Scarlatina in a light form in children. Symptoms and treatment of scarlet in adults

Rash on the skin of the body, damage to the throat and high temperature are the symptoms of many children's infections. One of these infectious diseases is scarlet. It is very common in childhood And may cause serious complications. And therefore, many parents are worried about the questions - how the child is infected with scarletina and what a rash looks like in this disease, as Scarlatina proceeds in children and what is dangerous such an infection, and many others.

What it is

Scarletina is called acute infection, the pathogens of which are hemolytic streptococci, belonging to the group A. Such bacteria can have toxic and septic, as well as an allergic effect on the human body due to the production of a special poisonous substance - erythrotoxin.

Scarlatina is transmitted not only by air-droplet, but also through clothes and things

It is this toxin that determines all the symptoms characteristic of scarletin. Due to the expansion of small vessels, the children appears, and the exposure to the erythrotoxin death of the epidermis becomes caused by the pronounced peeling of the skin.

As transmitted

Streptococci Groups and carriers and patients are transferred to healthy children mainly by air-droplet. Bacteria spread when sneezing either when coughing, therefore, people near the ill child are becoming infected. The transmission of the pathogen is also possible through clothes, polluted toys or food.

From whom you can get infected

Streptococci can cause Scarlacin, getting into the child's body from:

• A sick scarletina of a person who is especially infectious in the first days of the manifestation of infection.
• A sick of the pharyngitis of either an angina person if these diseases are caused by streptococci of group A.
• Recently recovered person, because bacteria continue to stand out in environment up to three weeks after improving the condition.
• The carrier of hemolytic streptococcus, which has no symptoms of the disease. Bacteria can live on the mucous membrane of the nose and pharynx, and at the same time not to cause scarletin from their carrier, but be dangerous for other people.

Streptococca carrier may never be sick of scarletnic, but a child infected him may be seriously sick

Incubation period

The first symptoms of the disease appear on average after 3-7 days from the date of infection. The most often incubation period in children lasts two to three days. Sometimes it is reduced to one day or even a few hours. In rare cases, the incubation period can be extended to twelve days.

How many days the child is infected

The sick child begins to highlight the causative agent of scarletin into the environment since the first manifestations of infection. The contagious period may have different durability - both a few days and a few weeks. If Scarlatina proceeds without complications and antibiotic treatment has begun, then after 7-10 days, it ceases to be contagious to others.

Can the child get an adult

Most often, scarletin is diagnosed in children from 2 to 10 years.The disease in most cases causes lifelong immunity, therefore, if an adult suffered such an infection in childhood, Scarlatina after contact with his illness often does not develop. Repeated disease is possible with a reduced adult immunity.

Adult who did not have a scarletina before he could get sick

If an adult scarletna was not before, he could get an air-droplet from the diseased child. At the same time, the severity of scarletins in adulthood can be different. There are both erased forms and toxic scarletin with a very difficult flow.

Symptoms

The initial stage of the scarletna in most children is short and lasts less than a day.The disease begins acutely with increasing body temperature and appearance of sore throats. Basic signs typical form Scarlants in children are presented:

• Symptoms of general intoxication. The disease is manifested by headaches, fever, common malaise, excited condition (less frequently lethargy), vomiting, fragmentation in muscles and joints, tachycardia.
• Small-point rash appearing on the first-third day of the disease.
• Angina, the flow of which may be harder than in conventional angins.
• By changing the language, due to which it is called "Malinov". Scarlatin language is first covered with a whitish flare, but on the second or fourth day from the beginning of clinical manifestations it becomes bright red. It expressed graininess, since the size of the papillas increases.
• The peeling of the skin, which appears about 1-2 weeks after the initial manifestations of the disease (it replaces rash). In the footsteps and palms, the skin is peeling with large parts, and on the torso, ears and neck there is a small peeling, called a bowl.

You can learn more about the symptoms that accompany the disease in the next video.

What a rash looks like

The rashes look like numerous dots of red or bright pink.Localization of the rash is presented in the main field of the face (on the cheeks), pahova region, flexion surfaces of the limbs, as well as side portions of the body.

At the same time, in the area of \u200b\u200belbow folds, under the arms, as well as under the knees, the rash is thickened, forming dark red stripes (this is called the symptom of grazing). In a plot, called the "nasolabial triangle", there is no rash with scarletin, and the skin of this part of the face will be pale (so manifests as a symptom of Filatov).

Rash begins to disappear on 3-7 days of illness

The nasolabial triangle with scarletin is not covered with a rash, but on the contrary, it becomes pale

If we moderately press the rash with a scarlet pan, the painting of the specks becomes clearer, but with a strong pressure, the rash disappears with the palm, and the skin looks yellowish (such a manifestation is called the "symptom of the palm"). To the touch, the skin of the baby with a rash is similar to the sandpaper.

After 3-7 days after the appearance, the rash begins to disappear, leaving behind the peeling. The peeling is especially pronounced in the hands - the skin is removed from the fingertips with large areas, like gloves. Pigmentation after such a rash does not remain.

When rash passes, the skin of the child begins to peel and climb

As angina manifests itself

Streptococcus's nasopharmal mucous membranes is settled on almonds and begins to distinguish toxin, which is the cause of the sore throat during scarletin. The child's throat acquires a bright red color (due to the strong inflammation, such a picture is called "flaming zev"), and the almonds are covered with a purulent raid.

Here are some photos of the throat with Scarletin in a child:

Almonds with scarletin acquire a purulent raid

The throat with scarletine becomes bright red

How much temperature is held

Fever is one of the most frequent symptoms initial stage Scarletins.The temperature rises sharply up to 38-40 ° C. In some children, due to such a rise, the appearance of febrile cramps is noted. The temperature decline in most children is celebrated from the third-fifth day of the disease.

Severing disease

Depending on the age, the state of immunity and clinical picture Scarlalat has a child:

• Easy.Symptoms of intoxication at such a course are expressed weakly, the fever does not exceed + 38.5 ° C, almonds can be without a raid, and rashes are less bright and abundant. A light form proceeds faster - by the fourth-fifth day the temperature is normalized and all sharp symptoms disappear. Nowadays, such a form in children is diagnosed more often than others.
• Mediterrianis.The disease begins acutely, the temperature rises to + 40 ° C, the child complains of headaches, weakness, it will notice vomiting, rapid pulse. The rash with this form is quite abundant, its painting is bright, and zev and almonds are covered with a purulent raid. The decrease in temperature and the disappearance of sharp symptoms are celebrated by the seventh-eighth day of the disease.
• Heavy.At this time, such a form is rarely developed. Because of the pronounced intoxication, such scarletin is called septic or toxic. In addition, the heavy form of scarletins is necrotic if the child begins necrotic inflammation of the tonsils, and lymph nodes are also inflamed. With severe forms of children, they necessarily have been hospitalized.

