7 kinds iersiny Are. From them for the person three are pathogenic vida. It is the plague activator (Yersinia pestis), the pseudo-tuberculosis activator (Yersinia pseudotuberculosis), the activator intestinal iersinioza (Y. Enterocolitica). studying History iersiny . Sam the activator has been opened for 80 years earlier, than the clinic became known. Have been opened vozbuditeli a pseudo-tuberculosis in 1883 Mallasse and Vinem. Two years pozzhe Eberg has described morphological changes which developed in amazed tkanjah and has noticed similarity of these changes to those at a tuberculosis (specific granulemy differed from tubercular subjects, that they, as a rule, ne obyzvestljalis, kazeoznoe regeneration, them came much faster, in okruzhenii granulem huge cages were not appreciable. These changes have named a pseudo-tuberculosis. Pervoe time a pseudo-tubercular microbe allocated from animals (cats, dogs, gryzunov). In 1889 the morphology of this activator is in detail described. A little pozzhe researcher Zlatogor has noticed that the activator has kulturalnye, biohimicheskie, immunologicheskie similarities to the plague activator. In 1959 in Vladivostoke there was a large flash of the captured 300 persons. Disease protekalo with a fever. A rash, defeat of joints. The infection had similarity with skarlatinoj. This diagnosis was otvergnut. Bylo the assumption that disease is passed food by. Disease is conditional bylo is named Far East skarlatinopodobnoj by a fever. Further was ustanovleno, that this fever meets and in Khabarovsk territory, Amur oblasti, on Sakhalin. Now it is established, that this illness meets povsemestno. In 1966 the aetiology Far East skarlatinopodobnoj fevers has been established by self-infection experience. This experience was made by the professor VMA Znamensky. The activator intestinal iersinioza have found out in 1923 in the USA. In nachale classified as atypical shtammy Posterella pseidotuberculosis. In 1972 to year the international committee on systematisation of bacteria has entered new patrimonial nazvanie Yersinia as which activators have been ranked, a pseudo-tuberculosis. Obedinjajushchim for iersinii a pseudo-tuberculosis and iersinii intestinal iersinioza javljaetsja that that these two activators call identical pathological changes u the person, their differential diagnostics therefore is difficult. the AETIOLOGY . Exciters a pseudo-tuberculosis and intestinal iersinioza enter into family Enterobacteriacea. Are Gr (-) sticks. Have the rounded off ends. Length 0.8-2 micron. Are painted bipoljarno and settle down in the form of chains. Dispute as pravilo, do not form, but capsules have. At 18-20 degrees it is enough iersinii podvizhny. Are facultative anaerobami. Are capable to grow on simple and obednennyh nutrient mediums (are unpretentious). Optimum for growth is temperatura 22-38 degrees. These microorganisms - psihrofily. Grow at temperature 0-5 degrees (refrigerator) and 45 degrees. Biochemical activity gorazdo above at Yersinia enterocolitica than at Yersinia pseudotberculosis. Razlichajut 5 biochemical variants Yersinia enterocolitica, disease voznikaet at infitsirovanii 2, 3, 4 biovarami. At destruction of a microbic cage vydeljaetsja endotoksin. 1 and 3 serovary Yersinia pseudotberculosis produce ekzotoksin. Iersinii possess a set of factors of pathogenicity, that is are capable to adhesion, invazii and to endocellular parazitirovaniju. These properties are expressed in bolshej mere at Yersinia pseudotberculosis. Yersinia pseudotberculosis more virulentna, chem Yersinia enterocolitica. Are very steady against low temperature. In water at temperature 18-20 degrees survive more than 40 days if the temperature falls do 4 degrees - there live 250 days. Can be saved in foodstuff (milk, hleb). Are especially well saved on fresh vegetables (carrots, apples) - to 2 mesjatsev. In excrements in the frozen status about 3 months are saved, and at komnatnoj to temperature of 7 days. Ploho transfer drying and