CHAPTER 4. ACTIVE PRIMARY GERPESVIRUSNAJA THE INFECTION AT CHILDREN WITH THE LONG SUBFEBRILE CONDITION

Under observation there were 15 children with a long subfebrile condition with primary acute gerpesvirusnoj an infection. Among children with a syndrome of a long subfebrile condition, perenosjashchihaktivnuju primary GVI, children of younger age prevailed, boys was in 2раза more than girls (10 and 5 accordingly).

Children to 1goda - 2, patients from 1 year till 3 years was 7, from 3 — till 6 years - 4, от10до 11let - 2 children.

Children arrived in a hospital with various diagnoses. At 13 from 15 children was diagnosis ORVI, including with complications (a pneumonia — at 4, an obstructive bronchitis — at 4, an exanthema of not specified aetiology — at 2, a Quincke's edema — at 2, a purulent lymphadenitis — at 1 patient), an infectious mononucleosis — at 2 of 15 children. T about, on pre-hospital etapegerpeticheskaja the infection has been suspected only at 2 children with the diagnosis «Infectious mononucleosis».

Etiological structure primary acute GVI at children with DS predstavlenana a drawing 8.

Drawing 8. Etiological structure pervichnojaktivnoj GVI at children with DS (n=15)

Apparently on fig. 8, at children with DS at primary acute GVI, prevails TSMVI and EBVI, both at a mono-infection, and at a multi-infection. Only 6 mono-infection is diagnosed for 2 children VGCH.

Let's survey diagnostic markers GVI which have allowed us to establish an aetiology of a long subfebrile condition at children.

For 2 children it is diagnosed acute TSMVI, confirmed with detection of DNA TSMV in blood and a saliva, presence of specific antibodies of class IgM and IgG in a diagnostic caption; acute EBVI (2) - confirmed with presence of DNA EBV in blood and detection of antigens in leucocytes of blood and specific antibodies EAEBVIgG, VCAIgM; at 2 patients — acute VGCH 6 And, on the basis of detection of DNA VGCH 6 in blood and a saliva, detection genoma a virus in lymphocytes of blood and presence of specific antibodies of a class and IgG; for 9 children it is diagnosed admixed ЭБВИ+ЦМВИ on the basis of detection of DNA TSMV in blood (8) and antigens TSMV in leucocytes of blood (5), TSMV Ig M (9), TSMV IgG (7) exceeding diagnostic level in 2-3 times, DNA EBV in blood (9) and antigens EBV (4), VCAEBVIgM (9), VCAEBVIgG (9), EAEBVIgG (7).ptsr on presence of DNA of a virus in bloods it is spent by all patient, on presence of DNA of a virus in a saliva and urine it is spent 13 patients. NRIF for detektsii virus antigens in lymphocytes it is spent by all 15 patients. IFA blood sera on presence AT of class IgM, and IgG to the specified viruses it is spent by all 15 patients.

Thus, at primary active GVI, AT class IgM 15 children, and AT class IgG in low diagnostic titre at half of children (57 %), to TSMV and EBV were taped at all; at ВГЧ6 — at 2 children IgG in low diagnostic titre, were taped along with IgM.

Frequency of revealing of antigens in lymphocytes and DNA of viruses method PTSR is presented by method NRIF in a drawing 9.

Drawing 9.

Apparently on fig. 9, at primary active EBVI, DNA EBV was defined in blood in 100 %, and antigenemija — in 2,5 times is more rare — in 40 %; DNA TSMV in blood was defined in 75 %, and antigenemija TSMV - in 60 % of cases, at children with ВГЧ6И has been taped simultaneously and DNA in blood and antigenemija.

Thus, for the purpose of rising of efficiency laboratory podtvezhdenija active primary GVI at children with a long subfebrile condition, it is necessary to use a complex laboratornyhmetodov.

The premorbidal condition has been burdened at 4 (26,6 %) children. Children were observed suvelichennymi by the adenoid vegetations (2), an open oval window (2), timomegaliej (2), a congenital cyst of a liver (1). At 2 children 2-3 burdening factors became perceptible. From the anamnesis of diseases it is known, that at all children development of a syndrome of a long subfebrile condition was preceded by clinic ORVI, against spent therapy of full recover from a respiratory infection did not come, the subfebrile condition 37,4-37 remained. 8 °s, within 28-58 days, and then, a condition of the child
Again there was a febrile fever, symptoms of an intoxication and clinic of complications, such as: an obstructive bronchitis (4), a pneumonia (4), an aphthous stomatitis (1), an ulitis (1), occurrence pjatnistoyopapuleznoj eruptions (3), a Quincke's edema (1), an intersticial postvirus nephritis (1), as served as an occasion to hospitalisation. At the moment of hospitalisation at 12 (80 %) children the subfebrile condition lasted 4-5 weeks, at 3 (20 %) children — 2 months.

