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Уровень 1
Уровень 2
Уровень 3
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            [DETAIL_TEXT] => 

Уровень 3: Симптоматика заболеваний

Представляет

Раводин Роман Анатольевич
Дерматовенеролог, дерматоонколог, дерматокосметолог
Доктор медицинских наук, доцент
Категория: первая
Консультирует взрослых и детей
Город: Санкт-Петербург
Стаж: 15 лет
Базовое образование:
Военно-медицинская академия им. С.М. Кирова с золотой медалью, 1999
Дополнительное образование:
Адъюнктура при кафедре кожных и венерических болезней Военно-медицинской академии (2002-2005)
Основное место работы:
ООО "НПЦ ЛОГОДЕРМ", Северо-Западный государственный медицинский университет им. И.И. Мечникова,кафедра дерматовенерологии
Должность:
Доцент
Профессиональный опыт:
Занимается лечением и диагностикой всего спектра дерматовенерологических заболеваний, уделяя особое внимание редким и атипичным формам. При необходимости самостоятельно берёт соскобы и мазки, микроскопирует их и выдаёт заключение. Выполняет лазерное удаление невусов (родинок) и опухолей кожи. Является автором и соавтором более 70 научных работ по дерматовенерологии, включая два изобретения.

Третий уровень содержит 80 двухчасовых занятий и посвящён симптоматике наиболее распространённых дерматовенерологических заболеваний, включая рекомендации по их обследованию и лечению.

Каждое заболевание можно разложить на составляющие его симптомы с учётом их специфичности.

Высокоспецифичные симптомы включают те симптомы, которые наиболее характерны для данного заболевания (являются патогномоничными) и/или встречаются практически всегда при этом заболевании.

Среднеспецифичные – те симптомы, которые могут встречаться при данном заболевании, но в ряде случаев могут отсутствовать.

Низкоспецифичные − симптомы, которые нехарактерны для данной нозологии.

Каждый симптом, который может быть визуализирован, снабжён фотографиями.

Общее описание заболевания включает также его клинические фотографии, а рекомендации по обследованию снабжены изображениями гистологических и микроскопических препаратов.

Рекомендации по лечению основаны на национальных клинических рекомендациях.

После изучения заболевания доступен промежуточный тест для  самопроверки.

По окончании ознакомления с материалами уровня Вам предлагается пройти итоговый тест.

[~DETAIL_TEXT] =>

Уровень 3: Симптоматика заболеваний

Представляет

Раводин Роман Анатольевич
Дерматовенеролог, дерматоонколог, дерматокосметолог
Доктор медицинских наук, доцент
Категория: первая
Консультирует взрослых и детей
Город: Санкт-Петербург
Стаж: 15 лет
Базовое образование:
Военно-медицинская академия им. С.М. Кирова с золотой медалью, 1999
Дополнительное образование:
Адъюнктура при кафедре кожных и венерических болезней Военно-медицинской академии (2002-2005)
Основное место работы:
ООО "НПЦ ЛОГОДЕРМ", Северо-Западный государственный медицинский университет им. И.И. Мечникова,кафедра дерматовенерологии
Должность:
Доцент
Профессиональный опыт:
Занимается лечением и диагностикой всего спектра дерматовенерологических заболеваний, уделяя особое внимание редким и атипичным формам. При необходимости самостоятельно берёт соскобы и мазки, микроскопирует их и выдаёт заключение. Выполняет лазерное удаление невусов (родинок) и опухолей кожи. Является автором и соавтором более 70 научных работ по дерматовенерологии, включая два изобретения.

Третий уровень содержит 80 двухчасовых занятий и посвящён симптоматике наиболее распространённых дерматовенерологических заболеваний, включая рекомендации по их обследованию и лечению.

Каждое заболевание можно разложить на составляющие его симптомы с учётом их специфичности.

Высокоспецифичные симптомы включают те симптомы, которые наиболее характерны для данного заболевания (являются патогномоничными) и/или встречаются практически всегда при этом заболевании.

Среднеспецифичные – те симптомы, которые могут встречаться при данном заболевании, но в ряде случаев могут отсутствовать.

Низкоспецифичные − симптомы, которые нехарактерны для данной нозологии.

Каждый симптом, который может быть визуализирован, снабжён фотографиями.

Общее описание заболевания включает также его клинические фотографии, а рекомендации по обследованию снабжены изображениями гистологических и микроскопических препаратов.

Рекомендации по лечению основаны на национальных клинических рекомендациях.

После изучения заболевания доступен промежуточный тест для  самопроверки.

По окончании ознакомления с материалами уровня Вам предлагается пройти итоговый тест.

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Уровень 4
Уровень 5
Уровень 6
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Уровень 13

Актиномикоз

Определение

Актиномикоз  – хроническое заболевание, вызываемое грамположительными, филаментозными бактериями и характеризующееся поражением различных органов и тканей с образованием плотных инфильтратов, впоследствии нагнаивающихся с появлением свищевых отверстий на коже или слизистой оболочке.

Синонимы

actinomycosis.

