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},
"code": "A82",
"name": "Бешенство",
"icd_name": "Бешенство",
"gender": 1,
"age_min": 0,
"age_max": 100,
"cause": [
2,
5,
9
],
"periodicity": 1,
"slug": "a82_beshenstvo",
"lead": "Острое природно-очаговое вирусное заболевание, распространенное преимущественно среди млекопитающих и передающееся через слюну",
"description": "",
"etiology": "<p>Бешенство – это вирусная инфекция, вызываемая Neuroiyctes rabid из семейства Рабдовирусов. </p>\r\n<p>В природе вирус циркулирует среди теплокровных животных и птиц. Источником инфекции является любое больное бешенством животное. Наиболее часто человек заражается от собак, кошек, волков, лисиц, летучих мышей, ворон, крупного рогатого скота. Обычно такие животные и птицы ведут себя неадекватно, нападают на людей и других зверей, кусая их и заражая таким образом. Считается, что больной бешенством человек, если укусит другого, также может быть источником инфекции. Вирус передается со слюной: при укусе и даже просто попадании слюны на кожу и слизистые (в связи с возможным наличием в этих местах микроповреждений, не заметных для глаза).</p>",
"pathogenesis": "<p>Инкубационный период (время от момента попадания возбудителя в организм до появления первых симптомов) длится в среднем от 10 дней до 3-4 месяцев. Зарегистрированы единичные случаи заболевания с инкубационным периодом около года. Сроки появления первых симптомов зависят от многих факторов: места укуса (самые опасные – в голову, половые органы, кисти рук), от количества вируса, попавшего в организм, состояния иммунной системы. Даже вид животного в этом случае играет роль. Следует знать, что любой укус животного рассматривается как потенциальный риск бешенства, и необходимо немедленно обращаться за медицинской помощью.</p>",
"diagnostics": "<p>Диагностика основывается на данных анамнеза: укус животного или ослюнение кожи. Затем играют роль специфические признаки бешенства: водобоязнь, к раздражителям (звукам, свету, сквозняку), обильное , приступы психомоторного возбуждения с судорогами (даже в ответ на малейшее движение воздуха).</p>\r\n<p>Из лабораторных методов можно отметить обнаружение антигенов вируса бешенства в отпечатках с поверхности роговицы. В анализе крови отмечается лейкоцитоз за счет увеличения содержания лимфоцитов. После гибели больного на вскрытии в веществе головного мозга обнаруживают тельца Бабеша-Негри.</p>",
"treatment": "<p>Статистически достоверных методов лечения бешенства не существует. Если у больного уже появились начальные признаки, то заболевание неизлечимо. Помочь больному можно только в инкубационный период, причем чем раньше, тем лучше. Для этого вводят вакцину против бешенства, но эта мера считается профилактической.</p>\r\n<p>Когда у больного уже появились признаки бешенства, обычно проводят так называемое симптоматическое лечение, чтобы облегчить его состояние. Для этого человека помещают в отдельную палату, изолируют его от света, шума, сквозняка (чтобы не провоцировать судороги). Из медикаментов применяют наркотические вещества, противосудорожные препараты, мышечные релаксанты. При наличии грубых дыхательных расстройств больного подключают к аппарату искусственной вентиляции легких. Эти манипуляции продлевают жизнь больному на несколько часов или даже дней, но исход все равно неблагоприятный: человек умирает. Введение антирабического иммуноглобулина и вакцины, когда уже появились симптомы бешенства, не эффективно!</p>\r\n<full></full>\r\n<p>С 2005 г. во всем мире зарегистрировано несколько случаев выздоровления от бешенства без применения антирабической вакцины. В 2005 г. в США 15-летняя девушка выжила в результате введения ее в искусственную кому с момента появления признаков бешенства. Пока она находилась в коме, ей применяли препараты, стимулирующие иммунную систему. Такое лечение было основано на предположении, что человеческий организм просто не успевает выработать антитела против вируса бешенства, и если «выключить» нервную систему на какое-то время, то есть надежда на исцеление. Произошло чудо – и девушка выздоровела. Подобный метод лечения назвали «протокол Милуоки». Позже этот протокол пробовали применить к другим случаям заболевания бешенством: из 24 попыток успехом завершилась только одна, остальные 23 человека погибли.