#1
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òèðåîòîêñèêîç
Ïàöèåíòêà, 65 ëåò. æàëîáû íà ñíèæåíèå âåñà íà 15 êã â òå÷åíèè 6 ìåñÿöåâ, äðîæü âî âñåì òåëå, ñêà÷êè àä. ñ ôåâðàëÿ 2017 ãîäà íàáëþäàëàñü ó òåðàïåâòà. âûÿâèëè èçìåíåíèÿ â îáùåì àíàëèçå êðîâè: ëåéêîöèòû 3,0*10/9 ã/ë, ãåìîãëîáèí 113ã/ë, ýðèòðîöèòû 3.21, ñîý 50 ìì/÷àñ. ñ òàêèìè àíàëèçàìè ïàöèåíòêà ëåæàëà è ñ îòðûì îòèòîì, ïíåâìîíèåé â ñòàöèîíàðàõ, äåëàëè àíòèáèîòèêè, àíàëèç êðîâè íå èçìåíÿëñÿ. â èþíå îáðàòèëàñü íà ïðèå ê ýíäîêðèíîëîãó è ïîëó÷èëè ñëåäóþùèå ðåçóëüòàòû: òòã 0.07 ììÅ/ë; ò4ñâ 3.8 (0.8-2); ò3 îáù 4.890.52-1.85), àò ê ðåöåïòîðó òòã 3.9(0-1). êàê ëå÷èòü â òàêîì ñëó÷àå ïàöèåíòêó , åñëè èçíà÷àëüíî èìååì ëåéêîïåíèþ?
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#2
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óçè ùèòîâèäíîé æåëåçû îò èþíÿ 2017 ãîäà: îáúåì 20.1 ñì3, â ïðàâîé äîëå îáðàçîâàíèå ðàçìåðîì 8 ìì ãèïîýõîãåííîå, íåîäíîðîäíîé ñòðóêòóðû, ñðîâíûì êîíòóðîì
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#3
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Ñêîðåå âñåãî, òèðåîñòàòèêàìè. Ðèñê èíôåêöèîííûõ îñëîæíåíèé âîçðàñòàåò ïðè àáñîëþòíîì êîëè÷åñòâå íåéòðîôèëîâ <500 â 1 ìêë.
Ïî ïðåäñòàâëåííûì äàííûì êîëè÷åñòâî ëåéêîöèòîâ - 3000 â 1 ìêë, íàäî òîëüêî ïîíÿòü, êàêèå êëåòêè âêëþ÷åíû â ýòî ÷èñëî â âàøåì àíàëèçå. |
#4
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Ïðî êëåòêè çàâòðà äîïèøó. Ïðîñòî àíàëèçà íåò ñåé÷àñ ïðåäî ìíîé. Ó ìåíÿ åù¸ òàêîé âîïðîñ. Ïàöèåíòêà íàçíà÷èë ýíäîêðèíîëîã â îáëàñòíîé áîëüíèöå: ìåòèëóðàöèë, Ïðåäíèçîëîí ïî 1 òàáëåòêè 3 ðàçà â äåíü è ïðîïèöèë . Íå ïîíèìàþ ñ êàêîé öåëüþ Ïðåäíèçîëîí( îôòàëüìîñêîïèè íåò, àìèîäàðîíîì íå ïðèíèìàåò, ãåïàòèò è ðàññåÿííûé ñêëåðîç íå ëå÷èò)? Ìåòèëóðàöèë âîîáùå âìåñòå? È ïàöèåíòêà ñêàçàëà äåíåã íà ïðîïèöèë íåò ,ìîæíî íàçíà÷èòü ìåðêàçîëèë?
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#5
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Ìåòèëóðàöèë ìîæåò íàì ïîìî÷ü â ýòîé ñèòóàöèè?
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#6
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Íó, ìåòèëóðàöèë-òî òî÷íî íå ïîìîæåò. Ïðåäíèçîëîí íå òî ÷òîáû î÷åíü ðåäêî íîðîâÿò íàçíà÷àòü â ñëó÷àå ëåéêîïåíè÷åñêîé ðåàêöèè, íî ýòà ïîçèöèÿ ëèøåíà äîêàçàòåëüíîñòè.
