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},
"code": "A48.3",
"name": "Синдром токсического шока",
"icd_name": "Синдром токсического шока",
"gender": 2,
"age_min": 15,
"age_max": 45,
"cause": [
"0"
],
"periodicity": 1,
"slug": "a48.3_sindrom_toksicheskogo_shoka",
"lead": "тяжелое острое полиорганное поражение, вызванное экзотоксинами золотистого стафилококка или пиогенного стрептококка",
"description": "<p><span id=\"docs-internal-guid-2f3c76f1-7fff-d4c1-3848-b9628f230f0d\"><span style=\"font-size: 7pt; font-family: Verdana; background-color: transparent; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;\">Синдром токсического шока — это </span></span><span style=\"background-color: transparent; font-family: Verdana; font-size: 7pt; white-space: pre-wrap;\">острое и тяжелое полисистемное заболевание, которое характеризуется внезапным началом высокой лихорадки, гипотензией, рвотой, диареей, эритематозными высыпаниями на коже, шелушащимися при выздоровлении, и поражением многих органов.</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;\">Синдром токсического шока вызывают экзотоксин-продуцирующие микроорганизмы, оказывающие системное воздействие на разные органы и ткани, — золотистый стафилококк и пиогенный β-гемолитический стрептококк группы А. В большинстве случаев заболевание возникает не в момент первичного заражения бактериями, а на фоне носительства инфекционных возбудителей при воздействии следующих предрасполагающих факторов:</span></p>\r\n<ul>\r\n<li><span style=\"background-color: transparent; font-family: Verdana; font-size: 7pt; white-space: pre-wrap;\">Использование тампонов. Вероятность развития СТШ возрастает при пользовании гигиеническими средствами с повышенными абсорбирующими свойствами и нарушении рекомендуемой частоты их замены.</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;\">Использование интравагинальных контрацептивов. Наличие во влагалище диафрагм, губок, колпачков создает благоприятные условия для размножения микроорганизмов.</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;\">Нарушение целостности слизистых оболочек. При травмах половых органов, наличии в матке остатков плацентарной ткани, плодных оболочек, крови после родов и гинекологических операций возникают оптимальные условия для бактериального обсеменения и проникновения микроорганизмов или их токсинов в кровь.</span></li>\r\n</ul>\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;\">Неменструальный синдром токсического шока может осложнять хирургические процедуры, при которых применяется перевязочный материал, накапливающий кровь (операции на полости носа с использованием турунд, тампонирование ран и др.), и травматические повреждения кожи. Сочетание указанных факторов с вирусными заболеваниями (ветрянкой, гриппом), приемом иммуносупрессивных препаратов повышает риск развития токсемии и бактериемии.</span></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;\"> </span></p>",
"pathogenesis": "<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;\">Ключевую роль в развитии синдрома токсического шока играют механические и химические воздействия, которые способствуют размножению бактерий и влияют на проницаемость тканей. Пусковым моментом служит проникновение в кровь значительных количеств специфических токсинов и их взаимодействие с Т-лимфоцитами. В результате массивно высвобождаются цитокины, вызывающие полиорганную токсическую реакцию. Расширяются сосуды и повышается проницаемость их стенки, что приводит к перемещению плазмы крови и сывороточных протеинов во внесосудистое пространство. При этом наблюдается резкое падение давления, возникают отеки, нарушается коагуляция, повышается температура. Под влиянием опосредованных иммунных реакций и прямого действия токсинов поражаются кожа, паренхима печени, легких и других органов.</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;\">С учетом полиорганного характера заболевания для постановки диагноза необходимо оценивать как локальные изменения со стороны женских органов, так и признаки нарушения других систем. </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;\">В комплексное обследование включены:</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;\">Осмотр гинеколога. Выявляются отечность и гиперемия половых органов, в некоторых случаях — скудные выделения гнойного характера из цервикального канала. Пальпаторно может определяться болезненность в области придатков.</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;\">Физикальное обследование. В 100% случаев наблюдается повышение температуры более 38,9°С и падение систолического давления ниже 90 мм рт.