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INFECTII ale CAVITATII BUCALE

6.1. INFECTIILE ODONTOGENE (IO)


6.1.1. Aspecte generale
IO contn!a sa constt!e o "portanta pro#le"a ep$e"ologca% n! n!"a prn &rec'enta
lor% $ar s prn co"plcatle se'ere pe care le pot $e('olta. )*$++$!
Cele "a co"!ne IO s!nt , cara $entara% p!lpta% a#ces!l perapcal% gng'ta% n&ectle
pero$ontale s n&ectle spatlor &ascale pro&!n$e.
Des !nele $ntre ele s!nt rare% "!lte IO s!nt potental se'ere% $atorta co"plcatlor pe
care le pot $e('olta, n&ect ntracranene% retro&arngene% ple!ro-p!l"onare% $se"nar
.e"atogene la n'el!l 'al'elor car$ace (en$ocar$ta n&ectoasa)/ "ecans"!l $e
pro$!cere al acestor co"plcat este, prn $se"nare .e"atogena sa! prn contg!tate.
In&ectle non-o$ontogene ale ca'tat #!cale (sto"atta !lcerat'a s gangrenoasa%
n&ectle glan$elor sal'are) 'or & tratate separat.
6.1.+. Etologa
6.1.+.1. 0cro&lora ca'tat #!cale
Flora #!cala nor"ala ncl!$e peste 1111 t!lpn #acterene% $ntre care% "!lte anaero#e.
In ta#el!l 6.1 este pre(entata% $str#!ta procent!ala a "plcar $&ertelor
"croorgans"e% ce colon(ea(a n "o$ nor"al% $'ersele reg!n ale ca'tat #!cale.
D!pa c!" se o#ser'a, a) peste 21 3 $n total!l "croorgans"elor c!lt'a#le $n
ca'tatea #!cala% s!nt repre(entate $e, 4treptococc!s% 5eptostreptococc!s% Vello- nella%
Lacto#acll!s% Cor6ne#acter!" s Actno"6ces/ #) &lora #!cala este $o"nata (22%73)
$e ger"en anaero#% rest!l $e
11%1 3 &n$ repre(entate $e #acter &ac!ltat'e/ c) "croorgans"ele Gra" negat'e%
neo#sn!t ntalnte la a$!lt!l sanatos% $e'n pre$o"nante% la persoanele c! n&ect
se'ere s la 'arstnc/ $) $es specle repre(entat'e ale aceste &lore pot & (olate $n
"a8ortatea (onelor ca'tat #!cale% an!"te s!pra&ete - l"#a% s!pra&ata $entara% gngle%
sal'a- tn$ sa &a'or(e(e colon(area pre&erentala c! an!"te "croorgans"e spec&ce
s an!"e,
9 4trept. sang!s% 4trept. "!tans% 4trept. "tor s Actno"6ces 'scos!s - colon(ea(a
pre&erental s!pra&ata $entara/
9 4trept. sal'ar!s s Vellonella% se local(ea(a pre$lect la n'el!l l"# s "!coase
#!cale/
9 F!so#acter!"% Bactero$es% 4proc.etele% se concentrea(a pe s!pra&ata gnglor.
TABEL 6.1. Dstr#!ta procent!ala a $'erselor tp!r $e #acter pe (one ale ca'tat
#!cale
5on$ere (3)
Tp GEN Cre'asa gng'ala
5laca $entara
L"#a 4al'a
BACTE:II FACULTATIVE
3 total $e #ac. &ac!ltat'e ;;.* <+.< 6=.< 61
4treptococ!s
Coc Gra"
(4."!tans%4. sang!s%
+*.2 +2.= ;=.2 ;6.+ po(t' 4. "tor% 4. sal'ar!s)
Coc Gra" negat' 0ora)ella 1.; 1.; =.; 1.+
Bacl Gra"
Lacto#acll!s po(t' Cor6ne#acter!" 1<.= +=.2 1= 11.=
Bacl Gra" negat' Entero#acteraceae 1.+ ND =.= +.=
ANAE:OBI
3 total $e anaero# <;.= ;*.< =6.< =7
Coc Gra" po(t' 5eptostreptococc!s *.; 1+.6 ;.1 1=.<
Coc Gra" negat' Vellonella 11.* 6.; 16 1<.7
Actno"6ces%
Bacl Gra" po(t'
E!#acter!"% Leptotrc.a%
Lacto#acll!s%
+1.+ 12.; 2.+ ;.2
Bacl Gra" negat'
Total 16.1 11.1 2.+ ;.2
F!so#acter!" 1.7 ;.1 1.* 1.=
5re'otella ;.* ND 1.+ ND
Bactero$es <.6 ;.2 <.1 +.;
Ca"p6lo#acter =.2 1.+ +.+ +.1
45I:OC>ETE
3 total $e sproc.ete 1.1 - - Trepone"a 1.1 ND ND ND
Factor care contr#!e la aceasta $str#!te pre$lecta ncl!$,
9 &actor select' $e a$erenta a an!"tor #acter la s!pra&ata an!"tor tp!r $e cel!le/
9 con$t "eta#olce locale legate $e p>-!l "e$!l!% potental!l $e o)$o-re$!cere/
9 &eno"ene $e coagregare #acterana s $e n.#te "cro#ana.
In a&ara acestor cons$erat anato"ce s #acterologce% n!"eros alt &actor
n&l!entea(a co"po(ta &lore #!cale. 5rntre acesta "a "portant s!nt, 'arsta% $eta%
er!pta $entara% gena orala% &!"at!l% pre(enta carlor $entare sa! a #ol pero$ontale%
trata"ente ant"- cro#ene% sarcna% sptal(area prel!ngta% &actor genetc s rasal.
O#ser'ate, 5rn pre(enta sa% &lora orala nor"ala contr#!e la protecta
"potr'a n&ecte prn,
9 pro$!cerea $e s!#stante #acterc$e/
9 pro$!cerea Ig A s pero)$a(e% care nteractonea(a c! on $e tocanat $n "ancare s
c! .$rogen-pero)$a(a pro$!sa $e &lora co"ensala/
9 pro$!cerea $e l(o(" s lacto&erna (c.elea(a &er!l necesar "eta- #ols"!l!
#acteran)/
9 e)stenta !nor protene sal'are% pot n.#a la ran$!l lor% a$erarea #acterlor pe
s!pra&ata $ntlor s a "!coase #!cale/
9 t!rn-o'er-!l rap$ $e la n'el!l eptel!l! #!cal% a8!ta $e ase"enea la n$epartarea
#acterlor care a! a$erat la acest n'el.
6.1.+.+. 5laca $entara
Bacterologa IO este $eose#t $e co"ple)a s re&ecta n general &lora en$ogena a ca'tat
#!cale. In c!$a aceste co"ple)tat% st!$ recente $o'e$esc rol!l $eter"nant al
an!"tor "croorgans"e spec&ce n $&ertele &or"e $e IO.
Des "cro&lora asocata IO este pol"cro#ana% "plcarea patogenetca a
co"ponentelor acestea este negala% ast&el ncat terapa e&centa a acestor n&ect n!
"plca era$carea co"pleta a aceste "cro&lore.
In pre(ent se ste ca IO s!nt ntate $e "croorgans"e care alcat!esc placa $entara% ar
nole "eto$e $e $agnostc (n specal nole te.nc $e $ent&care s c!lt'are a
#acterlor anaero#e) a! $o'e$t o an!"ta spec&ctate "cro#ana n $eclansarea
&ecar! tp $e n&ecte.
5laca $entara repre(nta o agregare $e #acter% pro$!s e)tracel!lar a #acterlor%
constt!ent a sal'e% care a$era &er" la n'el!l s!pra&ete $entare.
5re(enta plac per"te !n contact per"anent al #acterlor ac$o- genetce c! s!pra&ata
s"alt!l! $entar% !n$e pro$!s ac$!l! lactc nta(a $str!cta .$ro)apatte. Bacterle
constt!e +?= $n gros"ea plac $entare% ar n!"ar!l "croorgans"elor se r$ca la
1111 -/ 1111 ger"en? g $e placa $entara.
6.1.+.=. Corelat clnco - etologce n IO
In ta#el!l 6.+. se re$a! prncpalele asocer clnco-etologce n IO.
Ta#el!l 6.+. Corelata s!rsa $e n&ecte -IO 4!rsa $e n&ecte IO
4. "!tans
(serotp!l C)
- Cara $entara/
5laca s!pragng'ala - In&ect en$o$ontce/
(prepon$. "croorg. Gra" po(. 4.sang!s% Actno"6ces)
5laca s!#gng'ala
(prepon$. #acl Gra" neg. s "croorg. "o#le)
- A#cese perapcale/
- In&ect pero$ontce/
- Gng'ta (5re'otella nter"e$a)/
- 5ero$ontta a$!lt!l! (5re'otella gng'als)/
- 5ero$ontta 8!'enla (A. Actno"6cete"co"tans)/
- 5ercoronarte/
- In&. pro&!n$e ale sp. &ascale s osteo"elta/
6.1.+.=.1. Etologa care $entare
Este cert $o'e$ta asocerea etologca ntre cara $entara s 4tr. "!tans / se c!nosc 2
serotp!r antgence $stncte% serotp!l C &n$ cel "a &rec'ent "plcat. Alat!r $e 4tr.
"!tans% n etologa care $entare este ncr"nat s Lacto#acl!l(BGN)% nterea
proces!l! carogenetc &n$ real(ata $e 4tr. "!tans% ar $e('oltarea s ntretnerea l!%
este asg!rata $e Lacto#acl!s.
6.1.+.=.+. Etologa gng'telor s pero$onttelor
In gng'te s pero$ontte s-a $ent&cat o co"ponenta #acterana spec&ca a plac
s!#gng'ale/ la persoanele sanatoase "cro&lora spat!l! pero$ontal este alcat!ta $n
"croorgans"e Gra" po(- t'e(G5), 4tr. sang!s s Actno"6ces.
In pre(enta gng'te% "cro&lora plac s!#gng'ale se "o$&ca n sens!l !ne
prepon$erente a #acllor Gra" negat'(BGN) anaero# (&rec- 'ent 5re'otella
nter"e$a).
