4 курс / Дерматовенерология / Dermatologia_i_venerologia_KGMU_g_Simferopol_2012_g

3ITITiill cpep;w HaceneHIDI Ha HaQWOHaJibHOM ypoB1-1e: cnep;yeT opraH11Jo-

BbIBaTb KaMIIaHMw no npmmeqemno BHnMaHIDI K :now npo6rreMe cpep,M

unipOKJl!X CJlOeB HaceJieHIDI, npOBO,[J,Jfl'bnepBlll'IttyJOnpocpIDiaKTMKY, '.)IlJl!-

ll;HilJJ.30p M CKpm-nnir JHII~, He Jl!MeIOIUJl!X KJI11H11'1eCKJl!X01:MilTOMOB.

IlyTb nepe,naqn 3IIIIIIII 'lamescero rroaosoH:. BoAbIUoe 3Ha- q er-rHe s pacrrpoCTpaHeHl·m 3III1IIII HMeeT rror.osoe rrose,neHHe. "LfacTOTa 3nrrrrn y All~, HMeIOIUHX CAY"laHHbie ll 6ecrrop5I.D;O"lHbie IIOAOBbie

151

CB5I3H, B .n.ecHTKH pa3 npeBbill.IaeT 'IHCAOCAY'!aeB3I1IIIlI1, '!eMy AHU., HMelOUJ;HX 0,ll.HOro IlOAOBoro napTHepa H H36era10UJ,HX CAy'!aHHbIXnoAOBbIX CBSI3eH. HerrOAOB OH IlYTb nepe.n.a'IH 3HI1I1II (3arp5I3HeHHbie HHq>HU.HPOBaHHbIMH BbI,ll.eAeHH.HMH pyKH, 6eAbe, npe,ll.MeTbl TyMeTa) cyrn;eCTBeHHOro 3IlH,ll.eMHOAOrH'!eCKOro3Ha'leHH.HHe HMeeT.

y HHcpHU.HpOBaHHhIX M~HH nepBHqHo noproKaeTC5l Mo~xe­

HCTiyCKaTeAbHbIH KaHM (ypeTpHT), a 3aTeM MO)KeT pa3BHTI>C5l Bocna - AeHHe H ;.1.pynrx opraHOB (npOCTaTHT, 3ITH,ll.H,ll.HMHT, opXHT, npOKTHT , cpapHHrHT, KOHblOHKTHBHT, apTpHT) , B03MQ)KHQ pa3BHTHe HMilOTeH- U.HH H 6eCilAO,ll;HH.

y HHcpHU.HpOBaHHbIX )KeHllJ;HH qam;e BCero noproKaeTC5l K aHM ll.IeHKH MaTKH (u.epBHU.HT), IlOCAe qero MO)KeT B03HHKffYTb noproKe Hl·Ie H .npynrx opraHOB (ypeTpHT, U.HCTHT, 6apTOAHHHT, 3H,lJ.OMe TprIT, CaAbIIHHrHT, neAbBHOnepHTOHHT, cpapHHrHT, npOKTHT, KOHbIOHKTHBHT , apTpHT), B03M0)KH0 pa3BHTHe 6ecnAO):(lliI.

Bonpoc&l 3mmcu npu 3Illl1111.

KoHcpH):(eIUJ;HaAbHOCTb O'JeHbBroKHa ,ll;A5l AMI.I. c 3IIIIIIII MAH KOHCYAbTHpyIOilJ,HXC5I no IIOBO,ll;Y Il0,l(03peHllil Ha HaAH'!He 3IIIIIIII.

Bpa'!aMH BCeMY Me,l(HIJ.HHCKOMY nepCOHMY CAe.nyeT upoBO,l(HTb '<IeTKYIO not.HTHKY Koacpri:.neHIJ.HaAbHOCTH.

0CMOTp, o6ct.e):(OBaHHe H Ae'!eHHeTaKHx AIU.I. et.e.nyeT npoBOAHTb TOAbKO IlOCAC no.zx.po6Horo o6o5ICHeHHH nau.HeHTy Bcex acneKTOB , Kaca1oru.HXC5l 06c11e.n.0BaHlliI, J\e'ieHHH H ITOCAe.n.y10ru.ero na6 t.JO- ):(CHllil, H Il0AY'!eHH5lHa 3TO COrJ\aCllil naIJ.HeHTa. IlpH 3TOM Heo6xo- ,ll.HMO B COOTBeTCTByroUI.eii cpopMe ,IJ,aTb nau.HeHTy HHcpOpMaIJ.HlO 0 B03MO)KHOH Il0Ab3e H _pHCKe npOBOJJ:MMbIX MeponpirnTHH.

