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PSEUDOTUBERCULOSIS

Pseudotuberculosis is an acute infectious disease characterized by the polymorphism of the clinical manifestations, affection of the alimentary tract, locomotor system, liver and other organs, general intoxication, exanthema and frequently prolonged course with relapses.

Historic reference

The French scientists L. Malasser and W. Vignal first reported on the pseudotuberculosis microbe. In 1883 they isolated it from the organs of a guinea pig infected with the suspension of the caseous regenerated lymph node of the child who had died from "tuberculosis" meningitis.

In 1885 C. Eberth introduced the term "pseudotuberculosis" when he observed spontaneous epizootic in the rabbits, it was accompanied by an abrupt emaciation of the animals. At the post-mortem examination of the dead animals the anatomic pathological changes of the timer organs looked like the tuberculosis ones, but it was impossible to discover the tuberculosis pathogen, and the morphological characteristics of the isolated pathogen were identical to the microbe.

In 1889 A.Pfeiffer studied the characteristics of this microbe in detail and gave it the name "Bacterium pseudotuberculosis rodentium", he connected the isolation of this pathogen with a certain clinical picture in animals.

Etiology

The pseudotuberculosis microbe is a polymorph bacillus, which does not form spores and often has an ovoid form. It is Gram-negative, well painted by all aniline dyes. The question of a capsule in the pseudotuberculosis bacteria is still under discussion. The pseudotuberculosis bacteria grows at a temperature of 4-30 Ñ are actively mobile, have flagellum, whose length is 3-5 times bigger than the length of the body of the bacterial cell. At a temperature higher than 30 Ñ the flagellum atrophy and the mobility of the bacteria ceases. The pseudotuberculosis microbe is a facultative anaerobe,it is quite undemanding to the nutrition, and that is why it grows well on the common dense nutrient media, it can grow on the media without peptone. This characteristic of the pathogen was used to distinguish the pseudotuberculosis bacteria from the plague pathogen.

The bacteria contain H-antigen and O-antigen, which determine their variability. The H-antigen is thermolabile and is destroyed at boiling, it is synthesized at a temperature of 2-30 Ñ best of all.

Different biologically active substances, which are necessary to initiate and develop an infectious process, are produced'in the process of the yersinia pathogen

 

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vital activity. Besides this it is established that the yersiniosis pathogen strains of different pathogenicity circulate in the human population.

Epidemiology

Before the 60s of the 19th century the epidemiology of the human yersiniosis was almost unstudied. It is explained by the fact that the disease appeared in the form of sporadic cases. In such situations it was often impossible to discover the pathogen, find the disease source, discover the mechanism of its spreading. The situation changed when the Far East scarlatiniform fever mainly manifested by massive epidemic outbreaks was brought to light in the Far East.



Yersiniosis mainly embraces the urban population as in the cities there are more opportunities for the development of big outbreaks among the contingents of people united by public feeding. On the other hand, a more active revealing and better diagnostics of the disease as compared with the rural area is of a certain importance. Children fall ill the most often as compared with the other age groups of the population. The epidemic outbreaks are quite often observed in the organized collectives, especially, the preschool ones. First of all such outbreaks depend on the conditions of the fruit and vegetables storage as well as the condition of feeding the population.

Animals are a reservoir of the infection under the natural conditions. The pseudotuberculosis microbe was isolated from the organs and excrement of many kinds of the mammals, birds, reptiles, fish and arthropoda. Such a diverse and spontaneous infection of many kinds of animals by the pseudotuberculosis microbe gives a ground to think that none of them are a specific biological host of this pathogen and it testifies that in case its ubicvator spreading in nature all kinds of animals get involved in the general process of the microbe circulation and serve as a short-term or prolonged reservoir of the pathogen depending on the species susceptibility to it.

Rodents are the most frequent reservoir of the pseudotuberculosis microbe. It is explained by the fact that on the one hand, rodents are distinguished by a high susceptibility and sensitivity to the pseudotuberculosis microbe and on the other hand, they are considerably widespread on the Earth and the speed ^r their replication is high.