Gng'ta !lcero-necrotca (#oala Vncent) este $e etologe ")ta, trepone"e (Borella
Vncent) s anaero# (&!so#acter).
In pero$ontta% "cro&lora ncr"nata creste n co"ple)tate prn prepon$erenta BGN
anaero# ("a &rec'ent 5orp.6ro"onas gng'als) s "croorgans"e "o#le (Trepone"a
$entcola).
In pero$ontta 8!'enla ('aranta clnca ce a&ectea(a prepon- $erent a$olescent)% placa
s!#gng'ala este alcat!ta $e Actno#acll!s actno"6cete"co"tans s Capnoc6top.aga.
6.1.+.=.=. Etologa IO s!p!rat'e
In IO s!p!rat'e (a#ces!l perapcal% n&ect pro&!n$e ale spatlor &ascale)% este pre(enta
o &lora "cro#ana co"ple)a% ce ncl!$e spec aero#e s anaero#e% Gra" po(t' s
negat', F!so#acter!" n!cleat!"%
Bactero$es% 5eptostreptococc!s% Actno"6cetes% 4treptococc!s s "a rar% 4ta&lococc!s
s BGN aero#( la persoane "!no$epr"ate).
6.1.=. 5atogene
6.1.=.1. 0ecans"!l patogenetc al care $entare
0ecans"!l patogenetc al care% $es n$el!ng cercetat% ra"ane $est!l $e p!tn $e&nt.
Teora cea "a acceptata este aceea a act!n #acterlor as!pra .$rocar#!rlor% c!
pro$!cerea $e s!#stante ac$e care sta! la #a(a $e"neral(ar $ntlor s $sol!te
s!#stantelor sol$e $entare.
In $e('oltarea care $entare actonea(a snergc cel p!tn = &actor,
9 &actor a organs"!l! ga($a (o an!"ta s!scept#ltate a s!pra&ete $entare )/
9 &actor "cro#en (#acter ac$ogenetce pro$!catoare $e ac( s capa#le sa se
n"!lteasca la !n p> ac$)/ este $o'e$t cert ca 4tr. "!tans% n pre(enta s!cro(e%
&or"ea(a colon a$erente pe s!pra&ata $ntlor/
9 &actor $etetc (.$rocar#!r s (a.ar!r s"ple).
@5elc!la $o#an$taA $e orgne sal'ara% acel!lara s a#acterana% actonea(a ca o #arera
antac$a s antproteoltca. In ca(!l !ne gene $e&ctare ea 'a & rap$ colon(ata s
nloc!ta c! placa $entara.
5laca s!pragng'ala contne "croorgans"e c! capactate $e a$erenta la s!pra&ata
$entara% $etnan$ n acelas t"p s act'tate (a.aroltca% n t"p ce% "croorgans"ele
plac s!#gng'ale s!nt a(a.aroltce s n! necesta a$erenta.
6.1.=.+. 5atogena #ol pero$ontale
0cro&lora pero$ontala asocata c! placa s!#gng'ala are capactatea $e a penetra
eptel!l gng'al s a pro$!ce !n rasp!ns n&la"ator $n partea ga($e care% n &nal% $!ce
la $str!gerea pero$ont!l!.
4pre $eose#re $e cara $entara% $eta n! are !n rol se"n&cat'
n patogena #ol pero$ontale.
Factor &a'or(ant a gng'telor s!nt, 'arsta tanara (cop% a$olescent)% teren
"!no$epr"at $e ca!(a non-n&ectoasa ("aln!- trte)% gena $e&ctara% $e#ltate
ps.ca% stress.
Factor &a'or(ant a pero$ontte s!nt, gena $e&ctara s 'arsta nantata (rol "a8or)%
alat!r $e care nter'n, &actor .or"onal (c! e)a- cer#area #ol n c!rs!l p!#ertat%
"enstr!ate% sarcn)% $a#et!l (a.arat s o sere $e t!l#!rar genetce -n specal cele
asocate c! $e&cte "!nologce (cel!lare sa! !"orale)% c!" s!nt $e&ectele caltat'e ale
ne
!tro&lelor% agran!locto(a% #oala gran!lo"atoasa cronca.
6.1.=.=. Factor $e re(stenta a organs"!l!
Organs"!l "!noco"petent $etne o sere $e &actor $e aparare locala% care &ac ca
n&ectle ca'tat #!cale sa n! &e &oarte &rec'ente.
Intre acesta se n!"ara, a) re(stenta la colon(are% a$ca e)stenta "cro&lore #!cale ce
&!rn(ea(a o p!ternca reacte la colon(area "!coase $e catre ger"en patogen% prn
"ecans" $e co"pette #acterana/ #) ntegrtatea "!coase #!cale/ c) pre(enta s
co"po(ta sal'e,
Nor"al sal'a contne o sere $e s!#stante c! e&ect cert ant"cro#an prec!" l(o("%
lacto&erna% l(ne% lacto-pero)$a(a/ concentrata "are $e IgA secretore sal'ara% pre'ne
agregarea s atasarea "croorgans"elor $e "!coasa eptel!l!.
Canttatea $e sal'a este &oate "portanta% sca$erea e pre$sp!nan$ la n'a(e #acterana.
6.1.;. Ta#lo!l clnc
IO s a! orgnea s se nstalea(a !r"are a !nor a&ect!n ale p!lpe $entare% sa!
pero$ont!".
6.1.;.1. In&ect $ento-al'eolare
In&ectle p!lpare (p!lptele) apar cel "a &rec'ent ca s o consecnta a carlor $entare%
real(an$ &or"e clnce $e p!lpta local(ata sa! general(ata.
In a#senta $rena8!l! ca"ere p!lpare% se pro$!ce necro(a p!lpara% ar prol&erarea
"croorgans"elor en$otontce $!ce la n'a(a tes!t!rlor perapcale/ re(!lta a#ces!l
perapcal sa! al tes!t!l! osos al'eolar% c! ta#lo! $e a#ces al'eolar ac!t.
6.1.;.+. In&ectle pero$ontale
Boala pero$ontala $e&neste toate #olle pro$!se $e a&ectarea str!ct!rlor $e s!stnere a
$ntlor (pero$ont!"), gnga% lga"entele pero$ontale% tes!t osos al'eolar% c"ent!l
$entar.
In sta$le ncpente% n&ecta este local(ata la n'el!l gnge.
Ulteror% prn progres!nea #ol la n'el!l celorlalte str!ct!r% apare pero$ontta care 'a
$!ce la co"pleta $str!gere a pero$ont!"!l! s per$erea $e&nt'a a $ntlor.
In&ectle pero$ontale tn$ sa se local(e(e n tes!t!rle "o ntrao- rale s &oarte rar
$se"nea(a n str!ct!rle pro&!n$e ale gat!l! s &ete.
6.1.;.+.1. Gng'ta% percoronarta a) Gng'ta (ac!ta sa! cronca)
Este ntata $e rtata locala% !r"ata $e n'a(a "cro#ana/ placa s!#gng'ala este
tot$ea!na pre(enta.
Una $n pr"ele "an&estar este gng'oraga/ $e o#ce n! e)sta $!rere. a.1) Gng'ta
!lcero-necrotca (#oala Vncent)
Intal apar !cerat la n'el!l gnge% a&ectan$ pre'alent spatle nter$entare/ le(!nle
!lcerat'e se e)tn$ n s!pra&ata s n pro&!n("e% nstalan$!-se (one $e necro(a a
eptel!l! c! constt!rea $e &alse "e"#rane cen!s.
Este pre(enta o .alto(a caracterstca% t!l#!rar $e g!st s $!rer ' la "astcate.
Dn partea organs"!l! apare &e#ra% l"&a$enopate regonala s stare generala alterata.
In a#senta trata"ent!l!% n&ecta se e)tn$e spre &arnge s alte tes!t!r "o% constt!n$!-
se gng'o-sto"atta gangrenoasa. #) 5ercoronarta
Consta n n&la"area operc!l! gng'al ce acopera "olar!l $e "nte/ se nsoteste%
&rec'ent% $e trs"!s ce apare sec!n$ar rtate "aseterlor/ ne$renata% n&ecta se poate
e)tn$e $e-a l!ng!l plan!rlor &ascale spre tes!t!rle "o.
6.1.;.+.+. 5ero$ontta
5ero$ontta re&lecta o n&la"ate cronca a pero$ont!l!.
A&ectea(a 'arsta a$!lta% repre(entan$ o ca!(a "a8ora $e e$entate $e&nt'a/ placa
s!#gng'ala este tot$ea!na pre(enta.
4pre $eose#re $e p!lpte% n pero$ontte $rena8!l se pro$!ce l#er s $e aceea n! apare
$!rere/ pot & pre(ente, o sen(ate $e tens!ne la n'el!l gnge sa! nter$entar% .alto(a%
sens#ltate ter"ca% $!rer 'ag "an$#!lare.
Colecta p!r!lenta poate & e'$entata &oarte !sor prn $gto- pres!ne sa! poate $rena
spontan $e la n'el!l a#ces!l!.
5rogres!nea proces!l! n&la"ator $!ce la $str!gerea tes!t!rlor $e s!stnere s
per$erea $e&nt'a a $ntlor. a.) 5ero$ontta 8!'enla local(ata - este o &or"a
partc!lara $e pero$ontta $str!ct'a% care apare la a$olescent s se caracter(ea(a prn
per$erea rap$a a peretel! osos 'ertcal% a&ectan$ pr"!l "olar s ncs'/ placa
s!#gng'ala este "n"a% n aceste ca(!r &n$ ncr"nat !n $e&ect al c.e"ota)s"!l!
ne!tro&lelor.
#.) A#ces!l pero$ontal ($&!( sa! local(at) este ntot$ea!na n co"!ncare c! spat!l
pero$ontal% $n care p!ro!l poate & e'$entat prn $gtopres!ne.
6.1.;.=. In&ectle spatlor &ascale pro&!n$e
Atat n&ectle o$ontogene cat s cele oro&arngene se pot e)tn$e prn contg!tate spre
spatle &ascale $n (ona cranana n&eroara s port!nea cer'cala s!peroara.
