CHUYEN DE: HQI NGH! KHOA HOC NGANH Y TE T I N H KHANH HOA - LANTHLTII
nang khdng mong mudn nao sau tiem chimg.
Tan suat xuat hien phan ling giam din tir mui 1 den miii thir 3.
2. Khuyen nghi
Vi cd mpt ty le khdng nhd cac phan ling khdng mong mudn ciia vac xin 5 trong 1 do vac xin, nen can bd Y te can tang cudng hucmg dan ba me, ngudi cham sdc tre theo doi cac phan ling sau tiem chimg va each cham sdc tre cd phan ling sau tiem chimg mpt each thich hpp. Tuyet ddi tuan thu kham
phan loai trudc tiem va cac chdng chi dinh tiem vac xin 5 trong 1.
Keyword: An toan tiem chung, vac xin 5 trong 1, phan img sau tiem chimg, Khanh Hda
TAI LIEU THAM KHAO
1. http://www.ykhoanet.com/binhluan/Nguyen hainam/100420_nguyenhainam_vaccinphoih op.htm, doawnload 26/11/2010.
2 Vien Ve Sinh Dich TS Ha Npi-UNICEF (2004), Dir dn Tiem chimg md rgng-Gidm sdt phdn img sau tiem chiing, Ha npi.
NGHIEN CUU DAC DIEM BENH SOT MO VA DANH GIA HIEU QUA DIEU TR|
BANG CHLORAMPHENICOL
Le Hong Quang*,Tr^n Huy Hoiing*, Ho Le Cam Nhung*
TOM TAT
Muc tieu: Nghien ciru dac diem djch te, lam sang, xet nghiem va hieu qua dieu tri benh sot md bang Chloramphenicol. Phu'dng phap va ket qua nghien cu'u: Nghien ciru tien cu'u, md ta cat ngang 174 benh nhan (101 nam, 73 nii) sot md du'dc xac chan bang xet nghiem ELISA huyet thanh, tuoi trung binh 39,51±12,57 nam dieu trj tai Benh vien 87 tiT thang 1/2D08 den thang 2/2012, nhan thay benh hay xay ra vao miia mifa, doi tiTdng lao dpng song d ndng thon va lam nghe ndng trong dp tuoi 26-45 mac benh chiem ti le cao nhat. Cac trieu chu'ng hay gap:
sdt (100%), dau dau (97,1%), vet loet (75,9%), sung hach (43,7%), cac trieu chu'ng khac: non 28,1%, ia Idng 20,7%, ban ngoai da 33,3%. Xet nghiem 64,9% tang hoat dp transaminase.
25,8% tang bach cau >10 G/l va 40,8% giam tieu cau <100 G/l. Bien chiTng chung gap ti le 22,4%, trong dd viem cd tim 10, 9%. Oa so benh nhan dap irng tot vdi Chloramphenicol, khdng co tru'dng hpp nao tit vong. Thdi gian cat sot trung binh 45,65 ± 26,51gid. Ti le khdi benh 98,3%, tai phat 1,7%. Ket luan: Vet loet md dot la dau hieu chi. diem quan trpng trong chan doan benh.
Chloramphenicol la thuoc cd hieu qua tdt tnang dieu trj sot md.
ABSTRACT
Aim: To Identify epidemiological, clinical, laboratory and treatment of scrub typhus at the Army Hospital 87 from Jan 2008 to feb/2012.
Method and results: 174 patients (101 males and 73 females), a median age of 39,51±12,57, Khoa Truyen Nhiem- Benh vien 87
Y HOC VIET NAM THANG 5 - SO DAC BIET/2012 diagnosed with scrub typhus, were enrolled in
the prospective and cross-setional stydy. All cases were serologically confimed scrub typhus by using ELISA technique. Most of the cases were dignosed during the rainy season. Majority of the patients were farmers staying in rural areas and belonged to the age-group of 26-45.
The most common clinical features were high fever (100%), headache (97,1%), eschar (75,9%), lymphadenopathy (43,7%). vomiting (28,1%), diarrhea (20,7%), and rash (33,3%).
