DGI:ZNS-Infektionen/Tuberkulose Meningitis/Diagnostik: Unterschied zwischen den Versionen

Aktuelle Version vom 10. September 2026, 08:14 Uhr

Anamnese

Chronischer Husten? Gewichtsverlust? B-Symptomatik? (Lungen-TBC!)
Reiseanamnese
Herkunftsland
Frühere Tbc-Diagnose oder Therapie, TBC-Fall im sozialen Umfeld?

Risikofaktoren:
- Malnutrition
- Immunsuppression
- Andere Infektionen, v.a. HIV (Bei Erstdiagnose TBC immer HIV Test!)
- Chronischer Alkoholabusus

Radiologie:

CT Schädel, ggf. MRT (Sensitivität des MRT besser als das CT für die Erkennung der basalen Inflammation bei TBC-Meningitis)
Röntgen-Thorax

Liquor-Labor:


	Normal	Virale Meningitis	Bakterielle Meningitis	Tuberkulöse Meningitis
Aspekt	Klar	Klar	Trüb	Klar-trüb
Druck (cm H2O)	5-12	Normal oder (Pfeil nach oben)	>20	Normal oder (Pfeil nach oben)
Leukozyten (x 106/l)	1-4	< 1000 Lymphozyten	> 1000 (> 70% Neutrophile)	< 1000 (Mono- und Lymphozyten)
Glukose (% des Serumwertes)	50-80%	50-80%	< 40%	< 40%
Eiweiß (mg/l)	150-500	Normal oder (Pfeil nach oben)	>> 500
Laktat (mmol/l)	< 1,6	< 1,6	> 3,5	> 1,6
Direktpräparat	Negativ	Negativ	80% positiv	35% positiv

Mikrobiologie:

Goldstandard ist die Kultur auf Mykobakterien (deutlich sensitiver als Mikroskopie, ist in bis zu 50-70% positiv). Hierfür wird mind. 3 ml nativer (!) Liquor benötigt. Es wird bei den meisten mikrobiologischen Laboratorien nötig sein, diese Probe separat (!) mit einer eigenen Anforderung einzusenden. Unbedingt muss bei V.a. TBC-Meningitis (TBM) zusätzlich zur Kultur eine TBC-PCR aus dem Liquor angefertigt werden. Dies ist bei den meisten mikrobiologischen Labors aus der Probe für die Kultur zusätzlich möglich, muss aber ggf. extra angefordert werden (!). Bis das Kultur-Ergebnis mit der kulturellen Resistenzbestimmung für die Medikamente der Standardtherapie eintrifft, verstreichen meist 6 – 8, Wochen, im Extremfall länger [1-4, 6, 7].

Bei positiver TBC-PCR ist es heutzutage Standard, dass zusätzlich eine molekularbiologische Analyse der Genabschnitte des Isolats in Bezug auf Isoniazid- und Rifampicin-Resistenz angefertigt wird (z.B. Xpert-MTB/RIF). Dies erlaubt eine schnelle Erkennung der für die Therapie wichtigsten Resistenzmechanismen, womit die Therapie angepasst werden kann, lange bevor das kulturelle Resistenzergebnis verfügbar wird [1].

Tab.2. Empfohlene Diagnostik bei tuberkuloser Meningitis
Bereich	Empfehlung	Kommentar
Bildgebung	MRT Schädel mit Kontrastmittel, DWI/ADC, FLAIR, ggf. Gefäßdarstellung.	Basale Meningitis, Hydrozephalus, Infarkte und Tuberkulome erfassen.
Liquor	Zellzahl, Differenzialzellbild, Eiweiß, Glukose plus Serumglukose, Laktat, Eröffnungsdruck	Zellzahl, Differenzialzellbild, Eiweiß, Glukose plus Serumglukose, Laktat, Eröffnungsdruck
Mikrobiologie	Ziehl-Neelsen/Auramin, Mykobakterienkultur, Xpert MTB/RIF Ultra, Resistenzdiagnostik	Kultur langsam, aber für Resistenztestung essenziell.
Zusatzproben	Sputum/BAL, Urin, Lymphknoten, Biopsien, Blutkulturen je nach Kontext	Erhöht Diagnosechance und ermöglicht Resistenztestung.
HIV/ Immunsuppression	HIV-Test, CD4, Viruslast, Kryptokokken-Antigen bei passender Klinik	Wichtig für DD, Prognose und ART-Timing.