Эпидемиология

Возраст: любой, но чаще в 17 – 50 лет.
Пол: чаще болеют мужчины.

Анамнез

Наиболее часто встречается челюстно-лицевой актиномикоз, реже отмечаются другие его формы: торакальный, абдоминальный, аногенитальный (аноректальный), актиномикоз кожи и подкожной жировой клетчатки и мицетома конечностей. При челюстно-лицевом актиномикозе пациенты в е чаще всего указывают на нарушение гигиены полости рта, заболевания зубов и пародонта, травмы и хирургические вмешательства во рту. Наиболее часто инфекция начинается с зубной гранулёмы или периапикального абсцесса. Постепенно развивается плотный малоболезненный инфильтрат различной локализации (в зависимости от формы заболевания), приобретающий синюшно-красную окраску. При поражении лица отмечается его асимметрия. Затем в инфильтрате появляются очаги размягчения, которые самопроизвольно вскрываются, образуя свищи, отделяющие гнойное или гнойно-кровянистое содержимое, нередко с примесью желтых крупинок (друз). Свищи могут самопроизвольно закрываться до следующего обострения заболевания, учитывая его первично- хроническое течение.

Течение

постепенное начало с последующим медленным прогрессированием (в патологический процесс вовлекаются различные части тела и внутренние органы: голова (включая ЦНС, полость рта, язык, верхнюю и нижнюю челюсти), шея (с поражением гортани и трахеи), грудь (с поражением легких и органов средостения), живот (с поражением кишечника, печени, почек, позвоночника), мочеполовые органы, стопы (мадурская стопа), кожа и подкожная жировая клетчатка без тенденции к самопроизвольному разрешению. Заболевание может закончиться летально.

Этиология

актиномицеты (аctinomycetes) – род неподвижных, неспорообразующих, анаэробных или факультативно анаэробных, грамположительных, филаментозных бактерий (семейства Actinomycetaceae). Наиболее частыми возбудителями актиномикоза являются: Actinomyces Israeli, Actinomyces gerencseriae, Actinomyces radingae. В патологическом материале возбудитель встречается в виде друз (колоний), которые представляют собой желтоватые комочки диаметром 1-2 мм. При микроскопии в центре друз обнаруживаются скопления филаментов, напоминающих нити мицелия, а по периферии – колбовидные вздутия. Возбудители актиномикоза распространены повсеместно, поражают людей и сельскохозяйственных животных. Однако случаев заражения человека от больных людей или животных не описано. Актиномицеты обитают на растениях и в почве, их часто обнаруживают у здоровых людей в полости рта, зубном налете, лакунах миндалин, на слизистой оболочке желудочно-кишечного тракта.

Предрасполагающие факторы

  • работа в сельском хозяйстве;
  • травматизация (повреждение) кожи и слизистой оболочки;
  • истощение;
  • злоупотребление алкоголем;
  • употребление наркотиков;
  • ВИЧ;
  • иммунодефицитные состояния, не ВИЧ-обусловленные;

Жалобы

На безболезненное (иногда болезненное) уплотнение кожи (слизистой), которое в дальнейшем размягчается с образованием свищей, отделяющих гнойное содержимое с примесью желтоватых крупинок. Нередко имеются симптомы общей интоксикации (повышение температуры, озноб, общая слабость и недомогание). При поражении внутренних органов беспокоят боли в груди, животе, мошонке, головная боль. Возможен приступообразный кашель с гнойно-кровянистой мокротой и затруднение дыхания. Больные отмечают снижение массы тела.

Дерматологический статус

процесс поражения кожи носит распространенный или чаще - ограниченный характер, элементы сыпи на туловище могут располагаться изолированно или сливаться.

Элементы сыпи на коже

  • плоский или полушаровидный малоболезненный узел с гладкой или бугристой поверхностью, сначала цвета нормальной кожи, в дальнейшем приобретающий синюшно-красный цвет, характеризуется деревянистой плотностью, размеры узлов при их появлении не превышают 1-2 см, впоследствии (вследствие периферического роста и слияния) они могут достигать до 10 см в диаметре. Узлы постепенно размягчаются и вскрываются свищевыми отверстиями с отделением гноя, содержащего желтоватые зерна (друзы), реже они распадаются с образованием язв;
  • возможны болезненные язвы (после распада узлов) от 1 до 5 и более см в диаметре, с подрытыми неровными краями, дно их покрыто некротическими массами, может быть гнойным или гранулирующим, в основании язв сохраняется плотный инфильтрат. Язвы разрешаются с образованием мозаичных рубцов;
  • мозаичные нормо-, гипер- или атрофические рубцы, красного или перламутрово-белого цвета;

Элементы сыпи на слизистых

  • плоский или полушаровидный малоболезненный узел с гладкой или бугристой поверхностью, сначала цвета нормальной слизистой, в дальнейшем приобретающий синюшно-красный цвет, характеризуется деревянистой плотностью, размеры узлов при их появлении не превышают 1- 2 см, впоследствии могут увеличиваться. Узлы постепенно размягчаются и вскрываются свищевыми отверстиями с отделением гноя, содержащего желтоватые зерна (друзы), реже распадаются с образованием язв;
  • болезненные язвы (после распада узлов) от 1 до 5 и более см в диаметре, с подрытыми неровными краями, дно их покрыто некротическими массами, может быть гнойным или гранулирующим, в основании язв сохраняется плотный инфильтрат. Язвы могут приводить к перфорации твёрдого нёба, нередко разрешаются с образованием мозаичных рубцов;
  • мозаичные или полосовидные нормо-, гипер- или атрофические рубцы, красного или перламутрово-белого цвета ;

Локализация

лицо (углы нижних челюстей, щёки, подчелюстная область), шея, грудь, живот, промежность, ягодицы, бёдра, стопы, верхние конечности.

