NGHIEN ClJfU CAN NGUYEN, DAC DIEM LAM SANG, CAN LAM SANG VIEM PHOI DO VI RUT dTRE EM NHIEM HIV
TAI BENH VIEN NHI TRUNG l/ONG
Nguyen Van Lam', Pham Nh|t An'.
Nghien cuu dugc thuc hien nhSm muc tieu: mo ta dac diem lam sang, can lam sang viem phoi do vi rut 6 tre nhilm HIV/AIDS. Phuongphdp: mo ta, tiin cuu tren 83 benh nhan tii 1 thang - 15 tu6i dugc ch4n doan viem ph6i do vi rut a benh nhan da xac dinh HIV vao Benh vien nhi trung uong tu thang 6/2010 din thang 12/ 2013. Cac benh nhan dugc hoi benh su, tham kham lam sang, xet nghiem mau, dich npi khi quan tim vi khuan, vi nit, lao, nam. Kit qud vd kit lugn: Phan lap dugc 6 loai vi nit. Cytomegalovirus (CMV) co ti le cao nhat chiem 47,5%, tiep theo la Ep- stein - Ban- Virus (EBV) 24,8%, Rhinovirus 10,6%, adenovirus la 9,9%, ciim 4,3% va RSV 2,8%. Mpt tac nhan vi nit don thukn chilm 41%, co toi 59% benh nhi bi d6ng nhilm them mot hoac hai tac nhan khac. D6ng nhilm vi khu4n gap 32,6% va 10,8% co dong nhiem them hai tac nhan. Lam sang sot va ho la trieu chiing hay gap va xuat hien som nhat chiem 85,5% va 86,7%;
Met moi va roi loan y thuc chiem 76,5% va 14,7%; Kho tha chiem 59,0%, tim tai 42,2% va Sp02 < 92% chiem 39,8%; Nghe phoi co ran chilm 78,3% va the trang suy dinh duong chiem 72,3%. XQ phoi mo chiem 66,3% va viem phoi ke gap 28,9%; Cac ton thuang khac 4,8%. Hau het cac truang hgp deu a giai doan suy giam mien dich nang va tien trien (94%), dac bi?t suy giam miln dich nang theo tuoi la 83,2%. Tai lugng vi nit HIV trong mau tren 5.000 copy chilm 39,8% va tang cao 6 nhom hai tac nhan va ba tac nhan ph6i hgp la 47,5 va 55,6%.
Tir khoa: HIV/AIDS, tre em, viem ph6i do vi nit.
DAT VAN DE
Viem phoi (VP) la mot trong nhutig nguyen nhan hang dau gay benh va t i i vong d tre em dudi 5 tuoi cf cac nu^dc dang phat trien, uiclc b'nh 20% t i i vong do VP tren tong so h i vong 6 tre em (JE.f^\ Dich HIV da lam tang tan suat, miic dp nang va t i i vong 6 TE bi viem phoi, theo u'dc tinh cua To chiic Y te the gidi, tren the gicfi co 4 trieu tre em chet vi benh viem phoi moi nam, hau het la d cac nu'dc dang phat trien tai l<hu vut mien nam sa mac Saharat^'.
Tre em bj nhiem HIV co nguy cd chet vi benh viem phoi cao gap 40 lan cac em khad^. Ty le tu* vong do VP/HIV d
•"Bfnh vifn Nhi Trung uang Nf;ay nh^n b i i : 12/3/2015 Ngay phBD blfo song: 22'4/20l5.
Ngay duy^t d i n g : 27/4/2015
N g m i chiu t r i c b nhifm n^i dung khoa h9c: Nguyen Van Ldm. Khoa Truven nhim. Bfnh n j n Nhi Trung uang
Difnihoa, 0903229297. E-matl nguxenvanlam73@gmailcom
benh vien la 7% so vdi 1,5% d tre khong nhiem HIV. Hien nay, viec chan doan can nguyen viem phoi tren benh nhan HIV gap nhieu kho khan, chii yeu dya vao trieu chuVig lam sang, dau hieu X-quang (XQ). Song cac nghien ciiu ve viem phoi d tre em HIV cdn it va chUa day du. Do do, chung toi tien hanh nghien a i u nham muc tieu: (1) Xac djnh c3n nguyen vi rtt gay viem phoi d Ire nhiem HIV (2) Mo ta dac diem lam sang, can lam sang viem phoi do vi rut d tre em bj nhiem HIV.
