BAO CAO TRJONG HOP B^NH NHAN LAO TANG (SCROFULODERMA)
Iran Thj Huyen, Nguyen Hong Son*
I . G l d l T H l f U
Trong nhCfng n i m gan d i y cd sU gia t i n g benh lao ndi c h u n g v i lao da ndi r l l n g [3], Nguyen nhan cd t h e d o sii d u n g c i c thuoc ufe che mien dieh ngay c i n g nhieu, dai dich HIV/
AIDS va sU p h i t t h e n d u tjeh, di cU, n h i p cu.
Tuy nhien, lao da la m d t b e n h k h d n g p h o bien va khd chan d o i n nen nhieu trUdng h g p benh khdng dugc dieu trj sdm. Cd nhieu t h e Iao da k h i c nhau, t r o n g do lao t a n g l i m d t t h e tao da ma d nhiem khuan ban dau cd t h e l i tii hach, xuong hoac cac t o chijfc khae. Chiing tdi xin gidi thieu m o t t r u d n g h g p b e n h nhan scrofuloderma dugc chan doan m u d n n h u n g d i p l i n g t d t vdi cac thudc chong lao.
II. MO TA T R l / d N G HGfP BENH
Benh n h i n nam 25 t u d i , bj khiem t h j tii nhd, tam nghe hat rong. Benh dien bien 3 n i m nay (tii n i m 2009). ThUOng t o n ban dau la 2 khdi viem, nhd cao, vj tri: hai ben co, gan gdc ham.
Thuang t o n ve sau ed mUng m u , c h i y djch, mCi vang, cd noi t u lanh, khi lanh de tai seo m i u d d tim, nhan n h i i m . Sau d d xuat hien t h e m nhieu thuong t d n m d i phfa d u d i , dgc theo vdng ed vdi cac tfnh chat va d i e n bien t u o n g t u , tao thanh
dam loet tdn, c h i y djch m u , lau lanh, khi l i n h tao thanh seo eo keo han che van d d n g cd. Mpt n i m nay xuat hien t h e m t h u o n g tdn d trudc nach trai. Benh n h i n d i duac d u n g thude theo hudng lao t r o n g 3 t h i n g , benh khdng dd, ngay eang cd nhieu t h u o n g t o n loet hon. Khdng cd tien si!r chan t h u o n g , khdng sot, khdng ho keo dai, khdng hut thuoc la, khdng nghien ma tuy, khdng sCf d u n g cac thuoc tie ehe mien djch.
Khdm Idm sang Thuong ton coban:
• Loet kfch thudc tdn d quanh co, dudi ham, sau tai, tao hinh v o n g cd, nhieu v i y tiet vang, khd hoac Udt, c h i y mCi trang khi an xudng.
• Xung quanh l i cac seo m i u d d t i m , eo keo da lanh.
• 6 giCfa cdn v u n g da lanh.
• Khdng cd c i c lupome.
• Thuong t o n vdi tfnh chat tUOng tU d trUdc nach trai
• Hach CO hai ben to, an dau, di ddng, rd mCi (hinh 1,2,3)
Toon than ' The trang gay (39kg)
• Khdng sot
• Han che van d d n g cd
* Benh vien Da liiu Trung uamg.
S6 08 (Thang 11/2012) D A L I E U H O C 4 5
Difin Din
Thuang tdndcS Thuang tdn dc6 TrUdc trin nquc trdi
Hinh 1,2,3. Thitang tdn Id cdc ddm loit, chdy mu trdng, nhliu vdy tii't ddy, vdng hoac den,
khi Idnh di'lgl seo mdu tim co kio da Idnh. Nhliu 6 rd mi) tCtdUdi lin.
Hach c6 hai bin to, dn dau, di ddng, rd mu
Cdc xit nghlim:
• Phin Lfng tuberculin duong tinh (sin phu miu dd, 12 mm dUdng kinh)
• Nhudm soi khdng thay trUc khuin khing cdn, khing toan (AFB).
• PCR tim lao am tinh (hai tan).
• Nudi ciy/Wycobocrenumim tinh.
• Giai phau benh: phin ufng nang vdi sU ed mat cua te bio da nhin khdng Id, te bio b i n lien, cae te bao vilm, khdng thiy trUc khuin khing cdn khang toan.
• Cd nam Candida tai thuong ton, khdng co nam siu.
