NHAN MQTTRl/dNG HOP NHIEM TRUNG GIUN XOAN TRICHimtASPIRAUS
GAY VIEM VA PHU MACH TANG BACH CAU A! TOAN
Huynh Hong QuangS Nguyen Van Chu-ong'.
Giai thiiu: May day va phu mach co the xay ra den 25% dan so tren toan cau. Cac nguyen nhan benh ly nen rat da dang: Cac thudc, yeu to vat ly, cac yeu to tu mien, phan dug di ung, gia di dug va nhiem trung, dac biet vi khuan va ky sinh trung co the dan den bieu hien lam sang cua trieu chiing may day hoac phu mach khd co the phan biet benh ly nao. Viec chan doan la mpt thach thuc, dac biet khi cac trieu chiing dien tien man tinh va dap ung dieu tri khong dang ke.
Trinh bdy ca benh: Nhan day, chiing toi bao cao 1 ca benh phu mach vdi viem mach mau tang bach cau ai toan lien quan nhiem trung giun xoan Trichinella spiralis, dugc dieu tn khdi bang cac thuoe dac hieu. Kit luan: May day la mpt trong nhung rdi loan hay gap kem theo su cd mat cua phu mach dudi da do nhieu yeu to, ke ca ky sinh trung. Cac bang chiing lam sang gai y chan doan cung nhu khau tiep can dieu tri may day, phu mach nen tranh cac yeu to mang tinh khdi phat trieu chiing va dieu tri giam trieu chung.
Tir khoa: May day, phu mach, giun xoan.
DAT VAN DE
May day va phu mach la cac trieu chdng cd the gap phai it nhat tren V-i dan sd the gidi (CDC, 2013) trong ca cudc dbP\ May day cd the dien bien cap tfnh hoac man tinh, cd the sutig ne mpt thdi gian ngan va mat di trong vong 24 gid hoac cd the dien bien man ti'nh tdng ddt keo dai i i y thupe vao tac nhan hay yeu to thuan ldi can thiep (thuoe, hda chat, nhiem dpc, mien djch, dj nguyen, nhiem ti-ung vi khuan, ky sinh trung, nam). Phu mach (an- gioedema) la mpt dang cua may day, trong do sti suhg ne nam d phan sau du'di da va keo dai cd the hdn 24 gid.
Khoang 50% so ca may day cap ti'nh cd bieu hien phu mach(5).
Ve mat sinh ly benh, cac mo iien quan den may day va phiJ mach bieu hien phu du'di da hoac niem mac cung vdi sti lien quan den tham nhiem te bao lympho T, dai
'"Viin Sol rel - Ky sinh triing - Con Irung Quy Nhon. Binh Dinh Ngay nhan bii: 23/11/2014
Ngiy phin bijn long: 02/01/2015 Ngiy duyft ding: 28/01/2015
Ngirtri chju traeh ahif m ngi dung khoa hgc: Huynh Hdng Quang, Vifn Sol ret - Ky smh irung - Con triing Quy Nhan. Binh Dmh Difn IhoQi: 0905103496. E-mail: huynhhguangimpe@yahoo com
thu'c bao, bach cau ai toan va dddng bao (mast cells) quanh mach mau. Cac trieu chdng sdng ne va ngda lien quan den sti giang hda phdng thich cac dudng bao, trong do cac chat trung gian gay hoat mach ly giai t d cac te bao dudng bao va bach cau u'a base smh ra cac phan dng sting ne manh'^'. Mpt so cd che khac lien quan den tru'c tiep phan t d IgE hoac qua trung gian IgE. Viec chan doan va dieu tri la mpt thach thdc neu khong tim ra nguyen nhan cu the de gian doan. Qua tham kham benh sd, kliam thtic the va dieu tra tien sd cd the nhan ra mpt so nguyen nhan, han che mat thdi gian va tranh cac tac dung dgc do thuoe dieu tri khong can t h i ^ . Mac du benh bieu hien doi luc nghiem trpng, song phan Idn la lanh tfnh va tiT gidi han'^'. Viec tiep can dieu tri nham tranh cac tac nhan gay ra va giam trieu chuhg cho benh nhan, sd dung than trpng cac thuoe chong viem cort:ico5teroids dddng uong va thuoe khang histamine the he hai tac dung dung keo dai, cac H2 - receptor antagonists va thuoe doi khang leukotnene ehdng viem.
