MdT SO DAC DIEM DjCH TE HOC, BIEU HIEN LAM SANG VA CAN LAM SANG COA BENH NHAN NHIEM GIUN LUON
STRONGYLOIDES STERCORALIS DIEU TRI TAI BENH VIEN BACH MAI (2013 - 2014)
Ngo Thi PhuOTig NhungS Pham Thi Thanh Thuy'.
M{ic tieu: Md ta mdt sd dac diem dich td hpc, lam sang va can lam sang ctia benh nhan nhiem giun lucm S.stercoralis. Doi tuang: 45 benh nhan dugc chan doan xac diitii nhiem giun lucm tai Benh vien Bach Mai (2013 - 2014). Phuangphdp: Md ta cat ngang. Ket qud vd kit lugn: Benh nhan phin ldn sdng d ndng thdn (82,2%) va lam ndng nghiep (77,8%); ty le benh nhan Nam cao hem so vdi Nu (73,3% so vdi 26,7%); benh nhan d nhieu do tudi khac nhau va gan 50% tren 60 tudi. 90% benh nhan cd it nhat mdt benh ly man tinh hoac van de y khoa tnrdc dd, nhieu nhat la sti dung thudc tic che mien dich (chti yeu la corticoid), chiem 71,1%; 62,2% su dung ruou thudng xuyen. Benh thudng dien bien man tinh; cac bieu hien thucmg gap la trieu chiing ve tieu hda (100%), fr-ong dd ddy chudng bung (93,3%), dau bung (82,2%), chan an (75,6%), rdi loan dai tien (73,3%); sdt (75,6%), phu (62,2%), gSy sut can (66,7%), biSu hien ngoai da (68,9%), bidu hien hd hip (44,4%). Bach cSu ai toan trong mau tang d 75,6% sd benh nhan, hemoglobin giam (40%), albumin mau giam (93,3%) va rdi loan dien giai (68,9%).
Tu- khda: Strongyloides stercoralis, nhiem giun luon.
DAT VAN DE
Nhiim giun lUdn dUdng rudt Strongyloides stercoralis la benh diing thir tU trong eae benh nhiem giun dudng mpt quan tipng fren tiie gidlf^l U'dc tinh, S. stercoralis anh hudng den khoang 30 - 1 0 0 frieu ngUcfi fren toan the gidi, chil yeu d cac viing nhiet ddi va can nhiet ddi, trong dd cd Viet Nam. Benh cd the diin bien cap tfnh hoac man tinh, bieu hien chinh la roi loan tieu hda man tinh khdng dac hieui^l Q eae cd dja suy giam miin djch, dac biet la nhung ngUdi sti dung corticoid keo dai, au triing giun lUdn gay "tU nhiem" (autoinfedion), bieu hien bang hdi chimg tang nhiim hay nhiem lan tda d cac ed quan ngoai rudt nhu phoi, than, nao... gay ra benh canh lam sang nang, ti le tir vong cd the len den tren 85%ra.
i'>Khoa Truyen nhiem. Benh vien Bach Mau V\%kyn\i&abhi: 30/6/2016.
N g i y p h i n bifn xong: 12/7/2016.
N g i y duyft d i n g : 18/8/2016
NguM chju trach nhiem ngi dung khoa hpc: Nga Thi Phuang Nhung, Khoa Tniv^n nhJm. Benh vien B^ck Mai
Dien thoai 0984110285. E-mail: [email protected]
O Viet Nam, trong vai nam trd lai day, da cd mpt sd bao cao va nghien ciru ve nhiem giun lUdnt^''^''^. Tuy nhien, cac bao cao chii yeu xuat phat tir mien Nam va mien Trung, chUa cd nghien ciiti nao dUdc tien hanh tai mien Bac cho den nam 2013. Vi vay, chiing tdi tien hanh nghien cull nay vdi muc tieu mo ta cac dac diem djch t i hpc, bleu hien lam sang va cae bien doi can lam sang eac benh nhan nhiem giun lUdn S.sfercorafe tai Benh vien Bach Mai.
