Typhoid fever

Typhoid fever - refers to acute severe infectious diseases. The main link of the lesion is the lymphatic apparatus of the small intestine. Disease epidemiologists are called ubiquitous. This means that it is distributed in all natural areas and territories.

Despite the sufficient study of the pathogen and methods to combat it, there are still outstanding problems. They are dictated by the need to monitor the environment, water supply and sanitation. Untimely removal of impurities promotes the spread of a typhus.

Prevalence and current problems of

In the 19th and early 20th century, the incidence of typhoid fever was epidemic. It was especially high in cities where population density is high, and sanitary measures are always inadequate.

The disease "mowed" people during natural disasters, crop failures, hunger, wars. In recent years, the prevalence of typhoid fever has decreased 25 times. The use of antibiotics in therapy has significantly reduced the severity of clinical course and complications.

However, single cases of typhus or outbreaks of infection are reported in all countries. It is found 0.5-0.6 per 100 thousand of the population mainly in the southern countries of Europe and Russia, 30-70 cases in the countries of Asia and Africa.

Additional problems are caused by:

• increasing the proportion of patients with erased and atypical forms of typhus, which makes diagnosis difficult and contributes to the delay of anti-epidemic measures in the outbreaks;
• by changing the main source of the pathogen, now typhoid is spread not by patients, but by chronicles-bacterial carriers, whose treatment is not effective enough.

What is known from history?

Who will suggest the term "typhus"( meaning "smoke, fog") is unknown, since it was used even in the time of Hippocrates to describe the lesions of the brain and nervous system. In Russia they used the term "fever".

In a separate disease as an infectious disease, typhus was isolated only in the middle of the XIX century after the description by the French doctor Bretonneau( Pierre Fidel Bretoniou) of characteristic pathological-anatomical changes in the intestine.

The doctors began to use the name "typhoid fever" after 1829.In 1874, the pathogen was isolated Bronich in Krakow, in 1876 NI Sokolov in Petersburg, in 1880, Ebert in Germany. It is the German researcher who has the most complete description of the microorganism from the sections of the spleen and lymph nodes of the intestines of deceased patients.

Then the continued study of typhus allowed AI.Vilchuru in 2 years to allocate a blood culture, and G.Gaffky and EI.Bazhenov in 1884-1885 to represent the causative agent in the pure state. Paratyphs have been named very similar microorganisms, isolated from urine and pus, described by the French Aschar and Bonzod in 10 years.

Russian medical scientists S.P.Botkin, G.N.Minh, O.O.Mochutkovsky identified differences in typhoid with swelling and recurrent. The founders of laboratory diagnostics are Gruber and Vidal, who in 1896 proposed a technique for agglutination reaction.

Pathogen and its properties

Pathogens of typhoparathyphoid diseases belong to enterobacteria of the genus Salmonella. The Latin name is Salmonella typhi. Paratyphes A and B( B in Russian spelling not used by clinicians) are respectively named salmonella or bacteria of paratyphoid A and B.

The smear is well stained with aniline dyes, the rods are gram-negative, have rounded ends

They are equipped with flagella, so they are mobile. Do not form a dispute and capsules. Life requires oxygen( aerobes).Well grown in the laboratory on nutrient media with bile at a body temperature( 37 degrees) and in a slightly alkaline environment.

The microbiological method in typhus bacteria is characterized by 3 types of antigenic structures:

• somatic antigen-O - is resistant to high temperatures, withstands boiling for 5 hours;
• flagellum antigen-H - refers to the thermolabile.
• surface somatic antigen-Vi - thermolabile.

Bacteria form endotoxin. They have high stability in the external environment, they are preserved:

• in standing water bodies - 30 or more days;
• in garbage dumps - over 30 days;
• in the ice - 60 days.

Particular importance is given to the properties to preserve activity in food products:

• in bread - up to two months;
• in meat, butter, cheese - up to three months;
• on vegetables and fruits - up to 10 days.

What is the route of infection to a person?

By typhoid fever and paratyphoid A only people are sick, and paratyphoid B is common among some birds and animals. The most important source of infection is a sick person and a carrier.

