VI. Read the text and speak about the diagnosis and treatment of meningococcal infections
Meningococcaemia
Meningococcal septicaemia ihas a high mortality. It is an acute septicaemia with shock and a purpuric rash. Blood cultures should be taken. Antigen testing is very useful, particularly when antibodies have already been given. Lumbar culture should be considered, but may be contraindicated in a very ill child.
High-dosage penicillin should be started at once to any child with a suspicious rash.
Meningitis
The disease has specific signs such as headache and neck stiffness in older children, but they are often absent in young infants. Infants often present with non-specific signs of irritability, drowsiness, vomiting, anorexia, convulsions or fever. Bulging fontanelle, high-pitched cry and arching of the back are late signs. Any ill child with unexplained fever or convulsions should be suspected. Cerebrospinal fluid examination and culture will confirm the diagnosis.
Broad spectrum antibiotics should be given until the specific organism and sensitivities are known.
VII. Retell this text in English
Менингококковая инфекция
Менингококковая инфекция – одно из тяжелейших инфекционных завоеваний. Заболевают люди любого возраста, но больше всех страдают дети и молодёжь. В С.Петербурге от этой инфекции ежегодно погибают дети.
Возбудитель – Neisseria meninggitidis, грамотрицательная палочка, неустойчивая во внешней среде. Переносится людьми, особенно оласны бессимптомные носители и страдающие менингококковым назофарингитом, который трудно отличить от обычного ОРЗ.
Инфекции свойственна осенне-зимняя сезонность, заболеваемость возрастает каждые 115 лет.
Заболевание протекает в форме менингита или в форме менингококкового сепсиса (менингококцемии), при котором симптомов менингита может не быть. Эта форма болезни часто протекает молниеносно и в 12.5% случаев заканчивается летально из-за тяжёлых гемодинамических нарушений
Заболевание начинается внезапно, часто мама называет даже час начала болезни. Сильная головная боль, высокая температура, рвота, светобоязнь, вялость, сонливость и характерная сыпь – основные симптомы. Детям старше 1 года бывает трудно наклонить голову так, чтобы подбородок коснулся груди. Иногда отмечаются боли в суставах. Маленькие дети становятся очень вялыми и плаксивыми, отказываются от еды, могут стонать при прикосновении. Возможны генерализованные судороги или отдельные подёргивания мышц.
Высыпания носят геморрагический характер (петехии, экхимозы) и не всегда появляются в самом начале болезни.Часто элементы сыпи единичны и вначале присутствуют только на нижней половине туловища, бёдрах, в области гениталий. Поэтому необходимо полностью раздевать и тщательно осматривать кожные покровы больного ребёнка.В тяжёлых случаях количество высыпаний быстро нарастаетБ что указывает на плохой прогноз.
Ошибки в диагнозе с тяжёлыми последствиями происходят из-за недооценки тяжести состояния ребёнка и пропущенных высыпаний. При подозрении на менингококковую инфекцию немедленно следует ввести больному большую дозу антибиотика (пенициллин или певомицетин) и препараты, препятствующие сосудистому коллапсу (преднизолон, гидрокортизон) и доставить в специализированную больницу в сопровождении врача.
PART II THE ORIGIN OF INFECTIONS
The infectious diseases of man are usually divided into two
' large groups. Some diseases aftect only man, others affect both
man and animals, with man most frequently infected from animals.
Every infectious disease has not only characteristic clinical manifestations but also its own specific way of invasion into the human body.
Such a disease as dysentery, which is one of the diseases of the intestinal infections, is spread through the intestines and stools.
The infections of the respiratory tract compose the second subgroup. During coughing or talking the pathogens are discharged from the infected organism with the mucus from the membranes^ of the respiratory tract into the air in the form of drops. The infection is spread when the air containing drops of mucus with the pathogens in it, is, breathed in. The diseases of this subgroup are diphtheria, smallpox, etc.
The diseases of the third subgroup are spread through the skin and the mucosa in which the pathogens multiply. In some cases it is the skin, in others it is the mucous membrane of the eye. Direct contact and various things belonging to the sick may be responsible for spreading the infective agent.
