Addison Biermer's disease. How does Addison's disease manifest itself? What additional testing is needed?

Poteyko P.I., Kharkiv medical Academy postgraduate education, Department of Phthisiology and Pulmonology

Even in antiquity, 25 centuries ago, Hippocrates described changes in the shape distal phalanges fingers that occurred in chronic pulmonary pathology (abscess, tuberculosis, cancer, pleural empyema), and called them "drum sticks". Since then, this syndrome has been called by his name - the fingers of Hippocrates (PG) (digiti Hippocratici).

Hippocratic finger syndrome includes two signs: "hour glasses" (Hippocratic nails - ungues Hippocraticus) and clavate deformity terminal phalanges of the fingers according to the type " drumsticks» (Finger clubbing).

Currently, PG is considered the main manifestation of hypertrophic osteoarthropathy (GOA, Marie-Bamberger syndrome) - multiple ossifying periostosis.

Mechanisms for the development of GHGs are currently not fully understood. However, it is known that the formation of PH occurs as a result of microcirculation disorders, accompanied by local tissue hypoxia, impaired trophism of the periosteum and autonomic innervation against the background of prolonged endogenous intoxication and hypoxemia. In the process of PG formation, the shape of the nail plates (“watch glasses”) first changes, then the shape of the distal phalanges of the fingers changes in a club-like or cone-shaped form. The more pronounced endogenous intoxication and hypoxemia, the coarser the terminal phalanges of the fingers and toes are modified.

There are several ways to establish a change in the distal phalanges of the fingers according to the type of "drumsticks".

It is necessary to identify the smoothing of the normal angle between the base of the nail and the nail fold. The disappearance of the "window", which is formed when the distal phalanges of the fingers are compared with the back surfaces to each other, is the most early sign thickening of the terminal phalanges. The angle between the nails normally does not extend upwards more than half the length of the nail bed. With thickening of the distal phalanges of the fingers, the angle between the nail plates becomes wide and deep (Fig. 1).

On unchanged fingers, the distance between points A and B should exceed the distance between points C and D. With "drumsticks" the ratio is reversed: C - D becomes longer than A - B (Fig. 2).

Another important feature PG - the value of the angle ACE. On a normal finger, this angle is less than 180°, with "drumsticks" it is more than 180° (Fig. 2).

Along with the "fingers of Hippocrates" in the paraneoplastic syndrome of Marie - Bamberger, periostitis appears in the region of the terminal sections of the long tubular bones(usually forearms and shins), as well as the bones of the hands and feet. In places of periosteal changes, pronounced ossalgia or arthralgia and local palpation soreness can be noted, with x-ray examination a double cortical layer is detected, due to the presence of a narrow dense strip separated from the compact bone substance by a light gap (symptom of "tram rails") (Fig. 3). It is believed that Marie-Bamberger syndrome is pathognomonic for lung cancer, less often it occurs with other primary intrathoracic tumors ( benign neoplasms lungs, pleural mesothelioma, teratoma, mediastinal lipoma). Occasionally, this syndrome occurs in cancer. gastrointestinal tract, lymphoma with metastases to the lymph nodes of the mediastinum, lymphogranulomatosis. At the same time, the Marie-Bamberger syndrome also develops in non-oncological diseases - amyloidosis, chronic obstructive pulmonary disease, tuberculosis, bronchiectasis, congenital and acquired heart defects, etc. One of distinguishing features this syndrome in non-tumor diseases, there is a long-term (over the course of years) development characteristic changes musculoskeletal apparatus, while malignant neoplasms this process is calculated in weeks and months. After the radical surgical treatment Cancer Marie-Bamberger syndrome can regress and disappear completely within a few months.

At present, the number of diseases in which changes in the distal phalanges of the fingers are described as “drumsticks” and nails as “watch glasses” have increased significantly (Table 1). The appearance of PG often precedes more specific symptoms. It is especially necessary to remember the "ominous" connection of this syndrome with lung cancer. Therefore, the identification of signs of GHG requires the correct interpretation and implementation of instrumental and laboratory methods examinations for the timely establishment of a reliable diagnosis.

