{"id":28019,"date":"2023-12-25T16:35:52","date_gmt":"2023-12-25T13:35:52","guid":{"rendered":"https:\/\/www.klimikdergisi.org\/?p=28019"},"modified":"2024-06-25T14:47:57","modified_gmt":"2024-06-25T11:47:57","slug":"menenjit-tanisinda-pcr","status":"publish","type":"post","link":"https:\/\/www.klimikdergisi.org\/tr\/2023\/12\/25\/menenjit-tanisinda-pcr\/","title":{"rendered":"Menenjit\/Ensefalit Tan\u0131s\u0131nda Molek\u00fcler Y\u00f6ntemlerin Ak\u0131lc\u0131 Kullan\u0131m\u0131"},"content":{"rendered":"

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

Santral sinir sistemi (SSS) infeksiyonlar\u0131; menenjit, ensefalit, ensefalomiyelit, beyin apsesi, subdural ampiyem, epidural apse, intrakraniyal flebit gibi de\u011fi\u015fik klinik tablolarla seyredebilir. Bilin\u00e7 de\u011fi\u015fikli\u011fi, ba\u015f a\u011fr\u0131s\u0131, ate\u015f, kusma ve fokal n\u00f6rolojik bulgular en s\u0131k kar\u015f\u0131la\u015f\u0131lan ba\u015fvuru nedenleridir (1,2).\u00a0<\/span><\/span><\/p>\n

Santral sinir sistemi infeksiyonuna neden olan etkenler; viruslar, bakteriler, mantarlar, parazitler ve mikobakterilerdir. Y\u00fcksek mortalite oranlar\u0131n\u0131n yan\u0131 s\u0131ra, n\u00f6rolojik defisitler ve kognitif bozulma gibi uzun vadeli komplikasyonlara da neden olabilen bu hastal\u0131k grubunu taklit edebilen noninfeksiy\u00f6z kliniklerin de olmas\u0131 do\u011fru tan\u0131 ve erken tedaviye ba\u015flama s\u00fcresini olumsuz etkilemektedir (1,3,4).\u00a0<\/span><\/p>\n

Klinik \u00f6zellikler ile tek ba\u015f\u0131na menenjit tan\u0131s\u0131 konulmaz. Bu nedenle klinik olarak menenjit \u015f\u00fcphesi durumunda lomber ponksiyon yap\u0131larak beyin omurilik s\u0131v\u0131s\u0131 (BOS)\u2019n\u0131n incelenmesi gerekmektedir. Beyin omurilik s\u0131v\u0131s\u0131n\u0131n incelenmesi; tan\u0131n\u0131n konulmas\u0131, etiyolojik ajan\u0131n ve ajan bakterinin antibiyotik duyarl\u0131l\u0131\u011f\u0131n\u0131n belirlenmesi i\u00e7in gereklidir (5). Klinik bulgular ve biyokimyasal testler klinisyene menenjit tan\u0131s\u0131 i\u00e7in \u00f6n bilgi sa\u011flamaktad\u0131r. S\u00f6z konusu testler bakteriyel, viral ya da mikobakteriyel menenjitin ayr\u0131m\u0131nda yard\u0131mc\u0131 olmakla birlikte etkeni belirleyemez. Etkenin belirlenmesi i\u00e7in mikrobiyolojik testlere ihtiya\u00e7 duyulmaktad\u0131r. Beyin omurilik s\u0131v\u0131s\u0131n\u0131n k\u00fclt\u00fcr\u00fc bakteriyel menenjit tan\u0131s\u0131 i\u00e7in alt\u0131n standart olarak kabul edilir; ancak \u00fcreme saptama oran\u0131 d\u00fc\u015f\u00fckt\u00fcr. \u00d6zellikle tedavi sonras\u0131 al\u0131nan \u00f6rneklerin k\u00fclt\u00fcr\u00fcnde \u00fcreme oran\u0131 azalmakta ve zor \u00fcreyen mikroorganizmalar i\u00e7in yalanc\u0131 negatif sonu\u00e7lar elde edilmektedir. Gram boyama h\u0131zl\u0131 bir \u015fekilde tan\u0131 konulmas\u0131 i\u00e7in \u00e7ok \u00f6nemli olmakla birlikte \u00f6zg\u00fcll\u00fc\u011f\u00fc y\u00fcksek iken duyarl\u0131l\u0131\u011f\u0131 d\u00fc\u015f\u00fckt\u00fcr. Etkene ba\u011fl\u0131 olarak de\u011fi\u015fmekle birlikte Gram boyama, tedavi almayan bakteriyel menenjit olgular\u0131n\u0131n %60 ila %80\u2019inde ve k\u0131smen tedavi edilen olgular\u0131n ise %40 ila %60\u2019\u0131nda pozitiftir (6). K\u00fclt\u00fcr ve Gram boyama testlerinin y\u00fcksek \u00f6zg\u00fcll\u00fc\u011fe ra\u011fmen duyarl\u0131l\u0131klar\u0131n\u0131n d\u00fc\u015f\u00fck olmas\u0131, ampirik tedavi ba\u015flanan hastalarda yalanc\u0131 negatif sonu\u00e7lara neden olmas\u0131 ve molek\u00fcler testlere g\u00f6re daha uzun zaman almas\u0131 nedeniyle tan\u0131da molek\u00fcler testlerin kullan\u0131m\u0131 artmaktad\u0131r (7).\u00a0<\/span><\/span><\/p>\n

