1

Theme of the lesson:

PLAGUE. TULAREMIA.

Plague.

The Activator is Yersinia pestis – gram-negative bacillus with bipolar

colouring on Romanovsky. It forms toxic substance with properties of exo- and
endotoxin. It has 18-20 antigens. The antigenic generality with the activator of
tularemia is revealed; that provides efficiency of antitularemial vaccination for
reduction of a susceptibility to plague.

Epidemiology
Plague in the natural focuses is the disease of wild rodents. The person is
infected from animals at a sting of fleas, at direct contact to ill animals or their
corpses, by alimentary way at usage of meat (for example, of an ill camel) and
airborne way at contact to the ill person with pulmonary form of plague. At
pulmonary forms of plague epidemic danger of the ill person sharply raises.
Plague concerns to infections with various ways of transmission; conducting
way is transmissive.
The susceptibility of the person to plague infection is very high.
In development of epidemic of plague 3 phases are allocated:
1. A rodent - a flea - a rodent;
2. A rodent - a flea - the person;
3. The person, ill by secondary pulmonary plague, - the person, ill by initial
pulmonary plague – the person, ill by initial pulmonary plague.

Pathogenesis
The activator will penetrate into an organism of the person through a skin,
mucous membranes of eyes, a mouth, a nasopharynx, respiratory ways and a
gastrointestinal tract. The mechanism of transmission and a place of introduction of
plague bacillus determine pathogenesis and clinic of the disease.
At infection through a sting of a flea the activator with a current of lymph achieves a
regionar lymphatic node and reproduces in it, causing serous-hemorrhagic
inflammation with necrosis of a lymphoid tissue and expressed periadenitis (the
bubonic form).
Skin changes do not usually arise. Only in 3-4 % initial effect as ulcers is formed.
Initial generalization of process arises in result of loss of barrier function by
lymphatic node (uncompleted phagocytosis). The activator will penetrate by the
hematogenic way into internal organs and remote lymphatic nodes. The septic form is
developed. Necrosis, infiltration and serous impregnation of vascular walls arise. In a
cardiac muscle there are haemorrhages in a pericardium and under an endocardium, in
vessels there are necrotic changes, in a liver, a spleen, kidneys there are
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haemorrhages, dystrophy, focuses of necrosis. At the getting of plague microbes into
a pulmonary tissue pneumonia (secondary – the pulmonary form) arises. At hit of the
activator in an organism of the person in the airborne way the primary - pulmonary
form of plague with serous-hemorrhagic changes and the subsequent necrosis of walls
of alveoluses, capillaries and vessels is developed. Very quickly there is a
generalization of process.
Without treatment lethality at bubonic plague makes 60 %, at pulmonary - 100
%. The overcome illness usually leaves strong immunity.

