KY Yg'u CAC C 6 N G TRINH NGHlfeN CCfU KHOA HQC CHUYfeN NGANH HUY^T HQC - TRUYSN M A U
NGHIEN CCrU THAY DO! S6 LUONG TI^U CAU VA
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CAC CHJ SO DONG MAU 6 BENH NHAN S 6 T DENGUE XUAT HUYET
T 6 M TAT
Nghidn cUu vd rdi loan chf sd ddng mdu vd sd lupng tidu edu trdn 81 bdnh nhan Dengue xudt huydt cd tudi trung binh 32 tudi, 32 nam/49 nd. T^ Id bdnh nhdn nh§p vidn vao ngdy thU 5 cua bdnh Id cao nhdt vdi bidu hidn chO ydu Id sdt cao vd xudt huydt. 100%
bdnh nhan nghidn cUu ddu gidm sd lupng tidu edu (tU 8 ddn 132G/L). Cd 21 bdnh nhdn bi gidm ndng dd Fibrinogen trong mdu, chidm 25,93%; 20 bdnh nhan cd APTT kdo ddi chidm 24,69%. Kd't qud xdt nghidm phan dnh phu hpp vdi cdc tridu chdng lam sdng trong nghidn cUu vd phu hpp vdi tidu ehua'n chan dodn Dengue xuat huydt cOa TCYTTG (WHO, 1997).
SUMMARY
Research vi^as carried on indicators of coagulation disorders and platelet count in 81 patients with dengue hemontiagie. Average age of patients was 32 years old, 32 men/49 women. Pourcentage of hospitalization of patients on day 5 of disease is highest, all patients had high fever and bleeding. All study patients were thrombocytopenia (platelet count reduced from 8-132G/L) on average only 35.2G/L.
Coagulation dysfunction manifested in the results of coagulation tests. 21 patients have reduced levels of Fibrinogen in plasma accounted for 25.93%, 20 patients with prolonged APTT accounted for 24.69%.
Clinical results are consistent with the clinical symptoms consistent with research and diagnostic criteria of dengue hemorrhagic WHO (WHO, 1997).
i.
OAT VAN OESdt Dengue va sdt xud't huyd't Dengue (SD/SXHD) la bdnh truydn nhidm gdy dich
*Dai hoc Y Hd Noi
Nguydn Quang Tiing*, Dd Dure Thdng*
do virus Dengue gdy ndn, virus Dengue co 4 typ huyd't thanh la: DEN-1, DEN-2, DEN-3, DEN-4. Virus truydn tir ngudi bdnh sang ngudi lanh do mudi ddt, mudi Aedes Aegypti Id cdn triing trung gian truydn bdnh chii ydu.
Bdnh xdy ra quanh nam, nhung thudng gia tang vao cdc thdng mua mua. La mpt bdnh nhidm triing cdp tinh vdi cac tridu chdng thudng gap la sdt cao, xud't huydt, thoat huydt tuong ed thd ddn ddn sdc giam thd tich tu&
hoan, gan to, cd dac mau, giam tidu edu (TC) va rd'i loan ddng mau. Nd'u khdng dupc chdn doan sdm vd xir tri kip thdi se ddn den tir vong. Sdc va xudt huyet la nhung nguy6n nhdn chinh gdy tir vong trong benh SD/SXHD. Ti Id tu vong trong nhutig tnrdng hpp chay mau cao hon 3-4 ldn nhung trudng hpp khdng chay mau. Co che gay chay mau trong bdnh SD/SXHD da dupc mpt sd tac gia nghien edu bao gdm: benh thanh maeh, giam sd lupng va chdc nang tidu edu, rdi loan cac yd'u td ddng mau. Tuy nhidn cdn it nghien edu dd cdp ddy dii va hd thdng \'6 cac rd'i loan kd trdn, vi vay nghien edu nay dupc tid'n hanh nhdm muc tieu:
Khao sdt su thay ddi sd luong TC vd roi loan cdc chi so ddng mdu d benh nhdn Dengue xudt huyet.
II. 0 6 l Ta<?NG VA PHUONG PHAP
NGHIEN CCrU
L Ddi tupng nghien curu
81 bdnh nhdn nhdp vidn trong ndm 2009 tai Khoa Ndi tdng hpp - bdnh vidn Dai hpc Y
Y HOC VlfeT NAM T H A N G 5 - SO DAC BIET / 2011
id Ndi vdi chdn doan SD/SXHD ve ldm sang /a cdn lam sang theo tieu ehudn ciia (WHO) lam 1997.
2. Phuong phap nghien curu
Sir dung phuong phap nghien edu cat tigang md ta phan tich.
3. Tien hanh nghien curu
Thu thap thong tin tir bdnh an bdnh nhan cd chdn doan SD/SXHD.
