Tap ciu THONG TIN YDlfOC S3 6 nam 2010
CONG TRINH NGHIEN Cl/U
GIA TR| CUA CAC TEST Bi 0 BEIMH NHAN VIEM MUI Dl UNG DO Dl NGUYEN DERMATOPHAGOIDES PTERONYSSINUS
Vo Thanh Quang' TOM TAT
Muc tieu: nghien cu'u gia tri cua cac test noi bi va test lay da, danh gia do nhay va dp dac hieu cua cac test nay trong chan doan benh viem mui di utig do di nguyen Dermatophagoides pteronyssinus (D.pteronyssinus). Doi tupng va phUOng phap: thit nghiem lam sang cd ddi chUng, nhdm chiing (n=50), nhdm nghien ciiu (n=198 benh nhan (BN) viem mui di utig) dddc lam cac test bi vdi di nguyen D.pteronyssinus. Kit qua: test lay da: dp nhay la 81,3%, vdi mite dp dddng tinh chii yeu la td (++) trd len (chiem 88,2%>), dp dac hieu la 96%>. Test ndi bi: dp nhay la 92,4%o mdc dp dUdng tinh chii yeu (++) trd len, trong dd cao nhat la (+++) chiem ty le 35,3%, dp dac hieu la 92%>. Khdng cd sd khac nhau cd y nghia gida 2 dp dac hieu (p>0,05).
Kit luan: vdi di nguyen D.pteronyssinus, test npi bi cho dp nhay cao hdn test lay da. NgUdc lai, khdng cd sd khac nhau gida dp dac hieu cua hai test. Hai test cd gia tri bd sung cho nhau trong chan doan benh viem mui di dng do di nguyen bui nha.
SUMMARY
Value of skin tests in allergic rhinitis patients with Dermatophagoides pteronyssinus allergen
Objectives: to evaluate the sensibility and specificity of intracutaneous test and skin prick test and their value in the diagnosis of allergy rhinitis to Dermatophagoides pteronyssinus (D.pteronyssinus) allergen. Methods: controlled clinical trial with comparison between two groups 50 healthy peoples (control group) and 198 patients with allergic rhinitis who had been done the cutaneous tests with D.pteronyssinus allergen (case group). Results: skin prick test:
sensibility was 81.3%>, mainly in (++) degrees up, specificity was 96%>. Intracutaneous test:
sensibility was 92.4%>, mainly (++) degrees up, highest (+++) was 35.5%o, specificity was 92%o. There was no significant difference between two specificities (p>0.05). Conclusions:
with the D.pteronyssinus allergen, the sensibility of intracutaneous test was greater than skin prick test. No difference was found in comparing specificity of two tests. Both have necessary roles in diagnosis of allergy rhinitis to house dust mite allergen.
I. OAT VAN OE
Benh viem mui di d'ng da va dang dUdc nhieu tac gia trong va ngoai nUdc nghien cdu, cac bao cao cua nhieu tac gia trong nUdc gan day cho thay cd sU gia tang cac benh di dng, nhat la viem mui di dng [3,7],
Be chad doan mot benh di dng phai qua cac budc: khai thac tien sd, kham lam sang va dac biet la lam cac test dj uhg in vivo va in vitro, trong dd cd cac test bi nhU test lay da, test ndi bi do nhieu tac gia (Pasteur V.R. (1964), Zetlertrom (1980), Sullivant TJ. (1981),...) de xuat va third hien. DUa tren ket qua nhdng xet nghiem nay, ngUdi thay thudc phat hien chinh
xac dj nguyen gay benh, td dd cd bien phap phdng benh va dieu trj hieu qua nhat.
Viet Nam la nUdc cd khi hau nhiet ddi gid mua, nang, ndng, cd dp am cao, day la dieu kien thuan Idi cho mat bui nha phat trien, dac biet doi vdi loai phd bien nhU D.pteronyssinus, la loai gay benh viem mui di dng chu yeu d nUdc ta. Do dd, viec nghien cdu danh gia kha nang man cam cda dj nguyen D.pterenyssinus la mdt yeu cau cap thiet va cd y nghia khoa hgc. Chung tdi tien hanh nghien cdu de tai nay vdi muc tieu: nghien cdu gia tri ciia test ndi bi va test lay da, danh gia dd nhay va do dac hieu ciia cac test nay trong chan doan benh viem mui di dng do dj nguyen D.pteronyssinus.