Molek\u00fcler testler sayesinde menenjit ve ensefalit tan\u0131s\u0131nda b\u00fcy\u00fck ilerlemeler kaydedilmi\u015ftir. Y\u00fcksek duyarl\u0131l\u0131k ve \u00f6zg\u00fcll\u00fc\u011fe sahip olan molek\u00fcler testler \u00e7ok az hacimde BOS ile h\u0131zl\u0131 ve g\u00fcvenilir tan\u0131 sa\u011flamakta olup \u201cpolymerase chain reaction\u201d (PCR) kullan\u0131m\u0131 ile BOS\u2019ta viral etkenlerin saptanma olas\u0131l\u0131\u011f\u0131 da artm\u0131\u015ft\u0131r (6). \u00d6zellikle viral menenjitlerin tan\u0131s\u0131 i\u00e7in \u00f6nemli olan molek\u00fcler testler sayesinde erken tan\u0131 ve uygun tedavi ile hastanede kalma s\u00fcresi azalmaktad\u0131r (8). Molek\u00fcler testlerin g\u00fcn\u00fcm\u00fcz ko\u015fullar\u0131nda pahal\u0131 olmas\u0131 dezavantaj gibi g\u00f6r\u00fcnmekle birlikte h\u0131zl\u0131 tan\u0131 kapasiteleri, ba\u015fka testlere olan ihtiyac\u0131 azaltmalar\u0131, ampirik ba\u015flanan antimikrobiyal tedavinin sonland\u0131r\u0131lmas\u0131 ya da de\u011fi\u015ftirilmesine olanak sa\u011flamalar\u0131 ve hastane yat\u0131\u015f s\u00fcresini k\u0131saltabilmesi gibi nedenlerle tedavi maliyetinin azalmas\u0131 yoluyla maliyet tasarrufu da sa\u011flayabilmektedir. Bunun yan\u0131 s\u0131ra molek\u00fcler testlere a\u015f\u0131r\u0131 g\u00fcven, klinik ve laboratuvar bulgular\u0131n\u0131n g\u00f6z ard\u0131 edilmesine neden olacak kadar \u00f6n plana \u00e7\u0131kt\u0131\u011f\u0131nda maliyet etkinli\u011finden bahsetmek zorla\u015faca\u011f\u0131 gibi yanl\u0131\u015f tan\u0131 veya yanl\u0131\u015f negatifliklere de neden olarak klinisyenin yolunu kaybetmesine yol a\u00e7abilir.\u00a0<\/span><\/p>\n

\u00c7al\u0131\u015fmam\u0131z\u0131n amac\u0131; menenjit\/ensefalit (ME) paneli testinin ak\u0131lc\u0131 kullan\u0131l\u0131p kullan\u0131lmad\u0131\u011f\u0131n\u0131 belirlemek ve SSS infeksiyonlar\u0131na yakla\u015f\u0131mda etkin kullan\u0131m i\u00e7in \u00f6nerilerinde bulunmakt\u0131r.\u00a0 \u00a0<\/span><\/p>\n

Y\u00d6NTEMLER<\/h2>\n

Ocak 2022- Ocak 2023 tarihleri aras\u0131nda hastanemizin Mikrobiyoloji Laboratuvar\u0131\u2019na menenjit\/ensefalit paneli istemi ile g\u00f6nderilen 46 hastaya ait BOS \u00f6rnekleri \u00e7al\u0131\u015fmaya dahil edildi. Hastalar\u0131n; ya\u015f, cinsiyet, BOS l\u00f6kosit, eritrosit, glukoz ve protein de\u011ferleri, kan l\u00f6kosit ve C- reaktif protein (CRP) de\u011ferleri, ate\u015f, ba\u015f a\u011fr\u0131s\u0131, ense sertli\u011fi ve bilin\u00e7 bulan\u0131kl\u0131\u011f\u0131 bulgular\u0131n\u0131n varl\u0131\u011f\u0131 retrospektif olarak hasta dosyalar\u0131 ve hastane bilgi sistemi arac\u0131l\u0131\u011f\u0131yla elde edildi. \u00a0<\/span><\/span><\/p>\n

