TCNCYH Phu truung 80 (3A) - 2012
DAC DIEM LAM SANG, CAN LAM SANG BENH NHAN VIEM PHOl DO CYTOMEGALO VIRUS
Doan Thi Mai Thanh\ Nguyen Thanh Liem\ Hoang ThuyLon^
''Benh vien Nhi Trung wang,^VIen Ve sinh Dich ti Trung wong
Cytomegalovirus (CMV) ngay cang cd ty ie mdc cao d nhdm bdnh nhdn khdng thudc nhdm suy gidm miin dich mac phai Bdng phwong phdp nghien ciru tidn cwu. md ta 1 loat trwdng hap cho 61 bdnh nhdn vidm phii do CMV dwoc didu th tai khoa Hd hip, bdnh vidn Nhi Trung wang tw 1/2010 - 12/2011 thu dwoc kit qua nhw sau Da s6 binh nhdn dwdi 3 thdng tudi. benh didn bidn kdo dai > 7 ngdy S6t nhe, ho. khd tha vdl thdng klii phd' gidm ran dm hay gap > 90%, bdnh nhi. gan to > 50% trwdng hop. Bach ciu tdng chu ydu la tang bach ciu lym pho, CRP khdng tang (80,33%>), men gan tdng (50,82%o), Xquang phii tin thwang phdi ke Tdi luong vl rut CMV trong mdu 667 040 ± 2 744 760 copies/ml, thdp nhit 5000 copies/
ml. cao nhdt: 20.000.000 copies/ml nhiiu nhit 56 020 copies/ml vd sd Iwang CDA vd IgG giam Bidu hien Idm sdng cua vidm phdi do CMV khdng dac hieu. Thdu chwng hay gap cd tinh chit gai y chin dodn
• la' viem phdi keo ddi tren 1 tuin, sdt nhe, suy hd hip dai ding, gan to, khdng dap wng vdi diiu tn khdng sinli. Xquang cd hinh dnh vidm phdi kd Xdt nghiem midn dich ti bao gidm.
Tip khoa: Cytomegalovirus, viem phli, lam sang, can lam sang I. DAT VAN DE
Viem phli la benh ly pho biln d tre em vd nguyen nhan thudng la do virus Trude day, cac nghien cuu v l Cytomegalovirus (CMV) chl tap ehung chu y l u d nhdm benh nhdn c6 suy giam miin dich mae phai nhu HiV, sau ghep tang, sau ghep tiiy xuang, sau dtlu tri hda ehlt Tuy nhien hien nay ngudi ta thly ring CMV khdng ehi gdy benh d nhdm benh nhan suy giam miln dich mac phat ma cdn d nhdm benh nhan khdng suy giam mien dich.
6" nudc ta chu'a cd nghien ei>u ve viem ph6i tre em do CMV. Tai benh vien Nhi Trung uang ca benh d i u tten nam 2003. Chiing t6i tten hanh nghien eiru nay nhim muc tieu Mo ta dac diem lam sang, can lam sang cua tre bi viem phoi do Cytomegalovirus.
II. D 6 | TU'gNG VA PHU'ONG PHAP 1. Odi tu'O'ng nghien CLPU
Bao gom C 1 oenh nhan duac ehln doan xac dtnh la viem phlt do CMV vao dtlu trj tai khoa Ho hap, benh vien Nht Trung uang tir
thang 1/2010- 12/2012 - Tieu chuan chon benh nhan:
+ Benh nhan viem phdi theo tieu ehuin cua WHO 2006
+ PCR CMV mau va dich ndi khi quan duang tinh vdt tai luang virus tren 5000 copies/ml-
+ Benh nhdn duae dtlu tn bing thule khang vl rut dap irng,
- Tieu chuan loai trir.
+ Cae benh nhan thude nhdm suy gtam miin djch mac phai (HIV, sau ghep tang, sau ghep tuy xuang, sau dilu tri hda chat).
+ Cha me benh nhan tir chit khdng tham gia nghien ciru.
2. PhU'O'ng phap nghien ciPu
Phuang phap tiln eiru, mo ta mdt loat trudng hgp.
