• TAP CHI NGHIEN CU'U Y HOC
T O N THUaNG GAN TRONG BENH SOT XUAT HUY^T DENGUE d' NGU'ai TRU'ANG THANH
Dang Thj T h i j y \ Bui Vu Huy^ 0 6 Thj Thanh Thuy^
^B$nh vi$n B$nh Nhiet dai Trung wang. ^Trirnng Dai HQC YHa Npi. ^B$nh vien 198 Nghien ciru nhim dctnh gia ton thuong gan trong b$nh s6t xuit huyet (SXHD) Kit qua cho thiy cac bleu hien hay g$p la sot (100%), dau diu. chan an (98.7%). dau moi nguai/cokhdp (96.1%), xuat huyit (73.5%).
da xung huyet/phit ban (51.6%) va tieu ciu < 100 G/L (84.5%), hematocnt > 43% (28,4%) Bieu hien lam sang lien quan den ton thuong gan gom, dau vung gan (14,5%). gan to (3,2%), vang mit, vang da (1,9%).
Xet nghiem chux: nang gan- enzyme AST va />iLT tang tren 2 iin (68,4% va 53.9%). albumin mau < 30 g/l (0.6%), bitlimbin tang (7.5%), ti le PT < 70% (9.9%.). Fibrinogen < 2g/i (37%) va APTT > 40 giay (15.7%,).
Trong sdt xuit huyet dengue nang enzyme AST, ALT va bilHrubin tang khac biet so vdi hai the cdn lai. Trong benh sot xuat huyet dengue c6 tinh trang ton thuong chuc nang gan. lien quan vdi the lam sang nang. Cin nghien cuu them ve tdn thuang chuc nang gan de gdp phin tien lu^yng benh
TO khoa: sdt xuit h u y i t dengue, lam sang sdt xuat huyet
I. DAT
V A Ne&
Theo thdng bdo eua Td chirc Y t i T h i gidi (WHO), sdt x u i t h u y i t dengue la mdt trong mudi nguydn nhdn hdng ddu vd ty Id m i c bdnh va tir vong trdn todn c i u Hai benh canh lam sang nang cua bdnh sdt xudt h u y i t den- gue Id hdi chirng sdc do thoat h u y i t tuong vd x u i t h u y i t [1] Tuy nhien, theo nhung thong bao g i n day, ngodi hai benh canh trdn, trong bdnh sdt x u i t huyet dengue mot sd ca quan nhu than, gan, tim cijng bj anh h u d n g . . . Theo khuyin cdo eua Td chirc Y t i Thd gidi va mot sd y van, suy gan ndng vdi bieu hidn enzym gan tang cao Id mpt trong nhung bdnh canh cua sdt xuat h u y i t dengue nang [ 1 , 2], Tuy nhidn, ngodi b i i u hien huy hoai t i bao gan vdi hoat dd enzym ALT, AST tang cao, cac tdn thuong chirc ndng gan khde cung nhu cae mire dd ton thuang chua d u o c dd cap rd
Dia Chilian h$- D$ng Thi Thdy. Benh vien Benh nhiet d6i Trung uong
Email- thuysuny@yahoo com ngdy nh$n: 02/4/2014 Ngdy (JuQc chip thuan 26/06/2014
Viet Nam la mot trong nhirng nu'dc cd su luu hanh nang eua benh sdt x u i t h u y i t dengue [1], mdt sd nghien ciru cung da dua ra nhdn xdt v i cae b i i u hidn lam sdng va xet nghidm eo hen quan vdi rdi loan chirc nang gan trong benh sdt xudt huyet dengue [3; 4]
D^ gdp phdn tim hieu them ve tdn thuong gan trong benh sdt x u i t h u y i t dengue, chung tdi tidn hdnh nghien CLFU nay vdi muc tieu' md ta tdn thuang gan trong benh sdt x u i t h u y i t dengue va mdi lien quan vdi cdc the lam sang.