ст. (обычно с ортостатическим снижением на 15 мм рт.ст.).</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;\">Общеклинические анализы. Для ОАК характерны лейкоцитоз с высоким нейтрофилезом, сдвиг лейкоцитарной формулы влево, тромбоцитопения, анемия, повышение СОЭ. В общем анализе мочи определяется аномальный мочевой осадок с выщелоченными эритроцитами и стерильной пиурией.</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;\">Биохимический анализ крови. При нарушенной функции печени повышаются уровень билирубина и активность трансфераз (выявляется почти у половины заболевших), при почечной недостаточности возникает азотемия, креатининемия, при поражении мышц — повышенное содержание КФК. В коагулограмме увеличивается протромбиновое время и частичное тромбопластиновое время, определяются продукты деградации фибрина. Анализ крови на электролиты выявляет метаболический ацидоз, снижение уровня кальция, фосфора, натрия, калия.</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;\">Методы определения возбудителя. Для выявления инфекционного агента используют бакпосев мазка из половых органов с антибиотикограммой и посев крови (показан при подозрении на стрептококковый СТШ). Серологические исследования позволяют провести оценку показателей иммунной системы, исключить инфекционные заболевания со сходной клинической картиной.</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;\">Инструментальная диагностика. ЭКГ позволяет своевременно выявить нарушения сердечного ритма. Флюорография или рентгенография ОГК рекомендованы для оценки состояния легких.</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;\"> </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;\">При выборе схемы лечения синдрома токсического шока важно предусмотреть воздействие на факторы, вызвавшие заболевание, и мероприятия для стабилизации функций пораженных систем. Пациентке показаны:</span></p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </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;\">Санация бактериального очага. В первую очередь удаляют тампон, диафрагму, колпачок (при их наличии) и промывают влагалище стерильным раствором. При выявлении бактериально обсемененных ран возможно иссечение тканей с участками некроза.</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;\">Антибиотикотерапия. Выбор препарата основан на результатах определения чувствительности к противомикробным средствам. До получения таких данных назначается эмпирическая терапия с учетом вероятного возбудителя и его возможной антибиотикорезистентности. Курс составляет до 10 дней.</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;\">Инфузионная терапия. Ключевой элемент лечения — восстановление внутрисосудистого объема жидкости и стабилизация показателей гемодинамики. В зависимости от характера нарушений пациентке вливают кристаллоидные растворы, электролиты, свежезамороженную плазму крови, тромбоцитарную массу и т. п.</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;\">Вазопрессорные средства. Если коррекция объема внутрисосудистой жидкости не позволяет нормализовать АД, вводят препараты с прессорным эффектом.</span></li>\r\n</ul>\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 выраженной органной недостаточности пациентке могут назначаться гемодиализ (при острой почечной недостаточности), искусственная вентиляция легких с положительным давлением на выдохе (при респираторном дистресс-синдроме). Ряд авторов отмечают более быстрое выздоровление при назначении кортикостероидов и иммуноглобулинов.</span></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;\"> </span></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;\">Для профилактики СТШ важно соблюдать рекомендации по использованию тампонов и протоколы обследования перед родами и гинекологическими операциями для своевременного выявления возбудителей.</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;\">Ранние признаки СТШ могут появиться в течение 48 часов после введения или удаления тампонов. Чаще всего токсический шок развивается, если женщина использует тампон с большой впитывающей способностью и не заменяет его новым вовремя.</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;\">Заболевание развивается остро. К типичным признакам синдрома относятся:</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;\">лихорадка до 39 0С;</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;\">падение артериального давления;</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;\">высыпания на теле.