INFECTIOUS DISEASES : SEPSIS (SEPSIS, SEPTICAEMIA, SEPTICOPYAEMIA) - etiology, pathogenesis, symptoms and course of, recognition, prediction and prevention
Etiology. A variety of diseases can give the transition in sepsis, as well as primary sepsis can be caused by a variety of microorganisms. The microorganism imposes a known specific features on the disease, but the course and outcome of the disease depends not so much on the microorganism and the degree of virulence as on the ability of the microorganism by appropriate reactions to localize and to paralyze the action of the microbe.
Epidemiology. All conditions that increase the concentration of microbes in the environment, contamination of their skin or even clothing of a person, under certain conditions facilitate the growth of sepsis. Another important role played by the concentration of microbes in various body cavities and the conditions that facilitate their concentration in quantitative and qualitative terms. These provisions speak for the possibility of successful struggle with sepsis improvement of sanitary conditions, which have much more important than the fight against microbial factor.
The pathogenesis. The starting point of septic diseases is always any primary tumor site, the formation of which is often associated with hidden chronic or acute inflammatory processes: old chronic angina, carious teeth, inflammatory changes on the roots of the teeth, old sores, neglected diseases of the urogenital sphere, boils, panaritium, etc. essentially the difference between primary and secondary sepsis purely quantitative. A huge role in the appearance of the primary lesion playing injured most varied properties: wounded, a generic instrument, surgical intervention, stones, urinary and biliary tract. Organisms in which the microbes form the primary lesion, ill sepsis only when local reactive ability is insufficient to eliminate this primary focus, but also for its localization. Sometimes not only the Clinician, but the pathologist may not specify nor gate infection or primary tumor, which served as the starting point and septic diseases. These sepsis are called cryptogenic and arise from endogenous infection.
Than favorable conditions for microbial growth in the primary lesion (uterus after delivery or abortion, gaps at the old tonsillitis) and the richer equipped with these foci of lymphatic and blood vessels, the easier to breed in them the germs and penetrate into the blood. The infection spread from the primary tumor through the lymph system (lymphogenous sepsis) less dangerous. The penetration of infection into the blood vessels of primary tumor more adversely, as associated with damage to the endothelium and the formation of small septic thrombophlebitis, of which there is not only the flow in the blood of microbes, but the penetration into the bloodstream of infected emboli. Do germs and blood lymphogenous through the ductus thoracicus or directly, they remain in the blood for a relatively short time and in blood stream, as a rule, do not breed. The microbes die quickly in the blood, but their degradation products and endotoxins cause the temperature of the reaction, produce sensitization of the organism for its protein components, causing irritation of the reticulo-endothelial system and produce toxic deistvie. For sepsis is characterized by alternating chills, fever and sweat with periods of lower and sometimes normal temperature and chills followed by ledges for receipt of microbes in the blood (after 2 to 3 hours; it is important to obtain hemoculture). Circulating in the blood microorganisms caused mainly histogene reaction from all sections of the reticulo-endothelial system (blood, lymphatic system, liver, spleen, bone marrow); on the other hand, on the basis of malnutrition tissues and intoxication occurs a number of degenerative changes of the internal organs. Functional disorders resulting from these changes, further deduce the whole body from a state of stability and even more reduce resistance to infection. It turns out, therefore, a vicious circle. On the grounds of vascular changes embolism and eviction microbes creates a number of secondary lesions, the formation of which contribute significantly to a local allergic reaction. Crucial for the further course of sepsis is the appearance of endocarditis. Changes in the organs and systems. The circulatory system. Changes occur in the vascular wall and blood-forming apparatus. In the fight against infection participate cells adventitia and endothelial forming alopecia concentrations and circulating in the blood current (histiocytes). In connection with the violation of the integrity of the endothelium increases the porosity of the vessels (the formation of small hemorrhages) and creates fertile ground for the formation of blood clots. The accumulation of germs, trombicula capillaries, causing characteristic of sepsis skin phenomena hemorrhage with a white dot in the center. Under the influence of exposure on blood-forming organs morphological changes of the blood - increases the number of leukocytes, predominantly neutrophils, with an increase of young forms (left shift). In the blood begin to appear young unstable forms of erythrocytes (polychromatophilic and even normoblast). Gradually increasing anemia and polyplasmia. The effects of anemia especially increase during sepsis caused gemotoksicescoe infection (anaerobes, partly Streptococcus). From the heart, in addition to degenerative changes in the heart muscle, there is a frequent cuts due to the weakening of the inhibiting influence of the vagus nerve. On the significance of the defeat of the valves mentioned above. Changes in the blood and blood vessels entail changes in the number of organs due to the changing conditions of the blood supply and nutrition (icteric staining of the skin, congestion in the liver, spleen, lungs, and so on). Lymphatic apparatus can be involved early in the process (hyperplasia, lymphadenitis, limfangoita and so on). Spleen hyperplasias, becomes flabby; the opening of the pulp is easily scraped off. It often formed the heart attacks. The liver as an organ with phagocytic functions (copperhouse cells) overloaded decay products of bacteria; it sharply pronounced stagnation. The reduction of its functions contributes to the development of acidosis. In the lungs, in addition to the phenomena of stagnation, especially often get stuck emboli with the formation of heart attacks. The kidneys also suffer from degenerative changes in the parenchyma and formation of a small embolic abscesses or major heart attacks. Side joints - periarticular, serous and in rare cases, purulent arthritis.
