NHN MT TRNG HP DY TH SM NGUYN NHN TRUNG NG TR TRAI

Nguyn th Dim Chi,Nguyn th Hng H, Hong th Thu Yn Khoa Nhi Bnh Vin trung ng Hu

1. PHN HNH CHNH: H v tn: PHM NHT T. - Sinh ngy 03/10/1995. - a ch: 350/13 Phan Chu Trinh, phng An Cu, thnh ph Hu - Ngy vo vin: 19 gi ngy 23/08/2004 - L do vo vin: Nn 2. BNH S: Khi pht cch ngy nhp vin 3 thng vi trm ging, xut hin lng mu, c quan sinh dc nam pht trin, dng vt pht trin, c lng nch, cha xut tinh. Cch ngy nhp vin 20 ngy vi au u, nn sau n, nhn m, khng lit. nh bnh nhn c i khm v iu tr bc s t, bnh khng gim, chiu nay sau khi n bnh nhn nn, vo vin. c chn on: Theo di u no, c iu tr: Chng ph no, gim vim, chuyn dch. c lm cc xt nghim gip cho chn on. 3. TIN S: Con th 1, sinh thng, thng, PARA 2002, cn nng lc sinh 2700 gr, cai sa m lc 16 thng. 4. GHI NHN LC VO VIN : Mch:83 ln/pht, Nhit : 370C, HA:120/70mmHg, cn nng:33 kg, chiu cao:133,5 cm. Thnh thong tr au u, au theo mch p, sau au u bnh nhn nn. 5. THM KHM HIN TI Tng trng chung kh, da nim mc hng -Thn kinh: Tnh to, thnh thong au u, au theo mch p, sau au u bnh nhn nn. Mt nhn m, khng lit, khng c du hiu thn kinh khu tr. -Tiu ho: Nn sau n -Dy th: Lng mu P3, th tch tinh hon 6 ml (P3).

6. CN LM SNG 23/08: CTM : Bch cu 9,9 x 109 /l , Lymphocyte 26,4 %, Neutrophile 62,7 %, Hng cu 6,8 x 1012/l, Hb 13g/dl, Hct 43,5 %. 23/08: Glucose mu : 5,5 mmol/l, in gii : Na+ 138 mmol/l, + K 3,8 mmol/l, Ca++ 1,17 mmol/l. 23/08: Soi y mt: Gai th mt b, tnh mch gin ngon ngoo, vng mc ph v xut huyt ri rc, ph gai th hon ton. 24/08: CT Scanner s no : +Ca s xng: khng thy tn thng hp s +Trc tim thuc cn quang tnh mch: C mt khi tng t trng t nhin, c vi ho nt nh bn trong cu trc, kch thc 5,4 x 3,5 x 4 cm ngoi trc st lim no, pht trin v pha tri, gy chon ch bn cu no tri. Cu trc hnh thi, t trng ca m no, tiu no khng thy bt thng. +Sau tim thuc cn quang tnh mch: Khi u ngm thuc rt mnh, giu mch, khng c cu trc hoi t. M no, tiu no cn li khng thy hnh nh ngm thuc bt thng. Kt lun: Meningioma 25/08 : FSH < 0,1mIU/ml LH 4,44 mIU/ml Testosterone > 15 ng/ml 7. TM TT - BIN LUN - CHN ON Qua hi bnh s, thm khm lm sng v cn lm sng, trn bnh nhn ny chng ti thy c cc du chng v triu chng sau: 1. Du chng dy th sm: - xut hin lng mu (P3), th tch tinh hon 6 ml (P3) (>4 ml) - Cc c tnh sinh dc nam: trm ging, c quan sinh dc ngoi pht trin, dng vt pht trin. - FSH < 0,1mIU/ml, LH 4,44 mIU/ml, Testosterone > 15 ng/ml [6 ]. 2. Du chng thn kinh: Cc triu chng thn kinh ca khi u: + du tng p lc ni s : au u, au theo mch p, sau au u bnh nhn nn, nn ma. + ri lon th gic (nhn m). 3. Soi y mt: Gai th mt b, tnh mch gin ngon ngoo, vng mc ph v xut huyt ri rc, ph gai th hon ton. 4. Du chng khi u no: CT Scanner s no cho thy khi u kch thc 5,4 x 3,5 x 4 cm gy chon ch bn cu no tri. Kt lun : Meningioma. Tiu chun chn on dy th sm (DTS): Cc du hiu sinh dc ph xut hin trc 10 tui vi tr trai, trc 8 tui i vi tr gi [1]. Dy th sm thng thng c xc nh khi khi pht dy th trc 8 tui tr gi v trc 9 tui tr trai [5 ]. Cc du hiu lm sng gi DTS: - Tng tc pht trin chiu cao - Pht trin cc c tnh sinh dc ph : - V to, c th pht trin lng mu hoc khng ( tr gi)