Scarlatina in a child can be in lightweight, heavy and medium-hard form

Nepiypical Scarlatina

In some kids, the infection proceeds atypically (a hidden form develops). Doctors distinguish such scarlet forms in addition to typical:

• Eludy.With it, intoxication is expressed weakly, the angina is catarrhal, and the rash is pale, scarce and quickly disappears.
• Extrabic.With such scarlet, streptococci fall into the children's body through the affected skin.
• Scarlatin without rash.With such an infection, all the symptoms of the scarletin are present, but there are no rashes on the skin.

How many times they are sick

In most cases, after transferred scarletin, the person develops immunity to the erythrotoxin produced streptococci, so children often get such an infection once in life. However, although it is very rare, but there are occasions of repeated disease.

Most often, scarletina is just once in life

The transfer of antitoxic immunity from the scarletina of the mother's mother after birth causes the rarity of scarlet tribes in newborns. The child for six months after childbirth is protected from such an infection with maternal immunity.

Treatment

Most children with scarletin are assigned treatment at home.Hospitalization is required only in severe form or the emergence of complications, as well as in some other situations (for example, if a child fell out of the boarding school or in a family of a fallen child, there are persons who work with children, and they cannot be isolated).

Mode

Before the moment when the temperature decreases, the child must be in bed.In addition, in an acute phase, it is important to stick to the diet and enhance the drinking mode. Food is given in a semi-liquid or liquid form, and protein products limit. Drinking a sick-free child should a lot. It is best to give warm drink, such as tea.

Drug therapy

Medicase treatment of scarletins will certainly include antibiotics.Often, children are prescribed preparations of a penicillin row in a tablet form or in syrup, for example, amoxicillin, augmentin, amoxiclav, retarpen. The duration of use and dosage is determined by the doctor, but usually the course of antibiotic therapy lasts 7-10 days.

Additionally, the child gives vitamin preparations and antiallergic agents, and if the intoxication is expressed, infusion therapy is recommended (glucose and other drugs are introduced intravenously). For rinsing, the throat is used infusion of chamomile, a solution of furacin, a solution of soda, infusion of calendula and other antiseptics.

With scarletin, children are definitely prescribed antibiotics

Homeopathy I. folk remedies Can be used in the treatment of scarletna as auxiliary methods, but only after consulting a doctor.

Can I bathe a baby

Washing during scarletin is not prohibited. On the contrary, children should be bathed, as it will reduce the skin of the skin and will be the prevention of raschers.However, it is important to comply with some rules:

• Water in the bath should not be too hot or very cool.
• If a child has a fever, a bath is replaced by wiping.
• Skin should not rub with a washcloth or sponge.
• To wash off soap foam instead of the shower, it is better to dangle from the bucket.
• After swimming, wipe the child's towel is not advised. It is better to get water, wrapping the baby in a sheet or a diaper.

Complications

The risk of complications is significantly reduced by timely antibiotic therapy. In the development of lesions of the heart, joints and kidneys, the sensitization of the child's body is of great importance (its increased allergic sensitivity to erythrotoxin) is of great importance.

Opinion Komarovsky

Famous pediatrician quite often came across Scarletina in his practice. Komarovsky focuses on parents on such nuances:

• Streptococci have high sensitivity to penicillin antibiotics, so after several doses of the drug, the condition of the kids with scarletin is clearly improved.
• If the child has the intolerance of Penicillin, it will not be a problem either, since streptococci is sensitive and to many other antimicrobial drugs.
• Scarlatin can be called a disease in which the timely appointment of antibiotics provides promotional outcome. If such an infection is not treated, possible heavy complications (kidney and heart lesions).
• The treatment cannot be stopped as soon as the child has improved. It is important to finish the course of the antimicrobial preparation appointed by the doctor.
• Due to the timely appointment of antimicrobial agents, the streptococci is dying in children's body Very quickly, and immunity to their toxins do not have time to work out. This is the cause of repeated diseases that, according to Komarovsky, proceed easier than the first infection.
• Streptococcus can penetrate the child's body not only through the throat. There are cases of infection through wounds on the skin. At the same time, the child arises all signs of scarletins (there will not be only an angina). The treatment is prescribed the same as in conventional scarlet.
• A child who had to pass the scarletina, for some time after the disease should not be contacted with other people, since the reinstalling streptococcus threatens allergies and other complications. Komarovsky recommends starting to attend school or kindergarten after scarletna no earlier than in 3 weeks.

Light forms and most of the medium-wing forms of scarletin in children are safely treated at home. Kids isolate for 10 days, after which, with satisfactory condition, it is allowed to walk.

Effects

At the present time, the forecast for a child, sick scarletina, in most cases favorable.When the child recovered, it is important to monitor his well-being in order to identify possible complications in a timely manner. Close attention should be paid to the color of urine (it changes with kidney damage, becoming similar to "meat salts") and complaints of pain in the joints.

Doctors must control the status after scarletin in medium-wing or severe form within one month. If 3 weeks after recovery, the examination of the child, blood tests and urine do not show deviations, dispensary observation stop. Having revealed to the child who had a scarletary child, any alarming symptoms, he was sent to an inspection to a nephrologist or rheumatologist.

Prevention

It is known that vaccines protecting against scarletin does not exist. Protect the infection of children and adults who did not hurt earlier, can be measurable:

• To prevent infection of family members, in a room where a pretty child stays, it is important to carry out regular ventilation and wet cleaning.
• Care for a child with scarletin should be engaged in one person who is recommended to use specially selected clothes and a gauze mask.
• A sick child should be selected a separate towel, its dishes, a handkerchief, toys and other items that healthy family members should not be contacted.

If the child contacted a sick scarlet man and did not earlier with such an infection, it should be isolated from the children's team for 7 days. After a week of staying at home, such a child may return to school (it's about primary grades) or in kindergarten.

