Chu bien: GS TS HO HOU LtfONG NHIEM KHUAN HE THAN KINH NHA XUAT BAN Y HOC ■ CHU BlfiN: GS TS HO HUU LlTONG NHIEM KHUAN HE THAN KINH NHA XUAT BAN Y HOC HA NOI - 2005 cA c t Ac g ia GS TS Ho HCfu Luang GS TS Le Dire Hinh PGS.TS Nguy§n Hoang Tuan PGS TS Vu Hung Lien GS.TS N g u yin Van Mui TS Phan Viet Nga L0 NOI DAU Nhiem khuan than kinh dang la mot van de thdi sU, cap bach cua Y hoc va cua cac chuyen khoa Than kinh,Truyen nhiem, Hoi siic cap ciiu, Phuc hoi chtic nang , dang thu hut sii quan tarn nghien ciiu cua cac thay thuoc nhieu linh vile dieu tri, du phong Benh truyen nhiem than kinh, neu khong diiOc dieu tri sOm, benh nhan co the bi tii vong hoac di chiing nang ne, trO tan phe Muon dieu tri sdm cac benh nhiem khuan th in kinh thi phai phat hien benh s6m Muon phat hien benh s6m can phai co kien thilc va kinh nghiem ve cac benh nhiem khuan than kinh Cuon sach gi6i thieu nhiing kien th\ic va kinh nghiem cua cac tac gia ve cac benh nhiem khu&n than kinh thUdng gap Chung toi hy vong cuon sach co the gop phan vao viec giang day, nghien ciiu va dieu tri benh nhiem khuan than kinh de phuc vu siic khoe cho nhan dan Ha noi - - 2005 C ac ta c gia MUC LUC Ldi noi dau Viem nao virut Viem raang nao 35 Ap xe noi so 64 Sot ret ac ti'nh the nao 84 Viem cap 103 Benh bai liet 119 Giang mai than kinh 131 Nhutng thUdng ton than kinh gap nhiem HIV/AIDS 156 Viem da day than kinh 169 Viem da re - day than kinh cap ti'nh nguyen phat 185 Tai lieu tham khao 199 VIEM NAO VIRUT I DAI ClfONG VE VIEM NAO VIRUT Viem nao virut (VNVR) d to chiic nhu mo nao, than kinh gay Dac diem la hoi chufng nao cap, gay khac la mot qua trinh benh ly viem xay nhieu loai virut co ltfc vdi te bao lam sang da dang, nhiing chu yeu roi loan y thiic vdi nhieu miic Cac loai virut gay benh viem nao (theo Tyler K.L.,1998) 1.1 Cac loai virut thutfng gap Cac virut Arbo Cac virut diidng ruot (Entero virutes) - Virut Herpes simplex (HSV: Herpes simplex virut) - Virut quai bi 1.2 Cac loai virut it gap CMV (Cytomegalo virut) EBV (Epstein barr virut) HIV(Human immuno-deficiency virut) Virut sdi Virut thuy dau (VZV: Varicella zoster virut) 1.3 Cac loai virut hiem gap - Virut Adeno - Virut cum, a cum - Virut dai - Virut Rubella CTFV Reoviridae) (Colorado tick fever virut: virut thuoc ho LCMV (Lymphocytic chorio - meningitis virut: virut ho Arena - viridae) 1.4 Sap xep cac loai gay viem nao theo mua - Mua he den dau mua thu: virut Arbo, virut diidng ruot - Mua thu - dong: LCMV - Mua dong - xuan: virut quai bi - Khong theo mua: HIV, HSV NhCrng dac diem chung ve lam sang, can lam sang cua VNVR 2.1 Hoi chung nhiSm khuan - nhiSm doc ThUOng co nhieu bieu hien khac theo can nguyen Tuy nhien da so' co sot, mot so trUOng hdp co bach cau mau ngoai vi tang va ty le bach da nhan tang (hay gap VNVR virut Arbo) 2.2 Nhutig roi loan ve tam - than kinh Thifdng rat da dang vdi nhfing roi loan chmh sau: Thay doi ve y thtic: theo mute benh, co the gap Id md, ngu lim, ban hon me va hon me Roi loan tam than: me sang, mat dinh hifdng, ao giac, loan than, roi loan cii chi va nhan cach Co cdn co giat kieu dong kinh: thifdng gap d 50% so benh nhan nang, co