Bubonic plague: symptoms and treatment. Diagnosis of plague Plague manifestations

The Black Death is a disease that is currently the subject of legends. This is actually the name given to the plague that struck Europe, Asia, North Africa and even Greenland in the 14th century. The pathology proceeded mainly in the bubonic form. The territorial focus of the disease has become where this place is, many people know. The Gobi belongs to Eurasia. The Black Sea arose precisely there due to the Little Ice Age, which served as an impetus for sudden and dangerous climate change.

It took the lives of 60 million people. Moreover, in some regions the death toll reached two-thirds of the population. Due to the unpredictability of the disease, as well as the impossibility of curing it at that time, religious ideas began to flourish among people. Belief in a higher power has become commonplace. At the same time, persecution began of the so-called “poisoners”, “witches”, “sorcerers”, who, according to religious fanatics, sent the epidemic to people.

This period remained in history as a time of impatient people who were overcome by fear, hatred, mistrust and numerous superstitions. In fact, of course, there is a scientific explanation for the outbreak of bubonic plague.

The Myth of the Bubonic Plague

When historians were looking for ways the disease could penetrate Europe, they settled on the opinion that the plague appeared in Tatarstan. More precisely, it was brought by the Tatars.

In 1348, led by Khan Dzhanybek, during the siege of the Genoese fortress of Kafa (Feodosia), they threw there the corpses of people who had previously died from the plague. After liberation, Europeans began to leave the city, spreading the disease throughout Europe.

But the so-called “plague in Tatarstan” turned out to be nothing more than a speculation of people who do not know how to explain the sudden and deadly outbreak of the “Black Death”.

The theory was defeated as it became known that the pandemic was not transmitted between people. It could be contracted from small rodents or insects.

This “general” theory existed for quite a long time and contained many mysteries. In fact, the plague epidemic, as it turned out later, began for several reasons.

Natural causes of the pandemic

In addition to dramatic climate change in Eurasia, the outbreak of bubonic plague was preceded by several other environmental factors. Among them:

• global drought in China followed by widespread famine;
• in Henan province massive;
• Rain and hurricanes prevailed in Beijing for a long time.

Like the Plague of Justinian, as the first pandemic in history was called, the Black Death struck people after massive natural disasters. She even followed the same path as her predecessor.

The decrease in people's immunity, provoked by environmental factors, has led to mass morbidity. The disaster reached such proportions that church leaders had to open rooms for the sick population.

The plague in the Middle Ages also had socio-economic prerequisites.

Socio-economic causes of bubonic plague

Natural factors could not provoke such a serious outbreak of the epidemic on their own. They were supported by the following socio-economic prerequisites:

• military operations in France, Spain, Italy;
• the dominance of the Mongol-Tatar yoke over part of Eastern Europe;
• increased trade;
• soaring poverty;
• too high population density.

Another important factor that provoked the invasion of the plague was a belief that implied that healthy believers should wash as little as possible. According to the saints of that time, contemplation of one’s own naked body leads a person into temptation. Some followers of the church were so imbued with this opinion that they never immersed themselves in water in their entire adult lives.

Europe in the 14th century was not considered a pure power. The population did not monitor waste disposal. Waste was thrown directly from the windows, slops and the contents of chamber pots were poured onto the road, and the blood of livestock flowed into it. This all later ended up in the river, from which people took water for cooking and even for drinking.

Like the Plague of Justinian, the Black Death was caused by large numbers of rodents that lived in close contact with humans. In the literature of that time you can find many notes on what to do in case of an animal bite. As you know, rats and marmots are carriers of the disease, so people were terrified of even one of their species. In an effort to overcome rodents, many forgot about everything, including their family.

How it all began

The origin of the disease was the Gobi Desert. The location of the immediate outbreak is unknown. It is assumed that the Tatars who lived nearby declared a hunt for marmots, which are carriers of the plague. The meat and fur of these animals were highly valued. Under such conditions, infection was inevitable.

Due to drought and other negative weather conditions, many rodents left their shelters and moved closer to people, where more food could be found.

Hebei province in China was the first to be affected. At least 90% of the population died there. This is another reason that gave rise to the opinion that the outbreak of the plague was provoked by the Tatars. They could lead the disease along the famous Silk Road.

Then the plague reached India, after which it moved to Europe. Surprisingly, only one source from that time mentions the true nature of the disease. It is believed that people were affected by the bubonic form of plague.

In countries that were not affected by the pandemic, real panic arose in the Middle Ages. The heads of the powers sent messengers for information about the disease and forced specialists to invent a cure for it. The population of some states, remaining ignorant, willingly believed rumors that snakes were raining on the contaminated lands, a fiery wind was blowing and acid balls were falling from the sky.

Low temperatures, a long stay outside the host's body, and thawing cannot destroy the causative agent of the Black Death. But sun exposure and drying are effective against it.

Bubonic plague begins to develop from the moment of being bitten by an infected flea. Bacteria enter the lymph nodes and begin their life activity. Suddenly, a person is overcome by chills, his body temperature rises, the headache becomes unbearable, and his facial features become unrecognizable, black spots appear under his eyes. On the second day after infection, the bubo itself appears. This is what is called an enlarged lymph node.

A person infected with the plague can be identified immediately. "Black Death" is a disease that changes the face and body beyond recognition. Blisters become noticeable already on the second day, and the patient’s general condition cannot be called adequate.