HcmopUSi 6oR.e3H.U nayueHma c 311111111 iJo.nJICH.a e1CJ110"'am&:

•tj:>l13H'IeCKHe)i(aJI06bI M Cl1MUTOMbI,

•npeAsapttTeJibHhie AMarH03bI 3DI1IITI,

•ceKCYaJibHl>IM aHaMHe3, BKJllO'ia!OXU.HH AeTaJIH, Kacarom;Me or IIOJJOBblX napTHepoB Hacrom:u;ero speMeI-rn, Bl1~bl IIOJIOBbIX

KOHTaKTOB, nocne.a;osaTeJJbHOCTb l1 Ha)J;e)!(I{OCTb l1CllOJJb30BaHVU!: JallJ.HTHhIX cpe.a;crn,

•CMMUTOMbI l1 AHaTH03bl y IlOJIOBOro napTHepa,

•npe.n.mecrny10m;11:fl: o6ru;eMe.a;m:J;l1HCKHH aHaMHe3,

•npMHHMaeMbie B AaHHbnll: MOMeHT Me)J;HKaMeIITbI (BKJIIO<JasI H e- }J,aBHee npwMettem.fe aHTfL'111Kpo6ttbIXnpenapaTos),

•aJIJiepnno K rrei<apcrneHHbIM cpeACTBaM,

•cne11;mpwciecKHe cpaKTOpbI pucKa B ornomei-nrn. 3apa*eHID1 11ucpeKIJ;ID1MM BVfll 11: s11pycttoro rerraTHTa B,

152

•µ.mi: )f(eHID;HH - p;orroJIHttTeJibHO caep;ettmr o pogax tt a6opTax,

MeHcrpyanbHOM n;iume, rrp11ttnMaeMbtx KOHTpau;errrnaax.

II01ca3aH.u.R. 0JU1. npoeeoeH.u.R. o6CJteooeaH.UR u c1epuH.uH2a tt.a 31IIIIIII:

•gttarH03 JU06oro 3rmrrrI, BKmo<ra5r aHoreHHTaJibHbie 6opo.n;aaK11, reHHTaJibHbIM / rrepttreH11TaJibHbIM reprrec, KOFITarH03Hhn1 MonmocK, qecoTKy, no6KOBhrn rrep;11Kyne3, Bl1ll-11H<!JeKD;11ro, aw:pycHyro irn¢eKIJ;ttIO renanrra B;

•p HCKOBaHHoe B rniaHe 3apa)f(ettmr 3rmrrrI rroBep;ettMe: np0tmKarom;11e IlOJIOBble KOHTilKTbI 6e3 npw:MeI-IeHl151 cpe;o;cTB 3alll;HTbI c HOBbIM IIOJJOBbIM napTHepoM, HeCKOJJbKHMM ITOJIOBblMM napTHepaMtt, l1MeIOIIJ,11Ml1 O)J;HOBpeMeiilibie flOJIOBble KOJSfaKTbI c APYrHMM nw11,aMw; napTHepoM, KOTOPOMY Hep;anHo nocrannen p;warH03 3rmrrrI; nap1"HepoM, coo6m;arom;HM o HaJIH'Il1liy Hero CMMnTOMOB, npe;o;nonararoll.(IDC 3rmrrrI;

•BOBJieqeHJ;i:e B KOMMepqecKl1M ceKC (npocnrryu;M5I) B Ka•1ecTBe pa60THl1Ka HJUI KJitteHTa;

•no,IJ,o3pei-n;i:e rm ceKcyaJibHOe moynoTPe6nea11e 11JI11 nacIDrne;

•l10JJOBOM KOHTaKT c qenoBeKOM, MMerom;ruv1 mo6ol1 l13 nepeqv.rcJieHHblX BbIIIIe CHMIITOMOB/ Cl!IHJJ.POMOB;

•3arUiaHttpoBaHHOe BBe;a,e1rae l1HCTJ'YMeHTOBB rneuey MaTKM y )f(eHm;MH, B '!aCTHOcnlnptt a6opTe, BBe;o;e1-rn:e Br-JYTJ'HMaTO'lllbDC 1<0HTPa11,ennmon HJIH JaIIJiaHttponaHHOe 11cryccTBeHHOe om10JJ,OTBopeHl!le,

•Cl1MJIT0Mbl H.IHI <lJ1131'1'leCKl1enpl13HAKT'1, rrpe;o;nonararom;tte B03MO)K}IOe HaJil'1<rtte3IIIIDH -

y/ICeH.UJ,UH.:

"cwMnTOMbI B o6nacTw Bepxttero reHWTa.ITbHoro TPaKTa, npe;o;nona.rarom;Me B03MQ)KHYIO i1Hcp€Kll,l110 opraHOB MaJIOro Ta3a, 60.11« BH113Y )f(H'.BOTa,

anoMaJibHAA MeHcTpyau;1151, ,IJ,ttcnapeuypmr, snaraJrnlll;Hble BbJ,D,eJieHH5I;

y MY:?ICllUH.:

y o6oux noJwe:

reHMTaJibHbie tt3'b513BJieHmr,

153

6orr11 B rrpmiOH KHmKe wrn: Bbl]l,eJieHJ.OI'.(npw HaJil1'l:ID1B

attaMHe3e aHaJibHbIX IlOJIOBbIX KOHJ'aKTOB),

MOHO- l1Jll1 rro.rm:apTpMT,

KOHbIOHKTIIBl1T.

cf>u3uqecKuu oCM.omp npu o6CJteooeaKuu Ka 3nnnII

oon31CeK eJC1uoqam&:

