Journal of Clinical Practice

Quarterly peer-review medical journal.

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About

The main idea of our journal is to provide description and analysis of clinical cases with severe, rare and difficult for diagnoses diseases, occurred in the clinics of Federal Medical-Biological Agency of Russia. Such clinical analysis is aimed to develop “clinical” type of thinking, always have been the characteristic feature of Russian/USSR medical school. The journal purpose is also to improve scientific discussions and cooperation between physicians of different specialties.

Revival of historical traditions in our journal is the one of the components of continuing education, which is especially important in “closed” territories, where doctors can`t regularly participate in clinical conferences. An important aspect is to provide a printed tribune for any doctor who has an interesting clinical observation and wish to share his experience with colleagues. That is why we named our journal "Clinical Practice" and address it, first of all, those skilled in applied medicine. Of course, we also publish the results of original researches, clinical guidelines, current reviews and medical news. The journal is multidisciplinary and we hope that it will be interesting to doctors of different specialties. The journal is published by means of the Federal Research and Clinical Center of FMBA of Russia. Placement of all materials, except for advertising, are free of charge to authors.

Types of accepted articles

  • reviews;
  • systematic reviews and meta-analysis;
  • original study articles;
  • case reports and series of cases;
  • letters to the editor;
  • hystorical articles 

The joutnal accept manuscripts in English and in Russian.

Publication, distribution and indexation

  • Russian and English full-text articles;
  • issues publish quarterly, 4 times per year;
  • no obligatory APC, Platinum Open Access
  • articles distribute under the Creative Commons Attribution-NonCommercial-NoDerivates 4.0 International License (CC BY-NC-ND 4.0).

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Current Issue

Vol 14, No 4 (2023)

Original Study Articles

Surgical treatment of patients with symptomatic Kimmerle's anomaly using video endoscopy
Vinokurov A.G., Kalinkin A.A., Bocharov A.А., Yarikov A.V., Yusubalieva G.M., Kalinkina O.N.
Abstract

Background: Clinical manifestations of Kimmerle’s anomaly are detected in 5.5 to 20% of patients. The main reason for the development of symptoms is prolonged compression of the V3 (atlantic) segment of the vertebral artery in the bone ring as a result of the atlantooccipital membrane’s exostosis. To date, the final tactics for treating patients with Kimmerle’s anomaly has not been determined. The effectiveness of conservative methods of therapy does not exceed 40%. The aim Of this study was to evaluate the results of a minimally invasive surgical treatment of patients with symptomatic Kimmerle’s anomaly using video endoscopic assistance. Methods: In the period from 2020 to 2022, 15 patients were operated on. The indication for the surgical treatment was the lack of the conservative therapy’s effect for 1 year from the onset of the disease, aggravation of the disease symptoms, a decrease in the blood flow through the vertebral artery at the Kimmerle’s anomaly side when turning the head. The vertebral artery decompression was performed using video endoscopy through a posterior median approach in two (13%) patients and through a paravertebral intermuscular approach (4 cm incision in the occipitocervical region in the projection of the Kimmerle’s anomaly) in thirteen (87%) patients. Results: The outcome of the disease was assessed at the time of discharge from the hospital, as well as in 6 and in 12 months after the operation. Following the surgical treatment, all the patients showed the complete regression of symptoms and restoration of the blood flow velocities in the vertebral artery. There were no complications after the operation. The use of video endoscopy made it possible to reduce the size of the surgical wound from 12 cm to 4 cm, which contributed to a decrease in the intensity of pain in the postoperative period, early activation and a decrease in the duration of the inpatient treatment. Conclusion: With the proper selection of patients with Kimmerle’s anomaly, decompression of the V3 segment of the VA using video endoscopy is a safe and effective method of treatment.

