Infectious Disease Flashcards
Task 16
Patient R., 22 years old, a student, consulted a polyclinic doctor in connection with the detection of enlarged lymph nodes in the neck. He cannot report the age of this disease.
Body temperature is normal.
Objectively: the condition is satisfactory. Multiple injection marks on the hands. The anterior cervical, posterior cervical and axillary lymph nodes are enlarged up to 1.5-2.0 cm, densely elastic consistency, painless. No pathology was revealed on the part of the internal organs. No enlargement of internal lymph nodes was found (ultrasound of the abdominal cavity, Rn-graphy of the chest organs).
The task
1. What are your assumptions about the diagnosis?
2. Make an algorithm for examining the patient.
3. What are the principles of etiotropic therapy for this disease?
4. Indicate the main preventive and anti-epidemic measures for this infection.
1:* Diagnosis: HIV infection, latent III (stage of primary manifestations IIA).
2: The patient is most likely an injection drug addict, because there are injection marks on the hands. The anterior cervical, posterior cervical and axillary lymph nodes are enlarged up to 1.5-2.0 cm, densely elastic consistency, painless.
Laboratory diagnosis of HIV is carried out in two stages:
* ELISA
* immune blotting: 2. Determination of certain viral proteins (gp41, gp120, gp 160, p24, s55bz17) by immune blotting.
* PCR: Highly effective method of diagnosing HIV infection, PCR, allows you to detect fragments of RNA or DNA of the virus.
3: Etiotropic therapy: The timing of the onset, the choice of drugs depend on the clinical picture, stage of the disease and the degree of immunodeficiency . indication for starting antiretroviral therapy is HIV in the stage of primary manifestations (2B, 2C) and the stage of secondary diseases (4B, 4C).
* Cabenuva, which contains two different types of HIV drugs: cabotegravir and rilpivirine.(latest treatment ), You take it as an injection once a month or once every two months at your doctor’s office
*They use reverse transcriptase inhibitors (zidovudine, lamivudine, didanosine) - HIV protease inhibitors (verosept) . - nenukleazidnye (viramune, efaverens)
4: main preventive and anti-epidemic measures for this infection. Timely application protivovir Therapy can suppress HIV replication, which prevents the development of immunodeficiency, and at its presence leads to restoration of the immune status, regression of opportunistic infections,
* promotion of healthy lifestyles, safe sex with the use of condoms
* control donor blood and its preparations, donor organs, processing of medical instruments, use of syringes, needles, systems for transfusion and other single-use purposes, examination of pregnant women
* When HIV-infected pregnant women are identified, they are recommended to use antiviral drugs to prevent perinatal transmission of HIV , the issue of interrupting the pregnancy or delivery by cs, and refusal to breastfeed the child are considered.
Task 17
Patient A., 20 years old, was admitted to the infectious diseases clinic on the 2nd day of illness with complaints of diffuse headache, pain in the muscles of the neck and limbs, vomiting, photophobia, irritability and fever (39-40 ° C) .
Epidemiological data : 10 days before the disease - the fact of tick sucking (in the scalp ); specific immunoglobulin was introduced 2 days after tick removal.
Objectively: severe stiffness of the occiput muscles , positive Kernig and Brudzinsky symptoms , pulse - 124 beats per minute, blood pressure - 140/85 mm Hg. Art.
Analysis of cerebrospinal fluid: flowed out in a stream, transparent, cytosis - 0.036 G / L (of which 78% were lymphocytes ), protein - 0.16 g / L, glucose - 2.7 mmol / L.
The task
1. Formulate the clinical diagnosis and provide its rationale.
2. Assign a specific research plan.
3. Make a differential diagnosis with infectious diseases with meningeal syndrome.
4. Make a plan for treating the patient in accordance with the standards of care for the disease.
- Diagnosis: Tick-borne encephalitis, meningeal form, moderate.
2.Assign a specific research plan: meningeal syndrome (headache, vomiting, skin hyperesthesia, stiffness of the occiput muscles, Kernig’s symptoms, Brudzinsky’s upper and lower symptoms, etc. b and knee - it is impossible to expand in the knee; s-m Brudzinsky:
Hemolytic serum (Ab with this Er If there CEC, then no hemolysis )
* ELISA (day 4-5) or virus RNA by PCR method (posit after 24). It is important to diagnose the titer by 4 times.
3differential diagnosis: Meningococcal meningitis, Crimean-Congo Hemorrhagic Fever, Rocky Mountain Spotted Fever, Borreliosis (Lyme Disease
4* Treatment: antiencephalitic donor Ig i / m, 3-12 ml. Ribonuclease 25-30 mg / m for physical solution after 4 hours; interferon and its inducers ,fluids , small dose of corticosteroids - 2 mg / kg or dexazone 0.25 mg / kg per day, In severe cases with damage to the brainstem and musculature breath, oxygen therapy is of great importance, according to mechanical ventilation , and antioxidants, antipsychotics, lytic mixtures. In the restore-m per-de, they prescribe nootropics, vit B, physiotherapy
Prevention: EnceVir vaccine is a purified concentrated sterile suspension of tick-borne encephalitis virus inactivated by formalin, Vaccination is two times: Emergency response : within 72 hours, immunoglobe i / m 0.1 ml / kg 1 time
Task 18
Patient K., 46 years old, turned to a therapist with complaints of an increase in body temperature up to 37.5 ° C, moderate headache and malaise . In the neck area - a focus of hyperemia measuring 7 × 5 cm with clear contours, hot to the touch, moderately painful; enlarged regional lymph nodes are palpated .
Epidemiological history data: 6 days ago - the fact of a tick sucking in the neck; the duration of the tick’s suction is several hours ; I removed the tick myself; the study of the tick for the presence of tick-borne encephalitis virus and borrelia has not been carried out.
The task
1. Formulate the clinical diagnosis and provide its rationale.
2. Assign a specific research plan.
3. Make a plan for treating the patient in accordance with the standards of care for the disease.
4. Give a list of preventive measures for tick-borne infections.
- Diagnosis: Ixodic tick-borne borreliosis, acute course, erythemal form, mild severity. Lyme borreliosis
- Diagnostics . Isolation of a culture of borrelia from affected tissues and biological fluids (marginal zone of migratory erythema, skin biopsies, cerebrospin fluid ),
* Research of paired sera, taken with an interval of 20-30 days, use RNIF (r-i indirect immunofluorescence)
* ELISA, immunoblotting. IgM ,IgG
3: Treatment: In the 1st stage, from etiotropic drugs, it is preferable to use tetracycline drugs, in particular doxycycline 200mg for 10-30 days, or macrolides (sumamed, erythromycin
* penicillin in / m or in / in 200 - 300,000 U / kg per day for 10-30 days. Ampicillin.