The infection of humans can occur at a direct contact with domestic and wild animals, birds while skinning them and processing the carcasses. A possible mechanism of the infection of humans is using the food and water contaminated

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by the discharge of rodents and birds - carriers of the pseudotuberculosis microbe. Besides this there is a number of convincing investigations confirming that soil is a reservoir of the pseudotuberculosis pathogens. The authors think that the pseudotuberculosis microbe cannot exist in the soil for a long time without reproduction as it cannot form spores. It has saprophytic and parasitic characteristics and correspondingly has two natural biospheres of existing - the

 

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warm-blooded animals and environment. The pseudotuberculosis pathogen was isolated during the bacteriologic investigation of the soil from the fields where vegetables and edible roots, as well as wash-outs from them (beet-roots, carrots, cabbages, onions, potatoes).

The epidemiological examination of many outbreaks of the disease made it possible to ascertain that among all the food staffs vegetables, edible roots, dry food, some dry products, which are eaten without any thermal processing, are of the most importance in the pathogen transmission. The importance of vegetables and edible roots as a factor of the pathogen transmission was proved by the isolation of the pseudotuberculosis microbe from them during the outbreaks, the microbes were identical by their serologic variant to the cultures isolated from the sick people who had eaten that food. Such outbreaks most often occur when dishes from fresh cabbage are used as food at the public feeding places.

Besides vegetables and edible roots, the second important factor in the pseudotuberculosis pathogen transmission is dairy products. Such dairy products as cottage cheese, sour cream are the most important. It is necessary to note that the pasteurization of milk (at a temperature of 65 Ñ for 30 minutes) does not destroy the pathogen.

Water can also be a factor of the pseudotuberculosis microbe transmission under the favorable conditions.

Pathogenesis

The pathogens mainly penetrate the human organism through the mouth with the infected food and water. A further movement of the microbes to the esophagus and then stomach characterizes this phase. The acid medium of the stomach contents ruins most pathogenic microbes of the intestinal group perhaps including the pseudotuberculosis pathogen. Having overcome the stomach barrier, the pathogen gets into the intestines and an enteral phase develops, it is characterized by the penetration of the microbe into the mucous membrane of the intestines, then it goes to the regional mesenteric lymph nodes along the lymph paths. Here they reproduce and accumulate, later overcoming the lymphatic barrier the bacteria penetrate the blood and cause the reciprocal reaction of the organism to the toxic substances, which get into the blood vessels during the destruction and life of bacteria.

In rare cases an airborne way of infection, even marking out a pulmonary form of this infection. The pseudotuberculosis microbe possesses pneumotropism with the development of pneumonia and even lung abscess. As the clinical picture of pneumonia develops in later terms of the disease in experimental pseudotuberculosis, the lungs may be only an entrance gate for the development of the generalized process. Taking into account all the mentioned above facts, there is a ground to suppose that irrespective of the entrance gate pseudotuberculosis immediately takes a course of a generalized infection.

 

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The pathological process can stop at any of its phases. The pathogen of the disease can be blocked by the secretory immunoglobulins even on the mucous membranes of the intestines and respiratory tracts. While overcoming this barrier yersinia pseudotuberculosis penetrate the regional lymph nodes. Different macrophagal elements, immunoglobulins and immunocompetement cells take defensive measures.

The clinical process has periods of remissions and acute conditions. The recovery occurs after any phase. Thus, in human pseudotuberculosis there are two expressed pathogenic stages: 1) the pathogen penetration, primary and regional focal manifestations of the disease; 2) bacteriemia, hematogenic drift and septicemia, which develops, as a rule, after the first period, though sometimes it is not expressed distinctly.

The hematogenic dissemination of the pseudotuberculosis pathogen results in the development of the phase of the secondary focal changes in the organs and tissues. As a rule, this stage is accompanied by an expressed organism allergization.

The following phase of the pseudotuberculosis pathogenesis development is the phase of the specific immunity increase, which is followed by the release of the organism from the pathogen and recovery. Cultivating a strong antimicrobic immunity completes the disease. The possibility of the development of the disease chronic form is very rare.

Anatomic pathology

The pathoanatomists have found small necrotic or abscess-like grayish-white nodes in the enlarged liver and spleen, as well as in the lungs. Many researchers call these abscesses necrotic granulomas. Such granulomas with the central necrosis are considered to be a characteristic symptom of pseudotuberculosis. Besides this, there is swelling and necrosis of the lymph nodes follicles of the intestines and mesentery, hyperemia of the peritoneum covering them, edema and infiltration of the distal part of the iliac and proximal part of the large intestine, catarrhal-desquamative and ulceric enteritis (ileitis), congestion plethora,brain edema,dystrophy of the parenchymatous organs and hemorrhages in them. In some cases there is a picture of catarrhal, phlegmonous and gangrenous appendicitis.