D O I TirgNG VA PHU'ONG PHAP NGHIEN CUU Doi tu'dng nghien cu'u: 45 benh nhan dUdc chan doan xac djnh nhilm giun lUdn S.stercoralis tU cac khoa npi tru ciia Benh vien Bach Mai trong thdi gian hai nam 2013 - 2014.
Phu'dng phap: Nghien ciru md ta cat ngang Cach thtic tien hanh nghien cu'u:
Benh nhan nhiim giun lUdn dUdc xac djnh khi tren lam sang cd eac bieu hien gdi y nhilm giun lUdn, xet nghiem khang djnh nhiim giun lUdn tai khoa Vi sinh Benh vien Bach Mai hoac Phdng xet nghiem Khoa Truyen nhiim
TRUYEN NHliM VIET N A M * SO 3(15) - 2016 - 2 1
Benh vien Bach Mai bang phUdng phap huyet thanh hpe (ky tiiuat EUSA tim khang tiie IgG vdi au friing dang fi- larifbmi) hoac soi tim au titing giun lUdn(+) it nhat mpt trong cac mau benh pham phan, djch da day, ta frang, ddm, hoac dich phe quan, hoac hinh anh au tiuncf giun lUdn fren mo benh hpc. Chung tdi loai frti nhQng benh nhan nhiem ddng thdi nhieu loai giun dudng rudt de tianh sUtning hdp tiong benh canh lam sang.
Cac thong tin dUdc thu tiiap va dUa vao danh gia bao gdm cac thdng tin nhan khau hpc (tuoi, gidi, nghe nghiep, ndi d), eac yeu to benh tat (sti dung cortioid hoac cac thuoc ire ehe mien djch khac, lam dung rUdu, cac benh man ti'nh); bieu hien lam sang (thdi gian dien bien benh, cac bieu hien toan than - sot, phii, gay sut can, bieu hien da, tieu hda, hd hap...); cac bien doi can lam sang (bach cau ai toan, hemoglobin mau, albumin mau, rdi loan dien giai, chtie nang than...). Cac thong tin djch te hpc, lam sang va can lam sang dUdc khai thac tii benh an npi tiu ciia cae benh nhan.
Thu thap va xiir ly so lieu: Ket qua nghien cuti dUdc xir ty bang phan mem SPSS.
KfTQUA
Trong 2 nam 2013 - 2014, chung tdi xae dinh 6Mc cd tat ca 45 benh nhan dieu frj tei Benh vien Bach Mai dUde chan doan nhiim giun lUdn S. stercoralis thuoc 19 tinh thanh pho phan bo rai rac khap cac tinh tU mien Tmng ra mien Bac tren ca nUdc; tat ea 45 benh nhan deu cd xet nghiem phan soi au triing giun lUdn trong phan va EUSA h'm khang the IgG vdi au tning giun lUdn dUdng tinh; 2/17 benh nhan dUdc tim thay au trung S. stercorali^+) frong ddm; 29/41 benh nhan cd au triing giun lUdn tiong djch da day, ta tiing.
Ddc diem chung cua benh nhan
Bang 1 : Dac diem chung cua nhom benh nhin nghien cuti
Dac di^m
Gia tinh Nam
m
Tuoi tmng binh (TB) {n3m) Gidi han (f^in - Max)
Phan bo tuoi
NOi song
Nghe nghiep
<30 3 0 - 3 9 4 0 - 4 9 50-59
>60 Nong ttion Khong phai nong thon Lim rupng Nghe Ithac
Sdbenh nhan
33 12
T y l ? % (n = 45) 73,3 26,7 57,24 ± 16,3
22-86 4 4 6 9 22 37 8 35 10
8,9 8,9 13,3 20 48,9 82,2 17,8 77,8 22,2 Nhan xet: Ty le mic benh theo gicfi: nam (73,3%), nti (26,7%); frjoi frung binh la 57,24 ±16.3, tiiap nhat 22 tuoi, rao nhat 86 tuoi, benh nhan tii" 60 tijoi trd len ehiem gan 50%; 82,2% sd benh nhan song tai nong thon;
77,8% benh nhan lam ndng nghiep hoac lam nghe phai tiep xiic vdi rupng dat.
