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},
"code": "A39",
"name": "Менингококковая инфекция",
"icd_name": "Менингококковая инфекция",
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"age_min": 0,
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"slug": "a39_meningokokkovaya_infekciya",
"lead": "Нарушение здоровья, относящееся к группе другие бактериальные болезни",
"description": " Менингококковая инфекция – это инфекционное заболевание, которое передается воздушно-капельным путем, поражает центральную нервную систему, суставы, сердечную мышцу и нередко становится причиной инфекционно-токсического шока. ",
"etiology": "<p>Менингококк – это округлая грамотрицательная бактерия, неподвижная, спор не образует. В клетках человека он располагается попарно, формируя структуры, схожие по внешнему виду с кофейными зернами. Присутствует капсула, защищающая менингококки от различных воздействий, в первую очередь от фагоцитоза. Оптимальная температура для роста менингококков – 37 °С. </p>\r\n<p>Во внешней среде они малоустойчивы, быстро погибают при воздействии солнечных лучей, дезинфицирующих средств, при высыхании и понижении температуры до 22 °С. </p>",
"pathogenesis": "<p>Входными воротами (местом внедрения) являются слизистые оболочки верхних дыхательных путей (носо- и ротоглотки), где происходит размножение возбудителя. При высоком уровне местной защиты, локальных изменений в слизистых оболочках не происходит, человек на протяжении нескольких недель будет являться носителем менингококка. При недостаточном уровне местной защиты, развивается воспаление слизистой оболочки носоглотки — назофарингит. У некоторых больных менингококк преодолевает местный барьер и выходит в кровь, что может привести к развитию менингококкемии (менингококковому сепсису). В этом случае, бактерии с током крови заносятся в различные органы и ткани: кожу, надпочечники,почки, лёгкие и др. Менингококк способен преодолевать гематоэнцефалический барьер и вызывать поражение мозговых оболочек и вещества головного мозга (менингит, менингоэнцефалит). </p>\r\n<p>Важную роль в патогенезе генерализованных форм менингококковой инфекции играет эндотоксин — он является сильнейшим сосудистым ядом и высвобождается в большом количестве при гибели возбудителя. Воздействуя на внутреннюю стенку сосудов, эндотоксин вызывает микроциркуляторные расстройства, что в конечном итоге приводит к массивным кровоизлияниям во внутренние органы (в том числе в надпочечники с развитием смертельного синдрома Уотерхауса-Фридериксена). В головном мозге развивается отёк. </p>",
"diagnostics": "<p> Чтобы поставить правильный диагноз, необходимо изучить клиническую картину заболевания. Принимают во внимание также эпидемиологические данные, анамнез, результаты лабораторных исследований крови и цереброспинальной жидкости, взятой путем люмбальной пункции. При подозрении на менингококконосительство или менингококковый назофарингит проводят бактериологическое исследованиеслизи, которую собирают с задней стенки глотки. Используют также иммунологические методы.</p>",
"treatment": "<p>Медикаментозное лечение включает в себя: </p>\r\n<ol>\r\n<li>Антибактериальные препараты – используются препараты пенициллинового ряда широкого спектра действия (цефтриаксон, цефепим, бензилпенициллин, меропенем). Их вводят внутривенно, при необходимости – эндолюмбально (непосредственно в ликвор). При отсутствии эффекта в течение 5 суток антибиотик меняют с учетом чувствительности менингококка по данным бакпосева. </li>\r\n<li>Жаропонижающие – они нормализуют температуру тела и останавливают воспалительную реакцию в тканях, чаще всего назначаются аспирин, парацетамол, нимесулид. </li>\r\n<li>Глюкокортикоиды – обладают мощным противовоспалительным действием, их вводят внутривенно при менингите, отеке мозга для предотвращения повреждения нервной ткани. </li>\r\n<li>Растворы электролитов, глюкозы – их вводят внутривенно с целью дезинтоксикации, восстановления кислотно-щелочного баланса крови и поддержания артериального давления. </li>\r\n<li>Мочегонные – препараты назначаются при снижении диуреза для восстановления почечной фильтрации. При отеке мозга они оттягивают жидкость из нервной ткани в сосудистое русло, что необходимо для спасения жизни больного. Для поддержания диуреза назначается фуросемид, при отеке головного мозга — маннитол. </li>\r\n<li>Ноотропы – это вещества, которые защищают нейроны от гибели и сохраняют умственную деятельность больного (глицин). </li>\r\n<li>Витамины – для защиты нервной системы необходимы витамины группы В, для стимуляции иммунитета – витамин С. Их вводят внутривенно и внутримышечно. </li>\r\n</ol>",
