TCNCYH PhiJ tmung 80 (3A) - 2012
NGUYEN NHAN, OAC DIEM LAM SANG, CAN LAM SANG CUA VIEM PHOI KHONG DIEN HJNH a TRE EM:
KET QUA B U a C DAU
Pham Thu Hien\ Dao Minh Tuan\ Nguyen Phong Lan^,Phan Le Thanh Hu^n^
^Benh vien Nhi Trung wang, ^Vien Ve smh Dich t§ Trung wang Nhdm xdc dinh nguydn nhan vd nhan xet ddc diim lam sang, cdn Idm sdng viem phdi khdng didn hinh a tre em do M. pneumoniae, C pneumoniae va L pneumophylla gdy ra, 193 bdnh nhdn (tudi tu 12 thang din 15 tudi) vao khoa Hd hip bdnh vien Nhi Trung wong, Hd Noi vdi bidu hidn vidm phdi trong thai glan tif thdng 7/2010 din thdng 12/ 2010 da dwoc dwa vao nghidn cuv. Kit qua cho thdy viem phdi khdng diin hinh gap d 48/193 (24,8%,) bdnh nhan, tudi trung binh la 3,7 (tu 1 - 15 tudi) PCR Mpneumoniae duong tinh d 42 (21,8%) trudng hop, PCR C.pneumoniae dwang tinh trong 5 (2,6%>) trudng hop va PCR L pneumoniae dwang tinh d 1 (0,52%,) trwdng hap Tinh trang ddng nhidm gap d 11 (22,9%) benh nhan trong dd cd 2 trwdng hap ddng nhiim giwa t/l pneumoniae va C pneumoniae. Vidm phdi nang gap d 43,7%, benh nhdn. Tw dd cd thi kit luan trong nghidn cuu nay tac nhdn M pneumoniae. C pneumoniae va L pneumophylla chiim 24.8%, vidm phdi mdc phai d cdng ddng a trd em, tinh trang ddng nhidm chiim 22,9%). vidm phdi nang gap d 43,7%, benh nhdn Xdt nghidm Multiplex PCR giup chin dodn sdm nhidm trung do M pneumoniae, C pneumoniae, vd L pneumophylla a trd em
Tip khoa: Mycoplasma, Chlamydia, Legionella, viem phli I. DAT V A N Bt
f^ pneumoniae, C.pneumoniae va L.pneumophlla duac col Id nguyen nhan quan trong gay viem phlt d ea tre em va ngudi ldn tai cac nude phat Irlln nhung val tro cua nd d cde nude dang phat tnln dac biet la Viet Nam ehua duac bilt nhilu [1, 5, 6, 13] Viec xae dinh can nguyen gay viem phoi khdng phai d i dang khi ky thuat chin doan bing sinh hoc phan tir edn gidi han d mdt sg trung tam xet nghiem. Cde ky thuat xet nghiem trude day (nuoi ely, ELISA) mdi chl dap irng dwac mot phln yeu d u dilu tri.
Cac thly thuic thudng ItJ'a chgn khang sinh theo kinh nghiem vi vay k i t qua dilu tri, cdn han c h l chi phi y t l eao [8]
Vi vay, chiing tot nghien eiru d l tai nay nhim muc tieu: Xac djnh nguyen nhan va nhan xet dac diem lam sang, can lam sang viem phoi khong dien hinh a tre em tai benh vien Nhi Trung wang td 01/7/2010 d i n 31/12/2010
II. B6\ TU'gNG VA PHU'ONG PHAP 1. Odi tu'ang nghien CIPU
Gdm 193 benh nhi tu 1 tdi 15 tuli duae chin doan viem phli vao dilu trj tai benh vien Nhi Trung uang tir 01/7/2010 d i n 31/12/2010.
Tieu chuin chon d l i tugng nghien ciru Benh nhan duac chin doan viem phli vdi cdc tneu chirng theo WHO [11]:
Ho, sit. than nhiet > 37,5°C, thd nhanh, khd khe, phli cd ran I m to nho hat Xquang cd hinh anh tham nhilm nhu mo phli rai rac hai ben, tap trung tu'ng thiiy. phan thuy, tham nhiim md ke hoae hlnh anh hon hap.
Tieu ehuin viem phli do M pneumoniae.
C pneumoniae va L pneumophilla - Co dit tieu chuin ehan doan viem phli.
- Multiplex PCR Mpneumoniae va/hoac C pneumoniae va/ hoac L. pneumophila
TCNCYH Phu tmung 80 (3A) - 2012 trong dich ty hau duang tinh.
