Pharyngoconjunctival fever: causes, symptoms, diagnosis, treatment

Pharyngoconjunctival fever is an acute viral disease that does not belong to the epidemic category. It is caused by adenovirus III, V and VII serotypes. They are all resistant to low temperatures, transmitted by contact, and also by airborne droplets. When analyzing the age composition of the sick, it is revealed that basically they are children of preschool and primary school age. Eye disease is preceded by a clinical picture of acute catarrh of the upper respiratory tract. This is expressed in an increase in body temperature to 38-39 ° C, the appearance of pharyngitis, rhinitis, tracheitis, bronchitis, and sometimes otitis. Patients complain of weakness, malaise, a feeling of dryness and scratching in the throat, coughing, a runny nose. On examination, it is possible to see follicles on the posterior wall of the pharynx, sometimes in considerable numbers, located on a hyperemic basis, as well as grayish follicles on a small tongue. The process is characterized by a clear line of delimitation of the inflamed mucous membrane of the pharynx from the normal mucous membrane lining the hard palate.

Adenoviruses were discovered by W. Rowe in 1953 in the tissue culture of adenoids and tonsils of children. In the future, 24 serological types were identified (at present, several dozens of them have been isolated). Susceptibility to this infection is especially great in children from 6 months to 3 years. Sources of infection are sick people who excrete pathogens with secretions of the pharynx, respiratory tract, and feces. Adenovirus infections occur in the form of sporadic diseases and epidemic outbreaks in children's institutions. According to the statistics of the end of XX century. Adenoviral infections among adults were about 3% (in seasonal periods - 7-10%), among children - up to 23% (in seasonal periods - up to 35%).

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Symptoms of pharyngoconjunctival fever

Symptoms of pharyngoconjunctival fever are variable: it can manifest primarily catarrh of the upper respiratory tract (acute rhinitis, acute diffuse catarrhal pharyngitis, acute laryngitis and tracheitis), conjunctivitis (catarrhal, follicular, membranous), keratoconjunctivitis, pharyngoconjunctivitis fever, bronchitis and pneumonia. The most typical form is pharyngoconjunctival fever, which occurs with characteristic manifestations of adenovirus infection. Its causative agent are adenoviruses III, VII and VIII and other types.

The incubation period of pharyngoconjunctival fever is 5-6 days. The disease begins sharply with chills and a rise in body temperature to 38-40 ° C, moderate intoxication, catarrhal inflammation of the nasal mucosa, pharyngeal mucosa (clinical manifestations of various forms of acute pharyngitis are described below) and upper respiratory tract. There are abundant serous or serous-mucous discharge from the nose, cough in the first hours - dry, then moist with copious sputum discharge from the larynx and trachea. The body temperature of the continua type lasts up to 10 days. Catarrhal phenomena are usually persistent and prolonged, especially the common cold. During this period, an adenoviral lesion of the anterior paranasal sinuses can occur with a rapid attachment of the bacterial microbiota and the occurrence of secondary acute sinusitis. In some cases, there is a two- and even a three-wave fever.

From the first day of illness or a little later, conjunctivitis develops - an indispensable sign of pharyngoconjunctival fever, which is often unilateral at first, and then conjunctivitis of the second eye also occurs. Especially typical for pharyngoconjunctival fever is a filmy conjunctivitis, which determines the nosology of this form of adenovirus infection. Fillet raids appear more frequently on the 4th-6th day of the disease, initially in the region of the transitional fold, and then spread almost to the entire surface of the conjunctiva. Films thin, delicate, white or grayish-white, sometimes hold up to 13 days.

A frequent symptom of pharyngoconjunctival fever is an increase in submandibular lymph nodes. In the early days of the disease, sometimes there is vomiting, a quickening of the stool. In the blood in the early days of the disease without major changes, then moderate leukopenia, neutrophilia, increased ESR.

ENT specialist and ophthalmologist, who most often supervise such patients, it should be borne in mind that one of the most formidable complications in pharyngoconjunctival fever is adenovirus pneumonia, which in some cases can develop in the first days of the disease and determine its main severity. Adenovirus pneumonia is characterized by a severe and often protracted course, marked by intoxication, dyspnea and cyanosis, indicative of the presence of toxic myocarditis. Physically, the lungs are marked by pronounced changes in percussion sound and abundant, moist, various-sized wheezing. According to SNNosov et al. (1961), SN Nosova (1963), during some outbreaks among children under the age of 1 year there was a significant lethality.

