epStein – baris virusiT infeqcia infeqciuri mononukleozi · `epStein-baris virusiT infeqcia – infeqciuri mononukleozi~ ... baris virusiT infeqcia infeqciuri mononukleozi ... (LP)

1

epStein – baris virusiT infeqcia

infeqciuri mononukleozi

klinikuri marTvis nacionaluri rekomendacia

(gaidlaini)

2

klinikuri praqtikis erovnuli rekomendacia (gaidlaini)

`epStein-baris virusiT infeqcia – infeqciuri mononukleozi~

miRebulia klinikuri praqtikis erovnuli rekomendaciebis

(gaidlainebi) da daavadebaTa marTvis saxelmwifo standartebis

(protokolebi) SemuSavebis, Sefasebis da danergvis erovnuli

sabWos 2007 wlis 21 martis #1 sxdomaze da damtkicebulia

saqarTvelos Sromis, janmrTelobisa da socialuri dacvis

ministris 2007 wlis 21 dekembris # 365/o brZanebiT.

3

epStein – baris virusiT infeqcia

infeqciuri mononukleozi

1. daavadebis gansazRvreba, sinonimebi, klasifikacia, terminologia

daavadebis gansazRvreba:

infeqciuri mononukleozi ewodeba epStein-baris virusiT (EBV) gamowveul

pirvelad infeqcias, romelic xasiaTdeba cxelebiT, intoqsikaciiT,

tonzilitiT, elenTis, RviZlisa da limfuri kvanZebis gadidebiT,

periferiul sisxlSi atipuri mononuklearebis arsebobiT.

EBV, sxva herpesvirusebis msgavsad, axasiaTebs organizmSi xangrZlivi

persistencia da infeqciis qronikuli da latenturi formebi, perioduli

gamwvavebebiT.

daavadebis sinonimebi:

pirveladi epStein-baris virusiT infeqciis sinonimebia: filatovis

daavadeba, pfeiferis daavadeba, jirkvlovani cxeleba (n.p.filatovi,

n.feiferi, me-19 saukune). 1886 wlidan am daavadebam 60-ze meti saxelwodeba

Seicvala: subleikemiuri leikocitozi, keTilTvisebiani leikemia (1910-

1920w.w.), limfomonocituri angina, kocnis daavadeba da sxv.

saxelwodeba ,,infeqciuri mononukleozi" ekuTvnis Spruntsa da evanss (1920-

1921 w.w.).

ICD –10-is mixedviT infeqciuri mononukleozis kodia B 27

epStein-baris virusiT gamowveuli infeqciis klasifikacia:10

epStein-baris virusiT gamowveuli pirveladi infeqcia:

1. infeqciuri mononukleozi

2. dunkanis daavadeba.

qronikuli infeqcia:

1. berkitis limfoma

2. hojkinis daavadeba

3. dunkanis daavadeba

latenturi infeqciis reaqtivacia:

1. nazofaringeuli karcinoma

2. imunokomprometirebul pirebSi ganviTarebuli limfomebi.

4

infeqciuri mononukleozis klasifikacia:

daavadebis klinikuri gamovlinebis mixedviT arsebobs

infeqciuri mononukleozis klasifikacia, romelic

moicavs Semdeg formebs1:

1. klinikuri niSnebis mixedviT:

tipuri

atipuri

subklinikuri

2. simZimis mixedviT:

msubuqi

saSualo simZimis

mZime

3. mimdinareobis mixedviT:

mwvave

qronikuli

terminologia:

kafsidi - cilovani garsi, romelic gars akravs virusis dnm-s.

kafsomeri - kafsidis Semadgeneli morfologiuri suberTeuli.

episoma - virusis genomi, romelic mdebareobs ujredis birTvSi da ar

aris integrirebuli ujredis dnm-Si.

komplementi - organizmis araspecifikuri dacvis humoruli faqtori.

warmodgenilia sisxlis Sratis proteinebis kompleqsiT, romelic

Cveulebriv araaqtiur mdgomareobaSia. misi aqtivacia xdeba antigenis

antisxeulTan dakavSirebis an antigenis imunokompetentur ujredze

agregaciis SemTxvevaSi.

CD - ujredis membranis zedapirze arsebuli receptorebi. struqturulad

warmoadgenen glikoproteidebs (ingl. Cell Differentiation Antigens. Claster Definition).

CD21 - B limfocitebis zedapirze arsebuli receptori, romelic samiznea

komplementis C3d komponentisa da epStein-baris virusis gp 350/220 cilisTvis.

virioni - virusis ujredgare forma.

koinfeqcia - (laTinuri sityvaa da niSnavs ,,erTad") - ori sxvadasxva

mikrobuli faqtoriT inficireba.

5

agranulocitozi - granulocituri leikocitebis ricxvis mkveTri

Semcireba an sruli gaqroba periferiul sisxlsa da sisxlmbad

organoebSi.

transkrifcia - (laT. transcriptio - gadawera) – informaciul rnm-ze (i-rnm)

nukleinmJavadan genetikuri informaciis gadawera nukleotidebis

Tanmimdevrobis saxiT.

translacia - (laT. translatio - gadatana, gadayvana) - i-rnm-iT ribosomebze

genetikuri informaciis gadacema.

qromosomebis translokacia (laT. translocatio chromosomatum. laT - trans - gadaadgileba da locus - adgili) - qromosomebis struqturuli gardaqmnis

saxesxvaoba, romlis dros homologiur an arahomologiur qromosomebs

Soris romelime segmenti gadaadgildeba. termini SemoiRo bridJesma (1917w).

VCA - virusis kafsidis antigeni. EA - virusis adreuli antigeni.

EBNA - virusis nuklearuli (birTvis) antigeni.

LMP - latenturi membranuli antigeni.

EBER - virusSi kodirebuli rnm.

VAHS - virus asocirebuli hemofagocituri sindromi.

HRS ujredebi - hojkin-rid-Sternbergis ujredebi.

PTLD - transplantaciis Semdgomi limfoproliferaciuli daavadebebi.

dnm polimeraza - fermenti, romelic uzrunvelyofs virusis genomis

transkrifciasa da replikacias.

proteinkinaza - fermenti, romelic axdens virusis cilebis modificirebas.

seroprevalentoba (ingl. prevalence - gavrceleba) - serologiuri

gavrceleba.

2. epidemiologia

EBV mTel msoflioSi farTodaa gavrcelebuli. virusiT inficirebulia

mozrdili asakis mosaxleobis 90-95%.2 ganviTarebad da dabali socialur-

ekonomikuri statusis ganviTarebul qveynebSi adamianTa dainficireba

ZiriTadad bavSvTa an axalgazrda asakSi xdeba, xolo maRali socialur-

ekonomikuri ganviTarebis qveynebSi - sqesobrivi momwifebisa da

postpubertatul periodSi9 (sur.1).9

6

sur. 1

bavSvTa asakSi epStein-baris virusiT pirveladi infeqcia subklinikurad an

msubuqi tonzilitis saxiT mimdinareobs. ganviTarebad qveynebSi

klinikurad manifestirebuli infeqciuri mononukleozi SedarebiT

iSviaTad gvxvdeba. mozrdilebSi EBV pirveladi inficirebis Sedegad

viTardeba infeqciuri mononukleozis tipuri, mwvave forma. maRal

ganviTarebul qveynebSi klinikurad manifestirebuli infeqciuri

mononukleozi maRali sixSiriT gvxvdeba.

avadoba ufro xSiria 14-16 wlis gogonebsa da 16-18 wlis

vaJebSi.Ddaavadebis yvelaze maRali maCvenebeli 15-24 wlis asakobriv

jgufSi vlindeba. iSviaTad avaddebian 40 welze zemo asakis pirebi, Tumca

imunokomprometirebulebSi EBV reaqtivacia SesaZloa nebismier asakSi

moxdes.3,4

infeqciis wyaroa avadmyofi an virusmtarebeli. am mxriv gansakuTrebuli

roli eniWebaT subklinikuri formiT daavadebulebs. infeqciis gadacemis

gzebia: haer-wveTovani, kontaqturi, alimenturi, transfuziuli, sqesobrivi.

iSviaTad - vertikaluri, organoTa transplantacia. EBV gadacemis gzebidan

yvelaze mniSvnelovania kontaqturi. termini ,,kocnis daavadeba" miuTiTebs

infeqciis gadacemis yvelaze xSir gzas. ekonomikurad ganviTarebul

asaki (wlebi)

ganviTarebadi qveynebi

dabali socialur-

ekonomikuri statusis

qveynebi

maRali socialur-

ekonomikuri statusis

qveynebi

EBV-s seroprevalentoba ganviTarebad da ganviTarebul qveynebSi

EB

V seropozitiuri (%

)

