{"id":29137,"date":"2024-09-27T11:22:48","date_gmt":"2024-09-27T08:22:48","guid":{"rendered":"https:\/\/www.klimikdergisi.org\/?p=29137"},"modified":"2024-09-27T12:59:40","modified_gmt":"2024-09-27T09:59:40","slug":"ekstrapulmoner-tuberkuloz-olgularinin-retrospektif-degerlendirilmesi","status":"publish","type":"post","link":"https:\/\/www.klimikdergisi.org\/tr\/2024\/09\/27\/ekstrapulmoner-tuberkuloz-olgularinin-retrospektif-degerlendirilmesi\/","title":{"rendered":"Ekstrapulmoner T\u00fcberk\u00fcloz Olgular\u0131n\u0131n Retrospektif De\u011ferlendirilmesi"},"content":{"rendered":"

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

T\u00fcberk\u00fcloz (TB), Mycobacterium tuberculosis<\/i> complex olarak adland\u0131r\u0131lan bir grup mikobakterinin etken oldu\u011fu, gran\u00fclomat\u00f6z lezyonlarla seyreden bir infeksiyon hastal\u0131\u011f\u0131d\u0131r (1). D\u00fcnya Sa\u011fl\u0131k \u00d6rg\u00fct\u00fc (DS\u00d6)\u2019n\u00fcn 2023 y\u0131l\u0131 raporunda, t\u00fcm d\u00fcnyada 2022 y\u0131l\u0131nda 7.5 milyon yeni TB olgusu saptand\u0131\u011f\u0131 bildirilmi\u015ftir. Bu say\u0131 DS\u00d6\u2019n\u00fcn k\u00fcresel izlem yapmaya ba\u015flad\u0131\u011f\u0131 1996 y\u0131l\u0131ndan beri saptanan en y\u00fcksek olgu say\u0131s\u0131d\u0131r. \u00d6nceki iki y\u0131lda bildirilen yeni olgu say\u0131s\u0131 6.4 milyon ve 5.8 milyondur; COVID-19 pandemisi kaynakl\u0131 olarak sa\u011fl\u0131k hizmetlerinde olu\u015fan te\u015fhis ve tedavideki gecikmelerin bu azalmaya neden oldu\u011fu d\u00fc\u015f\u00fcn\u00fclmektedir. Ancak g\u00fcn\u00fcm\u00fczde, t\u00fcberk\u00fcloz hala \u00f6nemli bir halk sa\u011fl\u0131\u011f\u0131 sorunu olarak varl\u0131\u011f\u0131n\u0131 s\u00fcrd\u00fcrmektedir (2). D\u00fcnya n\u00fcfusunun yakla\u015f\u0131k \u00fc\u00e7te birinin latent TB infeksiyonuna sahip oldu\u011fu d\u00fc\u015f\u00fcn\u00fclmektedir (3). T\u00fcberk\u00fcloz ba\u015fta akci\u011ferler olmak \u00fczere b\u00fct\u00fcn organlar\u0131 etkileyebilir. Ekstrapulmoner t\u00fcberk\u00fcloz (EPTB) terimi akci\u011fer d\u0131\u015f\u0131ndaki organlarda ortaya \u00e7\u0131kan TB olgular\u0131n\u0131 tan\u0131mlar; s\u0131kl\u0131kla lenf bezlerinde, plevrada, kemiklerde ve eklemlerde, gastrointestinal sistem (G\u0130S)\u2019de, genito\u00fcriner sistem (G\u00dcS)\u2019de ve santral sinir sistemi (SSS)\u2019nde g\u00f6r\u00fcl\u00fcr (4). Verem Sava\u015f\u0131 2021 Raporu verilerine g\u00f6re 2005 y\u0131l\u0131nda \u00fclkemizde yeni tan\u0131 alan TB olgu say\u0131s\u0131 18 753 iken, EPTB olgu say\u0131s\u0131 5359 (%28.6)\u2019dur. 2020 y\u0131l\u0131nda ise yeni tan\u0131 alan TB olgu say\u0131s\u0131 8925\u2019tir ve bunlar\u0131n 3710 (%41.6)\u2019u ise EPTB olgusudur. \u00dclkemizde yeni tan\u0131 TB olgu say\u0131s\u0131 azal\u0131rken EPTB oran\u0131 artmaktad\u0131r (5). \u00c7al\u0131\u015fmam\u0131zda, EPTB tan\u0131s\u0131 ile izlenmi\u015f 81 olgu retrospektif olarak de\u011ferlendirildi.<\/p>\n

Y\u00d6NTEMLER<\/h2>\n

\u0130nfeksiyon hastal\u0131klar\u0131 klini\u011fi ve poliklini\u011finde, 01 Ocak 2013 ile 31 Aral\u0131k 2019 tarihleri aras\u0131nda, EPTB tan\u0131s\u0131 ile takip ve tedavi edilen, 18 ya\u015f ve \u00fczerindeki hastalar \u00e7al\u0131\u015fmaya dahil edildi. Hastalar\u0131n verilerine hasta dosyalar\u0131ndan ve elektronik belge y\u00f6netim sisteminden ula\u015f\u0131ld\u0131. \u00c7al\u0131\u015fmaya akci\u011fer t\u00fcberk\u00fclozuna ait bulgular\u0131 olan hastalar dahil edilmedi.<\/p>\n

