{"id":705,"date":"2025-07-16T09:58:22","date_gmt":"2025-07-16T06:58:22","guid":{"rendered":"https:\/\/tatd.org.tr\/geriatri\/?p=705"},"modified":"2025-07-16T09:58:23","modified_gmt":"2025-07-16T06:58:23","slug":"yasli-hastalarda-meningoensefalit","status":"publish","type":"post","link":"https:\/\/tatd.org.tr\/geriatri\/genel\/yasli-hastalarda-meningoensefalit\/","title":{"rendered":"Ya\u015fl\u0131 Hastalarda Meningoensefalit"},"content":{"rendered":"\n

*A\u011fustos 2024’de yaz\u0131lan bu blog yaz\u0131s\u0131 teknik sorunlar nedeni ile Temmuz 2025’de yay\u0131nlanm\u0131\u015ft\u0131r.<\/p>\n\n\n\n

Meningoensefalit; meninks ve beyin parankiminin inflamasyonu olarak tan\u0131mlanan ciddi bir durumdur. Viral, bakteriyel, fungal veya otoimm\u00fcn nedenler bu duruma yol a\u00e7maktad\u0131r. H\u0131zl\u0131 tan\u0131, yak\u0131n monit\u00f6rizasyon beraberinde antimikrobiyal, steroid, antiepileptik ve destekleyici tedavi ile ortaya \u00e7\u0131kan komplikasyonlar ve n\u00f6rolojik hasar en aza indirilebilmektedir (1).<\/p>\n\n\n\n

Epidemiyoloji<\/strong><\/p>\n\n\n\n

Yak\u0131n zamanda (2017-2020 y\u0131llar\u0131 aras\u0131nda yap\u0131lan ) Avrupa \u00e7ok merkezli prospektif yo\u011fun bak\u0131m \u00e7al\u0131\u015fmas\u0131 \u201cEURECA\u201d \u2018da 7 \u00fclkeden 68 merkezden yo\u011fun bak\u0131m yat\u0131\u015f\u0131 gerektiren 589 hasta, epidemiyolojisi ve sonu\u00e7 durumlar\u0131na g\u00f6re ara\u015ft\u0131r\u0131lm\u0131\u015ft\u0131r. Buna g\u00f6re bakteriyel menenjit,  vakalar\u0131n %42\u2019sini olu\u015fturmaktad\u0131r. Bu grupta streptococcus pneumoniae en s\u0131k tan\u0131mlanan patojen olup akut bakteriyel menenjit etkenlerinin %60’\u0131d\u0131r (2). \u015eekil 1\u2019de EURECA \u00e7al\u0131\u015fmas\u0131nda meningoensefalitin ba\u015fl\u0131ca nedenleri verilmi\u015ftir.<\/p>\n\n\n\n

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\u015eekil 1: Meningoensefalitin ba\u015fl\u0131ca nedenleri (2).<\/figcaption><\/figure>\n\n\n\n

Vakalar\u0131n %66’s\u0131nda, \u00e7o\u011funlukla vir\u00fcsler (%82) etkendir. Herpesviridae [herpes simpleks vir\u00fcs\u00fc (HSV) %35 ve varicella zoster vir\u00fcs\u00fc (VZV) %15 ] ve t\u00fcm meningoensefalit vakalar\u0131n\u0131n %27\u2019sinde etken ajand\u0131r (3). HSV nedeniyle olu\u015fan vakalar de\u011ferlendirildi\u011finde yo\u011fun bak\u0131m \u00fcnitesine yat\u0131\u015f \u00f6nemli \u00f6l\u00e7\u00fcde daha y\u00fcksektir. Arbovir\u00fcs ise, yo\u011fun bak\u0131m \u00fcnitesine yatmas\u0131 gereken hastalarda daha azd\u0131r (1). \u0130mm\u00fcn sistemi bask\u0131lanm\u0131\u015f hastalar de\u011ferlendirildi\u011finde %20 cryptococcus neoformans,  %13,5 VZV, %5,5 mycobacterium tuberculosis ve %4,5 enterobacterales g\u00f6r\u00fclmekte ve bunlar\u0131n yar\u0131s\u0131 geni\u015f spektrumlu beta-laktamaz \u00fcretmektedir. Enterobacterales etkeni olan  meningoensefalit, y\u00fcksek ve erken mortalite ile ili\u015fkili bulunmu\u015ftur  (%50-70, 1 y\u0131l) (4). <\/p>\n\n\n\n

