" TAP CHl NGHllN CU'U Y HQC
DAC DlfeM CAN L A M S A N G BENH D 6 DA T O A N T H A N
CHU'A RO C A N NGUYEN
Nguyin Thj Thanh Thiiy, Trln Vdn T i l n Bdnh vidn Da liiu Tmng wang Nghidn cdu dwac thwc hipn nhim khdo sdt ddc diim cdn Idm sdng cua bdnh dd da todn thdn ehwa rd can nguydn (DDTTCRCN). Kit qua nghidn cwu eho thiy td thdng 10/2008 din thdng 7/2009 ed 57 b$nh nhan DDTTCRCN didu trj ndi tm tpi bdnh vidn Da liiu Tmng wang Cdn Idm sang ddng ehu y Id thieu mdu (82,5%), gidm pmtein mau (54,4%), giam albumin mdu (21.1%), tdng bpch ciu eosinophil (35.1%). tdc dd lang mdu tang (33,3%), tang IgE tmng mdu (94,7%), md bdnh hpc Id vidm da khdng ddc hidu (80,7%). ciy vi khuan d da cd tu ciu (43.9%), khdng tim thiy te bdo Sdzary a cdc bpnh nhdn nghidn cwu. Tw do cd thi kit lupn, dpc diim cpn lam sdng cua bdnh DDTTCRCN thwdng khdng ddc hidu.
Tir khoa: do da toan than chua ro can nguydn, efn lam sang
I. OAT
V A N D ^Dd da todn thdn (DDTT) Id bfnh dd da bong vay chilm trdn 90% difn tfch ca thi.
Bfnh khdi phat tu tu vd filn triln man tfnh.
Theo Sehgal va Srivastava, ty If bfnh DDTT d An Dp la 35/100000 dan [7]. DDTT Id mpt hpi Chung lam sang vdi ba dac dilm chfnh:
tdn thuang da lan rdng, trim trong vd kdo ddi.
Nguyen nhdn DDTT gdm 4 nhdm ldn: do cdc bfnh da cd trudc, do thudc, do bfr.h dc tfnh, va nguyen phat (khdng fim dugc nguyen nhdn) hay cdn gpi Id dd da toan thdn chua rd can nguydn (DDTTCRCN). Vi vdy, vifc dilu tri benh cdn nhilu han c h l . Vdi mong mudn cd t h i fim ra dugc nhung thay ddi v l cdn ldm sdng trong bfnh DDTTCRCN d l ttr dd dilu chinh, dg phdng va tien lugng dugc nhfrng dien biln x l u cd t h i xay ra. Chung tdi tiln hdnh dk tai vdi muc tieu khao sdt ddc dilm can lam sang ciia benh DDTTCRCN.
II. D 6 I TUONG VA PHUONG PHAP
1. Ddi tugng
- Benh nhan dugc chin doan Id DDTTCRCN, n i m dilu trj npi trii tai bfnh vifn Da lieu Trung uang tu 10/2008 d i n 7/2009.
Tidu chuln chin dodn: chii y l u dga vdo Idm sdng.
Dd da bong vay chilm tren 90% difn tich ca thi.
Chua rd cdn nguyen.
Tieu chuin chon Iga.
Bfnh nhan ODTTCRNN ndm dieu tri nfi trii tai bfnh vifn Da lilu Trung u-ang.
Khdng phai cdc trudng hgp dd da todn thdn do thudc, do sau nhu-ng bfnh da da cd, do bfnh mdu dc finh.
Tudi tu 15 trd len.
Ddng y tham gia nghidn cuu.
- Tieu chuin loai tru.
Tudi dudi 15.
Cdc bfnh nhdn do da todn thdn dd fim thiy nguydn nhdn.
Bfnh nhdn khdng hgp tdc.