Mikrobiyolojik inceleme ve tetkiklerde hastalardan al\u0131nan numuneler i\u00e7in yap\u0131lan TB k\u00fclt\u00fcr\u00fc, Ehrlich-Ziehl-Neelsen (EZN) boyama, mikobakteri PCR testlerinden en az birinin pozitif sonu\u00e7lanmas\u0131n\u0131n EPTB tan\u0131s\u0131nda kullan\u0131ld\u0131\u011f\u0131 tespit edildi. Histopatolojik incelemelerde; gran\u00fclomat\u00f6z iltihap, nekrotizan gran\u00fclomat\u00f6z iltihap ve kazifikasyon nekrozu i\u00e7eren gran\u00fclomat\u00f6z iltihap ile uyumlu bulgular EPTB uyumlu olarak de\u011ferlendirilmi\u015fti. Santral sinir sistemi t\u00fcberk\u00fclozu olgular\u0131n\u0131n beyin g\u00f6r\u00fcnt\u00fclemelerinde; leptomeningeal tutulum, bazal meningeal tutulum, t\u00fcberk\u00fclom, hidrosefali, intrakranial \u00f6dem, vask\u00fclit bulgular\u0131n\u0131n varl\u0131\u011f\u0131, klinik, mikrobiyolojik ve histopatolojik bulgularla da desteklendi\u011fi takdirde t\u00fcberk\u00fcloz ile uyumlu bulgu olarak de\u011ferlendirilmi\u015fti.<\/p>\n

Yukar\u0131daki tan\u0131 y\u00f6ntemleri ile tan\u0131 konulamayan, klinik olarak EPTB \u015f\u00fcphesi olan ancak ba\u015fka bir hastal\u0131k saptanamayan hastalara antit\u00fcberk\u00fcloz tedavisi verilmi\u015f; klinik ve laboratuvar yan\u0131t al\u0131nan hastalar \u201ctedaviden tan\u0131ya\u201d giden hasta olarak kaydedilmi\u015fti.<\/p>\n

A\u015fa\u011f\u0131daki durumlarda, laboratuvar de\u011ferlerindeki anormalli\u011fi a\u00e7\u0131klayacak ba\u015fka bir durum saptanmad\u0131\u011f\u0131 takdirde ilaca ba\u011fl\u0131 hepatotoksisite geli\u015fti\u011fine karar verildi:<\/p>\n

Herhangi bir semptom olup olmad\u0131\u011f\u0131na bak\u0131lmaks\u0131z\u0131n aspartat aminotransferaz (AST) ve alanin aminotransferaz (ALT) de\u011ferlerinin normal \u00fcst s\u0131n\u0131r de\u011ferinin be\u015f kat\u0131n\u0131 a\u015fmas\u0131,<\/p>\n

\u0130\u015ftahs\u0131zl\u0131k, bulant\u0131, kusma, kar\u0131n a\u011fr\u0131s\u0131, halsizlik, sar\u0131l\u0131k gibi semptomlarla birlikte AST ve ALT de\u011ferlerinin normal \u00fcst s\u0131n\u0131r de\u011ferinin \u00fc\u00e7 kat\u0131n\u0131 a\u015fmas\u0131,<\/p>\n

Bilirubin de\u011ferlerinin 1.5 mg\/dl\u2019nin \u00fczerine \u00e7\u0131kmas\u0131.<\/p>\n

Verilerin analizi, SPSS (Statistical Package for the Social Sciences) versiyon 22.0 program\u0131 (IBM Corp., Armonk, NY, ABD) ile yap\u0131ld\u0131. T\u00fcm istatistikler i\u00e7in anlaml\u0131l\u0131k d\u00fczeyi p<\/i><0.05 olarak kabul edildi.<\/p>\n

\u00c7al\u0131\u015fma, Trakya \u00dcniversitesi T\u0131p Fak\u00fcltesi Dekanl\u0131\u011f\u0131 Bilimsel Ara\u015ft\u0131rmalar Etik Kurulu taraf\u0131ndan 24 A\u011fustos 2020 tarihinde 2020\/303 karar numaras\u0131yla onayland\u0131.<\/p>\n

BULGULAR<\/h2>\n

\u00c7al\u0131\u015fmada yer alan EPTB tan\u0131l\u0131 81 hastan\u0131n 49 (%60.4)\u2019u kad\u0131n, 32 (%39.6)\u2019si erkek olup ya\u015f ortalamas\u0131 49.55\u00b118.85 ve ya\u015f aral\u0131\u011f\u0131 18-89 y\u0131l olarak saptand\u0131 (kad\u0131nlar i\u00e7in 48.75\u00b118.57 ve 18-89; erkekler i\u00e7in 50.7\u00b119.5 ve 18-80). <\/span><\/p>\n