</p>\r\n<p>В 2008 г. удалось спасти 15-летнего мальчика из Бразилии. Для его лечения применяли протокол Милуоки, противовирусные средства, успокоительные и средства для анестезии. В 2011 г. выжил 8-летний ребенок, в 2012 г. – еще 5 человек. Во всех случаях лечение проводилось согласно протокола. Ученые до сих пор не сошлись во мнении, что же именно помогло этим больным избежать смерти. Предполагается, что главную роль сыграл необычайно сильный иммунитет и, возможно, ослабленная форма вируса, вызвавшего заболевание.</p>\r\n<p>В 2009 г. в США был зарегистрирован случай выздоровления у асоциальной женщины с симптомами бешенства, предположительно возникшими после укуса летучей мыши. Этот эпизод подтолкнул ученых к мысли, что у человека могут возникать абортивные формы бешенства по аналогии с животными. Ведь известно, что от 1% до 8% животных, которые были укушены заведомо больным животным, не заболевают бешенством.</p>",
"prevention": "<p>Существуют две российские вакцины от бешенства — «культуральная антирабическая вакцина» (КАВ) (концентрация 0,5 МЕ/мл) и \" концентрированная культуральная антирабическая вакцина\" (КоКАВ) (концентрация 2,5 МЕ/мл) . У вакцины КАВ есть и другое название — Рабивак-Внуково-32 или просто Рабивак. КАВ вводится в больших объемах и большее число раз, так что если есть возможность выбора, выбирайте КоКАВ.</p>\r\n<p>На Российском рынке еще представлена французская вакцина Верораб (фирмы Aventis Pasteur), содержащая инактивированный вирус (штамм Wistar, Rabies PM/Wi38–1503–3M) — 2,5 МЕ и немецкая Рабипур (фирмы Ciron Behring), состоящая из инактивированного (убитого) вируса бешенства (штамм Flury LEP).</p>\r\n<p>Есть еще французская прививка, которая называется Имогам Раж. Это иммуноглобулин, который вводится однократно, одновременно с вакциной и показан лицам с подозрением на инфицирование вирусом бешенства, особенно в случае значительных повреждений (в соответствии с рекомендациями ВОЗ — одиночные или множественные укусы или царапины с нарушением целостности кожных покровов).</p>\r\n<p>Побочные эффекты у всех вакцин примерно одинаковы и включают в себя местные реакции в виде болезненности, отека и уплотнения, , общее , , \"></a>, и аппетита, , а также иногда случается аллергия на компоненты вакцины.</p>",
"clinical_picture": "<p>1. Продромальная фаза (предвестники). У 50-80% больных первые признаки бешенства всегда связаны с местом укуса: появляется боль и , рубец вновь припухает и краснеет. Другие симптомы: тела, общее , \">, \">, затруднённое глотание, . Возможны повышение зрительной и слуховой чувствительности, беспричинный \">, нарушения сна (, кошмары).</p>\r\n<p>2. Энцефалитная фаза (возбуждение). Спустя 2-3 дня развивается период возбуждения, для которого характерны периодические приступы болезненных спазмов (судорог) всех мышц, возникающих от малейшего раздражителя: яркий свет (), шум (акустофобия), дуновение воздуха (аэрофобия). Иногда в этой стадии на фоне приступов больные становятся агрессивными, кричат, мечутся, рвут одежду, ломают мебель, обнаруживая нечеловеческую «бешенную» силу. Между приступами часто наступает , слуховые и .</p>\r\n<p>Температура тела повышается до 40-41 градуса, резко выражены , постуральное снижение АД, повышенное слёзотечение, \"> и саливация (обильное отделение слюны). Затруднения глотания слюны и вспенивание её воздухом при глотании дают характерный симптом бешенства — «пена изо рта».</p>\r\n<full></full>\r\n<p>Вслед за острым энцефалитом развивается стволовая симптоматика. Исчезает корнеальный рефлекс, пропадает глоточный рефлекс. Развивается гидрофобия — судорожные сокращения глотательной мускулатуры при виде воды или звуках льющейся воды.</p>\r\n<p>Появление уже на ранней стадии болезни симптомов дисфункции ствола головного мозга является отличительным признаком бешенства от других энцефалитов.</p>\r\n<p>3. Заключительная фаза (параличи). Если больной не скончался от длительного спазма дыхательных мышц, то ещё через 2-3 дня болезнь переходит в последнюю стадию, для которой характерно развитие параличей конечностей и нарастание стволовой симптоматики в виде поражения черепно-мозговых нервов (, лицевого нерва, неврит зрительного нерва), нарушение функции тазовых органов (приапизм, спонтанная эякуляция). Психомоторное возбуждение и судороги ослабевают, больной может пить и есть, дыхание становится более спокойным («зловещее успокоение»). Через 12-20 часов наступает смерть от паралича дыхательного центра или остановки сердца, как правило, внезапно, без агонии.</p>\r\n<p>Общая длительность болезни не превышает 5-7 дней.</p>",