Cac th6ng s l duae nghien ciru bao g i m : tuli, gidt, tiln sir san khoa, tien sir nuoi
125
TCNCYH Phu tmung 80 (3A) - 2012
dudng, thdi gian bi benh, trieu ehirng ca nang (sit, ho, kho khe), trieu chirng thuc t h i (nhip thd, d i u hieu riit lom ling nguc, co keo ca ho hip, tim moi va dau chl, Sp02, nghe phli phat hien cae ran benh ly tai phli. Trieu ehirng can lam sang: Huylt hgc: Cong thirc mau (sl luang bach elu, edng thire bach elu, tilu d u ) ; Sinh hda: CRP, khi mdu, Ure, crea- tin, Men gan (SGOT, SGPT), miln djch djch t h i (IgA, IgM, IgG), miin djch t l bao (CD4, CD8), LDH, Xquang tim phli thing.
3. XiVly sd lieu
Sd lieu duac thu thap bang philu thilt k l
s i n . S6 lieu dugc quan ly va phan tich bang phln mem Epi data, Stata.
III. K £ T QUA 1. Cac yeu to lien quan
Tuli: Tuli trung binh: 75,89 ± 58,30 ngay. Tuli nho nhlt: 31 ngay. Tudi Idn nhat:
14 thang. Trung vj: 59 ngay 25% bach phan vj: 46 ngay, 75% bach phan vj: 85 ngay.
- Gtdi: Nam cd 35 benh nhi (57,38%); nu gidi cd 26 benh nhi (42,62%).
Tiln si> san khoa, tlln sir nudi dudng duge trinh bdy trong bang 1 •
Bang 1. T i l n SLP san khoa, tien SIP nuoi du'dng Tieu 5LP
:2500g Can nang khi sinh > 2500g
Tien sir san khoa Khdng r6
So Con thir
6,56 59,02
Hoan toan Tien sir bii me 1 phan
Tien sir nudt dudng Khdng
Tai nha Nai nuoi dudng Trai tre Benh vien
33
86,88 6,56 2. Dac diem lam sang viem phoi do CMV
- Trieu chirng ca nang, thue t h i eiia viem phli dc CMV dugc t h i hien trgng bang 2:
Bang 2. Trieu chipng cua benh nhan khi nhap vien Trieu chipng
< 7 ngay 15
Trieu chirng ca nang "^hdi gian bi benh 7 - 1 4 ngay 29,51
Khd khe
s 14 ngay Cd Khdng
28 33 28 61
45,90 54,10 45,90 100
Ho 61
TCNCYH Phu truung 80 (3A) - 2012
Trieu chu-ng
Tneu ehirng thuc the
Ban tren da Tu'a mieng Tieu chay Da xanh Gan lach to Vang da Xult huylt Thd" nhanh Tim tai Rut Idm long ngyc SpOz < 92%
SpOz < 92%
Thong khi phdi Giam Binh thu'dng
10 3 18 21 32 1 4 61 57 61 46 15 30 31
16,39 4,92 29,51 34,43 52,46 1,64 6,56 100 93,44
100 75,41 24,59 49,18 50,82 Khdng ran
Ran benh ly tai phdi Ran am Ran rit
Ran am, ran rit 13 3. Dac didm can lam sang ciia viem phdi do CMV
- Dac dilm cong thirc mau ngoai vi diro'c t h i hien trong bang 3
Bang 3. Dac d i l m cdng thirc mau ngoai vi ciia benh nhi khi vao vien
Cong thirc bach cau Trung binh
BC (X ± SD) 15,73 ±6,42 (G/l)
BC >10G/I: 54/61 (88,52%) BCS10G/I 7/61 (11,48%) Trung tinh (X ± SD) 35,14 ± 16,33 (%)
Lympho (X ± SD) 3,30 ± 1475 (%)
Mono (X ± SD) 6,44 (%)
- Dac dilm sinh hda mau ngoai vi diroc t h i hien trong bang 4.
- Dac dilm vi sinh eua benh nhi khi vao vien:
+ Kit qua cly dieh ndi khi quan: Am tinh 45/61 (73,77%), Du'ong tinh vdi vi khuln, nim 16/61 (26,23%), Cay mau du'ong tinh 2/11 (18,18%) trirong hop.
