Gastrocnemius tenderness

Introduction The early clinical manifestations of leptospirosis are tenderness of the gastrocnemius, and the bilateral sides can also be unilateral, varying degrees. The lighter only feels the calf swelling, the mild pain of the pressure, the severe calf pain is severe, can not walk, refused to press. Leptospirosis, referred to as leptospirosis, is an animal-borne infection caused by pathogenic Leptospira. Rodents and pigs are the main source of infection and are prevalent worldwide. Clinically, it is characterized by early leptospirosis, intermediate organ damage and dysfunction, and various post-allergic symptoms. Severe patients may have liver and kidney failure and diffuse hemorrhage of the lungs, often endangering the lives of patients. The disease has spread over several continents, especially in the tropics and subtropics. The disease has been found in 28 provinces, municipalities and autonomous regions in China, and is highly prevalent in the central, southern, southwestern and eastern regions where rice is abundant. The onset season is mainly concentrated in the summer and autumn (June to October) rice harvesting period, often peaked from August to September, and the incidence rate of young and middle-aged farmers is higher. In areas with high temperatures, sporadic cases can be seen throughout the year.

Cause

(1) Sources of infection: mainly for wild rats and pigs. Apodemus acuminata is the most important source of infection for rice-type leptospirosis, while pigs mainly carry the Pomona group, which is the main source of infection for flood-type leptospirosis. Although nature has a variety of animals that can infect and carry Leptospira, it has little significance in the epidemic, and is only a general storage host. Although there are hooks in the urine of patients with hooks, the number is very small. So far, no human-to-human transmission has been confirmed, so people are less likely to be infected.

(2) Ways of transmission: The mode of transmission of leptospirosis is direct contact. Human infections, except for a few from laboratory infections, are caused by hooks that are exposed to the environment and exposed to infected animals. In the autumn harvest season, the voles clustered for food in the field. Among them, the sick mouse discharges the urine of the hook body into the contaminated field water and soil, and the peasants work barefoot in the field, and the hook body can invade the delicate damage of the skin of the hands and feet to cause infection. In the rainy season and flood season, the pig manure overflows and pollutes the environment. When people are exposed to the infected water, it often causes infection. Other routes of transmission include fishermen's exposure to contaminated water during fishing, wading swimming, miners and sewer workers.

(3) Susceptibility of the population: The population is generally susceptible to the hook body. Longer-lasting homotypic immunity can be obtained after infection, but there is no cross-immunization between different types. People in the new AIDS epidemic area are highly susceptible and easy to develop into heavy.

(4) Epidemic characteristics Because the hook body needs proper temperature and humidity to survive in the outside world, the way of infection needs to occur under specific conditions and circumstances. The epidemic of this disease has obvious seasonality, regionality, prevalence and certain occupationality. In most parts of China, the occurrence and popularity of the hooks are concentrated in the rainy and warm season. In the southern rice-producing areas, a large number of cases often occur in the short-term harvest season, becoming a local epidemic or pandemic. The occurrence of flood patterns is also concentrated in the short-term emergence of batches of cases after heavy rains. In the non-popular period, it is mostly sporadic. At this time, in addition to clinically easy to miss diagnosis and misdiagnosis, the actual situation of the epidemic is often underestimated. Since the 1970s, leptospirosis has changed from occupational contact to accidental contact in the field, and the age is also dominated by children. However, farmers, herders, slaughter workers, sewer workers, and hunters are still listed as susceptible populations. In addition, there are significant changes in the clinical types of leptospirosis and prevalence. For example, in the 1950s and 1960s, the serious type of epidemic was mainly jaundice bleeding type. In the 1970s, in the epidemic reports of leptospira in the southern provinces of China, South Korea, and Puerto Rico, the cases of death from severe pulmonary hemorrhage were the most prominent.

an examination

Related inspection

Electromyography plasma cell leptospira latex agglutination test

(1) In the early stage (the period of leptospirosis), within 3 days after onset, the outstanding performance of this period is:

1. Fever Most patients have a sudden onset of illness, accompanied by chills and chills. The body temperature can be as high as 39 °C in the short term. Common relaxation heat, sometimes can also be reserved for heat, a small amount of intermittent heat.

2. The headache is more prominent, the whole body muscle pain, especially the gastrocnemius or neck muscle, the back muscles, the thigh muscles and the chest and abdomen muscles are common. 3. The body is weak, especially the leg is soft and obvious, sometimes it is difficult to walk, and you can't get out of bed.

4. Conjunctival hyperemia, there are two characteristics, one is no secretion, pain or photophobia; the second is continuous congestion, and persists after fever.

5. Gastrocnemius tenderness, bilateral unilateral can also be unilateral, varying degrees. The lighter only feels the calf swelling, the mild pain of the pressure, the severe calf pain is severe, can not walk, refused to press.

6. The superficial lymph nodes of the whole body can be enlarged in the early stage of the disease, which is more common in the groin and axillary lymph nodes. Mostly the size of soybeans or broad beans, tenderness, but no congestion and inflammation, and no pus.