Clinic
The incubatory period makes 2-6 days. The beginning is acute, with sharp rise
in temperature of a body up to 39-40°C, accompanying by fever, headaches and
muscular pains, sometimes vomiting. At many patients psychomotor excitation,
delirium, hallucinations, unsteadiness of gait and indistinctness of speech (it is similar
to a condition of intoxication) are observed. A face of the patient expresses suffering,
its features are sharpened, puffiness and cyanosis as consequence of cardiac
insufficiency are possible. Borders of a heart are expanded, tones are deaf, frequency
of cardiac contractions achieves 150-160 in one minutes and does not correspond to a
body temperature; arrhythmia and dicrotism are possible. Arterial pressure (especially
- systolic) is reduced. Hepatosplenomegalia is revealed. The white (“as a chalk”)
membrane in a tongue is characteristic. In heavy cases the DIS-syndrome is
developed.
According to G.P.Rudnev's classification allocate the following forms of
plague:
A. Mainly local (dermal, dermal-bubonic, bubonic);
B. Internal - disseminated, or generalized (primary - septic, secondary - septic);
C. Externally - disseminated, or central (primary - pulmonary, secondary - pulmonary,
intestinal).
The intestinal form as independent disease does not meet now. Last years the
pharyngeal form and bacteriocarriage are allocated.
The dermal form is met seldom (3-4 %) and it is characterized by formation of
necrotic ulcers, furuncles, hemorrhagic carbuncles in a place of a sting of a flea,
distinguished by sharp morbidity and slow healing with outcome in cicatrization.
The bubonic form of plague is connected to formation of sharply painful dense
conglomerate of inflamed lymphatic nodes, comissured with subject tissues. A little
bit later the skin above a bubo reddens, tensioned. For 8-12 days of the disease the
bubo can be opened with excretion of yellow-green pus, however now on a
background of antibacterial therapy resorption or sclerosis are usually observed.
Localization of the bubo influences on the severity and the prognosis of the disease:
heavy current is marked at the localization of the bubo on a neck; lesion of axillary
lymphatic nodes is danger because of occurrence of secondary - pulmonary plague as
a result of distribution of the activator on lymph-and hematogenic ways.
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Lethality at bubonic plague without treatment by antibiotics was made in the past 40-
90 %.
SEPTIC FORMS of plague are developed very quickly (the incubatory period
at the primary - septic form proceeds from several hours till 1-2 day); they are
accompanied by expressed (stormy) intoxication at absence of lesion of a skin and
lymphatic nodes. In some hours from the beginning of the disease syndrome of
intoxication achieves the extreme expressiveness, there are symptoms of an
infectious-toxic shock and DIS-syndrome. Within 2-3 days almost all patients die at
the phenomena of hemorrhagic character or/and cardiac insufficiency.
PULMONARY FORMS are most dangerous for health people. The incubatory
period lasts from several hours to 3 days. At the first 24-36 hours of the disease
symptoms of lesion of lungs are not revealed, the expressed intoxication is marked.
For 2 day of the disease there are cutting pains in a chest, a dyspnea, fear of a deep
inspiration. Cough can join to a clinical picture of plague in the first day of the disease
or later. Firstly sputum is like glass, globular, and then becomes liquid, albuminoid,
with blood. More often a “damp” form with big quantity of sputum, less often – “dry”
(with excretion of very poor volume) are met. The physical data do not correspond to
the severity of the disease: the weakened breath with small quantity of damp rales and
crepitation is listened. Pains in a chest are amplified with each hour owing to
involving of a pleura, breath becomes superficial, with frequency till 50-60 in 1
minute. Lethal outcome becomes of 3-5 day of the disease at the phenomena of
progressing circulatory insufficiency, frequently - with edema of lungs.
TONSILLAR (PHARYNGEAL) FORM proceeds favorably; it is accompanied
by pains in a throat, enlargement of submaxillary and cervical lymphatic nodes,
sybfebrility. Antibacterial therapy of this form of plague is rather effective; duration
of disease is up to З days.
BACTERIOCARRIAGE (pharyngeal) is formed at people in an environment
of the patient by the pulmonary form with frequency up to 13 %. Virulence of strains
is high; however carriers do not fall ill with plague.
PLAGUE AT THE VACCINATED PEOPLE has the prolonged incubatory
period - about 10 days. In the first days of the disease on a background of subfebrility
painful bubo without the phenomena of periadenitis is appeared. At absence of
treatment by antibiotics in 3-4 days the plague gets typical current.

