Luu Thi Binh va Dtg T9p chi KHOA HOC & CONG NGH5 165(05): 3-8 N H ^ N XET 13 TRirofNG HgfP VIEM K H d P NHIEM KHUAN DIEU TRI TAI BfiNH VIEN TRUNG iTONG THAI NGUYEN
LuTi Thj Binh', Tran Thj Lan TrudTig Dgi hgc Y Dugc - OH Thdi Nguyen TOM TAT
Muc tieu: M6 ta d$c di6m lam sing va c^ln ISm sang cua c^c b?nh hhSn viSm Ichdrp nhiem khuan dieu tri t^ii khoa Co xuong khorp B?nh vi?n Trung uong Thai NguySn (BVTUTN). Doi tuyng v^
phinmg phdp nghiSn cihi: M6 tk cU ngang 13 b?nh nhan dupc chan doan viem khop nhiSm khuin t^i khoa co xucmg kh6p BVTUTN tii thang 02/2016 dSn 10/2016, Ket quii: Tu6i trung binh cQa benh nhSn: 59,23 ± 15,5. Ti 1$ nam/nft: 2,3/1. C6 38,5% b6nh nhan vifim khdrp co ti^n su sau tiem chpc vio 6 kh6p. 53,8% bi nhilm khuin tai khop g6i; 69,2% benh nhan dau khop miic d6 nang; kem Iheo t^i kh6p thuong g5p: sung ne (92,3%), Uan ^ich (69,2%), nong (61,5%), do (53,8%). Xquang khdrp: 30,7% cfi hlnh anh ton thuang khuyet, huy xuang; 84,6% bSnh nhan co viem ming ho^it djch vh 69,2% b§nh nhSn c6 tran djch trSn sieu am khap. Xet nghiem dich khap:
100% c6 b^ch ciu tang va te bao mu; vi Wiuan (+): 38,5% phat hi^n qua nhuOm soi, 53,8% qua nudi ciy trong do 42,9% la ty cau vang. Ket luan: Tiem chpc vao o khop la y€u to nguy co thuong g|ip ciia viSm kh6p nhilm khuin. Lim s^g thucmg biiu hi?n khop viem ro, hay gap a cac khcfp 1cm. Chin doan xSc dinh dya vio xet nghiem dich khdp ket hop vdi lam sang.
Tfr khda: viem khop nhiem khudn (VKNK), djch khop, yiu to nguy ca. vi khudn. ty cdu vdng.
DAT VAN DE
Viem khop nhiem khuan (VKNK) la vidm khop do vi khuan co mat trong khap gay nen.
Ti I? nhiem khuan xuang khop la 16,8% tong s6 cac benh nhSn nOi tni tgi khoa khop b^nh vi^n Bach Mai. Tai My hang nam co khoang hon 20.000 ca mlc b?nh. Viem khap nhiem khuan khfing do lau cau la mpt benh nguy hiem, CO ti le tu vong tijr 5-15% va ti I? ton thuong khop m^ui tinh gay tan tat la 25-60% [1], [7].
Tgi Benh vi^n Trung uong Thii Nguyen, khoa ca xirang khdp hang nam cung ghi nhan nhCmg truong hgp b?nh nhan viem khdp nhi^m khuan dugc phat hi$n va dieu tri, dgc biet trong so cdc benh nhan nSy c6 benh nhan bj nhilm khuSn thur phat sau tiem chpc vao 6 khdp. Qua th\rc te lam sang chiing toi nhgn thay CO nhiJng benh nhan bj chan doan sai, khong dugc chan doan xac djnh b?nh tu a cac tuyen y te truac nen khi den dieu tri da co bieu hien ngng ne gSy nhilm triing huyet v^
CO nguy ca tit vong; Cac benh nhan co ket qua xet nghi?m vi khuan hgc da dgng, chinh vi vay vi?c dieu tri nhieu luc g^p kho khan.
