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},
"code": "A24",
"name": "Сап и мелиоидоз",
"icd_name": "Сап и мелиоидоз",
"gender": 0,
"age_min": 1,
"age_max": 94,
"cause": [
2,
4,
5,
7
],
"periodicity": 1,
"slug": "a24_sap_i_melioidoz",
"lead": "Нарушение здоровья, относящееся к группе некоторые бактериальные зоонозы",
"description": "Мелиоидоз — острая инфекционная болезнь, протекающая в виде тяжелого сепсиса с образованием множественных абсцессов в различных органах или в виде относительно доброкачественных легочных форм.\r\nСап – инфекционное заболевание животных и человека, протекающее в острой или хронической форме с образованием в различных органах и тканях гранулем, пустул и абсцессов.\r\n",
"etiology": "<p>Возбудитель сапа — бактерия Pseudomonas mallei – неподвижная грамотрицательная палочка, жгутиков не имеет, спор и капсул не образует, обитает в почве, воде.</p>\r\n<p>Возбудитель мелиоидоза — бактерия Pseudomonas pseudomallei. Она представляет собой тонкую, грамотрицательную, биполярно окрашивающуюся палочку.</p>\r\n<p>Является аэробом, т.е. растет и размножается в присутствии кислорода. Бактерия подвижна, имеет жгутики, хорошо растет на простых средах, капсул не имеет, спор не образует.</p>\r\n<p>Возбудитель длительно сохраняется во внешней среде. Во влажной среде выживает до 30 дней, в гниющих материалах — 24 дня, в воде — до месяца и более. Погибает при нагревании и под воздействием дезинфицирующих средств.</p>\r\n<p>Источником возникновения инфекции являются больные животные, которые выделяют возбудителя во внешнюю среду с выделениями из носа, мочой, испражнениями. Факторами передачи инфекции являются, почва, вода и другие объекты внешней среды.</p>\r\n<p>Резервуаром инфекции в природе являются грызуны (крысы, мыши и др.), у которых болезнь может протекать хронически. Заражение происходит чаще алиментарным и аэрогенным путями, реже через кожу, возможен перенос микроба блохами, обитающими на крысах, в организме которых бактерии сохраняются до 50 дней. Заражение человека от человека наблюдается крайне редко.</p>",
"pathogenesis": "<p>Входными воротами (местом внедрения инфекции в организм человека) инфекции являются мелкие повреждения кожи или слизистой оболочки органов пищеварения или респираторного тракта. По лимфатическим сосудам возбудитель достигает регионарных лимфатических узлов, где размножается иногда с образованием гнойного очага.</p>\r\n<p>При септических формах мелиоидоза возбудитель проникает в кровь и по кровеносным сосудам распространяется по различным органам и системам, образуя там множество вторичных очагов с казеозным (творожистым) распадом и абсцессами. Большинство очагов развивается в легких, единичные абсцессы - в других органах.</p>\r\n<p>При подостром течении очаги в легких характеризуются большими размерами, а вторичные очаги обнаруживаются во всех органах и тканях - коже, подкожной клетчатке, печени, селезенке, почках, в костях, в мозговых оболочках, головном мозге, в лимфатических узлах. Вторичные очаги состоят из центральной зоны казеозного некроза, окруженной грануляционной тканью (богатая сосудами и молодыми клетками соединительная ткань).</p>\r\n<p>Септическое течение мелиоидоза наблюдается у резко ослабленных лиц. При хорошей реактивности макроорганизма чаще возникают относительно доброкачественно протекающие легочные абсцессы, при которых воспалительные изменения и абсцессы развиваются лишь в легких.</p>\r\n<p>После перенесенного мелиоидоза в крови появляются антитела. Случаи повторного заболевания не описаны.</p>\r\n<p> </p>",
"diagnostics": "<p>Диагноз ставится комплексно, учитываются эпизоотические данные, клинические признаки, патологоанатомические изменения и результаты бактериологических исследований.</p>\r\n<p>Лабораторная диагностика включает выделение возбудителя из крови, гноя, мокроты или определение антител к возбудителю методами серологической диагностики (РСК, РНГА). Одновременно рекомендуется заражение самцов морских свинок. В положительных случаях развивается орхит, и животное гибнет. На вскрытии обнаруживаются характерные патологоанатомические изменения.</p>",
"treatment": "<p>Больные сапом обязательно подлежат госпитализации, должен соблюдаться строгий постельный режим, предусмотренный для особо опасных инфекций.</p>\r\n<p>В качестве этиотропной (направленной на возбудителя) терапии рекомендуется применение сульфадиазидина в сочетании с витаминами и кислородотерапией. В тяжелых случаях целесообразно также сочетание сульфаниламидных препаратов, тетрациклинов и хлорамфеникола с иммуномодуляторами.</p>\r\n<p>При лечении мелиоидоза используется длительная этиотропая терапия. Наиболее эффективными являются тетрациклины, левомицетин и бактрим (бисептол). </p>",
