Primary pneumonic plague (plague pneumonia). Pneumonic plague Prevention and treatment of pneumonic plague

Plague is one of the most dangerous diseases that claimed thousands of human lives for several hundred years.

Unfortunately, this infection exists now, and from time to time in different countries of the world its outbreaks arise. As a result, a large number of people die. The pulmonary form of the disease is especially dangerous, as it is highly contagious.

Methods of infection with plague

This disease is considered very formidable, as it often leads to blood poisoning and death. It has been known since ancient times. Previously, the disease terrified people. They did not know what provoked it and how to cope with the terrible epidemics that devastated entire cities.

The causative agent of infection is Science knows several varieties of this microorganism. Plague wand can be transmitted by animals (hares, cats, camels, ground squirrels, rats).

Bloodsucking insects (mainly fleas) are also carriers. As a rule, animals die almost immediately after infection, or the disease in them passes in a latent form. Rodents (ground squirrels, marmots, jerboas) usually carry this form of the disease during hibernation. The plague bacillus is a fairly resistant microorganism. It can remain in the secretions of the patient (mucus, blood) and even in corpses for several months. There are four forms of disease caused by this microorganism. These are varieties such as:

1. bubonic form.
2. Septic plague.
3. skin form.
4. Pneumonic plague.

The last form is extremely severe. Mortality rates for this type of infection are very high.

Types of pneumonic plague

There are two types of this infection:

1. The primary pulmonary form is characterized by a short latent period - from one day to three days. The disease develops very quickly and is manifested by pronounced symptoms. In the absence of adequate therapy, a person dies two to three days after infection.
2. secondary form. Occurs as a complication of another type of plague. It develops gradually, at the beginning of the disease the symptoms are not pronounced.

Both varieties are characterized by similar characteristics and are considered highly contagious. This is because pneumonic plague is transmitted from person to person.

Methods of infection

There are several routes of transmission of the disease. These include the following:

Secondary pneumonic plague occurs when microorganisms enter the respiratory system through the blood or lymph fluid.

Stages of the disease

The primary pulmonary form of plague proceeds in three stages:

1. This is a short period (from several hours to several days) from the very moment of infection to the appearance of the first symptoms of the disease. At this stage, microorganisms actively multiply.
2. First stage. This is the period of occurrence of general signs of the disease. There are also specific signs of pneumonic plague, such as coughing and inflammation.
3. Second phase. This stage is characterized by the occurrence of pathological processes in the lungs and serious respiratory disorders. The patient during this period is extremely contagious.

Pneumonic plague is considered the most dangerous type of this infection, since even with treatment, five to fifteen percent of patients die. The presence or absence of timely and effective treatment largely determines whether the patient has a chance to survive or not.

Signs of illness

So how does pneumonic plague manifest itself? Symptoms in humans first appear general, characteristic of all forms of this infection. On the first day of illness, the temperature rises sharply (up to 40 degrees and above). Appear pain in the muscles, back and head, lethargy, nausea and vomiting (sometimes mixed with blood). Then the patient begins to cough, he feels a lack of air, it is difficult for him to breathe.

In pneumonic plague, the symptoms are such as respiratory problems (it becomes too frequent) and mucus discharge. At first, the patient's cough is accompanied by expectoration of light, almost transparent sputum. Sometimes the discharge contains pus. Then blood and foam appear in the sputum, a lot of it leaves. Usually, on the second day of illness, the patient's condition deteriorates sharply, and some die during this period due to serious violations of the functions of the heart and respiratory organs or as a result of the development of a shock state.

Diagnosis of the disease

It is quite difficult to identify an infection such as pneumonic plague. This is due to the absence of signs inherent only to this disease. For example, symptoms such as severe coughing and bloody sputum are characteristic of tuberculosis, and it is difficult for doctors to distinguish between these types of pathologies. Also, the infection develops very quickly, and this makes it difficult to diagnose. When there is an outbreak in a locality, health workers carefully examine people with symptoms such as coughing and bloody sputum. In such cases, patients with similar pathological phenomena are hospitalized and placed in separate wards. Doctors closely monitor them and monitor their condition. In order to identify the presence of the plague pathogen in the body, a special blood test is performed.

Also, drugs are injected under the skin, the patient's reaction to them is assessed and they decide whether to vaccinate. In some cases, a person needs to be re-vaccinated. If necessary, doctors conduct laboratory tests not only of blood, but also of other biological material (urine, feces, vomit, sputum).

Therapy

Since pneumonic plague is a disease characterized by rapid development, doctors begin treatment even before the end of the diagnosis. Since this type of infection is highly contagious, the patient is placed in a separate room. Therapy includes antibiotics, measures to cleanse the body of toxins and the introduction of a special serum.

In case of violations of the functions of the respiratory organs and the heart muscle, doctors conduct specific treatment. Additional therapy is also required if there is a threat of developing a shock state. Usually, in the absence of fever and pathogens in the blood, the patient is discharged from the hospital after six weeks of treatment. However, a person who has had pneumonic plague must be under the supervision of doctors for three months.

Preventive actions

Actions to prevent this dangerous disease include the following:

1. Assessing the state of wild animals, establishing restrictions on hunting for them during outbreaks of the disease.
2. Timely notification of people about epidemics and ways of infection.
3. Vaccination of persons with an increased risk of infection (hunters, biologists, geologists, archaeologists).
4. If a person shows signs of a disease such as pneumonic plague, treatment and isolation should occur as soon as possible. Relatives and friends of the patient are prescribed prophylactic antibiotics. They must also be in the hospital under the supervision of doctors for six days.
5. All belongings of the patient must be treated with a special disinfectant solution.
6. In the territory where the epidemic was registered, it is necessary to carry out measures to exterminate rats. They also exterminate sick animals living in wild nature(hares, gophers, marmots, and so on). In the territory where an outbreak of the disease is detected, quarantine is established.