In this issue, digestive symptoms such as nausea, vomiting, poor appetite, diarrhea, respiratory symptoms such as sore throat, cough, pharyngeal congestion, and tonsil enlargement may also occur. Some patients may have liver, splenomegaly, and bleeding tendency. Very few patients have symptoms of poisoning.

(2) Mid-term (organ injury period)

About 3 to 14 days after the onset of the disease, patients with this stage of the disease after the early infection and sepsis, such as hemoptysis, diffuse hemorrhage, jaundice, extensive bleeding of skin and mucous membranes, proteinuria, hematuria, tubular urine And renal insufficiency, meningoencephalitis and so on. The clinical manifestations of this period are the main basis for the classification of pulmonary hemorrhage, jaundice, kidney and meningitis.

Influenza typhoid

Most patients are characterized by systemic symptoms. Rapid onset, chills, fever (38 ~ 39 ° C) headache, conjunctival hyperemia, generalized muscle pain, especially the gastrocnemius muscle, and nasal congestion, sore throat, cough and so on. Clinical manifestations include influenza, upper respiratory infection or typhoid fever. No jaundice, no central nervous system symptoms, normal cerebrospinal fluid, no obvious lesions in the lungs. It is a continuation of early symptoms of leptospirosis. The natural course of disease is 5 to 10 days. There are also a few serious patients with bleeding in the digestive tract, skin, vagina, etc. Some severe patients are mainly gastrointestinal symptoms such as nausea, vomiting, and diarrhea. Can have hypotension or shock performance

2. Pulmonary hemorrhage type on the basis of leptospirosis, cough, blood stasis or hemoptysis, according to the depth and breadth of chest X-ray lesions, as well as cardiopulmonary function, clinically can be divided into lung common bleeding type and diffuse diffuse type of lung.

(1) common pulmonary hemorrhage type: clinical and leptospirosis similar, with varying degrees of hemoptysis or blood stasis, chest signs are not obvious, X-ray shows mild lung disease (increased lung texture), if not treated in time, can also be transferred It is a diffuse type of bleeding in the lungs.

(2) diffuse type of pulmonary hemorrhage (pulmonary hemorrhage type): After the hook body invades the human body, after 2 to 3 days after the latent period and short-term infection, the facial paleness suddenly appears, and the heart rate and breathing increase, palpitation, irritability, Finally enter the cycle and respiratory failure. The lungs are covered with wet rales, and the hemoptysis is progressively increased, but there is no hemoptysis. Mainly for a wide range of internal hemorrhage in the lungs, is a common cause of death caused by no jaundice-type leptospirosis in recent years. The X-ray showed extensive diffuse, patchy softening shadows in both lungs. At the end of the life, a large amount of blood rushed from the mouth and nose until death. If the application of penicillin and hydrocortisone can be applied in time, most patients can get a transfer. The symptoms are improved within 3 to 5 days, and the signs are quickly relieved. The lung lesions can be completely dissipated within 2 to 4 days. According to the research of this type by Huaxi Medical University, it is believed that this is due to the hypersensitivity reaction of the body to pathogens and their toxic substances. The reason is:

1 Clinically, the recovery is rapid, the lung lesions disappear quickly, and there is no rupture of blood vessels. Prompt that major bleeding is a serious consequence of congestion, blood stasis and hemorrhage;

2 hormone therapy has special effects;

3 The blood coagulation mechanism is normal, there is no DIC phenomenon, and no anticoagulant therapy is needed.

This model can be divided into the following three periods, but the third period is not completely separate.

1 aura: the patient is pale (individual can also be flushed), palpitation, irritability. Breathing, heart rate progressively accelerated, the lungs gradually appear rales, blood stasis or hemoptysis, X-ray chest film texture increased, scattered in the form of patchy shadows or small pieces fusion.

2 bleeding period: if not treated in time, in the short term, the face can be extremely pale or gray, lips cyanosis, palpitation, irritability, breathing, heart rate significantly accelerated, the first heart sounds weakened or galloping, double lung wet rales Gradually increased, hemoptysis continues, X-ray chestlets have a patchy shadow that expands and merges in large pieces.

3 dying period: If the above symptoms are not effectively controlled, the patient can progress rapidly in a short period of time (about 1-3 hours), and the irritability will turn into a coma. The throat has snoring, the breathing is not complete, and the hair is extremely cramped. The big mouth blood continuously rushes out from the mouth and nose (foaming), the heart rate slows down, and finally the breath stops.

