Spotted fever

Description:

The spotted fever - one of generalized clinical forms of a meningococcal infection - is caused meningokokky and is characterized by the acute beginning, emergence of all-brain and meningeal symptoms, and also signs of a toxaemia and bacteremia.

Symptoms of the Spotted fever:

The incubation interval of a meningococcal infection averages 2–7 days.

The clinical picture of a purulent spotted fever consists of 3 syndromes: infectious and toxic, meningeal and gipertenzionny. The leader is the infectious and toxic syndrome as even before development of meningitis of the patient can die from intoxication, and at children aged till 1 year all other syndromes in general can expressed be absent or be insignificant. The spotted fever begins sharply, violently, suddenly more often (mother of the child can often specify hour of developing of a disease). Less often meningitis develops after a nasopharyngitis or a meningococcemia. Body temperature reaches 38–40 °C, appear a fever, the headache quickly accrues, becomes painful, "arching" character. Dizziness, pain in eyeglobes disturbs, especially at their movement. Appetite disappears, there is nausea, there is repeated vomiting "fountain" which is not giving relief to the patient thirst torments. The sharp hyperesthesia to all types of irritants - to a touch, bright light, loud sounds is expressed. The tendinous hyperreflexia, trembling, twitching, start and other signs of convulsive readiness are characteristic, in some cases spasms of toniko-clonic character develop. Spasms at children of the first year of life often are the first and early symptom of meningitis whereas other symptoms including nape muscle tension, do not manage to develop. Convulsive twitchings at the beginning of a disease at children of advanced age testify to weight of a current and are considered as a terrible symptom. At some patients of a spasm can proceed as a big toniko-clonic attack. At a part of children early disorder of consciousness is noted: an adynamia, block, an oglushennost, sometimes - full loss of consciousness. The motive concern, hallucinations, nonsense are characteristic of most of patients of advanced age. From the first hours of a disease (in 10–12 hours) signs of defeat of a meninx are noted: nape muscle tension, Brudzinsky's symptoms, Kerniga and others. By the end of the first days the characteristic pose of "a gun dog of a dog" is observed. Often the general hypomyotonia comes to light. Tendon jerks are raised, there can be an anizorefleksiya. At heavy intoxication tendon jerks can be absent, cutaneous reflexes (belly, kremasterny), as a rule, decrease. At the same time pathological Babinski's reflexes, a clonus of feet are quite often observed. For the 3-4th day of a disease many children have herpetic rashes on a face, is more rare - on other sites of skin, on a mucous oral cavity.

At severe forms of meningitis involvement in process of cranial nerves is possible. Defeat of third cranial nerves (III, IV, VI couples) is shown by squint, a ptosis of an upper eyelid, sometimes an anisocoria; at defeat of a facial nerve (the VII couple) there is an asymmetry of the person. Close attention is required by identification of disorders of hearing, especially at small children which can arise from the first days of a disease, and disturbances of the acoustic analyzer are possible at various levels and can lead to partial or full deafness. Seldom II, IX, X pairs of cranial nerves are surprised. Refer emergence of symptoms of hypostasis swelling of a brain which are shown by attacks of the psychomotor excitement which is replaced by a soporous state with the subsequent transition to a coma to heavy manifestations of a spotted fever.

An essential role in clinical diagnosis of a spotted fever is played by its frequent combination with hemorrhagic - necrotic rash which develops on skin and children, mucous at 70–90%, during the first hours of generalization of an infection. The mechanism of its emergence consists in development of thrombovasculites of skin capillaries
with the subsequent formation of local necroses. Rash kpoyavlyatsya in 4–6 hours from the beginning of a disease, and the earlier there is rash, the disease proceeds heavier. Typical meningococcal rash has various sizes - from small petechias to larger ecchymomas, star-shaped, irregular shape, with a necrosis in the center, sometimes extensive (5–15 cm in the diameter) hemorrhages, dense to the touch, acts over the surface of skin. In the subsequent sites of a necrosis are torn away and formed defects, on site which at recovery there are hems. The gangrenosis of nail phalanxes, fingers of hands, stop, auricles is in exceptional cases possible. Hemorrhagic rash is usually localized on buttocks, hips, shins, centuries and scleras, is more rare - on upper extremities. But rash can be also other character - rozeolezny, papular, erythematic, herpetic on the trifacial course (an upper and under lip, a nose).

