HOl NGHI TOAN QUgC Vg CAC BgNH NHI^M TRJING VA HIV/AIDS (3 JRt EM NAM 2013
NGHIEN CU'U VIEM PHOI DO PNEUMOCYSTIS JIROVECI TREN BENH NHI HIV/AIDS TAI BENH VIEN NHI TRUNG U'O'NG
T 6 M TAT
Bat van de: Lieu phap khang retrovirus hoat tfnh cac cho benh nhi HIV da lam so hien mac ciia PCP thay doi kha nhieu nhu'ng chu ye!u tuy thuoc vao kha n§ng chan doan va dieu trj HIV bang thuoc khang vi rut ciia tifng quoc gia, M^ic tieu nghien citu: Xac djnh ti le PCP tren benh nhi nhilm HIV/AIDS bi viem phoi tai Benh vien Nhi trung u'dng va mo ta dac diem lam sang, can lam sang, dieu trj cua cac trUdng hdp benh. Sol tu'dng va phu'dng phtip nghien cu'u: Nghien cu'u cSt ngang mo ta cac tru'dng hap nhiem HIV/AIDS bi PCP trong so 79 ca viem phe quan phoi nam dieu tn tai khoa truyen nhiem va khoa hoi sire cap ciru, benh vien nhi trung Udng tif thang 1 nam 2011 den thang 1 nam 2013. Ket qua nghien cu\i: Ti le PCP tren benh nhan nhiem HIV/AIDS bj viem phe quan phoi ia 13,9%. 72,7% dong nhiem tir 1-3 tac nhan la vl rut, nam va vl khuan. 90,9% co ty le CD4 giam rat thap dufli 20%. Cac trieu chu'ng ho hap thu'dng gap trong PCP la ho (81,8%), Kho thd (72,7%), tim tai (72,7%), phoi cd ran benh ly (90,9%), SP02 < 90% (72,7%). Ton thUdng tren XQ phoi chii yeu ia tdn thudng mo ke phdi hdp hoSc ddn thuan (81,8%) va cd 2/11 (18,2%) cd md toan bp 2 phoi. Ket luan: PCP tren benh nhi nhiem HIV/AIDS bi viem phe quan phoi (ti ie chiem 13,9%) thudng dong nhiem nhieu tac nhan va cd suy giam mien djch rat nang. Can quan tam den PCP trong dieu tn va du phdng cac benh viem ph6"l tren benh nhi AIDS tai viet nam Tu'khda: Viem phoi, PCP, HIV, tre em
* Benii vi^n Nhi Trung trang Plidn bi^n klioa lipc: TS.Tran Minh flign 108
Nguyen Van Lam*, Pliam Nhat An*
SUiVlMARY
RESEARCH ON PNEUMOCYSTIC JIROVECI PNEUMONIA IN CHILDREN WITH HIV/AIDS AT VIETNAM NATIONAL
HOSPITAL OF PEDIATRICS Bacl<ground: Highly active antiretroviral therapy (HARRT) has dramatically changed the prevalence of PCP however it depends on the ability to diagnose and treat HIV with ARV of each nations. Objective: Identify the prevalence of PCP in HIV-infected children with pneumonia In Vietnam National Hospital of Pediatrics (VNHP) and describe the clinical, sub-cllnlcal characteristics and treatment of those cases.
Subject and methdds; Cross-sectional study of HIV-infected children with PCP among 79 cases with pneumonia treated in Infectious Diseases Department and Intensive Care Unit in VNHP from January 2011 to January 2013. Results:
The prevalence of PCP among HIV-infected children with pneumonia is 13.9%. 72.7%
children have co-infection with either virus, fungus or bacteria. 90.9% have C04 counts below 20%. The most common symptoms In PCP are cough (81.8%), dyspnea (72.7%), cyanosis (72.7%), pathological crackle in lungs (90.9%), oxygen saturation below 90% (72.7%). Chest radiographs usually show simple or combination interstitial lesions (81.8%) with 2/11 cases (18.2%) having total opacification on both lungs.