Elevated of transaminases were detected in 64,9% cases. Blood count showed leucocytosis (>10 G/l) in 25,8% and thrombocytopenia (<iao G/l) in 40,8% cases. Common complications were 22,4%, among them, 10,9% myocarditis.
Most of the patients responded well to Chloramphenicol withbout mortality. The average interval to defervescense after treament was 45,65 ± 26,51^/1* The cure rate was 98,3% and 1,7% relapses. Conclusions: The present of an eschar offers an important clue in making the diagnosis. Chloramphenicol is an effective antibiotic for scrub typhus.
I. OAT VXN of
Cho tdi nay, benh do Rickettsia gay ra da dupe phat hipn d nhieu quoc gia tren the gidi, tt^ong dd t?p trung chii yeu d cac nude thuoc khu vuc Ddng A, Ddng Nam A va Tay Nam Thai Binh Duong [1] ,[7].
Tac nhan gay benh sdt md la O.tsutsugamushi xam nhap vao ca the ngudi qua v^t du triing md dot. Tai Viet Nam, benh gap hdu hk a cac dia phuong, tuy nhien tap trung nhieu d khu vi^c mien Trung-Tay nguyen. Trong nhiing nam gan day benh cd xu hudng ngay cang gia tang, theo thdng bao ciia Benh vien Trung uong Hue nam 2006, da cd hang tram ca benh nhi bi benh sdt md
phai nhap vien dieu tri sau khi thanh phd Hue bi ngap lut.
Benh canh lam sang cua sdt md rat da dang, thudng bieu hien bang sdt keo dai, nhimg trudng hpp den mudn cd the cd ton thuong da phii tang. Ti le tir vong dao ddng 10-30% n6u khdng dupe dieu tri kip thdi [7].
Van de dat ra la can phai phat hien, chan doan som va dieu tri dac hieu kip thai de ban che ti le tdn thuang da phu tang va tii vong.
Do vay, chiing tdi tien hanh nghien cim de tai nay vdi cac muc tieu sau;
- Nghien cim dac diem dich tl, lam sang va can lam sang cua benh sdt md.
- Danh gia hieu qua dieu tri sdt md bang Chloramphenicol.
II. o6\ TUONG VA PHUdNG PHAP NGHIEN CClU 2.1 Doi tuong nghien cihi:
Gdm 174 benh nhan thu dung dieu trj tai Khoa Truyen nhiem tir thang 01/2008 - thang 2/2012 dupe chan doan xac dinh la sdt md, theo tieu chuan chan doan cua bp mdn truyen nhiem-Hpc vien Quan y (2005) [1], dua vao cac yeu td dich te, lam sang, xet nghiem va dieu tri dac hieu.
2.2. Phuong phap nghien cuu - Thiet ke nghien ciiu: Tien ciiu, md ta, cat ngang.
- Npi dung nghien ciiu:
+ Thdng ke cac dac diem dich te, lam sang, can lam sang va ket qua dieu tri theo mau phieu dieu tra thdng nhat.
+ Cac xet nghiem huyet hpc, sinh hoa thuc hien tai Khoa xet nghiem - Benh vien 87 Nha Trang.
+ Xet nghiem phat hien khang the IgM, IgG khang O.tsutsugamushi trong huyet thanh benh nhan bang phuong phap ELISA (lam 02 lan each nhau 7-10 ngay) bang sinh
85
CHUYEN BJ: HQI NGHj KHOA HOC NGANH Y T E T I N H KHANH HOA - L A N THLf II
phim SD-Bioline (Han Qudc) (cd dp nhay 98,6% va dp dac hieu 98,9%).
+ Phac do dieu tri: Chloramphenicol vien 0,25. Ngay dau 8v/ngay chia 2 idn each
8 gid, cac ngay sau 4v/ngay chia 2 lan each 8 gid (tdng lieu dieu tri 6 gram trong 5 ngay).
