now consider them as manifestation and current-siko-allergic process. Effect of streptococcal toxin is shown in the first days of a disease by rash and a complex characteristic of C. symptoms from c. N of page, endocrine and cardiovascular systems (see. Intoxication ). The allergic reorganization of an organism happening on 2 — 3rd week of a disease (so-called second period of scarlet fever), serves as a favorable background for development of late complications.

The pathological anatomy

In the place of implementation of the activator develops an inflammation and regional lymphadenitis, call primary scarlatinal affect or primary scarlatinal complex. In most cases primary affect is located in the field of palatine tonsils, is more rare in skin, lungs, a uterus (at ekstrabukkal-ache to a form C.). The inflammation in the field of affect has preferential alterativny character with a necrosis of fabrics and development on border with the unimpaired fabric of leukocytic inflammatory infiltrate. In regional limf, nodes it is observed lymphadenitis (see) with a myeloid metaplasia.

Scarlatinal rash microscopically represents the centers of a hyperemia with availability of perivascular infiltrates in a derma. Epidermis in the field of these centers becomes impregnated with exudate, gradually oro-govevat and is exfoliated. Keratinization (see) it is made not completely on type parakeratosis (see). Rejection of a corneous layer happens not small scales, but large plates and where the corneous layer of skin normal especially thick (e.g., on palms), arises a lamellar peeling, characteristic of S.

M. A. Skvortsov according to various morfol. allocates with changes in bodies three main forms C. — toxic, septic and mixed.

At a toxic form rash on skin is expressed indistinctly due to the lack of a hyperemia. Sharply expressed catarrh of a mucous membrane of a pharynx, throat and gullet is characteristic; it dark red with a cyanochroic shade, dim. Almonds are moderately increased, plethoric, juicy, without sites of a necrosis. Microscopically in them define myeloid cells, hypostasis, a plethora. In a spleen increase in follicles in the form of grayish-whitish points against the background of a plethoric pulp is noted; the hyperplasia of follicles and a karyorrhexis in the light centers are microscopically observed. In a liver, kidneys, less often in a myocardium disturbances of microcirculation and dystrophic changes of a parenchyma come to light.

At a septic form C. of an almond are considerably increased, in them the deep centers of a necrosis of yellowish-gray or whitish color are defined. In regional limf, nodes the centers of a necrosis and leukocytic infiltration with development of purulent lymphadenitis are noted. The spleen is increased by 3 — 5 times, is characterized sharply expressed мие-^м pulps that is typical for sei-others bodies the t characteristic of S. ин-^челоидными by cells with impurity of eosinophilic granulocytes is observed. In cases of a lethal outcome in the first week of a disease increase and deepening of a zone of a necrosis in a pharynx, in fabric of palatine tonsils, in limf, nodes of a neck with transition of process to surrounding soft tissues, purulent fusion of surrounding soft tissues with formation come to light retropharyngeal abscess (see), phlegmons necks (see), arrosion of large arteries. The necrotic inflammation of a middle ear (see Otitis) with transition of process to a bone tissue of a temporal bone, a firm cover of a head hmozg and its sine which is followed by development of a purulent pia-arachnitis is noted (see. Meningitis ), and also emergence of metastatic purulent arthritises (see), peritonitis (see).

From late complications at S. defeats of cardiovascular system and kidneys are observed: unsharply expressed intersticial myocarditis (the endocarditis, as a rule, does not meet), the arteritis caused by alterativny changes of an internal cover (intima) in the form of fibrinoid with the subsequent lipomatoz (see) and sclerosis (see), intersticial nephrite (see), arising at a septic form, and also a glomerulonephritis (see).

Immunity

the Persons who transferred S. get postinfectious immunity (see). The cases of recurrent diseases which became frequent recently are noted. For definition of a susceptibility to S. use Dick's test consisting in intradermal introduction to area of a forearm of divorced streptococcal erythrogene toxin. A skin dose of toxin call its minimum quantity capable to cause in the susceptible child a dermahemia on the site with a diameter of 1 cm (positive reaction). V. I. Ioffe's researches (1967) and JI. I. Fiks et al. (1972) is revealed frequent discrepancy of results of test of Dick with a condition of a susceptibility to S. that calls in question value of this reaction as reliable indicator of a condition of immunity to S. in modern conditions.

