Astrakhan fever is transmitted from person to person. Astrakhan tick-borne spotted fever. Treatment of Astrakhan rickettsial fever

In recent years medical service area is worried about new infectious disease entitled"Astrakhan tick-borne spotted fever." This disease occurs only in our region. At the beginning it was registered in one district - Krasnoyarsk, but now it is almost

throughout the region. Most often this disease is registered in the Krasnoyarsk, Narimanovsky, Volga regions and in Astrakhan

The morbidity season begins in April-May. Astrakhan tick-borne spotted fevers belong to natural focal areas. This disease occurs with severe symptoms fever, profuse skin rashes on the trunk, upper and lower extremities, including palmar and plantar surfaces. Patients are concerned about pain in muscles and joints.

Men of working age are often affected. Children get sick 5 times less often than adults. This disease is registered only in the warm season. During the entire observation period, not a single case was identified in January, February, March, November, December. The peak incidence occurs in August.

Over the years, there are more and more patients with severe forms. These patients are treated for a long time (up to a month) in inpatient conditions. Diagnosis and treatment of this disease have been developed.

The culprit in infecting people is a tick, which in nature is found on hedgehogs, hares, and at home on dogs and cats. People become infected with this infection after a tick bite while fishing, outdoor recreation, at recreation centers, in pioneer camps, working in the field, on personal plots.

A tick bite is painless and is not always noticed. It may take several hours for a tick to attach itself. The tick attaches itself in the armpits and groins, on the head, especially on the back of the head, as well as in the abdomen. Few people are able to feel the moment of a tick bite, since the tick numbs the bite site well.

For the purpose of prevention, the population needs to:

· When in nature, use repellent to repel ticks, treating clothes and exposed skin with it, and do not lie down or sit on the grass.

· When returning from outdoor recreation, fishing, summer cottage, etc. inspect skin and tick detection clothing.

· If you find a tick on your skin, you must contact your local medical facility. If this is not possible, you can use a handkerchief soaked in vegetable oil to treat the area of skin with the tick, and after 1-2 hours the tick will come off freely. If removal is difficult, in some cases the intervention of a surgeon is required.

· If you are bitten or come into contact with a tick, be sure to consult a doctor who will prescribe preventive treatment and observation for 14 days.

· At the slightest suspicion of the disease, mandatory hospitalization in an infectious diseases hospital is required.

THINGS TO REMEMBER:

TIMELY TICK REMOVAL

MAY PREVENT INFECTION.

Material prepared

Editorial and publishing department

GBUZ JSC "TsMP" - 2016

Since the beginning of the 70s, cases of febrile illness have been recorded in the Astrakhan region unknown origin, which was initially regarded as a viral exanthema, sometimes as pseudotuberculosis. Since 1983, there has been an increase in the detection of disease cases, the number of which has increased 20 times over the past 10 years. The rickettsial etiology of the disease was established. Clinical and epidemiological data (features of the territorial spread of the infection, seasonality, the presence of a tick bite, contact with dogs, primary affect, characteristic exanthema) and detection of the pathogen antigen by the Polymerase chain reaction method gave grounds to consider the infection as the well-known Mediterranean (Marseilles) rickettsial fever. Further study of the pathogen revealed its serological similarity to the causative agent of Marseilles fever with some antigenic differences, and biological properties tick-borne pathogen typhus North Asia, which indicates the uniqueness etiological factor, Astrakhan tick-borne fever (ATF) and allowed us to talk about its nosological independence. The carriers of the ACL pathogen are the so-called. dog ticks. Human infection in natural conditions occurs through the bite of an adult tick or its nymphs. The possibility of other ways of implementing the pathogen transmission mechanism cannot be ruled out. The incidence is recorded from April to October, but mainly from the end of July to the beginning of September. Most cases of infection occur in the hyperendemic zone, within the boundaries of which these areas, recreation centers, as well as a large industrial complex are located, where, along with local residents, teams of specialists from different regions of the CIS work on a rotational basis, which suggests the possibility of registering individual cases of the disease outside the Astrakhan region region.

During Astrakhan tick fever, several periods can be distinguished: incubation, initial, height, convalescence.

The incubation period ranges from several days to a month, most often being 1-2 weeks. The boundary between the incubation and initial periods - the appearance of fever - is always clearly expressed, although the so-called. “primary affect,” which can be considered the first sign of illness, is formed much earlier. It is detected upon careful examination in half of the patients and is localized in most cases - on the skin lower limbs, mostly on my knees. Somewhat less often - on the skin of the torso, and in isolated cases - on the neck, head, hands, penis. They are predominantly single, although double ones are occasionally observed. The formation of primary affects is not accompanied by any subjective sensations, although on the day of their appearance minor itching and soreness are sometimes noted. Primary affect is pink spot, sometimes on a raised base, from 5 to 15 mm in diameter. In the central part of the spot, a punctate erosion initially appears, which quickly becomes covered with a hemorrhagic crust. dark brown. Further evolution of the primary affect is manifested by a gradual fading of the brightness of the inflammatory color, a decrease in swelling from days 6-16 of the disease, ending on days 8-2 with pinpoint superficial atrophy at the site of the rejected crust. Unlike other tick-borne rickettsioses, infiltration at the base of the primary affect and hemorrhagic inclusions are not observed; the skin defect is exclusively superficial in nature without deep necrotic changes in the dermis. Sometimes it is difficult to recognize among other elements of the rash.