"prevention": "<p>Важно вовремя поставить диагноз больным с разными видами менингококковой инфекции и госпитализировать их. Противоэпидемическими мерами является выявление носителей инфекции и проведение им санации носоглотки. Большое значение для профилактики имеет повышение иммунитета людей. За теми, кто был в контакте с больным, устанавливается медицинское наблюдение и проводится бактериологическое обследование. По показаниям осуществляется вакцинация комплексной полисахаридной вакциной против менингококков серологических групп А и С, иммунитет от которой сохраняется в течение 3-5 лет. Повторную иммунизацию при угрозе эпидемии можно проводить через три года.</p>",
"clinical_picture": "<p>Менингококковый назофарингит. Заболевание начинается остро с заложенности носа, скудных слизистых выделений, сухого кашля. Температура повышается лишь у половины больных, не превышает 38,5 градусов С. Она сопровождается признаками интоксикации: ломотой в мышцах и суставах, головной болью, отсутствием аппетита, вялостью. Лихорадка длится не более 4-х дней, после чего больной быстро идет на поправку.</p>\r\n<p>Менингококкемия представляет острый менингококковый сепсис, для которого типично острое начало, высокая лихорадка, ряд септических явлений, в том числе значительные изменения в деятельности сердечно-сосудистой системы, раннее появлением сыпи и тяжелое течение. Сыпь появляется чаще на туловище и нижних конечностях в виде розеолезных и папулезных элементов интенсивно-розового или слегка синюшного оттенка. Кроме того, на коже бывают разной величины геморрагические элементы и звездчатые красные пятна, переходящие в некроз. </p>\r\n<p>Гипертоксическая (молниеносная) форма менингококковой инфекции протекает с инфекционно-токсическим шоком. Начало бурное с внезапного подъёма температуры тела до 39,5-40 °C и выше, озноба, появления обильной геморрагической сыпи. Элементы сыпи быстро (на глазах) сливаются, образуя обширные геморрагии багрово-цианотичного цвета (напоминают трупные пятна). Кожа бледная, холодная на ощупь, может быть покрыта липким потом. Вначале заболевания отмечается выраженное беспокойство ребёнка, но, с прогрессированием шока, сознание у ребёнка угнетается вплоть до развития комы. Артериальное давление в начале заболевания нормальное, или даже повышенное, но с течением времени (при дальнейшем развитии шока) прогрессивно падает, возникает тахикардия, пульс нитевидный, выражена одышка. Всё это говорит о развитии жизнеугрожающего синдрома Уотерхауса-Фридериксена. Также при молниеносной форме часто развиваются судороги. Температура тела в терминальной стадии шока снижается до нормальных значений, или даже низких. Кроме всего прочего, при данной форме менингококковой инфекции развивается острое набухание и отёк головного мозга. Клинически это проявляется сильной головной болью, судорогами, повторной рвотой, потерей сознания. </p>\r\n<p>Менингококковый менингит обычно начинается остро с озноба и повышения температуры до 38-40 °С. Общее состояние больного резко ухудшается. Основной жалобой являются сильнейшие головные боли, отмечается светобоязнь. Быстро появляются и прогрессируют менингеальные симптомы. Отмечается ригидность затылочных мышц, положительный симптом Кернига и другие. Характерны двигательное беспокойство, гиперемия лица, горячая на ощупь кожа, красный дермографизм, иногда наблюдается гиперестезия кожи. Больной занимает в постели вынужденную позу, для которой характерно запрокидывание назад головы и подтягивание ног к животу. Может наступить расстройство сознания и психические нарушения. Возможны бред, возбуждение, галлюцинации или адинамия, заторможенность, сопор, даже кома. </p>",
"image": null,
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},
{
"id": 8217,
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"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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},
"code": "D74",
"name": "Метгемоглобинемия",
"icd_name": "Метгемоглобинемия",
"gender": 0,
"age_min": 0,
"age_max": 100,
"cause": [
"0"
],
"periodicity": 1,
"slug": "d74_metgemoglobinemiya",
"lead": "состояние, характеризующееся повышенным содержанием метгемоглобина (окисленного гемоглобина) в крови и тканевой гипоксией",
"description": "",
