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24 окт€бр€ 2014, 20:46 226 0

÷итомегаловирус 

√руппа заболеваний: инфекционные и паразитарные болезни
—межные болезни: герпес опо€сывающий, герпес простой, мононуклеоз
¬рач в каталоге: инфекционист
ѕораженные органы: слюнные железы, половые органы, кожа
 

ќписание

÷итомегаловирус (англ. Cytomegalovirus, CMV) — род вирусов семейства герпесвирусов (Herpesviridae). ѕредставитель рода Human herpesvirus 5 (HCMV-5, или герпесвирус человека тип 5) способен инфицировать людей, вызыва€ у них цитомегалию.

¬се вирусы герпеса имеют свойство латентно находитьс€ в организме человека долгие периоды времени. ¬ирус имеет сродство к ткан€м слюнных желез, что зачастую позвол€ет находить и локализовывать его именно там. ƒанный вирус, как и все вирусы герпеса, имеет свойство посто€нно находитьс€ (персистировать) в организме человека при однократном заражении, однако сам по себе он не сильно заразен, поскольку дл€ этого требуютс€ частые и тесные контакты с носителем.

÷ћ¬ также весьма широко представлен в попул€ции, однако антитела в организме человека начинают выдел€тьс€ самосто€тельно.  ак правило, антитела обнаруживают у 10-15% подростков и 40% людей от 30-35 лет.

ѕричины

÷итомегали€ не €вл€етс€ высоко заразной инфекцией. ќбычно заражение происходит при тесных, длительных контактах с носител€ми цитомегаловируса. ÷итомегаловирус передаетс€ следующими пут€ми:

  • воздушно-капельным: при чихании, кашле, разговоре, поцелу€х и т.д.;
  • половым путем: при сексуальных контактах через сперму, влагалищную и шеечную слизь;
  • гемотрансфузионным: при переливании крови, лейкоцитарной массы, при пересадке органов и тканей;
  • трансплацентарным: во врем€ беременности от матери плоду.

—имптоматически протекает в форме упорной простуды. ќтмечаетс€ слабость, недомогание, головные и суставные боли, насморк, увеличение и воспаление слюнных желез, обильное слюноотделение. „асто протекает бессимптомно. “€жесть течени€ заболевани€ обусловлена общим состо€нием иммунитета. ѕри генерализованной форме т€желые очаги воспалени€ возникают во всем организме. ќпасна цитомегали€ беременных: она может вызывать самопроизвольный выкидыш, врожденные пороки развити€, внутриутробную гибель плода, врожденную цитомегалию.

ƒругие названи€ цитомегалии, встречающиес€ в медицинских источниках — цитомегаловирусна€ инфекци€ (÷ћ¬), инклюзионна€ цитомегали€, вирусна€ болезнь слюнных желез, болезнь с включени€ми. ¬озбудитель цитомегаловирусной инфекции  цитомегаловирус относитс€ к семейству герпесвирусов человека.  летки, пораженные цитомегаловирусом, многократно увеличиваютс€ в размерах, поэтому название заболевани€ «цитомегали€» переводитс€ как «клетки-гиганты».

÷итомегали€ €вл€етс€ широко распространенной инфекцией, и многие люди, €вл€€сь носител€ми цитомегаловируса, даже не подозревают об этом. Ќаличие антител к цитомегаловирусу вы€вл€етс€ у 10-15% населени€ в подростковом возрасте и у 50% взрослых людей. ѕо некоторым источникам, носительство цитомегаловируса определ€етс€ у 80% женщин детородного периода. ¬ первую очередь это относитс€ к бессимптомному и малосимптомному течению цитомегаловирусной инфекции.

Ќе все люди-носители цитомегаловируса €вл€ютс€ больными. Ќередко цитомегаловирус находитс€ в организме многие годы и может ни разу не про€вить себ€ и не нанести вреда человеку. ѕро€вление скрытой инфекции происходит, как правило, при ослаблении иммунитета.

”грожающую по своим последстви€м опасность цитомегаловирус представл€ет у лиц со сниженным иммунитетом (¬»„-инфицированных, перенесших трансплантацию костного мозга или внутренних органов, принимающих иммунодепрессанты), при врожденной форме цитомегалии, у беременных.