Since pneumonic plague is highly contagious, care must be taken to ensure that the infection does not spread.

Plague (pestis) is an acute zoonotic natural focal infectious disease with a predominantly transmissible pathogen transmission mechanism, which is characterized by intoxication, damage to the lymph nodes, skin and lungs. It is classified as a particularly dangerous, conventional disease.

ICD-10 codes

A20.0. Bubonic plague.
A20.1. Cellular skin plague.
A20.2. Pneumonic plague.
A20.3. Plague meningitis.
A20.7. Septic plague.
A20.8. Other forms of plague (abortive, asymptomatic, small).
A20.9. Plague unspecified.

Etiology (causes) of plague

The causative agent is a Gram-negative small polymorphic non-motile bacillus Yersinia pestis of the Enterobacteriaceae family of the Yersinia genus. It has a mucous capsule, does not form a spore. Facultative anaerobe. It is stained bipolar with aniline dyes (more intensively at the edges). There are rat, marmot, ground squirrel, vole and gerbil varieties of the plague bacterium. It grows on simple nutrient media with the addition of hemolyzed blood or sodium sulfate, the optimum temperature for growth is 28 °C. It occurs in the form of virulent (R-forms) and avirulent (S-forms) strains. Yersinia pestis has more than 20 antigens, including a thermolabile capsular antigen that protects the pathogen from phagocytosis by polymorphonuclear leukocytes, a thermostable somatic antigen, which includes V- and W-antigens, which protect the microbe from lysis in the cytoplasm of mononuclear cells, providing intracellular reproduction, LPS etc. The pathogenicity factors of the pathogen are exo- and endotoxin, as well as aggression enzymes: coagulase, fibrinolysin and pesticins. The microbe is stable in the environment: it remains in the soil for up to 7 months; in corpses buried in the ground, up to a year; in bubo pus - up to 20–40 days; on household items, in water - up to 30–90 days; tolerates freezing well. When heated (at 60 °C it dies after 30 s, at 100 °C - instantly), drying, exposure to direct sunlight and disinfectants (alcohol, chloramine, etc.), the pathogen quickly collapses. It belongs to the 1st pathogenicity group.

Plague epidemiology

The leading role in the preservation of the pathogen in nature is played by rodents, the main of which are marmots (tarbagans), ground squirrels, voles, gerbils, as well as hares (hares, pikas). The main reservoir and source in anthropurgic foci are gray and black rats, less often house mice, camels, dogs and cats. Of particular danger is a person with a pulmonary form of plague. Among animals, the main distributor (carrier) of plague is a flea, which can transmit the pathogen 3–5 days after infection and remains infectious for up to a year. The transmission mechanisms are varied:

• transmissible - when bitten by an infected flea;
• contact - through damaged skin and mucous membranes when removing skins from sick animals; slaughter and dressing of carcasses of a camel, a hare, as well as rats, tarbagans, which are eaten in some countries; in contact with the secretions of a sick person or with objects infected by him;
• fecal-oral - when eating insufficiently thermally processed meat of infected animals;
• aspiration - from a person sick with pulmonary forms of plague.

Diseases in humans precede epizootics in rodents. The seasonality of the disease depends on the climatic zone and in countries with a temperate climate is recorded from May to September. Human susceptibility is absolute in all age groups and with any mechanism of infection. A patient with the bubonic form of plague before the opening of the bubo does not pose a danger to others, but when it passes into the septic or pulmonary form, it becomes highly contagious, releasing the pathogen with sputum, bubo secretion, urine, and feces. Immunity is unstable, repeated cases of the disease are described.

Natural foci of infection exist on all continents, with the exception of Australia: in Asia, Afghanistan, Mongolia, China, Africa, South America, where about 2 thousand cases are registered annually. In Russia, about 12 natural focal zones are distinguished: in the North Caucasus, in Kabardino-Balkaria, Dagestan, Transbaikalia, Tuva, Altai, Kalmykia, Siberia and the Astrakhan region. Specialists of anti-plague institutions and epidemiologists monitor the epidemic situation in these regions. Over the past 30 years, group outbreaks have not been registered in the country, and the incidence rate has remained low - 12–15 episodes per year. Each case of human illness must be reported to the territorial center of Rospotrebnadzor in the form of an emergency notification, followed by the announcement of quarantine. International rules define a quarantine lasting 6 days, the observation of persons in contact with the plague is 9 days.

Plague is currently included in the list of diseases, the causative agent of which can be used as a means of bacteriological weapons (bioterrorism). Highly virulent strains resistant to common antibiotics have been obtained in laboratories. In Russia there is a network of scientific and practical institutions for the fight against infection: anti-plague institutes in Saratov, Rostov, Stavropol, Irkutsk and anti-plague stations in the regions.

Plague Prevention Measures

Non-specific

• Epidemiological surveillance of natural foci of plague.
• Reducing the number of rodents, carrying out deratization and pest control.
• Constant monitoring of the population at risk of infection.
• Preparation of medical institutions and medical personnel to work with plague patients, conducting information and explanatory work among the population.
• Prevention of the importation of the pathogen from other countries. The measures to be taken are set out in the International Health Regulations and the Territory Sanitary Regulations.

Specific

Specific prophylaxis consists in the annual immunization with a live anti-plague vaccine of persons living in epizootological foci or traveling there. People who come into contact with plague patients, their belongings, animal corpses are given emergency chemoprophylaxis (Tables 17-22).