Tieu c h u i n loai ra khdi ddi tipgng nghien ciru: Viem phli mac phai d benh vien (vao benh vien dtlu trj benh khae, sau 48 gid mic viem phil).
2. PhU'O'ng phap nghien CLPU Phuang phap nghien ciru tiln eiru md ta d t ngang
Benh nhan viem phil tren 1 tuli vao vien dugc Itj'a chon ngau nhien bing phuang phap chon mlu chiim kit hap chgn mlu he thing.
Benh nhan vdo vien duge lly benh phim dich ty hlu va mau trong vdng 48 gid d i u nhap vien. Cly ty hau tim tdc nhan vi khuln diln hinh va xet nghiem PCR d l chin doan tac nhan virus ddng nhiim
phim dugc bao quan d tiln hanh phan tieh.
Biln nghien ciru g i m : tuli, gidi, cac d i u 1. Tan suat mac benh
Tat ea benh 70°C cho tdi kht
hieu lam sang, xet nghiem can lam sang gdm c6ng thuc mau, CRP, Xquang nguc thing, cly dich ty hlu tal khoa vl sinh benh vidn Nhi Trung uang. Xet nghiem ehln doan M.pneumoniae,, C.pneumoniae va L.
pneumophila bang ky sinh hpc phan tu Multiplex PCR thue hien tai vien Ve sinh Djch te Trung uang, k i t qua Xquang do eac bac sT khoa Xquang doe.
Phan tieh, xir ly thing ke bang phln mim SPSS 13 0, tinh gia tn trung vj tuol, ngay benh, thdi gian dilu tri, ty le phln tram eac dac dilm lam sang va can lam sang III. KET QUA
Trong vgng 6 thang, tir 1/7/2010 din 31/12/2010 ed 193 benh nhdn viem phli cdng ding da duac dua vae nghien eiru. Ky thuat Multiplex PCR da dugc sir dijng d l sang lgc /W. pneumoniae, C. pneumoniae va L. pneumophila.
Bang 1. Tan suat nhiem M.pneumoniae, C. pneumoniae va L. pneumophila trong sd 193 benh nhan Tac nhan vi khuin
M pneumoniae C.pneumonia L.pneumoniae
Multiplex PCR 42/193
5/193 1/193
%
21,8 2,6 0,52
Bang 1 cho thly t i n suat mac it nhlt mgt loai vl khuln trong s l [>/l.pneumoniae, C.pneumoniae va L.peumophila tim thay d 48 benh nhan la 24 8%, trong dd M.pneumoniae la 42 trudng hgp (21,8%), C pneumoniae 5 (2,6%) va L.pneumoniae la 1 (0,52 %)
2. Phan bo benh nhan viem phdi khong d i l n hinh theo tudi Bang 2. Phan bd theo tudi Tudi
1 - 3 tudi 3 - 6 tudi 5 - 12 tudi Tdng
Sd benh nhan du'p'c xet nghiem
112 52 29 193
Benh nhan du'O'ng tinh
n % 19 17 12 23 17 58,6 48 24,8
TCNCYH Phu tnmng 80 (3A) - 2012 Bang 2 cho thly viem phdi do M.pneumoniae. C pneumoniae va L.pneumophlla gap a moi lira tuoi, nhdm tudi mac benh eao nhat la 6 - 12 tudi, chiem ty le 58,6%. Tuoi trung binh 3,7 ± 2 , 8 ( 1 - 9 ) tuoi.
3. Phan bd theo gid-i: Nam/nu': 31/17 = 1,8/1 4. Dac di§m lam sang, can lam sang
Bang 3. Dac dilm lam sang Dac diem lam sang
Ho • Sot Dau dau Khd khe Khan tieng ThO' nhanh Tho rut Idm Tim tai
n (%) 48(100) 46 (95,8) 21 (43,7) 29 (60) 15(31,2) 24 (50) 15(31,2)
6(12,5)
€)ac digm lam sang Hong do Tieu chay Ran Im Ran phi quan
Khdng ran HC dong dae phdi HC tran djch, khi mang phdi
n (%) 30 (62,5) 15(31,2) 35 (73) 26 (54,2) 11 (22,9) 6(12,5)
2 (4,2)
Olu hieu lam sang khdi phat noi bat la ho (100%) va s i t (95,8%), trieu chirng khac cua dudng hd h i p cQng gap nhu khd khe (60%). Kham lam sang thly niem mae hgng do (62,5%) va 22,9% khdng cd ran. Kham phdt cd ran p h i quan (54,2%), ran I m (73%). Cd 31,2% trudng hap thd nhanh, thd riit 16m, 12,5% trudng hap ed d i u hieu khd thd, tim tal, nghe duae nhilu ran lan toa 2 ben.
