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Ростовский Государственный Медицинский Университет

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Медицина общая

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Книга_2821_Библиотеки_им_академика_М_И_Перельмана

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prostheticvalveendocarditis,intravenousdrugendocarditis,andnosocomialendocarditis.

Thefollowingarethemainunderlyingcausesofnativevalveendocarditis:

Rheumaticvalvulardiseaseinvolvingthemitralvalvefollowedbytheaorticvalve Congenital heartdiseaseetiologiesincluding patentductusarteriosus,ventricularseptal

defect,ortetralogyofFallot Mitralvalveprolapse Degenerativeheartdisease,includingcalcificaorticstenosiscausedbyabicuspidvalve,

Marfansyndrome,orsyphiliticdisease

Approximately70% ofinfections in native valve endocarditis are caused byStreptococcus species, including Streptococcus viridans, Streptococcus bovis, and enterococci. Staphylococcusspeciescauseaboutaquarterofallcasesandfrequentlyareassociatedwitha moreaggressivecourse.

Infection associated with aortic valve prostheses is commonly associated with local abscessandfistulaformation,oftenresultinginvalvulardehiscence.Shock,heartfailure,heart block,shuntingofbloodtotherightatrium,pericardialtamponade,andperipheralembolito thecentralnervoussystemandelsewheremaylaterensue.

Diagnosisofinfectiveendocarditisinintravenousdruguserscanbedifficult.Two-thirds ofpatientshavenoprevioushistoryofheartdiseaseormurmur.Amurmurmaybeabsentin thosewithtricuspidinfectiveendocardialdisease,asaresultoftherelativelysmallpressure gradient across this valve. Pulmonary manifestations may be prominent in patients with tricuspid infection:one-thirdhave pleuriticchest pain,and three-quarters demonstratechest radiographic abnormalities. Staphylococcus aureus is the most common (50% of cases) etiologic organism in patients with intravenous drug infective endocarditis. Methicillin- resistant S. aureusaccounts for an increasing portion ofS. aureus infectionsandhas been associatedwithprevioushospitalizations,long-termaddiction,andpriorantibioticuse.Fungal infectiveendocarditisisalsofoundinintravenousdrugusersandintensivecareunitpatients whoreceive broad-spectrumantibiotics.Bloodcultures are oftennegative,anddiagnosisis frequentlymadeaftermicroscopicexaminationofsubsequentemboli.

Nosocomial infectiveendocarditismaybeassociatedwithintravasculardevicessuchas central or peripheral intravenous catheters, rhythm control devices suchas pacemakers and defibrillators,hemodialysisshuntsandcatheters,andchemotherapeuticandhyperalimentation lines. These patients tend to have significant comorbidities, more advanced age, and predominantinfectionwithS.aureus.Themortalityrateishighinthisgroup.

Ofall casesofinfectiveendocarditis, malesare morethanthreetimesatriskcompared withfemales.Infectiveendocarditishasnoracialpredilection.

LIVEDORETICULARIS

Livedoreticularisisaconditioncausedbyaninterruptionofbloodflowinthedermalarteries, resultingfromspasm,inflammation,orvascularobstruction,andisassociatedwithdiseasesof varying etiology and severity. It appears as a mottled, blotchy, reddish-violet reticulated

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discolorationoftheskin,oftenonthelegsorsolesofthefeet.Vascularobstructioncan,inturn, becausedbythrombosis,embolicevents,orvesselwallabnormalities.

Onoccasion,livedoreticularisissimplytheresultofbeingexposedtoacoldenvironment. Itmaybeasymptom,however,ofaseriousunderlyingcondition,suchasvasculardisease,an endocrine disorder, or a rheumatologic disease, such as systemic lupus erythematosus, polyarteritis nodosa, or rheumatoid arthritis. Livedo reticularis may also be related to a complication of kidney dialysis known as calciphylaxis. It may also result from certain medications,suchaswarfarin,andmedicationsusedtotreatmultiplesclerosis.

Livedo reticularis, without vasculitis or thrombosis, can also occur in systemic lupus erythematosus and rheumatoid arthritis. In suchcases, thecondition may be secondary to a slowing of the blood flow (caused by increased viscosity or thrombophilic states), to an intense vasoconstrictor reaction induced by cold, or to a combination of both these mechanisms.