The symptoms of plague in a medieval person are surprisingly different from those of a modern patient.

Clinical picture of the bubonic plague of the Middle Ages

“Black Death” is a disease that in the Middle Ages was identified by the following signs:

• high fever, chills;
• aggressiveness;
• continuous feeling of fear;
• severe pain in the chest;
• dyspnea;
• cough with bloody discharge;
• blood and waste products turned black;
• a dark coating could be seen on the tongue;
• ulcers and buboes appearing on the body emitted an unpleasant odor;
• clouding of consciousness.

These symptoms were considered a sign of imminent and imminent death. If a person received such a sentence, he already knew that he had very little time left. No one tried to fight such symptoms; they were considered the will of God and the church.

Treatment of bubonic plague in the Middle Ages

Medieval medicine was far from ideal. The doctor who came to examine the patient paid more attention to talking about whether he had confessed than to directly treating him. This was due to the religious insanity of the population. Saving the soul was considered a much more important task than healing the body. Accordingly, surgical intervention was practically not practiced.

Treatment methods for plague were as follows:

• cutting tumors and cauterizing them with a hot iron;
• use of antidotes;
• applying reptile skin to the buboes;
• pulling out disease using magnets.

However, medieval medicine was not hopeless. Some doctors of that time advised patients to stick to a good diet and wait for the body to cope with the plague on its own. This is the most adequate theory of treatment. Of course, under the conditions of that time, cases of recovery were isolated, but they still took place.

Only mediocre doctors or young people who wanted to gain fame in an extremely risky way took on the treatment of the disease. They wore a mask that looked like a bird's head with a pronounced beak. However, such protection did not save everyone, so many doctors died after their patients.

Government authorities advised people to adhere to the following methods of combating the epidemic:

• Long distance escape. At the same time, it was necessary to cover as many kilometers as possible very quickly. It was necessary to remain at a safe distance from the disease for as long as possible.
• Drive herds of horses through contaminated areas. It was believed that the breath of these animals purifies the air. For the same purpose, it was advised to allow various insects into houses. A saucer of milk was placed in a room where a person had recently died of the plague, as it was believed to absorb the disease. Methods such as breeding spiders in the house and burning large numbers of fires near the living area were also popular.
• Do whatever is necessary to kill the smell of the plague. It was believed that if a person does not feel the stench emanating from infected people, he is sufficiently protected. That is why many carried bouquets of flowers with them.

Doctors also advised not to sleep after dawn, not to have intimate relations and not to think about the epidemic and death. Nowadays this approach seems crazy, but in the Middle Ages people found solace in it.

Of course, religion was an important factor influencing life during the epidemic.

Religion during the bubonic plague epidemic

"Black Death" is a disease that frightened people with its uncertainty. Therefore, against this background, various religious beliefs arose:

• The plague is a punishment for ordinary human sins, disobedience, bad attitude towards loved ones, the desire to succumb to temptation.
• The plague arose as a result of neglect of faith.
• The epidemic began because shoes with pointed toes came into fashion, which greatly angered God.

Priests who were obliged to listen to the confessions of dying people often became infected and died. Therefore, cities were often left without church ministers because they feared for their lives.

Against the background of the tense situation, various groups or sects appeared, each of which explained the cause of the epidemic in its own way. In addition, various superstitions were widespread among the population, which were considered the pure truth.

Superstitions during the bubonic plague epidemic

In any, even the most insignificant event, during the epidemic, people saw peculiar signs of fate. Some superstitions were quite surprising:

• If a completely naked woman plows the ground around the house, and the rest of the family members are indoors at this time, the plague will leave the surrounding areas.
• If you make an effigy symbolizing the plague and burn it, the disease will recede.
• To prevent the disease from attacking, you need to carry silver or mercury with you.

Many legends developed around the image of the plague. People really believed in them. They were afraid to open the door of their house again, so as not to let the plague spirit inside. Even relatives fought among themselves, everyone tried to save themselves and only themselves.

The situation in society

The oppressed and frightened people eventually came to the conclusion that the plague was being spread by so-called outcasts who wanted the death of the entire population. The pursuit of the suspects began. They were forcibly dragged to the infirmary. Many people who were identified as suspects committed suicide. An epidemic of suicide has hit Europe. The problem has reached such proportions that the authorities have threatened those who commit suicide by putting their corpses on public display.

Since many people were sure that they had very little time left to live, they went to great lengths: they became addicted to alcohol, looking for entertainment with women of easy virtue. This lifestyle further intensified the epidemic.

The pandemic reached such proportions that the corpses were taken out at night, dumped in special pits and buried.

Sometimes it happened that plague patients deliberately appeared in society, trying to infect as many enemies as possible. This was also due to the fact that it was believed that the plague would recede if it was passed on to someone else.

In the atmosphere of that time, any person who stood out from the crowd for any reason could be considered a poisoner.