• Symptoms and treatment

Among the contact infectious diseases of Scarlatina in children occupies one of the leading places in the frequency of cases and severity of the symptoms issued. It is an intense form of damage to certain strains of streptococci and is a danger in terms of the development of rheumatoid manifestations against connective tissue. Quite often, with improper treatment, the development of arthritis, tonsillites and heart valves vices are observed.

Distinctive features - acute defeat of almonds with subsequent skin manifestations in the form of a finely purified rash of generalized character. A few days later, the peeling of the skin begins.

Causes of Disease Children's Scarlatina: How the pathogen is transmitted, the incubation period

Children's scarladine is a contact and very infectious infection that can be transmitted by air-droplet. Scarlatina's disease basically arises in the cold season, the peak of morbidity falls for October - November and February-April. At this time of the year, the child's body is most susceptible to various agents and there is a big crowding of children in children's preschool and school institutions. It provokes an increase in the risk of infection.

The causative agent of scarletins belongs to the group of hemolytic streptococcus, distinctive feature - A-shaped structure of the DNA molecule, which allows you to quickly spread throughout the body. More than 50 strains of this pathogen are known, all of them are extremely dangerous both for the cells of the mucous membranes of the upper respiratory tract, and for the immune system. This microbial group can cause sharp purulent processes of the upper respiratory tract, lymphatic system, apparent sinuses of the nose and middle ear. Therefore, complications often arise in the form of otitis of the middle ear, plug abscesses, front and sinusitis. For a long time, regional lymphadenitis remains (submandibular and cervical groups of lymph nodes are inflated).

The scarlet causative agent perfectly adapts to adverse environmental conditions. It can be kept in a frozen state for a long time, when heated, it does not lose adaptation properties for a long time, can save its virulence in the dried form. Disinfectants, boiling and ultraviolet rays are destructive for him.

The main danger to the human body is the production of streptococcus two species of specific toxins. The first one has the ability to destroy blood cells, mucous membranes and epithelium. The second toxin is a powerful allergen that can change the immunological status of the patient, causing autoimmune processes, which are subsequently difficult to correction. Lithic enzymes are actively producing, which are able to destroy almost all the fabrics of the human body, including hyalurone cartilage and muscle fibers. Therefore, complications may arise in the area of \u200b\u200bthe musculoskeletal system and the cardiovascular system.

It is also worth understanding how Scarlatina is transmitted from the patient to healthy person. The main path of infection is air-drip and contact. The pathogen is highlighted in the environment with sputum, mucus. Infectivity reaches a maximum in the first hours after the appearance typical symptoms. The food route of infection is often found in children's preschool institutions. The contact domestic path is possible if the rules of personal hygiene and isolation of the sick child.

The children aged from 2 to 10 years old are most susceptible to infection. In the first 12 months of life there is congenital immunity to this pathogen, so cases of infection are extremely rare.

The incubation period of scarletna ranges from 12 hours to 7 days. During this period, streptococcal on the lymphatic and blood system, active reproduction and the beginning of the products of specific toxins occur.

The main causes of scarletins are in the absence of specific immunity and weakening the body due to frequently and long cycling diseases. Also plays a role to comply with the rules of personal hygiene and preventing the spread of infection in children's preschool groups.

The first signs and symptoms of scarletin in children: photo - what a rash looks like

Scarlatina in children may occur suddenly, against the background of visible common well-being. Symptoms of scarletins are developing gradually, starting with inflammatory reactions at the entrance gate of infection. Symptoms of scarletin in children until the skin of the skin can resemble a clinical picture of angina or tonsillitis.

Signs of scarletins include throat pain, a sharp increase in body temperature to extremely high numbers, an increase, sealing and soreness of submandibular lymph nodes. The child becomes sluggish, capricious, refuses to eat food, complains of severe headache and lobs in large muscles. Spontaneous pain in the heart can occur. Signs of scarletins in children include the rapid appearance of small dotted rash saturated red. It usually occurs 12-24 hours after an increase in body temperature. Therefore, confuse the first signs of scarletins with others inflammatory diseases quite difficult.

On the pictures shown, it is great that Scarlalat looks like in children, but it is worth paying attention to other components of the triad symptoms - hyperthermia and an increase in regional lymph nodes.

Below are still photos of scarletins in children for more visual information on this issue:

When examining the patient, a bright hyperemia of the language is visible with a pronounced age of almonds on both sides and the presence of petechs common throughout the upper side. After 12 hours, lacunar develops purulent form bilateral angina, which can quickly go to the necrotic phase with rejection large number pus. The language is covered with a dense whitish tap, which is easily removed. However, after 48 hours, the color of the papillas of the tongue becomes a saturated raspberry shade, which is another a characteristic symptom Scarletins in children.

Specific rash, which appears totally throughout the body in the first 48 hours from the moment of the disease, deserves special attention. The greatest concentration of point rash elements is achieved in the elbow bends, in the area of \u200b\u200bgroin and the inner surface of the hips, from the sides chest And along the white belly line. At palpation, inflamed skin epidermis nipples are felt, which gives skin cover with light roughness. When trying to stretch the skin, the rash disappears, but after 10 - 20 seconds it appears again.

What do these symptoms of scarletin look like in the photo, you can see further:

When examining the doctor should pay attention to the state skin Pokrov Persons. With scarletin, children stand out triangle around the mouth and below the nose. Usually it has a wax white color and is not affected by phetechial rash.

Skin rash lasts 4-5 days, then its color changes, and gradually it disappears. Peeling can be preserved, which gives itching. Cooks are visible. All scarlet symptoms reach their peak on the 3rd day of the disease, then the gradual reverse development begins: the body temperature is reduced, the soreness of lymph nodes decreases, the number of point elements is reduced.

Could there be a disease of scarletin re-: diagnostics in children

Repeated Scarlatina in children is relatively rare. Can there be a re-infection, it largely depends on the developed immunity. In some cases, with incorrectly prescribed treatment, streptococcus carriage can be formed. Against this phenomenon, the symptoms may occur periodically.

The diagnosis of scarletin in children is primarily based on the patient's visual inspection data and comparing the symptoms of the clinical picture. In difficult cases, a serological test can be carried out, overlooking the mucus from the rotogling. The mandatory event is a stroke of a zoo to eliminate the attachment of diphtheria infection. This is especially true of children under the age of 5 years.

A general blood test is also carried out, in which there is a moderate leukocytosis and an increase in the rate of sedimentation of red blood cells. An neutrophilic shift of the formula to the left may be observed due to the increase in the body's allergic wall.