Leftatrialmyxomasarebenigntumorsthatoriginateinendothelialcells.Atrialmyxomas are the most frequent cardiac neoplasm and typically present with fatigue, murmur, and

arrhythmias.17 Tumor fragments can break off, causing distal emboli and characteristic symptomssuchaslivedoreticularis,necrosis,distalcyanosis,andsplinterhemorrhages.

Livedo reticularis may also result from cholesterol emboli secondary to rupture of atheromatousplaquesintheaortaorothergreatarteries,eitherspontaneouslyorastheresult ofsurgical procedures,catheterization,angioplasties, angiography,or following initiationof treatmentwithanticoagulantsorthrombolyticagents.Skinlesionssecondarytothepresenceof emboliinskinarteriesandarteriolesareverycommonandtendtobeoneofthefirstsignsof cholesterolembolization(Fig.3-7).

FIGURE3-7.Livedoreticularis.

Vessel wall disorders can also result in livedo reticularis. Disorders of calcium and phosphorus metabolism in patients with advanced renal failure and secondary

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hyperparathyroidismcancausemetastaticcalcificationsinthearteries,softtissues,joints,and organs.Calciphylaxisreferstothecalcificationofthemediaofarteriesandcanresultinthe sudden appearanceoflivedo reticularis, hemorrhagicinfarcts, necrosis, and ulceration.The plaquesarewelldefinedandareextremelypainful;theconditionisoftenfatal.Thereisahigh riskofcalciphylaxiswhenthecalcium–phosphorusproductisgreaterthan65mgpermL.

CONGESTIVEHEARTFAILURE

SymptomsofCHFconsistofpalpitations,orthopnea,coughwithfrothysputum,jugularvenous distension, systolic murmurs, andrales onauscultationof thebase ofboth lungs. Left-sided heartfailureresultsinpulmonaryedemaandeventuallyprogressestoright-sidedheartfailure. Inthelowerextremity,amajorsignofCHFispittingedema.Pittingedemaoccurswhenthe hydrostaticpressureincreasesortheoncoticpressuredecreaseswithinthevasculature,forcing fluidintotheinterstitium.Thisformofedemacanbeidentifiedbypressingafingerinto the

swollenlowerextremityandanimprintcanbeobserved.18Pittingedemaisoftenpainfulwith associatedhemosiderindepositionandoftenresultsinulceration.AnothersignofCHFinthe

lowerextremityisdecreasedwalkingvelocity.Peperaetal.19showedthatpatientswithCHF have a shorter step length and walkmore slowlyand thatthesealtered gaitmechanics may contributetolimitedexercisecapacity.

NAILCHANGES

Nail findings may provide important clues to the diagnosis of systemic illness, limit the differentialdiagnosis,andfocusonfurtherworkup.

Clubbing,spooning,pitting,depressions,pigmentedbands,andcolorchangesmustalways beevaluated.

A Quincke pulse is one example of cardiac issues, specifically aortic insufficiency, presenting as changes in thenail bed. This manifestation represents regurgitant blood flow duringdiastoleinthecardiaccycle.Thisdecreaseindiastolicpressurecausesanincreasein strokevolumethatcanbeseeninthenailbedasalternatingblanchingandflushing.

ClubbingofthedistalfingersandtoesisaconditioninwhichLovibondangleisincreased andthenailseemstofloatinsteadofbeingfirmlyattachedtothenailbed(Fig.3-8).Thereisa thickeningof thesoft tissuebeneath theproximal nail platethatresultsinsponginess ofthe proximalplateandthickeninginthatareaofthedigit.Thedistalportionofthefingerortoenail mayappearenlargedorbulging.Theexactpathophysiologyremainsunknown,buttheoriesof vasodilation(causingdistended blood vessels) or oversecretion ofgrowth factors from the lungs (such as platelet-derived growth factor and hepatocyte growth factor) have been proposed.IthasalsobeenhypothesizedthattheoverproductionofprostaglandinE2fromother

tissuesisacausativefactorforclubbingofthedigits.20Itcandevelop quickly, often within weeks.Ifthecauseistreatable,clubbingmaydisappearquicklyaswell.Unfortunately,most

clubbing occurs as a result of pulmonary neoplasms.20 Clubbing may also be present in children with congenital heartdisease such as tetralogy of Fallot. Itis also seen in cystic

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fibrosis,chroniclunginfections,asbestosis,pulmonaryfibrosis,inflammatoryboweldisease, andHodgkindisease.