Cac trieu ehirng ngoai phli bao gdm: phat ban 5 (10,5%), tieu chay 15 (31,2%), thilu mau 26 (54,2%), CO giat 2 (4,2%).
Bang 4. Dac dilm can lam sang Dac dilm can lam sang
BC> 15000/mm' BC 10000- 15000/mm^
BC< 10000/mm^
CRP > 12 mg/l CRP< 12 mg/l
n (%) 18 (37,5)
12 (25) 18(37,5) 37(77,1) 11 (22,9)
Thay ddi Xquang Phe quan p h i viem Viem phdi thiiy Viem phdi ke
Viem phoi mang phdi
n (%) 32 (66,7)
6(12,5)
• 8(16,7) 2 (4,2)
Xquang phdi phat hien viem phdi ke (16,7%) viem p h i quan phdi (66,7%)), viem phdi thiiy (12,5%), viem phdi mang phdi (4.2%). Hinh anh tdn thu'ong tren Xquang khong dae hieu khi so sanh vd'i viem phdi do eac nguyen nhan khac. Xet nghiem bach c l u khdng tang < 10.000/mm^
(37;5%); 37,5% benh nhan bach eau tang tren 15.000/mm^ CRP tang tren 12mg/l (77,1%) , CRP <12mg/l (22,9%)
5. Cac benh dl kem: Trong sd 48 benh nhan viem phdi khong dien hinh co 3 (6,2 %) benh nhan suy dinh dirong, 1 (2,08%) benh nhan cd di tat bim sinh tim - phoi k i t hgp, benh nhan ed tlln sir hen ehiSm ty le 2 (4,2 %).
TCNCYH Phu truung 80 (3A) - 2012 6.Tinh trang ddng nhiem
Bang 5. tinh trang ddng nhiem The benh
Odng nhilm Khdng dong nhiem
Viem phoi 0 27 (100%)
Tong so 27 (56,3%)
Viem phdi nang 11 (52,4_%) 10(47,6%) 21 (43,7%)
Tdng 11 (22,9%) 37(77,1%) 48(100%) Trong sd 48 benh nhan viem phdi khong dien hinh ed 11 benh nhan ddng nhiem (22,9%), trong do ed 2 trudng hgp ding nhilm M.pneumoniae va C.pneumoniae, 09 benh nhan cd dong nhiim vdl vt khuln diln hlnh khae (S.pneumoniae: 4, H.influenzae- 3, S.aurius: 1, Acinetobacter 1) Benh nhan viem phlt nang chiem ty le 43,7%, trong dd ed 11 benh nhan ding nhiim vdl vl khuln, chilm ty le 52,4%
IV. BAN LUAN
Qua nghien ciru 48 trudng hgp benh nhilm M.pneumoniae, C.pneumonia va L.
pneumoniae chung t6i nhan t h l y tuli trung binh la 3,7 tull, ehii y l u d nhdm tuoi 6 - 1 2 (58,6%), thudng gap d tre trai han tre gdi (1,8/1). Nghien ciru nay phii hap vdi kit qua nghien ciru ciia cac tae gia trong va ngoai nude [2, 6. 7, 8, 9]. Nghien ciru ciia chung toi ty le mac viem phli do M pneumoniae thip han so vdi cac tae gia trong nude cd le do su khac biet v l lira tudt cita d l i tugng nghien ciru va do nhay cua 2 phuang phap xet nghlem xac dinh vi khuln [7, 8]
Ve mat lam sdng, d tre em sit va ho, thudng la trieu chirng khdi phat cung la ly do khien benh nhan nhap vien (95,8%) Tneu chirng ho nli bat nhlt (100%), khdm phli ed t h i phat hien cae am bit thudng nhu ran I m (73%), ran p h i quan (54,6%) hodc khdng phat hien dugc gi (22.9%).
Nghien ciru ghi nhan s l luang bach c l u thudng tang nhe tren 10 000/mm^ va CRP tang tren 12mg/l Tuy nhien baeh d u khdng tang chilm ty le 37.5%, CRP dudi 12mg/l chilm ty le 22,9% Day Id nhirng trudng hap d l ehln doan nhim vdi tde nhan virut d i n d i n keo dat thdi gian benh, tang ty le lay lan VI khuln ra edng dlng.