In a patient, pathogenic microorganisms are excreted in the urine, feces, saliva. It becomes contagious at the end of the incubation period, the maximum period of infectiousness is the clinical height of the symptomatology. To spread the infection, urine is more dangerous than feces.

Bacteria live in flowing waters for up to 10 days

Bacteric carriers

Carrier carriers are formed in patients who have recovered, but not treated patients( convalescents) or in practically healthy contact persons. It can last for a duration of three months( acute), over this period is considered chronic. Among contact people bacteriocarrier is temporary. They are transient causes of typhoid fever.

The degree of danger of bacterial carriers is determined by:

• their work, communication with others;
• living and living conditions;
• compliance with personal hygiene requirements.

Special emphasis is given to typhoid carriers that have access to cooking, food packaging. Therefore, "Sanitary rules" of the kitchens require a quarterly inspection of all employees with a note in the san book. The same applies to monitoring contact persons.

Routes of infection

The main one is fecal-oral, microbes are first allocated with feces, then through dirty hands get into the mouth. Salmonella typhus comes to a person:

• with drinking contaminated water, or from unwashed dishes;
• with eating dirty hands or contaminated food;
• at contact with the patient at home( when touching the patient during care, through dishes, linens, door handles in the room and toilet).

Flies can become a carrier of typhus. Outbreaks of the disease are most often in the summer and early autumn, when a breach of precaution is exacerbated, and the air temperature in the middle latitudes is still quite warm. In persons who have experienced typhoid fever, life-long immunity is formed. Cases of recurrent disease are not described.

By the current of the lymph, the bacteria reach the mesenteric lymph nodes, then they are implanted in the retroperitoneal nodes with subsequent violations of

. How do typhoid bacteria behave after introduction into the body?

After entering the typhoid pathogen in the mouth, overcoming the acidity of the gastric juice and the effects of pepsin( physiological barriers), salmonella reaches the small intestine. Further changes are divided into phases.

From the first to the third week - the introduction and lymphatic drift. It corresponds to the beginning of the incubation period.

From the intestine, some of the typhoid bacteria is excreted with feces( bacteriostatic incubation period), the other - penetrates into the lymphatic structures of the small intestine wall.

The end of the incubation period is characterized by the development of inflammation of the lymphatic ducts and vessels. This is due to the special selective sensitivity of lymphoid tissue to typhoid antigens. In the nodes there is an increased multiplication and accumulation of a typhus.

From the first week of illness, the phase of bacteremia begins. It means the end of the incubation and the release of bacteria into the blood, which is accompanied by the first symptoms of typhoid fever. The barrier function of the lymph nodes is broken and the bacteria first enter the lymphatic duct, then pass into the bloodstream.

The phase of intoxication is associated with the counteraction of immune blood cells, the destruction of a portion of microorganisms and the release of endotoxin. It manifests itself in a classic typhoid state with a violation of the central and autonomic nervous system, cardiovascular changes.

The phase of parenchymal dissemination of microorganisms occurs at the height of the disease( 2-3 weeks).Typhoid salmonella settle in various organs, especially in lymph nodes, spleen, bone marrow, liver. Abdominal typhoid granulomas are formed. Characteristic of the appearance of changes in the vessels of the skin in the form of exanthema( rose-oleic rash).

The phase of secretion of typhoid bacteria from the body is ensured by the ability of the liver to discharge microorganisms into bile, then into the intestine.25% is excreted in the urine. A small part is removed with sweat, the patient's saliva. Nursing mothers have breast milk.

Phase of allergic reactions - in the lumen of the intestine appears a lot of typhoid salmonella, arrived with bile, from the tubular depressions between the epithelial cells( Liberecum glands).Unidentified bacteria are reintroduced into plaques and follicles, which are already sensitized, so a new intake of a pronounced allergic reaction with ulcers and necrosis of the intestinal wall is met.

The formation of immunity against typhus occurs with an increase in the production of antibodies, an increase in the activity of macrophages. Purification of ulcers from necrotic tissues, restoration of impaired functions occurs.

What anatomical damage causes typhoid fever?