•ocMOTP attorettl1TIUlbHOH o6naCTM y My)K'T11H11 )l(eHIIJ;HU,

•o6cne)J,OBauHe )!<ettm,111-1 c noMOID;bIO 3epKana,

•611MauyanbHOe 11cCJ1e)J,OBaI-Ine Manoro Ta3a y )Kettllf,l!!H npu ua- n 11q11J1 CHMITTOMOB B o6naCTM sepn1ero reHMTaJIDttoro Tpa KTa,

•npoKTOCKOmffi y MY)Ktll1H u )KeHIIJ;HH npw HaJIH<IHH C"1MIITOMOB

HJIH ceKcyanbttoro attaMHe3a,

•OCMOTp Apyrux CHCTeM opr aHH3Ma, ecn:w 3TO tteo6xo,o;11Mo l1Jll1

IIOKa3aHO no CHMilTOMaM.

11a6opamopn&ie ucCJteooeaHUR Ka 3nnnn oon31CK&i

e1CJ110qam&:

CTatt.n:apTHO ,lJ,AR acex nau,HeHTOB npoao.n:s:nc.H HCCAe.n:oaaHHR tta:

IlpH IlOKa3a.HH.HX no CMMilTOMaM, CeKCYaAhHOMY aHaMHe3y Hll.H cPH3H'leCKOMYOCMOTpy rrpoBO,ll,HTC.H HCCAeJJ:OBaHH.H H a:

•6aI<TepHaJlbHbl l1. Banu1.0J,

•1 KaH)J,11,lJ;OJ,

•TPHXOMOIU1a3,

•attoreHMTaJibHbIM repnec,

•'leCOTKY,

•no6KOl3b1i1 ne,o;wKyne3,

•rnattKpOHA,

•BeHep11qecKYIO nHMcporpattyneMY,

•naxosy10 rpattyn eMY,

•BMpycuyro 111ctcpeKLI;J1I0 renaTHTa B.

Cml>BAHC - o6UJ.ee HH¢eKI.I,HOHHoe 3a60Aeaam·1e, BhI3bIBa.e- Moe 6AeJJ:HOH TpenoHeMoH:, conpoao~a10w:eeC.H rroproKeHH eM KO:>KH, CAH3HCTblX 060Ao~1eK, onopHO-JJ:BHraTeAhHOl'O annap aTa, HepBHOH CHCTeMbl, BHyTpeHHHX opraHOB, caoeo6pa3HOH HMMyttHOH rrepe - CTpOHKOH H HMeIOUJ.ee BOAH006pa3HOe Te'leHHe co CMeHOH rrepHOJJ:OB MaHH¢eCTaI.I,HH, rrepH0,11,aMH CKpbITOH HH¢eKUHH.

154

Bo36y.n.nTeAb cm:j:m.AHca - 6Ae.n.Hrur .TpenoHeMa (Treponerna pallidurn) - 6bIAa OTKpb1Ta Schaudinn H Hoffman B 1905 rollY. IlpH-

H~e)J{llT K nopsr.n;ey Spirochaetalis, ceMeiicTBY Spirochaetacae, pollY Treponema.

Treponerna pallidurn rrpe,11,CTaBA.sreT co6oil: rrpoKapHOTHbIH MH1<:poopnUIH3M. Ha3BaI-IHe «6Ae,ll,Ha.lr» TpenoHeMa IIOA~IHAa H3-3a CAa6oi:i: crroco6HOCTH OKpaillHBaThCSi cnen;HcpH'IecKHMHKpacHTei\SIMH. ilMeeT orrpe.n:eAeHHbie MOpljJoJtOZU'lteCKUe npU3Har<:u: TOHKyIO HHTe- BHAH'.fI-0 cpop~i:y• .ZJ:AMHY 6-14 MKM, 8-12 paBHOMepHb!X 3aBHTKOB c 3aKpyrAeHHbIMH sepIIIHHaMH .

Pa3AH'laIOT4 OCHOBHble BH,na .D:BH:>KCHllil'6Ae,ll,HOH TpenoHe-

MbI: CrH6aTeAbHOe (Ka 'IaTeAbHOe, Ma.lrTHHK06pa3HOe), BpamaTCAbHOe, nocTyrraTei\hHOe H BOAH006pa3HOe. BAe):(HruI TpenoHeMa HMCeT CAellYlOUJ.He MOpcpoAOrll'!eCKHeKOMITOHeHTbI:

•npoTonna3MaTl'!.'IecKHfl U:IDIHH.D:p (BK11IO'laIOUJ,l1fl HyKJieo-rl1,!1,, QHTOIJJia3My, pw6oCOMbI, l\MTOTIJJa3MaTWieCKYIO MeM6paH)'),

•KJieTO'IHYIOCTeHKY c TpexCJJOHHOM MeM6paHoi1,

•Kancynono,n;o6 ttyro cy6crattu,1uo.