Nghien ciru eho thay Xquang phot cd lgi trong viec phan loat ban d i u chin doan nhiem trung dudng h6 hip dudi, giup hudng d i n dilu tn theo kinh nghiem va lam eac xet nghiem can lam sang Cac t h i lam sang ghi nhan qua nghien ciru nay la viem phil (66,7%), viem phli ke (16,7%), viem phot thuy (12,5%), viem phlt mang phot (4,2%)
Trong nghien cuu ndy chiing t i l nhan thly viem phlt nang chiem 43,7% trong dd cd tdi 22,9% la ding nhilm vi khuln khae, day la ylu t l lam nang them tinh trang benh [3, 10], Viem phoi do L pneumophylla d tre em hilm gap va thudng nang [1] Tac nhan gay viem phdi khdng diln hinh lam khdi phat can hen duge cho Id tae nhan p h i biln [9], trong nghien eiru nay chung toi nhan thly benh nhan nhiim C.pneumoniae lien quan din can hen d p d 4,2% trudng hgp. Cac biln ehirng ngoai phli nhu viem ea tim, viem noi tam mac khong gap trong nghien ciru nay
Tieu chuin vang d l chin doan benh n h i l m M.pneumoniae, Chlamydia pneumoniae va Legionella pneumophila theo kmh diln la d y benh phim tir dich mang phli, ddm, dieh mui hong Tuy nhien do nhQ'ng khd khan ve mat phuang phap ciia viee cly vi khuln khdng diln hinh va thai gian cd ket qua lau (sau 3 tuin) da d i n din
TCNCYH PhtJ tmung 80 (3A) - 2012 su phat triln cac xet nghiem khdng cin d y
Phuang phap chin doan huylt thanh hoc ddt hot mdt thdl glan ddl mdi ed k i t qua (han 10 ngay), nhu vay anh hudng r i t nhilu tdi vtec lua chon khang sinh dieu tn. Vdl nhirng tiln bd ciia khoa hoe cdng nghe sinh hoe, ky thuat PCR (polymerase chain reaction) da giup viee ehln doan nhiim trung do M pneumonia, C pneumoniae va L pneumophila dwac tiln hanh sdm (ngay sau khi benh nhdn nhap vien) va ed t h i eho kit qua trong eung ngay giup bae sy (^lu tri lua chgn thule thich hgp giup glam ty le biln ehung, gtam ty le tLr vong cita ngudi benh, ddc biet la tre nhd [2, 8]
Vdl ky thuat Multiplex PCR lln d i u tien thue hien tat Viet Nam, chung tdi da thanh cong khi tiln hdnh khao sat ty le mac viem phli do M pneumonia, C.pneumoniae va L.pneumophlla a tre em
Joseph F ghi nhan khdng cd mil tuang quan giQ'a do ndng lam sang va ton thuang Xquang, mdt van d l khdc la hinh anh Xquang phlt khdng t h i phan biet giira viem phli do M pneumonia, C pneumoniae va Lpneumophila va nhirng tae nhan khae [4]. Do dd trong nhu'ng tardng hap benh sir gai y va t i n thuang Xquang khong phii hap lam sang cd t h i ehi dinh PCR chin doan d l dinh benh.
V. K^T LUAN
Qua nghien ciru 193 benh nhan viem phdi vao vien Nhi Trung uang tir 7/2010 d i n 31/12/2010 chung toi di d i n k i t luan sau;
Ty le viem phoi khdng diln hinh d tre em do M.pneumoniae, C.pneumoniae va L.pneumophyla phat hien bang phuang phap Multiplex PCR la 24,8%, trong dd viem phli do M p n e u m o n i a e c h i l m 2 1 , 8 % , C.pneumoniae 2,6% va L.pneumophylla 0,52% Benh gap d nam nhieu han nu' (1,8/1) va nhdm t u l i hay gap la 6 - 12 tull (58,6%)
Viem phli do M.pneumonia, C.pneumoniae va L pneumophila gay benh eanh ldm sang vdi nhilu muc do ndng nhe khae nhau hoae bilu hien ngoai phli. Trong dd mirc do nang ehilm 43,7%; 22,9% eo ding nhiim vdi vi khuln (trong dd ed 2 tardng hap dong nhiim M pneumoniae va C.pneumoniae)
TAI LIEU THAM KHAO 1. Le Dinh Nhan, Trln Thj Minh Dilm va cong SIP (2005). Tinh hinh viem phdt do My- coplasma pneumoniae d tre 4 - 5 tuli tai benh vien Trung uang Hul. Y hgc thuc hanh (10): 6 7 - 7 0
2. David W.Fraser (2001). Legtonellosls, Bacterial Infections of Humans, Epidemiology and Control, 2'^ Chapter 15, 333 - 347.
