Quinsy

Quinsy - the acute infectious disease of mainly streptococcal aetiology characterised by the phenomena of an intoxication, a fever, inflammatory changes in lymphoid formations of a stomatopharynx (more often palatine tonsils) and regional lymph nodes.

Quinsy aetiology

In overwhelming majority of cases (almost in 80 %) quinsy is caused by beta hemolitic streptococcuses of bunch A Str. pyogenes. In 17,8 % it is caused by staphilococcuses (independently - in 8,6 % or in a combination to streptococcuses - in 9,2 %). Str. pyogenes represent the Gram-positive microorganisms which are settling down in a preparation under a microscope in pairs or in the form of chains. They are formative on the nutrient mediums containing animal protein. At cultivation on a blood agar form colonys in diameter to 1-2 mm with the big region a full hemolysis of erythrocytes. In a cellular side of streptococcuses antigenic materials (glucuronic and lypoteichoic acids, M - T - and R-proteins, lipoproteinase, a polysaccharide, a peptidoglycan, etc.) contain, which together with extracellular products (streptococcal ectotoxin, streptolysins About - and S - Hyaluronidasum, a proteinase etc.) play a part in a pathogenesis of quinsy and metatonsillar diseases.

Quinsy epidemiology

An infection contamination source are sick of quinsy, and also healthy carriers of streptococcuses. The greatest epidemic danger represent sick of quinsy which at conversation and tussis excrete a considerable quantity of originators in an external environment. The basic path of infestation - air-drop. Ability of originators of quinsy to propagate on some kinds of foodstuff serves as the precondition of occurrence of alimentary flashes of disease. Quinsy is observed usually in the form of sporadic diseases, mainly in osenne-winter months. The humans living in hostels, barracks is more often are ill. In the organised collectives the case rate quinsy can get epidemic character. Usually it is observed in 1-2 months from the moment of the organisation of collective or its innovation. The sensibility of humans to quinsy compounds approximately 10-15 % (for the organised collectives).

Quinsy pathogenesis

Infection atriums are lymphoid formations of ring Pirogova. Containing in a cover of beta hemolitic streptococcuses lypoteichoic acid possesses affinity to an epithelium of the lymphoid apparatus of a stomatopharynx and by that provides bracing of these microorganisms on a surface of tonsils or on other clumps of an adenoid tissue. The M-protein of streptococcuses, and also streptococcal toxins depress ability of phagocytes to absorb and digest microorganisms that promotes development of a bacteriemia and a long streptococcal antigenemia. Reproduction of streptococcuses in an organism is accompanied by production them of the toxins causing inflammatory reaction of tissues of tonsils. At penetration of streptococcuses and products of their vital activity on lymphatic pathes to lymph nodes there is a regional lymphadenitis. At congenial disease diffusion of microorganisms confines lymphoid formations of a stomatopharynx and regional lymph nodes. At insufficiency of barrier function of the tissues surrounding tonsils, streptococcuses can inpour into a peritonsillar fat and cause its inflammation (a peritonsillitis, a peritonsillar abscess). Pathogenic action of streptococcuses does not confine a stomatopharynx and regional lymph nodes. Streptococcal products, being soaked up in blood, cause thermoregulation disturbance, a toxic lesion central the excitatory, cardiovascular, Urinary excretory, bile secretory and other systems. Streptococcal toxin a streptolysin has cardiotoxic an effect. It quenches processes of histic breath in a muscle of heart and breaks carrying out of warm impulses. The streptococcal proteinase causes a mucoid swelling of connective-woven structures of heart. It is supposed, that it posesses the important role in a pathogenesis of changes, characteristic for a rheumatic disease initial stage. Streptokinasa transforms a blood plasmin into a plasminogen, having fibrinolitic an effect and raising permeability of antimicrobial barriers. Influence of streptococcal antigens on immune system leads to formation of humoral and cellular factors of immunodefence. Interaction of streptococcal antibodies with circulating streptococcal antigens conducts an antigen-antibody to formation of a considerable quantity of circulating cell-bound immune complexes, capable to settle on a basal membrane of renal glomuluses, causing their lesion. Besides, sensibilized T lymphocytes against streptococcal antigens are capable to enter cross-reactions with antigens of capillars of renal glomuluses. Changes of immunodefence and the lesions of nephroses bound to them are observed at late begun or is irregular spent treatment sick of quinsy more often. Autoimmune and immunopathological factors meet is more often and are more expressed at repeated streptococcal quinsy, than at primary. Accordingly the glomerulonephritis arises at the repeated form of disease in 4 times more often, than at the primary.