heating. At temperature above 60 degrees pogibajut in 30 minutes, to 100 degrees - perish at once. Are sensitive to dezinfitsirujushchim to solutions in working concentration. Have 2 antigenes - 0 (somatic) and N Yersinia pseudotberculosis have 2 antigenes: S and R. On a S-antigene they are subdivided on 6, and according to all available information on 8 serovarov. In 90 % sluchaev shtammy allocated from the person belong to the first serovaru, and in 9 % sluchaev to the third serovaru. The R-antigene is the general with Yersinia pestis. Yersinia enterocolitica has 50 serovarov. In a pathology of the person matter serovary O3, О5, О8, О9. These activators are sensitive to antibiotics from group levomitsetina, aminoglikozidov, tetratsiklina, tsefalosporinov. And eritromitsinu they are not sensitive To penicillin. EPIDEMIOLOGIJA . Mnogo similarities in epidemiological aspect. Both activators widely rasprostraneny in the surrounding nature also concern to saprozoonozam. In natural uslovijah many are ill animal (rodents, pets). Infection of the person v the natural centres extremely seldom occurs. Rodents the most susceptible to etomu to the activator. At them can arise epizootii, is available zimne-spring sezonnost. It is long allocate activators with excrements and with urine. Infect svoimi vydelenijami foodstuff and vodu. Vozbuditeli are very unpretentious, breed on use subjects, in water, pochve. The second tank in the nature (the first - rodents) - soil. Occurrence zabolevanija needs a considerable quantity of microbes (it pulls together them with / ruslovno-pathogenic microbes). More often diseases arise in cities, instead of in selskoj districts. The most amazed part of the population - persons of young age (15-40 years). What eat in a public catering is more often are ill. Disease registriruetsja all year long, but more often from February till May. The person catches alimentarnym by. The transfer factor - foodstuff (vegetables, salads, bread molochnye products) and water. Po the transfer mechanism iersiniozy can carry to group of intestinal infections. As pravilo, the person from the person does not catch (zoonoznaja an infection). To thicket zabolevanie arises as sporadic, but can be registered and group vspyshki, united by one power supply, and in district where the activator tsirkuliruet among rodents disease can carry endemichnyj character with ezhegodnymi liftings during zimne-spring time. PATOGENEZ the PSEUDO-TUBERCULOSIS . Psevdotuberkulez is zoonoznoe an infectious disease called vozbuditelem from sort Yersinia, proceeding with an intoxication, ekzantemoj, porazheniem ZHKT, a liver both other bodies and quite often accepting retsidivirujushchee techenie. Entrance gate - ZHKT. The first phase of infectious process - a phase zarazhenija. Microbes pass through an oral cavity transit, but in small percent sluchaev can hurt mucous and take root into fabrics, getting in regionarnye limfouzly, calling the phenomena of a pharyngitis and cervical limfadenita. Therefore at a part bolnyh in an initial phase of disease it can be marked kataralnyj a syndrome. Dalee the great bulk of microorganisms gets to a stomach. In a stomach of a condition for nih improper, they fall further - in distalnyj department of thin intestines (the most suitable conditions). The following phase patogeneza - a phase adaptatsii begins. The part of microbes gets in mucous and podslizistyj a layer, and vospalitelnye changes in this place happen very considerable. Can razvivatsja terminal ileit, at a part of patients - a sharp appendicitis. The part mikrobov does not hang in thickness of fabrics, and as though stick to a surface to the mucous membrane. Selected ekzotoksin and at patients the clinic diarejnogo a syndrome develops. Chastichno microbes can is brought in a thick gut, to call there damage. Razvivaetsja kolitichesky or dizenterijnopodobnyj a syndrome. The following phase - a phase regionarnoj infections. First three phases enter into the incubatory period - are not