{"id":24764,"date":"2022-05-23T12:33:27","date_gmt":"2022-05-23T09:33:27","guid":{"rendered":"https:\/\/www.klimikdergisi.org\/?p=24764"},"modified":"2022-06-27T13:30:38","modified_gmt":"2022-06-27T10:30:38","slug":"musta-tularemi-salgini","status":"publish","type":"post","link":"https:\/\/www.klimikdergisi.org\/tr\/2022\/05\/23\/musta-tularemi-salgini\/","title":{"rendered":"Mu\u015f\u2019ta \u0130lk Tularemi Salg\u0131n\u0131: 50 Olgunun De\u011ferlendirilmesi"},"content":{"rendered":"

G\u0130R\u0130\u015e<\/h2>\n

Tularemi,\u00a0Francisella tularensis<\/i>\u2019in neden oldu\u011fu, kuzey yar\u0131m k\u00fcrede g\u00f6r\u00fclen zoonotik bir hastal\u0131kt\u0131r. F. tularensis<\/i> aerobik, h\u00fccre i\u00e7i Gram-negatif bir kokobasildir. Do\u011fada olduk\u00e7a yayg\u0131n bulunur. Bakterinin do\u011fal rezervuarlar\u0131 yabani tav\u015fan, sincap, su ve tarla faresi, kunduz, rakun gibi kemiriciler ve\u00a0 <\/span>geyiklerdir. \u0130nsanlara vekt\u00f6rlerle (kene, sivrisinek), infekte hayvan ya da \u00e7\u0131kart\u0131lar\u0131n\u0131n do\u011frudan temas\u0131yla ve inhalasyon yoluyla bula\u015f\u0131r (1). T\u00fcrkiye\u2019de hastal\u0131\u011f\u0131n en s\u0131k bula\u015fma yolu kontamine su ve besinlerin t\u00fcketimidir (2). Asemptomatik hastal\u0131ktan septik \u015foka kadar gidebilen bu hastal\u0131ktaki klinik farkl\u0131l\u0131k mikroorganizman\u0131n virulans fakt\u00f6rleriyle, giri\u015f yoluyla, sistemik tutulumla ve kona\u011f\u0131n verdi\u011fi ba\u011f\u0131\u015f\u0131kl\u0131k cevab\u0131yla ili\u015fkilidir. <\/i><\/span>\u00dclserogland\u00fcler, gland\u00fcler, ok\u00fclogland\u00fcler, orofarengeal, tifoidal ve pn\u00f6monik form olmak \u00fczere alt\u0131 farkl\u0131 klinik formu vard\u0131r (3). D\u00fcnya genelinde \u00fclserogland\u00fcler en s\u0131k g\u00f6r\u00fclen form olup \u00fclkemizde en s\u0131k g\u00f6r\u00fclen form orofarengealdir (4-6). T\u00fcrkiye\u2019de tularemi epidemileri daha \u00e7ok Marmara, Karadeniz ve \u0130\u00e7 Anadolu b\u00f6lgelerinden bildirilmi\u015ftir (7).<\/p>\n

Daha \u00f6nceki y\u0131llara g\u00f6re 2017-2019 y\u0131llar\u0131 aras\u0131nda Mu\u015f ilinde tularemi olgular\u0131n\u0131n art\u0131\u015f g\u00f6sterdi\u011finin g\u00f6zlemlenmesi \u00fczerine bu \u00e7al\u0131\u015fma planland\u0131. Tularemi \u00f6zellikle birinci basamak sa\u011fl\u0131k kurulu\u015flar\u0131nda akla gelmedik\u00e7e g\u00f6zden ka\u00e7abilen bir hastal\u0131kt\u0131r. Bu hastalara s\u0131kl\u0131kla streptokoksik farenjit tan\u0131s\u0131 koyularak beta-laktam grubu antibiyotikler re\u00e7ete edilir. Bu durum tan\u0131da gecikme, tedavide zorluk ve lenfadenopatilerde (LAP) s\u00fcp\u00fcrasyon nedeniyle cerrahi m\u00fcdahaleye gidilmesine yol a\u00e7abilir. Bu \u00e7al\u0131\u015fmayla tularemi olgular\u0131n\u0131n epidemiyolojik, demografik ve klinik bilgilerini sunarak b\u00f6lgede tularemi fark\u0131ndal\u0131\u011f\u0131n\u0131n art\u0131r\u0131lmas\u0131 ama\u00e7land\u0131. Ayr\u0131ca t\u0131p literat\u00fcr\u00fcne tularemi hastal\u0131\u011f\u0131yla ilgili Mu\u015f\u2019tan ilk kez bir \u00e7al\u0131\u015fma sunulmaktad\u0131r.<\/p>\n