Table 17-22. Schemes for the use of antibacterial drugs in emergency prevention of plague

plague pathogenesis

The causative agent of plague enters the human body more often through the skin, less often through the mucous membranes. respiratory tract, digestive tract. Changes on the skin at the site of the introduction of the pathogen (primary focus - conflict) rarely develop. Lymphogenically from the site of introduction, the bacterium enters the regional lymph node, where it multiplies, which is accompanied by the development of serous-hemorrhagic inflammation that spreads to the surrounding tissues, necrosis and suppuration with the formation of a plague bubo. When the lymphatic barrier is broken, hematogenous dissemination of the pathogen occurs. The ingress of the pathogen through the aerogenic route contributes to the development of the inflammatory process in the lungs with the melting of the walls of the alveoli and concomitant mediastinal lymphadenitis. Intoxication syndrome is characteristic of all forms of the disease, due to the complex action of pathogen toxins and is characterized by neurotoxicosis, TSS and thrombohemorrhagic syndrome.

Clinical picture (symptoms) of plague

The incubation period lasts from several hours to 9 days or more (on average 2-4 days), shortening in the primary pulmonary form and lengthening in vaccinated
or receiving prophylactic drugs.

Classification

There are localized (skin, bubonic, skin-bubonic) and generalized forms of plague: primary septic, primary pulmonary, secondary septic, secondary pulmonary and intestinal.

The main symptoms and dynamics of their development

Regardless of the form of the disease, plague usually begins suddenly, and the clinical picture from the first days of the disease is characterized by a pronounced intoxication syndrome: chills, high fever(≥39 ° C), severe weakness, headache, body aches, thirst, nausea, and sometimes vomiting. The skin is hot, dry, the face is red puffy, the sclera are injected, the conjunctiva and mucous membranes of the oropharynx are hyperemic, often with pinpoint hemorrhages, the tongue is dry, thickened, covered with a thick white coating (“chalky”). In the future, in severe cases, the face becomes haggard, with a cyanotic tint, dark circles under the eyes. Facial features sharpen, an expression of suffering and horror appears (“plague mask”). As the disease progresses, consciousness is disturbed, hallucinations, delusions, and agitation may develop. Speech becomes slurred; impaired coordination of movements. Appearance and the behavior of patients resemble the state of alcoholic intoxication. Arterial hypotension, tachycardia, shortness of breath, cyanosis are characteristic. In severe cases of the disease, bleeding, vomiting with an admixture of blood are possible. The liver and spleen are enlarged. Note oliguria. The temperature remains consistently high for 3–10 days. In the peripheral blood - neutrophilic leukocytosis with a shift of the formula to the left. In addition to the described general manifestations of the plague, lesions characteristic of individual clinical forms of the disease develop.

Skin form rare (3–5%). A spot appears at the site of the entrance gate of infection, then a papule, a vesicle (conflict), filled with serous-hemorrhagic contents, surrounded by an infiltrated zone with hyperemia and edema. Flikten is characterized by severe pain. When opened, it forms an ulcer with a dark scab at the bottom. A plague ulcer is characterized by a long course, heals slowly, forming a scar. If this form is complicated by septicemia, secondary pustules and ulcers occur. Perhaps the development of a regional bubo (skin-bubonic form).

bubonic form occurs most often (about 80%) and is characterized by a relatively benign course. From the first days of the disease, a sharp pain appears in the region of the regional lymph nodes, which makes it difficult to move and makes the patient take a forced position. The primary bubo, as a rule, is solitary; multiple buboes are less common. In most cases, the inguinal and femoral lymph nodes are affected, axillary and cervical lymph nodes are somewhat less common. The size of the bubo varies from a walnut to a medium sized apple. Bright features are sharp soreness, dense consistency, adhesion to the underlying tissues, smoothness of the contours due to the development of periadenitis. Bubo begins to form on the second day of illness. As it develops, the skin over it turns red, shiny, often cyanotic. At the beginning it is dense, then it softens, fluctuation appears, the contours become fuzzy. On the 10-12th day of illness, it opens - a fistula, ulceration is formed. With a benign course of the disease and modern antibiotic therapy, its resorption or sclerosis is observed. As a result of hematogenous introduction of the pathogen, secondary buboes can form, which appear later and are small in size, less painful and, as a rule, do not suppurate. A formidable complication of this form can be the development of a secondary pulmonary or secondary septic form, which sharply worsens the patient's condition, up to death.

Primary pulmonary form is rare, during periods of epidemics in 5-10% of cases and is the most epidemiologically dangerous and severe clinical form of the disease. It starts sharply, violently. Against the background of a pronounced intoxication syndrome, dry cough, severe shortness of breath, cutting pains in the chest appear from the first days. The cough then becomes productive, producing sputum that may vary in amount from a few spittles to huge quantities, rarely absent at all. The sputum, at first frothy, glassy, ​​transparent, then acquires a bloody appearance, later becomes purely bloody, contains a huge amount of plague bacteria. Usually it is a liquid consistency - one of the diagnostic signs. Physical data are scarce: a slight shortening of the percussion sound over the affected lobe, during auscultation, non-abundant fine bubbling rales, which clearly does not correspond to the general serious condition of the patient. The terminal period is characterized by an increase in shortness of breath, cyanosis, the development of stupor, pulmonary edema, and TSS. Blood pressure falls, the pulse quickens and becomes threadlike, heart sounds are muffled, hyperthermia is replaced by hypothermia. In the absence of treatment, the disease is fatal within 2-6 days. With early use of antibiotics, the course of the disease is benign, differs little from pneumonia of another etiology, as a result of which later recognition of the pneumonic form of plague and cases of the disease in the environment of the patient are possible.