• Nudi ciy vi khuan i m tinh.
• Miu ling:
^ 1 gid: 86mm
•^ 2 gid: 94mm
• X-quang tim phdi: khdng cd hinh anh cua lao: Idng ngUc cin ddi, hai phe trudng sing deu, khdng cd hinh i n h tao xuong, lao phdi.
• Dinh lugng t l baoTCD4:525 te bao/\i\.
B ;
4.;
/ :
Hinh 4,5. Md benh hgc thuang tSn da: phdn Crng nang vdi sUcd mat cda tebdo da nhdn khong Id, tebdo bdn lien, cdc tibdo viem, khdng thSy trifc khudn khdng cdn khdng toan (A: Tebdo da
nhdn khdng Id; B: Tebda bdn lUn)
4 6 I D A L I E U HOC S6 08(ThSng11/2012)
^i-i-
DiSn D i nC i c c h ^ n d o i n d u g c c h i i n g tdi dat ra la: Mycobacterium khdng dien hinh, tao tang, benh nam actinomyces, g d m giang mai, v i l m NhOng d i e m p h i i h g p v i khdng phu hgp dugc da mii hoai thU, lupus tao, l o l t lao, benh do t d m t i t t r o n g b i n g sau:
D l l m ph6 hgp Diem khong phCi hgp
Actinomycose
Vi trf thuong tdn: cd Thuong tdn co b i n : lo^t, chiy mO vang, cdmau
Hach cd to
Nhuom sci v i nuoi ciy khong t h i y nam siu Mo benh hoc khdng c6 nam, ma cd p h i n iJng nang
Gom giang mai T i l n t r i l n cCia thudng tdn, dac diem ciia thuong tdn
Khong c6 cic trieu chijfng khic ciia giang mai 3 Phin ijfng huyet thanh giang mai am tinh
Viem da mii hoai thu
Thuong tdn loet, chiy mau, mii, dau nhieu, xet nghifem khong thay nam, vi khuan
Khdng c6 bd mau tfm dien hinh
Chua loai trCf dugc het cac nguyen nhan khac nhUmycofaoctenum
BenhdaM. awum Tfnh chat cOa thuong ton Xay ra tren cd dia khong suy giam mien djch
Lupus Iao
Phan Lfng tuberculin dUong tinh Mo benh hpc cd p h i n ufng nang, khdng cd true khuan khang con khang toan tai thuong ton
Khong cd cac cii lao Khong lanh seo dgiOa Nang lao khong cTten hinh Cothuongton hach PCR lao am tfnh Nuoi cay lao am tinh
Vi tri thuong ton Oac diem loet Co dia gay yeu
Phin iJng tuberculin duong tinh Mo benh hoc khong thay trUc khuin lao
Vi tri thuong ton Tien trien cua thUong tdn Thuong tdn da-hach Phan ling tuberculin duong tinh Md benh hoc c6 p h i n ling nang Tdc dp mau lang tang
PCR lao am tinh Nuoi cay am tinh
So 08 (Th^ng 11/2012) D A L l 6 U H O C I 4 7
DiSn Din
Vdi chin doin l i tao ting ed nhilu dllm phii hgp nhit v i sau 3 thing dllu trj bing thude chdng tao (rifamplcin, ethambutot.
streptomycin, Isoniazld, pyrazinamid), thuong tdn da d i p ting t6t, khdng cdn 16 rd, h i t mii va viy tilt, tin seo tdt (hinh 6,7,8).
Hinh 6, 7,8. Thtfcfng ton tien trien tot sau 3 thdng dieu tri bdng cdc thuoc chong lao:
khong con lo ro, het mO, het vdy tiet, khong co tht/ang ton mdi.
III.BANLUAN
Lao da la mpt benh ft gip, vdi tl Ie 3,5%
trong sd cic benh nhin tao ndi tang [5].
Scrofuloderma ed ngudn gdc tii lao xuong, khdp, hach [2]. Trudng hgp benh nhin cua ehiing tdi nghT nhieu tdi ngudn gdc lao hach vi ban dau cd nhilu thuong tdn hach to, chiy mCi.
