#1
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Âíóòðèóòðîáíûå èíôåêöèè
Íîâàÿ òåìà äëÿ ñîîáùåíèé ïî òåìå.
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#2
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Ê ñîæàëåíèþ ìîþ òåìó óæå çàêðûëè, íî îòâåòà ÿ íå ïîëó÷èë (âñå ñâåëîñü ê îáñóæäåíèþ àòîïè÷åñêîãî äåðìàòèòà è ïðèìåíåíèþ à/ãèñòàìèííûõ ïðåïàðàòîâ), âîçìîæíî ÿ íåïðàâèëüíî åãî ñôîðìóëèðîâàë. Ìåíÿ íå èíòåðåñóþò êîíêðåòíûå ñëó÷àè è ïðîÿâëåíèÿ. Ìåíÿ èíòåðåñóåò - êàê ê ýòîé ïðîáëåìå îòíîñÿòñÿ äðóãèå ïåäèàòðû. Äåëî â òîì, ÷òî ìíå óæå èçâåñòíû äâå òî÷êè çðåíèÿ:
1. Âíóòðèóòðîáíûå èíôåêöèè ëå÷èòü íå íàäî (àíòèáàêòåðèàëüíûå è ïðîòèâîâèðóñíûå ïðåïàðàòû), åñëè íåò âûðàæåííîé êëèíèêè ñ íàðóøåíèåì ôóíêöèèè îðãàíîâ èëè ñèñòåì, òàê êàê èììóíèòåò ðåáåíêà ñïîñîáåí ñäåðæèâàòü âîçáóäèòåëÿ. Ïðèìåíåíèå à/á è ï/â ïðåïàðàòîâ ìîæåò èçìåíèòü ðàâíîâåñèå ìåæäó èììóíèòåòîì ðåáåíêà è âîçáóäèòåëåì â ñòîðîíó ïîñëåäíåãî. Ëå÷åíèå äîëæíî áûòü ñèìïòîìàòè÷åñêèì èëè ëå÷åíèå îñëîæíåíèé. 2. Ëå÷åíèå â/ó èíôåêöèé íàäî ïðîâîäèòü îáÿçàòåëüíî, òàê êàê íàëè÷èå âîçáóäèòåëÿ ìîæåò ñïîñîáñòâîâàòü ïðîãðåññèðîâàíèþ ïîðàæåíèÿ îðãàíîâ è ñèñòåì. Îòíîñèòåëüíî ïðèâèâîê ó äåòåé ñ ÂÓÈ - áóäåò ëè ñîñòîÿòåëüíûì èììóíèòåò ïîñëå âàêöèíàöèè îò êëåùåâîãî ýíöåôàëèòà ó ðåáåíêà ñ öèòîìåãàëîâèðóñíîé èíôåêöèåé. Êñòàòè (àìîæåò è íåò), â ïåðâîì ñâîåì ñîîáùåíèè ÿ óïóñòèë îäíó äåòàëü - ðàçâèòèþ àòîïè÷åñêîãî äåðìàòèòà ó óêàçàííûõ äåòåé ïðåäøåñòâîâàëè ÷àñòûå àëëåðãè÷åñêèå äåðìàòèòû (â òå÷åíèè 3-5 íåäåëü - îò 1 äî 3 ñëó÷àåâ â íåäåëþ), èìåííî ïîýòîìó ÿ íàçíà÷àë äåòÿì à/ã ïðåïàðàòû. Äèàãíîç "àòîïè÷åñêèé äåðìàòèò" áûë óñòàíîâëåí ïîçäíåå â Äèàãíîñòè÷åñêîì Öåíòðå. |
#3
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Âîîáùå, ëîãè÷íî ëå÷èòü áîëåçíü â åå êëèíè÷åñêîì ïðîÿâëåíèè. Âîò ÷òî íàïèñàíî ïî-ïîâîäó ëå÷åíèÿ ÖÌ
Medical care consists of good nutritional support, vigorous supportive care for end-organ syndromes (particularly pneumonia in immunocompromised patients), and specific antiviral therapy.(Ïðàâèëüíîå ïîääåðæèâàþùåå ïòàíèå, ïîääåðæèâàþùàÿ òåðàïèÿ ïîðàæåííûõ îðãàíîâ è ñèñòåì, ñïåöèôè÷åñêàÿ àíòèâèðóñíàÿ òåðàïèÿ). Íî ýòî î ëå÷åíèè ÖÌÂ, òàê ñêàçàòü, âîîáùå. Òåïåðü, äàâàéòå ïîñìîòðèì, î êàêîé ôîðìå âðîæäåííîé ÖÌ èíôåêöèè èäåò ðå÷ü : Cytomegalic inclusion disease Approximately 10% of congenitally infected infants have clinical evidence of disease at birth. The most severe form of congenital CMV infection is referred to as cytomegalic inclusion disease (CID). (Îê.10% âíóòðèóòðîáíî çàðàæåííûõ ìëàäåíöåâ èìåþò êëèíè÷åñêèå ïðîÿâëåíèÿ í ìîìåíò ðîæäåíèÿ. Íàèáîëåå òÿæåëàÿ ôîðìà - CID). CID almost always occurs in women who have primary CMV infection during pregnancy, although rare cases are described in women with preexisting immunity who presumably have reactivation of infection during pregnancy. (CID íàèáîëåå ÷àñòî âîçíèêàåò ó æåíùèí, êîòîðûå ïåðåíåñëè ïåðâè÷íóþ èíôåêöèþ âî âðåìÿ áåðåìåííîñòè, íî, òàêæå îïèñàíû è ñëó÷àè ñâÿçàííûå ñ ðåàêòèâàöèåé ïðîøëîé èíôåêöèè âî âðåìÿ áåðåìåííîñòè.) CID is characterized by intrauterine growth