The theme of the lesson:

Structure and regimen of an infectious diseases hospital.

Safety instructions.
Influenza and other ARVI

Structure and regimen of an infectious diseases hospital

Infectious diseases hospital consists of the following structures:
1. boxed admission office;
2. specialized departments for hospitalization of patients with one type of
infection;
3. boxed department (for diagnostics);
4. department (or a ward) of intensive care and resuscitation;
5. X-ray and physiotherapeutic department;
6. clinical, biochemical, bacteriological and other laboratories;
7. sterilization room;
8. medical treatment room;
9. nutrition unit;
10. department of morbid anatomy.

Work of an infectious diseases hospital has peculiar features and is

executed in an antiepidemic regimen. The basis of the regimen is carrying out of
measures aimed at prevention of intrahospital infections of the patients and the
medical personnel, as well as stopping of spread of the infections outside the
hospital. A complex of the regiminal measures consists of disinfection of
utensils, linen, rooms and instruments. The furniture of an infectious diseases
department, the walls and the floor must be treated with disinfectants regularly,
in accordance with the instructions (depending on a group of the diseases), they
also must be exposed to ultraviolet irradiation with quartz apparatuses.
During admission to an infectious diseases department a patient must be
carefully examined by the doctor, it is necessary to obtain epidemiological
anamnesis (see “Scheme of a case report”). Data about the patient are registered
in the case history, and also in special diaries. The information of the diagnosis
is sent to the Center of national sanitary inspection for registration: during the
admission of the patient – by telephone and after making out of a clinical
diagnosis and laboratory verification – in a written form (“an urgent report about
an infectious patient”, usually confirmation of a diagnosis takes 2-3 days).
In infectious diseases departments separation of patients with different
infections is done. In one ward there can be patients only with one infection. An
exception is diseases, having which the people are not dangerous to those
around them (zoogenous infections: tularemia, brucellosis, leptospirosis,
 2

hemorrhagic fever with renal syndrome – in case of these diseases

contaminations happen only from animals). Infectiousness of the patient during
a certain periods of the disease is taken into consideration.
Patients with infections, transmitted in a respiratory way, during the
period when they are contagious must stay in boxes – they are wards with 2
lobbies (small rooms, separating the ward on the one side – from the hospital
corridor, on the other side – from a separate way out). Boxes have an
autonomous ventilating system; airflows from the boxes don’t get to the other
wards.
Patients with other infections (viral hepatitises, enteric infection and
others) must stay in small wards or semiboxes (wards with a lobby from the side
of the hospital corridor, without exit). In the wards there must be sanitary units –
water closets and bath (shower) rooms. The patients mustn’t leave their wards;
in an infectious diseases department there are no places for contact of the
patients – dining rooms, halls for rest of the recovering patients.

Working and safety instructions

in an infectious diseases clinic

1. Keeping of a protective and antiepidemic regimen in the hospital.

2. A compulsory change of gowns and footwear.
3. Sleeves and collars of outer clothing mustn’t be seen from under the
gown, hair must be well hidden under cap.
4. During an epidemic of influenza or during work with respiratory
infections it is necessary to wear respiratory gauze or disposable masks.
5. It is forbidden to bring to the ward books and other personal things,
which are no related to the therapeutic process.
6. It is not allowed to sit on the patient’s bed.
7. After each examination of a patient and before leaving the clinic – it is
necessary to wash hands.
8. It is forbidden to smoke in the hospital, it is necessary to take food only
in special places.

Influenza and some other acute respiratory viral infections (ARVI)

At present time about 200 causative agents, producing influenza-like

respiratory diseases, are known along with influenza virus. Among them there
are parainfluenza, adeno-, rhino-, entero-, RS-viruses, as well as mycoplasmas,
meningococci, pneumococci, hemophilic bacteria and others. An absolute
majority of respiratory infections – are viral. A unique variability of influenza
 3

virus causes periodic epidemic episodes and pandemics, forcing out other
viruses for this time.
An increase in number of acute respiratory viral infections (ARVI) is
observed during a transitional and cold season – period of a seasonal
immunodeficiency. It is determined by portal (respiratory tract) and channels of
transmission of ARVI – respiratory, contact. A summer increase in enterovirus
infection cases is associated with a fecal-oral mechanism of transmission of a
number of viruses of this group.

