I HC HU TRNG I HC Y DC HU

BNH TRUYN NHIM

B MN TRUYN NHIM 2008 Chng 1. I CNG

Bi 1. I CNG BNH NHIM TRNG -TRUYN NHIM

Mc tiu .1. M t c khuynh hng tn ti bnh nhim. BsCK2, Ths Phan Qun .2. M t c nhim khun, sng k sinh, cc tnh cht c bn ca cc tc nhn gy bnh. .3. M t c cc hnh thi dch, ngun truyn bnh, cch thc truyn bnh. .4. M t c c ch gy bnh, c ch bo v c th i vi s xm nhp tc nhn gy bnh. .5. M t phm vi - mc nhim trng, c im lm sng,cn lm sng bnh truyn nhim. Ni dung

I. DN NHP Mc du, trong nhiu thp k qua, y hc i mt bc kh di v nhng tin b trong iu tr v phng nga, nhng n nay bnh nhim cn l nguyn nhn t vong chnh v h gii. - Sau th chin th II c hng trm loi ho tr liu, khng sinh chng vi khun, virus, lc, an ton. Song li xut hin cc loi vi sinh vt khng thuc, thm ch mc bo ng. - Mt s bnh gn nh b tiu dit ti cc nc pht trin, nay bng pht li nhiu v nghim - Mt s tc nhn gy bnh trc y c mt v gy bnh nh, nay c nhng bin i v mt gy ra SARS-CoV. - Mt s tc nhn trc y gy bnh cho ng vt nay xut hin ngi v c kh nng gy bnh nng nh Lin cu ln, A(H5N1). - Khm ph thm mt s tc nhn gy bnh mi: xon khun bnh Lyme, HIV/AIDS, vim gan do vir dn chng minh vai tr gy cc bnh mn tnh do cc tc nhn vi sinh vt; hin nay, chng ta tc nhn n mc phn t. - Mt s bnh trc y khng ngh do cn nguyn nhim khun nay chng minh l vi khun nh: nhim lot d dy t trng v c th gy ung th. - Mt lng ln bnh nhn ang c iu tr cc bnh nhim khun c mt tnh trng suy gim - Tng nguy c mc bnh nhim khun do k thut iu tr, tng tip xc vi tc nhn gy bnh m, chc tnh mch v.v...) hoc trn nim mc (t ni kh qun, thng bng quang), a vt t thay i vi khun ch ng rut do dng khng sinh ko di. II. NHIM TRNG - TRUYN NHIM 1. Nhim Trng & nhim khun Ni n nhim trng khi tc nhn gy bnh c th l virus, chlamydia, vi khun, k sinh trng un tc cp nguyn nhn gy bnh l vi khun. 1.1.Nhim trng l g ? Nhim trng l hu qu gy ra gia tc nhn gy bnh vi phn ng c th ngi bnh khi tc n nh tu vo phn ng mnh - yu ca c th, bn cht ca tc nhn gy bnh, phn nh qua tri 1.2. Sng k sinh 2

Tn ti sng chung ho bnh gia vi sinh vt v c th ngi, phn ln vi sinh vt tn ti ro bo v ny, nn khng gy bnh (t cu da, corynebacteries hng). Sng k sinh c li cho c th nh sinh tng hp (commenalism: sng cng sinh) nh: E.coli tr phn vo s tiu ho thc n v tng hp vitamin K, hoc gip cho c th ngi c min dch t Khi cn bng sinh thi b ph v (nhim trng ni sinh), cc vi sinh vt mi biu hin vai tr vt qua hng ro bo v xm nhp cc tng ph v gy bnh. 1.3.Tc nhn gy bnh - Vi khun: L mt t bo c nht c kh nng ti sinh mt t bo khc. - Chlamydia: Lp trung gian gia virus v vi khun, sng nh vo t bo k ch. - Virus: Tc nhn tn ti v pht trin bng cch ho nhp vo gene ca t bo k ch, khng g ca k ch. - Nm bc thp: Vi sinh vt k sinh ngi v ng vt, t ti to nm mi bng chi.

- K sinh trng: Sng l thuc vo c th ca mt loi khc. - Prion: (gii thiu bit) Tc nhn gy bnh khng qui c (khng c acid nucleique), cu a chui peptide. Phng ty ngi ta nghi prion gy bnh xp no bn cp ngi c tn Creut g gy t vong c tnh cht gia nh. Bnh thuc loi him, hng nm 1/106 c dn mc bnh. N mc bnh do tc nhn ny gy nn. 2. Truyn nhim Bnh truyn nhim l bnh c tc nhn gy bnh tn ti trong mt s vt ch (ngun truyn bn th) qua ng xm nhp (ng vo), bnh ly trc tip hoc gin tip nh mt s yu t khc i sinh vt gy nn trn mt c th, trong khi bnh truyn nhim cng do vi sinh vt gy nn n ngi mc bnh. 2.1.Cc hnh thi dch t hc - Bnh l t ri rc (sporadic disease): ti mt a phng, mt thi gian di c vi trng h dch t hc. - Bnh dch nh: (endemic disease): cn gi l bnh lu hnh a phng. Ti mt a phng, lin h dch t hc. - Bnh truyn nhim gy dch ln: (epidemic disease): y l loi rt d dng ly lan,mt th hp bnh, trn mt a bn gii hn. - Bnh truyn nhim gy i dch: (pandemic disease): bnh ly lan nhanh chng, nhiu ngi mc trn phm vi mt quc gia, mt lc a. a s bnh truyn nhim xut hin di dng dch nh - ln (endemo - epidemics). 2.2. Ngun truyn bnh: l ni tn ti t nhin ca tc nhn gy bnh. - Ngi l ni cha tc nhn gy bnh: ngi bnh, ngi lnh mang mm bnh. - Ngun truyn bnh ng vt: ng vt b bnh, ng vt lnh mang mm bnh; ng vt cn l - Vt th mi trng: t, nc, khng kh cng cha tc nhn gy bnh cho ngi. Cch ly n uyn nhim. 2.3.Cch ly truyn bnh - Trc tip Ngi ly qua ngi: bnh hoa liu, cm, lao. ng vt qua ngi: gp trong qu trnh chm sc ng vt hoc b ng vt cn. Hoc tip xc cc sn phm bnh l: phn, nc tiu, mu, nc bt hoc cc vt thng. l c. - Gin tip 3