Cale $e e)tn$ere% $ar s "an&estarle clnce ale acestor n&ect% s!nt $eter"nate $e
e)stenta #arerelor locale osoase% "!sc!lare s &ascale.
Aceste n&ect pot & clas&cate n,
9 n&ect ale spatlor $n 8!r!l &ete (spat!l "astcatorlor% #!cal% cann% al parot$elor)/
9 n&ect ale reg!n s!pra.o$e (s!#"an$#!lar% s!#lng!al% latero&arngan )/
9 n&ect ale reg!n n&ra.o$e sa! gat!l! (retro&arngan% spat!l pretra.eal ).
Cale pos#le $e e)tn$ere a n&ecte spre spatle &ascale pro&!n$e s!nt re$ate sc.e"atc
n &g.6.1.
6.1.;.=.1. @AngnaA L!$Bg
Este o enttate clnca care "plca n&ecta !n! n!"ar 'arat $e spat anato"ce
(s!#lng!al s s!#"an$#!lar).
In <13 - 713 $n ca(!r% se $ent&ca o orgne $entara a angne% cel "a &rec'ent &n$
"plcat al $olea sa! al trelea "olar "an$#!lar.
In&ecta are &or"a clnca a !ne cel!lte n$!rate% rap$ e)tens'a% a&ectan$ #lateral
planse!l #!cal.
0astcata% $egl!tta s resprata s!nt $&cle% p!tan$!-se a8!nge c.ar la as&)e
"ecanca.
O#ect', se constata o t!"e&acte &er"a% 'ol!"noasa% a spat!l! s!#"an$#!lar%
planse!l #!cal% care este #o"#at% "pngan$ l"#a spre cer!l g!r. De o#ce% s!nt
pre(ente &e#ra s "an&estar sste"ce
(sepss).
6.1.;.;. Co"plcatle n&ectlor o$ontogene
4e pro$!c pe $o!a ca, a) $se"nare .e"atogena, #actere" tran(tor s!r'n $!pa
'arate "anopere sto"atologce% n specal $!pa e)tract $entare
(aparta en$ocar$te n&ectoase $!pa e)tract $entare septce &n$ #ne $oc!"entata)/
$atorta acestor rsc!r se "p!ne pro&la)e c! ant#otce% c.ar $aca n! este $o'e$ta o
a&ectare 'al'!lara car$aca pree)stenta. #) prn contg!tate (e)tense $recta)% ncl!(an$,
$se"narea "e$astnala% s!p!rata ntracranana (tro"#o(a $e sn!s ca'ernos)%
tro"#o&le#ta 8!g!lara s!p!rata% ero(!nea $e artera carot$a% sn!(ta "a)lara%
osto"elta c! local(are "a)lara sa! "an$#!lara.
4pat!l cann
Or#ta
4pat!l n&rate"poral
4pat!l #!cal
A#ces perapcal "a)lar
A#ces perapcal "an$#!lar
4pat!l parot$an
4pat!l s!#"an$#!lar s s!#lng!al
4pat!l "astcatorlor
("aseter% ptergo$an% te"poral)
Teaca carot$e
4pat!l latero- &arngan
4pat!l retro&arngan
Cran!
0e$astn
Fg.6.1. Cale pos#le $e e)tn$ere a IO spre spatle &acale
6.1.<. Dagnostc!l IO
Este s!stn!t clnc s con&r"at #acterologc.
6.1.<.1. Dagnostc!l #acterologc
Este $&cl $e real(at , pe $e o parte% $atorta e)stente !nor reale $&c!ltat n o#tnerea
c!lt'ar ger"enlor anaero# s pe $e alta parte% $atorta con$tlor $&cle $e recoltare a
pro#e #acterologce% ast&el ncat re(!ltatele o#tn!te sa &e nterpreta#le.
Orce pro$!s recoltat% se 'a c!lt'a atat pe "e$ aero#e% cat s pe "e$ anaero#e.
5entr! n&ectle $n spat nc.se% recoltarea se &ace prn asprare c! ac!l a secrete
p!r!lente $n &ocar!l colectat prntr-o a#or $are e)traorala a &ocar!l!/ pro$!s!l patologc
se transporta "e$at la la#orator (c! respectarea con$tlor $e anaero#o(a).
5entr! le(!nle ntraorale% este !tla e&ect!area $recta $e &rot!r (colorate Gra" pentr!
#acter% CO> pentr! &!ng) $n pro$!sele patologce% prele'ate c! !n ta"pon sterl/
conco"tent% se 'or e&ect!a s c!lt!r "cro#ene% o#tn!te prn nsa"antarea pro$!s!l!
patologc pe "e$ $e c!lt!ra a$ec'ate. La aceste e)a"nar #acterologce% se pot a$a!ga
"eto$e specale $e, "!no&l!orescenta% sa! te.nc $e $etectare a antgenelor #acterene
(!tle% n specal n ca(!l n&ectlor c! pro$!se $e "co#acter)% &!ngce sa! 'rale.
E)a"nar paraclnce $e e)cepte% s!nt !tle n st!at specale. Dntre ele en!"era", 9
#opsa ts!lara sa! osoasa% c! e&ect!area $e e)a"en .stopatologc -/ pentr! $agnostc!l
osteo"e- ltelor/ 9 ec.ogra&e% :0N% CT- pentr! prec(area topogra&e !ne cel!lte
o$ontogene (retro&arngan% pre'erte#ral% "e$astnal% etc.)/ 9 scntgra&e osoasa -/pentr!
$agnostc!l $&erental al osteo"eltelor ac!te sa! cronce &ata $e $&erte tra!"ats"e
sa! neoplas"e.
6.1.6. Trata"ent!l
4cop!l prncpal al trata"ent!l! n&ectlor o$ontogene (c! pre'e- nrea care s tratarea
pero$ontte) este acela $e a controla placa s!# s s!pragng'ala #acterana.
6.1.6.1. Trata"ent!l care $entare nen&ectate
Cara $entara nen&ectata (&ara p!lpta sa! a#ces perapcal) n! necesta trata"ent
ant#otc% &n$ s!&cente "as!r nespec&ce% care ncl!$ , a) aplcarea !nor agent topc
(local)% c! e&ect carostatc prec!",
9 &l!or$ele - &or"ea(a "pre!na c! crstalele $e apatta !n co"ple) ce pro"o'ea(a
re"neral(area le(!nlor $atorate care% e)erctan$ s !n e&ect #acterostatc (s-a!
$o'e$t cele "a e&cente preparate pe "o$ele !"ane)/
9 clor.e)$na (5lacD-O!t) -/ actonea(a ca !n $etergent catonc $str!gan$ n!"eroase
#acter% persstan$ la s!pra&ata $ntel! t"p n- $el!ngat% a'an$ rol n pre'enrea
a'ansar plac $entare ($n pacate% are !n g!st a"ar% colorea(a l"#a s $nt)/
9 ant#otce (5enclnele s Tetracclnele) $o'e$te a a'ea !n e&ect carostatc pe "o$ele
an"ale/ la o" nsa $oar aplcarea topca $e Vanco"cna s-a $o'e$t e&centa/ #)alte
"as!r nespec&ce prec!", 9 gena #!cala a$ec'ata/9 re- $!cerea &lore carogenetce
orale prn "o$&carea $ete c! s!#stt!rea s!cro(e/ 9 "!n(ar "potr'a pro$!cer
care% prn a$"nstrarea $e 'accn preparat $n t!lpn $e 4tr. "!tans.
6.1.6.+. Trata"ent!l p!lpte
In pre(enta n&ecte $ento-al'eolare (p!lpta) se "p!ne,
9 trata"ent sto"atologc% '(an$, n$epartarea tes!t!rlor n&ectate/ $rena8 al a#ces!l!
perapcal sa! c.ar e)tracta $entara/
9 e&ect!area o#lgatore a !n! trata"ent pro&lactc% c! ant#ot- ce% &n$ n$cat !n
ant#otc $n gr!pa A(al$elor, :o)tro"cna (:!l$)% n $o(a $e =11 "g?(% sa!
A(tro"cna (4!"a"e$)% <11 "g?(/ $!rata totala a trata"ent!l! este $e = -< (le.
A'anta8ele !tl(ar A(al$elor, 9 se pot a$"nstra s la copl/
9 n! colorea(a $nt/ 9 n! a! to)ctate sste"ca/ 9 t"p!l $e n8!"a- tatre este l!ng (11.
la :!l$% 62. la 4!"a"e$)% per"tan$ o a$"- nstrare $scontn!a% $e + or?( sa! n
$o(a !nca/ 9 asg!ra o co"planta #!na/ 9 concentrea(a &oarte #ne n tes!t!rle l"&atce
s osoase/ 9 a! e&ect postant#otc (perssta la loc!l n&ecte <-11 (le &ata $e nc.eerea
trata"ent!l! - A(tro"cna ).
6.1.6.=. Trata"ent!l pero$ontte
In pero$ontta a$!lt!l! - alternat'ele terape!tce s!nt, Do)c- clna% 0acrol$e%
Ce&alosporne (c! a$"nstrare orala)% asocate trata- "ent!l! sto"atologc local
pero$ontal.
In pero$ontta a'ansata% pe langa trata"ent!l sto"atologc $e specaltate ($e#r$are
"ecanca s n$epartarea "n!toasa a plac $entare)% re(!ltate &oarte #!ne s-a! o#tn!t
prn a$"nstrarea conco"- tenta $e 0etron$a(ol( + g?().
In gng'ta !lcero-necrotca% trata"ent!l $e electe se &ace prn asocerea $e 5enclna G
(;-6"l.U?() c! 0etron$a(ol (+ g?().
In pero$ontta 8!'enla% re(!ltate sats&acatoare s-a! o#tn!t prn a$"nstrarea $e
Tetracclna (+g?()% sa! Do)cclna (111 "g?()% n!"a asocat trata"ent!l!
sto"atologc local. Tetracclna este contran$cata s!# 'arsta $e 11 an% pana la aceasta
'arsta% ra"anan$ ca alternat'a% a$"nstrarea !n! 0acrol$ sa! a !ne Ce&alosporne (pe
cale orala).