At primary acute VGCH 6, TSMVI and EBVI, and also at combination TSMVI and EBVI, the polymorphic semiology was observed: a febrile fever, against a subfebrile condition and augmentation lymphatic uzlovu all 15 (100 %) patients, difficulty of nasal breath, a pain in gorlei a moderate hepatomegalia at 13 (86,6 %) patients, tussis at 12 (80 %) children, including at detejs an obstructive bronchitis, a splenomegaly — at 10 (66,6 %) patients. From other symptoms were observed: an abdominal pain — at 8 (53,3 %), quinsy, pastoznost persons, an exanthema — at 6 (40 %) patients, a rhinorrhea and osiplost voices — at 4 (26,6 %) children, a liquid chair and vomiting — at 3 (20 %), puffiness and an ecdysis of palms and feet — at 3 (20 %), an arthritis of a knee joint — at 1 (6,6 %) the child.

The characteristic of clinical symptoms primary acute GVI at children with a long subfebrile condition.

Temperature. At children of this group duration of a subfebrile condition has made 22-58 days.

At an estimation of features of temperature reactions at a subfebrile condition it is noticed, that at all 15 children became perceptible rise in temperature in the evening and night time, at one child the morning body temperature was not above vespers.

At 12 of 15 children the subfebrile body temperature became perceptible daily, at 3 — incidental rise in temperature (within 3-5 days the temperature was subfebrile, then decreased to 36,7-36,9 °s, and then - again raised to subfebrile digits). At 11 children were registered
Numerous liftings of temperature within day, at 10 of them the subfebrile condition became perceptible, mainly, in the evening. The low subfebrile condition is noted at 3 patients, scope of temperature to 38 °s — at 4.

The fervescence to febrile digits against a subfebrile condition is noted at all 15 sick (tab. 7).

Table 7

Features of temperature reactions n=15

Apparently from table 7, at 13 patients the body temperature raised to 39°С, and at 2 children-to 40⁰С.У 6 children the body temperature was febrile only one day, and then, remained subfebrile throughout all disease. Average value of a fever has made 38±0,76°С.

Duration of a febrile fever at 6 children has made — 3 days, at 9 patients — 4-5 days (3,25±1,5).

Thus, at an estimation of temperature curves, it is possible to notice, that for aktivnojgvi, it is characteristic: a daily high subfebrile condition, with numerous rising within day, mainly in the evening, and also short rise in temperature to febrile digits against a long subfebrile condition. Monotonous temperature krivoji morning liftings of temperature it is noted at one patient.

Intoxication. In most cases, at 13 sick (86,6 %) were observed the expressed symptoms of an intoxication (a headache, slackness, refusal of meal), at 2 children intoxication symptoms have been expressed moderately, during all acute period of disease, toksiko - allergic reactions were observed at 5 patients that has demanded carrying out of infusional therapy.

Lymphadenopathy. At all patients lymph nodes have been enlarged, including: at 5 — to 1,5 sm, at 4 — to 2 sm, at 6 — to 3-4 the Average sizes of lymph nodes see have made 2,14±1,21. More often lymphatic lymphonoduses zadneshejnoj, tonsillar and submandibular groups were enlarged. Zadneshejnye lymph nodes were palpated in the form of a chain located on back edge m. sternoclaidomastoideus. All groups of lymph nodes were mobile, an elastic consistence, painless at a palpation, thus at 1 patient the painful axillary lymphonodus in the size 8 ммх4 mm at which excising pus has been received, and at 1 patient — a conglomerate peredneshejnyh lymphonoduses, moderately painful was palpated at a palpation.

Thus, researches have shown, that the current is accompanied by augmentation zadneshejnyh, tonsillar and submandibular lymphonoduses in 100 % cases, including till the moderate sizes (no more than 2 sm), at 6 children to 3-4 see

Nasopharynx and fauces lesion. Nasal breath at 13 (86,6 %) from 15 detejbylo is complicated in connection with augmentation of the sizes of a nasopharyngeal tonsil. At 4 children zalozhennost a nose was insignificant, in the others
Cases — at 9 patients the expressed snoring breath, odutlovatost persons, pastoznost became perceptible a century. At all children the complicated nasal breath appeared already on the first week from the disease beginning. At 9 children with DS simultaneously with zalozhennostju a nose, we observed the catarral phenomena in the form of a rhinitis at 4 and tussis at 12 children. Markers of viruses of a flu, a parainfluenza, adeno - Rs - in didymous blood sera were negative. From 13 patients at 9 patients nasal breath remains complicated during 10 days, at 3 — 10 days are longer, and at 1 zalozhennost a nose remained about one month.

