Khoa hoc va ddi sdng I
BENH LAO KE NGUY HIEM NHU THE NAO?
PGS.TS Nguyen Thj Thu Ba, PGS.TS Nguyen Moai Nam
Benh viOn Quoc to M i n l i .Anh
La mpt the lao cap tmh do vi khuan lao lan tran theo dUdng mau - bach huyet lii 6 lao tdi phoi va cac cd quan khac, lao ke la mot can benh nguy hiem bcii trieu chifng khong ro rang, dl lan vdi mpt so benh thong thudng nhUsot ret... Diem dang quan tam la do cac bieu hien lam sang thay ddi va hinh anh X-quang khdng dien hinh nen chan doan lao ke thudng keo dai, trong khi so co quan nhiim benh thUdng da dang va dien tien phijfc tap, din tdi ty le id vong cao.
Moia^u
Lao kd (miliary tuberculosis) xuat phal Id tieng Latin miliarius, nghia la lien quan tdi hat ke, dupe John Jacob Mangel (Thuy Sy) dUa ra de md td ve mat benh hgc (giong vdi nhOng hat ke ve kich thude va sU xual hien). Ndi theo each co dien, sang Ihudng' cua lao ke tren X-quang dUdc dinh nghTa nhu la cac hat ke nhd rieng le d phoi ed cung kich thude va phan bo deu khap phdi, vdi dudng kinh 1-3 mm, trong dd khoang 10% not tren 3 mm. Chan doan lao ke can cd sU hien dien eua hinh anh ton thUOng tham nhiem dang ke lan Ida tren phim X-quang nguc hay tren CT ed do phan giai cao (high-resolution CT, HRCT) hoac bang chdng ve giai phau benh qua eac nang lao tren md sinh thiel td nhieu cd quan. Do bieu hien ldm sang didn bien phUc tap, hinh dnh X-quang khdng dien hinh nen dan den viec chan doan bj tri hoan, khien ty le td vong do lao ke rat cao
'La khoi mo phat tnen bat thi/cfng nam ti be mat hay ngay ben dUoi
Mbi sd tribu chijikig cua benh Trieu chdng lao ke khd da dang, de lan vdi mdt so benh thdng Ihudng^ nen dan tdi chan doan sai lech, khien bdnh thudng tien trien nang, gdy khd khan trong dieu trj.
Tneu chdng the tang: d ngudi Idn, phan Idn benh nhan cd sdt keo dai vai tuan, met mdi, an uong kdm, sut can, ho va "gai sot" vao eac buoi sang. Ddi vdi tre em, cac tneu chdng nhu lanh run, do mo hdi trdm, ho ra mau, ho khac ddm it gap hdn d ngUdi ldn; nhung hach ngoai bien, gan, lach to hdn. Mot so trieu chung can quan tam khac la: yeu dt, met moi, tdc nguc. khd thd. dau dau.
thay doi cam giac, dgng kinh. dau bung, budn ndn, tieu chay, trieu chung d dUdng tiet nieu kem an udng kem, sut can...
Ton thuong he thong: lao ke cd bieu hien cua ton IhUdng cae heed quan khae nhau va ho khan, ho ra mau, khd thd; ngudi benh cung gap ton thuong da dang
^Sol, lanh run cung thUdng gap d benh nhan sot ret. nhiem khuan huyet nen doi khi tao ra sU nham lan Irong chan doan benh
phat ban san hong (neu ed thi day la trieu chUng dien hinh). TrUdng hdp lao ke vong mac thudng gay ton thUdng 2 ben giac mac. khu vUe ton thuong cd mdu trdng xam, nhot nhal hay hdi vang, kich thude thudng nhd hdn dTa thi 1/4;
cae ton thUdng bao quanh day than kinh Ihj giac trong ban kinh khoang 2 em va thudng gap 6 trd em. Do dd, d nhdng benh nhan nghi ngd ed lao, viec tham kham mat mdt each loan dien, soi day mat sau khi nhd gian dong id la can thiel. Hinh 1 la hinh dnh ton thUdng da va vdng mac Iren benh nhan lao ke la Ire em.
Oieu dang quan tam la ty Id nhidm lao ke d benh nhan HIV giai doan sdm (T-CD4>200 te bao/mm^) khdng khac biet so vdi benh nhdn ed he mien djch binh thudng, tuy nhien trong giai doan mudn benh HIV-AIDS (T- CD4<200), ty le nay tang eao (20 so vdi 50%),
Tren thue te, benh nhan lao ke giai doan mudn thudng co tdn thuong da {san hdng ban mun nude, ddi khi loet chay mu rdi ddng vay khd cdng, hoae cd ap xe dudi da), ton thddng vdng mac,
KHOAHOC \/.. \ 55
I Khoa hgc va ddi song
H i n h 1 . T o n t h u o n g I r r n b e n h n h a n lao kc la t r e e r
B.ing 1 . T\ 1^ cac loai I o n thuOnt' cua b ? n h lao k e .
