Download MINISTRY OF HEALTH PROTECTION OF REPUBLIC KAZAKHSTAN

MINISTRY OF PUBLIC HEALTH OF THE REPUBLIC OF
KAZAKHSTAN
EDUCATIONAL METHODICAL SECTION OF THE HIGER
EDUCATIONAL INSTITUTIONS OF KAZAKH SMA
KARAGANDA STATE MEDICAL ACADEMY
A.O. Rakhimzhanova
Course of lectures on dermatovenerology
(educational-methodical manual)
Karaganda, 2007
UDK 615.5+616.97
BBK 55.81.Я 73
R15
Reviewers:
The head of the department of of dermatovenerology with course
dermatocosmetology КazSMA Аstana city, doctor of medical sciences
G.R. Batpenova
The head of the department of infectious deaseses of KSMA, doctor of medical
sciences G.K. Jumanbaeva
The head of the department of pharmacology with course clinical pharmacology
of KSMA, doctor of medical sciences, professor S.K. Jaugasheva
R15 Rakhimzhanova A.O. Course of lectures on dermatovenerology:
Educational-metodical manual. – Karaganda, 2007. – 145p.
ISBN 9965-781-73-7
Educational-methodical manual is meant for both teachers and students of foreign
department of medical higher institutions
BBK 55.81.Я 73
Р 4108090000
00 (05)-07
Confirmed and recommended for publication by Educational-methodical council
of RK medical higher institutions in KazSMA, protocol № 10, May, 21, 2007 y.
ISBN 9965-781-73-7
© A.O.Rakhimzhanova
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List of abbrevioations
STD
AG
AB
Ig
CIC
CNS
PAR
TAR
GIT
CIC
ENT-organs
PUVA
UVR
AIDS
SLE
DNA
RNA
ESR
Cyclic AMP
Cyclic GMP
PEL
SF
IFT
RW
TPI
UST
HIV
WHO
VHS
PCR
LCR
RC
EC
sexually transmitted diseases
antigen
antibody
immunoglobulin
circulated immune complexes
central nervous system
pseudo allergic reactions
true allergic reactions
gastrointestinal tract
circulated immune complexes
ear, nose, throat-organs
photochemotherapy
ultraviolet rays
acquired immunodeficiency syndrome
systemic lupus erythematosus
desoxyribonucleic acid
ribonucleic acid
erythrocyte sedimentation rate
cyclic adenozinmonophosphatis
cyclic guaninmonophosphatis
peroxide exudation of lipids
subcutaneous fat
immunofluorescence test
reaction of Wassermann
treponema pallidum immobilization test
unspesific serologycal tests
human immunodeficiency virus
World Health Organization
virus of simple herpes
polymeraz chain reaction
ligaz chain reaction
reticular corpuscle
elementary chain reaction
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Table of contents
List of abbrevioations
Table of contents
І
Introduction
1.1 Notion about subject, objects and methods of study of the
discipline
1.2 Role and place of dermatology among other disciplines
1.3 Method of checkup of a dermatological patient
1.4 Classification of primary and secondary morphological elements
of skin rash
1.5 Principles of general and external therapy of patients with skin
diseases
1.6 Issues of deontology and medical ethics in work of
dermatovenereologists
II
Notion of sensitization, allergy, immunological and autoimmune
processes in dermatovenereology. Role of genetic factors in skin
pathology. Age features of the skin
III
Eczema, ethiopathogenetic mechanisms of development, clinical
forms,
principles of therapy (general and external)
IV
Neurodermatoses (pruTPIus, prurigo, atopic dermatitis, Widal
herpes)
V
Lupus erythematosus
VI
Pemphigus
VII Pathogeny of syphilis and immunity
VIII Congenital syphilis
IX
Diagnostics and treatment of syphilis
X
Gonorrhoea
XI
AIDS
XII Pyodermas
XIII Mycoses
XIV Dermatitides
XV Professional skin diseases
XVI Lichen planus
XVII Herpes iris
XVIII Dermatozoonoses (leishmaniasis, scabies, pediculosis)
XIX Lepra
XX Cutaneous tuberculosis
XXI STD
XXII Tests
XXIII Literature
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3
4
5
5
5
6
7
12
18
18
27
34
40
45
51
57
66
72
82
89
96
106
109
112
114
120
125
130
132
137
145
І Introduction
The modern feature of present clinical medicine on the whole, and
dermatovenereology in particular is constant accumulation of new information
related first of all to principles of diagnostics, therapy of general diseases by
introduction of new methods and principles of laboratory inspection, and also
modern pharmacological and other means of medical correction.
This manual contains the complete course of lectures made in accordance with
the latest government program on dermatovenereology for students of medical
faculties of medical high schools. There is also material for practical exercises
necessary for giving sufficient information about the most widespread skin
diseases, having a supreme importance for the practical health protection in
countries, where students came from (viral and infectious diseases of the skin and
mucous membranes, STD, allergodermatoses, psoriasis, lichen planus,
leishmaniasis, lepra and etc.), and reflecting particular features of teaching at this
faculty.
1.1 Notion about subject, objects and methods of study of the discipline
Dermatology is derived from Greek «derma» -- skin and «logos» - science,
the science about diseases of the skin.
Dermatology deals with structure and functions of the skin in normal and
pathological states, interdependence of skin diseases with various pathological
states of the organism, and also deals with finding out reasons and pathogeny of
any dermatoses, with elaborating the issues of diagnostics, therapy, and
prophylaxis of skin diseases.
For this purpose clinical, histological, microbiological, immunobiological,
functional, biochemical, histochemical, experimental and statistical methods of
research are used.
General and particular dermatology is distinguished. Subject of the first one
is general issues - morphology and physiology of normal and diseased skin,
general regulaTPIies of development of skin diseases, principles of their therapy
and prophylaxis, and the second one – individual dermatoses and syndromes.
1.2 Role and place of dermatology among other disciplines
Dermatology is closely connected with many clinical disciplines, being
reflection of pathology of the inner organs. Dermatology is especially connected
with venereology, where such nosologies as syphilis, gonorrhoea, trichomoniasis,
clamidiosis, gardnerelyosis, cytomegaloviral infections and others are considered;
with infectious pathology - exanthemas and enantemas; child's diseases – German
measles, measles and others; inner diseases – pruTPIus, urticaria; endocrinology myxedema; surgery - furuncles, abscesses; gynaecology and obstetrics dermatoses of pregnants; neuropathology - lepra, syringomyelia and others;
ophthalmology - demodikosis of eyelids, early development of cataract in atopic
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dermatitis and others; psychiatry - pathomimia, trichotillomania and with other
disciplines. It has a great importance for the practical medicine as 10 % of all
diseases are related to skin diseases.
1.3 Method of checkup of a dermatological patient
The method of check up of a skin patient has some features different from
the method of checkup of patients of other types.
Having filled in a passport part of a case history, one should find out what a
patient complains of. Sometimes a dermatologist at first resorts to the visual
examination, but not to thorough gathering of anamnesis, that allows to gather
history more purposefully.
One begins questioning of a patient from finding out age, family status,
profession, bad habit routine, conditions of labour and way of life which can
contribute to the appearance of dermatosis. Sometimes it is important to know,
where a patient lived before. While learning about complaints subjective symptoms
or feelings (pruTPIis, burning, soreness, time of their appearance and etc.) are
usually found out.
Next information about former diseases, paying intention to the venereal
diseases, tuberculosis, operations etc. and family history is gathered.
To diagnose many dermatoses it is necessary to establish the fact of
seasonality of disease. Along with this, one should find out remoteness of disease,
primary localization of process, inclination to relapses, their reasons. If this disease
is a recurring one, it is necessary to learn about previous laboratory researches and
also about the character of medical treatment done before and its efficiency.
Thus, present history allows specifying, when and where the first
manifestations of disease appeared, how long they exist, their changes and course,
frequency and duration of relapses and remissions, connection of eruptions with
nutTPIion features, influence and efficiency of the previous therapy.
Finding out life history is similar to the one done in clinics of therapeutic
type. The special attention should be paid to the allergological history, hereditary
factor.
After the end of the questioning they begin to study objective data –
general condition of a patient. It is important to take into account concomitant
diseases of the inner organs. It is necessary to study the condition of the
cardiovascular system, respiratory and digestive organs, bonearticular apparatus,
lymph glands and etc. The checkup of general status of a dermatological patient is
made according to a plan of therapeutic one.
Then the local status is studied – checkup of the whole skin and visible
mucousas, and at last - areas of skin lesion are examined.
Conditions of check up:
1. temperature of a room 18 - 20 degrees centigrade;
2. dissipated daylight;
3. doctor turns one’s back to the source of natural light, and one’s face to a
patient;
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4. one should examine the whole skin regardless of localization of skin
process;
5. in the focuses of affection start examination and description from the
primary morphological elements.
Next goes the description of normal skin areas:
1. colour (pale, pinkish and etc);
2. turgor (lowered, retained);
3. moisture (moderate-moist, moist, dry and etc.);
4. skin outline (strengthening of relief, smoothening of skin furrows).
It is necessary to pay attention to the character of secretion of sebum,
traces of previous skin diseases, condition of appendages of the skin. They
examine hair (thickness, fragility, falling out), nails (colouring, shine, striation,
thickening).
Then they proceed to the direct description of morphological elements of
rash: the primary and secondary ones. Often to diagnose this or that skin disease, it
is necessary to use specific diagnostic tests or methods of diagnostics.
1.4 Classification of the primary and secondary morphological elements
of skin rash
Skin eruptions (rash) are considered as objective symptoms of checkup
consisting of various morphological primary and secondary elements, their totality
creates this or that picture of skin disease (dermatosis).
Primary elements are eruptions, appearing on an unchanged skin, red border
of lips, and mucous membrane of the mouth and not resulting from transformation
of eruptions existed before. The secondary elements are eruptions developed as a
result of transformation or injury of already existing elements. However this
division is relative, as there are diseases when the secondary elements are
considered as the primary ones. For example, the dry form of exfoliative cheilitis
begins from scales; in the erosive-ulcerous form of lichen planus erosions are not
resulted from bubles.
Primary morphological elements (figure 1). The primary elements are
subdivided into cavitary and uncavitary. Cavitary elements are eruptions having a
cavity filled with serous or purulent contents. They include vesicle, bulla and
pustule. Uncavitary are macula, nodule (papule), node, wheal, and tubercle (bulla).
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Primary morphological elements
Exudative
Bulla (bulla)
Wheal (urtica)
Pustule (pustula)
Vesicle (vesicula)
Infiltrative
Node (nodus)
Tubercle (tuberculum)
Papule (papula)
Macula (macula)
Secondary morphological elements
Secondary
maculas
Scales
- macroscaling
- microscaling
- branlike (branny)
Crusts
- serous
- purulent
hemorrhagic
Excoriations,
Fissures
- surface
- deep
Lichenifications
Ulcers
Vegetations
Erosions
Figure 1. Primary morphological elements
A macula is a limited change of colouring of the skin, which is not palpated;
is determined only by sight, because there is no cellular element in its basis. They
distinguish the makulas: vascular, related to expansion of a vessel (roseolar
makulas). As an example can be erythema due to the ultraviolet irradiation;
permanent makulas related to paresis of vessels (teleangiectasis). The vascular
asterisks in women on thighs exemplify too; hemorrhagic spots are related to the
trauma of vessel, with the increased permeability of vascular wall. If the rash is
tiny, size of a millet corn, this is petechiae. Larger ones named purpura. Large
bruises as a result of trauma - ecchymoses. Usually all hemorrhagic spots are
named purpura, and they disappear without trace. However on the mucous
membrane of the mouth on places, where appears purpura, the development after
while of superficial necrosis with subsequent erosiveness or ulceration is possible.
Pigmental: hyperpigmentated (moles, freckles, and tatoos) and hypopigmentated
(depigmentated) spots with the lowered content of pigment or complete its absence
(vitiligo, leukoderma).
On the mucous membrane of the mouth additionally one should mark out
spots appearing as a result of cornifications of mucousa, consequently the latter
one on the limited area gets a greyish-white color not rising above surrounding
surface that for example, is observed in the initial stages of leukoplakia.
A papule (papula) is a limited consolidation of the skin due to the cellular
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infiltration, which is determined not only by sight, but also palpation. There can be
the second spot as a result of papule bursting (figure 2).
Papules are distinguished
Dermal (syphilitic)
Epidermal (flat
warts)
flat
Epidermo-dermal
(lichen planus,
psoriasis,
neurodermitis)
conic
By form
Hemisphere-shaped
Plaques are formed by fusion
resolving
Result
scaling
de- (hyper-) pigmentation
Figure 2. Classification of papules
A tubercle (tuberculum) is an infiltrative element, by its size it can be similar
papule. The only difference - in the process of evolution the tubercle ulcerates,
leaving after itself a scar. The diameter of the element ranges from 1-2 to 5-10 mm.
Colour of tubercle is from pinky-red to cyanotic-purple one. This element occurs in
such diseases, as lupus vulgaris, lepra, tertiary syphilis.
Node (nodus) - infiltrate is conceived deeply in derma, gradually grows
through upper layers of the skin and becomes visible on the surface of the skin as
formation whose size is of cherry, pigeon egg. In the process of evolution the node
ulcerates, leaving after itself a scar (figure 3).
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NODES ARE DISTINGUISHED
Inflammatory
(tuberculosis, syphilis,
lepra)
Uninflamatory
(lipoma, fibroma )
calcification (fibrosis,
petIFTaction)
Result
Ulceration
(ulcer)
Scar
(cicatrix)
Figure 3. Classification of nodes
Wheal (urtica) – acute inflammatory, slightly rising above the level of the
skin, element. Its size - in diameter from a few millimeters up to 10 cm and more.
Arises up suddenly due to acute inflammatory edema of papillous layer of derma
and expansion of vessels. The appearance on the skin of wheals is accompanied by
intense pruTPIis. For example, after bite of mosquito, sting.
Vesicle (vesicula) - external, within the limits of epidermis, slightly rising
above the surrounding skin cavitary formation containing a serous liquid. Size
from 1 up to 3-5 mm. In the process of development it can burst, having formed
erosion, dry, having formed scales or leave after itself the temporal
hyperpigmentation (depigmentation). There are features of forming of vesicles (3
mechanisms, which cavitary elements are formed due to) - development in the cells
of hydropic (vacuolar and balloon) dystrophy and spongiosis, characteristic sign of
eczema.
A buble (bulla) is an element similar to the vesicle, but of larger size from 5
mm to 5 cm and more. It occurs in such diseases, as pemphigus, epidermophytia of
feet. The top of a buble can be comparatively thick (when it is formed under
epithelium) or thin (into the layer containing prickle cells) and in this case it
quickly ruptures, especially if it is localized on the mouth mucousa. The
mechanism of formation of bullas is different. Intraepidermal - due to acantholysis.
Acantholysis - peculiar change of cells of the layer containing prickle cells, based
on the immune mechanisms. There is fusion of intercellular connections, cells are
separated from each other and between them fissures appear, filled with exudation.
In these cells nuclei become large, and the cells themselves decrease in size and
become round. Subepidermal bullas are formed directly above or under the basal
membrane and are resulted from damage of durability of joining of fibres forming
it.
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Pustule (pustula) - cavitary acute inflammatory element with purulent
content. One distinguishes 3 kinds: follicular – connected with a follicle, in
localization of pustule round the mouth of hair follicle; phlyctena - bulla with the
purulent content, flabby top; acne. Besides epidermis, can take more deep layers of
skin, up to subcutaneous fat (figure 4).
Figure 4. Cavitary elements
The secondary morphological elements
Pigmentation (pigmentatio) is a change of colouring of the skin after
disappearance of some primary elements.
A scale (squama) is accumulation of seized horny cells which are visible by
eye. Scales are branny, microscaled or macroscaled, foliate. They can be in
psoriasis, seborrhea. On the mouth mucouss such falling away, as scaling of upper
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layers of the layer containing prickle cells, is observed only in mild leukoplakia.
Erosion (erosio) is surface defect of the skin within the limits of epidermis.
An ulcer (ulcus) is deep defect of the skin, achieving derma, subcutaneous
fat, fasciae, muscles, bones. Arises up on place of bursted tubercle, node, trophic
disorders, it can be of traumatic character.
A fissure (ragades) - defect of line form appearing because of excessive
dryness of the skin or loss of elasticity during the inflammatory infiltration.
External fissures are localized within the limits of epidermis. Deep - get into derma
itself, from them serous-bloody liquid oozes;
A crust (crusta) is dried exudate (serous, purulent, hemorrhagic).
A scar (cicatris) is connecting tissue on the place of deep defect of the skin.
Lichenification (lichenificatio) - consolidation of the skin due to the diffuse
infiltration, shows up as strengthening of skin picture. It occurs in the chronic
pruTPIis dermatoses.
Atrophy (atrofia) is wasting away of the skin with absence of skin picture.
Vegetation (vegetatio) is excrescence of epidermis with papillary layer of
derma.
Excoriation (excoriatio) – line-shaped defect, arises up as a result of
mechanical damage of the skin while scratching. In disintegTPIy of lower layers of
epidermis serous secretion appears, capillary bleeding with the subsequent
formation of crusts is possible. After they peel off scar will appear; abrasions can
be the only symptom in pathomimias.
In presence of one type of the primary morphological element of skin rashes
(for example, only papules or only vesicles) they say about the monomorphous
character of rash. In the case of simultaneous existence of two and more primary
elements (for example, papules, vesicles, erythemas) the rash is named
polymorphous (in the case of eczema) - polymorphism of the rash.
They distinguish true polymorphism from false (evolutional) polymorphism
of the rash, caused by appearance of various secondary morphological elements
(excoriations, scales, fissures and etc.) making it looks varied.
1.5 Principles of general and external therapy of patients with skin diseases
The medical treatment of dermatoses includes general and local therapy. In
order to choose a method of medical treatment of skin diseases, it is necessary
preliminary to do deep and comprehensive checkup of a patient, and also factors
allowing or predisposing to development of disease in every case. Division of
medical treatment into general and local is relative, as local application of
medications has more or less expressed influence on the general state of organism.
The choice of way or method of medical treatment completely depends on etiology
and pathogeny of disease. In those cases, when the reason of skin disease is clear,
it is necessary to administer etiotropic therapy. Pathogeneticly based therapy is,
essentially, the only type of medical treatment of a number of most frequent
occuring dermatoses, whose etiology is not studied enough yet. Prescribing
treatment to a patient, a doctor must take into account the role of the central
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nervous system. Efficiency of medical treatment depends in many respects on
relations between a patient and a doctor. With the purpose of general medical
treatment of skin diseases presently they use a lot of medical preparations and
methods: sedative, hyposensitizating, hormonal, immune, chemotherapy, antibiotic
treatment, resort therapy and others. However, division of remedies of general
therapy based on the character of their effect in some degree relative, as the same
remedy quite often has various effects. Nevertheless, with didactic purpose it
seems advisable, in consideration of remedies of general therapy, to arrange them
according to the character of basic effect.
Psychopharmacotherapy
Unmedicated methods:
1. psychotherapy
2. electro-sleep
3. acupuncture
Neuropharmacological methods:
1. sedative
2. tranquilizers
3. tricyclic antidepressants
4. analeptics
5. adrenoblockers
Hyposensitizating therapy
Specific - is used in chronic recurring piodermia, sycosis, furunculosis:
4. staphylococcal antitoxin
5. antiphagin
6. bacteriophages
7. staphylococcal vaccine
8. streptococcal vaccine
Unspecific:
1. antihistamine preparations
2. sodium thiosulphate
3. preparations of calcium
4. vitamins
5. corticosteroids
6. autohemotherapy
7. lactotherapy
3. Dietetic treatment
Specific dietetic therapy is used for patients having heightened sensibility to
some food products, and also in metabolic disturbance, GIT diseases:
9. exclusion of products-allergens
10. diet low in cholesterol
Unspecific dietetic therapy. Patients with eczema, neurodermatis, and
urticaria must not take all heavy digestible products and alcoholic drinks too.
Diseased people with skin tuberculosis, simple acne, neurodermatis, and eczema
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should be limited in taking of carbohydrates and sodium chloride.
Hormone therapy
The last decades can really be called era of corticosteroids, that in full
measure relates to dermatology too. The introduction of corticosteroids into the
dermatological practice changed prognosis of many diseases, foremost pemphigus,
system lupus erythematosus, medical treatment of them by these preparations not
only prevents death of patients, but also restores their ability to work.
Nowadays in dermatology they use prednisolone (from 5 up to 100 mg/day),
methylprednisolone, and dexamethasone (in 7 times more active than prednisolone
and many others).
Chemotherapy is always etiotropic; this is an influence on infectious or
blastomatose process with the purpose of its stopping, or weakening.
a. antibiotics
b. sulfonamides
c. antituberculous
d. antifungal
e. antiviral
Immunnocorrecting therapy
f. immunomodulators (T-aktivin, levamisole)
g. cytostatic (azathioprine, methotrexin)
Physical methods of medical treatment
h. phototherapy
і. photochemotherapy (PUVA-therapy)
j. laser treatment
k. ultrasound
External pharmacotherapy of dermatoses. The pathological processes
deve-lopping in skin are easily accessible to the external influence; therefore from
of old for the medical treatment of dermatoses the external medical treatment was
widely used. The modern knowledge in the sphere of endogenous etiologic factors
and pa-thogeny of diseases of the skin took out on the first plan the methods of
general the-rapy. However, and in our time, in spite of considerable increase of
number of highly active remedies of general therapy, the rationally administered
external medical treat-ment did not lose its importance for many skin diseases.
Because of presence in the skin of nervous-receptor apparatus, and also due to the
resorbtion effect external phar-macological remedies in this or that measure
influence the organism in a general way too. The reduction of unpleasant feelings
(pruTPIis, pain, burning and etc.) under in-fluence of external therapy positively
affects the general and emotional state of patients that promotes recovery.
Purposes of external therapy:
1. removal of the reason of disease (etiologic therapy), for example, in
pyodermatitides, superficial mycoses, scabies, pediculosis and etc.;
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2. removal of pathological changes in the skin (pathogenetic therapy);
3. removal of the subjective feeling (symptomatic therapy);
4. protection of the skin from irTPIating external influences (rays, moisture,
allergens and etc.).
These purposes are achieved by application of different pharmacological
reme-dies which are included into medicinal forms (bases). The medicinal forms
used for the external therapy render the therapeutic action due to to their physical
properties. Pharmacological remedies added to them in different concentrations
strengthen a medical effect and determine a direction of local influence of
medicine as a whole.
Basic principles of external therapy. The main meaning for success of
external medical treatment has a correct choice of medicinal form, as it affects the
skin physically and providing getting of pharmacological remedy to this or that
depth. Medicinal forms themselves render the medical influence and in a number
of cases can be used without the pharmacological remedies.
Choice of medicinal form is determined:
а) by how much inflammatory process is marked in the skin and necessary
depth of influence.
The more active inflammation, the more sparing external therapy must be,
on principle - «do not irTPIate an irTPIated one». The deeper action of a medicinal
form; the stronger it detains evaporation of moisture from the surface of the skin.
b) by spread of pathological process.
c) by localization of affection (smooth skin, folds, areas covered by hairs, areas
with thickened horny layer).
d) by the presence of concomitant diseases (obliterating diseases of vessels of
extremities, bronchitis, pneumonias, affections of kidneys, bronchial asthma).
Pharmacological medicines added into the medicinal form in different
concentrations determine a direction of action of an external remedy as a whole.
The medicinal form and its components must influence unilaterally, supplementing
each other. For example, salicylic acid prescribed with the purpose of providing
keratolitic action will not render the desired effect, being applied in the form of
powder or paste. Appointed in the same concentration, but in the form of ointment
or varnish, it will render the necessary action. Epithelialising remedies applied in
the form of ointments are more effective, than applied in paste.
A number of ingredients put into a medicinal form must be optimal in order
to avoid the undesirable mutual influence and allergic reactions (most often as
allergic contact dermatitis).
The strict individualization of therapy and permanent supervision is
necessary after the dynamics of pathological process with the purpose of timely
replacement of medicinal form or components (intolerance or adaption) or change
of their concentration.
15
One should prescribe to the patients external preparations in small quantities,
as with the change of state of the skin before appointed remedies can turn out
useless or even harmful.For example, lotions appointed in the acute form of
mycosis of feet, with disappearance of expressed inflammatory phenomena will
turn out harmful, cau-sing and supporting maceration of the skin. The lotions,
moistly drying bandages ap-pointed in acute eczema, will quickly render anti
inflammatory action; however, if not cancell them in time, they can overdry the
skin and cause worsening of the course of the disease.
It is necessary to mind the sequence in prescription of medicinal forms and
pharmacological remedies: from superficially acting to those influencing on deeper
layers of the skin, from less concentrated to more concentrated. Demonstrative
example of stages in the medical treatment - therapeutic approach in eczema. In
this disease they vary external therapy depending on the stage of process,
localization of lesion focuses, clinical form of dermatitis and other factors.
In the acute and subacute inflammatory process one should use superficially
acting forms of external remedies, at that the more acute process, the more
superficial action of medicinal form and its constituents: «the more acute process,
the milder therapy, and vice versa» (V. Yadasson). In chronic and infiltrated
processes one should prefer medicinal forms rendering more deep action.
The medicinal forms for the external therapy by degree of increase of depth
of influence are possible to arrange in the following way: powders – lotions moistly drying bandages - aqueous shaken meals - oily shaken meals hydrogels - pastes – creams a kind of «oil in water» - creams a kind of «water
in oil» - ointments - compresses - plasters - lacquers.
The exception from this rule is glucocorticoid creams which can be applied
in the acute stage of inflammation, because the local anti inflammatory action of
steroid hormone «blocks» an opposite physical effect of ointment basis.
In the choice of remedies for the external application one always should take
into account their accordance to stage of disease and tolerance (from data of
history).
It is advisable to apply a new external remedy at first to limited site of the
skin and only if it is tolerated well it can be used for the medical treatment of
widespread eruptions.
It is necessary to take into account the resorption action of preparations,
which is determined by the degree of their solubility in water and lipids, and also
by permeability of the skin. It is known too, that pathologically changed skin
(inflamed, erosive) possesses greater absorbing ability. Not indifferent remedies
for the organism with the expressed resorptive action (boric acid, tar, mercury,
dimedrol and etc.) must not be aplied to vast areas, because as a result of
penetration of such substances through the skin into vascular channel toxic
phenomena can develop.
In the ambulatory practice they should avoid external remedies strong
smelling and dirtying clothes, and also bandages hindering from professional
16
activity of a pati-ent. The excessive use of solutions of aniline dyes is unacceptable
from the aesthetic point of view and hinder a doctor to observe after the dynamics
of inflammatory process.
In adminestering of external medical treatment it is necessary to take into
account different reactivity of the skin of different areas of the body; the most
sensitiveness is of the skin of the face, neck, genitals, and bend surfaces of
extremities; considerably less - hairy part of the head, palm, and sole. In the
affection of palms and soles, especially in the persons of manual labour, it is
necessary take into account the thickened horny layer which can hinder to
penetration of medications.
Before to apply this or that remedy, one should clean a lesion focus from pus,
crusts, scales, shreds of covers of cavitary elements, remains of the used preparations, whose constituents can decompose and irTPIate the skin. PuIFTication of the
skin promotes in future closer contact with it of medicinal substances and, thus, allows getting a therapeutic effect. In piodermia, for example, remained crusts absorb dyes intended for disinfection of the skin; only after removing of crusts dyes
render the antiseptic action. However it is necessary to avoid traumatization, mechanical irTPIation of the pathologically changed skin. It is forbidden to remove
deeply located crusts, scales, remnants of ointments. The skin in the lesion focuses
is cleaned by careful wipe by tampon, abundantly moistened by any vegetable or
coal oil (sunflower, linseed, liquid paraffin). In 15-20 minutes the focus is cleansed
one more time, and if it has no effect, an oily bandage is kept for much longer time,
whereupon the crusts are removed by pincers. To remove necrotic decay out of
polluted erosions and ulcers they are cleansed by 3% solution of hydrogen peroxide. Wipe a surrounding skin down by solution of boric acid or other unirTPIating
disinfectant. In pyodermas one should repeat cleansing of the skin round the affectted focus, and sometimes lesion focus itself, they do it by 10% camphoric, 2% boric or 2% salicylic spiTPI. Warm water as general and local baths is used with success for cleaning of the skin in subacute eczema, erythrodermia and so on. For removing of scales, crusts, remnants of ointment from unirTPIated skin, for example, chronic, torpid, psoriatic plaques, psoriasis of the sculp it is recommended forceful washing by water with soap or medical shampoos or preliminary appli-cation
of 2-5% salicylic ointment as a compress (cover a bandage for deeper action by
oilcloth or compress paper). Liquid oils clean the skin of the sculp from the
secondary formations without or with admixture 2-5% salicylic acid.
Elimination of skin manifestations and subjective feelings (pruTPIis,
tenderness) by rational pharmacotherapy positively influences on psychoemotional
state of patients that in its turn plays an important role in achievement of
favourable results.
17
1.6 Issues of deontology and medical ethics in work of
dermatovenereologists
Psychotherapy of dermatological patients is begun from the moment they are admitted to a hospital or come to see a doctor. Psychotherapeutic influence depends
on ability of medical personnel to talk with a patient, console him/her, and
convince him-/her that s/he will recover and applied therapy will be correct and
effective. Unhappy phrase, inappropriate statement about prognosis of disease may
result in worsening of course of disease, especially in suspicious patients. A word
is a powerful medical fac-tor in many dermatoses, but it may result in development
of negative emotions too. One should always remember that words have not only
concrete meaning but also emotional expression. The same words said by different
tone, with a different inflection in one’s voice, can give an opposite psychotherapy
effect.
If issues of medical deontology in the practical activity of dermatologists substan-tially do not differ from those of other specialitites, in work of venere-ologists
they ha-ve their specificity, knowledge of which is necessary for a doctor working
in the field of venereology. For revealing, examination and medical treatment of a
diseased per-son, being the source of infection, and finding out of everyday and
especially sexual contacts of a patient a venereologist must study conditions of
one’s intimate life. The method of dispensary work of a venereologist is founded
on this; it is directed to time-ly stopping of further spreading of venereal disease.
For this purpose, one should cre-ate confiding atmosphere for conversation, it is
preferable to take sexual history after establishment of exact diagnosis and stage of
disease. Thus, in a patient with venere-al disease it is necessary to get information
about one’s sexual life after thorough cli-nical checkup and in case of need after
getting of results of laboratory investgations.
Issue concerning doctor secrecy is important in work of a venereologist. In this
case interests of a patient and society get mixed up closely and are quite often
opposite. In all cases, when this does not conflict with interests of society, a
venereologist, as well as doctors of other specialities, must keep doctor secret and
for its revealing one is called to account according to the law.
II Notion of sensitization, allergy, immunological and autoimmunne
processes in dermatovenereology. Role of genetic factors in skin pathology.
Age features of the skin.
The skin, being outer human covering is constantly exposed to influence of
various factors of the environment, as a result pathological processes quite often
develop in it. Physical (pressure, friction, high and low temperature, radiant
energy and etc.), chemical (acids, alkalis and etc.) and infectious (bacteria, viruses,
pathogenic fungi, protozoa) agents can be the reason of affections of the skin of
various clinical manifestations. Quite often the development of pathology in the
18
skin is related to influence of endogenous factors – disturbances of carbohydrate,
lipid, mineral types of metabolism, and balance of vitamins A, C, B complex,
chronic diseases the GIT, liver, kidneys, and dysfunction of a series of endocrine
glands. The focused infection can cause a number of pathological processes - from
acute vasomotor to severe degenerative-inflammatory ones.
In pathogeny of many diseasees of the skin important part is played by state
of reactivity of the organism. A lot of importance especially in development of
many dermatoses has a state of increased (changed) sensitiveness of the organism
in relation to any substances (allergens). In most cases the allergens get in the
organism from the environment (exogenous), but can appear in organism itself
(endo- and autoallergens). Exoallergens – house dust, pollen of plants, milk, eggwhite, food products, medicinal preparations, cosmetic remedies. As allergens can
be bacteria, fungi, viruses.
Antigens (AG) – substances specifically recognizable by receptors of T- and
B-lymphocytes can also be allergens. They subdivide AG into 3 basic types:
immunogens, haptens and tolerogens.
Immunogen – can independently produce an immune responce, and after
become a target of activity of the immune system. Terms «immunogen» and «AG»
are often, but not correctly used as synonyms.
Hapten is not able to produce an immune response by one’s own. However if
hapten is combined with large immunogen molecule (carrier), an immune answer
is produced, both against carrier and hapten, and hapten itself becomes target of an
immune response.
Tolerogen - substance, in the primary contact with the immune system
suppressing its reactions that causes subsequently specific inability to respond (t
Depending on character and type of disorder of immune reaction to the great
number of antigen influences this or that immunopathological syndrome is formed
- infectious, atopic, autoimmunne, lymphoproliferating or their combinations. All
of them are widely presented in the dermatological practice.
After an allergen got into the organism, sensitization takes place - process of
acquisition of hightened sensitiveness to this allergen. In the process of
sensitization an immunological response as formation of specific antibodies or
sensitized lymphocytes is produced. In the last years the role of Langerhans cells
becomes more evident in the primary immune response (antigenpresenting). The
process of development of sensitization is difficult and depends on the functional
state of the nervous and endocrine systems; epithelium barrier the state of
sensitization clinically is not expressed. The allergic reactions arise up only by
action of repeated, so-called allowing contacts of the organism with the same
allergen (antigen). As a result of co-operation of antigens with specific antibodies
or immune lymphocytes the allergic reactions develop. Depending on the clinical
manifestations, pathomorphologic changes, speed of development the allergic
reactions are divided into 2 large groups - reactions of immediate and slow types.
19
A general sign of the allergic reactions of immediate type is their rapid
development. In this case the reaction arises up in 15-20 minutes after influence of
specific antigen and on skin appears as a wheal. The hightened sensibility to the
antigen can be passed passively to other organism with the serum of blood from
the man suffering from allergy. They relate anaphylactic shock, urticaria, serum
sickness, pollinosis, Quincke’s edema to the allergic reactions of immediate type.
They mark out three stages in development of hightened sensibility of
immediate type: immunological, pathochemical and pathophysiological (A.D. Ado,
1978). The first stage is interaction of antigens with antibodies. The pathochemical
stage is characterized by secretion of biologically active substances - histaminee,
heparin,
serotonin,
bradykinin,
acetylcholine
and
others.
During
pathophysiological stage because of release of biologically active substances in the
organism there are functional disorders which are clinical picture of allergic
disease (contraction of smooth muscular system, eruptions, hemorrhage).
For the allergic reactions of immediate type, arising up under influence of
im-mune complexes (antigen-antibody) on tissue, morphology of hyperergic
inflame-mation, characterized by rapidity of development, predominance of
alterated and vascular-exudated changes and slow course of proliferated-reparated
processes, is typical.
The mechanism of development and morphological manifestations of
hightened sensibility are mostly determined by nature and quantity of an antigen,
duration of its influence (circulation in blood), character of thus formed immune
complex (circulated or fixed, heterological or autologic, generated locally due to
joining of antibodies with a structural antigen of tissue). To diseases of the skin,
when in the lesion focuses they often find components of the immune complex,
superficial allergic vasculites are related - hemorragic vasculitis, hemorragic
leukoclastic microbid, Ruiter arteriolitis. The acute forms of vasculites are
characterized by localized location of the immune complex in the walls of vessels
and perivascular areas of derma. In the chronically recurring course of vasculitis
the immune complex is revealed not only in vessels, but also in the area of basal
membrane of the skin and subpapillar layer of derma. In deep vasculites – in
nodulous erythema – the immune complex is revealed after considerable duration
of disease in the walls of deep layers of derma and subcutaneous fat diffusively.
Skin vasculites - deep and superficial - are characterized by presence in the blood
of vascular antigens diappearing as much as one recovers.
The hightened sensibility of slowed type was first described by R. Koch in
1890 in patients with tuberculosis after subcutaneous injection of tuberculin. It is
characterized by that:
1. not connected with antibodies circulatoring in the blood;
2. can not be transmitted to other organism in introduction of leucocytes or
lymphocytes;
3. characterized by the slow development of inflammatory reaction in response
to introduction of an antigen, in 24-48 hours.
The hightened sensibility of slow type develops in syphilis, gonorrhoea,
20
herpes, lupus erythematosus, and neurodermatis. Allergic contact dermatitis is one
of manifestations of the hightened sensibility of slow type. In development of the
hightened sensibility of slow type it is possible to distinguish three stages too. In
the immunological stage nonimmune lymphocytes after the contact with an antigen
in the skin are carried through blood and lymphatic vessels to lymph nodes, where
are transformed in blasts. The latter ones, multiply and turn into lymphocytes again
which get into the thymus gland. In the contact with specific antigens a sensitisized
lymphocyte is activated and a number of biologically active substances are
released etc. according to stages. Besides lymphocytes, macrophages participate in
forming of the hightened sensibility of slow type (histiocytes and monocytes).
Some dermatoses of nonallergic genesis are accompanied by defect or, vice
versa, suppression of cellular and humoral immunity. There are different
immunopathologic states as a result of defect of the immune system - from
tolerance (insufficiency) and immunodeficiency to excess reaction of the immune
system on endo- and exogenous allergens.
With pathology of the immune system autoimmunne disorders are especially
connected. In these cases the reaction of the immune system is directed against the
normal tissue antigens. According to the existing hypothesis, in the norm the B
lymphocytes after the contact with their own albumins under the influence of the
T-suppressors are not transformed in the plasmatic cells - producents of antibodies,
but pass to the state of tolerance. In the deficiency of T-suppressors B-lymphocytes
begin to react to the tissue antigens, produce antibodies and condition development
of autoimmunne disease. A deficiency of thymusproduced totality of cellssuppressors can be a result of congenital malformation of development of the
thymus gland or result of influence of chemical, including medicinal substances,
microbial, viral, physical factors. For example, viral infection, possibly, conditions
the deficiency of the T-suppressors in system lupus erythematosus. They consider
as the autoimmunne diseases of the skin lupus erythematosus, pemphigus,
pemphigoid, Düring’s herpetiformed dermatitis.
In system lupus erythematosus both in affected, and in healthy skin they reveal by the immunoluminescent method granular or stripe-shaped deposit of immunoglobulins (more frequently G) and complement in the area of basal membrane of the skin. In blood by the method of indirect immunoluminescence in 80-100
% of cases they find antinuclear antibodies in the high titres. In disseminated and
discoid lupus erythematosus without the signs of the system one reveals similar fixation of immunoglobulins and complement only in the affected skin. In the serum of blood of patients the antinuclear antibodies are present in low titres, or
absent.
There is an autoimmunne mechanism of forming of acantholysis - leading
pathogenetic phenomenon of formation of intraepidermal bullas in patients with
vesicular dermatoses. In the serum of patients with pemphigus they reveal AB to
antigen components of intercellular substance of the layer containing prickle cells
of epidermis, belonging mainly to the immunoglobulins of G class, partly to M
class. Change of antigen structure of cell surface and the appearance on the surface
21
of membranes of prickled epidermocytes «alien» AG results in producing of
specific AB, formation of the AG-AB complex, under their influence there is a
damage of permeability of cellular membranes, release of lysosomal enzymes from
a cell. The factors of humoral and cellular immunity are significant too in
pathogeny of pemphigus - cytotoxic autoantibodies, the titre of their content
correlates with seveTPIy of skin process.
In pemphigoids in lesion focuses in the area of basal membrane of the skin
they find the immune complex, more frequently IgG and complement. In Düring’s
herpesformed dermatitis in the papillae of derma one reveals grainular IgA
deposits without fixation of complement. In the serum of blood of patients there
are no circulated antibodies to the intercellular septum or basal membrane of flat
epithelium, but there are antibodies to the reticular fibres.
They assume that the immunological component participates in development
of large group of diseases, the role of which is not totally found out. They relate to
this group lichen planus, scleroderma, and dermatomyositis. So, probability of
allergic nature of lichen planus to some degree is confirmed by the results of
immunoluminescent research of affection - in the area of basal membrane of the
skin, more frequently in the papillae of derma, round capillaries there is granular
fixation of the immunoglobulins of G, M, A class and fibrin.
In scleroderma in the affected skin one can see the linear fixation of globulin
and complement in the area of basal membrane, circulated antinuclear antibodies
in 50-80% of patients in the high titres in systemic, in low - in the localized forms
of the disease.
In patients with chronic dermatoses they often find the diverse variants of
immune defects of different nature and degree of expressiveness. Manifestations of
immune insufficiency can be polymorphic and be expressed both in weakening of
elimination of alien antigens, and forming of hightened hypersensitivity to
bacterial, viral or fungous antigens. They are chronic, recurring pyodermatitides,
secondary pyodermas, complicating a course of other dermatoses, recurring
herpetic infection, and widespread mycotic affections of skin.
Immune insufficiency plays a considerable part in development of atopic
dermatitis, autoimmune diseases, and malignant neoplasms of the skin. In patients
with atopic dermatitis, along with the immune insufficiency, there is genetically
determined IgE hyperproduction, change of correlation of totality of
immunocompetent cells, the damage of phagocyted mechanisms. Insufficient
elimination of antigens (bacterial, parasitic, food, chemical and others) and
exaggerated humoral response of the organism, especially related to high IgE
concentration, promotes formation of the grave combined immunopathologic
condition. Clinically this manifests as widespread forms of dermatoses with
frequent seasonal and provoked by antigen load aggravations, quite often
accompanied by ethmoid bronchitis, bronchial asthma (dermato-respiratory
syndrome), by recurring infections and invasions.
22
The proliferated processes in the skin are also regulated by the immune system. Defect of immunological supervision, related to the T-cells deficiency, change
of production of cytokines, decline of functional activity of natural killers, insufficiency of the interferoned system - are the factors promoting development of malignant neoplasms of the skin. The danger of their appearance increases under influence of carcinogens possessing immunosupressive activity. In damage of immunological control, primary tumoural cell is not eliminated from the organism, but
actively proliferates. Most tumours are immunodependent. So, it was proved, that
basal cell carcinoma, which makes from 63, 5 up to 96, 4 % of all cases of malignant neoplasms of the skin, is immunodependent tumour. At that the immunopathologic changes concern not only lesion focus, but also visibly unchanged areas, i.
e. this disease of whole organism when all skin covering is prepared to
development of neoplasms.
The role of immunopathologic damages is also substantial in pathogeny of
psoriasis. The changes of quantitative, functional character, rise of circulated
immune complexes (CIC), decline of activity of unspecific factors of protection,
for the last years complemented by information about the considerable pathology
in the immune system of the skin itself. The close connection of processes of
excessive proliferation and inflammation in the psoriatic focuses, taking place
because of activation of keratinocytes and other immunologically active cells of
epidermis and derma, production and cytokine secretion by them, factors of growth
and eukozanoids, stimulative inflammation, migration and infiltration of epidermis.
There is an opinion, that this is disease of immunocytes.
Allergodermatoses - heterogeneous group of diseases of the skin, main part
in development of which is played by the allergic reaction of immediate or slow
type. This group consists of allergic dermatitides, toxicodermas, eczema, and
urticaria.
Allergic dermatitis arises up in response to the contact influence on the skin
of optional irTPIant, to which the organism is sensitized and with respect to which
this irTPIant is allergen (monovalent sensitization).
The allergic reaction of slow type is in the basis of allergic dermatitis.