7

qveynebSi EBV seroprevalentoba gansakuTrebiT maRalia sqesobrivad aqtiur

studentebSi.6

mwvave infeqciis dros virusi nerwyvTan erTad gamoiyofa 16-18 Tve.1,8

praqtikulad janmrTeli, latenturad inficirebuli pirebis 20-30% mTeli

cxovrebis ganmavlobaSi gamoyofs viruss.7

saqarTveloSi infeqciuri mononukleozi ZiriTadad sporaduli saxiT

gvxvdeba. daavadebis SemTxvevebis zusti aRricxva ver xerxdeba, radgan

msubuqi da saSualo simZimis formebi sxvadasxva diagnoziT binaze rCebian

yovelgvari registraciis gareSe (sur. 2).

saqarTveloSi klinikurad gamovlenili infeqciuri mononukleozis

yvelaze maRali maCvenebeli 4-14 wlis asakobriv jgufSi gvxvdeba. meore

adgilzea 14 wlis zemo asakis pirebi. Tumca 2003 wlidan aRiniSneba am

maCveneblis daqveiTebis tendencia 1-4 wlis asakis avadmyofTa raodenobis

zrdis xarjze. 0-1 wlamde asakis bavSvebSi klinikurad manifestirebuli

infeqciuri mononukleozi iSviaTad gvxvdeba (daavadebaTa kontrolis

erovnuli centri).

2000

weli

2001

weli

2002

weli

2003

weli

2004

weli

2005

weli

0%

10%

20%

30%

40%

50%

60%

70% 80% 90% 100%

2000-2005 wels saqarTveloSi registrirebuli infeqciuri

mononukleozis SemTxvevebis asakobrivi struqtura

3,3%

30%

46,6%

20,1%

0-1weli

0%

29,5%

45,4%

25,1%

0%

24,3%

40,5%

35,2%

11 4%

31,4%

37,1%

20,1%

0%

32,6%

44,8%

22,6%

1,8%

29%

34,5% 34,7%

1-4 weli

4-14 weli

> 14 weli sur. 2

8

prognozi

• mwvave infeqciuri mononukleozis gadatanis Semdeg

imunokompetenturi pirebi srulad gamojanmrTeldebian ramdenime Tvis

ganmavlobaSi, narCeni movlenebisa da garTulebebis gareSe.7

• hematologiuri cvlilebebisa da RviZlismieri garTulebebis

ukuganviTareba xdeba 2-3 TveSi.7

• garTulebebis gamovlenis SemTxvevaSi bavSvTa asakSi nevrologiuri

sindromi mokle droSi ganicdis ukuganviTardebas, mozrdilebSi ki -

SedarebiT xangrZlivad rCeba.7

• sxva herpesviresebiT gamowveuli infeqciebis msgavsad, EBV

inficirebisas yalibdeba infeqciis latenturi forma. gamomwvevi

persistirebs B limfocitebsa da orofaringeul epiTelur ujredebSi.

latentur formas axasiaTebs xangrZlivi, usimptomo mimdinareoba da

imunodeficitis SemTxvevaSi reaqtivacia.7

• mwvave infeqciuri mononukleozis SemTxvevaSi letaluri gamosavali

iSviaTia da ganpirobebulia zeda sasunTqi gzebis obstruqciiT,

elenTis gaskdomiT, nevrologiuri garTulebebiT, granulocitopeniiT,

agranulocitoziT, TrombocitopeniiT, RviZlis ukmarisobiTa da

miokarditiT.4

arakeTilsaimedo gamosavliT xasiaTdeba EBV asocirebuli daavadebebi

da sindromebi: hojkinis limfoma, transplantaciis Semdgomi

limfoproliferaciuli daavadebebi, nazofaringeuli karcinoma, kuWis

carcinoma, dunkanisa da hemofagocituri sindromi.2,52

3. etiologia, paTogenezi

epStein-baris virusi miekuTvneba herpesvirusebis ojaxsa da

Gammaherpsvirinae-s qveojaxs. virionis diametri 180-200 nm-ia. mis centralur

nawilSi moTavsebulia orjaWviani dnm (molekuluri masiT 101+3X106),

romelSic Dkodirebulia 80–mde proteini. dnm-is irgvliv mdebareobs

heqsagonaluri formis kafsidi. dnm da kafsidi erTad qmnis nukleokafsids,

romelic Sedgeba Tanmimdevrulad ganlagebuli kafsomerebisgan. garedan

virusi dafarulia lipoproteinuli garsiT, romlis zedapirze,

ganlagebulia glikoproteinebis molekulebi11 (sur.3).11

9

kafsidi da lipoproteinuli garsi: a) virions icavs garemos

araxelsayreli faqtorebisgan; b) ganapirobebs virionis adsorbcias

zogierT ujredebze; g) gansazRvravs virionis antigenur da imunogenur

Tvisebebs.11

epStein – baris viruss axasiaTebs arCeviTi adsorbcia B limfocitebsa da

piris Rrus epiTelur ujredebze.7,11 B limfocitebis zedapirze arsebobs CD21 receptorebi (savaraudod aseTive receptorebi aris orofaringeuli

epiTeluri ujredebis zedapirze), romelsac EBV ukavSirdeba virionis

garsis zedapirze arsebuli glikoprotein - gp 350/220-is saSualebiT, xdeba

ujredis membranisa da virionis garsis Serwyma(2), Tavisufldeba

nukleokafsidi, romelic virusul dnm-Tan erTad transportirdeba

ujredis birTvSi. Semdeg etapze mimdinareobs virusuli genomis

transkrifcia. warmoiqmneba informaciuli rnm(4). igi gadadis

citoplazmaSi, sadac iwyeba virusis cilebis sinTezi. esenia:

α - cilebi (I) - axasiaTebT maregulirebeli aqtivoba.

ß - cilebi (II) – fermentebi - dnm-polimeraza da Timidinkinaza.

monawileoben virusis dnm-is replikaciaSi.

γ - cilebi (III) - struqturuli cilebi _ virusis kafsidi da

glikoproteinebi. glikoproteinebi difuzurad ganlagdebian ujredis

birTvis garsze (5), warmoiqmneba modificirebuli membrana, romlidanac

Semdeg etapze yalibdeba virionis lipoproteinuli garsi. paralelurad

warmoiqmneba kafsidi, mis centrSi Tavsdeba virusis dnm (6,7), kafsidis

garSemo ki - modificirebuli membrana (8). sabolood yalibdeba virioni.

igi goljis aparatis saSualebiT gadadis citoplazmaSi da maspinZel

ujreds tovebs egzocitozis (9) an ujredis lizisis (10) gziT11 (sur. 4)11

epStein-baris virusis struqtura

sur.3

10

sur. 4

EBV cxovelmyofelobis periodSi axdens mTeli rigi antigenebisa da

proteinebis eqspresias. esenia: virusis kafsidis antigeni (VCA), adreuli

(EA) (Tavis mxriv igi arsebobs ori saxis - difuzuri (D) da citoplazmuri

(R)), nuklearuli (birTvis) antigenebi (EBNA) 1,2,3A, 3B, 3C,

EBV-Si kodirebuli rnm-I _ EBER1 da EBER2, membranuli proteinebi (LP) da latenturi membranuli proteinebi (LMP)1,2A da 2B.4,7,11

paTogenezi:

epStein - baris virusi organizmSi SeiWreba orofaringeuli gziT. sawyis

etapze virusi replikacias ganicdis epiTelur ujredebSi. warmoqmnili

virioni maspinZel ujreds tovebs egzocitozis an ujredis lizisis gziT

da vrceldeba sanerwyve jirkvlebsa da orofaringeul limfoidur

qsovilSi, viTardeba limfadenopaTia. Semdeg limfur-hematogenuri gziT

xdeba infeqciis generalizacia - virusemia, rac ganapirobebs

limfoidretikuluri qsovilis inficirebas (periferiuli sisxlis B limfocitebi, elenTa, RviZli, iSviaTad T limfocitebi ).1,7 garda amisa,

mocirkulire B ujredebis inficireba SesaZlebelia moxdes maTi

kontaqtisas orofaringeul epiTelur qsovilTan. virusi axdens B limfocitebis transformacias, ris Sedegad isini iZenen poliklonuri

proliferaciis unars.