Conclusion: PCP among HIV-infected children with pneumonia (prevalence 13.9%) usually have co-infection and severe immunodeficiency. It is necessary to pay attention to PCP while treating and providing
Y HOC VIET NAM THANG 10 - S6 2/2013
prophylaxis for AIDS children with pneumonia in Vietnam.
te/MTO/ife.-Pneumonia, PCP, HIV, Children
LCATVXNDI
PCP la mot trong nhirng benh nhiem triing ca hdi nang cd ti le tie vong cao d benh nhan nhiem HI'V/AIDS [1]. Trudc dai dich AIDS, PCP rit hiem gSp chi ghi nhan d nhimg ngudi suy dinh dudng nang, ngudi bj cac b?nh ac tinh hoSc diing cac thuoc giam mien djch keo dai. Khi d p djch HIV/AIDS biing phat. PCP gia tSng nhanh chdng tai cac nude phit trien. Viec ap dyng ii$u phap khSng retrovirus hoat tinh cao (HAART Highly Active Therapy) d cac qudc gia phat trien dS lam giam dang ke sd mdi m i c cac benh nhiem triing co hoi kdt hop vdi AIDS, trong dd cd PCP [2]. d cac nude dang phat triSn, PCP van duoc xem la mpt van de sue khoe quan trpng dii sd hien mac cua PCP thay ddi kha nhi§u chit yeu tiiy thupc vao kha nSng ehjn doan va dieu tri HIV bjng thudc khang vi rut ciia timg qudc gia [4].
Tai Viet Nam, trudc nam 2010 chi xac dinh dupe vai trudng hpp PCP tren benh nhi AIDS d BVNTW va hku hk dSu dua tren 13m sang. Vjn ik djt ra la ti le PCP trong ky nguyen cd dieu tri HIV bang thudc khang vi nit d tre em HIV/AIDS tai BVNTW va benh canh lam sang, cSn lam sang cua benh tren tre em nhiem HIV/AIDS tai Viet Nam nhu the nao chung tdi tien hanh nghien cuu Viem phdi do Pneumocystis Jiroveci d tre em nhiem HIV/AIDS tai BVNTW" vdi muc tieu:
- Xac dinh ti le PCP tren benh nhi nhiem HIV/AIDS bj viem phdi nhap vien tai BVNTW.
- Mo ta mdt sd d^c diem lam sang, can lam sang va diSu trj cac trudng hpp PCP tren b^nhnhi nhilm HIV/AIDS.
11.001TLTOIMG VA PHU'OfNG PHAP NGHIEN CUU 2.1. Doi tu'O'ng nghien cuu: Tat ca cac benh nhan tir 1 thang 15 tudi nhiem HIV/AIDS dupe chan doan PCP bang phuang phap PCR dich rira ndi khi quan trong sd cac trudng hpp viem ph6 quan phdi nam dieu tri tai khoa truyen nhiem va khoa hdi sire cap cuu, benh vien nhi trung uong tir thang 1 nam 2011 dSn thang 1 nam 2013.
2.1.1, Tieu chudn chpn benh nhdn:
- Tre tir 1 thang - 15 tudi xac djnh la viem phdi/HIV vao di6u tri tsii khoa truySn nhilm Benh vien nhi trung uong.
- Tieu chuan chan doan viem phoi ciia Td chuc y \i th6 gidi (WHO): Ho, sot, nhip thd nhanh (>60 Ian/phut d tre < 2 thang tudi, >50 ian/phiit d tre 2 - 12 thang tudi, >40 Ian/phut d tre >l tudi), cd the cd rut ldm Idng ngirc, nghe phoi cd the cd nhieu ran am nhd hat hoac kem theo ran rit, ran ngay. Ngoai ra neu viem phdi nang benh nhan cd the tim tai. khd thd nang hon, rdi loan nhjp thd va cd the ngimg thd, nhjp tim nhanh, gan to va cd the cd bieu hien cua suy tim-ngimg thd. De xac dinh chan doan cd the dua vao cd dau hieu tdn thuong tren phim chup phdi.
- Chin doan HIV:
Tre tren 18 thang xet nghiem mau dugc khing dinh cd khang th6 HIV duong tinh vdi 3 loai sinh pham khang nguyen khac nhau.
Tre dudi 18 thang cd xet nghiem PCR vdi HIV-DNA duong tinh.
- Chin doan PCP bang phuong phap PCR djch rua NKQ
2.1.2. Tieu chuin loai trir: Tit ca cac trudng hpp khdng du cac tieu chuan chpn benh nhan
2.2. Dia a i i m nghien cihi: Khoa truySn nhiem va khoa dieu tri tich cue benh vien nhi trung uong.
2.3. Phu'o'ng phap nghien ciru
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HOl NGHI TOAN QU6C Vg CAC B$NH NHI^M TRONG VA HiV/AIDS 6 T R £ EM NAM 2013
2.3.1. Thiit ki nghien ciru: Nghi6n ciiu cit ngang md ta mpt loat c4c trudng hpp benh.
2.3.2. phuang phdp chgn miu: Chpn tit ca b$nh nhan vao nim dieu tri tai khoa truyin nhiem b$nh vi$n nhi trung uong dip irng dii tieu chuin chpn b?nh nhdn.
2.3.3. N^i tung nghiin ciiu: Npi dung nghien cim dupe ghi chdp v4o mpt mau b$nh dn thiit ke rieng phyc vy cho nghien cuu.