3. The blood stasis type of the jaundice is formerly known as the external ear disease, which is caused by the serotype of the sputum of the jaundice. Clinically, jaundice is the main cause of bleeding, and the mortality rate is high. This type can be divided into three phases, namely sepsis, jaundice and recovery. 3 to 7 days after the onset of jaundice, 80% of cases with varying degrees of bleeding symptoms, common nasal, skin and mucous membrane defects, ecchymosis, hemoptysis, hematuria, vaginal bleeding, hematemesis, severe gastrointestinal bleeding He died of shock, and a small number of patients had pulmonary hemorrhage at the peak of jaundice. However, it is not known that there is no jaundice-type pulmonary hemorrhage. This type of liver and kidney damage is the main, hyperbilirubinemia, generally more than 5 times more than normal bilirubin, and AST rarely more than 5 times. 70% to 80% of cases involve the kidneys, and the kidneys vary in severity. The lighter ones are proteinuria, hematuria, a small amount of white blood cells and casts. The disease period is about 10 days, which is normal. Severe cases of renal insufficiency, oliguria or anuria, acidosis, uremia, coma, and even death. Renal failure is a common cause of death of jaundice, accounting for 60% to 70% of deaths. Meningeal irritation can still occur in 20% to 30% of cases.

4. The clinical symptoms of renal failure are characterized by renal damage, which is characterized by proteinuria, hematuria, tubular urine, oliguria, and urinary closure. There are varying degrees of azotemia and acidosis. Nitrogenemia usually begins on the third day of the disease, peaks from 7 to 9 days, and returns to normal after 3 weeks. This type has no jaundice, so it is easy to distinguish from jaundice bleeding type renal failure. Severe cases can die from kidney failure.

5. Meningoencephalitis In the case of sporadic aseptic meningitis, leptospirosis meningitis type accounts for about 5% to 13%. Clinically characterized by encephalitis or meningitis symptoms, severe headache, body aches, vomiting , gastrocnemius pain, diarrhea, irritability, unconsciousness, neck stiffness and positive Kline's sign. The number of cells in the cerebrospinal fluid before the immunization period may not be high, generally 10 to several hundred/mm3, and occasionally up to 1000/mm3; the protein reaction is weakly positive; the sugar and chloride are often normal. Clinically similar to aseptic meningitis.

(3) After the heat recovery in the recovery period or after the onset of symptoms, various symptoms gradually subsided, but there are also a few patients who have had fever after a few days to 3 months, and then have fever and symptoms, which are called after-effects.

Post fever

One to five days after the first fever subsided, the fever was reproduced, generally at 38 to 38.5 °C, and half of the patients were accompanied by an increase in peripheral blood eosinophils. The fever was resolved within 1 to 3 days regardless of the medication or not. Very few patients may have a third fever (about 18 days after onset) and will naturally retreat within 3 to 5 days.

2. The posterior ocular disease is more common in the north and may be related to the Pomora type. From 1 week to 1 month after the onset of illness, uveitis, iridocyclitis, and choroiditis are common, scleral epidermitis, retrobulbar optic neuritis, and turbidity of off-duty bodies also occur.

3. Nervous system after the onset

(1) Reactive meningitis

A small number of patients with post-heating accompanied by meningitis symptoms, but the cerebrospinal fluid examination is normal, can also be self-healing after treatment.

(2) occlusive cerebral arteritis

Also known as moyamoya disease, seen in the case of the leptospira type, is one of the most common and serious complications of the leptospirosis nervous system. In 1961, it was first reported by Takeuchi that since 1958, China has been an unexplained cerebral arteritis in rural children and young adults in popular areas such as Hubei, Guangdong and Zhejiang. In 1973, it was clearly caused by hook infection. The incidence rate is about 0.57% to 6.45% of leptospirosis. 90% of children under 15 years old, the rest is young and middle-aged. There is no difference in the incidence of men and women. The peak incidence was more than one quarter after the local leptospirosis epidemic, that is, from October to December, and the longest symptoms occurred 9 months after the illness. It is characterized by hemiplegia, aphasia, and repeated multiple limb paralysis. Cerebral angiography confirmed the stenosis of the upper part of the internal carotid artery and the proximal anterior middle cerebral artery, and most of them had a specific vascular network in the basal ganglia. In the autopsy brain tissue, the hook body can be found, and the prognosis is poor. In addition to the above-mentioned neurological complications, there are reports of peripheral nerve damage and spinal cord damage.

4. Before the heat. In a very small number of patients, the anterior humerus skin on both sides showed nodular erythema during the recovery period, accompanied by fever, and subsided in about 2 weeks. Related to immune response.

Differential diagnosis

The numbness of the gastrocnemius occurs during walking: the tonic muscle cramps of sudden onset of the gastrocnemius muscle, and the twisting and pain, such as twisting, last for tens of seconds to several minutes or more, and the pain is difficult to name.

Gastrocnemius tendon pain refers to gastrocnemius tendon caused by cold or sudden changes in posture of one or both calves, local pain, and inactivity.

The scientific name of cramps is called muscle spasm: it is a spontaneous tonic contraction of muscles. The common leg cramps are actually calf muscle spasm, which means that the calf muscles such as the gastrocnemius suddenly become very hard and the pain is unbearable, which lasts for a few seconds to tens of seconds.

Calf licking after walking: It is a frequent occurrence. Due to excessive walking or running time, the muscles of the lower limbs are overworked. After walking, the calf muscle spasm, local muscles bulge, can not stretch the legs, there will be soreness or severe pain.

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