Every fifth patient with primary affect has regional lymphadenitis. Lymph nodes do not exceed the size of a bean, and are more often the size of a pea, painless, mobile, not fused to each other. Lymphadenitis resolves on the 10-15th day of illness.

The initial (pre-exanthematous) period of Astrakhan tick-borne fever lasts 2-6 days. It begins with an increase in temperature and the appearance of a feeling of heat, headache, joint and muscle pain, and loss of appetite. All these phenomena are progressively increasing: the temperature already from the first day of illness reaches a level of 39-40 ° C, repeated chills are often noted, and an increased general weakness, intense arthromyalgia leads to a decrease in the mobility of the sick. Intensifies quickly headache, which in some patients becomes painful and deprives them of sleep. Sometimes dizziness, nausea and vomiting occur. In elderly people, fever may be preceded by prodromal phenomena in the form of rapidly increasing weakness, weakness, fatigue, and depressed mood. The febrile reaction is accompanied by moderate tachycardia. During this period, there is an increase in the size of the liver; The phenomena of scleritis and conjunctivitis are often recorded. Hyperemia of the mucous membrane of the posterior pharyngeal wall, tonsils, arches and uvula soft palate, which, in combination with complaints of sore throat and nasal congestion, are usually regarded as manifestations of acute respiratory disease, and if a cough is added - as bronchitis or pneumonia.

On days 3-7 of fever, a rash appears and the disease enters its peak period, which is accompanied by increased symptoms of intoxication.

The rash is symmetrical, widespread, and is localized on the skin of the trunk (mainly the anterolateral parts), upper (mainly on the flexor surfaces) and lower extremities, including the palms and soles. A rash on the skin of the face is rare, in cases with more severe intoxication.

Exanthema is usually polymorphic in nature, although in milder cases it can be monomorphic: it can be represented by vascular elements (roseola, erythema), hemorrhages, papules. Disappears with the formation of pigmentation. The rash on the palms and soles is papular in nature. Roseola elements of the rash are usually abundant, although occasionally isolated. Some of them rise above the surface of the skin. Color - pink or red, size - from 0.5 to 3 mm. In more severe cases, fusion of roseolae is observed due to their abundance. Roseola often transforms into hemorrhagic spots. Most often, a similar process occurs on the skin of the lower extremities, somewhat less frequently - on the skin of the abdomen and lateral parts of the torso.

A hemorrhagic rash of the pupra type, less often a petechial rash, appears against the background of a roseolous or papular rash, and occasionally occurs on unchanged skin (mainly in the form of petechiae). Hemorrhagic elements are not prone to fusion, have clear boundaries, a rounded shape, often single, more often severe cases- multiple. Localization of hemorrhages is on the lower extremities, especially the lower legs, the back and soles of the feet, less often on the skin of the abdomen and upper extremities. When hemorrhagic spots resolve, unstable pigmentation remains.

In most patients, muffled heart sounds and tachycardia are detected, corresponding to the severity of the temperature reaction, with a lower frequency - various disorders rhythm (paroxysmal tachycardia, extrasystole, atrial fibrillation), occasionally - arterial hypotension.

The tongue is covered with a grayish coating. Appetite is reduced to the point of anorexia. There are symptoms of cheilitis. Transient diarrhea is possible in the first days of illness. Every second patient experiences hepatomegaly, on average up to 10-12 days of illness. The liver is painless, densely elastic in consistency, its lower edge is even, its surface is smooth. An enlarged spleen practically does not occur.

Body temperature above 39°C persisted for 6-7 days; fever above 40°C was rarely observed. On average, until the 7th day, many patients are bothered by chills. The temperature curve is remitting, less often - constant or of the wrong type. The febrile period lasts on average 11-12 days, ending in most cases with shortened lysis.

When the temperature normalizes, a period of convalescence begins. Gradually, the patients’ well-being improves, symptoms of intoxication disappear, and appetite appears. In some recovering patients, the symptoms of asthenia persist for a relatively long time.

Astrakhan tick fever can be complicated by pneumonia, bronchitis, glomerulonephritis, phlebitis, metro and rhinorrhagia, infectious-toxic shock, acute cerebrovascular accident. Some patients have signs toxic damage Central nervous system (nausea or vomiting with severe headache, bright erythema of the face, stiff neck and Kernig's sign, ataxia), the increase of which may be a reason for lumbar puncture. When examining the cerebrospinal fluid, no inflammatory changes are detected.

Severe course is characterized by the most high fever and severe intoxication. Patients complain of severe headaches, muscle and joint pain and severe weakness that confines them to bed, anorexia up to complete refusal to eat for several days. There is a rapid and significant loss of body weight, sometimes up to 10% or more. There is an early, abundant, widespread rash with a predominance of hemorrhagic elements, sometimes acquiring a confluent character, a positive “tourniquet symptom.” The appearance of roseolous-papular rashes on the face is characteristic. In severe cases, complications occur much more often, fever and intoxication syndrome last longer. Significant proteinuria is detected. At the height of the disease, specific antibodies are not detected in the blood serum. Factors contributing to severe ACL are elderly age, concomitant diseases, including alcoholism, glucose-6-phosphohydrogenase deficiency, immunodeficiency states.