EBV inficirebis sapasuxod aqtiurdeba organizmis ujreduli imuniteti.

inficirebuli ujredebis ganadgureba xdeba CD8+ limfocitebiTa (T-citotoqsikuri) da naturaluri kilerebiT (NK-ujredebi). B limfocitebis

poliklonuri proliferaciis daTrgunva ki xdeba T supresorebiT. epStein-

virusis reproduqciis cikli

11

baris infeqciis dros antisxeulebs umniSvnelo damcvelobiTi roli

akisriaT. ZiriTadi pasuxi xorcieldeba ujreduli imunitetis saSualebiT.

swored amitom pirebi, romelTac aqvT ujreduli imunitetis Tandayolili

an SeZenili defeqti, uviTardebaT mZime infeqciuri mononukleozi, xSirad

letaluri gamosavliT.4,6,12,13

virusuli infeqciis sapasuxod xdeba humoruli imunuri pasuxis aqtivaciac.

warmoiqmneba heterofiluri da EBV antigenebis sawinaaRmdego specifikuri antisxeulebi. inficirebuli B limfocitebi warmoqmnian heterofilur

antisxeulebs, romelTac SeuZliaT moaxdinon sxva saxeobis organizmTa

(mag: cxvris, cxenis, xaris da a.S.) ujredebis (eriTrocitebis) aglutinacia.

aRniSnul reaqciazea dafuZnebuli paul-bunelis testi. heterofiluri

antisxeulebi miekuTvneba imunoglobulinebis M klass. maTi roli

daavadebis paTogenezsa da gamojanmrTelebaSi bolomde garkveuli ar aris.

ar arsebobs korelacia daavadebis simZimesa da heterofiluri

antisxeulebis titrs Soris.7,13

specifikur antisxeulebs miekuTvneba kafsidis (anti-VCA), adreuli (anti-

EA) da birTvis (anti-EBNA) antigenebis, aseve membranuli proteinebis

sawinaaRmdego antisxeulebi.16,17 garda amisa, pirveladi EBV infeqciis dros

aRmoCenilia antisxeulebi, romlebic boWaven Trombocitebs, neitrofilebs,

limfocitebsa da ampicilins. isini pasuxismgebelni arian EBV infeqciis

dros ganviTarebul autoimunur procesebze.8

rogorc aRvniSneT, epStein-baris virusi xasiaTdeba organizmSi

persistenciiT. latenturi infeqciis dros virusis dnm arsebobs

limfocitebisa da epiTeluri ujredebis birTvSi episomis saxiT. episoma

iSviaTad integrirdeba ujredis genomSi, Tumca ujredis gayofasTan erTad

xdeba virusis dnm-is replikacia da ujredTa axal Taobaze misi gadacema.7

latenturi infeqciis dros xdeba sxvadasxva proteinebis eqspresia.

arsebobs 3 tipis latencia:2,4,7

I - asocirebuli berkitis limfomasTan, eqspresirdeba EBER da EBNA1.

II - asocirebuli nazofaringeul karcinomasTan da infeqciur

mononukleozTan - LMP1, LMP2A da LMP2B, EBER, EBNA.

III - janmrTeli latenturad inficirebuli pirebi: EBER, EBNA, LMP1, LMP2A da LMP2B.

infeqciuri mononukleozis paTogenezi sakmaod rTulia da Tanamedrove

etapzec mimdinareobs misi srulyofa.

12

4. klinikuri simptomebi

klinikuri niSnebis mixedviT arCeven tipur, atipur da subklinikur

formebs.

daavadebis inkubaciuri periodi meryeobs 4-dan 18-dRemde, iSviaTad 8

kviramde. inkubaciuri periodi bavSvebSi ufro xanmoklea, vidre

mozrdilebSi.

daavadebis tipuri forma iwyeba mwvaved, erTbaSad, an prodromuli

niSnebiT, rogoricaa Semcivneba, oflianoba, mousvenroba, Tavis tkivili,

mialgia, uxalisoba, umadoba. prodromuli niSnebi SesaZloa 1-2 kvira

gagrZeldes, Semdeg ki vlindeba infeqciuri mononukleozisaTvis

damaxasiaTebeli triada: cxeleba, yelis tkivili da limfuri kvanZebis

gadideba.4,18

cxeleba pacientTa 90%-s aReniSneba. temperaturis pikia saRamos saaTebSi

da aRwevs 38-390C–s. cxeleba grZeldeba 10-14 dRe. Tumca SesaZloa iyos

subfebriluri da 1 Tvemdec gaxangrZlivdes. infeqciuri mononukleozis

dros temperaturuli mrudi raime specifikurobiT ar xasiaTdeba.4

daavadebis erT-erTi paTognomuri niSania tonziliti, igi SesaZlebelia

iyos kataruli, lakunuri, folikuluri da wylulovan-nekrozuli,

vlindeba daavadebis dasawyisSive, an odnav mogvianebiT daavadebis sxva

niSnebis gamovlinebisa da cxelebis Semdeg ( me-5-7dRe) (sur. 5)

zogjer anTeba imdenad intensiuria, rom nuSurebi erTmaneTs exeba. cxvir-

xaxis nuSurebis hiperplaziasTanaa dakavSirebuli cxviridan sunTqvis

gaZneleba, stridori, pirRia xmauriani sunTqva, cxviris tembriT

laparaki.18 aRniSnuli simptomi upiratesad 1-7 wlamde asakis bavSvebs

aReniSnebaT da aqvs sadiagnozo Rirebuleba. igi ganpirobebulia sasunTqi

gzebis, kerZod cxvir-xaxis lorwovanis anTebadi SeSupebiT. mozrdilebSi

es simptomi ufro naklebi intensivobiT vlindeba.

mniSvnelovania, rom mononukleozur tonzilitTan erTad SeiZleba

ganviTardes streptokokuli etiologiis faringiti.

infeqciuri mononukleozis dros xaxis ukana kedeli marcvlovani,

gafxvierebuli, SeSupebuli da hiperemiulia (sur. 6). sasis rkalebze, naqze,

sur. 5

lakunur-folikuluri

tonziliti

13

nuSurebze aRiniSneba nadebi, romelic moTeTro-moyviTaloa an

monacrisfro, fxvieria, advilad scildeba lorwovans da ar iwvevs

sisxldenas. infeqciuri mononukleozis dros tonzilitis xangrZlivoba

umetes SemTxvevaSi temperaturuli reaqciis xangrZlivobas emTxveva.1,4,18

sur. 6

xaxis ukana kedeli infeqciuri

mononukleozis dros

polilimfadenopaTia infeqciuri mononukleozis mudmivi klinikuri niSania.

yvelaze xSiri da tipuria mkerd-laviw-dvrilisebri kunTis gaswvriv

limfuri kvanZebis gadideba, romlebic Zewkvis msgavsad arian

ganlagebulni (sur 7). kvanZebi moZravia, umtkivneulo, palpaciisas odnav

mgrZnobiare. perilimfuri SeSupeba iSviaTia. gadidebuli limfuri kvanZebi

ar Cirqdeba. maTi moculobaSi Semcireba iwyeba temperaturis dacemidan

(me-10-15 dRe), magram Semcirebuli saxiT SeiZleba darCes Tveebis

manZilze.4,8,18

infeqciuri mononukleozis dros RviZli gadidebulia. SemTxvevaTa 90%-Si

xdeba aminotransferazebis saSualod 5-jer mateba,59 bilirubinis done ki

momatebulia avadmyofTa 5%-Si, rac ganpirobebulia, rogorc RviZlSida

qolestaziT, aseve hemolizuri anemiiT. iSviaTad viTardeba fulminanturi

sur.7

limfadenopaTia

14

hepatiti da RviZlis ukmarisoba. RviZlis dazianeba gamowveulia

aqtivirebuli T limfocitebis mier gaTavisuflebuli citokinebiT. xdeba T limfocitebiT RviZlis infiltracia. aRwerilia EBV mier uSualod T limfocitebis dainficirebac.61 am ujredebis ukontrolo gavrceleba

pasuxismgebelia mZime EBV hepatitis ganviTarebaze.62 inficirebuli T ujredebi axdenen virusis antigenebis mcire raodenobis eqspresias, rac

saSualebas aZlevs maT ufro advilad daaRwion Tavi imunur

zedamxedvelobas.

