GIM BCH CU HT BNH NHN CNG GIP

Nguyn Th Thnh1 SUMMARY GRANULOCYTOPENIA IN PATIENTS WITH HYPERTHYROIDISM Nguyn Th Thnh Data from 137 patients with hyperthyroidism hospitalized in Nhn Dn Gia nh Hospital in 2001 and 2002 were recorded. Granulocytopenia (<1800/mm3) occurred in 11.67% (16/137); 12.87% (13/101) of newlydiagnosed (and untreated) patients and 8.33% (3/36) of patients treated with anti-thyroid drugs. There are no difference between two groups about the rate of granolocytopenia and the change of the number of granulocyte after one week treated by anti-thyroid drugs. In the group of newly-diagnosed patients with granulocytopenia (<1800/mm3), the number of granulocyte increased clearly after 1week of treatment (p<0.05). Therefore, when a patient had granulocytopenia, we should know whether the patient had been treated by anti-thyroid medications or not. If granulocytopenia was due to hyperthyroidism, anti-thyroid medications would be useful for the patients. TM TT Qua nghin cu hi cu 137 bnh nhn cng gip nm iu tr ti bnh vin NDG trong nm 20012002 c bch cu (BC) ht <1800/mm3, chim t l 11,67% (16/137).Trong ,12,87% (13/101) bnh nhn mi chn on cha iu tr v 8,33% (3/36) ang iu tr vi thuc khng gip tng hp (KGTH). S bnh nhn gim BC ht hai nhm khng khc bit nhau (p>0,05) v s thay i BC ht sau 1 tun iu tr chung cho hai nhm ny cng khc bit nhau (p>0,05). Ring trong nhm mi chn on cha iu tr c s BC ht gim <1800/mm3, sau iu tr vi thuc KGTH 1 tun s BC ht tng ln r rt (p<0,05). Do , cn xc nh bnh nhn c iu tr bng thuc KGTH hay khng khi bnh nhn c gim BC ht. Thuc KGTH s hu ch cho bnh nhn gim BC ht do nhim c gip t.

T VN Trong bnh cng gip ngoi tr do vim gip ch iu tr triu chng cn cc loi khc thng phi iu tr bng KGTH. Khi iu tr bng phng x hay phu thut ngi ta cng hay bt u iu tr ni khoa vi thuc khng gip (2,4-7) Thuc KGTH c th gy nhiu phn ng ph (1-7), y chng ti xin cp n phn ng gy gim bch cu (BC) ht. Gim BC ht cng l bin chng ph ca thuc KGTH c ghi nhn t 0,3-0,5% ty theo cc tc gi.(1,3-7). Khi BC ht gim nhiu, nht l khi <500/mm3, bnh nhn d t vong (5), do c tc gi ngh khi BC<4000/mm3 v a nhn trung tnh <45%, hay khi BC ht trung tnh <1800/mm3, nn ngng thuc KGTH (4), v i sang thuc khc hay phng thc iu tr khc. Gim BC ht do KGTH ty loi c th ph thuc vo liu, thng hi phc sau khi ngng thuc. Ngi ta cng c th cho thm thuc kch thch to BC gip hi phc nhanh (1). Bn cnh , ngi ta cng ghi nhn gim BC ht cng c th do nhim c gip t. V th, cn theo di cng thc BC u n (1), trong khi cc tc gi khc cho rng theo di cng thc BC u n thng khng gip ch nhiu m nn
1

Khoa Ni Tit Thn Bnh Vin Nhn Dn Gia nh

cnh bo bnh nhn khi au hng, st, vim li, lot ming cn ngng thuc v nn nh gi BC ht v gim BC ht thng xy t ngt (3,7). Do chng ti nhn thy cn xem xt BC ht c thi thch ng trong iu tr. MC TIU NGHIN CU Nhn xt BC ht bnh nhn c chn on cng gip nm iu tr ti Khoa Ni Tit Thn trong nm 2001-2002. Qua tm hiu: BC ht bnh nhn cng gip mi pht hin. BC ht bnh nhn ang iu tr thuc khng gip tng hp. S thay i BC ht sau iu tr.

I TNG V PHNG PHP NGHIN CU Thit k nghin cu: Hi cu, ct ngang, m t v phn tch. i tng nghin cu: Bnh nhn nm iu tr ti khoa Ni Tit-Thn trong nm 2001&2002. Tiu chun nhn bnh: Nhng bnh nhn c triu chng cng gip lm sng v cn lm sng hoc cn lm sng bnh thng nhng c chn on cng gip v ang iu tr vi thuc KGTH. Lm y cc yu t c quan tm nh c xt nghim nh gi chc nng tuyn gip v cng thc mu t nht 1 ln lc vo. Bnh nhn cng gip ngng thuc v xt nghim nh gi chc nng tuyn gip trong gii hn bnh thng. Bnh nhn khng lm cng thc bch cu.