' Tel- 0915 717076. Email: [email protected],
dgc bi?t khi chua co ket qua khang sinh do ho5c nuoi cay am tinh... Tii thirc te lam sang chiing toi thay can thiet phai co mot nghien cuu dl xic djnh ro han ve cac dac diem lam sang cung nhu dac diem vi khuan hgc cua cac benh nhan viem khap nhiem khuan vao dieu tri tgi khoa Ca Xuang khdp nhiim giup tien lugng, nang cao chat lugng chan doan va dieu tri. Vi vgy, chiing toi thuc hien nghien ciiu nay vai muc tieu: Mo td dgc diim ldm sang vd can ldm sdng ciia cdc benh nhdn viem kh&p nhiem khudn diiu tri li' khoa Ca xuang khop benh viin Trung irang Thdi Ngm-en DOI TLTONG VA PHLTONG PHAP NGHIEN CUU
Doi tumig nghien cuu: 13 benh nhan dugc chan doan xac djnh viem khop nhilm khuan.
- Ti8u chuan lya chon:
+ Cac benh nhan co sirng dau khdp kieu viem + hgi chirng nhiem triing
+ Dich khap: Co bang chiing nhiem khuan' bgch cau tang >50 G/l, co te bao mii (bgch cSu da nhan thoai hoa) vd/hogc vi khuan (+).
+ Cac benh nhan dong y tham gia nghien ciiu
LuTi Thj Binh vo Dtg T^p chl KHOA HOC & CONU NUH^ 165(05): 3 - - Loai tru: Cac b^nh nhan co ket qua lao khop
qua xet nghiam djch khap (PCR va/hogc nhugm soi co AFB (+); te bao: thay tl bao ban tiSn, te bao khong 16, nhieu lympho bao) Phutmg phap nghien cii-u:
- Mo ta cat ngang, chgn mau thuan ti^n, ca mau la toan bg cdc b^nh nhdn vdo vien dilu trj tgi khoa Ca xuang khdp B?nh vien Trung ucmg Thai NguySn trong thai gian tu 02/2016 -11/2016.
Ngi dung nghiSn can:
- Tat cd cac b?nh nhdn dugc khai thdc b?nh sii, tien su, khdm lam sang vd Idm xet nghiem, neu dii tieu chuan dugc l\ra chgn vdo mdu nghien cuu, thu thgp so li?u theo mdu bfnh an nghien cuu thong nhdt.
- Ve Idm sang
+ Kham todn than: do nhiet dg (xac djnh sot khi t° > 37,5''C), hdi chilu cao, can nang (xac dinh gay siit khi chi so BMI <18,5).
+ Tai khdp ton thuong:
Trieu chutig dau: Vi trf dau (khdp g6i, khc^
hang, khdp khuyu...), khdi phat dau (dot nggt, khi vgn d0ng khdp, khi di lgi), tinh chat dau {dau am i, dau bu0c b?nh nhan khong di Igi, dau tang ve dem, giam dau khi ve dem va nghi ngai). ti'nh chat dau (ca hgc, kieu vi6m).
Mlic dg dau dugc danh gid theo thang dilm VAS (Visual Analog Scale) [3]. C6 4 muc dg:
Khong dau: 0 dilm (d), dau nh?: l-3d, dau vua: 4-6d, dau n§ng: >6d.
Cdc dau hieu di kem khac: nhiing thay d6i hinh thai cua khdp, cac bien dgng, trdn djch khdp goi (ddu hi?u bgp binh xuong banh che +), sung ne, nong, do, hgn che van dgng.
+ Tien sii; tiem chgc vao 6 khdp, hiit thuoc Id, nghien rugu, dung corticoid,.... Cdc b?nh kem theo: dai thao duong, suy gan, suy thgn,...
- Can ldm sang:
+ Xet nghiem mau gui mdu den cac khoa huyet hgc, sinh hoa: B?nh nhan nhin doi ft nhat 8 gia, mdu mau lay bu5i sang, g6m: cong thiic mau, Vss, glucose mau, acid uric, CK,...
