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I HC HU TRNG I HC Y DC HU

BNH TRUYN NHIM

B MN TRUYN NHIM 2008

Chng 1. I CNG
Bi 1.

I CNG BNH NHIM TRNG -TRUYN NHIM


BsCK2, Ths Phan Qun

Mc tiu
.1. M t c khuynh hng tn ti bnh nhim. .2. M t c nhim khun, sng k sinh, cc tnh cht c bn ca cc tc nhn gy bnh. .3. M t c cc hnh thi dch, ngun truyn bnh, cch thc truyn bnh. .4. M t c c ch gy bnh, c ch bo v c th i vi s xm nhp tc nhn gy bnh. .5. M t phm vi - mc nhim trng, c im lm sng,cn lm sng bnh truyn nhim.

Ni dung I. DN NHP
Mc du, trong nhiu thp k qua, y hc i mt bc kh di v nhng tin b trong iu tr v phng nga, nhng n nay bnh nhim cn l nguyn nhn t vong chnh v nh hng n iu kin sng ca hng triu ngi trn th gii. - Sau th chin th II c hng trm loi ho tr liu, khng sinh chng vi khun, virus, nm v k sinh trng rt hiu lc, an ton. Song li xut hin cc loi vi sinh vt khng thuc, thm ch mc bo ng. - Mt s bnh gn nh b tiu dit ti cc nc pht trin, nay bng pht li nhiu v nghim trng, nh : lao, thp khp. - Mt s tc nhn gy bnh trc y c mt v gy bnh nh, nay c nhng bin i v mt di truyn gy ra bnh nng hn, nh coronavirus hin gy ra SARS-CoV. - Mt s tc nhn trc y gy bnh cho ng vt nay xut hin ngi v c kh nng gy bnh nng nh Lin cu ln, A(H5N1). - Khm ph thm mt s tc nhn gy bnh mi: xon khun bnh Lyme, HIV/AIDS, vim gan do virus C, HGV.... Dn dn chng minh vai tr gy cc bnh mn tnh do cc tc nhn vi sinh vt; hin nay, chng ta bit c ch gy bnh mt s tc nhn n mc phn t. - Mt s bnh trc y khng ngh do cn nguyn nhim khun nay chng minh l vi khun nh: Helicobacter pylori gy nhim lot d dy t trng v c th gy ung th. - Mt lng ln bnh nhn ang c iu tr cc bnh nhim khun c mt tnh trng suy gim min dch. - Tng nguy c mc bnh nhim khun do k thut iu tr, tng tip xc vi tc nhn gy bnh trong bnh vin, vt rch da (vt m, chc tnh mch v.v...) hoc trn nim mc (t ni kh qun, thng bng quang), a vt thay th vo c th qua phu thut, thay i vi khun ch ng rut do dng khng sinh ko di.

II. NHIM TRNG - TRUYN NHIM


1. Nhim Trng & nhim khun Ni n nhim trng khi tc nhn gy bnh c th l virus, chlamydia, vi khun, k sinh trng, nm. Khi ni nhim khun tc cp nguyn nhn gy bnh l vi khun. 1.1.Nhim trng l g ? Nhim trng l hu qu gy ra gia tc nhn gy bnh vi phn ng c th ngi bnh khi tc nhn gy bnh xm nhp c th, hu qu ny nng - nh tu vo phn ng mnh - yu ca c th, bn cht ca tc nhn gy bnh, phn nh qua triu chng lm sng v sinh hc. 1.2. Sng k sinh

2 Tn ti sng chung ho bnh gia vi sinh vt v c th ngi, phn ln vi sinh vt tn ti da, nim mc c th khng vt qua hng ro bo v ny, nn khng gy bnh (t cu da, corynebacteries hng). Sng k sinh c li cho c th nh sinh tng hp (commenalism: sng cng sinh) nh: E.coli trong rut ngi gp phn vo s tiu ho thc n v tng hp vitamin K, hoc gip cho c th ngi c min dch t nhin vi mt s vi khun gram m khc. Khi cn bng sinh thi b ph v (nhim trng ni sinh), cc vi sinh vt mi biu hin vai tr sinh bnh, bng cch vt qua hng ro bo v xm nhp cc tng ph v gy bnh. 1.3.Tc nhn gy bnh - Vi khun: L mt t bo c nht c kh nng ti sinh mt t bo khc. - Chlamydia: Lp trung gian gia virus v vi khun, sng nh vo t bo k ch. - Virus: Tc nhn tn ti v pht trin bng cch ho nhp vo gene ca t bo k ch, khng th pht trin v nhn ln ngoi t bo sng ca k ch. - Nm bc thp: Vi sinh vt k sinh ngi v ng vt, t ti to nm mi bng chi. - K sinh trng: Sng l thuc vo c th ca mt loi khc. - Prion: (gii thiu bit) Tc nhn gy bnh khng qui c (khng c acid nucleique), cu to cc acid amin to ra chui peptide. Phng ty ngi ta nghi prion gy bnh xp no bn cp ngi c tn Creutzfeldt Jacob, v bnh mt ng gy t vong c tnh cht gia nh. Bnh thuc loi him, hng nm 1/106 c dn mc bnh. Nc ta, n nay cha tc gi no cp n trng hp mc bnh do tc nhn ny gy nn. 2. Truyn nhim Bnh truyn nhim l bnh c tc nhn gy bnh tn ti trong mt s vt ch (ngun truyn bnh) nht nh ly cho cc ngi nhy cm (cm th) qua ng xm nhp (ng vo), bnh ly trc tip hoc gin tip nh mt s yu t khc (vt trung gian). Bnh nhim trng l do vi sinh vt gy nn trn mt c th, trong khi bnh truyn nhim cng do vi sinh vt gy nn nhng ly lan lm nhiu ngi mc bnh. 2.1.Cc hnh thi dch t hc - Bnh l t ri rc (sporadic disease): ti mt a phng, mt thi gian di c vi trng hp bnh, nhng chng khng c mi lin h dch t hc. - Bnh dch nh: (endemic disease): cn gi l bnh lu hnh a phng. Ti mt a phng, c vi trng hp bnh ly lan d dng, c mi lin h dch t hc. - Bnh truyn nhim gy dch ln: (epidemic disease): y l loi rt d dng ly lan,mt thi gian nht nh c nhiu trng hp bnh, trn mt a bn gii hn. - Bnh truyn nhim gy i dch: (pandemic disease): bnh ly lan nhanh chng, nhiu ngi mc trn phm vi mt quc gia, mt lc a. a s bnh truyn nhim xut hin di dng dch nh - ln (endemo - epidemics). 2.2. Ngun truyn bnh: l ni tn ti t nhin ca tc nhn gy bnh. - Ngi l ni cha tc nhn gy bnh: ngi bnh, ngi lnh mang mm bnh. - Ngun truyn bnh ng vt: ng vt b bnh, ng vt lnh mang mm bnh; ng vt cn l vt ch trung gian ly truyn bnh cho ngi. - Vt th mi trng: t, nc, khng kh cng cha tc nhn gy bnh cho ngi. Cch ly ngun truyn bnh l nn tng phng nga bnh truyn nhim. 2.3.Cch ly truyn bnh - Trc tip Ngi ly qua ngi: bnh hoa liu, cm, lao. ng vt qua ngi: gp trong qu trnh chm sc ng vt hoc b ng vt cn. Hoc tip xc cc sn phm bnh l: phn, nc tiu, mu, nc bt hoc cc vt thng. l loi ly bnh khng qua mt khu trung gian no c. - Gin tip

3 Tc nhn gy bnh cho ngi qua trung gian mt cn trng, ng vt (rui, chut) hoc mt yu t vt th: nc, thc phm, khng kh, vi (formite). 2.4. ng xm nhp: rt a dng nh ng h hp, tiu ho, sinh dc, da, ng mu...

III. C CH GY BNH
Nhim trng l hu qu mt tc ng hai mt, mt bn l tc nhn gy bnh xm nhp c th v bn kia l phn ng c th ngi bnh i vi s xm nhp . Tc nhn gy bnh c kh nng sinh bnh tu vo bn cht ca chng. C ch bo v ca c th ngi nh n cc phng tin c th hc, phn ng c hiu hoc khng c hiu. 1. Kh nng sinh bnh ca tc nhn 1.1.Vi khun C 3 tnh cht gm: c tnh, to c t, to cc enzyme. 1.1.1. c tnh - S kt dnh, - Kh nng pht trin v nhn ln, - Khng li s thc bo. + Kt dnh: Mun xm nhp gy bnh trc ht vi khun phi dnh vo b mt ca t bo ch, theo mt c ch c bit, sau sau chng mi xm nhp c. + Nhn ln & pht trin: Loi vi khun pht trin v nhn ln trong t bo l k sinh ni bo tu , l vi khun lao, Brucella, Salmonella, Listeria, chng k sinh mt thi gian di hoc ngn trong t bo lin vng ni m hoc i thc bo, sau chng pht trin v nhn ln. Ngoi kh nng gy bnh, chng cn gy hin tng d ng hoc qu mn chm, kh nng sinh m km. Loi vi khun k sinh ngoi bo bt buc l cc vi khun nh t cu, lin cu..., chng c c lc mnh , c kh nng sinh m mnh, gy bnh nng. Nhng Riskettsia, Chlamydia nhn ln bn trong t bo k ch, l loi k sinh ni bo bt buc, kh nng sinh m km, nhng c tnh ca chng gy bnh ch yu l vim ni mc mch mu ti ni ng mch chia nhnh . + Khng li s thc bo: Khng thc bo gy bnh khc nhau tu loi vi khun. V d cc Salmonella typhi c khng nguyn Vi mi khng c s thc bo, nh c Vi m n dit cc tiu th thc bo (phagolysosome) ca i thc bo, cn vi khun Salmonella typhi khng c Vi th khng gy bnh c. 1.1.2. To ra c t l cht gy c i cho c th vi lng rt nh. - Ni c t (Lipopolysaccharide (LPS) ): vi khun gram m, nm trn thnh vi khun, khng nguyn O, c gii phng thch khi thn vi khun b tan, ng vai quan trng trong sc ni c t, ng mu ri rc ni mch. - Ngoi c t (protein): do vi loi vi khun tit ra, khuyt tn, gy hu qu khc nhau tu loi vi khun, i tnh thn kinh nh: c t un vn, bch hu v lp trng c (Botulism). - Mt s c t khc: + Toxin erythrogene: lin cu, i tnh mao mch da, gy dn mch-bong biu m da. + Exfoliatine: vi loi t cu, gy bong da. + c t tc dng t bo biu m rut gy a chy (Enterotoxin nh c t t,vi loi E. coli v t cu v.v...) 1.1.3. To ra nhng enzyme: Vi khun c kh nng to mt s enzyme, v d nh - Hemolysine: lm tan t bo - Strepotokinase: lm tan fibrin - Hyaluronidase: gy tan m lin kt, lm cho tc nhn gy bnh lan to trong m c th. - Streptolysin O,S: lm v mng bch cu, chng li s phng v ca c th ngi bnh. - Ngoi ra, chng c th to ra enzyme khng khng sinh nh Beta-lactamase, Acetylase, tu loi vi khun, c c hoc mt i do chu nh hng ca Plasmide, Transposons. 1.2.Virus

4 Virus gy bnh bng sinh bnh cho t bo k ch, bng phn ng to nn do c th k ch. Sau khi thm nhp c th virus vo mu v lun lu mt thi gian ngn, di tu loi virus (gi l virus huyt: viremia), tip n virus tn cng cc t bo ch, cc t bo y c receptor (tip th quan) c hiu vi chng virus gn ln b mt t bo, ri virus xm nhp vo bn trong t bo thc hin tin trnh sinh hc, nh vo cc Acid nhn ca t bo k ch sinh tng hp nhng tiu th virus mi hn. Kt qu lm bin dng v tiu hu t bo k ch ri gii phng nhng tiu th virus mi, sau xm nhp cc t bo ch khc. Mt s virus th hp tc vi b my di truyn ca t bo k ch, n tn ti mt thi gian di, t gy nguy hi n khi h min dch ca k ch b bin i, hoc b ri lon th n mi gy bnh vi triu chng nng, m v d in hnh nht l virus herpes. Mt khc, mt s virus gy nguy hi n h min dch ca c th, cho nn c th khng kh nng chng cc loi tc nhn vn khng gy bnh ngi bnh thng, l cc nhim khun c hi trong nhim HIV/AIDS. 1.3. Nm: Nm gy bnh nh 2 tnh cht c bn: - Xm nhp, nhn ln v pht trin trong m di dng si nm, lm nh hng n hot ng c quan b xm nhp. - Mt khc, trong qu trnh xm nhp c th gy ra phn ng qu mn qua min dch c th. 1.4. K sinh trng Kh nng gy bnh rt phc tp, a dng, chu k sinh hc ca chng c mt s giai on xm nhp c quan, tng ph vt ch, qua bin i hot ng c quan . Sng ni bo (k sinh trng st rt, Pneumocystis carinii). Sng ngoi bo (giun a, giun mc...). 2. Phng tin bo v ca c th i vi tc nhn gy bnh. 2.1. Ro chn c th hc 2.1.1.Lp da Vi khun ch xm nhp khi da rch, vt thng, bng, tim chch, hoc cn trng t, ng vt cn. Vi khun ch, pH acid ca da, cc acid bo c cc tuyn m hi tit ra, l cc yu t hn ch s xm nhp v pht trin tc nhn gy bnh (c bit, t cu ch yu da). 2.1.2.Nim mc - Nim mc h hp: nh c biu m lng rung ng v cht nhy nhm thi ra cc cht l c ht vo (k c vi khun). Nhng khng th IgA c chc nng chng li s kt dnh v xm nhp ca vi khun v virus trn t bo biu m, chng c th trung ho khng nguyn ti ch v dit khun. Lysozyme cng tham gia tiu dit vi khun, virus . - ng tiu ho : nh c vi khun ch, IgA, nhu ng ca ng tiu ho, cc cht tit nh acid d dy, mt c tc dng ngn cn s xm nhp ca tc nhn gy bnh. Ngoi ra hch hnh nhn (A) hng, cc mng peyer rut v rut tha l t chc bch huyt c tc dng ngn cn s xm nhp ca tc nhn gy bnh . - Nim mc mt, sinh dc, tit niu: Kh nng bo v thng km hn, cc lysozyme, pH acid ca ng thot tiu, m o, c kh nng chng li s pht trin ca tc nhn gy bnh. - Gim sc khng t nhin khi c thay i v c cu c th hc: + Ct 2 phn d dy, vt thng, vt bng, s xut hin tr cc ng thi trong c th ( si mt, si tit niu...). + a phng tin iu tr vo c th (sonde tiu, catether TM, van tim nhn to). 2.2.Phn ng ca c th: C th p ng tnh trng nhim khun vi phn ng khng c hiu - phn ng c hiu. 2.2.1. Phn ng khng c hiu: xut hin sm - Phn ng vim: p ng vim ca c th l quan trng trong vic chng li tnh trng nhim khun v thng biu hin thnh nhng du hiu v triu chng ca bnh. Nhim khun hnh thnh mt lot p ng phc tp ca k ch, lin quan n cc b th (C3a, C5a), cc kinin v nh hng n tin trnh ng mu ti ch. Kt qu nhng

5 bin i xy ra ti cc t bo ni mc mch mu, trn cc t bo ny hnh thnh cc Receptor cho cc t bo vim , lm cho cc t vim (cc bch cu) dnh vi cc t bo ni mc mch mu trc khi di chuyn qua thnh mch ti v tr nhim trng. Phn ng vim s to nn IL1, IL6, TNF (l cc cytokine) gy ra st, tiu protein ca c v gy hin tng xut tit, ph n, gin mch... IL8 c tc dng huy ng v hot ho bch cu a nhn trung tnh v to thnh cc p xe. Khi c th mt kh nng dit khun, vim thng nng hn . - S thc bo: Ti vim c s t tp bch cu a nhn trung tnh, i thc bo, thnh phn b th. Bch cu a nhn v i thc bo s thc bo vi khun, l hin tng tiu vi khun mt cch t nhin. Hoc c mt cc yu t c nh vi khun (opsonisant) nh b th v globulin min dch (phn Fc ca IgG) s c nh vi khun, sau , bch cu a nhn trung tnh s dit khun v tiu vi khun (nh c Lyzosome m thu phn v tiu vi khun). - i thc bo: Gm nhng monocyte tn ti di 2 dng: Tun hon trong mu, trong cc t chc ( trong ph nang, trong phc mc) hoc c nh ( gan,lch, hch) chc nng dit khun v thc bo ca chng th ging bch cu a nhn trung tnh, nhng i thc bo di chuyn chm hn bch cu a nhn v s thc bo ca chng l thuc rt t vo cc yu t c nh vi khun (opsonisant). Cui cng i thc bo ng vai tr thng tin khng nguyn cho cc t bo thm quyn min dch. - Vi yu t th dch khng c hiu: + Nh vai tr ca lysozyme. + H thng b th: L mt lot nhiu proteine (gn 30), to nn mt min dch khng khng c hiu, nhng cc globuline min dch c hiu khi pht s hot ho ca h thng b th. C 3 con ng hot ho h thng b th: * ng u tin l ng tt do ni c t v cc polysaccharide vi khun khi pht s hot ho b th. * ng th hai l ng c in do phc hp khng nguyn - khng th khi pht. Hai con ng ny, hot ho chui phn ng ca h thng b th dn n hnh thnh phc hp tn cng mng vi khun, to ra nhng l hng trn mng bo tng ca vi khun nhy cm do lm v vi khun (cc vi khun neisseria). V li, cc C3a v C5a c tc dng t tp bch cu a nhn trung tnh. * Con ng 3 c th do s c nh ca "protein gn vi ng manose" ln cc thnh phn ng thnh vi khun gy hot ho h thng b th. 2.2.2. Phn ng c hiu C bn l p ng ca h thng min dch ca c th ngi bnh i vi tc nhn gy bnh, l mt trng thi t nhin, tng t c mt vi ln nhim khun u tin thng qua c ch min dch th dch v t bo, min dch ny c c l nh chng nga. Trn lm sng, c khi phn ng min dch gy nn hin tng bnh l (thp khp cp). - Min dch th dch: l cc khng th, bn cht l glycoprotein, l nhng glubulin min dch, do cc Lymph B trng thnh to nn, lu thng trong cc dch th, c 5 loi (A,G, M, D,E), mi loi c tnh cht ring. + IgA: hin din trn b mt nim mc, c chc nng chng s kt dnh ca tc nhn gy bnh vi t bo nim mc v chng s xm nhp. + IgG & IgM: xut hin sm vo cui tun th nht ca nhim trng ln u v t nng cao tun th 3, c th tn ti n 3 thng (IgM). Khi IgM bt u gim th IgG mi bt u tng ln v tn ti nhiu nm sau. C hai c kh nng trung ho tc nhn gy bnh, c t v cc enzyme. Tu trng hp m cc khng th ny c kh nng ngng kt vi khun, ngng kt cc khng nguyn ho tan, c nh cc b th ln b mt cc tc nhn gy bnh.

6 S lin kt ca chng vi cc khng nguyn tng ng to thnh phc hp khng nguynkhng th khng ho tan v b h thng i thc bo tiu ho hoc phc hp min dch ho tan (cn gi l phc hp min dch lu hnh), phc hp ny c th c nh trn ni mc mch mu hay mng hot dch, to nn nhng phn ng vim xut hin trong vi bnh nhim trng (v d: thp khp cp, thp tim). + IgE: tham gia trong cc bnh d ng v k sinh trng. + IgD: tng ln trong cc nhim khun mn tnh nhng khng c hiu cho mt loi nhim khun no, c l IgD c vai tr nh l th th cho khng nguyn. - Min dch t bo: Gm vai tr ca Lymph T, i thc bo, t bo dit t nhin (natural killer cell), min dch t bo thng nhm chng li cc tc nhn gy bnh sng ni bo. C ch min dch ny l quan trng i vi nhiu tc nhn gy bnh bao gm hu ht cc virus v nhiu vi khun (Mycoplasma, Chlamydia, Listeria, Salmonella, HIV/AIDS), k sinh trng (Toxoplasma, Leishmania), nm (Histoplasma, Cryptococcus neoformans...). Loi min dch ny xut hin chm trong nhim trng ln u. Thng, khi c s hin din ca tc nhn gy bnh, Lymph B v Macrophage s hot ho Lymph T (lymph T ng vai tr ch o ca min dch t bo). Cc t bo T c hot ho, chng c th tn cng trc tip t bo vt ch c gn khng nguyn l; hoc, nh lymph T gip (T helper) gip kch thch t bo B to ra glubolin min dch, hoc gip Macrophage dit vi khun gy bnh, hoc kch thch cc t bo ADCC dit cc t bo mang khng th (antibody depending cytotoxic cellular: t bo c t bo l thuc khng th) Lymph T to cc cytokine nhm c ch s pht trin tc nhn gy bnh. Tm li: - S can thip ca min dch th dch gp trong a s trng hp, cn trong trng hp nhim vi khun k sinh ni bo tu hoc bt buc th vai tr min dch t bo l ch o. - Trng hp nhim virrus: trong giai on virus huyt th min dch th dch xut hin, nhng khi virus vo ni bo, th phn ng qu mn v gy c t bo (min dch t bo) l ch yu. Ngoi ra, Interferon do t bo nhim virus tit ra chng s xm nhp ca virus vo t bo mi, chng s sao chp v nhn ln ca virus (INF , , ). - Nhim nm cng xut hin min dch th dch v min dch t bo. - Nhim k sinh trng can thip bng c ch qu mn chm vi min dch th dch.

IV. V PHM VI V MC NHIM TRNG


1. Nhim trng ti ch Hin tng vim - nhim ch khu tr ti ng vo, cc triu chng vim ti ch gm nng, , sng, au, khng km triu chng ton thn nng n, trng thi chung ca ngi bnh gn nh bnh thng - mi sinh hot hng ngy khng b nh hng nhiu. 2. Nhim trng khu vc T v tr nhim trng khu tr lan ra mt khu vc theo ng tnh mch hoc bch huyt. Mc nhim trng pht trin nhiu hn so vi nhim trng ti ch. C cc triu chng nhim trng ti ch + cc triu chng ton thn do nhim trng khu vc gy ra, bnh nhn vn cn c th c gng c trong mt s cng vic. Tuy nhin, xut hin cc triu chng mt mi ton thn, au mi c khp, nht l khi c gng lm mt vic no mt hi th ngi bnh cm thy khng th lm tip na m phi i ngh. Bn cnh , cc triu chng nh st, nhc u, n lnh, r ri chn tay, n lnh, ming ng, bnh nhn c cm gic khng mun lm bt c vic g. 3. Nhim trng ton thn nh hng ton b c th, tc nhn gy bnh theo ng mu to nn cc triu chng mt s c quan v triu chng ton thn nng n hn nhiu, lc ny bnh nhn c th khng th c gng lm vic.

7 Tc nhn gy bnh c th to nn nhng tn thng trong khu vc chng xm nhp, nhng chng cng nh hng ti cc khu vc xa hn ca c th bng cc sn phm ca hin tng vim hoc phc hp min dch lu hnh.

V. HNH THI LM SNG V CN LM SNG


Da trn c s lm sng v cn lm sng, c th c dch t hc m ngi ta chn on c bnh nhim. Tuy nhin,nh nu trc c nhiu trng hp bnh khng biu hin lm sng, biu hin khng y cho nn rt kh chn on lm sng, thm ch rt kh xc minh bng xt nghim c hiu. 1.Hnh thi lm sng chung a s bnh truyn nhim din bin theo chu k, cc giai on nh sau: 1.1. bnh T lc tc nhn gy bnh xm nhp cho n khi triu chng lm sng khi u, thi gian ny tu thuc vo tng loi tc nhn gy bnh v phn ng ca c th. y l lng thi gian cn thit cho tc nhn gy bnh nhn ln v pht trin. 1.2.Khi pht Lc c triu chng ban u n khi c triu chng, l thi k phn ng c th y vi tc dng gy hi ca tc nhn gy bnh, ri hnh thnh triu chng lm sng v cc bin i sinh hc. Thng khi u vi st, c khi km rt run, v m hi, i khi km triu chng khu tr. Nu sp xp triu chng theo tun t cho ta nhiu gi chn on bnh thi k ny. 1.3.Ton pht Giai on m cc triu chng bc l tng i y . -Tng qut: st, rt run, v m hi,au khp, nhc u, mt ng, mt mi. - C nng v thc th: khi nhim trng khu tr, khu vc hoc lan to, s xut hin cc du hiu vim hoc nh hng ti c quan tng ph do hin tng vim, do nhim c hoc do min dch. 1.4.Thi k lui bnh - Khi bnh v thc th, c nng v sinh hc; bnh nhn c th hi phc li sc chm, nhanh tu loi tc nhn v th bnh lm sng v c th min dch bn hoc khng bn. - Khi bnh nhng c di chng li. - Khi bnh c th tm thi, c th ti li, do: + iu tr cha c y , tc nhn gy bnh cn tn ti. + nhim mt tc nhn tng t khng c min dch cho. + bt thng ca c th cha c khc phc. + thiu phng tin khng c hiu v khng c hiu. + tn ti vt l trong c th. - Bnh c th gy ra mt s bin chng. Trn y l hng din bin thun li, hoc c s can thip ca tr liu, bn cnh , c nhng trng hp qu nng, hoc khng thun li cho iu tr m bnh nhn c th t vong, mn tnh, iu ny cn tu thuc vo tc nhn gy bnh v bn thn sc khng ca c th, s can thip sm,mun thch hp hay khng . 2.Cn lm sng (c hiu - khng c hiu) 2.1. Du c hiu Nh c du c hiu m ta xc nh c cn nguyn gy bnh. C th soi cy trc tip, pht hin khng nguyn ho tan, pht hin khng th hoc cc on gene c hiu nh phng php khuyt i gene, hoc bng phng php min dch - pht hin khng th... 2.2. Du hiu khng c hiu Huyt hc: bch cu tng, bch cu gim, tng Lymph, tng Eosinophile. Mu: VS tng, Globulin tng, hin din CRP tng cao hoc khng (protein C phn ng), thay i vi thng s sinh hc...

8 Ngoi ra ngi ta cn c cc du hiu v hnh nh hoc siu m... Cu hi n tp 1. Hy lit k cc tc nhn gy bnh nhim trng, gii thch cc khc bit tnh cht gy bnh. 2. Hy m t tm tt cc c ch gy bnh ca vi khun. 3. Trnh by c ch bo v khng c hiu v c hiu ca c th chng bnh nhim trng. 4. M t phm vi - mc nhim trng v vn dng vo tnh hung lm sng c th. 5. M t din tin cc giai on lm sng ca mt bnh truyn nhim in hnh.

Bi 2.

NGUYN TC S DNG KHNG SINH TRONG BNH NHIM KHUN


Ts,Bs Trn xun Chng

Mc tiu
1. Phn tch c tm quan trng ca vic s dng khng sinh theo nguyn tc 2. Nhc li nhng im cn thit trc khi s dng khng sinh 3. Lit k c nhng nguyn tc chnh trong vic s dng khng sinh

Ni dung I. I CNG
1.nh ngha Thuc khng sinh c dng ch tt c nhng cht c ngun gc t nhin, tng hp v bn tng hp c th c ch hoc ph hy mt vi thnh phn cu vi khun. Nm 1928, Flemming pht hin nm Penicilium notatum dit c Staphylococcus aureus. Nm 1940, nhm nghin cu Oxford (Anh) gm Flory, Chain v Hartley tinh ch c penicilin v m ra k nguyn khng sinh tr liu bnh nhim trng. n nay c > 2000 cht khng sinh c xc nh, song ch mt s t (khong 50) c dng tr bnh ngi. 2.Tm quan trng ca thuc khng sinh Hin nay, bnh do vi khun cn l nguyn nhn chnh gy bnh v t vong trn th gii nht l nhng nc ang pht trin. Theo WHO (2005) bnh nhim trng l nguyn nhn gy t vong hng u tr em ti cc nc ang pht trin . Khng sinh l loi thuc c dng ph bin khp mi ni nht l nhng nc ang pht trin. Tuy nhin vn s dng hp l thuc khng sinh v d phng nhim vi trng trong cng tc chm sc sc khe ban u l ht sc quan trng nhm gim hin tng khng khng sinh, dit vi khun v t c mc tiu bo v sc khe cho mi ngi. Vn hin nay l khng khng sinh ngy cng gia tng i vi cc chng vi khun m trc y vn nhy, c bit Staphylococcus aureus, Salmonella typhi, v ngy cng tng vi Enterobacteriaceae. Chng ta bit, dng khng sinh ba bi d gy khng thuc. S khng khng sinh thng dng ca mt s vi khun thng gp sau y: (Ngun: B y t, Chng trnh gim st quc gia v tnh khng thuc ca mt s vi khun thng gp, 2003)
Vi khun SXT Amp Gen S. pneumoniae 45,0 8,7 H. influenzae 76,0 62,7 50,8 S. typhi 85,3 91,6 2,7 S.flexneri 90,1 59,8 S.aureus 21,0 28,8 E.coli 76,9 85,6 31,1 Bng 1: Mt s vi khun khng khng sinh theo t l phn trm Chl 18,0 31,8 86,2 59,8 50,4 82,8 Nor 20,9 18,9 0,0 0,0 46,3 21,0 Tet 45,9 032,7 14,8 92,9 55,2 82,3

II. PHN LOI THUC KHNG SINH


Nhiu cch phn loi khng sinh. Nh phn loi theo ph tc dng, phng thc tc dng 1. Phn loi theo ph tc dng C hai nhm l khng sinh c hot ph rng v khng sinh c hot ph chn lc.

10 1.1 Khng sinh c hot ph rng: Mt khng sinh c tc dng trn nhiu loi vi khun, c Gram dng v Gram m. Nhm aminoglycosid : streptomycin, gentamycin, amikacin Nhm tetracyclin Nhm phenicol Nhm sulfamid v trimetoprim 1.2 Khng sinh c hot ph chn lc Mt khng sinh ch c tc dng trn mt hay mt s loi vi khun nht nh. V d : Nhm macrolid: c tc dng trn vi khun Gram (+) v mt s trc khun Gram(-) nh erythromycin, roxythromycin, azithromycin Nhm polymycin hoc acid nalidixic: ch c tc dng trn trc khun gram(-). Nhm beta-lactam: gm c : Nhm penicilin: tc dng i vi vi khun Gram(+), b penicilinase phn hy. Nhm methicilin: tc dng i vi vi khun Gram(+), khng b penicilinase phn hy. V d cloxacilin, nafcilin Nhm ampicilin: hot ph rng, b penicilinase phn hy. V d : ampicilin, amoxicilin, pivampicilin Nhm cephalosporin: ph rng, b penicilinase phn hy. c chia thnh 4 th h. 2. Phn loi theo phng thc tc dng Ngi ta chia khng sinh thnh 2 loi : khng sinh c tc dng km khun v khng sinh c tc dng dit khun. Tuy nhin thc t khng c ranh gii r rng cho s phn bit ny v mt s khng sinh km khun nhng nng cao hn li c tc dng dit khun. Khng sinh c tc dng km khun: acid nalidixic, lincomycin, erythromycin, sulfamid, tetracyclin, trimethoprim Khng sinh c tc dng dit khun: aminoglycosid, cephalosporin, 5-nitroimidazol, penicilin, vancomycin, rifampicin

III. C CH TC DNG CA KHNG SINH


Sau khi vo c th, khng sinh ti ch tc ng s pht huy tc dng bng cch: - c ch sinh tng hp vch t bo vi khun : Vi khun sinh ra s khng c vch do d b tiu dit. V d khng sinh nhm beta-lactam, vancomycin - Gy ri lon chc nng mng nguyn tng, c bit l chc nng thm thu chn lc, lm cho cc thnh phn (ion) bn trong t bo b thot ra ngoi. V d polymicin - c ch sinh tng hp protein : im tc ng l ribosom 70S ca vi khun. kt qu l cc phn t protein khng c hnh thnh hoc khng c hot tnh sinh hc. - c ch sinh tng hp acid nucleic : Gm c : Ngn cn s sao chp ca ADN to ADN con. V d nhm quinolon c ch enzym gyrase lm cho phn t ADN khng m c vng xon. Cn tr sinh tng hp ARN nh rifampicin, gn vi ARN-polymerase l thuc ADN. - c ch sinh tng hp cc cht chuyn ha cn thit cho t bo. V d sulfamid v trimethoprim c ch qu trnh chuyn ha to acid folic-mt co-enzym cn cho vic tng hp mt s acid amin v cc purin, pyrimidin.

IV. NHNG C IM CA KHNG SINH


1. c tnh sinh vt hc 1.1.Hot tnh chng vi khun Khng sinh tc dng qua c ch dit khun (Bactericides): Beta - lactamines, aminosides, quinolones nh gi bng nng dit khun ti thiu v thuc khng sinh tc dng qua c ch km khun (Bacteriostatiques): Phenicoles, Cyclines, Macrolides v dn cht, nh gi bng nng c ch ti thiu. 1.2. S khng cu vi khun i vi khng sinh

11 Ngi ta phn bit khng t nhin v khng mc phi. khng t nhin c tt c cc vi khun cu cng mt loi v khng mc phi c vi chng ca cng mt loi. C ch cu khng c th do vic tit ra enzyme (Bta lactamase), s thay i v tr tc ng ca thuc chng nhim khun, s gim tnh thm ca mng t bo vi khun vi khng sinh hoc c ch plasmide hay s t bin. 2. c tnh dc hc ca khng sinh. Hiu qu v dc hc ca khng sinh c nh gi bi nng thuc trong huyt thanh v t chc, so snh theo thi gian sau khi dng thuc, qu trnh hp thu, phn b, chuyn ha v thi tr. T rt ra nhng thng tin v dc hc cn thit c lng, nh gi liu lng thuc v s ln dng trong ngy, liu thch hp bnh nhn vi kh nng bi tit v so snh thuc ny vi thuc khc. 2.1.S hp thu C th bng ng ung, ng tim bp hoc ng truyn tnh mch. 2.2.Phn b Sau khi hp thu , c hiu qu , nng ca thuc trong huyt thanh phi t c nng c ch ti thiu hoc nng dit khun ti thiu . Bi v hu ht nhim khun l ngoi mch mu , nn thuc phi phn b vo c quan b nhim khun. 3. Tc dng ph Vic hiu r tc dng ph ca khng sinh l mt phn trong vic la chn khng sinh khng gy nhng nguy c cho bnh nhn v kim tra kt qu iu tr: Tai bin do ri lon vi khun ch: vim i trng mng gi, tc dng ph ca thuc, tc dng ph do ng vo. Cn phi bit r tai bin do ng dng nh: apxe do tim bp, thuc gy kch thch tnh mch, tc nghn mch do truyn thuc liu cao ng tnh mch.

V. NGUYN TC S DNG KHNG SINH


1.Ch nh Khng sinh c ch nh trong bnh nhim khun, khng c ch nh trong nhim virus ngi khe mnh hoc tnh trng st n c. S dng khng sinh c gi l: - iu tr trong nhim trng do vi khun c ch im trn lm sng v vi khun hc. - D phng nh nhim trng trong hu phu, vim mng trong tim do vi khun, vim mng no do Meningococcus, thp khp cp. D phng nhim trng do vi khun.. D phng bng khng sinh ch dng trong mt s trng hp c th thc hin i vi mt nguy c nhim khun c th , cn mt khng sinh ph hp. Khng sinh d phng c th gy ri lon mi trng do gieo rc nhng mm bnh khng thuc. D phng ti pht ca bnh thp khp cp: Penicillin. D phng vim ni tm mc vi khun trn mt bnh nhn mc bnh tim , khi nh rng, phu thut tai mi hng ( penicillin chm ), thm d ni soi, phu thut bng, tit niu sinh dc (penicillin G hoc ampicillin + gentamycin). 2.Xc nh sm tc nhn gy bnh Da vo triu chng lm sng v xt nghim bnh phm nhum gram sm, l nguyn tc c bn, n gin, r tin, nn d chp nhn v t hiu qu cao trong chn la khang sinh. Sau , nui cy - lm khng sinh trc khi dng khng sinh. Nhum gram (dch no ty hoc m) hoc phng php pht hin khng nguyn trc tip (nh trong vim mng no) c th cung cp d kin dng khng sinh c hiu, trc khi c kt qu cy tm tc nhn gy bnh. Sau khi ly bnh phm cn cho thuc khng sinh ngay trong trng hp nhim khun nng, nhim khun huyt, vim cu thn, vim mng no, nhim trng ng tiu, nhim khun ngi suy gim min dch, lao, nhim khun bnh vin. 3.Chn thuc

12 Vic la chn ban u da trn phn tch mt vi tiu chun nh nhim khun khi im, tc nhn gy nhim, tnh trng bnh, c a bnh nhn, mc ch s dng: d phng, iu tr theo kinh nghim hoc iu tr sau khi xc nh tc nhn gy bnh. Ngoi ra cn phi cn nhc v c ch tc dng, c tnh dc hc, kh nng gy c v s tng tc ca thuc, hiu qu d an, s an ton, kinh nghim lm sng trc , gi thnh nu c, s khng v nhng nguy c lin quan vi bi nhim. bnh nhn c mt s yu t lin quan cn xem xt k nh c quan nhim khun, tnh trng min dch v kh nng o thi thuc 4.Phi hp thuc S dng khng sinh n c ni chung c hiu qu trong hu ht cc trng hp, vic s dng khng sinh kt hp p dng khi c nguy c ca s khng, t bin, nhim khun do nhiu loi vi khun nng. Mc ch phi hp khng sinh: Tm mt tc dng hp ng, phng nga khng khng sinh ca vi khun, m rng phm vi tc dng ca khng sinh, v d: iu tr theo kinh nghim hoc nhim khun do nhiu loi vi khun, c tc dng dit khun nhanh v y nh iu tr vim ni tm mc do Enterococcus hoc d phng vi khun khng thuc nh trong iu tr lao. Mt s nhim khun nh Lao, Brucella, Pseudomonas, hoc vi khun gram (-) c nhiu c ch khng qua t bin: Enterobacter, Serratia hoc nhim khun mt s ni nh vim ni tm mc, nhim trng no - mng no, nhim trng sau phu thut, vim mng bng, nhim Staphylococcus nng, bnh nhn gim bch cu... c th dng 3 loi khng sinh. 5.Liu lng v thi gian dng thuc 5.1.Liu lng - Liu c nh: Aminoside, Glycopeptide, Tetracycline , Macrolide, Fluoroquinolon. - Liu thay i: Bta lactamines ty mc nhim khun, nhy cm ca tc nhn v kh nng thm vo t chc . 5.2.Thi gian iu tr Thay i ty tc nhn, c quan b nhim khun v c a bnh nhn, nhng thng thng thi gian iu tr ko di 5-7 ngy . 5.3.Chn thuc khng sinh Ty thuc c quan b nhim khun: C quan b nhim khin c th gi vai tr chnh trong vic chn la thuc v liu lng khng sinh Bnh nhn nghi b vim mng no phi dng thuc c th thm qua hng ro mu no - nc no ty, thm vo thuc phi l dit khun nh Chloramphenicol . Kh nng thm ca khng sinh vo p xe l km Ngc li trong nhim trng ng tiu hu ht thuc c nng cao trong nc tiu hn trong mu , ngay c khi vi khun tm thy trong mu khng vi thuc nhng c th nhy cm vi nng trong nc tiu , nhng thuc ny c dng iu tr nhim khun ng tiu nh nitrofurantoin v mui methenamine. Trong vim ni tm mc do vi khun , chn khng sinh qua c ch dit khun v ng tnh mch dng thi gian di v liu cao m bo nng trong huyt thanh cao hn t nht 8 ln so vi liu dit khun ti thiu ca vi khun . 6. Tng tc thuc S tng tc khng sinh quan trng v lm sng nhng t c lu ti v trc kia bta-lactam l thuc hu nh c s dng nhiu nht, n t tng tc vi thuc khc ngi s dng. Tuy nhin, hin nay fluoroquinolone, macrolide, rifampin c dng rng ri hn cho nn tng tc thuc cng tng. S kt hp cc thuc khng phi lun lun gy hu qu lm sng quan trng, n ph thuc vo ng dng, liu dng v thi gian iu tr, nng huyt thanh ca thuc (khng phi khng sinh), s nhy cm bnh nhn i vi c tnh dc hc ca thuc, hoc cc yu t khc nh dng thng xuyn mt loi thuc.

13 7.S dng khng sinh mt s c a c bit 7.1.Tr em Thuc c thi qua thn chm hn ngi ln, trong iu kin thch hp nn s dng cc thuc nhm Bta-lactam: nh penicillin, ampicillin, y l nhng thuc sn c, d chi tr v r tin nn d c cng ng chp nhn. Khng nn s dng cc khng sinh sau: Phenicol, cycline (< 8 tui) quinolone (<15 tui). tr s sinh, nht l tr thiu thng, s dng khng sinh c th gy mt s tai bin do chuyn ho thuc mt cch bt thng: sulfamide v sulfamide chm, novobiocine. 7.2. Ph n c thai Cc thuc nhm Bta lactam: nh Penicillin, Ampicillin t gy c cho thai li l nhng thuc sn c, d chi tr v r tin, d c cng ng chp nhn, cc thuc khc c th gy qui thai trong 12 tun u hoc gy c cho tr trong qu trnh pht trin ca thai. Tuyt i khng dng Tetracycline, Aminoside, Phenicol, Rifampicin, sulfamide nitrofurantoin v dn cht cho ph n c thai nht l trong 3 thng cui cu thai k. S liu v s an ton ca nhiu loi khng sinh khc ph n c thai cn gii hn. Nhng thuc c th dng khi bt buc v nguy c bnh l aminoglycoside, azithromycin, imipenem, metronidazole, vancomycin. 7.3.Bnh nhn suy thn Trong nhiu trng hp cn gim liu i vi mt s khng sinh. - Khng sinh khng cn thay i liu: Erythromycin, Clindamycin, Chloramphenicol, Doxycyclin, Cefoperazon, Rifampicin, Metronidazol... - Khng sinh cn gim liu khi suy thn nng: Penicilin G, Amoxicilin, Cefalexin, Cefotaxim, Bactrim, Acid nalidixic, Ciprofloxacin... - Khng sinh cn gim liu khi c suy thn nh: Streptomycin, Kanamycin, Gentamycin, Vancomycin, Imipenem... - Khng sinh khng c ch nh dng khi suy thn: Tetracyclin, Nitrofurantoin, Sulfamid chm, Cephaloridin... 7.4. Bnh nhn suy gan Trnh dng cc thuc khng sinh nh Chloramphenicol, Lincocin, Clindamycin...v chng c thi tr v kh c u tin gan. Chloramphenicol d gy suy ty ngi suy gan. Tetracyclin c th lm tng transaminase bnh nhn vim gan siu vi. INH, Rifampicin c thi gian bn hy di bnh nhn x gan... 8. Theo di bnh nhn khi s dng khng sinh Theo di tai bin: Tai bin do ng vo, tai bin do liu lng, cch s dng thuc Theo di p ng thuc 9.Nhng iu cn trnh khi s dng khng sinh S dng khng sinh khng ng ch inh, s dng trn lan, cho rng khng sinh c th cha c mi chng bnh thng thng. Cu hi n tp 1. K tn cc phn nhm ca nhm Beta-lactam. Mi phn nhm nu tn mt khng sinh tiu biu ? 2. Nu nhng c ch khng khng sinh chnh ? 3. Nu c tnh dc hc ca cc thuc khng sinh ? 4. C s ca s la chn khng sinh iu tr mt bnh nhim trng ? 5. Nhng iu cn lu khi dng khng sinh tr em ?

14

Bi 3.

NHIM KHUN V SC NHIM KHUN


Ts, Bs CK1 Nguyn L

Mc tiu
1. Pht biu v phn bit c cc khi nim lin quan n nhim trng 2. Bit cch chn on, iu tr nhim trng nng, v sc nhim trng.

Ni dung I. MT S KHI NIM V NH NGHA V NHIM TRNG


D cha hon ton chnh xc, nhng thun li v mt thut ng, Hi Ngh 8 B mn Truyn nhim ca 8 trng i hc Y Vit Nam ti H long (Qung ninh) nm 2004 chp nhn thut ng Nhim trng bao gm nhim bt c vi sinh vt (VSV) no t virus cho n cc k sinh trng. T vi trng c thay bng t vi khun trnh nhm ln. Trong bi ging ny, chng ti tun theo quy c ny. V mt l lun, chng ta vn cn mt s chng cho ln nhau trong nhiu khi nim lin quan n nhim trng. trnh nhm ln, chng ti ngh mt s thut ng sau : 1. Mang trng Ch tnh trng c s hin din ca VSV ngi (hay vt ch), nhng ch mc dnh vo b mt ca da hay nim mc, cha xm nhp c qua lp biu b ca da v nim mc vo bn trong v khng gy phn ng bt li cho c th. Tnh trng t cu da, nim mc mi, E. coli trong ng tiu ha... l nhng v d. Trong trng hp vi sinh vt tuy cng ch bm v da v nim mc, nhng c th gy cc phn ng bt li, thm ch nguy him cho c th th vn xem nh l nhim trng. Nhim vi khun t ng tiu ha l mt v d. c th tn ti, VSV phi c kh nng bm dnh vo mt da v nim mc v khng li cc tc nhn st trng ti ch c ngay trn b mt da v nim mc. V d : tn ti c trn da, t cu phi c kh nng bm dnh vo lp thng b ( nhiu loi t cu c kh nng bm dnh rt mnh khng ch trn da m trn nn cc cht v c nh nha, kim loi... to nn nhim trng cc thit b y t nh catherter, ng sonde..), va phi c kh nng chng li nhiu yu t st trng trn da nh tnh axit ca m hi, cc cht lipid, cc khng th IgA tit ra theo cc tuyn nhy... Khi iu kin ti ch, hoc hng ro da v nim mc thay i, cc VSV ny c th xm nhp di lp biu b, v nu tn ti c, chng s tr thnh tc nhn gy nhim trng. Trong mt s trng hp, tnh trng mang trng ny dn n hin tng cng sinh vi vt ch. Khun ch ng tiu ha, m o ngn khng cho cc vi khun gy bnh pht trin. Mt s vi khun i trng to vitamin K cho c th... 2. Nhim trng Nhim trng xy ra khi VSV vt qua c hng ro da v nim mc, vo bn trong ni mi. Ngoi ra, nhng trng hp tuy ch mi bm dnh vo b mt ca da v nim mc, nhng c th phn ng bt li cho c th cng gi l nhim trng (nh cp phn mang trng)

15 Hin tng ny xy ra khi: - Hoc VSV c kh nng xm nhp c hiu qua da hay nim mc. V d : virus HIV c th xuyn qua nim mc mt, m o, nim mc trc trng nguyn vn vo bn trong c th. Tng hp tt c cc kh nng xm nhp vo ni mi v gy ri lon cho c th c gi l c lc ca VSV. - Hoc do chnh hng ro da v nim mc b thay i do nhiu yu t khc nhau ( xy xt, tn thng do c hc (rch da, nim mc do chn thng, do kim tim), ho hc (b n mn nh bng ha cht), nhit hc (bng), sinh hc (thay i hot ng cc t bo biu m h hp khi nhim lnh lm cc VSV vn ang b mt c th xm nhp bn di lp biu m..) 2.1. Nhim trng khng (hay cha c) triu chng Khi VSV xm nhp vo bn trong ni mi, nhng khng to nn mt phn ng no ca vt ch (ti ch hay ton thn, trc mt hay lu di) ta gi l nhim trng khng (hay cha c) triu chng. Khi nim nhim trng khng c triu chng t hu ch trn lm sng (nhng hu dng cho dch t hc), ch gii thch nhng trng hp tm c khng th c hiu cho mt VSV no (khng chng nga trc ) chng t c th tip xc v c min dch vi VSV ny, nhng khng h c mt biu hin no trong tin s. Khi nim ny thng dng khi nhim trng tim n cc VSV gy bnh cp tnh. Nhim vi khun thng hn khng c triu chng l mt v d. Vng trng huyt (c VSV trong mu, nhng khng gy mt phn ng no cho c th, d rng sau VSV c th n mt ni c tr mi v gy bnh ti c quan khc) l mt v d khc v khi nim ny. Khi nim nhim trng cha c triu chng c dng cho nhng VSV c kh nng gy bnh mn tnh, qu trnh gy bnh c th ko rt di. Hin ti ngi ta khng pht hin c mt ri lon no v lm sng v cn lm sng, nhng trong tng lai, c th c. V d : nhim virus vim gan B cha c triu chng. 2.2. Nhim trng c triu chng (mc bnh) Khi VSV xm nhp vo ni mi, to nn mt lot cc phn ng ca c th, tng tc cc phn ng gia vt ch v VSV, nu gy ri lon ni mi cho vt ch (d ti ch hay ton thn, cp hay mn tnh) ta c tnh trng mc bnh do nhim trng c triu chng. Hu qu ca cc tng tc phn ng ni trn c th c li cho c th ( tiu dit c VSV, to min dch lu di cho c th), nhng cng c th c hi cho c th ( tiu dit ngay cc t bo ca chnh c th c dnh dng n VSV, tn thng cc c quan khc do cc phn ng vim hay min dch gy ra). D c li hay c hi, trc mt, kt qu l lm ri lon cc hot ng bnh thng ca c th vt ch to nn cc triu chng c nng v thc th. Trong bi ny, khng cp n cc c ch kt dnh, ng vo ca cc VSV (cc bn c th tm c trong chng i cng v nhim trng) m ch yu ni n cc nhim trng c triu chng, nht l nhim trng c biu hin ton thn, nhim trng huyt v sc nhim trng.

II. MT S NH NGHA QUY C


Tuy cc nh ngha trn rt quan trng v mt l lun v gip ta hiu c bnh nguyn, bnh sinh ca qu trnh nhim trng (t kh nng kt dnh, xm nhp, c lc, phn ng vim, cc khng khng c hiu v c hiu ca c th cho n cc bnh t min khi pht bi nhim trng..), nhng trn thc t lm sng khng p dng c. Hi ngh v cc chuyn gia nhim trng ton th gii nm 1992 a ra mt s nh ngha mang tnh quy c, nhng c kh nng p dng thc hnh cao nh sau : 1. Vng trng huyt : C mt VSV trong mu (cy mu hay ko lam mu dng tnh) nhng khng c biu hin triu chng g trn lm sng.

16 2. Nhim trng huyt : C VSV hay c t ca n km theo ri lon ni mi, biu hin bng triu chng lm sng hay cn lm sng. 3. Hi chng p ng vim ton thn (systemic inflammatory response syndrome: SIRS): Khi c t nht 2 trong s cc triu chng sau : - St (nhit ly ming > 380 C) hay h nhit ( <36oC). - Th nhanh : Tn s th > 24 ln/pht. - Bch cu tng ( > 12.000 BC/mm3 mu ngoi vi) hay gim (< 4000/mm3) hay Bch cu ht (bands) chim > 10%. SIRS c th do nhim trng hay do mt nguyn nhn khng phi do nguyn no khc to nn. (Do tn hi chng ny kh di, chng ti ngh dng trc tip t vit tt SIRS nh ta vn quen dng AIDS trong nhim HIV) 4. Nhim trng c p ng ton thn (sepsis) Sepsis (chng ti ngh dng trc tip t ny nh trng hp ca SIRS) l SIRS c nguyn nhn do nhim VSV (chng minh c hay ch ang nghi ng). 5. Sepsis nng (hay cn gi l hi chng sepsis) Gm sepsis + cc triu chng biu hin ri lon chc nng mt hay nhiu c quan Gi l ri lon chc nng c quan khi c mt hay nhiu triu chng sau : 5.1. V tim mch : Huyt p tm thu 90 mm Hg hay Huyt p trung bnh 70 mm Hg v p ng vi truyn dch. 5.2. V Thn : lu lng nc tiu < 0,5 ml/kg/gi trong vng 1 gi d c truyn dch. 5.3. V h hp : t s PaO2/FI O2 250 hay nu ch c phi l c quan duy nht tn thng th t s ny 200 5.4. V Huyt hc : Tiu cu 80.000/mm3 mu hay gim 50% so vi ch s cao nht trong 3 ngy va qua. 5.5. V chuyn ha : C hin tng nhim toan chuyn ha khng gii thch c : pH mu 7,3 hay mc kim thiu (base deficit) 5 mEq/L hay lactate mu gp 1,5 ln tr s cao nht ca mc bnh thng. 5.6. V b dch : , biu hin bng p lc tnh mch trung ng 8 mmHg hay p lc ng mch phi bt 12 mm Hg 6. Sc nhim trng Gm sepsis + h huyt p ko di t nht mt gi d b dch . Sepsis + h huyt p. Ch duy tr c huyt p tm thu 90 mm Hg hay huyt p trung bnh 70 mm Hg khi c thuc vn mch. (H huyt p khi huyt p tm thu 90 mm Hg hay gim >40 mm Hg so vi huyt p tm thu bnh thng ca bnh nhn) 7. Sc nhim trng khng hi phc Khi sc nhim trng c h huyt p ko di trn 1 gi, khng p ng vi b dch hay cc thuc vn mch. 8. Hi chng ri lon chc nng a c quan (multiple-organ dysfunction syndrome: MODS) Khi c ri lon chc nng t hai c quan tr ln. Cn phi can thip mi gi c cn bng ni mi.

III. NGUYN NHN


Nguyn nhn ca nhim trng ton thn c th l bt k mt tc nhn VSV bt c lp no (vi khun, nm, k sinh trng..). Hin tng VSV c mt trong mu khng nht thit, cng khng gy nhim trng ton thn. Ngc li, khng cn n ton b bn thn VSV, ch

17 cn nhng phn t, nhng c t c ngun gc t VSV, ti ch hay lan to trong mu cng c th gy p ng nhim trng ton thn. Ngi ta ch pht hin c vi khun hay nm trong 24-40% trng hp c biu hin hi chng nhim trng (nhim trng ton thn nng) v 40-70% c sc nhim trng. a s l vi khun (gram m hay gram dng) chim 75-80% ; cn li l nhim nm huyt hay hn hp nhiu vi khun. nhng bnh nhn cy mu m tnh, thng tm thy tc nhn gy bnh ti ch. Tuy nhin, mt s trng hp, d biu hin lm sng ca hi chng nhim trng, thm ch sc nhim trng rt r, vn khng tm ra vi khun gy bnh.

IV. DCH T
Hoa k, ghi nhn nhim trng nng gy t vong > 100.000 ngi hng nm. Tn s mi mc ca hi chng nhim trng hng nm t 300-500.000 ca hng nm. Hn 2/3 trng hp nhp vin v nhng nguyn nhn khng nhim trng. Nhng yu t lm d qu trnh nhim trng gm: i tho ng, x gan, bng, c lm th thut xm nhp hay t thit b trong c th, iu tr cc thuc gy gim bch cu. Nhng yu t ch yu gy nhim trng huyt gram dng : t catheter tnh mch, t thit b c hc trong ngi, bng, nghin chch ma tu. Nhim nm huyt thng gp nhng ngi suy gim min dch, dng thuc gy gim bch cu, thng xy ra sau khi dng khng sinh ph rng. Tn s gia tng nhim trng huyt cn do tng tui th ca mt s bnh mn tnh, tng s bnh nhn nhim HIV/AIDS. X dng corticoide, khng sinh, t thit b nhn to trong ngi, th my cng l nhng yu t nguy c cao. Vit nam, cha c thng k c h thng. Tuy nhin, bt c khoa no, nhim trng huyt u xy ra, nht l khi c nhim trng mt c quan (thn, gan, phi.) khng c iu tr ng v kp thi. Nhim t cu t nhng nhim trng da khng c x l ng cng l mt nguyn nhn gy nhim trng ch yu vi khun gram dng nc ta.

V. SINH L BNH
Phn ng ca c th i vi nhim trng thng bt u khi VSV lan t ng tiu ho hay da vo cc m ln cn. Cc nhim trng ti ch c th a n vng trng mu hay nhim trng mu. Ngoi ra VSV c th trc tip vo mu qua ng tim chch. Trong nhiu trng hp khng tm thy nhim trng tin pht. Thng thng nhim trng ch xy ra khi VSV gy bnh vt qua c khng t nhin hay min dch ca c th. Nhng yu t ni ti ca c th gip cho vi sinh vt pht trin nh cc suy gim hay thiu khng th, b th, min dch trung gian t bo. 1. Cc tn hiu ca vi sinh vt Mt s phn t ca VSV c c th nhn din nh l tn hiu xm nhp ca VSV. Mnh nht v c nghin cu nhiu nht l ni c t c bn cht l lipopolysaccharide (LPS). Ni c t khi xm nhp vo mu s c mt protein ca c th gn vo v chuyn n cho phn t CD14 trn b mt cc t bo n nhn, cc i thc bo, cc bch cu a nhn trung tnh. Tng tc ny dn n sn xut v phng thch nhiu cht trung gian nh yu t hoi t u (tumor necrosis factor : TNF ), cht ny s khuych i cc tn hiu ca LPS n cc m v t bo khc. Cc phn t CD14 ha tan trong huyt tng cng s kt hp vi LPS v chuyn n cho cc t bo ni m ca mch mu, vn khng c sn phn t CD14 trn mng t bo. Mt s polysaccharide khc, mt s enzyme ngoi t bo, peptidoglycan v acide lipotechoic ca vi khun gram dng, mt s c t cng c kh nng kch thch cc phn ng c th tng t. Phn t CD14 v vy c th xem nh l th th nhn c nhiu tn hiu khc nhau ca vi khun, khi ng qu trnh phn ng c th khi c vi khun xm nhp. Cc c ch t c khc ca c th c kh nng nhn bit cc phn t ca vi sinh vt xm nhp gm: h thng b th (thng hot ho qua ng proverdin), protein kt hp vi mannose, protein C hot ha (C reactive protein : CRP). 2. Phn ng ca c th

18 p ng vi nhim trng ca c th l mt chui tng tc phc tp gia cc phn t pht tn hiu ca vi khun, cc bch cu, cc cht trung gian th dch v cc t bo ni m. 2.1.Cc cytokine Cc cytokin gy vim khuych i v lm bin i p ng. TNF kch thch bch cu v cc t bo ni m gii phng cc cytokine khc v ngay c chnh n, trnh din cc phn t kt dnh trn b mt cc t bo v tng cng chuyn ho acide arachidonic. nhng bnh nhn nhim trng nng, nng TNF rt cao. Hn na, trn thc nghim, khi truyn TNF c th to nn c nhiu triu chng c trng cho hi chng nhim trng v nhim trng huyt nh st, tim p nhanh, th nhanh, tng bch cu, au c, ng g. ng vt, liu cao TNF c th gy sc, ng mu ri rc lng mch v cht. Cht i khng c hiu vi TNF c th lm gim cc phn ng ca nhim trng v ngn nga c t vong ng vt b tim ni c t LPS. Tuy nhin, du ng vai tr quan trng nht, TNF cng ch l mt trong nhiu cytokine gp phn vo qu trnh nhim trng. Interleukin 1 chng hn l mt cytokin khc c nhiu phn ng tng t nh TNF , v cng ng vai tr quan trng hn khi tin trnh nhim trng cng nng. TNF, IL-1, interferon- v cc cytokine khc c l tng tc hp ng vi nhau v vi cc cht trung gian khc. Mt s cytokine nh TNF v IL-1 cn c kh nng kch thch sn xut ra chnh n theo c ch feed back dng. Khi qu trnh nhim trng nng hn, hn hp cc cytokine v cc cht trung gian khc tr nn rt phc tp. Ngi ta tm thy hn 30 phn t v tin phn t gy vim trng hp sc nhim trng. Trn thc nghim, ngi ta c th ngn chn phn ng nhim trng bng cch trung ho mt trong s nhng cytokine ni trn. Tuy nhin khi tin trnh tin trin, ngi ta khng cu thot c ng vt b nhim trng nng hay b sc nhim trng . 2.2. Nhng cht trung gian dn xut t Phospholipide Arachidonic acid, gii phng t phospholipide ca mng t bo do men phospholipase A2, s chuyn ho theo ng ca men cyclooxygenase to thnh prostaglandin v thromboxanes. Prostaglandin E2 v prostacyclin l nhng cht gy dn mch ngoi bin trong khi thromboxane gy co mch v kch thch ngng tp tiu cu. Mt cht trung gian c ngun gc t phospholipide cng quan trng trong nhim trng l yu t hot ho tiu cu (platele-activating factor : PAF). PAF kch thch mnh tp trung bch cu a nhn v phng thch cc cht cha trong ht ca cc t bo ny, kch thch ngng tp tiu cu, v c th lm tn thng cc m. 2.3. Nhng yu t ng mu Lng ng fibrin ni mch, to huyt khi v ng mu ri rc trong lng mch (DIC) l nhng c im quan trng ca p ng nhim trng. TNF gy ng mu ri rc trong lng mch theo c ch : Khi u, cht ny lm cc bch cu n nhn biu hin cc yu t m (tissue factors) ln b mt t bo. Cc yu t ny khi l ra s kt hp vi yu t ng mu VIIa thnh lp mt phc th hot ng c kh nng chuyn cc yu t X v XI thnh dng hot ng. Kt qu a n khi ng qu trnh ng mu ni sinh ln ngoi sinh, sau hnh thnh cc fibrin. Qu trnh ng mu cng c khi ng do h thng c ch ng mu ca protein C v protein S b tn thng. Hin tng tiu si huyt thng b c ch bi cht c ch hot ho plasminogen vn c nng cao trong qu trnh nhim trng.V vy c xu hng lng ng fibrin trong lng mch, to huyt khi v chy mu. Hot ho h thng tip xc lng mch (contact system) thng gy h huyt p hn l gy ng mu ri rc. 2.4. H thng b th Hot ho b th to nn cc sn phm cng vi C5a kch thch cc phn ng vi bch cu a nhn nh ho ng ng, tp trung, v cc ht trong lng bch cu, sn xut cc gc Oxy t do. Khi a vo ng vt thc nghim, C5a gy h huyt p, co mch phi, gim bch cu, tng tnh thm mao mch (mt phn do tn thng cc t bo ni m) 2.5. Hot ho t bo ni m

19 Nhiu m b tn thng trong qu trnh nhim trng. Cc ni m mch mu cng b tn thng, gy thm dch ra ngoi v to cc vi huyt khi trong lng mch, t cn tr qu trnh a oxy v c cht n cc t bo ca vng b nh hng. Cc cht trung gian ngun gc t bch cu, v cc huyt khi to bi si huyt, bch cu v tiu cu, cng c gp phn gy tn thng cc m, nhng vai tr ch yu trong qu trnh ny vn l t bo ni m mao mch. Cc cht kch thch nh TNF sn xut v phng thch cc cytokines, cc yu t tin ng mu, PAF, cc yu t dn mch (nitrite oxide) v cc cht trung gian khc. Ngoi ra, cc phn t iu ho kt dnh cng lm tng kh nng kt dnh ca bch cu vo ni m thnh mch. Trong khi cc phn ng ny lm tng kh nng thc bo ti vng vim nhim, hot ho cc kh nng khng khun ca c th, th s hot ho cc t bo ni m cng lm tng thm thnh mch, to huyt khi vi mch, ng mu ri rc v h huyt p. Hn na, thnh mch cn b tn thng bi cc enzyme ca bch cu a nhn (nh elastase) v cc cht chuyn ho trung gian c oxy gy c t bo, gy nn xut huyt cc b. Ngn cn qu trnh kt dnh bch cu vo b mt t bo ni m bng cch dng khng th n dng chng li yu t kt dnh 1 (intercellular adhesion molecule 1), c th phng c hoi t m khi tim ni c t vo ng vt thc nghim.

VI. LM SNG V THI X TR


Qu trnh nhim trng huyt thng khi u vi nhim tin pht, c khi r rng (nht da, vim ng mt cp, vim thn b thn..), c khi rt kn o khng thy ngay c. 1. X tr ban u 1.1.Nhng triu chng gi St, lnh run, mt mi ton thn. Him gp hn l nhng triu chng h nhit, suy tun hon cp, biu hin thn kinh trung ng (l ln, m sng, ri lon tm thn), vng da khng gii thch c. Nhng triu chng ny thng gp ngi ln tui. 1.2. Cng thc mu Thng cho thy tng bch cu, trong ch yu l a nhn trung tnh. 1.3. Cy mu Nn thc hin khi bnh nhn ang cao im cn st hay khi ang lnh run. Cy mu lp li t nht 3 ln trc khi cho khng sinh theo kinh nghim. Kt qu cy mu dng tnh s khng nh chn on nhim trng huyt sau ny. 1.5. Khm ton din - Tm ng vo ca vi khun : da, ng tiu, ng mt, tiu ho, phi hay tai mi hng. Trong trng hp nghi ng nhim trng bnh vin cn tm ng vo t cc ng tim truyn tnh mch, t cc thit b ng thng ng tiu, h hp hay ngoi da. - Tm nhng nhim trng th pht - Khm lm sng b sung vi cc xt nghim hnh nh hc (siu m, X quang, CT..) - Xt nghim vi khun ti nhim tin - th pht nu (+) dng khng sinh tr liu. 1.6. nh gi trm trng - Lu n c a (tui gi, bnh c sn trc , tnh trng suy gim min dch) - Bn cht ca ng vo v nhng khu tr th pht. - Tnh trng huyt ng. - Tnh trng thc. 1.7.Chn phng thc iu tr ban u Ch yu iu tr triu chng, bt buc nhp vin. iu tr bnh tim tng hay c trc, phng v iu chnh gim th tch. Cho khng sinh theo kinh nghim, da trn bi cnh khi u ca nhim trng v ph khng sinh, s nhy cm khng sinh ca vi khun theo tng a phng. X l ng vo (rt sonde, thay catheter, dn lu m..). 2. X tr khi c kt qu xt nghim 2.1. nh gi li khng sinh dng Tu theo kt qu vi khun v khng sinh .

20 2.2. nh gi hiu qu iu tr Da vo tnh trng ton thn, nhit , bch cu mu v cc nhim trng th pht. - Nu st vn tip tc sau 3 ngy iu tr, cn phi cy mu li. Cc kh nng c th: * Kt qu cy mu vn nh ln trc: Sai lm trong dng thuc (liu thp, thuc khng thm c vo nhim khun, tng tc thuc..), hoc nhim trng cha th dit ngay c sau 3 ngy: vim ni tm mc. * Kt qu vi khun ging nh cy ln u, nhng khng sinh khc: Vi khun t bin, tr nn khng thuc. Thng gp khi ch dng mt khng sinh (vi fluoroquinolone, fosfomycine, rifampicine, acide fusidique, cephalosporin th h 3) v hay gp i vi mt s vi khun nh t cu, P. aeruginosa, Enterobacter, Serratia, Citrobacter) * Cy mu c kt qu vi khun khc ln u : bi nhim. * Cy mu m tnh: nhim trng su cha dn lu, vim tnh mch vng tim truyn, nhim trng bnh vin km thm, d ng thuc, huyt khi tnh mch su

SC NHIM KHUN
L bin chng cp tnh, nng (c th t vong) ca nhim trng, c th cu c nu pht hin sm v iu tr ng nn chng ti tch hn ra thnh mt phn ring trong bi ny.

I. NHC LI NH NGHA
Nh ni trn, sc nhim trng gm : - Nhim trng c biu hin ton thn (sepsis ) - H huyt p: Huyt p tm thu < 90mm Hg hay gim hn 40mm Hg so vi huyt p tm thu lc bnh thng. Hoc huyt p ng mch (o trc tip bng thit b xm nhp vo ng mch ni vi mt monitoring). Khng tm thy l do no khc gy h huyt p. - H huyt p ko di t nht 1 gi b lng dch. Hay: Phi dng thuc vn mch mi duy tr c huyt p tm thu 90 mm Hg hay huyt p ng mch trung bnh 70 mm Hg Ranh gii gia nhim trng ton thn nng v sc nhim trng rt mong manh, v th iu tr tch cc nhim trng ton thn nng l mt hnh thc phng sc nhim trng. Bn cht ban u ca sc nhim trng l sc gim th tch, khng b dch kp thi cng vi iu tr nhim trng thch ng, s tin sang giai on sc lnh hay sc gim phn b mu (hypokinetic shock), gim ti mu cho m dn n toan mu, thiu niu, ri lon thc..).

II BNH NGUYN
1.Cc yu t khi u Gii phng cc thnh phn ca tc nhn gy bnh nh cc mnh ca vch t bo vi khun (peptidoglycan, axit techoic..), ngoi v ni c t (vi khun Gram m), trong thnh phn lipopolysaccharide (LPS) vi li trung tm lipide A c nghin cu nhiu nht. 2. ch tc ng 2.1. V th dch Hin tng hat ha b th, gii phng C3a v C5a v yu t ng mu XII. 2.2. V t bo Hot ha i thc bo, t bo n nhn, gii phng cc cytokin (TNF,IL1,IL6,IL8 ). 3. Hu qu Hot ha qu trnh ng mu, lin quan n nng ca tnh trang nhim trng. Hot ha cc bch cu trung tnh, dnh vo nhau v dnh vo t bo ni mc. Qu trnh ny a n hi chng ARDS phi.

21 Gii phng cc cht ca mng t bo nh acid arachidonic, cc gc t do v cc men thuc tiu th gy c t bo, lm tn thng t bo ni m mao mch, gy tng tnh thm mao mch v dn mch, trn lm sng biu hin bi sc gim th tch. Di tc ng ca ni c t v t bo ni m b tn thng, nhiu cht trung gian hot ha. Cng v v tr tc ng ca cc cht trung gian ny ln cc t bo (ri c quan), gii thch giai on lm sng, tin trin, kh nng hi phc hay khng ca sc nhim trng. Suy tun hon cp: L hu qu ca gim th tch tuyt i (dch thm ra ngoi lng mch) v tng i (lit mch do gim trng lc mch mu) v do tim khng b tr ni do tc dng inotrope (-) ca nhiu cht trong mu cha xc nh c.