arsebobs disociacia infeqciuri mononukleozis dros RviZlis dazianebis

bioqimiur da morfologiur niSnebs Soris. aris SemTxvevebi, romlis

drosac mkveTrad gamoxatuli siyviTlisa da hiperbilirubinemiis fonze

RviZlis histologiuri dazianeba umniSvneloa da piriqiT, RviZlis

mkveTrad gamoxatuli morfologiuri dazianebis fonze aRiniSneba

umniSvnelod gamovlenili klinikuri niSnebisa da bioqimiuri maCveneblebis

darRveva.21

elenTis gadideba warmoadgens infeqciuri mononukleozis erT-erT

kardinalur niSans. igi gamovlindeba daavadebis me-2-3 dRidan. iSviaTad,

splenomegalia SeiZleba mZime garTulebiT _ gaxeTqviT _ damTavrdes.

elenTis zoma normas ubrundeba me-3-4 kviridan.1,18

gamonayari avadmyofTa 5%-s aReniSneba. igi SesaZloa iyos makuluri,

papuluri, peteqiuri, qunTruSisebri, multiformuli eriTema, urtikaria da

rogorc wesi tansa da kidurebze gvxvdeba1,3,4 (sur. 8) avadmyofTa

umravlesobas, romlebic Rebulobdnen ampicilins aReniSnebaT kaSkaSa

wiTeli feris medikamenturi gamonayari – e.w. “makulo-papuluri afeTqeba”.

90_100%-Si igi vlindeba ampiciliniT mkurnalobis Sewyvetis Semdeg (Tumca

es ar niSnavs imas, rom daavadebuls aucileblad eqneba aseTi reqacia

penicilinis jgufis preparatebze).22,23

sur. 8 gamonayari

laboratoriuli maCveneblebidan damaxasiaTebelia: periferiul sisxlSi

leikocitozi (10-20х109/l). daavadebis pirvel-meore dRes SesaZloa iSviaTad

gamoxatuli iyos leikopenia, leikocitozi ki - gamovlindes me 5-6dRidan.

limfocitebis saSualo maCvenebeli 60%-mdea, xolo monocitebisa - 18-20%-

mde. aseve gamovlindeba atipuri mononuklearebi (12-20%) da plazmuri

ujredebi (8-12%).1 atipiuri mononuklearebi morfologiurad mrgvali an

ovaluri formis antigeniT aqtivirebuli T (CD8) ujredebia. maTi

protoplazma vakuolizebulia da didi zomis birTvs gars akravs

sartyeliviT, periferiaze ki gamoxatulia bazofilia. atipurma

15

mononuklearebma struqturis cvlilebis gamo miiRes “farToplazmuri

monocitebis“ da “monolimfocitebis” saxelwodeba. aRniSnuli cvlileba

SesaZloa 3-6 Tve da wlebis ganmavlobaSic ki SenarCundes. daavadebis

pirvel Tves SeiZleba iyos neitropenia da Trombocitopenia. eds

aCqarebulia. Secvlilia RviZlis bioqimiuri maCveneblebi. sisxlis SratSi

momatebulia aminotransferazebisa da tute-fosfatazis aqtivoba.

SedarebiT iSviaTad matulobs bilirubinis done.2

msubuqi forma

avadmyofis saerTo mdgomareoba damakmayofilebelia, subieqturi Civilebi

ar aqvs. aRiniSneba umniSvnelo intoqsikacia. damaxasiaTebelia Semdegi

klinikuri niSnebi: cxviridan gaZnelebuli sunTqva, tonziliti, limfuri

kvanZebis gadideba. aRniSnuli simptomebi gamoxatulia zomierad.

periferiuli sisxlis suraTi umniSvnelodaa Secvlili. temperatura 37,5-

380-is farglebSia. daavadeba daaxloebiT erT kviraSi mTavrdeba. aRiniSneba

klinikuri niSnebis swrafi alageba.18,21

saSualo simZimis forma

avadmyofs aqvs Semdegi Civilebi: cxviridan sunTqvis gaZneleba, saerTo

sisuste, umadoba, zogjer tkivili muclis areSi, iSviaTia Rebineba da

gulisreva. intoqsikacia zomierad aris gamoxatuli. temperatura - 38-390-ia.

cvlilebebi periferiuli sisxlis mxriv mkveTrad ar aris gamoxatuli.

avadmyofoba mTavrdeba daaxloebiT 10 dReSi. klinikuri niSnebis alageba

xdeba SedarebiT nela.18,21

mZime forma

klinikuri niSnebi mkveTradaa gamoxatuli, aRiniSneba Zlieri intoqsikacia.

elenTa NmniSvnelovnad aris gadidebuli. gamoxatulia hepatomegalia.

xSirad viTardeba am daavadebis mZime garTulebebi. temperatura 39,5 - 400C-ia. daavadeba xangrZlivdeba (15 dRe - 1 Tve da meti).18,21

infeqciuri mononukleozis atipuri forma18

aRiniSneba erTi an ori aramkveTrad gamoxatuli klinikuri simptomi (mag:

mxolod elenTis gadideba da temperaturis momateba an tonziliti da

ybisqveSa limfuri kvanZebis gadideba da a.S.)

vlindeba infeqciuri mononukleozisTvis arapaTognomuri simptomebi

(meningoencefaliti, perikarditi da sxv). aseT SemTxvevaSi diagnozi

dasturdeba periferiuli sisxlis analiziT da imunologiuri reaqciebiT.

infeqciuri mononukleozis subklinikuri forma:18

infeqciuri mononukleozisTvis damaxasiaTebeli klinikuri niSnebi ar aris

gamoxatuli. diagnozis dadastureba xdeba serologiuri reaqciebiT.18

16

infeqciuri mononukleozis qronikuli forma:

EBV pirveladi inficirebis SemTxvevaSi ganviTarebuli klinikuri niSnebi

iSviaTad grZeldeba 4 Tve. daavadebis 6 Tveze met xans gaxangrZlivebis

SemTxvevaSi yalibdeba mononukleozis qronikuli forma.5 misTvis

damaxasiaTebelia asTenovegetatiuri sindromi65 (uZlureba, daRliloba,

depresia57), gaxangrZlivebuli subfebriluri temperatura, perioduli

matebiT, morecidive faringiti, tkivili da simZimis SegrZneba marjvena

ferdqveSa areSi, meteorizmi, anoreqsia, arTralgia, mialgia. obieqturi

monacemebidan gamoxatulia - polilimfadenopaTia, hepatosplenomegalia.

cvlilebebia sisxlis Sratis cilovan fraqciebsa da RviZlis funqciur

sinjebSi. periferiul sisxlSi matulobs atipuri mononuklearebisa da

heterofiluri antisxeulebis raodenoba. serologiurad vlindeba

adreuli da nuklearuli antigenebis IgG (anti-EA-IgG,anti-EBNA-IgG). 65,24

zemoaRniSnuli klinikuri niSnebi SeiZleba ramdenime wlis (3-5 weli)

ganmavlobaSi gaxangrZlivdes, perioduli reaqtivaciiT.

infeqciuri mononukleozis qronikuli formis diagnozi eyrdnoba Semdeg

sam ZiriTad kriteriums:3

1. gadatanili mZime daavadeba (daaxloebiT 6 Tvis win), romelic

laboratoriulad dadasturebuli iyo, rogorc mwvave infeqciuri

mononukleozi. an aRmoCenili iyo EBV kafsidis antigenis

sawinaaRmdego antisxeulebis maRali titri, an adreuli antigenis

sawinaaRmdego antisxeulebi.

2. mTel rig organoebSi daavadebis histomorfologiuri cvlilebebis

dadgena:

a) intersticiuli pnevmonia.

b) Zvlis tvinis elementis hipoplazia.

g) uveiti.

d) limfadenopaTia.

e) persistuli hepatiti.

v) splenomegalia.

3. dazianebul qsovilebSi EBV birTvis antigenis aRmoCena

antikomplementuri imunofluorescenciis meTodiT.

qronikuli EBV infeqcia SesaZloa mimdinareobdes qronikuli hepatitis

saxiT, romlis diagnozi eyrdnoba 4 ZiriTad parametrs:19

1. RviZlis enzimebis - alaninaminotransferazasa da

aspartataminotransferazas donis matebas.

2. sisxlSi EBV serologiuri markerebis gansazRvras.