TRINH BAY CA BENH
Mpt benh nhan Nam 57 tiJOi, sdng tai thanh pho Tuy Hoa, tinh Phu Yen bj eac ddt may day nghiem tipng lien
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tue trong nhieu thang va kem theo cd dau hieu phu mach d mat va vung hau hpng, thinh thoang khd thd, ton tai hdn 24 gid. Benh nhan da ^ e u tri nhieu lan bdi eae thay thudc da lieu, npi khoa va da nhap Benh vien da khoa tinh Khanh Hoa 2 lan, song khi ra vien khoang 1 tijan benh tai phat sau khi het thudc ngoai t n i . Sau dd, benh nhan den kham va nhap vien tai Vien Sdt ret - Ky sinh ti-ijng - Con trijng Quy Nhdn:
ThSm kham, kiem tra eac nguyen nhan hoae benh ly nen sin cd khong cd gi dac biet, ngoai t n i lam nghe mo heo va hay an cac mdn thinh do benh nhan che bien;
Gan laeh khdng Idn, nhiet dp da hdi am, sdt 38°C nhieu ngay trtide khi den kham, met moi, nhdc toan tiian;
Kham khoi cd cang tay va bap ehan (T) rat dau, cd ndi suhg phong, dd da va ndng, cang cd dau nhieu hdn.
Cac trieu chuhg tieu hda, than kinh, tiet nieu deu tiding gidi han binh thtidng.
Xet nghiem can lam sang va chan doan hinh anh:
+ CTM toan phan cho thay ehi sd bach tau ehung tang eao va dae biet bach eau ai toan (BCAT) tang den 45,6% (gia tii tiiam ehieu 0 - 6%);
+ Men gan va chdc nSng gan, than khong cd bat thudng, khong cd viem gan B, C;
+ Toe dp mau lang tang cao, chi so CRP tang 21mg/L (gia ti-i tham chieu < 5mg/l);
+ Nddc tieu toan phan 10 tiidng so dio ket qua trong gidi han binh thu'dng;
+ Xet nghiem huyet tiianh hpc ve cac giun san: Strongy- loides stercoralis, Gnathostoma spinigerum, Cysticer- cus cellulose, Fasciola gigantica, Toxocara canis deu cho ket qua am b'nh (hieu gia khang the < 1.0);
+ Chup X quang phoi ngi/c ky thuat so cd tran dich mang phdi mdc dp nhe;
+ Sieu am bung tong quat chda thay dau hieu bat thudng;
+ Dien cd thay doi khong dang ke.
Danh gia ban dau ve benh ly khoi u hay dj dng tam thdi loai bd thdng qua xet nghiem sang Ipc mau. Nghi ngd benh nhan mSe mot benh ly ky sinh trung lien quan den benh nghe nghiep va thdi quen an uong, chuyen benh nhan vao Tnjng tam chan doan y khoa Hoa Hao de lam ttiem xet nghiem ELISA va Benh vien Dai hpc Y - Du'dc thanh pho Ho Chf Minh sinh thiet da cd.
Sinh thiet da cho thay hinh anh viem da vung thudng ton, viem da vung mao mach co tang bach cau ai baan, dieu nay phien giai nhti mpt dau hieu sdm, cap tinh eua viem mach tang bach cau ai toan (eosinophilic vasculitis).
Sinh thiet ed cd hinh anh ddng ken eua au trung giun xoan T. spiralis cung vdi ket qua huyet thanh hpc phat hien khang the du'dng tfnh, chi so BCAT len den 63%
trong cdng thdc mau va nhiem triJng vdi BC ehung 15.0000 X mi.
Thdng so creatine kinase cd trong gidi han binh thddng.
Sau khi tdng hdp ket qua can lam sang, ket hdp lam sang, chan doan xac djnh la: May day kem phu mach tham nhiem BCAT do nhiem giun xoan I spiralis.
Hinh 1 . Sinh thiet cd cho thay au trung dong ken cua giun Trichinella spiralis
Hinh 2. Sinh thiet da thay tham nhiem bach u u ai toan lan toa 6 mach mau Chi dinh dieu tri thudc thiabendazole vien SOOmg (biet du'dc Niczen), lieu trinh 7 ngay, kem theo thudc chdng
viem prednisolone 5mg ti'ong vdng 5 ngay lien tiep va khang histamine loai loratidine lOmg, cimg vdi thudc bo gan arginine 200mg ( t d ngay 12/02/2014 den 21/02/2014). Sau 10 ngay, benh nhan hoi phyc nhanh chdng bieu hien di lai khdng con dau cd, giam phii niem mac, dau may day cd cu'dng dp va so lan giam. Tuy nhien, den dau tfiang 3/2014, tten cd ttie benh nhan xuat hien ddt may day khac tai cac vijng xung quanh vj tii phu maeh cu, dd va sdt, suy nhtidc ed ben thUdng ton tien trien.