Tc nhn gy bnh cho ngi qua trung gian mt cn trng, ng vt (rui, chut) hoc mt yu h, vi (formite). 2.4. ng xm nhp: rt a dng nh ng h hp, tiu ho, sinh dc, da, ng mu... III. C CH GY BNH Nhim trng l hu qu mt tc ng hai mt, mt bn l tc nhn gy bnh xm nhp c th v bn kia l phn ng c th ngi bnh i vi s xm nhp . Tc nhn gy bnh c kh nng sinh bnh tu vo bn cht ca chng. C ch bo v ca c th ngi nh n cc phng tin c th hc, phn ng c hiu hoc kh 1. Kh nng sinh bnh ca tc nhn 1.1.Vi khun C 3 tnh cht gm: c tnh, to c t, to cc enzyme. 1.1.1. c tnh - S kt dnh, - Kh nng pht trin v nhn ln, - Khng li s thc bo. + Kt dnh: Mun xm nhp gy bnh trc ht vi khun phi dnh vo b mt ca t bo ch, theo mt c ch c bit, sau sau chng mi xm nhp c. + Nhn ln & pht trin: Loi vi khun pht trin v nhn ln trong t bo l k sinh ni bo ella, Salmonella, Listeria, chng k sinh mt thi gian di hoc ngn trong t bo lin vng bo, sau chng pht trin v nhn ln. Ngoi kh nng gy bnh, chng cn gy hin tng d Loi vi khun k sinh ngoi bo bt buc l cc vi khun nh t cu, lin cu..., chng c gy bnh nng. Nhng Riskettsia, Chlamydia nhn ln bn trong t bo k ch, l loi k sinh ni bo bt bu nhng c tnh ca chng gy bnh ch yu l vim ni mc mch mu ti ni ng mch chia nh + Khng li s thc bo: Khng thc bo gy bnh khc nhau tu loi vi khun. V d cc Sa Vi mi khng c s thc bo, nh c Vi m n dit cc tiu th thc bo (phagolysosome) typhi khng c Vi th khng gy bnh c. 1.1.2. To ra c t

 l cht gy c i cho c th vi lng rt nh. - Ni c t (Lipopolysaccharide (LPS) ): vi khun gram m, nm trn thnh vi khun, khng hng thch khi thn vi khun b tan, ng vai quan trng trong sc ni c t, ng mu ri r - Ngoi c t (protein): do vi loi vi khun tit ra, khuyt tn, gy hu qu khc nhau tu hn kinh nh: c t un vn, bch hu v lp trng c (Botulism). - Mt s c t khc: + Toxin erythrogene: lin cu, i tnh mao mch da, gy dn mch-bong biu m da. + Exfoliatine: vi loi t cu, gy bong da. + c t tc dng t bo biu m rut gy a chy (Enterotoxin nh c t t,vi loi E. coli v t cu v.v...) 1.1.3. To ra nhng enzyme: Vi khun c kh nng to mt s enzyme, v d nh - Hemolysine: lm tan t bo - Strepotokinase: lm tan fibrin - Hyaluronidase: gy tan m lin kt, lm cho tc nhn gy bnh lan to trong m c th. - Streptolysin O,S: lm v mng bch cu, chng li s phng v ca c th ngi bnh. - Ngoi ra, chng c th to ra enzyme khng khng sinh nh Beta-lactamase, Acetylase, tu loi vi khun, c c hoc mt i do chu nh hng ca Plasmide, Transposons. 1.2.Virus 4

Virus gy bnh bng sinh bnh cho t bo k ch, bng phn ng to nn do c th k ch. Sau khi thm nhp c th virus vo mu v lun lu mt thi gian ngn, di tu loi virus (g ia), tip n virus tn cng cc t bo ch, cc t bo y c receptor (tip th quan) c h virus xm nhp vo bn trong t bo thc hin tin trnh sinh hc, nh vo cc Acid nhn tiu th virus mi hn. Kt qu lm bin dng v tiu hu t bo k ch ri gii phng nhng khc. Mt s virus th hp tc vi b my di truyn ca t bo k ch, n tn ti mt thi gian di h b bin i, hoc b ri lon th n mi gy bnh vi triu chng nng, m v d in hnh nguy hi n h min dch ca c th, cho nn c th khng kh nng chng cc loi tc c hi trong nhim HIV/AIDS. 1.3. Nm: Nm gy bnh nh 2 tnh cht c bn: - Xm nhp, nhn ln v pht trin trong m di dng si nm, lm nh hng n hot ng c - Mt khc, trong qu trnh xm nhp c th gy ra phn ng qu mn qua min dch c th. 1.4. K sinh trng Kh nng gy bnh rt phc tp, a dng, chu k sinh hc ca chng c mt s giai on xm nh ot ng c quan . Sng ni bo (k sinh trng st rt, Pneumocystis carinii). Sng ngoi b ). 2. Phng tin bo v ca c th i vi tc nhn gy bnh. 2.1. Ro chn c th hc 2.1.1.Lp da Vi khun ch xm nhp khi da rch, vt thng, bng, tim chch, hoc cn trng t, ng vt , cc acid bo c cc tuyn m hi tit ra, l cc yu t hn ch s xm nhp v pht tr 2.1.2.Nim mc - Nim mc h hp: nh c biu m lng rung ng v cht nhy nhm thi ra cc cht l c chc nng chng li s kt dnh v xm nhp ca vi khun v virus trn t bo biu m, chng dit khun. Lysozyme cng tham gia tiu dit vi khun, virus . - ng tiu ho : nh c vi khun ch, IgA, nhu ng ca ng tiu ho, cc cht tit nh acid hp ca tc nhn gy bnh. Ngoi ra hch hnh nhn (A) hng, cc mng peyer rut v rut tha l t chc bch huyt gy bnh . - Nim mc mt, sinh dc, tit niu: Kh nng bo v thng km hn, cc lysozyme, pH acid c chng li s pht trin ca tc nhn gy bnh. - Gim sc khng t nhin khi c thay i v c cu c th hc: + Ct 2 phn d dy, vt thng, vt bng, s xut hin tr cc ng thi trong c th ( si mt, si tit niu...). + a phng tin iu tr vo c th (sonde tiu, catether TM, van tim nhn to). 2.2.Phn ng ca c th: C th p ng tnh trng nhim khun vi phn ng khng c hiu - phn ng c hiu. 2.2.1. Phn ng khng c hiu: xut hin sm - Phn ng vim:

p ng vim ca c th l quan trng trong vic chng li tnh trng nhim khun v thng b g ca bnh. Nhim khun hnh thnh mt lot p ng phc tp ca k ch, lin quan n cc b th (C3a ti ch. Kt qu nhng 5

