Brill's disease is the recurrence of an epidemic typhus keeping clinical displays of primary disease, but proceeding mainly benign. A characteristic clinical symptom is plentiful rozeolezno-petekhialny rash on skin, mucous membranes. As system manifestations serve fever, consciousness changes, tendency to tachycardia and hypotonia. The confirming diagnostic methods include detection of antibodies to a sypnotifozny rikketsiya and the activator in an organism. Treatment of a retsiviruyushchy typhus is carried out by means of etiotropny antibiotics, and also symptomatic medicines.
Brill's disease (Brilla-Tsinsser's disease, repeated sypny typhus) – the acute infectious disease proceeding with defeat of integuments, mucous is more rare than cardiovascular, nervous systems. For the first time the disease was described in 1910 by the American doctor N. Brill and added in 1934 by the epidemiologist H. Tsinsser. Scientists connected pathology symptoms with earlier postponed typhus that in sulfurs. The XX century it was confirmed with detection of rikketsiya in lymph nodes of the dead from the typhus recurrence for the first time postponed more than in 20 years prior to death. The disease has no accurate seasonality, has sporadic character, does not mean obligatory recent contact with louses or patients with a pediculosis.
As causative agents of an infection serve Provachek's rikketsiya which are in lymph nodes and other bodies had in the past epidemic sypny typhus of the person. Rikketsiya – obligate intracellular microorganisms, perish at boiling, use of standard solutions of disinfecting substances. An infection source for himself is the sick person, for people around it is not infectious only for lack of louses. In the presence of a pediculosis the patient with a disease Brilla can infect surrounding with an epidemic typhus by means of inoculable transmission of infection.
Traditionally the risk group joined only people 45 years, but in connection with high prevalence of HIV infection in the world are more senior, patients with a virus of an immunodeficiency can be subject to Brill's disease more than the general population. As starting factors of a recurrence usually serve sharp respiratory infections, exhaustion, long stressful situations, overcoolings, radiation, exacerbations of chronic diseases, a trauma, change of climate, work on harmful production, heavy immunodeficiency, etc. Children up to 18 years have no this pathology.
After the postponed epidemic lousy typhus of a rikketsiya the long time is persistirut in lymph nodes, parenchymatous bodies (most often in a liver, kidneys) and lungs. An important role in pathogenesis of a recurrent infection is played by quantity of rikketsiya (usually insignificant) which correlates with weight of clinical and morphological manifestations. In the presence of the corresponding conditions of a rikketsiya get into a system blood-groove, at the same time the main target for the activator is endoteliya of vessels. In endoteliotsita there is a reproduction of rikketsiya, inflammatory changes can take all thickness of a vessel, leading to a necrosis of a vascular wall. However specific sypnotifozny granulomas (Popov's small knots) are formed seldom.
The so-called warty endocarditis with defeat of valves of heart is characteristic of a disease. Owing to circular or segmentary vascular defeat blood clots are formed, at localization of thrombosis (or a thrombembolia) in vessels of a brain ischemic damages of nervous tissue are possible. Defeats of vessels cause also skin displays of a disease. Important feature of pathology is unsterile immunity therefore at full elimination of the activator perhaps new infection. However repeated cases of this pathology in the world are almost not recorded. Possibly, it is connected with morphological features of rikketsiya, their intracellular parasitizing allowing to be a long time inaccessible to cages of immune system of an organism.
Symptoms of a disease of Brill
The incubatory period of a disease lasts in certain cases from 3 to 50 years. The first clinical manifestations can begin in 5-7 days after influence of a provocative factor. The beginning of a recurrence sharp, with sharp rise in body temperature to high figures (it is above 39 °C), a fever, the expressed weakness, fatigue, a severe headache, a loss of appetite. Patients are excited, there can be sleep disorders, euphoria, depersonalization, a giperesteziya eye, acoustical, olfactory and other analyzers. The lowering of arterial pressure is noted (lower than 120/80 mm of mercury.). Not expressed hyperaemia of the person, an injection of vessels a skler is observed, from first days Kiari-Avtsyn's spots (single red-orange elements on an indistinct contour on a conjunctiva, a cartilage of an upper eyelid) and Rosenberg's enantema decide (small petekhiya on a cover of a soft palate, handles of almonds).
About 3-4 days of the beginning of a recurrence on skin emergence of the rozeolezno-petekhialny rash which is mainly concentrated on a body, the side surfaces of a trunk, the top extremities is noted; much less often elements are found on a face, palms and soles. Rash does not cause an itch, a peeling, passes completely (rozeola) or leaves sites of a depigmentation (petekhiya). Prevalence of petekhialny rashes is considered an adverse predictive sign, however at this nosology it is observed extremely seldom, as well as a current without emergence of an ekzantema. An infrequent, but terrible symptom is the brain substance inflammation which is shown consciousness violation, paralyzes, paresis.
The early request for medical care, the correct diagnostics, timely treatment allow to transfer a disease without complications. Patients with chronic system diseases are most often subject to development of the medium-weight and complicated forms of a disease of Brill. The most terrible consequences of a recurrence of a rickettsial disease are the tromboembolichesky syndrome, thrombophlebitises, infectious and toxic shock, secondary bacterial infections (hypostatic pneumonia, pyelonephritis, sepsis). Purulent complications because of invasive medical medical and diagnostic manipulations are possible (intravenous infusions, a kateterization of vessels, intramuscular injections and others).