KhtngcitMfitinijntMi |
Bieu do 1 : Dac diem ve tien suT cua benh nhan Nhan xet: Da so benh nhan mac benh man tfnh tiudc dd (88,9%); 71,1% sti dung thudc U'C che miin djch (chil yeu la corticoid); 28 benh nhan (62,2%) sti dung rUdu thudng xuyen, 20% benh nhan bj dai thao dUdng; so benh nhan mac benh huyet hpc, ung thU, benh than man it (ty ie ti/dng img lan lUdt la 2,2%, 4,4%, 6,7%).
Bieu hien lam sang
Thdi gian bi benh trung binh ciia eae benh nhan nghien ctiu la 25,7 ngay, dai nhat la 5 tiiang va ngan nhat la 3 ngay; da so benh nhan (31 ngUdi, chigm 68,9%) co
22 - TRUY^NHI&flVl|TNAM*s63(15) - 2016
cac benh l<eo dai tren 14 ngay tinh den thM diem duHc Chan doan. Th6i gian trung binh ke tiy l<hi nhap vien den khi benh nhan dirac chan doan xac Oinh nhilm giun luHn la 12 ngay (1 - 50 ngay).
Bang 2: Trieu chumg ISm sang chung cua benh nhiin Dac diem
Sot Khong sot Sot nhe Sot cao Co phu Co gay sijt can Co bieu hien ngoai da Co bieu hien ho hap Co bieu hien tieu hoa
Chan an, an khong tieu Day chu'dng bung Buon non, non Dau bung Roi loan dai tien XHTH
Sdbenh nhSn
11 25 9 28 30 31 20 45 34 42 13 37 33 3
TV lc Vt (n = 45) 24,4 55,6 20 62,2 66,7 68,9 44,4 100 75,6 93,3 28,9 82,2 73,3 6,7 Nhan xet: Cac trieu chting thudng gap la sot (75,6%), gay sut can (66,7%), phii (62,2%). Cac trieu chUng ngoai da gap d gan 70% cae benh nhan, chii yeu la ngu^a. Cd 20 benh nhan cd bleu hien hd hap, chiem 44,4%. Trong 45 benh nhan khdng gap frUdng hdp nao cd difu hieu than kinh tmng Udng. Tat ca cac benh nhan deu cd bieu hien tieu hda d cac mUe dp, trong dd: day chudng bung (93,3%), dau bung (82,2%), chan an- an khdng tieu (75,6%), rdi loan dai tien (73,3%), xuat huyet tieu hda cd 3 benh nhan (6,7%).
Thay doi can lam sang
Bang 3: Cac bien doi can lam sang d benh nhan nghien ctiu
Cac chi so c|n l i m sang TSng BC ai toan trong mau ngoai vi Thigu mau fHb < 90 g/L) Giam albumin mau (< 35 g/L) Roi loan iJien giai
So b@nli ntiSn 34 18 42 31
TV i | % (n = 45) 75,6 40,0 93,3 68,9
Nhan xet; Trong 45 benh nhan nghien ciru, 34 benh nhan cd tSng bach cau ai toan trong mau, ehiem 75,6%;
18 benh nhan cd xet nghiem Hb < 90 g/1, chiem 40%, 42 benh nhan cd xet nghiem albumin mau dudi 35g/l va 31 benh nhan (68,9%) cd rdi loan dien giai bao gom ca ha kali va ha natri mau.
BAN LUAN
Mac dii nhilm S.stercoralis la benh da dUdc phat hien tir rat lau (bac sy Louis Normand, tir nam 1876, d nhiJng ngudi ed roi loan tieu hda va da tUng sdng d Ddng DUdng), va viec chan doan tUdng ddi ddn gian, fren thUc te lam sang, chan doan nhilm giun lUdn thudng it dUdc dat ra va thudng mudn, dan den nguy cd t t i vong cao.