\"\"<\/a>

Tablo 1.<\/strong> Klinik Formlar ve Cinsiyet Da\u011f\u0131l\u0131mlar\u0131<\/p><\/div>\n

Tutulum b\u00f6lgelerine g\u00f6re de\u011ferlendirildi\u011finde; G\u0130S TB 18 (%22.3), kas-iskelet sistemi TB 17 (%20.9), lenf bezi TB 16 (%19.7), SSS TB 15 (%18.5), G\u00dcS TB 8 (%9.9), deri TB 3 (%3.8), adrenal TB 2 (%2.5), perikard TB 1 (%1.2) ve nazofarenks TB 1 (%1.2) hastada saptand\u0131 (Tablo 1).<\/p>\n

\"\"<\/a>

Tablo 2.<\/strong> Hastalar\u0131n \u00d6zellikleri<\/p><\/div>\n

Hipertansiyon (%50) ve diabetes mellitus (%17) en s\u0131k g\u00f6r\u00fclen ek hastal\u0131klard\u0131. Hastalar\u0131n hi\u00e7birinde akci\u011fer tutulumu yoktu. Ge\u00e7irilmi\u015f t\u00fcberk\u00fcloz \u00f6yk\u00fcs\u00fc olan hasta say\u0131s\u0131 13 (%16) iken 8 (%9.8) hastan\u0131n t\u00fcberk\u00fcloz tan\u0131l\u0131 ki\u015fiyle temas\u0131 oldu\u011fu belirlendi (Tablo 2).<\/p>\n

Gastrointestinal sistem TB tan\u0131s\u0131 alan hasta say\u0131s\u0131 18 (%22.3) idi ve \u00e7al\u0131\u015fmam\u0131zda t\u00fcm EPTB olgular\u0131 i\u00e7inde en s\u0131k g\u00f6r\u00fclen klinik formdu; 13 (%72.2) hastada peritonit, 5 (%27.8) hastada ileit g\u00f6r\u00fcld\u00fc. Kar\u0131nda \u015fi\u015flik (%72.2), kar\u0131n a\u011fr\u0131s\u0131 (%55.6) ve kilo kayb\u0131 (%44.4) en s\u0131k kar\u015f\u0131la\u015f\u0131lan ba\u015fvuru \u015fikayetleriydi.<\/p>\n

Peritonit tan\u0131s\u0131 alan hastalar\u0131n, periton s\u0131v\u0131s\u0131 beyaz k\u00fcre say\u0131s\u0131 ortalama 1297.4 (56-3200 aras\u0131nda) h\u00fccre\/mm3<\/sup> saptand\u0131. T\u00fcm periton s\u0131v\u0131 \u00f6rneklerindeki h\u00fccreler, %70-90 oran\u0131nda lenfosit hakimiyetindeydi. Adenozin deaminaz (ADA) enzim aktivitesi testi yap\u0131lan hastalarda ortalama aktivite 93.9 \u00dc\/lt saptan\u0131rken; en d\u00fc\u015f\u00fck de\u011fer 54 \u00dc\/lt, en y\u00fcksek de\u011fer 126 \u00dc\/lt idi. Pearson korelasyon analizi sonucuna go\u0308re periton s\u0131v\u0131s\u0131 beyaz k\u00fcre say\u0131s\u0131 ile ADA d\u00fczeyi aras\u0131nda istatistiksel olarak anlaml\u0131 d\u00fczeyde bir ili\u015fki saptanmad\u0131 (r=0.278, p<\/i>=0.438, p<\/i>>0.05).<\/p>\n

Kas-iskelet sistemi TB tan\u0131s\u0131 ile izlenen hasta say\u0131s\u0131 17 (%20.9) idi. Hastalarda en s\u0131k kar\u015f\u0131la\u015f\u0131lan ba\u015fvuru \u015fikayetleri bel (%41.2) ve s\u0131rt a\u011fr\u0131s\u0131 (%23.5) olup; 12 (%70.5) hastaya spondilodiskit ve di\u011fer hastalara tenosinovit (2), osteomyelit (2) ve apse (1) tan\u0131s\u0131 konulmu\u015ftu. On iki spondilodiskit olgusunun yedisinde torakal, be\u015finde lomber vertebra tutulumu g\u00f6r\u00fcld\u00fc.<\/p>\n

\"\"<\/a>

Tablo 3.<\/strong> Lenf Bezi Tutulum B\u00f6lgeleri<\/p><\/div>\n

Lenf bezi t\u00fcberk\u00fclozu, hastalar\u0131n 16 (%19.7)\u2019s\u0131nda g\u00f6r\u00fcld\u00fc; en s\u0131k olarak servikal lenf bezi tutulumu saptand\u0131 (Tablo 3). Histopatolojik inceleme sonu\u00e7lar\u0131na g\u00f6re; 9 (%64.3) hastada nekrotizan gran\u00fclomat\u00f6z iltihap, 3 (%21.4) hastada kazeifikasyon i\u00e7eren nekrotizan gran\u00fclomat\u00f6z iltihap ve 2 (%14.3) hastada gran\u00fclomat\u00f6z iltihap vard\u0131.<\/p>\n