HH.sr. KpoMe Toro, cymecTBYIOT <jJopMbL ycmoil'-lueozo 6bD1CUeaHUR, KoTOpb1e o6pa3YJOTC.li B opraHH3MC 'leAOBCKa H SIBM!IOTCSi OCHOBHblM crroco6oM coxpaHeHnsr H pa3MHO:>KeHH.sr HHcpe1ru:~m npH He6Aaronpu-

.HTHbIX ycAomrnx u HMeIOT 60Abu10e 3Ha'!eHHeJl.Afl n oHHMaHnsr naToreHe3a Il03.D:HHX H AaTeHTHblX cpopM CHcpHAHCa, B03HHKHOBCHIDI peLJ,H,ll;I'IBOBH aey.n:aq npH Ae'IeHHH. 3Tn cpopMbI ycroii'lHBhIK Bo3.n:eil:- CTBHIO He6AaronpIDITHblX cpaKTOpOB BHemHeH cpe)'.I,bI (aHTHTeA, AeKapCTBeHHbIX npenapaTOB, TeMnepaTypHblX B03):(eHCTBHH, o6Ayqe-

Hiffi). K HMM OTHOC.liTCR:

•l:\~lCTb! - lfMClOT 3alll,HTttyIO o6oJIO'IKY113 HCCKOJibKMX CJJoeB nHelllHero MeM6pattttoro noKpbITIDI M Kancynono,n;ofoiy10 MyKononwcaxapM.n;ttyIO cy6cTam,mo;

•L-cpopMbI - xapaKTepM3YIOTC51 qacrW'IHoi1IDil-1 noJIHol1: YTPa-

T011 KJleTO'IHOHCTeHKlf, CHJVKCHMCM MeTa60JTI13Ma, HapymeHMeM npou;ecca KlleTO<rHoro ,n;eJieHM51;

•3ep1rn IDIH cnopbI (cpparMeHTbI TpenoHeM};

•noJIMMeM6paHHbie cparocoMhI (rrpo,n;yKThr He3aBepmeHHoro ¢a- rou;Kr03a).

155

OrrTHMMhHOH TeMnepaTypo:ii .Zl.l\H cymeCTBOBaHHR T. pallidum srnAfleTC.H 37°C. BAe,n:Ha.H TperroHeMa He yCTO:W-l:Hsa so BHelllHe:H cpe,n:e: n on16ae T npH BblCYIIIHBaHHH, BblCOKOH TCMnepaTy- p e, )l.Ct°ICTBHH aHTHCCilTHKOB, xoporno n epeHOCHT HH3K)'IOTCMrrepaTypy, cox paH.HeTC.H BO BhruKHOH cpe,n:e, B K H ChOH H Ill.ChO'iHOHc p e,ll.e 6bICTpo rrorH6aeT.

Hcmoatnu1e 3apCJJKeHust - 6oAbHOH 'iCAOBeK. H aH6oAee 3apa3HhI 601\bHbIC B paHHHC nepHO,ZJ,bI CHcpHhHCa (Jl.O 2-x AeT c MOMeHTa 3apruKeHH.H) . Ha.H60AblllHi1 p HcK 3apruKem1.H cyrn;ecTByeT rrpH KOHTaKTe c 60hbHbI M BO BTOpH'iHOMnepHo,n:e CHcpHAHca, Kor.n:a BblCbUiaHH.H HMelOT pacnpoCTpaHCHHblH x a paKTep.

llymu 3apwx:enust:

•nonoaol1 (90-95 % CJiy'Iaea),

•6bITOBOlil: - q epe3 mo6hre rrpep;MCTbI 6brra, co)J,epx<eu.u;111e * .HB1>1e

•TpaHcnnau;eHTapHbIH (auyTpHyTpo6Hbn1:) - 3apa)l(e1me m10,IJ,a OT 6onhHOH MaTepn qepe3 nnau;eHTY,

•npocpeccHOHaJibHbllii - y MC,ll,Kl.l,l1HCKl1X pa6oTHl1KOB, rrp11 npoBC,ll,CHl1H pa3.\IH'iHblXMC,lJ,Ull;l11iCKHX MaHHII}'ruru;HM c nau;11-

e1-naM11 6onbHbIMl1 c111cpY1J1HCOM.

MHCa HhH IlOKpOBHOro 3IlHTehHH ChH3HCTOH o60 AO'iKH. 3 apa3Hbl h l06bIC 3 p03HBHblC npmIBAeHH.H nepBH'iHOI'O BTOpH'IHOI'OCHcpHAHCa. MOAOKO, cnepMa, BhaI"aAHIII,HaH ChH3b 60hbHblX 3apa3Hbl . CAIOHa 3apa3Ha np11 HM:W-IHH cneu.HcpH'IecKoro ·nopaJKeHH.H noAOCTH pTa. CeK- p eT n oTOBbIX »ceAe3, MO'laHe 3apa3HhI. Bonpoc o 3 apa3HOCTH CAC3HOH :>KHJJ:KOCTH OCTaCTCH OTKpb!TbIM.