- Tinh hon >30mm (6ml), c th pht trin lng mu hoc khng (tr trai). * Phi xc nh c tui xut hin cc du hiu lm sng. Cc xt nghim cn lm sng gip chn on DTS: - Tui xng (chp c v bn tay tri) - Test ng Gn - RH - nh lng testosterone hay estradiol - Siu m t cung - bung trng, niu bo tr gi. nh ngha dy th sm tht (DTST) : Dy th sm tht do hot ng sm ca trc h i - tuyn yn - tuyn sinh dc [2]. Chn on xc nh DTST: - Tui xng > tui thc. - Test Gn - RH: LH tng cao v cao hn FSH Chn on xc nh dy th sm trung ng bng test: Tim 100 mcg GnRH, gy tng LH nhiu hn tng FSH 20 - 40 pht sau tim 100 mcg GnRH [5]. - Chiu cao t cung > 36 mm, estradiol 30 pg/ml (tr gi) - Testosterone > 0,5 ng/ml (tr trai). Nng Testosterone c ch trong vic xc nh ngun gc ca cc triu chng dy th sm tr trai, cc gonadotropin nh FSH v LH c bit c ch nu nng vt qu 5 UI/L. y l mt ch im ca dy th sm. Nu FSH gim v LH gim km Testosterone tng cn ngh n dy th sm gi, tri ngc vi dy th sm trung ng [5]. Nguyn nhn DTST: + DTST tr gi > 80% l v cn. + DTST tr trai 80% l do u no. Xt nghim h thng chn on hnh nh no b bng CT Scanner hay MRI[2],[5]. MRI vng h i - tuyn yn gip oan chc chn on dy th sm trung ng sau khi xt nghim cc hormone [5].Cc nguyn nhn trung ng : tn thng h thn kinh trung ng, hoc tn thng tuyn yn, u tit Gonadotropin [3]. C 3 nhm nguyn nhn ca DTST: 1. NGUYN NHN DTST TI NO B * U t bo hnh sao, u thn kinh m, u t bo mm tit HCG (u tit Gonadotropin) nh gliome, u m tha vng di i (hamartomas) v cc tn thng h thn kinh do chn thng, tia x hoc abces [5]. Cc bt thng bm sinh nh no ng thu, cc nang khoang di nhn, v cc nang trn h yn (suprasellar) cng c th ct ngang tin trnh dy th bnh thng [5]. * Khng do u: Kyste tuyn tng, no ng thu * Kch thch no b * Chn thng no * Tin s vim mng no - vim no. 2. NGUYN NHN GIA NH 3. V CN [2] Chn on DTST nguyn nhn trung ng tr trai: Trong tnh hung ny, trc vng di i - tuyn yn - tuyn sinh dc s b hot ho sm [3],[4]. Lm sng: Th tch tinh hon tng hai bn i xng khng c u cc Cc vn v thn kinh: lit, ph gai th , xut huyt vng mc ... Xt nghim hormone c nng mc dy th (Testosterone >0,5 ng/ml) Sau khi xt nghim hormone, lm MRI v /hoc test kch thch bng GnRH hoc c hai, test kch thch bng GnRH to ra p ng dy th [3].