+ Cac xet nghiem vi rut dong nhiem RSV: dirong tinh 7/61 (11,54%), Adenovirus: du'ong tinh 2/61 (3,28%), cum A dyong tinh" 0/61 (0%), cum B: dyong tinh: 2/61 (3,28%), Rhinovirus:
dyang tinh 19/61 (31,15%)
+ Tai lygng vi riit trung binh ban dau. 667,040 ± 2744,760 nghin copies/ml.Thip nhlt 5000 127
TCNCYH Phu tmung 80 (3A) - 20^2
copies/ml, eao nhlt: 20.000.000 copies/ml. Trung vi: 56.020 copies/ml. 25%: 31.700 copies/ml, 75%: 200.000 copies/ml
Bang 4. Dac dilm sinh hda mau ngoai vi cua benh nhi khi vao vien
CRP Men gan
Chisd Binh thydng Tang Binh thyd-ng Tang
Tdng so n 49 12 30(61) 31 (61)
benh nhan
%
80,33 19,67 49,18 50,82 Binh thyo'ng 9 (36)
CD4 - - - Miln dich te bao Giam 27 (36) Binh thydng 35 (36)
CD8 Giam 1 (36)
Giam 4 (36)
IgG Binh thydng 32(36) Miln dich dich thi
IgA IgM
Giam 1 (36)
Binh thydng 35 (36) 97,22 Giam 1 (36) 2,78 Binh thyo'ng 35 (36)
Binh thydng 23 (26) 88,46 Tang 3(26) - Hinh anh Xquang ciia benh nhan khi vao vien dyge trinh bay g bang 5.
Bang 5, Hinh anh Xquang ciia benh nhan khi vao vien Hinh anh Xquang cua benh nhan khi vao vien
Tdn thyong phdi ke Ddng dac p h i nang Hinh anh kinh mg Tran djCh mang phdi
n 41/61
3/61 12/61 5/61
%
67,21 4,92 19,67 8,20
Hinh 1. Xquang ciia benh nhan Viem phdi do CMV CO tai lyang virus trong mau 160.000 copies/ml
TCNCYH Phu truung 80 (3A) - 2012
IV. BAN LUAN
Oac diem gidl tinh trong nghien euu cua chung toi cQng phu hgp vdi cac nghien ciru trudc dd ty le tre trai thudng hay m i c han tre gat Cdn dac dilm lira tuoi hodn toan phii hap vdl eae tae gia tren t h i gidl [2, 9].
Benh thudng gap d benh nhi la con diu, bu me hoan toan va tre duae nudi dudng tap trung (nha tre, trai tre). Oilu nay eung phu hgp vdl nghien ciru trudc day. CMV cd trong cae dich tilt ea t h i nen kht tre bii me md me bi nhiim CMV thi d l cd kha nang lay nhilm tir me va tre duac nudi dudng tap trung cang cd nguy ca lay nhiem cao so vdl tre khae kht benh nht tilp xue thudng xuyen vdi cac dich tilt ciia tre bi benh.
oac dilm lam sang: Trieu ehirng lam sang hay gap ho, khd khe, s i t la cac tneu ehirng hay gap va khdng dac hieu. Oieu nay cQng phu hgp vdl eae nghien eiru Rafalltdts P I.