Consequences of the Black Death

The Black Death had significant consequences in all areas of life. The most significant of them:

• The ratio of blood groups has changed significantly.
• Instability in the political sphere of life.
• Many villages were deserted.
• The beginning of feudal relations was laid. Many people in whose workshops their sons worked were forced to hire outside craftsmen.
• Since there were not enough male labor resources to work in the production sector, women began to master this type of activity.
• Medicine has moved to a new stage of development. All kinds of diseases began to be studied and cures for them were invented.
• Servants and the lower strata of the population, due to the lack of people, began to demand a better position for themselves. Many insolvent people turned out to be heirs of rich deceased relatives.
• Attempts were made to mechanize production.
• Housing and rental prices have dropped significantly.
• The self-awareness of the population, which did not want to blindly obey the government, grew at a tremendous pace. This resulted in various riots and revolutions.
• The influence of the church on the population has weakened significantly. People saw the helplessness of the priests in the fight against the plague and stopped trusting them. Rituals and beliefs that were previously prohibited by the church came into use again. The age of “witches” and “sorcerers” has begun. The number of priests has decreased significantly. People who were uneducated and inappropriate in age were often hired for such positions. Many did not understand why death takes not only criminals, but also good, kind people. In this regard, Europe doubted the power of God.
• After such a large-scale pandemic, the plague did not completely leave the population. Periodically, epidemics broke out in different cities, taking people’s lives with them.

Today, many researchers doubt that the second pandemic took place precisely in the form of the bubonic plague.

Opinions on the second pandemic

There are doubts that the "Black Death" is synonymous with the period of prosperity of the bubonic plague. There are explanations for this:

• Plague patients rarely experienced symptoms such as fever and sore throat. However, modern scholars note that there are many errors in the narratives of that time. Moreover, some works are fictional and contradict not only other stories, but also themselves.
• The third pandemic was able to kill only 3% of the population, while the Black Death wiped out at least a third of Europe. But there is an explanation for this too. During the second pandemic, there was terrible unsanitary conditions that caused more problems than illness.
• The buboes that arise when a person is affected are located under the armpits and in the neck area. It would be logical if they appeared on the legs, since that is where it is easiest for a flea to get into. However, this fact is not flawless. It turns out that, along with the plague, the human louse is also a spreader. And there were many such insects in the Middle Ages.
• An epidemic is usually preceded by the mass death of rats. This phenomenon was not observed in the Middle Ages. This fact can also be disputed given the presence of human lice.
• The flea, which is the carrier of the disease, feels best in warm and humid climates. The pandemic flourished even in the coldest winters.
• The speed of the epidemic's spread was record-breaking.

As a result of the research, it was found that the genome of modern strains of plague is identical to the disease of the Middle Ages, which proves that it was the bubonic form of pathology that became the “Black Death” for the people of that time. Therefore, any other opinions are automatically moved to the incorrect category. But a more detailed study of the issue is still ongoing.

A ten-year-old boy with bubonic plague was taken to the hospital in the Kosh-Agach district of the Altai Republic, reports lenta.ru.

The child was admitted to the infectious diseases department of the district hospital on July 12 with a temperature of about 40 degrees. He is currently in moderate condition. “Specialists found out that he had contact with 17 people, six of whom were children. All of them are placed in isolation and are under observation. So far, they have shown no signs of infection,” the hospital noted.

Health workers suggested that the boy could have contracted the plague while camping in the mountains. It is noted that in the region the disease was recorded in marmots.

Bubonic plague is an infectious disease that has claimed more human lives throughout history than all other diseases combined. Despite all the advances in medicine, it is impossible to completely get rid of the plague, since the causative agent of the disease - the bacterium Yersinia pestis - lives in natural reservoirs, where it infects its main carriers - marmots, gophers and other rodents. These reservoirs exist all over the world and destroying them all is unrealistic.

Therefore, about three thousand cases of bubonic plague are registered annually in the world, and outbreaks occur even in highly developed countries. Thus, in October 2015, it was reported that a teenage girl from Oregon in the USA was infected with bubonic plague.

However, in countries with an underdeveloped healthcare system, plague outbreaks occur much more often and lead to greater casualties. Thus, in 2014, an outbreak of bubonic plague was registered in Madagascar, which killed 40 people.

In August 2013, doctors confirmed a case of bubonic plague in Kyrgyzstan: 15-year-old Temirbek Isakunov contracted the dangerous disease after eating marmot kebab with his friends.

She commented on this incident on her blog:

The media begins to noisily discuss the possible consequences of the cases of bubonic plague that have appeared in Kyrgyzstan, or more precisely, in how many days will it begin in our country from the Kyrgyz who came to us and cough on us. In this regard, let me remind you that:

1. The danger of the appearance of plague on the territory of Russia is constant, since the plague is a zoonosis, that is, a disease the main reservoir of which is animals. These are gophers and a number of other species living in deserts, semi-deserts, steppes, etc. There are more than a thousand permanent plague foci on the territory of Russia, and there are also a lot of foci in the republics of the former USSR and other neighbors of Russia.

2. The main methods for controlling plague are as follows:

A) Limiting the number of natural hosts (poisoning gophers),

B) Vaccination of those who have to work in these outbreaks,

B) Border control of those entering (people and animals)

3. Human diseases of the plague are inevitable for countries with outbreaks. In Russia, the plague causes about one death per year; in the USA, as far as I remember, about 10 die per year.

4. Plague is a particularly dangerous disease due to its high mortality rate. If it is detected, emergency anti-epidemic measures are taken. The plague has a very bad reputation, since in medieval Europe one third of the population died from its epidemics. However, among infectious diseases it now accounts for only a small proportion of deaths. Malaria accounts for the largest number of deaths (more than a million per year).