"prevention": "<p>Для предупреждения мелиоидоза необходимо уничтожать грызунов основной резервуар возбудителя инфекции в природе. Поскольку возбудитель в больших количествах выделяется с экскрементами и секретами больных крыс и мышей нужно хранить корма в местах, недоступных для грызунов.</p>\r\n<p> С целью профилактики сапа организуется ветеринарный контроль, раннее выявление и забой больных животных, соблюдение правил личной защиты при уходе за животными с подозрением на сап (ношение защитных комбинезонов, перчаток, масок, очков), дезинфекция мест содержания этих животных. Для лиц, бывших в контакте с больными, устанавливается 21-дневный карантин. Инфицированным, но еще не заболевшим сапом пациентам, производится экстренная профилактика сульфатиазолом.</p>",
"clinical_picture": "<p>Септическая форма чаще начинается внезапно с озноба, высокой лихорадки, резкой головной боли, одышки. Больной может умереть через 2-4 дня (молниеносная форма), до развития вторичных очагов. Однако чаще в результате распространения возбудителя с током крови образуются множественные пустулы (гнойнички) на коже и абсцессы во внутренних органах, в мышцах. Быстрое развитие септической формы наблюдается у ослабленных людей (наркоманы, ВИЧ-инфицированные и т.д.). Отмечается фарингит, пустулезная сыпь по всему телу, жидкий водянистый стул, выраженная одышка, цианоз. У части больных появляются гнойные артриты, менингит, нарушение сознания. Эти формы болезни обычно не поддаются терапии.</p>\r\n<p>При подострых и хронических формах мелоидоза отмечается более длительное течение с образованием вяло текущих абсцессов в различных органах и тканях. Эти формы периодически дают ремиссии, однако без этиотропной терапии больные также умирают в течение месяца (подострые формы) или через несколько месяцев (хронические формы). Легочная форма мелоидоза может начинаться внезапно или постепенно. Основные признаки этой формы мелиоидоза - повышение температуры тела, кашель с гнойной, иногда кровянистой мокротой, нарастающая слабость, исхудание, боли в груди. Лихорадка имеет обычно неправильный или интермиттирующий (чередование периодов нормальной температуры тела и повышенной) характер с ознобом и потом. У больных появляются кашель с большим количеством гнойной мокроты, колющие боли в грудной клетке, понижается аппетит, отмечается слабость; потеря массы тела составляет в среднем 10-15 кг.</p>\r\n<p>Рецидивирующий мелиоидоз. Рецидив развивается через длительное время после первичного инфицирования в виде острого септического или легочного заболевания, или в виде хронического локализованного гнойного заболевания. Рецидив может быть спровоцирован хирургическим вмешательством, тяжелой гриппозной пневмонией, лучевой терапией и пр.</p>\r\n<p>Проявления сапа зависят от локализации входных ворот. Выделяют 4 варианта болезни: острую локализованную гнойную инфекцию, острую пневмонию, острую септицемию, хроническую гнойную инфекцию. Для всех форм характерны признаки интоксикации: лихорадка с ознобами, мышечные боли, сильная головная боль, резкая слабость, боли в груди. Отмечают также светобоязнь, слезотечение, понос, увеличение лимфатических (особенно шейных) лимфатических узлов, увеличение селезенки.</p>\r\n<p>При инфицировании через кожу в месте входных ворот образуется папула, окруженная зоной покраснения. Впоследствии папула превращается в геморрагическую пустулу, а за 2-3 дня в язву с подрытыми краями и «сальным» дном. На 4-8-й день температура тела вновь повышается, на коже появляются множественные узелки с последующим их превращением в геморрагические пузырьки, пустулы, язвы. Образуются абсцессы в мышцах (особенно икроножных), свищи с выделением зеленоватого гноя. В случае поражения легких появляются боль в грудной клетке, кашель с выделением слизисто-кровянистой или гнойной мокроты, цианоз губ, одышка</p>",
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"slug": "a39.0_meningokokkovyy_meningit_g01",
"lead": "форма менингококковой инфекции, которая характеризуется гнойным воспалением мягкой и арахноидальной оболочек головного мозга",
"description": "<p> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Менингококковая инфекция – это острое инфекционное заболевание, первым признаком которого является острый назофарингит или воспаление носоглотки, протекающее с последующим развитием менингококцемии и гнойного менингита. </span></p>",
