1. Put the preliminary diagnosis.

2. Perform differential diagnosis of viral hepatitis of various etiologies, and other infectious diseases proceeding with the development of jaundice.

3. Make a plan of patient examination and specify which laboratory parameters will allow to put a definitive diagnosis.

4. What should be the treatment strategy?

ANSWER

1. Given the acute onset with fever over 38 C, preicteric short period, no history of parenteral intervention, staying in a region with a high incidence of hepatitis with fecal-oral mechanism of transmission 2 months before the disease, the food in the dining room, vaccination against hepatitis B, the presence of acute hepatitis syndrome, improvement to the appearance of jaundice. You can put a preliminary diagnosis of "hepatitis A".

2. Taking into account that the vaccination history of hepatitis B, the absence of indications of parenteral intervention, improving the appearance of jaundice, presence of acute hepatitis patients with parenteral transmission is unlikely. Staying in endemic regions for HE, the use of raw water from open reservoirs, make spending differential. diagnosis with the disease. However, acute onset, high fever in the prodrome, reducing intoxication and fever with jaundice put this diagnosis into question. Acute onset of high fever, epidemiological history data, muscle pain on a background of fever, raise questions about the icteric form of leptospirosis. This diagnosis is uncertain because of the short hectic period with a gradual decrease in activity of fever, lack of characteristic clinical signs of leptospirosis (myalgia, back pain, renal failure, hemorrhagic manifestations), decrease in toxicity and improvement of the state, as well as the disappearance of fever with jaundice.

3. 3. It is necessary to carry out the biochemical analysis of blood, BA, UA, the definition of markers of viral hepatitis by ELISA, testing for leptospirosis - a reaction microagglutination and lysis. Laboratory signs of HAinorder to put a definitive diagnosis, are: increased ALT and AST 10-15 times, presence of blood anti-HAV IgM, the lack of blood HBsAg, anti-HBcore IgM, anti-HCV and anti-HEV IgM, negative results ofmicroagglutination reactions and lysis of normal blood and urine tests.

4. 4. Diet - table number 5, have rest, drink 1, 5 liters of fluid per day.

Task3

Patient, 35 years old, tuberculotherapist. On 03.09,pt felt ill with fatigue, decreased performance. Over the next 7 days I was growing weakness, body temperature did not rise. On 11.09,she felt no more pain in the knee joints and lower back, which were amplified in 3 days ago, body temperature 37, 2 C . on 15.09,she felt badat night duty at work where she had an injection of diclofenac, which has not brought relief. Against the background of weakness and pain in the joints with rash on the skin of the abdomen and thighs, decreased appetite, headache appeared, felt an aversion to meat and the smell of fried food. 17.09, the patient felt discomfort, heaviness in the epigastrium, slight nausea after eating. Appetite progressively deteriorated, and continue to have a disturbing pain in the joints.

On 20.09 she noticed the dark color of urine. 21.09 she went to the doctor clinic, laboratory tests have been made. Biochemical analysis of blood –hyperbilirunemia to 35 mol \ n due to direct fraction, increased ALT and AST greater than 10 standards.

She got Hospitalized to infectious diseases hospital with a diagnosis of "viral hepatitis?". When viewed in the hospital skin color was normal , sclera ikterichnost, no rash. The liver performs at 2 cm from under the costal arch, palpable spleen edge, the shape of the joints were changed. Complaints of weakness, lack of appetite, nausea, pain in the joints.

When refining history, it was revealed that the patient in the last 6 months undergoing treatment at periodontist, at this period also visited a gynecologist. She suffers from chronic cholecystitis and pancreatitis. Over the past 6 months I did not go out of Moscow. Works in the office, where we often deals with homeless, migrants. Not vaccinated against hepatitis B. Date of last menstrual period 25.08. Vegetarian, often eats salads of raw vegetables in the cafeteria hospitals, cafes and canteens.

22.09 in the hospital, the patient got jaundiced skin, increased weakness, appetite disappeared, there is dizziness when standing up from the bed. These biochemical blood tests: 35-fold increase in liver transaminases, hyperbilirubinemia - 200 mmol \ L, prothrombin index 54%.

1. Put the preliminary diagnosis and justify it.

2. How to confirm the diagnosis?

3. differential. diagnosis of viral hepatitis of various etiologies, yersiniosis.

4. What laboratory evidence provides a basis to predict the severity of disease?

ANSWER

1.Availability of parenteral manipulations in history, the gradual onset of the disease by asthenic - vegetative type of connection joint pain, low-grade fever and rash, the appearance of severe intoxication and dyspeptic disorders, jaundice, increase in liver transaminases 10-fold to 35-fold increase, decrease of prothrombin index allow UGA suspect.

