Can meningitis occur without fever. What are the symptoms of noninfectious meningitis. How is viral meningitis different from bacterial meningitis. What causes aseptic meningitis. When should you seek medical attention for suspected meningitis.

Understanding Meningitis: Types and Causes

Meningitis is an inflammation of the meninges, the protective membranes covering the brain and spinal cord. While many associate meningitis with fever, it’s crucial to understand that not all forms of meningitis present with this symptom. There are two main types of meningitis: infectious and noninfectious.

Infectious Meningitis

Infectious meningitis can be caused by various pathogens:

• Bacteria
• Viruses
• Fungi

Noninfectious Meningitis

Noninfectious meningitis, also known as aseptic meningitis, is not caused by bacterial infection. It can result from various factors, including:

• Autoimmune disorders
• Certain medications
• Chemical irritation
• Cancer

Viral Meningitis: The Most Common Form

Viral meningitis is the most prevalent type of meningitis. It’s often less severe than bacterial meningitis and typically resolves on its own without specific treatment. However, it can still cause significant discomfort and requires medical attention.

Viral meningitis is caused by various viruses, including:

• Enteroviruses
• Herpes simplex virus
• Varicella-zoster virus (which causes chickenpox and shingles)
• Mumps virus
• HIV

Meningitis Without Fever: Is It Possible?

While fever is a common symptom of meningitis, it’s not always present, especially in cases of noninfectious or viral meningitis. Some individuals may experience meningitis symptoms without running a high temperature. This can make diagnosis challenging, as fever is often considered a key indicator of infection.

Factors that might contribute to meningitis without fever include:

• The specific cause of meningitis
• Individual immune response
• Age of the patient
• Underlying health conditions

Recognizing Meningitis Symptoms Beyond Fever

Given that meningitis can occur without fever, it’s crucial to be aware of other potential symptoms. These may include:

• Severe headache
• Stiff neck
• Sensitivity to light (photophobia)
• Nausea and vomiting
• Confusion or altered mental state
• Fatigue
• Skin rash (in some cases)

In infants and young children, symptoms might also include:

• Irritability
• Difficulty waking from sleep
• Poor feeding
• High-pitched crying
• Bulging fontanelle (soft spot on the head)

The Importance of Prompt Medical Attention

Meningitis can be a life-threatening condition, particularly when caused by bacteria. Even in cases of viral meningitis, which is generally less severe, medical evaluation is crucial. If you or someone you know experiences symptoms suggestive of meningitis, with or without fever, seek immediate medical attention.

Healthcare professionals can perform tests to determine the cause of meningitis and provide appropriate treatment. These tests may include:

• Lumbar puncture (spinal tap)
• Blood tests
• Imaging studies (CT scan or MRI)

Diagnosing Meningitis in the Absence of Fever

When meningitis occurs without fever, diagnosis can be more challenging. Healthcare providers rely on a combination of clinical symptoms, physical examination, and diagnostic tests to make an accurate diagnosis.

Key factors in diagnosing meningitis without fever include:

• Thorough patient history
• Neurological examination
• Assessment of other meningitis symptoms
• Laboratory tests, including cerebrospinal fluid analysis

Treatment Approaches for Different Types of Meningitis

Treatment for meningitis varies depending on the underlying cause:

Bacterial Meningitis

Requires immediate antibiotic treatment, often before the exact cause is identified. Corticosteroids may be used to reduce inflammation.

Viral Meningitis

Generally resolves on its own within 7-10 days. Treatment focuses on managing symptoms and may include:

• Rest
• Adequate hydration
• Over-the-counter pain relievers
• Antiviral medications in specific cases

Noninfectious Meningitis

Treatment depends on the underlying cause and may involve:

• Corticosteroids to reduce inflammation
• Immunosuppressive drugs for autoimmune causes
• Discontinuation of offending medications
• Treatment of underlying conditions (e.g., cancer)

Preventing Meningitis: Vaccines and Lifestyle Measures

While not all forms of meningitis are preventable, there are steps you can take to reduce your risk:

Vaccinations

Several vaccines can protect against common causes of bacterial meningitis, including:

• Meningococcal vaccines
• Pneumococcal vaccines
• Haemophilus influenzae type b (Hib) vaccine

Lifestyle Measures

To reduce your risk of viral meningitis and other infections that can lead to meningitis:

• Practice good hygiene, including regular handwashing
• Avoid sharing personal items like toothbrushes or eating utensils
• Strengthen your immune system through a healthy diet, regular exercise, and adequate sleep
• Avoid close contact with people who have infections

Understanding that meningitis can occur without fever is crucial for early detection and treatment. By being aware of the various symptoms and seeking prompt medical attention when necessary, you can help ensure the best possible outcome in cases of suspected meningitis.