The relationship of PG with chronic lung diseases, accompanied by prolonged endogenous intoxication and respiratory failure(DN) are considered obvious: their formation is especially often observed in pulmonary abscesses - 70-90% (within 1-2 months), bronchiectasis - 60-70% (within several years), pleural empyema - 40-60% (within 3–6 months or more) (“rough” fingers of Hippocrates, Fig. 4) .

With tuberculosis of the respiratory organs, PGs are formed in the case of a widespread (more than 3-4 segments) destructive process with a long or chronic course(6-12 months or more) and are characterized mainly by the symptom of "watch glasses", thickening, hyperemia and cyanosis of the nail fold ("tender" fingers of Hippocrates - 60-80%, Fig. 5).

In idiopathic fibrosing alveolitis (IFA), PG occurs in 54% of men and 40% of women. It has been established that the severity of hyperemia and cyanosis of the nail fold, as well as the very presence of PG, testify in favor of an unfavorable prognosis in ELISA, reflecting, in particular, the prevalence of active damage to the alveoli (ground glass areas detected during computed tomography) and the severity of proliferation of vascular smooth muscle cells in the foci of fibrosis. GHG is one of the factors most reliably indicating high risk the formation of irreversible pulmonary fibrosis in patients with ELISA, also associated with a decrease in their survival.

At diffuse diseases connective tissue with involvement of the lung parenchyma PH always reflect the severity of DN and are an extremely unfavorable prognostic factor.

For other interstitial lung diseases, the formation of PG is less typical: their presence almost always reflects the severity of DN. J. Schulze et al. described this clinical phenomenon in a 4-year-old girl with rapidly progressive pulmonary histiocytosis X. B. Holcomb et al. revealed changes in the distal phalanges of the fingers in the form of "drumsticks" and nails in the form of "watch glasses" in 5 out of 11 examined patients with pulmonary veno-occlusive disease.

As lung lesions progress, PG appear in at least 50% of patients with exogenous allergic alveolitis. It should be emphasized that a persistent decrease in the partial pressure of oxygen in the blood and tissue hypoxia in the development of GOA in patients with chronic lung diseases should be emphasized. So, in children with cystic fibrosis, the values of the partial pressure of oxygen in arterial blood and forced expiratory volume in 1 second were the smallest in the group with the most pronounced changes in the distal phalanges of the fingers and nails.

There are isolated reports of the appearance of PG in bone sarcoidosis (J. Yancey et al., 1972). We have observed more than a thousand patients with intrathoracic sarcoidosis. lymph nodes and lungs, including skin manifestations, and in no case did we reveal the formation of PG. Therefore, we consider the presence/absence of PG as a differential diagnostic criterion for sarcoidosis and other organ pathologies. chest(fibrosing alveolitis, tumors, tuberculosis).

Changes in the distal phalanges of the fingers in the form of "drumsticks" and nails in the form of "watch glasses" are often recorded with occupational diseases occurring with the involvement of the pulmonary interstitium. Relatively early appearance GOA is characteristic of patients with asbestosis; this feature is indicative of a high risk of death. According to S. Markowitz et al. , during a 10-year follow-up of 2709 patients with asbestosis with the development of PH, the probability of death in them increased by at least 2 times.
GHGs were detected in 42% of the surveyed coal mine workers suffering from silicosis; some of them, along with diffuse pneumosclerosis foci of active alveolitis were found. Changes in the distal phalanges of the fingers in the form of "drumsticks" and nails in the form of "watch glasses" are described in match factory workers who were in contact with the rhodamine used in their manufacture.

The connection between the development of PH and hypoxemia is also confirmed by the repeatedly described possibility of the disappearance of this symptom after lung transplantation. In children with cystic fibrosis, the characteristic changes in the fingers regressed during the first 3 months. after lung transplant.

