Tgp chi THONG TIN YDLTOC So 10 nam 2012
NGMDI CUU GIA T M CUA PHAN UNG CHUYBU DANG TE BAO LYMPHO TRBV BBUH NHAN Dj UNG THUOC LOAI HJNH CHAM
Pham Cong Chinh*
TOM TAT
Muc tieu: mo ta va ntian xet mol lien quan cua phan iihg chuym dang tst}ao (CDTB) lymphd tren benh nhan dl iihg thuoc (BN DUt) loai hinh cham. Doi Wdng va phu'dng phap: tjen OJXJ, mo ta CO so sanh tren 45 BN DUt dieu bi tai Trung tam Di lihg-Miin dich lam sang, Benh vien Bach Mai va Benh vien Da lieu Tmng ifdng, tif 12/2005-12/2006. Ket qua: hen BN DUt n<^ chung, phan ung CDTB lymphd cho ket qua dutfng tinh ia 51,1 %, am tinh 48,9%; loai hinh cham: ty le phan ung CDTB lymphd dutfng tfnh la 81,8%; lo^l hinh nhanh: ty le nay la 21,7% (p<0,o6l). Trong DUt loai hinh cham, phan uhg CDTB lymphd co kha nMng dudng tinh cao gap 16,2 ^n so vdi DUt loai hinh nhanh (p<0,001). Ket luan: trong DUt loai hinh cham, phan uhg CDTB lymphd cho ket qua dudng tinh cao, cao hdn dl uhg loai hinh nhanh.
SUMMARY
S t u d y i n g t h e v a l u e o f l y m p h o c y t e t r a n s f o r m a t i o n t e s t i n p a t i e n t s w i t h d e l a y e d d r u g a l l e r g i c r e a c t i o n
Objectives: to descrlt)e the values of lymphocyte transformation test (L TT) In patients with delayed drug allergic reaction. Methods: a prospective comparative study, analyzed data of 45 patients with drug allergy treated in the Center of Allergology and Clinical Immunology (Bach Mai Hospital) and National Hospital of Dermatology and Venereology from Dec 2005 to Dec 2006. Results: In patients with drug allergy in general, LIT gives 51.1% of positive reaction and 48.9% of negative reaction; LTT positive rate is 81.82% for delayed drug allergic reaction and 21.74% for rapid drug allergic reaction (p<0.001). LTT of delayed drug allergic reaction is likely to be 16.2 times higher than that of rapid drug allergic reaction (p<0.001).
Conclusions: LTT gives high rate of positive reaction in delayed drug allergic reaction, much higher than that in rapid drug allergic reaction.
I . OAT VAN DE
DUT la nhuhg phin uhg, nhuhg hpi ehuhg hoac nhiJhg benh xuat hien trong hoac sau khi diing thuoc. Cic bigu hien lam sing do DUT gay ra rat da dang v i phong phu: cd khi chi l i iBn thUdng ngoii da ddn thuan, cd khi tdn thuUng phdi hdp ngoii da, nigm mac v i phii tang,... tham chf cd the gay tU vong cho BN [2,6]. DUT la thuat ngO" thdng thUdng dUdc diing de mieu t i nhuhg bien cd khdng mong mudn khi mdt ea thg diing thudc de phdng benh, dieu trj hay chan d o i n mdt btenh n i o dd.
Day l i mdi de dpa ddi vdi BN va eung l i ganh Ring, l i mdi lo ling ddi vdi thay thuoc [9].
Cd nhieu phUdng phip can lam sing giup eho xac ffinh thudc gay ra dj uhg gom eie test in wM3vi in vitro. Cie test In WVD thudng dudc sU dyng b-ong chan doan BN DUT loai hinh nhanh v i cd thg gay nhuhg tai bien nguy hiem dgn tinh mang ciia BN [4,7].