"image": "http://api.symptomd.ru/storage/2c51f02103b775e684bee973a4557a6a_N4QBkz7.png",
"image_alt": "Бешенство",
"standard_type": 1,
"danger": 91,
"published": 1,
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"block_rubric": 9,
"standards": []
},
{
"id": 6082,
"symptoms": [
{
"id": 2866,
"synonyms": [
{
"name": "гипертермия"
},
{
"name": "повышение температуры"
},
{
"name": "лихорадка"
},
{
"name": "жар"
}
],
"body_points": [
{
"x": -35,
"y": 2690,
"r": 0
}
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"etiology": "<p>Вирус японского энцефалита относится к семейству Flaviviridae, входит в экологическую группу арбовирусов. Вирус содержит РНК, его размеры не превышают 15—22 нм. При кипячении сохраняется в течение двух часов. Спирт, эфир и ацетон оказывают угнетающее действие на активность возбудителя только через 3 дня. При низких температурах может сохраняться более года. </p>\r\n<p>Источник заражения - дикие животные, птицы. </p>\r\n<p>Переносчиками вируса являются комары (Culex pipiens, Culex trithaeniorhynchus, Aedes togoi, Aedes japonicus).Заражение человека происходит в результате попадания слюны комара в ранку, возникающую при укусе. </p>",
"pathogenesis": "<p>После укуса инфицированным комаром вирус гематогенным путём попадает в ЦНС и в связи с выраженной нейротропностью быстро размножается в нервных клетках. По достижении максимальной концентрации вирус повторно выходит в кровь и действует общетоксически, что соответствует окончанию инкубационного периода и началу клинических проявлений. </p>\r\n<p>Наибольшие морфологические изменения обнаруживают в ЦНС. Макроскопически мозговые оболочки отёчны, гиперемированы, с точечными кровоизлияниями. Вещество мозга набухшее, дряблое, с локальными кровоизлияниями и очагами размягчения. Выраженные изменения отмечают в области зрительных бугров и стриарных образований. </p>",
"diagnostics": "<p>Специфическая лабораторная диагностика включает в себя: </p>\r\n<ul>\r\n<li>выделение вируса методом ПЦР (он может быть обнаружен особенно в первые 7 дней болезни в крови, моче и цереброспинальной жидкости), </li>\r\n<li>обнаружение вирусного антигена с помощью реакции иммунофлюоресценции и иммуноферментного метода; </li>\r\n<li>выявление 4-кратного и более нарастания титра антител в парных сыворотках, взятых в первые дни болезни и через 2-3 нед, с помощью РСК, РТГА, РН и др. </li>\r\n<li>Иногда применяют кожно-аллергическую пробу с введением суспензии мозга зараженных мышей. </li>\r\n</ul>\r\n<p>К инструментальным методам диагностики относятся: </p>\r\n<ul>\r\n<li>Эхо-энцефалография; </li>\r\n<li>ЭЭГ; </li>\r\n<li>Офтальмоскопия; </li>\r\n<li>КТ и МРТ головного мозга. </li>\r\n</ul>",
"treatment": "<p>Этиотропная составляющая предполагает назначение противовирусного фармпрепарата рибавирина. Параллельно осуществляется терапия интерфероном и его аналогами. Возможно использование специфического иммуноглобулина. </p>\r\n<p>Патогенетическая составляющая заключается в коррекции жизненно важных функций, применении противоотечных средств, антигипоксантов, нейропротекторов. Зачастую возникает необходимость в назначении глюкокортикоидов, обладающих выраженным противовоспалительным и противоотечным действием. </p>\r\n<p>Симптоматическая терапия подразумевает использование по мере необходимости психотропных средств (нейролептиков, транквилизаторов), противорвотных препаратов. </p>\r\n<p>Восстановительное лечение предусматривает сосудистую и нейропротекторную терапию с целью скорейшего и как можно более полного восстановления церебральных структур и их функций. При наличии парезов обязательными компонентами реабилитации являются массаж и ЛФК; возможно использование физиотерапии — электрофореза, электромиостимуляции, рефлексотерапии. </p>\r\n<p>При нарушениях психики необходима консультация психиатра с осуществлением коррекционной терапии, психотерапии, социальной адаптации.</p>",