III. LM SNG
C in ngi ta chia thnh 2 giai on: sc nng v sc lnh
Triu chng Sc nng (hyperkinetic) Nhp tim mch nhy mnh Huyt p Bnh thng, hiu p rng Du vn h (Marbrure) u gi Suy tim trn lm sng u chi Nng, kh, ti mu tt Nc tiu (t sonde theo di l tt) Bnh thng hay gim Bng 2: Phn bit sc nng v sc lnh trong sc nhim trng Sc lnh (hypokinetic) mch yu hiu p kp + + Lnh, vn cm thch < 20ml/gi

IV. X TR
1. Chn on sc nhim trng giai on sm thng rt kh chn on, tng ng vi giai on trc y gi l sc nng. Cn lu n cc triu chng nh khng c hiu nh : cm gic mt t ngt, kit sc, lo lng , thay i hnh vi bun nn, th nhanh. Huyt p s bo ng hay xc nh sc. Tuy nhin c trng hp sc xy ra t ngt vi triu chng nhim c nng ngay t u (t ban c tnh do no m cu) vi co mch mnh (sc lnh) Nu b kp v dch, thng hi phc nhanh v khng qua giai on suy tim Hin nay, lactate mu l mt xt nghim thng c x dng nghi ng c thiu Oxy ca cc c quan v c dng nh mt ch s chn on nhim trng biu hin ton thn nng v sc nhim trng. C th theo s sau y ( ca GS Bruyant Nguyn, i hc Loma Linda, Hoa k)

2. Xc nh bn cht sc v loi tr nguyn nhn khng phi nhim trng

22 Cn tm cc triu chng lin quan n nhim trng (hi chng nhim trng ton thn nng, nh hng ph tng, ng vo..). Tng hay h nhit, tng hay gim bch cu hay p ng vim ton thn, nu l du hiu duy nht th khng c hiu chn on nhim trng. 3. nh gi hu qu ca sc 3.1. Lm sng nh gi mc h huyt p, tun hon ngoi vi, chc nng thn (v niu, cn thm phn - chy thn nhn to), tnh trng phi (kh th, hi chng ARDS, cn th my), thn kinh (m kh qun, t sonde d dy, h hp h tr), tiu ha (chy mu, tc rut, vim i trng do thiu mu cc b). 3.2. Cn lm sng nh gi cc ri lon chuyn ha (Tng lactate mu > 2mmol/L, in gii , creatinin mu), chc nng gan ( mt, tiu t bo gan, suy gan), chc nng cm - ng mu ton b (DIC, tiu si huyt). 4. Xc nh nguyn nhn nhim trng Cy mu. Tm vi khun ng vo, cc nhim di tr (nhum soi, cy bnh phm). 5. Xt nghim khc ty theo gi lm sng.
C ch Nguyn nhn Nghn mch Thuyn tc phi mu v tim Suy tim Chn p do trn dch Nhi mu c tim Lon nhp Lm sng au ngc, suy tim phi, vim TM Mch nghch l, suy tim phi hay ton b au ngc, suy tim ton b Cn lm sng ECG, Phim phi, kh mu, phng x phi, chp mch mu phi ECG, siu m ECG, trophonin, siu m ECG Cng thc mu Amylase mu

Gim th tch Chy mu Xanh, chy mu ra ngoi tht s hay Phn v da, ph Quincke tng i Vim tu cp au bng Bng 3: Mt s xt nghim ty theo bnh cnh lm sng

V. IU TR C TH
Sau khi khm v cn nhc chn on mt cch nhanh chng, cn tin hnh iu tr ngay lp tc, khng ch i cc kt qu. 1. iu chnh huyt p Trc tin, phi b dch trong vng 20 pht, di hng dn ca p lc tnh mch trung tm. C th dng dung dch keo 500ml cho ngi ln hay 20ml/kg cho tr. Nu huyt p vn tip tc thp hay kp, hoc ci thin t, tip tc b dch ln 2. Nu vn tht bi, c th dng thuc vn mch nh Dopamin 10-20 g/kg/pht tng dn 2-5g/kg mi pht trong vng 10 pht. Nu khng c hiu qu, cn xem li tt c cc xt nghim lin quan nh hng iu tr. ngi ln, t sonde Swan-Gans theo di p lc ng mch phi v ng mch phi bt. Nu cc thng s chng t b dch cha , tip tc b dch. Nu c chng c suy tim, dng Dopamin 20g/kg/pht km Dobutamin 5-15 g/kg/pht. Nu khng ci thin c th dng Adrenaline 0,5-5g/kg/pht. tr em, qu trnh cng tng t, tuy nhin cn cn nhc khi cc thng s cho bit c th do lit mch. Trong trng hp lit mch, c th dng Noradrenalin (0,5-5g/kg/pht) km theo Dobutamin hay khng (5-15 g/kg/pht) hay ch dng mt mnh Adrenaline 0,55g/kg/pht. 2. iu tr nhim trng Nu thnh cng, x dng khng sinh theo kinh nghim v tip tc theo di, khi c kt qu khng sinh s iu chnh v tip tc theo di.

23 Cu hi n tp 1. Trnh by cc khi nim v mang trng, nhim trng c triu chng v nhim trng khng c triu chng. 2. Trnh by cc nh ngha theo quy c v hi chng p ng vim ton thn (SIRS), sepsis sepsis nng, h huyt p (trong nhim trng), sc nhim trng v hi chng suy a ph tng. 3. Phn bit vng trng huyt v nhim trng huyt. 4. nh ga t bo khng c cung cp oxy, trong sc hin nay ngi ta thng xt nghim thng s no? (gi s bn iu kin ca mt trung tm ICU hin i). 5. Trnh by li s chn on sepsis nng/sc nhim trng.

24

Bi 4.

ST KO DI CHA R NGUYN NHN


Ts, BsCK1 Nguyn L Mc tiu 1. Sinh vin bit v nm vng nh ngha quy c th no l st ko di cha r nguyn nhn. 2. Trong kh nng v phng tin sn c ty theo mi trng, c th x tr hp l trc mt trng hp st ko di cha r nguyn nhn.

Ni dung I. NH NGHA
Nm 1961, Petersdorf v Beeson nh ngha st ko di cha r nguyn nhn nh sau: - Nhit bnh nhn lun lun trn 38,2 C d o bt k lc no. - St ko di trong sut t nht 3 tun. - Tin hnh mi khm xt lm sng v cn lm sng trong phm vi c th c mt bnh vin, trong vng 1 tun vn khng tm ra c nguyn nhn. St ko di cha r nguyn nhn (SKDCRNN) v vy c th phn bit c vi nhng trng hp t to, thng c th chn an nhanh trong vng 24 gi. nh ngha ny c cng nhn v x dng rng ri trn ton th gii trong 30 nm v c xem nh l nh ngha c in. n nay, vi s tin b ca Y hc, Durack v Street ngh cch phn loi mi v st ko di cha r nguyn nhn nh sau:
Phn loi st ko di cha r nguyn nhn c im Ti bnh vin Gim bch cu Nhim HIV C in Tt c nhng ngi khc st ko di trn 3 tun Tnh trng bnh ang nm vin. nhn Khi vo khng st. ang cn sn sc c bit Thi gian t khi 3 ngy mc n khi khm bnh Mt s nguyn Vim tc TM nhn minh ha nhim trng, vim xoang, vim i trng gi mc, st do thuc BC trung tnh < Khng nh vi 500/mm3 hay l s Western Blot (+) gim xung mc ny trong vi ngy 3 ngy

3 ngy. Nu 3 ngy hay n ngoi tr l 3 khm 3 ln tip tun nhau (ngoi tr) Nhim trng. Bnh c tnh, cc bnh gy vim, do thuc.

Nhim trng Lao, lymphoma, quanh hu mn. do thuc ARV, Nhim nm nhim phc hp Candida, Mycobacteria Aspergillus khng in hnh

Bng 4: Phn loi st ko di cha r nguyn nhn

Tuy nhin trong bi cnh knh t -x hi v nn y hc ca nc ta, p dng nh ngha c in ca Petersdorf ph hp v thc t hn. V th trong bi ny, ch cp n st ko di cha r nguyn nhn c in.

25 Hi chng vim: Gi l hi chng vim cn lm sng khi c : VSS tng ( >16mm n ng, >25mm ph n theo phng php Westergreen, hoc >7mm nam gii, >16mm n gii theo phng php Wintrobe. Ngai ra, ngi ta cn lu rng mt s protein cng gia tng, ph bin nht l protein C phn ng (CRP).

II.CC BC CHN AN SKDCRNN


1. Tin s Hi bnh s v tin s cn thn l mt khu c bn trong chn an. Cn xc nh 7 im sau : - Cc thuc x dng - C i du lch u khng ? - C tip xc vi ng vt. - Ngh nghip - Li sng - Tin s bnh - Triu chng hin c. Mt s thuc c th gy st,nht l mt s khng sinh. Trong trng hp ny st bin mt trong vng 24 gi sau khi ngng thuc, v xut hin li khi thuc c tip tc dng. Du lch n nhng vng dch t ca st rt, st vng c th gi n cc bnh ny. Tip xc vi mt s ng vt c th l ngun gc ca mt s bnh c th gy st (bnh do Ricketsia, bnh Sodoku) Mt s ngh nghip c th to iu kin mc mt s bnh c st nh chn nui chim c th mc bnh st vt do Chlamydia Li sng cng nh hng n mt s bnh nh nghin ht c th dn n AIDS. Tin s c th gi cho mt nguyn nhn st. V d : tin s si mt gi n mt nhim trng ng mt. Nhng triu chng hin ti rt quan trng nh hng chn an. Tuy nhin theo nh ngha, cc triu chng khm c trong trng hp SKDCRNN thng rt ngho nn v khng cho php hng n mt cch r rt mt bnh no. 2. Phn tch din tin cn st Phn tch din tin cn st thng rt hu ch cho chn an. V d st thnh tng cn km theo run lnh thng xy ra trong nhng ca nhim trng huyt, st c chu k thng gp trong st rt 3. Khm lm sng t m v tan din Rt c ch cho chn an nguyn nhn st. Cn ch c st cn khng ? c ting thi tim khng ? (cnh gic vim ni tm mc), gan,lch, hch c ln khng ? Khm tuyn gip lai tr hoc cnh gac cc bnh v tuyn gip (cn bo gip ?) Khm k xoang ming, rng, tai mi hng tm cc bnh c th gy st vng ny, nu cn tham kho thm kin ca cc ng nghip v cc chuyn khoa ny. 4. Xt nghim cn lm sng : Ty theo trang b v phng tin ca c s. Tuy nhin, mt cch tng qut, trong tun u tin, ti thiu, chng ta phi kho st huyt , t bo vi trng nc tiu, cy mu. Ch cy mu phi c tin hnh trc khi cho khng sinh. Huyt thanh chn an thng hn, giang mai, Yersinia, c Brucellose nu c yu t dch t gi , v virus CMV, in di protein v calci mu. nh lng cc men transaminase, Phosphatase kim, phosphatase acid nam

26 gii. Chp X quang mt s c quan nghi ng c th b bnh nh phi, rng, xoangSiu m ni tng nh siu m gan, lch, tim cng cho php pht hin mt s bnh gy st (Vim ni tm mc bn cp chng hn). Kt qu ca mt s xt nghim cn phi l gii mt cch thn trng v khng thiu trng hp dng tnh gi. Cng nn lu rng nhng ngi gi, cng thc bch cu thng o ngc, phosphatase kim thng tng, yu t thp dng tnh mc du khng c bnh l g. Ngc li cn cnh gic nhiu trng hp m tnh gi. V d : Phim phi c th bnh thng trong nhiu tun trong mt ca lao ni tng tin trin. Trong nhng trng hp kh khn, i khi ta phi tin hnh mt s xt nghim gy phin phc, au n cho bnh nhn nh sinh thit, ty , ni soi, hoc nhng xt nghim tn km nh chp in tan ct lp 5. iu tr th Nhiu trng hp ta tin hnh iu tr th theo hng c nghi ng nhiu nht. Chin lc iu tr th thay i ty theo tng nc, ty theo tng a phng. V d nc ta, c th iu tr th st rt, thng hn, Trong trng hp nghi ng vim ni tm mc nhng cy mu m tnh, cng nn iu tr th vi khng sinh thch hp. 6. M thm d Nhiu trng hp c nhng triu chng nghi ng nhng khng xc nh c bn cht ca bnh ta c th m thm d. Tuy nhin cn phi cn nhc k lng, ng trn quan im v quyn li ca bnh nhn m quyt nh.

III. NHNG NGUYN NHN C TH DN N SKDKRNN


1. Nhim trng 1.1. Nhim trng tan th 1.1.1. Do vi khun - Nhim trng huyt do cc cu khun Gram dng : T cu, lin cu, ph cu. - Nhim trng huyt do cc vi khun Gram m nh Thng hn, E.coli,Listeria - Lu, giang mai - Leptospirose, bnh Lyme - Lgionellose - Dch hch v cc bnh do cc chng Yersinia khc - Lao - Nhim vi khun Whitmore - Bnh Hansen. - Ricketsia - Nhim Mycoplasma 11.1.2. K sinh trng - St rt - Toxoplasmose - Leishmaniose - Trypanosomiase - Cc bnh do giun sn (sn mng,amip ni tng..) 1.1.3. Nm - Nhim Candida - Nhim Cryptococcus

27 - Histoplasmose 1.1.4. Virus - Epstein Barr - Cytomegalovirus - HIV 1.2.Nhim trng ti ch 1.2.1. h tim mch - Vim ni tm mc - Vim mng ngai tim - Vim tc tnh mch (no, tnh mch ca..) - Phnh ng mch nhim trng 1.2.2. h h hp - Cc bnh vim phi, c bit lu n cc bnh phi co Chlamydiae, do Legionelle, do Pneusmocystis carinii - Vim mng phi c m. 1.2.3. bng - p xe gan - Vim quanh gan (do Chlamydiae) - p xe di c hanh - Vim ti mt, vim rut ha, vim ti tha Meckel, vim i trng sigma. - p xe lch - p xe thn, vim i b thn,Vim ty quanh thn. - p xe vng chu, vim vi trng, - Vim tuyn tin lit. 1.2.4. Thn kinh - p xe no - Vim mng no - Vim ngoi mng cng 1.2.5. Xng - Vim xng, vim xng-khp - Vim a ct sng 1.2.6. Vim xoang, vim li, rng. 2. Do u - Cc u lympho dng Hodgkin hay khng phi Hodgkin. - Ung th mu (leukemia) - Bnh Histiocytose - Cc khi ung th khc : tin pht nh K thn, K i trng, K phi, hoc t ni khc di cn n nh K gan - Cc u lnh tnh (U c trn ng tiu ha) 3. Cc bnh c bn cht vim. - Bnh Horton, bnh Takayasu - Vim mch mu hai t, bnh Wegener.

28 - Lupus ban ri rc. - Bnh vim c-b nhiu ni (Polydermatomyosite) - Thp khp cp - Vim a khp thp - Vim cng ct sng - Bnh Still - Bnh Crohn - Bnh Whipple - Sarcoidose - Bnh Bercet 4. Nhng nguyn nhn khc - Do thuc - Bnh huyt khi-thuyn tc - Vim gan do ru - Cng gip - U nhy - Cc bnh phi do lng ng min dch - Phnh ng mch ch - X ha sau phc mc - U x t cung (hai t v trng) - Ti hp th mt u mu - St gi v. Cu hi n tp 1. Phn bit st vi tng thn nhit c tnh (do say nng, say nng...). 2. Cc bnh nhim trng cp nguy him c biu hin u tin l st hay gp Vit Nam 3. Khi no th dng thuc h nhit trong mt trng hp st cp tnh? 4. Trnh by nh ngha c in v st ko di cha r nguyn nhn. 5. Trnh by cc nguyn nhn gy st thng gp trn mt s c a c bit: nhim HIV, gim bch cu ht.

29

Bi 5.

HI CHNG VNG DA TRONG CC BNH NHIM TRNG

BsCK2,Ths H th Thu Vng

Mc tiu
1.Trnh by c triu chng lm sng v cn lm sng ca hong m nhim khun. 2 .Chn on sm nguyn nhn gy hong m nhim khun. 3. Ch nh kp thi iu tr h tr v nguyn nhn. 4. Xc nh c cc bin php phng bnh

Ni dung I. I CNG
Hong m l biu hin lm sng ca tnh trng tng nng bilirubin trong mu trn mc bnh thng, to ra triu chng vng mt v da .Hong m nhim khun thng cn thit c mt chn on nguyn nhn khn trng nhm c bin php iu tr kp thi.

II. C CH HONG M
1. Tng sn xut bilirubin Do tn huyt nhiu hn bnh thng c th gp trong st rt, nhim trng huyt,... 2. Ri lan qu trnh thu nhn bilirubin vo t bo gan Gp trong vim gan nhim c do thuc (Rifamycin, novobiocin... ). 3. Ri lan qu trnh lin hp do thiu enzyme glycoronyl Gp trong vim gan, x gan, vng da tr s sinh. 4. Ri lan qu trnh vn chuyn bilirubin vo ng mt Gp trong x gan, vim gan nhim c thuc (INH, oestrogen, halothane... ). 5. Tng sinh ng mt - Vim gan qun mt - Tt nghn ng mt - Chn p ng mt: gp trong x gan, si mt, u ng mt, vim c vng odi, u u ty,

III. PHN LAI NGUYN NHN HONG M


1. Theo bilirubin mu 1.1.Tng bilirubin trc tip Nguyn nhn ch yu l cc bnh l t ng mt trong gan tr xung 2.2. Tng bilirubin gin tip Nguyn nhn c th l cc bnh l t t bo gan tr ln, nhng thng l trc gan 1.3. Tng bilirubin hn hp Thng gp trong vim gan cp hoc mn 2. Theo v tr 2.1. Hong m trc gan

30 Do hng cu v nhiu, gii phng nhiu huyt sc t. Nguyn nhn c th do :st rt, nhim trng huyt.... 2.2. Hong m ti gan Do tn thng t bo gan, lm cho mt cc vi ti mt qun d thm vo cc vi ti huyt qun, mt khc song song vi cc tn thng t bo gan, cc vi ti mt qun cng c th b tn thng, tit nhiu cht nhy, lm thnh nt nhy, gy tc cc vi ti mt qun . Nguyn nhn c th do: vim gan do virus, nhim xon khun, nhim trng mu .... 2.3. Hong m sau gan Do cn tr c gii trong hoc sau gan lm cho mt khng xung c ng tiu ha, li trong gan v thm vo mu. Nguyn nhn thng gp l tc mt do si

IV. LM SNG
1. Hi bnh 1.1. Tin s c nhn - Bnh l gan mt ( si mt ), tin s hang m tng thi k, cn au qun gan. - Ngh nghip: tip xc vi ha cht, sc vt, li vng m ly, sng sui. - Nhng thuc s dng gn y, ru - Tin s mi y: phu thut, sy thai, no ph thai, sinh , truyn mu hoc sn phm ca mu, mi n vng dch t st rt 1.2. Tnh cht ca vng da 1.3. Tin triu: Nhc u, au khp, ban 1.4. Du hiu i km: nga nhiu ( mt), au bng (si mt), au c (leptospirose) 1.5. Tin trin ca st: St cn c rt run kiu st rt, st gim khi xut hin vng da 2. Khm thc th: Nhm tm kim: 2.1. Cc du hiu nng ca bnh - S ri lan huyt ng: mch, huyt p, mu sc da, lng nc tiu. - S suy thoi t bo gan: hi chng xut huyt, bnh l no gan, din c ca gan gim, hi th hi mi gan ti. - Hi chng mng no kt hp thiu niu, v niu (leptospirose). - Nhng du hiu huyt tn cp ( da xanh, da nim mc nht, mch nhanh, lch ln...). 2.2. Cc du hiu khc -Tnh trng gan ( ln, mt , tnh cht, b mt gan, phn hi gan tnh mch c, ti mt ln). - Du hiu tng p lc tnh mch ca - Du hiu mt: da mt vng, nga, phn bc mu, nc tiu m mu, mch chm... 3. Cn thm khm mt cch tan th cho php ngi thy thuc c ci nhn tng qut

V. CN LM SNG
1. Bilan nhim trng Cy mu, cy nc tiu, chc d nc no ty nu c hi chng mng no. Tm k sinh trng st rt nht l khi c yu t dch t st rt Cc phn ng huyt thanh ty theo tnh hung 2. Chc nng gan, tnh trng mt - Hy hai t bo gan: SGOT, SGPT - mt: Tng bilirubin kt hp, phosphatase kim

31 - Suy t bo gan: t prothrombin gim, yu t V, fibrinogen, ng mu, albumin mu gim. 3. Huyt tn Tng bilirubin t do, t bo li, st huyt thanh, haptoglolin. Hemoglobin nc tiu (+). 4. Thm d v gan - Siu m gan: C ch li khi c hin din ca hi chng mt. - Chp ct lp:c th nh gi tnh trng ch m gan, ng mt, ty tng, lch, ti mt... - Chp ng mt: + Chp thng + C ung hoc tim thuc cn quang + Chp ng mt ngc dng + Chp ng mt trong khi soi bng - Ghi hnh gan bng ng vi phng - Soi bng - Sinh thit gan 5. Xt nghim min dch hc - Cc phn ng huyt thanh chn on vim gan siu vi nh :Tm HBsAg, anti-HBs, anti-HBc, anti-HBe, anti-HCV. - Cc khng th t mim nh khng th khng nhn, khng th khng c trn. - in di Globulin min dch.

VI. CHN ON NGUYN NHN


+ Chn on sm tin lng v iu tr kp thi v chuyn bnh nhn ng tuyn. + Cn phn loi cc nguyn nhn ca hi chng hong m: - Hi chng hong m do huyt tn: St rt, nhim trng huyt do vi khun k kh... - Hi chng hong m do tc mt: Si ng mt. - Hi chng hong m do vim gan: vim gan siu vi. + Chn on c mt s nguyn nhn gy hong m nhim khun thng gp: 1. Vim ng mt trong gan - Lm sng: tam chng: au, st, vng da mt. + au h sn phi hoc thng vi, au t nhin hoc khi n hay th su, au lan ln vai, thng km theo bun nn hoc nn ma + St cao t ngt, giao ng hay km rt run. + Vng da v nim mc kiu mt. Cng c nhng trng hp khng in hnh: khng vng da, khng au, ch st n thun. - Xt nghim: Bch cu tng, a nhn trung tnh tng, cy mu c th (+) (a s E.coli). Siu m: si ti mt, dn ng mt ch. V tr ch tc c th xc nh bng chp ng mt ngc dng. a s nguyn nhn l si, c khi l khi u bn ngoi hay trong ng mt, c khi do sn l gan, giun a... 2. Nhim trng mu Vng da gp khong15%, ch yu trong nhim trng mu do vi khun gr (-) bt ngun t ng tiu hoc t ng rut. Bn cnh bi cnh nhim trng huyt c th km theo hang m nhng mc khc nhau, gan to 30-50%, xy ra cng lc bt u ca nhim

32 trng huyt din bin trong 10-20 ngy song song vi tin trnh nhim trng, tin lng thng nng. Xt nghim: bilirubin kt hp tng km du hai t t bo gan hn l suy gan. 3. St rt Trong st rt thng c th c hang m nh, hong m r thng gp th st rt i Hemoglobin v st rt th gan mt 3.1. St rt i Hemoglobin + Lm sng: khi t ngt bun nn, nn ra dch nh mt, au vng hng, nhc u. thi k tan pht bnh nhn st lin tc hay tng cn, cn st i i vi t tn huyt. Nc tiu t ngt i thnh mu nu hoc nu en. Vng da l triu chng trung thnh ca bnh, xut hin t 6-12 gi sau khi i tiu en, lc u c th nh sau vng m tng dn, gan lch thng ln. Bnh c th a n thiu mu v suy thn, th nng t l t vong ln n 20-30% + Xt nghim: Hb niu (+),Hng cu niu (-), k sinh trng st rt (+) hoc (-) 3.2. St rt th gan mt Ngoi cc triu chng lm sng v cn lm sng ca st rt, bnh nhn c vng da v mt, tiu vng m, gan ln v au tc. Ri lan chc nng gan c th khng nghim trng lm, biu hin lm sng ca suy gan him gp. Trng hp nng bilirubin, SGPT, SGOT tng cao, thi gian Prothrombin ko di. 4. Nhim Leptospira L bnh ca sc vt hoang di v gia sc lan truyn cho ngi, c c im lm sng a dng, biu hin tn thng cng lc nhiu c quan, ch yu l gan, thn, mng no. Bnh thng gp vng nhit i, c bit vng nng thn, rung ry, khu chn nui. Lm sng bao gm 5 hi chng chnh, trong hi chng nhim trng l c bn + Hi chng nhm trng: St cao 39-40 t ngt, c th km rt run, mt nhiu, chn n, li b, au nhc lan ta, c bit au c d di t nhin v tng khi s nn nht l c bp chn, c i. Kt mc mt xung huyt, da c th ng do xung huyt. + Hi chng gan mt: vng da thng l mu cam ging mu lu chn, gan ln v au, i khi lch ln. + Hi chng thn: Ure, creatinin mu tng, nc tiu c albumin, hng cu, bch cu, tr niu. + Hi chng mng no: L biu hin quan trng trong giai an min nhim, dch no ty: bch cu tng a s lympho (50-100 mm3) + Hi chng xut huyt: Chy mu cam, ban xut huyt... 5. Vim gan siu vi Bnh thng gp ti gan do HAV, HBV, HCV, HDV, HEV, HGV... gy ra. 5.1. Lm sng Lm sng ca vim gan siu vi thay i, c th khng c triu chng hoc c th vng da v mt r, c khi din bin thnh th ti cp hay th mn tnh. Vim gan siu vi th cp in hnh din qua 4 giai an: + Thi k bnh: Thay i ty theo lai virus gy bnh + Thi k khi pht: St l du hiu thay i, thng bnh nhn st nh, mt mi, u oi, chn n,nhc u, au c, au khp ( thng gp trong vim gan siu vi B, C ) pht ban gp trong 5 - 15%, nn ma, au h sn phi, tiu t v m mu.

33 + Thi k tan pht: Bnh nhn ht st, mt mi v chn n hn. - Vng da - vng mt l du quan trng xut hin 4 - 10 ngy sau khi triu chng khi pht v ko di 2 - 8 tun sau gim dn, nc tiu m mu, phn bc mu, c th nga. - Gan ln va v au nh lc khm, lch c th ln trong 5 - 25% trng hp + Thi k hi phc: Bnh nhn cm gic khe, cc du hiu lm sng hu nh khng cn na, tuy nhin xt nghm chc nng gan cha tr v bnh thng, cn khang vi tun na mi c tnh trng hi phc v xt nghim. 5.2 Cn lm sng - Hi chng hy hai t bo gan: SGPT, SGOT tng 5-10 ln tr ln so vi tr s bnh thng, t l SGOT / SGPT < 1 - Hi chng mt: Bilirubin tng, ch yu bilirubin trc tip, sc t mt, mui mt nc tiu dng tnh. - T prothrombin bnh thng th thng thng, nu t l gim < 30% tin lng nng.

VII. IU TR
Cn iu tr h tr v iu tr nguyn nhn kp thi: 1. iu tr h tr Ty theo bnh cnh lm sng: - H nhit: Khng nn x dng mt cch h thng nht l khi cha tm ra nguyn nhn. - Chng chong nu c - Chuyn mu khi c thiu mu cp - Phng chng suy thn cp. 2. iu tri nguyn nhn - Nhim trng huyt, vim ng mt : Dng khng sinh. - St rt: Dng thuc khng st rt nh: Artesunate. Mefloqiune... - Nhim Leptospira :Khng sinh Penicillin 100.000 v/kg/ngy x 5 - 7ngy, Tetracyclin, doxycyclin 100mg x 2 vin/ngy X7ngy

VIII. PHNG BNH


Ty theo nguyn nhn Cu hi n tp 1. Trnh by c ch v phn loi vng da theo v tr 2. Trnh by cc du hiu nng ca hi chng vng da trong cc bnh nhim trng. Nu vi nguyn nhn ca cc du hiu nng ny 3. Nu mt s xt nghim chn on nguyn nhn thng gp ca hi chng vng da nhim khun 4. Trc mt bnh nhn c vng da cn hi g chn on nguyn nhn 5. iu tr h tr hi chng vng da nhim khun

34 6. Bi 6.

HI CHNG ST PHT BAN NHIM TRNG


Ts, BsCK1 Nguyn L

Mc tiu
1. Khm v ghi nhn y cc d kin lin quan n mt trng hp st pht ban. 2. C nh hng chn an v cho cc xt nghim cn thit xc nh nguyn nhn st pht ban.

Ni dung
C rt nhiu bnh c biu hin st v pht ban. Bn thn t ban cng bao hm nhiu hnh nh v mc thng tn khc nhau ( hu ht l tn thng mao mch hay phn ng ca da) biu hin da v nim mc. Do , st pht ban thng l mt cu kh khn cho ngi thy thuc lm sng. Tuy nhin a s nguyn nhn gy st pht ban l vi sinh vt, trong nh bnh sm s gip ch rt nhiu cho bnh nhn, ch t cng gim ly lan cho cng ng, v cao hn na , c th gip ngi bnh that cht trong mt s trng hp c chn an sm v iu tr ng nh ban xut huyt do no m cu. Cc hnh thc biu hin khc nhau ca cc lai ban s gip ngi thy thuc gii hn li cac nguyn nhn gy bnh, cng vi bi cnh lm sng v dch t, trong nhiu trng hp, c th cho chn an kh chnh xc trong nhng trng hp in hnh hay tm ra du c hiu.

I. MT S NGUYN TC KHM MT BNH NHN ST PHT BAN


1. Mt s vn cn lu - Tnh trng min dch hin ti ca bnh nhn. Tin s v chng nga. - Cc thuc x dng trong vng mt thng trc ngy c ban. - C tip xc vi ng vt g ? ( vt nui hay ngai nh). C b ng vt hay cn trng t ? - Du lch : c n vng no c cc bnh a phng c bit ang lu hnh ? - C tip xc vi ngi no c bnh tng t ? - C nguy c mc bnh ly qua ng tnh dc ? - Bnh nhn c chch ma ty v dng chung kim tim vi ngi khc khng ? - Bnh nhn c bt thng hay bnh tim mch ? Bnh nhn ang dng thit b tr gip nhn to no trong ngi ? ( van tim nhn to, catheter..) 2. Khm biu hin ban 2.1. Phn lai ban - Ban khng xut huyt (thng gi l ban , hng ban) - Ban xut huyt ( t ban : purpura) - Ban dng bng nc hay mn m. 2.2. Ban ni ln th no so vi b mt da ? (hnh thi ni dy: eruption) - Dt (macule): nm phng so vi mt da, vng thay i sc t gii hn tng i r.

35 - Sn (papule) : ni ln khi mt da, ng knh ban < 5mm - Mng (plaque) : ni ln khi mt da, ng knh > 5mm. C dng cao nguyn, b mt phng sau khi nh ln khi mt da. - Nt (nodule) : ni khi mt da, ng knh > 5mm, nhng b mt cong, khng phng nh mang. - My ay (wheals hay urticaria, hives) : dng sn hay dng mng. C th tp hp li thnh dng vng hnh nhn. My ay c in ( khng do mao mch) thng ch xut hin 24-48 gi ri ln. - Mn nc : vesicule ( < 5mm) v bng nc : bullae (>5mm) : nhng ti c cha dch ni ln khi mt da. - Mn m (Pustule) : l mn hay bng m dch cha l m. - T ban chm : khng s thy g ln mt da, do xut huyt. Gm: ban xut huyt lm tm (Petechiae) khi ng knh < 3mm v mng xut huyt (echymose) ng knh > 3mm. - T ban ni: g ln mt da, do vim thnh mch mu (vasculitis), sau xut huyt. 2.3. Mt s vn khc Cng cn xc nh thi im xut hin ban so vi st v mt s triu chng khc. Xc nh v tr xut hin u tin, c tnh khu tr hay lan tan thn. C i xng ? Qu trnh lan t thn ra t chi hay ngc li. Tc lan ca ban (nhanh hay chm). Trn cng mt vng, ban mc cng ln hay ln lt ? c cc ban cc tui khc nhau khng ? C ni ban trong nim mc cc xoang t nhin ? C li so hy du vt g trn da khi ban mt i khng ? 2.4. Khm tan din Khm tt c cc c quan v h thng khc pht hin cc triu chng khc. i khi rt quyt nh chn an nguyn nhn ( Du Koplik trong si..)

II. PHN LAI V MT S C IM THEO NGUYN NHN


phm vi bi ny, ch cp n mt s bnh tan thn c st v pht ban. Nhng biu hin ban cc b c th c km st nh vim m di da (cellulitis) hay chc (impertigo) c dnh cho gio trnh da liu. Chng ti cng ch trnh by mt s bnh ph bin hay c bit. Nhng trng hp khc, ngi c c th tham kho thm ti liu lin quan. C nhiu cch phn lai st pht ban. C th phn lai theo nguyn nhn: virus, vi trng, nm, d ng, do cc nguyn nhn khng nhim trng... y, chng ti phn lai theo tnh cht v phn b ca ban. Thit ngh nh th thun tin hn cho chn an. 1. Ban dt sn, ch yu mc thn : l lai st pht ban ph bin nht. - Si: thng mc u tin chn tc, sau lan dn xung thn v t chi. Nhng khng c lng bn tay v lng bn chn. u tin l nhng ban ring r, nhng v sau tp hp li ngy cng nhiu, khin ta c cm gic nh s vo vi nhung. Du c hiu ca si l du Koplik, mt trong m. Ch ng lm vi du Fordyce (tuyn b lc ch,khng c mng chung quanh v c th thy ngi bnh thng) - Si c (rubella) : Cng khi pht t chn tc nh si. Nhng khi lan xung thn th ban mt thng mt i. Nhng chm xut huyt vm ming khu ci ( du Forchheimer) gi , nhng khng c hiu v c th gp bnh tinh hng nhit hay nhim trng n nhn do EB. Hch sau tai, sau c c n chm, vim khp hay gp ngi ln. Cn trnh ly cho ph n c thai v c th gy d tt cho thai nhi. - Mt s enterovirus nh Echovirus hay Cosxackie, s nhim HIV, nhim trng n nhn do EBV cng c th c ban tng t nh si, km theo ni hch v vim hng.

36 - Hng ban nhim trng (erythema infectiosum) : do parvovirus B19 gy ra. Thng gp tr t 3-12 tui. Hng ban c nh trng, mu sng xut hin ma sau khi h st km vi vng da quanh ming xanh ti, cho hnh nh mt m phn ng sau mt ci tt. Hm sau, thn xut hin ban lan ta, thng c nga. Ban ny pht trin nhanh chng thnh mt mng li, c th thay i sc khi thay i nhit , ko di chng 3 tun. ngi ln, thng km thm vim khp. Thai nhi c th b ph khi m b nhim virus ny. - Ngai ban xut hin t ngt (exanthem subitum), cn gi l o ban (roseola), ch yu gp tr < 3 tui. Ban thng c mu hng sng, kch thc 2-3mm, dng dt hay dng sn xut hin ban u thn, c khi chi, nhung khng c mt. Ban bin mt sau 2 ngy. - Ban do phn ng thuc cng rt hay gp v khng th phn bit c vi ban do mt s virus. Ban d ng thng nga v c my ay, nhng khng phi lc no cng phn bit c. Da vo tin s c dng thuc, tan trng khng c v nhim trng phn bit. Ban c th ko di n 2 tun sau khi ngng thuc. Ban do d ng thuc thng gp mt s c a. Nhng ngi nhim HIV thng ni ban khi x dng sulfamide, nhng bnh nhn nhim virus Epstein - Barr thng ni ban khi dng Ampicilline. - Ban do st m: phn b ch yu thn. C tin s vo vng dch t a phng v thng tm thy vt en do m cn. Km theo c nhc u, au c, hch vng b m cn. T vong ln n 30% nu khng c iu tr kp thi. nc ta, gy bnh do Ricketsia tsutsumaguchi. - Ban do Leptospirose :Ban thng c dng dt sn, km theo xung huyt kt mc, chy mu kt mc. au c, vim mng no nc trong. Trng hp nng (bnh Weil) ban xut huyt, km theo hi chng gan thn. C khi ch xut hin i xng v khu tr xng chy. - Bnh Lyme : Ban di chuyn mn tnh (erythema chronicum migrans) l mt bnh mi pht hin . Cha c pht hin nc ta. - Ban thng hn : xut hin thn ri lan ra cc chi. L nhng chm hng, 2-4 mm. - Ban vng (Erythema marginatum) trong thp tim: thng kh ln, xut hin ri mt i theo tng t cp ca thp tim. Thng xut hin thn hay gc chi. C th xut hin ri mt trong vi gi. - Ban ca mt s bnh to keo : ban lupus ban thng c hnh cnh bm mt, nhng cng c nhng ni khc. Ban trong bnh Still : thng c mu nh c hi. 2. Ban ch yu mc chi Loi ny thng xut hin cc chi. Sau , c th lan vo thn hay khng. - St do Ricketsia ricketsi vng ni Hoa k : (Rocky moutain spotted fever) : Mc du cc Ricketsia khc thng c ban mc ch yu thn. Lai ny thng xut hin ban cc chi trc. L mt bnh nng, nhng c th iu tr d dng khi pht hin sm. Tuy nhin nc ta t gp, tr du khch hay Vit kiu v nc. - St v pht ban trc xng chy : mt dng nhim xon khun Leptospira. Bnh cnh thng thang qua trong mt vi ngy ri t hi phc. - Giang mai thi k 2: ban thng xut hin tan thn, nhng ch yu lng bn tay, lng bn chn, gp ngi quan h tnh dc rng ri. Tin s c th c sng giang mai. - Si khng in hnh: Thng gp ngi c chng nga si, nhng vi lai vaccine virus cht, hiu lc bo v km. Ban thng xut hin u tin cc u chi ri lan vo thn, c th chuyn thnh dng bng nc hay xut huyt. Khng c du Koplik. - Bnh l mm long mng ngi do virus Coxsackie A16: mm, xut hin nhng bng nc, n vo au. Bn tay v bn chn ban u xut hin nhng vng ban

37 dng sn, 0,25cm. V sau cng bin thnh cc bng nc. - Hng ban a dng: nhiu nguyn nhn: thuc (sulfa, h peni, h phenyltoin), nhim trng (herpes, Mycoplasma pneumoniae). Ban i xng u gi, khyu tay, lng bn tay, bn chn, c th lan tan thn - nh hng nim mc. Ban thng l mt vng , bao quanh bi mt vng sng v bn ngai c th c mt vng ban na. ng knh c th n 2 cm. - Vim ni tm mc nhim trng: Thng do lin cu, t cu...Th bn cp :xut hin cc nt Osler: l nhng nt hng, n au ngn tay hay ngn chn. Ban xut huyt da v nim mc. Hoc c tng mng xut huyt nh. Th cp ( do t cu): tn thng Janeway l nhng ban dt hay xut huyt, khng au lng bn tay hay lng bn chn. 3. Hng ban bong vy Cc ban v sau thng c hin tng bong vy. - Tinh hng nhit (Scarlatine fever) : Nguyn nhn ban u thng do ngai c t gy st A,B,C ca lin cu nhm A. Cc ban thng l hu qu th pht. c im ban : ban , n mt. Xut hin u tin mt, lan xung thn v t chi, chung quanh ban da nht mu. Da rp nh khi s vo giy nhm. nhng np ln da, c cc ng ban ( ng Pastia). Li ban u trng, sau v c dng nh du ty (strawberry tongue). Ban thng bong vy vo tun th 2. Hu ht gp tr 2-10 tui sau mt vim hng do lin cu nhm A. - Ban trong bnh Kawasaki : ban d dng nh tinh hng nhit hay hng ban a dng. Cng c li dng du ty. Nt mi,vim kt mc, ph bn tay, bn chn. V sau bong vy. Gp tr < 8 tui. Km theo hch c, vim hng v bnh mch vnh. Nguyn nhn cha r. - Ban do sc c t lin cu nhm A: ging ban tinh hng nhit. C th gp vim cn hai t (necrotizing fascilitis), nhim trng huyt, vim phi lin cu. T vong 30%. - Ban trong sc do t cu (SSS): thng do c t t cu 1 v c t rut B, C. Ban lan ta tan thn, k c nim mc. Vim kt mc. Bong vy sau 7-10 ngy. - Ban trong hi chng bong da do t cu (Staphylococcal scalded-skin syndrome) : Thng do t cu type phage II. Ch yu gp tr con v ngi ln suy gim min dch. Ban xut hin tan thn trc c st. n vo da au. giai an bong vy, khi n vo, ban d dng to thnh mt bng nc ( du Nikolsky). th nh, ban c dng nh tinh hng nhit, nhng khng c hnh nh li dy ty hay mng trng quanh ban. - Hi chng da bong vy: Thng n ng > 50 tui, c mt bnh da mn tnh nh vy nn, chm, d ng thuc, nm da. Ban tan thn, thng bong vy, xen k tn thng vi bnh da c sn. - Hai t da nhim c: ban lan ta, c khuynh hng hnh thnh cc bng nc. Du Nikolsky (+). Khc vi hi chng bng da t cu ch nh hng n lp nng, y tn thng tan b lp thng b. Nguyn nhn thng do thuc, nhim trng, ung th.. 4. Cc ban dng bng nc - Thy u : Ban u dng dt, ri sn ri thnh bng nc. ng knh 2-3mm trn mt nn . V sau c m ri bong vy. Hay gp tr em, nhng cng gp ngi ln. Bnh thng lnh tnh. Nhng ngi ln hay tr suy gim min dch thng c nhiu bin chng nng. - Ban do Rickettsialpox : Do Ricketsia akari nh thy u. Nhng thng tm thy vt en do m cn. - Ban do nhim Vibrio vulnificus v P. aeruginosa: gp nhng ngi suy gim min dch. Ban bng nc xut huyt trong bi cnh nhim trng nng. 5. Ban dng my ay My ay c in thng khng km theo st. Nu c st, my ay thng c ngun gc do vim cc mch mu nh (vasculitis). Khng ging nh my ay c in, thng bin

38 mt trong 24 gi, my ay c st ko di n 5 ngy. Nguyn nhn c th l bnh huyt thanh, bnh m lin kt, nhim trng. Mt s bnh c tnh cng c my ay km vi st. 6. Ban dng nt - Ban do nhim nm lan ta : Thng gp bnh nhn suy gim min dch. V d : nhim Candidasis ( thng l Candida tropicalis) vi st, au c, ban dng nt.Cc thng tn ca Crytococcus hay Penicillum marnerffei c th ging ht u nhy ly (molluscum contagium). Hai t cc nt gi nhim Aspergillosis v mucormycois. - Hng ban nt (Erythema nodosum) : biu hin bi cc nt ban di da, khng let, ln, mu hi tm, n au thng chi di nhng i khi cng c chi trn. Hay gp ph n t 15-30 tui. Km theo au khp (50%). Nguyn nhn thng do nhim trng, do thuc. - Hi chng Sweet: Biu hin cc nt ph, n au to cm gic nh mt bng nc. Thng xut hin mt, c, chi trn. Khi c chi di, thng gi n hng ban nt nhiu hn.Thng gp ngi 30-60 tui , a s ph n. 7. Ban xut huyt - Nhim khun huyt cp do no m cu : Ban u l nhng chm xut huyt nh, s lng tng rt nhanh, ngy cng ln dn v tr thnh bng nc. Ban ch yu mc thn v cc chi. Nhng cng c xut hin mt, bn tay, bn chn. C th tin trin thnh ban xut huyt c tnh. Hay gp tr em v nhng ngi ct lch hay gim b th ( C5-C8). - Ban xut huyt c tnh trong hi chng Waterhouse-Friderichson : L nhng mng xut huyt, c ranh gii r rt, hnh sao. Nhanh chng bin thnh mng nc xut huyt, ri hai t. - Ban nhim khun no m cu mn tnh: c nhiu dng ban. Dng dt sn, dng nt, dng ban xut huyt, nhng vng xut huyt vi tm mu xanh xm nht. Thng chi di. - Nhim lu cu lan ta: Dng sn (1-5 mm) ri bin thnh mn m xut huyt vi mt li hai t xm gia ch trong 1-2 ngy. Him hn, c khi dng bng nc xut huyt Cc tn thng (thng s lng < 40) thng phn b quanh cc khp, nht l chi trn. - Ban xut huyt do enterovirus : nguyn nhn l echovirus 9 v Coxsackievirus A9. c im: ban xut huyt ri rc, c th dng dt sn, mn nc hay my ay. - Ban do st xut huyt Dengue : Ban xut huyt lm tm. - Ban do gim tiu cu (thrombotic thrombocytopenic purpura): dng ban xut huyt lm tm c st, cha r nguyn nhn. Cu hi n tp 1. Phn loi cc loi ban theo quan im Ty y? 2. K mt s bnh nhim virut c biu hin ban ton thn hay gp Vit Nam. 3. Phn bit hng ban v t ban. 4. K mt s bnh nguy him n tnh mng c biu hin ban da. 5. Thy u c xp vo loi ban no, bn cht c ging hng ban hay t ban khng?

39

Bi 7.

NHIM TRNG NHIM C THC N


Ts, Bs Trn xun Chng

Mc tiu
1. Xc nh c nguyn nhn v mt s yu t dch t hc ca bnh. 2. Trnh by c cc triu chng lm sng v cc xt nghim. 3. X l ban u, chuyn ln tuyn trn ng lc v kp thi. 4. Xc nh c cc bin php phng bnh

Ni dung I. I CNG
Nhim trng nhim c thc n l nguyn nhn gy tiu chy cp thng gp, ngay cc nc c mc sng cao, do n phi thc n b nhim vi khun hay c t cu chng.

II. NGUYN NHN


1. Nhim trng nhim c thc n do Salmonella Type huyt thanh thng gp l S. Typhi murium, S. Enteritidis, s lng vi khun gy bnh thng > 106 vi khun, thc n b nhim thng gp l trng khng c nu chn. 2. Nhim trng nhim c thc n do t cu Nhim trng nhim c thc n do ngoi c t t cu, thc n thng b ly nhim bi ngi mang t cu vng (nht, chn m..), thi gian nung bnh t 1-6 gi 3. Nhim trng nhim c thc n do cc vi khun khc qua trung gian c t - Clostridium perfringens: thng do n tht khng c nu chn hay thc n hm li khng k, thi gian nung bnh 8 -12 gi. - Clostridium botulinum.

III. DCH T HC
1. Phng thc ly truyn Ch yu l ng phn ming , do ung nc hoc n thc n b nhim bn 2. Ngun bnh - Ngui bnh - Ngi lnh mang trng : y l ngun ly quan trng 3. Tui : c th gp tr ln v ngi ln . 4. Gii : Khng c s khc bit gia nam v n 5. Ma: Bnh thng xy ra vo ma nng. 6. Tnh hnh kinh t, x hi Bnh thng xy ra cc nc nhit i, km pht trin, iu kin v sinh km. 7 . Yu t nguy c

40 - C a: Tr nh, tr suy dinh dng, ngi suy gim min dch. - Tp qun n ung thiu v sinh : n thc n cha c nu chn, hm li nhiu ln, khng c thi quen ra tay trc khi n v sau khi i cu. - iu kin v sinh km - S dng ngun nc khng sch

IV. SINH L BNH


1. Do vi khun sinh c t Staphylococus, C. Perfringens sn xut ra ngoi c t trong thc n gy bnh cnh vim d dy- rut cp, c t ca vi khun hot ha h adenylcyclase ca t bo rut gy tng s bi tit ca nc v in gii rut non m ch yu l hng trng, trong lng rut hin din mt lng ln cc dung dch c p lc thm thu cao vt qu kh nng hp thu ca rut nn bnh nhn thng tiu chy nhiu. Chc nng hp thu ca rut non v i trng vn cn nguyn vn. 2. Do vi khun xm nhp vo thnh rut. Vi khun bm dnh, xm nhp vo trong thng b, gy nn cc tn thng i trng, dn n s tit ra cht nhy, tng m nim mc hoi t, hng cu, bch cu. Phn thng lng l do nh hng trc tip n s hp thu ca i trng . 3. C ch phi hp Salmonella c th gy i chy bng c ch phi hp: do c t v xm nhp

V. LM SNG
1. Nhim trng nhim c thc n do Salmonella Pht bnh thng t ngt, thi gian bnh thng t 12-36 h, phn lng, thi, km st cao, nhc u, nn, au bng, bng chng triu chng ko di 2-3 ngy ri khi nhanh. 2. Nhim trng nhim c thc n do t cu Bnh khi cp tnh vi: bun nn, nn ma, i cu phn lng, ton nc, s lng nhiu, phn c th khng thi hoc thi, khng nhy mu, nhiu ln trong ngy. Bnh nhn thng khng st hoc st nh, au bng t hn so vi hi chng l, c th km theo nn ma, c th gy mt nc nhanh v nng, c bit tr nh v ngi gi. Bnh nhn d b mt nc, c khi gy try mch, bnh thng tin trin thun li. Cy phn khng c gi tr chn on .Khng iu tr khng sinh.
Nguyn nhn Thc n Thi gian bnh St Nn ma Tiu chy Staphylococus Sa, tht, sn phm ca tht Ngn (6-12 gi) (-) (++) (+++) Salmonella spp. Sa, cc cht c s,Trng,Tht, bin Di (12-36 gi) (+) ( ) (++) C. Perfringens Tht, sn phm ca tht (ng hp) Ngn (12 gi) (+) ( ) (+)

Bng 5: Phn bit nguyn nhn theo triu chng

VI. CN LM SNG
1. Quan st trc tip mt mu phn ti

41 C th cho php nh hng chn on trong mt s trng hp. 2. Soi phn Tm bch cu hoc vi khun .C bch cu khi i chy do tc nhn xm nhp nim mc rut, m tnh khi i chy do vi khun khng xm nhp nim mc rut hoc do c t rut. 3. Cy phn xc nhn tc nhn gy bnh chnh cn s dng nhiu loi mi trng hiu kh, k kh, mi trng c bit, ty theo yu cu chn on, tuy nhin rt kh, v khi cy phn (+) li c th do tc nhn gy bnh khc. 4. Cc xt nghim khc Nhm hng dn tr liu trong cc trng hp nng nh: Hct, ure mu, in gii , d tr kim.

VII. IU TR
1. Nguyn tc iu tr + iu chnh, ngn nga, chng mt nc v in gii v ri lon thng bng kim toan. + iu tr nhim trng rut bng khng sinh nu cn. + Bo m dinh dng y theo yu cu iu tr trong v sau khi ht a chy. + iu tr triu chng v bin chng nu c 2. B dch v in gii nh gi lng nc mt s khi, thng da vo lm sng v cn nng. 2.1.B nc v in gii, iu chnh thng bng kim toan: ty thuc vo mt nc v loi vi khun gy bnh - Mt nc nh hoc trung bnh ( cn ung c) cho ung dung dch in gii ORS - Mt nc nng hay trung bnh nhng i nhiu khng ung c: i vi ngi ln: Chuyn cc dung dch ng trng nh Ringer lactat, dung dch mui ng trng, khi u truyn ht tc cho n khi bt c mch quay (ngi ln c th chuyn 1 lt trong vng 10- 15 pht). Sau iu chnh dch truyn chm hn. 2.2. iu tr duy tr Sau khi b s lng nc mt s khi, cn b s nc mt thm sau khi nhp vin, v lng nc cn thit cho nhu cu bnh thng ca c th 3. iu tr nhim khun + i vi vi khun sinh c t: Khng iu tr khng sinh. + i vi Salmonella: c th dng cc khng sinh nh: Bactrime, Acid Nalidixic, tuy nhin hin nay khng sinh thng dng cc Fluoroquinolones nh: - Ofloxacine 0,2g x 2 vin / ngy - Ciprofloxacine 0,5g x 2-3 vin / ngy 4. Bo m dinh dng y trong v sau khi ht tiu chy 5. iu tr triu chng v bin chng - Thuc cm a chy - Thuc hp ph ( kaolin, than hot... ) khng c tc dng

42 - Thuc phin v dn xut phin: Lm gim au nhng lm chm thi vi khun nguy him vi ngi gi v tr nh c th gy t vong - H st bng lau mt , lau m , cn thn khi dng thuc h st tr nh - Chng co git: Nu km st cao th phi h nhit . Mt nc v ri lon in gii th phi bi hon, h ng huyt th phi chuyn ng - Trnh dng cc thuc nng huyt p, tr tim, cortcoide

VIII. PHNG BNH


1. V sinh n ung v v sinh thc phm - Khng n cc thc n sng tr nhng rau qu ti c th bc v v n ngay sau khi bc - un nu thc n cho n khi chn - n thc n khi cn nng hoc un li hon ton trc khi n - Gi thc n chn v bt a sch cch ly vi thc phm v bt a c th b nhim. - Ra tay bng x phng trc khi nu n, trc khi n ung , trc khi cho tr n v sau khi i tiu tin bin php ny d thc hin, hiu qu v thch hp mi ni - Khng rui bu vo thc n bng cch y lng bn, 2. Pht hin v iu tr ngi mang mm bnh 3. Nc ung - Ngun cung cp nc phi bo m sch, khng b nhim bi cc ngun nc bn ngm vo, phi xa cc h x - Bo qun cc ngun nc, ngn khng cho sc vt li gn - Cha nc trong cc thng sch, y np kn, dng go c cn di mc nc. - Nc ung phi c un si ngui 4. V sinh cc nh n tp th, cc ni ch bin thc n cng cng - Bp nu n phi bo m h thng mt chiu - Kim tra sc khe nh k nhn vin nu n v phc v n ung - Qun l nhn vin mc bnh nhim trng mn tnh, nht l nhim trng ng rut, da . 5. H x - Cn c h x hp v sinh, tt c mi ngi trong nh phi i cu vo h x , phi gi cho h x sch s . - Nu khng c h x th cn phi x l phn xa nh , ng i hoc ni tr em hay chi a, xa ngun nc s dng t nht 10 m. 6. Gio dc nhn dn hiu cc bin php phng bnh Cu hi n tp 1. K tn nhng tc nhn ph bin gy nhim trng nhim c thc n Vit Nam ? 2. Nu c im c ch bnh sinh ca vi khun sinh c t ? 3. Triu chng lm sng nhim trng nhim c thc n do Salmonella ? 4. K tn cc khng sinh c th dng iu tr nhim trng nhim c thc n do Salmonella ? 5. Nu cc bin php v sinh cng cng d phng nhim trng nhim c thc n ?

43

Chng 2. CC BNH DO NHIM KHUN


Bi 8.

BNH VIM MNG NO M


Ths, BsCK1 ng th Nga

Mc tiu
1. Lit k c tn v tn sut mc cc tc nhn gy vim mng no m thng gp. 2. Phn tch c cc iu kin lm d v cc yu t nguy c gy vim mng no m .3. Chn on xc nh lm sng bnh vim mng no m 4. Phn bit c cc bin i dch no ty mt s bnh vim mng no thng gp 5. S dng khng sinh ng trong iu tr vim mng no m 6. Hng dn cch d phng mt s bnh vim mng no m thng thng

Ni dung I . I CNG
nh ngha: Vim mng no m ch tnh trng khi bt k mt phn no ca t chc mng no b tn cng bi cc vi khun sinh m v phn ng vim ca mng no s lan ta i khp ni biu hin trn lm sng mt hi chng nhim trng v hi chng mng no T chc mng no bao ph ton b no, sng no, no tht v ty sng; bo gm mng cng, khoang di mng cng , mng nhn , khoang di nhn. Do v tr tip cn ca no v mng no nn i khi bnh l mng no cng c th c nhng biu hin cc triu chng ca no. Khi lm sng c biu hin ca hi chng mng no th chnh l mt tnh trng cp cu cn phi cho bnh nhn nhp vin ngay chn on nguyn nhn. Vic iu tr tr s tng t l t vong v i khi cn li di chng

II. NGUYN NHN


ngi trng thnh S. pneumoniae l tc nhn gy vim mng no thng gp nht, k n l Neisseria meningitidis v Listeria monocytogene. ngi trn 60 tui tc nhn gy bnh c th tm thy l cc trc khun gram m khc. tr em Hemophilus influenza, Streptococcus pneumoniae, Neiseria. meningitidis l cc nguyn nhn gy vim mng no thng gp. Tr s sinh streptococcus nhm B cng nh trc khun gram m, c bit Echeria coli v Listeria monocytogene cng l nguyn nhn hay gp. Sau phu thut thn kinh cc tc nhn gp tn sut cao l Staphylococcus aureus, Pseudomonas aeruginosa v trc khun gram m. Ngi nhim HIV, ngoi tc nhn gy vim mng no thng gp l nm th c nguy c cao nhim Listeria monocytogene.

III. DCH T HC
Bnh xy ra ma lnh, cao im l ma xun - ma thu. Ti M hng nm 10/105 ngi mc, trong tr < 6 tui t l 87/105 ngi. T l ny cao hn 3-4 ln cc nc pht trin.

44 Bnh kh ph bin nc ta, v cc yu t gy vim vo mng no qua mu t cc nhim tin pht t xa trn c th. nc ta, bnh nhim trng cn ph bin do vim mng no ch yu l do vi khun, khong 10 % trng hp vim mng no khng tm ra tc nhn gy bnh nn rt kh iu tr.Theo bo co ca vin V sinh dch t trung ng trong 10 thng u nm 2002 c nc ta c 352 trng hp vim mng no do no m cu t l t vong khong 2%. 1 Cc yu t nguy c 1.1 Ngoi cnh - Nhim trng ng h hp trn, vim phi - Cc nhim trng cnh mng no: Vin xoang sng, xoang bm , xoang trn - Vim tai gia , vim tai xng chm. - Abces no - Vim ni tm mc , huyt khi tnh mch , t catheter tnh mch - Chn thng s no 1.2 Ni ti - Cc tnh trng bnh l ton thn: i ng, suy dinh dng, gim min dch, iu tr corticoide, lao, nghin ru, giang mai thi k 2, - C a + Nam mc nhiu hn n + S sinh v tr nh , ngi gi yu mc nhiu hn tr ln v ngi ln + Ngi b ct lch d b vim mng no do ph cu , haemophilus influenza type B v trc khun gram (-) 1.3. Mi trng: Hemophilus influenza, Neiseria. meningitidis c th gy dch vim mng no nh tr, mu gio . 2 Tn sut mc bnh theo nhm tui
tui Tc nhn gy bnh Haemophylus influenza Neisseria meningitidis S. pneumonia E. coli Streptococcus Staphylococcus Listeria monocytogenes Vi khun khng xc nh 0- 2 % 0-1 1-4 30-50 40-60 2-5 2-10 5-10 40-50 % 20-30 10-30 1-4 2-5 1-2 1-2 5-10 5% 25-40 40-50 5-10 1-3 5-10 5 5-10 S sinh < 2 thng > 2 th- 6 tui > 6 tui & ngi ln

Bng 6: Tn sut mc bnh theo nhm tui

45

IV. C CH BNH SINH


Tc nhn gy bnh thng t nhim tin pht t ng h hp trn, phi, ni tm mc, da, ch t catheter; i khi t cc nhim cn mng no nh vim xoang, vim tai gia, vim tai xng chm ... vo mu, vt qua hng ro mch nu no ri sng c trong dch no ty. Vim mng no do vi khun xy ra khi cc yu t c sinh bnh vt qua c ch khng ca c th ngi bnh. Cc c ch khng ny bao gm: - Tc nhn gy vim mng no kt dnh c v nh khu trn b mt biu m nim mc ngi bnh. - Xm nhp v sng st trong lng mch mu. - Vt qua hng ro mu no. - Sng c trong dch no ty. kt dnh v nh khu trn b mt biu m nim mc, tc nhn gy bnh phi sn xut cc protease IgA lm cho cc IgA y mt chc nng. Sau khi gn v xm nhp c vo biu m nim mc, vi khun i vo v sng trong lng ni mch; trong lng ni mch vi khun s tm cch ln trnh h thng b th lu hnh khi b tiu dit . Nu vi khun c tim nng i tnh vi h thng thn kinh (nh ph cu, no m cu, HI, E.Coli), th s tm cch lt qua hng ro mu no vo trong dch no ty. Bnh thng nng b th trong dch no ty thp, c bit hot ng ca globulin min dch v b th dng nh khng c hiu qu. Mc khc hin tng opsonine ha tiu dit tc nhn gy bnh t ra km hu hiu ngay c khi hng ro mu no b ph v trong vim mng no do vi khun. y l iu kin thun li cho cc tc nhn gy bnh khi vt qua c hng ro mu no s pht trin v lan trn rt nhanh. Chnh s lu thng lin tc ca dch no ty kt hp vi s ri lon tnh thm ca mng no khi b vim khin cho bnh cnh lm sng ca vim mng no thng din bin cp tnh. Nh c mng nui che chn nn tc nhn gy vim khng xm nhp trc tip vo m no, tuy nhin cc phn k cn mng no c th xung huyt, ph n. Nhng tri li, khi vi khun i vo mng no qua dng mu t no th cng c bnh cnh vim no - mng no.

V. GII PHU BNH


- Phn ng vim mng nui, mng nhn v dch no ty lm cho mng no dy ra. Trong vim mng no m t bo vim xm nhp xung quanh mch mu v mng nui c th b x rch . Cc cu trc cnh no cng c th c nhng thay i bnh l nh vim tc tnh mch v no, cc ng mch mng nui c th to thnh mch lu v tc mch - Nh c mng nui che chn nn tc nhn gy vim khng xm nhp trc tip vo m no, tuy nhin cc phn k cn mng no c th xung huyt, ph n . - Cc bin i khc c th gp l: + Trn dch mng cng + Vim ng mch no + Vim tc tnh mch v no + Vim tc mao mch lp v mng no k cn vi mng no vim + ng ty sng cng c th cha dch vim, dch vim hin din khoang di nhn + Tn thng cc dy thn kinh s no xy ra ni tch t nhiu dch vim, hoc vim (nh trong cc ht lao y s gy tn thng dy thn kinh s no ). + Ph no, tng p p ni s thng do:

46 Cht t bo Tng tnh thm mao mch do cc cytokin Tng p lc thy tnh (ph no k) do tc nghn ti hp thu dch no ty . Do tng tit ADH bt thng gy nc qu mc

VI. TRIU CHNG LM SNG


Lm sng chung ca vim mng no biu hin u tin v ph bin l hi chng nhim trng v hi chng mng no - St cao t ngt , hoc st cao t t , c khi du hiu st rt kn o - Hi chng mng no thng gm cc triu chng: Du c nng:Nhc u Nn To bn Du thc th : thm khm c th pht hin: Cng c, Kernig (+), Brudzinski(+), Vch mng no (+), Tng cm gic da Din bin vim mng no rt phc tp, mt t l thp tin trin mn tnh v c tnh hi qui nh vim mng no lao, nm, leptospira, amip, toxoplasma, him hn Listeria monocytogenes .

VII. LM SNG MT S VIM MNG NO M THNG GP


1 Vim mng no do no m cu - Bnh c th thnh dch v xut hin theo ma nht l mu lnh. - ng xm nhp thng l mi hng - Du mng no c km theo vi tnh trng nhim trng ton thn , c bit vi ban xut huyt ton thn. Trong trng hp nng c ban xut huyt hoi t km chong. Tuy nhin c khong 20-40% s bnh nhn c vim mng no m khng c biu hin lm sng ca nhim khun huyt do no m cu do chn on phi da vo vic tm vi khun trong dch no ty. - Cn lm sng Cng thc mu: s lng bch cu tng, tng bch cu a nhn trung tnh. Nc no ty: tng s lng bch cu, a nhn trung tnh tng, mu sc c khi c nh nc vo go , soi ti nhum Gram c th tm thy mng no cu khun - ngi ln iu tr p ng tt vi Penicilline G (300.000v/ kg/ 24h ) hoc Ampicilline 200mg/kg/24gi, ng tnh mch, chia u mi 4 gi . Nu d ng vi Penicilline G c th dng Chloramphenicol 50mg /kg/24 gi, chia u mi 6 gi; hoc Ceftriaxone 2g -4g/24gi, chia u mi 12 gi. Thi gian iu tr ko di n khi ht st t 5- 7 ngy. 2 Vim mng no do ph cu - ng vo: Cc nhim trng tai mi hng nh vim xoang, vim tai, vim phi , chn thng s no kn, h. Mt i khi vim mng no do ph cu c th khi pht nh mt bnh nguyn pht khng c du hiu bo trc ca bt k mt ch nhim khun no trc. Him hn, bnh nhn b vim ni tm mc do ph cu cng c th a n vim mng no do chnh tc nhn ny. - VMN m do ph cu i khi rt nng, cc bin chng nh hn m, ri lon thn kinh thc vt, protein nc no tu cao lm d vch ha mng no, tc nghn nc no tu v t vong. - Cn lm sng: Nc no ty c, c t bo thoi ha v ln song cu khun Gram(+) hnh ngn nn ng tng i; prtein rt tng > 2g/l c khi 6 - 8 g/l.

47 - iu tr p ng tt vi Ampicilline 150- 200 mg/kg/ 24gi, ng tnh mch, chia u mi 4 gi. Nu ph cu khng thuc c th thay th bng Ceftriaxone 2g -4g/24gi chia u mi 12 gi. Chloramphenicol cng l thuc c chn la iu tr vim mng no m do ph cu khi bnh nhn d ng vi Betalactam. - Nu iu tr tch cc bnh thng hi phc tt. 3 Vim mng no do Listeria monocytogenes - Ngoi du hiu vim mng no c th km du hiu no; hay gp ngi gi, ngi suy dinh dng, tr s sinh. tr s sinh, vim mng no c th biu hin trong mt thng sau sinh, lm sng c th c st hoc khng, i khi c cc biu hin thng tn thn kinh trung ng - Lm sng ging nh bnh cnh vim mng no cp - Nc no ty th khng c s bin i v sinh ha, hoc khi pht t t nh mt vim mng no lao, nc no ty lympho tng, ng gim, c th tm thy Listeria trong nc no ty; c cc du hiu ca no v cc dy thn kinh s no. - Thuc chn la: Ampicilline 200mg/kg/24gi (ngi ln), chia u mi 4 gi; mt loi thuc c th thay th l sulfamethxazol - trimethoprim ng tnh mch; phi chc d ty sng sau 48 gi kim tra kt qu iu tr. Thi gian dng thuc i vi Listeria l 2 tun l 4 Vim mng no do Haemophylus influenza - H. influenza l nguyn nhn ph bin nht ca bnh do vi khun tr em. Vim mng no chim hn 50% s cc bnh do H. influenza xm nhp. Bnh phn ln tr em t 2 -6 tui. T l t vong khong 5%. - ng vo hay gp l tai mi hng. Lm sng thng m trong vng vi ngy ri t tr nng trong vng vi gi. Biu hin cc triu chng ging nh vim mng no m do bt k nguyn nhn no; di chng nhiu v thn kinh v tri gic . - iu tr: Trc y thuc chn la l Ampicilline, nhng H.influenza ngy cng khng vi Ampicilline nn thuc thay th l Cephlosporin th h III c th Cefotaxime (2-12g/24gi, chia u mi 6 gi), hoc ceftriaxon (2-4g/24gi, chia u mi 12 gi). Vi H.influenza, d dng khng sinh liu nhng nghi cn vi khun mi hng bnh nhi, do , trc khi ra vin nn dng mt liu Rifampicine 20 mg/ kg / 24 gi x 4 ngy ung phng ly cho ngi khc nh. 5 Vim mng no do t cu - Thng th pht sau nhim khun da, phi, hay sau phu thut tim mch, s no... - Biu hin lm sng rm r km ri lon tinh thn kinh, - Dch no ty c, bch cu cao, soi ti v nhum gram c th pht hin t cu gy bnh - iu tr kh khn. Thuc u tin c chn la l Vancomycin v Cefotaxim hoc Fluroquinolon, song song phi hp iu tr nhim trng tin pht trit .

VIII. CHN ON GIN BIT


1. Vim mng no lao - Thng th pht sau mt bnh lao khng iu tr ng phc - Lm sng: Hi chng mng no t r nt, xut hin t t, vi nhc u, st nh, km n, mt mi; du hiu gi l ri lon tm thn kinh nh trm cm hoc kch thch, mt ng, mt i khi c du tn thng cc dy thn kinh s no nh lc mt, song th, lit mt trung ng. - Cn lm sng: Chp film phi, lm IDR l bt buc.

48 - Chc ty sng: p lc tng, nc vng chanh, trong; c khi m nh. Protein tng 0,5 -2 g/l c khi cao hn. Cl- : gim. Glucose: bnh thng hoc gim t. Tm vi khun lao trong dch no ty cho kt qu mun v nui cy vi khun mc tr. C th lm PCR tm vi khun lao. - iu tr: dng phc khng lao. 2 Vim mng no virus - Lm sng l mt hi chng mng no vi dch no ty trong, tng lympho. - Da vo yu t dch t ca tng tc nhn v lm sng nh Myxovirus (cm, quai b, si) hoc Enterovirus (bi lit, coxsackie), hoc Herpes - zona, Rubeole, Mononucleose infectieus. - Hi chng mng no rm r, t ngt vi nhc u d di, nn ma, c khi km du hiu ca no nh ri lon thc, ri lon nh hng khng gian , thi gian... - Cn lm sng: nc no tu trong, p lc tng, c khi m nh v t bo tng , a s l bch cu lymphocyte t 100 - 500 . Protein bnh thng hoc tng nh . - iu tr: khng c iu tr chng virus c hiu ngoi tr vim mng no do Herpes, cn li ch iu tr h st, gim au. 3 Vim mng no do nm - Gp trn ngi suy gim min dch , hoc s dng corticoide ko di . - Hay gp l Cryptococcus neoformans, din bin phc tp, nhc u ko di. - Chc d ty sng c th phn lp c Cryptococcus neoformans, hay gp nhng bnh nhn AIDS. Ngoi ra him hn c th gp vim mng no do Candida albicans. 4 Mt s bnh cnh khc - Abces no - Chn thng vo u gy t mu di mng cng - Chy mu di mng nhn - Bnh no do chuyn ha.

IX. THI X TR
Phi nh rng vim mng no l mt cp cu ni khoa, cn chn on sm, iu tr tch cc 1 Nguyn tc iu tr - Khng sinh dit khun - iu tr h tr - Phi theo di din bin v nh gi kt qu iu tr 2 iu tr c th - Khng sinh: bt buc trong iu tr vim mng no m. Theo khng sinh khi xc nh c chng vi khun. Cha xc nh vi khun th da vo lm sng, tn sut mc bnh chn khng sinh. Thuc phi c hiu vi tng loi vi khun, c kh nng i qua mng no tt v dit khun; nn dng ng tnh mch vi liu cao duy tr sut thi gian iu tr. - Thi gian dng khng sinh: Trong qu trnh iu tr cn theo st din bin lm sng v dch no ty. Nu lm sng din bin khng thun li th sau 36 - 48 gi chc li dch no tu; nu thnh phn dch no ty din bin cha tt, nn iu chnh liu khng sinh hoc thay i khng sinh thch hp. Ngng khng sinh khi lm sng din bin tt km theo dch no ty protein tr v bnh thng , bch cu <10 t bo ch yu l lymphocyte. - iu tr h tr: Bnh nhn c th c cc ri lon khc i km do :

49 + Cn bng nc, in gii. + X tr cp cu khi c ri lon thn kinh thc vt nghim trong e da tnh mng bnh nhn nh ri lon h hp, ri lon tun hon, ri lon thn nhit... + Chng co git: bng Diazepam hoc Phenobarbital + Corticoide: dng cho trng hp hn m hoc ri lon tri gic ko di nghi ng c tng p lc ni s. Dexamethasone 0,5mg/kg/24gi dng 4 ngy song song vi khng sinh.

X. BIN CHNG V TIN LNG


1. Bin chng - Suy h hp, suy tun hon do ph no gy tt kt. - Tng p lc ni s - Bi nhim do nm lu, ri lon nc , in gii - Trn dch di mng cng, t m di mng cng . - Abces no, vim no tht, no ng thy tr nh 2.Tin lng - Tui cng nh hoc cng gi , suy dinh dng, hoc gim min dch cng xu. - Thi gian t lc c triu chng n lc iu tr cng mun cng xu - Loi vi khun gy bnh 3. Di chng - ic: Ph bin nht (do ph cu 37%, no m cu 10%, HI 5- 20 %) - Ri lon nhn cch vi nhiu mc khc nhau - Ri lon th gic - Ring tr em di chng v sau gm chm pht trin tinh thn , ngn ng

XI. PHNG BNH


Nc ta, vim mng no ch yu do nhim trng v vy phng mt s bnh nhim trng s gim t l mc bnh. Khi b bnh, iu tr sm v ng s hn ch t l di chng v t vong. C th mt s vim mng no gy dch c th phng bng khng sinh v vaccine. 1 i vi Haemophylus influenza - Vaccine d phng : C th phng nhim HI bng vaccine. Tt c tr di 5 tui u phi c chng nga; trn 5 tui tn sut mc bnh gim dn do c min dch t nhin - Thuc: phng vim mng no m do HI bng thuc ch khi trong tp th nh tr hay mu gio c > 2 trng hp bnh trong 1 thng hoc gia nh c tr < 4 tui hoc ph n c thai sng chung vi tr b vim mng no m do HI. Dng Rifampicine 20 mg/kg/24 h x 4 ngy. Phng bng thuc cng dng cho nhng ngi c tip xc vi bnh nhn. Rifampicine ung mt liu duy nht 5 mg/kg/2 ln /ngy hoc ceftriaxone liu duy nht 200mg tnh mch/tim bp; Ampicilline ch c tc dng dit HI hu v hin nay HI c khuynh hng khng thuc ny. 2 i vi no m cu - Vaccine hin nay c 3 loi vaccine polysaccharide ca no m cu l : mt thnh phn A, 2 thnh phn A v C, 4 thnh phn A,C,Y v W135) + Tr < 2 tui dng 1 liu vaccine duy nht type C c th hiu qu phng bnh 70 % trong 6- 9 thng.

50 + Tr > 2 tui c tip xc vi bnh nhn nhim no m cu th ngoi chng nga vaccine phi ung thm Rifampicine phng v cc loi vaccine ny p ng min dch yu. - Thuc: Thuc phng dng cho ngi tip xc vi bnh nhn. Rifampicine ung mt liu duy nht 5 mmg/kg/2 ln /ngy hoc ceftriaxone mt liu 200mg tim tnh mch hoc tim bp. Cu hi n tp 1. Hy trnh by tn v tn sut xut hin ca cc tc nhn gy vim mng no m thng gp. 2. Gii thch cc iu kin lm d v cc yu t nguy c gy vim mng no m. 3. Hy m t cch chn on lm sng vim mng no m 4. Hy phn tch tnh cht dch no ty mt s vim mng no thng gp 5. Trnh by cch thc iu tr vim mng no m

51

Bi 9.