"TS., TruSng Dai hoc Y DuWc Ttiai Nguyen
Cic test in vitro nhU phin uhg phan hiiy te bao mast, phin iihg tieu trach eau dac higu, phin LJhg ngUng ket hdng eau thu dong, phan iihg khuyeeh tan tren thach, phin img CDTB lymphd,... trong dd, phan uhg CDTB lympho l i mot phudng phip da dUde cic t i c gia i p dung trong viee chan d o i n DUT loai hinh chim [3,5]. Vi vay, chiing tdi tien hinh nghien cuU nay nham mo t i v i nhan xet mdi lign quan eiia phin iihg CDTB lymphd tren BN DUT loai hinh c h i m .
I I . O O i TU'gNG VA PHU'DNG PHAP I. Odi tu'dng nghien cuts 45 BN dUdc chan d o i n l i m sang la DUT, dieu tri npi trii tai Trung t i m Dj uhg-Mien dich l i m sing, Benh vign Bach Mai va Benh vien Da lieu Trung Udng, tU tiiang 12/2005-12/2006.
* Tigu chuan lUa chpn:
Tien sU: BN co tien sU dung tan dUde trong thdi gian 15 ngiy gan d i y , chUa 6Mc diing khing histamin hoac corticoid.
Tgp chi THONG TIN YDVQC S610 nam 2012
- L i m s i n g : + Cd n i n g : ngu^a, r i t .
+ Thyt thg: BN ed bigu hign l i m sing nhU dd da, myn nudc, bpng nude, logt trdt da-nigm m?e,...; toin tfiin: sdt, mgt mdi, dau dau, rdi lo^n tieu hda,...; BN ddng y nghign ciru.
* TIgu chugn lo^i trU:
- Khdng nhd ho$c khdng chSc chin trUde dd cd sir dyng thudc.
- Diing thude nam ho$c thudc b i c ho^c kdt hpp c i t i n dui?c vdi thude nam hoqic thude bSc.
- Khdng dSng y tham gia nghign cuU.
2. Phutfng phip nghiSn cuii 2.1. ThiSt kinghiSn cut/, tign cUU, md t i cd so sinh.
2.2. mnh^nlr.
* Ky thu§t ehpn mSu: thugn tign.
' Cd m§u: t o i n bp (tich Iuy trong q u i trinh nghign cCrtj).
' Tieu ehl phan lo^l phin ung nhanh c h i m [ 1 ] :
- Phin lihg nhanh: x i y ra trong vdng 5 gid ngay sau khi diing thuoc vdi bieu hien lam sing: m i y day, phii Quincke, ban dd.
- Phin uhg cham: x i y ra sau 5 gid ti'nh tU khi b i t dSu diing thudc vdi bieu hien l i m sang: do da toan than, hdng ban da dang, hpi chCiVig Stevens-Johnson.
* Xic (Jnh g i i tri ciia phin Uhg CDTB lymphd:
- Ty le dupng b'nh chung.
- Ty le dudng b'nh ciia dj ifhg nhanh, cham.
- Lien quan giOa phin uhg CDTB lymphd vdi di uhg chim.
* Ky thuat xet nghiem: tien h i n h tai labo Mien didi - Sinh hpc phan tU, Vien Ve sinh Dich te Trung Udng.
- Nguygn ly: trong mdt trUdng nudi cay, te b i o lymphd khi du^c kich thidi b i n g khing nguygn hoic cic chat p h i n b i o khdng d$c hieu se d i p uhg vdi cae yeu to kfch thieh tren b i n g cich nhin Ign, bigt hda v i ho^t hda. Khi te b i o nhan len thi q u i trinh tdng hdp acid nhan (Acid Desoxyribonudeic, ADN) se dien ra. Trgn cd sd dd, ed the danh gia k h i n i n g nhan len eiia ^ b i o lympho dUdc hoat hda bing cich do h i m IUdng add nhin mdi 6\S<:}c ^ n g hdp.
- Hda chat va vat lieu nghien euU:
+ Heparrin.
+ Dung dich dem PSB (Phosphate Buffered Saline), pH=7,2-7,4.