Y\u00d6NTEMLER<\/h2>\n

Ocak 2017 \u2013 Aral\u0131k 2019 tarihleri aras\u0131nda Mu\u015f ilinde g\u00f6r\u00fclen tularemi olgular\u0131, Mu\u015f \u0130l Sa\u011fl\u0131k M\u00fcd\u00fcrl\u00fc\u011f\u00fc Tularemi Hastal\u0131\u011f\u0131 Bilgi Sistemi\u2019nden geriye d\u00f6n\u00fck olarak incelendi. Tularemi \u015f\u00fcphesi olan hastalar\u0131n serumunda F. tularensis<\/i> mikroagl\u00fctinasyon testi (MAT) T\u00fcrkiye Halk Sa\u011fl\u0131\u011f\u0131 Kurumu Ba\u015fkanl\u0131\u011f\u0131 Ulusal Tularemi Referans Laboratuvar\u0131\u2019nda \u00e7al\u0131\u015f\u0131ld\u0131. Ate\u015f, bo\u011faz a\u011fr\u0131s\u0131 ve LAP gibi tularemiyle uyumlu bulgular\u0131 olan ve F. tularensis<\/i> MAT \u2265 1\/160 ya da en az iki hafta arayla bak\u0131lan antikor titresinde 4 kat art\u0131\u015f saptanan olgular kesin olgu olarak kabul edildi. \u00c7al\u0131\u015fmaya kesinle\u015fmi\u015f olgular dahil edildi; bunlar\u0131n epidemiyolojik, demografik ve klinik bilgileri daha \u00f6nceden haz\u0131rlanan formlara kaydedildi. Bu \u00e7al\u0131\u015fmada ate\u015f ve\/veya bo\u011faz a\u011fr\u0131s\u0131 \u015fikayeti olan hastada tonsillit, farenjit, a\u011f\u0131zda \u00fclser olu\u015fmu\u015fsa ve servikal LAP geli\u015fmi\u015fse tulareminin orofarengeal formu olarak kabul edildi. Sadece ate\u015f ve\/veya LAP\u2019\u0131 olan hastalar ise gland\u00fcler form olarak de\u011ferlendirildi.<\/p>\n

BULGULAR<\/h2>\n
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Tablo 1.<\/strong> Tularemi Olgular\u0131nda Saptanan Mikroagl\u00fctinasyon Titre Da\u011f\u0131l\u0131m\u0131<\/p><\/div>\n

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Tablo 2.<\/strong> Elli Tularemi Olgusunun Semptom ve Bulgular\u0131n\u0131n Oran\u0131<\/p><\/div>\n

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Tablo 3.<\/strong> Tulareminin Olas\u0131 Risk Fakt\u00f6rlerinin Oran\u0131<\/p><\/div>\n