INFLUENZA

Causative agents are: influenza viruses of А (А1 and А2), В and С types.
Viruses of A type have a great variability, most often the disease is caused by
viruses of subtypes Н1N1, H2N2, H3N2. Recently new subtypes of the viruses,
causing severe diseases– Н5N5, Н7N1, have appeared. Influenza viruses are
tropic to epithelium of the upper airways, nerve cells and vascular wall.

The source of the infection: patients with apparent (manifest) and

subclinical forms of influenza. The main channel of the transmission – is
respiratory, a contact contamination is also possible.

Clinical presentation
The incubation period – is from 8-12 to 48 hours. In typical cases the
onset is acute: from chill, rise in temperature up to 39-40оС, muscle and articular
pains, moderate catarrhal occurences – tickling in the throat, xeromycteria
(rhinitis is not typical, it can occur in 2-3 days as a result of a secondary
infection). From the first hours of the disease there is an evident neurotoxicosis:
headache in the frontotemporal region, photophobia, sometimes – vomiting.
During examination hyperemia, granulosity, hemorrhages are detected in the
fauces; an objective confirmation of neurotoxicosis can be nystagmus, and in
number of cases – also meningeal symptoms. In 2-3 days clinical presentation of
tracheitis appears (it is not a complication, but one of the major clinical
manifestations of influenza): dry cough and burning retrosternal pains. During
the whole disease, especially – in several days of aspirin intake (it is
anantiaggregant, influencing blood coagulation), epistaxis and other
manifestations of hemorrhagic syndrome are possible.
Among atypical forms there are afebrile, acatarrhal (without involvement
of the upper airways, but with tracheitis) and fulminant influenzas.
Complications are: pneumonia, myocarditis, otitis, sinusitis,
meningoencephalitis.
Pneumonias, occurring on the first day of the disease, have an extremely
severe clinical course as a result of involvement of both lungs (total, subtotal,
 4

with hemorrhagic pulmonary edema) and the lethality is about 80% (up to
100%). During the ensuing days severe pneumonias are also possible, mainly –
croupous ones; after the 5-6th day the risk of such serious complications
decreases, pneumonias have a focal character and a favorable prognosis.
Ethiology of influenza virus pneumonias is dual: the viral component is present
in the course of the whole fundamental illness (up to a week), the bacterial one –
appears in a few hours after the onset of the complications. The major bacterial
agent – is streptococcus of pneumonia (pneumococcus).
Myocarditises occur in 10% of patients with influenza, but they are
diagnosed more seldom – in 1% of the cases. Clinical manifestations are:
weakness, asthenia, subfebrile temperature, dyspnea, in EKG – there is a voltage
decrease, disorders of impulse conduction.
Otitis and sinusites belong to common influenza complications; otitis
usually appears during an acute period of the disease, sinusites (more often –
maxillary sinusitis) – during the last days of the disease and the recovery period.
Meningitis and meningoencephalitis are not common.

Parainfluenza
Parainfluenza in many respects resembles clinical picture of influenza, but
unlike it intoxication is less evident, and localization of the inflammatory
changes is, mainly, in the larynx and bronchi. Clinically parainfluenza proceeds
in the form of acute “catarrh of the upper airways”; pains and tickling in the
throat, a hoarse voice, stuffiness in nose, dry cough are observed.
In some of the patients, especially –in children, against a background of
apparent catarrhal occurrences and intoxication intensification “false croup” can
develop, and acute pneumonia can also occur. Normocytosis or moderate
leucopenia is detected in the hemogram. ESR is within the normal range.

Rhinoviral infection
A rhinoviral infection declares itself by not full-blown symptoms of
intoxication and involvement of mucous membrane of nose (rhinitis,
rhinorrhea). Clinical course of the disease is favorable; its duration is 5-7 days.
Complications are uncommon, mainly – sinusites.

Adenovirus diseases
An adenovirus infection is characterized mainly by lesion of respiratory
apparatus, eyes and lymph nodes. The major clinical forms are:
rhinopharyngitis, pharingoconjunctival fever.