Tiu chun loi tr:

Cc bc tin hnh: - Chn nhng bnh nhn nm iu tr ti khoa Ni Tit-Thn trong nm 2001 v 2002 tho cc tiu chun nhn bnh v tiu chun loi tr. - Xt nghim chc nng tuyn gip v cng thc bch cu da vo kt qu ca phng xt nghim bnh vin Nhn Dn Gia nh. Chc nng tuyn gip c o bng my t ng Asxym ca hng Abott vi phng php min dch hunh quang. Cng thc BC da vo my huyt hc t ng Technichon H.1 - Bch cu ht c ghi nhn thp khi s lng BC<4000/mm3 v a nhn trung tnh <45% (4), hay khi BC ht trung tnh <1800/mm3. - Qun l v x l s liu: chng ti dng phn mm Excel v SPSS. Cc php so snh trung bnh t-test hay php kim 2 c ngha thng k khi p<0,05. KT QU c im bnh nhn (BN) (Bng 1): S BN Nam 26 % 19% BN cha iu tr 19 % BN ang iu tr 7 %

N TC

111 137

81%

82 101 73.2%

29 36 26.27%

Tui: Nh nht 18; Ln nht: 79; Trung bnh:48,7, lch chun (SD):15,8. Bch cu ht lc vo (Bng 2): BC ca137 bnh nhn Nh nht Ln nht Trung bnh 308 18083 4668.3(33 59.5) BC ca101 bnh nhn cha iu tr 308 18083 4722.9(3310) BC 36 bnh nhn ang iu tr 450 17772 4626.7(3481.7) t = 0.11; p>0.05 Khc bit v BC nhm iu tr & cha iu tr

S bnh nhn gim BC ht <1800/mm3 (bng 3): S BN % 101BN KT % 36 BN .T %

BC<180 0 BC( 180 0

16 121 137

11,67 %

13 88 101

12.87%

3 32 36

8.33%

S khc bit v BC<1800 nhm T v KT ( 2 = 0.1695; p>0.05). So snh BC ht trc v sau iu tr (1 tun) 21 bnh nhn (bng 4): S BC ht lc vo Nh nht Ln nht Trung bnh 772 18083 4434(4111) S BC ht sau 1tun iu tr 913 12799 3197(2736) t =-1.62 p>0.05 S khc bit trc & sau iu tr

So snh BC ht trc v sau iu tr (1 tun) bnh nhn c BC ht lc vo <1800/mm3 (bng 5) 6 bnh nhn BC ht <1800/mm3 Nh nht Ln nht Trung bnh BN LUN c im bnh nhn: Trong 137 bnh nhn cng gip nm iu tr chng ti n chim t l 81% (111/137) cao hn hn nam 19% (26/137), tp trung trong tui 48,7( 15,8) nm.V S BC ht lc vo 772 1514 1085 256 S BC ht sau (1 tun iu tr) 1224 2784 1914 590 t=3.52 p<0.05 S khc bit BC ht trc & sau iu tr

bnh nhn mi c chn on chim t l 73,2% (101/137) cao hn hn bnh nhn ang iu tr 26,27% (38/137). S bnh nhn gim BC ht <1800/mm3: Trong 137 bnh nhn nghin cu chng ti c 16 bnh nhn c BC ht <1800/mm3 chim t l 11,67% (16/137). Trong 13 bnh nhn nhm cha iu tr 12,87%(13/101) v 3 bnh nhn trong nhm ang iu tr chim t l 8,33% (3/36). Qua php kim chi bnh phng, chng ti nhn thy s bnh nhn gim bch cu ht nhm cha iu tr v iu tr khng khc bit nhau ( 2 =0,1695 p>0,05). Nh th, nhm cha iu tr BC ht vn gim khng khc nhm ang iu tr. iu ny cho thy BC ht cng c th gim do nhim c gip t. T l gim BC ht bnh nhn chng ti l 8,33% trong khi theo cc y vn l 0,3-0,5% (1,3-7). C l do chng ti ly gii hn gim BC ht mc cao <1800/mm3, v gim BC ht nguy him khi <500/mm3. So snh BC ht trc v sau iu tr (1 tun) 21 bnh nhn. y l nghin cu hi cu, chng ti ch c c 21 bnh nhn c lm xt nghim 2 ln lc vo v sau 1 tun iu tr. Chng ti nhn thy s BC ht trung bnh lc vo l 4434(4111)/mm3 v BC ht sau iu tr 1 tun l 3197(2736) /mm 3. Vi php kim T, chng ti thy BC ht trc v sau iu tr khng khc bit nhau (vi t=-1,62 ; p>0,05). iu ny c ngha sau 1 tun iu tr c bnh nhn tng BC ht c th do nhim c gip t nay c iu tr, BC cu ht ci thin, cng c bnh nhn gim BC ht do phn ng ph ca thuc KGTH (1-7) do o kt qu sau cng tr s trung bnh nhm bnh nhn ang iu tr v cha iu tr khng khc bit nhau. So snh BC ht trc v sau iu tr 1 tun <1800BC/mm3: bnh nhn c BC ht lc vo