- Thu thdp sd lieu gdm: Cbi sd ddng mau PT, Fibrinogen, APTT, SLTC.
- Cae xet nghiem ddng mau dupc tid'n hanh bang may xet nghiem ddng mau tu ddng Sysmex CA 500.
- Cac xet nghidm huyd't hpc dupc tid'n hanh bang may xet nghiem huyd't hpc tu dpng Sysmex KX-21.
- Cac xet nghidm dupc tid'n hanh tai Khoa Xet nghidm-Bdnh vidn Dai hpc Y Ha Npi. Xir ly sd lieu bang phdn mdm SPSS 16.0.
III. KET QUA NGHIEN CQU
Nhom nghidn edu gdm 81 bdnh nhdn, dp tudi trung binh la 32 tudi, cd ca tre em va ngudi gia (td 9 dd'n 82 tudi), ty Id mdc gida nam/nd la 32 nam/ 49 nd. Sd lupng bdnh nhan c6 bidu bidn sdc la 37 trudng hpp, chid'm 45.67%.
1. Thay ddi sd lupng tieu edu
Trong 81 bdnh nhan nghidn edu, tdt ca ddu bi giam tidu edu kha nang, trung binh la 35 ± 24 G/L (tir 8 den 132 G/L). Mdc dd giam CO khac nhau, cu thd dupc trinh bay trong bang 1.
1.1. Phdn bd sd luong tieu cau trong nhdm nghien edu Bang 1. Phdn bd sd lupng tieu cau
Sd lupng TC 100<TC<149 50<TC<100
TC<50 Tong sd
n 1 18 62 81
Tyle%
1,23 22,22 76,54 100%
Nhdn xet: Sd lupng tieu edu giam nang ti^r dudi 50 G/L chid'm ty le cao nhdt (62 bdnh nhdn, chid'm ty Id 76,54%).
1.2. Diin Men gidm tieu cau theo thdi gian mdc benh.
Theo ddi dpc thdi gian mdc bdnh, ke't qua cho thd'y sd lupng tidu edu giam ddn ngay tir iigay thd 2 va thdp nhdt vao ngay thd 6 kd td khi sdt, sau dd tang ddn trd lai. Kd't qua dupc
trinh bay trong bidu dd I sau ddy:
KY Y^U CAC C 6 N G TRINH NGHIDN CLTU KHOA HQC CHUYiN NGANH HUY^T HQC - TRUYJN MAU
So li/dng tieu cau (G/L)
So li/dng TC (G/L) 200
150 100 50
0
•;
I 7 J>S
Ngay sot thif
Bieu dd L Thay ddi sd lupng tidu edu theo thdi gian2. Thay ddi cac chi sd ddng mau
Tdt ca 81 benh nhdn ddu dupc khao sat cae chi sd ddng mau co ban, bao gdm: APTT, PT va dinh lupng fibrinogen. Ke't qua dupc trinh bay trong bang 2.
Bang 2. Gia tri trung binhciia cac chi sd ddng mau huydt tuong
ChisdXN PT(%)
INR Fib (g/L) APTT(s) APTT(b/c)
;r±sD
128,9±25,7 0,88±0,11 2,383±0,668
31,9515,65 1,185±0,205
Min 76 0,71
1.4 21,3 0.79
Max 186.3
1.71 5.1
42 1.43
Nhdn xet: Gia tri cdc chi sd xet nghidm
ddng mau co ban thay ddi trong khoang gia tri kha ldn.
Ty Id PT% trung binh Id 128,96% (td 76% ddn 186,3%).
INR tmng binh la 0,88 (tirO,71 dd'n 1,17).
Gia tri APTT bdnh/cbdng trung binh la 1,18 (tir 0,79 dd'n 1,84).
Gia tri Fibrinogen trung binh la
2,383g/L (tir l,4g/L dd'n 5,1 g/L). J Tid'p tuc phdn tich su thay ddi sd lura!
tidu edu va cac chi sd ddng mau theo nhom
bdnh nhdn cd bode khdng cd bieu hidn sdc-
bidu hidn ldm sang ndng nd, cd nguy co anli
hudng dd'n tinh mang ngudi bdnh, kdt qua
dupc trinh bay trong bang 3.
Y HQC VIET NAM T H A N G 5 - SO OAC BIET / 2011
Bang 3. Sd lupng tieu edu va cac chi sd dong mau d nhom benh nhan co va khdng bieu hien sdc
Chi sd (don vj)
TC (G/L) PT (%) INR Fib (g/L) APTT (s) APTT (r)
Khong soc (n = 44) ' 53,5±32,6
127,4±26,3 0,87±0,1 1,92±0,52 36,74±4,34
0,92±0,1
Co sdc (n = 37) 28,2±21,7 123,8±29,1
0,88±0,1 2,78±1,32 32,47±6,7 1,1±0,18
P
<0.01
>0.05
>0.05
>0.05
>0.05
>0.05
Nhdn xet: Sd lupng tidu edu trung binh ciia nhom bdnh nhdn co bidu hidn sdc (28,2G/L)
»iam rd ret so vdi nhdm khdng cd bidu hien sdc (53,5G/L) vdi p<0.01.
