Tgp ch[ Tai MOi Hgng Vi^t Nam - Volume (58-15). N°3 - May, 2013
NGHIEN CUtJ GIA TRI CUA CAC TEST BI Vdl DT NGUYEN DERMATOPHAGOIDES PTERONYSSINUS d BfNH NHAN
VIEM MUI DI ITNG
Phgm Van Mgnh*, Nguyin Xuan Bdi*, Phgm Van Thuc**, Phgm KUn Hiru***
T6M TAT
Dgt van &e: Cac test bi la phuang phdp de lam, co hi^u qua cao thuang duac phoi hap vai test in vivo khdc trong chart dodn xdc dinh di nguyen D.pte gay binh VMDlf. Muc tieu: Bdnh gid gid tri cua cdc test bi trong chart dodn dgc hi^u binh VMDlf do di nguyen D.pte; So sdnh do nhgy va dg dgc hieu cua 2 test nay di khdng dinh them gid tri rieng cua moi test. Boi tirffng vd phmfng phdp nghien cu-u: Gom 120 benh nhdn VMDlf vai D.pte nghien cieu mo td cat ngang, tien cuu tai B^nh vien DHY Hdi phong. Ket qua: Test lay da:
dg nhgy 71,67%, do dgc hieu 93,3%. Test noi bi: do nhgy 95%, dg dgc hieu 90%. So sdnh 2 test: test noi bi vai di nguyen D.pte cho do nhgy cao han test lay da (p<0,001). Do dgc hieu ctka 2 test nay khdng c6 su khdc biet. Ket lugn: Phoi hgp giua 2 test lay da vd test noi bi trong chdn dodn VMDlf vai di nguyen lam tang do chinh xdc cua chdn dodn.
Tu khoa: Viim mui di trng
SUMMARY
STUDYING THE VALIDIY OF SKIN TESTS IN PATIENTS WITH ALLERGIC RHINITIS SENSITIZED TO DERMATOPHAGOIDES PTERONYSSINUS Introduction: Skin test that is easy and effective usually coordinated with other in vivo test to make diagnosis of allergic immunologic diseases to Dermatophagoides pteronyssinus (Dp). Objective- to evaluate the validity of skin test in the specific diagnosis of allergic rhinitis to Dp, compare sensitivity and specificity of 2 tests to enhance the validity of each test. Patients and Method: 120 patients with allergic rhinitis to Dp were enrolled in the descriptive and prospective study at Haiphong Medical University Hospital.
Results: Prick test: sensibility was 71.67% and specificity 93.3%. Intracutaneous test- sensibility was 95%, specificity 90%. Sensibility of intracutaneous test was greater than that of prick test. No difference can be found in the comparison specificity of both tests.
Conclusion: The combination of intracutaneous test and prick test to make specific diagnosis of allergic rhinitis revealed highly effective.
Key words: allergic rhinitis
1 n A T VA1V n F ^^ ^ ^ ^ dodn dac hieu, ma con ve ket qua dieu tri. De chan doan mot benh di ling Trong mdy chuc nam gSn day, su nhit thik phai qua cac buac; khai thac ti8n sang ph6i hc^j giita cac chuyen khoa trong su di ung, kham lam va lam cac test di ung nghien cuu viem miJii di ling (VMDU) da ,„ vivo va in vitro. Cac xet nghiem d l chin mang lai nhihig thanh c6ng khong nhimg ^oan V M D L T duac ap dung ngay cang c6 rT~7T , , ™ ^ . „ , . he thong va hieu qua hem. Trong do, tnrac
* Dai hpc Y Thdi Binh , ; , . , , . , , ,
** Dai hoc Y Uki Ph6ng '^^^ ^^ ^^^ ^^° ^^^^ trong cua cac test bi bao
*•* Dai hoc Y Duoc TP. H 6 Chi Minh Nhan m 24/5. Duvat in 5/6/2013
Tgp ch[ Tai MOi HQng Vt$t Nam - Volume (58-15). N°3 - May, 2013
g6m: test idy da (prick test), test npi bi do nhilu tdc gia dl xuat va thurc hi$n: Pasteur, VR (1964), T.JuUivant (1981), Zetlertrom (1980). Ngoai ra, con c6 cac lo^i test: test kich thich mui, test kich thich phe qudn cung duoc ap dung rat hi?u qud trong chan doan cac b?nh di ling. Dua tren nhung co so ve lam sang va x^t nghiem de ph^t hi$n di nguyen gay VMDU" la vi?c v6 ciing quan trong. No giup thay thuoc de ra c^c bi?n phap dieu tri phu hop va hi?u qua nhat.
