Case history of herpes zoster. Respiratory system. VIII. Data from laboratory and instrumental studies

In men and women, a disease such as recurrent herpes is common. It is called so because after the treatment, the rash appears again. Most often, weakened people face a similar problem. may be negative.

Chronic recurrent herpes is a viral disease that affects the skin and mucous membranes. The causative agent of infection -. Chronic herpes develops against the background of acute in the absence of proper treatment and a decrease in immunity. The risk group includes weakened people. Herpes is widespread throughout the world. The virus is present in 90% of people, but only a small proportion of those infected develop symptoms.

By the age of 40, the risk of infection increases to 40-50%. There are simple and. The causative agents in both cases are HSV types 1 and 2. The skin of the face, genitals and internal genital organs are affected. The relapsing form of the disease develops when the virus is reactivated in the body. There are 3 degrees of severity of herpetic infection.

With a mild form, relapses are observed less than 1 time in 4 months. With moderate herpes, the recurrence rate is 4-6 times per year. In severe cases, rashes and other symptoms appear monthly. Chronic recurrent genital herpes can occur in different forms. The following types are known:

subclinical;
asymptomatic;
abortive;
macrosymptomatic.

In the first case, the symptoms are mild. Patients are concerned about mild itching and cracks in the affected area. In the macrosymptomatic form, there is itching and pain. The danger in terms of the spread of infection is hidden herpes. Such patients are unaware of the disease, but can infect their sexual partners.

Main etiological factors

The reason for the development of herpes is not one. The disease is highly contagious. The virus can enter the human body even in childhood. This is carried out mainly by a contact or aerosol mechanism. occurs during unprotected sexual intercourse.

During the period of exacerbation, the probability of transmission of the virus reaches 100%. Initially, the pathogen penetrates the nervous tissue. There he is able to live for years without causing a rash. The basis of frequent herpes appears is a decrease in protective forces. This is the starting factor for the activation of the virus.

The causative agent begins to multiply actively. The following causes of the development of recurrent herpes are known:

decreased immune status;
addiction;
chronic alcoholism;
contact with sick people;
use of other people's things;
promiscuity;
engaging in commercial sex;
acquired immunodeficiency syndrome on the background of HIV;
hypothermia.

Chronic recurrent herpes is more often detected in certain categories of people. These include prostitutes, homeless people, drug addicts, alcoholics and homosexuals. Rashes are often found in people after major operations and radiation therapy. The appearance of herpes is directly related to human activity.

Risk factors are:

hypothermia of the body;
insufficient intake of vitamins and animal proteins with food;
poor living conditions;
non-compliance with personal hygiene;
stress;
overwork;
work at night;
hypodynamia;
insufficient hardening;
abortion;
taking immunosuppressants or systemic corticosteroids.

If it often appears, then close contact with an infected person may be the cause. . In women, the occurrence of relapse may be associated with the menstrual cycle.

Signs of herpes simplex

The most common is simple (labial) herpes. With the development of relapse, the symptoms will be less pronounced than in the acute form of the disease. The main symptom is the appearance of a rash on the skin. Vesicles (vesicles) appear. They have the following features:

reach a size of 1-3 mm;
itchy;
accompanied by burning;
rise above the skin;
occur predominantly around the mouth and nose;
contain liquid inside;
burst and dry out in 5-7 days;
located in small groups;
accompanied by reddening of the skin.

The recurrence of herpes is characterized by the presence of 1 or 2 foci of the rash. After a few days, the exudate becomes cloudy. The onset of relapse is characterized by the appearance of burning and itching. There may be mild soreness. The general condition of patients does not change. Within a week, the bubbles open, and erosions form in their place.

Active stage of herpes simplex.

They are bright red, painful and irregular in shape. Soon, a yellowish coating appears on the erosions. Hemorrhagic crusts often form in the lip area. In some cases, regional lymph nodes are enlarged. After the disappearance of the rash, a slight pigmentation of the skin remains. She disappears after a few days. Scars are not formed.

Often jumps out herpes on the oral mucosa. The palate, gums and cheeks are affected. If herpes often forms in the same place, then we are talking about a fixed form of the disease. In childhood, this pathology recurs, causing stomatitis. For some people, the symptoms of the disease appear at certain times of the year.

Recurrent genital herpes

The rash may appear in the genital area. In this case, we are talking about recurrent genital herpes. This pathology proceeds in a monotonous, arrhythmic or subsiding form. Relapses occur in 50-70% of patients who have had this infection in the past. Frequent herpes with practically unchanged phases of remission indicates a monotonous form of this pathology.

The arrhythmic course is distinguished by different duration of remission periods. They can be delayed for 5 months or 2 weeks. The longer the remission, the more intense the relapses. The subsiding form proceeds most favorably. With it, the severity of relapses decreases, and the periods of remission are lengthened.

Chronic herpes develops against the background of acute in the absence of proper treatment and a decrease in immunity. The risk group includes people with weakened immune systems.

You need to know not only the causes of herpes in men and women, but also why it is dangerous. Despite the poorer symptoms, relapses are more dangerous than the primary form of the disease. If a rash often pops up, then this can lead to problems in family life, sleep disturbance, irritability, and even depression.

Movement is often difficult. Frequent relapses of herpes can lead to serious consequences. The following complications are possible:

gingivitis;
stomatitis;
cystitis;
urethritis;
vulvovaginitis;
colpitis;
prostatitis;
lymphadenopathy.

They develop with untimely treatment. If genital herpes constantly recurs, then there is a risk of infertility. The virus is most dangerous for weakened people. If the treatment of recurrent herpes during pregnancy is not carried out and the woman does not get rid of the virus, then the risk of miscarriage, early birth and fetal damage increases.

Investigation for suspected herpes

Before you get rid of rashes, you need to conduct a number of studies. In case of damage to the genitals and internal genital organs, a consultation with a gynecologist is required. The following research will be required:

scraping analysis;
linked immunosorbent assay;
analysis for other STIs;
cytological analysis;
polymerase chain reaction;
general blood analysis.

Before you treat a sick person, you need to isolate the virus. This will require a PCR study. The diagnosis is confirmed by the detection of specific antibodies in the blood. To establish the possible causes of relapses, you will need a comprehensive examination. An HIV test is required. The physician should rule out pemphigus, erythema multiforme, and syphilis.

What to do in case of recurrence of the disease

Permanent herpes without the development of complications is treated on an outpatient basis. The main goals of therapy are to reduce the frequency of relapses and increase the duration of remission. This is achieved through the use of systemic antiviral drugs and an increase in the immune status. The herpetic vesicle that appears on the body is the reason for etiotropic therapy.

The most accessible are. No less effective drugs, which include famciclovir and valaciclovir. In the treatment of the disease, drugs such as Valtrex, Zovirax, Famvir, Valzikon, Valvir, Panavir and Famacivir are used. Their use will reduce the frequency of relapses.

To reduce the recovery time, ointments and gels are used. Herperax medicine is very much in demand. What to do with frequent relapses of the disease is known to all experienced dermatovenereologists. Immunostimulants are prescribed to increase the body's defenses. These include Amixin, Cycloferon and Neovir.

Lavomax, Tiloram, Tiloron and Tilaxin are often prescribed. All of them stimulate the production of antibodies and increase immunity. With pain syndrome, Nimesil can be prescribed. Patients need to drink vitamins more often and walk in the fresh air. Physiotherapy, physical activity and interferon inducers are useful.

To reduce the frequency of relapses, ascorbic acid is administered. The elderly, people with immunodeficiency and relapses are vaccinated more often 3 times a year. The drug is administered intradermally. Treatment of chronic herpes without exacerbation includes physiotherapy (UVI or infrared radiation).

Frequent exacerbation of the infection may be the result of serious diseases (tumors, leukemia), so an examination is required. All patients need to diversify the menu. Thus, what to do with relapses of herpes, the doctor should tell the sick. Proper therapy can improve immunity and achieve stable remission.

Etiology (causes) of chronic recurrent herpes

The causative agent is the herpes simplex virus (Herpes Simplex Virus), which is transmitted both by contact and by airborne droplets. Moreover, it is important to understand that once once in the body, the herpes simplex virus will never come out of it. So an acute herpetic lesion eventually flows into chronic herpes, which from time to time gives relapses.

The frequency of relapses directly depends on the state of the patient's immune system and can vary from 3-4 times a month to 1-2 times a year. Thus, a recurrence of chronic herpes can provoke everything that reduces immunity: stress, hypothermia, other viral infections, pneumonia, etc.

According to Columbia University scientists, the herpes simplex virus may be a predisposing factor for the development of Alzheimer's disease. Studies have shown that 90% of Alzheimer's plaques in the patient's brain contain herpes simplex DNA.

Symptoms of chronic recurrent herpes

The clinic of chronic recurrent herpes is characterized by the formation of vesicles on the hyperemic mucous membrane or skin. The diameter of the bubbles is usually 1-3 mm. The localization of the vesicles can vary - they can occupy almost any part of the mucous membrane or skin, but the herpes simplex virus has "favorite" zones. In most cases, blisters form at the border of the red border of the lips with the skin (herpes labialis) or under the nose (herpes nasalis). Herpes of the hard palate, back of the tongue, gums and buccal mucosa are also common.

It is characteristic that before the formation of bubbles, the patient is disturbed by a burning sensation or itching, in place of future bubbles. The general condition of the patient, with chronic recurrent herpes, as a rule, does not worsen.

Bubbles quickly open, forming bright red painful erosions. Over time, erosions are covered with a whitish-yellow fibrinous coating, and then with hemorrhagic crusts. Healing occurs in 8-10 days, without scarring.

Treatment of chronic recurrent herpes

There are local and general treatment of chronic recurrent herpes.

Local treatment It is carried out with the help of various drugs that are applied to the affected area in order to alleviate the course of the disease, or speed up recovery. For this purpose, apply:

Anesthetics (lidocaine, proposol) are used to anesthetize the affected areas (herpetic erosions are quite painful)
Enzymes (trypsin, chemotrypsin) are applied to erosions to eliminate fibrinous plaque
Means that promote epithelialization (carotolone, sea buckthorn oil), are used after the elimination of fibrinous plaque to speed up the healing process of herpetic erosions
Antiviral ointments (0.5% interferon ointment, 0.5% bonafton ointment) are applied within 3-4 days from the onset of the disease

The goal of general therapy is the desensitization of the body (diphenhydramine, suprastin) and increase immunity. In order to increase immunity, vitamins are prescribed: especially vitamin C, and immunocorrectors.

Anti-relapse agents such as bonafton and interferon are also used. In addition, patients with chronic recurrent herpes are shown a high-calorie diet with plenty of fluids.

Manifestation of endogenous (latent) herpetic infection; relapses of the disease occur against the background of a weakened immune system.

Spreading. Persons of any age and gender who have previously undergone primary infection with the herpes virus are ill.

Localization.

In the oral cavity: hard palate or attached gum or back of the tongue (typical places are normally keratinizing epithelium).

Red border of lips.

Symptoms.

The general condition, as a rule, does not suffer (sometimes rashes are preceded by general malaise, subfebrile body temperature).

The reaction of regional lymph nodes is usually absent.

clinical picture. On the hyperemic, slightly edematous mucous membrane, painful erosion is visible, with uneven scalloped edges (a consequence of the opening of a group of merged vesicles). In its circumference, individual small erosions (1-3 mm) of rounded outlines can be observed (after opening single vesicles); on the red border of the lips - a group (more often) of small merged bubbles.

Diagnostics. Based on:

clinical data;

Cytological picture of scraping from the surface of erosion or the contents of the vesicle (characteristic giant multinucleated cells of the epithelium modified by the virus - are found only on the 1-2nd day of the disease).