retardation, hepatosplenomegaly, hematological abnormalities (particularly thrombocytopenia), and a variety of cutaneous manifestations, including petechiae and purpura (ie, blueberry muffin baby). However, the most significant manifestations of CID are those involving the central nervous system. Microcephaly, ventriculomegaly, cerebral atrophy, chorioretinitis, and sensorineural hearing loss are the most common neurological consequences of CID. (CID õàðàêòåðèçóåòñÿ âíóòðèóòðîáíûì çàìåäëåíèåì ðîñòà è ðàçâèòèÿ ïëîäà, ãåïàòîñïëåíîìåãàëèåé, ãåìàòîëîãè÷åñêèìè íàðóøåíèÿìè, ÷àùå òðîìáîöèòîïåíèÿ, ðàçëè÷íûìè âàðèàíòàìè êîæíûõ ìàíèôåñòàöèé, âêëþ÷àþùèõ ïåòåõèè è ïóðïóðó. Îäíàêî, íàèáîëåå çíà÷èìàÿ ìàíèôåñòàöèÿ CID âêëþ÷àåò ïîðàæåíèå ÖÍÑ. Ìèêðîöåôàëèÿ, âåíòðèêóëîìåãàëèÿ, öåðåáðàëüíàÿ àòðîôèÿ, õîðèîðåòèíèò è ñåíñîíåâðàëüíàÿ ïîòåðÿ ñëóõà -íàèáîëåå çíà÷èìûå íåâðîëîãè÷åñêèå ïðîÿâëåíèÿ CID). |
#4
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Intracerebral calcifications typically demonstrate aperiventricular distribution and are commonly encountered by CT scan (see Image 2). The finding of intracranial calcifications is predictive of cognitive and audiologic deficits in later life and predicts a poor neurodevelopmental prognosis. (Âíóòðè÷åðåïíûå êàëüöèôèêàòû...ëåãêî îïðåäåëÿþòñÿ ñ ïîì.ÑÒ. Ýòà íàõîäêà ïðåäîïðåäåëÿåò ðàçâèòèå êîãíèòèâíûõ è ñëóõîâûõ ïðîáëåì â áóäóùåì è ïå÷àëüíûé íåâðîëîãè÷åñêèé ïðîãíîç... ).
Overall, 90% of infants who survive symptomatic CID have significant long-term neurological and neurodevelopmental sequelae. Indeed, it has been estimated that congenital CMV may be second only to Down syndrome as an identifiable cause of mental retardation in children.(Áîëåå 90% äåòåé, ïåðåíåñøèõ CID èìåþò ñåðüåçíûå, â ò.÷., è îòäàëåííûå ïîñëåäñòâèÿ, ñâÿçàííûå ñ íàðóøåíèå íåðâíî-ïñèõè÷åñêîãî ðàçâèòèÿ.  äåéñòâèòåëüíîñòè, CID ñòîèò íà âòîðîì ìåñòå, ïîñëå ñèíäðîìà Äàóíà, êàê ïðè÷èíà âûðàæåííîãî îòñòàâàíèÿ â ïñèõè÷åñêîì ðàçâèòèè.) Asymptomatic congenital CMV (Àñèìïòîìàòè÷åñêàÿ âðîæäåííàÿ ÖÌ èíôåêöèÿ) Most infants with congenital CMV infection are born to women who have preexisting immunity to CMV. These infants appear clinically normal at birth; however, even though infants with congenital CMV infection appear well, they may have subtle growth retardation compared to uninfected infants. Although asymptomatic at birth, these infants, nevertheless, are at risk for neurodevelopmental sequelae. (Áîëüøàÿ ÷àñòü ìëàäåíöåâ ñ âðîæäåííîé ÖÌ ðîæäàåòñÿ ó ìàòåðåé, ó êîòîðûõ áûë ïðåäûäóùèé èìóíèòåò ê ÖÌÂ. Ýòè äåòè êëèíè÷åñêè õîðîøî âûãëÿäÿò ïðè ðîæäåíèè, îäíàêî, íåñìîòðÿ íà ýòî ó íèõ ìîæåò áûòü íåáîëüøîå çàìåäëåíèå ðîñòà è ðàçâèòèÿ ïî ñðàâíåíèþ ñ íåèíôèöèðîâàííûìè äåòüìè. Àñèìïòîìàòè÷íûå ïðè ðîæäåíèè, ýòè äåòè íå ïîäâåðæåíû ðèñêó ðàçâèòèÿ íåðâíî- ïñèõè÷åñêèõ íàðóùåíèé, ñâÿçàííûõ ñ ÖÌÂ.) The major consequence of inapparent congenital CMV infection is sensorineural hearing loss. Approximately 15-20% of these infants will have unilateral or bilateral deafness. Routine newborn audiologic screening may not detect cases of CMV-associated hearing loss because this deficit may develop months or even years after delivery. (Îñíîâíîå îñëîæíåíèå âðîæäåííîé àñèìïòîìàòè÷íîé ÖÌ èíôåêöèè -ñåíñîíåâðàëüíàÿ ïîòåðÿ ñëóõà. Îê.15-20% ýòèõ ìëàäåíöåâ áóäóò èìåòü îäíî- èëè äâóñòîðîííþþ ãëóõîòó. Ïðè÷åì, ðóòèííîå îáñëåäîâàíèå íîâîðîæäåííûõâ ýòîì ñëó÷àå ìàëîèíôîðìàòèâíî, ò.