Allergens mostly are chemical substances (washing powders, insecticides, chrome,
nickel), medicinal and cosmetic remedies (synthomycin emulsion and other
ointments with antibiotics, hair-dyes and others). Allergens are quite often haptens,
generating in joining with albumens of the skin a complete antigen. In forming of
contact hypersensitivity important part is played by macrophages of epidermis.
Already in the first hours after bringing of allergens their quantity in the skin
increases. At that an allergen is connected with macrophages. Macrophages present
this allergen to the T-lymphocytes, and as a response there is proliferation of Tlymphocytes with forming of totality of cells specific to the antigen. In the
repeated contact of the allergen circulated sensitized lymphocytes are directed to
the focus of the allergen influence. Secreted by lymphocytes lymphokins attract
macrophages, lymphocytes, and polymorphic-nuclear leucocytes to the focus.
23
These cells also secrete mediators, producing an inflammatory reaction of the skin.
Thus, the changes of the skin in the allergic dermatitis appear after the repeated
bringing of an allergen in the conditions of the organism sensitization.
Toxicoderma - acute toxico-allergic inflammatory affection of the skin, being
an allergic reaction on introduction to the organism (inhalation, taking orally,
parenteral administration) of substances possessing sensibilizating properties.
The mechanism of development of toxicoderma differs from such in dermatitis: in dermatitis the allergen gets into the skin through epidermis, by the direct
contact, and in toxicoderma - hematogenally. This also explains possible development of general phenomena (fever, headache, stomachaches and etc.) in toxicoderma. The reasons of appearance of toxicoderma more frequently are medications (antibiotics, sulfonamides, analgesics and etc.) and food products because of it
they distinguish medicinal and alimentary toxicoderma with similar clinical course.
Eczema is a frequent chronic recurring disease of the skin of allergic genesis,
characterized by polyvalent sensitization and polymorphic pruTPIis rash (vesicles,
erythema, and papules). Eczema is a disease with polyvalent sensitization, in
development of which both exogenous (chemical substances, medicinal, food and
bacterial allergens) and endogenous (antigen determinants of microorganisms from
focuses of chronic infection, intermediate products of metabolism) factors take part.
The leading role in pathogeny of eczema belongs to the immune inflammation in
the skin, developing on background of suppression of cellular and humoral
immunity, unspecific resistance of inheTPIed genesis. In patients high frequency
of the antigens of histocompatibility HLA-B 22 and HLA-C1 is marked.
The functional damages of the CNS and vegetodystonia with predominance of
parasympathetic influences, neuroendocrine damages, change of functional activity
of digestive tract, metabolism, and trophics of tissues are characteristic too. Large
significance in development of true eczema is attached to the reflex influences
originating from the CNS, inner organs and skin, and in development of microbial
and professional eczemas - sensitization correspondingly to the microorganisms or
chemical substances. The exacerbations of eczema arise up under influence of
psychoemotional stresses, inadequate diet, contacts with chemical substances and
other allergens.
Urticaria are an allergic disease of the skin and mucous membranes,
characterized by formation of the ephemeral eruptions - wheals accompanied by
pruTPIis and burning pains. They distinguish acute and chronic urticaria.
Reasons of development of acute urticaria are different exogenous irTPIants
(nettle, bites and touches of insects), physical agents - cold (cold urticaria), sunbeams (solar urticaria), food products (fish, crawfish, eggs, strawberry, honey and
others), medications (aminazin, vitamins of B group, medical serums, vaccines).
The reasons of development of chronic urticaria are focuses of chronic
infection, chronic diseases of digestive tract (stomach, intestines, pancreas, and
liver), blood, and endocrine system. In children the reason of chronic urticaria can
be intestinal worm invasion, in adults - liambliosis, amebiasis. The toxic
substances, not completely decomposed albumens can play part of allergens. In the
24
basis of development of urticaria, as a rule, there is the allergic reaction of
hypersensitiveness of immediate type, being an anaphylactic reaction of the skin to
the biologically active substances. The key part in formation of wheals in urticaria
is played by the functional vascular damages as a rise of permeability of capillary
wall, mainly in regard to plasma. In development of these vascular damages
important part is played by mediators of inflammation - histamine, serotonin, and
bradykinin. In development of urticaria acetylcholin participates from the physical
influences (cholinergic urticaria). In development of chronic urticaria functional
damages of the central and vegetative nervous system matter too.
Allergic dermatoses can proceed according to mechanisms of both true
allergic reactions (TAR) and pseudoallergic reactions (PAR). The most important
immunological processes in allergic dermatoses, proceeding by the TAR
mechanisms, are sensitization and immune response after the repeated contact with
an allergen. There are four types of the TAR, differentiating by the mechanisms of
development. First three types (anaphylactic, cytotoxic and immunocomplex) are
related to the B-dependent reactions and proceed by the mechanisms of
hypersensitiveness of immediate type, and the fourth one - T-dependent, cellularindirect type, proceeds by the mechanisms of hypersensitiveness of slow type. In
any type of the TAR, lying in the basis of allergic dermatoses, conditionally it is
possible to distinguish three stages - immunological, pathochemical,
pathophysiological. In the PAR they distinguish only two stages: pathochemical
and pathophysiological, at that in the pathochemical stage release of mediators is
done by nonspecific way. It becomes clear, that the identical symptoms developing
in the TAR and the PAR are conditioned by participation in their forming of the
same mediators (histamine and others), that makes the PAR different from other
reactions of intolerance, related to the gene damages, fermentopathies, toxicity or
overdosage of preparations. Thus, depending on paramount participation of these
or those mechanisms in pathogeny of disease, it is possible to distinguish an
immunological type of allergic dermatoses, which proceed with participation of
immune reactions, and nonimmunological, ones without participation of immune
reactions. The immunological type of allergic dermatoses can include an allergic
type (mediated by participation of specific allergic antibodies or sensitized
lymphocytes) proceeding according to the mechanisms of hypersensitiveness of
immediate type or hypersensitiveness of slow type, and nonallergic type (including
the PAR) which do without participation of specific immune reactions (for
example, conditioned by defect in the system of complement, in particular,
inheTPIed angioneurotic edema). Allergic type of allergic dermatoses can be
represented by atopic form of urticaria, conditioned by participation of specific
IgE-antibodies, nonatopic form of allergic urticaria conditioned by participation of
other classes of specific antibodies, for example, IgG, infectious-allergic form of
urticaria, characterized by combination of allergy and clinical and/or laboratory
signs of immune insufficiency, immunocomplex forms and others.
Policy of management and medical treatment of patients with urticaria and
angioneurotic edema, proceeding according to both the TAR and PAR mechanisms,
25
are fundamentally different. The basic pathogenetic methods of therapy of urticaria
and angioneurotic edema proceeding by type of the TAR are elimination, specific
immu-notherapy and immunomodulating therapy. In urticaria and angioneurotic
edema proceeding according to the mechanisms of the PAR, patients after the complete clinical, allergic and immunological examination need elimination of the factors promoting development of pseudoallergy: normalization of the GIT function,
functions of hepatobiliary, neuroendocrine systems, metabolic processes and so on.
The correction of diet with limitation of the products rich in histamine, tyramine,
histaminoliberators, prescription of enzymes, normalizations of microflora of intestines and so on is necessary. As long as in the mechanism of urticaria and angioneurotic edema excessive specific and nonspecific release of histamine matters
a lot, with the purpose of symptomatic therapy patients are prescribed
antihistamine preparations.
Thus, in development of skin diseases the great role belongs to the immune
changes, definite disorders of the CNS, vegetative nervous system. Quite often it
succeeds to define connection of appearance of dermatoses with damages of
ductless glands - myxedema of the skin in patients with the diseases of thyroid,
bronze colouring of the skin in Addison’s disease, appearance of simple acne as a
result of dysfunction of genital glands and others. The development of a series of
diseases depending on the menstrual cycle, pregnancy - recurring herpes,
climacteric gingivitis is possible. The particular meaning in the appearance of a
number of skin diseases belongs to the genetic factor. Role of heredity becomes
apparent most distinctly in such diseases, as ichthyosis, xeroderma pigmentosum,
bullous epidermolisis, keratoderma, atopic dermatitis, psoriasis and etc. InheTPIed
predisposition of a human being to this or that dermatitis, implies, that parents pass
to children those features of matabolism, homeostasis, functions of organs, systems
of the organism, intracellular biochemical reactions and other signs which
condition their similar character of reaction to the irTPIation and so on. It is this
fact that determines identical susceptibility to this or that illness of children and
their parents realized in presence of definite complex of factors or one factor
aggravating this susceptibility.
Features of structure of the skin of children. In a new-born the degree of
development of epidermis is uneven. It is especially tender and thin in the area of
the face and folds. On palms and soles all layers of epidermis are 2, 5-3 times
thiner, than in adults. Distinctly expressed and formed as that in adults it becomes
in children at the age of 12. Granular or keratohyaline layer can be found in
children only on palms and soles. Nuclei of granular cells are smaller, poor in
nucleoplasma, but in children under 5 years their capacity for the division is saved.
The shining layer is barely determined on palms and soles, on the rest area of the
skin covering it can not be practically found.
Derma of children differs from derma of adult by predominance of the cellular elements, not enough differentiated fibred structures. Morphologically im-
26
matuTPIy of cellular and fibred substances of derma, their biological activity, especially fat cells, condition peculiaTPIy of forming of allergic reactions in children.
The subcutaneous layer is characterized by friability and abundance of
adipose lobules. The mass of hipoderma to the whole mass of the body in children,
is 5 times more than, in adults. The circulated and lymphatic system of children is
identical to those in adults. The abundant capillary system with undifferentiated
endothelium, constantly being in a state of dilatation, explains physiological
hyperemia of the skin covering of a new-born.
The protective function is especially incomplete. Because of tenderness and
friability of epidermis, morphological inferioTPIy of elastic and collagen fibres,
the skin of a child is easily exposed to the mechanical, radiation, thermal and
chemical irTPIations.
The process of warmproduction is not active enough, and heat emission due
to heat radiation, thermal conductivity and perspiration is expressed intensively.
The excretory function - because of abundant sweat production excretory
ducts of sweat-glands widen and tiny retentive cysts appear on the skin of the trunk.
The considerable part of interchange of gases in children is done through the
skin. Resorption is realized through oil-glands and hair follicles therefore
substances soluble in fats are absorbed and taken up very well.
Therefore application of ointments and creams, containing tar, phenol,
salicylic and boric acids, hormonal ointments is especially dangerous.
III Eczema, etiopathogenetic mechanisms of development, clinical forms,
principles of therapy (general and external)
Idiopathic eczema (from exeo - to boil up) is superficial erythematosevesicular inflammation of the skin of allergic genesis, characterized by symmetry
of eruptions, their polymorphism (true and false), polyvalent sensitization, chronic
recurring course; weeping, subjective strong pruTPIis and inclination for spreading
outside of the focus. A primary morphological element is a vesicle (as a result of
vacuole dystrophy and spongiosis).
Etiology and pathogeny. Nowadays it is accepted to consider, that eczema
is a polyetiologic disease. In Russian dermatology there are opinions of two
schools concerning eczema:
- Saint Petersburg: eczema is neurosis of the skin, conditioned by genetically
determi-ned lability and functional insufficiency of the peripheral and central
nervous systems.
Neurogenenic factor in development of eczema is proved by:
1.
2.
3.
4.
presence of pruTPIis;
symmetric localization of eruptions;
the first manifestation after the nervous tension or psychotrauma;
round lesion focus – disturbance of tactile sensation, thermoesthesia,
algesia;
27
5. positive effect after the use of electro-sleep, acupuncture-reflex therapy,
sedative remedies.
- Moscow: besides mentioned above functional disturbances eczema is disease of
allergic genesis.
Allergic factor is proved by:
1. presence of hypersensitivity to a number of irTPIants (polyvalent
sensitization);
2. combination with bronchial asthma, allergic rhinitis;
3. disturbance of immune status;
4. there is damage of trophycs because of disturbance of the CNS state,
alien products appear in the skin, after antibodies are formed
(autoimmunization) and then there are high titres of AB against one’s
own skin;
5. background is a purulent infection;
6. there is damage of permeability of membranes as a result of dysfunction
of the GIT, incomplete products of decomposing of albumens - allergens
get in the blood;
7. dysfunctions of endocrine glands are favourable conditions for
development of sensitization.
They distinguish following stages:
1. erythematous stage. Makulas of inflammatory character appear, gradually
fusing with each other;
2. papulose stage. Scarlet nodules appear their size is up to 2-3 mm, with
distinct margins;
3. vesicular stage. On the surface of nodules vesicles appear with serous
content up to the size of pin head;
4. stage of weeping. The vesicles burst and on their place dotty erosions
appear, serous wells from which exudation is secreted;
5. crust stage. Serous liquid dries to greyish-yellow crusts which the horny
layer is gradually restored under;
6. stage of scaling. It is characterized by presence on the surface of the skin
of large number of peeling crusts and scales.
7. resolution.
weeping
vesicular
papulose
erythematous
crustal (crusts)
squamose (scaling)
resolution
Figure 5. Kreibich’s triangle
28
These stages can have different duration and begin in different time, that
condition presence of clinical signs of different stages in one focus. Quite often
there is regress of eruptions in the central areas, and on periphery - fresher
elements. The symptoms of main affected zones are characteristic - allergids,
pyoallergids, mikids. They are predecessors of spreading out of the limits of basic
focus of the disease.
Weeping - specific, pathognomonic sign of eczema and appears as a result of
simultaneous bursting of great number of vesicles and seropapules (Monro’s wells).
They distinguish the following clinical forms of eczema:
1. true (endogenous);
2. microbial;
3. seborrheic;
4. professional;
5. infantile.
Serious complication of eczema is joining of herpetic infection - eczema
herpeticum or Kaposi’s varicelliform eruption.
True eczema is characterized by the chronic course, inclined to frequent
exacerbations, appears as progress of the acute inflammatory focuses located
symmetrically, more frequent on the bare areas of the skin. Basic symptoms of the
disease are edema, vesiculation and acutely expressed weeping. Within the limits
of lesion focuses it is possible to find out the good number of vesicles, located as
groups. They are filled with transparent liquid, after bursting of which the so-called
«serous wells» are formed they are called so because on their surface there is
slightly opalescent liquid resembling dew. On periphery of the focus it is possible
to reveal singly located nodular eruptions and vesicles. In future the quantity of
vesicles diminishes, secretion on the surface of microerosions dries to crusts, after
cicatrization of microerosions fine branlike desquamation remains. In eczema the
polymorphism of both the primary and second elements is marked. The disease is
accompanied by intensive pruTPIis. In a number of cases besides the basic lesion
focuses, on different areas there are scattered eruptions, but weeping is not
expressed. In the chronic course of inflammatory process the clinic is characterized
by the stagnant hyperemia, infiltrations in the focus, exaggerated skin pattern and
hyperpigmentation. Histology— in the stage of exacerbation they reveal spongiosis
with a lot of tiny vesicles in the epidermis, intracellular edema in the cells of layer
containing prickle cells, in the derma expansion of vessels of superficial system,
and also edema of papillae and lymphoid-cellular infiltration round vessels. In the
chronic course of inflammation the changes in the derma become the most
important, where they find perivascular infiltrate consisting of lymphocytes,
fibroblasts, histiocytes, eosinophils. In the epidermis there is acanthosis,
hyperkeratosis, parakeratosis; the edema of epidermis is expressed insignificantly.
The establishment of diagnosis of eczema does not cause difficulties: acute onset,
favouTPIe localization of process is on the face and extremities, symmetry of
lesion focuses, presence of characteristic signs of the disease (edema, hyperemia,
vesiculation, polymorphism of elements, expressed weeping).
29
Microbial eczema is characterized by the asymmetric location of focuses,
mainly on the lower extremities and in the folds of the skin. It progresses on place
of chronic focuses of pyoderma: infected wounds, trophic ulcers, fistulas and etc.
Often these areas are covered by sulphur – or greyish-yellow crusts, after their
removal red, weeping surface with «serous wells» is revealed. Inclination to the
peripheral growth is present. Around, on the externally healthy skin, the focuses of
sifting out are often seen - separate tiny pustules and small focuses. The process is
accompanied by pruTPIis. The margins of affection are uneven, skin within the
limits of focuses of cyano-red colour, infiltrated; there are distinctly delimited
round and large-scalloping focuses with the «collar» of peeling horn at the
periphery. They observe weeping and purulent crusts. At the periphery of focuses
it is possible to find the singly located pustular (ostiofolliculites, impetiginous
crusts) and papulo-vesicular eruptions. In pathogeny of microbial eczema quite
often varicose complex of symptoms (varicose eczema), trauma (paratraumatic
eczema (near-wound)) - at first the process is localized round a wound, and then on
other areas of the skin; fungous infection (mycotic eczema) are important.
Histologically massive acanthosis is characteristic, spongiosis, exocytosis with
formation of vesicles in the epidermis, in the derma there is edema, massive
lymphoid infiltration with the presence of plasmocytes; sclerosis of the derma is
marked.
Professional eczema is a protractedly proceeding allergic inflammatory
disease of the skin, appearing after the contact with substance irTPIating the skin
in the conditions of production. As etiology and pathogeny of professional eczema
influence of particular production factor, dynamic disorders of functioning of
nervous, vascular and other systems of organism, which determine the dynamics of
allergic reactions and a clinical course of disease. In first a heightened sensibility
of patients with professional eczema is characterized by monovalency. If contact
with production allergens continues it can become polyvalent one, lacking
specificity. The clinical picture of professional eczema is very similar to
manifestations of true eczema: eruptions are on open areas of the skin (mainly on
hands) and spread on periphery. Similar eruptions can appear in different distance
from the main lesion centre. The development of eczema on open areas (hands,
forearm, foot, face, neck) is caused by irTPIating substances fallen on the skin in
the conditions of production. If there are repeated contacts with them then in first
redness, edema appear, after – vesicle eruption. Professional eczema will be over
after the end of the contact with an agent which made for development of disease
(positive elimination syndrome). Every subsequent exacerbation proceeds more
painfully. Diagnostics of professional eczema is based on the following cTPIeria:
lesion focuses are as a rule, on open areas of the skin; without the contact with
irTPIants the disease regresses; while making skin tests (with a drop of allergen,
using gauze bandage) a heightened sensibility is marked to the «guilty» allergens,
that is to substances which a patient contacts with in production. From other
varieties of eczemas differs by rapid disappearance of clinical manifestations if
sensibilizating factor is removed. Histologically in professional eczema changes of
30
the skin, characteristic for true or microbial eczema are revealed.
Seborrheic eczema is considered by not all specialists. It develops in
seborrhea, possibly, first appears after the coming of puberty period. In seborrheic
eczema the lesion focuses are mainly on the areas of the skin, rich in oil-glands: on
a hairy part of a head, in the natural folds, behind auricles, on the skin of forehead,
axillae, around umbilicus, on the skin of breast, back, flexural surfaces of
extremities. On a hairy part of a head one can see the dryness of the skin,
hyperemia, grey branny scales. The lesion boundaries are acute. In a number of
cases there is exudation, and the skin of a head is covered by serous or serouspurulent scabs, after the removal of them a weeping surface is revealed. Folds have
a marked edema, hyperemia, weeping, deep painful fissures. In periphery of
focuses there are greyish-yellow scales and scale-crusts. On body and extremities
there are distinctly marked, yellowy-rose peeling maculae, in their center eruptions
of tiny papules can be found.
As for histology some features of seborrheic eczema are revealed. In
epidermis one can find hyperkeratosis, parakerinosis, intracellular edema and little
acanthosis, which can be accompanied by lengthening of epidermal outgrowthes,
because of them picture looks similar to those of neurodermatis and psoriasis. In
derm there is dilation of vessels, accumulation of glycosaminglucans, increase of
activity of enzymes of Krebs cycle (succinate dehydrogenase, malate
dehydrogenase), weakening of activity of respiratory enzymes, loosening of
collagen stroma, and hardening of elastic fibres. One may see peIFTolliculitis,
coccus flora and lipids in the superficial layers of epidermis, what is not
characteristic for true eczema.
Differential diagnostics is for different clinical variants of eczema (true,
microbe, seborrheic, professional). It is necessary also to distinguish eczema from
neurodermatis, dermatitis, and premycotic period of fungous mycos.
In neurodermatis unlike eczema there is no vesiculation and lichenification
of the lesion focuses is marked, whose favouTPIe localization – flexible surfaces
of extremities. Besides, seborrheic eczema is differentiated from rose herpes,
erythemic pemphigus, psoriasis, plaque parapsoriasis, and discoid lupus
erythematosus. Microbial eczema is differentiated from psoriasis, chronic family
benign pemphigus, primary reticulosis of the skin. True eczema is differentiated
from scab, zoster.
There are also:
- dyshidrotic eczema, when eruptions are on palms, soles and lateral surfaces
of fingers is also differentiated. Clinically it is characterized by appearance of
vesicles. Because of thick corneous layer vesicles join with each other and form
large vesicles. After cutting a weeping surface comes to light, in periphery of
which there is a border of undermined corneous layer.
- eczema of lips or eczematous chilitis, appearing as eruptions on the red
border of lips. The process is not accompanied by considerable inflammation;
31
wetting is minimal, in the chronic period lichenification is insignificant. The
picture of subacute inflammation with formation of little that crusts and scales
prevails, there can be numerous fissures covered by little crusts with blood.
Differential diagnostics is mainly done with neurodermatis, but eczema of
lips – with atopic, actinic and contact chilitis. The diagnosis is made on the totality
of clinical data.
Medical treatment. First of all it is based on nervous-allergic pathogeny of
eczema. Taking into account the role of disorders of neuroendocrine system,
metabolism, pathologies of inner organs, influence of environment factors and,
finally, age features of organism - removal of functional disorders of different
organs and systems. In the same time one should also consider a heightened
sensibility of the skin of patients with eczema to different chemical substances.
They can inadequately react to medicinal preparations and foremost in
exacerbation period.
The medical treatment includes:
1) diet therapy: diet therapy means easily assimilated, rich in vitamins, proteins,
carbohydrates food. One should not forget that many patients with eczema suffer
from fermentopathy. Boiled meat, fish, dairy products, a lot of vegetables are
recommended.
2) general medical treatment: a) normalization of neurological condition
 sedative (bromine, valerian, sonapax, electro-sleep, hypnotherapy,
acupuncture, aminazine, haloperidol, luminal, Pavlov’s mixture,
Bekhterev’s mixture), minor tranquilizers
 gyno-suggestive therapy
 doctor-psychoanalyst
b) leveling of dissonance of separate constituents of the immune
system, hyposensitization
 antihistamine preparations (ketotifen, piTPIol, fenkarol, diazolin,
suprastin, cynarisin (stugeron) - inhibitor of H-1 and H-2 histamin
receptors)
 solution of calcium chloride - 10% intravenously or 0,25%
intramuscular – reduces permeability of cellular membrane
 sodium hyposulphite 30% intravenously
 histoglobulin (complete antigen) according to medical regimen
 glucocorticoids – so called «the last hope» have:
- immunodepressive
- antiallergic
- anti-inflammatory effects
c) pathogenetic therapy
 neutralization, sanation of intercurrent pathology
 immunostimulators (timalin, timozin, splenin, taktivin) – only
individually on results of immunogramms
32
 vitamins of group A, B, C, provitamins
Hyposensibilizative therapy - sodium tiosulfin, calcium chloride. Many
authors recommend in the complex of preparations used for medical treatment of
eczema, include the vitamins of B complex for hyposensitization, also a
hypodermac injection of histaglobulin 2 times per week with 0,2; 0,3; 0,4; 0,5; 0,6;
0,7; 0,8 ml in order for an injection. Antihistamine preparations - tavegily and
others. A specific hyposensitization is injection of specific allergens in minimal
doses parenterally. Disadvantages — it takes a lot of time for 1 course (1, 5-2
months and an interval between courses is about 6-7 months). Insufficient
efficiency as can be accompanied by worsening of dermatosis or development of
inflammatory phenomena in place of allergen introduction.
In severe forms of eczema general and local application of corticosteroids is
necessary. Taking into account a considerable role of activinion of callicrein-kinin
system in pathogeny of eczema, the method of medical treatment of patients with
eczema by proteinases and unsteroid anti-inflammatory preparations was worked
out. It includes – mefenamic acid 0, 5 3 times a day and aminocapron acid 2-3 g 3
times a day. In persevering course, and also weeping one – intravenous injections
of these acids and indomethacin up to 100-150 mg a day, for 30 days.
For normalizinion of cellular immunity - levamisole (dekaris) in the
deficiency of the T- cellular system, 150 mg for 2 days with 5 day interruptions for
2 months. Taktivin, diuciphon, adaptogenes can also be used.
As patients have considerable damages of peripheral circulinion,
microcirculation of blood, it is recommended to include in the medical treatment
teonikol (komplamin - analogue of ksantinol nikotinine) 150 - 300 mg 3 times,
parmidin 0,75 mg for 20-25 days, reopoliglukin daily 5 ml/kg for 3-4 days, after
every other day.
Pirroksan – if there are marked vegetative disorders. In increased tone of the
parasympinhetic system - injections of adrenalin 0,2-0,3 ml 0,1% solution.
From the physiotherapeutic remedies it is advisable to apply inductotherm
on the area of adrenal glands with preliminary (1 hour earlier) taking of dopegit (1
pill), lowering the tone of the sympinico-adrenal system; indirect diinhermy,
sometimes ultraviolet radiinion treatment is used. Resort therapy – balneotherapy:
hydrogen sulphide, sulfide, radon, naphthalan and other kinds of baths. Also baths
with coniferous extracts: duration of binh is 15-20 minutes, temperature 37-38
centigrade, for one hour before sleep, with subsequent smearing of focuses.
External medical treatment. It depends on period of process. In acute,
subacute and aggravated eczema if there is wetting then cold lotions are applied –
solution of boric acid 2%, 1% solution of resorcine, solution of aethacridine lactate
1:1000, solution of silver nitrine 0,25%, 1% solution of tannin. If wetting stops or
is absent then oily, aqueous or aqueous-spiTPI shaken up meals are used. After
ceasing of acute inflammatory phenomena it is possible to include 5-20% ichthyol
or naphthalan in mash ingredients. To reduce itch – menthol is used. Then they
begin an ointment therapy, in first go pastes – boric-tar, serous-ichthyol and others
with ensuing increase of concentration of applied components for infiltration
33
resolution. In this period it is also possible to use physiotherapy, include dimexide
in ointment ingredients to improve absorption. Corticosteroid ointments such as
polkortolon, oxycort, lorinden C, gioxizon can be applied.
Prophylaxis. In the prophylaxis of eczema timely removal of influence of
external and internal factors causing dermatoses in patients which liner turn into
eczema plays an important role. The prophylaxis consists of rational medical
treatment of traumatic lesion and care of the healthy skin surrounding a wound,
and also of timely treatment of traumas and burns. Both medical treatment and care
of the skin must prevent development not only eczeminous process, but also
pyoderma as quite often it turns into microbial eczema.
The prophylaxis of professional eczema also consists of realization of
measures of fighting against professional insalubTPIies — preservinion of the skin
of workers from trauminizinion, wearing of special clothes, observance of hygienic
norms and concentrations of industrial allergens, supply of skin protecting means –
in professional eczema. Important moments are timely medical treatment of
professional dermatitis already existing and revelinion of antigens for the removal
of their influence.
General prophylactic measures are directly related to prevention and
medical treatment of chronic diseases of inner organs, disorders of metabolism and
activity of the nervous system, endocrine disorders, that are factors favouring to
development of eczema and sensitization. Proper diet, washing, good nervouspsychic condition of patients, normal sleep, and removal of risk factors are also
important.
IV Neurodermatoses (skin pruTPIis, prurigo, atopic dermatitis, Widal
herpes)
Neurodermatoses are characterized by pruTPIis and are accompanied by the
neurotic disorders. They are:
-pruTPIis of the skin (localized and generalized)
- neurodermatis (limited and diffusive)
- urticaria (acute, chronic, papulous, Quincke’s edema – giant urticaria)
- chronic prurigo of adults
- infantile prurigo
- Hayd nodular prurigo
Itch of the skin is feeling accompanied by irrepressible desire to scrinch an
affected area. It appears as a result of influence of exogenous and endogenous
factors on the receptor apparatus of the skin. A physiological itch is an adequine
reaction of the organism on bites of insects, influence of plants. A pathological itch
appears because of this or that pathological condition of the organism. Etiology can
be various:
34
- increase of sensitiveness to food products, medications
- autointoxicinion
- sometimes it is the first manifestation of affection of blood creation
organs
- result of nervous disorders
- can be an individual disease
- can be a disease symptom (neurodermatis, eczema).
Pathogeny: some specialists consider pruTPIis as a changed feeling of pain.
They thatk that they are weak, quickly following each other action potentials,
which spread slowly in the nervous system by sympinic fibres. The condition of
the vegetative nervous system is of great importance.
They distinguish limited and diffusive pruTPIis. The course of them is
various. If a man has pruTPIis for a long time then morphological elements appear:
excoriations, papules.
Neurodermatis - chronically recurring skin disease, which changes mainly
develop as a result of scrinching of the skin, caused by primary appearing pruTPIis.
Clinical forms: limited neurodermatis and diffusive neurodermatis (atopic
dermatitis).
Genetic factors creating predisposition to atopic allergy play an important
part. One of mechanisms – blockade of beta-adrenergic receptors; one determine
an increased production of IgE and in the same time reduction in the peripheral
blood of the T-cells quantity, Ig A and M and increase of G.
Clinical picture: adult men have limited neurodermatis more frequently.
There are 1-2 pruTPIis focuses in sites of neck, inside surface of thighs, scrotum,
and anus. The main clinical sign is lichenification of the skin.
Diffusive neurodermatis (atopic dermatitis) begins as a rule in infancy as
exudative diathesis turning into child's eczema, then in the age of 7-8 into diffusive
neurodermatis itself. It appears as acute pruTPIis that especially disturbs in night.
Localization: area of lateral surfaces of the neck, breast, forehead, cheeks, red
margin of lips, elbow and popliteal folds. An affected skin is slightly hyperemiric,
dry, lychenifed and it has many excoriations, crusts. The edges of lesion are
unacute, on sites of scratchings - exudation. The red margin of lips and adjoining
skin is sometimes involved in process - atopic cheilitis. The course is protracted
and aggravations are mainly in the fall-winter period.
Urticaria is an allergic disease characterized by rapid more or less spread
skin eruption of pruTPIis wheals. Variety of urticaria – Quincke’s (giant urticaria).
A general pathogenic part is increase of permeability of microcirculation
channel, development of acute edema in the surrounding area. In wheal area
loosening of collagen fibres, intercellular edema of epidermis and appearance with
different speed of development and degree of expression prevascular mononuclear
infiltrations are marked. They distinguish allergic, physical, endogenous, pseudo
35
allergic urticaria.
Clinical picture is characterized by monomorphous rash; primary element –
wheal is a rapidly appearing edema of papilla layer of derma. It begins suddenly as
an intensive pruTPIis of the skin of various areas. In these areas hyperemiric sites
of rash, which are above surface appear, edema grows, capillaries are squeezed and
wheal turns pale. If there is a lot of exudation vesicle with exfoliation of epidermis
can form. The size of rash elements varies; they can be separate or merge with
each other and form ring-shaped elements undergoing reverse development in their
center.
Quincke’s edema – this edema spreads deeply, seizing the whole derma and
hypodermac-adipose cellular tissue. Large, pale unpruTPIis infiltration appears,
after pressing there is no pit. It appears more often in areas with loose cellular
tissue, can also appear on mucous membranes. There is difficulty of breathing in
area of larynx; sick people can die from asphyxia
Medical treatment: it is desirable to remove an allergen. One should
prescribe antihistamine, desensitization remedies; sodium thiosulfate 1-2 ml
parenterally. In giant urticaria - 0,1% solution of adrenalin hypodermacally, if
there is edema of larynx - 60 mg of prednisolone intramuscularly, hot foot baths,
inhalations of euspiran, isadrin, 2 ml 1% lasix intramuscularly. Externally –
rubdown by table vinegar or ointments containing 2-5% of anesthesin.
Prurigo – edema papules with acute pruTPIis appear. Infantile prurigo
occurs in the age of 5 months up to 5 years and is usually skin syndrome of
exudative diathesis. Development of infantile prurigo is more often caused by food
sensitization (milk, chocolate, honey, berries, albumen, meat soups, smoked
products), rarer by medicinal sensitization and intestinal worm invasion. A primary
element is a small bright-pinky edema papule, in the center of which a little vesicle
is formed. Localization: on the extensor surfaces of extremities, nates, face.
Eruptions appear in different quantity, are characterized by intacklike pruTPIis
(especially at night), that results in scratchings, sometimes complicated by
pyoderma. There can be general phenomena. Course of active condition is
recurring one.
Adult prurigo occurs in women of middle age. The disease can be caused by
food irTPIants, nervous-psychic disorders and various general diseases. Acute
pruTPIis tiny pinky excoriate papules are usually situated on the extensor surfaces
of forearms, stomach, back, buttocks. Course of disease is chronic and recurring
one. The patients must be examined thoroughly to find a causal factor.
Hayd nodular prurigo occurs mainly in women older than 30 years, having
unstable nervous system. Localization: on the extensor surfaces of shins, face, and
hairy part of a head. 2-3 dozen of isolated, hemispheric, acute pruTPIis papules
appear and they can be up to the size of pea. They extend (grow) slowly and
become solid, fulvous-brown ones. Course is chronic, lingering.
36
Child's urticaria or child's prurigo occurs in children from the age of 5
months up to 3 years. It can appear on background of exudative diathesis in
hightened sensitiveness of a child to some products (eggs, milk, meat, citrus plants,
sweets and others) or on background of inefficient nutTPIion and overfeeding.
Unlike ordinary urticaria, child's urticaria is characterized by eruption of tiny
wheals, in their center in a few hours (sometimes days) papule-vesicule by the size
of pin head will appear. After that wheal will disappear, but papule-vesicule as a
result of scratchings turns into bloody crust. Localization - on the extensor surfaces
of extremities, body. Mucous membranes are not affected. Many authors attribute
this disease to prurigos, because in the age of three it can turn into chronic prurigo
or neurodermatis.
General principles of medical treatment. In medical treatment of
neurodermatoses the main thatg is an observance of food and hygienical routine.
Diet is mainly milk-vegetable with limitation of salt consumption. Conservinive
routine is of great importance, it means complete sleep and rest, no overstrain and
stress situations. One should not wear tight and very warm clothes, woolen and
synthetic tissue is undesirable.
To normalize the CNS, reduce neurotic reactions they use
neuropharmacological therapy with prescription of sedative preparations - bromids,
motherwort, valerian, somnolents; neuroleptics (aminazin), tranquilizers
(chlozepide, sibazone, nozepam and others).
Elimination diets feature in medical treatment. They are milkless, eggless,
grainless ones. Duration of application of elimination diets is 1, 5-2 months. They
favour reverse development of the disease. Next dietotherapy implying step by step
inclusion of new products in diet is done. In that observance of hypoallergene diet exclusion of foodstuff having high sensitization activity is very important.
The modern methods of pharmacotherapy are divided into 2 basic groups:
1 group - medicinal preparations applied for removal of acute symptoms of
allergic inflammation. Antiserotonin and antihistamine preparations of the first
(dimedrol, suprastin, pipolfen, tavegil, diazolin, phencarole) and second generation
(terfenazin, astemizol, lorinadin, cetirizin) are indispensable. Antihistamine
preparations blocking H-1-receptors, by their connection, favour reduction of
pruTPIis and removal of allergic inflammation of the skin. Course of medical
treatment by the antihistamine preparations is 1, 5-2 weeks. Repeated courses of
therapy can be done if it is necessary.
In aggravation, accompanied by acute pruTPIis, antihistamine preparations of the
1st generation, possessing a sedative effect are very useful. Along with sedative
effect if applied for a long period of time these preparations can cause a
phenomenon of autoinduction of cellular metabolism when intensity of destruction
of preparation increases and its concentration in blood and tissues reduces.
2 group are medicinal preparations used for prevention of elimination of
biologically active substances - reduction of cells number having mediators,
suppression of synthesis of mediators and their blockade.
Among
them
preparations of preventive effect - ketotifen, zaditen, intal, nalkrom; possessing
37
hyposensitization effect - histoglobulin (8-10 injections intracutaneously 2 times
per week by age doses 0,2-1,0 ml), seroglobulin, allergoglobulin. Ketotifen or
zaditen is given to children at the age of 6 months up to 3 by 0, 05 mg/kg of body
mass 2 times a day. Course of medical treatment is 1-3 months for children over 3
years, one-time dose of zaditen - 0, 001 g is prescribed; it can be used for a long
period of time (6-12 months) in frequent aggravations. The use of these
preparations in syrup is possible.
Highlyeffective remedies in medical treatment are preparations of sodium
cromoglicine (intal, nalkrom). Nalkrom is given to children at the age of 2 months
up to 2 years by 20-40 mg/ kg of body mass 4 times per day. Course of medical
treatment continues from 2 to 6 months. Nalkrom is taken 30-40 minutes before
meal. The mechanism of action of nalkrom or zaditen consists in stabilization of
membrane of fat cells and eosinophils that provides prevention of allergic reactions.
It is necessary to exagerine that nalkrom effectively inhibits inflammatory reaction
of mucous membrane of intestines that’s why preference is given to patients with
food allergy combining with gastrointestinal forms of allergy and atopic dermatitis.
The important role is given to preparations improving active conditions of
digestion and absorption of food (enzymic preparations), normalizing intestinal
microflora (prebiotics of metabolic type «Hilаc-fort»), arresting stagnant focuses
of excitement in brain (sedative preparations, tranquilizers) and sanation of chronic
focuses of infection (medical treatment of lambliases, helminthiasis, hepinitis,
cholecystitises, diseases of the ENT organs).
For recent years they found an application for preparations correcting
disorders of the immune system - reaferon, viferon, and immunostimulating
preparations.
Local therapy which is done taking into account the degree of seveTPIy of
inflammatory reaction and morphological changes on the skin takes a special place.
In acute inflammation with the phenomena of exudation and wetting they apply
lotions and aniline dyes taking drying and antiseptic action. They mainly use
lotions with solution of tannin 2%, rivanol 1:1000, 10% solution of ichthyole for
reduction of edema and hyperemy of the skin. These lotion solutions are applied
when cooled to the temperature of 18-20 centigrade, with 10 layers of gauze and is
kept for 4-5 hours. Application is no more than for 3-5 days. Simultaneously with
lotions aniline dyes are used in aggravation – methene blue, Castellani, fuxin,
brilliant green. Ointments with corticosteroids - gioxizon, lorinden C, aerosols oxiciclozol, polkortolon - H are applied on limited lesion focuses.
After arrest of wetting they begin to prescribe pastes and shaken up meals
combined with creams or ointments. This paste is ASD 3 fraction and others. In the
medical treatment of the lesion skin accompanied by marked dryness they apply
creams and ointments containing vitamins A, E, D. The oily solution of vitamin A,
Unn cream is especially effective. In 70-80% of children with atopic dermatitis,
they culture the flora of Candida albikans in the biological liquid. Therefore
pathogenetic medical treatment by antifungous preparation Kandibene cream 1%30g is advisable. In the insufficient efficiency of unspecific anti-inflammatory
38
remedies, the local medical treatment of corticosteroids takes place, they favour
reduction of pruTPIis, take strong anti-inflammatory action, cause constriction of
skin capillaries, hardening of endothelium of vessels, prevent transudation of liquid
from vessel empty spaces into tissue medium, and also migration of cells from
capillaries to tissues. So, basic principles of therapy are:
- elimination of allergens
- use of hypoallergenic diets excluding necessary and optional
allergens
- prescription of antihistamine and antimediator preparations
- enterosorption
- recovery of injuried GIT functions
- correction of digestion and absorption processes
- recovery of functional condition of the central and vegetative
nervous systems
- rational external therapy
The main preparation for the medical treatment of cold urticaria cуproheptadine (of the class of piperidins). Piperazins are effective too, in
particular, hydroxyzin, however these preparations are contra-indicated in
pregnancy. The H-1-blockers of the 1st generation (forementioned), it is better to
give before sleep, as they have marked somnolent action. Hydroxyzin is appointed
1 time per day before going to bed. Although even in such way of use it takes
marked somnolent action during a day (24 hours). This is because of a long halflife of active metabolite of hydroxyzin - cetirizin. The dose of preparations is
selected individually, increasing it every 5-7 days. One should take into account,
that the majoTPIy of H-1-blockers cause weight gaining. All preparations are
metabolized in the liver.
Doxepin is sometimes appointed to adults, it is strong H-1- and H-2-blocker;
it is taken by 25 mg 2 times per day. The most marked side effect is somnolent one;
in high doses it causes arrhythmias. Doxepin possesses M-holinoblocading action.
In prescription of preparation in dose 75-100 mg per day it is necessary to
determine concentration of doxepin in serum. Total level of these metabolits must
not exceed 300 mg%, because the overdose can cause deinh.
Medical treatment by autoserum. On the height of disease or after the
provocative test from the vein of a patient 10 ml of blood is taken. This blood is
processed by spin dryer. Got as a result autoserum is dissolved by izototic solution
of sodium chloride as 1:10 1:100. The medical treatment begins from dissolving as
1:100 (0, 1 ml hypodermacally), a dose is daily increased by 0, 1- 0, 2 ml, up to 1
ml (end result). After they begin to dissolve as 1:10, up to undiluted autoserum
(end result). The medical treatment by autoserum is repeated in 6 months resulting
in the clinical effect. The preparation of autoserum is done in the strictly sterile
conditions.
Corticosteroids are used in severe cases, when the edema of larynx,
39
threatening with asphyxia can be seen, in combination of urticaria with the
bronchial asthma of difficult course and anaphylactic shock. An individual dose is
up to 4-5 days, gradually reduced by 1, 25 mg daily (1/4 of pill).
In the anaphylactic shock - 0,5 ml hypodermacally 0,1% adrenalin
hydrochloride solution, corticosteroids intravenously 75-125 mg hydrocortisone or
30-60 mg prednisolon.
Physiotherapeutic medical treatment: general and local UVR by erythemic
doses, selective phototherapy, PUVA-therapy, electro-sleep, reflexotherapy and
others. Paraffin and ozoceTPIe applications are useful too. Resort medical
treatment: balneotherapy - sulphuretted hydrogen, sulfide, nitric, naphtalan, radon
and air baths. In climinic resorts - heliotalassotherapy.
Prophylaxis, rehabilitation, clinical examination of patients with
neurodermatoses: oservation of pregnant ones and recomendation of diet with
limitation of food allergens, exclusion of alcohol and others. Children born by
mothers with unfavorable allergoanamnesis must be observed by paediatricians
and dermatologists. An important purpose of clinical examination is prophylaxis of
relapses, increase of duration of remissions of dermatoses. It is necessary to keep
order: hospital — out-patient treatment – clinical medical treatment – resort. The
work, related to the contact with dust, industrial allergens, in rooms with damp
microclimate and high temperature is contra-indicated to such patients. In the
universal skin lesion the 2nd group of disability is given.
V Lupus erythematosus
Lupus erythematosus (lupus erythematodes) - is characterized by the system
affection of connecting tissue, skin and inner organs with difficult pathogenetic
syndrome (with autoimmune mechanism). It is related to diffusive diseases of
connecting tissue (collagenoses).