Primary septic form it happens rarely - when a massive dose of the pathogen enters the body, more often by airborne droplets. It begins suddenly, with pronounced symptoms of intoxication and subsequent rapid development. clinical symptoms: multiple hemorrhages on the skin and mucous membranes, bleeding from internal organs("black plague", "black death"), mental disorders. Progressive signs of cardiovascular insufficiency. The death of the patient occurs in a few hours from TSS. There are no changes at the site of introduction of the pathogen and in the regional lymph nodes.

Secondary septic form complicates other clinical forms of infection, usually bubonic. The generalization of the process significantly worsens the general condition of the patient and increases his epidemiological danger to others. Symptoms are similar to the clinical picture described above, but differ in the presence of secondary buboes and a longer course. With this form of the disease, secondary plague meningitis often develops.

Secondary pulmonary form as a complication occurs in localized forms of plague in 5–10% of cases and sharply worsens the overall picture of the disease. Objectively, this is expressed by an increase in symptoms of intoxication, the appearance of chest pain, coughing, followed by the release of bloody sputum. Physical data allow diagnosing lobular, less often pseudolobar pneumonia. The course of the disease during treatment can be benign, with a slow recovery. The addition of pneumonia to low-infectious forms of plague makes patients the most dangerous in epidemiological terms, so each such patient must be identified and isolated.

Some authors single out the intestinal form separately, but most clinicians tend to consider intestinal symptoms (severe abdominal pain, profuse mucosal bloody stools, bloody vomiting) as manifestations of a primary or secondary septic form.

With repeated cases of the disease, as well as with plague in vaccinated or chemoprophylactic people, all symptoms begin and develop gradually and are more easily tolerated. In practice, such conditions are called "small" or "outpatient" plague.

Complications of the plague

There are specific complications: ITSH, cardiopulmonary insufficiency, meningitis, thrombohemorrhagic syndrome, which lead to the death of patients, and non-specific ones caused by endogenous flora (cellulitis, erysipelas, pharyngitis, etc.), which is often observed against the background of an improvement in the condition.

Mortality and causes of death

In the primary pulmonary and primary septic form, mortality reaches 100% without treatment, more often by the 5th day of illness. In the bubonic form of the plague, lethality without treatment is 20–40%, which is due to the development of a secondary pulmonary or secondary septic form of the disease.

Plague diagnosis

Clinical diagnostics

Plague can be suspected by clinical and epidemiological data: severe intoxication, the presence of an ulcer, bubo, severe pneumonia, hemorrhagic septicemia in persons who are in the natural focal zone for plague, living in places where epizootics (cases) were observed among rodents or there is an indication of registered cases of illness. Every suspicious patient should be examined.

Specific and non-specific laboratory diagnostics

The blood picture is characterized by significant leukocytosis, neutrophilia with a shift of the formula to the left and an increase in ESR. Protein is found in the urine. During X-ray examination of organs chest in addition to an increase in mediastinal lymph nodes, one can see focal, lobular, less often pseudolobar pneumonia, in severe cases - RDS. In the presence of meningeal signs (stiff neck, positive Kernig's sign), a lumbar puncture is necessary. In the CSF, three-digit neutrophilic pleocytosis, a moderate increase in protein content, and a decrease in glucose levels are more often detected. For specific diagnostics, bubo punctate, ulcer discharge, carbuncle, sputum, nasopharyngeal swab, blood, urine, feces, CSF, sectional material are examined. The rules for the collection of material and its transportation are strictly regulated by the International Health Regulations. The sampling of the material is carried out using special utensils, biks, disinfectants. The staff works in anti-plague suits. A preliminary conclusion is given on the basis of microscopy of smears stained by Gram, methylene blue or treated with a specific luminescent serum. The detection of ovoid bipolar rods with intense pole staining (bipolar staining) suggests a diagnosis of plague within an hour. For the final confirmation of the diagnosis, isolation and identification of the culture, the material is sown on agar in a Petri dish or on broth. After 12–14 hours, a characteristic growth appears in the form of broken glass (“lace”) on agar or “stalactites” in broth. The final identification of the culture is carried out on the 3rd–5th day.

The diagnosis can be confirmed by serological studies of paired sera in RPHA, but this method is of secondary diagnostic value. Pathological and anatomical changes are studied in intraperitoneally infected mice, guinea pigs after 3–7 days, with the inoculation of biological material. Similar methods of laboratory isolation and identification of the pathogen are used to detect plague epizootics in nature. For research, materials are taken from rodents and their corpses, as well as fleas.

Differential Diagnosis

The list of nosologies with which it is necessary to carry out differential diagnostics depends on the clinical form of the disease. The cutaneous form of plague is differentiated from the cutaneous form of anthrax, bubonic - from the cutaneous form of tularemia, acute purulent lymphadenitis, sodok, benign lymphoreticulosis, venereal granuloma; pulmonary form - from lobar pneumonia, pulmonary form of anthrax. The septic form of plague must be distinguished from meningococcemia and other hemorrhagic septicemias. Diagnosis of the first cases of the disease is especially difficult. Of great importance are epidemiological data: stay in the foci of infection, contact with rodents with pneumonia. It should be borne in mind that the early use of antibiotics modifies the course of the disease. Even the pneumonic form of plague in these cases can proceed benignly, but patients still remain contagious. Given these features, in the presence of epidemic data in all cases of diseases that occur with high fever, intoxication, lesions of the skin, lymph nodes and lungs, plague should be excluded. In such situations, it is necessary to conduct laboratory tests and involve specialists from the anti-plague service. The criteria for differential diagnosis are presented in the table (Tables 17-23).

Table 17-23. Differential Diagnosis plague

Indications for consulting other specialists

Consultations are carried out, as a rule, to clarify the diagnosis. If a bubonic form is suspected, a surgeon's consultation is indicated, if a pulmonary form is suspected, a pulmonologist.