Di nguyen Dermatophagoides pteronyssinus (D.pte) la nguyen nhan chinh gay benh VMDLT. Gan day dj nguyen D.pte da dugc dieu che va chuan hoa tai Viet Nam. Do vay, viec nghien cuu, danh gia gia tri cua cac test bi voi di nguyen D.pte trong chan doan va dieu tri VMDU" la h^t sue can thiet. Chinh vi vay chung toi nghien cuu de tai nay voi muc tieu:
1. Ddnh gid gid tri cua cdc test bi trong chdn dodn dgc hieu benh VMDlf do di nguyen D.pte.
2 So sdnh do nhgy vd do dgc hieu cua 2 test nay de khang dinh them gid tri rieng cua moi test.
2. DOI TU'gnVG VA PHU*ONG PHAP NGHIEN C ^
2.1. Doi tirg^g nghien cihi 2.1.1. Nhom benh nhan
Bao g6m 120 benh nhan VMDLT duoc lira chon trong qua trinh kham lam sang va khai thac tien sii di ung tai Khoa Dj ung Miln dich Benh vien tnrong Dai hoc y Hai phong nam 2012. Tu6i benh nhan tir 18-55.
2.1.2. Nhom chung
Gom 30 benh nhan cung lua tu6i vai
nhom b?nh nhSn, kh6ng mac b^nh VMDU, tim mgch, b^nh ngodi da va d6ng y lam cac test bi, 1 ^ nh6m chijmg trong cac test in vivo nham phAn dnh r5 sir khac bi?t \h k^t qud cua nh6m.
2.2. Phu-cmg ph^p nghien cihi 2.2.1. Chpn bfnh nhan: dugc thirc hi?n bang khai th^c tien tien sii lam sang 2.2.2. Khai thac tien su: vd kham lam sang:
Van de khai thdc lien sir di tbig dugc thtrc hien dua theo:
- Mau 25'' cua WHO ve h6i tiSn sir di trng.
- Mau cau hoi chi tiet c6 tinh diem ciia ISAAC (International study of allergy and asthma childhood 1994).
Ve viec khdm lam sang vd tinh diem, chung toi dua theo mau:
- Thang cho diem danh gia cac trieu chOmg mui ciia Bent Weeke va Niels Mygind, Copenhagen, Dan M^h 1985.
- Mgt so cau hoi chi tiet ve lam sang dugc xem xet va bo sung.
2.2.3. Khdm todn dien
Nhimg b?nh nhan dugc chgn, se dugc kham de loai trir cac benh ve tim m?ch, gan, than a giai doan mit bu, benh ngoai da. Tir do chgn ra dugc 2 nhom benh nhan.
2.2.4. Lam test bi
Tien hanh lam cac test bi tren ca 2 nhom: nhom b$nh va nhom chimg de so sanh.
2.3. Xir ly ket qua: dung cac phucmg phap thfing ke y hoc de xii ly kSt qua.
Tgp chi Tai MQi Hgng Vifet Nam - Volume (58-15). N°3 - May. 2013
3. KET QUA NGHIEN ClTU
3.1. So sanh ket qua cua cac test bi giua nhom benh nhan va nhom chung, chung toi cd ket qua sau:
BDng 1: Dop Dng cDa test IDy da vQi dD nguydn D.pte
Nh6m
N Ty 1$ %
P
B$nh nhan (n=120) dLFong tinh (+) 86 71.67
§m tinh
(-)
34 28,33
Nh6m chi>ng (n=30) dirang tinh (t) 2 6,7
3m tinh (-)
28 28 0,001
Nhan xet-
Ty le phan ung duong tinh a nhom VMDU" dat 71,67% trong khi 6 nhom chiing chi dat 6,7%. Sir khac biet nay co y nghia thdng ke (P<0,001).
BDng 2: MDc DD phQn Qng dDDng tdnh cDa test IDy da
Chi so ^ \ So b^nh nhan T v l e %
1 W 17 14,17
2(+) 42 35
3(+) 34 28,33
4(+) 27 22,5
Tong 120 100
Nhan xet:
Nhom benh nhan co xet nghiem test lay da duong tinh vai di nguyen D.pte 100%. Trong do da so cac truong hgp duong tinh deu d muc 2 (+) tro len.