bin i xy ra ti cc t bo ni mc mch mu, trn cc t bo ny hnh thnh cc Receptor cc bch cu) dnh vi cc t bo ni mc mch mu trc khi di chuyn qua thnh mch ti Phn ng vim s to nn IL1, IL6, TNF (l cc cytokine) gy ra st, tiu protein ca c v g n, gin mch... IL8 c tc dng huy ng v hot ho bch cu a nhn trung tnh v to thn Khi c th mt kh nng dit khun, vim thng nng hn . - S thc bo: Ti vim c s t tp bch cu a nhn trung tnh, i thc bo, thnh phn b th. Bch c tiu vi khun mt cch t nhin. Hoc c mt cc yu t c nh vi khun (opsonisant) nh b c ca IgG) s c nh vi khun, sau , bch cu a nhn trung tnh s dit khun v tiu v tiu vi khun). - i thc bo: Gm nhng monocyte tn ti di 2 dng: Tun hon trong mu, trong cc t chc ( trong ph na hoc c nh ( gan,lch, hch) chc nng dit khun v thc bo ca chng th ging bch c chuyn chm hn bch cu a nhn v s thc bo ca chng l thuc rt t vo cc yu t c bo ng vai tr thng tin khng nguyn cho cc t bo thm quyn min dch. - Vi yu t th dch khng c hiu: + Nh vai tr ca lysozyme. + H thng b th: L mt lot nhiu proteine (gn 30), to nn mt min dch khng khng dch c hiu khi pht s hot ho ca h thng b th. C 3 con ng hot ho h thng b * ng u tin l ng tt do ni c t v cc polysaccharide vi khun khi pht s hot * ng th hai l ng c in do phc hp khng nguyn - khng th khi pht. Hai con n hnh thnh phc hp tn cng mng vi khun, to ra nhng l hng trn mng bo tng ca vi k vi khun neisseria). V li, cc C3a v C5a c tc dng t tp bch cu a nhn trung tnh. * Con ng 3 c th do s c nh ca "protein gn vi ng manose" ln cc thnh phn n 2.2.2. Phn ng c hiu C bn l p ng ca h thng min dch ca c th ngi bnh i vi tc nhn gy bnh, l qua c ch min dch th dch v t bo, min dch ny c c l nh chng nga. Trn lm sng, c khi phn ng min dch gy nn hin tng bnh l (thp khp cp). - Min dch th dch: l cc khng th, bn cht l glycoprotein, l nhng glubulin min dch, do cc Lymph B t trong cc dch th, c 5 loi (A,G, M, D,E), mi loi c tnh cht ring. + IgA: hin din trn b mt nim mc, c chc nng chng s kt dnh ca tc nhn gy bnh v + IgG & IgM: xut hin sm vo cui tun th nht ca nhim trng ln u v t nng cao Khi IgM bt u gim th IgG mi bt u tng ln v tn ti nhiu nm sau. C hai c kh n nzyme. Tu trng hp m cc khng th ny c kh nng ngng kt vi khun, ngng kt cc khn cc tc nhn gy bnh. 6

S lin kt ca chng vi cc khng nguyn tng ng to thnh phc hp khng nguyn- khng t ho hoc phc hp min dch ho tan (cn gi l phc hp min dch lu hnh), phc hp ny c dch, to nn nhng phn ng vim xut hin trong vi bnh nhim trng (v d: thp khp + IgE: tham gia trong cc bnh d ng v k sinh trng. + IgD: tng ln trong cc nhim khun mn tnh nhng khng c hiu cho mt loi nhim khun th th cho khng nguyn. - Min dch t bo: Gm vai tr ca Lymph T, i thc bo, t bo dit t nhin (natural killer cell), min dch tc nhn gy bnh sng ni bo. C ch min dch ny l quan trng i vi nhiu tc nhn g i khun (Mycoplasma, Chlamydia, Listeria, Salmonella, HIV/AIDS), k sinh trng (Toxoplasma, Leishmania), nm (Histoplasma, Cryptococcus neoformans...). Loi min dch ny xut hin chm trong nhim trng ln u. Thng, khi c s hin din ca hage s hot ho Lymph T (lymph T ng vai tr ch o ca min dch t bo). Cc t bo T c hot ho, chng c th tn cng trc tip t bo vt ch c gn khng nguy kch thch t bo B to ra glubolin min dch, hoc gip Macrophage dit vi khun gy bnh, h ADCC dit cc t bo mang khng th (antibody depending cytotoxic cellular: t bo c t b

th) Lymph T to cc cytokine nhm c ch s pht trin tc nhn gy bnh. Tm li: - S can thip ca min dch th dch gp trong a s trng hp, cn trong trng hp nhim buc th vai tr min dch t bo l ch o. - Trng hp nhim virrus: trong giai on virus huyt th min dch th dch xut hin, nhn , th phn ng qu mn v gy c t bo (min dch t bo) l ch yu. Ngoi ra, Interferon s xm nhp ca virus vo t bo mi, chng s sao chp v nhn ln ca virus (INF , , ). - Nhim nm cng xut hin min dch th dch v min dch t bo. - Nhim k sinh trng can thip bng c ch qu mn chm vi min dch th dch. IV. V PHM VI V MC NHIM TRNG 1. Nhim trng ti ch Hin tng vim - nhim ch khu tr ti ng vo, cc triu chng vim ti ch gm nng, , n, trng thi chung ca ngi bnh gn nh bnh thng - mi sinh hot hng ngy khng b n 2. Nhim trng khu vc T v tr nhim trng khu tr lan ra mt khu vc theo ng tnh mch hoc bch huyt. Mc vi nhim trng ti ch. C cc triu chng nhim trng ti ch + cc triu chng ton thn d h nhn vn cn c th c gng c trong mt s cng vic. Tuy nhin, xut hin cc triu hi c gng lm mt vic no mt hi th ngi bnh cm thy khng th lm tip na m phi , r ri chn tay, n lnh, ming ng, bnh nhn c cm gic khng mun lm bt c vic g. 3. Nhim trng ton thn nh hng ton b c th, tc nhn gy bnh theo ng mu to nn cc triu chng mt s c ny bnh nhn c th khng th c gng lm vic. 7

Tc nhn gy bnh c th to nn nhng tn thng trong khu vc chng xm nhp, nhng chng c c th bng cc sn phm ca hin tng vim hoc phc hp min dch lu hnh. V. H NH THI LM SNG V CN LM SNG Da trn c s lm sng v cn lm sng, c th c dch t hc m ngi ta chn on c bnh nhim. Tuy nhin,nh nu trc c nhiu trng hp bnh khng biu hin lm sng, bi hm ch rt kh xc minh bng xt nghim c hiu. 1.Hnh thi lm sng chung a s bnh truyn nhim din bin theo chu k, cc giai on nh sau: 1.1. bnh T lc tc nhn gy bnh xm nhp cho n khi triu chng lm sng khi u, thi gian ny tu ng ca c th. y l lng thi gian cn thit cho tc nhn gy bnh nhn ln v pht tri 1.2.Khi pht Lc c triu chng ban u n khi c triu chng, l thi k phn ng c th y vi t lm sng v cc bin i sinh hc. Thng khi u vi st, c khi km rt run, v m hi, chng theo tun t cho ta nhiu gi chn on bnh thi k ny. 1.3.Ton pht Giai on m cc triu chng bc l tng i y . -Tng qut: st, rt run, v m hi,au khp, nhc u, mt ng, mt mi. - C nng v thc th: khi nhim trng khu tr, khu vc hoc lan to, s xut hin cc du hi tng ph do hin tng vim, do nhim c hoc do min dch. 1.4.Thi k lui bnh - Khi bnh v thc th, c nng v sinh hc; bnh nhn c th hi phc li sc chm, nhanh t h min dch bn hoc khng bn. - Khi bnh nhng c di chng li. - Khi bnh c th tm thi, c th ti li, do: + iu tr cha c y , tc nhn gy bnh cn tn ti. + nhim mt tc nhn tng t khng c min dch cho. + bt thng ca c th cha c khc phc. + thiu phng tin khng c hiu v khng c hiu. + tn ti vt l trong c th. - Bnh c th gy ra mt s bin chng. Trn y l hng din bin thun li, hoc c s can thip ca tr liu, bn cnh , c nh r m bnh nhn c th t vong, mn tnh, iu ny cn tu thuc vo tc nhn gy bnh v bn h hp hay khng . 2.Cn lm sng (c hiu - khng c hiu) 2.1. Du c hiu