6.1.6.;. Trata"ent!l n&ectlor s!p!rat'e o$ontogene
In&ectle s!p!rat'e o$ontogene% #ene&ca(a $e !n trata"ent co"ple) ce '(ea(a, E
a$"nstrarea terape ant#acterane/E trata"ent sto"atologc $e specaltate, $rena8!l
colecte% n$epartarea tes!t!rlor
necro(ate% etc.
Terapa ant"cro#ana este o#lgatore,
9 pentr! pre'enrea e)tn$er locale a n&ecte s a $se"nar .e"a- togene (e'tarea
nstalar sepss-!l!)/
9 n pre(enta &e#re s?sa! a constt!r $eter"narlor loco-regonale
(l"&a$enta)/
9 n ca(!l e)stente !n! teren "!noco"pro"s prn, l"&oa"e% le!- ce"% pacent
ne!tropenc% $a#etc% 'al'!lar% .epatopat cronce% alcools" cronc% n&ecte >IV
sta$!l 4IDA% etc.
Ca s prncp generale% ant#otcoterapa 'a prece$a ntot $ea!na nter'enta
c.r!rgcala% contn!an$ n t"p!l act!l! c.r!rgcal s cate'a (le (=-<(le) $!pa
nter'ente.
Alegerea ant#otc!l! n! necesta o#lgator! asteptarea $ent&car ger"en!l! s
o#tnerea ant#ogra"e/ trata"ent!l ant#ac- teran% se #a(ea(a ntal pe crter!l ratonal
(ce tne cont $e &lora #acterana c!nosc!ta a & pos#l "plcata).
Varante $e ant#otcoterape $e pr"a ntente (e"prc),
A) Deoarece "a8ortatea ger"enlor aero# s anaero# s!nt sen- s#l la 5enclna% la
persoanele "!noco"petente trata"ent!l e"prc se nta(a c! $o(e "ar $e 5enclna G
(6-11 "l.U?()% n "onoterape sa! asocat c! 0etron$a(ol (+ g?()% a$"nstrat .'.% pe o
$!rata $e 11
-/ 1; (le.
B) In ca( $e alerge la penclna% se poate &olos Cln$a"cna
(+g?().
C) Alte 'arante terape!tce s!nt, Ce&o)tna (gen. II)% n $o(a $e
6-2 g?( sa! Ce&t(o)"a (gen.III) +-; g?(.
D) In trata"ent!l a"#!lator al &or"elor clnce &ara ele"ente $e gra'tate% se poate
rec!rge la A"o)clna (sng!ra sa! n asocere c! !n n.#tor $e #etalacta"a(a
-A!g!"entn) sa! la Cpro&lo)acna (n "ono- terape sa! asocata c! 0etron$a(ol).
O#ser'ate, Ertro"cna s Tetracclna n! s!nt n$cate n trata- "ent!l IO% $eoarece
&a'or(ea(a $e('oltarea rap$a $e re(stenta n ran$!l anaero#lor oro&arngen.
E) In pre(enta n&ectlor se'ere (n&ect ale spatlor pro&!n$e)% a nstalar
co"plcatlor% $aca rasp!ns!l terape!tc este ne&a'ora#l la "onoterapa c! 5enclna%
s?sa! n ca(!l e)stente !n! teren "!noco"pro"s% trata"ent!l ant#otc tre#!e sa &e
s!stn!t% ast&el ca sa acopere !n spectr! larg $e ger"en (BGN% CG5% aero# s anaero#)/
n aceste ca(!r se rec!rge la asocer $e ant#otce% care% $e reg!la% ncl!$, o
Betalacta"na F !n A"noglco($ (gen.II sa! III) F Fl!oroc.nolona.
Dntre Betalacta"ne se reco"an$a ant#otce ce &ac parte,
9 &e $n gr!p!l 5enclnelor antpse!$o"onas, 5peraclna G Ta(o- #acta" (Ta(ocn)
sa! Tcarclna GAc$ cla'!lanc (T"entn)/ n a"#ele ca(!r% se a$"nstrea(a $o(a
"a)"a, 1+g?(/
9 &e $ntre Car#apene"e, I"pene"?clastatn (Tena") - +g?(.
Dntre A"noglco($e, Genta"cna (+)21"g?() sa! A"Dacna
(+)<11"g?().
Dntre Fl!oroc.nolone, Cpro&lo)acna(+)<11"g?() sa! 5e&lo)a- cna (+);11 "g? ().
O#ser'ate, Trata"ent!l c.r!rgcal% la &el $e "portant ca s cel ant#otc% tre#!e aplcat
la "o"ent!l oport!n s an!"e% n sta$!l $e
@colectareA a &ocar!l! s!p!rat' s n! n acela $e n&ecte $&!(a local(ata/ $aca
"o"ent!l nc(e este ncorect ales% se 'a $eclansa $oar #actere"a (c! rsc "a8or $e
$se"nare a n&ecte)% &ara a se o#tne nsa s $rena8!l colecte p!r!lente.
6.+. INFECTII ale 0UCOA4EI BUCALE
6.+.1. 4to"atte
4!nt procese n&la"ator ale "!coase #!cale.
5rncpalele &or"e clnce $e sto"atte, sto"atta gangrenoasa
(No"a)% sto"atta !lcero-necrotca% sto"atta a&toasa% sto"atta .erpe- tca% sto"atta
'e(c!loasa c! e)ante".
6.+.1.1. NO0A (4to"atta gangrenoasa)
No"a nsea"na gangrena o#ra(!l! (Acancr!" orsA)/ este !n proces n&la"ator
$str!ct' $e ca!(a n&ectoasa% ce a&ectea(a "!coasa #!cala% a'an$ e'ol!te gra'a.
6.+.1.1.1. Etologe
Etologa este ")ta, trepone"e (Borrela Vncent)G &lora anaero#a
(F!so#acter)G Bactero$es (Bactero$es "elannogenc!s).
Boala apare n conte)t!l !nor &actor &a'or(ant legat $e sarace, cop% a$!lt% "aln!trt
sa! $e#ltat $atorta pree)stente !nor #ol cronce non-n&ectoase.
6.+.1.1.+. Ta#lo! clnc
De#!t este #r!sc c! s!#&e#rltat% astene% re&!(!l al"entate $a- torta nstalar $!rer
la tentat'a $e "astcate.
Intal% la n'el!l "!coase #!cale apare o le(!ne !lcerat'a $e
$"ens!n "c% local(ata la n'el!l pre"olarlor sa! "olarlor n&eror
("an$#!lar).
In a#senta trata"ent!l!% le(!nea se e)tn$e rap$ % aparan$ (one $e gangrena% nsotta $e
cel!lta e)tnsa% ce a&ectea(a #!(ele s o#ra8.
:ap$% (onele necro(ate se el"na% e)p!nan$ 'e$er os!l% $nt s tes!t!rle pro&!n$e
$en!$ate.
6.+.1.1.=. Trata"ent
Trata"ent etologc, 5enclna G (+)=-; "l.U?() G 0etron$a(ol n8..'. (11 "l?Dgc?().
D!pa a"elorarea clnca s paraclnca% este necesara% $e reg!la% nter'enta c.r!rgcala
plastca $e resta!rare a tes!t!rlor necro(ate.
6.+.1.+. 4TO0ATITE ULCE:O-NEC:OTICE
6.+.1.+.1. Etologe
4!nt ca!(ate $e o asocere $e agent #acteren aero#? anaero#, F!sosprl? Clostr$!"
G 4trepto?4ta&lococ.
4!r'n pe teren "!no$epr"at prn,
9 e)tre"e $e 'arsta (s!gar%copl "c%'arstnc)/
9 e)stenta !nor #ol non-n&ectoase ,procese neopla(ce?.e"opat% #ol cronce
anerg(ante, $a#et (a.arat% .epatopat cronce% etls" cronc% colagena(e%etc.
6.+.1.+.+. Ta#lo! clnc
A. De#!t #r!sc c! &e#ra (peste =7HC)% &rsoane% stare generala alte- rata% ce&alee% trs"!s%
.alena &et$a% saloree.
B. 5eroa$a $e stare
5erssta &e#ra% &rsoanele% c! nstalarea &eno"enelor $e soc to)co- septc, .potens!ne%
ta.car$e% p!ls "percept#l% e)tre"tat rec% ca- notce% polpnee% ta.pnee% olg!re.
Local, 9 trs"!s% saloree &et$a/ 9 apar s se e)tn$ rap$% n s!pra&ata s pro&!n("e (la
n'el!l partlor "o)% le(!nle !lcerat'e% ne crotce/ 9 a$enta satelta "presonanta.
In &or"ele clnce gra'e% n a#senta trata"ent!l! ant#acteran% le(!nle necrotce pot
a8!nge pana la per&orarea o#ra(!l! (&st!l(are). O#ser'ate, 4to"atta !lcero-necrotca
poate constt! poarta $e ntrare pentr! nstalarea sepss-!l! se'er c! soc to)co-septc. In
ca(!l nstalar soc!l! septc% la e)a"en!l clnc se $epstea(a s alte "o$&car
patologce (se"n&cat' &n$ nstalarea &ocarelor septce sec!n$are, &rec
'ent #ron.opne!"one G?- a&ectare .epatca% renala% etc).
6.+.1.+.=. Dagnostc
A. Dagnostc!l po(t' are la #a(a, a) Ep$e"ologc, $ate ce s!stn !n teren
"!no$epr"at se'er/ #) Clnc, sn$ro" n&ectos ,&e#ra (peste =7HC)% &rsoane% saloree
&et$a/ le(!n e)tnse !lcero-necrotce G a$enopat satelte. c) Ur"atoarele e)a"nar
paraclnce,
9 e)!$at &arngan (nsa"antat pe "e$ aero#e?anaero#e)/
9 &rot! colorat Gra" (pentr! $ent&carea &!sosprllor)/
9 .e"oc!lt!ra (e'ent!al po(t'a)/
9 $eter"narea procalctonne (5CTIJ+ng?"l/ $aca 5CT IJ11 ng?"l este ca( $e sepss
se'er)/
9 V4> cresc!t% le!cocto(a c! pre$o"nanta 50N/
9 &#rnogen s protena C react'a cresc!te.
B.Dagnostc $&erental
4e &ace c!, sto"atte $e alte etolog (.erpetca% 'e(c!loasa c! e)ante")/ gng'ta
!lcero-necrotca (Vncent)% agran!locto(a/
5rognostc!l #ol este re(er'at.