Hasta \u00f6rnekleri, QIAstat-Dx Analyzer cihaz\u0131 (Qiagen, Hilden, Almanya), QIAstat-Dx\u00ae<\/span> Meningitis\/Encephalitis (ME) Panel kiti (Qiagen, Hilden, Almanya) ile \u00e7al\u0131\u015f\u0131ld\u0131. Panel kit; Escherichia coli<\/i> K1, Haemophilus influenzae, Listeria monocytogenes, Neisseria meningitidis<\/i>, Streptococcus
\nagalactiae, Streptococcus pneumoniae, Mycoplasma pneumoniae, Streptococcus pyogenes, Herpes simplex virus-<\/i>1 (HSV-1), Herpes simplex virus-<\/i>2 (HSV-2), Human herpes virus-<\/i>6 (HHV-6), Enterovirus, Human parechovirus, Varicella-zoster virus<\/i> (VZV) ve Cryptococcus neoformans\/gatti<\/i> etkenlerinin tespit edilmesine olanak sa\u011fl\u0131yordu. G\u00f6nderilen \u00f6rneklerin Thoma lam\u0131nda do\u011frudan <\/b>h\u00fccre say\u0131m\u0131 ger\u00e7ekle\u015ftirildi ve %5 koyun kanl\u0131 agar, \u00e7ikolata agar ve \u201ceosin methylene blue\u201d (EMB) agara ekimi yap\u0131ld\u0131.\u00a0<\/span><\/p>\n

\u00c7al\u0131\u015fma i\u00e7in Giresun E\u011fitim ve Ara\u015ft\u0131rma Hastanesi Klinik Ara\u015ft\u0131rmalar Etik Kurulu\u2019ndan 30 Ocak 2023 tarihinde 30.01.2023\/11 karar numaras\u0131yla onay al\u0131nm\u0131\u015ft\u0131r.<\/p>\n

\u0130statistiksel Analiz<\/h3>\n

Verilerin tan\u0131mlay\u0131c\u0131 istatistiklerinde; ortalama, standart sapma, medyan en d\u00fc\u015f\u00fck ve en y\u00fcksek, frekans ve oran de\u011ferleri kullan\u0131ld\u0131. De\u011fi\u015fkenlerin da\u011f\u0131l\u0131m\u0131 Kolmogorov-Simirnov testi ile \u00f6l\u00e7\u00fcld\u00fc. Nicel ba\u011f\u0131ms\u0131z verilerin analizinde Mann-Whitney U<\/i> testi kullan\u0131ld\u0131. Nitel ba\u011f\u0131ms\u0131z verilerin analizinde \u03c7\u00b2\u00a0testi, \u03c7\u00b2\u00a0test ko\u015fullar\u0131 sa\u011flanamad\u0131\u011f\u0131nda ise Fisher kesin testi kullan\u0131ld\u0131.<\/p>\n

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

Tablo 1.<\/strong> Klinik, Mikrobiyolojik ve Biyokimyasal Parametreler<\/p><\/div>\n

Ocak 2022-Ocak 2023 tarihleri aras\u0131ndaki bir y\u0131ll\u0131k d\u00f6nemde Mikrobiyoloji Laboratuvar\u0131\u2019na menenjit paneli istemi ile g\u00f6nderilen 46 BOS \u00f6rne\u011finin 22\u2019sinin kad\u0131n ve 24\u2019\u00fcn\u00fcn erkek hastaya ait oldu\u011fu tespit edildi. Hastalar\u0131n ya\u015f ortalamas\u0131 60.2\u00b1<\/b>19.2 y\u0131l idi.\u00a0 <\/span>Be\u015fi kad\u0131n, d\u00f6rd\u00fc erkek hastaya ait olmak \u00fczere toplam dokuz \u00f6rne\u011fin menenjit panelinde \u00fc\u00e7 VZV, iki <\/i>HSV-1, iki Cryptococcus neoformans\/gatti, <\/i>bir E. coli<\/i> K1 ve bir L. monocytogenes<\/i> pozitifli\u011fi tespit edildi; toplam pozitiflik oran\u0131 %19.5 idi (Tablo 1). Hastalar\u0131n klinik, mikrobiyolojik ve biyokimyasal parametrelerine ait sonu\u00e7lar Tablo 1\u2019de verildi.\u00a0<\/span><\/p>\n