Etiology and pathogeny are not found out. There is a supposition about the
viral appearance of lupus erythematosus. Viral infection is on background of
genetically determined affections of immunity. They discovered in individual
researches, that infection of cultures of cells of human being and monkeys by
material taken from patients of lupus erythematosus allowed finding out in a
number of cases the viruses possessing cytopathogenic action. However these
viruses were not specific, that does not exclude their role, as well as other
infectious agents, in pathogeny of lupus erythematosus. E.M. Rahmalevich and
A.T. Akopyan (1962) showed that in blood and urine of patients there is a living
agent, taking cytopathogenic action in the cultures of tissues and causing
appearance of erythema in chicken embryos, reminding that of lupus
erythematosus.
A great number of supporters shared the streptococcus theory based on
frequent discovery of streptococci in lesion focuses and blood of patients,
discovery of sepsis in dissection of people died of systemic lupus erythematosus
40
(SLE), appearance of aggravated reaction in focuses after application of
streptococcus vaccine.
Many researchers emphasize focal streptococcus infection, whose
elimination in many cases resulted in the improvement of active condition that can
be explained by stopping of sensitization from infection centre. It is determined
that sometimes chronic lupus erythematosus can turn into severe form, being a
septic disease caused by streptococcus. Severe lupus, in opinion of many
specialists, is an allergic reaction to many exogenous and endogenous irTPIants.
Lupus erythematosus is an infectious-allergic disease characterized by fibrinoid
dystrophy of connecting tissue in many organs. The results of histochemical
researches testify to similaTPIy of severe and chronic forms of this disease.
Nowadays autoimmune theory of disease won the recognition. The
circulated antibodies and most of all antinuclear antibodies to the whole nucleus
and its components appearing as a result of the disease, saved on the basic
membranes, cause their injury with development of inflammatory reaction.
Abundant production of isogenous and heterogenous autoantibodies revealed in the
discovery in patients with any form of lupus erythematosus LE-factor,
anticardiolipin, antibodies to leucocytes, thrombocytes, erythrocytes,
anticoagulants and formation of antibodies to the cellular components (DNA, RNA,
nucleoprotein, histodissolvable nuclear components). The presence of antibodies of
cytotoxic action to the elements of blood in patients with lupus erythematosus
explains the existence of LE-phenomenon first discovered in 1948 by Hargreaves,
Richmond and Morton as nucleophagocytosis in marrow of people with SLE. The
cells of lupus erythematosus and antinuclear factor revealed in patients with SLE,
but they can also be found in patients with toxicodermaas, rheumatism,
sclerodermaa, Düring disease, that means their relative character. The antinuclear
antibodies are revealed more constantly in SLE.
Factors favouring the rise of disease or its aggravation can be stress
situations, traumas, influence of medicinal preparations, infection, cold and etc.
The cases of aggravation of chronically proceeding lupus erythematosus because
of influence of sun or ultraviolet artificial rays – photosensitization are well known.
The presence of acroasphyxia, Raynaud’s disease, chilblain, predisposes to
development of lupus erythematosus on these areas of the skin. The role of
neuroendocrine disfunctions is known; family-genetic predisposition was proved.
The development of mucoid degeneration and marked depolimerization of
basic substance of connecting tissue with subsequent precipitation in affected
fibrinoid tissues are typical. Interaction of AB with SG of connecting tissue results
in release of glycosaminglucans and glycoproteids that is haptens. For newly
formed AG immunocompetent lymphocytes produce proper AB. In patients with
lupus erythematosus they reveal oppression of function of adrenal gland cortex,
disfunction of sexual and other endocrine glands, and also disorders of albuminous,
carbohydrine and adipose exchange. The role of affections of porphyrin exchange
is suggested. As a result of rise of level of porphyrins in the skin fat got by
lysosoms porphyrin under the influence of sunbeams destabilizes the membranes
41
of lysosoms that influence production of the skin fat and absorption of cells of
surrounding tissues. Thus, one should emphasize in pathogeny following parts:
1. neurohormone disorders (pregnancy, abortions, childbirths, beginning of
menstrual function)
2. CIC formation, saved on the basal membranes of different organs resulting
in their injury and inflammation
3. formation of circulated autoantibodies (antinuclear antibodies)
4. hyperreactivity of humoral immunity related to affections of cellular
immunoregulation
5. hyperestrogenemia, accompanied by decrease of CIC clearance.
Lupus erythematosus occurs rarely: its frequency is 0, 25-1% of skin diseases.
SLE is observed much rarer than discoid one. The disease is more widespread in
countries with moist marine cold climate. It occurs more frequently in blond
people, than dark ones, in women more frequently, than men. Higher morbidity of
women is explained by the fact that their skin is that and tender, and also by
definite influence of activity of genital glands, it is proved by aggravation of
disease course during pregnancy and after childbirths. Lupus erythematosus is
observed in the age of 20 up to 40. 2-3% of cases accounts for the child age.
The classification distinguishes chronic diskoid, chronic disseminated and
systemic lupus erythematosus (SLE). Different organs and systems can be affected
in the last form (period).
In discoid lupus erythematosus active condition begins as appearance (usually
on the face) of pinky-red edema makule, which gradually gets harder and is
covered by tiny greyish scales firmly sitting in mouths of hair follicles. On the
lower surface of a scale if it is removed one will see tiny spikes («dame’s heel») corneous corks which are tightly enter into the mouths of hair follicles. In attempt
to remove them a sick person feels a pain (Besnier – Meshchersky symptom).
After removing of scales the surface of centre resembles a lemon peel. The area of
lesion centre gradually increases and new focuses appear. The infiltration,
cornification, redness and edema intensify on periphery. In the center scar atrophy
gradually develops, the skin becomes thatner, can be folded easily. Scar atrophy
more frequently develops on the sculp. Basic characteristic features of lesion
focuses of discoid lupus erythematosus are erythema, infiltration, hyperkeratosis
and atrophy. Besides teleangiectases, hyperpigmentation can be observed. The
degree of expression of signs of lupus erythematosus varies, it depends on form
and duration of disease, and therefore clinical picture is various.
The size of lesion focuses of lupus erythematosus is different, diameter is 0,5-5
cm and more. Quantity ranging from 1 to many, located on face, sculp, breast.
Localization on nose and cheeks (in a butterfly pattern) is typical. Rarer they
appear on auricles and mucous membranes. If they are on the skin of auricles in the
hyperkeratotical changed mouths of follicles punctuated comedos collect,
resembling a surface of a thimble from outside (G.H. Hachaturyan symptom). On
the hairy part of head is characterized by rapid development of atrophy along with
disappearance of oIFTices of hair follicles and then steady baldness. In
42
dissemination of process the pads of fingers are affected. There can be eyes lesion
as blepharoconjunctivitis, keratitis, and chorioiditis.
There are a lot of varieties of chronic discoid lupus erythematosus depending on
predominance of basic symptoms. Distinctly marked hyperkeratosis results in
formation of stratification of hardened corneous scales or abundant tiny white
scales resembling chalk. In germination of epithelium papillae by strong corneous
stratifications, much higher than surface of the skin, the picture of papillomatose or
verrucose lupus erythematosus can be seen.
Tumor-shaped lupus erythematosus is characterized by violet-red plaques with
the hydropic edges. In this form the basic sign can be absent - hyperkeratosis, that
makes difficult for diagnostics.
A rare form of discoid lupus erythematosus is superficial lupus erythematosus centIFTugal erythema.
Clinical picture of centIFTugal erythema considerably differs from diskoid
lupus erythematosus by absence of infiltration, hyperkeratosis and atrophy in
lesion centre. A centre is distinctly limited, a little hydropic erythema of pinky-red
colour, located on the back of nose or on nose itself and cheeks symmetrically in a
butterfly pattern, spreading centIFTugally. Sometimes erythema appears only on
cheeks, there can be slight peeling on the surface of lesion centre. There is little
pigmentation or insignificant atrophy after resolution. The subjective feelings are
absent. The course of centIFTugal erythema differs from discoid lupus
erythematosus, because it is easily treined, but often recurs, that’s why they call it
migrant one. CentIFTugal erythema – relatively rare disease, among patients with
lupus erythematosus it accounts 5-11%. It is considered, that it turns into SLE.
Kaposi-Irgang deep lupus erythematosus occurs rarely and is
characterized that along with typical lesion focuses of diskoid lupus erythematosus
there are lesion focuses as thick nodes deeply located in the subcutaneous tissue.
The skin above them is smooth, of stagnant bluish colouring. On the surface of
nodes there are focuses of hyperkeratosis and atrophy. It is accompanied by
general severe phenomena (artralgia, subfebrilitetis, anaemia, leucopenia,
accelerated ESR).
Disseminated lupus erythematosus appears as plural dissipated lesion
focuses on the skin of face, breast, hands, feet and etc. This form occurs in 12, 522% of patients with lupus erythematosus. The focuses of disseminated lupus
erythematosus have an erythematous-squamous character with the presence of
follicle hyperkeratosis and scar atrophy and without them. Localization of
eruptions is face, sculp, breast, back (resembling a necklace). There are abundant
bluish-red makules of irregular shape without distinct margins along with distinctly
marked infiltrative elements. They are localized on palm surface of hand fingers
and in feet area. The bluish colouring intensifies in aggravation of active condition,
when usually new focuses which can resemble the focuses in SLE.
Resemblance of disseminated lupus erythematosus and SLE is proved by
other changes too, but not distinctly expressed: anaemia, leucopenia, accelerated
ESR, hypergammaglobulinemia, subfebrile temperature, joint pains. Focuses of
43
focal infection are usually revealed in patients with disseminated lupus
erythematosus and SLE. Disseminated lupus erythematosus can turn into discoid
lupus erythematosus or system form (type).
Seasonality of aggravations (spring-summer period) and relief in autumnwinter period is noticed. Diskoid lupus erythematosus can be complicated by
erysipelatous inflammation and become malignant (more frequent in area of back
of nose and on the lower lip in erosive-ulcerous variant). There are also mutilining
and pigmental forms of discoid lupus erythematosus.
The subjective feelings are slight pruTPIis and pricking. In the laboratory
diagnostics: anaemia, accelerated ESR, reduction of quantity of albumens and
increase of a number of globulins, especially gamma ones, appearance of the Creactive albumen and cryoglobulins. In patients with discoid lupus erythematosus
are revealed dystrophic changes of connecting tissue not only in focuses, but also
on visibly healthy skin. In patients with diskoidnoy lupus erythematosus are
mentioned increase of permeability of capillaries, disfunction of adrenal glands,
thyroid, reduction of a number of 17-ketosteroids and corticoids in urine, hightened
sensibility to light, mechanical, physical and infectious agents. Many sick people
have neurotic reactions, affections of liver function, lowered acidity of gastric
juices. However mentioned above changes are considerably less expressed in
discoid form of lupus erythematosus, than in systemic form of lupus erythematosus.
Systemic (acute) lupus erythematosus can develop suddenly, idiopathicly,
without the preceding chronic form and proceeds severely combined with
affections of the cardio-vascular system, organs of respirinion and digestion,
kidneys. But can also appear on background of chronic form of lupus
erythematosus. It begins from the period of prodrome (temperature, joint pains),
appearance of vast erythematous and hydropic areas of stagnant-livid colouring.
Besides along with them rashes can appear as vesicles, vesicles, wheals, pustules,
the presence of lesion focuses on face (butterfly-shaped), sculp, neck (steady
erysipelas of face) is possible. Quite often it can affect mouth mucousa, a red lip
margin, cheeks, gums, paline. On mucousa they distinguish four varieties of
disease - typical, without clinically expressed atrophy, erosive-ulcerous, deep.
Differential diagnostics is done in the initial period for psoriasis, seborrheic
eczema, trichophytosis, pinky blackheads, tubercular lupus erythematosus,
papulose syphilid, and erythematous pemphigus.
Medical treatment. Unbalancing of lymphocytes is the reason for
immunomodulining therapy: levamisole is given by 150 mg as a dose in a day, for
3 days, as 4 cycles with intervals for 4-5 days. Tactivin is injected by 1 ml
hypodermacally; timozin, thymaline, leacadine are used too. To restore a normal
correlinion of cyclic AMP/cyclic GMP it is necessary to prescribe methylxanthines
- euphyllin, thеоphyllin.
Photodesensitizing medicines - chingamin, delagil, chlorohin, plakvenil - by
cycles of 5-10 days with an interval for 2-5 days are used. They also prescribe
vitamins with anti-inflammatory and fotodesensitizing effect - nicotine acid,
44
vitamins of group B, C, retinoids - tigazon. In the SLE – use of corticosteroids,
often combined with antibiotics, for prevention of secondary contamination – with
immunostimulating preparations - methyluracile, pеntoxyle, sodium nucleinate and
others. Diet with a lot of animal albumens and limitation of carbohydrines.
Plasmapheresis to eliminine autoantigens, autoantibodies and pathological CIC is
advisable. The E vitamins are used for the normalizinion of the POL.
The combined medicinal preparations containing several necessary medical
ingredients are convenient, for example, presocil, which contains 0, 04 g of
chlorohin, 0,75 mg of prednizolon, 0,2 acetylsalicylic acid and also sentol
(prednisolone, potassium, calcium, B12 vitamins, A, E, C, P). External medical
treatment is an additional, although it may decrease duration of existence of
clinical manifestations of the disease. One externally applies ointments and creams
containing corticosteroids - flucinar, synalar, ultralan, celestoderm, and
hydrocortisone ointment. In discoid lupus erythematosus injection of antiinflammatory preparations into lesion focuses is effective. Pricking all round of
focuses by hydrocortisone suspension, by 5 or 10% solution of chingamin favours
rapid resolution of infiltrative discoid plaques. In limited diskoid lupus
erythematosus it is possible to apply cryotherapy by liquid nitrogen.
Prognosis. The chronic form proceeds in a benign way, with good prognosis
in regard to capacity for work and recovery, only in the exceptional cases transformation in the system form. Severe one – treined badly, causes incapacity
for work of a patient, which is the reason of unfavorable prognosis in all aspects.
The prognosis in systemic form arising because of aggravation of chronic lupus
erythematosus is more favourable, but sinisfactory results can be achieved only if
the disease is early revealed and there is a rational medical treatment.
Prophylaxis is in two ways. One should do so called the «D» oservation - by
derminologist, adjoining specialists, free of charge medical treatment, saninoryresort medical treatment. Application of protective creams against insolinion,
periodic application of enterosorbents for detoxicinion, diet.
VI Pemphigus
A pemphigus is a malignant disease clinically expressed by formation of
bullas on the uninflamed skin and mucous membranes, in overwhelming majoTPIy
of cases quickly spreading on the whole skin, causing deinh of a sick person.
Position of this disease among other dermatoses is 0, 7 up to 1% cases.
Women suffer from pemphigus more frequently in the age from 35 till 65. Some
authors say about predomininion of men.
Nowadays intention is paid to the study of autoimmunne mechanisms of
development of pemphigus. By the method of indirect immunofluorescence an
antibody to antigen components of intercellular substance of spike-shaped layer of
epidermis was first discovered in serum of diseased people with vulgar pemphigus.
Different works of foreign and domestic scientists testify that the discovery of
45
antibodies in pemphigus means specificity of them for the disease. There is
correlated direct connection between seveTPIy of course of pemphigus and titre of
autoantibodies. In the period of remission antibodies are not revealed or their titre
is lowered.
It was found out that in true pemphigus bonding of antibodies takes place in
areas, where the earliest signs of acantholysis were revealed. Possibly, AB react
with antigens being on the surface of cells of spike-shaped layer of epidermis. Also
in the intercellular space of epidermis in patients with pemphigus. There are steady
fixed IgG, localized in the cytoplasm of acantholytic cells in the area of
acantholysis. This fixation is not revealed in other cystic dermatoses. The general
mechanism of formation of bullas in various clinical forms of true pemphigus
comes to acantholysis. Tsank discovered acantholytic cells in smears-imprints
from the bottom of erosions - in pemphigus they are one of the most essential
diagnostic signs of disease.
Morphological signs of acantholytic cells: if coloured by RomanovskyGimza method
- their size is less than normal that of normal cells, but nucleus is much more
larger;
- nucleuses have intensive colouring;
- there are 2-3 large nucleoluses in enlarged nucleus;
- cytoplasm is much bazophiled, irregular painted: there is a light blue zone
around nucleus, on periphery there is an intensively dark blue rim (zone of
concentration);
- cells quite often contain several nucleuses.
The phenomenon of acantholysis is the basis of the Nikolsky’s symptom and
consists in detachment of the visibly unchanged epidermis in the sliding pressing
on its surface. Detachment is both near bullas, and in distant areas of the skin.
Variants of Nikolsky’s symptom are Asbo-Hansen symptom: increase of bulla area
in pressing on its central part and also phenomenon of pear described by Sheklakov
- under weight of liquid saved in bulla the area of its foundinion increases and
bulla becomes pear-shaped.
They distinguish several (4) clinical forms of true pemphigus.
Pemphigus vulgaris (ordinary one). The clinical presentation is
characterized by sudden, without apparent reasons development of unicameral
bullas on the unchanged skin or mucousas, of various size - from tiny, tense ones
having shiny surface to large bullas (diameter of 10 cm and more) of oval, pearshaped or irregular form. Cover on such bullas quickly becomes flaccid. The
content is in first transparent, with hemorragical tint, further - purulent because of
addition of infection. The skin around bullas is not changed; there is an
inflammatory erytheminic aureole round them. The cover bursts during 1-2 days,
and weeping scarlet erosions appear. Because of peripheral growth and appearance
of new bullas vast lesion focuses appear. In most cases the initial period is
characterized by appearance of separate bullas then erosions with weeping surface
take their place, after that such erosions are covered by serous-bloody or by
46
impetiginous crusts. The Nikolsky’s symptom is positive.
If mouth mucousa or genitalsare affected bullas burst very quickly and their
appearance remains unnoticed by patients. Affection may spread on mucousa of
paline, cheeks, gums, on the back side of pharynx, larynx, oesophagus and others.
The research for acantholytic cells - positive analysis.
Histological changes of the skin and mucousas consist in formation of
intraepidermal bullas as a result of acantholysis. Bullas are in the overbasal layer.
The bottom is uneven due to excrescence of papillae. There is edema in the derma;
perivascular infiltration is of inflammatory character. By the method of indirect
immunofluorescence – steady fixed IgG are revealed.
Diagnostics of pemphigus vulgaris is based on the presence of the
monomorphous eruptions as bullas and erosions appearing in seniors, steady
progresses course, the positive Nikolsky’s symptom, finding of acantholytic cells
in smears-imprints from the bottom of erosions, intraepidermal, overbasal location
of bullas and presence of fixed IgG in the intercellular substance of epidermis.
Pemphigus vulgaris is differentiated from actual nonacantholytic pemphigus
(Lever), bulla form of Düring’s dermatitis, multiform exudative erythema.
Pemphigus vegetans. The clinical presentation is characterized by the
sudden appearance of bullas filled with serous-hemorragical contents, with flaccid,
quickly bursting cover. There are eruptions on the skin in the natural folds
(inguinal-femoral, underarm, breasts), and also on the genitals and on the mucous
cavity of mouth, where it turns into skin. In stead of bursted bullas erosions
inclined to the peripheral growth, on their surface succulent vegetations of scarlet
colouring with fetid secretion will develop for 4-6 days. The vegetining plaques
appear their diameter is 10-15 cm; there are sometimes pustules in their periphery.
In the protracted course exudininion dry to crusts with warty stratifications. The
lesion focuses are not inclined to generalizinion and in the terminal period, without
corticosteroids in 6 months or 2-3 years since the beginning of the disease there
will be plural bullas. Nikolsky’s symptom in the most patients is positive in the
direct closeness from centre, but on the unchanged skin only in the terminal period.
They find the acantholytic cells. Histologically - presence of the intraepidermally
located bullas formed by acantholysis. In the vegetining plaques - acanthosis,
papillomatosis, intraepidermal abscesses with eosinophils.
Diagnostics of pemphigus vegetans is based on the presence of vegetining
plaques with fetid secretion, localized in the natural folds of the skin, the positive
Nikolsky’s symptom on the areas adjoining directly to the focuses, acantholytic
cells and histology - intraepidermal bullas and pustules containing eosinophils.
Pemphigus vulgaris differs from pemphigus vegetans by generalized
eruptios as bullas and erosions on the skin of body and mouth mucousa, by absence
of development of vegetations on the bottom of erosions, by the positive
Nikolsky’s symptom as near focuses as on the apparently unchanged skin, in
histology they find bullas located above basal layer; marked acanthosis,
papillomatosis and intraepidermal eosinophilous abscesses are absent.
Pemphigus foliaceus. The initial manifestations can resemble erythematous47
squamous changes in eczema, seborrheic dermatitis, toxicodermia or be similar to
manifestations of Düring’s dermatitis and pemphigus vulgaris. The characteristic
features are found out in pemphigus foliaceus - appearance on unchanged or
slightly hyperemiric skin surface flaccid bullas with a that cover, the bullas are not
distinctly marked, but uneven outlines of surface of epidermis can be determined.
The bullas burst quickly, erosions of scarlet colouring, filled with exudation,
drying to strinified scale-crusts. The disease is characterized by repeated
continuous formation of surface bullas under crusts in place of former erosions.
Nikolsky’s symptom is expressed both near focuses, and on distant areas. In
smears-imprints - acantholytic cells. Because of generalizinion of process the
condition of diseased ones becomes worse, rise in temperature, the secondary
infection, the cachexy and as a result patients die (without corticosteroids).
Histologically: presence of intraepidermal fissures and bullas, localized under
granular or corneous layer of epidermis, marked acantholysis. In former focuses hyperkeratosis, parakeratosis, and degenerinive changes in granular layer acantholysis of granular cells resembling «grains» in Darie disease pinhognomonical sign of pemphigus foliaceus.
Diagnostics is based on the presence of the flaccid surface bullas bursting
quickly, fusing with each other, inclined to generalizinion and development of
large lamelline scaling, because of it a presentation of partial or complete
eTPIrodermy is creined. Important diagnostic signs of pemphigus foliaceus are
repeated appearance of bullas on those areas, where there were erosions and crusts
before, the positive Nikolsky’s symptom on the apparently unchanged skin,
presence of acantholytic cells, location of bullas under the corneous or granular
layer of epidermis, and also acantholysis of granular cells.
Brazilian pemphigus. In opinion of some authors Brazilian pemphigus is
identical to pemphigus foliaceus. Sheklakov considers Brazilian pemphigus as a
form, clinically similar to foliceus and seborrheal pemphigus. A distinctive feature
is endemic character of its spreading in the south-west areas of Brazil and
adjoining terTPIories. The family cases of the disease were described. The
Brazilian pemphigus can develop in any age, but more often in women till 30.
The clinical presentation is characterized by appearance on the face and
breast flin bullas with erythematous base. These bullas burst quickly, on their place
serous-bloody strinified crusts appear. Quite often the active condition is limited.
Next exfoliinive eTPIrodermy spreads and develops. They distinguish bulla,
pustular, foliaceus, erythrodermal, herpetiform and others, that indicines clinical
polymorphism of Brazilian pemphigus. In the chronic course (2-9 months)
hyperkeratosis of palms and soles, onichorexis, vegetations in arm-pits resembling
black acanthosis develop.
There can be anchylosises of large joints, atrophy of skeletal muscles,
shedding of eyebrows and eyelashes, disfunction of endocrine glands. The acute
and subacute forms are accompanied by the rise of temperature, fever, final end.
Nikolsky’s symptom is positive at the height of the disease. There are acantholytic
48
cells in contents. Histology—formation of intraepidermal fissures and bullas in the
medium and upper parts of sprout layer.
The diagnosis of Brazilian pemphigus is based on clinical presentation, but
mainly on the endemic, sometimes family character of the disease.
Pemphigus erythematosus or Senir-Asher’s syndrome is one of variants of
true pemphigus; it is proved by quite often observed cases of its transition to
pemphigus vulgaris or foliaceus.
The clinical presentation is characterized by the symptoms of lupus
erythematosus, true pemphigus and seborrheic dermatitis. There are eruptions on
the face and after on the body. On cheeks and back of nose there are erythematosus
focuses with distinct edges, on the surface of them that and loose crusts of grayishyellow color. In the case of weeping focuses are covered by greyish-yellow or
brownish crusts. Bullas are flaccid with a that cover and burst quickly. Focuses on
the face are from a few months till 5-7 years. Further one can see generalizinion of
process on the body, breast, in the interscapular area, paravertebral sites. Tearing
away of crusts is painful, on the surface there are little spikes corresponding to
mouths of hair follicles.
One can see on the sculp a kind of seborrheic dermatitis, in future alopecia
and scar atrophy. Sometimes along with plaques - papuloshaped spotted elements
with easily peeled greasy scales. Nikolsky’s symptom is positive in lesion zone in
almost all patients. Mucousas are affected in 1/3 of patients. The course is
protracted with remissions. It resembles lupus erythematosus, pemphigus vulgaris
or foliaceus, seborrheic (psoriasoformed) dermatitis by clinical presentation.
Histologically – clinical presentation resembles that of pemphigus foliaceus that is
there are fissures and bullas under corneous or granular layer of epidermis. Quite
often follicle hyperkeratosis is pinhognomonical.
Diagnostics of pemphigus erythematosus is based on the features of clinical
presentation - presence of erytheminous-squamous butterfly-shaped focuses on the
face, on the body in the medium area of chest, in interscapular area, and also on the
erosive areas and dicreased bullas, finding of positive Nikolsky’s symptom and
acantholytic cells in smears, results of histology – intraepidermal fissures, bullas
and follicle hyperkeratosis.
Differential diagnostics. Pemphigus erythematosus should be differentiated
from lupus erythematosus, seborrheic eczema, pemphigus vulgaris and foliaceus,
Brazilian pemphigus.
Lupus erythematosus quite often resembles Senir-Asher’s syndrome by
localization of butterfly-shaped lesion focuses on the face and by presence of
erytheminous-squamous eruptions. It is especially difficult to make differential
diagnostics of these dermatoses in the case of the isolated localization of centre of
pemphigus erythematosus on the hairy part of a head with development of alopecia
and scar atrophy. However unlike lupus erythematosus in seborrheal pemphigus
the lesion focuses are formed as a result of formation of quickly bursting flabby
49
flin bullas. The clinical course of pemphigus erythematosus does not depend on the
season (in erythematosus acute condition is in spring and summer). In the
widespread form of seborrheal pemphigus there are no capillaTPIes and other
symptoms of systemic erythematosus. In addition, in lupus erythematosus
Nikolsky’s symptom is negative, acantholytic cells are absent and in histology they
do not find fissures and bullas under corneous layer.
Seborrheic eczema is in spite of formal resemblance to pemphigus
erythematosus, easily distinguished because of the positive Nikolsky’s symptom,
acantholytic cells, affections of mucousas of mouth cavity, and histological
features.
In typical cases it is possible to distinguish pemphigus vulgaris and foliaceus
from erythematosus one on the basis of clinical presentation and hystomorphology.
One has difficulties of differential diagnostics if there is transformation of
erythematosus pemphigus into vulgaris or foliaceus and it depends on the degree of
expression of clinical and histomorphological symptoms of mentioned forms of
pemphigus.
Medical treatment. Glucocorticosteroids are the only remedy possible to
save patients with pemphigus nowadays. The medical treatment is begun with
knock-out doses, stopping of medical treatment quickly results in relapse of the
disease; therefore diseased people must constantly get minimum maintaining doses.
The size of knock-out dose depends on seveTPIy and amounts 60-100 mg
(sometimes 180-360 mg) of prednisolone. After stopping of eruptions and
cicatrization of erosions the dose is the same for a week. The subsequent lowering
till a supporting dose takes a few months. In the case of acute condition of process
one should wait for some time and if the focuses do not resolve spontaneously it is
necessary to double a dose. The most part of a day's dose is prescribed after
breakfast, a lesser amount - in the second half of a day. Pills of the supporting dose
are recommended to take one time after breakfast.
Corticosteroid therapy is accompanied by a number of following remedies:
anabolic steroid preparations, 10% solution of sodium chloride, glycerophosphine,
pantotenat, and calcium pangamat, ascorbic acid. The application of antibiotics is
indicated only if there is aggravation by repeated infection. Medical treatment of
patients by the high doses of corticosteroids results in reduction of titre of autoAB
till zero. IN disappearance in serum and in skin can be one of the reasons to stop
giving the supporting dose to patients.
If pemphigus is resistant to corticosteroids or bad tolerance of them one
should change a preparation or prescribe additionally remedies having
immunodepressive action - methotrexate, azathioprin, chingamin.
In recent years to remove autoAB from the organism they use
plasmapheresis with substitution of plasma of a patient by fresh plasma in the
continuous stream. The repeated procedures result in the temporal decline of
autoAB and even in their disappearance that allows decreasing greatly a dose of
corticosteroids, methotrexate and other immunodepresants. The application of
plasmapheresis is recommended in those cases, when pemphigus is resistant to
50
ordinary methods of therapy.
External medical treatment is warm baths with potassium permanganate (0,
5 g for a bucket of water), antibacterial ointments or water solutions of aniline dyes.
In affection of mucousas - lotions and rinses by decoction of camomile in half with
2% solution of boric acid, by solution of borax, furacilin (1:5000) and by other
astringent and disinfective remedies. Food must contain a lot of albumen, vitamins,
in limitation of carbohydrines, fins, liquid and sodium chloride in the same time.
The application of corticosteroid ointments and aerosols for mucousas is
sufficiently effective, although this is fraught by development of candidiasis.
VII Pathogeny of syphilis and immunity
Syphilis (syphilis) is a general infectious disease caused by treponema
pallidum and affecting all organs and tissues of a human being, in that especially
characteristically skin and mucous membranes. Pinhogene of syphilis - treponema
pallidum, weak-painting spiroid microorganism with 8-14 correct frizzes, identical
by form and size which are saved during any motions of treponema pallidumi even
it is between some solid particles (erythrocytes, specks of dust and etc). They
distinguish 4 types of motion of treponema pallidumi:
- forward (back and forth)
- rotinory
- flexive, including swinging, as pendulum and whip (under
influence of the first injections of penicillin)
- contractile (undulating, convulsive)
The spinlike (spiral) motion observed sometimes is caused by combination
of the first three ones. Mentioned signs of treponema pallidumi allow
differentiining it from other treponemas located on the genitalsand mucous mouth
cavity. In comparison with treponema pallidum they are harder and thicker, shorter
or longer; their motions are quick, abrupt; the frizzes during motion change their
size and form. Dental treponema looks very similar to treponema pallidum,
however in the thorough study it is possible to notice, that it is less mobile, shorter
and thicker, its frizzes are acute and angular.
The best method of laboratory diagnostics of syphilis is a discovery of living,
mobile treponema pallidum. The taking of material for research is got mainly from
the surface of chancre and erosive papulae. Preliminary they clear them by lotions
with physiological solution (but not disinfective) from various types of
contaminations and external medications used before. Before the taking of material
the surface of chancre or other syphilid is dried out by gauze, then infiltration is
grasped by 2 fingers of the left hand (in a rubber glove!) and is slightly squeezed
from sides, erosion is carefully stroked by a platinum loop or wadding-gauze
tampon till appearance of tissue liquid (without blood). Drop of got liquid is
carried by a loop on that preliminary degreased by mixture of alcohol and ether
object-pline, mixed with equal quantity of physiological solution and is covered by
51
thin coverslide. This preparation with living treponemas is microscoped in the dark
field of vision.
Contamination by syphilis is by the contact – more frequently direct, rarer
indi-rect. In the direct contact by sexual intercourse or kiss. One should take into
account the homosexual contact and peroral way of contamination. The physicians
must remember about possibility of professional contamination by the direct
contact with a patient during check-up and medical treatments. The indirect contact
is by various objects infected by contagious material (spoons, mugs, cigarette-butts
and etc.).
All manifestations of syphilis on the skin and mucousas are called syphilids.
Contagious are such syphilids which are fully or partly deprived of epithelium. In
these cases treponema pallidumi are on the surface of the skin or mucous
membrane. In definite conditions contagious can be milk of a nursing mother,
sperm, secretion of cervical canal of uterus, blood, including menstrual one.
Sometimes treponemas pallidum are found in patients with syphilis in the elements
of skin rash of some dermatoses, for example in contents of vesicles of herpes and
bullas of dermatitis. The corneous layer is impenetrable for treponema pallidum,
therefore contamination with syphilis through the skin happens only in damage of
its integTPIy, which can be microscopical and unnoticeable by an eye.
Treponema pallidumi, penetrined into the skin and mucousas, spread rinher
qui-ckly from the place of inoculinion. In an experiment they are revealed in the
lym-phinic nodes, blood, and cerebral tissue in a few hours and even minutes after
con-tamination. For a human being a personal prophylaxis done by the local
trepone-macide medications justifies it self only if a period of infection is 2-6
hours. Sp-reading of treponema pallidum in the organism is by the lymphinic and
blood vessels; however, being optional anaerobes, they multiply only in the lymph
which contains oxygen in 200 times less than arterial blood and, in 100 times less
than venous one.
The course of syphilis is protracted. They distinguish several periods of it:
incubinion, primary, secondary, tertiary.
Incubinion period is period from moment of contamination to appearance of
the first symptoms of the disease. Its duration in the case of syphilis is 3-4 weeks.
In seniors and weakened patients it is longer, in introduction of great number of
treponema pallidum in a few «gines» of infection - less long one. The considerable
lengthening of incubinion period (till 6 months) happens as a result of use for some
concomitant diseases of penicillin, erythromycin or other antibiotics, influencing
on treponema pallidum in the doses insufficient for their elimination. Similar
prolonginion of incubinion is observed in the case of reception of antibiotics by the
source of infection.
In incubinion period treponema pallidumi, multiply in the lymphinic tissue
and penetrine into the blood, therefore the direct transfusion of such blood can
cause in recipient development of syphilis. In citrined blood treponema pallidumi
perish for five-day preservinion.
52
The primary period of syphilis begins from appearance on place of
inoculinion of treponema pallidum peculiar erosion or ulcer which called primary
syphiloma or chancre. The second symptom peculiar to the primary period is
regional lymphadenitis (concomitant bubo) forming for 5-7 days (till 10 days) after
formation of chancre. Duration of primary period is approximinely 7 weeks. Its
first half is characterized by the negative results of the Wassermann’s reaction and
is named primary sulfurnegative syphilis. In 3-4 weeks the reaction becomes
positive, and syphilis turns into sulfurpositive syphilis. Poliadenitis develops in this
time – extension of all peripheral lymphinic nodes. Affection of back cervical and
cubital nodes is most characteristic; affection of peripapillary nodes is almost
pathognomonical, but occurs rarely.
1-2 weeks before the end of primary period the quantity of multiplying
treponema pallidum achieves a maximum and a lot of them penetrine in the
subclavian vein through the pectoral lymphinic channel, and cause septicemia.
Some patients have septicemia accompanied by fever, headache, rheuminic pain in
bones, joints. These phenomena are considered as premonitory, i. e. preceding
detailed clinical presentation of the disease.
For syphilitic prodrome no connection between temperature and general
condition of patients is characteristic; they feel themselves rinher sinisfactorily
with high temperature. Dissemination of treponemas pallidum in great quantity in
the whole organism results in appearance of widespread rashes on the skin and
mucousas, and also in affection of inner organs (liver, kidneys), nervous system,
bones, and joints. These symptoms signify beginning of the secondary period of
syphilis.
One should exaggerine that the primary period is over not after resolution of
chancre, but when secondary syphilids appear. Therefore in some patients
cicatrization of chancre, in particular ulcerous, is already over in secondary period,
but in others erosive chancre has time to resolve even in the middle of primary
period - in 3-4 weeks after its appearance. In some cases manifestations of primary
syphilis can be absent and in 10-11 weeks after infection secondary syphilids
develop right away. It can be related to penetration of treponema pallidum directly
in blood, escaping the skin or mucousa – because of blood transfusion, as a result
of cut or prick. Such syphilis is called «beheaded».
Secondary period of syphilis begins with spotted, papulous and pustulous
syphilids. Its duration is 2-4 years, but can continue up to 20 years. Secondary
period is characterized by interchange of active clinical manifestations (fresh and
recurrent syphilis) with periods of hidden (linent) syphilis. Initial eruptions related
to generalize dissemination of treponema pallidum different by extension and
correspond to secondary fresh syphilis. Its duration is 4-6 weeks. Subsequent flareups developing for an undefinite period are accompanied by limited skin lesion and
characterize secondary recurrent syphilis. Secondary linent syphilis is revealed by
specific serological reactions.
The reason of development of relapses is dissemination of treponema
pallidum from the lymphinic nodes where they remain and multiply for the linent
53
period of syphilis. Appearance of syphilids on these or those areas of enveloping
epithelium are favoured by different exogenous factors trauminizing the skin
(sunburn, tintoo, cupping-glasses) or mucous membranes (carious teeth, smoking).
More frequently suffers subjected to friction the skin of genitals and anal area.
Quite often differential diagnostics of fresh and recurrent syphilis is of great
difficulty. It can be related to two circumstances. In those cases, when a patient
with fresh secondary syphilis has widespread rash, for example, out of roseolas on
the body and papulae in the area of anus, the first burst earlier, than the second, and
in the moment of examination skin lesion can be limited (in the area of anus), that
is characteristic for recurrent syphilis. The second circumstance is that nowadays
fresh syphilis manifests sometimes very poorly and thus simulates recurrent one.
Tertiary period develops approximinely in 50% of patients with syphilis and
is characterized by formation of gumma and tubercles. Usually tertiary syphilis is
observed in 3-6 year of the disease. However it can manifest even in 20 years after
contamination, but sometimes – during the first year after several relapses of
secondary period, following each other («galloping syphilis»). Ability to
contaminate of tertiary syphilids is little one.
Tertiary period is characterized by more severe affections of inner organs
(cardio-vascular system, liver and etc.), nervous system, bones and joints. In
development of bone gummas and arthropathies provoking part is played by
various traumas. Tertiary syphilis is characterized as well as secondary one by
interchange of clinical relapses (active tertiary syphilis) with remissions (linent
tertiary syphilis). The reason of development of tertiary syphilids is apparently not
hematogene dissemination of treponemas pallidum, but their local activinion. In
favour of this stinement testifies, in first, that fact, that the blood in tertiary period
is contagious in exceptionally rare cases and, secondly, inclininion of papulose
syphilid to excrescence on periphery.
Hidden syphilis. Quite often the diagnosis of syphilis is first made by
positive serological reactions revealed only by chance. If one was able to find out a
character of previous clinical presentation, solution of question about what period
this hidden syphilis is related to faces great difficulties. It can be primary period
(chancre and concomitant bubo have already bursted, but secondary syphilids did
not appear yet), linent period, substituted by secondary fresh or recurrent syphilis
and, finally, linent period of tertiary syphilis.
Since periodizinion of hidden syphilis is not always possible, by the modern
classification, it is accepted to subdivide it into early, line and unspecified
(«unknown»). Early hidden syphilis is related to primary period and beginning of
secondary (with remoteness of infection up to 2 years), line one – to the end of
secondary and tertiary period.
The diagnosis of early hidden syphilis is based on the following cTPIeria:
presence of active manifestations of syphilis in a partner, high titre of reagins in
Wassermanan’s reaction, history data about self-treatment or medical treatment of
gonorrhoea, relatively rapid negativation of serological reaction and normalizinion
of spinal liquid.
54
Features of course of syphilis. The first feature consists in regular alterninion
of active and linent manifestations of syphilis, peculiaTPIy - the change of its
clinical finding in the change of periods. These features are conditioned by
development in the organism of a patient with syphilis of specific immune
reactions - immunity and allergy. The alterninion of active and linent periods of
syphilis, characterizing the first feature of its course, is conditioned by stine of
immunity. Immunity in syphilis is of infectious, unsterile character; it exists only
in presence of infection in the organism, its tensity depends on the quantity of
treponema pallidum, after their elimination the immunity disappears. Beginning of
development of infectious immunity in syphilis is on 8-14 day after formation of
chancre. Because of multiplicinion of treponema pallidum, resulting in appearance
of secondary syphilids, tensity of immunity increases and, eventually, achieves the
maximum causing deinh of treponemas. Syphilids burst, linent period comes. In
the same time, there is a decline of tensity of immunity, as a result treponema
pallidumi remained in linent period on place of former syphilids and in the
lymphinic nodes, activine, multiply and cause development of relapse. Tensity of
immunity increases again; and all cycle of course of syphilis repeins itself. As
times goes by the quantity of treponema pallidum in the organism decreases,
therefore a regular wave of immunity rising gradually becomes less every time.
Along with the stage after stage description of course of syphilis, sometimes
one can observe its protracted symptomless course ended in many years by
development of syphilis of the inner organs or nervous system. In some cases such
syphilis is diagnosed by chance in line hidden period («unknown syphilis»).
Possibility of protracted asymptominic course of syphilis is conditioned,
presumably, by the treponemostatic properties of normal immobilizins, contained
in serum of healthy people. One should take into account that immobilizins of
serum of patients with syphilis are different from normal immobilizins. The first
ones are specific immune AB; the second are normal serum albumen-globulins.
As the reason of transformation of clinical presentation of syphilis in the
change of its periods (the second feature of course of syphilis) they earlier
considered the changes of biological properties of treponema pallidum. However
afterwards it was proved, that inoculinion of treponema pallidum, taken from
chancre, in the skin of a patient with secondary syphilis causes development of
papula, and inoculinion in the skin of a patient with tertiary syphilis - development
of tubercle. The result of contamination of a healthy person by a diseased one with
secondary or tertiary syphilis is formation of chancre. Thus, the character of
clinical presentation of syphilis in this or that period depends not on properties of
treponema pallidum, but on reactivity of the organism of a patient. Its specific
manifestation is an allergic reaction which appears right away after contamination
and gradually but steadily intensifies.
In the beginning of development of the disease there is an allergic reaction of
slow type in the foreground, as a result of it chancre appears. Its histological
structure is presented by perivascular infiltration consisting mainly of lymphocytes
and plasmatic cells. As allergo-cellular reaction to treponema pallidum intensifies,
55
as a result, clinical finding of syphilis changes. Secondary syphilids are
characterized by infiltration consisting of lymphocytes, plasmatic cells and
histiocytes. In the tertiary period, when the allergic reaction is most expressed,
typical infectious granuloma develops (necrosis in the center of infiltration,
consisting of lymphocytes, plasmatic, epithelioid and giant cells). Its clinical
manifestations are tubercle and gumma.
In those cases, when the immune reactions are depressed (in people
extremely weakened by hunger, wasted by chronic diseases), so-called malignant
syphilis can develop. The primary period is thus shortened till 3-4 weeks; regional
lymphadenitis is absent, Wassermann’s reaction remains negative. Eruptions of
secondary fresh syphilis are ordinary pustules; only in the repeated flare-ups which
follow each other, specific infiltration appears in base of pustules.
Reinfection and superinfection in syphilis. As reinfection and
superinfection repeated disease is understood. The difference between them
consists in that reinfection develops as a result of repeated infection of a person
who had syphilis before, superinfection - repeated infection of a patient with
syphilis. Reinfection is possible because of disappearance of immunity after
recovery from syphilis. Superinfection develops extremely rarely, as infectious
immunity of a patient prevents from it. It is possible only in linent period and for
the first 2 weeks of primary period, when there is no immunity yet; in tertiary
period and in line congenital syphilis as focuses of infection are so few, that they
are incapable to support immunity and finally, because of failure of immunity as a
result of insufficient medical treatment, that causes suppression of antigen
properties of treponema pallidumi. It can also develop as a result of bad nutTPIion,
alcoholism and other wasting chronic diseases.