Chronic recurrent herpes: a local figure of small confluent erosions on the mucous membrane of the hard palate.

Histological picture. Balloon dystrophy of the epithelial cells of the spinous layer, the formation of intraepithelial cavities.

Treatment.

General.

Inhibition of the reproduction of the herpes simplex virus antiviral drugs - acyclovir 200 mg 5 times a day (alpizarin) for 5-10 days.

Improving the body's immunity (prescribed with frequent recurrences of herpes) - interferon inducers, or interferonogens (exogenous stimulants of endogenous interferons), - mefenamic acid (0.5 g 3 times a day), prodigiosan, dibazol, arbidol, poludan, polyvalent antigenic complex imudon; antiherpetic immunoglobulin.

Vaccination (prescribed for frequent recurrences of herpes) - a polyvalent antiherpetic vaccine of 0.1-0.2 ml intradermally with an interval of 2-3 days (5 injections per course of treatment), a second course after 10 days; a year later, you can repeat the vaccination schedule.

Vitamin therapy - vitamin C 1 rjCYT., vitamin A to improve the regenerative capacity of the epithelium - 10 drops of an oil solution 2-3 times a day for 1 month.

Local.

Antiviral ointments - 3-5% acyclovir, 0.5% florenal, 2-5% alpizarin, etc. (prescribed in the first days of the disease).

Anti-inflammatory, analgesic drugs - mundizal-gel, holisal.

Epithelializing agents - applications of an oil solution of vitamin A, sea buckthorn oil, rosehip oil or solcoseryl preparations (gel, ointment, adhesive paste), aerosols with keratoplastic action livian, vinizol.

Aniline dyes - 1-2% alcohol solution of brilliant green (promotes drying and falling off of crusts on the red border of the lips and skin).

Forecast. Favorable, healing occurs in 7-10 days, relapses are possible.

THIS IS IMPORTANT TO KNOW. The course of chronic recurrent herpes, which acquires permanent development, with frequent relapses, with a tendency to spread and torpidity to treatment, may be the result of severe immune damage (against the background of taking immunosuppressants, corticosteroids, cytostatics for leukemia, HIV infection).

Foot and mouth disease (aphthous fever, epizootic stomatitis)

An acute viral disease that occurs when infected from sick artiodactyl animals, through household items or non-disinfected dairy products, meat of sick animals.

Prevalence. More common in children under 5 years.

Localization.

The mucous membrane of the oral cavity - gums, tongue, palate, lips, cheeks, pharynx.

The mucous membrane of the nose, the conjunctiva of the eyes, the genital area.

Skin - interdigital folds of hands, feet, base

nails, soles, wings of the nose.

Symptoms.

Acute onset, weakness, diarrhea.

Headaches, muscle pains.

Increase in body temperature up to 38-390C.

The reaction of regional lymph nodes (their increase, soreness).

Profuse salivation.

clinical picture. On the hyperemic edematous mucous membrane of the oral cavity, rashes of rapidly opening vesicles from 1 to 7 mm in diameter, painful erosions of rounded, oval outlines are formed (similar changes on other mucous membranes).

On the skin, in typical places - multiple vesicles, after opening them, the well-being of patients noticeably improves.

Diagnostics. Based on:

characteristic clinical manifestations; laboratory data (biological samples or virus culture isolation).

Multiple minor erosions and aphthae on mucous membrane of the upper lip.

General principles of patient management. Patients are subject to mandatory hospitalization.

Physician tactics.

It is necessary to isolate the patient and contact the local veterinary service to find out the epidemiological situation in the area for FMD.

A quarantine is declared providing for certain measures to prevent the spread of the disease among people and animals. .

Treatment.

On the skin and mucous membranes - antiviral ointments.

In the oral cavity - solutions of antiseptics and painkillers.

On the skin - aniline dyes.

Forecast. Favorable, after 7-20 days. recovery is coming.

THIS IS IMPORTANT TO KNOW. An effective measure for the prevention of FMD infection is the disinfection of food - the heat treatment of milk and meat.

CHRONIC RECURRENT APHTHOSIS STOMATITIS

Etiology.

Infectious allergy (mainly to herpes simplex virus or cytomegalovirus, bacterial antigens).

Against the background of blood diseases (in particular, with her tropenia, the so-called neutropenic aphthae develop).

Idiopathic (not of a clear nature).

Prevalence. The most common disease of the oral mucosa (up to 20%); sick persons aged 20-40 years, more often women.

Localization. Everywhere on the oral mucosa (except for the hard palate and attached gums).

Forms. Light, medium, heavy.

Symptoms.

The frequency of occurrence of aphthae - single aphthae once every few years (light); several times a year (moderate); continuous recurrence (severe).

The general condition does not suffer (with mild and moderate forms).

Regional lymphadenitis is possible (usually in severe form).

Soreness in the mouth (at the time of the rash).

clinical picture. Aphtha (Greek - ulcer) up to 1 cm in size, has a round-oval outline, covered with a fibrinous gray-yellowish coating, surrounded by a sharply demarcated hyperemic rim; at the base, a small infiltrate, edema and hyperemia of the surrounding tissues are possible; solitary or multiple rashes (usually from 1 to 2-3 in the oral cavity).

Chronic recurrent aphthous stomatitis; a small single aphtha on the mucous membrane of the lower lip.

Chronic recurrent aphthous stomatitis; aphthae on the mucous membrane of the upper lip.

Diagnostics. Based on:

history data;

clinical picture;

The results of a cytological examination of a scraping from the surface of the ulcer (a picture of nonspecific inflammation);

Identification of a high titer of antibodies to the herpes simplex virus and cytomegalovirus.

Histological picture. Deep fibrinous-necrotic inflammation, accompanied by vasodilation, perivascular infiltration, epithelial necrosis.

Features of the management of patients.

Identification of foci of chronic infection.

Sanitation of foci of infection.

Nutrition correction (exclusion of irritating food).

Dispensary supervision.

Treatment. With a diagnosis of "neutropenic aphthae", the treatment is carried out by a hematologist. If a patient has a herpes simplex virus and (or) cytomegalovirus detected in the saliva (by seeding or polymerase chain reaction - PCR), or in the blood of high titers of antibodies to these viruses, the following is prescribed:

Antiviral agents - acyclovir or valtrex 1 g per day from 5-8 days to several months;

Antiherpetic immunoglobulin 3 ml intramuscularly 2 times a week - 5 injections;

Interferon inductors - poludan, cycloferon, dibazol;

Immunomodulators - decaris, licopid;

Antihistamines;

Small doses of corticosteroid hormones. With the idiopathic nature of the disease, the following is prescribed:

Corticosteroid hormones in small doses in combination with cytostatics (colchicine 1 mg / day);

Courses of injections of histoglobulin 1-2 times a year;

Courses of injections of human donor immunoglobulin 1-2 times a year.

locally.

Solcoseryl (adhesive paste) is used for all types of aft.

Applications of anesthetic solutions, ointments (recommended before clinical treatment, before eating, sleeping).

Antiseptics (weak solutions of hydrogen peroxide, furatsilina).

Proteolytic enzymes (trypsin, chymopsin, chymotrypsin) to cleanse the surface of aphthae from necrotic plaque.

Stimulants of local immunity - imudon (dissolve 6-8 tablets per day for 20 days).

Laser therapy - helium-neon laser (with torpidity to epithelial therapy).

The prognosis is favorable.

THIS IS IMPORTANT TO KNOW. Aphthous lesions of the oral mucosa, often occurring and characterized by a long course, may be associated with HIV infection.

HERPANGINA (enteroviral vesicular pharyngitis, Coxsackie-ECHO)

The disease is caused by the RNA-containing enterovirus Coxsackie group A and the ECHO virus.

Prevalence. Children get sick more often.

Localization. Posterior wall of the pharynx, tonsils, mucous membrane of the anterior palatine arches, soft palate, uvula.

Symptoms.

Acute deterioration of health.

Headache.

The rise in body temperature (39-400C).

Pain when swallowing.

Reaction of regional lymph nodes.

clinical picture. In the posterior sections of the oral cavity, against the background of hyperemic edematous mucous membrane, small, rounded erosions covered with a gray coating (in place of opened vesicles) are visible.

Treatment. Symptomatic: elimination of intoxication (plentiful drink, salicylates, vitamin C in therapeutic doses), prevention of secondary infection (antiseptics).

Forecast favorable, recovery occurs in 7-10 days.

Herpangina: small rounded erosions and vesicles on the hyperemic mucous membrane of the pharynx.

VINCENT STOMATITIS (ulcerative necrotic gingivostomatitis)

The disease is caused by opportunistic anaerobic flora of the oral cavity - spindle-shaped sticks

(Bacillus fusiformis,Clostridium mu/tiforme) and spirochetes (Borellia Vincepti, Borellia bucca/is), which acquire virulence against the background of a decrease in immunity.

Prevalence. Most often, young, practically healthy men aged 17 to 30 get sick.

Localization. Gingival margin (always), cheek, retromolar region, tonsils - Vincent's angina (rarely).

Symptoms.

Increase in body temperature up to 37.5-38 0С.

Regional lymph nodes are enlarged, painful on palpation, mobile.

Putrid odor from the mouth.

Bleeding and sharp pain of the gums.

clinical picture. The gums are hyperemic, edematous, along the gingival papillae and the marginal edge are foci of necrosis, covered with a gray, gray-green coating that is difficult to remove; under the necrotic masses - an ulcerative surface that can spread to the adjacent buccal mucosa and the retromolar region, which leads to trismus, pain when swallowing and swelling of the cheek due to swelling of the surrounding tissues.

Diagnostics. Based on:

clinical data;

Bacterioscopic examination of plaque (in a smear stained with azure-eosin, against the background of epithelial cells and elements of nonspecific inflammation, a large number of spindle-shaped rods and spirochetes are found);

Ulcerative-necrotic gingivitis in the retromolar region during tooth eruption.

Ulcerative necrotic gingivitis: a significant destructive lesion of the bone tissue of the teeth of the lower jaw, with an advanced course of the disease.

Data from a clinical blood test, characteristic of a nonspecific inflammatory process (small leukocytosis, a shift of the leukocyte count to the left, a moderate increase in ESR).

Histological picture. Ulceration of the mucous membrane with necrosis of the surface layer, the underlying tissue is edematous, infiltrated by neutrophils and lymphocytes.

Features of the management of patients.

home mode.

Daily, professional treatment of teeth and oral mucosa.

Treatment.

Local.

Application anesthesia (2% solution of trimecaine, lidocaine).

Proteolytic enzymes (trypsin, chymopsin).

Antiseptics containing oxygen, chlorine (solutions of potassium permanganate - 1:5000, hydrogen peroxide 1-2%, chloramine - 0.25%, chlorhexidine - 0.06%).

Metronidazole, Cifran@ ST (RANBAXY) (in the form of applications of softened tablets on the gingival margin for 15-20 minutes or metrogildent gel).

General.

Antibiotics (for severe disease) Cifran CT (RANVACHU).

Metronidazole inside 0.25 g 3 times a day for 5-7 days.

Vitamin C (up to 1 g per day).

Antihistamines (suprastin, fenkarol 1 tab. 2-3 times a day).

Forecast. Favorable (recovery occurs within 3 to 7 days; relapses are possible with poor oral hygiene).

THIS IS IMPORTANT TO KNOW. Similar processes in the oral cavity develop with a decrease in immunity against the background of agranulocytosis, leukemia or HIV infection, therefore, all patients with ulcerative necrotic gingivostomatitis must undergo a general clinical blood test and a test for HIV infection.

HAIRY LEUKOPLAKIA

The occurrence is associated with the activation of the Epstein-Barr virus.