2. Phuang phdp
Nghidn cuu filn cuu, md ta d t ngang. Cd miu thudn fifn, todn bf bfnh nhan DDTTCRCN n i m dilu tn tai bfnh vifn Da lieu Trung uang trong thdi gian nghidn cuu. T i t ca cdc bfnh nhdn ndy d i u dugc Idm cdc xet
TCNCYH 77 (6) - 2011 51
TAP CHf NGHllN CO'U Y HQC
nghifm edng thuc mdu, sinh hda, djnh lugng IgE trong huylt thanh, nudi cly vi khuln tgi tdn thuang da,
Xii- ly do- lifu trdn mdy tInh bdng phin mim thdng kd SPSS 17,0,
1. Kit qud xdt nghifm huylt hgc
III. K^T QUA
Tir 10/2008 din 7/2009, cd 57 bfnh nhdn DDTTCRCN trong tdng sd 121 bfnh nhdn DDTT nim dilu trj tgi bfnh vifn Da lilu Trung uang. Kit qui nghidn cO-u nhu sau.
Bdng 1. Thay ddi cdng thii'c mdu (n = 57)
Cdc tham sdHdng c l u thlp (< 4 trifu)
Hemoglobin thlp (nam < 140g/l, nO- < 125g/l) Bgch d u cao (> 10000 TB/pl)
Bgch d u da nhdn trung tfnh > 72%
Bach clu di toan > 500TB/pl
Tilu d u thay ddi (< 150000TB/M1 hofc > 400000 TB/pl) Mdu ling tdng
2. Xet nghiem IgE todn phdn huylt thanh
Bdng 2. Thay ddi ndng dd IgE trong Ndng do IgE
10-100IU/ml 100-500 1U/ml 500-1000 lU/ml
>1000 1U/ml Tdng
IgE trung binh (]v± SD)
n 3 11 13 30 57
mdu n 21 47 20 24 20 8 19
(n = 57)
1335,1 ± 908,9 lU/ml
% 5,3 19,3 22.8 52,6 100
% 36,8 82,5 35,1 42.2 35.1 14,1 33,3
3. Kit qud xdt nghifm sinh hda 4. Xdt nghifm vi khuln
Khi filn hdnh nudi cly fim vi khuin d da trdn 57 bfnh nhdn, chiing tdi thiy ed 25 miu c6 tg clu vdng (Staphylococcus aureus) gdy bfnh mpc, chilm ty If 43,9%. Cd 1 bfnh nhdn d y mdu duang tfnh vdi tg clu vdng gdy bfnh. Cy tit c l ede miu nudi d y , khdng fim thiy mft trudng hap ndo cd lidn ciu khuln.
52 TCNCYH 77 (6)-2011
TAP CHf NGHllN CLPU Y HQC Bang 3. Thay ddi sinh hda (n = 57)
Thay ddi cdc thdng sd sinh hod mdu n % Ure mau tang (> 7,5 mmol/l) 15 26,3 Dudng mau tdng (> 6,4 mmol/l) 9 15,8 Creafinin mau thay ddi (nu- > lOOpmol/l; nam >
SGOT tang (> 37 U/1/ - 37°C) SGPT tdng (> 40 U/1/ - 37°C) Protein mdu giam (< 65g/l) Albumin giam (< 35g/l)*
Globulin thay ddi (< 24g/l hofc > 38g/l) Ty If /VG thay ddi (< 1,3 hodc > 1,8)
120pmol/l)
Cholesterol thay ddi (< 3,9mmol/l hodc > 5,2mmol/l) Triglyceride thay ddi (< 0,46mmol/l hodc > 1,88mmol/l) HDL-cho < 0,9mmol/l
LDL-cho > 3,4mmol/l
Na'^thay ddi (< 135mmol/l hoac > 145mmol/l) K'^thay ddi (< 3,5mmol/l hoac > 5mmol/l) Crthay ddi (< 98mmol/l hoac > 106mmol/l)
5. K i t qua xet nghiem nuac t i l u
Bang 4. Thay ddi mot sd thdng sd tronc Tdng phan tich nuac t i l u
Binh thudng
Cd Albumin, hdng d u , bach d u , trg Cd bach d u
1 n u d c n 36 10 6
4 25 13 31 13 26 24 33 7 4 2 6 6 6
7,1 43,9 22,8 54,4 22,8 45,7 42,1 57,7 12,3 7 3,5 10,6 10,6 10,6
t i l u (n = 57)
% 63,2
17,5 10,5
Cd hdng d u 3 5,3 Thay ddi khac 2 3,5 Tdng 57 100
Kit qua ciia bang 4 eho thiy 36,8% bfnh nhdn DDTTCRCN cd sg thay ddi mft sd thdng sd trong nudc tilu.