The appearance of PH in a patient with interstitial disease lungs, especially long experience disease and in the absence clinical signs activity of lung lesions, requires a persistent search for a malignant tumor in lung tissue. It has been shown that in lung cancer that developed against the background of ELISA, the frequency of GOA reaches 95%, while in lesions of the pulmonary interstitium without signs of neoplastic transformation, it is detected more rarely - in 63% of patients.

Fast development changes in the distal phalanges of the fingers in the form of "drumsticks" - one of the indications for the development of lung cancer and in the absence precancerous diseases. In such a situation, clinical signs of hypoxia (cyanosis, shortness of breath) may be absent and this feature develops according to the laws of paraneoplastic reactions. W. Hamilton et al. demonstrated that the probability of a patient having PH increased by 3.9 times.

GOA is one of the most common paraneoplastic manifestations of lung cancer; its prevalence in this category of patients can exceed 30%. The dependence of the frequency of detection of GHGs on morphological form lung cancer: reaching 35% with a non-small cell variant, with a small cell this figure is only 5%.

The development of GOA in lung cancer is associated with hyperproduction of growth hormone and prostaglandin E2 (PGE-2) tumor cells. partial pressure of oxygen in peripheral blood while it may remain normal. It was found that in the blood of patients lung cancer with the symptom of PH, the level of transforming growth factor β (TGF-β) and PGE-2 significantly exceeds that in patients without changes in the distal phalanges of the fingers. Thus, TGF-β and PGE-2 can be considered as relative inducers of PG formation, relatively specific for lung cancer; apparently, this mediator is not involved in the development of the discussed clinical phenomenon in other chronic pulmonary diseases with DN.

The paraneoplastic nature of the “drum stick” changes in the distal phalanges of the fingers is clearly demonstrated by the disappearance of this clinical phenomenon after successful resection. lung tumors. In turn, the reappearance of this clinical sign in a patient in whom lung cancer treatment was successful is a likely indication of tumor recurrence.

PH may be a paraneoplastic manifestation of tumors localized outside the lung area, and may even precede the first clinical manifestations malignant tumors. Their formation is described in a malignant tumor of the thymus, cancer of the esophagus, colon, gastrinoma, characterized by a clinically typical Zollinger-Ellison syndrome, and pulmonary artery sarcoma.

The possibility of PH formation in malignant tumors of the mammary gland, pleural mesothelioma, which was not accompanied by the development of DN, has been repeatedly demonstrated.

PG is detected in lymphoproliferative diseases and leukemias, including acute myeloblastic, in which they were noted on the arms and legs. After chemotherapy, which stopped the first attack of leukemia, the signs of GOA disappeared, but reappeared after 21 months. with tumor recurrence. In one of the observations, a regression of typical changes in the distal phalanges of the fingers was stated with successful chemotherapy and radiotherapy lymphogranulomatosis.

Thus, PG, along with various types of arthritis, erythema nodosum and migrating thrombophlebitis are among the frequent extraorganic, nonspecific manifestations of malignant tumors. The paraneoplastic origin of changes in the distal phalanges of the fingers in the form of "drum sticks" can be assumed with their rapid formation (especially in patients without DN, heart failure and in the absence of other causes of hypoxemia), as well as in combination with other possible extraorganic, nonspecific signs of a malignant tumor - an increase in ESR, changes in the picture of peripheral blood (especially thrombocytosis), persistent fever, articular syndrome and recurrent thrombosis different localization.

One of the most common causes the appearance of PG are considered congenital heart defects, especially the "blue" type. Among 93 patients with pulmonary arteriovenous fistulas, observed in the Mauo clinic for 15 years, such changes in the fingers were registered in 19%; they exceeded hemoptysis in frequency (14%), but were inferior to noises over pulmonary artery(34%) and shortness of breath (57%).

R. Khousam et al. (2005) described ischemic stroke embolic origin, which developed 6 weeks after delivery in an 18-year-old patient. The presence of characteristic changes in the fingers and hypoxia, which required respiratory support, led to the search for an anomaly in the structure of the heart: transthoracic and transesophageal echocardiography revealed that the inferior vena cava opened into the cavity of the left atrium.