Clinical forms of adenovirus infection

- rhinopharyngitis
- pharyngitis
- rhinopharyngotonsillitis
 5

- rhinopharyngobronchitis
- pharingoconjunctival fever
- epidemic keratitis-conjunctivitis (keratoconjunctivitis)
-pneumonia
- diarrhea with mesenteric lymphadenitis.
The fever lasts for 8-14 days; often it has a two-wave character.
Intoxication signs, except severe forms, are slightly evident. Sometimes such
manifestations of adenovirus infection as diarrhea, acute mesoadenitis,
tonsillitis, myocarditis can be observed, it presents certain difficulties in
diagnostics. Prevalence of an exudative component, reaction of lymphoid tissue
is characteristic for adenovirus infection. An acute onset of the disease with an
evident fever, voluminous rhinorrhea, keratoconjunctivitis, angina,
lymphadenitis, hepatosplenomegaly – is the most typical.

RS-infection
Respiratory syncytial infection most often affects children and is
characterized by inflammatory changes of the lower part of respiratory tract. In
typical cases together with a slightly apparent intoxication signs of
nasopharyngitis appear, and then bronchitis, bronchiolitis, pneumonia can occur.
Asthmatic component is typical. The disease can prolong for 2-3 weeks.

Enterovirus infection
Enterovirus diseases, brought on by viruses from Coxsackie and ЕСНО
groups, are distinguished by variety of their clinical presentations and cause
affection of myocardium, CNS, muscles, skin. Among mechanisms of infection,
except aerogenic, a fecal-oral one is important. The most common clinical forms
are herpangina, serous meningitis, encephalitis, pericarditis and myocarditis,
infectious exanthema, “little disease”, diarrhea, epidemic conjunctivitis.

Clinical forms of enterovirus infection

- herpangina (herpetiform angina)
- epidemic myalgia
- serous meningitis
- tertian fever (ARVI)
- gastroenteritis
- encephalomyocarditis of infants
- myocarditises, pericarditises
- polio-like enteroviral diseases
- vesicular dermatostomatitis
- infectious exanthema.
 6

The disease sets in acutely from temperature rise, shiver, headache,

weakness, and then symptoms, typical of one of some mentioned clinical forms,
appear.

Mycoplasmal infection
In case of mycoplasmal infection the upper and the lower airways are
affected. The onset is usually gradual. There are the following major clinical
forms: pharyngitis, rhinopharyngitis, laryngopharyngitis, bronchitis and acute
pneumonia.
Lesion of the upper air passages happens typically – with catarrhal
occurances (rhinitis, tickling in the throat, cough).
Clinical presentation of acute pneumonia during mycoplasmal infection
has a number of peculiarities. The most typical is combination of a pulmonary
pathology (dullness of percussion sound, rough breath sounds, diffused dry or
small bubbling rales) with myalgias, arthralgia, polymorphous exanthema with a
predominant localization around joints. An excruciating cough is accompanied
by chest pains, weakness. In the hemogram there is a moderate leukocytosis,
neutrophilia, an acceleration of ESR.

Diagnostics of influenza and other acute respiratory viral infections is

based on clinical-epidemiologic evidence. It is necessary
to distinguish the cardinal syndromes of involvement of the respiratory
tract (rhinitis, pharingoconjunctivitis, laryngitis, tracheitis, bronchitis,
bronchiolitis, pneumonia)
to compare them with the character of toxic syndrome, nonrespiratory
manifestations of the disease.

The method of an early detection is mucus study (smears, smears-

imprints) and swabs from nose, nasopharynx, pharynx with the help of
immunofluorescence reaction (IF). Besides, two tests are used: complement-
fixing reaction (CFR) and reaction of indirect hemagglutination (RIHA), more
seldom – neutralization reaction (NR). The investigation is carried out in paired
serums (the blood is taken from the patient during an acute phase and during a
recovery period with an interval of 7 – 10 days. An increase of the antibody titer
in 4 and more times is diagnostically true.
Virological methods (isolation of viruses on developing hen embryos and
in the tissue culture) don’t have a decisive importance in practical work. The
exception is an enterovirus infection, in case of which isolation of the virus from
the feces and cerebrospinal fluid is done.