Long-Term Effects and Complications of Meningitis

While many people recover fully from meningitis, some may experience long-term effects or complications. The severity and likelihood of complications often depend on the type of meningitis, how quickly treatment was initiated, and individual factors.

Potential long-term effects of meningitis include:

• Hearing loss
• Vision problems
• Memory and concentration issues
• Balance and coordination difficulties
• Epilepsy
• Learning disabilities
• Behavioral changes

It’s important to note that these complications are more common in bacterial meningitis cases. Viral meningitis typically has a better prognosis with fewer long-term effects.

Follow-Up Care After Meningitis

After recovering from meningitis, follow-up care is essential to monitor for any potential complications or lingering effects. This may include:

• Regular check-ups with your healthcare provider
• Hearing and vision tests
• Neurological examinations
• Cognitive assessments
• Psychological support if needed

Meningitis in Special Populations

Certain groups may be at higher risk for meningitis or may experience the disease differently:

Infants and Young Children

Meningitis in infants can be particularly challenging to diagnose as symptoms may be subtle or nonspecific. Parents should be vigilant for signs such as:

• Unusual crying or irritability
• Refusal to eat
• Sluggishness or inactivity
• Bulging fontanelle

Elderly Adults

Older adults may present with atypical symptoms of meningitis, including:

• Altered mental status
• Weakness
• Lethargy

The absence of classic symptoms like fever or neck stiffness can make diagnosis challenging in this population.

Immunocompromised Individuals

People with weakened immune systems, such as those with HIV/AIDS or undergoing chemotherapy, may be more susceptible to meningitis and may experience more severe symptoms or complications.

The Role of Research in Understanding Meningitis

Ongoing research is crucial in advancing our understanding of meningitis, its causes, and potential treatments. Current areas of research include:

• Development of new vaccines
• Improved diagnostic techniques
• Novel treatment approaches
• Understanding the long-term effects of meningitis
• Investigating the relationship between viral infections and meningitis

These research efforts aim to improve prevention, diagnosis, and treatment strategies for all forms of meningitis, including cases that occur without fever.

In conclusion, while fever is a common symptom of meningitis, its absence does not rule out the condition. Being aware of the various symptoms, risk factors, and types of meningitis can help ensure prompt diagnosis and treatment, potentially reducing the risk of complications and improving outcomes. If you suspect meningitis, regardless of the presence or absence of fever, seek medical attention immediately.

Meningitis – Symptoms – NHS

Symptoms of meningitis can appear in any order. Some may not appear at all. In the early stages, there may not be a rash, or the rash may fade when pressure is applied.

You should get medical help immediately if you’re concerned about yourself or your child.

Trust your instincts and do not wait for all the symptoms to appear or until a rash develops.

Symptoms of meningitis and sepsis include:

• a high temperature
• cold hands and feet
• vomiting
• confusion
• breathing quickly
• muscle and joint pain
• pale, mottled or blotchy skin (this may be harder to see on brown or black skin)
• spots or a rash (this may be harder to see on brown or black skin)
• headache
• a stiff neck
• a dislike of bright lights
• being very sleepy or difficult to wake
• fits (seizures)

Babies may also:

• refuse feeds
• be irritable
• have a high-pitched cry
• have a stiff body or be floppy or unresponsive
• have a bulging soft spot on the top of their head

Someone with meningitis or sepsis can get a lot worse very quickly.

Call 999 for an ambulance or go to your nearest A&E immediately if you think you or someone you look after could have meningitis or sepsis.

Call NHS 111 for advice if you’re not sure if it’s anything serious.

If you’ve had medical advice and are still worried or any symptoms get worse, get medical help again.

The rash usually starts as small, red pinpricks before spreading quickly and turning into red or purple blotches.