PGs can “discover” the existence of pathological shunting from the left heart to the right, including those formed as a consequence cardiac surgery. M. Essop et al. (1995) observed characteristic changes in the distal phalanges of the fingers and increasing cyanosis for 4 years after balloon dilatation of rheumatic mitral stenosis, a complication of which was a small defect interatrial septum. During the period that has passed since the operation, its hemodynamic significance has increased significantly due to the fact that the patient also developed rheumatic stenosis of the tricuspid valve, after the correction of which these symptoms completely disappeared. J. Dominik et al. noted the appearance of PH in a 39-year-old woman 25 years after successful elimination atrial septal defect. It turned out that during the operation, the inferior vena cava was erroneously directed to the left atrium.

PG is considered one of the most typical non-specific, so-called non-cardiac, clinical signs. infective endocarditis(IE) . The frequency of changes in the distal phalanges of the fingers in the form of "drumsticks" in IE can exceed 50%. In favor of IE in a patient with PH is evidenced by high fever with chills, increased ESR, leukocytosis; anemia, a transient increase in the serum activity of hepatic aminotransferases, and various variants of kidney damage are often observed. To confirm IE, transesophageal echocardiography is indicated in all cases.

According to some clinical centers, one of the most common causes of the PH phenomenon is cirrhosis of the liver with portal hypertension and progressive dilatation of the vessels of the pulmonary circulation, leading to hypoxemia (the so-called pulmonary-renal syndrome). In such patients, GOA, as a rule, is combined with cutaneous telangiectasias, often forming "fields spider veins» .
A relationship has been established between the formation of GOA in liver cirrhosis and previous alcohol abuse. In patients with cirrhosis of the liver without concomitant hypoxemia, PG, as a rule, is not detected. This clinical phenomenon is also characteristic of primary cholestatic liver lesions requiring its transplantation into childhood, including congenital atresia bile ducts.

Repeated attempts have been made to decipher the mechanisms of development of changes in the distal phalanges of the fingers according to the type of "drumsticks" in diseases, including those mentioned above ( chronic diseases lungs, congenital heart defects, IE, liver cirrhosis with portal hypertension), accompanied by persistent hypoxemia and tissue hypoxia. Hypoxia-induced activation of tissue growth factors, including platelet growth factors, plays a leading role in the formation of changes in the distal phalanges and nails of the fingers. In addition, in patients with PH, an increase in the serum level of hepatocyte growth factor was detected, as well as vascular factor growth. The connection between the increase in the activity of the latter and the decrease in the partial pressure of oxygen in the arterial blood is considered the most obvious. Also, in patients with PH, a significant increase in the expression of factors of type 1a and 2a induced by hypoxia is found.

In the development of changes in the distal phalanges of the fingers according to the type of "drumsticks", endothelial dysfunction associated with a decrease in the partial pressure of oxygen in the arterial blood may have a certain significance. It has been shown that in patients with GOA, the serum concentration of endothelin-1, the expression of which is induced primarily by hypoxia, significantly exceeds that in healthy people.
It is difficult to explain the mechanisms of PH formation in chronic inflammatory diseases intestines, for which hypoxemia is not typical. However, they are often found in Crohn's disease (with ulcerative colitis they are not characteristic), in which a change in the fingers of the type of "drumsticks" may precede the actual intestinal manifestations diseases.

Number probable causes, causing a change in the distal phalanges of the fingers according to the type of "watch glasses", continues to increase. Some of them are very rare. K. Packard et al. (2004) observed the formation of PG in a 78-year-old man who took losartan for 27 days. This clinical phenomenon persisted when losartan was replaced by valsartan, which allows us to consider it adverse reaction to the entire class of angiotensin II receptor blockers. After switching to captopril, the changes in the fingers completely regressed within 17 months. .

