Y HOC VI^T NAM THANG 10 - SO 2/2013
VIEM PHOI KHONG DIEN HINH DONG NHIEM:
TAN SUAT VA TIEN LlTaNG
Pham Thu Hien*, Dao Minh Tuan*, Nguyen Phong Lan**, Tr^n Quang Binh**, Phan Le Thanh Huffng**
T O M TAT
Muc tieu xac dinh ty le viem phoi khdng dien hinh do A/, pneumoniae, C. pneumoniae, va L pneumophila d tre em va sff lien quan giffa dong nhiem vdi tinh trang nang ciia benh, Ket qua sang Ipc 722 benh nhi tff 1 den 15 tuoi bj viem phoi bang ky thuat Multiplex PCR va ELISA da phat hien 215 trffdng hdp (29,8%) mac viem phoi khong dien hinh, trong do cd 26,3% M.
pneumoniae, 3,7% C. pneumoniae va 1,8% L pneumophyla. Tinh trang dong nhiem chiem ty le 33%, trong dd dong nhiem vl khuan gay viem phoi dien hinh chiem ty le cao nhat 17,7%, dong nhiem vi rut la 8,8%, dong nhiem giffa cac vi khuan gay viem phdl khong dien hinh la 7,0%.
Nguy cd viem phoi nang d tre mac viem phdl khdng dien hinh cd dong nhiem cao gap 4,42 lan so vdi tre mac viem phoi khong dien hinh ddn thuan (p<0,001). Nguy cd viem phdi nang d tre mac viem phoi khdng dien hinh dong nhiem vdi vi khuan dac hieu cao gap 4,55 lan ( p< 0,0001), dong nhiem vdi vi riit cao gap 4,01 lan so vdi viem phdi khdng dien hinh ddn thuan ( p<0.05).
Nghien cffu cho thay viem phoi khong dien hinh cd ty le dong n h i l m cao va tinh trang dong nhiem lam tang mffc dp nang ciia benh trong quan the tre viem phoi nhap vien.
Tu'kh6a:y\Qn\ phoi khdng dien hinh. Mycoplasma, Chlamydia, Legionella, dong nhiem, tre em.
* Benh vien Nhi Trung uo'ng
** Vien Ve smh Dich le Trung irirng Pltan bien khoa hgc: TS. Tr3ii Minh Dlln
SUMMARY
ATYPICAL PNEUMONIA OF COINFECTION: PREVALENCE
AND PROGNOSIS
To assess factors related to the severity of atypical pneumonia caused by M. pneumoniae, C.
pneumoniae and L pneumophila in children, Nasopharyngeal swabs or aspirates and paired sera of total 722 patients (ranging 1 t o l S years of age) treated in Respiratory Department of National Hospital of Pediatrics in Vietnam during 7/2010- 3/2012, were collected. Multiplex PCR and enzyme-linked immunosorbent assay were used to detect M. pneumoniae, C. pneumoniae and Lpneumophila in those specimens. Status of co-infection with virus and/ or typical respiratory bacteria were evaluated and graded. Results:
percentage of community -acquired pneumonia due to M. pneumoniae, C. pneumoniae, and L pneumophila in hospitalized children have age of 1-15 years was 29.8%. I^ycoplasma pneumoniae positive in 190 (26.3%) cases, C. pneumoniaein 27 cases (3.7 % ) , L pneumophila in 13 cases (1.8%). In general, co-infectiori in 76 cases (33%). Among them, co-infection of atypical etiology in 15 cases ( 7 % ) ; co-infection with typical bacteria in 38 cases (17,7 % ) ; co-infectlon with respiratory viruses in 19 cases (8.8%).
Patients positive for atypical bacteria co-infected with virus and/ or typical bacteria were significantly more likely to have severe pneumoniae than patients infected with only atypical bacteria (44.33% vs 15.25%; 0 R = 4.42;
p<0.001), which were (27.8% vs 9.3% ; OR = 4.55; p<0.0001) with typical bacteria, and
HOI N G H I T O A N QU6C \ t CAC B E N H NHI^M T R U N G V A HIV/AIDS 6 T R £ E M NAM 2013
(13.4% vs 5 . 1 % ; 0 R = 4 . 0 1 ; p<0.005) with virus.
Conclusion: atypical pneumonia have high rates of co-infection. There is an asignlficant relationship between atypical bacterial- typical bacteria and viral co-lnfectlon and severity of disease in this population.
Key words: Atypical pneumonia, Mycoplasma, Chlamydia, Legidneiia, Co- infection. Mixed infection, children.