Clinical manifestations

The diversity of the pseudotuberculosis clinical manifestations, the involvement of different organs and systems in the pathologic process are the basis for the suggestions of numerous classifications of this disease. The least cumbersome classification, though it does not lack drawbacks, is the classification by N.U. Zalmower,which is based on the syndrome principle with the following clinical forms:

1. A scarlatiniform characterized by the general intoxication symptoms, fine-dot rash, fever.

 

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2. An arthralgic form resulting in the joints affection, it takes a course of arthralgia, less often - arthritis.

3. An abdominal form with the. primary affection of different parts of the alimentary tract, sometimes in the initial period.

4. A generalized form with the affection of different organs and systems when it is impossible to pick out any main syndrome.

5. An icteric form, in which the affection of the liver with a jaundice syndrome is the primary symptom.

The clinical manifestations of pseudotuberculosis are characterized by a great polymorphism with the prevalence of the general intoxication, which makes an early diagnostics extremely difficult. As well as other acute diseases pseudotuberculosis has a certain cyclic recurrence. The development of the cycle's periods with a certain time limitation, which is accompanied by different morphologic, immunologic and clinical changes, results in a characteristic picture of the disease. There are following periods in pseudotuberculosis: an initial period, a high point, a period of acute courses and relapses, convalescence.

Evaluating the descriptions of the clinic given in the literature and observing the patients, it is necessary to note that in each certain case these periods can be manifested in different ways depending on the reactivity of the macroorganism, virulence of the pathogen,the time when the treatment began,the quantity of the daily and course doses of the medications and other factors. All the periods of the disease can be observed in the typical cases in half the patients (especially, in case of the pathogenic therapy and short courses of some antibiotics). In other cases some of them cannot be observed or they can be slightly manifested. There can be only some symptoms of the initial period without a temperature rise in the deleted forms of the disease.

Judging by the epidemiological history, the incubation period in this infection most often lasts 7-10 days with the fluctuations from 3 to 18 days. In this period the disease does not usually have any clinical manifestations, the people consider themselves to be practically healthy and continue working.

The initial period is the time when the first symptoms of the disease develop till the highest possible development of the clinical picture with the symptoms of the local affection.

In most patients the disease has an acute course with a rapid temperature rise, which is accompanied by chills. The prodromal phenomena in the form of malaise, slight chills, the development of uncertain pains in the abdomen, which developed 1-2 days before the onset of the disease, were described only in some cases.

This period is clinically characterized by expressed polymorphism and absence of specific symptoms typical of only this disease. The temperature rise is accompanied by a headache of different intensity with its primary location in the forehead and temple areas, pain in the muscles, joints, waist, general asthenia, weakness and lack of appetite. In a number of cases the sick people complain of

 

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the pain in the throat at swallowing. In some cases patients complain of pain in the stomach, diarrhea 2-3 times a day, nausea and single or recourse vomiting. There is brief fainting in some patients in the first hours of the disease together with general asthenia. An early toxicosis resulting in a lethal outcome can develop in rare cases, especially, in children during 2-4 days.

While examining the patients it is possible to observe hyperemia of face and neck, some puffiness of the face, hyperemia of the conjunctiva and an injection of the sclera vessels,there is a pale nose-lip triangle in some patients. There is often herpetic rash on the lips and the nose wings,expressed hyperemia of the throat, which is of different intensity, less often - an enanthema on the soft palate, angina. During the first days of the disease the tongue has a grayish-white patch, which begins to clear and becomes raspberry with expressed papilla on the third day.

There are symptoms of acute catarrh of the upper respiratory tract such as a running nose, cough, pains in the throat at swallowing in most patients in the initial period of the disease. Similar symptoms of the disease sometimes result in diagnosing catarrh of the upper respiratory tract and difficulties in deciphering the outbreak.