+ ChSt t i c h te bao bach cau ddn nhin Ficcli-Hepaque, ty trpng 1,077.
+ Mdi trUdng nudi c i y te b i o IMDM (Iscoves Modified Dulbacco's Medium).
+ C h i t kich thich chuyen dang khdng d i e higu PHA (Phytohemagglutinin).
+ Dung djch khing nguygn (tiiuSc) pha d cic ndng d$ khic nhau.
+ Ha-Thymidin.
+ Miy do nhSp n h i y Idng "Packard" - Tri - Carb 2900TR (Hoa Ky).
+ Miy g i t tg b i o 'Titertek" - Hamble 503 - SDH model CH2 H/W (Anh).
+ Miy ly t i m "Haraeus".
+ Til i m , phign nhUa nudi c i y te b i o 36 gigng, d i y hinh chu'U.
- Tign hinh ky thuft: ISy 5 ml nrau tfnh mach, chdng ddng bing Hepamn. Tich te bao bach cau ddn nhan ngoai vi theo p h u t ^ phap sau:
-I- Pha loang m i u BN gap ddi bang cich cho 5 ml dung djch PBS vao ong nghiem cd chUa m i u cua BN. Cho m i u da pha loang sang 1 dng nghiem khac cd chu^ dung djch Rcoll- Heparin (eho nhe nhing de mau khdng bi pha trdn vdi Ficoli).
+ Tich t g b i o lymphd ngoai vi bang cich ly tam gradien ty trpng tren m i y Haraeus, toe dp 2.000 vdng/phut, trong 20 phut.
+ Rira te b i o bach cau ddn n h i n 2 lan bing dung djch dem PBS. Tg b i o bach cau ddn nhan sau l^i da ruci dUdc hda tan trong mdi trUdng nudi cay te bao cd bo sung 10%
huyet thanh ngudi nhdm mau AB da b i t hoat bd t^e d nhiet dp 56°C/30 phut, sau dd dUdc nudi cay vao phien nuoi cay (96 gieng). Sd IUdng m6i gieng khoing 5-7,5 x 10^ te b i o .
Cic gieng nudi cay theo thU tU nhu sau: 3 gieng dau ehl cd te bao; 3 gieng tiep theo cho chat kich thi'eh chuyen dang khdng d i e higu PHA, nong dp 10 pg/ml; moi hang gieng tigp theo (gSm 12 gigng) dUdc thU cho mpt thude (xet nghiem dUdc thir vdi t i t c i c i c loai thudc ma BN da su* dung). Nong dp thudc dUde pha loang d 4 ndng dp khac nhau, ndng dp Idn nhat dUdc ti'nh b i n g each lay lieu luUng thudc m i BN da sU dung chia cho 5.000 (tUdng dUdng vdi the b'ch m i u trong ed t h ^ , mSi nong dp tiep theo d u % g i i m di 4 fan.
-t- De phien nudi cay vao tii am 37°C, ed 20% CO;. Ket qua dpc dUdc cho tiiay, ddi vdi
Tgp chi THdNG TIN Y Dl/QC So 10 nam 2012
phien 4 ngay, sau 72 gid cho vao cic gieng nuoi cay 20 pi dung djch H3 - Thymidin va tiep tue nuoi cay them 18 gid nu:a, sau do g i t te bao de cd duUe ADN ciia te b i o lymphd d i dudc dinh dau phdng xa bdi dung dich H3 - Thymidin g i n tren giay Ipc thiiy tinh b i n g m i y gat te bio "Titert:ek"; ddi vdi phign nudi cay 7 ngiy, den ngiy tiiU 6 eho 20 pi dung djeh H3 - Thymidin va g i t tg bao vao ngiy thU 7.
- Dinh g i i ket q u i : x i c djnh hoat tinh phong xa tren may do phdng xa nhap nhay Idng Packard. MUc dp chuyen dang ciia te bao lymphd dUdc x i c djnh b i n g mUe hoat tinh phdng xa do dUdc cua ADN da g i n phong xa H3 - Thymidin trong qua trinh chuyen dang va dUdc tinh bSng sd xung/phut (Counts per minute, Cpm).