HMMynumem npu .cut/JUJtuce. B Te'ieHHeCHcpHAHTH'ICCKO

HHcpCKll,HH B opraHH 3 Me 60hbHOrO pa3BHBa eTC.H T aK Ha3bIBaCMblH H e- cmepW1.b1-/.bLU, UHcj>eKJJ,U01-/.1-/.bLU UM.MyHumem. 3TOT HMMYHHTCT B 0 3HHKaCT KaK OTB CTHaH peaKU.HH opraHH3Ma Ha Hai\H'iHCB HCM B036y,n:H- TCJ\H 6oAC3HH H cym.ecTByeT, IlOKa B opraHH3 Me HMCCTCH 6ACJ1:Ha.H TpenoHeMa. KaK TOhbKO npOHCXO.D:HT IlOhHa.H r H6ehb BCCX 6ACJJ:H bIX T penoHeM H HacrynaCT Bbl3,ll.Op0BhCHHe, HHcpeKIJ:HOHHblH HMMYHHTCT HC'iC3aCT H opraHH3M CTaHOBHTCH BHOBb BOCilpHHM'iHBblMK 3apruKeHHIO. T a KHM o6pa30M , npH CHcpHAHCe HMCCTCSI B 0 3MmKHOCTb IlOBTOp-

156

HOI'O3apruKeHlliJ "'ieAOBeKaIIOCAe Bbl3,Z!;OpOBAeHHSI (pew-u:jJeKJJ,UR.). IlpH

3TOM Te"'ieHHepeHH<lJeKJJ;HH He OTAH"'-!aeTCROT KAaccnqecKOI'O.

Cynepw-ujJeKJJ,U5l - nosTopnoe 3apa2KeHHe n oAHOCThJO ne H3- ti.e"'-!HBrnerocsr "'-!eAOBeKa, KOr,n;a B HeOCB060,ZJ;HBlliHHCR OT 6Ae,ZJ;HblX TperroHeM opraHH3M ITOCTyTiruoT HOBbie HX •ITOPUHH•, npOHCXOAHT KaK 61>1 HaCAOCHHe HOBOH cmpHAHTH"'iCCKOH HHQJCKJJ;HH Ha pKe HMeJOlll;HHCR CHQJHJ\HC. CynepHHcjJeKJJ;IDI MO:>KeT HMeTb Mecro:

•a 11HKy6au;~mHHoM rrep11op,e 11 rrepab1e 10-14 P,Hew nepa11qHoro rrepi10p,a, KOrAa 11HcpeK1J,HOHHbl l1 11MM)'H1'1TeTem;e n e ccpopMHpoaaJirn (K 3apa)l(ettm0 B 3TO apeM>! MoryT rrpHBO)J,MTb IlOBTOp-

Hhie IIOJIOBbie KOHTaKThJ c 6omHhIM CMc:jHUTJIJCOM);

• rrpH IT03,0:HeM ·rpeTH'IliOMCHcprun1ce - B03MO:>KHOCTb pa3B~ cyrrepHHcpeKIJ;HH B )J,aHHOM cnyqae ofrbSICWleTCSl Ff113KOM Harrpsi:)l(eHHOCThIO HMM)'l-HITeTa B CBJl3H c Ot:reHb M3JiblM cop;ep)f(a- HHeM TpenoHeM B opraHH3Me.

B KAaCcH'-lecKoMTe"'ieHHH rrpHo6peTetmoro cHcjJHA11ca Bhr,n;e- AR"EOT CAe..nyIOm;He rrepHO,ZJ;bI.

1.Hu;cy6aifU01-t1tbtti nepuoo - speM.si OT MoMeHTa. 3apa.)l(eIDUJ ;a;o noS1BneHmr rrepBtt'IHOroacpcpeKTa (TBepr~oro maHKpa). B cpeAHeM cocraarucer

OKono 3-4-x tte,o:eno. OrrHcatto yKopo'leHHe HHKY6au;m~m-:i:.oro rrepHo,o:a ,o:o 9 - 15 ,o:Hei71 '11 yWI11Hem:1e r.r,o 4 - 6 Mecm~es.

}> YKopoqettMe HffKY6aQHOHHoro nep11op;a Ha6mop;aeTC.SI B CJI}"lae 6Mnom1pHoro pa.cIIOJIQ)Kelflffi TBep,O:bIX ma.HKpOB, npH BHe,o:peHl1 H: Cl1cpIDIMTK'leCKOH micpeKIJ,Jrn B opra.mn M qepe3 pa.3Hbie y-qaCTK11 Tena (ttarrpH:Mep rron oabre opr aHbI » n onoCTb pTa); npH 3TOM npoHcxor.r,'11T 6onee 6brcrp oe Hacbrm;eHMe opraHl13Ma. 6JTe[.l;HbIMl1 TpenoHeMaMM, y cKopSllOIQee reHepam13aU,l1JO 11HcpeK1J,HM l1 pa.3Bl1Tile l1MMYI·IHbIX H3MeHefmi1, a TfflOKe y ocna.6- JieHHbIX 6oJibHbIX c Bb1pm1<eHHOH l1MM)'HHOHp;enpecc11el1:.

}> Y AJIMHeHMe '11IiK)'6an;Mommro rrepHoAa OTMe'laeTcsinp11 npHeMe aHTM6MOTl1KOB, no noao,o:y 11.pyrID< 3a6oJieBaHHV1 anyTpeHHHX opra.HOB '11 CMC'reM.