5. Methods of combating the plague epidemic are very simple. They identify the sick person, drag him into quarantine and treat him, at the same time they grab and drag into quarantine everyone with whom he has been in contact for the last few days. If one of those people gets sick, they seize and isolate those with whom he was in contact. So, in the conditions of a state that is organized enough to carry out such a thing, outbreaks are nipped in the bud.

6. An interesting feature of the plague is that there is one pathogen, but two diseases: pneumonic plague and bubonic plague. The form of development of the disease depends on where the pathogen enters: into the blood or into the lungs.

7. If the pathogen enters the lungs, pneumonic plague develops. It progresses as a rapidly developing acute respiratory infection, followed by hemoptysis and death. From the moment of infection to the first pronounced symptoms - about a day, until death - about 3. Mortality - 100%. It can be successfully treated with some modern antibiotics, but only if treatment is not started too late. Therefore, in the case of pneumonic plague, the outcome depends on the timeliness of hospitalization and the start of treatment, and literally minutes count.

8. If the pathogen enters the bloodstream, bubonic plague develops - a severe blood fever with a mortality rate (in the absence of antibiotic treatment) of about 50%. The duration of the disease from infection to recovery or death is about a couple of weeks. It got its name from the characteristic giant enlargement of the axillary lymph nodes to formations similar in size and shape to a bunch of grapes.

9. The two indicated forms of plague with the same pathogen are associated with a transmission option. With pneumonic plague, the patient sneezes and coughs, droplets of saliva containing the pathogen scatter and infect others, getting into the lungs. In bubonic plague, the carrier is blood-sucking insects: fleas, lice, etc. People are often infected through bloodsuckers from mice and rats suffering from the plague. By the way, plague epidemics in medieval Europe were also associated with the fact that there were a lot of brown rats. In recent years they have been replaced by another species, white and larger, which is less susceptible to plague.

In principle, it is possible for the plague to transition during epidemics from the bubonic to the pneumonic form and back, but due to these features, epidemics usually occur either only as bubonic, or only as pneumonic.

There is a third, more exotic form of plague - intestinal, when the pathogen enters the stomach, but for this you have to go to India, to the sacred waters of the Ganges...

10. If a plague patient is identified (including a deceased person), due to the above, fun begins, accompanied by panic: platoons of police with machine guns that surround the building with identified contacts, and serious people in anti-plague suits with flamethrowers, scared to death of them (joke).. Over the past 50 years, there have been several (about three) cases of detection of plague being brought into Moscow and several false panics.

11. There is no need to be more scared than usual by people who cough and sneeze. Spraying nearby eastern people with insect repellents from spray cans is the same.

It could be worse

In addition to the plague, outbreaks of an even more dangerous disease - anthrax - are regularly recorded in the vastness of our homeland. The source of this infection is domestic animals: cattle, sheep, goats, pigs. Infection can occur when caring for sick animals, slaughtering livestock, processing meat, as well as through contact with animal products (hides, skins, fur products, wool, bristles) contaminated with spores of the anthrax microbe.

Infection can also occur through soil in which spores of the anthrax pathogen persist for many years. Spores enter the skin through microtraumas; When contaminated foods are consumed, an intestinal form occurs. The high lethality of the pulmonary and intestinal forms, as well as the ability of the pathogen spores to remain viable for many years, are the reason for the use of the anthrax bacillus as a biological weapon.

The largest epidemic of this disease occurred in 1979 in Sverdlovsk. Since then, small outbreaks of this disease have occurred regularly. Thus, in August 2012, an outbreak of anthrax with fatal cases was recorded in the Altai Territory - in the village of Marushka and the village of Druzhba.

In August 2010, an anthrax outbreak was recorded in the Tyukalinsky district of the Omsk region. The epidemic began with the death of horses on a private farm, which the owners did not report. The dead animals were not even properly buried. As a result, at least six people fell ill, at least one of whom, 49-year-old Alexander Lopatin, died.

In addition, rumors of smallpox cases regularly arise, although the World Health Organization has officially declared the disease eradicated. However, rumors, as a rule, are not confirmed, and one of the last outbreaks of smallpox was recorded in Moscow in the fifties of the last century. He talks about her:

I got vaccinated today at clinic 13 (it was moved from Neglinnaya to Trubnaya St., 19с1, by the way, a long time ago). While they were waiting for the sister, the doctor, an elderly but cheerful, clear-eyed aunt, told a story about the smallpox epidemic in Moscow in the 50s.

I found it on Wiki and am posting it here:

In the winter of 1959 we found ourselves in a bad situation. Moscow artist Kokorekin visited India. He happened to be present at the burning of a deceased Brahmin. Having gained impressions and gifts for his mistress and wife, he returned to Moscow a day earlier than his wife was waiting for him. He spent this day with his mistress, to whom he gave gifts and in whose arms he spent the night, not without pleasure. Having timed the plane's arrival from Delhi, he arrived home the next day. After giving the gifts to his wife, he felt bad, his temperature rose, his wife called an ambulance and he was taken to the infectious diseases department of the Botkin Hospital.

The senior surgeon on duty, Alexey Akimovich Vasiliev, in whose team I was on duty that day, was called for a consultation in the infectious diseases department with Kokorekin, regarding the imposition of a tracheostomy on him due to breathing problems. Vasilyev, having examined the patient, decided that there was no need to apply a tracheostomy and went to the emergency room. By morning the patient became ill and died.