II. OOl TU^ONG vA PHU'ONG PHAP
1. Doi tu'O'ng
Gdm 155 benh nhdn, tren 18 tudi, khdng phan bidt gidi tinh, d u a c c h i n dodn xac dmh sdt x u i t h u y i t dengue didu tn tai bdnh vien Bdnh nhiet ddi Trung uang, trong thdi gian tir thang 12/2011 d i n thang 8/2013
2. Phifong phap
Thiet ke nghien ciru mo ta cat ngang Ddl t u o n g nghidn CLFU d u a c chon theo phuang phdp thuan tidn cd chii dich Bdnh
TCNCYH 88 (3) - 2014
TAP CHi NGHIEN CIJU Y HOC
nhdn nhap vien, cd b i i u hien nghi ngd sdt xuit huyit dengue, d u a c chon vdo sdng ipc.
Nhi>ng benh nhdn du tidu c h u i n nghidn ciru se duac chon vao danh gia.
Tieu chuin chon vao nghien ciru: bdnh nhan cd k i t qua xdt nghiem IgM {+) hoac ca lgM(+)vaNS1(+)
Tieu chuan loai trif
+ Benh nhan cd bdnh ly kem theo nhu nhidm trCing, vidm gan virus
+ Bdnh nhdn trong tidn sir co cdc bdnh ly gan mat
+ Benh nhan khdng ddng y tham gia nghien ciru
Cdc ehi sd duac ddnh gia gdm;
V i lam sang' benh nhdn dupe hdi lai bdnh su va theo doi didn b i i n lam sang hang ngay cho d i n ngay thir 10 cua benh
Ve xet nghiem benh nhan duac l i y mau lam xdt nghiem c h i n doan nhidm virus Dengue (phat hidn khdng t h i IgM dac hieu vd
khdng nguyen NS1 vi rut Dengue) vd cdc xet nghidm nghien ciru bao gdm cdng thirc mau, enzyme ALT va AST, bilirubin (todn phan, tn,rc t i i p , gian t i i p ) , albumin mau vd chLFC nSng ddng mau (PT, APTT, fibrinogen).
Tieu chuan chan dodn va phdn logi Idm sang theo h u d n g d i n cua To chirc Y td Thi gidi [1].
Thu thap s 6 lieu: B i n g mau bpnh an nghien CLFU t h i i t k i sdn,
Phdn t i c h s d lieu; Bdng p h i n mem SPSS 1 6 0
Dao d i j c n g h i e n cipu: Nghidn ciFu du'O'c thdng qua Hdi ddng Dao dire bdnh vidn Bdnh Nhiet ddi Trung u o n g , sd c h i p thudn 41A/
HDDD-NDTW, ngdy 16/04/2013.
III. K^TQUA
155 bdnh nhan sdt x u i t h u y i t dengue Qu tieu c h u i n da d u p e chon vdo nghien ciru, kit qua nhu sau:
Bang 1. B i i u hien lam sang, xet nghidm cua benh s d t x u d t h u y e t dengue
Lam sang va xet nghiem n = 155
%
Lam sang S6t
Dau {JSu, Chan an, buon non Dau moi ngw&i. ca khdp Xuat huy4t
Da xung huygt, phat ban
155 163 149 114 80
100,0 98,7 96,1 73,6 51.6 Xet nghiem
Hematocnt > 43%
Tieu c§u < 100 g/L
44 131
28.4 84,5
Cdc bieu hidn lam sang hay gap gdm sdt, t i i p theo Id dau dau, chan dn, budn ndn; dau moi ngudi, ca khdp; xuat h u y i t va bieu hidn da xung huyit, phdt ban, Ve xdt nghiem, gia tri hema- tocrit trong mau tang trdn 4 3 % va sd lupng t i i u c i u giam < 100 g/L Id cac bieu hidn hay gdp.