"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;\">Метгемоглобин может быть увеличен за счет двух основных причин. Часть случаев заболевания имеет генетическую причину, это означает, что врожденная метаболическая ошибка способствует увеличению доли метгемоглобина в крови. В большинстве случаев метгемоглобинемия, однако, является приобретенной, а не врожденной. Воздействие некоторых окислителей может привести к превращению гемоглобина в метгемоглобин. Известные токсины, которые могут вызвать это заболевание:</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: #252525; 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;\">анилиновые красители;</span></p>\r\n</li>\r\n<li style=\"list-style-type: disc; font-size: 6.5pt; font-family: Verdana; color: #252525; 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;\">нитраты или нитриты;</span></p>\r\n</li>\r\n<li style=\"list-style-type: disc; font-size: 6.5pt; font-family: Verdana; color: #252525; 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;\">употребление большого количества различных лекарств;</span></p>\r\n</li>\r\n<li style=\"list-style-type: disc; font-size: 6.5pt; font-family: Verdana; color: #252525; 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;\">лидокаин, пролокаин;</span></p>\r\n</li>\r\n<li style=\"list-style-type: disc; font-size: 6.5pt; font-family: Verdana; color: #252525; 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;\">дапсон – препарат, используемый для лечения и профилактики пневмоцистной инфекции.</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;\">С химической точки зрения метгемоглобин формируется присутствием в эритроцитах железа в трехвалентной форме вместо обычной формы железа. Это приводит к снижению доступности кислорода к тканям. Симптомы заболевания обычно проявляются пропорционально уровню метгемоглобина. Только внешне болезнь проявляется, пока количество метгемоглобина не достигнет показателя 15%. Если эта величина превышается, появляются неврологические и кардиологические симптомы, являющиеся следствием гипоксии.</span></p>",
"pathogenesis": "",
"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;\">Важным диагностическим признаком метгемоглобинемии служит темно-коричный цвет крови, которая, будучи помещенной в пробирку или на фильтровальную бумагу, не изменяет свой цвет на красный. При положительной пробе проводится спектроскопия, определение концентрации MtHb, активности НАД-зависимой метгемоглобинредуктазы, электрофорез гемоглобина.</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 общем анализе крови может присутствовать компенсаторный эритроцитоз, увеличение Hb, ретикулоцитоз, уменьшение СОЭ. При исследовании биохимических показателей крови определяется незначительная билирубинемия, обусловленная увеличением непрямой фракции пигмента. Для хронической метгемоглобинемии типично появление в эритроцитах телец Гейнца-Эрлиха.</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;\">У больных с энзимопенической или токсической метгемоглобинемией показательна терапевтическая проба с внутривенным введением метиленового синего – после инъекции цианоз быстро исчезает, а кожа и видимые слизистые приобретают розовую окраску.</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 анализе причин метгемоглобинемии важно выяснить, имел ли больной контакт с токсическими веществами, принимал ли метгемоглобинобразующие лекарственные препараты. При подозрении на врожденную метгемоглобинемию изучается родословная, проводится консультация генетика, определяется тип наследования патологии крови. </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;\">Ранняя диагностика заболевания и начало лечения, в особенности при обнаружении приобретенной формы метгемоглобинемии, имеют решающее значение в управлении симптомами заболевания и сохранении жизненных функций пациента. Больные нуждаются в комплексных исследованиях, иногда и инвазивных, для исключения сердечной и легочной патологии. Первая помощь при метгемоглобинемии заключается во введении дополнительного количества кислорода и устранении отравляющего вещества, токсина, окислителя.</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;\">Пациенты с разовой метгемоглобинемией, возникшей в результате отравления отравляющим веществом, могут быть выписаны после 6-часового наблюдения, если симптомы заболевания были устранены. Симптоматические пациенты с длительной метгемоглобинемией должны наблюдаться в стационаре, в особенности при осложняющих факторах, таких как анемия, интенсивный цианоз, сопутствующее заболевание сердца или периферических сосудов.</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;\">Лекарственным средством первой линии против метгемоглобинемии является внутривенное введение метиленового синего. Рекомендовано также переливание крови и гипербарическое лечение кислородом. В качестве вспомогательного средства лечения применяется аскорбиновая кислота (витамин С) в таблетках или любой другой фармакологической форме.</span></p>",