Diagnosis example

A20.0. Plague, bubonic form. Complication: meningitis. Heavy flow.
All patients with suspected plague are subject to emergency hospitalization on special transport to an infectious diseases hospital, in a separate box, in compliance with all anti-epidemic measures. Personnel caring for plague patients must wear protective anti-plague suits. Household items in the ward, the discharge of the patient are subject to disinfection.

plague treatment

Mode. Diet

Bed rest during the febrile period. There is no special diet. It is advisable to sparing food (table A).

Medical therapy

Etiotropic therapy should be started if plague is suspected, without waiting for bacteriological confirmation of the diagnosis. It includes the use of antibacterial drugs. When studying natural strains of the plague bacterium in Russia, no resistance to common antimicrobial drugs was found. Etiotropic treatment is carried out according to approved schemes (Tables 17-24–17-26).

Table 17-24. Scheme of the use of antibacterial drugs in the treatment of bubonic plague

Table 17-25. Scheme of the use of antibacterial drugs in the treatment of pneumonic and septic forms of plague

** Used to treat plague with CNS damage.

Table 17-26. Schemes for the use of combinations of antibacterial drugs in the treatment of pneumonic and septic forms of plague

* There are injectable forms of the drug for parenteral administration.

In severe cases, it is recommended to use compatible combinations during the first four days of illness. antibacterial agents at the doses indicated in the schemes. In the following days, treatment is continued with one drug. The first 2-3 days, the drugs are administered parenterally, and then they switch to oral administration.

Along with the specific, pathogenetic treatment is carried out aimed at combating acidosis, cardiovascular insufficiency and DN, microcirculation disorders, cerebral edema, and hemorrhagic syndrome.

Detoxification therapy consists of intravenous infusions of colloidal (rheopolyglucin, plasma) and crystalloid solutions (glucose 5–10%, polyionic solutions) up to 40–50 ml/kg per day. The anti-plague serum and specific gamma globulin, which were previously used, proved to be ineffective during the observation process, and at present they are not used in practice, and the plague bacteriophage is also not used. Patients are discharged after complete recovery (with the bubonic form not earlier than the 4th week, with the pulmonary form - not earlier than the 6th week from the day of clinical recovery) and a three-time negative result obtained after sowing the bubo punctate, sputum or blood, which is carried out for 2- 1st, 4th, 6th days after stopping treatment. After discharge, medical supervision is carried out for 3 months.

Main article: Pneumonic plague

The pneumonic form of plague is a primary pneumonia and develops when a person is infected by airborne droplets from his respiratory organs. Another way of infection is the direct application of the infection with contaminated hands or objects (for example, a smoking pipe) to the mucous membranes. Clinical data also indicate the possibility of infection through the conjunctiva of the eyes. The pulmonary form is characterized by the development of foci of inflammation in the lungs as the primary symptoms of plague. There are two stages of pneumonic plague. The first stage is characterized by the predominance of general plague symptoms, in the second stage of the pulmonary form there are sharp changes in the patient's lungs. In this form of the disease, there is a period of febrile excitement, a period of the height of the disease and a terminal period with progressive dyspnea and coma. The most dangerous period is characterized by the release of microbes into the external environment - the second period of the disease, which has a critical epidemic significance. On the first day of illness, a patient with a pneumonic form of plague is diagnosed with chills, headaches, pain in the lower back, limbs, weakness, often nausea and vomiting, redness and puffiness of the face, fever up to 39-41 degrees, pain and a feeling of constriction in the chest, shortness of breath, restlessness, rapid and often arrhythmic pulse. Then, as a rule, rapid breathing and shortness of breath are present. In the agonal period, shallow breathing and pronounced adynamia were noted. A weak cough is fixed, sputum contains streaks of blood and a significant amount of plague microbes. At the same time, occasionally, sputum is absent or has an atypical character. The clinic of plague pneumonia is characterized by a pronounced scarcity of objective data in patients, which is not comparable with the objectively serious condition of patients, changes in the lungs are practically absent or insignificant at all stages of the disease. Wheezing is practically not audible, bronchial breathing is heard only in limited areas. Patients with the primary pulmonary form of plague without the necessary treatment die within two to three days, while almost absolute (98-100%) mortality and a rapid course of the disease are characteristic.

Diagnosis

The most important role in the diagnosis in modern conditions is played by the epidemiological history. The arrival from plague-endemic areas (Vietnam, Burma, Bolivia, Ecuador, Karakalpakia, etc.), or from anti-plague stations, of a patient with the signs of the bubonic form described above or with signs of the most severe - with hemorrhages and bloody sputum - pneumonia with severe lymphadenopathy is a fairly serious argument for the doctor of the first contact to accept all measures for the localization of the alleged plague and its accurate diagnosis. It should be emphasized that in the conditions of modern medical prophylaxis, the probability of illness of personnel who have been in contact with a coughing plague patient for some time is very small. Currently, there are no cases of primary pneumonic plague (that is, cases of infection from person to person) among medical personnel. The establishment of an accurate diagnosis must be carried out with the help of bacteriological studies. The material for them is the puncture of a festering lymph node, sputum, bloody, discharge from fistulas and ulcers.

Laboratory diagnostics is carried out using a fluorescent specific antiserum, which stains smears of discharge from ulcers, punctate of lymph nodes, culture obtained on blood agar.

Pneumonic plague in humans develops with an airborne transmission mechanism. The respiratory organs serve as the entrance gate. The primary reaction in the patient's body is expressed by the development of foci of inflammation in the lungs.