BDng 3- D5p Dng cDa lest nDi b9 vDI dD nguydn D pie
Nh6m N Ty 1$ %
P
B^nh nhSn (n=120) du-ang tinh (+) 114 95
3m tinh (-)
6 5
Nh6m chu'ng (n=30) duong tinh (+) 3 10,00
3m tinh
(-)
27 90,00 P<0,001
Nhan xet.
Test noi bi voi di nguyen D.pte a nhom benh nhan dat ty le duong tinh kha cao (95%). Nhom chung co ty le duong tinh la 10%. Sir khac biet ve do nhay cua 2 nhom CO y nghia thong ke (P<0,001).
BDng 4: MDc DD dDDng tdnti cDa test nDi be Mljc
N
1 %
1(+) 9mm 18 15
2(+) 9- 12mm
42 35
3(+) 13- 20mm
34 28.33
4(+)
>20mm 26 21,67
Tong 120 100
Nhan xet:
Muc dp duong tinh 2 (+) tro len chiem dai da so cac truong hgp, trong do chu yeu la muc 2 (+) va 3 (+) chiem 6%.
3.2. So sanh d6 nh^y va dQ d|ic hieu cua test lay da va noi bi vol di nguyen D.pte Tir ket qua thu dugc a tren giua 2 loai test, chiing toi co bang so sanh sau day:
BDng 5: So sonh OD nhDy vD DD DDc hlDu cDa lest IDy da vD nDi b9:
So sanh Ket qua test
Lay da NoibI P
€)0 nh^y BN
120 120
(+) 86 114
(-)
34 6
%
71,67 95
<0,001
OO d$c hieu n
30 30
(*>
2 3
(-)
28 27
%
93,3 90
>0.05
Tap chi Tai MQi Hgng Vi$t Nam - Volume (58-15). N°3 - May, 2013
Nhan xet.
Dg nhay cua test ngi bi cao hon ciia test lay da mgt cdch c6 y nghTa thong ke (p<0,001). Do dac hi$u ciia 2 test n^y diu kha cao, sir khdc nhau ve dg d^c hi^u ciia 2 test nay chua c6 y nghTa thong ke (p>0,05).
4. BAN LUAN
4.1. V^i net ve d^c tinh dj nguyen D.pte NDm 1920 Kern va Cooke phot hiDn bDi nha la mOt trong nhDng nguydn nhon goy bDnh VMDD. NDm 1932 S.V.Lecuven ncm vai tru cDa mDt bOi nha trong bDi nha.
NDm 1964, R.Woohorst va E.Spieksma D6 chDng minh thanh phDn khong nguycm quan trDng nhDt cDa bDi nha la coc loDi mDt bDi nha, DDc biDt la loDi D.pte va cho rDng D.pte mang tDi 70% t ^ h khong nguycm cDa bDi nha 11]. Ngoai mDt bDi nha, trong bDi nha cun cu coc tDp chDt khoc bao gDm;
xoc cun trung, vi khuDn, nDm mDc, vDy da ngDDi, lung syc vDt...
Mat bui nha co ten la Acarien (tilng Phap) hay House dust mite (tieng Anh) thupc lop nhen (Arachnide), nganh chan khop (Arthropode). Mat co binh trung hoi dai, than co long, co 8 chan g6m nhi^u d6t.
Thai gian song trung binh cua mat bui nha la 3 thang. Dieu kien t6i uu dk chiing phat triln la nhiet do 25"C, do dm la 80%. Khi moi truong khong thuan Igi chiing c6 th6 chuyen sang giai doan tiem tang d^ s6ng [1]. Den nay, ngucri ta da phat hi?n dugc hon 130 loai mat bui nha thugc 27 hp trong cac mau bui nha 6. Tuy nhien trong do chi CO 2 loai ph6 bidn nhk la D.pleronyssinus va D.farinae va chiing phan b6 vd mat dia iy nhu sau:
Dermatophagoides pteronyssinus:
Chau Au (nhieu nhit 6 Anh), ChSu A - Dermatophagoides farinae: B4C H%
Nh^t,Y,Th6NhTKy.
- D.pteronyssinus va D.farinae: Lye dia phia Dong.