</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;\">Сыпь располагается различных частях тела: на лице, туловище и конечностях. Вначале она напоминает легкий солнечный ожог. Через 3-7 дней кожа начинает шелушиться, а на ладонях и стопах — сходить лоскутами, как кожура.</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;\">Также в острый период СТШ могут беспокоить:</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;\">повышенная болезненность кожи;</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;\">“ломота” и боли в мышцах и суставах;</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;\">слабость;</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;\">сонливость;</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;\">заторможенность;</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;\">спутанности сознания;</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;\">тошнота и рвота.</span></li>\r\n</ul>\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;\">Иногда наблюдается покраснение кожи вокруг входа влагалища и гнойные выделения из половых путей. Но чаще симптомы инфекции половых путей отсутствуют, потому что стафилококки не вызывают местного воспаления.</span></p>",
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{
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],
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},
"code": "A48.0",
"name": "Газовая гангрена",
"icd_name": "Газовая гангрена",
"gender": 0,
"age_min": 15,
"age_max": 100,
"cause": [
"0"
],
"periodicity": 1,
"slug": "a48.0_gazovaya_gangrena",
"lead": "осложнение раневого процесса, возникающее при обсеменении раны бактериями рода Clostridium",
"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;\">Газовая гангрена — это омертвение тканей организма, вызванное инфекцией, обусловленной ростом и размножением в тканях клостридиальной микрофлоры.</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;\">Газовая гангрена вызывается бактериями из рода клостридий, которые в норме обитают в кишечнике травоядных домашних животных, откуда попадают в землю, уличную пыль, на одежду и т. д. В отдельных случаях обнаруживаются в фекалиях и на коже здоровых людей. Размножаются только в безкислородной среде, но в присутствии кислорода могут длительное время сохраняться в виде спор.</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;\">В 90% случаев возбудителем газовой гангрены является Clostridium perfringens. Обычно газовая гангрена развивается в результате обширных размозженных ран и травматических отрывов конечностей, реже – в результате ранений толстого кишечника и попадания инородных тел. В отдельных случаях причиной возникновения могут стать даже небольшие раны (особенно – загрязненные обрывками одежды или частицами почвы).</span></p>",
"pathogenesis": "",
"diagnostics": "<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;\">Диагноз газовая гангрена выставляется на основании клинической картины и подтверждается дополнительными исследованиями. При изучении раневого отделяемого под микроскопом обнаруживаются клостридии. Рентгенологическое обследование подтверждает наличие газа в тканях. </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;\">Лечение включает в себя неотложное оперативное лечение в сочетании с активной общей терапией. Рану широко вскрывают лампасными разрезами (широкими продольными разрезами на протяжении всего сегмента, включающими в себя разрез кожи, подкожной клетчатки и собственной фасции). Все нежизнеспособные ткани иссекают, рану промывают раствором перекиси водорода. При наличии подозрительных участков на соседних сегментах там также производят лампасные разрезы.</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;\">Раны обязательно оставляют открытыми и рыхло дренируют марлей, пропитанной раствором марганцовки или перекиси водорода. В течение первых 2-3 суток перевязки производятся 2-3 раза в день, в дальнейшем – ежедневно. При быстром прогрессировании, вовлечении в процесс всех мягких тканей и омертвении конечности выполняется ампутация или экзартикуляция. Ампутация проводится гильотинным способом, с отсечением всех слоев на одном уровне. Рану оставляют открытой, на культе выполняют лампасные разрезы, раны дренируют, используя марлю, смоченную в растворе перманганата калия или перекиси водорода.</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;\">Сразу после постановки диагноза начинают массивную инфузионную терапию с использованием плазмы, альбумина, растворов белков и электролитов. При анемии проводят переливание крови. Антибиотики вводят в высоких дозах внутриартериально или внутривенно. В послеоперационном периоде пациентам назначают гипербарическую оксигенацию. Выполняют внутривенное введение противогангренозной сыворотки. При установленном возбудителе используют моновалентную сыворотку, при неустановленном – поливалентную.</span></p>",