Laboratory diagnostics
For correct and timely making of the diagnosis it is not only necessary
carefully clinically to survey the patient but also to take into account the data of the
epidemiological anamnesis (contact to rodents, hunting on тарбаганов, marmots,
presence of similar diseases, stay in the natural focuses of plague). The main role in
distribution of the disease timely laboratory diagnostics is played. Researches will be
carried out in the special laboratories working in a regimen of antiplague
establishments.
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For bacteriological seed Hottinger’s mediums, Marten’s mediums, beef-extract
agar are used. Cultures are accomodated in thermostat at 28-30°С; the first viewing is
possible in 18-20 hours, final - in 5 days.
Biological tests are put on porpoises and white mice. For serological
diagnostics reaction of passive hemagglutination, reaction of inhibition of passive
hemagglutination and immunofermentative analysis are applied. Search of capsule
antigen by a method of reaction of neutralization of antibodies is possible.
Express - methods:
1) Luminescent – serological research;
2) A method of complex research of E.I.Korobkov (accelerated incubation,
bioprobes, bacteriophages);
3) A method of accelerated revelation with the help of bacteriophage;
4) stage-by-stage research of bioprobic animals;
5) biopropes on the animals processed by a chicken yolk.

Treatment
Patients ill by plague requires urgent isolation and hospitalization. Early
appointment of antibiotics - streptomycin, tetracyclins (Doxicyclin etc.),
Rifampicinum, Chinoxydinum is necessary.
Streptomycin at the bubonic form of plague is appointed intramuscularly in a daily
doze 3,0 g, at the pulmonary and the septic - 4,0 g; the doze can be reduced at a
combination with other antibiotics.
Oxytetracyclinum is introduced intramuscularly on 0,2 g once a day (1,2 g per day),
Laevomycetinum - intravenously on 2,0 g 3-4 times per day (6-8,0 g per day).
Duration of treatment by antibiotics does not depend on the form of plague and
makes not less than 7-10 days. It is possible to introduce antibacterial preparations in
a bubo.
Desintoxicational, cardiac preparations, glucocorticosteroids are widely used.
The persons who have overcome with plague leave from hospital after
disappearance of all symptoms of disease in 10-12 days; after the pulmonary forms -
in 2-3 weeks. The extract of reconvalescents is possible only after the repeated
negative bacteriological control. After an extract from a hospital there is medical
supervision for reconvalescents during 3 months.

Prophylaxis
In a basis of prophylaxis of plague in the natural focuses the epizootological
control which is carried out by the various organizations, including – antiplague
stations, departments of Center of hygiene and epidemiology lays.
At suspicion on plague patients are immediately hospitalized. The contact
(including contact on ventilating systems) are isolated for 6 days, to them preventive
treatment by Streptomycin - on 0,5 g 2 times per day is carried out.
Introduction of quarantine is accompanied by a series of the actions stipulated in
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plan of work in case of revealing of patients with Especially Acute Infection.
Antiplague suits of the 1st type are given out to the medical personnel.
Corpses of the died from plague persons are cremated or buried on depth of 2
meters with filling up by dry chloric lime (on a bottom - a layer not less than 10 sm).
Vaccination against plague will be carried out on plan and special epidemiological
indications. Supradermally or intradermally an alive vaccine EV promoting
development of the expressing immunity by duration not less than 6 months is
applied.

The order of putting on and taking off of an antiplague suit

An antiplague suit needs to be put on in the certain sequence:
1. Pyjamas (or an overalls);
2. Socks, boots;
3. Big kerchief (or a hood);
4. Antiplague dressing gown;
5. Padded-gauze bandage;
6. Glass;
7. Gloves.
Phonendoscope put on before a kerchief. Tapes on a collar of a dressing gown and
as a belt are tied up in front on the left side, necessarily by a loop; then tapes on
sleeves are tied up. A mask put on on the face so that the mouth and a nose were
closed, therefore the top edge of a mask should be at a level of the bottom part of an
eye-socket, and bottom - under a chin. Tapes of a mask are tied up by a loop on type
of four-tailed bandage. Putting up the mask, on each side of wings of a nose wadded
tampons to air did not pass under a mask are pawned. Glasses of spectacles are
rubbed with a slice of a dry soap for their prevention from the misting. A towel is
pawned for a belt.
The order of taking off. After the ending of work a suit is taken off slowly, in
strictly established order, immersing hands in gloves in a disinfectant solution after
taking off of each part of a suit. Boots are wiped from up to down by the separate
tampons moistened by disinfecting solution. A towel is taken out. Take off the glass
by the movement upwards and back. Not concerning by open sites of a skin there is
released from a phonendoscope. Glasses and a phonendoscope put in a bath with 70
% spirit. Taking off the mask, holding for outsets, and not letting go them, put a mask
by lateral side inside. Then, having lowered the upper edges of gloves, taking off a
dressing gown, simultaneously turning off it by lateral side inside. Untie and taking
off a kerchief, then gloves and, at last, a pyjamas. Having released from a suit, hands
process by 70 % spirit and carefully wash with soap.
After each application an antiplague suit is disinfected.