Santral sinir sistemi TB tan\u0131s\u0131 alan 15 (%18.5) hasta meningoensefalit klini\u011fi ile takip edilmi\u015fti. En s\u0131k kar\u015f\u0131la\u015f\u0131lan ba\u015fvuru \u015fikayetleri; ate\u015f y\u00fcksekli\u011fi, ba\u015f a\u011fr\u0131s\u0131 ve bilin\u00e7 bulan\u0131kl\u0131\u011f\u0131yd\u0131. Beyin omurilik s\u0131v\u0131s\u0131 (BOS) incelemelerine g\u00f6re ortalama beyaz k\u00fcre say\u0131s\u0131 336.7 (0-1760 aras\u0131nda) h\u00fccre\/mm3<\/sup> idi. Bir hastan\u0131n insan ba\u011f\u0131\u015f\u0131kl\u0131k yetmezli\u011fi virusu (human immunodeficiency virus – HIV) infeksiyonu mevcuttu ve BOS incelemesinde beyaz k\u00fcre saptanmam\u0131\u015ft\u0131; ancak PCR test sonucunda
\nM. tuberculosis<\/i> DNA\u2019s\u0131 pozitif saptanm\u0131\u015ft\u0131. Bu hasta d\u0131\u015f\u0131ndaki hastalar\u0131n BOS incelemesinde, beyaz k\u00fcrelerin %85.7 oran\u0131nda lenfosit hakimiyetinde oldu\u011fu g\u00f6r\u00fcld\u00fc. Ortalama BOS proteini 409.6 (94-3400 aras\u0131nda) mg\/dl, ortalama BOS glikozu 53.9 (7-114 aras\u0131nda) mg\/dl idi. Beyin omurilik s\u0131v\u0131s\u0131ndaki glikoz miktar\u0131n\u0131n e\u015f zamanl\u0131 kan glikozuna oran\u0131 ortalama 0.46 olarak tespit edildi. Beyin omurilik s\u0131v\u0131s\u0131 \u00f6rneklerinde
\n1 (%6.7) hastada EZN boyama pozitif sonu\u00e7lanm\u0131\u015ft\u0131, 6 (%40) hastan\u0131n TB k\u00fclt\u00fcr\u00fcnde M. tuberculosis <\/i>\u00fcremi\u015f ve 2 (%13.4) hastan\u0131n PCR test sonucu M. tuberculosis<\/i> DNA\u2019s\u0131 i\u00e7in pozitif sonu\u00e7lanm\u0131\u015ft\u0131. \u0130ntrakranial kitle sebebiyle opere edilen bir hastaya yap\u0131lan beyin biyopsisinde gran\u00fclomat\u00f6z iltihap saptanm\u0131\u015ft\u0131.\u00a0<\/span><\/p>\n

\u00c7al\u0131\u015fmam\u0131z kaspam\u0131nda de\u011ferlendirilen 8 (%9.4) hastada G\u00dcS TB,
\n3 (%37.5) hastada b\u00f6brek tutulumu, iki hastada over, birer hastada da serviks, prostat ve mesane tutulumlar\u0131 g\u00f6r\u00fcld\u00fc. Be\u015f (%62.5) hastaya histopatolojik inceleme ile, 3 (%32.5) hastaya mikrobiyolojik tetkiklerle tan\u0131 konulmu\u015ftu. Sadece \u00fcriner sistem tutulumu olan hastalar\u0131n 3 (%60)\u2019\u00fcnde idrar EZN boyama pozitif saptan\u0131rken 2 (%40)\u2019sinde idrar TB k\u00fclt\u00fcr\u00fc pozitif sonu\u00e7lanm\u0131\u015ft\u0131.<\/p>\n

Tan\u0131 Y\u00f6ntemleri<\/h3>\n
\"\"<\/a>

Tablo 4.<\/strong> Klinik Formlara G\u00f6re Tan\u0131 Y\u00f6ntemleri<\/p><\/div>\n

\"\"<\/a>

Tablo 5.<\/strong> Klinik Formlara G\u00f6re Tan\u0131 Y\u00f6ntemleri<\/p><\/div>\n

\"\"<\/a>

Tablo 6.<\/strong> Klinik Formlara G\u00f6re Tan\u0131 Y\u00f6ntemleri<\/p><\/div>\n