Bpnh nhSn dupe hdi bpnh siir, tham khdm lam s4ng, xit nghipm mdu, djch npi khi qudn tim PCP, vi khuin, vi rut, lao, nim.
IILKfTQuANGHieNCCrU
- Qua xet nghipm PCR djch rua NKQ cua 79 benh nhi Viem phdi/HIV phdt hien 11 truang
hpp duong tinh vdi P.Jiroveci chiem ti le 13,9%.
- Ty I? nam/nu la 1,2 :l; thdng tudi trung binh Id 10 (sip xIp tit 2 - 54 thang); 9/11 (72,7%) tre < 6 thang tudi, 2/11 (18.2%) tre tit 6-12 thang, 1/11 (9,1%) tre > 12 thtog tudi. 10/11 (90,9%) tre chua dupe diiu tri du phdng PCP bang Cotrimoxazol vd cd 8/11 (72,7%) me chua bilt minh bj nhilm HIV trude khi vdo vipn.
- Dac diim lam sdng cdc trudng hpp PCP:
81,8% bpnh nhan cd thdi gian bj benh trudc nhap vien tren 7 ngdy, trung binh 10 ± 6 ngay. Khd thd Id nguyen nhan chu yeu khiln bpnh nhan nhap vipn (72,7%), kem theo ho (81,8%), sot (63,6%).
Bdng I: Bieu hien hd hap cua cdc trudng hop PCP Bieu hien lam sdng
Ho Khd thd Tim mdi Ran benh ly
Sp02 khi chua cd Oxy(< 90%)
So tru'dng hop 9 8 8 10 8
Tnp(%)
81,8 72,7 72,7 90,9 72,7Bdng 2: Cdc bieu hien lam sang khac Bieu hifn lam sdng Sdt
la chay Tua mipng Hach ngoai bien Gan to Lach to
So tru'dng hpp 7 3 4 3 6 4
Tii le (%) 63,6 27,3 36,4 27,3 54,5 36,4
Bdng 3: Cac tdc nhdn ddng nhiem vdi PCP Tac nhan
Vi khuan Nam Virut
So tru'dng hop 3 3 8
Ti le (%) 27,3 27,3
72,7
•rM
Y HOC V I E T NAM T H A N G 10 - SO 2/2013
- CD4 cdc trudng hop PCP: 10/11 (90,9%) trudng hop cd suy gidm miln dich nang theo tudi CD4 < 20%, cd trudng hpp giam < 5%.
- CRP: 9/11 (81,8%) trudng hpp CRP <6
- X quang phdi: 6/11 (54,5%) cd tdn thuong mo ke phdi hpp; 3/11 (27,3%) cd tdn thuong md ke dan thuin; 2/11 (18,2%) cd md todn bp 2 phdi.
Ket qua dieu trj Khdi
Jii vong, xin ve
So tru-dng hpp 5 6
Ty U (%) 45,5 54,5
IV. BAN LUAN
Vdi 79 b$nh nhdn nhilm HIV/AIDS bj viem phdi duac lay djch rua NKQ de phan lap tdc nhdn gay bdnh va sir dung phuang phap PCR dl chin dodn PCP cho thiy PCP chiem ty Ip 13,9%. Theo bdo cdo ciia CDC tir nam 1994-2001 ty le nhiem trimg PCP gidm xuong: tir 25 tre nhilm/nara 1994 (trong sd 1000 tre nhiem HIV) xudng 18 ca vao nam 1996 vd 6 ca vao ndm 2001 [7]. Theo Hpp tac nghien cijru lay truyen AIDS chu sinh cho thiy 95% gidm nhilm PCP (cho 100 tre/ndm): ttr 5,8 (trudc ky nguyen HAART) xudng 0,3 (trong ky nguyen HAART) [4].