Scarlatina disease often gives complications on the heart, so during the recovery period it is desirable to conduct an ECG study that allows the development of valve vices on early stage. Also, changes in the electrocardiogram may indicate the presence of rheumatic myocarditis.

Requires careful differential diagnosis To eliminate cases of the disease and the Pader. Corey typical phenomena are cough with sputum release and the strongest sinusitis from the initial stage of the disease. During the rubella, there is an increase and painfulness of cervical lymph nodes. The Pader can be characterized by the lack of increasing body temperature and the rapid tendency to open the skin bubbles with subsequent suppuration.

Possible complications and consequences of scarletins in children

Among possible complications Scarlants in children most often marked rheumatism and the development of heart valve vices. But recently, due to the use of modern groups of antibiotics, complications are developing very rarely and only in cases of absence of adequate and timely therapy.

The consequences of scarletins in the form of a change in immunological and allergic status can manifest itself several months and even years. The toxin distinguished by the pathogen provokes the development of the deformation of the genome responsible for the response allergic and autoimmune response to the introduction of alien protein. Allergies can be provoked by any trigger that most often affects the child's body. Other manifestations of autoimmune violations may be hidden for the destruction of cartilage and connective tissue, chronic pancreatitis and thyroiditis. It is less likely to develop glomerulonephritis and toxic hepatitis.

In the short term can develop purulent otiti Middle ear, etmoiditis, frontitles and other forms of sinusitis. Pneumonia and bronchitis are relatively rare complications. More often purulent angina With the development of cap abscesses. Myocarditis occurs about 5% of sick children. Rheumatoid polyarthritis May develop for 2 - 3 months.

How to treat scarlatin in children with antibiotics?

Before treating Scarlacin in children, careful differential diagnosis is carried out. This is necessary because for adequate therapy it will require the purpose of various groups of antibacterial and antimicrobial drugs. During rubella and measles these medicinal products not used.

Further reviewed how to treat Scarlatin at home, since hospitalization may be required only with severe forms of infection and the availability of signs of developing formidable complications. Most often therapy is carried out at home with a patient insulation from other households.

A strict bed mode is assigned at least 7 days. Reasonable drinking is recommended. Drinking mode is enhanced to 3 liters of fluid per day. The reception of antihistamine drugs is required: "Supratin" with 200 mg 2 times a day, "diazoline", "ketotifen", "Pipolfen" and a number of other means. Vitamins of groups C, A, E. It is advisable to appreciate the calcium gluconate and "ascorutin" in order to strengthen the vascular wall and preventing generalized development of phetechial rashes.

Scarletna treatment with antibiotics is shown - drugs are prescribed as early as possible, immediately after identifying a typical triad symptoms. Preference is given to the drug with wide spectrum actions. This may be "amoxicillin" 250 mg 3 times a day (doha is calculated based on the weight and age of the baby). Also used "Azitral", "Azitromycin", "Erythromycin", "Sumamed", "Ciprofloxacin", "Ampioks", "Digger" and "Cefalexin". If necessary, the action of antibiotics for the treatment of scarletin is intensified by antimicrobial drugs. This may be "Biseptol-240" 1 tablet 3 times a day, Metronidazole, Trichopol 125 mg 3 times a day. (Dosages are children, designed for the age of the child up to 10 years).

To prevent the development of complications in the form of rheumatism, myocarditis and connecting tissue lesions, a course of non-steroidal anti-inflammatory drugs is required. Most often an acetylsalicylic acid is 500 mg 3 times a day for 10 days. This drug is known as "aspirin" and helps to reduce body temperature, remove pain syndrome.

Stripping of the throat with solutions "Furatcilina" or soda solutions can be used pile of pharmaceutical chamomile. Also, Powder "Strepsid" can also be used - it effectively affects this type of pathogenic microflora in the field of almonds and the upper heaven. It is possible to treat with a solution of "Lugol".

For skin treatment during rash, you can use "diamond green", powders, antihistamine ointmentwhich remove itching and prevent the rejection of the secondary microbial infection by the appearance of combs.

Standards of the prevention and treatment of scarletin in children

Scarletin treatment is carried out only with antibiotics, without these drugs, the risk of secondary complications in the short-term and long-term perspective is high. Exist medical standardsFor which Scarlantine treatment is carried out in young children. First of all, the emphasis is done on the prevention of various complications and consequences. This requires a technique of non-steroidal anti-inflammatory drugs.

Prevention and treatment of scarletins in children walk "hand in hand", since only with the help of preventive measures can be prevented by the distribution of infection in the children's team and localize the focus. In this regard, from the first days of the disease, an emergency isolation of a patient child is carried out. A quarantine regime is included in the children's preschool institution, during which the health of children in contact with the patient is paid to maximum attention. When the first signs appear again, the sick isolate.

At home, it is necessary to highlight a child with a scarletina of a separate room with an active ventilation system. It is advisable to spend in the morning and in the evening wet cleaning with use disinfectants. It is also desirable to ensure the quartzing of the room 3 times a day. Individual dishes and hygiene products are allocated, which after use are soaked in a 10% solution of chlorine lime at least 30 minutes

Specific scarlet prophylaxis in children is not provided with vaccination. In special cases, emergency prevention can be used with the introduction of gammaglobulins. Usually this technique is used in weakened children who in contact with an infected person. Held this procedure Until the occurrence of specific symptoms.

The main emphasis in the prevention of scarletins in children is made on compliance with the rules of the sanitary and epidemiological regime in the face of children's preschool institutions.

Compliance with the rules of personal hygiene is the basic basis for the active prevention of this infection. It is also important to pay maximum attention to strengthening the protective forces of the body. To prevent the risk of influenza disease, it is necessary to use vaccination capabilities. Hardening, consumption vitamin complexes. Important It has zinc content in the food diet.

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According to statistical data, 80% of scarlet diagnoses are delivered to patients under the age of 10. And the kids up to the year are outside the risk group, cases of infant infections are practically not found. In adults, such a disease is rarely developed: for example, those who are in contact with the patients have a weakened immunity, autoimmune violations. Therefore, the disease is often mistakenly considered exclusively "children's".

The causative agent of scarletin is hemolytic streptococcus, actively developing when penetrating the body. Erythrotoxins are produced that quickly multiply. These microorganisms cause acute inflammatory processes of the lymphatic system, upper respiratory tract. This group of streptococci is resistant to temperature drops, does not die outdoors. Only ultraviolet, boiling or pharmacy antiseptics can destroy them.

