OAC DIEM DKH TE, LAM SANG, CAN L A M SANG Of BENH N H A N V I E M NAO NHAT BAN DIEU TRj TAI BENH VIEN NHI DONG 2 (1/2011 -12/2014)
Huynh Lam Thiiy Trinh', Do Chau Viet', Nguyin Tr4n Nam'.
Muc tieu: Mo ta dac diem dich te hpc, lam sang, can lam sang cua cac benh nhan Viem nao Nhat Ban va moi lien he giua cac yeu to tren vcri tmh trang h6i phuc cua benh. Boi tuang vd phucmg phdp nghien cuu: Nghien cuu hoi cmi mo ta hang loat ca tren 91 benh nhi tCr 1 thang d6n 15 tu6i duoc diSu tn tai Benh vien Nhi d6ng 2 tu 01/01/2011 din 01/12/2014, chSn doan xac dinh viem nao Nhat Ban dua tren kit qua MAC ELISA duong tinh trong dich nao tuy va hoac trong mau. Ket qud: Bieu hien lam sang thuong gap: sot, co giat, dau dau, roi loan tinh than, non 6i, dau than kinh dinh vi, than kinh khu tni. 71% ghi nhan bat thudng tren EEG, trong do hoat dpng cham khu tni hoac lan toa chiim 45,2%. MRI sp nao ghi nhan co 62,7% ton thuang o vung doi thi va cuong nao. Ty le tir vong 9,8%. Co su khac biet co y nghia thong ke ve su hien dien cac trieu chung sot, roi loan nhip tho, co giat, dau than kinh dinh vi, than kinh khu tni, tang tiet dam, glasgow < = 8 va tiem ngua vac xin o nhom hoi phuc va nhom khong hoi phuc. Kit luan: Viem nao Nhat Ban la mpt benh ly ton thucmg nao cap, de lai di chung than kinh nang ne 6 tre em. Viec tiem ngira vac xin gop phan han che tir vong va di chung sau nay.
Tir khoa: Viem nao Nhat Ban.
DAT VAN DE
Hgi chutig nao cap xay ra thu'dng xuyen hang nam d Viet Nam, gay ton that dang ke ve ngu'di va de lai nhieu hau qua su'c khoe cung nhu' tam ly nang ne cho tiTng gia dinh Cling nhu" toan xa hpi. So ca mac hpi chiing nao cap trung binh hang nam 2440 tru'dng hpp, so tir vong 103.
Tai Viet Nam thudng gap sieu vi thupe nhdm Arbovirus nhom B, nhat la sieu vi viem nao Nhat Ban (VNNB).
Benh xay ra tai hau het cac dja phu'dng d mien Bac, nhat la d mien Trung du va vung Oong bang chau tho song Hong, cd nOi ty le m3c benh hang nam len tdi 6 - 10/100.000 dan, vdi ty le tu" vong td 5,7% - 28,5% va sieu vi VNNB la tac nhan gay ra 50% - 70% Hoi chiitig nao cap (HCNC). Tai mien Nam viem nao sieu vi xay ra rai
">Bfnh vien Nhi ddng 2. Ihdnh pho Ho Chi Minh.
N g i y n h ^ b i i : 22'8/2015 N g i y phan bifn xong; 15/9/2015 N s i y duyet d i n g : 30/10/2015
Ngiriri cbju trich nhi^ro nOI dung khoa hgc: Huynh Lam Thiiy Trinh.
Bitih yifn Sh, ding 2. ihanh phd H6 Chi Mmh.
Di?ntho<fi 09I8S27385 Email hllhuyirinh260855@yahoo com
rac quanh nam, so mac cao nhat vao nam 1980 vdi ty le 4,95/100.000 dan va ty le tu" vong 27,46%, thu'dng tap trung nhieu d Dong bang sdng Culi Long vuia lua cua mien Nam, nOi cd thdi quen nuoi heo gan nha.
