4 - 4 - 4 ^ NGHliN o i u KHOA HOC
MOI UEN QUAN G I O A DIEM m-RODNAN TAI CHO VC5I MO BENH HOC DA CUA BENH NHAN XO CLfNG Bl HE THONG
Vii Nguyet M i n h * * * , Le Hiifu D o a n h * " , H o a n g T h j Phifcfng', N g u y e n Le Hoa*, Tran M a n C h u '
TOMTAT
Xo cdng bi he t h o n g la m p t benh t u mien he t h o n g man t i n h . Trong cac t h u o n g t o n da cua xo cdng bi he thdng, t h u o n g t o n day da la trieu chUng dien hinh hay gap nhat. Nghien cdu danh gia moi lien quan gida diem m-Rodnan tai eho vdi m d benh hpc da tren benh nhan x o cdng bi he t h d n g .
Doi tuang va phuang phdp: Bleu tra m d ta cat ngang t h u o n g t d n day da t h e o phUOng phap ddn da va mo benh hoc da cua 11 benh nhan x o cUng bi he t h d n g vao kham tai Benh vien Da lieu Trung Udng tU05/2013den 11/2013.
Ket qua. Bieu hien t e o thUOng bt, day t r u n g bi tang len cung vdi mdc d p day da tren lam sang. Hien tuong giam so l u p n g - k i c h thude mach mau va phan phu, giam t h a m nhap viem tang len cung mUc dp day da. Day Idp sdng, day sdng nang Idng, tang sac t d gap d hau het cac manh sinh thiet. Khdng cd bat thudng vCing ha bi.
Kit luan: Mo benh hoc da p h d h o p vdi d p day da tai vi t r i cat sinh thiet nhung lai la m o t xet nghiem xam nhap va can nhieu kinh nghiem ve giai phau benh de khang dinh chan doan nen cancan nhac trong viec cat sinh thiet da cho cac benh n h a n x o c U n g bi h e t h d n ^ va cd t h e d u n g do day da d e d a n h gia thay t h ^ cho m d benh hpc.
TUkboa: Xo cdng bi he t h o n g , m-Rodnan, m d benh hpc da.
LDATVAND^
Trong cac t h u o n g t o n da cCia benh xo cUng bi he thong (XCBHT), thUdng t d n day da la trieu chdng dien hinh hay gap nhat va t h u d n g lien quan tdi mdc d p nang cua benh [ 1 ; 2; 3; 4]. Chinh vi vay, tren the gidi da co nhieu p h u o n g phap de danh gia mdc d p day da n h u durometry, elastometry, sieu am da, sinh thiet da va sd d u n g eac t h a n g di^m ban djnh lugng. Rodnan la ngudi tien p h o n g trong viec danh gia thUong t o n day da tren benh nhan XCBHT bang p h u o n g phap ban dinh lupng
• B^nh vi^n Da lieu Trung uang,
" Trudng Dgi bgc YHa Not
Phdn bt$n khoa hgc: PQS.TS Nguyen Duy Hung
t h d n g qua kham lam sang. Qua nhieu nam, thang diem Rodnan da dugc cai tien nhieu lan va hien nay thang diem Rodnan Ccii tien (Modified Rodnan skin score hay mRSS hay m-Rodnan) dUOc sd d u n g rdng rai nhat [5]. Gan day, m d benh hpc da cua benh nhan XCBHT dupe quan t a m nhieu hon trong cac t h d nghiem de danh gia hieu qua tae dpng cda t h u o c cung nhU t i m hieu ve benh sinh hpc cua benh. Theo tien trien cua benh, m d benh hpc da se bieu hien cac dac diem khac nhau [6].
Mac d u da cd n h d n g nghien cUu ve thang diem m-Rodnan n h u n g viec danh gia mdi lien quan gida m-Rodnan tai cho vdi m d benh hoc da van cdn rat
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it. Vi vay, chung tdi lam nghien cdu nay vdi muc tieu: Khao sat moi lien quan gida diem m-Rodnan vdi mo benh hpc da cua benh nhan XCBHT.
II. DOI TUONG VA PHl/ONG PHAP N G H | £ N COX)
- Doi tugng nghien cdu: 11 benh nhan chandoan xac dinh la XCBHT theo tieu chuan cua Hoi khdp hpc My dUOc kham va quan ly tai phdng kham chuyen de cac benh tU mien tai Benh vien da lieu Trung uong.
- Phuang phap nghien cUu: md ta cat ngang thdc hien dieu tra tUOl/05/2013 den 30/11/2013.
