Transcript TB meningitis diagnostikis zogierTi sakiTxi
TB
meningitis diagnostikis zogierTi sakiTxi
Sorena sabanaZe, TinaTin bakuraZe, “samSabaToba”, 01.02.11
TB
meningiti tuberkulozis erT-erTi yvelaze mZime formaa
droulad dasmuli diagnozi da Sesabamisi mkurnalobis dawyeba mniSvnelovnad amcirebs garTulebebis da sikvdilianobis maCvenebels; M. tuberculosis tipi: aRwevs ra subaraqnoidalur sivrces iwvevs cns-is dazianebas da Sesabamisad yalibdeba sxvadasxva TB TB meningiti; meningo-encefaliti; TB meningo-encefalo-mieliti; cns-is tuberkulomebi.
TB meningiti meoradi daavadebaa, romlis drosac pirveladi kera aris: filtvis da filtvgareTa tuberkulozis sxvadasxva forma, miliaruli tuberkulozi, diagnozis dasmis dros mxedvelobaSi miiReba: gadatanili TB , gadatanili kontaqti TB -s Semdgomi nazi, an tlanqi narCeni cvlilebebi, TB pacientTan. tuberkulozis sxvadasxva formasTan SeuRlebuli diagnozis dasma siZneles ar warmoadgens; TB meningitis “izolirebuli” meningitis dros, rodesac pirveladi keris dagena ver xerxdeba, diagnostika garkveul siZneleebTan aris dakavSirebuli.
2009 wlis maisSi samxreT afrikis q. keiptaunSi Catarda 3 dRiani seminari, romelic TB diagnostikis sakiTxebs mieZRvna; mizani TB meningitis diagnostikis ZiriTadi kriteriumebis SemuSavebis dros konsensusis miRweva iyo; Sexvedras 7 qveynis (aSS; didi britaneTi; malaizia; samxreT afrika; indoeTi; indonezia; vietnami) 41 warmomadgeneli eswreboda: 13 saerTaSoriso eqsperti, bavSvTa da mozrdilTa nevrologebi, neiroqirurgebi, infeqcionistebi, mikrobiologebi, mecniermuSakebi.
seminaris monawileTa azriT TB meningitis diagnostikaSi ZiriTad kriteriumad tuberkulozis pirveladi keris dadgena CaiTvala rodesac TB meningiti SeuRlebulia filtvis da filtvgareTa tuberkulozis formebTan warmoebs: naxvelis, an biologiuri masalis baqterioskopiuli da kulturaluri gamokvleva; rentgenogramebis gadaReba; avadmyofobis anamnezis dawvilebiTi Seswavla.
vinaidan ukanaskneli 10-15 wlis ganmavlobaSi e.w. “izolirebuli” meningitis xvedriTma wonam 5-6-jer moimata, liqvoridan mJavagamZle baqteriis amoTesva ki dabal procentSi xdeba, seminamrma diagnozis dasmis dros ZiriTad kriteriumad miiCnia: klinikuri; liqvoraluri; radiologiuri kriteriumebi.
klinikuri kriteriumebi: TB TB meningitis dasawyisi moicavs 2-4 kviras; meningitisaTvis damaxasiaTebelia: fsiqoasTeniuri sindromi, subfebriluri, an febriluri cxeleba, Tavis tkivilebi, gulisreva pirRebinebiT dReSi 3-4-jer; meningialuri niSnebi – kefis kunTebis rigidoba da kernigis niSani ormxriv; dadebiTi zeda da qveda bruZinskis niSnebi, simfizis fenomeni, babinskis paTologiuri refleqsi;
bazaluri meningitis dros ziandeba:
III;
VI;
VII wyvili nervebi. da yalibdeba:
fTozi; egzofTalmi;
diplopia; SigniTa da gareTa sielme; saxis nervis qvemo totis parezi.
daavadebis progresirebis SemTxvevaSi yalibdeba tuberkulozuri meningo-encefaliti: metyvelebis moSla, cnobierebis Secvla; epilefsiuri gulyrebi; hemiparezebi, hemiplegiebi.