"prevention": "<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;\">Основным средством профилактики газовой гангрены является адекватная своевременная первичная обработка раневой поверхности и назначение антибиотиков широкого спектра действия. В процессе обработки должны быть иссечены все нежизнеспособные ткани, а также дно и края раны. Следует помнить, что антибиотикотерапия обязательна при любых обширных ранах, особенно – обильно загрязненных и сопровождающихся размозжением тканей. Профилактическое использование противогангренозных сывороток недостаточно эффективно и может стать причиной развития анафилактического шока.</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;\">Пациентов с газовой гангреной изолируют, выделяют им отдельный сестринский пост, перевязочный материал немедленно сжигают, инструменты и белье подвергают специальной обработке. Споры клостридий обладают высокой устойчивостью к кипячению, поэтому инструмент следует обрабатывать в условиях повышенного давления в паровом стерилизаторе либо в сухожаровом шкафу. Любые медицинские мероприятия необходимо проводить в резиновых перчатках, которые по окончании процедуры сжигают или погружают в дезинфицирующий состав (лизол, карболовую кислоту, хлорамин).</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;\">Заболевание начинается стремительно, уже на первый-третий день после ранения или травмы развивается отек тканей, в ране продуцируется мутное отделяемое с пузырьками газа и крайне неприятным запахом. Отечность быстро распространяется, на коже появляются пузыри с геморрагическим содержимым внутри, пятна зеленого цвета. Конечность становится холодной, мышцы приобретают вид вареного мяса, их волокна расслаиваются. За 10-12 часов один из видов клостридии способен разрушить подкожную клетчатку до костей.</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;\">Нарастают симптомы общей интоксикации организма:</span></p>\r\n<ul style=\"margin-top: 0; margin-bottom: 0; padding-inline-start: 48px;\">\r\n<li style=\"list-style-type: disc; font-size: 6.5pt; font-family: Verdana; color: #333333; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre;\" dir=\"ltr\">\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;\">Учащенное сердцебиение;</span></p>\r\n</li>\r\n<li style=\"list-style-type: disc; font-size: 6.5pt; font-family: Verdana; color: #333333; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre;\" dir=\"ltr\">\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;\">Гипертермия до 39-40°;</span></p>\r\n</li>\r\n<li style=\"list-style-type: disc; font-size: 6.5pt; font-family: Verdana; color: #333333; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre;\" dir=\"ltr\">\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;\">Ломота в мышцах;</span></p>\r\n</li>\r\n<li style=\"list-style-type: disc; font-size: 6.5pt; font-family: Verdana; color: #333333; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre;\" dir=\"ltr\">\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;\">Частое дыхание;</span></p>\r\n</li>\r\n<li style=\"list-style-type: disc; font-size: 6.5pt; font-family: Verdana; color: #333333; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre;\" dir=\"ltr\">\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;\">Жажда;</span></p>\r\n</li>\r\n<li style=\"list-style-type: disc; font-size: 6.5pt; font-family: Verdana; color: #333333; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre;\" dir=\"ltr\">\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;\">Бессонница;</span></p>\r\n</li>\r\n<li style=\"list-style-type: disc; font-size: 6.5pt; font-family: Verdana; color: #333333; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre;\" dir=\"ltr\">\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;\">Головная боль;</span></p>\r\n</li>\r\n<li style=\"list-style-type: disc; font-size: 6.5pt; font-family: Verdana; color: #333333; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre;\" dir=\"ltr\">\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;\">Повышенная возбудимость или, наоборот, подавленность;</span></p>\r\n</li>\r\n<li style=\"list-style-type: disc; font-size: 6.5pt; font-family: Verdana; color: #333333; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre;\" dir=\"ltr\">\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;\">Уменьшение количества выделяемой мочи, далее ее полное отсутствие;</span></p>\r\n</li>\r\n<li style=\"list-style-type: disc; font-size: 6.5pt; font-family: Verdana; color: #333333; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre;\" dir=\"ltr\">\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;\">Крепитация (треск) при нажатии на поврежденные ткани.