Phan utig MAC EUSA: du'dc sd dung tim IgM dac hieu trong DNT va trong mau de xac dinh benh VNNB tren cac benh pham. Phan u'ng nay cd dp nhay 75%
trong giai doan cap, tren 95% trong giai doan dang hoi phuc, vdi dp chinh xac > 95%. Benh cd kha nang phong ngii^ bang tiem chung theo Ijch chung ngifa VNNB d i o tre tren 1 tuoi va chu'a du'dc ap dung md rpng cho tat ca tre em tai Viet Nam.
Tai Benh vien Nhi dong 2 tu" nam 2010 den nay, vdi su" hdp tac vdi Vien Pasteur thanh pho Ho Chf Minh nham xac dinh chan doan bang phu'dng phap MAC ELISA tim VNNB trong djch nao tuy va mau benh nhan, dong thdi vdi chan doan hinh anh hpc da giup cho chung toi rat nhieu thdng tin hdn ve benh canh VNNB. Do dd, chung toi thUc hien nghien cutj nay nham tim hieu rd hdn ve dich te hpc, trieu chutig lam sang, can lam sang va cac yeu to lien
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quan den mii'c do nang oia nhijtig benh nhan du'dc chan doan xac djnh VNNB tai Benh vien Nhi dong 2. Mue deu nghien cdu nham: (1) Mo ta cac dac diem djch te hpc, lam sang, can lam sang cua cac tru'dng hdp VNNB tai Benh vien Nhi dong 2 du'dc nhap vien tir ngay 01/01/2011 d e l ngay 01/12/2014. (2) Xac dinh cac yeu to lien quan den dien tien nang cua benh nhan bi VNNB nhap Benh vien Nhi dong 2 tCr 01/01/2011 den ngay 01/12/2014.
DOI Tl/gNG VA PHU'aNG PHAP NGHIEN CUU Doi tu'dng nghien cu'u: 91 Benh nhi tii 1 thang den 15 tudi du'dc dieu tri tai Benh vien Nhi dong 2 tir 01/01/2011 den 01/12/2014 du'dc chan doan VNNB thda man cac tieu chuan lam sang va can lam sang theo WHO.
Phu'dng phap: Nghien cuU hdi ciili md ta hang loat ca.
Tieu chi chpn mau
Tieu chuan dda vao: Benh nhi tiy 1 thang den 15 tuoi dUdc dieu trj tai Benh vien Nhi dong 2 tir 01/01/2011 den 01/12/2014 dUdc chan doan VNNB thda man cac tieu chuan lam sang va c|n lam sang theo WHO.
Cdmau: Mo ta hang loat ca lay tron.
Cac bddc tiin hanh:
Tat ca benh nhi thda man tieu chf chpn mau du'dc du^
vao 16 nghi§n cutj khao sat toan bp dac diem djch te, lam sang, can lam sang danh cho cac ddi tu'dng nghien culi, dUdc thu thap du' lieu tai Benh vten Nhi dong 2, dda tren phieu dieu tra ca benh VNNB. Chiing tdi ghi nhan day dii cac dff lieu tir ho sd benh an vao benh an theo thir t y sau:
Thd nhat, dac diem lam sang: tuoi, gidi tfnh, ly do nhap vien, tien sir tiem vac xin VNNB, sdt, ndn, dau dau, trieu chutig tim mach (mach, huyet ap), trieu chutig hd hap (nhip thd, thd nguc bung, ngutig thd), trieu chiitig than kinh (Glasgow, co giat, rdi loan tinh than, dau mang nao, dau than kinh ^ n h vj), trieu chutig rdi loan thi/c vat (va mo hoi, tang tiet dam nhdt).
Thd hai, dac diem can lam sang: Cdng thii'e mau (Bach cau), CRP, Ion do, dich nao tuy, huyet thanh chan doan, dien nao do, MRI sp nao.
Thu thap va xu" ly so lieu: Theo phu'dng phap thdng ke yhpc.
KET QUA: Trong vdng 4 nam, cd 91 trudng hdp thda man tieu chuan duidc dda vao nghien cuU cung nhd ghi nhan dd lieu dich te, lam sang va can lam sang.