the co giat cuc bo hoac toan than Thifdng ton than kinh khu tru: mat van dong ngon ngut, that dieu, bai hoac liet nhe, tang phan xa gan xUOng, xuat hien phan xa benh ly bo thap (+), rung giat cd, liet cac day than kinh van nhan, day VII Cac trieu chilng thifdng ton true dudi doi - tuyen yen (roi loan than kinh thvfc vat) nhif: roi loan dieu hoa than nhiet, tang tiet mo hoi, dai thao nhat 2.3 Xet nghiem djch nao 2.3.1 Te bao dich nao tuy: Hau het (85% trUdng hdp) co tang nhe te bao (tren den vai chuc te bao/mm3), chu yeu la te bao lympho Tuy nhien, d lan choc ong song that lufng dau tien (giai doan s6m) hoac d benh nhan suy giam mien dich khong thay tang te bao dich nao Khoang 10% so' benh nhan co so liidng te bao lympho dich nao ldn hdn 500/mm3, so' it co the >1000/mm3 (hay gap viem nao ngvfa mien Dong, viem nao California, viem nao virut quai bi va LCMV ) - - Mot so" VNVR khong tang te bao lympho, thifdng gap EBV, CMV va HSV - Mot so viem nao co tang bach cau trung ti'nh DNT (hay gap viem nao ngiia mien Dong, viem nao virut ECHO va mot so' virut dtfdng ruot khac) Tuy nhien, nhufng triidng hdp xet nghiem dich nao co bach cau trung ti'nh tang cham (sau >48 gid), can phan biet vdi cac can nguyen vi khu&n, hoac cac can nguyen khac Mot so" triidng hdp (khoang 20% trUdng hdp VNVR HSV, CTFV va viem nao California) DNT co the co hong cau >500 te bao/mm3 2.3.2 X et nghiem sinh hoa dich nao tuty: - Protein: thiidng tang nhe Glucose: thUdng la binh thUdng, doi tang nhe 2.4 Di chung VNVR Neu benh nhan VNVR khong tvf vong co the de lai nhieu loai di cluing khac nhau, chu yeu la cac di chiing ve tarn than kinh Khoang 80% nang ve than kinh viem nao ngila mien Dong co di chiing - VNVR it gay di chiing: EBV, California, viem nao ngUa Venezuela - Ty le va nnic di chiing phu thuoc vao tuoi, tinh trang y thiic cua benh nhan vao vien: benh nhan hon me sau, Glasgow < diem thi de til vong hoac de lai nhilng di chiing nang; benh nhan ^ 30 tuoi va it ro'i loan y thilc thildng khoi hoac chi co di chiing nhe Nhurng xet nghiem chan doan can nguyen 3.1 Xet nghiem tim can nguyen dich nao - Phan lap virut dich nao thildng khong ket qua Ky thuat PCR (khuyech dai acid nhan virut) dich nao tuy: hien dang dUdc sU dung rong rai va difdc xem nhii 10 mot ky thuat cO ban chan doan VNVR d cac nifdc tien tien, dac biet VNVR CMV, EBV, virut thuy dau va virut difdng ruot Tim khang nguyen dich nao tuy: nhiing trifdng hop nghi ngd VNVR HSV co the tim khang nguyen glycoprotein cua HSV dich nao Nhifng xet nghiem can phai lam sdm tuan dau cua benh Phat hien khang the dac hieu chong virut dich nao va huyet Cac xet nghiem can dUOc lam lan, cach tuan de xac dinh bien dong cua khang the Khi phat hien thay khang the dac hieu chong virut typ IgM dich nao va huyet cung co gia tri chan doan Chi so" khang the dac hieu chong virut dich nao so vcfi huyet > 1,5 lan cung co gia tri chan doan з.2 Ghi dien nao (EEG), chup cat I dp vi tinh (CT Scan) va chup cong huong tCf(MRI) Cac ky thuat chi co gia tri dinh hudng cac thUOng ton nao la lan toa hay cuc bo Vi vay, chi co the giup cho hUOng chan doan nghi ngd la VNVR, chii