"prevention": "<p><span id=\"docs-internal-guid-3b15565d-7fff-b966-7154-4d9082696da3\"><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;\">Пациентам с подобной патологией следует избегать контакта с метгемоглобинобразующими веществами, переохлаждений и других провоцирующих факторов. Профилактика врожденной метгемоглобинемии заключается в проведении медико-генетической консультации для выявления гетерозиготных носителей среди будущих родителей.</span></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;\">Учитывая тип метгемоглобинемии, следует знать, что симптомы заболевания могут отличаться. В некоторых случаях присутствует только внешнее проявление (легкие наследственные подтипы заболевания), могут иметь место и тяжелые неврологические симптомы. Нормальное количество метгемоглобина в человеческой крови составляет около 1% (диапазон от 0-3%).</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;\">Симптомы, связанные с различным уровнем метгемоглобина, превышающим норму:</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: #252525; 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;\">3-15% - незначительные изменения цвета кожи (например, бледная, серая, синяя);</span></p>\r\n</li>\r\n<li style=\"list-style-type: disc; font-size: 6.5pt; font-family: Verdana; color: #252525; 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;\">15-20% - цианоз, хотя не исключено бессимптомное течение;</span></p>\r\n</li>\r\n<li style=\"list-style-type: disc; font-size: 6.5pt; font-family: Verdana; color: #252525; 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;\">25-50% - головная боль, одышка, головокружение, обмороки, общая слабость, спутанность сознания, учащенное сердцебиение, боль в груди;</span></p>\r\n</li>\r\n<li style=\"list-style-type: disc; font-size: 6.5pt; font-family: Verdana; color: #252525; 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;\">50-70% - аномальные сердечные ритмы; изменения психического состояния, бред, судороги, кома, глубокий ацидоз;</span></p>\r\n</li>\r\n<li style=\"list-style-type: disc; font-size: 6.5pt; font-family: Verdana; color: #252525; 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;\">> 70% - летальный исход.</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;\">Физические признаки: изменение цвета кожи и крови, судороги, изменение цвета конъюнктивы, скелетные аномалии, явная умственная отсталость.</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;\">Системы организма с высокими потребностями в кислороде (например, центральная нервная система и сердечно-сосудистая система) первыми проявляют признаки заболевания. Кровь, содержащая большее, чем необходимо количество метгемоглобина, приобретает красно-коричневый цвет.</span></p>",
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"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;\">В процессе метаболических превращений в крови здоровых людей в очень небольших количествах образуются дисгемоглобины: карбоксигемоглобин, сульфгемоглобин, метгемоглобин (0,1-1 %). Вместе с тем, в эритроцитах содержится ряд факторов, которые поддерживают долю фракции метгемоглобина на уровне, не превышающем 1,0-1,5% от общего Hb. В частности, в реакции восстановления метгемоглобина в гемоглобин участвует фермент метгемоглобин-редуктаза. В отличие от оксигемоглобина (НbО2), содержащего восстановленное железо (Fe++), в метгемоглобине содержится окисленное железо (Fe+++), не способное переносить кислород. Поэтому при метгемоглобинемии, прежде всего, страдает кислородно-транспортная функция крови, следствием которой служит тканевая гипоксия.</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;\">Наследственные формы метгемоглобинемии представлены либо ферментопатиями (врожденной низкой активностью или отсутствием фермента метгемоглобин-редуктазы), либо М-гемоглобинопатиями (синтезом аномальных белков, содержащих окисленное железо).