Dac diem djch te hoc Gi6i: Nam/NC = 1,6/1.
Tuoh trung binh: 7,8 tudi, nhd nhat: 3 thang, Idn nhat:
14 tuoi.
Tan so
Hinh 1 : Phan bo theo tinh thanh
Tiem vac xin
• Khdng tidm • Tigm • Khdng rO
24%
Hinh 2: Tiem vac xin
Dac diem lam sang
Bang 1 : Li do nhap vien Li do nhgp vien
Sot + dau dau Sot + CO giat Yeu liet Ldmrf Kiiac
tan so 10 54 11 IS 1
%
10,9 59,3 12,1 16,5 1,1 Ngay nhap vien sau khdi benh: trung binh: 3,2 +/- 1,4 ngay; sdm nhat: 1 ngay, va mupn nhat: 9 ngay.
Ngay xuat hien trieu chulig than Icinh: trung binh:
3,0 +/-1,3 ngay; sdm nhat: 1 ngay, mupn nhat: 9 ngay.
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Bang 2: trieu chihig than itinh Cd dia, tienh nen
Sot Nonoi Dau dau Roi ioan niijp tiid Glasgow </= 8 Co giat CoguHng Dau TKICr/TKDV Roi loan tinii tiian Va mo hoi Tang tiet dam nhcit
l^nso 83 53 61 36 38 65 46 51 58 4 31
%
91,2 58,2 67,1 39,6 41,8 71,4 50,5 56,4 63,7 4,4 34,1 Trieu chutig kem theo: ho ctiay mui 6,6%, tieu chay 6,6%, phat ban 3,3%.
Dac diem can lam sang
Sac/} cau m a u ; trung binh: 13,4 +/- 6,8; nho nhat: 2,4;
Icin nhat: 36,2, Neutro chiem uU the 93,4%.
CRP: trung binh: 26,7 +/- 28,7; Nho nhat; 0; Lcin nhat:
117.
Natri miu <125 mEq/L: co 32 tru'dng hdp (35,2%).
Djch nao tuy
Co 82 tru'dng hdp (90,1%) dich nao tuy trong, vdi 65,9% tru'dng hdp te bao dich nao tuy < 100 tb/mm', lym- pho chiem uli the 70,3%.
Cd 44 tru'dng hdp (49,4%) dam trong djch nao tuy >
0,4 g/L. Cd 2 tru'dng hdp (2,2%) du'dng giam va lactate tSng trDng djch nao tuy.
Phan &ng MAC ELISA; Trong 4 nam, chung toi thUc hien tam scat 578 ca, ket qua 91 ca VNNB, chiem ty ie 15,7 %, trong dd cd 42 ca (46,2%) du'dng tinh trong dich nao tuy, 21 ca (23,1%) du'dng tfnh trong mau, 28 ca (30,7%) du'dng tinh trong djch nao tuy va trong mau.
EEG: Cd 31 tru'dng hdp do EEG, trong dd cd 9 tru'dng hdp (29,0%) binh thddng, hoat dong cham khu tru hoac lan tda chiem 14 tru'dng hdp (45,2%); 4 tru'dng hdp (12,9%) Lfc che hoat ddng vd nao, 3 d-Udng hdp (9,7%) xao tron nen chung.
M R I sp nao: 51 tru'dng hdp, ket qua: 32 tru'dng hdp tdn thu'dng doi thi, cudng nao (62,7%); 11 tru'dng hdp binh thddng (21,6%); 8 trddng hdp tdn thu'dng vj tri khac.
Bieu tri: Thd may: chiem 36 tru'dng hdp (39,6%) thdi gian thd may trung binh: 6,2 +/-15,5 ngay, dai nhat 85 ngay. Trong do, cd 12 tru'dng hdp (13,2%) dung van mach, 69 tru'dng hdp (75,8%) cd diing Mannitol. Thdi gian dieu trj trung binh la: 20,7 ngay, ngan nhat ia 3 ngay va dai nhat ia 120 ngay.