FIGURE3-8.Clubbingofdigits.

Koilonychiaisnotedbythepresenceoftransverseandlongitudinalconcavityofthenail, resultingina“spoon-shaped”nail.Althoughkoilonychiamayalsoresultfromtrauma,constant occupational exposure of the hands to petroleum-based solvents, or nail–patella syndrome, koilonychiahasbeenassociatedwithirondeficiency.Occasionally,koilonychiahasbeenseen inpatientswithhemochromatosis.

Pittingofthenailsappearsaspunctatedepressionsinthenailplate.Itisusuallyassociated withpsoriasis,affecting10%to50%ofpatientswiththatdisorder.Individualswithpsoriatic pittinghaveahighincidenceofpsoriaticbonedisease.

Transverse linear depressions inthe nail platehave been called Beaulines. Beaulines occuratthesamespotofthenailplateinmostoralloftheperson’snailsandmaybecaused byanydiseasesevereenoughtodisruptnormalnailgrowth.Knowingthatnailsgrowabout1 mmevery6to10days,thetimingofthediseaseprocessmaybeestimatedbymeasuringthe distancefromthelinetothenailbed.ThefindingofBeaulinesmayindicateprevioussevere illness,trauma,orexposuretocoldtemperaturesinpatientswithRaynauddisease.

Longitudinal pigmented bands are normal findings in the nails of dark-skinned persons, occurringinmorethan77%ofblacksolderthan20years.Thesefindingspresentadiagnostic problembecausetheymustbedifferentiatedfromsubungualmelanoma,whichalsooccursin olderagegroupsandconstitutes50%ofmelanomasindark-skinnedpopulations.

Colorandsizechangesinthelunulamaybeindicativeofchronicdisease.Inpatientswith

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Wilson disease (hepatolenticular degeneration), the lunula takes on a blue coloration, a phenomenon called azure lunula. Patients with chronic renal failure and increased melanin productionmaycausethedistalpartofthenailbedtoturnbrown.Heartfailurecanturnthe lunulared,andtetracyclinetherapycanturnityellow.Silverpoisoningwillturnthenailitself ablue-graycolor.Excessivefluorideingestioncanturnnailsbrownorblack.

InpatientswithTerrynails,mostofthenailplateturnswhite,andthelunulaisobliterated. Theconditionmay occurononlyonedigit,butmorecommonlyall digitsare affected.This conditionwasdescribedoriginallyinrelationtohypoalbuminemiasecondarytosevereliver disease, usually cirrhosis, with 80% of these patients having Terry nails. In patients with severe renaldisease,the proximal portionofthe nail bed often turnswhite,obliterating the lunula and giving a half-brown, half-whiteappearance, also called half-and-half nails, and alsoknownasLindseynails.SeventypercentofrenaldialysispatientshaveLindsaynails.

Differential cyanosis is a condition whereby the patient will have well-perfused pink upperextremitiesevidentbythepinkfingernails,whereasthelowerextremitieswillhaveboth cyanosisandclubbingofthetoes.Inadults,itiscommonlyseeninpatientswithpatentductus arteriosus when pulmonary hypertension has developed (right to left shunting of blood, or Eisenmenger syndrome). This occurs because venous blood shunts through the ductus and enterstheaortadistaltothesubclavianarteries.

Insummary,manyacuteandchronicpathologies thatmanifestinthelowerextremitycan provideimportantinformationregardingthegeneralhealthofthepatient.

REFERENCES

FowkesFG,RudanD,RudanI,etal.Comparisonofglobalestimatesofprevalenceandriskfactorsforperipheralartery

diseasein2000and2010:asystematicreviewandanalysis.Lancet.2013;382(9901):1329–1340.

HirschAT,CriquiMH,Treat-JacobsonD,etal.Peripheralarterialdiseasedetection,awareness,andtreatmentinprimary

care.JAMA.2001;286(11):1317–1324.

BhattDL,StegPG,OhmanEM,etal.Internationalprevalence,recognition,andtreatmentofcardiovascularriskfactorsin

outpatientswithatherothrombosis.JAMA.2006;295(2):180–189.

StegPG,BhattDL,WilsonPW,etal.One-yearcardiovasculareventratesinoutpatientswithatherothrombosis. JAMA.