In last years for a meningococcemia there was characteristic a damage of joints that was observed almost in 50% cases, and a choroid of eyes that was noted in 11%
cases. Now joints are surprised seldom, thus small joints suffer more often: metacarpal, radiocarpal, also larger occasionally can be surprised. Children hold fingers spread wide, react to touch crying, joints look edematous, skin over them is hyperemic. However the outcome of arthritises favorable, special treatment is not required.

Defeats of a choroid of an eye (syndrome of a "rusty" eye) in the form of an iridokhorioidit (uveitis) also meet now extremely seldom (1,8%).

Complications. The most terrible and often found complications at young people are acute hypostasis and swelling of a brain, infectious and toxic shock.

Acute hypostasis and swelling of a brain arise more often at the end of the first - the beginning of second day of a disease. Against the background of a rapid current of meningitis with sharp symptoms of intoxication, all-brain frustration and psychomotor excitement of the patient there comes the loss of consciousness. Patients do not react to strong irritants. The general kloniko-tonic spasms appear and accrue. Fading of corneal reflexes, narrowing of pupils and their sluggish reaction to light are noted. Bradycardia quickly is replaced by tachycardia. Arterial pressure in the beginning labile, with bent to considerable decrease, in an end-stage - high, to 150/90-180/110 mm of mercury. Quickly an asthma till 50-60 dykhaniye in 1 min. accrues, breath becomes noisy, superficial, with participation of auxiliary muscles, then - arrhythmic. Meningeal symptoms die away, the increased likvorny pressure decreases. Involuntary defecations and an urination are noted. The fluid lungs develops, there is hemiparesis. Death is caused by paralysis of a respiratory center at an apnoea, cordial activity can continue 5-10 more min.

Infectious and toxic shock arises against the background of a rapid current of a meningococcemia. At patients with high fever and the expressed hemorrhagic syndrome body temperature critically falls to normal or subnormal figures. During the first hours patients are in full consciousness. The sharp hyperesthesia, the general excitement are characteristic. Skin is pale. Pulse is frequent, almost inaudible. Arterial pressure promptly falls. Cyanosis, short wind accrue. The mocheotdeleniye (renal failure) stops. Excitement is replaced by prostration, there are spasms. Without intensive treatment death can come in 6-60 h from the moment of emergence of the first signs of shock. In the conditions of an ekologo-professional stress at young people infectious and toxic shock proceeds, as a rule, in combination with acute hypostasis and swelling of a brain. Against the background of sharp intoxication and all-brain frustration hemorrhagic rash and disturbances of cardiovascular activity develop. Skin is pale, cyanosis of lips and nail phalanxes. Tachycardia accrues, arterial pressure promptly decreases. Sharply signs of all-brain frustration accrue, breath becomes frequent to 40 and more in 1 min., there comes dead faint, there are general klonikotonichesky spasms, corneal reflexes die away, pupils are narrowed and almost do not react to light. There is an anury. The lethal outcome comes in 18-22 h after emergence of the first signs of the combined complications.

Features of defeat of TsNS at other forms of a meningococcal infection
It is necessary to carry its combination to a meningococcemia, development of serous meningitis, purulent meningitis to likvorny hypotension to features of clinic of a spotted fever, Uoterkhauz's syndrome - Frideriksena, and also development of complications in the form of infectious and toxic shock, an encephalomeningitis and an ependimatit.