In the pulmonary form, two stages of the disease are distinguished. The first is characterized by the predominance common symptoms, during the second stage, changes in the lungs are pronounced. During the course of the disease, there is a period of initial febrile excitement, a period of the height of the disease and a soporous (terminal period) with progressive dyspnea and sometimes coma. Epidemiologically the most dangerous is the second period, accompanied by an intensive release of microbes into the external environment.

Clinical picture pneumonic plague, especially in the initial period of the disease, can be very diverse. The onset of the disease is usually sudden, without prodromal phenomena. The patient develops chills, severe headaches, pain in the lower back and limbs, weakness, often nausea and vomiting. The face becomes puffy and red. The temperature quickly rises to 39.5-40.5. The patient is restless, complains of chest pain. The pulse is frequent, sometimes arrhythmic. These symptoms appear on the first day of the disease.

At the height of the disease, patients have rapid breathing and shortness of breath, which increase with the development of the disease. Patients complain of pain and a feeling of constriction in the chest, often feel a lack of air and experience a feeling of fear of death, try

Get up and leave the room. In the agonal period, patients have shallow breathing, pronounced adynamia.

A common symptom of plague pneumonia is a cough, usually mild with or without sputum production. The secreted sputum may initially be mucous or mucopurulent, but soon blood streaks appear in it. In typical cases, the sputum becomes frothy, bright red in color, liquid in consistency and is excreted in large quantities. At the beginning of the disease, the plague microbe may not be detected in a sputum smear or occur in small numbers. At the height of the disease in the sputum - a large number of plague microbes.

Primary plague pneumonia does not always proceed in a typical form. Quite often, the sputum in patients with plague resembles sputum in croupous pneumonia and its discharge is short-lived. In rare cases, sputum is absent. Sometimes patients have copious hemoptysis, which causes suspicion of tuberculosis. In extremely severe forms, patients do not cough, but if you ask them to cough, then a characteristic blood-stained sputum appears.

Changes in the lungs at the onset of the disease are mild or absent. These data are scarce even in the midst of the disease. The clinic of plague pneumonia is characterized by the absence of objective data in patients and this is in conflict with their severe general condition. Even with extensive and deep lung damage in plague patients, dullness on percussion is often not observed or it is noted in small areas. Wheezing is also mostly not audible.

Untreated patients with primary pneumonic plague die within 2-3 days. The disease proceeds rapidly with high contagiousness with a lethal outcome up to 100%.

Emergency prevention of pneumonic plague

Streptomycin is administered at 0.5 g 2 times a day. When prescribing monomycin, it is administered intramuscularly at a dose of 0.5 g 2 times a day. Emergency prophylaxis can also be carried out with tetracycline antibiotics alone and in combination with other drugs.

Prevention. A vaccine made from heat-killed plague pathogens can induce immunity after 3 doses 2 weeks apart. In the future, to maintain immunity, it is necessary to carry out revaccination every 2 years. Live dry anti-plague vaccine is administered once and creates immunity lasting up to 6 months. In particularly unfavorable epidemic conditions, revaccination is carried out after 6 months.

Laboratory diagnostics is based on the isolation of the plague pathogen or the determination of an antigen in the test material and the detection of specific antibodies in the blood serum. All studies are carried out in special laboratories. The material for the study is: the contents of the bubo, vesicles, pustules, carbuncles, discharge of ulcers, sputum and mucus from the nasopharynx (in the pulmonary form), blood in all forms of the disease, feces in the presence of diarrhea.

In the blood, neutrophilic leukocytosis is detected, during the recovery period, leukopenia, lymphocytosis, a decrease in the amount of hemoglobin and erythrocytes may occur. In the urine - reveal traces of protein, erythrocyturia and cylindruria. For bacterioscopic examination, smears are prepared from the patient's secretions. The presence of clinical and epidemiological data, the detection of gram-negative ovoid bipolar-stained rods makes it possible to suspect the plague. The final diagnosis is made on the basis of the isolation and identification of the culture.

Antibiotics for prophylactic treatment of plague - Streptomycin, Dihydrostreptomycin, Pasomycin, Chlortetracycline, Dibiomycin, Oxytetracycline, Monomycin

Cultures are usually differentiated from pathogenic intestinal microflora, the causative agent of hemorrhagic septicemia and tularemia, according to morphological, cultural-biochemical and serological characteristics. It is more difficult to differentiate the microbes of plague and pseudotuberculosis.

The main difference between the causative agent of pseudotuberculosis: virulence in the S-form, insensitivity to the plague bacteriophage, mobility at a temperature of 20 degrees C due to the presence of flagella, fermentation of urea, glycerol, rhamnose, sensitivity to pesticin I, absence of fraction I antigen, fibrinolysin and plasmacoagulase.

Serological method - reaction of passive hemaagglutination, neutralization of antibodies and antigen, inhibition of passive hemagglutination. The serological method allows in a short time to examine the territory where diseases of rodent plague are found, and to determine the boundaries of the epizootic. Serological diagnostic methods can be used only in some patients. Thus, the reaction of passive hemagglutination to the I fraction of the plague pathogen becomes positive only starting from the 5th day after the onset of the disease and reaches a maximum by the 14th day of the disease.

Average doses of antibiotics in the treatment of patients with bubonic plague

The luminescent-serological method for determining the antigen in the test material is an express method for diagnosing plague. the method is based on the use of specific antibodies labeled with fluorescent substances.