2007;297(11):1197–1206.

Kownator S, Cambou JP,Cacoub P, etal. Prevalence ofunknownperipheral arterial disease in patients withcoronary

arterydisease:datainprimarycarefromtheIPSILONstudy.ArchCardiovascDis.2009;102(8-9):625–631.

RutherfordRB, Baker JD,Ernst C, et al.Recommended standardsfor reportsdealing with lower extremity ischemia:

revisedversion.JVascSurg.1997;26(3):517–538.

Aboyans V, Criqui MH, Abraham P, et al. Measurement and interpretation of the ankle-brachial index: a scientific

statementfromtheAmericanHeartAssociation.Circulation.2012;126(24):2890–2909.

AnkleBrachialIndexCollaboration,FowkesFG,MurrayGD,etal.AnklebrachialindexcombinedwithFraminghamrisk

scoretopredictcardiovasculareventsandmortality:ameta-analysis.JAMA.2008;300(2):197–208.

NewmanAB,ShemanskiL,ManolioTA,etal.Ankle-armindexasapredictorofcardiovasculardiseaseandmortalityin

thecardiovascularhealthstudy.Thecardiovascularhealthstudygroup.Arterioscler ThrombVascBiol. 1999;19(3):538–

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WildSH,ByrneCD,SmithFB,etal.Lowankle-brachialpressureindexpredictsincreasedriskofcardiovasculardisease

independent of the metabolic syndrome and conventional cardiovascular risk factors in the Edinburgh artery study.

DiabetesCare.2006;29(3):637–642.

AllisonMA,HiattWR,HirschAT,et al.Ahighankle-brachialindexisassociatedwithincreasedcardiovasculardisease

morbidityandlowerqualityoflife.JAmCollCardiol.2008;51(13):1292–1298.

LondahlM,KatzmanP,FredholmO,etal.Ischronicdiabeticfootulceranindicatorofcardiacdisease?JWoundCare.

2008;17(1):12–16.

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CrandallMA,BradleyDJ,PackerDL,etal.Contemporarymanagementofatrialfibrillation:updateonanticoagulationand

invasivemanagementstrategies.MayoClinProc.2009;84(7):643–662.

JohnsonJA,EverettBM,KatzJT,etal.Clinicalproblem-solving.Painfulpurpletoes.NEnglJMed.2010;362(1):67–73.

YeeJ,McAllisterCK.Osler’snodesandtherecognitionofinfectiveendocarditis:alesionofdiagnosticimportance.South

MedJ.1987;80(6):753–757.

GunsonTH,OliverGF.Osler’snodesandJanewaylesions.AustralasJDermatol.2007;48(4):251–255.

Bursztejn AC, BellutA,Weber-Muller F, etal. Erythematous macules onthe feet in acase ofcardiac myxoma. Acta

DermVenereol.2009;89(3):321–322.

Navas JP, Martinez-Maldonado M. Pathophysiology of edema in congestive heart failure. Heart Dis Strok e.

1993;2(4):325–329.

PeperaGK,SandercockGR,SloanR,etal.Influence ofsteplengthon6-minutewalktestperformance inpatientswith

chronicheartfailure.Physiotherapy.2012;98(4):325–329.

SarkarM,MaheshDM,MadabhaviI.Digitalclubbing.LungIndia.2012;29(4):354–362.

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Table4-1.

1.

2.

THEHOSTRESPONSETOINFECTION

Infectioncanhaveaprofoundsystemiceffectonthehumanbody.Intheeventofseverelower extremityinfections,sepsisandevendeathcanoccur.In1992,theAmericanCollegeofChest Physicians(ACCP)andtheSocietyofCriticalCareMedicine(SCCM)introduceddefinitions forbacteremia,systemicinflammatoryresponsesyndrome(SIRS),sepsis,severesepsis,septic shock,andmultipleorgandysfunctionsyndrome.Table4-1liststhedefinitionsforsepsisand

organfailure.