Differentialdiagnose

Andere bakterielle Meningitiden (Neisseria meningitidis, Streptococcus pneumoniae, Haemophilus influenzae, Listeria monocytogenes, Streptococcus, agalactiae), Neuroborreliose
Pilze: Cryptococcus spp.
Parasiten: Toxoplasma gondii
Nicht-infektiös: Sarkoidose, tumorös (Meningiosis carcinomatosa)

@@ Zeile 1: / Zeile 1: @@
-==<span class="mw-headline" id="Diagnose" style="box-sizing: inherit;">Diagnose</span>==
+====Anamnese====
-====<span class="mw-headline" id="Anamnese" style="box-sizing: inherit;">Anamnese</span>====
+*Chronischer Husten? Gewichtsverlust? B-Symptomatik? (Lungen-TBC!)
-<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Symbol;&quot;}" style="box-sizing: inherit; font-family: Symbol;"><span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}" style="box-sizing: inherit;">· <span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font: 7pt \&quot;Times New Roman\&quot;;&quot;}" style="box-sizing: inherit; font: 7pt &quot;Times New Roman&quot;;">       </span></span></span>Chronischer <span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-family: Arial, sans-serif;">Husten? Gewichtsverlust? B-Symptomatik?</span>
+*Reiseanamnese
+*Herkunftsland
+*Frühere Tbc-Diagnose oder Therapie, TBC-Fall im sozialen Umfeld?
-<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Symbol;&quot;}" style="box-sizing: inherit; font-family: Symbol;"><span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}" style="box-sizing: inherit;">· <span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font: 7pt \&quot;Times New Roman\&quot;;&quot;}" style="box-sizing: inherit; font: 7pt &quot;Times New Roman&quot;;">       </span></span></span><span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-family: Arial, sans-serif;">Reiseanamnese</span>
+*Risikofaktoren:
+**Malnutrition
+**Immunsuppression
+**Andere Infektionen, v.a. HIV (Bei Erstdiagnose TBC immer HIV Test!)
+**Chronischer Alkoholabusus
-<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Symbol;&quot;}" style="box-sizing: inherit; font-family: Symbol;"><span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}" style="box-sizing: inherit;">· <span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font: 7pt \&quot;Times New Roman\&quot;;&quot;}" style="box-sizing: inherit; font: 7pt &quot;Times New Roman&quot;;">       </span></span></span><span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-family: Arial, sans-serif;">Herkunftsland</span>
+======Radiologie:======
+* CT Schädel, ggf. MRT (Sensitivität des MRT besser als das CT für die Erkennung der basalen Inflammation bei TBC-Meningitis)
+* Röntgen-Thorax
-<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Symbol;&quot;}" style="box-sizing: inherit; font-family: Symbol;"><span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}" style="box-sizing: inherit;">· <span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font: 7pt \&quot;Times New Roman\&quot;;&quot;}" style="box-sizing: inherit; font: 7pt &quot;Times New Roman&quot;;">       </span></span></span><span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-family: Arial, sans-serif;">Frühere Tbc-Diagnose oder Therapie, Tbc-Fall im sozialen Umfeld?</span>
+======Liquor-Labor:======
+{| class="wikitable "
-<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Symbol;&quot;}" style="box-sizing: inherit; font-family: Symbol;"><span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}" style="box-sizing: inherit;">· <span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font: 7pt \&quot;Times New Roman\&quot;;&quot;}" style="box-sizing: inherit; font: 7pt &quot;Times New Roman&quot;;">       </span></span></span><span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-family: Arial, sans-serif;">Risikofaktoren:</span>
+|+
+|+Tabelle 1: Differentialdiagnostische Liquoranalyse
-*Malnutrition
+!
-*Immunsuppression
+!Normal
-*Andere Infektionen, v.a. HIV (Bei Erstdiagnose Tbc immer HIV Test)
+!Virale Meningitis
-*Chronischer Alkoholabusus
+!Bakterielle Meningitis
+!Tuberkulöse Meningitis
-======<span class="mw-headline" id="Radiologie:" style="box-sizing: inherit;"><span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-family: Arial, sans-serif;">Radiologie''':'''</span></span>======
