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The source of the infection. The main reservoirs and sources of Hantaan
virus – are field mice, red-gray field-voles and Asiatic forest mice, of Puumala
virus – red field-voles (in endemic focuses of Central Russia their contamination
amounts to 40-57%). In cities house mice can be reservoirs of the infection. The
rodents excrete the viruses together with feces and urine. Contamination of a
man happens in an air-dust way, more seldom – during contacts with rodents
and infected objects of environment (brushwood, hay and others), in an
alimentary way – through vegetables, which are not heated. People are not
sources of the infection for those around them.
Clinical presentation
The incubation period is from 7 to 46 days, on average 2 weeks. The first
period – is febrile – it breaks out acutely, with chill and rise of temperature to 38
– 40оС and above. Fever can last for 7–8 days, in severer cases it also continues
during the next period. The patient complains of headache, weakness. There is
hyperemia of face, the upper part of chest, injection of sclerae and conjunctivas,
hyperemia of the fauces (without catarrhal occurances). A short-term visual
impairment is typical (insufficiency of accommodation: for example,
impossibility to distinguish a clock dial, small text). During this phase of the
disease there can be nausea, vomiting, heaviness and tenderness in the lumbar
region.
On the 2-4th day of the disease oligoanuric period starts. Symptoms of
intoxication augment; hemorrhagic syndrome appears (petechial hemorrhages
on skin, sclerous, nasal, gastric and intestinal hemorrhages). Renal insufficiency
progresses. Temperature, as a rule, falls. Objectively the patients have edemas:
puffy faces, pale eyelids. Visual acuity decreases. There is relative bradycardia,
hepatomegaly, a sharp tenderness during palpation in the lumbar region.
Palpation of the loins (Pasternatsky's symptom) is painful on the both sides –
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Treatment. Usually etiotropic preparations are not used; there are data on
an effectiveness of amikacin. Pathogenetic treatment includes disintoxication
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When and how (presumably) did the contamination of the patient happen?
It is necessary to find out epidemiological anamnesis: sanitary living and
feeding conditions, presence of rodents at home, trips to the countryside. What
is the duration of the incubation period?
Objective data of the patient’s examination: condition, color of skin,
presence of dryness or edema of skin and mucous membranes, appearance of
skin rash. Condition of the cardiovascular (tachycardia, arrhythmia; pulse rate,
level of arterial pressure when it was measured by a doctor last time) and
respiratory system, gastrointestinal tract (presence of erosions, hemorrhages,
enteroparesis – during examination, palpation and according to indirect signs). A
special attention should be paid to condition of urinary system: diuresis, color of
urine, tenderness during palpation of the lumbar region – test of this symptom
must be carried out very carefully!
Case history of the patient with HFRS is discussed in the group. The
students together plan the examination of the patients. The teacher introduces
the students to the results of the laboratory examinations. On the basis of all
available data the students make out a diagnosis indicating a period and severity
of the disease. The treatment is discussed. The students together plan the
treatment of the patient, discus it with the teacher. Making out this plan it is
necessary to take into consideration a period of the disease, urinary output
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during a day – depending on it, to determine the volume of the introduced fluid.
It is necessary to discuss a list of preparations, normalizing microcirculation in
kidneys, as well as indications for prescription of diuretics and usage of
extracorporal hemodialysis.
At the end of the lesson the students do clinical tasks and answer the
questions to them. Accomplishing the tasks the students write in their copy-
books:
clinical diagnosis (taking into consideration the form and severity of the
disease);
plan of the patient’s examination;
they write out in Latin preparations having antibacterial and pathogenetic
actions.
Task №1
A male patient P., aged 30, consulted a therapeutist on 15 October,
complaining about weakness, headache, chill, raise of temperature to 380С,
photophobia, visual impairment (diffusiveness of objects), low back pains.
Case history. The patient fell ill on 8 October, when he felt an intense
headache, weakness, pains in joints. Temperature rose to 37.50С. During the
ensuing days the patient felt worse, low back pains appeared; he didn’t consult a
doctor. On 14 October temperature rose to до 390С, weakness augmented, low
back pains intensified. Eyesight became worse: illegibility of contours of some
objects occurred; he couldn’t read text, written in a small print. On skin rash
appeared. There was nosebleed twice a day.
Objective examination: general condition is mild. Skin is hyperemic. On
the shoulders and back – there is a petechial skin rash. In the lungs the
respiration is vesicular. Heart sounds are muted, the rhythm is regular. The pulse
is 66 beats per minute. АBP – is 100/60 mm of mercury column. Pasternatsky's
symptom (palpation) is positive on the both sides. Stool is normal.
Epidemiological anamnesis: from 11 September till 9 October he was in
the countryside. In a house, where he lived, there were a lot of mice.
Questions:
1. What is a presumptive diagnosis?
2. Plan of the examination
3. With which disease it should be differentiated?
4. Therapeutic approach (conditions of transportation and hospitalization;
treatment).
Task №2
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Questions:
1. What is a presumptive diagnosis?
2. Plan of the examination.
3. Plan of the treatment.