Plague

Plague (pestis) is an acute natural focal infectious disease caused by the plague of the plague-Yersinia pestis. Refers to especially dangerous infections. On the globe, a number of natural foci are preserved, where the plague is constantly found in a small percentage of rodents that live there. The epidemics of plague among people were often caused by the migration of rats infected in natural foci. From rodents to humans, microbes are transmitted through fleas, which in the mass death of animals change the host. In addition, the path of infection is possible when hunters process hides of killed infected animals. Essentially different is the infection from person to person, carried out by airborne droplets. Sporadic cases of plague have been reported in various countries, including the United States.

Etiology, pathogenesis. The causative agent of the plague is resistant to low temperatures, it is well preserved in sputum, but at 55 ° C it dies within 10-15 minutes, and when boiled - almost immediately. It enters the body through the skin (with a flea bite), mucous membranes of the respiratory tract, digestive tract, conjunctiva.

When a bite of plague-infected fleas is infected, a person may have a papule or a pustule at the site of the bite, filled with hemorrhagic contents (cutaneous form). Then the process spreads through the lymphatic vessels without manifestation of lymphangitis. Reproduction of bacteria in macrophages of lymph nodes leads to their sharp increase, fusion and formation of a conglomerate (bubonic form). Further generalization of infection, which is not strictly mandatory, especially in the conditions of modern antibiotic therapy, can lead to the development of a septic form, accompanied by the defeat of almost all internal organs. However, from the epidemiological point of view, an important role is played by the "screening" of infection in the lung tissue with the development of the pulmonary form of the disease. Since the development of plague pneumonia, the sick person himself becomes a source of infection, but at the same time from the person to the person the pulmonary form of the disease is already transmitted - extremely dangerous, with a very fast current.

Symptoms, course. Bubonic form of the plague is characterized by the appearance of sharply painful conglomerates, most often inguinal lymph nodes on one side. The incubation period is 2-6 days (less often 1-12 days). Within a few days the size of the conglomerate increases, the skin above it can become hyperemic. Simultaneously, there is an increase in other groups of lymph nodes-secondary buboes. The lymph nodes of the primary focus are softened, with their puncture getting purulent or hemorrhagic contents, microscopic analysis of which reveals a large number of gram-negative bipolar sticks. In the absence of antibacterial therapy, suppurated lymph nodes are opened. Then the fistula is gradually healed. The severity of the condition of patients gradually increases by the 4th-5th day, the temperature can be increased, sometimes a high fever occurs, but at first the condition of patients is often generally satisfactory. This explains the fact that a person who fell ill with bubonic plague can fly from one part of the world to another, considering himself healthy.

However, at any time, the bubonic form of the plague can cause the generalization of the process and turn into a secondary-septic or secondary-pulmonary form. In these cases, the condition of patients very quickly becomes extremely difficult. Symptoms of intoxication accrue by the hour. The temperature after the strongest chill rises to high febripnyh figures. All signs of sepsis are noted: muscle pains, severe weakness, headache, dizziness, congestion of consciousness, up to its loss, sometimes agitation (the patient rushes in bed), insomnia. With the development of pneumonia, cyanosis increases, a cough appears with the separation of frothy bloody sputum containing a huge number of plague rods. It is this sputum that becomes the source of infections from person to person with the development of the now primary pulmonary plague.

The septic and pulmonary forms of the plague flow, like any severe sepsis, with manifestations of the syndrome of disseminated intravascular coagulation: small hemorrhages may appear on the skin, bleeding may occur from the gastrointestinal tract (vomiting bloody masses, melena), pronounced tachycardia, rapid and requiring correction Dopamine) drop in blood pressure. Auscultatory - a picture of bilateral focal pneumonia.

The clinical picture of the primary septic or primary pulmonary form does not fundamentally differ from the secondary forms, but the primary forms often have a shorter incubation period - up to several hours.

