THEME OF THE LESSON:

DIPHTHERIA. INFECTIOUS MONONUCLEASIS.

Diphtheria The Activator: toxigenic strains of Corynebacterium diphteriae. Depending on

ability to ferment starch allocate the following variants: mitis, intermedius and gravis (prevails recently). Severity of the disease depends not on variant, and from ability to formation of toxin. Toxin causes infringements of microcirculation in locus of lesion, renders significant general influence on internal organs, especially - on a myocardium, capillaries and peripheral nervous system (demyelinisation).

Nontoxigenic strains of corynebacteria are allocated from healthy people, epidemic danger do not represent.

The Source of an infection: patients with diphtheria and carriers of toxigenic diphtheritic bacilluses (are most infectious at presence of the catarrhal phenomena). The way of infection is air - drop, less often is air - dust.

Clinic The incubatory period is from 2 about 10 days. The beginning of disease is sharp,

from the phenomena of intoxication (with a fever) and local lesions (an inflammation with fibrinous patches). Distinguish diphtheria of an oropharynx (fauces), a throat, a nose, an ear, a skin, external genitals, and also the combined form.

Diphtheria of an oropharynx meets in 92 % of cases and can proceed in the located, widespread and toxic forms.

At the located form patches do not fall outside the limits of tonsils, intoxication is moderate. Variants of current are possible:

The catarrhal form - without patches, with a moderate edema and hyperemia of tonsils, submaxillary lymphadenitis, subfebrile temperature;

The insular form - it is similar, but with more expressed intoxication and islands of fibrinous films on tonsils;

The filmy - with a fever, continuous patches on edematous tonsils; hyperemia of tonsils - with a cyanotic shade, precise borders; patches are of white or grayish color, badly removed by spatula, leaving bleeding, erosions; submaxillary lymphatic nodes are enlarged and painful; pains in a throat are insignificant.

The widespread diphtheria of a fauces is characterized by distribution of patches for limits of tonsils - on arches, a small uvula, a soft palate, and also more expressed intoxication: a fever, paleness, weakness, deafness of cardiac tones.

The toxic diphtheria is accompanied by amplification of the phenomena of intoxication. Even at a moderate fever state of health is bad: sharp weakness, fear of death, asthma owing to significant edema of tonsils. Conducting diagnostic attribute is edema of a hypodermic cellular tissue: at subtoxic diphtheria - in submandibular area, at

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toxic diphtheria of the 1st degree - up to middle of a neck, the 2nd degree - up to a clavicle, the 3rd degree - lower than clavicle.

Diphtheria with lightning increase of an intoxication and development of the disseminated intravascular coagulation-syndrome is counted hypertoxic.

Diphtheria of a larynx: the gradual beginning, subfebrility, insignificant intoxication, stenosis of a larynx (the 1st stage - proof huskiness of a voice, “barking” cough; the 2nd degree - aphonia, retraction of pliable places of a chest, participation in the act of breath of auxiliary muscles; the 3rd degree - asphyxia, characterizing by cyanosis, hyperhidrosis, excitation, tachycardia, drowsiness.

Diphtheria of a nose and an eye can proceed in the catarrhal and the filmy forms, with a weak intoxication; seldom there are toxic forms.

The diphtheria of a skin meets, mainly, in tropical countries, has easy current.

Complications are characteristic for toxic diphtheria of an oropharynx (myocarditis, polyradiculoneuritis, glomerulonephritis, infectious - toxic shock) and diphtheria of a larynx (acute respiratory insufficiency - at children).

Laboratory diagnostics The basic method is bacteriological: plating from a mucous membrane of an

oropharynx or other focuses on the transport medium; preliminary result of research is in 48 hours, final (with definition of toxigenicity) is in 72 hours. Bacterioscopic research of smear with the purpose of rough urgent diagnostics is possible. A level of antitoxic antibodies in blood is also determined.

Active early revealing. There is carried out momentary bacteriological research of a fauces:

Patients with anginas, laryngitises, pharyngitises. Material is taken away prior to the beginning of treatment by antibiotics or serum per day of address (in an unusual case - next day at active visiting of the patient). Delivery of the material in a laboratory should be carried out within 2-3 hours from the moment of the taking.

Persons entering again in kindergartens, boarding schools, special establishments for children with lesion of central nervous system, in sanatoriums for children with tuberculous intoxication, children’s and adult (psychoneurological) hospitals on scheduled treatment.