Danh gia: s6 lugng bgch cdu (tang khi > 9 G/l), ti 1? bgch cdu da nhdn trung ti'nh (tang khi >75%). Toe do mau ling dugc danh gia bdng phuong phap Westergren, xet nghiem dugc coi la tang khi mau ldng a nam giai: >
15mm/h dau (<50 tu6i) vd >20mm (>50 tuoi) a nii gioi: > 20mm (<50 tuoi) va
>30mm (>50 tuli).
+ Lam xet nghiem dich khdp: gui mdu d6n cac khoa huylt hgc, vi sinh va gidi phdu benh:
Xet nghiem t l bdo (tim bgch cdu da nhan thoai hoa, tang so lugng BC >50,0 G/l [4], tl bao bdn Uen - kh6ng lo...), nhugm soi (tim vi khuan, AFB) nudi cdy phdn lap vi khudn va lam khang sinh do dich khdp, PCR lao.
+ Xquang khc^j ton thuang tgi khoa chdn doan hinh anh: Chyp khop ton thuong va khdp doi dien tu thi thdng vd nghieng dl so sanh 2 ben, danh gid khe khop (h^p - rgng), ba khe khop nham nha, co 6 tieu - huy, dgc xuong,...
+ Sieu am khap: dugc thuc hien tren may sieu am PHILIPS ddu dd tin s6 cao 15 MHz tgi khoa Tham do chuc nang. Sieu dm va dgc ket qua do bac sT chuyen khoa thuc hien.
Danh gid ton thuang viem mang hogt djch, tran dich, cac ton thuang khac (khuylt, hiiy xuong..). Ddnh gia tin thuang viem mang hogt djch khi cd 1 trong 3 tin thuang sau:
Day mdng hogt dich, khi dg day MHD > 4mm.
C6 hinh dnh tang sinh mang hogt dich (tang dm lan tda hogc dgng nhii qua phat).
Tang sinh mgch mau mang hogt djch (MHD CO tfn hieu pho xung hogc pho Doppler nang lugng)
Danh gia tran dich khdp khi: dg day lop dich khdp >4mm (vdfi khdp Ion) hoac >2mm (vdi khap nho).
XiJr ly phan tich so IiSu: Su dung phan mem SPSS 16.0
KET QUA - Ti I? nam/nii = 2,3/1.
- Tuli trung binh ciia benh nhdn la 59,25 ± 15,5 (thdp nhat: 41 tuoi, cao nhdt: 78 tuoi).
Luu Thi Binh vd Dtg
Gi6i
Diadu
Nghg nghigp Biing
T?p chl KHOA H p c & CONG NGHg , Phdn bo doi tir^g nghien dm
D^c diem Nam
Na Thinh thj N6ng th6n CSnb?
Cdng n h ^ , n6ng dan
theo gi&i. dla dir vd n » 1 3 9 4 6 7 6 7
nghe nghifp
165(05): 3 - 8
%
69,2 30,8 46,2 53,8 46,2 53,8 Nhgn xet: Ti le b?nh nhan gap nhieu hon a cdc doi tugng nam, khong c6 sir khac biet ve ti le theo dia du va nghe nghiep.
• Tiem chgc vao 6 khap Khong xac dinh du'ang vao
Hinh 1. Yiu td nguy ca gdy viim khop nhiem khudn
Nhgn xet: Co 38,5% trudmg hgp xac djnh dugc tien su viem khap nhiem khuan sau tiem chgc vao 6 khdp.