* Ceftriaxone is highly effective, especially for the pores of the central nervous system, heart and joints, 2 g 1 p / d i / m 2 weeks .
4: Measures of protection against attack of ticks (repellents, protective suits).
task 20
Patient Ch., 28 years old, a teacher, called a doctor in connection with poor health and the inability to continue working at school. Ill for 3 days. The disease began elk with rhinitis and cough, shortly body temperature climbed to 38 ° C . Complains of headache, weakness, sore throat, pain in the eyes and watery eyes.
On examination, nasal congestion, sneezing, wet cough , scanty mucus-bloody nasal discharge, skin irritation under the nose and above the upper lip were noted . The mucous membrane of the pharynx is moderately hyperemic, loose, the tonsils are enlarged, the mucous overlays in the lacunae. The conjunctiva is hyperemic, mostly on the left. Enlarged submandibular and
anterior cervical lymph nodes. In the lungs and heart - no pathology. Pulse - 80 beats per minute, blood pressure - 110/70 mm Hg. Art. The abdomen is painless, the edge of the liver is at the costal arch. There are no meningeal phenomena. Physiological functions are normal.
The task
1. What are your assumptions about the diagnosis?
2. Features of the pathogenesis of this disease?
3. Assign a specific research plan (taking into account the spectrum of differentiated diseases).
4. List the possible complications of this infection.
- Diagnosis. ARVI.Adenoviral infection, pharyngo-conjunctival fever, moderate severity. SARS,
it is predominantly affecting the pharynx, tonsils, conjunctiva, as well as lymphadenopathy and fever.
2: Adenovir penetrates the mucus of the upper respiratory tract, conjunctiva and mucus of the digestive tract. Replication of predominant cells in the nuclei is sensitive to the viral of cells and leads to damage to the latter, Having developed an inflamed process, accompanied by exudation, fibrin loss and necrosis . As a result of viremia, dissemination may occur. Lymphogenous disseminated induction will inflame the LN. Possibly connecting a secondary pneumonia tank . - differential diagnosis. Determination of Ag virus in smears of imprints from the nose, eyes, feces by the method of immunofluorescence. Serology: ELISA, RSK, RN and RPGA for detecting AT
*bacterial pneumonia
*influenza
*corona virus
4: Complications. Pneumonia (viral - bacterial, bacterial), sinusitis, otitis media, tonsillitis.
Task 21
Patient S., 36 years old, turned to the therapist on 16.04 with complaints of sore throat when swallowing, fever up to 38.6 ° C and moderate headache .
Data from the anamnesis of the disease: fell ill on 14.04, when a sore throat appeared, with an increase in intensity over time ; in the morning of 15.04, when examining the oropharynx with the help of a mirror, the patient saw a plaque on the tonsils ; rinsing with sodium chloride solution did not bring any improvement; 04.16 in the morning the patient discovered a swelling under the lower jaw on the right and consulted a doctor .
The doctor noted the patient’s moderate condition, pallor of the face, the presence of a pasty swelling of the neck to its middle (the skin above the surface of the edema of the usual color), enlarged and slightly painful submandibular lymph nodes on the right . Examination of the oropharynx revealed a purplish-cyanotic coloration of the mucous membrane , a sharp swelling of the right tonsil and the presence of a continuous coating of a dirty gray color on it, passing to the soft palate, uvula and right arch; when trying to remove plaque with a spatula, the mucous membrane was bleeding . Breathing is not difficult, the voice is normal. Tachycardia (100 beats per minute), blood pressure - 170/90 mm Hg. Art.
The task
1. Formulate a clinical diagnosis.
2. Provide a pathogenetic rationale for the clinical syndrome complex.
3. Make a differential diagnostic algorithm.
4. What are the principles of etiotropic therapy for this disease?
1.Diagnosis. Diphtheria of the oropharynx, toxic, grade I, moderate course
2.provide a rationale for the clinical syndrome : entrance gates are usually mucous membranes of the oropharynx ( microbes use mucus as a habitat ), nose, larynx, less often eyes, genitals, and skin. The pathogen is fixed at the site of introduction, and multiplies there, releasing exotoxin. Pathological changes in the patient’s body - intoxication, local inflammatory process, early and late complications - are caused by the damaging effect of the toxin, which consists in blocking protein synthesis by the cell.
Fibrinogen, under the influence of thrombokinase released from necrotic tissue, coagulates and turns into fibrin . This is how a fibrinous film is formed, which is the most characteristic sign of diphtheria. Those areas of integumentary tissues that have a stratified epithelium (oropharynx) are covered with a hard-to-remove film .
Regional lymph nodes are involved in the process , they increase due to sharp plethora, edema and proliferation of cellular, mainly reticuloendothelial, elements . This edema is due to serous inflammation with numerous cellular infiltrates, and the general toxic effect is due to toxin entering the blood .
3: Difiagnosis with angina unlike sore throat, swelling of the tonsils and the entire palate is more extensive With angina, redness and plaque do not go beyond the boundaries of the amygdala, and with diphtheria, they spread far beyond its limits (on the palate, tongue).
The color of plaque in angina is yellowish, and in diphtheria it is white with a grayish-dirty tinge . With angina, deposits are superficial and when examining the pharynx with a spoon, they can be easily removed from tonsils. In diphtheria, the plaque adheres firmly to the tonsils and is removed with difficulty with a spoon, leaving behind a bleeding surface
*Infectious mononucleosis : Pharyngeal diphtheria can be mistakenly suspected in cases of infectious mononucleosis. Severe consequences occur when pharyngeal diphtheria is mistaken for infectious mononucleosis and, therefore, appropriate treatment is not carried out.
4: Treatment
* Hospitalization and isolation. Strict bed regime.
* Antitoxic antidift serum, neutralizes diphthyria toxin, circulation in the blood, is administered immediately, intramuscularly or intravenously
* In case of medium and heavy AB penicillins, cephalosporins 5-8 days.