Reinfection and superinfection should be differentiated from the relapse of
syphilis. Proofs of the repeated contamination are:
1. finding out of a new source of infection
2. classic course of syphilis of a new generation, since formation of chancre
(on other place unlike the first one) after proper linent period
3. regional lymphadenitis, and in reinfection - pozitivinsiya with
accumulation of titre of reagins of early serological reaction.
To prove reinfection one need additional data telling that the first diagnosis
of syphilis was reliable, a patient got full medical treatment and serological
reactions of blood and spinal liquid finally became negative. In some cases
reinfection is possible to establish by the less number of cTPIeria, not only in
primary, but also in secondary, including hidden, periods. However one should do
it rinher carefully.
56
VIII Congenital syphilis
The epidemic of syphilis of recent years causes serious anxiety related to its
snowball growth, to transformation of «classic» course, involvement of
unprotected levels of the population - children and teenagers, and also women of
childbearing age, therefore it is not only medical but also social problem. The main
way of transmission is sexual one, on the second place is pre-natal and, rarer they
register contact and transmissive ways.
As congenital syphilis (syphilis connina, syphilis congenita) they understand a
syphilitic infection existing in a child pre-ninally before final separinion from the
organism of mother that is contamination of a child by syphilis before birth. In
contamination of a child by syphilis while going through minernal passages
chancre appears they say not about congenital but about acquired syphilis.
The only universally recognized way of contamination by congenital syphilis transmission of infection to fetus by mother diseased with syphilis, through
placenta, that happens in three ways:
1. through the umbilical vein
2. through the lymphinic fissures of umbilical vessels
3. by the minernal blood through the injured placenta.
Full specific medical treatment of women with syphilis, before and during
pregnancy in overwhelming majoTPIy of cases prevents birth of children with
congenital syphilis. The danger of appearance of congenital syphilis to some
degree depends on duration of syphilis in mother, and also its period. So, if many
years passed after contamination of mother by syphilis, activity of infection
decreases and a healthy child can be born. Considerably rarer become infected by
congenital syphilis children whose mothers have tertiary or congenital syphilis. In
the same time it is necessary to tell about possibility of transmission of congenital
syphilis in the second and third generations. In line hidden syphilis of a mother,
about 45% of children become infected by congenital syphilis. There is a great
danger of birth of children with congenital syphilis in women suffering from
secondary syphilis and it amounts 100%.
By character of manifestations they divide congenital syphilis into:
- syphilis of fetus
- syphilis of infancy
- syphilis of early child's age (from 1 year till 4 years)
- line congenital syphilis (from 4 years and older) and
- hidden congenital syphilis occurring in babies and in children in the age
from 1 year and older.
Syphilis of fetus. Congenital syphilis is one of the reasons of perininal
mortality. The penetration of treponema pallidumi with blood current of a mother
with syphilis causes after 5 months of pregnancy reaction in the cellular elements
of fetus mesenchyme. The affection of his/her inner organs is characterized by
57
infiltrations, consisting of lymphocytes, histiocytes - plasmatic cells, and
sometimes miliary or solitary gummas are revealed. In the inner organs one is able
to find a good number of treponema pallidum. Most substantial and characteristic
are changes related to blood vessels: different periods of endarteTPIis up to
obliterating, infiltration of adventitia by tiny cellular elements, with quick
thickening due to new formation of connective tissue. In this change of vessels T.P.
Pavlov saw the main reason of deinh of children with congenital syphilis or
conditioning various malformations or retardation of development. The specific
pathological affections are revealed in liver, spleen, lungs, kidneys, pancreas and
other organs. The liver is enlarged very much, its surface is smooth and on the cut
of fallow color development of sclerotic changes is possible; right up to diffuse
fibrosis with atrophy of parenchyma. The spleen is enlarged, thickened. In the
lungs - specific infiltration of interalveolar partitions, hyperplasia and
desquamation of alveolar epithelium, that conditions greyish-white colouring of
affected tissue similar to white pneumonia and results in deinh of fetus in the
womb of mother or during the first days after birth. In the GIT – changes are rare.
In the kidneys there is a special infiltration, often specific changes are in the
pancreas, adrenal glands, hypophysis and testicles. Affection of endocrine glands
and the CNS - productive leptomeningitis, meningoencephalitis and sclerosing of
vessels which influence mental and physical development of fetus.
A frequent manifestation of congenital syphilis is affection of the bone
system, which can to be found on 6-7 month of pre-ninal development, - on border
between cartilage and bone of long bones in zone of calcificinion of
osteochondTPIis phenomenon. Typical features are distinctly expressed
hyperplasia of cells of stroma and endothelium of capillaries and obliterating
endoarthTPIis. The diagnosis of syphilis of fetus is established on the basis of
clinical, serological, pinhologoaninomical studies and roentgenologic finding of
long bones. Final diagnosis is established if they reveal in affected organs an agent
of syphilis causing affection of almost all organs and is a result of treponem
septicemia. The fetus dies between 6 and 7 month, and sometimes 5-6 month of
pre-natal development.
Syphilis of babies. New-borns with congenital syphilis have wrinkled
flaccid skin of specific dirty-yellow discolourinion which remains for a long time.
The «senile» appearance is typical there are pigmentations similar to chloasma on
one’s face. Quite often they observe that the head is enlarged, distinct network of
vein vessels, the head is covered by scales of seborrheic kind, almost complete
absence of PGK, and bedsores can be result of it. Such children put on weight
slowly, they are fidgety and weep. Scream in quick movements - Sisto’s symptom.
Deinh can develop because of adding of infections.
Manifestations of congenital syphilis in babies varies greatly. Syphilis in
children born by untreined mothers with active manifestations of secondary
syphilis is an extremely severe disease accompanied by affection of almost all
visceral organs, bone system and specific changes of the skin and mucousas
(visceral and parietal syphilis).
58
One of early changes of the skin is syphilitic pemphigus – no more than in 223% of diseased children. Contents of bullas are serous in the beginning, then
turbid and bloody, localized on palms and soles, rarely in elsewhere. The bullas are
surrounded by slightly lilac inflammatory rim, gradually burst, on their place
erosions, on periphery - fringe of exfoliined corneous layer. By terms of
appearance and externally a syphilitic pemphigoid looks like a staphylococcus one.
However in linter bullas are localized on the back, chest, very seldom - in the area
of palms and soles. It appears on 3-5 day after birth, there is no inflammatory
slightly lilac coloured aureole, in contents of bullas in syphilitic pemphigoid treponema pallidum.
A frequent sign of congenital syphilis is diffuse skin lesion, in 60-65% of
children with congenital syphilis; it occurs more frequently on 8-10 week of life of
a child. Diffuse infiltration is preceded by diffuse erythema. The diffuse infiltration
is characterized by thickening of skin of palms, soles, buttocks, back surface of
thighs, face and sculp. The diffuse infiltration has some features depending on
localization, if it is in the area of palms and soles - the skin is thickened, smooth,
tense, glossy, loses elasticity, the fissures appear. In future the skin becomes shiny,
lacquered and these changes are ended by laminar scaling. The diffuse infiltration
of palms and soles is quite often combined with affection of face, especially lips
and chin. Around mouth and on lips – reddened and infiltrated sites, the red margin
of lips turns pale. The lesion skin is tense, tiny folds on lips diminish, can become
completely smooth. In the area of red border, corners of mouth cavity and on the
chin - great number of erosions and fissures covered by fawn crusts on place of
bloody secretion. In fissures - treponemas pallida. There are striped, coiled furrows
after cicatrization of erosions and deep fissures - scars (Parro-Furnie’s furrows).
These changes are diagnostically typical to congenital syphilis.
On the border of a hairy part of a head and forehead, in the area of
superciliary arcs and bridge of nose diffuse infiltration is characterized by
thickening of the skin, and the normal folds begin to look as deep folds. There are
Parro-Furnie’s furrows on forehead, going upright from top to bottom. On
eyebrows and a hairy part of a head diffuse infiltration simulines phenomena of
seborrheal dermatitis, but dryness of affected focuses, specific shine, yellow-dirty
color with other manifestations of congenital syphilis differ diffuse infiltration of
this localization from seborrheal dermatitis. In diffuse infiltration in the area of
cheeks the number of folds decreases, the skin of grey tint and all face looks like a
mask.
In localization of diffuse infiltration in the area of buttocks and genitalssysteminic irTPIinion of these areas by urine and feces causes marked
inflammatory changes, appearance of erosions and ulcerations, the erosive papulae
may appear.
On 2-3 week of life of a child they often observe spotted exanthema inclined
to fusion, on place of the former eruptions there is scaling.
A frequent manifestation is papulose rash which appears in 4-8 weeks after birth
and is quite often combined with the typical signs of diffuse infiltration. It is
59
localized mainly on the face, extremities, buttocks and in the area of genitals.
Unlike papulae characteristic for acquired syphilis, tendency to fusion of elements
is marked quite often.
Some children have specific paronychia and onychia. There is edema,
redness, erosions, fissures, falling off of nail plates is possible. In other type –
marked only peeling on the surface of nails which are atrophied, fragile. The
change of nails when they look like a tennis racket is possible.
The hair is often affected: circular alopecia or diffuse loss of hair on a head,
the loss of cilia and eyebrows is possible.
Out of diseases of mucous membranes - syphilitic cold which appears right
away after birth, in the first 4 weeks of life. It has 60-78% of children. There are
following periods:
1. dry - considerable swelling of mucousa of the nose;
2. cinarrhal – out of the nose in pressure the mucous secretion is exuded, in
future - purulent or with blood;
3. ulcerous – abundant purulent-bloody excretions, reddening and
tumefaction of the nose, fissures, ulcerations, swells round nares, causing
hissing puffing. A child breinhes through mouth, diverts from breast
during nursing, causing malnutTPIion. In nosal secretion - treponema
pallidum. The transition of pathological process to cartilage and bones is
possible, that results in necrosis of nasal septum with perforinion and to
secretion of little bone sequestrations. There is deformation of the nose seddle nose, pressed and extended back of nose. In spreading of process
the round perforinion can appear on the hard paline.
Some children have changes of larynx mucousa of specific character hoarse voice and aphony, in fauces - erosive specific papulae.
Syphilis of the bone system is one of main and most important signs of
congenital syphilis. Such frequent affection of the bone system is conditioned by
the fact that already on 5 month of pre-natal development between epiphysis and
diaphysis in the area of proliferation of cartilage of long bones the increased influx
of blood, hyperemia are marked, conditions favourable for multiplicinion of
treponema pallidum are creined. Vegner’s osteochondTPIis phenomena - damage
of formation of osteoblasts and they reveal osteochondTPIes in the first 3 month of
life in 85%, and after the 4th month of life - only in 5% of patients. After the first
year of life osteochondTPIes are exceptionally rare. In some children they can be
the only sign of early congenital syphilis. Although phenomenon of
osteochondTPIis in the area of ribs, scapula, pelvic bones and skull, but 2 X-rays
are sufficient for the practical purposes – 1st - of both forearms with the distal end
of humerus, 2nd – of both shins with the distal end of femur. They distinguish 3
periods of osteochondTPIis:
1.
bright or whity-yellow slightly denticulined fascia of 2 cm in width
in the area of preliminary calcificinion;
2.
there is irregular, extended till 2-4 mm bright fascia with jagged
edges turned toward epiphysis, typical is expansion of area of
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calcificinion, dentinion and fascia of rarefaction under the area of
calcificinion;
3.
granular tissue located under the cartilaginous layer closer to
diaphysis appears, on the X-ray they see dark, 2-4 mm in width
rarefied bar, a few bone cross-beams and the intraepiphysis fracture
of bone is possible and there is similar to paralysis condition –
Parro’s pseudoparalysis. These changes can begin in the first
months after birth. In Parro’s pseudoparalysis an affected extremity
is motionless, passive motion results in sudden soreness and a child
weeps. The sensitiveness remains.
4.
already in birth or in the first months of life in 45-55% of diseased
children they reveal periostitesses, mainly of long bones, sometimes
in the bones of skull. OsteochondTPIes and periostites in early
congenital syphilis are observed in several bones and are
characterized by symmetry of location (for the differential
diagnostics).
Changes of joints are rare.
In babies with congenital syphilis the specific changes of the inner organs
are marked well - in the liver and the spleen in 100 %, in blood vessels in 94%, in
the adrenal glands, genital glands in 85%, in the kidneys in 64%.
Leucocytosis, hypochrome anaemia, accelerated ESR, decelerinion of
coagulinion are often marked.
In congenital syphilis the changes related to the CNS are also marked.
There are cramps, groundless cry because of rise of intracranial pressure Sisto’s symptom, similar to epileptic attacks. dropsy of cerebrum develops on 2-3
month of life, the form of skull changes; it gets extended form with protruding
frontal hillocks. The size of skull increases. Specific meningitises are characterized
by cramps, paralyses and unevenness of pupils. The general histological changes in
the nervous system in early congenital syphilis are marked in brain vessels as
sclerotic changes, obliterating endarteTPIis, swelling of tissue of brain-tunic and
infiltration by lymphoid and plasmatic cells.
One often observes conjuctivitises,
chorioretinites of 4 type seldom - keratites.
iTPIes,
papilloretinites
and
If there are manifestations of congenital syphilis, Wassermann’s reaction and
the sedimentary reactions are positive in the most patients. Sometimes the negative
Wassermann’s reactions may be in the presence of active manifestations of
congenital syphilis that is explained by the lowered reactivity of a baby in the first
days of life. Thus it is recommended to take blood on research not early than 10
days after birth of a child. In hidden syphilis - the negative Wassermann’s reaction
becomes positive before 1-2 weeks till appearance of signs of syphilis or
simultaneously with their appearance. In the most patients early congenital syphilis
they observe positive TPI and IFT.
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Presently difficulties in diagnostics emerge in connection with blurry
symptominology of congenital syphilis of infancy, absence of typical changes of
the skin and mucousas, not distinctly marked changes related to inner organs.
In diagnostics of hidden forms of congenital syphilis of infancy special
intention is paid to serological reactions - Wassermann reaction, sedimentary
reactions, TPI, IFT and X-ray research of the bone system. Often mothers of
children infected by monosymptom congenital syphilis, as a rule suffer from
hidden or insufficiently treined syphilis; these children had no specific changes of
the skin, mucousas and visceral organs. It manifested in the way of chorioretinite,
osteochondTPIis of 2 degree and positive serological reactions. There are
considerable difficulties in diagnostics of early congenital syphilis based only on
anamnesis and results of serological reaction. In some of children standard
serological reactions are negative, and TPI and IFT are distinctly positive.
Meantime, according to data of different authors the passive transfer of reagins is
possible from mother to child. And if child is healthy, in 2-5 months after birth,
reagins will disappear and Wassermann reaction in child becomes negative.
Usually in healthy children the titre of reagins gradually falls, but in diseased ones
it increases. Nowadays one can be sure that the passive way of transmission of
reagins from mother to child is possible. Therefore positive TPI is not absolute
sign of congenital syphilis. If child is healthy, immobilizins will disappear from
blood in 5-7 months after birth. Because of it - child has no manifestations of
syphilis, and his mother was treined before, sometimes during pregnancy – then
only on the basis of results of positive serological reaction one should not begin
medical treatment for 6-7 months expecting that if child is healthy then during this
term reagins and immobilizins will disappear from blood. But it is risky too, as
specific medical treatment begun till 3 months after birth protects children from
dystrophy of teeth and keratits and most successful is medical treatment of children,
started in the first 1-2 month after birth. In new-borns negative serological
reactions to syphilis are not excluded, therefore for diagnostics of congenital
syphilis anamnesis, remoteness of disease of mother of child, quality of her
medical treatment before and during pregnancy, careful research of visceral organs
of child, nervous system, eyes, X-ray of tubular bones, TPI, IFT are very important.
Syphilis of early child's age. The most characteristic signs of active
congenital syphilis – syphilitic cold, diffuse infiltration, syphilitic pemphigoid,
changes related to visceral organs, nervous system, typical osteochondTPIes - in
first 4-5-months of life, by the end of the first half year do not occur. On the skin
and mucousas they more often observe papulose and pustulous changes, bone ones
- periostitesses. Rarer – marked changes of visceral organs. There are papulous
eruptions on various sites. Unlike acquired syphilis rarely - roseolar eruptions,
often vegetating papulae in the area of the anus and inguinal folds, weeping
papulae between toes, behind auricles, rarely papules-pustules are in the area of
sculp and on face. Quite often there are syphilitic affections of mouth cavity and
fauces and they look like those in acquired syphilis. One observes erosive papulae
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of corners of mouth cavity «perlèche», there is a strip of infiltration of crimson
colour, getting to mucousa. There is no fringe of exfoliined corneous layer and
treponema pallidum are absent. Sometimes mucousa of the larynx is affected hoarse voice, aphonia. There is not distinctly marked extension of lymphinic nodes.
Bone changes - periostites of shinbones and phenomenon of osteosclerosis. They
occur in 60% of diseased children. Quite often changes of the liver and spleen,
phenomenon of nephrosonephTPIes. In children mental retardation, hydrocephalus,
similar to epileptic attacks and other changes of the nervous system - meningitises,
choreoretinites, atrophy of optic nerve.
Serological reactions - Wassermann reactions, sedimentary, TPI, IFT are
positive. If there are changes only in bones standard reactions can be negative, but
in majoTPIy TPI, IFT are positive. One can face difficulties of diagnostics of
congenital syphilis of early child's age and acquired (nonsexual) one. In acquired
syphilis - discovery of residual phenomena of primary syphilis, regional
lymphadenitis in the area of cervical and submaxillary lymphinic nodes - primary
syphiloma in the nonsexual contamination more frequent is localized on lips; there
are no marked changes of inner organs, rarely periostites of long bones. One
should examine family members.
Late congenital syphilis. As line congenital syphilis they understand
manifestations, which because of congenital infection develop in later childhood,
youth or minure age, regardless whether they appear in this age for the first time or
they are preceded by other phenomena of the same ninure in babyhood. This
extended determininion is tested by time. In some patients the changes
characteristic for early congenital syphilis preced manifestations of line congenital
syphilis, but in the majoTPIy of patients with line congenital syphilis, early
congenital syphilis proceeds asymptomicly (early hidden congenital syphilis) or in
some of them early hidden congenital syphilis is even absent, that is in these
children before development of symptoms of line congenital syphilis the infection
does not show neither clinically, nor serologically.
The first manifestations of line congenital syphilis develop in the age from 4
till 17, that is while teeth eruption or in the period of puberty beginning. The first
signs occur in 60-70% in the age from 5 till 10. Several signs of this disease are
marked in most cases.
Papulo-ulcerous and gummatous affections of the skin and mucousa do not
substantially differ from corresponding changes in tertiary, acquired syphilis.
Papulo-ulcerous syphilis often affects large areas of the skin and shows in the
phagedenic forms, conditioning mutilations, destruction of the nose, lips and etc.
Papulo-ulcerous and gummatous affections of mucous membrane of the nose
sometimes include cartilaginous and bone parts, causing a perforinion of nasal
septum and falling back of bridge of the nose. scars near the mouth never observed
in acquired syphilis are very characteristic - are located on the lips, chin radially to
the oIFTice of the mouth and on the red border of the lips as surface, that, linear,
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whitish strips, being residual after the deep fissures, while infiltration of face skin
VRS infancy.
Hutchinson’s triad - parenchymatous keratitis, labyrinth deafness,
Hutchinson’s teeth are indisputable signs of line congenital syphilis.
Parenchymatous keratitis - slight turbidity in the area of descemet
membrane, going up to the center; in 4-6 weeks the ciliary injection will appear on
the limb. While examination one observes diffuse or focal corneal opacity,
newformed vessels from the ciliary vessels of the sclera as panicles. They mention
photophobia, blepharospasm, eyewatering, pericorneal injection of vessels, iTPIis,
chorioretinite. Parenchymatous keratitis is bilateral. Not in all cases of
parenchymatous keratites positive serological reactions are revealed. The outcome
dependes on the timely diagnostics and character of medical treatment. The
prognosis in relinion to the complete renewal of sight is doubtful.
The second manifestation of the triad is labyrinth deafness. In 3, 5% of
patients with line congenital syphilis it develops between 8-15 years, more
frequently in girls. Both ears, both labyrinths are affected. The pathological
changes are related to the lesion of auditory nerve. In first one mentions dizziness,
tinnitus and ringing in the ears, there can be a symptomless course too, damage of
bone excitability, deaf-mutism. To indentify labyrinth deafness presence of other
signs of line congenital syphilis and positive serological reactions is important.
Hutchinson’s teeth - both front incisors have a tubby form or form of
screwdriver. Teeth at the neck level, narrowed in the direction of cutting surface.
On free edge are semilunar cavities. In the middle part of cutting edge of tooth
after eruption 3-4 little acute spikes, which will soon brake off. After a number of
years edges of teeth grind off and up to 20-22 years become short, with wide, even
and carious edge. The most patients have positive serological reactions.
One of the most frequent manifestations of line congenital syphilis affection of the bone system. In X-ray research there are osteoperiostites and
osteomyelites. The Gummatous changes amount 47% of all changes of the bone
system. There are symmetric affections of several long bones, changes of bones of
hands and feet, saddle nose and its varieties in 15-20% of patients. Bones of skull
are affected in 6, 3% of patients. Sabre shins as a result that one had in the infancy
osteochondTPIis and indisputable sign of line congenital syphilis.
They observe various dystrophies such as looking as nates skull, saddle nose
and etc. relining to probable, but not indisputable signs of line congenital syphilis.
In these cases one needs purposeful clinico-serological and X-ray research to
establish diagnosis.
A symptom of thickening of right collar-bone in its thoracic end is a
probable sign of line congenital syphilis.
Two forms of disease of joints in congenital syphilis: chronic hydroarthrosis
and false white tumour of knee and elbow joints. Affections of such a kind require
64
serological checkup and clinical research.
The specific changes of organs manifest rarely. They mention affection of
the liver as diffuse hardening, jaundice, affection of the spleen, nephroses and
nephrosonephTPIes, changes of the cardio-vascular system - mesaorthite and etc.
The affection of the endocrine system is typical. Changes of the nervous system as
affection of cerebrum, youth tabes dorsalis, jacksonian epilepsy, atrophy of optic
nerve, mental retardation and etc. There is family ataxy. Classic serological
reactions are positive in 92% of patients. In line congenital syphilis especially
hidden one, standard serological reactions are positive in 70-80% of patients. TPI
and REEF are often positive.
It is easy to diagnose if there are indisputable signs. To distinguish it from
acquired syphilis one should take into account probable signs of line congenital
syphilis - chorioretinite, dental dystrophies, irregular forms of skull, and also
anamnesis (form and remoteness of the disease of mother of child, manifestations
of congenital syphilis in other family members). In some patients the diagnostics is
facilitined in the discovery of residual effects on the skin and in the mouth cavity,
data of X-ray research of long bones. Infantile little finger, accreted ear lobes,
absence of xiphoid process, hypertrichosis on the forehead, high paline, cross-eye,
Milian’s deep fissure and etc. are not important for diagnostics.
Prognosis of congenital syphilis. Formerly morbidity before introduction of
penicillin in the clinical practice was high. So, up to 50% of diseased died for the
first year of life and 25% - for the second year. The prognosis depends on quality
of specific medical treatment of a mother before and during pregnancy, seveTPIy
of the disease and secondary intercurrent infections of a child. Prognosis is
worsened by active forms of mother secondary syphilis, distinctly marked changes
of the liver, spleen, lungs and the nervous system of a diseased child. Nursing and
baby-minding minter a lot. Full medical treatment will result in negativation of
standard serological reaction in 5-6 months in 90-95%, and by the end of 1 year of
life almost in 100%. In the cases of beginning of medical treatment after the first
half-year till the end of second one, negativation of serological reaction is only in
86%. Positive serological reactions in line congenital syphilis turn into negative
ones considerably rare. Considerable part of diseased children remains serostable
(TPI). Relapses of early congenital syphilis are in 6% because of insufficient
medical treatment.
Prophylaxis. Basic principles: serocontrol of pregnants. Specific medical
treatment of pregnants, in the presence of syphilis in the last 2 weeks of pregnancy
there are positive serological reactions - careful study in 14 days after delivery TPI, IFT. Pregnants diseased with syphilis before and not taken off the books are
appointed the prophylactic medical treatment during every pregnancy even if there
are negative serological reactions. Pregnants got full medical treatment, are
subjects to prophylactic medical treatment during the first pregnancy after taking
off the books. The prophylactic medical treatment consists of 3 courses of
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penicillin, 140 000 units for 1 kg of body mass, but no less than 8 400 000 units for
a course. Women got preventive medical treatment in the past are not subjects to
prophylactic medical treatment during pregnancy.
Postnatal prophylaxis. If there are no symptoms of congenital syphilis in
children but they were born by diseased mothers - research to exclude congenital
syphilis. They should get 2-3 courses of medical treatment for prophylaxis.
Approach is similar to that to children with congenital syphilis. There is an opinion
to appoint medical treatment to such children after 7 months of life, if TPI remains
positive. Medical treatment is according to plan for primary sulfurnegative
syphilis. The prophylactic medical treatment is not required, if mother during
pregnancy got full medical treatment. Such children are on the clinico-serological
control for a year. If a pregnant was not treined or was treined insufficiently, they
trein children as those with congenital syphilis. Basic principles and methods of
prophylactic medical treatment are stined in instruction for medical treatment. In
children born by diseased mothers, one must examine the skin, mucousas, study
the nervous system, inner organs, fundus of the eye, nasopharynx, and spinal liquid.
They do serological reactions in the first 3 month after birth, X-ray examination of
long bones.
Children born by diseased mothers, but got full medical treatment before and
during pregnancy, without clinical presentation and negative serological reactions
are not subject to the medical treatment, but remain under supervision till puberty
beginning.
If a well treined mother has positive serological reactions, a child undergoes
3 courses of prophylactic medical treatment by penicillin. The same is done if a
mother was not treined well but serological reactions are negative and there are no
signs of syphilis in children. Children born by diseased mothers, who did not get
medical treatment or medical treatment was begun in the last months of pregnancy,
but serological reactions are positive, even if there are no signs of congenital
syphilis in children and analyses are negative – are treined according to plan for
early congenital syphilis. If there are no signs in children, but mothers during
pregnancy had phenomena of secondary active syphilis prophylactic medical
treatment takes place in the first 3 months after birth, if phenomena were liner –
then according to plan for early congenital syphilis. If a child has diagnosis of
congenital syphilis, his junior sisters and brothers, in spite of absence of signs of
syphilis, are treined prophylactically according to plan for congenital syphilis.
They are under supervision for 5 years.
IX Diagnostics and medical treatment of syphilis
Diagnostics of Syphilis is based on:
- study of complaints of a patient, moment of their appearance, probable reasons;
66
- data of examination;
- laboratory data (microscopic research of the discharge of hard chancre, tissue
liquid for treponema pallidum from erosive and ulcerous eruptions on the skin and
mucousas, from the surface of hyperthrophic papulae, study of punctate of lymph
nodes; serological dignostics - search for antibodies produced by the organism
against treponema pallidumi - microreaction of precipitation and Wassermann
reaction and etc. If one supposes neurosyphilis research of spinal-cerebral liquid
must be done.
Serologic diagnostics of syphilis. It is used to conform clinical diagnosis of
syphilis, to establish diagnosis of hidden syphilis, to control efficiency of medical
treatment and as one of cTPIeria of curability of patients with syphilis. It is also
used for prophylactic examination of definite groups of population.
In the immune response of the organism both cellular (macrophages, Tlymphocytes) and humoral mechanisms (synthesis of specific antibodies) take part.
The appearance of antisyphilitic antibodies takes place in accordance with general
pattern immune response: in first IgM are produced, as far as the disease develops
IgG synthesis begins to prevail; IgA are produced in comparinively small
quantities. The issue of IgE and Ig D synthesis is presently not enough studied. Ig
M appear on 2-4 week after contamination and will disappear in untreined patients
approximinely in 18 months; in the medical treatment of early syphilis - in 3-6
months, line one- in 1 year. Ig G appear usually on 4 week after contamination and
achieve much high titres, than Ig M. Antibodies of this class can remain for a long
time even after clinical recovery of a diseased person.
Following antigens of treponema pallidum are most studied: protein AG –
highly immunogene, antibodies against them appear in the organism in the end of
linent period or during the first week after appearance of hard chancre. Antigens of
polysacharide nature – little immunogene, because antibodies against them do not
achieve considerable titres and their role in serologic diagnostics is insignificant.
Lipidic AG of treponema pallidum make about 30% of cell dry weight. Besides
lipids of treponema pallidum in the organism of a patient a great number of
substances of lipidic nature as a result of destruction of cells of tissues appears,
mainly lipids of mitochondrial membranes. The antibodies in the organism of a
patient appear approximinely on 5-6 week after contamination.
The modern methods of serologic diagnostics of syphilis are based on
revealing in the organism of a patient of antibodies of different classes. Depending
on the character of the determined antibodies all serological reactions to syphilis
are as a rule subdivided into specific and unspecific.
Unspecific serological tests (UST). The tests of this group are based on the
finding in the organism of a patient of antilipidic antibodies. These tests are based
on 1 of 2 principles.
1. Tests based on the principle of binding of complement - Wassermann
reaction and its numerous modificinions. This test with the purpose of serologic
diagnostics of syphilis is used in qualitinive and quantitinive variants, carried out
by the classic method and method of binding in the cold. The test is done with 2
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antigens: of cardiolipin and treponema, got from Reiter’s treponemas destroyed by
ultrasound. In the primary period of syphilis the test will become positive in 2-3
weeks after appearance of hard chancre or on 5-6 week after contamination. In the
secondary one - almost in 100% of patients, in tertiary active - 70-75%, in tabes
dorsalis - in 50%, progressive paralysis in 95-98%. Wassermann reaction often
gives false-positive results if there are bacterial viral and protozoal infections, in
patients with malignant neoplasms, and also in healthy people after alchohol
drinking, quite often in women on 8 month of pregnancy and after delivery.
2. Tests based on principle of agglutininion of cardiolipin. The
microreactions with plasma of blood and inactivined serum are related to methods
of express-diagnostics of syphilis. The microreaction is done by allergic test (dropallergen) with the use of special AG. Most sensible and specific enough is a
reaction with plasma. These tests are suitable as selective during medical
examinations.
Specific serologic tests. Tests of this group are based on revealing of
antibodies to an agent - treponema pallidum. They are following tests:
1. Reaction of immunofluorescence (IFT). AG is influenced by studied
serum, which is treponema pallidum of Nicols culture, got from the rabbit orchitis
dried on microscope slide and fixed by acetone. After irrigation this preparation is
influenced by luminescent serum against human globulins. The fluorescent
complex (antihuman globulin+fluorescin tioisocyanate) binds with human globulin
on the surface of treponema pallidum and can be identified by the method of
luminescent microscopy. For serologic diagnostics a few modificinions of IFT are
used - IFT-abs (with absorption): high sensitiveness, positive in the beginning of
3rd week after contamination (before appearance of hard chancre or simultaneously
with it) is the method of early diagnostics of syphilis. Quite often the serum
remains positive for a few years after full medical treatment of early syphilis, in
patients with line syphilis - for decades.
- IgM-IFT-abs. IgM appear for the first weeks of the disease and are carriers of
specific properties of the serum. Much liner IgG begin to prevail. The same class
of immunoglobulins is responsible for false-positive results, as group antibodies
can be the result of the immunizinion by saprophyte treponemas for a long time
(mouth cavity, genitals). A separate study of classes of immunoglobulins is of
special interest in serologic diagnostics of congenital syphilis, when
antitreponemic antibodies synthesized in the organism of child, represented by IgM,
but Ig G will be of maternal appearance. The test is based on the use in the second
phase of conjugate anti-ІgM in place of antihuman fluorescent globulin. The test is
done for: serologic diagnostics of congenital syphilis, in differentiating of
reinfection from the relapse of syphilis (IFT-abs is positive, and Ig M-IFT-abs is
negative), estiminion of the results of medical treatment of early syphilis is
negative.
2. Treponema pallidum immobilization test (TPI). In mixing of the serum
of a patient with meal of pathogenic treponema pallidum in presence of
complement mobility of treponema pallidum is lost, while mixing meal of
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treponema pallidum with the serum of people without syphilis, mobility of
treponema pallidum remains for a long time. Revealed in that AB-immobilizins
related to line AB and they appear liner than complementbinding AB, achieving a
maximal titre till the 10th month, therefore they are not used as early diagnostics of
syphilis. However in secondary untreined syphilis the reaction is positive in 95%
of patients. In tertiary one - 95-100%. In congenital syphilis of inner organs 100%. Negativation not always begins and can remain positive for a long time.
3. Immunofermented analysis (IFA). The antigens of treponema pallidum
sensibilizate surface of solid phased carrier (sockets of panels of polysterene or
acryl). Then in the sockets the studied serum is put. If there are AB against
treponema pallidum in the serum the AG-IN complex connected with the surface
of carrier is formed. In the next stage in the sockets they pour an antispecific
(against human globulins) serum marked by an enzyme (peroxidase or alkaline
phosphatase) marked AB (conjugate) interact with the AG-AB complex, forming a
new complex. For its finding in the sockets they pour solution of substrate (5aminosalicylic acid). Under influence of the enzyme the substrate changes its color
pointing to the positive result of the reaction. It is close to IFT-abs by sensitiveness
and specificity. It is used for diagnostics of early forms of syphilis, as a cTPIerion
of successful medical treatment, if there are positive results of Wassermann
reaction for lack of clinical presentation, the false-positive Wassermann reactions,
hidden forms of syphilis, when the clinical presentation is present, but the positive
results of Wassermann reaction are absent.
4. Reaction of indirect hemagglutination (RIHA). As AG are used
formalinized and tanninized red corpuscles on which AG of treponema pallidum
are adsorbed. In addition of such AG to the serum of a patient takes place
agglutination of red corpuscles - hemagglutination. The reaction is positive on 3rd
week after contamination and remains positive for a long time.
5. Reaction of hemabsorption in a solid phase (IgM-SPHA). This is a new
serologic test, it is highly sensitive and specific, becomes positive since 2nd week
after contamination. The walls of sockets of polysterene panel are covered by antiІgM against human serum. Then in sockets they pour the studied serum containing
special absorbing diluent. On 3rd stage they put erythrocyte diagnosticum in
sockets. There is hemagglutination in the positive cases - erythrocytes are fixed on
the walls of sockets, in negative ones settled to the bottom as a disk.
Medical treatment of syphilis is done only after establishment of diagnosis
and confirminion of it by laboratory methods of research.
Basic principles of medical treatment of patients with syphilis:
- specific medical treatment - after establishment of diagnosis;
- preventive medical treatment - with the purpose of preventing syphilis of people
who had sexual and close domestic contact with people infected by contagious
forms of syphilis;
- preventive medical treatment – for pregnants, diseased now or diseased before by
syphilis, and for children born by such mothers;
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- trial medical treatment - it is possible to appoint in suspicion of the specific
affection of the inner organs, nervous system, organs of sense, musculoskeletal
system, when there is no possibility to confirm a diagnosis by convincing
laboratory data, and the clinical presentation does not allow to exclude possibility
of syphilitic infection;
- patients with gonorrhoea with unrevealed sources of contamination are subject to
the preventive antisyphilitic medical treatment in the case of impossibility of
dispensary observation.
A basic type of medical treatment is antibacterial therapy. Treponema
pallidum is most sensible to the antibiotics of group of penicillin (penicillin,
bicillin-1, 3, 5). They also use biiochinol for tertiary syphilis. If there are allergic
reactions to penicillins they use such antibiotics, as sumamed (azitromicin),
erythromycin, tetracyclin, oxaciclin.
Self-treatment is dangerous, as recovery is determined only by the laboratory
methods.
Preventive medical treatment. It is done for people having a sexual or close
domestic contact with diseased by contagious forms of syphilis, if from the
moment of contact passed no more than 3 months. Example: water-soluble
penicillin - 400 000 units 8 times per day, for 14 days, for the course - 44 800 000
units.
If since the moment of the contact passed 3 till 6 months such people get
double with interval for 2 months clinico-serologic study. If from the moment of
the contact passed more than 6 months, single clinico-serologic study is carried out.
The preventive medical treatment is got by a recipient who was transfused
blood of a patient with syphilis, if from the moment of transfusion passed no more
than 3 months. If passed from 3 till 6 months, the recipient is subject to the clinicoserologic control (with carring out of UST, IFT, TPI) twice with interval for 2
months. If after the blood transfusion passed more than 6 months, single clinicoserologic study is carried out.
Medical treatment of patients with primary and secondary fresh syphilis - 16
days, on 16 day in 3 h after ending of penicillin therapy singly bicillin-3 4 800
000 units (on 2 400 000 units intramusculary in two moments in every buttock) or
bicillin-5 3 000 000 units with prescription 30 minutes before injection 1 pill of
antihistamine preparation.
Medical treatment of patients with secondary recurrent and hidden early
syphilis - water-soluble penicillin (sodium salt), single dose is 1 000 000 units
diluted in 2 ml of physiological solution or distilled water), 6 times, for 28 days
(course - 168 000 units), and people helping in antiepidemic work.
Medical treatment of patients with hidden line syphilis (acquired and
congenital). It begins with preparation by biiochinol 2 ml in a day, intramusculary
till achieving 12-14 ml, after that they add penicillin therapy 400 000 units in 3
hours, for 28 days. They increase general dose of biiochinol to 45-50 ml. After 30
70
day break they appoint the second similar course of penicillin- bismuth therapy, in
that penicillin can be substituted by bicillin. Bicillin-1 is injected by single dose 1
200 000 units, bicillin-3 – by dose 2 400 000 units, bicillin-5 - 1 500 000 units,
injections 2 times per week, for the course - 8 injections.
Medical treatment of patients with visceral and tertiary syphilis. The
specific medical treatment is done according medical regimen for line hidden
syphilis with longer preparation by biiochinol, the dose of preparation is up to 20
ml. For medical treatment of line syphilitic hepinitises and also specific affections
of kidneys and mochevivodyashih ways the preparations of bismuth are not
appointed. In the other cases the issue about application of bismuth is decided
individually.
In syphilitic aortitis, aggravated by aneurism of aorta or insufficiency of
aortic valves, preparation by biiochinol must begin from the single dose of 1 ml (3
injections), with the subsequent increase up to 1, 5 ml (3 injections), after up to 2
ml. After injecting of 25-30 ml of the preparation one adds penicillin therapy and
begins it with the single dose of 50 000 units in 3 hours. The increase of single
dose is done in a day according to following plan: 50 000 - 100 000 - 200 000 400 000 units. Duration of penicillin therapy is 28 days. After 30 day break they
appoint the second course of penicillin- bismuth therapy, with the use of
bismoverol (16-20 ml for the course). If there are still clinical symptoms of the
disease after 2 penicillin- bismuth courses, it is expedient to appoint additionally 2
courses of bismuth therapy, one of which is done by biiochinol (40-50 ml for the
course), the other - bismoverol (16-20 ml for the course).
Medical treatment of patients with neurosyphilis. In the early forms of
neurosyphilis medical treatment is done according to the method for the medical
treatment of patients with secondary recurrent syphilis. To increase concentration
of penicillin in the spinal liquid it is expedient to appoint preparations stopping
getting an antibiotic out of the organism, in particular ethamide by 1, 05 (3 pills) 4
times per day for 10 days.
In line hidden syphilis the combination of preparations of bismuth with the
antibiotics of reserve is possible or medical treatment by only these antibiotics 2-3
courses on the whole. Course - 28 days, break between courses - 2 weeks in
application of only antibiotics, 4 weeks - in their combination with bismuth.
Preventive medical treatment of pregnants. Water-soluble penicillin is
injected by 400 000 units 8 times per day for 14 days. Course dose is 44 800 000
units. It is advisable to use oxacillin for pregnants, which injected intramusculary
by 1 000 000 units with intervals for 6 hours, 4 times per day, for 14 or 28 days
depending on period of the disease.
Medical treatment and prophylaxis of syphilis in children. The preventive,
prophylactic and specific medical treatment is done by preparations of penicillin:
children under 2 years - by the sodium and novocaine salts of penicillin, for the
medical treatment of children over 2 years can also be used bicillins. Day's dose of
penicillin (sodium and novocaine salts): 100 000 units/kg for children under 6
months, 75 000 units/kg – in the age of 6 months up to 1 year, 50 000 units/kg 71
over 1 year. Day's dose is divided into 6 equal single doses of water-soluble
penicillin and into 2 doses of its novocaine salt.
While medical treatment of patient with syphilis and preventive medical
treatment UST research is necessary one time for 2 weeks. Primary sulfurnegative
syphilis is diagnosed on the basis of the negative UST results and Colmer’s
reactions. The final diagnosis of primary sulfurnegative syphilis can be established
only in the end of medical treatment.
If in UST slightly positive result is got singly, the diagnosis of primary
sulfurpositive syphilis is established.
X Gonorrhoea
A gonorrhoea is an infectious disease caused by gonococci, transmitted, as a
rule, sexually and usually affects urino-genital organs, occasionally - mucous
membranes of cavity of mouth, pharynx (in the orogenital contact) and rectum (in
the homosexual contact). Nonsexual contamination can be in little girls in washing
of their genitals by sponges, infected by secretions of mothers with gonorrhoea, if
they use the same chamber pot, bed etc., causing in them - inflammation of the
vulva and vagina. The gonococci are able to cause the affection of conjunctiva that
is observed for example, in fetus passing through the maternal passages of diseased
mother, or in patient with gonorrhoea as a result of contamination of eyes by
contaminined hands. As a result, it is accepted to distinguish gonorrhoea of
genitals (genital), extragenital, and metastatic, which is aggravation of the first two.
And a source of infection is people with few symptoms or chronically proceeding
forms of gonorrhoea or asymptomatic gonorrhoea.
Gonorrhoea is characterized by development of inflammatory reaction which
has no specific features and does not differ from inflammation of urino-genital
organs of other etiology. Therefore diagnostics of gonorrhoea without the
discovery of gonococci in excretions is not possible. Gonococci are pair cocci
(diplococci), which form resembles coffee beans or kidneys placed toward each
other by concave surfaces. Unlike other cocci, discovered in the urino-genital
organs, gonococci are gram-negative: in Gram’s stain they become colourless.
Besides the microscopic research in diagnostics of gonorrhoea they use cultures on
the special artificial nutrient mediums. The gonococci parasitize on mucousas
covered by cylindrical epithelium - urethra, cervical canal, lower part of rectum,
eye conjunctiva. The affections of external genitals and pharynx are rare, because
this is flin multi-layer epithelium – occasionally because of trauma. The gonococci
got on mucousa of urethra achieve after 3-4 days subepithelial connecting tissue
through intercellular spaces and cause inflammation, urethral discharge - result is
migration of neutrophils, lymphocytes and plasmatic cells to the place of
introduction of gonococci. This is so-called incubinion period. Lymphogene
spreading takes place too and, what is proved by focal affection of the uretral
glands surrounded by the dense network of lymphinic vessels with the rapid
72
transition of inflammation to the back part of the urethra and development of
adnexites in women.
Gonorrhoea has an effect on the immunobiological condition of the
organism, specific and unspecific reactivity changes. A series of factors of natural
immunity, bactericidal activity of the serum, lysozyme, and complement is
oppressed. This is more characteristic for the chronic form of gonorrhoea; in fresh
gonorrhoea they do not reveal marked damages.