Prevalence. Occurs only in AIDS patients.

Localization. Lateral surfaces of the tongue (back of the tongue or buccal mucosa, less often).

Symptoms. The course is asymptomatic.

clinical picture. A limited area of thickened mucous membrane of opal-white color, with fuzzy borders ranging in size from a few millimeters to 3 cm or more (the entire lateral surface of the tongue). In the lesion, white thin stripes are visible, located parallel to each other, formed by small hairy papillomas.

Diagnostics. Based on serological test results confirming HIV infection.

Treatment underlying disease.

Forecast. Bad, the appearance of hairy leukoplakia in AIDS patients indicates a severe change in immunity.

anogenital warts - diagnosis and treatment

warts (Copdylomata acumipata) are benign anogenital warts caused by the human papillomavirus (HPV); moreover, genotypes 6 and 11 are detected in > 90% of cases

DIAGNOSTICS

Clinical diagnostics

Multiple localization

Genital warts usually occur in places that are traumatized during sexual contact. Lesions may be solitary, although, as a rule, 5 to 15 or more elements with a diameter of 1-10 mm are detected. Possible fusion of elements into plaques, which is most often observed in immunosuppressed individuals and in patients with diabetes mellitus.

In men with uncircumcised foreskin, the anatomical structures that enter the preputial cavity (glans penis, coronal sulcus, frenulum, and inner sheet of the foreskin) are most often affected. In men with a circumcised foreskin, lesions are often located on the body of the penis. In addition, warts can occur on the skin of the scrotum, groin, perineum, and perianal region. In women, the folds of the labia, the labia major and minor, the clitoris, the external opening of the urethra, the perineum, the perianal region, the vestibule of the vagina, the entrance to the vagina, the hymen, the vagina and the outer part of the cervix are affected. The external opening of the urethra is affected in 20-25% of men and 48% of women. Anal warts are rarely found proximal to the dentate line. Anal warts are most often found in people who practice passive anal sex.

Multiform morphology

The color of the rash can vary from pinkish-crimson to orange-red (non-keratinized warts), grayish-white (with severe keratinization), and from ash gray to brownish-black (hyperpigmented warts). As a rule, unpigmented condylomas meet; pigmented condylomas are most often located on hyperpigmented skin (labia majora, body of the penis, pubis, inguinal region, perineum and perianal region).

Types of lesions

Warts can be divided into three main types.

Genital warts usually localized on the epithelium of mucous membranes, including the mucosa of the preputial cavity, the external opening of the urethra, labia minora, the entrance to the vagina, vagina, cervix, anus and anal canal. It is also possible to damage the inguinal region, perineum and anal region.

Warts in the form of papules most often found on keratinized epithelium (outer layer of the foreskin, body of the penis, scrotum, lateral region of the vulva, pubis, perineum and perianal region).

Giant condyloma Buschke-Lovenshtein

This is a very rare type of disease associated with HPV types 6 and 11. It is characterized by aggressive growth deep into the underlying structures of the dermis.

Clinical examination

The purpose of the examination is to establish an accurate diagnosis, choose a method of treatment and reduce the psychosexual consequences of the disease. Removal of genital warts appears to reduce the risk of sexual partners becoming infected. Patients with warts should be tested for other STDs.

Examination of the external genitalia

Meatoscopy - examination of the sponges of the urethra - a small mirror (retractor) or otoscope is used. Sometimes ureteroscopy is performed.

Anoscopy - carried out by a proctologist

Acetic acid test After treatment with a 5% acetic acid solution, HPV lesions become greyish-white for a few minutes.

Differential Diagnosis

Differential diagnosis is carried out with skin diseases such as molluscum contagiosum, fibroepithelial papilloma , seborrheic keratosis. With localization in the anus, with hemorrhoids and recurrent syphilis (primarily with wide warts). In men, a physiological condition, the so-called "papular necklace of the penis", is most often mistaken for genital warts. It is observed in adolescents and is manifested by 1-3 rows of separate, non-confluent papules with a diameter of 1-2 mm, located around the circumference of the crown of the glans penis and / or symmetrically near the frenulum of the foreskin. The papules are small, do not merge, the surface is smooth, the vascular pattern characteristic of genital warts is absent. With a differential diagnosis in women, it is necessary to exclude the physiological variant of the norm - non-merging papules of the correct form, located symmetrically on the inner surface of the labia minora and in the area of the vestibule of the vagina ("micropapillomatosis of the labia"). The sebaceous glands in the foreskin and vulva in healthy individuals and in pathology (sebocystomatosis) also often look like multiple, separate, non-hardened greyish-yellow papules located on the inner surface of the foreskin and labia minora, on the scrotum.

Histological examination

A biopsy is mandatory if bowenoid papulosis, Bowen's disease, or giant condyloma is suspected.

TREATMENT

Generalprinciples

Ideally, treatment for warts should result in a complete cure, or at least long-term remission (no warts or symptoms/signs). However, none of the modern methods leads to a complete cure and elimination of the virus and does not guarantee the absence of relapses. The recurrence rate is 20-30%. In addition, all treatments are accompanied by local reactions, including itching, burning, erosion and pain. Some treatment regimens require multiple visits to the doctor and are therefore inconvenient for the patient.

The European STD guidelines divide the treatment of anogenital warts into 2 parts:

Podophyllotoxin (0.15% cream or 0.5% solution);

Imiquimod (5% cream).

Electrocoagulation (or laser therapy, or curettage, or excision with scissors);

radio wave surgery;

Cryotherapy;

Trichloroacetic acid

The choice of method of treatment depends on the morphology and prevalence of warts and should be made after agreeing the doctor's opinion and the patient's wishes. Usually the patient has a relatively small number of warts, and in such cases most treatments are effective. If there are few warts (1-5), it is best for the patient to use the simplest method carried out in a medical institution.

Treatment at home by the patients themselves

podophyllotoxin(0.5% solution or 0.15% cream) - in the Russian Federation it is sold under the commercial name "Condilin".

The drug is a purified extract from a plant of the genus Podophyllum. Podophyllotoxin binds to cell microtubules and inhibits mitotic activity. As a result, necrosis of genital warts develops, reaching a maximum 3-5 days after the use of the drug. In this case, due to necrosis of warts, shallow erosions may occur, which heal within a few days.

During one course of treatment with podophyllotoxin, the patient independently applies the drug to the warts 2 times a day for 3 days, then takes a break for 4-7 days. With warts of the penis, it is more convenient to use a 0.5% solution of podophyllotoxin. With warts in the vulva and anus, it is more convenient and effective to use 0.15% cream (it is easier for the patient to feel and treat warts with a finger smeared with cream).

In men with uncircumcised foreskin, in 70-90% of cases, genital warts of the penis are resolved after 1-2 courses of application of a 0.5% solution of podophyllotoxin; in 60-80% of cases, 14 courses are sufficient. The effectiveness of the podophyllotoxin solution is lower in women and in men with a circumcised foreskin - in these cases, warts are treatable in less than 50% of cases. Independent use of 0.15% podophyllotoxin cream is effective in 60-80% of cases of warts in the vulva and anus after 1-4 courses. The frequency of relapses after the use of podophyllotoxin, according to various authors, is 7-38%. If warts remain after 4 courses, the treatment method should be changed. To treatment with podophyllotoxin, warts of the external opening of the urethra and warts located on keratinized areas of the skin are often resistant.

Up to 50-65% of patients using podophyllotoxin report transient mild burning, soreness, erythema and/or erosions within a few days when wart necrosis occurs. Side effects usually occur only during the first course of treatment. In men with uncircumcised foreskin, during treatment with podophyllotoxin, pain may occur when pulling the foreskin over the glans penis.

Imiquimod(5% cream) (drug not available)

Imiquimod (imidazolquinolineamine) is a nucleoside-type substance that, when applied to warts, acts as an immune response modulator, inducing local production of interferon alpha and gamma and activation of immune cells, including CD4+ T lymphocytes. This process leads to the regression of warts and is accompanied by a decrease in the amount of HPV DNA.

Imiquimod (5% cream) is applied to the warts from disposable packs 3 times a week at bedtime, and in the morning the drug is washed off with soap and water. Treatment is continued until the disappearance of the warts or a maximum of 16 weeks. The use of the drug may be accompanied by local reactions, and, if necessary, you can take a break for a few days.

Clinical studies have shown that imiquimod is effective in 56% of patients. It was more effective in women (77%) than in men (40%) (most of the men included in the study had their foreskin circumcised). Mean wart clearance time with imiquimod treatment was shorter in women (8 weeks) than in men (12 weeks). The recurrence rate was 13%.

The most common side effect was erythema. Erosion and burning also occurred.

Special situations

Podophyllotoxin is contraindicated in pregnant women. Women of childbearing age should use a reliable method of contraception or abstain from penetrative sexual intercourse during treatment with podophyllotoxin. Studies on the possibility of prescribing imiquimod to pregnant women have not been conducted, although in animal studies this drug did not have a teratogenic effect.

Skin reactions to podophyllotoxin usually develop on the third day of treatment, to imiquimod - 3-4 weeks after the start of treatment. In most cases, they resolve spontaneously within a few days of drug withdrawal.

A rare but serious complication in the treatment of multiple warts of the foreskin is difficulty pulling the foreskin over the glans penis due to painful erosions and swelling. Patients should be advised to contact their doctor if such a complication occurs. Treatment is carried out in a medical facility and is limited to daily washing of the foreskin with saline or applying corticosteroids under it until the condition improves.

Treatment in a medical facility

Surgery

It is not possible to give precise guidelines as to which surgical method to use as it depends on the prevalence of warts, local traditions, and the skill and experience of the doctor. The surgical method may be the method of first choice. Most patients use local anesthesia.

With proper surgical treatment, warts disappear, however, regardless of the technique used, 20-30% of patients develop new lesions at the border between excised and apparently healthy tissues and / or in other places.

Appears very often at any age in people previously infected with the herpes simplex virus and do not have virus-neutralizing antibodies. Under unfavorable general or local conditions for the body, unstable immunity weakens. This leads to cooling of the body, common diseases (influenza and adenovirus diseases, pneumonia, malaria, etc.), intoxication, stress, sensitization.

(Slide 12) Clinical picture. There are 5 periods of development (according to T. F. Vinogradova): incubation, prodromal, development of the disease, extinction and clinical recovery (reconvalescence). The most pathognomonic are the latent and the period of development (rash) of elements. The prodromal period is characterized by general malaise, fever, enlargement of regional lymph nodes.

There are hypersalivation, general catarrhal inflammation of the mucous membrane, and often of the gingival margin, headache, restriction of food intake due to severe pain syndrome. On the mucous membrane of the lips, cheeks, tongue, hard palate, from 2-3 to several dozen small bubbles adjacent to each other appear, which quickly open. In their place, superficial erosions tend to merge, and a period of disease development begins. Erosions have scalloped edges due to the fusion of bubbles and are on a sharply hyperemic base, very painful. When localized on the lips, erosion can be covered with crusts, often the skin of the oral region is involved in the process. If an exacerbation occurs against the background of a cold or SARS, then the mucous membrane of the palatine arches and pharynx is often affected. The period of development of the elements ends, as a rule, by the 4-5th day. Then comes the epithelialization of the elements, which usually ends by the 8-12th day from the onset of the disease. The severity depends on the number of elements and general symptoms. Severe forms are due to reduced reactivity and the presence of chronic general somatic diseases. Such an unfavorable background creates conditions for recurrence and chronicity of herpetic stomatitis.

