INFECTIOUS DISEASES : SCARLET FEVER (SCARLATINA) - etiology, pathogenesis, symptoms and course of, recognition, prediction and prevention
Etiology. The causative agent of scarlet fever is hemolytic streptococci that produce exotoxin composed of two main fractions: thermolabile (the toxin) and thermostable (allergen). Hemolytic streptococci are divided into seven groups, of which group a pathogenic for humans; this group includes a large number (46) serological types. From scarlatina patients in different places and at different times there are different dominant at this time of serological types. Pathogenic significance of certain types in relation to scarlet fever has not been studied. Thermolabile fraction of toxin introduced in small quantities (skin dose) in human skin, susceptible to scarlet fever or ill, in the first three days of illness causes a specific skin reaction (reaction dick), disappearing as the acquisition of immunity natural or artificial means. Skin reaction with thermostable fraction is typically negative in the first days of the disease and becomes positive in the next few days. Immunization thermolabile fraction leads to the production of antitoxic immunity. The introduction of significant amounts of this fraction is sensitive to the subject causes the clinical effects similar to scarlet fever (exanthema, General intoxication). The founders of the theory of streptococcal etiology of scarlet fever were G. N. The g.n.gabrichevsky and I. G. Savchenko. The viral theory, which had earlier many supporters, have not received confirmation.
Epidemiology. Scarlet fever occurs mainly in the cities and spread easily along the routes. Reservoirs of the virus are the only people who are suffering from scarlet fever. It is essential the presence of difficult recognized erased forms of scarlet fever and uncertain duration of infectious period of reconvalescence. Early detected and isolated scarlet fever usually does not give infections not only in the hospital (measles, diphtheria Department), but even at home in close contact. Very important are the patients who have pathological effects on the tonsils, nose and the nasopharynx; they should be compared to the active bazillionaires. The causative agent of scarlet fever belongs to very resistant microorganisms that retains its virulence outside of the human body. The allocation of infection occurs mainly by droplets; peeling itself is not contagious; flakes peeling infectiosn only insofar as they are infected by the same droplets. The most contagious scales with hands covering his hand when sneezing and coughing). Like the scales are infected by the settling of tiny droplets of different things and people that were in contact with the patient. Thus, the transmission can sovershitsya both through direct and indirect contact (contaminated utensils, dishes, third parties). Outdoors infection is possible only through close contact (kissing, shaking hands). Transmission via foods (milk, ice cream) is possible, but relatively rare. Susceptibility to scarlet fever detected by means of the reaction of dick. The most susceptible children, starting from the second half of life, and boys up to 20 years (about 60%); aged 20 - 40 years susceptibility decreases to 23 - 25%and after 40 years becomes negligible. The incidence depends on the combination of susceptibility with contacts.
The pathogenesis. The causative agent of scarlet fever is introduced through the cervical lymph ring and only rarely through damaged skin (surgical, burn scarlet fever). Initial reaction to the place of introduction is manifested in the form naturalnego adenoid inflammation of all formations pharyngeal ring (angina) and responses by regional lymph nodes (lymphadenitis). The clinical picture of scarlet fever depends on three main factors: intoxication, the direct impact of Streptococcus and allergic reactions. Intoxication covers the first period of the disease. Acting directly on the Central nervous system, the toxin causes hyperaemia of the brain and meninges and serous soaking cortex (fever of Central origin, tachycardia, vomiting, dimming of consciousness, convulsions). Scarlatina rash also applies to the toxic manifestations (extinguished when intradermal 0.1 ml of serum of convalescents). It covers all the skin and consists of small papular elements (roughness, "sharepost" skin), relevant dermal papilla, which are concentrated pathological changes - serous soaking cell infiltration. The rash elements are located on damaged skin, irritation which gives, almost as a rule, persistent white dermographism. The faster intoxication, the stronger jeltushnosti leather-dependent hemolytic action of the toxin. The superficial layers of the epidermis undergo so strong changes that begin to clusivity large reservoirs (scarlatina peeling). This change is also occurring on the mucous membrane of the soft palate (anathema in the form of very small hemorrhages), and on the tongue, where hyperplasia of papillae is especially clear after desquamation of the epithelium. The capillary porosity increases with any form of scarlet fever (positive endothelial symptom and symptom pinch), but in difficult cases come extensive destructive changes of the capillaries with the formation of multiple hemorrhages. The primary toxic nephritis occurs, depending on the degree of intoxication, or with lesions of interstitial tissue, or hemorrhagic type and ends with the termination of the direct action of the toxin on the kidney.