Meningoensefalit vakalar\u0131n\u0131n %11-25\u2019inin yo\u011fun bak\u0131m \u00fcnitesine yat\u0131\u015f gerektirecek kadar ciddi oldu\u011fu ve sa\u011f kal\u0131m oran\u0131 %15-25 olanlarda ciddi fonksiyonel kay\u0131p s\u00f6z konusu olmakla birlikte k\u00f6t\u00fc prognoz ile ili\u015fkili oldu\u011fu g\u00f6sterilmi\u015ftir (1,5). EURECA \u00e7al\u0131\u015fmas\u0131nda yer alan k\u00f6t\u00fc sonu\u00e7larla ili\u015fkili fakt\u00f6rler; ileri ya\u015f (>60 ya\u015f), imm\u00fcn sistemi bask\u0131lanmas\u0131, fokal bulgular (hemiparezi \/ hemipleji), Glasgow koma skalas\u0131 (GKS) \u2264 3, anormal n\u00f6rog\u00f6r\u00fcnt\u00fcleme bulgular\u0131, kardiyovask\u00fcler ve solunum yetmezli\u011fi ve yo\u011fun bak\u0131ma yat\u0131\u015f s\u00fcresinin > 1 g\u00fcnden uzun olmas\u0131 \u015feklinde belirtilmi\u015ftir.  Ek olarak yat\u0131\u015f g\u00fcn\u00fcnde 3. ku\u015fak sefalosporin ve asiklovir uygulanmas\u0131 daha iyi sonu\u00e7larla ili\u015fkili oldu\u011fu da g\u00f6sterilmektedir (1). <\/p>\n\n\n\n