Tularemi \u015f\u00fcphesiyle referans laboratuvar\u0131na serum \u00f6rne\u011fi g\u00f6nderilen 87 hastan\u0131n 50 (%57.4)\u2019sinde\u00a0F. tularensis<\/i>\u00a0MAT 1\/160 titre ve \u00fczerinde saptand\u0131 (Tablo 1). Tularemi olgular\u0131n\u0131n %52\u2019si erkek, ya\u015f ortalamas\u0131 23\u2019t\u00fc; 22 (%44) hasta ise 18 ya\u015f ve alt\u0131ndayd\u0131. Hastalar\u0131n \u015fikayetlerinin ba\u015flang\u0131c\u0131ndan sonra hastaneye ba\u015fvuru s\u00fcresi ortalama 23 g\u00fcnd\u00fc (3-79). LAP (%100), bo\u011faz a\u011fr\u0131s\u0131 (%78), halsizlik (%66) ve i\u015ftahs\u0131zl\u0131k (%60) hastal\u0131\u011f\u0131n ba\u015flang\u0131c\u0131nda en s\u0131k rastlanan belirti ve bulgulard\u0131 (Tablo 2). <\/span><\/p>\n

\"\"<\/a>

\u015eekil 1.<\/strong> Mu\u015f ilindeki tularemi olgular\u0131n\u0131n aylara g\u00f6re da\u011f\u0131l\u0131m\u0131.<\/p><\/div>\n

Hastalar\u0131n %94\u2019\u00fc k\u0131rsal b\u00f6lgede ya\u015famaktayd\u0131; %82 (n=41)\u2019si Mu\u015f\u2019un Bulan\u0131k il\u00e7esindendi. \u0130\u00e7me suyu olarak \u015febeke suyu kullananlar\u0131n oran\u0131 %84 olup geriye kalanlar kuyu suyu kullan\u0131yordu; \u015febeke suyu klorlanma oran\u0131 hasta beyan\u0131na g\u00f6re %30\u2019du. Mahalle halk\u0131nda %46 oran\u0131nda benzer hastal\u0131k vard\u0131. Y\u0131llara g\u00f6re da\u011f\u0131l\u0131m\u0131na bak\u0131ld\u0131\u011f\u0131nda; olgular\u0131n 17\u2019si 2017 y\u0131l\u0131nda, 20\u2019si 2018 y\u0131l\u0131nda ve 13\u2019\u00fc 2019 y\u0131l\u0131nda g\u00f6r\u00fcld\u00fc. Haziran 2017- Kas\u0131m 2017 ve Eyl\u00fcl 2018 \u2013 Nisan 2019 aras\u0131nda iki epidemi izlendi (\u015eekil 1). Mevsimsel da\u011f\u0131l\u0131m\u0131na bakt\u0131\u011f\u0131m\u0131zda ise olgular\u0131n \u00e7o\u011fu (%76) sonbahar ve k\u0131\u015f mevsiminde g\u00f6r\u00fcld\u00fc (Tablo 3).<\/p>\n

Olgular\u0131n 45 (%90)\u2019inde orofarengeal form, 5 (%10)\u2019inde gland\u00fcler form g\u00f6r\u00fcld\u00fc. Orofarengeal form g\u00f6r\u00fclen hastalar\u0131n hepsinin tek tarafl\u0131 servikal LAP\u2019\u0131 vard\u0131. Ate\u015f ve halsizli\u011fin yan\u0131 s\u0131ra gland\u00fcler form g\u00f6r\u00fclen hastalar\u0131n 2\u2019sinin inguinal, 2\u2019sinin epitroklear ve 1\u2019inin aksillar LAP\u2019\u0131 vard\u0131. Bu hastalar\u0131n bir di\u011fer ortak \u00f6zellikleri gen\u00e7 eri\u015fkin erkek olmalar\u0131 ve Mu\u015f Karasu Nehri mevkiinde s\u0131\u011f suda bal\u0131k tutma ve\/veya y\u00fczme \u00f6yk\u00fclerinin bulunmas\u0131yd\u0131. Bu durum saptand\u0131ktan sonra belirtilen yerdeki s\u0131\u011f suyun \u00e7e\u015fitli noktalar\u0131ndan al\u0131nan su \u00f6rnekleri referans laboratuvar\u0131na g\u00f6nderildi. Su \u00f6rneklerinin k\u00fclt\u00fcr\u00fcnde F. tularensis<\/i> <\/i>g\u00f6sterilemedi ancak al\u0131nan t\u00fcm \u00f6rneklerde Escherichia coli<\/i> \u00fcredi.<\/p>\n