2. The diagnosis must be confirmed in a blood separation HBV markers (HBsAg, anti-HBcore Ig M).

3.Diff.diagnosis should be conducted with HD, HA, yersiniosis and pseudotuberculosis, and (taking into account the contact with homeless people and migrants) with HE. The greatest difficulty is diff.diagnosis HB and HB with delta-agent. As a rule, it is only possible with the help of specific markers for a double test. However, hepatitis B with delta-agent is usually shorter prodrome with fever to 38 C. Given the rash, the temperature reaction, severe intoxication, joint pain, then we should excludyersiniosis and pseudotuberculosis. They are not characterized by a gradual onset of the disease with a long prodromal period, against the background of jaundice and hepatitis is not as pronounced cytolysis and downs prothrombin index. For the HEPATITIS E is not typical of infestation team, sharing or at work, so is unlikely to significantly expressed intoxication and fall of prothrombin index as the manifestation of a severe course of hepatitis in a non-pregnant.

4. Reduction of the prothrombin index to 54%.

Task 4

The patient, 27 years old, from Moscow, an accountant, pregnancy of 30 weeks. 07.10 she noted the appearance of heartburn several times during the day. In the following days, heartburn regularly harassed, briefly held after the reception of mineral water. On 14.10she noted the appearance of moderate pruritus, on 16.10 there was weakness, decreased appetite, darkened urine. 17.10 at morning, the surrounding noticed yellowness sclera. The patient was hospitalized by ambulance to the infectious diseases hospital with a diagnosis of "hepatitis".

On questioning it turned out that this second pregnancy, proceeded without complications, the first ended with the medical abortion. With 14 years observed in infectious disease with the diagnosis «HBsAg carrier". Patients was followed by gynecologist in the early weeks of pregnancy, I gave blood twice at the antenatal clinic, other parenteral interventions over the past 6 months. did not have. From Moscow did not go out in the last 12 months, she lives in a separate apartment with her husband, eats only at home and at work. she was not Surrounded by a patient with hepatitis. My husband did not leave Moscow for six months.

On examination: a state of moderate severity. Complaints of itching, mild heartburn, weakness, loss of appetite. skin with jaundice, the skin of the abdomen and arms with traces of scratching hemorrhagic elements, no edema. Palpation of the abdomen is painless, fetal heart auscultated. The patient is conscious, answers the questions clearly, no drowsiness, occasionally wince with belching.

Submitted BA, blood biochemistry. ON 17.10 at 15.00 obtained survey results: total protein 42g \ L, prothrombin index 38%, the content of ALT and AST increased 2 times, total bilirubin above normal in 7 times, due to direct fraction AP exceeds the normal values by 3 times. BA: leukocytosis 18.0 109 g \ L, red blood cells and hemoglobin in the norm. UA-NORM. After receiving the analysis of the state is regarded as serious.

Task5

Patient, 19 years old, student, returned on 28.08from 15 -days tourist trip to India. Rest on the sea, lived in a hotel, eat in restaurants.On 10.09 body temperature raised to 37,8 c with weakness, headache, body aches. On 11 - 14.09 above symptoms persisted, the patient take aspirin, your doctor did not address.On 15.09 body temperature raised to 39, 5 C, there were a sore throat, nasal congestion, snuffles, pain in the neck and submandibular region, nausea. On 16.09 she noticed dim skin rash thighs and abdomen. 17.09 against the background of preserved fever and all of the above symptoms appeared jaundiced skin. The patient was admitted to the infectious diseases hospital. On examination revealed changes in the configuration of the neck ( "bull neck") due to increase in all groups of lymph nodes, catarrhal angina, yellowness of the skin and sclera, hepatosplenomegaly. It was found that over the last 6 month, no parenteral intervention.

1. Place the preliminary diagnosis. Justify.

2.Specify most characteristic symptoms of the disease.

3.With what diseases it is necessary to conduct differential. diagnosis?

4. What changes in laboratory parameters you expect to see, some laboratory data to confirm the diagnosis?

5. What is the treatment tactics?

Answer

1. Given the onset with fever and its gradual increase, the presence of symptoms of intoxication, the subsequent joining of pain in the throat, neck, rash, nasal congestion, joining jaundice, increase in cervical lymph node groups, the presence of angina, enlarged liver and spleen, you can put a preliminary diagnosis "infectious mononucleosis".

2. infectious mononucleosis is characterized by a combination of fever, intoxication, tonsillitis, lymphadenopathy with a predominant increase in cervical lymph node groups, nasal congestion without explicitly separated from it, nasal voice, hepatolienal syndrome and the possiblility of presence of jaundice, typically a rather long development of the disease, with the gradual addition of new symptoms.