+|-
-<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Symbol;&quot;}" style="box-sizing: inherit; font-family: Symbol;"><span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}" style="box-sizing: inherit;">· <span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font: 7pt \&quot;Times New Roman\&quot;;&quot;}" style="box-sizing: inherit; font: 7pt &quot;Times New Roman&quot;;">       </span></span></span><span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-family: Arial, sans-serif;">Röntgen-Thorax</span>
+!Aspekt
+|Klar
+|Klar
+|Trüb
+|Klar-trüb
+|-
+!Druck (cm H2O)
+|5-12
+|Normal oder (Pfeil nach oben)
+|>20
+|Normal oder (Pfeil nach oben)
+|-
+!Leukozyten (x 106/l)
+|1-4
+|< 1000 Lymphozyten
+|> 1000
+(> 70% Neutrophile)
+|< 1000
+(Mono- und Lymphozyten)
+|-
+!Glukose (% des Serumwertes)
+|50-80%
+|50-80%
+|< 40%
+|< 40%
+|-
+!Eiweiß (mg/l)
+|150-500
+|Normal oder (Pfeil nach oben)
+|>> 500
+| 500 > |
+|-
+!Laktat (mmol/l)
+|< 1,6
+|< 1,6
+|> 3,5
+|> 1,6
+|-
+!Direktpräparat
+|Negativ
+|Negativ
+|80% positiv
+|35% positiv
+|}
-<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Symbol;&quot;}" style="box-sizing: inherit; font-family: Symbol;"><span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}" style="box-sizing: inherit;">· <span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font: 7pt \&quot;Times New Roman\&quot;;&quot;}" style="box-sizing: inherit; font: 7pt &quot;Times New Roman&quot;;">       </span></span></span><span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-family: Arial, sans-serif;">Sensitivität MRT > CT für pathogene Tbc-Assoziation</span>
+======Mikrobiologie:======
+Goldstandard ist die Kultur auf Mykobakterien (deutlich sensitiver als Mikroskopie, ist in bis zu 50-70% positiv).
+Hierfür wird mind. 3 ml nativer (!) Liquor benötigt. Es wird bei den meisten mikrobiologischen Laboratorien nötig sein, diese Probe separat (!) mit einer eigenen Anforderung einzusenden. Unbedingt muss bei V.a. TBC-Meningitis (TBM) zusätzlich zur Kultur eine TBC-PCR aus dem Liquor angefertigt werden. Dies ist bei den meisten mikrobiologischen Labors aus der Probe für die Kultur zusätzlich möglich, muss aber ggf. extra angefordert werden (!). Bis das Kultur-Ergebnis mit der kulturellen Resistenzbestimmung für die Medikamente der Standardtherapie eintrifft, verstreichen meist 6 – 8, Wochen, im Extremfall länger [1-4, 6, 7].<br>
-<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Symbol;&quot;}" style="box-sizing: inherit; font-family: Symbol;"><span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}" style="box-sizing: inherit;">· <span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font: 7pt \&quot;Times New Roman\&quot;;&quot;}" style="box-sizing: inherit; font: 7pt &quot;Times New Roman&quot;;">       </span></span></span><span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-family: Arial, sans-serif;">Ggf. SPECT, PET</span>
+Bei positiver TBC-PCR ist es heutzutage Standard, dass zusätzlich eine molekularbiologische Analyse der Genabschnitte des Isolats in Bezug auf Isoniazid- und Rifampicin-Resistenz angefertigt wird (z.B. Xpert-MTB/RIF). Dies erlaubt eine schnelle Erkennung der für die Therapie wichtigsten Resistenzmechanismen, womit die Therapie angepasst werden kann, lange bevor das kulturelle Resistenzergebnis verfügbar wird [1].
-======<span class="mw-headline" id="Mikrobiologie:" style="box-sizing: inherit;"><span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-family: Arial, sans-serif;">Mikrobiologie''':'''</span></span>======
+{| class="wikitable"
-<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-family: Arial, sans-serif;">Liquor</span>
+|+ Tab.2. Empfohlene Diagnostik bei tuberkuloser Meningitis
-{| class="wikitable sortable mw-collapsible filterable MsoTableGrid" border="1" cellspacing="0" cellpadding="0" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; border-collapse: collapse; border-spacing: 0px; background-color: rgb(255, 255, 255); font-size: 14px; color: rgb(51, 51, 51); font-family: \&quot;Open Sans\&quot;, Roboto, arial, sans-serif; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial; border: none;&quot;}" style="box-sizing: inherit; border-collapse: collapse; border-spacing: 0px; background-color: rgb(255, 255, 255); font-size: 14px; color: rgb(51, 51, 51); font-family: &quot;Open Sans&quot;, Roboto, arial, sans-serif; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial; border: none;"
