Brill’s disease is a relapse of epidemic typhus, preserving the clinical manifestations of the primary disease, but occurs predominantly in the form of light. The characteristic clinical symptom is abundant rosolino-petechial rash on skin, mucous membranes.
Systemic manifestations are fever, change of consciousness, a tendency to tachycardia and hypotension. Confirming diagnostic methods include the detection of antibodies against typhus rickettsiae and the pathogen. Treatment recoverage typhus is carried out using specific antibiotics and symptomatic drugs.
Brill’s disease (Brill’s disease-Zinsser, another typhus) is an acute infectious disease, occurring with lesions of the skin, mucous membranes and, less frequently, cardiovascular and nervous systems. Disease was first described in 1910 by the American physician N. Brillon and supplemented in 1934 by epidemiologist H. Tissera.
Scientists have linked the symptoms of the disease with a previously migrated typhus, in the middle. The twentieth century was confirmed by the detection of rickettsiae in lymph nodes died of a relapse of typhus, was first postponed for more than 20 years before death. The disease has no clear seasonality has been sporadic, does not imply that recent contact with head lice or pediculosis sick.
Causes of Brill disease
The pathogens of infection are Rickettsia of Provasca that are found in the lymph nodes and other organs have undergone in the past, epidemic typhus of the person. Rickettsia – obligate intracellular microorganisms are killed by boiling, using standard solutions of disinfectants. The source of infection for themselves is himself a sick man, to others he is not contagious only in the absence of lice. In the presence of pediculosis the patient with Brill’s disease can infect typhus epidemic with vector-borne transmission.
Traditionally, the risk group included only people older than 45 years, but due to the high prevalence of HIV infection in the world, patients with HIV may be vulnerable to disease Brill to a greater extent than the General population. Trigger factors of relapse usually are acute respiratory infections, exhaustion, prolonged stress, hypothermia, radiation, exacerbation of chronic diseases, injuries, climate change, work in hazardous work, severe immunodeficiency States, etc. Children under 18 years do not suffer from this pathology.
After suffering a lousy epidemic typhus Rickettsia a long time persistiruut in the lymph nodes, parenchymatous organs (most often liver, kidney) and lungs. An important role in the pathogenesis of recurrent infection is the number of Rickettsia (usually insignificant), which correlated with the severity of clinical and morphological manifestations. Under appropriate conditions rickettsiae penetrate into the systemic circulation, thus the main target of the pathogen is in the vascular endothelium. In endothelial cells the reproduction of Rickettsia, inflammatory changes can capture the entire thickness of the vessel, resulting in necrosis of the vascular wall. However, specific cyproterone granulomas (nodules Popova) are formed rarely.
The disease is characterized by the so-called verrucous endocarditis affecting the heart valves. Due to the circular or segmental vascular lesion formed thrombus, in the localization of thrombosis (or thromboembolism) in the blood vessels of the brain, possible ischemic injury of the nervous tissue. Damage to blood vessels and cause cutaneous manifestations of the disease. An important feature of the pathology is non-sterile immunity, therefore, the total elimination of the pathogen may new infection. However, repeated cases of this disease in the world practically is not fixed. This is probably due to the morphological characteristics of rickettsiae, their intracellular parasitism, allowing long time to be out of reach for cells of the immune system.
Symptoms of Brill disease
The incubation period of the disease lasts in some cases from 3 to 50 years. The first clinical symptoms can begin within 5-7 days after exposure to a provoking factor. The beginning of the relapse of acute, with a sharp rise in body temperature to high numbers (above 39°C), chills, severe weakness, fatigue, severe headache, decreased appetite. Excited patients may experience sleep disturbances, euphoria, depersonalization, hypersensitivity ocular, auditory, olfactory and other analyzers. There is a decrease in blood pressure (below 120/80 mm Hg. calendar). Unexpressed observed redness of face, injection of vascular sclera, with the first day defined spots Chiari-Avtsyn (single red-orange items with a vague outline of the conjunctiva, cartilage of the upper eyelid) and enanthema Rosenberg (small petechiae on the shell of the soft palate, arches of the tonsils).
With a 3-4 start date of the recurrence on the skin, the appearance of rosealina-petechial rash mostly on the body, sides of the torso, upper extremities; much rarer elements found on the face, palms and soles. The rash does not cause itching, flaking, goes unnoticed (roseola) or leave areas of depigmentation (petechiae). Bad prognostic sign is the prevalence of petechial rash, however, this nosology is observed very rarely, as for without the appearance of the exanthema. Infrequent but dangerous symptom is inflammation of the brain, manifested by impaired consciousness, paralysis, paresis.