* Carry out detoxification therapy with crystalloid and colloidal solutions intravenously (polyionic solutions, glucose-potassium mixture with the addition of insulin, rheopolyglucin, fresh frozen plasma).
* In severe cases, glucocorticoids are added to the injected solutions (prednisolone at a dose of 2-5 mg / kg).
* Toxic diphtheria of II and III degrees, hypertoxic form and severe combined forms of the disease are indications for plasmapheresis.
Complications
*Av block (arrhythmias)
*Myocarditis
*Shock
*Degeneration of myelin sheat
*renal failure
Task 22
Patient P., 19 years old, was admitted to the infectious diseases department of a medical and prophylactic institution. When you receive impose Well and loby to fever, fatigue, lack of appetite, lethargy, appearance of tumorous formations on the left and right side of the neck .
On objective examination, the patient’s condition is closer to severe, body temperature - 39 ° C. The skin is clean, normal color. On palpation in the neck area, enlarged and moderately painful lymph nodes of dense elastic consistency are determined . Axillary and inguinal
lymph nodes are also enlarged. Spilled hyperemia of the oropharyngeal mucosa, hyperemia and swelling of the tonsils. Enlargement of the liver and spleen.
Hemogram: leukocytes - 9.0 G / l, segmented neutrophils - 17%, stab neutrophils
- 2%, lymphocytes - 64%, monocytes - 17%, eosinophils - 0%, atypical mononuclear cells (15%), ESR - 20 mm / h.
The task
1. Formulate the clinical diagnosis and provide its rationale.
2. Assign a plan for specific studies, provide serological and gene diagnostic markers of this disease.
3. What are the principles of therapy for this infectious pathology?
4. Indicate the possible outcomes of the infectious process.
- Clinical diagnosis and rationale: Infectious mononucleosis, moderate severity,
Diagnosis based on clinical picture and atypical mononuclear cells in the UAC. Exciting: Epstein-Barr virus (EBV) lymphotropic, family Herpesviridae, DNA-containing. Anthroponosis; source-patient, carrier. Route of transmission: air-cap., Through saliva, in childbirth, blood transfusion. More often men are ill, more often at the age of 14-29. Pathogenesis: nasopharynx → oropharynx → pores of the epithelium and lymphoid tissue → B-lymph. secrete IgM, the appearance of atypical mononuclear cells (pathognomonic!). EBV persists for life in B-lymphs.
2. Research studies
* Serological diagnostics by ELISA with determination of EBV- (IgM VCA-, IgG EA-, IgG VCA-avidity) and CMV-infection (IgM-, IgG-avidity) markers in the blood;
* DNA-EBV, DNA-CMV were determined by PCR
* immunological parameters (IgA, IgM, IgG, CD4, CD8, CD4 / CD8, RBTL with PHA, CEC, NBT-test); standard laboratory and instrumental studies were carried out.
3: Treatments
* ganciclovir (500 mg 3p per day intravenous or intravenous at 5-15 mg / kg per day) for 10-15 days.
* Human hyperimmune Ig. Immunomodulators (T-activin, decaris, etc.).
* Rinsing the throat with iodinol, furacillin, warming a compress on the neck.
4: outcomes: The prognosis is favorable. Complications are rare: otitis media, paratonsillitis, sinusitis, pneumonia. Sometimes rupture of the spleen, o. hepatic failure, o.Hemolytic anemia, myocarditis, meningoencephalitis, neuritis, polyradiculoneuritis.
Task 25
Patient A., 36 years old, was acutely ill: at night there was a watery stool without pathological impurities, by the morning the stool became more abundant and acquired the appearance of “ rice water”, vomiting, weakness and dizziness joined. With a diagnosis of food poisoning, she was admitted to an infectious diseases hospital , where in the admission department, gastric lavage and a subcutaneous injection of cordiamine( Cordiamine stimulates the central nervous system and especially the centers of the medulla oblongata — respiratory and vasomotor. )were made . The patient’s condition over time worsened: watery stools without counting, vomiting more than 20 times (vomit like “rice water”), thirst, cramps of the calf muscles.
Objectively: the condition is very serious, consciousness is preserved. The skin is cold to the touch, diffuse cyanosis, a sharp decrease in the turgor of the subcutaneous tissue (“washerwoman’s hands”). Facial features are sharp, sunken eyeballs, a symptom of “sunglasses “. Hoarseness of voice.
Periodic cramps in the muscles of the limbs. The body temperature is 35.6 ° C, the pulse is threadlike, the blood pressure is 40/0 mm Hg. Art., tachypnea (36 breaths per minute ). Phenomena of anuria.
The task
1. Formulate the clinical diagnosis (indicating the degree of dehydration) and provide its rationale.
2. Assign a specific research plan.
3. Make a program of rehydration therapy (patient’s body weight - 60 kg).
4. Make a plan of anti-epidemic measures in the focus of this disease.
1.Diagnosis; Cholera, severe course (grade IV dehydration). Dehydration shock III degree.
Criteria for cholera: no temperature pain alive, diarrhea first, then vomiting , painless bowel movement, fast hypovolemia . The patient’s condition over time worsened: watery stools without counting, vomiting more than 20 times (vomit like “rice water”), thirst, cramps of the calf muscles, The skin is cold to the touch, diffuse cyanosis, a sharp decrease in the turgor of the subcutaneous tissue (“washerwoman’s hands”). Facial features are sharp, sunken eyeballs, a symptom of “sunglasses “..
- Research plans: Microscopy of stool and vomit smears.
* immunofluorescence microscopy
* Serology for retrospective diagnosis.
* Objective study of feces, emetic mass, portions B, C of bile, sectional material, water, food and other objects of the environment - Treatment
* Rehydration therapy (patient’s body weight - 60 kg). We will need 6 litters if 1l is 10kg,60kg will be 6 litters
* Duration of rehydration is 36-72 hours - Anti-epidemic measures: Discharged after clinical failure, 3x tank research Special prof: cholerogenanatoxin vaccine.
Task 27
Patient A., 24 years old, called an ambulance doctor on 21.01 due to the presence of weakness, a feeling of dry mouth, “fog”, blurred contours of objects in front of the eyes and their double vision, difficulty in swallowing food and saliva, hoarseness, headache and dizziness.
She fell ill acutely in the evening of 20.01, when there was bloating and, almost simultaneously, the above symptoms. Over the next day, the condition continued to deteriorate.
