Infectious toxicosis

Infectious toxicosis is an emergency condition that can occur with any acute bacterial or viral infection in children from 3 months to 2 years old. Patients with infectious toxicosis make up 7-9% of all patients admitted to the intensive care unit with infectious pathology.

According to some data, in 53% of observations in children with infectious toxicosis, the invasive form of acute intestinal infections was proven, and in 27% - viral-bacterial associations of pathogenic bacteria with respiratory viruses.

The main link in the pathogenesis of infectious toxicosis is the sympathoadrenal crisis.

[ 1 ], [ 2 ], [ 3 ], [ 4 ], [ 5 ], [ 6 ]

Symptoms of infectious toxicosis

In most children, the disease begins suddenly and violently with a rise in body temperature to 39-40 °C, vomiting, anxiety, loose stools 3-4 times a day. Only in 11% of cases do parents note that the day before hospitalization the child was capricious, ate poorly, and twitched in his sleep. In 53.4% of observations, children develop clinical tonic convulsions or convulsive twitching, and in 26.6% they begin at home.

All patients with an unclosed large fontanelle are admitted with one of three conditions: the fontanelle is full, bulging, or pulsating. This is a characteristic sign that allows us to differentiate infectious toxicosis from intestinal exsicosis, in which the large fontanelle always sinks.

All children are characterized by hyperthermia from 38.8 to 40.5 °C, tachycardia 180-230 per minute, hypertension, dyspnea 60-100 per minute, which indicate increased sympathoadrenal activity. The color of the skin varies from hyperemia to pronounced pallor with cyanosis of the nail plates. Pastosity of the eyelids and shins is noted, CVP is normal or increased. A constant sign of infectious toxicosis is decreased diuresis, although it is also noted in other emergency conditions.

All patients develop neurological disorders. In 58.6% of cases, negativism and severe anxiety, monotonous crying and hyperkinesis are noted. The remaining patients are admitted in a stupor. All children have increased tendon reflexes and increased tone of the limbs. In 43.1%, rigidity of the occipital muscles is detected, in 38% - convergent strabismus with constricted pupils. Patients develop an increase in systolic and diastolic blood pressure by 20-40 mm Hg. The clinical picture of infectious toxicosis is very diverse due to disorders in many organs and systems. Only those symptoms that develop in almost all patients are given.

Signs of infectious toxicosis in children

Signs	Values of attributes
Neurological disorders
Consciousness	Anxiety, stupor, coma
Muscle tone	Hyperkinesis, increased muscle tone, rigidity of the occipital muscles
Physical activity
Cramps	Often - convulsive twitching, clonic-tonic seizures, seizures that do not stop
Tendon reflexes	Hyperreflexia
Circulation
HELL	Increased 100/70-140/90 mm Hg
CVP	Normal or elevated
Pulse rate	Tachycardia or paroxysmal tachycardia 180-230 bpm
Large fontanelle	Done, bulging, pulsating
Temperature	Hyperthermia 38 8-40.5 C
Signs of exsicosis	Not expressed
Urinary system	Infrequent urination, azotemia, proteinuria
Dyspnea	Tachypnea - 60-100 per minute
KOS
PH	Metabolic acidosis 7.22-7.31
VE	Base deficit -8 -17
RS02	Hypocapnia 23.6-26.8 mm Hg
LII	2.9-14
Leukocytes	12.8-16x10 9 /l
DIC syndrome	I-II-III stages

From a tactical point of view, it is advisable to distinguish the following clinical variants of infectious toxicosis: encephalic form, cerebral edema and paroxysmal tachycardia. Identification of these forms is necessary for choosing pathogenetic therapy. If intensive therapy is not administered in a timely manner, paroxysmal tachycardia is complicated by cardiogenic shock.

The encephalic form occurs more often than others (82-83%), cerebral edema - up to 7%, and paroxysmal tachycardia is about 10%. In the latter case, the issue is resolved using an ECG or monitoring.

In paroxysmal tachycardia in children, the pulse rate exceeds 200 per minute, the P wave is superimposed on the T wave due to frequent contractions. The ST interval is below the isoelectric line.

Cerebral edema in patients is characterized by coma, convergent strabismus, and uncontrollable seizures, which serves as the main differential sign. High pressure is noted during spinal puncture, and clinical analysis of the CSF does not reveal signs characteristic of meningitis or encephalitis.

Thus, there are no strictly specific signs for infectious toxicosis. But the combination of laboratory and functional data and the described clinical symptoms with a predominance of neurological disorders and signs of increased activity of the sympathoadrenal system allows diagnosing this emergency condition without any particular difficulties.

Treatment of infectious toxicosis

Intensive pathogenetic therapy of infectious toxicosis includes:

• stopping convulsions and restoring adequate breathing,
• blockade of sympathoadrenal activity, restoration of adequate central hemodynamics and cardiac rhythm,
• prevention and treatment of possible complications (cerebral edema, acute respiratory failure and renal dysfunction).

Convulsions are stopped by general inhalation or intravenous anesthesia.

At the same time, prednisolone is administered at a rate of 3-5 mg/kg or dexamethasone (dexazone) in an equivalent dose to stabilize cell membranes.

In case of recurrent convulsions, diagnostic spinal puncture is indicated. The absence of pathological cytosis (up to 16-20x10 ⁶ /l) and protein (up to 0.033 g/l) in the CSF excludes neuroinfection in children and confirms infectious toxicosis.

The main method of treating hemodynamic disorders with uncomplicated forms of infectious toxicosis in young children is ganglionic blockade.

Pentamin is used at a rate of 5 mg/kg or any other drug with a similar effect, which is administered intravenously (20 drops per minute) in 50 ml of 5% glucose solution.

An attack of paroxysmal tachycardia can be stopped by a non-selective beta-blocker or slow calcium channel blockers: propranolol is administered by titration of 0.1 mg/kg per 10 ml of glucose, verapamil 0.25 mg/kg. The drugs block the effect of catecholamines on adrenergic receptors. Clinically, this is manifested by a decrease in dyspnea and tachycardia, a decrease in body temperature, normalization of blood pressure, an increase in diuresis and an improvement in skin color.

Infusion therapy at this stage is carried out with solutions that do not contain sodium salts, the average volume of infusions is 80-90 ml/kg. The total volume of fluid for the patient in the first day does not exceed 170-180 ml/kg.

In children with cerebral edema, in addition to the above measures, artificial ventilation is performed through a nasotracheal tube with pCO2 maintained _at 33-34 mm Hg. The average duration of artificial ventilation is 32 hours. It is important to transfer the child to artificial ventilation in a timely manner and quickly stop the cerebral edema. In this case, the vast majority of patients can expect complete restoration of brain function.

Indications for stopping mechanical ventilation include adequate independent breathing through the endotracheal tube, absence of convulsions, and restoration of consciousness and reflexes.

During the rehabilitation period, children who have suffered from cerebral edema receive therapy and physiotherapy procedures under the supervision of a neurologist.

Timely and adequate intensive therapy of other forms of infectious toxicosis is effective, and the recovery period, as a rule, does not exceed 3-4 days.