Such diversity of symptoms testifies about the involvement of different organs and systems in the pathological process even on the first days of pseudotuberculosis infection, which is often the reason for a false diagnostics in this period. The most part of such patients are treated at home, the smaller part is sent to a hospital with the diagnoses: acute respiratory disease, polyarthritis, gastroenteritis, catarrhal angina, scarlatina and others. These diagnoses often remain the final ones as a doctor examines a patient for a second time only in the period of convalescence and does not pay attention to some important symptoms of the disease (rash, "raspberry" tongue, pain in the ileocecal area, etc.)

Rash is one of the most striking symptoms of this period. It develops on the l-4th day of the disease, sometimes on the 5-6th day. According to its character it is often fine-spotted on the hyperemic background or normal skin. During the first outbreak of the disease in some patients it is fine-spotted, and in combination with angina, the enlargement of the submandibular lymph nodes, "raspberry" tongue, the development of peeling typical of scarlatina in the later period gave a ground to first diagnose "scarlatina" in all patients. Later during the development of other pseudotuberculosis outbreaks and the exposure of the sporadic cases of this disease it was found out that the rash can be spotty (looking like German measles and measles) and confluent erythematous. The spreading of the rash can be different, if it is spread all over the body, it is mainly located on the symmetrical parts. The rash is not often found on the face and neck. There is often hyperemia and swelling of the skin on the hands and feet -the symptoms of "gloves" and "socks". The petechial-hemorrhagic elements are mainly localized in the natural folds of the skin and on each side of the chest. The development of hemorrhages in the form of stripes and changes on the side surfaces of the shoulders and in the area of the armpit line. There are endothelial

 

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symptoms of plait, pinch with hemorrhages in the patients with a severe form. The development of rash can be accompanied by the deterioration of the patients' condition, pulse acceleration, hypotonia and even a collapse condition.

There is scaly laminar peeling on the skin of the chest, abdomen, lobes of the ear and then on the dorsal surface of the hands, feet, palms during the 2-3rd week of the disease. The duration of the initial period is 1-5 days.

The highest point of the pseudotuberculosis infection is manifested by the maximum development of fever and other symptoms of intoxication and expressed signs of the local affection. The highest point of the disease, especially, the first days are characterized by considerable intoxication, which is manifested by the affection of the central nervous system - general asthenia, hypotonia, dizziness, intense headache, tactile hyperesthesia, photophobia, vomiting, insomnia, increased excitability or suppression. In a severe course there are manifestations of meningoencephalitis with the symptoms characteristic of it: a headache, nausea, vomiting, drowsiness, suppression, consciousness disorders, signs of irritation of the meninges and the substance of the brain. There are such meningeal symptoms as rigidity of the neck muscles, Kernig and Brudzinsky symptoms, in the cerebrospinal liquid the cytosis is more than 400 cells,the increased protein contents. Besides the mentioned symptoms there are characteristic disorders of the vegetative nervous system function. In some patients the affection of the nervous system is similar to the intercostal and nape neuralgia or lumbosacral radiculitis.

The changes of the locomotor system are observed almost in all patients. There is often arthralgia, sometimes with very intense pain in the sacrum, waist, joints and less often - acute polyarthritis, which is characterized by swelling of the tissues around the joints with skin hyperemia. The radiocarpal, interphalangeal, knee and ankle joints are most often affected in pseudotuberculosis, less often -shoulder and hip joints. Acute polyarthritis is often confused with the attacks of acute rheumatism in case of the poor knowledge of the pseudotuberculosis clinic. The pain syndrome depends on the severity of the disease and can be weak or strong, hindering free movement. The joints are swollen, painful, hot.

Most patients complain of myalgia in the acute period of the disease. It prevails in the muscles of the neck, abdomen, and extremities. In some cases myalgia of the abdomen muscles is sharply expressed, which simulates "acute abdomen". In such cases it is necessary to pay attention even to slight manifestations of other symptoms of the disease.

The submaxillary, neck and axillary lymph nodes can be enlarged in the acute period of the disease. They are slightly painful, elastic, not united with one another and the surrounding tissue.

The changes of the cardiovascular system at the highest point of the disease are manifested by hypotonia, dullness of the heart sounds, and in some patients there is a systolic murmur at the apex and extrasystole. In spite of the fact that in a considerable number of patients the subjective symptoms of the heart affection (pain, heartbeat, arrhythmia, and others) are extremely rare, the

 

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electrocardiograms show changes, some of them are considerable. The decrease of P and T waves voltage is the most frequent of them,less often - the deformation as a result of the toxic-infectious influences on the cardiac muscle. There were sometimes symptoms of its diffusive affection.