Spotted fever in combination with a meningococcemia
The combination of a spotted fever to a meningococcemia is the most frequent form of a disease. It is caused by the fact that its development is the cornerstone uniform mechanisms, generalized distribution of a meningokokk in an organism with defeat of many bodies and systems is basic of which. The disease proceeds, as a rule, in medium-weight or heavy forms and is characterized by typical manifestations in the form of infectious and toxic, meningeal, gipertenzionny syndromes and development characteristic hemorrhagic - necrotic rash. At the same time the mixed form is more "clear" for the doctor as the classical beginning of a meningococcal infection in the form of star-shaped hemorrhagic rash in the center happens to a necrosis at several o'clock, and even days earlier, than there are symptoms of defeat of a meninx, and at the same time points also to an etiology of purulent meningitis that gives the chance to the doctor, without waiting for results of bacteriological researches, to prove and without hesitation to carry out early purpose of penicillin, a tsefotaksim, levomycetinum, tseftriakson and other antibiotics. Apparently, active therapy without vyzhidaniye and doubts explains more bystry and full sanitation of liquor at the mixed forms of a meningococcal infection in comparison with the isolated meningitis and meningoentsefalita.

Serous meningitis
In practical activities the doctor should face the fact when clinical laboratory signs of a spotted fever (namely existence expressed infectious and toxic and meningeal syndromes, characteristic star-shaped hemorrhagic with a necrosis in the center of rash, essential changes in peripheral blood - a neutrophylic leukocytosis, shift of a blood count to the left, the raised SOE, an aneosinophilia) are combined with the liquor changes typical for serous meningitis; i.e. with substantial increase of pressure, a pleocytosis of the mixed character or with dominance of lymphocytes, increase in protein content, decrease in glucose. In these cases, despite evidence of a bacterial purulent infection as an etiological factor, results of a research of liquor (a pleocytosis with dominance of lymphocytes) force the doctor to make the diagnosis of serous meningitis, and to treat as purulent. It is necessary to emphasize an important detail: vast majority of such patients are hospitalized in the first days and it appoints adequate antibacterial therapy which as consider, and does not give the chance to develop to a purulent inflammation (V. I. Pokrovsky et al., 1987).

Clinical features of a serous spotted fever consist available prodromes in the form of an acute nasopharyngitis; in bystry, within 5–10 days, disappearance of clinical displays of meningitis and in sanitation of liquor by 7-10th day of a disease. However at a part of patients, despite intensive antibacterial care, transformation of serous meningitis in purulent with the corresponding weighting of a clinical picture of a disease and changes in a picture of peripheral blood and the indicators of liquor corresponding to purulent inflammatory process is possible.

Uoterkhauz's syndrome - Frideriksena
Development of adrenal insufficiency is to some extent characteristic of any acute infectious process. However the specific and deep damage of adrenal glands leading to a lethal outcome is characteristic of a meningococcal infection. At the same time Uoterkhauz's syndrome - Frideriksena extremely seldom develops at a spotted fever.

The beginning of this clinical form is typical for a meningococcal infection: suddenly, with the indication of the exact time of developing of a disease. Body temperature which increases to 38,5–39,5 °C is combined with symptoms of intoxication in the form of a headache, nausea, slackness, a skin hyperesthesia. Degree of manifestation of these symptoms, as a rule, does not cause special alarm neither among parents, nor among district doctors, nor among the emergency doctors who took the child to hospital. The most essential and important for them - emergence in the beginning on the lower koknechnost, buttocks, and then on a trunk of star-shaped hemorrhagic rash, sometimes in some elements of rash were observed the outlined necrosis centers. Changes from cardiovascular system were shown by rapid lowering of blood pressure, sharp tachycardia, threadlike pulse. Breath became frequent, was frequent discontinuous, the diuresis decreased or was absent. Changes of TsNS accrued from somnolence to a coma and were followed by further disturbance from various bodies and systems. Total cyanosis of integuments, a cold clammy sweat, further decrease in systolic and diastolic pressure which quite often reached a zero point, body temperature to 36,6 °C and below were noted. From a respiratory organs were noted an asthma, the percussion sound was with a bandbox shade, wet mixed rattles on both sides were listened. Cardiac sounds were deafs, high tachycardia came to light. The diuresis was absent. At a lumbar puncture liquid followed under supertension, transparent; the neutrophylic pleocytosis was moderate or was absent; отмечалось¬ increase in level of protein. Changes from liquor to a large extent depended on the term of carrying out a puncture. If from the moment of a disease there passed hours, the composition of liquor corresponded stated above if days and more, changes corresponded to that at purulent meningitis. Especially it is necessary to emphasize that the high lethality (80–100%) is characteristic of this clinical form of a meningococcal infection.

