Journal of Turgut Özal Medical Center 5(1): 1998 87 Botulizm Dr. Hakan Ekmekçi
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- Bu səhifədəki naviqasiya:
- Anahtar Kelimeler
- Journal of Turgut Özal Medical Center 5(1):1998
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Journal of Turgut Özal Medical Center 5(1):1998 87 Botulizm Dr. Hakan Ekmekçi 1 'U ø +DOLO g]HURO 2 'U +LNPHW <ÕOPD] 1 %RWXOL]P JHQHOOLNOH &ORVWULGLXP ERWXOLQXP WDUDIÕQGDQ UHWLOHQ ERWXOLQXP Q|URWRNVLQOHULQLQ VHEHS ROGX÷X Q|URSDUDOLWLN ELU KDVWDOÕNWÕU %RWXOLQXP WRNVLQOHUL ELOLQHQ HQ NXYYHWOL EL\RORMLN WRNVLQOHUGLU %X WRNVLQOHU KHPDWRMHQ \ROOD SHULIHULN NROLQHUMLN VLQDSVODUD XODúÕU YH LUUHYHUVLEO RODUDN Q|URPXVNOHU NDYúDN YH GL÷HU SHULIHULN RWRQRP VLQDSWLN UHVHSW|UOHUH ED÷ODQDUDN DVHWLONROLQ VDOÕQÕPÕQÕ EORNH HGHUOHU %RWXOL]P LQ NDUDNWHULVWLN EXOJXVX GHVHQGDQ VLPHWULN IODNV SDUDOL]LOL KLSRWRQLGLU 3DUDOL]LOHU \] EDú YH IDULQNV NDVODUÕQÕ HWNLOH\HQ ELODWHUDO NUDQL\DO VLQLU WXWXOXPX\OD EDúODU YH GDKD VRQUD WRUDNV YH HNVWUHPLWH NDVODUÕQD GR÷UX LOHUOHU 7DQÕ VHUXPGD GÕúNÕGD PLGH YH\D NXVPXN NDSVDPÕQGD WRNVLQLQ J|VWHULOPHVL YH GÕúNÕGDQ & ERWXOLQXP XQ L]ROH HGLOPHVL LOH \DSÕOÕU ø\LOHúPH VROXQXP GHVWH÷L VÕYÕ YH HOHNWUROLW GHQJHVLQLQ VD÷ODQPDVÕ YH HQIHNVL\RQODUÕQ |QOHQPHVL JLEL ED]Õ IDNW|UOHUH ED÷OÕGÕU >7XUJXW g]DO 7ÕS 0HUNH]L 'HUJLVL @ Anahtar Kelimeler: Clostridium botulinum, botulizm, nörotoksin, paralizi, infant, yara Botulism Botulism is a severe neuroparalytic disease produced by botulinum neurotoxins of Clostridium botulinum. Botulinum toxins are the most potent poisons for humans. These toxins are haematogenously disseminated to peripheral cholinergic synapses where toxins bind irreversibly to the receptor sites at the neuromuscular junction and other peripheral autonomic synaptic sites, and block acetylcholine release. The characteristic clinical finding of botulism is hypotonia with a descending symmetric flaccid paralysis which begins with bilateral cranial nerve impairment involving muscles of the face, head, and pharynx and then descends symetrically to involve muscles of the thorax and extremities. The clinical diagnosis of food-borne botulism can be confirmed by assaying the toxin in serum, feces, gastric or vomitus contents, and isolation of C. botulinum from the feces of the patient. Recovery depends upon several factors such as the effectiveness of respiratory care, maintenance of fluid and electrolyte balance, and prevention of infection. [Journal of Turgut Özal Medical Center 1998;5(1):87-96] Key Words: Clostridium botulinum, botulism, neurotoxin, paralysis, infant, wound
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øQ|Q hQLYHUVLWHVL 7ÕS )DNOWHVL 0LNUREL\RORML YH .OLQLN 0LNUREL\RORML $QDELOLP 'DOÕ 0DODW\D Botulizm, genellikle Clostridium botulinum olmak ]HUH NORVWULGLXP WUOHULQLQ UHWWL÷L SRWHQW ELU SURWHLQ nörotoksin olan botulinum toksininin kraniyal sinirleri HWNLOHPHVL LOH EDúOD\DQ YH HNVWUHPLWHOHUGHQ NDXGDOH GR÷UX LOHUOH\HQ Q|URSDUDOLWLN ELU KDVWDOÕNWÕU %X ROJXODU NDWHJRUL\H D\UÕODELOLU 1. *ÕGD N|NHQOL botulizm ROJXODUÕ C. botulinum'la kontamine olan ve ERWXOLQXP WRNVLQL NDSVD\DQ JÕGDODUÕ VLQGLUHQOHUGH 2. øQIDQW ERWXOL]PL ROJXODUÕ JDVWURLQWHVWLQDO WUDNWXVXQGD C. botulinum kolonizasyonu ve botulinum nörotoksini UHWLOPLú RODQ D\OÕNWDQ NoN LQIDQWODUGD 3. Yara botulizmi ROJXODUÕ WRNVLQ UHWHELOHQ RUJDQL]PDODU LOH NRQWDPLQH WUDYPDWLN \DUDOÕ LQVDQODUGD ve 4. 6ÕQÕIODQGÕUÕODPD\DQ ROJXODU ise tespit edilebilen bir 7XUJXWg]DO7ÕS0HUNH]L'HUJLVL H. Ekmekçi ve ark. Botulizm
EXODúPD YDVÕWDVÕ ROPDGDQ WLSLN ERWXOL]P VHPSWRP YH EHOLUWLOHUL J|VWHUHQ ELU \DúÕQ ]HULQGHNL oRFXNODUGD görülmektedir (2). C. tetani QLQ UHWWL÷L Q|URWRNVLQOHU LOH C. botulinum Q|URWRNVLQOHULQLQ \DSÕ YH IRQNVL\RQX birbirlerine oldukça benzer, ancak sinir sisteminde IDUNOÕ KFUHOHUL KHGHIOHGLNOHUL LoLQ NOLQLN HWNLOHUL GUDPDWLN ELU