' TS., Benh vien Tai Mui Hong Trung UUng
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Tap chi THONG TIN YDlfOC So 6 nam 2010
II. OOI TUOINIG VA PHl/ONG PHAP 1. Ooi tugng nghien cu'u
- Nhdm chdng: gom 50 sinh vien khoe manh, khong mac cac benh di dng cung nhU cac benh toan than khac. Tinh nguyen tham gia nghien cu'u.
- Nhom BN: gom 198 BN mac benh viem mui di d'ng kham tai Khoa Di dng lam sang, Benh vien Tai Mui Hgng Trung Udng td thang 6/2006 den thang 6/2008. Khdng mac cac benh npi khoa toan than nang hoac mat bu.
2. PhUOng phap nghien cu'u
* Thiet ke nghien cu'u. thd nghiem lam sang cd ddi chdng.
* Cac budc tien hanh:
- Chpn ddi tupng nghien cdu: khai thac tien sd va tham kham lam sang theo mau 25B cua To chdc Y te The gidi (WHO).
Danh gia ket qua test lay da (prick test):
- Mau cau hoi chi tiet cd tinh diem cua ISAAC (International Study of Allergy and Asthma Childhdod - 1994).
- Thang cho diem danh gia cac trieu chdng mui cua Bent Weeke va Niels Mygind, Copenhagen, Dan Mach, 1985.
- Lam test bi:
+ Test lay da: theo ky thuat Sullivan, lam sach mat da vung trUdc cang tay bang con 70°, de khe, lan lu'dt nhd tren mat da d cac vi tri khac nhau, each nhau 3-4cm, mdi chd 1 gipt cac dung dich thd (di nguyen D.pteronyssinus nong dp lOOOPNU/ml) va chdng (NaCI 9%o). Dung kim tiem vd khuan (so 24) cham vao 2 gipt tren (mdi gipt dung kim rieng), qua Idp thu'dng bi, tao vdi mat da mdt gdc 45° roi lay nhe, khdng dUpc lam chay mau. Sau 20 phut dpc va danh gia ket qua.
Muc do Ky hieu Bieu hien
Am tinh Nghi ngd DUdng tinh nhe DUdng tinh vUa DUdng tinh manh DUdng tinh rat manh
+/-+ + + + + + + + + +
Gidng nhUchUng am tinh Ban san dUdng kinh <3mm
DUdng kinh ban san 3-5mm, ngUa, xung huyet DUdng kinh ban san 6-8mm, ngda, xung huyet DUdng kinh ban san 9T2mm, ngUa, chan gia DUdng kinh tren 12mm, ngUa nhieu, nhieu chan gia + Test ndi bi: lam sach mat da vung trUdc
cang tay bang cdn 70°, de khd, tiem trong da d cac vj tri khac nhau each nhau 3-4cm, lan I Udt 0,1ml dung dich thd (di nguyen D.pteronyssinus nong dp 1000 PNU/ml) va chdng (NaCI 9%o). Dpc ket qua sau 15-20 phut. Danh gia mdc dp dUdng tinh dua vad dUdng kinh vung quang dd va not san.
* Xd ly so lieu: bang phan mem Stata 11.
III. KET QUA
1. Nghien cu'u test lay da vdi di nguyen D.pteronyssinus
Bang 1: Dap dng cua test lay da
\ . Nhdm Nhdm chdng BN VMDLT (n=50) (n-:198) P Kit qua\^ SL TL % SL TL %
DUdng tinh 2 4 161 81,3 <0,05 Am tinh 48 96 37 18,7 Tonq 50 100 198 100
Ty le dudng tinh qua test lay da vdi di nguyen D.pteronyssinus d BN viem mui di dng dat 81,3%, nhdm chdng cd ty le dUdng tinh la 4%, sU khac biet ve mdc dp dUdng tinh cua 2 nhdm la cd y nghia thong ke (p<0,05).