Journal of Clinical Practice. 2023;14(4):7-17
pages 7-17 views
Instrumental and clinical diagnosis of interdigital Morton neuroma
Bolshakova D.A., Kardanov A.A., Maysigov M.N., Akhpashev A.А., Ilyin D.O., Korolev A.V.
Abstract

Background: Interdigital neuroma is one of the most common diseases in foot surgery. It is a common cause of metatarsalgia leading to debilitating pain. At the same time, the diagnosis of neuroma can be a difficult task for an orthopedic surgeon due to the complex anatomy of the forefoot and a large number of soft-tissue and bone structures. Besides, the existing manual testing methods are not pathognomonic specifically for neuroma. The clinical symptoms and history, as well as a physical exam and instrumental evidence are important in assessing and grading the disease. However, there are no recommendations in the modern Russian literature regarding the need for routine visualization of neuroma. The reproducibility of the study, the absence of ionizing radiation and the possibility of obtaining a second opinion, as well as high sensitivity makes magnetic resonance imaging an important diagnostic tool in the diagnosis of neuroma. Aim: To evaluate the importance of the anamnesis and complaints and the sensitivity of clinical tests and magnetic resonance imaging of the foot in the diagnosis of interdigital neuromas. Methods: The study presents a retrospective analysis of the medical histories and outpatient records of 28 patients (8 men and 20 women) treated at the EMC ECSTO in the period from 2017 to 2022. The examination was performed according to a standardized protocol: collection of complaints and anamnesis, palpation, manual testing, including Mulder's click test. As a part of examination, magnetic resonance imaging of the foot was performed for all the patients. The average patient’s age at the time of the surgical treatment was 45 years. The resection of a part of the affected nerve with the subsequent histological examination was considered a gold standard for the treatment and verification of interdigital neuromas. In all the cases, the histopathological study confirmed the diagnosis. Results: The sensitivity of magnetic resonance imaging in the diagnosis of interdigital neuromas was 86%, the sensitivity of the Mulder test was 61%. Pain during the palpation of the affected interdigital space was determined in 100% of cases. Conclusion: The combination of a manual examination and magnetic resonance imaging, along with the analysis of complaints and anamnesis makes it possible to diagnose Morton's neuroma in most cases.

Journal of Clinical Practice. 2023;14(4):18-25
pages 18-25 views
Anatomy of the terminal branches of the superior rectal artery during selective doppler controlled dearterialization of the hemorrhoidal nodes (HAL-RAR)
Davidovich D.L., Filisteev P.А., Smirnov A.V., Burovskiy A.K., Solomka A.Y., Tariverdiev A.M., Tomashevskiy G.S., Razbirin D.V., Loshchenov M.S.
Abstract

Background: To date, there is no single standard for conducting HAL-RAR operations. The constant discussion raises the question of the number of terminal branches of the superior rectal artery, which must be ligated in the submucosal layer of the rectum in order to provide the adequate dearterialization of hemorrhoids. Aim: To study the anatomy of the branches of the superior rectal artery and to develop recommendations for the optimal ligation of the terminal branches of the superior rectal artery. Methods: 150 protocols of the previous operations have been studied. In order to further objectify our results, the results of radiation diagnostics (CT and MRI) were revised for 100 patients without pathological changes of the rectum and anal canal to study the variant anatomy of the superior rectal artery and its terminal branches in the rectal wall. Results: In 148 patients, 6 terminal branches were identified, in 2 (1.333%) patients, 5 branches were found. 100 cases without pathological changes were also analyzed (60 MRI and 40 CT scans). In all the cases, 6 terminal branches of the superior rectal artery were determined, located at 1, 3, 5, 7, 9 and 11 o'clock positions of the conventional dial. At the same time, a large number of identified anatomical options for the branching of the VPA and the method for reaching the rectal wall should be noted, which we used as a basis to propose a classification. Conclusion: In the vast majority of cases, there are 6 terminal branches of the superior rectal artery, located in the lower ampulla of the rectum at approximately 1, 3, 5, 7, 9 and 11 hours of the conventional dial. A number of variants of the vascular anatomy of the proximal branches are possible, but 6 distal branches are involved in the direct blood supply of the hemorrhoids. When performing selective Doppler-controlled dearterialization of hemorrhoids, it is expedient to ligate 6 arterial vessels.