Oe giup cac thay thude lam sang djnh hUdng ehan doan nhiim giun lUdn, chiing tdi md ta cac yeu td djch t i hpc va cac bieu hien lam sang cua cac benh nhan dUde chan doan xac dinh can benh nay.
Trong 45 benh nhan, cd 33 benh nhan Nam (73,3%) va 12 benh nhan NU (26,7%), ty le Nam/Nti la 2,74, tUdng t u vdi nhieu nghien culi tren the gidi cho rang Nam gidi cd nguy ed mac benh cao hdn so vdi Nti gidi^^]. Benh nhan cua chiing tdi d mpi luS frJoi (tU 22 den 86 tuoi), tiJOi tiung binh 57,24, tUdng tU vdi nghien ctiu ciia Yupin va cdng sU tien hanh tai Thai Lan[6]. Dd tuoi tap frung nhieu benh nhan nhift la tii 60 tuoi trd len, ehiem gan 50% sd benh nhan. 45 benh nhan phan bd d 19 tinh, thanh pho d mien Bac va mien Trung trong ca nUde, da so cac benh nhan sdng tai viing ndng thdn (82,2%). Cd 77,8% benh nhan lam ndng nghiep hoac lam nghe phai tiep xuc vdi rupng dat, tUdng dUdng vdi nghien ciiti cua Huynh Hdng Quang va cpng sU tien hanh tai cac tfnh mien Trung vdi ngudi lam nghe ndng chiem da so (35/46 - 78,3%)[''i va qua dd cd the khang djnh ndi sdng d vimg ndng thdn va lam nong ngiep la yeu td nguy cd ciia nhiem giun lUdn^^l
Trong sd 45 benh nhan nghien cu'u, chi cd 5 benh nhan (11,1%) chu^ phat hien benh man tinh gi trUde do, 40 benh nhan mac benh man tinh chiem 88,9%. 20% cac benh nhan bi dai thao dudng, 6,7% mac ung thU, 6,7%
cd benh than man tinh; 35,6% cd cac benh man tfnh khac chil yeu bao gom benh ly cd xUdng khdp man tinh, cac benh he thdng va tU mien. SU cd mat benh man tinh ciia benh nhan trong nghien cUu tUdng tU trong nghien culi ciia Yupin va cdng sU nhU dai thao dUdng (21,1%), ung thU (10%), benh than man (7,8%), nhdm benh ly ed xUdng khdp man tfnh, benh he thdng va cac benh khac chiem 43,2%[^l Trong nghien ciru ciia Yupin tai Thai Lan,
T R l i Y ^ N N H l i M V l f T N A M * s 6 3(15) - 2016 - 2 3
chf cd 5,6% benh nhan cd tien sti sir dung rUdu, trong khi dd con sd nay trong nghien ciru ciia ehiing tdi len tdi 62,2%, ndi len tam quan trpng cua yeu to sir dung rUpu trong nhilm giun lUdn tai Viet Nam.
Lam sang ciia nhilm giun lUdn phu thupc vao thdi gian nhiim giun, mtic dp va dap ting ciia he mien djch.
Thdi gian nhiim thudng keo dai, ft khi xac dinh dUdc chinh xac thdi diem nhiem giun lUdn.
Trong sd eac benh nhan cua chung tdi, 31 benh nhan cd frieu chUng keo dai tren 14 ngay (ehiem 68,9%), frong dd cd nhCmg benh nhan cd benh keo dai den vai tiiang (thdi gian dai nhat trong nghien culi ciia chimg tdi la 150 ngay). Dieu nay phii hdp vdi dac diem va sinh benh hpc eua nhiem giun lUdn, thUdng diin bien man tfnh, it khi phat hien dUdc benh nhan trong giai doan nhiem cap ti'nh.
Do cd chu frinh tU nhiem hoac co the do tinh frang ph(^
nhiem lien tuc khi benh nhan song trong vimg djch te ma giun lUdn cd the ton tai trong cd the ngUdi qua nhieu thap ky va gay ra cac bieu hien lam sang sau mpt thdi gian rat dai tU khi nhiim dau tient^'. Dieu nay dUdc quan sat thay d cac til nhan chien tranh viing Ddng Nam A, frong do cd Viet Nam, hp da dUde tim thay bj nhilm giun lUdn sau hdn 40 nam ke tir khi phdi nhiim'^i-t^i.