The diseases of the fourth subgroup are spread by living insects. The pathogens causing these infections circulate in the blood or lymph and are not discharged from the organism. The insects become infected as they ingest the blood of a diseased man. They become infectious for other people after the pathogens have multiplied in their organism.. All these diseases, of which encephalitis is an example, are called blood infections.
INFECTIONS IN CHILDREN
Once healthy children are past the first few months of life they are able to combat infections as well as adults. During the first few months the child may not have developed a sufficient number of antibodies to be able to combat successfully the many bacteria in his environment.
The process of developing antibodies takes place rapidly after six months of age, and healthy children may show an even greater resistance to the ordinary bacterial infections than adults.
Children tend to develop an immunity to the bacteria that flourish in their environment. However, such bacteria as staphylo-coccus, streptococcus, colon bacillus, and others can cause an
infection if they gain access, to the child's body through a break in the skin or through one of his apertures.
There are some conditions which can affect a child's ability to combat an infection.
1. If a child is undernourished and lacks sufficient body proteins,
vitamins and essential minerals, he will be poorly equipped to
combat infections.
2. An anemic child will find it more difficult to mobilize his
body resources to combat infections.
3. If there is a disease in one of the major organs, such as
liver, kidneys, or bone marrow, a child will be less able to fight
off the invasion of bacteria.
Any infection may cause temperatures as high as 105 °F to 106 °F in a, child. This is not a bad indication, as it demonstrates the child's ability to mobilize his defence mechanisms.
It is necessary to give a patient large quantities of fluids because most generalized infections are associated with temperature elevation and profuse sweating. Furthermore, large quantities of fluids tend to dilute the toxins produced by the bacteria.
Bed rest and prompt treatment of minor infections such as head colds or other upper respiratory infections will often prevent the onset of a more serious infection such as pneumonia.
It must be remembered that antibiotics are usually ineffective in ridding the body of a viral infection. However, they may be given to prevent a secondary invasion of bacteria that would complicate the original viral infection.
In certain instances the vaccines are effective in preventing the viral infection but not in curing it. For example, the measles virus can be prevented from taking hold within the body by vaccinating the child against it.
DISEASE
DISEASE is the unhealthy state of a body part, a physiological system, or the body as a whole. A disease may be a structural anomaly, such as a congenital heart defect, or a functional condition such as high blood pressure or trauma.
An important aspect of any disease is its etiology. Many diseases are known to be caused by infectious agents for example, childhood infectious diseases; the common cold and the flu and catarrhal jaundice are considered to be viral infections while inflamatory processes and abscesses being caused by bacteria. Another important aspect of a disease is the way of its manifestation — the symptoms and signs.
Diagnosis, the determination of the nature of a disease, is based on many factors including the signs, symptoms and often, laboratory arid clinical findings. To make a diagnosis a physician obtains information from a physical examination, from interviewing the patient or a family member, as well as from a medical history of the patient.
The physician having made a diagnosis states the possible prognosis of the disease, the course it is to take and an outcome of the disease.
The treatment considered most effective should be prescribed and may include medication, surgery, radiation therapy, etc.
Physicians know the course of the disease often to vary. It may have a sudden onset and a short duration in which case it is stated to be an abute disease. A disease may begin insidiously curable one or have a fatal outcome.
Acute Tonsillitis
Acute tonsillitis is a systemic infection characterized by an acute inflammatory process, it may have drastic effect on many vital organs of the body.
Acute tonsillitis may be due to different bacteria. The most common cause is the haemolytic streptococcus. Its highest, incidence is between October and March. Care must be taken to prevent spread of infection. In the early stages it may be difficult to differentiate from diphtheria, and if there is any doubt as to diagnosis, a throat swab must be taken to determine the infecting organism. Acute tonsillitis is caused by the contact with infectious patients, through articles. The child may carry a dormant infection in his decayed teeth or chronically inflamed tonsils. And when his body is weakened or he is subjected to prolonged chilling he falls ill.
Protection against tonsillitis includes elimination of factors that lower resistance to disease. An important factor in the prevention of tonsillitis is the protection of healthy children against exposure to it and as well as to other diseases, such as upper respiratory catarrhs, grippe, colds.
There are several forms of acute tonsillitis, depending on the nature of the lesion: catarrhal, follicular and lacunar tonsillitis.
