{"id":25478,"date":"2022-09-28T11:00:36","date_gmt":"2022-09-28T08:00:36","guid":{"rendered":"https:\/\/www.klimikdergisi.org\/?p=25478"},"modified":"2022-09-28T12:35:23","modified_gmt":"2022-09-28T09:35:23","slug":"kedi-tirmalama-hastaligi-ve-nororetinit","status":"publish","type":"post","link":"https:\/\/www.klimikdergisi.org\/tr\/2022\/09\/28\/kedi-tirmalama-hastaligi-ve-nororetinit\/","title":{"rendered":"Kedi T\u0131rmalama Hastal\u0131\u011f\u0131\u2019n\u0131n Nadir G\u00f6r\u00fclen Formu : N\u00f6roretinitli Bir Olgu Sunumu ve T\u00fcrkiye\u2019den Bildirilen Olgular\u0131n Derlemesi"},"content":{"rendered":"

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

Bartonella henselae, <\/i>Gram-negatif, h\u00fccre i\u00e7i, oksidaz negatif, aerobik bir basil olup kedi t\u0131rmalama hastal\u0131\u011f\u0131 etkeni olarak kar\u015f\u0131m\u0131za \u00e7\u0131kmaktad\u0131r. Bu bakterinin ana rezervuar\u0131 kediler olup kedi temas\u0131 hastal\u0131\u011f\u0131n ba\u015fl\u0131ca bula\u015f yolu olarak g\u00f6r\u00fclmektedir (1).<\/p>\n

Kedi t\u0131rmalama hastal\u0131\u011f\u0131nda tipik bulgu; kutan\u00f6z inok\u00fclasyonu takip eden 1-8 hafta sonras\u0131nda\u00a0 <\/span>lenfadenopati geli\u015fmesi olup nadiren n\u00f6rolojik tutulum, g\u00f6z tutulumu, osteomyelit, atipik pn\u00f6moni ve endokardit gibi farkl\u0131 klinik tablolar da ortaya \u00e7\u0131kabilmektedir (2).\u00a0<\/span><\/p>\n

Bu \u00e7al\u0131\u015fmada, Bartonella henselae<\/i>\u2019ye ba\u011fl\u0131 olarak geli\u015fen n\u00f6roretinit tan\u0131s\u0131 ile takip ve tedavi edilen bir olgu sunuldu. Ayr\u0131ca \u00fclkemizden bildirilen olgular g\u00f6zden ge\u00e7irildi.<\/p>\n

OLGU<\/h2>\n
\"\"<\/a>

Resim 1.<\/strong>Hastan\u0131n ba\u015fvurdu\u011fu esnadaki fundus g\u00f6r\u00fcnt\u00fcs\u00fc: Optik sinir ba\u015f\u0131nda siliklik, optik sinir sa\u011f \u00fcst k\u00f6\u015fesinde n\u00f6roretinite ba\u011fl\u0131 inflamatuar kabar\u0131kl\u0131k se\u00e7ilebilmektedir.Optik sinirin sa\u011f kenar\u0131ndan foveaya \u0131\u015f\u0131nsal tarzda uzanan mak\u00fcler y\u0131ld\u0131z g\u00f6r\u00fcn\u00fcm\u00fc izlenmektedir.<\/p><\/div>\n

\"\"<\/a>

Resim 2.<\/strong>Tedavi sonras\u0131 fundus g\u00f6r\u00fcnt\u00fcs\u00fc: Sol g\u00f6z\u00fcn tedavisi sonras\u0131nda optik sinir kabar\u0131kl\u0131\u011f\u0131n\u0131n geriledi\u011fi, mak\u00fcler y\u0131ld\u0131z\u0131n ortadan kalkt\u0131\u011f\u0131 g\u00f6r\u00fclmektedir. Peripapiller alanda eksuda kal\u0131nt\u0131lar\u0131n\u0131n azald\u0131\u011f\u0131 ancak halen mevcut oldu\u011fu g\u00f6r\u00fclmektedir.<\/p><\/div>\n