ELoLPGH IDUNOÕGÕU %RWXOLQXP Q|URWRNVLQOHUL WHPHOGH SHULIHUDO Q|URPXVNOHU NDYúD÷Õ YH RWRQRPLN VLQDSVODUÕ HWNLOHU YH SULPHU RODUDN JoV]ON úHNOLQGH NHQGLQL J|VWHULU 7HWDQR] WRNVLQL GH D\QÕ VLVWHPOHUL HWNLOH\HELOLU DQFDN VDQWUDO VLQLU sisteminin (SSS) inhibitör hücreleri üzerine olan HWNLOHUL GDKD EDVNÕQGÕU YH SULPHU RODUDN ULMLGLWH YH spazma neden olurlar. Hem botulizm hem de WHWDQR]XQ \NVHN IDWDOLWH KÕ]ÕQD VDKLS ROPDVÕ YH KDVWD EDNÕP PDOL\HWOHULQLQ \NVHN ROPDVÕ QHGHQL\OH EX KDVWDOÕNODUGDQ NRUXQPDN LoLQ H÷LWLP YH KDON VD÷OÕ÷Õ |QOHPOHULQLQ |QHPL JQFHOOL÷LQL NRUXPDNWDGÕU %RWXOL]POL KDVWDODUÕQ WÕEEL EDNÕP JLGHUOHULQLQ KDVWD EDúÕQD \DNODúÕN ROGX÷X KHVDSODQPÕúWÕU %X PDNDOHGH ERWXOL]P KDNNÕQGD ELOLQPHVL JHUHNHQ ELOJLOHU GHUOHQPLúWLU
¶XQFX \]\ÕOGD $YUXSDGD VRVLV YH GL÷HU HYGH KD]ÕUODQPÕú JÕGDODUÕ \L\HQOHUGH SDUDOL]LOHUOH VH\UHGHQ ]HKLUOHQPH VDOJÕQODUÕ J|UOPúWU $OPDQ\D¶OÕ -XVWLQXV .HUQHU VRVLV ]HKLUOHQPHVL YDNDODUÕQÕ WDQÕPODPDN LoLQ ODWLQFH VRVLV DQODPÕQD JHOHQ botulus kelimesinden esinlenerek botulizm terimini NXOODQPÕúWÕU $\QÕ G|QHPOHUGH 5XV\DOÕ ELU KHNLP benzer klinikli bir tabloyu EDOÕN ]HKLUOHQPHVL olarak WDQÕPODPÕúWÕU GH YDQ (UPHQJHQ WDUDIÕQGDQ KDVWDOÕ÷ÕQ HWNHQL RODQ C. botulinum WDQÕPODQPÕú YH hayvanlarda da insanlardakine benzer kas JoV]O÷QH \RO
DoDELOHQ ELU
WRNVLQLQ EX PLNURRUJDQL]PD WDUDIÕQGDQ VDOJÕODQGÕ÷Õ J|VWHULOPLúWLU 6RQUDNL \ÕOODUGD EX WRNVLQLQ WLS % ROGX÷X ELOGLULOPLú ¶GH LVH WLS $ WDQÕPODQPÕúWÕU 1943’de yara botulizmi, 1976’da infant botulizmi WDQÕPODQPÕúWÕU \ÕOÕQGD LVH EHOLUOL ELU QHGHQ EXOXQDPD\DQ oR÷XQOX÷X JDVWURLQWHVWLQDO kolonizasyonla ilgili olan sporadik vakalar WDQÕPODQPÕúWÕU 7LS $ WRNVLQ ¶GD L]ROH HGLOPLúWLU Etiyolojik etken C. botulinum türleri, |]HOOLNOH WRSUDN GHQL]DOWÕ YH ]LUDL UQOHUGH ROPDN ]HUH WDELDWWD \D\JÕQ RODUDN bulunan subterminal sporlu, zorunlu anaerob, gram- SR]LWLI EDVLOOHUGLU (ULúNLQ LQVDQODU WD]H ]LUDL UQOHUOH DOGÕNODUÕ
VSRUODUÕQÕ VLQGLUGLNOHUL LoLQ QRUPDO JDLWD IORUDVÕQGD EX PLNURRUJDQL]PD\D UDVWODQPDPDNWDGÕU hUHWLOHQ
toksinlerin antijenik spesifitelerine göre A’dan G’ye 8 PLNURRUJDQL]PD WU WDQÕPODQPÕúWÕU & WRNVLQOHULQLQ C 1
2 ROPDN ]HUH LNL WLSL YDUGÕU %RWXOLQXP toksinleri bilinen en kuvvetli biyolojik toksinlerdir. .DQ GRODúÕPÕQGDNL -9 mg/kg dozu insanlar için öldürücüdür. Tip A, B ve E toksin üreten türler VÕNOÕNOD WLS ) YH * WRNVLQ UHWHQ WUOHU LVH QDGLU RODUDN LQVDQODUGD LQIHNVL\RQODUD QHGHQ ROPDNWDGÕU )L]\RORMLN NDUDNWHUOHULQH J|UH JUXSOX ELU VÕQÕIODPD VLVWHPL EHOLUOHQPLúWLU Grup 1 organizmalar kültürlerde proteolitiktir ve tip A, B ve F toksin üretebilirler. Grup 2 organizmalar nonproteolitiktir ve tip B, E ve F toksini üretebilirler. Grup 3 organizmalar tip C ya da D, Grup 4 ise tip G toksini üretirler. Tek cins sadece tek tip toksin üretir. Grup 2 organizmalar 25°C ile & DUDVÕQGD oR÷DOÕUNHQ GL÷HU WLSOHU & LOH & DUDVÕQGD oR÷DODELOPHNWHGLU +HU FLQV WLSLN RODUDN toksin kodlayan birkaç plasmid içerirken tip G bir adet SOD]PLG LoHUPHNWHGLU øQIDQW ERWXOL]PLQH VHEHS olan C. butyricum ve C. baratii JLEL GL÷HU Clostridium WUOHULQLQ GH WRNVLQ UHWWL÷L J|VWHULOPLúWLU C.
WLSOHUL SURWHROLWLN DNWLYLWH LOH JÕGDODUGD pütrifikasyona neden olurken nonproteolitik tipler JÕGDODUGD GH÷LúLNOL÷H \RO DoPD]ODU A, B, E ve nadiren de F toksini üreten C.
WLSOHUL LQVDQGD KDVWDOÕ÷D \RO DoDU * WRNVLQL üreten C. botulinum tipleri (günümüzde C.
RODUDN DGODQGÕUÕOPDNWDGÕU DQL |OPH VHEHS RODELOLU IDNDW Q|URSDUDOLWLN KDVWDOÕ÷D \RO DoPD] +D\YDQODUGD WLS & YH ' KDVWDOÕNODUÕ GDKD VÕNWÕU øQVDQODUGD ROGX÷X JLEL GL÷HU FDQOÕODUGD GD WDQÕ nörolojik bulgular ve toksinin gösterilmesi veya PLNURRUJDQL]PDQÕQ L]RODV\RQX LOH \DSÕOÕU
'Q\DGD \D\JÕQ RODQ LQVDQODUGD J|UOHQ ERWXOL]PLQ WHPHO IRUPX JÕGD N|NHQOL NODVLN entoksikasyon formudur. Yara botulizmi en nadir olan KDVWDOÕN IRUPX LVH GH VRQ \ÕOODUGD $%'¶GH ELOGLULOHQ YDNDODUGD LON VÕUD\Õ DOPÕúWÕU Journal of Turgut Özal Medical Center 5(1):1998 Botulism