Journal of Clinical Practice. 2023;14(4):26-33
pages 26-33 views
Diffusion-kurtosis magnetic resonance imaging of the brain in the differential diagnostics of metastases of tumors of various primary localization
Garanina N.V., Dolgushin M.B., Fadeeva L.M., Pogosbekyan E.L., Sashin D.V., Nechipay E.A., Dvoryanchikov A.V.
Abstract

Background: Metastatic brain lesions lead to the most unfavorable prognosis for the course of an oncological disease. Most often, brain metastases arise from primary tumors such as lung cancer, breast cancer, and melanoma. Of particular interest are groups of secondary intracranial tumors without an identified primary focus. Methods of non-invasive differential diagnosis based on a possible histological affiliation, including diffusion-kurtosis magnetic resonance imaging, can improve the diagnostic search for the primary tumor. Aim: The aim of this study is to improve the quality of differential diagnosis for brain metastases of tumors of different primary localization by introducing the diffusion-kurtosis magnetic resonance imaging technique into the magnetic resonance scanning protocol. Methods: Our work included studies of 60 patients who underwent examination and treatment at the N.N. Blokhin National Research Medical Center of Oncology of the Ministry of Health of Russia from October 2019 to March 2022. According to magnetic resonance imaging, metastatic formations were detected in the brain of the patients, with different localizations of the primary tumor. 20 patients were diagnosed with lung cancer (33.3%), 20 patients with breast cancer (33.3%) and 20 patients with melanomas (33.3%). We evaluated the tumor size, diffusion and kurtosis parameters, such as the mean kurtosis, axial kurtosis, radial kurtosis, kurtosis anisotropy, radial diffusion, and fractional anisotropy, and relative anisotropy, axial diffusion of the extra-axonal fluid, radial diffusion of the extra-axonal fluid, axonal fluid fraction, and tortuosity of the diffusion trajectory. Results: Statistically significantly (p <0.05) differing parameters of diffusion and kurtosis in the comparative evaluation of the above indicators were identified in the structure associated with melanoma and lung cancer axial diffusion, fractional anisotropy, relative anisotropy, radial kurtosis and tortuosity of the diffusion trajectory, as well as in the structure of melanoma and breast cancer — axial diffusion, axonal fluid fraction, fractional anisotropy, axial diffusion of extra-axonal fluid, mean kurtosis, relative anisotropy, radial kurtosis and tortuosity of the diffusion trajectory. Conclusion: Diffusion-kurtosis magnetic resonance imaging is a promising technique that allows obtaining additional differential information in the case of metastatic lesions of the brain matter, especially those from an undetected primary focus.

Journal of Clinical Practice. 2023;14(4):34-48
pages 34-48 views

Reviews

Mesenchymal stem cells in the treatment of ischemic stroke
Namestnikova D.D., Kovalenko D.B., Pokusaeva I.A., Chudakova D.A., Gubskiy I.L., Yarygin K.N., Baklaushev V.P.
Abstract

Over the past two decades, multiple preclinical studies have shown that transplantation of mesenchymal stem cells leads to a pronounced positive effect in animals with experimental stroke. Based on the promising results of preclinical studies, several clinical trials on the transplantation of mesenchymal stem cells to stroke patients have also been conducted. In this review, we present and analyze the results of completed clinical trials dedicated to the mesenchymal stem cells transplantation in patients with ischemic stroke. According to the obtained results, it can be concluded that transplantation of mesenchymal stem cells is safe and feasible from the economic and biomedical point of view. For the further implementa-tion of this promising approach into the clinical practice, randomized, placebo-controlled, multicenter clinical trials are needed with a large sample of patients and optimized cell transplantation protocols and patient inclusion criteria. In this review we also discuss possi-ble strategies to enhance the effectiveness of cell therapy with the use of mesenchymal stem cells.

Journal of Clinical Practice. 2023;14(4):49-64
pages 49-64 views
Drainage methods in patients with unformed intestinal fistulas during the preparation to the surgical treatment
Akhtanin E.A., Markov P.V., Goev A.A., Struchkov V.Y., Martirosyan T.A., Shukurov K.U.
Abstract