Bang 2: Mdc do dddng tinh cua test lay da
Mdc do SL TL %
( + ) 19 11,8
(++) 48 29,8
(+ ++) 62 38,5
(+++ + ) 32 19,9
Tonq 161 100
Trong sd 161 BN dUdng tinh vdi di nguyen D.pteronyssinus trong test lay da, da so td mdc dp 2+ trd len (88,2%), mdc dp dUdng tinh 3+ (38,5%) chiem ty le cao nhat, thap nhat la ty le 1+(11,8%).
2. Nghiin cdu test noi bi vdi di nguyin D.pteronyssinus
Bang 3: Dap dng cua test noi bi
\Nhdm Nhdm chdng BN VMDlf (n=50) _[n=198) P Ketqua\^ SL TL % SL TL %
DUdng tinh 4 8 183 92,4 <0,05 Am tinh 46 92 15 7,6 To'ng 50 100 198 100
Qua thd test ndi bi vdi di nguyen D.pteronyssinus thay ty le dUdng tinh d BN viem mui di dng la 92,4%, nhdm chdng cd ty 15
Tap chi THONG TIN YDUOC S3 6 nam 2010
le dutfng tinh la 8%, Sd khac biet ve mdc do dddng tinh cua 2 nhom la cd y nghia thong ke vdi p<0,05.
Bang 4: Mdc do dddng tinh ctia test ndi bi
Mute do SL TL °/o
(+) 22 12,0
(++) 56 30,6
(+ + + ) 65 35,5
(++++) 40 21,9
Tong 183 100
Mdc dp dUdng tinh cua test ndi bi chu yeu td 2+ trd len (88,0%), mdc do dUdng tinh 3+ chiem ty le cao nhat (35,5%), thap nhat la 1+ (12,0%).
3. So sanh dp nhay cua test lay da va test npi bi
Bang 5: So sanh do nhay cua test lay da va test noi bi
~~~~~-~-^Test Test lay da Test noi bi Ketqua^-^, (n=198) (n=198) P DUdng ti'nh 161 183
Am tinh 37 15 <0,05
Do nhay (%) 81,3 92,4
Do nhay cua test ndi bi cad hdn test lay da vdi di nguyen D.pteronyssinus cd y nghTa thdng ke vdi p<0,05.
4. So sanh dp dac hieu cua test lay da va test npi bi
Bang 6: So sanh do dac hieu cua test lay da va test ndi bi
^^^Test Test lay da Test noi bi Ket qu£^~^^~^ (n=50) (n=50) P
DUdng tinh 2 4 >0,05
Am tinh 48 46
Dd dac hieu (%) 96,0 92,0
Dp dac hieu cua test lay da va test ndi bi vdi di nguyen D.pteronyssinus khac nhau khdng cd y nghTa thdng ke vdi p>0,05.
IV. BAN LUAN
1. Di nguyen D.pteronyssinus Di nguyen mat bui nha ddpc tinh che td dich chiet hon hpp nuoi cay mat bui nha (House Dust Mites) bao gom cac chat td cd the mat, trdng, au triing, cac hat phan, cac chat phan huy cua mat va ca cac chat c nhiem cua mdi trUdng nudi cay [6]. Chiet tach di nguyen dUdc thu'c hien theo phUdng phap Ado ket hpp vdi phUdng phap Sutherland cd cai tien cua Khoa Mien dich-Di nguyen, Benh vien Tai Mui Hpng Trung Udng [6].
2. Ket qua ciia test lay da
Test lay da hien nay la mpt xet nghiem cd ban va dUpc thu'c hien dau tien de chan doan dj dng. Ket gua cua test lay da la mot can cd quan trpng cho viec chan doan va dieu tri dac hieu benh dj dng. Di nguyen dUdc dUa qua da bang mpt kim chich chuan (dau nhpn cua kim chi dai 1mm khdng gay tdn thUdng Idp ha bi) khdng gay chay mau. Neu cac te bao mast d dUdi da cua BN mang tren be mat chung cac IgE dac hieu vdi dj nguyen nay thi cac te bao se thoat hat gay ra phan dng san ngda (tam chdng Lewis) trong 10-15 phut sau. Day la test rat chinh xac va cd dp nhay cao neu thu'c hien dung tieu chuan [8,9,10].