The respiratory organs also get involved in the pathological process in pseudotuberculosis. Pain in the throat, hyperemia of the fauces mucous membrane, spotted enanthema on the mucous membrane of the soft palate, rhinitis, cough, dry rale in the lungs testify of their affection. There is dulling of the percussion sound over the pulmonary fields and moist rale in the limited areas in some patients who suffer a severe course of the disease. The x-ray investigations usually demonstrate the intensification of the bronchial-vascular picture, the opacity of the roots, less often - infiltration of the lung tissue.

In a mild case of the disease the affection of the alimentary tract is manifested by complaints of a poor appetite, nausea, less often - vomiting diarrhea. The stool is fluid or watery 3-5 times a day with admixture of mucous. The pain at the abdomen is observed in a half of the patients and is often revealed only at palpation. The tongue is furred, it becomes raspberry when it gets cleaned.

The changes of the alimentary tract are strongly expressed and prevail over the rest ones in a more severe course. In this case a pseudotuberculosis abdominal form is diagnosed. It is characterized with a pain in the epigastric area of the abdomen, umbilical or right iliac area, less often -in the right hypochondrium and left iliac area. The abdominal syndrome is clinically revealed primarily in the form of the symptoms of mesenteric lymphadenitis, terminal ileitis, acute appendicitis. Mesenteric adenitis of the pseudotuberculosis etiology without any other manifestations is quite often observed in the countries of Western Europe. The affection of the mesentery lymph nodes can occur in different periods of the infectious process, more often in the initial period and at the high point of the disease. In this case there is pain in the right iliac and paraumbilical area, the palpation demonstrates an enlarged, painful and "grumbling" cecum and mesenteric lymph nodes. Such patients come to hospital with various diagnoses: "acute appendicitis", "acute cholecystitis". These patients can come to both infectious and surgical hospitals, and only the carefully collected history of the disease and the clinical investigation data allow to diagnose pseudotuberculosis.

The intensity of pain in the ileocecal area can be different. In some patients that is revealed only at palpation, in others there are constant aches, in some patients they are so intense that the patients groan and take a forced position with their knees pulled to the abdomen. The patients cannot remain in the same position for a long time. The pain subsides and ceases troubling the patients on the 2-3th day from the time of their appearance. However^ in 3-4 days they recommence and become more intense.

The local manifestations of mesadenitis are usually accompanied by general symptoms. They are temperature increase, sometimes up to 39 Ñ, chills, which intensify with the development of pain in the abdomen, diarrhea - 2-3 stools a

 

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day without admixture of mucous or blood, nausea, and vomiting in almost half of the patients. Besides the patients complain of headaches, pains in the joints of the upper and lower extremities, body muscles, general asthenia, sore throat.

The skin of the face, neck, chest is often hyperemic in the patients with mesenteric lymphadenitis. In certain cases there is fine-spotted rash, which rise above the skin in the area of the chest, abdomen, groin folds, axillary region, forearms and thighs, the rash gets pale at pressing.

There is muscles tension and other symptoms of the peritoneum irritation, which are very similar to the picture of the "acute abdomen" in case of a severe course of the disease. However, in contrast to acute appendicitis in the mesadenitis patients the pain in the abdomen do not increase when the abdominal press is strained. This new symptom was observed in all the cases of pseudotuberculosis mesadenitis.

The clinic of acute appendicitis in pseudotuberculosis has its peculiarities connected with the fact that besides the affection of the vermicular process the patients have the manifestations of the main disease. As a rule, the patients, in whom the appendicular syndrome develops during treatment in the infectious hospitals or who arrived with the diagnosis "pseudotuberculosis" and have an expressed appendicular syndrome are not operated on, and the disease has a favorable outcome after the conservatory treatment. It is natural that such patients should be carefully observed by both an infectious doctor and a surgeon in order not to miss authentic appendicitis, whose pathogen can be pseudotuberculosis along with other microbes. It is known that the pseudotuberculosis microbe is isolated in about 7 % cases during the bacteriological investigation of the processes ablated during the appendectomy. The surgical aspects of pseudotuberculosis are of a great practical interest and need to be thoroughly studied.