(Slide 13) Differential diagnosis. Chronic recurrent herpetic stomatitis should be distinguished from recurrent aphthous stomatitis, allergic rashes, syphilis, and erythema multiforme exudative. In addition to the features of the clinical picture, a cytological examination of the contents of the vesicles and scrapings or prints from the bottom shortly after they are opened (the first 2-3 days) can provide valuable assistance in diagnosis. In the preparations, Langhans giant cells are found in large numbers.

(Slide 14) Treatment. Aimed primarily at preventing relapse. To this end, eliminate the foci of chronic inflammation in the body, including in the oral cavity (periodontitis, periodontitis, tonsillitis), eliminate local causes that contribute to rashes (dry lips, injuries, chronic lip cracks). If relapses occur frequently, an antiherpetic polio vaccine is successfully used. In the interrecurrent period, it is administered intradermally at a dose of 0.2 ml into the forearm 5-10 times with an interval of 1-3 days. After 3-6 months, the course of treatment is repeated. Some success was obtained from the parenteral administration of deoxyribonuclease 10-50 mg 2 times a week, for a course of 6-10 injections. To stimulate humoral immunity and as an anti-relapse agent with a good effect, gamma globulin is also used intramuscularly, 3 ml every 3-4 days, 6 injections per course, with intervals between courses of 2 months. Vitamin C is prescribed inside. Local applications of antiviral agents also have a positive effect. The use of a helium-neon laser is effective, inside - imudon - 6-8 tablets per day. Persistently recurring rashes oblige the doctor to conduct an additional examination of the patient to exclude general somatic diseases.

(Slide 15) Shingles (herpes zoster), or shingles, is caused by the varicella zoster virus. There are two clinical forms of the disease: chicken pox and herpes zoster. (Slide 16) Chickenpox occurs upon initial contact with the virus. Herpes zoster develops only in individuals who have previously had chickenpox and have virus-neutralizing antibodies. It occurs as a result of activation of a latent virus or secondary exogenous infection. With a generalized form of herpes zoster, both clinical forms of the disease are combined with the same virus.

Herpes zoster affects children and adults, but more often the elderly. The infection is transmitted by contact or airborne droplets. Outbreaks of the disease increase more often in autumn and winter and are characterized by fever, inflammation of the ganglia of some cranial and intervertebral nerves, erythematous-vesicular rashes on the skin and mucous membranes along the affected sensory nerves. The manifestation of the disease on the oral mucosa is associated with the involvement in the process of the gasser node (herpetic ganglionitis), the second and third branches of the trigeminal nerve. At the same time, the corresponding areas of the skin are also affected. In isolation, the oral mucosa is rarely affected.

clinical picture. The incubation period is 7-14 days. Then malaise, headache, chills appear, the temperature rises to 38-39 ° C. However, the effects of intoxication may not be so pronounced. Simultaneously with the general symptoms or somewhat later, burning paroxysmal neuralgic pains appear along the affected nerves, pain radiating to the tooth, aggravated by stimuli. After 1-4 days or later, vesicles with a diameter of 1 to 6 mm are poured out on edematous hyperemic skin. Simultaneously with skin rashes, multiple vesicles appear in the oral cavity against the background of hyperemic edematous mucous membrane (vesicular form). Vesicles quickly burst, forming single or confluent erosions covered with fibrinous plaque. One-sidedness of the lesion and localization of lesions in the region of innervation of certain branches are characteristic. There are regional lymphadenitis. On the skin, vesicles form crusts; after their exfoliation remains pigmentation of the skin. The vesicular form of herpes zoster described here is the most common. Less commonly, the vesicles have hemorrhagic contents (hemorrhagic form) or necrotic (gangrenous form).

Herpes zoster lasts an average of 2-3 weeks. The prognosis is usually favorable. Less commonly observed complications in the form of neuralgia, trophic disorders of the affected area, hyperpathy and hyperesthesia for several months and years.

The disease leaves long-term immunity, but cases of recurrent course are possible. Additional research methods include a general clinical blood test, virus isolation from vesicles and blood, cytological examination of the contents of vesicles and scrapings from the bottom of erosions. The cytological picture in herpes zoster is the same as in recurrent herpes simplex (vesicles are formed intraepithelially).

(Slide 17) Differential diagnosis. Herpes zoster should be distinguished from pulpitis, acute herpetic stomatitis, allergic rashes, pemphigus, pemphigoid, and on the skin - with erysipelas. An important diagnostic sign of herpes zoster is the one-sidedness of the lesion.

(Slide 18) Treatment. Analgesics, ganglion blockers, vitamins of group B are prescribed. Good results are given by antiviral agents metisazon, deoxyribonuclease, bonafton. Metisazon is prescribed orally at 0.2-0.5 g 1 hour after meals 2 times a day for 6-10 days; deoxyribonuclease - 30-50 mg intramuscularly 1 time per day for 7-10 days (in a hospital every 4 hours, 25-30 mg); bonafton - 0.1 g 3-5 times a day, course - 3 cycles of 5 days with 1-2-day breaks. Effective use of acyclovir (0.2 g 4 times a day for 5 days), the use of laser therapy.

AIDS

(Slide 19) An infectious disease of a viral nature that causes suppression of natural immunity.

Etiology and pathogenesis. The causative agent of AIDS is considered to be the HIV virus (HIV - human immunodeficiency virus). When the pathogen enters the human blood, the T-lymphocyte system is damaged. When introduced into a cell, the virus irreversibly changes it, as it uses the genetic material for its own reproduction. There are quantitative, as well as numerous qualitative changes in T-helpers and T-killers. HIV is found in blood, semen, vaginal secretions, lacrimal fluid, and saliva. The concentration of HIV in the blood is negligible. So, if 1 ml of the blood of patients with hepatitis contains 100 million viral particles, then 1 ml of the blood of AIDS patients contains only 10. In the oral fluid, the concentration of HIV is much lower than in the blood, so the risk of infection through this fluid is very small.

(Slide 20) Clinical picture. The manifestations of the disease in the oral cavity are divided into three groups. The first includes lesions clearly associated with HIV infection: candidiasis (erythematous, pseudomembranous hyperplastic), hairy leukoplakia, marginal gingival erythema, necrotizing ulcerative gingivitis, necrotizing ulcerative periodontitis, Kaposi's sarcoma, and non-Hodgkin's lymphoma. The second group consists of lesions less clearly associated with HIV infection: bacterial infections, including tuberculosis, diseases of the salivary glands, thrombocytopenic purpura, viral lesions. The third group is characterized by lesions that can be observed with HIV infection, but are not associated with it. Of greatest clinical interest is the first group, since these lesions are localized on the mucous membrane and may be the first clinical symptoms of AIDS.

Clinical manifestations on the mucous membrane are very similar to those in the same independent nosological forms; the difference lies in the lack of treatment effect. (Slide 21) (Slide 22) HIV-specific lesions are candidiasis, (Slide 23-28) hairy leukoplakia and Kaposi's sarcoma. "Hairy" leukoplakia is a whitish non-removable strips located on the sides of the tongue. In the etiology of this lesion attach importance to the Epstein-Barr virus. The lesion is characterized by the absence of an inflammatory tissue reaction.

Kaposi's sarcoma (vascular tumor, angioreticulosis) is localized mainly in the sky and has a specific color - cyanotic-violet, sometimes with a reddish tint. Common manifestations of AIDS include regional lymphadenitis, subfebrile body temperature, weight loss, weakness, malaise, the addition of a secondary infection in the form of bronchitis, pneumonia, etc.

Treatment and prevention. Treatment is specific, in a specialized institution. The patient is required to receive dental care.

In terms of protecting medical personnel and preventing transmission of infection, all precautions that are indicated for hepatitis B should be observed. Personal protective equipment is gloves, masks, goggles. Strict sterilization of instruments is required (it is better to use disposable instruments). The immunodeficiency virus is quickly inactivated by dry and wet sterilization, as well as at high body temperature.

common infectious symptoms: fever, chills, intoxication;
skin lesions: blistering rashes;
severe pain syndrome (which is explained by the fact that Varicella Zoster, being a dermatoneurotropic virus, penetrates through the skin and mucous membranes, affects the spinal and cerebral ganglia, in severe cases, the anterior and posterior horns of the spinal cord and the brain - sections of the spinal cord, including responsible for pain sensitivity).
there are several clinical varieties of herpes zoster

Herpes zoster (SH) may have a typical or atypical clinical presentation. A typical form of OH is characterized, as a rule, by unilateral localization within one dermatome. Lesions are represented by edematous erythema and vesicles with serous contents grouped against its background. A typical localization of rashes is most often the skin innervation zone from the II thoracic to the II lumbar segment, but in children, areas innervated by the cranial and sacral nerves may be involved in the process. With the defeat of the fifth pair of cranial nerves (trigeminal nerve), its branches may be affected. When the upper branch is involved, skin changes are observed on the scalp, in the forehead, nose, eyes, with damage to the middle branch - in the area of the cheeks, palate, with damage to the lower branch - in the region of the lower jaw, on the tongue. With damage to the VII pair of cranial nerves (facial), rashes are observed in the external auditory canal. The occurrence of atypical forms of OH is due to pronounced disorders of immune reactivity and is accompanied by the appearance of hemorrhagic, ulcerative necrotic (chronic ulcerative lesions), gangrenous, bullous elements, as well as a tendency to dissemination - generalization.

high affinity for virus thymidine kinase (100 times higher) and more pronounced blocking of virus replication between doses of the drug;
famciclovir has the highest bioavailability (77% versus 10-20% for acyclovir) and the longest residence time in a virus-infected cell (up to 20 hours); [. ] famciclovir has the ability to penetrate the Schwann cells surrounding the nerve fibers;
a constant concentration of the drug in infected cells provides a long-term antiviral effect and makes it possible to take the drug less often (for herpes zoster - 500 mg every 8 hours - 3 times a day - for 7 days ... compare - acyclovir for shingles is taken at 0.8 g 5 times a day for 7 days);
famciclovir is the only antiviral drug that reduces the duration of postherpetic neuralgia in herpes zoster (by 100 days compared with placebo).

(Russian Society of Dermatovenerologists, 2010) … read

Case history of infectious diseases: Herpes zoster I branch of the right trigeminal nerve

Shingles of the 1st branch of the right trigeminal nerve

IHD, NK I, hypertension stage II, non-insulin-dependent diabetes mellitus type II, chronic atrophic gastritis, chronic cholecystitis, prostate adenoma

I. Passport part

Full Name: -

Age: 76 (11/14/1931)

Permanent residence: Moscow

Date of receipt: 06.12.2007

Curation date: 10/19/2007 – 10/21/2007

II.Complaints

For pain, hyperemia and multiple rashes in the forehead on the right, swelling of the upper eyelid of the right eye, headache.

III. History of the present disease (Anamnesis morbi)

He considers himself ill since December 6, 2007, when for the first time, at night, a headache and swelling of the upper eyelid of the right eye appeared. The next morning, the edema intensified, hyperemia and a rash in the form of multiple vesicles were noted in the area of the right half of the forehead. Body temperature 38.2°C. Regarding the above symptoms, he called an ambulance, an injection of analgin was made. On the evening of December 6, 2007, the patient was hospitalized at the Central Clinical Hospital of the UD RF No. 1.

IV. Life history (Anamnesis vitae)

He grew and developed normally. Higher education. Living conditions are satisfactory, nutrition is full-fledged regular.

Bad habits: smoking, drinking alcohol, drugs denies.

Past illnesses: childhood infections do not remember.

Chronic diseases: coronary artery disease, NK I, hypertension stage II, non-insulin-dependent diabetes mellitus type II, chronic atrophic gastritis, chronic cholecystitis, prostate adenoma

Allergic history: no intolerance to food, drugs, vaccines and serums.

V.Heredity

In the family, the presence of mental, endocrine, cardiovascular, oncological diseases, tuberculosis, diabetes, alcoholism denies.