Ekmekçi H, et al. 89 *ÕGD N|NHQOL ERWXOL]P VÕNOÕNOD WRSOX ROXúXPODUGD WDQÕPODQÕUNHQ GL÷HU IRUPODUÕ VSRUDGLNWLU %RWXOLQXP WRNVLQ ND\QDNODUÕQÕ EX \]\ÕOÕQ EDúÕQGD HQ VÕN SL\DVDGD VDWÕODQ
NRQVHUYHOHU ROXúWXUXU LNHQ JQP]GH HY \DSÕPÕ VHE]H PH\YH YH EDOÕN UQOHUL ROXúWXUPDNWDGÕU $ODVND \HUOLOHULQGH ROGX÷X JLEL ED]Õ NOWUOHUGH VÕNOÕNOD EDOÕN IHUPHQWDV\RQX LoLQ \DSÕODQ |Q KD]ÕUODPD LúOHPL EHVLQOHUGH ERWXOLQXP WRNVLQOHULQLQ ROXúPDVÕQD \RO DoPDNWDGÕU %X ROJXODUGD HQ VÕN WLS ( WRNVLQ VXoODQPDNWDGÕU dLQGH ELOGLULOHQ HQ VÕN ND\QDN LVH HY \DSÕPÕ IHUPHQWH EH]HO\HGLU +DOHQ UHVWRUDQ \HPHNOHUL YH KD]ÕU JÕGDODU ND\QDN ROPD\D GHYDP HWPHNWHGLU %X UQOHULQ RUWDN |]HOOL÷L JHQHOGH S+ GH÷HULQLQ ¶GDQ GDKD \NVHN ROPDVÕGÕU $%'¶QLQ EDWÕVÕQGD WLS $ ERWXOL]PL GR÷XVXQGD LVH WLS % GDKD VÕNWÕU %X GD÷ÕOÕP EX E|OJHOHUGH EXOXQDQ VSRU WLSOHULQL \DQVÕWPDNWDGÕU 7LS ) LVH GDKD D] WDQÕPODQPÕú FR÷UDILN GD÷ÕOÕP
J|VWHULU ROXUODU LQIDQW ERWXOL]PL WLS $ % \D GD ) WDUDIÕQGDQ ROXúWXUXODELOLU %X NRQXGD HQ NDSVDPOÕ ND\ÕWODUÕ ROXúWXUDQ $%'¶GH \ÕOGD RUWDODPD NORVWULGL\DO besin zehirlenmesi epidemisinin ve 30-80 infant ERWXOL]PLQLQ J|UOG÷ ELOGLULOPHNWHGLU $%' GH \ÕOOÕN VUHGH ELOGLULOHQ \DUD ERWXOL]PLQOHULQLQ ¶L tip A, % 28’i tip B, % 2,1’i tip A ve tip B birlikte ve ¶L WLSL ELOLQPH\HQ WRNVLQOHUH ED÷OÕ ROGX÷X WHVSLW HGLOPLúWLU øQIDQW ERWXOL]PL oR÷XQOXNOD EDO WNHWLPL LOH LOLúNLOHQGLULOLU ]LUD EDO GÕúÕ EHVOHQPH |\NV RODQ LQIDQW ERWXOL]PL ROJXVX QDGLUGLU øNL LQIDQWGD
WRSUDN NRQWDPLQDV\RQX DUDFÕOÕ÷Õ\OD ERWXOL]PLQ ROXúWX÷X ELOGLULOPLúWLU $\UÕFD LQIDQW botulizmin C. baratii ya da C. butyricum ¶OH ELUOLNWHOL÷L J|VWHULOPLúWLU (WL\RORMLVL ELOLQPH\HQ HULúNLQ ERWXOL]PLQGH HQ VÕN WLS $ WRNVLQL GDKD D] RUDQGD WLS % ve tip F toksini tespit edilmektedir (24). Tip F ERWXOL]P¶OL ELU HULúNLQ ROJX GD C. baratii izole HGLOPLúWLU LOH \ÕOODUÕ DUDVÕQGD +DVWDOÕN .RQWURO YH .RUXQPD 0HUNH]L¶QH &'& JÕGD N|NHQOL YH WRSOX ROD\ ELOGLULOPLúWLU %X ROD\ODUGD RUWDODPD HWNLOHQHQ ROJX VD\ÕVÕ RODUDN KHVDSODQPÕúWÕU 7HN ROJXOX ROD\ODUGD JHQHOOLNOH HY \DSÕPÕ JÕGDODU VXoODQPÕúWÕU 5HVWRUDQ ND\QDNOÕ ELUGHQ ID]OD ROJXOX ROD\ODU WP ROD\ODUÕQ ¶QÕ ROXúWXUPDNWDGÕU EDNÕP X\JXODPDODUÕQGDNL JHOLúPHOHU |QFHVL IDWDOLWH
¶Õ DúDUNHQ ¶OHULQ EDúÕQGD EX GH÷HU ¶H DUDVÕQGD LVH ¶D LQGLULOPLúWLU
\DúÕQGDQ E\N YDNDODUGD |OP KÕ]Õ ¶GXU øON HWNLOHQHQ ROJXODU ³LQGHNV ROJX´ RODUDN
DQÕOÕU øQGHNV ROJXODUGD HQWRNVLNDV\RQD ED÷OÕ IDWDOLWH RUDQÕ LNHQ VRQUDNL YH HUNHQ WDQÕ NRQXODQ
olgularda fatalite riski % 4’dür (27). %RWXOL]P KD\YDQODU DOHPLQGH GDKD VÕNWÕU
øQVDQODUGDNL HWNLQ IRUPX GDKD oRN WLS $ YH % LNHQ NXúODU DOHPLQGH YH LQVDQ GÕúÕ PHPHOL WUOHUGH WLS &¶GLU
(13).
VSRUODUÕ GQ\DQÕQ KHU DODQÕQGD WRSUDN |UQH÷LQGH YH GHQL] WRUWXVXQGD EXOXQXU
(28). Bu sporlar 1 atm’de 100°C’ye birkaç saat GD\DQDELOPHNWHGLU .RQVHUYH JÕGDODUÕQ KD]ÕUODQPDVÕ
DPDFÕ\OD
ND\QDWPD
VÕUDVÕQGD VROXV\RQODUÕQ DQDHURELN |]HOOL÷L DUWPDNWD YH GDKD
VRQUD ÕVÕ\D GD\DQÕNOÕ VSRUODUGDQ ROXúDQ C. 6X\XQ ND\QDPD QRNWDVÕQÕQ GúN ROGX÷X \NVHN UDNÕPOÕ E|OJHOHUGH NRQVHUYH JÕGD KD]ÕUODQPDVÕQGD
X\JXQ GGNO WHQFHUHOHULQ NXOODQÕOPDVÕ LOH VSRUODU öldürülebilmektedir.
*ÕGD N|NHQOL ERWXOL]P LoLQGH WRNVLQ UHPLú JÕGDODUÕQ \HQPHVL VRQXFX ROXúXU $OÕQDQ WRNVLQ
öncelikle duodenum ve jejenumdan emilip kana NDUÕúDUDN SHULIHUDO NROLQHUMLN VLQDSVODUD XODúÕU
Q|URPXVNOHU ELOHúNH GDKLO YDNDODUÕQGD VSRUODUÕQ \DUD LoLQGH JHUPLQH ROPDVÕ YH
lokal toksin üretilmesi, infant ve kökeni bilinmeyen ERWXOL]P YDNDODUÕQGD LVH VSRUODUÕQ D÷Õ] \ROX\OD DOÕQÕPÕ
söz konusudur. Aklorhidri ve antibiyotikler C. RODELOLU .OLQLN EXOJXODU WRNVLQLQ UHGL÷L \HUGHQ ]L\DGH WLSLQH ED÷OÕGÕU
7DQÕPODQPÕú VHNL] WRNVLQ WLSLQGHQ $ % & 1
, C
,
D, E, F, G), C hariç tümü nörotoksindir. C 2 , klinik