A. Harris et al. found characteristic changes in the distal phalanges of the fingers in a patient with primary antiphospholipid syndrome, while signs of thrombotic damage to the pulmonary vascular bed he was not identified. The formation of PGs is also described in Behcet's disease, although it cannot be completely ruled out that their appearance in this disease was accidental.
PG is considered among the possible indirect markers of drug use. In some of these patients, their development may be associated with a variant of lung damage or IE that is characteristic of drug addicts. Changes in the distal phalanges of the fingers according to the type of "drumsticks" are described in users of not only intravenous, but also inhaled drugs, for example, in hashish smokers.

With an increasing frequency (at least 5%), PG is recorded in HIV-infected people. Their formation may be based on various forms of HIV-associated lung diseases, but this clinical phenomenon is observed in HIV-infected patients with intact lungs. It has been established that the presence of characteristic changes in the distal phalanges of the fingers in HIV infection is associated with a lower number of CD4-positive lymphocytes in the peripheral blood, in addition, interstitial lymphocytic pneumonia is more often recorded in such patients. In HIV-infected children, the appearance of PH is a likely indication of pulmonary tuberculosis, which is possible even in the absence of Mycobacterium tuberculosis in sputum samples.

Known so-called primary, not associated with diseases internal organs a form of GOA, often of a familial nature (Touraine-Solanta-Gole syndrome). It is diagnosed only with the exclusion of most of the causes that can cause the appearance of PG. Patients with the primary form of GOA often complain of pain in the area of altered phalanges, excessive sweating. R. Seggewiss et al. (2003) observed primary GOA involving fingers only lower extremities. At the same time, when stating the presence of PH in members of the same family, it is necessary to take into account the possibility that they have inherited birth defects heart (for example, non-closure of the ductus arteriosus). The formation of characteristic changes in the fingers can continue for about 20 years.

Recognition of the causes of changes in the distal phalanges of the fingers according to the type of "drumsticks" requires differential diagnosis various diseases, among which the leading position is occupied by those associated with hypoxia, i.e. clinically manifested DN and / or heart failure, as well as malignant tumors and subacute IE. Interstitial lung disease, primarily ELISA, is one of the most common causes of PH; the severity of this clinical phenomenon can be used to assess the activity of the lung lesion. The rapid formation or increase in the severity of GOA necessitates the search for lung cancer and other malignant tumors. At the same time, one should take into account the possibility of this clinical phenomenon occurring in other diseases (Crohn's disease, HIV infection), in which it can occur much earlier than specific symptoms.

Symptoms of anemia (Addison-Birmer's disease)

Clinic

Addison-Birmer anemia most often affects women aged 50-60 years. The disease begins slowly and gradually. Patients complain of weakness, fatigue, dizziness, headache, palpitations and shortness of breath on movement. In some patients in clinical picture dyspeptic symptoms dominate (belching, nausea, burning at the tip of the tongue, diarrhea), less often nervous system(paresthesia, cold extremities, unsteady gait).

Objectively, pale skin (with a lemon tint), slight yellowness of the sclera, puffiness of the face, sometimes swelling of the legs and feet, and almost naturally - pain in the sternum when tapped.

The nutrition of patients was preserved due to a decrease in fat metabolism. The temperature, usually subfebrile, rises to 38-39°C during a relapse.

Characterized by changes in the digestive system. The edges and tip of the tongue are usually bright red with cracks and aphthous changes (glossitis). Later, the papillae of the tongue atrophy, in connection with which it becomes smooth, "varnished". Due to atrophy of the gastric mucosa, achilia develops and, in connection with it, dyspeptic symptoms (less often diarrhea). In half of the patients there is an increase in the liver, and in the fifth part - an increase in the spleen.

Changes in the cardiovascular system are manifested by tachycardia, hypotension, heart enlargement, deafness of tones, systolic murmur over the apex and over the pulmonary artery, "top noise" over the jugular veins, and in severe cases - circulatory failure. As a result dystrophic changes in the myocardium on the ECG, a low voltage of the teeth and an elongation of the ventricular complex are determined; T waves in all leads decrease or become negative.