</span></p>\r\n</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;\">В крови стремительно разрушаются эритроциты, возникает анемия и гемолитическая желтуха.</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;\">В своем развитии гангрена проходит 4 стадии:</span></p>\r\n<ul style=\"margin-top: 0; margin-bottom: 0; padding-inline-start: 48px;\">\r\n<li style=\"list-style-type: disc; font-size: 6.5pt; font-family: Verdana; color: #333333; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre;\" dir=\"ltr\">\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;\">Стадия ограниченной гангрены. Отек тканей и отделяемое минимальны, рана сухая, имеется боль, кожа бледная.</span></p>\r\n</li>\r\n<li style=\"list-style-type: disc; font-size: 6.5pt; font-family: Verdana; color: #333333; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre;\" dir=\"ltr\">\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;\">Стадия распространения. Поражение и некроз тканей продвигаются по конечности, боль приобретает распирающий характер, мышцы обескровлены, кожа желтеет, на ней заметны пятна.</span></p>\r\n</li>\r\n<li style=\"list-style-type: disc; font-size: 6.5pt; font-family: Verdana; color: #333333; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre;\" dir=\"ltr\">\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;\">Третья стадия. Боль уменьшается или прекращается совсем, конечность увеличивается, холодеет, пульсация прекращается. Отечность и газы распространяются по большой площади тела, на коже образуются пузыри с бурым содержимым.</span></p>\r\n</li>\r\n<li style=\"list-style-type: disc; font-size: 6.5pt; font-family: Verdana; color: #333333; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre;\" dir=\"ltr\">\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;\">Стадия сепсиса. Интоксикация организма значительна, рана наполняется гноем, очаги с гнойным содержимым фиксируются отдаленно от первичного внедрения бактерий.</span></p>\r\n</li>\r\n</ul>\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;\">Если больной не получает своевременную помощь, через 2-3 дня наступает летальный исход.</span></p>",
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"code": "A46",
"name": "Рожа",
"icd_name": "Рожа",
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"cause": [
2,
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"slug": "a46_rozha",
"lead": "Нарушение здоровья, относящееся к группе другие бактериальные болезни",
"description": "Рожистое воспаление— острое, нередко рецидивирующее инфекционное заболевание, вызывается бета-гемолитическим стрептококком группы A, поражающее преимущественно кожные покровы и слизистые оболочки. Рожа входит в число самых распространенных бактериальных инфекций, болеют в основном женщины.\r\n\r\n",
"etiology": "<p>Рожу вызывает бета-гемолитический стрептококк группы А, чаще всего вида Streptococcus pyogenes. Стрептококки широко распространены в природе, относительно устойчивы к условиям внешней среды. Рост заболеваемости наблюдается в летне-осенний период, входными воротами инфекции служат мелкие травмы, ссадины, потёртости. Источником инфекции является больной любой формой стрептококковой инфекции или стрептококконоситель. Возможно экзогенное инфицирование через загрязненные инструменты, перевязочный материал, а также из хронических стрептококковых очагов инфекции (например у больных с хроническим тонзиллитом).</p>\r\n<p> </p>",
"pathogenesis": "<p>Входные ворота — поврежденная кожа и слизистые оболочки (при экзогенном заражении). В отдельных случаях заболевание возникает при заносе возбудителя в кожу или слизистые оболочки из имеющихся в организме стрептококковых очагов (эндогенное заражение). Предрасположенность к роже возрастает при сниженной общей сопротивляемости организма; чаще болеют недоношенные, дети, страдающие расстройствами питания, экссудативным диатезом.</p>\r\n<p>Стрептококк обусловливает местные и общие изменения в организме:</p>\r\n<ul>\r\n<li>Местное действие СГА приводит к возникновению серозного воспаления, которое проявляется яркой эритемой, отеком и мелкоочаговой инфильтрацией пораженных участков кожи и подкожной клетчатки. В патологический процесс вовлекаются лимфатические (лимфангоит), артериальные (артериит) и венозные (флебит) сосуды. Пораженные лимфатические сосуды расширены за счет накопления серозного экссудата, в месте их расположения отмечается отек подкожной клетчатки. Возможно тромбирование сосудов, стойкий лимфостаз.</li>\r\n<li>Общее действие токсина СГА при роже проявляется лихорадкой, интоксикацией, токсическим поражением внутренних органов.</li>\r\n</ul>",