Cac chi sd ddng mau co ban cd thay ddi giu'a bai nhom benh nhan, tuy nhidn su thay ddi nay khdng cd y nghia thdng ke vdi p>0.05.
IV. BAN LUAN
Kd't qua nghidn edu tren 81 benh nhdn dupc chdn doan va dieu tri tai Benh vien Dai hpc Y Ha Npi trong nam 2009 cho thdy benh cd the bi mdc d mpi Ida tudi. Trong nhom nghien edu cd 37 trudng hpp bi sdc (SD/SXHD dp III va dp IV) chiem ty Id 45.67%. Sdc trong SXH cbii yd'u do giam the tich thd phat xay ra khi bi mat huyet tuong do tang tinh tham thanh mach. Bieu hien lam sang nang nd nay thudng xay ra tir ngay thd 3 dd'n ngay thd 6 ciia bdnh.
Sd lupng tidu edu giam d tdt ca 100%
bdnh nhdn, tham chi giam tha'p dd'n mdc nguy hidm dudi 20 G/L. Day la mdt trong nhihig hdu qua nang ne, cd nguy co anh hudng dd'n tinh mang ngudi benh do chay mau, dac biet khi ket hpp vdi nhihig rdi loan dong mau huyd't tuong va tinh trang sdc. Hien nay cd nhidu gia thuyd't dd cdp dd'n nguyen nhdn gdy giam tidu edu trong sdt xud't huyd't: (1) Pha hiiy tieu edu do khang the, (2) Thuc bao tidu edu qua hidn tupng "opsonin", (3) dc che mdu tieu edu trong tuy xuong va (4) Tdn
thuong td bao npi mach gdy kd't dinh tidu edu vao ldp dudi npi mac. Td nhChig gia thuyet nay de co the de ra cac bidn phap dieu tri dng dung tren ldm sang nhu sii dung cac chd't tai tao be mat te bao npi mach...tuy nhidn, giai phap dc che midn dich (vi du sir dung corticoid) cdn chua co hieu qua ro rang va cdn dupc can nhdc cu the.
Vd cac chi sd ddng mau, ke't qua nghidn edu cho thd'y cd 21 benh nhdn giam ndng dp Fibrinogen trong mau chid'm 25,93%; co 20 bdnh nhdn co APTT keo dai chid'm 24,69%.
Theo TCYTTG, APTT va PT keo dai d 30- 50% BN SD/SXHD, ty le nay con cao hon d nhom BN cd sdc. Thdi gian APTT keo dai, giam ndng dp Fibrinogen cd thd ddn dd'n tinh trang xudt huyd't, dac biet la XHTH va gay sdc. Khi ciing ke't hpp vdi hien tupng giam sd lupng tidu edu co the ddn dd'n rdi loan va tdn thuong nang nd cac co quan. Rd'i loan ddng mau do sir keo dai APTT, giam ndng dp Fibrinogen trong mau cd thd do mdt sd co chd': (1) do tdn thuong gan xudt hidn mupn hon trong giai doan cua bdnh ndn anh hudng
KY Yfe'u CAC C 6 N G T R I N H NGHlfeN CCfU KHOA HQC CHUYfeN NGANH HUYfeT HQC - TRUYJN MAU
dd'n qua trinh tdng hctp yd'u td ddng mau, tinh trang sdc SXH keo ddi. Trong sdc SXH (2)cac yd'u td ddng mdu phu thudc vitamin K kdo ddi, lupng Fibrinogen mau bi tidu thu bi anh budng chung, (3) do virus tdn cong trong qud trinh ddng mau nhieu hon cac ca vao he thdng ddng mau va (4) do qua trinh sdc dap dng tdt vdi didu tri. Ngoai cae chi s6 sdt va \iCMii gay hoat hda mdt sd yeu td gay ddng mau co ban ndu trdn thi cac tdc gia cd tang hay keo ddi APTT. Thdng thudng trong nghidn edu cdc cbi sd khac nhu rd'i loan ddng vicMii va sol ndng dd librinogen mau tang, mau ndi mach lan tda (DIC), D-dimer... d^
nhung trong SXH do gan bi tdn thuong nang danh gia thdm vd chdc nang ddng mau.