VI. Present status (Status praesens)

Moderately severe condition, consciousness - clear, position - active, physique - correct, constitutional type - asthenic, height - 170 cm, weight - 71 kg, BMI - 24.6. Body temperature 36.7°C.

Healthy skin is pale pink. The skin is moderately moist, the turgor is preserved. Male pattern hair. The nails are oblong in shape, without striation and brittleness, there is no symptom of "watch glasses". Visible mucous membranes are pale pink in color, moistened, there are no rashes on the mucous membranes (enanthems).

Subcutaneous fat is moderately developed, the deposition is uniform. There are no edema.

The parotid lymph nodes on the right are palpable in the form of rounded, soft-elastic consistency, painful, mobile formations, 1 x 0.8 cm in size. elbow, inguinal, popliteal lymph nodes are not palpated.

The muscles are developed satisfactorily, the tone is symmetrical, preserved. The bones are not deformed, painless on palpation and tapping, there is no symptom of "drum sticks". The joints are not changed, there is no pain, hyperemia of the skin, swelling over the joints.

The shape of the nose is not changed, breathing through both nasal passages is free. Voice - hoarseness, no aphonia. The chest is symmetrical, there is no curvature of the spine. Breathing is vesicular, chest movements are symmetrical. NPV = 18/min. Breathing is rhythmic. The chest is painless on palpation, elastic. Voice trembling is carried out in the same way on symmetrical sections. A clear pulmonary percussion sound is detected over the entire surface of the chest.

Circulatory system

The apex beat is not visually determined, there are no other pulsations in the region of the heart. The boundaries of absolute and relative stupidity are not shifted. Heart sounds are rhythmic, muffled, the number of heartbeats is 74 per 1 minute. Additional tones are not heard. are not heard. The pulsation of the temporal, carotid, radial, popliteal arteries and arteries of the dorsal foot is preserved. Arterial pulse on the radial arteries is the same on the right and left, increased filling and tension, 74 per 1 minute.

Blood pressure - 140/105 mm Hg.

Digestive system

The tongue is pale pink, moist, the papillary layer is preserved, there are no raids, cracks, ulcers. Shchetkin-Blumberg's symptom is negative. On palpation, the abdomen is soft and painless. The size of the liver according to Kurlov: cm The edge of the liver is pointed, soft, painless. Gallbladder, spleen is not palpable.

Urinary system

The symptom of tapping is negative. Urination free, painless.

Nervous system and sense organs

Consciousness is not disturbed, oriented in the environment, place and time. Intelligence saved. Rough neurological symptoms are not detected. There are no meningeal symptoms, no changes in muscle tone and symmetry. Visual acuity is reduced.

VII. Local Status

Skin process of an acute inflammatory nature in the region of the right half of the forehead, right eyebrow, upper right eyelid. Eruptions are multiple, grouped, not merging, evolutionarily polymorphic, asymmetrical, located along the first branch of the right trigeminal nerve.

The primary morphological elements are pale pink vesicles protruding above the surface of the hyperemic skin, 0.2 mm in diameter, hemispherical in shape, with rounded outlines, the borders are not sharp. The vesicles are filled with serous contents, the lid is dense, the surface is smooth.

Secondary morphological elements - crusts, small, rounded, 0.3 cm in diameter, serous, yellow-brown in color, weeping erosions remain after removal.

Rashes are not accompanied by subjective sensations.

There are no diagnostic phenomena.

Hairline without visible changes. Visible mucous membranes are pale pink, moist, no rashes. The nails of the hands and feet are not changed.

VIII. Data from laboratory and instrumental studies

1. Complete blood count dated 07.12.2007: moderate leukocytopenia and thrombocytopenia

2. Urinalysis dated 12/07/2007: within normal limits

3.Biochemical blood test dated 12/12/2007: within normal limits

4. Wasserman's reaction from 10/12/2007 is negative

IX. Clinical diagnosis and justification

Clinical diagnosis: Herpes zoster I branch of the right trigeminal nerve

The diagnosis was made on the basis of:

1. The patient complains of pain, hyperemia and multiple rashes in the forehead on the right, swelling of the upper eyelid of the right eye

2. Anamnesis: acute onset of the disease, accompanied by symptoms of general intoxication (fever, headache)

3. Clinical picture: Multiple vesicles are located on the hyperemic skin along the first branch of the right trigeminal nerve, as a result of the evolution of which crusts are formed.

4. The presence of somatic diseases - diabetes mellitus, leading to impaired peripheral circulation and a decrease in local immunity

X. Differential diagnosis

Differential diagnosis is carried out with the following diseases:

1. Herpes simplex. Herpes simplex is characterized by relapses, and not by an acute, sudden onset. As a rule, the age of manifestation of the disease is up to 40 years. The severity of symptoms in herpes simplex is less. With herpes simplex, there are fewer rashes and their location along the nerve fibers is not typical.

2. Dermatitis herpetiformis Dühring. With Dühring's dermatitis herpetiformis, polymorphism of elements is observed, there are urticarial and papular elements that are not characteristic of herpes zoster. Duhring's dermatitis herpetiformis is a chronic relapsing disease. The pain syndrome and the location of the elements along the nerve fibers are not characteristic

3. Erysipelas. With erysipelas, the rashes are distinguished by more pronounced redness, greater delimitation of edema from healthy skin, roller-shaped edges, uneven edges. The lesions are continuous, the skin is dense, the rashes are not located along the nerves.

4. Secondary syphilis. With secondary syphilis, the Wasserman reaction is positive, the rashes are generalized, painless, true polymorphism is observed.

XI. Treatment

1. General mode. It is necessary to consult a neurologist to determine the degree of damage to the first branch of the trigeminal nerve on the right.

Exclusion of irritating foods (alcohol, spicy, smoked, salty and fried foods, canned food, chocolate, strong tea and coffee, citrus fruits).

3.1. Famvir (Famciclovir), 250 mg, 3 times a day for 7 days. Etiotropic antiviral treatment.

3.2. Sodium salicylic, 500 mg, 2 times a day. To relieve perineural edema.

3.3. Antiviral gamma globulin. 3 ml IM for 3 days. Immunostimulating, antiviral action.

Virolex (acyclovir) - eye ointment. Apply a thin layer on the affected eyelid 5 times a day for 7 days

5.1. Diathermy 10 sessions of 20 min. current strength 0.5A. Decreased irritation of the affected nerve

5.2. Laser therapy. Wavelength 0.89 µm (IR radiation, pulsed mode, laser emitting head LO2, output power 10 W, frequency 80 Hz). The distance between the emitter and the skin is 0.5–1 cm. The first 3 procedures: the time of exposure to one field is 1.5–2 minutes. Then 9 procedures: the time of exposure to one field is 1 min.

Stimulation of the immune system and reduction of irritation of the affected nerve

6.Sanatorium-resort treatment Consolidation of the results of therapy

Disease history

Herpes zoster, herpetic conjunctivitis and comorbidities

The main diagnosis: Herpes zoster in the projection of the 1st branch of the 5th nerve on the right. Herpetic conjunctivitis.

Concomitant diagnosis: ischemic heart disease, angina pectoris. Violation of the rhythm by the type of paroxysmal extrasystole.

Patient information

2. Age: 74 (11/27/35)

3. Place of residence: Ryazan, st. Berezovaya d.1 "B" apt. 61

4. Profession, place of work: pensioner

5. Date of illness: 09/30/10

6. Date of admission to the hospital: 2.10.10

7. Date of start and end of curation: 6.10.10-12.10.10

At the time of curation (6.10.10.-7 day of illness) the patient had no complaints.

morbi

He considers himself ill since 09/30/10, the first day of illness, when, after an eyebrow bruise, she noticed a red formation with a diameter of 0.2 mm. There was also swelling of the right eyelid and redness of the mucous membrane of the right eye. Notes a slight rise in temperature up to 38 C and itching. On October 1, 2010, the second day of illness, erythema began to grow, and already on October 2, 2010, the third day of illness, it occupied the right half of the face. She asked for help at the emergency hospital, where she was diagnosed with erysipelas of the face and the patient was referred to the infectious diseases department of the Semashko City Clinical Hospital. Hospitalized. October 8, 10 - the ninth day of illness, complaints of swelling of the right eyelid, headache. The general condition is satisfactory, locally without dynamics. 11.10.10-general condition is satisfactory, complaints of swelling of the right eyelid. Locally there is a positive trend. There are no new rashes, in place of the old ones, dried crusts.

Epidemiological history

Everyone around is healthy. 09/30/10 there was a bruise in the forehead as a result of a fall. Contact with infectious patients denies.

vitae

Born in Ryazan. She grew and developed normally. Graduated

secondary school. Upon graduation, she entered the RRTI at the Faculty of Engineering, after which she worked as an engineer at the CAM plant. Since 1964 she worked as an engineer at RKB GLOBUS. Retired from 1990 to present. Material and living conditions are good, he eats 3 times a day, takes hot meals.

Past illnesses and surgeries:

Chicken pox, rubella, SARS, acute respiratory infections. Cholecystectomy in 1998. Mastectomy in 2010.

Family life: married, has 2 children.

Obstetric and gynecological history: menstruation since the age of 15, menopause since 1988. Pregnancies-2, childbirth-2.

Heredity: grandmother suffers from hypertension.

Allergic history: denies allergic reactions to odors, foods, drugs and chemicals.

praesens

1. General state: satisfactory

2. Patient position: active

3. Consciousness: clear

4. Build: normosthenic: epigastric angle approximately 90o. Height 162 cm, weight 59 kg.

Food: normal, skinfold thickness 0.5 cm

5. Leather: normal color, elastic, skin turgor is reduced, moderately moist. There are no hemorrhages, scratches, scars, “spider veins”, angiomas. In the region of the right half of the forehead and scalp, edema, infiltration, skin hyperemia. Against this background, small group vesicular elements.

6. Mucous membranes: the state of the nasal mucosa is satisfactory, the mucous membrane of the oral cavity and the hard palate is of normal color. The gums are not bleeding, not loosened. The tongue is of the usual shape and size, moist, lined with white coating, the severity of the papillae is within the normal range. There are no cracks, bites, sores. The mucous membrane of the throat is of normal color, moist, there are no rashes and raids. In the OD area, the conjunctiva is edematous and hyperemic.

8. Subcutaneous tissue: the development of subcutaneous adipose tissue is moderate. The thickness of the skin fold in the region of the triceps muscle of the shoulder, scapula, under the collarbone - 0.5 cm. No edema. The saphenous veins are hardly noticeable, there are no subcutaneous tumors.

9. Lymphatic system: lymph nodes: (occipital, parotid, submandibular, axillary, inguinal, popliteal) - not enlarged (in the form of peas), painless, of normal density, mobile,

10. Muscular system: it is moderately developed, there is no pain on palpation, no differences in diameter were detected when measuring the limbs, the muscles are in good tone. There is no involuntary muscle tremor.

12. Bone-articular apparatus: there is no pain on palpation, no percussion of the bones, the joints are of the usual form, painless, the skin over them is unchanged. Movements in the joints are preserved in full, without crunch, free. There is no pain on palpation of the joints. The skin temperature over the joints is not changed. The gait is normal. Spine. Mobility in all parts of the spine is not limited. Bending the trunk forward in a sitting position is not limited. There is no pain on palpation. The range of motion is performed.

Study of the cardiovascular system

Examination of the region of the heart.

The shape of the chest in the region of the heart is not changed. The apical impulse is visually and palpation determined in the 5th intercostal space, 1.5 cm medially from the linea medioclavicularis sinistra, reinforced, with an area of 1.5 cm. The cardiac impulse is not palpable. Cat's purring in the second intercostal space on the right side of the sternum and at the apex of the heart is not defined. "Dance of the carotid" is absent. Physiological epigastric pulsation is palpable. On palpation, the pulsation in the peripheral arteries was preserved and the same on both sides.