REALIZATION THE LESSON

The purpose of the lesson is to learn to diagnose plague according to clinic, the
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epidemiological anamnesis, laboratory research and also to make the plan of
treatment. It is paid attention to the natural focuses of plague.

Control questions to the beginning of the lesson

1. Name a source of an infection and the mechanism of infection.
2. Characterize a role of the person in morbidity of plague.
3. Give the general clinical characteristic of plague.
4. Enumerate clinical variants of plague.
5. Determine a degree of contamination of the patient depending on the
clinical form of the disease.
6. Than the bubonic form of plague is characterized by?
7. Enumerate methods of laboratory diagnostics of plague. Express -
diagnostics.
8. Name etiological preparations, their daily dozes, duration of course of
treatment.
9. Enumerate criteria of recovery at plague.
10. How is prophylaxis of plague carried out?

The test
1. The basic pathogenetic mechanisms of plague are:
1. Lymphogenic dissemination
2. Hematogenic dissemination
3. Toxemia
4. Disturbance of reological properties of blood and microcirculation
5. Metabolic destructive changes in organs and tissues
2. The basic factors of pathogenesis of the bubonic form of plague are:
1. Introduction of the activator through integuments
2. Inflammatory, hemorrhagic and necrotic changes in regionar lymphatic nodes
3. Generalized lymphoadenopathy
4. Toxicosis
5. Fibrinous inflammation on a place of an entrance gates
3. The basic factors of pathogenesis of the pulmonary form of plague are:
1. Regionar lymphadenitis
2. Periadenitis
3. Sharp pains at palpation of a bubo
4. Hepatolienal syndrome
5. General-toxic syndrome
6. Clinical manifestations of septic plague:
1. The expressed infectious-toxic syndrome with development of an infectious-
toxic shock
2. Hemorrhagic syndrome
3. Secondary bubos
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4. Encephalopathy
5. “Cretaceous” tongue (as a chalk)
7. Methods of laboratory diagnostics of the plagues having deciding value are:
1. Bacteriological
2. Bacterioscopic
3. Biological
4. Serological
5. Immunological
8. Suspicion on plague cause:
1. Stay in region, epidemical on plague, for 5 days prior to the beginning of the
disease
2. Acute fevering condition with the phenomena of neurotoxicosis
3. Hemorrhagic manifestations
4. Regionar lymphadenitis
5. All complex of the enumerated facts
9. Principles of treatment of plague are:
1. Introduction of antitoxic serum
2. Antibacterial therapy
3. Intensive desintoxicational therapy
4. Surgical processing of a place of an entrance gates
5. Correction of metabolic disturbances
10. Principles of antibacterial therapy at plague are:
1. Maximum early beginning
2. Parenteral introduction of antibiotics
3. Dozes of preparations, exceeding average therapeutic
4. Combination of antibacterial preparations
5. Long course of treatment