When chronostasis the body's response to infection qualitatively the same as in acute advanced form, but it is expressed quantitatively weaker. This condition can last for years, but at the same time harmful external influences and even some physiological processes (birth) can interrupt this state and to cause a sharp aggravation.
Symptoms. With many similarities reactions with different etiology of sepsis is still marked specific impact on such important symptoms, as the temperature curve, the health of the patient, localization of secondary centers, various skin rashes, etc., So about the features of sepsis with different etiology will be discussed separately. Especially difficult symptomology of the initial period, as certain signs appear sometimes with great continuity. The symptoms of the underlying disease (scarlet fever, pneumonia, typhoid, and others)that caused arising sepsis, often obscure signs of developing septic conditions. The main symptoms of sepsis associated with its pathological mechanism, are periodic, often randomly following a rise in temperature, chills, sweats with temperature remission, little facilitating the well-being of the patient; dryness of the tongue, pulse frequency higher temperature level; change in color of the skin, skin rashes of various nature (roseola, petechiae, erythema, skin embolism); increased soft spleen.
For. The clinical course of sepsis is known based on the localization of the primary tumor and its nature.
Streptococcal sepsis is about 65% of all septic diseases, and comes from a variety of foci: wounded random nature and operational wounds, vaginal, urinary tract, tonsillitis, periodontitis, otitis, mastoiditis, etc. From the blood inoculated: Streptococcus vulgaris haemolyticus, Streptococcus mitior s. viridans, Streptococcus putridus s. anaerobius, Streptococcus mucosus, Streptococcus anhaemolyticus vulgaris. Most frequent first two types. The first of them often released during acute flowing sepsis, second in chronic, but first can go second in the human body that it is easy to see from the same patient when many multiple posavac blood. Change hemolytic Streptococcus greenish improves the prediction. If there are injuries, sepsis precede inflammation from wounds. The sepsis these are heavy, as in most cases they occur in tromboflebitichesky type. Chronic (sepsis lenta, chroniosepsis) streptococcal sepsis associated with the presence of old inflammatory foci, so sluggishly flowing that looking for them is very difficult. The disease develops so slowly that sick for a long time do not give value to their ailments: low-grade temperature, sometimes even does not exceed the upper limits of the norm, but there are possibleway and esparina. When more worrisome thermometry easily detected incorrectly successive lifts of varying heights. Such patients are often treated as tuberculosis or malarial. Striking their pale grayish-yellowish or coffee shade. Increasing anemia, leukocytosis, and the ratio of neutrophils to lymphocytes vary depending on exacerbations appear histiocytes. Serous inflammation of certain joints. On the skin exanthema erythematous, roseolous or petechial nature; often appear painful infiltrates on fingers in the nail bed. The spleen is slightly enlarged, soft. The occurrence of endocarditis is not accompanied by a noticeable deterioration of the disease, but the pulse quickens, appear delicate, the changing nature of the noise, which at first often interpreted as anemic. Clinical manifestation of endocarditis often precedes pericarditis, masking gentle intracardially noise. Even in the presence of endocarditis periods of exacerbation are followed by improvement, but the temperature is kept high, all phenomena primout more acute, there are sudden chills and pain at various sites, depending on embolism and heart attacks, which are indicators of the approaching junction. However, the presence of endocarditis does not define a certainly fatal prognosis, since the elimination of the primary tumor in many cases gives a significant improvement and even cure, but at least the Outlook is deteriorating.
Pneumococcal sepsis occurs much less frequently strep. Often develop after lobar pneumonia, in which bacteremia with positive seeding mankelevich pneumococcus is a frequent phenomenon. The presence of bacteremia is significantly worsens the prognosis, but not said yet about the presence of sepsis, emerging only when obrzovanie metastases, in which outbreaks of pneumococcus, the Beginning of sepsis often follows the crisis of pneumonia. The propensity to metastasis and development of endocarditis, damaging the valves and the right and left halves of the heart, puts pneumococcal sepsis in the category of very serious diseases. The forecast becomes hopeless when meningeal phenomena. The disease occurs at high temperature. On the skin very often herpes in major joints and the rear stop of erythematous WASAPI.