+|-
-|+
+! Bereich !! Empfehlung !! Kommentar
-| style="width:80.5pt;" width="107" valign="top" data-ve-attributes="{&quot;style&quot;:&quot;width:80.5pt;&quot;}" |
+|-
-| style="width:53.95pt;" width="72" valign="top" data-ve-attributes="{&quot;style&quot;:&quot;width:53.95pt;&quot;}" |'''<span class="ve-pasteProtect" style="color: black" data-ve-attributes="{&quot;style&quot;:&quot;color: black&quot;}">Normal</span>'''
+| Bildgebung || MRT Schädel mit Kontrastmittel, DWI/ADC, FLAIR, ggf. Gefäßdarstellung.
-| style="width:92.1pt;" width="123" valign="top" data-ve-attributes="{&quot;style&quot;:&quot;width:92.1pt;&quot;}" |'''<span class="ve-pasteProtect" style="color: black" data-ve-attributes="{&quot;style&quot;:&quot;color: black&quot;}">Virale Meningitis</span>'''
+ || Basale Meningitis, Hydrozephalus, Infarkte und Tuberkulome erfassen.
-| style="width:114.25pt;" width="152" valign="top" data-ve-attributes="{&quot;style&quot;:&quot;width:114.25pt;&quot;}" |'''<span class="ve-pasteProtect" style="color: black" data-ve-attributes="{&quot;style&quot;:&quot;color: black&quot;}">Bakterielle Meningitis</span>'''
+|-
-| style="width:112pt;" width="149" valign="top" data-ve-attributes="{&quot;style&quot;:&quot;width:112pt;&quot;}" |'''<span class="ve-pasteProtect" style="color: black" data-ve-attributes="{&quot;style&quot;:&quot;color: black&quot;}">Tuberkulöse Meningitis</span>'''
+| Liquor || Zellzahl, Differenzialzellbild, Eiweiß, Glukose plus Serumglukose, Laktat, Eröffnungsdruck || Zellzahl, Differenzialzellbild, Eiweiß, Glukose plus Serumglukose, Laktat, Eröffnungsdruck
-|- data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}" style="box-sizing: inherit;"
+|-
-| style="width:80.5pt;" width="107" valign="top" data-ve-attributes="{&quot;style&quot;:&quot;width:80.5pt;&quot;}" |<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;">Aspekt</span>
+| Mikrobiologie || Ziehl-Neelsen/Auramin, Mykobakterienkultur, Xpert MTB/RIF Ultra, Resistenzdiagnostik || Kultur langsam, aber für Resistenztestung essenziell.
-| style="width:53.95pt;" width="72" valign="top" data-ve-attributes="{&quot;style&quot;:&quot;width:53.95pt;&quot;}" |<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;">klar</span>
+|-
-| style="width:92.1pt;" width="123" valign="top" data-ve-attributes="{&quot;style&quot;:&quot;width:92.1pt;&quot;}" |<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;">klar</span>
+| Zusatzproben || Sputum/BAL, Urin, Lymphknoten, Biopsien, Blutkulturen je nach Kontext || Erhöht Diagnosechance und ermöglicht Resistenztestung.
-| style="width:114.25pt;" width="152" valign="top" data-ve-attributes="{&quot;style&quot;:&quot;width:114.25pt;&quot;}" |<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;">trüb</span>
+|-
-| style="width:112pt;" width="149" valign="top" data-ve-attributes="{&quot;style&quot;:&quot;width:112pt;&quot;}" |<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;">klar-trüb</span>
+| HIV/ Immunsuppression || HIV-Test, CD4, Viruslast, Kryptokokken-Antigen bei passender Klinik || Wichtig für DD, Prognose und ART-Timing.
-|- data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}" style="box-sizing: inherit;"
-| style="width:80.5pt;" width="107" valign="top" data-ve-attributes="{&quot;style&quot;:&quot;width:80.5pt;&quot;}" |<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;">Druck</span>
-<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;">(cm H<sub data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-size: 11px; line-height: 1; position: relative; vertical-align: baseline; bottom: -0.25em;&quot;}" style="box-sizing: inherit; font-size: 11px; line-height: 1; position: relative; vertical-align: baseline; bottom: -0.25em;">2</sub>O)</span>
-| style="width:53.95pt;" width="72" valign="top" data-ve-attributes="{&quot;style&quot;:&quot;width:53.95pt;&quot;}" |<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;">5-12</span>