"diagnostics": "<p>Диагностика включает в себя сбор анамнеза, обьективный осмотр и лабораторную дивгностику. При этом используют бактериологический метод (высев стрептококка); в общем анализе крови наблюдается типичная картина бактериального воспаления (лейкоцитоз, нейтрофилез, повышенная СОЭ). Определенное диагностическое значение имеют повышенные титры антистрептолизина-Ои других противострептококковых антител, возможно выявление стрептококка в крови больных с помощью метода ПЦР.</p>",
"treatment": "<p>Лечение больных рожей комплексное. Постельный режим — на 5—6 дней, диета — по возрасту с добавлением витаминов (А, С, В). </p>\r\n<p>Этиотропная (направленная на возбудителя) терапия необходима всем больным рожей. Наиболее эффективным препаратом является бензилпенициллина натриевая соль в возрастных дозах курсом 7—10 дней. При ее непереносимости используют макролиды, цефалоспорины I поколения. Хороший эффект отмечают при лечении рожи антибиотиком в сочетании с криотерапией (кратковременное замораживание поверхностных слоев воспаленной кожи струей хлорэтила). Патогенетическое лечение включает дезинтоксикационную и витаминотерапию, антигистаминные средства. При буллезных формах рожи производят вскрытие пузырей и накладывают часто сменяемые марлевые салфетки с антисептическими средствами. Мази не прописывают, чтобы лишний раз не раздражать кожу и не замедлять заживление. При рецидивирующей и буллезной формах рожи рекомендуются глюкокортикоиды. Больным рецидивирующей рожей проводят повторные курсы антибиотиков, физиотерапевтическое лечение (УВЧ, кварц).</p>\r\n<p>В некоторых случаях рецидивирующих форм больным назначают курсы противорецидивного лечения бензилпенициллином внутримышечно раз в три недели. Упорно рецидивирующая рожа нередко лечится курсами инъекций на протяжении двух лет. При имеющихся остаточных явлениях после выписки больным могут назначать курс антибиотикотерапии на срок до полугода.</p>",
"prevention": "<p>Общая профилактика рожи включает меры по санитарно-гигиеническому режиму лечебно-профилактических учреждений, соблюдение правил асептики и антисептики при обработке ран и ссадин, профилактику и лечение гнойничковых заболеваний, кариеса, стрептококковых инфекций. Индивидуальная профилактика заключается в соблюдении личной гигиены и своевременной обработке повреждений кожи дезинфицирующими средствами.</p>",
"clinical_picture": "<p>Инкубационный период продолжается от нескольких часов до 5 суток. Заболевание, как правило, начинается остро с симптомов интоксикации и лихорадки. Появляются озноб, общая слабость, головная боль; могут отмечаться мышечные боли, тошнота, рвота, тахикардия. Температура тела повышается до 39—40° С. Нарушается общее состояние больного, возможны беспокойство, иногда — бред. Через 12—24 ч после начала заболевания на месте возникновения рожистого воспаления (на лице, конечностях, туловище) появляется яркая гиперемия (покраснение), отек кожи, боль. Кожа пораженного участка плотная, отмечаются увеличение и болезненность регионарных лимфатических узлов.</p>\r\n<p>По характеру местных поражений различают эритематозную, эритематозно-буллезную, эритематозно-геморрагическую и буллезно-геморрагическую формы рожи. </p>\r\n<p>При эритематозной форме заболевания участок рожистого воспаления представляет собой пятно ярко-красного цвета, вначале небольшое, но быстро увеличивающееся в размерах. Пораженная кожа обычно окружена плотным приподнятым фестончатым краем, отграничивающим воспаление от неизмененной окружающей ткани. </p>\r\n<p>Эритематозно-буллезная форма рожи характеризуется появлением на фоне эритемы буллезных элементов (пузырей) различных размеров с желтоватым содержимым. В дальнейшем пузыри могут вскрываться с образованием эрозий. </p>\r\n<p>Эритематозно-геморрагическая форма отличается развитием в коже на фоне эритемы кровоизлияний различных размеров.