2.3. Xu ly so lieu: Sd lieu dupe xu ly tren chuang trinh EPI.INFO version 6.04.
III. KET QUA
Bane 3.1. Phan bo benh nhan thu dung dieu tri theo khu vuc Khu vifc
Nqoai 6 thanh pho Nha Tranq Cac huyen
Tonq
So lu'dng (n=174) 85 89 174
Ty le C/o) 48,8 51,2 100 Ngoai d thanh phd Nha Trang ti le mac benh chiem 48,8%, cac huyen cdn lai ti le mac benh chiem 51,2%.
15 - 10
XI
1 2 3 4 5 6 7 8 9 10 11 12
Bieu do 3.1. So lugng benh nhan thu dung dieu tri theo thang
Benh nhan thu dung rai rac vao cac thang quanh nam nhung co xu hudng tang vao cac thang mua mua.
Bang 3.2. Phan bo benh nhan theo tu5i (n = 174)
Nhom tuoi So lu'dng Tv le (%)
<25 30
46,0
> 4 5 64 36,8
Tuoi trunq binh 39,51 ± 12,57
Nghien ciiu bao gom 101 nam (58%) va 73 nir (42%). Tuoi trung binh 39,51 ± 12,57.
Trong do, nhom tuoi tir 26-45 mac benh vai ty Ie cao nhat (46%o).
Bang 3.3. Phan bo b^nh theo tinh chat nghe nghiep (n= 174) Nqhe nghiep
Conq nhan Um nong Lam ruonq
Lam ray Tu'do
Khac
So lu'dng 28 63 32 23 28
Tv le (»/o) 16,1 36,2 18,4 13,2 16,1 Nhdm doi tuong lam nghe ndng: lam rupng, lam ray mac benh vai ti le cao nhat (54,6%)
Y HOC VlET NAM THANG 5 - SO Bi.C BIET/2012
BiinK 3.4. Thai gian mdc benh tinh den thoi diem nhap vien (n=174) Tuan le
So lu'dng Ty le (%)
< 1 Tuan 75 43,1
> 1 Tuan 99 56,9
Tong 174 100 Da sd cac benh nhan vao vien tu tuan thii 2 ciia benh (56,9 %).
Bang 3.5. Chan doan cua tuyen trudc Chan doan
Sot keo dai CRNN Thu'dnq han Sot mo
Tinh tranq nhilm trunq Nhiem vi rut cap Sot ret Sot xuat huyet Viem nao Benh khac Tonq
So lu'dng (n=174) 26
6 47 17 46 7 17 2 6 174
TV le (»/o) 14,9
3,4 27,1
9,8 26,4 4,1 9,8 1,1 3,4 100
Ti le chan doan nham a tuyen trudc chiem 72,9%; trong do 14,9% dupe chan doan la sdt keo dai chua ro nguyen nhan. Chi cd 47/174 (27,1%) sd benh nhan dupe chan doan la sdt md d tuyen trudc.
Bane 3.6. Trieu chi Trieu chu'nq
Sot
mg lam sang va c^n lam sang 6 nhom benh nhan n 38- 39°C
>39°C Not loet mo dot
Si/ng hach Ban
Hach khu virc Hach toan than Ban dat san Ban xuat huyet Dau dau
Gian mach xunq huyet nqoai da Non
ia long
Cac bieu hien bat thudnq ve tim mach Cac bieu hien ton thu'dnq than kinh trunq i/dnq So lUdnq bach cau > lOG/l
So lu'dnq Tieu cau qiam < lOOG/l Tanq ALT va AST > 2 ^n qidi han tren BT Tanq urea va creatinin
So lu'dng (n=174) 141
33 132 76 51 56 02 169 165 49 36 25 19 45 71 113 07
^hien cim.