"prevention": "<p>В очагах японского энцефалита проводят комплекс противокомариных мероприятий, осуществляют меры по защите от нападения комаров и созданию активного иммунитета у населения. Иммунизацию проводят по эпидемическим показаниям населению эндемических очагов с помощью формолвакцины. Для экстренной пассивной профилактики применяют однократно 10 мл гипериммунной лошадиной сыворотки или 6 мл иммуноглобулина. </p>",
"clinical_picture": "<p>Инкубационный период (от заражения до появления симптомов) 5-14 дней. Начало острое, температура до 40 °С в течение 7-10 дней. Первые дни - озноб, головная боль, ломота, тошнота, рвота, мышечная гипертония. </p>\r\n<p>С 3-4-го дня болезни в случаях с тяжелым течением на первый план выходят признаки поражения центральной нервной системы. Нарастает головная боль, отмечаются заторможенность или периодически психомоторное возбуждение, бред и галлюцинации, нередки клонические или тонические судороги. </p>\r\n<p>В течение 2-3 дней часто развивается коматозное состояние. Помимо общемозговых симптомов, наблюдаются менингеальный синдром и разнообразные очаговые неврологические симптомы (спастические парезы и параличи, нарушение речи, гипертонус мышц, гиперкинезы (патологические непроизвольные движения), эпилептиформные припадки, признаки поражения ядер черепных нервов и др). </p>\r\n<p>Развиваются резкая одышка, потливость, покраснение лица, шеи и верхней части туловища, пульс до 120-140 и более в минуту, понижение или, реже, повышение артериального давления. Может быть небольшое увеличение печени и селезенки. </p>\r\n<p>Реконвалесценция (выздоровление) длительная. В периоде реконвалесценции продолжительностью 4-7 недель температура тела нормальная, сохраняются некоторые остаточные симптомы органического поражения головного, мозга (парезы, мышечная слабость). </p>",
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"code": "A84",
"name": "Клещевой вирусный энцефалит",
"icd_name": "Клещевой вирусный энцефалит",
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"age_min": 1,
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"slug": "a84_kleschevoy_virusnyy_encefalit",
"lead": "Нарушение здоровья, относящееся к группе вирусные инфекции центральной нервной системы",
"description": "<p>Клещевой энцефалит – это вирусное, природно-очаговое (характерное только для определенных территорий) заболевание с преимущественным поражением центральной нервной системы.</p>",
"etiology": "<p>Вирус клещевого энцефалита — нейротропный, РНК-содержащий. Относится к семейству Flaviviridae экологической группы арбовирусов. Возбудитель способен длительно сохранять вирулентные свойства при низких температурах, но нестоек к высоким температурам (при кипячении погибает через 2-3 мин), дезинфицирующим средствам и ультрафиолетовому излучению. </p>\r\n<p>Основным резервуаром, поддерживающим существование возбудителя, являются иксодовые клещи — Ixodes persulcatus (преимущественно в азиатском регионе России) и Ixodes ricinus (преимущественно в европейском регионе). </p>\r\n<p>Кроме человека, вирус может поражать диких и домашних животных, в том числе коров и коз. Поэтому заражение может происходить как напрямую – при укусе человека клещом или случайном раздавливании насекомого при попытках его извлечь, так и при употреблении молока и молочных продуктов, не прошедших термическую обработку и полученных от больных животных.</p>",
"pathogenesis": "<p>Вирус попадает в организм человека двумя путями: через укус клеща и алиментарно. Алиментарное заражение происходит при употреблении сырого молока, а также молочных продуктов, приготовленных из молока зараженных коров и коз. При укусе клеща вирус сразу попадает в кровь. Однако при обоих способах заражения вирус проникает в нервную систему гематогенно и по периневральным пространствам. Вирус обнаруживается в ткани мозга через 2-3 дня после укуса, а максимальная концентрация его отмечается уже к 4-му дню. </p>",