3. RviZlis bioptatSi damaxasiaTebel histomorfologiur cvlilebebs.

4. polimerizaciis jaWvuri reaqciiT (pjr) da hibridizaciis gziT

virusuli genomis aRmoCenas RviZlis bioptatSi.

qronikuli EBV hepatitis dros RviZlis bioptatSi damaxasiaTebeli

histomorfologiuri suraTia, rac limfoplazmocituri elementebis

infiltraciaSi, atipuri blasturi ujredebis arsebobaSi, kupferis

17

ujredebis gaaqtivebasa da hepatocitebis maRal regeneraciul aqtivobaSi

gamoixateba. aRsaniSnavia, rom virusi ainficirebs limfocitebs (ZiriTadad

CD8+ T ujredebs) da ara hepatocitebs.19,61

mononukleozur hepatits upiratesad axasiaTebs RviZlis dazianebis

infiltraciuli da proliferaciuli, iSviaTad nekrozuli varianti.18,21

rogorc aRvniSneT, EBV msoflioSi farTodaa gavrcelebuli. mosaxleobis

90-95% latenturad aris inficirebuli, Tumca virusis klinikurad

gamoxatuli reaqtivacia iSviaTad xdeba. EBV pirveladi inficirebis asaki,

individis imunuri statusi, genetikuri, socialuri da geografiuli

faqtorebi gansazRvravs daavadebis mimdinareobis klinikur formas.9

garda keTilTvisebiani infeqciuri mononukleozisa, EBV iwvevs epiTeluri

da limfoiduri qsovilebis malignizaciiT mimdinare daavadebebs. virusi

asocirebulia mTel rig limfomebTan: hojkinis limfoma (25-50%-Si, aiv

inficirebulebSi 100%-Si)6, berkitis limfoma, centraluri nervuli

sistemis limfoma, transplantaciis Semdgom ganviTarebuli

limfoproliferaciuli darRvevebi, X qromosomasTan SeWiduli

limfoproliferaciuli daavadeba (dunkanis sindromi).25,26

epStein-baris virusi asocirebulia: nazofaringeul karcinomasTan, piris

Rrus Tmovan leikoplakiasTan, kuWis karcinomasTan, hemofagocitur

sindromTan.

berkitis limfoma (endemuri, afrikuli berkitis limfoma, B ujreduli

limfoma) - farTod aris gavrcelebuli afrikis mosaxleobaSi,

gansakuTrebiT malariis endemur zonebSi. simsivnis ganviTarebaSi

mniSvnelovania genetikuri da garemo faqtorebis roli. ZiriTadad

avaddebian 5-7 wlis bavSvebi. adreul asakSi EBV inficireba ganapirobebs

didi raodenobiT B limfocitebis produqcias. malariis gamomwvevTan

kontaqti ufro metad zrdis B ujredebis poliklonur proliferacias,

radgan aRniSnul infeqcias axasiaTebs mitogenuri aqtivoba da EBV-

specifikuri T ujreduli imunitetis daTrgunva. B ujredebis intensiuri

produqcia zrdis qromosomuli translokaciebis albaTobas, Sedegad

viTardeba onkogenuri aqtivoba da yalibdeba berkitis limfoma.28

daavadebis sawyis etapze xdeba limfuri kvanZebis gadideba kisris da qveda

ybis midamoSi. kvanZebi umtkivneuloa, mkvrivi konsistenciisa da axasiaTebs

swrafi zrda. daavadebis progresirebisas procesSi erTveba sxva

organoebic: sakvercxeebi, saTesle jirkvlebi, sanerwyve, farisebri, sarZeve

jirkvlebi, Tirkmelebi, cns, Zvlis tvini.27 simsivnuri qsovilis abdominuri

lokalizaciisas ziandeba elenTa, mezenteriuli limfuri kvanZebi, RviZli,

kuW-nawlavi.28

berkitis limfomis dros ganviTarebuli simsivnuri qsovili yvelaze

xSirad azianebs Tavis qalas saxis nawils - zeda da qveda ybas,

Tvalbudesa da rbil qsovilebs28 (sur. 9)

18

daavadebisTvis damaxasiaTebelia wonaSi swrafad kleba (TveSi 10-15-20kg)

kaxeqsiamde, gamoxatuli oflianoba, febriluri cxeleba.28 simsivnuri

qsovili swrafad izrdeba, Tumca agresiuli qimioTerapiis fonze prognozi

SedarebiT keTilsaimedoa.

hojkinis limfoma (limfogranulomatozi) - gvxvdeba mTel msoflioSi,

gansakuTrebiT ganviTarebad qveynebSi, adreuli asakis bavSvebSi. .hojkinis

limfomaTa 25-50%-Si simsivnur qsovilebSi aRmoCenilia EBV dnm da misi

genebis produqtebi (LMP1, LMP2, EBNA1)42. histomorfologiurad simsivnur

qsovilebSi arsebobs virusiT inficirebuli hojkin-rid-Sternbergis (HRS) ujredebi. isini Secvlili B limfocitebia, Seicaven erT an ramdenime

birTvs. maT zedapirze mudmivad eqspresirdeba CD15, CD30 da CD40, Tumca

HRS ujredebSi EBV-is replikaciis procesSi CarTulia mcire raodenobiT

proteinebi. esenia: LMP1, LMP2, EBNA1. mniSvnelovania, rom aseTi fenotipis

ujredebis zedapirze ar xdeba imunoglobulinebis eqspresia32 (sur. 10)31

sur. 10

marcxena suraTze ilustrirebulia HRS ujredebi, xolo marjvenaze - EBV-iT

inficirebuli B limfocitis normaluri fenotipi. am ujredSi sinTezdeba virusis

mravali cila, xolo zedapirze eqspresirdeba CD20 da imunoglobulinebi)

sur. 9

berkitis limfoma

19

hojkinis limfomis klinikuri suraTi xasiaTdeba Semdegi niSnebiT:

cxeleba, Ramis profuzuli oflianoba, sxeulis masis kleba, kanis qavili.

daavadeba mimdinareobs 4 stadiad:29

I stadia - ziandeba limfuri kvanZebis erTi jgufi an limfuri kvanZis

axlos mdebare erTi organo.

II stadia - ziandeba limfuri kvanZebis ori an ramdenime jgufi

diafragmis cal mxares an limfuri kvanZis axlos mdebare erTi organo

da ramdenime limfuri kvanZi.

III stadia - ziandeba limfuri kvanZebi diafragmis orive mxares, rasac

SesaZlebelia Tan axldes procesSi limfuri kvanZis axlos mdebare

erTi organos an elenTis dazianeba.

IV stadia - xdeba simsivnuri qsovilis diseminireba.

hojkinis limfoma xasiaTdeba mZime mimdinareobiT, Tumca daavadebis

adreul stadiebze, zogjer mogvianebiTac, SesaZlebelia misi gankurneba.

qromosomasTan SeWiduli limfoproliferaciuli daavadeba (dunkanis

sindromi. Syndrom Dunkane) - dunkanis sindroms axasiaTebs

imunodeficituri mdgomareoba (ujreduli imunitetis Tandayolili

defeqti) maRali letalobiT. am sindromis mqone pacientebis EBV

inficireba ganapirobebs infeqciuri mononukleozis mZime, fulminantur

mimdinareobas (60%-Si). avadmyofebi iRupebian daavadebis gamovlenidan 1-12

Tvis ganmavlobaSi, rac gamowveulia specifikuri T citotoqsikuri

limfocitebis deficitiT. avadmyofTa nawils uviTardeba

hipogamaglobulinemia, aplasturi anemia, avTviasebiani limfoma. aRniSnuli

darRvevebis ganviTarebis sixSire gansakuTrebiT maRalia 3-7 wlis asakis

vaJebSi.37,38

nazofaringeuli karcinoma - gavrcelebulia CineTis samxreT regionebSi.

simsivnis ganviTarebis xelSemwyobi pirobebia geografiuli mdebareoba,

garemo faqtorebi (gansakuTrebiT kancerogenuli garemo) da genetikuri

ganwyoba. nazofaringeuli karcinomis qsovilebSi aRmoCenilia EBV genomi,

xolo avadmyofis sisxlSi - EBV specifikuri antisxeulebi, gansakuTrebiT

maRalia anti - VCA IgA. daavadebuli nazofaringeul sekretTan erTad

gamoyofs gacilebiT met viruss, vidre janmrTeli seropozitiuri

pirebi.4,35

simsivnis zrda iwyeba cxvir-xaxis epiTeliumidan. aseTi lokalizaciis gamo

simsivnuri qsovili SeumCneveli rCeba da daavadebis pirveli klinikuri

gamovlena SesaZlebelia iyos kisris gadidebuli metastazuri kvanZi.

nazofaringeul karcinomas klinikurad axasiaTebs: cxviridan sisxldena

(epistaqsisi), cxvir-xaxis obstruqcia, Sua yuris anTeba, smenis dakargva.