\"\"<\/a>

Tablo 2.<\/strong> Panel (-) ve Panel (+) Olan Gruplar Aras\u0131nda Yap\u0131lan Test Sonu\u00e7lar\u0131<\/p><\/div>\n

Test panelinde pozitiflik (+) ve negatiflik (-) tespit edilen hastalar istatistiksel a\u00e7\u0131dan de\u011ferlendirildi\u011finde ya\u015f ve cinsiyet da\u011f\u0131l\u0131mlar\u0131 a\u00e7\u0131s\u0131ndan anlaml\u0131 d\u00fczeyde bir farkl\u0131l\u0131k tespit edilmedi (p<\/i>>0.05). Panel (-) ve panel (+) gruplar; BOS l\u00f6kosit, eritrosit de\u011feri, bilin\u00e7 bulan\u0131kl\u0131\u011f\u0131, kan l\u00f6kosit say\u0131s\u0131 ve CRP de\u011ferleri a\u00e7\u0131s\u0131ndan kar\u015f\u0131la\u015ft\u0131r\u0131ld\u0131\u011f\u0131nda anlaml\u0131 d\u00fczeyde (p<\/i>>0.05) bir farkl\u0131l\u0131k g\u00f6r\u00fclmezken panel (+) olan grupta ate\u015f, ba\u015f a\u011fr\u0131s\u0131, ense sertli\u011fi parametreleri panel (-) olan gruptan anlaml\u0131 d\u00fczeyde (p<\/i><0.05) daha y\u00fcksek bulundu. Panel (+) saptanan dokuz hastan\u0131n yedisinde ate\u015f, be\u015finde ba\u015f a\u011fr\u0131s\u0131, \u00fc\u00e7\u00fcnde ense sertli\u011fi saptan\u0131rken ense sertli\u011fi panel (-) olan hi\u00e7bir hastada saptanmad\u0131. Ayr\u0131ca panel (+) olan grupta BOS protein y\u00fcksekli\u011fi ve BOS glukoz d\u00fc\u015f\u00fckl\u00fc\u011f\u00fc panel (-) olan gruba g\u00f6re istatistiksel olarak anlaml\u0131 d\u00fczeyde idi (p<\/i><0.05).\u00a0 <\/span>Ayr\u0131ca BOS protein normal de\u011feri 45 mg\/dl olarak al\u0131nd\u0131\u011f\u0131nda panel (+) olan dokuz hastan\u0131n tamam\u0131nda BOS protein de\u011ferinin y\u00fcksek oldu\u011fu g\u00f6r\u00fcld\u00fc. Panel (-) ve panel (+) olan gruplar aras\u0131nda yap\u0131lan Mann-Whitney U<\/i> testi ve \u03c7\u00b2\u00a0test (Fisher kesin testi) sonu\u00e7lar\u0131 Tablo 2\u2019de verildi. Ayr\u0131ca BOS\u2019ta l\u00f6kosit varl\u0131\u011f\u0131, protein pozitifli\u011fi ve glukoz d\u00fc\u015f\u00fckl\u00fc\u011f\u00fc parametrelerinin birlikteli\u011fi panel (+) dokuz hastan\u0131n yedisinde saptan\u0131rken, panel (-) 37 hastan\u0131n hi\u00e7birinde yoktu (p<\/i><0.001).<\/span><\/p>\n

\u0130RDELEME<\/h2>\n

Molek\u00fcler testlerin klinik prati\u011fe girmesinin ve yayg\u0131nla\u015fmas\u0131n\u0131n hem hekimler hem de hastalar i\u00e7in olumlu sonu\u00e7lar verdi\u011fi a\u00e7\u0131kt\u0131r. \u00d6zellikle viral etkenlerin saptanma olas\u0131l\u0131\u011f\u0131n\u0131 88 kat art\u0131rd\u0131\u011f\u0131 bildirilmektedir (9). Menenjit\/ensefalit etkeni olan patojenlerin k\u0131sa s\u00fcrede tespit edilip uygun tedaviye bir an \u00f6nce ba\u015flanmas\u0131 mortalite ve morbiditesi y\u00fcksek olan bu hastal\u0131k grubunda olduk\u00e7a \u00f6nemlidir. G\u00fcn\u00fcm\u00fczde viral, bakteriyel ve fungal patojenlerin ve polimikrobiyal etkenlerin do\u011frudan BOS \u00f6rne\u011finden \u00e7ok k\u0131sa s\u00fcrede tespiti molek\u00fcler y\u00f6ntemler ile m\u00fcmk\u00fcnd\u00fcr. Menenjit\/ensefalit paneli \u00e7ok \u00e7e\u015fitli patojenlerin az miktarda numune kullanarak h\u0131zl\u0131 bir \u015fekilde tespit edilmesini sa\u011flayan tam otomatize multipleks PCR sistemidir (10). Ancak g\u00fcn\u00fcm\u00fczde ula\u015f\u0131labilen tetkik say\u0131s\u0131n\u0131n artmas\u0131 ile fizik muayenenin daha az yap\u0131ld\u0131\u011f\u0131, hastal\u0131klar ile ilgili bilgi birikimini dikkate almadan kestirmeden sonuca gidilmeye \u00e7al\u0131\u015f\u0131ld\u0131\u011f\u0131n\u0131 da g\u00f6rmekteyiz.\u00a0<\/span><\/p>\n