According to course it is accepted to distinguish recent (up to 2 months
remoteness):
Classification of gonorrhoea
A. Acute
B. Sunbacute
C. Torpid (few symptoms)
and chronic forms (over 2 months and undefined remoteness)
Asymptomatic gonorrhea.
By localization of affection of urogenital tract they distinguish:
A. Female gonorrhoea
1. gonorrhoea of lower part of urogenital tract
urethTPIis
paraurethTPIis
1.3. vulvitis
1.4. bartholiitis
1.5. endocervicitis
2. ascending gonorrhoea
endometTPIis
metroendometTPIis
salpingooophoTPIis
pelvipeTPIonitis
B. Male gonorrhoea
1. urethTPIis
2. paraurethTPIis
3. epididymitis
4. prostatitis
5. prostatic abscess
6. paraprostatitis
7. vesiculitis
II. extragenital gonorrhoea
73
1. gonococcal proctitis
2. gonorrhoea of the eyes
3. oropharyngeal gonorrhoea
4. gonococcal arthTPIis
III. Disseminated gonoccal infection
The clinical diagnosis also must take into account localization of focuses of
inflammation (topic diagnosis), character of complicinions and presence of other
pathogenic agents.
As one sees from classification based on course of the disease, gonorrhoea
manifests in recent and chronic forms. The incubinory period is usually 3-5 days,
however it can vary from 1 day up to 3 weeks and more. Recent gonorrhoea can be
acute, subacute and torpid (languid, having few symptoms) – this is the disease
whose remoteness is no more than 2 months. In the more protracted course they
diagnose chronic gonorrhoea. It is necessary to mention that it is very difficult to
find gonococci in patients with chronic form of gonorrhoea. It can be done only
after repeated researches, with the help of provocations, and sometimes only in
cultures.
Male gonorrhoea. For recent gonorrhoea foremost characteristic is
inflammation of urethra - recent gonorrhoeal urethTPIis. Acute urethTPIis is
characterized by cutting pains in urininion, swelling and hyperemia of sponges of
the external urethral meatus, abundant purulent discharge. The inflammatory
process is either limited by the anterior of urethra (anterior urethTPIis), or spreads
to its back-end (total urethTPIis). For anterior urethTPIis colic in the beginning of
urininion are characteristic, for total one - in the end of it. Patients with total
urethTPIis suffer, in addition, from frequent irrepressible urges to void urine. In
subacute urethTPIis all these symptoms are expressed in less degree, and
manifestations of torpid urethTPIis is limited by the scanty mucous-purulent or
mucous discharge (sometimes only in mornings or if squeezed out), by
agglutininion of sponges in the mornings, by feeling of pruTPIis or tickling while
urininion. Sometimes in torpid gonorrhoea the clinical symptoms are absent.
With the purpose to find out localization of inflammatory process in the
urethra the 2-glass test of urine is used. A patient passes urine by turns in two
glasses. In anterior acute urethTPIis the pus is washed off by urine to the first glass,
therefore urine in the second glass will be transparent. In total acute urethTPIis
urine will be turbid in both glasses. Patients with torpid urethTPIis have only
slightly dimmed urine (opalescent) or transparent one, but with purulent filaments
and flakes settling to the bottom: in the 1st glass - in front urethTPIis, in both - in
total one.
Chronic gonorrhoeal urethTPIis by its clinical presentation resembles torpid
recent one. However for it following features are characteristic:
- development in the urethra of infiltrates, granulinions, strictures,
inflammation of glands, metaplasia of epithelium and other affections
revealed by urethroscopy, bougienage, urethrography;
74
- periodic exacerbations of inflammatory process with appearance of
symptoms of acute or subacute urethTPIises;
- appearance of such complicinions as inflammation of prostate (prostatitis),
epididymis (epididymitis), seminal vesicles (vesiculitis), urinary bladder
(cystitis), renal pelves and kidneys (pyelitis and pyelonephTPIis) and many
others.
The only morphological cTPIerion of turning of recent process into chronic
one is formation in the urethra of deep focal infiltrates and appearance in them of
fibroblasts and fibrous tissue.
Urethroskopy allows defining accurately location and character of
morphological substrate of inflammatory process in the form of different changes
of mucous membrane of urethra. The endoskopic finding reflects
pathologoanatomic processes in tissues of urethra. And it can be the only
cTPIerion of differential diagnosis of torpid and chronic gonorrhoea. So, marked
focal character of endoscopic changes of mucousa, presence of transitional and
solid infiltrates testify to chronic urethTPIis. There are also Perin’s plaques in this
form - scarlet bleeding spots of mucousa, covered by tiny granulinions, in their
brush cytology one finds gonococci in untreined people. Urethroskopy is
therapeutic procedure too for medical treatment of prolonged and chronic forms
and establishment of recovery. The formation of urethral strictures is possible only
in the timely discovery and medical treatment of soft and transitional infiltrates.
Local complicinions of gonorrhoeal urethTPIis is lesion of skin of penis and
additional formations of this skin, periurethral tissues, Cowper’s glands, prostate,
seminal vesicles, testicular ducts and epididymes.
Female gonorrhoea. They found out in recent decade, that gonorrhoea in
women courses languidly, without distinct subjective disorders regardless duration,
but with affection of almost all parts of the urino-genital system, and rectum too (in
women in the moment of contamination several organs become infected at once or
one after another, that is multifocal affection develops in 60%). Ascending
gonorrhoea is in 54, 7% in recent acute condition and in 69, 2 % in chronic,
proceeds asymptominicly and diseased people can be revealed only during
prophylactic medical measures.
Torpid course of gonorrhoea is conditioned, presumably, as by lowering of
reactivity of macroorganism, as by change of biological properties of gonococcus,
especially under influence of antibiotic treatment. Important thing is also decrease
of function of ovaries, which shows up as decline of excretion of estrogens sum,
and their fractions too. The second feature of female gonorrhoea is that it proceeds
frequently in combination with other infections. If abundant excretions are marked,
their combination with trichomonads is possible, what is diagnosed in 70-80%. In
the gonococcal-candidiasis infection the percent is up to 28, 6. It is necessary to
remember about the simultaneous contamination by syphilis. There is development
of erosion of cervix of the uterus in gonococcal -trichomonadic infection.
The transition of process to the body of uterus and its appendages is
accompanied by the more or less considerable disturbance of general condition 75
by pains below stomach, rise of temperature, change of hemograms (accelerated
ESR in low quantity of leucocytes). Because of such difference in clinical
presentation one divides the disease topicly into gonorrhoea of lower part
(urethTPIis, paraurethTPIis, bartholinitis, vestibulitis, cervicitis, endocervicitis,
and proctitis) and gonorrhoea of upper part of genitals or ascending one
(endometTPIis, metroendometTPIis, adnexitis, pelveopeTPIonitis). Incubation
period is from 3 to 5 days, but quite often is equal to 14-15 days.
Acute urethTPIis is characterized by purulent excretions from urethra, some
patients complain on pains (sharp ones) during urininion. In chronic urethTPIis one
succeeds to find out scanty serous-purulent excretions only after the massage of
urethra which is felt as solid band of fibrous tissue. As often as urethTPIis, in
patients with gonorrhoea there is inflammation of cervix of the uterus (cervicitis
and endocervicitis).
Asymptomatic gonorrhea is presence of agents on the surface of mucousa
without the reaction of vessels, going out of cellular elements and appearance of in
least a little of exudation. If gonococci are not on the surface of mucousa, but in
the pouched focuses deeply in tissues or in accessory genital glands, they say about
linent gonorrhoea.
More frequently there is mixed course along with other agents – trichomonads, chlamydias, rarer - with corynebacteria (hemophilia bacillus) and fungi of
the genus Candida. In other cases the gonococci cause intensificinion of existing
before having few symptoms or latent infection, conditioned by the mentioned
microorganisms which were not suppressed or not sensitive to antigonococcal
therapy. The mixed infection influences clinical finding, course of gonorrhoea and
results of therapy. For example, with trichomonads - the incubinory period become
longer, is complicated because of affection of accessory genital glands or erosion
of cervix of the uterus. It makes very difficult to diagnose gonorrhoea, what is
epidemiologically important, because the potential sources of gonorrhoeal
infection are hidden. Finally, the mixed infection worsens the results of medical
treatment of gonorrhoea. In women more frequently than in men, the infection is
accompanied by pyogenic bacteria (staphylo- and streptococci) which, as well as
trichomonads cause acute course of inflammation and abundant discharge.
General principles of medical treatment of gonorrhoea. Success of medical
treatment of gonorrhoeal infection depends on the rational use of antimicrobial
therapy, immunotherapy, local medical treatment and physiotherapy procedures.
The recent and chronic gonorrhoea is treated in hospital. In the acute and subacute
stages of noncomplicated gonorrhoea one should administer medical treatment
with the use of antibiotics according to approved treatment regimen. The local
medical treatment is thus done only in presence of contra-indicinions to application
of antibiotics. Basic antibiotics are preparations of penicillin group.
As a result of therapy by the antibiotics of penicillin group inflammatory
phenomena usually greatly diminish for 5-7 days, excretions become scanty,
mucous, there are no gonococci in them. In case of successful medical treatment in
the end of 7-10 days after ending of introduction of antibiotics one should begin to
76
find out curability. If after expiry of 10-12 days after ending of antibiotic therapy
and exception of gonococci after provocinion the inflammatory phenomena
(excretions from urethra, filaments in urine and etc.) remain, these phenomena
should be considered as postgonococcal. A patient should be examined in
accordance with etiologic and topic diagnosis and they begin medical treatment.
In case of failure after antibiotic therapy, the clinical improvement is brief,
as a rule, early relapses of the disease appear. In 3-5 days (and sometimes liner,
withat the month) after introduction of antibiotics discharge from urethra increases
in them can also be found gonococci. For line relapses which occur rarer languid,
having few symptoms clinical course is characteristic.
In acutely proceeding noncomplicated relapses of gonorrhoea they should
use other antibiotic from the group of tetracyclins, macrolides, aminoglycosides
and etc. For patients with languid having few symptoms course of relapse of
antibiotic therapy should be done only after local medical treatment.
In acute stage of complicated and ascending gonorrhoea they should begin
medical treatment with introduction of bеnzylpenicillin on background of
autohemotherapy. Only after reduction of acute inflammatory phenomena one
should start immuno- and physiotherapy. Local medical treatment is administered
out after ending of the course of antibiotics.
For languidly proceeding (torpid) and chronic forms of gonorrhoea medical
treatment must be complex. The immunotherapy and local medical treatment must
precede prescription of antibiotics for medical treatment of such patients.
For supposed sources of infection and people having sexual contacts with
patients with gonorrhoea whom the gonococci are not found in, it is necessary to
carry out the medical treatment by regimen for chronic gonorrhoea.
Antibiotics. To prevent allergic reactions it is recommended 20-30 minutes
before introduction of antibiotics to appoint antihistamine preparations (dimedrol,
pipolphen and etc. by one pill).
Preparations of penicillin group are basic antibiotics for medical treatment of
gonorrhoea, and others - are antibiotics of reserve. This is bеnzylpenicillin (sodium
or potassium salt) in the physiological solution: knock-out dose 600 thousand units,
subsequent ones - by 400 thousand units with interval for 3 hours. The introduction
of whole course dose is possible 3 million units with 5 ml of one’s own blood or
durant preparations of penicillin.
Bicillin-1, bicillin-3, bicillin-5 (single introduction of bicillin-3 in dose 2 mn.
400 thousand units (by 1 m. of 200 thousand units of preparation in every
buttock) – in recent acute and subacute gonorrhoea)
Ampicillin, ampiox, oxacillin, cаrfecillin, augmentin, laevomycetin – side
effects in introduction of medical doses of these preparations are observed rarely headache, suppressed appetite, nausea, more frequent defecinion, loose stool - but
this does not require to stop it. Only if there is high temperature, general weakness,
vomiting and diarrhoea - it is necessary to stop it and for reduction of side effects
to appoint vitamins B 1, B 2, C and drops.
Antibiotics of tetracyclin type are tetracyclin, chlortetracyclin, oxitetracyclin,
77
metacyclin (rondomicin) - synthetic derivative of tetracyclin. For men and women
with recent noncomplicated gonorrhoea it can be applied the one-day medical
treatment of metacyclin: given in a 2 doses by 1, 2 g after meal with 8 hour break,
for the course 2, 4 g. Doxicyclin by 0, 1 g (the first dose 0, 2 g) every 12 h, for the
course - 1 g. In other forms - by the same method, but for the course 1, 5 g.
Macrolide antibiotics are erythromycin, oletetrin, erycyclin, macrapen.
Azaleides - azitromycin, roxitromycin, josamycin, medecamycin.
Antibiotics-aminoglycosides - kanamycin (in the protracted application it
provides nefro- and ototoxic action and it is forbidden to appoint it with other
antibiotics possessing otonephrotoxic action.
IFTampicins - IFTampicin.
Cefalosporins - cеfalexin, cefebid.
Sulfonamide preparations of the prolonged action - sulfamonomethoxin,
sulfadimethoxin, biseptol, sulfaton.
Fluorinated chinolons - cyprobay, tarivid, abactal, maxakvin. Application of
them is contra-indicated to pregnants and children under 14 years.
Spectinomycin (trobicin) is indicated for the medical treatment of recent
acute noncomplicated gonorrhoea in men and women, as a single injection 2
moments in a dose 2, 0 g, in women - 4, 0 g. For the medical treatment of children
40 mg singly of preparation is sufficient.
The complex application of antibiotics is indicated for heavily proceeding
forms, complicated and ascending gonorrhoea, gonorrhoea of rectum, presence of
the mixed infection or suspicion on such one and failed medical treatment by the
consistently applied antibiotics; the course doses and method are the same, as in
their separate prescription.
Immunotherapy is subsidiary method of the medical treatment of
gonorrhoeal diseases and is used along with other types of therapy with the
purpose of rise of reactivity of organism in struggle against infection. They
distinguish specific and unspecific immunotherapy.
Specific: 1. Vaccine therapy with the use of gonococcal vaccine - indicinions:
after failed antibiotic therapy in languidly proceeding relapses, in recent torpid and
chronic forms of the disease, for men with complicated and women with ascending
gonorrhoea (after subsidence of acute inflammatory phenomena). Contraindicinions: active tuberculosis, organic affections of the cardio-vascular system,
hypertensive disease, severe diseases of the kidneys and liver, emaciation, marked
anaemia, allergic diseases, menstruation.
For out-patient treatment gonococcal vaccine is appointed simultaneously
with antibiotics, in clinic - the antibiotics are appointed either in time or in the end
of vaccine therapy. It is injected intramusculary or intradermally in complicated
gonorrhoea with 200-250 m. of microbic bodies. If while injection they observe
high temperature, disturbance of general condition, acute tenderness in the affected
organ – the vaccine is abolished. In torpid and chronic gonorrhoea they begin with
300-400 m. of microbic bodies. Intervals between injections are 1-2 days, with the
increase of dose on 150-300 m. of microbic bodies. Maximal dose must not exceed
78
2 mlrd of microbic bodies, and the number of injections - 6-8.
Unspecific immunotherapy. Руrogenal is used with the purpose of unspecific
immunotherapy in patients with recent torpid and chronic forms and in the
nongonococcal inflammatory diseases of lower part of urino-genital organs, and
also in complicinions (prostatite, epididymitis and others). It is appointed
beginning from 2, 5-5 microgramm for women and with 5-7, 5 microgramms for
men intramusculary, in 1-2 days. The dose of pyrogenal is increased on 2, 5-5-10
microgramms (depending on the reaction). The maximal single dose must not
exceed 100 microgramms. Course of medical treatment consisits of 10-15
injections. A rise of temperature must be no more than 1 degree. In very high
temperature, acute chills, headache, vomiting, pain in waist and below stomach it
is recommended not to lower a dose, but increase an interval between injections
(for 1-2 days) or repein the last dose.
Pyrogenal is used simultaneously with gonococcal vaccine: pyrogenal in
dose 2,5-5 microgramms, gonococcal vaccine - a 200-300 m. microbic bodies.
Then the single doses increase on 5-15 microgramms, and gonococcal vaccine - on
150-300 m. microbic bodies. Maximal dose of pyrogenal 10 microgramms, gonococcal vaccine - 1,2 billion Both preparation - in one syringe. Contra-indicinions
to application of pyrogenal: acute fever, pregnancy, hypertensive disease, active
tuberculosis, menstruinion, patients with diabetes mellitus - with carefulness.
Prodigiosan - unspecific immunostimulinor, increases intesity of reparativerestorinion processes. Indicinions are the same as for pyrogenal, and also in the
protracted gonococcal processes resisting treatment by antibiotics. Contraindicinions: diseases of the cardio-vascular system and nervous system. It is
injected intramusculary beginning from 15 microgramms, with the increase on 1015 microgramms depending on the reaction (general, local, focal). For the course 4 injections with interval for 4-5 days. Maximal single dose - 75 microgramms.
Levamisole is used orally by cycles 150 mg one time per day for 3 days they
repein it in 4 days. Course consists of 4 cycles. It is used to trein repeated diseases
of gonorrhoea, torpid and chronic course of complicated gonorrhoea.
Potassium orotate stimulines restorinion processes in the inflamed-changed
tissues. It is used orally 0, 5 g 4 times per day for 20-30 days.
Мethyluracil stimulines producing of antibodies, increases phagocytic
reaction, and accelerines the reverse development of inflammatory processes. It is
taken orally after meal by 0, 5 g 2 times, the course is 10-14 days.
Glусуrrаm is in dosage of 0, 05 g 3 r during 10 days. Tactivin is 0, 01%
solution 0,5 ml subcutaneously, only 7-8 injections.
Thymactin - domestic immunocorrector in complicated gonorrhoea, 0, 1 g
one time for 3 days, on course is 0, 5 g.
Autohemotherapy. Indicinions: gonococcal complicinions accompanied by
acute tenderness in the affected organ, high temperature and grave condition of a
patient. After resolution of these phenomena – they pass to more active
immunotherapy.
Reinfusion of one’s own blood treined with laser light.
79
Biogenic stimulators. They are applied for accelerinion of resorption of
infiltrates in urethra and genital glands. Contra-indicinions: cardio-vascular
diseases, hypertension, acute gastro-intestinal disturbances, nephrosonephTPIis,
cirrhosis, pregnancy over 7 months - aloe 1 ml, for the course 15-30; FIBS - 1 ml,
for the course 15-20.
It is rational to administer all types of immunotherapy before psrescription
of antibiotics. Taking into account epidemic circumspection the antibiotics with
immunotherapy are appointed simultaneously for out-patient treatment.
CTPIeria of recovery of gonorrhoea. Recovery is defined by clinical,
bacterioscopic and bacteriological researches. However the absence of excretions
and disappearance of gonococci from the surface of mucousa not always means
convalescence, because the gonococci can remain for a long time in the pouched
focuses of infection. Difficulty of discovery of gonococci by bacteriscopic research
resulted in application of different methods of provocinion and method of culture,
based on irTPIating of tissues with the purpose of revealing of infection in the
hidden focuses.
The following types of provocations are used:
Chemical - in which they smear the urethra 1-2 cm in depth and lower part
of rectum 4 cm in depth by 1-2% solution of silver nitrine or Lugol’s solution in
glycerin, and cervical canal - in depth of 1-1,5 cm by 5% solution of silver nitrine.
Biological - introduction of gonococcal vaccine intramusculary 500 million
of microbic bodies or introduction of gonococcal vaccine simultaneously with
pyrogenal (200 MPD). If gonococcal vaccine was used for the medical treatment,
for provocinion they appoint the double last therapeutic dose, but no more than 2
mlrd. microbic bodies; in the conditions of clinic it is possible to enter gonococcal
vaccine regionaly - in the submucous layer of cervix of the uterus and urethra (100
m. microbic bodies).
Mechanical - for men they enter straight bougie in the urethra and leave it
for 10 minutes or do frontal urethroscopy.
Thermal – warming-up of genitals by inductothermic current. They carry out
diathermy daily during 3 days for 30-40-50 minutes in order or inductotherapy for
3 days during 15-20 minutes. Excretion for research is taken every day in 1 hour
after warming-up.
Physiological – they take swabs during periods.
Alimentary - salty, spicy food.
Swabs from secretion of all lesion focuses are taken in 24-48 and 72 hours
after provocation.
Combined methods of provocations are the best. More frequently they do the
chemical and alimentary provocations with the simultaneous introduction of
gonococcal vaccine. In the protracted, chronic cases of urethTPIis it is expedient to
cause the irTPIinion of mucousa of urethra by massage on straight bougie or tube
of urethroscope and by intramuscular introduction of gonococcal vaccine.
The bacteriological method of research should be applied both for the
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primary diagnostics of gonorrhoea, and for the control of recovery. The
bacteriological researches are indicated in the discovery in swabs suspicious on
gonococci of gram-negative diplococci, in presence of the history suspicious on
gonorrhoea, clinical finding and negative microscopic researches, for diagnostics
and establishment of recovery in patients which, in spite of absence of gonococci,
still have inflammatory phenomena.
Frontal urethroscopy allows defining a character of inflammation after
disappearance of gonococci in acute manifestations of gonorrhoea what is
important for prescription of proper local medical treatment.
For men the control of recovery is done in the following way: bacteriscopic
research of discharge from urethra or brush cytology from urethra is carried out,
beginning from the next day after ending of the medical treatment, for three days in
order. In the positive results they start a new course of medical treatment. In the
negative results of bacteriscopy in 7-10 days after ending of medical treatment: 1st
day is examination of a patient, bacteriscopic research of discharge from urethra
and brush cytology from mucousa, 2-glass test, palpated study of prostine, seminal
vesicles and microscopic research of their secretion, frontal urethroscopy. The
combined provocinion is administered - instillation in urethra of 0, 5% solution of
silver nitrine and intramusculary 500 m. of bodies of gonococcal vaccine. On the
2nd day - bacteriscopic research of brush cytology from the mucousa of urethra, 2glass test, microscopy of secretion of prostine and seminal vesicles.
For women the control of recovery is done in the following way:
bacteriscopy of brush cytology of urethra of cervical canal beginning from the next
day after ending of medical treatment during 3 days in order. The first control
study in 7-10 days after ending of medical treatment – examination, bacteriscopy
of brush cytology from urethra and lower part of rectum, combined provocinion intramusculary 500 m. of bodies of gonococcal vaccine, smearing of urethra and
cervix of the uterus by 1-2% solution of silver nitrine or 1% Lugol solution in
glycerin. After the combined provocinion they do bacteriscopy on the first and
third day and bacteriological research on the third day since the day of provocinion.
The second control research is administered on the 2nd and 3rd day of the
next menstruinions - brush cytology from urethra, cervix of the uterus and lower
part of rectum for bacteriscopy and bacteriological research.
The third control research is administered after the end of menstruinions;
they repein the combined provocinion with followed bacteriscopic study on the 1st
and 3rd day and bacteriological one in 3 days after provocinion. If there are
favourable results of clinico-laboratory studies – a patient is taken off the books.
For children: after the end of the medical treatment they are examined for 1
month for establishment of recovery. While this time they do 3 provocations by
gonococcal vaccine and 3 bacterial cultures (1 time per 10 days). On the first, 2, 3
day after provocinion they take smears from urethra, vagina and rectum. Bacterial
culture is on 3rd day.
If there is an oropharyngeal infection - the bacteriological research of the
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secretion of fauces is carried out in 7 days after ending of the medical treatment.
The 2nd and 3rd controls are done with 1 month intervals.
XI AIDS
Acquired immunodeficiency syndrome (AIDS) is comparinively recently
(1981) identified infectious disease. An agent is the human immunodeficiency
virus - HIV, which is neuro- and lymphotropic retrovirus. The disease is
characterized by different tumours, the secondary opportunistic infections with the
extremely severe course and prognosis unfavorable for the life. The disease may
appear as complex of signs of severe immunodeficiency or proceed
asymptomaticly. There is a large number of variants of clinical and immunological
manifestation of AIDS between these two extreme forms of the course.
HIV is related to RNA-containing retroviruses («reverse» viruses),
possessing the special way of inheTPIed information transfer. Thanks to presence
in these viruses of enzyme of revertase they are able to «rewTPIe» in host cells
viral RNA to DNA. The latter then integrates (is built) in the chromosomes of
nuclear apparatus of the affected cells. The main object of HIV affection is Thelpers, what is favoured by the presence of special receptors for HIV on the
surface of the helper T cells, called CD-4, it is they that are «recognized» by HIV
and in this place penetrates into helper T cell.
Unlike other lymphotropic viruses causing multiplication of lymphocytes,
HIV destroys helper T cells affected by it, which results in deep, irreversible
damages of the whole immune system of a diseased person, which manifest as
stable immunodeficiency with absence of helper T cells on the height of disease
conditioning clinical presentation of AIDS. There are data, that HIV, besides
helper T cells, affects Langerhans cells, glial cells of CNS.
HIV, while accumulating in lymphocytes, is contained in the biological
liquids of patient too, however in sufficient for the infection quantity virus is
revealed only in blood, sperm and vaginal excretions, extremely rarely in breast
milk.
It was established for certain, that a basic way of HIV transmission is sexual
one. In addition, the infection can be transmitted by transfusion of the blood of a
donor or its preparations from a diseased person, the use of unsterile syringes,
needles and other instruments contaminated by the infected blood.
It is necessary to point out the absence of the inaktiviruyushego influence of
the serum of blood on HIV and role of the sperm possessing immunosupressive
action in relation to blood and other liquids and cellular formations of female
organism, favoring contamination by AIDS.
Other ways of transmission of the infection (airy-kapelniy, alimentary,
contact-domestic) have no meaning in AIDS. Sanguivorous insects and arthropoda
are not carries of HIV, because the virus quickly perishes in their organism.
Among infected by HIV, 70-75% are homosexuals presenting a basic group
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of risk. It is explained by the fact that during the intercourse of these people
fissures of mucous membrane of the rectum, anus often occur, as a result the virus
easily gets into the blood. The presence in the rectum of the special receptors
(similar to CD-4 on helper T cells) is not excluded, in the place of their localization
the viruses penetrate through the mucous membrane of the rectum into the blood.
In the physiological sexual contact between man and woman possibility of
HIV penetration into the blood is created much rarer. In these conditions women
are infected much more frequently.
Certainly, disorder sexual intercourses have an important epidemiologic
meaning for contamination.
A group of risk secondary by importance is drug addicts injecting drugs
intravenously, especially in the group use of unsterilized syringes and needles.
They make from 15 up to 40% of HIV infected.
The third group of risk is prostitutes, whose contamination rate gradually
increases. In a number of countries about 80% of such women are HIV infected.
As a group of risk one should consider people which got the donor blood or
preparations of blood were injected without the preliminary control for the
presence of HIV, patients with haemophilia, residents of countries, where AIDS is
widely spread.
Got this or that way into blood, the virus selectively affects helper T cells,
whi-ch become carriers of the virus and transmit it to daughter's cells while
division, but at definite mutation of the virus, it being in cell, kills it. These
processes go on with different speed that, ultimately, determines duration of the
hidden period that is term passing from the moment of contamination to
development of the clinically expressed disease. This period may last only for 4-6
weeks, but more frequently - for years.
The character of course of the infection determines mutual relation between
cells that is helper T cells and HIV. If there is mass helper T cells destruction the
clinically expressed immune deficiency develops, which manifests as different infections arising up in patients as a result of their lost possibilities to resist to any infection. In addition, helper T cells destruction stops their organizing and stimu-lative activity in the protective reactions of the organism. This results in the decreese
of B-lymphocytes activity producing antibodies, disorganization of the killer T
cells and macrophages. At that if in the beginning of the disease the quantity of
helper T cells simply diminishes, in future it catastrophicly falls, and in the moment of height of the disease helper T cells are practically absent in the peripheral
blood. The ratio of helper T cells and suppressors is disturbed as a result - in HIV
carriers this index is approximinely 1, 0, and in patients with AIDS diminishes up
to 0, 4-0, 6 and less.
It should be noted that in response to introduction of HIV in the organism
the antibodies specific for it appear in the peripheral blood not right away, but after
2-8 weeks.
HIV causes protractedly, for years proceeding disease, thus nobody can
predict to present day, when after contamination various clinical manifestations
83
will appear in this patient. Different affections of the skin and mucous membranes
are very frequent manifestation of HIV contamination. They arise up practically in
all clinical forms of the disease, but not only in the period of full-blown AIDS, and
have an important diagnostic and prognostic meaning.
Approximinely in 20-25% of HIV infected people the acute period of
disease will develop in 2-8 weeks after infection which includes high temperature,
affection of tonsils similar to this in mononucleosis, diarrhea, and pains in muscles.
Polyadenitis also develops with extension of two or three and more groups of
lymphatic nodes. They are moderately painful, mobile, not united with each other
and with surrounding tissues. Nonsymptom spread symmetric rash resembling rash
in measles or syphilitic roseola simultaneously appears almost in half of such
diseased people. The rash is mainly localized on the body; separate elements
appear on the face, neck and etc. The rash stays from 3 days up to 2-3 weeks.
Histologically such exanthema is characterized by perivascular infiltrates from
lymphocytes and histiocytes. In the blood they reveal transitory thrombopenia, and
lymphopenia, index of helper T cells and T-suppressors ratio is more than 1, 0.
The exanthema in AIDS in adults should be differentiated from
toxicodermia, rose lichen, syphilitic rozeola and others.
In the acute period of disease there may be hemorrhagic makulas by
diameter up to 3 mm, similar to eruptions in hemorrhagic allergic vasculitis. Such
eruptions can be accompanied by ulcerations of mucous membranes of the mouth
and esophagus and expressed disphony. Besides, appearance of viral affections of
the skin is possible - herpeses, molluscum contagiosum and others.
The acute period of the disease lasts from a few days up to 1-2 months, whereupon all symptoms of the disease disappear and the disease passes to nonsymptom phase which can proceed for indefinitely long time. At that in some pati-ents
who had the acute form before, persisting generalized lymphadenopathy is saved,
not having influence on state of health of these people and their sexual activity.
As a result of the violinion of the immune system gradually developing
under HIV influence, decrease of protective properties of organism-carrier
periodically can arise up different viral, microbic, fungous diseases, including of
the skin which usually have a limited character, torpid course and treated with
difficulty.
In the latent period of in absence of other clinical signs in 10% of patients
one reveals seborrheal dermatitis (seborrheic eczema), at that in the acute phase of
the dis-ease it is marked rarer, and in the period of full-blown AIDS occurs in 4683% of pa-tients. In some patients seborrheal dermatitis is the first clinical sign of
AIDS, arising up sometimes 1-2 years before appearance of other clinical
symptoms of the disease.
The process usually proceeds chronically, with exacerbations, is localized on
the face periorally, periorbitally, on the cheeks (adjacent to the nose and etc.), hairy
part of a head, upper part of the body, that is usually in the places of the largest
accumulation of sebaceous-glands.
On the skin of the face and the body seborrheal dermatitis is characterized
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by erythematous, distinctly limited makulas of different size and outlines covered
by scales quite often greasy ones or greyish-yellow scale-crusts. The process can
be accompanied by the strong pruTPIis, especially in the area of the sculp. On the
face eruptions sometimes resemble discoid lupus erythematosus, psoriasis and
others. They think that large spreading of eruptions and fusion of elements in the
erythrodermic form is unfavorable prognostic sign. On the sculp seborrheal
dermatitis usually manifests as abundant scaling resembling marked dandruff.
Methods of diagnostics of HIV infection. They are based on the clinical
symptoms and laboratory data. To the diagnosis of AIDS can testify with the large
probability the histologically confirmed Kaposi’s sarcoma in persons 30-55 years
and younger, and also lymphoma, not related to lymphogranulomatosis, with the
high degree of malignancy and lymphoid infiltration of indefinite etiology,
resistant to the ordinary chemotherapy; pneumocystic pneumonia; protracted fever
of indefinite etiology; generalized lymphadenopathy of indefinite genesis; chronic
diarrhea syndrome (over 1-2 months), being the result of both enterobacteriosis,
and coccidiosis, isosporiosis, cryptosporidiosis and others; causeless loss of body
mass of a patient by 10% and more for a month; bronchial and pulmonary
candidiasis; endogenous and exogenous reinfection and superinfection.
For the exposure of antibodies to HIV the serologic methods of diagnostics
are used: reactions of immunoferment analysis (IFA), immunofluorescence,
immunoblotting and etc.
For the discovery of the virus virological methods of research are used:
culture of blood or other material in the culture of tissue, electronic microscopy,
polymerased chain reaction (PCR) and etc. In practice as most accessible reactions
of the IFA and immunoblottinga are used most often.
The IFA is used as an indicated reaction to the discovery of antibodies for
the whole group of HIV albumens. It can give false-positive results in a number of
diseases of allergic character, biochemical changes in the organism, in pregnancy,
alcoholism, tumours and some other changes.
The reaction of immunoblotting exposes the specific HIV albumens, getting
of complete set of them is the confirmative test; otherwise it is necessary to
observe a patient for a long time with the purpose of differentiation of infection
from other diseases of autoimmune genesis.
Skin diseases often occur in HIV-infection
Neoplastic diseases
Kaposi’s sarkoma
Lymphoma
Epidermoid cell carcinoma
Bаsal cell carcinoma
Papulosquamous diseases
Seborrheal dermatitis
Xerosis/acquired ichtiosis
Vulgar psoriasis
Infectious diseases
Bacterial:
Infections caused by staphylococcus
aureus
Syphilis
Bacillus angiomatosis
Fungous:
Candidiasis
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Reiter’s syndrome
Infections caused by viruses
Virus of human papilloma
Molluscum contagiosum
Virus of simple lichen
Virus of zoster
Virus of cytomegalia
Virus of Epstein-Bar
Diseases caused by arthropoda
Scabies
Dermatomycosis
Cryptococcosis
Histoplasmosis
Various:
Eosinophilic folliculitis
Medicinal rashes
Hyperpigmentation
Photodermatitides
PruTPIis
4 forms of candidiasis of mucousas of the mouth and pharynx, marked in
HIV infection
1. Candidiasis of the mouth and pharynx, pointing out progressing of
AIDS, shows up in the clinical forms:
Pseudomembranous (white mouth)
Erythematous (atrophy)
Hyperplastic
Angular cheilitis (perlèche)
2. Pseudomembranous candidiasis shows up as whitish looking like cream
or pressed cottage cheese, coating anywhere in mouth cavity and pharynx. Films
are deleted by erasure, uncovering a reddish surface.
3. Erythematous candidiasis manifests as well distinct makulas of
erythema on the palate or upper side of tongue. Elements of erythematous
candidiasis on the tongue may look smooth, deprived of papillae.
4. Hyperplastic candidiasis shows up as white film coating on the dorsum.
5. Angular chilitis consists of erythema, fissures and folds in the corners of
the mouth. Simultaneously there can be two and more forms of candidiasis.
Approachs of managing of person suspected for HIV infection and medical
treatment of patients with HIV infection. For the medical treatment of the diseases
caused by the human immunodeficiency virus (HIV), selective inhibitors of HIV
proteinases, synthetic analogues of thymidine nucleoside and etc. are indicated.
The main preparation which able to stop HIV replication - azidothymidine used in
combinations with other medications.
Invirase is appointed 600 mg 3 times per day, in combination with
zalcigabip 750 mg, zidopudin 200 mg. In the case of monotherapy invirase is
appointed by 600 mg 3 times per day.
Such medical treatment though does not result as a rule in elimination of the
virus, but is able to stop the course of the disease, considerably prolonging a life of
patients.
Prophylaxis of AIDS. As well as in any other infection there are the
national and personal measures of prophylaxis of AIDS.
The national measures include the following:
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 propaganda among the population of knowledge about the ways of HIV
transmission, possible factors of contamination, measures of the personal
prophylaxis;
 creation of the system of timely discovery of HIV-infected people and taking
measures to exclude spreading HIV-infection by them (organization of the
specialized service, wide consultation of the population, accessibility of
examination including anonymous one, explanatory work with HIV carriers and
etc.);
 taking a complex of measures to prevent HIV transmission through the donor
blood, organs, tissues;
 creation of material and technical base for diagnostics of HIV infection,
foremost laboratory one;
 elaboration of legislative acts and etc.
The measures of the personal prophylaxis are directed to the following:
 reduction of a number of sexual partners;
 use of a contraceptive in the sexual intercourse.
At the medical prophylactic establishments measures of prophylaxis are
directed to preventing of intrahospital spreading and the professional HIV
contamination.
In the conditions of widening HIV spreading every patient must be
considered as a potential carrier of HIV infection. Used for his/her study and
medical treatment instruments, apparatuses, laboratory glassware and others must
be processed in accordance with the requirements of instructional-methodical
documents on disinfection and sterilization. As the basis one should take
requirements made for the prophylaxis of viral hepatites.
To the measures of prophylaxis of the intrahospital HIV transmission the
timely discovery of HIV infected among patients in accordance with the Rules of
medical examination for AIDS is related. In the medical prophylactic
establishments it is used if there are signs stated in the given rules.
Must not be admitted to service work with any type of patients, with
biomaterials from them and objects infected by them medical and technical
workers having damages of the skin: wounds, fissures, exudative affections,
weeping dermatoses. Abrasions, scratches and other damages are pasted by court
plaster.
While manipulations, laboratory researches with the possible getting on the
medical worker of the blood or other biological liquid from patients or dead bodies
individual means of protection, safely covering the skin and mucousas of a worker,
are used: obligatory coat of a surgical type, rubber gloves, glasses, mask (or shield).
While delivery, dissection of dead bodies and in other types of works, where the
abundant contamination is possible, it is necessary to put on moisture-proof aprons,
sleeve-protectors, shoe covers (or rubber boots).
The medical staff must take precautions while they manipulate with the
cutting and pricking instruments (needles, scalpel, scissors etc). All job positions
87
must be provided with the disinfectant solutions and standard medicine chest for
the urgent prophylaxis. The system of realization of prophylactic measures in case
of unforeseen situation must be worked through till automatic state.
Any damage of the skin, mucousas, spattering with their blood or other
biological liquid of a patient in providing medical care to him/her must be
estimated as a possible contact with material, containing HIV or other agent of
infectious disease. If the contact of a medical worker with blood or other liquids
happened with damage of integTPIy of skin covers (prick, cut), s/he must:
 quickly take off a glove with the working surface inwardly;
 right away squeeze blood out of the wound;
 process the affected spot by one of disinfectants (70% spiTPI, 5% tincture of
iodine for cuts, 3% solution of hydrogen peroxide for pricks and etc.);
 wash the hands under the running water with soap and then wipe by spiTPI
again;
 put a plaster on the wound, put on finger-stall;
 if it is necessary to continue work to put on new gloves.
In the case of contamination by blood or other biological liquid without the
damage of the skin a medical worker must:
 process the skin by spiTPI, and in its absence 3% hydrogen peroxide, 3%
solution of chloramine or other disinfectant solution;
 wash the place of contamination by water with soap and repeatedly process by
spiTPI.
If biomaterial got on the mucous membranes it is necessary:
 to rinse the mouth cavity by 70% spiTPI;
 stain 30% solution of sulfacetamide from tube-dropper into the nasal cavity;
 wash the eyes by water (with clean hands), stain a few drops of 30% solution of
sulfacetamide from tube-dropper.
If there is no 30% solution of sulfacetamide for processing of mucousas of
the nose and eyes it is possible to use 0, 05% solution of potassium permanganate.
In the getting of biomaterial on a dressing-gown, clothes it is necessary
immediately to process the spots by one of disinfectant solutions.
It is necessary if clothes are drenched:
 disinfect the gloves;
 take off clothes and soak it in one of disinfectant solutions (except for 6%
hydrogen peroxide and neutral calcium hypochloTPIe, which destroy tissues) or
put it into a polyethylene package for autoclaving;
 wipe the skin of hands and other areas of the body under contaminated clothes
by 70% spiTPI, after wash by water with soap and repeatedly wipe by spiTPI.
Contaminated shoes are processed by the double wiping by rags moistened
in solution of one of disinfectants.
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XII
Pyodermas
Definition, prevalence. Pustulous diseases of the skin or pyodermatites make
the most part of skin diseases, taking the first place among all dermatoses. They
are named pyodermatites (from Greek pyon - pus.). Pyodermas (pustulous diseases
of the skin) - group of diseases of the skin, caused by pyogenic microorganisms,
mainly by staphylococci, streptococci, rarer by others (pseudomonous infection
and etc.).
About half of all cases of incapacity for work caused by diseases of the skin is
the result of pyodermatites. Though they occur in all groups of the population
frequently enough, pustulous diseases of the skin relatively more frequently are
registered in people working in the definite fields of industry - construction,
metallurgical, mining, at transport and etc., where they are already professional
diseases. In this plan the struggle with the pustulous diseases of the skin has a state
importance and is a social problem of medicine.
In child's dermatological practice pyodermatites are the most widespread
diseases of all dermatoses of child's age too. The various manifestations of
pustulous diseases of the skin arise up initially (as different independent nosology
forms) or as complications of other dermatoses, especially in patients with itching
dermatoses (neurodermatoses, scabies, pediculosis).
Role of damages of the skin and factors favouring development of the disease.
Pyodermas - the most widespread diseases of the skin in all age groups.
Presumably, this is conditioned by the fact that staphylococci, streptococci are
often revealed in human environment (in the air, dust of rooms, and also on clothes,
skin). Undamaged clean skin serves as the reliable barrier to penetration of bacteria
inside. However in the damages of the skin (abrasions, fissures, and traumas), its
pollution by lubricating oils, dust, inflammable liquids, at the wrong care of the
skin its functions are disturbed, including protective ones. Development of the
disease is favoured by decline of immune defense of the organism, damages of
content of sweat and change of acidity of aqua-lipid mantle of the skin,
composition and quantity of adipose secretion, unbalanced nutrition,
hypovitaminosis (A, C, groups B), endocrine damages (saccharine diabetes and
etc.), overstrains, becoming too cold and other ones. In healthy people even in
presence of massive and virulent infection the disease does not arise up. Decisive
part in development of pustulous diseases of the skin is played by local and general
antibacterial resistance of macroorganism. From penetration of microbs through
the skin the organism is protected by the protective factors. So, the corneal layer of
the skin possesses a large thickness and durability. A keratin of this layer is
chemically nonactive substance, and the cornified cells can be melted only in the
very concentrated acids and bases. There is constant shelling of upper layers of the
epidermis and mechanical deleting of microorganisms. The skin and a bacterial
cell have a positive electric charge that also favours deleting of microorganisms
from the surface of the epidermis.
89
The bactericidal function of the skin decreases as a result of wide, at times
irrational application of antibiotics which favours ousting of normal microflora of
the organism and reduces to zero its antagonistic action on pathogenic
microorganisms what is favourable to increased multiplicaion of the latter on the
skin and mucous membranes.
As a result of damage of integrity and function of epidermis conditions for
penetration of microorganisms in the deep laying tissues are created. «Entrance
gates» for infection are microtraumas of the skin. Their appearance is favoured by
maceration and rapid thinning of corneal layer.
Unfavorable factors are overcooling and overheating of the organism,
negatively influencing metabolic processes in the skin. The influx of tissue liquid
to the skin is thus damaged; content and quantity of tissue liquid, sweat and skin
fat, their bacterial properties go down.
The appearance of pyodermas is favoured by: diseases of the central and
vegetative nervous systems, overstrain, starvation, malnutrition (lack of albumens,
vitamins, salts), organism wasting diseases, irradiation by x-rays, medical
treatment by corticosteroid and immunodepressive preparations.
