rotavirus

1. Viral diarrhea: Rotavirus diarrhea. Norwalk virus
diarrhea. Enteroviral diarrhea. Dysentery. Infectious
toxic shock
Rehydration therapy in children. Treatment of
acute intestinal infections in children
Abdukadyrova H.M

2. ROTAVIRAL INFECTION.
Rotavirus infection is an acute
infectious disease of humans and
animals caused by rotaviruses,
belongs to the group of intestinal
infections, characterized by lesions
of the gastrointestinal tract by the
type of gastroenteritis.

3. • Etiology. All humans and animals rotaviruses are divided into 5
groups according to the presence of a type-specific antigen: A, B,
C, D, E. Most of the rotaviruses isolated from humans belong to
group A. Rotavirus - RNA containing, remains viable when frozen.
The virus withstands the action of ether, chloroform, ultrasound.
• Epidemiology. The main source of infection is a patient with
gastroenteritis, a virus carrier. The main mechanism of infection
transmission is fecal-oral. Ways of transmission - rotaviruses are
transmitted by food, water and contact-household ways, but the
possibility of dust and aerogenic ways is not excluded. The high
resistance of rotaviruses in the external environment has been
proven, especially in feces, where they are difficult to inactivate
under the action of conventional disinfectants, which in turn leads
to the accumulation of the virus in the environment.

4. • With sporadic morbidity, the contact-household route of
transmission of the infection is predominantly observed,
which is often implemented in hospitals, home . Children of
the first years of life are more often ill, especially children
aged 9 to 12 months of life. The high contagiousness of
rotavirus infection contributes to the development of large
outbreaks, group and family , and sporadic cases.
Nosocomial infection among infants is possible. Rotavirus
infection has a pronounced winter seasonality. Winter
seasonality is associated with better survival of rotaviruses in
the environment at low temperatures. The incidence
increases in the autumn months, remaining at a high level in
December - February.

5. • Pathogenesis. On the first day of illness, rotavirus is already found in
the epithelial cells of the 12th duodenum and in the upper part of
the small intestine. The penetration of rotaviruses into villus
epithelial cells depends on a number of reasons: the state of acidity
of the gastrointestinal tract (high acidity has a detrimental effect on
rotavirus), the presence of a trypsin inhibitor (trypsin is necessary
for the active growth of rotavirus), the number of functionally
immature epitheliocytes (they do not have receptors for attaching
rotaviruses). The penetration of rotaviruses causes damage to
epitheliocytes and their rejection from the villi. At this time, "bare"
tops of the villi are found. At the same time, the advancement of
epitheliocytes from the base to the top of the villus is accelerated.
Accelerated mitotic activity leads to the fact that cells do not have
time to differentiate and arrive structurally and functionally
immature.

6. • The loss of epitheliocytes and the appearance of functionally
defective cells causes enzymatic deficiency, as a result of which
the breakdown of disaccharides in the small intestine suffers.
The occurrence of disaccharide deficiency, primarily lactase
deficiency, leads to the accumulation of unsplit disaccharides
with high osmotic activity. An excess amount of fluid and
electrolytes enters the intestinal lumen, both as a result of
impaired absorption and due to hyperosmolarity. Dehydration
develops. The cessation of diarrhea and recovery is associated
with the complete replacement of mature epithelial cells with
functionally immature epithelial cells, to which rotaviruses do
not attach. In the pathogenesis of the disease, a certain place is
given to viremia, it is also possible to damage other organs and
systems, but this issue needs additional study.

7. • Clinic. The incubation period is 1-3 days. The disease begins
acutely, body temperature rises, vomiting and loose stools.
Repeated vomiting is the leading sign of rotavirus infection and
is short-lived (1-2 days). The increase in body temperature is
moderate, the upper limit reaches 39 0C, the fever lasts 2-4
days, often accompanied by other symptoms of intoxication -
lethargy, weakness, loss of appetite, etc. Intestinal dysfunction
occurs as watery diarrhea (gastroenteritis, enteritis). Moderately
severe pain in the abdomen, bloating is characteristic. The chair
is liquid, watery, without pathological impurities. The duration of
diarrhea is 3-6 days. The frequency of bowel movements is
determined by the severity of the intestinal process, amounting
to 2-5 times a day in mild forms of the disease, up to 20 or more
in severe form.