Clinical picture

Fig. 1 — 6. External displays of scarlet fever. Fig. 1. Bright red language with the acting nipples ("crimson language"). Fig. 2. A punctate rash on skin of a trunk. Fig. 3. Plentiful rash on cheeks of the patient and absence of rash, characteristic of scarlet fever, on skin of a nose, in a circle of a mouth and on a chin (Filatov's triangle). Fig. 4. Plentiful rash to areas of an elbow bend (a symptom of Pastia). Fig. 5. A white dermographism against the background of a punctate rash on skin of a trunk. Fig. 6. A peeling of skin of a stomach with formation of small scales.

The incubation interval from 1 to 12 days, is more often than 2 — 7 days. The disease begins sharply with bystry rise in temperature, an indisposition, a headache and pharyngalgias during the swallowing. At the expressed intoxication there is numerous vomiting. Quinsy (see), the constant and typical symptom of S., is characterized by a bright hyperemia of a mucous membrane of a pharynx and a soft palate, increase in palatine tonsils, in lacunas (crypts) and on a surface to-rykh yellow-white plaques quite often are found. Language is laid over in the beginning, with 2 — the 3rd day it begins to be cleared with a tip and by 4th day becomes bright red, with the acting nipples — so-called crimson language (tsvetn. fig. 1). From the first day of a disease are palpated increased, dense, painful cervical limf. nodes.

On the 1st, 2 days less often than a disease on skin there is a bright pink or red punctate rash (see) on a hyperemic background which is followed by an itch. It is especially plentiful in the bottom of a stomach, inguinal area, on buttocks, an inner surface of extremities. Skin of a nose, area of lips, a chin remains pale, forming a so-called nasolabial triangle of Filatov (tsvetn. fig. 2 and 3). Skin folds in the field of joint bends become dark red — a symptom of Pastia (tsvetn. fig. 4), in the same place at survey come to light dot hemorrhages, to-rye it is possible to cause and is artificial, moderately squeezing a skin fold (Konchalovsky's way) between fingers or having imposed a plait on area of a shoulder (Rumpel's test — Leede). Clearly white is expressed dermographism (see) — tsvetn. fig. 5). Sometimes rashes accept miliary character, at the same time emergence of numerous very small bubbles with transparent or rather turbid contents is noted. Depending on disease severity rash sticks to from 2 — 3 to 4 — 6 days and longer. At «blossom fading» of rash the peeling — on a face and a trunk begins small scales (tsvetn. fig. 6), and on extremities, especially in the field of brushes and feet, more or less large layers. Than rash was brighter and more plentiful, especially also the symptom of a peeling is expressed. On average the period of a peeling proceeds 2 — 3 weeks.

In the onset of the illness symptoms of defeat of c appear. the N of page (excitement, nonsense, sleeplessness or, on the contrary, apathy, drowsiness, sometimes spasms, the meningeal phenomena), expressiveness to-rykh depends on S.'s weight and degree of intoxication; they are most expressed at a toxic form. The symptoms of defeat of century of N of page studied by A. A. Koltypin and his pupils are characteristic. In the first 5 days of a disease the increase in a tone of a sympathetic nervous system (simpati-kus-phase) which is shown tachycardia, increase in the ABP, a negative Aschner's reflex is noted (see. Oculocardic reflex ), a white dermographism with the extended eclipse period. Further there is an increase in a tone of a parasympathetic nervous system (vagus - fa - for) which is shown bradycardia, decrease in the ABP, a positive Aschner's reflex, a white dermographism with shortened hidden and extended explicit with the periods.

In the heat of a disease increase in a liver is noted, and at severe forms and spleens.

Depending on weight a wedge, pictures domestic pediatricians distinguish easy, medium-weight and heavy forms C. The severe form depending on dominance of a toxic or infectious (septic) component is subdivided on toxic and septic, at expressiveness of both components it is defined as toksi-to-septic.

The easy form which is most often found now is characterized by moderate temperature increase, insignificant disturbance of the general state. Vomiting can be absent. Quinsy has catarral character. Rash is typical, sometimes pale and scanty. Symptoms of defeat of c. N of page are expressed slightly. Acute manifestations continue 3 — 4 days.

At a medium-weight form all described S.'s symptoms are brightly expressed. Temperature increases to 39 °. In lacunas of almonds little necrotic changes quite often are found. To 7 — to the 8th dtsyu temperature decreases, initial symptoms disappear. Complications meet more often than at an easy form.

