Sorena sabanaZe, TinaTin bakuraZe, “samSabaToba”, 01.02.11

TB meningitis diagnostikis zogierTi sakiTxi

TB meningitituberkulozis erT-erTi yvelaze mZime formaa

droulad dasmuli diagnozi da Sesabamisi mkurnalobis dawyeba mniSvnelovnad amcirebs garTulebebis da sikvdilianobis maCvenebels;

M. tuberculosis aRwevs ra subaraqnoidalur sivrces iwvevs cns-is dazianebas da Sesabamisad yalibdeba sxvadasxva tipi:

TB meningiti; TB 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 TB -s Semdgomi nazi, an tlanqi narCeni

cvlilebebi, kontaqti TB pacientTan. tuberkulozis sxvadasxva formasTan SeuRlebuli TB

meningitis diagnozis dasma siZneles ar warmoadgens;“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 CaiTvalarodesac 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 meningitis dasawyisi moicavs 2-4 kviras;TB 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.

•TB-s SemTxvevaSi kt-s sarwmunoeba 50%-ia;•bazaluri meningitis dros kt-s cvlilebebi vlindeba 80%-Si; •hidrocefalia – 70%;•infarqti – 10%•tuberkuloma – 20%

radiologiuri kvleva

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-infeqciaTB 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 difdiagnostikis dros pirvel rigSi unda gamoiricxos kriptokokuli meningiti. 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;

TBTB meningiti saqarTveloSi meningiti saqarTveloSi TB meningiti da filtvis TB

2001

2002

2003

2004

2005

2006

2007

2008

2009

diseminirebuli TB

2 3 3 3 3 4 3 7 4

miliaruli TB - - - 1 - 1 2 3 -

fibrozul-kavernozuli TB

2 8 2 6 4 5 1 3 1

kerovani TB - - 1 - 1 3 1 - 1

infiltraciuli TB - 2 - - - - 2 - 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

“izolirebuli” TB meningiti

2001 2002 2003 2004 2005 2006 2007 2008 2009

31 11 21 31 20 31 23 33 35

TB meningiti

2001 2002 2003 2004 2005 2006 2007 2008 2009

36 27 29 41 33 44 35 51 42

Sidsi

2001 2002 2003 2004 2005 2006 2007 2008 2009

- - 1 1 1 7 7 11 4

sikvdilianoba

2001 2002 2003 2004 2005 2006 2007 2008 2009

5 8 4 5 3 4 7/

2 AIDS

4/3

AIDS

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 pleocitozi cila Saqari

12/IV 694/3 2.31% 12

30/IV 1080/3 6.6%

11/V 965/3 9.9%

18/VI 210/3 0.99%

16/VIII 200/3 3.3%

8/XI 420/3 3.3%

4/I 190/3 0.99%

PDR-Bmasalis aRebis TariRi: 12/IV

rezistentuli: S H E Eto;snsitiuri: R Km Cm Ofx PAS Cs

DOTS+ programaSi CaerTo 4/V-dan

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 pleocitozi cila Saqari

3/VI 240/3 2.31% 29

22/VI 90/3 0.66%

16/VII 190/3 0.33%

6/VIII 90/3 0.33%

26/VIII 150/3 1.32%

3/XII 180/3 1.32%

MDRmasalis aRebis TariRi: 3/VI

rezistentuli: S H R E Eto;snsitiuri: Km Cm Ofx PAS Cs

DOTS+ programaSi CaerTo 25/VI-dan

03.06.10 - zomieri hidrocefalia10.11.10 – 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.

gmadlobT yuradRebisTvis