TCNCYH 88 (3)-2014
• TAP CHi NGHIEN CCTU Y H p C Bang 2. Tdn thu^ong chu'c nang gan
Lam sang va xdt nghiem
Lam s^ng Dau vung gan Gan to du-ffi ba siro-n Vang mSLvang da
23 5 3
14,6 3,2 1,9 X6t nghiem
AST > 80 U/L 106 68,4
ALT > 80 U/L Albumin < 30 g/L Biilirubin > 17 pmo/l PT < 70%
Fibrinogen < 2g/L APTT > 40 giay
68 1 9 13 48 20
53,9 0,6 7,6 9,9 37,0 16,7
Bang 3. Doi chieu gia trj xet nghiem chu'c nang gan theo t h i lam sang benh s6t x u i t h u y i t dengue
Sot xuSt huyet Sot xuat huyet Sot xuiit huyet dengue (1) dengue canh bao (2) dengue nang (3)
AST (U/L) 104,4 ± 1 7 , 9 144,6 ± 1 2 , 6 354,9 + 71,6
TCNCYH 88 (3) - 2014
p1,2 = 0,002 p1,3 = 0,000
ALT (U/L) Bilirubin toan phan (pmo/l) Albumin (g/L) PT(%) Fibrinogen (g/L) APTT (giay)
82,4 ± 15,7
10,2 ± 4 , 8
42,1 ± 4 , 6 9 1 , 6 ± 17,9 2,62 ± 0,95 28,87 ± 5 , 1 5
103,6 ± 1 4 , 4
10,3 ± 3 , 7
41,3 + 4,9 90,6 + 19,4 2,31 ± 0,67 34,22 ± 7.22
216,6 ± 4 1 , 7
1 7 , 9 ± 1 1 , 1
38,3 ± 6 , 6 90,9 ± 18,8 2,20 ± 0,85 36,81+ 11,98
p1,3 = 0,001 p2;3 < 0,06 p 1 ; 3 < 0 , 0 6
>0,05
>0,05
> 0 , 0 5
> 0 , 0 5
TAP CHi NGHIEN CU'U Y HOC •
Trong nghien ciru nay, ede b i i u hidn lidn quan ddn tdn t h u o n g gan trdn lam sdng 6IF(?C ghi nhdn nhu: dau vung gan, gan to d u d i bd s u d n va vang m i t , vang da. Cac b i i u hipn tdn thuong chirc ndng gan tren xdt nghidm gdm ede enzyme AST vd ALT tSng cao tren 2 l i n (gid th binh thudng cua AST va ALT, tuong irng dudi 37U/L va 40U/L), albumin mau giam (gidi hgn binh thudng < 30 g/L), billirubin tang (gia tri binh thudng < ITpmo/l) Cac b i i u hidn rdi loan chirc ning ddng mdu gdm tl Id PT < 70%, Fibnnogen < 2g/L vd thdi gian APTT kdo dai trdn 40 giay
Cd su tdng cao khde bidt v i ndng do enzym ALT vd bilirubin giija sdt x u i t h u y i t dengue nSng so vdi sdt xuat huyit dengue va sdt x u i t huyit dengue canh bao, cung nhLr ndng dp enzym AST tang khac bipt giija 3 t h i lam sang
IV. BAN LUAN
Trong nghien ciru nay, 155 bdnh nhdn eua chiing tdi duac khdng dmh c h i n doan nhidm VI rut dengue b i n g xdt nghidm phat hien khdng the IgM dac hieu vdi vi riit dengue, hodc b i n g ca xdt nghiem phdt hien khang nguyen NS1 [1]. Cac b i i u hien lam sdng hay gdp cua nhtdm' vi rut dengue bao gdm sdt (100%) va cdc b i i u hidn dau d i u , chan an, budn ndn (98,7%); dau mdi ngudi, co khdp (96.1%), x u i t h u y i t (73,5%) vd da xung h u y i t - phat ban (51,6%) (bang 1) Cae nghien cuu trong vd ngoai nude cung gap cac bleu hidn tren trong bdnh
sdt x u i t huyit dengue nhu cua chiing tdi, nhung vdi ty Id cao han [3, 5]. Day cung la cac b i i u hidn lam sang d u a c Td chirc Y t i T h i gidi goi •jf dung de chan dodn lam sang sdt x u i t huyit dengue [1]. Trong nhdm bdnh nhdn nghien ciru cua chung tdi chi gap tl Id 28,4% CO gid tri hematocnt tang eao trdn 43%