The pathologist who performed the autopsy invited the head of the department, Academician Nikolai Aleksandrovich Kraevsky, into the dissecting room. An old pathologist from Leningrad came to visit Nikolai Alexandrovich and was invited to the dissecting table. The old man looked at the corpse and said, “Yes, my friend, variola vera is black smallpox.” The old man was right.

They reported to Shabanov. The machine of Soviet health care began to spin. They imposed a quarantine on the infectious diseases department, and the KGB began tracing Kokorekin’s contacts. The story of his early arrival in Moscow and a night of bliss with his mistress was revealed. As it turned out, the wife and mistress behaved in the same way - both ran to thrift stores to hand over gifts. There were several cases of smallpox in Moscow that ended in death. The hospital was quarantined, and it was decided to vaccinate the entire population of Moscow with smallpox vaccine.

There was no vaccine in Moscow, but there was one in the Far East. The weather was bad and no planes were flying. Finally the vaccine arrived and vaccinations began. I suffered it very hard, I did not have immunity against smallpox, although I was vaccinated in 1952, when an epidemic of smallpox began in Tajikistan, brought from Afghanistan in the traditional way - carpets were thrown across the border on which patients with smallpox lay.

Update: I found the details here. It turns out that the ill-fated Kokorekin was present not only at the burning of the Brahmin, who definitely died of smallpox, but also the Brahmin’s hut. And I thought - how did he manage to get infected, how? After all, before burning the body is wrapped in several layers of cloth, and the high temperature of the fire should have killed all the vibrios. But vibrio is “resistant to the effects of the external environment, especially to drying and low temperatures. It can persist for a long time, for a number of months, in crusts and scales taken from pockmarks on the skin of patients” (wiki). In that hut there were millions of flakes of skin and dust with vibrios - that’s how I became infected.

And it was after this incident and thanks to the USSR that they adopted a program to eradicate smallpox throughout the world. In the wild forests of India, tribes were shown photographs of people suffering from smallpox. So they got rid of it!

Plague (pestis) is an acute zoonotic natural focal infectious disease with a predominantly transmissible pathogen transmission mechanism, which is characterized by intoxication, damage to the lymph nodes, skin and lungs. It is classified as a particularly dangerous, conventional disease.

Codes according to ICD -10

A20.0. Bubonic plague.
A20.1. Cellulocutaneous plague.
A20.2. Pneumonic plague.
A20.3. Plague meningitis.
A20.7. Septicemic plague.
A20.8. Other forms of plague (abortive, asymptomatic, minor).
A20.9. Unspecified plague.

Etiology (causes) of plague

The causative agent is a gram-negative small polymorphic non-motile bacillus Yersinia pestis of the Enterobacteriaceae family of the genus Yersinia. It has a mucous capsule and does not form spores. Facultative anaerobe. Dyed with bipolar aniline dyes (more intense at the edges). There are rat, marmot, gopher, field and sand lance varieties of the plague bacterium. Grows on simple nutrient media with the addition of hemolyzed blood or sodium sulfate, the optimal temperature for growth is 28 ° C. It occurs in the form of virulent (R-forms) and avirulent (S-forms) strains. Yersinia pestis has more than 20 antigens, including a thermolabile capsular antigen, which protects the pathogen from phagocytosis by polymorphonuclear leukocytes, a thermostable somatic antigen, which includes V- and W-antigens, which protect the microbe from lysis in the cytoplasm of mononuclear cells, ensuring intracellular reproduction, LPS etc. The pathogenicity factors of the pathogen are exo- and endotoxin, as well as aggression enzymes: coagulase, fibrinolysin and pesticins. The microbe is stable in the environment: it persists in soil for up to 7 months; in corpses buried in the ground, up to a year; in bubo pus - up to 20–40 days; on household items, in water - up to 30–90 days; tolerates freezing well. When heated (at 60 °C it dies in 30 s, at 100 °C - instantly), drying, exposure to direct sunlight and disinfectants (alcohol, chloramine, etc.), the pathogen is quickly destroyed. It is classified as pathogenicity group 1.

Epidemiology of the plague

The leading role in preserving the pathogen in nature is played by rodents, the main ones being marmots (tarbagans), ground squirrels, voles, gerbils, as well as lagomorphs (hares, pikas). The main reservoir and source in anthropurgic foci are gray and black rats, less often - house mice, camels, dogs and cats. A person suffering from pneumonic plague is especially dangerous. Among animals, the main distributor (carrier) of plague is the flea, which can transmit the pathogen 3–5 days after infection and remains infective for up to a year. Transmission mechanisms are varied:

• transmissible - when bitten by an infected flea;
• contact - through damaged skin and mucous membranes when skinning sick animals; slaughter and cutting of camel, hare carcasses, as well as rats, tarbagans, which are used as food in some countries; in contact with the secretions of a sick person or objects contaminated by him;
• fecal-oral - when eating insufficiently heat-treated meat from infected animals;
• aspiration - from a person suffering from pulmonary forms of plague.

Diseases in humans are preceded by epizootics among rodents. The seasonality of the disease depends on the climate zone and in countries with a temperate climate is recorded from May to September. Human susceptibility is absolute in all age groups and for any mechanism of infection. A patient with the bubonic form of plague before the opening of the bubo does not pose a danger to others, but when it passes into the septic or pneumonic form, he becomes highly infectious, releasing the pathogen with sputum, bubo secretions, urine, and feces. Immunity is unstable, repeated cases of the disease have been described.