D ViDt Nam, mDt bDi r\hk chD yDu Ik loDi D.pte [I, 2, 3, 5]. DD nguydn mDt bDi nha cu cD trong mDt bOi nhd sDng va chDt nhDt la trong coc vicm phon cDa ch5'ng. Cfic vidn phon cii kdch thDDc khoDng 20|i m DDDng k6nh, tDDng DDDng vDi k6nh cQ cDa mDt hDt phDn hoa. Coc phDn tD dD nguy&n ID IDng trong khung khd sD kdch thdch sinh bDnh D cD thD mDn cDm.
4.2. Ve ket q u a cua test lay da Trong 120 benh nhan VMDU" di/ac lam test lay da voi di nguyen D.pte, phan ling duong tinh xay ra 6 86 nguoi (71,67%). Ty le nay tuong duong voi ket qua cua nhieu tac gia trong va ngoai nuac khi nghien ciiu VMDLT do cac nguyen nhan khac nhau [2, 6]. Test lay da hien dang ta mot trong nhung bien phap d^c hieu dugc sir dung rgng rai trong chan doan cac benh di ung. Theo nhan djnh ciia nhilu t ^ gia, test nay co dg tin c^y Ion hon so voi test npi bi, do it gap truong hgp duong tinh gia.
O trong nuoc, cac nghien cim cua cac tac gia Nguyen Nang An, Phan Quang Doan, Vii Minh Thyc, Trinh Manh Hiing... cho thay ty le duong tinh cua test lay da nam trong khoang tir 65-71%. Nghien cihi cua Eriksson N.E, Holmen A. keo dai 11 nam (1981-1992) cho 7099 benh nhan lam test l4y da voi cdc di nguyen khac nhau cho thay muc dg duong tinh trong khoang 65- 70%. Nghien cuu ciia Codina-R va cgng su [7] cho 365 benh nhdn VMDU voi bgt ddu
Tgp ch[ Tai MQi Hgng Viet Nam -Volume (58-15). N ° 3 - May, 2013
nay thay ty le duong tinh ciia test lay da chi la 59,4%. Del-Rio-navaro-B.E va cpng sy lai CO ket qua test lay da duong tinh 92,5%
[8]. Tasman A.J. va Wizel A. nghien cuu a b?nh nhan VMDLT vol bgt mi thay dap ling cua test lay da voi cac di nguyen khac nhau thi ty le duong tinh chenh lenh kha Ion [9].
Ket qua ciia cac tac gia khac nhau khong nhieu, co the co nhiing sir sai lech ket qua do ki thuat lam test, do nong do di nguyen thii... Dg nhay cua test lay da tuy khong cao nhung it duong tinh gia, vi mire do lam ton thuong da it hon, khoi lugng dung dich dua vao da ciing it hon nen it kich thich da gay duong tinh gia hon so voi test npi bi.
Ve miic dp duong tinh cua test lay da:
o Bang 2 chiing toi thay dai da so benh nhan co dap ling tir miic 2 (+) tro len 85,83%). Trinh Manh Hung [3] lam test Idy da voi di nguyen bui nha a 171 benh nhan thdy miic duong tinh 53%, nhung voi di nguyen D.pte cua Phap nen ket qua co su khac nhau, do chiing toi sir dung di nguyen dugc chiSt xudt va chuan hoa tai Viet Nam.
4.3. Test noi bi
K^t qua test npi bi ciia chiing toi tren 120 benh nhan VMDLT cho ty le duong tinh 95%, am tinh 5%. Dp nheiy ciia test nay rat cao. Nhom chiing co ty le duong tinh la 10%. K8t qua nay phii hgp voi nghien ciiu ciia nhieu tac gia khac [4, 6, 8]. Mac dii do nhEiy cao song test ngi bi thuong c6 Ian mpt ty le duong tinh gia va co nhung phan ling khong dac hieu (do kim tiem gay ton thuong trong da nhiSu hon 6 test lay da, lugng thuoc thu dua vao Ion hon toi 0,2- 0,3ml).
Ngoai ra, test ngi bi tuy co do nhay cao
nhung ciing de tai bien hon so v<5fi test lay da. Da co mgt so tac gia neu nhihig truong hgp shock phdn ve khi lam test ngi bi. So sdnh hai test lay da va npi bi (bdng 5) chung t6i thdy dg nhay ciia test lay da kem hon so v6i ngi bi (p<0,001). Dp dac hieu khdc nhau khong co y nghTa (p>0,05). Cac tdc gia Vu Minh Thyc, Vu Cao Thien, D.R.