"diagnostics": "<p>Серологический метод. Материалом являются парные сыворотки больного. Определение диагностического нарастания титра антител в реакциях РТГА(реакция торможения гемагглютинации) и ИФА (иммуноферментный анализ). </p>\r\n<p>Молекулярно-биологический метод. Материалом является клещ. Клеща исследуют на наличие антигена вируса клещевого энцефалита, реже с помощью ПЦР (полимеразно-цепная реакция) выявляют вирусную РНК (клеща). Для исследований на наличие антигена используют живой материал, ПЦР диагностика возможна по фрагментам клеща. </p>\r\n<p>Вирусологический метод. Выделение вируса из крови и спинномозговой жидкости путём введения материала в мозг новорожденным белым мышам. </p>",
"treatment": "<p>Лечение включает специфическую (направленную на возбудителя), патогенетическую (блокирующую механизмы развития заболевания) и симптоматическую терапию. Больному назначается строгий постельный режим. Схема специфического лечения зависит от времени, прошедшего с момента появления первых симптомов. В самом начале заболевания (первая неделя) высокую эффективность показало назначение больным противоклещевого иммуноглобулина. Его вводят в течение 3 дней. Также при ранней диагностике хорошие результаты дает применение противовирусных препаратов: рибонуклеазы, рибавирина, интерферона, экстракт побегов картофеля. </p>\r\n<p>Все эти препараты неэффективны на поздних стадиях заболевания, когда вирус уже поразил центральную нервную систему. В этом случае лечение направлено не на борьбу с возбудителем болезни, а на патологические механизмы, угрожающие жизни пациента. Для этого используют подачу кислорода через маску, ИВЛ при нарушении дыхания, мочегонные средства для снижения внутричерепного давления, препараты, увеличивающие устойчивость мозга к кислородному голоданию, нейролептики, глюкокортикоиды. </p>",
"prevention": "<p>В качестве специфической профилактики применяют вакцинацию, которая является самой надежной превентивной мерой. Обязательной вакцинации подлежат все лица, проживающие в эндемичных районах или въезжающие в них. Население в эндемичных районах составляет примерно половину всего населения России. </p>\r\n<p>Неспецифические меры профилактики сводятся к предупреждению присасывания клещей, а также к их раннему удалению. </p>\r\n<p>Избегать посещения мест обитания клещей (лесные биотопы с высокой травой, кустарником) в апреле-июле. Энцефалитные клещи нападают, цепляясь за проходящих мимо теплокровных животных и людей, как репейник. Местом для поджидания жертвы они избирают запачканые потовыми следами теплокровных травинки и веточки в тенистых травянистых местах. С учетом этого в походах следует держаться подальше от троп животных, и домашнего скота. На дорожках и широких тропах держаться середины троп,избегая контакта со свешивающейся на тропу растительностью. </p>\r\n<p>Применять репелленты, содержащие ДЭТА или перметрин. </p>\r\n<p>Следует надевать одежду с длинными рукавами и штанинами без дыр и отверстий, штанины желательно заправлять в длинные носки, рубашку в брюки. Волосы следует прятать под головной убор. Чтобы клещей было легче заметить, предпочтительно надевать светлую одежду. </p>\r\n<p>Во время пребывания в лесу рекомендуется регулярно осматривать одежду и контролировать открытые участки кожи (шею, запястья рук). При соблюдении правил носки одежды, указанной пунктом выше, клещи, не снятые с одежды, неизбежно попадают на шею, где их легко обнаружить. </p>\r\n<p>По возвращении из леса производится осмотр одежды и тела. Поскольку некоторые участки тела недоступны самоосмотру, следует прибегнуть к посторонней помощи для осмотра спины и волосистой части головы. </p>\r\n<p>Поскольку личиночные формы клещей очень мелки, их можно не заметить на одежде. Во избежание их присасывания одежду рекомендуется простирать в горячей воде. </p>\r\n<p>При обнаружении присосавшегося клеща его следует немедленно удалить. Чем раньше клещ удален, тем меньше вероятность заражения. Удалять клеща можно маникюрным пинцетом или нитью, обвязав её вокруг головы паразита. Клещ удаляется раскачивающе-выкручивающими движениями. Избегайте раздавливания клеща! Ранку можно обработать любым дезинфицирующим раствором (хлоргексидин, раствор йода, спирт, и т. п.). </p>",