Thdi gian t t i luc nhap vien den luc benh nhan dUdc chan doan xac djnh trung binh ciia benh nhan trong nghien cUu la 12 ngay, dieu nay chimg td tuy khi benh nhan den vien kham va nhap vien da cd cac bieu hien lam sang nhUng thudng 6MC chan doan xac dinh mudn.
Trieu chiing lam sang nhilm giun lUdn khdng dac hieu va thay doi rat khac nhau tren tting benh nhan, nhUng nhdm frieu chUng thudng gap nhat la bieu hien tai dudng tieu hda do rudt non la ndi ky sinh ciia giun lUdn cai frudng thanh frong cd the. Tuy eung da cd nhiing bao cao fren the gifi md ta nhiing benh nhan khdng gap bat ky trieu chting dUdng tieu hda naoi'"'. Trong nghien culi ciia Chung tdi, 100% cae benh nhan cd bieu hien tai dUdng tieu hda; eac bleu hien tieu hda tUOng ddi da dang va day ciJng thudng la cac trieu chii'ng khien benh nhan di kham benh. Bleu hien tieu hda thudng gap nhat la day chudng bung (93,3%) va dau bung (82,2%), thudng khien benh nhan bj chan doan la mac cac benh ly da day dan den viec dieu tri trong khoang thdi gian dai trUdc khi dUdc xac dinh nhiim giun lUdn. Cac frieu chiing thudng gap khac la chan an, an khdng tieu (75,6%) va roi loan dai tien ndi chung
(73,3%). Ket qua cua ehimg tdi thap hdn ket qua frong nghien ciiU eiia Huynh Hong Quang va rong a i cd bieu hien dau bung 95,65%, chan an va buon ndn 82,61%, dai tien phan Idng 89,13%t'']; tUdng dUdng vdi ket qua aia nhdm tac gia Hari Polenakovik va edng sU nghien oiu bieu hien dau bung va tieu chay ehiem gan 78%!"'. NhU vay, cd tiie nhan Oiay bieu hien tieu hda frung nhiem giun luon tUdng ddi phtic tap nhung khdng dac hieu, rat de chan doan nham vdi mpt sd benh ly tieu hda khae neu l^ong nghl den nhiim giun lUdn.
Ngoai cac frieu chimg thUdng gap d dUdng tiai hda, hd hap, eac trieu chimg khac hay gap frong nhiem giun lUdn bao gom bieu hien ngoai da, sdt, siit can va phu chiem ty le frTdng ting la 68,9%, 75,6%, 66,7%, 62,2%, cd the giai thfch bang sU tU nhiem va di trii ciia au tiung giun lUdn frong cac md ed the, va a i the la yeu to dj ung vdi cac khang nguyen ciia au tning giun lUdn.
Cac bien doi can lam sang chiing tdi danh gia d cac benh nhan nghien ciiti la cac hau qua ciia nhiem giun, bao gom tang bach rau ai bDan trong mau (34 benh nhan, chiem 75,6%), tinh frang suy dinh du8ng (thieu mau, gap d 40% so tienh nhan, giam albumin mau (gap d 93,3% so benh nhan) va rdi loan dien giai (gap d 68,9% so benh nhan). Cae bien doi nay lien quan t f i sinh benh hpc ciia nhiim giun lUdn va la nhung gdi y nhiim giun ciing nhU cac yeu td lam tinh frang ngUfi benh nang can dUdc cham sdc tfch eUc.
KET LUAN
Qua nghien culi 45 benh nhan dUdc chan doan nhilm giun lUdn tai Benh vien Bach Mai trong hai nam 2013 - 2014 chiing toi cd mdt sd ket luan sau:
Benh nhan phan bd d nhieu dp tiJOl khac nhau, chu yeu song d ndng thdn va lam ndng nghiep.