present kliniki. Microorganisms from a gut wall get in solitarnye follicles, mezenterialnye limfouzly. On occasion microbes remain only in regionarnyh limfouzlah without the further generalisation. Similar meets at latentnoprotekajushchej infections. If the lymphatic barrier is overcome by microbes sledujushchaja a stage - a phase gematogennoj disseminatsii. The beginning clinical projavleny as at destruction of microbes it is allocated endotoksin. Endotoksin circulates in blood, amazes TSNS, vegetative nervous system, sosudy, a liver, kidneys. The microbe with a blood current is carried on an organism and gets glavnym in the image in parenhimatoznye bodies (rich retikulogistiotsitarnymi kletkami). It leads to development of secondary pathological changes in these organah (in a liver to a spleen, lungs). The activator can be allocated from bodies: pochki - with urine, intestines - kal, with bile, with a saliva, with mokrotoj. In separate sluchajah at patients with a secondary immunodeficiency disease can accept septicheskoe a current. The microbe possesses strong sensibilizirujushchim action. Trety the factor patogeneza - allergic. In an organism of patients come to light priznaki rezchajshego irritations of immune system. In clinic it is marked reactions GNT in a kind giperartralgy, there are reactions GZT (specific granulemy). Harakteren the expressed immune answer. It was the bacterial period. After bakterialnym the period jet statuses to which it is possible otnesti knotty eritemu, syndrome Rejtera, mono - or oligoartrity etc. ustanovleno can develop, that Yersinia pseudotberculosis can be a push to development sistemnyh diseases (kollagenozov).immunitet is provided as gumoralnymi, tak and cellular factors of protection, and the leader is fagocitoz. Specific antibodies appear by the end of the first week of illness. Titr accrues ko to the second and third week. Immunity is formed slowly, unstable, sohranjaetsja about one year. Waviness techenija with the remission and aggravation periods is peculiar to clinical process. Are frequent seronegativnye cases, in svjazi with it repeated diseases are possible also. Recently it has been established, that at porazhenii a human body iersinijami can decrease functional aktivnost macrophages. Disbalans at level fagotsitarnogo an immunity link rassmatrivaetsja as the leading reason of formation of relapses. PATHOANATOMICAL CHANGES . U the lost patients changes in the majority of bodies and systems are marked. Most vyrazheny in lymphatic system where are formed specific granulemy and mikroabstsessy. In other bodies defeat is carried nonspecific dystrophic harakter. by CLINIC. polymorphism of clinical displays Is characteristic. For a pseudo-tuberculosis svojstvenna accurate recurrence of the periods bolezni. Periody:

In typical cases all periods bolezni. the Incubatory period are shown. Duration from 3 till 18 days (in srednem 10-11 days). The Initial stage is the period from the beginning clinical projavleny before rash occurrence (if rashes are not present - that till the end of the first feverish volny). At 90 % of patients disease begins sharply. On the average duration nachalnogo the period - 1-3 days. In the clinical relation this period has patognomonichnyh no symptoms. It is presented by the intoxication phenomena (a fever, golovnaja the pain, weakness).rezhe can be kataralnye the phenomena on type to a pharyngitis. U separate patients during this period there can be first symptoms local porazheny: ZHKT - a nausea, vomiting, a liquid chair; oporno-impellent system - pains v muscles, joints. the heat Period . Those symptoms which have appeared in an initial stage dostigajut the maximum degree of expressiveness. Symptoms local porazheny join. The most constant symptom - a fever. Some types temperaturnyh curves are characteristic. More often the fever carries remmitirujushchy character, can be intermittirujushchej or a constant. At patients with retsidivirujushchim current type lihoradka the wavy. At an