Nh c du c hiu m ta xc nh c cn nguyn gy bnh. C th soi cy trc tip, pht h cc on gene c hiu nh phng php khuyt i gene, hoc bng phng php min dch - ph 2.2. Du hiu khng c hiu Huyt hc: bch cu tng, bch cu gim, tng Lymph, tng Eosinophile. Mu: VS tng, Globulin tng, hin din CRP tng cao hoc khng (protein C phn ng), thay i h hc... 8 Ngoi ra ngi ta cn c cc du hiu v hnh nh hoc siu m...

Cu hi n tp 1. Hy lit k cc tc nhn gy bnh nhim trng, gii thch cc khc bit tnh cht gy bnh 2. Hy m t tm tt cc c ch gy bnh ca vi khun. 3. Trnh by c ch bo v khng c hiu v c hiu ca c th chng bnh nhim trng. 4. M t phm vi - mc nhim trng v vn dng vo tnh hung lm sng c th. 5. M t din tin cc giai on lm sng ca mt bnh truyn nhim in hnh. 9 Bi 2.

Mc tiu NGUYN TC S DNG KHNG SINH TRONG BNH NHIM KHUN

Ts,Bs Trn xun Chng 1. Phn tch c tm quan trng ca vic s dng khng sinh theo nguyn tc 2. Nhc li nhng im cn thit trc khi s dng khng sinh 3. Lit k c nhng nguyn tc chnh trong vic s dng khng sinh Ni dung

I. I CNG 1.nh ngha Thuc khng sinh c dng ch tt c nhng cht c ngun gc t nhin, tng hp v bn t khun. Nm 1928, Flemming pht hin nm Penicilium notatum dit c Staphylococcus aureus. Nm 1940 nghin cu Oxford (Anh) gm Flory, Chain v Hartley tinh ch c penicilin v m ra k ngu tr liu bnh nhim trng. n nay c > 2000 cht khng sinh c xc nh, song ch mt s 2.Tm quan trng ca thuc khng sinh Hin nay, bnh do vi khun cn l nguyn nhn chnh gy bnh v t vong trn th gii nht l WHO (2005) bnh nhim trng l nguyn nhn gy t vong hng u tr em ti cc nc ang p Khng sinh l loi thuc c dng ph bin khp mi ni nht l nhng nc ang pht tri v d phng nhim vi trng trong cng tc chm sc sc khe ban u l ht sc quan trng nh dit vi khun v t c mc tiu bo v sc khe cho mi ngi. Vn hin nay l khng khng sinh ngy cng gia tng i vi cc chng vi khun m trc us, Salmonella typhi, v ngy cng tng vi Enterobacteriaceae. Chng ta bit, dng khng sin

d gy khng thuc. S khng khng sinh thng dng ca mt s vi khun thng gp sau y: (Ngun: B y t, Chng trnh gim st quc gia v tnh khng thuc ca mt s vi khun thn Vi khun SXT Amp Gen Chl Nor Tet S. pneumoniae 45,0 8,7 18,0 20,9 45,9 H. influenzae 76,0 62,7 50, 8 31,8 18,9 032,7 S. typhi 85,3 91,6 2,7 86,2 0,0 14,8 S.flexneri 90,1 59,8 59,8 0,0 92,9 S.aureus 21,0 28,8 50,4 46,3 55,2 E.coli 76,9 85,6 31,1 82,8 21,0 82,3 Bng 1: Mt s vi khun khng khng sinh theo t l phn trm II. PHN LOI THUC KHNG SINH Nhiu cch phn loi khng sinh. Nh phn loi theo ph tc dng, phng thc tc dng 1. Phn loi theo ph tc dng C hai nhm l khng sinh c hot ph rng v khng sinh c hot ph chn lc. 10

1.1 Khng sinh c hot ph rng: Mt khng sinh c tc dng trn nhiu loi vi khun, c Gram dng v Gram m. Nhm aminoglycosid : streptomycin, gentamycin, amikacin Nhm tetracyclin Nhm phenicol Nhm sulfamid v trimetoprim 1.2 Khng sinh c hot ph chn lc Mt khng sinh ch c tc dng trn mt hay mt s loi vi khun nht nh. V d : Nhm macrolid: c tc dng trn vi khun Gram (+) v mt s trc khun Gram(-) nh erythromycin, roxythromycin, azithromycin Nhm polymycin hoc acid nalidixic: ch c tc dng trn trc khun gram(-). Nhm beta-lactam Nhm penicilin: tc dng i vi vi khun Gram(+), b penicilinase phn hy. Nhm methicilin: tc dng i vi vi khun Gram(+), khng b penicilinase phn hy. V d clo ilin Nhm ampicilin: hot ph rng, b penicilinase phn hy. V d : ampicilin, amoxicilin, pivampicilin Nhm cephalosporin: ph rng, b penicilinase phn hy. c chia thnh 4 th h. 2. Phn loi theo phng thc tc dng Ngi ta chia khng sinh thnh 2 loi : khng sinh c tc dng km khun v khng sinh c tc hin thc t khng c ranh gii r rng cho s phn bit ny v mt s khng sinh km khun n hun. Khng sinh c tc dng km khun: acid nalidixic, lincomycin, erythromycin, sulfam id, tetracyclin, trimethoprim Khng sinh c tc dng dit khun: aminoglycosid, cephalosporin, 5-nitroimidazol, penicilin, vancomycin, rifampicin III. C CH TC DNG CA KHNG SINH Sau khi vo c th, khng sinh ti ch tc ng s pht huy tc dng bng cch: - c ch sinh tng hp vch t bo vi khun : Vi khun sinh ra s khng c vch do d b t eta-lactam, vancomycin - Gy ri lon chc nng mng nguyn tng, c bit l chc nng thm thu chn lc, lm cho b thot ra ngoi. V d polymicin - c ch sinh tng hp protein : im tc ng l ribosom 70S ca vi khun. kt qu l cc ph hoc khng c hot tnh sinh hc. - c ch sinh tng hp acid nucleic : Gm c : Ngn cn s sao chp ca ADN to ADN con. V d nhm quinolon c ch enzym

gyrase lm cho phn t ADN khng m c vng xon. Cn tr sinh tng hp ARN nh rifampicin, gn vi ARN-polymerase l thuc ADN. - c ch sinh tng hp cc cht chuyn ha cn thit cho t bo. V d sulfamid v trimethopr ha to acid folic-mt co-enzym cn cho vic tng hp mt s acid amin v cc purin, pyrimidi IV. NHNG C IM CA KHNG SINH 1. c tnh sinh vt hc 1.1.Hot tnh chng vi khun Khng sinh tc dng qua c ch dit khun (Bactericides): Beta - lactamines, aminosides, quin lones nh gi bng nng dit khun ti thiu v thuc khng sinh tc dng qua c ch km Phenicoles, Cyclines, Macrolides v dn cht, nh gi bng nng c ch ti thiu. 1.2. S khng cu vi khun i vi khng sinh 11