Epidemiological data: on 20.01 in the afternoon I was visiting, where I ate salted mushrooms and home-made juices; one of the guests , K., 36 years old, has already been hospitalized with similar manifestations of the disease.
Objectively: a state of moderate severity, active. The face is pale. In the lungs - no pathological changes. Respiration rate is 18-28 per minute, heart sounds are muffled. Tongue dry, overlaid with white-yellow bloom. The abdomen is soft and painless. I remembered that in the evening of 20.01 there were loose single stools and abdominal pains of a diffuse nature . Neurological symptoms revealed ptosis on the left, restriction of movement of the right eyeball, decreased pupillary reactions, difficulty in swallowing fluid (no choking), slight hoarseness and difficulty speaking. The task
1. Prospective diagnosis?
2. Provide a pathogenetic rationale for the clinical syndrome complex.
3. Assign a patient examination plan.
4. Medical tactics?
1.diagnosis: Botulism, moderate severity.
2.Rationale and clinical syndrome: The source is soil, animals, birds, people .. the fur was fecal-shouted. Infection with the use of spore-infected products: canned food - mushrooms, vegetables, etc. acute Botulism infectious disease, associated with the use of food, contains the toxin Clastridium botulinum
Syndromes: paralytic, gastrointestinal, intox . The beginning of the period: gastroenteric ( epigastric pain, cramping, a single vomiting is possible , stool looseness No increase in tempera, there is DRY of the oral mucosa.
Ocular variant : the appearance of fog in front of the eyes, flies, parity is lost, Then ogre movement of the eye until paresis of the gaze, ptosis, strabismus, vertic nystagmus, diplopia, mydriasis Then, swallowing and speech disorders, dysphonia (first hoarseness, decreased temperature due to dry mucus; then dysarthria due to disturbed movement of the tongue-nasal voice, due to paresis) Palatine curtains - full aphonia, paresis of the vocal cords), dysphagia. Later, the defeat of the CVS and DS. Expanded boundaries of heart dullness, deafness, thirst, abdominal distension, constipation, paresis and paralysis of muscles, dyspnea
PATHOGENETIC JUSTIFICATION OF syndrome
* ophthalmoplegic and bulbar symp. Fog before the eyes, blurred vision, double vision - due to impaired transmission of nerve impulses and paresis of the circulatory muscles and nar-e accommodation . The defeat of the glosopharyngial muscles was due to the hoarseness of the voice, swallowing. Bloating, abdominal pains are caused by intestinal paresis.
3.Assign patients examination plan
* Neutralization reaction in mice (use 4 mice within 4 days injecting the mouse with the toxin obtained from the canned food if mouse dies then it’s confirmed, Laboratory confirmation is done by demonstrating the presence of toxin in serum, stool, or food, or by culturing C. botulinum from stool, a wound or food.
* ELISA, PCR.
4 . Medical tactics :
* Botulism is a rare but serious illness caused by a toxin produced by the bacterium Clostridium botulinum. The treatment plan for botulism typically involves hospitalization and supportive care, as well as administration of antitoxin and antibiotics. Here are some of the key components of the treatment plan:
- Hospitalization: Patients with botulism are typically hospitalized and closely monitored. In some cases, they may require admission to an intensive care unit (ICU) to receive specialized care.
- Antitoxin: The antitoxin is a medication that can help neutralize the botulinum toxin in the body. It is administered as soon as possible after diagnosis to prevent further absorption of the toxin. The antitoxin is most effective if given early in the course of the illness, so prompt diagnosis and treatment is essential.
- Antibiotics: Antibiotics may be given to treat any bacterial infection that may be present, as well as to prevent secondary infections.
- Respiratory support: Botulism can cause respiratory failure, so patients may require mechanical ventilation to help them breathe.
- Feeding support: Patients with botulism may experience difficulty swallowing and require feeding support, such as a feeding tube.
- Follow-up care: Patients with botulism may require ongoing care and monitoring after they leave the hospital, including physical therapy to help regain muscle strength and function.
Overall, the treatment plan for botulism is designed to address the underlying toxin and provide supportive care to help the patient recover. With prompt diagnosis and treatment, most patients with botulism recover fully.
* Hospitalization, gastric lavage with a thick probe 9 for the first 2 days of illness) and a siphon enema. (5% p-rum Na hydrogencarbonate)
* Treatment: + monovalent p / botulinum sera A, B, E, if the type is not known polyvalent syv (10 thousand IU A and B and 5tys E) is introduced into / in or / m Regardless from the strand,
* therapeutic dose is injected diluted in 200 ml of isotone , under the cover of prednisolone, before the introduction, a test is carried out according to Bezreko, first a reconnaissance in 100r 0.1 ml intradermally, we wait 20 minutes (infiltration, increase by that),
* For oxygen and vegetative situation give - chloramphenicol and tetracyclines ; detox; To fight against respiratory diseases: HBO, mechanical ventilation (with ↓ VC up to 30%, shortness of breath> 40). There is an anti-botulism plasma and an immunoglobulin
task 31
On the 6th day of illness, patient K. , 20 years old, was admitted to the infectious diseases clinic with complaints of high fever, chills, dizziness, nausea, poor appetite, cutting pains in the right hypochondrium and epigastric region, yellowing of the skin and darkening of urine .
From the anamnesis it was found that 3 weeks before the disease she ate freshly salted ides
An objective examination revealed subictericity of the sclera and skin, lining of the tongue, tenderness on palpation of the abdomen in the right hypochondrium and the gallbladder point , a positive Ortner symptom and hepatomegaly . Body temperature - 38.5 ° С, pulse - 108 beats per minute, blood pressure - 115/85 mm Hg. Art.
In the hemogram - leukocytosis (12.0 G / l), eosinophilia (35%), increased ESR (24 mm / h).
The task
1. Formulate the clinical diagnosis and provide its rationale.
2. Assign a patient examination plan taking into account the spectrum of differentiated diseases.
3. Make a treatment plan.
4. Indicate the main preventive measures for
1.clinical diagnosis: Acute opisthorchiasis (less than 3 months, history, bright clinic), hepatocholangitis variant (pain, dark urine), moderate severity (temperature 38.5).
Rationale: Epidemiology data it was found that 3 weeks before the disease she ate freshly salted ides .clinical syndrome : dizziness, nausea, poor appetite, cutting pains in the right hypochondrium and epigastric region, yellowing of the skin and darkening of urine .