6.+.1.+.;. Trata"ent
Internare n sptal% n secte $e ATI pentr! "ontor(area &!nctlor 'tale.
A) Trata"ent etologc, pres!p!ne !tl(area !nea $n !r"a- toarele asocer $e
ant#otce,
9 5enclna G (6-2 "l.U?(% a$".la 1+ .) G A"noglco($e?Fl!oroc.no- lone G
0etron$a(ol(+g?(..'.)/
9 Unas6n ( =)1%< g?()GCln$a"cna .'. ( 611 "g?()/
9 Tena" (1%< g?() F A"noglco($ F Cln$a"cna /
9 T"entn G Cln$a"cna.
D!rata trata"ent!l!, *-11 (le.
B)Trata"ent patogenetc "plca reec.l#rare .$ro-electro- ltca s ac$o-#a(ca
(con&or" para"etrlor paraclnc s a $atelor cln- ce)/ n &!ncte $e e'ol!ta ca(!l!% se
"a poate a$"nstra,
9 >>C (n ca( $e soc) =11-611"g?(/
9 Dopa"na% 1-+&ole% $(ol'ate n <11"l sol.gl!co(a <3% rt"!l $e a$"- nstrare &n$
lent (;-<Kg?Cgc?"n.).
C)Trata"ent s"pto"atc , antalgc% antter"c% se$at'. D)Trata"ent!l local #!co-
"a)lo-&acal pres!p!ne, toaleta locala (c! sol!te apa o)genata% antalgce s
$e(n&ectante locale)%
nlat!rarea (onelor necro(ate.
6.+.1.=. 4TO0ATITA AFTOA4A
Este cea "a &rec'enta ca!(a a le(!nlor #!cale rec!rente.
6.+.1.=.1. Etologe
Etologa este neprec(ata. 4e pres!p!ne !n "ecans" "!n $e $eclansare, !r"are a
reacte antgen-antcorp se &or"ea(a co"ple)e "!ne crc!lante (antcorp s l"&octe T
sens#l(ate) care n$!c aparta le(!nlor la n'el!l "!coase #!cale.
Factor &a'or(ant, E persoane c! o gena $entara $e&ctara/
E n&ect cronce o$ontogene/ E teren "!no$epr"at.
6.+.1.=.+. For"e clnce
E)sta = &or"e clnce $e sto"atta a&toasa, c! le(!n "nore/ c! le(!n "a8ore/ c!
le(!n .erpet&or"e.
A. For"a clnca c! le(!n "nore
La n'el!l "!coase #!cale s la#ale% apar "c le(!n !lcerat'e% &oarte $!reroase% $e
c!loare al#a-cen!se% ncon8!rate $e (one $e .pere"e "argnala. Ulteror% acest tp $e
le(!n se pot e)tn$e la n'el!l palat!l! "oale sa! pe l"#a ("a ales &ata $orsala).
4ec!n$ar aparte s e)tn$er le(!nlor% #olna' o#ser'a aparta !ne a$enopat $e
'ecnatate. De o#ce% aparta s cresterea $"ens!nlor a$enopate satelte%
e)teror(ea(a% clnc% nstalarea s!pra n&ecte le(!nlor !lcerat'e.
E'ol!ta este 'ara#la% p!tan$!-se a"elora sa! 'n$eca spontan $!pa 11-1; (le.
B. For"a clnca c! le(!n "a8ore
Le(!nle !lcerat'e s!nt "a n!"eroase s $e $"ens!n "a "ar% s!nt $se"nate
nteresan$ toate (onele "!coase ca'tat #!cale% ncl!s' tot palat!l "oale s s!pra&ata
a"g$alelor.
C. For"a clnca c! le(!n .erpet&or"e
Ulceratle a&toase .erpet&or"e s!nt "c% n!"eroase s &oarte $!reroase. Este
caracterstca local(are !lceratlor a&toase, "argnle laterale s 'ar&!l l"#.
Bolna'!l ac!(a saloree% pacent re&!(a al"entata% ar "astcata se real(ea(a c!
$&c!ltate.
6.+.1.=.=. Trata"ent!l
Este n!"a s"pto"atc s pr'este,
9 toaleta ca'tat #!cale/
9 a$"nstrarea $e aneste(ce locale% $e pre&ernta nante $e "asa c! =1 "n!te, se &ace
#an$8ona8 #!cal (=-; or?() c! sol. $e glcerna #ora)ata c! aneste(na (1g)/
9 &olosrea !ne sol!t contra a&telor , A&tol(ol $e = or?(%etc.
N! este n$cata &olosrea cortco(lor nc local s n nc !n ca( pe cale generala ($at
&n$ nec!noasterea etologe s pre(!"ta ca acest tp $e sto"atta se nstalea(a n!"a
pe teren "!no$epr"at).
6.+.1.;. 4TO0ATITA >E:5ETICA
Este cea "a &rec'enta ca!(a $e sto"atta la cop c! 'arsta s!# = an.
Etologe, pr"on&ecte c! .erpes s"ple) 'r!s 1% +.
Ta#lo! clnc pres!p!ne,
De#!t #r!sc c! &e#ra% .persal'ate% re&!(!l al"entate% .alena &et$a/ Local, le(!n
'e(c!loase% ntal gr!pate n @#!c.eteA pe &on$ con- gest'% care se e)!lcerea(a rap$%
acopern$!-se $e !n $epo(t $e c!loare cen!se.
N! e)sta le(!n la n'el!l a"g$alelor.
6.+.1.<. 4TO0ATITA VELICULOA4A c! EMANTE0
4e "a n!"este, #oala "anlor% pcoarelor s a g!r (@>an$%
Foot an$ 0o!t. DseaseA).
6.+.1.<.1. Etologe
Agent!l ca!(al este 'r!s!l Co)sacDe A 16 ("a rar A<% A*% A7% A11% B+% B<). Vr!s!l
poate & (olat $n le(!nle c!tanate care se nstalea(a sec!n$ar% !r"are a pro$!cer
're"e.
:ar% a&ect!nea poate & $ata s $e Entero'r!s!l *1% e)stan$% aso- cat% le(!n c!tanate s
"!coase prec!" s a&ectarea 4NC-!l!.
6.+.1.<.+. Ep$e"ologe
Boala se nstalea(a !(!al% la cop c! 'arsta s!# 11 an% n "o$ c!rent e)stan$
trans"tere ntra&a"lala.
6.+.1.<.=. Ta#lo! clnc
De#!t!l este ac!t% c! &e#ra peste =7HC pentr! 1-+ (le% $s&age% "astcate $&cla.
E)a"en!l o#ect' $ent&ca, 'e(c!le $se"nate atat la n'el!l "!coase #!cale cat s
pe l"#a/ aceste 'e(c!le se trans&or"a !lteror n #!le care se e)!lcerea(a rap$.
In peroa$a $e stare (er!pt'a)% caracterstc este pre(enta !n!
e)ante" c! $str#!te topogra&ca elect'a, la n'el!l "anlor (pal "e) s la n'el!l
plantelor (talple pcoarelor). Er!pta este #laterala $ar n! s"etrca. Ve(c!lele a! !n
contn!t clar (a&ectea(a s!#ep$er"!l)% &n$ ncon8!rate $e o (ona erte"atoasa.
6.+.1.<.;. Dagnostc po(t' s $&erental
Dagnostc!l po(t' se #a(ea(a pe !r"atoarele $ate,
9 ep$e"ologce, pos#la e)stenta "a "!ltor ca(!r ntra&a"lal/
9 clnce, le(!n 'e(c!loase $sp!se #lateral% la n'el!l pal"elor% plantelor s "!coase
#!cale (ncl!s' pe l"#a)/
9 e).paraclnce, $ent&carea 'r!s!l! (Ag) prn "!no&l!orescenta s $eter"narea (n
$na"ca) a ttr!l! antcorplor prn e&ect!area >AI s :FC.
Dagnostc!l $&erental se &ace c!,
E.erpangna (enante" local(at &rec'ent pe palat!l "oale)% a#senta e)ante"!l!/ E
'arcela/ E gng'o-sto"atta .erpetca (sn$ro" n&ectos s er!pt' ntens% nsott $e
a$enopate cer'cala satelta).
6.+.1.<.<. Trata"ent
Trata"ent!l este n!"a s"pto"atc c! "entnerea !ne gene rg!roase a le(!nlor $n
ca'tatea #!cala pentr! e'tarea nstalar s!pran&ectlor.
6.+.1.6. ALTE 4TO0ATITE
6.+.1.6.1. 4to"atta ang!lara
4e "a n!"este s sto"atta co"s!rala% N(a#al!taA.
Apare &rec'ent post ant#otcoterape prel!ngta s poate & $e ca!(a
4trepto?4ta&lococca.
6.+.1.6.+. A&to(a #polara To!rrane
Este caracter(ata $e aparta !nor le(!n ce sea"ana c! le(!nle a&toase a'an$ nsa
local(are conco"tenta la n'el!l "!coase #!cale% gentale s pergentale.
4"lar le(!nlor a&toase% are o patogene a!to"!na.
6.+.1.6.=. 4n$ro"!l >gas.-Be.cet
Etologe nec!nosc!ta% pro#a#l "ecans" a!to"!n.
Ta#lo!l clnc este caracter(at $e ,
9 aparta $e a&te $se"nate la n'el!l "!coaselor #!cala s gentala/
9 s"!ltan% e)sta "an&estar $e, con8!nct'ta% r$occlta% no$!l c!tanat%
tro"#o&le#ta% artrta% colta s "an&estar $e a&ectare ne!rologca/ n $e#!t!l acestor
"an&estarlor pacent pot pre(enta &e#ra.
E'ol!ta este rec!rentala% nen&l!entata $e trata"ent!l ant'ral.
Trata"ent c! re(!ltate $sc!ta#l po(t'e, a$"nstrarea $e cortcoterape s
"!nos!presoare.
6.+.1.6.;. 4arco"!l Capos
Apare n!"a la persoane c! teren se'er "!no$epr"at prn n&ecte >IV sta$!l 4IDA%
posttransplant $e organe% #ol a!to"!ne% .e"opat "algne% c."o s ra$oterape.
