Skiepytų asmenų erkinio encefalito diagnostikos sunkumai

Skiepytų asmenų erkinio encefalito diagnostikos sunkumai

Įvadas

Erkinis encefalitas (EE) – viena žinomiausių ir dažnai diagnozuojamų centrinės nervų sistemos infekcijų Lietuvoje. Pastebima tendencija, kad sergamumas EE pastaraisiais metais didėja. Tai lemia keletas priežasčių. Viena jų yra klimato kaita – visuotinis atšilimas, kuris prailgina erkių aktyvumo laikotarpį ir lemia erkių populiacijos didėjimą. Vienas tokio fakto įrodymų yra pranešimai apie erkių aptikimą 1 800 m aukštyje, nors anksčiau buvo teigiama, kad aukščiau nei 800 m jos nepakyla. Kita priežastis – lietuviai daugiau laiko praleidžia gamtoje, pavyzdžiui, sodybose pamiškėse ir paežerėse. Dar viena priežastis – mažas žmonių, kurie skiepijasi nuo EE, skaičius.

 

Sergamumo EE statistika

Baltijos šalyse 2015 metais registruotas didžiausias sergamumas EE (Lietuvoje – 11,5 atvejų 100 tūkst. gyventojų, Estijoje – 8,76, Latvijoje – 7,1) [3]. Tais pačiais metais Austrijoje, Kroatijoje, Slovakijoje, Suomijoje, Švedijoje, Vokietijoje registruotas mažas sergamumas EE – mažiau kaip 2 atvejai 100 tūkst. Gyventojų [4]. Praėjusiais metais Lietuvoje EE sirgo 633 asmenys [2]. Visa tai leidžia Pasaulio sveikatos organizacijai teigti, kad Lietuva, vertinant sergamumą EE, yra endeminė zona.

Savaime suprantama, kad, esant dideliam EE atvejų Lietuvoje skaičiui, didėja ir nepalankių išeičių skaičius. Nors specifinių vaistų nuslopinti EE virusą kol kas neturime, tačiau išvengti ligos galima pasiskiepijus. Tai geriausiai įrodo Austrijos pavyzdys. 1982 metais Austrijoje, kurioje sergamumo EE rodiklis siekė 8,75 atvejo 100 tūkst. gyventojų, pradėta visuotinė žmonių vakcinacija nuo EE. Dabar, kai 90 proc. šalies gyventojų yra pasiskiepiję nuo šios ligos, EE atvejų sumažėjo daugiau kaip 12 kartų (ULAC). Austrų autoriai pateikia įdomius duomenis: tinkamai pasiskiepijus, vakcinos efektyvumas siekia 99 proc., nesilaikant skiepijimosi schemos – 95 proc. [1]. 2000–2006 metais Austrijoje vakcinacija leido išvengti 2 800 EE atvejų.

Deja, Lietuvoje padėtis gerokai prastesnė – 2015 metais nuo EE pasiskiepijo tik 2,14 proc. šalies gyventojų [5].

Nepaisant vakcinos efektyvumo, kai kurie asmenys EE suserga ir pasiskiepiję. Kad taip gali atsitikti, ir norime parodyti pateikdami klinikinį atvejį.

 

Klinikinis atvejis

2016 metais rugsėjo 21 dieną 51 metų ligonė V. M. buvo hospitalizuota į Kauno klinikinės ligoninės (KKL) Reanimacijos skyrių. Pacientė 2 savaites iki hospitalizacijos karščiavo, blogai jautėsi. Rugsėjo 18 dieną jai ėmė skaudėti galvą, vėmė, temperatūra pakilo iki 40 °C. Pacientė kreipėsi į Jonavos ligoninę. Įtarus virusinį meningokokinį encefalitą, ligonė paguldyta į KKL. Atvykusi į KKL pacientė buvo dezorientuota, nekritiška, elementarius paliepimus vykdė, bet visaverčio kontakto nebuvo. Apžiūros duomenys: sprandas rigidiškas, kiti meninginės simptomai neigiami, vyzdžiai lygūs, foto r-ja (teigiama), Rombergo pozoje nestabili, einant mėto į šonus, kalba sutrikusi. Neuroinfekcijai patvirtinti atlikta juosmeninė punkcija. Gautas skaidrus bespalvis likvoras. Nustatyta 420 x 106/l ląstelių (35 proc. – neutrofilų, 65 proc. – limffocitų), baltymai – 1,03 g/l, gliukozė – 2,8 mmol/l (serume – 5,0 mmol/l). Tyrimai leido patvirtinti virusinę neuroinfekcijos versiją.

Etiologijai nustatyti tirti antikūnai prieš EE virusą. IgM klasės antikūnų nebuvo, tačiau nustatyti IgG klasės antikūnai (optinis tankis – 1,173, o norma – 0,230). Tokie radiniai buvo interpretuoti kaip vakcinacijos padarinys, nes renkant anamnezę paaiškėjo, kad ligonė skiepijosi nuo EE (vakcinacijos datos: 2004 metais gegužės 3 dieną, 2004 metais gegužės 31 dieną, 2005 metais balandžio 29 dieną, 2009 metais birželio 1 dieną, 2014 metais balandžio 3 dieną). Neuroinfekcijos etiologijai patikslinti papildomai buvo atliktas herpes simplex viruso bei borelijų tyrimas likvore. Abiem atvejais atsakymai buvo neigiami, todėl teko patvirtinti neaiškios kilmės virusinio encefalito diagnozę…

Daugiau skaitykite „Infekcinės ligios“ Nr.1 (11), 2017

Ambraška, K. Vieželis

Kauno klinikinė ligoninė


137 mintys apie “Skiepytų asmenų erkinio encefalito diagnostikos sunkumai

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