The aim of the study is to analyze the data of the modern foreign and domestic literature on intestinal fistulas, including high unformed small intestinal fistulas, their classification, treatment methods, drainage methods, their types and effectiveness. Research method: the search in the elibrary, CyberLeninka, PubMed and SpringerLink databases. Intestinal fistulas, often found in the surgical practice, appear due to a number of reasons (errors in the surgical technique and conservative treatment, tactical errors, the presence of severe concomitant diseases, etc.) and present a high-risk factor for death. Clinically, intestinal fistulas can differ depending on their localization, etiology, morphology, function, complications, etc., that causes certain difficulties in choosing the treatment method and reduces its success. Special attention is paid to high unformed small intestinal fistulas, which are accompanied by pronounced impairment of the body's homeostasis system, on the one hand, and the need for a multi-stage treatment, on the other hand. The treatment regimen for high unformed small intestinal fistulas includes both conservative and surgical approaches. The conservative method of treatment includes an intensive infusion therapy, control of the source of infectious complications, reduction of irretrievable losses, nutritional therapy, and a local treatment, which consists in protecting the tissues from the aggressive intestinal content and various methods of adequate drainage of the wound. The drainage methods used for intestinal fistulas differ depending on the principle of their operation, the surgical drain material, the configuration of the wound, the fistula morphology, the number of fistulas, etc. Active and vacuum methods seem to be used most frequently and efficiently in the local treatment of high unformed small intestinal fistulas. So far, according to the (very limited) modern literature, there has been a diversity in the effectiveness of the drainage treatment approaches in patients with high unformed small intestinal fistulas, thus, further studies are needed to study and evaluate their pathogenetic role and effectiveness.

Journal of Clinical Practice. 2023;14(4):65-74
pages 65-74 views
Cardioprotection of cancer patients receiving cardiotoxic chemotherapy — current status
Peresada A.K., Dundua D.P., Kedrova A.G., Oleynikova I.N., Masterkova A.V.
Abstract

Certain drugs used for the treatment of cancer can have a toxic effect on various organs and tissues, including the heart. Not only high-dose monotherapy can lead to damage to the heart muscle, but also a combination of two or three chemotherapy drugs can do so. Cancer patients receiving combination of potentially cardiotoxic anticancer therapy have an increased risk of cardiovascular complications. Heart rhythm disturbances, arterial and venous thrombosis, coronary heart disease, valvular lesions, arterial hypertension and, in particular, chronic heart failure may be induced by chemotherapy. An important aspect is to identify groups of individuals with an initially high or very high risk of cardiotoxicity. Such patients should be under the supervision of a cardiologist or a multidisciplinary team for the entire duration of antitumor therapy and undergo additional examinations. Without the necessary laboratory and instrumental monitoring, it is impossible to predict in advance the development of heart failure, which often complicates life-saving chemotherapy, and in some cases even causes its cancellation. It is turned out that cardioprotection aimed at preventing myocardial dysfunction in cancer patients can prevent the development of heart failure and not to interrupt patients’ life-saving treatment even at a late stage of the disease. In the case of verified chronic heart failure, which occurred before the chemotherapy or during antitumor treatment, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers and beta-blockers are used, drugs with a proven cardioprotective potential. Data is gradually accumulating on the significant effect of other groups of drugs used on the regression of chronic heart failure in cancer patients. The purpose of this review is to briefly outline the mechanisms of cardiotoxicity in various chemotherapy regimens, as well as current and future options for cardioprotection in cancer patients receiving cardiotoxic chemotherapy.

Journal of Clinical Practice. 2023;14(4):75-87
pages 75-87 views
Effects of disease-modifying drugs in multiple sclerosis on the gut microbiome
Omarova М.А., Boyko А.N.
Abstract

Over the past decade, the scientific research has shown that the community of microorganisms that inhabit the gut, known as the gut microbiota, is closely linked to human health and disease, in part as a result of its influence on the systemic immune responses. The accumulated evidence suggests that these effects on the immune system are significant in neuroinflammatory diseases such as multiple sclerosis, and that modulation of the gut microbiota may be a potential therapeutic target in these conditions. In recent years, more and more studies have been appearing devoted to the role of microbiota in the development of various pathological processes in the central nervous system, including multiple sclerosis, through the brain-gut axis. In this regard, the question of finding ways to influence the microbiome is interesting. In addition to the existing attempts through the use of probiotics and fecal microbiota transplantation, of particular interest is the search for other ways of influencing the microbiome, including the effect of multiple sclerosis modifying therapies on the microbiota’s composition. The purpose of this review is to summarize the current evidence investigating the effects of disease-modifying treatment on the gut microbiome.