Ta#lo!l clnc, la n'el!l "!coase #!cale apar le(!n $str!ct'e e)tnse eptelal% pe
&on$!l carora se nstalea(a s!pran&ect #acterene% 'rale?&!ngce.
Descrerea $etalata a le(!nlor% 'a & pre(entata n ca$r!l n&ecte
>IV.
6.+.+. ACTINO0ICOLA
6.+.+.1. ETIOLOGIE
Actno"co(a este o #oala n&ectoasa c! e'ol!te cronca% $eter- "nata $e Actno"6ces
srael% care !(!al este nca$rat n &lora sapro&ta (en$ogena) a ca'tat #!cale.
:e(er'or!l $e ger"en, pacent c! porta8 cronc $e spec $e
Actno"6ces n &lora sapro&ta #!cala% gng'o$entara.
Factor &a'or(ant a #ol,
9 gena $e&ctara a ca'tat #!cale/
9 e)stenta !nor n&ect cronce "!ltple $ento-al'eolare negl8ate/
9 pree)stenta% anteror $e#!t!l! #ol c! apro)"at' +1-=1 $e (le% a !nor "anopere
c.r!rgcale sto"atologce neprote8ate ant#otc.
6.+.+.+. 5ATOGENIE
5entr! a se $eclansa #oala% este necesar sa e)ste patr! con$t, a) pre(enta% n plan local%
a !nor &actor "!nos!presor% prec!",E tra!- "ats"e operator (a"g$alecto"e%
"anopere sto"atologce)/ E nter- 'ent e&ect!ate pe t!#!l $gest' n scop $agnostc
(gastroscop% en$oscop)% sa! terape!tc (nter'ent c.r!rgcale pe eso&ag% sto"ac% etc.)/
#) pre(enta la n'el!l ca'tat #!cale a !ne &lore "cro#ene asocate% care sa cree(e
con$t $e "!ltplcare a speclor $e Actno"6ces/ c) $e('oltarea% pe "!coasa ca'tat
#!cale% a !nor le(!n $estr!ct'e
(tes!t!r $e'tal(ate% necro(e% !lcerat)% la n'el!l carora sa se nstale(e con$t $e
anaero#o(a/ $) e)stenta !n! teren "!noco"pro"s% prn a$"nstrarea $e l!nga
$!rata% a "e$cate "!nos!presoare s?sa! cortcoterape.
6.+.+.=. TABLOU CLINIC
Inc!#ata este $e ;-6 sapta"an.
In &!ncte $e loc!l port $e ntrare% ntenstatea "!ltplcar agent!l! ca!(al s gra$!l $e
"!no$eprese al organs"!l! ga($a% actno"co(a poate pre(enta !r"atoarele &or"e
clnce, cer'co-&acale% p!l"onare% ntestnale% cere#rale s% "a rar% c.ar sepss.
6.+.+.=.1. For"a cer'co-&acala
Este &or"a clnca cea "a raspan$ta (<1-613 $n ca(!r).
De#!t!l este ns$os% necaracterstc, la n'el!l reg!n cer'co- &acale se nstalea(a o
t!"e&acte% #ne $el"tata% aparent a$erenta $e plan!rle pro&!n$e% c! consstenta $!ra%
care se e)tn$e% crescan$ treptat n $"ens!n.
Caracterstc o#ect'e,
9 pacent!l este a&e#rl sa! s!#&e#rl ("a)" =*%<O C)% ar &or"at!nea n! pre(nta se"ne
celsene/
9 n a#senta sta#lr $agnostc!l! clnc% t!"e&erea se e)tn$e% ar n t"p ((le-
sapta"an) apare o &st!l(are spontana/
9 la n'el!l &st!le se sc!rge o secrete p!r!lenta% gr!n8oasa $e aspect
("acroscopc) caracterstc, gal#en c! gr!n8 'er( (ase"anatoare gran!lelor $e s!l&).
In a#senta trata"ent!l! spec&c ant#acteran% n&ecta $se"- nea(a prn @ contg!tateA
spre "an$#!la% sn!s!r sa! or#ta% p!tan$ sa se nstale(e% la acest n'el% o osteo"elta
cronca.
6.+.+.;. DIAGNO4TIC
A. Dagnostc!l po(t' se #a(ea(a pe !r"atoarele,
1A) Date ep$e"ologce, E)stenta n antece$ente% la o persoana c! teren
"!noco"pro"s% a !nor "anopere sto"atologce% sa! c.r!rgcale
n reg!nea cer'co-&acala/
+A) Date clnce,
9 pacent &ara sn$ro" n&ectos,
9 &or"at!ne t!"orala% &ara se"ne celsene pre(ente% ten$nta la &st!l (are spontana%
secrete p!r!lenta c! gr!n8 'er(! (ase"anatoare gran!lelor $e s!l&).
=A) E)a"ene paraclnce,
9 e)a"en #acterologc% e&ect!at $n secreta p!r!lenta% nsa"antat pe "e$ anaero#e
"#ogatte (re(!ltat tar$'% $aca e)sta o &lora aero#- anaero#a)/
9 e)a"en .stologc al pro$!s!l! #optc, conglo"erate $e cel!le n&la- "ator s
"!ltple canale &st!loase.
B. Dagnostc!l $&erental are n 'e$ere, E t!"or "algne c! local(are cer'co-&acala/ E
a$eno&leg"oane/E osteo"elta "a)lara/
Esn!(ta "a)lara.
6.+.+.<. T:ATA0ENT
A. Trata"ent etologc
Ant#otc!l $e electe este 5enclna G% a$"nstrata parenteral% n $o(e $e + ) <
"l.U?(% t"p $e ;-6 sapta"an% pana la re"sa co"- pleta a &eno"enelor locale.
Trata"ent ant#otc alternat', A!g"entn (A"o)cla')% p.o.%
= ) 1 g?(.
O#ser'ate, Daca pacent!l este alergc la #etalacta"ne se pot a$"nstra Lncosa"$e
(Cln$a"cna = ) 1 caps!la $e =11 "g?()% pe o $!rata $e +1-=1 (le.
B. Trata"ent c.r!rgcal '(ea(a, $rena8!l a#ceselor s re(ol- 'area traectelor &st!loase%
n scop!l e'tar rec$'elor.
6.=. ANGINE
Angnele s!nt procese n&la"ator ce a&ectea(a oro&arngele% respect'% nel!l l"&atc s
a"g$alele palatne.
Angnele a! o "or#$tate cresc!ta% oc!pan$ loc!l al $olea $!pa n&ectle ac!te ale
calor resprator s!peroare.
6.=.1. ETIOLOGIE
In etologa angnelor pot & "plcate, 'r!s!r% #acter sa! &!ng/ $eseor nsa% se
constata e)stenta !ne etolog ")te, 'ro-#acterene% ger"en aero#-anaero# s?sa!
&!ng.
In etologa angnelor% #acterle (olate s!nt, pre'alent% strepto- coc!l #eta-.e"oltc gr!p
A% !r"at $e sta&lococ!l a!re!% pne!"ococ% "enngococ% #acl Gra" negat'.
Dntre 'r!s!r% &rec'ent "plcate s!nt a$eno'r!s!rle (ce pro$!c angnele la s!gar s
copl!l s!# = an).
0a rar% angnele pot & ca!(ate $e, &!ng% c.la"6$% "6coplas"e.
In ca$r!l #ollor $e sste" (agran!locto(a% le!ce") sa! a !nor #ol n&ectoase
(scarlatna% $&tere% "onon!cleo(a n&ectoasa% &e#ra t- &o$a)% pre(enta angne (a'an$
$&erte aspecte clnce) constt!e !na $ntre ele"entele clnce esentale% n sta#lrea
$agnostc!l! po(t' al #ol respect'e.
6.=.+. 5ATOGENIE
4treptococ!l a$era la n'el!l "!coase &arngene (poarta $e ntra- re)% !n$e se "!ltplca/
$rept consecnta% la acest n'el% apar &eno"ene n&la"ator $e $&erte ntenstat
(coresp!n(ator gra$!l! $e "!ltplcare a streptococ!l!).
De la poarta $e ntrare% streptococ!l poate $se"na, 9 prn con tg!tate% !r"are a car!a
se constt!e, a$enta satelta% sn!ste% otte% etc./ 9 pe calea .e"atogena can$ poate apare%
c.ar s septce"e ($aca teren!l organs"!l! ga($a este "!no$epr"at).
5ree)stenta !ne n&ect 'rale local(ate la n'el!l calor respra- tor s!peroare s?sa!
sca$erea re(stente organs"!l! ga($a (e). prn s!prasolctare &(ca s ps.ca% #ol
cronce anerg(ante)% &a'or(ea(a
(sec!n$ar n&ecte 'rale)% nstalarea angne streptococce.
6.=.=. TABLOU CLINIC
D!pa aspect!l clnc% angnele se pot "part n, angne ros% angne al#e s angne
!lcero-necrotce.
6.=.=.1. ANGINE (&arngte) :O4II
Acest tp $e angna% poate & pro$!s atat $e 'r!s!r cat s $e #acter/ n &!ncte $e agent!l
ca!(al% e)sta !nele partc!lartat clnce% ce orentea(a $agnostc!l.
Angnele ros c!prn$, &arngta ac!ta% angnele ros $e ca!(a #acterana s angnele ros
$e ca!(a 'rala.
6.=.=.1.1. Farngta ac!ta
Farngta ac!ta apare la copl!l s!# = an.
A. De#!t!l este ns$os% c! s!#&e#rltat% o#str!cte na(ala% secrete rno-p!r!lenta.
B. 5eroa$a $e stare
Bolna'!l pre(nta s!#&e#rltat sa! &e#ra pana la =2HC% $s&age% 'oce na(onata%
o#str!cte na(ala% sen(ate $e !scac!ne la n'el!l &arngel!.
