{"id":624,"date":"2012-07-21T12:52:10","date_gmt":"2012-07-21T09:52:10","guid":{"rendered":"http:\/\/www.hvtd.org\/?p=624"},"modified":"2012-07-21T12:52:10","modified_gmt":"2012-07-21T09:52:10","slug":"miyastenia-gravisli-bir-pilot","status":"publish","type":"post","link":"https:\/\/www.hvtd.org\/?p=624","title":{"rendered":"Miyastenia Gravis\u2019li Bir Pilot"},"content":{"rendered":"
\n

\"\"<\/a>Olgu:<\/strong> 63 ya\u015f\u0131nda erkek, genel havac\u0131l\u0131k pilotu. 1995 y\u0131l\u0131nda \u00e7abuk yorulma yak\u0131nmas\u0131 nedeniyle incelenmi\u015f. N\u00f6rolojik muayene ve baz\u0131 testler sonucunda miyasteni (MG) tan\u0131s\u0131 alm\u0131\u015f. Mestinon (prostigmin) kullan\u0131ld\u0131\u011f\u0131nda semptomlar\u0131 belirgin bi\u00e7imde kayboluyor ve yan etki g\u00f6r\u00fclm\u00fcyor. G\u00fcnl\u00fck aerobik idmanlar yapmakta, kilo kontrol\u00fc alt\u0131nda. 26 y\u0131l \u00f6nce ba\u015fka nedenle hastanede yatarak tedavi g\u00f6rd\u00fc\u011f\u00fcnde de MG\u2019li oldu\u011fu notu mevcut. U\u00e7u\u015f doktoru muayenesinde; Patolojik bulgu yok, AKB: 122\/82 mm\/Hg, Nab\u0131z: 76, Yak\u0131n g\u00f6rme 20\/50 (tashihle 20\/25), Uzak g\u00f6rme 20\/25 (tashihle 20\/20). Almakta oldu\u011fu ila\u00e7lar: Mestinon 60mg (6\u00d71) + 180 mg (yatarken), Imuran (azathioprine) 75mg\/g\u00fcn, Prednisone 5 mg\/g\u00fcn a\u015f\u0131r\u0131. Ayr\u0131ca ihtiya\u00e7 halinde Omeprazole ve Claritin de al\u0131yor.<\/p>\n

De\u011ferlendirme:<\/strong> Bu t\u00fcr olgularda moniterial g\u00fc\u00e7 performans testleri ve laboratuar tetkikleri yan\u0131 s\u0131ra, g\u00f6\u011f\u00fcs r\u00f6ntgeni \u00e7ekilmeli; tiroid fonksiyon testleri yap\u0131lmal\u0131 (antitiroit antibodiler); immunoprecipitation testlerinde ACh-R antibodiler serum i\u00e7ersinde ara\u015ft\u0131r\u0131lmal\u0131; thymoma veya thymic hiperpilazi CT veya MRI ile ekarte edilmelidir.<\/p>\n

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

1. Semptomatik tedavi: Kas-sinir kav\u015fa\u011f\u0131na \u00e7\u0131kan Ach molek\u00fcllerinin hidrolize olmas\u0131n\u0131 engellemek i\u00e7in antikolinestaras preperatlar\u0131 verilir. B\u00f6ylece kav\u015fakta daha fazla Ach molek\u00fcllerinin kalmas\u0131 sa\u011flanarak, postsinaptik membrandaki fonksiyonel Ach resept\u00f6rleriyle kar\u015f\u0131la\u015f\u0131p membran\u0131 depolarize etme \u015fans\u0131 art\u0131r\u0131l\u0131r.<\/p>\n