Ngi ta phn bit khng t nhin v khng mc phi. khng t nhin c tt c cc mt loi. C ch cu khng c th do vic tit ra enzyme (Bta lactamase), s thay i v tr tc tnh thm ca mng t bo vi khun vi khng sinh hoc c ch plasmide hay s t bin. 2. c tnh dc hc ca khng sinh. Hiu qu v dc hc ca khng sinh c nh gi bi nng thuc trong huyt thanh v t c g thuc, qu trnh hp thu, phn b, chuyn ha v thi tr. T rt ra nhng thng tin v v s ln dng trong ngy, liu thch hp bnh nhn vi kh nng bi tit v so snh thu 2.1.S hp thu C th bng ng ung, ng tim bp hoc ng truyn tnh mch. 2.2.Phn b Sau khi hp thu , c hiu qu , nng ca thuc trong huyt thanh phi t c nng Bi v hu ht nhim khun l ngoi mch mu , nn thuc phi phn b vo c quan b nhim kh 3. Tc dng ph Vic hiu r tc dng ph ca khng sinh l mt phn trong vic la chn khng sinh khng im tra kt qu iu tr: Tai bin do ri lon vi khun ch: vim i trng mng gi, tc dn Cn phi bit r tai bin do ng dng nh: apxe do tim bp, thuc gy kch thch tnh mc liu cao ng tnh mch. V. NGUYN TC S DNG KHNG SINH 1.Ch nh Khng sinh c ch nh trong bnh nhim khun, khng c ch nh trong nhim virus ngi S dng khng sinh c gi l: - iu tr trong nhim trng do vi khun c ch im trn lm sng v vi khun hc. - D phng nh nhim trng trong hu phu, vim mng trong tim do vi khun, vim mng no do , thp khp cp. D phng nhim trng do vi khun.. D phng bng khng sinh ch dng trong m i vi mt nguy c nhim khun c th , cn mt khng sinh ph hp. Khng sinh d phng c th gy ri lon mi trng do gieo rc nhng mm bnh khng thuc. D Penicillin. D phng vim ni tm mc vi khun trn mt bnh nhn mc bnh tim , khi nh r hng ( penicillin chm ), thm d ni soi, phu thut bng, tit niu sinh dc (penicillin G llin + gentamycin). 2.Xc nh sm tc nhn gy bnh Da vo triu chng lm sng v xt nghim bnh phm nhum gram sm, l nguyn tc c bn, o trong chn la khang sinh. Sau , nui cy - lm khng sinh trc khi dng khng sinh. ty hoc m) hoc phng php pht hin khng nguyn trc tip (nh trong vim mng no) c iu, trc khi c kt qu cy tm tc nhn gy bnh. Sau khi ly bnh phm cn cho thuc khng sinh ngay trong trng hp nhim khun nng, nhim thn, vim mng no, nhim trng ng tiu, nhim khun ngi suy gim min dch, lao, nh 3.Chn thuc 12

Vic la chn ban u da trn phn tch mt vi tiu chun nh nhim khun khi im, tc mc ch s dng: d phng, iu tr theo kinh nghim hoc iu tr sau khi xc nh tc nh Ngoi ra cn phi cn nhc v c ch tc dng, c tnh dc hc, kh nng gy c v s tn lm sng trc , gi thnh nu c, s khng v nhng nguy c lin quan vi bi nhim. bnh nhn c mt s yu t lin quan cn xem xt k nh c quan nhim khun, tnh trng mi 4.Phi hp thuc S dng khng sinh n c ni chung c hiu qu trong hu ht cc trng hp, vic s dng k

ca s khng, t bin, nhim khun do nhiu loi vi khun nng. Mc ch phi hp khng sinh: Tm mt tc dng hp ng, phng nga khng khng sinh ca v sinh, v d: iu tr theo kinh nghim hoc nhim khun do nhiu loi vi khun, c tc d vim ni tm mc do Enterococcus hoc d phng vi khun khng thuc nh trong iu tr lao. Mt s nhim khun nh Lao, Brucella, Pseudomonas, hoc vi khun gram (-) c nhiu c ch Enterobacter, Serratia hoc nhim khun mt s ni nh vim ni tm mc, nhim trng no phu thut, vim mng bng, nhim Staphylococcus nng, bnh nhn gim bch cu... c th dn 5.Liu lng v thi gian dng thuc 5.1.Liu lng - Liu c nh: Aminoside, Glycopeptide, Tetracycline , Macrolide, Fluoroquinolon. - Liu thay i: Bta lactamines ty mc nhim khun, nhy cm ca tc nhn v kh nng th 5.2.Thi gian iu tr Thay i ty tc nhn, c quan b nhim khun v c a bnh nhn, nhng thng thng thi gi 5.3.Chn thuc khng sinh Ty thuc c quan b nhim khun: C quan b nhim khin c th gi vai tr chnh trong vic sinh Bnh nhn nghi b vim mng no phi dng thuc c th thm qua hng ro mu no - nc no ty, thm vo thuc phi l dit khun nh Chloramphenicol . Kh nng thm ca khng sinh vo p xe l km Ngc li trong nhim trng ng tiu hu ht thuc c nng cao trong nc tiu hn trong trong mu khng vi thuc nhng c th nhy cm vi nng trong nc tiu , nhng t ntoin v mui methenamine. Trong vim ni tm mc do vi khun , chn khng sinh qua c ch dit khun v ng tnh mc o m bo nng trong huyt thanh cao hn t nht 8 ln so vi liu dit khun ti thiu 6. Tng tc thuc S tng tc khng sinh quan trng v lm sng nhng t c lu ti v trc kia bta-lact vi thuc khc ngi s dng. Tuy nhin, hin nay fluoroquinolone, macrolide, rifampin c o nn tng tc thuc cng tng. S kt hp cc thuc khng phi lun lun gy hu qu lm iu dng v thi gian iu tr, nng huyt thanh ca thuc (khng phi khng sinh), s n , hoc cc yu t khc nh dng thng xuyn mt loi thuc. 13