Some patients indicate as the direct reason of disease that their close relatives
have various purulent skin diseases for a long time.
Modern classification of superficial and deep pyodermas
Superficial
Deep
І. Staphylodermas
1. Osteal folliculitis
1. Deep folliculitis
2. Folliculitis superficial
2. Furuncle, furunculosis
3. Vulgar sycosis
3. Carbuncle
4. Simple acne
4. Hidradenitis
5. Epidemic impetigo of the newborn
II. Streptodermas
1. Streptococcal impetigo
1. Cellulitis
а) streptococcal perlèche
а) acute streptococcal - erysipelas
b) intertrigenous
2. Ordinary ecthyma
c) bullous
d) resembling syphilis
e) surface whitlow
2. Dry streptoderma
а) simple lichen of the face
III. Strepto- staphylodermas
1. Vulgar impetigo (mixed)
1. Chronic ulcerous pyoderma
2. Chancriform pyoderma
Folliculitis - purulent inflammation of hair follicle. They distinguish osteal
folliculitis, surface folliculitis and deep one.
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Osteal folliculitis (synonym is Bokhart staphylococcal impetigo) is
characterized by tiny surface follicle cone-shaped pustule which diameter 1-2 mm
with a purulent head located in the mouth of hair follicle. Its center is pierced by
hair (which is not always distinct), on periphery one sees a rosy rim 1 mm in width.
As a rule, osteal folliculites have plural character, are localized on the face, body,
extremities. In 3-5 days the content of pustules will shrink as crusts which peel off
without traces.
Folliculitis superficial is remarkable only for a little large size (0, 5-0, 7mm
in diameter) and depth of affection (captures about 2/3 of hair follicle). Forming
pustule also has a cone-shaped form, it is pierced by hair, erythematous area round
it is 2-3mm, cover of pustule is solid, slight tenderness is possible, after dissection
of pustules and secretion of pus subjective feelings disappear. The general state of
health is usually not poor.
Deep folliculitis is characterized by larger size of pustules (1-1, 5 cm in
diameter), fully capturing a hair follicle, and expressed tenderness. It is however
different from furuncle by absence of necrotic core. At the good number of
eruptions there can be subfebrile and febrile fever, changes of blood (leukocytosis,
accelerated ESR). Deep folliculites can be signs of diabetes, immunodeficient state,
and anaemia.
Sycosis vulgaris is chronic pustulous process characterized by inflammation
of hair follicles of areas of beard and moustaches, rarer other areas (pubis area).
Men have it – not following hygienical rules while shaving. Endocrine damages,
immunodeficiency, beriberi and focuses of chronic infection (rhinitis, sinusitis,
antritis) are also important. The disease is characterized by continuously recurring
eruption of osteal folliculitis and folliculites, containing pus, a little painful,
sometimes accompanied by itching, with the small hyperemia on periphery. The
focuses fuse, forming vast areas of affection. The process takes chronic languid
course. General state of a patient is not poor, but affected skin gives an untidy,
unwell-groomed appearance. The scar changes are not observed.
Vulgar acne is chronically proceeding disease with the affection of sebaceous
glands. It arises up at the age of 14-16 because of inherited predisposition,
dysfunction of the hormonal system with predominance of androgenic and the lack
of oestrogenic hormones, focal infection. Clinical picture: favourite localization is
the skin of the face, chest and back. In the debut of the disease as a result of
thrombosis of mouths of hair follicles by corneal masses and skin fat comedones
appear as black spots, then painful infiltrate develops - papulous form, in future as
a result of joining of staphylococcal infection pustule is formed in the center of
nodules, drying with formation of crust or bursting (pustulous form).
A furuncle is deep staphyloderma, characterized by purulent-necrotic
inflammation of a hair follicle and surrounding tissue with self-restricted character
of process due to the granulation tissue. More frequently it is localized on the face
(nose and cheek area), neck, shoulders, thighs or buttocks. The chronic recurring
course of process for a few months or years is possible, when different furuncles
are in different stages of development and periodically appear new elements
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(furunculosis), that in the great deal is determined by weakening of immune status
(defect of hemotaxis of neutrophils, hypogammaglobulinemia, immunodeficient
state in connection with thymoma, diabetes mellitus and etc.). Quite often
furunculosis complicates different skin diseases (eczema, scabies and others.). The
furuncle is characterized by deep pustule as painful nodulose infiltrate which
diameter is 3-5 cm and more of scarlet color which in a few days will begin to
fluctuate in the central part and protrude cone-shapedly, forming at that a necrotic
core. Then the furuncle bursts with secretion of great quantity purulo-necrotic
masses, the process ends with scarring. Evolution of furuncle on the average is 2
weeks. The general state is usually not poor because of single furuncles; in the
plural furuncles and furunculosis there can be a fever, indisposition, headaches, in
blood - leukocytosis, accelerated ESR. At localization of furuncles on a head
(especially in the area of nose, cheeks) and neck the complication as meningitis,
trombornlebitis of cerebral sinuses, sepsis is possible.
A carbuncle is purulent-necrotic inflammation of several hair follicles with
formation of merged inflammatory infiltrate localized in derma and hypodermic
cellular tissue and a few purulent-necrotic bars. Size of carbuncle is considerable
larger, it achieve 5-10 cm in diameter. Affected skin is of purple-red color, hot by
touch, hipodermo-infiltrative on the vast area (for example, back surface of neck).
The general state of a patient is disturbed: fever, indisposition, acute pain in the
focus of affection, headaches. Leukocytosis, accelerated ESR is registered in blood.
In a few days in the focus of affection zones of fluctuation wil appear and
carbuncle will burst with formation of several (unlike furuncle) purulent-necrotic
bars, in the zone of which after the secretion of pus and necrotic masses ulcerous
purulent slow healing (2-4 weeks and more) surface got revealed. There is a rough
star-shaped scar on the place of carbuncle. The complications are possible:
lymphangitis, lymphadenitis, meningitis, sepsis.
Hidradenitis - purulent inflammation of apocrine sweat-glands, caused by
staphylococci, penetrating into the glands through their ducts, small traumas of the
skin, arising up quite often at shaving of axillas.
Hidradenitis is mainly observed early in life, when the apocrine glands
function especially actively. The affection is localized more frequently in the
axillas, that it is related to the basic localization of apocrine sweat-glands, rarer in
the area of genital organs and anus. The process begins from one or a few painful
solid nodulose infiltrates in the thickness of the skin and hypodermic cellular tissue
gradually increasing to 1-2 cm in diameter, joined with the skin which becomes red,
and then purple-cyanotic one. Gradually infiltrate takes a conical shape («bitch
udder»), in its center there is fluctuation (due to forming of abscess), and through
formed fistulous opening creamlike pus is discharged. The process lasts on the
average for 2 weeks, ending with scarring. Often there are relapses. The general
state of a patient changes a little, high temperature, and weakness is possible, in the
blood tests - leukocytosis, accelerated ESR. At the lowered immunity,
hypovitaminosis the process can take chronic recurring course, forming whole
conglomerates of inflammatory nodules in different stages of development.
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Epidemic impetigo of the newborn - contagious surface staphyloderma,
developing usually on 3-5 day of life of a new-born. Medical staff and women in
labor can be a source of infection. The process shows up as plural disseminated
bullous efluorescences, arising up more frequently in the 1 st week of child life.
Evolutional polymorphism of eruptions is characteristic. Simultaneously it is
possible to find out the flaccid bubbles (phlyctenas) with serous content, vesicles
with serous-purulent exudation. There are hydropic erythematose areas with
erosions on place of bursted bubbles. Eruptions more frequently are localized on
the stomach, back, large folds. On place of epithelized erosions and dried bubbles
the numerous serous-purulent crusts are located. The disease is accompanied by
high temperature of body up to 38 centigrade. There is disturbed general state of a
child (tearfulness, refusal to eat, vomiting, dyspeptic phenomena). At the
favourable course the duration of the disease is 2-4 weeks.
Impetigo is contagious disease of the skin, caused by streptococci and
staphylococci, characterized by formation of phlycten-nefollicular pustules looking
as flat bubbles with flabby cover and inflammatory aureole.
Development of impetigo is favoured by microtraumas, nonobservance of
skin hygiene, weakening of immunity. Impetigo can complicate different
dermatoses (eczema, dermatitis, scabies) accompanied with itching, especially in
children.
They distinguish streptococcal and strepto-staphylococcal (vulgar) impetigo.
Streptococcal impetigo more frequently occurs in children and young
women is characterized by appearance of flabby, easily bursting phlyctena with
thin top and dimmed content; diameter is from 2 to 10 mm. On place of bursted
phlyctena succulent bright-rosy erosions are visible; secretion of phlyctena can dry
to bright-yellow thin crusts falling off in 3-7 days, whereupon there is a fresh
epithelized pinky site of the skin or focus of temporal depigmentation. To the
varieties of streptococcal impetigo fissureus impetigo is related it is localized in the
skin folds: behind auricles, around the nose, in the corners of the mouth streptococcus perlèche; bullous impetigo is different by the largenesses of bubble,
ring-shaped impetigo - appearing at the expressed centrifugal growth of focus,
when in center skin has already become epithelized, and around phlyctenas remain;
resembling syphilis impetigo localized in area of genitals, nates and resembling
syphilitic papulae, and also surface whitlow - impetigo of back nail walls.
Strepto-staphylococcal impetigo differs by purulent yellowish thick content
of phlyctena, inclined to dry to thick yellowy-green crusts under which moist
erosive surface is revealed. Vulgar impetigo differs by specific contagiousness and
inclination to the rapid spread. Basic localization of impetigo - skin of the face,
opened areas of extremities. In the severe cases in children, the complication as
acute nephritis is possible.
Dry streptodermia is surface streptodermia, appearing as formation of rosy
peeling rounded makulas of different sizes leaving temporal depigmentation on
their place, localized on the skin of back, buttocks, extremities and especially often
on the face, where it got the name «simple lichen of the face», considered as
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atypical nonphlycten variant of streptococcus impetigo.
Boys have it more frequently at the age of 7-10 years, contagiousness is
marked. On the skin of the face (rarer in other areas) faintly pink rounded, covered
by microscaled (resembling flour) makulas (one or a few) appear gradually
achieving 3-4 cm in diameter, subjectively not disturbing a patient. Under
influence of insolation eruptions disappear, leaving temporal hypopigmentation
(pseudoleukoderma) after them.
Cellulitis - deep inflammatory affection of the skin and hypodermic cellular
tissue, characterized by erythema, edema of tissues and pain.
Manifestations of disease is characterized by diffuse acute inflammatory
erythema solid, hot and painful at palpation, with degraded edges. For cellulitis
large hydropic plaques of rounded outlines with unclear margins are characteristic.
On their surface bubbles or phlyctenas can appear. Their surface is hot by touch,
externally resembles an orange peel.
Ecthyma - deep streptococcus affection of the skin, which in the developed
state is an ulcerous defect with abruptly raising edges, purulent soft bottom and
billow of inflammatory painful infiltrate.
The skin above the focus is brightly reddened, its size achieves a few
centimetres, and margins are unclear (vulgar ecthyma). The ulcer is quite often
covered by solid purulent crust from dried purulent exudation. Sometimes this
crust is especially strongly expressed (oyster-shaped), abruptly rises above the
surrounding skin (rupee). A depth of ecthymas can be various; cases of penetrable
ecthymas, destroying soft tissues up to the bones, are known (protruding ecthyma).
In these cases, as a rule, mixed infection is found, at which, besides streptococci
(later joining) staphylococci, pseudomonous flora participate. The latter quite often
stipulates a necrotic component of process (ecthyma necrotic, synonym blazing).
The most frequent localization of ecthymas is the skin of shins, usually the
elements of ecthymas are single (no more than 10 elements are described). Rarer
ecthymas are localized on buttocks, thighs, body. The immuno-complex reactions
developing to the infectious antigens and affecting vessels of derma participate in
development of necrotic (gangrenous) ecthymas that becomes one of leading
components of pathogeny, because of that some authors consider it as angiites of
the skin. Vulgar ecthyma during 2-4 weeks is exposed to scarring. The course of
gangrenous ecthymas is more protracted.
Chronic ulcero-vegetating pyoderma is mixed strepto-staphylococcal chronic
form of deep pyoderma.
Development of the disease is increased by grave immunodeficient conditions
related to concomitant diseases, intoxications (ulcerous colitis, malignant tumours
of the inner organs, lymphomas, alcoholism, drug addiction) resulting in the deficit
of the T- and B-cellular systems of the immunity. The affections of the skin carry a
persistent ulcerous character (more frequently on the lower extremities). The ulcers
have undermined uneven edges; languidly granulating, covered by serous-purulent
solid coating (ulcerous form) or abundant extremely protruding vegetations
(ulcerous-vegetating form) their bottom with serous-purulent excretion. The skin
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around the ulcerous surfaces is inflamed; it is possible to see follicular and
nonfollicular surface pustules, here and there fusing in entire fields of affection,
covering by purulent crusts which serous-purulent exudation oozes from. The
process spreads, taking new areas of skin covering, accompanied by tenderness,
limitations of motions in extremities. Such a process is considered as skin angiitis.
Chancriform pyoderma - form of chronic mixed ulcerative pyoderma,
resembling a hard chancre of syphilis.
It is located in the area of genitals; at that ulcerous defect has a rounded shape
and hardening in its base. However unlike a hard chancre solid infiltrate lying in
base of ulcer, oversteps the limits of ulcerous defect. The researches for treponema
pallidum and serological reactions for syphilis help to distinguish chancriform
pyoderma from a hard chancre.
Medical treatment. The regime of a patient with pyoderma supposes a rational
care of skin as in the lesion focus as outside it. Diet of patients must be regular, full
value, rich in vitamins; it is desirable to limit consumption of carbohydrates, salt;
completely eliminate alcohol drinks.
External therapy. Antiseptics, their purpose: suppression of pathogenic
pyococci and other pyogenic microflora. They do antiseptic procedures - from 3 to
5 times per day.
Antiseptics are:
а) Dyes. They provide strong antiseptic effect, but remarkable for low ability to
penetrate into the skin. Side action is photosensitization. To dyes are related:
gencyanotic violet, brilliant green, fuxin basic, lactate etakridin. They are used in
impetigo, osteal folliculites, folliculites.
b) Nitrofurans. They provide bacteriostatic action not only on bacteria, but also on
fungi. One preparation is only used - furacillin (in the acute period of
streptoderma).
c) Acids. They are used for surface forms of pyoderma - 2% water solution of
benzoic acid, boric acid, 2% spirit solution of salicylic acid.
d) Oils. They possess moderate antiseptic, but sufficiently strong antiinflammatory action. They include ichthyol applied at furuncle, hidradenitis, and
deep folliculitis. They prescribe it as clear ichthyol in the form of pastilles, 5-30%
ointments, ichthyol-zinc paste and etc.
e) Aldehydes. Citral - oily liquid with lemon smell, showing sedative, antiinflammatory and antiseptic action. It is used for pyoderma in new-borns in the
form of 0, 01 % aquaspirt solution of citral, and also for mastites of nursing women.
f) Mupirocin - new antiseptic antibacterial preparation. The sensitiveness of
microflora to mupirotcin is saved at the protracted courses of medical treatment of
pyoderma. The absence of general action and good tolerance is marked. It is
appointed in the form of 2% ointment 3 times per day.
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XIII Mycoses
With the fungus infections (by mycoses) the civilization became acquainted
from the deep antiquity. The beginning of study of mycoses in medicine goes back
to the ancient epoch. White mouth was described by Hippocrates and Galen, favus
and infiltrative-purulent trichophytosis - Celsus, and modern name of
dermatornytiae (Tinea) appeared in Ancient Rome. Due to invention of microscope,
development of other sciences (botany, mycology, study about infections) allowed
to the middle of XIX century to discover germs of dermatornytiae, candidiasis,
moldy mycoses. Such people as Virhov, Gruby, Remak, Shenlein, Saburo are
closely connected with history of medical mycology establishment. On the border
of XIX-XX centuries almost all basic human mycoses and their germs were
described.
The second half of XX century was accompanied by the considerable growth
of morbidity by mycoses. Increase of migration of the population, the change of
way of life in the industrial countries resulted in spread of dermatornytiae.
Presently dermatornytiae affects 5-20% of whole adult population, mycosal
candidiasis and chromatornytosis occur quite often. Deep mycoses are also wellknown. Medical treatment by antibiotics, yatrogene immunodeficiencies after the
medical treatment of oncological diseases and transplantations, and then AIDS,
gave a chance to become as germs of deep mycoses to ordinary fungi seemed
harmless before. In the list of potential germs of mycoses there are 400 types of
fungi. Increasing significance of mycoses made to improve methods of their
diagnostics and medical treatment, used for new germs and forms of infection.
Considerable clinical experience in the study of all known mycoses is accumulated,
the criteria of diagnostics, medical treatment are developed, algorithms of
estimation of severity and prognostication of superficial and deep infections.
Presently they develop and implement more than 10 antimycotic remedies of
different classes per year, the problem of stability of germs became real at the
opportunistic infections.
Fungous skin diseases (mycoses) develop as a result of introduction into it of
pathogenic microfungi. Morbidity by mycoses takes 2 and 3 place in the structure
of whole skin morbidity, giving way to pyodermatites and dermatitis 1 and 2 place.
Classification by N.D. Sheklakov (1976). In accordance with the given
classification 4 groups of mycoses and the fifth group of pseudomycoses are
distinguished. To mycoses are related:
1. Keratomycoses (chromatomytosis, piedra, tinea imbricata).
2. Dermatomycoses (epidermophytosis, mycosis, conditioned by red
trichophyton, trichophytosis, microsporia, favus).
3. Candidiasis (surface candidiasis skin and mucous membranes, visceral
candidiasis, chronic generalized, granulematous candidiasis).
4. Deep (visceral, system) mycoses: histoplasmosis, coccidiosis,
blastomycosis, cryptococcosis, geotrichosis, chromomycosis, rinosporidiosis,
aspergillosis, penicillinosis, mucorosis.
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The surface forms (eritrazma, axillary trichomycosis) and deep forms
(actinomycosis, micromonosporosis, nocardiosis, mycetomas) are related to the
group of pseudomycoses. An inclusion in this classification of pseudomycoses is is
not well-founded and done to some degree by tradition, because eritrazma is an
infectious disease, caused by corynebacteria, and pathogenic actynomicets are,
unlike fungi, procariots and morphologically close to the propion bacteria,
mycobacteria of tuberculosis and corynebacteria. In culture and tissues of a man
they, however, have definite likeness with fungi, because form thin dendritic
mycelium.
The most suitable is classification of fungous skin diseases depending on
etiology: mycoses, conditioned dermatornytiae; mycoses, conditioned by fungi
resembling yeast and mycoses conditioned by the moldy fungi. The special group
includes deep and system mycoses which are not pathologies of the skin. Within
the etiologic classification the fungus diseases, for their turn, are subdivided into
different clinical forms mainly taking into account location of pathologic process
and features of its course.
The fungi consist of dendritic mycelium, multiply by spores, differentiated on
antropophilic, antropozooophilic and zooophilic. They grow on the artificial
environments (Saburo, glucose, blood, wort). A source of infection is a diseased
man, animal. Ways of transmission: direct and indirect contact.
Promoting factors:
- exogenous:
1. virulence of germ
2. state of the skin
3. high temperature
4. rise of pH
- endogenous:
1. presence of concomitant pathology
2. endocrine disorders
3. hypovitaminoses
4. damages of microcirculation of the skin
5. protracted therapy by antibiotics, glycocorticosteroids, cytostatics
In diagnostics of most mycoses substantial part is played by the microscopic
researches of scales, covers, vesicles, nail plates, hairs. The germ of fungus disease
succeeds to be found after clarification of corneal substance in the hot solution of
caustic alkali. For this purpose decomposed pieces of studied material is put on the
microscope slide and bring a drop of 20% solution of caustic potassium on them.
After that the slide is heated above flame of gas-ring until appearance of a drop of
white rim from the crystals of alkali on periphery. Then the preparation is covered
by coverslide and they begin to study it under a microscope. The discovery of
fungus - filaments of mycelium and spores serves as the positive results of research.
Pityriasis versicolor is characterized by the affection of only corneal
substance of epidermis, absence of inflammatory phenomena and very
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insignificant contagiousness. It is located mainly on body, predominantly on chest
and back, rarer – on neck, external surface of shoulders, sculp. Increased
perspiration is a predisposing reason of development of mycosis.
The affection of the skin begins from appearance of tiny spots having in
various patients different tints of brown colour (that’s why it is called
chromatornytosis). The spots become bigger and fuse with each other, forming
more or less large focuses with microscalloping outlines. On their surface there is
barely noticeable branny scaling, caused by loosening of corneal layer by fungi
light. At last, in the doubtful cases it is possible to expose it by scratching the spot
by nail: at that corneal masses are removed like shavings. Other method: smearing
of the spot and surrounding skin by spirit iodine solution or aniline dye. As a result
of intensive absorption of solution by the corneal layer made light the affected skin
is dyeed considerably brighter, than healthy. In diagnostics of pityriasis versicolor
of hairy part of head luminescent method means a lot: under Wood’s rays
(ultraviolet rays of quartz lamp, passed through glass, impregnated by salts of
nickel) in a black-out room spots get the reddish-yellow or brown luminescence.
The disease continues for many months and years. In sunburnt people
affections look lighter, than healthy skin (pseudoleukoderma). This is explained by
the fact that under influence of the sun they burst however through the loosened
corneal layer the skin gets insufficient dose of insolation. It is necessary to
remember, that the white spots on neck and upper parts of chest and back can turn
out manifestation of syphilis. Besides other signs one should remember in mind
that unlike syphilitic leukoderma, the light makulas of pityriasis versicolor have
different sizes and fuse with each other. In addition, in unsufficiently treated
patients one is able to reveal a «symptom of shaving» and get positive result of
iodine test, and also to discover mycelium in scales at microscopy.
The medical treatment is done by fungicide remedies in the form of solutions,
creams, ointments (Andriasyan’s liquid - urotropin, solution of vinegar acid,
glycerin; salicylic-resorcin spirit, 10% sulphuric ointment, mycosolon, treatment
by Demyanovich, batrafen, daktarin, mycospor, nizoral, pevaril, travogen, exoderil,
ultraviolet radiation).
Particular features of course of pityriasis versicolor on the background of
HIV-infection:
disease shows up as numular papulae and plaques, but not artificial
spots;
tendency to dissemination of lesion focuses;
torpidity to administered therapy.
Inguinal epidermophytosis. The infection is the result of at the use of
mutual bath, through bath sponges, linen, bedpans and oilcloth, thermometers.
Predisposing factors are increased perspiration, high temperature and high
humidity of the environment; hyperhidrosis, it occurs more frequently in men.
The lesion focuses of the disease are localized mainly in the inguinal folds.
Rarer they are observed in the axillas and under the mammary glands. The disease
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is characterized by formation of slightly peeling, distinctly outlined inflammatory
spots of pinky color, which, overgrow on periphery, fuse with each other and
having resolved in the center they form ring-shaped and garland-shaped figures
spreading outside folds. Lesion focuses can be slightly hydropic, their edges –
roller-shaped, covered by tiny vesicles and crusts. Mycosis, accompanied by the
insignificant itching, exists for many months. Inguinal epidermophytosis should be
differentiated from eritrazma – corynebacteria affection of corneal layer of the skin,
contiguous surfaces of folds - femoral-scrotum, rarer - internate, axillary, under the
mammary glands, sometimes between toes of feet. A predisposing reason is
increased perspiration. Focuses of affection are brownish distinctly outlined
makulas. As well as in pityriasis versicolor, there is loosening of corneal layer,
which is revealed either as barely noticeable branny scaling, or by scratching of
spots, or the iodine test. The disease continues infinitely long.
Medical treatment. They use batrafen, daktarin, mycospor, pevaril, travogen.
For acute inflammatory processes one should begin the medical treatment with
ointments, possessing anti-inflammatoryi and antifungous properties - travokort,
triderm, exoderil.
Epidermophytosis of the feet. Germ of epidermophytosis of the feet affects
not only the skin but also nails. The skin changes show up in 3 clinical forms squamous, intertriginous and dishydrotic.
Squamous epidermophytosis is characterized by microscaling on soles and
in folds between toes, more frequently – between 4 and 3. Sometimes there is a
fissure deep at the fold. Subjectively – slight itching. In a number of cases these
symptoms are so poorly expressed, that patients do not notice their disease (effaced,
hidden epidermophytosis).
Intertriginous epidermophytosis develops in the sole folds between toes,
quite often first signs as in squamous epidermophytosis such as hyperemia of the
skin and maceration of corneal layer manifest in 3rd and 4th folds. As a result of
tearing away of macerated epidermis erosion bordered by white collar of incresed
corneal layer is revealed. Gradually the process spreads on the sole surface of toes
and adjoining part of the sole. The patients complain about itching and pains
hampering walking.
Dishydrotic epidermophytosis is localized on soles, mainly on the arch of
feet and is characterized by eruptions of itching vesicles in size of a pea with thick
top. They can be single and plural, grouped. In course of time vesicles either dry to
crusts, or burst with formation of erosions. At their confluence the continuous
erosive focus on background hyperemia is formed, having clear scalloping outlines
and bordered by the collar of corneal layer. There are phenomena of squamous
epidermophytosis at cicatrization of focuses of affection, at exacerbation of which
dishydrotic vesicles appear again.
One should pay attention that dishydrotic epidermophytosis of the feet can
be accompanied by similar eruptions on palms, reflecting eczematization of
mycotic process (epidermophytids). Therefore in those cases, when patients
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complain about the affection of hands, it is obligatory to examine of the skin of
feet. There are no fungi in epidermophytids.
Mentioned above changes of the skin are not specific. They are observed, in
particular, in interfinger intertrigos, dermatites, toxicodermas, eczema and other
dermatoses. Besides, one should remember that untimely medical treatment of
epidermophytosis of the feet can be complicated by the pyococcal infection that
results in strengthening and spread of hyperemia, appearance of edema,
transformation of vesicles into pustules, development of lymphangiitis,
lymphadenitis, relapsing erysipelas and trombornlebitis.
Epidermophytosis is manifested by beginning of the disease from one foot,
involving of nails in the process. However these signs are not enough for
establishment of final diagnosis, therefore it must be based on data of laboratory
researches. In scales, in the macerated corneal layer and in the covers of vesicles
the dendritic filaments of mycelium are revealed.
Infection of epidermophytosis of the feet is through scales which get on the
skin of a healthy man, more frequently in bath-houses, shower rooms, gyms, and
also through group slippers, sport shoes, hospital shoes, socks, foot wraps.
Sometimes the infection is possible by the direct contact in the mutual bed.
Increased sweating of feet, their soaking, soiling, abrasions, fissures,
vascular disorders related to the protracted overheating or overcooling of feet are
predisposing reasons of infection.
Medical treatment. It is done by analogy with inguinal epidermophytosis.
Antirelapsing medical treatment has extreme significance. At complication of
epidermophytosis by pyococcal infection they appoint antibiotics - augmentin,
keyten, klacid, neutromicin, ospexin, rulid, tarivid, cyprobay. The patients with
dishydrotic epidermophytosis should be prescribed zirtek, klaritin, for
epidermophytids corticosteroid ointments are prescribed - advantan, dermatop,
elokom.
Prophylaxis of epidermophytosis. With the purpose of the reduction of
sweating of feet, playing substantial role in development of mycoses, one should
apply highly effective preparation -- borozin. Borozin also possesses antiseptic
properties, therefore it is used for the antirelapsing medical treatment after
antimycotic therapy. Periodically they fill shoes with the powder.
Rubromycosis. Rubromycosis (rubrophytosis) is the most widespread
fungus disease affecting mainly, soles and palms, and also nails. The skin of hands
and soles is rough, dry, thickened due to diffuse hyperkeratosis, quite often
developing to formation of callosities with deep painful fissures. Scaling in the
skin furrows resembling flour is very typical. The changes of the skin on feet may
look like those of squamous or dishydrotic epidermophytoses; all interfinger folds
in rubromycosis are affected. In the large folds of the skin rubromycosis manifests
similar to inguinal epidermophytosis.
In the pathological process the skin of shins, buttocks can be involved,
rarer – the stomach, back, face; sometimes it gets quite widespread character. At
that they observe eruptions of peeling erythemas, of cyanotic tint and follicular
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nodules. Important differential-diagnostic signs are: scalloping outlines of focuses,
irregularity of their margins, grouping of nodules, forming from them arched, ringshaped, garland-shaped figures on periphery of erythematous-squamous affections.
In the lanugo hair the elements of fungus, located mainly within hair, are revealed
quite often, that conditions duration of course of the disease and resistance to it in
relation to the external fungicide therapy.
Rubromycosis of hairy part of the head, upper lip, and chin sometimes
resembles sycosis. Thus, rubromycosis can simulate many dermatoses; therefore it
is very difficult to establish diagnosis. As confirmation of fungus etiology of
affection of the skin serve, as in epidermophytosis, positive results of microscopic
study, however the decision of issue about the character of mycosis quite often
requires culture of pathological material at artificial nourishing environments
(culture diagnostics). Ways and conditions of infection by rubromycosis are the
same as in epidermophytosis. Moreover, the transmission of infection through
towel, gloves and mittens is possible. The medical treatment of rubromycosis of
palms and soles is started with exfoliation of corneal masses by keratolitic
remedies. After exfoliation they take antimycotic remedies in the form of solutions,
creams, ointments - batrafen, daktarin, mycospor, pevaril, travogen, travokort,
triderm, exoderil. Medical treatment of lesion focuses not on palms and soles is
done at once by antimycotic preparations.
At the affection of lanugo hairs they appoint perorally antimycotics: nizoral,
orungal. After the medical treatment they do antirelapsing therapy, disinfection of
shoes, socks, stockings, gloves, linen.
Prophylaxis of rubromycosis is the same as for epidermophytosis.
Features of rubromycosis on the background of HIV-infection:
affection of palms and soles develops as that in keratoderma;
at involving of smooth skin eruptions are flat papulae;
- sometimes the disease proceeds as seborrheic dermatitis, MEE, rozacea;
- paronychias often develop;
- tendency to generalization of process;
- torpidity to therapy.
Trichophytosis is caused either by anthropophile fungi parasitizing only, or
zoophile, which parasitize both in a human being, and in animals (cattle, horses,
cats, dogs, mice and others).
Anthropophile trichophytons are characterized by the fact that at the affection
of hair the elements of fungus are located mainly into hair, not causing acute
inflammatory reaction of the skin. The affection caused by them is of surface
character and differs by subacute or chronic course - ringworm of the body.
Zoophile trichophytons differ by predominant location round a hair and in the
epithelium of inner hair vagina. Affection of the skin caused by them - infiltrativepurulent (deep) trichophytosis - is characterized by formation of perifollicular
inflammatory infiltrate resulting in the purulent fusion of hair follicles and
surrounding connecting tissue.
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Ringworm of the body of smooth skin is most observed in children;
characterized by formation of reddened, slightly hydropic, distinctly outlined,
branny-peeling spot, on whose background tiny vesicles, drying to crusts, are
visible. The spot possesses the peripheral growth, in course of time bursts in the
center and takes ring-shaped form. There can be a new focus within the ring that
results in formation of «ring within ring». In the case of formation of a few focuses
of trichophytosis they, fusing, get garland-shaped outlines. At the microscopic
research the filaments of mycelium and sometimes spores are revealed.
Medical treatment. External antimycotic remedies, nizoral, orungal are
appointed in the affection of lanugo hairs.
Ringworm of the sculp is characterized by formation of a few tiny rounded
baldy spots due to thinning of hairs. At scrutiny one reveals, that it is related not to
the falling out of hair, but to their breaking at different levels. Some hair are
broken on height of 2-3 mm and look like stumps of grayish color, others - in the
mouth of hair follicle and look like black dots. Skin of the area of little baldy spots
barely notedly reddened and it slightly peels. The disease begins, as a rule, in
child's age and continues for years. At that little baldy spots are slowly increased.
In the period of pubescence the focuses can independently resolve, and hair cover
is fully restored.
In adults the development of this form of trichophytosis in the area of growth
of moustaches and beard is possible. Microscopically a broken hair looks as though
filled by round and cubiform spores.
Medical treatment. It is done by general (nizoral and orungal) and external
antifungous remedies.
Chronic trichophytosis of the scalp is observed almost exceptionally in
women. As a rule, it is continuation of ringworm of the body of child's age, not
resolved in the period of pubescence. The clinical manifestations are so scanty that
remain unnoticed for decades and are revealed only at special examination of
mothers and grandmothers, done with the purpose of discovery of sources of
infection of children, as black points on background of insignificant scaling (black
dotty trichophytosis). Black dots are stumps of broken hairs in the mouths of
follicles. Quite often it is possible to notice tiny atrophy scars. For diagnostics of
this form of trichophytosis affections of smooth skin and nails occurring
simultaneously with it.
Chronic trichophytosis of smooth skin is characterized by formation of
peeling pinkish-violet spots with irregular, degraded margins. Tiny red nodules
located by groups or as ring-shaped figures can appear on their background. The
most frequent localization is shins, buttocks, forearm, and extensor surfaces of
knee and elbow joints. The disease continues for many years, because of
unnoticeable affection of lanugo hair.
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Disorders of the endocrine system, hypovitaminoses A, C, impairment of
circulation in the skin and others are predisposing causes.
Medical treatment. Nizoral, orungal, external fungicide remedies, in
endocrinopathies - proper hormones.
Chronic trichophytosis of palms and soles manifests as hyperkeratosis and
scaling. Also for the disease ring-shaped scaling and formation of bubbles are
characteristic. The clinical diagnosis is facilitated by concomitant affection of nails.
Infiltrative-purulent trichophytosis of smooth skin is characterized by
formation of the rounded, distinctly outlined inflammatory plaque of scarlet colour,
rising above the level of the skin. On its surface plural pustules, drying to purulent
crusts are visible. The plaque is gradually increased, however in a few weeks its
peripheral growth stops and there will be spontaneous resolution. On place of
former lesion focus pigmentation and sometimes small dotty scars remain.
Infiltrative-purulent trichophytosis of the scalp is painful, solid, distinctly
limited, tumular rising inflammatory infiltrate of semispherical or uneven form, on
the surface of which they reveal pustules and broken hair. At the microscopic
research of the affected hair one sees a row of round spores located longitudinally
around hair. In course of time infiltrate grows soft and is covered by the purulenthemorrhagic crusts. After their removing tiny follicular openings are revealed,
resembling honeycombs by sight (hence an ancient name of the disease - «kerion»).
At squeezing of infiltrate from the opening, as through sieve, a drop of pus is
excreted. The affected hair are torn away along with crusts and pus.
As a result of peripheral growth the lesion focus can attain pretty large sizes
(6-8 cm in diameter). Quite often it is accompanied by painful regional
lymphadenitis, rise of temperature of body, indisposition. The germs of deep
trichophytosis (zoophile trichophytons) cause development of immunity, therefore
in 2-3 months there will be its spontaneous resolution after forming of infiltrate.
Infiltrative-purulent trichophytosis of the area of beard and moustaches
(parasitic sycosis) is not different from the previous form. Differential diagnostics
of staphylococcal (vulgar) sycosis and parasitic sycosis is based on such signs of
the latter one, as cancer of the infiltrate, its distinct margins, deeper purulent fusion,
inclination for the spontaneous resolution, and absence of relapses. In the doubtful
cases the diagnosis is confirmed by the laboratory study of hair and pus. Pus is
examined under microscope in a drop of glycerin.
Medical treatment. After tearing of pus away - fungicide ointments.
Trichophytids. One should remember that untimely application of ointments,
before subsiding of acute inflammatory phenomena and complete excretion of pus,
results in penetration of fungi or products of their disintegration into the blood and
thus conditions development of the secondary rashes - trichophytids. They
represented by tiny follicular papules, diffuse erythemas, rarer by nodes and, as a
rule, are accompanied by feeling of weariness, the rise of temperature of body,
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sometimes by arthralgias, by leukocytosis. Erythematous trichophytids burst in a
few weeks, papular and nodulose - in 1-2 weeks. One fails to discover the fungi in
them.
Microsporia is caused by the antropophile fungi parasitizing only in a human
being, or zoophile, parasitizing both in people, and in animals (most frequently in
cats and dogs). Those and other microspora form around hair cover out of tiny
spores which unlike the germ of infiltrative-inflammatory trichophytosis located
not in a row, but chaotically (mosaicly). Children mainly have it; in the period of
pubescence the disease usually is spontaneously resolved. Microsporia is, as a rule,
superficial one. The infiltrative-purulent form and affection of nails is observed
extremely rarely.
Microsporia of the smooth skin is practically similar to ringworm of the body.
Microsporia of the scalp manifests dually. In those cases, when a germ is the
zoophile fungus, there is 1-2 large rounded or oval, distinctly outlined lesion
focuses, within them all hair are broken at the same height (5-8 mm.) and look,
therefore as though they were cut. The broken hair have a white color due to
coupling of spores, are easily pulled out. At that the skin is thickly covered by
flour-like scales. Microsporia, caused by the antropophile fungus, resembles
ringworm of the scalp a lot, the only difference is that the hair are broken (not all!)
higher and have a white color. Greenish luminescence of the affected hair by
microsporum in Wood’s rays is of great differential-diagnostic meaning. It is
necessary to use widely this luminescent method for inspection of children having
a contact with a patient with microsporia, and also cats and dogs suspected to be
infected. The inspection is done in the black-out room.
Medical treatment. They use solutions, creams and ointments of batrafen,
daktarin, microspor, nizoral, pevaril, travogen, travokort, exoderil, at involving of
hair - nizoral, orungal in pills.
Onychomycoses are fungus affections of nails observed in patients with
epidermophytosis of the feet, rubromycosis (on feet and hands), chronic
trichophytosis and favus (mainly on hands), extremely rarely - in microsporia.
Presently rubromycosis and epidermophytosis of nails have the most practical
meaning. Onychomycosis begins from free or lateral edge of a nail plate. In its
thickness rounded and stripe-shaped spots of yellowish, rarer - greyish-white color
appear which gradually fuse with each other; subnail hyperkeratosis develops, the
nail is thickened, loosened, becomes fragile and crumbles. The process of
destruction, slowly spreading, can seize the whole nail. At the same time in
rubromycosis of the nails of hands nail plates, remaining smooth and shiny, can
become thin or exfoliate from nail bed; exfoliated part gets a dirty-grey color.
Onychomycosis can be isolated, that is without the affection of the skin and
hair. At the microscopic research of pieces of the affected nails one finds mainly
filaments of the mycelium.
The medical treatment of the nail plates affected by fungi has large
difficulties. Experience shows, that at involving in the process of good number of
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nail plates, at their total affection traditional external therapy is practically
ineffective. In these cases prescription of tabletted antimycotic preparations is
recommended, in particular lamizil, nizoral, orungal. At involving of some nail
plates, their partial affection one should administer the medical treatment by
antimycotics in the form of varnish - batrafen, luceril or by the cream of mycospor
in the set for nails. In the entire affection of nail plate it is necessary to combine
general and external local therapy.
Superficial candidiasis
Candidiasis - disease of the skin, mucous membranes and internal organs,
caused by yeast-like fungi of genus Candida. The affections of the skin, visible
mucosas and nails are related to superficial candidiasis. The provoking factor in
development of candidiasis is quite often protracted application of antibiotics and
glycocorticosteroids.
Mycosal candidiasis («white mouth») is observed most often in the mouth
cavity, rarer - in vagina (mycotic vulvovaginitis). The process begins from
appearance on background of hyperemia of white crumb-like patch resembling
farina. Then there is a film, which firstly can be easily removed, but after becomes
solid, gets a dirty-gray color and firmly holds out on surface of the mucosa (after
its removal there is bleeding erosion).
White mouth is often observed in new-borns. Vulvovaginitis is accompanied
by the painful pruritus and crumb-like vaginal discharge. Yeast-like fungi can be
transmitted by the sexual way. Candidiasis balanoposthitis is characterized by
maceration of limited areas of head of penis and internal layer of prepuce with the
subsequent formation of erosions. In development of balanoposthitis and
vulvovaginitis diabetes mellitus plays a great part: sugar discharged with urine is
good nutrient medium for yeast-like fungi.
Mycotic perlèche is observed most frequently in people accustomed to lick
their lips or sleep with opened mouth, which saliva moistening corners of the
mouth flows out. The lesion focus is erosion surrounded by the collar of swollen
corneal layer. There is a fissure at depth of the fold. Honey-yellow crusts appearing
round the streptococcal erosion, in yeast affection are absent. The insignificant
infiltration, that can simulate one of the forms of papulo-erosive syphilid, develops
at protected existence of mycotic perlèche.
Medical treatment. Rinse by 5% solution of household soda, pills of
dekamin put behind cheeks every 2 hours, solutions, creams and ointments of
batrafen, daktarin, mycospor, nizoral, pevaril, klotrimazol, travogen, travokort,
triderm, exoderil. In vulvovaginites they use syringing by furacillin, klotrimazol vaginal pills, gino-daktarin, gino-pevaril 50, ginopevaril 150, gino-travogen,
nizoral as suppoitories. In the persistent cases they appoint nizoral, orungal orally.
Intertrigenous candidiasis (yeast intertrigo) by clinical picture, pathogeny
and methods of medical treatment practically does not differ from intertrigenous
streptodermia. For yeast affections there is very characteristic interfinger erosion,
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developing usually between 3 and 4 fingers of hands in housewifes dealing with
vegetables and fruits, in workers of pastry, fruit and vegetable and similar
productions. In interfinger fold and on adjoining lateral surfaces of fingers there is
maceration and tearing of corneal layer away, as a result of it erosion of cherry-red
color, bordered by white collar of swollen horn, appears.
The medical treatment is administered by principles of therapy of superficial
candidiasis.
Candidiasis (mycotic) paronychias and onychias. Infection by yeast-like
fungi is the result of, as a rule, of the same conditions, as in interfinger erosion.
The process begins from the back nail wall, passes to lateral, and then spreads on
the nail plate. The walls become hydropic, scarlet, acutely painful. Quite often
from beneath the back wall it is possible to squeeze out a drop of pus. Adjoining
part of nail plate becomes cloudy and is painted, forming a socket.
Medical treatment. They use anticandidiasis antibiotics - nistatin,
amfotericin, nizoral. They appoint batrafen, daktarin, mycospor, nizoral, pevaril,
travogen, travokort, triderm, exoderil, quite often - lamizil, nizoral, orungal orally.
Features of course of superficial candidiasis on background of HIVinfection:
- primary affection of mucosa of oral cavity, genitals, perianal area,
involving of oesophagus is possible;
- propensity to fusion of focuses with their subsequent ulceration;
- torpidity to therapy;
- development of candidiasis in young men whose history has no
information they take antibiotics, hormones, cytostatics.
XIV Dermatites
Dermatites are inflammatory reactions of the skin in response to influence
of irritants of external environment. Contact dermatites arise up under direct
influence of external factors on the skin, unlike toxicodermas, which arise up after
penetration into the inner medium of the organism.
Etiology. The irritants conditioning dermatitis can have physical, biological
or chemical nature:
1. obligated irritants cause simple (artificial) dermatitis in everybody. Friction,
pressure, radiation and temperature influences, acids, alkalis, some plants are
related to them (nettle, fraxinella, caustic buttercup, spurge);
2. optional irritants cause inflammation of the skin in people having increased
sensitiveness to them: allergic (sensitized) dermatitis appears.