D\u0131\u015f merkeze, sa\u011f g\u00f6zde ani ba\u015flayan g\u00f6rme kayb\u0131 nedeniyle ba\u015fvuran 46 ya\u015f\u0131nda erkek hasta, 32 mg metilprednizolon tedavisi ile taburcu edilmi\u015f; \u015fikayetinin gerilememesi \u00fczerine hastanemiz G\u00f6z Poliklini\u011fi\u2019ne ba\u015fvurmu\u015ftur. Markette depo \u00e7al\u0131\u015fan\u0131 olan hastan\u0131n kedi taraf\u0131ndan t\u0131rmalanma \u00f6yk\u00fcs\u00fc bulunmamaktayd\u0131. Muayenesinde lenfadenopati saptanmayan hastada n\u00f6roretinit ile uyumlu olan optik sinir \u00fcst yar\u0131s\u0131nda kabar\u0131kl\u0131k, peripapiller hemoraji ve mak\u00fcler y\u0131ld\u0131z g\u00f6r\u00fcn\u00fcm\u00fc mevcuttu (Resim 1). Laboratuvar tetkiklerinde; l\u00f6kosit say\u0131s\u0131 9500\/mm3<\/sup><\/span>, n\u00f6trofil y\u00fczdesi %54, hemoglobin 16.9g\/dl, trombosit say\u0131s\u0131 281 000\/mm3<\/sup>, sedimantasyon 4 mm\/saat ve CRP<0.2mg\/dl idi. Anti-HIV, \u201crapid plasma reagin\u201d (RPR), Treponema pallidum<\/i> indirekt hemaglutinasyon (IHA), toksoplazma imm\u00fcnoglob\u00fclin (Ig) M\/G, CMV IgM\/G ve Lyme IgM\/G seroloji sonu\u00e7lar\u0131 negatif olarak saptand\u0131. \u0130ki y\u00f6nl\u00fc akci\u011fer grafisi normal, BCG (Bacillus Calmette-Gu\u00e9rin) a\u015f\u0131s\u0131 skar\u0131 olan hastada t\u00fcberk\u00fclin deri testinde end\u00fcrasyon 12 mm olarak \u00f6l\u00e7\u00fcld\u00fc. Yap\u0131lan tetkiklerde Bartonella<\/i> IgM:1\/320 (+) ve IgG:1\/320(+) olarak sonu\u00e7land\u0131. Sa\u011f g\u00f6zdeki g\u00f6rme azl\u0131\u011f\u0131 d\u0131\u015f\u0131nda \u015fikayeti bulunmayan ve steroid tedavisi sonras\u0131 g\u00f6rme bulgular\u0131nda bir miktar d\u00fczelme olan hasta, Bartonella<\/i> n\u00f6roretiniti olarak de\u011ferlendirildi. Doksisiklin 2x100mg PO tedavisi ba\u015fland\u0131. Doksisiklin tedavisinin alt\u0131nc\u0131 haftas\u0131nda Ankara Halk Sa\u011fl\u0131\u011f\u0131 Kurumu Bula\u015f\u0131c\u0131 Hastal\u0131klar\u0131 Birimi\u2019ne Bartonella henselae<\/i> IgG g\u00f6nderildi; tetkik 1\/64(+) olarak sonu\u00e7land\u0131. G\u00f6rme bulgular\u0131\u00a0 <\/span>belirgin olarak d\u00fczelen hastan\u0131n tedavisi sekiz haftaya tamamlanarak kesildi. Tedavi s\u00fcrecinde g\u00f6rme keskinli\u011fi artan olgunun g\u00f6z muayenesinde n\u00f6roretinit tablosu geriledi, mak\u00fcler y\u0131ld\u0131z g\u00f6r\u00fcn\u00fcm\u00fc ortadan kalkt\u0131 (Resim 2).\u00a0<\/span><\/p>\n