Credit:

Mediscan / Alamy Stock Photo https://www.alamy.com/meningococcal-rash-image1683649.html?pv=1&stamp=2&imageid=83D4AFC7-AC4B-4271-B09C-727E90532943&p=17774&n=0&orientation=0&pn=1&searchtype=0&IsFromSearch=1&srch=foo%3dbar%26st%3d0%26pn%3d1%26ps%3d100%26sortby%3d2%26resultview%3dsortbyPopular%26npgs%3d0%26qt%3dATB0C2%26qt_raw%3dATB0C2%26lic%3d3%26mr%3d0%26pr%3d0%26ot%3d0%26creative%3d%26ag%3d0%26hc%3d0%26pc%3d%26blackwhite%3d%26cutout%3d%26tbar%3d1%26et%3d0x000000000000000000000%26vp%3d0%26loc%3d0%26imgt%3d0%26dtfr%3d%26dtto%3d%26size%3d0xFF%26archive%3d1%26groupid%3d%26pseudoid%3d788068%26a%3d%26cdid%3d%26cdsrt%3d%26name%3d%26qn%3d%26apalib%3d%26apalic%3d%26lightbox%3d%26gname%3d%26gtype%3d%26xstx%3d0%26simid%3d%26saveQry%3d%26editorial%3d1%26nu%3d%26t%3d%26edoptin%3d%26customgeoip%3d%26cap%3d1%26cbstore%3d1%26vd%3d0%26lb%3d%26fi%3d2%26edrf%3d0%26ispremium%3d1%26flip%3d0%26pl%3d

It does not fade if you press the side of a clear glass firmly against the skin.

Credit:

Alamy Stock Photo https://www.alamy.com/testing-of-meningococcal-rash-image589611.html?pv=1&stamp=2&imageid=6C8D2A33-C874-43AF-A58B-398C0D9552AF&p=17774&n=0&orientation=0&pn=1&searchtype=0&IsFromSearch=1&srch=foo%3dbar%26st%3d0%26pn%3d1%26ps%3d100%26sortby%3d2%26resultview%3dsortbyPopular%26npgs%3d0%26qt%3dA8FF2B%26qt_raw%3dA8FF2B%26lic%3d3%26mr%3d0%26pr%3d0%26ot%3d0%26creative%3d%26ag%3d0%26hc%3d0%26pc%3d%26blackwhite%3d%26cutout%3d%26tbar%3d1%26et%3d0x000000000000000000000%26vp%3d0%26loc%3d0%26imgt%3d0%26dtfr%3d%26dtto%3d%26size%3d0xFF%26archive%3d1%26groupid%3d%26pseudoid%3d195878%26a%3d%26cdid%3d%26cdsrt%3d%26name%3d%26qn%3d%26apalib%3d%26apalic%3d%26lightbox%3d%26gname%3d%26gtype%3d%26xstx%3d0%26simid%3d%26saveQry%3d%26editorial%3d1%26nu%3d%26t%3d%26edoptin%3d%26customgeoip%3d%26cap%3d1%26cbstore%3d1%26vd%3d0%26lb%3d%26fi%3d2%26edrf%3d0%26ispremium%3d1%26flip%3d0%26pl%3d

The rash can be harder to see on brown or black skin. Check paler areas, such as the palms of the hands, soles of the feet, roof of the mouth, tummy, whites of the eyes or the inside of the eyelids.

Credit:

Meningitis Research UK https://hscic365.sharepoint.com/sites/Pilot/NHSUK/Health%20AZ/Forms/AllItems.aspx?id=%2Fsites%2FPilot%2FNHSUK%2FHealth%20AZ%2FHealth%20A%2DZ%2FA%2DZ%20content%20audit%2FM%2FMeningitis%2FImage%20and%20section%20review%2007%202019%2FRe%5FPhotography%20of%20the%20meningitis%20rash%2Eeml&parent=%2Fsites%2FPilot%2FNHSUK%2FHealth%20AZ%2FHealth%20A%2DZ%2FA%2DZ%20content%20audit%2FM%2FMeningitis%2FImage%20and%20section%20review%2007%202019

If a rash does not fade under a glass, it can be a sign of sepsis (sometimes called septicaemia or blood poisoning) caused by meningitis and you should call 999 straight away.