Tren phim chup tim phdi khdng thay thuong tdn tao d xuong, phdi. Mac du xet nghilm nudi eay vi khuan, PCR vdi tao i m tfnh nhung chan doin lao tang la phu hgp nhat vi h'tnh i n h lam sing khi dien hinh, tren hinh i n h mo benh hoc cd phin ling nang tao vdi sU cd mat cCia t l bao ban lien, te bao da nhin khdng td, nhilu bach cau lympho. Mat khac benh nhin nay d i p ufng rat tdt vdi cae thude chdng tao.
Mac du nudi cay tao duong tfnh la tieu chuan ving d l chan doin benh tao, PCR ed t h i cd dp nhay cao hon nudi cay. Mdt Uu diem khic cCia PCR ti cho phep chan doan sdm va xiy dUng phac dd dieu tri eho nhu'ng benh nhan niy.
Nghien cOu eCia Negi so sanh do nhay cua xet nghiem PCR vdi nhudm soi thdng thudng bang Zieht-Neelsen (ZN), nudi cay tren mdi trudng Lowenstein-Jenssen cho thay su khic biet cd y nghia ve do nhay nhu sau: PCR 74,4%; nhudm soi ZN 33,79%; nudi eay 48,9%. Vdi benh nhin cCia chOng tdi, k i t q u i PCR i m tinh trong c i hai tan xet nghiem, dieu nay, mdt phan, ed the do benh nhin da duge dieu trj bang thudc chdng tao trUdc dd hoae lay mau benh pham khdng chfnh xae. Cic t i c gia d Singapore cho ring khi nghi ngd thuong tdn lao ft vl khuan, ket qui PCR i m tinh khdng loai trii dugc chan doin tao da, nhUng khi kit qui dUOng tinh cd the cCing cd t h i m chan doan tao da v i benh nhin nen difOc diiu tn bing thudc chdng tao [4]. Mot nghien cufu khic eho thay chi cd 1 trong 3 benh nhan scrofuloderma cd k i t q u i PCR duong tfnh va benh nhan do ciing cd ket qua duong tfnh khi nhudm soi v i nudi cay M. tuberculosis [^ ].
Sau 3 thing dieu tri bSng thudc chdng tao
4 8 I DA LI^U HOC S6 08 (Thdng 11/2012)
ket hgp vdi cat tgc t h u o n g t d n , dan tUu m u , t h u o n g t d n cOa b e n h n h i n t i e n trien t d t , t o i n trang cCia b e n h nhan dugc cai t h i e n , chat lugng cudc sdng t d t h o n , xet n g h i e m chiic nang gan than t r o n g gidi han b i n h t h u d n g , k h d n g cd bieu hien di tifng vdi t h u o c c h o n g tao. Hien tai benh nhan van tiep tuc u d n g t h u d c chong lao vdi hai loai ethambutot va isoniazld theo phac d d dieu tri tao da.
IV. K^T L U A N
Lao t i n g la m d t t h e lao da hiem gap, eac xet nghiem 6i chan d o i n t h u d n g ft khi cho ket q u i d u o n g t i n h do d d v i l e chan d o i n t r d nen khd khan hon. Khi trieu c h i i n g l i m sang got y lao tang v i cd xet nghiem cCing cd chan doan, benh n h i n nen dugc dieu t n kjp t h d i b i n g c i c thudc chdng lao.
T A l L I f U T H A M K H A o
1 . Arora SK, Kumar B, Sehgal S.Development of a polymerase chain reaction dot-blotting system for detecting cutaneous tuberculosis. Br J Dermatol 2000; 142:72-6.
2. Fitzpatrict's d e r m a t o l o g y in general medicine (2010), Tuberculosis and Infections with Atypical Mycobacteria, p. 1769-1788.
3. Kivanc-Altunay I, Baysal Z, Ekmekci.
Incidence of cutaneous tuberculosis in patients with organ tuberculosis. Int J Dermatol 2003;
42:197-200
4 . Tan SH, Tan H H , Sun YJ, Goh CL. Clinical utility ofpolymerasechain reaction in thedetectlon of Mycobacterium tuberculosis In different types of cutaneous tuberculosis and tuberculosis. Ann Acad Med Singapore 2001; 30:3-10.
5. Yates V M , Ormerod LP. Cutaneous tuberculosis in Blackburn district (U.K): a 15-year prospective series, 1981-95. Br J Dermatol 1997;
136:483-9.
S6 08 (Thang 11/2012) D A L l E U H O C I 4 9