D O I Tl/ONG VA PHUONG PHAP
Doi Wcfng: Tat ca cac benh nhan tir 1 thang tuoi -15 tuoi du'dc chan doan viem phoi do vi nit tren benh nhan 6a xac dmh HIV vao vien tir thang 6/2010 den thang 12/2013. 77eu chuan chgn benh nhan: Tre tir 1 thang -15 tuoi xac d[nh la viem phoi do vi rut d benh nhi HIV vao dieu tn tai khoa truyen nhiem Benh vien Nhi Taing udng.
Tieu chuan chan doan viem phoi cua To chiTc y te the gidi
6 8 - TRUY6«NHlfeMV1$TNAM*s6 2 ( 1 0 ) - 2 0 1 5
(WHO): Ho, sdt, nhjp thd nhanh (> 60 Ian/phut d tre < 2 thang tijoi, > 50 Ian/phut d tre 2 - 1 2 thang tuoi, > 40 Ian/phut d tre > 1 tuoi), cd the cd nit lom long ngiic, nghe phoi CO the cd nhieu ran am nhd hat hoac kem theo ran rit, ran ngay. Ngoai ra neu viem phdi nang benh nhan cd the tim tai, kho thd nang hdn, roi loan nhip thd va cd tiie ngutig thd, nhjp tim nhanh, gan to va cd the co bieu hien ciia suy tim-ngCrng thd. Oe xac djnh chan doan co the dya vao cd dau hieu ton thu'dng tren phim chyp phoi. Xet nghiem d[ch NKQ du'dng tfnh vdi vi nit bang phu'dng phap PCR. Chan doan HIV; Tre tren 18 thang xet nghiem mau dude khang dinh cd khang the HIV du'dng ti'nh vdi 3 loai sinh pham khang nguyen khac nhau. Tre dUdi 18 thang cd xet nghiem PCR vdi HIV - DNA du'dng tinh. Tieu chuan loai tni: Tre dudi 18 thang tudi co viem phoi vi rut va xet nghiem khang the HIV du'dng tinh nhuTig xet nghiem PCR vdi HIV - DNA am tinh.
Dja diem nghien cu'u: Khoa truyen nhiem, Benh vien Nhi Trung u'dng.
Phu'dng phap: Thiet ke nghien cdu: Nghien CLTU tien ciiu, mo ta cat ngang. Phddng phap chon mau: Chpn tat ca benh nhan vao nam dieu tri tai khoa truyen nhiem benh vien nhi trung u'dng dap iing du tieu chuan chpn benh nhan.
Npi dung nghien ciiu: Noi dung nghien culi du'dc ghi chep vao mpt mau benh an thiet ke rieng phuc vu cho nghien ciru. Benh nhan du'dc hoi benh sii, tham kham lam sang, xet nghiem mau, dich npi khi quan tim vi khuan, vi rut, lao, nam.
KET QUA
Nghien ciru du'dc tien hanh tren 83 benh nhan nhiem HIV mac viem phoi do vi riit dap iihg day du tieu chuan ly'a chpn va khong cd bat ky cac chong chi djnh ve cac tieu chuan loai trir, nhap vien vao khoa Truyen nhiem Benh vien Nhi Tnjng Udng tirthang 6 nam 2010 den tiiang 12 nam 2013. Ket qua nghien ciiU thu du'dc nhu* sau: Gid^:
nam/nu': 44/39 = 1,3/1; Tuoi: nhom tuoi < 12 thang tuoi chiem ti le cao nhat 34 ca (4,0%), tiep theo la nhdm tii 1 tuoi - < 3 tuoi 23 ca (27,7%), nhom > 5 tudi 16 ca (19,3%) va nhom tir 3 tudi - < 5 tuoi 10 ca (12,0%). Ty 1^ h i vong: 14/83 chiem 16,9%.