Da sd eac trudng hgp ed hlnh anh md bfnh hpc la vidm da khdng ddc hifu, chilm 80,7%
(bang 5).
TCNCYH 77 (6) 2011 53
TAP CHl NGHllN CCPU Y HQC 6. K i t qud md b f n h hgc
Bdng 5. NhQ'ng thay ddi v l md b f n h hgc (n = 57)
Hinh dnh md bfnh hpc n Hudng din di u-ng thudc 1 Hudng din viy nln 10 Vidm da khdng dfc hifu 46 ,
• Tdng 57 7. Kit qud xdt nghifm chin dodn hinh dnh
Bdng 6. Kit qud xdt nghifm chin dodn hlnh dnh (n •
Xdt nghifm n Sidu dm cd hlnh anh bit thudng 22
X quang phdi cd hlnh anh bit thudng 39
%
1,8 17,5 80,7 100
= 57)
%
38,6 68.4
IV. BAN LUAN
Thay ddi v l h u y l t hgc
Trong 57 bfnh nhdn, hifn tugng giam he- moglobin chilm 82,5%. K i t q u i ndy tuang duang vdi nghidn cuu eiia Pal vd Haroon (72,2%) [5], cao han so vdi nghidn cuu ciia cdc tdc gia khde [3, 6].
Mdu ling tdng chilm 33,3%. K i t qua ndy tuang tg nghidn cuu ciia cdc tdc gid khde tgi Vift Nam [3], cao han so vdi nghidn cuu ciia Rym vd cfng sg (ty If 15%) [6] vd thlp han nghidn cii-u ciia Pal vd Haroon (ty Id 50%) [5].
sd lugng bgch c l u di toan tdng (> 500 TB/pl) gdp d 35,1% sd bfnh nhdn nghidn cu-u.
Kit q u i ndy tuang tg nhu nghidn cii-u ciia cdc tdc g i i khde [6]; cao han nghidn cuu cua Pal vd Haroon (17,7%) [5], thlp han VQ Hdng Thdi (50%) [1].
Thay ddi v l sinh hda
Hifn tugng giam protein mdu chilm ty If 54,4%, trong sd dd cd 13/57 bfnh nhdn (22,8%) giam protein todn phin ehii y l u Id do
gilm albumin. Nguydn nhdn ed t h i do bfnh nhdn DDTTCRCN cd hidn tugng bong vay da nhilu Idm m i t lugng Idn protein vd kha ndng hip thu protein cung nhu dilu kifn nu6i dudng, sinh hogt ciia bfnh nhdn cOng g6p phin gdy gilm protein mdu. Mdt khde trong nghidn cuu eua ehiing tdi da phin Id bfnh nhdn ldn tudi, da sd d ngogi tinh, ddc bift Id a nh&ng vimg ndng thdn, ddi sdng kinh t l kh6 khdn, ndn cd t h i lugng protein cung clp cho ca t h i khdng ddm bdo. Nhu-ng rdi logn khde: ddc bift Id ehue ndng gan, k i t qua ciia Chung tdi t h i y tdng SGOT g f p trong 43,9%, tdng SGPT g f p trong 22,8% trudng hgp, phil hgp vdi k i t qua nghidn ciru ciia cdc tdc gid khde tgi Vift Nam [1, 3]. Rdi loan md mdu gdp trong 57,7%, bao gdm nhO-ng trudng hgp tdng hofc gidm cholesterol.
Thay ddi m i l n djch trong mdu
Trong nghidn ciru eiia ehiing tdi, ed 94,7%
trudng hgp tdng ndng dd IgE trong mdu.
Trong dd 52,6% trudng hgp cd ndng df IgE tdng cao g i g hdng ehge l i n (> lOOOIU/ml).