2.llepB11'l1-tbt1i nepuoo cttcp=ca Ha•rnHaeTcsi: c MOMeHTa. n ommeIDUJ TBep11.oro lliaHKpa. 1II rrpop:oJDKa.eTCH JJ;O IIO:IBJleH'l1SIHa KO)!(e T1 CJIH3MCTl>IX MHQ)J(ecTBeHHbIX CHcpIDI'l1Tif"<IeCKl'1X Bb1Cbma.H11J1. 3ToT rrepHOA AHMTOI 6- 8 HeAeJib 11 nop;pa3AeJUieTCSI Ha rrepBH'IHbIHceponezamu81-tbtii

(Kor,o:a. cTatt,o:a.pTHble ceponorwrecKl!Ie peaK1.~K11 OTpmJ;aTenbHbI, P,JIMTCSl

3-4 He.r:r.e1n1 nocne B03Hl'1.KHOBeHvtsi: ruep,o:oro ma.HKpa) 11 cepono3umu8- Hotii (Korp,a cTaI-1Aa.pn1bre ceponorntieCKMe peaKI~MM CTa.HOB5ITC51 nono-

>Kl1TeJJbHbIM11, AJIMTCSl 3-4 HeAeJIH).

157

3.Bnwpu'lubtii nepuoiJ cmpHJT11ca xa paKTepM3yercH rroHBneffifeM MHOlKe-

CTBeHHbIX BbICbinanl111 Ha KO)l(e n CJIM3HCTbIX o6ono'IKax.Ha'IHHaeT01 B

cpe,ll,HeM qepe3 Mecm:i;a c MOMe HTa 3apa*eHl1H w npo.o;oJI)f(aeTCH

6e3 neqeHl1H 2-4 ro.o;a. BTopwn-1brn cttcj:>wrnc rro.o;pa3,!J;eruIIOT Ha pu11.Hbtit cBe>KUU (Korp;a Ha KO)l(e l1 CJll13l1CTblX o6orro'IKaX BnepBbie IIOHBJUUOTOI MHO)f(eCTBeHHble Cl1¢Wil1TI".t'leCKl1eBbICbIIIaHml, npM 3TOM coxpaIDiercsi: wep.o;ul!! maHKp mrn em ocra.TKM), 8mopu11. H&1u pe71uau6Hb1it

(nepMO)J; nocn e.o;yIOll111X IIOBTOpH blX BbICbiriaHKI!!) H BmopwtHblU CKpblmbtii. (rrep110.o; 6e3 BbICbllJaHHH Ha KO)l(e l1 CJIM3HCTbIX o6oJIO'IKax).

4.Tpemut1Hbllt nepuo iJ 01cj:>l1Jll1ca pa3BMBaeT01 y He ne'IMBnrnxcsr 11.mi:

IIJioxo Jie'IMBIIIHXCH 6orrhHbIX Cll)'CTH 3-5 neT noo 1e 3apa*eHl1Sl. Ero

no,n;pa3,D;e.JISllOT Ha aKt11U8HblU nepuoa (np11cyTCTByIOT KJIMHJir'IeCKMe CMM-

IITOMbl c mpl1ffifc a w noJIO)KMTe.JibHbJe ceponorn-qecKwe peaKiiHM) 11

CKpbtmbtit nepuoa (KJim-IM'IeCKMe npoHBJJeHMH 6orre3Hlf oTCyTCTBYIOT, c e - ponorw1ecKMe pea~ww nonO)l(HTeJihHbre).

ECAH y 6oAbHoro OTCYTCTBYlOT 8.KTHBHbie rrpoSIBAeHHSi cHqm-

AHca, TO Ha OCHOB8.HHH ,Zl;aHHbIX 8.H8.MHe3a, BH3Y8.AbHOro OCMOTpa H

cepOAOrll'JeCKoro HCCAe,Zl;OB8.Hllii 60AbHOMY BbICT8.BA.!IlOT ,Zl;H8.I'H03

CKpblm-020 cucf>wiuca, KOTOp bIH IlO,Zl;pa3,Zl;eAfieTCSI Ha paH.HUU Cl\.pbtmbtil

(cpoK 3a60AeBaHHH .n;o 2-x Ae T) H no3oliuil cKpbtmbtil (cpoK 3a60Aesa-

Hllil CBhIIlle 2 -x AeT) .

K.nuH.u..,,ecKue nposte.n.eH.USt nepeui.l.H.ozo cucpUJtuca:

n epB::l'IHl>JHaq1«1>eKT (Teep.llbIH waHKp t. Bo3HHKaeT B MecTe n pOHHKH OBeHHH 6Ae,Zl;HOH TperroHeMbl qepe3 KO)f()" HAR CAH3HCTbi e o6oaoqKH. )l.ecjJeKT ¢opMHpyeT CSI BCAe,Zl;CTBHe C,Z1;8.BAemrn IIA.a3MO!..I;H- TapHbIM HHcf:JHAbTpaTOM KpOBeHOCHbIX c o cy.n;oB B MeCTe B X O,Zl;HbIX BO-

3HaKOB:

•JIOKamoaI.,MSl - qarn;e no1to8aJ1. (tta KO)l(e l1 C.TH13l1CTbIX o60JIO"lKa x IlOJJOBbIX opraHoB) M 3l!a"lwre.TibHO pe)Ke 8HenOA06aJI. (CJI113J.1CTbie o60JIO'lKM