In typhoid, the main anatomical changes are located in the lymphatic system of the ileum, in the area of ​​the connection with the blind. All pathological disorders are divided into 5 stages:

• "cerebral swelling" ( 1 week of illness) - enlarge and swell plaques and follicles, protrude into the intestinal lumen;
• necrosis ( 2 weeks) - a gray and greenish coating of necrotic tissue appears on the plaques;
• ulceration of ( end 2, beginning of 3 weeks) - ulcers are formed in the wall of the ileum;
• of clean ulcers ( end 3, beginning 4 weeks) - after rejection of necrotic masses, the surface of ulcers is cleared;
• healing ( 5-6 weeks) - with a successful course of typhus, scarring and healing occurs, pigmentation remains in the areas of ulcers.

Spread on the tracheobronchial, parotracheal and mediastinal lymph nodes

. In the spleen and bone marrow, hemorrhages, small areas of necrosis, specific granulomas are found. In the liver tissue appears protein and fatty degeneration. The substance of the brain swells due to swelling, the vessels are dilated, nodules are formed in small arteries.

Possible degenerative changes in the autonomic nervous system, sympathetic nodes, solar plexus. The heart and blood vessels affect typhoid endotoxin due to its ability to disrupt the regulation process in the brain nuclei. The myocardium undergoes degenerative changes.

Classification of

Among infectious diseases, the classification of forms of typhoid is accepted, authored by B.Ya. Padalka. She suggests isolating clinical forms of typhoid:

• in a typical course - mild, moderate and severe;
• with atypical - abortive, erased( including "outpatient" typhus), undiagnosed( without temperature or with subfebrile condition), disguised.

By type of typhoid "mask" are possible: pneumothyphus( affects the lungs), meningotyphus( develops in the meningeal membranes of the brain), colitis( major disorders in the large intestine), nephrotiph( kidney pathology), typhoid septicemia.

How does the classical form of typhus go?

Symptoms of typhoid fever occur after an incubation period of 7 to 14 days, rarely up to 23. This depends on the amount of contagious material the patient has received from individual immunity.

Typhus has a pronounced cyclicity and is divided into periods:

• of the initial( increasing phenomena);
• full development of the disease;
• the highest voltage pathological processes;
• weakening manifestations;
• recovery( convalescence).

The disease begins gradually( in rare cases, acutely) with malaise, cognition, headache, loss of appetite. Then insomnia is added, the headache increases, the temperature rises( by the fourth day, up to 39-40 degrees).

In a patient with typhoid, tongue is lined, the abdomen is palpated, the edge of the enlarged spleen is palpated, there is a decrease in the pulse( bradycardia).In the blood test, leukocytosis passes into leukopenia with relative lymphocytosis, loss of eosinophils.

Typhoid status occurs on the 5th-7th day. Patients do not move, the mental state is represented by delirium, hallucinations, disturbed consciousness. Against this background, a high temperature holds. Perhaps convulsive twitching of the muscles of the face, finger movements, involuntary urination, defecation.

Patients with painful headache, insomnia

Pale, puffy, cracked lips, loss of facial expression are noticeable on the face. On the tip and edges of the tongue the raid disappears, they have a bright red color. The heavier the condition, the more pronounced the dryness of the tongue, the plaque becomes brown, the imprint of the teeth, the thickening of the tongue, and trembling.

Zev red, enlarged tonsils( typhoid angina).Defecation is delayed. Myocardial intoxication is manifested by hypotension, a rare pulse. The severe condition lasts 3 weeks. Then gradually the temperature drops, the tongue is cleared, the appetite appears, the size of the liver and spleen diminishes.

Consciousness becomes clear, sleep is restored. For a long time, there is weakness and irritability. In this period, instead of recovering, a relapse of the disease is possible( in 3-10% of patients), complications appear.

What are the complications of typhoid fever?

Complications are subdivided:

• into specific, depending on the effects of the pathogen and typhoid toxin;
• nonspecific, caused by a concomitant microflora.

The first include:

• intestinal bleeding;
• perforation of the intestinal wall;
• is an infectious-toxic shock.

On the eighth day on the abdomen, the chest appears roseose rash in the form of small pink spots disappearing when pressed, the number of elements is small

. The second type includes various inflammatory diseases against the backdrop of a sharp suppression of immunity( pneumonia, pyelonephritis, meningitis, parotitis, stomatitis).The most noteworthy are specific complications. They can occur from the second week of illness and later.