Regional ileitis in the abdominal form of pseudotuberculosis is more often observed in the relapse and remission period of the disease. In this case the pains in the abdomen develop on the background of the seeming convalescence, they are accompanied by a recurring rise of the body temperature up to 38-39 Ñ and chills. The pain is usually moderate, it is of attack-like character. In 2-3 days from pain development it becomes less intensive, in some cases it ceases troubling a patient. However, on the 3-4th day they increase and become very intense.

In some patients pseudotuberculosis begins with the symptoms of regional ileitis. In such cases the pseudotuberculosis symptoms are poorly expressed. This results in the diagnostic mistakes. In case of regional ileitis the pain in the stomach is often accompanied by nausea. In half of the patients there is vomiting, sometimes repeated. The affection of the terminal part of the ileum can be accompanied by watery stool up to 3 times a day without an admixture of mucous and blood. The abdomen is sometimes bloated. The right iliac area is the most painful, there is also muscle tension of the front wall of the abdomen. The similarity of the clinical picture of regional ileitis to that of acute appendicitis is a characteristic feature. In ' many cases it is extremely difficult to diagnose the case before a surgery.

 

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The patients with the pseudotuberculosis abdominal form often have gastroenteritis. Its development can be observed in all periods of the disease. Gastroenteritis usually has a rapid development. The disease starts with pain in the abdomen, nausea, vomiting, it is usually accompanied by the abdomen inflation, watery or pasty stool up to 2-3 times a day, general asthenia, chills, headache and other pseudotuberculosis manifestations. Sometimes gastroenteritis takes a chronic course. In these cases patients complain of the periodic pain in the abdomen, which disturb them, general asthenia, headache, general malaise. The stool in such patients is unstable. There is an expressed asthenia right after the meals. The pains in the abdomen can resemble attacks and do not have a distinct localization. The symptoms of the general intoxication are often expressed.

The affection of the alimentary system is not only limited by the pathologic changes of the gastrointestinal tract. The liver affection of any degree is often observed in almost half of the patients, actually it is acute parenchymatous hepatitis, its expressiveness depends on the severity of the disease. The affection of the liver is manifested by the enlargement of its size, icteric color of the skin and scleras, the bilirubin increase in the blood, it sometimes resembles the clinic of viral hepatitis.

The thorough comparison of the clinical symptoms with the biochemical investigations shows the involvement of the pancreatic gland in the pathologic process. The patients complain of pain in the abdomen, which resembles attacks and is localized in the epigastric area, in the right and left hypochondrium. In some cases it irradiates in waist or back. The patients complain of nausea, vomiting and general asthenia. There can be watery stool. The amylase level of blood and urine as well as the lipase activity in blood can confirm the diagnosis. Some authors pay much attention to elastase. In 1986 V. A. Ivanis noted that the elastase level depended on the severity of the disease and its indexes normalized in the period of convalescence.

The generalized form of the disease is characterized by the combination of a high temperature, exanthema, and severe intoxication with all the main syndromes of the disease: terminal ileitis, parenchymatous hepatitis, acute polyarthritis, meningeal symptoms and a long relapsing character.

Diagnosis

There are no reliable diagnostic tests on pseudotuberculosis among the nonspecific laboratory signs. In particular the blood clinical analysis is not informative. The changes of the morphological blood contents do not take place in all the patients and are of a moderate character.

The specific laboratory diagnostics of pseudotuberculosis is very important in its diagnosing. It is of primary importance in the mild and unexpressed forms of the disease, especially, occurring in the form of separate sporadic cases.

The main material for the bacteriologic investigation is excrement and in lesser degree - washouts from the fauces, urine and the appendicular processes, which are ablated during the surgery. The pseudotuberculosis patients excrete

 

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bacteria with mucous from the fauces, excrement, urine. The duration of their excreting with mucous and urine is not long. The pseudotuberculosis pathogen is found in excrement during all the disease and in the period of relapses. In separate cases it can be excreted with excrement for about 75 days.

The serologic investigations began to be done after the discovery of the Far East scarlatiniform fever. In the beginning the agglutination reaction with alive cultures as an antigen was used, later a reaction of indirect hemagglutination as well as the reaction of the bacterial lysis, method of fluorescent antibodies and others. In spite of the fact that the pseudotuberculosis diagnostics is improving every year, it does not satisfy the practical doctors so far. The percentage of the bacteriologic confirmation of the diagnosis remains low, and the reaction of indirect agglutination, which is used everywhere, is not enough sensitive and specific. The reaction of coagglutination and immune ferment analysis, which make it possible to discover both the antigen and antibodies to it during the first 3-5 days from the disease onset, is considered to be promising.