Chi so kich thieh dUde tinh b i n g edng thUc sau:
Cpm nudi cay ed thudc S I =
Cpm nudi cay khdng cd PHA Khi SI (Stimulation Index) >2 l i ket q u i dUdng tinh (tg b i o lymphd dudc danh g i i l i ed su ehuyen dang vdi thude).
2.3. Xiyiysoiieu. bing phan mem SPSS 11.5.
I I I . KET QUA
Bsngl: Phan bo BN theo toalhhh DUt (n=45) Loai hinh di Cenq 1 SL
Nhanh 23 Cham 1 22
re%
51,1 48,9
Ket qui Dutfng tinh Am tinh
SL 23 22
TLVo 51,1 48,9 23 BN DUt loai hinh nhanh (51,1%) va 22 BN DUt loai hinh cham (48,9%). Nhif vay, mau nghien cull cua 2 nhom BN la tuUng di/cAig.
Bang 2: Ty le phan ling LTT duOng ti'nh tren tong so BN xet nghiem (n=45)
trang so 45 BN D U t v6l cac t h ^ lam sang khac nhau bao gom ca di utig nhanh va dj utig diam du'dc Ben hanh phan img CDtB lympho, m 23 BN cho ket qua duHng tinh (51,1%).
Bang 3: Ty le phan ijtig CDTB lymphd difdnq tinh tren cac loai hinh PUT
BN D U t lo?i hinh ch§m co ty le L t t du'dng tinh cao hdn D U t loai hinh nhanh (81,8% so vdi 21,7%). Sir khac biet co y nghTa, vdi /7<0,001.
Bang 4: Moi lien quan giu^ phan iihg CDTB lymphd vdi DUt loai hinh cham
K»qui
Chjm (n=22) Nhanh(n=23)
IS 05
04 18
OR
16,2 <OfBl Vdi nhiing BN di ung loai hinh cham, ph^n utig CDtB lympho cho k€t qua dudng tinh cao hdn so vdi D U t loai hinh nhanh. Su khac biet cd y nghia thong ke, vdi / K O , 0 0 1 . I V . BAN LUAN
trong DUt, thuoc ddng vai tro la chat kich thich d3c hl§u lam tang qua trinh tong hdp ADN cua te bad lympho. Ket qua phan utig duwc danh gla bang ham luWng ADN tiong mau ngoai vi cua BN thong qua chat phdng xa H3- thymidln, tren cd sd dd xac djnh cac BN dj utig do dap Lftig mien djch qua trung gian te bao.
t i e n hanh xet nghiem phan utig CDtB lympho cho 45 BN DUt, trang dd 23 BN d! ftig loai hinh nhanh va 22 BN d! ung loai hinh cham (bang 1). Ket qua Chung cho ca 2 loai hinh d| ung nhanh va cham: cd 23/45 BN dutJng tinh (51,1%) (bang 2). Neu tach rieng nhdm BN dj ung nhanh va cham, thi ty le du'dng tinh thed so BN dl u'ng loai hinh cham cd 18/22 tru'dng hdp (81,8%), trong khi dd, ty le du'dng tinh tren cac BN dj ung loai hinh nhanh la 21,7% IjxOfiOi.) (bang 3). Nghien cutj cua mpt so tac gla nhu Nguyen Van Doan, ty le dUdng tinh cua phan ung L t t trong chan doan dl img thuoc ndi chung la 76,2% [3], ciia cac tac gia nu'dc ngoai nhu Kano Y., Hirahara K.[8], Nyfeler B., PIchler W.J. [10] va Pichler W.J., tllch J. [11],... deu chd thay, ty l i phat hien thudc gay dj img Idal hinh cham ciia phan iing CDtB lympiid dat tit 70-80%. Bang phu'dng phap tfnh ty suat chenh OR, danh gia mol lien quan giu^ phan ung CDtB lympho va dj img loai hinh cham. Vdi nhiing BN DUt loai hinh chSm, phan img CDtB lympho cho ket qua du'dng tinh cao hdn nhiing BN D U t loai hinh nhanh, vdi OR=16,2; / K O , 0 1 (bang 4). Ket qua nay cho thay, gla trj ciia phan img CDtB lympho trong xac djnh thuoc gay dj iitig loai hinh cham, dieu nay cung dUdc Nguyin Van Doan [3], Phan Quang Doan [4] va Nguyen
Tgp chi THONG TIN YDUQC So 10 nam 2012
. chUng minh trong nghign Thj Minh Thu [5],..