L\u0130TERAT\u00dcR \u0130NCELEMES\u0130: T\u00dcRK\u0130YE VER\u0130LER\u0130<\/h2>\n
\"\"<\/a>

Tablo 1.<\/strong>Kedi T\u0131rmalama Hastal\u0131\u011f\u0131 ve N\u00f6roretinit Tablosu ile Seyreden T\u00fcrkiye\u2019den Bildirilmi\u015f Olgu Raporlar\u0131<\/p><\/div>\n

T\u00fcrkiye\u2019den bildirilen, kedi t\u0131rmalama hastal\u0131\u011f\u0131 ve n\u00f6roretinit tablosu ile seyreden olgu sunumlar\u0131 incelendi\u011finde s\u0131n\u0131rl\u0131 say\u0131da yay\u0131na ula\u015f\u0131lm\u0131\u015ft\u0131r (Tablo 1). Cevher ve arkada\u015flar\u0131n\u0131n (3) \u00e7al\u0131\u015fmas\u0131nda; ciddi g\u00f6rme kayb\u0131 ile ba\u015fvuran, muayenesinde papil\u00f6dem ile birlikte mak\u00fcler y\u0131ld\u0131z bulunan, d\u00f6rt hafta s\u00fcre ile oral doksisiklin ve rifampisin tedavisi verilen 14 ya\u015f\u0131nda bir olgu sunulmu\u015ftur. Ak ve arkada\u015flar\u0131n\u0131n (4) \u00e7al\u0131\u015fmas\u0131nda da;\u00a0 <\/span>benzer \u015fekilde acil servise tek tarafl\u0131 ani geli\u015fen g\u00f6rme kayb\u0131 ile ba\u015fvuran, muayenesinde optik diskte belirginle\u015fmeyle birlikte mak\u00fcler \u00f6dem ve splinter hemoraji saptanan 25 ya\u015f\u0131nda bir erkek hasta sunulmu\u015ftur. Saatci ve arkada\u015flar\u0131n\u0131n (5) \u00e7al\u0131\u015fmas\u0131nda sunulan olgu ise, tek tarafl\u0131 n\u00f6roretinit tablosu ile birlikte servikal lenfadenopatisi bulunan ve di\u011fer olgulardan farkl\u0131 olarak bir ay boyunca trimetoprim-sulfametoksazol (2x 800\/160mg PO) tedavisi ile izlenen bir hastad\u0131r.\u00a0<\/span><\/p>\n

Oray ve arkada\u015flar\u0131 (6); g\u00f6z tutulumu ile seyreden serolojik test sonu\u00e7lar\u0131 ile birlikte kedi t\u0131rmalama hastal\u0131\u011f\u0131 tan\u0131s\u0131 alm\u0131\u015f toplam 10 olguyu incelemi\u015f olup d\u00f6rt g\u00f6zde n\u00f6roretinit, bir g\u00f6zde n\u00f6roretinite sekonder lokalize eksudatif retina dekolman\u0131, iki g\u00f6zde optik n\u00f6ropati, alt\u0131 g\u00f6zde retinal infiltratlar, bir g\u00f6zde retinokoroidit, \u00fc\u00e7 g\u00f6zde retinal arter dal t\u0131kan\u0131kl\u0131\u011f\u0131 ve bir g\u00f6zde endoftalmi saptam\u0131\u015ft\u0131r. Kedi temas\u0131 hikayesi 10 hastan\u0131n 9\u2019unda mevcuttur; t\u00fcm hastalarda Bartonella henselae<\/i> Ig M ve\/veya G pozitifli\u011fi saptand\u0131\u011f\u0131 bildirilmi\u015ftir. Olgular\u0131n fizik muayene bulgular\u0131na bak\u0131ld\u0131\u011f\u0131nda toplam \u00fc\u00e7 hastada mak\u00fcler y\u0131ld\u0131z, bir hastada preretinal hemoraji, bir hastada papil\u00f6dem ile birlikte iki hastada optik disk infiltrasyonu saptand\u0131\u011f\u0131 g\u00f6sterilmi\u015ftir.\u00a0<\/span><\/p>\n