Tan\u0131<\/strong><\/p>\n\n\n\n

Meningoensefalitin bakteriyel nedenlerinin tan\u0131s\u0131nda,  gram boyama ve bakteri k\u00fclt\u00fcrleri hala alt\u0131n standartt\u0131r, en s\u0131k g\u00f6r\u00fclen viral nedenler beyin omurilik s\u0131v\u0131s\u0131 (BOS) real- time polimeraz zincir reaksiyonu (PCR) y\u00f6ntemi ile tan\u0131mlanmaktad\u0131r (1). Son zamanlarda Chandran ve arkada\u015flar\u0131n\u0131n yapt\u0131klar\u0131 bir \u00e7al\u0131\u015fmada FilmArray menenjit\/ensefalit (FA-ME) paneli ile tan\u0131 da verimlili\u011fin artt\u0131\u011f\u0131 g\u00f6sterilmi\u015f ayn\u0131 zamanda enfeksiyonlar\u0131n tan\u0131s\u0131na ili\u015fkin mikrobiyolojik i\u015f ak\u0131\u015f\u0131na da katk\u0131 sa\u011flanm\u0131\u015ft\u0131r. FA-ME panelinin,  \u00e7ok k\u0131sa bir s\u00fcrede birden fazla patojeni ayn\u0131 anda test edebilme avantaj\u0131 s\u00f6z konusudur (6,7). Bu panel ile bakteri ( Escherichia coli K1, Haemophilus influenzae, Listeria monocytogenes , Neisseria meningitidis , Streptococcus agalactiae , S. pneumoniae) vir\u00fcs [sitomegalovir\u00fcs (CMV), enterovir\u00fcs, HSV-1, HSV-2, insan herpes vir\u00fcs\u00fc 6 (HHV-6), insan parechovir\u00fcs\u00fc, VZV] ve maya (C.neoformans\/gattii) BOS taramalar\u0131nda g\u00f6r\u00fclebilmektedir (6). Multipleks PCR, ampirik antibiyotik tedavisi g\u00f6ren akut bakteriyel menenjit hastalar\u0131nda dikkat \u00e7ekicidir. Yap\u0131lan \u00e7al\u0131\u015fmalarda multipleks PCR’\u0131 sistematik olarak ger\u00e7ekle\u015ftirmek i\u00e7in 10 h\u00fccre\/\u03bcl’den fazla sistematik BOS beyaz k\u00fcre (WBC) say\u0131s\u0131 e\u015fi\u011finin kullan\u0131lmas\u0131 gerekti\u011fi \u00f6ne s\u00fcr\u00fclm\u00fc\u015ft\u00fcr (8). Pozitif FA-ME paneli olmas\u0131 durumunda antibiyotik azat\u0131m\u0131 ve bu panelin  HSV-1 PCR sonu\u00e7 s\u00fcresini ve intraven\u00f6z asiklovir tedavi s\u00fcresini k\u0131saltt\u0131\u011f\u0131 ve potansiyel olarak hastane tedavi maliyetini azaltt\u0131\u011f\u0131 yap\u0131lan \u00e7al\u0131\u015fmalarda g\u00f6sterilmi\u015ftir (9). Son y\u0131llarda yap\u0131lan \u00e7al\u0131\u015fmalarda FA-ME panelinin kullan\u0131lmas\u0131 ile birlikte bakteriyel menenjitin te\u015fhisinde ba\u015far\u0131l\u0131 ve erken uygun antibiyotik tedavisinin de ba\u015flan\u0131lmas\u0131 sonucu klinik bak\u0131m\u0131nda  \u00f6nemli \u00f6l\u00e7\u00fcde etkilendi\u011fi g\u00f6sterilmi\u015ftir. Ayr\u0131ca multipleks n\u00fckleik asit amplifikasyon testi;  merkezi sinir sistemi (MSS) enfeksiyon panelleri hen\u00fcz geli\u015ftirilme a\u015famas\u0131ndad\u0131r (10). Meningoensefalit otoimm\u00fcn nedenlerinin,  viral nedenlerden ayr\u0131m\u0131 i\u00e7in BOS incelenmesi de\u011ferlidir. BOS de\u011ferlendirmesinde g\u00f6r\u00fclen lenfositik pleositoz, y\u00fckselmi\u015f protein seviyesi ve normal BOS \/ plazma glikoz oran\u0131 tipik olarak viral meningoensefalit lehinedir (11). <\/p>\n\n\n\n

HSV meningoensefaliti yo\u011fun bak\u0131m \u00fcnitesine yat\u0131\u015fa yol a\u00e7an patojendir (2,5). Akut HSV ensefalitinin MRG Flair g\u00f6r\u00fcnt\u00fclemesinde bilateral, birle\u015fmeye e\u011filimli, asimetrik olan beyaz cevher hiperintensiteleri, kortikal dif\u00fczyon k\u0131s\u0131tl\u0131l\u0131\u011f\u0131  ve genellikle T2 sekans  g\u00f6r\u00fcnt\u00fclemede hemorajik de\u011fi\u015fiklikler g\u00f6r\u00fclmektedir. HSV-1 ensefaliti ise spesifik bir da\u011f\u0131l\u0131m\u0131 olmayan HSV-2’nin aksine limbik sistemde daha bask\u0131nd\u0131r (12). HSV ensefalitinin akut faz\u0131nda, beyindeki yayg\u0131n MRG de\u011fi\u015fiklikleri ve talamik dif\u00fczyon sinyali ba\u011f\u0131ms\u0131z olarak k\u00f6t\u00fc sonu\u00e7larla ili\u015fkili olarak bulunmu\u015ftur (13).  Varisella zoster vir\u00fcs\u00fc (VZV)  ensefaliti  %80 altta yatan imm\u00fcnsupresyon ile ili\u015fkilidir. MRG yap\u0131ld\u0131\u011f\u0131nda 2\/3\u2019\u00fcnde anormal bulgular g\u00f6r\u00fclm\u00fc\u015ft\u00fcr ve bunlar\u0131n %15\u2019inde serebral vask\u00fclit belirtileri g\u00f6r\u00fclmektedir. Mirouse ve arkada\u015flar\u0131n\u0131n yapt\u0131klar\u0131 \u00e7al\u0131\u015fmada yo\u011fun bak\u0131m \u00fcnitesindeki \u00f6l\u00fcm oran\u0131 %25 olarak verilmi\u015f ve taburcu olduktan 1 y\u0131l sonra ise ancak  vakalar\u0131n %36’s\u0131nda olumlu n\u00f6rolojik sonu\u00e7lar oldu\u011fu g\u00f6sterilmi\u015ftir. \u0130leri ya\u015f ve invaziv mekanik ventilasyon ihtiyac\u0131, mortalite riskinin artmas\u0131 ile ili\u015fkilendirilmi\u015ftir (14). Erken ba\u015flanan  intraven\u00f6z asiklovir daha iyi bir prognoz ile ili\u015fkilendirilmi\u015ftir (15). <\/p>\n\n\n\n