Against the background of common clinical manifestations or with some of their stihanii (usually on the 2-4th day of the disease) there is a one- or two-sided conjunctivitis. Its clinical picture consists of hyperemia and roughness of the conjunctiva of the eyelids, the appearance of small follicles in the region of the lower transitional fold, sometimes the appearance of filmy deposits of grayish color. Detachable from the conjunctival cavity is most often serous-mucous.

A fairly typical symptom is the reaction of the pre-limb lymph nodes. In some cases, especially in children with anamnesis, weighed with allergy and diathesis, a more common reaction of the adenoid tissue is observed. This is expressed in the increase and soreness of the submaxillary, cervical, subclavian and even axillary lymph glands. Pediatricians believe that such a reaction should be regarded as a complex clinical picture of acute respiratory disease.

Against the background of the described clinical picture, lesions of the cornea often occur. The cornea is involved in the process simultaneously with the conjunctiva. There is a small-dot superficial keratitis of epithelial localization. Infiltrates of gray color are stained with fluorescein. Verify their presence and differentiate them from the changes characteristic of corneal damage in epidemic keratoconjunctivitis, it is possible only by biomicroscopy. All clinical symptoms, which form the basis of pharyngoconjunctival fever, last no more than two weeks. The phenomena of keratitis disappear without a trace.

In the literature, cases of recurrence of pharyngoconjunctival fever are described. Relapse is usually provoked by a catarrhal factor. It is possible that this is due to the lack of stable immunity in fever and that a second outbreak of the disease is caused by infection of adenovirus with another serotype, in relation to which the body does not have immunity.

Diagnosis of pharyngoconjunctival fever

The diagnosis of adenovirus infection in the presence of a typical syndrome of pharyngoconjunctival fever, especially with the phenomena of pleural conjunctivitis, can be made on the basis of clinical symptoms and taking into account epidemiological data.

Differential diagnosis is mainly carried out with influenza, and in the presence of filmy conjunctivitis - with diphtheria. The exact diagnosis, the need for which occurs in epidemic outbreaks in children's groups, is established by the method of virological research.

Practically, it is necessary to differentiate not only the three forms of viral conjunctival lesions. First and foremost, we should strive to distinguish them from conjunctivitis of bacterial origin, without which it is impossible to assign a reasonable pathogenetic treatment. Currently, bacterial conjunctivitis is most often caused by staphylococcal infection. Usually they differ from viral conjunctivitis by a large amount of detachable from the conjunctival cavity and its other character. The separated very soon becomes purulent. With bacterial conjunctivitis, as a rule, there is no general reaction in the form of an increase in body temperature, weakness and other sensations. The follicular reaction from the conjunctiva is not characteristic of them (with the exception of cases of follicular catarrh). In most cases, regional lymph nodes are not involved in the process.

Particular attention in differential diagnosis should be given to the study of the cornea. Decrease in its sensitivity, precipitation of point (and in some cases coin-like) infiltrates of epithelial or subzipithelial localization should direct the diagnostic thought of the doctor towards a viral infection. If the differential diagnosis of conjunctivitis is difficult (bacterial or viral), as well as in cases of mixed infection, which can cause an unclear picture of the clinical manifestations of the process, it is advisable to perform bacterioscopic (bacteriological) and cytological studies. These techniques can be used in any medical institution with a minimum of laboratory equipment and a conventional light microscope. The detection of neutrophilic leukocytes and microbial flora (staphylococcus, pneumococcus) in the smear of leukocytes gives grounds for diagnosing bacterial conjunctivitis.