Treatment of patients with influenza and ARVI is realized, as a rule, at

home with compulsory measures for isolation of the patient from other members
 7

of the family. People with severe and complicated forms of the disease are to be
admitted to an infectious diseases hospital. It is necessary to have a rest cure
during the first days of the disease, when the patient feels better a semi-bed
regimen is recommended. Food must correspond with diet № 2 by Pevzner (full
value contents of proteins, fats, carbohydrates, high-vitamin drinks) and then
change to diet № 15. The basis of outpatient therapy of influenza and ARVI is a
peroral disintoxication. An abundant drinking of tea with honey, mint,
origanum, brotherwort, raspberry, lime-blossom; tinctures and decoctions of
dog-rose, roots of althaea; diluted juices and compotes, mineral alkaline waters;
kissels, milk, fruit drinks – is rather not a complete list of simplest means,
having a complex of disintoxication, anti-inflammatory, softening and
expectorative properties. Rhinovasospastic drugs are used in case of profuse
rhinorrhea, lacrimation, edemas of mucous membranes. In case of hemorrhagic
manifestations citrus plants are taken, ascorbic and aminocapronic acids are
prescribed. Prescription of analgesic and antipyretic drugs is indicated in case of
fever. If there is hyperthermia domestic physiotherapy can be used: cold or ice
on the head, wet rub-downs or packs.
Signs of excitement, spastic syndrome, which are not arrested by ice on
the head, presuppose use of sedatives and anticonvulsants, they are indications
for hospitalization. Under the hospital conditions in case of severe forms of
influenza and ARVI pathogenetic therapy is supplemented with parenteral
disintoxication, forced diuresis.
In case of parainfluenza inhalation therapy has a cardinal importance:
cametonum, vapor and oil inhalations with soda, Furacillin, infusions of
chamomile, sage, eucalyptus. A positive local reflex effect is reached by
applying of mustard plasters, warm compresses, foot and arm hot baths,
cupping-glasses.
As an antiviral agent and an immunomodulator it is possible to use
arbidol (0.1 g tablets) by 0.2 g 4 times a day, before a meal, during 5-7 days. It
is also possible to take aflubin by 10 drops up to 8 times a day (according to the
drug dosage regimen, see instruction to the preparation), as well as
immunomodulators:
timogen – to apply by dropping into each nasal meatus by 1 dose 2 times
a day or by 2 doses 1 time a day, the course of the treatment – is 10 days;
cytovir-3 (a peroral preparation of timogen) – 1 capsule 3 times a day, the
course – is 4 days;
imudon by 1 tablet 8 times a day (resolve), the course – is up to 10 days.

In case of influenza it is desirable to use drugs with an antiviral action:

during the first day of the disease remantadinum by 0.1 g is prescribed (2 tablets
is the dose; 1 tablet contains 0.05 g of the preparation) 3 times, during the
second and the third day – 2 times by 0.1 g, on the fourth day – 0.1 g one time.
The drug is taken after a meal. Remantadinum stops propagation of the virus,
 8

therefore it is efficient only in case of an early initiation of the treatment –

during the first day of the disease, at least – an the beginning of the second day
of the disease.
Arbidol (the dosage regimen is mentioned above), virasol by 200 mg 3-4
times a day during 3 days and deutiforin (intake is according to the dosage
regimen, similar to remantadinum) are also used. Aflubin and
immunomodulators: timogen, cytovir-3, imudon can also be used.
Except viricides in case of influenza pathogenetic therapy is used:
abundant high-vitamin drinking, decoctions and infusions of herbs (raspberry,
teil, origanum and others), honey, of medicines – ascorbic acid (from 0.6 to 1.0
g a day), rutin, lactate or gluconate of calcium, antihistamines, by indications –
antipyretics (acetylsalicylic acid, paracetamol).