The quantity of optional irritants (sensibilzators) is enormously and
continuously increased. The most important are is salts of chrome, nickel, cobalt,
formalin, turpentine, polymers, medicines, washing powders, cosmetic remedies,
and insecticides, some plants (aloe, tobacco, geranium, and garlic).
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Pathogeny of simple dermatitis: develops after the direct damage of tissues
of the skin. Therefore the clinical manifestations and course are determined by
force (by concentration), duration of influence and nature of irritant. The affection
of the skin arises up immediately or soon after the first contact with irritant, and
the area of affection strictly corresponds to the area of this contact.
Pathogeny of allergic dermatitis: first of all it is monovalent sensitization of
the skin. Sensibilizators, causing allergic dermatites, are usually haptens
(incomplete allergens). Uniting with the albumens of the skin, they form
conjugates, possessing properties of complete allergens, under influencing of
which lymphocytes are stimulated, that conditions development of sensitized
dermatitis as an allergic reaction of slow type. The role in the mechanism of
sensitization is played by the individual features of the organism: state of the
nervous system (including vegetative), genetic predisposition, previously had and
concomitant diseases (mycoses of feet), state of aqua-lipid mantle of the skin,
functions of sebaceous and sweat glands. Monovalent sensitization determines the
features of clinic and course of allergic dermatitis:
1.
distinct specificity: dermatitis develops under influence of strictly
definite irritant;
2.
presence of the hidden period between the first contact with irritant and
appearance of dermatitis (from 5 days up to 4 weeks);
3.
unusually intensive inflammatory reaction of the skin, inadequate to
concentration of irritant and period of its influence;
4.
amplitude of the affection going beyond the limits of the area of influence
of irritant.
Clinical picture of simple dermatitis. They distinguish three stages of acute
dermatitis:
1. erythematous - hyperemia and swelling of a different degree of expression;
2. vesiculous or bullous - on erythematous-hydropic background vesicles and
bubbles drying to crusts or bursting with formation of weeping erosions;
3. necrotic - disintegration of tissues with formation of ulcerations and
subsequent scarring.
Acute dermatites are accompanied by itching, burning or pain.
Chronic dermatites, whose cause is protracted influence of weak irritants,
are characterized by the stagnant hyperemia, infiltration, lichenification, fissures,
increased cornification, sometimes by atrophy of the skin.
Abrasion is the most frequent variety of acute dermatitis, arising up usually
on palms, especially in people not having habit of manual labour, and on feet while
walking in uncomfortable shoes. Clinic: distinctly outlined hypodermic hyperemia
on background of which under proceeding influence of irritating factor there are
large bubbles - «aquatic callosities».
Callosity - chronic form of mechanical dermatitis - develops because of the
protracted and systematic pressure and friction on hands at implementation of hand
operations, on feet - at wearing of tight shoes.
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Solar dermatites clinically proceed according to the erythematous or vesiclobullous type, differ by the presence of short (up to several hours) hidden period,
amplitude of affection and outcome in pigmentation (sunburn); general phenomena
are possible. Similar changes can give and sources of artificial ultraviolet radiation.
Chronic dermatitis develops as a result of the protracted insolation.
Radiation dermatites proceed similarly regardless of type of ionizing
radiation.
Acute radiation dermatitis appearing because of single radiation, rarer in the
radiotherapy (radioepidermitis), can be erythematous, vesiclobullous or necrotic,
that depends on the dose of radiation. The shorter hidden period, the severer
dermatitis proceeds. Ulcers differ by the torpid course (for many months, even
years) and excruciating pain. The general phenomena with the changes of
composition of blood are marked. Chronic radiation dermatitis develops as a result
of the protracted influence of ionizing radiation in small, but exceeding maximum
doses: dry, atrophic skin is covered by scales, teleangiectases, depigmentated and
hyperpigmentated spots, hyperkeratoses, trophic ulcers inclined to malignization.
Acute dermatitis caused by acids and alkalis courses by the type of chemical
burn: erythematous, vesiclobullous or necrotic. Weak solutions under protracted
influence cause chronic dermatitis as infiltration and lichenifications different by
degree of expression.
The diagnosis of simple dermatitis is established: distinct connection with
influence of irritant, rapid appearance after the contact with it, sharp boundaries of
affection, rapid involution after the removal of irritant.
The clinical picture of allergic dermatitis is characterized by the bright
erythema with the distinctly expressed edema. There may be numerous vesicles
and bubbles causing weeping erosions on this background. In subsiding of
inflammation the crusts and scales are formed, after their falling off the cyanoticpinky spots remain for some time. The allergic tests are used for confirmation of
diagnosis.
Medical treatment. Removal of irritant. At the erythematous stage indifferent powders and water-shaken up meals. Bubbles, especially in abrasions,
should be opened and processed by the aniline dyes. At the vesiclobullous stage cold lotions. For all forms and stages, except for ulcerous, corticosteroid ointments
are indicated, in the pyococcal complications - with disinfectant components. In
the chemical burns the first aid - immediate abundant and long washing off by
water. The medical treatment of ulcero-necrotic affections is done in the conditions
of clinic.
Prophylaxis. Minding of accident prevention at production and in private
life; timely sanation of focal infection and mycoses of the feet; application of
antibiotics and sensitizating remedies strictly according to indication taking into
account their tolerance in the past.
The prognosis is usually favourable, except for necrotic dermatitis of
chemical and, especially radiation etiology.
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XV Professional diseases of the skin
Professional diseases of the skin – group of dermatoses, conditioned by
action of industrial irritants to the skin.
Professional stigma is a change of the skin, which can develop in the group
of workers of the same profession. Industrial irritants: chemical - 95 %, physical,
bacterial, parasitic, vegetable.
Pathogeny. A number of compounds (salts of chrome, zinc, cobalt, copper),
penetrating into the skin, form the complexes with albumens, to these AG AB are
produced, AG-AB complexes appear, an allergic reaction appears.
Development of sensitization is promoted by:
1. presence of purulent focal infection;
2. presence of mycotic infection;
3. damage of CNS functions.
Classification of professional dermatoses:
Professional dermatoses because of the influence of chemical irritants:
1. because of influence of obligate irritants:
- epidermitites
- contact dermatites
- chemical burns
- ulcerations of the skin and mucosas
- onychias and paronychias
1. allergic professional dermatoses:
- contact allergic dermatitis
- eczema
- toxidermia
- hives
2. oily folliculites:
- toxic melanodermia
- hyperkeratoses
- photodermatoses
3. dermatokonioses
Professional dermatoses under the influence of physical irritants:
1. under the influence of mechanical factors:
- callosity
- mechanical dermatitis
- traumatic damages
2. under the influence of thermal factors:
- chilblains
- frostbite
- burns
3. under the influence of radiation factors:
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- solar dermatitis
- radiation burns
- radiation dermatites
4. electrotrauma;
Infectious and parasitic etiology:
1. bacillary damages
- erysipeloid
- anthrax
2. viral:
- nodules of milkers
3. dermatozoonoses
4. mycoses
Epidermites - develop after the contacts with fat-soluble substances,
because of insufficient secretion of skin fat. Objectively: erythema, surface fissures,
scaling, dryness of the skin. Subjectively: sense of dryness, sometimes slight
itching. Medical treatment: nourishing creams, ointments. Prophylaxis: application
of individual means of protection, protective creams, ointments.
Simple contact dermatitis can appear as erythema or on background of
erythema there can be bullous and pustulous elements. The medical treatment
depends on stage: erythema is treated by zinc paste with 5% of naftalan; bullous
elements are treated by lotions. In the limited forms temporal loss of ability to
work is 8-10 days, in widespread – 2-3 weeks.
Ulcerations – causes: influence of acids, alkalis, salts of chrome, copper,
nitrates, nitrites. On background of erythema ulcers with roller-like obtrusive edges
appear, and the center is covered by the crimson crust.
Onychias and paronychias - arise up as a result of contact with formalin,
alkalis, chloride of lime, compounds of arsenic. Traumas, impairment of integrity
of the skin, nail wall promote it. A nail plate loses brilliance and transparency,
crumbles; subnail hyperkeratosis, complete destruction of a nail plate sometimes
develops. The nail wall swells up, sense of pain and burning appears.
Chemical burns - can show up as erythema, erosion, affection of all layers
of the skin. Temporal loss of ability to work: 4 days, up to 12 days, up to 12
months.
Professional eczema - is localized on open areas of the body, proceeds more
benignly, there is considerable improvement during vacation. Temporal loss of
ability to work is up to 30 days. Medical treatment is in clinic, move to new
production.
Oily folliculites and acne: appear as a result of contact with mineral oils.
Localization: in the places of contact. The black points in the mouths of follicles
appear, then papulous elements of cyanotic-red color are formed. Their formation
is conditioned by increased keratinization in the area of follicle. After resolution –
surface scars. In the widespread process - hospitalization is up to 2 weeks.
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Photodermatitis: 1st stage - erythema, itching, paresthesias; 2nd stage - on
background of hypodermic erythema bubbles with transparent contents appear.
Medical treatment: photodesensitization, antihistamine preparations.
Toxic melanodermia - develops as a result of contact with the products of
processing of petroleum, coal. It is characterized by erythema on the skin of the
face, neck, breast. On background of erythema - reticulated asp-grey pigmentation.
In the affections of the liver teleangiectases appear.
Dermatokonioses are conditioned by penetration of dust into sweat-glands
and hair follicles, the papulous elements are formed, burning, pain, itching appears.
Prophylaxis: improvement of production, protective creams and ointments.
Callosity - on place of contact there is focal hyperkeratosis.
Mechanical dermatitis - for erythema they use zinc paste with naftalan; if
there are bubbles with transparent liquid, they are opened, they also use lotions.
Chilblain arises up because of the protracted work at temperature about zero,
because of work with quickly evaporating liquids. On face, auricles cyanotic
formations of doughlike consistency appear, then on their place teleangiectases
appear - long unhealing ulcers. The damage of circulation of blood lies in basis.
Solar dermatitis. There is erythema, bubbles; burns of 3rd degree are
possible. Temporal loss of ability to work is about 2-3 days.
Acute radiation dermatitis passes the following stages:
1. erythematous - at dose of 400-800 r. Hidden period is 12-14 days.
There is hypodermic erythema accompanied by pain and burning. On place of
erythema - pigmentation, slight erythema, after depigmentation, papilomatous
excrescences;
2. bullous - at 800-1200 r. Hidden period is 10 days. On background of
hypodermic acute erythema bubbles with hemorrhagic content appear. Long
unhealing erosions appear after opening - pigmented and depigmented spots;
3. at dose more than 1200 r. there is disturbance of general state, severe
headache, deep and slowly scarring ulcers appear. Hidden period is 3-5 days.
Chronic radiation dermatitis - at the protracted influence of small doses of
radiation in roentgenologists, radiologists. The skin becomes thin, pinkish, dry and
it is easily injured; gets spotted coloring, chronic ulcers can develop. Medical
treatment is an oil of sea-buckthorn and wild rose, general improving health
therapy; remedies improving trophicity. In ulcers - surgical medical treatment.
Diagnostics of professional dermatoses is based on:
1. analysis of industrial irritants, similar cases with other workers, changes
during vacation, diseases of the skin before one started to work;
2. doing of skin tests with supposed irritants or allergens.
Prophylaxis of professional dermatoses: includes strict and complete
registration of all diseases of the skin, careful analysis of morbidity, processing of
places of traumas, preliminary and periodic examinations of workers, sanitaryeducational activity, improvement of production, providing of working with
cleansers, overalls, protective pastes, ointments. To establish diagnosis of acute
professional disease, the case must be investigated during 24 hours, if it is chronic
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one - for a week. Diseases intensified under the influence of professional
insalubrities are not professional (production conditioned).
XVI Lichen planus
Lichen planus is a type of reaction of the organism of indistinct origin with
papular eruptions and protracted course. Probably, this is multifactor dermatosis. In
development of dermatosis there are quite a bit proofs of meaning of damages of
the nervous system (psychotraumas, stress situations), infection (more often viral
one), immune disturbances, and also as a result of the protracted taking of many
medications - toxic-allergic reactions (antimalarial preparations, bismuth, penicillin,
hipotiazid and others) and arising up at the contact with photo reagents. There is an
assumption about existence of predisposition to this disease. There are data about
the meaning of dysfunctions of the liver and carbohydrate metabolism in
development of the disease. From observation of A.A. Kalamkaryan and coauthors (1983), the majority of patients observed by them connect development of
the disease with psychical traumas, considerably rarer it developed after the
protracted taking of medications, contact with photo reagents, because of quinsy,
flu. It occurs in any age.
The clinical picture is characterized by the monomorphous tiny (diameter 25 mm), polygonal papules of reddish-violet color with flat shining surface (waxlike shining which is more distinct at lateral illumination) and nivel-shaped
indentation in center. Scaling usually insignificant, scales are separated difficultly,
sometimes, however, scaling can resemble psoriatic one. Localization: in most
cases the rash is located separately, symmetric on the flexor surfaces of extremities,
stomach, small of the back, body, genital organs, quite often - on the mucous
membrane of oral cavity and is accompanied by severe itching. Palms, soles and
face are rarely affected. There may also be one-sided affection of the skin. The
papules can fuse with formation of small plaque with shagreen-shaped surface - by
the type of «cobbles». On the surface of larger nodules, especially after smearing
by vegetable oil or water, it is possible to discover whitish netlike pattern
(Wickham’s net symptom). Sometimes the papules form ring-shaped figures.
Round plaque there can be new papules located more or less densely. The quantity
of eruptions is different: from single (in the oral cavity, on the genital organs) to
plural covering considerable areas of the body, so that can be given the impression
of total affection of the skin, sometimes by the type of erythrodermia. On place of
resolving papules often there is stable pigmentation. For lichen planus during the
period of intensification the positive Köbner ’ s phenomenon is characteristic appearance of new nodules on place of traumatization of the skin. Quite often there
are changes of nails, especially in those cases, when there are plural eruptions, but
this is not the rule. In some patients the change of nails precedes eruptions on the
skin and even can be the only manifestation of dermatosis.
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Differential diagnostics is done with papular syphilid, toxidermia, diffuse or
limited neurodermitis, psoriasis, lichen parapsoriasis.
Clinical varieties:
- lichen planus annularis. Papules, fusing, form small rings and arcs;
- lichen planus verrucosus. Favourite localization is front surfaces of shins,
rear of foot;
- zosteriform lichen planus. The typical elements are located along the nerve;
this variety resembles zoster by localization.
An affection of mucous membranes (cavity of mouth, genitals) can be
isolated or combined with the affection of the skin. On the inner surface of cheeks,
red border of lips, lateral surfaces of tongue, on vulva or the head of penis there are
tiny shining whitish papules formating a «picture of fern» or net. Other varieties
of lichen planus on the mucous membranes are possible too:
- exudative-reddened: differs by the location of papules on the hydropic
reddened (exudative) background;
- erosive-ulcerous. It is accompanied by formation of erosions or tiny ulcers
surrounded by papules (quite often it develops in patients with diabetes
mellitus and hypertension).
The disease is characterized by the chronic relapsing course. It is diagnosed
on the basis of characteristic type of papules, presence of Wickham’s net, typical
localization, marked itching.
Medical treatment:
1.
discovery and removal of medicinal preparations and chemical
substances causing a pathological reaction of the organism;
2.
careful inspection of patients for the exposure in them of inner
diseases: GIT research, blood sugar levels, nervous-mental status, sanation
of oral cavity;
3.
in all forms they appoint antihistamine, sedative preparations
(fenazepam during 10 days, vitamins C, A, B groups, preparations of
calcium);
4.
in severe cases - antibiotics of wide spectrum, antimalarial
preparations - delagil 0,25 g 3 times per day during 5 days, then break for 3
days, 4-5 courses in all; system course of corticosteroids can be useful;
5.
externally – shaken-up mixture (oxide of zinc, talc, starch 10 g,
glycerin 20 ml, distilled water about 100 ml) corticosteroid ointments (better
under the occlusive bandage);
6.
physical therapy methods and hypnosis: electro-sleep (it is possible
in combination with diathermy of adrenals), diadynamic currents
paravertebrally.
Duration of stationary medical treatment - depending on severity of the
course – up to 30-40 days.
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XVII Herpes iris
Herpes iris is an inflammatory disease of the skin and mucous membrane,
for which the acute beginning and polymorphism of elements of affection is
characteristic (macules, papules, blisters, vesicles, bubbles).
Herpes iris is known as independent disease already for more than 100 years,
since 1860 when Hebra described its clinical picture. The latter included a presence
of typical erythematous, erythematous-bullous and papular elements growing
eccentrically («target», «iris», «bull’s eye»), predominant localization on the
extensor surfaces of extremities and body, seasonality and idiopathy. After they
began to call this way all clinically similar rashes arising up after application of
different medicines and previously had infections, the classification of herpes iris
was introduced. It started to be divided into idiopathic (Hebra ’ s type) and
symptomatic type, the latter includes infectious-allergic and toxic-allergic forms.
Forms of exudative erythema:
- Infectious-allergic (idiopathic). In this form the focuses of chronic
infection as tonsillitis, carious teeth are revealed in the considerable part of patients,
granulemi, parodontosis. They also suppose viral nature of this disease. The
recurring course of the disease (intensifications in the spring and autumn periods),
observed approximately in 50% of patients, is characteristic. The disease can
proceed for many years. It occurs more often in males of young and middle age.
- Toxico-allergic (symptomatic). The symptomatic form of herpes iris has
allergic genesis and is related to development of allergic reaction, mainly, to the
medicinal preparations (antibiotics, sulfonamide preparations, barbiturates,
antipyrine, amidopyrine, serums, vaccines and others).
Pathogeny: basic mechanism of pathogeny – 3rd type of allergic reaction –
Artus’s reaction. From position of allergology herpes iris - mixed reaction with
the features of hypersensetiveness of both immediate and slow type. Basic
elements of affection – subepithelial bubble (as a result of thrombosis of capillaries
of submucous layer, necrosis, exudation), and also multiform erythema - enantema.
Background of herpes iris - atopy, expressed in the rise of general Ig E; persistence
of chronic infection in the organism; Ig A decline, one of representatives of the
«first line of defence» of the skin and in the greater degree of mucous membranes.
As impact to the relapse of herpes iris can often be stress or overstrain.
Clinical picture: it is characterized by the acute onset of the disease. In the
case of idiopathic (infectious-allergic) herpes iris the disease can begin from the
prodromal phenomena (pains in throat, muscles, reumatoid pains, subfebrile
temperature, sometimes up to 38-40 centigrade, indisposition), which develop on
background of overcooling, acute respiratory disease, quinsy, more frequently in
the period of bloom or in the regressive stage of the disease. The symptomatic
(toxico-allergic) form develops after taking of medicinal preparations or injection
of serums and vaccines. In future in the clinical picture of these two forms there
are practically no distinctions.
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A primary morphological element of rash is inflammatory spots (or hydropic
papules) with sharp limits, rounded form, diameter 3-15 mm., pink-red or scarlet
color (usually with cyanotic border), different by the centrifugal growth and with
falling back of their central part, as a result ring-shaped elements arise. A roller
appears on the edge of eruptions, and the center of element, gradually falling back,
gets cyanotic tint. The spots are inclined to fusion and formation of figures with
polycyclic outlines (garlands, arcs and etc.). Quite often along with the
inflammatory spots (hydropic papules) blisters appear separately, rarer vesicles and
bubbles (bullous form). The first flare-up will be over in 4-10 days, however as a
result of the repeated eruptions the disease can proceeds for 2-5 weeks, rarely – for
2 months. Every element exists during 7-8, sometimes 12 days.
They also distinguish spotted, papular, spotted-papular, vesiculous, bullous
and vesicobullous varieties of the disease. Predominant localization: the face,
mucosas, body, extensor surface of extremities, backs of hands, feet, palm, sole
rarely - hairy part of the head. The location of rash is always symmetric. In
addition, eruptions can arise up on genitals, conjunctiva, and also in the folds of the
skin, where they turn into weeping erosions covered by bloody or purulent crusts.
Quite often, usually in erythematous-bullous form, in process the mucous
membranes and red border of lips are involved. The mucous membrane of the oral
cavity is affected in 59 % of patients, in 5 % of patients there is an isolated
affection of mucous membrane of cavity of mouth, appearing as formation of large
bubbles on the reddened background. Erosions remaining after their opening are
covered by fur of original slightly brownish color – white coffee colour. The
bubbles on the red border of lips dry to bloody crusts.
The name «multiform» is justified by the fact that patients may have various
number of macules, pustules, bubbles, rarer there are elements by the type of
«palpated purpura» in the case of monomorphous vesicular rash, in default of or
small quantity of typical «targets», the diagnosis of herpes iris can cause
difficulties. In spite of variety of color «palette» of elements in different patients
almost always there is pink or violet tint probably related to predominance of
lymphocytes. Nikolskiy’s symptom is negative. The regional lymph nodules are
tender, enlarged. The resolution of eruptions will be in 2-3 weeks.
The course of herpes iris is acute; there is propensity to relapsing with this or
that frequency. Rarely relapsing forms are self-limited or treated minimally.
Features of clinical presentation of toxic-allergic form of herpes iris is
characterized by brighter hyperemia, tendency to fusion of focuses, frequent
affection of mucosas including genitals, more expressed epidermolytic component
(bubbles), isomorphous reaction.
Infectious-allergic form of herpes iris more frequently shows up as small
elements, more «stagnant tint, not having a tendency to fusion, drawn toward
localization on extremities and rarer affecting mucosas. This form occurs more
frequently and creates much more therapeutic difficulties. A lot of bacterial and
viral agents which provoke development of herpes iris are known. As a rule, this is
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germs which form in the organism a focus of chronic persistence with periodic
intensifications that promotes sensitization to infecting substance.
It turned out that quite lot of medicines can cause toxic-allergic form, but
they also discovered a great deal of infectious agents playing etiologic part in
development of herpes iris. There were reports about development of herpes iris
after one previously had flu, paragrippe, infectious mononucleosis, nodules of
milkers (doiltchits). As the cause of development of dermatosis can also be
mycoplasmas, chlamydias, yersinias, streptococci, staphylococci and etc. The virus
of simple herpes (VSH) is one of the most common causes of appearance of
infectious-allergic form of herpes iris, according to some authors’ information
about 50% cases of this form have herpes-viral nature. The development of
relapses of herpes iris because of these or those definite reasons is necessarily
reflected on the clinical picture of dermatosis. The development of toxic-allergic
form excludes because of clear reasons factor of seasonality, and thorough history
taking can reveal «guilty preparation». Position of toxic-allergic form of herpes iris
is relatively small. Out of 100 patients with herpes iris, inspected and treated by
A.L. Mashkilleyson and A.M. Alihanov, only in 7 people there were data about
taking of medications and serums at their history, in particular in 3 - tetracycline.
In all 7 cases the process developed directly after application of preparation, and
the clinical presentation included the affection of cavity of mouth: appearance on
unchanged skin or on background of hyperemia and edema of more often not
numerous bubbles with subsequent forming of slowly healing erosions. Maybe,
predominant localization in the cavity of mouth conditions low percent of the
discovery of this form of the disease, because it promotes establishing of other
diagnosis, for example, toxicoderma. The prophylaxis of intensifications of these
forms includes prohibition to use «guilty» preparation and ones similar to it by
chemical structure. Infectious-allergic form of herpes iris occurs far more
frequently and is treated with difficulty. This is conditioned by the features of
immunogenesis of every particular germ and the necessity of suppression of its
reproduction along with stopping of manifestations of herpes iris itself. Standard
approach to the medical treatment of infectious-allergic form includes application
simultaneously of antibiotics and glycocorticosteroids or hyposensitizating
preparations of other action, for example antihistamine ones. However such
approach not always guarantees success, especially at persistence of infectious
agent in the host organism that in the greater degree related to therapy of virusinducted forms of herpes iris. This is conditioned by the fact that in often relapsing
forms of dermatosis repeated prophylaxis but not arresting of concrete
intensification becomes the main goal. The presence of skin manifestations of
simple herpes for a few hours or days before development of relapse of herpes iris
allows establishing diagnosis of herpes-associated multiform erythema (HAME)
and concentrating efforts on suppression of reproduction of virus etiologically, by
taking of synthetic nucleosides (aciclovir, zoviraks, valtreks, famvir) with the
subsequent transition to immunemodulation (if it is necessary). The influence on
the immune system should be done after evaluation of immune status of a patient –
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based on evidences. It can include application of vaccine or different immune
stimulators, the choice of which is huge.
Histologically in spotted-papular form of the disease that observe spongiosis,
intracellular edema in epidermis, edema of papillar layer of derma and infiltrate
near vessels consisting mainly of lymphocytes and small quantity of
segmentnuclear neutrophils, sometimes eosinophiles. There can be multicameral
intraepidermal and subepidermal bubbles, accompanied by necrobiotic changes,
penetration of infiltrate into epidermis, development of necrosis, all that allows
differentiating this disease from toxic epidermal necrolisis (Layell’s syndrome).
Cytological research: clinical picture of acute unspecific inflammation.
Diagnostics of typical herpes iris does not represent any difficulties. It is based on
the acute onset of the disease (more frequently on background of acute respiratory
disease at idiopathic form or after taking of medicinal preparations at symptomatic
form), symmetry of eruptions with preferred localization on the extensor surfaces
of extremities, with involving in the process of mucous membrane of the mouth,
including lips. They also take into account presence of characteristic primary
elements as inflammatory spots (hydropic papules) of scarlet colour with the
centrifugal growth; ring-shaped elements with falling back central part of cyanotic
tint and peripheral roller are formed as a result. At the height of the disease the
polymorphism of rash is usually marked (maculas, papules, blisters, rarer vesicles,
bubbles). For diagnostics of symptomatic herpes iris it is possible to use
immunological tests (Shelly, blastransformation of lymphocytes and etc.).
Differential diagnostics:
- pemphigus (positive Nikolskiy’s symptom, acantholysis of cells, acute
initial period);
- pemphigoid (less acute course, there is no general symptomatics, large
number of eosinophiles in vesicular liquid);
- secondary syphilis (hyperemia as a rim, treponemas pallidum);
- lichen planus;
- Düring’s disease (large number of eosinophiles in vesicular liquid).
Herpes iris should be distinguished too from fixed sulfonamide erythema,
centrifugal ring-shaped Darie ’ s erythema, disseminated lupus erythematosus,
nodulose erythema, chilblains.
Nodulose erythema differs from herpes iris by the character of eruptions - as
nodules painful by palpation of scarlet colour which changes by the type of «
flowering of bruise» (but not spots, what easily revealed by palpation), without
characteristic for herpes iris falling back in the center of the elements localized
mainly on the front surface of shins.
Chilblain is similar to idiopathic form of herpes iris by the character of
course (relapses, seasonality), localizations of focuses of affection on the skin of
distal parts of extremities, but differs by the character of morphological elements
of rash. In chilblain unlike herpes iris there are nondistinctly limited erythematous
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spots and nodules without characteristic for herpes iris falling back in the center,
accompanied by itching which intensifies when a patient enters in a warm room.
If clinical picture of herpes iris is sufficiently typical, necessity of the biopsy
is rare. Pathohistologic identification helps a lot in diagnostics, if the clinical
picture of herpes iris is mainly presented by bubbles. Smears-imprints allow
excluding some diseases.
Medical treatment is a cancel of medicinal preparation, prescription of
antihistamine remedies. In the severe cases they apply corticosteroids (prednisolone 20-30 mg per day during 5-7 days, gradually lowering the dose; triamcinolone or dexamethasone in the proper doses); sodium thiosulfate 10 ml 30% solution is intravenously daily 8-10 injections, hаеmodes, rheopolyglucin, keyten,
klacid, ospexin, tarivid, cyprobay. On crusts - ointments of baktroban, baneocin.
The medical treatment is done in clinic. They administer symptomatic therapy and
prophylaxis of complications locally. In frequent relapses of herpes iris and impossibility to reveal the trigger, especially if there are allergic reactions in one’s
histo-ry, it is possible to recommend keeping a food diary with the purpose of
disco-very of food allergen. The obvious prevailing of psychological tension as the
trig-ger underlines actuality of minding by patients with recurring herpes iris of the
rational regime of labour and rest, as a component of prophylaxis of
intensifications.
A severe clinical form of exudative erythema is Stevens-Johnson syndrome,
described in 1922, which in 3 stages of its development can turn into Layell
syndrome. According to some authors, Stevens-Johnson syndrome occurs in 2-4
times more frequently in males (usually young and middle aged), especially in the
cold period of year (in winter, early spring and autumn), and it courses with the
considerable disturbances of general state, affection of the skin, mucosas of the
oral cavity, eyes, genitals, inner organs. Frequency of morbidity is increased in the
last decades.
They distinguish 2 forms of Stevens-Johnson syndrome: one of them is
malignant variant of idiopathic herpes iris, the most frequent cause of which is the
virus of simple herpes and rarer by Mycoplasma pneumoniae. The second form is
represented by severe variant of symptomatic herpes iris that is by the type of
medicinal toxicoderma. Thus, the development of the disease is connected with
influence of infectious or medicinal factors, in the basis of their action there are
toxic-allergic processes. Genetic readiness of the organism to development of
Stevens-Johnson syndrome is assumed. The causal factors provoke sensitization of
the organism, showing up as allergic reaction according to the immediate or slow
type, directed to keratinocytes, with CIC formation in the blood serum, the deposit
of IgM and S 3-component of complement along the basal membrane of epidermis
and in the upper dermal blood vessels. Development of cellular immunodeficiency
can be promoted by overcooling, focal infection, helio-magnetic influences.
The disease begins acutely from the high fever, arthralgia, myalgias,
sometimes with the prodromal grippe-like period. Then the affections of mucosas
appear from a few hours up to 2-3 days, which unlike bullous herpes iris are
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involved in process no less than in 2 different organs. Mucosa of the oral cavity is
affected in 100% with formation of bubbles and erosions with grey-white films,
hemorrhagic crusts on the red border of lips. Affection of eyes in 91% cases and is
characterized by the severe catarrhal, purulent conjunctivitis with development of
bubbles and erosive-ulcerous areas, keratitis, uveitis, panophthalmitis, which in
10% result in the decline of acuity of vision. Mucosas of genitals are affected with
development of urethritis, vulvovaginitis. There can be retention of urine at
involving of the urinary bladder. Mucosa of the anus is involved in process in 5%,
bronchial tubes - in 6%. The affection of the skin is characterized by the
disseminated erythematous-papular elements with purple peripheral area and
cyanotic falling back center. Usually eruptions do not fuse. Preferred localization is
the body, perineum and scrotum. In less degree - extremities. On the skin there are
also vesicles and bubbles of serous and hemorrhagic content, after bursting there
are sappy scarlet erosions covered by crusts. The severe general phenomena with
the fever proceed during 2-3 weeks. Pneumonia can develop on this background
that in 18 % results in death. There can be development of pneumothorax,
mediastenal emphysema, and affections of kidneys by the type of
glomerulonephritis with progressing renal insufficiency, development of diarrhea,
inflammation of middle ear, strictures of the oesophagus. The course of the
Stevens-Johnson syndrome continues about 6 weeks and in 5-10 % results in the
lethal outcome.
It is necessary to pay the special attention to the fact that the clinical picture
of Stevens-Johnson syndrome does not differ from the initial symptoms of acute
epidermal necrolysis (Layell syndrome) - one of severe manifestations of druginduced disease with frequent lethal outcome. Therefore such diseased people must
be immediately hospitalized and treated according to principles of medical
treatment of Layell syndrome (corticosteroids in average doses, enterosorbents,
hemosobsorption, plasmapheresis, physiological solution, Ringer’s solution, 5%
glucose solution, albuminous preparations - albumin, plasma, hаеmodes, taking of
diuretics, anabolic hormones, preparations of potassium, calcium, antihistamine.
To establish connection of the disease with the infection they use antiviral
preparations and antibiotics. Erosions on mucosas are smeared by egg-white,
dermatol, xeroform, solcoseryl ointments.
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XVIII Dermatozoonoses
Zoonosal dermatoses are formed because of parasitic insects (ticks, lice,
fleas), penetrate into the human skin. Dermatozoonoses are: scabies, cutaneous
leishmaniasis, infestation with lice.
Cutaneous leishmaniasis (Borovski disease) is endemic infectious disease
caused by protozoa of genus Leishmania. Endemically for regions with warm
climate with the temperature of air is not below 20 C.
There are two varieties in Russia - anthroponous type (is caused by
Leishmania tropica minor) and zoonosal type (is caused Leishmania tropica major).
Both varieties of leishmanias were first described by Borovski P.F., differentiating
by the biological features and epidemiology of process. Leishmania tropica minor
parasitizes in human beings only; Leishmania tropica major lives and parasitizes
in rodents of sandy fields (gophers, hedgehogs, rats), and also in dogs.
Carriers are different types of mosquitoes. As the source of infection of the
urban type of the disease is usually a human being, for rural - wild rodents.
Classification of Borovski disease:
- acute necrotizing type (rural, Pendjdeh ulcer, zoonosal type, the
secondary type of Borovski disease);
- late ulcerative (urban, anthroponous type, dry leishmaniasis, the first
type of Borovski disease);
- tuberculoid type (lupoid leishmaniasis).
Anthroponous type of cutaneous leishmaniasis is characterized by the
protracted hidden period (3-9 months), sometimes up to 1-2 years. The small solid
tubercle of corporal or reddish color with shining surface appears on place of a bite
(diameter is 2-3 mm.). It slowly grows, in 3-6 months is covered by the scaly crust
which the ulcer is revealed under. It is usually not deep, with uneven, steep edges
and scanty serous-purulent discharge or without it. In the circumference of ulcer
the border of inflammatory infiltrate usually appears, on periphery nodular
lymphangoits can appear - «rosary», they can ulcerate, turning into tiny «daughter»
leishmaniomas. It is healed during a year or more with formation of scar.
The rare clinical form related to the athroponous form - lupoid or tuberculoid
cutaneous leishmaniasis (metaleishmaniasis). By clinical picture it is similar to
lupus vulgaris because of the presence of tubercles on place of scars, after regress
of leishmaniomas or on the edges of tubercles. The given type of leishmaniasis is
localized on the skin of the face and is observed in child's and youth age. They
relate development of this form to inferiority of immunity because of presence of
focus of chronic infection, overcooling, trauma or natural superinfection.
Mucocutaneous leishmaniasis and diffuse cutaneous leishmaniasis are
related to the atopic form of anthroponous type. For them the slow forming of
process is characteristic. Ulcerations develop lately or are generally absent.
Resolution of process is during 1-3 years or more. Initially the elements similar to
the ordinary type develop (nodule or tubercle with ulceration). In future metastases
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on mucosa of the mouth, nose, pharynx in the early stage or sometimes after a few
weeks, what is accompanied by destruction of soft tissues, cartilages of cavity of
the mouth, nasopharynx, edema of mucosa of the nose, red border of lips. And it is
ended by mutilations.
Diffuse cutaneous leishmaniasis shows up as widespread elements (plaque,
papules, plural tubercles on the face and opened areas of extremities. This
resembles the focuses of affection in lepra. The absence of ulcerations and
affections of mucosa is characteristic. The disease differs by propensity to the
relapses after the medical treatment.
Zoonosal type of cutaneous leishmaniasis is characterized by the more short
hidden period (up to 3 weeks) and not very protracted course. The plural acute
inflammatory painful tubercles which are quickly multiplied in sizes on
background of inflammatory edema of skin appear on place of bites, in a few days
its diameter achieves 10-15 mm. Quickly enough there will be ulcers with steep
edges, necrotic base abundant serous-purulent discharge, which sometimes dries to
crusts. On periphery of ulcers there can be considerable inflammatory infiltrate,
and also tiny tubercles of semination. The diameter of ulcer sometimes reaches up
to 5 cm. From the process of formation of tubercle to scarring of ulcer no more
than 4-6 months pass with the development of firm immunity to this type of germ.
Tuberculoid type occurs rarely both in the first, and in the second type.
Favorite localization is the face. A basic element – tubercles, being unripened
leishmaniomas, passed to the protracted form. On the skin of the face round scars
on place of former ulcers tiny, dough-like consistence tubercles of rather yellowbrown color appear. Sometimes the same elements can appear on the surface scars.
The tubercles do not have tendency to ulceration or resorption and can remain up
to 15-20 years.
For diagnosis is important information telling that once was endemic for
leishmaniasis regions for recent 1-2 years, characteristic clinical symptoms, pattern
of blood and changes of albuminous composition in visceral leishmaniasis. As
evidence of the disease is discovery of leishmanias (material from tubercle,
punctates of the marrow, lymph nodules). For diagnostics the skin test with
leishmanin is used (Montenegro test).
The differential diagnosis is done with tubercular lupus, the syphilids of the
secondary and tertiary period, chronic ulcerative pyoderma, malignant new
formations, sarcoidosis.
Medical Treatment.
1. surgical
2. physical therapy
3. chemotherapeutic
In accordance with the stage of the disease, prevalence and localization. In the
limited focuses - cryotherapy, laserotherapy, elektro- and diatermocoagulation. In
plural - complex one - chemotherapy, physio- and external anti-inflammatory
antibacterial remedies. Often - metronidazol, rifampicin, nizoral.
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In cutaneous leishmaniasis – monomicin 250 000 units intramuscularly 3
times per day during 10-12 days. Locally - apply monomicin ointment (70 g
vaseline, 30 g lanolin and 2 000 000 units of monomicin), protargol 5-10%,
streptocide 5-10 %, akrichin 1-2%, metaciclin 3%, tetraciclin 5%. In cutaneous
leishmaniasis zoonosal type it is possible to use solusurmin. The course of medical
treatment takes 10-12 days. Sometimes they appoint aminochinol (orally 0,1-0,2 g
3 times per day during 10-12 days), however it is less effective. Amonochinol and
furazolidon - antileishmaniasis.
The prognosis at the modern methods of medical treatment for the life is
favourable. Scarring of ulcers in cutaneous forms can last depending on type of the
disease from a few months up to 1-2 years.
Prophylaxis. Before exposure and medical treatment of patients, fight with
mosquitoes-carries, the use of deterrent remedies. For the last years they do the
inoculations against cutaneous leishmaniasis. The inoculations are done by the
living cultures of leishmanias on the closed areas of the skin.
Scabies is caused by the veritable parasite of the skin - by itch-mite, turtlelike type, of whitish-yellow colour. Length of female is about 0, 5 mm., length of
male is less. Impregnated female getting on the skin, for 15-30 minutes gnaws
through a corneal layer and, moving up, in its depth, parallel to surfaces of the skin,
forms scabies passage in which lays eggs. Speed of moving of female 1 mm. per
day. Periodically it is stopped for drilling in the «roof» of passage of openings,
necessary for getting of air which the tick perishes without, and for going out of
the skin of young individuals. Males do not do passages, after the impregnation of
females they perish.
Scabies more frequently occurs in winter and in autumn. The infection is the
result of the direct (close and protracted) contact, including sexual, and also
through clothes, bed linen and other articles of everyday life. The bath-houses,
showers, locker rooms can serve as nursery of scabies.
The clinical picture of scabies is characterized by following symptoms:
acutely expressed itching appearing or increasing at night; excoriations; scabby
passages; papulovesiculous rash developing as a result of intoxication by the
products of vital functions of ticks; pyodermatites (folliculites, furuncles, impetigo,
ecthymas) as a result of scratching of the skin. Sometimes there is albuminuria and
eosinophilia.
Primary localization of itch is very characteristic, and also excoriations,
papulovesicles and pyodermatites: hands, flexor surface of radiocarpal joints,
extensor surface of elbow joints, front axillar folds, lateral surfaces of thorax,
lower part of stomach, inner surface of thighs, buttocks, penis. The itching and
eruptions are absent on the head and neck, in the axillas, on the upper part of back,
soles, however in the little children can be everywhere.
Scabby passages have the appearance of thin dirty-gray rectilinear, winding
or s-shaped strips of the length 0, 5-0, 75 cm. (in the rare cases they achieve 4 cm).
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On one end of scabby passage it is possible to notice a dark point («mine», place of
penetration of a tick); on the other, blind end - knoll or bubble (location of a tick
now). Scabby passages are revealed more frequently in the interfinger folds and
lateral surfaces of fingers of hands, on hands, flexor surface of radiocarpal joints,
in area of mammillas in women, on penis in men. In the last case scabby passages
are revealed on the front axillar fold, where they, as well as on penis, can have an
inflammatory character, on stomach and on buttocks. In the little children they can
be on soles, shins, and in infants on face and nail plates. On soles in children the
bubbles develop quite often.
One should remember that, in spite of characteristic simptomatics of scabies,
its diagnostics is not always easy. This can be conditioned by the fact that
pyodermatites, which sometimes spread outside the classic localization of scabies,
shade its clinical picture and scabby passages one does not succeed to discover.
Characteristic localization of itching allows suspecting in these cases scabies.
However and this sign not always rescues, because extremely excitable patients
quite often scratch all skin covering. However as a result of application by the
patients of corticosteroid ointments itching can be very weak or be absent at all.
However strengthening or appearance of it at night-time, must point to the correct
diagnosis.
Characteristically, that activating of ticks at night is unconnected with the
bed heat. That is why daily sleep, daily work in the hot workshops, high daily
temperature of body do not influence in patients with scabies on intensity of itch,
but during work it increases in night shift. In addition, presently quite often there
are effaced forms of scabies. The careful minding of hygienic rules results in that
scabby passages become invisible. In cleanly people, and also in workers, the
hands of which are exposed to influence of inflammable-lubricating substances, the
affection of hands can be absent.
The clinical picture of the disease is sometimes limited by the single tiny
urtiko-like hydropic spots and nodules, vesicles, papulo-vesicles, hemorrhagic
crusts. For establishing of diagnosis of scabies their pair location corresponding to
two ends of scabby passage is especially important. Confirming its presence is
succeeded by smearing by solution of iodine or aniline dye. The corneal layer of
scabby passage is dyed more intensively, than skin surrounding it. One should pay
attention to the affection of elbows (spotted hemorrhagic crusts, impetigo, ecthyma)
and mammillas characteristic for scabies, especially in girls (impetigo, microbe
eczema).
At presence of doubtful elements of skin rash, the diagnosis is established by
the microscopic research of their content. Material for research is possible to be got
by dissection of bubbles by needle either surface cutting by razor-blade all element
away, or deep scratching of it (to the blood) by eye spoon. Microscoping is
conducted in 20% solution of caustic alkali. Simple and more reliable there is track
method: on the suspicious element of skin rash the drop 40% solution of milk acid
is inflicted; in 5 minutes the loosened epidermis is scraped with the seizure of the
unaffected skin by the acute eye spoon to appearance of blood; got material is
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observed under microscope in the drop of the same solution of milk acid. In place
of milk acid it is possible to use a 10% - solution of caustic alkali: in 2 minutes
after putting of it on the skin the macerated corneal layer is scraped and
microscopic research is conducted. In patients with scabies they reveal the eggs of
vermin, females, larvae, nymphs, excrements, and sometimes - whole passages.
Medical treatment. Spregal, 20% benzil-benzoat; in the case of development
of the secondary infection - the proper therapy before prescription of antiscabby
preparations, in eczematization - preliminary application of advantan, dermatop,
elokom.
Norwegian scabies. The disease is caused by the same itch-mite, as ordinary
scabies. The main factor resulting in the original course of scabies, there is an
immunodeficient state of macroorganism.