8. • Diagnosis and differential diagnosis. Even in the presence of
peculiar clinical manifestations of rotavirus infection, the
diagnosis is based on the results of the detection of viral
antigen and / or positive serological reactions. Electron
microscopy (EM) is used to detect rotavirus, the method is
highly specific. Among the methods of serological diagnostics,
the reaction of neutralization, inhibition of hemagglutination,
and complement fixation are distinguished.Differential
diagnosis is carried out with shigellosis, salmonellosis,
escherichiosis, acute intestinal infections caused by
opportunistic enterobacteria. A distinctive clinical feature of
rotavirus infection is the acute onset of the disease, low fever
and the appearance of vomiting as the first sign of the disease.
The phenomena of colitis, hemocolitis are absent.

9. •Intestinal yersiniosis. The causative agent is a Gram-
negative ovoid microorganism Yersinia enterocolitica of
the Enterobacteriaceae family of the Yersinia genus.
According to the antigenic structure (O and H antigens),
The optimal growth temperature is 22-28ºС, but it can
also multiply at a low temperature of 0-4ºС. When dried,
under the influence of direct sunlight, chlorine-
containing preparations die within a few minutes.
Pathogenicity factors: adhesiveness, invasiveness, exo
and endotoxins. Yersiniosis refers to anthropozoonotic
infections.

10. • The source of yersiniosis is animals (dogs, cats, rodents, birds). A
sick person as a source of infection is of less importance. The
main reservoir of infection are small rodents. Another reservoir
of Yersinia is the soil. Intestinal yersiniosis has been identified in
all countries of the world, but the level of the disease is higher
in economically developed countries with a developed network
of centralized food supply. Group diseases of yersiniosis are
more often associated with the use of vegetable salads stored in
vegetable stores contaminated with rodent secretions. Familial
and nosocomial outbreaks have been described. Mostly
residents of cities and urban-type settlements are ill, where the
population more often uses public catering establishments.
People of all ages get sick, but more often young children (1-3
years) and adults.The main route of distribution is food.

11. • Yersiniosis is registered throughout the year, slightly increasing in
October-March. Nosocomial infections with yersiniosis do not have
seasonality and are associated with infection from carriers.Immunity
is type-specific, unstable.

12. Norovirus infection
• Norovirus infection can cause severe vomiting and diarrhea that start
suddenly. Noroviruses are highly contagious. They commonly spread through
food or water that is contaminated during preparation or through
contaminated surfaces. Noroviruses can also spread through close contact
with a person who has norovirus infection.
• Diarrhea, stomach pain and vomiting typically begin 12 to 48 hours after
exposure. Norovirus infection symptoms usually last 1 to 3 days. Most
people recover completely without treatment. However, for some people —
especially young children, older adults and people with other medical
conditions — vomiting and diarrhea can be severely dehydrating and require
medical attention.
• Norovirus infection occurs most frequently in closed and crowded
environments. Examples include hospitals, nursing homes, child care centers,
schools and cruise ships

13. • Symptoms
• Signs and symptoms of norovirus infection may start suddenly and include:
• Nausea
• Vomiting
• Stomach pain or cramps
• Watery or loose diarrhea
• Feeling ill
• Low-grade fever
• Muscle pain
• Signs and symptoms usually begin 12 to 48 hours after your first exposure to
a norovirus and last 1 to 3 days. You can continue to shed virus in your stool
for several weeks after recovery. This shedding can last weeks to months if
you have another medical condition.
• Some people with norovirus infection may show no signs or symptoms.
However, they're still contagious and can spread the virus to others.