-| style="width:92.1pt;" width="123" valign="top" data-ve-attributes="{&quot;style&quot;:&quot;width:92.1pt;&quot;}" |<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;">Normal oder</span> <span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-size: 11pt; font-family: Symbol;&quot;}" style="box-sizing: inherit; font-size: 11pt; font-family: Symbol;"><span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}" style="box-sizing: inherit;"></span></span>
-| style="width:114.25pt;" width="152" valign="top" data-ve-attributes="{&quot;style&quot;:&quot;width:114.25pt;&quot;}" |<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;">> 20</span>
-| style="width:112pt;" width="149" valign="top" data-ve-attributes="{&quot;style&quot;:&quot;width:112pt;&quot;}" |<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;">Normal oder</span> <span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-size: 11pt; font-family: Symbol;&quot;}" style="box-sizing: inherit; font-size: 11pt; font-family: Symbol;"><span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}" style="box-sizing: inherit;"></span></span>
-|- data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}" style="box-sizing: inherit;"
-| style="width:80.5pt;" width="107" valign="top" data-ve-attributes="{&quot;style&quot;:&quot;width:80.5pt;&quot;}" |<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;">Leukozytenzahl</span>
-<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;">(x 10<sup data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-size: 11px; line-height: 1; position: relative; vertical-align: baseline; top: -0.5em;&quot;}" style="box-sizing: inherit; font-size: 11px; line-height: 1; position: relative; vertical-align: baseline; top: -0.5em;">6</sup>/l)</span>
-| style="width:53.95pt;" width="72" valign="top" data-ve-attributes="{&quot;style&quot;:&quot;width:53.95pt;&quot;}" |<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;">1-4</span>
-| style="width:92.1pt;" width="123" valign="top" data-ve-attributes="{&quot;style&quot;:&quot;width:92.1pt;&quot;}" |<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;">< 1000</span>
-<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;">Lymphozyten</span>
-| style="width:114.25pt;" width="152" valign="top" data-ve-attributes="{&quot;style&quot;:&quot;width:114.25pt;&quot;}" |<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;">> 1000</span>
-<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;">(> 70% Neutrophile)</span>
-| style="width:112pt;" width="149" valign="top" data-ve-attributes="{&quot;style&quot;:&quot;width:112pt;&quot;}" |<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;">< 1000</span>
-<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;">(Mono- und Lymphozyten)</span>
-|- data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}" style="box-sizing: inherit;"
-| style="width:80.5pt;" width="107" valign="top" data-ve-attributes="{&quot;style&quot;:&quot;width:80.5pt;&quot;}" |<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;">Glukosegehalt</span>
-<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;">(% des Serumwertes)</span>
-| style="width:53.95pt;" width="72" valign="top" data-ve-attributes="{&quot;style&quot;:&quot;width:53.95pt;&quot;}" |<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;">50-80%</span>
-| style="width:92.1pt;" width="123" valign="top" data-ve-attributes="{&quot;style&quot;:&quot;width:92.1pt;&quot;}" |<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;">50-80%</span>
-| style="width:114.25pt;" width="152" valign="top" data-ve-attributes="{&quot;style&quot;:&quot;width:114.25pt;&quot;}" |<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;">< 40%</span>
-| style="width:112pt;" width="149" valign="top" data-ve-attributes="{&quot;style&quot;:&quot;width:112pt;&quot;}" |<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;">< 40%</span>
-|- data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}" style="box-sizing: inherit;"
-| style="width:80.5pt;" width="107" valign="top" data-ve-attributes="{&quot;style&quot;:&quot;width:80.5pt;&quot;}" |<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;">Eiweiß (mg/l)</span>
-| style="width:53.95pt;" width="72" valign="top" data-ve-attributes="{&quot;style&quot;:&quot;width:53.95pt;&quot;}" |<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;">150-500</span>