2. \u0130mmunosupresif tedavi: Ama\u00e7 Ach resept\u00f6r antikorlar\u0131n\u0131n yap\u0131m\u0131n\u0131n ve postsinaptik membran morfolojisinin bozulmas\u0131n\u0131 engellemektir. Antikolinesterazlar, kortikosteroidler, azathioprine gibi sitotoksik ajanlar immunosupresif tedavide kullan\u0131lmaktad\u0131r. Timektomi de g\u00f6z ard\u0131 edilmemelidir.
\nU\u00e7u\u015fa elveri\u015flilik durumu: <\/strong>Bu pilotta kronik dinamik bir hastal\u0131k s\u00fcreci mevcuttur. Zay\u0131fl\u0131k semptomlar\u0131 i\u00e7in uygun \u015fekilde tedavi verilmi\u015f olmakla birlikte, fiziksel veya mental streslerin, ilac\u0131n kapasitesini a\u015facak bir alevlenmeye yol a\u00e7abilece\u011fine dair kayg\u0131lar da mevcuttur. 14-CFR-61,53 no\u2019lu y\u00f6nerge maddesi, u\u00e7ucular\u0131n bir u\u00e7a\u011f\u0131 emniyetle kullanabilmelerine engel olabilecek bir ila\u00e7 veya t\u0131bbi durumun varl\u0131\u011f\u0131n\u0131 bile bile u\u00e7mamalar\u0131 gerekti\u011fini hat\u0131rlat\u0131r. Baz\u0131 vakalarda ilac\u0131n kendisi sorun olabilir; bu olgu Imuran kullanmaktad\u0131r. Tamal etkile\u015fimleri alt\u0131n, antimalaryeller, penisilamin ve allop\u00fcrinol iledir. Alkilleyici ajanlarla birlikte veya sonras\u0131nda kullan\u0131m\u0131nda artm\u0131\u015f kanser riski mevcuttur. Imuran, ACE inhibit\u00f6rleriyle birlikte al\u0131nd\u0131\u011f\u0131nda l\u00f6kopeni veya anemiye yol a\u00e7abilir; ayr\u0131ca Warfarin\u2019i antogonize edebilir. Yan etki olarak \u015fiddetli l\u00f6kopeni veya trombositopeni, sekonder infeksiyonlar, mutajenik veya karsinojenik potansiyel, bulant\u0131, pankreatit, hepatotoksisite, d\u00f6k\u00fcnt\u00fc ve alopesi g\u00f6r\u00fclebilir. Pilotun kullanmakta oldu\u011fu (bir kolinesteraz inhibit\u00f6r\u00fc olan) Mestinon, non-depolarize adale gev\u015feticilerin etkilerini geri d\u00f6nd\u00fcrebilir ve atropin taraf\u0131ndan antagonize olur. Mide-barsak rahats\u0131zl\u0131\u011f\u0131, t\u00fckr\u00fck ve bron\u015fiyal sekresyon art\u0131\u015f\u0131, miyozis, diafori, adale kramplar\u0131 ve nadiren zay\u0131fl\u0131\u011f\u0131na yol a\u00e7abilir.<\/p>\n

Bu pilot uzun s\u00fcredir tedavi alt\u0131nda olmas\u0131na ra\u011fmen hastal\u0131\u011f\u0131n\u0131n stabil seyretti\u011fi, ila\u00e7 yan etkilerinin minimal veya hi\u00e7 d\u00fczeyinde oldu\u011fu bir tabloya sahip gibi g\u00f6r\u00fcnmektedir. Sertifika yenilenmesi d\u00f6nemlerinde n\u00f6rolojik durum de\u011ferlendirmesini AME\u2019ye g\u00f6stermeli ve tedavisini d\u00fczenleyen uzman hekimin tedavide veya genel durumda olabilecek de\u011fi\u015fiklikleri de i\u00e7eren bir raporunu yan\u0131nda bulundurmal\u0131d\u0131r.<\/p>\n

Sonu\u00e7:<\/strong> Bu pilota 3. S\u0131n\u0131f sa\u011fl\u0131k sertifikas\u0131 verilmi\u015f; ancak sonraki kararlar\u0131 i\u00e7in d\u00fczenli olarak g\u00f6zlem alt\u0131nda bulundurulmas\u0131 da ko\u015ful olarak karara eklenmi\u015ftir (1).<\/p>\n

Miyastenia Gravis:<\/strong> \u0130stemli kaslarda fl\u00fcktuasyon g\u00f6steren g\u00fc\u00e7s\u00fczl\u00fc\u011f\u00fcn g\u00f6r\u00fcld\u00fc\u011f\u00fc bir kas- sinir kav\u015fa\u011f\u0131 hastal\u0131\u011f\u0131d\u0131r. Temel patofizyoloji, postsinaptik membranda nikotinik Ach resept\u00f6rlerinin azalmas\u0131 olup, timus\u2019un ve otoimm\u00fcn sistemin de katk\u0131s\u0131 vard\u0131r. Timus\u2019un rol\u00fc, imm\u00fcn cevaplarla ilgisi olan s\u00fcpres\u00f6r T-lenfositlerinin \u00fcretimini etkilemesidir. MG\u2019de otoimm\u00fcn olu\u015fan antikorlar postsinaptik membrandaki Ach resept\u00f6rlerini hem bloke, hem de tahrip eder. Ach resept\u00f6r antikor d\u00fczeyleri, ok\u00fcler MG\u2019de %70, jenaralize MG\u2019de %85-90, timomal\u0131larda %90 artar.<\/p>\n