Ket qua: 49 tru'dng hdp hoi phuc hoan toan (53,9%), 33 tn/dng hdp di chimg (36,3%), 9 tru'dng hdp tir vong hoac benh nang xin ve (9,8%).
Bang 3: Moi lien quan giu'a cac yeu to djch t l , lam sang va can lam sang vdi ket qua diieu tri
Gi6i nam Ngay nhap vien sau khcli
benh > 3 ngay Ngay xuat hien tneu chiTng
than kinh > 3 ngay Tiem vacxin
Sot Nondi DaudSu 1^1 loan nhip thd
Glasgow </= 8 Gjgiat Dau TKDV/TKia Tang t i ^ dam nhdt Ha Na <125 mEq/L Thd may Van mach Mannitol
Phi^c hBi
33 (67,4%) 25 (51,0%)
19 (38,8%) 22 (44,9%) 41 (83,7%) 31 (63,3%) 35 (71,4%) 4 (8,2%) 4 (8,2%) 27(55,1%) 15 (30,6%) 4 (8,2%) 11 (22,4%)
4 (8,2%) 3 (6,1%) 31 (63,3%)
Khong phuc hoi N = 4'2 23 (54,7%) 9 (21,9%)
4 (9,5%) 7 (16,5%) 42 (100%) 22 (52,4%) 26 (61,9%) 32 (76,2%) 34 (80,9%) 38 (90,5%) 36 (85,7%) 27(64,3%) 21 (50,0%) 32 (76,2%) 9 (21,4%) 37 (88,1%)
P 0,21
<0,05
<0,05
<0,05
<0,05 0,29 0,33
<0,05
<0,05
<D,05
<0,05
<0,05
<0,0S
<0,05
<0,05
<0,05
Nhan xet: Trong 4 nam, chung toi thu nhan dddc 91 trddng hdp viem nao Nhat Ban, trong do co 2 benh nhan bj viem nao Nhat Ban trong benh canh ton thu'dng da cd quan, dddc Ipc mau, 1 benh nhan tir vong trong giai doan cap, benh nhan cdn lai qua dddc giai doan cap tinh, t d vong trong giai doan di chutig sau 95 ngay diilu tri.
BAN LUiilN Dac diem dich t l hoc
Phan tich theo gidi tinh, ket qua dieu tra cho thay. Nam gidi CO nguy cd mac VNNB nhieu hdn NiJ gidi mot each ro ret.
Phan tich tiieo sif phan /»:• Binh Dddng va Bong Nai la hai b'nh CO ty suat mac VNNB cao nhat. Nguyen nhan cOa sir
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phan bo nay co the la do su* chuyen vien theo dung tuyen dieu t i , do cac yeu to tu" nhien va xa hoi tac dpng den sinh thai hpc cua benh, den chuoi mat xich bao gom cac tac nhan - vat chii - vectd - khoi cam nhiem: phat trien nganh chSn nuoi heo, thoi quen khong ngu man.
Ve tiem vac xm phong ngua, qua so lieu thong ke cho thay: Trong so cac tru'dng hdp tiem vac )dn co 44,9% ca hoi phuc va 16,7% ca khong hoi phtjc. Tuy ty le hoi phuc chda phai la tuyet doi, song ket qua do ding cho thay viec tiem vac xin la viec can thiet de han che benh dien tien nang va han che di chiJtig sau nay.
Theo nghien cxiu ciia Campell va cac cpng sy' ve dich te hpc 6 24 nu'dc chau A va Tay Thai Binh Du'dng cho thay: Co 8 1 % tru'dng hdp chung ngu^ vie xin, 19%
tru'dng hdp khong chung ngiia hoac chiing nguS chi 1 lan.
Dac diem lam sang
Trong nghien culi ciia chung toi, cac tru'dng hdp nhap vien sau khdi benh 3 ngay, ngay xuat hien trieu chutig than kmh sau 3 ngay co ty le hoi phuc cao (51,0% va 38,8%) CO the do ton thu'dng than kinh it nang ne hdn, cac trieu chiitig lam sang it ram rp hdn so vdi giai doan cap tfnh trong 3 ngay dau.