Discharge from the hospital of persons who have had a local form of plague is made no earlier than 4 weeks after the normalization of body temperature, and those who have had disseminated (pulmonary and septic) forms of plague - no earlier than 6 weeks if there are negative results of the study of punctate from bubo, sputum , mucus from the nasopharynx (depending on the form of the disease), taken on the 2nd, 4th and 6th day after the end of etiotropic therapy. For convalescents, dispensary observation is carried out for 3 months. Convalescents with preserved sclerosed buboes can be discharged from the hospital after a double bacteriological examination of the bubo punctate.

is an acute, highly contagious infectious disease with airborne transmission. Characterized by the appearance of symptoms of severe general intoxication, signs of damage to the respiratory and cardiovascular systems, sepsis. The basis of diagnosis is bacteriological method and PCR, various body fluids are used for research. Additionally carry out serological tests. As a specific therapy, antibacterial drugs are used, primarily aminoglycosides and tetracyclines. Parallel appoint symptomatic treatment to improve the patient's condition.

ICD-10

A20.2

General information

Pneumonic plague is not a separate disease, along with bubonic plague is considered as a form of plague. Cases of the disease are registered in many countries of Africa, Asia, South America, in the territories of the Caucasus, in Altai. Currently, the most endemic regions are Madagascar, Congo, Peru. According to WHO, in the world for the period 2010-2015. 3,248 cases of illness were registered, of which 584 were fatal. Susceptibility is high, people are infected regardless of gender and age. Men suffer more often, which is associated with their greater employment in the rodent industry, their passion for hunting. In countries with a temperate climate, the peak incidence occurs in the summer-autumn period, with a hot one - in the spring season.

The reasons

The causative agent is the gram-negative bacterium Yersinia pestis. The pathogen is quite stable in the external environment. At a temperature of 22 ° C, it can remain viable for up to 4 months, at 100 ° C it is inactivated after 1 minute. Yersinia dies under the influence of solutions of lysol, sublimate and carbolic acid, direct sunlight. Sensitive to drying and antibiotics. In sputum and blood remains up to a month.

Due to the presence of exo- and endotoxin, the bacterium has a pronounced toxic effect on the human body. Specific factors of aggression and invasion allow it to inhibit the activity of macrophages and persist in them. At 37 ° C in an infected organism, the microbe forms a capsule, as a result of which its virulence increases. The source of the disease is a person with a primary or secondary pulmonary form of plague. Transmission occurs through the air.

Pathogenesis

In primary infection, the entry gates are the mucous membranes of the respiratory tract. With the flow of lymph, the bacillus enters the regional lymph nodes, where it is absorbed by macrophages. Incomplete phagocytosis contributes to the survival and reproduction of microbes inside phagocytes. In the place of localization of the pathogen, serous-hemorrhagic inflammation occurs. The lung parenchyma becomes plethoric, interstitial and alveolar edema is formed. The pleura is often involved in the process. Due to toxins, the vascular endothelium is damaged, stasis, blood clots, foci of hemorrhages, and necrosis zones are formed.

The entry of the pathogen into the blood contributes to the generalization of the infection. Bacteremia occurs, secondary screenings appear. Paresis of capillaries causes dysfunctions of the cardiovascular system, kidneys and other organs. Those who are infected die from heart failure or respiratory failure. In sepsis, patients die of shock with DIC. The secondary form is due to the drift of Yersinia into the lung tissue as a result of bacteremia, in the subsequent pathological process develops as in the primary type of pathology.

Classification

As an independent disease, pneumonic plague is not isolated, it is considered a type of pathology caused by a plague bacillus. The pulmonary form is one of the most severe variants of the course of the disease, it can cause the development of epidemics, which made it possible to classify it as a particularly dangerous infection. There are the following types:

• Primary pneumonic plague. It develops when the pathogen is transmitted through an aerosol upon contact with a sick pulmonary infection. A very severe course is characteristic, symptoms of intoxication, pleuropneumonia with bloody liquid sputum. Buboes are rarely identified. Without appropriate treatment, death occurs in 3-4 days. With a fulminant course, patients die on the first day.
• Secondary pneumonic plague. The patient is infected by transmissible, contact or alimentary routes, the lungs are affected in 5-10% of cases as a result of hematogenous introduction of the pathogen. Objectively detected buboes of the first and second orders. On the background clinical manifestations the main form on the 2nd-3rd day, the same signs of plague pneumonia appear as in the primary variant. The patient becomes a source of aerogenic infection.

Symptoms of pneumonic plague

The incubation period is from 3 to 10 days, on average 4-6 days, can be reduced to one day. The course of infection is conditionally divided into three periods: initial, peak of the disease and terminal. Pathology manifests suddenly with a sharp rise in body temperature to 39-40 ° C. Symptoms of severe intoxication, headaches and muscle pain, weakness, chills, vomiting are noted. Patients complain of shortness of breath, cough with discharge of glassy transparent sputum. Often worried about cutting pain, heaviness in the chest, tachycardia, conjunctivitis.

As the disease progresses, the nature of the sputum changes. It becomes liquid, bloody (with an admixture of scarlet blood or rusty), with the addition of pulmonary edema - pink, foamy. Allocations contain a large amount of the pathogen. A picture of lobar or focal pleuropneumonia is formed. Poor auscultatory data do not correlate with the severe condition of the patient. Objectively determined hyperemia of the skin, puffiness of the face, injection of blood vessels of the sclera, the so-called "bloodshot eyes". The tongue is densely coated with white coating - as if "rubbed with chalk."

At the height of the plague, symptoms of a disorder in the activity of nervous structures attract attention. On the early stages patients are agitated or inhibited. As the pathology progresses, toxic encephalopathy develops. Speech becomes slow, slurred, coordination of movements is disturbed, sensitivity to sound and light stimuli increases. Various degrees of impaired consciousness are formed up to coma.

As a result of paresis of the vascular bed and microcirculation disorders, deviations from the cardiovascular system occur, acute renal failure. Cyanosis and chest pains are growing, facial features are sharpened, shortness of breath is detected up to 60 per minute. There is a deafness of heart tones, tachycardia, the pulse may be arrhythmic. The pressure drops sharply, in the terminal period it is almost not determined. Hemorrhagic syndrome joins. On the skin are visible areas with hemorrhages, petechiae. Patients die from respiratory failure or severe hemodynamic disorders.