-| style="width:92.1pt;" width="123" valign="top" data-ve-attributes="{&quot;style&quot;:&quot;width:92.1pt;&quot;}" |<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;">Normal oder</span> <span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-size: 11pt; font-family: Symbol;&quot;}" style="box-sizing: inherit; font-size: 11pt; font-family: Symbol;"><span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}" style="box-sizing: inherit;"></span></span>
-| style="width:114.25pt;" width="152" valign="top" data-ve-attributes="{&quot;style&quot;:&quot;width:114.25pt;&quot;}" |<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;">>> 500</span>
-| style="width:112pt;" width="149" valign="top" data-ve-attributes="{&quot;style&quot;:&quot;width:112pt;&quot;}" |<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;">>> 500</span>
-|- data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}" style="box-sizing: inherit;"
-| style="width:80.5pt;" width="107" valign="top" data-ve-attributes="{&quot;style&quot;:&quot;width:80.5pt;&quot;}" |<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;">Laktat (mmol/l)</span>
-| style="width:53.95pt;" width="72" valign="top" data-ve-attributes="{&quot;style&quot;:&quot;width:53.95pt;&quot;}" |<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;">< 1,6</span>
-| style="width:92.1pt;" width="123" valign="top" data-ve-attributes="{&quot;style&quot;:&quot;width:92.1pt;&quot;}" |<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;">< 1,6</span>
-| style="width:114.25pt;" width="152" valign="top" data-ve-attributes="{&quot;style&quot;:&quot;width:114.25pt;&quot;}" |<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;">> 3,5</span>
-| style="width:112pt;" width="149" valign="top" data-ve-attributes="{&quot;style&quot;:&quot;width:112pt;&quot;}" |<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;">> 1,6</span>
-|- data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}" style="box-sizing: inherit;"
-| style="width:80.5pt;" width="107" valign="top" data-ve-attributes="{&quot;style&quot;:&quot;width:80.5pt;&quot;}" |<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;">Direktpräparat</span>
-| style="width:53.95pt;" width="72" valign="top" data-ve-attributes="{&quot;style&quot;:&quot;width:53.95pt;&quot;}" |<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;">Negativ</span>
-| style="width:92.1pt;" width="123" valign="top" data-ve-attributes="{&quot;style&quot;:&quot;width:92.1pt;&quot;}" |<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;">Negativ</span>
-| style="width:114.25pt;" width="152" valign="top" data-ve-attributes="{&quot;style&quot;:&quot;width:114.25pt;&quot;}" |<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;">80% positiv</span>
-| style="width:112pt;" width="149" valign="top" data-ve-attributes="{&quot;style&quot;:&quot;width:112pt;&quot;}" |<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;">35% positiv</span>
 |}
-<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-family: Arial, sans-serif;">Tabelle 1: Differentialdiagnostische Liquoranalyse</span>
-<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-family: Arial, sans-serif;">Goldstandard: Kultur auf Tbc (sensitiver als Mikroskopie, ist in bis zu 50-70% positiv). Dauer der Kultur bis 8 (-12) Wochen <span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}" style="box-sizing: inherit;">[8</span></span><ref><span style="font-size:12.0pt;line-height:107%;
-font-family:&quot;Times New Roman&quot;,serif;mso-fareast-font-family:&quot;Times New Roman&quot;;
-mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA">8.        Schaberg T, et al., Tuberculosis Guideline for Adults - Guideline for Diagnosis and Treatment of Tuberculosis including LTBI Testing and Treatment of the German Central Committee (DZK) and the German Respiratory Society (DGP). Pneumologie 2017; '''71'''(6): 325-397</span></ref><ref><span style="font-size:12.0pt;font-family:&quot;Times New Roman&quot;,serif;
-mso-fareast-font-family:&quot;Times New Roman&quot;">9.        Wilkinson RJ, et al., Tuberculous meningitis''.'' Nat Rev Neurol, 2017; '''13'''(10): 581-598</span></ref><ref><span style="font-size:12.0pt;font-family:&quot;Times New Roman&quot;,serif;
