HFRS合并腎病綜合征的出血熱學習教案

1、會計學1HFRS合并腎病綜合征的出血熱合并腎病綜合征的出血熱2Febrile phase, Hypotensive (shock) phase,Oliguric phase, Diuretic phase, Convalescent phase第1頁/共102頁3Epidemic Hemorrhagic Fever ( EHF)Suggested name by WHO in 1982:Hemorrhagic Fever with Renal Syndrome (HFRS)第2頁/共102頁4Hantan virus Member of the family of Bunyaviridae F

2、eature of virus Single-strand negative RNA virus Circular or oval in shape 78210 nm in diameter Envelope proteins:glycoprotein1(G1) glycoprotein2(G2) Viral genomeRNA: L M S gene Etiology第3頁/共102頁5第4頁/共102頁6 Serologic type of Hantan virus Over twenty serologic types hantaan virus (type I, HTNV) (漢灘病毒

3、漢灘病毒) seoul virus(type II, SEOV) (漢城病毒漢城病毒) puumala virus (type III,PUUV) (普馬拉病毒普馬拉病毒) prospect hill virus(type IV,PHV) (希望山病毒希望山病毒) dobrava-belgrade virus (DEOV) (多布拉伐病毒多布拉伐病毒) 第5頁/共102頁7Human HFRS: caused by four type of virus: hantaan virus (type I, HTNV) seoul virus(type II, SEOV) puumala virus

4、(type III,PUUV) dobrava-belgrade virus(DEOV) China: Hantaan virus Seoul virushantaan virus and DEOV show stronger pathogenicity than type II and III virus第6頁/共102頁8 Resistance of virus Low resistance: Inactivated by acid (Type III hypersensitivity reaction Hantan virus infectioninduce specific antib

5、odiesimmune complex-activating complements-accumulation of immune complex in small blood vessels, basement of glomerulus and renal tubule- damage第17頁/共102頁19 2 Other hypersensitivity reaction Type I-IgE mediated damage. Type II- linear IgG immune complexaccumulation in platelet and basement membrane

6、s of renal tubule Type IV CD8+ cell mediated immune damage.第18頁/共102頁20 3.Cellular immune response: Hantan virus infection activation of CD8+ T cellsCTL responserelease lymphokines damage 4.Hantan viruslymphocyte and macrophagecytokins: such as interleukin1(IL-1), IFNr, tumor necrosis factor(TNF)dam

7、age第19頁/共102頁21第20頁/共102頁22第21頁/共102頁23第22頁/共102頁24第23頁/共102頁25第24頁/共102頁26第25頁/共102頁27第26頁/共102頁28第27頁/共102頁29第28頁/共102頁30第29頁/共102頁31 Clinical Manifestations第30頁/共102頁32For most cases, going to more serious with pyrexia gradually disappeared 第31頁/共102頁33第32頁/共102頁34第33頁/共102頁35第34頁/共102頁36第35頁/共10

8、2頁37第36頁/共102頁38第37頁/共102頁39第38頁/共102頁40 Clinical Manifestations第39頁/共102頁41 Clinical Manifestations第40頁/共102頁42第41頁/共102頁43第42頁/共102頁44第43頁/共102頁45 Clinical Manifestations第44頁/共102頁46more serious although urine increasehigh mortality第45頁/共102頁472. Early stage of diuretic phase urine volume 2000ml/2

9、4h no marked decrease in azotemia3. Late stage of diuretic phase a. urine volume 3000ml/24h in most of cases: 4000 to 8000/24h, 15000ml/24h b. azotemia improving, BUN falling down c. Secondary shock, dehydration hypokalemia, hyponatremia第46頁/共102頁48Five phase be not seen in every case. hypotension a

10、nd /or oliguria phase may be absent in atypical cases Clinical Manifestations第47頁/共102頁49第48頁/共102頁50第49頁/共102頁51第50頁/共102頁52第51頁/共102頁53第52頁/共102頁54第53頁/共102頁55第54頁/共102頁56第55頁/共102頁57第56頁/共102頁58第57頁/共102頁59第58頁/共102頁60第59頁/共102頁612. Complication in central nervous system Encephalitis and meningit

11、is Intracranial hemorrhage and cerebral edema 第60頁/共102頁62第61頁/共102頁63第62頁/共102頁64第63頁/共102頁65第64頁/共102頁66Five phase is not observed in every case. hypotension and /or oliguria phase may be absent in atypical cases第65頁/共102頁67第66頁/共102頁68 Differential diagnosis 1. In febrile phase with common cold,