\u00dclkemizde yap\u0131lan bir di\u011fer \u00e7al\u0131\u015fmada ise olgumuzun \u00f6zelliklerine benzer \u015fekilde kedi t\u0131rmalamas\u0131 hikayesinin yan\u0131 s\u0131ra sistemik bulgular saptanmayan toplam 3 n\u00f6roretinit olgusu sunulmu\u015ftur. G\u00f6z bulgular\u0131 olarak mak\u00fcler y\u0131ld\u0131z ve yayg\u0131n papillit tablosu hastalar\u0131n hepsinde mevcut olup bir hastada \u00f6n \u00fcveit ve vitrit tablosu bildirilmi\u015ftir (7).\u00a0<\/span><\/p>\n

Di\u011fer \u00e7al\u0131\u015fmalardan farkl\u0131 olarak, Eiger-Moscovich ve arkada\u015flar\u0131 (8) i\u00e7erisinde \u00fclkemizden Bartonella henselae<\/i> infeksiyonu tan\u0131l\u0131 g\u00f6z tutulumlu olgular\u0131n da bulundu\u011fu retinal arter t\u0131kan\u0131kl\u0131\u011f\u0131 saptanan toplam alt\u0131 hastan\u0131n \u00fc\u00e7\u00fcnde ek olarak n\u00f6roretinit tablosu bulundu\u011funu bildirmi\u015ftir (8).\u00a0<\/span><\/p>\n

\u0130RDELEME<\/h2>\n

Kedi t\u0131rmalama hastal\u0131\u011f\u0131, genellikle b\u00f6lgesel lenfadenopati ile karakterize bir zoonotik hastal\u0131kt\u0131r. Bu olgu sunumu; n\u00f6roretinit tan\u0131s\u0131yla takip edilen hastalarda tipik tutuluma oranla daha az s\u0131kl\u0131kta g\u00f6r\u00fclmesine ra\u011fmen kedi t\u0131rm\u0131\u011f\u0131 hastal\u0131\u011f\u0131n\u0131n tek ba\u015f\u0131na g\u00f6z tutulumuyla da seyredebilece\u011fini vurgulamaktad\u0131r.<\/p>\n

Mabra ve arkada\u015flar\u0131 (9), kedi t\u0131rm\u0131\u011f\u0131 hastal\u0131\u011f\u0131nda olgular\u0131n yakla\u015f\u0131k %4.4\u2019\u00fcnde g\u00f6z bulgular\u0131n\u0131n saptand\u0131\u011f\u0131n\u0131 bildirmi\u015ftir. Kedi t\u0131rmalama hastal\u0131\u011f\u0131 g\u00f6z bulgular\u0131 incelendi\u011finde; Parinaud ok\u00fcloglanduler sendromu, n\u00f6roretinit, multifokal retinit, \u00fcveit, retina dekolman\u0131, retinal ven t\u0131kan\u0131kl\u0131\u011f\u0131 gibi farkl\u0131 tablolar kar\u015f\u0131m\u0131za \u00e7\u0131kmaktad\u0131r. G\u00f6z tutulumu bulunan kedi t\u0131rm\u0131\u011f\u0131 tan\u0131s\u0131 ile takip edilen toplam 86 hastan\u0131n incelendi\u011fi bir \u00e7al\u0131\u015fmada, en s\u0131k bulgu optik disk \u00f6demi (%88) olarak saptanm\u0131\u015ft\u0131r; bu olgular\u0131n %64\u2019\u00fcn\u00fcn ba\u015fvuruda, %15\u2019inin ise takip s\u00fcrecinde n\u00f6roretinit olarak de\u011ferlendirildi\u011fi belirtilmi\u015ftir. Ayn\u0131 \u00e7al\u0131\u015fmada incelenen olgular\u0131n %40\u2019\u0131nda optik sinir lezyonu, %36\u2019s\u0131nda \u00fcveit, %33\u2019\u00fcnde optik n\u00f6ropati ve %7\u2019sinde retinal damar t\u0131kan\u0131kl\u0131\u011f\u0131 saptanm\u0131\u015ft\u0131r (10).<\/p>\n