"clinical_picture": "<p>Выделяют пять клинических форм клещевого энцефалита: </p>\r\n<ol>\r\n<li>лихорадочную (стертую); </li>\r\n<li>менингеальную; </li>\r\n<li>менингоэнцефалитическую; </li>\r\n<li>полиомиелитическую; </li>\r\n<li>полирадикулоневритическую. </li>\r\n</ol>\r\n<p>Лихорадочная форма клещевого энцефалита характеризуется благоприятным течением с быстрым выздоровлением. Продолжительность лихорадки - 3-5 дней. Основными клиническими признаками ее являются токсико-инфекционные проявления: головная боль, слабость, тошнота - при слабо выраженной неврологической симптоматике. Показатели ликвора без отклонений от нормы. </p>\r\n<p>Менингеальная форма является наиболее частой формой клещевого энцефалита. Больные жалуются на сильную головную боль, усиливающуюся при малейшем движении головы, головокружение, тошноту, однократную или, многократную рвоту, боли в глазах, светобоязнь. Они вялы и заторможены. Определяется ригидность мышц затылка, симптомы Кернига и Брудзинского. Менингеальные симптомы держатся на протяжении всего лихорадочного периода. Иногда они определяются и при нормальной температуре. Продолжительность лихорадки в среднем 7-14 дней. В спиномозговой жидкости изменения, характерные для вирусного мнгингита. </p>\r\n<p>Менингоэнцефалитическая форма клещевого энцефалита отличается более тяжелым течением. Нередко наблюдаются бред, галлюцинации, психомоторное возбуждение с утратой ориентировки в месте и во времени. Могут развиваться эпилептические припадки. </p>\r\n<p>При диффузном менингоэнцефалите выражены общемозговые нарушения (глубокие расстройства сознания, эпиприпадки вплоть до эпилептического статуса) и рассеянные очаги органического поражения мозга в виде псевдобульбарных расстройств (нарушение дыхания в виде урежения или учащения частоты, появление патологического дыхания), неравномерности глубоких рефлексов, асимметричных патологических рефлексов, центральных парезов мимической мускулатуры и мышц языка. </p>\r\n<p>При очаговом менингоэнцефалите быстро развиваются парезы, эпилептические припадки, реже - подкорковые и мозжечковые синдромы. В редких случаях может развиваться синдром желудочного кровотечения с кровавой рвотой. Характерны очаговые поражения черепных нервов. </p>\r\n<p>Полиомиелитическая форма клещевого энцефалита наблюдается почти у трети больных. Характеризуется продромальным периодом (1-2 дня), в течение которого отмечаются общая слабость и повышенная утомляемость. Затем выявляются периодически возникающие подергивания мышц. Внезапно может развиться слабость в какой-либо конечности или появление чувства онемения в ней (в дальнейшем в этих конечностях нередко развиваются выраженные двигательные нарушения). В последующем на фоне фебрильной лихорадки и общемозговых симптомов развиваются вялые парезы шейно-плечевой (шейно-грудной) локализации, которые могут нарастать в течение нескольких дней, а иногда до 2 нед. Наблюдаются следующие симптомы: \"свисающая на грудь голова\", \"горделивая осанка\", \"согбенная сутуловатая поза\". вялые парезы рук и спастические - ног, комбинации амиотрофий и гиперфлексии в пределах одной паретической конечности. В первые дни болезни у больных этой формой клещевого энцефалита часто резко выражен болевой синдром. Наиболее характерная локализация болей в области мышц шеи, особенно по задней поверхности, в области надплечий и рук. В конце 2-3-й недели болезни развивается атрофия пораженных мышц. </p>\r\n<p>Полирадикулоневритическая форма клещевого энцефалита характеризуется поражением периферических нервов и корешков. У больных появляются боли по ходу нервных стволов, парестезии (чувство \"ползания мурашек\", покалывание). Появляются расстройства чувствительности в дистальных отделах конечностей. Могут возникнуть вялые параличи, которые начинаются с ног и распространяются на мускулатуру туловища и рук. Восхождение может начинаться и с мышц плечевого пояса, захватывать шейные мышцы. </p>",
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}
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}