Page last reviewed: 25 October 2022
Next review due: 25 October 2025

Viral Meningitis | Cape May County, NJ

1. What is viral meningitis?

   Viral meningitis (aseptic meningitis, nonbacterial meningitis) is an inflammation of the thin lining covering the brain and spinal cord called the meninges. Infectious meningitis may be caused by bacteria, fungi or viruses. Viral meningitis, the most common form of meningitis, is caused by an infection with one of several types of viruses.

2. What are the symptoms?

   The most common symptoms are fever,
   severe headache, stiff neck, bright lights hurting the eyes, drowsiness
   or confusion, nausea and vomiting. These symptoms are often difficult to
   identify in infants, who may become irritable, lethargic, inconsolable
   or refuse to eat.

3. Is viral meningitis a serious disease?

   Viral meningitis is
   serious but rarely fatal in persons with normal immune systems. Usually,
   the symptoms last from 7-10 days and the person recovers completely.
   Bacterial meningitis, on the other hand, can be very serious and result
   in disability or death if not treated promptly. Often, the symptoms of
   viral meningitis and bacterial meningitis are the same. For this reason,
   if you think you or your child has meningitis, see your doctor as soon
   as possible.

4. What causes viral meningitis?

   Many different viruses can cause
   meningitis. About 90% of cases of viral meningitis are caused by members
   of a group of viruses known as enteroviruses, such as coxsackieviruses
   and echoviruses. These viruses are more common during summer and fall
   months. Herpesviruses and the mumps virus can also cause viral
   meningitis.

5. How is viral meningitis treated?No specific treatment for
   viral meningitis exists at this time. Most patients completely recover
   on their own. Doctors often will recommend bed rest, plenty of fluids
   and medicine to relieve fever and headache
6. How is the virus spread?

   Enteroviruses, the most common cause
   of viral meningitis, are most often spread through direct contact with
   respiratory secretions (e.g., saliva, sputum, or nasal mucus) of an
   infected person. This usually happens by shaking hands with an infected
   person or touching something they have handled, and then rubbing your
   own nose, mouth or eyes. The virus can also be found in the stool of
   persons who are infected. The virus is spread through this route mainly
   among small children who are not yet toilet trained. It can also be
   spread this way to adults changing the diapers of an infected infant.
   The incubation period for enteroviruses is usually between 3-7 days from
   the time you are infected until you develop symptoms. You can usually
   spread the virus to someone else beginning about 3 days after you are
   infected until about 10 days after you develop symptoms.

7. Can I get viral meningitis if I’m around someone who has it?

   The
   viruses that cause viral meningitis are contagious. Enteroviruses, for
   example, are very common during the summer and early fall, and many
   people are exposed to them. However, most infected persons either have
   no symptoms or develop only a cold or rash with low-grade fever.
   Typically, less than 1 of every 1,000 persons infected actually develop
   meningitis. Therefore, if you are around someone who has viral
   meningitis, you have a moderate chance of becoming infected, but a very
   small chance of developing meningitis.

8. How can I reduce my chances of becoming infected?

   Because most
   persons who are infected with enteroviruses do not become sick, it can
   be difficult to prevent the spread of the virus. If you are in contact
   with someone who has viral meningitis, however, the most effective
   method of prevention is to wash your hands thoroughly and often. In
   institutional settings such as child care centers, washing objects and
   surfaces with a dilute bleach solution (made by mixing approximately
   1/4-cup of bleach with 1 gallon of water) can be a very effective way to
   inactivate the virus.

9. Should a person with viral meningitis be isolated?

   Strict
   isolation is not necessary. Since most cases are due to enteroviruses
   that may be passed in the stool and possibly through respiratory
   secretions, people diagnosed with viral meningitis should be instructed
   to thoroughly wash their hands after using the toilet or blowing their
   noses. The infected person should also cover coughs and sneezes.


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How to recognize the symptoms of meningitis?

Meningitis is an inflammation of the membranes surrounding the brain and spinal cord. This is an extremely dangerous disease that causes a variety of symptoms. In the most severe cases, it damages the brain and can lead to stroke and even death.

According to experts from the Centers for Disease Control and Prevention (CDC), if the cause of the disease lies in a bacterial infection, death can occur within a few hours. Therefore, when symptoms appear, you can not wait or self-medicate – you need to urgently call an ambulance.

Often the initial symptoms are very flu-like. They can develop in a few hours or a few days. If the cause is a bacterial infection, most symptoms appear within 3 to 7 days of infection.