\u00dclkemizden bildirilmi\u015f olan olgu raporlar\u0131 incelendi\u011finde, a\u011f\u0131rl\u0131kl\u0131 olarak lenfadenopati ile seyreden ve tipik formla uyumlu olan olgular\u0131n \u00f6nemli bir k\u0131sm\u0131nda kedi temas\u0131 bulundu\u011fu g\u00f6r\u00fclmektedir (11). Literat\u00fcrden farkl\u0131 olarak \u00e7al\u0131\u015fmam\u0131za konu olan olguda bilinen bir kedi temas\u0131 \u00f6yk\u00fcs\u00fc yoktu ve lenfadenopati tablosu saptanmad\u0131; bu durum hastal\u0131\u011f\u0131n tan\u0131s\u0131n\u0131 g\u00fc\u00e7le\u015ftirmi\u015f olup n\u00f6roretinitin ay\u0131r\u0131c\u0131 tan\u0131s\u0131nda klinik \u015f\u00fcphe ve g\u00f6z muayenesinin \u00f6nemini ortaya koymu\u015ftur.<\/p>\n

Olgumuzda, muayene bulgular\u0131 patognomonik olmamakla birlikte, literat\u00fcre benzer \u015fekilde mak\u00fcler y\u0131ld\u0131z, peripapiller hemoraji ve optik disk \u00f6demi bulgular\u0131 bulunmaktayd\u0131. Mak\u00fcler y\u0131ld\u0131z g\u00f6r\u00fcn\u00fcm\u00fc baz\u0131 hastalarda ba\u015fvuruda g\u00f6r\u00fclmemekle birlikte, g\u00f6rme kayb\u0131ndan birka\u00e7 g\u00fcn sonra ortaya \u00e7\u0131k\u0131p ve 2-3 hafta i\u00e7erisinde daha belirgin bir hal alabilmektedir (12).<\/span><\/p>\n

Hastal\u0131\u011f\u0131n tan\u0131s\u0131nda; serolojik y\u00f6ntemler, molek\u00fcler y\u00f6ntemler, k\u00fclt\u00fcr ve histopatolojik inceleme kullan\u0131labilmektedir. K\u00fclt\u00fcr incelemesi, etkenin yava\u015f \u00fcreme \u00f6zelli\u011fi ve \u00f6zel ortam ko\u015fullar\u0131 gereklili\u011fi nedeniyle rutin laboratuvar prati\u011finde \u00f6ncelikli olarak tercih edilmemektedir. Histopatolojik inceleme ise giri\u015fimsel bir i\u015flem olup \u00f6zellikle olgumuzdaki gibi atipik klinik formlarla ba\u015fvuran hastalarda uygulanmas\u0131 m\u00fcmk\u00fcn de\u011fildir. Molek\u00fcler incelemeler ise olduk\u00e7a pahal\u0131 y\u00f6ntemlerdir; her merkezde yap\u0131lamamakta ve yeti\u015fmi\u015f elemana ihtiya\u00e7 duyulmaktad\u0131r. Bu nedenle tan\u0131sal s\u00fcre\u00e7te s\u0131kl\u0131kla serolojik tetkikler kullan\u0131lmakta olup indirekt imm\u00fcnfloresan antikor (IFA) testi veya enzim imm\u00fcnoessey (EIA) testlerinden faydalan\u0131lmaktad\u0131r. Tan\u0131sal olarak IgM pozitifli\u011finin yan\u0131 s\u0131ra s\u0131n\u0131r de\u011fer olarak IgG 1\/64 ve \u00fczeri de\u011ferler anlaml\u0131 kabul edilmekle birlikte tek ba\u015f\u0131na serolojik testlerin negatif olarak saptanmas\u0131 kedi t\u0131rmalama hastal\u0131\u011f\u0131n\u0131 ekarte ettirmemektedir (13).\u00a0<\/span><\/p>\n