"etiology": "<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Бактерия передается от человека человеку через капли выделений из дыхательных путей или горла носителя. Тесный и продолжительный контакт, такой как поцелуй, чихание или кашель в сторону другого человека или проживание в непосредственной близости с инфицированным человеком-носителем (например, в одной квартире или при совместном пользовании посудой), способствует распространению болезни. Обычно инкубационный период длится 4 дня, но может варьироваться от 2 до 10 дней.</span></p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Предрасположенность к развитию менингококкового менингита формируется в условиях снижения местной и общей резистентности организма. Факторами риска признаются врожденный дефицит комплемента, ВИЧ-инфекция, анатомическая или функциональная аспления. Слизистая оболочка носоглотки повреждается при курении и ОРВИ, что повышает риск бактериальной инвазии. Распространению инфекции способствует большая скученность населения.</span></p>",
"pathogenesis": "<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Входными воротами становится слизистая носоглотки, где развивается первичный воспалительный процесс. В 10-20% случаев микробы, преодолев защитные механизмы, проникают в кровоток, где размножаются, инициируя кратковременную бактериемическую фазу. В субарахноидальные пространства головного мозга нейссерии заносятся гематогенным путем, реже – лимфогенно, периваскулярно и периневрально через пластинку решетчатой кости.</span></p>\r\n<p> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">При размножении менингококка развивается вначале серозно-гнойное, затем гнойное воспаление мягкой и паутинной оболочек. Чаще всего поражаются конвекситальные поверхности и основание головного мозга, иногда процесс распространяется в спинальном направлении. Макроскопически мягкая оболочка выглядит отечной, гиперемированной, мутной, поверхность мозга будто покрыта шапочкой из гноя. Микроскопическая картина представлена выраженной инфильтрацией полиморфноядерными мононуклеарными клетками. Спаечный процесс может вызвать закупорку путей ликворооттока.</span></p>",
"diagnostics": "<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Установить происхождение менингококкового менингита на основании клинических данных удается при его сочетании с бактериемией. На вероятную этиологию изолированных форм болезни косвенно указывает эпидемиологическая и анамнестическая информация (наличие назофарингита, контакт с больным). </span></p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Точную верификацию патологии обеспечивают лабораторно-инструментальные методы:</span></p>\r\n<ul>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Клинические анализы. Гемограмма показывает выраженный лейкоцитоз со сдвигом формулы влево, анэозинофилию, ускорение СОЭ. В спинномозговой жидкости отмечается полиморфноядерный плеоцитоз, снижение концентрации глюкозы, повышение белка. Изменения в анализе мочи неспецифичны, свидетельствуют о токсических явлениях.</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Бактериоскопия и посев. Менингококки выявляются в нейтрофилах при прямой бактериоскопии окрашенных по Граму мазков. Посев ликвора на сывороточный агар или другие питательные среды дает возможность уточнить культуральные, ферментные, антигенные свойства возбудителя, определить его чувствительность к антибиотикам.</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Серологические тесты. После выделения менингококка идентифицировать его по серогруппам можно при постановке реакции агглютинации. Для обнаружения антител в крови применяют РНГА, экспресс-диагностику проводят с помощью ИФА, методов встречного иммуноэлектрофореза.</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Молекулярно-генетический анализ. В дополнение к стандартным процедурам используют ПЦР, позволяющую выявить бактериальную ДНК. Это быстрый и чувствительный диагностический тест. Особую ценность он приобретает при невозможности выделить возбудителя из ликвора или крови.</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Нейровизуализация. Показаниями для церебральной томографии могут быть нарушения сознания, очаговые неврологические симптомы. КТ головного мозга подтверждает ликворную гипертензию, внутримозговые кровоизлияния, церебральный отек. МРТ с контрастированием предпочтительнее, так как лучше визуализирует менингеальную оболочку, субарахноидальное пространство.</span></li>\r\n</ul>\r\n<p> </p>\r\n<p><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">В качестве дополнительного исследования при судорогах для регистрации биоэлектрической активности мозга назначают ЭЭГ. Помощь в диагностическом поиске оказывают офтальмолог (осмотр глазного дна), инфекционист. </span></p>",