Thi/c hien cdng thdc mau cho Oiay nhilm tnjng khdng con nhdng chi sd dap dng mien dieh tang len (BCAT tang hdn luc dau 67,3% va nong dp IgE tang gap hai lan tii sd binh tiiudng). Cac kham nghiem lam sang va can lam sang khac loai tid benh ly tan sinh, hay nhiem khuan, nghl nhieu den ddt tai phat hoac phan uhg dpi sau dieu tri (rebound/Herx reaction) thuoe Uiiabendazole da giet chet mot lupng Idn eac giun xoan va ehi cho dung thudc chdng di dng va da sinh td, truyen djch vitamin cung nhti uong nu'dc trai eay, sau 3 ngay benh nhan hdi phuc hoan toan.
Ket qua kiem tra tdng tiie ve huyet hoc, sinh hda cho cac thdng sd trd ve binh thu'dng, song chi ed tri so EUSA van cdn khang the chdng lai tac nhan giun xoan Trichinella spiralis vcfi hieu gia thap dUdng tinh, BCAT tid ve 7%. Den nay, sau 10 ngay, benh nhan khdng cdn tai phat nuS.
BAN LUAN
Giun xoan Trichinella spiralis: Can benh truyen t d dong vat sang ngu'di nguy hiem
Benh giun xoan gay ra bdi Trichinella spiralis, la mdt benh giun tion truyen t d ddng vat sang ngudi qua dtidng thdc 3n hay gap nhat. Heo (ldn) la ddng vat nudi thtidng nhiem benh nhat. 6 ngudi, ty le mac le thupe vao so lu'dng au tmng song cua Trichinella spiralis d\idc tieu hda hay thjt ehtia nau chin hoac cdn song'^. Ty le nhiem giun xoan khae nhau tuy thupe viJng b'en the gidi, le thudc vao thdi quen an udng va bien phap phdng, chdng mang ti'nh dieu luat ve sinh an toan. Su" yeu cau mang tinh phap ly de phdng, chdng thu y va cac Id mo, khdng phai ludn luon hjan thu, dac biet cac 16 md khong dang ky.
Acid da day giup phdng thieh cac nang giun di vao, phat tiien thanh con tru'dng thanh. Cae au ti-ung non cua con tnj'dng thanh di xuyen qua thanh rupt va di chuyen ttidng qua ddng mau. Chung cd die tim ttiay tiong tim va nhu mo nao eung nhu cae ed van. Chu ky phat trien cua
ky sinh trung dddc hoan thanh khi au trung trd nen dong nang tai vung cd sau. Mpt benh sd chi tiet eho thay benh nhan cd thdi quen an thjt heo chu^ nau chin va lam nghe nghiep cd lien quan'^. Nhtidc cd va dau cd co lien quan den hinh anh benh hpc tren dien ed do va cac thay d6i ve hinh thai benh ly cd khdng dac hieu tren mau sinh thiet cd, nhting sinh thiet cd da phat hien hinh anh giun xoan ddng ken (hinh 1). D3c diem ve mat va than kinh cua benh giun xoan ed the loai trd. Du^ tien ehan doan benh giun xoan, chi dinh thudc dac hieu eung thuoe ehong viem cho thay cac thong so xet nghiem va toan bp cae trieu chdng lam sang dddc cai thien, cijng vdi khdng xuat hien trieu chdng may day va cac dau chutig khac, sau lieu trinh thd 2 sau dd.
Trieu chu'ng lam sang dac tru'ng cho benh giun xoan Trichinella spiralis
Cae trieu ehuhg lam sang cua giun xoan dau tien lien quan den he tieu hda (40% - 60%), chang han non mita, tieu chay va dau da day rupt. Cac trieu chdng lam sang khdng dae hieu nhU yeu ngu'di (75%) hoae sdt (60 - 75%), dau ed va dau khdp (75%) hoae tham ehi ton thu'dng den cd tim cap. Cac dau hieu than kinh khu tid, benh ly nao va dau dau lan tda (50% - 60%) da dddc ghi nhan. Cac tiieu chuhg tten da niem gom phiJ quanh mi mat, may day, cham xuat huyet ket mac. Xuat huyet cac giUdng mdng tay va ban dd tren da khdng dac hieu hoSc ban trong Idng ban tay, cac dau hieu nay xuat hien khoang 10% ttong benh giun xoan. Cac ban dd cd d hai ben tay bi sutig va ban dd mang dpc theo vanh ngoai eua Idng ban tay va gan bay tay, tiep theo sau dd la hinh anh bong trdc vay. PhiJ mach la mdt dau hieu khdng thtidng xuyen cua nhiem trung giun san va viem mach do giun xoan lai cang hiem gap hdn'''.
