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"slug": "a39.0_meningokokkovyy_meningit_g01",
"lead": "форма менингококковой инфекции, которая характеризуется гнойным воспалением мягкой и арахноидальной оболочек головного мозга",
"description": "<p> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Менингококковая инфекция – это острое инфекционное заболевание, первым признаком которого является острый назофарингит или воспаление носоглотки, протекающее с последующим развитием менингококцемии и гнойного менингита. </span></p>",
"etiology": "<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Бактерия передается от человека человеку через капли выделений из дыхательных путей или горла носителя. Тесный и продолжительный контакт, такой как поцелуй, чихание или кашель в сторону другого человека или проживание в непосредственной близости с инфицированным человеком-носителем (например, в одной квартире или при совместном пользовании посудой), способствует распространению болезни. Обычно инкубационный период длится 4 дня, но может варьироваться от 2 до 10 дней.</span></p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Предрасположенность к развитию менингококкового менингита формируется в условиях снижения местной и общей резистентности организма. Факторами риска признаются врожденный дефицит комплемента, ВИЧ-инфекция, анатомическая или функциональная аспления. Слизистая оболочка носоглотки повреждается при курении и ОРВИ, что повышает риск бактериальной инвазии. Распространению инфекции способствует большая скученность населения.</span></p>",
"pathogenesis": "<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Входными воротами становится слизистая носоглотки, где развивается первичный воспалительный процесс. В 10-20% случаев микробы, преодолев защитные механизмы, проникают в кровоток, где размножаются, инициируя кратковременную бактериемическую фазу. В субарахноидальные пространства головного мозга нейссерии заносятся гематогенным путем, реже – лимфогенно, периваскулярно и периневрально через пластинку решетчатой кости.</span></p>\r\n<p> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">При размножении менингококка развивается вначале серозно-гнойное, затем гнойное воспаление мягкой и паутинной оболочек. Чаще всего поражаются конвекситальные поверхности и основание головного мозга, иногда процесс распространяется в спинальном направлении. Макроскопически мягкая оболочка выглядит отечной, гиперемированной, мутной, поверхность мозга будто покрыта шапочкой из гноя. Микроскопическая картина представлена выраженной инфильтрацией полиморфноядерными мононуклеарными клетками. Спаечный процесс может вызвать закупорку путей ликворооттока.</span></p>",
"diagnostics": "<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Установить происхождение менингококкового менингита на основании клинических данных удается при его сочетании с бактериемией. На вероятную этиологию изолированных форм болезни косвенно указывает эпидемиологическая и анамнестическая информация (наличие назофарингита, контакт с больным). </span></p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Точную верификацию патологии обеспечивают лабораторно-инструментальные методы:</span></p>\r\n<ul>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Клинические анализы. Гемограмма показывает выраженный лейкоцитоз со сдвигом формулы влево, анэозинофилию, ускорение СОЭ. В спинномозговой жидкости отмечается полиморфноядерный плеоцитоз, снижение концентрации глюкозы, повышение белка. Изменения в анализе мочи неспецифичны, свидетельствуют о токсических явлениях.</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Бактериоскопия и посев. Менингококки выявляются в нейтрофилах при прямой бактериоскопии окрашенных по Граму мазков. Посев ликвора на сывороточный агар или другие питательные среды дает возможность уточнить культуральные, ферментные, антигенные свойства возбудителя, определить его чувствительность к антибиотикам.</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Серологические тесты. После выделения менингококка идентифицировать его по серогруппам можно при постановке реакции агглютинации. Для обнаружения антител в крови применяют РНГА, экспресс-диагностику проводят с помощью ИФА, методов встречного иммуноэлектрофореза.</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Молекулярно-генетический анализ. В дополнение к стандартным процедурам используют ПЦР, позволяющую выявить бактериальную ДНК. Это быстрый и чувствительный диагностический тест. Особую ценность он приобретает при невозможности выделить возбудителя из ликвора или крови.</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Нейровизуализация. Показаниями для церебральной томографии могут быть нарушения сознания, очаговые неврологические симптомы. КТ головного мозга подтверждает ликворную гипертензию, внутримозговые кровоизлияния, церебральный отек. МРТ с контрастированием предпочтительнее, так как лучше визуализирует менингеальную оболочку, субарахноидальное пространство.</span></li>\r\n</ul>\r\n<p> </p>\r\n<p><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">В качестве дополнительного исследования при судорогах для регистрации биоэлектрической активности мозга назначают ЭЭГ. Помощь в диагностическом поиске оказывают офтальмолог (осмотр глазного дна), инфекционист. </span></p>",
