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Синдром токсического шока
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Синдром токсического шока

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by admin30.07.2015
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При инфицировании стафилококками возможно развитие двух дерматологических синдромов, вызванных действием микробных токсинов. Это ошпаренной кожи (СОК) и (СТШ). Оба состояния могут иметь серьёзные последствия и приьести к смерти больного. К счастью, типичные клинические и гистологические признаки чаще всего позволяют вовремя диагностировать СОК или СТШ, не допустить развития тяжёлых осложнений и своевременно начать лечение.

Доктор Риттер бон Риттершайн в 1878 г. впервые описал СОК. В его работах упоминается о 297 случаях эксфолиативной экзантемы у новорождённых. Роль стафилококков в развитии СОК и бактериофагов в высвобождении токсинов из бактериальных клеток была установлена позже, в 40-50-х гг. XX в. К настоящему времени известно, что клиническая картина и гистологические особенности СОК связаны со стафилококковым токсином. Он высвобождается из инфицированных бактериофагами штаммов 71 и 55 золотистого стафилококка и вызывает лизис эпидермиса. Мишенью его действия служат те же клетки, что и при акантолической пузырчатке. При обоих заболеваниях токсин провоцирует распад одной из молекул адгезии семейства кадгеринов — антигена десмоглеина , Таким образом, эти заболевания имеют общий компонент патогенетического механизма. Стафилококковый токсин выводится почками, в связи с чем у больных детей и взрослых с нарушением функций почек при СОК часто отмечают снижение почечного клиренса, В отличие от детей, у взрослых пациентов с СОК нередко развивается септицемия. Показано, что взрослые больные СПИДом весьма склонны к развитию СОК.

СТШ был описан значительно позднее СОК. Связь между инфицированием определёнными штаммами стафилококков, мультиорганным системным токсическим шоком и менструациями у женщин, использующих суперабсорбирующие тампоны, была установлена только в начале 80-х гг. прошлого века. Хотя первые случаи СТШ были зарегистрированы у женщин во время менструаций, позже было показано, что эта патология может возникать в результате инфицирования кожи или мягких тканей токсинпродуцирующими штаммами S, aureus. Микроорганизм может проникнуть в кожу через ссадины, ожоги, раны, а также во время предшествующего хирургического вмешательства. В настоящее время, когда суперабсорбирующие тампоны изъяты из продажи, преобладают именно случаи СТШ, не связанные с менструациями. Нередко развитию СТШ предшествует стрептококковый некротический фасциит. Патологическое состояние связано с проникновением в кровоток больного токсинов типа TSST-1 и энтеротоксина С1, продуцируемых стафилококками без участия бактериофагов. Эти токсины действуют подобно ФНО-а и вызывают гипотензию, лихорадку и активацию лейкоцитов.

Клиническая картина СОК и СТШ очень специфична. СОК может протекать в трёх формах: генерализованной, локальной и абортивной. Наиболее тяжёлая — генерализованная форма нередко сопровождается различными осложнениями. Генерализованный СОК часто обусловлен распространением возбудителя из очагов инфекции на голове или шее, например со слизистой оболочки глаз (на фоне конъюнктивита) или из среднего уха (при воспалении). Первым признаком СОК служит возникновение оранжево-красной (нередко болезненной) пятнистой сыпи чаще всего (обычно вокруг рта и носа) или сгибательных поверхностях суставов. Через 24-48 ч образуются вялые пузыри. Возможно формирование объёмных пузырных элементов (особенно в паховой и подмышечной областях). Вблизи элементов обычно наблюдают положительный симптом Никольского (отслаивание эпидермиса при лёгком надавливании на кожу). После вскрытия пузырей на их месте остаются гладкие блестящие эрозии.

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