 ак развиваетс€ болезнь

ѕопада€ в кровь, цитомегаловирус вызывает выраженную иммунную реакцию, про€вл€ющуюс€ в выработке защитных белковых антител  иммуноглобулинов ћ и G (IgM и IgG) и противовирусной клеточной реакцией  образованием лимфоцитов CD 4 и CD 8.

”гнетение клеточного иммунитета при ¬»„-инфекции приводит к активному развитию цитомегаловируса и вызываемой им инфекции. ќбразование иммуноглобулинов ћ, свидетельствующих о первичной инфекции, происходит спуст€ 1-2 мес€ца после заражени€ цитомегаловирусом. „ерез 4-5 мес€цев IgM замен€ютс€ на IgG, обнаруживающиес€ в крови в течение всей последующей жизни.

ѕри крепком иммунитете цитомегаловирус не вызывает клинических про€влений, течение инфекции происходит бессимптомно, скрыто, хот€ наличие вируса определ€етс€ во многих ткан€х и органах.

ѕоража€ клетки, цитомегаловирус, вызывает увеличение их размера, под микроскопом пораженные клетки похожи на «глаз совы». ÷итомегаловирус определ€етс€ в организме пожизненно.

ƒаже при бессимптомном течении инфекции носитель цитомегаловируса €вл€етс€ потенциально заразным дл€ неинфицированных лиц. »сключение составл€ет внутриутробный путь передачи цитомегаловируса от беременной женщины плоду, который происходит в основном при активном течении процесса, и лишь в 5% случаев вызывает врожденную цитомегалию, в остальных же носит бессимптомный характер.

—имптомы

÷итомегаловирусные инфекции наиболее опасны в перинатальном периоде и у людей с иммунодефицитами.

Ѕеременность и врожденна€ инфекци€

HCMV относитс€ к группе TORCH-инфекций, привод€щих к врожденным патологи€м. Ёто токсоплазмоз, краснуха, цитомегаловирус и простой герпес. ћать заражает ребЄнка при первичной инфекции или реактивации вируса перед родами.

ƒо 5/1000 новорожденных инфицированы. ” 5 % развиваетс€ цитомегали€, напоминающа€ по симптомам краснуху. ” других 5 % впоследствии развиваетс€ церебральна€ кальцификаци€, сопровождающа€с€ снижением коэффициента интеллекта, нейросенсорной глухотой и психомоторной заторможенностью.

¬рожденна€ цитомегали€

¬ 95% случаев внутриутробное инфицирование плода цитомегаловирусом не вызывает развити€ заболевани€, а протекает бессимптомно. ¬рожденна€ цитомегаловирусна€ инфекци€ развиваетс€ у новорожденных, матери которых перенесли первичную цитомегалию. ¬рожденна€ цитомегаловирусна€ инфекци€ может про€вл€тьс€ у новорожденных в различных формах:

  • петехиальна€ сыпь  мелкие кожные кровоизли€ни€ (встречаетс€ у 60-80% новорожденных);
  • недоношенность и задержка внутриутробного развити€ плода (встречаетс€ у 30% новорожденных);
  • желтуха;
  • хориоретинит  острый воспалительный процесс в сетчатке глаза, часто вызывающий снижение и полную потерю зрени€.

Ћетальность при внутриутробном инфицировании цитомегаловирусом достигает 20-30%. »з выживших детей больша€ часть имеет отставание в умственном развитии или инвалидность по слуху и зрению.

ѕриобретенна€ цитомегали€ у новорожденных

ѕри инфицировании цитомегаловирусом в процессе родов (при прохождении плода по родовым пут€м) или в послеродовом периоде (при бытовом контакте с инфицированной матерью или грудном вскармливании) в большинстве случаев развиваетс€ бессимптомное течение цитомегаловирусной инфекции.

ќднако у недоношенных младенцев цитомегаловирус может вызывать зат€жную пневмонию, к которой часто присоедин€етс€ сопутствующа€ бактериальна€ инфекци€.

„асто при поражении цитомегаловирусом у детей отмечаетс€ замедление в физическом развитии, увеличение лимфоузлов, гепатит, сыпь.