7.S dng khng sinh mt s c a c bit 7.1.Tr em Thuc c thi qua thn chm hn ngi ln, trong iu kin thch hp nn s dng cc thuc ampicillin, y l nhng thuc sn c, d chi tr v r tin nn d c cng ng chp nhn. Khng nn s dng cc khng sinh sau: Phenicol, cycline (< 8 tui) quinolone (<15 tui). t h, nht l tr thiu thng, s dng khng sinh c th gy mt s tai bin do chuyn ho thuc v sulfamide chm, novobiocine. 7.2. Ph n c thai Cc thuc nhm Bta lactam: nh Penicillin, Ampicillin t gy c cho thai li l nhng thu r v r tin, d c cng ng chp nhn, cc thuc khc c th gy qui thai trong 12 tun in ca thai. Tuyt i khng dng Tetracycline, Aminoside, Phenicol, Rifampicin, sulfamide nitrofuranto in v dn cht cho ph n c thai nht l trong 3 thng cui cu thai k. S liu v s an to khc ph n c thai cn gii hn. Nhng thuc c th dng khi bt buc v nguy c bnh l aminoglycoside, azithromycin, imipenem, metronidazole, vancomycin. 7.3.Bnh nhn suy thn Trong nhiu trng hp cn gim liu i vi mt s khng sinh. - Khng sinh khng cn thay i liu: Erythromycin, Clindamycin, Chloramphenicol, Doxycyclin , Cefoperazon, Rifampicin, Metronidazol... - Khng sinh cn gim liu khi suy thn nng: Penicilin G, Amoxicilin, Cefalexin, Cefotaxim, Bactrim, Acid nalidixic, Ciprofloxacin... - Khng sinh cn gim liu khi c suy thn nh: Streptomycin, Kanamycin, Gentamycin, Vancomycin, Imipenem... - Khng sinh khng c ch nh dng khi suy thn: Tetracyclin, Nitrofurantoin, Sulfamid ch oridin... 7.4. Bnh nhn suy gan Trnh dng cc thuc khng sinh nh Chloramphenicol, Lincocin, Clindamycin...v

chng c thi tr v kh c u tin gan. Chloramphenicol d gy suy ty ngi suy gan. Tetracyclin c th lm tng transaminase b n siu vi. INH, Rifampicin c thi gian bn hy di bnh nhn x gan... 8. Theo di bnh nhn khi s dng khng sinh Theo di tai bin: Tai bin do ng vo, tai bin do liu lng, cch s dng thuc Theo di p ng thuc 9.Nhng iu cn trnh khi s dng khng sinh S dng khng sinh khng ng ch inh, s dng trn lan, cho rng khng sinh c th cha Cu hi n tp 1. K tn cc phn nhm ca nhm Beta-lactam. Mi phn nhm nu tn mt khng sinh tiu biu 2. Nu nhng c ch khng khng sinh chnh ? 3. Nu c tnh dc hc ca cc thuc khng sinh ? 4. C s ca s la chn khng sinh iu tr mt bnh nhim trng ? 5. Nhng iu cn lu khi dng khng sinh tr em ? 14 Bi 3.

Mc tiu NHIM KHUN V SC NHIM KHUN

Ts, Bs CK1 Nguyn L 1. Pht biu v phn bit c cc khi nim lin quan n nhim trng 2. Bit cch chn on, iu tr nhim trng nng, v sc nhim trng. Ni dung

I. MT S KHI NIM V NH NGHA V NHIM TRNG D cha hon ton chnh xc, nhng thun li v mt thut ng, Hi Ngh 8 B mn Truyn n g (Qung ninh) nm 2004 chp nhn thut ng Nhim trng bao gm nhim bt c vi sinh vt k sinh trng. T vi trng c thay bng t vi khun trnh nhm ln. Trong bi ging ny V mt l lun, chng ta vn cn mt s chng cho ln nhau trong nhiu khi nim lin quan n nhim trng. trnh nhm ln, chng ti ngh mt s thut ng sau : 1. Mang trng Ch tnh trng c s hin din ca VSV ngi (hay vt ch), nhng ch mc dnh vo b iu b ca da v nim mc vo bn trong v khng gy phn ng bt li cho c th. Tnh tr ng ng tiu ha... l nhng v d. Trong trng hp vi sinh vt tuy cng ch bm v da v ni bt li, thm ch nguy him cho c th th vn xem nh l nhim trng. Nhim vi khun t c th tn ti, VSV phi c kh nng bm dnh vo mt da v nim mc v khng li cc t mc. V d : tn ti c trn da, t cu phi c kh nng bm dnh vo lp thng b ( nh m trn nn cc cht v c nh nha, kim loi... to nn nhim trng cc thit b y t nh hi c kh nng chng li nhiu yu t st trng trn da nh tnh axit ca m hi, cc cht l heo cc tuyn nhy... Khi iu kin ti ch, hoc hng ro da v nim mc thay i, cc VSV ny c th xm nhp d nhn gy nhim trng.

Trong mt s trng hp, tnh trng mang trng ny dn n hin tng cng sinh vi vt ch. vi khun gy bnh pht trin. Mt s vi khun i trng to vitamin K cho c th... 2. Nhim trng Nhim trng xy ra khi VSV vt qua c hng ro da v nim mc, vo bn trong ni mi. Ngo bm dnh vo b mt ca da v nim mc, nhng c th phn ng bt li cho c th cng gi l 15

Hin tng ny xy ra khi: - Hoc VSV c kh nng xm nhp c hiu qua da hay nim mc. V d : virus HIV c th xuyn trc trng nguyn vn vo bn trong c th. Tng hp tt c cc kh nng xm nhp vo ni - Hoc do chnh hng ro da v nim mc b thay i do nhiu yu t khc nhau ( xy xt, tn do chn thng, do kim tim), ho hc (b n mn nh bng ha cht), nhit hc (bng), sinh m h hp khi nhim lnh lm cc VSV vn ang b mt c th xm nhp bn di lp biu m. 2.1. Nhim trng khng (hay cha c) triu chng Khi VSV xm nhp vo bn trong ni mi, nhng khng to nn mt phn ng no ca vt ch (ti di) ta gi l nhim trng khng (hay cha c) triu chng. Khi nim nhim trn g khng c triu chn g t hu ch trn lm sng (nhng hu d hch nhng trng hp tm c khng th c hiu cho mt VSV no (khng chng nga trc khng h c mt biu hin no trong tin s. Khi nim ny thng dng khi nhim trng tim vi khun thng hn khng c triu chng l mt v d. Vng trng huyt (c VSV trong mu, n c th, d rng sau VSV c th n mt ni c tr mi v gy bnh ti c quan khc) l m Khi nim nhim trn g ch a c tri u ch n g c dng cho nhng VSV c kh nng g h c th ko rt di. Hin ti ngi ta khng pht hin c mt ri lon no v lm sng v nhim virus vim gan B cha c triu chng. 2.2. Nhim trng c triu chng (mc bnh) Khi VSV xm nhp vo ni mi, to nn mt lot cc phn ng ca c th, tng tc cc phn n ho vt ch (d ti ch hay ton thn, cp hay mn tnh) ta c tnh trng mc bnh do nhim tr Hu qu ca cc tng tc phn ng ni trn c th c li cho c th ( tiu dit c VSV, t cho c th ( tiu dit ngay cc t bo ca chnh c th c dnh dng n VSV, tn thng cc min dch gy ra). D c li hay c hi, trc mt, kt qu l lm ri lon cc hot ng bn v thc th. Trong bi ny, khng cp n cc c ch kt dnh, ng vo ca cc VSV (cc bn c th t trng c triu chng, nht l nhim trng c biu hin ton thn, nhim trng huyt v sc n II. MT S NH NGHA QUY C Tuy cc nh ngha trn rt quan trng v mt l lun v gip ta hiu c bnh nguyn, bnh g kt dnh, xm nhp, c lc, phn ng vim, cc khng khng c hiu v c hiu ca c nhng trn thc t lm sng khng p dng c. Hi ngh v cc chuyn gia nhim trng ton th gii nm 1992 a ra mt s nh ngha man hnh cao nh sau : 1. Vng trng huyt : C mt VSV trong mu (cy mu hay ko lam mu dng tnh) nhng khng c biu hin triu chng g trn lm sng. 16