Infectioncanbedefinedasaninflammatoryresponsetothepresenceofmicroorganismsor theinvasionofnormallysterilehosttissuebythoseorganisms.1Bacteremiacanbedefinedas

thepresenceofviablebacteriaintheblood.Sepsisisdefinedasseveresystemicinflammation inresponsetoinvadingpathogens,oranuncontrolledhyperinflammatoryresponse.2SIRSis

the systemic responsetoaninfectiousornoninfectiousinsultandischaracterizedbytwoor moreofthefollowing:bodytemperature>38°Cor<36°C,tachycardia(>90beatsperminute), respiratoryrate>20breaths per minute, PaCO2 < 32 mm Hg, and leukocytosis (>12,000or

<4,000permm3)or10%immature(band)forms.Itisnonspecificastoetiology.Sepsis,onthe other hand, is defined as the systemic response specifically to infection, its criteria being

otherwiseidenticaltoSIRS.

DefinitionsforInfectionandSepsis

Infection

Theinflammatoryresponsetothepresenceofmicroorganismsortheinvasionofnormallysterilehosttissueby

thoseorganisms.

Bacteremia

Thepresenceofviablebacteriaintheblood.

SystemicInflammatoryResponseSyndrome

Thesystemicresponsetoinflammation,eitherinfectiousornoninfectious. Twoormoreofthefollowingconditions:

Temperature>38°Cor<36°C Heartrate>90beatsperminute

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3.

4.

1.

2.

3.

4.

Respiratoryrate>20breathsperminuteorPaCO2<32mmHg WBCcount>12,000permm3,<4,000permm3,or>10%immature(band)forms

Sepsis

Thesystemicresponsetoinfection. Twoormoreofthefollowingconditionsasaresultofinfection:

Temperature>38°Cor<36°C Heartrate>90beatsperminute Respiratoryrate>20breathsperminuteorPaCO2<32mmHg

WBCcount>12,000permm3,<4,000permm3,or>10%immature(band)forms.

SevereSepsis

Sepsisisassociatedwithorgandysfunction,hypoperfusion,orhypotension.Hypoperfusionandperfusion

abnormalitiesmayinclude,butarenotlimitedtolacticacidosis,oliguria,oranacutealterationinmentalstatus.

SepticShock

Sepsisinducedwithhypotensiondespiteadequatefluidresuscitationalongwiththepresenceofperfusion

abnormalitiesthatmayinclude,butarenotlimitedto,lacticacidosis,oliguria,oranacutealterationinmental status.Patientswhoarereceivinginotropicorvasopressoragentsmaynotbehypotensiveatthetimethat perfusionabnormalitiesaremeasured.

Sepsis-InducedHypotension

Systolicbloodpressure<90mmHgorareductionof>40mmHgfrombaselineintheabsenceofothercausesof

hypotension.

MultipleOrganDysfunctionSyndrome

Presenceofalteredorganfunctioninanacutelyillpatientsuchthathomeostasiscannotbemaintainedwithout

intervention.

ReprintedfromBoneRC,BalkRA,CerraFB,etal.AmericanCollegeofChestPhysicians/SocietyofCriticalCare MedicineConsensusConference:definitionsforsepsisandorganfailureandguidelinesfortheuseofinnovative therapiesinsepsis.CritCareMed.1992;20:864–874,withpermission.

PurpuraFulminansastheHostResponsetoSepsis

Sepsis is associated with multiple alterations in procoagulating and anticoagulating mechanisms,

4,5

whichmayleadtofull-blowndisseminatedintravascularcoagulation.

Sepsis-induced purpura fulminans (sometimes referred to as disseminated intravascular coagulation syndrome) is a relatively rare, multisystem disorder characterizedby cutaneous hemorrhagic infarction, occlusion of dermal venules and capillaries by microthrombi. Skin necrosismayultimatelyresultindry,gangrenouschangestothefingersandtoes(Fig.4-1).Itis causedbydisseminatedintravascularcoagulationanddermalvascularthrombosis.

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FIGURE4-1.Patientwithpurpurafulminans.Notegangrenouschangestobothfeetandtoes.(FromMarkKosinski,

DPM,FIDSA,withpermission).

Acuteinfectiouspurpurafulminanspresentsconcurrentlywith thesignsand symptomsof sepsis. Clinically, the patient with purpura fulminans has concomitant disorders including

septicemia,shock,anddisseminatedintravascularcoagulation.

Cutaneousnecrosisbeginswitharegionofskindiscomfortthatquicklyprogresseswithin hourstopetechiae,whichcoalescetoformecchymoses.7Purpuricskinlesionsdevelopover

the distalaspectsofthefeetandtoesandtendtobesymmetrical.Theselesionscanrapidly progresstohemorrhagic necrosis.Proximalextensionoflower extremitylesionsanddiffuse patchyinvolvementoftheabdomenandupperextremitiescanoccur.Vascularchangesarenot limited to the skin; thrombosis and hemorrhagic necrosis are also common in other organ systemsincludingthelungs,kidney,andadrenalglands,leadingtomultiorganfailure.