14. TOXICOSIS WITH EXICOSIS (DEHYDRATION).
• Toxicosis and exsicosis (TE) develops in children mainly in severe
forms of acute intestinal infections. With invasive AII, infectious
toxicosis develops more often, and with watery diarrhea - exsicosis.
Exsicosis is caused by significant uncompensated fluid loss with
vomiting and pathological stools, which leads to deterioration of
central and peripheral hemodynamics, pathological changes in all
types of metabolism, accumulation of toxic metabolites in cells and
intercellular space and their secondary effect on the organs and
tissues of patients. Therefore, severe dehydration (exicosis) is
combined with toxicosis.

15. • The reason for the frequent occurrence of TE in young children is
considered to be anatomical and physiological features that cause a
rapid breakdown of adaptive mechanisms and the development of
decompensation of the functions of organs and systems in conditions
of infectious pathology, accompanied by loss of water and
electrolytes. Patients with severe infection can lose up to 50-100
ml/kg or more of water per day with vomit and pathological stools, up
to 10-20 mmol/kg of sodium and potassium, as well as a large
amount of amino acids, lipids, microelements, which significantly
affects on metabolism.In the pathogenesis of exicosis, dehydration is
of primary importance, as a result of which there is a deficiency in the
extracellular volume of fluid and the volume of circulating blood . In
response to a decrease in Volume in the body of children, a spasm of
small arteries and veins occurs, accompanied by centralization of
blood circulation and a gradual shutdown of the active circulation of
the skin, muscles, liver, kidneys, which leads to the occurrence of
circulatory tissue hypoxia and functional failure of many organs.

16. • At the cellular level in children, the uncoupling of redox processes is
progressing, and the energy deficit is growing. The accumulation of
hydrogen ions in cells and extracellular space leads to the
development of metabolic acidosis, which inhibits enzymatic
processes. In cell membranes, the processes of lipid peroxidation are
activated, which first contribute to an increase in their permeability,
and then to cell destruction. DIC develops - a syndrome leading to
vascular thrombosis, and this increases hemodynamic disturbance,
tissue hypoxia, i.e. there is a vicious circle of the pathogenesis of
increasing intoxication.

17. • There are 3 degrees of dehydration:
• Grade 1 - weight loss up to 5%, moderate thirst, dryish or moist mucous
membranes, tissue turgor is preserved, diuresis is normal. The number of
bowel movements is moderate, 5-7 times a day. The health of patients
does not suffer.
• 1 degree of dehydration corresponds to the WHO classification "no signs of
dehydration".
• Grade 2 - weight loss 7-9%, frequent stools (more than 10 times) per day,
anxiety, severe thirst, dry mucous membranes, large sunken fontanelle,
decreased diuresis. The patient's condition is grave. The second degree
corresponds to the WHO classification of "moderate" dehydration.
• 3rd degree of dehydration - weight loss of 10% or more, frequent watery
stools, skin and mucous membranes are dry, the skin fold on the abdomen
straightens out slowly, a large fontanel is very sunken, oliguria / anuria,
decreased blood pressure, intestinal paresis. The patient's condition is
extremely serious. The third degree corresponds to the WHO classification
of "severe" dehydration.

20. • CLASSIFICATION OF DEHYDRATION (according to WHO):
• 1. No signs of dehydration
• 2. Moderate dehydration
• 3. Severe dehydration
• No signs of dehydration:● The child is conscious, active● Eyes not
sunken●Liquid drinks willingly or does not want to drink, because. no
dehydration●The skin fold straightens quickly.
• Signs of mild dehydration:●Restless●Sunken eyes●Drinks with greed,
thirst●Skin fold straightens out slowly.(if a child has 2 or more of the
listed signs, this will be moderate dehydration).
• Signs of severe dehydration:●Child is lethargic (unconscious) or very
lethargic●Sunken eyes●Cannot drink or drinks little●Skin fold
straightens out very slowly(if the child has 2 or more of the listed
signs, this will be severe dehydration)