At the height of ACL disease, the blood picture is not very characteristic. Normocytosis is noted, there are no significant changes in the formula, indicators of phagocytic activity, or blast transformation of lymphocytes. Otherwise, in severe cases, which are characterized by leukocytosis, thrombocytopenia, and signs of hypocoagulation. The content of blood immunoglobulins changes little.

Urinalysis reveals in some cases proteinuria, an increase in leukocytes in the urine.

Passport part

2. Age: 58 years old

3. Place of residence:

4. Position: pensioner

5. Date of admission to the hospital:

6. Date of supervision:

7. Diagnosis of the referring institution: Astrakhan rickettsial fever Diagnosis at admission: Astrakhan rickettsial fever

8. Preliminary clinical diagnosis: Astrakhan rickettsial fever

9. Final clinical diagnosis:

a) Main: Astrakhan rickettsial fever (based on the clinical picture, epidemiological history, laboratory data - PCR diagnosis is positive from 08/30/2010)

b) Concomitant: Diabetes mellitus

Anamnesis morbid

The patient has been diagnosed since August 25, 2010, when she began to notice increased temperature, weakness, headaches and pain in the legs. I brought down the temperature with paracetamol. The patient's condition worsened, an ambulance was called, she was examined and hospitalized in the Regional Clinical Hospital for the purpose of examination and treatment.

Epidemiological history

The patient is engaged in agricultural activities. On the eve of the disease, she was working on a plot of land, where she felt a bite in the area of her left shoulder blade, after which itching and burning appeared and the patient began to be bothered by the complaints described above.

Born in Astrakhan 1952, during her second pregnancy. She was breastfed, started walking at 1.5 years old, started talking at 2 years old, and was vaccinated on time. At the age of 7 I went to school, studied well, and did not lag behind my peers in mental and physical development. Married, has two children. Material and living conditions are satisfactory. The food is good. He denies hepatitis, tuberculosis, and sexually transmitted diseases. The allergic history is calm and he has no bad habits. There were no blood transfusions before admission to the hospital. Geographical and hereditary anamnesis without features.

The patient's condition is moderate. The patient's position in bed is active. Consciousness is clear. The physique is correct, normosthenic type of constitution. The skin has a physiological coloration, increased humidity, reduced elasticity, a rash on the inner surface of the thighs and buttocks, and a hyperemic spot with a core in the center measuring 2x2cm is observed in the area of the left shoulder blade. The subcutaneous fat layer is moderately developed, evenly distributed, and there is no edema.

Lymph nodes: submandibular, supraclavicular, subclavian without changes. The cervical, axillary, and inguinal nodes are not enlarged and are not limited in mobility. The general development of the muscular system is satisfactory; no pain is observed upon palpation of the muscles. Muscle tone is the same on both sides. When examining the bones of the skull, chest, spine, and limbs, no pain or deformation is noted. Joints of the correct configuration are painful with significant physical activity. Active and passive movements in full.

Respiratory system.

Breathing through the nose, the shape of the nose is not changed. The chest is of the correct configuration of the normosthenic type, chest type of breathing. Breathing is rhythmic, respiratory rate is 19 per minute. The breathing movements on both sides of the chest are medium in depth, uniform and symmetrical. Accessory muscles are not involved in the act of breathing.

Percussionlungs

Comparative percussion of the lungs reveals a clear sound.

Data from topographic percussion of the lungs:

The standing height of the apex in front: on the right 3 cm above the level of the clavicle, on the left 3 cm above the level of the clavicle, behind: at the level of the spinous process of the 7th cervical vertebra.

Lower borders of the lungs:

Linea parasternalis 5th intercostal space 5th intercostal space

Linea mediaclavicularis 6th intercostal space 6th intercostal space

Linea axilaris anterior 7 intercostal space 7 intercostal space

Linea axilaris media 8 intercostal space 8 intercostal space

Linea axilaris posterior 9th intercostal space 9th intercostal space

Linea scapularis 10 intercostal space 10 intercostal space

Linea paravertebralis spinous process of the 11th thoracic vertebra

Mobility of the lower edges of the lungs (see):

Topographic lines right left

Linea mediaclavicularis 2 2 4 2 2 4

Linea axilaris media 3 3 6 3 3 6

Linea scapularis 2 2 4 2 2 4

Auscultation of the lungs

On auscultation over the lungs, vesicular breathing is detected, wheezing is not heard.

The cardiovascular system.

The area of the heart is not changed, the apical impulse is not visualized, palpated in the 5th intercostal space 1.5 cm inward from the left midclavicular line, 2 cm wide, of low moderate strength. There is no heartbeat.

Percussionhearts

Limits of relative dullness of the heart:

Right - 1 cm outward from the right edge of the sternum (in the 5th intercostal space)

Upper - at the level of the 3rd intercostal space

Left - 1.5 cm medially from the left midclavicular line (in the 5th intercostal space), the configuration of the heart is not changed.

Limits of absolute dullness of the heart:

Right - left edge of the sternum

Upper - at the level of 4 ribs

Left - 2.5 cm medially from the left midclavicular line (in the 5th intercostal space)

Auscultation of the heart

The sounds at the apex of the heart are muffled, rhythmic, there is a systolic murmur, the heart rate is 76 beats per minute. Blood pressure 110/70 mmHg. Pulse 76 beats per minute, rhythmic, satisfactory filling and tension, normal value, the same on both sides.