Reasons of the Spotted fever:

Infestant is motionless gram-negative менингококк, differing in big variability. Meningokokk is very unstable in external environment: it is sensitive to drying, sunshine, cold, quickly perishes at temperature deviation from 37 °C. A factor of pathogenicity is the capsule protecting a microbe from absorption by phagocytes and from other adverse factors. Toxic properties of a meningokokk are caused by the endotoxin representing липополисахарид, similar on chemical and biological properties with endotoxins of enterobakteriya, but surpassing them in force of the action at 5-10 times. On antigenic properties менингококк subdivide into 11 types (And, V, S, D, Z, H, U, and also not agglutinating types 29E, 135, B0 and N). In Ukraine and Russia continuous circulation of meningokokk of a serogroup And which periodically cause incidence growth, and also strains In and With which cause diseases in Western Europe more often takes place. In typical cases менингококк in drugs looks as the motionless diplococcus who is located inside - and vnekletochno in pairs, similar to coffee grains that is used as preliminary diagnosis. Meningokokk grows on Wednesdays with addition of blood, serum or ascitic liquid, milk or yolk. The microbe is an aerobe, optimum temperature for reproduction of a meningokokk are 36–37 °C at alkalescent RN = 7,2–7,4.

Treatment of the Spotted fever:

Early the begun and adequate therapy allows to save life of the patient and defines the favorable social and labor forecast. In the acute period of a disease the complex therapy including purpose of etiotropic and pathogenetic means is carried out.

In causal treatment drug of the choice is benzylpenicillin which is appointed at the rate of 200 thousand. Piece/kg of body weight of the patient a day. The drug is administered with an interval of 4 h intramusculary (it is possible to alternate intramuscular and intravenous administration of penicillin). An indispensable condition of use of benzylpenicillin in these doses is co-administration of the means improving its penetration through a blood-brain barrier. Co-administration sodium benzoate caffeine (in a single dose of 4-5 mg/kg), lasixum (0,3-0,6 mg/kg) and isotonic solutions of sodium of chloride or glucose (15-20 ml/kg) is optimum. These drugs are administered intravenously with an interval of 8 h. Therapy duration usually 6-7 days. Reduction of a dose of penicillin as well as cancellation of the specified pathogenetic means, during treatment are inadmissible. The indication for cancellation is reduction of a cytosis in liquor lower than 100 cells in 1 мкл with explicit dominance of lymphocytes. Antibiotics of a reserve are levomycetinum succinate, Kanamycinum sulfate and rifampicin. These drugs can be used at individual intolerance of penicillin, lack of medical effect at its use or for an aftercare of patients. Levomycetinum succinate is applied on 1,0-1,5 g intravenously or intramusculary in 8 h, rifampicin - orally on 0,6 g in 8 h (for improvement of absorption to wash down atsidinpepsiny or 0,5 g of ascorbic acid in 100 ml of water). Possibly, perspective will be a use of a new ampoule dosage of rifampicin for parenteral administration. In the conditions of arid hot climate and the mountain and desert area, especially in the presence patients of deficit have body weights, therapy has some features that is connected with heavier course of an infection and more frequent development of the combined complications in the form of infectious and toxic shock against the background of dehydration in combination with hypostasis and brain swelling. At the same time, first, therapy is aimed first of all at providing sufficient perfusion of fabrics, a regidratation and desintoxication. For this purpose appoint intravenous administration of 500 ml of isotonic solution of sodium of chloride (5% of solution of glucose, Ringer's solution) with simultaneous use of Prednisolonum in a dose of 120 mg (intravenously) and 5-10 ml of 5% of solution of ascorbic acid. In cases of sharp falling of arterial pressure in addition intravenously enter 1 ml of 1% of solution of a phenylephine hydrochloride into 500 ml of isotonic solution of sodium of chloride. Experience showed inexpediency of use of colloidal solutions (Haemodesum, Polyglucinum, реополиглюкин, etc.) in connection with danger of development of an acute heart failure and a fluid lungs (especially at introduction of large amounts of these solutions - to 1 l and more).