Bacteria produce two types of toxins, one of which causes a mutation of blood cells and destroys the mucous membranes, and the second - gives the strongest allergic reactions, provoking autoimmune processes. If a child or adult does not receive adequate treatment, complications in the area of \u200b\u200bthe musculoskeletal system or impaired heart and blood vessels will begin with a large proportion.

Signs of scarletins are manifested only after incubation periodwhich will be from 3 days before the week:

• The most common airfield of the dissemination of infection remains.
• A contact-household option is possible- after the patient's care is a reasonable step will be sobbing hands and household items.
• Sometimes the alimentary method is relevant: for example, the use of infected food, drinking.

Scarlatina is a seasonal disease with a peak at the end of autumn. Earlier it was believed that all people who have had this disease are produced by specific antibodies, there is no re-infection. Modern medicine There is also other data: during autoimmune pathologies, relapses are possible, although such cases constitute only 10 and less percent of total Sick. Signs of scarletna in adults most often lubricated, rarely can be stormy, but the sick in the first hours of beginner attendant.

Scarlatina: Legend Stages of Starting Disease

Doctors allocate several stages of the appearance of scarlet signs:

• The sluggish incubation period, which averages 3 days, but in some cases It can last only 1 day or a whole week. This difference is due to the characteristics of the body of each child or adult. During this time, it often happens increased fatigue, drowsiness.
• Starting stage: manifestation of the first symptoms of the disease. Most often that general signs ORVI: Temperature, chills, lubrication in the muscles and joints, complaints of pain in the throat, an increase in the lymph nodes of the sub-surround region.
• ACTIVE PERIOD: Rapid spread of rash for skin cover. At the same time, purulent alarms with the presence of a large amount of exudate are rapidly developing with the achees. The inflammation of the almonds is accompanied by regional lymphadenitis.

In the language, it is originally observed easily with a white flare, and after a couple of days its surface becomes raspberry. This color does not leave for 10-14 days. Next, with appropriate treatment, signs of signs and complete recovery should be "attenuation".

At the very beginning of the disease, the final diagnosis is rare. Usually, Scarlacin directly indicates such a symptom as a characteristic rash. But in some cases, doctors pay attention to other deaths.

Can scarletta flow without rashes? Signs of atypical disease

Scarlatina in adults or in children in particularly serious cases can flow with a small amount of rashes or at all without them. Septic, toxic shapes assume the presence of small point manifestations on the skin folds, face or neck, and erased - and it flows into the lubricant: the rashes quickly disappear or virtually invisible. The rash can be pale and localized in one or two places, the peeling in such cases is delayed.

Scarlatina without rashes is determined by the general state of the almonds and the language, the lymph nodes are given only small changes in lymph nodes during the first night. It is only a challenge, and then color of the tongue and moderate pain in the throat. This form of the disease is not diagnosed immediately, the patient does not always appeal to the doctor in time. Therefore, at similar course, scarletins are more common complications: up to 20% of cases are given additional pathological conditions. After the suffered scarletin, sinusitis or otitis can be exacerbated, the most complex consequences remain streptococcal sepsis and adenoflems.

In this case, a special role in the diagnosis is assigned laboratory researchSuppose to determine the pathogen, put the correct diagnosis and choose the optimal treatment regimen.

Special view of scarletna - extrafaringeal. Streptococci penetrate the body through the damage to the epithelium and mucous membranes. For this type, the presence of standard races is characterized, but the complete absence of angina signs. Such children are not dangerous for others.

Rare atypical forms of the disease are found in categories with a weak immune system. In fact, it is special view Angina, accompanied by complications in the form of allergic rash and inflammation of lymph nodes.

Symptoms of the disease at different stages, localization of rashes

The first signs of scarletin in the child are similar to the development of angina:

• Increases temperature.
• The pain in the throat is intensified.
• The child feels a common weakness, his muscular discomfort appears, complaints of headache come, fever begins.
• Allowed: nausea, tachycardia, abdominal pain.

Therefore, during this period, adults believe that a banal angina will follow and do not suspect that Scarlatina begins.

But then a seal should be sealing, an increase and pronounced soreness of submandibular lymph nodes. And by the end of the first day of the disease or on the second day appears small rash - Spot, scattered over the entire body surface. accompanied by redness of the mucous membrane, the appearance of multiple flat spotted hemorrhages - Petechius.

Signs of scarletins at each stage of the disease differ significantly. The first rash appears in the neck and on the upper third of the chest. The cheeks become pink, and lips - swelling. The nasolabial triangle against the background of the general reddish shade of the skin on his face looks particularly pale - there is no rash on it.

The rash is then applied throughout the skin. They are especially intense on elbow bends, under the knee, in other folds of the skin. It is also characterized by the localization of rashes on the sides of the chest, along the light lines of the abdomen. Tasp skin seems rough. If you spend your finger on pink stains, a fake line will appear for a few seconds, when stretching the skin, the rash "disappears", but after a moment it appears again. Usually, the rash holds 3-5 days, then pale and disappears. The skin begins to peel, on the hands of the hands and the surface of the stop, it peers especially intensively for several weeks.

Signs of scarletins in children are always pronounced brighter than adults. And rash covers most of the body and limbs. The points are very small and cover extensive areas of the skin, so from afar and in the photo may seem like the usual reddish stains. Since the disease is accompanied by essential irritation of the epidermis, it is possible to pronounced itching. To remove discomfort doctors prescribe antihistamines.

Diagnosis and treatment

The developing scarlet signs require laboratory clarification. The doctor necessarily appoints a stroke from the Zew and a general blood test. In the blood noted elevated ESP, leukocytosis, standard shift leukocyte formula Left: neutrophils not only in more quantities, but also presented by a number of immature cells.

In the blood serum there is anti-estreptolysin about - a special antibody, able to fight the virus causing scarletin. Such an analysis is needed in order to make sure the streptococcal infection.

Scarlatina is treated at home under the supervision of the doctor. But in some cases, hospitalization is obligatory: children from risk group are sent to the infectious department - with cardiopathy, other somatic diseases, as well as kids from families with children under 11, who have not previously suffered another disease.

In the usual course of the disease, children are recommended for the period acute form - From 7 to 10 days. Be sure to increase the consumption of warm liquid, it is possible if necessary to drink antipyretic suspensions or tablets, you can use rectal candles with similar components.