On palpation of the radial arteries, the pulse is the same on both hands, synchronous, rhythmic, with a frequency of 84 beats per minute, satisfactory filling, not tense, the shape and magnitude of the pulse are not changed. There are no varicose veins.

Limits of relative cardiac dullness

The right border is determined in the 4th intercostal space - 2 cm outward from the right edge of the sternum; in the 3rd intercostal space 1.5 cm outward from the right edge of the sternum.

The upper border is defined between linea sternalis and linea parasternalis sinistra at the level of the 3rd rib.

The left border is determined in the 5th intercostal space 1.5 cm outward from the linea medioclavicularis sinistra; in the 4th intercostal space 1.5 cm outward from the linea medioclavicularis; in the 3rd intercostal space 2 cm outward from the parasternalis sinistra line.

Limits of absolute cardiac dullness

The right border is determined in the 4th intercostal space 1 cm outward from the left edge of the sternum.

The upper border is defined on the 3rd rib, between linea sternalis and parasternalis.

The left border is determined by 0.5 cm medially from the left border of relative cardiac dullness.

The vascular bundle is located - in the 1st and 2nd intercostal space, does not extend beyond the edges of the sternum.

On auscultation of the heart, clear heart sounds are heard. Rhythm disturbances by the type of paroxysmal extrasystole. There is no bifurcation, splitting of tones. Pathological rhythms, heart murmurs and pericardial rub are not detected. Blood pressure at the time of examination 125/80.

Respiratory system

The chest is of the correct form, normosthenic type, symmetrical. Both halves of it evenly and actively participate in the act of breathing. Type of breathing - chest. Breathing is rhythmic with a frequency of 17 respiratory movements per minute, of medium depth.

The chest is painless, rigid. The voice trembling is the same on both sides.

Shingles

Complaints of the patient upon admission to inpatient treatment for pain, hyperemia and multiple rashes in the area of the left half of the tongue, lower lip, chin. Data from the examination of the patient's organs. Substantiation of the clinical diagnosis: herpes zoster.

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Ministry of Health of the Russian Federation

State budget educational institution

higher professional education

I.M. Sechenov First Moscow State Medical University

Department of Therapeutic Dentistry

B02 - Shingles

Student of the 5th year of the 4th group

Patient Name: ______

Address, phone: Moscow, _____

Year of birth: 1982

Date of access: 27.10.2015

Patient Questioning Data

Complaints: Pain, redness and multiple rashes in the area of the left half of the tongue, lower lip, chin. Pain radiates to the left ear, eating is difficult.

Development of the present disease: He considers himself ill for about 2 days, when there was a sharp pain in the tongue, the left side of the face. More than 1 week ago I had a slight runny nose and cough. She was not treated, she looked after her son, who was sick with chicken pox. Previously, such rashes were not observed.

Patient's life history

Place of birth: Moscow, Russian Federation.

Past diseases: according to the patient, there were no injuries, no operations. Chickenpox at age 10.

Hereditary history: according to the patient, there are no hereditary diseases.

Allergological history: not burdened.

Objective Research Data

General condition: Chills, malaise, headache. Body temperature 38.9°C.

Facial examination: The configuration of the face is not changed. On the skin of the chin and the red border of the lower lip on the left, there are multiple bubbles arranged in the form of a chain. Some of the vesicles are open, covered with yellowish crusts.

Mouth opening: free

Examination of the lymph nodes: the submandibular lymph nodes on the left are enlarged up to 1 cm, painful on palpation, mobile.

Oral examination

Attachment of the frenulums of the upper and lower lips: within the physiological norm.

Condition of the oral mucosa: On the mucous membrane of the lower lip, cheek, lateral surface of the tongue on the left, there are multiple small-pointed and extensive erosions with scalloped edges on a hyperemic background, covered with fibrinous plaque, sharply painful on palpation.

Inspection of the dentition

Anomalies in the shape, position and size of the teeth were not found. Non-carious lesions of the teeth (hypoplasia, fluorosis, wedge-shaped defect, abrasion) are absent.

In the area 3.1 3.2 4.1 4.2 there is supragingival tartar of light brown color. In the area of teeth 1.7 1.6 1.5 1.4 2.4 2.5 2.6 2.7 there is a large amount of soft plaque.

supragingival calculus

B02 Shingles

K03.6 Deposits on teeth

K02.1 Dentinal caries - tooth 28

The diagnosis was made on the basis of the patient's complaints, the features of the development of the disease, the results of an external examination and examination of the oral cavity, and the main research methods.

Substantiation of the clinical diagnosis

1) the disease was preceded by SARS;

2) contact with a patient with chickenpox;

3) in the prodromal period, fever, malaise, headache;

4) neuralgic pain along the third branch of the trigeminal nerve on the left;

5) unilateral (asymmetric) lesions;

6) consecutive rashes: hyperemia (spot), vesicle, erosion, crust;

7) merged erosions with scalloped edges on the mucous membrane;

8) the disease appeared for the first time;

9) lack of intolerance to drugs

Shingles with involvement of the third branch of the trigeminal nerve on the left

Under application anesthesia "Lidoxor-gel" medical treatment of erosions with 1% solution of hydrogen peroxide was carried out, soft plaque was removed. The application of Valaciclovir under the Diplen-Dent film was carried out.

General treatment prescribed:

Antiviral drugs - herpevir 200 mg 4 times a day after meals for 5 days.

Effective use of deoxyribonuclease (50 mg. 2-3 r per day intramuscularly)

Analgesics and non-steroidal anti-inflammatory drugs - ibuprofenpomg two to three times a day for five days.)

Vitamin preparations - vitamin B-I2 - cyanocobalamin in pomg injections daily or every other day, the course of treatment is up to 2 weeks;

Interferon inducers - poludan, 2 drops in each nostril 5 times a day

Antihistamines: claritin (cetrin, loratadine) 1 tab. 2-3 times a day.

Inspection data: Regression of the inflammatory process, positive dynamics in the healing of erosions.

Under application anesthesia Lidoxor-spray 15%, an antiseptic treatment of the oral cavity with a solution of hydrogen peroxide 1%, an application of "Solcoseryl" (dental adhesive paste) was carried out.

Inspection data: Residual pigmentation is observed on the skin, slight paresthesia in the chin and lower lip area, complete healing of the mucous membrane in the oral cavity.

10/27/2015 The patient complains of pain, hyperemia and multiple rashes in the area of the left half of the tongue, lower lip, chin. Pain radiates to the left ear, eating is difficult. When collecting an anamnesis, it was found that the development of the disease was preceded by contact with a patient with chickenpox, as well as a sharp pain in the tongue, the left side of the face. More than 1 week ago I had a slight runny nose and cough. Examination: On the skin of the chin and the red border of the lower lip on the left, there are multiple rashes arranged in the form of a chain. Erosions are covered with crusts, located on a hyperemic background. The body temperature is 38.9°C. On the mucous membrane of the lower lip, cheek, lateral surface of the tongue on the left, there are multiple small-pointed and extensive erosions with scalloped edges on a hyperemic background, covered with fibrinous plaque, sharply painful on palpation. In area 42 there is supragingival tartar of light brown color.

Diagnosis: Shingles with lesions of the third branch of the trigeminal nerve on the left

Treatment: Assigned to the general treatment in the form of reception: herpevir 200 mg 4 times a day after meals for 5 days; ibuprofen pomg two to three times a day for five days, vitamin B-I2 - cyanocobalamin pomg injections daily or every other day, the course of treatment is up to 2 weeks; poludan, 2 drops in each nostril 5 times a day claritin (cetrin, loratadine) 1 tab. 2-3 times a day.

Local: Under application anesthesia "Lidoxor-gel" medical treatment of erosions with 1% solution of hydrogen peroxide was carried out, soft plaque was removed. The application of Valaciclovir under the Diplen-Dent film was carried out. Recommendations: Applications "Kamistad-gel", oral hygiene with a soft toothbrush, re-examination after 3 days.

10/30/2015 On examination: Regression of the inflammatory process, positive dynamics in the healing of erosions.

Local treatment was carried out: under application anesthesia Lidoxor-spray 15%, antiseptic treatment of the oral cavity with a solution of hydrogen peroxide 1%, application of Solcoseryl (dental adhesive paste) was carried out.

11/13/2015 On examination: Residual pigmentation is observed on the skin, slight paresthesia in the chin and lower lip area, complete healing of the mucous membrane in the mouth. .

The prognosis of the disease is favorable. Relapse is unlikely.

Case history of herpes zoster

The underlying disease Shingles in the zone of innervation Th 3 -Th 7 on the left; a common gangliocutaneous form with the addition of a secondary infection.

3. Age - 67 years old

4. Permanent place of residence - Rep. Ingushetia, Karabulak

5. Profession - pensioner

COMPLAINTS (at admission) on: intense burning pain in the left half of the chest, skin rashes, general weakness.

HISTORY OF THE PRESENT DISEASE (Anamnesis morbi)

He considers himself ill since December 4, 2010, when, 2 days after hypothermia, nausea, weakness, rise in body temperature to 38 ° C in the morning, stabilization to 36.6 ° C in the evening, pain in the left half of the chest, the next day blisters appeared on the skin of the chest on the left. She was treated on an outpatient basis. Topically applied rubbing, chlorhexidine, triderm, moisturizer; inside - no-shpa, voltaren, antibiotic (does not remember the name) - without a significant effect, severe pain in the area of rashes remained, weeping crusts appeared. She was referred for a consultation with an infectious disease specialist, on December 19 she was hospitalized in the infectious diseases department of the Central Clinical Hospital of the UDP RF for examination and treatment.

Not working, doing housework. Living conditions are satisfactory. Travels outside the place of residence (in the last 2 years), contacts with sick people and animals, parenteral manipulations (in the last 6 months) denies.

LIFE HISTORY (Anamnesis vitae)

She was born in 1943, grew and developed normally.

Past illnesses: chickenpox in childhood, myocardial infarction in 1975 after spontaneous abortion, stapedoplasty for otosclerosis on the right and left (gg), chronic cholecystitis, chronic pancreatitis.

Heredity and family history: father died in middle age, the cause is heart disease (does not remember the nosology), mother died at an advanced age from heart failure (does not know the etiology), relatives are healthy, five pregnancies, four children, children are healthy.

Type of nutrition: regular, complete, balanced diet.

Bad habits: smoking, drinking alcohol and drugs denies.

Allergological history and drug intolerance: not burdened.

PRESENT STATE (Status praesens)

on admission, the state of moderate severity, satisfactory at the time of curation

State of mind: not changed

The position of the patient: sitting, stiffness in the movements of the left hand and inclinations.

Build: normosthenic type, height 165 cm, weight 55 kg (BMI = 20.2), stooped posture, slow gait.

Body temperature: 36.6 o C.

Facial expression: calm.

Skin: swarthy; on the skin of the left half of the chest in the zone of innervation of Th 3 -Th 7 against the background of hyperemia, confluent weeping crusts and erosions with scanty purulent discharge are observed. The skin is dry, turgor is reduced.

Nails: regular shape (there are no “watch glasses” and koilonychia forms), pink color, no striation.

Visible mucous membranes: pink, moist; sclera pale; there are no rashes and defects;

Hair type: female.

Subcutaneous fat: moderately developed, painless on palpation.

Lymph nodes: occipital, parotid, submandibular, cervical, supraclavicular, subclavian, axillary, elbow, inguinal and popliteal lymph nodes are not palpable.