2: Assign research plan: spectrum Differential diagnosis: Acute (up to 3 months): latent and clinically expressed (typhoid-like, hepatocholangitis, gastroenterocolitic
* Chronic (more than 6 months): latent or wedge-expressed (cholangitis, cholangiocholecystitis, cholangiohepatitis, cholangiohepatopancreatitis, cholangitic cirrhosis of the liver).
* Complicated: bacterial gastrointestinal tract infection, liver abscess, biliary peritonitis, primary liver cancer, primary pancreatic cancer.
* Residual phenomena: cholangitis, cholangiocholecystitis, cholangiohepatitis, cholangitis cirrhosis of the liver.
Course options: typhoid, hepatocholanget, gastroenterocolitis, broncholeg
* eggs in the feces and duodenal contents,
* seroimmunology (ELISA: AT Ig M to opist. AG). Blood eosinoph, maximum 18-28 days, lecocytosis (it is normal earlier)
Differential Diagnosis
* OVG B (beginning period (7-14 days) - no tº (mb subfib-t), syndrome 4 - arthralgic, dyspeptic, asthenovegetative, mixed; yellow period (3-4 weeks) - ↑ tº, exp. disp. syndrome)
* Infec. mononucleosis (acute onset, tonsillar. s / d, hepatosplenomegaly, lymphadenopathy, in the blood - mlnuclear lymph, monocytosis).
* G. JKB (pain provokes an error in the diet, no tº, nausea and vomiting, bringing temporary relief, (+) SM Ortner, Murphy, Mussey).
3.make a treatment plan
*Anti-parasitic drug praziquantel 75mg/kg patients weight
* Prepare stage: 7 days Choleretic (holosas)
* antispasmodics (duspatolin) Dicycloverine Adult: 10-20 mg tid.
* hepatoprotectors, 200 to 400 mg/day silymarin , Ursodeoxycholic Acid. 300mg, antihistamines Allegra 60 mg twice daily or 180 mg once daily with water.
* Cancel choleretic. Biltricid: night regimen (because predominance of n.vagus: relax bile. ducts), daily dose of 60 mg / kg - 22.00-02.00-06.00 in the morning duod. sounding. 3. Choleretic, hepatoprotectors, tubazh, repeated probing after 3 months.
4. Preventive measures
* Compliance with the rules of culinary processing of fish (cooking-frying not <20 minutes, salt - 1/5 of the salt by weight of the fish for 14 days).
* Alcohol consumption
task 33
Patient L., 23 years old, was admitted to an infectious diseases hospital with complaints of weakness, lack of appetite, nausea , pain in large joints, an increase in body temperature to 37.8 ° C and darkening of urine . Ill for 8 days, in recent days he noted the appearance of an icteric color of the sclera and skin , increased intensity of pain in the joints and a deterioration in general well-being.
From the epidemiological history: within 2 years - regular parenteral drug administration, promiscuous sexual intercourse.
Objectively: a state of moderate severity. The skin and sclera are icteric , there is no rash. The tongue is coated at the root with a yellow bloom. Joints are of normal configuration, movement is in full. The lower edge of the liver protrudes from under the costal arch by 2 cm, smooth, painful on palpation. Kera’s and Ortner’s symptoms are negative. The spleen is not palpable. Dark urine, grayish feces.
The task
1. Formulate the clinical diagnosis and provide its rationale.
2. Assign a plan of examination of the patient, indicate the specific diagnostic markers of this disease.
3. Make a differential diagnosis with infectious and non-infectious diseases with jaundice syndrome.
4. Make a treatment plan.
1.Diagnosis: Acute viral hepatitis B, icteric form
Rationale: high-risk group (injecting narcotics, risky sexual behavior), preicteric period (about 2 weeks), arthralgic
- Clinical diagnosis: Hepatitis B with acute hepatitis and jaundice syndrome. The patient has a history of high-risk behavior for hepatitis B infection, and the symptoms of weakness, lack of appetite, nausea, pain in large joints, and an increase in body temperature are consistent with acute hepatitis. The presence of icteric sclera and skin, yellow tongue coating, and dark urine indicate jaundice syndrome. The liver is enlarged and painful on palpation, further supporting the diagnosis of acute hepatitis.
- Plan of examination:
- Blood tests: Hepatitis B surface antigen (HBsAg), hepatitis B core antibody (anti-HBc), hepatitis B surface antibody (anti-HBs), alanine aminotransferase (ALT), aspartate aminotransferase (AST), bilirubin levels, complete blood count (CBC)
- Imaging: Abdominal ultrasound to assess liver and spleen size and rule out other causes of jaundice
- Viral load testing for hepatitis B to assess the severity of the infection and guide treatment decisions - Differential diagnosis:
Infectious diseases with jaundice syndrome:
- Hepatitis A
- Hepatitis C
- Epstein-Barr virus (EBV)
- Cytomegalovirus (CMV)
Non-infectious diseases with jaundice syndrome:
- Alcoholic liver disease
- Non-alcoholic fatty liver disease
- Drug-induced liver injury
- Autoimmune hepatitis
- Treatment plan:
- Supportive care with bed rest, adequate hydration, and a balanced diet
- Antiviral therapy with entecavir 0.5mg
1mg or tenofovir to suppress viral replication and prevent chronic hepatitis B
- Pain management with non-steroidal anti-inflammatory drugs (NSAIDs) or acetaminophen
- Monitoring of liver function tests and viral load
- Referral to a specialist for further management and follow-up, including vaccination for hepatitis A and B to prevent future infections.
task 34
Patient I., 36 years old, turned to the local therapist with complaints of rapid fatigue, periodic nausea and a feeling of heaviness in the right hypochondrium, aggravated after eating fatty foods, poor appetite and episodes of darkening of urine . It was found that the patient works as an operating nurse of the surgical department.
Examination revealed subicteric sclera, lining of the tongue, hepatomegaly and enlargement of the spleen .
In a biochemical blood test: total bilirubin - 25 μmol / L (direct - 7, indirect - 18), thymol test - 6 units , ALT activity - 110 U / L, AST - 70 U / L.
The task
1. What is your opinion on the diagnosis?
2. Make an algorithm for examining the patient, taking into account the spectrum of differentiated diseases.
3. A set of therapeutic measures for this disease?
- Forecast?