BNH L TRC KHUN


BsCK2,Ths H th Thu Vng Mc tiu 1. Xc nh c nguyn nhn, dch t hc ca bnh, ch n tnh trng khng thuc 2. M t lm sng, cn lm sng v cc bin chng chnh 3. Chn la phc iu tr thich hp 4. Trnh by c cc bin php phng bnh

Ni dung I. I CNG
L trc khun l bnh nhim khun cp tnh rut do trc khun Shigella gy ra, y l mt bnh tiu chy nguy him nht trong cc loi bnh tiu chy v l mt bnh ph bin cc nc nhit i ang pht trin nh nc ta, c th xy ra cc v dch ln, t l t vong cn cao c ni ln n 15%. Biu hin bnh l thay i t th tiu chy nh n cc th bnh nng vi hi chng l v hi chng nhim trng c.

II. NGUYN NHN


1. c im vi khun Shigella l mt loi trc khun gram m, khng di ng, thuc h Enterobacteriaceae. Da vo c im khng nguyn thn O v cc c tnh sinh ha, ngi ta chia l 4 nhm chnh A,B,C,D. Khng nguyn O c hiu type, ngoi ra cn c cc khng nguyn K l khng nguyn b mt, mi nhm chnh c phn ra nhiu type huyt thanh - Nhm A: S. dysenteriae, nhm ny bao gm 10 type huyt thanh khc nhau, trong S. dysenteriae type 1 ( trc khun Shiga) c mt ngoi c t hot tnh mnh gy bnh nng hn cc type khc v c th gy dch . - Nhm B : S. flexneri c 8 nhm huyt thanh - Nhm C: S. boydii, bao gm 18 type huyt thanh, v mt sinh ha n rt gn vi nhm B, nn tn ti phn ng cho vi nhm B - Nhm D : S. sonnei, ch c mt type huyt thanh nhng c nhiu sinh type . 2. c t Cc loi Shigella c ni c t c hot tnh sinh hc ging nh ni c t ca cc loi enterobacteriaceae khc Ngoi ra S. dysenteriae I ( trc khun Shiga) cn tit ra ngoi c t vi mt lng ng k gi l Shigatoxine, ngoi c t ny c kh nng c ch khng phc hi s sinh tng hp protein ca t bo, c tc dng nh mt enterotoxine . Shigella flexneri v sonnei cng sinh ngoi c t nhng s lng t hn . Ngoi c t gm 2 bn n v l phn gn dnh v phn hot ha. Sau khi c tit ra, c t s gn dnh vo cm th th ( c bn cht l glucoprotein ) mng t bo. Sau phn hot

52 ha c chuyn vo bn trong t bo v ngn cn s tng hp protein phn 60 S ca ribosome trong bo tng . 3. Sc khng S lng vi khun thi ra trong phn ngi b l khong106 - 108 vi khun / gram phn. Hin nay, cha r S. dysenterie tn ti bao lu mi trng bn ngoi. Ring loi S. sonnei c th sng trong o qun vy phn t 9 - 46 ngy, trong nc n 6 thng, trong cc thc n t 3 tun n 6 thng. nhit < 25 chng c th sng lu hn. Shigella c th sng trn 30 ngy trong sa, trng, chng c th tn ti 3 ngy trong nc bin

III. DCH T HC
1. Phn b a d v tnh hnh bnh tt Bnh do Shigella thy khp th gii, hin nay vn cn l bnh quan trng ti cc nc thiu v sinh v c tnh trng suy dinh dng ph bin v l bnh nng e da t vong nhiu hn cc loi tiu chy khc. Trn th gii hng nm c khong 140 triu trng hp mc bnh v khong 600 ngn trng hp t vong .
Chng vi khun S. flexneri S.dysenteria 1 S. dysenteria 2 -10 S. boydii S. sonnei Tng s S bnh nhn vo vin 2319 1251 132 303 145 4150 S bnh nhn t vong 230 99 13 31 12 385 T l t vong % 10 8 10 10 8 9

Bng 7: Tnh hnh l trc trng nhp vin trong 5 nm ti Dhaka, Bangladesh

cc nc pht trin bnh l trc trng thng gii hn trong cc tp th nh nh nh tr , bnh vin ... c th c cc dch nh nhng thng c dp tt nhanh chng cc nc ang pht trin cc v dch ln l mi e da cho ngnh y t. T l t vong ca l c th ln n 15 % v ngay c iu tr ng cch vn c 5 % t vong. Hai chng ph bin gy l trc trng cc nc ang pht trin l S. dysenteria v S.flexneri . Vit nam trc nm 1968 chng S. flexneri l chng ph bin, t 1968 n 1980 l chng S. dysenteria v t 1980 n nay S. flexneri tr thnh chng u th, l do ti sao c s chuyn chng hin nay cha r . C nhiu v dch xy ra chu phi, , M la tinh do S. dysenteria type 1. V dch chu M la tinh nm 1969 v 1973 c 500.000 ngi mc bnh 20.000 bnh nhn t vong c l do s trm trng ca bnh v tnh a khng thuc ca vi khun. Gn y mt lot dch l xy ra mt s nc ti min ng, Trung v Nam Phi bao gm Rwanda, Brundi, Malawi, Zambia , Zimbawe, Swaziland , Mozambique . 2. Phng thc ly truyn L ng ming, ch cn 10-100 vi khun cng gy bnh ngi ln tnh nguyn mnh kho. Nu 200 vi khun th c th gy bnh 25 %, nu 105 vk th c th gy bnh 75 %. iu ny cho thy tnh cht ly truyn ca l trc trng rt mnh . Bnh thng ly truyn trc tip t ngi sang ngi qua trung gian tay bn hoc vt dng b nhim, c th ly gin tip qua thc n nc ung. Rui ng vai tr quan trng trong c ch truyn bnh

53 3. Yu t nguy c Tnh trng v sinh km, ch ng c, c bit ni c nhiu tr em suy dinh dng, s mt mi, thay i thi tit, thay i ch n .... 4. Ngun bnh Ngi l ngun bnh duy nht, c th ngi bnh, ngi ang thi k hi phc, ngi lnh mang trng. Nu khng iu tr, ngi bnh c th thi vi khun ko di t 7-12 ngy. Tuy vy nhng trng hp mn tnh, c bit nhng tr suy dinh dng th thi gian thi khun c th ko di hn 1 nm 5. Tui - gii i tng mc bnh thng gp l tr em 1- 4 tui ngi ln bnh thng xy ra n hn nam c l do tip xc gn gi tr em . 6. Ma Ti vng c dch lu hnh th bnh c cao im vo ma h thu 7. Tnh hnh khng thuc S. dysenteria khng mt s khng sinh nh sulfamide, streptomycin, tetracyclin, chloramphenicol. Ngoi ra, t l khng Ampicilline, cotrimoxazol, acide nalidixic tng ln.

IV. SINH BNH HC


Do tnh cht khng vi acid d dy, shigella d dng xm nhp vo ng tiu ha. Sau thi gian bnh 24 - 72 gi, vi khun vo rut non v n xm nhp vo t bo thng b rut gi, tng sinh trong ni bo gy nn phn ng vim cp tnh lp nim mc i trng. Giai on ny tng ng vi thi k khi pht vi cc triu chng nhim trng khng c hiu, au bng, a chy . Sau lp t bo thng b cha vi khun b hu hoi v bong ra to nn nhng lot nng, trn nn lp nim mc vim lan ta cha nhiu cht nhy v bch cu a nhn. Giai on ny bnh nhn thi nhiu vi trng theo phn ra ngoi, thng tn gy ra phn c mu . Tn thng lc u khu tr i trng Sigma v trc trng sau c th lan ln phn trn ca i trng, trong trng hp nng vim lan ta ton b khung i trng, lan n on cui ca hi trng, tiu chy do ri lon hp thu nc, in gii do vim i trng v do c t rut gy ra. Vai tr khng ca c th i vi Shigella hin nay cha c r. Acid d dy v mt cha phi l hng ro bo v chnh, tri li tng nhu ng rut trong lc b bnh c xem l c ch chnh ca thi khun. Cc loi thuc cm tiu chy, thuc chng co tht l nhng loi thuc lm cn tr thi khun l nguyn nhn gy ra cc bin chng nghim trng. Vi khun ch bnh thng ca rut cng ng vai tr c ch s pht trin ca vi khun .IgA cng c xem l yu t bo v ca c th chng li l. Cc khng th huyt thanh c hiu i vi khng nguyn O c pht hin thy trong huyt thanh 1- 2 tun sau khi b bnh. p ng min dch t bo trong v sau khi b bnh cha c r. Kho st trong ng nghim cho thy cc Lymphocyte mang b phn th Fc, cc n bo v bch cu a nhn c th tiu dit c Shigella vi s hin din ca khng huyt thanh Shigella . Khi b bnh, nim mc rut gi b let lan rng vi cht xut tit cha t bo nim mc rut gi b bong, bch cu a nhn, hng c. Tn thng let trng ging nh mng gi. Cc t bo ni mc mao ng mch va mao tnh mch b ph n km theo bch cu a nhn di chuyn trn thnh mch. Vi khun c th thy c trong t bo cht

54 tr em nhim S. dysenteria type 1 vi vim i trng nng c th xut hin hi chng huyt tn ure mu cao ( v hng cu v lng ng cc cc fibrin gy tc mch mu cu thn ). Tr b m chng li l trc trng tt hn nh khng th c trong sa m v nhng yu t chng nhim trng.

V . LM SNG V TH LM SNG
1. Th in hnh 1.1. Thi k bnh : Khng c triu chng lm sng, thng ko di 12- 72 gi ( trung bnh 1- 5 ngy ). 1.2. Thi k khi pht : Bnh khi pht t ngt vi cc triu chng khng dc hiu nh st cao t ngt, n lnh, au nhc ton thn, nhc u, mt mi, bing n, bun nn km theo tiu chy v au bng 1.3. Thi k ton pht : Bnh din bin thnh bnh cnh l y i cu phn nhy mu vi au bng qun dc khung i trng, mt rnl cm gic bnh nhn mun i cu nhng khng i c, mt rn do co tht c trn hu mn. Mt rn nhiu c th lm sa trc trng v trong nhng th nng gy lit c vng hu mn lm hu mn gin rng. i cu nhiu ln trong ngy t 20-60 ln/ ngy, phn t, c nhy mu, v sau khng c cht phn. Trong thi k ny bnh nhn cn st nhng nh hn, ngi mt mi, th trng suy sp, mt hc hc, mi kh li vng bn. 1.4. Thi k li sc: thng sau 1-2 tun , nu khng iu tr bnh cng c th t ci thin. th nng thi k li sc ko di, th t cp c th a n hn m v t vong 2. Th nng ti cp Xy ra vi st cao run lnh, l m, i cu ra mu t, ngi suy kit, ri lon nc v in gii dn n suy tun hon, suy thn, d gy t vong thng do S. dysenteria type 1. 3. Th l ko di hay th l suy kit Trong mt s v dch, c mt s bnh nhn b l ko di trn 2 tun, thng l tr suy dinh dng hay ngi gi suy kit, b khng thuc do S. dysenteria type 1. Lc u hi chng l rt in hnh tr i cu phn nhy mu, mt rn, s ln i n vi chc ln, lng phn t tr mt rn nhiu n ni sa trc trng, c vng hu mn b lit v hu mn n rng. Nhng bnh nhn ny nhanh chng b ph thiu mu v suy kit. St trong th ny tht thng lc cao lc nh, lc h thn nhit. Din bin th ny a n cc bin chng nh: phn ng tu gy tng bch cu mu, nhim trng mu v hi chng huyt tn ure mu cao. 4 Th khng in hnh 4.1. Th a chy Trong th ny, triu chng a chy l chnh bnh khi vi au bng qun, st cao > 39 C, bnh nhn nhanh chng b nhim trng nhim c, sau tiu chy xut hin, phn khng thi, v sau phn c th t mu. Th lm sng ny thng gp tr em v hay co git vi t l 1045 % nu km theo st cao. Tuy vy cng c trng hp tr khng st cao nhng vn co git. Cc biu hin thn kinh ny c th khin nhm vi mt s bnh l ca h thn kinh trung ng nh vim mng no m, vim no hay hi chng no cp. Triu chng co git i khi xy ra trc khi tiu chy hay a phn mu gy kh khn cho chn on ban u. Trong th ny cn c mt s triu chng khc nh hn m, th khng u hoc ngng th ging nh thy trong hi chng Reye, hoc l m l ln, c c cng v c o gic ( lc ny thm trc trng c khi gp nhy mu gip hng ti chn on )

55 Trc y ngi ta cho rng cc triu chng ny l do c t ca Shigella gy ra, nhng hin nay kin ny b bi b. Trong mt s trng hp ngi ta ghi nhn c h Calci v Natri mu cng nh thy bin i v t bo v protein trong nc no ty. Cn lu l vim mng no do Shigella rt him gp. Trong th tiu chy c th km theo du mt nc. 4.2. Th nh (thng do nhim S. sonnei) Biu hin vi tiu chy nh hoc khng c triu chng r ch au bng m , a chy thong qua v bnh t gii hn .

VI. CN LM SNG
1. Cng thc mu t c gi tr chn on, bch cu tng vi a nhn trung tnh tng, i khi km phn ng tu gy tng bch cu mu > 30.000 bc/mm3 mu ( him gp).. 2. Xt nghim phn T l phn lp vi trng t phn ti thp nn cn cy phn 3 ngy lin tc, kt qu (+ ) t c trong 24 h sau khi bnh nhn c triu chng lm sng, t l cao nht l trong 3 ngy u ca bnh v ko di vi tun nu khng iu tr khng sinh. 3. Soi trc trng Thy hnh nh vim lan ta cp tnh nim mc trc trng vi nhng lot cn c xut huyt. 4 . Huyt thanh chn on: t c gi tr chn on trn thc t - Phn ng min dch hunh quang trc tip - Phn ng ngng kt :

VII. CHN ON PHN BIT


c t ra vi nhng bnh vim i trng c cc triu chng st, i cu phn c mu v c bch cu trong phn do: 1. E .Coli: c 1 s nhm E.coli gy hi chng l - EIEC (E.Coli Entero-invasive) bnh xy ra tr em, ngi ln, vi hi chng l tng t nh l trc khun. - EHEC (E. Coli Entero Hemorragique colitis): gy i chy phn nhy mu. 2. Yersinia Yersinia enterolytica hin din trong nhiu thc n nh rau, tht, sa... Bnh cnh lm sng gm mt hi chng tiu chy c st v au bng vng h chu phi, c khi c mu trong phn c th xy ra vng khun huyt hay nhim khun huyt, sau giai on nhim trng c th pht hin hng ban dng nt hay vim khp dng thp, trong giai on a chy, chn on da vo cy phn, cn huyt thanh chun on c gi tr th ngoi ng tiu ha, bnh ny gy sng hch mc treo rut, nht l vng hi manh trng. 3. Campylobacter jejuni Hin din trong ng tiu ha ca nhiu ng vt v gia cm, ly sang ngi qua ng tiu ha, gy bnh cnh vim rut, hay gp tr em sng trong iu kin v sinh km. Thi gian bnh 1-3 ngy, lm sng biu hin i chy c st, phn thng c mu km au bng. Bnh thng din bin lnh tnh. 4. Vim i trng mng gi (do Clostridium difficile )

56 Thng xy ra trong lc ang dng mt s khng sinh ko di hay sau khi ngng khng sinh. Lm sng: st cao 39 -40 C km ton thn suy sp, au bng d di v a chy c khi km mu v mng nim mc (mng gi). Bch cu mu tng, a nhn trung tnh tng. Chn on da vo: soi i trng, c th quan st thy nim mc i trng xung huyt v ph vi s hin din mng gi di dng nhng mng nh trng vng t vi mm n vi cm. 5. L amip Do Entamoeba histolytica, khng st, ton thn t thay i, s ln i cu thng < 15 ln / ngy, phn thnh khun km nhy mu bm phn v cui bi c vi git mu. V lm sng i khi rt kh phn bit l trc trng vi cc nguyn nhn k trn, tuy vy phn ln trng hp i cu phn c mu km st, cc nc ang pht trin c xem do Shigella (v bnh ph bin hn ).

VIII. BIN CHNG


Thng t xy ra ngay c trng hp khng iu tr tr tr nh v ngi gi . 1. Bin chng ti ch 1.1. Hoi t rut: Bnh nhn i cu ra mt cht dch nng mi km mng hoi t mu xm hay mu en . 1.2.xut huyt : Bnh nhn i cu ra mu ti nhiu gy thiu mu cp 1.3. Thng i trng gy vim phc mc ( t gp ) 1.4. Ri lon vi khun ch (do l ko di hoc dng khng sinh ko di ) . 1.5. Sa trc trng 2. Bin chng ngoi rut 2.1. Suy dinh dng tr em, l bin chng thng gp ca l trc khun, tn thng let trong l trc khun l ngun gc mt m qua tn thng, do nhu cu c th lm lnh vt let v do chn n khi b bnh. Thng gp bin chng ny khi c khng thuc. L trc khun l bnh tiu chy gy suy dinh dng thiu m nhanh nht. 2.2.Mt nc v in gii nht l h Natri mu, c th gy suy tun hon , suy thn 2.3. Vng khun huyt: Bin chng vi t l 8% nhng bnh nhn b l ti Dhaka, Bangladesh, vng khun huyt thng do Shigella dysenteria type 1 hn cc chng khc v t vong cao (20-50 %) c bit i vi tr nh tr nh tr suy dinh dng v ngi gi. 2.4. Hi chng huyt tn ure mu cao. Bin chng ny xy ra vi S. dysenteria typ 1 (cng c th vi S. flexneri) v thng xut hin vo ngy cui ca tun th 1, trong khi hi chng l bt u n nh. Hi chng ny c lin quan n vai tr ca c t shigatoxine (Enterohaemorrhagic E coli cng c c t tng t nh shigatoxine v cng gy huyt tn ure mu tng). Biu hin lm sng l t nhin bnh nhn da ti xanh, tiu t v dn dn v niu gy suy thn, thiu mu, suy tim, xt nghim cho thy Hct gim nhanh, cng thc bch cu c hnh nh gi bach cu cp, tiu cu gim . Cc bin chng nh vim phi, vim m o, vim kt gic mc v pht ban t gp. Hi chng Reiter gm vim khp, vim niu o, vim kt mc mt c th gp ngi c khng nguyn tng hp HLA - B 270 (hi chng ny do chlamydia, bedsonia ch khng phi shigella nhng hay xy ra ng thi vi l trc khun).

IX. IU TR
1. iu tr c hiu

57 ngi mnh khe, bnh c th t gii hn. Khng sinh c vai tr rt ngn thi gian bnh v thi gian thi khun ra phn, dng khng sinh ngm qua nim mc rut. Vi cc khng sinh nh sulfamide, streptomycin, tetracyclin, chloramphenicol khng nn dng v t l khng thuc qu cao, cn ampicilline th ch nhy vi a phng, c th dng cotrimoxazol hay acide nalidixic trong khi i kt qu khng sinh . Do c im khng nhanh vi khng sinh ang dng, ngi ta tm kim cc khng sinh mi v an ton hn. Hin mt s khng sinh mi c hiu qu tt trong iu tr l trc khun nh: + Nhm fluoroquinolon: Liu lng : ngi ln, dng 1 trong cc lai sau : - Ofloxacin 200mmg x 2 vin/ ngy - Ciprofloxacin 500 mmg x2 -3 vin / ngy Cc fluoroquinolone iu tr l trc trng ngi ln vi hiu qu tt, nhng tr em cha c nh gi v gy tn thng sn xng v chm tng trng xng sc vt th nghim. + Nhm cephalosporin th h 3: - Cefixime 8 mg/kg/ngy, ngi ln 400 mg/ngy - Ceftriaxone 50 mg /kg /ngy, ngi ln 2g/ngy Ngoi ra trong trng hp khng thuc c th dng: Azithromycin: 12 mg/kg ngy th nht, 6 mg/kg x 4 ngy tip theo Thi gian iu tr khng sinh l 5 ngy . 2. iu tr triu chng - Bi hon nc v in gii: Trong giai on khi pht tiu chy t d dn n ri lon nc v in gii nn cn thc hin nh cc trng hp tiu chy khc vi dung dch ORS ung sm hoc chuyn dch nu mt nc v in gii nng. Trong trng hp suy kit nng cn truyn plasma, alvesin, chuyn mu nu mt mu nhiu. - Khng c dng cc thuc lm gim nhu ng rut v gim au, cc loi dn xut t cy thuc phin v khng nhng chng lm chm thi vi khun v ko di thi gian bnh m cn c th lm cho bnh nng thm, lm c ch h hp, lit rut, chng bng. Trng hp bnh nhn au bng nhiu, mt rn nhiu, e da sa trc trng c th cho thuc an thn nh diazepam - H nhit khi st cao , km theo thuc an thn phng co git. 3. Ch n Bnh nhn n cht dinh dng, gio dc nhn dn b tp qun n king khi b a chy ni chung v c bit l l trc khun v l mt bnh gy suy dinh dng nhanh nht.

X. TIN LNG
T vong t xy ra i vi tr khe mnh, tr ln hay ngi ln tri li tr suy dinh dng, tr nh, ngi gi suy kit, b h thn nhit mt nc v ri lon in gii nng, suy thn, vng khun huyt l nhng yu t tin lng nng .

XI . PHNG BNH
1. Gio dc y t Qun chng phi c thng v cch ly truyn v cch phng chng s ly truyn , c th tuyn truyn gio dc ti nh, c s y t, trng hc 2. Ra tay bng x phng

58 C th l bin php hu hiu nht phng chng s ly nhim, vic ny cn c khuyn khch n tng gia nh, ra tay sch sau khi i cu, sau khi ra ry cho mt a tr khi i cu sau khi phn ca tr, trc khi nu n v trc khi n, nu khng c x phng c th ly tro ra bn tay. 3. An ton thc phm - Khng n thc n sng tr nhng rau qu ti c th bc v v n ngay sau khi bc - un nu thc n cho n khi chn - n thc n khi cn nng hoc un li hon ton trc khi n - Gi thc n nu v bt a sch cch ring vi nhng thc phm sng v nhng bt a c th b nhim . - Ra k tay bng x phng trc v sau nu n - Khng rui bu vo thc n bng cch y lng bn. 4. Nc ung sch Nc cung cp bng h thng ng phi c clor ha cn thn vi hm lng cho php . Khi dng nc ly t sng ngi h ao hoc ging khi ch ly nc phi c bo v trnh cho ngi v sc vt lm nhim, khng c cho nc ma chy vo ch ly nc ung, ch phng u khng c php gn ch ly nc trong phm vi 10 m v phi di ngun nc. Khi ngun nc ti ch chc chn b nhim phi cung cp nc ung tm thi bng xe c tc ch nc. Gia nh c th tr nc trong cc chum vi c np y khng cho sc vt n gn v dng 1 go ging c cn di mc. Nc ung phi un si . 5. Thi phn Phi bo m x l an ton cc cht thi ca ngi, phi c h thng h x thch hp vi iu kin a phng . Gio dc y t cn nhn mnh n vic tng ngi phi s dng ng cc h x k c tr con, cn phi nhn mnh n vic phng u ra t gn ngun nc. nhng ni khng c h x vic phng u phi thc hin trong nhng ni quy nh v phi chn phn 6. Phng chng s ly lan ti cc c s y t Cung cp y nc v x phng ra tay Ra tay bng x phng trc v sau khi khm bnh. Khng c phn nhng nhn vin y t phc v nhng bnh nhn l vo vic nu bp hay phc v vic n ung chung. Phi phn bnh nhn vo nh v sinh, thng xuyn git gi v ty u qun o , vi tri ging ca bnh nhn. 7. Khng dng khng sinh phng chng l trc trng, vic ny khng t ra c kt qu m cn lm tng khng thuc v lm cho vic iu tra bnh tr nn kh khn. 8. Vaccine - Cc vaccine cha vi khun cht thng khng c hiu qu. - Ngi ta nghin cu 1 loi vaccine cha vi khun sng gim kh nng gy bnh bng cch lm mt kh nng xm nhp hay chuyn 1 phn nhim sc th t E.coli sang shigella .Tuy nhin cc phng php ny cha cho kt qu hon ho. Cu hi n tp 1. Vai tr ca c t trong bnh sinh ca l trc khun

59 2. Nu mt ch n c th cho mt bnh nhn l trc khun v gii thch 3. Lm sng ca l trc khun th ko di 4. Chn on phn bit l trc khun v l amip 5. iu tr mt trng hp l trc khun c try tim mch

60

Bi 10.

BNH DCH T
Ths, BsCK1 ng thi Nga

Mc tiu
1. Phn tch c cc c im dch t hc ca bnh dch t 2. Gii thch cch gy bnh ca vi khun t 3. M t lm sng mt bnh nhn dch t v nh gi mt nc , ri lon in gii 4. Ch nh cc xt nghim c gi tr chn on xc nh. 5. iu tr c bnh t v tuyn truyn phng chng bnh dch t

Ni dung I. I CNG
Bnh dch t l mt bnh nhim trng nhim c cp tnh ca ng tiu ha, c th lan trn thnh dch ln gy ra do Vibrio - cholera ch yu nhm O1 v O139 Lm sng c trng l tiu chy d di km nn ma dn n hu qu mt nc in gii, nu khng iu tr kp thi s t vong do kit nc v ri lon in gii .

II. TC NHN GY BNH


Tc nhn gy bnh do Vibrio cholera. Vi khun ny l loi trc khun gram (-), hnh hi cong nh du phy, di ng c nh c mt lng u . Vibrio cholera c khng nguyn thn O v khng nguyn lng H. Cn c vo tnh c hiu ca khng nguyn thn O ngi ta chia vi khun t ra lm 6 nhm k hiu O1-O6 . Vi khun gy bnh nm nhm O1. N gm c hai type sinh vt l Vibrio Cholera v Vibrio Eltor v ba nhm huyt thanh Inaba, Ogawa, v Hikojma. Ngoi ra cn nhm huyt thanh mi serotype O139 c th gy bnh n v Banglades. Vi khun t c sc khng yu, b tiu dit nhit 55oC/1gi v 80oC/5 pht . ngoi cnh sng c kh lu nh sng ngi, ao h nht l khi nc nhim mn c th 3- 50 ngy. Khng sng c trong sa chua, ru vang, mi trng kh ro .... Nui cy c khi c106 vi khun/g phn. Mi trng nui cy thng l canh thang, pepton kim pH 8,6 hoc thch kim mui, hoc thch TCBS (Thiosulfat Citrate Bile Salt). c t vi khun t: Vibrio Cholera sn xut c t rut gi l choleragen (ging nh cholera enterotoxin) gm 2 thnh phn A: Phn hot c (Active) B: Phn gn dnh (Binding) Phn B ca c t gn vi th th GM1 ( ganglioside) b mt t bo biu m nim mc rut, sau phn A s xm nhp vo t bo biu m rut . S c mt ca phn A trong t bo s gy mt chui ri lon trong ng k l s hot ha men adenylcyclase (c thnh t bo nim mc rut), lm cho ATP (c trong t bo nim mc rut) bin thnh AMP vng. Khi AMP vng gia tng th t bo biu m rut s tng thi in gii qua mng t bo vo lng rut ko theo mt lng ln nc.

61
c t rut (+)

Adenylcyclase

ATP
Thi Na+, Cl-, HCO3-,H2O

AMPC S c ch gy a chy trong t

III. DCH T
Bnh t c t lu trn th gii, bt ngun t chu th sng Hng (n ) v c nhiu i dch xy ra . Ngy nay nh c vaccine v bin php kim dch cht ch do bnh xy ra ch yu cc nc km pht trin . Trong 3 thp nin cui ca th k 20, i dch ln th 7 trn ton cu xy ra, do V. Cholera O1, biotype Eltor lan trn t n v ng nam sang chu Phi, Trung, ng, Nam chu u v cc o Ty Thi Bnh Dng. Nm 1991 dch t nhm V. Cholera O1, serotype Inaba biotype Eltor lan n Peru v hu ht cc nc Bc v Nam Phi. M, c ri rc vi trng hp do ngi du lch t chu M la tinh hoc Chu mang sang c ghi nhn. Nm 1992 c 358.581 trng hp mc bnh v t vong 3871 trng hp trong 14 nc Bc v Nam Phi Nm 1993 dch xy ra do V. Cholera O1, biotype Eltor. Tng s c 376.845 ngi mc v 6781 trng hp t vong /78 nc. T l t vong l 1,8%. y l con s cc nc c t cao nht cha bao gi c . c bit trong v dch 1993 xut hin serotype non O1 l do V. Cholera O139 ( Bengal), c phn lp t nm 1992 trong v dch ln n , li xut hin ti 7 nc chu . . - Theo WHO nm 2001 chu c 10.340 trng hp, t vong 138 ; chu Phi c 173.359 trng hp , t vong 2590; chu M c 535trng hp, khng t vong ; chu u c 58 trng hp, khng t vong - Vit nam bnh t c ghi nhn u tin nm 1862 qun i vin chinh Php xm lc nc ta, lm t vong gn 1/3 qun s - Ring Vit nam theo thng k ca vin V sinh dch t Trung ng nm 2002 th t nm 19991 n nm 2000 lun lun c bnh dch t xy ra trn ton lnh th. Tc nhn gy bnh c phn lp trong cc v dch l Vibrio El Tor O1, c typ huyt thanh l Inaba v Ogawa. T nm 1996 t l mc lun lun di 0,85/100.000 dn. Tn s mc cao nht l min Trung v min Nam. Tuy nhin nm 2000 min Bc c dch xy ra Ngh an, Thi bnh, Nam nh, nhng min Nam khng thy xut hin trng hp no. 1.Ngun bnh a s ngi ang mc bnh thi mt lng ln vi khun ra mi trng xung quanh .y l ngun ly chnh. Ngi lnh mang vi khun l ngun gieo rc vi khun tn phm vi rng ln 2. Cch ly truyn Bnh c th ly truyn theo hai cch: - Gin tip: L ch yu, thng do: + Ngun nc b nhim vi khun: ngun nc b nhim vi khun ng mt vai tr ch yu trong cc v dch. Khi dch xy ra, th chnh nh vo ngun nc m dch lan ra nhanh

62 chnh v pht trin thnh nh cao ngay vo tun l th 2. Nu x l tt ngun nc, th dch ch ko di khong 10 n 20 ngy. + Thc n: cng ng mt vai tr ng k nh rau sng bn phn ti trong v dch khng x l k, tm, s, hn mm ruc ... - Trc tip: t gp, ch xy ra nhn vin y t, ngi nui bnh hoc nhn vin khm lim t thi 3. Cc yu t nguy c - Bnh thng xut hin vng dn c ng c, iu kin v sinh km, nc khan him - Ngi c t dch vi nh ct d dy, teo nim mc d dy, hoc pH dch v cao - Ti vng dch lu hnh, tr em d mc bnh hn ngi ln, v ngi ln c min dch mc phi trc . Cn trong vng cha c dch, kh nng nhim bnh ca mi ngi v mi gii nh nhau - Ngi c nhm mu O c nguy c mc bnh cao hn 4. Ma nc ta dch xy ra vo ma kh nng t thng 5 n thng 8 khi nc ao h cn kit, nc sng b nhim mn, nhng cng c khi tn pht vo ma ng. Dch c xu hng xy ra 4 nm mt ln. T l t vong cao ngi gi v tr con nht l tr b giun sn v suy dinh dng.

IV. SINH L BNH


Qu trnh gy bnh ca vi khun t c th chia lm 3 giai on: 1. Vt qua hng ro dch v Vi khun vo c th qua ng tiu ha . Mt phn ln b tiu dit d dy bi pH acide y. Do vy m thc n ng vai tr quan trng vi khun vt qua, v thc n c th trung ha tm thi acide dch v . 2. Vi khun sinh sn v pht trin t trng v rut non Phy khun t sng trong mi trng kim cho nn t trng l mt mi trng thch hp cho s pht trin ca vi khun. Ch sau 7 gi vi khun s bao ph ton b b mt ca t trng v sau lan nhanh xung rut non. Khi vo n rut non vi khun pht trin mnh hn, bm cht vo thnh rut n n tn y cc nhung mao, nhng khng xm nhp gy tn thng t bo biu b nim mc rut . 3. Sn xut c t Vo n rut non vi khun pht trin v sn xut c t. c t t vo trong t bo nim mc rut khong 10 pht sau th kch hot, gy cc bin i ln : - T bo crypt (hang): tng thi in gii v nc d di. - T bo goblet (tit nhy): tng tit cc cht nhy (lm sng thy cc ht ln cn trng). Cc t bo villus (nhung mao) khng b nh hng, do kh nng hp thu nc v in gii vn nguyn vn, nhng khi khi lng nc v in gii tit ra nhiu vt qu kh nng ti hp thu ca t bo villus th s xut hin tiu chy trn lm sng . Dch tit ra trong lng rut non l mt th dch c xem nh gn ng trng so vi huyt tng gm c Na+, K+, Cl- ; khng c hng cu, bch cu ; protein < 200 mg % v nc . Tiu chy nhiu a n hu qu gim th tch tun hon, chong v t vong. Thnh phn in gii trong phn c khc nhau ty la tui, nhn chung tr em mt nhiu + K cn ngi ln th mt nhiu HCO3Min dch trong t l mt loi min dch khng bn. S hnh thnh khng th c xut hin bi bn thn vi khun v c t t, do c khng th khng khun v khng th khng c t . Da trn tnh cht ny ngi ta sn xut c 2 loi vaccine : vaccinee vi khun v vaccine c t (s dng phn B ca c t)

63

V. GII PHU BNH


- Rut: cc quai rut mu tm, trn vi th lp biu b vn nguyn vn. - Thn: Tn thng l hu qu ca s mt nc khng b c - Gan: c th to ra, ti mt c th cha mt cht dch mu en rt qunh, c khi tm thy vi khun t trong mt - Cc c quan khc: Ch tm thy mt tnh trng kit nc trm trng

VI. LM SNG
C nhiu hnh nh lm sng khc nhau t nh n nng 1.Th in hnh 1.1 Thi k bnh: Vi gi n vi ngy, trung bnh 4 gi n 1 ngy khng c triu chng c bit. 1.2 Thi k khi pht: t ngt, bnh nhn c th thy kh chu, si bng, bun nn v nn, km tiu chy. Lc u nn v tiu chy cn c thc n v phn, v sau ton nc . Ton thn khng st, khng au bng (tr ngi gi), c khi cm thy gai rt v au bng lm rm. 1.3 Thi k ton pht Nn ma, tiu chy t v kit nc - Tiu chy xi x: Phn ton nc c l hoc trong c vi ht trng ln nhn nh ht go. Vi khun rt nhiu trong phn, thng > 106/g phn. S ln c th 5-7 ln/ngy hoc 20- 30 ln/ngy. Mi ln c th ln n 1 lt nc. Phn tanh, khng nhy mu, pH kim (8- 8,5). Lng nc mt ti a trong 24 gi u sau gim i - Nn: nhiu tng ng vi tiu chy. Nn xut hin sm l do c t t tc dng ln b phn cm th d dy rut, v sau nn do toan huyt. Trong cht nn cng cha nhiu vi khun . - Kit nc v ri lon in gii: l hu qu ca nn v tiu chy . Lm sng rt r vi: * Da kh, casper (+), mt trng . * Mt kh, khng c nc mt * Hng kh, ni thu tho, th nhanh nng * Chut rt cc c (c bng th phi chn on phn bit vi au bng) * Mch nhanh nh, huyt p tt kp, try mch hon ton, i t hoc v niu. Bnh nhn vn tnh to hon ton cho n khi cht Cn c vo s mt nc, c th chia lm 3 x tr * 1: Du mt nc nh, casper (+) kht nc. Mch nhanh nhng huyt p n nh. Mt < 5% trng lng. Mt 50 ml / kg. * 2: Nn ma, tiu chy nhiu, casper (++), mch 100 ln /pht, huyt p ti a 70- 80 mmHg. Mt 6-9 % trng lng, hoc 70- 80 ml/kg * 3: Try mch hon ton . Mt > 10 % trng lng hoc 100- 120 ml /kg. V niu, ri lon nhp th, tim nhanh nh, thc l m, u m thiu oxy t bo. Tin trin: 1 v 2 c iu tr hi phc nhanh sau 3- 4 gi. th nng nu b dch nhanh chng v kp thi hi phc tt sau 2 ngy. Da hng, chi m, casper (-), mch, huyt p n nh, tiu c. Khng iu tr t vong cao > 50 % trong bnh cnh c mu, try mch .

VII. CN LM SNG
1. Xt nghim c hiu Phn lp vi khun t phn v cht nn - Soi ti phn:

64 * Knh hin vi thng khng thy vi khun t, ch thy phn khng c HC, BC . * Knh hin vi nn en: Chn on nhanh thy vi khun di ng dng rui bay . Chn on type nh khng huyt thanh chuyn bit cho tng type - Cy: Chn on (+) sau 24 gi 2 Cc xt nghim khc - CTM: HC tng, BC tng - Hct: tng - T trng huyt tng tng - Ri lon v in gii : Na+ bnh thng hoc gim. K+ lc u tng sau gim (nhng s tng nu c suy thn cp), d tr kim gim . - pH phn kim Chn on sm da vo: Bnh xy ra trong v dch, nn ma d di, tiu chy t, phn ton nc c ln nhn cc ht trng mi tanh, khng st, khng au bng. Cc du hiu ny phi c tuyn truyn rng ri trong cng ng bng cc phng tin thng tin i chng, nhm pht hin sm trng hp t u tin kp thi c bin php ngn nga khng cho dch xy ra

VIII. CHN ON GIN BIT


1. Cc bnh tiu chy nhim khun - Nhim trng nhim c thc n do t cu vng: Lm sng gn ging nhng phn thi, tc dng ca c t nhanh hn, tiu chy ngn hn nhng nn nhiu hn v c th try mch. - Nhim salmomella hoc shigella: Phn lng, thi, c au bng v c v mt nhim trng, c st, km nhc u - a chy do Vibrio parahemolyticus, Vibrio minicus ... Lm sng gn ging t nhng tc dng ca c t nhanh hn v thi gian tiu chy ngn hn, c st c au bng . 2. Cc bnh tiu chy khng nhim khun - St rt c tnh th tiu ha - Ng c: Arsenic, nm, sn, thy ngn. - Tng ur mu...

IX. IU TR
Cn phi nhanh chng, khn trng, ng quy cch. Nguyn tc iu tr - Cp cu try tim mch: b nc v in gii. C th b bng ng ung hoc tuyn tnh mch. Vi ng ung c th s dng cc loi nc sn c nh nc go rang, nc hoa qu,nc cho, dung dch ORS, - Khng sinh c hiu. Tetracycline l thuc u tin c ch la iu tr t. y l lai khng sinh thng thng, r tin, c th s dng rng riti cng ng khi c dch xy ra, ngoi tr tr nh v ph n c thai thi thay bng ampicilline hoc bactrim 1 B nc v in gii C hai giai on mt nc cn c quan tm l lng nc mt trc khi iu tr v trong khi ang iu tr. 1.1 Xc nh lng nc mt tnh lng dch b
Mt I <5% II 6- 9 % III > 10 % Bng 8: mt nc v lng dch b Tng ng 50 ml / kg 70- 80 ml /kg 100- 120ml / kg B 40- 50 ml/kg 60-80 ml/kg 100-110 ml/kg

65 1.2 Chn dch: Thnh phn phn t c khc nhau gia ngi ln v tr em
Nng mEq/l Phn t ngi ln Phn t tr em Na+ 135 105 K+ 15 25 Thnh phn Cl100 90 HCO345 30

Mt dung dch thay th cn phi bo m cung cp Na+: 130 -155mEq/l, Cl-: 90 - 110 mEq/l, vi p lc thm thu 250-290 mosmol/l HCO3-: 28 - 52 mEq/l K+: 15- 20 mEq/l V chc nng hp thu ca nim mc rut vn tt v glucose s chim ch lin kt ca phn B c t t nim mc rut nn T chc y t th gii khuyn co nn ung sm dung dch ORS. Ngoi ra, tr em mt K+ rt quan trng, ngoi vic ung ORS, truyn dch nn kt hp ung km KCl nu dch khng cha K+. Dung dch ORS c cho trong 4 h u
Tui Trng lng (kg) Lng (ml) dch ORS < 4 th <5 200-400 4-11 th 5-7,9 400-600 12-23 th 8- 0,9 600-800 2-4 tui 11-15,9 800-1200 5-14 tui 16-29,9 1200-2200 >15 tui > 30 2200-4000

1.3 Cc giai on b dch - Giai on 1: B nhanh li khi lng tun hon, c th truyn 2-3 dy. Tr em c th bm trc tip tnh mch, cho n khi c mch bt c, gim tc dch truyn (1/2 lng nc mt b trong 1- 2 h u, 1/2 cn li trong 2-3 gi k). Ch bnh nhn gi, c bnh tim, ph mn tnh gim tc dch truyn . - Giai on 2: Dch duy tr: Nn nh bnh nhn vn tip tc nn v tiu chy trong giai on u iu tr vn nn phi ttp tc duy tr dch vi tc nhanh hay chm ty theo din bin lm sng (c th > 100 git/pht) ng vi gim tc dch truyn cn 20- 30 git/ pht v bnh nhn d try mch tr li v trnh suy thn do gim cung lng tun hon qu lu. Khi HA, M tr v bnh thng bnh nhn nn nn cho ung ORS. Ngng truyn khi ti tnh da, nim mc bnh thng, ht tiu chy, phn st vng (thng khong 12- 24 gi sau khi b dch ) Nn nh khng dng cc thuc nng HA nh: Isuprel hoc dopamin, corticoide... 2 Khng sinh Khng sinh c hiu iu tr vi khun t l:
Khng sinh Tr em Chn la u tin Tetracyline Doxycycline Khi khng vi IMP-SMX Tetrcyline Furazolidone 12,5mg/kg x 4l/j x 3j Liu duy nht 6mg/kg 5mg+25mg/kg x2l/j x3j 1,25mg/kg x4l/j x3j Liu lng Ngi ln 500mg x4l/j x 3j 300 mg liu duy nht (160+800)ng x2l/j x3j 100mg x4l/j x3j

Hu ht kim tra phn (-) sau 48 gi C th dng Chlorocide, Bactrim, Ampicilline... 3. iu tr triu chng

66 Khng nn cm tiu chy bng cc thuc lm gim nhu ng rut nh morphin, atropine... hoc cc thuc loi hp ph nh pectin, kaoline, than hot... v lng nc mt vn tip tc tit ra trong rut m khng tng ra ngoi, nn khng tnh c lng nc mt thc s. C th dng aspirin, indomethacine, chlopromazin... gim s bi xut nc, in gii qua c ch gim AMP vng. Cc tai bin cn ch trong khi iu tr t - Co git do truyn nhiu nc qu - Suy tim tri, OAP do tha nc hoc vn tc truyn qu nhanh - Chong dch truyn - Gim K+ gy lit rut v ngng tim 4.Vn nui dng - Vn tip tc cho tr b m hoc b bnh. - Khi ngng nn ma, ch tit thc bnh thng khng thay i

IX.PHNG BNH
1 Gio dc sc khe Gio dc sc khe cho dn chng l iu thit yu trong phng chng bnh t. Cc thng tin quan trng phi n tn nhm dn hay vng cn quan tm bng cc phng tin truyn thng i chng hoc ph bin ti trng hc, cc bui hp thn x . 2 Gim st t Theo quy nh ca t chc y t th gii (WHO 1969) th c quan ph trch y t quc gia phi bo co cc trng hp nghi ng t ti ni ca mnh cho t chc y t th gii cng nhanh cng tt v bo co s trng hp mc bnh cng nh t vong do bnh t . gip vic gim st ti a phng c thc hin d dng, bo co phi y chi tit sau: - Tui - V tr a l/ a ch - Nhp vin hay khng nhp vin - Kt qu iu tr Cc thm tra v dch t hc ca v dch cn phi cho nhng thng tin chi tit v ngun ly v ng ly truyn bnh. 3 phng s lan truyn rng ri ca bnh t - Cch ly dch, kim tra dch v kim sot bin gii khi ang c dch xy ra mt vng no - Hn ch tp trng ng ngi nh trong cc tang l, hi h, hp ch trong vng dch t ang e da, v dch c th lan rt nhanh qua thc n, nc ung. Nu cn thit phi t chc cc cuc hi hp th phi thit lp cc bin php bo m cung cp nc sch, nu n an ton v x l phn hp v sinh - Cung cp nc v v sinh: Bo m cho mi ngi c y h thng x l phn v nc ung an ton, i tiu ng ni quy nh, ung nc un si ngui, st trng h thng phn phi nc v h thng nc ti nng thn bng clo v iod . V sinh thc phm: * Trnh khng thc n, nc ung b nhim bi phn, khng n tri cy, rau sng gn t c ti bng nc b nhim phn hay bn phn ti. Nn n thc n nu chn . * Khng nn n thc n c ch bin hay thu hoch ti vng nc b nhim nh s, hn, tm lm gi (khng nu) hoc nu cha chn . * Cc thc n p lnh hay ng lnh ch hn ch sinh sn ca vi khun t nhng li ko di s sng ca n . * Cc thc n c th xem l an ton, t c nguy c cha Vibrio Cholera nh:

67 Thc n chua pH < 4,5 Thc n un nng, tit trng, ng hp. Hoc cc thc n cha t nc nh: Rau kh, sa bt, thc n bo qun bng mui nh c mui, thc n bo qun bng ng nh mt. 4 Chng nga Ngy nay c ba loi vaccine t ung cho thy an ton v hiu qu. Nhng vaccinee ny c php s dng mt s nc v khch du lch. Mt loi vaccine kt hp gia xc ton phn Vibrio cholera O1 vi phn B ca c t t ti t hp c tinh ch (WC/rBS: killed Whole Cell V cholera O1 with purified recombinant BSubnit of cholera toxin). Kt qu th nghim Bangladesh, Colombia, Peru, Sweden thy an ton v hiu lc bo v 85 - 90% sau 2 ln ung cch nhau 1 tun. Bangladesh hiu lc bo v gim nhanh sau 6 thng tr nh, nhng vn cn khong 60% tr ln v ngi ln sau 2 nm. Mt bin th ca vaccine WC/rBS khng cha phn c t B ti t hp c sn xut v th Vit Nam. Dng 2 liu cch nhau 1 tun. Th nghim Vit Nam t 1992 - 1993 thy hiu qa bo v khong 66% trong 8 thng cc nhm tui. Ch c giy php dng Vit Nam. Mt loi khc l CVD - 103 -HqR c th nghim nhiu ni vi mt liu duy nht cho thy hiu qu an ton v min dch cao. Trn ngi tnh nguyn M cho thy 1 liu vaccine ung duy nht hiu qu bo v n 95% chng li Vibrio cholera c in v 65% chng li Vibrio cholera El Tor sau 3 thng. Thng 5/1999 WHO triu tp mt cuc hp bn v gi tr s dng ca vaccine t ung v a ra khuyn co nh sau: - Vaccine t ung WC/rBS nn c xem nh l mt cng c ngn chn bnh t trong cng ng c nguy c bnh t xy ra trong vng 6 thng v khng va tri qua mt v dch, bao gm c nhng cng ng c nguy c cao nh ngi t nn, nhng ngi dn thng tr trong cc khu chut ca thnh ph. - Mt l t nht l 2 triu liu vaccine t ung WC/rBS nn c trang b s dng trong nhng vng c nguy c cao, c s ny cn c b sung kp thi. - L vaccine ny c nh gi bi mt nhm c vn cc nc qua theo di tng trng hp v phi thng xuyn lin h vi nh sn xut vaccine - Vic s dng vaccine t t l ny nn c lin kt chc ch nh gi nh hng ca n trn sc khe cng ng. 10.5 Ha d phng Trc y ngi ta c p dng bin php ha d phng rng ri bng khng sinh cho cng ng ang c dch nhng khng mang li kt qu mong mun hn ch vic lan truyn bnh t v bnh thng lan truyn rt mnh trc khi ha d phng c t chc v hiu qu ca thuc ch c 1- 2 ngy sau ngun ung d dng b nhim bnh . c hiu qu ti a, ha d phng chn lc phi thc hin nhanh trong khi trng hp u tin xy ra gia nh, tt c nhng ngi n ung chung, sinh hot chung vi bnh nhn u phi ung thuc. Khng sinh v liu dng d phng cng ging nh trong iu tr trong dch t Thuc u tin l doxycycline ung 1 liu duy nht 300 mg: ngi ln v 6 mg /kg tr em. Cu hi n tp 1. Trnh by cc c im dch t hc ca bnh dch t 2. M t c ch bnh sinh ca vi khun t 3. M t bnh cnh lm sng, nh gi mt nc, ri lon in gii do bnh dch t gy ra. 4. M t cch iu tr bnh dch t. 5. Tm tt cch phng chng bnh dch t

68 Bi 11.

BNH THNG HN
BsCK2, Ths Phan Qun

Mc tiu
1. Xc nh c tm quan trng, tnh ph bin ca bnh i vi i sng nhn dn. 2. M t cc c im chnh ca tc nhn gy bnh, cch ly v cc yu t nguy c. 3. Gii thch triu chng lm sng, bin chng bng c s gii phu bnh v sinh l bnh. 4. Chn on lm sng sm, mun, cc bin chng, v cc th lm sng 5. iu tr c th bnh thng thng v m t cch thc phng chng bnh.

Ni dung I. I CNG
Vi khun Salmonella gy bnh ngi gm cc bnh cnh chnh nh nhim khun khu tr, vim d dy - rut cp tnh, nhim khun huyt, bnh thng hn - ph thng hn. Vim d dy - rut cp l nguyn nhn hay gp cc nc ang pht trin, th n bnh thng hn ph thng hn. Trong phm vi bi ny chng ti ch trnh by v bnh thng hn. Vim d dy - rut cp tnh (cn gi nhim trng - nhim c thc n) c trnh by mt bi ring trong mt phn khc ca gio trnh ny, ring nhim khun khu tr v nhim khun huyt cc bn c th tham kho thm u trong cc gio trnh bnh truyn nhim c xut bn trong v ngoi nc di tiu nhim Salmonella khng gy bng thng hn (Salmonella spp.). 1.nh ngha Thng hn - ph thng hn, bnh nhim khun - nhim c ton thn do Salmonella typhi, Salmonella paratyphi A,B,C gy ra. Ly theo ng tiu ha, c bnh cnh lm sng phong ph: st, nhc u, thng gy st ko di nu khng c iu tr, c th gy bin chng. L bnh xy ra quanh nm, cao im vo ma h - thu, gy dch. 2.Tc nhn gy bnh Thuc nhm Salmonellae (Salmonella group), trc khun, c lng, di ng, i kh v k kh ty nghi, ni bo ty , sng lu trong mt. Khng nguyn H (lng vi khun), khng nguyn O (thn vi khun) l ni c t c gii phng khi vi khun b phn hy. Vi khng nguyn b mt, phn nh c tnh vi khun, cho php trnh s thc bo, c Salmonella typhi, Salmonella paratyphi C, Salmonella Dublin, gn ging khng nguyn O. Vi khun thng hn tn ti lu mi trng bn ngoi. 3.Dch t hc 3.1. Phn b v t l Nc ta bnh lu hnh nng min Nam, nht l ng bng sng Cu Long, mt s tnh duyn hi min Trung, mt s tnh min Bc. Thng c dch xy ra. Phn b s mc bnh nm 1995: min Nam 90,9%; min Trung 5,2%; min Bc 3,5%; Ty Nguyn 0,4%. Nm 1986 - 1995 t l mc chung l 0,01 %. T l cht/mc 0,3%. Trn th gii bnh gp cc nc ang pht trin ; cc nc pht trin bnh tn pht hoc nhp vo t cc nc ang pht trin do du lch, cng tc hoc do dn nhp c. T l chung 0,36%, cc nc ang pht trin 0,5%. Bnh hay gp tui thanh thiu nin, lao ng (10 - 40), cng ln tui bnh cng t.

69 Ngi lnh mang mm bnh gp n, t l nam / n: 1/4, 85% ngi lnh mang mm bnh > 50 tui. 3.2. Cch thc ly truyn: c 2 cch ly Trc tip: do tip xc trc tip cc cht thi ca bnh nhn c vi khun nh phn, nc tiu, dng-qun o; t ngi lnh mang mm bnh hoc bnh nhn. Gin tip: cch ly ch yu, thc n, nc ung nhim khun. Rui ng vai tr ly truyn bnh; ngun nc nh sng, ging, ao b nhim khun; thc phm nh c, s, hn, rau, tht, trng, sa b nhim khun. 3.3. Cc yu t nguy c Mi trng b nhim nng, cung cp khng nc sch cho nhn dn. Vn v sinh thc phm khng an ton. Tp qun sinh hot , v sinh km. Tp qun n ung ca mt s b phn dn c cn lc hu, d lm cho bnh ly lan. Nguyn nhn gy gim dch d dy: vim mn tnh, ct d dy, thuc khng acid ko di. Ngi mang mm bnh trong cng ng cha c nghin cu v x l mt cch y .

II. SINH L BNH


Sau khi n, vi khun Salmonella vt qua hng ro ca d dy ti rut non. Qua thc nghim 103 vi khun khng gy bnh, m 105 vi khun gy bnh lm sng chng 27%, ngi tnh nguyn cho thy: ngi nhim lng vi khun cng ln th cng d mc bnh. Cc nghin cu ng vt gi rng Salmonella xm nhp vo phn trn ca rut non, ri vo mu gy nn vi khun huyt khng triu chng v thong qua s bt u theo thi k bnh. Cc vi khun Salmonella ny b cc i thc bo bt, bn trong i thc bo chng vn cn sng. Bt u thi k khi pht, vi khun huyt tn ti lu. Do cha c khng th c hiu dit khun, cc vi khun b thc bo trong dng cn sng, do cc vi khun ny pht trin v nhn ln trong i thc bo nh vo cc yu t ni ti ca vi khun (khng nguyn Vi), gip cho vi khun khng s thc bo, Khi lng vi khun trong i thc bo t mc ti a, chng lm v ri vo mu, mt s b ly gii gii phng ni c t thc y tnh trng min dch qua trung gian t bo, c bit l hot ha t bo Lympho T. gy ra p ng vim ton thn to nn tnh trng st ko di trn lm sng. Tip n vi khun xm nhp vo t chc to nn mt s triu chng: vim ti mt, chy mu tiu ha, thng rut... Khi xm nhp ti mt, cc mng Peyer vi khun li vo lng rut, nn tun th 2 cy phn dng tnh. Xm nhp vo thn, cy nc tiu dng tnh. Ni c t vi khun lipopolysaccharide (LPS) gp phn gy st, h BC, v cc triu chng ton thn khc qua trung gian ca cytokin phng thch ra t cc n nhn i thc bo, khi c th b nhim Salmonella. Bnh c min dch bn t khi mc li ln 2.

III.C TH BNH
Bnh nh hng n nhiu c quan, nh gy tn thng r nt rut, hch mc treo. 1.Rut Thng gp on 30 cm cui hi trng, him khi i trng, thng tn ch yu l cc nang kn, mng Peyer, cc thng tn tri qua 3 giai on: 1.1. Giai on thm nhim Trong giai on khi pht, nim mc b xung huyt vim long, cc nang bch huyt kn, cc mng Peyer sng v g ln b mt ca nim mc, c mu hng, lc u cn cng sau mm nhn. 1.2. Giai on lot T sau ngy th 10, vng gia mng Peyer bt u hot t, lot rng hnh bu dc, c lc dy 2 cm, c lc lot su vo lp thanh mc d gy xut huyt v thng rut.

70 1.3. Giai on ha so Thng xy ra vo tun th 4, tng sinh v pht trin t chc ht, nhng khng bao gi gy hp lng rut. 2.Cc c quan khc 2.1. D dy Chy mu khu tr lot rt him khi xy ra. 2.2. Lch Sng mu ta, cc tiu th Malpighi cng din bin qua 3 giai an trn: thm nhp bch cu a nhn v i thc bo, cc hoi t khu tr, ha so. 2.3. Gan Thng sng, t tp t bo mn ch m gan, phn ng vim ng mt, c th c p xe nh trong gan. Vim ti mt. 2.4. Tim Vim c tim, c tim nht mu v c chm xut huyt ri rc, thoi ha ht, thoi ha m, hoc thoi ha hyalin.

IV. LM SNG
1.Th bnh in hnh 1.1. Thi k bnh Thng l 15 ngy, ngn di ph thuc vo lng vi khun xm nhp, khng triu chng. 1.2. Thi k khi pht Trung bnh 1 tun, bnh c tnh cht tng dn. - nh hung ton thn : nhc u, mt mi, mt ng. - St: lc u nh, tng dn ln trong vng 4-7 ngy, sng thp chiu cao, chnh 0,5 - 10C, st nng c khi km theo lnh run. - Ri lon tiu ha: chn n, to bn, bun nn. - Chy mu cam: 1- 2 ln. - Khm lm sng: li hoc trng bn, bng chng nh, din lch dc, mch nhit phn ly ( du c in) hin nay t gp. 1.3. Thi k ton pht Bt u tun th 2, ko di 2 - 3 tun. - Nhc u, tai, lng tai. - Du hiu ton thn: ngi rt mt, mt ng. - St: mc ti a 39,5 - 410C, lin tc dng cao nguyn, sng chiu chnh nhau 0,50C. - Ri lon tiu ha: phn lng vng, c khi en, 2 -3 ln/ngy, c khi tiu chy nhiu ln, chn n, au bng lan ta. - Du Tuphos: v mt bt ng, ng ngc, nhn chm chm mt khng nhp nhy, thnh thong ni lm nhm, lay gi khng tr li. - Khm lm sng: + Mch nhit phn ly (him gp). + Bng chng, c ch h chu phi, lch to mm, gan to nh, n au. + y phi phi g c; hoc vi ran ph qun, c khi c 2 phi; ho khan. + Hng ban c th gp, 3 dng: Ban dt: gp lng, ngc, tay, chn l mt m hng ban c gii hn r rng. Ban bo tm: gp bng, vng trc 2 mng sn, di v, trn rn, khng bao gi qu 30 nt. Ban dng si: nh si, mc mt lc t u xung chn. + Lot hng Duguet:

71 lot tr trc mn hu, i xng, bu dc, y sch, nut khng au, hng khng , khng sng hch v tinh. + Mch nhanh, tim nhanh, c khi ting tim m (vim c tim). + Li kh bn. 1.4. Thi k lui bnh Bnh nhn c iu tr khng sinh sau 3 ngy (ti thiu) - 7 ngy (ti a) nhit h dn, thi k li sc ngn. Nu bnh nhn khng c iu tr s thi k lui bnh ko di, hi phc ko di. 2.Th lm sng 2.1. Th khi pht bt thng - Khi pht t ngt: st cao 39 - 400C, lnh run, au mi ton thn nh cm, do nhim mt lng ln vi khun (ph thng hn > thng hn). - C khi st vi hm km theo rt run, ri xut huyt tiu ha, hoc thng rut lm cho bnh cnh nng ln. - C khi khi u bng st, km du hiu vim ph qun, rut tha vim, vim ng mt trong gan, d lm lch hng chn on. 2.2. Th bnh theo tui, c a - Thng hn ph n c thai: c nguy c sy thai, sinh non, cc du hiu bng thng kh gii thch (au bng, chng bng...) - Ngi ln tui: bnh t khi gp, thng l nng, st t hay c bin chng try tim mch, bin chng phi, hi phc ko di. - Tr nh: him gp < 6 thng tui, kh chn on lm sng, cy mu kh, cy phn thun li. - Tr ln: mch nhanh, him c du Tuphos, khng li b m sng, st tht thng, i lng hn l to bn, him khi bin chng gim. Kh chn on lm sng. 2.3.Th phi hp Bnh thng hn c th phi hp vi mt bnh khc, lm cho bnh cnh lm sng phc tp thm, kh chn on. Hay gp l phi hp vi st rt, l trc trng....

V. TIN TRIN V TIN LNG


Din bin t nhin khng iu tr, bnh nhn c th t vong trong thi k ton pht do mt s th bnh nng, nu tin trin thun li sau thi k ton pht cc triu chng gim dn, thi k hi phc ko di v c th xy ra cc bin chng. T khi c khng sinh tr liu (1948, chloramphenicol), din bin bnh c rt ngn nhng iu tr khng liu trnh bnh s ti pht 7 - 15 ngy sau khi ngng thuc . Trc thi i khng sinh t l t vong cao, ty theo nhm kinh t x hi. Khi c Chloram phenicol n nay t l t vong <1% ti cc nc pht trin, cc nc chm pht trin t l ny cao hn. Nc ta, t l rt thp.

VI. BIN CHNG


1.Bin chng tiu ha 1.1.Xut huyt tiu ha Lot cc mng Peyer lm v mch mu ; xut huyt nh i cu phn en ; xut huyt nng phn c nhiu mu bm, mu ti, ngi bnh mt l, xanh nht, mch nhanh, huyt p h, c th t vong nu khng pht hin, iu tr kp thi. Xut huyt tiu ha bo trc du hiu thng rut. 1.2.Thng rut Cn phn bit gi thng gp thng hn nng, iu tr mun ; do nh hng thn kinh giao cm bng, triu chng nh thng rut, ch khc: gi thng khng c lim hi. - Thng rut th kch lit (sthenic form)

72 Thng rm r, au bng di hoc h chu phi, bng chng, phn ng thnh bng (+). Khm: bng cng, tu cng au khi thm trc trng, b trung i tin, vng c trc gan mt, huyt p tt, mch nhanh, nhit h, bnh nhn ri vo tnh trng sc, Xquang: lim hi di c honh ; x tr: m cp cu, hi sc ni khoa. - Thng rut th m (asthenic form) Triu chng khng r, kh pht hin: bng chng nh, au khng nhiu, khu tr khng r, mch nhanh-huyt p h. Cn lu tnh trng sc: mt my hc hc, da lnh, rm rp m hi. Phi chp X quang tm lim hi khi nghi thng rut. 1.3. Cc bin chng tiu ha khc v c quan k cn - Thng hn th i trng: a chy nhiu ln, au bng, bng chng. - Vim rut tha, vim phc mc. - Vim gan nhim trng, vim ng mt trong gan, vim ti mt. 2. Bin chng tim mch 2.1. Vim c tim Nhp tim nhanh, ting tim m, lon nhp, ting nga phi, vim c tim gy suy tim cp, tin lng xu, ECG: PR ko di, T v ST o ngc, QRS in th thp. 2.2. Try tim mch Nhit tt, huyt p h, mch nhanh, chn tay lnh, da nht nht, v m hi, mt my hc hc; tin lng nng. 2.3. Cc bin chng him gp khc Vim mng ngoi tim, ni tm mc; vim ng mch chi di, tnh mch (thng chi tri). 3. Bin chng thn kinh 3.1. No vim thng hn Bin chng nng, nh hng n no gia, thnh no tht, cc nhn xm trung ng, vng trn bn hoc ton b trc thn kinh. Tin lng xu. 3.2. Vim mng no thng hn Thng gp tr em hn l ngi ln, c khi nc no ty trong, tng lymph hoc m c, c khi cy Salmonella typhi (+); c khi ch l phn ng mng no. 4. Cc bin chng him gp khc 4.1. H hp Vim ph qun, vim ph qun phi; trn dch mng phi (gp tr em). 4.2. Vim xng, vim khp. 4.3. Vim thn, vim a c, vim dy thn kinh th gic.

VII.CHN ON
1. Chn on lm sng 1.1. Chn on lm sng giai on sm (thi k khi pht): Thng kh, da vo mt s triu chng c tnh cht nh hng - St tng dn, km mt mi tng dn, nhc u, mt ng, mi kh li bn. - To bn ri sau i lng. - Khm khng thy biu hin nhim trng r nt mt b phn c th no. - Bnh nhn sng vng dch lu hnh. - Bch cu mu gim hoc bnh thng, lymph tng tng i. 1.2. Chn on lm sng thi k ton pht Khi triu chng ca bnh xut hin cng lc cng r nt hn nh m t phn lm sng. 1.3. Chn on khi c cc bin chng Xut huyt tiu ha, thng rut, vim c tim, vim no. Xy ra, khi bnh cnh lm sng ko di. 2. Chn on bng xt nghim

73 2.1. Cng thc mu Bch cu gim hoc thng, 4-5 x 109/L, gim Neutrophile (40-50%), nh hng chn on. 2.2. Cy mu T l (+) 80-90% tun u, 50% tun th 2, v sau t l thp (cy mu trc dng KS). 2.3. Cy phn Kt qu (+) cao tun th 2; chn on bnh v pht hin ngi mang mm bnh (sau 1 nm (+)). 2.4. Cy ty xng Kt qu (+) cao, thm ch sau khi dng khng sinh mt thi gian ngn. 2.5. Phn ng Widal - Ti thiu xt nghim 2 ln xc nh ng lc khng th. - Khng th O (+) ngy th 7-10, tn ti trong vng 3 thng. - Khng th H (+) ngy th 12 -14, tn ti nhiu nm. O c gi tr hn H. Nng khng th O = 1/100, H = 1/200 l (+) ngi cha chng nga. Tuy nhin, c th (+) v (-) gi, v c trng hp cy mu (+) m Widal (-) hoc Widal (+) nhng khng phi thng hn. Widal c th (+) trong vi bnh: do cc Rickettsia, mt s bnh gan mn tnh, mt s nhim khun gram (-), nn phn ng Widal c gi tr nh hng chn on m thi. Tm li, chn on xc nh bnh thng hn: + Bnh cnh lm sng + Cy mu hoc cy phn hoc cy ty (+). + Bnh cnh lm sng + Widal (+) vi ng lc khng th cao. 3.Mt s k thut chn on mi (ch tham kho thm): cha dng ph bin nc ta. 3.1. Phng php ELISA - Tm khng th khng Lipopolysaccharide ca Salmonella (typhi-paratyphi A,B,C) v khng th khng Porines. - Tm khng - khng nguyn bao Vi pht hin ngi mang mm bnh mn tnh. 3.2. Phng php ngng kt hng cu th ng tm khng - khng nguyn bao Vi. 3.3. Phng php PCR (phn ng chui polymerase) Lng DNA vi khun trong cc mu nghim (mt, mu, phn) s c khuych i xc nh. 4.Chn on phn bit Trn thc t c nhiu tnh trng lm sng c din bin gn ging thng hn. 4.1.Giai on sm ca bnh (thi k khipht) - St siu vi: St t ngt, au mi ton thn, bch cu bnh thng hoc gim, khng din bin ko di. - St m (Orientia tsutsugamushi): Khi pht t ngt; xung huyt kt mc, da; pht ban; mt mi; vt lot vng kn: tht lng, bn nch....iu tr bng tetracycline, chloramphenicol. - St rt tin pht: Khi pht t ngt, st lin tc, ri lon tiu ha, tm KST st rt, yu t dch t. - Nhim trng cp cc mc khc nhau ti cc b phn c th. 4.2. Giai on ton pht Phn bit mt s trng hp c th gy st ko di. - Cc nung m su (p xe gan, vim quanh thn...) - Cc trng hp nhim trng huyt: cy mu, nhim tin pht, di bnh th pht, sc. - Lao phi: st tht thng, ho ko di, X quang phi, VS, cy mu (-), IDR. Hoc lao ni khc. - Vim ni tm mc cp, bn cp: d nhm vi thng hn nu khng c kt qu cy mu.

74

VIII. IU TR V D PHNG
1. iu tr 1.1. Thuc c tr phng th nghim vi khun thng hn nhy cm nhiu khng sinh, trn c th vi khun sng ni bo ty , nn thuc ngm ni bo tt mi dng iu tr. Cc thuc c in Chloramphenicol, Bactrime, Ampiciline. Thuc mi nh Cephalosporine th h II (cefuroxim), III (cefotaxim...); fluoroquinolon rt hiu qu. Tuy nhin, nc ta mt s ni vi khun thng hn khng acid nalixidic, khi dng Fluoroquinolone thi gian ct st di hn (7 ngy ; thng 3 ngy). Thuc c hai dng ung v tim, ch dng mt thuc khng phi hp. 1.2. Liu lng 1.2.1. Ni cha b khng thuc kinh in: vn c th dng cc thuc sau (r, d kim). - Chloramphenicol: Ngi ln: 1 - 1,5 g/ngy, ung 2 ln (sng - chiu). Tr em : 50 mg/kg/ngy, ung 2 ln (sng-chiu). - Ampiciline hoc Amoxiciline: 50 - 100 mg/kg/ngy /ngy/ 4 ln. - Co-trimoxazol: (Trimethoprim - Sulfamethoxazol): 50 mgTri. + 10 mg Sulfa. /kg/ngy / ung 4 ln, Tt c cc thuc trn u dng lin tc trong 14 ngy. 1.2.2. Vng b khng thuc kinh in: Dng thuc mi - Pefloxacine 400mg; Ofloxacine 200mg; Ciprofloxacine 500mg. Dng 1 trong 3 loi trn, ngy 2v x 7 -10 ngy, ung 2 ln (sng-chiu). - Cefuroxim 1,5g/ngy x 10 ngy (vin 250mg), ung 3 ln /ngy. - Rocephine 1- 2g/ngy hoc Ceftriaxone 1- 2g/ngy x 10 ngy, tim bp 2 ln /ngy. Ht st sau 3 - 4 ngy iu tr. Ph n c thai, tr < 15 tui, dng Cephalosporine th h 2 - 3. Khng dng Fluoroquinolone. Chn la iu tr theo vng, s chp nhn ca bnh nhn theo kh nng chi tr. Tuy nhin, thuc mi c li hn v kinh t v chng tnh trng ngi mang mn bnh do dit sch vi khun 2.iu tr triu chng, chm sc v n ung 2.1. Try tim mch, vim c tim Gim liu KS hoc ngng, hi sc tim mch, Hydrocortison hemisuccinate 100 mg/ngy x 2-3 ngy. 2.2. No vim hoc nhim c nng Nhim c nng dng Hydrocortison hemisuccinate 100 mg/ngy x 2-3 ngy. No vim: Dexamethazole 3 mg/kg, sau 30 pht 1mg/kg c 6 gi/ln/ 24 gi (tim tnh mch 1-2 ngy) + khng sinh (Harrison 1992), theo mt s tc gi nc ngoi th hiu qu cu sng 50% trng hp no vim thng hn. 2.3. Chy mu tiu ha nng Truyn 1 - 2 n v mu, chm bng. 2.4. Kit sc, suy kit do m lu Huyt tng, m thy phn, polyvitamin. Chm sc v sinh rng ming hng ngy. 2.5. Ch n ang st th n lng, xp nghin. Ht st cho n nho, cho, xp ri n c dn nhng trnh cht x. cht dinh dng. 3.Phng bnh 3.1. Khi cha c bnh (d phng cp 0) - Tng cng gim st dch ti cc dch c, cc vng c nguy c cao (ng dn c; v sinh km, s dng nc ao, h, sng; vng bnh lu hnh).