Tavis tvinTan simsivnis axlos lokalozaciis gamo xSiria nevrologiuri

simptomebis ganviTareba: diplopia, ftozi, saxis nervis dazianeba da sxv.35

daavadebis prognozi mZimea da damokidebulia simsivnis zomaze,

lokalizaciasa da gavcelebaze.

20

transplantaciis Semdgomi limfoproliferaciuli daavadebebi (PTLD) -

transplantaciis Semdgomi darRvevebi dakavSirebulia zogjer EBV

asocirebulia. pacientebis umravlesobis sisxlSi maRalia inficirebuli B limfocitebis done. virusis intensiuri replikacia kavSirSia

imunosupresiuli Terapiis fonze ganviTarebul citotoqsikuri T limfocitebis deficitTan. PTLD-is sixSire, magaliTad Tirkmlis

transplantaciis recipientebSi 1-2%-ia, xolo gul-filtvis recipientebSi -

5-9%; limfoproliferacia viTardeba transplantaciidan 1 wlis

ganmavlobaSi. PTLD-is dros procesSi erTveba limfuri kvanZebi, RviZli,

filtvebi, Tirkmelebi, Zvlis tvini, wvrili nawlavi, elenTa, cns,

tonzilebi, sanerwyve jirkvlebi. daavadebis klinikuri suraTi

variabeluria. viTardeba cxeleba, limfadenopaTia, gastrointestinuri

simptomebi, fulminanturi infeqciuri mononukleozis msgavsi sindromi,

nevrologiuri simptomebi, wonis kleba.40 gansakuTrebiT mZimea da

prognozulad arakeTilsaimedoa cns-is dazianeba, romelic 88%-

SemTxvevaSi iwvevs letalobas.52

piris Rrus Tmovani leikoplakia (Hairy Leukoplakia) - warmoadgens EBV

inducirebul epiTeluri qsovilis hiperplazias, romelic lokalizdeba

ZiriTadad enis lateralur kideebze, Tumca SesaZloa gavrceldes loyis

lorwovanze. Tmovani leikoplakia asimptomurad viTardeba da pacientebis

umravlesobisTvis SeumCneveli rCeba. daavadebuls enisa da loyis

lorwovanze uviTardeba moTeTro gofrirebuli laqebi (sur. 11), romelSic

SesaZlebelia EBV dnm aRmoCena. Tmiani leikoplakia aiv inficirebis erT-

erTi adreuli niSania.4,8

EBV asocirebuli hemofagocituri sindromi (VAHS) - sindromi pirvelad

aRwerilia 1985 wels. mas axasiaTebs makrofagebisa da dendrituli

ujredebis mier eriTrocitebis fagocitozi. klinikurad vlindeba cxeleba,

saerTo sisuste, mialgia, generalizebuli limfadenopaTia,

hepatosplenomegalia. laboratoriulad - periferiul sisxlSi aRiniSneba

pancitopenia, koagulaciis darRveva. VAHS -is mqone pacientebs advilad

uviTardebaT oportunistuli infeqciebi, rac SemTxvevaTa 45%-Si

letalobiT mTavrdeba.39

sur. 11

piris Rrus Tmovani

leikoplakia

21

kuWis karcinoma - EBV mniSvnelovan rols asrulebs kuWis avTviasebiani

simsivnis ganviTarebaSi. kuWis karcinomis mqone pacientebis 10% simsivnur

qsovilSi xdeba EBV genomis aRmoCena. Helicobacter pylori - Tan koinfeqciisas

izrdeba kuWis avTviasebiani karcinomis ganviTarebis riski.54

infeqciuri mononukleozis garTulebebi

hematologiuri garTulebebi

infeqciuri mononukleoziT daavadebulTa 0,5-3%-Si viTardeba autoimunuri

hemolizuri anemia. hemolizi vlindeba daavadebis me-2-3 kviras da

grZeldeba 1-2 Tve.42

infeqciur mononukleozs axasiaTebs umniSvnelo Trombocitopenia.

gaurTulebel SemTxvevaSi misi maCvenebelia 140000/mm3. iSviaTad aris Rrma

Trombocitopenia sisxldeniT (1000/mm3). Zvlis tvinSi megakariocitebis

normaluri an momatebuli raodenoba da periferiul sisxlSi

antiTrombocituli antisxeulebis arseboba miuTiTebs autoimunuri

procesis arsebobaze.43

infeqciis gamovlenidan pirvel kviras sisxlSi aRiniSneba zomieri

neitropenia, Tumca agranulocitozisa da aplasturi anemiis Semswavleli

saerTaSoriso asociaciis monacemebis mixedviT, EBV gamowveuli infeqciis

4%-i SeiZleba garTuldes autoimunuri agranulocitoziT, mwvave

daavadebis gadatanidan 1 wlis Semdegac ki.64 aRniSnul garTulebas xSirad

Tan axlavs baqteriuli superinfeqcia, pnevmoniisa da sefsisis ganviTareba,

rac xSirad letaluri gamosavlis mizezi xdeba.4

elenTis gaskdoma

SesaZloa ganviTardes infeqciuri mononukleoziT daavadebidan me-2-3

kviras (0,1-0,55%-Si).55 mamakacebSi 5-jer meti sixSiriT gvxvdeba, vidre

qalebSi. aRniSnuli garTuleba dakavSirebulia elenTis kafsulis,

trabekulebisa da sisxlZarRvebis kedlis limfocitur infiltraciasTan.44

zogjer adgili aqvs elenTis ormag gaxeTqvas: pirvelis dros sisxli

Caiqceva elenTis kafsulaSi. klinikurad vlindeba tkivili muclis qvemo

nawilSi, ecema hemoglobinis done, viTardeba kolafsi. hematomis

moculobaSi zrda iwvevs kafsulis gaxeTqvas da sisxlis CaRvras muclis

RruSi. aRniSnuli garTulebis Tavidan acilebis mizniT aucilebelia

daavadebis pirvel 2-3 kviris ganmavlobaSi fizikuri datvirTvis

SezRudva.18,21

nevrologiuri garTulebebi

epStein-baris virusiT infeqciis dros rogorc imunokompetentur, aseve

imunokomprometirebul pirebSi SesaZloa ganviTardes nervuli sistemis

sxvadasxva daavadebebi: meningiti, encefaliti, gien-bares sindromi, mieliti,

mieloradikuliti, encefalomieloradikuliti, mxedvelobis nervis anTeba,

retrobulburi nevriti, kraniuli nervebis dambla, mxris wnulis

neiropaTia, krunCxvebi, qvemwvave masklerozebeli panencefaliti,

22

SebrunebiTi mieliti, fsiqozi, demielinizacia, hemiplegia. aiv

inficirebulebsa da transplantaciis recipientebSi viTardeba cns-is

limfomebi.45

RviZlis dazianeba

mononukleozuri hepatiti (aRwerilia pirveladi mwvave infeqciuri

mononukleozis ganxilvisas) Cveulebriv keTilTvisebianad mimdinareobs,

Tumca epStein-baris virusma iSviaTad SeiZleba gamoiwvios fulminanturi

hepatiti, RviZlis ukmarisoba da cirozi.21,61

garTuleba Tirkmlebis mxriv

vlindeba iSviaTad, mikrohematuriisa da proteinuriis saxiT. iSviaTad

viTardeba Tirkmlis mwvave ukmarisoba.47

garTuleba gulis mxriv

gvxvdeba iSviaTad. ZiriTadi cvlilebebi vlindeba ekg-ze. Tumca SesaZloa

perikarditisa da fataluri miokarditis Camoyalibebac.48,49

sasunTqi gzebis dazianeba

iSviaTad viTardeba zeda sasunTqi gzebis obstruqcia, romelic limfuri

kvanZebis hiperplaziis Sedegia.4

infeqciuri mononukleozis dros SesaZloa intersticiuli pnevmoniis

ganviTareba. filtvis dazianebis mizezad epStein-baris virusi maSin

CaiTvleba, rodesac moxdeba sxva gamomwvevi agentis gamoricxva.50

garTulebebidan letaluri gamosavlis yvelaze xSiri mizezia:4 zeda

sasunTqi gzebis obstruqcia, nevrologiuri garTulebebi,

granulocitopenia da agranulocitozi, Trombocitopenia, RviZlis

ukmarisoba, miokarditi da elenTis gaskdoma.