Gan 90% benh nhan mac ft nhat mdt benh ly man tfnh frUde dd, nhieu nhat la sir dung tiiuoc tie che miin djch (chil yeu la corticoids), sU dung rUdu thUdng xuyen hoac dai thao dudng.
Dien bien benh da so man tfnh, v&\ cac tiieu diifiig lam sang khdng dac hieu, 100% sd benh nhan ed bieu hien frieu chimg tieu hda; cac frieu chiing lam sang khac bao gom sdt, phii, gay siit can, bleu hien ngoai da va bleu hien ho hap. Cac bien doi can lam sang cd frie gap bao gdm tang bach cau ai toan tiiang mau, thieu mau, giam al- bumin mau, va rdi loan dien giai.
2 4 - T R U Y i N N H l i M V i e T N A M * s 6 3 ( 1 5 ) - 2 0 1 6
TAI LIEU THAM KHAO
1. Afzal A. Siddiqui, Robert M. Genta, Ismael Maguilnik va cac cpng su. (2011), ••Stix)ngyloidiasis", Tropical Infec- tious Disease: Principles, Pathogens, Ptactice, Saunders, ti 805 - 1 2 .
2. D. I. Grove (1996), "Human strongyloidiasis", Adv Patasltol, 38, fr 251 - 309.
3. Tran Phu Manh Sieu, Biii Trpng Hdp, Nguyen Thj Minh Tuyet va cac cdng sU. (2006), 'Vai tid ciia giun lutJn tiung benh ly da day ta trang qua khao sat cac benh nhan tai benh vien Tmng VUdng, Benh vien Nhiet 6&i TP HCM nam 2004 - 2006", Y hpc thanh pho Ho Chi Minh, 10(4), fr. 236, 240.
4. Huynh Hdng Quang, Trieu Nguyen Trung, Nguyin Van ChUdng va cac cdng sU. (2013), "Lam sang, can lam sang va hieu lUe phac do Albendazole (ALB) fren benh nhan nhiim au friing giun lUdn Strongyloides stercoralis ehUa bien chiing tai 5 tinh ven bien mien frung Viet Nam", Y Hoc TP. Ho Chl Minh, 17(1), fr 116,122.
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Clinical Microbiology Reviews, 17, tr. 208 - 217.
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(2004), "Chronic Stiungyloides stercoralis infection in for- mer British Far East prisoners of war", Q3M, 9i7.
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REVIEW SOME EPIDEMIOLOGICAL, CLINICAL AND SUBCLINICAL CHARACTERISTICS OF PAHENTS INFECTED WITH STRONGYLOIDES STERCORALIS TREATED
I N BACHMAI HOSPITAL (2013 - 2014)
Summary
Objectives: review some epidemiological, clinical and and subcliniral characteristics of patients infected with Sfrongyloides stercoralis. Studied subjects: 45 patients di- agnosed positive by S. stercoralis at Bachmai Hospital from 2013 - to 2014. Methods: A cross - sectional study Results and conclusions: majority of the patients live in rural areas (82.2%), and work as farmer (77.8%); the male patients predominate compared to female (73.3%
versus 26.7%); the patients were from different age group, and up to 50% of patients were older than 60.
Ninety percent of patients had at least one chronic dis- ease or medical condition, 71.1% of the patients had his- Key words: Strongyloides stercoralis, Strongyloidiasi.
tory of using immunosuppressive drugs (mainly corticos- teroids); 62.2% used alcohol regulariy The disease is often chronic; most common symptoms include gastroin- testinal disturbance (100%), of which, abdominal dis- comfort is seen in 93.3% of the patients, abdominal pain - 82.2%, anorexia - 75.6%, abnormal bowel movement - 73.3%. Other clinical symptoms include fever (75.6%), edema (62.2%), weight loss (66.7%), skin manifestations (68.9%), respiratory manifestations (44.4%). Eosinophylia was seen in 75.6% of the patients, low hemoglobin (40%), hypoalbuminemia (93.3%), and electrolyte dis- balance (68.9%).
TRUY6NNHiiMVieTNAM*s6 3(15) - 2016 - 2 5