75 - Bo co u n bnh trong khu vc theo quy nh B Y t. - Tng cng ci thin cung cp nc sinh hot, x l cht thi bnh vin, kim tra bin php v sinh an ton thc phm, v sinh mi trng. - Tng cng cng tc tuyn truyn, gio dc v sinh phng bnh cng ng, n chn, ung chn, cng ng tham gia phng bnh bo v c nhn-cng ng. 3.2. Vi bnh nhn (d phng cp 1) - iu tr dt im, liu thuc, trnh iu tr d dang d thnh ngi mang mm bnh. - Pht hin, qun l v iu tr ngi lnh mang mm bnh. 3.3. Khi c dch - Bin php t chc + Thnh lp ban ch o chng dch cca tnh, thnh ph. + T chc i lu ng, trang b thuc men, ha cht, phng tin, h tr ni c dch. - Bin php k thut: + Gim st pht hin, iu tr sm cc ca bnh u tin c pht hin ti bnh vin; pht hin lm sng, cy mu, phn, lm khng sinh . + Thng bo cho c quan y t d phng cng cp, c bin php chng dch v h tr. - Cc bin php v sinh mi trng, tham gia chng dch ca cng ng . + X l phn: x l vi bt hoc ha cht phn bnh nhn trc khi vo h thng chung. + Kh nc sinh hot bng Chloramin B nng chlore 0,3mg/l, nc ging cng vy. + Gii quyt rc: vi bt, dit rui, x l rc cng cng. + V sinh thc phm n ung. + Ly mu thc phm, nc phn lp vi khun, c bit, khu vc c bnh nhn. + Kim tra, thanh tra v sinh thc phm thng xuyn, t xut. + Tuyn truyn n chn, ung chn. + Xt nghim phn cc i tng: ngi phc v n ung, ch bin thc phm, c nui dy tr, ngi tip xc bnh nhn. pht hin ngi lnh mang mm bnh. - Vc xine phng bnh: C 2 loi vc xin phng bnh (ung v tim). C th dng vc xin cho ngi tip xc bnh nhn, cc i tng vng nguy c cao, dch c. Dng theo hng dn s dng. Cu hi n tp 1. M t cc c im chnh v dch t hc bnh thng hn nc ta. 2. M t cc c im chnh tc nhn gy bnh, cch ly, yu t nguy c ca bnh thng hn. 3. M t gii phu bnh, sinh l bnh gii thch triu chng v du hiu lm sng thng hn. 4. Trnh by chn on lm sng sm, mun, bin chng, v cc th lm sng bnh thng hn. 5. M t iu tr th thng thng v th nng bnh thng hn.

76 Bi 12.

BNH ST M
BsCK2, Ths Phan Qun

Mc tiu
1. M t tnh cht ca tc nhn gy bnh, ng ly, c im cn trng trung gian, i tng c nguy c mc bnh. 2. M t lm sng,gii thch mt s triu chng bnh bng c s gii phu bnh v sinh l bnh. 3.Chn an bnh st m th thng thng. 4.M t cc cch thc iu tr. 5. M t cch thc phng chng bnh st m.

Ni dung I. I CNG
Bnh st m c mt trn 1.000 nm trc Nht, Trung Quc. Sau ny bnh c xp vo nhm bnh do Rickettsia, mt ngi M nghin cu v sau ng cht v bnh ny khi nghin cu, l Howard Taylor Ricketts (1871-1910). Hin nay, do cu trc di truyn c s sai bit vi nhm cc rickettsia, nn c xp vo mt nhm ring, c gi l Orientia tsutsugamushi v cng thuc h Rickettsia. Cn trng trung gian bnh l u trng m. Nm 1906 Kitashima v Miyajima xc nh c tc nhn gy bnh v thnh cng trn thc nghim, vi nm sau Wolff pht hin huyt thanh ca bnh nhn st m ngng kt dch nui cy vi khun Proteus OXK (Khng ngng kt vi huyt thanh ca bnh nhn mc cc Rickettsia khc). 1.nh ngha St M, bnh cp tnh do Orientia tsutsugamushi (O.T.), tc nhn gy bnh ly truyn qua vt u trng m t. Bnh c c im khi pht t ngt, gm st 40-410C, kt mc-da xung huyt, pht ban, ngi mt nhiu, thn kinh tr tr, c khi ni sng. c bit ni m t c sn , sau ng vy en. Bnh c th t vong do bin chng phi, tim v gp trong th nng. 2.Tc nhn gy bnh Orientia tsutsugamushi (O.T.) gy bnh st M, trung gian gia virus v vi khun, ging vi khun v c lp v, bo tng, v cc ht vi bn trong, mt khc ging virus v y l loi vi khun k sinh ni bo bt buc, ngha l ch c th pht trin v tn ti bn trong nhn ca t bo ch. Cui cng ngi ta xp vo lp vi khun gram m a dng (pleomorphis), v c kh nng sao chp v nhn ln trong t bo vt ch, cc phn t cu thnh tng t vi khun gram m khc. Chng nhy cm vi khng sinh. O.T. c nhiu dng, nhng 3 dng KARP, GILLIAM, KATO c s dng khng nguyn rng ri. Hnh dng O.T. ging cc Rickettsia khc, do sng ni bo bt buc cho nn pht trin tt trn mi trng nui cy c t bo, tt nht l phi g-vt ; tim vo tin phng mt th, kh, chut nht. Tim vo tinh hon vt th nghim gy vim tinh hon thc nghim. Chut nht trng nhy cm vi O.T. v dng chn on sinh vt hc.

77 O.T. pht trin tt trong iu kin kh hu, a l nhit i v bn nhit i vi nhit ti u 27-280C (22-350C), ma nhiu (lng ma > 1300mm), m cao (> 85%), cy ci rm, nhiu sng sui, rng ni rm rp. 3.Dch t hc Ngi ta ghi nhn st m c mt rt sm, nhiu ti liu m t bnh ht sc phong ph nhiu ni chu . Vi nhiu tn gi khc nh st trin sng Nht Bn; Tsutsugamushi, gi thng hn, st bi rm (scrub typhus). Trn th gii, c ng Nam , Nht Bn, cc qun o Ty Thi Bnh Dng, c bit l vng Pakistan, n , Srilanca, ti Ty-Nam Trung Quc, Triu Tin, i Loan, Ty Tng, v pha bc Lin Bang X Vit c, Tn Guinea, Phi lut Tn, t duyn hi pha bc bang Queensland ti pha ng Australia. Nc ta, theo Bi i, bnh c mt vng Ty Bc, Sn La, Ngh Tnh, Mc Chu. Nam v tuyn 17, trong thi tm chim, mt s y vn ghi lnh M mc bnh. Nh vy, da vo sinh thi, c im kh hu, t liu, cho thy nc ta c s lu hnh ca bnh v c th nhiu dch t nhin. S bnh nhn c th nhiu, nhng do nhiu l do khc nhau m chn on nhm vi bnh khc nh thng hn, st rt, leptospira, dch hch, nhim khun mu, st dengue..., nu khng ch . Ti min Trung, trn thc t lm sng nhiu trng hp bnh xut hin. Bnh theo ma, vng a l r. Khu vc trin sng, vng bn sn a nhiu bi rm v di nhiu cht mn, quanh nm m t; vng nng nghip, ngi hay lui ti d nhim bnh. 3.1. Cn trng trung gian l u trng m Trombicula (acarien), ngoi c mu nhung hoc cam ti, u trng m cha O.T., c s truyn O.T. t th h m trng thnh sang th h u trng m. Trng ca m b nhim tn ti trong t m nhiu cht mn, thnh u trng ri b vo cc bi cy thp ln tn n l, chng s bm vo cc ng vt c xng sng (loi c v hoc chim) khi c iu kin, trn thn cc ng vt ny vi ngy ri ri xung t v pht trin thnh nhng (nymphs) v ri m trng thnh. Khi chu k ny c tip tc, th s truyn O.T. qua trng s m bo cho th h sau b nhim. O.T. nhn ln trong tuyn nc bt u trng m vi lng ln, v vy d gy nhim cho vt nhy cm khi b t. Cn lu , ch c u trng m mi t ngi v sc vt v ch t mt ln trong chu k sng, m trng thnh khng t. ngi, u trng m thng bm vo cng, i ri di chuyn n nhng ni kn, c m hi m, dng li (tht lng, bn, ngc, nch...), chng c nh bng cch chch vi vo da. u trng m khng n mu, khi t chng bm nc bt vo vt t trong c O.T., nc bt cha cc enzyme tiu protein lm tiu cc t bo vt ch ri to nn mt cht nho c cht dinh dng m u trng ch vic ht chng, sau khi no u trng ri xung t mn tip tc chu k sng. u trng m t vo ban mai v lc tri sp ti. khu vc kh hu nng m, bnh xy ra quanh nm (nc ta), tri li vng lnh nh Nht Bn th hay gp vo ma thu. 3.2. Vt ch Vt ch cha tc nhn gy bnh rt a dng, m loi gm nhm ng vai tr c bn duy tr O.T. trong thin nhin, loi chut b bnh khng r, to iu kin ly nhim cho vec t truyn bnh (u trng m), ch yu l chut Rattus rattus ng v nh, cc loi chut khc, th cng c th l ni lu gi mm bnh. Loi chim nhim t nhin, cng c th dng thc nghim, c bit l chim s, chng mang mm bnh tim tng v l ni lu tr ca m Trombicula, do m chng lm lan to O.T.

78 v vec t truyn bnh cho cc qun o trn i dng, ni m chng lu tr trong qu trnh di chuyn. M trng thnh c xem l vt ch th yu v c cha O.T. 3.3. Cc yu t nguy c - Nhng ngi lm nng nghip, lm nghip, cng tc kim lm..., c iu kin tip xc cn trng truyn bnh ti cc b sng sui, nhiu bi rm. - Nhng ngi tham quan du lch vo vng bnh lu hnh. - Nhng ngi cha tip xc dch d mc bnh hn nhng ngi trong vng dch lu hnh.

II. C TH BNH
1. Ti v tr b u trng m t O.T. nhn ln v pht trin, ri lan to. y, c vt lot hoi t, nh hng n lp t bo biu m da, to thnh lot hnh trn c gii hn r rng. 2. Hch bch huyt Lin quan ti v tr u trng m t; hch v tinh sng,hoi t trung tm ca hch. C th sng hch ton thn (tuy nhin, khng ho m nh cc vi khun sinh m). 3. Mch mu O.T. c i tnh vi cc t bo ni mc mch mu, gy thng tn ni mch, xung quanh cc mch mu nh v ln (ng, tnh mch, mao mch, ging mao mch) c bit l mch da,c tim, no, phi. 4. Phi Ngi ta tm thy tn thng trong lng mch vi hin tng thuyn tc v chy mu, cc t bo mono, tng bo, lymph xm nhp thnh mch v thnh mch b ph n, thnh ph nang dy ln, khoang gia cc ph nang c hin tng xut tit huyt thanh v ng hng cu. 5. C tim T bo mono xm nhp khe c tim v hoi t khu tr, vim k c tim, mao mch nh ca c tim b nhi mu li ti tng m. 6. No Ri rc c phn ng vim quanh mch no v tng sinh t bo m, cc mao mch ca t chc no c t bo mono xm nhp v hoi t khu tr do nhi mu li ti. 7. Lch Lch sng to v c cc bin i nh trong nhim khun mu, km theo hoi t khu tr. 8. Gan Gan sng, xung huyt, hoi t khu tr. 9. Thn C vi khu vc thn xung huyt, v thn nht mu v sng. Bng k thut hunh quang, ngi ta c th pht hin ra O.T. trn t chc no, phi, c tim v cc t chc khc

III. BNH SINH - SINH L BNH


O.T. pht trin v nhn ln ti v tr u trng m t; sau mt thi gian bnh chng thm nhp vo mu, thng l vi gi trc khi pht bnh, chng li tip tc xm nhp cc t bo ni mc mch mu, chng tng sinh v pht trin to ra cc bin i ti mch mu, gy vim, xung huyt v pht ban. Trng hp nng (giai on sm), gy suy tun hon ngoi bin, thng xut hin trong tun u ca bnh do hin tng dn mch v tr mu lu thng, cha c hin tng tng thm mao mch, hoc thot dch ra khong gian bo. V li, trong cc trng hp nng (giai on mun), c thng tn tng sinh v thuyn tc xut hin trong cc mao mch nh, kt qu gy nn

79 hin tng hoi t v tng thm mao mch t nhiu gy gim th tch mu, ph n khong khe quanh mch mu (ph trn lm sng), c bit nht l giai on mun trn bnh nhn nng. Bnh cn biu hin ph v thiu mu c tim, trn t chc hc v in tim, i khi lon nhp xoang nng. Kt qu ca suy tun hon ngoi bin gp trong cc trng hp bnh nng, gy thiu niu, v niu trn lm sng, tng ur mu, creatinin mu; gim protid mu, natri mu; ph v hn m. C khi ri lon chc nng gan hoc c ng mu ri rc ni mch. Cc nghin cu v cc t bo b nhim O.T., cc i thc bo trn t chc nui cy, ngi ta thy c s tng thm mao mch gy ra thot huyt tng vo khong gian bo. Nguyn nhn ny l do cc t bo ni mc mao mch v i thc bo thng tn gii phng cc prostaglandin (nht l PG1 v PG2) v Leucotrienes. Bnh c min dch khng bn, d mc li, dn bn a t mc v nh hn dn ngoi lai, c chng 1 - 2 thng, c chng n 2 nm.

IV. LM SNG
1.Th bnh in hnh 1.1. bnh Trung bnh 10-15ngy, c nt sn do u trng m t, c th gp t 10-90% trng hp, tu tng ni. Ngoi ra, khng c triu chng no khc. 1.2. Khi pht Khi pht t ngt vi cn rt run, st cao, ngi mt mi ton thn, nhc u nhiu vng trn hoc thi dng, au dc ct sng-c khp-cc chi; sau thi gian ngn ri vo thi ton pht. 1.3. Ton pht - St: st cao 40-410C, dng cao nguyn trong vi 3 ngy u, sau gim, ri tip tc tng n 39-400C v duy tr mc y trong 2-3 tun, nhit sng thp chiu cao. - Tim mch: nhanh (bnh nng), chm (th nh). C th tru tim mch (mch nhanh, h huyt p, kh th & tm ti), vim c tim hay gp (tim nhanh, ting tim m), c khi ngoi tm thu. - H hp: biu hin vim ph qun (nh), vim phi khng in hnh do O.T. (nng). - Thn kinh: nhc u nhiu, s nh sng, mt ng; bnh nng c du kch ng, vt v, m sng, u m, mt nhiu v m, lng tai, nhng nc no tu bnh thng. Nu vim mng no thng l nng. - Tiu ho: li kh, xung quanh, trng hoc en chy gia. i khi tiu chy hoc xut huyt tiu ho. Lch ln, gan sng. - Da v kt mc: xung huyt; pht ban gp 2/3 trng hp, xut hin ngy th 4-7, khi u u mt sau lan ra thn mnh, t chi. Loi ban dt sn i khi bin thnh mng nc, thng mt i khi n; chm xut huyt (th nng); ban ch xut hin mt t. Ni ban mn hu, hng. Ti vt t xut hin mng nc, sau hoi t v hnh thnh mt lp vy kh, ng knh 45mm, xung quanh hi , c khi nga-au nh, c sng hch khu tr km theo nhng khng ho m. Nt lot thng bn, bu, tht lng, l rn, nch, ngc, di tai.... - Tit niu: i dm, b i, albumin v tr niu, ur mu bnh thng, him khi vim thn. - Hch ton thn: i khi c gp, r nht l c, nch v bn, hi rn, n au nh, hch khng ho m, hch s mt i trong thi gian hi phc. 1.4. Lui bnh Sau 14-30 ngy, nhit gim nhanh, bnh nhn cm thy d chu, i nhiu. Ngi cn yu v mt, n ung km. Thi gian hi phc ko di nhiu tun ti nhiu thng. Bnh nh thi k ny ngn hn. 2. Th bnh khng in hnh

80 Khng c nt lot, khng pht ban v ch st trong vng 5-10 ngy, kh chn on. Mt s th bnh biu hin c quan nht l phi biu hin vim phi khng in hnh c kh th, th bnh vim c tim,v.v..

V. TIN LNG & BIN CHNG


Tin trin nng nh tu a phng, tui bnh nhn (tui cao bnh nng). T l t vong mt s ni nh Indonesia-i Loan 5-20%, Nht 20-60%; M Lai 15%, Vit Nam 0,6% (th nh). Nguyn nhn t vong thng do tru tim mch, vim c tim, xut huyt, bi nhim phi, bin chng vim no- mng no. Nu c pht hin v iu tr sm bnh gim st nhanh trong vng 12, 24-48 gi; thi k hi phc v li sc sm.

VI. CHN ON
1.Lm sng Ch yu da vo tnh cht khi pht t ngt vi - St cao lin tc - Nt lot, km sng hch v tinh (nt lot l du in hnh trong bnh st m, tuy nhin c khi khng tm thy cho nn kh chn on) - Xung huyt kt mc, da; pht ban - Sng hch ton thn - Vim c tim 2.Cn lm sng - Bch cu mu: thng khng tng, thay i t 3-22 x 109 / mL, lymphocte > 70%. - Chn on min dch hc: + Khng th hunh quang gin tip (Indirect Fluorescent Antibody: IFA): Dng khng th KARP, GILLIAM, KATO pht hin khng nguyn (kh nhy). Bnh nhn c nng 1: 40 t ngy th 9 ca bnh tr i, nng cao nht vo tun th 2. Gi tr (+) tu thuc tng phng th nghim c th 1 : 640 hoc 1 : 1280, nhng nu c iu tr trong 4 ngy u th p ng min dch c th gim (xt nghim chun ca WHO, nhng do kh v k thut, cha p dng rng). + Min dch gin tip Peroxidase ( indirect Immunologic Peroxidase: IIP) l phng tin h tr tt tic rng khng c dng ph bin. - Phn ng Weil Felix: Phn ng (+) vi OX-K bt u t ngy 5 sau st, hiu gi cao nht vo tun th 3, ri gim dn t tun th 4. Cc trng hp c hiu gi ngng kt vi OX-K trn 1 : 160 v ho long, hoc ln 2 gp ln u 4 ln u c gi tr chn on, vi 2 ln cch nhau 2 tun. - Phn lp O.T.: Ly mu bnh nhn lc st cao, tim phc mc chut, nu trong vng 13-16 ngy chut cht chng t trong mu c O.T.. Nhum t thit gan, lch, hch bng giemsa, soi knh hin vi s pht hin O.T., i khi phi tim chuyn tip 2-3 chut mi pht hin (+). 3.Dch t hc Bnh nhn ang sinh sng, lm vic, hoc vo vng bnh lu hnh.

VII. IU TR
1.Nguyn tc iu tr - iu tr c hiu cng sm cng tt. - Chng ch nh cc thuc c Sulfonamide v s lm cho bnh nng thm. - Trong trng hp c sng hch ton thn, hch v tinh th cn iu tr ko di chng ti pht. - iu tr h tr, nht l trng hp nng s gp phn lm gim cc bin chng v t l t vong. 2.iu tr thc t 2.1. iu tr c hiu

81 - Nu iu tr sm, trc khi pht ban th rt hiu qu, nhit tr v bnh thng trong vng 24 gi, nu iu tr mun khi ban xut hin, c xut huyt th p ng chm hn. - Thuc c hiu lc Chloramphenicol; Tetracyclin (Doxycyclin); cn Azithromycin c tc dng vi dng O.T. khng Tetracyclin trn ng nghim, ng dng c hiu qu lm sng. - Liu lng: Chloramphenicol 30 mg/ kg/ ngy; Tetracyclin 20-30 mg/ kg/ ngy; Doxycyclin 100mg x 2 vin / ngy (ngi ln). Ch dng mt thuc; dng 7 ngy; khi hch sng dng 14 ngy. Khng sinh dng bng ng ung; nhng bnh nng v c iu kin dng tnh mch (vd: bnh km theo vim mng no) Ch : Fluoroquinolone khng hiu qu vi O.T. ch vi Rickettsia conorii (Mediterranean spotted fever). 2.2. iu tr h tr - Dch truyn: Glucose hoc Ringers Lactate nhm hi phc nc & in gii, lng tun hon; cn lu trng hp vim phi, vim c tim khng truyn nhiu. - Ch n ung: nn n xp, cho long khi cn st, m bo cht dinh dng. - V sinh rng ming, lau sch ton thn hng ngy, trnh lot cho cc trng hp nng. - Thiu mu do xut huyt tiu ho, nn truyn mu ti. - Trng hp nng hoc c bin chng (tim, phi, thn kinh...) v nht l cc ca iu tr mun, tu trng hp dng thm corticosteroid liu cao, ngn ngy : Hydrocortison: 100 mg / ngy x 3 ngy, c th thay bng Depersolon.

VIII. PHNG & CHNG BNH ST M


1.Khi cha mc bnh: c cc hng d phng nh sau 1.1. Dit vt ch v cn trng trung gian Ti khu vc dn c sinh sng, c quan n v ng chn, nhn vin y t cn quan tm dch lu hnh nht l vng trung du, ng rung, c nhiu bi rm v sng sui. Chut v cc loi gm nhm: ni c dch lu hnh, ni lao ng cn pht ng phong tro dit chut thng xuyn bng mi bin php t th cng n ho cht. Cn t chc pht quang, lm sch c v bi rm quanh nh , pht quang ri t tp trung, c th phi hp phun ho cht dit cn trng (Trung quc p dng c hiu qu khng c m tn ti n 40 ngy). Cng vic ny cn tin hnh thng xuyn. 1.2. Bo v c nhn, hn ch, trnh u trng m t Khi lao ng, di chuyn n vng c bi rm cn ct cht ng qun tay o, hoc mang dy c bt tt cao c. Thi gian ngh sau lao ng, ngh dc ng, khng nn nm hoc b o qun trn c rm. Sau lao ng hoc vo cc khu vc trn nn tm ngay trong ngy, lau sch ngi nht l cc vng kn (bn, nch, tht lng, c...) 1.3. Vaccine Trong th chin II, cc tc gi Anh, M xut loi vc xin Rickettsia cht, khng hiu qu. Nm 1952, cc nh khoa hc M lai nghi dng vc xin cht kt hp khng sinh, xut ny khng hp l, v gy bnh ri dng khng sinh th bnh nh nhng khng to min dch bn c. 1.4. iu tr d phng Ngay sau khi b u trng m t ung 1 ln 2gram chlorocid hoc 1.5 gram Tetracyclin, sau hng tun ung 1 ln, trong thi gian 4 tun, th bnh nh hoc khng pht ra. Tt nht, bnh mi chm dng thuc bnh s nh hn nhiu. 2. Khi c ngi mc bnh

82 Cn pht hin sm iu tr, nht l vng bnh lu, hnh nhn vin y t cn quan tm n bnh cnh lm sng pht hin sm. Khi c bnh nhn cn theo di cc bin chng c th xy ra. Cu hi n tp 1. M t tnh cht tc nhn gy bnh, ng ly, c im cn trng trung gian, i tng nguy c mc bnh. 2. Trnh by v sinh l bnh ca bnh st m 3. M t cc im chnh gii phu bnh ca bnh st m 4. Trnh by v sinh l bnh v gii thch din trin lm sng ca bnh st m. 5. M t cch thc iu tr bnh st m.

83

Bi 13.

BNH NHIM NO M CU
Ts, BsCK1 Nguyn L

Mc tiu
1.Chn on sm v chuyn kp thi nhng bnh nhn nhim no m cu nng. 2. Bit cch iu tr v phng bnh no m cu cho nhn dn. Ni dung Nhim trng huyt v vim mng no m do no m cu l hai bin chng nng v hay gp nht ca lai vi khun ny. Cn nh, nhim no m cu c tin trin rt nhanh, c th gy t vong nhanh chng trong vng 24 gi mt ngi trc ang cn khe mnh. .

I TC NHN GY BNH
Da trn bn gen, ngi ta xp no m cu vo nhm -proteobacterium c lin h n cc h vi khun Bordetella, Burkholderia, Kingella, v Methylomonas, xa hn l cc h Vibrio, Haemophilus, v Escherichia coli. Theo c in ngi ta xp loi no m cu da trn cc h thng phn loi huyt thanh, cn c vo s khc nhau v (nhm huyt thanh), cc protein chnh mt ngoi mng t bo (major outer-membrane : OMP) ti cc l thng mng t bo (type huyt thanh), cc OMP khc (cc phn type huyt thanh), cc lipo-oligosaccharide (LOS, type min dch). V d : mt chng no m cu c k hiu l B:2b:P1.5:L3,7,9 ngha l : chng ny thuc nhm huyt thanh (B), type huyt thanh (2b), phn nhm (P1.5), v type min dch (L3,7,9). No m cu c xp thnh cc nhm huyt thanh ty thuc vo tnh khng nguyn ca polysaccharide ca v, phn nh cu trc khc nhau ca cc carbohydrate. Trn th gii c 5 nhm huyt thanh (A, B, C, Y v W135) gp trong hn 90% bnh cnh ca no m cu. Cc chng thuc nhm A, thng gy nhng v dch ln trong na u th k XX, hin nay thng gy nhng v dch ti hi vng h sa mc Sahara (Phi chu) v mt s a phng khc nhng nc ang pht trin. Nhm B v C thng gy nhng ca ri rc hay thnh dch nhng nc k ngh ho. Hoa k v Canada, trong sut thp nin 1990, nhm B hay gp nht nhng trng hp ri rc, cn nhm C thng gy dch bc pht. Nhm Y mi c pht hin gn y v chim gn 1/3 bnh cnh no m cu Hoa k. Nhm Y thng gy bnh nhng ngi gc Phi, c sn mt bnh mn tnh. Nhm Y v W 135 cng hay gp nhng bnh nhn c biu hin vim phi do no m cu. Xp loi theo nhm huyt thanh c khuyt im l khng theo di c qu trnh thay i nhm ca vi khun, v cc gen m ha sinh tng hp v vi khun c th chuyn i t vi khun ny sang vi khun khc, v do chng c th thay i nhm huyt thanh. Hin nay c nhiu phng php xp loi khc tt hn, cho php theo di qu trnh thay i ca cc chng vi khun. Cc type huyt thanh v c cc phn type huyt thanh c xc nh bi khng nguyn ca cc OMP c hiu khc nhau. in di enzyme nhiu v tr (multilocus) gip phn loi vi khun theo cc type in di. Ngoi ra cn c phng php xp loi theo in di gel

84 trong trng xung in hoc phng php khuych i chui gen bng PCR. Cc phng php ny c dng phn lp cc chng gy bnh cc v dch no m cu. Chng hn trong v dch Nepal t 1983 - 1984, ln u ngi ta tm c phc hp dng vi khun III-1 c c lc ca vi khun nhm huyt thanh A. Chng ny lan n Mecca, sau ti vng di sa mc Sahara v n vng chu Phi n i. Phc hp ET-5 thuc nhm huyt thanh B phn lp ln u Na uy vo thp nin 1970, sau gy nhng v dch chu u, Cuba, Nam ri Bc M, gn y nht l Ty Bc Thi bnh Dng. Phc hp ET -37 (cn gi l ET- 24) thuc nhm huyt thanh C tng gy bc pht dch v nhng ca ri rc Canada v Hoa k, v thng kt hp vi t l mc bnh v t vong cao.

II. DCH T HC
Bnh no m cu ph bin ton th gii, thnh tng ca ri rc hay nhng v dch nh lng, x, tp th, c quan, nhng cng cng c th thnh nhng v dch ln. Mc du c khng sinh v c vaccine c hiu qu, no m cu vn l mt nguyn nhn gy vim mng no v nhim trng nng hng u trn th gii, gy t vong nhanh chng cho mt ngi trc cn kho mnh bnh thng. No m cu l tc nhn gy bnh duy nht trong s nhng vi khun gy vim mng no c th gy thnh dch bn cnh nhng ca ri rc. Tnh chung, hng nm c n 300.000 n 500.000 trng hp vim mng no trn ton th gii do no m cu (s bnh nhn ch gp nhng v dch ln !). T s bnh mi hng nm ca vim mng no do no m cu chim t 1 - 2/100.000 dn trong nhng trng hp mc bnh ri rc, t 5 - 10/ 100.000 nhng vng c dch nh v t 10 cho n > 1000 ca /100.000 trong nhng v dch ln hay i dch. Vng ai h sa mc Sahara n nay vn l vng c ri rc v bng thnh nhiu t dch no m cu. V dch ln nht vng ny t 1996 -1997 ghi nhn hn 300.000 ngi bnh trong 30.000 t vong do vi khun nhm A. Nhng v dch do nhm B v cc t bc pht do nhm A hay C cng c ghi nhn chu u, Hoa k, Canada, Trung quc, Nepal, Mng c, New Zealand, Cuba, Braxin, Chil, rp Saudi, v Nam Phi t 1990. Trong nhng nm 200 -2002, nhng v dch vim mng no do nhm W135 thng kt hp vi nhng t hnh hng ca ngi Hi gio ti Mecca v vng ai no m cu h sa mc Sahara. Nhng trng hp u tin ca dch vim mng no do no m cu thng xy ra do nhng tip xc trong gia nh hn l t cng ng. T l ly nhim cho ngi th hai l 400 1000 /100.000 thnh vin trong gia nh. Ly lan trng hc cng c ghi nhn, nhng t l ch 2 - 4 /100.000. Trong cc v dch lng i hc, t l ly lan cao nht nhng sinh vin c x. Nhng trng hp ly a s xy ra trong vng 2 tun k t khi c trng hp mc bnh u tin, nhng cng c trng hp ko di n vi thng sau. Vi khun no m cu c trong mi hu (ngi mang vi khun) v c th tn ti hng thng. Trong giai on khng c dch khong 10 % ngi bnh thng c mang vi khun ny. Nhng yu t thun li ly no m cu l sng chung nh vi ngi mc bnh hay ang mang vi khun, nh hay c quan cht chi, ht thuc l ch ng hay th ng v tin s c nhim trng ng h hp trn gn y. Cc yu t ny cng lm tng nguy c vim mng no do no m cu. Ngi l ngun bnh duy nht. Vi khun thng khu tr vng mi hu. Ly truyn ch yu qua ng h hp. Thn nhn ngi nhim, cc tp th ( doanh tri qun i, tri giam..), cc khu ph ng c, v sinh km l nhng iu kin thun li gy nn nhng v dch no m cu. No m cu nhm A, trc y thng gy dch. Hin nay u th thuc v nhm B v C. Nhm B thng gy bnh tr nh. Nhm C nhm tr ln v ngi tr tui.

III. BNH NGUYN


T nim mc mi, no m cu c th xuyn qua cc t bo ny, lch qua thnh mch vo mu. , nu c th c sn khng th c hiu, vi khun s b tiu dit ngay. Nu

85 khng, vi khun s sinh si ny n, to nn nhim trng huyt v theo mu n cc ni khc trong c th, c bit l mng no (n xuyn qua hng ro mch no, n u tin no tht ri lan n khoang di nhn), da, khp, thng thn, tim, mng ngai tim.. Nhim no m cu cn ty thuc vo c a bnh nhn. a s u c khng th chng no m cu. Nhng thng u sau khi sinh do m truyn cho. V sau, c min dch t nhng chng khng gy bnh c khng nguyn tng t . Nhng ngi c h min dch khng tan vn thng d nhim no m cu : thiu mt thnh phn b th (T C5-C9), thiu proverdine, gim -globulin mu, ct lch ( hay lch mt chc nng). Nhim cm cng l mt yu t thun li cho nhim no m cu.

IV. LM SNG
99% biu hin ca nhim no m cu l nhim trng huyt (NTH), vim mng no m hay phi hp c hai. Nhim no m cu khu tr nhng c quan khc rt t gp. Thng thng, bnh nhn c triu chng h hp trc khi c bnh cnh NTH hay vim mng no. 1.Nhim trng huyt 30-40% nhim trng huyt n thun khng c km thm vim mng no. Bi cnh lm sng rt khc nhau. Khi bnh t ngt, vi st, n lnh, bun nn, nn, ni ban, au khp, au c. St thng cao ( 39-41 C) mc du trong trng hp c tnh c th khng st hay h nhit. Ban l mt triu chng quan trng ( gp 3/4 cas) c th dng dt sn, xut huyt hay mng bm mu. Ban dt sn thng xut hin sm ngay sau pht bnh, ng knh 2-10 mm, mu hng, phn b tha tht thn v cc chi. gia c th c chm xut huyt. Trong vng vi gi, nu bnh tin trin nng, ban ny c th bin thnh xut huyt. Ban xut huyt c ng knh 1-2 mm thng c thn v chn, nhng cng c th gp mt, vm ming v kt mc. Nhng ca tng i nng, ban xut huyt t li thnh mt bng xut huyt v let lan rng. Ban xut huyt lan rng, h huyt p, gim tun han ngai vi, khng c vim mng no km theo l nhng ch im tin lng xu.

nh 1 : Ban xut huyt trong nhim no m cu

1.1.Nhim trng huyt c tnh (Hi chng Waterhouse- Frederichsen). Chim 10-20% vi c im tin trin nng rt nhanh : cc ban xut huyt lan rng thnh cc mng bm mu, sc, ng mu ri rc lng mch (DIC), v suy nhiu c quan. ng lu l bnh nhn c th vn tnh to d rng h huyt p. Cc ban xut huyt ln nhanh, gy tn thng da, nim mc, c vn, tuyn thng thn v i khi c tuyn yn. C tim gim sc co bp, gp phn vo tnh trng sc. Ri lan tan thn gm toan mu, ri lan in gii, thiu niu, bch cu gim, gim cc yu t ng mu. T l t vong rt cao, ln n 50-60% ngay c cc trung tm hi sc tin tin.

86

nh 2 : Ban xut huyt hnh sao trong nhim trng huyt c tnh do no m cu

1.2.Nhim trng huyt mn Chim 1-2% gm : tng t st hi quy, ban dt sn, au khp ko di hng tun hay hng thng. Cc ban dt sn c th bin thnh ban xut huyt. Gia nhng t, bnh nhn gn nh bnh thng. Tuy nhin, nu khng iu tr c th dn n nng. 2.Vim mng no. Thng kt hp vi nhim trng huyt. Khi bnh c tnh cht tan thn, cc triu chng mng no thng khng r. Tuy nhin, hu ht cc bnh nhn sau u xut hin cc triu chng in hnh ca vim mng no 3.Cc biu hin khc ca nhim no m cu. t gp. C th vim khp, vim phi, vim xoang, vim tai gia, vim kt mc, vim ni tm mc, vim mng ngai tim, vim niu o. 4. Bin chng Chim 5% nhng ngi that cht. - H hp : thng c bi nhim VK khc, nht l khi c th my. - Thn kinh : vim no, p xe no, co git, du thn kinh khu tr, ph no, dch di mng cng, tn thng cc dy thn kinh s no (ic).

V. CN LM SNG
- Phn lp c vi khun trong mu, dch no ty, dch khp, cc dch cc xoang nh mng ngai tim v ngay c trong cc ban xut huyt. - PCR tm DNA vi khun : c hiu v nhy nhng t tin. - Cng thc mu : thng c bch cu tng cao, ch yu bch cu a nhn trung tnh. Tuy nhin, trong nhiu trng hp c tnh, bch cu li gim. Ty theo tnh trng v giai an ca sc, ta c cc xt nghim v toan mu, suy h hp, gim ti mu cho m..

87

VI. CHN AN
- Giai an sm : rt kh phn bt vi bi cnh mt nhim virus, nht l khi khng c vim mng no. Tuy nhin, triu chng gi l ban hng sng nh trong thng hn. Khi ban tr thnh ban xut huyt th bnh cnh kh r rng. Ch phn bit vi cc ban do cc bnh virus, Mycoplasma .. - Chn an xc nh nh vo phn lp c vi khun trong bnh phm. Ch : phn lp vi khun mi hu khng c gi tr chn an bnh v c th ch l ngi mang vi khun.

VII. IU TR
Do tnh cht nghim trng v tin trin nhanh ca bnh, cn iu tr ngay khi nghi ng, hoc chuyn cp cu ln tuyn trn lp tc. Ly ngay cc bnh phm cn thit (cy mu, dch no ty..) sau iu tr ngay khng ch kt qu. 1.iu tr nguyn nhn: Khng sinh liu php Khi khng phn bit c no m cu vi cc nguyn nhn gy bnh khc, nht l trong vim mng no, c th dng ngay cephalosporine th h ba nh cefotaxime hay ceftriaxone. Liu: cefotaxime 150-200mg/kg/ngy TM (ti a 12 g), Ceftriaxone : 75-100 mg/kg/ngy TM (ti a 5g). Tuy nhin, khi bit chc no m cu v cn nhy cm vi penicilline th Penicilline G vn l thuc tt nht. Liu 200.000-300.000 UI/kg/ngy TM. (Ti a 24 triu UI). Khi bnh nhn d ng vi Penicilline, c th dng Chloramphenicol 75-100mg/kg/6 gi TM. Ti a 4g/ngy. 2.iu tr nng Phi lun lun cnh gic v din tin ca khng tin lng trc c v din tin rt nhanh. Theo di rt k trong 48 gi u cc ch s huyt p, mch, nhit trung tm v ngai bin, lu lng nc tiu, tnh trng ti mu, thng kh pht hin sc, chy mu thng thn. Khi c sc : tham kho thm bi sc nhim trng.

VIII. PHNG BNH


Nc ta cha x dng rng ri vaccine no m cu. Phng bnh ch yu cho nhng ngi sng gn bnh nhn (trong gia nh, khu tp th, nhn vin y t sn sc ngi bnh) Thuc dng : Rifammycine 10 mg/kg/12 gi ( ti a 600mg/12 gi) trong 2 ngy i vi nhng ngi c tip xc vi bnh nhn. Vi tr < 1 tui : dng liu 5 mg/kg. Ngi ln c th dng Ofloxacine 400mg/ngy thay cho Rifampin. Ph n c thai : dng ceftriaxone 250mg TB mt ln duy nht. Tr < 12 tui cng c th dng thuc ny vi liu 125mg. Cu hi n tp 1. K cc i tng c nguy c nhim no m cu nng 2. Trnh by lm sng v cn lm sng cc th nhim trng huyt do no m cu 3. Chn on xc nh nhim no m cu 4. Cc nguyn tc iu tr nhim trng huyt ti cp do no m cu 5. Phng bnh cho cng ng khi xy ra dch do no m cu.

88

Bi 14.

BNH NHIM T CU
Ths, BsCK1 ng th Nga

Mc tiu
1. M t c mt s hnh thi lm sng nhim t cu hay gp 2. Lit k c cc bin chng do nhim t cu gy ra 3. Pht hin sm v x tr ng cc bin chng do nhim t cu 4. Tuyn truyn phng nhim t cu

Ni dung I. I CNG
T cu ch yu l t cu vng, l mt tc nhn gy bnh quan trng ngi, n nh c da v nim mc ca k ch. Nu hng ro bo v da v nim mc b ph v do chn thng hoc phu thut, t cu s xm nhp vo t chc bn di , pht trin, nh c thnh abces. Mc d nhng nhim trng di da khng nguy hi, t gii hn, nhng cng c trng hp t cu xm nhp vo h thng bch huyt v mu dn n mt lot cc biu hin ton thn nng n vi nhiu bin chng nguy him.

II. BNH NGUYN


1 c tnh T cu thuc h Micrococcaceae l mt loi cu khun Gr (+), ng knh 0,7-1,2 nm, i kh hoc ym kh khng bt buc. Trn thch mu n mc thnh cc khun lc c ng knh 1-4mm, trn nhn, bng v c bao bc xung quanh mt vng tan huyt. T cu c sc khng kh vng, 40oC gi nguyn sinh lc trong 3 thng, b tiu dit mi trng kh ro, 58oC/60, nng mui cao, thuc st khun thng thng nh: Iode.. Chng gy bnh ch yu l t cu vng v chng c c lc cao. T cu trng cng hin din da v nim mc, tng i t gy bnh; mt phn nh chng s tr nn gy bnh nh vim ni tm mc hoc nhim trng huyt 2.Cu trc t bo Ba thnh phn chnh ca vch t bo vi khun t cu vng l: Peptidoglycan, Phosphat Containing Polymer v Protein A. 3.Cc yu t gy bnh ca t cu 3.1 c lc ca t cu Phc hp peptidoglycane lm vch ca vi khun vng chc kh b ph v v c th hot ho b th mnh m gp phn tham gia vo c ch sinh shock v CIVD. Ngoi ra t cu cn sn sinh nhiu enzym m chinh enzym ny gp phn vo s gia tng c lc ca vi khun nh : nuclease, protease, lipase, catalase, hyalurmidase, lisozime, latamase, actate dehydrogenase. T cu cn sn xut ra mt lng ln ngoi c t lm ri lon nhiu chc nng nghim trng nh: hemolysine, leukocidin, enterotoxin, epidermolytic toxin A v B, TSST1 (Toxic Shock Syndrome Toxin group 1) 3.2 Sc khng ca vt ch Khi hng ro da v nim mc b tn thng vi khun t cu xm nhp vo, hn 50% nhim truing t cu t chc su u bt ngun t biu b, mt s nh t ng h hp, tiu ho,

89 him khi t ng niu sinh dc. Bnh nhn bnh vin th t cu vng c th c a vo mu t cathetere tnh mch hoc t nhng ngi lm dng thuc. Ti nhim trng c phn ng vim hoi t ti ch, phn ln t cu b bch cu a nhn trung tnh v i thc bo tiu dit, cc mao mch chung quanh tc nghn, fibrine lng ng chung quanh v sau t bo x lm thnh v bc, abces c hnh thnh. Nh vy abces bao gm: phn trung tm cha bch cu, vi khun cht cng vi dch tit, chung quanh c t chc x bao bc, do kh p ng khng sinh. Khi c th gim sc khng, t cu vo h thng bch huyt ri vo mu n nh c cc ni khc nh u cc xng di, phi, thn, valve tim, c tim, gan, lch, no.. Mt s t cu vng c th sng trong thc bo nn bnh kh iu tr v s ti pht. Tt c cc la tui u c th b nhim t cu nhng c bit l ngi gi v tr em th thng gp hn v nht l khi c bnh mn tnh

III. MT S HNH THI LM SNG NHIM T CU HAY GP


1 Cc nhim trng nng 1.1. Da - Chc l: c bng nc trong, sau vi gi c kh v li vy vng nh sp ong, nga. Thng gp mt, da , t chi. - Nht sau khi c m th t chc xung quanh b hoi th nu nht cm li gi l hu bi (gp vai ) - Chn m - Vim nang lng - Vim bch mch, vim mao mch 1.2. T chc di da - Thng gp l vim m t bo (cellutite) - Nhim t cu cc ng tuyn nht l tuyn m hi nch, chung quanh hu mn, sinh dc 1.3. Nim mc - Vim hch hnh nhn - Vim xoang - Vim tai - Nht tin nh mi 2. Cc nhim t cu c quan 2.1 Nhim khun huyt Nhim khun huyt do t cu khng hn l s sinh sn ca vi khun trong mu m ch l s lan trn ca vi khun trong chc lt sau vo cc ni tng (vng khun huyt) to thnh cc di bnh ti cc c quan. Tm nhim khun huyt do t cu rt kh, a s l vng khun huyt. Vng khun huyt do t cu c th bt ngun t bt c mt nhim khun ti ch no, nhng trng hp ny do dng khng sinh ba bi hoc xy ra sau phu thut xng, thn kinh, tim mch, h hp, tit niu, hoc cc th thut t sonde, cathetere, m kh qun, khai kh qun, v thng thng a s l do can thip khng ng cc nht (nn nht sm, vy bn..) Lm sng ca vng khun huyt : Hay gp vi: - St dao ng, rt run, c khi st lin tc - Lch to - Trn da c pht ban, i khi thy cc microabces - Tin lng nng v tin trin khng lng trc c, shock xy ra khong 8-10%, c bit l khi nhim t cu c v bc v v bc l nguyn nhn gy shock. 2.2 Vim ni tm mc

90 y c xem nh l mt bin chng ca nhim khun huyt do t cu. Valve 2 l v valve ng mch ch l hai v tr hay b tn cng nht. Lm sng biu hin vi: - St dao ng, rt run, c khi st lin tc - Lch to - Xut hin cc ting tim bnh l bt thng. - Thiu mu - Bnh tin trin nng vi cc bin chng suy tim, tc mch nhiu ni - Siu m c th pht hin c cc m si trn cc valve. 2.3 Vim phi v t cu phi mng phi - tr ln v ngi ln khe mnh, vim phi do t cu thng xy ra sau khi mc mt bnh nhim trng h hp nh cm, si hoc cc virus khc. Bnh khi pht t ngt vi st cao, ho, au ngc, khc m c th c ln mu hoc m thc s. - tr nh vim phi do t cu thng biu hin bng st cao v ho. Sau hnh thnh cc abces c thnh mng hoc hnh nh cc thng tn c mc hi nc trn phim chp X quang. Mt i khi cc abces cnh l tng v vo mng phi gy nn trn m mng phi. - T cu thng c tr cc ph qun ca tr em b bnh x ha nang v c th gy nn cc t vim ph qun phi ti pht 2.4 Cc bnh cnh khc ca nhim t cu c quan - Xng khp: (xa khuu gn u) nh xng chy, xng i, cnh tay, c tay, vim a m, vim m cc khp ln, xng c. - No mng no: Abces no, vim mng no m. - Vim c. - Tit niu, sinh dc: vim tinh hon, vim ty quanh thn, abces tuyn lit tuyn 3 Nhim trng nhim c thc n - Vi khun gy bnh bi mt loi c t rut trong thc phm b nhim mm bnh, a s c ly nhim t ngi lnh mang mm bnh - Thi gian bnh ngn khong 1-6 gi sau khi n, bnh nhn nn , au bng, a chy - Bnh khi sau 12 gi. 4 Cc bnh gy ra do c t t cu 2.1 Hi chng bong da: SSSS ( Staphylococus Scalded Skin Syndrome) - Do nhim t cu c men gy trc vy (epidermatolysine) hoc c t gy trc vy ( exfolicetin toxin) hay gp tr s sinh, tr cn b, him gp ngi ln - Bnh khi u vi nhim trng di da ti ch; khu tr hay lan to, pht ban dng scalatin ti ch sau hnh thnh bng nc ri v ra li da trn ng khi dng tay ch nh da bong ra ngay 2.2 Hi chng sc c t TSST1: (Toxic Shock Syndrome Toxin group I) - Pht hin u tin do Tood, nm 1978 m t trn tr em - Lm sng: st cao, ban rm nng da (sunburn rash) hoc bong vy, huyt p h; phn lp c t cu vng nhm 1

IV. CHN ON
Chn on xc nh : - Tm vi khun thng tn v cy mu ( cn cn thn khi khi ly bnh phm v t cu hin din nhiu ni) - Chn on xc nh khi cy mu (+) nhiu ln hoc tm thy vi khun trong phn , hoc nc tiu, nc no tu, cc m, cc mu sinh thit xng, nc ra ni kh qun.

V. IU TR
1.T cu da v nim mc - St trng da v lm v sinh, nu mn nht hay ti i ti li hoc vng c nguy c dng: * Cephalosporine th h I : c th Cephalexin 1,5g - 2g/ ngyx 7 ngy

91 * Hoc Oxacilline 2g / ngy x 7ngy 2.Nhim t cu nng - Nguyn tc cy bnh phm v lm khng sinh trc khi cho khng sinh. - Thuc dng bng ng tnh mch hay tim bp. Thng l Chng khng sinh Penicillinase : Penicillin G :4 triu n v/4h Gentamycine 1mg/kg/8h Cephalosporin th h I Nu d ng Penicilline hoc nhim t cu khng Methiciline thay bng Vancomycine 0,5g/6h 3.Nhim khun huyt Phi hp khng sinh l bt buc - Nu cn nhy cm vi Penicillin : Penicillin (M) + Gentamycine - Nu d ng Penicillin : Cephalosporin th h I + Gentamycine - Nu t cu khng Methicicline Glycopeptide (vancomycine) + Aminoside Phosphomycine + Rifamycine Fluoroquinolone + Glycopeptide hoc Aminoside 4 Nhim khun nng vim ni tm mc nhim khun Glycopeptide (vancomycine) + Aminoside Phosphomycine + Aminoside 5 Thi gian iu tr nhim khun huyt c khu tr Tim: 4 tun Phi: 4 - 6tun Ni tm mc: 6 tun Xng khp: 6 tun - 3 thng

VI. PHNG BNH


1. C nhn Ngi lnh mang t cu khng gy nguy him cho bn thn. Ngi b nht hoc mang t cu mi cn lu iu tr ng nhim trng ton thn. 2. Tp th - Cch li bnh nhn c nhim t cu - Dng thuc st trng iu tr nhim trng da ti ch - Kim tra u n nhn vin k ngh thc phm pht hin ngi mang mm bnh - Tn trng quy ch thanh trng khi phu thut - Khng dng khng sinh sai ch nh trnh chng t cu a khng khng sinh - Dng khng sinh lun chuyn, dnh cc khng sinh mnh iu tr trng hp nng. Cu hi n tp 1. Trnh by cc c im sinh vt hc v cc yu t gy bnh ca t cu. 4. Trnh by mt s hnh thi lm sng nhim t cu hay gp. 5. M t v gii thch cc cc bin chng do nhim t cu gy ra. 6. Trnh by cch chn on v cc bin chng do nhim t cu gy ra. 4. Trnh by cch thc iu tr v phng bnh do t cu gy ra.

92

Bi 15.

BNH UN VN
Ts, Bs Trn xun Chng

Mc tiu
1.M t c cc c im chnh ca tc nhn gy bnh v tm quan trng ca bnh un vn. 2.Trnh by c cc triu chng lm sng, th lm sng, cc bin chng bng kin thc sinh l bnh. 3.Chn on c v tin lng c cc th bnh un vn v bin chng. 4.M t c cch thc iu tr bnh, bin chng v cch thc d phng.

Ni dung
Un vn (Tetanus, Tetanos) l mt ri lon thn kinh, c trng bi tng trng lc c v cc cn co git, gy nn bi c t Tetanospasmin. Bnh un vn c nhiu dng, bao gm un vn ton thn, un vn cc b, un vn s sinh.

I.NGUYN NHN
Vi khun gy bnh l Clostridium tetani, k kh, Gram(+), thng tn ti khp ni quanh chng ta di dng bo t, rt kh tiu dit. Bo t c th tn ti nhiu nm trong nhiu mi trng, bn vng vi nhiu loi thuc dit khun v un si di 20 pht. Khi nhim vo c th v c iu kin thun li, bo t chuyn thnh dng hot ng, tit ra c t Hemolysin v Tetanospasmin gy bnh. - Hemolysin t quan trng trn lm sng - Tetanospasmin gy ra cc triu chng ca bnh un vn. Tetanospasmin l mt chui polypeptide n, bao gm 1 chui nng (100 kDt) v 1 chui nh (50 kDt). Chui nng gn vo th th t bo thn kinh v thm nhp vo trong t bo cn chui nh c ch s phng thch cc cht dn truyn thn kinh.

II.DCH T HC
- Trc khun un vn c tm thy trong lp nng ca t, trong t giu cht hu c v trong phn mt vi ng vt nh tru , b, nga.., gp vng kh hu nng v m,. - Bnh khng gy dch m l bnh lu hnh a phng, do nhim bo t un vn qua vt thng ngoi da hoc nim mc. - Bnh ph bin trn ton th gii, ch yu cc nc ngho, y t lc hu, khng tim phng un vn cho ton dn. Nm 2000 ton th gii c 9.766.000 trng hp un vn, trong c 309.000 t vong (theo s liu ca T chc Y t Th gii ). - Nc ta cha c thng k y trn phm vi ton quc nhng nh chng trnh tim chng m rng v pht trin mng li h sinh, t l un vn rn gim r rt. Tuy nhin, t l ngi ln vn cn cao. BVT Hu, s bnh nhn un vn trong nhng nm 19962005 khong 12-15 ngi/ nm, chim 0,3-0,6% bnh nhn Khoa Truyn Nhim.

III.SINH L BNH
a s vt thng u c nhim bo t un vn. Tuy nhin ch khi c iu kin thun li, thiu Oxy, bo t mi chuyn thnh dng vi khun hot ng. Vi khun un vn khng gy phn ng vim. Chng sn xut ngoi c t Tetanospasmin, c t ny theo mu n cc u mt thn kinh a vn ng. c t khng trc tip vo h thn kinh trung ng v khng thm qua hng ro mch mu no. T a vn

93 ng, c t ngc dng thn kinh vn ng vo trung ng, n phong ta cc synap c cha GABA (gamma amino butyric acid) v Glycin l cc cht dn truyn thn kinh. S co cng c ton thn xut hin khi mt s c ch ca lung thn kinh t trung ng n ngoi vi. c t un vn cng c tc ng ln h thn kinh giao cm, to nn mt hi chng cng giao cm, lm tng lng catecholamin, gy nn tng huyt p mnh, mch nhanh, st cao, v nhiu m hi, tng tit m di.. Biu hin lm sng l tnh trng co cng cc c qu mc, tng trng lc c thng xuyn, ri lon thn kinh thc vt v mt s trng hp lit vn ng cc dy s no. C nhai c dy vn ng ngn nht, nn c t vo sm nht . V vy bnh nhn c biu hin lm sng u tin l cng hm. Min dch khng y , c t ch c trung ha mt s ni, gy nn th cc b. c t Tetanospasmin rt c, ch mt lng rt nh gy bnh , nhng khng kch thch c th to min dch. V th, ngi bnh khng c min dch m phi chng nga nh ngi cha mc bnh.

IV. LM SNG
1. Th ton thn in hnh - bnh: trung bnh 7-10 ngy; c 15% trng hp < 3 ngy v 10% trng hp > 14 ngy. Thi gian bnh cng ngn, tin lng cng nng. -Khi pht: t khi cng hm (trismus) n khi co cng ton thn, thi gian t vi gi n vi ngy, trung bnh 48 g. Mc cng hm tng dn n khi kht hm, lan ra cc c vng mt , vng hu hng, vng c lm bnh nhn kh nhai, kh ni, kh nut. Bnh nhn c v mt au kh (risus sardonicu ): trn nhn, lng my xch ln, khe ming b ko tr ra ngoi c hai bn. -Ton pht: cng c lan n cc c c, c lng, c bng ri t chi. Trng lc c tng thng xuyn. C khi co tht t ngt gy ngt, gy t vong bt ng. Bnh nhn thng tng phn x qu mc. Cc c c, c lng co cng gy nn tnh trng co cng ton thn in hnh ca un vn: bnh nhn n cong ngi, lng ri khi ging, tay co rt, cc c chn dui ra (opisthotonos). Cc kch thch nh nh nh sng, ting ng, s, tim thuc, hoc nhng kch thch t bn trong c th nh bng quang cng y nc tiu, phn ng do to bn u c th gy nhng cn co git kch pht trn nn co cng y, gy au n nhiu cho bnh nhn. Nu cn ko di, bnh nhn c th ngt th v cc c h hp co cng ko di. Nhng trng hp bnh nng c ri lon thn kinh thc vt km theo.Biu hin nh: v m hi, st (khng c bi nhim km theo ), nng hn : tng hay h huyt p ko di hoc xen k, nhp tim nhanh hoc lon nhp, i khi ngng tim t ngt. Bnh un vn din tin ko di v c t gn vo thn kinh rt bn, trung bnh 4-6 tun. Nu ngun nhim c gii quyt, bnh nhn hi phc nhanh hn. Cc cn co gim tn s. Hm h to dn. Bnh nhn c th ung c ri n tr li v lnh bnh. Trong giai on ton pht c th xy ra nhiu bin chng. 2. Un vn s sinh a s do nhim khun rn. Xy ra tr s sinh v m khng c min dch chng un vn. Bnh khi pht khong hai tun sau sinh. Triu chng ban u l kh b, ming chm li ri khng b c. Sau bnh nhn co cng, ln cn co git ton thn v thng dn n t vong do suy h hp. T l t vong rt cao, t 70-80%. 3. Un vn cc b Ch biu hin co cng mt s c, khu tr v tr tng ng vi ni xm nhp ca vi khun un vn. Bnh thng gp ngi c min dch mt phn vi Tetanospasmin. Tin lng thng nh, tuy nhin cng c mt s trng hp tin trin thnh th ton thn. 4. Un vn th u

94 L mt th c bit ca un vn cc b. Thng do vt thng vng mt c. Biu hin gm cng hm, lit mt s dy thn kinh s no, thng l dy VII. C th chuyn qua th ton thn. 5. Phn un vn Da vo mc nng ca bnh, ngi ta chia lm 4 : - 1 (nh): cng hm nh n va phi, co cng ton thn, khng c cn co git, khng ri lon h hp. - 2 ( trung bnh ): cng hm va phi, cn git nh n trung bnh nhng ngn, kh nut nh, suy h hp ( tn s th 30-35 ln/ pht ). - 3 ( nng ): cng hm nng, co cng ton thn, cn git xut hin t nhin v ko di, kh nut, suy h hp ( th 35-40 ln/ pht ), nhp tim nhanh > 120 ln/ pht. - 4 ( rt nng ): bnh cnh lm sng nh 3 km ri lon thn kinh thc vt: huyt p cao v mch nhanh xen k vi huyt p thp v mch chm, huyt p cao ko di ( HA tm trng > 110 mm Hg ) hoc huyt p thp ko di ( HA tm thu < 90 mmHg ).

V. CHN ON
1. Chn on xc nh Ch yu da vo lm sng vi cc du chng : - Cng hm, khng km theo au vng mt c - Du tng trng lc c ton thn lin tc - Cc cn co git in hnh tng t - Trong mt s trng hp c th pht hin ng xm nhp ca vi khun, thng gp nht l vt thng chn, tay.. Trong trng hp un vn cc b, th u, du hiu cng hm gip ta ngh n bnh un vn. Nu ming vn h to c nhng kh khn khi nhai, nut, tng phn x cn cng gip chn on. Cc xt nghim cn lm sng ch c gi tr ch im cc bin chng ( bch cu tng trong bi nhim, gim PaO2 trong suy h hp ) 2. Chn on gin bit - Ch c triu chng cng hm : Phn bit vi cng hm do bnh nhn au khng dm h ming trong cc bnh vim khp thi dng- hm, vim amidal, p-xe quanh amidal, tai bin rng khn. Thng c thm cc triu chng khc km theo ( st trong p-xe, cng hm bui sng trong thp khp ). Dng li lm h ming d dng. - Cng c v cng lng : Cn gin bit vi vim mng no v vim no. - Cn co git ton thn : gin bit vi bnh di ( c biu hin s gi, s nc ), tnh trng tetani ( thng khng cng hm, calci hoc magne mu thp hoc c du hiu kim h hp ), ng c Strychnin ( tin trin rt nhanh, tin s ung thuc, tm thy cht c trong d dy v nc tiu), ng c Phenothiazine hoc Metoclopramide( cng hm km theo rung cc chi..) v vi Hysteria.

VI. BIN CHNG


1. Do c t un vn gy co git - suy h hp cp ( co tht thanh hu, cn co ko qu di gy ngt ) - ngng tim t ngt ( him ), tng hay gim huyt p nghim trng - gy xng, nht l xng sng tr nh, rch c, t dy chng, t mu trong bao c (do co cng c qu mc) 2. Do nm lu - thuyn tc ng mch phi, xp phi - bi nhim: vim phi thu hoc vim ph qun-phi, vim bng quang, nhim trng huyt ( dng catheter ko di ) - lot d dy t trng 3. Cc tai bin do iu tr

95 - tai bin huyt thanh (dng SAT nga) - tai bin do m kh qun : hp kh qun, n tht kh qun, so li, trn kh di da, trn kh trung tht - ng c cc thuc an thn v dng qu liu - tai bin do th my ko di.

VII. TIN LNG


Trc y tin lng da vo: - Thi gian bnh (t khi vi khun xm nhp n triu chng u tin): cng ngn cng nng. Thi gian bnh < 3 ngy : un vn ti cp, 3-7 ngy : un vn cp. - Thi gian khi bnh (t khi cng hm n khi co cng ton thn): cng ngn cng nng. Nu di 24 gi: rt nng. Trn 5 ngy : tng i nh. - ng vo v vi khun: Nu tm c v gii quyt trit , tin lng tt. Nu khng tm thy ng vo hay nhim kh can thip ( su, nhiu ngc ngch, ni tng ) : tin lng xu - Tn s cn co git: cng dy cng xu, nu hn 4 cn/ gi km co tht hng, thanh qun gy ngt, kh th th tin lng rt nng. - Ri lon thn kinh thc vt: st > 40C, mch nhanh > 120 ln/ ph, v nhiu m hi, tng tit m di : tin lng nng. Hin nay, tin lng cn phi cn c vo tui (tui > 50 nng hn ngi tr), tnh trng sc khe (c bnh l mn tnh km theo nh suy thn, x gan, bnh tim, nghin ru...bnh cng nng),tnh trng min dch ca bnh nhn, cht lng iu trTrong cht lng iu tr l quan trng nht. T l t vong do un vn ngi ln khong 10-20%, ring Khoa Truyn nhim (ngi ln), Bnh vin T Hu, trong cc nm 1996-2005 khong 12-15%.

VIII. IU TR
1. Kim sot cc cn co git Thuc tt nht l Diazepam ( SEDUXEN, VALIUM ), ng tnh mch. Liu dng: khi u 1-2 ng 10 mg cho ngi ln, sau nu cn tim lp li. Liu ti u c xc nh khi khng ch c cc cn co git ton thn m bnh nhn vn cn tnh. Lng thuc thay i ty theo tng bnh nhn v ty theo din bin lm sng, nhng khng qu 7 mg/ kg/ ngy. Khi khng c Diazepam hay dng liu kh cao m khng ch ng c cn git, c th i hay phi hp thm vi Phenobarbital. Tuy nhin, lu dng Phenobarbital c c ch h hp. Cc thuc khng ch cn co git khc nh Chlopromazine, Pancuronium ch c dng cc trung tm ln, bo m c h hp h tr. 2. Dit vi khun + Penicilline, 3 - 5 triu n v /ngy, tim tnh mch x 10 ngy. + Metronidazole 1 - 2 g/ ngy x 10 ngy, truyn tnh mch, c u im hn v mt l thuyt (khng i khng vi GABA nh Penicilline ) ln thc hnh, nhng gi thnh t hn. C th dng ring l hay phi hp c hai khng sinh trn. + Nu tm c ng vo, phi m rng, dn lu, ly cc d vt, cc m hoi t v ra bng Oxy gi. Dng thm cc khng sinh khc nu c bi nhim. 3. Trung ha c t + Globulin min dch un vn t ngi (HTIG : Human tetanus immunoglobulin): Khng gy sc phn v v bnh huyt thanh, bo v c 8 -14 tun. Liu dng : 500 v tim bp hoc tim tnh mch c hiu qu tng ng vi liu cao hn (3000-5000 v). + SAT: nc ta hin nay cha c khng huyt thanh ngi, ch c SAT ngun gc t nga. Tuy gi thnh r hn, nhng SAT nga d gy phn ng, bnh huyt thanh v thi gian khng th tn ti trong ngi ngn (ch 1 tun). Liu dng: 10.000-50.000 v tim bp. Phi th phn ng trc khi dng. Nu c d ng, phi gii mn cm bng cch tim tng liu

96 nh tng dn (phng php Besredka). Tuy nhin, d test th m tnh vn c th xy ra phn ng thuc. 4. Sn sc bnh nhn + Nui dng hoc bng ng tnh mch, hoc nu c th t ng thng d dy. + Bo m nhu cu calo, nc, in gii, protide, lipide, vitamin v mui khong cho bnh nhn. + Xoay tr chng lot. giai on hi phc, tp v xoa bp cc c, phng cng c v khp v sau. + C th dng thuc chng ng phng thuyn tc. 5. Theo di v x tr cc bin chng + Quan trng nht l nguy c ngt th do co tht thanh mn v suy h hp do cc c h hp co cng ko di . Khi khng khng ch c cn co: m kh qun cp cu v h hp h tr (th my). Mt s tc gi c ch nh m kh qun sm, nhng phi iu kin v trng v sn sc bnh nhn tch cc. + Bin chng ngng tim thng t ngt v kh x tr. Kch thch in hay c hc km theo xoa bp tim ngoi lng ngc c th cu c bnh nhn. + H huyt p : truyn dch v dng cc thuc vn mch + Tng huyt p : dng thuc chn alpha - beta nh Labetalol + Theo di cc chc nng thn , bng quang, rut. phng lot, chy mu tiu ha + Pht hin v iu tr bi nhim.

IX. PHNG BNH


1. Tim phng + nc ta, tim phng un vn c trin khai trong chng trnh tim chng m rng cho tr di 1 tui. Thng phi hp vi vaccine ho g v bch hu (DPT). Tim t thng th 2 tr i, ba ln lin tip, cch nhau 1 thng. Tuy nhin, ln tim nhc li sau 3-5 nm cha c ch trng. + Ph n c thai c tim phng 2 ln vo qu cui v 1-2 tun trc khi sinh. + Hu hiu nht l tim phng cho ton dn. Tim lin tip 3 mi, cch nhau mt thng, 5 nm ri 10 nm tip theo, tim nhc li mi ln mt mi, c tc dng phng bnh gn nh sut i. Bnh nhn sau khi khi un vn cng phi tim phng. + Ci thin cht lng cc nh h sinh c s, nng cao kin thc v sinh cho nhn dn cng lm gim t l un vn s sinh ng k, nht l nhng vng cha tim phng rng ri c. 2. X l vt thng c nguy c un vn Ra sch vt thng bng nc m v trng. Ly sch cc d vt, cc m hoi t. Ph b cc ngch, dn lu, st trng bng Oxy gi, h vt thng, khng sinh. Trong trng hp khng x l trit c, bn cnh khng sinh c th dng SAT (1500-3000 v, tim bp ), sau tim phng un vn ( 0.5ml Anatoxin, tim bp, tim nhc li sau 1 thng v 6 thng ). Cu hi n tp 1. M t cc triu chng ca giai on khi pht bnh un vn. 2. M t cc du hiu ca Hi chng cng giao cm bnh nhn un vn ? 3. Nu mt s bin chng thng gp ca bnh un vn. 4. Trnh by phc kim sot cn co git ca bnh un vn. 5. Trnh by cch x l vt thng phng bnh un vn.

97

Bi 16.

BNH DCH HCH


Ts, Bs Trn xun Chng

Mc tiu
1. Xc nh c tm quan trng, nguyn nhn v yu t dch t hc ca bnh. 2. Trnh by c cc triu chng lm sng v cc xt nghim. 3. Chn on sm v tin lng ng. 4. iu tr sm v kp thi. 5. Xc nh c cc bin php phng bnh Ni dung

I. I CNG
Dch hch l bnh truyn nhim rt nguy him gy dch, c th gy i dch do trc khun Yersinia pestis gy nn. Hin nay tuy bnh khng cn ph bin nh trc nhng n vn l mt bnh quan trng. Nu khng lm tt cng tc chm sc sc khe ban u v iu tra dch t hc bnh c th bc pht thnh dch tr li do s pht trin ca bnh rt nhanh.

II. BNH NGUYN


Yersinia pestis l mt cu trc khun Gr (-), sc khng ca Y. pestis tng i km. C 2 loi c t - Ngoa c t: khng chu nhit, ha tan, gm 2 thnh phn, phn A v phn B - Ni c t: chu nhit, khng ha tan C hai loi c t tc dng trn cc mch mu ngoi vi gy c c mu v sc, ni c t c i tnh vi h thn kinh.

III DCH T HC
1. Yu t ngh nghip Nhng ngi lm ngh c tip xc vi cc loi gm nhm, ng vt hoang di nh ngi lm rng, th sn, kim lm, nng dn .. nguy c mc bnh cao hn. 2. Ngun bnh ng vt gm nhm l vt ch mang mm bnh dch hch, c 2 loi ngun bnh : - Vt ch chnh gp trong dch thin nhin, c sc duy tr mm bnh lu di - Vt ch th yu tuy c vai tr trong qu trnh sinh dch nhng ring mt mnh n kh duy tr dch lin tc nhiu nm nu thiu nhng ngun truyn bnh chnh 3. Cn trng trung gian B cht l cn trng trung gian truyn bnh trong cc ging chut v t chut sang ngi. Tt c cc loi b cht u c th l mi gii truyn bnh c bit l Xenopsylla cheopis l mi gii chnh, ngoi ra ngi ta tm thy Y. pestis trong Pulex irritans.

IV. SINH L BNH


Vi khun dch hch xm nhp vo c th qua da ( ch yu do vt t ca b cht) v nim mc (mng tip hp, nim mc hu hng, ng tiu ha, ng h hp). Sau theo dng bch huyt n hch khu vc, ri vi khun li theo dng bch huyt n cc hch su hoc xa hch khi im, cui cng mi vo mu. Trong mu vi khun cn b i thc bo gi li v tiu ha. Qu trnh bnh l c th dng li y. Ngc li nu gan lch khng lc c th vi khun s trn vo mu gy nhim trng huyt. c t ca vi khun dch hch c i tnh vi t chc thn kinh gy li b m sng v cc tn thng thoi ha xut huyt, lan rng trong ni tng.

98 Trong dch hch th phi, vi khun qua mi xm nhp vo nim mc ng h hp trn nhng khng nht thit phi a n vim phi. Bnh gy min dch kh bn vng, him khi ti pht.

V. LM SNG
1. Th vim hch Chim 90 -95% trong dch hch. 1.1. Thi k nung bnh T 1 n 5 ngy, c th ngn hn (vi gi) hay di hn (8 -10 ngy) nhng t gp. 1.2. Thi k khi pht Trc khi ni hch, bnh khi t ngt ngi khe mnh vi mt mi, kh chu, nhc u, chng mt, au khp ngi, st, c khi rt run. C trng hp khi pht bng triu chng nhim c, au nhiu vng sp ni hch . 1.3.Thi k ton pht - Vim hch: bt k ni no ca h thng bch huyt ngoi bin, lin quan n ni b cht t, thng xut hin 1-2 ngy sau st, phn nhiu ni hch bn (62- 80%) , k l nch (14 -20%), c, di hm, dc c c n chm (15 -18%), hch trn khy tay hoc kheo chn rt him, thng ch 1 hch. c im hch vim: au xut hin sm trc khi sng, au cng nhiu bnh cng nng. Khi hch vim ty th rt au, lc u cn di ng, dn dn quanh hch b vim dnh nn kh xc nh ranh gii v kch thc. - Hi chng nhim trng nhim c: St, mch nhanh, nhp th tng, ngi l , mt mi, ht hong v m sng. V mt nhim trng nhim c. 1.4. Thi k lui bnh Hch vim s ha m, t v, chy ra mt cht nc hung hung . Bnh c th khi sau > 1 thng vi vt so co rm. Nhng thng tin trin n cc th nng nh nhim trng huyt hay vim phi lm cht nhanh. Nu c iu tr ng phc , hch s tiu nh, ht st, bnh s khi sau 1 tun iu tr . 2. Th nhim trng huyt 2.1 Tin pht Bnh khi t ngt, kch lit vi st cao 40-410C, kch ng, m sng, nn ma, tiu chy, bng chng, th nhanh, xut huyt, sau chong nhim trng, ng mu ri rc thnh mch v t vong nhanh chng 2.2 Th pht: sau vim hch Bnh cp tnh nhng t rm r. Tin lng kh quan hn nu c iu tr tch cc. 3. Th phi 3.1 Tin pht Him gp. Nung bnh ngn chng vi gi. St rt cao km rt run, mch tng, bnh nhn mt mi nhc u ngy cng tng. Khong 20 -24 h sau cc biu hin tn thng ngy cng r: au ngc, ho tng cn, khc nhiu m, kh th. Triu chng thc th thng ngho nn t khi nghe rales bnh l . Xquang: Hnh nh c phi hay hnh nh bong bng nh trong t cu phi . 3.2 Th pht Thng gp hn, l bin chng ca th hch khng c pht hin v iu tr kp thi. Chn on: da vo hnh nh chp X quang, xt nghim: vi khun c mt cht nhy hng.

VI. CN LM SNG
- Bnh cng nng bch cu cng tng, th nhim trng huyt tin pht bch cu tng rt cao ti 50.000/mm3, N > 80%; c khi bch cu gim 1000/mm3, L >80% - Tiu cu gim trong th nng, nht l khi c hin tng ri lan ng mu. Tm Yersinia pestis trong cc bnh phm nh chc ht hch, mu, m, cht nhy c hng, dch no ty.

99 - Soi pht mu ngoi vi (+) :thng gp trong th nhim trng huyt tin pht. Soi pht mu ngoi vi thng (-) trong nhim trng huyt th pht. - Cy mu : Thng (+) th nhim trng huyt, vim phi. - Tm khng th trong huyt thanh bnh nhn .

VII. CHN ON
Dch t hc - Vng dch lu hnh - Mc chut v b cht tng cao - C chut cht t nhin v nhiu - Cha tim phng dch hch Lm sng: Hi chng nhim trng nhim c nng km au vng hch (lc hch cha sng) Cn lm sng: Cng thc mu bch cu tng.