At a pharyngoscope in 100 % of cases following changes are noted: augmentation of tonsils and a hyperemia mucous, handles, a soft palate, "granularity" to a back wall of a pharynx. At 13 of 15 patients the tonsillitis was catarral. Applyings on tonsils met at 6 children, were not plentiful, as lacunar quinsy, belovato-yellow colour. This patient had been carried out bacteriological research of smears from fauces on flora. From them at 2 have been allocated Candidaalbicans, at 4 — Streptococcusviridance. In one case the diphtheritic rod has not been allocated. Applyings on tonsils remained in srednem3-5 days. After disappearance of applyings a hyperemia and razryhlennost tonsils remained within 10-15 days. A tonsillitis bind to immediate action EBV, and also activation own and joining of secondary bacteriemic flora [1] /

At 2 children the ulitis phenomena, at 3 — an aphthous stomatitis are noted.

Thus, from features of a lesion of a nasopharynx and fauces at primary acute GVI at children with DS it is possible to notice, that long difficulty of nasal breath, a tonsillitis, applyings on tonsils were observed at 7 children (46,6 %), the phenomena of a rhinitis, a stomatitis, an ulitis are possible.

Hepatomegalia. The liver augmentation was observed at 13 (86,6 %) from 15 children with DS at active primary GVI. At 10 (77 %) from 13 children the hepatomegalia was 3 sm, at 2 (15,3 %) - 5 sm, at 1 (7,7 %) from 13 children
The hepatomegalia was appreciable, to 7 the Liver see was an is dense-elastic consistence, painless at a palpation. Izmennie colours of integuments it is noted at one patient. The biochemical blood analysis has been spent to all children. At 5 (33,3 %) from 15 children have been noted rising the AlAT and the AsAT. Thus rising urovnjatransaminaz was insignificant in 1,5 times above norm (level the AlAT fluctuated from 57 to 62 ed/l, the AsAT — from 61 to 77 ed/l (64,25±8,77). Markers of virus hepatitises In and With were negative. Levels of bilirubin at all patients were in norm limits.

Splenomegaly. The augmentation of a lien at bolnyhaktivnoj primary GVI is taped at 10 (66,6 %) from 15 patients. At 6 (60 %) children the lien was enlarged moderately, acting from under costal edge on 1-2 sm, at 4 (40 %) patients augmentation was 3 see At a palpation the lien was moderate density, painless. The augmentation of the sizes of a lien reached a maximum during rise in temperature telado 38-39 ⁰С. In process of disappearance of symptoms of an intoxication, depression of temperature, restoration of nasal breath, there came also reduction of the sizes of a lien.

Thus, the clinic primary active GVI at children with a long subfebrile condition is accompanied by liver augmentation, and liens in most cases (86,6 % and 66,6 % accordingly). These changes have moderate character, as much as possible proving by 14-18 day DS. The liver augmentation is accompanied by moderate rising of transaminases in 1,5 times above norm at 2 of 6 patients.

Exanthema. At 6 (40 %) from 15 children on a skin became perceptible rashes. At 2 of 6 children eruption elements were plentiful melkotochechnye, and at others 4 — the eruption was plentiful spotty-papular, inclined to merge. The eruption at them appeared after priemaaugmentina, settled down on various sites of a skin (the person, the neck, a trunk, extremities), had etapnosti and favourite localisation, pojavljalasv no different time of duration of a subfebrile condition.

.privedennye data show, that the eruption at primary active GVI is bound not only sprjamym by cytopathic action of a virus on an endothelium of vessels, but also to damage of an endothelium of vessels by the immune complexes formed at a prescription of antibiotics against GVI.

As an example it is resulted following observation:

Madina A, 3 years (07.06.2008) case history №34021поступила in 19 unit MDGKB with the diagnosis: ORVI, the Rubella? Toksiko-allergic reaction. A Quincke's edema. A postinfectious subfebrile condition.

The girl from the first pregnancy proceeding with presenilation of a placenta on 8 month of pregnancy, operative sorts because of narrow tazana to 39 week. Масса=3750, рост=52см. An estimation on scale Apgar of 8/9 points. Grew and developed normally. Preventive inoculations are executed in time on a calendar. The transferred diseases: ORVI 2 times a year with implications of an aphthous stomatitis. The girl visits a kindergarten.