</p>\r\n<p>Буллезно-геморрагическая форма болезни имеет проявления, сходные с эритематозно-буллезной рожей. Однако в отличие от нее, пузыри заполнены не серозным, а геморрагическим (с кровью) содержимым и имеют обычно темную окраску с просвечивающими желтоватыми включениями. </p>\r\n<p>Воспалительные изменения кожи сохраняются при эритематозной форме 5—8 дней, при других — 10—14 дней и более. </p>\r\n<p>По распространенности рожистого воспаления различают локализованную форму — ограниченное поражение кожи в пределах одной анатомической области и распространенную, при которой поражаются обширные участки кожи, выходящие за пределы анатомической области. </p>\r\n<p>Мигрирующая (ползучая, блуждающая) форма является разновидностью распространенной. Она характеризуется тем, что патологический процесс быстро распространяется («ползет») при одновременном стихании воспалительных явлений в месте первоначальной локализации рожистого воспаления. </p>\r\n<p>Метастатическая рожа встречается редко и проявляется возникновением новых очагов воспаления, удаленных от первоначально пораженных участков кожи, что обусловлено распространением стрептококка с током крови. </p>",
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{
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},
{
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},
{
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},
{
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},
{
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},
{
"name": "Болит живот сверху"
},
{
"name": "Боль в правой части живота"
},
{
"name": "Боль в животе у ребенка"
},
{
"name": "У ребенка болит живот"
},
{
"name": "Острая боль в животе"
},
{
"name": "Резь в животе"
},
{
"name": "Боль под ложечкой"
},
{
"name": "Боль после еды"
},
{
"name": "Боль при аппендеците"
}
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{
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{
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{
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{
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{
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},
"code": "A44",
"name": "Бартонеллез",
"icd_name": "Бартонеллез",
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"age_min": 0,
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"cause": [
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],
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"slug": "a44_bartonellez",
"lead": "группа заболеваний, вызываемых бактериями из рода Bartonella, протекающих с преимущественным поражением эндотелиальных клеток и эритроцитов",
"description": "",
"etiology": "<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;\">В организм человека бактерии проникают через укусы комаров, клещей, вшей или микроповреждения кожи. Резервуаром инфекции является человек, больной острыми формами, либо бессимптомный бактерионоситель. Частота бессимптомной бактериемии у носителей инфекции достигает 50%. Восприимчивость к бартонеллезу у жителей эндемичных районов высокая. Антисанитарные условия, скученность людей способствуют увеличению частоты инфицирования.</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;\">В месте проникновения возбудителя образуется первичный аффект – папула, везикула или пустула. Далее с током лимфы возбудитель проникает в лимфатические узлы – развивается лимфаденопатия. При преодолении лимфатического барьера патоген поступает в кровь – наступает бактериемия. Наиболее чувствительными к бартонеллам являются эритроциты и эндотелиальные клетки сосудов, костный мозг, клапаны сердца. Активное размножение возбудителя в эритроцитах и их разрушение вызывает развитие гемолитической анемии.</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 острых процессах в клетках эндотелия преобладают некротические изменения, стенка сосудов инфильтрируется лейкоцитами и макрофагами с образованием гранулем, явления пролиферации выражены незначительно. В слизистых оболочках, коже появляются мелкие кровоизлияния. Для хронического течения бартонеллеза характерно образование новых мелких сосудов с формированием ангиоэндотелиом. При состоятельности системы иммунитета образуются антитела с последующей элиминацией возбудителя. В случае иммунодефицитных состояний происходит хронизация процесса с длительной персистенцией бартонелл в крови. Отсутствие лечения в такой ситуации может привести к летальному исходу. У выздоровевших пациентов формируется стойкий иммунитет.</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;\">При подозрении на бартонеллез необходима консультация терапевта, инфекциониста, дерматолога, в случае поражения нервной системы – невролога, развития гнойных осложнений – хирурга. Во время физикального обследования отмечается бледность, на коже – первичный аффект с регионарной лимфаденопатией, при пальпации – увеличенная печень, селезенка. В диагностике используются следующие 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;\">Исследования крови. В общем и биохимическом анализах крови наблюдается гемолитическая макроцитарная нормо- или гипохромная анемия, маркеры воспаления (СРБ, прокальцитонин, повышение уровня глобулинов), ускорение СОЭ. Лейкоцитоза может не быть, при тромбозе отмечается снижение показателей фибриногена, повышение уровня Д-димеров.