As for the cytological method of conjunctival research, the technique of its conduction is as follows. The procedure for scraping the conjunctiva should be preceded by a good anesthetic. It is caused by a three-fold instillation into the conjunctival cavity of a 1% solution of dicaine. It is also advisable to use another method, applying an application with dicain to the region of the lower transition fold. For this, a cotton wick, moistened with 0.5-1% solution of dicaine, is placed in the lower conjunctival for 3-5 minutes. Such anesthesia makes the procedure for scraping completely painless. If the material for the study needs to be taken also from the region of the upper transitional fold, similar application can be made also in the region of the upper coyaccumulatory vault. When the anesthesia is reached with a blunt slide, with the help of a blunt Gref knife or a platinum loop, the skin of the conjunctiva tissue is scraped from the desired area with pressure. Transferring the material to a slide, fix it for 10 minutes in ethyl alcohol, then air dry. The color is produced according to Romanovsky for 40 minutes, washed off with water from the tap and again dried in air. Then proceed to a microscopic examination.

In viral infection, lymphocytic and monocytic reactions take place, the tissue cellular elements are greatly altered. Lysis and fragmentation of the nucleus, vacuoles in the cytoplasm of the epithelium of the conjunctiva are observed. The cell envelope can be destroyed, the destructed nucleus can be outside the cell. Sometimes cellular elements with destroyed shells, merging, represent a giant cellular multinuclear structure, the so-called symplast. The presence of symplasts is very typical for a viral infection. In order for the described picture not to be of an artifical nature, it is necessary to very carefully produce a scraping from the conjunctival tissue, by allowing it to mash. As for hemorrhagic epidemic conjunctivitis, in this case, red cell is found in large amounts in the scrapings of the conjunctiva, which indicates the toxic effect of the virus on the vessels. Mononuclear type of cellular exudate is characteristic, there are histiocytes.

These changes, typical for viral infection, are due to the fact that the viral infectious principle has the ability to reproduce only intracellularly - in a living organism or tissue culture. When encountered with a cell, the virus is adsorbed on it in accordance with the tropism to this or that tissue. After adsorption on cellular receptors, it is captured by a cell membrane that invaginates inside the cell, forming a vacuole. The capsid is then destroyed and the viral nucleic acid is released.

The nucleic acid of the virus reconstructs the vital activity of the cell in such a way that the infected cell is no longer able to continue its former existence. All the energy resources it gives to the formation of viral progeny. In this case, the nucleus, nucleolus, and cytoplasm of the cell are used. All this, figuratively speaking, is the building material for the formation of initial viral particles. Hence it is clear why it is with viral infection that conjunctival cells lose their normal appearance, irretrievably losing their architectonics. Over time, a new progeny of viruses leaves the cellular structures. In this case, the cell membrane bursts and the nucleus of the cell, its nucleolus through the formed defect can reach the surrounding space. Thus, the cytological picture of scrapings of conjunctival tissue can be invaluable in the diagnosis of viral infection and differential diagnosis of viral and bacterial infection.

To identify a specific pathogen of a viral infection, a method for immunofluorescence or fluorescent antibodies has been developed. Immunofluorescence is a luminescence in ultraviolet light of a biological object microscope containing the antigen under study after its preliminary treatment with specific antibodies labeled with fluorochrome (fluorescein). Currently, it is used only in large ophthalmologic institutions, where there is a luminescent microscope and corresponding sera containing antibodies to various pathogens of viral infections. Nevertheless, a practical ophthalmologist should have an idea of this diagnostic method. The essence of it is that a colored serum (labeled with antibodies, for example, adenovirus VIII serotype) is applied to the material of the conjunctival scraping on the slide. If the patient has acute epidemic adenoviral conjunctivitis, the antibodies penetrate the virus (antigen) located in the cells of the conjunctiva scraping. When viewed in the light of a luminescent microscope, such a cell begins to fluoresce.

This diagnosis is an indisputable proof of a viral infection and allows to determine the serotype of a virus or several viruses in a mixed form of infection. Recently, up to 7 types of antibodies of stained blood serum have been used.

[2], [3], [4], [5], [6]

Treatment of pharyngoconjunctival fever

In the event of bacterial complications (sinusitis, bronchopneumonia, keratitis - treatment in the relevant profile departments.

Prevention of pharyngoconjunctival fever

General preventive and anti-epidemic measures consist in isolation of patients, restriction of contact of non-attendant persons with them, allocation of individual household items, dishes, linen. Communication with patients should be carried out only when wearing a gauze mask. The items that were in use by the patient must be disinfected.