Natural foci of infection exist on all continents, with the exception of Australia: in Asia, Afghanistan, Mongolia, China, Africa, South America, where about 2 thousand cases are registered annually. In Russia, there are about 12 natural focal zones: in the North Caucasus, Kabardino-Balkaria, Dagestan, Transbaikalia, Tuva, Altai, Kalmykia, Siberia and the Astrakhan region. Anti-plague specialists and epidemiologists are monitoring the epidemic situation in these regions. Over the past 30 years, cluster outbreaks have not been registered in the country, and the incidence rate has remained low - 12–15 episodes per year. Each case of human illness must be reported to the territorial center of Rospotrebnadzor in the form of an emergency notification, followed by the announcement of quarantine. International rules specify quarantine lasting 6 days, observation of persons in contact with the plague is 9 days.

Currently, the plague is included in the list of diseases, the causative agent of which can be used as a means of bacteriological weapons (bioterrorism). Laboratories have obtained highly virulent strains that are resistant to common antibiotics. In Russia there is a network of scientific and practical institutions to combat infection: anti-plague institutes in Saratov, Rostov, Stavropol, Irkutsk and anti-plague stations in the regions.

Plague prevention measures

Nonspecific

• Epidemiological surveillance of natural plague foci.
• Reducing the number of rodents, carrying out deratization and disinfestation.
• Constant monitoring of the population at risk of infection.
• Preparing medical institutions and medical personnel to work with plague patients, conducting awareness-raising work among the population.
• Prevention of pathogen importation from other countries. The measures to be taken are set out in the International Health Regulations and the Sanitation Regulations.

Specific

Specific prevention consists of annual immunization with a live anti-plague vaccine of persons living in epizootic outbreaks or traveling there. People who come into contact with plague patients, their belongings, and animal corpses are given emergency chemoprophylaxis (Table 17-22).

Table 17-22. Schemes for the use of antibacterial drugs for emergency prevention of plague

Pathogenesis of plague

The causative agent of plague enters the human body most often through the skin, less often through the mucous membranes of the respiratory tract and digestive tract. Changes in the skin at the site of pathogen penetration (primary focus - phlyctena) rarely develop. Lymphogenously from the site of introduction, the bacterium enters the regional lymph node, where it multiplies, which is accompanied by the development of serous-hemorrhagic inflammation, spreading to surrounding tissues, necrosis and suppuration with the formation of a plague bubo. When the lymphatic barrier breaks through, hematogenous dissemination of the pathogen occurs. Entry of the pathogen via the aerogenic route promotes the development of an inflammatory process in the lungs with melting of the walls of the alveoli and concomitant mediastinal lymphadenitis. Intoxication syndrome is characteristic of all forms of the disease, is caused by the complex action of pathogen toxins and is characterized by neurotoxicosis, ITS and thrombohemorrhagic syndrome.

Clinical picture (symptoms) of plague

The incubation period lasts from several hours to 9 days or more (on average 2–4 days), shortening in the primary pulmonary form and lengthening in vaccinated individuals.
or receiving prophylactic medications.

Classification

There are localized (cutaneous, bubonic, cutaneous bubonic) and generalized forms of plague: primary septicemic, primary pulmonary, secondary septic, secondary pulmonary and intestinal.

Main symptoms and dynamics of their development

Regardless of the form of the disease, plague usually begins suddenly, and the clinical picture from the first days of the disease is characterized by a pronounced intoxication syndrome: chills, high fever (≥39 ° C), severe weakness, headache, body aches, thirst, nausea, and sometimes vomiting. The skin is hot, dry, the face is red and puffy, the sclera is injected, the conjunctiva and mucous membranes of the oropharynx are hyperemic, often with pinpoint hemorrhages, the tongue is dry, thickened, covered with a thick white coating (“chalky”). Later, in severe cases, the face becomes haggard, with a cyanotic tint, and dark circles under the eyes. Facial features become sharper, an expression of suffering and horror appears (“plague mask”). As the disease progresses, consciousness is impaired, hallucinations, delusions, and agitation may develop. Speech becomes slurred; coordination of movements is impaired. The appearance and behavior of patients resemble a state of alcohol intoxication. Characterized by arterial hypotension, tachycardia, shortness of breath, cyanosis. In severe cases of the disease, bleeding and vomiting mixed with blood are possible. The liver and spleen are enlarged. Oliguria is noted. The temperature remains constantly high for 3–10 days. In the peripheral blood - neutrophilic leukocytosis with a shift to the left. In addition to the described general manifestations of plague, lesions characteristic of individual clinical forms of the disease develop.

Cutaneous form is rare (3–5%). At the site of the entrance gate of infection, a spot appears, then a papule, a vesicle (phlyctena), filled with serous-hemorrhagic contents, surrounded by an infiltrated zone with hyperemia and edema. Phlyctena is characterized by severe pain. When it is opened, an ulcer forms with a dark scab at the bottom. A plague ulcer has a long course and heals slowly, forming a scar. If this form is complicated by septicemia, secondary pustules and ulcers occur. The development of a regional bubo (cutaneous bubonic form) is possible.