ћононуклеозоподобный синдром

” лиц, вышедших из периода новорожденности и имеющих нормальный иммунитет, цитомегаловирус может вызывать развитие мононуклеозоподобного синдрома. “ечение мононуклеазоподобного синдрома по клинике не отличаетс€ от инфекционного мононуклеоза, вызываемого другой разновидностью герпесвируса  вирусом Ёбштейна-Ѕарр. “ечение мононуклеозоподобного синдрома напоминает упорную простудную инфекцию. ѕри этом отмечаетс€:

  • длительна€ (до 1 мес€ца и более) лихорадка с высокой температурой тела и ознобами;
  • ломота в суставах и мышцах, головна€ боль;
  • выраженные слабость, недомогание, утомл€емость;
  • боли в горле;
  • увеличение лимфоузлов и слюнных желез;
  • кожные высыпани€, напоминающие сыпь при краснухе (обычно встречаетс€ при лечении ампициллином).

¬ отдельных случа€х мононуклеозоподобный синдром сопровождаетс€ развитием гепатита  желтухой и повышением в крови печеночных ферментов.

≈ще реже (до 6% случаев) осложнением мононуклеозоподобного синдрома служит пневмони€. ќднако у лиц с нормальной иммунной реактивностью она протекает без клинических про€влений, вы€вл€€сь лишь при проведении рентгенографии легких.

ƒлительность течени€ мононуклеозоподобного синдрома составл€ет от 9 до 60 дней. «атем обычно наступает полное выздоровление, хот€ на прот€жении нескольких мес€цев могут сохран€тьс€ остаточные €влени€ в виде недомогани€, слабости, увеличенных лимфоузлов. ¬ редких случа€х активизаци€ цитомегаловируса вызывает рецидивы инфекции с лихорадкой, потливостью, приливами и недомоганием.

÷итомегаловирусна€ инфекци€ у лиц с ослабленным иммунитетом

ќслабление иммунитета наблюдаетс€ у лиц, страдающих синдромом врожденного и приобретенного (—ѕ»ƒ) иммунодефицита, а также у пациентов, перенесших пересадку внутренних органов и тканей: сердца, легкого, почки, печени, костного мозга. ѕосле пересадки органов пациенты вынуждены посто€нно принимать иммунодепрессанты, ведущие к выраженному подавлению иммунных реакций, что вызывает активность цитомегаловируса в организме.

” пациентов, перенесших трансплантацию органов, цитомегаловирус вызывает поражение донорских тканей и органов (гепатит  при пересадке печени, пневмонию при пересадке легкого и т. д.). ѕосле трансплантации костного мозга у 15-20% пациентов цитомегаловирус может привести к развитию пневмонии с высокой летальностью (84-88%). Ќаибольшую опасность представл€ет ситуаци€, когда инфицированный цитомегаловирусом донорский материал пересажен неинфицированному реципиенту.

÷итомегаловирус поражает практически всех ¬»„-инфицированных. ¬ начале заболевани€ отмечаютс€ недомогание, суставные и мышечные боли, лихорадка, ночна€ потливость. ¬ дальнейшем к этим признакам могут присоедин€тьс€ поражени€ цитомегаловирусом легких (пневмони€), печени (гепатит), мозга (энцефалит), сетчатки глаза (ритинит), €звенные поражени€ и желудочно-кишечные кровотечени€.

” мужчин цитомегаловирусом могут поражатьс€ €ички, простата, у женщин  шейка матки, внутренний слой матки, влагалище, €ичники.

ќсложнени€ми цитомегаловирусной инфекции у ¬»„-инфицированных могут стать внутренние кровотечени€ из пораженных органов, потер€ зрени€. ћножественное поражение органов цитомегаловирусом может привести к их дисфункции и гибели пациента.

ƒиагностика

— целью диагностики цитомегаловирусной инфекции проводитс€ лабораторное определение в крови специфических антител к цитомегаловирусу - иммуноглобулинов ћ и G.

Ќаличие иммуноглобулинов ћ может свидетельствовать о первичном заражении цитомегаловирусом либо о реактивации хронической цитомегаловирусной инфекции. ќпределение высоких титров Igћ у беременных может угрожать инфицированию плода. ѕовышение Igћ вы€вл€етс€ в крови спуст€ 4-7 недель после заражени€ цитомегаловирусом и наблюдаетс€ на прот€жении 16-20 недель.