Digestive system.

The mucous membrane of the oral cavity is pale pink in color. The tonsils are not enlarged, the tongue is red, slightly covered with a white coating. The abdomen is not enlarged. On superficial palpation the abdomen is soft and painless. The symptom of peritoneal irritation (Shchetkin - Blumberg) is negative. There is no pain at McBurney's point. With deep palpation according to the Obraztsov-Strazhesko method, the sigmoid colon is palpated in the left iliac region, for 11 cm, cylindrical in shape with a diameter of 3 cm, dense elastic consistency, painless and does not rumble. The cecum is determined on the right in the form of a moderately tense, slightly expanding cylinder with a rounded bottom, rumbling when pressed. The ileum is defined as a dense rumbling cylinder. The ascending and descending parts of the colon are painless on palpation. The transverse colon does not growl and is painless. Using the methods of percussion and deep palpation, the lower border of the stomach is determined 4 cm below the navel; the lesser curvature and the pylorus are not palpable. The pancreas is not palpable. When auscultating the abdomen, peristaltic bowel sounds are heard. There is no splashing noise.

Dimensions of hepatic dullness according to Kurlov.

Linea mediaclavicularis - 9 cm.

Linea mediana - 8 cm.

Arcus costae sinistra - 7 cm.

The liver is palpated at the edge of the costal arch; the edge of the liver is soft, sharp, and smooth. Smooth, moderately painful, gallbladder is not palpable. No protrusion or deformation in the liver area is detected. The spleen is enlarged; no protrusion or deformation is observed in its area.

Urinary organs.

When examining the kidney area, are there any pathological changes? no deformations were detected. The kidneys are not palpable, the effleurage symptom is negative on both sides. There is no swelling on the face or legs. The bladder does not protrude above the pubis upon percussion and is not palpable. There is no pain along the ureters.

Nervous system. Consciousness is clear and adequate. Thinking and memory are not changed. Meningeal signs and pathological reflexes are absent. The gait is stable, hearing, taste, vision and smell are not changed.

Endocrine system.

The thyroid gland is not enlarged; upon palpation, the parenchyma has a soft consistency and is mobile and painless. There is no exophthalmos. Secondary sexual characteristics correspond to age. Hair loss is noted, the type of hair growth is female.

Preliminary clinical diagnosis:

Based on complaints: For increased temperature, weakness, headaches, vomiting, poor appetite, nausea, bitterness and dry mouth, rash, pain in the legs.

Epidemiological history: The patient lives and is engaged in agricultural activities. On the eve of the disease, she was working on a plot of land, where she felt a bite in the area of her left shoulder blade, after which itching, burning appeared and the patient began to be bothered by the complaints described above.

Objective research

Survey plan.

1. General blood test.

2. General urine analysis.

3. Blood sugar test.

4. Biochemical blood test.

5. PCR diagnostics.

6. Plasma analysis for malaria.

7. Feces on worm eggs.

General blood analysis.

Hb - 120 g/l

· Red blood cells - 3.84 * 10 12

· Color index - 0.9

· Platelets - 157.0

· Leukocytes - 6.1*10 9 g/l

Lymphocytes - 29

Monocytes - 7

· ESR 25 mm/h.

General urine analysis.

· Quantity - 200 ml

Colour: straw yellow

· Reaction - 5

· Protein - no

Glucose - positive

· Salts - oxalates

· Squamous epithelium 0-2 in p/z

· Renal epithelium 0-1 in p/z

· Glucose - 7.3 mmol/l

Blood chemistry.

ASAT - 40.25 U/l

ALAT - 33.6 U/l

· Total bilirubin - 13.2

Direct bilirubin - 1.9

Thymol test - 3.3

Differential diagnosis

Astrakhan rickettsial fever

Astrakhan rickettsial fever is differentiated from Crimean hemorrhagic fever and Q fever.

Crimean hemorrhagic fever begins acutely, often so suddenly that some patients can even indicate the hour when they fell ill, but our patient does not note such accuracy, worsening over several days. Those sick with Crimean hemorrhagic fever develop severe chills, then fever. Body temperature rises to 39-40°C. While our patient’s temperature rises gradually, then fever. More rare symptoms of Crimean hemorrhagic fever include dizziness, dry mouth, thirst, catarrhal symptoms, and severe pain in the calf muscles. But in our patient, headaches, vomiting, poor appetite, nausea, bitterness and dry mouth are the main symptoms. In the pre-hemorrhagic period of the Crimean hemorrhagic fever A number of patients experience some specific symptoms: repeated vomiting, abdominal pain, more often in the epigastric region, and lower back pain. Most patients experience hyperemia of the face and neck, scleritis, and conjunctivitis. In some cases there is subictericity of the sclera, in some patients there is subscleral hemorrhage. Our patient complains of a rash and severe pain in her legs.