La e)a"en!l o#ect' se poate constata pre(enta !ne congest &a
rngene,
9 ntensa s #ne $el"tata - n ca(!l etologe streptococce/
9 "precs $el"tata% "a $screta &n$ nsotta !neor $e cate'a p!ncte .e"oragce
(Naspect $e pc.ete!A) la n'el!l 'al!l! palatn - n ca(!l etologe 'rale/
9 conco"tent% #olna' pot pre(enta, a$enta satelta s?sa! a$eno- $ta ac!ta% (can$ la
n'el!l &arngel! posteror este pre(enta o secrete p!r!lenta).
6.=.=.1.+. Angne ros $e ca!(a #acterana
E)sa $o!a &or"e, angna erte"atoasa s &leg"on!l a"g$aln.
A. Angna erte"atoasa
4!r'ne pre'alent n ca(!l "plcar streptococ!l! #eta-.e"oltc $e gr!p A s
caracter(ea(a e'ol!ta o#sn!ta a angne.
Inc!#ata este $e 1 - = (le.
De#!t!l este #r!sc% c! &e#ra (=7H- ;1HC)% &rson% $s&age% ce&alee% 'arsat!r al"entare%
!neor trs"!s% stare generala alterata.
O#ect' se constata, o congeste &arngo-a"g$alana #ne $el- "tata% $e c!loare ros!
'!% c! a"g$alele .pere"ce.
Boala are o e'ol!te &a'ora#la s!# trata"ent c! 5enclna G.
B. Angna &leg"onoasa (&leg"on!l a"g$alan)
4e constt!e n ca(!l e'ol!te ne&a'ora#le% &n$ &rec'ent $e etologe streptococca.
De#!t!l este #r!sc% c! &e#ra (=7H-;1HC)% &rsoane% ce&alee% $s&a- ge ("pos#ltatea
$egl!tte)% saloree a#!n$enta% trs"!s% 'oce na(o- nata stearsa% !neor resprate $&cla.
La e)a"en!l o#ect' se constata o congeste &arngo- a"g$alana ntensa% #ne
$el"tata% c! a"g$ale .pere"ce s .per- tro&ce% e$e" pera"g$alan !nlateral (c!
pre$o"nenta a"g$ale $ncolo $e lna "e$ana s $e'erea l!ete $e aceeas parte)%
a$enta satelta. Can$ t!"e&erea a"g$ale $e'ne &l!ct!enta% s-a constt!t a#ces!l
a"g$alan% care se poate $esc.$e spontan sa! prn nc(e.
6.=.=.1.=. Angne ros $e ca!(a 'rala
Dn aceasta categore &ac parte, angna .erpetca% >erpes-(oster &arngan s .erpangna.
A. Angna .erpetca
Este $ata $e 'r!s!l .erpes s"ple) tp 1% +.
De#!t!l este #r!tal c!,&e#ra% &rsonete% c!r#at!ra% a$enopate cer- 'cala satelta.
E).o#ect', la n'el!l &arngel!% palat!l! "oale s #!(elor apar% caracterstc%
"cro'e(c!le $sp!se @n #!c.etA% pe !n &on$ erte"atos. 0cro'e(c!lele se !lcerea(a%
aparan$ ero(!n s!per&cale% &oarte $!re roase% ncon8!rate $e !n l(ere! erte"atos.
Le(!nle se acopera rap$ c! !n e)!$at cen!s!-gal#!. Daca teren!l organs"!l! ga($a
este "!no- co"petent% e'ol!ta este spontan &a'ora#la.
B. >erpes-(oster &arngan
Etloge, 'r!s!l .erpes- (oster.
Caracterstc,
9 este o ne!ro-ra$c!lta% ce a&ectea(a ganglon!l spnal s ner' cranen
V s IM/
9 s!#ect' , pacent!l pre(nta !nlateral% pe traect!l er!pte% $!rer '% c! e)acer#ar
paro)stce s pareste( #!co-&arngene/
9 o#ect', apar le(!n 'e(c!loase% ce se e)!lcerea(a rap$% $atorta "astcate% l!an$
aspect $e @a&taA/ le(!nle a! topogra&e !nlaterala% ne$epasn$ lna "e$ana.
C. >erpangna
Este ca!(ata $e 'r!s!l Co)sacDe A.
Clnc, la n'el!l &arngel! apar% pe !n &on$ $e congeste erte- "atoasa $&!(a%
n!"eroase "cro'e(c!le% ce se pot e)!lcera rap$.
E'ol!ta este spontan &a'ora#la% n <-*-(le pro$!can$!-se ep- tel(area.
6.=.=.+. ANGINE ALBE
In aceasta categore se nca$rea(a angnele p!ltacee s angnele pse!$o"e"#ranoase.
6.=.=.+.1. Angna p!ltacee
Este $e etologe pre'alent streptococca.
De#!t!l este #r!sc c! sn$ro" n&ectos% pacent pre(entan$ ace- leas ac!(e ca s la
angna erte"atoasa (rose).
La e)a"en!l o#ect'% pe &on$!l congeste &arngo-a"g$alene #ne $el"tata% apar
$epo(te p!ltacee la n'el!l a"g$alelor.
6.=.=.+.+. Angna pse!$o-"e"#ranoasa (Ang5se0e")
O#sn!t este $e etologe streptococca% $&terca sa! $e alte ca!(e.
A. Ang5se0e" $e etologe streptococca.
De#!t!l este #r!sc% c! sn$ro" n&ectos (&e#ra% &rson% stare generala alterata)% $s&age
ns!porta#la c! saloree a#!n$enta% trs"!s. Falsa "e"#rana (pse!$o-"e"#rana) are
!r"atoarele caracte- rstc, 9 este $e c!loare al#a/ 9 n! $epaseste s!pra&ata a"g$alelor/
9este &ra#la s se $etasea(a !sor/ 9 n! lasa (one sangeran$e post $eta
sare/ 9 n! se re&ace !sor/ 9 $lacerea(a p!sa ntr-!n pa.ar c! apa.
B. Ang5se0e" $e etologe $&terca.
Caracterele pse!$o-"e"#rane (ce constt!e ele"entele $e $agnostc po(t') s!nt,9 este
$e c!loare al#-cen!se/ 9 se e)tn$e la n'el!l stalplor a"g$alen% l!ete% larngel!/ 9
este consstenta% groasa% real(an$ !n "!la8 al &arngel!/ 9 se $etasea(a gre!% lasan$ $!pa
$eta- sare !n aspect sangeran$ la n'el!l &arngel!/ 9 se re&ace rap$/ 9 n! $lacerea(a
p!sa ntr-!n pa.ar c! apa.
C. Ang5se0e" c! alte ca!(e $e aparte a pse!$o"e"#rane- lor, 9 n ca$r!l !ne
etolog "cotce (Can$$a al#cans% Leptot.r))/
9 posta"g$alecto"e/ 9 post ngerare $e s!#stante ca!stce.
6.=.=.=. Angne ULCE:O-NEC:OTICE
6.=.=.=.1. Angna >enoc.
Etologe, este $ata $e asocerea 4treptococ!l! #eta-.e"oltc gr!p A c! o &lora ")ta
anaero#a (Clostr$!"% Bactero$es &!n$!l&or"s% Bacl!l :a"os!s).
5atogena este con$tonata $e coe)stenta a $o &actor,
9 etologe ")ta aero#-anaero#a/
9 teren "!no$epr"at se'er, pacent casectc $atorta c."oterape postneopla(ce%
n&ecte c! >IV (sta$!l 4IDA)% .e"opat "algne% neoplas" a"g$alan s!pran&ectat.
Ta#lo! clnc
De#!t ac!t, c! &e#ra (;1OC)% &rsoane sole"ne% 'arsat!r al"en- tare% stare generala se'er
alterata (.potens!ne arterala% p!ls &l&or")% stare $e prostrate% $s&age ntensa% pare(a
$e 'al palatn c! 'oce na(onata% re&l!area lc.$elor pe nas% .alena &et$a% .persal'ate.
O#ect' se constata, 9 .pere"e ntensa c! !lcerat s placar$ necrotc% nsotte $e
per$er se'ere $e s!#stanta ($n str!ct!ra a"g$alelor)/ 9 le(!nle necrotce s!nt ntal%
local(ate la n'el a"g- $alan% p!tan$ nsa sa se e)tn$a rap$ s la n'el!l 'al!l!
palatn/ 9 le- (!nle pot progresa n! n!"a n s!pra&ata c s n pro&!n("e% $!can$ la
per&orarea a"g$alelor s nstalarea $e .e"orag/ 9 conco"tent e)sta (one $e a$enta s
pera$enta "arcata (#loc ganglonar)% la n'el s!#- "a)lar.
5rognostc!l este &oarte re(er'at, $eces!l poate s!r'en &rec'ent% !r"are a nstalar !ne
.e"orag "as'e (prn ero$area !nor 'ase "ar) sa!% prn pos#la nstalare a sepss-!l!
se'er c! soc septc s 0OD4.
6.=.=.=.+. Angna 5la!t-Vncent
Este $e etologe ")ta, &!sosprl s #acl Gra" negat'.
Ta#lo!l clnc este ase"anator angne !lcero-necrotce% "o$&- carle locale a'an$
aceas gra'tate s e'ol!te clnca% $ar% ca topogra&e s!nt &rec'ent !nlaterale.
6.=.=.=.=. O#ser'at
Aspect $e angna !lcero-necrotca poate & ntalnt rar s n ca(!l etologe 'rale
(.erpes'r!s!r).
In &e#ra t&o$a este pre(enta $e ase"enea% o angna c! aspect !lcero-necrotc% angna
ND!g!etA.
5re(enta angnelor !lcero-necrotce c! e'ol!te ne&a'ora#la s!# trata"ent!l ant#otc
a$"nstrat% poate r$ca s!spc!nea !ne #ol $e sste" (agran!locto(a% le!ce") sa! a
!n! proces neopla(c a"g$alan.
6.=.=.;. CO05LICATII
A. Co"plcat precoce (prn contg!tate)% a! ca e)plcate constt!reaNcatar!l! t!#arA%
pe &on$!l !ne n&la"at cronce (&on$ $e angna crptca). Ele pot &, sn!(te% otte "e$
s!p!rate% oto"asto$te% &leg"on al planse!l! #!cal (angna NL!$BgA)% pera$ente.
Datorta $se"nar .e"atogene se pot constt! septce".