Discussion of the theme of the lesson is preceded with work of the student with
the thematic case history. The student prepares for the brief report in the offered case.
The following data are necessary:
1. Surname, name, patronymic, age, a residence and works, date of disease and
hospitalization;
2. Complaints at the moment of hospitalization;
3. The first symptoms of the disease: rise in temperature of a body (sudden, sharp
or gradual, its degree and duration), the phenomena of intoxication (headaches,
weakness, a sleeplessness, delirium);
4. Development of these symptoms during the disease (increase, stability,
reduction);
5. The epidemic data: stay in the natural focus of an infection, direst or indirect
contact with the fevering diseased, an patients with pneumonia, duration of the
incubatory period
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The objective data:
1. General condition, expressiveness of neurotoxication;
2. Color of external covers;
3. Condition of the lymphatic apparatus (enlargement, sharply painful lymphatic
nodes with periadenitis);
4. Condition of respiratory system (a dyspnea, fused (lobar) pneumonia with
plentiful bloody sputum);
5. Condition of cardiovascular system (sharp tachycardia, sharp downturn of the
arterial pressure);
6. Condition of digestive system (enlargement of a liver and a spleen);
7. Condition of urine-excretory system (shocking coma)
On the end of this work the student writes a substantiation of the provisional
diagnosis. Then the case history of the patient with plague is reported and discussed in
group. Students jointly make up the plan of examination of the patient, then get
acquainted with results of laboratory researches and discuss them.
On the basis of all available data the diagnosis with the indication of the period
and severity of the disease is made. Treatment is discussed: conditions of
hospitalization, a regimen, a diet, necessity of the control for diuresis and defecation.
The prognosis of specific complications is marked. Criteria of recovery and an extract
of the patient are discussed.
In the end of the lesson students solve clinical situational problems and answer
on the questions to them.

PROBLEM
The Patient B. 29 years, he is examined in-home. He was ill in 2 days after
returning from Transbaikalia. The chilling, a body temperature is 40°C, sharp
headaches and muscular pains has appeared. Sharp pains in a chest, a dyspnea, cough
with plentiful sputum, all over again like glass, and later bloody have joined in the
evening. During З of days the condition remained heavy. At survey a condition is
heavy, in a place and time he is not focused, a face is puffiness, cyanotic, and eyes are
red. On a skin there are petechias which merge in extensive haemorrhages. Meningeal
symptoms are negative. Breath is superficial, a dyspnea, tachypnoe is 40 in one
minute. Tones of a heart are deaf, the arterial pressure is not determined, pulse is
frequent, arrhythmic. The frequency of cardiac contractions is 126 in one minute. A
tongue is covered with a white membrane, vomiting with blood. A liver and a spleen
are enlarged. He is not urinated. Stool is detained 3 days.

1. The diagnosis?
2. Tactics of the doctor?
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PROBLEM
The patient M., 40 years is delivered in infectious branch by a brigade of the
first aid on the 2nd day of disease. At receipt there are complaints to high temperature,
a headache, nausea, vomiting with an impurity of blood, muscular pains, lacrimation,
a dyspnea, cough.
The epidemiological anamnesis: 6 days ago he has returned from Angola
where was in official journey.
Objectively: an average condition, the patient is delayed, on questions he answers not
at once, answers are inadequate. A skin of a face is hyperemic, a face if puffiness.
Other sites of a body are pale, acrocyanosis is marked, Т is 40,5°С. In lungs breath is
vesicular, rales are not present. Number of breaths is 34 in one minutes. Heart: tones
are muffled, rhythmical. The frequency of cardiac contractions is 108 in 1 minute.
The arterial pressure is of 90/60 mm. The liver is enlarged, on 3 sm comes forward
from under a costal edge. The spleen is palpated. Stool is detained.

1. Prospective diagnosis.
2. Necessary laboratory researches.
3. Treatment.

Tularemia.

The Activator: Francisella tularensis Mc Coy et Chapin - motionless

polyamorphous bacteria. They have somatic and membrane antigens to which
virulence and immunogenicy of the activator are connected. On prevalence three
subspecies of a microbe: non-arctic (american) with the greatest pathogenicity,
golarctic (or european-asian) and central-asian are allocated.