Coli-septicaemia. The starting point is relatively rarely, the bowel, often the gallbladder and biliary tract, urinary tract, and is very seldom the uterus. The accession number of sepsis to the underlying disease (cholecystitis, cholangitis, Pelit, cystitis, etc.,) there is a terrific fever, rapid pulse. Fever comes on intermittently, the type with the evening rises up to 40 ° , each time with a spectacular chills. The daily UPS - curve-type "harmonics". The sepsis is relatively benign, but long. Metastases are rare. Often herpes labialis.
Staphylococcal sepsis. The most common organism is Staphylococcus aureus (St. aureus), rarely white (St. albus) or lemon (St. citreus). Pathogens may be only staphylococci with hemolytic properties. The presence of hemolysins, leukocidin and endotoxin is most important properties of pathogenic staphylococci, are meaningful to the Clinician. The primary foci are often very miserable: panaritium, extruded acne, boils, especially around the mouth, the slivers. Skin lesions are the most frequent. Mucous membranes, especially of the urinary tract (catheterization), female genital organs (puerperal uterus), and less tonsils form the second group. The third group of bone injuries and osteomyelitis. Staphylococcal sepsis belong to the most severe. They are usually the type of pyemia with multiple purulent metastases, most often in the lungs, kidney, parametrium, in the subcutaneous tissue. Endocarditis develops more often than with streptococcal sepsis, affecting mostly bivalves and less aortic and tricuspid valves. The temperature is more constant type, but with the advent of endocarditis acquires remitting nature. On the skin of various WASAPI erythema, hemorrhage, embolism and small pustules.
Less common gonococcal and meningococcal sepsis. During their lot in common, if you understand meningococcal sepsis is a common disease with presence of meningococci in the blood, but without meningitis. In both forms the frequent destruction of the joints, mainly the mono -, polymorphous rash on the skin. Heart damage is relatively rare, but usually endocarditis coincides with pericarditis. Temperature gonococcal sepsis continuous or remittent, when meningococcemia - malariaproblem attacks.
Recognition of sepsis represents a significant challenge. In addition to the clinical symptom complex, important blood count with leukocyte formula, the study punctate bone marrow from the sternum, the seeding of the primary tumor and blood cultures. In acute period with a constant temperature possible confusion:
1) with typhoid fever,
2) with typhus,
3) with brucellosis.
When chronostasis possible confusion with tuberculosis and malaria. In recognition of used x-ray examination, clinical and bacteriological examination of blood.
Prevention of sepsis should especially be widely applied to wounds and childbirth. When fresh wounds, depending on their nature, apply streptocid or protivomigrenoznae serum. When older wounds with suppuration - piopi, penicillin. The frequency of sepsis dental origin requires very careful attention to the patients teeth, periodic rehabilitation of the oral cavity and critical attitude to dental crowns (not ience, after x-ray). With frequent angina should be a reasonable hardening of the body, strengthening exercises for chronic tonsillitis - tonsillotomy.
Most important to find and eliminate the primary focus is often surgery (removal of the tonsils, the operation of mastoiditis with removing the clot from the sinus, treatment of the wound, sometimes the ligation of the efferent veins). The primary method of treatment is penicillinate 4 hours at 75 000 - 100 000 units, while sulfanilamidnaya (4,0 -6,0 day in equal portions over 4 hours), pneumatic, fees and meningococcal sepsis, sulfa drugs under the scheme. Calcium chloride intravenous is used to activate the reticulo-endothelial system (10 - 20 ml of 10% solution). Intravenous infusion of glucose (40% - 10 - 20 ml) with ascorbic acid, 40% solution of urotropine 5 - 10 ml Subcutaneous century of Lebanon 5 % glucose solution in large quantities. Blood transfusion: start early, dose from 50 to 100 ml, the intervals of 3 to 4 days. Autohemotherapy (3 - 5 ml). If possible, use of penicillin, sulfa drugs and blood transfusions, many methods have lost their value, but they still should not be overlooked. In the presence of endocarditis should be considered contraindicated all intravenous purpose and methods aggravating actions. Symptomatic treatment, warm, dry banks. If necessary, long-term penicillin therapy that can lead to dysfunction of the myocardium due to changes in currents of redox processes in it, it is recommended to appoint a thiamin and Riboflavin (vitamin b complex). To reduce acidosis - 10 - 15 units of insulin daily. The most significant value in therapy has increased resistance of the body through proper nutrition and elaborate regime of the patient. Food should be easily digestible and rich in vitamins (see typhoid fever, dietetics). It is necessary to strengthen digestive ability by giving natural gastric juice (after eating), Pancreatin; drink plenty of water, drip enema (from 10% glucose solution). Large amounts of vitamin a and C.