The incubation period for Q fever is from 3 to 32 days, more often 12-19 days, and in our patient the temperature began to rise 2 days after the bite appeared. In most cases, Q fever begins acutely, while in our patient the disease developed gradually. Complaints with Q fever: headache, pain in the lower back, muscles, joints, feeling of weakness, dry cough, sweating, loss of appetite, sleep disturbance. Our patient complains of severe headaches, poor appetite, nausea, bitterness and dry mouth, rash and pain in the legs. With Q fever, upon examination, facial hyperemia, injection of scleral vessels, and pharynx hyperemia are revealed. And our patient has normal skin color and the pharynx mucosa is unchanged. In most patients with Q fever, hepatolienal syndrome appears early. While our patient’s liver is not enlarged, her spleen is only slightly enlarged. The temperature for Q fever is 39-40°, the temperature curve is varied - constant, remitting, wavy, irregular. The duration of fever is within two weeks, but relapses are possible. In our patient, the body temperature increased gradually, the duration of fever was 10 days.

Final clinical diagnosis:

Based on complaints: For increased temperature, weakness, headaches, vomiting, poor appetite, nausea, bitterness and dry mouth, rash, pain in the legs.

The patient lives in is engaged in agricultural activities. On the eve of the disease, she was working on a plot of land, where she felt a bite in the area of her left shoulder blade, after which itching, burning appeared and the patient began to be bothered by the complaints described above.

Objective research: in the area of the left shoulder blade there is a hyperemic spot with a core in the center, measuring 2x2 cm.

Laboratory data: PCR diagnosis is positive.

1. Table No. 13 - a diet with energy value, reduced to a large extent due to fats and carbohydrates, with a high content of vitamins.

2. Bed rest.

3. Immunostimulating, antiviral and anti-inflammatory effects

Rp: Cycloferoni 0.15 No. 10

D.S. 2 tablets each. 2 times a day before meals

Rp: Tab. Arbidoli 0.05

S. 1 tab. 1 time a day before meals

4. Impact on the pathogen

Rp: Doxycycline 0.2 No. 50

D.S. 1 tablet each. 2 times a day

5. Detoxification.

Rp: Sol. Glucosi 5% 200 ml

D.t.d. No. 5 in flac.

S. IV drip 5 times a day

Rp: Sol. Acesoli 200 ml

D.t.d. No. 5 in flac.

S. IV drip 3 times a day

06.09.2010 Condition of moderate severity. Complaints of slight weakness, moderate sweating. The skin and mucous membranes are of physiological color, with the exception of spots on the buttocks and thighs. Vesicular breathing is heard in the lungs, there are no wheezes. NPV - 19 per minute. BP-110/70 mmHg. Heart sounds are loud and rhythmic. Heart rate 74 per minute. The abdomen is soft and painless. Treatment as prescribed.

07.09.2010 Condition of moderate severity. Complaints of slight weakness, skin and mucous membranes are pale pink in color. The rashes persist. Vesicular breathing is heard in the lungs, there are no wheezes. t 36.5, blood pressure-130/80 mmHg. Heart rate 80/min. Heart sounds are loud and rhythmic. The abdomen is soft and painless. Treatment as prescribed. The dynamics are stable.

May 24, 2010 Condition of moderate severity. The patient makes no complaints. Visible mucous membranes and skin are clean. The rash is present. Heart sounds are loud and rhythmic. Heart rate 80 beats per minute. Vesicular breathing is heard in the lungs, there are no wheezes. t 36.7, blood pressure 120/70 mmHg. The abdomen is soft and painless. Treatment as prescribed. The dynamics are stable.

The patient was admitted to the Regional Clinical Clinical Hospital on September 3, 2010 as an emergency with a diagnosis of Astrakhan rickettsial fever.

· Based on complaints: For fever, weakness, headaches, vomiting, poor appetite, nausea, bitterness and dry mouth, rash, pain in the legs.

· Epidemiological history: The patient lives in Atal is engaged in agricultural activities. On the eve of the disease, she was working on a plot of land, where she felt a bite in the area of her left shoulder blade, after which itching, burning appeared and the patient began to be bothered by the complaints described above.

· Objective research: in the area of the left shoulder blade there is a hyperemic spot with a core in the center, measuring 2x2 cm.

Laboratory data:

General blood analysis.

Hb - 120 g/l

· Red blood cells - 3.84 * 10 12

· Color index - 0.9

· Platelets - 157.0

· Leukocytes - 6.1*10 9 g/l

Neutrophils: p/poison - 1, s/poison - 36

Lymphocytes - 29

Monocytes - 7

· ESR 25 mm/h.

General urine analysis.

· Quantity - 200 ml

Colour: straw yellow

Relative density - 1015

· Reaction - 5

· Protein - no

Glucose - positive

· Salts - oxalates

· Squamous epithelium 0-2 in p/z

· Renal epithelium 0-1 in p/z

· Glucose - 7.3 mmol/l

Blood chemistry.

ASAT - 40.25 U/l

ALAT - 33.6 U/l

· Total bilirubin - 13.2

Direct bilirubin - 1.9

Thymol test - 3.3

· PCR diagnosis is positive

Plasma test for malaria - negative

· Feces for worm eggs - not detected

· Sinus rhythm. Horizontal position of the electrical axis of the heart.

· Differential diagnosis.

The diagnosis was confirmed: Astrakhan rickettsial fever.

Forecasts.

1. Prognosis guoad vitam - optima

2. Prognosis guoad valitudinem - optima

3. Prognosis guoad laborum - optima

4. Prognosis guoad functionem - optima

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Etiology (causes) of Astrakhan rickettsial fever

They are cultivated in tissue culture, as well as in the yolk sac of a developing chick embryo and in affected mesothelial cells of laboratory animals (golden hamsters). A detailed analysis of the molecular genetic characteristics of rickettsiae that cause ARL makes it possible to differentiate them from other pathogens of rickettsial diseases of the LLP group.