tuberkulozuri meningo-encefalo-mielitisaTvis damaxasiaTebelia: tkivilebi qvemo kidurebSi; mcire menjis Rrus organoebis funqciis moSla Sardis Sekaveba an Seukavebloba, yabzoba; qvemo paraparezebi da paraplegiebi.
daavadebis terminalur stadiaSi viTardeba bulbaluri sindromi, ziandeba IX; X; XII wyvili nervebi; Sesabamisad pacients aqvs: slokini; ylapvis gaZneleba; sunTqvis riTmis darRveva; bulbaluri sindromis ganviTareba pacientisaTvis arakeTilsaimedo prognozis maCvenebelia.
liqvoraluri kriteriumi: Tav-zurg tvinis siTxeSi momatebulia cila 0.99% _ 1.65% da meti; zomierad momatebulia pleocitozi, ZiriTadad limfocitebis xarjze _ 200-400 da meti; mkveTrad dadebiTia pandis reaqcia, dadebiTia none apeltis reaqcia, uaryofiTia veix-Sbrotis reaqcia; dabalia Saqari, rac paTognomuria TB meningitisaTvis; warmoiqmneba nazi fibrinuli bade;
radiologiuri kriteriumi _ Tavis tvinis kompiuteruli da magnitur-rezonansuli gamokvlevis Sedegebis Sefaseba TB meningitisaTvis damaxasiaTebelia: intrakranialuri hipertenzia dinamikaSi hidrocefaliiT; Tavis tvinis TeTr nivTierebaSi hiperintensiuri kerebi; subkortikalurad hiperintensiuri kerebi fiqsirdeba naoWebis saxiT; vaskuliti – kapilarebis doneze sisxlZarRvebis dazianeba irgvliv iSemiuri kerebiT;
TB meningitisaTvis damaxasiaTebeli struqturuli cvlilebebi fiqsirdeba: naTxemis qvemo fexebSi; naTxemis hemisferos kaudalur midamoSi; safeTqlis mediobazalur struqturebSi; Tavis tvinis kontrastuli gamokvlevis Sedegad aRiniSneba: Tavis tvinis garsebis; parkuWis kedlebis; liqvoro-cirkularuli gzebis kontrastuli gaZliereba; cns-is tuberkulomebis dros hipointensiuri kerebi, irgvliv zomieri perifokaluri SeSupebiT.
radiologiuri kvleva
• TB -s SemTxvevaSi kt-s sarwmunoeba 50%-ia; • bazaluri meningitis dros kt-s cvlilebebi vlindeba 80%-Si; • hidrocefalia – 70%; • infarqti – 10% • tuberkuloma – 20%
seminarma konsensusis saxiT SeimuSava TB meningitis diagnostikis ZiriTadi principebi, romelic eyrdnoba: klinikuri; liqvoraluri; radiologiuri kriteriumebis Sejamebas da analizs. damatebiT gamokvlevebad CaiTvala: bavSvebSi mantus sinji; liqvoris gamokvleva PCR -iT.
TB meningitis diagnostikis dros difdiagnostika unda gatardes: sxva etiologiis neiroinfeqciebTan: baqteriuli; virusuli; kandidozuri; kriptokokuli meningitebi; Tavis tvinis moculobiT procesebTan; Tavis tvinis sisxlis mimoqcevis moSlasTan.
q. keiptaunSi calke jgufad gamoiyo pacientebi eWviT TB meningitze, maTTanac: diagnostika emyareba klinikur, liqvoralur da radiologiur kriteriumebs; tubsawinaaRmdego mkurnaloba mTeli sifarTiT iwyeba eWvis gaCenis pirvelsave dRes da wydeba rodesac mTlianad gamoiricxeba specifiuri procesi;
TB meningitis atipiuri SemTxvevebi: daavadebis mwvaved dawyeba; daavadebis dawyeba arteriuli hipertenziiT, fsiqikis SecvliT, abdominaluri da radikulitis CivilebiT; TB meningitis duned dawyeba mcired gamoxatuli meningialuri niSnebiT; TB meningiti arapaTognomuri liqvoriT; TB meningitis mcire simptomebiT dawyeba im pacientebSi, romlebic adre, an TB meningitze gamokvlevis dros mkurnalobdnen antituberkulozuri preparatebiT; xanSiSesulTa meningiti; orsulTa meningiti, rodesac meningitis Civilebs miaweren orsulTa toqsikozebs; TB meningiti Sidsis dros.