Tv le (»/o) 81,1 18,9 75,9 43,7 29,3 32,2 1,1 97,1 94,8 28,1 20,7 14,4 10,9 25,8 40,8 64,9 4,0
87
Y HOC VIET NAM THANG 5 - SO BAC BIETaOl2
Cac benh nhan vao vien deu cd sdt (100%); trong dd cd 18,9% sdt > SQ^C. Bi^u hien dau dau gap d hau het cac trudng hop (97,1%), 75,9% cd v^t loet, 94,8% cd bidu hien gian mach xung huyet tai thdi diem vao vien, simg hach khu vuc gan noi md dot 43,7% (29,3% sung hach toan than). Cac trieu chiing khac: ndn 28,1%, la Idng 20,7%
va ban ngoai da 33,3%. 14,4% benh nhan cd
bieu hien b4t thuang tim mach. Cd 25,8% sd benh nhan tang bach ciu > lOG/1 (trung binh 8.71 ± 3,920/1) va 40,8% giam tilu ciu
<100G/1 (tnmg binh 117 ± 45,50 G/l). Tang boat dp Transaminase gap 64,9% sd benh nhan vdi tri sd trung binh cua AST; ALT lan lupt tuong ling: 109,49 ± 89,71 U/L; 118,49
± 93,35U/L; 4,0% sd benh nhan cd tang urea va creatinin.
Bang 3.7. Vi tri cac vet loet Vi tri cac vet loet Ben
Nach Viinq sinh due l^anq sUdn Bunq Dau, mat, co Tav Chan Honq Co 02 vet loet
Solifdng(n=174) 29 23 19 17 13 11 4 7 9 02
Tv le (%) 16,7 13,2 10.9 9,8 7,5 6,3 2,3 4,0 5,2 1,1
Vet loet do au trimg md dot gap ti le chung 75,9%, trong dd, tap trung d viing ben (16,7%), nach (13,2%) va vimg sinh due (10,9%)
Bang 3.8. Bien chung a nhom benh nhan nghien cim Bien chu'nq
Viem cd tim Suy than Viem phoi ke Viem manq nao Tran dich manq phoi
So lu'dng (n=174) 19
7 5 3 5
Tv le (°/o) 10,9 4,0 2,9 1,1 2,9 Ty le bien chiing chung la 22,4%. Bien chiing viem co tim hay gap nhat (10,9%) Bang 3.9 Ket qua dieu tri
Chi tieu theo dol
Thdi gian cat sot
< 24 gid 25 -36 qid 37- 48 qid 49 - 72 qid
>72 gid Thdi qian cat sot trunq binh (qid) Tai phat
So lu'dnq (n=174) 35 38 78 21 2
Tv le (%) 20,1 21,8 44,9 12,1 1,1 45,65 ± 26,51
3 1 1,7
Y HQC VigT NAM THANG 5 - SOPAC BlgT/2012
Benh nhan dupe dieu tri bang Chloramphenicol. Thdi gian cat sot tnmg binh 45,65 ± 26,51 gio. Ti le khdi benh dat 98,3%, cd 1,7% tai phat, khdng cd trudng hpp nao tii vong.
IV. BAN LUAN
Khanh Hda la mpt tinh thudc khu vuc nam Trung Bd, cd dia hinh ddng bing xen lan vdi he thdng sdng sudi kha phong phii, ket hpp vdi thdi tiet khi hau ndng am, do vay rat thuan Ipi cho cdn trimg phat trien trong dd cd au trung mo. Nghien ciiu cho thay, benh xay ra quanh nam, nhung tap trung chii y6u vao mua mua, dieu nay hoan toan phii hpp vdi dac diSm sinh thai phat trien ciia au trimg md.
Trong nghien ciiu cda chiing tdi, dp tudi mac benh cao nhat 26 - 45, chii yeu lam nghe ndng (lam rupng, phat ray) (54,6%) va sdng d ndng thdn (51,2%). Nghien ciiu mpt lan niia khang djnh nhiing nguoi lam nghe ndng cd nguy co phoi nhiem au triing md cao nhat va la ddi tuang chinh mac benh.
Ti le benh nhan nhap vien sau 1 tuan trong nghien curu cua chiing tdi la 56,9%.