The onset of tonsillitis is usually sudden with malaise, pain on swallowing, a sensation of chilliness, .fever, impaired sleep and appetite. On examination one or both tonsils are found to be enlarged and covered with whitish or grey material.
This material or exudate consists of purulent discharge from the tonsil. The inflammatory process is seldom restricted to the tonsils, and the whole of the throat is reddened and inflamed. The tongue is covered with a thick fur, and the breath has often an unpleasant odour. There is sometimes pain in the ear on the affected side, it may lead to infection of the ear with serious consequences.
The most frequent complications of acute tonsillitis are rheumatic fever and kidney trouble. A condition called chronic tonsillitis may develop following recurrent .attacks of acute tonsillitis.
A sick child must be put to bed immediately. Particular care should be taken to give the child a lot of vitamins, the patient's food must be soft and warm. The children have to gargle their throats with a solution of salt, soda and boric acid. Vapour inhalations through the mouth are sometimes comforting. Warm compresses to swollen lymph nodes are useful. The drugs usually prescribed for acute tonsillitis are streptocide (sulfanilamide) or other sulfonamides. The child is given drugs to bring the t°down.
Chronic tonsillitis is treated by irrigating the tonsils with various preparations or exposing them to ultraviolet rays. The tonsils may be removed surgically if treatment is of no avail.
DIPHTHERIA
Diphtheria is an acute infectious disease caused by Corynebac-terium diphtheriae.The microorganism produces an exotoxin which is responsible for the resulting pathologic process. The disease is characterized clinically by a sore throat and a membrane which may cover the tonsils, pharynx and larynx.
Epidemiologic factors.The highest seasonal incidence occurs during the autumn and winter months.
Diphtheria is acquired by contact with either a case or carrier, the microorganisms being disseminated by the acts of coughing, sneezing or talking.
Pathogenesis and Pathology.Virulent diphtheria bacilli lodge in the nasopharynx of a susceptible individual. Bacterial growth taking place in the secretions and epithelial debris, a toxin is elaborated and absorbed by the local mucous membrane. The toxic effect on the cells causes tissue necrosis. In addition to the necrosis, an inflammatory and exudative reaction is also induced by the toxin. The necrotic epithelial cells, leucocytes, red cells, ftorinous material, diphtheria bacilli, and other bacterial inhabitants of the nasopharynx — all these elements combine to form the typical "membrane". It sloughs off during the recovery period.
Clinical Manifestations.Diphtheria develops after a short incubation period of 2 to 4 days.
For clinical purposes it is convenient to classify the disease in accordance with the anatomic location of the membrane. The following types of diphtheria may occur: (1) tonsillar (faucial), (2) laryngeal or laryngotracheal, (3) nasal and 4) nonrespiratory types including skin wounds, conjunctival and genital lesions.
Diagnosis.An early diagnosis of diphtheria is essential because delay of administration of antitoxin may impose a serious risk on the patient. The diagnosis of diphtheria must be made clinically.
The bacteriologic confirmation by means of culture is of the greatest importance. The method of accelerated bacteriological diagnosis when the material secured with the aid of a specially prepared moist tampon is placed in a thermostat for 4—6 hours should be more widely employed. A tellurium test has been recently employed as a method of rapid diphtheria diagnosis.
Treatment.It is necessary to isolate the patient at once. Diphtheria antitoxin must be given promptly and in adequate dosage. In severe toxic forms of diphtheria it is advisable in addition to the serum to administer intravenously a hypertonic glucose solution, give the patients vitamins in the form of nicotinic acid and ascorbic acid for a period of 2—3 weeks, some. authors recommending administration of atrychnine from the 1-st days of the disease. Bed rest is very important. Other supportive measures include maintenance of hydration, a high caloric liquid or soft diet rich in vitamins, aspirin or codeine for sore throat and malaise. The patient must gargle his throat several times a day with a 2% boric acid solution. The patient's room must be aired.
Patients with laryngeal diphtheria require special treatment. In very advanced cases with severe symptoms of growing asphyxia, if there is increasing restlessness, irritability and anxiety, associated with progressive respiratory distress, a tracheotomy is indicated for the relief of obstruction. It should be performed before the child becomes cyanotic and exhausted.