Changes in the nervous system occur in approximately 50% of cases and are characterized by damage to the posterior and lateral columns. spinal cord(funicular myelosis), manifested by paresthesia, decreased tendon reflexes, impaired deep and pain sensitivity, and in severe cases - paraplegia and dysfunction of the pelvic organs.

On the part of the blood - a high color index (up to 1.2-1.3). This is due to the fact that the number of erythrocytes decreases to a greater extent than the hemoglobin content. At qualitative analysis a blood smear reveals pronounced macroanisocytosis with the presence of megalocytes and even single megaloblasts, as well as a sharp poikilocytosis. Often there are erythrocytes with the remains of nuclei - in the form of Cabot rings and Jolly bodies. On the part of white blood - leukopenia with hypersegmentation of neutrophil nuclei (up to 6-8 segments instead of 3). Permanent feature Birmer's anemia is also thrombocytopenia. The amount of bilirubin in the blood is usually increased due to increased hemolysis of megaloblasts and megalocytes, the osmotic resistance of which is reduced.

Pernicious anemia (Addison-Birmer disease or megaloblastic anemia) is characterized by impaired hematopoiesis that occurs when there is a deficiency folic acid and vitamin B12 in the body. Previously, this pathological process was called malignant anemia. The nervous system and bone marrow are particularly sensitive to the lack of this vitamin. At the same time, many immature large precursors of megaloblasts (erythrocytes) are formed in the body.

Causes of pernicious anemia

In the body, vitamin B12 is absorbed in the area ileum, or rather, its lower part. Anemia can develop due to not enough of this vitamin in foods included in the diet. Also the reason for the development pathological process may consist in insufficient production of Carls factor (intrinsic) in the region of parietal gastric cells.

Vitamin B12 deficiency with the development of a clinical anemic picture or in its absence can cause neurological disorders, which occurs due to the inevitable synthesis fatty acids. This may result in irreversible damage. nerve cells and demyelination, which is accompanied by tingling or numbness of the extremities, as well as ataxia.

Symptoms of pernicious anemia

The pernicious form of anemia develops slowly, therefore, at the very beginning of the onset, it is not accompanied by bright severe symptoms. At the same time, there are such manifestations as rapid fatigue, weakness, heart palpitations, shortness of breath and dizziness.

Symptoms pernicious anemia as it progresses, the following symptoms appear:

pale icteric skin;
yellowness of the sclera;
swallowing disorder;
pain in the tongue;
glossitis development ( inflammatory process language);
enlargement of the liver, spleen.

A characteristic feature of pernicious anemia is the defeat of nerve cells, which is called funicular myelosis. With its development, sensitivity is disturbed, permanent pain in the limbs, resembling tingling. At the same time, there is numbness and a feeling of "crawling crawling". Patients note the presence of a pronounced muscle weakness which leads over time to gait disturbance and muscle atrophy.

Diagnosis of pernicious anemia

The diagnosis is made on the basis of the results of the following research activities:

The blood test for pernicious anemia is the most informative method diagnostics, as it allows you to determine the level of vitamin B12 in the serum.
Urinalysis is a mandatory research event, which also makes it possible to determine how much of the vitamin is excreted from the body.
Examination of feces reveals the presence of helminthic invasions.

Diagnosis of pernicious anemia also includes determining the underlying cause of the development of the disease. First of all, the state of the gastrointestinal tract is examined for the presence of gastritis, ulcers and other pathologies that affect the absorption nutrients. AT without fail the condition of the kidneys is checked, since in the presence of diseases such as pyelonephritis or kidney failure treatment with injections of vitamin B12 does not work.

Treatment of pernicious anemia

Pernicious anemia requires timely treatment, otherwise there is Great chance spinal cord injury. First, there is a symmetrical violation of the functioning of systems and muscle structures in the region of the lower extremities, and then a violation of pain and surface sensitivity develops.