The severity of the initial intoxication is of varying degrees, from barely perceptible to a physician to lightning deaths. The action of Streptococcus typically starts with a 3-day illness, i.e., overlapped not ended yet the period of intoxication (6 days). Angina changes: you receive fibrinous inflammation with a tendency to necrosis, and the process captures not only the lateral amygdala, but all adenoid education (lingual, palatal and paired - the outer openings of the Eustachian tubes).
The spread of the infection is per continuitatem and lymphatic routes; in the first case captures the nasopharynx, throat, esophagus, through the Eustachian tubes affected the cavity of the middle ear, mastoid; possible development of basal meningitis. Through the lymph system infection penetrates into the submandibular, salustia and cervical cancer and goes on cervical tissue (angina Ludovici). Inflammatory exudate everywhere rich in fibrin and cellular elements, as a consequence, the characteristic scarlet fever necrotic and purulent processes. This massive primary tumor site created very favorable conditions (mainly the brain) for the development of acute streptococcal sepsis (see Sepsis). Thus, there is a very complex and diverse picture of the disease, depending, on the one hand, from the action of the toxin and Streptococcus, on the other - from the reactive abilities of the body. Duration streptococcal period different with different epidemics and, in addition, subject to significant fluctuations in individual persons.
Study on the identification of serological types of hemolytic Streptococcus in patients with streptococcal complications proved that very often these complications appear in connection with re (nosocomial) infection other serological type of Streptococcus that is different from the selected at admission of the patient. In the acute period may cause sensitization of the organism of bacterial proteins and cellular debris, and some of these products circulate in the blood, the part retained in the tissues. Organisms with intense enzymatic activity so quickly destroy enters the bloodstream of a foreign protein that antibodies, which you want to generate long term (8 to 12 days), do not have time to form and sensitization does not occur. On the contrary, when the slow development of defensive enzymes sensitization occurs.
Symptoms. Acute onset with rapid rise in temperature, often vomiting, single or multiple, increased heart rate to 140 to 150 beats per minute, white furred tongue, aspiring to be cleansed from the 3rd day of the disease and finally purified by the 6th day (raspberry with hyperplasia of papillae - "cat's tongue"). The most important symptom - scarlatina angina: intense, sharply cut and redness of tonsils, bows and soft palate with small cell lung anandamoy at the base of the tongue. Lymphadenitis bilateral, but with larger dense and painful glands on one side. Rash covering the whole body, consists of small, raised above the skin of the elements located on the background of the General hyperemia; condensed in the field of axillary pits, groin and elbow bends. Vasospasm in the nasolabial triangle; the frequency and persistence of white dermographism and often varying degrees of getosname skin. Small dot hemorrhages are skin folds, leaving long streaks of pigmentation: when the infringement of the skin and the tourniquet PA shoulder are hemorrhage. Peeling starts with small circular defects of the epidermis, the corresponding elements of the rash; these defects grow, connect, and the epidermis can't exfoliate in large reservoirs that are most pronounced on the hands and feet.
For. The incubation period of scarlet fever - from days to 12 days, usually 3 to 6 days. The severity of clinical disease depends not only on the strength of infectious beginning, but on the body's ability to resist intoxication and infection. In the presence of antitoxic immunity, albeit incomplete, the initial period may be extremely easy, but the same patient may be totally incapable of dealing with Streptococcus and die from septic scarlet fever; on the contrary, after severe intoxication effects may not follow any signs of action Streptococcus. Thus, in the basis of scarlet fever can be divided into toxic, which is a fulminant form, infectious, as the highest manifestation of which is sepsis. Most often, there is a mixed form.
The so-called "vulgar scarlet fever", which are the effects and intoxication and streptococcal infections, proceeds at a fairly severe reaction on the part of the body (reactive form). Onset is sudden, the temperature rises sharply, pain when swallowing, the tongue coated white bloom, single or repeated vomiting. Fauces typical angina, lymphadenitis. The rash appears on the 1st or 2nd day. Pulse Ochsen to 140 - 150. General condition: it may be a delusion (or attempt to leave). The more often vomiting, higher temperature, more oppressed consciousness, the less clearly supports the rash and the more it hemorrhages, the more intense yellowness of the skin, the more pronounced intoxication and the worse the prognosis. The duration of the initial intoxication of about 6 days (when serum treatment is shorter). Then the temperature falls critically or two ledges, the rash fades, disappears in the shed intense redness, but still noticeable redness and enlarged tonsils. The heart rate slows down to 90 - 100. In the future you may not see any complications, but it is not more than 20 - 25%.