Navaro, Dreborgs khi so sdnh hai loai test nay deu cho n h ^ xet tuong ty [5,6, 8].
Test lay da dii dp nhay khong cao bang test ngi bi song vi ky thuat don gian va dp an toan cao, rat nhieu tdc gia da de nghi truoc tien chi nen lam test lay da, neu test lay da am tinh hoac nghi ngo thi moi tien hanh test ngi bi [10]. Tuy nhien, trong qud tinh nghien cuu ve VMDl/ do di nguyen D.pte chiing toi lam song song 2 test nham trdnh bo sot benh nhan. Dong thai viec so sanh cdc test in vivo trong bSnh VMDLT ciing cho thay dugc gid tri rieng cua moi test.
5. KET LU^N
Dua tren k6t qua test lay da va test ngi bi voi di nguyen D.pte den khdm tai Benh vien, chung toi co mgt so ket luan sau day:
- Test Idy da: Dp nhay 71,67% voi miic do duong tinh chu yeu tir 2 (+) tro len chi6m 85,83%. Dp dac hieu 93,3%.
- Test ngi bi: Do nhay 95% 6 miic dp duong tinh chu yeu la 2 (+ ) va 3 (+) chiem 63,33%. Dp dac hieu 90%.
So sdnh 2 test: test ngi bi voi di nguyen D.pte cho dp nhay cao hon test lay da (p<0,001). Dp dac hieu cua 2 test nay khong CO su khac biet (p>0,05).
Tgp chl Tai Mui Hpng Vi^t Nam - Volume (58-15). N°3- May, 2013
TAI LI$U THAM KHAO
1. Pham Quang Chinh (2004;' "Nghien cuu tdch chiet vd mgt so dgc tinh hod sinh mien dich cua dj nguyen mgt bui nha nuoi cay Dermatophagoides pteronyssinus va buac dim ung dung y hoc". Luan dn tien sT y hpc, vi?n cong nghp sinh hpc.
2. Doan Thj Thanh Ha (2002), "Nghien cuu chdn dodn va diiu tri mien dich viim mm di ung do di nguyen biti nha", Luan dn Tien sy y hgc, Hgc vien quan y 108. Ha Ngi.
3. Trinh Manh Hiing (2002). "Kit qud buac ddu trong chdn dodn vd diiu trj dgc hieu di thig duong ho hap do bui nha". Luan an Tien sy Y hpc, Dai hpc Y Ha Npi.
4. Huynh Mai Phuong (1994). "Gopphdn nghien cuu dieu tri benh viim mui dj ung", Luan van tot nghiep Bdc sy chuyen khoa II, DHY Ha Npi.
5. Vii Minh Thyc, Vii Cong Thuong va CS (2000), Nghiin ciru 1 s6 dgc tinh ciia di nguyin bui nha tren dpng vat thuc nghiem vd benh nhdn hen phi quan atopy.
Vu Cao Thi?n (1999), "Nghien cm 1dm sang vd mgt so test trong chdn dodn viem mUi di ung", Luan an Thac sy y hpc, Trudmg dai hgc Y Ha Npi.
Codina-R; Ardusso-1.; Lockey-R.F.;
Crisci-C; Bertoya-N (2000).
"Sensitization to soybean hull allergems in subjects exposed to different levels of soybean dust inhalation in Argentina", 1. Allergy-Clin-Immunol. Mar, 105 (3), pp. 570-576.
Del-Rio-Navaro B.E, Mercado-Ortiz-V;
Lerma-Ortiz-L.; et col (1996).
"Comparison of 2 skin test methods for the diagnosis of allergic diseases", Rev- AUerg, Mex., Jun-Aug. 43 (4), pp 100- 103.
Tasman-A.J.; Witzel-A.; Simol-B.;
Sohmen-R (1999), "The skin prick test and nasal provocation test with individually prepared flow extracts in patients with baker's rhinitis and asthma", UNO. Aug, 47 (8), pp. 718-722.
, Robert-A.B.; Marilyn-H. et col,
"Distribution of IgE community population sample correlation mth age, sex. and allergan skin test reactivity", J- Allerg-Clin-Imm. 68, No. 2, pp. 106-1U.