Cae thddng tdn may day la da hinh thai, hinh trdn hoac bd khdng deu phu len tren so vdi be mat da, co ngda, vdi nhieu kfch thtidc khac nhau t d vai mm den nhieu cm. Cac thu'dng tdn co tiie hinh thanh bat ky ndi dau tren cd the va lan rpng do qua ttinh gai, cao khien lifin ket lal lan rdng thanh dam Idn, mang dd. Ddi khi hien hidng lan maeh gay nen cac thUdng ton sung huyet tiung tam vdi mot vdng ti-ang ben ngoai. Phu maeh cd the xay ra ddn thuan hoae di kem vdi may day, dac tfnh la khdng bap benh, khdng nqiia hoac khd chiu, sdng phong liSn quan den cac md dudi da (mat, smh due, mdng, tay), cac
5 0 - TRUY&«NHi&WIVieTNAM*s6 1(9) - 2015
cd quan ttong bung va dudng ho hap tien. Phu mach co xu hudng xay ra tien mat va tay, gay nen bien dang ro ret.
Phu vung hau hpng la mpt cap cdu y khoa can ho ttd dieu tri cap, cac suhg phong vung da day rudt gidng tneu ehiing cap cuti ngoai khoa bungt'''^'.
Viec phan ra may day cap ti'nh hay man ti'nh la cac ttieu chdng tdn tai trong thdi gian it hdn 6 tuan va tten 6 tijan. Trong mdt nghien cud gan day 47% benh nhan may day man tinh khong ro nguyen nhan va t d khdi hay giam t d phat sau 1 nam™. May day cap tfnh cung phan biet vdi may day man tinh qua dien tien hay keo dai trieu chuhg ttidng qua sti dieu tiet IgE. May day man tfnh va phu mach CO xu hu'dng tU phat, khdng xac djnh nguyen nhan hoac do nhieu yeu td ndi sinh, ngoai sinh, mien djch hoae khdng lien quan den mien djch.
Mdt nghien ciiti tong hdp hdn 6.000 benh nhan may day va phij maeh cho thay eac xet nghiem can lam sang tiiu'dng quy sang Ipc ft le thupe vao tien sd benh nhan eiJng nhti kham thiic the, vi cae test nay it cd gia tri trong viee phat hien ra nguyen nhan phan uhg, do vay ft khi tim ra nguyen do (chang han IgE hay test da).
May day ed hoac khdng kem theo phu mach u'dc tfnh cd ty le khoang 25% trong dan sd ehung toan eau. Trong so cac benh nhan bj may day, ft nhat gan 30% cd viem mach. Chan doan phan biet may day vdi viem da tang BCAT (eosinophilic dermatitis) va viem mach may day (eosinophilic vasculitis) gom co eac phan dng qua man cung nhu hdi chdng Churg - Strauss, cac hpi chdng tang BCAT Wiac va nhiem ky sinh tnjng'^i''^'. Viem mach cd lien quan den benh ly ky sinh ttung la mpt benh ly hiem gap ti-en thtic hanh lam sang va tren bao cao y van.
Chan doan xac djnh le thupe vao tim kiem cac phdc hdp (ky sinh bdng - te bao) ddng vach trong md smh tiiiet cd soi dtidi kfnh hien vi hoac phat hien DNA dac hieu Trichinella spiralis bang ky thuat PCR. Sinh thiet cd cd the am ti'nh do sd ludng au trung thap trong giai doan sdm cua benh. Cac bang chiihg gian tiep cho nhiem trung ed the thdng qua benh sd, trieu chdng lam sang, tang bach cau ai toan trcing mau ngoai vi, tang men cd va test huyet ttianh hoe nhd EUSA.
Hinh anh mo benh hoc ciia giun xoan Trichinella spiralis khi gay benh vung cd, da niem
Cac md ta ve mat md benh hpc gom cd viem da ddng mach nut,ti'am nhiem tang BCATdda niem. Sii xuat hien dong thdi cua viem mach va benh ky sinh tnJng cd the dan den t d : (1) SU tac dong triic tiep cua ky sinh tning len he thong mach mau nhU da nhin thay vach thanh mach thay doi ve mat md benh hpc; (ii) Hien tUdng mien dich benh ly xay ra trong khi ed dap iihg mien dich chdng lai ky sinh trung, (iii) Sd lang dpng cac phdc hdp mien djch luti hanh, phan dng cheo cua cac thanh phan IgE chdng lai ky smh trung va eac khang nguyen thanh mach mau, hoac ton thUdng md do tang BCAT. Trong trUdng hdp benh nhan Nam nay, viem maeh may day ed the do dap utig mien djch qua manh bdi mpt IUdng au trung T.