ê. ïîòåðÿ ñëóõà ìîæåò ðàçâèòüñÿ ÷åðåç ìåñÿöû èëè äàæå ãîäû ïîñëå ðîæäåíèÿ). Áîëåå ïîäðîáíî íà ññûëêå [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] Èñõîäÿ èç ýòîé èíôîðìàöèè, ìîæíî ðåøèòü, ëå÷èòü èëè íå ëå÷èòü ÖÌÂ, â ÷àñòíîñòè. Ñîáñòâåííî, âñå ýòî îòíîñèòñÿ è ê êðàñíóõå, è ê òîêñîïëàçìîçó, è, âîîáùå ê TORCH- ñèíäðîìó, ñ òåìè èëè èíûìè óòî÷íåíèÿìè äëÿ êàæäîé êîíêðåòíîé èíôåêöèè. |
#5
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Öèòàòà:
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#6
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Îáùåïðèíÿòàÿ òàêòèêà òàêîâà: åñëè ðåáåíîê àñèìïòîìàòè÷åí, òî ó íåãî íèêòî íè÷åãî íå èùåò. Åñëè åñòü ñèìïòîìàòèêà, òî îáñëåäóþò íà îñíîâàíèè ñóùåñòâóþùåé ñèìïòîìàòèêè (ïðè íàëè÷èè ñîîòâåòñòâóþùåé ñèìïòîìàòèêè îáñëåäóþò â ò.÷. è íà â/ó èíôåêöèè ), â ñîîòâåòñòâèè ñ äèàãíîçîì íàçíà÷àåòñÿ è ëå÷åíèå .
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#7
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Öèòàòà:
Èòåðåñóþñü íå èç ïðàçäíîãî ëþáîïûòñòâà, ñëèøêîì ÷àñòî âñòðå÷àåòñÿ ïîäîáíàÿ ñèòóàöèÿ. |
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#8
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#9
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Íåò, íå êîíêðåòíûé ðåáåíîê. Íåñêîëüêî ìîèõ äåòåé îáñëåäîâàíû â ãîðîäå. Äèàãíîçû ÷àùå òàêèå:"Àòîïè÷åñêèé äåðìàòèò(ýêçåìà), ñòàäèÿ íåïîëíîé ðåìèññèè. ÖÌÂÈ â íåàêòèâíîé ôàçå (èëè íîñèòåëüñòâî)".  ðåêîìåíäàöèÿõ - íàçíà÷åíèå öèêëîôåðîíà â/ì â âîçðàñòíîé äîçèðîâêå ïî ñõåìå:1,2,3,5,7,10,13,16,20,24,28,30 äíè äàëåå 1 ðàç â íåäåëþ 1 ìåñÿö.
Ïî ñóùåñòâóþùèì ïðèêàçàì ÿ äîëæåí ïðîâåñòè ëå÷åíèå ñîãëàñíî ðåêîìåíäàöèÿì ñïåöèàëèñòà. Íàñêîëüêî îïðàâäàíî òàêîå ëå÷åíèå è êàêîâà âàøà òàêòèêà? |
#10
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Ìíå ýòè ðåêîìåíäàöèè íåïîíÿòíû. ß íå îáñëåäóþ äåòåé ñ àòîïè÷åñêèì äåðìàòèòîì (åñëè ýòî èõ åäèíñòâåííàÿ ïàòîëîãèÿ ) íà CMV.
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#11
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Êëèíèêà
Áåçóñëîâíî â äåëå äèàãíîñòèêè è ëå÷åíèÿ ÂÓÈ êëèíèêà íà ïåðâîì ìåñòå, îíà æå è îïðåäåëÿåò íàøó òàêòèêó. Íî ÿ åùå îáðàùàþ îñîáîå âíèìàíèå íà àíàìíåç ìàòåðè. Ê ïðèìåðó åñëè ó ìàìû áûë ãåïàòèò Ñ èëè Â, òî ÿ îáÿçàòåëüíî îáñëåäóþ ðåáåíêà.
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#12
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#13
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#14
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Öèòàòà:
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#15
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Öèòàòà:
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