Pham Thj Thanh Thuy thay thai gian bi benh hung binh trudc khi vao vipn ciia benh nhan sdt md la 11,52± 5,23 ngay [2]. Do benh canh l^m sang khdng dien hinh, cac dau hieu chi diem ngheo nan, thieu kinh nghiem lam sang va cac xet nghiem chan doan xac djnh nen cd tdi 72,9% sd benh nhan duac tuyen trudc chan doan nham vai benh khac (trong do 14,9% dupe chan doan la sdt keo dai chua rd nguyen nhan). Nghien ciiu cua Pham Thi Thanh Thuy, Digra cho thay cd den 30% cac trudng hpp sdt md vao vien dupe chan doan sot keo dai khong rd nguyen nhan [2], [4].
Cac benh nhan vao vien deu cd sot (100%), trong dd sot cao 18,9%, dau diu 97,1%, da gian mach xung huyet 94,8%,
sung hach tai khu vuc glm vdt loet 43,7%. Ti le sung hach trong nghien ciiu cua chiing tdi tuong duong vdi nghien cthi cua Jim (42,9%) [6]; thap hon cac nghien ciiu khac: Digra 61,9%; Pham Thi Thanh Thiiy 63,7% [4],[2].
Phat ban trong sdt md duoc Biii Dai coi la mpt trong ba trieu chiing co ban cua benh (v^t loet, phat ban va sung hach bach huydt) [1]. Trong sd cac benh nhan ciia chiing tdi, 33,3% cd phat ban. Nghien ciiu ciia chung toi gap 75,9% sd benh nhan cd vk loet, Pham Thi Thanh Thiiy gap it hon 64,9% [2]. Cac nghien ciiu cua Cracco va Jim gap vk loet md ddi vdi ty le Idn lupt, tuang ling 63,5%
va 69% [3], [6]. Chung tdi phat hien vk loet nhieu nhat d cac viing da kin, km nhu: ben (16,7%), nach (13,2%) va sinh due (10,9%).
Vet loet ngoai da la mpt ddu hieu hk siic quan trpng de chan doan benh sdt md. Cac not loet da phan d nhiing vi tri kin dao, da mem, mdng am; vi vay viec kham xet cdn ti mi, ky cang mdi phat hien dupe. Qua cac sd lieu tren c6 the thay neu benh nhan cd dii 3 trieu chiing lam sang kinh dien nhu da neu thi viec chan doan lam sang sdt md khdng khd, song neu khdng cd cac trieu chimg dd thi Cling khdng the loai trir benh sdt md.
Sdt md la b?nh ciing hay gay ra cac bien chiing, trong dd thudng gap la viem co tim, hdi chiing gan th|in...Chiing tdi gap 64,9% so benh nhan cd enzyme transaminase tang > 2 lan gidi han tren ciia binh thudng. Pham Thi Thanh Thuy gap vdi ti le 82% [2]. Nghien ciiu ciia Jim va cdng su gap 77% benh nhan cd tang enzyme transaminase [6]. Tang urea va creatinin trong nghien ciiu chiing tdi gap 4,0%, Pham Thi Thanh Thuy gap cao hon (9,6%) [2]. Ti le gap bien chiing chung ciia chiing tdi la 22,4%, trong dd, viem co tim chiem ty le cao nhat (10,9%); cac bien chiing cdn lai gap vdi ti le thap: viem phdi ke 2,9%;
89
CHUYEN DE: HOt NGHj KHOA HQC NGANH Y Tg TJNH KHANH HOA - L A N T H L J I I
tran dich mang phdi 2,9%; viem mang nSo 1,1% ; suy than 4,0%, khdng cd trudng hop nao cd hdi chiing gan than. Nghien ciiu ciia Pham Thi Thanh Thiiy gap ty le bien chiing chung trong sdt md la 58,4%, trong dd:
40,4% bi^u hien phdi (11,4% cd suy hd hdp) 9,6% suy than va 7,9% viem mang nao [2].