54
TAP CHf NGHllN CCPU Y HQC Hifn tu-gng tang lu-gng IgE trong mdu d
nhung bfnh nhdn DDTTCRCN cdn dugc quan sdt thiy d nghien cuu cua Thestrup Id 69% [8].
Madalen (1990) cho ring nguydn nhdn tang IgE trong benh DDTTCRCN cd t h i cd vai trd cua khdng nguyen tg d u vdng. Khdng nguydn nay se k i t hgp vdi khdng t h i gdy phan ung di ung Idm tang IgE trong mdu [5].
Thay ddi gidi phlu benh
Hlnh anh md benh hoc cua DDTTCRCN trong nghidn cuu ciia chiing tdi cho thiy phin Idn cac tru-dng hgp la vidm da khdng dfc hifu (chilm 80,7%). Mot sd trudng hgp hudng din vay nln. Tuy nhidn, dga vdo hinh anh md benh hoc cung chua the khlng dinh hay loai tru dugc mpt nguyen nhan gay benh ndo. Bdi vi, theo cac nha nghien cuu md bfnh hoc thi benh do da toan than do mot sd can nguydn khac nhau nhilu khi lai cd hinh anh md bfnh hoc tu-ang tg nhau. Theo Botella va Estrada thi chu-a xac djnh dugc mdi tuang quan giCJ-a lam sang va md benh hpc eiia bfnh DDTT [4].
Do vfy, vifc sinh thiet thuang tdn da d l chan doan md bfnh hoc ddi vdi bfnh DDTTCRCN chl cd finh chit tham khao mot khi khong thdy nhung hlnh anh dac hifu eiia mot bfnh da nao dd. Walsh da d l nghj nen sinh thiet nhilu vj trf da khac nhau, nhilu lan, theo doi trong thdi gian dai k i t hgp vdi huylt dd fim t l bdo Sezary d l cd t h i phat hifn dugc nhti-ng biln ddi cua benh giiip chan doan va dieu tri kjp thdi [2].
Qua trinh filn then cua benh DDTTCRCN cung lam thay ddi hinh anh md benh hoc. Giai doan d p chii ylu-la hifn tugng xdp bao va a strng. Giai doan man thudng thay hinh anh tang gai vd mdo thugng bi bj keo dai ra. Cd t h i vife khao sat mdi tu-ang quan gitra lam sang va md benh hpc se giup chimg ta cd hudng chan doan va xu- trf tdt han.
V. K^T LUAN
Nghidn CLPU 57 trudng hgp bfnh nhdn do da todn thdn chu-a rd cdn nguydn dieu trj nfi trii tai bfnh vifn Da lilu Trung u-ang tu- thdng 10/2008 d i n thdng 7/2009, chimg t6i riit ra mft sd kit lufn v l nhu-ng thay ddi efn Idm sdng nhu- sau:
Thilu mdu gfp trong da sd tru-dng hgp 82,5%.
Sd lugng bach d u tdng > 10 000 TB/pl chilm 35,1%, trong 66 sd lu-gng bach d u di toan tdng > 500 TB/pl cd 35,1%. Khdng fim thay t l bdo Sdzary trong mdu.
Giam protein mdu gdp 54,4%, trong d6 giam albumin mdu chilm ty If 21,1%.
Hau h i t bfnh nhdn DDTTCRNN cd tdng hdm lu-gng IgE trong huylt thanh 94,7%, trong dd 52,6% trudng hgp cd tang trdn 1000IU/ml.
Da sd cdc tru-dng hgp DDTTCRNN cd mo bfnh hoc Id hinh anh viem da man finh khong dac hieu, 80,7%.
Gin nu-a sd tru-dng hgp DDTTCRNN khi d y vi khuan thay 43,9% co tu cau vang gay benh d tren tdn thuang da. Khdng trudng hgp nao d y cd lien c l u .
TAI LIEU THAM KHAO
1. V6 Thj Nhu Huf (2007). Nghien cuu ve bfnh DDTT gdp tai bfnh vifn Da lilu tu 1999- 2004. Sinh hoat khoa hpc ky thuft Da lilu, sd 1:6-19.