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Once thought to be the result of septic embolization, purpura fulminans is caused by enhanced expression of the natural procoagulants anddepletion ofthe natural anticoagulant

proteins,particularlyproteinC.6Sepsis-relatedpurpurafulminansisassociatedwithsevere, acute bacterial or viral infection, and has been most commonly associated with infections becauseofmeningococci,Neisseriameningitidis,Streptococcus pneumoniaeGram-negative bacteria, Haemophilus influenza, group A and B streptococci, Staphylococci and

rickettsia.

8–11

 The cutaneous lesions of sepsis-induced purpura fulminans are similar, regardless ofthe causative organism.Culturesofskinlesionsare usuallynegative, although bacterial colonization may occur with time. Amputation of the gangrenous portion of the

extremityafterdemarcationmaybecomenecessaryinseverecases.

12,13

DIABETICFOOTINFECTIONS

Diabetic foot infections (DFIs) are perhaps the most common and most limb-threatening infectiouscomplications of systemic disease. Itis estimated that approximatelyone in four people withdiabeteswill develop anulcer during their lifetime andthatasmanyashalfof

theseulcerationswilldevelopaninfection.14Approximately15%to20%oftheestimated16 millionpersonsin the United Stateswithdiabetes mellitus will be hospitalizedwith afoot

complicationatsometimeduringthecourseoftheirdisease.15Forthosewithdiabetes,ithas beenestimatedthatthelifetimeriskofdevelopingaDFIisabout15%to25%,althoughonly

abouthalfofDFIsareclinicallyinfectedonpresentation.

16,17

Treatment of DFIs, whether bone or soft tissue, should be conducted as part of a multidisciplinary approach,with tight control of blood glucose and revascularization when necessary.

MostofthewritingsonDFIthroughoutthe1980sandintotheearly1990swerebasedon studiesfromthe1970sthatseemedtosuggestthatallDFIswerepolymicrobial.Wenowknow thatmildlyinfecteddiabeticwoundsharborpredominantlyaerobicGram-positive cocci, not anaerobes.Staphylococcusaureus andGroupBStreptococcusare byfar the mostcommon pathogens in the infected diabeticfoot ulcerations.Unfortunately, thereis a seriousconcern about increasing ratesofmultidrug-resistant organisms (MDROs)ingeneral andmethicillin resistanceinS.aureusisolatesinparticular.

There havebeenmanyattemptstoclassifyDFIs.Probablythemostcommonly usedwas introduced by Wagner,18 which originally addressed only the dysvascular foot, but did not

adequatelyaddressalldiabeticfootulcerationsandinfections.

TheInfectiousDiseasesSocietyofAmerica(IDSA)PracticeGuidelinesfortheDiagnosis andTreatmentofDFIsisperhapsthemostwidelyusedtreatment-basedclassificationsystem

incurrentuseandhasbeenvalidatedasausefultoolforgradingfootinfections.19Thissystem canassisttheclinicianindecidingwhetherornotanantibioticisindicated,whichantibioticto choose,whentouseaparenteralversusanoralantibioticagent,whentohospitalizeapatient, and when to consider surgical intervention. Under these guidelines, DFIs are classified as beingmild,moderate,orsevere.

https://t.me/medicina_free

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02.09.202620 Мб0Книга_2812_Библиотеки_им_академика_М_И_Перельмана.epub
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02.09.202619 Мб0Книга_2815_Библиотеки_им_академика_М_И_Перельмана.pdf
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02.09.202619 Мб0Книга_2818_Библиотеки_им_академика_М_И_Перельмана.pdf
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05.09.202619 Мб1Книга_2821_Библиотеки_им_академика_М_И_Перельмана.pdf
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05.09.202618 Мб0Книга_2822_Библиотеки_им_академика_М_И_Перельмана.pdf
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31.08.202626 Мб0Книга_29_библиотеки_им_акад_М_И_Перельмана.pdf
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31.08.202625 Мб0Книга_30_библиотеки_им_акад_М_И_Перельмана.pdf