The clinical presentation is characterized by the good number of crusts,
hyperkeratotic masses on different areas of skin cover, including on the hairy part
of head, the face, neck. The crusts of black with the smooth or uneven surface
thick up to 2-3 cm are located by layers. In the layer of crust and under crust large
quantity of ticks, that determines high contagiousness of the disease. At tearing of
crusts away the erosive weeping surface is revealed. The itching is insignificant or
absent.
Medical treatment. 1 stage - removing of crusts by the sulphuric-salicylic
ointments, soda and soapy baths; 2 stage – antiscabby therapy (20% benzil-benzoat,
33% sulphuric ointment, spregal); immunostimulating therapy.
Infestation with lice is a parasitic disease. Three types of lice can parasitize on
the skin:
1.
Head louse. It is passed from man to man by the direct contact, at the use by
the mutual combs, shawls, tooth-combs. For all its life the female lays about 150
eggs-nits, gluing them to the hairsprings by the chitinous substance. The nits have
a greyish-white color and are well visible by the unarmed eye. In 5-6 days the
young lice which in 3 weeks are able to procreate appear from nits. Localization:
hairy part of the head, eyebrows, beard, moustaches. Bites the lice and action of
enzymes of their saliva cause severe itching, that results in scratchings,
introduction of pyococci and development of pyodermic elements, most frequently
as vulgar impetigo. In the neglected cases the head is crusty, the hairs stick in the
more or less thick bunches (plica) together, neck lymph nodules enlarge. The
diagnosis is confirmed by the discovery of nits and lice.
2.
Clothes louse - larger than the head lice. The bites of lice cause a severe itch
and result in linear excoriations, which can be complicated: region of neck,
shoulder-blades, small of back, i.e. areas of the skin, closely contiguous with linen.
On these areas there is brown pigmentation for a long time. Chronic longstanding
pediculosis results in dryness of the skin, scaling, its thickness with formation of
dirty-gray pigmentations, scars (skin of tramp).
3.
Pubic louse. The strong itch is subjectively marked. Quite often on the
places of stay of pubic lice remain round, by size of pea hemorrhagic spots from
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pale-dark blue to the pale-grey color, appearing as a result of actions of enzymes of
saliva of pubic lice on haemoglobin and not vanishing at pressure by finger.
The infection is the result of intercourse or mutual use of the bed.
Medical treatment: in infestation with lice on the hairy part of the head the
hair is moistened by the mixture of kerosene with the vegetable oil (in half), after
lay on a bandage with wax-paper for 12-15 hours. After two procedures the head is
washed by hot water with soap, rub vinilin, the nits removed by comb, moistened
table vinegar. It is possible on hairs to apply 10% and 20% suspension of benzilbenzonat, which inflict on hairs and rub in skin. One should avoid getting of
preparation in eyes, nose, and mouth. Tie a head by the triangular scarf, in 30
minutes preparation is carefully washed off by the running water, after by soap or
shampoo. By the wadding tampon, moistened by nittifor, carefully wipe the hairs
and skin of the head. Tie a head by the triangular scarf and in 40 minutes the hair
are washed in ordinary way or apply shampoo of pedillin.
Pediculosis of the body is washing with soap, frequent change of linen,
bedding preliminary disinfected.
Pubic pediculosis – aerosols para-plus, spray-plus.
Prophylaxis: cleanliness, do not use other’s toiletries and clothes.
XIX Lepra
«There is one diagnosis which can not be established, if one is not
completely sure in its reliability – diagnosis of lepra». The uniqueness of this
disease consists in the organic combination of the severe physical suffering of a
patient, complications of medical character and its social meaningfulness. Lepra one of the ancient diseases known to humanity. The oldest information about lepra
is related to the epochs of slave-owning system and feudal one. The consideration
of a patient as a leper was equivalent to one’s civil death. Diseased people were
banned from the society, derived of succession and etc. in many places they read
the burial service for them as deceased.
Presently, from data of the report of expert commission of WHO (1987), a
number of patients with lepra steadily goes down, that presumably, is related to the
wide introduction of the effective anti-epidemic programs and anti-leprous projects.
However on territory of Russia and Kazakhstan still there are sporadic cases of
leprous infection, greater part of which is at North Caucasus and lower reaches of
Volga.
In spite of the expressed decline for the last years of morbidity by lepra, this
fact must not cause the complacency of doctors of both dermatologists and doctors
of other specialities, as manifestations of lepra are characterized by the huge
variety of clinical symptoms.
Lepra is a chronic infectious disease caused mycobacteria of lepra, is
characterized by the affection of skin, mucous membranes, peripheral nervous
system, eyes, some inner organs. A germ is a bacillus discovered by Hansen is
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Norwegian doctor. From 1931 year, according to the decision of the International
conference on lepra, Hansen bacillus was related to genus Mycobacteria and called
Mycobacteria lepra hominis. This Grampositive spirit- and acid proof bacillus, for
the last years for the bacterioscopic diagnosis of lepra they use colouring by
Marcinovski method. Mycobacteria of lepra form L-forms, grainy and filtered
forms. In biomaterial they are revealed in great numbers with the slightly acute
ends and parallel location as «cigar packs» or as balls surrounded by the
transparent shell. Mycobacteria of lepra do not have a capsule and do not form the
spores.
A source of infection is a diseased man. Considerable part is played by the
social factors and economic development of a country that can explain the spread
of this pathology among the poor population of countries of Asia. There is large
danger of infection of the children inclined to the allergic diseases.
Ways of transmission: airy-drop, rarer – through skin (in damage of skin
cover) or from ulcerating lepromas. Urine, tears, sperm, discharge from urethra,
mother milk and blood in the periods of reactivation of leprous process are
contagious. Possibility of transmission by the bloodsucking insects is assumed.
Classification of basic forms:
- tuberculoid
- border-line-tuberculoid
- dimorphous
- border-line-lepromatous
- lepromatous.
Additional:
- non-differentiated
- subpolar lepromatosis
Forming of type of lepra depends on the degree of immunobiologic
resistance of a patient. In people with the phenomena of astenisation,
immunodeficiency, along with the negative lepromin test, more frequently
contagious type of lepra develops – lepromatous. In people with the high
immunobiologic reactivity, the positive lepromin test they observe favourable type
- tuberculoid.
Non-differentiated type - in people with undetermined immunoreactivity and
in future can be transformed in two mentioned types of lepra.
During process there are 4 stages - progressing, stationary, regressive and
residual phenomena.
On place of introduction the inflammatory reaction does not develop. At the
domestic contacts the possibility of infection makes 10%, if natural resistance to
lepra is lowered - 70%. Pathomorphology: specific granulema appears consisting
of leprous cells stuffed with large quantity of mycobacteria of lepra, plasmacytes,
epithelioid cells.
Immunity: usually there is relatively high natural resistance to mycobacteria
of lepra. Pathogenetic significance is attached to damage of microcirculation of the
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skin, varicose syndrome, mycoses of the feet - especially epidermophytoses and
candidiases.
Hidden period - from 3 months up to 20 years, 3-7 years are ordinary. The
prodromal period is general indisposition, tenderness in joints, gastro-intestinal
disorders, neurological pains.
Tuberculoid form. There is affected skin, peripheral nervous system on the
early stages. Mucous are not affected, inner organs - rarely. The early change of
all types of sensitiveness up to anaesthesia (pain, temperature and tactile) is
characteristic. That conditions frequent burns, injuries with formation of ulcers,
scars. The lepromin test is positive. On body, the face, upper extremities hypochrome spots, the plural polygonal papules appear round them, more
frequently with the infiltrated plaques, with the distinct margins, rising above the
skin, inclined to the peripheral growth. In the center of focuses - disintegration.
There is oppression of functions of sweat, sebaceous glands, the lanugo hair falls
out, the hair loses its shining, are dry, strongly thinned. The radial and peroneal
nerves are affected - are enlarged and well palpated.
Lepromatous form. The most severe type of lepra and differs by
polymorphism of clinical manifestations. The skin, mucous, inner organs,
peripheral nervous system on the early stages are affected. In brush cytology of
mucosa of the nose - great number of mycobacteria of lepra. The lepromin test is
negative - low resistance of organism to mycobacteria of lepra. Appearance of
pigmental or erythematous, symmetric located spots without the distinct margins.
They are dark, after rather yellow, brown; the skin is smooth, shining. In the initial
stage lepromas have greasy, moist shine, hyperesthesia develops. The secretion of
oil-glands increases, hair follicles, the mouths of excretory ducts, sebaceous and
sweat glands are extended, the skin resembles a lemon peel. Hyperfunction will be
replaced by hypofunction of sebaceous and sweat glands. The skin becomes dry,
rough, fissuring. At the same time in area of «immune zones» (flexor and extensor
surfaces of elbows) the trophic functions and innervation are saved. The trophic
damages are accompanied also by damage of pigmentproducing in the skin, there
are focuses of hyper- and hypopigmentation.
In 3-5 years - the hair of eyebrows, cilia fall out. In the focuses of affection
the nodules (lepromas) lie in derma or hypoderm. They exaggerate natural folds of
the skin, eyebrow, nose, and lips - «leonine facies». The nodules disintegrate with
formation of the ulcers slowly healing, inclined to the peripheral growth. The
rough scars appear after the medical treatment.
Lepromas are inclined to ulceration and penetration with destruction of
muscles, tendons, up to amputation of fingers of hands and feet, the forms of
mutilating lepra develop. There is spontaneous primary mutilation with gradual
resorption of bone elements of skeleton, muscles, hands and feet, by destruction
and deformation of nails - seal paw or paw of frog. Because of uneven atrophy of
extensors of muscles of hands, feet, forearms and shins the tone of flexors prevails
in patients - flexor contraction. Fingers also in the bend position - a kind of claw.
Atrophy of circular muscles of eyes leads to the incomplete closing of eyelids,
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affection of facial nerve - atrophy of mimic muscles, the face is sad, mask-shaped «mask of Saint Anthony». Severety of disease is aggravated by the plural visceral
pathology.
For the general course of lepra and especially lepromatous type the periodic
development of intensifications is characteristic - leprous reactions. They arise up
because of different provoking factors - concomitant pathology, nervous-emotional,
cold, efficient interferences, inadequate medical treatment, abuse by the iodine
preparations, during pregnancy, births, lactation. Reactions of intensification
suddenly, sometimes gradually, with the acute activating of all manifestations of
lepra. The relapses are accompanied by the affection of lymphatic vessels, damage
of reologic properties of blood and agregation of trombocytes that results in
lymphostasis and development of elephantiasis. The development of unspecific
rashes is possible - rozeolas, papules, by herpes iris type and nodulose erythema,
intensifications are more frequent in spring and in autumn.
It is characteristic:
- leproms are never located in the axillas, inguinal, knee, elbow areas, on the
hairy part of the head - «immune zones»;
- mucosas are affected: nose mucosa acquires cyanotic colouring, the nose
becomes deformed from disintegration and scarring of lepromas;
- the liver (lepromatous hepatitis), kidneys is often affected;
- the peripheral nerves are affected at the late stages.
Border-line-tuberculoid type. It resembles tuberculoid one, but plaques are
smaller, the margins are less distinct, symmetrically located, plural. Damage of
functions of sebaceous, sweat glands and damage of all types of sensitiveness in less degree. The lepromin test is positive or slightly positive.
Dimorphous type. The plural asymmetric spots of wrong form with the
indistinct margins appear, with the protuberant central part (resembles the inverted
saucers). In the center of focuses there is a great number of the tiny orifices. On
periphery of focuses - tiny focuses. The damage of sensitiveness in focuses is
moderate, the lanugo hair is partly saved. The lepromin test is negative.
Border-line-lepromatous form. The papules, diffuse infiltrate are
characteristic. Difference from lepromatous type: presence of the perforated
elements with the raised border edges. In some focuses the sensitiveness is lowered;
the functions of sweat-glands do not suffer, the growth of lanugo hairs is violated.
There is no fall of eyebrows, cilia, deformation of nose. The lepromin test is
always negative.
Subpolar lepromatous type. Develops because of sharply lowered resistance
of the organism. Shows up as lepromatous type, but the elements are more
distinctly limited, asymmetric.
Diagnostics:
- history (whether there were contacts with patients with lepra);
- clinical presentation;
- results of research of nose mucosa, biopsy of focuses;
functional tests:
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1. lepromin test: 0,1 ml suspension of mycobacteria of lepra injected
subcutaneously. The tubercle with necrosis appears in 2-3 weeks. In
lepromatous type the test is negative, tuberculoid - positive (similarly as well as
in the healthy men); in dimorphous - can be positive or negative. The test is
used for the differential diagnostics of different types of lepra and for the
inspection of groups of population with the increased risk of disease (exposure
of people with the negative test);
2. 15% morphine;
3. 0,1% histamine: drop on the affected and healthy areas, in the center of drop
prick. At suction of histamine erythema, after blister appears in normal state; in
lepra the reaction is poorly expressed or absent;
4. test for sweating;
5. test with the nicotine acid;
6. 5-8 ml 1% nicotine acid intravenously - diffuse erythema, in norm in 15-20
minutes begins to disappear; at the affection - remains.
Medical treatment is combined. Apply no less than 2-3 preparations, one of
which sulphonous kind (diafenilsulphon, solusulphon, diuciphon). Preparations are
changed every 2 months.
Unspecific therapy: polyvitamins, gamut-globulin, metiluracil, pirogenal.
The course includes 4-5 week cycle, after every cycle there is break for 2 weeks.
The break between courses - 1, 5-2 months, duration of medical treatment 5-10
years in lepromatous type, out of them 3-5 years in hospital for lepers. In other
types 3-8 years.
The prognosis depends on the type of lepra, the earlier diagnosis is
established, the better prognosis. Efficiency of medical treatment is estimated on
results of bacterioscopic control and histological research.
Prophylaxis. At the exposure of a patient with lepra quickly fills in the
urgent notification about s/he, with notification of organs of health service, that
secures hospitalization of a patient and primary inspection of contact people. All
family members are exposed to the inspection not rarer 1 time in year. New-borns
are taken away and are switched to the artificial feeding, clinic-laboratory control
is not rarer than 2 times a year. In places, endemic for the disease - mass inspection.
Where the patients are revealed, they conduct with the purpose of prophylaxis the
mass BCG inoculations (they discovered allied antigen characteristics of
mycobacteria lepra and Koch mycobacteria). To the contact people - preventive
medical treatment at the discovery of active form of lepra. According to the
international agreement - the departure abroad to the patients, work in child's
establishments, food industry is forbidden.
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XX Cutaneous tuberculosis
Cutaneous tuberculosis is a very vast and various by its manifestations group
of dermatoses, the origin and development of which is conditioned by penetration
into skin and subcutaneous fat of tubercular mycobacteria. Almost in all cases a
tubercular affection of skin is secondary and endogenous.
The germ usually gets into the skin and subcutaneous fat by the lymphogene
path from the focuses of tuberculosis in other organs, sometimes the infection gets
to the skin on the extent - from the affected neighbouring organs; very rarely there
is exogenous infection of skin - through its damages.
They distinguish:
- focal forms of cutaneous tuberculosis are lupus vulgaris, scrofuloderma,
verrucous and ulcerative tuberculosis;
- disseminated forms of cutaneous tuberculosis are tuberculosis papulonecrotica,
indurative erythema.
Localized forms:
- Tubercular (vulgaris) lupus. Arises up usually in the school age from
appearance of a few lipomas - tiny rather yellow-rose flat soft tubercles
discovering at diascopy semilucent yellowness (phenomenon of «apple jelly»), and
at pressing by the button-shaped probe on - extraordinary mildness and
vulnerability («phenomenon of probe»). Gradually lipomas are multiplied in sizes
and number, can be covered by scales, to ulcerate. After cicatrization of ulcers or
resorption of lipomas there are thin smooth white atrophy scars resembling the
crumpled cigarette-paper.
Favourite localization: the face (nose, upper lip, cheeks, auricles), buttocks,
extremities. The mucous membrane of cavity of mouth is often affected, where the
process usually gains ulcerous character, ulcers are tender. The disfigurement of
exterior of a patient can come because of destruction of the affected areas
(destruction of nose, lips, and auricles). The course of process is chronic, torpid,
with worsening in the cold time of year; can be complicated by the erysipelas and
skin cancer.
Differential diagnostics - with tertiary defector syphilis and lupus
erythematosus. In tertiary syphilis the tubercles are deprived rather yellow tint,
have solid consistency, differ by the rapid evolution with formation of the «inlaid
scars», never appear on the old places, do not give the phenomena of «probe» and
«apple jelly»; the serologic reactions on syphilis (RW, RIF, RIBT) are positive.
Lupus erythematosus usually does not begin in child's age, shows up symmetric
erythematous spots with the solidly sitting greyish scales, does not ulcerate,
relapses and gets worse in the spring-autumn period, rarely affects mucous
membranes, does not give the phenomena of «probe» and «apple jelly».
- Scrofuloderma (tuberculosis cutis colliquativa). Is observed mainly at
children and teenagers, suffering by tuberculosis of hypodermic lymphatic nodules
which the process passes from to the hypodermic fatty cellulose; infection can take
place also by the hematogene path. In the submaxillary region, on neck, breast,
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extremities there are single or plural cyanotic-red nodules with the subsequent
central softening influence and formation of deep soft, almost painless ulcers with
the overhanging edges. Separated ulcers - purulent-hemorrhagic or crumble-like,
due to necrotic masses. The course of process is chronic with tendency to the
spontaneous recovery. There are wrong «bridge-like» scars after cicatrization of
ulcers.
- Verrucous cutaneous tuberculosis arises up at exogenous infection of the
skin, quite often in connection with profession (at pathologists, working butchery from here vivid name «corpse tubercle»). Usually on the fingers of hands or rear of
hands small painless infiltrate of cyanotic-red color appears with the warty
excrescences on surface, afterwards exposed to scarring.
Ulcerative cutaneous tuberculosis is observed in the acutely loosened
patients with the active tubercular process in lungs, intestine, kidneys. The
affection of skin arises up as a result of by autoinoculation by sputum, excrement
or urine containing tubercular Mycobacteria. On the mucous membranes and skin
there are small soft painless ulcers with the overhanging edges and uneven base at
the natural opening, with the tiny abscesses (Trel dots). The base of ulcers can be
covered by crusts.
Disseminated forms:
Tuberculosis papulonecrotica. Arises up early in life as small cyanotic-red
nodules with the necrotic scabies in center, at falling of which off there are
«pressed scars». Eruptions are located symmetrically, mainly on extremities and
buttocks. The subjective feeling is absent. Course of process is recurring.
Indurative (more solid) Bazen erythema. It is usually observed in the young
women. In the basis of disease deep allergic vaskulitis lies in combination with
pannikulitis, caused by the increased sensitiveness to mycobacteria, which get in
skin mainly by the hematogene way. Clinical picture: appearance on the shins of
symmetric, deeply located nodules of dough-like and tightly elastic consistency.
Nodules are usually tender a little, isolated from each other. The skin above
nodules as far as their growth becomes reddened, cyanotic, fused with them. Part
of nodules in center grows soft and ulcerates. The appearing ulcers are more
frequently tiny, have a yellow-red base covered by the languid granulations and
serous-purulent discharge. The edges of ulcers are steep, quite solid due to the halo
of nondisintegrating infiltrate. They differ by the torpid course. The process is
predisposed to the relapses in the fall-winter period.
The diagnosis of cutaneous tuberculosisis is based on history, clinical
features, presence of affection of other organs, positive tuberculed tests, and
discharge of tubercular mycobacteria from the ulcerous focuses. In the difficult
cases they make the pathohistologic research of skin, inoculation to the
experimental animals and trial medical treatment.
Medical treatment. It is administered in accordance with the general
principles of anti tubercular therapy. Usually use the complex medical treatment by
streptomicin, ftivazid, rifampicin in average therapeutic doses. Conduct one basic
and two fastening (antirelapsing) courses. Duration of basic course 6 months
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fastening - 3 months. Intervals between courses - 4-6 months. In complex with the
specific preparations by patient appoint general improving health remedies,
vitaminized diet, rational regime. In the ulcerous forms they apply disinfectant
washing and ointments.
The prognosis in majority cases is favourable. The prophylaxis is the same,
as in tuberculosis.
XXI STD
It is ureaplasmic infection. A group of microorganisms under the name of
mycoplasms is one of reasons of postgonococcal infections, conditioning
pathology of urinogenital tract and pelvic organs.
Etiology. Ureaplasms - tiny Gram-negative coccobacillar microorganisms of
0,3 mcm in diameter. These are the smallest bacteria in the world. Ureaplasmic
etiology makes about 60% all forms of infectious vaginites, complicating a course
of other infections passed by the sexual way.
Clinical picture. There are no characteristic signs, they differ a little from the
inflammatory diseases of urinogenital organs of other etiology. The disease courses
with less, than they, acuteness, with the greater frequency of complications and
considerable stability to the administered therapy. The infection can course without
symptoms and without the subjective feeling, and that is why revealed lately, in the
chronic form, periodically activating.
Diagnostics. A basic method is cultivation of microorganism on the liquid
and solid nutrient media from discharge of mucous membranes of urinogenital
organs. IFA is also used, PCR.
Medical treatment. Use tetraciclins, aminoglikozids, ftorchinolons,
macrolids. In chlamydial-ureaplasmic infection - azitromicin; in gonococcalureaplasmic - ftorchinolons. In mixed trichomonad-chlamydia- ureaplasmic
infection they begin the medical treatment with metronidazol, from the 2-3rd day
they join tetraciclins.
Prophylaxis. An active discovery and bringing of patients in to the medical
treatment is one of methods of successful fight with the disease which in many
women and men courses in the hidden form, without the clinical manifestations.
Urogenital chlamydiosis - infectious disease of urinogenital organs, caused
by different types of chlamydias.
Factors of risk. A basic factor of risk is young age in the sexually active
women, which the features of epithelium in area of genitals are related to. Direct
dependence is present between the number of sexual partners and frequency of
infection in men and women. From mother the infection can be passed to new-born.
Etiology. Germ of the disease - chlamydia trahomatis, the Gram-negative
bacterium which belongs in classification of microorganisms to special genus
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Chlamidiseya. They distinguish the following kinds: chlamydia trahomatis,
chlamidia psittachi, chlamydia pneumonie and chlamydia pekorum.
Chlamydia possesses a unique cycle of development which a change of one
form of its existence is in the process of - elementary corpuscle (EC) by other form
- by the reticular corpuscle (RC). The germ has not own ATF and is by the obligate
intracellular parasite, preferring a cylindrical epithelium.
Pathogeny. The infection is the result of metabolic nonactive EC, which in
the cytoplasm of cell will be transformed in metabolic active, but uninfectious RC,
it is repeatedly divided by the binary division, and then is transformed in an EC
new generation, able to infect next cells. The cycle of development occupies 48-72
ch.
Clinical presentation. The hidden period lasts 10-14 days. Basic
manifestations of illness at men: scanty mucous-purulent excretions from urethra,
feeling of discomfort in urethra (itch, sometimes tenderness at urination), turn of
sponges of urethra red. Nonsymptomic courses at 10% men of chlamydiosis. There
is the proper clinic at complications (epidydimitis, prostatitis).
Basic manifestations of chlamydiosis in women: mucous-purulent excretions
from the cervical channel; ektopia/erosion of neck of uterus (follicular cervicitis).
The infection courses nonsymptomic more than in 75% cases. At presence of
complications they observe the proper clinic.
Diagnostics. For research they take brush cytology (cells of cylindrical
epithelium) or biological liquids.
Laboratory methods of research:
- culture methods - on the artificial nutrient media of chlamydias from the
obligate intracellular parasitizing do not grow. The isolation of germ is possible on
the culture of cells or on the chicken embryos. The methods require severe tolls of
time (about 4 days), but are informing, forasmuch as able to define a presence of
persisting infection;
- immunofluorescent methods - use monoclonal antibodies able to discover
extracellary located ET. This is the most rapid method of exposure of chlamydias
(30 minutes), insignificantly yielding to culture on sensitiveness and specificity;
- immunoferment methods expose a presence of antibodies to chlamydia
trahomatis in blood or antigen in brush cytologies. By spectrophotometr they
determine discoloration environment. Estimation of results is less subjective, than
at the immunofluorescent method, but yields to it in sensitiveness and specificity;
- serologic methods are comfortable for the screening researches, but at the
positive result require confirmation by other methods. About activity of process it
is possible to judge at the simultaneous Ig decision And, M, G;
- methods of DNA-diagnostics - PCR, ligaz chain reaction (LCR), DNAprobes.
This is the most modern hi-tech methods allowing discovering single
microorganisms. Require the special equipment; PCR and LCR allow finding out
chlamydias in urine.
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The medical treatment of chlamydial infection must be carried out only
under the control doctor. At the wrong use of antibiotics the chlamydial infection
passes to the chronic form which treats oneself far more difficult, than acute. Both
partner necessarily must treat oneself. During the medical treatment sexual contact
must be halted. Use the antibiotics (macrolids, tetraciclins, ciprofloksacin). Except
for the reception of medications orally, appoint the local purpose of medications.
For prevention of fungus affections appoint nistatin. polyvitamins prescribed for
strengthening of organism, adaptogens (the extract of eleuterococus is liquid,
brandy of limonnik, tincture of ginseng). For the improvement of work of the
immune system - interferon (locally) and inductor (stimulator of making) of
interferon (orally).
Bacterial vaginosis is a wide-spread infectious disease of women, in the
basis of which the damage of mikrobiotsenoza vagina lies, increased growth of
aerobic and anaerobe microflora substituting for lactobacillar microflora.
«Gardnerellesis» was named before, «anaerobe vaginosis». Etiology: acute decline
or disappearance of lactobacteria, noticeable predominance of bacteroids,
gardnerell, mycoplasms, peptostreptococci. Factors promoting the development:
- endogenous - change of hormonal factor, damage of microbiocenosis of
intestine;
- exogenous - concomitant inflammatory diseases of urinogenital tract, previous
antibacterial therapy.
Clinic. Manifestations are been by the homogeneous cream-like excretions
of grey-white color, adhesive on the mucous membrane of vagina, having an
unpleasant smell. Inflammatory reaction of mucous vaginas is not characteristic for
bacterial vaginosis, but does not eliminate this diagnosis, revealed in third of
patients. The subjective feeling as an itch and burning are possible.
The laboratory confirmation of diagnosis is carried out by measuring of pH
vaginal separated, by raising of aminotest, by the method of microscopy of the
stroke dyed on Gramm, and native preparations with the decision of key cells.
Selection of net culture of Gardnerella vaginalis beside the purpose, forasmuch as
this microorganism is revealed in the healthy women.
The diagnosis is considered established at presence of even 3 from 4 signs:
- homogeneous cream-like excretions, adhesive on the mucous membrane of
vagina and having an unpleasant smell;
- exposure of key cells (scaling cells of flat epithelium, covered by the gram
variable microorganisms);
- positive aminotest (fish smell at mixing in different quantity separated vagina
and 10% solution KOH);
- pH vaginal separated more than 4,5.
Medical treatment. The patients not always need therapy, but from the
danger of origin of severe infectious complications at pregnancy, gynaecological
diseases, surgical interferences on the organs of small pelvis at the infected women
the medical treatment is necessary.
Recommended regimens:
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- metronidasol-gel 0,75% is entered by standard applicator in dose 5 g
intravaginally 1 times per day during 7 days;
- klindamicin phosphate - 2% vaginal cream - is entered by standard applikatora
in the razovoy dose 5 g intravaginally 1 time per day during 7 days.
Trichomoniasis - disease of the urinogenital system, caused by the onecelled Trichomonos vaginalis parasite. The germ related to the class of wisped,
strictly specific parasite of man. Out the still human organism the germ perishes at
drying (for a few seconds), heating over 40 centigrade ruins trichomonad.
Basic transmitters of infection are women of reproductive age. The disease is
passed: by the sexual path, the infection is rarely possible through the
contaminated surfaces and can course as nonsymptomic carrying and clinically
expressed vulvovaginitis. T. vaginalis infects exceptionally squamous epithelium
of urogenital tract.
Hidden period - from 4 about 28 days at approximately 50% infected the
faces, but about 1-3 days can grow short.
Clinical picture. A acute form of infection at women is diffuse
vulvovaginitis because of vast leukorreas (discharge from the vagina of whiteyellow viscous liquid with mucus or pus). Discharge usually foamy, yellow or
green color, mucous-purulent consistency. Approximately at 2% patients can be
found out insignificantly expressed gemorragias on mucous vagina, neck of uterus
and cervical channel («strawberry display»).
Slightly expressed simptomatics prevails at the chronic course of illness: itch
and pains during coitus by reason of scanty vaginal secret. This form of disease is
especially important from the epidemiology point of view, forasmuch as such the
faces are by the main sources of infection.
Up to 25-50% infected women have nonsymptomic form at the normal
values of pH vagina 3,8-4,2 and in relation to to the normal vaginal flora. If at such
women carrying of trichomonad is established, as a rule, the clinical symptoms
develop only at the half of patients during 6 months, subsequent after the primary
appeal.
Vaginites - the most frequent display of trichomoniasis at women. The
Bartoliniev gland also can be by the frequent focus of infection.
Is characteristic polyfocal affections at urinogenital trichomoniasis:
adneksites, piosalpingites, kolpites, endometrites, erosions of neck of uterus, tsistiti,
urethritisi.
Masculine trichomoniasis more frequent nonsymptomic courses than all, in
this connection men also can be by the T transmitters. vaginalis. Most expressed
clinical manifestations: urethro- and vesiclesoprostatitisi. Considerably rarer
develop orchitis and orhoepidimites, that it is conditioned by the mixed protozoabacterial urogenital infection. The general complaints in men include the scanty,
mucous-purulent excretions, disuria, weak itching or burning is immediate after
coitus. The complications related to trichomoniasis include nongonococcal
urethritis and other urogenital diseases: prostatitis, vesiclest, balanopostit,
epididimit.
135
Laboratory diagnostics. Diagnostics is based on the exposure of clinical
signs of disease and discovery in explored T.vaginalis material, however at raising
of diagnosis do not lean exceptionally against clinic on the following reasons:
1. indicated clinical symptoms can be. by the manifestations of other
infections of urogenital tract;
2. classic and pathognomonic for the trichomoniasis «strawberry» symptom
occurs only in 2% of patients;
3. foamy excretions which are possible to be linked to the active growth of
trichomonad, is observed approximately at 12% infected women;
4. Presently apply a 4 laboratory method of decision of trichomonos vaginalis:
microscopic, culture, immunological and genodiagnostic.
Medical treatment. It follows to conduct at the discovery of germ regardless
of presence or absence at the inspected patients of signs of inflammatory process.
Tinidazol - 2,0 g singly perorally. AltepHative regimen: metronidazol- 500
mg 2 times per day perorally during 7 days, ornidazol - 500 mg 2 times per day
perorally during 5 days.
At the relapsing course expediently to apply solkotrihovak - 0,5 ml v/m, 3
injections with interval for 2 weeks, after in year 0,5 ml singly.
At presence of testimonies it is recommended to appoint pathogenetic and
local therapy.
Locally acting preparations: metronidazol - vaginal marbles (pills) 0,5 g 1
times are appointed per days of intravaginally during 6 days, ornidazol - vaginal
pills 0,5 g are entered in vagina singly during 3-6 days.
Medical treatment of pregnant: metronidazol (eliminating the first trimester
of pregnancy) in dose 2,0 g perorally singly.
Metronidazol for children at the age from 1 up to 5 years perorally 1/3 t,
containing 250 mg, 2-3 time per days; 6-10 years - 0,125 g 2 times per day; 11-15
years - 0,25 g 2 time per days during 7 days.
To establish criteria of recovery of urinogenital trichomoniasis they begin in
7-10 days after completion of medical treatment by the microscopic and culture
methods of research. The patients with urogenital trichomoniasis should be
informed about the necessity of inspection and medical treatment of sexual
partners, abstention from intercourse until the recovery.
136
Tests
The note: For each question either the uncomplete statement one or several
answers are true. Choose:
A If it is true 1,2,3
B If it is true 1 and 3
C If it is true 2 and 4
Д If truly only 4
Е If it is true all
1. Specify primary elements of a rash:
1. A macule
2. A pustule
3. A papule
4. А сrust
2. Specify secondary elements of a rash:
1. a plaque
2. exoriation
3. a blister
4. erosio
3. Specify mechanisms of formation of a bulle:
1. a vacuolar dystrophia
2. balloon dystrophia
3. spongiosas
4. acantosis
5. an exocytosis
4. In ambulatory the patient with complaints on appearance of the bright pink, hydropic elements accompanying with a strong itch has addressed. In 23 hours after appearance elements completely regress. Name an element:
1.
tubercle
2.
nodule
3.
crust
4.
blister
5.
vesicle
5. The ulcer is:
1. 1. defect of a skin within epiderm
2. The change of a skin connected to a massive infiltration of its papillary
stratum
3. Result of growth of a papillary stratum of a derma with a simultaneous
137
thickening of an spinous stratum of epiderm
4. Defect of skin or hypodermic cellulose
6. The true polymorphism is:
1. Presence of one kind of primary elements
2. Presence of various primary elements
3. Predilection of elements to coalescence
4. Presence of various secondary elements
5. Predilection of an element to peripheric growth
7. Cavity primary elements are:
1. blister
2. vesicle
3. papule
4. node
5. tubercle
8. Caveless primary elements are:
1. macule
2. papule
3. blister
4. tubercle
5. All listed true
9. Specify, what clinical attributes are characteristic for staphylodermas:
1. connection pustules to hair follicles, sebaceous and sudoriferous glands
2. The conic and ball-shaped form of pustules
3. An intense cover of pustules
4. connection pustules to skin,s folds
10. Specify, at what forms of a pyoderma the phlyctena is the basic
morphological element:
1. sycosis vulgar
2. hydradenitis
3. furunculosis
4. impetigo vulgar
11. Antibiotics is considered obligatory at:
1. The pyodermas accompanying with a fever
2. The relapsing, complicated pyodermas
3. Localization of pyodermas on the face and a head
4. Single furuncles
12. In prophylaxis of pyodermas matters:
138
1.
2.
3.
4.
The count and analysis of a case rate
Strengthening physical condition of the population
Sanitary - educational work
Preventive treatment
13. A stuff for carrying out of the КОН-test is:
1. The broken off hair
2. Squamae from the focus of a lesion
3. The changed nails
4. Histic juice from a ulcer
14. At the child the microsporia of a hair part of a head is suspected. Name
methods of diagnostics of this disease:
1. Microscopic examination of a hear from the foci of a lesion
2. Cultural method of diagnostics
3. A luminescent method
4. Studying an epidemiological anamnesis
15. What factors promote infestation with epidermophytosis:
1. Using the general footwear
2. Presence of a sick cat at home
3. Visits of baths, shows-rooms,water-pools
4. Using the common headdresses
16. The most typical clinical signs of rubromycoses are:
1. A primary lesion of mucosas
2. The tendency to general purpose a lesion of nail plates of hands and
solex
3. A generalized lesion of a hear part of a head
4. Erythematic - squamous character of skin of lesion feet
17. List attributes of an onychomycosis:
1. yellowish-grey colour of a nail
2. hyponychial hyperkeratosis
3. dystrophia of a nail plate
4. sign of "thimble"
18. The agent of multi-coloured lichen is:
1. Trichophyton rubrum
2. Microsporum canis
3. Pityrosporum orbiculare
4. Сandida albicans
19. Name clinical forms epidermophitosis of feet:
1. intertriginisuos
139
2.
3.
4.
5.
dishydrotic
erased
squamous-hyperkeratosous
All listed true
20. At treatment of a tuberculosis is used:
1. Isoniazidum
2. Rifampicinum
3. Ethambutolum
4. Delagilum
21. The tuberculoid type of a lepra differs by:
1. Not numerous erythematic maculae
2. reddish-cyanotic papules
3. An atrophy
4. Clusters with an ulceration
22. Clinic of a uncomplicated scabies characterized by:
1. Psoric courses
2. papules, squamae
3. papules, vesicles
4. tubercules, ulcers, cicatrix
23. What primary element at a leishmaniasis of a skin:
1. A macule
2. A papule
3. A vesicle
4. A tubercle
24. Typically for anthroponosous dermal leishmaniasis:
1. brownish-red tubercle
2. brownish-red papule
3. a spherical ulcer with miserable greyish-purulent abjointed
4. ulcer with abundant purulent abjointed and the undermined edges
25. Name the clinical form of an eczema, as a rule, not accompanying with
wipping:
1. True
2. dishydrotic
3. Microbial
4. Seborrheal
5. Professional
26. Specify the most typical attribute of an allergic dermatitis:
140
1.
2.
3.
4.
Arises only at the persons sensitized to the given stimulus
There is a polyvalent sensibilization
The area of an inflammation depends on concentration of a stimulus
A resistance to anti-inflammatory treatment
27. At what disease the white dermographism more often is defined:
1. atopic dermatitis
2. urticaria
3. allergic dermatitis
4. true eczema
5. psoriasis
28. What pimples make clinical pattern of a dermal itch of the listed
elements:
1. Papules
2. Blisters
3. Erosions
4. Vesicles
5. Excoriation
29. The itch of a skin as a sign accompanies diseases:
1. A diabetes
2. A helminthic invasion
3. Illnesses of liver
4. Herpes surrounding
30. What zones are maked in the locus of a lesion at a circumscribed
neurodermite:
1. lichenification
2. vesiculation
3. Isolated flat papules
4. Atrophies
31. Specify characteristic signs of a lesion of a skin at discoid to lupus
erythematosus:
1. An erythema
2. A follicular hyperkeratosis
3. A cicatrical atrophy
4. lichenification
32. Specify the basic pathohistologic attribute of a true pemphigus:
1. Spongiosas
2. An acanthosis
3. An acantolysis
141
4. A hyperkeratosis
5. A parakeratosis
33. What laboratory research is necessary to do for carrying out
confirmation the diagnosis of a vulgar pemphigus:
1. Unguentums - impresses on acantholytic cells
2. Analysis of a blood on Saccharum
3. Clinical analysis of a blood
4. Sowing contents of bladder on flora
5. Research of contents of bladder on an eosinophilia
34. The clinical pattern of the primary period of lues is characterized by
the following attributes:
1. A hard ulcer
2. regional scleradenitis
3. lichenification lymphadenitis
4. roseolous pimple on a trunk
35. What clinical signs are not at patients with an primary lues:
1. Papules of palms and soles
2. The erythematic angina, a cicatrizing hard ulcer
3. Labyrinthine deafness
4. saber-shaped anticnemions
36. What from the listed attributes are characteristic for a typical hard
ulcer:
1.
A plate infiltrate in the establishment of a ulcer
2.
Polycyclic outlines
3.
souse-shape edges
4.
abundant purulent discharge
37. What diagnoses can be made to the patient with sharply positive
serological tests on a lues at absence of clinical signs:
1. A lues hidden early
2. A lues hidden not specified
3. A lues hidden late
4. A lues decapitated
38. What clinical signs are characteristic for the secondary recurrent lues:
1. A leukoderma
2. branny lichen
3. A syphilitic dysphonia
4. Surrounding herpes
142
39. What combination of clinical exhibitings typically for the secondary
fresh lues:
1. alopecia, papules of palms and soles
2. An erythematic angina, flat condylomas
3. A leukoderma, flat condylomas intergluteal fold
4. An erythematic angina, oddments of a hard ulcer
40. Syphilides of the tertiary term:
1. Papules
2. Tubercule
3. A leukoderma
4. Nodes
41. Inspection of patients by a tertiary lues necessarily includes
consultations:
1. The oculist
2. The neuropathologist
3. The otolaryngologist
4. The therapist
42. Features of signs of a tertiary lues:
1. Wavy flow
2. Long terms of development of a lesion
3. Slight number acyanotic treponema
4. Insignificant infectivity
43. Probable attributes of a serotinal{late} congenital lues include:
1. A syphilitic chorioretinitis
2. saber-shaped anticnemions
3. A saddle shaped nose
4. gluteal-shaped skull
5. All listed true
44. List signs, characteristic for the early congenital lues, not meeting at
the got lues:
1. Gogzinger,s diffuse infiltration
2. A syphilitic pemphigus
3. A syphilitic rhinitis
4. Flat condylomas
45. Specific drugs used for treatment of patients by a lues:
1. Drugs of penicillin
2. Pyrogenic drugs
3. Drugs of bismuth
143
4. Vitamins
46. Criteria curability lues are:
1. High-grade treatment
2. benign clinic-serologic control,s result
3. Absence of attributes of a lues at inspection on all members and
systems
4. Negative results RIT
47. At inspection of the patients, suffering with urethrites of the contagious
nature, it is necessary carry out the following researches:
1. A capture of Unguentums from a urethra
2. cytoscopic research
3. A blood analysis on КSR
4. A biochemical blood analysis
48. What should be tactics of the doctor after the terminal of therapy of the
patient with a gonorrheal acute urethritis:
1. A capture of Unguentums from urethra and at reception of a negative
taking out from the count
2. Carrying out of control inspection after provocation and in case of
absence of an infection contamination the terminal of observation of the
patient
3. Assignment of preventive treatment of others possible STD
4. The further observation of the patient with control inspection in a
month for exception other STD
49. Specify, in what cases you will not appoint preventive treatment to the
patient having sexual contact to the patient by a lues by the woman if after
contact has passed:
1. From 4 till 6 weeks
2. From 2 till 4 weeks
3. More than 6 months
4. From 1 till 2 weeks
5. Till 3 weeks
50. Patient О., 35 years, is directed on advisory reception to
дерматовенерологу with the diagnosis of the early hidden{concealed} lues.
What exhibitings can be at the patient:
1. Skins and seen mucosas are free from specific rashes, a mesaortitis
2. Gummous ulcers of an anticnemion, RIT it is sharply positive
3. An abundant shallow roseola, polyadenitis, oddments of a hard ulcer
4. Skins and seen mucosas are free from specific rashes, an internals and
nervous system without the expressed pathology, the complex of serological
tests is three times sharply positive, RIT - 100 %.
144
Standards of answers
1. А
2. С
3. Д
4. Д
5. Д
6. 2
7. 2
8. Е
9. А
10.Д
11.А
12.А
13.А
14.Е
15.В
16. С
17. А
18. 3
19. Е
20. А
21. А
22. В
23. Д
24. Д
25. Д
26. 1
27. 1
28. 5
29.А
30. В
31. А
32. 3
33. 1
34. А
35. Е
36. В
37. А
38. В
39. Д
40. С
41. Е
42. Е
43. Е
44. А
45.В
46.А
47.А
48.С
49.С
50.Д
The literature
1. Венерические болезни под ред. член-корр. АМН СССР, проф. О.К.
Шапошникова. М.: Медицина, 1980,527 с.
2. Дифференциальная диагностика кожных болезней / Руководство для
врачей под ред. проф. Б.А. Беренбейна, проф. А.А. Студницина. М.:
Медицина, 1989, 671с.
3. Иванов О.Л. Кожные и венерические болезни (учебник для студентов
медВузов). М.: Шико, 2002, 477с.
4. Самцов А.В. Заразные дерматозы и венерические болезни. Современные
методы лечения / Справочник. Санкт-Петербург: Специальная литература,
1997,139с.
5. Скрипкин Ю.К., Машкиллейсон А.Л., Шарапова Г.Я.
Кожные и
венерические болезни (учебник для студентов медВузов). М.: Медицина,
1997,462с.
145
A.O. Rakhimzhanova
Course of lectures on dermatovenerology
(educational-methodical manual)
Отпечатано в типографии КГМА
г. Караганда,
ул. Гоголя, 40
Объем 9.2 уч. печ.. л.
Тираж 100 экз.
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147
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