khong co gia tri chan doan xac dinh Tuy nhien, cac ky thuat co the rat co gia tri chan doan phan biet vcfi cac benh ly khac cua nao (nhu и, ap xe, xuat huyet nao ) C3 benh nhan VNVR, cac ky thuat EEG, CT Scan, MRI co the thay cac hinh anh sau: EEG: giai doan cap co the co nhiing song gai nhon xuat hien co chu ky tren nen song gai cham, bien thap Cac song thifdng gap d thuy thai dufdng Giai doan ban cap thay xuat hien song delta va theta CT Scan: co the thay nhiing vung giam ty khong dong deu, ranh gidi khong ro, hap thu cham, kich thifdc ldn lan 11 Gia thuyet benh ly cua mang hong cau (Miller va CS, 1971; Lee va CS, 1992) Cac tac gia tren cho rin g nhiing hong cau nhiem P falciparum trd nen ciing mang hong cau day va co nhiing biidu (Knobs) Do vay hong cau khong the luon lach diidc qua cac mao mach va chung von lai gay tac Hau qua cua sii tac mao mach la gay thieu oxy va cuoi cung la gay thoai hoa va hoai tii te bao Gia thuyet benh ly cua mach (Maegraith va Fletcher, 1972) Sii tac mach bdi cac hong cau nhiem KSTSR diidc cac tac gia giai thich la tang tinh tham mach gay thoat huyet tiidng ngoai khoang gian bao lam cho co mau va tac lai Theo cac tac gia thi d benh nhan sot ret co hien tiidng viem mach cac doc to" va cac chat trung gian hoa hoc cua KSTSR tao Nhu vay hien tiidng phu to chiic (phu nao SRAT the nao) la hien tiidng benh ly hang dau can quan tam Cung vi le da co mot thdi gian dai viec dieu tri cd che benh sinh SRAT the nao nhieu tac gia da chu chUdng chong phu ne nao tich ciic Ho cho r in g sd di benh nhan hon me la phu nao Nam 1986 Warrell D.A va CS diia nhiing bang chiing de chiing minh la SRAT the nao khong he co phu nao Gia thuyet ket dinh te bao (Citoadherence) Nhieu tac gia thay rang co sii ket dmh giiia hong cau nhiem P falciparum vdi te bao noi mac mach mau Mat khac cac hong cau nhiem KSTSR lai ket di'nh vdi cac hong cau chua bi nhiem 88 NgUdi ta da tim thay nhiing diem dinh (adhesion) tren mang hong cau chiia diing d nu loi va ca nhiing vung mang khac, la cac protein giau histidin va protein cua mang hong cau Howard R.J va CS (1987) da tim cac diem dinh la: H R Pl (histidin rich protein 1), HRP.2, EM P.l (erythrocyte membrane proteinl) EMP.2 d te bao noi mac mao mach cung co cac thu cam the (receptor) tiidng ting vdi cac diem dinh cua mang hong cau Muanza K (1996) da tim thay thu cam the khac nhau: CD36 (CD = cluster of differentiation), thrombspondin, ICAM - (intercellular adhesion molecule 1.), VCAM - (vascular cellular adhesion molecule 1), E.Selectin Hien tiidng ket dinh giiia nhiing hong cau nhiem KSTSR va hong cau khong nhiem la hien tiidng tao hoa hong Nam 1992 Wahlgren M da tim phan tham gia tao hoa hong (rosettine) co tren mat cac hong cau nhiem KSTSR Gia thuyet ve roi loan dap urng mien djch Nghien ciiu cua Michael F Good (1997) cung nhieu tac gia khac cho thay dap ling cua mien dich te bao co vai trd quan trong benh sinh cua SRAT, dac biet la T - CD4 Theo cac tac gia thi te bao lympho T la quyet dinh dap iing mien dich cua tuc chu vcfi KSTSR Tuy nhien cac nha lam sang deu nhan thay rang SRAT chi hay xay d nhiing ngiidi mdi vao vung sot