Treatment. Antidiphtheric antitoxic srum is entered at a toxic diphtheria in maximum early terms (it is most effective in the first day of the disease) in a doze from 40000 of International Units (IU) (at subtoxic) up to 200000 IU (at toxic diphtheria of the 3rd degree). Excess of the dosages stipulated by order of Ministry of Health of The Russian Federation, is not supposed owing to toxicity of the preservatives included in

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whey. The question on decrease of a doze of serum - in the limits which are not exceeding 100000 IU recently is discussed. Antibacterial therapy of all forms of diphtheria includes Penicillin, Tetracyclin or Macrolids; pathogenetic - glucose-potassium-insulin mixture, glucocorticosteroids etc.

Registration at suspicion on diphtheria or seeding of toxigenic strain of corynebacteria there is immediate telephonogramm in Center of Sanitary Supervision.

Hospitalization of patients with diphtheria is obligatory. To immediate hospitalization in boxes or separate chambers of infectious hospitals patients with diphtheria, with clinical suspicion on diphtheria, with diagnoses "angina", "croup" from the focus of diphtheric infection, bacteriocarriers of toxigenic corynebacterias of diphtheria are subject.

At suspicion on diphtheria patients are hospitalized in diagnostic hospital without carrying out of preliminary bacteriological research and introductions of antidiphtheric serum (at a condition of hospitalization during the first 3 hours after revealing the patient).

Sanitation of carriers on a place (without hospitalization) is supposed in collective of children and teenagers with number no more than 300 person at a condition of full scope by vaccination against diphtheria, daily medical supervision, bacteriological examination of children (1 time per 2 weeks) and personnel (weekly) and etc. Carriers from number of adult persons are isolated from collective.

Prophylaxis. The vaccines containing adsorbed diphtheritic anatoxin (APDT, ADT-M) are applied. Vaccination begin with 3-month's age - 3-multiplely, with intervals in 1-1,5 months. Scheduled revaccinations will carry out in 6, 11 and 16 years. To the adult only ADT-M: in 26, 36, 46 and 56 years is introduced. For emergency prophylaxis AD-M is used.

It is developed and resolved to application for children than 6 years, teenagers and adults a vaccine against hepatitis B, diphtheria and tetanus of BUBO-M (with the reduced maintenance of antigens). Initial vaccination of children who are more than 6 years and teenagers, who are not vaccinated earlier against diphtheria, tetanus and hepatitis B, will be carried out 3-multiplely under the circuit: 1 doze - in any day (simultaneously with other calendar of vaccinations or in one month after last), 2 doze - in 1 month, 3 doze - in 6 months after the first doze. For scheduled age revaccinations of children than 6 years, teenagers and adults, earlier not vaccinated against hepatitis B, the circuit, on terms conterminous with the circuit of use of ADT-M is applied; the subsequent rate of introduction of a vaccine against a virus of hepatitis B (the second and the third introduction) will be carried out by vaccine “Combiotex”.

REALIZATION OF THE LESSON The purpose is to learn to diagnose diphtheria according to clinic, the

epidemiological anamnesis and also to make the plan of inspection and treatment of the patient.

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Control questions to the beginning of the lesson1. Etiology of diphtheria.2. Name sources of infection.3. Enumerate the ways of transfer at diphtheria.4. Name clinical forms of diphtheria.5. Name complications.6. What urgent conditions can be observed at diphtheria?7. What methods of laboratory diagnostics are used at diphtheria?8. With what diseases it is necessary to differentiate diphtheria?9. What principles of treatment of diphtheria?10. As preventive maintenance of diphtheria is carried out?

The test

1. Consequences of toxinemia at diphtheria are:1. Disturbance of cardiac-tissue permeability.2. Change of reological properties of blood.3. Disturbance of microcirculation.4. Regionar lymphadenitis and edema of surrounding tissues.5. Inflammatory-destructive processes in organs and tissues.

2. Clinical attributes of the located diphtheria of an oropharynx are:1. Subfebril fever within 2-3 days.2. Stagnant hyperemia in an oropharynx, moderate edema of tonsils, a soft palate

and arches.3. Patches located only on tonsils.4. Regionar lymphadenitis.5. Edema of a hypodermic cellular tissue of a neck.