"treatment": "<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Любые формы генерализованной инфекции сопряжены с высокой опасностью летального исхода и тяжелых осложнений. Поэтому менингококковый менингит должен рассматриваться как неотложное состояние, требующее срочной госпитализации в профильный стационар. Обычно пациенты сразу попадают в палату интенсивной терапии под круглосуточное наблюдение специалистов. Им показан строгий постельный режим. </span></p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Основой лечения является фармакотерапия:</span></p>\r\n<ul>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Этиотропная. Центральное место отводится антибиотикотерапии препаратами пенициллинового (бензилпенициллином, ампициллином) или цефалоспоринового ряда (цефтриаксоном, цефотаксимом). Альтернативными медикаментами выступают карбапенемы, хлорамфеникол. Сначала назначается эмпирическая терапия, которая затем корректируется с учетом данных антибиотикочувствительности.</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Патогенетическая. Для купирования отека головного мозга используются глюкокортикоиды, осмотические и петлевые диуретики (маннитол, фуросемид). Гемодинамическая нестабильность и токсикоз требуют инфузионной поддержки (кристаллоидами, коллоидами, плазмой), введения вазопрессоров, оксигенотерапии. В тяжелых случаях проводят экстракорпоральную детоксикацию.</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Симптоматическая. В комплексном лечении менингококкового менингита применяют симптоматические препараты. При судорожной активности показаны антиконвульсанты (диазепам, натрия оксибутират). Высокую лихорадку купируют жаропонижающими средствами.</span></li>\r\n</ul>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Выписка из стационара осуществляется при полном клиническом выздоровлении. Все пациенты, перенесшие менингококковый менингит, должны находиться под диспансерным наблюдением невролога с прохождением регулярного обследования. Последствия и остаточные явления устраняются комплексной реабилитацией, которая включает физиотерапию, лечебную гимнастику, когнитивную коррекцию.</span></p>\r\n<p> </p>",
"prevention": "<p> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Профилактика подразумевает воздействие на все звенья эпидемического процесса. В отношении источника инфекции проводят раннее выявление, изоляцию и лечение больных, санацию носителей. Разорвать механизмы передачи помогают санитарно-гигиенические мероприятия, дезинфекция в очаге. Для создания специфического иммунитета у восприимчивых лиц рекомендуют вакцинацию против менингококковой инфекции. Повышению неспецифической резистентности способствует закаливание, своевременная терапия респираторных заболеваний.</span></p>",
"clinical_picture": "<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Началу болезни обычно предшествует назофарингит, но симптомы могут возникнуть внезапно, на фоне полного благополучия. С большим постоянством в клинической картине обнаруживают так называемую менингеальную триаду – головные боли, лихорадку, рвоту. Температура резко поднимается до 40-42° C, сопровождается сильным ознобом. Мучительные головные боли носят диффузный давяще-распирающий или пульсирующий характер, локализуются преимущественно в лобно-теменной области, усиливаются в ночное время, при перемене положения головы, действии внешних раздражителей.</span></p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Рвота при менингококковом менингите возникает без предшествующей тошноты, «фонтаном», не приносит облегчения. Клиническая картина дополняется кожной гиперестезией, повышением чувствительности к звуковым, световым и болевым стимулам, запахам. Иногда уже в первые часы болезни возникают тонико-клонические судороги. Важное место в структуре общемозговых симптомов занимает психомоторное возбуждение и нарастающие расстройства сознания – от оглушения до комы.