ret, chiia co mien dich; tai vung sot ret liiu hanh, d nhiing ngiidi dia phiidng SRAT chi gap d tre em, rat it gap d ngiidi trUdng va ldn tuoi Karlon D.C (1994) da chiing minh cau true he khang nguyen cua KSTSR rat phiic tap Ngoai cac khang the chong lai cac khang nguyen cua KSTSR cd the san xuat cac khang the chong lai cac doc to", cac cytokin vv NhU vay co the noi la dap iing mien dich dich the SRAT rat phiic tap va chUa dude nghien ciiu day du 89 Trong benh sinh cua SRAT ngiidi ta thay sii tham gia cua cac cytokines nhif: TNF (tumor necrosis factor), NPT (neopterin), IL - (interleukin - 6), IL - 10, IFN7 (interferon gama) Nhieu cong trinh gan day chiing minh rang d nhiing benh nhan SRAT xet nghiem thay TNF tang rat cao Tren thiic nghiem cac tac gia cung thay TNF gay difdc mot so bien chiing SRAT nhif difdng mau, soc, tang dinh ket te bao Ngifdc lai dung anti - TNF co the ngan ngiia SRAT xay hoac han che til vong d nhiing benh nhan SRAT Cac cytokines khac (NPT, IL- 6, IL-10, IFN7) cung deu tang cao SRAT Khi dung cac chat khang hoac tic che cac cytokines tren cung lam giam nhe diidc benh canh cua SRAT SRAT la qua trinh viem Viem dUdc hieu ddn gian la mot qua trinh benh ly dUOc bieu hien bang cac trieu chiing: sifng, nong, do, dau va nhiing roi loan chiic nang Cuoi the ky XIX, Elic Metchnhicop da phat hien vai tro cua dai thiic bao viem va da dUdc giai thiidng Nobel Niia cuoi the ky XX nhd sii phat trien cua hoa sinh, cac nha nghien ciiu da tim nhieu chat diidc tiet tai o viem co hoat tinh sinh vat hoc cao, dong vai tro quan trong cd che benh sinh cua qua trinh viem nhu: kinin, serotonin, bradykinin, histamin vv Nhiing nam gan day v6i sii phat trien cua chuyen nganh mien dich hoc da cho phep ngifdi ta md rong khai niem viem nhii mot bieu hien cua dap ilng mien dich co vai tro rat quan cua nitric oxyd (NO) va cac cytokines Clark I.A (1996) da thay ring NO tang cao se gay gian mach, ilc che ho hap te bao, gay hoai tii te bao cua cac cd quan noi tang va dan tdi soc, truy tim mach Nam 1996 Anstey N.M cung da chiing minh NO tang cao d cac benh nhan SRAT, mile tang cua NO phu hdp vcfi mile nang cua benh Nhii vay SRAT nhin d khia canh nav cung la mot qua trinh viem 90 III PHAN LOAI SRAT Nhif phan cd che benh sinh da neu: tac mach hong cau nhiem KSTSR co the xay d bat ky cd quan phu tang nao, hien tUdng noi bat d dau ta co SRAT the Tuy vay ngUdi ta thay rin g chu yeu tic mach lai xay d nao, do the nao cung la chu yeu Ngufdi ta chia SRAT nhom: nhom co hon me va nhom khong co hon me (chi co hoi chiing phu tang) Noi cach khac la SRAT co the: the nao (co hon me) va the phu tang (khong co hon me) Trong the nao cung dUdc chia ra: the nao ddn thuan (thudng la giai doan dau) va the nao ket hdp vdi phu tang (thUdng la giai doan muon) Sd phan loai SRAT: 91 Theo phan loai cua Bui Dai va CS (2000) 1.1 SRAT the nao (sot ret P falciparum co hon me va roi loan y thiic) - The nao ddn thuan - The nao phoi hdp vdi mot hoac nhieu hoi chiing phu tang: + Nao + suy tuan hoan cap/soc + Nao + suy than cap + Nao + suy thd cap (phu phoi/ARDS) + Nao + suy gan cap 1.2 SRAT the phu tang (chi co hoi chiing