Ekstrapulmoner t\u00fcberk\u00fcloz tan\u0131s\u0131 32 (%39.6) hastaya sadece histopatolojik, 30 (%37) hastaya ise sadece mikrobiyolojik y\u00f6ntemlerle konulmu\u015ftu; histopatolojik incelemelerde yer alan hasta say\u0131s\u0131 44 (%54.3), mikrobiyolojik incelemeler de yer alan hasta say\u0131s\u0131 44 (%54.3) idi (Tablo 4). Hastalar\u0131n 71 (%87.6) \u2019inden al\u0131nan \u00f6rneklere EZN boyama ve TB k\u00fclt\u00fcr\u00fc yap\u0131lm\u0131\u015f olup 27 (%38)\u2019sinde k\u00fclt\u00fcr pozitifli\u011fi saptanm\u0131\u015ft\u0131 (Tablo 5). Histopatolojik inceleme yap\u0131lm\u0131\u015f olan olgularda en s\u0131k saptanan bulgu nekrotizan gran\u00fclomat\u00f6z iltihapt\u0131 (Tablo 6).<\/p>\n

Tedavi<\/h3>\n

Seksen (%98.7) hastaya ba\u015flang\u0131\u00e7ta izoiazid (INH), rifampisin (RIF), pirazinamid (PZA) ve ethambutol (EMB) ile standart d\u00f6rtl\u00fc antit\u00fcberk\u00fcloz tedavisi ba\u015flanm\u0131\u015ft\u0131. Bir hastaya kronik viral hepatit C tan\u0131s\u0131 almas\u0131 sebebiyle ba\u015flang\u0131\u00e7 tedavisinde PZA verilmemi\u015f olup hasta INH, RIF ve EMB ile toplam yedi ay tedavi g\u00f6rm\u00fc\u015ft\u00fc. Ortalama tedavi s\u00fcresi 8.69\u00b13.38 ay, en k\u0131sa tedavi s\u00fcresi bir ay, en uzun tedavi s\u00fcresi 19 ay olarak tespit edildi. Yayg\u0131n \u00fcrtikeryal d\u00f6k\u00fcnt\u00fc ve ka\u015f\u0131nt\u0131 geli\u015fen bir hastan\u0131n tedavisi birinci ayda kesilmi\u015fti. Klini\u011fi geriledikten sonra tekrar ula\u015f\u0131lan bu hasta tedaviye devam etmeyi reddetmi\u015fti. On dokuz ay tedavi verilmi\u015f olan bir hasta kas-iskelet sistemi TB tan\u0131s\u0131yla takip edilmi\u015f olup tedavinin ikinci ay\u0131ndan sonra \u015fiddetli bulant\u0131 \u015fik\u00e2yeti olmas\u0131 sebebiyle ila\u00e7 kullanmay\u0131 aral\u0131klarla b\u0131rakm\u0131\u015ft\u0131; hastan\u0131n ila\u00e7lar\u0131 temin etmesine ra\u011fmen kullanmad\u0131\u011f\u0131 d\u00f6nemler mevcuttu. \u015eiddetli bulant\u0131 yan etkisi ve hasta uyumsuzlu\u011fu sebebiyle tedavi s\u00fcresi 19 aya kadar uzam\u0131\u015ft\u0131.<\/p>\n

Santral sinir sistemi TB olgular\u0131n\u0131n en uzun s\u00fcre tedavi verilen olgular oldu\u011fu tespit edildi; ortalama tedavi s\u00fcresi 11.3\u00b14.5 ayd\u0131. Tedavi s\u00fcresinin en uzun oldu\u011fu ikinci hasta grubu ise kas-iskelet sistemi TB olgular\u0131 olup ortalama tedavi s\u00fcresi 10.2\u00b13.4 ayd\u0131.<\/p>\n

\"\"<\/a>

Tablo 7.<\/strong> Tedavi S\u0131ras\u0131nda G\u00f6ru\u0308len Yan Etkiler (N=29)<\/p><\/div>\n

Farkl\u0131 yan etkilerin g\u00f6r\u00fcld\u00fc\u011f\u00fc hasta say\u0131s\u0131 29 (%%35.8) olarak tespit edildi. Hepatotoksisite (%23.4) ve bulant\u0131 (%20.9) antit\u00fcberk\u00fcloz tedavi s\u0131ras\u0131nda en s\u0131k g\u00f6r\u00fclen yan etkilerdi (Tablo 7).<\/p>\n

Tedavileri devam ederken hayat\u0131n\u0131 kaybeden \u00fc\u00e7 hasta saptanm\u0131\u015f olup hepsi SSS TB tan\u0131s\u0131yla takip edilmi\u015fti. Bir hasta tedavisinin \u00fc\u00e7\u00fcnc\u00fc ay\u0131nda aspirasyon pn\u00f6monisi sonras\u0131 geli\u015fen solunum yetmezli\u011fi sebebiyle, bir hasta ise tedavisinin alt\u0131nc\u0131 ay\u0131nda n\u00f6bet ge\u00e7irdikten sonra takip edildi\u011fi yo\u011fun bak\u0131m \u00fcnitesinde ventilat\u00f6r ili\u015fkili pn\u00f6moni ve \u00e7oklu organ yetmezli\u011fi sonras\u0131nda hayat\u0131n\u0131 kaybetmi\u015fti; \u00fc\u00e7\u00fcnc\u00fc hastan\u0131n \u00f6l\u00fcm sebebi belirlenemedi.<\/p>\n