Muscles: underdeveloped. The tone is normal. There is no pain or tenderness on palpation.

Bones: there are no deformations and pain on palpation, tapping.

Joints: the configuration is not changed, painless on palpation. Edematous feet and legs; no hyperemia. The movements are painless, their restrictions are not observed.

Nose: the shape of the nose is not changed, breathing through the nose is free.

Larynx: there are no deformities and swelling in the larynx; quiet, clear voice.

Chest: The shape of the chest is normosthenic. Symmetrical. Over- and subclavian fossae are expressed. The width of the intercostal spaces is moderate. Epigastric angle 90 o. The shoulder blades and collarbones protrude moderately. The shoulder blades fit snugly against the chest. There is no spinal deformity.

Breathing: chest type. The number of respiratory movements is 18 per minute. Breathing is rhythmic, of the same depth and duration of the inhalation and exhalation phases. Both halves equally participate in the act of breathing.

Palpation: Painless. Rigid.

Percussion of the lungs: difficult on the left due to severe pain in the area of skin lesions.

With comparative percussion: a clear pulmonary sound is heard above the symmetrical sections of the lungs.

Herpes zoster: Aia's case history

Shingles - Treatment and recovery

Shingles treatment

Homeopathic treatment for herpes zoster

Before starting homeopathic treatment

Blisters, severe pain and itching in the back, shoulders, upper chest. Even after the disappearance of the blisters, he suffers from pain for a long time.

Results of homeopathic treatment

Full recovery, blisters, itching and pain gone.

return hope for restoration of health and joy of life.

SHINGLES

About the article

For citation: Korsunskaya I.M. Shingles // BC. 1998. No. 6. S. 10

Key words: Herpes - virus - nervous system - ganglia - sensitivity - antiviral agents - metisazon - acyclic nucleotides - analgesics.

Shingles is a viral disease that often occurs, especially against the background of immunosuppression. Diagnosis is based on clinical manifestations. Treatment should be comprehensive and include antiviral drugs, ganglion blockers, analgesics.

Key words: Herpes - virus - nervous system - ganglia - antiviral agents - methisazone - acyclic nucleosides - analgetics.

Herpes zoster is a viral disease that is most common especially in immunodeficiency. The diagnosis is based on its clinical manifestations. Treatment should be combined and include antiviral, ganglion-blocking, and analgetic agents.

THEM. Korsunskaya - Ph.D. honey. Sci., Assistant Professor, Department of Dermatovenereology, Russian Medical Academy of Postgraduate Education

I.M.Korsunskaya, Candidate of Medical Sciences, Assistant, Department of Dermatovenereology, Russian Medical Academy of Postgraduate Training

Shingles (Herpes zoster) is a common viral disease that attracts the attention of not only dermatologists, neurologists and virologists, but also doctors of other specialties.

The history of this disease is very old, but only at the end of the last century, neuropathologists Erb (1893) and Landori (1885) first suggested the infectious genesis of Herpes zoster, which was confirmed by the following clinical data: fever, cyclic course, disease of two members of the same family and more. The virus (Varicella zoster - VZ) belongs to the group of DNA-containing viruses. The size of the virus is from 120 to 250 microns. The virion core consists of DNA covered with protein. The composition of the virion includes more than 30 proteins with a molecular weight of up to 2.9 10 daltons. Viruses of this group begin to reproduce in the nucleus. In cross-neutralization experiments performed by Taylor-Robinson (1959), the varicella-zoster virus and the Herpes zoster virus were equally neutralized by the sera of convalescents. At the same time, sera taken from patients with Herpes zoster in the acute period had a greater neutralizing activity than sera taken at the same time from patients with chickenpox. A. K. Shubladze and T. M. Maevskaya believe that this is apparently due to the fact that Herpes zoster is a secondary manifestation of an infection caused by the varicella-zoster virus. Most modern researchers consider the VZ virus to be the cause of this disease.

To understand the pathogenesis of Herpes zoster, the data of post-mortem studies are important, indicating the connection of the rash sites with the lesion of the corresponding ganglia. Later, Head and Campbell (1900), on the basis of histopathological studies, came to the conclusion that both neurological phenomena in Herpes zoster and the zones of skin rashes that characterize them arise as a result of the development of a pathological process in the intervertebral nodes and their homologues (Gasser's node, etc.) . But already Volville (1924), having studied the nervous system of patients who died from the generalized form of Herpes zoster, came to the conclusion that the defeat of the intervertebral ganglia in Herpes zoster is not mandatory. The spinal cord is often involved in the inflammatory process, and not only the posterior horns are affected, but also the anterior ones. Volville and Shubak (1924) described cases when herpetic eruptions were the first manifestations of a polyneurotic process proceeding according to the type of Landry's paralysis. Volville believes that the inflammatory process first affected the sensitive neurons, and then spread to the spinal segments and peripheral nerves. In the case described by Shubak, a pathoanatomical examination revealed nests of inflammatory infiltration in the sciatic nerves, cervical sympathetic nodes and the corresponding spinal ganglia, dorsal horns of the spinal cord.

Stamler and Stark (1958) described the histological picture of fulminant ascending radiculomyelitis zoster, in which death occurred as a result of bulbar and spinal respiratory paralysis. Demyelination of the spinal cord conductors with glial and lymphocytic reaction, perivascular infiltration and proliferation, changes in the neurons of the spinal ganglia, dorsal horns, and dorsal roots were found.

In 1961, Kro, Dunivits and Dalias reported seven cases of Herpes zoster affecting the central nervous system. The disease proceeded in the form of aseptic meningitis, meningoencephalitis involving the cranial nerves, encephalomyelitis, polyradiculoneritis. Histopathological examination revealed a picture of "posterior poliomyelitis". The authors consider it sufficient for the histological diagnosis of Herpes zos ter, when the disease proceeds without clear herpetic eruptions.

Pathomorphological and virological studies indicate that the Herpes zoster virus is widely disseminated throughout the body: during illness, it can be isolated from the contents of vesicles, saliva, lacrimal fluid, etc. This gives reason to believe that herpetic eruptions can be caused not only by sedimentation virus in the sensitive ganglia and the defeat of the parasympathetic effector cells located in them, but also by its direct introduction into the skin. Penetrating into the nervous system, it is not only localized within the peripheral sensory neuron (spinal ganglia, etc.), but also spreads to other parts of the central nervous system. When it is introduced into the motor cells and roots, a picture of amyotrophic radiculoplexitis occurs, in the gray matter of the spinal cord - myelitis syndrome, in the cerebrospinal fluid system - meningoradiculoneuritis or serous meningitis, etc.

The clinical picture of Herpes zoster consists of skin manifestations and neurological disorders. Along with this, most patients have general infectious symptoms: fever, enlargement of hormonal lymph nodes, changes (in the form of lymphocytosis and monocytosis) of the cerebrospinal fluid. Usually, erythematous spots of round or irregular shape, raised, edematous, are found on the skin, when you run a finger over them, some pebbly skin (tiny papules) is felt. Then, in these areas, groups of bubbles appear sequentially, often of different sizes. Bubbles can merge, but most often they are located in isolation, although close to one another - the vesicular form of Herpes zoster. Sometimes they look like a small bubble surrounded by a red rim around the periphery. Since the rash occurs simultaneously, the elements of the rash are at the same stage of their development. However, the rash may appear within 1 to 2 weeks in the form of separate groups. In the latter case, when examining a patient, rashes of various stages can be detected. In typical cases, the bubbles have a transparent content for the first time, quickly turning into a cloudy one, and then dry out into crusts. A deviation from the type described is the milder abortive form of Herpes zoster. With this form, papules also develop in the foci of hyperemia, which, however, do not transform into vesicles, this form differs from vesicular. Another variety is the hemorrhagic form of Herpes zoster, in which the vesicles have bloody contents, the process extends deep into the dermis, the crusts become dark brown. In severe cases, the bottom of the vesicles becomes necrotic - the gangrenous form of herpes zoster, after which cicatricial changes remain. The intensity of the rashes in this disease is very variable: from confluent forms, leaving almost no healthy skin on the side of the lesion, to individual vesicles, although in the latter case the pain can be pronounced. Such cases have given rise to the assumption that Herpes zoster can exist without skin eruption.

One of the leading symptoms of the disease are neurological disorders, usually in the form of pain. Most often it occurs 1 - 2 days before the appearance of rashes. The pains, as a rule, are of an intense burning character, the zone of their distribution corresponds to the roots of the affected ganglion. It should be noted that the pain syndrome intensifies at night and under the influence of a variety of stimuli (cold, tactile, kinesthetic, barometric) and is often accompanied by vegetative-vascular dystonia of the hypertonic type. In addition, patients have objective sensitivity disorders: hyperesthesia (the patient can hardly tolerate the touch of linen), hypoesthesia and anesthesia, and hyperalgesia may exist simultaneously with tactile anesthesia.

Objective sensory disturbances are variable in form and intensity, usually limited to temporary sensory disturbances in the area of the rash or scarring. Anesthesias concern all kinds of sensitivity, but in some cases a dissociated type of disorder is observed; sometimes within the same kind of sensitivity, such as hot and cold. Occasionally, hyperesthesia takes on the character of irritation in the form of causalgia.

Not in all cases, the intensity of the pain syndrome corresponds to the severity of skin manifestations. In some patients, despite the severe gangrenous form of the disease, pain is minor and short-lived. In contrast, a number of patients have a prolonged intense pain syndrome with minimal skin manifestations.

Some patients in the acute phase have diffuse cephalgia, aggravated by a change in the position of the head, which may be associated with a shell reaction to Herpes zoster infection. In the literature there are indications of damage to the brain and its membranes.

According to a number of authors (A.A. Kalamkaryan and V.D. Kochetkov 1973; M.K. Zucker 1976, etc.), herpetic ganglionitis of the gasser node are more common than ganglionitis of the intervertebral nodes. In most patients with this localization of the process, there is an increase in temperature and swelling of the face on the affected side, as well as pain at the exit points of the trigeminal nerve.

The cornea is often affected in the form of keratitis of a different nature. In addition, other parts of the eyeball are affected (episcleritis, iridocyclitis, iris zoster). The retina is involved very rarely (hemorrhages, embolisms), more often the changes concern the optic nerve - optic neuritis with an outcome in atrophy, possibly due to the transition of the meningeal process to the optic nerve. With ophthalmic herpes (iritis), glaucoma may develop; usually, with zoster, gynotension of the eyeball is observed, which is apparently caused by damage to the ciliary nerves. Complications of zoster from the motor nerves are quite common, they are arranged in the following order: III, IV, VI nerves. Of the branches of the oculomotor nerve, both external and internal branches are affected. Ptosis is often observed. Skin rashes in ophthalmic zoster are usually more severe than in other parts of the body, perhaps depending on the structure of the skin in the eye area. Quite often, necrosis of the vesicles, severe neuralgia, accompanied by lacrimation, are observed. Bubbles pour out not only on the skin, but also on the mucous membranes of the eye.

As a result of the process in the cornea with ophthalmic zoster, atrophy of the optic nerve and complete blindness may develop. In addition, some patients note the loss of eyebrows and eyelashes on the side of the lesion.

The maxillary branches of the trigeminal nerve are affected both in the area of the skin and in the area of the mucous membranes (half of the hard and soft palate, the palatine curtain, the upper gum, the inner surface of the buccal mucosa, while the nasal mucosa may remain unaffected). Branches supplying mucous membranes may be more affected than cutaneous branches, and vice versa. Damage to the nerves of the upper and lower jaws does not always remain strictly localized, since pain sometimes radiates to the region of the ophthalmic and other branches.