1.Diagnosis: Chronic viral hepatitis C. RNA virus
2.Algorithm for examining patient taking into account of differential diagnosis
* A. Toxic liver damage (alcoholic, drugs: p / tuberk LS, tetracycline, tranquilizers): anamnesis with contact with poison, nephropathy.
* Infectious mononucleosis: atypical mononuclear cells in the blood, lesion of the peripheral l / u, pharynx (hyperemia, swelling of the tonsils, plaque is easily removed), light feces.
* Obstructive jaundice: no symptoms of intoxication, increased bound bilirubin (unconjugated normal), no hyperenzymemia, intense pruritus, spleen intact, fecal acholia.
* Hemolytic anemia: liver function tests are normal, anemia, hyperbilirubinemia due to unconjugated, no pain in the liver area, pallor of the skin, no pruritus, feces are colored normally
3:Treatment
* TREATMENT of HEPATITIS C
* Hepatitis C is treated using direct-acting antiviral (DAA) tablets.
DAA tablets are the safest and most effective medicines for treating hepatitis C.
They’re highly effective at clearing the infection in more than 90% of people.
The tablets are taken for 8 to 12 weeks.
NHS-approved hepatitis C medicines include:
sofosbuvir
a combination of ledipasvir and sofosbuvir
a combination of ombitasvir, paritaprevir and ritonavir, taken with or without dasabuvir
a combination of elbasvir and grazoprevir
a combination of sofosbuvir and velpatasvir
a combination of sofosbuvir, velpatasvir and voxilaprevir
a combination of glecaprevir and pibrentasvir
ribavirin
Pegylated IFN and RIBAVARIN
Others ; Declatasivir + Sofosbivir
Elbasivir/grazoprevir
Ledipasvir/sofosbivir
Glecaprevir/pibretasvir
* Semi-bed rest, hepatic table SD No. 5, enterosorbents, a complex of vitamins (C, B1, B6, B12), drinking plenty of fluids in accordance with the principles of oral rehydration with mild severity.
* With severe intoxication - infusion therapy (acesol, quartasol, glucose, rheopolyglucin, albumin, polydesis).
* With the development of cholestasis syndrome - preparations of ursodeoxycholic acid (ursofalk, ursosan 10-15 mg / kg 1 time in the evening). P / viral: alpha-IF (reaferon, intronA, roferonA) course 6-12 months.
* If HCV RNA is retained from the start of treatment for 3 months, then we add analogs of anomalous nucleosides (riboverin, labivudine).
4 . Forecast or outcome
* 50 -100% chronicity, many getting rid of the virus in the acute phase. 1/3 of patients with chronic HCV: cirrhosis. 20-30% have hepatocarcinoma (if they survived in the cirrhosis phase). Progresses rapidly in narcotics (max 10 years).
task 35
Patient O., 56 years old, was admitted to the infectious diseases clinic with complaints of an increase in body temperature up to 38.7 ° C, chills, weakness, headache, the presence of redness on the skin of the left leg, accompanied by a burning sensation .
Data of the anamnesis of the disease and the epidemiological history: fell ill the night before, when fever and severe chills appeared; in the morning, when getting out of bed, noted pain in the left lower limb; for 10 years suffering from thrombophlebitis of the superficial veins of the lower extremities.
On examination: on the skin of the upper third of the left leg (spreading to the thigh) - bright erythema , clearly delimited from healthy skin by a roller, with uneven edges , hot to the touch, moderately painful on palpation, mainly along the periphery; against the background of erythema - several large blisters filled with serous contents; in the area of the lower leg and thigh - pronounced edema of a doughy consistency; enlarged and painful inguinal lymph nodes on the left are palpated . Muffled heart sounds, tachycardia (104 beats per minute).
The task
1. Formulate the clinical diagnosis and provide its rationale.
2. Make a differential diagnostic algorithm.
3. Make a plan to treat the patient in accordance with the standards of care for the disease.
4. Indicate the possible complications of this infection.
1.Diagnosis: Erysipelas of the left lower extremity, widespread (lower leg + thigh), erythematous-bullous form (there is still erythematous, eryth-hemorrhagic, bullous-hemorrhagic), moderate severity (fever 38-40, fever up to 5 days, common form, no complications) , primary .
2.make a plan to treat the patient in accordance with the standard of care for the disease
* A. Thrombophlebitis of the superficial veins of the thigh on the left (occurs in the presence of chronic venous insufficiency. Supporting diagnostic signs: the presence of anamnestic indications and objective signs of chronic venous insufficiency,
* Phlegmon of the right leg (diffuse purulent inflammation of the subcutaneous tissue, proceeds with an acute, sometimes violent onset, high fever, severe intoxication, rapidly developing and significant inflammatory changes in the blood. Accordingly, differentiation from erysipelas, especially in the initial period of the disease, can present significant difficulties Supporting diagnostic signs: severe pulsating pain in the inflammatory focus, sharp pain on palpation, the presence of severe swelling and dense tissue infiltration with frequent subsequent softening and the appearance of fluctuations, bright hyperemia, clearly delimited, pronounced lymphangitis and lymphadenitis.
+ Specific symptoms, laboratory nonspecific (leukocytosis, toxic granular NF, increased ESR), rheumatic tests (CRP, RF, seromucoids, AT titers), coagulogram (thrombocytopenia, hyperfibrinogenemia),
*Treatment : - if complications.
Erysipelas is a type of bacterial skin infection that is usually caused by Streptococcus pyogenes bacteria. The treatment plan for erysipelas typically involves a combination of antibiotics and supportive care. Here are some of the key components of the treatment plan:
- Antibiotics: The first line of treatment for erysipelas is usually antibiotics. Penicillin V 500mg 4 times a day is the preferred antibiotic, but other options may include cephalosporins, macrolides, or fluoroquinolones. The duration of treatment typically lasts for 7-10 days, but may be extended if the infection is severe or if the patient has underlying medical conditions.
- Pain relief: Erysipelas can be painful, so pain relief measures may be necessary. Over-the-counter pain medications, such as acetaminophen 500-1000mg 2 times a day or ibuprofen, may be recommended. In severe cases, prescription pain medications may be necessary.
- Rest and hydration: Rest and hydration are important to help the body fight off the infection. Patients are advised to rest and drink plenty of fluids to stay hydrated.
- Wound care: If the erysipelas infection has caused an open wound, wound care may be necessary. This may include cleaning the wound, applying topical antibiotics, and covering the wound with a sterile bandage.