21. • HOW TO CHECK WHETHER A CHILD IS THIRST?Offer your child water from a
cup or spoon. Watch how the child drinks.If a child reaches for a cup /
spoon when you offer him water, asks for more to drink and cries when you
remove the water, he has signs of “drinking liquid with greed, thirst”.
• HOW TO CHECK THE SKIN FOLD ON THE ABDOMEN?
• To test for skinfold response:● work with your thumb and forefinger, do not
use your fingertips as how it can hurt.● choose a place on the abdomen
in the middle between the navel and the side wall of the abdomen.● The
arm should be parallel to the child's body.If the skin fold unfolds within 2
seconds, the child has the sign "skin fold unfolds slowly." If the skin fold
unfolds for more than 2 seconds, the child has the sign "skin fold unfolds
very slowly." If a child's skin fold expands in less than 2 seconds, the child
does not have this symptom.However, it should be remembered that in an
overweight child or with protein-free edema, the skin fold straightens out
quickly, even if the child is dehydrated. In a child with grade 3 malnutrition,
toxic dystrophy (“skin and bones”), the skin fold can slowly straighten out,
even if the child is not dehydrated.

23. • WHO classification of malnutrition
• Hypotrophy of the 1st degree - a mass deficit of 9%;
• Hypotrophy of the 2nd degree - deficiency of body weight 10-19%;
• Hypotrophy of the 3rd degree - deficiency of body weight 20-29%;
• Severe malnutrition - underweight of 30% or more
• a) kwashiorkor (protein-free edema)
• b) insanity ("skin and bones")In children of early age with acute intestinal
infections, not only dehydration develops, but also infectious toxicosis,
especially in invasive variants of the course of intestinal infections. Very
often, dehydration of the 3rd degree (severe dehydration) is combined
with infectious toxicosis.

24. •There are 3 stages of infectious toxicosis:
•Stage 1 of toxicosis (hyperkinetic) is characterized by
agitation and anxiety of the child, the child refuses to
breastfeed, vomiting is noted, body temperature rises to
39-40 C, heart sounds are muffled, tachycardia, rhythmic
pulse. BP is normal or slightly elevated. Consciousness is
preserved. Tendon reflexes are elevated or normal. Blood
clotting is moderate, there is a tendency to
hypercoagulability.Stage 2 toxicosis (soporous-adynamic)
is manifested by depression of the cerebral cortex.
Patients are lethargic, consciousness is disturbed
(somnolent or soporous).

25. • Appetite is reduced significantly, up to anorexia. Heart
sounds are muffled, tachycardia, shortness of breath are
noted. The skin is pale with a pronounced "marble" pattern,
the limbs are cold to the touch. There is a thickening of the
blood, signs of toxic damage to the kidneys (protein, traces
of sugar, cylinders) appear in the urine, oliguria develops.
• Stage 3 of toxicosis develops a cerebral coma, is
characterized, children are adynamic and indifferent to the
environment. Consciousness is absent, tonic convulsions
appear Heart sounds are deaf, bradycardia, arterial pressure
is low. Renal failure develops. In the absence of timely
intensive care, the child dies.

26. • NUTRITION OF PATIENTS WITH ACUTE DIARRHEA.
• For a child less than 6 months old:-
• A child who is breastfed should be applied to the breast at the request of
the child, without observing hourly feeding, without a night break.- A child
who is on mixed and artificial feeding should receive the food that he
received before the illness. In the early stages of the disease, it is necessary
to introduce lactose-free mixtures into the diet - NAN-lactose-free.- Feed
the child according to his appetite. Food should be varied, freshly
prepared, complete, mashed.
• For a child aged 6 to 12 months: Feeding according to age (breastfeeding
and complementary foods that the child received before the disease).
From 6 months (the time of introducing complementary foods), it is
desirable to introduce fish, meat, vegetable puree, rice, beans into the diet.
• Child over 12 months old:- The food that the child received before the
illness in a pureed form, table number 4.