Treatment of pernicious anemia should be carried out under the supervision of a physician. All measures are aimed at eliminating the causes of development pathological changes. First of all, measures are taken to treat diseases of the gastrointestinal tract, and the patient is prescribed balanced diet. To normalize hematopoiesis in the area bone marrow replacement therapy is prescribed, which consists in inflammation of vitamin B12 deficiency.

After the first injections, there is an improvement in well-being and normalization of blood counts.

The duration of the course of treatment is from 1 month or more, which depends not only on the stage of the disease, but also on the intermediate results of therapy. In order to achieve stable remission, it is necessary to carry out medical measures for six months, it is recommended to adhere to the following actions:

Enter cyanocobalamin daily for 2 months.
After 2 months, inject the drug once every 2 weeks.

Secondly, patients have circulating autoantibodies: in 90% - to the parietal cells of the stomach, in 60% - to the intrinsic factor of Castle. Antibodies to parietal cells are also detected in every second patient with atrophic gastritis without impaired absorption of vitamin B12 and in 10-15% of randomly selected patients, but they usually do not have antibodies to internal factor Castle.

Thirdly, relatives of people with Addison-Birmer's disease are more likely to suffer from this disease, and even those of them who do not have anemia can detect antibodies to the internal factor of the Castle.

The clinical picture consists mainly of signs of vitamin B12 deficiency (see "Vitamin B12 deficiency: an overview"). The disease begins gradually and progresses slowly. Laboratory examination reveals hypergastrinemia and absolute achlorhydria (hydrochloric acid is not produced even in response to the introduction of pentagastrin), as well as changes in the blood picture and other laboratory parameters (see "Megaloblastic anemia: diagnosis").

Replacement therapy completely and permanently eliminates in these patients the disorders caused by vitamin B12 deficiency, except in those cases when irreversible changes in nervous tissue occurred before treatment. However, patients are extremely predisposed to adenomatous gastric polyps and are about twice as likely to develop gastric cancer. They are shown observation, including regular guaiac samples, and, if necessary, additional studies.

Addison-Birmer disease is chronic illness, characterized by progressive anemia, damage to the nervous system and gastric achylia.

Addison-Birmer disease is the result of impaired hematopoietic function of the bone marrow due to a deficiency of vitamin B12 in the body. In some cases, the disease develops due to a lack of folic acid.

Addison-Birmer disease - symptoms

The onset of Addison-Birmer disease is accompanied by fatigue, weakness, shortness of breath and palpitations on movement, and dizziness. Against the background of symptoms of anemia, dyspeptic phenomena are often noted: burning at the tip of the tongue, nausea, belching, diarrhea, in some cases, there are disorders of the nervous system (staggering gait, cold extremities, paresthesia).

Patients with Addison-Birmer disease have pale skin with a lemon-yellow tint. Depletion is not observed, in some cases nutrition is increased. There is swelling in the area of the feet, the face is puffy.

From the side digestive tract some changes are observed. The tongue is usually bright red and fissured. Research gastric juice allows you to identify ahiliya.

Palpation reveals an enlarged spleen and liver. There may be pain in the region of the heart. long current diseases can lead to fatty degeneration of the heart.

Changes in the activity of the nervous system are characterized by damage to the lateral and posterior columns of the spinal cord - funicular myelosis. It is manifested by a decrease in tendon reflexes, paresthesias, impaired pain and deep sensitivity with a disorder in the function of the pelvic organs.

Diagnosis of Addison-Birmer disease

Diagnosis of the disease consists in the detection of large erythrocytes (megalocytes), erythrocytes and megaloblasts with the remains of nuclei in the blood. Due to the predominance of megablasts, the bone marrow punctate was hyperplastic.

Addison-Birmer disease - treatment

In the treatment of Addison-Birmer disease greatest effect brings the use of vitamin B12. Improvement occurs within a day after the first injection. The drug is injected intramuscularly. Favorable results can also be achieved by taking vitamin B12 orally in combination with gastromucoprotein (bifacton, biopar, mucovit).