T i n t h u o n g hpt ke 50°.
T^n Ihuong g6m nhang hat k6 nh6 kich thuoc tu 1-3 m m . diu nhau it d j m . b6 khOng rfi, phfin b6 dfiu khgp 2 b&n ph6\
l6nthuong p h ^ l k h 6 n g d p n g hpt k6 10-30S Ton Ihuong dang not k h i n g do^ »ung. n i l dmh VOI nhau I6m ddm
h^ch ngoai bien, hdi chdng suy hd hdp nang gdy nhiem trung bao tu. suy than cap. va soi cay ddm It khi dUdng tinh. Cac trieu chdng It gap hon (lao ke the dn) la sdt khdng ro nguyen nhan. sdc, rdi loan da ed quan, tran khi mang phoi. tran khi trung that, vidm mu mang phoi cap. thieu mau hoai td tuy. thieu mau tan huyet mien dich, benh ndi tiet. nhiem doc giap-'. viem cd tim cd/khdng Iran djch mang lim, hoai tu co tim cap, phinh ddng mach chu, benh van tim bam smb. vang da ldc mat.
cac tneu chUng khac cua lao ke la thieu mau (lang hoac giam baeh cau). giam Na. tang can- xu Bieu hien de phat hien nhat la thdng qua hinh anh phdi tren phim X-quang voi eae toai tdn thUdng duoe de cap d bang 1
J6n t h i r o n g khac <5''o
T6r\ thudng d ph^i, Tdn Ihudng nhu mo vS lao hang Segmental consoddalton, day vach lien thuy; tran d i d mang phoi, tr^n mu mang pndi, tran khi mang ph6i. trim khi ifung thSt.
- D^u hi$u khac. Ir^n dich mang Um. hach trung that phi dai.
Mdt so lull y trong phong va tri benh Ddn nay, vide dieu tr; lao ke can tudn thu mdtsd nguyen tdc va phac dd dieu in lao cua ChuOng Irinh phdng chdng lao quoc gia Phac do, thdi gian dung thuoc la ca biet hda: trudng hdp cay vi khuan lao (-(•), iam khang sinh do va dieu tri Iheo khang sinh do, nhat la d ngUdi Idn da mde lao, dac diet la lao mang nao, hoae dong nhiem HIV. dieu trj kel hdp nhieu benh khac khien cd the suy kiet do ton thuong nhieu cd quan, Dieu can luu y them la trong dieu tri benh can theo doi sat cac phan Ung cua thude khang lao gay ra, dac biet la ton thuong gan Khi cac chi sd men gan AST, ALT tang hon 3 Ian gioi han thdng thudng can dUng sd dung eac loai thuoc gay ton thuong gan va thay the bang eac dong khang sinh nhu" Ethambutol. Streptomycine, Fluoroquinolone- Hien sd dung cortieoid - mdt loai thude khang
viem, Chong dl ung, u c c h n v e d,ch • doi vo, d,eu tn lao ks van con tranh caMuynh.en tren thUc ,e CO nhieu Id. the « ^i?' '^
no tro dieu tn benh nhan lao ke CO viem rrang nao do lao, tran dich mang tim vd, Mong d|Ch nhieu, viem than mien djch va thUc bao mau (hiem gap nhimg nguy hilm)- Trong truong hop lao ke dong nhi§m HIV, can theo do, tuong tac thuoc giua thuoc l<hang lao va ARV - nhom thuoc khang HIV co cd che uc che gen sao chep ngUdc lam uc che su nhan doi cua te bao T, bao toan he thong miSn dich. Ben canh do. ngoa, khoa co va, trd quan trong trong lay mSu benh pham lam xet nghiem, hoac trong mpt so trudng hdp nhu thung rupt non do lao. that bai trong dieu tri npi khoa (Chen ep tiJy song do ton thudng lao).
Nhin Chung, quy trinh tham kham phat hien benh lao ke thudng gom: chijp X-quang phoi (tren phim phoi cho thay tdn thuong hat, ndt vdi tinh chat dien hinh la 3 deu: kich thude, do can quang va su phan bd); cay ddm;
soi phe quan; s,nh thiet phdi; chup cong hudng tir dau; cay mau; soi day mat; do dien tim. Tuy nhien, viec phat hien, dieu trj lap ke la kha phdc tap, do do, phdng ngda benh la phudng phap hieu qu^
nhat bang v,ec t,em ngira vac xin lao BCG, dac biet la d tre em. Ddi vdi nhdng benh nhan da nhiem lao t,em an, suy g,am mien dich nhu benh nhan nhiem HIV-AIDS bien phap nay khong h,eu quli ma can cd vac xin moi ^
56 KHOAHOC \ V 3ni