Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Behçet's disease wikipedia , lookup
Germ theory of disease wikipedia , lookup
Infection control wikipedia , lookup
Sjögren syndrome wikipedia , lookup
Hygiene hypothesis wikipedia , lookup
Management of multiple sclerosis wikipedia , lookup
Hospital-acquired infection wikipedia , lookup
Epidemiology of syphilis wikipedia , lookup
Globalization and disease wikipedia , lookup
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 2 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 3 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 4 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 5 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; 6 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). 7 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 8 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). 9 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. 10 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 11 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 12 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 13 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.; 14 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 60 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. 61 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 62 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, 63 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 65 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 67 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 68 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; 69 - 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 80 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 81 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 82 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 84 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 85 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: 86 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. 88 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. 90 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 91 (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. 92 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 93 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 94 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. 95 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. 96 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 97 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 98 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 99 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 100 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. 101 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. 102 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, 103 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 104 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, 105 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). 106 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. 107 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. 108 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: 109 - 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. 110 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 111 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. 112 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. 113 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. 114 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 115 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 – 116 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 117 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 118 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. 119 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 120 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. 121 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). 122 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 123 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 124 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 125 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 126 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, 127 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: 128 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. 129 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, 130 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 131 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 132 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. 133 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: 134 - 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. 146 147 148