easy current temperature subfebrilnaja or normalnaja. More often temperature high - 38-39 degrees. On the average prodolzhitelnost the feverish period of 1-14 days. Po expressivenesses of a fever define weight of a current. The easy form - a fever prodolzhaetsja 3-5 days. Srednetjazheloe a current - till 10 days. A heavy current - bolee 3 weeks. Appearance of the patient is characteristic. The person giperemirovano and odutlovato. The injection skler, giperemija glotki is marked giperemija necks, konjunktivit. In the soft sky it is frequent dot enantema. Occurrence otgranichennoj giperemii brushes of hands - " is characteristic; a symptom gloves", stop - " a symptom noskov". The brightest symptom - a rash (ekzantema). It settles down on neizmenennoj or giperemirovannoj a skin background. More often for 2-6 day from the beginning bolezni. At the majority it plentiful, melkotochechnaja, but can carry papuleznyj ili eritematoznyj character. Chashche it is localised on a stomach, on lateral surfaces of a trunk, on finitenesses vokrug joints. It is saved from several o`clock till 8 days. After disappearance sypi on the second - the third week, there is a peeling on palms and soles krupnoplastinchatoe, on a breast, a stomach - otrubevidnoe. From party ZHKT are marked projavlenija in the form of a gastritis, gastroenterita, terminal ileita, appenditsita. Pri palpatsii a stomach morbidity and rumbling in ileotsekalnoj areas is marked. V heavy cases appear peritonealnyj symptoms. At deeper palpatsii it is possible to find out a conglomerate mezenterialnyh limfouzlov, as a rule, palpatsija it is painful. Thereof the positive symptom Padalki (as can be defined at belly a typhus) - perkutornoe prituplenie in ileotsekalnoj oblasti. At 2/3 patients the liver increases, from under a costal arch acts on 1-2 sm, soft, slightly painful. For 2-3 day at patients can appear zheltuha. Its expressiveness is various - from subekterichnosti skler to bright zheltushnosti. 5-7 days, sometimes are saved longer. Harakterny changes are marked in urine. In urine there are bilious pigments (urine temnaja). In blood level of bilirubin and ALT (it is insignificant - in 3-5 raz) raises. At 20 % of patients the spleen increases. Language is densely imposed by white touch, and za the second weeks it is cleared, gets crimson colouring with gipertrofirovannymi sosochkami. Changes from nervous system: Head bol, weakness, dream infringement, at a part of patients - the phenomena meningizma, are more rare razvivaetsja a serous meningitis, is even more rare - meningoentsefalit. Defeat vegetativnoj nervous system: alternation oznobov and potlivosti, flying pains in kostjah, joints and on a course of nerves. / the rserdechno-vascular system substantially suffers: priglushennost tones of heart, a hypertension, otnositelnaja a bradycardia or a tachycardia. Defeat of joints - at half bolnyh is marked, more often in a kind artralgy, but can be and artrity. Kataralnye the phenomena or gradually die away, or pale into insignificance. Klinicheski in blood lejkotsitoz, nejtrofilez with palochkojadernym shift, limfopenija. Period remissions. Comes after disappearance of a rash and temperature normalisation. Postepenno local symptoms die away. As a rule, in most cases the period remissii coincides with the recover period. At other patients after the period remissii which 1-30 days proceed, again there comes relapse. For relapses harakterno insignificant display of a syndrome of an intoxication or absence ego. More often relapses are shown by defeat ZHKT and joints. Vyvod: for all patients are characteristic intoksikatsionnyj a syndrome, are characteristic allergicheskie displays, and displays the local various. At one dominiruet defeat ZHKT, at others - defeat of joints, at the third - defeat pecheni. Some in general do not have symptoms of local defeats. Depending on vyrazhennosti local defeats classification of a pseudo-tuberculosis (Clinic VMA) has been created clinical klassifikatsija. Klinicheskaja.