At a severe toxic form an onset of the illness rough, with high temperature, repeated vomiting, sometimes a diarrhea, symptoms of defeat of c are expressed. N of page. At deep intoxication the loss of consciousness, a syndrome of vascular insufficiency (see) owing to sharp falling of a tone of a sympathetic nervous system are possible. At a toxic form of the scarlet fever which is followed by wet brain sometimes develops coma (see).

At a severe septic form of the phenomenon of intoxication pale into insignificance. The disease is characterized by development of necrotic quinsy, at a cut on a surface of almonds there are dirty-white sites of necroses having tendency to extend to a mucous membrane of palatal handles, a soft palate, a throat. The expressed inflammatory reaction from regional limf, nodes with involvement in process of surrounding cellulose and development of purulent lymphadenitis or an adenoflegmona is noted (see. Lymphadenitis ). The septic form C. on 3 — the 5th week of a disease can be complicated by a vascular embolism of a brain with the phenomena hemiplegia (see).

At a severe toksiko-septic form symptoms of toxic and septic forms are combined. Recently severe forms of scarlet fever represent a big rarity.

In addition to the main forms, allocate atypical forms C.: erased and ekstrabukkalny. Now considerably cases of the erased form of a disease became frequent, at a cut all symptoms are expressed poorly, is rudimentary or nek-ry of them (e.g., rash) are absent at all. Temperature increases slightly and quickly. The general condition of patients is not broken.

At an ekstrabukkalny form C. entrance infection atriums is not the pharynx, but the injured skin or a mucous membrane. Distinguish the following options of this form: burn, wound traumatic, wound postoperative, puerperal S. Otmechayetsya small contageousness of such patients in connection with switching off of the airborne mechanism of transfer. The incubation interval is often shortened up to one days. Absence of quinsy, initial rash and development of regional lymphadenitis near entrance infection atriums is characteristic. This form meets very seldom.

In the second period of S. sometimes there is recurrence of quinsy, and in 1 — 4% of cases — a recurrence of Page. They develop hl. obr. in connection with the reinfection (see) occurring at disturbance a dignity. - epid. the mode in scarlatinal department-tsy. A part is played by an allergic condition of an organism, inferiority of immunity. The recurrence of scarlet fever is characterized by return of all main initial symptoms of a disease.

Mental disturbances at scarlet fever treat infectious psychoses (see). The nature of mental disturbances depends on a form of a disease and its current. At an easy form for the 2nd day after possible short-term excitement asthenic symptoms in the form of drowsiness, slackness, decrease in mood develop. At medium-weight and heavy forms C. the adynamy at children in the first 3 — 4 days is combined with an easy oglushyonnost (see Devocalization). Patients hardly understand sense of a question, cannot concentrate, answer after a pause, in monosyllables, badly perceive and do not remember read, quickly are tired. At severe forms of S. development of a delirium is possible (see. A delirious syndrome) and oneiroid (see. Oneiric syndrome). At the toxic and septic forms C. which were complicated by encephalitis or meningitis in the remote period development an epileptifor a lot of syndrome (see), decrease in memory, intelligence is possible.

Complications

the Number of complications at S., in the past very frequent and various, recently in connection with a lung a wedge, disease, improvement of its treatment and rationalization of placement and keeping of patients in a hospital was sharply reduced. Gnoynoseptichesky complications (purulent lymphadenitis, otitis, a mastoiditis, sinusitis, a septicopyemia, etc.), and also complications of allergic character (a glomerulonephritis, a synovitis) arising usually in the second period of S. meet now seldom. Simple lymphadenitis, catarral otitis, secondary catarral quinsy, scarlatinous heart is more often observed.

Scarlatinous, or infectious, the heart described by N. F. Filatov and further studied by V. I. Molchanov, A. A. Koltypin, etc., arises at the end of the 1st or the beginning of the 2nd week that is connected with defeat of century of N of page, and it is characterized by bradycardia, arrhythmia, sometimes small expansion of borders of heart and quite often systolic noise on a top, decrease in the ABP. These frustration usually disappear in 2 — 3 weeks. Also the syndrome described by A. A. Koltypin is high-quality; the syndrome develops in the second period of S. and is shown by tachycardia, decrease in arterial and venous pressure, acceleration of a blood-groove (vegetovascular scissors, or A. A. Koltypin's phenomenon). Sometimes changes in heart are more resistant that indicates a possibility of development of organic process in a myocardium — allergic myocarditis (see).