VIII. IU TR
1. Cc bin php x l sm - Phi dng khng sinh sm - Cch ly bnh nhn trm x phng x - Nn t chc iu tr ti ch, nu xt cn phi chuyn sm iu tr sm khi nghi ng, th thng thng gim t l t vong 40 %, th phi gim 5-10% 2. Phc iu tr 2.1. Th nh: Dng mt khng sinh ung 7 ngy lin tc Tetracycllin hoc Chloramphenicol 40mg /kg /ngy hoc cotrimoxazol 480 mg X 4 vin /ngy. 2.2. Th trung bnh: streptomycine 50mg /kg/ngy tim bp + tetracyclline ung 50mg /kg /ngy hoc chloramphenicol 7-10 ngy lin tc, tr sc, truyn dch nu cn. 2.3. Th nng -Khng sinh dng phi hp 3 khng sinh vi liu nh trn, khi bnh gim 2 th khng sinh sau c th dng ng ung. - Corticoide: Depersolone 30 -60 mg - Bin php hi sc: Truyn dch, th Oxy, tr sc, nng cao th trng, tr tim mch. -Thuc an thn h nhit . - Chm sc bnh nhn: v sinh rng ming, thn th.

IX. PHNG BNH V CHNG DCH


Cc bin php chng dch hch khi c dch : - Bo co dch khn cp v bt buc - Cch ly bnh nhn hon ton - Cht thi ca bnh nhn nh nc tiu, phn, m, m x l bng nc Javen. - X l t thi bnh nhn dch hch: T thi bc trong vi tm lysol 5% hoc chloramin 3% . Bn trong quan ti phi rc chlorua vi, sau em chn su 1,5 - 2 mt. - Ung thuc phng i tng cho ung thuc phng khn cp l ngi tip xc bnh nhn v ngi sng chung nh bnh nhn hay ngi sng nh c nhiu chut cht t nhin, nghi ngh dch hch. Thng dng Tetracycline 1 g/ngy hay Cotrimoxazol 480 mg x 4 vin /ngy x 7 ngy Nhng ngi tim phng dch dch cha qu 6 thng khng cn ung phng . - Tim chng : c nghin cu t lu nhng hiu lc ca n khng cao. Khi c dch bng pht nn tim phng cho nhn dn cc vng ln cn, khng tim cho ngi trong dch. Thng dng loi vc xin sng gim c lc, tim mt ln, to min dch nhanh (5 - 7 ngy sau khi tim) - Dit b cht v dit chut (dit b cht trc dit chut) - y mnh cng tc tuyn truyn nhn dn hiu r s nguy him ca bnh. Cu hi n tp

100 1. Ngun bnh v cn trng trung gian gy bnh dch hch l g ? 2. Nu c im vim hch trong dch hch th hch ? 3. c im lm sng ca dch hch th phi ? 4. Phc iu tr dch hch th nh v trung bnh ? 5. Cc bin php chng dch hch khi c dch ?

101

Bi 17.

BNH NHIM LEPTOSPIRA


(LEPTOSPIROSIS)
BsCK2,Ths H th Thu Vng Mc tiu 1. Trnh by c tnh cht ph bin v cc yu t dch t ca bnh nhim Leptospira. 2. M t c triu chng lm sng, cc bin chng thng gp ca bnh nhim Leptospira. 3. Trnh by c cc phng php iu tr bnh nhim Leptospira. 4. M t c cc bin php d phng bnh nhim Leptospira trong cng ng.

Ni dung
Nhim xon khun Leptospira l bnh ca sc vt hoang di v gia sc lan truyn cho ngi. Bnh c c im lm sng a dng, gy tn thng cng lc nhiu c quan. Hi chng Weil l mt bnh cnh nng ca nhim xon khun, c trng bi xut huyt, vng da, suy thn.

I.NGUYN NHN
Leptospira l mt loi xon khun thuc h Leptospiraceae, c kch thc rt mnh , trn knh hin vi nn en c th ging nh chui cu trng, khng bt mu nhum gram thng thng, ch pht hin bng nhum nitrat bc, c nhiu type huyt thanh khc nhau. C n hn 200 type, chia thnh 23 nhm. Ch c mt s type hay gp v gy bnh cho ngi. Tc nhn gy bnh thng gp nht l L. ictero haemorrhagiae. Mt type huyt thanh c th gy nhiu bnh cnh khc nhau. Ngc li, mt bnh cnh lm sng c th do bt k type no trong nhm gy bnh to nn.

II. DCH T HC
Leptospira l bnh ch yu ca cc ng vt, nht l cc ng vt gm nhm nh chut v gia sc nh ch, heo, tru, b.... Ngi ch mc bnh khi tip xc vi t, nc c xon khun thi ra t nc tiu ng vt hay t mu hoc xc ng vt mc bnh. Bnh thng xy ra vo ma h-thu, lc con ngi phi lao ng hay gii tr ngai tri. Nam mc bnh nhiu hn n. Tui t 10-50 tui hay mc. Nhim xon khun cng l bnh ngh nghip, lin quan n cng vic dm nc v t m hoc tip xc vi gia sc : nng dn, cng nhn v sinh cng rnh, th m, cn b th y ...v thng xuyn tip xc vi ngun bnh.

III. GII PHU BNH V SINH L BNH


Sau khi qua da v nim mc, Leptospira vo mu, lan trn khp c th gy nhng biu hin bnh l nhiu c quan.. Leptospira di chuyn xon c nn c th lch qua cc m lin kt d dng. Ngoi ra, cng pht hin hyaluronidase t cht lc canh cy Leptospira, chnh cht ny gip Leptospira xm nhp bt thng vo nhiu c quan Nhng pht hin v lm sng v m hc trn ngi v ng vt cho thy tnh cht gy bnh ca Leptospira mt phn do ni c t, mt phn do enzyme v cc cht bin dng khc to ra t s ly gii ca Leptospira Bn cht ca cc ri lan l thng tn mng cc mch mu nh, a n vim mao mch, thot dch v xut huyt. Tn thng thng biu hin r cc c quan gan, thn, c, v t cc mao mch c th gy tn thng cho bt k c quan no khc nh mng no, tim, phi, m di da..

102 - Gan: hoi t trung tm cc thy km cc t bo Kuffer phnh to. Tuy nhin khng c hoi t t bo gan nng n. - Thn: Thng c vim thn k v hoi t ng thn. Leptospira thng c tm thy trong lng ng thn. Nguyn nhn chnh ca tn thng ng thn c l do thiu oxy mu hoc tc ng gy c trc tip ca Leptospira. Cc bin i ca hin tng vim ti thn c th thy giai on mun, c phc hp min dch lu hnh v s lng ng b th ti cu thn, gi vim vi cu thn do phc hp min dch - Leptospira c th tm thy d dng trong dch no tu vo tun u ca bnh, thng lc khng c du mng no. Biu hin vim mng no ch xut hin khi nng khng th trong huyt thanh bt u tng, khi leptospira bin mt trong dch no tu. iu ny gi vim mng no c l do phn ng khng nguyn- khng th. - C:: Mc d au c xut hin sm v trm trng nhng thay i m hc thng khng ng k. Cc t bo c thng thng ph v thnh lp nhiu khng bo. Giai on khi bnh nhiu si c mi c thnh lp.

IV. LM SNG
Bnh cnh lm sng c th nh hoc rt nng. Th nng c trng bi xut huyt, vng da, suy thn (hi chng Weil) do L.autumnalis, L. bataviae, L. copenhageni...gy ra. Bnh thng din bin theo 2 pha : 1.Pha nhim khun huyt (Acute leptospiremic phase) 1.1.Thi k bnh Trung bnh t 1-2 tun, c th dao ng trong khong 2-26 ngy. 1.2. Thi k khi pht Khi pht thng vi cc triu chng st, nhc u, s nh sng, rt run, v m hi v au c. St thng rt cao: 39-400C, trc khi st thng c cn rt run. Nhc u c th vng trn, hai bn thi dng, c th vng chm. Bnh nhn van nhc mi cc c, nht l cc c vng i, c lng, cng chn. Xoa bp c lm cn au tng ln. Vng da xut hin 5-7 ngy sau khi khi pht. 1.3. Thi k tan pht Cc triu chng trn tip tc pht trin nng hn. Bnh nhn au c nhiu hn, c khi khng i c, km theo nn ma. Bp vo c cng au hn. Mt b xung huyt. Trn da thng c ni cc ban dng dt hay dng ban lm tm khu tr hay ri rc. thi k ny bnh nhn c th c chy mu cam, au hng , ho. Cn lm sng : trong giai an tan pht (thng l tun u tin), ta c th tm thy vi khun trong mu, trong dch no ty v tun th hai trong nc tiu. Tuy nhin giai an ny cc xt nghim huyt thanh thng m tnh. Cng thc mu cho thy bch cu tng cao, ch yu a nhn trung tnh trong phn ln trng hp. C th c nhng biu hin tng ur mu v creatinine mu tm thi. 1.4. Thi k hi phc tm thi Phn ln cc triu chng bin mt sau 1 tun. Sau 1-3 ngy, cc triu chng xut hin tr li mt s trng hp. l pha min dch ca bnh. 2.Pha min dch (Immune leptospiruric phase) S bt u pha min dch c lin quan n s xut hin cc khng th. Biu hin hay gp l vim mng no, suy thn, vim gan. C khi vim c tim v vim no. - Vim mng no: thng c hi chng mng no r, nhng dch no ty trong, khng tm thy vi khun. Bch cu tng cao, ch yu l lympho nh trng hp vim mng no virus. Tuy nhin trong mu cng thc bch cu c th vn cao, ch yu a nhn trung tnh. - Suy thn cp : c th xy ra ngay trong giai an tan pht v ko di, khng c giai an hi phc tm thi Khi u thng thiu niu ri v niu. Xt nghim c th c hemoglobin niu, hng cu, tr ht, cc cn lng ca hng cu v cc mnh ca t bo ng thn. Ur mu v creatinin mu tng cao.

103 - Vim gan: Th vim gan cp vi cc triu chng gan to, au. Vng da r do mt . - Xut huyt nhiu ni : biu hin thng di da vi nhng mng rng l mt biu hin nng ca bnh c th t vong v thiu mu v suy khi lng tun han. - Hi chng Weil :L th nng nht ca bnh, c trng bi vng da, suy thn, xut huyt v c t l t vong cao. Cc triu chng trn thng xut hin sau khong 4-9 ngy. Vng da khng c lin quan n hoi t t bo gan. Suy thn l hu qu ca hoi t ng thn cp, gy ra bi gim th tch tun hon v gim ti mu thn.

V. CN LM SNG
1. Cng thc mu: Bch cu thng tng khong 10.000 20.000/mm3, a s a nhn trung tnh, c th bch cu bnh thng hoc gim. Bnh nhn vng da cng nng bch cu cng tng cao. Hng cu gim nhiu nu c tn huyt ni mch hoc xut huyt Tiu cu gim, him khi n mc gy xut huyt nng 2. Nc tiu: hemoglobin niu, hng cu, tr ht, cc cn lng ca hng cu v cc mnh ca t bo ng thn 3. Chc nng thn: Ur, creatinin mu thng tng rt cao trong cc trng hp c vng da, ngay c khi bnh nhn c iu tr khng sinh 4. Chc nng gan: SGOT, SGPT thng tng di 5 ln tr s bnh thng. Bilirubin tng thng di 20 ln tr s bnh thng. 5. Chn on vi sinh: + Soi: Phng php quan st trc tip xon khun trong mu hay nc tiu bng soi knh hin vi nn en c nhy ( 40,2%) v dc hiu (60,1%) thng thp Mt s phng php nhum nh nhum min dch hunh quang, nhum nitrat bc thng khng c s dng rng ri do thiu ho cht v nhy tng i thp + Phn lp xon khun - Cy mu: Ch dng tnh trong tun u tin ca bnh. - Cy nc tiu: Ch dng tnh sau tun u tin ca bnh v ko rt di v sau v bnh nhn c th thi xon khun ra theo ng tiu hng thng sau khi khi bnh. C th phn lp c xon khun t dch no tu, dch thm phn phc mc + Cc xt nghim huyt thanh :Cc phng php chn on hay dng hin nay l : - Ngng kt vi th (MAT: microscopic agglutination test) dng tnh khi hiu gi 1/100. Ch pht hin vo tun th hai ca bnh. - Test ELISA ( enzyme-linked immuno-absorbent assay) : nhy nhng t tin. - PCR: c dng pht hin chui DNA ca Leptospira; ch thc hin cc trung tm ln.

VI. CHN ON
Chn an xc nh nh tm c vi khun trong mu hay trong nc tiu. Ngai ra cn c th xc nh bng cc xt nghim huyt thanh v k thut PCR. 1. Cc du hiu gi trn lm sng : + Tin s c tip xc vi ngun bnh trong vng 1 thng. + Ngh nghip c nguy c nhim xon khun. + Cc triu chng : st, au c, vng da, xung huyt kt mc, suy thn, xut huyt. 2. Xt nghim cn lm sng: - Cy mu : Ch dng tnh trong tun u tin ca bnh. - Cy nc tiu : Ch dng tnh sau tun u tin ca bnh v ko rt di v sau v bnh nhn c th thi xon khun ra theo ng tiu hng thng sau khi khi bnh. - Cc xt nghim huyt thanh

VII. IU TR
1. iu tr nguyn nhn Xon khun nhy cm vi hu ht cc khng sinh thng thng. Trng hp nng nn dng Pnicillin G, Amoxicillin, Ampicillin hoc Erythromycin ng tnh mch.

104 Liu Pnicillin: 6 triu n v/ ngy, chia 4 ln trong 7 ngy. Liu Amoxicillin v Ampicillin : 4g/ngy x 7 ngy. Trng hp bnh nh c th dng Tetra cyclin, Doxycyclin, Amoxicillin hoc Ampicillin bng ng ung. Tuy nhin khng sinh ch c hiu lc khi dng sm, trong vng 5 ngy k t khi pht bnh. Khi chuyn qua pha 2, khng sinh thng khng c hiu qu. 2. iu tr triu chng Cn ti lp cn bng nc v in gii. Bnh nhn c hi chng Weil cn c truyn mu v tiu cu. Chy thn khi c suy thn cp, Th my khi c suy h hp, nht l ARDS .

VIII. PHNG BNH


1.Cc bin php chung - Dit chut v cc lai gm nhm, trnh tip xc vi nc tiu v ng vt cht. - S dng gng tay, ng bo h khi phi lm vic trong mi trng c nhiu xon khun nh khai thng cng rnh, lm m, cy rung... - Theo di nh k cc ngh nghip c nguy c mc xon khun cao. - Trng hp mi nhim c th dng Doxycyclin, 200mg, liu duy nht mi tun. 2. Tim chng - Vaccine c kh nng bo v chng xon khun vng da xut huyt (L. icterohemorrhagiae) trong 3 nm. Hiu lc bo v xut hin sau ln tim th ba (mi ln cc nhau 15 ngy, 1ml/ln). C th tim phng vaccine cho sc vt: tru b, ch, heo... Cu hi n tp 1. Cc yu t nguy c ca bnh leptospira 2. Lm sng ca bnh leptospira pha min dch 3. Cc xt nghim gip chn on xc nh bnh leptospira 4. iu tr mt trng hp bnh leptospira c suy thn cp 5. Trnh by cc bin php phng bnh do leptospira.

105

Chng 3. CC BNH DO NHIM VIRUS


Bi 18.

NHIM HIV/ AIDS


Ts,BsCK1 Nguyn L

Mc tiu
1. T vn c cho ngi nhim HIV, thn nhn v nhng ngi c nguy c nhim HIV v ng ly truyn, cch phng chng ly nhim. 2. Theo di v sn sc c hiu qu ngi nhim HIV trong mi giai an

Ni dung I. NH NGHA
Nhim HIV l tnh trng c virus HIV trong c th. Tuy chm, nhng chng ngy cng tn cng mt s c quan v chc nng ca c th, nh h thn kinh trung ng, v c bit h min dch, lm c th mt dn kh nng min dch v cui cng t vong do nhim trng hay do chnh virus HIV. n nay, l mt bnh cha c thuc iu tr tht s, ch km hm c tin trin ca bnh, v t vong chc chn khi khng c thuc hay s km hm mt hiu qu do nhiu nguyn nhn khc nhau.

II. S LC LCH S
Nhng trng hp nhim trng c hi hay u Kaposi do suy gim min dch u tin c ghi nhn chnh thc ti Hoa k nm 1981. Nm 1983, Luc Montagnier (Php) phn lp c HIV 1, nm sau 1984, tm c HIV2. Bnh c nhanh chng lan truyn v pht hin ln lt trn th gii mt cch nhanh chng, c bit cc nc chu Phi, M v chu u trong cui thp nin 1980, lan n chu mun hn, nhng hin nay c nguy c tng nhanh hn cc chu lc khc, sau chu Phi. Trn lm sng, nhiu phng thc c gng h thng ha biu hin ht sc a dng ca cn bnh ny. Nhng cch xp lai ca hi ngh Bangui (1985), ca Walter Reed (1986), ca CDC (1987), ca WHO ri ca CDC ci tin (1993) vi nhng u v khuyt im ring, ln lt ra i gip cho cc nh lm sng, dch t v min dch, thng nht quan im, phn lai v theo di bnh nhn. V iu tr, cng c nhng tin b vt bc. Thuc khng HIV u tin (AZT) c th nghim (1985) ri nhanh chng p dng (1987). Tip theo cc nhm thuc khng HIV khc ln lt pht hin. K t 1995, liu php kt hp 3 thuc khng HIV em li nhiu hiu qu trong vic chn ng tin trin ca bnh, thm ch c hy vng bin nhim HIV thnh mt bnh mn tnh sut i. Tuy nhin do gi thnh qu t, tc dng ph v s xut hin virus khng thuc khi dng lu di lm cho hiu qu p dng thc t trn th gii cn rt nhiu hn ch.

III. TC NHN GY BNH v SINH L BNH I CNG


Virus HIV hin nay c pht hin c 2 lai HIV1 v HIV2, khc nhau kh nhiu v mt s khng nguyn. Tuy nhin v c ch gy bnh v din tin lm sng khng khc nhau lm. Nhim HIV2 c tin trin n giai an AIDS chm hn HIV1.

106 C hai lai u l nhng Retrovirus, vi acid nhn l RNA, chng c kh nng tng hp thnh DNA t nhng m di truyn ca RNA nh vo mt men c bit gi l men sao m ngc (reverse transcriptase, vit tt l RT). S sao m ngc ny thng khng han chnh, hay c sai st so vi nguyn bn ban u. iu ny, gip cho virus thay i khng nguyn, to nn nhiu bin chng khc nhau, gip cho virus that khi s tm dit ca h min dch. Virus c bc bi mt lp v ngai, gm cc glycoprotein 120 v glycoprotein 41, c kh nng nhn din cc receptor l nhm CD4 v cc coreceptor khc. Hai coreceptor ni ting ca HIV l nhng th th ca chemokine, mt c cu trc dng CCR5, mt c cu trc CXCR4. Mt s ngi (thng thuc chng tc Cacause, da trng), khng c th th CCR5, nn min dch mt phn vi virus HIV, iu ny gii thch nhng trng hp nhim HIV tin trin ko di n 15-16 nm. Mt nhm men quan trng ca virus l cc men tiu proteine (cc protease). Cc men ny gip cc thnh phn virus va c tng hp, nhm li thnh nhng virus han chnh v ph v t bo vt ch phng thch cc virus th h sau ra bn ngai, tip tc tn cng cc t bo ch khc. c ch c nhm men ny s c ch c s nhn ln ca virus. Virus HIV khng c kh nng tn ti lu ngai cnh. Chng b dit bi nhit > 56 C, vi cn, vi cc cht ty v dit trng thng thng nh dung dch cloramin, nc Javel, hi nc nng. Tuy nhin trong c th ngi nhim, virus kh b tiu dit. Chng tn cng cc t bo c mang phn t CD4 cng vi cc phn t c i tnh vi chemokin nh cc t bo lympho T gip (c gi l cc t bo CD4+), t bo Langerhans di da, cc t bo m (glial cell) h thn kinh, cc i thc bo, cc t bo mono v cc t bo lympho vng mm ca hch bch huyt. Chng n trong cc hch bch huyt giai an u, kh nng thay i khng nguyn thng xuyn gip trnh c cc khng th v cc t bo git ang tm cch dit chng. Sau , nh vo chc nng trnh din khng nguyn ca cc i thc bo, chng c tip cn vi cc t bo c receptor thch hp, c bit t bo T CD4+, xm nhp v ph hy t bo ny. T bo T CD4+ l t bo quan trng trong iu ha min dch ca c hai h min dch th dch v min dch trung gian t bo. S gim dn s lng T CD4+ lm c th mt kh nng min dch vi ngai cnh, dn n nhim trng d dng v t vong. Bn thn virus HIV cng c th tn cng mt s c quan c nhiu t bo mang receptor CD4 nh t bo m thn kinh, gy nn cc bin chng thn kinh quan trng.

IV. DCH T HC
T nhng pht hin u tin nm 1981 ti Hoa k, bnh nhanh chng lan truyn khp th gii theo chn s nghin chch ma ty v mi dm.T lan n cho ngi hn phi v tr em ra i t nhng ngi m HIV (+). Mt s trng hp ly qua ng truyn mu v ch phm ca mu, nhng ng ny ngy cng hn ch do nhng bin php pht hin HIV trc khi cho mu ngy cng tt hn v hu nh c x dng bt buc. Bo co ca WHO vo 31/12/2007: Uc tnh ton th gii c khong 65 triu ngi nhim HIV, t vong chng 33,2 triu, Phn b theo a l nh sau Chu M : 3. 000.000 Chu u : 1. 880.000 trong ng u 1.3 triu Chu Phi vng h sa mac Sahara : 25.000.000 Bc Phi v Trung ng : 480.000 Chu c : 32.000 Chu : ch yu Nam v NA : 7.400.000.

107 Tuy nhin, s ngi nhim mi cc nc pht trin nh Ty u v Bc M ngy cng gim, trong khi tng rt nhanh cc nc ng u v ng Nam . Vng bin Caribe v chu Phi vng h sa mc Sahara vn cn gi mc cao. Vit Nam, bo co ca y ban phng chng HIV/AIDS quc gia c tnh n cui 2007 c khong 400.000 ngui nhim HIV (t l 1/200 dn s). Cc tnh v thnh ph c s lng nhim HIV cao : TP HCM, H ni, An giang, Hi phng, Qung ninh, Vng tu, ng thp, ng nai, Ngh an, Cn th Ngun ly : Hin nay HIV ch c vt ch l ngi. Cc virus tng t (nh SIV), c th gy bnh cho mt s kh, nhng li khng gy bnh cho ngi. Ngc li, HIV1 v HIV2 cng khng gy bnh cho cc ng vt khc, k c cc lai kh. Tuy nhin, m hnh mc bnh kh tng t nhim HIV ngi v l m hnh tt nghin cu HIV ngi. ng ly truyn: Hin nay, HIV ly qua ba ng : - ng mu: Mu, huyt tng, cc dch c th ngi nhim HIV a trc tip vo mu hay qua da v nim mc b xy xt u c th ly bnh. Tuy nhin, mc ly ty thuc vo nng virus. Nng ny thay i ty theo giai an ca bnh nhn, ty theo lai dch. Cc dch ngai tit nh m hi, nc bt, m, nc tiu, phn...c mt virus thp. Ch ly khi c c hi tip xc rt lu hoc rt nhiu ln v ni tip xc l da hay nim mc b xy xt. Dch sinh dc v cc dch kn trong c th (dch no ty, dch khp, mu, huyt tng...) c mt virus cao. Nhng tr quan h tnh dc, a s ly qua cc dch ny l tai nn ngh nghip ca ngnh y t. Trong thc t, ly truyn qua ng mu ch yu xy ra nhng ngi nghin chch ma ty dng chung bm v kim tim. Ly nhim t truyn mu hay cc ch phm ca mu ngy cng t, nhng khng trit tiu hn v khng th pht hin c nhim HIV trong thi k ca s. Cc xy xt qua da v nim mc do dng chung nhng dng c nh dao co ru, dng c ct mng tay, dng c y t khng thanh trng k.. l nhng ng ly cn lu . n nay cha c bng chng ly qua cc cn trng ht mu (mui, rn, rp...) - ng tnh dc: L con ng ly truyn kh ph bin v kh ngn cn do thiu hiu bit. Nguy c ly lan ty thuc vo nhiu yu t: Nguy c ln hn khi giao hp qua ng trc trng, sang chn khi giao hp, c bnh hoa liu khc b phn sinh dc. Nam thng gy nhim cho n nhiu hn. - Ly t m qua con: c th ly trong giai an thai k, trong thi gian chu sinh v trong khi cho con b d rng mt virus trong sa m thp.

V. CC GIAI ON NHIM HIV


1. Giai an s nhim Giai an ny tnh t lc virus HIV xm nhp vo n lc c th c khng th chng li HIV (chuyn i huyt thanh). Thng ko di 4-6 tun. Trong giai an ny, mt virus rt cao, nn rt d ly nhim. S lng t bo T CD4+ gim thp. Giai an ny, bnh nhn c mt s biu hin lm sng ca nhim virus chung chung nh st, au c, nhc u, au khp, ni hch. C khi biu hin vim phi, ri lan tiu ha, thm ch nhng triu chng thn kinh. Nhng biu hin s nhim c gi tr tin lng thi gian tin n AIDS. Biu hin cng nng, cng nhanh tin n giai an cui. Trong giai an ny, cc xt nghim tm khng th u m tnh v c th cha sn xut. Ch pht hin virus (phng php PCR) hay cc sn phm ca HIV (gp 20, gp40..). nc ta, cc xt nghim ny cha ph bin. Cui giai an s nhim, lng virus trong mu gim xung, v khng th khng HIV bt u xut hin. Lc ny cc xt nghim tm trc tip virus c th m tnh do lng virus qu thp hay do virus n trong cc hch bch huyt. Nhng cc xt nghim tm khng th vn

108 cha dng tnh. Giai an m tnh gi ny gi l giai an ca s.

Biu 1: Din bin s t bo T CD4+ v nng HIV ngi nhim HIV

2. Giai an tim n Sau thi k s nhim, c th bt u to khng th tm dit HIV. Trong giai an ny, virus thng khu tr trong vng mm (germinative zone) ca cc hch bch huyt. Chng thay i khng nguyn v trong cc i thc bo nn trnh c s tm dit ca cc t bo gy c v t bo git. Mt virus lc ny trong mu thp, nhng nguy him v ngi nhim khng c biu hin g, vn tham gia sinh hat bnh thng trong x hi, tip tc hat ng tnh dc nn lm tng kh nng truyn bnh. Bn trong c th virus tip tc sinh sn v hy hai dn t bo T4. Sau mt giai an kh di, thay i ty tng c nhn (Nhanh nht l 3 nm, di nht c th n 16 nm. Trung bnh 10 nm), lng t bo T4 khng cn kh nng b tr s hy dit ca virus s c biu hin suy gim min dch. Nng virus trong mu tng dn theo thi gian (do kh nng ly cng mnh hn). Do c b tr, lng T4 giai an ny vn nm trong gii hn bnh thng. Giai an ny c th pht hin nhim HIV bng cc phng php tm khng th, hin ang x dng nc ta. 3. Giai an tin AIDS (Trc y gi l giai an c biu hin cc phc hp lin quan n AIDS) : Giai an ny, bnh nhn thng c cc biu hin lm sng vi nhng hi chng gi n nhim HIV: st ko di, tiu chy trn 1 thng, st cn 10% trng lng c th M KHNG TM C L DO no khc (lao, cng gip, ung th, i ng khng iu tr...). Bnh nhn thng b nm candida xoang ming, m o, p ng km vi iu tr. Ph n c th lan sn hay K c t cung ti ch, vim vi trng a n p xe bung trngvi trng. Zona nhiu vng trn c th, ti pht nhiu ln l mt bnh hay gp giai an ny. Giai an ny T4 gim nhng cn cao hn 200/mm3. 4. Giai an AIDS Theo quy nh ca CDC, mi trng hp c T4 < 200/mm3 u xp vo giai an AIDS. H min dch lc ny khng cn c kh nng bo v c th. Trn lm sng bnh nhn thng mc cc nhim trng c hi, mt s bnh c tnh c th c ngun gc virus (K c t cung xm ln, u Kaposi). Mt s c cc bin chng do chnh virus HIV gy ra (vim no do HIV..).Cc bnh ny c xp vo nhm C trong phn lai ca CDC 1993. Cc bnh c hi

109 thng kh cha, v d khng thuc. Nu cha khi thng hay ti pht, i hi phi ung thuc phng u n v sut i. Bnh nhn li thng mc nhiu bnh nhim trng cng lc cho nn rt kh iu tr v bnh nhn thng t vong . Giai an ny mt virus trong mu rt cao. Nhng do khng cn hat ng c nn nguy c ly lan cho x hi gim nhiu. Ch yu ly cho bn cng tim chch hay do tai nn ngh nghip y t. Trong bi cnh nc ta, ngi nhim HIV thng c nhng biu hin nhim trng c hi. Mt s c biu hin ung th nh lymphoma, K c t cung xm ln. Nhng u Kaposi, d rt ph bin cc nc, nc ta cha thy bo co. Cc bnh do chnh virus HIV th cha c phng tin khng nh. V th, y ch cp n nhim trng c hi.

VI. NHIM TRNG C HI (NTCH)


1. nh ngha NTCH l nhng bnh ch xy ra trn nhng c a suy gim min dch (leucemie, dng thuc c ch min dch, hay nhim HIV giai an AIDS). Trn c th bnh thng cc tc nhn gy bnh thng b h min dch c th tiu dit. Tuy nhin, khi nim ny hin nay c m rng gm c nhng bnh nhim trng nhng bnh nhn suy gim min dch do AIDS mc d chng cng c th gy bnh ngi bnh thng nh lao, vim phi vi khun thng thng. iu khc bit l trn bnh nhn AIDS, cc bnh ny thng tin trin nhanh chng, p ng chm vi khng sinh c hiu, ti pht nhiu ln.. 2. Mt s bnh c hi hay gp Vit Nam Danh sch bnh c hi trong AIDS rt nhiu, v ngy cng c b sung thm. N ty thuc vo mi trng, tp qun, c a ca bnh nhn v vng bnh nhn sng. Chng ti ch k n mt s bnh hay gp nc ta. 2.1. Lao Lao l bnh c hi hng u ngi nhim HIV nc ta. Lao lm tin trin HIV nhanh hn n giai an cui. Ngc li, nhim HIV lm lao d lan ta tan thn, kh iu tr v lm xut hin cc chng khng thuc nhiu hn. 2.2. Nm Candida Hay xut hin xoang ming v m o. Tuy nhin khi tnh trng min dch gim, nm lan n thc qun, gy nut au, kh nut hay lan vo nhu m phi ...thm ch gy nhim nm huyt, lan n cc ni tng khc. iu tr rt kh. 2.3. Nhim nm Penicillum marnerffei Lai nm ny ch ph bin ng nam , c ngun gc t chut ng (Bambou Rat). Thi Lan c bo co l NTCH th ba. Vit Nam, tuy cha c cng b chnh thc, nhng pht hin nhiu trng hp c ba min. Thng c biu hin nhim nm huyt, phi v da. da, biu hin d lm vi u nhy ly (Molluscum contagium). iu tr kh khn vi thuc khng nm. T vong cao. iu tr vi Itraconazol tim TM 400mg/ngy khi c nhim nm huyt hay ni tng. Ung thng cho kt qu chm hn. Sau khi iu tr khi phi ung thuc phng (Fluconazole sut i cng vi thuc khng HIV. 2.4. Vim phi do P. jeroveci (trc y gi l Pneumocystis carinii ) L bnh c hi ph bin cc nc Chu u v M. nc ta bo co chnh thc ch c 5 trng hp thnh ph HCM. Trong thc t chng ta c th gp nhiu trng hp vim phi k, khng p ng vi cc khng sinh ph rng v cc thuc khng nm, nhng p ng vi Bactrim liu cao. C th y l do nhim P. jeroveci. y l mt bnh phng c. Khi bnh nhn c TCD4+ < 200/mm3. Cn cho dng thuc ny hng ngy d phng.

110 2.5 Tiu chy Do rt nhiu nguyn nhn. Vi cc vi khun thng thng, d c p ng vi Fluoroquinolone phi hp vi Metronidazole, bnh thng ti pht nhiu ln vi khong cch rt gn. C trng hp ch p ng vi Bactrim . 2.6. Vim mng no do nm Crytococcus neoformant Cn cnh gic khi bnh nhn HIV(+) c hi chng mng no. Cn cho xt nghim dch no ty (nhum bng mc tu pht hin). iu tr vi Amphotericine B hay Fluconazole. 2.7. Nhim Toxoplasma L mt bnh c th phng c bng cch khuyn bnh nhn khng tip xc vi mo v phn mo. C th phng bnh bng cch x dng Bactrim hay Pyrimethamine.

VII. CHN ON
1. Chn on nhim HIV Do tnh cht quan trng v tnh trm trng (khng cha c, chc chn t vong) cho c nhn cng nh nguy him cho cng ng, nh hng rt ln n i sng bnh nhn v mt th cht cng nh tm l, nh hng n uy tn c nhn v danh d gia nh, chng ta phi ht sc thn trng khi kt lun mt ngi nhim HIV. Ch nh v kt qu xt nghim cn ty giai on ca bnh nhn. 1.1 Xt nghim pht hin khng th L cc xt nghim ang c x dng ph bin nc ta. Cc xt nghim ny khng pht hin c HIV giai an s nhim. V vy khi m tnh, phi khuyn bnh nhn xt nghim ln 2, sau 3 thng khng c tip xc vi ngun ly nhim no khc. Nu vn m tnh mi c quyn kt lun l khng nhim. Ngc li, tr < 1 tui, m HIV (+), nu xt nghim dng tnh, vn khng kt lun c chu b nhim, v l khng th khng HIV ca m truyn qua. Do phi xt nghim li trong nhng nm sau t 18 thng tui tr ln. C ba lai xt nghim pht hin khng th khng HIV ang dng nc ta: Test Serodia : nhy thp, nhng c hiu cao. Ch c gi tr sng lc ban u. Nhng ngi Serodia (+) l nhng ngi c th nhim, cn xc nh thm bng cc xt nghim khc trc khi khng nh. Ngc li, ngi Serodia (-) th rt t c nguy c nhim HIV. Test ELISA : pht hin mt lai khng th ty theo kit chn trc. Phn ng ny c nhy cao, > 90%. nhy v c hiu cng cao vi cc th h XN sau. Tuy nhin vn khng chc chn 100%. Test Western - Blot : Kt lun ch chc chn 100% khi ngi bnh c xt nghim HIV (+) vi phng php Western - Blot. Phng php ny pht hin mt lot nhiu khng th c hiu chng nhiu lai khng nguyn khc nhau ca virus HIV. Do lai tr c phn ng dng tnh gi. Tuy nhin do xt nghim Western-blot rt t tin, khng th x dng i tr m s ngi nhim HIV nc ta ngy cng cao, hin nay ngnh Y t quy nh : Vn xem nh l (+) nhng trng hp ELISA (+) 2 ln vi 2 lai kit khc nhau (pht hin 2 khng th khng HIV khc nhau ). Xc sut dng tnh gi khi xt nghim 2 ln vi 2 lai khng nguyn khc nhau ht sc thp nn him khi gp sai lm trong thc t. 1.2. Xt nghim tm trc tip virus hay cc sn phm virus Ngi ta c th pht hin trc tip s hin din ca virus trong mu hay dch c th bng phng php khuych i gen (PCR), phng php dng gen mi thm d. Cc phng

111 php ny c hiu, cho php pht hin ngay c trong giai an s nhim. Ngai ra, cn dng nh gi hiu qu ca cc thuc khng virus (o nng virus trong mu), pht hin tr s sinh c nhim HIV hay khng. Tuy nhin do k thut phc tp v t tin, hin nay ch x dng cc trung tm nghin cu quc gia, cha p dng i tr. Cc k thut tm cc protein virus nh p24 (Hin nay test ELISA th h 4 va cho php pht hin khng th, va pht hin KN p24) c tnh c hiu, nhng khng hng nh. Phn lp virus HIV : chnh xc v c th kho st c nhiu c tnh ca virus. Nhng cha thc hin c nc ta. 2. Chn on giai on ca bnh Mc du tin trin v mt sinh l bnh c 4 giai on, nhng trn thc t lm sng, biu hin bnh do nhim HIV rt phong ph v a dng. Do , nhiu phng php xp loi c ngh ph hp hn vi lm sng v dch t hc. Trn thc t lm sng, ngi ta thng chn on giai on nhim HIV da vo mt trong nhng cch xp loi c cng nhn rng ri. Ni ting nht l cch xp loi ca CDC 1993 dnh cho ngi ln nhim HIV
S t bo T CD4+ /mm3 hay t % > 500 (>29%) 200 - 499 (14-28%) < 200 ( <14%) Bng 9: Cch xp loi ca CDC 1993 A A1 A2 A3 B B1 B2 B3 C C1 C2 C3

Nhng bnh nhn thuc vo nhm C v/hay c ch s 3 c xp vo giai on AIDS. Do khun kh c hn, chng ti khng trnh by cc bnh c th cc triu chng v bnh c xp vo cc nhm. Ngi c c th tm c d dng trong rt nhiu ti liu lin quan n phn loi giai on nhim HIV trn cc sch Y hc v trn cc trang Web lin quan n lm sng v dch t nhim HIV. Nhng bnh nhn xp vo nhm thp hn, d sau c ci thin lm sng, vn khng chuyn nhm. Phng php xp loi ny c u im d theo di, tin lng v d cn nhc x dng thuc khng virus HIV cng nh thuc d phng mt s bnh c hi. Tuy nhin tiu chun m s t bo T CD4+ kh thc hin a s cc nc ngho (nh Vit nam). Cc phng php tnh gin tip s t bo T CD4+ qua s lng t bo lympho ngoi vi, qua cc phn ng b, c ng dng mt s ni nhng kt qu khng thng nht nn cha c cng nhn rng ri V th, T chc Y t th gii (WHO) gii thiu mt cch xp loi khc, trong khng x dng s lng t bo T CD4+ m thay th bng mc sinh hat ca bnh nhn trong ngy. Cch chia ca WHO ch c 4 giai on. Chng ti khng trnh by y bng xp loi theo WHO y v khun kh bi hc . Cc xp loi ca T chc Y t Th gii d dng cho cc nc ngho, thun tin cho dch t hc. Tuy nhin, n khng gip nhiu cho cc nh lm sng quyt nh dng thuc khng HIV hay cho thuc phng mt s bnh c hi. i vi tr em, do cc c th ring, c c mt bng xp loi khc ca CDC 1993. C th tham kho trong bi nhim HIV tr em.

VIII. CHM SC V IU TR NGI NHIM HIV


Do c qu nhiu vn , trong phm vi bi ny, chng ti ch nu ln mt s nguyn

112 tc chung. Chi tit xin tham kho nhng ti liu lin quan. 1. Nguyn tc : 1.1.Chm sc tan din : Hin nay chm sc ton din ngi nhim HIV bao gm cc lnh vc : chm sc th cht, chm sc tm l, chm sc tm linh, chm sc x hi v phng bnh. 1.2. V th cht Khm sc khe nh k cho bnh nhn v bt k lc no c bnh. Mc ch theo di gm c : pht hin bnh c hi v iu tr sm. Xc nh tnh trng min dch ca bnh nhn (l tng l m s lng t bo TCD4+), tnh trng virus (nu c iu kin) khng nh hiu qu ca thuc khng HIV nu ang dng. Khi bnh nhn sp ri vo giai an AIDS, c th x dng thuc phng mt s bnh c hi nh Bactrim (phng vim phi do P. carinii, Toxoplasma..), cc thuc khng nm phng mt s bnh v nm..Vn tim vc xanh phng mt s bnh nh nhim ph cu, cm, H. influenza.. cho bnh nhn HIV nc ta cha c bn n. Nu c ch nh dng thuc ARV, cn t vn k v thnh lp hp ng cht ch vi bnh nhn, ngi gim h v t chc mng li cp thuc cho bnh nhn. Trnh tnh trng ung thuc ARV khng u n v khng ng gi, khng liu, t ngng thuc v khng ch li g cho bnh nhn m cn c th chn lc ra cc chng HIV khng thuc. Lu n cc tc dng ph ca cc thuc x dng cho bnh nhn c th iu tr kp thi 1.3. Chm sc tm l Bnh nhn phi c t vn, trnh khng hong tm l vo lc pht hin nhim HIV. Trnh cc phn ng tiu cc nguy him cho bn thn (t t) hay x hi (tr th bng cch c gy ly nhim cho ngi khc). Nu c cc biu hin trm cm nguy him, c th hi chn thm vi chuyn khoa tm thn h tr, thm ch iu tr bnh nhn bng thuc. Khi tm n nh v tm l giai on u, cn gip bnh nhn vt qua cc k th v phn bit i x co x hi cn hiu lm mang li, gip h vt qua c mt cc sng t tin v hu ch hn. 1.4. Chm sc tm linh ng trc bnh khng cha c v d b k th, ban u v nht l lc sp t vong, bnh nhn thng lo lng, suy ngh v nhng vn trit hc (d t gic hay khng t gic) nh Cht l g? Sau khi cht ta i v u? C thin ng, a ngc khng? C kip sau khng? Ti mun sm hi, cu nguyn th lm th no ? Chm sc tm linh gip ngi bnh chp nhn mt cch an bnh nhng au n v tinh thn v th xc h ang chu ng khi y hc khng gip c, gip h tha th hay bnh tm vi ngi thn, ngi gy au kh cho h Ty theo tn gio ca bnh nhn (hay khng theo tn gio no), to iu kin cho bnh nhn gp g cc chc sc tn gio khi h c yu cu, tn trng nhng nim tin v cu nguyn ca h ngay c khi ang Bnh vin, nhng khng bnh nhn sa vo m tn d oan v vi phm ni quy iu tr. Cng khng truyn gio theo tn gio mnh ang theo cho bnh nhn. 1.5. Chm sc x hi To iu kin cho bnh nhn n nh cuc sng. Gi b mt c nhn cho bnh nhn. ng vin bnh nhn c thc gi gn cho bn tnh, cc ngi khc khng b ly nhim. (Xin tham kho thm v k thut t vn). Gii thch cho thn nhn v nhng ngi lin quan bit bnh nhn nhim HIV i x hp l vi bnh nhn, khng xa lnh, cch ly khng cn thit. Khng phn bit i x. Gip bnh nhn dnh li mt s quyn li chnh ng theo quy nh ca php lut m ngi nhim c th b tc ot do k th (quyn tha k, di chc)

113 1.6. Phng bnh : Ngi sn sc v thn nhn c th sinh hot vi bnh nhn bnh thng, ngoi tr quan h tnh dc khng bo v. ng thi phi bit mt s ng ly do v tnh (dng chung dao co ru, bn chi nh rng), bit cch phng h cho c nhn khi phi sn sc bnh nhn giai an cui (x l bnh phm, o qun, chn mn c dnh mu, dch ca bnh nhn..). ch phng ly lao phi nu bnh nhn c nhim lao nh mi trng hp nhim lao phi khng nhim HIV khc 2.Thuc khng virus HIV n nay c 2 nhm 2.1. Cc thuc c ch men sao chp ngc RT: gm c - Cc thuc tng tranh c cu trc nucleoside : Gm AZT (Zidovudine), Didanosine (ddI), Zalcitabine (ddC), Stavudine (d4T), Lamivudine (3TC), Abacavir (ABC). - Cc thuc khng c cu trc nucleoside: Nevirapine, Efavirenz, Delavirdine. Cc thuc nhm ny d b khng nn khng bao gi c dng mt mnh. Nhiu tc dng ph. 2.2. Cc thuc c ch men protease : c ch giai an trng thnh ca virus. Gm : Indinavir (Crixivan), Ritonavir (Norvir), Saquinavir HGC (Invirase), Saquinavir SGC (Fortovase), Nelfinavir (viracept), Amprenavir (Agenerase), ABT 378/r (Lopinavir/r : Kaletra). Mt s phc phi hp 3 thuc khng HIV - AZT + ddI + Indinavir - AZT + 3TC + Nelfinavir - d4T + ddI + Ritonavir - d4T + 3TC + Efavirenz ( hayNevirapine, Abacavir, Lopinavir) C th thay i nh sau : - AZT + ddC + Amprenavir - DdI + 3TC + Saquinavir... 2.2. Ch nh Do nhng kt qu lm gim nng virus ng k, nhng khng dit c virus, phi hp 3 thuc c nhng ngi giu c xem nh l mt cu cnh, thm ch khng cn cnh gic vi cn bnh. Tuy nhin, trong thc t, dng lu di em n nhiu tc dng khng mong mun quan trng v hin tng khng thuc, nn ch nh hin nay c phn hn ch hn so vi ch nh nhng nm u tin khi liu php ny mi ra i. Ch nh chung cho tt c mi ngi nhim HIV d giai an no ang c nhiu bn ci, v cha ng ng. Ty thy thuc v trng hp c th. Tuy nhin, nhng ch nh sau y c thng nht : 1. Nhng bnh nhn c triu chng ( giai an B v C theo CDC 1993) 2. Bnh nhn khng c triu chng nhng s lng T CD4+ < 350/mm3. 3. Bnh nhn khng triu chng, 350 < T4 < 500/mm3 nhng nng RNA HIV > 30.000 copies/mm3. Nu RNA < 30.000 th ty quyt nh thy thuc. 4. Bnh nhn khng triu chng, T4 > 500 : Hin nay c khuyn co khng nn dng. 3. iu tr phi nhim (tai nn ngh nghip) Nhng ngi c tip xc vi ngun c nguy c nhim HIV (tai nn ngh nghip ca y t, c quan h tnh dc vi ngi nhim HIV, b tn cng bi dng c c cha mu hay dch ngi nhim.) Nu c iu kin, XN ngay nng HIV ngun nhim v ngi b nn. Sau x dng thuc khng HIV (3 thuc, nu khng , c th x dng hai lai thuc) trong vng 1

114 thng. Sau khi chm dt liu trnh, nn xt nghim tm khng nguyn p24 sau 15 ngy ri sau 1 thng, 3 thng, 6 thng theo di s chuyn i huyt thanh nu c. Ngoi ra cng cn t vn cho nn nhn trong giai an ch i kt qu (+) hay (-).

IX. PHNG BNH


Khi tip xc vi ngi bnh, khng dng chung nhng dng c c kh nng gy tn thng da hay nim mc nh dao, ko, dng c lm mng tay, co ru, bn chi nh rng c bit bm v kim tim. Trng hp nhn vin y t, khi thao tc c kh nng xm nhp vo bnh nhn nhim HIV, cn mang gng c cht lng, o qun, khu trang, knh eo mt, ng, o chong kn. Thanh trng ngay sau khi dng. Khng vt b ba bi cc dng c v bnh phm bnh nhn sau dng xong. Dng c phi c ngm cn, cloramin T hay hp hi nc 100 /20 pht. Khng quan h tnh dc vi ngi khng bit c nhim HIV hay khng. Nn nh, bao cao su ch an tan khi tip xc tnh dc kiu t nhin ( sinh dc-sinh dc), khng an tan khi qu trnh tnh dc c nhng hnh vi khc (tay b xy xt sn tip xc vi dch sinh dc ngi nhim), tip xc ming-sinh dc khng an tan v c th b xy xt li, nim mc hng, amygdale m khng bit. Trong truyn mu, tt nht l truyn mu t thn. Truyn mu t ngi khc khng r lai lch, d c sng lc k vn khng an tan tuyt i v c giai an ca s. Ph n nhim HIV khng nn c thai. Nu c thai, phi dng thuc khng HIV ( AZT, nevirapine gim nguy c cho thai nhi.). Vn phng bnh cho thai nhi khi m nhim HIV, xin xem chi tit bi HIV v sc khe sinh sn. M nhim HIV khng nn nui con bng sa m. Tuy nhin, ty bi cnh x hi, c nhiu vng ngho kh, nguy c tr cht v suy dinh dng do thiu sa m cn cao hn nguy c nhim HIV th vn phi cho con b. Khng nghin ht ma ty (ri s a n giai an chch ma ty), khng x dng chung bm, kim tim khi l nghin chch ma ty. Quyt tm cai ma ty cho c nhn. V mt cng ng, tng cng bi tr ma ty, gip nhng ngi nghin ma ty cai nghin. Hn ch mi dm. Nu khng hn ch c, ph bin tnh dc an tan cho nhng ngi hnh ngh mi dm v khch hng dng bao cao su. Cu hi n tp 1.ng dng cc c im phn b HIV trong c th ngi nhim gii thch ti sao khng cn cch ly ngi nhim ra khi cuc sng gia nh v cng ng ? 2. Cc dng c ni soi thng c dit trng bng cch no khi ly truyn HIV? 3. Ti sao vit Nam, khng nn x dng phn ng b tuberculine phng nhim lao cho nhng ngi nhim HIV? 4. Trnh by cc nguyn tc chm sc ton din ngi nhim HIV 5. Cc nhm thuc khng HIV. u v khuyt im cho ngi nhim khi dng thuc khng HIV.

115 Bi 19.

BNH VIM GAN VIRUS


BsCK2,Ths Phan Qun

Mc tiu
1. Xc nh vai tr quan trng ca vim gan virus i vi sc kho cng ng. 2. Phn bit c cc virus gy vim gan v v cu trc sinh hc, dch t,vi yu t lm sng. 3. M t c tin trin lm sng ca vim gan do virus B. 4. M t cch phng v iu tr vim gan virus cp v mn tnh.

Ni dung I. I CNG
- Mt bnh nhim c tnh h thng, virus gy bnh i tnh vi gan, gy vim, tn thng t bo gan, thoi ha t bo gan - mt v tng transaminase. Trn c s virus, dch t hc, lm sng hin ngi ta c 5 loi vim gan do 5 virus A,B,D (Delta) virus C, E. Thm 2 virus mi tm thy l G v TTV m vai tr lm sng cha r rt. - Cc virus trn c th gy vim gan cp; virus B, D, v C c th gy vim gan mn tnh, gy x gan v ung th t bo gan nguyn pht (HCC: Hepato cellular carcirnoma). - Theo Vin y hc lm sng nhit i H ni, nc ta c mt 6 loi virus ni trn, tr TTV. - Trong cc virus gy bnh trn, vim gan virus B l vn nghim trng v: + T l mang thai c HBsAg (+) rt cao (12,7%). + Nguy c ly chu sinh cho con rt cao (44,72%), nu m c HBeAg (+) 96,49%. + Trong dn chng bnh thng khng c bnh gan m HBsAg (+) 10-14%. Anti HBs (+) 35-37%, chng t nhim HBV rt cao. + i tng nguy c cao nhim HBV theo theo th t: Tim chch ma ty, bnh nhn chy thn nhn to nhiu ln, ngi c truyn mu (test sng lc khng m bo). - Vim gan do virus C cng nghim trng: + HCV hot ng (HCV - RNA) ngi cho mu (0,8-16,1%), m ta cha c iu kin xt nghim pht hin HCV mt cch ng lot ngi cho mu v cc mu mu. + Nu cho mu thi im HCV hot ng th nguy c rt ln; c th ly cho ngi khc nu phng tin tim chch tit trng khng tt. + Khng th HCV ngi cho mu cng rt cao (0,8 20,6%). + Nhim HCV qun th 4 - 9%. Rt cao i tng tim chch ma ty (31-87%), bnh nhn chy thn nhn to, hoc truyn mu nhiu ln. - Virus vim gan G mi c pht hin ta.

II. CC LOI VIM GAN VIRUS


1. Vim gan do virus A 1.1. Dch t: ngi l vt ch duy nht; ly qua ng tiu ha, do thc n - nc ung nhim virus; c kh nng gy dch, lin quan mi sinh, kinh t - x hi. Ly cao nht l 2 tun trc khi biu hin lm sng. Ngoi ra, c th ly ng mu (giai on virus huyt). 1.2. Virus vim gan A (HAV) thuc h picornavirus, cu trc RNA khng v. Trong vim gan cp, virus huyt xut hin 2 tun trc hong m v c th tn ti vi ngy sau hong m (ngn), iu ny gii thch virus rt t kh nng ly qua ng mu, xut hin trong phn 2 tun trc hong m v tn ti 7-10 ngy sau hong m. 1.3. Lm sng: bnh 2- 6 tun.

116 Th bnh cp tnh, in hnh gm: - Giai on tin hong m 1-3 tun ng ch l: + Chn n, n kh tiu, bun nn, tc hoc au h sn phi. + Ngi mt nhiu, mt ng. + Biu hin nh hi chng cm: st, vng u, au mi c khp. + Ni mn. - Giai on hong m: mt - da vng; nc tiu t, m mu; him khi nga. Khm lm sng khng c du hiu g ngoi gan hi to, hi au v c khi lch to. Th khng hong m thng gp (90%): khng vng mt - da, nhng tng transaminase (nh hng chn on). 1.4. Xt nghim sinh hc: - V gan: +Hi chng tiu t bo: tng transaminase 20-40 ln (thi k tin hong m c ga tr chn on vim gan). + Hi chng mt: tng bilirubin, ch yu l kt hp. Sc t mt, mui mt trong nc tiu (thi k tin hong m c ga tr chn on). + T prothrombine, nu bnh rt nng t P gim nhiu, a s l bnh thng. - V virus: + Khng th khng HAV IgM xut hin sm khi c du hiu lm sng u tin, chng tng nhanh n cc i v ko di 60-90 ngy sau ly bnh, Ri tip tc gim nhng cn cao, lp IgG xut hin mun, tn ti nhiu nm. Min dch c hiu bn (IgG Anti-HAV ). + Chn on (giai on cp tnh) da vo IgM anti-HAV bng phng php min dch phng x hoc min dch enzyme, tm IgG anti - HAV c gi tr chn on dch t. 1.5. Tin trin: - Tt, trong 10-15 ngy, tiu trong, phn m mu, hong m nht dn, cc du lm sng v sinh ha tr li bnh thng, khng c di chng. - Mt s trng hp rt him: + Th ko di: tn ti du lm sng v sinh ha nhiu tun, nhiu thng, khng gy vim gan mn. + Th mt: triu chng nh hong m tc mt c hc, nhng gan khng ln, du nhim trng (-). + Th ti pht: c th xy ra sau mt thng, tin lng tt. + Th ti cp: rt him 1/104. 2.Vim gan do virus B 2.1. Dch t: ly ng tim truyn, tnh dc v m ly sang con trong k chu sinh. - Ton th gii, 2 t ngi nhim HBV, 350 triu nhim virus mn tnh, 1,1 triu ngi cht/nm, nguyn nhn gy ung th hng th 5. Trn th gii hin c 3 vng dch t: + Vng dch lu hnh thp (Ty u, Bc M, c ): bnh him tr em; 3 - 5% ngi c anti - HBs; 0,1- 0,5% ngi mang HBsAg mn. + Vng dch lu hnh va (a Trung Hi, Trung ng, Nam M, ng u, cc nc thuc Lin X c): 20 - 50% ngi c anti - HBs; 2 - 7% ngi mang HBsAg mn tnh. + Vng dch lu hnh cao (Trung quc, ng Nam , cn sa mc Sahara): hay gp ly chu sinh tr s sinh; 70 - 95% ngi c anti - HBs; 8-15% ngi mang HBsAg mn tnh. - Virus huyt ko di, cho nn d ly qua tim truyn, mu, cc ch phm ca mu, tim chch (truyn mu nhiu ln, lc thn nhn to nhiu ln, tim chch ma ty, nhn vin y t nht l ngi lm vic n v thn nhn to v phng xt nghim phn tch mu). - Virus qua cc cht tit ch yu qua sinh dc, nhng nc bt v sa nng virus thp hn, c th ly nh bnh hoa liu. Lu , chng 50% trng hp khng tm thy ng vo. - Ly m sang con l nghim trng: Nhim Virus tr s sinh c nguy c gy vim gan mn tnh. Ch yu gp vim gan cp m trong 3 thng cui thai nghn hoc trong k sinh ,

117 hoc ngi c thai vim gan mn. Ch yu ly bnh lc chu sinh, khi m c HBeAg (+) nguy c ly cho tr ny l 90%, nguy c thp hn (25%) m c HBeAg (- ). 2.2. Virus vim gan B (HBV): h hepadnavirus, virus DNA, c capside - mt v. - HBsAg c mt lp v; cn capside c hnh thnh do kt hp 2 khng nguyn c hiu HBeAg, HBcAg (gi l khng nguyn li). Tm thy HBsAg, HBeAg trong mu, nhng HBcAg ch c trong t bo gan. - Virus hon chnh c v bao quanh capside gi l tiu th Dane. - Trong capside c acid nhn, v 2 enzyme ng vai tr nhn ln v s trng thnh ca Virus: ADN polymerase v proteinkinase. - Khi Virus nhn ln & pht trin trong t bo gan, c th phn ng vi s nhim virus, iu ny cho thy tnh a dng ca vim gan virus. Ni chung, vic thi loi t bo gan b nhim ty thuc vo c ch min dch th dch v t bo. Bn cht v cht lng p ng min dch ny tun th cc yu t quyt nh di truyn (a dng), c 4 mi tng quan gia c th v virus nh sau: + Phn ng min dch mnh: phn ng mnh thi loi virus lu thng trong mu v trong cc t bo gan b nhim s gy ra vim gan cp tnh, sau thi gian b bnh s din tin khi bnh hon ton. Phn ng c th qu nng, km hoi t phn ln t bo gan gy teo gan vng cp, a s t vong. + Phn ng min dch yu nhng cn bng: nhim virus khng triu chng v tin trin khi bnh. + Phn ng min dch yu v khng cn bng: to nn tnh trng dung np tng phn; kt hp virus pht trin, nhn ln ko di (HBsAg (+) ko di) v s ph hy m thm t chc gan, y l s thi loi mn tnh, ko di nhiu thng, nhiu nm gy vim gan mn, v tin trin x gan. Chnh qu trnh ko di ny, v di s nh hng cc ng yu t (cofactor ) (v d: cht c, thc phm), t bin t bo gan gy ra ung th gan nguyn pht. + H min dch c th khng phn ng: y l trng thi ngi mang virus khng triu chng, c th dung np hon ton, nhng c lc virus B nhn ln mnh m. 2.3. Lm sng: a dng, nhim virus c th cp tnh, qu cp, hoc mn tnh; thng tn t bo gan cng rt khc nhau, gy hy t bo khng c hong m hoc tim tng ton b, hoc hoi t cp hoc vim gan mn tn ti, tn cng, gy x gan ri ung th gan nguyn pht. - Thi k bnh 4-28 tun, a s l 60-120 ngy, nhng c khi n 180 ngy, thng nhim virus B gii hn trong cc dng sau: + Th bnh khng triu chng (90%), khng r bnh xut hin lc no. + Hoc th cp c bnh cnh lm sng tng t nh vim gan A. + Tin trin ca bnh ni chung thng ko di nhiu tun. 2.4. Xt nghim sinh hc: - V gan: + Hin tng tiu t bo gan: tng transaminase (ALAT, ASAT) + Khi t Prothrobin > 60% khng c du hiu suy t bo gan. - Cc ch im (markers) virus B khi xt nghim mu: + Virus B khng th nui cy c, ch c 3 khng nguyn: HBsAg, HBcAg, HBeAg, c 3 khng th tng ng Anti - HBs, Anti - HBc, Anti - HBe. + Nh cc Virus c v khc, ch Anti - HBs c tnh bo v (to min dch b sau nhim virus, hoc chng nga) + Xt nghim v HBsAg v Anti-HBs; HBeAg; Anti-HBc huyt thanh (thc hin thng qui); DNA polymerase huyt thanh (thc hin phng xt nghim c bit); HBcAg v HBsAg c trong trong t chc gan. HBV DNA c trong huyt thanh, trong t bo gan. + HBsAg xut hin trong huyt thanh: 1-3 thng sau ly bnh; 2-4 tun trc khi tng transaminase. HBsAg tn ti 1- 2 thng, nhng c khi tn ti vi tun sau khi transaminase tr

118 v bnh thng. + Anti - HBc xut hin trong huyt thanh 1-2 tun sau HBsAg xut hin; Anti - HBc IgM, l du hiu s nhim, tn ti vi thng. + HBeAg (+) trong huyt thanh chng t virus ang hot ng, nhn ln mnh m, tin lng xu, v rt d ly lan. HBeAg bin mt trc HBsAg. S xut hin anti - HBe cha phi l khi bnh, m l yu t tin lng tt hn, ni ln virus ngng hot ng Trong 80-90% trng hp, 1 - 3 thng sau khi HBsAg bin mt, th anti- HBs xut hin, cho thy bnh khi v c min dch. Anti - HBs tn ti < 10 nm (nguyn tc chung) sau khi khi vim gan B. Trong vi trng hp anti - HBs xut hin thong qua ri bin mt trong vi thng, ch tn ti anti - HBc lp IgG. Chn on mc vim gan B mi y: tm Anti - HBe IgM. 2.5. Tin trin: - Vim gan cp tnh in hnh hoc khng triu chng: Tin tin lnh tnh, trong vi tun transaminase tr v bnh thng, HBsAg bin mt, chng t virus ngng s pht trin v nhn ln, Anti - HBs xut hin l du khi bnh. - Cc th bnh cp tnh khc: + Th mt ko di, th ti pht c th tin trin nh vim gan in hnh cp tnh. + Th cp tnh nng: nh hng gan nng n, t l prothrombin < 50%. + Th vim teo gan ti cp: Him, 1/103 ca vim gan B, t prothrombin 30%, bnh l no gan, khi bnh c triu chng lm sng nh th thng thng, tip n bnh l no gan xut hin ( ri lon thc, rung git nhm c (asterixis) tin trin trong 2 tun u ca thi k hong m. C khi, ngay t nhng ngy u ca bnh, xut hin ri lon thc, ri nhanh chng i vo hn m, km theo hong m, h ng mu, hi chng tiu t bo gan rt r, km ri lon ng mu.Th bnh ny t vong 80%, nu khng c ghp gan (d vim gan ti pht sau ghp gan), trng hp khi khng li di chng. - Cc th mn tnh: Gp 10% trng hp, virus tn ti trong t bo gan, mang HBsAg (+) > 6 thng, hay gp sau vim gan cp th khng triu chng, hoc biu hin lm sng nh, c bit hay gp 50% ngi suy gim min dch v 90% tr s sinh b vim gan. + Ngi mang HBsAg mn tnh khng triu chng: 30% nhng ngi mang HBsAg mn tnh; transaminase bnh thng; virus khng nhn ln; HBeAg, HBV DNA; DNA polymerase trong huyt thanh (-); vi th c th cho thy thy tn thng gan dng x ha khng ng k. Tuy nhin, ngi mang HBsAg c th ti hot ng mt vim gan cho nn cn sinh thit gan; hoc xt nghim transaminase, HBeAg hoc HBV DNA, anti - HBs u n (4 6 thng/ln). + Vim gan B mn: HBsAg (+) v tng transaminase > 6 thng. Khi pht hin HBsAg (+) tnh c, th vim gan mn c xc nh khi anti - HBc IgG (+). * Vim gan mn tn ti: 40% nhng ngi mang HBsAg mn tnh, hnh nh sinh thit gan thy t bo vim xm nhp v hoi t t bo gan ch khu tr khong ca v khng lan ta, c th khi bnh sau 2 - 7 nm tin trin (him hn tin ti vim gan tn ti ko di), c khi tin n vim gan mn tn cng v x gan. * Vim gan mn tn cng: 30% vim gan mn, sinh thit thy c t bo vim thm nhp v hoi t t bo gan khu tr khong ca v quanh khong ca, dn ti hoi t cu ni lm tch ra t chc thy gan nh, cui cng gy x gan. ** Lm sng: Triu chng vim gan mn thng ngho nn, c khi bnh nhn than phin mt mi, tc h sn phi. Khm lm sng khng pht hin g. Transaminase tng nh (gp 1,5 - 2 ln gii hn trn bnh thng). Cc xt nghim sinh ha khc bt thng ty vo tin trin bnh gan. Khng th khng c trn (-) hoc (+) nh. Cc biu hin ngoi gan gp trong vim gan mn tn cng v cng gp th bnh cp thng thng, nh sng khp, vim cu thn v vim nt quanh ng mch.

119 ** Huyt thanh ngi vim gan mn: (1) HBsAg (+), IgM anti-HBc (-), IgG anti-HBc (+): xc nh vim gan mn B mn tnh. (2) HBV DNA (+) v tn ti HBsAg (+) > 6 thng: xc nh vim gan B mn tnh. Nhng HBsAg (-) vn cha th loi tr chn on (do t bin o thot), t bo gan b nhim HBV mn tnh c c im l tng hp lin tc HBsAg v hoc HBcAg ch trong t bo gan, m c th pht hin bng sinh thit gan v nhum min dch hunh quang c hiu. Nu vim gan mn m anti-HBc (+) v HBsAg (-), cn biopsie, c bit nu Anti-HBc (+) vi nng yu. M ngi ta gi vim gan B mn tnh th n. (3) HBeAg (+) ko di l tin lng xu c nguy c vim gan mn tin trin ti x gan (ch , trng hp c bit t bin pre C c HBeAg (-)). Tri li, anti-HBe (+), xt nghim sinh ha bnh thng tc l khng cn tn thng gan l mt tin trin tt. Trong trng hp thch hp hn cng thy lc u HBeAg (+) ri chuyn i huyt thanh qua HBeAg (-) v anti-HBe (+); HBsAg (+) ri chuyn i huyt thanh qua HBsAg (-) v anti-HBs (+). ** Tin trin vim gan mn: - Din tin khi bnh vi chuyn i huyt thanh t nhin 3% - 5%/nm. - Hay gp hn, tin lng thng d dt do cc bin chng (nhng t vim gan ti pht, t nhin hoc do mt thuc gim min dch khi ng) v nguy c do x gan v ung th gan nguyn pht e da n cuc sng trc mt hoc lu di. Tin trin ca vim gan mn c 3 giai on: + Giai on u: Virus nhn ln & pht trin mnh m (HBV DNA tng trong huyt thanh), tng nh transaminase, trn sinh thit gan c du hiu vim gan nh. + Giai on hai: vi nm sau, tng ng p ng min dch mnh: tnh trng vim gan tng ln (tng transaminase, tn thng mu sinh thit gan) v virus gim hot ng. L giai on hnh thnh x ha vi x gan ti a. Nhiu t ti pht ca bnh mn tnh c th lm virus ngng pht trin & nhn ln v chuyn i huyt thanh mt HBeAg v anti - HBe (+). Trng hp ny, tnh trng vim gan bin mt (transaminase bnh thng, khng cn hoi t v vim trong gan). + Giai on ba: virus khng nhn ln v khng tin trin vim gan. Giai on ny, c th xut hin x gan v ung th gan nguyn pht. Cn thit gim st alpha - foetoprotein v siu m gan u n (6 thng/1ln). C th pht hin HBsAg (+), c th xy ra mt vim gan ti hot ng (virus nhn ln, tng transaminase, tn thng t bo gan ti xut hin). V vy, gim st transaminase v cc khng nguyn ch im virus nhn ln l rt cn thit: - X gan sau vim gan: L bin chng tin trin ca vim gan B mn tn cng, nhng x gan cng c th pht hin nhim HBV mn tnh. Ngoi bin chng do x gan (tng p tnh mch ca, suy t bo gan) cn c tng t ti hot ng vim gan mn v ung th gan nguyn pht. Nhiu yu t nguy c gy tin trin x gan ngi vim gan mn nh: ln tui, nng virus cao trong mu, ng nhim virus D, C, HIV, ung ru, transaminase tng cao lin tc, kiu gene C. - Ung th gan nguyn pht: Ni chung, xy ra ngi c x gan trc. vng dch t vim gan B lu hnh cao (Phi chu) nhim t khi sinh v hoc km cc ng yu t gy ung th th tn sut ung th gan rt ln: 40-50% s b nhim trong s nhim tr nh cht do x gan hoc ung th gan. Ch yu l u t bo n dng lan ta trong gan. 3. Vim gan virus delta 3.1. Dich t: M t ln u , c mt nhiu ni trn th gii, ch yu a Trung hi, ng u, vi vng chu Phi, M la tinh; M v Ty u him gp. Lin quan ch yu ngi nghin ma ty, quan h tnh dc ba bi. Ly ging nh HBV do tim chch ma ty, ch phm t mu hoc do tip xc qu mc thn thit gia cc c nhn. 3.2. Virus D (HDV):

120 L virus RNA khng hon chnh, x dng v ca virus vim gan B (HBsAg). Gy bnh bng cch cng sinh vi v HBV c i tnh vi t bo gan. 3.3. Lm sng: - Nhim ng thi virus D v HBV: phn ln trng hp c triu chng nh vim gan B thng thng, c s hin din ca virus D khng tng nguy c tin ti vim gan B mn. Tri li,nhim ng thi 2 virus trn lm tng nguy c vim gan th teo gan vng cp. - Ngi vim gan B mn bi nhim HDV: virus D tm thy iu kin thch hp ngi vim gan B mn (tha HBsAg) virus nhn ln nhiu v ko di. Bi nhim gy nhiu hu qa: + HDV giao thoa vi sinh tng hp ca HBV, ngi ta thy gim nhy cm, hoc bin mt cc ch im (marker) trong huyt thanh v t bo gan chng c v s nhn ln ca HBV (HBV DNA). + HDV lm tng s nghim trng cc tn thng gan. V lm sng, bi nhim HDV gy ra vim gan cp, trong 80% trng hp tin trin qua vim gan D mn do bin chng vim gan B mn 3.4. Mt s im ch : Nhng ch im huyt thanh mt vim gan D trn bnh nhn mang HBsAg(+). + Phm vi dch t hc: Ngi tim ma ty, quan h tnh dc ba bi, ng tnh luyn i, lin quan vng dch HDV (, Trung Cn ng). + Phm vi lm sng: Vim gan cp qun th ngi nguy c vim gan D, vim gan cp ngi mang HBsAg mn tnh, vim gan mn hoc x gan nhm ngi tr c nguy c vim gan D, vim gan cp ti pht, teo gan vng cp, vim gan cp c HBsAg (+) v tin trin nhanh qua vim gan mn tn cng. 3.5. Tin trin: Nhim HBV, HDV biu hin di 2 dng: + ng nhim HBV/HDV: nguy c teo gan cp 10-20 ln so vi vim gan B cp. + Bi nhim HDV ngi nhim HBV: d tin ti vim gan mn tn cng - x gan. 4. Vim gan virus C (HCV) 4.1. Dch t: Ly qua mu 90%, qua vt liu dnh mu v v trng km, thng gp ngi chch ma ty dng kim chung (70%). Ngi khe mnh c th ly qua tnh dc (+/-). 4.2. Tc nhn gy bnh: Virus C thuc h Flavivirus, virus RNA. Khng phn lp c virus m ch tch c gene di truyn (acid nhn) trong huyt tng ngi b nhim (HCV RNA). 4.3. Lm sng: bnh 4-6 tun, 95% vim gan C cp khng triu chng v khng hong m, thng tng transaminase nh, bnh ko di nu khng cng c s dao ng transaminase so mc bnh thng. Sau giai on cp tnh 15-20% tin trin khi bnh, him xy ra teo gan vng cp. Transaminase bnh thng > 6 thng v PCR (-) l khi bnh. 4.4. Huyt thanh: Anti-HCV xut hin mun, 5-6 thng sau nhim (trung bnh 15 tun sau vin gan). Cha c test th IgM anti-HCV hoc khng nguyn HCV. Da vo test huyt thanh khng phn bit ngi mang Virus mn tnh vi ngi khi bnh c min dch sau mc vim gan C. Tm HCV RNA trong huyt thanh bng phng php khuch i gene (PCR) phn bit ngi c tiu th virus C (viron) trong mu v ngi vim gan mn tnh khng do HBV m anti-HCV(-). xc nh chn on vim gan C cp, cn loi tr nhim HBV [HBsAg (-) v IgM anti-HBc (-)], loi tr HAV [IgM anti-HAV(-)], loi tr Epstein-Barr virus [IgM anti-VCA ()], loi tr Cytomegalovirus [IgM anti-CMV (-)], tin s khng dng thuc gy c gan. xc nh vim gan C mn tnh, phi loi tr nhim HBV v cc nguyn nhn gy vim gan mn tnh him gp khc.Vim gan t min, do thuc, bnh wilson. 4.5. Tin trin:

121 Nhim HCV c 10 - 15% khi bnh, 20% ngi lnh mang virus, 60 - 70% vim gan mn tnh trong c 20% x gan v 3 - 5% ung th gan nguyn pht/nm. Vim gan C mn tnh khng triu chng vi transaminase bnh thng v tn thng gan ti thiu (sinh thit) 1525%; s cn li vim gan mn tnh tn cng. Trong s vim gan tn cng, x gan xut hin 20% trong thi gian 10 - 20 nm sau vim gan. Cc nguy c ung th gp ngi ln tui, ung ru, ng nhim HIV hoc HBV. Khi nhim HIV lm tng nng HCV trong mu s tng nguy c ly qua tnh dc v ch yu m sang con lc chu sinh, tng tin trin x gan v ung th gan, cc nguy c ny cn tng ln ngi > 45 tui 5. Vim gan virus E (HEV) 5.1. Dch t Ly qua ng tiu ha, bnh hay gp , Phi chu, cc trng hp bnh gp Bc M, u chu c lin quan du lch ti cc vng bnh lu hnh. 5.2. Tc nhn: Virus E thuc h Calicivirus, virus RNA. HEV c thi ra nhiu trong phn. 5.3. Lm sng: Nhim cp thng c hong m vi th bnh in hnh. 5.4. Huyt thanh: Khng c ch im huyt thanh, chn on vim gan E c bn da trn s ly v loi tr cc nguyn nhn gy vim gan khc [IgM anti- HAV (-); HBsAg v IgM anti- HBc (-)]. 5.5. Tin trin: Lnh tnh, thng gp th nng ch yu ph n c thai v nht l 3 thng cui thai k (t vong > 10%), bnh khng tin trin mn tnh. 6. Vim gan virus G (HGV) - Pht hin nm 1995, virus c mt trn th gii vi vng lu hnh nng l chu Phi v ng u, cch ly ch yu qua mu, nhng c th ly m sang con, ng tnh dc. - H Flavivirus, cu trc gene RNA-c v. C th pht hin virus bng PCR. Vai tr gy bnh cha xc nh, ngi ta thy virus nhim kt hp vi HCV, c khi HBV trong cc trng hp vim gan mn tnh 7. Virus TTV Phn lp nm 1997, t l ngi cho mu nhim 1% M, 12% Nht v 36% Thi lan. Pht hin virus bng PCR. Virus DNA chui xon i, gn gi vi h Parvovirus, c 2 - 6 genotype khc nhau. Kh nng gy bnh cha c xc nh, c vai tr no gy vim gan cp sau truyn mu hoc vim gan mn tnh.