MRI cho thy tn thng vng di i, tuyn yn, h thn kinh trung ng [3]. tr trai dy th sm tht thng do bnh l trong no m 80% trng hp l do u no [2]. Theo Nguyn Ph t, nguyn nhn dy th sm tr trai nh sau : u no chim 57,1%, d dng no 14,3%, cha r nguyn nhn 28,6% [1]. iu ny chng t dy th sm tr trai a s do thn kinh trung ng, cn xt nghim h thng hnh nh no b C.T hay MRI. nc ta chn on DTS tht hay gi cn tng i kh khn do chng ta cha lm c test ng Gn - RH, do kt lun DTST cn khm lm sng khm i khm li nhiu thi im v lm cc xt nghim h tr chn on nhiu ln. bnh nhn ny c 2 kh nng chn on c t ra: 1. U mng no ny l mt loi u tit (-) HCG, DTST ny do u mng no. 2. U mng no ny khng phi l loi u tit (-) HCG, DTST ny khng lin quan n u mng no m c th c gii thch bng nhng nguyn nhn cn li (nh do kch thch no b...). bnh nhn ny qua khai thc li bnh s, chng ti ghi nhn du chng dy th sm xut hin trc cc du hiu tng p lc ni s bnh nhn ny kh lu, tuy nhin liu cc du chng dy th sm ny c mi lin h vi u mng no (meningioma) hay khng? Rt tic chng ti khng o c nng (-) HCG (do ht thuc th) cng khng c c kt qu nh lng (-) HCG ca t chc u no nn kh c th kt lun rng u mng no ny c phi l u ca t bo tit (-) HCG hay khng nhng cng khng loi tr c kh nng chn on th nht. Kh nng chn on th hai bnh nhn ny l mt dy th sm km u mng no m u mng no ny khng phi l loi u tit (-) HCG, vy th DTS ny khng lin quan n u mng no m c th c gii thch bng nhng nguyn nhn cn li (nh do kch thch no b...). Nu tr ny vo kh nng chn on th nht, nu cc du hiu dy th sm ny c pht hin sm v tr c lm cc xt nghim gip chn on cn nguyn ca dy th sm ny th phi chng gip pht hin sm hn u no bnh nhn ny. Trong trng hp ny, tht l mt s ng tic cho bnh nhn ny khng c chn on u no sm hn. 8. KIN NGH Ti cc c s y t nh cc trm y t, cc bnh vin huyn, cc bnh vin tnh khi khm bnh nhn cn khm ton din tr nh o chiu cao, khm dy th, khi pht hin trng hp no nghi ng bt thng v dy th so vi tui cn chuyn ngay bnh nhn n tuyn trn ni c chuyn khoa Ni tit hoc ni c th lm cc xt nghim thm d v hormone, ni tit, lm CT Scanner hoc MRI s no( nht l trong trng hp DTS xy ra tr trai) tr khng b b st chn on, c chn on sm, chnh xc, kp thi, trnh phi gii quyt hu qu ng tic v sau. TI LIU THAM KHO 1.Nguyn Ph t, Cao Quc Vit (2001), " c im lm sng, cn lm sng v nguyn nhn dy th sm tr em", K yu ton vn cc ti khoa hc, i hi " Ni tit i tho ng Vit nam " ln th nht - H ni,433 - 440. 2. Hong th Thu Yn (2002), S pht trin dy th bnh thng v bnh l, Bi ging Ni tit nhi khoa sau i hc,1 - 10 . 3.Blondell and coll (1999), Disoders of Puberty, American Academy of Family Physicians, 60, 209-24. 4.Bridges N.A., Brook C.G.D. (1995), Disoders of Puberty, Clinical Pediatric Endocrinology, 253 - 273. 5.Fagan Ronald A. (1999), Precocious Puberty, Emedicine 6.Appendix : Normal Values (1995), Clinical Pediatric Endocrinology, 796 - 797.