For stopping of preferential hypertensive dehydration use of isotonic crystalloid solutions is preferable. At the same time the speed and duration of perfusion, total quantity of the entered liquid, glucocorticoids, pressor amines are regulated depending on the level of arterial pressure and a diuresis. Regular auscultation of lungs is necessary (danger of a fluid lungs!).

In an initial phase of shock introduction intravenously of 10-20 thousand is obligatory. Heparin piece for prevention of a syndrome of an intravascular blood coagulation.
The second important feature of therapy of patients with severe forms of a disease is reasonable rational purpose of etiotropic means. Penicillin use, especially in massive doses - 32-40 mln units a day, leads to a sharp aggravation of symptoms of patients due to deepening of shock and is tactically wrong. In these cases it is reasonable to begin causal treatment with purpose of levomycetinum succinate on 1,5 g in 8 h parenterally, up to removal of the patient from shock. Surely include a constant oxygenotherapy in a complex of medical actions (including hyperbaric oxygenation), a regional cerebral hypothermia (bubbles with ice to the head and large main vessels), administration of cardiac glycosides, drugs of potassium, antigipoksant (sodium hydroxybutyrate, Seduxenum). After removal of the patient from shock at the remaining symptoms of hypostasis and swelling of a brain continue the therapy providing strengthening of dehydrational and disintoxication actions (a complex of diuretics, introduction of glucocorticoids, antipyretics, if necessary - lytic mix) under obligatory control of the entered and removed liquid, electrolytic and acid-base balance of an organism. In some cases use of sorption methods of a detoxication (haemo - and a plazmosorbtion) can appear successful.

In the period of early reconvalescence immediately after cancellation of etiotropic means are appointed:
- the drugs improving microcirculation in brain vessels (trental or эмоксипин on 2 dragees 3 times a day or Doxium to 0,25 g 3 times a day during 3 weeks);
- the drugs of "nootropic" action normalizing processes of fabric metabolism of a brain (Pantogamum on 1 tablet 3 times or piracetam on 2 capsules 3 times or Aminalonum on 2 tablets 3 times a day during 6 weeks);
- after completion of treatment means of adaptogenny action are appointed the drugs improving microcirculation (from 4th week of recovery treatment): Pantocrinum till 30-40 drops 2 times a day or левзея till 30-40 drops 2 times a day or элеутерококк till 30-40 drops 2 times a day during 3 weeks.

Throughout the entire period of recovery treatment patients receive polyvitamins (Undevitum, Hexavitum), calcium glycerophosphate on 0,5 g 2 times a day and glyutaminovy acid of 1 g 2 times a day. At long sanitation of liquor (more than 30 days from an initiation of treatment) aloes appoint 1 ml subcutaneously daily within 10 days or pyrogenal intramusculary every other day (doses need to be selected individually - the initial dose makes 25-50 MPD, then establish the dose causing fervescence to 37,5-38,0 °C and its introduction before the temperature increase termination then the dose is gradually raised on 25-50 MPD repeats; the course of treatment consists of 10 injections.

The forecast at timely treatment is in most cases favorable. Lethal outcomes are possible at development of infectious and toxic shock and hypostasis and swelling of a brain. Such crushing organic lesions as hydrocephaly, dementia and an oligophrenia, an amaurosis, became a rarity. The residual phenomena meet more often and happen more expressed at persons whose treatment was begun in late terms of a disease. Preferential functional disturbances of psychological activity (an asthenic syndrome, a delay of rate of mental development) are noted.