Viec thu'c hien test luon kem theo chdng am va chdng dUdng de tham khao. DUdng tinh gia cd the thay d chdng am khi cd ton thUdng da tai chd hoac phan dng van mach khdng dac hieu d ngUdi cd chdng da ve ndi. Am tinh gia cd the thay d chdng dUdng khi ngUdi benh sd dung mpt sd thudc hoac chiet xuat dj nguyen bi bien chat hay da bj mat nUdc. Khi khdng cd phan dng d chdng am thi mdt not san nhd dudng kinh trung binh td 3mm trd len ket hpp vdi quang dd va ngda dUpc coi la dap dng mien djch dUdng tinh.
Trong nghien cdu nay, ket qua cho thay d 198 BN viem mui dj dng dUdc lam test lay da vdi dj nguyen D.pteronyssinus cho phan dng dUdng tinh la 161 ngUdi (81,3%). Ty le nay tUdng dUdng vdi nhieu tac gia treng nUdc va ngoai nUdc [3,5,7] khi nghien cdu viem mui dj dng dd cac nguyen nhan khac nhau, hau het cac ca cd dp dUdng tinh td mdc 2+ trd len, chu yeu la mdc 2+ va 3 + .
So vdi ket qua nghien cdu ciia Vu Minh Thuc [4] va Trinh Manh Hung [3] ddi vdi BN hen phe quan dd di nguyen D.pteronyssinus, cho thay khoang 60% BN cd test lay da 1+, 30% BN cd mdc 2+, dudi 10% BN cd mdc dUdng tinh 3+ va 4+. Cac ket qua cua Vu Minh Thuc, Pham Van Thdc, Vu Van San [5]
khi ngnien cdu mdc dp man cam ciia BN viem mui dj dng nghe nghiep cd mire dp dUdng tinh 2+ va 3+ d test lay da la 82,86%.
Nghien cdu ciia Codina R. va cdng sd tren 365 BN viem mui dj dng vdi bpt dau nanh cho thay, ty le dUdng ti'nh cua test da la 59,4%.
Tasma A.J. va cdng sU nghien cdu d BN viem mui dj dng thay dap dng ciia test lay da vdi 16
Tap chi THONG TIN Y DUOC S3 6 nam 2010
cac dj nguyen khac nhau thi ty le dUdng tinh chenh lech kha Idn.
3. Test npi bi
Tren 198 BN viem mui dj dng lam test npi bi vdi dj nguyen D.pteronyssinus cho ty le dUdng tinh la 183 trUdng hpp (92,4%). Dp nhay ciia test nay rat cao. Nhdm chdng cd ty If dUdng tinh la 8%. Ket qua nay phd hdp vdi nhieu nghien cdu cua cac tac gia khac. Mac dii dp nhay cao, song test ndi bi thudng cd lan mdt ty le dUPng tinh gia va cd nhdng phan dng khdng dac hieu (do kim tiem gay tdn thUPng trong da nhieu hdn so vdi test lay da, lupng dj nguyen dUa vao cung Idn hdn). Test npi bi tuy cd dp nhay cao nhUng cung de tai bien hPn, da cd mdt so nghien cdu neu nhffng trUdng hdp sdc phan ve khi lam test ndi bi.
4. So sanh test lay da va test npi bi Nghien cdu tren cho thay, dp nhay ciia test lay da kem hdn so vdi test npi bi, sU sai khac nay cd y nghia thdng ke vdi p<0,05. Dp dac hieu khac nhau khdng cd y nghia thong ke vdi p>0,05. Cac tac gia Vu Minh Thuc, Pham Van Thdc va cpng sU [4,5], Dreborg, Navaro khi sd sanh hai bai test nay deu cho ket qua tUdng tff.
Dp nhay cua test lay da tuy khdng cad nhUng it dUdng tinh gia, vi mdc dp lam tdn thUdng da it, khdi Iffpng dung djch dUa vao it nen it gay kich dng da hdn so vdi test ndi bi.