III. D PHNG V IU TR VIM GAN VIRUS


1. D phng 1.1. D phng trc khi nhim l quan trng nht. - Vi HAV: + Ngi ln: tim Havrix (loi ngi ln, virus bt hot) hoc Avaxim Nhn vin y t, ngi dng ng. Nhng ngi cha min dch vo vng dch lu hnh. Nhm nguy c: nghin chch ma tu, ng tnh luyn i, bnh a chy mu truyn mu nhiu ln. Tim 2 mi cch nhau 6 - 12 thng p ng bo v > 95%, ko di t nht 10 nm. + Tr con: trn 1 tui tim Havrix (loi cho tr); hoc vaccine Twinrix (kt hp HBV v HAV), tim 3 mi (ngy 0, cch 1 thng, cch 6 thng). - i vi HBV, HDV dng vaccine d phng + Cc i tng c nguy c cao: Nhn vin y t Truyn mu nhiu ln (ghp tng, bnh a chy mu vv...), ngi chy thn nhiu ln. Tim chch ma ty, ng tnh luyn i m bn tnh HBsAg (+).

122 Ngi nh c HBsAg (+), tr s sinh c m HBsAg(+). Ngi cha min dch, ngi chm pht trin tr tu. + Vaccine ti t hp gene (Gen Hevac B Pasteur hoc Engrix B). p ng min dch tt; ch 4 - 10% khng p ng khng th, ch yu ngi ln > 40 tui, ngi suy gim min dch, nghin ru. Vaccine ch cha HBsAg nn p ng anti-HBs, dung np tt. Ty theo tui - gii m hiu lc vaccine khc nhau. Min dch tt ph n, ngi < 40 tui. + Chng nga 3 ln tim bp cch nhau thng 1 ln, hoc ngy 0, thng 1, thng 6. + Nhc li 1 mi sau 5 nm, nu chng nga sau 25 tui v kim tra nng khng th sau 2 thng, nu 10 IU th khng cn tim nhc li. + Phi hp tim HBIg v chng nga vim gan B (tim bp HBIg 3 ln, 0,1ml/ln x 6 thng/ln, kt hp chng nga vim gan B cho i tng mi phi nhim (ngi cha min dch tip cn mu, tai bin ngh nghip,v.v.) + Khng c vaccine ring i vi vim gan Virus D. - i vi HCV v HEV hin cha c vaccine c hiu. 1.2. Phng nga sau phi nhim : i vi HBV khi m b nhim th phng cho con vo k chu sinh, dng HBIg phi hp vaccine trong 24 gi sau sinh, v cc tr s sinh nhim c nguy c cao vim gan mn. 2. iu tr 2.1. iu tr vim gan virus cp: ch yu l h tr, dinh dng c vai tr nht nh. - Thc n lng c ch cho bnh nhn bun nn v nn. Hn ch m, m. Hi phc nc - in gii. Ngng bia ru, cht gii kht ln men. Bnh nhn chn n, suy dng: dng vitamin. Hn ch hot ng khi cn triu chng lm sng v xt nghim vim gan virus. - Gim st, theo di bnh nhn vim gan cp ch yu da vo ASAT/ALAT biliribin, chc nng tng hp albumin, t prothrobin nh gi trin trin ca bnh. Khi bnh nhn suy gan cp cho thy gim transaminase, gim Albumin, tng bilirubin, gim t Prothrombin; lm sng cho thy mt ng, chn n. 2.2. Suy gan cp (teo gan vng cp) - Ngoi vim gan virus, suy gan cp c th do ng thuc, thiu mu gan nng, c t, gan nhim m cp trong thai nghn, bnh wilson, hi chng Reye. - Lm sng: bnh l no gan, tt huyt p, mch nhanh, vng mt - da m, xut huyt tiu ha, bi nhim, ri lon ng mu, h ng mu, suy thn, ri lon in gii - toan kim. + ng mu thng gim < 60mg/dl th cn truyn thm ng. + Khng acid, khng H2 Receptor, duy tr pH d dy > 5 phng chy mu tiu ha. + Chy mu nhiu: truyn huyt tng lnh, mu ti cng nhm. + Bnh nhn c tng p ni s hoc hn m gan giai on III, IV: dng mannitol tnh mch 1g/kg, hoc glucose 30% tnh mch 100 150ml, Lasix. + Neomycin 0,25g x 4v- 8v ngy chia 2-3ln/ngy x 5 - 7 ngy, c th metronidazole 1g/ngy x 5 - 7 ngy. Bi nhim, dng khng sinh khng c gan (Amoxicillin). + Tht tho phn 2 ln/ ngy, km theo Lactulose 50% (a ng sorbitol, lactose, galactose ) ngi ln 2gi/ngy (lm nhun trng, tng o thi cc acid hu c khi i trng,c ch vi khun ch, chuyn NH3 thnh NH4 + khng hp thu v o thi theo phn). + Ghp gan (trng hp do HBV, sau ghp gan c th ti nhim virus ) + Mi y (2004) N-acetyl cysteine (Acemuc) c dng trong suy gan bn cp khng r nguyn nhn, liu 150mg/ngy trong 3 tun ri dng 75mg/ngy/4 ln/ngy (tim TM, nu bnh nhn nn): 7/9 (77%, nhm dng thuc) v 1/6 (17%, nhm chng) khi bnh. Dng trong suy gan cp do dng qu liu paracetamol. - T vong do suy gan tin trin, chy mu tiu ha, nhim trng, ri lon nhp tim, try mch, suy thn & v niu, hi chng phi - gan. 2.3. Vim gan virus mn tnh

123 2.3.1. Vim gan B mn tnh - Ch nh dng thuc cho vim gan B mn tnh th hot ng. - Mc tiu iu tr l c ch s hot ng virus cui cng lm ngng tin trin vim gan mn hot ng v ngn nga x gan, ung th gan. V vy phi iu tr giai on sm Interferon alpha - Tim bp, di da 9 - 10 triu x 3 ln/tun (4 - 6 thng) chuyn i huyt thanh 20 - 30%. - p ng tt bnh nhn c: HBV DNA thp; ALAT tng cao; c tn thng vim-hoi t trong gan; bnh nhn khng phi ngi chu; nhim virus khi ln tui. - Hiu qu khi: transaminase bnh thng; cc marker nhn ln ca virus HBV DNA, HBeAg m tnh, anti - HBe (+); l tng l HBsAg (-) v anti-HBs (+). Tuy nhin c mt s trng hp virus nhn ln v hot ng li sau khi ngng thuc. Pegylated interferon alpha 2a hoc 2b (kt hp interferon vi glycol polyethylene, nn thi qua thn chm, dng tun/ln). - Tim bp, di da 180 mcg/tun Peg. interferon alpha 2a (Pegasys) cho thy hiu qu 28% so vi interferon alpha 12%, khi dng 4 - 6 thng. - p ng: mt HBeAg, HBV DNA < 500.000 copies/mL, transaminase bnh thng. Lamivudine - Ung 100mg/ngy, c ch virus nhn ln 80%, nhng xut hin khng do t bin (15%/nm, ch yu dng YMDD), tuy nhin, t bin o thot cha r trn lm sng, khi c t bin khng ngng thuc, tr khi dng thuc thay th s virus pht trin tr li. Adefovir dipivoxil - Thuc tng t nucleoside, tc dng cnh tranh vi deoxyadenosine triphosphate c ch polymerase DNA v enzyme sao chp ngc ca HBV, chm dt s tng hp chui DNA. - Liu ung 10 mg/ngy, dng 48 tun cng nhm placebo c t l chuyn i anti-HBe tng ng l 12% v 6%, ci thin t chc hc gan 53% v 25%, khng pht hin nng HBV DNA tng ng l 21% v 0% bnh nhn. Dng cho trng hp khng Lamivudine. Tenofovir - Thuc tng t nucleoside, tc dng c ch HBV v HIV. - Dng cho ngi ng nhim HIV v HBV, gim nng virus > 4 log10 v hiu qu trng hp HBV khng Lamivudine. Cc thuc khc Hin nay ang iu tr th cc thuc tng t nucleoside: Entecavir, Entricitabine, Clevudine. Phi hp thuc - Adefovir phi hp pegylated interferon trong HBV khng Lamivudine. - Bnh nhn x gan mt b do HBV khng dng interferon. Nhng dng Lamivudine, Adefovir hoc Tenofovir n thun 2.3.2. Vim gan C mn tnh Ribavirine - Dng ng ung liu 10,6 mg/kg - Thuc c th gy gim hemglobine nh do tn huyt, gim bch cu ngoi bin. Pegylated interferon alpha 2b hoc alpha 2a Thng dng Pegasys (Peg alpha 2a) 180 mcg tim bp hoc di da. Phi hp thuc Thng kt hp hai thuc trn v ribavirine c tc dng hip ng vi interferon. Cho bnh nhn ung paracetamol trnh st do interferon. Cu hi n tp 1. Trnh by nh hng ca vim gan virus i vi sc kho cng ng. 2. M t cu trc sinh hc, dch t, vi yu t lm sng ca cc virus gy vim gan nguyn pht thng gp.

124 3. Trnh by cc vng lu hnh vim gan B trn th gii v cc hnh thi phn ng ca c th khi nhim virus vim gan B. 4. M t tin trin lm sng v biu th cc marker trong vim gan B cp v mn tnh. 5. Trnh by cch thc phng nga v iu tr vim gan virus cp v mn tnh.

125

Bi 20.

BNH NHIM VIRUS DENGUE


BsCK2,Ths Phan Qun

Mc tiu
1. Xc nh tm quan trng, tnh ph bin, v phm vi nh hng ca bnh. 2. M t mt s c im tc nhn gy bnh, ng ly, tp tnh cn trng trung gian, cc yu t nguy c gy dch. 3. Gii thch c cc th lm sng bng c th bnh hc, bnh sinh-sinh l bnh 4. Phn loi th bnh, m t cc bc iu tr st dengue, dengue xut huyt v th c sc. 5. M t c cch thc phng chng st dengue xut huyt.

Ni dung I. I CNG
Bnh dengue c in gm st cao, au khp, au c c bit hn mt th k trc. 1953, ln u xc nhn st dengue xut huyt Phi lut tn, Thi lan (1958), bnh lan ra mt s nc ng Nam khc. 1. nh ngha St dengue v st dengue xut huyt l bnh nhim do virus dengue gy ra, lm sng gm st cao t ngt, gy xut huyt. Khc vi st dengue, st dengue xut huyt l bnh cnh nng, c th sc v lin quan cht ch tng tnh thm thnh mch, h tiu cu v c c mu. C th t vong nu khng c iu tr thch hp v kp thi. C th gy dch lu hnh v dch ln. 2.Tc nhn gy bnh Virus dengue, h Flaviviridae, nhm Arbovirus (do mui truyn), c 4 type huyt thanh D1, D2, D3, D4. C 4 type ny u c th gy dch st dengue, st dengue xut huyt. Cc nghin cu cho thy D2 c lin quan ti st dengue xut huyt / dengue xut huyt c sc, gn y th lin quan ti D3. Nhim virus dengue ln u to ra min dch bn sut i vi type nhim. Ngoi ra, min dch cho mt phn vi 3 type cn li v c tnh bo v nht thi (6 thng). Nh vy, nu nhim ln 2 vi mt type virus dengue khc (nhim th pht) s mc bnh. 3. Dch t hc 3.1. Vt ch Ngi l vt ch chnh, ngoi ra loi kh rng M lai v Ty Phi cng ng vai tr vt ch. 3.2. ng ly truyn v cn trng trung gian - Ly cho ngi qua mui ci Aedes aegypti t (gin tip), mui nhim virus c kh nng truyn bnh khi t ngi. Virus dengue lu hnh trong mu t khi st. Mui cha nhim t, ht mu bnh nhn c virus, virus pht trin v nhn ln trong c th mui v truyn bnh sau chng mt tun. - Nc ta, Aedes aegypti l mui truyn bnh chnh, c mt hu ht cc tnh, tr lt, vng ni cao - kh hu lnh pha bc. + Mui Aedes aegypti sng gn nh, trong nh, nc trong v sch (vt thi rn ng nc nh v hp, lp xe, v chai, hc cy, hoc chum vi cha nc, hn non b...). u ni treo o qun, bn t, t khi tng. + Mui t ngi nhiu nht lc 9 -10gi sng v hot ng n 17 - 18gi. + Chu k pht trin: trng thnh nhng ri mui trng thnh. + Mui pht trin 20 - 300c, chu k pht trin nhanh 9 ngy, trung bnh 12, chm 20 ngy.

126 - Ngoi ra, ngi ta cn phn lp virus mui Aedes albopictus ti Chu - Thi Bnh Dng, hin xut hin mt s ni trn th gii, k c nc ta. 3.3. S phn b v t l 3.3.1. Trn th gii - Virus dengue c cc nc nhit i, bn nhit i. Cc type huyt thanh lu hnh ng Nam : D1, 2, 3, 4; Ty phi: D1, 2; ng phi: D2; vng bin Carribea: D1, 4; Bc m: D2, 3. - Ln u tin dengue xut huyt Phi lut tn (1953), sau ng Nam , cc qun o Thi Bnh Dng, Trung Quc, Lo, Campuchia, v cc nc khc. - Nm 1956 - 1990 c 3.071.245 ca mc bnh, 51.087 ca t vong (Bo co t 12 nc Chu , cc o Thi Bnh Dng, Cu Ba, Venezuela). 3.3.2. Nc ta - St dengue, st dengue xut huyt quanh nm, dch thng xy ra cui h, u ma ma. Vng ng bng sng Cu Long v cc tnh ven bin min Trung l vng lu hnh cao chim 84% s mc ca c nc. Nm 1997, bnh xy ra ti 50/61 tnh, thnh vi 107.188 ca bnh, 226 cas t vong. S mc tng 19% so vi nm 1996. Nm 1998. Tnh n ngy 16/8 c 84.505 ca bnh v t vong 186. Chu k dch 3-4 nm. - i tng mc bnh ch yu tr t 3- 9 tui, thanh thiu nin v trung nin. Cc tnh pha nam, tr em mc n 90%. Trong khi pha Bc, t l ngi ln trong cc v dch 9,6% 38,6%. Khng khc bit gii. Trc y dch thnh ph, th x, nay lan rng n nng thn. 3.4. Cc yu t nguy c dch xy ra - Mt dn cao, v sinh mi trng km, l iu kin tn ti v pht trin mui truyn bnh. - thc phng bnh km, vt ba bi vt dng tha, cht thi rn ng nc quanh vn. - Nhit thch hp cho mui Aedes aegypti pht trin (20 - 300C), gi ma lm dch tng. - Ch s nh c b gy Aedes aegypti hoc ch s vt cha c b gy 2% l cho dch lan truyn (vt cha b gy/100 nh, t l % vt cha b gy). - Ngi giao lu mnh t vng dch n vng khc ni c vect lm dch lan truyn rng.

II. C TH BNH
- Trng hp t vong do st dengue xut huyt, chy mu da, t chc di da, nim mc ng tiu ha, tim, gan cc mc khc nhau. t khi chy mu no, di mng nhn chy mu t. - Trn dch thanh mc vi protein cao (ch yu albumin) nh mng phi, xoang bng. - Thnh mch (soi di knh hin vi quang hc) thay i khng c ngha, hay gp ti cc c quan b tn thng, ti y mao ng mch-tnh mch xung huyt v xut huyt xung quanh. Monocyte v lymphocyte xm nhp quanh mch mu. Trong lng cc ng mch nh c nhng cc mu ng gp bnh nhn ngi ln xut huyt nng. - Ph nang: t bo n nhn thm nhp vo thnh ph nang v t chc khe. - Tim: tng vng c tim xung huyt. - Gan: t bo hoi t khu tr, ph n; theo Innis (1990) c hnh nh t bo lan rng trn t thit. T bo Kupffer thoi ha hyalin; xoang gan, khong ca t tp nhiu t bo Mono v Neutro. - T chc lymph: tng hot h thng B lymph, tng sinh tng bo, mu bo lymph, mm tng trng trung tm tng hot mnh, tng sinh s ln nguyn bo min dch. - Khng nguyn virus dengue c t bo gan, lch, tuyn hung, hch bch huyt, t bo Kupffer, t bo lt trong xoang gan, t bo lt ph nang. - Ty xng: thnh phn ty xng b c ch, ci thin sau khi ht st. - Thn: phc hp min dch dng vim cu thn, khi khng li di chng. - Monocyte v lymphocyte xm nhp cc mao mch da; b th, globulin min dch v fibrinogen ng trn thnh mch mu da. - Mu sinh thit da bnh nhn st dengue xut huyt soi di knh hin vi in t cho thy trong cc t bo ni mc, tng s lng cc khng bo v cc th m bo, l bng chng gy thot huyt tng t mao mch vo khong quanh mao mch.

127

III. BNH SINH - SINH L BNH


1. Cc bin i bnh l trong st dengue xut huyt c sc 1.1. Tng thm thnh mao mch Thot huyt tng vo khong gian bo v cc xoang (mng phi, mng bng v.v.), gy c c mu, nu mt nhiu gy gim th tch mu, huyt p tt, mch yu v sc. (cn xt nghim Hct, thng tng vo ngy 3-7 sau st, vo lc h nhit ). 1.2. Cc bin i v tnh trng cm mu: lin quan n 3 yu t ch yu: - Nhng thay i v thnh mch mu. - S lng v tp trung tiu cu gim (< 100.000/mL ngy th 2-3 sau st, trc Hct tng). - Ri lon ng mu. C 3 yu t ny c st dengue xut huyt/dengue xut huyt c sc, nhng mc khc nhau quyt nh th lm sng. 2. Hai gi thuyt v c ch bnh sinh 2.1. Thuyt nhim virus th pht Cn gi tng cng nhim virus do min dch ln u, Halstead xut sau khi nghin cu dch t Thi lan. Khi nhim dengue ln 2; v ln u nhim mt type khc nn c mt phn min dch cho vi ln 2, phn Fc ca khng th ln u gn vi yu t ni kt trn t bo n nhn / i thc bo. Phc hp ny thc y virus thm nhp n nhn/i thc bo d hn, gy nhim mt lng ln virus, gy ra cc th lm sng nng. T bo n nhn/i thc bo b nhim virus tr thnh ch ca c ch min dch o thi, cc t bo ny b hy, gii phng cc cytokin (IL,TNF), yu t hot ha tiu cu (PAF) v Urokinase (plasminogen). Chng l cht trung gian ha hc ny gy tng thm mao mch, hot ha b th, suy tun hon, ri lon thromboplastin t chc, ri lon ng mu. 2.2. Thuyt c lc virus dengue Tnh trng nng st dengue xut huyt / dengue xut huyt c sc xy ra trong nhim virus tin pht, nghin cu cho thy l chng c c lc mnh hoc yu. Hin nhiu quan im cho l c lc ca chng virus l yu t quan trng quyt nh mc nng nh ca bnh. Tm li, quan im khc nhau v bnh sinh st dengue xut huyt cha c thng nht. Duy ch mt iu khi nhim virus dengue gy hu qu tng thm thnh mch, h tiu cu, gy ri lon ng mu cn phi x tr sm nu khng c th t vong do th nng c sc.

IV. LM SNG
bnh 4-6 ngy, c 2 tnh hung: c triu chng, khng triu chng. Loi c triu chng gm 3 dng lm sng: dengue c in, dengue xut huyt, dengue xut huyt c sc. 1.St dengue Bnh cnh l thuc tui, tr con v tr em c th c bnh cnh st khng r nguyn nhn km ban sn. Tr ln v ngi ln thng st cao t ngt, au u nhiu, au h mt, au c - khp, pht ban; xut huyt da him gp (dy tht (+), hch c n chm, hch trn li cu, gan lch bnh thng. BC gim, c khi tiu cu gim, Hematocrit bnh thng, transaminase bnh thng, din bin trong vng mt tun, thi gian hi phc 1-2 tun, mt mi ko di. Vng ng Nam st do virus Chikungunia c bnh cnh lm sng nh st dengue. S khc bit dengue c in (t c xut huyt, khng tng Hct) vi dengue xut huyt (c xut huyt, tng Hct). 2. St dengue xut huyt St dengue xut huyt in hnh thng c 4 triu chng lm sng: st cao, xut huyt (c khi gan to, thng suy tun hon), gim tiu cu nh n nng, ng thi vi c c mu (Hct tng) l du c trng ca st dengue xut huyt. - Khi pht t ngt, st cao, mt - mt xung huyt, nhc u nhiu, au sau h mt, au c khp, bun nn, chn n, c khi au hng v hng , kh chu thng v, tc h sn phi, au ton bng hay gp.

128 - St 2-7 ngy, ri nhit bnh thng, gn bnh thng. St 40-41 C, c th km co git. - Du xut huyt: hay gp dy tht (+), c nhng vt bm tm, hoc chy mu ti ni tim chch, a s trng hp: xut huyt dng chm cc chi, nch, chy mu mi, chy mu chn rng, c khi i mu, hnh kinh ko di, c khi xut huyt ng tiu ha l tin lng nng; pht ban da cng gp. - Gan to xut hin sm trong giai an st, t s c cho n 2-4cm di sn, n tc. Khng c mi lin h gia gan to v trm trng ca bnh. Nhng gan to hay gp trong trng hp sc, transaminase tng nh, gan mm, c khi (rt him) vng mt,da. - Sng hch: trn li cu, dc theo c c n chm; n hi tc, khng da, c khi sng hch ton thn, hch xut hin sm. Din bin xu xy ra lc h nhit, sau st 3-4 ngy, c khi km du hiu ri lon tun hon vi mc nng nh khc nhau. Nh th v m hi nh, u chi hi lnh, nhp tim nhanh, huyt p hi h do thot huyt tng nh.Vi trng hp nng do thot mt lng huyt tng ln, sc c th xy ra din bin ti sc nng nu khng cp cu kp thi s t vong. Mc nng nh ca bnh ty vo vic chn on, x tr sm hoc mun. Gim tiu cu v tng Hct thng c trc sc. 3. St dengue xut huyt c sc Bnh nhn ang st cao, t ngt tng trng xu i vi du hiu tin sc xut hin, thng ngy 3-7 ca bnh: - Thn kinh: Tr hi ly b, vt v, ht hong, quy khc, ngi ln th tnh to. - au bng: nht l au vng gan, c khi au ton bng. - u chi hi lnh, trong khi thn nhit cao. - C th tt nhit . - Ngi nhm nhp m hi trn, mt Sc xut hin: Mch nhanh nh kh bt, huyt p kp bt k mc no, hoc huyt h km theo da lnh, u chi tm ti, ngi vt v; thm khm, c khi trn dch mng phi, mng bng, c khi khng c xut huyt da. Bnh nhn sc c th t vong, nu khng iu tr kp thi v ng th sc su hn, mch khng bt c, huyt p khng o c. a s bnh nhn vn tnh to cho n giai on cui cng. Khi sc khng c x tr s gy cc bin i: toan chuyn ha, chy mu tiu ha (d dy - rut) v cc c quan khc, c th xut huyt no gy hn m, t vong. Thi k hi phc ca st dengue xut huyt/dengue xut huyt c sc thng l ngn, trng hp sc nng nu qua khi trong vng 2-3 ngy, bnh nhn n ngon tr li l du tin lng tt. Thi k hi phc thng c mch chm, lon nhp xoang, c khi rt chm.

V. BIU HIN LM SNG V BIN CHNG HIM GP


1. Thn kinh - St dengue xut huyt km biu hin vim no ( M lai, Min in, Thi lan, Cng ha Dominica, Puerto - Rico) - C khi co git, co cng, ri lon thc, c khi km theo lit (dch no tu bnh thng). 2. Gan Tn thng gan gp tr con (< 12 thng tui), lu ng c thuc do qu liu Paracetamol. 3. Thn Suy thn cp do sc ko di, hi chng tn huyt tng ur mu. 4. ng mu ri rc ni mch C th xy ra trong a s trng hp sc nng, nht l khi c chy mu trn lm sng.

VI. XT NGHIM
1. Mu - Tiu cu: < 100.000/ mm3 (ngy th 3-7), tp trung gim. - C c mu (Hct tng ) trong trng hp c sc Hct tng > 20% so vi mc bnh thng. L 2 du c trng trng trong st Dengue xut huyt .

129 - Bch cu mu: thng gim s lng. 2. Mt s thnh phn khc trong mu - Protein mu gim, Natri mu gim. - Transaminase tng nh. - Toan ha mu: trng hp sc ko di. 3. Cc yu t ng mu - Fibrinogen gim, Prothrombin gim; VIII, XII, antithrombin III, alpha - antiplasmin, u gim; thi gian thromboplastin tng phn ko di. 4. Phn lp virus (thc hin trong nghin cu hoc gim st) Phn lp t huyt thanh, huyt tng, t mu sinh thit - t thit (gan, lch, hch, thymus). Ly mu nghim sm, trong qu trnh bnh, chuyn nhanh n phng th nghim, l xt nghim c hiu nhng t l (+) thp, (ch thc hin phng xt nghim cao cp). 5. Chn on huyt thanh (dng chn on xc nh v nghin cu) C 2 loi p ng min dch trong nhim dengue cp tnh: p ng tin pht gp ngi cha b nhim hoc chng vc xin chng flavivirus (st vng, vim no Nht Bn ), nng khng th tng chm. p ng th pht gp ngi b nhim hoc chng vc xin nga flavivirus (st vng vim no Nht Bn), nng khng th tng nhanh. 5.1. Phn ng c ch ngng kt hng cu ngng (HI) Da vo kh nng khng th dengue c ch ngng kt hng cu, cn thc hin cng sm cng tt trong qu trnh bnh. Tt nht lm c 4 type v 2 mu cch nhau 1-4 tun, hiu gi ln 2 gp 4 ln hiu gi khng th ln u l (+) in hnh. 5.2. Phn ng c nh b th Phn ng ny khng nhy bng HI, phn ng ny l tin li v ch IgG khng Dengue mi c nh b th vi khng nguyn dengue. Nng khng th c nh b th ln 2 tng gp 4 ln u, 2 ln ly mu cch nhau < 2 tun th c ngha nhim trng th pht. 5.3. Phn ng trung ha C nhiu loi phn ng trung ha trong chn on nhim dengue, nhng c l c hiu v nhy cm nht l pha long huyt thanh. i vi nhim tin pht, khng th trung ha n type c pht hin sm trong giai on u ca k hi phc. i vi nhim th pht, khng th trung ha c nng cao, chng li 2 ti 4 type virus dengue. 5.4. Pht hin IgM v IgG v nhng khng th khng dengue khc - Khng th IgM khng dengue c to nn tm thi c trong nhim tin pht, ln th pht; pht hin n c ngha ang nhim hoc va mi nhim dengue. - Khng th IgG khng dengue cng gp trong c nhim tin pht, nhng lng khng th trong nhim th pht ln hn nhiu so vi nhim tin pht . Ngi ta c th dng phng php MAC - ELISA ly mu ch mt ln sau ngy th 5 ca bnh. (IgM Antibody Capture - ELISA). Gn y hn c phng php min dch enzyme (dot enzyme immuno - assay: DEIA) pht hin khng th dengue c c hiu cao (97,3%)

VII. CHN ON
1. Chn on lm sng 1.1. Chn on st dengue - Tr: st + pht ban. - Tr ln, ngi ln: + st cao t ngt + Nhc u nng, au h mt. + Xung huyt. + au c khp. 1.2. Chn on st dengue xut huyt (c h tr ca xt nghim)

130 Gm 4 tiu chun: - St: Tnh cht khi pht t ngt, cao, ko di 3-7 ngy. - Nhng biu hin xut huyt: gm t nht dy tht (+), (2,5cm2 c trn 20 chm xut huyt c th (-) hoc (+) nh trong giai on sc nng. Ri (+) c khi rt mnh giai on khi sau sc) hoc mt trong nhng triu chng sau. + Chm xut huyt, m xut huyt, m bm tm. + Chy mu cam, chy mu chn rng. + Nn mu v / hoc a phn en - Gim tiu cu <100.000/mm3 . - C c mu: Hct tng ( > 20% so vi mc bnh thng; hoc chng c khch quan tng tnh thm thnh mao mch. Chn on st dengue xut huyt c sc: Gm cc triu chng ca st dengue xut huyt + du hiu suy tun hon (-mch nhanh v yu; tt huyt p hoc huyt p kp; km theo da lnh, m, ngi vt v). 2.Chn on nng nh ca st dengue xut huyt / c sc I: St + Triu chng ton thn khng c hiu + du dy tht (+) II: I + xut huyt t nhin da v hoc ni khc. III: Suy tun hon (mch nhanh, yu; huyt p kp hoc h; da lnh m; vt v) IV: Sc nng (mch + huyt p khng c). Hin din gim tiu cu, c c mu phn bit st xut huyt dengue I,II vi st dengue. Phn nng nh hu ch v lm sng v dch t hc trong cc v dch tr em. Mt s lu khi theo di v chn on - S khc bit gia st dengue v st dengue xut huyt ch st dengue khng c tng thm thnh mch v vy th tch huyt cu bnh thng (Hct) hoc khng c trn dch cc mng c th, trong khi st dengue xut huyt c tng thm thnh mch (Hct tng 20% so vi mc bnh thng) hoc c trn dch cc mng c th. - Nhim virus dengue ngi ln, s lng tiu cu mu c th gim < 150.000tc/mm3 v tp trung gim c th gp c trong st dengue ln st dengue xut huyt, thay v < 100.000tc/mm3 nh tiu chun ca WHO a ra, mi gi l st dengue xut huyt. - Trong qu trnh lm sng ca nhim virus dengue, trong giai on u kh c th phn bit st dengue vi st dengue xut huyt, nht l khi cc bng chng ti thiu gip chn on cha c y , ngi thy thuc cn quan tm theo di nh l mt trng hp st dengue xut huyt. phn loi st dengue v st dengue xut huyt ch c th thc hin sau cng khi m din tin lm sng chm dt. 3. Chn on gin bit 3.1. Giai on sm ca st dengue xut huyt Gin bit bnh nhim khun: st rt, nhim cc virus khc vi khi pht t ngt. - Xon khun Leptospira: khi pht t ngt au c t nhin hoc thm khm (c cng chn, i, tht lng); xung huyt kt mc, da. - St m: khi pht t ngt, xung huyt ngoi da, au mi c khp, lin quan dch t. - Cm: St, vim long h hp, dch t. - St rt: St lin tc, c khi xung huyt da, kt mc nh, lch to, lin quan dch t. 3.2. Ngy th 3-4 tr i Khi c suy tun hon, km c c mu v h tiu cu c gin bit sc nhim khun no m cu hoc vi khun khc. VIII. IU TR 1. Nguyn tc Kp thi, khn trng, y , thch hp. - Ngay t khi st, tt nht nn bi ph nc in gii bng ORS sn c trm y t.

131 - H st khi > 39oC, nht l tr em; p khn t h nhit, hn ch thuc h nhit tr khi cn. Khng dng thuc c gc A. salicylique. - Khi sc, hi phc tch cc bng dung dch Ringers, lactate, Natri clorua 9%o; nu cha n dng dch keo. - Xut huyt nng, gim tiu cu nng c th truyn mu hoc tiu cu khi. - Truyn dch phi theo di v kim tra bng Hct, p lc tnh mch trung tm nu c th. 2. iu tr thc t 2.1. St Dengue xut huyt ( I & II) : iu tr tai tuyn c s. - B nc in gii: + Ung ORS, tr em 150ml/kg/ngy, ngi ln 1-2 gi ung/ngy. C th ung nc tri cy, nc da, chanh ng v.v.. + Truyn dch: nn nhiu, khng ung c, ngi hi vt v mt, st cao (1 NaCl 9o/oo + 1.Glucose 5%, 5%, Ringers Lacte). Lng dch v tc ty thuc vo lm sng: mch, huyt p, nhp th, Hct. Tr em: Khi u 6-7ml/kg/gi. Lng dch trung bnh 100-120ml/kg/ngy. Ngi ln: 1-1,5 lt/ngy ty trng hp. - H st : st > 390C, trnh co git: + Gim bt o qun, chm khn t. + Paracetamol: Tr < 12 tui liu khng qu 60mg/kg/ngy. Tr ln v ngi ln 300600mg/ln x 3 - 4 ln /ngy. + Khi nhit tt cn p m. - iu tr triu chng khc: + An thn: Seduxen 0,2-0,8mg/kg/ngy, phng co git khi st cao. + Vitamin C. - Ngi ta c th dng thuc nam : c tc dng thanh nhit, lng huyt, ch huyt, gii c, nng cao th trng. iu tr dnh cho I&II. Ch ung thuc nam, ngh ngi,n nh (Hng dn ca B y t 4882/YT-YH) L cc tn 12 gram. C nh ni 16 gram. M 16 gram. Trc bch dip (sao en) 16 gram (thay bng l sen sao 12 g). Sn dy c 20 gram (c th thay bng 16g l du). Rau m 16 gram. Gng ti 3 lt. Cch dng: 60ml nc sch, un si 30 pht, ung ngy 3 ln, ung lc cn m (ngi ln). Tr 1-5 tui: 1/3 liu ngi ln 6-13 tui: 1/2 liu ngi ln > 14 tui: bng liu ngi ln. 2.2. St Dengue xut huyt c sc ( III&IV): iu tr ti tuyn cao hn. - Truyn dch: + Vi cc dch nu, tt nht l Ringers Lactae hoc NaCl 9o/oo 20mg/kg/gi. + Truyn n khi huyt p n nh v mch chm, bnh nhn ht vt v, tiu c, sau 1 gi nu ht sc th gim xung cn 10ml/kg/gi ri sau gim xung cn 3ml/kg/gi. + Nu sc ko di: dng Dextran 40, 10ml/kg/gi cho n khi sc ci thin. + Ri duy tr dch ng trng da vo Hematorit. Lu dch tha do ti hp thu dch gian bo. - Thng bng kim toan: Da vo xt nghim pH mu, HCO3- , b NaHCO3 14o/oo. Khi no ngng chuyn dch ? Khi c nguy c : hi kh th, phi ran m. Tnh trng lm sng n nh: mch, huyt p n nh; HCT ,40%.

132 Nu o c p lc tnh mch trung tm (CVP) t c 5cm H2O, huyt p n nh. Khi CVP 5 - 10 cm H2O, huyt p vn cha ln dng Dopamin 5 mcg/kg/pht hoc Dobutamin 10 mcg/kg/pht. - Oxy: cho th trong trng hp c sc. - Truyn mu: Xut huyt nng - thiu mu: Hct gim m huyt p khng ln cn truyn mu. Xut huyt nng, Hct vn cao th truyn huyt tng giu tiu cu, hoc tiu cu khi. - Thuc khc: + An thn: khi st cao hoc vt v, Diazepam tr 0,2-0,8mg/kg/ngy,ngi ln 510mg/ngy. + Adrenoxyl (10mg) ngi ln 1-3 vin, tr > 2 tui 1-2 vin: khi chy mu. + Li tiu furosemide khi c du hiu tha dch. - Theo di iu tr sc: + Mch, nhit, huyt p, nhp th, lng tiu 15-30 pht/ln cho n khi ht sc, sau theo di 1-2 gi cho n khi n nh. + C sc theo di Hct (khi sc 1gi/ ln, ht sc 2 - 3 gi / ln n n nh). + Theo di bi lan dch, ch khng c truyn tha dch. 3. Tip nhn bnh nhn - St dengue xut huyt I: iu tr ti tuyn c s, theo di chuyn , d bo sc. - St dengue xut huyt II: - C chm xut huyt ngoi da: iu tr ti tuyn c s, theo di chuyn , d bo sc. - Khi c xut huyt tng ph: s cu bnh x x, chuyn tuyn trn c nhn vin cp cu km theo. - St dengue xut huyt III&IV: - Cp cu ti ch c tng cng tuyn trn. Chuyn bnh khi cp cu, duy tr dch truyn khi chuyn.

IX. D PHNG
1. Khi cha c dch, bnh Bin php tt l gim st v phng mui Aedes egypti. 1.1. Phng mui Aedes: bin php hiu qu, nht l qun l mi trng, bng gim st mi trng, c cng ng tham gia nh k theo 3 dng: - Thay i mi trng: thay i lu di ni vect (dn vt ng nc, y kn nc..). - Vn ng mi trng: thay i tm thi, mui khng c iu kin sng-sinh sn (dn vt ng nc, y kn nc, phun thuc khi c dch, khng thng xuyn). - Thay i ni , hnh vi con ngi: gim tip xc con ngi - cn trng trung gian - tc nhn gy bnh (nm mn, khng vt rc thi ba bi...) 1.2. Gim st mui Aedes aegypti Da cc ch s sau gim st mt mui Aedes aegypti, nhm dng bin php kp thi. T l phn trm nh c b gy; T l phn trm vt cha nc c b gy; Ch s Breteau = vt cha c b gy/100 nh iu tra; T l mui u hoc mt u ngh trong 1 khong thi gian (phng php nhy nhng tn km). Ti mt s nc nhit i, s vng khng Aedes aegypti vic gim st l quan trng, trnh mui xm nhp. Ch cng, sn bay, nhng ni nhp cnh. 2. Gim st, phng, chng dch bnh 2.1. Gim st st dengue, st dengue xut huyt: Mc ch l pht hin sm v dch, lm tt cng tc ny cn gim st: - Gim st cc trng hp st Phng khm im hoc tuyn y t c s c dch c, phi bo s ca st/tun cho c quan y t, theo qui nh h thng gim st. - S bnh nhn st > 38 C. Phng php ny c th pht hin t l mi st tng, xc nh nguyn nhn st bng nui cy virus hoc huyt thanh hc.

133 - Ph bin kin thc t chm sc cho dn, khi c ngi mc bnh phng hu qu xu: triu chng st dengue xut huyt; n trm x sm c chm sc (tiu chun chn on), pha ch ORS ung khi b st. - Nhn vin y t chn on st dengue, st dengue xut huyt. c tnh, nu 100-200 ca st dengue s c 1 bnh nhn sc do st dengue xut huyt vo bnh vin. - Bo co ca bnh Trng hp nghi st dengue xut huyt cn bo co theo h thng. 2.2. Gim st mui Aedes aegypti Thc hin gim st c nc xc nh mt qun th mui, lu hnh theo ma. 2.3. Gim st v virus Phn lp virus t bnh nhn, t mui Aedes aegypti nh type huyt thanh l quan trng. 2.4. Phng chng dengue xut huyt phng dch bng pht, phi khng ch mui, cch ly-iu tr bnh nhn vin. - Khng ch mui khn cp: khi nghi ng c dch cn tin hnh + Truyn thng cho cng ng v c im ca bnh, bin php c nhn dng gim nguy c nhim bnh: phun thuc trong nh, gim ni mui -sinh sn trong nh, ngoi vn. + Khoanh vng khu vc phun - dit mui, ni c bnh nhn, ni mt mui cao. + Chun b trc cc thuc dit mui, cc phng tin phun thuc. - Cch ly v iu tr bnh nhn ti vin gim c ngun ly Mc ch: gim mt mui nhim virus ct ng ly, lc ngi bnh hi phc. Tht bi, khi mt mui khng gim sau chin dch. 3. Phng nga dch st xut huyt Hin cha c vc xin phng bnh, nn bin php phng bnh l phng mui Aedes aegypti t. - Gim st v iu tr theo tuyn. - Gim st v phng mui, qun l mi trng, khng ch bng ha cht, sinh hc (th c, mesocyclops). - D tr nc an ton (y kn chum vi nc), qun l v sinh v cc cht thi rn. - Gio dc sc khe, tuyn truyn y t cng ng, huy ng cng ng tham gia. Cu hi n tp 1. M t dch t hc ca bnh do virus dengue gy ra nc ta. 2. M t c im tc nhn gy bnh, tp tnh cn trng trung gian, yu t nguy c dch st dengue xut huyt. 3. Trnh by c th bnh hc, bnh sinh-sinh l bnh st dengue xut huyt 4. Phn loi th bnh, m t cc bc iu tr st dengue, dengue xut huyt v th c sc. 5. Trnh by cch thc phng chng st dengue xut huyt.

134

Bi 21.

BNH CM, CM H5N1 V HI CHNG H HP CP TNH NNG (SARS)


Ts, Bs Trn xun Chng

Mc tiu
1. Trnh by c tnh cht chung ca cc tc nhn gy bnh v cch thc ly bnh cm, cm A (H5N1) v SARS 2. M t cch pht hin, chn on v iu tr ban u nhng trng hp cm c bin chng, cm A v SARS.. 3. Trnh by cch t chc phng v chng cc bnh trn cho c nhn v cng ng.

Ni dung I. BNH CM
Bnh cm l mt bnh truyn nhim cp tnh ng h hp do virus influenza gy nn. Tuy trong a s trng hp, bnh ch khu tr ng h hp trn vi tin trin lnh tnh, nhng c th gy t vong khi c bin chng. Chng thng gy nn nhng v dch, thm ch i dch, do s ngi t vong v cm rt ng k. 1. Tc nhn gy bnh Virus cm c tn khoa hc l virus influenza, thuc h Orthomyxoviridae, c phn bit thnh ba typ A,B,C da trn s khc nhau ca cc khng nguyn. Cu trc ca virus cm gm hai phn : - Phn li c cha mt si ARN mang nhng thng tin di truyn. - Phn v c 3 khng nguyn : + Khng nguyn S (Soluble): l khng nguyn ho tan. + Khng nguyn H (Hemaglutinin): gip virus bm dnh vo t bo cm th + Khng nguyn N (Neuraminidase): gip gii phng virus th h sau ra khi t bo. Hai khng nguyn H v N ca typ thng c nhng thay i. S thay i khng nguyn c th xy ra t t, to nn nhng v dch nh hay c th t ngt, to nn nhng i dch. Virus B v C t thay i khng nguyn v ch thay i chm nn him khi gy dch ln. - S ngng kt hng cu xy ra khi virus tip xc vi b mt ca hng cu. Ngi ta da vo hin tng ny nghin cu s nhn i ca virus v o nng khng th. 2. Dch t hc - Bnh rt d ly v ly rt nhanh trong cng ng. Trong cc v dch, c n 30-60% dn c trong vng c dch b mc bnh. Cc v dch xut hin khng theo chu k r rng. - ng ly : ch yu l ng h hp. Cc git nc bt rt nh ca ngi bnh d dng lt vo ng h hp ca ngi tip xc v gy bnh nu ngi b nhim khng c min dch tng ng. Ngi bnh c th ly cho ngi khc t 6 ngy trc khi c triu chng cho dn 1 -2 tun sau khi bnh. - S thay i khng nguyn (nht l virus typ A) lm gim kh nng min dch ca nhng ngi tng b mc cm trc , do lm tng t l mc bnh trong cng ng, gy nn nhng v dch, thm ch i dch nu s thay i khng nguyn nhiu v t ngt. - Bnh thng xy ra vo ma lnh, t cui thu n ma xun nm sau. Dch t n cao im 1-2 tun sau khi khi u v ko di khong 1 thng.

135 - T vong thng xy ra nhng ngi c nguy c b bin chng cao. l nhng ngi gi yu (trn 65 tui), ph n c thai, c cc bnh v chuyn ho , c bnh tim phi mn tnh, suy thn mn, nhng ngi suy gim min dch.. 3. Sinh l bnh Sau khi vo c th theo ng h hp, virus bm dnh ri thm nhp vo t bo biu m ca ng h hp trn v nhn ln . Trong qu trnh nhn ln v pht trin ca vi-rt bn trong t bo, vi-rt lm ri lon chuyn ho t bo v ph v t bo lnh r tip tc ph v cc t bo khc. Qu trnh ny xy ra kh nhanh nn ch trong mt thi gian ngn, virus c th lan ton b nim mc ng h hp trn, c khi lan n tn ph nang. Cc t bo biu m s sung huyt, ph n, hoi t v bong ra. S bong ra ca nim mc ng h hp trng vi s xut hin st v s mi. Tuy nhin sau khi khi bnh, chng thng c thay th bi cc t bo biu m mi t lp t bo mm bn di. 4. Lm sng 4.1 Th in hnh 4.1.1 Thi gian bnh Ko di 1-3 ngy, trung bnh 48 gi. Bnh khi pht t ngt vi st, n lnh, nhc u, s mi, au c, mt mi. 4.1.2 Thi k khi pht Thng t ngt, st cao 39-400C, rt run, nhc u, bun nn, au mi ton thn. 4.1.3 Thi k ton pht: c 3 hi chng: * Hi chng nhim trng: - St : t ngt v tng ln nhanh chng trong nhng ngy u tin, c khi ln n 40 C km n lnh. Sau gim dn v tr li bnh thng trong vng 1 tun. - Mt mi ton thn, chn n, mi kh, li bn. * Hi chng au lan to: - Nhc u: quanh hc mt, vng trn hay thi dng. C trng hp vng chm. Nhc u thng gim dn t ngy th ba n ngy th nm, gn tng ng vi cn st. - au c khp : au ton thn, nhng r nht l cng chn v vng tht lng. * Du hiu vim long ng h hp trn: Thng c s mi, ho khan, i khi c m, rt hng. - Khm thc th : c khi khng pht hin g. Nhim virus typ B c th gp cc triu chng mt: au mt, s nh sng, vim kt mc. - Tin trin : bnh thng t hi phc trong vng 4-7 ngy khi khng c bin chng. Tuy nhin chn n, ho v mt mi cn ko di n 3 tun sau, nht l ngi gi. 4.2. Cm c tnh C biu hin ca hi chng suy h hp cp do virus cm gy ra. Thng gp nhng ngi suy h hp, c bnh van hai l, ph n c thai, gi yu hay c suy gim min dch. - Lm sng: th nhanh, tm u chi, phi c ran n hai bn. C th c du suy tim phi v ri lon thc. Him hn c th vim c tim, vim mng ngoi tim, suy thn, suy gan.. - X quang phi : m lan to hai phi. Bnh nhn thng t vong do thiu Oxy nng. 4.3.Bin chng 4.3.1. Bi nhim ph qun-phi do vi khun y l bin chng thng gp nht ca cm. - Tc nhn gy bnh thng l Haemophilus influenza, ph cu, lin cu, t cu vng.., thng gp ngi gi v ngi b suy h hp mn tnh. - Triu chng bo hiu thng l st tng tr li sau khi gim xung 1-2 ngy. Bnh nhn ho nhiu km khc m, au ngc. Nghe phi c nhiu ran n, c th c hi chng c phi hoc vim ph qun. - C th dng khng sinh phng bi nhim nhng ngi c nguy c.

136 4.3.2. Bi nhim Tai-Mi-Hng Him gp hn, ch yu tr em, bao gm: - vim tai gia - vim xoang - vim thanh qun 4.3.3. Bin chng khc Rt him gp, gm c : - vim c tim, vim mng ngoi tim - vim mng no lymph c hoc khng km du hiu vim no - sy thai ph n c thai - Hi chng Reyes : ph no, h ng huyt, tn thng t bo gan v thn. Thng ch gp tr di 15 tui, c dng Aspirin h st. - Hi chng Guillain - Barre 5. Chn on 5.1. Chn on Chn on cm thng da vo : 5.1.1 Lm sng - Cc triu chng nhim virus ni chung : st cao t ngt, mt mi, chn n.. - Hi chng au - Du hiu vim long ng h hp trn. 5.1.2 Yu t dch t : C nhiu ngi cng mc bnh trong vng bnh nhn ang sng. 5.1.3 Chn on xc nh + Phn lp virus : c th phn lp virus trong dch xut tit mi hng hay kh qun, cy trn t chc phi g. + Chn on huyt thanh: phng php c ch ngng kt hng cu (Hemagglutination inhibition) hoc c nh b th (Complement fixation). Cn ly mu 2 ln, cch nhau 7-10 ngy. Kt qu (+) khi hiu gi t 1/1280 hoc khng th ln 2 tng gp 4 ln so vi ln u. Cc phng tin chn on xc nh bng phng php huyt thanh hc hay phn lp virus rt t v khng thc t. Chng thng ch dnh cho cc nghin cu dch t hc, phc v cng tc d bo v lm vaccine. 5.2 Chn on bin chng Da vo cc triu chng lm sng v cc xt nghim lin quan. 5.3 Chn on gin bit - Trn lm sng, rt kh phn bit vi cc bnh do cc loi virus khc nh virus parainfluenza, rhinovirus, adenovirus.. gy ra. Ch yu da vo yu t dch t. - Phn bit vi vim phi do Mycoplasma, Chlamydia, vim hng do cc vi khun..Cc bnh ny thng khng t gii hn v p ng vi khng sinh thch hp. 6. iu tr 6.1 Nguyn tc - Khng c iu tr c hiu. Ch yu iu tr triu chng v cc bin chng. - Nng cao th trng bnh nhn . 6.2 iu tr c th - Ngh ngi, n ung v b nc cho bnh nhn. Ch hot ng tr li dn dn khi hi phc, nht l nhng trng hp nng. - Nu bnh nhn st cao : h nhit bng Paracetamol 500 mg x 3-4 ln/ ngy. Khng dng Aspirin hay cc dn xut c Salicylate khc, nht l cho tr em. - Vitamin C, 1 -2 g/ ngy. - Cc thuc iu tr triu chng (khng histamin, long m, gim ho..): ch dng khi cn thit. Nu c ho khan v au sau xng c c th dng Codeine, 16 - 64 mg mi 4 -6 gi.

137 - i vi cc bnh nhn c nguy c cao ( tr s sinh, ngi gi, ngi c suy h hp mn tnh, suy tim.. ) c th cho khng sinh phng bi nhim. - Thuc chng virus c hiu : Ribavirin, Amantadine v Rimantadine ch c hiu lc nhng khng cao lm vi virus cm typ A v phi dng rt sm ngay sau khi nhim virus . - iu tr cc bin chng : Khng sinh thch hp nu c bi nhim vi khun ( ch yu khng li T cu, Ph cu v H. influenza ). Bo m h hp. Trng hp hi chng Reyes: truyn Glucose, chng ph no. - iu tr cm c tnh : + Theo di v iu tr ti phng Hi sc cp cu. + Hi sc h hp v cc bin php khc : th Oxy, th my, cn bng nc-in gii, khng sinh. 7. Phng bnh - Tuyn truyn rng ri kin thc v cm cho nhn dn. c bit nhn mnh n kh nng ly lan mnh v nhanh, ch cc i tng c nguy c bin chng cao khi mc cm. - Cch ly bnh nhn nghi cm. Khng cho nhng ngi c bnh tim mch mn tnh, gi yu..tip xc vi bnh nhn cm. Nu c tip xc, c th d phng bng Amantadine ( hay Rimantadine ) 200 mg/kg/ngy x 3-7 ngy. Kh nng bo v khong 70% i vi virus cm A, nhng khng c hiu qu i vi virus B. Thuc khng virus mi Ribavirin, dng ng ung hoc kh dung, t ra c hiu qu tt trong d phng v iu tr bnh cm. - Trn th gii, ngi ta thng chng nga vaccine vo u ma thu (trc ma dch hng nm). Vaccine thng c sn xut da trn cc virus cm gy dch nhng nm trc, thng c hiu qu bo v tt (khong 65 - 70%). Thi gian bo v 3 - 6 thng. V bnh cm thng t gii hn v t l t vong khng cao nn vaccine cm khng c a vo chng trnh tim chng i tr. Tuy nhin khi c t bin ca virus th ngi chng nga vn c th mc cm.

II. BNH CM A (H5N1)


1. Gii thiu Bnh cm g xut hin ln u tin Hng Kng nm 1997 v mt s nc khc sau . Ring nc ta t nm 2004 xut hin cm g do virus cm H5N1gy ra. y l mt bnh c kh nng gy dch nh ti a phng cng nh dch ln nhiu vng trong c nc. Dch ny gy tn tht rt ln cho ngnh chn nui ni ring cng nh cho nn kinh t ni chung v gy nguy him n tnh mng ca ngi dn. Tnh n 30.09.2005 nc ta c hn 90 bnh nhn nghi b cm H5N1, trong c 21 trng hp t vong. 2. Tc nhn gy bnh Tc nhn gy bnh l virus cm, thuc h orthomyxoviridae. Virus c 3 type, type A thay i khng nguyn rt nhanh v gy hu ht cc v dch cm. V ca virus c cha hai protein hemagglutinin (H) v neuraminidase (N). Hin c 15 ph type ca H (c k hiu H1-H15) v 9 ph type N (N1-N9). Virus cm hin ang gy dch nc ta l loi H5N1. 3. Dch t hc v c ch bnh sinh 3.1. Dch t hc - Ngun bnh: + Ngi ang nhim virus. + G hoc gia cm mc bnh: ngi ta nghi ng c s ly lan khi tip xc vi gia cm mc bnh hoc mi trng b nhim virus. - ng ly: + ng h hp, do nc bt ca ngi nhim virus khi ho, ht hi. + Do tip xc vi nc bt ca ngi bnh hoc vi gia cm b bnh ri a vo mi, ming ngi lnh. + Thi gian ly: 1 ngy trc khi c triu chng v ko di 3-7 ngy sau khi khi bnh.

138 3.2. C ch bnh sinh: Tng t c ch bnh sinh ca cc bnh cm thng thng. 4. Triu chng lm sng v cn lm sng Xem phn triu chng lm sng bnh cm. 5. Chn on 5.1. Chn on Chn on cm thng da vo : - Cc triu chng nhim vi-rt ni chung : st, mt mi, chn n.. - Tn thng ng h hp, suy h hp cp. - X quang phi: c hnh nh m lan ta c hai phi. - Yu t dch t: C tip xc vi bnh nhn cm H5N1 hoc vi gia cm b mc bnh. 5.2. Chn on xc nh : + Phn lp virus: bng k thut PCR c th phn lp virus trong dch xut tit mi hng hay kh qun. + Chn on huyt thanh: bng phng php c ch ngng kt hng cu hoc phng php C nh b th. 6. iu tr 6.1.iu tr cm thng thng - Ngh ngi ti ging, n ung v b nc cho bnh nhn. Ch c hot ng tr li dn dn khi hi phc, nht l nhng trng hp nng. - Nu bnh nhn st cao: h nhit bng Paracetamol 500 mg x 3-4 ln/ ngy. Khng dng Aspirin hay cc dn xut c salixylat khc, nht l cho tr em. - Vitamin C, 1 -2 g/ ngy. - Cc thuc iu tr triu chng (khng histamin, long m, gim ho..) : ch dng khi tht cn thit. Nu c ho khan v au sau xng c c th dng Codein, 16-64 mg mi 4 -6 gi. - i vi cc bnh nhn c nguy c cao (tr s sinh, ngi gi, ngi c suy h hp mn tnh, suy tim..) c th cho khng sinh phng bi nhim. - iu tr nguyn nhn: Dng thuc khng virus Tamiflu (Oseltamivir). Liu dng: vin 75mg x 2 ln/ngy trong 5 ngy. - iu tr cc bin chng : Khng sinh thch hp nu c bi nhim vi khun ( ch yu khng li T cu, Ph cu v H. influenza ). Bo m h hp. 6.2. iu tr cm c suy h hp - Cho th Oxy, th my, cn bng nc-in gii, khng sinh. - Xt nghim: cng thc mu, kh mu, in gii ..., chp X quang phi hng ngy. 7.Phng bnh - Tuyn truyn rng ri cc kin thc v cm cho nhn dn. c bit nhn mnh n kh nng ly lan mnh v nhanh, ch nhng vng c gia cm cht hng lot khng r l do. - Tt c gia cm trong phm vi 3 km quanh ni c dch u phi c tiu hu. Tuyt i khng vn chuyn gia cm t vng c dch n cc vng khc. Gia cm hoc tht gia cm u phi c kim dch trc khi bn ra th trng. - Tt c bnh nhn b cm hoc nghi b cm do H5N1 u phi c cch ly tuyt i.

III. HI CHNG H HP CP TNH NNG (SARS)


1. Gii thiu Hi chng h hp cp tnh nng (Severe acute respiratory syndrome, vit tt l SARS) hay cn gi l Hi chng vim ng h hp cp, l mt bnh truyn nhim cp tnh do virus gy ra, c kh nng gy dch ln nhiu khu vc trn th gii. Dch xut hin ln u vo thng 11.2002 Qung ng (Trung Quc), sau nhanh chng lan rng ra nhiu nc, trong c Vit Nam. T thng 11.2002 n 07.08.2003 dch lan rng n 29 nc v vng lnh th. Tng s bnh nhn l 8096 ngi, c 774 trng hp t vong; ring nc ta c 63 bnh nhn SARS v c 5 bnh nhn t vong.

139 Bnh c t l t vong cao, cha c thuc iu tr c hiu v cha c vaccine. Dch SARS nh hng nghim trng n kinh t, du lch, chnh tr x hi ca nhiu nc. Theo c tnh dch SARS gy thit hi hn 150 t -la M cho cc nc trong vng dch. 2. Tc nhn gy bnh Tc nhn gy bnh l mt loi coronavirus, thuc h coronaviridae, mt loi ARN virus. SARS coronavirus c cu trc phn t ging 60-70% loi coronavirus trc y. Coronavirus kinh in thng gy vim cp tnh nh ng h hp trn, ch yu ngi trng thnh. SARS coronavirus l loi rt mnh, c kh nng ph hu t chc v t bo ng h hp nng n hn coronavirus trc y. SARS-CoV c th sng st bn ngoi c th tng i bn vng, nht l trong iu kin nhit thp, thi tit mt v lnh. Virus c th tn ti 3-4 ngy trn cc vt liu g, vi, giy, kim loi, da; 4-5 ngy trong nc bt v cht thi ca bnh nhn. Virus c th tn ti vi c lc cao 4-20 0C trong 5 ngy. Tia cc tm v cc ho cht kh trung y t nng thong thng c th dit c virus trong vng 60 pht. 3. Dch t hc v c ch bnh sinh 3.1. Dch t hc - S lu hnh bnh: Ch trong vng 9 thng, bnh SARS lan truyn nhanh chng ra 29 nc c 5 chu lc. iu ny cho thy kh nng pht tn v lan truyn ton cu ca bnh. Cc virus corona kinh in cng c chng minh l c mt nhiu khu vc trn th gii. Nh vy kh nng lu hnh rng ri ca SARS-CoV l rt cao. Tuy nhin, cng nh nhiu dch bnh ng h hp khc, khu vc chu vi mt dn c ng v nhiu yu t t nhin thun li cho s bng pht dch h hp, c th vn l im xut pht v l ni lu hnh thng xuyn nht ca dch bnh SARS. - cha: Ngi ta cho rng ngun gc ca cc tc nhn gay bnh SARS l sc vt hoang d.Cc nh khoa hc Trung Quc xt nghim trn 300 mu mu t cy hng ni xy ra dch SARS ca tnh Qung ng v pht hin trn 70% s mu ny c SARSCoV vi nhng c im ging nh SARS-CoV c phn lp ngi mc bnh. - Ngun ly: Bnh nhn SARS ang trong giai on khi pht v ton pht l ngun bnh nguy him nht. Ngi v sc vt mang coronavirus khng c triu chng cng l ngun ly bnh trong cng ng. - ng ly: ng h hp: nc bt v dch tit ng h hp ca bnh nhn khi ni, ho, khc. ng tip xc: dch tit ng h hp v cc cht thi khc c virus ca bnh nhn c th lm nhim b mt phng bnh hay trong nh cng cc vt dng c nhn, t qua tay ngi thm nhp vo nim mc ming, mi v mt. 3.2. C ch bnh sinh Phn ln coronavirus nhn ln cc t bo biu m ca ng h hp v gy nn cc triu chng h hp ti ch. ARN ca virus ho nhp vo nhn t bo ca vt ch, iu khin t bo tng hp nhng thnh phn khng nguyn, cc v, cc enzym thch hp. Sau chng s ghp li thnh cc virus mi v tip tc tn cng cc t bo khc. Qu trnh ny xy ra kh nhanh nn ch trong mt thi gian ngn, virus c th lan ton b nim mc ng h hp trn n tn ph nang. Cc t bo biu m s sung huyt, ph n, hoi t v bong ra. S trao i kh gia mng-mao mch b gim st lm cho nng O2 trong mu gim i nhanh chng. cc khong k c s tng tit gy vim khong k. 4. Triu chng lm sng v cn lm sng 4.1. Lm sng 4.1.1 Thi gian bnh: 7-10 ngy, c th dao ng trong khong 3-14 ngy. Trong Thi gian bnh mc d c th nhim virus cha ghi nhn trng hp ly bnh. Do ngi ta thy rng khi tip xc vi ngi bnh SARS sau 10 ngy m khng b st th coi nh khng b ly nhim SARS.

140 4.1.2 Thi gian khi pht: trung bnh 1 tun sau khi tip xc vi ngun ly. * Triu chng ton thn: - St cao t ngt, thng st lin tc trn 380C, i khi rt run. Thi gian st ko di 5-15 ngy, trung bnh 10 ngy. Mt , mch nhanh, n km. - au u v au mi cc c, au sau hc mt. C th sng hch ngoi bin. - Mt mi, n ung km - Nhc u, chng mt -Tiu chy: mt s bnh nhn a chy 3-4 ln/ngy, phn lng vng, khng nhy mu. * Triu chng h hp: C mt hoc nhiu triu chng sau: - Ho: thng ho khan, c th c m trng. - Kh th: th nhanh, nng, trn 25 ln/pht. C cc du hiu suy h hp cp. - Nghe phi c th c nhiu ran rt, ran ngy hoc ran m mt bn hoc hai bn phi. Mt s ngi bnh khng c ran. - Rung thanh v g u bnh thng. Nh vy biu hin tn thng phi bnh nhn SARS l c trng ca vim phi khng in hnh. 4.1.3 Thi k hi phc: Sau khong 10-15 ngy bnh nhn ht st, ht ho, n ng bnh thng. Hnh nh tn thng phi dn dn thu nh li v mt i. 4.2. Cn lm sng - CTM: S lng BC v TC bnh thng hoc gim. BC tng khi c bi nhim vi khun. S lng t bo lympho tuyt i h. - Kh mu: gim Oxy mu nng vi SpO2di 90% hoc PaO2 di 60 mmHg, PaCO2 bnh thng hoc tng. - S lng T CD4, T CD3 gim. - Transaminase tng khong 2-6 ln. Chc nng thn bnh thng. - X quang phi: c hnh nh vim phi k, lc u khu tr, sau lan to. T ngy u c nhng m m thm nhim mt hoc hai bn phi. Tn thng tin trin nhanh tng ngy. Sau 1-2 ngy lan n 1/2 hoc 2/3 phi. Trng hp nng c th m ton b hai bn phi lm cho bnh nhn kh th v suy h hp nng. Tn thng phi l nhng m thm nhim khong k hoc nhng m m ranh gii khng r rt mt bn hoc hai bn phi. 5. Chn on 5.1. Yu t dch t Ngi bnh vng dch lu hnh hoc c nghi ng tip xc vi ngi bnh SARS. Nhn vin y t trc tip chm sc, iu tr bnh nhn SARS. 5.2. Lm sng C triu chng st v kh th nh trn. 5.2.1 Trng hp nghi ng SARS: - St cao t ngt (>380C) - au c, au mi ton thn - C mt hoc nhiu triu chng h hp (ho, au ngc, au hng, th nhanh, kh th) - Trong tin s 10 ngy trc c tip xc vi ngi b vim ng h hp cp hoc cht m di ca ngi bnh hoc c i du lch n vng ang b dch SARS. 5.2.2 Trng hp c kh nng b SARS: - St cao t ngt (>380C) - au c, au mi ton thn - C mt hoc nhiu triu chng h hp (ho, au ngc, au hng, th nhanh, kh th) - X quang phi c vim phi hoc c hi chng h hp cp - Trong tin s 10 ngy trc c tip xc vi ngi b vim ng h hp cp hoc cht m di ca ngi bnh hoc c i du lch n vng ang b dch SARS.

141 5.3. Cn lm sng C hnh nh X quang phi c trng. Chn on xc nh bng phn lp virus trong mu, m, dch ph qun bng phn ng chui polymerase phin m ngc (PCR) hoc pht hin khng th ca viru s bng cc phng php th nghim min dch men (ELISA), min dch hunh quang gin tip (IFA). 5.4 Chn on phn bit Khi b vim phi do SARS cn phn bit vi: 5.4.1 Vim phi thu do vi khun (ph cu, lin cu, t cu) y l loi vim phi in hnh, c cc triu chng lm sng ch yu nh: - St cao t ngt 39-400C, rt run - au ngc d di - Ho c m, m c m hoc c mu mu r st - Kh th, th nhanh v nng - Khm thc th c hin tng ng c phi - Bch cu mu tng, a s l a nhn trung tnh. X quang c hnh nh vim phi thu. 5.4.2 Vim phi khng in hnh do virus: Rt nhiu loi virus ng h hp c th gy vim phi khng in hnh. - Triu chng lm sng: st cao t ngt, ho, nhc u, mt mi, s mi. Nghe phi c ran rt, ran ngy, ran m. - X quang: c tn thng phi hnh mng li, thm nhim thu phi, rn phi m. - Bch cu mu bnh thng hoc gim. 6. iu tr 6.1. Nguyn tc - Mi trng hp c pht hin bnh hoc nghi ng mc bnh u phi nhp vin v cch ly hon ton. - Ch yu l iu tr triu chng. Pht hin v x tr kp thi tnh trng suy h hp. - Thng bo ngay tt c nhng trng hp bnh c pht hin v Trung tm Y t d phng ca a phng v B Y t. - Phng iu tr bnh nhn: Khng c dng my iu ho nhit . tt c cc ca s phng phi m thng kh v ng thi lm gim c mt virus trong phng. mt s nc, ngi ta ng kn ca phng v dng my c p lc m thng kh, y khng kh trong phng bnh ra ngoi v nhn kh ngoi tri vo. 6.2. iu tr nguyn nhn Ribavirin 400mg tim TM 3 ln/ngy trong 3 ngy hoc n khi tnh trng bnh nhn ci thin, sau chuyn sang dng ng ung, 2400 mg/ ngy, chia 2 ln. Mt s nc c dng Oseltamivir (Tamiflu), vin 75 mg, ung 2 ln/ ngy hoc Amantadin 100 mg x 2 vin/ ngy. Tuy nhin cho n nay ngi ta vn cha chng minh c cc thuc ny c tc dng khng virus SARS hay khng. Ti Vin Y hc LS cc bnh nhit i khng dng thuc khng virus cho tt c bnh nhn SARS, k c nhng bnh nhn suy h hp nng. 6.3. iu tr triu chng - Dng thuc gim ho nu c ho khan nhiu. Nh mi bng Naphazolin. - H st: Paracetamol, 2g/ngy cho ngi ln, 50-60mg/kg cn nng/ngy cho tr. 6.4. iu tr h tr - Methylprednisolon tim TM , liu 1mg/kg/ngy khi c suy h hp hoc tnh trng nhim trng nng nhng khng nn qu 5 ngy. - C th dng Gammaglobulin truyn TM 200-400mg/kg, ch dng mt ln. Hoc albumin 20% x 100ml/ln truyn TM ba ngy mt ln. 6.5. Dinh dng - m bo dinh dng. Ung nhiu nc hoa qu.

142 - Truyn dch NaCl 0,9%, Ringer lactate, Glucose 5%, m.. tu tnh trng bnh nhn. 6.6. iu tr suy h hp cp - Bo m thng kh, th Oxy qua ng sonde mi hoc mt n. Lu lng 4-10 l/pht. - Theo di lin tc SpO2 hoc PaO2. - t ni kh qun v th my khi c ri lon thc, th nhanh qu 35 l/pht hoc chm di 10 l/pht, toan ho mu nng: pH < 7,25. 7. Phng bnh 7.1. Phng bnh trong bnh vin - Bnh nhn mc bnh hoc nghi ng mc bnh SARS phi lp tc c cch ly nhng khu vc ring trong bnh vin. Ngi bnh xc nh bnh phi phng ring, khng chung phng vi ngi nghi ng mc bnh. - Cho bnh nhn sc ming bng dung dch st khun ng mi hng. - Tt c bnh nhn phi mang khu trang tiu chun nh N95. Mi th thut, xt nghim u phi c thc hin ti ch. - Cm ngi nh v khch n thm khu cch ly. - Nhn vin y t chm sc bnh nhn SARS phi mc o chong bo h (o giy, dng mt ln), mang khu trang N95, knh bo h hoc mt n che mt, gng tay. - Dng c dng cho ngi bnh phi c ra v ty u bng x phng v ho cht kh khun hng ngy. vi phi hp t di p lc trc khi git. 7.2. Phng bnh trong cng ng - Tuyn truyn trn cc phng tin thng tin i chng v dch SARS, cc triu chng thng thng ca bnh v cch phng nga. - Thnh lp cc khu vc cch ly cc vng c dch, cng hng khng quc t, cng bin, ca khu...Tt c hnh khch t cc vng c dch phi c theo di, kim tra v cch ly nu mang mm bnh. Kim tra nhit bng my o thn nhit hng ngoi hoc nhit k o qua tai. Cu hi n tp 1. Trnh by mt s c im dch t hc ca virus cm. 2. Trnh by triu chng lm sng v cn lm sng ca cm c tnh. 3. Trnh by nguyn tc iu tr bnh cm. 4. Th no l mt trng hp nghi ng SARS ? 5. Trnh by cc nguyn tc iu tr bnh SARS.

143

Bi 22.