The acute glomerulonephritis meets seldom now, develops in vtorokhm the period of a disease, usually on the 3rd week, begins sharply and proceeds on average 3 — 6 weeks, sometimes recovery drags on for several months. Transition in hron. a form it is observed seldom.

Sometimes in the second period «unmotivated» subfebrile condition and short-term rises in temperature (allergic waves) in the absence of other symptoms are observed.

The diagnosis

S.'s Recognition at a typical current comes easy. At the erased forms is of great importance epidemiol. anamnesis. For diagnosis allocation from a pharynx of a sick hemolitic streptococcus of group A is flimsy. In blood from the first days there is an increase of leukocytes to 10 000 — 30 000 in 1 mkl, increase in quantity of neutrophils up to 60 — 70% and more, nuclear shift of neutrophils to young forms to the left, and in hard cases — to myelocytes. From the 3rd day of a disease the maintenance of eosinophils reaching sometimes 15 — 20% increases. ROE, especially at severe forms, is accelerated to 20 — 50 mm an hour. Now in connection with dominance of easy forms C. of change of blood are expressed poorly or absolutely are absent.

Differential diagnosis is carried out with measles, a rubella, the Far East scarlatiniform fever, a staphylococcal infection, medicinal rashes.

Measles (see) differs from S. in existence of an initial stage, the expressed catarral phenomena, enantemy and Velsky's spots — Filatova — Koplika on a mucous membrane of an oral cavity, the nature of rash (spotty and papular on not changed background), staging of a rash and tendency to merge of elements of rash.

At to a rubella (see) unlike S. rash is localized preferential on a trunk and extensor surfaces of extremities. Quinsy is absent. Swelling occipital, lateral cervical and others limf, nodes, in blood — a leukopenia, a neutropenia, plasmocytes is observed.

With S. the staphylococcal infection (see) which is followed by scarlatiniform rash has strong likeness. In this case' there is a suppurative focus (osteomyelitis, phlegmon, a felon, etc.)» quinsy is absent.

The Far East scarlatiniform fever (see the Pseudotuberculosis) preferential adult have. True quinsy is absent, the hyperemia of a mucous membrane of a pharynx at not changed almonds is noted, bradycardia, joint pains and muscles of extremities, went. - kish. frustration, and sometimes sharp pains in the right ileal area (a mezenterialny adenitis), rash quite often gains hemorrhagic character; the diagnosis is specified by means of reactions agglutinations (see), indirect hemagglutination (see), an immunofluorescence (see).

The rash at a medicinal allergy (see) arising after reception of streptocides, antibiotics and other pharmaceuticals is sometimes similar with scarlatinal, but has no localization, typical for S. Quinsy, regional cervical lymphadenitis and other symptoms typical for S., and also the main gematol. shifts are absent. In the anamnesis often there is an instruction on earlier observed reactions from skin to the same medicine.

Mental disturbances at S. should be differentiated with the mental diseases which are shown or becoming aggravated against the background of an infection and also with organic diseases of a brain, napr, a neurorhematism (see Rheumatism).

Treatment

S.'s Treatment in connection with dominance of easy forms is carried out recently generally in house conditions. Send to hospitals on clinical (severe forms of a disease, existence of complications) and on epidemiol. (children from large families and the closed child care facilities) to indications. Patients are placed in boxes or in the scarlatinal departments consisting of small chambers, to-rye filled within 2 — 3 days. Patients remain in them for all term of stay in a hospital and do not communicate with children from other chambers. Department establishes the corresponding dignity. - epid. mode. In house conditions of the patient place a screen in the certain room of an ilshchz. It uses separate ware, toys, bedding and a towel. One person looks after him, whenever possible. Communication with other children during all term of isolation is not allowed. It is allowed to get up on 5 — the 6th day of a disease after disappearance of the initial acute phenomena. In the feverish period of the patient receives digestible food: milk, dairy products, vegetable soups, meat and fish dishes, liquid porridges, puree, compotes, vegetable and fruit juice, white loaf. After decrease in temperature resolve usual food.