Benh nhan 6uac danh gia thuong tdn da vung cat sinh thiet, dp day da bang phuong phap don da thUe hien theo thang diem m-Rodnan tai vjtri cat sinh thiet va danh gia tieu ban sinh thiet da nhudm Hematoxylin Eosin theo eae tieu ehi liet ke san tren benh an mau.
m. KET QUA
1. Vj tri cat sinh thiet thifc hien d cang tay Trong so 11 vj tri cat sinh thiet, vj tri cat sinh thiet d cang tay chiem da so tuong Ung vdi 82%.
Day la vi tri hay gap trong bieu hien XCBHT.
1, 9 %
n Cang tay • M u tay D CSng chan
Bieu do 1: Phan bo vj tri cat sinh thiet 2. Dac diem lam sang chu yeu la day da va roi loan sac to
Roi loan Viem do Gian m a c h sac 16 da
Bieu do 2: Ddc diem lam sang vimg da c6t sinh thiet
Da so thuang ton tai vung da eat sinh thiet bieu hien day da (9 benh nhan, tUong dng vdi 81,8%) vS rdi loan sac td da (B benh nhan, tuang dng 72,7%). Khdng cd benh nhan nao cd bieu hien gian mach hay teo da.
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3. Phsn b6 do day da blng phuong phap dSn da tai viing cit sinh thi^t
27,3%
^?fi'v^:,"S3
27.3%
f i x 36.4%
0.3 0.2 0.1 0 -
0 diem 1 fliem 2 diem 3 diem
Bieu do 3: Phan bo do day da tgi vi trf cat sinh thiet
Trong 11 benh nhan cat sinh thiet, so benh nhan co do day da tai vung cat sinh thiet bang 1 la cao nhatti/ong Qng vdi 4 benh nhan {36,4%} va so benh nhan co do day da tai vung cat sinh thiet bang 3 la thap nhat tuong u'ng vdi 1 benh nhan (9,1%).
4. Dac diem phan thuong bi cOa cac benh nhan XCBHT Co cat sinh thiet
Sdng 7; Dac diem thuang bi cua cdc benh nhan trong nghien ciiu
^^^^-...^^^^ Mufc do day da Mo benh hoc ^ ~ ' ~ ' ^ ^ ^ ^ - Thuong bi teo
- Chieu day t r u n g binh {ldp te bao) - Thoai hoa long Idp day - DayldpsL/ng - Day si^ng nang long - D^y m^ng day - Tang sac to
0 (n = 3) 1 {33,3%)
7,7 1 (33,3%) 3(100%) 1 (33,3%) 3(100%) 2 (67,7%)
1 (n = 4) 2 (50%) 7,3 1 (25%) 3 {75%) 4(100%) 4(100%) 4(100%)
2 (n = 3)
0 7,7 0 3(100%) 3(100%) 3(100%) 2 (67,7%)
3 (n = 1) 1 (100%)
7 0 1 (100%)
0 1 (100%)
0
Nhdm cd do day da cao dau hieu teo thugng bi nhieu hon d nhom ed dp day da thap.Thoai hda Idng Idp day gap d benh nhan cd dp day da thap nhieu hon nhdm cd dd day da cao. Day mang day gap d 100%
b4nh nhan.
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5. Dac diem phan t r u n g bi cua cac benh nhan XCBHT co cat sinh t h i e t Bang 2: Dgc diem trung bi cda cdc benh nhan trong nghien cihi
^ — - . . . ^ ^ ^ IMUc do day da M o benh hoc ^^"^'^——-...^^^^
- T r u n g bl day + Tang t o n g hop collagen + Tang soi fibrin, nguyen bao spi - So luong phan phu cua da giam + Kfch thude phan phu giam - So lugng mach mau giam + Kich thude mach mau giam - Tham nhiem v i e m + Loai te bao t h a m nhiem + Vi t r i viem
0 (n = 3) 2 (67,7%) 3(100%)
0 1 (33,3%) 1 (33,3%) 1 (33,3%) 1 (33,3%) 1 (33,3%) l y m p h o quanh mach,
phan phu 1 (n = 4) 1 (25%) 4(100%) 2 (50%) 2 (50%) 2 (50%) 2 (50%) 3 (75%) 2 (50%) l y m p h o
2 ( n = 3) 2 (67,7%) 3(100%)
0 1 (33,3%) 1 (33,3%) 1 (33,3%) 3(100%)
0 0
3 (n = l ) 1 (100%) 1 (100%)
0 0 0 0 .j 1 (100%) •
0 0
Benh nhan cd dp day da cao cd t y l e t r u n g bl day nhieu hon va k i ' c h t h u d c m a c h mau giam hon nhdrp cd dp day da thap. Bieu hien t h a m nhiem viem chi gap d n h d m d p day da t h a p . Tang t o n g hdp collagep.
g a p d 100% benh nhan cd cat sinh thiet.