Çíà÷èò, ìåðêàçîëèë. |
#7
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À ëåéêîöèòû ìîãëè ñíèçèòüñÿ íà ôîíå òèðåîòîêñèêîçà è åñòü øàíñ , ÷òî íà ôîíå âîññòàíîâëåíèÿ ãîðìîíîâ è ïîâûñÿòñÿ ëåéêîöèòû? Åñòü ëè â äàííîé ñèòóàöèè ïðåèìóùåñòâà ó ïðîïèöèë ïåðåä ìåðêàçîëèëîì? ( Ïî âëèÿíèþ íà ëåéêîïåíèþ)
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#8
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Êîãäà Âû ïèøåòå "ëåéêîïåíèÿ", ïî ñìûñëó äëÿ âðà÷à åòî ðàâíîñèëüíî êîíñòàòàöèè "íàðóøåíèå ôóíêöèè èëè áîëåçíü øèòîâèäíîé æåëåçû", â ñâÿçè ñ òåì, ÷òî áîëåå 50% â êðîâè ëåéêîöèòîâ - åòî íåéòðîôèëû ñ áîëåå ÷åì 50% óâåðåííîñòüþ ìîæíî ïðåäïîëàãàòü, ÷òî ðå÷ü èäåò ïðåèìóøåñòâåííî î íåéòðîïåíèè, îáñëåäîâàíèå ïî÷òè 100 ïàöèåíòîâ ñ íåéòðîïåíèåé è çàáîëåâàíèÿìè øèòîâèäíîé æåëåçû âûÿâèëî ñëåäóþøóþ êàðòèíó:
47% had Hashimoto thyroiditis (HT), 8% Graves disease (GD), 16% nontoxic multinodular goiter (NTMG), 10% subclinical hypothyroidism, and 6% had undergone total thyroidectomy associated with nodules (TTM).
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Èñêðåííå, Âàäèì Âàëåðüåâè÷. |
#9
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Leukopenia is reported in 15-30% of untreated thyrotoxicosis,
but is usually associated with pancytopenia. Relative lymphocytosis with a normal or slightly low white blood cell count are the characteristic blood findings of Graves’ disease, called Kocher’s blood picture. It is suggested that a cross antigenicity between human TSH receptors and polynuclear neutrophils, a decreased circulating time of granulocytes, and a reduced marrow granulocyte reserve are the causes of neutropenia in thyrotoxicosis. --- èç A Case of Pancytopenia with Hyperthyroidism [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ]
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Èñêðåííå, Âàäèì Âàëåðüåâè÷. |
#10
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Áûëî òàêîå èçûñêàíèå: Drugs Corrects Mild Neutropenia in Graves' Disease
N. Aggarwal; S. A. Tee; W. Saqib; T. Fretwell; G.P. Summerfield; S. Razvi - Clin Endocrinol. 2016;85(6):949-953. ([Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ]). Åñòü õîðîøàÿ [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] Antithyroid Drug-Induced Agranulocytosis: State of the Art on Diagnosis and Management, Drugs R D. 2017 Mar; 17(1): 91–96. Published online 2017 Jan 19. doi: 10.1007/s40268-017-0172-1, â íåé åñòü äàííûå î òîì, ÷òî ïðîïèöèë â ïëàíå ðèñêà àãðàíóëîöèòîçà, êàê ìèíèìóì, íå ëó÷øå ìåòèìàçîëà, à òî è ïîõóæå. |
#11
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Ñïàñèáî âñåì áîëüøîå çà ïîìîùü. Ñêàæèòå à âîîáùå â ïðàêòèêå ìåòèëóðàöèë ìîæíî â êàêèõ_ òî ñëó÷àÿõ ïðèìåíÿòü? Ó íàñ åñëè ëåéêîöèòû ñíèæàþòñÿ íà ôîíå òèðîçîëå ñðàçó íàçíà÷àåòñÿ äàííûé ïðåïàðàò. Ïðàâû ëè äîêòîðà?
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#12
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Êòî æ åãî çíàåò... Íà [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] è [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] îí óêàçàí êàê ðàäèîïðîòåêòîð íà îñíîâàíèè äàííûõ ñòàðûõ ñîâåòñêèõ ðàáîò, íî íàäî ïîíèìàòü, ÷òî â ñîâðåìåííûõ ðåêîìåíäàöèÿõ ïî ëåéêîïåíèè Âû âðÿä ëè åãî íàéä¸òå. Ïîèùèòå êàêèå-íèáóäü ïóáëèêàöèè ïî èíòåðåñóþùåìó ïîêàçàíèþ (õîòü è îòå÷åñòâåííûå), ì.á., ÷òî-òî è íàéä¸òñÿ. Âîò òîëüêî íàäî áóäåò ïîäóìàòü, íàñêîëüêî äîáðîñîâåñòíî òàêèå ðàáîòû áóäóò âûãëÿäåòü.
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