Bang 3. Trieu chung ldm sdng
Trif u chung toan than Vi tri Idiop viSm Mile dp dau Idiop (theo thang dilm VAS) Han chl v ^ dOng Idiop
Trieu chiing item theo tai Ididrp
Ton thuong da 0 vimg Ithdp B&c dilm
S6t Gay Slit Khop goi
lOicrp idiac (hing,c6 chan, Ithuyu, lie don ..) Nh5
Trung binh N5ng
It Nhilu ICh6ng van dong duoe
Sung n l N6ng
Do Tran dich C6 vigm lolt
n - 1 3 10 4 7 6 2 2 9 3 9 1 i2 8 7 9 2
T6ng 76,9
%
30,7 53,8 46,2 15,4 15,4 69,2 23,1 69,2 7,7 92,3 61,5 53,8 69,2 15,4 Nhgn xet: Vi tri hay gap nhat la khop goi (53,8%), b?nh nhan chii ylu dau miic do ngng, lam hgn chl vgn dgng. Thudng kem theo cac tri?u chiing nhu: sung ne (92,3%), tran djch (69,2%).
Luu Thj Binh vo Stg Tjp chl KHOA HOC & CONG NGH? 165(05): 3-81 Bang 4, Bdc diim mot sSxit nghiam c4n
Huylt hgc Hinh anh Idiuyet, hiiy xuong
tren Xquang Ididp Sieu &m Ididp
DSc dilm Bach cSu tang
Bach cau da n h ^ tnmg tinh t ^ g Vss tang
C6 Khang Trftn dich Vigm ming hoat djch IChdng phat hign tdn thuong
ldm sdng 1
Ton^
1 = 13 12 10 13 4 9 9 11 2
92,3
%
76,9 100 30,7 46,2 69,2 84,6 15,4
»
Nhgn xet: 100% benh nhan tang toe dg mau lang, 92,3% benh nhan co so lugng bach ciu tang.
30,7% benh nhdn cd hinh anh ton thuang khuylt, hiiy xuong 84,6% b6nh nhan c6 viem mang hoat dich tren sieu am.
Nhuom soi
Nufli cay
T i b i o
Nufli cav (+)
(-)
(+)(-)
Bing 5, Kit
Gram (+) Gram (-) Gram(+) Gram (-) Bach cau tang Tfl bao mii
qud xet nghierr. 1 dfch khop n - I 3
2 3 8 3 4 6 13 13
15,4
%
23,1 61,5 23,1 30,7 46,2 100 100 Nh^n xet: Nuoi cay djch khdp cho kSt qua duang tfnh 53,8%. cac truing hgp. Xet nghi?m te bao 100%o bfnh nhdn tang bgch cau va tl bao mu.
Bdng 6. Kit qud djnh danh vi khudn trong cdc mdu djch khdp (+) (n=7) fljnh danh vi khuin
Staphylococcus Aureus H.influenzae Kpneumonia PantoeaSPPS
42,9 28,5 14,3 14,3
Nhgn xet: Trong tong so vi khuan gay viem khap nhilm khudn thi ti Ie VKNK do Staphylococcus Aureus chilm ti I? cao nhit (42,9%), tilp theo \k H.injluenzae (28,5%).
BAN LUAN
Trong nghiSn ciiu ciia chung t6i: cac b?nh nhan co tuoi trung binh la 59,25 ± 15,50, gap d mgi nhom tuoi, bgnh nhan tre nhat la 41 tuli, bgnh nhan cao tuli nhat la 78. Do so lugng benh nhdn it nen chua noi dugc ti lg nam/ nfi nhu the nao Id chudn, nhung theo so ligu chiing toi thong ke dugc thi ti I? nam/nff xdp xi khoang 2,3/1.
Qua tim hieu ve nguyen nhdn gay benh, chiing toi thay rdng 38,5% bgnh nhan xdc djnh dugc yeu t l nguy ca la co tiln sOr tiem chpc vao 6 khdp trucfc khi khdp cd bieu hien 6
sung ne. Dieu nay tuang ung vdi so lieu thong k6 tgi bfnh vien Bgch Mai, ylu tl nguy ca gay bgnh hang ddu dugc phat hien la cac benh nhdn co tiln su tiem chgc vao 6 khdp tru6cd6 [1].