\u00c7al\u0131\u015fmam\u0131zda hastalar\u0131n klinik bulgular\u0131na bak\u0131ld\u0131\u011f\u0131nda, ME paneli pozitif sonu\u00e7lanan grupta ate\u015f, ba\u015f a\u011fr\u0131s\u0131 ve ense sertli\u011finin ME paneli negatif sonu\u00e7lanan hasta grubuna g\u00f6re istatistiksel olarak anlaml\u0131 d\u00fczeyde daha s\u0131k saptanmas\u0131 beklenen bir sonu\u00e7tur (p<\/i><0.05). Yine BOS protein y\u00fcksekli\u011fi ve glukoz d\u00fc\u015f\u00fckl\u00fc\u011f\u00fcn\u00fcn de bu grupta anlaml\u0131 d\u00fczeyde olmas\u0131 beklenmektedir (1). \u00d6rneklerin bir \u00f6n elemeden ge\u00e7irildikten sonra molek\u00fcler sistem ile \u00e7al\u0131\u015f\u0131ld\u0131\u011f\u0131 durumlarda pozitiflik oran\u0131 artmaktad\u0131r (5). \u00c7al\u0131\u015fmam\u0131zda panel istemi yap\u0131lan 46 hastadan sadece dokuzunda pozitiflik saptand\u0131. Oysa klinik olarak uyumlu hasta grubunda panel \u00f6ncesi h\u0131zl\u0131 bir do\u011frudan bak\u0131 ile \u00f6rnekte h\u00fccre olup olmad\u0131\u011f\u0131na bak\u0131lmas\u0131 ve biyokimyasal a\u00e7\u0131dan de\u011ferlendirilmesi gerekirdi. \u00c7al\u0131\u015fmam\u0131za bu a\u00e7\u0131dan bakt\u0131\u011f\u0131m\u0131zda; panel (-) 37 hastan\u0131n hi\u00e7birinde BOS\u2019ta l\u00f6kosit varl\u0131\u011f\u0131, protein y\u00fcksekli\u011fi ve glukoz d\u00fc\u015f\u00fckl\u00fc\u011f\u00fcn\u00fcn bir arada olmamas\u0131, panel (+) grupta dokuz hastan\u0131n yedisinde her \u00fc\u00e7 parametrenin birlikte olmas\u0131 istatistiksel olarak anlaml\u0131 olmas\u0131n\u0131n yan\u0131 s\u0131ra panelin etkin kullan\u0131lmamas\u0131 a\u00e7\u0131s\u0131ndan d\u00fc\u015f\u00fcnd\u00fcr\u00fcc\u00fcd\u00fcr (p<\/i><0.001). T\u00fcm bunlara klinik tecr\u00fcbe, ayr\u0131nt\u0131l\u0131 anamnez ve anlaml\u0131 fizik muayene bulgular\u0131n\u0131n eklenmesi ile molek\u00fcler testler daha uygun bir \u015fekilde kullan\u0131labilir.\u00a0<\/span><\/p>\n

Menenjit\/ensefalit tan\u0131s\u0131nda molek\u00fcler y\u00f6ntemler kullan\u0131l\u0131rken yukar\u0131da bahsedilen klinik ve BOS bulgular\u0131 yan\u0131nda panelin \u00e7al\u0131\u015fma ko\u015fullar\u0131 ve etkene y\u00f6nelik duyarl\u0131l\u0131\u011f\u0131, \u00f6zg\u00fcll\u00fc\u011f\u00fc de dikkate al\u0131nmal\u0131d\u0131r. \u00d6rneklerin uygun saklama ko\u015fullar\u0131nda tutulmas\u0131 sa\u011flanarak ve gerekli kontaminasyon \u00f6nlemleri al\u0131narak deneyimli laboratuvar \u00e7al\u0131\u015fanlar\u0131 taraf\u0131ndan yap\u0131lan \u00e7al\u0131\u015fmalarda panelin do\u011fru sonu\u00e7 verme oran\u0131 y\u00fcksektir (11,12).\u00a0<\/span><\/p>\n