Because immune alterations reach the greatest expression in a stage of an early reconvalescence, metatonsillar diseases arise in the season when clinical signs of quinsy have already disappeared also convalescents consider itself completely healthy. From first day of illness inflammatory reaction of a mucosa of a soft palate, a uvula, palatal handles and tissues of tonsils becomes perceptible. The surface of these organs becomes bright red colour, is covered by a layer of dense cloudy slime (a catarral tonsillitis). In 1-2 days on a surface of tonsils there are white colour of formation of the roundish form in the dimension of 2-3 mm in diameter, a little towering over a surface of surrounding tissues of the tonsils, representing nectoric the lymphoid follicles variated and subjected to purulent fusion (a clump of lymphoid cells). Usually these changes correspond to a follicular tonsillitis. The basic part of lymphoid follicles is concentrated to those fields of tonsils which adjoin to a surface of lacunas. Necrotic changes and purulent fusion of these clumps of lymphoid cells the dense consistence, containing a considerable quantity of neutrophils, macrophages, and also the lost lymphocytes is accompanied by appearance in lacunas of purulent contained white or serovato-white colour enough. Such picture is characteristic for a lacunar tonsillitis. When the inflammation of tonsils has sharply expressed character (the serious form of disease), the field of a tissue of tonsils to 10-20 mm in diameter is exposed to a necrosis. It of usually irregular form, dark grey colour also has accurate border with other tissues. After a sloughing rather deep defect of a tissue of tonsils with a rough hilly and bleeding bottom is formed.

Symptoms and quinsy flow

According to clinical classification distinguish following clinical forms of streptococcal quinsy: 1) primary and repeated, 2) catarral, follicular, lacunar and necrotic; on localisation - palatine tonsils, a lingual tonsil, lateral platens of a pharynx, guttural; on gravity - easy, medium serious, serious.

Primary should consider quinsy which has arisen for the first time or not earlier than in 2 years after before tolerated. The diseases observed throughout two years after the primary concern the repeated. Repeated quinsy grows out of a becoming infected streptococcuses of humans, as a rule, possessing to them the raised sensibility.

The incubation interval at quinsy compounds 1-2 days the Beginning of disease the acute. There is a fever, the general delicacy, a headache, an ache in joints, a pharyngalgia at swallowing. The fever proceeds during 15 mines-1 of hour, and then is replaced by sense of fever, at serious forms of illness the fever repeats. The headache stupid, has no certain localisation and remains during 1-2 days appetite and a sleep Is broken. Simultaneously there is a pharyngalgia, in the beginning insignificant, disturbs only at swallowing, then gradually strengthens and becomes a constant. In other cases patients have in the beginning only general symptoms (a fever, sense of fever, a fever, a headache, an ache in joints and in a loin) and only in 6-12 hours (not later than 1 days) the pharyngalgia joins at swallowing.

Much less often quinsy begins with inflammatory changes in tonsils, and general toxic symptoms come a little bit later. In these cases in the beginning patients are disturbed by pharyngalgias at swallowing which within days join a fever, the general delicacy, a headache and others. The body temperature within days reaches the maximum size (38,0-40,0C°). The fever proceeds 3-6 days. Longer fervescence testifies to complication apposition. In the feverish season the face skin is hyperemic, and with body temperature normalisation gets a light pink coloration. At serious forms of illness pallor of a skin becomes perceptible from first days of disease. Eruptions do not happen. At the expressed fluctuations of a body temperature the sweating becomes perceptible. At uncomplicated quinsy opening of a mouth the free. Palatal handles, a uvula, tonsils, and sometimes and a soft palate in the first days of illness are brightly hyperemic. Tonsils hydropic ("juicy"). In cases when changes in a stomatopharynx it confines, diagnoses catarral quinsy. More often from 2nd day on hyperemic and juicy tonsils there are white colour follicles in the dimension of 2-3 mm in diameter, tissues a little towering over a surface. These changes correspond to a follicular tonsillitis. But the majority of patients, along with presence on a surface of tonsils of white colour of follicles, in lacunas has yellow-white colour purulent contents. These signs are characteristic for follicular-lakunarnogo a tonsillitis. Pus in lacunas testifies to a lacunar tonsillitis. For the serious form of quinsy necrotic changes in tonsils are characteristic. The amazed fields have dark grey colour. After their tearing away deep defect of a tissue in the dimension of 1-2 sm in a diameter, often irregular form with rough hilly is formed in the bottom. Except palatine tonsils can be amazed and other lymphoid formations of ring Pirogova: Lingual tonsil (quinsy with a lesion of a lingual tonsil), an adenoid tissue of a back side of a pharynx (quinsy with a lesion of lateral platens), a larynx adenoid tissue (quinsy with a larynx lesion).