</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 структуре приобретенных (вторичных) метгемоглобинемий выделяют токсические экзогенные и токсические эндогенные формы. Метгемоглобинемии экзогенного происхождения могут быть связаны с передозировкой лекарственных средств (сульфаниламидов, нитритов, викасола, противомалярийных препаратов, лидокаина, новокаина и др.) или отравлением химическими агентами (анилиновыми красителями, нитратом серебра, тринитротолуолом, хлорбензолом, питьевой водой и пищевыми продуктами с высоким содержанием нитратов и др.).</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;\">Повышенный уровень MtHb в крови наблюдается у недоношенных и доношенных новорожденных, что связано с низкой активностью фермента метгемоглобин-редуктазы и окислительным стрессом в родах. Однако даже при тяжелой гипоксии и желтухе новорожденных подъем MtHb не столь выражен и клинически значим, чтобы послужить причиной метгемоглобинемии. Однако при диарее, бактериальных и вирусных энтероколитах, в условиях метаболического ацидоза у детей первого года жизни может легко развиться приобретенная эндогенная метгемоглобинемия.</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;\">О смешанной форме патологии говорят в том случае, если метгемоглобинемия развивается под воздействием экзогенных факторов у здоровых лиц, являющихся гетерозиготными носителями генов наследственной формы заболевания.</span></p>",
"pathogenesis": "",
"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;\">Важным диагностическим признаком метгемоглобинемии служит темно-коричный цвет крови, которая, будучи помещенной в пробирку или на фильтровальную бумагу, не изменяет свой цвет на красный. При положительной пробе проводится спектроскопия, определение концентрации MtHb, активности НАД-зависимой метгемоглобинредуктазы, электрофорез гемоглобина.</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 общем анализе крови может присутствовать компенсаторный эритроцитоз, увеличение Hb, ретикулоцитоз, уменьшение СОЭ. При исследовании биохимических показателей крови определяется незначительная билирубинемия, обусловленная увеличением непрямой фракции пигмента. Для хронической метгемоглобинемии типично появление в эритроцитах телец Гейнца-Эрлиха.</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;\">У больных с энзимопенической или токсической метгемоглобинемией показательна терапевтическая проба с внутривенным введением метиленового синего – после инъекции цианоз быстро исчезает, а кожа и видимые слизистые приобретают розовую окраску.</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 анализе причин метгемоглобинемии важно выяснить, имел ли больной контакт с токсическими веществами, принимал ли метгемоглобинобразующие лекарственные препараты. При подозрении на врожденную метгемоглобинемию изучается родословная, проводится консультация генетика, определяется тип наследования патологии крови. Наследственные метгемоглобинемии требуют дифференциации с врожденными пороками сердца синего типа, аномалиями развития легких и другими состояниями, сопровождающимися гипоксией.</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;\">Больные с отсутствием клинических проявлений не нуждаются в специальной терапии. При значительной концентрации MtHb в крови и развернутой симптоматике метгемоглобинемии назначается медикаментозная терапия, способствующая превращению метгемоглобина в гемоглобин. Такими восстанавливающими свойствами обладают аскорбиновая кислота и метиленовый синий. Аскорбиновая кислота назначается внутрь сначала в больших, а по мере нормализации состояния - в поддерживающих дозах. Раствор метиленовой сини вводится внутривенно. При выраженном цианозе проводится кислородная терапия. Тяжелая форма метгемоглобинемии является показанием к обменному переливанию крови.</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;\">Течение наследственной и лекарственной метгемоглобинемии, как правило, доброкачественное. Неблагоприятный исход возможен при тяжелых формах токсической метгемоглобинемии с высоким содержанием MtHb в эритроцитах. Пациентам с подобной патологией следует избегать контакта с метгемоглобинобразующими веществами, переохлаждений и других провоцирующих факторов. </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;\">Профилактика врожденной метгемоглобинемии заключается в проведении медико-генетической консультации для выявления гетерозиготных носителей среди будущих родителей.