ѕовышение иммуноглобулинов G развиваетс€ в период затухани€ активности цитомегаловирусной инфекции. »х наличие в крови говорит о присутствии цитомегаловируса в организме, но не отражает активности инфекционного процесса.

ƒл€ определени€ ƒЌ  цитомегаловируса в клетках крови и слизистых (в материалах соскобов из уретры и цервикального канала, в мокроте, слюне и т.д.) используетс€ метод ѕ÷–-диагностики (полимеразной цепной реакции). ќсобенно информативно проведение количественной ѕ÷–, дающей представление об активности цитомегаловируса и вызываемого им инфекционного процесса.

ѕостановка диагноза цитомегаловирусной инфекции основана на выделении цитомегаловируса в клиническом материале или при четырехкратном повышении титра антител. 

¬ зависимости от того, какой орган поражен цитомегаловирусной инфекцией, пациент нуждаетс€ в консультации гинеколога, андролога, гастроэнтеролога или других специалистов. ƒополнительно по показани€м проводитс€ ”«» органов брюшной полости, кольпоскопи€, гастроскопи€, ћ–“ головного мозга и другие обследовани€. 

Ћечение

Ќеосложненные формы мононуклеазоподобного синдрома не требует специфической терапии. ќбычно провод€тс€ меропри€ти€, идентичные лечению обычного простудного заболевани€. ƒл€ сн€ти€ симптомов интоксикации, вызываемой цитомегаловирусом, рекомендуетс€ пить достаточное количество жидкости.

Ћечение цитомегаловирусной инфекции у лиц, вход€щих в группу риска, проводитс€ противовирусным препаратом ганцикловиром (цимевеном). ¬ случа€х т€желого течени€ цитомегалии ганцикловир вводитс€ внутривенно, т. к. таблетированные формы препарата обладают лишь профилактическим эффектом в отношении цитомегаловируса. ѕоскольку ганцикловир обладает выраженными побочными эффектами (вызывает угнетение кроветворени€ - анемию, нейтропению, тромбоцитопению, кожные реакции, желудочно-кишечные расстройства, повышение температуры и ознобы и др.), его применение ограничено у беременных, детей и у людей, страдающих почечной недостаточностью (только по жизненным показани€м), он не используетс€ у пациентов без нарушени€ иммунитета.

ƒл€ лечени€ цитомегаловируса у ¬»„-инфицированных наиболее эффективен препарат фоскарнет, также обладающий р€дом побочных эффектов. ‘оскарнет может вызывать нарушение электролитного обмена (снижение в плазме крови магни€ и кали€), изъ€звление половых органов, нарушение мочеиспускани€, тошноту, поражение почек. ƒанные побочные реакции требуют осторожного применени€ и своевременной корректировки дозы препарата.

ѕрофилактика

ќсобенно остро вопрос профилактики цитомегаловирусной инфекции стоит у лиц, вход€щих в группу риска. Ќаиболее подвержены инфицированию цитомегаловирусом и развитию заболевани€ ¬»„-инфицированные (особенно больные —ѕ»ƒом), пациенты после трансплантации органов и лица с иммунодефицитом иного генеза.

Ќеспецифические методы профилактики (например, соблюдение личной гигиены) неэффективны в отношении цитомегаловируса, так как заражение им возможно даже воздушно-капельным путем.

—пецифическа€ профилактика цитомегаловирусной инфекции проводитс€ ганцикловиром, ацикловиром, фоскарнетом среди пациентов, вход€щих в группы риска. “акже дл€ исключени€ возможности инфицировани€ цитомегаловирусом реципиентов при пересадке органов и тканей необходим тщательный подбор доноров и контроль донорского материала на наличие цитомегаловирусной инфекции.

ќсобую опасность цитомегаловирус представл€ет при беременности, так как может провоцировать выкидыш, мертворождение или вызывать т€желые врожденные уродства у ребенка. ѕоэтому цитомегаловирус, нар€ду с герпесом, токсоплазмозом и краснухой, относитс€ к числу тех инфекций, обследоватьс€ на которые женщины должны профилактически, еще на этапе планировани€ беременности.

 
–едакци€ портала
24 окт€бр€ 2014, 20:46
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