In severe cases intensive care is performed under hospital conditions –

introduction of anti-influenza gammaglobulin or human immunoglobulin
(intramuscularly by 3-6.0 ml with the interval of 8-12 hours till reaching of the
clinical effect), parenteral disintoxication treatment. In case of pneumonia an
agent of choice is penicillin (or semisynthetic penicillins with antistreptococcic
activity), it is possible to use amoxiclav, cephalosporin. In most cases
pneumonia can be brought on by streptococcus of pneumonia
(“pneumococcus”), highly sensitive to these drugs.

Prophylaxis of influenza and other ARVI includes antiepidemic

measures:
ventilation of the rooms,
use of bactericidal lamps,
boiling and disinfection of linen, utensils,
keeping of personal hygiene rules,
tempering,
using of food, containing phytoncides – onion, garlic, vitamin-containing
foodstuffs,
wearing of protective gauze bandages,
quarantine of the patients and so on.

A specific prophylaxis of influenza – is vaccination. A domestically

produced vaccine “Grippol” or imported ones – “Influvac” “Vaxigripp” are
used. The vaccination is done beforehand, it is desirable to do it – 1-2 months
before a supposed beginning of an epidemic of influenza. A specific prophylaxis
of ARVI has not been worked out.
 9

CONDUCTION OF THE LESSON

An introductory part
At the beginning of the lesson the teacher introduces the students to the
safety instructions during working with infectious patients, to the structure and
working regimen of the infectious diseases hospital.
Hereon the introductory part of the lesson is over, and the teacher goes on
to the main question of the subject: “Influenza and other ARVI”.
The purpose – is to learn how to diagnose influenza and other ARVI on
the basis of clinical data, epidemiological analysis, laboratory examination, as
well as to make up the treatment plan.

Control questions at the beginning of the lesson:

1. Name the major nosologic forms of diseases, belonging to the group of
ARVI.
2. Give clinical-and-epidemiologic characteristics of influenza.
3. Enumerate clinical forms of influenza.
4. Name cardinal symptom complexes in case of parainfluenza.
5. Enumerate clinical forms of adenovirus infection.
6. Name clinical forms of enterovirus infection.
7. Name peculiarities of mycoplasmal pneumonia.
8. Name peculiarities of RS-infection.
9. How laboratory diagnostics of influenza and other ARVI is carried out?
10. What are the main treatment principles and modes for influenza and
other ARVI?

To discuss the topic of the lesson a student manages a patient, makes a

brief report about the patient’s history (in the absence of such patients in the
department – an archive case history is used).
It is necessary to find out the following data about the patient:
surname, name, patronymic; place of work and residence; date of falling
ill; complaints at the present time;
the first symptoms of the disease: temperature rise (up to which level,
during how many days); intoxication; presence of catarrhal-respiratory
syndrome; exanthema.
When and how (hypothetically) did the contamination of the patient
happen? It is necessary to ascertain epidemiological anamnesis: situation in this
region concerning influenza, probability of a contact with ill people having
ARVI at the place of residence, in transport, indoors. Presence of a specific
vaccination, its date.
 10

Objective data of the examination:

condition (color) of skin, lymphadenopathy, state of masses in the fauces
(hyperemia, edema, granulosity, dry mouth, tonsils, palatal arches, hard and soft
palate, uvula), presence or absence of conjunctivitis, scleritis, rhinitis, state of
the respiratory system (nasal breathing, rales in the lungs).
State of the cardiovascular system (tachycardia, arrhythmia, pulse rate,
arterial pressure level).
Condition of the digestive system (sizes of liver, spleen, estimation of
stool).
State of the urinary system (regularity of urinary excretion, color of
urine).
State of the nervous system (presence of meningeal symptoms, signs of
peripheral NS involvement).
Case report of the patient with influenza and ARVI is discussed in the
group. The students together plan the patient’s examination. The teacher
introduces the students to the results of the laboratory examinations. On the
basis of all the available data a diagnosis is made out with indication of the
period and severity of the disease. Treatment principles are discussed. The
students without assistance make up the treatment plan and discuss it with the
teacher. A special attention is paid to prophylactic measures.

At the end of the lesson the students solve clinical problems and answer
the questions to them. Accomplishing the tasks the students write in their copy-
books:
clinical diagnosis (taking into consideration the form and severity of the
disease),
plan of the patient’s examination,
copy out in Latin preparations with antibacterial and pathogenetic actions.