Was ill 09.11.11 acutely from a fever to 39 °s, there was a tussis, a cold, the girl is examined by the pediatrist who has diagnosed: ORVI. The Acute bronchitis. It is prescribed Augmentin, symptomatic therapy. To 14­15.11.11-state of health of the Girl good, but remained tussis and subfebrile temperature (37,3-37,4 °s) in a current of 14-15 days, antibacterial therapy has been continued. 30.11 there was not plentiful eruption on the person, breasts. By the pediatrist has been prescribed zirtek, smekta, by the evening it has become perceptible zalozhennost a nose without separated, the eruption accrued, there was a puffiness of the person. The girl has been hospitalised in MDGKB.

At entering 1.12.2011. (21 day of illness) a condition of the moderately severe child, temperature 37,3 °s, complaints to pains at swallowing, zalozhennost a nose. Integuments light pink, on cheeks, a breast skin, in the field of a stomach, on extremities spotty-papular, places confluent, with an exudative component. It became perceptible pastoznost puffiness of the person. Nasal breath is complicated considerably, separated was not, visible mucous pink wet, tongue is imposed by white scurf. Fauces
giperimirovan, tonsils are hydropic, in lacunas white scurf. Breath puerile, cardiac sounds clear, rhythmical, systolic hum on an apex. Mucous stomatopharynxes moderately giperemirovana, on mindaliah from two parties ostrovchatye applyings. Plural lymph nodes tonsillar, submandibular, zadneshejnye in the form of a chain To 2,0-3,0 sm, dense to the touch, mobile, painless are palpated. In lungs breath rigid, is spent to all departments, absent-minded wire rhonchuses. Cardiac sounds clear, rhythmical. A stomach soft, moderately painful, without accurate localisation. The liver acts from under edge of a costal Arch on 2,5+3,0см, the lien on 1,5 see For 4 days of disease an eruption began to die away, puffiness of the person has decreased.

The blood analysis for 21 Day of illness: N — 132 g/l, Eritr. — 5,26^h1012/l, Lejkots. — 10,0^h109/l, Trombots. — 188^h109/l, n/я — 1, s/ja — 30, mon. — 11, limfots.-58, an ESR — 10 mm/hour., atypical mononuklearov - is not present.

For 25 Day of illness the body temperature was normalised, an eruption in a fading stage, has turned pale for 4 days of a finding in a hospital. Applyings on tonsils were within 5 Days.

By the moment of an extract from a hospital (29 Day of illness): zalozhennost a nose has decreased, tonsillar lymphonoduses — To 1,5 sm, a liver About 2 sm, an eruption on a skin in a pigmentation stage, in the general analysis krovi:-without a pathology were reduced.

In bacteriological crops of a smear from fauces on flora for 22 Day of illness it was allocated Candidaalbicans. In the biochemical analysis moderate rising of level of transaminases the AlAT - 42, the AsAT - 52 units Crops on the Diphtheritic rod negative became perceptible. In IFA antibodies to chlamydias and a mycoplasma also were not defined.

PTSR: DNA EBV; VPG I, II, TSMV, ВГЧ-6-are negative;

NRIF: antigen TSMV in blood leucocytes is found out; VPG I, II, TSMV, ВГЧ-6-are negative;

IFA: antibodies EBVVCAIgM, EAIgG it is-is positive; antibodies Ig M to TSMV — it is positive; antibodies Ig M and IgG to VPG I, II, VGCH 6 — were not defined.

The conclusion: On the basis the Diagnosis has been clinico-datas of laboratory made: admixed gerpesvirusnaja Epstein's infection — Barr virus and tsitomegalovirusno aetiologies. Toksiko - allergic reaction as an urticaria and a Quincke's edema. The combined treatment with application antiviral and immunomodulirujushchih preparations has led to appreciable clinical improvement, subfebrile condition cupping on 8­й Day of stay in a hospital.

Other symptoms primary active GVI at children with a long subfebrile condition. From other symptoms GVI have been noted tussis, at children with an obstructive bronchitis 12 (80 %) osiplost voices 4 (26,6 %), a rhinorrhea 4 (26,6), an abdominal pain 8 (53,3 %), a liquid chair without revealing of the originator 4 (26,6 %), an arthritis knee sutava (1). In connection with a hyperplasia of lymphoid elements of a nasopharynx the lymphostasis leading to an edema and odutlovatosti of the person 6 (40 %), puffiness and an ecdysis of palms and feet 3 (20 %), a Quincke's edema (1) developed.