Kriptokok meningoensefalit, imm\u00fcn sistemi bask\u0131lanm\u0131\u015f hastalarda \u00f6nemli morbidite ve mortalite nedenidir (16,17). Alanazi ve arkada\u015flar\u0131n\u0131n yapt\u0131\u011f\u0131 \u00e7al\u0131\u015fmada kriptokok menenjit hastalar\u0131nmda agresif BOS ponksiyonu ile artan intrakraniyal bas\u0131n\u00e7, sa\u011f kal\u0131m ile ili\u015fkili bulunmu\u015ftur (18). Paraziter nedenler aras\u0131nda serebral toksoplazmoz ve n\u00f6rosistiserkoz da  yer almaktad\u0131r (19). <\/p>\n\n\n\n

Tedavi<\/strong><\/p>\n\n\n\n

            <\/strong>Multipleks PCR ile tedavinin derhal ba\u015flat\u0131lmas\u0131 i\u00e7in erken tan\u0131 zorunludur (20). Antimikrobiyal tedavilerin erken kullan\u0131m\u0131 daha iyi sonu\u00e7larla ili\u015fkilendirilmi\u015ftir (2).<\/p>\n\n\n\n

Bakteriyel nedenler<\/strong><\/td>Tedavi i\u00e7in se\u00e7ilen ila\u00e7lar<\/strong><\/td><\/tr>
S. pneumoniae, N. meningitidis Listeria<\/td>3.  ku\u015fak sefalosporin  Amoksisilin + Gentamisin<\/td><\/tr>
Viral nedenler<\/strong>HSV-1\/2<\/td>Asiklovir<\/td><\/tr><\/tbody><\/table><\/div>
Tablo 1. Bakteriyel ve viral meningoensefalit tan\u0131s\u0131n\u0131n etkene y\u00f6nelik tedavisi (2).\u00a0<\/figcaption><\/figure>\n\n\n\n

Bakteriyel menenjit \u015f\u00fcphesi varsa en k\u0131sa s\u00fcrede steroid ba\u015flanmal\u0131d\u0131r (21). Viral ensefalit olan hastalarda steroidler endike de\u011fildir ve HSV ensefaliti alan\u0131nda randomize kontroll\u00fc bir \u00e7al\u0131\u015fma devam etmektedir (22). Otoimm\u00fcn ve enfeksiy\u00f6z ensefalit, diren\u00e7li n\u00f6betler a\u00e7\u0131s\u0131ndan y\u00fcksek risklidir. Otoimm\u00fcn ensefaliti olan hastalarda, n\u00f6bet tedavisi antiepileptik ila\u00e7larla birlikte imm\u00fcnoterapiyi i\u00e7erir ve belirli durumlarda karbamazepin veya lakosamid gibi sodyum kanal blokerlerine \u00f6ncelik verilir (anti-LGI1 ensefaliti) (23). T\u00fcm hastalarda antiepileptik ila\u00e7lar\u0131n uzun s\u00fcreli uygulanmas\u0131 gerekli olmay\u0131p, tedavi stratejileri heterojendir.  Antiepileptik ila\u00e7lar\u0131n kullan\u0131m s\u00fcresine ili\u015fkin g\u00fcncel bir k\u0131lavuz hen\u00fcz bulunmamaktad\u0131r (1). <\/p>\n\n\n\n