Task № 1
A 20-years-old male patient К. consulted the health unit of RSMU on the
th
17 December, complaining about headache, weakness, dry cough, high
temperature, muscle and articular pains. From the case history it is known, that
the disease set in acutely on the 15th December, when chill, headache occurred,
body temperature rose to 38.50. The next day tickling in the throat, dryness in
the nose, muscle and joint pains appeared besides above-listed symptoms. The
patient treated himself with aspirin, analgin, tetracycline. He didn’t feel better
and appealed for medical aid.
Objective data of the examination: body temperature – was 38.60, the face
was hyperemic, edematic. There were scleritis, brightly hyperemic tonsils and
palatine arches, granulosis in the area of the arches. Respiration was vesicular;
there were solitary dry rales in the upper lobes of the lungs. There was a normal
 11

heart rate, tachycardia. Pulse rate – was 110 beats per minute, ABP – was
120/70 mm of mercury column. The tongue was dry, slightly furred with a white
coating. The abdomen was soft, painless. The liver and spleen were not
enlarged. Physiological functions were normal.
Epidemiological anamnesis: the patient lives in the hostel, the room is for
4 persons, one water closet on the whole floor; lately a lot of the students have
been ill (with fever).

QUESTIONS:
1. Name the major syndromes, which were observed in this case.
2. Make out a provisional diagnosis.
3. Therapeutic approach.
4. With which laboratory data it is possible to confirm the diagnosis?
5. Plan the treatment of the patient.

Task № 2
A 46-years-old female patient S. consulted the district doctor on the third
day of the disease, complaining about headache, chill, weakness, dry cough.
Objective data: t – 38.70, the face was of a normal color, keratoconjunctivitis,
rhinorrhea. The tonsils, palatine arches were hyperemic. The submandibular,
posterior cervical and axillary lymph nodes were enlarged. In the lungs there
was a vesicular respiration, no rales. The cardiac rate was normal. The pulse –
was 160 beats per minute, ABP –was 110/70 mm of mercury column. The
tongue was clean, dry. The abdomen was soft, painless. The liver was 2 cm out
of the costal edge. The spleen was not palpated. Physiological functions were
normal. From the case history it was found out, that it broke out acutely with
cough, rhinitis, lacrimation, and then headache, chill, temperature rise up to
37.50 occurred. The patient treated herself with an expectorant mixture, aspirin,
naphthizin. There wasn’t any amelioration.
Epidemiological anamnesis: in the family, where the patient lives, a
granddaughter, going to a kindergarten, had a light temperature rise, cough,
reddening of the eyes. A husband of the patient now is at a \medical department
because of pneumonia.

QUESTIONS:
1. Name the major pathological syndromes, which were observed in this
case.
2. Make out a provisional diagnosis.
3. Therapeutic approach.
4. Laboratory diagnostics.
5. Plan the treatment of the patient.
 12

Task № 3
A 15-years-old female patient M. consulted doctors of the polyclinic on
the 17 January during the 3d day of the disease.
th

She had complaints about harsh barking cough, a hoarse voice.

The disease set in with rhinitis, mild pyrexia, at the same time the patient
felt well. The next day hoarseness occurred, today – there is barking cough.
During the examination the state of health was satisfactory. The body
temperature was 37.30. There were serous discharges from the nose. The fauces
was hyperemic. The tonsils are not enlarged. In the lungs there was a vesicular
respiration, solitary dry whistling rales. The heart sounds were clear, the rhythm
was normal. The rate of heartbeats – was 80 per minute.
Epidemiological anamnesis. A younger brother of the patient (2-years-
old) became ill with ARVI 2 days before: barking cough, hoarseness of the
voice, temperature 37.50. In two days after the onset of the disease at night a
heavy hoarse breathing, dyspnea, cyanosis suddenly appeared. “Ambulance car”
was called; the child was admitted to a hospital, now he feels better.

QUESTIONS:
1. Name the major pathological syndromes, which were observed in this
case.
2. Make out a provisional diagnosis.
3. Plan the treatment of the patient.
4. What is the disease of the patient’s younger brother? What complicated
the course of his disease?