Bubonic form occurs most often (about 80%) and is distinguished by its relatively benign course. From the first days of the disease, sharp pain appears in the area of ​​the regional lymph nodes, which makes movement difficult and forces the patient to take a forced position. The primary bubo, as a rule, is single; multiple buboes are less often observed. In most cases, the inguinal and femoral lymph nodes are affected, and somewhat less frequently, the axillary and cervical lymph nodes. The size of the bubo varies from a walnut to a medium-sized apple. Vivid features are sharp pain, dense consistency, adhesion to the underlying tissues, smoothness of contours due to the development of periadenitis. The bubo begins to form on the second day of illness. As it develops, the skin over it turns red, shiny, and often has a cyanotic tint. At the beginning it is dense, then it softens, fluctuation appears, and the contours become unclear. On the 10th–12th day of illness it opens - a fistula and ulceration form. With a benign course of the disease and modern antibiotic therapy, its resorption or sclerosis is observed. As a result of hematogenous introduction of the pathogen, secondary buboes can form, which appear later and are small in size, less painful and, as a rule, do not suppurate. A serious complication of this form can be the development of a secondary pulmonary or secondary septic form, which sharply worsens the patient’s condition, even leading to death.

Primary pulmonary form It occurs rarely, during periods of epidemics in 5–10% of cases and represents the most dangerous epidemiologically and severe clinical form of the disease. It begins sharply, violently. Against the background of a pronounced intoxication syndrome, a dry cough, severe shortness of breath, and cutting pain in the chest appear from the first days. The cough then becomes productive, with the production of sputum, the amount of which can vary from a few spits to huge quantities, it is rarely absent at all. The sputum, at first foamy, glassy, ​​transparent, then takes on a bloody appearance, later becomes purely bloody, and contains a huge amount of plague bacteria. It usually has a liquid consistency - one of the diagnostic signs. Physical data are scanty: a slight shortening of the percussion sound over the affected lobe; on auscultation, there are not a lot of fine wheezes, which clearly does not correspond to the general serious condition of the patient. The terminal period is characterized by an increase in shortness of breath, cyanosis, development of stupor, pulmonary edema and ITS. Blood pressure drops, the pulse quickens and becomes thread-like, heart sounds are muffled, hyperthermia is replaced by hypothermia. Without treatment, the disease ends in death within 2–6 days. With early use of antibiotics, the course of the disease is benign and differs little from pneumonia of other etiologies, as a result of which late recognition of the pneumonic form of plague and cases of the disease in the patient’s environment are possible.

Primary septic form It happens rarely - when a massive dose of the pathogen enters the body, usually by airborne droplets. It begins suddenly, with pronounced symptoms of intoxication and the subsequent rapid development of clinical symptoms: multiple hemorrhages on the skin and mucous membranes, bleeding from internal organs (“black plague”, “black death”), mental disorders. Signs of cardiovascular failure progress. The patient's death occurs within a few hours from ITS. There are no changes at the site of introduction of the pathogen and in the regional lymph nodes.

Secondary septic form complicates other clinical forms of infection, usually bubonic. Generalization of the process significantly worsens the general condition of the patient and increases his epidemiological danger to others. The symptoms are similar to the clinical picture described above, but differ in the presence of secondary buboes and a longer duration. With this form of the disease, secondary plague meningitis often develops.

Secondary pulmonary form as a complication occurs in localized forms of plague in 5–10% of cases and sharply worsens the overall picture of the disease. Objectively, this is expressed by an increase in symptoms of intoxication, the appearance of chest pain, coughing, followed by the release of bloody sputum. Physical data make it possible to diagnose lobular, less often pseudolobar pneumonia. The course of the disease during treatment can be benign, with a slow recovery. The addition of pneumonia to low-infectious forms of plague makes patients the most dangerous in epidemiological terms, so each such patient must be identified and isolated.

Some authors distinguish the intestinal form separately, but most clinicians tend to consider intestinal symptoms (severe abdominal pain, profuse mucous-bloody stool, bloody vomiting) as manifestations of the primary or secondary septic form.

With repeated cases of the disease, as well as with plague in people who have been vaccinated or received chemoprophylaxis, all symptoms begin and develop gradually and are more easily tolerated. In practice, such conditions are called “minor” or “outpatient” plague.

Complications of the plague

There are specific complications: ITS, cardiopulmonary failure, meningitis, thrombohemorrhagic syndrome, which lead to the death of patients, and nonspecific complications caused by endogenous flora (phlegmon, erysipelas, pharyngitis, etc.), which are often observed against the background of improvement of the condition.

Mortality and causes of death

In the primary pulmonary and primary septic form without treatment, mortality reaches 100%, most often by the 5th day of illness. In the bubonic form of plague, the mortality rate without treatment is 20–40%, which is due to the development of a secondary pulmonary or secondary septic form of the disease.

Diagnosis of plague

Clinical diagnosis

Clinical and epidemiological data allow one to suspect the plague: severe intoxication, the presence of an ulcer, bubo, severe pneumonia, hemorrhagic septicemia in persons located in the natural focal zone for the plague, living in places where epizootics (deaths) among rodents were observed or there is an indication of registered cases of illness. Every suspicious patient should be examined.