Дифференциальный диагноз

Скрофулодерма, хромомикоз, гангренозная пиодермия, хроническая язвенная (язвенно-вегетирующая, абсцедирующая) пиодермия, поражения кожи, вызванные атипичными микобактериями, сифилитические гуммы.

Сопутствующие заболевания

менингит, энцефалит, дивертикулит, аппендицит, эпителиальный копчиковый ход, остеомиелит, лёгочные инфильтраты, очаги хронической инфекции в организме (хронический синуит, хронический отит, аднексит, тонзиллит, зубные гранулёмы, хронические пиодермии), иммунодефицитные состояния (не ВИЧ- обусловленные), ВИЧ, остеомиелит, сахарный диабет.

Диагноз

Обычно основывается на клинической картине (сочетании следующих трех клинических признаков: наличие глубоких плотных воспалительных инфильтратов в коже и подкожной жировой клетчатке; образование в инфильтратах свищевых ходов с гнойным отделяемым; отсутствие или временный эффект от краткосрочных курсов антибиотикотерапии), а также на результатах микроскопии и кожно-аллергических пробах с актинолизатом.

Патогенез

Наибольшее признание получила гипотеза эндогенного заражения, при которой возбудитель, постоянно сапрофитирующий в организме (в полости рта, желудочно кишечном тракте, верхних дыхательных путях), приобретает патогенные свойства. Возникновению заболевания (переходу возбудителя от сапрофитического к паразитическому состоянию) способствуют ослабление иммунитета, хронические инфекции, переохлаждение и др. Защитные свойства слизистой оболочки нарушаются за счет местных воспалительных процессов и микротравм. Возможно также экзогенное инфицирование открытых травм (возбудитель обитает в почве и на растениях) с последующим распространением инфекции на окружающие ткани гематогенным, лимфогенным и/или контактным путём. Антигены актиномицетов приводят к специфической сенсибилизации и аллергической перестройке организма (гиперсенсибилизация замедленного или туберкулинового типа), а также к образованию антител (комплементсвязывающие, агглютинины, преципитины и др.). В месте экзогенного или эндогенного внедрения возбудителя образуется инфекционная гранулема, которая «прорастает» в окружающие ткани. В центре гранулёмы возникают некроз и абсцессы, которые, прорываясь, образуют свищи, при этом поражение кожи носит вторичный характер. В образовании нагноений играет роль также и вторичная, преимущественно стафилококковая инфекция.

Дополнительные исследования

Бактериологическое исследование

Проводят посев гнойного отделяемого с поверхности язв (свищей) на среду Сабуро и через 3-4 недели появляются медленно растущие лучистые колонии. Ввиду трудоемкости и длительности практическое использование данного диагностического метода ограничено.

Микроскопическое исследование

Отделяемого свищей, при котором обнаруживают друзы актиномицетов.

Серологическое исследование

Реакция иммунофлуоресценции (РИФ) со специфическими антигенами позволяет определить вид актиномицетов.

Кожные пробы

Кожно-аллергическая проба с актинолизатом.

Диагноз

Обычно основывается на клинической картине (сочетании следующих трех клинических признаков: наличие глубоких воспалительных инфильтратов кожи и подкожной жировой клетчатки; образование в инфильтратах свищевых ходов с гнойным отделяемым; отсутствие или временный эффект от краткосрочных курсов антибиотикотерапии), результатах микроскопии и кожно-аллергических пробах с актинолизатом.

Хирургическое лечение

Вскрытие и дренирование гнойных очагов, последующее выскабливание грануляций, обработка пораженных тканей 5% спиртовой настойкой йода, введение порошка йодоформа.

Общее лечение

  • Актинолизат внутримышечно по 3–4 мл или внутрикожно начиная с 0,5 мл до 2 мл 2 раза в неделю, на курс 20–25 инъекции;
  • Антибиотики — бензилпенициллин (натриевая соль) не менее 12 млн ЕД/сут в/в в течение 2 нед, затем феноксиметилпенициллин по 1 г 4 р/сут или тетрациклин по 500 мг внутрь каждые 6 часов.

Дезинтоксикационная терапия

Внутривенно капельно вводят раствор гемодеза, реополиглюкина с добавлением витаминов, кокарбоксилазы. В комплекс лечения хронической интоксикации включают поливитамины с микроэлементами, энтеросорбенты, обильное питье с настоями лекарственных трав.


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