önemi bilinmeyen bir sitotoksindir. Sindirim sistemi YH\D \DUD \HULQGHNL ERWXOLQXP Q|URWRNVLQL GRODúÕPD NDUÕúÕU YH Q|URPVNOHU NDYúDN SRVWJDQJOLRQLN SDUDVHPSDWLN VLQLU XoODUÕ YH SHULIHULN JDQJOLRQODU olmak üzere periferik kolinerjik sinir terminallerine WDúÕQÕU 6DQWUDO VLQLU VLVWHPL HWNLOHQPH] $NWLI Q|URWRNVLQLQ N'D ELU D÷ÕU ]LQFLU N'D YH bir de hafif zincir (50 kDa) olmak üzere iki NRPSRQHQWL YDUGÕU 1|URWRNVLQLQ DNWLYLWHVL LoLQ ED]Õ EDVDPDNODUÕQ DúÕOPDVÕ JHUHNLU 0\RQ|UDO ELOHúNHGH SUHVLQDSWLN VLQLU KFUHOHULQH |]JQ RODUDN ED÷ODQPDOÕ 2. Sinir hücresinde vezikül içine toksin girebilmeli, 3. 7XUJXWg]DO7ÕS0HUNH]L'HUJLVL H. Ekmekçi ve ark. Botulizm
Sitozol içinde transloke olabilmeli ve 4. 1|URHN]RVLWR] DSDUDWÕQÕQ WRNVLQ ELU
oLQNR HQGRSHSWLGD] WDUDIÕQGDQ SURWHROL]L LOH Q|URWUDQVPLWWHU DVHWLONROLQ VDOÕQÕPÕ HQJHOOHQPHOLGLU ø\LOHúPH \HQL VLQLU WHUPLQDOOHULQLQ WRPXUFXNODQPDVÕ LOH JHUoHNOHúLU 6LQLU XoODUÕQGD \HQL SUHVLQDSWLN WHUPLQDOOHULQ ROXúPDVÕ LoLQ KDIWDOÕN ELU VUH JHUHNPHNWHGLU Botulinum toksini bir tek polipeptid zinciri olarak sentezlenir. Daha sonra bakteriyel proteaz ile oHQWLNOHQHUHN KDILI ]LQFLUL WRWDO D÷ÕUOÕ÷ÕQ oWH ELUL RODFDN úHNLOGH LNL ]LQFLUH D\UÕOÕU 0ROHNOHU D÷ÕUOÕN ED]ÕQGD WLS $ WRNVLQ GR÷DGD EXOXQDQ HQ SRWHQW WRNVLQGLU 6SRUODUÕQ DNVLQH WRNVLQ ÕVÕ\D GX\DUOÕGÕU 'H÷LúLN WRNVLQ
WLSOHUL GH÷LúLN
SRVWVHQWHWLN basamaklardan geçebilirler (31). .DV EL\RSVLVLQGH \DSÕODQ PLNURHOHNWURG oDOÕúPDODUÕQGD HQ oDUSÕFÕ EXOJX VRQ SODN SRWDQVL\HO (33 ¶LQLQ NXDQWDO LoHUL÷LQGH D÷ÕU ELU D]DOPD YH (33¶QLQ ODWDQVÕQGDNL EHOLUJLQ GH÷LúNHQOLNWLU Ancak spontan minyatür son plak potansiyelleri 0633 ¶QLQ QH DPSOLWGQGH QH GH IUHNDQVÕQGD D]DOPD ROPD] %X EXOJXODU ERWXOL]PGH DVÕO ROD\ÕQ motor sinir terminallerinde kalsiyumun hücre içine DOÕQÕPÕ LOH LQGNOHQHQ X\DUÕP VRQUDVÕ VLQDSWLN YH]LNO VDOÕQÕPÕQGDNL LúOHPOHULQ ER]XOPDVÕQD \RO DoDQ nöromusküler iletimin presinaptik düzeyde çok güçlü ELU úHNLOGH HQJHOOHQGL÷LQL J|VWHUPHNWHGLU
%RWXOL]P ROJXODUÕQGD NODVLN RODUDN VLPHWULN desendan güçsüzlükle birlikte akut, bilateral kraniyal Q|URSDWL VDSWDQÕU &'& QLQ ERWXOL]P WDQÕ NULWHUOHUL RODQ úX EHOOL EDúOÕ EXOJXODU GLNNDWL oHNPHNWHGLU $WHú \RNWXU ELU HQIHNVL\RQ NRPSOLNDV\RQX ROPDGÕ÷Õ sürece), 2) Nörolojik bulgular simetriktir, 3) Hasta X\DQÕNWÕU 1DEÕ] QRUPDO \D GD KLSRWDQVL\RQ \RNOX÷XQGD \DYDúWÕU 'X\X ND\EÕ \RNWXU EXODQÕN J|UPH KDULo øON LNL EXOJX |]HOOLNOH poliomiyelitin ekarte edilmesi için çok önemlidir. $\UÕFD
EX NULWHOHUH X\PD\DQ LVWLVQDODU GD ELOGLULOPLúWLU *ÕGD N|NHQOL ERWXOL]P JHQHOOLNOH SUHIRUPH KDOGH WRNVLQ LoHUHQ JÕGDODUÕQ DOÕQPDVÕQGDQ VRQUDNL LOH VDDW LoLQGH JHOLúLU %X VUH VDDW LOH JQ DUDVÕQGD GH÷LúHELOLU øQNEDV\RQ VUHVL QH NDGDU NÕVD LVH KDVWDOÕ÷ÕQ úLGGHWL R NDGDU ID]ODGÕU øON |QFH EXOEHU NDVODU HWNLOHQLU 'LSORSL \DNÕQ ELU QRNWD\D fokuslamada zorluk, disfoni, dizartri ve disfaji ortaya oÕNDU .ROLQHUMLN RWRQRP VLQLU VLVWHPLQLQ HWNLOHQPHVL LOH WNUN VDOJÕVÕQGD D]DOPD D÷Õ] NXUXOX÷X ER÷D]GD D÷UÕ LOHXV YH ULQHU UHWDQVL\RQ RUWD\D oÕNDU %X G|QHPGH EXODQWÕ NXVPD DEGRPLQDO D÷UÕ YH LVKDO GH olabilir. Hastalar, önce kollara daha sonra vücuda ve EDFDNODUD \D\ÕODQ JoV]ONWHQ úLND\HW HGHU Nörolojik muayenede kraniyal sinir disfonksiyonu WHVSLW HGLOLU ODWHUDO UHNWXV NDVÕQGD ]D\ÕIOÕN .UDQLDO VLQLU SWR]LV GLODWH SXSLOODODU |÷UPH UHIOHNVLQGH D]DOPD YH PHGL\DO UHNWXV SDUD]LVLQH VÕN UDVWODQÕU Bu dönemden sonra desendan motor sinir tutulumu RUWD\D oÕNDU 6ROXQXP NDVODUÕ GDKLO SHULIHULN NDVODU HWNLOHQLU %D]Õ KDVWDODUGD SDUDOL]L KDILI LNHQ GL÷HUOHULQGH KDIWDODUFD \R÷XQ GHVWHN WHGDYLVLQL JHUHNWLUHELOLU ùXXU DoÕNWÕU DWHú J|UOPH] Q|URORMLN GLVIRQNVL\RQ YDUGÕU DQFDN VLPHWULN ROPD\DELOLU 3XSLOOHU UHDNVL\RQ PRWRU L\LOHúPHGHQ D\ODU VRQUD ELOH DQRUPDO NDODELOLU 1LVWDJPXV VÕNOÕNOD J|UOU VÕNOÕNOD GD WLS $ KDVWDOÕ÷ÕQGD ROXU øQJLOWHUH GH RUWD\D oÕNDQ YH \D\ÕQODQPÕú HQ E\N WRSOX ERWXOL]P ROD\ÕQGD ROJXODUÕQ ¶VLQGH Q|URRIWDOPLN EXOJX\D UDVWODQPÕúWÕU %X JUXSWDNL D÷ÕU ROJXODUGD RNOHU YH bulbar semptomlar birlikte görülürken, hafif olgularda LON |QFH GLVIDML JHOLúPHNWH YH DUGÕQGDQ VDDW LoLQGH YL]HO HWNLOHQPH J|UOPHNWHGLU 'LNNDWL oHNHQ GL÷HU bir husus ise respiratuar paralizi ve yetmezlik tespit HGLOHQ ROJXODUGD VROXQXP VLVWHPL EXOJXODUÕQÕQ NUDQL\DO VLQLU SDUDOL]LQLQ EDúODQJÕFÕQGDQ VRQUDNL LON VDDWWH