MG herhangi bir \u00e7izgili kas grubunda ba\u015flarsa da, g\u00f6z kaslar\u0131ndaki tutulmayla pitozis veya diplopiye neden olur. Daha sonra \u00e7i\u011fneme kaslar\u0131, \u00fcst ve alt ekstremite proksimal kaslar\u0131n tutulmas\u0131 izler. Y\u00fczde anlams\u0131z bir ifade, ba\u015f\u0131 dik tutamama, yutma g\u00fc\u00e7l\u00fc\u011f\u00fc, \u00e7abuk yorulma g\u00f6r\u00fcl\u00fcr. Spontan olabilece\u011fi gibi egzersiz ile art\u0131\u015f g\u00f6sterir. \u0130leri safhalarda solunum felci, gaita ve idrar inkontinensi olabilir.<\/p>\n

ABD\u2019de g\u00f6r\u00fclme s\u0131kl\u0131\u011f\u0131 1\/25.000 olup, kad\u0131n\/erkek oran\u0131 6\/4 d\u00fcr. Hastal\u0131k her ya\u015fta g\u00f6r\u00fclebilirse de vakalar\u0131n %90\u2019\u0131 yeti\u015fkindir ve 40 ya\u015f alt\u0131 kad\u0131nlarda erkeklere g\u00f6re 3 kat fazlad\u0131r. Kal\u0131tsal ge\u00e7i\u015f oran\u0131 %3\u2019t\u00fcr (2).<\/p>\n

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

1. Nidal El Rimawi. An airman with myastenia gravis. The Federal Air Surgeon\u2019s Medical Bulletin. 2006; 44:1<\/p>\n

2. Yaltkaya K, Balkan S, O\u011fuz Y. N\u00f6roloji Ders Kitab\u0131. Palme Yay. Ankara 1996 s.419-30<\/p>\n

Haz\u0131rlayan :<\/strong> Dr. Abdullah \u00d6KS\u00dcZ (Psikiyatri Uzm. Eski\u015fehir)<\/p>\n<\/div>\n","protected":false},"excerpt":{"rendered":"

Olgu: 63 ya\u015f\u0131nda erkek, genel havac\u0131l\u0131k pilotu. 1995 y\u0131l\u0131nda \u00e7abuk yorulma yak\u0131nmas\u0131 nedeniyle incelenmi\u015f. N\u00f6rolojik muayene ve baz\u0131 testler sonucunda miyasteni (MG) tan\u0131s\u0131 alm\u0131\u015f. Mestinon (prostigmin) kullan\u0131ld\u0131\u011f\u0131nda semptomlar\u0131 belirgin bi\u00e7imde kayboluyor ve yan etki g\u00f6r\u00fclm\u00fcyor. G\u00fcnl\u00fck aerobik idmanlar yapmakta, kilo kontrol\u00fc alt\u0131nda. 26 y\u0131l \u00f6nce ba\u015fka nedenle hastanede yatarak tedavi g\u00f6rd\u00fc\u011f\u00fcnde de MG\u2019li oldu\u011fu notu mevcut. U\u00e7u\u015f doktoru muayenesinde; Patolojik […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_eb_attr":"","_jetpack_memberships_contains_paid_content":false,"footnotes":""},"categories":[6],"tags":[],"class_list":["post-624","post","type-post","status-publish","format-standard","hentry","category-bulten"],"jetpack_featured_media_url":"","jetpack_sharing_enabled":true,"jetpack-related-posts":[],"_links":{"self":[{"href":"https:\/\/www.hvtd.org\/index.php?rest_route=\/wp\/v2\/posts\/624","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.hvtd.org\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.hvtd.org\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.hvtd.org\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.hvtd.org\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=624"}],"version-history":[{"count":1,"href":"https:\/\/www.hvtd.org\/index.php?rest_route=\/wp\/v2\/posts\/624\/revisions"}],"predecessor-version":[{"id":626,"href":"https:\/\/www.hvtd.org\/index.php?rest_route=\/wp\/v2\/posts\/624\/revisions\/626"}],"wp:attachment":[{"href":"https:\/\/www.hvtd.org\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=624"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.hvtd.org\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=624"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.hvtd.org\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=624"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}