Bi^u hien lam sang ciia hau het cac tru'dng hdp gom cac trieu chiing nhu": sot (91,2%), co giat (71,4%), dau dau (67,1%), rDi loan tinh than (63,7%), non di (58,2%), dau TKKT/TKDV (56,4%). Trong do, cac trieu chiitig nhu"
sot, roi loan nh|p thd, co giat, dau TKKT/TKDV, tang tiet dam, glasgow </= 8, co sd thay doi ve tl le benh giO^
nhom CO va khong hoi phuc. Khoang 41,8% tru'dng hdp CO chi so Glasgow </= 8 trong nghien cutj ciia chiing toi.
Dieu nay tu'dng tu" vdi nhan dinh ciia Kakoti va cpng sd, 40,3% benh nhan co chi so Glasgow tir 3 - 8 diem.
Khoang 34 tru'dng hdp nay cd ty le di chutig va tiT vong cao (80,9%). GCS cang thap, mifc dp ton thu'dng than Idnh va di chiitig tren benh nhan cang cao.
Dac diem c^n lam sang
Til* ket qua nghien cutJ cho thay: ha Natri mau chiem ty le 50% so trudng hdp khong hoi phuc. Mirc dp ha Natri mau lien quan den mu'c dp ^ n thudng than kinh cd the
do cac nguyen nhan nhu': hpi diiitig tang tiet ADH khong thich hdp, hpi chutig mat mua do nao, hoac do gidi han dich qua mirc. Co 65,9% trdiSr^ hdp te bao djch nao tiiy
< lOOtb/mm^ va 49,4% tru'dng hdp dam Uong dich nao tiiy > 0,4g/L. Ket qua nay cung kha tu'dng dong vdi ket qua nghien CU\J ciia Kakoti, 77% te bao > Smm^, 52,5%
dam > 0,4g/l.
Tir ket qua nghien cutJ cho thay, trong 31 truing hdp do EEG, CO 7 1 % bat thu'dng: hoat dong cham khu tru hoac lan tda chiem 45,2%, ii'c che hoat dpng vd nao chiem 12,9%. Theo nghien cuU ciia Le Van Tuan va Vu Thj Thuy thi cd 84,40% ket qua dien nao bat thu'dng tren benh nhan viem nao. Hoat dong nen cham ciia dien nao khong lien quan vdi tien lu'dng benh nhan khi xuat vien (p
= 0,267).
Trong nghien ciru ciia chiing toi, cd 51 tn/dng hdp du'dc lam MRI sp nao, 32 m/dng hdp (62,7%) ghi nhan ton thu'dng d vung doi thj va cuong nao. Dieu nay phu hdp vdi y van va nhieu nghien ciru khac: Chii yeu la ton thu'dng lan toa, thoai hda myelin, va cd hinh anh ciia xuat huyet doi thi.
KET LUAN
Viem nao Nhat Ban la mot benh ly ton thu'dng nao cap, de lai di chutig than kinh nang ne d tre em. Viec tiem ngira vac xin gdp phan han che tir vong va di chutig sau nay. Vi vay, tre em trong dp tuoi tiem chiing md rpng can phai du'dc tiem vac xin de phdng ngiia VNNB.
Bieu hien lam sang thu'dng gap ciia VNNB bao gom:
sot, CO giat, dau dau, roi loan tinh than, non 61, dau than kinh khu t n i ; trong dd, sot, roi loan nhjp thd, co giat, dau Oian kinh khu tni, tang tiet dam, glasgow </= 8; Ha Natri mau cd sd thay doi ve ti le benh giiJa nhdm co va khong hoi phuc. Ty le tu' vong 9,8%. Vi v|y, khi co nhutig bleu hien neu tren, a n phai du^ ngay ngu'di benh den cd sd y te de du'dc can thiep kip thdi cang sdm cang tot. Ben canh dd, trong qua trinh kham, chu^ benh cung can dac biet quan tam den cac bieu hien lam sang k i t r e n d e sang lpc benh va de ra phu'dng phap dieu trj phiJ hdp, nham han che thap nhat t / le tir vong va di chutig sau nay.