va 84,5% sd bdnh nhdn cd s d ' l u p n g t i i u edu giam dudi 100 G/L (bang 1) Ti Id nay t h i p han so vdi nghidn ciru eua Amrita Roy (tiiu c i u < 100 G/L la 90%) [5], hoac eua Dmh The Trung (95%) [4] Day Id cae b i i u hidn hay gap trong benh sdt xudt h u y i t dengue, nhu vay, bdnh canh lam sdng tren nhdm bdnh nhan
nghien cCru eua chung tdi nhe han so vdi cac nghien ciru khde [3, 4; 5]
v i ede d i u hieu vd tndu chirng lidn quan vdi tdn thuang gan, ti le gan to d u d i bd sydn la 3,2%), tl Id dau vung gan Id 14,5% va co b i i u hidn vdng da, vdng mdt Id 1,9% (bang 2) Cdc chi sd ndy cd s u khde nhau giCpa cSc nghidn CLFU, trong tndu chung dau byng, theo Dinh Thd Trung [4], gdp 58% d nhdm khdng sdc vd ed ti le la 85% nhdm sdt x u i t huyit dengue sdc, theo Om P [6] ty Id nay Id 18,2%
Ti le gan to trong sdt x u i t h u y i t dengue cOng khac nhau giCra cac nghidn giru tiF 3% den 12% tuy theo t h i bdnh [4], hodc 3 9 , 1 % [7], tham chi 50% [8] Theo To chirc Y t i T h i gidi, gan to cd the 'gap d 6 0 % benh nhdn trudng thdnh [1] Hon nCra, dau hidu gan to nhanh, dau vOng gan Id cdc d i u hidu d u o c To chirc Y t i T h i gidi k h u y i n eao diing tidn luang sdt x u i t huyet dengue nang Bieu hien vdng da, vdng mat trong cac nghien ciru trudc ddy cung ehi gdp vdi ti le t h i p d u d i 2 % [4], hoSc 4 , 1 % [7]
V i xdt nghidm chirc ndng gan, cac ton thuong bao gdm: tinh trang huy hoai t i bao gan nhu enzym AST vd ALT tdng eao trdn 2
TCNCYH 88 (3) - 2014
• T A P CHi NGHIEN CU'U Y HOC lan ( l i n luot Id 68,4% vd 53,9%), rot loan
chuyen hda mdt nhu billirubin tdng tren gidi han binh t h u d n g (7,5%), suy t i bao gan nhu albumin mau giam (0,6%) vd rdi loan chirc nang ddng mdu gdm ti Ip phdu thudt giam (9,9%), ndng dd Fibnnogen giam (37%) va thdi gian APTT kdo ddi tren 40 gidy (15,7%) De tim h i i u ky hon tinh trang tdn thuong gan, chiing tdi phdn loai cdc b i i u hidn rdi loan chirc ndng gan theo the lam sdng cua bdnh sdt x u i t huyit dengue (bang 3) Trong sdt x u i t h u y i t dengue nang, tinh trang huy hoai t i bdo gan (ALT vd AST) vd rdi logn chuyen hda bilirubin thay ddi r6, khde bidt so vdi hai the Idm sang cdn Igi ta sdt x u i t h u y i t dengue va sdt x u i t huyet dengue ed dau hipu canh bdo Ddc bidt enzym AST cOng tdng khac biet trong sdt x u i t huyet dengue cd d i u hidu canh bao so vdi sdt x u i t huyet dengue. Tuy nhidn, trong nghien ciru ndy, bieu hipn suy t i bao gan nhir chi sd albumin vd cac chi sd ddng mdu (PT, fibrino- gen, APTT) tuy cd thay doi d ca ba the lam sdng, nhung s u khde bidt chua cd y nghTa thdng kd, (p > 0,05).