- Follow-up care: Patients with erysipelas should follow up with their healthcare provider to ensure that the infection has been successfully treated. If the infection does not improve or if it worsens, further testing or treatment may be necessary.
Overall, the treatment plan for erysipelas is designed to address the underlying infection and provide supportive care to help the patient recover. With prompt and appropriate treatment, most cases of erysipelas can be successfully treated.
NSAIDs (no more than 3-5 days). Local treatment only in case of bullous forms (Vishnevsky is not allowed, you cannot bandage, you need a bandage desenf, 3-4 days reparative ointment
4.possible complications
* local : abscess, phlegmon, skin necrosis, ulcers, bullae pustulization, phlebitis, thrombophlebitis.
* general : itch, encephalopathy, acute vascular insufficiency, sepsis, secondary infection.
task 36
Patient K., 38 years old, works as a milkmaid . Was admitted to the infectious diseases clinic on the 52nd day of illness. The disease began gradually: there were periodic chills, an increase in body temperature in the evening hours up to 38.5 ° C, headache, weakness and severe sweating; repeatedly applied for medical help at the feldsher-obstetric center, carried out ARVI treatment ; During treatment, she noted a temporary improvement and continued to work, but her condition worsened over time, irritability and pain in the large joints of the extremities appeared .
An objective examination revealed hyperhidrosis , dense sensitive nodules up to 1 cm in the subcutaneous tissue of the lumbosacral region, an increase in the submandibular, axillary and inguinal lymph nodes to the size of a bean, hepato- and splenomegaly . There are no objective changes in the joints.
The task
1. Formulate the clinical diagnosis and provide its rationale.
2. Assign a specific research plan.
3. Make a plan to treat the patient in accordance with the standards of care for the disease.
4. Indicate the possible outcomes of the infectious process.
1.Diagnosis: Acute brucellosis (less than 6 months), moderate severity (temperament from 38 to 39.5).
- The clinical diagnosis is likely to be brucellosis, based on the patient’s occupation, symptoms, and examination findings. The presence of hyperhidrosis, subcutaneous nodules, lymphadenopathy, and hepatosplenomegaly are typical features of brucellosis. The prolonged course of the disease and lack of response to ARVI treatment also suggest a bacterial infection.
- The specific research plan should include:
- Blood tests for brucellosis serology (Rose Bengal test, Wright test, ELISA)
- Blood cultures for Brucella species
- Imaging studies, such as ultrasound or CT scan of the liver and spleen, to assess organ involvement
- Joint aspiration and culture, if joint symptoms are present
- Other tests to rule out other infectious or inflammatory diseases, such as Lyme disease or rheumatoid arthritis. - The plan to treat the patient in accordance with the standards of care for brucellosis may include:
- Antibiotic therapy with doxycycline and rifampin for a period of 6-8 weeks or Treatment options include doxycycline 100 mg twice a day for 45 days, plus streptomycin 1 g daily for 15 days. The main alternative therapy is doxycycline at 100 mg, twice a day for 45 days, plus rifampicin at 15mg/kg/day (600-900mg) for 45 days.
- Symptomatic treatment, such as analgesics and anti-inflammatory drugs for joint pain
- Rest and avoidance of strenuous activities during the treatment period
- Follow-up blood tests to monitor treatment response and prevent relapse
- Education on preventive measures, such as wearing protective clothing and gloves when handling animals or animal products. - The possible outcomes of brucellosis depend on the severity and duration of the infection, as well as the patient’s immune status. With appropriate antibiotic treatment, most patients recover completely without sequelae. However, complications such as endocarditis, neurobrucellosis, or chronic arthritis may occur in some cases. Relapse may also occur if the treatment is not completed or if the patient is re-exposed to the bacteria.
2.Research plan
* Bacteriology (blood, bone marrow, urine, bile, sputum, CSF, l / u, spleen punctate).
* Biological research (urine, feces, corpses, milk, food products, objects of the external environment)
* Serology (blood): Wright’s RA titer 1: 200; Heddelson’s RA 0.02; RPGA; Coombs ave. Allergological examination: Burne test (intravenous administration of brucellin, accounting after 24-48 hours).
3.Treatment
* Bed rest. Table number Always use combination therapy for Brucellosis 5. Antibacterial: gentamicin i / m 0.5 2 times + rifampicin per os 0.3 3 times + ciprofloxacin i / v 0.4 2 times. Disintox: 400 5% glu + reopolygluck 200 (i / v ). Desensitisation: 10% Ca gluconate 5.0 v / v, spurastin, tavegil, diazolin. UHF, exercise therapy, massage.
4. Outcomes : Often, residual effects are mainly of a functional nature due to immunoallergic restructuring of the body and a disorder of the autonomic NS: sweating, irritability, arthralgia. Sometimes organic changes in the musculoskeletal system (joint deformities due to the proliferation of periarticular tissue). Special Prof. Zhivaya Vakina. - Animal husbandry workers.
Task 38
The ambulance doctor was called to the patient N., 30 years old . According to relatives, N. had flown in from Kazakhstan the night before. In the morning he felt unwell: there was a strong chill followed by fever, a sharp headache and pain in the muscles; body temperature has risen to
39 ° C; at the same time there was pain in the right axillary region . The patient took analgin, but the pain in the armpit continued to intensify, in the evening the condition worsened, nausea joined in, and speech became slurred.
On examination: body temperature - 40.2 ° C. Hyperemia and puffiness of the face, vascular injection of the sclera and conjunctiva, hyperemia of the oropharyngeal mucosa . The tongue is dry, thickly coated with a white coating (“chalky “), its tremor is expressed . In the right axillary region, a thick, sharply painful, poorly contoured lymph node measuring 3x3 cm is determined , the skin above it is cyanotic. In the lungs - vesicular breathing, no wheezing. Respiratory rate - 22 per minute. Heart sounds are muffled , the rhythm is correct. Pulse - 120 beats per minute. BP - 100/60 mm Hg. Art. The abdomen is soft and painless. The liver and spleen are not enlarged. The symptom of tapping in the lumbar region is negative on both sides. There was no stool on the day of illness. There are no meningeal symptoms.
The patient is agitated, trying to get up, constantly muttering something indistinct.
The task
1. Formulate the clinical diagnosis and provide its rationale.
2. Assign a specific research plan.
3. Make a plan for treating the patient in accordance with the standards of care for the disease.
4. Make a plan of anti-epidemic measures in the focus of this disease.
1.Diagnosis: severe bubonic plague
Rationale: epidemiological data shows patient N had flown in from Kazakhstan the night before.