Tularemi tan\u0131s\u0131 koyulan hastalar\u0131n 28\u2019ine streptomisin 2 x 1 gr IM (10 g\u00fcn) ve 22\u2019sine siprofloksasin 2 x 750 mg oral (14 g\u00fcn) tedavi ba\u015fland\u0131. Hastalarda mortalite izlenmedi. Ayr\u0131ca geriye d\u00f6n\u00fck kay\u0131tlar incelendi\u011finde Mu\u015f ilinde 2011-2016 y\u0131llar\u0131 aras\u0131nda toplam 33 tularemi olgusu saptand\u0131\u011f\u0131 g\u00f6r\u00fcld\u00fc; 2019 Kas\u0131m ay\u0131ndan bu yana da b\u00f6lgede herhangi bir tularemi olgusuna rastlanmam\u0131\u015ft\u0131r.<\/p>\n

\u0130RDELEME<\/h2>\n

\u00c7al\u0131\u015fmam\u0131zda, T\u00fcrkiye\u2019nin Mu\u015f ilinden tularemi epidemileri sunuldu. 1937 y\u0131l\u0131nda Tatvan, 2004-2005 y\u0131llar\u0131 aras\u0131nda Kars\u2019tan bildirilen olgulardan (1, 8) sonra olgular\u0131n benzer kaynaktan oldu\u011fu bir tularemi salg\u0131n\u0131 b\u00f6lgeden bildirilmemi\u015f olup \u00e7al\u0131\u015fma bu y\u00f6n\u00fcyle \u00f6nem ta\u015f\u0131maktad\u0131r. Mu\u015f ilinde son 3 y\u0131lda (2017-2019) \u00f6nceki y\u0131llara g\u00f6re tularemi tan\u0131s\u0131 alan olgu say\u0131s\u0131 olduk\u00e7a fazlayd\u0131. Olgular\u0131n 2017-2019 y\u0131llar\u0131 aras\u0131nda iki kez art\u0131\u015f g\u00f6sterdi\u011fi ve bu zaman dilimlerinde ba\u015fvuran hastalar\u0131n ayn\u0131 b\u00f6lgeden oldu\u011fu g\u00f6r\u00fcld\u00fc. \u00d6zden ve arkada\u015flar\u0131 (9) da 2018 y\u0131l\u0131nda Do\u011fu Anadolu B\u00f6lgesi\u2019ndeki illerden kendi merkezlerine ba\u015fvuran 26 hastan\u0131n 4\u2019\u00fcn\u00fcn Mu\u015f\u2019tan geldi\u011fini belirtmi\u015ftir.<\/p>\n

T\u00fcrkiye\u2019de tulareminin en s\u0131k bula\u015fma yolu kemiriciler taraf\u0131ndan kontamine edilmi\u015f su ve besinlerin t\u00fcketimidir (5-7, 10-12). Bu \u00e7al\u0131\u015fmada \u015febeke suyunun depoland\u0131\u011f\u0131 depolardan inceleme yap\u0131lmad\u0131 ancak hastalar\u0131n girdi\u011fi s\u0131\u011f sudan \u00f6rnekler al\u0131nd\u0131. Daha \u00f6nceki epidemilerde su kaynaklar\u0131ndan genellikle F. tularensis<\/i> izole edilememi\u015f ancak PCR y\u00f6ntemiyle varl\u0131\u011f\u0131 g\u00f6sterilmi\u015ftir. G\u00fcrcan ve arkada\u015flar\u0131 (13), \u00fclkemizdeki alt t\u00fcr\u00fcn F. tularensis<\/i> <\/i>subsp<\/span>. <\/i><\/span>holarctica<\/i> <\/i>(tip B) oldu\u011funu saptam\u0131\u015ft\u0131r. Hastalar\u0131n ge\u00e7 ba\u015fvurmas\u0131 ve epidemiyolojik incelemelerin gecikmesinin sularda birka\u00e7 ay canl\u0131 kalabilen F. tularensis<\/i>\u2019in izole edilememesine neden olabilece\u011fi bildirilmi\u015ftir (14). Kocaeli\u2019nden bildirilen su kaynakl\u0131 bir salg\u0131n incelemesinde, uygun miktarda al\u0131nan \u00f6rneklerde gerekli teknikler uyguland\u0131ktan sonra F. tularensis<\/i> PCR testinin yap\u0131lmas\u0131n\u0131n \u00f6nemi vurgulanm\u0131\u015ft\u0131r (15).<\/p>\n