Nghien cim cua Digra nhan thay ti le bien chiing viem mang nao 19,04% va 14,2%
viem CO tim [4].
Cho den nay. Chloramphenicol van la thudc cd hieu luc dieu tri cao ddi vdi Rickettsia. Thdi gian cat sdt trung binh trong nghien cim cua chung tdi: 45,65 ± 26,51 gid.
Da sd benh nhan (87,7%) cat sdt trong vdng 48 gid ke tir khi bat dau dimg thudc, cd 2 trudng hop (1,1%) sau khi dimg dii Heu khang sinh van khdng cat sot, chiing tdi phai sii dung corticoid lieu thap (Img/kg) mdi cat sdt dupe (van de nay ciing da duac de cap trong y van). Thdi gian cat sdt trung binh trong nghien cim ciia Pham Thi Thanh Thuy 2,6 ± 2,2 ngay [2]. Ti le khdi benh dat 98,3%, cd 3 trudng hpp tai phat (1,7%) nhung khdng cd trudng hpp nao tii vong trong nghien ciiu ciia chung tdi.
V. KET LUAN
Nghien ciiu 174 benh nhan sdt md thu dung dieu tn tai benh vien 87 tir 1/2008 dSn thang 2/2012 chiing tdi riit ra mpt so ket luan sau:
- Benh sdt md xuat hien quanh nam, nhung chii yeu vao miia mua. Doi tuong mac benh chii yeu lam nghe ndng, sdng d ndng thdn, trong dp tudi 26-45.
- Da sd cac benh nhan (56,9%) nhap vien tir tuan thii 02 ciia benh; ti le chan doan nham vdi cac benh khac ciia tuyen trudc la 72,9%.
Cac trieu chiing hay gap; sdt (100%) (sot cao 18,9%), dau ddu 97,1%, vk loet 75,9%, sung
hach 43,7%, mot sd trieu chimg khac ndn 28,1%, ia Idng 20,7% va ban ngoai da 33,3%.. Bach cSu >10G/1 gap d 25,8% sd benh nhan va 40,8% tiSu cku < lOOG/1 va 64,9% tang Transaminase. Ti le bien chiing chung 22,4%; trong dd viem co tim chiem ty le cao nhlt (10,9%).
Chloramphenicol dat hieu qua cao trong dieu tri sdt md; tl le khdi benh dat 98,3%. cd 03 truong hpp tai phat (1,7%), khdng cd tir vong. Thoi gian cat sdt tmng binh: 45,65 ±26,51 gid
TAI LIEU THAM KHAO
1. Bill Dai (2005) Benh sdt au triing md. Benh hoc truyen nhiem. Nha xuat ban Y hoc. Ha Noi.
2. Pham Thi Thanh Thuy (2007), Nghien ciru dgc diem lam sang, phuong phap chan doan va dieu tri benh sdt md( scmb ^ h u s ) . Luan an tien sy Y hpc chuyen nganh B?nh Tmyen nhilm.
3. Cracco C , Delafosse C , Baril L., Lefort Y,.IVIorelot C,. Derence J.P., et al.(2000), Multiple organ failure complicating probable scrub typhus. Clin. Infect.Dis.;
31(1): 191-2.
4. Digra Sanjeev Kumar, Ghan Shyam Saini, Virender Singh, Sunil Dutt Sharma, Rajesh Kaul (2010). Scrub Typhus in Children. Jammu Experience Journal of Mecical Education and research;12 (2).
5. Huang CT, Chi H , Lee HC, Chiu Nc, Huang FV(2010), Scrub typhus in Children in a teaching hospital in eastern Taiwan 200 - 2005. Southeast Asian J Trop Med Public Health; 40 (4): 789-94.
6. Jim WT. et al. (2009), Clinical manifestations laboratory findings and complications of pediatric scmb typhus in eastern Taiwan, Pediah-Neonatol; 50(3):96-IOI.
7. World Health Organization (2002), WHO Recommended Surveillance Standards.
Second edidtion. Scrub typhus pp.l23-4.