Tac nhan va can nguyen viem phoi Bang 1 : Phan loai can nguyen viem phoi theo
sd benh nhan xet nghiem ( + )
^~'~~~'~~~~~,^^^^^^^ Benh nhan Can n g u y e n ^ — ^ , , _ ^ ^
Mot vi rut ddn thuan Can nguyin phoi htip Vi khuan + Vi nit VinJt + Lao Vi nit + Nam VinJt + PCP Vi nit +Nam+lao Vi nit +Nam+PCP Vi khuan + Vi nit+PCP Vl khuan + Vi nit+Lao Vl khuan + Vi nit+Nam
SoluVng benh nhan: 83
34 49 27 5 3 3 1 1 1 5 3
Tyri<Ki 100 41,0 5,0 32,6 6,0 3,6 3,6 1,2 1.2 1,2 6,0 3,6
So benh nhan cd 1 can nguyen la 34 chiem 41,0% va can nguyen ket hdp la 49 tru'dng hdp chiem 59,0%, trong do phoi hdp giiia vi rut va vi khuan 27 tru'dng hdp (32,6%), con lai 3 can nguyen phoi hdp (VK, Lao, Nam/PCP) 9 tru'dng hdp (10,8%).
Bang 2: Can nguyen virut theo m l u xet nghiem du'dng tmh
Loai virut CMV EBV Rhino Adeno Cum RSV Tong
So lu'dng benh nhan 67 35 15 14 6 4 n = 141
Tyie%
47,52 24,82 10,64 9,93 4,26 2,84 100
Tren 83 benh nhan lam xet nghiem, tong so 141 xet nghiem can nguyen virut thi CMV chiem ty le cao nhat 47,52% va thap nhat la RSV chiem 2,84%.
Dac diem lam sang
Bang 3: Trieu chiing cd nang
Lam sang Sot Non iaiong hio Tiitngut
Virut 34 29(85,3)
3(8,8) 11(32,4) 29(85,3) 1(2,9)
Virut+1 tac nhan Viriit+Z tac nhin 40 9 33(82,5)
6(15) 16(40) 36(90) 2(5)
9(100) 1(11,1) 4(44,4) 7(77,8) 0(0}
83 71(85,5) 18(12,0) 31(37,3) 72(86,7) 3(3,5)
TRUY6UNHl6MVieTNAM*s62(10) - 2015 - 6 9
Ho, sdt la trieu chiing thudng gap va xuat hien sdm nhat chiem 86,7 va 85,5%.
Bang 4: Trieu chuTng thu'c the
Lim sang TTietrang SDO
Pliat ban XuKtiuya - Mama
Ra loan y thjc Oiu^bung Ganto lidita
Hadingoa<vi Viiiit
26(76,5) im)
0(0) 26 (76,5) 5(14,7) 0(0) 18 (52,9) 7(20,6) 7(20,6)
VR+ltacnhan
(«)
27(67,5) 6(15) 0(0) 26(65) 6(15) 0(0) 27(67,5)
12(30) 6(15)
VR+2tacnlian (9) 7(77,1) 1(11,1) 2(22.2) 7(77,8) 2(22,2) 3(33,3) 3(33,3) 2(22,2) 3(33,3)
83 60(72,3) 10(12,0) 2(2,4) 59(71,1) 13(15,7) 3(3,6) 48 (57,8) 21 (25,3) 16(19,3) The trang suy dinh dudng chiem ty le 72,3%. I 71,1% va rdi loan y thiic chiem 15,7%.
Bang 5: Trieu chiing ho hap
Lam sang Kliothfl Canh miJi phap phong Oau 9it gii Rut 13m nggt Rollo^nthilr Tim tai Ngjjtigthcl SP02<92 Phoi CO ian
VI nit (34) 21 (61,8) 16 (47,1) 9(26,5) 17(50) 0(0) 16(47,1)
0(0) 16(47,1) 27(79,4)
m + t t a c nhan (40) 23(57,5) 13(32,5) 8(20) 16(40) 1(2,5) 16(40]
1(2,5) 15(37^
32 (BO) VR+2lxnhSn
(9) 5(55,5) 2(23,2) 1 (11,1) 2(22,2) 0(0) 3(33,3) 1 (11,1) 2(22,2) 6(66,7)
83 49 (59,0) 31(37,3) 18 (21,7) 35 (42,2) 1(1,2) 35 (42,2)
2(2,4) 33 (39,8) 65 (78,3) C:ac trieu chu)ig ve ho hap rat nang va cap tinh nhu*
Itho thd CO ti le l<ha cao chiem 59%, tim tai 42,2% va 2,4% CO bieu hien ngimg thcr l<hi vao vien. Phdi co ran cung chiem tS\ 78,3%.