3. Fang - Ching Liu, Po - Yen Chen, Fang - Liang Huang et al (2007) Rapid di- agnosis of Mycoplasma pneumoniae infec- tion in children by polymerase chain reaction.
Journal of mierobiolagy, Imunolagy and Infec- tion 40(6).
4. F. Gutierrez, M. Masia, J. C.
Rodriguez, C. Mirete et al (2005) Community - acquired pneumonia of mixed etiology prev- alence, clinical characteristics, and outeome.
Eur J Clin Microbiol Infect Dis 24' 377 - 383 5. A. Forest W. Arnold, James T. Sum- mersgill et al (2007). A Worldwide Perspec- tive of Atypical Pathogens in Community acquired Pneumonia. American Jeurnal of.
Respiratory and Critical Care Medicine Vol 175. 1086-1093
6. Joseph F, Ploufe (2011). Importance of Atypical Pathogens of Community - Ac- quired Pneumonia. Oxford Journals Medicine Clinical Infectious Diseases, July 15, Volume 31, S35-S39
7. Ken B, Waitesi and Deborah F, Talk- ington (2004). Mycoplasma pneumoniae and
123
TCNCYH Phu truung 80 (3A) - 2012 Its Role as a Human Pathogen. 7 (4):
697 - 728.
8. Mujgan Sidal, Ayse Kilic, Emin Un- uvar et al (2007) Frequency of Clamydia pneumoniae and Mycoplasma pneumoniae Infections in Children. Journal of Tropical Pe- diatrics 2007, 53(4) 225-231.
9. Phan Le Thanh Huong, Ngo Thi Thi, Tsuguo sasaki et al (2007). First report on clmieal features of Mycoplasma pneumoniae infections in Vietnamese children. Jpn.J. In- fec.Dis (60): 370-373.
10. Tsai MH, Huang YC, Chen CJ, Lin
PY et al (2005). Chlamydial pneumonia in children requiring hospitalization- effect of mixed infection on clinical outcome. J Micro- biol Immunol infect 38 (2), 117 - 22
11. WHO (1994). Manual for the national surveillance of respiratory Infection. WHO Geneva 23-25.
12. W. Forest,Arnold, James T. Sum- mersgill et al (2007) A Woridwide Perspec- tive of Atypical Pathogens in Community - acquired Pneumonia. Amencan Journal of Respiratory and Critical Care Medicine (175):
1086- 1093 Summary
ATYPICAL PNEUMONIA CAUSED BY MYCOPLASMA PNEUMONIAE, CHLAMYDIA PNEU- MONIAE AND LEGIONELLA PNEUMOPHYLLA IN CHILDREN: INITIAL RESULTS The study was conducted to assess the role of M.pneumoniae, C.pneumoniae, and L.pneumophlla in community - acquired pneumonia in children. 193 patients (age from 12 months to 15 years), admitted to the Respiratory Department of the National Hospital of Pediat- rics, with symptoms of pneumonia from July 2010 to December 2010, were enrolled in the study. Multiplex PCR on nasopharyngeal aspirates were used to establish the diagnosis of acute M.pneumoniae, C.pneumoniae and L.pneumophylla infection The results showed that atypical pneumonia was identified In 48/193 (24.8%i). The median age was 3,7 (range 1-15) years Mycoplasma pneumoniae PCR was positive in 42 (21.8%) cases, C. pneumoniaein 5 (2.6%) cases, L.pneumophylla in one (0 52%) case and co - infection was present in 11 (22.9%). Two cases had co - infection with M. pneumoniae and C.pneumoniae Severe atypical pneumonia was occurred In 43 7%. In conclusion, M.pneumoniae, C.pneumoniae, L.pneumonla were identified in 24 8%> of children with CAP in this series and mixed infections were common (22.9%) and severe atypical pneumonia was occurred in 43.7%. Multiplex PCR assay could pro- vide earlier diagnosis of M.pneumoniae, L.pneumophylla , C pneumoniae infection.
Keywords: Mycoplasma, Chlamydia, Legionella, pneumonia