Cac k i t qua nghien ciFu trudc day cung da 6h edp d i n tinh trang tdng ALT vd AST trong sdt xuat h u y i t dengue [3; 5, 7, 8], theo Aminta AST, ALT cd s u tdng khde biet giua t h i lam sdng nang vdi cac t h i cdn lai [5]. Tuang t u , albumin giam cOng d u p e Amirita nhdn xet co su khde nhau giu'a cdc the Idm sdng V i rdi loan chirc ndng ddng mdu cdc nghien cu'u cung nhdn thay cd s u thay ddi [3; 4], nhung theo Amirita cac chi sd nay ed thay ddi khde bipt giu'a cdc t h i Idm sang, [5]
V. K^T LUAN
Qua nghien ciru tdn t h u a n g gan trong bdnh sdt xuat h u y i t dengue d 155 benh nhdn tai bdnh vidn Bdnh Nhidt ddi Trung uang trong giai doan 12/2011 - 08/2013 cho t h i y cd
tinh trang tdn t h u a n g td bao gan trong bdnh sdt x u i t h u y i t dengue, lidn quan vdi cdc t h i lam sang nang
Lo"! c a m a n
Chung tdi xin giri Idi cam an d i n Ban Gidm ddc bdnh vien Bdnh Nhidt ddi Trung uang, D o n vi nghien ciru Idm sdng trudng Dai hpc Oxford 1ai Viet Nam dd tao moi d i i u kien cho chiing tdi thuc hidn nghidn ciru nay.
TAI LIEU THAM KHAO
1. W o r l d Health Organization (2009).
Dengue guideline for diagnosis, treatment, prevention and control, Nevi/ edition, WHO.
Geneva
2. Ducan T\. Smith, Atefeh Khakpoor (2009). Involvement of the Liver in dengue infections Dengue Bulletin. (33), 75 - 86
3. Hoang Thai Du-ong, N g u y i n Quang T r u n g (2013). Dac diem va didn t i i n Idm sang, can lam sang d benh nhan ngudi Idn sdt x u i t huydt dengue cd b i i u hidn sdt x u i t h u y i t dengue nang, tdn thuang tang Y Hoc thanh ph6 H6 Chi Minh. 17(1), 1 9 8 - 2 0 3 .
4. Dinh The T r u n g , Le Thi Thu Thao, Tran T.H et al (2010). Liver Involvement Associated with Dengue Infection in Adults in Vietnam. Am. J. Trap Med. Hyg, 83(4), 774 - 780
5. A m r i t a Roy, Debalina Sarkar, Sohini Chakraborty et al (2013). Profile of Hepatic Involvement by Dengue Virus in Dengue Infected Children. N AM -J Med Sci. 5(8), 480 - 485.
6. Om P., A y s h a A., SWI Wasim J et al (2010). Severity of acute hepatitis and its outcome inpatients with dengue fever in a tertiary care hospital Karachi, Pakistan (South Asia) BMC Gastroenterology. 10(43), 2 - 8.
TCNCYH 88 (3)-2014 59
TAP CHi NGHIEN CLFU Y HOC
7. Arun Sedhain, Gandhi R. Bhattarai, 8. Vaibhav Shukia, Ashok Chandra ShitalAdhikari (2013). Liver Involvement As- (2013). A Study of Hepatic Dysfunction in;
socialed with Dengue Infection During A Major Dengue. Journal of Association of Physicians Outbreak in Central Nepal Journal of Ad- India. (6), 24 - 25.
vances in Internal Medicine. 2(4), 42 - 46.
Summary
EVALUATION OF LIVER INVOLVEMENT IN DENGUE HEMORRHAGIC FEVER IN ADULTS
The purpose of this study was to evaluate liver lesions in dengue hemorrhagic fever (DHF), The results showed that the most common clinical manifestations were fever (100%), headache, anorexia, nausea (98.7%), muscles and joints pain (96,1%), hemorrhage (73.5%), skin rash (51.6%) and platelets 100 g/L, hematocrit > 43% (84,5% and 28.4% respectively). The spectrum of hepatic manifestations are hepatic tenderness (14 5%), hepatomegaly (3.2%) and jaundice (1 9%) Liver function tests showed elevated aspartate transaminase (AST) and alanine transaminase (ALT) (68 4 % and 53 9% respectively), bilirubin (7 5%), reduced serum albumin (0.6%), prolonged prothrombm time (9,9%), reduced Fibrinogen (37%) and prolonged APTT (15 7%), In severe DHF group, AST, ALT enzymes and bilirubin levels were elevated significantly when compared with DHF group and DHF with warning signs group. In conclusion, there were hepatic dysfunction in DHF, specifically in severe DHF There is a need to continue to study he- patic dysfunction to support prognosis
Keywords: dengue hemorrhagic fever, dengue hemorrhagic fever clinical
TCNCYH 88 (3) - 2014