Early seeking medical care, correct diagnosis, timely treatment allows you to transfer the disease without complications. Patients with chronic systemic diseases are often prone to the development of medium-severe and complicated forms of the disease Brill. The most fearsome consequences of relapse rickettsias are thromboembolic syndrome, thrombophlebitis, toxic shock, secondary bacterial infection (hypostatic pneumonia, pyelonephritis, sepsis). Possible purulent complications due to invasive medical treatment and diagnostic manipulations (intravenous infusion, catheterization of vessels, intramuscular injections, etc.).
To confirm or exclude the diagnosis of recurrent fever consultation of infectious disease specialist, cardiologist, dermatologist. If signs of CNS after the examination by a neurologist.
Diagnosis of CHF is done by careful collection of epidemiological anamnesis, a correct interpretation of the data examination, results of laboratory and instrumental studies:
- Physical examination. An objective study of the patient draws attention to moderate psychomotor agitation, sometimes a tremor of fingers of hands and jerky pushing of the tongue forward (symptom Govorov-Godele). Rosealine observed and petechial rash on the skin, the conjunctiva, the soft palate. On palpation of the abdomen can detect enlargement of the liver, spleen (hepatosplenomegaly). Characteristic positive symptoms harness and pinch (artificial evocation of a rash when compression of the skin).
- Studies of blood and urine. In the clinical analysis reported the presence of neutrophilic leukocytosis with stab shift to the left, lymphocytopenia, eosinopenia, acceleration ESR. Biochemical studies show an increase in creatinine, hyperglobulinemia, hypoalbuminemia. In General, the analysis of urine is an increase in the density, albuminuria, cylindruria, microhematuria rarely.
- Identification of infectious agents. Mandatory for diagnosis is serology (IFA, RSK, IF) detection of immunoglobulin G (IgG) against Rickettsia of Provasca. The presence of the pathogen may prove by PCR. Bacteriological examination of blood is a laborious and expensive process, is carried out only in laboratories especially dangerous infections.
- The diagnosis. The ECG revealed tachycardia, signs of myocardial hypoxia, at least – the failure of the affected valves. When the ECHO detected vegetation with feathered contour, heterogeneous echographic signal, thickening of the valves of the valves, sometimes the formation of valvular insufficiency, worsening of regurgitation.
Differential diagnosis is carried out with endemic typhus, rubella, measles, syphilis, sepsis, spotted fever of the rocky mountains, influenza, typhoid fever, paratyphoid A and b, hemorrhagic fever with renal syndrome, meningococcal disease (meningococcemia and meningococcal meningitis), leptospirosis. Given the damage to the heart caused by a relapse of typhoid fever, and often of concomitant cardiac pathology, it is necessary to differentiate the disease with infective endocarditis, rheumatic heart disease, cardiomyopathy. Psychomotor agitation or retardation, and possible episodes of hallucinations, delirium can be caused by alcoholic, narcotic intoxication, or be a debut of mental rastrojstvo senile dementia.
The treatment of the disease Brill
Patients with suspicion on this pathology are subject to hospital treatment. Mode sheets should be maintained a predominantly horizontal position to 5-6 days of normal temperature. And resolves non-durable travel under the supervision of health care workers, then – independently within the Department. The need for regular blood pressure monitoring. Some effectiveness could be the use of compression hosiery for the prevention of deep vein thrombosis of the lower extremities and pulmonary embolism. It is recommended to increase fluid intake, a diet with the exception of alcohol, fried and fatty foods.
Etiotropic drugs for the treatment of the disease Brill – tetracycline antibiotics, rifamitinov row, and also macrolides (e.g., doxycycline, tetracycline, rifampicin or azithromycin). Pathogenetically justified the use of vitamins C and P, with vasoprotective properties. Symptomatic therapy includes antipyretics, detoxification drugs (chlosol, acesol, Hartman’s solution, ringer, glucose-salt and a succinate-containing infusion solutions), sedative (barbiturates, diazepam, and others). All patients, particularly the elderly, it is recommended the use of anticoagulants (heparin).
Prognosis and prevention
The prognosis for most often favorable, mortality is 1-2%. On the course of infection may influence comorbid conditions and age of the patient, most often febrile stage of the disease lasts about 7-8 days, full recovery takes up to 2-3 weeks. About 70 % of cases occur in light or moderate form.
Specific prevention of the disease is the use of vaccines on epidemiological indications. The most common practice of vaccination with a live typhus vaccine and its analogue – dry chemical preparation that contains killed Rickettsia. The use of means of specific prophylaxis is indicated to people temporarily or permanently in contact with sick lice and typhus, as well as living together with a sick Brill’s disease in unfavorable sanitary and epidemiological conditions.
The main method of nonspecific prevention of pathology is the control of body lice (preventive examinations in educational institutions and workplace), sanitary-educational work with the population, instilling hygienic habits to the children. Need a complete pest control locations, clothing, personal items of patients with lice. It is important early identification, isolation, rational antibiotic therapy of patients with epidemic typhus.