ROXúPDVÕGÕU
$OW NUDQL\DO
VLQLU GLVIRQNVL\RQODUÕ GLVIDML GL]DUWUL KLSRJORVVDO güçsüzlük olarak görülür. Respiratuar disfonksiyon; \D VROXQXP HVQDVÕQGD ]D\ÕIODPÕú JORWWLVLQ NDSDQPDVÕ nedeniyle üst solunum yolu obstruksiyonu ya da GLDIUDJPD NDVÕQÕQ JoV]O÷ VRQXFX ROXúDELOLU %X WDEOR\D VDKLS KDVWDODUÕQ PHNDQLN YHQWLODV\RQ JHUHNVLQLPL YDUGÕU C. botulinum besin zehirlenmesinde esas ölüm sebebi respiratuvar veya EXOEHU SDUDOL]L YH GHVWHN WHGDYLVL VÕUDVÕQGD RUWD\D oÕNDQ LQIHNVL\|] NRPSOLNDV\RQODUGÕU Otonom sinir sistemi ile ilgili problemler; JDVWURLQWHVWLQDO GLVIRQNVL\RQODU LVWLUDKDW NDOS KÕ]ÕQGD GH÷LúPH SRVWXUDO GH÷LúLNOL÷H YH\D KLSRWDQVL\RQD FHYDEÕQ
ND\EROPDVÕ KLSRWHUPL YH\D ULQHU
UHWDQVL\RQGXU .ROLQHUMLN EORNDM LOH RUWD\D oÕNDQ Q|URPXVNOHU YH RWRQRPLN HWNLOHU ùHNLO GH |]HWOHQPLúWLU $\UÕFD
ED÷ÕUVDN NRORQL]DV\RQ ERWXOL]PL WDQÕPODQPÕúWÕU dRN QDGLU ELU WDEOR ROPDVÕQD UD÷PHQ EDúODQJÕoWD LQFH ED÷ÕUVDN IRQNVL\RQXQGD GH÷LúLNOLN
Journal of Turgut Özal Medical Center 5(1):1998 Botulism
Ekmekçi H, et al. 91 Nöromusküler etkiler Otonomik etkiler 1|URPXVNOHU NDYúDNWDNL nikotinik kolinerjik iletimdeki azalma iskelet NDVODUÕQGD ]D\ÕIODPD\D QHGHQ olur
3DUDVHPSDWLN Q|URQODUÕQ VLQDSVODUÕQGD PXVNDULQLN kolinerjik iletimdeki azalma otonom disfonksiyona neden olur ùHNLO . %RWXOL]PLQ ROXúWXUGX÷X NROLQHUMLN EORNDMÕQ NOLQLN görünümü. Tablo 1 %RWXOL]PLQ WLSOHULQLQ EXOJX YH VHPSWRPODUÕ Tip A (%)
Tip B (%)
Tip E (%)
Nörolojik semptomlar Dizfaji
$÷Õ] NXUXOX÷X Diplopi
Dizartri Kollarda güçsüzlük Bacaklarda güçsüzlük %XODQÕN J|UPH Dispnea Paresteziler Gastrointestinal bulgular Konstipasyon %XODQWÕ Kusma
Abdominal kramplar Diare
'L÷HU VHPSWRPODU Yorgunluk %R÷D] D÷UÕVÕ %DúG|QPHVL Nörolojik bulgular Pitoz
Gag refleksinde azalma Oftalmoparezi Fasiyal paralizi Dilde güçsüzlük Dilate veya fiks pupiller Nistagmus Kollarda güçsüzlük Bacaklarda güçsüzlük Ataksi '75¶OHULQGH D]DOPDDOÕQDPDPD DTR’lerde hiperaktivite %DúODQJÕoWDNL PHQWDO GXUXP .ROD\ X\DUÕOPD Letarji
6WXSRUNRQI]\RQ DUDVÕ 96 83 90 100
86 76 100 91 20 73 73 70 33 35 92 75 86 96 81 87 84 91 33 44 91 82 24 54 12 88 4 8 97 100 92 69 64 64 42 34 12 73 57 50 46 8 69 39 30 55 54 46 48 31 56 4 62 59 13 29 0 93 4 4 82 93 39 50 EE EE 91 88 EE 52 84 96 EE 39 84 38 63 46 EE EE EE 66 75 EE EE EE EE EE EE 27 73 0 .ÕVDOWPDODU (( (OGH HGLOHPHPLú '75 'HULQ WHQGRQ UHIOHNVL gözlenen ve desendan paralizi ile seyreden olgularda akla gelmelidir (39). 'H÷LúLN WLS WRNVLQOHULQ HQWRNVLNDV\RQODUÕQGD UDVWODQDQ NOLQLN EXOJXODUGDNL IDUNOÕOÕNODUÕ DQDOL] DPDFÕ\OD OLWHUDWUGHNL YHULOHU 7DEOR GH |]HWOHQPLúWLU (17, 29, 40, 41). 7LS $ DQODPOÕ GHUHFHGH VÕNOÕNWD GL]DUWUL EXODQÕN J|UPH GLVSQH GL\DUH ER÷D] D÷UÕVÕ EDúG|QPHVL pitoz, oftalmopleji, fasiyal parezi ve üst ekstremite JoV]O÷ LOH ELUOLNWHGLU 7LS % YH ( GDKD oRN otonomik disfonksiyon ile seyreder. Ancak bu IDUNOÕOÕNODUÕQ KLo ELUL WRNVLQ WLSLQLQ GLDJQRVWLN EXOJXVX GH÷LOGLU +DVWDODUÕQ ¶VLQGHQ GDKD D]Õ GLODWH YH\D ÕúÕ÷D \DQÕWVÕ] SXSLOODODUD VDKLSWLU YDUOÕNODUÕ WDQÕ DoÕVÕQGDQ ROGXNoD |QHPOL EXOJXODUGÕU \RNOX÷X LVH KLoELU úHNLOGH ERWXOL]P RODVÕOÕ÷ÕQÕ D]DOWPD] øQIDQW ERWXOL]PL NRQVWLSDV\RQOD EDúODU VRQUDNL G|QHPGH EHVOHQPH JoO÷ KLSRWRQL VDO\DGD DUWPD YH ]D\ÕI D÷ODPD RUWD\D oÕNDELOLU %D]HQ LON EXOJX entübasyon gerektirecek kadar ciddi olan üst solunum \ROX REVWUXNVL\RQXGXU $÷ÕU ROJXODUGD NUDQL\DO VLQLU Q|URSDWLOHUL VROXQXP JoV]O÷ YH ¶\H YDUDQ VROXQXP \HWPH]OL÷L WHVSLW HGLOLU %X WDEOR KDIWD VUHU ø\LOHúPH EDúODPDGDQ |QFH KDIWDOÕN ELU G|QHP LoLQ VWDELOOHúLU øQIDQW ERWXOL]PGH relapslar olabilir (45). Oldukça nadir görülen, ancak HUNHQ WDQÕ YH \HWHUOL \R÷XQ EDNÕP GHVWH÷L LOH WDPD \DNÕQ L\LOHúPH ELOGLULOHQ LQIDQW ERWXOL]PL JHQHOGH X]XQ hospitalizasyon gerektirir (46).