Epidemiology of Astrakhan rickettsial fever

The main epidemiologically significant factor in ARF foci is the constant and fairly extensive infestation of dogs with the Rhipicephalus pumilio tick, the main reservoir and vector of rickettsia. The tick affects not only stray dogs, but also animals kept on a leash and guard dogs that do not leave their yards.

Significant infestation of R. pumilio ticks has been detected in wild animals (for example, hedgehogs, hares). Ticks can crawl from dogs, from the surface of soil and plants onto humans. Ticks are unevenly distributed throughout the region depending on the microclimate, landscape, number and nature of the distribution of hosts: hedgehogs, hares, etc. Several decades ago, the R. pumilio tick was rarely found on farm and domestic animals, although the number of affected wild animals and the degree of their tick infestation The northern Caspian region were high. Under anthropogenic influence (industrial development of the Astrakhan gas condensate field, construction and commissioning of two stages of a gas condensate plant), a low-active natural focus of previously unknown rickettsiosis turned into a manifest natural-anthropurgic focus of ARF.

Ticks retain rickettsia for life and transmit them transovarially.

A person becomes infected when a tick is sucked on. Infection is possible by contact when rubbing the hemolymph of a crushed tick, its nymph or larvae into damaged skin, mucous membranes of the eyes, nose, or through an aerosol suspension. Natural susceptibility to ARF is of all ages; residents of rural areas of the Astrakhan region are more often affected: adults of working age and elderly (work in gardens, dachas, agriculture), children of preschool and primary school age (greater contact with pets).

The disease is seasonal: April–October with a peak incidence in July–August, which is associated with an increase in the number of ticks at this time, mainly its juvenile forms (nymphs, larvae). The incidence of ARF has also been identified in regions neighboring the Astrakhan region, in particular in Kazakhstan. Cases of ARF were noted among vacationers in the Astrakhan region after their departure.

Pathogenesis of Astrakhan rickettsial fever

At the site of tick suction, the pathogen begins to multiply and a primary affect is formed. Then the rickettsiae penetrate the regional lymph nodes, where they also reproduce, accompanied by an inflammatory reaction. The next stage is rickettsia and toxinemia, which form the basis of the pathogenesis of ARL. Morphologically, in the primary affect, necrotic damage to the epidermis and neutrophilic microabscesses of the papillary layer of the skin are observed.

Acute vasculitis of vessels of different diameters develops with pronounced swelling of the endothelium, in places with fibrinoid necrosis, destruction of the elastic framework, swelling of collagen fibers of the dermis. Dilated lumens of blood vessels are noted; some of the vessels contain blood clots. Vasculitis is initially local in nature, within the primary affect, and with the development of rickettsiaemia it becomes generalized. The vessels of the microvasculature are mainly affected: capillaries, arterioles and venules. Disseminated thrombovasculitis develops.

Hemorrhagic elements are caused by perivascular diapedetic hemorrhages. By the beginning of recovery, proliferation of basal keratocytes begins in the epidermis; hyperpigmentation develops as a result of the breakdown of red blood cells and hemoglobin; infiltration and swelling of the endothelium are reduced; smooth muscle elements of the vascular wall proliferate; fibrinoid swelling of collagen fibers and edema of the dermis gradually disappear.

Rickettsia disseminates into various parenchymal organs, which is clinically manifested by enlargement of the liver, spleen, and changes in the lungs.

Clinical picture (symptoms) of Astrakhan rickettsial fever

There are four periods of the disease:
· incubation;
· initial;
· height;
· convalescence.

The incubation period ranges from 2 days to 1 month.

The first sign of the disease is the primary affect at the site of tick suction. The main symptoms of the disease are given in table. 17-46.

Table 17-46. Frequency and duration of individual symptoms in patients with Astrakhan rickettsial fever

Symptom	Number of patients, %	Duration of symptoms persistence, days
Fever	100	9–18
Weakness	95,8	12
Headache	88,5	10
Dizziness	33,9	7
Insomnia	37,5	7
Conjunctivitis	42,7	7
Scleritis	45,8	7
Throat hyperemia	70,8	8
Hemorrhages into the mucous membranes	15,1	6,5
Hemorrhagic rash	41,7	11
Rash macular-roseolous-papular	100	13
Rash with persistent pigmentation	59,9	11,5
Localization of the rash: hands	98,9	12
legs	100	11
torso	100	11
face	39,1	11
soles	43,2	10
palms	34,9	11
Enlarged lymph nodes	15,6	7

The onset of the disease is acute, with the onset of fever. In half of the patients, fever is preceded by the appearance of a primary affect. In most cases, it is localized on the lower extremities, somewhat less frequently on the torso, and in isolated cases on the neck, head, hands, and penis. The primary affect is predominantly single, with two elements occasionally observed. The formation of primary affect is not accompanied by subjective sensations, but on the day of its appearance, slight itching and soreness are sometimes noted. The primary affect appears as a pink spot, sometimes on a raised base, 5 to 15 mm in diameter. In the central part of the spot, a punctate erosion appears, quite quickly becoming covered with a dark brown hemorrhagic crust, which is rejected on the 8th–23rd day of the disease, leaving pinpoint superficial atrophy of the skin. At the base of the primary affect, unlike other tick-borne rickettsioses, no infiltration is observed; the skin defect is exclusively superficial in nature without deep necrotic changes in the dermis. Sometimes it is difficult to recognize among other elements of the rash.