Among the possible signs of this disease, which appear in any patient older than 2 years:

• Sudden “jump” high temperature,
• Hardening of the muscles of the neck,
• Severe headache, which is not like normal,
• Headache with nausea and vomiting,
• Confusion or difficulty concentrating,
• Seizures and convulsions,
• Drowsiness or difficulty waking up from sleep,
• Hypersensitivity to light,

90 011 Lack of appetite or desire to drink liquids ,

• Sometimes – skin rashes.

Symptoms of neonatal meningitis include:

• High fever,
• Constant crying,
• Excessive sleepiness or irritability,
• Inactivity or sluggishness,
• Poor appetite,
• Bulge in the soft spot on the top of the head (fontanelle),
• Hardening of the neck and other parts of the body.

Babies can be very difficult to soothe and may even cry more when held.

All of these signs of meningitis are strong indications for calling an ambulance. Delayed treatment increases the risk of irreversible brain damage or death.

It is important to note that this disease is transmitted from person to person. Therefore, when in contact with the patient, you need to consult a doctor. In this case, the person will need to take medication to prevent infection.

Viruses are the most common culprits, followed by bacterial infections and rarely fungal infections. Because bacterial infections can be life-threatening, early diagnosis and treatment are essential.

Bacterial meningitis

A bacterium that enters the bloodstream and reaches the brain and spinal cord causes an acute bacterial infection. However, the disease can also develop when the bacterium penetrates directly into the meninges. This happens after an ear or sinus infection (sinusitis), a broken jaw, and very rarely after certain surgical procedures.

Several strains of bacteria can cause acute bacterial meningitis. Most often to blame:

1. Streptococcus pneumoniae. It is the most common cause of illness among newborns, young children and adults. Most often, it causes pneumonia, an infection of the ear and paranasal sinuses. To prevent this type of infection, it is necessary to get vaccinated.
2. Meningococcus (neisseria meningitidis). This is the second most common cause of the development of a bacterial-type disease. Usually this type of bacteria causes an upper respiratory tract infection, but when it enters the bloodstream, it causes meningococcus. It is a highly contagious infection that mainly affects teenagers and adults. It is capable of causing a local epidemic in university dormitories, boarding schools and military units. To prevent it, you also need to be vaccinated.
3. Haemophilus influenzae. This type of bacteria was once the main cause of meningitis in children. But since the development of a vaccine, the number of infections has dropped significantly.
4. Listeria (listeria monocytogenes). This type of bacteria can be found in unpasteurized cheeses, hot dogs and savory meats. The most vulnerable to this bacterium are pregnant women, newborns, the elderly and people with weakened immune systems. Listeria is able to cross the placental barrier, and infection in late pregnancy can be fatal to the baby.

Viral meningitis (aseptic) 9 0062

This type of infection is usually harmless and often goes away on its own. In most cases, enteroviruses are to blame, which are activated on the hottest days of summer and the first half of autumn. Also, this form of the disease can lead to: herpes simplex virus, HIV, mumps and other viral infections.

Chronic meningitis

penetrate into the membranes and the fluid surrounding the brain. The development of the disease takes 2 or more weeks. Signs of chronic meningitis include headaches, high fever, vomiting, and mental confusion.

Fungi are relatively rare in causing this disease. But the fungal form of the disease has a peculiarity – it is not transmitted from person to person. Cryptococcal meningitis is a common fungal form of the disease that affects people with immunodeficiency (AIDS). If this condition is not treated with antifungal drugs, the person is at risk of death.

Other causes of meningitis include:

• Noncommunicable diseases, such as reactions to chemicals, including drug allergies,
• Some types of cancer,
• Inflammatory diseases, such as sarcoidosis.

Among the risk factors:

• Skipped or refused vaccination in children and adults.
• Age. Most cases of viral meningitis occur in children under 5 years of age. The bacterial form of the disease is common among people under the age of 20 years.
• Living among a large number of people. The meningococcus bacterium is transmitted through the respiratory tract and spreads rapidly through large groups of people.
• Pregnancy. In women in position, the risk of developing listeriosis increases, which in turn can cause meningitis.
• Weakened immunity. Among the diseases and factors that weaken the immune system: AIDS, alcoholism, diabetes, the use of immunosuppressants. Another risk factor that weakens the immune system is the removed spleen. For this reason, any person who has had their spleen removed should be vaccinated to minimize risk.