Journal of Clinical Practice. 2023;14(4):88-93
pages 88-93 views

Case reports

A clinical case of post-COVID-19 myoendocarditis and arrhythmic syndrome at the outpatient stage
Pavlyukova T.S., Klimova T.S., Esina E.Y., Lagutina S.N., Skuratova O.S., Zuikova A.A., Dobrynina I.S., Shevtsova V.I., Chizhkov P.A.
Abstract

Background: Infection with the SARS-CoV-2 virus entails the development of complications which affect the prognosis of the underlying disease. More than 40% of COVID-19 complications represent diseases of the cardiovascular system, most of which are the rhythm and conduction disturbances. In order to avoid these complications, it is necessary to detect cases of infection in a timely manner at the outpatient stage. Clinical case description: A 40-year-old patient came to the clinic with complaints of interruptions in the heart rhythm that appeared after the coronavirus infection. The laboratory examination (CBC) revealed signs of systemic inflammation (leukocytosis 12.6×109 U/l; erythrocyte sedimentation rate 18 mm/h, C-reactive protein 18 mg/l); the instrumental examination of the heart revealed the rhythm disturbances in the form of frequent ventricular ectopic activity and weakness of the SA node. The patient received propafenone (150 mg, 3 times a day) as a therapy with a positive effect. Against the background of improvement in the patient’s condition and despite the history of myocarditis and a positive result of enzyme immunoassay for antibodies to SARS-CoV-2 (IgG, 10 BAU/ml), the patient was prescribed immunization with the CoviVac vaccine. After the immunization, the condition worsening was observed in the form of an increase in the rhythm disturbances, which required an inpatient treatment. A clinical diagnosis of recurrent ventricular arrhythmia — ventricular extrasystole was established, and the therapy was corrected. The outcome was favorable. Conclusion: Myocarditis is one of the most common complications of SARS-CoV-2 and should be kept in mind at all stages of medical care. This clinical case demonstrates the importance of the correct diagnosis and treatment of post-COVID myocarditis, as well as the need to assess contraindications for SARS-CoV-2 vaccination in patients with cardiac complications.

Journal of Clinical Practice. 2023;14(4):94-99
pages 94-99 views
A chronic form of tick-borne encephalitis. Case report
Ostapchuk E.S., Reihert L.I., Kicherova O.A., Verbakh T.E.
Abstract

Background: Chronic tick-borne encephalitis is a rare and not fully understood pathology in which the body is not able to completely get rid of the virus. The virus remains in the nervous system mainly in the motor structures, supporting the degenerative-inflammatory process in them. Clinical case description: A clinical case of a chronic form of tick-borne encephalitis, steadily progressing, in a young man with a completely intact cognitive sphere is described. Damage to the motor nuclei of the trunk, motoneurons of the anterior horns of the spinal cord led to gross bulbar disorders, severe diffuse muscle atrophy with difficulty in independent movement. Conclusion: The above observation of the amyotrophic form of tick-borne encephalitis reflects the remitting-progressive nature of the course for 1.5 years.

Journal of Clinical Practice. 2023;14(4):100-107
pages 100-107 views
Some features of the diagnosis and clinical manifestations of pathological fractures of the spine in Bekhterev's disease (а clinical case)
Potapov V.E., Gorbunov A.V., Larionov S.N., Zhivotenko A.P., Sklyarenko O.V.
Abstract

Background: A prolonged course of the autoimmune inflammatory process in Bekhterev's disease is accompanied by calcification of the vertebral column’s ligaments, damage to the costovertebral and true joints of the spine, and their ankylosis, that ultimately leads to a decrease in the support capacity of the spine, so that even a minor injury can lead to a fracture. Spinal fractures in ankylosing spondylitis often have an unstable character and a high risk of the spinal cord injury. The main methods for diagnosing the spinal instability in Bekhterev's disease are multispiral computed tomography and magnetic resonance imaging, since the informative significance of survey radiography is not high. An early surgical treatment is the method of choice for unstable fractures in ankylosing spondylitis, despite the comorbid pathology and age, which significantly burden the prognosis. Сlinical case description: Patient K., born in 1969, injured on October 07, 2021 as a result of falling on his back from a height of 2 meters. An MSCT study of the thoracolumbar spine revealed a fracture of the ThXII–LI vertebrae, rupture of the anterior longitudinal ligament, and instability of the ThXII–LI vertebral-motor segment. The following diagnosis was established: closed uncomplicated injury of the thoracolumbar spine; grade I unstable compression fracture of the ThXII, LI vertebrae with a damage to the posterior support complex against the background of ankylosing spondylitis; grade I kyphotic deformity of the thoracolumbar spine; bilateral vertebrogenic lumboishialgia syndrome; pronounced persistent pain and muscle-tonic syndromes. A surgical treatment was applied which included correction of the spinal deformity and stabilization of the thoracolumbar spine using a transpedicular fixation system. The pain vertebrogenic syndrome and clinical neurological disorders regressed. The MSCT control was carried out in 6 months with the detected completed fusion at the ThXII–LI level. Conclusion: A timely diagnosis using multispiral computed tomography and magnetic resonance imaging data allows us to assess the full picture of traumatic changes in the spinal column and choose the most effective type of surgical intervention, using, if necessary, stabilizing systems.