6. Dac diem phan ha bi cua cac benh nhan XCBHT co cat sinh thiet
Bang 3: Dgc diem hg bi cua cdc benh nhdn trong nghien cUu
^~~~''~~~~~..^^^^^ MUc do day da Mo benh hoc^^"'""----..,,^^^
- Ha bl day - V i e m mo m d - D a c diem mach mau - T h a m nhiem v i e m
0 (n = 3)
0 0 0 0
1 (n = 4) 1 (25%)
0 0 0
2 (n = 3)
0 0 0 0
3 (n = 1) K
0 0 0 0 Ha bl khong thay doi t r o n g hau het cac benh nhan cd cat sinh thiet.
IV. BAN LUAN
Trong nghien cdu, c h u n g tdi c h u d p n g c h o n VI t r i cat smh t h i e t d cang tay c h i e m da sd tUOng d n g vdi 82%. Bay la vi t r i t h u a n lgi de cat sinh thiet, de lien t r o n g so cac vj t r i t h u d n g gap day da
tren benh nhan XCBHT VI vay, nhieu tac gia khi n g h i e n cdu ve m d b e n h hoc da cua benh nhan XCBHT c u n g Ida c h p n cat sinh t h i e t da tai vung cang tay n h u tac gia Van Praet va cdng sU [6]. 9 t r o n g t d n g sd 11 b e n h nhan cat sinh thiet da c6 bieu hien day da (81,8%) va 8/11 b e n h nhan cd roi
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loan sac t d da (72,7%). K h d n g b e n h n h a n nao cd bieu hien gian mach hay teo da tai vj t r i cat sinh thiet. Ket qua nay p h u h g p vdi bieu hien lam sang hay gap cua benh XCBHT la day da va rdi loan sac t d da. Cac dac d i e m lam sang nay c u n g p h i j hgp vdi ket qua m d b e n h hoc da eho t h a y 8/11 benh nhan cd tang sac t d d t h u g n g bl va 100% benh nhan cd day t r u n g bl d o t a n g lang d p n g collagen.
Trong nghien cUu cua c h u n g t d i , d n h d m cd dp day da cao t r i e u c h d n g t e o t h u g n g bi nhieu hon so vdi n h d m cd dp day da t h a p . T h u g n g bl teo duoc danh gia b a n g q u a n sat tren t i e u ban md benh hpc cd h i n h anh nhu t r u n g bi phang va sd Idp te bao gai gida hai n h u t r u n g bi giam.
Hien t u o n g nay p h u h d p vdi h i n h anh lam sang cua benh nhan XCBHT va c u n g d u g c d a n h gia ket qu^ tuong t u t r o n g n g h i e n cUu cua Van Praet va cdng su [6]. Tuy nhien, do sd l u g n g b e n h nhan cat sinh thiet it nen chua t h a y d u g c m d i lien quan cd y nghla t h d n g ke gida do day da va chieu day thuong bl tren ket qua cua c h u n g t d i . Thoai hda Idng Idp day gap d benh nhan cd dp day da t h a p nhieu hon n h d m cd d p day da cao. Day mang day gap d 100% benh nhan. Day Idp sUng, day sdng nang long cung gap d hau het cac manh sinh thiet trong nghien cUu. Cac dac d i e m nay la bleu hien chung cua b e n h t o chUc lien ket. Tuy nhien, day la cac dac d i e m dac t r u n g cho lupus ban do nhieu hon xo c d n g bi nen can phai ket hgp vdi c^c dac diem khac tren m d b e n h hge de dua ra c h i n doan xac d i n h . Ket qua nay cho thay can phSi rat cd kinh n g h i e m t r o n g viec doc ket qua md b&nh hoc da de chan d o a n chinh xac.
Ve phan t r u n g b i , n g h i e n c d u cua c h u n g tdi cho thSy n h d m b e n h nhan cd dp day da cao cd ty le trung bi day nhieu h d n va kich t h u d e mach
mau giam hon n h d m cd d o day da thap. Mac d u nghien c d u chUa t h e hien mdi lien quan cd y nghla t h d n g ke nhUng ket qua nay cung rat phu h g p vdi benh sinh cua XCBHT. Trung bi day len t r o n g benh XCBHT chu yeu do t a n g sinh collagen.