2. Hd Vdn Phudc (2007). Sg thay ddi mo benh hoc cua dd da todn thdn do chdm vd vay nln qua phdn tfch cdc trudng hgp tgi bfnh vifn Da lilu ( 2001- 2006). Sinh hpat khoa hpc ky thudt Da lilu, sd 2: 23-27.
3. Vu Hdng Thai, Ngd Minh Vinh, Nguyin Vu Hodng (2008). Khao sdt ddc dilm djch t l hoc, nguydn nhdn, Idm sdng vd can lam sdng eua dd da toan thdn. Sinh hoat khoa hpc ky thudt Da lilu, sd 3.
TCNCYH 77 (6)-2011 55
TAP CHf NGHllN CCPU Y HQC
4. Botella-Estrada R, Sanmartin O, Oliver V et al (1994). Erythroderma: a clinicopathological study of 56 cases. Arch Dermatol; 130: 1503-1507
5. Pal S, Haroon TS (1998). Erythroderma:
a clinieo-efiologic study of 90 cases, Int J Dermatol; 37: 104-107.
6. Rym BM, Mourad M, Bechir Z et al (2005). Erythroderma in adults: a report of 80 cases. Internafional Journal of Dermatology;
44 (9): 731-735.
7. Sehgal VN, Srivastava G, Sardana K (2004). Erythroderma /exfoliative dermatifis: a synopsis. Internafional Journal Dermatol; 43 (1): 39-47.
8. Thestrup-Pedersen K, Halkier- Sorensen L, Sogaard H, Zachariae H (1988).
The red man syndrome: exfoliafive dermatitis of unknown etiology: a description and follow-up.
Summary
LABORATORY CHARACTERISTICS OF IDIOPATHIC ERYTHRODERMA
The study was caried to invesfigate characteristics of laboratory indicators in idiopathic erythroderma. The results showed that, from October, 2008 to July. 2009, there were 57 patients with diagnosis of idiopathic erythroderma hospitalized in the National Hospital of Dermatology and Venereology, Hanoi, Vietnam. The common changes in laboratory indicators found were anemia (82.5%), low level of serum protein (54.4%) and albumin (21,1%), eosinophilia (35.1%). elevated erythrocyte sedimentafion rate (33.3%), high level of serum IgE (94.7%). The histopathology of idiopathic erythroderma was shown to be nonspecific dermatitis (80.7%); S. aureus was found in the skin through culture (43.9%). Seszary cells were not found in any pafient of the study. In conclusion, in idiopathic erythroderma, the changes in laboratory indicators were usually non-specific.
Key words: idiopathic erythroderma, laboratory characteristics
SUY THAT P H A I C A P DO TANG AP DONG MACH P H 6 | SAU
P H A U THUAT BENH TIM B A M SINH TAI BENH VIEN TIM H A NOI
* • • • • •
Ngg Vdn Thanh, Nguyin Vdn Mdo, Trln Mai Hiing va CS Bdnh vidn Tim Ha Np/
Nghidn cuv dwac thwc hidn nhim tim hiiu nhdng biin ddi dp Iwc ddng mpch phdi (ALDMP) vd mOt so dpc diim suy thit phdi cip do tdng dp ddng mpch phdi (TADMP) sau phiu thudt Kit qud cho thiy ALDMP giam PAPs td 79,5 ±13 cdn 44 ± 16,1mmHg (p < 0.001), PAPm tw 54,9 ± 11.8 cdn 33,1 ± 13,2mmHg (p < 0.001), PAPd tw 38,3 ±13,4 cdn 24,4 ±11,3mmHg (p < 0.001) sau phiu thudt Suy thit phdi dp do TADMP 5/27 bdnh nhdn (18,5%), tmng dd 1 bdn.i nhdn td vong sau md xwang uc (3.7%). Td dd cd thi kM lupn, suy tim phdi cip do can tdng dp ddng mpch phdi cd nguy ca tw vong cao sau phiu thudt bdnh tim bim sinh tdng dp ddng mpch phdi ndng.
Tu khoa: bfnh tim bim sinh, can tdng dp phdi nguy clp, phdu thudt tim
Sfi Tr^hinvu 77 /«i _ omi