JDVWURLQWHVWLQDO ER]XNOXNODUÕQÕ J|VWHUPH] DQFDN GL÷HU \|QOHUL\OH EHQ]HUGLU $WHú YDUVD QHGHQL ERWXOL]PGHQ
ziyade yara enfeksiyonunudur. Nadiren nörolojik WDEOR JHOLúWL÷L DQGD \DUDQÕQ NHQGLVL L\LOHúPLú RODELOLU
Aksine
.RNDLQ ED÷ÕPOÕVÕ ELU KDVWDGD EX RUJDQL]PDQÕQ QHGHQ ROGX÷X VLQX]LW YH ERWXOL]P WHVSLW HGLOPLúWLU
%LOGLULOHQ LQNEDV\RQ SHUL\RGX LOH JQ DUDVÕQGD GH÷LúPHNWHGLU
7XUJXWg]DO7ÕS0HUNH]L'HUJLVL H. Ekmekçi ve ark. Botulizm
/LWHUDWUGH NODVLN Q|URORMLN EXOJXODU \DQÕVÕUD ELOLQHQLQ DNVLQH GX\VDO ER]XNOXNODUÕQ GD ELUOLNWH VH\UHWWL÷L EHOLUWLOHQ ROJX VXQXPODUÕ GD PHYFXWWXU %X GXUXPGD WDQÕGD UHSHWHWLI VLQLU X\DUÕPÕ YH HGURIRQLXP HQMHNVL\RQX LOH GHNULPHQWDO \DQÕWÕQ D]DOGÕ÷ÕQÕQ J|VWHULOPHVLQLQ ROGXNoD
|QHPOL ROGX÷X
YXUJXODQPDNWDGÕU 7DQÕ
ùSKHOHQLOHQ ERWXOL]PLQ WLSLQH X\JXQ |\N HQ |QHPOL WDQÕVDO WHVWWLU %DúNDODUÕ GD HWNLOHQPLúVH GXUXPXQ WDQÕQPDVÕ oRN GDKD NROD\ RODFDNWÕU WRNVLQ \L\HFHN JÕGDODUD WDP GD÷ÕOPDPÕú RODELOHFH÷L LoLQ EDúND KDVWDQÕQ \RNOX÷X WDQÕ\Õ RUWDGDQ NDOGÕUPD]
/DERUDWXYDU GH÷HUOHQGLUPHVLQGH VHUXP JDLWD PLGH NDSVDPÕ YH XODúÕODELOL\RUVD NRQWDPLQH JÕGDQÕQ
LQFHOHQPHVL JHUHNLU 'ÕúNÕ YH JÕGDGDQ NOWU \DSÕODUDN DUDúWÕUÕOÕU YH KD\YDQ GHQH\L LOH ERWXOLQXP WRNVLQL DUDúWÕUÕOÕU 7RNVLQ WLSOHPHVL YH
GR÷UXODQPDVÕ YDNDGD PPNQ ROPDNWDGÕU (UNHQ ROJXODUGD GDKD oRN WRNVLQ oDOÕúPDVÕ\OD
LOHUOHPLú ROJXODUGD LVH WRNVLQGHQ ]L\DGH SR]LWLI NOWU VRQXFX LOH WDQÕ NRQXU gUQHNOHU X\JXQ
HSLGHPL\RORMLN NRúXOODUGD DOÕQPDOÕ YH VDNODQPDOÕGÕU 7RNVLQ LoLQ HQ GX\DUOÕ WHVW IDUH GHQH\LGLU
Toksinin letal etkisini göstermek için incelenecek materyaller fare peritonuna enjekte edilir, letal etkinin
WLSH VSHVLILN DQWLVHUXP YHULOHQ IDUHOHUGH ND\ÕS ROGX÷XQXQ J|VWHULOPHVL GH JHUHNLU )DUH GHQH\LQH
alternatif olarak, antijen tespit eden ELISA kitleri JHOLúWLULOPLú
ROPDVÕQD
\D\JÕQ
NXOODQÕOPDPDNWDGÕU %RWXOL]P NOLQLN EHOLUWLOHULQL J|VWHUHQ KDVWDODUÕQ QGH VHUXPGD QGH GÕúNÕGD
WRNVLQ
LOH
LVH
PLNURRUJDQL]PDQÕQ L]ROH
HGLOPHVL
WDQÕ
konulabilmektedir. Alternatif olarak toksin ELISA ile WHVSLW HGLOHELOLU +DVWDOÕ÷ÕQ EDúODQJÕFÕQGDQ LWLEDUHQ WRNVLQ DWÕOÕPÕ D\ ER\XQFD VUHELOLU EX SHULRGGD JDLWD kültürleri pozitif kalabilir. $NXW IODNV SDUDOL]L JHOLúHQ KDVWDODUGD |]HOOLNOH bilateral 6. kranial sinir disfonksiyonu, gastrointestinal VHPSWRPODU EHOLUOL ELU JÕGD \HPH |\NV YH EX JÕGDGDQ \L\HQ EDúND KDVWDODUGD GD D\QÕ VHPSWRPODUÕQ VDSWDQPDVÕ KDOLQGH ERWXOL]PGHQ úSKHOHQPHN JHUHNLU %RWXOL]P ROJXODUÕQÕQ P\DVWHQLD JUDYLV (DWRQ/DPEHUW sendromu, kene paralizisi, Guillain-Barré sendromu, 3ROLR KLSHUPDJQH]HPL GLIWHUL ED]LOHU DUWHU GDOODUÕQÕ LOJLOHQGLUHQ VHUHEURYDVNOHU ROD\ODU WULúLQR]LV hipokalsemi, organofosfat zehirlenmesi, atropin LQWRNVLNDV\RQX YH SVLNL\DWULN VHQGURPODUOD D\ÕUÕFÕ WDQÕVÕQÕQ \DSÕOPDVÕ JHUHNLU 0\DVWHQLD JUDYLV ve Lambert-Eaton myastenik sendromu (LEMS) ERWXOL]PLQ ED]Õ RUWDN |]HOOLNOHULQL SD\ODúÕU DQFDN bunlar nadiren fulminan olurlar ve otonomik bulgu J|VWHUPH]OHU (GURIRQLXP WHVWLQGH NXYYHWWHNL L\LOHúPH P\DVWHQLD JUDYLVH SDWRJQRPRQLN GH÷LOGLU ERWXOL]PGH de tespit edilebilir (50). Kene paralizisi iyi bir fizik PXD\HQH LOH D\ÕUW HGLOHELOLU ]LUD Dermacentor keneleri KDOHQ \DSÕúÕN RODFDNWÕU .ODVLN DNXW HQIODPDWXDU polinöropati (AIPN, Guillain-Barré Sendromu) VÕNOÕNOD PRWRU \DNÕQPDODUOD EDúODU KÕ]OD DUHIOHNVLN ROXU QDGLUHQ NUDQL\DO VLQLU GLVIRQNVL\RQX EDúODU YH SXSLOOHU WXWXOXP J|VWHUPH] %RWXOL]PGH HWNLOHQPLú NDV JUXEX WDP SDUDOLWLN ROPDGÕ÷Õ VUHFH DUHIOHNVL ROPD] $,31¶OL KDVWDQÕQ VHUXPX IDUHGH SDUDOL]L\H QHGHQ ROPDNWDGÕU %X QHGHQOH IDUH GHQH\L LOH ERWXOL]PGHQ D\ÕUW HGLOHPH] $,31¶QLQ 0LOOHU )LVKHU YDU\DQWÕQGD RNXORPRWRU GLVIRQNVL\RQ VDSWDQÕU GL÷HU NUDQL\DO VLQLU WXWXOXPX RODELOLU DQFDN ERWXOL]PGH J|UOPH\HQ EHOLUJLQ DUHIOHNVL YDUGÕU 3ROLR¶OX KDVWDODUGD EDúODQJÕoWD DWHú YH DVLPHWULN kuvvetsizlik mevcuttur. Magnezyum entoksikasyonu botulizmi taklit edebilir (51). (OHNWURIL]\RORMLN WDQÕ %RWXOL]PLQ GL÷HU Q|URORMLN VHQGURPODUGDQ D\ÕUW edilmesi için 40 Hz veya daha yüksek frekansta UHSHWLWLI VWLPXODV\RQOX HOHNWURP\RJUDIL NXOODQÕODELOLU Botulizme ait elektrofizyolojik anormallikler EDúODQJÕoWD ROPD\DELOLU (WNLOHQHQ NDVODUGD ELOHúLN NDV DNVL\RQ SRWDQVL\HO DPSOLWGOHUL NoNWU DQFDN VLQLU LOHWL oDOÕúPDODUÕ QRUPDOGLU %D]Õ KDVWDODUGD GúN IUHNDQVOÕ VLQLU LOHWL X\DUÕPÕQGD GHNUHPHQWDO SDWHUQ J|]OHQHELOLU %X WHVW ROGXNoD D÷UÕ vericidir, ancak botulizm veya LEMS ciddi olarak GúQOG÷QGH \DSÕOPDOÕGÕU %RWXOL]P HOHNWURIL]\RORMLN RODUDN /(06¶GHQ D\UÕODELOLU 7HN OLI (0*¶GH LVH EHOLUJLQ DUWPÕú MLWWHU YH EORN J|]OHQLU %X EXOJXODU /(06¶GHNLQH EHQ]HU úHNLOGH ERúDOÕP KÕ]Õ DUWWÕNoD D]DOPD J|VWHUHELOLU øQIDQW ERWXOL]PLQGHNL HOHNWURIL]\RORMLN EXOJXODU HULúNLQGHNLOHUH EHQ]HUOLN J|VWHULU 7DQÕGD úX WULDG NDEXO J|UPúWU 1.