atipiuri mimdinareobis mqone pacientebi xvdebian: Terapiul, infeqciur, nevrologiur, fsiqiatriul, qirurgiul klinikebSi maT usvamen: qolecistitis, gastritis, muclis tifis, radikulitis, arteriuli hipertoniis, fsiqozis diagnozebs utardebaT operaciebi: apendicitis, frontitis gamo specifiur klinikaSi ki gadmohyavT mxolod mas Semdeg, rac yalibdeba meningialuri sindromi.
HIV/AIDS – TB ko-infeqcia TB meningiti, iseve rogorc tuberkulozis sxva formebi xSirad atipiurad mimdinareobs; sustad aris gamoxatuli meningialuri niSnebi – kefis kunTebis rigidoba da kernigis niSani ormxriv; liqvorSi gamoxatulia mcire anTebiTi cvlilebebi: pleocitozi – normis farglebSi an mcired momatebuli; cila mkveTrad momatebuli 0.99%-3.3%-mde da meti; mniSvnelovnad daklebulia Saqari; HIV/AIDS – TB ko-infeqciis dros Tavis tvinis kompiuteruli gamokvleviT sWarbobs encefaliti;
difdiagnostikis dros pirvel rigSi unda gamoiricxos kriptokokuli meningiti.
Sidsis dros SesaZlebelia SeuRlebuli oportunistuli infeqciebis arseboba: citomegalovirusi, herpesvirusi, toqsoplazmozi, ebStein baris virusi, kandidozi; diagnozi ismeba serologiuri reaqciebis daxmarebiT; difdiagnostika unda Catardes Tavis tvinis limfomebTan da toqsoplazmebTan: limfomebis dros Tavis tvinis kompiuteruli tomografiiT korZiani sxeulis da parkuWis sxeulis garSemo Warbobs hipointensiuri ubani, romelic mkveTrad irTavs kontrasts; toqsoplazmebis dros Tavis tvinis TeTr nivTierebaSi aRiniSneba hiperintensiuri ubnebi mas efeqtiT;
Sidsis dros TB meningiti mZimed, xangrZlivad da talRiseburad, perioduli gamwvavebis da naTeli periodebis monacvleobiT mimdinareobs; prognozi arakeTilsaimedoa;
diseminirebuli TB miliaruli TB fibrozul-kavernozuli TB kerovani TB infiltraciuli TB
TB
meningiti saqarTveloSi
TB meningiti da filtvis TB
2001 2002 2003 2004 2005 2006 2007 2008 2009
2 2 3 8 2 3 2 1 3 1 6 3 4 1 4 1 5 3 3 2 1 1 2 7 3 3 4 1 1 6 sul 4 13 6 10 8 13 9 13 6
TB meningiti da filtvgareTa TB
2001 2002 2003 2004 2005 2006 2007 2008 2009
eqsudaciuri plevriti 1 1 1 limfuri kvanZebis TB 1 1 1 1 Zval-saxsris TB 3 2 2 4 uro-genitaluri TB 1 1 sul 1 3 2 5 3 5 1
2001
31
2001
36
2001
-
2001
5
2002
11
2002
27
2002
-
2002
8
2003
21 “izolirebuli” TB meningiti
2004
31
2005
20
2006
31
2007
23
2003
29
2003
1
2004
TB meningiti
2005 2006
41 33 44
2004
1 Sidsi
2005
1
2006
7
2007
35
2007
7
2003
4
2004
sikvdilianoba
2005 2006
5 3 4
2007
7 / 2 AIDS
2008
33
2008
51
2008
11
2009
35
2009
42
2009
4
2008
4 / 3 AIDS
2009
6 / 2AIDS