BNH RUBELLA
BsCK2,Ths Phan Qun

Mc tiu
1. M t c c im, tnh cht ly, bnh sinh ca virus rubella 2. Xc nh c tnh nghim trng ca bnh i vi ph n c thai. 3. M t c lm sng v chn on gin bit rubella mc phi vi mt s bnh pht ban. 4. M t c hnh thi rubella bm sinh. 5. M t cch thc phng nga rubella

Ni dung I. I CNG
Bnh virus, c pht ban hoc khng, d ly, min dch bn sau mc bnh, lnh tnh, gp tr em thi k 2, ng ngi l thai ph mc bnh tng nguy c thai nhi d tt bm sinh. 1. Tc nhn gy bnh Virus RNA, rubivirus, h togaviridae. Gn ging alphavirus, phn bit cu trc khng nguyn (hemagglutinine, khng nguyn c nh b th), v ca phn ng huyt thanh c hiu. 2. Tn sut bnh v nhm nguy c Dch t hc ca bnh thay i nh chng nga rng cho tr. Trc y, dch tin trin theo chu k ma xun, tng mnh m 6 9 nm/ln. Cc v dch ln xut hin cch y 30 nm, trong thi gian ngi ta thy s sinh mc d tt bm sinh tng, cho bit r hn rubella bm sinh (v dch nm 64 65 M, Anh nm 1978). Tr tr s sinh v tr con, bnh gp tr i hc (5 9 tui) v ngi ln cha min dch (10% qun th ngi ln). 3. Ni cha virus v s ly nhim - Nhim cp tnh, ch tn ti ngi. C c mt min dch xc nh. Bnh ly qua khng kh (rubella mc phi) v qua nhau thai (rubella bm sinh). - Ni cha virus gm: + Ngi nhim virus khng hoc c triu chng, virus tn ti hng ca h 7 10 ngy trc pht ban v 10 15 ngy sau pht ban (v th bin php cch ly khng hiu qu). + Tr s sinh mc rubella bm sinh, rt ly v thi virus t 4 - 6 thng, d c khng th trung ho trong c th. - Bnh ly yu hn si: 50% tr 10 tui, 75% v thnh nin, 90% ngi ln khng min dch.

II. BNH SINH


bnh 14 23 ngy (trung bnh 14 18 ngy) sau khi xm nhp mi hng. Virus huyt 8 ngy trc pht ban v bin mt cng vi ban, khi c min dch. Min dch bn, IgMc hiu xut hin khi pht ban v bin mt sau 3 thng, ri IgG xut hin. Nu nhim rubella ln 2 s khng c virus huyt, khng triu chng, m IgG tng nhanh v c khi tng IgM.

III. RUBELLA MC PHI


1. Lm sng Rubella khng biu hin triu chng, hoc khng r, ch pht ban thong qua. Khi pht ngn (1 2 ngy) v khng r, st nh, au c khp, hch c sau tai, c sau v di chm. Hch nh, khng au, tn ti nhiu tun. Pht ban khng hng nh. Khi u mt v lan rng trong 24 gi n thn v chi trn. Ban dng si, ngy u ban dt hoc ban dt sn, c bit mt, i khi dng scarlatine ngy th 2, c bit mng v gc i; mt vo ngy th 3 khng du vt.

144 Ni ban (c nt xut huyt vm hu, vim kt mc, chy mi nh), lch sng nh. St, < 3805C, bin mt t ngy th nht sau pht ban. 2. Chn on xc nh Huyt : gim bch cu a nhn, i khi tng lymph a kim, c khi tng tng bo (5 10%) gip nh hng chn on. Huyt thanh tng quan chn on chc chn l bng chng chuyn i huyt thanh. Lng khng th c ngay t khi pht ban, tng nhanh trong 2 tun k tip. gii thch kt qu ng cn xt nghim 2 ln cch nhau 10 ngy, ln u c thc hin ngay v nng khng th ln 2 tng gp 4 ln u. Nu xt nghim huyt thanh mt ln khng gii thch c kt qu. Phi cnh gic iu m 2 mu huyt thanh c x l ng thi trong cng mt phng xt nghim, phi gi li 2 mu huyt thanh t nht 6 thng ch yu cc thai ph. 3. Chn on gin bit - Trc mt pht ban dng si cn gin bit vi mt s bnh c pht ban: + Tinh hng nhit: Ch chn on lm sng, bng chng sinh hc khng chc, khng c bng chng lin cu tan huyt nhm A nhim ban u. Yu t gi : tui (tr), vim hng cp c trc, pht ban khng c khong da lnh cc np gp, vim thanh mn chu k, bong mng da cc u chi. Hay gp th khng in hnh. Tinh hng nhit lin cu do phu thut v sn khoa biu hin nh nhau nhng ngoi ban quanh vt m trc khi lan ton thn. + Si: tr 3 7 tui, cc yu t chn on nh s ly lan v cha chng nga, vim long h hp trn, vim kt mc - chy nc mt trc khi pht ban si, du Koplik trc pht ban. Ban pht bt u u mt, ri thn mnh n t chi (trong 3 ng y), khi ban xut hin th ht st, ch mt t ban. Huyt thanh chn on IgM ch dng th bnh khng in hnh. + Pht ban ma xun (exanthme subit): tr con s nhim virus herps type 6 (HHV6), ch yu st km pht ban, gy min dch, c im ch gp tr 6 thng 3 tui, khng ly nhim v khng gy dch. St n thun trc pht ban, t ngt 39 400C. St 3 ngy ri ht. Ban xut hin ch yu c v thn, bin mt nhanh, tn ti 12 24 gi, bch cu mu lun lun gim. Cha c chn on sinh hc. + S nhim HIV: ban dt sn thn, mt, c, gp s nhim HIV c triu chng, trung bnh 10 ngy. Cc biu hin khc: st, au c, au khp, lot hng v hoc lot sinh dc, sng hch, him hn l a chy, nm ming, vim mng no. Giai on ny huyt thanh HIV m tnh v chn on da vo khng nguyn P24 hoc HIV RNA mu. + S nhim Epstein - Barr virus: pht ban dng si t nhin ch gp 5 10% trong cc trng hp tng bch cu n nhn nhim khun. Tri li, khi mc bnh v dng ampicillin s gy pht ban dng si hoc tinh hng nhit. Hi chng tng bch cu n nhn nhim khun (tng n nhn a kim gi chn on) v test huyt thanh xc nh chn on. + Pht ban do enterovirus: cc enterovirus khng gy bnh bi lit nh ECHO (entero cyto human orphanan) hoc Coxsackie, gy pht ban dng rubella kn o, xy ra cc v dch nh ma h. Pht ban km triu chng nhim trng khng c hiu: gi cm, a chy, au u, au c. i khi, ch yu l vim mng no tng lymph hoc bnh Bornholm (im au khu tr lin sn, gy kh th, nhng khng c du hiu triu chng ca phi, X quang phi bnh thng, do virus coxsackie) kh gi . C th phn lp virus trong phn, him hn trong nc no tu. Nhiu type huyt thanh virus c th l nguyn nhn gy bnh (ECHO1 9, 11, 14, 18, 19, 25, 30, Coxsackie B1 6). c hiu: "pht ban Boston do virus ECHO16 c c im gy dch v hi chng vim mng no - pht ban do ECHO9 biu hin pht ban c xut huyt vi hi chng mng no. Enterovirus 71: st, pht ban tay - chn - ming, a chy, vim no - mng no, hn m. + Ngoi ra, cc virus c th gy pht ban: virus vim gan B, adenovirus, virus cm, myxovirus, arbovirus,. Mt s vi khu n cng gy pht ban,. Mt s k sinh trng. - Trng hp sng hch c km du nhim trng cn gin bit bnh c triu chng tng t: + Tng bch cu n nhn nhim khun do virus Epstein Barr.

145 + Do cytomegalovirus. + S nhim HIV giai on sng hch ton thn. + Nhim cc adnovirus. + Vim hch do cc vi khun sinh m, lao. 4. Tin trin v bin chng 4.1. Vim a khp bnh nhn v thnh nin, ngi ln v c bit l ph n. Xut hin ngy th 2 tr i. Cc khp u lin quan nhng c bit l cc khp nh, cc khp bn tay, khp thi dng hm, cng nh khp c tay, u gi. Vim khp c th bng pht mt t vim khp dng thp c. Bin mt trong vng 15 30 ngy khng di chng. Hi chng au c tn ti him gp, m ch yu gp con gi tr. 4.2. Xut huyt gim tiu cu sau pht ban. Him (1/3.000), hay gp tr hn ngi ln, xut hin 10 15 ngy sau pht ban chm dt. Mc du him nhng nng, mt s trng hp tiu cu gim rt thp. Hi phc 2 4 tun hoc ngn hn khi dng corticoid. C th xut hin ring l v l triu chng ca rubella. 4.3. Vim no mng no Him hn (1/5.000 1/25.000) so vi vim no do si, xut hin ngy th 2 4 sau pht ban vi bnh cnh lm sng thn kinh (co git, ri lon thc, cc chuyn ng bt thng, tht iu) v vim mng no. Nng (ng g: 20 50%). Khi bnh khng li di chng. 4.4. Cc bin chng khc Vim gan tiu t bo va phi v vim thn kinh (thn kinh to) him gp. 5. iu tr n thun iu tr triu chng.

IV. RUBELLA BM SINH


Nhim virus rubella m - con hay gp, c nhng vn t nh trong vic chn on v thi tr liu (chm dt thai k hay khng ?) Tng quan s ly qua nhau thai vi d tt bm sinh trong 3 thng u thai nghn. Rubella bm sinh gy ra nhiu vn nghim trng tri li ngi ln mc bnh th lnh tnh. 1. Cc d kin dch t hc Tn s Rubella bm sinh trong cc v dch trn qun th gim ng k nh d phng. Nm 1998, thnh ph ca Php, tn s mi nhim Rubella hng nm trong qu trnh thai nghn l 3,7/105 tr s sinh v tn s d dng bm sinh do Rubella l 0,41/105 tr s sinh.
S tun mang thai S % d dng hoc khuyt tt 08 85% 9 12 52% 13 20 16% > 20 tr ln 0% Bng: Xc xut nhim m - con tng quan trc tip vi th gian mang thai

Trong khi mt s ly bnh mun khng bo v khi Rubella tin trin bm sinh. 2. Thai nhi chm pht trin Ngi ta c th gp hai bnh cnh nh sau 1.1. Hi chng d dng (cn gi l hi chng Gregg) Gregg m t nm 1941. Pht hin vo lc sinh, v di chng Rubella bm sinh ch c th xc nh chc chn sau nhiu nm. Thc ra, nhiu tn thng tin trin ko di. Cc khim khuyt v tri gic hoc tm thn - vn ng, ch c pht hin trong qu trnh pht trin vn ng v tm thn ca tr, c khi ch pht hin c tui i hc. Mt, c quan thnh gic, tim, h thn kinh trung ng l cc c quan b nh hng chn lc. Cc d dng thng l nhiu v hay kt hp vi nhau.

146 - Tn thng tn mt: ch yu c thu tinh th hai bn. C th thy mt nh, tng nhn p (glaucome), c m th mi (cornenne). - Thng tn thnh gic: ic, thng mt bn, him khi ic hon ton. y l mt gim thnh lc, iu ng quan tm l ic tng tn s. - Tim bm sinh: c th tt c, nhng thng l tn ti ng thng ng tnh mch v teo hp ng mch phi. - Thng tn thn kinh: chng u nh, chm pht trin tinh thn. - Cc d dng bm sinh khc: rt him, nht l rng (hypoplasie, agnsie de certaines dents, micrognathie). 1.2. Rubella bm sinh tin trin Tng ng vi nhim virus mn tnh ton thn. Virus tn ti cc c quan v hng, gp tr s sinh, rt d ly (trong vng 6 thng). Ni chung chng kt hp vi cc d dng c pht hin khi sinh. S tn ti virus dn n tn thng nhiu c quan tin trin m n c th thoi lui hoc tn ti vi nhiu di chng. Rubella tin trin lc sinh nh cu no km pht trin (pondrale) v ton b bt thng kt hp vi t nhiu tnh cht phc tp: xut huyt gim tiu cu, vim gan c gan lch to vi hong m, vim mng no tng lymph c hoc khng triu chng thn kinh, vim c tim, vim phi k, tn thng xng trn X quang (cc dy trc mtaphysaire mt calci v m). T vong 1/5 ca. V sau, ngi ta c th pht hin cc bt thng v thn kinh, chm pht trin tm thn - vn ng, qua c th pht hin vim no do rubella tin trin. Tin lng xa rubella bm sinh d dt, nht l lin quan pht trin tm thn - vn ng ca a tr trong tng lai. 3. Chn on Thng l cc bng chng hi cu v bnh cnh d dng ca a tr. Trng hp rubella s sinh ring bit, cn tin hnh cc bc sau: - Phn lp virus tr s sinh (hng, nc tiu, nc no tu). - Hin din IgM c hiu lc sinh hoc mt chn on huyt thanh (+) trong vng 6 thng. 4. Phng nga Khng c iu tr c hiu, ch c th chm dt thai k trnh sinh ra a tr d dng hoc nhim virus nng. Xc nh huyt thanh rubella ph n: khm tin hn nhn, khm thai (thai 3 thng u) 4.1. Phng nga cho thai ph huyt thanh (-) hoc khng bit c min dch cha - Cc ph n ny cn c theo di c bit 3 thng u thai nghn v nhiu vn t ra trong 2 tnh hung xc nh sau: + tip xc mt ngi nghi l rubella. + Nghi ng cc triu chng pht ban mt ph n. Ch chn on bng huyt thanh: xut hin mt chuyn i huyt thanh vi IgM c hiu. Cn tin hnh 2 ln xt nghim lin tip cng thi im ti cng phng xt nghim vi k thut tin cy c. - Chn on rubella thai nhi ch thc hin bng cch tm IgM mu cung rn c chc ht di siu m; nhng phi thc hin tun 22 ca thai k. - Cui cng cn phi: + Phng ly cho cc nhn vin chuyn nghip nht l ph n tr lm vic mi trng d ly nhim (y t, gio dc). + Hiu lc ca globulin min dch cn bn ci. + Ch nh chm dt thai k khi xc nh nhim virus rubella 3 thng u thai nghn. - Cc bin php trn s khng cn na khi chng nga c tin hnh cho mi qun th. 4.2. Chng nga trong qun th nc ngoi ngi ta c lch chng theo qui nh + Chng nga c nhn

147 Dng cho ph n tui sinh , hoc xt nghim khng th m tnh, hoc ngi khng c bin php bo v c bit. Cn chng v s ngi mang thai ngoi hn nhn tng m khng kim tra khng th trc mang thai. Do vaccine virus sng gim c lc, cn trnh thai mt thng trc v 2 thng sau chng nga. Cnh gic v chng nga c th gy qui thai, chng ch nh ph n c thai. Tuy n nay cha thy trng hp rubella bm sinh no do chng nga. - Tng cng chng trnh chng nga di dng chng nga ton dn, vi cc mc ch: + Ngn nga s lu hnh virus d ly cho thai ph: chng nga cho tr em hai gii; vi phm vi bao ph tng ln c th khi u vic loi tr bnh rubella. + Duy tr v tng cng chng nga cho tr gi 11 13 tui - Cch tin hnh tim chng tr em: + T 12 thng tui tr i, chng nga c phi hp Si Quai b - Rubella: liu th nht (phi hp hoc khng vi mi nhc li DTCP Haemophilus b c tim v tr khc) + Gia 3 n 6 tui, chng nga mi th 2 Si Quai b - Rubella. + Gia 11 n 13 tui, tip tc tim phng Si Quai b - Rubella vi tr cha c tim phng hoc tin s chng cha mc 3 bnh . V. PHNG NGA - Ch c th phng nga bng bin php chng nga. - C th, chng nga trc mang thai cho ph n tui sinh trnh nguy c cho thai nhi. - Tp th, dng vaccine rng ri tr em lm mt s lu hnh virus v trnh ly cho thai ph. 1. Chng nga Vaccine sng gim c lc (plotkin RA 27/3), c th ch tim mt mi di da hoc bp tht, ring bit (Rudivax) hoc phi hp khng nguyn si v quai b (ROR Vax, Priorix), c th c kt hp vi cc thuc chng ph bin: DTC, polio, BCG. - Vc xin dung np tt: st nh, au khp v pht ban thong qua ngi ln < 5%. - To min dch hiu lc ti a (97%) sau chng bn v n nh. Tim nhc li khng c li d nng khng th sau chng yu hn sau mc bnh; khi khng cn nguy him. 2. Chng trnh tim chng - t 2 mc ch: + p dng rng ri cho tr em hai gii gim ni cha virus, trnh ly cho thai ph. + Bo v ph n tr cha min dch (tin hn nhn) trc mang thai ln u hoc ngay sau sinh. - c p dng cho tr c 2 gii: + Chng nga cho tt c tr tui 12 thng 24 thng, phi hp vi vaccine Si, Quai b ri chng nga li vo tui 3 6 tui (ROR Vax, Priorix); + Chng cho tr 2 10 tui cha c chng, c khi tui nh tr hoc tui tiu hc; + Chng cho tr 12 13 tui, hoc l chng ln u hoc l chng li ln 2; c th vi liu nhc li c kt hp vi DTP, vi BCG; + Chng nga cho ph n tr, c ngh vi trng hp thch hp (t vn tin hn nhn hoc t vn trnh thai), v cc trng hp khng kim tra huyt thanh trc (c bit yu cu vi nhn vin y t). ph n tr, chng nga cn kim sot trnh thai cht ch mt thng trc v hai thng sau chng nga. Tuy nhin, cha c trng hp rubella bm sinh no do chng nga gy nn.

Cu hi n tp
1.Trnh by c im, tnh cht ly, bnh sinh ca virus rubella 2. M t tnh nghim trng ca bnh rubella i vi ph n c thai. 3. Trnh by lm sng v chn on gin bit rubella mc phi vi mt s bnh pht ban. 4. M t cc hnh thi rubella bm sinh. 5. Cch thc phng bnh rubella

148

Bi 23.

BNH VIM NO NHT BN


Ths, BsCK1 ng th Nga

Mc tiu
1. M t c nh ngha , tm quan trng ca bnh vim no Nht bn 2. M t c dch t , lm sng , cn lm sng chnh ca bnh vim no Nht bn 3. Trnh by c nguyn tc iu tr , phng bnh chnh trong bnh vim no Nht bn

Ni dung I.I CNG


1.nh ngha Vim no Nht Bn l mt bnh truyn nhim cp tnh do mt loi virus c i tnh vi nhu m no gy ra. Trn lm sng thng c biu hin hi chng nhim trng v ri lon thn kinh nhiu mc khc nhau, iu ng lo ngi l bnh thng li di chng trm trng v t l t vong cao. 2.Tm quan trng L bnh c bit hn 100 nm trc y . Cui th k XIX lin tip cc v dch xy ra cc vng ni Nht Bn vo ma h- thu vi nhiu bnh nhn nng v t l t vong ti 60 %. Bnh nh hng ti sc khe cng ng, nhng bnh nhn sng st sau vim no c th li nhiu di chng v tm thn , vn ng, kh nng thch ng vi i sng gia nh v x hi b ri lon. ngi ln c nhng ri lon tinh thn v ri lon nhn cch, mt ch, mt kim ch, o gic, mt cc k nng tinh vi trong ngh nghip. tr em c nhng ri lon v tr tu v pht trin tm thn kinh, chm bit ni, khng th ha hp v tip thu bi hc nh cc em cng lp. Ngoi ra tr cn c th km theo yu lit chi lm kh nng thch ng vi x hi cng kh khn hn. Do vy vim no Nht Bn l bnh c tm quan trng x hi to ln, i hi cc bin php d phng c hiu c hiu qu v c cc bin php iu tr thch hp gim ti a cc di chng c th xy ra II. DCH T HC 1.Tc nhn gy bnh Virus Vim no Nht bn thuc nhm arbovirut nhm B, h Togaviridae, ging Flavivirus, kch thc 15 -22 nm. C cu trc ARN; pht trin t bo phi g v t chc nui cy; khng chu nhit , chng b bt hot 56oC trong 30 pht , 100oC trong 2 pht . 2.ng ly truyn Virus c truyn qua mui , ngi l k ch tnh c, ngun ly ch yu l ngi bnh, ln, nga. Khi cm th ngi: tr em , ngi cha c min dch. 3.Mt s c im dch t hc vim no Nht bn B - dch thin nhin: Vim no Nht bn B c khp ni , virus lu hnh trong cc dch cc loi th v chim . Vit nam phn lp c virus t chim liu iu . - Cn trng trung gian truyn bnh : Trong thin nhin virus c truyn t cc vt ch vi nhau v sang ngi nh mui ging Culex (cc chng C.pipiens, C.tritaeniarhynchus, C.bitaeniarhynchus..) l ch yu , ngoi ra cn c th c c ging Aedes (A. togoi, A. Japonicus) c kh nng truyn bnh. - Vit nam loi mui Culex tritaeniarhynchus sinh si mnh vo ma h (nht l t thng 3 n thng 7) , hot ng mnh vo bui chp ti . Loi mui ny c mt cao

149 vng ng bng v trung du , n l vt ch trung gian truyn bnh ch yu bnh vim no Nht bn nc ta. Sc cm th cao vi tr em di 10 tui , ngi ln t l c khng th cao do vy t mc bnh hn. T l mc bnh ng bng cao hn vng rng ni v nng thn cao hn thnh ph. Sau khi b bnh li min dch chc chn v vng bn.

III . LM SNG
1. Triu chng lm sng th thng thng in hnh 1.1.Thi k nung bnh Ko di t 5 n 14 ngy , trung bnh l 1 tun 1.2.Thi k khi pht Bnh thng khi pht rt t ngt vi st cao 39oC - 40 oC hoc hn . Bnh nhn au u, c bit l vng trn, au bng, bun nn v nn. Ngay trong 1 -2 ngy u ca bnh xut hin cng gy, tng trng lc c, ri lon s vn ng nhn cu. V tm thn kinh c th xut hin l ln hoc mt thc. Nhng ngy u phn x gn xng tng, xung huyt gin mch r. mt s tr nh tui, ngoi st cao c th thy i lng, au bng, nn. Tm li trong thi k khi pht c im ni bt ca bnh l st cao t ngt , hi chng mng no v ri lon thc t nh n nng (li b, kch thch, vt v, u m, mt thc hon ton) Thi k khi pht ca bnh tng ng vi lc virus vt qua hng ro mch mu no vo t chc no v gy tn thng nn ph n no. 1.3.Thi k ton pht T ngy th 3 -4 n ngy th 6 -7 ca bnh. Thi k ny tng ng vi thi k virus xm nhp vo t bo no tu gy hu hoi cc t bo thn kinh Bc sang ngy th 3 -4 ca bnh cc triu chng ca thi k khi pht khng gim m li tng ln. T m sng, kch thch, u m lc u dn dn bnh nhn di vo hn m su dn. Cc triu chng ri lon thn kinh thc vt cng tng ln nh v nhiu m hi, da lc , lc ti, ri lon nhp th v tng tit trong lng kh qun do vy khi nghe phi c th thy nhiu ran rt, ran ngy v c ran n. Mch thng nhanh v yu . Ni bt trong giai on ton pht l s xut hin cc triu chng tn thng no ni chung v tn thng thn kinh khu tr. Bnh nhn cung sng, o gic, kch ng, tng trng lc c kiu ngoi thp lm cho bnh nhn nm co qup. Trong trng hp tn thng h thng thp nng c th thy co git cng hoc git rung cc c mt v c t chi hoc lit, lit cng. mt s bnh nhn xut hin trng thi nh hnh, gi nguyn t th. Do ri lon chc nng vng di i lm cho mch nhanh 120 -140 ln / pht , tng p lc ng mch v co mch ngoi vi. Cc dy thn kinh s no cng b tn thng, c bit l cc dy vn nhn ( III, IV, VI ) v dy VII. Ri lon trung khu h hp dn ti th nhanh nng, xut tit nhu kh ph qun v c th thy vim phi m hoc vim phi thu . Soi y mt trong giai on cp tnh thng thy xung huyt gai th, i khi thy c ph n v xut huyt. Bnh nhn ri lon nhn cm mu sc v nh sng, th trng b thu hp Tm li thi k ton pht din ra ngn , bnh nhn nhanh chng ri vo tnh trng hn m su vi ri lon cc chc nng sng . Do vy bnh nhn thng t vong trong vng 7 ngy u . Nhng bnh nhn vt qua c thi k ny th tin lng tt hn. 1.4.Thi k lui bnh T ngy th 7, 8 tr i, lm sng xut hin nhng bin chng v di chng . Thng thng bc sang tun th 2 ca bnh, bnh nhn dn, nhit gim t st cao xung st nh v vo khong ngy th 10 tr i nhit tr v bnh thng nu khng c bi nhim vi khun khc . Cng vi nhit , mch cng chm dn v bnh thng, nhp th khng ri lon. Hi chng no - mng no cng dn dn mt: Bnh nhn t hn m dn dn tnh, trng lc c gim dn v khng cn nhng cn co cng. Bnh nhn ht nn v au u, c mm, cc du mng no cng tr v m tnh.

150 Trong khi hi chng nhim trng , nhim c v hi chng mng no gim dn th cc tn thng khu tr li r hn trc. Bnh nhn c th bi v lit chi hoc lit cc dy thn kinh s no hoc ri lon s phi hp vn ng. Thi k ny c th xut hin nhng bin chng sm nh: vim ph qun, vim phi hoc vim ph qun - phi do bi nhim hoc phi h hp vin tr, ht m di khng v trng, vim b thn, bng quang do thng tiu hoc t sonde dn lu; lot v vim tc tnh mch do nm lu v ri lon dinh dng. Nhng di chng sm c th gp l bi hoc lit na ngi, mt ngn ng, ma git, ma vn, ri lon phi hp vn ng, gim tr nh nghim trng, ri lon tm thn.. T cui tun th 2 tr i l thi k ca nhng bin chng v di chng mun. Nhng bin chng mun c th gp l: vim phi, vim b thn- bng quang, lot nhim trng, ri lon giao cm, ri lon chuyn ho. Nhng di chng mun c th xut hin sau vi nm hoc thm ch hng chc nm m thng gp l ng kinh v parkinson 1.5. Tin lng Bnh c t l t vong cao (25 - 80 %). T vong thng xy ra trong 7 ngy u khi bnh nhn c hn m su, co git v nhng triu chng tn thng hnh no. T vong gai on sau ch yu do cc bin chng c bit nh vim phi, suy kit. Nhng bnh nhn qua khi c th li nhng di chng sut i m hay gp l ri lon tm thn 2. Mt s th khng in hnh 2.1. Th n Khng c biu hin lm sng 2.2 Th ct Ch c hi chng nhim khun , nhim c 3.Th vim mng no Gp tr ln v thanh nin , din bin ging vim mng no do virus khc

IV. CN LM SNG
1.Bch cu mu ngoi vi Nhng ngy u bch cu thng cao 15 000 - 20 000 /ml , trong bch cu a nhn trung tnh tng 75 -85 % , v sau bch cu tr v bnh thng 2.Bin lon nc no ty p lc dch no tu tng, dch trong, protein tng nh (60 - 70 mg %), t bo tng nh (thng di 100 t bo/ml) v lc u l bch cu a nhn, v sau nhanh chng chuyn sang lympho, glucoza trong dch no tu t thay i hoc tng nh (phn bit vi bin lon nc no ty do cc nguyn nhn khc nh vim mng no m , vim mng no lao ...) 3.Phn lp virus Trong 2 -3 ngy u, bnh phm l mu, dch no tu hoc no t thi mi cht trong vng 2 gi 4.Huyt thanh chn on Phn ng kt hp b th (dng tnh t tun th 2) hoc phn ng ngng kt hng cu v phn ng trung ho (dng tnh ko di nhiu thng sau). Phng php min dch men (ELISA) l phng php c p dng rng ri c nhy v c hiu cao

V. CHN ON
1.Chn on xc nh Lm sng : Hi chng nhim trng - nhim c ton thn nng + Hi chng thn kinh + Ri lon thn kinh thc vt nng Cn lm sng: xt nghim c hiu, Phn lp virus hoc phn ng huyt thanh Dch t : ni c dch lu hnh 2.Chn on phn bit - Vim no th pht sau si , cm , thu u , ho g .. thng khi t li di chng - Hi chng no cp : do ri lon chuyn ho dn ti h ng huyt , ri lon nc in gii nng

151 Vim mng no m hoc vim mng no lao

VI.IU TR
1.Nguyn tc iu tr - Khng c thuc chng virus c hiu - iu tr triu chng l ch yu - Nng cao th trng - Pht hin kp thi iu tr phng cc bin chng 2. iu tr c th - Chng ph no: - Truyn dung dch u trng nh dung dch Glucose 10 - 20 -30 % - Cc thuc li tiu nh Manitol 20 % 1- 2 g/ kg tc nhanh. - Trng hp ph no nng c co git th dng corticoid: Dexamethason 10 mg tim tnh mch , sau mi 5 gi tim 4 mg - An thn: Seduxen qua sonde hoc tim bp hoc tim tnh mch . Nu bnh nhn c co git nhiu th dng Gardenal - H nhit: thuc h nhit qua sonde d dy hoc t hu mn loi paracetamol 0,5g x 2 -3 ln / ngy - Hi sc h hp v tim mch : Th oxy , ht m di , h hp vin tr khi ri lon nhp th nng hoc ngng th ,thuc tr tim, iu chnh nc , in gii kp thi - Phng bi nhim v dinh dng chng lot: Khng sinh ph rng, v sinh thn th, rng ming, dng m sao su nm chng lot, ch dinh dng: bo m m, vitamin qua sonde d dy

VII.PHNG BNH
- Tim chng vaccinee phng bnh - Tuyn truyn cc bin php phng bnh cho nhn dn , v sinh mi trng 1.Vaccinee Mc ch chnh ca vaccinee l to c min dch c hiu bo v sc khe Hai loi vaccine bt hot c s dng chng vim no Nht bn, mt loi sn xut t virus mc trn no chut v mt loi kia ly t virus mc trn t bo thn chut Hamster con thun chng. Tim 2 ln cch nhau 7 - 14 ngy, sau 1 nm chch nhc li mi th 3, c mi 3 -4 nm tim nhc li. Tim chng phng nga l bin php gim st gim st thc t nht nhng cn xc nh i tng. Nhng ngi nhy cm nht l nhng ngi i t vng khng c dch n vng c dch nh chu , c bit trong ma ma nn dng vacin. Vit nam tim phng cho tr t 3 n 15 tui 2. Bin php d phng cng ng Khng ch vector truyn bnh l iu kh thc hin i vi vim no Nht bn B.Bin php p dng i vi vt ch l dng virus sng bt hot to min dch cho ln con d phng nhim virus mu. nc ta nn dit mui Culex tritaeniarhynchus, chng mui t c nhn (d thc hin, t tn km, hiu qu cao): V sinh nh ca, ng nm mn, che ph da bng qun o v bi thuc xua mui, c th dng nhng bin php nh dit cn trng trung gian, dit hoc to min dch d phng i vi vt ch t nhin v bo v ngi bng phng php min dch . Nui ln xa nh v ln l cha, mui t ln s lan trn virus i xa Cu hi n tp 1. Trnh by nh ngha, tm quan trng ca bnh vim no Nht bn 2. Trnh by v dch t hc bnh vim no Nht Bn. 3. M t lm sng bnh vim no Nht bn. 4. M t cn lm sng ca bnh vim no Nht Bn. 5. Trnh by nguyn tc iu tr, cch phng bnh bnh vim no Nht bn

152

Bi 24.

BNH DI
Ts, BsCK1 Nguyn L

Mc tiu
1. Chn on c bnh di. 2. Bit cch x tr khi mt ngi b ng vt nghi di cn. 3. Bit c mt s lai vaccine, cch phng di trc v sau khi nhim virus di.

Ni dung I. NH NGHA
Di l mt bnh nhim virus di h thn kinh trung ng. Bnh nh hng n cc ng vt c v v truyn qua vt cn ca ng vt b bnh. Him hoi c trng hp truyn bnh qua ng h hp hoc qua ng ghp c quan. Bnh nng thng gy t vong.

II. NGUYN NHN


Virus di thuc nhm rhadovirus, ging lyssavirus. Ra ngai c th ng vt, virus rt d cht v b tiu dit d dng bi x phng, ether, cc dn xut ammoniac ha tr 4.

III. DCH T
Di l bnh ca ng vt mu nng, c xng sng, ngi ch l vt ch tnh c. C ba dng dch: 1.Dch hoang d Truyn ch yu qua nc bt cc ng vt hoang d. Ty theo vng m c mt vt ch thin nhin khc nhau: co chu u, chn hi M 2.Dch ng ph Ch yu do ch nh . 3.Dch do di Nam M.

IV. NG TRUYN BNH


Ch yu truyn qua nc bt ng vt b nhim bnh . Him hoi truyn qua bi cha phn di c virus. ng vt mc bnh c th truyn virus 5-7 ngy trc khi c triu ch?ng lm sng v ko di cho n cht. Virus ch yu truyn qua vt cn, co. Him c trng hp truyn qua trung gian vt. Virus khng th xuyn qua da lnh.

V. LM SNG
Biu hin lm sng ca di c th chia thnh 4 giai an: tin triu; giai an vim no; giai an ri lan chc nng trm trng cung no, to ra hnh nh lm sng c trng cho di; cht hay rt him, hi phc. 1. Giai an tin triu Giai an ny ko di t 1 n 4 ngy, vi cc du hiu st, nhc u, mt mi, au c, mt mi ngy cng gia tng. C th c bun nn, nn, au hng v ho khan. Triu chng gi n di gi tr nht l d gic v git c ti ch hay quanh vng nghi c virus xm nhp.

153 Nhng cm gic ny c th lin h n s nhn ln ca virus hch sng lng ca dy thn kinh cm gic phn b vng b cn. T l c cc triu chng ny ln n 50 - 80 %. 2. Giai an vim no Giai an ny thng c bo hiu bi nhng thi k vn ng qu mc, kch ng v bt an. L ln, o gic, cng c dng mng no, t th n cong ngi, co git , lit khu tr dn dn xut hin. Cc thi k l ln thng xen k vi nhng thi k han tan minh mn, nhng khi bnh tin trin, thi k minh mn cng lc cng ngn dn v sau cng bnh nhn ri vo hn m. y l mt din bin kh c trng ca bnh. Tng cm gic a n s nhy qu mc vi cc kch thch nh nh sng chi, ting ng n o, s m v ngay c vi nhng cn gi thang nh. Khm thc th c th pht hin bnh nhn st cao, c th n 40,6 . Km theo cc du hiu ri lon thn kinh thc vt nh ng t dn mt cch bt thng, tng tit nc mt, nc bt, m hi, h huyt p theo t th, Cc triu chng lit vn ng cao, tng phn x gn xng v Babinsky (+) l nhng du hiu thng gp. Lit dy thanh m cng l triu chng kh c th. 3. Giai an ri lan chc nng cung no Giai an ny xy ra ch mt thi gian ngn sau giai an vim no. Lit cc dy thn kinh s no gy nn cc triu chng nhn i, lit mt, vim thn kinh th v c bit l kh nut.. Kt hp hin tng tng tit nc bt vi kh nut to nn hnh nh si bt mp in hnh ca di. S nc, co tht khng t v gy au d di ca c hanh, , cc c h hp ph, c hu, c thanh qun khi nut nc, thng gp n 50% trng hp di. Tn thng nhn amydale hnh no biu hin vi cng cng dng vt v xut tinh t nhin. Bnh nhn s ri vo hn m, v khi trung tm h hp b nh hng , bnh nhn s t vong v ngng th.. Cc triu chng ni bt ca ri lan chc nng cung no, khi xy ra sm thng cho php phn bit vi cc vim no khc, nhng ng thi cng bo hiu bnh s xu dn nhanh chng. Thi gian trung bnh t khi xut hin cc du hiu ca giai an cung no n khi cht l 4 ngy. Lu nht l 20 ngy. 4. Giai on cht hay hi phc Hu ht bnh nhn t vong. Mt vi trng hp c hi sc thnh cng v that cht. Tuy nhin sau giai an cung no, nhng bnh nhn may mn phi tri qua nhiu bin chng nh: hi chng tng tit ADH khng thch hp, i nht, lan nhp tim, bt n mch mu, hi chng ARDS, chy mu tiu ha, gim tiu cu, v lit rut. Hi phc rt him, v xy ra t t. 5. Cc th khc ca di 5.1. Lit tun tin dng Landry- Guilliam Barr Th lit thng hay gp nhng bnh nhn mc di t di (Nam M), sau c tim vaccine. Th ny cng thng gp ng Nam . 5.2. Di do ghp gic mc. Trong ngi cho c triu chng ca th lit dng Guilliam Barr. Sau khi t vong, no ngi cho v ngi nhn u c tiu th Negri. V ngi ta phn lp c virus di mt ngi cho c gi ng lnh.

IV. CN LM SNG
Giai an u ca bnh, cc xt nghim mu v sinh ha khng c g bt thng. Tuy nhin, v sau khi bnh tin trin, s c cc ri lan xut hin. Bch cu hi tng (12.000 17.000/mm3), nhng cng c trng hp bch cu bnh thng hay rt tng (c trng hp n 30.000/mm3).

154 Cng nh cc virus khc, chn an dc hiu bnh di da vo : - Phn lp c virus trong dch tit ca c th.(nc bt, dch no ty) hay trong m mc bnh (no) - Huyt thanh chn an giai an cp. - Pht hin khng nguyn ca virus trong cc m b nhim. - Pht hin acide ca virus (ARN) bng phng php PCR. Cc mu no do sinh thit hay ly sau khi bnh nhn cht, thng c dng : - Tim vo chut phn lp vi rut. - Dng phng php khng th hynh quang pht hin khng nguyn ca virus. - Xt nghim t bo hc v m hc vi knh hin vi thng thng v knh hin vi in t ( tm th Negri chng hn). - Pht hin ARN ca virus vi k thut PCR. K thut tim vo chut v phng php khng th hynh quang nhy v ng tin cy. Tuy nhin nu ngi bnh c kh nng ko di cuc sng v xut hin khng th chng virus, qu trnh t v trng ha c th xy ra v hai k thut trn s cho kt qu m tnh gi. Cn xc nh s hin din virus hoc trc tip bng huyt thanh hc hoc bng cch xc nh khng nguyn virus hay ARN khi bnh nhn ang cn sng . Bnh phm ly t sinh thit da, gic mc hay nc bt. Nu bnh nhn khng c tim phng di, hiu gi khng th trung ha tng gp 4 ln cho php chn an dng tnh.Nu bnh nhn c tim chng, c th chn an da vo s hin din ca khng th trung ha dch no ty. Tim phng sau khi b nhim virus di him khi c khng th trung ha trong dch no ty, nu c cng ch mc hiu gi thp (< 1/64). Hiu gi khng th dch no ty mt bnh nhn khng chng dch no ty thng rt cao, t 1/200 n 1/160.000.

V. CHN AN GIN BIT


Rt kh phn bit gia di v nhng vim no khc. Chng c duy nht ngh n di l c tin s b ng vt nghi di cn. Ngai ra ta cn phi phn bit vi cc bnh cnh khc nh : - Hysterie phn ng sau khi b ng vt cn. -Hi chng Landry/Guilliam - Barr. - Bi lit. - Vim no d ng sau khi tim huyt thanh phng di. Bin chng ny xy ra khi dng vacccine c ngun gc t no ng vt c di, thng xy ra 1 n 4 tun sau khi tim vaccine.

VI. IU TR
Trc mt bnh nhn n khm nghi ng di, ta phi xc nh nhng yu t sau : - Bnh nhn c tip xc trc tip vi nc bt hay cc cht khc c kh nng hin din virus di hay khng ? - Bnh nhn c trong vng dch lu hnh ca di khng ? - Tnh trng khi bnh nhn b ng vt tn cng : ng vt c b khiu khch hay khng khi cn bnh nhn. Trong trng hp b ng vt cn, tt nht l gi ng vt li theo di. Nu ng vt b cht, nn gi u ng vt n vin Pasteur gn nht.

155 Nu khng bt c ng vt, tt c cc con vt khng bit tung tch, khng c chng nga di, tn cng ngi bt ng m khng b khiu khch, thay i hnh vi t ngt, hoc c kh nng tip xc vi ng vt khc b di u phi xem nh bnh nhn c nguy c mc di. Trng hp gia sc cn v c th theo di c, nn theo di trong 10 ngy. Nu con vt cht hay c thay i hnh vi, git ri tm virus di bng phng php khng th hynh quang. Nu ng vt vn sng v khe mnh, km theo khng c chng c v dch t trong vng v di, c th xem nh bnh nhn khng b nhim virus di trng thi gian b cn. Tuy nhin trong vng c dch vi lu hnh cao, nn git con vt xt nghim no tm virus.

VII. PHNG BNH


1. Phng bnh sau khi tip xc vi virus di. Gm c : sn sc vt thng ti ch , tim vaccine phng di v nu c iu kin, dng khng huyt thanh chng di. 1.1. Sn sc vt thng ti ch Rt quan trng trong phng chng di. Ra vt thng vi x phng. Ch xt mnh. Sau ra li bng nc. Lm sch vt thng bng c hc hay bng ha hc u quan trng nh nhau. Cc hp cht ammonium ha tr 4 nh benzalkonium chloride 1% hay 4 % hay Bromide cetrimonium 1% u c th bt hat virus di. Tuy nhin, Benzakonium 0,1% khng hiu qu bng dung dch x phng 20 %. Ngai ra, ngi ta dng thm khng sinh v gii c t un vn. 1.2. Min dch th ng vi huyt thanh chng di Huyt thanh chng dI c th t nga hay t ngi. Globulin min dch c ngun gc ngi tt hn ca nga v him khi gy bnh huyt thanh.Liu dng: 20UI/kg vi huyt thanh ngi (40UI/kg vi huyt thanh nga), chia lm hai phn. Mt na tim trc tip vo quanh vt thng. Phn cn li tim mng. 1.3. Min dch ch ng vi vaccine chng di cc nc pht trin, ngi ta thng dng vaccine sn xut t t bo lng bi ca ngi. V d : M, ngi ta dng Imovax cha chng virus di Pitman - Moure, bt hat vi propiolactone. Hoc vaccine ca i hc Michigan, dng chng virus di Kissling cy trn t bo lng bi ca kh Rhesus, bt hat vi nhm. C hai lai u c hiu qu tt, nhng gi thnh t. Tc dng ph ca c hai lai vaccine ny rt him. Ch 1/650 ngi c mn nga. St, nhc u thng nh v ch chim 1 -4 % ngi x dng. Cc phn ng ti ch tim nh sng, da, cng vng tim chim 15 -20 % bnh nhn. cc nc ang pht trin, cc lai vaccine sn xut t t bo phi g, chut hamster, t bo Vero, v t bo phi vt u c x dng rng ri. Cc vaccine ny c v an tan, c tnh khng nguyn v c hiu qu phng bnh. Cch dng : vi vaccine phng di lai t bo lng bi, ngi ta tim 5 ln, mi ln 1ml. Liu u tin tim cng sm cng tt sau khi b nhim virus. V tr tim tt nht l c delta. Cc liu sau theo th t vo cc ngy th 3, 7, 14 v 28. T chc y t th gii cng a ra cc liu trnh 21 v 90 ngy. S phi hp gia vc xanh v khng huyt thanh chng di, s to nn khng th trung ha virus trong hu ht bnh nhn, v c hiu qu rt cao trong phng chng di. Tht bi trong phi hp rt him gp. Tuy nhin, nu ch dng n thun vaccine, t l tht bi cao hn, nht l khi vt cn su v nguy him. V l do kinh t, cc nc ang pht trin, ngi ta thng dng vaccine theo ng tim trong da. Mi liu ch 0,1 ml. Phi hp khng huyt thanh chng di vi liu trnh tim vaccine trong da c chng minh l c kt qu tt trn lm sng.

156 Liu trnh vaccine trong da gm : Ngy u tin tim vaccine trong da 8 v tr. Ngy th by 4 v tr. Ngy th 28 v 91 mt v tr. T chc Y t th gii a ra mt liu trnh khc : Tim trong da hai v tr vo cc ngy u tin, ngy th 3, th 7 v mt v tr vo ngy 21 v 90. 2. Phng bnh trc khi tip xc vi virus di Nhng ngi c nguy c cao tip xc vi virus di nh th y, nhng ngi thm him hang ng, nhn vin phng th nghim virus di, nhng ngi lm cc ngh c tip xc thng xuyn vi ng vt, cn phi tim phng vaccine phng chng di. Vaccine t t bo lng bi ngi l tt nht. Tim ba ln, tim bp (1ml) hay tim trong da (0,1 ml) vo cc ngy 0,7,21 v cn thn c th dng thm liu th t vo ngy th 28. Nhng cc vaccine iu ch bng cch hp ph th khng tim trong da c. Cn kim tra hiu gi khng th trung ha sau khi tim vaccine. Khng nn dng Choloroquin ng thi vi vaccine v n ngn cn s p ng to khng th ca c th. Ty theo mc nguy c, cn kim tra huyt thanh nh k , khang cch t 2 n 6 nm. Khi hiu gi khng th gim xung cn 1/5, cn tim nhc li. Liu nhc li ch 1 ln 1ml tim bp hay 0,1 ml trong da. Vi nhng ngi c tim phng khi c nguy c nhim virus di, ch dn tim li hai mi vaccine t bo lng bi ngi vo ngy u tin v ngy th ba. Khng huyt thanh khng dng trong trng hp ny. Tim nhc li vaccine thng c tc dng ph, gy st, nhc u, au c, au khp chng 20 % bnh nhn. Su phn trm ngi tim vaccine nhc li c phn ng nh l phn ng ca phc th min dch gm : ni my ay, vim khp, bun nn, nn,, v i khi ph mch (angioedema). Cc phn ng ny thng t gii hn v c lin quan n s hin din ca albumin ngi b bin i bi (-propiolactone v c s gia tng khng th IgE vi khng nguyn ny. Nhng ngi cng tc c nguy c cao phi c kim tra hiu g khng th nh k, v tim nhc li bt c lc no hiu gi khng th thp. Nhng ngi t c nguy c cao th khng cn phi kim tra thng xuyn, nhng phi tim nhc li ngay khi c nguy c tip xc vi virus di. 3. Phng bnh chung cho cng ng Phng bnh di cho cng ng nc ta ch yu l phng di cho ch. tim phng di nh k cho ch nh, hng nm. Vn ng ch nui ch dn ch i tim nh k v cp giy chng nhn ch c tim phng di Vn ng, tuyn truyn ch nui ch c bin php hu hiu khng cho ch cn ngi khc ( xch ch nui trong nh. Khi ra ng c eo mm, c dy dn. Khi ch b? bnh, nht l khi c biu hin hung d, thay i thi , hnh vi, tn cng c ngi quen hay bi lit, cn tham kho kin ca th y v nu cn phi git. Nhng ngi c nguy c d b di nh bc s th y cn c tim phng trc. Cu hi n tp 1. Trnh by cc yu t c th nh hng n thi gian bnh ca bnh di. 2. Cc ng ly truyn ca bnh di. 3. X l tc thi mt trng hp b ng vt nghi di cn. 4 . Phng bnh di trc khi phi nhim cho cc i tng no? 5. Cc nguyn tc phng bnh di cho cng ng.

157

Bi 25.

BNH THU U
Ts, Bs Trn xun Chng

Mc tiu
1. Trnh by c tnh cht ph bin v cc yu t dch t ca bnh thy u. 2. M t c triu chng lm sng v cc bin chng ca bnh thy u. 3. Trnh by c cc phng php iu tr bnh thy u . 4. Trnh by c cc bin php d phng bnh thy u trong cng ng.

Ni dung I. NH NGHA
Bnh Thu u l bnh truyn nhim rt hay ly, do mt loi virus gy ra. Bnh c trng bng st, ni ban kiu nt u da v nim mc. Bnh c bi Richard Morton bc s ngi Anh thng bo ln u nm 1694 v c gi l Chickenpox.

II. TC NHN GY BNH


Tc nhn gy bnh l Herpes varicellae hay Varicella-Zostervirus (VZV), thuc h Herpesvirus, c phn lp nm 1952. S d virus c tn nh trn v khi ngi ta phn lp virus t nhng bnh nhn b Thu u v bnh Zona (Zoster) th thy chng hon ton ging nhau. Theo gi thuyt ca Hope-Smpon a ra nm 1965 th Thu u l p ng min dch tin pht ca k ch i vi virus, cn bnh Zona l do s ti hot ng ca virus tn ti trong c th dng tim tng (latent form) cc hch ca thn kinh cm gic.

III. DCH T HC
Bnh Thu u ch ngi. Mi la tui u c th mc, nhng 90% bnh nhn l tr em 1-14 tui. Tr em < 1tui v ngi ln > 19 tui ch < 3% s bnh nhn. Tuy nhin cc nc nhit i tn sut bnh ngi ln thng cao hn. Bnh xy ra khp ni trn th gii, c bit nhng ni dn c ng c nh nh tr, trng hc, khu tp th.... Hoa K mi nm c khong 3 triu trng hp mc bnh Thu u . Bnh thng xy ra vo cui ng, u xun, cao im l vo cc thng 3 - 5. ng ly ch yu l ng h hp qua nhng bt nc bn ra t ngi bnh, mt s t ly do tip xc trc tip vi nt u. Thi gian ly bnh bt u 24 gi trc khi c pht ban v ko di cho n khi cc nt u ng my (7-8 ngy). C th b nhim VZV m khng c biu hin lm sng. Thu u gy min dch vnh vin sau khi b nhim virus ln u, ch c mt t l nh bnh nhn b bnh ln hai.

IV. C CH BNH SINH


Sau khi xm nhp vo c th theo ng h hp, virus tng sinh ti y ri n h vng ni m ri i vo mu n gy tn thng da v c quan ni tng. Ti da v nim mc, cc t bo y v t bo gai ca ni mc vi qun lp sng b phnh to, cha nhiu dch tit, ng thi xut hin nhiu t bo a nhn khng l cha nhiu n th. nhng nt u c cha nhiu dch tit vi nhiu bch cu a nhn, t bo thoi ho, fibrin v rt nhiu virus. Virus cng c th ly qua tip xc trc tip vi ngi b Thu u hoc Zona.

V. TRIU CHNG LM SNG V CN LM SNG


1. Lm sng - Thi k bnh: thay i t 10-21 ngy, trung bnh 15 ngy. - Thi k khi pht: Bnh nhn c th st nh, mt mi, nhc u, i khi c au bng nh. C th xut hin nhng nt hng ban, kch thc vi mm ni trn nn da bnh

158 thng. Thi k ny di khong 24 gi. thiu nin v ngi ln triu chng thng nng hn. Bnh nhn b suy gim min dch thng st cao hn v thi gian khi pht di hn. - Thi k ton pht: Trn da mt, u, nim mc, c, lng ni nhng nt u hnh trn hoc hnh git nc trn vin da mu hng. Nt u c ng knh 3-10 mm, lc u cha mt cht dch trong, sau khong 24 gi th ho c. Chng mc nhiu t trn mt vng da nn ta c th thy chng nhiu la tui khc nhau : dng pht ban, dng nt u trong, nt u c, dng ng my. Cc nt u xut hin lin tc trong vng 5 ngy u tin; chi di l ni cui cng c cc nt u. Nt u c th mc nim mc ming, ng h hp, tiu ho, tit niu, m o, gy ra cc triu chng nut au, kh th, tiu rt... Bnh nhn thng b nga nh, c th st nh hoc khng st. S lng nt u cng nhiu bnh cng nng. Tr nh thng c bnh cnh nh hn tr ln. Nhng ngi suy gim min dch hoc dng thuc c ch min dch ko di c bnh cnh nng n v ko di hn. a s c st cao, ho, au bng, au c. Nt u thng mc nhiu, ko di, dng xut huyt. Cc bin chng thng gp l nhim trng da do vi khun Gram (-), vim phi, vim hch, tn thng a c quan nh phi, gan, thn kinh trung ng... - Thi k hi phc: Sau mt tun, nt u ng my, kh v rng i, khng so. 2. Cn lm sng - Cng thc mu : bch cu bnh thng hoc tng nh. - Huyt thanh chn on : C th pht hin khng th khng virus Thu u bng cc phng php sau : + Test Kt hp b th + Phng php Min dch hunh quang trc tip + Test ELISA v test FAMA (Fluorescent antibody to membrane antigen ) - Phn lp virus t dch nt u.

VI. BIN CHNG


1. Bi nhim Thng gp nhim trng da do Lin cu v T cu vng. Bin chng xy ra do nt u b v hoc da b try xc do bnh nhn gi. Hoi t Thu u (varicella gangrenosa ) do Lin cu nhm A gy ra l mt bin chng rt nng . 2. Vim phi Chim t l 20-30% ngi ln v ngi b suy gim min dch, him gp tr em. Bnh nhn st cao, kh th, au ngc, ho ra mu. X quang c hnh nh tm nhun dng nt v vim phi m k. 3. Hi chng Reye Gp tr ung Aspirin trong giai on u mc. giai on hi phc hi chng Reye xut hin vi triu chng nn ma, ri lon cm gic, kch thch hoc hn m, co git do ph no. Bnh nhn c th c xut huyt ni tng, xt nghim c tng amoniac, tng ng huyt v Transaminase mu. 4. Vim no Triu chng thng gp l tht iu, rung git nhn cu, ma vn, nhc u, c th c co git, hn m. Bnh thng bt u sau khi nt u mc 5 ngy v ko di vi tun, c khi n mt thng. Dch no tu c Protein v bch cu tng, a s l lym ph. T vong khong 5-25%. Cc bin chng thn kinh khc c th gp l vim mng no, p-xe no hoc tu sng. 5. D tt bm sinh Tr em c m b Thu u trong 3 thng cui ca thai k, sau khi sinh ra c th b d tt bm sinh nh so da, teo c, bt thng mt, co git, chm pht trin tr tu...

VI. CHN ON
1. Chn on xc nh

159 Da vo cc c im lm sng v kt qu CLS nh nu phn trn. 2. Chn on phn bit Bnh Thu u cn chn on phn bit vi cc bnh sau : 2.1 Zona: Cng do VZV gy ra. Thng gp ngi ln tui v nhng ngi c tnh trng suy gim min dch: nhim HIV, bnh Hodgkin, Lymphoma, ang iu tr bng cc thuc c ch MD... Lm sng: a dng: zona ngc, zona mt, sau tai, u... - ngc: thng gp nht. Cc nt phng thng ch xut hin mt bn, dc theo cc dy TK lin sn. u tin xut hin cc nt nh, mu hng. Sau chng tr nn trn v to hn, nm thnh tng nhm. Dch c sau 5 ngy v ln sau 10 ngy, li so nh mu hng nht. Zona ngc gy au n cho bnh nhn. Vng da ti ch thng gim cm gic. Tin trin: 2-3 tun. - mt: Thng gp ngi gi. Tn thng mt trong ba nhnh ca dy TK th gic. C th vim gic mc km lit vn nhn. Bin chng thng gp: au ko di sau zona. 2.2 Nt u do HSV (Herpes Simplex Virus): Nhim trng do HSV thng gp trn nhng vng da c sn bnh nh chm, vim da d ng. Bnh nhn thng khng st, s lng v kch thc nt u nh hn. Chn on xc nh da vo phn lp virus. 2.3 Chc l (Impertigo): Do Lin cu tan mu bta nhm A gy nn. Bnh thng xy ra tr em sau khi da b try xc, b tn thng do gh, chm...ri b nhim trng dn n vic to ra nt u.

VII. IU TR
Bnh Thu u tr bnh thng ni chung lnh tnh v t gii hn, khng cn iu tr c hiu. V sinh thn th tt c th hn ch bi nhim. Tr nh cn c ct mng tay v mc o qun mng trnh trt da. 1. iu tr triu chng - Gim nga bng cc loi Antihistamin ( Promethazine, Chlorpheniramine...) - Gim au, h st bng Paracetamol. Khng dng Aspirin tr em. 2. iu tr nguyn nhn Dng cc thuc chng virus nh Vidarabine , Acyclovir, Interferon alpha... - Vidarabine (Adenine arabinoside) : Liu dng : 15mg/kg/ngy, tim TM. C c tnh thn kinh nng n v khng hi phc nn t c dng. - Acyclovir (Acyclo-guanosine): hiu qu chng VZV nhng bnh nhn c c a min dch bnh thng nu c s dng trong vng 24 gi sau khi khi pht. Acyclovir gip gim st, gim cc triu chng ton thn, gim s lng nt u v ko di thi gian xut hin cc nt u mi. Khng nn iu tr cho tr di 6 tui b Thu u cha c bin chng. Liu dng : 7,5-10 mg/kg/ ngy, tim TM mi 8 gi. Thi gian iu tr : 5-7 ngy. - Interferon alpha : c s dng trong iu tr Thu u nhng hiu qu cha c nghin cu y . 3. iu tr bin chng Dng khng sinh trong cc trng hp bi nhim. Bnh nhn c hoi t Thu u phi c iu tr tch cc bng Penicillin, 150-200 mg/kg/ngy, tim TM mi 4 gi kt hp vi ct lc.

VIII. PHNG BNH


- Cch ly bnh nhn cho n khi cc nt u ng my. Bnh Thu u rt kh phng nga v bnh c th ly 24-48 gi trc khi c nt u. - Chng nga :

160 + To min dch th ng: Globuline min dch (VZIG) c th c s dng cho nhng ngi tip xc vi bnh nhn nhng cha c min dch hoc c cc yu t nguy c nh tr b suy gim min dch mc phi, ph n c thai, bnh c tnh, ngi ang dng cc thuc c ch min dch... Liu dng : 125 n v / 10kg, tim bp. Liu ti a 625 v. Thuc ch hiu qu khi dng trong 96 gi sau khi tip xc v c th lp li sau 4 tun. + To min dch ch ng : Ch dng cho nhng ngi b suy gim min dch. Vaccine lm bng virus sng gim c lc. Kh nng to min dch khong 85-95%; thi gian c min dch ko di 10 nm. Bin chng him gp l Thu u hoc Zona nh hoc va. Cu hi n tp 1. ng ly v thi gian ly bnh ca thy u ? 2. Nu c im ca cc nt u trong bnh thy u ? 3. Nu cc bin chng thng gp trong bnh thy u ? 4. Nguyn tc iu tr bnh thy u ? 5. Nu cc bin php d phng bnh thy u ?

161 Bi 26.

BNH QUAI B
BsCK2,Ths H th Thu Vng

Mc tiu
1. Trnh by c tnh cht ph bin v cc yu t dch t ca bnh quai b. 2. M t c cc hnh thi lm sng khc nhau ca bnh quai b. 3.Trnh by c cc phng php iu tr cc biu hin ca bnh quai b. 4. Trnh by c cc bin php d phng bnh quai b trong cng ng.

Ni dung
Quai b l mt bnh nhim virus ton thn cp tnh c trng bi sng tuyn mang tai v cc tuyn nc bt khc do mt loi Paramyxovirus gy nn. Bnh thng gp tr em v thanh thiu nin; bnh ch mc mt ln. Ngoi biu hin vim tuyn nc bt cn co th gp vim tinh hon, vim tu, vim mng no...

I.TC NHN GY BNH


Nguyn nhn gy bnh quai b l vius thuc h Paramyxovirus c hnh cu, khng u,ng knh khong 200nm. Virus c mt lp li hnh xon c kn cha chui RNA c bc trong mt lp v lipid v protein. Virus quai b c hai khng nguyn: khng nguyn S xut pht t mng nhn v khng nguyn V t hemaggglutinin b mt. Khng nguyn V gy bnh v ngng kt hng cu. Hin nay ngi ta ch bit 1 typ huyt thanh Virus quai b rt nhy cm vi mi trng bn ngoi do lp v lipid km bn vng, tn ti 40C trong vi ngy, - 650C t vi thng n nhiu nm

II. DCH T HC
Bnh thng xy ra cui ma Xun, c bit vo thng 4 v 5. Ly t ngi ny sang ngi khc qua ng h hp hoc qua tip xc trc tip vi nc bt. Bnh thng d ly lan nhng ni tp trung nhiu ngi nh vn tr, trng hc, doanh tri b i... Thi gian ly truyn: Nguy c ly truyn cao nht t 6 ngy trc khi khi pht v ko di n 2 tun sau khi sng tuyn mang tai. Ly cao nht khong 2-4 ngy sau khi bnh khi pht. Ngi ta phn lp c virus trong nc bt 7 ngy trc n 9 ngy sau khi khi pht, d cho thi k ly nhim c khi ngn hn. i tng: nam nhiu hn n. Bnh him tr < 2 tui do chng cn c bo v bi cc khng th t m. nh cao t 10-19 tui (tui thanh thiu nin), t gp ngi cao tui. Bnh gy min dch bn vng, d c hay khng c triu chng lm sng. Vit Nam t l mc bnh quai b cn kh cao, tuy nhin c chiu hng gin dn, nm 2002, ti bnh vin bnh nhit i c 121 trng hp quai bi nhp vin v khng ghi nhn t vong

III.SINH BNH HC
Virus quai b xm nhp vo c th qua ng h hp. Trong sut thi k bnh (khong 12-25 ngy) virus pht trin, nhn ln trong biu m ng h hp trn v cc t chc bch huyt vng c. giai on xm nhp, virus theo ng mu n cc c quan khc nh mng no, tuyn sinh dc, ty, tuyn c, gan, tim, thn v thn kinh trung ng, ring tuyn nc bt c l th pht sau nhim virus mu. giai on ton pht, virus c c nh

162 cc c quan tuyn v c quan thn kinh. Virus c thi ch yu qua nc bt, nhng cng c thi qua nc tiu trong nhng ngy u tin ca bnh.

IV.GII PHU BNH


Nhng thay i bnh l c ghi nhn ti tuyn mang tai trong sut thi k quai b cp gm ph t chc k, tm nhun t bo lympho v xut tit cc si tng dch. ng tuyn cha y t bo hoi t v neutrophiles. Nhng tn thng tng t cng c tm thy cc c quan khc nh ty v tinh hon. Trong bi cnh vim tinh hon do quai b ngi ta thy c nhng vng nhi mu v phn ng vim nng n, hu ht nhng vng ny c hin tng t bo biu m sinh tinh b hyaline ha v x ha Khi no b thm nhim, th vim no mng no tin pht vi tiu hy t bo thn kinh hoc thai ha myeline sau vim no c th xy ra.

V. LM SNG
C khong 1/3 trng hp nhim virus quai b khng c triu chng. - Thi k bnh: trung bnh 18-21 ngy (thay i t 12-25 ngy) - Thi k khi pht: trung bnh 24 - 36 gi. Ton thn: mt mi, chn n, au nhc mnh my, st nh, vim hng, au tai ko di vi ngy trc khi sng tuyn mang tai - Ton pht: Bt u sng tuyn mang tai, st gim (chng 380C), au u, c th c cc biu hin triu chng ti cc c quan khc. 1. Biu hin cc c quan tuyn 1.1 Vim tuyn nc bt mang tai v cc tuyn nc bt khc L biu hin lm sng thng gp nht ( khong 70 % trng hp ).Thng t ngt sau thi k khi pht, tuyn mang tai sng t ti a sau 1 - 3 ngy ( c ti liu : 2 - 6 ngy ) v gim dn sau 7 - 10 ngy. u tin ch c sng mt bn, sau c th sng tuyn bn kia. Sng c 2 tuyn chim 2/3 trng hp, mt i khi km sng tuyn nc bt di hm v di li. Tuyn mang tai sng t tai n di hm v lan ra tn g m, mt rnh trc v sau tai. Vng da trn tuyn khng nng v nh trong vim tuyn mang tai nhim trng, c tnh n hi v khng li u n ngn tay. Bnh nhn c cm gic au tai, nht l khi n hoc ung cc thc n c v chua do nghn ng Wharton hoc Stenon. Khm hng thy ming cc l ng tuyn nc bt c th tr nn , ph n v c nhng im xut huyt nh. C th sng cc hch di hm. Sau 1 tun tuyn mang tai gim au v nh dn, cc triu chng au hng, kh nut gim v t t khi bnh 1.2 Vim tinh han-mo tinh han Xy ra 20-30% nam gii sau tui dy th b quai b , him gp tr nh. Trong s ny ch c 15-25% xy ra hai bn; 2/3 trng hp xy ra trong tun l u. Tan thn: St cao 39-410C, n lnh, nn ma, au vng bu, au lan ln bng v i. Thm khm: Vng da bu , nng, tinh han sng to gp 3-4 ln bnh thng. Cc triu chng ny bin mt sau 1-2 tun . Gn 85% trng hp vim tinh han l vim mo tinh han. C 0,5% trng hp teo tinh han v thng l 1 bn, nu teo xy ra 2 bn c th v sinh hoc c th c bt thng v tinh dch. 1.3 Vim ty Gp ngi ln v tr em. Xy ra ngy th 3-7 sau sng tuyn mang tai. Bnh nhn st 39-400C, nn ma, au thng v, bng c khng nh. Phn ln trng hp thng hi phc hon ton sau mt tun. Him gp bin chng sc hoc nang gi tu th pht.

163 1.4 Vim tuyn v v vim bung trng Xy ra n sau tui dy th: Vim tuyn v (7-30%) Vim bung trng (5%): Triu chng gm: st, nn ma , au bng au h chu. Khm vng h chu thy bung trng cng, bin chng v sinh t gp. 2. Biu hin cc c quan thn kinh 2.1. Vim mng no Gp 5 - 10 % trng hp quai b, xy ra 3-10 ngy sau sng tuyn mang tai (c khi 2-3 tun sau). Lm sng thng c mt hi chng mng no c st. Cc triu chng ny gim dn sau 3-10 ngy v thng khi han tan, khng li di chng. Dch no ty c nhng bin i bt thng c th ko di khang 1 thng: Protein bnh thng hoc tng nh, Glucose bnh thng, T bo < 500/mm3, a s l Lympho, c khang 20-25% trng hp c Neutrophile tng. 2.2. Vim no Vim no quai b t xy ra hn, tn sut 0,5%, nam > n, xy ra 7-10 ngy sau sng tuyn mang tai hoc xy ra cng lc. Lm sng : hi chng nhim trng, hi chng mng no v cc du hiu tn thng no : du thn kinh khu tr, l m, hn m hoc co git. Bnh tin trin c khi rt nng v li di chng vn ng v/hoc tm thn, no ng thu, t vong ( 1,5% trng hp). 3. Cc biu hin khc - Vim c tim v mng ngoi tim, - Vim khp, Ri lan chc nng thn. - Vim tuyn gip bn cp, tn thng tuyn c - Biu hin mt: Vim tuyn l, thn kinh th gic, mng b o, kt mc, vng mc, tc tnh mch trung tm thong qua - Tn thng gan: t triu chng lm sng, thng ch ri lon chc nng gan - H hp: Vim thanh kh ph qun, vim phi k, thng gp tr di 5 tui 4. Quai b ph n c thai Trong 3 thng u ca thai k c th gy sy thai, d dng bo thai. Cn trong 3 thng cui c th gy cht lu hoc sm. Kh nng gy qui thai ca virus quai b cn cha r. VI. CHN AN V CHN ON GIN BIT 1. Chn on - tuyn y t c s : Ch yu da vo lm sng v dch t : Bnh nhn c cc triu chng nhim virus, sng tuyn nc bt, vim tinh hon...Trong gia nh hoc lp hc c ngi b quai b trc vi ngy hoc ang b... - tuyn tnh, trung ng: Chn on da vo lm sng, dch t, kt qu xt nghim: + CTM: Trong quai b ch c BC gim nh km tng cc t bo lympho. Trng hp c vim tinh hon hoc tn thng cc c quan khc bch cu c th tng vi a s l bch cu a nhn trung tnh. + Amylase mu v niu : Tng trong vim ty v vim cc tuyn nc bt + Phn lp virus: Virus c th phn lp c t mu, cht tit c hng, nc bt, t ng Stenon, DNT, nc tiu. + Test ELISA, Min dch phng x, Test c nh b th cho php xc nh hm lng cc khng th IgM v IgG nhanh chng v c hiu. 2. Chn on gin bit - Trng hp c sng tuyn mang tai ta cn gin bit vi vim tuyn mang tai do

164 nhim cc virus khc (coxaskievirus, virus cm v ph cm) hoc vi khun (c m chy ra l ca ng Stenon, thng do t cu hoc lin cu ) hoc vim hch bch huyt gc hm do bch hu. - Phn bit vim tinh han do quai b v mt s vim tinh han do nhim khun hay gp l: lu, lao, Lepstospira, thy u , Brucellose...hoc xon tinh hon.

VII. IU TR
Cha c iu tr c hiu, tc dng ln virus quai b. Ch yu l iu tr cc triu chng xut hin trn lm sng: 1.Trng hp ch c sng tuyn nc bt n thun - V sinh rng ming, trnh thc n qu chua, n lng nh,giu nng lng. - Ngh ngi ti ging khi cn st, c th dng cc thuc Paracetamol hoc Aspirin khng vim, gim au v h st. Trnh dng cc thuc khng vim nonsteroid tr em. - C th dng thm vitamine C 1-2 g/ngy/ung. 2.Trng hp c vim tinh han - Ngh ngi tuyt i ti ging, chm lnh, mc qun lt b st.. - Dng thuc gim au v chng vim nh Aspirin v thuc khng vim non-steroid. - Vn dng corticoid ch t ra khi c vim no hoc mng no quai b hoc c vim tinh han trm trng , vim ty . 3.Trong cc trng hp vim ty Cho bnh nhn ngh ngi, truyn dch, nhn n, dng cc thuc gim au, chng nn. 4. Vim no - mng no Bnh nhn phi c iu tr phng cp cu.

VIII. D PHNG
1.D phng tp th Tuyn truyn cho cng ng bit cc du hiu nghi ng quai b v cch phng bnh. Ngi mc quai b phi c cch ly ti thiu 9 ngy khi lm sng c triu chng sng tuyn mang tai, nht l khi bnh nhn trong cc tp th nh nh tr, trng hc ,tri lnh .v.v. 2.To min dch ch ng Vc xin quai b c hiu qu bo v > 95% trng hp c tip xc vi ngun bnh. Vc xin c tim di da liu duy nht 0,5 ml, c th dng n c hoc kt hp vi si v Rubella (MMR: Mump, Measle, Rubella). i tng chng nga l tr >12 thng tr i . Tr em, thanh thiu nin v ngi ln u c th chng nga quai b. 3.Min dch th ng Dng globuline min dch chng quai b. Ch hiu qu trong 4 ngy u sau nhim virus. Liu duy nht 0,3 ml/kg cn nng, tim bp cho i tng cha c min dch hoc ph n c thai.tip xc ngi bnh. Cu hi n tp 1. Trnh by cc yu t dch t ca quai b 2. c im vim tuyn nc bt ca quai b 3. Trnh by mt s biu hin thng gp ngoi vim tuyn nc bt ca quai b 4. iu tr mt trng hp quai b c vim tinh hon 5. Trnh by cc bin php phng bnh c hiu ca quai b

165

Chng 4. CC BNH DO NHIM K SINH TRNG


Bi 27.

BNH ST RT THNG
Ths, BsCK1 ng th Nga

Mc tiu
1. M t cc chu trnh ca tc nhn gy bnh v c ch bnh sinh ca bnh st rt 2. Chn on sm bnh st rt trong cng ng v phn bit vi mt s bnh khc 3. Phn bit tc dng ca cc thuc iu tr st rt thng thng 4. Hng dn thc hin cng tc phng chng st rt trong cng ng .

Ni dung
St rt l mt bnh ly thng gp v l mt vn lu tm cho cc nc sng gia khong 60 v Bc v 40 v Nam nh Nam M, Phi Chu, ng Nam . Bnh do k sinh trng Plasmodium gy nn v c truyn t ngi ny sang ngi khc qua vt t ca mui Anopheles. Ngy nay c khong 2 t 700 triu ngi sng trong vng dch t st rt v khong 400 triu ngi st rt hng nm trong c khong 2 triu ngi cht

I. TC NHN GY BNH, VECT TRUYN BNH


1 Tc nhn gy bnh 1.1 Loi Plasmodium C chng 140 loi Plasmodium, nhng ch 4 loi gy bnh cho ngi l P.falciparum, P.vivax, P.malariae v P. ovale. Plasmodium falciparum l nguyn nhn gy st rt nng v t vong. nc ta P. falciparum 70 - 80% P. malariae 1% P. vivax 20 - 29% P. ovale (nc ta khng c, chu Phi). 1.2.Chu trnh pht trin Plasmodium pht trin 2 giai on: giai on hu tnh mui, giai on v tnh ngi. - Giai on hu tnh Mui Anopheles ci t ngi mang k sinh trng st rt ht mu, vo trong d dy mui mu c tiu ho. Nu hng cu c giao t c v giao t ci (gametocytes), khi hng cu b hy s phng thch ra dng cc phi t (gametes), cc phi t phi hp nhau thnh hp t (zygotes); hp t pht trin thnh non ng (ockinites) ri nang (ocytes), nang bm cht vo thnh d dy ln ln ri thnh cc t bo hnh kim c gi l thoa trng (sporozoites), chng n thc qun ri khu tr tuyn nc bt mui, khi mui t chng s vo c th ngi. Giai on ny ngn hay di ty vo nhit mi trng, mui v loi k sinh trng, trung bnh khong 7-21 ngy. - Giai on v tnh: c 2 chu k. * Chu k ngoi hng cu: 30 pht sau khi vo c th, cc thoa trng xm nhp vo t bo gan, pht trin thnh th t dng (trophozoites), ri th phn lit (schizontes), chng ph v t bo gan v thnh cc tit trng cn gi l tiu th hoa cc (merozoites) vo mu xm nhp hng cu. Chu k ny di 5-7 ngy vi P. falciparum, 10 -15 ngy vi P. vivax . + i vi cc tiu th hoa ca P. falciparum sau khi vo mu khng tn ti trong gan na, cho nn khng gy ra ti pht xa.

