Maisarah Repin Group 531-F

HFRS Acute zoonotic infection with a clear cyclic clinical syndrome with febrile state, oligouric, polyuric & hemorrhagic syndrome Caused by viruses Family : Bunyavirus Asian : Hantan virus causes disease with prevalence of hemorrhagic syndrome Puumala virus (Puumala is a Finnish river) causes predominantly acute renal failure Zoonosis Main source = reservoirs/rodents latent CM of disease. MOT : aerogenic (inspiration of dust with viruses), alimentary (eating of food with viruses), close contact with viruses Men > Women Post infectious immunity is stable & life-long Definition

Leptospirosis Disease caused by variety of pathogenic spirochetes of the genus Leptospira and is one of the most widespread zoonosis in the world Leptospira is highly coiled & mobile microorganism with a hooked end. There are 79 serotypes that are pathologic to human. They prefer alkaline, moist environment

Etiology

Epidemiology

Viruses fixed in regional LN and replicates during 1-7 weeks Enter into blood stream, generalized viremia occurs Massive viremia = Onset of Ds Generalized vasculitis develop Paresis of blood vessel ITS develop permeability of blood vessel & output of fluid into surrounding tissues Accelerate forming of BAS coagulation of tissue proteins and forming of autoAg Triggers into autoimmune Damage BV and tissue Maximal dose of viruses fix at kidney, its main target organ damage Oligoanuric period develop Canals are damage Polyuric dt canal function (disturbance of reabsorption). A lot of extravasation in kidney may lead to kidney rupture After Ab formation (end of 2nd week, >3-4 weeks) virus is connected & eliminated Main target damage - BV : vasculitis & hemorrhagic fever

Pathogenesis

Zoonosis MOT : drinking/swimming in moist water can penetrate healthy skin & mucous membrane. May enter through microwound of skin Primarily disease of animals Men > infected - Coal miners - Harbours Human-to-human spread is as rare as vertical transmission After infection, microorganism fixate at regional LN and during the next 3 weeks, multiplication takes place Generalisation of process = generalized bacteremia Vasculitis Peculiarity : ability to penetrate Blood-Brain Barrier In case of high dose of microbe, brain edema develop Later, pathological process in cranial meningoencephalitis Dissemination in 1st week Toxic symptoms + Hemorrhagic syndrome 2nd week : microorganism @ parenchymal organs - liver -kidney - spleen Period of organ manifestation - meningoencephalitis - iridocyclitis - hepatitis - Renal Failure - Hemorrhagic Syndrome At end of 2nd week, antibodies form. Short time improvement but in spite of blood Ab, tissue immunity is absent.

Maisarah Repin Group 531-F

Clinical Course first 5-6 days : Febrile Next 3-4 days : Oligoanuric Next 6-8 days : Polyuric After : Reconvalescent

Febrile Abrupt onset T up to high figures Generalized toxicosis Muscle and back pain HA Sx of HF hyperemia, enlargement of sclera vessels, hemorrhage at sites of pressing, Red Cherry Sign (bleeding into sclera of eyes), +ve tourniquette test, strong back pain (tenderness to percussion @ costovertebral angel reflect massive retroperitoneal) Oligouric In 5-6 days, T but patients condition becomes worse. Main Sx: Abrupt of dieresis (dt no filtration), production of nitrogen metabolism Strong HA, BP (dt juxtaglomerular mechanism activation) Renal eclampsia develop (high BP dt JG) Renal encelopathy develops - Loss of consciousness - Apathy - Tremor of lips, fingers - Uremic colitis Azotemic uremia - lvl of creatinine & urea in blood Severe Hemorrhagic Syndrome * bruises * nose & teeth bleeding * hematuria Polyuric In 3-4 days, dieresis restored & but its not reconvalescent. Its Polyuric period. Disturbance of tubular function (hypo and isosthenuria)