Treatment of meningitis

Bacterial requires immediate treatment. You need intravenous antibiotics that can cross the blood-brain barrier (the membrane that prevents harmful microorganisms and chemicals from entering the brain). Sometimes corticosteroids are also prescribed. Antibiotics kill the bacterium, while corticosteroids speed up recovery and reduce the chances of developing cerebral edema and seizures.

The choice of a particular antibiotic or combination of antibiotics depends on the strain of bacteria that caused the meningitis. If necessary, doctors drain infected sinuses or mastoid processes, the bones behind the outer ear that connect to the middle ear.

After starting antibiotics, the patient gets better within 48-72 hours.

Antibiotics are not prescribed for the viral form . In most cases, only observation of the patient is required. The condition usually improves on its own within a few weeks. In mild cases, treatment of viral meningitis requires:

1. Bed rest,
2. Drinking plenty of fluids,
3. Taking over-the-counter pain relievers to “relieve” body pain and reduce fever.

Doctors may prescribe corticosteroids to reduce swelling in the brain and anticonvulsants to control seizures. If the cause of the disease is the herpes simplex virus, you will need to take antiviral drugs.

For the treatment of chronic disorders of a fungal nature, antifungal agents are prescribed. If the cause of the disease has not been established, both antiviral and antibiotics are prescribed to treat meningitis. At this time, laboratory tests will help to figure out what exactly became the culprit. If the cause is non-infectious, the patient is prescribed corticosteroids.

What are the complications of meningitis?

The consequences of this disease are very severe. The longer a person goes untreated, the higher the risk of irreversible damage to the nervous system. If not treated promptly, complications may include:

• Hearing loss,
• Memory loss,
• Learning disability,
• Brain damage,
• Gait disturbance,
• Seizure ki,
• Renal failure,
• Onset of shock,
• Death.

Never ignore the signs of meningitis. If there is even the slightest suspicion, it is better to immediately call an ambulance. And, of course, do not forget about timely and complete vaccination. Be healthy!

Sources:

1. Meningitis, Mayo Clinic,
2. Meningitis and Encephalitis Fact Sheet, National Institute of Neurological Disorders and Stroke,
3. Bacterial Meningitis, National Center for Immunization and Respiratory Diseases.

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Serous meningitis: symptoms and prevention of the disease

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• Symptoms and prevention of serous meningitis

Recently, the topic of serous meningitis has become very popular. We decided to talk about the prevention and symptoms of this insidious disease.

Serous meningitis is an inflammatory disease of the brain. Allocate fungal, viral and bacterial meningitis. It can be primary or secondary.
The cause of primary meningitis is Coxsackie, ECHO, viral choriomeningitis.

Secondary inflammatory reactions in the meninges can occur with chickenpox, measles, mumps, influenza, and some other viral infections.
The course of viral serous meningitis is often benign, with no serious complications.

But in any case, treatment should begin immediately after the first symptoms are detected. Without timely and qualified treatment, serous meningitis in children can lead to the most serious consequences. Children are more susceptible to the disease; in adults, the disease is registered against the background of general immunodeficiency, depletion of protective forces after a long struggle with a chronic disease.

The source of infection is a sick person, as well as a carrier of the virus, which itself remains healthy. The virus is transmitted by the fecal-oral route: through poorly washed vegetables and fruits, and other food products. It is very important to wash your hands before eating! The pathogen can also be transmitted by airborne droplets, including from open water bodies and pools while swimming.

Serous meningitis in children usually begins acutely with severe symptoms:

• fever (up to 40 degrees)
• persistent headache
• muscle pain
• Possible diarrhea and vomiting, abdominal pain, general restlessness
• in severe cases convulsions, delirium

Treatment must be carried out immediately! When the first symptoms appear, you should seek medical help and in no case self-medicate!

How to prevent serous meningitis?

• Young children and adolescents should not be allowed to swim in open waters
• Drink only boiled water
• Wash and boil fruits and vegetables before eating
• Wash hands before eating
• Lead a healthy lifestyle, keep a daily routine and strengthen immunity

Petrova Oksana Ivanovna – pediatrician, leading specialist of the clinic, conducts an appointment in the Children’s building of the clinic on Usacheva.