3. Jaundice - a possible, but not mandatory clinical sign of infectious mononucleosis, and, along with a moderate increase in liver aminotransferases, is manifestation of hepatitis caused by EBV. Given the patient's stay in India, the development of symptoms of acute hepatitis, it is necessary to conduct differential. diagnostics from HE and HA. Very short incubation period and the presence of high fever in the prodrome, casts doubt on the diagnosis of the HE. Availability lymphadenopathy, sore throat, nasal congestion does not speak in favor of the HA and HE.

4. In the clinical analysis of blood - the normal amount of white blood cells or moderate leukocytosis with neutropenia and lymphocytosis, atypical mononuclear cells of more than 12%. In the biochemical analysis of blood - moderate increase in ALT and AST (2 - 6 times), hyperbilirubinemia due to direct fraction. Confirmation of the diagnosis is the detection of antibodies to EBV capsid antigen of IgM ELISA.

5. The specific causal therapy does not exist. With the development of secondary bacterial complications apply antibiotics. Strongly contraindicated ampicillin because of the high likelihood of toxic and allergic reactions. Have rest, detoxification therapy.

Hepatitis B and D

Task 1

Patient, 18 years, appealed to the clinic with complaints of nausea, vomiting, epigastric pain, increased body temperature. Acutely ill, a week ago, with the increase in body temperature up to 38-38,5 ° C, chills, headache. Two days ago there was a nausea, vomiting after eating, pain in the epigastric region. He took no-silos. Directed district doctor in the hospital with a diagnosis of "food poisoning."

Epidemiological history: living in a dorm, eats at the cafe. A month ago, vacationing in the krim city

On examination: a state of moderate severity. The body temperature of 37 2 C. clean skin. The sclera and visible mucous membranes of the oral cavity are icteric. In the lungs vesicular breathing. Heart sounds are muffled. BP 100 \ 60 mm Hg, pulse rate 62 per minute. Language coated with white bloom. The abdomen was soft, painful epigastric and right upper quadrant. little painfulpalpable liver edge. The spleen is not palpable. The stool color was changed 2 days ago. The urine is dark in color.

1. Do you agree with the diagnosis of a GP? What additional methods of inspection are required? Justify diagnosis.

2. Give advice on patient treatment.

3. Make a plan of action in the focus of infection.

Answer

1. The local doctor was wrong. The preliminary diagnosis: acute viral hepatitis, probably A. Grounds: acute onset of illness with symptoms of intoxication, dyspepsia, jaundice, increased pain with palpation of the liver, stay in the epidemic unfavorable region. To confirm the diagnosis needed results blood count (normal settings), general analysis of urine (detection of bile pigments in normal performance of other parameters), biochemical analysis of blood (high, more than 20 rules, ALT and AST activity, increased total bilirubin). Clarify the diagnosis should ELISA (detection of IgM anti-NAU).

2. Hospitalization in infectious hospital. Diet - sparing table, ward mode. Abundant, fractional liquid drink - to 1.5-2.5 liters per day.

3. The final disinfection in a dorm room. Observation of the contact person within 45 days (1 day a week - thermometry, control of urine color, skin and sclera, the definition of the liver and spleen size). Biochemical analysis of blood (ALT, AST) when a complaint or change in condition.

Task 2

The patient, 28 years old, admitted to the hospital complaining of severe fatigue, nausea, vomiting after eating, hiccups, dizziness, insomnia, jaundice of the skin and sclera, dark urine, nosebleeds, fever, pain in the knee and wrist joints.

She fell ill a week ago, when she noticed the appearance of weakness, fatigue, increase in body temperature to 38 C. All the days of fever. In the following days there was nausea and vomiting, darkened urine color. There was a pain in the joints. On the eve of yellowing of the sclera, she could not sleep at night, had nosebleeds.

Epidemiological history: 1, 5 months ago, the patient came to the emergency with birth blood loss and subsequent blood transfusion, plasma. In the past, she suffered a viral hepatitis B.

On examination: clear consciousness. Sluggish, adynamic. The body temperature is 37 2 C. The skin and sclera are bright yellow. Petechial rash on the skin of the body and the inner surface of the shoulder. In the lungs vesicular breathing. Heart sounds are muffled. BP 100 \ 60 mm Hg, pulse rate 92 per minute. Language coated with white bloom. The abdomen was soft, painful in the right hypochondrium. The edge of the liver at the level of hypochondria. The spleen is palpated. Urine dark.