Tgi thai dilm nghien ciiu, phdn Idn benh nhan trong nghien cuu c6 vj tri tin thuang a khdp gdi (53,8%). Mlic do dau dugc danh gia theo thang dilm VAS va chiing toi nhdn thay 69,2% benh nhan a miic dg ngng. 100% bgnh nhan c6 tic dg mau lang tang. Hau het cac benh nhan co hgi chiing nhilm triing bilu hien tren ldm sdng bdng cdc triSu chiing sot
Luu Thi Binh vd Dtg T^ip chf KHOA HQC & CONG NGH$ 165(05): 3 - » - Ldm sang:
+ 3 8 , 5 % bgnh nhan viem khdp sau tiem chgc vao I k h a p .
+76,9 % bgnh nhan cd sot
+ Khdp g i i id vj trf hay bi n h i l m khudn nhdt, chiem 53,8%
+ 69,2% benh nhdn dau khop miic do ngng, kem theo thudng gap: Tran djch khdp (69,2%).
- Cgn lam sang:
+ 100% benh nhdn cd tang toe do mdu lang, 92,3%) cd bgch cau tang trong mau.
+ 3 0 , 7 % khdp cd hinh dnh ton t h u a n g khuyet, hiiy xuong tren Xquang
+ 84,6%i khdp cd viem mang hogt djch va 6 9 , 2 % khdp cd trdn dich trSn sieu dm.
+ Xet nghigm djch khap: 100% cd bach ciiu tang va te bao mu; vi khudn (+): 3 8 , 5 % phdt hign qua nhugm soi, 53,8% qua nudi cay trong do 4 2 , 9 % la ty cau vdng.
(Staphylococcus aureus).
(12/13 bgnh nhdn), s l lugng bgch cdu tdng, ti If bach cau da nhan trung tinh tang. Tuy nhien trong nghien cuu ciia chiing toi ciing ghi nhdn gap 1 truong h g p benh nhdn khong CO b i l u hign s i t , xet nghigm mau binh thuang, chi c6 b i l u hien k h d p trdn djch miic do ft vd dau nhg n h u n g khi nhugm soi va nuoi cay deu cho k i t qua (+) v a i tu cau vdng, qua trudng hgp bgnh nhan nay chung toi t h i y vigc chgc hut dich k h o p lam xdt nghifm la rat cdn thiet va cdn phdi d u g c lam t h u a n g qui d l logi trir V K N K t r u 6 c khi d i l u trj theo hucmg bgnh ly khac, dac biet la trong d i l u tri c o tiem corticosteroid vao 6 khdp d l gidm dau.
K i t qua xet nghigm t l bdo djch k h a p cho thdy 100% bgnh nhdn c6 bgch cau tang va t l bao mii, ddy Id nhijng b i l u hign ggi y nhung cGng rat CO gia tri giup cho chan doan viem khop nhiem khudn khi nuoi cay mau va djch khdp d l u dm ti'nh. Vdi ti lg kha cao (46,2%)) benh nhan cd ket qud nuoi cay vi khuan dich khq>
am tinh, tinh trgng ndy c6 the do hign tugng bgnh nhan da diing khdng sinh. Nghien cuu cua chiing toi c6 ti lg bgnh nhan d u a n g ti'nh khi nuoi cdy khd thap (53,8%) khi so vdi k i t qua nghien cuu cua tdc gid Nguyen Thj Kim Thanh (2014) [2] Id 71,6%, Khan (2013) [4]
Id 71,6%, CO the do cd' mdu cua chiing toi con it vi nghien ciiu mdi d u g c t h u c hign trong 1 nam trong khi d e co so lugng c& mdu ldn khi nghiSn ciiu v l bgnh nhdn viSm khop nhiem khudn, cac nghien cixu ciia cdc tdc gid tren deu phdi t h u c hien trong nhieu ndm tgi nhieu khoa ciia bgnh vign. Ket qud nuoi cdy phdn Idp vi khuan cho thay cd cac vi khuan gram am gdy benh n h u : H influezae, K.
pneumoniae, Pantoeg spp... tuy nhien chung tdi nhgn thay tu cdu vang (5. aureus) co ti lg cao nhdt chilm 4 2 , 9 % cac truong hgp. Nghien cuu ciia chiing toi cfing cho ket qud tucmg t\f nhu ket qud nghien cim cua cdc tdc gia trong vd ngoai nude [1], [2], [3], [4].