Olgular\u0131n ikinci kez artmas\u0131ndan sonra epideminin yo\u011fun izlendi\u011fi Bulan\u0131k il\u00e7esinde i\u00e7me sular\u0131n\u0131n klorlanmas\u0131nda aksakl\u0131klar oldu\u011fu belirlendi; bir d\u00f6nem \u015febeke suyuna, klorlama yap\u0131lmayan bir kaynak suyunun ba\u011fland\u0131\u011f\u0131 tespit edildi. Su depolar\u0131n\u0131n temizlenip klorlama i\u015flemlerinin d\u00fczenli yap\u0131l\u0131r hale gelmesinden sonra tularemi tan\u0131s\u0131 alan hasta say\u0131s\u0131nda belirgin azalma oldu\u011fu g\u00f6r\u00fcld\u00fc. En son olgu 2019 Kas\u0131m ay\u0131nda g\u00f6r\u00fclm\u00fc\u015f olup 2020 y\u0131l\u0131nda Mu\u015f\u2019ta tularemi olgusuna rastlanmad\u0131. Bu nedenle bu \u00e7al\u0131\u015fmada olgular\u0131n \u00e7o\u011funda bula\u015fma yolunun ayn\u0131 su deposundaki klorlanmam\u0131\u015f kontamine su t\u00fcketimi oldu\u011fu d\u00fc\u015f\u00fcn\u00fcld\u00fc. Ayr\u0131ca epidemiyolojik veriler, k\u0131rsal ya\u015fam alan\u0131nda bulunma, kemiricilerin varl\u0131\u011f\u0131, do\u011fal kaynak sular\u0131n\u0131n t\u00fcketilmesi ve bu sulara girme gibi davran\u0131\u015flar Mu\u015f\u2019ta g\u00f6r\u00fclen tulareminin su kaynakl\u0131 oldu\u011funu desteklemektedir.<\/p>\n

Olgular\u0131n ortalama ya\u015f\u0131 di\u011fer benzer \u00e7al\u0131\u015fmalara g\u00f6re d\u00fc\u015f\u00fckt\u00fc (4-6, 9, 16-18). Bunun nedeni 18 ya\u015f ve alt\u0131 hasta oran\u0131n\u0131n (%44) daha fazla olmas\u0131 olabilir (19, 20<\/span>). \u00dclkemizdeki benzer \u00e7al\u0131\u015fmalardaki kad\u0131n cinsiyet hakimiyetine kar\u015f\u0131n (5, 6, 16-19, 21) bu \u00e7al\u0131\u015fmada erkek cinsiyet hakimdi. Erkeklerin b\u00f6lgede k\u0131rsal alanda aktif olmas\u0131, hayvanc\u0131l\u0131kla ve a\u011f bal\u0131k\u00e7\u0131l\u0131\u011f\u0131yla u\u011fra\u015fmalar\u0131 hastal\u0131\u011fa yakalanma risklerini art\u0131rm\u0131\u015f olabilir.<\/p>\n