Changes from blood

During primary active GVI, clinically, we suggest to allocate following clinical stages: a stage of initial implications (5-7 days), a stage of development of a secondary infection — height of illness (since 7-14 days), a stage stihanija clinical implications.

Clinically, the secondary infection at observable patients was shown by presence of secondary bacteriemic complications (a pneumonia — at 4 children, a tonsillitis with applyings-3ostryjgnojnyj a lymphadenitis — 1, an ulitis) and reactive changes of the blood count (nejtrofilnyj a leukocytosis, a high ESR).

Hematological indicators at children with a long subfebrile condition at the height of illness are resulted in table 8.

The leukocytic formula was estimated separately at children aged till 5 years and is more senior 5 years. At children till 5 years the lymphocytosis more than 60 % was considered pathological, is more senior 5 years — more than 45 %, rising of segmented leucocytes more than 50 % and 65 % accordingly.

Table 8

Hematological indicators at children with a long subfebrile condition in height pervichnojaktivnoj GVI (n=15)

Apparently from table 8, the quantity of erythrocytes and indicators of haemoglobin at the majority of children were within norm, at 2 (13,4 %) patients became perceptible insignificant depression of haemoglobin to 105 g/l.

The quantity of leucocytes at 7 (46,6 %) patients remains normal throughout all disease, at 8 (53,4 %) primary acute GVI proceeded with the raised maintenance of leucocytes, the leukocytosis was moderated to 2040⁹/l. A leukocytosis vyjavljalsjau half of children on the second week of illness. Normalisation of quantity of leucocytes at all children occurred on 3-4 week of illness.

In the beginning of illness at 8 (53. 4 %) children the neutrocytosis and at 1 of 8 children formula shift to the left while in height of illness - limfomonotsitoz it was taped at half of patients became perceptible, reaching the maximum digits, on the second and third week of disease.

Atypical mononukleary (AM) have been found out only at 2 (13,3 %) children, — on the first week of illness, were defined in number of 18-24 %. AM have disappeared from peripheric blood by 16-24 day of illness.

At 11 (73,3 %) patients level of thrombocytes was in norm. Change of number of thrombocytes has been noted at 4 (26,7 %) patients, and has made 559h109/l-693h109/l.trombotsitoz it was taped on the second week of illness.

At 4 (26,7 %) patients in peripheric blood were found out plasmatic kletkiot 2 % to 6 %, on the first week of illness.

Thus, at the majority of children with a long subfebrile condition at the height of primary active GVI in the general analysis of blood indicators of red blood remained within norm with 86,6 % of patients, more than at half of children the moderate leukocytosis, with limfomonotsitozom, skorenie СОЭв71,5 % of cases became perceptible. Atypical mononukleary were taped on 1st week of disease at 2детей. The disease beginning could be accompanied at the majority of children by a neutrocytosis, in 20 % of cases sosdvigom formulas to the left.

In summary it is necessary to tell, that the complex clinico-laboratory researches of children carried out by us with a long subfebrile condition
Have shown, that more often primary acute GVI at children with DS it is diagnosed for children of younger age from 1 till 6 years among which boys prevail. In most cases disease proceeds under the scenario serious ORVI sochetannoj a virusno-bacteriemic aetiology, with joining of secondary bacteriemic complications (which the expressed symptoms of an intoxication and change in a haemogram cause), and as simtomamiaktivnoj replikatsii gerpesvirusov: a febrile fever against a subfebrile condition, difficulty of nasal breath, a hyperadenosis, an acute tonsillitis from applying on tonsils, a hepatomegalia, a splenomegaly, an exanthema. Vobshchem the blood analysis, it is necessary to note high frequency of revealing limfomonotsitoza (46,6 %). Thus, to differentiate primary acute GVI TSMV, EBV or VGCH 6 — aetiologies on klinikoyolaboratornym to signs, and also on character of a temperature curve, it is not obviously possible. However revealing of DNA TSMV (100 %), EBV (75 %) or VGCH 6 in blood (100 %), along with detektsiej antigens TSMV (60 %), EBV (40 %) and ВГЧ6 (100 %) in blood leucocytes, presence of antibodies of class IgM (100 %) to the specified viruses, allow to diagnose active gerpesvirusnuju an infection. Therefore at cupping of acute bacteriemic complications, despite clinical improvement of a condition, the current primary active GVI remains, chtoi can cause remaining subfebrile condition at these children.