Kedi t\u0131rmalama hastal\u0131\u011f\u0131n\u0131n tedavisinde \u00f6n planda, azitromisin, doksisiklin, rifampisin gibi antibiyotikler kullan\u0131lmaktad\u0131r; n\u00f6rolojik ve\/veya g\u00f6z tutulumu olan eri\u015fkin hastalarda \u00f6nerilen tedavi s\u00fcresi 4-6 hafta aras\u0131ndad\u0131r (14, 15). N\u00f6roretinit ay\u0131r\u0131c\u0131 tan\u0131s\u0131nda infeksiy\u00f6z etkenler olarak toksoplazmoz, sifiliz, \u201ccytomegalovirus\u201d (CMV) infeksiyonu ve Lyme gibi hastal\u0131klar yer almaktad\u0131r. Olgumuzda yap\u0131lan serolojik tetkikler sonucunda bu hastal\u0131klar a\u00e7\u0131s\u0131ndan da anlaml\u0131 sonu\u00e7 saptanmam\u0131\u015ft\u0131r.<\/span><\/p>\n

Sonu\u00e7 olarak, <\/b>sadece g\u00f6rme kayb\u0131 ya da sistemik bulgular ile birlikte ortaya \u00e7\u0131kan g\u00f6rme kayb\u0131 ile ba\u015fvuran olgularda Bartonella henselae<\/i> etken olarak akla gelmelidir. Hastalar\u0131n kedi t\u0131rmalama hastal\u0131\u011f\u0131 a\u00e7\u0131s\u0131ndan sorgulanmalar\u0131 ve tetkik edilmeleri \u00f6nem arz etmektedir.<\/p>\n","protected":false},"excerpt":{"rendered":"

G\u0130R\u0130\u015e Bartonella henselae, Gram-negatif, h\u00fccre i\u00e7i, oksidaz negatif, aerobik bir basil olup kedi t\u0131rmalama hastal\u0131\u011f\u0131 etkeni olarak kar\u015f\u0131m\u0131za \u00e7\u0131kmaktad\u0131r. Bu bakterinin ana rezervuar\u0131 kediler olup kedi temas\u0131 hastal\u0131\u011f\u0131n ba\u015fl\u0131ca bula\u015f yolu olarak g\u00f6r\u00fclmektedir (1). Kedi t\u0131rmalama hastal\u0131\u011f\u0131nda tipik bulgu; kutan\u00f6z inok\u00fclasyonu takip eden 1-8 hafta sonras\u0131nda\u00a0 lenfadenopati geli\u015fmesi olup nadiren n\u00f6rolojik tutulum, g\u00f6z tutulumu, osteomyelit, […]<\/p>\n","protected":false},"author":4,"featured_media":25666,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"footnotes":""},"categories":[5131],"tags":[5522,5521,5520],"class_list":["post-25478","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-olgu-sunumu","tag-bartonella-henselae-2","tag-kedi-tirmalama-hastaligi","tag-nororetinit"],"acf":[],"_links":{"self":[{"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/posts\/25478","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=25478"}],"version-history":[{"count":2,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/posts\/25478\/revisions"}],"predecessor-version":[{"id":25677,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/posts\/25478\/revisions\/25677"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/media\/25666"}],"wp:attachment":[{"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/media?parent=25478"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/categories?post=25478"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/tags?post=25478"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}