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E-MED.CO.IL 19/11/2019  הדפס מאמר  הדפס מאמר
 
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15/10/2009 האם יש לבצע ניקור לומבאלי לכל תינוק עם עלייה בחום הגוף ובו נמצא גם מרפס בולט?

 בליטה של המרפס הקדמי אצל תינוק, תמיד מדליקה אצלנו נורה אדומה – שמא מדובר בדלקת קרום המוח על רקע חיידקי. לכן אנחנו מבצעים ניקור לומבאלי. מנגד, אצל רוב הילדים הלוקים בחום ובליטה של המרפס הקדמי, הסיבה היא מחלה שפירה. השאלה היא האם בלתי אפשרי להימנע מניקור לומבאלי ולסמוך יותר על החוש הקליני? כדי להדגים כמה ניקורים לומבאליים אנחנו מבצעים, על מנת לאבחן מקרה אחד של דלקת קרום המוח חיידקית החוקרים מבית החולים אסף הרופא בדקו באופן רטרוספקטיבי את התיקים של כל  התינוקות בגיל 3 חודשים ועד 18 חודש שהגיעו לבית החולים אסף הרופא משך תקופה של שמונה שנים בתלונה של עלייה בחום הגוף ובבדיקה נמצאה בליטה של המרפס. יש לציין שהמרפס נבדק כאשר הראש היה 30 ועד 45 מעלות מעל עצם כתף.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        

 מאה חמישים ושלושה חולים נכללו בניתוח של הממצאים. היחס של זכרים לנקבות היה 100:53 כלומר פי שתיים יותר זכרים. הגיל הממוצע 5 חודשים. עלייה במספר הכדוריות הלבנות בנוזל השדרה נמצא ברבע מהמקרים, כולל מקרה אחד של דלקת קרום המוח חיידקית. מלבד מקרה זה, האבחנות לפי סדר שכיחותם היו דלקת קרום המוח ויראלית ב- 27%, דלקת של דרכי הנשימה העליונות, מחלה ויראלית לא מוגדרת, אביבית פתאומית (כלומר roseola infantum)  ודלקת אוזניים, דלקת ריאות, pyelonephritis, אלח דם, shigellosis  או זיהום בסלמונלה. בכל המקרים האחרונים הבירור המעבדתי גילה את הגורם החיידקי.

           

החוקרים מסכמים כי כל התינוקות שלא נראו חולים בעת הקבלה לא נמצאה מחלה חיידקית. מסקנתם היא כאשר אנחנו בודקים תינוק הלוקה בעלייה בחום הגוף והמרפס בולט אנחנו חייבים לשאול את עצמנו האם התינוק נראה חולה ? ואם לא – אפשר לעקוב מקרוב אחר השתלשלות המחלה ולהימנע מניקור לומבאלי אלא אם תחול הרעה במצבו.

 

המאמר הופיע בירחון Archives of Disease in Childhood  מחודש ספטמבר 2009.

 

ד"ר שחם, כותבת המאמר, מוסיפה כי בכל שנה יש מספר ילדים עם דלקת קרום המוח אך ההתבטאות הקלינית אינה חום ומרפס תפוח אלא חום ומראה ספטי/הקאות/פורפורה/ ובילדים גדולים יותר קישיון עורף. המחקר התמקד בילדים שהפרזנטציה שלהם היתה חום ומרפס תפוח ובמשך כל השנים האלה היתה רק תינוקת אחת עם חום ומרפס תפוח שהיה לה דלקת קרום המוח חיידקית. התינוקת עם דלקת קרום המוח נראתה חולה, ספטית, נאנחה ללא הרף. גם בדיקות הדם שלה הצביעו על אפשרות של זיהום חידקי.

 

Bulging fontanelle in febrile infants : Is lumbar puncture  -mandatory ? et al Arch Dis Child200;94:690 Shacham S2.

 

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