nhung khae vdl benh viem phlt do vl khuln benh nht thudng bilu hien benh diin diln biln keo dai, benh nhi kh6ng s i t hoac s i t nhe keo dai, benh nht nhap vien trong tinh trang suy hd h i p nang, gan to va it dap irng vdl dilu tri khang sinh mac dii dugc dilu tri nhilu loai khang sinh tai y t l ea sd. Dae dilm can lam sang: Cdng thirc mau t h i hien bach d u tang dae biet la ty le bach c l u lympho. S l luang bach d u trung binh 15,73 + 6,42 (G/l), s l lugng bach d u > 10G/1 54/61 (88,52%), con s l luang bach c l u < 10 G/l: 7/61 (11 48% (17,49 f 8,5 G/l), ty le bach d u da nhan trung tinh (39 4 i 16.85 %), ty le bach d u lympho 49,30 ± 14,75 (%). Nghien ciru phil hap vdi k i t qua eiia tae gta Khuc Van Lap [2] s l luang bach c l u trung binh la 15,68 ± 16,20 G/l va ty le da nhan trung tinh la 44,91 + 16,39 % Ty le CRP < 6mg/l la 88,33% Day la xet nghiem cd gta tn trong djnh hudng ehln doan do vt rut. Tat lugng vt
rut trung binh ciia benh nhi trude dilu trj ta 667,040 ± 2744,760 copies/ml. Thip nhlt 5000 coptes/ml, cao nhlt 20.000 000 copies/
ml- Trung v\ 56.020 coptes/ml 25%: 31 700 copies/ml, 75%: 200.000 eoples/ml. Trong khi ciia tac gia Khuc Van Ldp La. Tai luang virus trung binh la: 216 636,9 ± 738.558,2 copies/
ml (trung vi: 6790 copies/ml) Tal lugng virus thap nhlt la 5000 copies/ml; tat luang virus eao nhlt la 200.000.000 coptes/ml Cd 36 benh nhan duac lam xet nghlem miln dich nhung chung ta eQng thly rd ed su glam 28/36 trudng hgp suy gtam miin dieh t l bao va miin dieh dich t h i d 6/36 trudng hap mac dil benh nhan khdng thudc nhdm benh ed suy mie phai (HIV, sau ghep tang, sau ghep tuy xuang, sau dtlu tri hoa chit) Kit qua nghien ciru eho thly su phu hgp vdi eac nghien ciru trude day ring nhiim CMV thudng xay ra d benh nhan suy gtam miin dich.
V. K^T LUAN
Benh ehii yeu gap d tre trai, tuoi dudi 6 thang Tneu chung lam sang hay gap e6 tinh ehlt ggl y chin doan la: thdi glan bt benh keo dai tren 1 tuin, s i t nhe, suy ho hip, dai dang, gan to va khdng dap ung vdt dtlu tn khang smh. Olu hieu can lam sang: S6 luang baeh c l u da s l la tang va tang chu y l u bach clu lympho Xquang cd hinh anh viem phli ke lan tda Xet nghiem miln dich thly miln dich ehu y l u la mien dich t l bao (CD4)va dich t h i (IgG)
TAI LIEU THAIVI KHAO 1. Nguyin Cong Khanh, Bui Ngoc Lan (2004). Nhilm Cytomegalovl rut b i m sinh, nhan trudng hgp d i u tien duac chin doan tat benh vien Nht Trung uang. Tap chi Nht khoa. Ting hoi Y Duac hgc Viet Nam (12)
2. Khuc Van Lap (2009) Nghien ciru dae diem lam sang, can lam sang eac the benh 129
TCNCYH Phu tnmng 80 (3A) - 2012
do CMV g tre em t?i Benh vien Nhi Trung ygng. Luan van eao hpc. Tryd'ng Dai hpe Y Ha Ndi.
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1066- 1069.
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13. Yan S.S, Fedorko D.P (2002). Recent advances in laboratory diagnosis of human cytomegalovirus infection Clinical and Ap- plied Immunology Reviews 2: 155-167 Summary
CLINICAL AND PARACLINICAL CHARACTERS OF CHILDREN WITH CMV PNEUMONIA Cytomegalovirus (CMV) can cause increasingly incidence in non acgulred immunodeficiency patients group. This prospective and case series study focused on 61 cases of CMV pneumonia admitted to the Respiratory Department of NHP from 1/2010 - 12/2011. Of 61 CMV pneumonia cases: This disease mostly appeared in children under 3 months of age and the illness already had a duration greater than 7 days. Mild fever, cough, wheezing, difficulty breathing, tachyp- noea. reduced breathing, crackles ware common In >90% patients, hepatomegaly > 50%. WBC increased especially lymphocyte, CRP < 6mg/l (80.33%), Increased liver enzymes (50.82%), chest x-ray: infiltration, RT-PCR: 667.040 ± 2.744.760 copies/ml. Min: 5000 copies/ml. Max:
20.000.000 copies/ml. Mod: 56.020 copies/ml, low CD4, IgG level ware immune status signs, in conclusion: clinical characters of CMV pneumonia ware not specific. Suggested symptoms. Du- ration of illness over than 7 days, mild fever, persistent respiratory failure, hepatomegaly and unresponsibillty to antibiotic therapy Chest X ray: Infiltration; Low cellular immunity level.
Keywords: Cytomegalovirus, pneumonia clinical, laboratory
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