phu tang ddn thuan, khong co hon me) - Suy tuan hoan cap /soc Roi loan tieu hoa nang/giong ta Suy gan cap Suy than cap Phu phoi cap/ARDS - Xuat huyet /CIVD (dong mau rai rac noi mach) Dai huyet c&u to" Hoi chiing bung cap Phan loai theo Trjnh Kim Anh va CS (1994) 92 Nhom Bien chiing SRAT T if vong SR mdi chi co bien chiing nao ddn thuan (bien chiing mot phu tang) -10% II SR phu tang ddn thuan: suy than cap, dai HCT, vang da, choang, truy tim mach, ngirng tim, ngifng thd - 20% III - A SR bien chiing nao va lan sang mot phu tang khac (bien chiing hai phu tang) - 20% III - B SR bien chiing nao va lan sang it nhat hai phu tang khac (bien chiing da phu tang) > 40% IV LAM SA N G VA C H AN OOAN SR A T THE NAO (Trong pham vi bai chung toi chi khao sat ve SRAT the nao) Lam sang Bieu hien lam sang chu yeu cua SRAT the nao la: 1.1 Hon me (roi loan y thiic nang) Khoang 80% cac trUdng hdp SRAT the nao, hon me xay til til sau mot so" sot ret cdn roi dan dan chuyen vao trang thai ly bi hoac kich thich vat va, me sang roi vao hon me Khoang 20% trifdng hdp SRAT the nao lai co hon me xay dot ngot Benh nhan dang sinh hoat binh thifdng dot nhien nga bat tinh, vat va va co the co kem theo cdn co giat kieu dong kinh Co trUdng hdp benh nhan vao hon me dot ngot roi mdi sot sau Dai da so cac trUdng hdp hon me 93 khong kem theo trieu chiing dinh khu Thong thudng neu dUdc dieu tri dung bang thuoc sot ret thi hon me chi keo dai - ngay, rat it gap hon me keo dai > ngav neu nhif khong co nhifng bien chiing nhoi mau hoac xuat huyet nao Sau khoi hon me benh nhan hoi phuc hoan toan, rat it de lai di chiing 1.2 Ccfn co giat kieu dong kinh Co khoang 20 -30% trifdng hdp SRAT the nao co cdn co giat kieu dong kinh Co giat thifdng xay muon benh nhan da vao hon me sau Tuy nhien d nhiing benh nhan hon me xay dot ngot thi co giat cung co the co tif nhiing gid dau, dau Da so" cac trifdng hdp la co giat toan than, keo dai - phut hoac ngan hdn, thUa thi - cdn/ngay hoac mau - gid/lcdn Nhiing trUdng hdp co cdn co giat mau thudng kem kho thd, tim tai va de doa ngat, loai can phai hoi siic tich ciic Mot so" it benh nhan SRAT the nao co co giat cuc bo kieu Bravais - Jackson (thudng giat ban tay, ban chan, cd nhai, nhan cau) 1.3 Hoi chung than kinh khu tru Trong SRAT the nao it gap hoi chiing khu tru Thudng chi thay cac dau hieu dinh khu d nhiing trUdng hdp co bien chiing nhoi huyet hoac xuat huyet nao Tuy vay mot so" trUdng hdp SRAT the nao ddn thuan kham cac dau hieu thudng ton thap (Babinski, Oppenheim, Gordon vv ) thay dUdng tinh ca hai ben bo thap bj kich thich 1.4 Roi loan tam than Mot so benh nhan SRAT the nao ma hon me xay tif tif thi co the co nhifng bieu hien roi loan tam than trUdc vao hon me Bieu hien roi loan tam than dien da dang nhU: 94 tram uat, me sang, thao cuong, di lai va noi nang lung tung Mot so ft trUdng hdp roi loan tam than lai xay sau benh nhan thoat khoi hon me Tuy vay nhiing roi loan chi ton tai vai roi trd ve binh thiidng Chan doan SRA T the nao Muc tieu cua cac nha lam sang la chan doan sdm SRAT tif giai doan tien ac tfnh bdi vi da vao SRAT thi da la muon Nhieu nghien ciiu tong ket dUa