Prognosis and Complications,in spite of the low fatality rate sudden death may be caused by a variety of unpredictable events, such as (1) the sudden complete obstruction of the airway by a detached piece of membrane, (2) the development of myocarditis and heart failure, and (3) the late occurrence of the respiratory paralysis due to phrenic nerve involvement. Patients surviving following myocarditis and neuritis, the recovery is a rule.
Immunity.For determining immune status the Shick test is useful. Active immunity may be induced by either an attack of diphtheria or more commonly to-day by inoculations of diphtheria \ toxoid. Immunity following an attack of diphtheria may be either j, permanent or temporary; recurrent attacks of the disease are not \ unusual. The widespread and routine immunization of infants and
children having had a profound effect on the immune status of the population at large, the incidence of diphtheria among inoculated children is lower, and the disease runs a milder course.
BRONCHITIS
This is probably the most common respiratory disorder of childhood. The inflammation affects the mucosa of the bronchial system. In the majority of cases it is harmless, but in very young patients or those weakened by ill health, it may develop into bronchopneumonia.
Bronchitis may be primary, but is very often an accompaniment of some other infection, as tuberculosis, pneumonia, influenza, whooping-cough, diphtheria. Bronchitis may occur at any age.
Etiology.Bronchitis is due to virus and bacterial infection. The microorganisms most frequently found are the staphylococcus, streptococcus, pneumococcus.
Pathology.Bronchitis is usually part of a general inflammation which may include any or all of the respiratory tract. The infection can begin at any point, and extend down as far as the alveoli, where it results in pneumonia. In a simple case the changes are usually minor: hyperemia of the bronchial mucosa and desquamation of ciliated epithelial cells, with loss of cilia; the mucous glands become distended, the bronchial secretion increases.
Symptoms.The mildest form is confined to the larger tubes. The onset may be sudden or gradual sometimes accompanied by slight fever, from 37.7 °C to 38.8 X, during the first day or two usually there are but few general symptoms. Respiration may be accelerated, and is usually audible. There may be either constipation or diarrhea. The child may be restless and irritable, though giving little evidence of being sick. Catarrh of the upper passages may be associated. Usually there is a dry, hoarse cough, either mild or severe, which may interfere with the taking of food. There may be pain under sternum. When the inflammation reaches the intermediate tubes, the fever is usually higher for the first two or three days, after which it gradually declines. Both respiration and pulse are accelerated. In children over three years old bronchitis is not unlike that in adults. There is not the same danger as in infants, of the infection passing over into the smaller bronchi. Often there is no fever, the patient feels well and has a good appetite. ;The symptoms are cough, which is worse at night and soreness over sternum. The cough is with a small amount of whitish expectoration. The cough usually lasts from one to two weeks. In severe cases older children may complain of headache, chilliness, pain in the back, and a feeling ef tightness in the chest.
Expectoration is more profuse, sometimes blood-streaked. Sometimes bronchitis may be more protracted; this is connected with the duration of the primary disease and with domestic conditions, particularly when the child is deprived of fresh air and sunlight for prolonged periods. Such unfavourable factors may lead to a number of complications auch as, otitis media, pyelitis, secondary anemia. Bronchopneumonia is the most frequent complication in infants.
Prognosisis good for acute bronchitis; in childhood the conversion to chronic forms is rare. Even in protracted cases uncomplicated by pneumonia complete recovery is often obtained by proper care and improved domestic conditions.
Treatment.Bronchitis usually requires only fresh air, good ventilation of premises, a well-balanced diet. Warm baths are indicated, especially for infants. Mustard plasters and mustard packs are recommended. The symptomatic drugs administered are usually expectorants or, on the contrary, anesthetics to keep the cough down.
ACUTE BRONCHITIS
Acute bronchitis is an acute disease of the bronchi, characterized by an inflammation of their mucous membrane, caused by the chemical and biological extension of irritation from the upper air passages, often following a rhinitis or a laryngotracheitis. The larger bronchi are first affected. Affection of the smaller bronchi may be secondary to affection of the larger tubes. Further spread of the infection may cause bronchopneumonia. The condition is also found in association with influenza, measles, scarlet fever, and some of the other acute febrile diseases.
Symptoms:These are retrosternal pain, hoarseness, cough, and often soreness; there may be a slight rise of temperature, though the temperature often remains normal.