Symptomatic treatment is to rinse the throat with chamomile hacks - chamomile, sage or antiseptics - furaticiline solutions, chloromexedin. For the treatment of kids, you can apply aerosols: inhalipt, hexoral, "ambulance" balm.

With scarletin, it is necessary to assign antibacterial drugs. This will help to avoid the severe course of the disease and the development of complications. Traditionally, the penicillin group is traditionally effective - for example, phenoxyethylpenicillin or cephalosporins. If these drugs are unacceptable, medications are prescribed with active substance azithromycin. The recommended course of treatment depends on the severity of the disease, but is usually 10 days.

Auxiliary drugs - antihistaminesallowing you to reduce discomfort, remove the swelling and stop the acute body reactions to the cocci, remove the stormy signs.

After the disease, quarantine is withstanding - usually 12 days, and only after that the child is allowed to attend kindergarten or school. If in the children's group turned out to be sick, then the regime restrictions are valid for the week until the possible incubation period is over.

There are many diseases of infectious nature provoking the appearance of a rash on the skin in a child. One of them is with kartina in children. Symptoms and treatment, prevention, photosigns of the disease - these items that will be discussed in detail in this article.

Scarlatina: It's what is

Many parents are wondering what is Scarlatina. Scarlatina - infection Bacterial nature, which is caused by beta hemolytic streptococco Group A.. This microorganism synthesizes and emits erythrotoxic substances provoking hemolysis. To understand what disease is scarlatina, as transmittedand what methods it can be cured, it is necessary to study the causes and mechanisms of pathogenesis of the disease.

Scarlatina, like many infectious diseases ( , pig, windmill) is transmitted by air droplet, although each of the listed pathologies - viral infection , and Scarlatina - bacterial. This is a very disease contagiousand has a number of other paths of infection - alimentary, contact and water - but they are extremely rare.

Pathogenic streptococcus provokes not only scarletin, but also a number of other pathologies, namely: pyodermia, angina, intestinal infections, "silent inflammation. Scarlatina when infected with streptococcus develops in the absence of immunity to erythrotoxic substances produced by a microorganism. In most people in adolescence, such immunity has already been formed due to other streptococcal pathologies, the immunity is also transferred to the transplascentary from the mother to the fetus, and after birth, it remains up to 2 years. According to this data, the risk of scarlet fever is highest in children of age range from 3 to 10 years.

Features of such a disease, as pathology will be discussed in detail below.

Scarletina infection is possible not only from one who is directly sick. Patients with various forms of streptococcal infections can act sources of infections, in the event that the bacterial strain refers to the toxin-commercial. It is possible to infect patients with such diseases as:

• scarlet fever;
• angina;
• erysipelas;
• streptococcal pyodermia;
• intestinal infections;
• pyelonephritis;
• pneumonia;
• naphorgitis;
• otitis.

In very rare cases, infection is possible upon contact with streptococcus carriers.

Scarlay incubation period in children and adults It lasts from 2 days to 1 week, less often - up to 10 days. Most often it lasts 3-4 days. The incubation period is a period of time from the moment of infection until the moment of the first signs of the disease. The patient becomes contagious most often the day before the start of symptoms. When identifying scarlet in kindergarten in obligatory declared quarantine.

Scarlatina is characterized by sharp, sudden beginnings - symptoms develop literally for several hours. So, as manifest This is a disease in childhood, in boys And girls? Allocate three main clinical manifestations that have scarlatina, - Signs Inxication, angina and rash.

- This is what can be found in this and the subsequent sections of the article.

Intoxication

Among its manifestations are the following:

• an increase in temperature above 39 degrees;
• drowsiness and lethargy;
• permanent nausea, periodic vomiting;
• abdominal pain;
• headaches.

Angina

With scarletin, symptoms of the involvement of respiratory tract arise into an infectious-inflammatory process. First, the manifestations are catarp - there is no plaque on the almonds.

An important symptom this disease It is the so-called "flaming zev": when inspection of the patient's throat, a bright, limited hyperemia of a soft sky, almonds, tongues and pagan meek are noted. These structural formations become rich red. Such symptoms arise in children, Photoclinical manifestations reflect the severity of the inflammatory process.

The child may make complaints on the pain in the throat area, and the painful syndrome may have different intensity - from easy turning time to severe pain. Children becomes difficult to swallow, often they refuse food meals.

With the further progression of the process, especially in case of neglecting therapy measures, the catarrhal manifestations are replaced by lacunar (there is a raid on almonds), follicular (the formation of purulent traffic jams and bubbles), necrotic (the formation of necroca foci with a variety of shade).

Also, as the disease progresses, inflammation of regional lymph nodes is developing, changes in language tissues are observed. The surface of the tongue is covered with a whitish bloom, and increased nipples of a bright pink shade are visible through it.

After 2 days after the start of the symptoms, the language becomes bright red,

this sign is also called the "raspberry language".

Sweeping on the skin

Rash in a child Appears a few hours after the incubation period is completed. First appear ,

The brightest and vast rashes appear on the most tender skin - inguinal, pond, axillary, elbow folds, leather on the neck and in the pubic area. At these places, the rash is the most thick. With a scarletin of a pinkish or bright red shade, finely melted.

Less often arises hemorrhagic rash, more often observed in the form of brown or crimped points. Hemorrhagic rashes are often merged, while the bands are formed, which remain even after the rash passes.

Skin covers with rashes become dry and rough. For the face of the child is characterized by swelling, red cheeks, cherry lips, pale nasolabial triangle.

Rash on the face, body and limbs in some cases pass after hours, but more often persist within a few days. After falling, the skin covers are peeling - on the body it is a bison, and on the limbs - a large-pointed one.

The answer to the question, scarletten itches or not, is positive. It is characterized by a temperate intensity.

Of course, more often Scarlatina is developing in childhood, but this disease can hit the adult. Scarlatina in children, symptoms and treatment, prevention, photo pathology is extremely important, but also in adult patients is possible heavy flow Diseases. Clinical symptoms It is implicitly expressed, since the immune system is struggling with an infectious agent, and a person may not distinguish scarletin from the usual ARVI. In some cases, Scarlatina in adults has more pronounced symptoms, initial stageit is characterized by a difficult flow.