"treatment": "<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Любые формы генерализованной инфекции сопряжены с высокой опасностью летального исхода и тяжелых осложнений. Поэтому менингококковый менингит должен рассматриваться как неотложное состояние, требующее срочной госпитализации в профильный стационар. Обычно пациенты сразу попадают в палату интенсивной терапии под круглосуточное наблюдение специалистов. Им показан строгий постельный режим. </span></p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Основой лечения является фармакотерапия:</span></p>\r\n<ul>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Этиотропная. Центральное место отводится антибиотикотерапии препаратами пенициллинового (бензилпенициллином, ампициллином) или цефалоспоринового ряда (цефтриаксоном, цефотаксимом). Альтернативными медикаментами выступают карбапенемы, хлорамфеникол. Сначала назначается эмпирическая терапия, которая затем корректируется с учетом данных антибиотикочувствительности.</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Патогенетическая. Для купирования отека головного мозга используются глюкокортикоиды, осмотические и петлевые диуретики (маннитол, фуросемид). Гемодинамическая нестабильность и токсикоз требуют инфузионной поддержки (кристаллоидами, коллоидами, плазмой), введения вазопрессоров, оксигенотерапии. В тяжелых случаях проводят экстракорпоральную детоксикацию.</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Симптоматическая. В комплексном лечении менингококкового менингита применяют симптоматические препараты. При судорожной активности показаны антиконвульсанты (диазепам, натрия оксибутират). Высокую лихорадку купируют жаропонижающими средствами.</span></li>\r\n</ul>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Выписка из стационара осуществляется при полном клиническом выздоровлении. Все пациенты, перенесшие менингококковый менингит, должны находиться под диспансерным наблюдением невролога с прохождением регулярного обследования. Последствия и остаточные явления устраняются комплексной реабилитацией, которая включает физиотерапию, лечебную гимнастику, когнитивную коррекцию.</span></p>\r\n<p> </p>",
"prevention": "<p> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Профилактика подразумевает воздействие на все звенья эпидемического процесса. В отношении источника инфекции проводят раннее выявление, изоляцию и лечение больных, санацию носителей. Разорвать механизмы передачи помогают санитарно-гигиенические мероприятия, дезинфекция в очаге. Для создания специфического иммунитета у восприимчивых лиц рекомендуют вакцинацию против менингококковой инфекции. Повышению неспецифической резистентности способствует закаливание, своевременная терапия респираторных заболеваний.</span></p>",
"clinical_picture": "<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Началу болезни обычно предшествует назофарингит, но симптомы могут возникнуть внезапно, на фоне полного благополучия. С большим постоянством в клинической картине обнаруживают так называемую менингеальную триаду – головные боли, лихорадку, рвоту. Температура резко поднимается до 40-42° C, сопровождается сильным ознобом. Мучительные головные боли носят диффузный давяще-распирающий или пульсирующий характер, локализуются преимущественно в лобно-теменной области, усиливаются в ночное время, при перемене положения головы, действии внешних раздражителей.</span></p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Рвота при менингококковом менингите возникает без предшествующей тошноты, «фонтаном», не приносит облегчения. Клиническая картина дополняется кожной гиперестезией, повышением чувствительности к звуковым, световым и болевым стимулам, запахам. Иногда уже в первые часы болезни возникают тонико-клонические судороги. Важное место в структуре общемозговых симптомов занимает психомоторное возбуждение и нарастающие расстройства сознания – от оглушения до комы.</span></p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Среди объективных симптомов на первое место выходят менингеальные знаки, которые появляются в самом начале заболевания и быстро прогрессируют. Наиболее постоянными являются ригидность затылочных мышц, симптомы Кернига и Брудзинского (верхний, средний, нижний). У детей отмечают признак Лесажа, выбухание и пульсацию родничка. Пациент принимает вынужденную позу – лежа на боку с запрокинутой назад головой и подтянутыми к животу коленями. Выраженность менингеального синдрома может не соответствовать тяжести патологии.</span></p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">При неврологическом осмотре часто выявляют асимметрию сухожильных и кожных рефлексов, ослабляющихся по мере нарастания интоксикации, патологические стопные знаки. Базальные менингиты сопровождаются поражением черепных нервов, особенно III, IV, VII, VIII пар. Наличие стойкого красного дермографизма говорит о сопутствующих вегетативных расстройствах. Признаками интоксикации являются вначале тахикардия, а затем относительная брадикардия, гипотония, приглушенность сердечных тонов. У пациентов учащается дыхание, язык обложен грязно-коричневым налетом, сухой.</span></p>",
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