Quinsy with a lesion of a larynx and a lingual tonsil shows a fever, a toxicosis, pharyngalgias at swallowing - the signs inherent to quinsy with a lesion of palatine tonsils. To diagnose quinsy with a lesion of a larynx and a lingual tonsil it is possible only after survey of a stomatopharynx by means of a guttural mirror, and quinsy of lateral platens - by a usual pharyngoscope. In the latter case on lateral surfaces of a back side of a pharynx two hyperemic platens about 4-6 mm on which surface there are individual punctual follicles or scurf of white colour are visible in the thickness.

Quinsy is accompanied by a hyperadenosis. Usually they in the dimension from 1,0 to 2,5 sm in diameter, elastic, painful, with surrounding tissues are not soldered, mobile. From first days of disease disturbance of cardiovascular system (a tachycardia, a dullness or weakening of warm tints) is taped. With normalisation of a body temperature the tachycardia is replaced by a bradycardia. Dullness or weakening of warm tints become even more expressed. Separate patients have retrosternal pains, mainly in the evening, and at half - the perverted reaction of cardiovascular system to an exercise stress: at an easy exercise stress shock and minute volume are not enlarged, as it is observed at healthy, and on the contrary - decrease. Arterial pressure decreases. At 1/3 convalescents at electrocardiographic research signs of a hypoxia of a myocardium are taped, is rarer - disturbance of intraventricular conductivity. Frequency, expression and duration of these changes do not depend on the clinical electroform of quinsy. The trachea and bronchuses at quinsy are not amazed. The liver and a lien happen are enlarged was rarely and only in the first 2-3 days of disease. At 1/5 parts sick quinsy in an acute stage of illness taps a microhematuria which is caused by influence of toxins on a tissue of nephroses. As a rule, with disappearance of a syndrome of an intoxication these disturbances disappear. In blood in the acute season of disease it is observed neutrophilic a leukocytosis (9-15o109 cells in litre). In most cases haemogram disturbances disappear for 5-6 days of a normal body temperature, the ESR, as a rule, remains at this time raised (14-20 mm/ch). In the subsequent it is rather quickly normalised. However at occurrence of complications can raise even more.

At bacteriological research of a microflora of a surface of tonsils at streptococcal quinsy continuous growth of beta hemolitic streptococcuses on 5 % a blood agar is taped. At serological research of the didymous blood sera taken in first and for 10-12 days of disease, antiserum capacity increase to a streptolysin, Streptokinasa, a streptococcal polysaccharide is found. Research of hypersensitivity of the slowed down type to a streptococcal polysaccharide (in reaction of inhibition of migration of leucocytes) from 8-12th day from the moment of disease in 95 % gives a positive take.

Complications at quinsy

At sick by quinsy complications - a peritonsillitis and a peritonsillar abscess, an otitis, etc. They can be observed, as a rule, arise at humans who are hospitalised in rather serotinal terms - after 3rd day from the moment of disease. The peritonsillitis and a peritonsillar abscess have similar semiology. It is characterised by a high fever, prevalence of secund pains in a stomatopharynx, sharply strengthening at the swallowing, the raised sialosis, difficulty and morbidity of opening of an oral cavity, secund edemas, a soft palate hyperemia, an edema of the palatal handle on the lesion party, and also shift to the centre of the struck tonsil and asymmetry of a uvula.

Except complications, at quinsy there can be metatonsillar diseases - rheumatic disease, an infectious-allergic myocarditis and a polyarthritis, cholecystocholangitis. At modern rational means of treatment of rheumatic disease sick of quinsy and the polyarthritis does not happen, but other metatonsillar illnesses - a glomerulonephritis - at 0,8 % can be observed at primary quinsy and at 3,0 % at the repeated form of disease. The myocarditis educes at primary quinsy in the first days of the season of a reconvalescence, and at repeated - from first days of illness. It was rarely shows classical symptoms of this disease. More often unique signs of a myocarditis are the nonperishable changes of an electrocardiogram testifying to a focal lesion of a muscle of heart, and moderate rising of 1-2nd fractions of a lactate dehydrogenase.

Glomerulonephritis development corresponds to a heating-up period autoimmune (against tissues of nephroses) and immunopathological factors for 5-6 days of a normal body temperature (8-10 days of disease). The glomerulonephritis proceeds without extrarenal symptoms. Its unique implication is the nonperishable urinary syndrome in the form of a moderate proteinuria (0,033-0,099 g/l), leukocyturias (10-50 cells in sight in a preparation from an urocheras), erythrocyturias (3-20 cells in sight) and cylindrurias.