Theo nghien cuu khac, ty le mic PCP/100 tre/nam la 1,3 khi chua cd HAART (1981- 1988) vd dudi 0,5 khi ed diiu tri HAART (2001-2004) [5],
Tudi hay gdp Id dudi 6 thdng tudi chiim 72,7%, 10/11(90,9%) tre deu chua duoc diiu trj d\r phdng PCP bdng Cotrimoxazol va 72,7% cdc bd mp chua biet minh vd con minh bi nhilm HIV trudc khi vao vien. Cac benh nhan thudng nhap vien mupn sau 7 ngdy (81,8%), khd thd Id ly do vdo vien thudng gjp (72,7%) vd cd tdi 54,5% phdi dat NKQ thd mdy ngay khi BN vao vipn. Cdc tripu ohiing hd hip thudng gap trong PCP la ho
(81,8%), Khd thd (72,7%), tim tai (72,7%), phdi ed ran benh ly (90,9%), SP02 < 90%
(72,7%). Cdc trieu chimg khac nhu sdt cao (63,6%), nam mieng (36,4%), ia chdy (27,3%). gan Idch to (54,5%), hach to (27,3%). Tdn thuang tren XQ phoi chii yeu la tdn thuong md ke phdi hpp hodc don thuan (81,8%) vdcd2/ll (18,2%)cdmdtoanbd2 phdi. Cd tdi 72.7% ddng nhiem tir 1-3 tac nhan la vi rut, nam va vi khuan. 100% cdc trudng hop cd suy giam mien dich nang theo tudi, trong dd cd 90.9% cd ty le CD4 giam rit thap dudi 20%, cd trudng hpp giam dudi 5% d tre mdi 4 thdng tudi vd 81.8% cdc trucmg hap cd CRP khdng tdng (< 6). Theo cdc nghien cim ve Viem phdi d tre era nhiem HIV cd bdn trieu chirng lam sang gpi y nhilm PCP: tudi <6 thang, nhjp thd > 59 Idn/phut, bao hda oxy dpng mach <92%, va tre khdng ndn [3], X quang phdi cd hinh anh tham nhilm nhu md lan tda dang "kinh md"
hodc hinh anh ludi hat. nhung cung cd the la binh thudng hoac chi cd tham nhilm nhe nhu md. Ton thuong sdm nhat d viing rdn phdi, tiln triln ra ngoai bien trudc khi den dinh phdi. Hilm khi thiy tdn thuong dang d, nang, ndt, hoac ke, trdn khi mang phdi hoac tran khi trung that [6].
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HOI NGH! TOAN QU6C Vt CAC B$NH NHl^M TRONG VA HlV/AlDS d TRg EM NAM 2013
Kit qua diiu tri: khdi 5/11 (45,5%i) trudng hpp diu cd thdi gian dieu trj kdo ddi tren 45 ngay, trung binh Id 54 ± 6 ngdy. Tir vong 6/11 (54,5%) trudng hpp d i u vdo vipn trong tinh trang suy hd h i p ndng phdi ho trp thd mdy, 5 trudng hpp d tuoi 2.5 thdng - 4 thang tudi, ehi cd 1 trudng hpp 4,5 tudi that bai dieu trj ARV, ed tinh trang suy gidm mien djch rit nang (18 TB CD4) vd dong nhilm 4 loji tdc nhdn trong dd cd 2 lojii vi rut va 2 loiii nim Id Penicilium mamerfei vd Candida abican. Thdi gian dieu trj trung binh Id 7 ± 5 ngdy. Chinh vi nhitng ly do ndy ma kit qua diiu tr; PCP d Viet nam cdn han che vd ti le tir vong cdn cao so vdi cac nghien cuu d cdc nude phat trien.
V. KET LUAN
Ti le PCP tren benh nhdn nhiem HIV/AIDS bj viem phi qudn phdi la 13.9%.
Benh thuimg ddng nhiem nhieu tdc nhdn.
bieu hien lam sang. X quang rdt da dang vd cd suy giam mien djch rat ndng nen gdy khd khan cho chan dodn vd dieu trj, ti Ip tit vong 54,5%. Can quan tdm den PCP trong dieu trj vd du phdng cdc benh viem phdi tren benh nhi AIDS tai viet nam.
TAI UlU THAM KHAO
1. Bp Y te (2011). "Hudng din chan doan va dieu trj HIV/AIDS", So 4139/OB-BYT, Ha Npi,
2. Alison M, Jens D.L, et al. (2004), "Cumnl epidemiology of Pneumocystis Pneumonia", CDC Emerging Infectious Diseases,vol.lO, pp.1713-1720.
3. Fatti, G. L., Zar, H. J., and Swingier, G. H (2006), "Clinical indicators of Pneumocystis jiroveci pneumonia (PCP) in South African children infected with the human immunodeficiency virus", Int J Infect Dis 10, pp. 282-5.
4. Gifford S.L (2005), "Pneumocystosis and H I V , HIV InSite Knowledge Base Chapter April 2005.
5. (iona P., Van Dyke R. B., Williams P. L.,el al. (2006). "Incidence of opportunistic and other infections in HIV-infected children in the HAART era". .lAMA. 296(3). 292-300.
6. Kaut D. (2011). "Opportunistic infections in HIV infected children". Indian J Pediatr, 78(4). 471-2.
7. Morris A., Lundgren J. D., Masur H., et al.
(2004). "Current epidemiology '^f Pneumocystis pneumonia". Emerg Infect Dis, 10(10), 1713-20.