</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;\">Прямое обнаружение возбудителя. При микроскопии мазков крови, окрашенных по Романовскому–Гимзе, патогенные микроорганизмы выявляются снаружи и внутри кровяных телец. Также в качестве препарата может использоваться биопсийный материал из лимфатических узлов или элементов сыпи. По посеву крови предварительно судить о наличии и степени бактериемии возможно через 3 дня, окончательно – через 7-10 дней. ДНК возбудителя идентифицируют методом ПЦР.</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 методы диагностики. Проводят определение антител (IgM и IgG) в сыворотке крови пациента методом реакции гемагглютинации, связывания комплимента, непрямой иммунофлюоресценции, иммуноферментного анализа. Для обнаружения антигенов бартонелл выполняют иммуноблоттинг, вестерн-блоттинг.</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;\">УЗИ органов брюшной полости. УЗИ ОБП не является специфическим методом выявления бартонеллеза. Во время процедуры определяется увеличение печени, селезенки, внутрибрюшных лимфоузлов. Возможно выявление в паренхиматозных органах полостей, заполненных жидкостью, очагов пролиферации. Подобная картина может напоминать множество других заболеваний.</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;\"> </span></p>",
"treatment": "<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;\">Лечение осуществляется в инфекционном стационаре. Необходимо соблюдение постельного режима. Проводится этиотропная терапия антибактериальными препаратами. Поскольку возможно последующее вторичное присоединение сальмонеллеза, рационально использовать ципрофлоксацин или хлорамфинекол в сочетании с β-лактамным антибиотиком. Препаратами резерва являются макролиды, тетрациклины, рифампицин. При необходимости назначается симптоматическое лечение (дезинтоксикационная терапия, жаропонижающие препараты, гепатопротекторы, переливание эритроцитарной массы). На инфицированные кожные элементы после промывания антисептиками накладывают повязки с антибактериальными мазями.</span></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;\">Специфическая профилактика не разработана, но вакцина, не предохраняя от заболевания, значительно облегчает клиническое течение болезни. Основная мера профилактики бартонеллеза — борьба с переносчиками болезни (москитами) и предохранение от их укусов в местностях, эндемичных для этого заболевания.</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;\">Болезнь может протекать в виде острой или хронической фазы. Возможно одновременное развитие клиники обеих стадий. В классическом варианте хроническая стадия сменяет острую через 1-2 мес.</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;\">Инкубационный период бартонеллеза от 10 до 120 дней (в среднем около 2-х месяцев). При развертывании клинической картины появляется лихорадка неправильного типа, подъем температуры до 39–40°С сопровождается ознобом, а снижение – потливостью, напоминая малярию. Пациенты жалуются на головные боли, недомогание, боли в животе, суставах, мышцах. Характерна выраженная бледность за счет анемии. Могут появляться различные симптомы нарушения неврологического статуса вплоть до развития комы. На коже, слизистых оболочках возникают мелкие кровоизлияния. Увеличивается печень, селезенка, лимфатические узлы. При благоприятном исходе заболевания человек выздоравливает, однако без лечения летальность составляет от 40 до 90%.</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 сохранении возбудителя в организме бартонеллез переходит в латентную стадию с последующей реактивацией и развитием хронической фазы ‒ перуанской бородавки. Вновь повышается температура. На теле появляется папулезная сыпь, которая со временем трансформируется в узелки от 3 мм до нескольких сантиметров в диаметре. Чаще всего высыпания локализуются на лице, шее, конечностях. Наблюдается поражение слизистых оболочек рта, влагалища, желудочно-кишечного тракта и др. Узлы могут кровоточить и изъязвляться с присоединением вторичной инфекции. При благоприятном течении через 1-2 мес. наступает выздоровление, узлы разрешаются без рубца.</span></p>",
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}
]
}