2.
Tetanik ve posttetanik fasilitasyon, Journal of Turgut Özal Medical Center 5(1):1998 Botulism
Ekmekçi H, et al. 93 Tablo 2. Mekanik ventilasyon gereksinim yüzdesi Toksin ve olgu % Tip A
Tip B Tip E
øQGHNV ROJX Toplu olgularda 67 52
85 42 3. 3RVWWHWDQLN WNHQPHQLQ ROPDPDVÕ $\UÕFD HQ VÕN WDQÕPODQDQ EXOJX +]¶OLN X\DUÕ KÕ]ÕQGD ¶GHQ ID]OD LQNUHPHQWDO SDWHUQLQ gözlenmesidir (42, 56).
%RWXOL]PGH RUWD\D oÕNDQ HQ |QHPOL NRPSOLNDV\RQ DQL VROXQXP GXUPDVÕGÕU %X QHGHQOH KDVWDODUGD YLWDO kapasitenin monitorize edilmesi ve ventilatör GHVWH÷LQLQ VD÷ODQPDVÕ JHUHNLU hVW VROXQXP \ROX REVWUXNVL\RQX \D GD GLDIUDJPD NDVÕ JoV]O÷ RODQ KDVWDODUÕQ PHNDQLN YHQWLODV\RQ JHUHNVLQLPL YDUGÕU 7DEOR (Q D÷ÕU WDEOR\X ROXúWXUDQ WLS $ YDNDODUÕQGD RUWDODPD JQ WLS % LoLQ LVH JQ mekanik ventilasyon gerekmektedir (37). C. botulinum besin zehirlenmesinde esas ölüm sebebi respiratuvar veya bulber paralizi ve destek tedavisi VÕUDVÕQGD RUWD\D oÕNDQ LQIHNVL\|] NRPSOLNDV\RQODUGÕU *DVWURLQWHVWLQDO VLVWHPGHNL WRNVLQLQ X]DNODúWÕUÕOPDVÕ DPDFÕ\OD KDVWDOÕ÷ÕQ HUNHQ ID]ÕQGD JDVWULN ODYDM NDWDUWLN YH PVKLO NXOODQÕODELOLU .DQGDNL WRNVLQL nötralize edebilmek için antitoksin, barsaklarda toksin UHWHQ PLNURRUJDQL]PD VD\ÕVÕQÕ D]DOWPDN LoLQ RUDO penisilinler verilmelidir. Özellikle ventilatör GHVWH÷LQGHNL YH \R÷XQ EDNÕPGDNL LOHUOHPHOHULQ HWNLVL\OH NORVWULGLDO EHVLQ ]HKLUOHQPHVL ROJXODUÕQÕQ ]HULQGHNL PRUWDOLWH KÕ]Õ XQ DOWÕQD GúUOPúWU %X RUDQODU ERWXOL]P LoLQ GHVWHN WHGDYLQLQ |QHPLQL YXUJXODPDNWDGÕU (QWXEDV\RQ NDUDUÕ úX WHPHOOHU ]HULQH RWXUWXOPDOÕGÕU 1.
hVW VROXQXP \ROODUÕQÕQ \HWHUOLOL÷LQ \DWDN EDúÕQGD VD÷ODQPDVÕ 2.
PONJ¶GDQ GDKD GúN ELU YLWDO NDSDVLWH |OoP entübasyon için yeterli endikasyondur). $\UÕFD KDVWDQÕQ HQWEH HGLOPHVL LoLQ S&2 2 ’nin DUWPDVÕ YH\D S2 2 ¶QLQ GúPHVL EHNOHQPHPHOLGLU Tetanozun aksine otonomik disfonksiyonlar ERWXOL]PGH oRN KD\DWL WHKOLNH ROXúWXUPD] L\L YH X\JXQ KDYD \ROX YH YHQWLODWRU X\JXODQÕPÕ LOH ELU NRPSOLNDV\RQ JHOLúPHGLNoH KDVWD L\LOHúLU 'úN EDVÕQoOÕ HQGRWUDNHDO WS YH \NVHN YROPOH HQWEH HGLOPLú KDVWDODUGD WUDNHRVWRPL DoÕOPDPDOÕGÕU PHNDQLN nedenler hariç entübasyonun süresi de bu konuda |QHPOL GH÷LOGLU (÷HU KDOHQ NRQWDPLQH JÕGD JDVWURLQWHVWLQDO WUDNWXVGD EXOXQX\RUVD YH LOHXV JHOLúPHPLúVH SXUJDWLIOHU \DUDUOÕ RODFDNWÕU $QWLWRNVLQ WHGDYLVL WULYDODQ DW VHUXPX LOH \DSÕOÕU WLS $ % YH ( %LOGLULOPLú KLSHUVHQVLWLYLWH RUDQÕ LOH DUDVÕQGD GH÷LúPHNWHGLU $QDILODNVL\H RUDQÕQGD UDVWODQÕU $QWLWRNVLQ X\JXODQÕPÕ |QFHVL GHUL WHVWL \DSÕOÕU 6WDQGDUW DQWLWRNVLQ GR]X KHU ELUL ,8 tip A, 5500 IU tip B ve 8500 IU tip E kapsayan iki IODNRQGXU %LU IODNRQ LQWUDYHQ|] YH GL÷HUL LQWUDPXVNOHU \ROGDQ YHULOLU $÷ÕU \D GD SURJUHVLI YDNDODUGD KHU G|UW VDDWWH EX GR] WHNUDUODQÕU $QWLWRNVLQ tedavisi özellikle tip B ve tip E botulizmde çok \DUDUOÕGÕU øQVDQ ERWXOLQXP LPPXQJOREXOLQL LQIDQW ERWXOL]PLQGH NOLQLN oDOÕúPDODUÕQ GÕúÕQGD KHQ] NXOODQÕPD JLUPHPLúWLU Yara botulizmi olan hastalar, yara iyiye gidiyor gözükse bile debride edilmelidir. Anaerobik kültürler FHUUDKL G|QHPLQGH DOÕQPDOÕGÕU $QWLWRNVLQLQ ORNDO X\JXODQÕPÕQÕQ \HUL WDP ELOLQPHPHNWHGLU $QWLEL\RWLN tedavisi tam net olmamamakla birlikte 10-20 MU JQON SHQLVLOLQ * VÕNOÕNOD |QHULOLU (WNLOL ELU DOWHUQDWLI tedavi de metronidazol'dur. Aminoglikozidler ve WHWUDVLNOLQOHU Q|URQ NDOVL\XP JLULúLQL ER]DUDN LQIDQW ERWXOL]PL N|WOHúWLULUOHU %X HWNL HULúNLQGH ELOGLULOPHPLúWLU 1|URPXVNOHU NDYúDNWD DVHWLONROLQ VDOÕQÕPÕQÕ DUWÕUPDN DPDFÕ\OD PJNJ GR]XQGD JXDQLGLQ KLGURNORULW NXOODQÕOÕU $QFDN EX WHGDYLQLQ HWNLQOL÷L WH\LG HGLOPHPLúWLU %RWXOL]PLQ L\LOHúPHQLQ LON o D\ÕQGD HQ \NVHN NDV JFQH XODúÕOPDVÕQD UD÷PHQ KDVWDODU ELU \ÕOD NDGDU X]DQDQ L\LOHúPH YH NXYYHWOHQPH J|VWHULUOHU %RWXOL]POL KDVWDODUGD UXK VD÷OÕ÷ÕQÕ HWNLOH\HFHN NDOÕFÕ SVLNRORMLN GLVIRQNVL\RQODU GD J|UOHELOLU %RWXOLQXP WRNVLQLQLQ WHGDYL DPDoOÕ NXOODQÕPÕ 1|URPXVNOHU NDYúDNWD IRQNVL\RQHO GHQHUYDV\RQD \RODoDQ ERWXOLQXP WRNVLQL EX |]HOOL÷L QHGHQL LOH ED]Õ NOLQLN