Select a number of clinical manifestations of the disease in adult patients:

• Light form: Easy zea hyperemia, which can be noted on photo of the throat, soreness, symptoms of intoxication. Pale rash appears, but not in all cases. In this way, the answer to the question, Scarlatina happens without rash, is affirmative.
• Heavy form: temperature rise, chills, pulse. Characteristic symptoms of intoxication: nausea and vomiting. Appears in the first days of the disease, simultaneously with pain and redness in the throat. Reflects the brightness of the severe form of the disease. As progressing is possible complications in the form of otitis, abscesses in the pharyngeal region, hemorrhage into various internal organs. At a later time, rheumatism, myocarditis, glomerulonephritis is possible.

Scarlatina in adulthood also provokes dryness and peeling of skin. Treatment of this disease will be discussed in more detail below.

Quite often arises scarlatina in children, symptoms and treatment, prevention, photo- This is what the doctor must familiarize with the parents. Therapeutic scarlet correction measures will appoint a specialist only after examining the patient. In severe cases, inpatient treatment is possible, but usually Scarlatina is quite fast treated at home.

During treatment, it is important to comply with the following measures:

1. Correct care Behind the patient. Bed regime and restriction of activity is needed even after a sickness of the first manifestations of the disease. It is necessary to regularly air the premises, carry out wet cleaning. You need to change both bed and underwear in a timely manner, giving the benefits to natural materials.
2. Correction diet. Suggests abundant drink, you can give a patient tea, warm milk, compotes, fruits, mineral water. When the appetite decreases, it is not necessary to insist on meals: such a reaction is a reflection of the intricaciation of the body. Gradually, in the diet, you can enter soups, mashed potatoes, porridges, vegetable stew. All products should easily be used and be nutritious. Due to the throat pain, it is recommended to serve food in a semi-liquid or liquid form so that the patient is easier to swallow. Need to limit salty, sharp dishes. Additionally, you can enter vitamin and mineral complexes.
3. Medical correction with the help of antibiotics. It is impossible to cure scarletin without antibioticsWhich other tablets or ways. Antibacterial therapy is a mandatory measure. Antibiotic drugs The doctor appoints, in treatment, it is necessary to strictly adhere to its recommendations regarding the dosage, the multiplicity of reception and the duration of the course therapy. Amoxicillin-based drugs are prescribed more often ( Flexin-Solutab, Amoxiclav, Ampisid and a number of others). Perhaps the appointment of macrolides ( azithromycin, macropen, josamicine). Cefalospierine antibiotics are relatively rarely prescribed.
4. Antipyretic means. For 12 years, these medicines are suitable for 12 years as Calpol, Panadol, Nurofen Children. For senior patients school age Conducted treatment nimesulide, aspirin. The most efficient use of antipyretic drugs in the form of candles, after a period of intoxication, it is possible to give syrups or tablets to children. You can bring down the temperature and other methods: abundant drinking tea with raspberry, cranberry or currant sea, wiping.
5. Horn Medicines. For this purpose, local antiseptics are well suited, only before use you need to consider age restrictions. The most effective preparations: Hexoral, Inhalipt, Stop Angry, Tantuum Verde, Kameton. It is also useful to rinse the throat of herbal decoctions, a solution of furaciline. It is possible to eliminate symptoms using tablets for resorption.

By the end of the first week of pathology and children, and adults are already unsuccessful for others. But still the extract is possible on only 21 days after the start active phase Diseases. Such a duration of the home regime is explained by the high risk of complications for the organism weakened after the scarletna. If the child is in kindergarten earlier, then after contact with children it is possible to attach a secondary infection and a significant deterioration in the state of the kid.

For the prevention of scarlet infection, any specific measures are not developed, that is, there is no vaccine vaccinations. To prevent infection, it is important to limit contact with patients who have identified streptococcal infection. It should also be strengthened with immunity, hardened, take immunomodulators.

In the treatment and prevention of scarletin, it is important to strictly follow the appointments and recommendations of the doctor, to comply with all prescriptions and dosages of drugs. It is not necessary to deal with self-medication: it can aggravate the condition and provoke very difficult complications that all organism systems are exposed. The price of health and child, and an adult is very high, and should not once again expose themselves to such a big risk.

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Scarlatina is a highly disabilities of an infectious disease that can affect people of any age, but children of 2-10 years old are most often suffering from him. The main causative agent of this disease is streptococcus, and the source of infection is always a sick person. Children usually carry Scarlatin much harder adult patients. In their environment, the disease extends very quickly and can take the nature of the epidemic.

Causes of scarlet development

The causative agent of the disease is toxic hemolytic streptococcus group A. He is able to produce very toxic substanceswhich penetrating the bloodstream have a pronounced negative effect on the entire human body. So develops strong intoxication. It should also be borne in mind that this pathogen can be carried out not only to scarletna, but also other diseases: for example, there are corrosive inflammation or rheumatism.

A disease is caused by a toxic hemolytic streptococcus group A

Previously, scientists have attempted to bind some viruses to develop this disease, but they were not crowned with success, and the cause of the disease was recognized yet Streptococcus. But it is necessary to remember that it is often encountered by his asymptomatic carriage, which does not require treatment. In the sick concentration of this bacterium in the blood, in the urine, as well as in strokes with almonds, much exceeds the indicators of healthy people.

How is infection?

The most dangerous in terms of infection for the child is contact with a sick person in the acute period of the disease. In this case, it can be infected with air-droplet, even with a conventional conversation. But it is possible to pick up hemolytic streptococcus, not only from the acute patient, but also at any stage of the development of the disease. Patients with structures or asymptomatic forms of disease are sufficiently dangerous for others. Approximately two thirds of the sick scarlet fell that way.

Scarlatina is known to humanity for more than 400 years: for the first time it was described by 1554th year, and in the 1675th she received its name that comes from Italian Scarlatto - a crimson or purple.

The pathogen of this disease is usually highlighted in the mucus of the oral cavity and nasopharynx and spread through the air during cough or sneezing. Scarlantine transmission from healthy carriers of this microorganism was not fixed. It is also not proven to today the possibility of infection through household items. In external environment Hemolytic streptococcus cannot exist and dies very quickly.

You can get infected with scarletin only from a sick person

Scarlatina refers to infections that can be sick with only once in life, since after recovery, resistant immunity remains. It can be formed as after acute diseases and after frequent repeated contacts with the causative agent, which will not lead to the appearance of symptoms.