</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;\">Признаки наследственной метгемоглобинемии становятся заметны в период новорожденности. На коже и видимых слизистых ребенка (в области губ, носогубного треугольника, мочек ушей, ногтевого ложа) заметен цианоз. Кроме наследственной метгемоглобинемии, у детей часто выявляются другие врожденные аномалии - изменения конфигурации черепа, недоразвитие верхних конечностей, атрезия влагалища, талассемия и пр. Нередко дети отстают в психомоторном развитии.</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 зависимости от уровня фракции MtHb, выраженность проявлений врожденной и приобретенной метгемоглобинемии может значительно варьировать.</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 концентрации MtHb в крови:</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;\"><3% клинические проявления отсутствуют</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;\">3-15% - кожные покровы приобретают сероватый оттенок</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;\">15-30% - развивается цианоз, кровь становится шоколадно-коричневого цвета</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;\">30-50% - появляется слабость, головная боль, тахикардия, одышка при физической нагрузке, головокружение, возникают обмороки</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;\">50-70% - возникает аритмия, учащенное дыхание, судороги; развивается метаболический ацидоз; отмечаются признаки угнетения ЦНС, возможна кома</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;\">>70% - выраженная гипоксия, летальный исход.</span></li>\r\n</ul>\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\"> </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\"> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </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;\">Для любых форм метгемоглобинемии характерна грифельно-серая окраска кожных покровов, однако отсутствуют характерные для сердечно-легочных заболеваний изменения ногтевых фаланг по типу «барабанных палочек». Акроцианоз усиливается при охлаждении, употреблении в пищу нитратосодержащих продуктов, при токсикозах беременности у женщин, а также приеме метгемоглобинобразующих медикаментов.</span></p>",
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"name": "Болит левый бок"
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"lead": "Болезненные ощущения внизу живота описываются в медицинской литературе, как тазовые боли. Они характерны для острых и/или хронических заболеваний внутренних органов, сосудов, лимфатических узлов малого таза, суставов и костей тазового пояса",
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},
"code": "B87",
"name": "Миаз",
"icd_name": "Миаз",
"gender": 0,
"age_min": 5,
"age_max": 74,
"cause": [
2,
5,
7
],
"periodicity": 1,
"slug": "b87_miaz",
"lead": "Нарушение здоровья, относящееся к группе педикулез, акариаз и другие инфестации",
"description": "Миазы – группа заболеваний, обусловленных паразитированием в тканях и полостях человека личинок некоторых видов мух. ",
"etiology": "<p>Основные возбудители миаза - личинки мухи тумбу (Cordylobia anthropophaga) и песчаная блоха (Tunga penetrans), самки которой проникают в кожу по сделанным ими ходам, где оплодотворённое животное раздувается от яиц до размеров горошины, вызывая развитие болезненных изъязвлений. В отечественной практике известны случаи паразитирования у человека личинок вольфартовой мухи (Wohlfahrtia magnifica) и различных оводов (обычно русского и овечьего). </p>\r\n<p>Личинки мух сравнительно стойки по отношению к различным факторам, в частности к химическим реагентам. Можно отметить способность личинки мухи Eristalis к обитанию в сточных водах и др. весьма загрязненных местах (скопление жидких фекалий и др.); личинки многих мух долго по сравнению с личинками других насекомых не гибнут в растворах формалина или спирта. Все эти особенности личинок мух определяют их способность жить тот или другой срок в необычной для них среде, например, в кишечнике человека, куда они могут попасть с пищей. </p>",
"pathogenesis": "<p>Развитие заболевания происходит преимущественно вследствие откладывания яиц насекомыми в глаза, нос, уши и раны человека. Часто личинки вводятся подкожно. Немного реже диагностируется висцеральная инвазия организма, при которой происходит случайное проникновение личинок в организм, заглатываемых вместе с осемененными продуктами. </p>",