\u0130RDELEME<\/h2>\n

D\u00fcnya Sa\u011fl\u0131k \u00d6rg\u00fct\u00fc\u2019n\u00fcn 2023 y\u0131l\u0131 raporu verileri son \u00fc\u00e7 y\u0131lda insidans\u0131n artt\u0131\u011f\u0131n\u0131 ve t\u00fcberk\u00fclozun hala \u00f6nemli bir sa\u011fl\u0131k sorunu oldu\u011funu g\u00f6stermektedir (2). \u00dclkemizde 2020 y\u0131l\u0131nda g\u00f6r\u00fclen EPTB olgular\u0131n\u0131n; %42\u2019sinin lenf bezi, %22.3\u2019\u00fcn\u00fcn plevra, %8.2\u2019sinin kas-iskelet sistemi, %7.1\u2019inin G\u0130S, %4.6\u2019s\u0131n\u0131n G\u00dcS, %4.6\u2019s\u0131n\u0131n SSS, %3.3\u2019\u00fcn\u00fcn millier ve %7.8\u2019inin ise di\u011fer organ tutulumlar\u0131 oldu\u011fu bildirilmi\u015ftir (5). Ta\u015fbakan ve arkada\u015flar\u0131 (6) taraf\u0131ndan yap\u0131lan bir \u00e7al\u0131\u015fmada, k\u00fclt\u00fcr ile kan\u0131tlanm\u0131\u015f 165 EPTB olgusu de\u011ferlendirilmi\u015f ve en s\u0131k kar\u015f\u0131la\u015f\u0131lan tutulum b\u00f6lgeleri lenf bezi (%36.3), plevra (%19.3), kemik (%15.1) olarak bildirilmi\u015ftir. Tanyel ve arkada\u015flar\u0131 (7) taraf\u0131ndan yap\u0131lan \u00e7al\u0131\u015fmada yer alan 119 EPTB olgusunda, tutulum b\u00f6lgeleri %50.4 lenf nodu, %12.6 merkezi sinir sistemi, %17.7 vertebra ve di\u011fer kemikler, %5.9 G\u00dcS, %10 periton ve G\u0130S olarak bildirilmi\u015ftir.<\/span><\/p>\n

\u00c7al\u0131\u015fmam\u0131zdaki olgular klinik formlara g\u00f6re de\u011ferlendirildi\u011finde bir EPTB formu olarak literat\u00fcrden farkl\u0131 bir \u015fekilde en s\u0131k G\u0130S TB (%21.2) tespit edildi; bunu kas-iskelet sistemi TB (%20), lenf bezi TB (%18.8) ve SSS TB (%17.6) izlemekteydi. Merkezimizde gastroenteroloji, onkoloji ve giri\u015fimsel radyoloji kliniklerinde malignite \u00f6n tan\u0131s\u0131yla yap\u0131lan G\u0130S \u00f6rneklemelerinden elde edilen materyaller s\u0131kl\u0131kla TB \u00f6n tan\u0131s\u0131yla da tetkik edilmekte olup \u00e7al\u0131\u015fmam\u0131zdaki hastalar\u0131 takip eden hekimlerin \u00f6n tan\u0131lar\u0131n\u0131n aras\u0131na t\u00fcberk\u00fclozu da almalar\u0131 sebebiyle G\u0130S TB\u2019nin daha fazla saptand\u0131\u011f\u0131 d\u00fc\u015f\u00fcn\u00fcld\u00fc.<\/p>\n

Gastrointestinal sistem t\u00fcberk\u00fclozunda en s\u0131k tutulan b\u00f6lgeler ileum ve \u00e7ekum olarak bildirilmi\u015ftir (8). \u00c7al\u0131\u015fmam\u0131zdaki olgular de\u011ferlendirildi\u011finde 13 (%72.2) hastada peritonit, 5 (%27.8) hastada ileit g\u00f6r\u00fcld\u00fc. Periton s\u0131v\u0131s\u0131 ADA aktivitesinin 30 \u00dc\/lt\u2019nin \u00fczerinde olmas\u0131 TB peritonit tan\u0131s\u0131 i\u00e7in anlaml\u0131 kabul edilmektedir (9). Riquelme ve arkada\u015flar\u0131 (10) taraf\u0131ndan yap\u0131lan \u00e7al\u0131\u015fmada, ADA aktivitesi i\u00e7in s\u0131n\u0131r de\u011ferler 36-40
\n\u00dc\/lt olarak kabul edildi\u011finde duyarl\u0131l\u0131k %100, \u00f6zg\u00fcll\u00fck %97 olarak bildirilmi\u015ftir; t\u00fcberk\u00fcloz peritonit tan\u0131s\u0131nda kullan\u0131lmak \u00fczere optimum s\u0131n\u0131r de\u011fer ise 39 \u00dc\/lt olarak saptanm\u0131\u015ft\u0131r. Bizim \u00e7al\u0131\u015fmam\u0131zda ortalama ADA d\u00fczeyi 93.9 \u00dc\/lt saptan\u0131rken, en d\u00fc\u015f\u00fck de\u011fer 54 \u00dc\/lt, en y\u00fcksek de\u011fer 126 \u00dc\/lt idi ve t\u00fcm hastalarda \u00f6nerilen optimum de\u011ferin \u00fczerindeydi.<\/p>\n

