Typhoid
Description:
Typhoid - an antroponozny acute infectious disease with the fecal and oral mechanism of transfer. It is characterized by defeat of the lymphatic device of intestines, the bacteremia expressed by intoxication, increase in a liver and spleen, rozeolyozny rash and in some cases enteritis.
Tank and source of an infection - the person (the patient or a bakteriovydelitel). Danger of the patient to people around during the different periods of a disease is not identical. In an incubation interval the infected person is almost not dangerous. Danger of the patient to people around increases in process of a course of a disease and reaches a maximum on the 2-3rd week of a disease - during allocation of bacteria with excrements, urine and then; also they can be found in breast milk and a nasopharynx. The most part of had is exempted from the activator in the first 1 2 weeks or in the closest 2-3 months of reconvalescence. About 3-5% remain carriers for long term, and some - for the rest of life. Epidemiological danger of the chronic carrier is defined by its profession and depends on observance of rules of personal hygiene by it. Special danger is constituted by the carriers having access to preparation, storage and implementation of foodstuff.
The transfer mechanism fecal and oral, is implemented water, food and household by ways; in areas with the increased incidence distribution goes preferential the waterway. The last happens due to use of the water taken from the polluted open or technical reservoirs and also because of an unsatisfactory sanitary condition of water and sewer constructions. The uses of the infected water result the acute and chronic water flashes capable is long to proceed and cover big groups of the population. Lead accidents on water supply systems and constructions to emergence of water flashes, pressure differences and an irregularity of water supply which are followed by a suction of the infected ground waters through untight pieces of networks. From foodstuff the milk and milk products, creams, salads and other products serving as the favorable environment for reproduction of bacteria are most dangerous. Infection can sometimes occur also through vegetables, especially at their watering by sewage or fertilizer excrements. The household way of transfer is possible at low culture of bacillicarriers or patients with the erased disease form. At the same time there is infection of surrounding objects, and in the subsequent - food infection.
Natural susceptibility of people. The susceptibility to a disease high, the postponed disease leaves durable lifelong immunity. Recurrent diseases are extremely rare.
Typhoid symptoms:
The incubation interval varies of several days to 3 weeks (on average 10-14 days). Earlier it was considered to be that the typhoid begins gradually. However now more than in 2/3 cases observe the acute beginning of a disease. The first week of clinical manifestations is designated as an initial stage of a disease. If the disease develops gradually, then during the first 3-4 days there is an increase of the temperature reaction reaching by the end of this term of 39-40 °C. Also gradually intoxication syndrome which is shown a headache, anorexia, the progressing general weakness, dizziness, sleeplessness develops. At the acute beginning of a disease symptoms of intoxication develop in more short time (1-2 days).
At survey of the patient pallor of integuments in most cases attracts attention, however at a part of patients the person can be slightly hyperemic, especially in case of the acute beginning of a disease. The language thickening is characteristic; at the same time in the center it is laid over by a plaque, and edges and a tip remain pure. At big puffiness of language it is possible to observe prints of teeth on its edges. The stomach is blown usually up owing to a meteorism, peristaltic waves of intestines are slowed down. Locks are characteristic, however in an initial stage of a disease the ease of a chair with a fecal masses in the form of "pea soup" is possible. A stomach palpation (it is necessary to carry out carefully!) reveals easy morbidity in the right ileal area, in the same place it is possible to note rumbling and a dullness (Padalki's symptom). By 3-4th day of a disease at the patient the sizes of a liver and spleen increase. At a palpation they are a little condensed, but are painless. Cardiac sounds are muffled. Bradycardia, characteristic of a disease, usually develops on later terms. Increase of pulse in an initial stage does not exclude the diagnosis of a typhoid.
The period of a heat is the share of the end of the first - the beginning of the 2nd week of a disease and can proceed of several days to 2-3 weeks. Increase of symptoms of intoxication is characteristic. Body temperature remains high, gets a constant, wavy or wrong current.
For the 8-9th days of a disease it is possible to find the typroid roseolas (roseolae elevatae) which are slightly rising over the surface of skin and located on a front abdominal wall and the lower part of a breast in patients. The quantity of roseolas is insignificant, sometimes only 2-5 elements. Roseolas disappear for the 3-4th day after their emergence, however after emergence of the first roseolas new podsypaniye are possible. Lack of a dieback does not exclude the diagnosis of a typhoid. Development of bradycardia is characteristic, pulse rate considerably lags behind the level of temperature reaction. Cardiac sounds, as a rule, deafs, pulse of small filling, arterial pressure it is inclined to decrease. In more hard cases observe an oliguria. At a severe disease the so-called typhus status with prostration of the patient, sharp weakness, an adynamia, apathy, stupefaction, and in certain cases with motive concern can develop. Now the similar state is met rather seldom.
The period of reconvalescence is shown by temperature drop of a body (sometimes on amphibolic type) and obsolescence of symptoms of intoxication. It is necessary to emphasize that despite disappearance of symptoms of intoxication, especially under the influence of medical actions, time frames of formation of ulcers in a small bowel remain therefore there is a danger of development of intestinal bleedings and perforation of a gut.
It must be kept in mind that the clinical picture of a typhoid is not always characterized by the specified complex of symptoms; many of them are shown poorly or can be absent completely. The similar situations known as atypical forms, are difficult for diagnosis ("out-patient typhus"). The abortal form of a disease which is characterized by short-term fever within only several days and bystry disappearance of intoxication is also known. The erased form of a typhoid is shown by short subfebrile condition, lack of a dieback and poorly expressed intoxication symptoms.