spiralis. Vl vay, sinh thiet cd da cho thay hinh anh au tidng ddng ken va huyet thanh mien dich (+) manh. Dieu nay eung cd the giai thfch hieu gia khang the cao ciing vdi IUdng BCAT tang cao trong mau ngoai vi tren ca benh nhan nay
Histamine ly giai ra t d cae dudng bao dudi da va bach cau da base trong dap dng vdi eac chat kfch thfch la khau khdi phat dau tien eua may day Trang qua trinh nay, cac khang the IgE dac hieu lien ket cheo vdi IgE receptisrs gan vdi eae dudng bao va kich thieh sinh ra cac chat gay viem.
Cac dpc to phan ve bo sung cung cd the gay ly giai hista- mine t d dudng bao hoac thdng qua sU hoat hda te bao tiiic tiep khdng lien quan den mien djch va t d do sinh phii maeh va viem<^'''^'.
KET LUAN
May day la mdt trong nhdng rdi loan hay gap kem theo sd cd mat eua phu mach dUcfi da do nhieu yeu td, ke ca ky sinh trimg. Cac bang ehiing lam sang gdi y ehan doan ciJng nhd khau tiep can dieu ttj may day, phii maeh nen tranh chi dieu trj giam trieu ehdng ma phai tim nguyen nhan.
Diilu trj d3c hieu nhiem giun xoan T. spiralis thudc lUa chpn la thiabendazole, mebendazole hoae albenda- zole, can phoi hdp thudc prednisolone chdng viem de giam dap utig viem tren benh nhan, hoac thudc ha sdt va giam dau ttong sudt giai doan cd dau hieu dau cd'^^
TAI LIEU THAM KHAO
1. Fox RW et al., (2001), Chronic urticaria: mecha- nisms and ti^tinent. Ailergy Asthma Proc. 2001;22: 97 - 100.
2. Kaplan AP (2002), Clinical [xacbce: chronic urticaria and angioedema. N Eng J Med. 2002;346:175 - 9.
3. Kozel MM, Mekkes JR, Bossuyt PM, Bos JD (2001), Natural course of physical and chronic urticaria and an- gioedema in 220 patients. J Am Acad [)ermatol. 2001;45:
387 - 91.
4. Kozel MM, Bossuyt PM, Mekkes JR, Bos JD (2003), Laboratory tests and identified diagnoses in patients with physical and chronic urticaria and angioedema: A sys-
tematic review. J Am Acad Dermato/. 2003;48:409 -16.
5. Lhote F et al. (2004), Systemic vasculitis during parasitosis. Presse Med 2004; 33: 1389 -1401.
6. Pmssin C, Mebalfe DD (2003), IgE, mast cells, ba- sophils, and eosinophils, J Allergy Clin Immunol.
2003;111(2 suppi): S486-94.
7. Walsh DS, Jongsakul K, Watt G (2001), Hand rash in trichinosis. Clin Exp Dermatol 2001; 26: 272 - 273.
8. Wedi B, Raap U, Kapp A (2004), Chronic urticana and infections. Curr Of^n Allergy Oin Immune^ 2004; 4:
387 - 396.
A CASE REPORT: TRICHINELLA SPIRALIS INFECTION AND EOSINOPHIUC VASCULITIS WITH ANGIOEDEMA
Summary
Bad^grounds: Uriiicaria and angioedema occur in up ti) 25% of ttie global population at some point in tiieir life- time. Underiying causes can be highly heterogeneous, such as various drugs, physical fectors, auto-immunolog- ical fecti)rs, allergic and pseudoallergic reactions or infec- tions, especially in bacteria and parasite. These causes can result in the clinical manifestation of urticaria, or an- gioedema which is a sympbam rather than a distinct dis- ease. Diagnosis can be challenging, especially if symptoms are chronic or minimally responsive tiD therapy. Case pres- Key words: Urticaria, angioedema, Trichinella spiralis.
entation: Here, we report a special case of angioedema with eosinophilic vasculitis caused by Trichinella spiralis in- fection treated with effective and anti-inflamatory med- ications. Conclusions: Urticaria is a common disorder that often presents with subcutaneous angioedema due to var- ious factors, including parasite agents. Clinical dues and associated rationale for diagnosis as well as approach to treatment of urticaria/angioedema should avoid known triggering agents and alleviating associated symptoms.
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