\u00dclkemizde, kas-iskelet sistemi TB olgular\u0131, t\u00fcm EPTB olgular\u0131n\u0131n %8.2\u2019sini, ABD\u2019de ise %13.7\u2019sini olu\u015fturmaktad\u0131r (5,11). Bir \u00e7al\u0131\u015fmada EPTB olgular\u0131 i\u00e7indeki kas-iskelet sistemi olgular\u0131n\u0131n oran\u0131 Danimarka\u2019da %15, Hollanda\u2019da %10.6, ABD\u2019de %11.3 ve T\u00fcrkiye\u2019de %11 olarak bildirilmi\u015ftir (12). <\/b>\u00c7al\u0131\u015fmam\u0131zda kas-iskelet sistemi TB olgular\u0131 t\u00fcm olgular\u0131n %20\u2019sini olu\u015fturmaktad\u0131r. <\/b>Spondilodiskit tan\u0131s\u0131 alan olgularda en s\u0131k L4-L5 (%25), T7-T8 (%16.6), T9-T10 (%16.6), L1-L2 (%16.6) seviyelerinde tutulum saptanm\u0131\u015ft\u0131r. \u00c7e\u015fitli \u00e7al\u0131\u015fmalarda en s\u0131k tutulumun torakal ve lomber seviyelerde oldu\u011fu belirtilmi\u015ftir (13,14).<\/p>\n

Lenf bezi TB en s\u0131k bildirilen EPTB formu olup en s\u0131k servikal lenf bezinde g\u00f6r\u00fcld\u00fc\u011f\u00fc bildirilmi\u015ftir (15,16). Ta\u015fbakan ve arkada\u015flar\u0131 (17) taraf\u0131ndan yap\u0131lan \u00e7al\u0131\u015fmada 694 lenf bezi TB olgusu incelenmi\u015f, tutulan lenf bezleri servikal (%61.4), mediastinal (%20.5), aksiller (%6.4) b\u00f6lgede saptanm\u0131\u015ft\u0131r. Ba\u015fka \u00e7al\u0131\u015fmalarda en s\u0131k tutulumun servikal ve aksiller lenf bezlerinde oldu\u011fu bildirilmi\u015ftir (18,19). Bizim \u00e7al\u0131\u015fmam\u0131zda da en s\u0131k servikal lenf bezi (%50) tutulumu g\u00f6r\u00fclm\u00fc\u015ft\u00fcr; ikinci s\u0131rada ise %19 oran\u0131 ile inguinal lenf bezi tutulumu saptanm\u0131\u015ft\u0131r.<\/p>\n

Baz\u0131 \u00e7al\u0131\u015fmalarda, SSS TB olgular\u0131nda en s\u0131k kar\u015f\u0131la\u015f\u0131lan ba\u015fvuru \u015fikayetleri ba\u015f a\u011fr\u0131s\u0131, ate\u015f y\u00fcksekli\u011fi, kusma ve bilin\u00e7 bulan\u0131kl\u0131\u011f\u0131 olarak bildirilmi\u015ftir (20,21). \u00c7al\u0131\u015fmam\u0131zda da benzer \u015fekilde en s\u0131k kar\u015f\u0131la\u015f\u0131lan ba\u015fvuru \u015fikayetleri ate\u015f y\u00fcksekli\u011fi (%66.7)<\/span>, ba\u015f a\u011fr\u0131s\u0131 (%66.7)<\/span>, bilin\u00e7 bulan\u0131kl\u0131\u011f\u0131 (%40)<\/span>, bulant\u0131 (%33) ve kusma (%33) olarak tespit edildi.<\/p>\n

Erdem ve arkada\u015flar\u0131 (22) taraf\u0131ndan yap\u0131lan \u00e7al\u0131\u015fmada BOS bulgular\u0131 incelendi\u011finde ortalama beyaz k\u00fcre say\u0131s\u0131 320.5 h\u00fccre\/mm3<\/sup>, ortalama protein de\u011feri 307.1 (21-3500) mg\/dl, ortalama BOS glikozu\/serum glikozu oran\u0131 0.28 olarak bildirilmi\u015ftir. Tayland\u2019da yap\u0131lan bir \u00e7al\u0131\u015fmada ise ortalama beyaz k\u00fcre say\u0131s\u0131 139 h\u00fccre\/mm3<\/sup>, ortalama protein de\u011feri 175 mg\/dl, BOS glikozu\/serum glikozu oran\u0131 0.32 saptanm\u0131\u015ft\u0131r (23).\u00a0 <\/span>Bizim bulgular\u0131m\u0131z da s\u00f6z konusu \u00e7al\u0131\u015fmalarla benzer olup ortalama BOS beyaz k\u00fcre say\u0131s\u0131 336.7 h\u00fccre\/mm3<\/sup>, BOS proteini 409.6 mg\/dl ve BOS glikozu\/serum glikozu oran\u0131 0.46 olarak tespit edildi.<\/p>\n