nhiing trieu chiing co y nghia dii bao SRAT the nao hay goi la nhiing trieu chiing de doa ac tfnh Nhiing trieu chiing thiidng co trUdc - triidc SRAT the nao xay Bui Dai va CS (1995) diia 10 dau hieu dii bao SRAT the nao ma tac gia goi la hoi chiing tien ac tfnh Cac trieu chiing cua hoi chiing tien ac tfnh dUdc xep theo thii tii gia tri dii bao tif cao den thap la: + Sot lien tuc, giao dong kieu chif W- M, chong cdn (2 - cdn 24 gid) hoac cdn keo dai >24 gid + Doi luc mat dinh hiidng thoang qua + Mat ngu trang dem 1-2 + Mo hoi va giot + Ly bi hoac kfch thfch (xao xuyen, vat va hoac ban than, cham chap) + Nhiic dau du doi + Dai dam (tuy chua hon me nhUng lang quen) + Non thoc thao + Mat KSTSR > 40.000/mm + la long toe nU6c 95 - Warrell D.A nhan manh dau hieu: + Sot cao > 39°C lien tuc + Bien doi tam thin (ki'ch thich hoac lie che) + KSTSR day dac (> 2% hong cau bi nhiem KSTSR) + Thiidng ton phu tang, suy gan than Chan doan SRAT the nao d benh nhan sot ret (co KSTSR P falciparum) co hon me Do vay co the noi trieu chiing quan dau tien cua SRAT the nao la hon me nen mot so niidc goi la sot ret hon me Di nhien can phai loai tri* hon me nhiing nguyen nhan khac khong phai sot ret (chan doan phan biet) Chan doan phan biet SRAT the nao 3.1 Vdi viem nao virut Viem nao virut cung la benh hay gap d Viet Nam Liia tuoi tre em ( < tuoi, dac biet la < tuoi) thiidng mac viem nao virut Arbo nhom B hay goi la viem nao Nhat Ban Trong viem nao Nhat Ban hon me cung xay nhanh nhUng thudng kem theo nhiing dau hieu than kinh khu tru, hay co viem ca mang nao kieu dich, hon me thiidng keo dai va co hang thang, sau hoi phuc thiidng de lai di chiing Doi v6i viem nao virut d ngiidi 16n: hon me cung thiidng keo dai ngay, dau hieu thiidng ton thap hay gap, KSTSR am tfnh Benh tien trien nang va neu qua khoi da so cung de lai di chiing 3.2 Vdi Dengue xuat huyet the nao Sot khong cdn, keo dai - 96 Thifdng co xuat huyet difdi da, niem mac hoac xuat huyet noi tang, dau hieu day that (+) Tieu cau giam va hematocrit tang - Hon me xay tif tti, l't co co giat kieu dong kinh Xet nghiem KSTSR (-), xet nghiem Mac ELISA (+) hoac ngan ngifng ket hong cau IH (+) 3.3 Vdi xuat huyet nao (XHN) Hon me cung dot ngot (giong 20 - 30% SRAT the nao) nhifng thifdng trifdc sot nhieu gid hoac - ngay, co the sot vtia hoac cao nhifng khong cdn va khong co ret run Khong co thieu mau; gan, lach khong to, hong cau khong giam ro Thifdng co hoi chting than kinh khu tru (neu xuat huyet d ban cau dai nao) Thifdng tren nhting benh nhan co benh huyet ap cao, benh tim mach, ngifdi cao tuoi - Hon me keo dai neu o xuat huyet ldn, benh nhan thd sau, phi - Xet nghiem KSTSR (-) - Chup CT hoac MRI se thay vung tang ty 3.4 Vdi mot so hon me cac nguyen nhan khac Hon me difdng huyet hoac tang difdng huyet: thifdng biet ro tien sti dai thao difdng hoac difdng huyet dieu kien lao dong nang lai bi doi Xet nghiem difdng huyet se cho chan doan chinh xac Mot diem dang lifu y la d 97 benh nhan sot ret P.falciparum lai dUdc dieu tri bang quinin thi thifdng se gay dUdng huyet Luc hon me difdng huyet se nham vdi SRAT the nao Do benh nhan bi hon me co KSTSR