I.OATVANOI
M. pneumoniae, C. pneumoniae va L pneumophila dugc coi la nguyen nhan quan trpng gay viem phoi tai cac nude phat trien nhung vai trd ciia nd d cac nuac dang phat tri^n dac biet la Viet Nam chua dugc biet nhieu [5].
Viem phoi khdng dien hinh do M, pneumoniae, C. pneumoniae, L. pneumophila cd the benh canh lam sang nhe hoac tu gidi han [3], [5], [7]. Nhung cd trucmg hgp benh viem phdi khdng dien hinh dien bien nang [1], [6]. Mot trong cac nguyen nhan dan den tinh trang nang tham chi tu vong cua benh cd lien quan den tinh trang dong nhiem vdi vi khuan hoac virus khac [4].
Nham xac dinh ty le viem phdi khdng dien hinh do M. pneumoniae. C. pneumoniae.
va L pneumophila d tre em va su lien quan giua ddng nhiem vdi tinh trang nang ciia benh d tre em. chung tdi tien hanh nghien cffu de tai nhSm muc tieu: "''Xac dinh tan suat mdc viem phoi khong dien hinh va yeu to lien quan den tien Iwdng nang ciia benh d tre em".
II. OOI JirgwG VA PHITOTNIG PHAP NGHIIN cCru 2.L Doi tiTffng nghien cihi:
Benh nhan viem phoi khong dien hinh tudi tu 1-15 tudi vao dieu tri tai khoa Hd hap.
Benh vien Nhi Trung uomg tff thang 7.2010 ddn 3.2012.
2.2. Tieu chuSn chon doi tirgmg nghien ciru:
+ Benh nhan dugc chSn doan viem phdi vdi cac trieu chffng theo WHO [8]
+ Tieu chuan phan loai viem phoi nang cua Td chuc Y t^ The gidi (WHO) va Hiep hgi Truyen nhiem Nhi khoa My [8], [10] , + Tieu chudn nhiem M.pneumoniae, C.pneumoniae va L pneumophila:
' Multiplex PCR M.pneumoniae va/hoac C '.pneumoniae va/hoac L pneumophila trong dich rffa phe quan. tam bong hong va ty hiu duong tinh
- Hoac IgM M. pneumoniae va/ hoac C.
pneumoniae va/hoac L pneumophila duong tinh trong mau huyet thanh kep.
2.3. Tieu chuan Ioai trtr khoi nghien cihi: viem phoi mac phai d benh vien (vao benh vien dieu tri benh khac. sau 48 gid mac viem phdi).
2.4. Phu-ffng phap nghien ciru: nghien cffu md ta ngang ket hgp nghien cffu benh chffng khdng ghep cap.
Benh nhan cd du tieu chuan nghien cffu dugc kham Iam sang, hdi benh ty my va kiem tra: cong thuc mau. CRP, cac globulin mien dich trong huyet thanh. chup X-quang tim phoi. las benh pham dich ty hau va 2 mau mau trong vong 48 gid dau nhap vien va sau 3 tu^n ddn 1 thang. Phan ffng Multiplex PCR, ELISA trong mau huyet thanh kep dugc sff dung de sang Igc M. pneumonia, C.
pneumoniae. L pneumophila tu dich ty hau (Khoa Vi khuan Vien Ve sinh Dich te Trung uong). Cay ty h4u tim tac nhan vi khuan dien hinh va xet nghiem PCR d^ chSn doan tac nhan virus dong nhilm (Khoa Xet nghiem Vi sinh Benh vien Nhi Trung uong).
Y HOC VIET NAM T H A N G 10 - SO 2/2013
Cac bien nghien cffu gom cac dac diem;
d^c diem dich te hgc, cac dau hieu lam sang, xet nghiem can lam sang, X quang nguc thang, kSt qua cay dich ty hau, ket quA xet nghiem Realtime- PCR chSn doan virus dudng hd hap va ket qua xet nghiem
M.pneumoniae, C.pneumoniae, L.
pneumophila bSng ky sinh hpc phan tff Multiplex PCR, ELISA va kit qua X quang.