Every fifth patient with primary affect has regional lymphadenitis. Lymph nodes are no larger than the size of beans; they are painless, mobile, and not fused to each other.

The initial (pre-exanthematous) period of ACL lasts 2–6 days. It begins with an increase in body temperature, reaching 39–40 °C by the end of the day; with the appearance of a feeling of heat, repeated chills, headache, joint and muscle pain, loss of appetite. The headache quickly intensifies, in some patients it becomes painful and deprives them of sleep. Sometimes dizziness, nausea and vomiting occur. In elderly people, fever may be preceded by prodromal phenomena in the form of increasing weakness: weakness, fatigue, depressed mood. The febrile reaction is accompanied by moderate tachycardia. During this period, liver enlargement is noted. The phenomena of scleritis and conjunctivitis are often recorded. Hyperemia of the mucous membrane of the posterior wall of the pharynx, tonsils, arches and uvula of the soft palate, combined with complaints of sore throat and nasal congestion, is usually regarded as manifestations of acute respiratory infections, and in the case of coughing - as bronchitis or pneumonia.

On the 3rd–7th day of fever, a rash appears and the disease enters its peak period, which is accompanied by increased symptoms of intoxication.

The rash is widespread and localized on the skin of the trunk (mainly the anterolateral sections), upper (mainly on the flexor surfaces) and lower extremities, including the palms and soles. A rash on the face is rare, in cases with more severe intoxication.

The exanthema is usually polymorphic macular-roseolous-papular, hemorrhagic in nature, in milder cases it can be monomorphic.

After the rash disappears, pigmentation remains. The rash on the palms and soles is papular in nature. Roseola elements are usually abundant, occasionally single; pink or red, with a diameter of 0.5 to 3 mm. In more severe cases, fusion of roseolae is observed due to their abundance. Roseola often transforms into hemorrhagic spots, most often on the lower extremities.

In most patients, muffled heart sounds and tachycardia are detected, corresponding to the severity of the temperature reaction; various rhythm disturbances (paroxysmal tachycardia, extrasystole, atrial fibrillation), and occasionally arterial hypotension are observed less frequently.

The tongue is coated with a grayish coating. Appetite is reduced to the point of anorexia.

The phenomena of cheilitis are observed. In the first days of illness, transient diarrhea is possible. Every second patient experiences hepatomegaly, on average until the 10th–12th day of illness. The liver is painless, densely elastic in consistency, its lower edge is even, its surface is smooth. Enlargement of the spleen practically does not occur.

Body temperature above 39 °C persists for 6–7 days; fever above 40 °C is rarely observed. On average, until the 7th day, many patients experience chills. The temperature curve is remitting, less often - constant or of the wrong type. The febrile period lasts on average 11–12 days, ending in most cases with shortened lysis.

With the normalization of temperature, the period of convalescence begins. The patients’ well-being gradually improves, symptoms of intoxication disappear, and appetite appears. In some convalescents, the phenomena of asthenia persist for a relatively long time.

ARF can be complicated by pneumonia, bronchitis, glomerulonephritis, phlebitis, metro- and rhinorrhagia, ITS, and acute cerebrovascular accident. Some patients show signs of toxic damage to the central nervous system (nausea or vomiting with severe headache, bright erythema of the face, stiff neck and Kernig's sign, ataxia). When examining the cerebrospinal fluid, no inflammatory changes are detected.

The blood picture is usually uncharacteristic. Normocytosis is noted; There are no significant changes in the formula and indicators of phagocytic activity. In severe cases, leukocytosis, thrombocytopenia, and signs of hypocoagulation are observed. Urinalysis in many cases reveals proteinuria, an increase in the number of leukocytes.

Diagnosis of Astrakhan rickettsial fever

Diagnostic criteria for APD:
· epidemiological data:
- seasonality of the disease (April–October),
- stay in a natural (anthropurgic) focus,
- contact with ticks (adults, larvae, nymphs);
· high fever;
· severe intoxication without the development of typhoid status;
· arthralgia and myalgia;
· profuse polymorphic non-confluent and non-pruritic rash on the 2-4th day of illness;
· primary affect;
· scleritis, conjunctivitis, catarrhal changes in the pharynx;
· enlarged liver.

For specific diagnosis of ARL, the reaction of RNIF with a specific antigen of the pathogen is used. Paired blood sera taken at the height of the disease and during the period of convalescence are examined. The diagnosis is confirmed by a 4-fold or more increase in antibody titers. The PCR method is also used.

Differential diagnosis

During prehospital examination, diagnostic errors were made in 28% of patients with APD. ARF should be differentiated from typhus, measles, rubella, pseudotuberculosis, meningococcemia, Crimean hemorrhagic fever (CHF), leptospirosis, enterovirus infection(enteroviral exanthema), secondary syphilis (Table 17-47).