5. daavadebis diagnozi

infeqciuri mononukleozis diagnozi eyrdnoba Semdeg klinikur niSnebsa

da laboratoriul monacemebs:

23

a) 1. infeqciur mononukleozi saeWvoa, Tu pacients aReniSneba:

klinikuri niSnebi:

cxeleba da erTi niSani CamoTvlilidan: tonziliti, limfadenopaTia,

splenomegalia.

laboratoriuli maCveneblebi:

• leikocitozi

• limfocitozi

• monocitozi

• atipuri mononuklearebi

2. diagnozi savaraudoa, Tu zemoT CamoTvlil niSnebTan erTad sisxlSi

serologiuri gamokvlevebiT aRmoaCndeba:

• heterofiluri antisxeulebi

heterofiluri antisxeulebis gansazRvra xdeba heterohemaglutinaciis

reaqciiT (paul-bunel-davidsonis reaqcia). rodesac antisxeulebis titri

1:40 aRwevs infeqciuri mononukleozis diagnozi savaraudoa.1,5,7

arsebobs heterofiluri antisxeulebis aRmoCenis swrafi slaid-testi - e.w.

Monospot cda, romelic aseve efuZneba heterohemaglutinaciis reaqcias.5,7

pacientTa 50%-Si heterofiluri antisxeulebi vlindeba daavadebis pirvel

kviras, xolo 60-90%-Si - me-2-3 kviras. me-4 da me-5 kviridan iwyeba

antisxeulebis titris daqveiTeba. avadmyofTa 20%-i 1-2 wlis ganmavlobaSi

rCeba heterofil-pozitiuri. rac Seexeba bavSvTa asaks, infeqciuri

mononukleozis SemTxvevaSi, heterofiluri antisxeulebi yovelTvis ar

warmoiqmneba. mxolod 2 wlamde asakis 10-30% da 2-4 wlis asakis 50-75% aris

heterofil-pozitiuri.5,7

3. infeqciuri mononukleozis dadasturebuli SemTxveva

infeqciuri mononukleozze saeWvo da savaraudo SemTxvevis dros iwyeba

daavadebis klinikuri marTva. amasTan erTad grZeldeba pacientis Semdgomi

kvleva EBV infeqciaze:

24

• sisxlSi EBV-is sawinaaRmdego specifikuri antisxeulebis

gansazRvra.

• Oorofaringeul sekretSi polimerizaciis jaWvuri reaqciiT

(pjr) virusis dnm gansazRvra*

virussawinaaRmdego specifikuri antisxeulebis gansazRvra xdeba

arapirdapiri imunoflourescenciis, imunoblotisa da enzimniSandebuli

imunoanalizis meTodiT. daavadebis sawyisi etapze warmoiqmneba virusis

kafsidis sawinaaRmdego IgM da IgG (anti-VCA-IgM da anti-VCA-IgG). IgM maRal titrSi rCeba 2 Tve, xolo IgG - mTeli cxovreba. IgM-is titri

maqsimums aRwevs daavadebis 2-3 kviras, xolo IgG - me-2-3 Tveze.5,7

adreuli antigenis sawinaaRmdego antisxeulebia (anti-EA) difuzuri (anti-D) da citoplazmuri (anti-R). anti-D piks aRwevs daavadebis dawyebidan me-3-4 kviras da persistirebs 3-6 Tvis ganmavlobaSi, xolo anti-R vlindeba me-2

kviridan an ramdenime Tvis Semdeg da rCeba 2-3 wlamde. nuklearuli

antigenis sawinaaRmdego antisxeulebi (anti-EBNA) mogvianebiT -

rekonvalescenciis periodSi vlindeba (saSualod me-3-6 kviras) da rCeba

mTeli cxovrebis manZilze.5,7 (cxrili #2)2

* ZiriTadad diagnozis sabolood dasadastureblad sakmarisia serologiuri reaqciebis

Catareba, radgan pjr SeiZleba dadebiTi iyos praqtikulad janmrTel, latenturad

inficirebul pirebSi.Aamitom infeqciuri mononukleozisTvis kvlevis am meTodis Catareba

aucilebeli ar aris. AM M A

25

EBV-s asocirebuli daavadebebis dros EBV-is sawinaaRmdego

antisxeulebis serologiuri nimuSebi2

cxrili #2

daavadebis

forma

antisxeulebi

infeqcia ar

aris

infeqciuri

mononukleozi

subklinuikuri

pirveladi

infeqcia

gadatanili

infeqcia

reaqtivacia

imunodeficitTan

erTad

berkitis limfoma

nazofaringeuli

karcinoma

VCA

EA - D

EA - R

EBNA

heterofil

uri

antisxeule

bi

IgM IgG IgA IgG IgA IgG IgG IgM IgM

-

+

+

-

+/-

-

-

-

+/+

+

+

+/+

+/+

+/+

-

-

-

-

+/-

-

+

-

+

+/-

+/-

+/+

+/-

++

-

-

-

-

+/-

-

+

-

+/-

-

-

+/-

+/+

-

-

-

+/-

+

+/-

+

+

-

+/-

+

+/-

+/-

ND

ND

-

+

-

+/-

-

-

+/+ - antisxeulebis mzardi titri

+ - antisxeulebi pozitiuria

- _ antisxeulebi negatiuria

ND - ar aris monacemebi

26

diferenciuli diagnozi (CamonaTvali)

infeqciuri mononukleozis diferenciul diagnozs atareben Semdeg

daavadebebTan:1,4

• toqsikuri difTeria.

• streptokokuli etiologiis angina.

• virusuli hepatitebi.

• citomegalovirusuli infeqcia.

• mwvave toqsoplazmozi.

• adenovirusuli infeqcia.

• mwvave leikozi.

• pirveladi aiv-infeqcia (mwvave retrovirusuli sindromi).

• wiTura.

27

6. gamokvlevis sqema

infeqciuri mononukleozis damadasturebeli da gamomricxavi

kriteriumebi

(algoriTmi)

1. gamokvlevis sqema pirveladi jandacvis rgolisTvis

klinikuri niSnebi:

cxeleba da erTi niSani CamoTvlilTagan: tonziliti,

limfadenopaTia, splenomegalia.

laboratoriuli maCveneblebi:

• leikocitozi

• limfocitozi

• monocitozi

• atipuri mononuklearebi

saeWvoa infeqciur

mononukleozze

arc erTi niSani ar aris

saxeze

avadmyofi gadaagzavneT

specializebul klinikaSi

Semdgomi gamokvlevebisa

da klinikuri

marTvisTvis

infeqciuri

mononukleozi

gamoricxulia

28

2 avadmyofis klinikuri gamokvlevis sqema specializebuli

klinikisTvis

klinikuri niSnebi:

cxeleba da erTi niSani CamoTvlilTagan:

tonziliti, limfadenopaTia, splenomegalia.

* ZiriTadad diagnozis sabolood dasadastureblad sakmarisia serologiuri reaqciebis

Catareba, radgan pjr SeiZleba dadebiTi iyos praqtikulad janmrTel, latenturad

inficirebul pirebSi. Aamitom infeqciuri mononukleozisTvis kvlevis am meTodis

Catareba aucilebeli ar aris. AM

laboratoriuli maCveneblebi:

• leikocitozi

• limfocitozi

• monocitozi

• atipuri mononuklearebi

arc erTi

niSani saxeze

ar aris

saeWvoa infeqciur

mononukleozze.

daiwyeT klinikuri

marTva

sisxlSi

heterofiluri

antisxeulebis

gansazRvra

uaryofiTi

Sedegi

infeqciuri

mononukleozi

gamoricxulia

dadebiTi Sedegi

savaraudoa infeqciuri

mononukleozi.

grZeldeba kvleva EBV

specifikur

antisxeulebze

uaryofiTi

Sedegi

infeqciuri

mononukleozi

gamoricxulia

dadebiTi Sedegi pjr-iT virusis dnm-is

gansazRvra*

dadebiTi Sedegi

diagnozi: infeqciuri mononukleozi

29

7. mkurnalobis sqema

dReisTvis infeqciuri mononukleozis etiotropuli mkurnaloba ar

arsebobs. ZiriTadad atareben paTogenezur da simptomur Terapias.

daavadebis pirveli 2 kviris ganmavlobaSi rekomendebulia

woliTi reJimis dacva, gansakuTrebiT gamoxatuli splenomegaliis

dros.4

naCvenebia advilad mosanelebeli, vitaminebiT mdidari da

maRalkaloriuli sakvebis da siTxeebis miReba.57

simptomuri Terapia:

daavadebis mwvave fazaSi atareben piris Rrus sanacias

antiseptikuri xsnarebiT.4,57

cxelebis SemTxvevaSi gamoiyeneba arasteroiduli

anTebis sawinaaRmdego saSualebebi da acetaminofeni.1,4

gamoxatuli intoqsikaciis dros atareben intravenur

dezintoqsikaciur infuzur Terapias.

garTulebebis mkurnaloba

glukokortikosteroidebi (prednizoloni, prednizoni) gamoiyeneba

infeqciuri mononukleozis mZime mimdinareobisa da Semdegi garTulebebis

SemTxvevebSi:4 (aRniSnuli rekomendacia Seesabameba mtkicebulebis siZlieris I

dones (Muir Gray) da rekomendaciis AAxarisxs (Cook et al).