Usually, after suffering the scarletin, the body produces antibodies to toxic substances released by hemolytic streptococcus, and not to the microorganis itself.
Although most people have a lifetime immunity after this disease, approximately 1-1.5% of all patients are reheated.

Symptoms of scarletins

Symptoms of the disease is usually caused by septic and toxic factors. The first lead to local affection and appear in the form of an angina, otitis, lymphadenitis. Toxic factors cause an increase in temperature, headache, vomiting and characteristic rash.

Complications after transferred disease can manifest themselves after a while after complete recovery, so it is very important to follow the well-being of a child, the color of his urine and pay attention to possible appearance Bolshes in joints.

The incubation period during scarletine lasts 2-5 days, and at this time the patient's condition does not change. And the disease is usually beginning with a sharp and sudden rise in temperature, headaches, vomiting and throat pain. At the same time, it can be noted that the patient's zev sharply hypertized. This condition is called still burning zev. On the almond surfaces, you can see the protruding follicles, and the red dots are noticeable on the soft nose, the red dots walls, which disappear during the transition to a solid palate. The cervical lymph nodes increase, become painful.

The main symptom of scarletins - characteristic rash

Scarletin has a very characteristic. At first it is covered with dense raid, and the edges become bright red, the nipples swell themselves - this is called white crimson. A few days later, it is gradually cleaned of the fall and acquires a red color similar to a shade of fresh raw beef - this condition is called the raspberry.

After about 24-28 hours, the field appearance of the first signs of the patient is covered with a rash in the form of small red dots located very thickly. If you have looked published, then the examtum during scarletin merges into a solid red stain. First, the rash appears on the neck, chest and stomach, then it spreads throughout the body. Only the nasolabial triangle remains pale. In the elbow, inguinal and other natural folds of the skin, the rash acquires a dark red color. In these places, it remains longer.

Scarlatina - Symptoms, Treatment and Prevention

When pressing the rash disappears, and at the same time the skin subcomes appears. The symptom of RUME-LEEDE with a scarlet examine is positive, as the capillaries of the skin are damaged.
After 3-4 days after the appearance of the rash, it begins to gradually fade. She disappears in the same sequence as it appeared. In the second week, a plate peeling appears characteristic of this disease. It happens noticeable to 4-5 weeks. Sometimes the excanthema is manifested in the form of miliary or hemorrhagic rash, or in papular form.

In parallel, the rest of the symptoms are beginning to disappear with the extinction of the rash. For 4-5 days the temperature drops, the overall state is improved. In the fevering period, urobiline geneuria is often found, sometimes feverish albuminuria is also there.

Special clinical forms

The compositions described above can be considered classic, but non-discontinued from it. The first week of the disease can proceed much easier or harder. Fine forms are often found quite often, which do not even fall under the supervision of doctors. In such cases, fever is insignificant, ZEV also changes rigorously. Small rash parents often simply do not notice, especially since they are not accompanied by peeling even in the absence of treatment.

Previously, in Spain, this disease was called "Garotillo" - "Iron Collar" due to swollen and painful cervical lymph nodes.

But there are much more complex situations. Toxic scarletta is a very dangerous disease, which before the appearance of antibiotics often led to fatal outcomes . Even in our time when there are effective methods The treatment of septic forms, it often leads to the death of patients. With toxic scarlet, the body temperature sharply increases, apathy, lethargy, nonsense comes, then loss of consciousness and convulsions. After that, a picture of a complete vascular shock may be taken out of which the patient is not easy.

Often when scarletina is observed white raids on almonds

Septic Scarlatina is caused by the local action of a microbe with a reduced immune response of a child. With this form of the disease, the necrotic process is developing in Zeva. Approximately on 3-4 days of the disease, it is possible to notice whiteish and then dirty gray raids on almonds. So the necrotic process is manifested, accompanied by the decay of the tissues and the ulceration of the vessel walls, which leads to bleeding. Very quickly necrosis spreads deep into the tongue, a soft palate and the walls of the pharynx.

In parallel, lymphatic nodes are strongly swell, the temperature is strongly rising. Quite quickly, the infection spreads throughout the body, causing the ear, larynx, mediastinum. Even in remotely arranged organs, metastases appeared. Before the invention of antibiotics, this disease very often led to the death of patients. But today, recovery takes many weeks.

Diagnostic methods

The clinical picture with scarletine is so bright that it is possible to diagnose with a simple examination of the patient. But to confirm its correctness will not prevent several analyzes:

• Common (clinical) blood test makes it possible to notice an increase in leukocytes, characteristic of bacterial infections, as well as an increase in ESP.
• The smear from the oV allows you to select the characteristic microflora, namely Streptococci Group A.
• Blood analysis on the definition of antibody titer to scarletin. This study is carried out several times to monitor changes in the dynamics.

Scarletna treatment in children (video)

Since this disease is caused by bacteria, the main method of treatment is the correct and timely use of antibiotics. In this situation, Penicillin analogues are usually used - for example, amoxicillin, or drugs from a group of macrolides, including azithromycin. In difficult situations, cephalosporins (ceftriaxone) are used.

To facilitate the condition of the child, disintellation must be carried out.. If it is estimated as severe or medium-sized, then intravenous infusion is recommended. In more easy situations, it is enough to organize the right drinking mode. The necessary fluid volumes determines the doctor, based on the age, weight and state of the child.

With scarletin, bedding is required for 5-6 days, if necessary, it can be extended.

Streptococcus highlights many toxins, so antihistamines are usually prescribed by patients. Only a doctor should choose them, as many anti-allergic drugs have a significant list of contraindications.

With the right timely treatment Scarlatina retreats

For high temperatures Children give non-steroidal anti-inflammatory agents, except aspirin, the use of which in pediatrics is prohibited. Most often, medications based on paracetamol or ibuprofen. When hemorrhages appear, they prescribe drugs, strengthening vessels - for example, askorutin. To facilitate the symptoms of angina, local antiseptic solutions often use.

Prevention of the disease

Unfortunately, vaccines from this disease do not exist, so the main means of prophylaxis can be considered a limitation of contacts with sick, as well as timely detection and proper use of antibiotics. It is very important to identify all the fallen and isolate them in time.

If the disease is found at the student school or other educational institution, quarantine events are held in it. Sick children are forbidden to visit the team for 22 days after infection. In addition, before returning to public life, it is important to obtain a negative bacteriological analysis for streptococcus. If the child did not pain, but he had contact with the sick, he is forbidden to attend any children's institutions for a week.