Herpes zoster usually affects the autonomic nervous system. However, clinical observations have shown that the animal nervous system can also be involved in the pathological process. Evidence of this is that in some patients, simultaneously with the defeat of the Gasser node, there was a peripheral paresis of the facial nerve on the side of herpetic eruptions. With ophthalmic zoster, both the external and internal muscles of the eye are paralyzed. IV pair paralysis is rare. Oculomotor paralysis is usually partial rather than complete; more often than other muscles, m. levator palpebrae. There are cases of ophthalmic zoster with an isolated change in the shape and size of the pupil; unilateral Argil-Robertson symptom (Guillen). These paralysis sometimes partially or completely disappear spontaneously, without special treatment.

And Nordal (1969) was the first to point out the defeat of the geniculate node in this form of Herpes zoster. Usually on the auricle or around it, and sometimes in the ear canal and even on the eardrum, herpetic eruptions appear. There is a sharp pain in the circumference of the auricle, swelling of the lymph nodes, impaired sensitivity. Disorders of the functions of the facial, cochlear, vestibular nerves occur in the first days of rashes or precede them. Pain in such cases is localized in the depth of the auditory canal and auricle with irradiation to the mastoid, auricular and temporoparietal regions. Objective sensitivity disorders are found behind the ear, in the fold between the auricle and the mastoid process. This skin area is supplied by the ear branch of the X pair, which innervates the posterior walls of the ear canal. Finally, in cases of a very common ear zoster, the latter captures not only the external auditory canal, the auricle, the mastoid process, but also the tympanic membrane, which sometimes suffers extremely severely. In such cases, the area innervated by the V, VII and X pairs is affected, and the defeat of these nerves is accompanied by damage to the ganglia of the corresponding cranial nerves or anastomoses that connect the terminal branches of all the listed nerves.

Often, simultaneously with paralysis of the VII pair, paralysis of the soft palate, anesthesia and paresthesia in the tongue are observed, often a taste disorder in the anterior two-thirds of the tongue due to damage. The defeat of the Vlll pair usually begins with tinnitus, which sometimes persists for a long time after the disappearance of other phenomena. Hyperacusia in the defeat of the VIII pair is called paresis n. stapeblii, although this symptom may also occur in isolated and previous lesions of the auditory nerve and is in such cases a symptom of irritation. Hypoacusia can occur regardless of the damage to the auditory nerve due to local lesions of the middle ear, the rash of bubbles on the eardrum, the laying of the external auditory canal, due to swelling of the mucous membrane due to the rash of zoster.

Vestibular phenomena, in contrast to cochlear ones, usually develop extremely slowly and are expressed differently: from mild subjective symptoms of dizziness to significant static disorders.

Neuralgia in ear zoster, in contrast to ophthalmic zoster, is rare.

Long-term results are not always favorable, as persistent paresis of the facial nerve and deafness may occur.

Volville emphasizes that the combination of paralysis of the VlI and VIII pairs, although it occurs especially often in zoster, nevertheless happens with the defeat of the gasser node, ll, lll, cervical ganglia, and, finally, all these areas can be affected simultaneously.

Rashes of zoster are also described in the region of innervation of the IX pair: the back of the soft palate, arches, posterolateral parts of the tongue, part of the posterior pharyngeal wall; the same area is innervated, in addition to IX, also by the branches of the X pair: the root of the tongue, larynx, proglottis, basal and posterior part of the pharyngeal wall. Although zoster predominantly and even selectively affects the sensitive systems, however, movement disorders are sometimes observed with it, especially when rashes are localized in the head, neck, and extremities. Paralyzes in zoster are radicular in nature, and the defeat of the posterior roots in these cases is accompanied by phenomena from the corresponding anterior roots.

The defeat of the cervical sympathetic nodes is often accompanied by rashes on the skin of the neck and scalp. Pain in this case is observed not only in the places of rashes, but also in the area of paravertebral points. Sometimes there may be seizures that mimic facial sympathy.

With ganglionitis of the lower cervical and upper thoracic localization, along with the usual symptoms of this disease, Steinbrocker's syndrome can be observed. Dominant in the picture of this syndrome are pains of a sympathetic nature in the form of a burning sensation or pressure, which occur first in the hand, and then in the entire hand. Soon appears and quickly increases swelling of the hand, spreading to the entire arm. Trophic disorders are added in the form of cyanosis and thinning of the skin, hyperhidrosis, brittle nails. The movements of the fingers are limited, painful. Often, pain and other autonomic disorders persist even after the rash has disappeared. Ganglionitis of thoracic localization often simulate the clinical picture of myocardial infarction, which leads to errors in diagnosis.

With herpetic lesions of the ganglia of the lumbosacral region, rashes are most often localized on the skin of the lower back, buttocks and lower extremities; along with pain in the places of rashes, pain syndromes can occur that simulate pancreatitis, cholecystitis, renal colic, appendicitis. Herpetic lesions of the lumbosacral ganglia are sometimes accompanied by involvement in the process of the animal nervous system, which gives a picture of ganglioradiculitis (radicular syndrome of Nori, Matskevich, Wasserman).

Sometimes, along with rashes along the nerve trunk, vesicular rashes appear all over the skin - a hepatic form of herpes zoster. Usually the disease does not recur. However, it is known from the literature that there are recurrent forms of the disease against the background of somatic burden: HIV infection, cancer, diabetes mellitus, lymphogranulomatosis, etc.

In the treatment of Herpes zoster of various localization and severity, early administration of antiviral drugs is necessary. It is known that the composition of the virus includes proteins that form its shell and carry the enzymatic function, as well as nucleic acid - the carrier of its genetic properties. Penetrating into cells, viruses are released from the proteinaceous protective shell. It has been shown that at this moment their reproduction can be inhibited with the help of nucleases. These enzymes hydrolyze the nucleic acids of viruses, but do not damage the nucleic acids of the cell itself. It was found that pancreatic deoxyribonuclease sharply inhibits the synthesis of DNA-containing viruses, such as herpes viruses, vaccinia, adenoviruses. Taking into account the above, it is recommended for patients with Herpes zoster to prescribe deoxyribonuclease intramuscularly 1-2 times a day, 30-50 mg for 7 days. In addition, in patients with rashes on the oral mucosa, conjunctiva and cornea, the drug is used topically in the form of an aqueous solution. The appointment of deoxyribonuclease contributes to the rapid regression of skin rashes and a decrease in pain.

Good results are obtained by the use of metisazon. It is prescribed orally at the rate of 20 mg per 1 kg of the patient's body weight per day in 3 divided doses after meals for 6 to 7 days. The drug is contraindicated in severe lesions of the liver and kidneys, gastrointestinal diseases in the acute stage. It is not recommended to take alcoholic beverages during treatment. No complications were observed during the use of the drug.

Metisazon does not affect the adsorption of the virus by the cell and its penetration into the cell. It does not affect the synthesis of viral DNA and does not interfere with the synthesis of many viral proteins. The drug apparently interferes with the synthesis of late proteins involved in the construction of a viral particle. It has also been suggested that metisazon induces the formation of a new ribonucleic acid in the cell, which provides the synthesis of a protein with antiviral properties. When administered orally, metisazon can be detected after 30-40 minutes in the blood serum, and after 2-3 hours - in the urine.

In recent years, antiviral chemotherapy drugs from the group of synthetic acyclic nucleosides have been used to treat Herpes zoster. The most well studied at present is acyclovir. The mechanism of action of acyclovir is based on the interaction of synthetic nucleosides with the replication enzymes of herpesviruses. Herpesvirus thymidine kinase binds to acyclovir thousands of times faster than cellular thymidine, so the drug accumulates almost exclusively in infected cells. This explains the complete absence of cytotoxic, teratogenic and mutagenic properties in acyclovir. The synthetic nucleoside is built into a chain of DNA being built for the "daughter" viral particles, and this process is interrupted, thus stopping the reproduction of the virus. The daily dose of acyclovir for herpes zoster is 4 g, which should be divided into 5 single doses of 800 mg. The course of treatment is 7 - 10 days. The best therapeutic effect is achieved with early administration of the drug; the terms of rashes are reduced, there is a rapid formation of crusts, intoxication and pain syndrome are reduced.

Acyclovir of the second generation - valacyclovir, retaining all the positive aspects of acyclovir, due to increased bioavailability, allows you to reduce the dose to 3 g per day, and the number of doses - up to 3 times. The course of treatment is 7 - 10 days.

Famciclovir has been used since 1994. The mechanism of action is the same as that of acyclovir. The high affinity of the thymidine kinase of the virus for famciclovir (100 times higher than the affinity for acyclovir) makes the drug more effective in the treatment of herpes zoster. The drug is prescribed 250 mg 3 times a day for 7 days.

Along with antiviral drugs, ganglionic blockers such as ganglerone are used to reduce pain. Gangleron is used intramuscularly in the form of a 1.5% solution of 1 ml 1 time per day for 10-15 days or 0.04 g in capsules 2 times a day for 10-15 days, depending on the severity of the pain syndrome. In addition, the use of carbamazepine gives good results, especially in Herpes zoster gasser node, the drug is prescribed from 0.1 g 2 times a day, increasing the dose by 0.1 g per day, if necessary, up to 0.6 g daily dose (in 3 - 4 doses). After the reduction or disappearance of pain, the dose is gradually reduced. Usually the effect occurs 3-5 days after the start of treatment.

With a pronounced pain syndrome, analgesics are prescribed per os and in the form of injections, reflexology. In reflexology, both points of general action and points corresponding to the affected ganglion are usually used, the course is 10-12 sessions. It is also recommended to prescribe multivitamins, in particular vitamins of group B. Local irrigation with interferon or ointments with interferon, aniline dyes, eridine aerosol, florenal ointments, helepin, alpizarin can be used locally. With gangrenous forms of herpes zoster, pastes and ointments containing an antibiotic, as well as solcoseryl, are used.

After resolution of skin rashes, treatment is carried out by neuropathologists until the disappearance of neurological symptoms.

Thus, the treatment of herpes zoster should be comprehensive and include both etiological and pathogenetic agents.

1. Barinsky I.F., Shubladze A.K., Kasparov A.A., Grebenyuk V.N. - "Herpes". - M. - 1986.

2. Shishov A.S., Leshinskaya E.V., Martynenko I.N. – Journal of Clinical Medicine. - 1991. - No. 6. – P. 60–72.

3. Batkaev E.A., Korsunskaya I.M. - Viral dermatoses. - M. - 1992.

Case history of herpes zoster. Respiratory system. VIII. Data from laboratory and instrumental studies

Main etiological factors

Signs of herpes simplex

Recurrent genital herpes

Investigation for suspected herpes

What to do in case of recurrence of the disease

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Etiology (causes) of chronic recurrent herpes

Symptoms of chronic recurrent herpes

Treatment of chronic recurrent herpes

Case history of infectious diseases: Herpes zoster I branch of the right trigeminal nerve

I. Passport part

II.Complaints

III. History of the present disease (Anamnesis morbi)

IV. Life history (Anamnesis vitae)

V.Heredity

VI. Present status (Status praesens)

VII. Local Status

VIII. Data from laboratory and instrumental studies

IX. Clinical diagnosis and justification

X. Differential diagnosis

XI. Treatment

Disease history

morbi

Epidemiological history

vitae

praesens

Shingles

Complaints of the patient upon admission to inpatient treatment for pain, hyperemia and multiple rashes in the area of ​​the left half of the tongue, lower lip, chin. Data from the examination of the patient's organs. Substantiation of the clinical diagnosis: herpes zoster.

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About the article

Complaints of the patient upon admission to inpatient treatment for pain, hyperemia and multiple rashes in the area of the left half of the tongue, lower lip, chin. Data from the examination of the patient's organs. Substantiation of the clinical diagnosis: herpes zoster.