"diagnostics": "<p>При кожном виде болезни личинки размером до 1–1.5 см обнаруживаются на поверхности раны или язвы. При кишечной форме паразиты можно увидеть в испражнениях и рвотных массах. С диагностической целью делают анализ кала на обнаружение паразитов. </p>\r\n<p>В общем анализе крови при заболевании выявляется эозинофилия. Иммунный анализ крови (ИФА) показывает увеличение в сыворотке IgE. Интрацеребральная форма болезни выявляется компьютерной томографией. </p>\r\n<p> </p>",
"treatment": "<p>Лечение миаза кожи заключается в удалении личинок из очага поражения путем промывания раны антисептическими растворами (калия перманганата, фурацилина и др.). Для облегчения удаления личинки в отверстие инфильтрата можно залить несколько капель стерильного масла; лишившись доступа воздуха, паразит показывается на поверхности кожи и может быть легко захвачен пинцетом или зажимом. После этого освободившаяся полость подвергается обработке дезинфицирующими средствами и закрывается асептической повязкой. При развитии гнойных осложнений применяются противомикробные мази или системные антибиотики. </p>\r\n<p>При кишечной форме миаза назначается промывание желудка, прием слабительных и противопаразитарных препаратов. Лечение мочеполового миаза заключается в промывании уретры для удаления личинок. Из конъюнктивальной полости личинки извлекаются остроконечными глазными иглами после инстилляциианестезирующих и антисептических капель. В остальных случаях личинки подлежат удалению хирургическим путем. </p>",
"prevention": "<p>Для предотвращения миазов кожи необходимо применение репеллентов, отпугивающих мух и оводов. С целью недопущения глубокого проникновения паразитов необходимо своевременное и рациональное лечение всех поражений кожи. Важное значение имеет уничтожение мух и очагов их выплода; хранение продуктов в местах, недоступных для мух; защита ран от инвазии личинками мух; предупреждение и лечение миазов у животных.</p>",
"clinical_picture": "<p>Поверхностный кожный миаз протекает доброкачественно. Личинки возбудителей поверхностных миазов питаются только гноем и разложившимися некротизированными тканями, поэтому больных беспокоит умеренный зуд в ране и ощущение «ползания мурашек». При осмотре очага поражения определяются белые копошащиеся островки в виде манных крупинок. После окончания цикла созревания личинки выпадают из раны и окукливаются вне человеческого организма. При глубоком миазе кожи у больного повышается температура тела, возникает слабость, головные боли. Нестерпимая острая боль в области раны, где паразитируют личинки, может приводить к обморокам. </p>\r\n<p>При локализации на конъюнктиве, в полости рта и носа личинки разъедают слизистые оболочки и мягкие ткани, проникая до фасций и надкостницы, разрушая хрящи и кости гортани, носоглотки, пазух носа, глазниц и т. д. </p>\r\n<p>Кишечный миаз развивается в результате случайного проглатывания личинок мухи с пищей. При паразитировании личинок в желудке основные проявления включают тошноту, рвоту, боль в эпигастральной области. Нахождение паразитов в кишечнике вызывает тифоидное состояние, симптомы длительно текущего энтерита и колита (абдоминальные боли, поносы, болезненные позывы к дефекации, примесь крови в испражнениях и др.). </p>\r\n<p>Тяжелое течение миаза наблюдается при паразитировании личинок на слизистой оболочке глаз, носа, ушей. Мочеполовой миаз возникает при попадании яиц на грязное нательное и постельное белье, с которого личинки проникают на слизистую гениталий и в уретру. При урогенитальном миазе может развиваться клиника вульвита, вагинита, уретрита, цистита. </p>\r\n<p>При глазной форме миаза (офтальмомиазе) личинки овода паразитируют в конъюнктивальном мешке, вызывая явления конъюнктивита, иридоциклита, образование язв роговицы. В особо тяжелых случаях они могут проникать в слезный мешок и внутрь глазного яблока, вызывая его разрушение. </p>\r\n<p>Паразитирование личинок в носовых ходах сопровождается повышением температуры, головной болью, слизисто-гнойным насморком. </p>\r\n<p>Отомиаз может сопровождаться перфорацией барабанной перепонки и проникновением паразитов к мозговым оболочкам. Возбудители полостных миазов могут паразитировать в полости рта, придаточных пазухах, анальном канале. </p>",
"image": null,
"image_alt": null,
"standard_type": 3,
"danger": 58,
"published": 2,
"parent": null,
"block_rubric": 18,
"standards": []
}
]
}