Cac mach mau g i a m di ve sd luong va kich thude do bi b d p hep lai, gay ra cac bieu hien ve mach mau tren lam sang. Ket qua nay cung phu hop vdi lam sang cac vi t r i cat sinh t h i e t t r o n g nghien cdu cua chung t d i khdng cd benh nhan nao cd gian mach. Bieu hien t h a m nhiem viem chi gap d n h d m dp day da thap. Ket qua nay phu hgp vdi tien trien lam sang cua benh xo cUng bi he t h d n g : giai doan dau cd hien tUdng viem, phu ne.
Benh cang t i e n trien lau, bieu hien viem cang it di va t h e hien m g t m d benh hgc vdi phan t r u n g bi ngheo nan te bao. Tham nhiem te bao viem t r o n g XCBHT chu yeu la lympho quanh cae mach mau va phan p h i j , phu h g p cac nghien cdu ve m d benh hpc trUdc day [6].
Trong nghien cUu cda chung t d i , ha bl khdng thay doi t r o n g hau het cac benh nhan cd c I t sinh thiet. Ket qua nay p h u h g p vdi benh sinh cua XCBHT. -Dac d i e m nay cung giup phan biet t h e benh xo edng bi vl t r o n g the xo cdng bi khu t r u sau, ha bi cd nhieu thay ddi hon t r o n g XCBHT va x o e d n g bi khu t r u ndng.
V. KET LUAN
M 6 benh hpc da phu h o p vdi dp day da tai vi t r i cat sinh t h i e t nhUng lai la m p t xet nghiem x a m nhap va can nhieu kinh n g h i e m ve giai phau benh de khang d m h chan doan nen can can nhac t r o n g viec cat sinh thiet da cho eae benh nhan XCBHT va e d t h e d d n g dp day da de danh gia thay t h e eho m d benh hgc.
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TAI L I | U T H A M K H A O
[1] Christopher RD. ,Carol M.B.: Scleroderma (Systemic sclerosis). Fitzpatrick's d e r m a t o l o g y in general medicine, 7'^ edition, chapter 158,2008
[2] Connolly M.K.: Systemic sclerosis (scleroderma) and related disorders. Dermatology, 2"" edition, chapter 4 4 , 2 0 0 8
[3] John v.: Overview o f t h e clinical manifestations of systemic sclerosis (scleroderma) in adults. Uptodate, 2012
[4] Nicolas H. ,Thomas K.: Progressive systemic scleroderma. A u t o i m m u n e diseases of t h e skin.
1 6 5 - 1 8 3 , 2 0 0 5
[5] Clements PJ., Lachenbruch P.A., Seibold J.R. et al: Skin thickness score in systemic sclerosis:
an assessment o f interobserver variability in 3 i n d e p e n d e n t studies. J Rheumatol, 20 (11): 1892- 6,1993
[6] Shand L., Lunt M., Nihtyanova S. et a|- Relationship b e t w e e n change in skin score and disease o u t c o m e In diffuse cutaneous system^
sclerosis. Arthritis Rheumatism, Vol.56, No. 7,2422- 2431,2007
THE RELATIONSHIP BETWEEN m - RODNAN A N D CUTANEOUS HISTOPATHOLOGY IN SYSTEMIC SCLEROSIS
Background: Scleroderma Is a chronic a u t o i m m u n e multisystem disease. In skin lesions of scleroderma, skin thickening is t h e most c o m m o n typical s y m p t o m . The study assessed tiie relationship between m - R o d n a n score and cutaneous hlstopathology In scleroderma patients.
Subjects and Methods: This cross-sectional descriptive survey assessed skin t h i c k e n i n g based on the incremental skin approach and cutaneous hlstopathology in 11 scleroderma patients examined in the A/at/ona/Hospital o f Dermafo/ogy and I'enereo/ogy from May 2013 t o November 2013.
Results: Atrophic epidermis and dermis thickness increased w i t h t h e degree o f skin thickness. The reduction in t h e n u m b e r and size of blood vessels and appendages as well as in inflammatory infiltrate simultaneously increased w i t h skin thickness. Epidermal thickness, hair follicles thickness and epidermal pigmentation were f o u n d in almost all biopsy pieces. It was not a b n o r m a l in subcutis region.
Conclusions: Cutaneous hlstopathology was consistent t o skin thickness at c u t t i n g positions.
However, this procedure was a penetrating test and required a lot o f experience o f hlstopathology to confirm t h e diagnosis. Therefore, it is necessary to take consideration in skin biopsy for scleroderma patients and able to use t h e m-Rodnan to substitute for cutaneous hlstopathology.
Keyvfords: Scleroderma, m-Rodnan, cutaneous hlstopathology.
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