Intestinal bleeding - is caused by vascular lesions during ulceration and rejection of necrotic masses. The patient pales, the console becomes more frequent, the arterial pressure decreases, the tarry liquid stool appears on the second day.

Wall perforation occurs after the formation of ulcers. This pathology was found in 30% of those who died from typhus."Signal" is pain in the abdomen during the height of the swell. In typhoid, there are no "dagger" pain, so attention should be drawn even to weak ones.

Signs of typhoid fever do not exclude the tension of the abdominal muscles. Should be determined by local sensitivity, increased muscle protection, listen to intestinal noises, monitor the participation of the abdominal wall in breathing. Emergency care for bleeding and perforation of the intestinal wall consists in urgent surgery for vital signs.

How is the diagnosis carried out?

Laboratory methods provide early and reliable diagnosis of typhoid. The blood test for haemoculture is performed at any period of the disease against a background of high temperature. Sowing 10 ml of venous blood is done on the bile broth, Rappoport medium.

Usually, the intravenous system, from where the blood is taken, is placed immediately upon admission of the patient. Inoculate the cups directly at the patient's bedside. An initial analysis is important before using antibiotics. If the first analysis showed a negative result, then it is more convenient to use the reaction of increasing the phage titer and the method of immunofluorescence.

Serological studies include the indirect hemagglutination reaction( RNGA), which replaces the Vidal method. If Vidal's method reveals the specific agglutinins accumulated in the patient's blood on the O and H antigens, then the RNGA with erythrocyte diagnosticums makes it possible to detect Vi-antigenic structures.

In addition, Vidal's reaction gives a positive result in other salmonellosis. In the diagnosis of typhus, it is important to increase the titer of antibodies in a re-examination. Sometimes a passive agglutination reaction is prescribed to detect antibodies with known antigens.

Patient with suspicion of typhoid is to be hospitalized and treated in a separate box of the infectious disease unit, the staff is trained in protective measures and uses them when taking care of the patient,

treatment procedures. Serological tests give positive results on the 4-5th day of the disease. It is important to consider how much analysis is done. Bacteriological cultures of feces, intestinal contents from the probe, urine are ready in the final version after 4 days( the preliminary answer will be given by the laboratory in 2 days).

The reaction of immunofluorescence with labeled sera allows you to know the preliminary result within an hour, the final - in 5-20 hours. When the RNGA is performed, the response is received after 18-20 hours.

Typhoid treatment

Typhoid patients need bed rest for the entire period of elevated temperature and a week after normalization. Important importance is attached to the organization of care, with a daily toilet of the oral cavity, wiping the skin with camphor alcohol.

Clinical recommendations for the therapy of typhoid fever start with the organization of the patient's nutrition. The diet should compensate for the loss of energy reserves of the patient at high temperature, contain enough nutrients, protein to restore the intestinal wall, at least 3500 kcal per day for adult patients.

Nutrition in typhus is carried out in small portions, but often. The dishes are semi-liquid, cooked. Products that negatively affect the liver and require prolonged digestion, which cause increased gas production, are excluded. Prepare special jelly from berries and fruits. It is necessary to drink a lot.

Typhoid is treated with antibiotics and anti-inflammatory drugs, to which the typhoparathyphoid flora is sensitive. Accepted schemes take into account the tolerability of tablets, resistance to antibiotics. Successfully used Levomycetin, a combination of Levomycetin and Tetracycline, Ampicillin intramuscularly.

The drug is prescribed until the tenth day of normal temperature

If complications caused by another flora occur, antibiotics of a wide range of action of the latest generation are used. The combination includes furazolidone, Biseptol. To increase the immune defense against the typhus, simultaneously with antibiotics, vaccination with a typhoid vaccine with Vi-antigen is carried out. In severe course, steroid hormones are prescribed.

The patient is discharged from the hospital after confirmation of clinical recovery, no earlier than 21 days from the normalization of temperature. In the recovery period, patients need multivitamins, expansion of diet, restorative massage.

The observation period for the sick is established individually. To confirm the absence of carrier, he drops the urine and the urine three times on the tank.analysis( at intervals of 5 days).The solution of the problem of detection and timely treatment of bacterial carriers will help to destroy the natural foci of typhus.