27 wlis 6 Tvis fexmZime pacienti stacionarSi Semovida 8/IV 10-Si; kaspis raionis macxovrebeli; daavadeba daewyo TandaTanobiT, Tavis tkiviliT, umadobiT, SeuCerebeli RebinebiT; cxeleba t38C; cnobierebis Secvla; tfdec-Si moTavsda daavadebis dawyebidan 2-3 kviris Semdeg; Catarda: liqvoris saerTo analizi; baqterioskopia; baqteriologiuri kvleva; magnitur-rezonansuli kvleva; sisxlis klinikuri da bio-qimiuri kvleva;
TariRi
12/IV 30/IV 11/V 18/VI 16/VIII 8/XI 4/I
pleocitozi
694/3 1080/3 965/3 210/3 200/3 420/3 190/3
cila
2.31% 6.6% 9.9% 0.99% 3.3% 3.3% 0.99% PDR-B masalis aRebis TariRi: 12/IV rezistentuli: S H E Eto; snsitiuri: R Km Cm Ofx PAS Cs DOTS+ programaSi CaerTo 4/V-dan
Saqari
12
04.07.10 - marjvena gverdiTi parkuWis sxeulis zeda kedlis mcire deformacia, konveqsitaluri qselqveSa sivrceebi zomierad gafarToebuli.
daskvna: diagnostikis sirTule adreul etapze ganapiroba pacientis fexmZimobam; intoqsikaciis niSnebi: gulisreva, umadoba, Tavis tkivili, pirRebineba aRqmul iqna rogorc orsulTa toqsikozis niSnebi; ar iyo gaTvaliswinebuli ojaxuri TB kontaqti; yovelivem ganapiroba gviani diagnostika, pacientis mdgomareobis damZimeba da mkurnalobis aradrouli dawyeba (3 kviris Semdeg);
pacientis CarTva MDR-TB programaSi moxda kliniko-laboratoriuli monacemebis gauaresebis; TB kontaqtis gamovlenis safuZvelze; CarTvisas SeirCa empiriuli samkurnalo reJimi; DST profilis gansazRvris Semdeg dainiSna individualuri samkurnalo sqema;
27 wlis pacienti stacionarSi Semovida 2/VI-10-Si; kaxeTis regionis macxovrebeli; TB kontaqtis dadgena ver moxerxda; xangrZlivi anamneziT; daavadeba daewyo TandaTanobiT, hospitalizacia moxda klinikuri niSnebis gamovlenidan 21 dRis Tavze; cxeleba t38C; bazaluri simptomatikis gamovlena; cnobierebis Secvla; Catarda: liqvoris saerTo analizi; baqterioskopia; baqteriologiuri kvleva; magnitur-rezonansuli kvleva; sisxlis klinikuri da bio-qimiuri kvleva;
TariRi
3/VI 22/VI 16/VII 6/VIII 26/VIII 3/XII
pleocitozi
240/3 90/3 190/3 90/3 150/3 180/3
cila
2.31% 0.66% 0.33% 0.33% 1.32% 1.32% MDR masalis aRebis TariRi: 3/VI rezistentuli: S H R E Eto; snsitiuri: Km Cm Ofx PAS Cs DOTS+ programaSi CaerTo 25/VI-dan
Saqari
29
03.06.10 - zomieri hidrocefalia
10.11.10 – iSemiuri ubani marjvniv TalamusSi, zomieri hodrocefalia, kortikaluri atrofiebi (neiroinfeqcia, vaskuliti);
daskvna: dagvianebulma diagnostikam da mkurnalobis dawyebam gamoiwvia garTulebebis ganviTareba hidrocefalia; iSemiuri kera TalamusSi; rac SesaZloa arakeTilsaimedo gamosavalis mizezi gaxdes.