3. Clinical attributes of the widespread diphtheria of an oropharynx are:1. Long fever.2. Patches on tonsils and behind their limits.3. Purulent lymphadenitis, periadenitis.4. Pasty painless edema of a hypodermic fatty cellular tissue of a neck.5. Puffiness of soft tissues of an oropharynx.

4. Attributes of the toxic diphtheria of an oropharynx are:1. High fever from the first o'clock of disease.2. Distribution of fibrinous patch for limits of tonsils.3. Edema of soft tissues of an oropharynx.4. Edema of a hypodermic cellular tissue of a neck.5. Development of myocardiopathy and polyneuropathy.

5. Stages of development of diphtheria of a larynx are:1. Grippe-like2. Dysphonic

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3. Croupous4. Stenotic5. Asphyxic

6. Clinical attributes of diphtheria of a larynx are:1. “Barking” cough2. Husky voice, aphonia3. Noisy breath with the complicated inspiration4. Retraction of intercostal intervals at breath5. Sensation of asthma

7. Pathogenetically caused complications of diphtheria are:1. Infectious-toxic shock2. Myocarditises3. Polyneuropathias4. Toxic nephrosis.5. Acute respiratory insufficiency.

8. Laboratory diagnostics of diphtheria is:1. Allocation of the activator from the focus of an inflammation.2. Allocation of the activator from blood3. Definition of toxic properties of the activator4. Definition of antitoxic antibodies in pair serums5. Bacterioscopic research of smears-imprints.

9. Principles of treatment of diphtheria are:1. Specific detoxication2. Nonspecific detoxication3. Antibacterial therapy4. Hyposensitizing therapy.5. Surgical processing of an entrance gates in an oropharynx

10. At introduction of antidiphtheric serum it is necessary:1. Early introduction at the clinical diagnosis of diphtheria2. Preliminary realization of skin-allergic tests.3. Adequate medical doze. 4. Application at the located diphtheria of an oropharynx after the 4th day of the

disease.5. Hyposensitization by antihistaminic and hormonal preparations.

For discussion of the theme of the lesson students study a clinical problem. At the decision of problems students write in writing-books the clinical diagnosis in view of the form and severity of the disease, the plan of laboratory-instrumental inspection of the patient, the plan of treatment with writing out in Latin language of preparations of antibacterial and pathogenetic action.

PROBLEM

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Patient P., 32 years, being at home, has felt the general indisposition, a headache, pains at swallowing, the temperature 38,2С, decrease of appetite was marked. It was treated independently hot it is expected also by honey. For the 3rd day of disease she was examined by the local doctor.

Objectively: a skin of the person is of pale color, tonsils are edematous, covered with a membrane of grey color, with a smooth surface and the nacreous shade, precisely outlined edges. Patches are removed hardly, exposing bleeding surface. The enlargement of regionar lymphatic nodes from both sides, mobile, moderately painful is revealed. Tones of heart are muffled, a rhythm is correct. The arterial pressure is 110/80, pulse is 110 in one minute. On other organs there is without pathology.

Epidemiological anamnesis: the woman works as the seller, has contact to a plenty of people.

1. Prospective clinical diagnosis.2. With what diseases it is necessary to carry out differential diagnostics?3. Tactics of the local doctor.4. Make the plan of inspection and treatment.5. Write out in Latin language the basic medical preparations of etiological and

pathogenetic action.

Infectious mononucleasis The Activator: an Ebstain-Barr virus from family of Herpes-viruses. The Source of an infection: the patient. Disease is small-contagious. Ways of

transfer: air-drop, contact (with saliva), hemotransfusional. After an initial infection the virus is periodically allocated from an organism of reconvalescent in an environment till 1-1,5 years.

Clinic Incubation is from 4 about 15 days. The beginning is sharp, from a fever up to

39-40С, symptoms of intoxication, and pains in a throat. Tonsillitis can be catarrhal, lacunar or ulcerous - necrotic. The enlargement of lymph nodes is typical, especially - back-cervical and submaxillary; generalized lymphoadenopathy and mesadenitis are frequent. Hepatosplenomegalia appears for 3-5 days of the disease and it is kept about one month and is longer. Disturbance of function of a liver (hepatitis – non-icteric and icteric) is possible. It is quite often marked exanthema: for 3-5 days (is more often - on a background of reception of Ampycillinum or other antibiotics) there is measles-like or smallmacular, roseolous, papulous rash disappearing in 1-3 days. In the general analysis of blood leukocytosis, absolute and relative lymphocytosis, atypical mononuclears (from 10 up to 80 %) are revealed.