27. • REHYDRATION THERAPY:
• In the absence of symptoms of dehydration, treatment is carried out
according to plan A:To prevent the development of dehydration, prescribe
after each stool ORS (Regidron), boiled water or food-based liquids (liquid
soup, liquid porridge, rice water, kefir, ayran) at the rate of:
• children under 2 years old 50-100
• children from 2 to 10 years ------------100-200 ml.
• children over 10 years old ------------ how much they want
• Regidron powder is stored for 3 years, and Regidron solution - 1 day,
diluted with boiled and cooled water at the rate of 1 powder per 1 liter of
water.
• For moderate dehydration, prescribe treatment according to plan B:
• Assign ORS within 4 hours: the volume of ORS is determined by the
formula: P = M x 75, where P is the volume of ORS, M is the weight of the
patient, 75 is the coefficient.If the weight of the patient at the time of the
examination cannot be determined, then the calculation of the ORS
solution is carried out according to the following table:

28. • Age up to 4 m. from 4 to 12 m, 12 m up to 2 y ,from 2up to 5 years 5-14 yea
• Weight less than 6 kg 6-10 kg 10-12 kg 12-19 kg > 19 kg
• ORS (ml) 200-400 400-700 700-900 900-1400 1400-2200

29. • • if the child wants to drink more ORS, give him more;• give ORS
to a child under 2 years old, 1 teaspoonful every 1-2 minutes, over
2 years old - in frequent sips;• if the child is vomiting, wait 10
minutes, then continue giving ORS 1 teaspoon every 2-3
minutes;• if the child has swelling, stop giving ORS and give water
or breast milk, after the disappearance of the swelling, start giving
ORS again;• If ORS is administered too quickly, bloating may
develop. In this case, the administration of ORS should be stopped
until the bloating disappears.Monitoring of rehydration therapy:
● Assess the child's condition after 4 hours, ● Reclassify the
degree of dehydration and determine the appropriate plan (A, B,
or C) to continue treatment.

30. • Indications for infusion rehydration therapy:
• - dehydration II-III degree, hypovolemic shock
• - uncontrollable vomiting- failure of oral rehydration
• - coma
• - profuse diarrhea
• - bloating
• - not drinking liquids well
• In these cases, infusion therapy, in addition to rehydration goals, should
include measures aimed at eliminating hemodynamic disorders, blood
rheological properties, metabolic, including water and electrolyte shifts,
correction of tissue metabolism and detoxification.

31. • For severe dehydration, start treatment with Plan B.The ideal solution for
rehydration infusion therapy is Ringer's solution. If fluid therapy is delayed,
start ORS orally or through a nasogastric tube.
• Calculation of Ringer's solution (100 ml / kg of weight), the rate of fluid
administration depends on age:
• Age 1 stage(30 ml/kg) Stage 2(70 ml/kg)
• up to 12 months 60 minutes 5 hours
• over 12 months 30 minutes 2.5 hours
• Monitoring of rehydration therapy: evaluate the child's condition after 15-
30 minutes; evaluate heart rate, pulse filling;- if the condition does not
improve (PS is weak or not determined), increase the rate of fluid
administration, again repeat 30 ml / kg; if the condition has improved - go
to stage 2 (prescribe liquid in a volume of 70 ml/kg).

32. • PROBIOTICS.
• Indications for prescribing probiotics:• secretory diarrhea - course of
treatment 1-2 weeks;• invasive diarrhea of moderate and severe form
- the course of treatment is 1-2 weeks; prescribed after the end of the
course of antibiotic therapy• prolonged diarrhea - course of
treatment 3-4 weeks Probiotics are prescribed 20-30 minutes before
meals, diluting the indicated doses in a small amount of room
temperature water.

33. • ETIOTROPIC THERAPy.
• Antibacterial agents are used as etiotropic agents for the treatment of
acute intestinal infections. Etiotropic therapy is indicated for invasive
intestinal infections (an admixture of mucus, blood, pus in the stool), which
often proceed as "dysentery".Currently, due to the widespread
uncontrolled use of antibiotics, there is an increase in antibiotic-resistant
microorganisms, which requires a periodic study of the sensitivity of AII
pathogens to various antibacterial drugs in a certain region.The course of
antibiotic therapy should be no more than 5 days and no more than 2
courses. The leading route of administration of antibacterial drugs is oral.
However, in recent years, information has appeared about the possibility of
parenteral administration of antibiotics in the treatment of children with
acute intestinal infections.