Journal of Clinical Practice. 2023;14(4):108-115
pages 108-115 views
A rare form of the thyroid gland cancer against the background of autoimmune thyroiditis
Ryabchenko E.V.
Abstract

Background: Sclerosing mucoepidermoid carcinoma of the thyroid gland was first reported in 1991. This type of a tumor may develop in connection with Hashimoto's thyroiditis. There are two variants of mucoepidermoid carcinoma of the thyroid gland: the normal and sclerosing types. Sclerosing mucoepidermoid carcinoma of the thyroid gland has recently been recognized by the World Health Organization as a separate disease. Сlinical case description: We present a clinical case of a 51-year-old woman who was observed for 2 years for autoimmune thyroiditis with nodulation. The patient had no symptoms or signs of compression. The level of thyroid–stimulating hormone was 15.8 (range 0.4–4.0), the level of antibodies to peroxidase was 150 IU/ml. Thyroid scintigraphy revealed a dominant cold node (1.5×2 cm) in the right lobe of the gland. During the control ultrasound examination of the neck, negative dynamics was observed, then a fine needle aspiration biopsy of the thyroid node was performed. A follicular tumor was found against the background of Hashimoto's thyroiditis, which was the reason for a timely treatment. In the described case, the patient underwent a total thyroidectomy without neck lymph node dissection, no postoperative radiotherapy or other auxiliary treatments were performed. A full-body scintigraphy showed no recurrence of the disease in 10 months after the initial treatment. Conclusion: Given the rarity of the disease and the impossibility to differentiate it from other thyroid tumor’s, a more thorough examination of the nearby lymphatic collectors is necessary to exclude metastatic lesions, and in the presence of altered lymph nodes, additional diagnosis by fine-needle aspiration biopsy with subsequent determination of the scope of surgical treatment and postoperative management of this category of patients is indicated.

Journal of Clinical Practice. 2023;14(4):116-121
pages 116-121 views
Listeria monocytogenes meningoencephalitis against the background of the new coronavirus infection: a clinical case
Ulyanova O.V., Ermolenko N.A., Banin I.N., Belinskaya V.V., Dutova T.I., Kulikov A.V., Golovina N.P.
Abstract

Background: Among the bacteria that affect the central nervous system, Listeria monocytogenes (facultative intracellular bacterium) is one of the most lethal to humans and animals. Listeriosis affects domestic and farm animals (pigs, small and large cattle, horses, rabbits, less often cats and dogs), as well as domestic and ornamental birds (geese, chickens, ducks, turkeys, pigeons, parrots and canaries). L. monocytogenes can be detected in fish and seafood (shrimp). The source of L. monocytogenes infection are animals in which the disease may manifest itself or occur in erased and asymptomatic forms followed by the transition to a long-term carriage. This pathogen is found throughout the world in foodstuffs, and most cases of infection occur through the ingestion of contaminated food. Particularly susceptible to the disease are embryos, newborns, the elderly and individuals with immunodeficiencies and chronic diseases. L. monocytogenes can cause intracranial hemorrhage, meningitis, meningoencephalitis, and rhombencephalitis. Clinical case description: This paper presents our own clinical observation of the development of severe listeriosis meningoencephalitis in a 47 year-old patient against the background of the new coronavirus infection (COVID-19). We describe the details of the clinical presentation, the treatment and the favorable outcome in our patient. Conclusion: Invasive listeriosis is a rare disease. The knowledge about the clinical manifestations of this disease is needed not only for epidemiologists and infectious disease specialists, but also for physicians of other specialties. Untimely diagnosis and inadequate antibacterial therapy are dangerous leading to severe somatic and neurological complications with a lethal outcome or disability both in children and adult persons.

Journal of Clinical Practice. 2023;14(4):122-128
pages 122-128 views


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