cUu ciia minh.
V. KET LUAN
Trong DUT lo^i hinh chgm, p h i n ifhg CDTB lymphd cho kgt q u i dUdng tinh 81,8%, cao hdn DUT k)?l hinh nhanh.
* KhuySh nghi: trudc BN DUT bigu hign l i m sing cua lo^i hinh dj Uhg c h | m , ngn lua chpn p h i n iihg CDTB lymphd dg gliip cho x i c dmh thudc g i y dj uhg.
T A I L I | U THAM KHAO
1. Nguy&n NJtng An: Chuygn tfS D| iltig hqc. AlhS XuSibSn Yhocl998, ^pl, tr.IS-16.
2. Nguy£n Nftng An, L£ VJIn Khang, NguySn V i n Tu'dng v^ CS: Tinh hinh dj Cmg do thu5c d nu'dc ta, d5 xuSt nhung bl^n phip can thi§p. Pe tAld0c l$p cdp Nhi nutk 2000-2003, 2003, tr. 19-20.
3. NguySn VSn Doin: Gdp phSn nghilSn cuU d| uTig ttiu6c t?l Khoa Dj ijtig • Mien dldi iam s&ng, B$nh vi$n 6?ch Mai (1991-1995). Lu^n ^ Phd TJ^ sykhoa hgc Y-Dupc Tnidng Dal hoc Y Ham 1996, lr.42 4 Phan Quang Do^n: Cic phutfng phip chSn doin
di utig d3c hi^u. Chuyen d§ Di utjg hoc, t$p 1. Nhk Xuatt}an Yhgc, 1997, tr.112-128.
Nguyfin Thj Minh Thu: 0$c digm ISm sSng v i ch^n doin thuSc gSy dj liTig I09I hinh ch|m bSng k9 thu$t kfch thich lymphd bdo. Lu$n vSn Th^ sy Yhgc,Hgcvl$n QuSn Y, 2003
Botchers A.T., Lee 3.L., Naguwa S.M., Cheema G.S.: Stevens-Johnson symdrome and Toxic epidermal necrolysis. Autolmmun Rev, Sep, 2008, 7(8), pp.598-605.
Carlos PJLG., Carios P.M.L, Medina M.: 'In vTvo"
and "In vmx>" test In the diagnosis of Beta-ladarm allergy. Qinkal A/lergy Immunotogy Center, Lisbon, Portugal, 2007, 39(5), pp.157-161.
Kano Y., Hirahara K., Mitsuyama v., T^kkahashi R., Shk)hara T.: UWity of the lymphocyte transformation test in the dIagnOGis cf dnjg sensitivity;
dependence on its timing and the type of drug eruptloa Allergy, Dec2007,62 (12), pp.14^1444.
Matsumoto K., Saida T.: Cutaneous toxicity. G^
ToKagaku, Ryoho, Oct 2008,35(10), pp.1645-16^.
Nyfeler B., PIchier W J . : The lymphocyte transformation test for the diagnosis of dmg allergy: sensitivity and specificity. Oin Exp Allergy, 1997, 28 (2), w.75-81.
Pichler W.J., Tiich 3.: The lymphocyte transformation test in diagnosis of drug hypersensitivity. Allergy, Aug 2004, 59 (8), pp.809-820.e
Q\k\ 6.000 dong