Oac diem can lam sang Oac diem XQ phoi
Bang 6: Bleu hien tren piiim cliup XQ plioi T i c nhSn
VI rut Vi rut + 1 tic nhan Vi nit + 2 tac nhan Tong
n 34 40 9 83
X Q m d i r i i S i 25(73,5) 25(62,5) 5(55,6) 55(66,3}
V P k e 9(25,5) 12(30,0) 3(33,3) 24(28,9)
Khac 0
1(11,1) 4(4,8) XQ phoi md gap 55 trudng hap chiem 66,3% va viem phoi ke gSp 24 tmdng hdp chiem 28,9%, cac ton thUdng l<hac gSp 4,8%
Sac diem suy giam mien djcli theo T-CD4 Bang 7: Can nguyen va suy giam mien djdi
Tac nhan Virut Vl rut + I tac nhan Vi rut + 2 tac nhan
Tong Khong
0(0,0) 1(2,5) 0(0,0) 1(1,2)
Nhe 2(5,9) 2(5,0) 0(0,0) 4(4,8)
Tien trien 2(5,9}
4(10,0) 3(33,3) 9(10,8}
N^ng 30(88,2) 33(82,5) 6(66,7) 69(83,2)
Tong 34 40 9 83
Hau het cac tru'dng hdp deu d giai doan suy giam mien djch nang va tien trien (94%) trong do suy giam mien dich nang theo tuoi la 83,2%.
Bac diem tai lW0ig Virut
Bang 8: Can nguyen viem phoi va tai lu'dng HIV
Tac nhan VinJt Vl nJt + 1 tac nhan
\fi nit + 2 tac nhan Tong
du'di nguSng 24 (70,6) 16 (40,0) 4 (44,4) 44 (53,0)
<1DOO ] 0(0,0) 4 (10,0)
0(0) 4 (4,8)
L0OO-<5DaD >5000 1 (2,9) 1 (2,5) 0(0) 2(2,4)
9(25,5) 19 (47,5) 5(55,6) 33 (39,8)
Tong 34 40 9 83 Cac trudng hdp co tai IUdng vi rut HIV trong mau tren 5.000 copy chiem 39,8% va dac biet tang cao d nhom hai t i c nhan va 3 tac nhan ia 47,5 va 55,6%.
BAN LUAN
KIghien ciiu ciJa chung toi co 83 benh nhi bi viem phoi do vi rut (bang 1) cho thay chi co 34 benh nhi bi viem phoi do mot tac nhan vi nit chiem 4 1 % , con lai 49 benh nhi deu phoi hdp 2 hoac 3 t i c nhan la vi Ithuan, lao, nam va PCP chiem 59%. Trong cac can nguyen phoi hdp thi vi khuan va vi rut gap cao nhat 27 trudng hdp chiem 32,6%.
Ngoai ra phoi hdp 3 can nguyen trong nghien cutJ cua Chung toi cung gap 9 trUdng hdp la vi khuan, vi rut va lao, nam hoac PCP chiem 10,8%. Trong khi d bang 2 Chung toi thu dUdc 141 mau xet nghiem dUdng tinh vdi 6 loai vi njt khac nhau la CMV, EBV, rhinovius, adenovirus, RSV va cum. Theo cac nghien cuU viem phoi tren tre HIV d Nam Phi cho thay can nguyen do vi njt chiem tU 22-78% trang do CMV cao nhat chiem 47 - 51%I>1. Theo Cristina O'Callaghan - Gordo ti le Viem phoi do Vi rijt d b|nh nhi HIV cao gap 5,5 - 1 6 lan so vcB he thudng, ti le cac Vi nJt gap trong nghien ciJu nay theo thU tU la Rhino 30%; Cum 25%; Adeno 24%; EV 14% va RSV 10%Bi. So vdi ngu'di ldn, theo nghien ciJu ciJa Kibiki va CS. cho thay can nguyen Vi khuan 29,2%; Lao 23,3%; Nam l l , 7 % i i i , theo
7 0 - THUY6UNH*MVieTNAI«* SO 2(10)-2015
Nguyen Tien I j m Benh vien Benh nhiet ddi Trung u'dng ti ie VI khuan la 70%; Nam 24% va Lao 10%f3. Theo Marco Zampoli va CS. d chau Phi cho thay do Vi nit chiem 54%;
Nam 27% trong khi thu" tu" ciia cac vi nit phan lap du'dc ia CMV 36%; RSV 19%; Adeno 9% va Ciim 4%; 17% cd ti^
2 tac nhan dong nhiem va 43% khong tim thay nguyen nhan'^. Nghien ciili ciia chiing toi phan lap dUdc 6 loai vi nit, Cytomegalovirus (CMV) cd ti le cao nhat chiem 47,5%, tiep theo la Epstein - Barr Virus (EBV) 24,8%, Rhinovirus 10,6%, adenovirus la 9,9%, ciim 4,3% va RSV 2,8%.