cung phai lam xet nghiem difdng huyet de loai trif - Roi loan nifde, dien giai nang: cac trUdng hdp m at nUdc nang lao dong dudi nang nong cung co the dan tdi hon me Nhiing trUdng hdp xet nghiem dien giai va hem atocrit se thay co bien doi ro ret Torn lai: Chan doan SRAT the nao diia vao nhiing tieu chuan cd ban la: Co trieu chiing cua sot ret va dUdc khang dinh bang xet nghiem KSTSR (+) loai P falciparum Co hon me du la xuat hien tii tif hay dot ngot (sau da loai trif cac hon me cac benh ly khac da noi tren) Tuy vay de tranh bo sot chan doan can phai lUu y may diem sau day: + Khi khong tim thay KSTSR d mau ngoai vi chd nen loai trif SRAT, bdi vi xet nghiem phu thuoc vao dan tieu ban, cach nhuom va kinh nghiem soi Mat khac d mot so benh nhan giai doan SRAT (hon me) KSTSR d mau ngoai vi lai rat ft ma chu yeu tap trung d mau noi tang, nen nhieu sau dieu tri, benh nhan khoi hon me roi luc xet nghiem mau ngoai vi lai bat gap KSTSR + Mot so trUdng hdp SRAT the nao vao hon me dot ngot benh nhan chua he co sot Doi mot so" trieu chiing dau tien khong dien hinh (ia long, dau bung, co giat ) lam sai dinh hudng chan doan + Khi khai thac tien sii, ngUdi ho tong khong ro benh nhan da d vung sot ret lUu hanh nen khong khai bao 98 V D IE U TR | SR A T TH E NAO Nguyen t i c chung dieu trj SRAT the nao Phat hien sdm va cap ciiu khan trifdng tai tuyen cd sd Khi co nhiing trieu chiing dii bao SRAT (tien ac tinh) benh nhan phai diidc cap ciiu dieu tri nhii SRAT thiic sii Dieu tri dac hieu theo dung phac do: can sii dung cac thuoc tac dung nhanh, tot nhat la dung diidng tiem dac biet la tiem tinh mach Chu y dung lieu liidng va khoang cach giiia lan cho thuoc de tri nong thuoc du diet KSTSR mau lien tuc Het siic coi viec cham soc, theo doi va che dinh diidng cho benh nhan SRAT tii dau Dieu trj cu the 2.1 Dieu trj dac hieu Dung mot cac loai thuoc sau day theo thii tii liu tien: 2.1.1 Thuoc tiem: lie ky, 5,4 ml trUdng Artesunat: lo 60 mg hoa vdi 0,6 ml natri bicacbonat 5% tiem b ip thit Neu tiem tinh mach thi phai pha them NaCL d in g trUdng (0,9%) hoac ml glucose d in g (5%), tiem cham - phut C a ch t ie m : gid dau = lo, gid thii = lo, nhiing sau moi tiem lo (neu hon me) hoac lo (neu da tinh), dung - A rtem eth er: thuoc hoa tan dau nen chi tiem b ip thit, ong dong 100 mg 99 C a ch tie m : dau tiem ong cach gid, nhiing sau moi ong, dung - Quinin dichlohydrat: ong 0,5g pha vdi 250ml glucose 5% hoac NaCL 0,9% truyen tinh mach, cach - gid dung ong cho den benh nhan tinh thi chuyen sang tiem bap thit hoac uong, ddt dieu tri - 10 - Quinin chlohydrat: ong 0,5g tiem bap thit, lieu liidng va thdi gian giong nhii quinin dichlohydrat 2.1.2 Thuoc uong: - Artesunat vien 50mg: hoa tan dUa qua ong thong da day C ach d u n g : hon me thi cach gid uong vien Khi khoi hon me thi cach 12 gid uong vien cho du - Atemisinin vien 0,25g: hoa tan diia qua ong thong da day C ach dung', gid dau vien, sau cach gid uong vien tdi tinh chuyen gid uong vien Tii het sot cho vien de du 2.1.3 Thuoc dan: Artemisinin dan: co cac loai dan lOOmg, 200mg, 300mg dung cho cac benh nhi, ngUdi SRAT cd non nhieu va nhiing vung