T\u00fcberk\u00fcloz tedavisinde ba\u015flang\u0131\u00e7 d\u00f6neminde etkili ve g\u00fc\u00e7l\u00fc bir kombine tedavi verilmesi, diren\u00e7li mutant su\u015flar\u0131n olu\u015fmas\u0131n\u0131 engellemek i\u00e7in \u00f6nem arz etmektedir. Ba\u015flang\u0131\u00e7 d\u00f6neminde standart d\u00f6rtl\u00fc tedavinin INH, RIF, PZA, EMB ile iki ay olmas\u0131 \u00f6nerilmektedir. Ba\u015flang\u0131\u00e7 d\u00f6nemi tamamland\u0131ktan sonra standart idame tedavinin INH ve RIF ile s\u00fcrd\u00fcr\u00fclmesi, tedavi s\u00fcresinin bu iki ajanla tamamlanmas\u0131 \u00f6nerilmektedir (24,25). G\u00fcney Kore\u2019de yay\u0131mlanan rehberler kas-iskelet sistemi TB olgular\u0131na 9-12 ay, SSS TB olgular\u0131na ciddi morbidite ve mortalite riski sebebiyle en az 12 ay tedavi verilmesini \u00f6nermektedir. (26). \u00dclkemizde yay\u0131mlanan ulusal rehberde bunlara paralel olarak SSS TB olgular\u0131na 12 ay, kas-iskelet sistemi TB olgular\u0131na dokuz ay tedavi verilmesi \u00f6nerilmektedir (24). \u00c7al\u0131\u015fmam\u0131zda en uzun s\u00fcre tedavi verilen olgular s\u0131ras\u0131yla SSS TB (11.3\u00b14.5 ay) ve kas-iskelet sistemi TB (10.2\u00b13.4 ay) olgular\u0131yd\u0131. Olgular\u0131m\u0131z\u0131n tamam\u0131n\u0131n ortalama tedavi s\u00fcresi 8.47\u00b13.4 ayd\u0131. Ortalama tedavi s\u00fcresinin alt\u0131 aydan uzun olmas\u0131n\u0131n sebebi SSS TB ve kas-iskelet sistemi TB olgular\u0131n\u0131n t\u00fcm olgular\u0131n %43.2\u2019sini olu\u015fturmas\u0131d\u0131r.<\/p>\n

Sonu\u00e7 olarak; DS\u00d6\u2019n\u00fcn g\u00fcncel raporlar\u0131nda da g\u00f6r\u00fcld\u00fc\u011f\u00fc \u00fczere, TB ve EPTB hala \u00f6nemli bir halk sa\u011fl\u0131\u011f\u0131 sorunu olarak \u00f6nemini korumaktad\u0131r. Ay\u0131r\u0131c\u0131 tan\u0131da TB mutlaka akla getirilmelidir.<\/p>\n","protected":false},"excerpt":{"rendered":"

G\u0130R\u0130\u015e T\u00fcberk\u00fcloz (TB), Mycobacterium tuberculosis complex olarak adland\u0131r\u0131lan bir grup mikobakterinin etken oldu\u011fu, gran\u00fclomat\u00f6z lezyonlarla seyreden bir infeksiyon hastal\u0131\u011f\u0131d\u0131r (1). D\u00fcnya Sa\u011fl\u0131k \u00d6rg\u00fct\u00fc (DS\u00d6)\u2019n\u00fcn 2023 y\u0131l\u0131 raporunda, t\u00fcm d\u00fcnyada 2022 y\u0131l\u0131nda 7.5 milyon yeni TB olgusu saptand\u0131\u011f\u0131 bildirilmi\u015ftir. Bu say\u0131 DS\u00d6\u2019n\u00fcn k\u00fcresel izlem yapmaya ba\u015flad\u0131\u011f\u0131 1996 y\u0131l\u0131ndan beri saptanan en y\u00fcksek olgu say\u0131s\u0131d\u0131r. \u00d6nceki iki […]<\/p>\n","protected":false},"author":4,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"footnotes":""},"categories":[5129],"tags":[3414,3134,2911],"class_list":["post-29137","post","type-post","status-publish","format-standard","hentry","category-ozgun-arastirma","tag-antituberkuloz-tedavi","tag-ekstrapulmoner-tuberkuloz","tag-tuberkuloz"],"acf":[],"_links":{"self":[{"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/posts\/29137","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=29137"}],"version-history":[{"count":4,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/posts\/29137\/revisions"}],"predecessor-version":[{"id":29490,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/posts\/29137\/revisions\/29490"}],"wp:attachment":[{"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/media?parent=29137"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/categories?post=29137"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/tags?post=29137"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}