2. Nhim trng huyt : C VSV hay c t ca n km theo ri lon ni mi, biu hin bng tri 3. Hi chng p ng vim ton thn (systemic inflammatory response syndrome: SIRS): Khi c t nht 2 trong s cc triu chng sau : - St (nhit ly ming > 380 C) hay h nhit ( <36oC). - Th nhanh : Tn s th > 24 ln/pht. - Bch cu tng ( > 12.000 BC/mm3 mu ngoi vi) hay gim (< 4000/mm3) hay Bch cu ht (bands > 10%. SIRS c th do nhim trng hay do mt nguyn nhn khng phi do nguyn no khc to nn. (Do chng ti ngh dng trc tip t vit tt SIRS nh ta vn quen dng AIDS trong nhim HIV) 4. Nhim trng c p ng ton thn (sepsis) Sepsis (chng ti ngh dng trc tip t ny nh trng hp ca SIRS) l SIRS c nguyn nh y ch ang nghi ng). 5. Sepsis nng (hay cn gi l hi chng sepsis) Gm sepsis + cc triu chng biu hin ri lon chc nng mt hay nhiu c quan Gi l ri lon chc nng c quan khi c mt hay nhiu triu chng sau : 5.1. V tim mch : Huyt p tm thu 90 mm Hg hay Huyt p trung bnh 70 mm Hg v p ng 5.2. V Thn : lu lng nc tiu < 0,5 ml/kg/gi trong vng 1 gi d c truyn dch.

5.3. V h hp : t s PaO2/FI O2 250 hay nu ch c phi l c quan duy nht tn thng th t s ny 200 5.4. V Huyt hc : Tiu cu 80.000/mm3 mu hay gim 50% so vi ch s cao nht trong 3 ng 5.5. V chuyn ha : C hin tng nhim toan chuyn ha khng gii thch c : pH mu 7,3 hay mc kim thiu (base deficit) 5 mEq/L hay lactate mu gp 1,5 ln tr s cao nht c hng. 5.6. V b dch : , biu hin bng p lc tnh mch trung ng 8 mmHg hay p lc ng mc 6. Sc nhim trng Gm sepsis + h huyt p ko di t nht mt gi d b dch . Sepsis + h huyt p. Ch duy tr c huyt p tm thu 90 mm Hg hay huyt p trung bnh mch. (H huyt p khi huyt p tm thu 90 mm Hg hay gim >40 mm Hg so vi huyt p tm thu bnh thng ca bnh nhn) 7. Sc nhim trng khng hi phc Khi sc nhim trng c h huyt p ko di trn 1 gi, khng p ng vi b dch hay cc thu 8. Hi chng ri lon chc nng a c quan (multiple-organ dysfunction syndrome: MODS) Khi c ri lon chc nng t hai c quan tr ln. Cn phi can thip mi gi c cn bng n III. NGUYN NHN Nguyn nhn ca nhim trng ton thn c th l bt k mt tc nhn VSV bt c lp no (vi khun, nm, k sinh trng..). Hin tng VSV c mt trong mu khng nht thit, cng khn Ngc li, khng cn n ton b bn thn VSV, ch 17

cn nhng phn t, nhng c t c ngun gc t VSV, ti ch hay lan to trong mu cng c th Ngi ta ch pht hin c vi khun hay nm trong 24-40% trng hp c biu hin hi chng nng) v 40-70% c sc nhim trng. a s l vi khun (gram m hay gram dng) chim 75-80% ; hay hn hp nhiu vi khun. nhng bnh nhn cy mu m tnh, thng tm thy tc nhn gy d biu hin lm sng ca hi chng nhim trng, thm ch sc nhim trng rt r, vn khng IV. DCH T Hoa k, ghi nhn nhim trng nng gy t vong > 100.000 ngi hng nm. Tn s mi mc ca hi chng nhim trng hng nm t 300-500.000 ca hng nm. Hn 2/3 trng hp nh nhim trng. Nhng yu t lm d qu trnh nhim trng gm: i tho ng, x gan, bng, c c th, iu tr cc thuc gy gim bch cu. Nhng yu t ch yu gy nhim trng huyt gram hc trong ngi, bng, nghin chch ma tu. Nhim nm huyt thng gp nhng ngi suy gim cu, thng xy ra sau khi dng khng sinh ph rng. Tn s gia tng nhim trng huyt cn do mn tnh, tng s bnh nhn nhim HIV/AIDS. X dng corticoide, khng sinh, t thit b nhn g l nhng yu t nguy c cao. Vit nam, cha c thng k c h thng. Tuy nhin, bt c khoa no, nhim trng huyt mt c quan (thn, gan, phi.) khng c iu tr ng v kp thi. Nhim t cu t nhng nh gy nhim trng ch yu vi khun gram dng nc ta. V. SINH L BNH Phn ng ca c th i vi nhim trng thng bt u khi VSV lan t ng tiu ho hay da vo cc m ln cn. Cc nhim trng ti ch c th a n vng trng mu hay nhi vo mu qua ng tim chch. Trong nhiu trng hp khng tm thy nhim trng tin pht. VSV gy bnh vt qua c khng t nhin hay min dch ca c th. Nhng yu t ni ti cc suy gim hay thiu khng th, b th, min dch trung gian t bo. 1. Cc tn hiu ca vi sinh vt Mt s phn t ca VSV c c th nhn din nh l tn hiu xm nhp ca VSV. Mnh nht v saccharide (LPS). Ni c t khi xm nhp vo mu s c mt protein ca c th gn vo v c t bo n nhn, cc i thc bo, cc bch cu a nhn trung tnh. Tng tc ny dn n sn t hoi t u (tumor necrosis factor : TNF ), cht ny s khuych i cc tn hiu ca LPS t CD14 ha tan trong huyt tng cng s kt hp vi LPS v chuyn n cho cc t bo ni m 4 trn mng t bo. Mt s polysaccharide khc, mt s enzyme ngoi t bo, peptidoglycan v hoic ca vi khun gram dng, mt s c t cng c kh nng kch thch cc phn ng c th t th nhn c nhiu tn hiu khc nhau ca vi khun, khi ng qu trnh phn ng c th kh c th c kh nng nhn bit cc phn t ca vi sinh vt xm nhp gm: h thng b th (th in kt hp vi mannose, protein C hot ha (C reactive protein : CRP). 2. Phn ng ca c th 18