Last years it is diagnosed chronic mononucleosis, accompanying by the phenomena of intoxication, lymphoadenopathy, polyorganic pathology (pneumonias, pharyngitises, uveitises, hepatitises). The diagnosis proves to be true by revealing of immunoglobulins of M-class in high titers (to capsid antigen of the virus - in a titer 1:

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5120 and higher, to early virus antigen - in a titer 1:650 and higher). Complications: rupture of a spleen, lesions of the central and peripheral nervous

system, hepatitis, myocarditis, interstitial pneumonia, obstruction of respiratory ways, hemolytic anemia and other disturbances of hemopoiesis.

Laboratory diagnostics. Reactions of heterohemagglutination: Paul - Bunnel (nonspecific results are often), Goffe-Bauer, Lovric. Last time IFA with definition of immunoglobulins of classes M and G is used.

Treatment: pathogenetic, at connection of bacterial complications - antibiotics (penicillinic line and others). It is possible to useinductors of interferonogenesis (cycloferon, viferon), immunomodulators (including - children's anaferon).

Actions in the focus will not be carried out. Prophylaxis is not developed.

REALIZATION OF THE LESSON The purpose is to learn to diagnose infectious mononucleasis according to clinic,

the epidemiological anamnesis and also to make the plan of inspection and treatment.Control questions to the beginning of the lesson

1. Etiology of infectious mononucleasis.2. Name a source of an infection.3. Enumerate the ways of transfer at infectious mononucleasis.4. Name clinical forms of infectious mononucleasis.5. Name the complications meeting at infectious mononucleosis.6. What methods of laboratory diagnostics are used for statement of the diagnosis?7. With what diseases it is necessary to differentiate infectious mononucleosis?8. What principles of treatment of infectious mononucleosis?

The test1. The basic parts of pathogenesis of infectious mononucleosis are:

1. Virusemia.2. Replication of the virus in B-lymphocytes.3. Replication of the virus in T-lymphocytes.4. Systemic hyperplasia of lymphoid and reticular tissues.5. Occurrence of atypical mononuclears in blood.

2. Occurrence of atypical mononuclears in peripheral blood at infectious mononucleasis is caused by:

1. Hyperplasia of lymphoid and reticular tissues.2. Increase of quantity and activity of T- lymphocytes.3. Lesion of T4-lymphocytes.4. Development of reaction of hypersensitivity of the slowed down type.5. Amplified reproduction of interferons.

3. The basic clinical syndromes of infectious mononucleasis in the period of heat:1. Intoxicational syndrome2. Angina

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3. Diarrheal syndrome.4. Hepatolienal syndrome.5. Lymphoadenopathy

For discussion of the theme of the lesson students study a clinical problem. At the decision of problems students write in writing-books the clinical diagnosis in view of the form and severity of the disease, the plan of laboratory-instrumental inspection of the patient, the plan of treatment with writing out in Latin language of preparations of antibacterial and pathogenetic action.

PROBLEM Sasha K., 16 years, was ill February, 10. The temperature up to 38,5 has raised,

the difficulty of nasal breath has appeared. The local doctor was called. At survey the increase of the right tonsil which is covered with a continuous white - yellow patch, hyperemic arches were found out. The diagnosis “angina” was put and treatment in-home by “Biseptol” is appointed. But the temperature was not reduced within 3 days, the patient was hospitalized. At inspection: enlargement of posteior - cervical, inguinal and axillary lymph nodes up to 3 sm in diameter. Lymphatic nodes are of dense consistence, painful at palpation, not comissured among themselves and surroinding tissues. The liver comes forward on2 sm from under a costal arch; its edge is dense, painless. The spleen comes forward from under a costal arch on 1 sm. The analysis of blood: Erythrocytes - 3,8·1012/l, Hemoglobin - 118 g/l, Colour index - 0,76, Leukocytes - 14,0·109/l, Eosinophils - 1 %, Segmented neutrophils - 36 %, Lymphocytes - 45 %, Monocytes - 15 %, RSE - 15 mm / h.

1. Provisional clinical diagnosis.2. With what diseases it is necessary to carry out differential diagnostics?3. Make the plan of inspection.4. Make the plan of treatment.5. Write out in Latin language the basic medical preparations of etiological and

pathogenetic action.

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