Cac s6 lieu thu th^p dugc su ly va phan tich theo chuong trinh STATA 10.0 va SPSS 13.0
III. KET QUA
Bang 1: Tan suat mac benh viem phdi khdng diin hinh Dac diem
Viem phoi
Khong dien hinh Dien hinh Viem phoi Ichong dien hinh
VP khong dien hinh dan thuan VP Ichong dien hinh + dien hinh VP Ithong dien hinh + virus VK khong dien hinh + dien hinh + virus Viem phoi khdng dien hinh
Nhiem 1 loai vi khuan Nhiem tir 2 loai tra len
So lu-Qng 722 215 507 215 154 38 19 4 215 200 15
Tyle(%) 100 29,8 70,2 100 71,6 17,7 8,8 1,9 100 93 7 Ty le mac viem phoi khong dien hinh trong nhom nghien cuu la 29,8%: ly le mac M.
pneumoniae la 26,3%, C.pneumoniae 3.7%: Lpneumophyla I.H%,. Tinh trang dong nhiem chiem ty le khd cao 33%. trong do dong nhiem vi khuan khac chiem ty le cao nhat 17,7%, dong nhiem vi riil la 8,8%, dong nhiem giua cac vi khuan gay viem phoi khong dien hinh v&i nhau la 7,0%,.
Bans 2; Lien quan giua tinh trang dong nhiem vai mire do nang cua benh Viem phoi
IGiong dong nhiem Dong nhiem
Viem phoi nhe n(%) 100(84,7)
18(15,3)
Viem phoi nang n(%) 54 (55,7) 43 (44,3)
OR (95%CI) 1 4,42 (2,33-8,41)
P
< 0,001
-
Nguy ca viem phoi ngng ff tre mac viem phoi lihong dien hinh dong nhiem cao gap 4,42 lan so v&i tre mac viem phoi khong dien hinh dan thuan (P < 0,001).
Bang 3: Lien quan Dong nhiem Khong d6ng nhiSm Vai vi khuan khac Vai Virut
Vai virut + vi khuan khac
:ua can'nguyen gay dong nhiem vai muc do nang cua benh Viem phoi nhe
n (%) 100(84,7)
11(9,3) 6(5,1) 1 (0,8)
Viem phoi nang n (%) 54 (55,7) 27 (27,8) 13(13,4) 3(3,1)
OR (95%CI) 1 4,54 (1,98-10,9) 4,01 (1,32-13,55) 5,56 (0,53-294,5)
P
<0,0001
-
0,005 0,101
HOI NGH! TOAN QU(3C ve CAC B$NH NHI^M TRtJNG VA HIV/AIDS 6 TR^ EM NAM 2013
Nguy Cff mac viem phoi nang d tre mac viem phoi khong dien hinh dong nhiem vai vi khuan ddc hieu cao gap 4.54 lan (p < 0.000J), ddng nhiem v&i vi riil cao gdp 4.01 lan so v&i tre mdc viem phoi khong dien hinh dan Ihudn (p < 0.05).
IV. BAN LUAN
4.1. Tan suat mac viem phoi khdng dien hinh
Trong sd 722 bfnh nhan nghien cffu, ly I?
mic viem phdi khong dien hinh trong sd
\'iem phdi mac phdi cgng dong vao vipn I^
29,8%. Trong do ty I? mSc M. pneumoniae la 26,3%, C. pneumoniae 3,7%; L pneumophyla 1,8% ( bang 2). Ket qua nghien cffu nay phu hgp vdi k^t qua nghien cffu cua Phan Le Thanh Hirang ve ty le nhiem M pneumoniae [5], tuy nhien, ket qua nay cao hem so vdi nghien cffu cua Yun va cs cd the do khac nhau ve lua tudi cua doi tugng nghien cuu [II].
Theo F. Gutierrez, dong nhiem vdi vi khuan khac hoac vi rut khdng phai hilm gap trong nhdm viem phdi khdng di^n hinh [4].
Trong sd 215 ca viem phoi khong dien hinh, ty Ie ddng nhiem chiem 33%. Trong dd. ddng nhiem vdi vi khuan gay viem phoi didn hinh chi^m ty le cao nhdt 17,7% ( Bang 2). Ty Ie dong nhiem nay thap hem so vdi tac gia F.
Gutierrez 28.6% [4], Tinh trang ddng nhiem giua cac vi khuan gay viem phoi khdng di^n hinh vdi nhau la 7,0% ty Ie nay cao hon so vdi ket qua nghien cffu cffa Nuanchan Prapphal (0,4%) [9], Su khac biet nay cd th6 do doi tugng benh nhan nghien cffu cua Nuanchan Prapphal gom ca benh nhan npi tru va ngoai tru. Trong khi cua chung ldi 100%
la benh nhan dieu tri ndi tru trong benh vien.