Epidemiology
The basic reservoir and a source of an infection of tularemia are rodents. The
activator also can be kept in ixodic ticks. The susceptibility of people to tularemia is
almost absolute.
Ways of infection are:
1. Direct contact to an ill animal or secondary source of an infection (through
a skin, mucous membranes);
2. Alimentary infection through mucous of an oropharynx or a digestive tract
at the useage of the infected water or foodstuff;
3. Aspiration infection through respiratory ways - the dust containing the
activator;
4. Transmissive infection with blood-sacking carriers.
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Ixodic and Gamasic ticks, mosquitoes, gadflies, fleas can be carrier. From ill
people the infection is not transmitted to the healthy person.

Pathogenesis
The activator of tularemia will penetrate into an organism of the person through a
skin (even not damaged), mucous membranes of eyes, organs of breath and a
gastrointestinal tract. Localization of an entrance gate influences of the form of
pathological process. In this place the initial affect is developed: on a skin - papule,
passing in a ulcer, on mucous of tonsils - angina, in respiratory ways - lesion of
bronchial tubes and pulmonary parenchyme with the focuses of necrosis. At the
abdominal form there is an edematous mucous membrane of intestine with necrosises
and ulcerations, at lesions of eyes - papule on a mucous membrane of eyelids.
From initial affect on lymphatic vessels microbes achieve the regionar lymphatic
nodes where they are reproduces or partially die with excretion of endotoxin. There
are inflammatory reactions with lymphadenitis and insignificant periadenitis.
Development of regionar lymphadenitis is completely necessary for any clinical form
of tularemia. At insufficient barrier function of lymphatic nodes the activator will
penetrate into blood that leads to bacteriemia with generalization of process and
formation of the disseminated inflammatory focuses in lymphatic nodes, a spleen,
cardiovascular system and other organs. Dystrophic changes in a cardiac muscle and
proliferation of cells of vascular walls are developed. A liver and a spleen are
enlarged.
After the disease there is a proof immunity.

Clinic
The incubatory period continues 3-7 days. To all clinical forms tularemia a number
of the general symptoms is peculiar. The beginning of the disease is acute. Within
several hours the body temperature raises up to 38,5-40°C, intoxication, sometimes
with neurotoxicosis, euphoria is developed. Pulse corresponds to temperature or lags
behind a little. The arterial pressure is decreased. A face is hyperemic, scleras are
injected. A liver and a spleen can be enlarged. Remitted and intermitted fevers with
duration from 6 about 25-30 days are the most characteristic.
The general semiology is supplemented with a number of symptoms depending on
localization of an entrance gate.
The most widespread form of tularemia is BUBONIC accompanied by
enlargement of lymphatic nodes up to 1-5 sm in diameter. Bubos (conglomerates of
lymphatic nodes) are poorly painful, have clear contours. At half of patients they are
slowly - within several months - resolved. Other variant of development of a bubo is
also possible: in 2-4 weeks from the beginning of disease there is a softening, and
then - opening with excretion of rich creamy pus.
THE ULCEROUS-BUBONIC form is accompanied by dermal manifestations
in a place of introduction of the activator (initial affect). At THE EYED-BUBONIC
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form in a place of an entrance gate of an infection on a conjunctive of one eye there
are yellowish follicles, bubo is located in parotid or submaxillary areas.
At alimentary infection THE ANGINOSOBUBONIC form of tularemia with
ulcerous-necrotic (less often – catarrhal) angina, simultaneous enlargement of
submaxillary and cervical lymphatic nodes and slow return development can arise.
Membranes on tonsils have a rather dirty shade and are hardly removed, that results in
necessity to differentiate this condition from diphtheria of an oropharynx.
THE PULMONARY FORM of tularemia can proceed in bronchitic and
pneumonic variants. Clinical manifestations consist in moderately expressed
semiology of focal pneumonia with unproductive cough sometimes - with bloody
sputum. At rediography only since 2-3rd weeks the enlargement of radicial,
paratracheal, mediastinal lymphatic nodes in the 1st and the 2nd oblique positions is
revealed. Current of the disease has long character, about 2 months and more.
Complications are possible: abscesses, bronchiectasises, pleurisies.
Semiology of THE ABDOMINAL FORM of tularemia is caused by lesion of
mesenteric and other lymphatic nodes on a course of gastrointestinal tract.
Occurrence of THE GENERALIZED FORM is connected to the big doze of the
infect, its high virulence and, especially, with a low level of the immune answer of the
macroorganism. Clinic-pathogenetic essence of this form is a sepsis of specific
etiology.