Du dp nhay ciia test lay da khdng cao bang test ndi bi song vi ky thuat ddn gian va dp an tdan cac nen nhieu tac gia da de nghj trUdc tien chi nen lam test lay da, neu test lay da am tinh hoac nghi ngd thi mdi tien hanh lam test ndi bi vi trong nghien cdu ciia chiing tdi va nhieu tac gia nhan thay nhieu trUdng hdp BN cd lam sang bieu hien rat r5 nhffng khi lam test lay da thi khdng cd dap dng. Test ndi bi lam sdng song vdi test lay da trong trUdng hdp nay se la bien phap nham tranh bd sdt BN.
V. KET LUAN
DUa tren nghien cdu ket qua test lay da va test ndi bi vdi dj nguyen D.pteronyssinus d 198 BN viem mui dj dng, chiing tdi cd ket luan sau:
- Ve gia trj ciia test lay da va test ndi bi trong chan doan benh viem mui dj dng do di nguyen D. pteronyssinus:
+ Test lay da: do nhay la 81,3%, vdi mdc do dffdng tinh chii yeu la td (++) trd len (chiem 88,2%), dp dac hieu la 96%.
+ Test npi bi: dp nhay la 92,4%, mdc dp dUdng tinh chii yeu (++) trd len, trong dd cac nhat la (+ ++), chiem ty le 35,5%.
- Doi vdi di nguyen D.pteronyssinus thi test ndi bi cho dp nhay cac hdn test lay da, cdn dp dac hieu ciia hai test khdng khac nhau. Hai test cd gia tri bd sung cho nhau trong chan doan viem mui dj uhg dd dj nguyen mat bui nha.
TAI LIEU THAM KHAO
1. Ado A.D.: Di Ung hoc dai cUdng. Dich gia tieng Wet:
Nguyen Nang An, Nha Xuat ban MIR-MaxcoVa, 1986.
2. Nguyen Nang An: May van de y hoc cd sd trong cac phan Ung va benh di Ung. Nha Xuat ban yhoc, Ha Npi, 1995.
3. Trinh Manh Hung: Ket qua budc dau trong chan doan va dieu tri dac hieu di Ung dUdng ho hap do bui nha. Luan an Tien syY hpc, Dai hpc YHa Npi, 2002.
4. Vu Minh Thuc: Cac phUdng phap labo trong chan doan cac benh di iitig. Nha Xuat ban Yhoc, Ha Npi, 2005.
5. Vu Minh Thuc, Pham Van Thu'c, Vu Van San, TrUdng Thj An: Nhu'ng ket qua budc dau cua phUdng phap giam man cam dac hieu trong VMDff do bui nha va bui long vu. Bao cao khoa hpc, Hpi nghi giang day va nghien ciiu mien dich hoc hang nam lan IX, thang 3, 1999.
6. Vu Minh Thuc, Vd Thanh Quang, Phan Quang Doan, Pham Van Thirc va cs: Nghien cUu cong nghe san xuat vac xin chdng di Ung tU mat bui nha acarien Dermatophagoides pteronysinus de Ung dung trong chan doan, dieu tri mpt sd benh di Ung:
hen phe quan, viem mui di Ung, viem ket mac. Bao
cao de tai khoa hoc cap nha mfdc, ma so KC10- 10/06-10, Bo Khoa hoc va Cong nghe, Ha Noi, 2009.
7. Berger W.E.: Treatment update: allergic rhinitis. Allergy Asthma Proc, 22, 2001, pp.191-198.
8. Chalal I., Horat M., Segalen C: Comparison between modified skin test with standardized allergen extracts and phazet. J.Allergy din.
Immunol, 82, Nov, 1998, pp.878-881.
9. Dreborg S.: Skin test used in type I allergy testing.
Position paper/prep by the sub-comm-on skin tests of the Europe, Acad, of Allergo and Clin-immuno-Copenhagen-Munlsgrard, Vol 44, N.10, 1989, pp.59-61.
10 Navarro D.R.B.E., Ortiz M.V., Ortiz L.L. et al: Comparison of 2 skin test methods for the diagnosis of allergic diseases. Rev-Allerg, Mex, 43, 4, Jul-Aug, 1996, pp. 100-103. &
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