IIOJIOCTli pTa, 1y6bI, IDbIK, MJ1H,!J;filfMHbI, CJll13MCTaSl 3a,D;Hero npoxo,a;a T1:

mo6b1e .o;pyrMe yqaCTI<M KO)l(l;t, r.o;e npow30IIIJIO npoHMKHOBettHe 6ne,a;-

l

•rrpep;crasrrner co6oM: 3po3-r1ro MJT11 51313y;

•Kp<Ui 3p0311:H (j{JBbI) pOBHble, CJierKa B03BblillalOT01 H orrycKaIOTCH KO AH}' (6mop;n;eo6pa3Hasr cpopMa);

•pe3KHe 'leTK11erpaHmJ;bI, ocrposocrranl'1TI!JibHbiesmrreHJUI oTCyTcTsy10T; ll,BeT .s!pKO-KpaCHbllf (QBeT «CBe )l(ero MHCa» );

•AHO rrrap;Koe, B OCHOBaII11'11,IJ;Ha IIaJThIIHpyercH IIJIOTHbIB HHcpHJibT}JaT;

•oTµ;errne Moe - CKYAHOe, cepo3ttoe (Affil 3p03lnt), cepo3HO-KpOBHHl1CTOe (wrn j{JBh1);

•B OTp;eJUleMOM o6HapyHrn:BaJOTC51 6rre)l;HhJe T}JeilOHeMhl; cy6oeKTHBHO - oTCyTcra11e 6orreBbIX or.u;ym;e1-rnM:;

•n?crre Ja)l(HBJieHm! H3BeHHbrn TBepJJ.bIH mam<p OCTaBJI5JeT py6en;, a 3po3HBHbIH Ja)l(HBaeT 6eccrrep;Ho.

Amunwu-tbLe <jJop.Mbt meepoozo waHKpa. IloMHMo THilJ.NHbIX cpopM TBep.n;oro IllaHKpa pa3AWJaIOT TaJOKe aTHilJ.NHbie, KOTOpbie He HMelOT xapaKTepHblX KAHHH"ieCKMX rrpH3HaKOB, npHCYUJJIX THIIH"i- HhIM cm:j:HlAOMaM Iii BCTpeqaIOTCH 3Ha'IHTeAhHO pe)Ke.

Pa3AH"iaIOT CAe.uyroIU,He BHJ1.hI aTHilH"iHbIX IllaHKpoB.

•11HAypaTHBHblff OTeK - CTOHKHH cne11,11qmqeCKMH JIHMcpaHmMT, conponmKJJ.a1om;m1:csr .smneHMIDrn: m tMcpocraJa. 11opaJKaJOTCsr MaJibie H 60Jiburne IIOJIOBbJe ry6bI, KO)l(a IlOJIOBOro 'llieHa11 MOlllOHKK. 110paJKeHHasr <i:acTb yaeJ1J1qi:reaeTCsr B pa3Mepax, rrpHo6peraer JaCTOHHOKpacHbIH. ~eT, CTaHOBHTCSI: IIJIOTHOH, n pH 3TOM OCTaBaSI:Cb 6e36orre3HeHHOH. Jl11Mcpan1qecKHe y3Jl1>1 co~pattm0T ace xapaKrepttwe·rrptt3HaKM cucpHJI11nrqecKoro nopa)((eHIDI. 3po3i;m wm SI:3Ba onyrcrnyeT.

•IllaHKp-ar.mr.a;amu - cnen;11cpHqecKoe nopaJKem1e MHHJJ,aJil1H. Ilp11 3TOM HMeeTCH O)J,HOCTopoHHee )'BeJIM'IeHHeMHHAa.rIHHbl 3aCTOHHOKpacHoro 11,aera, 3Haqvrre.JJbHOe ee YIL'IOTHeHMe.B TO )((e apeM,SJ oTcyT-

CTBYeT xapaKrepttasr 3po311sr 11JIH sr:rna. Ha cropoHe rropa)!(eHHoM:

MHJ-I)J;anl-1HbI o6uapy)!(JIBaIOT llOA"leJIIOCTHOCi: HJil1 meHHblH mi:McpaAeHl1T. 06rn,ee COCTOHI-rne He C'Ipa;r:r;aeT, TeMn epa-rypa He IIOBblllleHa. oOJJbttoH. MO)f(eT or.u;ym;aTh JaT}Jy;r:r;ttem1e H He6oJibirryJO 6oneJHeHHOCTh rrpu r n onunrn:.

•IllaHKp-rra11apuu;m1: JIOKanl13yeTCSJ Ha AHCTlUlbHOH cpanaHre ITaJibJ.J;a M HMeeT 60JiblllOe KJll1H!1"CfeCKOe CXOACTBO c 6aHaJibHbIM IIa.HapHll;H- eM. Tipe;r:r;CTaBJIBeT co6o H. r n y60Ky 10 ~BBY c a epOBHbIMl1 KpasrMH, HeKpoTINeCKMMM MaccaMU Ha ;o;He, OKpyX<eHffYIO 3aCTOUHOH r1111epeMJ1eM: H pacn:on araroIIJ,yJOCH Ha OTe'L{HOMKOfllleB01'1cpa.riaHre. noKTeBble 11 nop;Mhrrueqffb1e II11Mcpoy3Jlb1 Ha rropa*eHHOM cTopoHe yBentt'!eHbI

159

" 6oJie3HeHHbI. XapaKTepm.1 nnoKe pe3KHe crpemnom.He 6on11: B

nam>t\e.