Confirmation or an exception of the diagnosis of recurrent typhus requires consultation of the infectiologist, cardiologist, dermatovenerologist. At emergence of signs of defeat of TsNS survey of the neurologist is obligatory. Diagnostics of a nosology is carried out by the careful collecting the epidemiological anamnesis, the correct interpretation yielded survey results of laboratory and tool researches:
- Fizikalny inspection. At an objective research of the patient moderate psychomotor excitement, sometimes – a tremor of fingers of brushes and tolchkoobrazny pushing out of language attracts attention forward (Govorov-Godelye's symptom). Rozeolezny and petekhialny rashes on integuments, a conjunctiva of eyes, a soft palate are observed. At a palpation of a stomach it is possible to find increase in a liver, spleens (gepatosplenomegaliya). Positive symptoms of a plait and a pinch (artificial calling of rash are characteristic at a skin sdavleniye).
- Blood test and urine. In the all-clinical analysis existence of a neytrofilny leykotsitoz with stab shift to the left, limfotsitopeniya, an eozinofilopeniya, acceleration of SOE is noted. Biochemical researches show increase in indicators of creatinine, a giperglobulinemiya, a gipoalbuminemiya. In the general analysis of urine – increase in density, an albuminuriya, a tsilindruriya, is more rare a mikrogematuriya.
- Identification of infectious agents. For diagnostics serological blood test (IFA, RSK, RNIF) with detection of immunoglobulins of a class G (IgG) to Provachek's rikketsiya is obligatory. It is possible to prove existence of the activator in an organism by means of PTsR. Bacteriological blood test is labor-intensive and expensive process, if necessary is carried out only in laboratories of especially dangerous infections.
- Cardiodiagnostics. On an electrocardiography tachycardia, symptoms of a hypoxia of a myocardium comes to light, is more rare – insufficiency of the struck valves. At EHO-KG vegetations with the shaded contour, a non-uniform ekhografichesky signal, a thickening of shutters of valves, sometimes – formation of valvate insufficiency, aggravation of a regurgitation are found.
Differential diagnostics is carried out with an endemic typhus, a rubella, measles, syphilis, sepsis, spotty fever of the Rocky Mountains, flu, a typhoid, paratyphus And yes In, hemorrhagic fever with a kidney syndrome, a meningococcal infection (a meningokoktsemiya and meningococcal meningitis), leptospirosis. Considering the damages of heart caused both a recurrence of typhus, and often accompanying kardialny pathology, it is necessary to differentiate a disease with an infectious endocarditis, rheumatic heart diseases, cardiomyopathies. Psychomotor excitement or block, and also possible episodes of hallucinations, nonsense can have the reason alcoholic, narcotic intoxication or be a debut of mental disorders or senile dementia.
Treatment of a disease of Brill
Patients with suspicion of this pathology are subject to hospitalization. A bed rest, it is necessary to keep mainly horizontal position till 5-6 in the afternoon of normal temperature. Then incontinuous movements under supervision of health workers, then – independently within office are allowed. Regular monitoring of arterial pressure is necessary. Application of compression jersey for prevention of thrombosis of deep veins of the lower extremities and TELA can have some efficiency. It is recommended to increase the liquid use, to adhere to a diet with an exception of alcohol, the fried and fat dishes.
Etiotropny medicines for treatment of a disease of Brill – antibiotics of a tetracycline, rifamitsinovy row, and also macroleads (for example, doxycycline, , rifampicin or ). Pathogenetic use of vitamins C and P, having vazoprotektorny properties is proved. Symptomatic therapy includes febrifugal, dezintoksikatsionny medicines (, , Hartman's solution, Ringera, the glyukozo-salt and succinate-containing infusion solutions), sedatives (barbiturates, diazepam and others). To all patients, especially advanced age, use of anticoagulants is recommended (heparin).
Forecast and prevention
The forecast of a state most often favorable, a lethality makes 1-2%. Komorbidny states and age of the patient can exert impact on the course of an infection, most often the feverish stage of a disease lasts about 7-8 days, the complete recovery takes up to 2-3 weeks. About 70% of cases proceed in an easy or medium-weight form.
Specific prevention of a disease consists in application of vaccines according to epidemiological indications. Practice of vaccination by a live sypnotifozny vaccine and its analog – the dry chemical medicine supporting the killed of rikketsiya is most extended. Application of means of specific prevention is shown to persons, temporarily or the pediculosis which is constantly in contact with patients and a typhus and also in common living with the patient with Brill's disease in adverse sanitary and epidemiologic conditions.
The main way of nonspecific prevention of pathology is fight against louses (routine inspections in educational institutions and working collectives), sanitary and educational work with the population, inoculation of hygienic skills to children. Full disinsection of the places of residence, clothes, personal belongings of patients with a pediculosis is necessary. Early identification, isolation, rational antibiotic treatment of patients with epidemic typhus is important.