WDEORODUGD WHGDYL
DPDoOÕ NXOODQÕOPD\D EDúODPÕúWÕU .RQYDQVL\RQHO RODUDN WLS $ WRNVLQL NXOODQÕOPDNWDGÕU 7HPHO NXOODQÕP DODQÕ GLVWRQLOHUGLU
7XUJXWg]DO7ÕS0HUNH]L'HUJLVL H. Ekmekçi ve ark. Botulizm
.oN RUDQGD HQMHNVL\RQ WHNUDUODUÕ VRQXFX WLS $ WRNVLQLQH NDUúÕ DQWLNRU JHOLúHELOPHNWH EX GXUXPGD HWNLQ NHPRGHQHUYDV\RQ LoLQ GL÷HU WLS WRNVLQOHU VÕNOÕNOD WLS ) NXOODQÕOPDNWDGÕU Botulinum toksin, blefarospazmda % 95, spazmodik disfonide % 90, servikal distonide % 85, RURPDQGLEXODU YH HO GLVWRQLOHULQLQ E\N NÕVPÕQGD HWNLQ RODUDN NXOODQÕOPDNWDGÕU (O YHYH\D NDID WUHPRUOX ROJXODUÕQ ¶VLQGHQ ID]ODVÕQGD LúH \DUDPDNWDGÕU Tedavinin komplikasyonu, ilgili sahaya lokalize JoV]ONOH VÕQÕUOÕGÕU gUQH÷LQ EOHIDURVSD]P YH blefaroklonusdan sonra major problem pitoz olabilir (30, 66). Servikal distoni tedavisinde disfaji JHOLúHELOLU dR÷X NRPSOLNDV\RQODU LOH KDIWDGD spontan olarak çözülür (66). $FLO \DNODúÕP $OÕúÕOGÕN \ROODUÕQ GÕúÕQGD RUWD\D oÕNDQ KDILI ERWXOL]P WDEORVX NROD\OÕNOD \DQOÕú WDQÕ DODELOLU %X QHGHQOH DNXW NUDQL\DO VLQLU GLVIRQNVL\RQODUÕQÕQ EXOJX YH VHPSWRPODUÕ RODQ ROJXODUÕQ D\ÕUÕFÕ WDQÕVÕQGD DFLO RODUDN ERWXOL]P PXWODND GúQOPHOLGLU Botulizm de dahil olmak üzere ciddi bir Q|URPXVNOHU KDVWDOÕNOD NDUúÕODúDQ DFLO VHUYLV KHNLPOHULQLQ NOLQLN ER]XOPD\Õ YH PHYFXW NDV JoV]O÷QQ QHGHQLQL DUDúWÕUÕUNHQ |\N IL]LN PXD\HQH YH Q|URORMLN GH÷HUOHQGLUPHGHQ \ROD oÕNDUDN JHQLú WDEDQOÕ D\ÕUÕFÕ WDQÕ ]HULQGH oDOÕúPDODUÕ JHUHNLU (70).
Korunma %HVLQ ]HKLUOHQPHVL ROJXODUÕQÕQ HVDV QHGHQL EHVLQOHUGHNL VSRUODUÕQ JHUPLQH ROPDVÕ YH WRNVLQ UHWLOPHVL ROGX÷X LoLQ EX WU ERWXOL]PGHQ NRUXQPDQÕQ HQ |QHPOL \ROX JÕGDODUGDNL VSRUODUÕQ \RNHGLOPHVL germinasyonun inhibe edilmesi veya preforme haldeki WRNVLQLQ WDKULS
HGLOPHVLGLU %X DPDoODUÕ JHUoHNOHúWLUPHN LoLQ ,VÕ YH\D UDG\DV\RQ X\JXODQDUDN JÕGDODUGDNL VSRUODU WDKULS HGLOHELOLU 7LS A ve B C. botulinum VSRUODUÕ ND\QDPD\D ELUNDo VDDW GD\DQÕNOÕGÕU %X QHGHQOH |]HOOLNOH VX\XQ ND\QDPD QRNWDVÕ GúN RODQ \NVHN UDNÕPOÕ E|OJHOHUGH EHVLQOHU GDKD X]XQ VUH SLúLULOPHOLGLU 'GNO WHQFHUHGH & ÕVÕGD HQ D] GDNLND SLúLULOPHOLGLU 7LS ( C. botulinum VSRUODUÕ ÕVÕ\D GD\DQÕNVÕ]GÕU & GH GDNLNDGD WDKULS ROXUODU *ÕGDODUGDNL VSRUODUÕQ JHUPLQDV\RQXQX |QOHPHN DPDFÕ\OD JÕGDODUÕQ S+ QÕQ GúUOPHVL SLúLUGLNWHQ VRQUD GRQGXUDUDN VDNODQPDVÕ NXUXWXOPDVÕ YH\D WX] úHNHU \D GD VRG\XP QLWULW JLEL LQKLELW|U PDGGHOHULQ HNOHQHUHN LúOHQPHVL YH KD]ÕUODQPDVÕ JHUHNLU 2OXúPXú WRNVLQLQ LQDNWLYH HGLOPHVL LoLQ JÕGDODUÕQ \HQPHGHQ |QFH & GH YH\D & GH GDNLND ÕVÕWÕOPDVÕ JHUHNLU +DILI úLúNLQOHúPLú NRQVHUYH NXWXODUÕQGDNL JD]GD C.
EXOXQDELOPHVL QHGHQL\OH DoÕOPDPDOÕGÕU %R]XOPXú J|]NHQ JÕGDODU WDGÕOPDPDOÕGÕU $÷ÕU KDVWDOÕN JHoLULOPHVLQH UD÷PHQ ERWXOLQXP WRNVLQLQH NDUúÕ LPPQLWH JHOLúPHPHNWHGLU ]LUD UHNXUUHQV YDNDODUÕ ELOGLULOPLúWLU /DERUDWXYDU SHVRQHOL LoLQ GHQH\VHO DúÕODPD oDOÕúPDODUÕ PHYFXWWXU
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Alaskan Eskimo. N Engl J Med 1990; 322: 855. øQ|Q hQLYHUVLWHVL 7ÕS )DNOWHVL Nöroloji ABD 44069 MALATYA Yüklə 177,77 Kb. Dostları ilə paylaş:
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