B. Co"plcat tar$'e% apar la + - ; sapta"an $e la angna s s!nt, :AA%
glo"er!lone&rta ac!ta $&!(a% coreea "nor% erte" pol"or&% erte" no$os% etc.
6.=.;. DIAGNO4TIC
Dagnostc!l po(t' se sta#leste n conte)t!l $atelor ep$e- "ologce% clnce s a
e&ect!ar !r"atoarelor e)a"nar paraclnce,
9 e)!$at &arngan% nsa"antat pe "e$ $&erte $e c!lt!ra, "e$!l agar- sange% "e$!l
LP&&ler% "e$!l 4a#o!ra!$%etc./
9 test!l $e coagl!tnare% ttr!l A4LO% V4>% .e"ole!cogra"a% reacta 5a!l-B!nnel% 5CT%
5C:% .e"oc!lt!r (nsa"antate pe "e$ aero#e% ana- ero#e% "e$! 4a#o!ra!$% etc.)/
9 reacta Q$al%VD:L.
Dagnostc $&erental, c! toate celelalte ca!(e $e angne pse!- $o-pe"#ranoase%
colageno(e% neoplas" &arngan% l!es sec!n$ar% "ono- n!cleo(a n&ectoasa% &e#ra
t&o$a%etc.
6.=.<. T:ATA0ENT
6.=.<.1. Trata"ent!l etologc
In &!ncte $e &or"a clnca $e angna ($!pa recoltarea e)a"narlor #acterologce)% se
nstt!e trata"ent!l etologc ntal% pe #a(a crter!l ratonal% $e pr"a ntente/ $!pa
o#tnerea re(!ltat!l! e)a"narlor #acterologce s al ant#ogra"e% se poate "o$&ca
sc.e"a $e trata- "ent ant#acteran (con&or" ant#ogra"e)% $aca e'ol!ta ca(!l! este
ne&a'ora#la.
A. Angna streptococca are ca n$cate $e electe trata"ent!l c!,
9 5enclna G , + ) 1-+ "l.U?(% rt" $scontn!!% la 1+ . nter'al/ $!rata totala a
trata"ent!l! este $e * (le/ $!pa ter"narea trata"ent!l! c! 5enclna G% se 'a
a$"nstra 0ol$a"n (&lacon a
611.111 sa! 1.+11.111.U? sapta"ana% t"p $e +1 (le.
9 n ca( $e alerge la 5enclna G% se 'or a$"nstra 0acrol$e
(Ertro"cna% Clartro"cna% :o)tro"cna% n $o(ele c!nosc!te).
B. Angnele !lcero-necrotce ,
In &!ncte $e ca(% se reco"an$a aplcarea "onoterape sa! aso- cerea a +-= ant#otce.
Ast&el n ca(!l, a) angne >enoc.% se n$ca a$"nstrarea $e 5enclna G (+-6 "l.U?()
F 0etron$a(ol (11 "l?Dgc?() .'./ #) angne 5la!t-Vncent% se n$ca &olosrea aceleas
sc.e"e $e la a)% la care tre#!e asocat &e !n AG(Genta"cna% A"Dacna)%
Cln$a"cna sa! o Ce&.gen.II?III/ c) angnelor !lcero-gangrenoase% e)sta $&erte opt!n
$e ant#o- tcoterape (n &!ncte $e gra'tatea s teren!l organs"!l! ga($a), 9 I"-
pene"?Clast.(Tena")+g?(/ 9 Cln$a"cna(1%7-1%+g?()GCpro&lo)acna
(1g?()/ 9 T"entn(1+ g?() F 0etron$a(ol (+g?().
6.=.<.+. Trata"ent!l patogenetc
5entr! e&ect!l sa! antn&la"ator% se poate a$"nstra .e"s!cc- nat $e .$rocort(on (<1
- 111 "g?().
5er"anent% #olna' 'or #ene&ca $e reec.l#rare .$ro-electroltca s ac$o-#a(ca% n
&!ncte $e ca(.
6.=.<.=. Trata"ent s"pto"atc
Este $e tp, antalgc% antter"c% se$at'. 5acentlor l se 'a asg!ra,
9 o gena rg!roasa a ca'tat #!cale% ncercan$ sa se n$eparte(e tes!t!rle necro(ate%
prn "anopere sto"atologce spec&ce/
9 c! =1 "n!te nante $e "esele prncpale e&ect!area $e #a$8onar re- petate c! sol!t
$e glcerna #ora)ata G aneste(na% ar postal"entar
($!pa $e(n&ecta locala a ca'tat #!cale)% se 'a aplca sol!te $e Nsta- tn% sol!t contra
a&telor% gargara c! sol!te $e #car#onat $e Na% cea $e "!setel% etc.
6.;. DIFTE:IA
Boala n&ectoasa pro$!sa $e #acl!l $&terc.
Anteror 'accnar% letaltatea prn $&tere era $e =1-<13/ asta(% $atorta 'accnar%
aparta $&tere este &oarte rara.
6.;.1. ETIOLOGIE
Bacl!l $&terc este !n #acl Gra" po(t'. 5e &rot!l colorat Gra"% #acl!l $&terc are
aspect $e ltere c.ne(est ($atorta pre(ente gran!latlor "etacro"atce Ba#es-Ernst).
Este re(stent n "e$! e)tern% sens#l la cal$!ra s $e(n&ectante o#sn!te.
E)sta = tp!r $e #acl $&terc, "ts% gra's s nter"e$!s% care pro$!c% coresp!n(ator%
&or"e !soare% gra'e sa! "e$ $e $&tere.
In stare $e l(ogentate (tpare c! !n &ag spec&c)% #acl!l $&terc el#erea(a o e)oto)na.
N!"a t!lpnle to)gene pro$!c $&tere% cele neto)gene $eter"na o n&ecte local(ata
(real(an$ "!n(area oc!lta a pop!late).
E)oto)na este !n polpept$ alcat!t $n $o!a co"ponente,
9 &rag"ent!l A - repre(nta co"ponenta act'a% a'an$ !n trops" larg% prn care se
e)ercta act!nea to)ca a e)oto)ne/
9 &rag"ent!l B - are rol n &)area #acl!l! $&terc la n'el!l port $e ntrare% asg!ran$
penetra#ltatea &rag"ent!l! A. Are o str!ct!ra co"- ple)a% contnan$, .al!ron$a(a%
&actor necrotc% .e"ol(na.
6.;.+. E5IDE0IOLOGIE
D&tera are o raspan$re !n'ersala.
4!rsa $e n&ecte -/ #olna' c! &or"e clnc "an&este sa! p!r- tator cronc $e #acl
$&terc neto)gen% care a $e'ent to)gen.
Trans"terea se &ace,E pe cale aerogena (prn pcat!rle FlRgge)/
E prn contact!l c! le(!n teg!"entare ($&tere c!tanata)/E prn o#ecte proaspat
conta"nate.
5oarta $e ntrare poate &, E "!coasa calor resprator s!per- oare (&rec'ent "!coasa
&arngana% larngana% na(ala)/ E "!coasa con8!nct'ala/ E "!coasa '!l'o-anala/ E le(!n
teg!"entare.
6.;.=. 5ATOGENIE
La n'el!l port $e ntrare% #acl!l $&terc se "!ltplca s% a&lat n stare $e l(ogentate%
el#erea(a e)oto)na.
5rn nter"e$!l &rag"ent!l! B% se real(ea(a &)area e)oto)ne% care !lteror $&!(ea(a
.e"atogen.
Frag"ent!l B% prn co"ponentele sale (&actor necro(ant% .al!ro- n$a(a% .e"ol(na)%
$eter"na le(area s necro(a eptel!l!% le(!n ale peretel! 'asc!lar (c! cresterea
per"ea#ltat 'asc!lare s e)tra'a(are $e plas"a)% care pro$!c e$e" s &or"area !ne
retele $e &#rna ce se constt!e n &alse "e"#rane.
In !r"a $&!(!n% &rag"ent!l A% a8!ns n cel!le% ne!tral(ea(a &actor!l $e elongate
(FE+)% s #loc.ea(a snte(a proteca% $eter"nn$ necro(a cel!lelor.
La n'el!l (onelor ntens 'asc!lar(ate% $se"narea .e"atogena a e)oto)ne este
"a)"a.
Ur"are a $se"nar% e)oto)na,E $eter"na &eno"ene generale to)e"ce (&e#ra% paloare%
sca$erea tens!n arterale)/ E se &)ea(a la n'el!l "ocar$!l!% &cat!l!% splne% 4NC-
!l! (!n$e &or"ea(a !n co"ple) re'ers#l ce n! poate & ne!tral(at prn a$"nstrarea
$e ser ant$&terc).
Gra'tatea #ol $epn$e $e p!terea to)gena s 'r!lenta t!lpn $e #acl $&terc%
sca$erea aparar locale sa! e)stenta !nor asocer #acterene.
6.;.;. TABLOUL CLINIC
6.;.;.1. DIFTE:IA FA:INGIANA
Inc!#ata este $e =-* (le.
De#!t!l este ns$os c! s!#&e#rltat% ce&alee% paloare% astene% a$na"e% ta.car$e%
ten$nta $e sca$ere a tens!n arterale s $s&age $screta% c! aparta la n'el!l
&arngel!% a !n! e)!$at opaln% care se 'a trans&or"a rap$ n &alsa "e"#rana.
5eroa$a $e stare este $o"nata $e ntrcarea &eno"enelor locale% to)ce s $e 'ecnatate.
Feno"enele to)ce $e la $e#!t!l #ol se accent!ea(a% &e#ra este "o$erata% &n$ pos#la
o .potens!nea arterala "arcata.
Caracterstc pentr! $agnostc este aspect!l angne pse!$o- "e"#ranoase, pe &on$!l
!n! e$e" &arngan ntens% &alsa "e"#rana este $e c!loare al# cen!se% consstenta%
a$erenta pe plan!rle s!#acente% se $etasea(a gre! (lasan$ o (ona sangeran$a) s se
re&ace rap$/ se e)tn$e spre palat!l $!r (real(an$ !n "!la8 al a"g$alelor s al l!ete) s
spre larnge/ n! $soca(a p!sa ntr-!n pa.ar c! apa.
Feno"enele $e 'ecnatate consta! n pre(enta !ne a