Viral etkenler i\u00e7inde klinisyeni en fazla endi\u015felendiren HSV-1 ensefaliti tan\u0131s\u0131 i\u00e7in duyarl\u0131l\u0131k %96 \u00f6zg\u00fcll\u00fck %99 olarak belirtilmi\u015f olup yanl\u0131\u015f pozitiflik oran %2-6 aras\u0131ndad\u0131r. \u00d6te yandan erken klinik d\u00f6nemde \u00f6zellikle ilk \u00fc\u00e7 g\u00fcnde al\u0131nan BOS\u2019ta \u00e7al\u0131\u015f\u0131lan PCR sonucunun HSV-1 a\u00e7\u0131s\u0131ndan yalanc\u0131 negatif olabilece\u011fi bilinmektedir (12,13).\u00a0<\/span><\/p>\n

Herpes ensefalitinin \u00e7o\u011fu zaman farkl\u0131 klinik \u015fekillerde kar\u015f\u0131m\u0131za \u00e7\u0131kmas\u0131 ve pleositoz olmayabilece\u011fi bizleri h\u0131zl\u0131ca molek\u00fcler y\u00f6ntemlere itebilir ancak bir\u00e7ok \u00e7al\u0131\u015fmada bu hastalarda g\u00f6r\u00fclen tipik manyetik rezonans (MR) ve elektroensefalografi (EEG) bulgular\u0131 klinisyenleri zaten tedavi a\u00e7\u0131s\u0131ndan y\u00f6nlendirmektedir (14,15).\u00a0<\/span><\/p>\n

Menenjit\/ensefalit panelinde olan her bir etken i\u00e7in de duyarl\u0131l\u0131\u011f\u0131n ve \u00f6zg\u00fcll\u00fc\u011f\u00fcn farkl\u0131 oldu\u011funu bilmek gerekir. Varicella-zoster <\/i>virus\u2019un PCR duyarl\u0131l\u0131\u011f\u0131 %80 civar\u0131nda iken \u00f6zg\u00fcll\u00fc\u011f\u00fcn\u00fcn \u00e7ok daha y\u00fcksek oldu\u011fu bildirilmektedir. Enteroviruslara gelindi\u011finde bu durum daha da karma\u015f\u0131kt\u0131r (12). P\u00e9rez-V\u00e9lez<\/span> ve arkada\u015flar\u0131 (16) taraf\u0131ndan yap\u0131lan \u00e7al\u0131\u015fmada n\u00f6rolojik semptomu olan yak\u0131n temasl\u0131 16 \u00e7ocuk hastan\u0131n tamam\u0131nda BOS\u2019ta pleositozu olmas\u0131na ra\u011fmen sadece be\u015f \u00e7ocukta BOS PCR sonucunda Enterovirus<\/i> 71 (EV71) tespit edilmi\u015ftir. Salg\u0131n ara\u015ft\u0131rmas\u0131 yap\u0131lan bu \u00e7al\u0131\u015fmada t\u00fcm hastalardan al\u0131nan solunum rektal veya BOS PCR sonucunun en az birinde EV71 tespit edildi\u011fi bildirilmi\u015ftir (16).\u00a0<\/span><\/p>\n

HHV-6\u2019n\u0131n panelde tespit edilmesi halinde ise kromozoma entegre olabilece\u011fini, sa\u011fl\u0131kl\u0131 beyin dokusu ve BOS dahil t\u00fcm v\u00fccut s\u0131v\u0131lar\u0131nda bulunabilme ihtimalini de ak\u0131lda tutarak elimizdeki di\u011fer klinik ve laboratuvar parametreler ile birlikte durumu de\u011ferlendirmek daha ak\u0131lc\u0131 olacakt\u0131r (17).\u00a0<\/span><\/p>\n

Bakteriyel ve fungal etkenlere gelindi\u011finde viral etkenlerde oldu\u011fu gibi panelde sadece s\u0131k g\u00f6r\u00fclen etkenlerin bulundu\u011fu unutulmamal\u0131d\u0131r. \u00c7ok d\u00fc\u015f\u00fck say\u0131daki bakteriyi dahi saptayabilmesi, ampirik ba\u015flanm\u0131\u015f olan antibiyoterapiden sonucun etkilenmemesi ve \u00e7e\u015fitli \u00e7al\u0131\u015fmalarda y\u00fcksek duyarl\u0131l\u0131k ve \u00f6zg\u00fcll\u00fck belirtilmesi panelin \u00f6nemli avantajlar\u0131d\u0131r fakat antibiyotik duyarl\u0131l\u0131\u011f\u0131na ula\u015fabilmemiz i\u00e7in ampirik tedavi \u00f6ncesi k\u00fclt\u00fcr al\u0131nmas\u0131 gereklidir (18,19).\u00a0<\/span><\/span><\/p>\n