Ve dSc diem lam sang ciia viem phoi vi riit tren benh nhi HIV d bang 3 cho Oiay sot va ho la trieu chiitig hay gap va xuat hien sdm nhat chiem 85,5% va 86,7%. Bang 4 cho thay bieu hien met mdi va roi loan y thu'c the hien tre vao vien trong tinh trang nang chiem ti le la 76,5% va 14,7%. The trang SDD chiem tdi 72,3%. Nhu" vay day cung la yeu to cd dja rat thuan Idi cho cac nhiem trung cd hpi gay benh cho tre bj HIV. Bang 5 cho thay cac trieu chutig ve ho hap d benh nhi viem phoi/HIV khi vao vien rat nang ne nhu" kho thd chiem 59,0%, tim tai 42,2% va Sp02 < 93% (khong co 02) cung chiem 39,8%. Nghe phoi CO ran chiem 78,3%. Nhu" vay trong nghien cutJ ciia chiing toi cho thay khoang 60% tre vao vien trong tinh trang viem ph6i n|ng va cd suy ho hap.
Ve XQ phoi (bang 6) the hien XQ phoi md gap 55 tru'dng hdp chiem 66,3% va viem phoi ke gap 24 tnj'dng hdp chiem 28,9%, cac ton thu'dng khac gap 4,8% va chi gcip d cac can nguyen phoi hdp.
Ve suy giam mien dich theo tuoi (bang 7) hau het cac tru'dng hdp deu d giai doan suy giam mien dich nang va tien trien (94%) dac biet suy giam miln dich nang theo tuoi la 83,2%. Day cung la yeu to lam cho tre rat d l mac viem phoi do vi riit ma dac biet la bj nhiSu tac nhan dong thdi lam cho benh rat nang va rat khd dieu tri, ti le td vong
cao 16,9%. Ve tai lu'dng vi nit HIV (bang 8) chi ra cac tru'dng hdp cd tai lu'dng vi rut HIV trong mau tren 5.000 copy chiem 39,8% va dac biet tang cao d nhdm hai tac nhan va ba tac nhan phoi hdp la 47,5 va 55,6%. Oieu nay cho thay rat can thiet chan doan sdm tre nhiem HIV va dieu tri bang thuoe khang vi nit HIV (ARV) cho tat ca tre em du'di 5 tuoi nhiem HIV ma dSc biet la tre du'di 2 tuoi nhu' phac do ciia Bo Y te hien nay, gop phan lam giam ti le mac va ti le tir vong do viem ph6i d tre em nhiem HIV.
KET LUAN
Nghien cufu 83 benh nhi HIV bi viem phoi do vi riit chiing toi rut ra mpt sd ket luan sau:
1. Phan lap du'dc 6 loai vi nit, Cytomegalovirus (CMV) cd ti le cao nhat chiem 47,5%, tiep theo la Epstein - Barr Virus (EBV) 24,8%, Rhinovirus 10,6%, adenovirus la 9,9%, ciim 4,3% va RSV 2,8%.
- Mpt tac nhan vi riit ddn thuan chiem 4 1 % . - Vi rut vdi mpt hoac hai tac nhan khac 59%.
- Vi nit vdi vi khuan gap 32,6%.
2. Lam sang cd sot va ho la trieu chutig hay gap va xuat hien sdm nhat chiem 85,5% va 86,7%; met mdi va roi loan y thu'c 76,5% va 14,7%; khd thd chiem 59,0%, tim tai 42,2% va Sp02 < 92% cung chigm ti le 39,8%;
nghe phoi cd ran 78,3% va the trang SDD: 72,3%.