</span></p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Среди объективных симптомов на первое место выходят менингеальные знаки, которые появляются в самом начале заболевания и быстро прогрессируют. Наиболее постоянными являются ригидность затылочных мышц, симптомы Кернига и Брудзинского (верхний, средний, нижний). У детей отмечают признак Лесажа, выбухание и пульсацию родничка. Пациент принимает вынужденную позу – лежа на боку с запрокинутой назад головой и подтянутыми к животу коленями. Выраженность менингеального синдрома может не соответствовать тяжести патологии.</span></p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">При неврологическом осмотре часто выявляют асимметрию сухожильных и кожных рефлексов, ослабляющихся по мере нарастания интоксикации, патологические стопные знаки. Базальные менингиты сопровождаются поражением черепных нервов, особенно III, IV, VII, VIII пар. Наличие стойкого красного дермографизма говорит о сопутствующих вегетативных расстройствах. Признаками интоксикации являются вначале тахикардия, а затем относительная брадикардия, гипотония, приглушенность сердечных тонов. У пациентов учащается дыхание, язык обложен грязно-коричневым налетом, сухой.</span></p>",
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},
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"name": "Поздний сифилис",
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"lead": "Нарушение здоровья, относящееся к группе инфекции, передающиеся преимущественно половым путем",
"description": "Сифилис– венерическое заболевание, имеющее длительное волнообразное течение и поражающее все органы.",
"etiology": "<p>Бледная трепонема представляет собой микроорганизм спиралевидной формы; число оборотов спирали от 8 до 12, ее завитки равномерны, имеют идентичное строение. Совершает характерные виды движения: вращательные, поступательные, волнообразные и сгибательные. Размножается преимущественно путем поперечного деления на два или несколько сегментов, каждый из которых вырастает затем во взрослую особь. </p>\r\n<p>Микроорганизм также может существовать в виде цист и L-форм. Циста является формой выживания бледной трепонемы в неблагоприятных условиях среды и рассматривается как стадия покоя T. рallidum; обладает антигенной активностью. L-форма является способом выживания бледной трепонемы внутри организма без оболочки.</p>",
"pathogenesis": "<p>Бледная трепонема после контакта со слизистой или кожными покровами инфицированного человека бледная трепонема проникает в глубокие слои покровного эпителия. Проникая глубже, бактерия оказывает повреждающее действие на стенку сосудов – вызывая локальное ее разрушение и формирования микротромбов. Потому дальнейший процесс разрушения пораженной ткани происходит через некроз (омертвение) тканей с их последующим разрушением. Распространение бледной трепонемы в ближайшие ткани происходит с током лимфы. <br class=\"SCXW233802150\" /> <br class=\"SCXW233802150\" />В отдаленные органы бледная трепонема попадает с током крови. Доступ в кровеносное русло бледная трепонема получает в результате токсического действия на пораженные сосуды. Потому на поздних стадиях возможно поражение сифилисом сердца, скелета и иных органов, содержащих соединительную ткань. <br class=\"SCXW233802150\" /> <br class=\"SCXW233802150\" />Стоит обратить внимание на то, что бледная трепонема, даже будучи поглощенной иммунной клеткой, может сохранять свою жизнеспособность, находясь внутри фагоцита. Тем самым повышается устойчивость возбудителя сифилиса к антибиотикам и неспецифическому иммунитету. </p>",
"diagnostics": "<p>Абсолютным доказательством наличия заболевания является обнаружение бледной трепонемы в образцах, полученных из очагов поражений, с помощью микроскопии в темном поле зрения или прямой иммунофлюоресценции, а также выявление специфической ДНК и РНК возбудителя методом полимеразной цепной реакции (ПЦР). </p>\r\n<p>Используются методы определения специфических иммуноглобулинов к белой трепанеме - ИФА, иммуноблоттинг. </p>\r\n<p>Серологические методы исследования - РПГА, РИФ, РИБТ - позволяют выявить специфические антитела к бледной трепанеме. Диагностически значимым считается увеличение титра специфических антител в 4 раза и более. </p>\r\n<p>Диагностика сифилитического поражения внутренних органов и опорно-двигательного аппарата основывается также на клинических проявлениях, данных инструментальных исследований (рентгенологических, ультразвуковых, магнитно-резонансной томографии, компьютерной томографии). </p>",