LAP, hastalar\u0131n t\u00fcm\u00fcnde izlendi; bo\u011faz a\u011fr\u0131s\u0131 ve\/veya tonsillit hastalar\u0131n %78\u2019inde e\u015flik ediyordu ancak ilk ba\u015fvuruda ate\u015f hastalar\u0131n yar\u0131s\u0131ndan az\u0131nda g\u00f6r\u00fcld\u00fc. \u00dclkemizden bildirilen di\u011fer olgularda oldu\u011fu gibi hastalarda en s\u0131k orofarengeal form g\u00f6r\u00fcld\u00fc. T\u00fcrkiye\u2019den bildirilen en fazla hasta say\u0131l\u0131 olgu serisinde %83 orofarengeal form g\u00f6r\u00fclm\u00fc\u015f; LAP %85, bo\u011faz a\u011fr\u0131s\u0131 %58 ve ate\u015f %66 oran\u0131nda saptanm\u0131\u015ft\u0131r (22). \u00dclkemizdeki di\u011fer tularemi \u00e7al\u0131\u015fmalar\u0131nda da ate\u015f g\u00f6r\u00fclme oran\u0131 %58-%94 aras\u0131nda de\u011fi\u015fmektedir (4, 5, 9, 16-19, 21). Samsun\u2019dan 2019 y\u0131l\u0131nda bildirilen bir \u00e7al\u0131\u015fmada da \u00e7al\u0131\u015fmam\u0131zla benzer olarak hastalar\u0131n ba\u015fvuru s\u00fcresi ortalama 23.4 g\u00fcn olarak saptanm\u0131\u015f; ba\u015fvuruda ate\u015f g\u00f6r\u00fclme oran\u0131 %18.8 ile daha d\u00fc\u015f\u00fck bulunmu\u015ftur (6). Hastalar\u0131n ge\u00e7 ba\u015fvurmas\u0131, tan\u0131da gecikmeler nedeniyle sadece LAP ile ba\u015fvurabilecekleri, ate\u015fin g\u00f6r\u00fclmeyebilece\u011fi unutulmamal\u0131d\u0131r. Tularemide, hastal\u0131\u011fa \u00f6zg\u00fc olmayan halsizlik, i\u015ftahs\u0131zl\u0131k gibi \u015fikayetler de yayg\u0131n olarak g\u00f6r\u00fclebilir.<\/span><\/p>\n

Tularemi epidemileri mevsimsel da\u011f\u0131l\u0131m g\u00f6sterir. \u00c7al\u0131\u015fmam\u0131zda da olgular\u0131n 3 y\u0131l i\u00e7inde iki kez art\u0131\u015f g\u00f6sterdi\u011fi ve s\u0131kl\u0131kla sonbahar ve k\u0131\u015f aylar\u0131nda izlendi\u011fi g\u00f6r\u00fcld\u00fc.\u00a0 <\/span>F. tularensis<\/i> <\/i>subsp. <\/i>holarctica<\/i> <\/i>genellikle sonbahar ve k\u0131\u015f aylar\u0131nda epidemiler yapar. T\u00fcrkiye\u2019de y\u0131l boyunca olgular g\u00f6r\u00fclmekle birlikte sonbahar\u0131n ge\u00e7 d\u00f6neminde (Kas\u0131m ay\u0131) ve k\u0131\u015f aylar\u0131nda art\u0131\u015f g\u00f6sterir, bahar ve yaz aylar\u0131na do\u011fru gittik\u00e7e azal\u0131r (20).<\/p>\n

\u00c7al\u0131\u015fmam\u0131zda olgular\u0131n sadece epidemiyolojik ve klinik bilgilerine yer verilmi\u015f olup laboratuvar bulgular\u0131 ve tedavi sonras\u0131 durumlar\u0131 hakk\u0131nda ayr\u0131nt\u0131l\u0131 bilgilere yer verilemedi. Klasik mikrobiyolojik y\u00f6ntemlerle etken g\u00f6sterilemedi\u011finden salg\u0131n incelemesinde \u015f\u00fcphelenilen t\u00fcm su kaynaklar\u0131ndan etyolojik inceleme yap\u0131lamad\u0131. Bunlar \u00e7al\u0131\u015fman\u0131n k\u0131s\u0131tl\u0131l\u0131klar\u0131d\u0131r.<\/p>\n