In rare instances the disease can proceed in the form of pneumo - meningo-, kolo-and a nefrotifa. At the same time disease usually heavy, against the background of the expressed intoxication signs of defeat of appropriate authorities and systems prevail.
Aggravations and recurrence. In certain cases the disease can gain the long character caused by development of aggravations. They usually arise against the background of reduction of symptoms of intoxication and decrease in the body temperature, however, which is not reaching normal indicators. On this background all symptoms of a disease amplify again, body temperature increases, there are new elements of a typroid dieback, the liver and a spleen increase in sizes.
Recurrence of a disease differs from aggravations in the fact that again intoxication symptoms develop, there are fresh roseolas, body temperature increases to high figures after already normalized temperature reaction and satisfactory health of the patient. At 7-9% of patients a recurrence arises on the 2-3rd week of an apireksiya; in certain cases they can be observed also on later terms. The number of a recurrence usually does not exceed 1-2, in rare instances - 3. As a rule, a recurrence begins sharply, within 1-2 days the full clinical picture of a disease develops. Especially it is necessary to emphasize that at a recurrence the dieback can be found in the first days. The current of a recurrence is easier, and their duration is shorter than primary disease.
Typhoid reasons:
The activator - Salmonella typhi, a gram-negative mobile stick of the family Salmonella of the Enterobacteriaceae family. Bacteria are unpretentious and grow on usual mediums. At S. typhi allocate thermostable somatic Au-Ag, thermolabile flagellar N-Ag, thermolabile somatic Vi-Ag, etc. Bacteria of exotoxins do not form. At destruction of microorganisms the endotoxin playing the main role in a disease pathogeny is released. To some extent pathogenicity of typroid bacteria is also defined by "aggression enzymes" - hyaluronidase, fibrinolysin, a lecithinase, hemolysin, a catalase, etc. On sensitivity to standard bacteriophages allocate more than 100 stable fagovar. Definition of a fagovar of the activator - a convenient marker for identification of epidemiological bonds between individual diseases, clarifications of a source and ways of transfer of the activator. In unfavorable conditions, for example in an immune organism, a bacterium pass into L-forms. Bacteria are moderately steady in external environment - in the soil and water can remain up to 1-5 months, in excrements - up to 25 days, on linen - to 2 weeks, on foodstuff - from several days to one weeks. Remain slightly longer in milk, mincemeat, vegetable salads where at a temperature over 18 "With are capable to breed. When heating the activator quickly perishes, disinfecting solutions in usual concentration affect it perniciously. If in 1993-1995 fagovara of A, K1, B2 dominated, then in 1997 prevailed фаговар 28, fagovara of F4 and 45 appeared. Existence of the antibiotikorezistentny strains of the activator capable to cause large disease outbreaks is established.
Treatment of the Typhoid:
In all cases, even at suspicion of a tifo-paratyphoid disease, patients are subject to hospitalization. The diet of patients has to carry mechanically and chemically sparing character. Usually sick appoint a table No. 4 (in an infectious hospital it is often designated as a table No. 4abt). Dishes have to be boiled and wiped through a sieve. Food is shown fractional, small portions; food should be washed down with a large amount of liquid.
The bed rest of the patient is caused by need to avoid a stomach muscle tension that can provoke perforation of a gut or bleeding. The sparing diet and a bed rest have to proceed until the end of the 4th week of a disease, i.e. until approach of a reparation of a mucous membrane of a gut. The diet and the mode need to be observed regardless of terms of disappearance of intoxication.
Usually apply levomycetinum on 0,5 g of 5 times a day till the 2nd day from the moment of normalization of body temperature to causal treatment (inclusive), then on 0,5 g 4 times a day till the 10th day of an apireksiya. In hard cases of a disease appoint levomycetinum succinate intramusculary on 3 g/days. Considering the increasing resistance of a typroid stick to levomycetinum, in treatment of patients also apply ampicillin on 0,5 g in 4 times a day, azithromycin of 500 mg in the first days, and further on 250 mg/days orally, generation cephalosporins III (цефтриаксон on 2 g/days intramusculary) and ftorkhinolona (ciprofloxacin inside on 500 mg 2 times a day). Duration of rates of these drugs at their clinical performance can be reduced to the 5-7th days of an apireksiya.
Considering existence of an intoksikatsionny syndrome, all patients need to carry out active disintoxication therapy by intravenous administration of colloidal and crystalloid solutions.
In cases of intestinal bleeding to the patient to 12-24 h appoint absolute rest in situation on spin, hunger, limited amount of liquid (no more than 500 ml, teaspoons). Expansion of a diet is possible not earlier than the 2nd day from the beginning of bleeding; include beef-infusion and fish broths, juice, kissels, jelly, soft-boiled eggs in a diet. In case of the termination of bleeding the diet within 3-5 days is gradually expanded to a table No. 4abt. From the first hours of bleeding the patient needs to suspend the bubble with ice which is slightly concerning a front wall of a stomach. From medicamentous means apply solution of aminocapronic acid, blood substitutes, fibrinolysis inhibitors to a stop of bleeding. For prevention of repeated bleeding appoint Vikasolum.
At diagnosis of perforation of a gut of the patient arrives under observation of the surgeon.
The extract of convalescents from a hospital at absolute clinical recovery is possible after the 21st day of normal body temperature, however day of an extract cannot be before the termination of the 4th week of a disease.