Clinical features also shows According to relatives, N. had flown in from Kazakhstan the night before. In the morning he felt unwell: there was a strong chill followed by fever, a sharp headache and pain in the muscles; body temperature has risen to
39 ° C; at the same time there was pain in the right axillary region . The patient took analgin, but the pain in the armpit continued to intensify, in the evening the condition worsened, nausea joined in, and speech became slurred.
On examination: body temperature - 40.2 ° C. Hyperemia and puffiness of the face, vascular injection of the sclera and conjunctiva, hyperemia of the oropharyngeal mucosa. . The tongue is dry, thickly coated with a white coating (“chalky “), its tremor is expressed . In the right axillary region, a thick, sharply painful, poorly contoured lymph node measuring 3x3 cm is determined , the skin above it is cyanotic. The patient is agitated, trying to get up, constantly muttering something indistinct.
2: Assign research plan
* Blood cultures should be sent together with other appropriate clinical samples, ideally before antibiotics are given.
* Appropriate samples may include bubo aspirates (bubonic plague), sputum (pneumonic plague), and cerebrospinal fluid (CSF) if meningeal symptoms are present (septicaemic plague).
* Clinical samples should be examined with Gram and Wright-Giemsa or Wayson stains and cultured in broth or on blood agar. Y. pestis appears as gram-negative coccobacilli and as a light-blue bacillus with dark-blue polar bodies on Wright-Giemsa or Wayson stain. This “safety pin” appearance is suggestive, but not pathognomonic, of plague but gives a rapid presumptive diagnosis
3. Treatment .
* Begin appropriate IV therapy as soon as plague is suspected. Gentamicin and fluoroquinolones are typically first-line treatments in the United States. Duration of treatment is 10 to 14 days, or until 2 days after fever subsides. Oral therapy may be substituted once the patient improves.
-Gentamicin: 5 mg/kg once daily, or 2 mg/kg loading dose followed by 1.7 mg/kg every 8 hours
-Levofloxacin 500 mg once daily
4: anti-epidemic measures of this disease
*infection control :patients with suspected cases are immediately sent to laboratory to confirm diagnosis and patients with uncomplicated form can start treatment , patients with pneumonia should be placed in isolation
* wearing protective clothing and equipment against plague such has mask , gloves, boots and face shield
*chemoprophylaxis: antibiotics such as doxycycline 100mg twice daily for 7 days or levofloxacin 500mg daily for 7 days
*vaccination:killed whole cell vaccine (KwC) and live-attenuated vaccine
* environmental control:people living in epidemic regions should wear protective clothing,face masks. Using repellents and keep rodents and fleas from food
Task 39
Patient I., 16 years old, was admitted to the infectious diseases hospital on the 2nd day of illness. Acutely ill : runny nose, headache, severe weakness, chills, fever up to 39.6 ° C; after 12 hours, a rash appeared on the skin of the buttocks; there was epistaxis against the background of a progressive deterioration in general well-being.
The task
1. Formulate the clinical diagnosis (underlying disease, complication).
2. Provide a pathogenetic rationale for the clinical syndrome complex.
3. Assign a specific research plan.
4. Make a treatment plan.
1: Diagnosis: Severe meningococcal infection, meningococcaemia. Second-degree toxic shock syn-
drome
2:pathogenetic rationale for clinical syndrome complex
* Pathogenesis of syndromes. At high concentrations of endotoxin (lipopolysaccharide), severe course — ITSH (fulminant form). ITS: 1 stage of massive bacteremia — a lot
endotoxin - hemodynamic disorder (spasm of capillaries, arterioles, dilatation of the venous
basin), damage to the endothelium — increased vascular permeability and capillary dilation; 2
stage of microcirculation disturbance, hypoxia, DIC, metabolic disorder (acidosis); 3 stage acute
adrenal insufficiency (Waterhouse-Friederiksen syndrome - thrombohemorrhagic
adrenal necrosis).
3. Assign a research plan
* Bacterioscopy (blood, cerebrospinal fluid, rash): this is indicative. Bacteriological method: blood, cerebrospinal fluid, rash. Detection of hypertension in cerebrospinal fluid (latex agglutination reaction,
* PCR (90%)).
* Immunology (RPHA): an auxiliary method.
* Antigen detection in CSF Serogroup A, B, C, Y, and W-135 polysaccharide antigen can be detected by latex agglutination in 40% to 95% of patients with meningococcal meningitis.
* Rapid tests are most useful when it is desirable to individually tailor antibiotic therapy or if identification of a meningococcal infection has immediate public health implications, such as the need to provide antibacterial prophylaxis to close contacts.
* Nasopharyngeal cultures Nasopharyngeal cultures are of limited usefulness in routine patient management. The isolation of N. meningitidis from the nasopharynx of a patient with sepsis or meningitis
* Cerebrospinal fluid testing CSF cultures should be considered in patients with signs and symptoms of meningitis. A lumbar puncture (LP) is contraindicated in patients with cardiovascular or respiratory instability, coagulopathy, or infection (including petechial or purpuric lesions) overlying the puncture site.
4.Make a treatment plan
* Hospitalization in the intensive care unit.
* Infusion therapy: crystal: colloids = 3: 1, cryoplasm.
* N. levomycytin succinate 1g 4p / d - as it has a bacteriostatic effect before the elimination of ITS, after ceftriaxone.
* GCS: prednisolone 5-10mg / kg.
* DOXA: 1-2ml 3 r / day / m.
* Correction of acidosis: quartasol, glu-K mixture.
* Lasix 1mg / kg after hemodynamic stabilization.
* Dopamine 1-7mg / kg / min. Ser.d glycosides. Potassium up to 2-3 days. Needs. Plasmapheresis.
Prevention and control Primary prevention Vaccines approved in the US for prevention of meningococcal infections include 2 tetravalent meningococcal polysaccharide conjugate vaccines (Menactra® [MenACWY-D] and Menveo® [MenACWY-CRM], both also known as MenACWY
* Immunoprophylaxis • In on-going outbreaks of meningococcal infection caused by vaccine-preventable serogroup A, B, C, Y, and W-135 organisms, immunisation of contacts may prevent secondary cases. The preferred vaccine varies according to the individual’s age and the serotype of the outbreak strain.