2 2 - T R U Y ^ N H i ^ M V i e T N A M * s 6 4 ( 1 2 ) - 2 0 1 5
TAI LIEU THAM KHAO 1. Auerbach (2011), Wilderness Medicine, 6th ed;
Chapter 48 - Mosquitoes and Mosquito - Borne Diseases
> Japanese Encephalitis, Mosby.
2. Gitali Kakoti et al (2013). ainical Profile and Out- come of Japanese Encephalitis in Children Admitted with Acute Encephalitis Syndrome. BioMed Research Interna- tional Volume 2013, Article ID 152656, 5pages.
3. Grant L Campbell, Susan L Hills, Marc Fischer et al. Estimated global incidence of Japanese encephalitis:
a systematic review, Bulletin of the World Health Organi- zation; Type: Research Article ID: BLT 10.085233.
4. 2. Kalita, DM; U. K. Misra, DM, (2003). A Com- parison of Clinical and Radiological Findings in Adults and Children With Japanese Encephalitis, Arch Neurol.
5. Kalita J, Misra UK (2003). Neurophysiological changes in Japanese encephalitis, Neurology India, Vol.
51, No. 1, pp. 55 - 59.
6. Le Van Tuan, Vu Thi Thuy (2013). Characteristics
of tiie eledroencephalography in encephalibs. Y Hoc Ho Chi Minh city* Vol. 17 - Supplement of No 1 - 2013: 211 - 216
7. Masri Sembiring Maha et al. Outcome and extent of disability following Japanese-encephalitis in Indonesian children.
8. Pham Ngpc Dmh (2005), De tai cap bp: "Nghien cu\j mpt so dac diem djch te, lam sang va can nguyen benh Viem nao cap do vi nit d tre em tai mpt so khu virc phia Bac Viet Nam", Ha Npi.
9. S. B. Halstead (2007). "Japanese encephalitis"
in Nelson Texttrook of Pediatrics, R. M. Kliegman, R. E.
Behrman, H. B. Jenson, and B. F. Stanton, Eds., pp. 1410 - 1411, Saunders, Philadelphia, Pa, USA.
10. Solomon T, Thao TT, Lewttiwaite P, et al (2008).
A cohort study to assess the new WHO Japanese en- cephalitis surveillance standards. Bull World Health Organ;
86:178.
THE EPIDEMIOLOGICAI^ C U N I C A L , PARACLINICAL CHARACTERISnCS I N PATIENTS JAPANESE ENCEPHALITIS AND THE REUTIONSHIP BETWEEN THESE FACTORS WITH
RECOVERY OF THE DISEASE
Summary
Objectives: Describe the epidemiological, clinical, par- aclinical characteristics of Japanese encephalitis and the relationship between these factors with recovery of tiie disease. Methods: Retrospective descriptive study, from 01/01/2011 to 01/12/2014,91 Japanese encephalitis pa- tients from 1 month to 15 years old, who had positive MAC ELISA results in tJie CSF and, or blood, were enrolled. Re- sults: Common clinical manifestations were fever, convul- sions, headache, mental confusion, vomiting, focal neurological deficits. 7 1 % of patients had abnormal EEGs, mainly localized or diffused slowing waves (45.2%).
Key words: Japanese encephalitis.
62.7% of lesions on cranial MRIs appeared in the hip- pocampus and brainstem. Mortality rate was 9.8%. There was a significantiy statistical difference in fever, breathing disturbances, seizures, focal neurological deficits, in- creasing secretion of phlegm, glasgow <= 8, and vacci- nation status between recovery and non - recovery groups. Conclusions: Japanese encephalitis (JE) caused severe neurological sequelae in children. Vaccination has an important rale in reducing mortality and neurological sequelae.
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