Secondary pneumonic plague is formed as a complication against the background of the main form of pathology. Symptoms of damage to the central nervous system, respiratory and vascular systems correspond to the above description. After the infection, persistent cellular immunity is formed, however, with massive infection, re-infection is not ruled out.

Complications

The most common complication is the development of acute cardiovascular and respiratory failure. Frequent episodes of infectious-toxic shock and DIC. Due to increased thrombus formation, gangrene of the fingertips is formed, possibly acute damage to the kidneys. Subsequent disorders of the blood coagulation system contribute to massive bleeding. Toxic damage to the central nervous system is complicated by coma; the facts of plague meningitis are described in the literature. Bacteremia and the formation of new foci in various organs lead to sepsis.

Diagnostics

The pulmonary variant of the pathology is diagnosed on the basis of clinical and laboratory data. On an objective examination of initial stages the infectious disease doctor draws attention to puffiness and flushing of the face, injection of scleral vessels, furry tongue. Febrile fever, cough with an admixture of blood, pain in the chest are noted. On auscultation, small bubbling wet rales, pleural friction noise, tachypnea are heard, in the heart points - deafness of tones, tachycardia, arrhythmias. Increasing hypotension.

In the terminal phase, cyanosis of the skin is expressed. In the case of secondary involvement of the respiratory tissue, buboes are identified. The appearance of neurological symptoms as a consequence of infectious-toxic encephalopathy is characteristic. With the development hemorrhagic syndrome bleeding, hemorrhages in the skin and mucous membranes are detected. The following methods are used to confirm the diagnosis:

• General laboratory research. AT general analysis blood leukocytosis is noted with a shift of the formula to the left, acceleration of ESR. Urinalysis reveals proteinuria and hematuria, hyaline and granular casts. When DIC is attached, changes in the coagulogram correspond to the stage of the process.
• Agent identification. The determining method in diagnosis is the bacterioscopic method. The material used is sputum, blood, swabs from the pharynx, punctate from buboes, separated from ulcers. Perform smear microscopy. Perform sowing of biological fluids on nutrient media. PCR is considered a fast and high-quality analysis. Additionally, ELISA, RIF, RPHA are used. A biological method with infection of laboratory animals is possible.
• Chest X-ray. X-ray examination determined focal and infiltrative shadows, which confirms the presence of pneumonia. Often, the images show signs of pleural involvement, and an effusion may be detected.

Differential diagnosis is carried out with croupous pneumonia. It is important to distinguish pathology from the pulmonary form of anthrax. Plague pneumonia may resemble changes in tularemia, typhoid and typhus, lung damage during influenza infection. In case of secondary infection, it is necessary to exclude acute purulent lymphadenitis of streptococcal and staphylococcal origin, sodoku, cat scratch disease.

Treatment of pneumonic plague

Conservative therapy

Patients with suspected plague are subject to isolation in compliance with anti-epidemic measures. The patient must comply with strict bed rest. The therapy has a complex character, it combines etiotropic and pathogenetic aspects. Specific etiological treatment is carried out antibacterial drugs from the group of aminoglycosides, tetracyclines. Streptomycin is used intramuscularly and tetracycline intravenously. Alternatively, gentamicin, doxycycline, rifampicin, ciprofloxacin, cephalosporins are used.

With the development of meningitis, chloramphenicol is prescribed in combination with other antibiotics. The duration of the course of taking the drugs is at least 10 days, then - according to indications. The management of pregnant women has some difficulties due to the undesirable effects of many drugs on the fetus. The scheme of drug therapy in such cases is made taking into account possible risks, foreign experts recommend giving preference to gentamicin.

For the purpose of detoxification, infusion therapy with colloid and crystalloid solutions with forced diuresis, plasmapheresis is prescribed. If necessary, use cardiotonic drugs, antipyretic drugs, glucocorticosteroids. Fresh frozen plasma, human albumin is administered in violation of hemostasis and protein synthesis. Proton pump inhibitors are recommended to prevent the development of stress ulcers. Perhaps the introduction of anti-plague serum and gamma globulin.

The addition of complications, such as pulmonary edema, sepsis, DIC, requires correction of therapeutic measures. The treatment plan includes plasma proteinase inhibitors, hemostatics, adreno- and sympathomimetics, and other drugs. In case of respiratory failure, inhalation of an oxygen-air mixture is necessary, according to indications - transfer to mechanical ventilation. Additionally, vitamins of group B, vitamin K are used.

Surgery

Surgical interventions may be required for secondary pneumonic plague, accompanied by the formation of buboes. With suppuration and opening of inflamed lymph nodes, their surgical treatment is carried out. Local administration of antibiotics active against staphylococci is also used, directly into the bubo after the appearance of fluctuation or spontaneous drainage.

Forecast and prevention

The prognosis is serious. The mortality rate without therapy is 30-100%. Properly selected treatment can significantly reduce this figure. Non-specific prevention measures are aimed at identifying and neutralizing foci, hospitalization and isolation of infected people, and veterinary supervision of animals. An important element in the fight against the spread of plague is the destruction of rodents and fleas.

After recovery, convalescents are registered at the dispensary for 3 months. All contact persons are subject to isolation and emergency prophylaxis with doxycycline or streptomycin for a course of 7 days. An extract is carried out with a complete clinical recovery (not earlier than 6 weeks) and only after a triple negative bacteriological examination. Specific prophylaxis is carried out by immunization of the population from risk groups with a dry live attenuated vaccine.