\u00d6ncelikle g\u00fc\u00e7l\u00fc bir klinik \u015f\u00fcphe varl\u0131\u011f\u0131, ard\u0131ndan biyokimyasal ve mikrobiyolojik testlerin kullan\u0131m\u0131 ve bu testlerin sonu\u00e7lar\u0131na g\u00f6re molek\u00fcler tan\u0131ya y\u00f6nelmek testin ak\u0131lc\u0131 kullan\u0131m\u0131n\u0131 sa\u011flayacakt\u0131r.\u00a0 <\/span>Ate\u015f, ba\u015f a\u011fr\u0131s\u0131, ense sertli\u011fi ve bilin\u00e7 bulan\u0131kl\u0131\u011f\u0131 en \u00f6nemli klinik bulgulard\u0131r ve bunlar\u0131n pozitifli\u011fi molek\u00fcler tan\u0131 isteminde yol g\u00f6sterici olmaktad\u0131r. \u00c7al\u0131\u015fmam\u0131zda panelde etken saptanan grupta; ate\u015f y\u00fcksekli\u011fi, ba\u015f a\u011fr\u0131s\u0131 ve fizik muayene bulgusu olarak ense sertli\u011finin saptanmas\u0131 ve yine bu gruptaki BOS bulgular\u0131nda protein y\u00fcksekli\u011fi ve glukoz d\u00fc\u015f\u00fckl\u00fc\u011f\u00fcn\u00fcn olmas\u0131 maliyet etkinlik a\u00e7\u0131s\u0131ndan uygun hasta grubunda istenmesi gerekti\u011fini d\u00fc\u015f\u00fcnd\u00fcrmektedir. Yap\u0131lan \u00e7al\u0131\u015fmalarda menenjitin h\u00fccresel ve biyokimyasal \u00f6zelliklerine sahip BOS \u00f6rneklerinde multipleks PCR verimlilik g\u00f6sterirken, h\u00fccresel ve biyokimyasal \u00f6zellikleri normal olan \u00f6rneklerde PCR ile pozitiflik oran\u0131nda d\u00fc\u015f\u00fckl\u00fck oldu\u011fu g\u00f6r\u00fclm\u00fc\u015ft\u00fcr. Gram boyama, l\u00f6kosit say\u0131s\u0131 ve y\u00fcksek klinik \u015f\u00fcphe \u00f6zelliklerine sahip BOS \u00f6rneklerinde menenjit paneli ile pozitiflik oran\u0131n\u0131n y\u00fcksek bulunmas\u0131n\u0131n nedeninin bir \u00f6n eleme sonras\u0131 \u00f6rneklerin \u00e7al\u0131\u015f\u0131lmas\u0131 oldu\u011fu de\u011ferlendirilmi\u015ftir (5,20,21). Benzer bulgular \u00e7al\u0131\u015fmam\u0131z i\u00e7in de ge\u00e7erlidir. Santral sinir sistemi infeksiyonu d\u00fc\u015f\u00fcn\u00fclen hastalar klinik ve laboratuvar ayr\u0131lmaks\u0131z\u0131n bir b\u00fct\u00fcn olarak de\u011ferlendirilmelidir. Bunun yan\u0131nda laboratuvar parametrelerinin de birbirleriyle beklenen uyumu g\u00f6z ard\u0131 edilmemelidir. \u00c7al\u0131\u015fmam\u0131zda panel (+) grupta BOS protein y\u00fcksekli\u011fi ve glukoz d\u00fc\u015f\u00fckl\u00fc\u011f\u00fcn\u00fcn istatistiksel olarak anlaml\u0131 d\u00fczeyde olmas\u0131n\u0131n yan\u0131 s\u0131ra panel (-) hasta grubunda BOS\u2019ta l\u00f6kosit varl\u0131\u011f\u0131, protein y\u00fcksekli\u011fi ve glukoz d\u00fc\u015f\u00fckl\u00fc\u011f\u00fc parametrelerinin her \u00fc\u00e7\u00fcne birden sahip herhangi bir hastan\u0131n olmamas\u0131 dikkat \u00e7ekicidir. Ate\u015f, ba\u015f a\u011fr\u0131s\u0131, ense sertli\u011fi bulgular\u0131n\u0131n yan\u0131 s\u0131ra BOS\u2019ta l\u00f6kosit, protein y\u00fcksekli\u011fi ve glukoz d\u00fc\u015f\u00fckl\u00fc\u011f\u00fc birlikteli\u011fi de testin istenmesinde yol g\u00f6sterici olmal\u0131d\u0131r. Klinik tecr\u00fcbe ve SSS infeksiyonu ile ilgili ge\u00e7mi\u015f birikim dikkate al\u0131narak yap\u0131lan panel istemlerinin ak\u0131lc\u0131 ve maliyet etkin olaca\u011f\u0131 a\u00e7\u0131kt\u0131r.\u00a0<\/span><\/p>\n