The major place in S.'s treatment is taken by penicillin and drugs of a penicillinic row (ampicillin, Oxacillinum, etc.). Use also drug of the prolonged action — Bicillinum, to-ry enter once intramusculary in a dose 20 000 PIECES on 1 kg of body weight. At intolerance of penicillin use tetracycline, erythromycin.

At the expressed intoxication carry out intravenous injections of plasma substituting liquids, Ringer's solution, 25% of solution of glucose. At severe forms of S. apply corticosteroids (Prednisolonum of 1 — 1,2 mg/kg a day, with a gradual dose decline in 2 — 3 days within 5 — 7 days).

Treatment of mental disturbances at S. is directed first of all to a basic disease, and also includes use fortifying and sedatives. At psychoses intramusculary enter Seduxenum, and in more hard cases — aminazine, a haloperidol.

At emergence of complications carry out their treatment (see the relevant articles, e.g. Glomerulonephritis, Myocarditis etc.). At scarlatinous heart recommend a bed rest, do not appoint medicinal therapy.

The forecast and Prevention

the Forecast, in the past serious, became favorable now. The result of mental disturbances at S. most often favorable. The mental state is normalized in process of recovery.

Prevention. Irrespective of S.'s weight of the patient is subject to isolation (see Isolation of infectious patients). This measure is taken also in respect of patients with quinsy, at to-rykh suspect the scarlatinal nature of a disease. Sick S.' treatment does not promote increase in incidence at home. However indications to it should not be expanded excessively. The contact with children is allowed after a wedge, recovery, but not earlier than the 10th day of a disease. Visit by convalescents of preschool child care facilities and the first two classes of schools is allowed in 12 days upon termination of the term of isolation. These rules extend also to the patients treated houses and also to the patients with quinsy revealed in the scarlatinal center. All persons who were in contact with sick S. are subject to medical examination for the purpose of identification of cases of the erased form of a disease. For the children who were in contact with the patient, visiting preschool institutions of N the first two classes of school and earlier not being ill the quarantine for 7 days from the moment of isolation of the patient is established. In the apartment where there is sick S., carry out regular current disinfection (see).

Specific prevention is not developed.

Scarlet fever at adults

Scarlet fever at adults has all the wedge, the forms which are observed at children. Women are ill preferential that is substantially caused by infection at patient care by children. In most cases disease typical, but lung. Severe forms meet at elderly people or at women in a puerperal period more often. The initial symptoms connected with intoxication at adults are more expressed, than at children, but reparative processes happen quicker. The feverish period proceeds no more than 1 — 2 days. Rash usually keeps one day. Catarral or the angina follicularis lasts 3 — 4 days. Necrotic quinsy meets seldom.

In families where children are ill typical S., adults quite often have its atypical forms in the form of quinsy, pharyngitis or a nasopharyngitis without rash. However in the subsequent the peeling and complications, characteristic of S., are observed. Patients with an atypical current are also dangerous to people around.

One of forms of a disease at adults is puerperal (puerperal) the Page. The contagium gets into an organism of the woman through genitalias. The incubation interval is short, sometimes several hours. The disease develops in 1 — 5 days after the delivery, begins sharply, with a fever, temperature increase, vomiting. Rash and an erythema develop in the first days on a stomach in the beginning, then on a breast and extremities. Quinsy usually does not happen, but the enantema on a mucous membrane of a mouth and glotkd is noted. Fetid purulent discharges from a vagina are characteristic. Disease severity at puerperal S. is various, septic and hemorrhagic forms quite often meet, to-rye difficult to differentiate with gynecologic sepsis (see).

Changes the same blood, as at children.

Complications (lymphadenitis, arthritis, a synovitis, otitis) at lungs and средне^ severe forms bolezny arise seldom and do not happen dangerous. Changes from heart and kidneys passing and short-term. A recurrence is observed seldom.

The diagnosis is made on the basis of Epi-demiol. the anamnesis, characteristic rash and a peeling, a leukocytosis and an eosinophilia in blood.

Treatment depends from a wedge, forms of a disease and does not differ from therapy at children.

The forecast at timely and correct treatment favorable at all forms of a disease.

Prevention consists in early detection and isolation of patients, observance a gigabyte. the mode at patient care, carrying out the current disinfection.



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S. D. Nosov; H. V. Astafyeva (scarlet fever at adults), T.E. Ivanovskaya (a stalemate. An.), I. M. Lyampert (etiol., mt. issl.), M. A. Tsivilko (psikhiat.).

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