Theo Curi Kim va cs nghien ci'm tren quan the trai ty nan, trong 113 b?nh nhan viem phdi khdng dien hinh do M.
pneumoniae, C pneumoniae va L pneumophyla. Ket qua nghien cffu cho thiy ty Ie ddng nhilm vdi it nhit mot virut la 54%, dong nhiem vdi nhi^u vi riit la 32,8%o [2], Tinh trang ddng nhilm virut cao hem nghien cuu cua chung tdi, Iy giai la do mdi 6
Irudng trai ty nan la quan the kin, ddng due.
Han nua ddi tugng nghien cffu cua tac gia la benh nhan tu 2 thang den 60 tudi. chinh vi vay tan xuat ddng nhiem cao han trong nghien cffu cua chung tdi.
4.2. Lien quan ctia tinh trang dong nhiem vdi muc dg n|ing ciia viem phoi
Theo F. Gutierrez, ddng nhiem cd lien quan den mffc do nang cua benh d nhieu cac bieu hien nhu: tan xuat phai nhap vien tang vdi linh trang tran djch mang phdl, thieu 6 xy va tang ly le tu vong. Khi so sanh cac bieu hien: tran dich mang phoi, mu mang phdi, xep phoi. thdng khi nhan tao, sdc nhiem triing, dng da tim thay ddng nhiem la yeu to nguy CO lam gia tang tinh trang nang cua viem phoi [4].
Kel qua nghien CIJU cua chung tdi hoan toan phii hgp vdi nhan xet cua F. Gutierrez va cs (Bang 3). Nguy co viem phdi nang dtre mac viem phdi khdng dien hinh cd ddng nhiem cao gap 4.42 lan so vdi tre mac viem phoi khong dien hinh dan thu4n (p<0,001).
Curi Kim va cs cung quan sat thay. tinh trang ddng nhiem giffa vi khuan gay viem phdi khdng dien hinh va \ i rut cd lien quan den muc do nang cua benh [2].
Chung tdi di sau tim hieu can nguyen ddng nhiem lien quan den mffc dp nang cua viem phoi khdng dien hinh (Bang 4). E)i6u thu \\ dd la. nguy ca viem phoi nang d tre mac viem phdi khdng dien hinh ddng nhiem vdi vi khuan gay viem phdi dien hinh cao gap 4,54 lan so vdi tre mac viem phdi khdng di^n hinh dem thudn (p<0,0001), ddng nhilm vdi vi rut cao gap 4.01 l^n so vdi tre mic viem phdi khdng didn hinh dan thu^n (p<0.05). K6t qua nghien c\m cua chung tdi hoan toan phu hgp vdi nhan dinh cua Curi Kim [2].
Y H p c VI^T NAM THANG 10 - SO 2/2013
Nhu vay, ca vi rfft va vi khuin di6n hinh deu la thff pham gay len tinh trang nang
cffa viem phdi khdng di^n hinh. DSy la co sd d8 bac sy Iam sang xem xet lua chon, phdi hgp khang sinh bao phu ca hai tac nhan vi .khuin gay viem phdi diin hinh va vi khuAn gay viem phdi khdng diin hinh trong nhung trudng hgp viem phoi nang, de dga tinli mgjig hoac viem phdi keo dai cd cac bien chutig nang.
V. KET LUAN
Nghien cffu 722 b^nh nhi tff 1-15 tudi bi viem phdi vao Benh vien Nhi Trung ucmg tff 1/7/2010 din 31/3/2012 cho thdy:
Ty le viem phdi khong dien hinh d tre em do M.pneumoniae, C. pneumoniae vd Lpneumophila phat hien bIng phuang phap iVIuItiplex PCR va ELISA la 29,8%, trong dd viem phdi do M pneumoniae chiem ty le cao nhat la 26,3%.. Viem phdi do C.pneumoniae va L pneumophyla it gap.
Nghien cffu cho thay viem phdi khdng dien hinh cd ty Ie dong nhiem cao va tinh trang dong nhiem lam tang mffc do nang cua benh trong quan the tre viem phoi nhap vien.
TAI LIEU T H A M KHAO
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3. Erik Normann (2003), '^Chlamydia pneumoniae in children - epidemiology and
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Comniiiiiity-acquired pneumonia of mixed etiology: prevalence, clinical characteristics, and outcome", Eur J Clin Microbiol Infect /)K.24(6):377-83.
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Infec.Dis, 60:370-373.
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Clinical Practice Guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America", Clin Infeci Dis 53(7):e25-76.
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