K E T L U A N
- Tuoi trung binh cua bgnh nhan Id 59,25±
15,5, t i l g n a m / n u = 2,3/1.
TAI LIEU T H A M K H A O 1. Tang Thi Hgnh Nhdn (2006), Nghiin cicu ddc diem ldm sdng, cgn ldm sdng vd diiu tri vtem khap nhiim khudn, Khda luan tot nghi?p bac sT da khoa, Truemg Dai hoc Y Hd N^i,
2. Nguyin Thi Kim Thanh, Nguyin Dinh Khoa (2014), "D?LC diem lam sdng, cgn lam Sting vd vi khuan hpc d b$nh nhan viera khdp nhilm khuSn", Tgp chi Noi khoa. so dac biet thdng, U. 128-135.
3. Khan F. Y,, Abu-khatta M,, Baagar., et al.
(2013), "Characteristics of patients with definite septic arthritis at Hamad General Hospital, Qatar:
a hospital -based study from 2006-2011", Cim Rheumatol. 32(7), pp, 969-973.
4. Morgan D, S., Fisher D,, Merianos A, &
Currie B J., (1996), "An 18 year clinical review of septic arthritis from tropical Australia", Epidemol Infect. 117(3), pp, 423-428.
5. Pereira D., Severe M,, (2013) "The effect of depressive symptoms on the association between radiographic osteoarthritis and knee pain", BMC rf/s, 22(l):p.214
6. Philip Seo, et al (2013), Oxford American hanbook of Rheumatology, second edition, chapter 22, "Septic arthritis", pp. 562-567.
7. Katie A. Sharff, Eric P. Richards, John M.
Townes Curr. (2013), "Clinical Management of Septic Arthritis", Rheumatol Rep 15:332.
Luu Thi Bmh vd Dtg Tgp chi KHOA HQC & CONG NGHE 165(05): 3 - ff^
SUMMARY
CHARACTERISTICS OF 13 P A T I E N T S W I T H SEPTIC A R T H R I T I S IN THAI N G U Y E N N A T I O N A L H O S P I T A L
Luu Thi Binh', Tran Thi Lan College of Medicine and Pharmacy - TNU Aim: To described 13 patients with septic arthritis treated at Thai Nguyen National Hospital.
Subjects and methods: Cross-sectional study, 13 patients with arthritis diagnosed at Thai Nguyen National Hospital from February 2016 to November 2016, Results: The average age of patients is 59.25 ± 15.5; ratio of male patients is 69.2%; 8.5% of patients with arthritis had a history of injection. 53.8% knee joint is infection, accounting for; 69.2% of patients with severe joint pain, X-ray of the joints: 30.7% of the image is missing lesions, bone destruction; 84.6% of patients had synovitis on ultrasonography. Testing of Joint fluid: 100% of patients increase white blood cell count and pus; Bacteria {+): 38.5% detected through staining, 53.8% through culture, of which 42.9% were Staphylococcus aureus. Conclusion: The history of injection is a common risk fector of septic arthritis, definition of diagnostic the septic arthritis by testing the joint fluid.
Keyv/ord: septic arthritis, joint fluid, risk factor, bacteria. Staphylococcus aureus (S aureus).
Ngay nhgn bdi: 05/4/2017, Ngdy phdn bi^n: 20/4/2017, Ngay duyet Mng: 12/5/2017 Tel: 0915 717076. EmaiT luubinh,yln@gmail com