12、influenza, Septicemia. 2. In Hypotensive phase with other infection shock 3. Pyrexia, intracrania hemorrhage and cerebral edema with meningococcal meningitis 第67頁/共102頁694.Oliguria and renal failure with acute nephritis 5.Pyrexia and hemorrhage with Leptospirosis6.Marked hemorrhage with: thrombocyto

13、penic purpura, gastrointestinal bleeding caused by gastric ulcer.第68頁/共102頁70第69頁/共102頁71第70頁/共102頁72 Treatment Supportive treatment Anti-viral therapy Symptomatic treatment第71頁/共102頁73第72頁/共102頁742. Treatment in febrile phase Principle of treatment a.Anti-virus therapy b.Reduce exudation of plasma

14、c.Reduce intoxicating symptoms d.Preventing from DIC第73頁/共102頁75 1.Anti-viral therapy: important giving anti-virus drug in early stage. (Ribavirin(virazole) 1.0g iv drip with 10%GS qd for 3-5 days 2.Reduce permeability of small vessel and exudation Lutin and Vitamin C 第74頁/共102頁76第75頁/共102頁774.Preve

15、ntion from DIC a. Reduce the blood viscosity Danshen solution, Dextran 40 b. anti-coagulation therapy Heparin should be given once the CT is less than 3 min or APTT less than 34 seconds.第76頁/共102頁78 3.Treatment in Hypotensive phase Principle of treatment: Supplement blood volume Correct metabolic ac

16、idosis 第77頁/共102頁791.Supplement blood volume : early rapidly adequate B:kinds of fluids: Crystalloid fluids and Colloid fluids containing suitable glucose, electrolytes and vitamins: Ringers Solution Normal saline solution Dextran, 20% Mannitol Plasma, albumin, Artificial plasma.第78頁/共102頁802Correct

17、 metabolic acidosis 5% sodium bicarbonate solution. The amount calculated according to CO2CP value. 3.Blood vessel activating drugs for hypotension and shock: aramine, dopamine, et al. 第79頁/共102頁814.Corticosteroids Reduce severe toxemia, Reduce permeation of small vessel Improving microcirculation o

18、f tissue. 1020mg of Dexamethasone is given by intravenous drip.第80頁/共102頁82 4.Treatment in oliguric phase Principle of treatment : Balance intra-environment Diuretic therapy Catharsis therapy for preventing from hypervolemia Dialysis therapy第81頁/共102頁83 1.Balance intra-environment a.Correct imbalanc

19、e of fluid electrolytes, acid- base Closely observe and record urine volume. Examine blood biochemical parameter and renal function adjusting amount of fluid and electrolytes 第82頁/共102頁84 b. Reducing protein degradation and control of azotemia. Food containing high vitamins high carbohydrate, low pr

20、otein. For the serious patient: Supplement glucose 200300g every day by intravenous drip 20-25% GS with insulin.第83頁/共102頁85 2.Diuretic for oliguria 20%Mannitol solution, given intravenously l a s i x ( f u r o s e m i d e ) , g i v e n i n j e c t i o n intravenously with grudualy increasing dose,

21、and repeating every 4 to 6 hours according to the urine amounts.3Catharsis therapy for hypervolemia inducing diarrhea to take out fluids by intestinal. 50% Magnesium Sulfate solution 20%Mannitol solution 第84頁/共102頁86 Reducing blood volume therapy For hypervolemia with cardiac failure and pulmonary e

22、dema, taking out 300ml 400ml blood may be useful.used rare now第85頁/共102頁87第86頁/共102頁88第87頁/共102頁895. Treatment in Diuretic phase a. Keeping balance of fluid and electrolytes. and treatment secondary infection: antibiotics第88頁/共102頁90 6.Convalescent phase a:Supplement nutrition food. b: Examining of

23、renal function, blood pressure, pituitary function at regular interval.第89頁/共102頁917.Complications treatment 1. Hemostatics therapy for heavy bleeding such as gastrointestinal hemorrhage treatment of DIC: according to different phase of DIC, giving EACA, protamine ,respectively. 第90頁/共102頁92 2.Treatment ARDS a: Control of amount of intravenous infusion. b: Giving oxygen, or mechanical ventila