Trong 137 bnh nhn nm iu tr chng ti ch tm thy c 6 bnh nhn c BC ht <1800BC/mm3 c lm xt nghim cng thc mu nh gi BC ht sau 1 tun iu tr. C 6 bnh nhn ny u l bnh nhn mi c chn on cha iu tr. Chng ti nhn thy sau 1 tun iu tr vi thuc KGTH, s lng BC ht nhm ny tng r rt (t = 3,52 ; p<0,05). iu ny ni ln BC ht c th gim do nhim c gip t, do khi bnh nhn c iu tr vi thuc KGTH, s lng BC ht tng ln r rt v c ngha thng k. KT LUN Qua nghin cu 137 bnh nhn cng gip nm iu tr ti khoa NiTit-Thn trong nm 2001 v 2002 chng ti c nhn xt sau: - S bnh nhn gim BC ht <1800/mm3 bnh nhn cha iu tr do nhim c gip t 12,87%(13/101) v bnh nhn ang iu tr do thuc KGTH 8,33% (3/36) khng khc bit nhau ( 2 =0,1695 P>0,05). - Trong nhm c hai loi bnh nhn cha iu tr v ang iu tr : S lng BC ht trc v sau iu tr (1 tun) khng khc bit nhau (t =-1,62; p>0,05). - nhm bnh nhn cng gip cha iu tr c s lng BC ht < 1800BC/mm 3, sau iu tr 1tun s lng BC ht tng ln r rt (t=3,52 p<0,05). Do , gim BC ht bnh nhn cng gip c th do nhim c gip t. Vic iu tr bng thuc KGTH c th lm tng s lng BC ht. ngh: - Trc khi iu tr cng gip, cn hi r bnh nhn c dng thuc KGTH cha v m cng thc BC.

- Nu bnh nhn cha iu tr v s BC ht thp: Bnh nhn c th gim BC ht do nhim c gip t, iu tr bng thuc khng gip c th lm tng s lng BC ht ny. Vic theo di cng thc BC sau 1-2 tun l cn thit theo di din tin ca BC ht do iu tr. - Trong qu trnh iu tr lu di vic cnh bo bnh nhn cn ngng thuc khi au hng, st, lot ming, vim li v i xt nghim xc nh gim BC ht l cn thit v gim BC ht c th xy ra t ngt. Nu c gim BC ht, ty theo mc hay loi KGTH ngi ta c th gim liu hay ngng KGTH v i sang thuc hay phng thc iu tr khc. TI LIU THAM KHO 1.ALAN P.FARWELL AND LEWIS E.BRAVERMAN.(1996). Thyroid and antithyroid drug In Good Man &Gilmans the Pharmacological Basis of Therapeutics Ninth Edition PP:13971406.McGraw-Hill, USA. 2. BRAUNWALD E (2002).Thyrotoxicosis.In Eugene Braunwald .<et al>.Harrissons Manual of Medecine. 15th Edition; p 774-781. McGraw-Hill International Edition, India. 3.JOHNC. MORRIS,MD.(1996). Thyroxicosis. In Robert E.Rackel,M.D . Conns Current Therapy, 48th edition PP 619- 624.W.B Sauders , the United states of America. 4.MAI TH TRCH (2000). Cng Gip . Trong Ni Tit Hc i Cng (Mai Th TrchNguyn Thy Khu ch bin). Tr:212-137. Nh xut bn Thnh Ph H Ch Minh. 5.ROBER D.UTIGER.(1995).The Thyroid: Treatment of Thyrotoxicosis. In Philip Felig, M.D.Endocrinology And Metabolism, Third Edition. Volume 1, PP 479-492.McGraw-Hill, Inc.USA. 6.THI HNG QUANG(1997).Bnh Basedow . Trong Bnh Ni Tit (Thi Hng Quang ch bin) Tr:116-171 Nh xut bn Y Hc, H Ni. 7.WILLIAM E.CLUSTTER.(2001).Hyperthyroidism.In Shubhada N.Ahya.The Washington Manual of Medical Therapeutics. 30Edition PP.473-490,Wolters Kluwer, USA . Tn tc gi: Hc v: Chc v: Nguyn th Thnh. Tin s. Trng khoa Ni Tit Thn Bnh Vin Nhn Dn Gia nh

a ch lin h: Bnh Vin Nhn Dn Gia nh S 1 N Trang Long Bnh Thnh.TP H Ch MInh Nh : 46 inh Tin Hong Phng 1 Qun Bnh Thnh TP H Ch Minh. in Thoi: Email: 8412381 0913651815 tsbsthanh@yahoo.com tsbsthanh@hcm.fpt.com