sau, vung xa khong cd thuoc tiem, khong dat diidc ong thong da day L ie u ItfOng- 20mg/kg/ngay, dat hau mon cho den benh nhan tinh thi chuyen sang uong cho du Chu y: khong dung dan artemisinin cho nhiing benh nhan cd ia long 100 2.1.4 Thuoc dieu tri ket hop: De han che tai phat can dung them mefloquin hoac doxycyclin (mefloquin vien 0,25 lieu 15 - 25mg/kg uong lan, doxycyclin vien lOOmg/ngay, dung - ngay) 2.2 Dieu trj trieu chimg va bien chung 2.2.1 D ieu chinh ro i loan nude, dien giai va can being kiem toan: Theo Vu Van Dinh va CS (1993) co tdi 75% benh nhan SRAT la thieu nUdc va dien giai sot cao, va mo hoi, non, di long Do vay bo sung nUdc, dien giai la rat can thiet Co the truyen cac dung dich d in g trUdng NaCl 0,9%, glucose 5% hoac ringer lactat theo mile mat nUdc, dien giai Dieu chinh nhiem toan chuyen hoa bang truyen dung dich natri bicarbonat (1,4%, 5%, 7,5%) 2.2.2 Ha sot, an than, c i t co giat: Khi co sot cao > 40°c (> 39°c vdi tre em) thi can sot b in g cac bien phap vat ly va paracetamol lieu 15mg/kg Khi benh nhan vat va, cuong sang can cho thuoc an than Seduxen Neu benh nhan cd cdn co giat kieu dong kinh thi mile tu: nhe den nang ma xU dung: Seduxen lieu cao; Seduxen + Dolargan; Seduxen + Dolargan + Gacdenal Neu co giat lien tuc ma cac bien phap tren khong cat dUdc thi truyen thiopental 1% tinh mach, dat noi quan de thd may 2.2.3 DU phdng va dieu tri suy ho hap: Benh nhan SRAT the nao rat de dan tdi tinh trang suy ho hap un tac ddm dai, tut lUdi, phe quan phe viem boi nhilm Do vay can phai thudng xuyen hut ddm dai de thong dUdng thd Thay nong ong Krishaberg hoac noi quan, sat 101 trung can than Thiidng xuyen thay doi tu the nam, vo nen phoi Ve sinh rang mieng hang 2.3 Theo ddi, cham soc, nuoi dudng va ho ly Benh nhan SRAT can diidc theo doi 24/24gid (cif y ta rieng), thiidng xuyen thay doi tii the cho benh nhan (toi thieu - gid/llan) Theo doi phat hien kip thdi cac trieu chiing mat niidc, un t&c diidng thd, loet cac diem ty, boi nhiem Do liidng niidc vao ra, ap liic tinh mach trung lidng lan va nhiing can Dam bao dinh diidng tut dau bang xup va dich long qua ong thong da day, ti'nh du calo (khoang 3000 calo/ngay) - Nhiing xet nghiem can theo ddi: + KSTSR, cong thiic mau, hematocrit + Ure, creatinin, dien giai (chu y K+) + PH mau, acid lactic, C 3H ', P C 2i, P 2i, glucose mau + Cay mau cd nghi ngd nhiem khuan 2.4 Tieu chuan vien Benh nhan hoan toan tinh tao, het sot, het KSTSR (it nhat lan am tfnh) Hong cau > 3,5 trieu /1m m mau; bach cau, cong thiic bach cau binh thiidng Cac chi so: mach, huyet ap, thd, dai tieu tien binh thiidng 102 [...]... 7 -14 1/ 12 moi tuoi 1 2 Xuan - He - Ixodes Nga persulcatus 3 4 5 6 7 7 -14 ■ moi tuoi 20 nhieu 10 - moi tuoi 10 nhieu ngudi I6n ( ) 50-75 80% - Dong vat co vu Pow assan - Ixodes cookei - Khi hoang dai Ngira - C uliseta mien m elanura Dong - 5 -10 Chim 1/ 40 tre em 1/ 17 Ngira - Culex tarsal is mien Tay - Chim Ngira ChiTa ro Venezuela 5 -10 r ) moi tuoi 3-7 it-vira 1- 5 ngifdi I6n moi tuoi gan hiem 1/ 250 10 ... truyen benh va benh thu mac vat chu chinh (ngay) benh benh 1 2 3 4 5 6 7 La Crosse - Aedes triseriatus 3-7