Immunoreactive form of scarlet fever (erased) differs slightly bent main symptoms or loss of some of them. Naturalna angina with a little discomfort and a small temperature increase often exhausts all the symptoms of the disease. The rash may be ephemeral in nature, quickly disappear, grouped only in some places. Complications or nothing happens, or suddenly appears jade, forcing the physician to recall postponed three weeks before easy angina, on the specific features of which (sharp restriction redness of tonsils, bows and soft palate) was not addressed in a timely manner of attention, May also appear flaky or any of the complications (otitis media, lymphadenitis, and others). This form is of great epidemiological significance: its recognition and although difficult, but very important in the initial period and retrospectively in search of the source mass diseases in one hearth.
Extraboline (trauma, burns) scarlet fever occurs due to atypical unusual for her gate infection. Incubation was shortened to 1 to 2 days. The first symptoms of wound inflammation, sometimes fibrinous plaque. The rash appears around the frame and extends to the trunk. Angina and enanthema appear on the 3 - 4th day. Over easy. Little infection to others.
Areactive forms: Toxic (gipertoksicheskaya) occurs extremely rapidly from the first hours of the disease. Symptoms of intoxication: hyperpyrexia, multiple or uncontrollable vomiting, loss of consciousness, delirium, convulsions. Rash matte shades, cyanotic, paler than usual, or with the crimson hue: the abundance of hemorrhages. The skin is severely icteric. Mucous membranes are dry, sore throat sharply expressed. Pulse frequent, weak filling, or filiform. There are parenchymatous, atlanticheskoi and lightning form. The first one lasts 2 to 3 days, the second one takes place with a predominance of lesions of the Central nervous system (convulsions), and ends in death in 24 to 36 hours, and the last kills patients within a few hours.
Septic form. Regardless of the degree of intoxication since the end of the 1st day or 2nd day of angina takes fibrinous nature, strikes quickly spread beyond the tonsils; on 3 - 4th day develop necrosis. Submandibular and cervical cancer very sharply increase, you receive the inflammatory swelling of the fiber and cellulitis of the neck. Nose rich serosanguineous discharge, irritating the nose and the skin of the upper lip. The corners of the mouth and lips also wounded. Rash purple shade with numerous hemorrhages and skin deep. 9 - 10-th day the skin appears septic erythema in the form of large Barbarash spots with numerous hemorrhages on them; the epidermis on them easily peel off, exposing the moist surface. Appear tumors of the large joints, which are relatively rare nagnaivajutsja. Very often appears embolic nephritis, heart attacks, lung, spleen, purulent mediastinic. From this anergicakimi form should distinguish sepsis originating from streptococcal vulgar complications of scarlet fever, which, flowing reactive type, give a much better prediction.
The hallmarks of cardinal symptom is angina, see infectious Angina. You can mix with diseases that occur with a rash or giving peeling: Corü easily distinguishable from scarlet fever by the presence of naturalnych phenomena, symptom Filatov, the stages of the rash. In the presence of polymorphic rash with elements similar to measles (severe form), scarlet fever is set by the nature of angina, skin haemorrhage (rare when measles) and partly by the presence of a large number of hemolytic Streptococcus in the shed.
Scarlatina rubella hardly different from the erased form of scarlet fever to increase the occipital, but not under - and zakluchnnyh glands and lack scarlatinous angina. In zagadnienia cases to use the phenomenon of quench rashes, reactions dick, seeding from the pharynx and further observation (the occurrence of peeling or complications).
Smallpox: a) prodromal rash is localized; redness of the throat lacks sharp boundaries, no adenopathy; with the fall of temperature is the true smallpox exanthema; b) purpura variolosa is falling temperature, the size and color of hemorrhages.
Typhus in rare cases skarlatinopodobnoy rash, especially in the elbow, but it appears on the 5 - 6th day, and there are always roseolous and petechial elements that are not similar to scarlatinous.
Erythema characterized by the absence of marbling, sore throat and lymphadenitis. From medicinal eritem (salicylic, antipilingovaya and others) are most similar to scarlatinal rash of mercury and, in particular, calomel erythema. The difference in the absence of angina with lymphadenitis and gingivitis. Adults need to remember about the possibility of mercury treatment for syphilis (careful anamnesis).
When sepsis (surgical and puerperal) the rash appears later, is not condensed in the armpits and young, and are distributed correctly. When surgical scarlet fever rash around the site of introduction of infection abundant.