Diagnosis. The most important role in diagnosis in modern conditions is played by epidemiological anamnesis. Arrival from zones endemic to the plague (Vietnam, Burma, Bolivia, Ecuador, Turkmenistan, Karakalpak ASSR, etc.), or from the patient's antiplague stations with the above-described signs of bubonic form or with signs of severe pneumonia with hemorrhages and bloody sputum Lymphadenopathy is for the physician of the first contact a sufficiently serious argument for taking all measures of localization of the suspected plague and its accurate diagnosis. It should be specially emphasized that in the conditions of modern medicamentous prophylaxis the probability of the disease of personnel who has been in contact with a coughing sick plague for a while is very small. Currently, cases of primary pulmonary plague (i.e., cases of human-to-human infection) are not observed among medical personnel. The establishment of an accurate diagnosis must be carried out with the help of bacteriological studies. The material for them is puncture of the suppurated lymph node, sputum, the patient's blood, fistula and ulcers. Laboratory diagnostics is carried out with the help of a fluorescent specific antiserum, which is stained with strokes of distant ulcers, punctate lymph nodes, culture obtained on blood agar. Treatment. If a plague is suspected, the patient should be immediately hospitalized in the box of the infectious hospital. However, in some situations it may be more appropriate to hospitalize (until an accurate diagnosis is established) in the institution where the patient is at the time of the assumption of a plague. Medical measures are inseparable from the prevention of infection of personnel, which should immediately wear 3-layer gauze masks, shoe covers, a scarf made of 2 layers of gauze, completely covering the hair, and goggles to prevent sputum from splashing into the mucous membrane of the eyes. If possible, the staff wears an antiplague suit. All the personnel in contact with the patient remain to further assist him. A special medical post isolates the compartment where the patient and the treating staff are located, from contact with other people. In the isolated compartment must enter the toilet and treatment room. All the personnel immediately receive preventive antibiotic treatment (see Annex 5), which continues all the days that he spends in the prison.

When the bubonic form of the plague, the patient is given intravenous streptomycin 3-4 times a day (a daily dose of 3 g), tetracycline antibiotics (vibromycin, morphocycline) iv in A-6 g / day. With intoxication intravenously injected saline solutions, haemodesis. The drop in blood pressure in the bubonic form itself should be regarded as a sign of generalization of the process, a sign of sepsis; With the need to carry out resuscitation, the introduction of dopamine, the establishment of a permanent catheter. With pulmonary and septic forms of the plague, the dose of streptomycin is increased to 4-5 g / day, and tetracycline - to 6 g. In forms resistant to streptomycin, it is possible to administer levomycetin succinateto 6-8 g IV. When the state of the dose is improved, antibiotics are reduced: streptomycin - up to 2 g / day until the temperature normalizes, but for at least 3 days, tetracyclines - up to 2 g / day daily inside, levomycetin - up to 3 g / day, total 20-25 g. With great success it is used in the treatment of plague and biseptol.

With pulmonary, septic form, the development of hemorrhages immediately begin to stop the syndrome of disseminated intravascular coagulation: plasmapheresis is carried out (intermittent plasmapheresis in plastic sacs can be performed on any centrifuge with special or air cooling with a capacity of 0.5 liters and more) in the volume of the removed Plasma 1-1.5 l when replaced with the same amount of fresh frozen plasma. In the presence of hemorrhagic syndrome, daily injections of fresh frozen plasma should not be less than 2 liters. Prior to the severed acute manifestations of sepsis, plasmapheresis is performed daily. The disappearance of signs of hemorrhagic syndrome, stabilization of blood pressure, usually with sepsis, are the grounds for stopping plasmapheresis sessions. At the same time, the effect of plasmapheresis in the acute period of the disease is observed almost immediately, the symptoms of intoxication decrease, the need for dopamine to stabilize blood pressure decreases, muscle pain subsides, and shortness of breath decreases.

In a team of medical personnel providing treatment for a patient with a pulmonary or septic form of the plague, there must be an intensive care specialist.

Forecast. In modern therapy, mortality with bubonic form does not exceed 5-10%, but in other forms the percentage of recoveries is high enough if treatment is started early. If the plague is suspected, the sanitary-epidemiological station of the district is immediately notified of this. The doctor who suspects the infection is filled in by the notification, and the head physician of the institution, where such a patient is found, provides his shipment.