Differential diagnosis

The variety of pseudotuberculosis clinical manifestations often causes big amount of diagnostic errors. Thus, acute beginning, intoxication, headache, cough, face reddening can be considered as influenza. Fever, intoxication hepatomegaly, lymphadenopathy, sore throat make us think about infectious mononucleosis. In case of catarrhal manifestations, intoxication, characteristic skin eruption measles and rubella should be excluded. The list of diseases to be considered in process of pseudotuberculosis differential diagnostics could be continued. So such main disease characteristics should be taken into account in order to make correct diagnosis: period of disease, its recurrence, polyorganic disorders due to pseudotuberculosis, correct interpretation of laboratory findings. Sometimes only results of bacteriologic research can verify the diagnosis.

Treatment

It is impossible to agree with the recommendations of some author about the possibility of treating the pseudotuberculosis patients at home. In spite of some positive results the possibility of sudden acute forms development and relapses obliges to treat the patients only in hospital and to follow thoroughly the regimen and an according nursing.

The patients do not need a special diet. The nutrition is typical of the patients with an acute fever. The food should be easily assimilating and high-calorie, containing a sufficient amount of vitamins. A daily food allowance should contain 3,200-3,500 kcal. The patients with the predominant liver affection, are prescribed diet ¹ 5 containing a sufficient amount of carbohydrates and a limitation of fat, especially, refractory.

The treatment depends on the clinical form, the period and gravity of disease. Among etiotropic agents there are used levomycetin, metacyclin, tetracyclin,

 

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streptomycin, gentamicin, ampicillin in moderate therapeutic doses during not less than 7 days and more. At severe course of disease, the septic form the best results can be gained if simultaneously use 2-3 antibiotics and one of them infuse into vein: course of treatment prolongs up to 10-14 days, and through 6-7 days it is replaced by preparations with the account of antibioticosensitivity of allocated yersinias. Cefazolin (kefzol), cefotaxim (claforan) are effective as alternative preparation may be bactrim (biseptol). Less effective are nitrofuranes and sulfanilamid preparations.

With the purpose of desintoxication and rehydratation of the organism 5 % solution of a glucose, a seralbum,reopolyglycin,threesault,quartasault are indicated. Widely there are used vitamins, antihistamine preparations and agents stimulating regenerative processes - diprazin, suprastin, tavegil, methyluracil (methacil), pentoxyl, apylac, natrii nucleinic, thymalin etc. At gastroenterocolitic form enterosorbents (activated microspherical coals, sillard P, enterosgel, smecta), replaceable fermental therapy (festal, pancreatin, pancurmen, pancitrat), diet ¹ 4 are indicated. Colibacterin, bificol and other biological preparations are indicated in case of development of dysbacteriosis. At acute tonsillitis gargles should be indicated. Development of arthritis, myocarditis, Reiter syndrome is the indication to use indomethacin, ibufrofen, diclofenac-natrii (ortophen) and other not steroid preparations.

All the patients are prescribed vitamin therapy in the form of complex B, vitamins A, C, PP and others.

The therapeutic tactics should be strictly individual in case of every patient who is to be constantly looked after. Only an individual approach and a complex of the treatment measures can bring invariable success and allow to achieve good results.

Prophylaxis

In spite of the achieved success in the pseudotuberculosis study, the problems of the specific prophylaxis have not been worked out so far.

A complex of nonspecific measures directed at the source and transmission factors is widely used in the medicine to prevent the pseudotuberculosis spreading.

Control questions:

1. Etiology, epidemiology, and incidence of pseudotuberculosis.

2. Pathogenesis of pseudotuberculosis.

3. Anatomic pathology of disease.

4. Main clinical symptoms and signs of pseudotuberculosis.

5. Laboratory methods of pseudotuberculosis diagnostics.

6. Criteria of diagnosis.

7. Differential diagnosis of pseudotuberculosis.

8. Treatment of pseudotuberculosis.

9. Prophylaxis of pseudotuberculosis.

1.

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Date: 2014-12-21; view: 803


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