Laboratory diagnostics
Bacteriological researches are poorly accessible and insufficiently effective. To
confirmation of the diagnosis serological reactions: agglutinations, RPHA, PNHA are
applied; they become positive on the 2nd week of the disease (a diagnostic titer is
1:100). Since 3-5 days of the disease intradermal test with tularine can be put.
Biological methods of diagnostics are also used.

Treatment.
For the realization of etiological therapy streptomycin in daily doze 1,0 g (at
pulmonary and generalized forms 2,0 g) during 8-10 days is applied.. It is possible to
appoint also Tetracycline (2,0 g per day), Laevomycetinum (2-2,5 g per day).
Duration of reception of antibiotics is up to 5-7 days of a normal body temperature. In
case of long current in former years treatment by a killed vaccine was applied.

Prophylaxis
Against tularemia under epidemic indications vaccination with supradermal
introduction of an alive vaccine is carried out. After vaccination proof immunity is
formed by duration of 5-15 years. Epizootological and the epidemiological control,
deratizational and other actions directed on decrease of probability of contact of the
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person with a source of an infection or its carrier will be carried out.

REALIZATION THE LESSON

The purpose of the lesson is to learn to diagnose tularemia according to clinic, the
epidemiological anamnesis, laboratory research and also to make the plan of
treatment. It is paid attention to the natural focuses of tularemia.

Control questions to the beginning of the lesson

1. Name a source of an infection and the mechanism of infection.
2. Characterize a role of the person in morbidity by tularemia.
3. How is early diagnostics of tularemia carried out?
4. Enumerate clinical variants of tularemia.
5. Than is the bubonic form of tularemia characterized by?
6. Enumerate differences of the bubonic form of tularemia and plague.
7. Name etiological preparations at tularemia.
8. How is laboratory diagnostics of tularemia carried out?
9. Name possible outcomes of a bubo at tularemia.
10. How is prophylaxis of tularemia carried out?

The test.
1. In pathogenesis of tularemia have a value:
1. Dynamic development of initial affect
2. Regionar lymphadenitis
3. Syndrome of intoxication
4. Toxic-allergic reactions
5. Development of secondary bubos
2. The bubonic form of tularemia is shown by:
1. Regionar bubo
2. Moderate morbidity at palpation of the enlarged lymphatic node
3. Clear contours of a bubo
4. Fever
5. Intoxication
3. Lesions of a skin at ulcerous-bubonic tularemia are:
1. Macula
2. Papule
3. Vesicle
4. Pustule
5. Ulcer with the raised edges and a crust in the form of “cocarde”
4. The eyed-bubonic form is shown by:
1. Papular and then erosive-ulcerous formations on a conjunctive
2. Edema of eyelids
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3. Regionar lymphadenitis
4. Lesion of a cornea
5. Long heavy current
5. Signs of the anginous-bubonic form of tularemia are:
1. Pains in a throat at swallowing
2. Hypertrophy of tonsils
3. Edema of palatine arches and an uvula
4. Necrotic changes on tonsils
5. Regionar bubos in submaxillar, cervical or parotid areas
6. The abdominal form тof tularemia includes:
1. Pains in an abdomen
2. Gastroenteritis, colitis
3. Symptoms of irritation of a peritoneum
4. Hepatolienal syndrome
5. Enlargement of mesenteric lymphatic nodes
7. The pulmonary form of tularemia is shown by:
1. Clinical signs of tracheobronchitis
2. Enlargement of bronchial, mediastinal, paratracheal lymphatic nodes
3. Development of pneumonia
4. Hemoptysis
5. Aerogenic way of infection
8. Methods of laboratory diagnostics of tularemia are:
1. RA
2. RNHA
3. Toxicological methods
4. Dermal-allergic test with tularine
5. Biochemical methods
9. Principles of therapy of tularemia:
1. Etiological treatment
2. Desintoxicational therapy
3. Opening of suppurative bubos
4. Hyposensitizating therapy
5. Application of specific antitoxic serum