Physical Signs: Inspection of the chest is negative; the trachea and pharynx may be infected. Nothing abnormal is elicited by palpation and percussion, but on auscultation the respiratory murmur may be harsh, and numerous large moist or dry rales are found along the large bronchi, which of.ten disappear after cough and expectoration.
CHRONIC BRONCHITIS
This is a chronic inflammatory condition of the medium sized and small bronchi, associated with destructive changes in the bronchial wall and peribronchial space. As a rule, it is a secondary
disease. It is characterized by dyspnea, cough and various types of expectoration.
Most cases of chronic bronchitis occur in those past middle life. In the young it may be caused 'by some irritating condition within the upper air passages, the trachea or the bronchi, and also by the presence of enlarged tonsils, sinus infections, focal infections, enlarged pendulous uvula, adenoids, congenital malformation of the trachea. A foreign body in the bronchi or lungs may at times be the cause of chronic bronchitis.
Symptoms:These are cough which occurs in paroxysms, copious expectoration, absence of fever, and a history of long-standing cough.
Physical signs:A person suffering from chronic bronchitis is usually emphysematous. Inspection, therefore, will reveal an em-physematous chest. Palpation will give evidence of diminished tactile fremitus throughout the- chest. Percussion will elicit a hyperresonant note, except when associated congestion of the bases is present, in which case, impaired resonance or relative dullness is obtained over these areas. On auscultation the examiner will hear low-pitched, prolonged inspiration, accompanied by low-pitched, prolonged wheezy expiration. The rales heard will be large and small, moist and dry. A profusion of all kinds of rales is usually audible in this class of cases, though the rales may disappear temporarily after the secretion has been coughed up.
BRONCHIAL ASTHMA
General Considerations
Familial susceptibility, environmental exposure, and such modifying factors as psychogenic stimuli must all be considered in the etiologic evaluation of an allergic patient. Half of these patients give a definite history of family allergy (rhinitis, asthma, eczema, urticaria). Seventy-five per cent of children with 2 allergic parents will be allergic. A familial history gives no information, however, about the specific clinical expression of the allergy.
Most allergic disorders of the respiratory tract are caused by inhalant allergens, principally pollens (especially the ragweed family), animal danders, and housedusts.
Modifying factors (psychic stress infections, endocrine disturbances) may precipitate symptoms by upsetting the "balance" between the patient and his allergenic environment. The antigen-antibody reaction then results, and leads to the rapid appearance of reversible tissue changes; increased capillary permeability, increased secretion of mucus, spasm of smooth muscle, and increased
numbers of eosinophils in the tissues, secretions and peripheral blood.
The onset of bronchial asthma is usually before 20 years of age.
Clinical Findings
A. Symptoms and signs:Bronchial asthma is characterized by
recurrent acute attacks of wheezing, dyspnea, cough, and expec
toration of mucoid sputum (especially at the end of an attack).
Coughing at night, coughing and wheezing on exertion, and a
history of frequent "colds" may be more prominent in children
than clear-cut paroxysms of wheezing. Nasal symptoms (itching,
congestion, and watery discharge) may precede attacks of wheezing.
The acute attack presents a characteristic picture. The patient sits up, "fighting for air", with his chest fixed in the inspiratory position and using his accessory muscles of respiration. Great difficulty is evident with expiration. Wheezing may be audible across the room and usually overshadows other pulmonary signs.
When bronchial asthma becomes prolonged, with acute, severe, intractable symptoms, it is known as status asthmaticus.
B. Laboratory findings:The sputum is characteristically tena
cious and mucoid, containing "plugs" and "spirals". Eosinophils are
seen microscopically.
C. X-ray findings:Chest films usually show no abnormalities.
Emphysema may be acute (reversible) in severe paroxysms or
chronic (irreversible) in long-standing cases. Transient, migratory
pulmonary infiltrations have been reported. Pneumothorax may
complicate severe attacks.
Complications.Chronic bronchial asthma may lead to such complications as chronic pulmonary emphysema and chronic cor pulmonale. Other complications are atelectasis, pulmonary infection and pneumothorax.