Table 17-47. Differential diagnosis of Astrakhan rickettsial fever

Nosoform	Symptoms common to APD	Differential diagnostic differences
Typhus	Acute onset, fever, intoxication, central nervous system damage, rash, enanthema, liver enlargement	Fever lasts longer, up to 3 weeks, damage to the central nervous system is more severe, with disorders of consciousness, agitation, persistent insomnia, bulbar disorders, tremor; The rash appears on the 4th–6th day of illness, does not rise above the surface of the skin, and is roseola-petechial. The face is hyperemic, the sclera and conjunctiva are injected, Chiari-Avtsyn spots; the spleen is enlarged, there is no primary affect, lymphadenopathy. Seasonality is winter-spring, due to the development of pediculosis. Positive RNIF and RSC with Provachek antigen
Measles		Catarrhal phenomena are pronounced, the rash on the 4th–5th day, rashes in stages, rough, confluent, Belsky-Filatov-Koplik spots. There is no rash on the palms and soles. There is no connection with tick suction (contact), as well as primary affect
Rubella	Fever, rash, lymphadenopathy	The fever is short-lived (1–3 days), there is no rash on the palms and soles, and intoxication is not pronounced. The posterior cervical lymph nodes are predominantly enlarged. There is no connection between the disease and tick suction (contact), as well as primary affect. In the blood - leukopenia and lymphocytosis
Pseudotuberculosis	Acute onset, fever, intoxication, rash	The rash is rough, more abundant in the joint area; symptoms of “socks”, “gloves”, dyspeptic syndrome. Neurotoxicosis, arthralgia, polyarthritis are not typical, there is no connection between the disease and tick suction (contact), as well as primary affect
Meningococcemia	Acute onset, fever, intoxication, rash	The rash that appears on the first day is hemorrhagic, mainly on the extremities, rarely abundant. From the 2nd day, most patients have purulent meningitis. Liver enlargement is not typical. Primary affect and lymphadenopathy are not observed. In the blood - neutrophilic leukocytosis with a shift to the left. No connection with tick suction (contact) is observed
KGL	Acute onset, fever, intoxication, rash, facial hyperemia, central nervous system damage, primary affect, tick bite	The rash is hemorrhagic, other manifestations of hemorrhagic syndrome, abdominal pain, dry mouth are possible. Severe leukopenia, thrombocytopenia, proteinuria, hematuria. Patients are contagious
Leptospirosis	Acute onset, chills, high fever, rash	The fever level is higher, the rash is ephemeral and not pigmented. Jaundice. Hepatolienal syndrome. Myalgia and kidney damage up to acute renal failure are pronounced. Often - meningitis. In the blood - neutrophilic leukocytosis, in the urine - protein, leukocytes, erythrocytes, casts. There is no connection between the disease and tick suction (contact), as well as primary affect. No lymphadenopathy
Enteroviral exanthema	Acute onset, fever, intoxication, maculopapular rash, enanthema	Catarrhal symptoms are evident. A rash on the palms and soles is rare; conjunctivitis and enlarged cervical lymph nodes are typical. Often serous meningitis. There is no connection between the disease and tick suction (contact), as well as primary affect
Secondary syphilis	Roseolous-papular rash, lymphadenopathy	Fever and intoxication are not typical, the rashes are stable and persist for 1.5–2 months, including on the mucous membranes. There is no connection between the disease and tick suction (contact), as well as primary affect. Positive serological syphilitic tests (RW, etc.)

An example of a diagnosis formulation

A77.8. Astrakhan rickettsial fever; moderate course (based on clinical, epidemiological, serological RNIF data).

Indications for hospitalization

Indications for hospitalization:
· high fever;
· severe intoxication;
· tick suction.

Treatment of Astrakhan rickettsial fever

Etiotropic therapy is carried out with tetracycline orally at a dose of 0.3–0.5 g four times a day or doxycycline on the first day 0.1 g twice a day, on subsequent days 0.1 g once. Rifampicin 0.15 g twice a day is also effective; erythromycin 0.5 g four times a day. Antibiotic therapy is carried out until the 2nd day of normal body temperature, inclusive.

For severe hemorrhagic syndrome (profuse hemorrhagic rash, bleeding gums, nosebleeds) and thrombocytopenia, ascorbic acid + rutoside, calcium gluconate, menadione sodium bisulfite, ascorbic acid, calcium chloride, gelatin, aminocaproic acid are prescribed.

Forecast

The prognosis is favorable. Patients are discharged 8–12 days after body temperature normalizes.

Prevention of Astrakhan rickettsial fever

No specific prevention of APD has been developed.

Disinsection of dogs and catching stray dogs are important.

In epidemic foci, while staying outdoors during the ARF season, it is necessary to conduct self- and mutual examinations in order to detect ticks in a timely manner.

You should dress so that your outerwear, if possible, is plain, which makes it easier to find insects. It is recommended to tuck trousers into knee socks, and shirts into trousers; Sleeve cuffs should fit snugly to your arms. You cannot sit or lie on the ground without special protective clothing, or spend the night outdoors unless safety is guaranteed.

To reduce the risk of ticks crawling from livestock and other animals to humans, in the spring and summer it is necessary to systematically inspect animals, remove attached ticks with rubber gloves, and avoid crushing them. Ticks collected from animals should be burned.

A tick that has attached itself to a person must be removed with tweezers along with the head; treat the bite site with a disinfectant solution; send the tick to the State Sanitary and Epidemiological Supervision Center to determine its infectiousness.

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