Discussion of the theme of the lesson is preceded with work of the student with
the thematic case hystory. The student prepares for the brief report in the offered case.
The following data are necessary:
1. Surname, name, patronymic, age, a residence and works, date of disease and
hospitalization;
2. Complaints at the moment of hospitalization;
3. The first symptoms of illness: rise in temperature of a body (sudden, sharp or
gradual, its degree and duration;
 14
4. Development of these symptoms during the disease (increase, stability,
reduction);
5. Epidemic data: direst or indirect contact to rodents, the usage of not boiled
water from open reservoirs, stings of the insects, similar diseases among
environmental people, presence of a vaccination against tularemia;
The objective data:
8. General condition;
9. Color of external covers, presence of specific affect in a place of an entrance
gate of an infection;
10. Condition of the lymphatic apparatus (enlargement of lymphatic nodes);
11. Condition of respiratory system (bronchitis, pneumonia);
12. Condition of cardiovascular system (dullness of tones, AP);
13. Condition of digestive system (condition of a tongue, mucous of oropharynx);
14. Condition of urine-excretory system.
On the end of this work the student writes a substantiation of the provisional
diagnosis. Then the case history of the patient with tularemia is reported and
discussed in group. Students jointly make the plan of inspection of the patient, then
get acquainted with results of laboratory researches and discuss them.
On the basis of all available data diagnosis with the indication of the period
and severity of the disease is made. Treatment is discussed: conditions of
hospitalization, a regimen, a diet, necessity of the control for diuresis and defecation.
The prognosis of specific complications is marked. Criteria of recovery and an extract
of the patient are discussed.
In the end of the lesson students solve clinical situational problems and answer
the question to them.

PROBLEM
In clinic of infectious diseases in the middle of May the patient M., 30 years,
with the diagnosis “grippe” was delivered.
He complained of feeling of heat, a headache. He is sick З day. Condition is
satisfactory, temperature is 38 °C. The rash is not present, pulse is 100 in one minute.
By the side of internal organs pathology is not revealed, at survey of the patient
asymmetry of the face is noticed due to enlargement of a lymphatic node in
submaxillary area. At palpation it is marked: a lymphatic node in size is about a
pigeon egg, moderate morbidity, borders of unit are clear, with subject tissues node is
not comissured.
Epidemiological anamnesis: the patient did not leave village before disease;
during flood of river Oka he was borrowed the most part of time with catching of logs
from r. Oka for construction of a house. On logs he frequently noticed rats. He caught
logs by boat-hook, but pulled out them on a coast by the unprotected hands.

1. Of what disease is it possible to think?

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2. Make the plan of inspection.
3. Actions in the focus.

PROBLEM
Patient M., before disease he was engaged in hunting for a water rat, processed
hides in domestic conditions. He was ill through З day sharply: a fever, hidrosis at
night, rise in temperature up to 38 °C, weakness, a headache, pains in muscles. He
was treated by aspirin and penicillin from “grippe”, but there wasn’t improvement. At
survey – a face is hyperemic, pulse is frequent. The arterial pressure is 105/65. In
axillary area the enlarged lymphatic node, poorly painful, not comissured with
surrounding tissues is determined; the skin above the bubo is not changed.

1. The diagnosis?
2. With what is it necessary to differentiate?
3. Examination, treatment.