-mso-fareast-font-family:&quot;Times New Roman&quot;">10.        Ducomble T, et al., The burden of extrapulmonary and meningitis tuberculosis: an investigation of national surveillance data, Germany, 2002 to 2009. Euro Surveill, 2013; '''18'''(12)</span></ref><ref><span style="font-size:12.0pt;font-family:&quot;Times New Roman&quot;,serif;
-mso-fareast-font-family:&quot;Times New Roman&quot;">11.         in Tuberculosis: Clinical Diagnosis and Management of Tuberculosis, and Measures for Its Prevention and Control. 2011; London</span></ref><ref><span style="font-size:12.0pt;font-family:&quot;Times New Roman&quot;,serif;
-mso-fareast-font-family:&quot;Times New Roman&quot;">12.        Thwaites G, et al., British Infection Society guidelines for the diagnosis and treatment of tuberculosis of the central nervous system in adults and children. J Infect, 2009; '''59'''(3): 167-87</span></ref><span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-family: Arial, sans-serif;"><span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}" style="box-sizing: inherit;">-12</span></span><span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-family: Arial, sans-serif;"><span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}" style="box-sizing: inherit;">, 14</span></span><ref><span style="font-size:12.0pt;font-family:&quot;Times New Roman&quot;,serif;
-mso-fareast-font-family:&quot;Times New Roman&quot;">14.         Chin JH, Tuberculous meningitis: Diagnostic and therapeutic challenges. Neurol Clin Pract, 2014; '''4'''(3):199-205</span></ref><span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-family: Arial, sans-serif;"><span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}" style="box-sizing: inherit;">, 15</span></span><ref><span style="font-size:12.0pt;font-family:&quot;Times New Roman&quot;,serif;
-mso-fareast-font-family:&quot;Times New Roman&quot;">15.        Marais S, et al., Tuberculous meningitis: a uniform case definition for use in clinical research. Lancet Infect Dis, 2010; '''10'''(11): 803-12</span></ref><span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-family: Arial, sans-serif;"><span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}" style="box-sizing: inherit;">]</span>.</span>
-<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-family: Arial, sans-serif;">Xpert MTB/Rif, PCR zur Bestimmung von Tbc sowie Rifampicin-Resistenz, welches ein Hinweis für eine MDR-Tbc ist. Die Verlässlichkeit eines resistenten Ergebnisses (positiv prädiktiver Wert) ist abhängig von der Häufigkeit der Resistenz in der untersuchten Bevölkerung. Liegt die MDR-Rate, wie in Deutschland, unter 5%, sinkt der positiv prädiktive Wert auf unter 70% <span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}" style="box-sizing: inherit;">[1</span></span><span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-family: Arial, sans-serif;"><span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}" style="box-sizing: inherit;">]</span>.</span>
 ===<span class="mw-headline" id="Differentialdiagnose" style="box-sizing: inherit;"><span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-family: Arial, sans-serif;">Differentialdiagnose</span></span>===
-*Andere bakterielle Meningitiden (Neisseria meningitidis, Streptococcus pneumoniae, Haemophilus influenzae, Listeria monocytogenes, Streptococcus, agalactiae), Neuroborreliose
+*Andere bakterielle Meningitiden (''Neisseria meningitidis, Streptococcus pneumoniae, Haemophilus influenzae, Listeria monocytogenes, Streptococcus, agalactiae''), Neuroborreliose
-*<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-family: Arial, sans-serif;">Pilze: Candida spp., Aspergillus spp., Kryptokokkus spp.</span>
+*Pilze: ''Cryptococcus'' spp.
-*<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-family: Arial, sans-serif;">Parasiten: Echinokokkus spp., Toxoplasma</span>
+*Parasiten: ''Toxoplasma gondii''
-*<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-family: Arial, sans-serif;">Nicht-infektiös: Sarkoidose, tumorös (Meningiosis carcinomatosa)</span>
+*Nicht-infektiös: Sarkoidose, tumorös (Meningiosis carcinomatosa)
-<references />