Molek\u00fcler testlerin SSS infeksiyonlar\u0131n\u0131 de\u011ferlendirmedeki \u00f6nemi yads\u0131namaz. Ancak g\u00fc\u00e7l\u00fc bir klinik \u015f\u00fcphe varl\u0131\u011f\u0131 ile al\u0131nan BOS \u00f6rneklerinin mikrobiyolojik ve biyokimyasal olarak de\u011ferlendirilmesi sonras\u0131 ak\u0131lc\u0131 bir algoritma ile ME paneli istenmesi uygun ve maliyet etkin olacakt\u0131r. Molek\u00fcler testler sayesinde etkenlerin h\u0131zl\u0131, duyarl\u0131 ve \u00f6zg\u00fcl olarak tan\u0131nmas\u0131yla gereksiz antibiyotik veya antiviral kullan\u0131m\u0131n\u0131n yan\u0131 s\u0131ra ek testlerin yap\u0131lmas\u0131 \u00f6nlenecek ve hastanede kal\u0131\u015f s\u00fcresinin azalmas\u0131 gibi kazan\u0131mlar sa\u011flanacakt\u0131r. Panelin uygun laboratuvar ko\u015fullar\u0131nda, kontaminasyonu \u00f6nleyecek tedbirler al\u0131narak ve deneyimli \u00e7al\u0131\u015fanlar taraf\u0131ndan uygulanmas\u0131, panelde olmayan etkenlerin de ay\u0131r\u0131c\u0131 tan\u0131da d\u00fc\u015f\u00fcn\u00fclmesi, panelde saptanan etkenin hastan\u0131n ya\u015f ve di\u011fer klinik bulgular\u0131 ile uyumunun de\u011ferlendirilmesi son derece \u00f6nemlidir. Her etkenin farkl\u0131 duyarl\u0131l\u0131k ve \u00f6zg\u00fcll\u00fckte oldu\u011funu ve \u00f6zellikle klinisyenleri endi\u015felendiren herpes ensefalitinde erken d\u00f6nemde al\u0131nan BOS PCR sonucunun negatif olabilece\u011fini ak\u0131lda tutman\u0131n g\u00fcnl\u00fck pratikte \u00f6nemli oldu\u011fu kanaatindeyiz.<\/p>\n","protected":false},"excerpt":{"rendered":"

G\u0130R\u0130\u015e Santral sinir sistemi (SSS) infeksiyonlar\u0131; menenjit, ensefalit, ensefalomiyelit, beyin apsesi, subdural ampiyem, epidural apse, intrakraniyal flebit gibi de\u011fi\u015fik klinik tablolarla seyredebilir. Bilin\u00e7 de\u011fi\u015fikli\u011fi, ba\u015f a\u011fr\u0131s\u0131, ate\u015f, kusma ve fokal n\u00f6rolojik bulgular en s\u0131k kar\u015f\u0131la\u015f\u0131lan ba\u015fvuru nedenleridir (1,2).\u00a0 Santral sinir sistemi infeksiyonuna neden olan etkenler; viruslar, bakteriler, mantarlar, parazitler ve mikobakterilerdir. Y\u00fcksek mortalite oranlar\u0131n\u0131n yan\u0131 […]<\/p>\n","protected":false},"author":6,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"footnotes":""},"categories":[5129],"tags":[2698,5822,5821],"class_list":["post-28019","post","type-post","status-publish","format-standard","hentry","category-ozgun-arastirma","tag-menenjit","tag-menenjit-ensefalit-paneli","tag-molekuler-testler"],"acf":[],"_links":{"self":[{"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/posts\/28019","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\/6"}],"replies":[{"embeddable":true,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/comments?post=28019"}],"version-history":[{"count":4,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/posts\/28019\/revisions"}],"predecessor-version":[{"id":28773,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/posts\/28019\/revisions\/28773"}],"wp:attachment":[{"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/media?parent=28019"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/categories?post=28019"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/tags?post=28019"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}