On weight: often there is an easy form (60 %), average weight (30 %), tjazhelaja (10 %). Besides, disease can proceed with relapses and without retsidivov. Skarlatinopodobnaja the form - is characteristic a fever and skarlatinopodobnaja a rash. Disease proceeds is good-quality, without relapses. Vyzdorovlenie comes after the heat period. Meets at 20 % of patients. Artralgicheskaja the form - joins all symptoms of the previous form plus porazhenie joints. The wavy current is characteristic. There is in 15 % sluchaev. an Icteric form - disease proceeding with the expressed defeat pecheni, infringements of its function, a jaundice syndrome, gepatosplenomegaliej. Vstrechaetsja in 5-7 % of cases. Abdominalnaja the form - it is characteristic preobladanie symptoms of defeat ZHKT. Most the frequent form - in 50 % of cases. More often than other forms gives relapses. Generalizovannaja the form - along with intoxication and fever symptoms razvivajutsja various sochetannye local defeats. Disease proceeds dlitelno and it is heavy. Meets in 2-3 % of cases. Kataralnaja the form - practically ne is diagnosed. Usually make diagnosis ORZ. in a basis of definition of weight of a current of illness the height and duration lihoradki is put, expressiveness intoksikatsionnogo a syndrome and weight along with manifestnymi clinical cases there can be cases when signs zabolevanija are shown insufficiently or are absent completely. Then speak about stertom or a latent current. Complications: polyarthritises, knotty eritema, sindrom Rejtera, infectious-allergic miokardit, meningoentsefalit, sharp appenditsit. DIAGNOSTICS. Laboratory diagnostics plays a main role directed by the diagnosis. Laboratornye tests: bacteriological, serologichesky, immunologichesky. Naibolee the informative test for early diagnostics of a pseudo-tuberculosis is iimmunologichesky which it is possible to name the express train - methods. He allows obnaruzhit an antigene of the activator with the help immunofermentnogo the analysis (IFA), reaktsii to agglutination and reaction indirect gemaggljutinatsii with an antibody for diagnostiki. Naibolshe the number of finds happens in the first week of illness. After desjatogo day for an antigene to search it is useless. Excrements serve basically as a material (positive finds in 60 % of cases), urine (20 %), is much more rare nosoglotochnaja slime. Bakteriologichesky a method. The method in the first week of illness is most effective. Material - excrements, urine, blood, limfouzly, contents of abscesses, washouts from rotoglotki. For revealing of pure culture of the activator the method Patersona and Cook who is based on ability of microbes to grow at low temperaturah is used. The definitive answer receive in 17-21 day from the moment of the beginning issledovanija. A method retrospective. Serologicheskie reactions - reaction of agglutination and RNGA. Are positive at 60 % bolnyh. Estimation spend in dynamics on increase titra antibodies. Diagnostic titr - 1/200. Blood take in the end of the first week and in 7-10 days. At a number bolnyh antibodies are not developed also reactions will be negative. Differential diagnostics is spent with a wide range infektsionnyh and neinfektsionnyh. Difficulties at a differentiation with virusnymi hepatitises, with a scarlet fever, with enterovirusnymi infections, with leptospirozom, with rheumatism, with sharp appenditsitom. Indications to hospitalisation : 1. A heavy current; 2. Development simptomov local defeats (terminal ileit with the irritation phenomena brjushiny, the expressed defeats of a liver accompanied by a jaundice, polyarthritises and t.d.) . TREATMENT . Dolzhno to be complex and to switch on as etiotropnuju, and pathogenetic, immunnostimulirujushchuju, giposensibilizirujushchuju therapy. Should be, it is adequate klinicheskoj to the form and weight of a current of illness. A diet: 1. The table №5 on Pevzneru if u patients leader is defeat of a liver and is a jaundice. 2. A table №4, if dominiruet intestinal frustration. Antibakterialnaja therapy: levomitsetin (0.5 h 4 times a day); tetratsiklin (0.3 h 4 times a day), aminoglikozidy (gentamycin, kanamitsin), tsefalosporiny, ftorhinolony. A course of antibacterial therapy - 2 weeks. It is possible to spend two semidnevnyh a course with antibiotic change. If the antibiotic is cancelled earlier, uvelichivaetsja percent of relapses. If there are expressed phenomena of an intoxication pokazana dezintoksikatsionnaja therapy (polyionic solutions, glucose solutions, gemodez). Taking into account frequency of allergic displays it is shown desensibilizirujushchaja terapija. In case of a heavy current application gljukokortikoidov. Obshcheukrepljajushchaja, stimulating therapy is possible. If the expressed defeat of joints naznachajut protivorevmaticheskie means. In case of appendicitis development - operatsija. Term of time disability depends on the clinical form and tjazhesti currents. As a rule, makes - 3-4 weeks. The core of a condition of an extract - clinical recover and normalisation of biochemical indicators. Kontrolnoe bacteriological research is not spent.

Article is published on a site http://www.rusmg.ru