Komplikasyon<\/strong><\/p>\n\n\n\n

            <\/strong>Artm\u0131\u015f intrakraniyal bas\u0131n\u00e7, meningoensefalitin ciddi bir komplikasyonudur. Sekonder beyin hasar\u0131 ve daha k\u00f6t\u00fc sonu\u00e7larla ili\u015fkilidir (24). Artm\u0131\u015f intrakraniyal bas\u0131nca neden olan mekanizmalar karma\u015f\u0131k g\u00f6r\u00fclmekle birlikte inflamasyon, arteriyel vazodilatasyon, BOS ak\u0131\u015f\u0131n\u0131n t\u0131kanmas\u0131 ve ven\u00f6z tromboz gibi durumlar\u0131 kapsamaktad\u0131r (25). Yap\u0131lan \u00e7al\u0131\u015fmalarda intrakraniyal bas\u0131n\u00e7 takibinin sistematik olarak yap\u0131lmas\u0131 \u00f6nerilmektedir. Bilgisayarl\u0131 tomografi (BT), MRG g\u00f6r\u00fcnt\u00fclemede g\u00f6r\u00fclen bazal sisternalarda kompresyon veya orta hatta g\u00f6r\u00fclen \u015fiftin olmas\u0131, yap\u0131lan ultrasonografide \u00f6l\u00e7\u00fclen artm\u0131\u015f optik sinir k\u0131l\u0131f\u0131 \u00e7ap\u0131, transkranial doppler ile \u00f6l\u00e7\u00fclen azalm\u0131\u015f diyastolik h\u0131zlar ve \/ veya de\u011fi\u015fmi\u015f otomatik pupillometri parametreleri artm\u0131\u015f intrakraniyal bas\u0131n\u00e7 ve olu\u015fabilecek daha ciddi sonu\u00e7lar\u0131n olu\u015fma riskinin de g\u00f6stergesi olabilmektedir. Olu\u015fabilecek hidrosefali veya ventrik\u00fclit durumlar\u0131nda ekstraventrik\u00fcler drenaj giri\u015fimine ek olarak intrakraniyal bas\u0131n\u00e7 takibinin yap\u0131lmas\u0131 \u00f6neriler aras\u0131nda yer almaktad\u0131r (26).<\/p>\n\n\n\n

            Sonu\u00e7 olarak meningoensefalit tablosuna \u0131\u015f\u0131k tutacak zaman\u0131nda m\u00fcdahale ve kapsaml\u0131 bir tan\u0131 yakla\u015f\u0131m\u0131 \u00f6nemlidir. Meningoensefalitten \u015f\u00fcphelenilen ya\u015fl\u0131da LP gibi tan\u0131sal testler, BT ve MRG gibi g\u00f6r\u00fcnt\u00fcleme testleri, kons\u00fcltasyonlar zaman ge\u00e7irmeden ger\u00e7ekle\u015ftirilmeli ve multidisipliner yakla\u015f\u0131m devreye girmelidir. <\/p>\n\n\n\n

Kaynaklar<\/strong><\/p>\n\n\n\n

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  27. Sonneville R, de Montmollin E, Gaudemer A, et al. Meningoencephalitis requiring intensive care and neuromonitorization. Author\u2019s reply. Intensive Care Med 2023; 49:884\u2013885.\u00a0<\/li>\n<\/ol>\n","protected":false},"excerpt":{"rendered":"

    *A\u011fustos 2024’de yaz\u0131lan bu blog yaz\u0131s\u0131 teknik sorunlar nedeni ile Temmuz 2025’de yay\u0131nlanm\u0131\u015ft\u0131r. Meningoensefalit; meninks ve beyin parankiminin inflamasyonu olarak tan\u0131mlanan ciddi…<\/p>\n","protected":false},"author":1185,"featured_media":708,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"inline_featured_image":false,"_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"categories":[1,10014],"tags":[10018,10057],"class_list":["post-705","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-genel","category-akademik-blog-yazisi","tag-geriatri","tag-menenjit"],"acf":[],"_links":{"self":[{"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/posts\/705","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/users\/1185"}],"replies":[{"embeddable":true,"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/comments?post=705"}],"version-history":[{"count":0,"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/posts\/705\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/media\/708"}],"wp:attachment":[{"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/media?parent=705"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/categories?post=705"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/tags?post=705"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}