Specific and nonspecific laboratory diagnostics

The blood picture is characterized by significant leukocytosis, neutrophilia with a shift to the left and an increase in ESR. Protein is found in the urine. During an X-ray examination of the chest organs, in addition to enlarged mediastinal lymph nodes, one can see focal, lobular, less often pseudolobar pneumonia, and in severe cases - RDS. In the presence of meningeal signs (stiff neck muscles, positive Kernig's sign), a spinal puncture is necessary. In the CSF, three-digit neutrophilic pleocytosis, a moderate increase in protein content and a decrease in glucose levels are more often detected. For specific diagnostics, bubo punctate, ulcer discharge, carbuncle, sputum, nasopharyngeal smear, blood, urine, feces, CSF, and sectional material are examined. The rules for collecting material and its transportation are strictly regulated by the International Health Regulations. The material is collected using special dishes, containers, and disinfectants. The staff works in anti-plague suits. A preliminary conclusion is given on the basis of microscopy of smears stained with Gram, methylene blue, or treated with a specific luminescent serum. Detection of ovoid bipolar rods with intense staining at the poles (bipolar staining) suggests a diagnosis of plague within an hour. For final confirmation of the diagnosis, isolation and identification of the culture, the material is sown on agar in a Petri dish or in broth. After 12–14 hours, characteristic growth appears in the form of broken glass (“lace”) on agar or “stalactites” in the broth. The final identification of the culture is made on the 3rd–5th day.

The diagnosis can be confirmed by serological studies of paired sera in the RPGA, but this method has a secondary diagnostic value. Pathological changes in intraperitoneally infected mice and guinea pigs are studied after 3–7 days, with the inoculation of biological material. Similar methods of laboratory isolation and identification of the pathogen are used to identify plague epizootics in nature. For research, materials are taken from rodents and their corpses, as well as fleas.

Differential diagnosis

The list of nosologies with which differential diagnosis must be carried out depends on the clinical form of the disease. The cutaneous form of plague is differentiated from the cutaneous form of anthrax, bubonic - from the cutaneous form of tularemia, acute purulent lymphadenitis, sodoku, benign lymphoreticulosis, venereal granuloma; pulmonary form - from lobar pneumonia, pulmonary form of anthrax. The septic form of plague must be distinguished from meningococcemia and other hemorrhagic septicemia. Diagnosis of the first cases of the disease is especially difficult. Epidemiological data are of great importance: stay in foci of infection, contact with rodents with pneumonia. It should be borne in mind that early use of antibiotics modifies the course of the disease. Even the pneumonic form of plague in these cases can be benign, but the patients still remain infectious. Considering these features, in the presence of epidemic data, in all cases of diseases occurring with high fever, intoxication, lesions of the skin, lymph nodes and lungs, plague should be excluded. In such situations, it is necessary to conduct laboratory tests and involve anti-plague service specialists. The criteria for differential diagnosis are presented in the table (Tables 17-23).

Table 17-23. Differential diagnosis of plague

Indications for consultation with other specialists

Consultations are usually carried out to clarify the diagnosis. If the bubonic form is suspected, a consultation with a surgeon is indicated; if the pulmonary form is suspected, a consultation with a pulmonologist is indicated.

An example of a diagnosis formulation

A20.0. Plague, bubonic form. Complication: meningitis. Heavy current.
All patients with suspected plague are subject to emergency hospitalization on special transport to an infectious diseases hospital, in a separate box, in compliance with all anti-epidemic measures. Personnel caring for plague patients must wear a protective anti-plague suit. Household items in the ward and the patient's excretions are subject to disinfection.

Treatment of plague

Mode. Diet

Bed rest during the febrile period. There is no special diet provided. It is advisable to have a gentle diet (table A).

Drug therapy

Etiotropic therapy should be started if plague is suspected, without waiting for bacteriological confirmation of the diagnosis. It includes the use of antibacterial drugs. When studying natural strains of plague bacteria in Russia, no resistance to common antimicrobial drugs was found. Etiotropic treatment is carried out according to approved schemes (Tables 17-24–17-26).

Table 17-24. Scheme for the use of antibacterial drugs in the treatment of bubonic plague

Table 17-25. Scheme for the use of antibacterial drugs in the treatment of pneumonic and septic forms of plague

** Used to treat plague affecting the central nervous system.

Table 17-26. Schemes for the use of combinations of antibacterial drugs in the treatment of pneumonic and septic forms of plague

* There are injection forms of the drug for parenteral administration.

In severe cases, it is recommended to use compatible combinations of antibacterial agents in the doses indicated in the regimens during the first four days of illness. In the following days, treatment is continued with one drug. For the first 2–3 days, the medications are administered parenterally, and subsequently switch to oral administration.

Along with specific treatment, pathogenetic treatment is carried out aimed at combating acidosis, cardiovascular failure and DN, microcirculation disorders, cerebral edema, and hemorrhagic syndrome.

Detoxification therapy consists of intravenous infusions of colloidal (reopolyglucin, plasma) and crystalloid solutions (glucose 5–10%, polyionic solutions) up to 40–50 ml/kg per day. The previously used anti-plague serum and specific gamma globulin turned out to be ineffective during the observation process, and at present they are not used in practice, nor is the plague bacteriophage used. Patients are discharged after complete recovery (for the bubonic form no earlier than the 4th week, for the pulmonary form - no earlier than the 6th week from the day of clinical recovery) and a three-fold negative result obtained after culture of bubo punctate, sputum or blood, which is carried out on 2- th, 4th, 6th days after cessation of treatment. After discharge, medical observation is carried out for 3 months.