Clinical Manifestations

3rd & 4th week relapses 5th week strong immunity form, reconvalescence occurs Ability to call non-sterile immunity In accordance with pathology, the clinical periods are : 1) Initial febrile period (1 week) 2) Organ manifestations 3) Relapses (3-4th week) 4) Reconvalescent ( 5th week) Febrile Looks like HFRS Abrupt onset T Generalized toxicosis : HA, myalgia Hemorrhagic syndrome Loss of vision (dmg of retinal vessels) Bruises Symptom of red cherry Difference : great risk of brain symptom development, strong diffused muscle pain especially at calf muscle (dt lactate) Organ Manifestation Damage of liver Jaundice HSM Change of liver enzymes Damage of kidney (ARF same like HFRS) Meningoencephalitis - local Sx of damage of certain part of brain - meningeal sx Iridocyclitis - refer to ophthalmologist Relapse At 3rd-4th week Reconvalescence At 5th week Period of disappearance of CM & normalization of laboratory values

Maisarah Repin Group 531-F

Reconvalescent Reconvalescence lasts 1 year. In this period, maybe PN, kidney rupture. Must be supervised by nephrologist If patient presents with - Fever suspect - Hemorrhagic Syndrome HFRS - Renal dysfunction Must DDx with Leptospirosis Rickettsia Flu Sepsis Method of specific Ix - luminescent reaction of Ab reaction - only after 2nd week!! Febrile Leucopenia Lymphocytosis Monocytosis ESR is normal w/o change Oligouric Leucocytosis ESR Anemia TCP Neurophilosis density High, transient proteinuria Hematuria () Casturia Epithelial cells Polyuric w/o changes

Investigations & Diagnosis

Leptospira x grow into media Serologic Passive hemagglutination Pair serum 1st : 2nd week or less 2nd : in 7-10 days titre confirms the diagnosis Sometimes material from patient maybe diagnosed using darkfield microscopy (x stain with aniline) They are transparent & motile

GBT

Urine analysis

Hypoisosthenuria

Biochemistry creatinine K BUN Oligoanuric : control these factors everyday to see dynamics and indications to hemodialysis

Maisarah Repin Group 531-F

Febrile Infective Toxic Shock Oligoanuric Kidney rupture ( even during Pasternatsky sign elicitation!) - Unilateral back pain - BP - Anemia - Abdominal palpation infiltrate hematoma Rx : Surgery Renal Eclampsia - repeated alteration of tonic-clonic cramps dt BP Azotemic Uremia - Renal encephalopathy Depends on stage Febrile Traditional solutions (5% glucose, 0.9% NaCl) Restore BV wall (Vit C, Ca) Steroids microcirculation (rheopolyglucine, trental) Analgesics Oligoanuric Diuretics + 1L = volume of detox infusion Diuretics : 80mg Furosemide (lasix). If dieresis x , then diuretics are CI!! Non-efficacy : - 10% 10ml CaCl2 - 2.4% 10ml euphylline - 0.25% Novocain (100-150ml) IV drops At end of injection, add 10-20% 10ml Glucose, 6-8 Units of insulin to transform extracellular K+ into intracellular space (if hyperpotassemia) Meteorism vomiting arrhythmia bradycardia Inject 10% NaCl!

Complications

At 4th-5th week - Infectious Allergic Complication! * GN * Pancreatitis * Myocarditis During late reconvalescent, of hearing & vision may develop Post-leptospirosis Cx - Leptospira Ictera-Hemorrhagia of Polyorgan Failure - Will-Vaselev disease (?)

Treatment

Early antibiotic therapy Penicillin 6-12 million Units/day IM q4-6hours To prevent relapses, at 3-7 days add tetracycline 0.3mg qid for 5 days. Other methods are the same as HFRS! After reconvalescent, must supervise for 6 months to prevent late complications!

Maisarah Repin Group 531-F

Hemorrhagic Syndrome Vit C Na ethamzilate Fresh frozen plasma (FFP) If x efficacy add Dopamine (very slow injection to enlarge renal vessels) If x efficacy during 1 day, estimate indication for hemodialysis. Indications: - Oliguria >4days - non-protein nitrogen > 60 - BU >20 - K+ > 7mmol Polyuric Restore salt maintenance Inject poluion salt solution Rule of discharge? Mild 2 weeks Moderate 3 weeks Severe 4 weeks Supervise for 1 year!