Treatment.The treatment during attacks consists mainly of the administration of substances that alleviate or arrest the paroxysm. Such old substances as adrenaline and ephedrine have not lost their efficiency and are still prescribed in severe and prolonged paroxysms.
Besides those in some subacute cases when typical expiratory dyspnea, cyanosis restlessness and tachycardia are observed the preparations of theophedrine, antasthmane, euphylline, novodrine, neoepinephrine* and others are administered. In severe cases hormonotherapy (ACTH, cortisone, prednisolone) is indicated.
neoepinephrine — изадрин
To support the cardiac activity strophanthin or isolanid (a digitalis preparation) as well as oxygen therapy should be prescribed.
To dissolve mucoid expectorations aerosolic inhalations and bronchial lavage should be provided.
Change in environic conditions is very desirable for the asthmatic patients, climatic therapy (altitute and sea sanatoriums, altitude chambers* and salt mines**) being the most beneficial.
However, before any treatment is administered all possible alimentary allergens and those of environments must be elicited and removed.
The attack often subsides without treatment, sudden death during paroxysms is rare. Proper hygienic measures, relief of apprehension by reassurance, fresh air and rest are the most reliable agents for checking asthma. The institution of such a regimen for prolonged periods causes the attacks to subside.
Sometimes relief is obtained by the. surgical removal of enlarged tonsils and adenoids, and also by nose therapy (rhinitis), as these are also frequent factors in the origin of respiratory disorders.
Prognosis.Most patients with bronchial asthma adjust, well to the necessity for continued medical treatment throughout life. Inadequate control or persistent aggravation by unmodifiable environmental conditions favors the development of incapacitating or even life-threatening complications.
ACUTE VIRAL HEPATITIS
This is a common worldwide disease, which occurs sporadically and in epidemics with outbreaks, most commonly in institutions, in rural areas and in military forces during wars. Incidence is the highest in autumn and early winter.
There are two types of hepatitis with distinctive clinical, epidemiological and immunological features. The two types of disease are caused by two different viruses. The disease associated with virus A is the classical type of mfectious hepatitis, in former years it was also known as epidemic jaundice and acute jaundice. The disease associated with virus В resembles serum hepatitis, post-transfusion hepatitis and postvaccinal hepatitis. Detection of the infection depends on the demonstration of an antigen, hepatitis В
antigen (HBAg or Australia antigen) or its antibody (HBAb) in the serum of exposed individuals.
It is well recognized that viral A hepatitis is a contagious disease and that the most common mode of transmission is by the intestinal-oral route. Man is a reservoir and source of infection.
Virus В is mainly transmitted parenterally. Transfusion of contaminated blood or blood products is a usual source of infection, although the use of needles by drug abusers is also responsible for the infection. Nonparenteral spread can also occur.
Virus A infection has an incubation period of 2 to б weeks, virus В — about 6 to 25 weeks. All age groups are affected.
The prodromal phase begins suddenly with malaise, nausea, vomiting and fever. Jaundice reaches a peak within 1 to 2 weeks. Then the recovery phase begins. The liver is usually enlarged and tender.
High values of transaminase appear early in the prodromal stage and slowly fall during the recovery phase. Urinary bile appears before jaundice; its early detection provides a valuable clue to the diagnosis. The WBC count is usually low — normal and blood smear often shows a few atypical lymphocytes. In the prodromal phase hepatitis mimics a variety of illnesses and is difficult to diagnose. Where the diagnosis is uncertain, liver biopsy usually helps.
A favourable prognosis in hepatitis В is less certain than in virus A infection, especially in elderly people where mortality is 10 to 15%.
Personal hygiene helps to prevent spread of hepatitis A with a particular emphasis on disposal of feces. Globulin provides' protection against hepatitis A and should be given to close contacts.
Hepatitis В is minimized by proper technical procedures to prevent transmission by blood from an infected donor or through the use of properly sterilized syringes and needles. High immune serum globulin against virus В provides partial protection but is not yet available.
In most cases no special treatment is required. Appetite usually returns to normal after the first few days and the patient need not be confined to bed. Restrictions on diet or activity are unnecessary and have no scientific basis. Vitamin supplements are rarely required. Corticosteroids are contraindicated in ordinary cases. Most patients can safely return to work before jaundice completely resolves and before transaminases are normal.