ndn su long hpp Fibrinogen giam ddn dd'n Ngoai ra, su lidn quan gida rdi loan ddng ndng dp Fibrinogen trong mau giam. Ngodi mau va SLTC cung vdi tinh trang tdn thuong ra Fibrinogen co thd bi lidu thu dang kd do cac coquan cung dupc cac tac gia nghi nhan.
hidn tupng ddng mau nii rac trong long
mach. Ket qua thu dupc trong nghidn edu ndy v. KET LUAN
cung phii hpp vdi mdt so nghidn edu trudc do Qua nghidn edu 81 bdnh nhan SD/SXHD cua mdt sd tdc gia trong nudc. Nguydn Ngpc irong nam 2009 cho tha'y:
Rang cdng bd rdng d bdnh nhan SXH, thdi . oiam TC d tdt ca cac BN, giam dk gian APTT keo dai trong 49% trudng hpp vd ngay tir ngdy sdt thd 2 va thdp nhdt vao ngay PT keo ddi trong 28% cac trudng hpp, mdc thd 6 kd tir khi sdt, sau dd tang ddn trd lai.
dd keo ddi CO lidn quan dd'n tinh trang nang . R^J loan ddng mau xay ra d cac mk cua benh. Theo nghien edu ciia Ta Van Trdm dd khac nhau, bao gdm cdc bieu hien: M thi APTT, PT keo dai ehiem 77,5% va 61,2%
d nhdm cd bidu hidn sdc, cao hon rd rdt so Fibrinogen giam.
gian PT va APTT keo dai, ndng do vdi nhdm khdng sdc (p<0,001). Thdi gian
APTT va PT trung binh d nhdm SXH keo dai 21,06 ± 1,74% vd 77,28 ± 7,33% so vdi nhdm chdng va su khac bidt nay cd y nghia thdng kd (p<0,001). Nhu vdy, cd thd ndi rdng APTT va PT keo dai la yd'u td giup tidn lupng trong sdc do SXH keo ddi. Vd lupng Fibrinogen trong mau, theo mdt sd tae gia nudc ngodi, khi dinh lupng cac yd'u td ddng mau trong SXH, fibrinogen la yd'u td ddng mau huydt tuong duy nhdt giam gdn nhu hang dinh va mdc dp giam ed lidn quan dd'n dp ndng ldm sang. Kd't qua nghidn edu eiia Ta Van Trdm cho thd'y lupng Fibrinogen giam dudi l,5g/L chidm 58,1% cac ca sd'c, trong dd nhdm sdc SXH keo dai chid'm 92,5%. Ty Id nay cao hon so vdi nhdm chdng la 42,5%
mdt each cd y nghia vdi p<0,001. Vdy hdu qua giam Fibrinogen mau cd lien quan dd'n
Cd sir khac biet cd y nghia \e mdc do rdi loan ddng mau gida cac trudng hpp sdc va khdng sdc.
TAI LIEU THAM K H A O
1. Bach Van Cam, LAm Thj My, Nguyen Minh Tien (2006): Tdn thuong cac co quan trong sdc sdt xudt huyd't Dengue keo dai, Y hpc TPHCM, Tap 10, sd 1:143-
151.
2. Nguydn Thai Scm, Nguydn Trong Lin (1998). "Rdi loan ddng mau trong sdt xuat huyd't Dengue va cac yd'u td ti6n lupng"
3. Nguydn Thanh Hikng, Nguydn Trong L&n, Le Bich Lien va cpng sur: Dac didm Idm sang, cdn ldm sang va didu tri sdt xud't huyd't Dengue d tre nhu nhi, Y hpc TPHCM Tdp 17, sd 1:1-38-144.
4. Hoang Lan Phuong, Peter J. de Vries, Khoa T. D. et al (2006). "Dengue virus infections in Viet Nam" Tip of the iceberg. Dengue bulletin. Vol. 30.
5. Ta Van Trdm (2007). "Rdi loan ddng mau trong sdc sdt xud't huyet Dengue keo dai d tre em". Hdi nghi khoa hpc nganh Y tinh Binh Duong ldn thd 1.
6. Ing-Kit Lee, Jien- Wei Liu and Kuender D. Yang (2008). Clinical and laboratory charac^sristics and risk factors fatality in enderly in patients with Dengue haemorrhagic fever. Am. J. Trop.
Med. Hyg. 79(2), 2008, pp 149-153.
Y HQC VIET NAM T H A N G 5 - SO D A C B I § T / 2011
Saito M., Oishi K., Inoue S. et al (2004),
"Association of increased platelet- associated immunoglobulins with thrombocytopenia and the severity of disease in secondary Dengue virus infection" Clin Exp Immunol, 138: 299- 303.
Zhihua K., Matthew Q., Chen H., et al.
(2008). "Monocytes, but not T or B cells, are the principal target cells for Dengue virus infection among human peripheral blood mononuclear cells" Joumal of medical virology, 80: 134-146.