XQ phoi md chiem 66,3% va viem phoi ke gap 28,9%, cac ton thu'dng khac 4,8%.
Hau het cac tri/dng hdp deu d giai doan suy giam mien djch nang va tien trien (94%), dac biet suy giam mien dich nang theo tuoi la 83,2%. Tai lu'dng vi rut HIV trong mau tren 5.000 copy chiem 39,8% va tang cao d nhdm vi riit ket hdp vdi mot hoac hai tac nhan la 47,5%
va 55,6%.
TRUYENNHliMVl6TNAM*s62(10) - 2015 - 7 1
TAI UEU THAM KHAO
1. Zar K) (2004). Pneumonia in HIV-infected and - un- infected children in developing countries: epidemiology, dinicai features, and management. Curr Opin Pulm Med.
2004 May; 10 (3): 176-82.
2. Cristina O'Callaghan-Gordo, Quique Bassat. (2011), Etiology and Epidemiology of Viral Pneumonia Among Hospitalized Children in Rural Mozambique. A Malaria En- demic Area With High Prevalence of Human Immunodefi- ciency Virus, Pediatr Infect Dis J; 30: 39 - 44.
3. Kibiki GS, Beckers P, Mulder B et al (2007). Aetiol- ogy and presentation of HIV/AIDS-associated pulmonary
infections in patients preventing for bronchoscopy at a re- ferral hospital in northern Tanzania. East Afr Med J. Sep;
84(9): 4 2 0 - 8 .
4. Nguyen Tien Lam (2011). Nhan xet ve can nguyen gay nhiem trung du'dng hd hap tren 50 benh nhan AIDS du'dc npi soi phe quan tai benh vien nhiet ddi trung u'dng nam 2011, Bp y te, Y hpc thu'c hanh so 781 - 2011.
5. Marco Zampoli, et al (2011). Prevalence and Out- come of Cytomegalovirus-associated Pneumonia in Rela- tion to Human Immunodeficiency Virus Infection, Pediatr Infect Dis J;30: 4 1 3 - 4 1 .
EnOLOGY, CLINICAL AND SUB-CLINICAL FEATURES OF VIRAL PNEUMONIA AMONG HIV- INFECTED CHILDREN TREATED AT THE
NATIONAL HOSPHAL OF PEDIATRICS ( 6 / 2 0 1 0 - 1 2 / 2 0 1 3 )
Summary
The aim of this study is to describe the clinical and sub-clinical features of viral pneumonia among HIV - in- fected children. Subjects and methods: Longitudinal de- scriptive study with 103 patients from 1 month -15 years old who was diagnosed with pneumonia In HIV at the Na- tional Hospital of Pediab-ics from april 2010 to april 2012.
The history, examination, chest radiology images and blood tests (including bacterial culture and HIV testing) were collected. Bronchoalveolar lavage (BAL) was ob- tained for bacteria, vinjs, fungus, TB detection. Results and conclusions: 6 viruses were isolated. CMV was high- est 47.5%, followed by EBV 24.8%, Rhinovirus 10.6%, adenovirus 9.9%, influenza 4.3% and RSV 2.8%. One pathogen accounte for 4 1 % , 59% had co - infection from
Keywords: HIV/AIDS, children, viral pneumonia.
one or two other pathogen. Co-infection with bacteria ac- counts for 32.6% and 10.8% had co-infection from two pathogens. Fever and cough were the commonest and earliest symptoms, aaounting for 85.5% and 76.7% re- spectively; tiredness and altered conciousness 76.5% and 14.7%; dyspnea 59.0%; cyanosis 42.0%, SpO; < 92%
39.8%; pneumonia rales 78.3% and malnutrition 72.3%.
Images with opaque in the lung accounts for 66.3%, in- stitial pneumonia 28.9%, other lesion 4.8%. Almost cases were severe and progressing immunodeficiency (94%).
Viral load with more than 5000cp/ml accounts for 39.8%
and higher in patients with two or three pathogens (47.5 and 55.6%).
7 2 - T R U Y t e N H i i M V l | T N A M * s 6 2 ( 1 0 ) - 2 0 1 5