Diagnosis and the differential diagnosis

Quinsy diagnosis is based on clinical and clinico - datas of laboratory: the acute beginning of disease, a fever, a tonsillitis with a lymphadenitis, and also neutrophilic a leukocytosis and raised by an ESR.

Differential diagnostics of quinsy should be carried out with the diseases proceeding with a syndrome of a tonsillitis - with the localised forms of a diphtheria of fauces, a scarlatina, infectious a mononucleosis, the anginous form of a tularemia, leukoses, an agranulocytosis, a flu and other acute respiratory diseases, a herpangina, a stomatopharynx candidiasis, an adenoid disease exacerbation.

The localised forms of a diphtheria differ from quinsy the gradual beginning of disease, specific implications of the general intoxication in the form of pallor of a face skin, a moderate adynamia and slackness (a fever, an ache in a body, pains in muscles and joints, characteristic only for quinsy), disharmony of objective and subjective implications of illness (an insignificant pharyngalgia at swallowing in the presence of the expressed inflammatory changes from tonsils), features of inflammatory process in a stomatopharynx, characterised by is congestive-cyanotic colour of a hyperemia and the expressed edema of tonsils with presence on their surface of the membraneous difficultly taken out scurf abandoning after defect of a tissue. At atypical flow of a diphtheria that is observed at half of adult patients, scurf is taken out easily, not abandoning defect of a tissue. However and in these cases other remain characteristic for a diphtheria of fauces signs.

Fusospirillosis is characterised by slightly expressed general implications (a short-term subfebrile body temperature, absence of the general delicacy, a headache, etc.), a lesion only one tonsil in the form of an ulcer in the dimension of 5-10 mm, covered with easily taken out yellow-white or belovato-grey scurf, presence in preparations from abjointed ulcers, spindle-shaped rods and spirochetes. The regional lymphadenitis is not expressed.

The scarlatina differs from quinsy appearance in the first days of illness on all body, except a nasolabial triangle, the abundant punctual eruption located on a hyperemic background, condensed on a neck, lateral surfaces of a thorax and in Simon's triangle and skin especially expressed in natural cords, and also characteristic implications of a tonsillitis in the form of bright red colour of a hyperemia of tonsils, palatal handles, a uvula and a soft palate ("glowing fauces").

For an infectious mononucleosis are characteristic, except a tonsillitis (it is purulent-nekroticheskogo or fibrinous), a polyadenitis, augmentation of a liver and a lien with simultaneous appearance atypical mononuclear and plasmocytes.

Anginous form of a tularemia differs from quinsy rather serotinal appearance (for 3-5 days) the secund catarral or necrotic tonsillitis, the expressed augmentation of regional lymph nodes to the struck tonsil which continue to be enlarged and after tonsillitis disappearance.

For leukoses and an agranulocytosis is typical rather later (for 3-6 days of illness) appearance of a necrotic tonsillitis with diffusion of necrotic changes on a mucosa of palatal handles, a uvula, cheeks; presence of a septic fever, a hepatolienal syndrome and characteristic changes of a haemogram (hiatus leucemicus - at leukoses and sharp depression of quantity of neutrophils at an agranulocytosis).

At a herpangina are observed, along with a fever and an intoxication, aboriginal changes in a kind of a hyperemia of a mucosa of a stomatopharynx and presence on palatal handles, a uvula, a soft palate, and sometimes - on tonsils and tongue of separate papules in the dimension of 2-4 mm in diameter, quickly turning to blisters of white-grey colour, and then erosion. The acute respiratory diseases proceeding with a syndrome of a catarral pharyngitis, show a fever, an intoxication, a diffusive hyperemia of a mucosa of a stomatopharynx, including a surface of tonsils with a simultaneous lesion of other parts of a respiratory tract (a rhinitis, a tracheitis, a laryngitis or a tracheobronchitis). The lymphadenitis thus is not present.

Stomatopharynx candidiasis proceeds with a normal or subfebrile body temperature, good state of health of patients, presence on a surface of tonsils, a uvula, palatal handles, and sometimes and on a back side of a pharynx of scurf of white colour in the form of easily taken out islets in the dimension of 2-3 mm in diameter. In the anamnesis there are indicatings on more or less long application of antibiotics of a wide action spectrum or their combinations.

Adenoid disease exacerbation differs from repeated quinsy the gradual beginning, flaccid and rather long flow of disease with a changeable subfebrile body temperature, absence of the expressed intoxication, moderate pains and unpleasant sensations in a throat at swallowing, congestive character of a hyperemia is cicatrical the tonsils variated and soldered to palatal handles, presence caseous contained in lacunas, a hyperadenosis, characterised by a dense consistence and moderate morbidity, normal indicators of quantity of neutrophils in blood or slightly expressed neutrophilic a leukocytosis.