•IllanKpbI IlleHKJ1 J\laTI<H H npHMOH KHillKH OTHOOITOl K aTMitlf<!- HbIM cpopMaM H3-3a HeB03MO:lKI-IOCTll: nponam>IIHpOBaTb nepwcpepHqecKffe JIHMcpaTu-tJecKwe YJJII>I, T.K noCJieAHHe YBeJilf<IHBaIOTOl B MaJIOM TaJy.

OC!lo.JKH.eH.11.51. meepoow u.tar-aqJa o6ycAOBAeHbI npHcoe.n;HHeHH-

eM BTOpWIHOH HH¢eKIJ.HH, 'ITOnpOSIBAfleTC.H HeCBOHCTBeHHb!MH nepBWIHOH cH¢HAoMe KAHHH'ieCKHMHcuMnToMaMH. OT,n;eMJ eMoe cTaHo-

BHTCR cepo3Ho-rHOHHhIM. BoKpyr 3 p03HH pa3BHBaeTCsi: .HpKa.H n:mepeMH.H H OTeK, nO.HBAflCTCH 6oAe3HCHHOCTh, qyBCTBO :>KlKCHH.H. IlpH A0KaAH3 aIJ;HH OCAO}{QieHHOH CHtPHAOMbI Ha I'OAOBKe IlOAOBOI'O 'iJ\.eHa, OCTpbre BOCilaAHTeAhHble .Sl.BAeHH.H pacnpocrpaH.HIOTCSI Ha Hee c pa3-

BHTHCM 60JLaHuma. B ,ll;aJ\.hHCHllICM BOCilaACHHC MO)KeT nepeHTH Ha npHAeraIOW.HC yqaCTKH KpaH:HeH IlJ\.OTH, 3aTeM 6hICTpO pacnpOCTpaHHTbCSl Ha Bech BHyTpCHHHH ee A H CTOK, npH 3TOM pa3BHBaCTCSI

H.Onocmum BaAaHOilOCTHT MO)KCT npHBO,ll;HTh K c~eHHIO KpaiiHeH

OTBepCTH.H npenyu;HaAhHOrO MernKa BhI,ll;ei\SleTCSI rHOH.

IlpH OTeKe KpaH:ue l1J\.OTH IlOAOBOro 'iJ\.eHa pa3BJ·rnaeTC:.H na-

pacjJUM03 (•y.n;asKa•). K 3 TOMY )Ke MO)KeT npHBeCTH nonbITKa HaCHAhCTBeHuoro OTKpbITHSI roAOBKH IlOAOBOI'O'iJ\.eHanpH HaAM'l:HHtPHM03a.

H J\.HMcj:>oo6pa1.n:eHHSI OTC'IHOCTb)'BCAH'-l:HBaeTcsrEcAM. CBOCBpeMeHHO He np"I-nrnTi. MepbI, TO MO)KeT HacrynHTh OMCpTBeHHe TKaHeH I'OAOBKH not.osoro 'IACHaH Kpail:I-1e.H nAOTH. B Ha"lMhHbIX CTa.D.H.HX napa¢HM03a Bpa"l, BblilYCTHB HrAOH cep03ffYIO )KH,ll;KOCTb H3 OTe'IHOH IlOAOCTH Kpai1:Heli nAOTH, .n;eAaeT non1>1Tey •BrrpaBAeHHSI• roAOBKH . IIpu oTcyrCTBHH 3¢¢eKTa rrpu6ermoT K pacceqemuo IIOAOCTH KpaHHeH: llJ\OTH.

BoAee T.H)KeAMMH H pe.n;KHMH OCJ\O)KHeHH.HMH TBep.n;oro lllaHKpa SIBAfllOTCSI 2QH2peHWQlJ,u..H (Ha IIOBepXHOCTH lllaHKpa o6pa3yeTCSI rpsr3HO-'IepHbIHCTpyn}, KOTOpa.H MO)KeT pacrrpoCTpaHSIThCSI 3a npe.n;e- Abl nepBH'I OH cmpHAOM bI (cjJazeoeHU3.M), <J;TO BCTpe"laeTCSI B OCHOBHOM y OCAa6AeHHhIX 601\hHbIX B p e 3y AbTa'renpHCOC,ll;HHCHHSl: cpy3ocnepHAAe3HOH HHcj:>eKIJ;HH. Ilpou:ecc conpoBmK,ZJ:aeTC.H IlOBbUileHHeM TeM - nepazyphl, 03H060M, I'OAOBHOH 601\hIO H .n;pyrHMH o6rn,HMM RBACH:IDJ.- MH. IIpH OTTOp:lKeHHH CTpyrra o6pa3yeTcsr o6rnHpHa.H H3Ba, yseAH'iH-

160