1. sasunTqi gzebis obstuqcia.

2. Trombocitopenia

3. hemolizuri anemia

4. nervuli sistemis dazianeba

5. miokarditi, perikarditi.

prednizoloni iniSneba Semdeg dozebSi: mozrdilebSi - 40-80mg dReSi per os. efeqti miiRweva male, amitom erT-or kviraSi aucilebelia dozis kleba.

bavSvebSi - iniSneba 1mg/kg wonaze.

antivirusuli mkurnaloba

acikloviri amcirebs EBV gamoyofas orofaringeuli sekretiT, Tumca ar

iZleva dadebiT Terapiul efeqts daavadebis klinikur mimdinareobaze.67

(mocemuli rekomendacia Seesabameba mtkicebulebis siZlieris I dones (Muir Gray) da rekomendaciis AAxarisxs (Cook et al).

aRniSnuli preparati ver anadgurebs viruss inficirebul B limfocitebSi, amitom acikloviris gamoyeneba gaurTulebeli infeqciuri

30

mononukleozis dros naCvenebi ar aris.68 (mocemuli rekomendacia Seesabameba

mtkicebulebis siZlieris I dones (Muir Gray) da rekomendaciis AAxarisxs (Cook et al).

zogierTi mkvlevaris azriT, acikloviris gamoyeneba rekomendebulia

Semdeg SemTxvevebSi:2 (rekomendacia Seesabameba mtkicebulebis siZlieris Vb dones (Muir Gray) da rekomendaciis DAxarisxs (Cook et al).

1. generalizebuli meningoencefaliti - acikloviri 10mg/kg i/v.

2. obstruqciuli faringotonziliti - acikloviri 5mg/kg 8sT-Si

erTxel i/v.

3. intersticiuli pnevmonia - acikloviri 5mg/kg 8sT-Si erTxel i/v.

4. imunosupresiuli pacientebi - acikloviri 10mg/kg 6sT-Si erTxel.

mZime hepatitis acikloviriT mkurnaloba naCvenebi ar aris. am SemTxvevaSi

gamoiyeneba gancikloviri. igi ganapirobebs avadmyofis zogadi

mdgomareobis swraf gaumjobesebasa da RviZlis enzimebis donis

koreqcias.58 (rekomendacia Seesabameba mtkicebulebis siZlieris Vb dones (Muir Gray) da rekomendaciis DAxarisxs (Cook et al).

agranulocitozis ganviTarebis SemTxvevaSi hemopoezis stimulaciis mizniT,

rekomendebulia filgastrimis gamoyeneba.64 (rekomendacia Seesabameba

mtkicebulebis siZlieris Vb dones (Muir Gray) da rekomendaciis DAxarisxs (Cook et al).

filgastrimis rekomendebuli dozebia: 1,0mln. s.e. (10mg/kg) 24 saaTiani

uwyveti i/v infuziiT an kanqveSa ineqciiT dReSi erTxel. mkurnalobis

xangrZlivoba ganisazRvreba periferiul sisxlSi neitrofilebis

absoluturi ricxvis mixedviT.

antibiotikTerapia

daavadebis baqteriuli superinfeqciiT garTulebisas atareben

antibiotikTerapias gamomwvevis preparatisadmi mgrZnobelobis mixedviT.

gafrTxileba:66

infeqciuri mononukleozis dros ar aris rekomendebuli:

ampiciliniT mkurnaloba, vinaidan mkurnalobis Sewyvetis

Semdeg viTardeba gamonayari.

simptomuri TerapiisTvis aspirinis gamoyeneba rei-s

sindromis ganviTarebis maRali riskis gamo.

31

8. reabilitacia/meTvalyureoba

EBV axasiaTebs organizmSi persistencia da latencia. infeqciuri

mononukleozis gadatanis Semdeg kvireebisa da Tveebis manZilze SesaZloa

darCes sisuste, daRliloba, Tavis tkivili, mialgia, periodulad

temperaturis mateba, limfuri kvanZebis gadideba, tkivili marjvena

ferdqveSa areSi, meteorizmi, anoreqsia, hepatosplenomegalia, cvlilebebi

sisxlis Sratis cilovan fraqciebsa da zogjer, RviZlis funqciur

sinjebSi.

daavadebis narCeni klinikuri niSnebi, romlebic 6 Tvis ganmavlobaSi

ubrundeba normas ganixileba, rogorc infeqciuri mononukleozis

rekonvalescenturi sindromi. yovelive zemoaRniSnulis gamo, infeqciuri

mononukleozis rekonvalescentebi ayvanil unda iqnan dispanserul

meTvalyureobaze, raTa Cvenebis mixedviT CautardeT saTanado gamokvlevebi

da mkurnaloba. es iqneba infeqciuri mononukleozis qronikuli formis

profilaqtikis ZiriTadi RonisZieba. dauSvebelia daavadebuli 6 Tvis

manZilze iyos sisxlis donori.

qronikuli da latenturi formebis meTvalyureoba (dispanserizacia) unda

gagrZeldes wlebis manZilze, rom droulad iqnes gamovlenili is

damaxasiaTebeli mZime sindromebi, romlebic qronikuli da latenturi

formis reaqtivaciis dros gvxvdeba. am mizniT, klinikur gamokvlevebTan

erTad avadmyofis simZimis Sesafaseblad da sindromis ebStein-baris

infeqciasTan dasazusteblad aucilebelia Caataron yvela arsebuli

laboratoriuli kvlevebi.

9. praqtikaSi adaptaciis da protokolis SemuSavebis rekomendaciebi

rekomendebulia eqimTa farTo sazogadoebis gacnobiereba epStein-baris

virusiT gamowveuli qronikuli, latenturi formebisa da damaxasiaTebeli

mZime sindromebis Sesaxeb.

10. gaidlainis gadasinjvis da ganaxlebis vada

vinaidan dReisTvis EBV gamowveuli infeqciis etiotropuli mkurnaloba

SemuSavebuli ar aris, sasurvelia gaidlaini weliwadSi erTxel

gadaisinjos yovelwliuri siaxleebis Setanis mizniT.

11. gaidlainis miRebis xerxi/wyaro

gaidlaini miRebulia sxvadasxva gaidlainebis, saxelmZRvaneloebis da

saerTaSoriso JurnalebSi gamoqveynebuli publikaciebis da statiebis

SejerebiT.

32

12. alternatiuli gaidlaini amJamad ar arsebobs

13. gamoyenebuli literatura

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14. avtorebi:

s.s. infeqciuri paTologiis, Sidsisa da klinikuri imunologiis samecniero-praqtikuli centri

akad. eTer bocvaZe

marina beJuaSvili

marina kaxoberaSvili

eqspertebi:

saqarTvelos infeqcionistTa, hepatologTa, parazitologTa, mikrobiologTa da epidemiologTa asociacia

med.Mmec.Kkand. Tengiz cercvaZe

prof.Mmarina kvitaSvili

doc. Tina kacitaZe

giorgi beitriSvili

lela woworia _ saqarTvelos Sromis, janmrTelobisa da socialuri

dacvis saministros janmrTelobis dacvis departamenti;

Tea TavidaSvili _ saqarTvelos Sromis, janmrTelobisa da

socialuri dacvis saministros janmrTelobis dacvis departamenti.