Clusively dermatitis Wilson (dermatitis exfoliativa Wilsonii) similar to scarlet fever on the nature of the rash at the beginning of the disease, and language. Differences: the rash appears with hands, when spread over the body takes a blue-purple color, skin edema, angina and lymphadenitis no. Temperature is normal; the plate is peeling and rash, is not circular in nature.
The diagnosis of severe scarlet fever can be easily put, sooner if the patient comes under observation. In doubtful cases, each subsequent day erases the symptoms that existed before. Often it is necessary to restore the symptoms in their tracks. Angina and after their extinction remains limited hyperemia. Lymphadenitis retains its asymmetry and the prevalence increased several glands on each side). The remains of rashes longer stored locally thickening, saved symptoms pinch and harness; in the skin folds are preserved red malogaboritnye or pigmented line. If there manoharachary rash is possible to check the phenomenon of quench (introduction in thickness covered with a skin rash 0.2 - 0.3 ml serum scarlatinous of convalescents or antitoxic calls after 7 to 8 hours sudden blanching rash - white spot on a red background); the same method can be used in the very late days of the disease (serum suspicious of the patient into the skin scarlatinous patient in the blooming stage). Indirect symptoms can be obtained by sowing detachable throat (culture-negative said against scarlet fever). A positive result has value only when very large numbers of Streptococcus determined according to the method of counting colonies. The positive reaction of dick in the first days of the disease, then passing in a negative, speaks for scarlet fever. In some cases it is necessary to isolate suspicious of the patient for long-term observation - up to 23 days (the use of these methods, waiting peeling or complications).
Complications of scarlet fever in its etiology are divided into streptococcal and allergic.
Fibrinous-differencesa angina: with a 3-day illness strikes with a tendency to leaf tissue becoming necrotic (danger of destruction of the walls of a. palatina ascendens and a. tonsillaris fatal bleeding), breath; in the shed, in addition to Streptococcus, found fusospirochetal Association.
Rhinopharyngitis: serous or serous-spotting, irritating the nose and the corners of the mouth.
Purulent lymph adenet: cancer is greatly increased, increasing pain, some glands merge into packets and grow together with covering their tissues (lose mobility), with the superficial fascia and skin, which hyperammonaemia. If in time not to operate, the collapse of the gland, which began with the centrally located necrotic lesion, occurs very quickly. Spontaneous breakthrough pus occurs or through the aperture of the mouth, or under the fascia (dangerous neighborhood neurovascular bundle, the possibility of phlegmon of the neck). Inflammation of the middle ear (otitis media purulenta) observed more often in children due to anatomical features (short and gaping Evstafieva pipe), but the children on the pain does not complain (requires systematic examination of the eardrum). You receive the redness of the eardrum with a protrusion (shortening of the light cone); through it shines at first serous, and then purulent exudate. Without surgical intervention (paracentesis) is perforation. Possible necrosis and sequestration auditory ossicles, the destruction of the bone plate, which separates the cavity of the middle ear cavity from the skull (meningitis), and the transition process at the mastoid. In many cases, otitis diagnosticums the appearance of purulent discharge from the ear, which indicates a bad observation.
Purulent mastoiditis begins with pain in the mastoid, especially when tapped; the ear on the affected side is bulged, skin creases are smoothed out, at the tip of the mastoid process increases lymph gland; the skin covering the bone, pasty. In case of delayed surgical intervention leather hyperammonaemia, swells, formed subperiosteally abscess. Dangerous possibility of septic thrombosis of the venous sinus.
All these complications are local in nature, but can turn into sepsis. All they are accompanied by a thermal reaction. The time of their occurrence is usually limited to 15 - 16th day, but in some cases they can appear very late in the 30 - to 35-day and even later (feature separate epidemics). Between the 17th and the 23rd day of may appear allergic complications, wearing not so much local as General in nature as it affects the whole system.
Serial lymphadenitis occurs more often other complications. The preferential localization of the upper part of the neck, but often increase abdominal cancer, mediastinal, tracheobronchial, portal, etc. With increasing mediastinal glands appears dullness in the field arm of the sternum and scraping the compression noise at the base of the heart. The increase in the tracheobronchial glands was detected by dulling in the interscapular space on both sides of the spine and strengthening bronchophony through the spinous processes of the third to the fifth thoracic vertebrae. With the increase of portal glands develops ascites due to pressure enlarged glands on v. portae at her entrance into the liver. Lymphadenitis accompanied remitting temperature; the current favorable. Unlike streptococcal they are not nagnaivajutsja. Synovitis captures one or more large joints, which become swollen and very painful. Especially unpleasant for the patient rarely observed synovitis of the intervertebral joints. Duration - 5 to 7 days; go unnoticed.
