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"Child`s Health" 4 (47) 2013

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Guess a melody. Multicomponent, cyclic and acyclic infectious processes in the pediatric practice

Authors: Kruger Е.А., Bogadelnikov I.V., Bobrysheva A.V., Mazinova E.R., Diadiura E.N., Smirnov G.I., Crimea State Medical University named after SI St. Georgievsky, Department of Pediatrics with the Course of Child''s Infectious Diseases, Simferopol, Ukraine

Categories: Pediatrics/Neonatology

Sections: Specialist manual

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Last century the main pathogens, cause infectious disease at children, were streptococcus and staphylococcus, which was one of etiologic agent (pathogen). However, times have changed. For diseases such as shigellosis, plague, salmonellosis, rotavirus infection, anthrax, Legionnaires' disease, pseudotuberculosis, and others there is the following formula for the pathogenesis of infectious diseases: the agent → human →disease→development of sterile immunity→ eradication of agent from the human body → recovery (first strategy of parasitism  microorganisms by M.V.Supotnitsky, 2000). In these diseases the duration of infection limited by the human immune system (the first strategy of parasitism by M.V.Supotnitsky). Currently, there are infectious agents that had a different strategy of parasitism, and characterized by their hematogenous and sexual way of transmission, the ability to spread at a low density of population and the ability not only to "escape" from the immune response, but also to use it for their reproduction and enhance virulence, no bacterial eradication from the body after decrease clinical symptoms during convalescence, despite the presence of high titers of specific IgG in the blood, simultaneous activation of multiple pathogens in the body, a combination of microorganisms that use the first strategy of parasitism, and most importantly - a gradual and steady destruction of  the immune system (the second strategy of parasitism by M.V.Supotnitsky, 2000).

For an example we present the following case report. Girl S., 8 years, was admitted to the hospital infectious diseases at 23.11.12, with complain: increase body temperature up to 40 ˚ C during 2 weeks, weakness, decrease appetite. Anamnesis morbi: was ill acute in 9.11.12, when  appear  first increase body temperature up to 39 ˚ C,  pain in the throat and headache. District doctor was diagnosed tonsillitis and prescribed symptomatic treatment. But there are still patients had fever within the limits 39-40 ˚ C, and have been hospitalized in hospital at the place of residence with a diagnosis: fever of unknown origin. Prescribed treatment: i/v fluid glucose-saline, antibiotic and symptomatic therapy. However, during treatment persisted febrile fever (38-38,5˚C) and at 11.23.12 the child was admitted to the Republican Children's infectious diseases hospital in Simferopol. Epidemiological history: absent contact with infectious patients. Contact with a tuberculosis patient denies. Vaccinated by age. The Mantoux tuberculin test: 2005 - hyperemia 12 mm., 2006 - hyperemia 10 mm., 2007 - hyperemia 10 mm., In 2008-2009. - not conducted, in 2010 - hyperemia 12 mm, 2011 - hyperemia 12 mm, in 2012 - was not done. Life history was normal.  In admission: general condition severe, caused by intoxication syndrome. The body temperature is 38,2˚C, respiratory rate 28/min., Heart rate 100/min. Conscience is clear. Meningeal symptoms are negative.

Turgor and elasticity of the skin are reduced. Peripheral lymph nodes: palpable all the groups, the size of 0.3 x 0.5 cm in diameter, elastic consistency, mobile, painless. Skin is pale, no rash. Nasolabial triangle is pallor. Oropharynx is bright hyperemia of the palatine arches, the posterior pharyngeal wall, tonsils without membranes. Tongue dry, coated with white membranes. Nasal breathing free. Heart sounds are muffled, rhythmic. The liver and spleen were not palpable. Diagnosis on admission: fever of unknown etiology, convalescents after tonsillitis. Lab tests: General blood test in dynamics

23.11. – Hemoglobin 123, red blood cells 4,1, white blood cells 10,8, ESR 32, stab neutrophils 21, segmented 57, lymphocytes 14, monocytes 6, plas.cell 2. 29.11. – Hemoglobin 124, red blood cells 4,0, white blood cells 9,7, ESR 37, stab neutrophils 7, segmented 65, lymphocytes 20, monocytes 6, plas.cell 2. 17.12.-  Hemoglobin 124, red blood cells 4,0, white blood cells 9,4, ESR 6, stab neutrophils 8, segmented 41, lymphocytes 49, monocytes 2. Bacterioscopy of blood 23.11.12  and 24.11.12 - found gram (+) cocci. Biochemical investigations of blood: total bilirubin 10,  direct 3,  indirect 7,  ALT 0,76. AST 0,41.   thymol test 7,8. CRP: increased rates of C-reactive protein - 16.76 mg / l (normal for children - up to 10 mg / l). Sowing of material from the throat flora: allocated Streptococcus-β haemolytic. ELISA blood test for HIV (26.11.12) - HIV antibodies were detected. ELISA blood test for cytomegalovirus, herpes virus type 1 and 2 found elevated titers of IgM-CMV - 1.8 (positive> 1.1) and herpes virus type 1 and 2, 2.77 (positive> 1.1). PCR for Epstein-Barr virus positive. Ultrasound of the abdomen and kidneys: the liver parenchyma revealed hypoechoic lesions with a maximum size of 12 mm in diameter. In the gate of the liver - lymph nodes with a diameter of 12 mm. In the splenic parenchyma hypoechoic lesions with a maximum size of 12 mm in diameter. Сomputer tomography of the abdomen: in the spleen on the background parenchyma observed accumulation of contrast to 9.0 units. H, defined gipodensivnye foci density of about 60 units. H, without clear contours of 5 to 7 mm in diameter, in an amount of about 5. Conclusion: abscesses of spleen. Child consult: phthisiologist: infection of the MBT5.4 Bk, which indicates the presence of tubercle bacilli in the body, treatment of this condition does not require only observation.

Based clinical diagnosis: main: poliherpesvirus infection (cytomegalovirus, herpes virus type 1 and 2, infectious mononucleosis caused by the Epstein-Barr virus), severe course. Accompany: infection of MBT 5.4 Bq; spleen abscess, secondary immunodeficiency. Treatment: diet № 5, infusion therapy glucose-saline solution for 3 days.; antibiotic and  symptomatic therapy. After treatment the baby's temperature returned to normal, improved appetite and well-being, returned to normal peripheral blood. The girl was discharged home with recovery. After discharge from the hospital repeated laboratory tests of blood on the ELISA antibody titer (IgM, IgG) to cytomegalovirus, herpes virus type 1 and 2, and Epstein-Barr virus. Found decreased IgM titers to all three types of viruses and high titers of IgG-CMV - 5.8 (positive 1.1), a herpes virus type 1 and 2 - 2.2 (positive - more than 1,1).

Conclusions: it is shown that, on the background of the progress of infection (infection with Mycobacterium tuberculosis) develop typical, classic cyclic process (tonsillitis), which ends of eradication causative agent from the body. However, against the background of development secondary immunodeficiency activated poliherpesvirus infection (EBV, CMV, HSV), that is, developing acyclic infectious process, which causes severity of the condition and fever, despite the absence of clinical symptoms of them.

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