\u00c7al\u0131\u015fmam\u0131zda, \u00fc\u00e7 y\u0131l i\u00e7inde g\u00f6r\u00fclen iki tularemi epidemisi ve alt\u0131 sporadik olgunun verileri sunuldu. Tulareminin \u00e7ocukluk \u00e7a\u011f\u0131nda da g\u00f6r\u00fcld\u00fc\u011f\u00fc unutulmamal\u0131, \u00f6zellikle sonbahar ve k\u0131\u015f mevsiminde LAP, bo\u011faz a\u011fr\u0131s\u0131, halsizlik, i\u015ftahs\u0131zl\u0131k, ate\u015f \u015fikayetleriyle gelen t\u00fcm ya\u015f grubu hastalarda akla gelmelidir. Atipik yerle\u015fimli LAP\u2019\u0131 olan hastalarda kontamine sularla temas sorgulanmal\u0131, ayr\u0131nt\u0131l\u0131 epidemiyolojik \u00f6yk\u00fc al\u0131nmal\u0131d\u0131r. Erken tan\u0131nmas\u0131 komplikasyonlar\u0131n geli\u015fmesini \u00f6nleme a\u00e7\u0131s\u0131ndan \u00f6nemlidir. Endemik alanlarda hekimlerin kendi b\u00f6lgelerindeki tularemi olgular\u0131n\u0131n y\u0131ll\u0131k ve mevsimsel da\u011f\u0131l\u0131m\u0131n\u0131 bilmesi hastal\u0131\u011f\u0131n tan\u0131nmas\u0131nda yol g\u00f6sterici olacakt\u0131r. Olgu say\u0131s\u0131nda art\u0131\u015f olan b\u00f6lgelerde gerekli incelemelerin yap\u0131lmas\u0131n\u0131n ve al\u0131nacak sanitasyon \u00f6nlemlerinin olas\u0131 salg\u0131nlar\u0131n \u00f6n\u00fcne ge\u00e7mede olduk\u00e7a \u00f6nemli oldu\u011fu unutulmamal\u0131d\u0131r.<\/p>\n","protected":false},"excerpt":{"rendered":"

G\u0130R\u0130\u015e Tularemi,\u00a0Francisella tularensis\u2019in neden oldu\u011fu, kuzey yar\u0131m k\u00fcrede g\u00f6r\u00fclen zoonotik bir hastal\u0131kt\u0131r. F. tularensis aerobik, h\u00fccre i\u00e7i Gram-negatif bir kokobasildir. Do\u011fada olduk\u00e7a yayg\u0131n bulunur. Bakterinin do\u011fal rezervuarlar\u0131 yabani tav\u015fan, sincap, su ve tarla faresi, kunduz, rakun gibi kemiriciler ve\u00a0 geyiklerdir. \u0130nsanlara vekt\u00f6rlerle (kene, sivrisinek), infekte hayvan ya da \u00e7\u0131kart\u0131lar\u0131n\u0131n do\u011frudan temas\u0131yla ve inhalasyon yoluyla bula\u015f\u0131r […]<\/p>\n","protected":false},"author":4,"featured_media":24996,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"footnotes":""},"categories":[5129],"tags":[5440,5438,5439,5373,3174],"class_list":["post-24764","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-ozgun-arastirma","tag-francisella-tularensis-2","tag-mus","tag-orofarengeal-form","tag-salgin","tag-tularemi"],"acf":[],"_links":{"self":[{"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/posts\/24764","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/users\/4"}],"replies":[{"embeddable":true,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/comments?post=24764"}],"version-history":[{"count":3,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/posts\/24764\/revisions"}],"predecessor-version":[{"id":25132,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/posts\/24764\/revisions\/25132"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/media\/24996"}],"wp:attachment":[{"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/media?parent=24764"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/categories?post=24764"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/tags?post=24764"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}