Erythema (erythema postscarlatinosum) pours strictly symmetrical in major joints, on the extensor sides of the legs and on the buttocks. Erythema accompanied by itching; go unnoticed. Not to be confused with septic scarlatinous erythema (see).
Heart myasthenia gravis (myasthenia cordis) is manifested by a sharp deceleration pulse, increased heart left, arrhythmia, systolic murmur at the apex and the splitting of the second tone. To return the heart to normal enough bed rest.
The greatest attention should be consistent jade, which is in contrast to the primary toxic nephritis serious complication, often giving uremia. Extensive skin lesions characteristic of scarlet fever acidosis tissues delay in the tissues of sodium chloride and polyplasmia create an unfavorable condition for the kidneys. The nature of jade largely depends on the nature of the epidemic and individual characteristics of patients: simpatico more interstitial nephritis in children with exudative diathesis - mainly glomerulonephritis. Serial scarlatinous jade begins with a prodromal phenomena - pallor, and some puffiness of the face (predemo Vidal), increased frequency and hardness of heart rate, decrease in amount of urine, pain complaints. Changes in the urine most often appear suddenly, often in the form of significant albuminuria and often in the form of hematuria and hemoglobinuria. Beginning jade is usually accompanied by a significant rise in temperature and vomiting. Duration jade from 3 to 6 weeks and sometimes several months; after uraemic fit often quickly eliminated. Stand out jade septic flowing-type embolic with the formation of small abscesses and heart attacks.
Isolation of reservoirs of the virus is achieved not only by the isolation of patients, but also the examination of the environment (the erased form, "sore throat" in the environment), the search of the source of infection. Of particular importance it has in groups of children (schools, nurseries, where the appearance of recurrent disease must be carefully examined primarily children who are not attending institutions directly before the time of possible infection, then children in the class or group and adults (teachers, Tutors, nannies and so on). Quarantine on others, not ill with scarlet fever, is applied for daycare settings for 12 days after separation with the patient, for ill with scarlet fever and not ill, but not with the nature of work contact with children, prior to disinfection. Disinfection preferred formalin or wet with sending soft goods on disinfection station. Monitoring focus (inspection nebolisa) carried out on 3rd, 6th and 12th day. The term isolation of patients is 40 days. Reduction of up to 30 days allowed with the permission of epidemiologists against uncomplicated scarlet fever. Nosocomial regime should ensure the prevention of cross-infections of different serological types of Streptococcus. Before discharge, you must not have contact with fresh and complications of scarlet fever within 5 - 7 days. At discharge to instruct parents about the dangers of reconvalescent to others. In children's institutions issued allowed 15 days after the examination. Active immunization is organized among children after examining the reaction of dick. Immunization is carried out scarlatinous toxin. Each is imparted to 5 injections. The intervals between the 1st, 2nd and 3rd injection, and between the 4th and 5th set in 7 to 15 days, between 3rd and 4th in 10 to 15 days. At intervals over the month vaccinations should begin again with the first dose. With strong local and General reactions injected the same dose as in the last vaccination. Revaccination is epidemiological evidence; if a period of less than 2 years after complete vaccination--2 injections: 1-I - 1 skin 000 units, 2-I - 5 000 skin units; if a period of more than 2 years to 3 injections: 1-I - 500 skin units, 2-I - 2 000 and C-I - 6 000 skin units. Intervals of 10 to 15 days. Injections give local and General or toxic reaction. The reaction is celebrated through the night: no reaction - no local or General phenomena; weak reaction redness and infiltration less than 4 x 4 cm, common phenomena are absent; the average reaction - redness and infiltration larger than 4 x 4 and less than 10 x 10 cm with a complete lack of common phenomena; the sharp reaction of redness and infiltration is greater than 10 x 10 see General response is assessed as medium in the presence of malaise and low-grade fever (up to 38º), sharp - at a higher temperature and toxicity - in the presence of vomiting, rash and high fever. Due to the reactivity of vaccination medical screening of persons for vaccination should be agreed with pediatricians: contraindications are the same as for immunization against diphtheria (see Diphtheria. Prevention). Check the effectiveness of vaccination is produced through reaction of dick, and is determined not only immunity, but its intensity (1, C and 10 skin doses). Passive immunization is carried out in children who were in contact with scarlatinous positive reactions dick. It is especially recommended weak TRIPTYKON, lymphaticum and suffering from exudative diathesis. Serum scarlatinous patients (10 ml) or serum adults (60 ml) is injected intramuscularly.