"treatment": "<p>В основе лечения сифилиса – применение антибиотиков пенициллинового ряда, к которым бледная спирохета проявляет высокую чувствительность. При аллергических реакциях больного на производные пенициллина в качестве альтернативы рекомендуются эритромицин, тетрациклины, цефалоспорины. В случаях позднего сифилиса в дополнение назначают препараты йода, висмута, иммунотерапию, биогенные стимуляторы, физиолечение. </p>\r\n<p>Важно установить половые контакты больного сифилисом, обязательно провести превентивное лечение возможно зараженных половых партнеров. По окончании лечения все ранее больные сифилисом остаются на диспансерном наблюдении у врача до полного отрицательного результата комплекса серологических реакций. </p>\r\n<p>При лечении нейросифилиса препаратами пенициллина обязательно сочетание перорального или внутримышечного введения антибактериальных препаратов с их эндолюмбальным введением и с пиротерапией, повышающей проницаемость гемато-энцефалического барьера. </p>\r\n<p>При распространённом третичном сифилисе на фоне выраженной устойчивости бледной трепонемы к антибактериальным препаратам и при хорошем общем состоянии больного, допускающем определённую токсичность проводимой терапии, может быть рекомендовано добавление к антибиотикам производных висмута или производных мышьяка. </p>",
"prevention": "<p>Профилактика сифилиса — выявление заражённых и круга их половых партнёров, превентивное лечение и личная гигиена после полового акта. Обследования на сифилис людей, принадлежащих к группам риска – медиков, учителей, персонала детсадов и учреждений общепита. </p>",
"clinical_picture": "<p>Если больной сифилисом не лечился или лечение было неполноценным, то через несколько лет после заражения у него появляются симптомы третичного сифилиса. Происходят серьезные нарушения органов и систем, внешность больного обезображивается, он становится инвалидом, в тяжелых случаях вероятен летальный исход. </p>\r\n<p>Клинические проявления раннего нейросифилиса появляются в первые 2—3 года после заражения и соответствуют вторичному периоду заболевания. Клиническая картина раннего нейросифилиса зависит от поражённых структур и во многом схожа с инфекционно-воспалительными заболеваниями мозга другой этиологии. </p>\r\n<p>Асимптомный нейросифилис - состояние, при котором клинических симптомов поражения нервной системы нет, а диагноз устанавливается на основании воспалительных изменений в ликворе. Воспалительные изменения в спиномозговой жидкости обнаруживаются в течение 12—18 месяцев с момента заражения. </p>\r\n<p>Спинная сухотка характеризуется поражением спинальных нервов, нервных ганглиев и задних столбов спинного мозга. В результате у больного формируется специфическое нарушение походки — сенситивная атаксия. Больной во время ходьбы не ощущает опоры. Он не может передвигаться с закрытыми глазами, теряется ощущение положения тела в пространстве. </p>\r\n<p>Прогрессивный паралич представляет собой прогрессирующий менингоэнцефалит, развивающийся постепенно с пиком заболеваемости в 15—20 лет после инфицирования. Имитирует проявления многих психических заболеваний. Начинается с раздражительности, снижения памяти, невозможности сосредоточиться и изменения личности. По мере прогрессирования присоединяются расторможенность, асоциальное поведение и бред. В терминальных стадиях развиваются деменция, параличи и нарушения функции тазовых органов. </p>\r\n<full></full>\r\n<p>Атрофия зрительного нерва может являться самостоятельной формой нейросифилиса. Характерно одностороннее ухудшение зрения, которое постепенно распространяется и на второй глаз. Лечение сифилиса приостанавливает снижение зрения. Исходом заболевания у нелечённых больных является слепота вследствие атрофии зрительного нерва. </p>\r\n<p>Гуммы головного мозга встречаются редко. Излюбленная локализация — основание мозга; реже располагается в мозговом веществе. Приводит к повышению внутричерепного давления. Клиническое течение напоминает таковое при опухоли мозга, с которой и следует проводить дифференциальный диагноз. </p>\r\n<p>Поздний висцеральный сифилис представляет собой поражение внутренних органов человека, чаще всего страдает сердечно-сосудистая система, на втором месте поражения печени, остальные органы поражаются значительно реже, хотя поздние поражения регистрировались во всех внутренних органах человека. </p>\r\n<p>Не осложненный сифилитический аортит является наиболее частым проявлением позднего висцерального сифилиса. При данной форме заболевания происходит расширение аорты, больные жалуются на слабость, головокружение, чувство сердцебиения, при малейшей нагрузке и в покое. При аускультацииу больного отмечается мягкий, не резко выраженный систолический шум и акцент 2 тона, на аорте. Также при сифилисе могут поражаться другие крупные сосуды и клапаны сердца, что приведёт к появлению клиники и жалоб, характерных для поражения этих отделов сердечно-сосудистой системы. </p>\r\n<p> </p>",
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}