166 + i vi cc tiu th hoa cc ca P. vivax mt s vo mu mt s cn tn ti trong t bo gan (cn gi l th ng) song song vi chu k hng cu, gy cc t ti pht xa. * Chu k hng cu: Cc tiu th hoa cc vo mu s xm nhp hng cu, ri pht trin thnh t dng, ri th phn lit, ri thnh tiu th hoa cc. Cc tiu th hoa cc ph v hng cu (gy st) ri vo mu v xm nhp hng cu khc to mt chu k mi v c th ngy mt trn ngp nhiu hn trong mu nu khng iu tr. Chu k ny thay i 24 - 48 gi cho P. falciparum (cn st cch nht c tnh); 36-48 gi cho P. vivax (cn st cch nht lnh tnh) 2.Vect truyn bnh: Mui Anopheles ci l vect truyn bnh v l vt ch tm thi. Trn th gii, c chng 60/400 loi c th truyn bnh st rt. Nc ta c 4/50 loi truyn bnh: - A. minimus: vng nc chy ni rng su trong c nc. - A. dirus (balabacensis): vng rng t ranh gii Ngh An, Thanh Ha vo min Nam - A. sundaicus: Vng bin nc l Nam b. - A. subpictus: Di Linh, Lm ng Nhn chung, nhng loi mui ny sng vng ni, va trong nh, va ngoi tri. Sinh sn nhiu v ma ma, v rt d khng vi cc thuc dit mui thng dng nh malathion, DDT. Anopheles ci t v ht mu ngi, ri u mt ni tiu ha v ch trng chn, bay tm ch , sau bay i tm mi (Anopheles thng hot ng vo na m v sng 22gi - 4gi). Mi ln mui chng 100 - 200 trng, trng pht trin thnh b gy - lng qungri mui trng thnh. nhit ti u 20 -300C, mui Anopheles sng chng 4 tun l, thi gian ny cho Plasmodium c th hon chnh chu k hu tnh mui (khong 10 -16 ngy). iu ny gip cho Anopheles tr thnh trung gian truyn bnh v vt ch tm thi.

II. DCH T HC
1. ng ly truyn Bnh st rt ly truyn qua nhiu ng - Mui t l ch yu - Truyn mu b nhim k sinh trng. - Dng chung kim chch c dnh mu mang KSTSR khng tit trng (rt him, ngi s dng ma ty), - Qua nhau thai m c KSTSR (+) c m t mt s nc. 2. Cc yu t nguy c 2.1.Mi trng t nhin & sinh hc - Nhit mi trng: ti u 20 - 300C - m mi trng: > 50% - Ma: trc, trong, sau ma ma (nc ta t thng 4 - 10 hng nm) - V tr a l: ni i, cao nguyn, rng rm hoc ven bin nc l, ph hp vi iu kin sinh thi ca vect - S nhy cm ca vect i vi ha cht ang s dng 2.2.Yu t kinh t - x hi - Tui v gii: mi la tui v mi gii u c kh nng mc bnh - Phong tc tp qun: thi quen ng khng c mn, ng ry ca ng bo dn tc, di chuyn a im sng hoc hnh hng trong ma l hi. - Mc sng: ngho nn, lc hu, thiu n, dinh dng km, n tm b. - Ngh nghip: ngh nghip d tip xc vect nh lao ng vng rng ni, khch du lch. - Nhng hot ng c kh nng tng st rt: o h ao, pht trin thy li, thy in, khai hoang rng tre na li gc

167 - Cc yu t lm d cho bnh nng: ph n c thai, tr em, ngi cao tui, nghin ma ty, suy gim min dch

III. MIN DCH ST RT


Trong 30 nm qua, do tm kim vc xin hiu lc m min dch st rt c nghin cu su hn. 1. Min dch t nhin - Ngi khng mc bnh do cc loi Plasmodium chim, b st v gm nhm. - Ngi c HbF, HbS v HbC (homozygous C) c min dch t nhin vi P. falciparum. - Ngi Phi chu v M da en thiu khng nguyn hng cu nhm Duffy - l yu t khng t nhin vi P. vivax nn him b nhim P. vivax. 2.Min dch th c - p ng min dch thu c khi mc st rt c 2 tnh cht chnh l tnh ghi nh v tnh c hiu. Ln u tin tip xc vi KSTSR h thng min dch ghi li cc thng tin. Khi tip xc ln 2, h min dch p ng l nh thng tin ghi nhn vo ln u. vng dch t st rt, tr con di 6 thng tui c min dch th ng qua nhau thai t m, trong thi gian ny nu tr nhim KSTSR th khng c triu chng lm sng do c th c khng th v tr t to c khng th, sau 6 thng tr ht khng th ca m bo v th c th t chng vi bnh c. - S nhim KST lin tc s to cho c th mt p ng min dch i vi st rt m ngi ta gi l hin tng tin min dch (premunition). Trong ln s nhim vai tr min dch ch yu l hin tng thc bo. Trong ln ti nhim, min dch t bo tr nn rm r hn, mnh m hn nh cc lympho T c mn cm vi khng nguyn t trc. Ngoi ra cn c s ng gp tch cc ca cc Lympho B ghi nh, vai tr ca khng th, nht l IgG, IgM v IgA. Tuy nhin IgG tng cao hn IgA v tn ti lu hn. Trong huyt thanh, nng IgG cao s chng li cc tiu th hoa cc xm nhp hng cu, do KST d dng b cc i thc bo tiu dit. - c tnh trng min dch ny, h lin vng ni m c th phi hot ng ht sc tch cc, phn nh trn lm sng l gan, lch ln. Lch c mt vai tr c bit trong bnh st rt, lch l ni tp trung v dit cc hng cu b nhim KSTSR, nh cc Lympho T v Lympho B cng cc cht gy c t bo khc. - Nh c hin tng tin min dch, lng KSTSR s duy tr mc thp trong mt thi gian di, m khng c triu chng lm sng. Min dch c hiu cho tng loi Plasmodium. - Qu trnh hnh thnh min dch ny i hi mt thi gian kh di phi vi nm v i hi phi ti nhim lin tc. Do nu khng ti nhim kch thch min dch th tnh min dch s gim dn v xut hin triu chng lm sng (gp ngi ra khi vng dch t st rt). Min dch cng gim ngi mang bnh c tnh, ct lch, suy gan hoc mang thai...Nh vy, min dch th c trong st rt l min dch khng bn.

IV. TNH HNH K SINH TRNG KHNG THUC


1. Xc nh nhy v khng thuc - Nhy cm: Sau 48 gi iu tr, mt k sinh trng gim 75% so vi ngy u, ri sch hn vo ngy 6 7, khng xut hin li trong 28 ngy sau iu tr. - Khng: I (RI): sch k sinh trng nh trng hp nhy cm, nhng xut hin li trong 28 ngy. II (RII): mt k sinh trng gim 75% sau 48 gi, nhng khng ht hn trong tun u. III (RIII): mt k sinh trng khng gim m tng trong 48 gi u, hoc gim < 75%

168 2. K sinh trng khng thuc trn th gii Hu ht cc vng st rt lu hnh trn th gii c k sinh trng khng thuc cc mc khc nhau (73/95 quc gia v lnh th, theo thng bo ca WHO,1994). - Plasmodium falciparum khng thuc Khng vi quinin c pht hin 1910 Brazil. Khng vi Proguanil v pyrimethamin t u nhng nm 1950. * Khng vi Chloroquine 1960 bin gii Columbia v Venezuela, tip n Thi lan nm 1961. Khng vi Amodiaquin 1961 Brazil. Fancidar Thi lan 1980. Khng vi Mefloquin Thi lan nm 1982 v tng nhanh v sau, v c khng cho vi halofantrin. Khng vi Artemisinin v dn cht ch thy trn m hnh ng vt th nghim 1985 (P. Bergei). - Plasmodium vivax khng thuc Khng vi Fansidar c thng bo nm 1979. Khng vi Chloroquin c thng bo ln u 1989. Khng vi Amodiaquin gp (thng bo 1996). Cha thy thng bo khng quinin hoc mefloquin 3 Nguyn nhn khng thuc 3.1 Nguyn nhn ch yu - p lc thuc: dng nhiu mt loi thuc trong thi gian di cng ng rng s to iu kin KSTSR bin d, hoc thch nghi dn gy ra khng thuc tng ln. Hin tng khng c th mt i sau mt thi gian ngng dng. - Di bin ng dn c: lm cc chng khng thuc lan ra. 3.2 Hu qu khng thuc - Kh iu trt tit cn - Bnh st rt d din tin nng - Kh khn phng cc v dch st rt - Chi ph iu tr v phng bnh rt tn km 4 Bin php phng chng khng thuc 4.1 Nga khng - Hng dn v gim st iu tr ng liu ti c s - Truyn thng cng ng bit t chn on v hng dn iu tr liu thuc - Tng cng kim tra KST bnh nhn v iu tr tit cn, liu, khng p dng iu tr phng on - La chn phc nhy cm, dng liu - Gim st k sinh trng khng thuc. 4.2 Bin php x tr i vi k sinh trng khng thuc - Tm phc chng khng (ti u l phi hp thuc - Qun l tt ngun bnh, trnh mm bnh khng thuc lan truyn - y mnh iu tr tit cn, ngng dng thuc b khng - Nghin cu sn xut thuc mi.

V. LM SNG
1. Lm sng st rt in hnh 1.1. bnh Thay i ty loi k sinh trng; 7-10 ngy i vi P. falciparum, 14-17 ngy i vi P. vivax, i khi lu hn. Khng triu chng. 1.2.Khi pht Trong st rt tin pht (mc bnh ln u) c th khi pht theo nhiu cch: - St cao lin tc.

169 - St nh, c cm gic n lnh, - St nh, nhc u v tng dn (biu hin nh thng hn) - St cn, c chu k (t gp). Qua giai on ny, bnh i vo thi k ton pht, hoc cn st c th dt nhng vn tn ti k sinh trng trong mu. Khi c iu kin s xut hin st cn tr li 1.3.Ton pht c im cn st: cn st rt c 3 giai on v c tnh chu k - Rt run: hoc l ch cm gic n lnh dc xng sng v vai, cn rt run c th t 15 pht n 1 gi, tng ng giai on cng giao cm. - Giai on nng: nhit tng cao 39 - 400C, c th t 30 pht n vi gi. - Giai on v m hi: nhit gim, v m hi, d chu. Gia 2 cn st, bnh nhn vn bnh thng, c th sinh hot. Cn st c chu k. Vi P. falciparum v P. vivax u l st cch nht nhng P. vivax l st cn cch nht lnh tnh. Tuy nhin trong thc t lm sng c khi cn st xy ra hng ngy cho c hai loi trn, do hai chu k ca KSTSR gi u nhau, iu ny c cng ng khoa hc chp nhn. - Ton thn: + Nhiu t hng cu b ph v s gy thiu mu, vng mt, tiu vng. + Gan, lch thng to ra. - Din bin: Nu khng c iu tr tch cc bnh s din bin nng, 85% do P. falciparum, nhng vi P. vivax v P. malariae c th ng nn c th chuyn sang ti pht gn hoc xa. Nu iu tr v phng bnh tt s hn ch ti pht v ti nhim, bnh nhn thng hi phc tt khng li di chng, nht l khi bnh nhn ra khi vng dch t st rt lu hnh 2.St rt nhng c a c bit 2.1.Ph n c thai Khi mang thai c tnh trng gim min dch, nn rt d bc pht bnh hoc d ti pht nu c sn KSTSR trong ngi. Bnh nhn d h ng huyt khi mc bnh do P. falciparum v dng quinin. Khi chuyn d, tuy lng KSTSR gim xung sau khi sinh nhng bnh nhn li d chuyn sang st rt c tnh, chuyn d ko di, xut huyt, suy h hp. Bnh nhn mc st rt d sy thai, sinh non, cng gp tr s sinh thiu cn, hoc st rt bm sinh. 2.2 Tr em Lm sng st rt tr em thng a dng, triu chng t r nt nht l tr nh, c th st, i ma, tiu chy, gan lch sng. Tr nhim bnh thng ko di, suy dinh dng v thiu mu, d mc st rt c tnh. 2.3.Nghin ma ty v suy gim min dch C th gp st rt th gi lnh, st khng r thng km tiu chy v h ng huyt, ko mu pht hin k sinh trng tnh c. T vong cao. 3. Bin chng - Bin chng trc mt: Khi nhim P. falciparum d xy ra st rt c tnh nu khng iu tr ng cch v sm. . - Nu lu trong vng dch t st rt. B ti pht v ti nhim nhiu ln s dn n mt s ri lon chc nng ca mt s c quan nh Gan: Ri loan chc nng gan. Lch: lch to l c trng ca bnh nhn st rt trng din. V vy lch to c s dng lm ch s nh gi v mt dch t hc st rt. Ngoi ra s gia tng chc nng qu mc trong p ng min dch c th dn n bin chng cng lch. Ton thn: ph, thiu mu, suy dinh dng, thiu vitamin...

VI. CHN ON
1 Cn lm sng - Cng thc mu: hng cu gim, Hb bnh thng hoc gim. Bch cu bnh thng, c th tng bch cu nht l khi st rt c tnh (khng c hiu).

170 - Ko mu tm KSTSR trn git c v git n. - Chn on huyt thanh: Ch c gi tr nghin cu hn l chn on v iu tr. 2 Chn on sm da vo - Bnh s: tm yu t dch t st rt - Lm sng: cn st in hnh, gan lch to, thiu mu - Ko mu tm KSTSR. - Test nhanh (tm Pf. HRP2 i vi P. falciparum; cn (+) 14 - 21 ngy sau iu tr thnh cng) 3 Chn on phn bit t ra nht l khi k sinh trng m tnh. St dengue, cm cm, nhim trng huyt, thng hn, nu c vng mt - da cn phn bit vi leptospira, nhim trng ng gan mt,v.v. C khi phi iu tr th loi tr khi khng c phng tin xt nghim. 4 nh ngha ca bnh 4.1 Xc nh ca st rt : C k sinh trng st rt trong mu: - Nhum gim sa (+). - Hoc test nhanh (+) i vi P. falciparum. Bao gm: - St rt thng - St rt c tnh - Ngi mang k sinh trng lnh trong 7 ngy qua v hin khng st. 4.2 Ca st rt lm sng (nghi st rt) t ra i vi bnh nhn khng c xt nghim mu, cha c kt qu xt nghim hoc xt nghim mu (-) v c 4 c im sau: - Hin ang st ( 37,50C) hoc st trong 3 ngy va qua. - Khng gii thch st do cc nguyn nhn khc. - ang hoc qua li vng st rt trong 6 thng gn y. - p ng tt vi thuc st rt trong vng 3 ngy.

VII . IU TR
1. Nguyn tc - Chn on sm, iu tr sm, liu lng. - iu tr nguyn nhn: ct cn sm, tit cn tt, chng ti pht v chng ly lan. - iu tr ton din - Dng thuc an ton, ng liu trnh khng thuc 2. Cc thuc chng st rt 2.1 Quinin - Thuc r, t b khng, dit tt cc th v tnh trong hng cu, ung hp thu hon ton, khng b ph hy rut, nng cao sau 3 gi, bn hy 10 gi. - Thuc c th gy tai, chng mt, nhc u, nn, i Hb (ngng thuc ngay), h ng huyt, tim bp d gy p xe. - Liu: 10 mg/kg mi 8 gi . Hoc 1,5-2 g/ ngy, tng liu < 15 g/ t tn cng. 2.2. Choroquine (nhm 4 amino quinolein) - Vin chloroquin diphosphate 0,25g (150mg base chloroquin) hoc dung dch (0,2g) tim bp, tnh mch. Chloroquin sulphate (Nivaquin) vin 0,1g. Amodiaquine vin 0,2g. - Thuc dit th v tnh trong hng cu, nhng hin b P. falciparum khng nhiu ni trn th gii. Thuc cn dit giao t P. vivax v P. malariae. - Tng liu mi t tn cng < 2,5g. Ung 4v-4v-2v. Tnh mch hoc tim bp thng thng 0,6g - 0,4g - 0,4g 2.3. Primaquin (Nhm 8 aminoquinolein: vin 13,2mg, cha 7,5mg base): - Thuc dit giao bo (chng ly) liu duy nht 30mg (4 vin/ ngy) chia 1 hoc 2 ln. - Chng th ng P.vivax (chng ti pht) liu 7,5 mg x 2vin / ngy x 10 ngy

171 - Tc dng ph: i Hb ngi gim men G6PD, n km, nn, tm mi. Khng dng cho ph n c thai v tr < 4 tui. 2.4. Tetracycline: Dit th v tnh trong cu nhng ct st v sch k sinh trng chm, d b khng nn phi phi hp thuc. Liu tetracyclin 1g/ngy x 7 ngy, hoc doxycycline 100 mg/ngy x 7 ngy. 2.5. Nhm Diamino pyrimidin i din pyrimethamin, thng phi hp vi sulphamide chm (fansidar = sulphadoxine + pyrimethamin). Tc dng yu v chm, tc dng ch yu trn th v tnh ngoi hng cu. 2.6.Mefloquin (quinoleine methanol) - Dn xut 4 amino quinolein; vin 250mg. Tc dng tt vi v tnh trong hng cu v thoa trng P. falciparum. - Liu duy nht 1250- 1500 mg/ngy chia 3 ln: gi u 750 mg, cch 8 gi 500 mg, 8 gi sau 250 mg (3-2-1). Khi phi hp artesunate th liu trnh nh sau: 3 ngy u liu artesunate l 4v - 2v - 2v; ngy th 3 dng mefloquin 3 vin (750mg) liu duy nht. - Tc dng ph (lin quan liu lng) gm: bun nn, chng mt, c khi ri lon tm thn v co git. C th gy chm nhp xoang nn chng ch nh dng chung vi cc thuc c ch (hoc c ch calci). Khng dng cng quinin hoc quinidin v gy tng c tnh. 2.7. Halofantrin Thuc tan nhanh trong m, vin 250mg, 500 mg. Ung khi i, tc dng gn ging mefloquin. Liu 500mg x 3 ln cch nhau 6 gi, liu duy nht, t nng nh 6 7 gi. (quinghaosu v dn cht) Quinghaosu c ly t cy Artemisina annual (Trung quc, rng Ty bc nc ta). Tc dng dit nhanh k sinh trng v tnh trong hng cu, thuc tt nh lm sch nhanh k sinh trng mu, t tc dng ph v r. Ngoi ra cn tc dng c ch giao bo, chng hng cu nhim k sinh trng kt dnh lin bo ni mch v to hoa hng Hin nay, song song vi quinin thuc dng rt hiu qu iu tr st rt. Tuy nhin, thi gian bn hu nhanh, nn d ti li, v vy cn phi hp thuc. - Artesunate (theo pht mi ca B Y t nm 08/2003) + Vin 50 mg x 4 vin / ngy u; cc ngy sau ung 2 vin/ny (6ngy) (liu 800mg) + ng 60 mg, dung mi Bicarbonate natri 5%. Tim tnh mch: 1 ml dung mi ho thuc lc k thuc tan hon ton sau thm 5ml mui ng trng. Nu tim bp khng cn thm dung dch mui ng trng, liu u 2,4mg/kg (2 ng); 24 gi sau tim nhc li 1,2mg/kg (1 ng); sau mi ngy tim 1 ng cho n khi bnh nhn tnh ri chuyn sang ung liu thuc. 2.9 Vin st rt CV-8 Thuc dng iu tr st rt khng bin chng t l khi bnh cao, t ti pht. Vin CV8 c 4 thnh phn: 32mg dihydroartemisimin (DHA) + 320mg piperaquin phosphat + 90mg trimethoprim + 5mg primaquin phosphat. Liu ngi ln: 4 vin/ngy u chia 2 ln: 2vin gi th nht v 2vin gi th 8; 2 ngy sau mi ngy ung 2 vin (tng 8 vin). 3. iu tr c th Cc thuc iu tr st rt sn c ti y t c s, pht min ph, d thc hin cng ng. 3.1. iu tr ct cn Dng thuc dit k sinh trng v tnh trong hng cu. Nn phi hp 2 thuc trnh P. falciparum khng thuc. - Vi P. falciparum ct cn st l tit cn: u tin l quinine, artesunate hoc CV-8 - Vi P. vivax dng chloroquine hiu qu tt (tuy nhin, khi khng nm chc k sinh trng, nn iu tr nh P. falciparum)

172 3.2. iu tr tit cn t ra i vi P. vivax, P. ovale: chng ti pht xa bng primaquin 7,5mg x 2v/ngy x 10 ngy dit th ng. 3.3. Chng ly lan Primaquin 7,5mg x 4v/ngy, liu duy nht khi c giao bo trong mu. 3.4 Nng cao th trng Ch n giu dinh dng: m, ng, m v vitamin. Truyn mu ti ch khi hng cu v th tch huyt cu gim qu nng. 3.5. iu tr triu chng H nhit v an thn t ra khi st cao v c nguy c co git nht l tr em. iu tr cc triu chng khc.

VIII. PHNG CHNG ST RT


Tc hi ca st rt i vi kinh t - x hi rt ln. Nu u t mt cch tha ng th vic phng chng s c hiu qu. phng chng st rt tt cn tin hnh cc bin php sau: 1.Tuyn truyn gio dc cng ng tham gia phng chng st rt ti vng bnh lu hnh, tuyn truyn gio dc l bin php cn thc hin thng xuyn, lin tc do cn c s phi hp lin ngnh, dng mi phng tin truyn thng i chng. 2.Nng cao sc kho cng ng Cn ci thin ch dinh dng, ch lao ng ca dn sng vng st rt lu hnh, nht l ph n c thai, ngi gi v tr em. V vy, cn chm sc sc kho ca nhn dn, nng cao i sng vt cht tinh thn, pht trin sn xut 3.Vc xin phng st rt: hin ti vn cha c v xin s dng. 4.Ha d phng Ung thuc phng (ha d phng tp th): bin php khng c tn thnh, v dng thuc ko di s gy p lc thuc, lm k sinh trng d khng thuc, chi ph cao, khng c iu kin dng thuc lin tc... Cho nn, ung phng ch p dng cho ngi c nguy c mc bnh nh ngi cha c min dch st rt hoc vo vng st rt trong mt thi gian ngn: ngi i cng tc, du lch th dng: mefloquin 250 mg x 1v / tun. Dng 2 tun trc lc vo, lc v 6 tun sau khi ra khi vng dch. 5. Cc bin php phng chng vect Ni chung, cc bin php phng chng vect cn p dng ni c vect, cc bin php thch hp c dng gm: 5.1. Ci to mi trng Lm v sinh ngoi cnh, khi thng cng rnh, lp cc ao t nc ng, pht quang, v sinh chung gia sc... loi tr ni mui sng. Vic pht trin kinh t - x hi i km pht trin cc h thng thy li, xy h cha nc, thy in ... to iu kin cho mui truyn bnh pht trin, v vy, cn theo di v gam st cht ch mt mui, b gy, nht l khi c s hin din ca mui truyn bnh trong vng , c bin php khng ch thch hp. 5.2. Bo v c nhn Bin php c dng rng ri v d thuyt phc nht: nm mn , rm, vng tm permethrine. Nu c p dng ng k thut v gio dc nhn dn vng st rt c thi quen nm mn tm s gim c t l mc bnh. 5.3.Bin php sinh hc dit b gy, lm gim mt vect nhng vng st rt khng n nh. Bin php ang c thc hin l dng Bacillus thuringiensis H14 v c (trm c, r phi, by mu, sn st... ) th vo ao h, cc ni c nc. 5.4 Phun thuc tn lu Hin nay vect khng nhanh cc thuc phun. Bin php ny trong thc t gim s lan truyn bnh m khng lm gim t l mc bnh. Thuc phun phi an ton, khng mi v

173 vt phun c nhn dn chp nhn, ga c hp l vi iu kin kinh t ca dn vng st rt. Cu trc nh ca cng nh hng n hiu qu ca bin php ny, v d: nh phi kn, c din phun, tng nh phi ph hp vi tn lu ca ha cht. Do cn chun b ha cht v dng phun theo khuyn co ca WHO. Trong y t cng ng, phun tn lu cn chn thuc tan trong nc, thuc hin ang dng ICON. Tuy nhin, hin ang c gng gim dn phun ha cht tn lu; ch thc hin cc bnh vng trng im, vng st rt lu hnh nng v ni khng p dng c tm mn bng permethrine. Tm li: St rt l mt vn ln ca cc nc trong vng nhit i. Vic chn on bnh sm v ng, iu tr sm, liu v c bin php phng chng tt v ton din s khng ch c bnh st rt n mc thp nht. Cu hi n tp 1. M t cc chu trnh ca tc nhn gy bnh st rt 2. Trnh by c ch bnh sinh ca bnh st rt 2. M t cch chn on sm v chn on gin bt bnh st rt. 3. Lit k v phn bit tc dng ca cc thuc iu tr st rt thng 4. Trnh by cch hng dn cng tc phng chng st rt.

174

Bi 28.

BNH ST RT C TNH
Ths, BsCK1 ng th Nga

Mc tiu
1. Xc nh c cc i tng v iu kin c nguy c cao xy ra st rt c tnh 2. Phn tch c cc bin i ca hng cu trong bnh cnh st rt c tnh 3. D bo cc du hiu chnh trn lm sng ca st rt c tnh. 4. Phn loi cc th lm sng ca st rt c tnh. 5. Gio dc, kin ton mng li y t a phng gim t l st rt c tnh. 6. Thit k pht iu tr mt s th lm sng ca st rt c tnh.

Ni dung I.I CNG


St rt c tnh l mt tnh trng nhim KST st rt nng n c nhiu bin chng nhiu c quan quan trng nh no, gan, thn, phi...nguy c t vong cao. St rt c tnh do Plasmodium falciparum gy ra v vect truyn bnh l mui Anopheles ci.

II. DCH T HC
Nguy c xy ra st rt c tnh (SRAT) nhng iu kin sau: - Ngi cha c min dch, cha b st rt ln no hoc mc di 6 ln (t l 97,2%) - Dn tc kinh chim a s hn dn tc t ngi (t l 93,4%) - Ngi mi vo vng dch t st rt di 6 thng d b hn ngi sng lu (t l 81,7%) - Tui 16 -30 (t l 74%) - Lm rng ry, lao ng nng hoc ang di chuyn hnh qun - Nh xa trm x hoc pht hin mun v iu tr mun - ang c dch st rt xy ra trong vng chim t l 51,2%

III. C CH BNH SINH


1. Cc c im ca P. falciparum khi xm nhp vo hng cu - Plasmodium Falciparum c kh nng xm nhp vo hng cu mi la tui: non, tr, gi, do c th 40 -50% hng cu b nhim KST. Mt KST cng cao cng c nhiu bin chng - Khi xm nhp vo c th, KSTSR c kh nng gii phng ra c t, bn cht c t l glycosyl - phosphotidin - inotide - lipide lm hng cu d v - So vi cc loi Plasmodium khc th trong mt hng cu s lng cc merozoide (tiu th hoa cc) c th gp i. C th l c th ln n 16 -32 merozoide/1 hng cu trong khi i vi P.vivax ch l 6 - 12 merozoide / 1 hng cu - Khi xm nhp vo bn trong hng cu mt s KSTSR nh P. Falcifarum to nn cc nt li (knobs )trn b mt cc hng cu. Cc nt ny s gn vo cc receptor tng ng b mt cc lin bo ni mc ca mch mu su to nn hin tng kt dnh hng cu b nhim vi cc t bo ni mc mch mu gy nn tc mch nht l no Cc protein nt li lm chc nng nhn bit cc receptor l: Pf.EMP1 ( Plasmodium Falciparum Erythrocyte Menbranous Protein 1) Pf.EMP 2 ( Plasmodium Falciparum Erythrocyte Menbranous Protein 2) Pf.HRP1 ( Plasmodium Falciparum Histidin Rich Protein 1)

175 Pf. HRP 2 ( Plasmodium falciparum Histidin Rich Protein 2) - Hng cu b nhim KSTSR (th tropozoide gi ) c th dnh cc hng cu khng mang KSTSR to ra hin tng hoa hng d gy tc mch (khng xy ra vi P. vivax). 2. Cc bin i chnh ca hng cu khi b nhim KSTSR - B mt hng cu xut hin cc n li nn khng trn, d dnh v gy tc mch. - n hi mng HC gim - mt kh nng mm do nn kh n mao mch su. - Mng hng cu tng tnh thm i vi Natri lm cho hng cu d v gy tn huyt - bn ca mng hng cu gim st do khi th phn lit pht trin nhiu d v hng cu, c bit nhng ngi thiu men G6PD. C th tm tt c ch bnh sinh ca SRAT nh sau:
P.falciparum

trong hng cu
Lm v cc HC b nhim KSTSR Gii phng c t To hoa hng Kt dnh

Ph hu hng cu khng mang KST

c ch h hp t bo

Lp mch v ng mu ni mch

Thiu Oxy c quan Bng 10: Tm tt c ch bnh sinh

3. Bin i cc c quan 3.1 Ton thn - St: do tc dng ca sc t st rt v c t KST tit ra tc ng ln trung tm iu nhit v do tc dng ca cc lymphokin c tit ra t cc i thc bo khi phn hy mnh vn hng cu v KSTSR. - Thiu mu: V hng cu hng lot m c ch ni trn - H ng huyt: do + Tng nhu cu s dng oxy v glucose ca c th . + Tng nhu cu glucose do phn hy glucose theo con ng ym kh. + Gan khng to c glucose t glycogen v tn to glucose t cc cht khc. + Vic s dng quinine s kch thch o langerhan ca ty tit insulin gy h glucose mu. + n ung km. - CIVD: Nghn mch to iu kin cho CIVD cc trng hp nng. Trong cc trng hp ny phc hp V, VII, VIII, X gim km vi gim tiu cu v fibrin cng nh gim prothrombin gy chy mu nng. 3.2 Cc c quan: Ni chung l do hin tng thiu oxy do c ch bnh sinh m t trn.

176 - No: c 3 thng tn chnh l tc nghn cc mao mch, ph n v xut huyt quanh cc mao mch + Nghn mch l hin tng ph bin nht, nhng hu nh khng li di chng khi khi bnh. + Thiu oxy no lm cho qu trnh chuyn ha glucose no chuyn sang con ng ym kh sn sinh ra nhiu sn phm chuyn ha d dang trong lactate gia tng d di trong st rt c tnh th no, phn nh qua dch no ty c s gia tng lactate. + Trong cc trng hp nng s thiu oxy lu s dn n hin tng ph n v xut huyt quanh cc mao mch, c bit c quan st no ca cc bnh nhn t vong - Thn: Thng tn ng thn do i Hb. Thiu oxy gy hoi t v thn, lm ri lon chc nng bi xut nc tiu v suy thn. - Gan: Tng hot h thng vng ni m thc bo, phn nh qua s tng sinh cc t bo kuffer v cc lympho histocytes khong ca. Nghn mch gy thiu mu, thiu oxy, cc t bo phnh to, hoi t km mt t bo gan chung quanh cc tnh mch trung tm - Phi: Do c tnh ca KST cng cc cht lymphokine ca i thc bo gii phng ra s gy tng tnh thm mao mch lm thot dch gy ph phi.

IV. CC TH LM SNG
pht hin sm mt st rt thng c nguy c chuyn sang st rt c tnh, phi theo di cc du hiu u tin: - St lin tc ko di koc nhiu cn k tip nhau, v m hi nhiu - Mt ng nng > 2 ngy, nhc u nhiu . - Ri lon tinh thn nh thong qua hoc thnh thong mt nh hng khng gian, thi gian. - Li b hoc kch thch vt v. - Mt KST cao: 1 -10 KST/ vi trng. - Nn nhiu hoc a chy. T chc y t th gii a ra cc tiu chun chn on SRAT bao gm: 1. Trong SRAT th no phi hn m t nht giai on 2 (glasgow 7 im cho ngi ln v 2 im cho tr em ). 2. Co git ton thn > 2 cn /ngy 3. Thiu mu : Hematocrit < 15 - 20 % hoc hemoglobin <5 -6 g/l 4. Suy thn: S lng nc tiu < 400ml/24 gi, hoc 12 ml / kg /24 gi 5. Ph phi vi du hiu suy h hp cp. 6. H ng huyt: Glucose mu < 2,2 mmol/ lit ( 0,4 mg%) 7. Try tim mch. 8. Chy mu hay ng mu ri rc ni mch. 9. Toan chuyn ha. 10. i Hb khi lng ln Ngoi ra cn c cc tiu chun ph, nhng khi nhng tiu chun ph ny ng ring r th khng iu kin khng nh SRAT: 1. Tri gic u m, cha hn m 2. 2. Mt k sinh trng trong mu: > 5%. 3. Vng da: bilirubin mu > 50 mmol/l hoc > 30 mg%. 4. St cao > 41oC hay h nhit < 36oC. 1.St rt c tnh th no nc ta, st rt no chim 55% trong s st rt c tnh. Gi st rt c tnh th no khi bnh nhn hn m 2 tr ln (glasgow < 7 im ) km du thn kinh ni bt l co git. 1.1 Thi k khi pht - C th t ngt st cao lin tc hoc st cn, nhng nhiu cn lin tc k tip nhau. - Ri lon tri gic, ri lon thc, li b hoc kch thch cung sng.

177 1.2 Thi k ton pht - St vn tip din - Cc du hiu thn kinh ni bt vi li b ri i vo hn m, co git. - Hn m thng trng thi nm yn, gim trng lc c, nhng khi c tnh trng tn thng no gia s c tnh trng dui cng mt no (tay dui, chn dui) hoc co cng mt no (2 tay co, 2 chn dui, lng un cong, mt ngc nhn ln) thng nng. - Co git: thng xy ra cn co git ton thn ngn theo kiu ng kinh hoc cc du tn thng thp hoc ngoi thp nht thi, nu hi phc khng li di chng. - Cc du hiu ton thn khc + Ri lon h hp: tng tit m gii, ri lon nhp th, m ri lon tun hon . + Tit niu: Tiu t, ure creatinin mu c th tng. + Gan, lch c th ln, vng da nh. - Cn lm sng: + Cng thc mu: hng cu gim, c th thy hng cu non mu ngoi vi. Bch cu bnh thng c khi tng nht l neutrophile + Ko mu tm KSTSR + C ri lon v men gan: SGOT, SGPT tng, bilirubin tng 1.3 Tin trin v tin lng - Din bin tt khi + ang hn m bnh nhn t ngt la ht vt v + Cc phn x (gn xng, da bng, da bu, m mt) gim hoc mt xut hin tr li . + Nhit h dn, mch v huyt p n nh + Bnh nhn tiu nhiu hn - Din bin xu khi + Hn m ngy cng xu hn v ko di trn 3 ngy km mt phn x nut + Co git nhiu km nhng cn ngng th tm ti + St cao lin tc hoc h thn nhit km ri lon tun hon, huyt p tt kp. + i t hoc v niu + Nn nhiu, ra dch nu hoc mu Thng t vong trong tnh trng suy h hp hoc suy tun hon 2. St rt c tnh th i Hb Thng xut hin sau cn tn huyt t ngt, gii phng lng ln Hb t do, nc tiu c Hb (lc u mu hng, v sau mu nu en) km theo thiu mu cp v vng mt nh. St rt i Hb thng xut hin nhng bnh nhn sng vng dch t st rt hoc b st rt nhiu ln c th c thi gian hnh thnh min dch. Trong trng hp ny cc hng cu cha k sinh trng st rt bin dng thay i cu trc v c th sn xut ra cc khng th khng hng cu lm v hng lot cac hng cu nhim v khng nhim k sinh trng st rt Bnh nhn thiu G6PD mc st rt c th i Hb khi iu tr quinine hoc primaquine. Lm sng thng biu hin: - Khi pht t t vi st khng r hoc t ngt vi st cao, nn ma nhiu ra nc vng xanh, nhc u v c bit l au vng h hng, tiu vng m - Ton pht: St lin tc hoc thnh cn, thiu mu lm sng nhanh nh nim mc mt nht mu, da xanh, vng nh sau m dn tng ng vi cc t tn huyt km mt mi, suy nhc; nc tiu t vng sm chuyn sang mu nu en m nh b c ph. - Gan, lch to ra - Cm gic au m vng lng km nn i. Nu tnh trng tn huyt trm trng c th tt mch v huyt p, thiu niu, ri v niu. Thng t vong trong bnh cnh suy thn Cn lm sng - Mu: Hng cu gim, bch cu bnh thng c khi tng cao ch yu neutrophiles Hct gim. C th khng thy k sinh trng st rt.

178 - Nc tiu: Hb niu (+), khng c hng cu nguyn vn, sc t mt (+) - Ure, creatinine mu tng (nhiu hay t ty mc tn thng thn) - Bilirubin ton phn tng trong ch yu l bilirubine gin tip. - G6PD c khi gim hoc mt hon ton. Din bin v bin chng - Nu iu tr ng, tch cc cc t tn huyt gim i nc tiu trong dn v lui bnh - Bin chng thng gp v nng nht l suy thn cp do vim tc ng thn; t vong do ri lon chuyn ha v ion, tng kali mu, toan chuyn ha. 3. St rt c tnh th gan mt - Sau thi k khi pht, bnh cnh lm sng nng n vi st cao, da mt vng m, nn nhiu, nn ra mt, c khi nn ra ln mu bm - Gan to, au tc - Xt nghim chc nng gan cho thy: Bilirubin tng, t l prthrombin gim, SGPT, SGOT tng. Cc xt nghim ny x hi phc khi khi bnh . 4. St rt c tnh th phi Ch yu l du hiu ph phi vi kh th, tm ti, th nhanh 40 -50 l/ph, khc m c bt hng, nghe phi y phi c rales m to v nh ht. Tin lng chung: theo GS. Trnh kim nh (bnh vin Ch Ry) nh gi tin lng chung nh sau: Nhm I: SRAT th no n thun, t vong 0 -10% Nhm II: Th ph tng n thun: t vong 0 -20 %. Nhm III: SRAT th no+ bin chng 1 ph tng t vong 0 -20 %. Nhm IV: SRAT th no + > 2 ph tng: t vong 50%.

V. IU TR V D PHNG
SRAT l mt bin chng nng do P. falciparum .V cha c vaccine phng st rt v bin php ha d phng tp th khng p dng trong vng c dch st rt lu hnh, do lm gim t l SRAT v t vong cn: - Nng cao mc sng ca ngi dn vng dch t st rt gim nguy c mc bnh - Ci thin ch lao ng hp l. - vng bnh lu hnh, gio dc qun chng phng chng bnh gim t l mc. - T chc v kin ton mng li y t c s pht hin trng hp bnh, iu tr ng - liu s gim s st rt thng chuyn sang st rt nng. - C s theo di v qun l i tng c KSTSR (+) v iu kin lm vic, sinh hot ca h. Ko mu nh k pht hin KSTSR. - Ti n v iu tr, SRAT cn chm sc, iu tr sm, ng gim t l t vong. Nguyn tc iu tr st rt c tnh - Phi lm gim v dit KSTSR trong mu cng sm cng tt bng thuc khng st rt nh quinine v artesunat nht l tr con v ph n c thai - Chm sc v hi sc nh mt cp cu ni khoa: chng ph no, co git, suy thn, suy h hp, thiu mu, ph phi, suy gan, cn bng in gii toan kim, chng bi nhim. iu tr c th 1. SRAT th no 1.1 Chm sc theo di - Bnh nhn hn m: t t th nm nghing, ht m gii ng th thng thong. - Chng let cc im tip xc bng xoa bp, thay i t th hoc k m hi. - V sinh hng ngy 1.2 iu tr nguyn nhn: Cc thuc chng st rt l phng tin c sn trm x, r tin, d c cng ng chp nhn Dng thuc khng st rt: Thuc ngh c dng u tin l Quinine v Artesunate ( dit KST nhanh v t khng ) giai on u thuc hon ton ng tnh mch

179 - Quinine chlohydrate hoc dichlohydrat: 8 -10 mg /kg /8h pha vo dung dch glucose 5% hoc chlorua natri 9%O chuyn TM XXX /1 pht. Ln u tin c th dng liu ti 20mg/kg nu cha dng quinin trc . Tip tc trong 2-3 ngy u . Khi ra khi hn m, chuyn bin tt, chuyn sang ng ung cho tng liu(<13,2 g). - Artesunate: Trong st rt c tnh lun lun phi phi hp artesunate vi mt loi thuc khng st rt khc. C th dng ng tim bp, tim tnh mch hoc ung qua sonde d dy hoc nht hu mn . Thng th dng artesunate 60 mg TB hoc TTM, tng liu <400 mg. Gi th 1: 2ng. Sau c 24 gi tim 1 ng n khi bnh nhn tnh th chuyn sang ung 7 ngy.(phc ca B Y t) - C th dng Artesunate: vin n t hu mn: 100mgx3 vin/ngy n khi bnh nhn tnh th chuyn sang ung cho 7 ngy 1.3. iu tr h tr - Chng co git: Phenobarbital 0,2g x 1 ng tim bp khi ln cn Seduxen 10 mg x 1 ng TM - Chng ph no: bng cc dung dch u trng glucose 20% hoc manitol 20% - Chng suy h hp do ng m di v ph phi. - B dch v cn bng in gii: ch bnh nhn lun lun b e da bi hin tng ph phi, ph no v suy thn, nhng cng d b tnh trng thiu nc do st cao, nn, nh hng n tun hon. Do bnh nhn phi c theo di bng in gii v o p lc tnh mch trung tm (CVP).Dch vo thng l Ringer, glucose 5%, chlorua natri 9%o, c th dng glucose 10 % nu c nguy c h ng huyt. - Chng bi nhim nht l khi nm lu v c can thip cc th thut nh t sonde, t catheter, CVP ... Thng dng khng sinh c ph khun rng. 2.iu tr st rt i huyt sc t bnh nhn i Hb cn hi tin s, bnh s, dng thuc v xt nghim tm KSTSR. - Nu bnh nhn ang iu tr vi mt thuc st rt no v i ra Hb th xem xt li v ngng thuc , thay bng thuc khc; ng thi lm xt nghim tm men G6PD . Nu khng thy thiu men G6PD th c th tip tc dung quinine, artesunate . - Lun lun theo di mu sc v s lng nc tiu mi 8 gi v tng lng nc tiu 24 gi, c gng duy tr lng nc tiu t 1,2 -1,5 l / 24 gi. - Phi lun lun nh nguy c cao ca SRAT i Hb l vim tc ng thn dn n suy thn do phi theo di v gii quyt trit khu ny bng: - Thuc li tiu: ch s dng sau khi b dch m khng c nc tiu hoc tiu t. Thuc c s dng l Furosemide: liu khi u 40 mg TM. Sau nu vn khng c nc tiu th ty tnh hnh m tng dn liu 80 mg, 160 mg... - Nu vn v niu c th hoi t ng thn cp cn theo di ure, creatinine mu, in gii v chc nng ng mu ton b chy thn nhn to lc cn. - Corticoide: c th kim sot c cn tn huyt, dng Depersolon 100 mg hoc hydrocortisol hemisucsinate 200 mg/ ngy, cho n khi nc tiu trong. - Vic truyn mu tt nht nn kim tra hng cu v Hct thng xuyn, khi thy 2 tr s ny tt nhanh chng (Hct <20%, HC <2 triu) phi t ra ngya nn truyn mu ti. - Cn bng nc - in gii v toan kim: da bilan nc, kim ha nc tiu trnh Hb kt ta lng ng ti ng thn. Tm li SRAT l mt bin chng nng ca st rt P. falciparum, chn on sm, iu tr ng, cng nh tuyn truyn vn ng phng chng st rt s gim t l t vong SRAT. Cu hi n tp 1. Trnh by cc iu kin v cc i tng c nguy c cao st rt c tnh.

180 2. Trnh by cc bin i hng cu trong st rt c tnh v cc d bo st rt c tnh trn lm sng. 3. Phn loi v m t cc th lm sng st rt c tnh. 4. Trnh by cch gio dc, kin ton mng li y t nhm gim t l st rt c tnh. 5. Thit k pht iu tr mt s th lm sng ca st rt c tnh.

181

Bi 29.

BNH L AMIP
BsCK2,Ths H th Thu Vng

Mc tiu 1. Xc nh c nguyn nhn v mt s c im dch t hc ca l amip 2. M t c lm sng, cn lm sng v bin chng ca l amip cp v mn 3. Chn an sm v iu tr ng phc phng bnh din sang mn tnh. 4. Xc nh c cc bin php phng bnh Ni dung I. I CNG
Bnh amp l mt bnh ph bin nc ta cng nh trn th gii v l mt bnh quan trng v n nh hng n sc khe ca nhn dn Nhim Amip l tnh trng mang Entamoeba histolytica c hay khng c triu chng lm sng. Theo t chc Y t th gii , bnh amip c phn loi nh sau : - Bnh amip khng triu chng - Bnh amip c biu hin lm sng: + Bnh amip rut: L amip, Vim i trng mn, U Amip, Vim rut tha do Amip + Bnh amip ngoi rut: Bnh Amip gan, phi, no, lch, da ... L amip l tnh trng nhim trng rut gi do E. histolytica,

II. BNH NGUYN


1. Hnh thi Entamoeba gy bnh cho ngi tn ti ba dng: 1.1 Th hot ng n hng cu ng knh 30-40 micromet sng trong vch i trng, tng trng tt di iu kin k kh, s hin din vi khun khc gip cho amip pht trin, tm thy trong phn bnh nhn l cp tnh, c gi tc, trong t bo cht c khng bo, hng cu v 1 nhn. 1.2. Th khng n hng cu Tm thy trong phn ngoi giai on cp tnh, ng knh 14-16 micromet, cc gi tc di chuyn chm, trong t bo cht khng c hng cu, ch c vi trng v glycogen. 1.3. Th bo nang (kn) ng knh 10-15 micromet, hnh cu, chit quang, kn non c mt nhn, kn trng thnh c 4 nhn . 2 . H thng enzym Amip c gy hoi t m nh enzym tiu hy protein t chc (hot tnh ging pepsine,trypsine, hyaluronidase). Th dng bo gy c bch cu, nh vy m chng mi vt qua hng ro t chc lympho rut n cc ph tng, khng c ni hay ngoi c t. 3. c tnh sinh bnh ca Entamoeba histolytica

182 Sau khi nut, kn amip vo n rut non nguyn vn, khng b tc dng ca dch v.Ti rut non, di tc dng ca dch tiu ha, mng bc kn b v ra, bo nang 4 nhn bin thnh 8 nhn, t phn chia ra thnh 8 Amip. Th khng n hng cu k sinh trn nim mc rut, n vi trng v cc b thc n, c th chuyn thnh dng tin kn ri kn hay chuyn sang th n hng cu

III. DCH T HC
1. S phn b a d Bnh Amip l mt bnh ph bin nc ta cng nh trn ton th gii, nm 1981 t chc Y t th gii cho bit c khong 480 triu ngi mang kn amip trong phn. Trc y s ngi mang kn amip cn cao hn v c xp th 3 trong danh mc cc bnh ton cu. Hin t l nhim Entamoeba histolytica trn th gii khong 10 % ( 1-69 %), hng nm c khong 10.000.000 b nhim vi 30.000 - 40.000 ngi t vong. cc x nhit i, t l nhim amip 25-40%, c ni ln n 50-83 % nh Phi Chu, Nam M, Ai cp, Vin ng, Mecico t l 25-40%, Colombia (Medellin) ,50% Costa Rica( San Jose 72%). vng n i mc sinh hot cao (u Chu, Bc M ) s ngi b nhim di 5%, Vit nam t l ngi lnh mang mm bnh c ni ln n 25%, theo thng k ca thnh ph H Ch Minh trung bnh 8%.Thng k ca bnh vin Vit tip 15,46% ( tp san nghin cu khoa hc tp II, 1996) Triu chng lm sng khc nhau tlin quan n mt s yu t nh: vng kh hu n i thng nh hn vng nhit i, yu t chng tc (nng i vi ngi chu Phi), sc khng ca c th, tu thuc chng amip, cc yu t dinh dng, cc vi khun cng sinh rut.
Khu vc Chu Chu Phi Nam M Chu u Nhim amip % 3-47 2-11 2-72 2-5 Bnh amip % 14 2 1 0,1 Amip gan % 25 5 1 1

Bng 11:T l nhim Entamoeba histolytica, mc bnh khc nhau cc vng trn th gii.

2. Tui - gii Tuy cc la tui u c th mc bnh nhng hay gp cc la tui 15-65 (81%), nhiu nht 20-30 tui, nam nhiu hn n (Nouvelle caledonic 76-79) 3. Tnh hnh kinh t - x hi Bnh thng gp x nng vng nhit i, c bit cc nc c iu kin sinh hot thp km, mt mt do kh hu thun tin cho vic truyn bnh, mt khc do tnh trng v sinh ngoi cnh thp ( cha gii quyt tt phn nc rc ), n ung khng cht dinh dng . 4. Ngun bnh Ngi mang kn amip l ngun ly duy nht: ngi bnh, ngi va khi bnh, ngi lnh mang kn l ngun ly quan trng nht. Trong phn ca bnh nhn va c th dng bo, va kn .Th dng bo d b tiu hy, tri li kn c sc sng cao . Marion v Sweetsir nghin cu trn 1000 lnh M th tm thy 168 ca c amip trong - Ngi lnh mang kn amip khng triu chng : 76,2% - Bnh amip kinh nin : 20,2 % - L amip cp : 3,6 % 5. Phng thc ly truyn 5.1 Ly gin tip

183 L ng ly ph bin, mt ngi bnh c th thi qua phn vi triu kn c khi 300 triu kn. Liu nhim bnh khong 1000 kn c khi ch 1 kn. Trong ngoi cnh kn sng rt lu, trong phn lng 12 ngy, trong t 10-20 ngy, trong nc 10-30 ngy. Nc di 50 , ha cht chlor, iode nng thp khng dit c kn. Ngi nhim amip khi nut phi kn trong thc n b nhim, nc ung khng chn. Rui, cn trng trung gian truyn bnh nguy him. Thy 3/4 rui trong nh ngi b l amip c mang kn (Frye v Meleney (1936)). Kn c th sng chn rui 48gi. 5.2.Ly trc tip T ngi sang ngi do tay bn, kn c th tn ti 5 pht bn tay, 45 pht di mng tay. Dn, chut lang, kh, ch, ln cng mang kn amip nhng t khi truyn bnh cho ngi. 5.3.Ly qua ng tnh dc Thng xy ra nhng qun th ng tnh luyn i nam. 6. C th cm th Trong cc vng kh hu nng v m, nhim amip kh trnh, c ngi sau khi nut kn nhng khng tr thnh ngi mang k sinh trng, c l do thng bng trong mi trng rut khng b ri lon ( vai tr vi khun ch rut, cc cht xut tit, c bit cc khng th ca rut), c ngi b ti nhim nhiu ln v mang amip mt thi gian di nhng khng biu hin bnh l, cn li l nhng ngi s tr thnh ngi bnh sau khi nut kn 1 thi gian di hay ngn ty vo mt s iu kin nh: lao ng qu sc, thay i tit ch, suy gim min dch.... 7. Hnh thi dch - Vng bnh amip lu hnh, v sinh phn nc km, bnh c th bc pht thnh dch nh, c bit nhng ngi mi n c tr, sng tp th, thnh thong c th pht thnh dch ln nu gp iu kin thun li no nh v dch nm 1933 Chicago vi 1400 ngi mc v 100 ngi cht do nc cha kn amip . - Vng n i bnh ch c tnh cht tn pht l t . 8.Yu t nguy c - Chng amip: Nhiu tc gi cho rng chng amip vng ng Nam c c tnh cao hn cc vng Bc Phi, cc chng amip ni a vng n i thng khng c c lc - S ri lon vi khun ch rut . - S suy gim sc khng ca c th .

IV. BNH SINH V GII PHU BNH


C th tm thy trong lng rut c th kn ln th hot ng ca amip, nhng ch c th hot ng c kh nng xm nhp. Trn ng vt, cc hin tng nh ph hy lp nhy, vim lan to v v hng ro biu m rut xut hin trc khi th hot ng tip xc trc tip vi nim mc rut gi. Th ny tip xc vi cc t bo tit nhy v biu m ca rut gi nh cht lectin c ch galactose (galactose-inhibiting lectin). Tn thng rut sm nht l cc vt vi lot nim mc manh trng, rut gi sigma, hay trc trng, gii phng hng cu, cc t bo vim v cc t bo biu m. Soi trc trng pht hin cc vt lot nh vi b chng ln nhau, xen k vi vng nim mc bnh thng. Vt lot n xung tn nim mc, to nn hnh nh c in hnh cc o, trong c th tm thy amp ni giao tip gia cc m lnh v m hoi t. Trong giai on cp c th c s xm nhim cc t bo trung tnh, nhng hu ht trng hp ngi, rt t cc t bo vim, mt phn c

184 l do b th hot ng ca amp thc bo. Cc vt lot c iu tr s lnh v khng ln so. Tuy nhin mt s trng hp c th hoi t su v thng rut. Him hn, c th to thnh khi gi l u amp trong lng rut. Lp nim mc bc quanh mng v d lot trong khi cc lp khc th dy, ph v xut huyt. U amp l do phn ng thnh lp m ht u th km vi mt t m si. Mt s yu t gy c gip E. histolytica c th xm nhp cc biu m gia cc tuyn. Mt enzyme ngoi bo l cystein proteinase c th thoi ha colagen, cc cht n hi, IgA tit v cc thnh phn b th gy phn v nh C3a v C5a. Cc enzyme khc cng ph v cc cu ni glycoprotein gia cc t bo biu m nim mc rut. Amp cn ly gii bch cu trung tnh, bch cu n nhn, lympho v cc t bo biu m ca rut gi v gan. Tc dng gy tiu t bo ca amp i hi phi tip xc trc tip vi t bo ch v lin quan n s gii phng phospholipase A v cc peptide to l thng mng t bo. p xe gan lun lun xy ra sau khi c nhim amp rut d c th khng c triu chng. Cc mch mu b tn thng sm do hin tng tiu cc thnh mch v thnh lp huyt khi.. E. histolytica n gan qua tnh mch ca, v c kh nng khng vi c ch tiu t bo qua trung gian b th, nh n c th tn ti khi vo mu. E. dispar b ly gii bi b th nn n ch khu tr ti rut. a trc tip amp vo gan chut hamster, thy c xm nhim cc t bo vim, ch yu l a nhn trung tnh. V sau, cc t bo trung tnh s b ly gii khi tip xc trc tip vi amp. Cc enzyme trong t bo trung tnh gii phng ra s gp phn lm hoi t cc t bo gan. Vng hoi t c bao quanh bi mt vng mng cc m gan xung huyt. Cht hoi t trong lng p xe gan amip thng c m t c mu s c la, mc du mu sc c th thay i v thng l cc mnh vn v trng vi rt t hay khng c t bo no. Nhim amip khng gy min dch, nhng mc l hay p xe gan nhiu ln cng t gp. Cc khng th khng bo v oc ti nhim. Hiu gi khng th lin quan n thi gian mc bnh hn l trm trng ca bnh. Nghin cu trn ng vt cho thy min dch trung gian t bo ng vai tr quan trng hn trong bo v vt ch mc du bnh nhn AIDS khi nhim amp khng nng hn ngi bnh thng.

V. LM SNG V TH LM SNG
Bnh amip c th c hoc khng triu chng, c khi bin mt t nhin. V vy kh xc nh thi gian nung bnh. Sau khi nut kn c th khng mc bnh hay bnh pht sau vi tun, vi thng hay vi nm, cng v lu biu hin i trng thnh mn tnh, triu chng a dng kh chn on bnh nguyn l amip . 1. Th cp din 1.1. Thi k bnh : kh xc nh 1.2. Thi k khi pht Thng m thm, khng st hay st nh (nu c bi nhim), ton thn t thay i, c th a chy vi ln trong ngy, au bng m h ... 1.3.Thi k ton pht: in hnh vi hi chng l Ton thn t thay i, c th st nh, khng c du hiu mt nc

185 Hi chng l : - au bng qun, mt rn . - Tnh cht phn: lc u bnh nhn c th i cu phn lng v sau phn nhiu nhy ln mu hay nu, trung bnh 10-12 ln/ngy, c khi phn thnh khun, nhy mu bm xung quanh v cui cng c vi git mu. ngi gi v tr suy dinh dng, hi chng l khng in hnh, c khi ch i cu mu. 1.4. Thi k lui bnh Bnh c th t n nh v ti pht khi gp yu t thun li 1.5. Giai on di chng Bnh c xu hng mn tnh nu khng pht hin v iu tr kp thi, d gy di chng vim i trng mn. 2. Bnh l amip th ti cp (c tnh) Gp c th suy gim min dch, hoc suy kit vi tn thng hoi t lan khp i trng - Hi chng nhim trng nhim c ton thn nng vi st cao c khi h thn nhit, tng trng suy nhc, l m, mt nc, try tim mch. - au bng d di, nn nhiu, i tin khng t ch, hu mn gin rng, i cu ra cht nc nhy thi ln mu. Gan c th ln v au, bng chng c phn ng thnh bng nh. 3. Bnh l amip mn tnh 3.1. iu kin xut hin - Bnh Amip khng c chn on - Bnh Amip khng c iu tr trit 3.2. Lm sng 3.2.1. Th l: Cm gic nng bng, nhng cn au bng qun sau n hay cm lnh, i cu 5-6 ln/ngy phn nhy mu km mt rn, ngi gy da kh, suy nhc, n ung km . 3.2.2. Th tiu chy: thng au bng m bui sng ri i cu phn nho c dnh nhy hoc tiu chy 5-6 ln /ngy dai dng hng thng, c khi phn nhy mu, ton thn gy st. 3.2.3. Th to bn: Thng gp ngi ln tui b l amip trong tin s, th trng tt, i cu 4-5 ngy/ln, phn rn, t cui cng ra t nhy mu. 3.2.4. Th xen k to bn vi a chy: Bnh tin trin dai dng tng t to bn xen k vi tng t a chy, thnh thong c mt t l. 3.3. Biu hin thn kinh ca bnh amip mn Cc qu trnh vim v let mn tnh i trng lan dn n cc m ri thn kinh mt tri, m ri mc treo v h v. Do nh hng n nhu ng rut, n s bi tit v hp thu ca rut. Ngoi ra cn c th qua trung gian giao cm v dy ph v m gy nn cc ri lon: lon nhp tim, tng hay h huyt p, co tht mch mu ngoi vi... c th biu hin nh: - Bnh d dy rut : au bng vng thng v, chua, i tin ri lon. - au h sn phi. - i but, i rt. - Kh th, nh trng ngc, au vng trc tim, c khi c ngoi tm thu, huyt p h. - Suy nhc c th v ri lon tm thn. 4. Th phi hp: L amp v l trc trng vi 2 kh nng 4.1. Hai bnh song hnh din bin cp tnh Hi chng nhim trng, nhim c ton thn.

186 Hi chng l hoi t: au bng nhiu, nn ma d di, i tin nhiu ln ton m mu hoc nc hung hung nh nc ra tht, hi thi. 4.2. L amip bi nhim Shigella: St cao, hi chng l gia tng mc nng, sau khi iu tr l trc trng, cc ri lon tiu ha vn ko di, xt nghim phn thy c amip.

VI. CN LM SNG
1. Phn Xt nghim phn nhiu ln sau ung sulfat magnesium, nu c iu kin nn xt nghim li sau iu tr 1 tun/ln trong 6 tun, 1 thng/ln trong 6 thng v 6 thng/ln trong 2 nm. C th pht hin ngi lnh mang kn, gim ti pht v gim chuyn th mn tnh . 1.1. Soi ti Tm thy amip th dng bo n hng cu di ng, hng cu ng m, bch cu, kn amip 1-4 nhn, tinh th Charcot Leyden. Th dng bo d b tiu hy, tri li kn amip c sc sng cao nn cc th amip rut nng t ly hn ngi lnh mang kn v thi ra nhiu th dng bo hot ng d cht trong phn. Do dch t hc bnh amip phc tp v nhng ngi mang kn l ngun truyn bnh chnh li khng c triu chng nn t c s quan tm ca cc t chc y t. 1.2. Cy phn Trn cc mi trng khc nhau, tm thy cc dng amip v cc vi trng bi nhim Gram(-), mm(+), vi trng, k sinh, nm. 2. Ni soi trc trng - Hnh nh vim trc trng lan ta, r rt nht khong 13 - 20 cm cch l hu mn, nim mc , xung huyt, tng tit m nhy ri rc tng ch c im bm tm. - Tn thng let in hnh: dng vt cu, cc o, gia nhng vng nim mc tn thng l vng nim mc bnh thng. 3. Xquang rut gi: Khng c hnh nh c hiu, c th thy cc hnh nh do bin chng ca l amip nh u amip, tc rut, lng rut, xon rut... 4. Huyt thanh chn on: Amip xm nhp lm xut hin khng th c hiu, pht hin bng phng php min dch hc nh : - Phn ng khuych tn kt ta trn thch. - Min dch hunh quang gin tip . - Phn ng ngng kt hng cu gin tip...

VII. CHN ON
1. Chn on sm da vo - Tin s - Lm sng - Tm kn amip trong phn , xt nghim ny c th pht hin bnh sm khi cha c triu chng lm sng , d thc hin , t tn km nn c th chi tr c 2. Chn on phn bit 2.1. L trc trng: Bnh cnh cp tnh vi st cao, tnh trng nhim trng, nhim c, ri lon in gii, c th try tim mch - i cu rt nhiu ln 20 - 30 l/ngy. - Cy phn c Shigella. - Soi trc trng c tn thng lan ta. 2.2. Hi chng gi l do E.coli.

187 2.3.Hi chng gi l do cc loi virus ECHO, coxackie. 2.4. Hi chng gi l do u x t cung , ung th i trng, u x tin lit tuyn.

VIII. BIN CHNG


1. Ti rut 1.1. Thng rut gy vim phc mc, c th xy ra th trung bnh hay th nng, bnh nhn st cao , au bng d di, co cng thnh bng. 1. 2. Xut huyt tiu ha: do tn thng mch mu, i khi rt trm trng, i hi phi chuyn mu v dng cc thuc chng amip cng sm cng tt. 1.3. U amip, tc rut, lng rut, xon rut do u. 1.4. Vim i trng hoi t. 1.5. Sa trc trng. 2. Ngoi rut 2.1. Abces gan: giai on u l vim gan nu khng iu tr th chuyn sang abces gan. 2.2. Amip phi, mng phi: amip t gan qua c honh, c th qua ng mu hay bch mch. Lm sng thng gp: - Vim y phi phi cp hay bn cp . - Abces phi ri thng vo ph qun gy khc c m ... phn ng mng phi, trn dch mng phi. 2.3. Tn thng ngoi tm mc - Do v m abces gan vo mng tim. - Vim ngoi tm mc phn ng hay c m. 2.4. Bnh amip no 2.5. Bnh amip lch: Vim quanh lch tng ng vi tn thng amip gc i trng tri. 2.6. Bnh amip da : xut pht t 1 bnh amip rut hoc gan . - Quanh hu mn: vt let ni g, y bn, cha nhiu cht hoi t. - Quanh cc vt m abces gan hay mng phi do amip. 2.7.Bnh amip sinh dc- tit niu Vim bng quang, abces quanh thn do amip t gan n , bnh amip dng vt, m o, t cung.

IX. TIN LNG


Bnh amip thng p ng tt vi iu tr thch hp, tuy nhin t l ti pht kh cao (35%) sau 1 ln iu tr. Amip rut v gan khng bin chng t l t vong <1%. Vim phc mc do thng rut amip hay pxe gan v t l t vong khong 35%. L amip th ti cp t l t vong > 70 % . Bnh nng tr nh, ngi gi, ph n mang thai .

X. IU TR
1. Cc nhm thuc iu tr amip 1.1 Thuc dit amip khuych tn 1.1.1 Emetin: Tc ng n amip trong thnh rut, khng tc dng vi amip trong lng rut . (hin nay t dng) - c tnh i vi tim: c th gy au ngc, kh th, vim c tim nhim c, ri lon nhp tim . Thn kinh: vim a dy thn kinh. Ri lon tiu ha: nn ma, tiu chy.

188 - Liu lng v cch dng: 1mg/kg/24 gi tim di da su, tng liu khng qu 1cg/kg. - Chng ch nh : bnh tim, bnh thn, thai nghn (3 thng u) tr di 1 tui. Dehydroemetine : C hiu lc hn emetin v t i hn, liu 1-2 mg/kg/ngy. 1.1.2. Amino chloroquin : Trc y c dng iu tr abces gan .Liu 1g/ngy trong 2 ngy sau 0,5 g /ngy trong 19 ngy tip theo (iu tr phi hp) 1.2.Thuc dit amip khng khuych tn 1.2.1. Thuc c arsen: Stovarsol, Bemarsol. Liu 2 g/ngy x 10 ngy. 1.2.2. Dn xut c iod ca Quinolein tc dng va dit trng va dit kn amip. - iodoquin 650 mgX 2 ln/ ngy X 20 ngy. - irexiode 210 mg X 4-6 vim/ ngy X 15 -20 ngy. 1.2.3. Diloxanid furoate ( Furamide). Dng cho bnh nhn c kn trong phn . Vin 0,5g X3 vin/ngy. 1.2.4. Khng sinh: - Paramomycine (humatin) Khng b hp thu nim mc rut, khng gy nhim c, tc dng va dit trng va dit amip trong lng rut . Liu 2g X 3 ln/ngy X 10 ngy. - Oxytetracyclin ( tetracycline). Liu 2g/ngy X 10 ngy. - Erythromycine : dng trong bnh l xm ln c bit tr em. 1.3. Thuc dit amip ton din: 5-nitro- Imidazole L 1 khng sinh dit amip v kn hu hiu, t c, dng cho amip trong v ngoi rut. 1.3.1. Metronidazole (Flagyl, klion, vagyl): r tin, d kim, hp thu tt. Liu: Tr em 35-50 mg/kg/24 gi X 10 ngy Ngi ln: 750 mg X3 ln / ngy. c tnh: Thn trng dng ngi c bnh thn kinh trung ng , bnh gan nng, hn ch i vi ph n c thai v b m cho con b ( nng thuc trong sa tng ng nng trong huyt tng ) thuc c kh nng gy u bu cho tr em. Tc dng ph: Ri lon tu ha: bun nn, chn n, i ma, tiu chy, au thng v. Nhc u, chng mt, d cm chi, au khp, mt ng, pht ban, ni m ay . 1.3.2. Cc thuc sau Metronidazole Tinidazole (Fasigyn) 2 g/ ngy X 3-5 ngy. Secnidazole (Flagentyl) 2 g liu duy nht. Ornidazole (Tiberal) 1,5g/ngy X 3-5 ngy. Cc thuc ny c hot tnh vi amip th hot ng, th minuta v kn, thi gian bn hy ko di, d hp thu v dung np, ph n c thai sau thng th 3 c th dng. 2. p dng thc t 2.1. Amip i trng cp Dng Metronidazole, cn au gim sau 24- 48 gi, phn tr v bnh thng sau 2-3 ngy, amip bin mt trong phn sau 3-6 ngy, tn thng trc trng thnh so sau 10- 15 ngy. Cui t kim tra phn nhiu ln, nu cha sch kn th phi iu tr thm thuc dit amp khng khuych tn trnh ti pht hay chuyn sang mn tnh. 2.2. Ngi mang kn trong phn khng triu chng iu tr bng: Diloxanide furoate, Diidohydroxyquin, Metronidazole, Paramomycine.

189 2.3.Bnh amip gan iu tr bng Metronidazole thm iodoquinole hay dehydroemetin hay Chloroquin 2.4. Bnh amip i trng mn Phi xc nh bnh nhn cn mang amip hay khng, cn xt nghim phn nhiu ln sau khi ung thuc ty v soi i trng cao tm tn thng. Nu cn amip, cho thuc dit amip ton din. Thm thuc bng nim mc rut, ch phm cha Bacillus, subtilis, Lactobacillus. 3. Ch n King thc n nhiu bt, ng, nhiu cellulose, cc thc n m bnh nhn d ng.

XI. PHNG BNH


- V sinh phn rc , qun l vic dng phn trong nng nghip. - Xy cc h x hp v sinh - X l tt nc thi v nc ung, chlor v iode nng ung c th khng dit amip, cn phi hp lc nc v ung nc chn. - V sinh thc phm, n ung, ra tay sch trc khi n, n chn ung chn, ra sch rau sng, y k thc n trnh rui. L cch t tn, d lm, c cng ng chp nhn. - Dit rui dn d thc hin, chi tr v chp nhn. - Khng cn ung thuc phng v khng c hiu lc thit thc. - Vaccine cha c ng dng trong thc t - Xt nghim thm d, pht hin ngi lnh mang kn nht l ngi lm ngh ch bin thc n, nui dy tr, nhng ngi mi n t nhng vng c bnh amip lu hnh, phi c bin php iu tr, qun l ngi mang k sinh trng. - Nng cao i sng v trnh vn ha trong cng ng. - Gio dc v sinh phng bnh. Cu hi n tp 1.Trnh by cc hnh thi amip rut ngi v vai tr ca mi th 2.Cc yu t nguy c ca l amip 3.Trnh by lm sng v iu ca th thng gp nht ca l amip 4.Cc xt nghim cn thit chn on l amip 5.Nu cc bin chng ngoi rut ca l amip

MC LC
Trang

Chng 1. I CNG
1. i cng bnh nhim trng - truyn nhim..........................................................................1 2. Nguyn tc x dng KS trong bnh nhim khun..................................................................9 3. Nhim khun - sc nhim khun...........................................................................................14 4. St ko di cha r nguyn nhn..........................................................................................24 5. Hi chng vng da trong cc bnh nhim trng...................................................................29 6. Hi chng st pht ban nhim trng.....................................................................................34 7. Nhim trng nhim c thc n............................................................................................39

Chng 2. CC BNH DO NHIM KHUN


8. Bnh vim mng no m.....................................................................................................43 9. Bnh l trc khun...............................................................................................................51 10. Bnh dch t........................................................................................................................60 11. Bnh thng hn.................................................................................................................68 12. Bnh st m.......................................................................................................................76 13. Bnh nhim no m cu......................................................................................................83 14. Bnh nhim t cu...............................................................................................................88 15. Bnh un vn......................................................................................................................92 16. Bnh dch hch....................................................................................................................97 17. Bnh nhim leptospira ....................................................................................................101

Chng 3. CC BNH DO NHIM VIRUS


18. Nhim HIV/AIDS.............................................................................................................105 19. Bnh vim gan virus........................................................................................................115 20. Bnh nhim do virus dengue............................................................................................125 21. Bnh cm (gm H5N1) v SARS.....................................................................................134 22. Bnh rubella......................................................................................................................143 23. Bnh vim no Nht Bn.................................................................................................148 24. Bnh di............................................................................................................................152 25. Bnh thu u..................................................................................................................157 26. Bnh quai b......................................................................................................................161

Chng 4. CC BNH DO NHIM K SINH TRNG


27. Bnh st rt thng...........................................................................................................165 28. Bnh st rt c tnh............................................................................................................174 29. Bnh l Amp....................................................................................................................181 Ti liu tham kho................................................................................................................182

190

TI LIU THAM KHO


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