p ng vi nhim trng ca c th l mt chui tng tc phc tp gia cc phn t pht tn ian th dch v cc t bo ni m. 2.1.Cc cytokine Cc cytokin gy vim khuych i v lm bin i p ng. TNF kch thch bch cu v cc t y c chnh n, trnh din cc phn t kt dnh trn b mt cc t bo v tng cng chuyn ho nhim trng nng, nng TNF rt cao. Hn na, trn thc nghim, khi truyn TNF c th to chng nhim trng v nhim trng huyt nh st, tim p nhanh, th nhanh, tng bch cu, au NF c th gy sc, ng mu ri rc lng mch v cht. Cht i khng c hiu vi TNF c ng vt b tim ni c t LPS. Tuy nhin, du ng vai tr quan trng nht, TNF cng ch l mt trong nhiu cytokine gp trng. Interleukin 1 chng hn l mt cytokin khc c nhiu phn ng tng t nh TNF , v khi tin trnh nhim trng cng nng. TNF, IL-1, interferon- v cc cytokine khc c l t cc cht trung gian khc. Mt s cytokine nh TNF v IL-1 cn c kh nng kch thch sn x eed back dng. Khi qu trnh nhim trng nng hn, hn hp cc cytokine v cc cht trung gi tp. Ngi ta tm thy hn 30 phn t v tin phn t gy vim trng hp sc nhim trng. g nhim trng bng cch trung ho mt trong s nhng cytokine ni trn. Tuy nhin khi tin tr ta khng cu thot c ng vt b nhim trng nng hay b sc nhim trng . 2.2. Nhng cht trung gian dn xut t Phospholipide Arachidonic acid, gii phng t phospholipide ca mng t bo do men phospholipase A2, s chu o theo ng ca men cyclooxygenase to thnh prostaglandin v thromboxanes. Prostaglandin E prostacyclin l nhng cht gy dn mch ngoi bin trong khi thromboxane gy co mch v kch iu cu. Mt cht trung gian c ngun gc t phospholipide cng quan trng trong nhim trng l yu t latele-activating factor : PAF). PAF kch thch mnh tp trung bch cu a nhn v phng thc trong ht ca cc t bo ny, kch thch ngng tp tiu cu, v c th lm tn thng cc m 2.3. Nhng yu t ng mu Lng ng fibrin ni mch, to huyt khi v ng mu ri rc trong lng mch (DIC) l nhng TNF gy ng mu ri rc trong lng mch theo c ch : Khi u, cht ny lm cc bch cu ors) ln b mt t bo. Cc yu t ny khi l ra s kt hp vi yu t ng mu VIIa thnh l X v XI thnh dng hot ng. Kt qu a n khi ng qu trnh ng mu ni sinh ln ngoi mu cng c khi ng do h thng c ch ng mu ca protein C v protein S b tn thng ch hot ho plasminogen vn c nng cao trong qu trnh nhim trng.V vy c xu hng l , to huyt khi v chy mu. Hot ho h thng tip xc lng mch (contact system) thng . 2.4. H thng b th Hot ho b th to nn cc sn phm cng vi C5a kch thch cc phn ng vi bch cu a nh lng bch cu, sn xut cc gc Oxy t do. Khi a vo ng vt thc nghim, C5a gy h huy tnh thm mao mch (mt phn do tn thng cc t bo ni m) 2.5. Hot ho t bo ni m 19

Nhiu m b tn thng trong qu trnh nhim trng. Cc ni m mch mu cng b tn thng, g khi trong lng mch, t cn tr qu trnh a oxy v c cht n cc t bo ca vng b v cc huyt khi to bi si huyt, bch cu v tiu cu, cng c gp phn gy tn thng c vn l t bo ni m mao mch. Cc cht kch thch nh TNF sn xut v phng thch cc cyto yu t dn mch (nitrite oxide) v cc cht trung gian khc. Ngoi ra, cc phn t iu ho kt dnh ca bch cu vo ni m thnh mch. Trong khi cc phn ng ny lm tng kh nng th kh nng khng khun ca c th, th s hot ho cc t bo ni m cng lm tng thm thnh m uyt p. Hn na, thnh mch cn b tn thng bi cc enzyme ca bch cu a nhn (nh elast ian c oxy gy c t bo, gy nn xut huyt cc b. Ngn cn qu trnh kt dnh bch cu v chng li yu t kt dnh 1 (intercellular adhesion molecule 1), c th phng c hoi t m hc nghim. VI. LM SNG V THI X TR Qu trnh nhim trng huyt thng khi u vi nhim tin pht, c khi r rng (nht da, vim ng mt cp, vim thn b thn..), c khi rt kn o khng thy ngay c. 1. X tr ban u 1.1.Nhng triu chng gi St, lnh run, mt mi ton thn. Him gp hn l nhng triu chng h nhit, suy tun hon c g ng (l ln, m sng, ri lon tm thn), vng da khng gii thch c. Nhng triu chn 1.2. Cng thc mu

Thng cho thy tng bch cu, trong ch yu l a nhn trung tnh. 1.3. Cy mu Nn thc hin khi bnh nhn ang cao im cn st hay khi ang lnh run. Cy mu lp li t inh theo kinh nghim. Kt qu cy mu dng tnh s khng nh chn on nhim trng huyt sa 1.5. Khm ton din - Tm ng vo ca vi khun : da, ng tiu, ng mt, tiu ho, phi hay tai mi hng. Tr vin cn tm ng vo t cc ng tim truyn tnh mch, t cc thit b ng thng ng - Tm nhng nhim trng th pht - Khm lm sng b sung vi cc xt nghim hnh nh hc (siu m, X quang, CT..) - Xt nghim vi khun ti nhim tin - th pht nu (+) dng khng sinh tr liu. 1.6. nh gi trm trng - Lu n c a (tui gi, bnh c sn trc , tnh trng suy gim min dch) - Bn cht ca ng vo v nhng khu tr th pht. - Tnh trng huyt ng. - Tnh trng thc. 1.7.Chn phng thc iu tr ban u Ch yu iu tr triu chng, bt buc nhp vin. iu tr bnh tim tng hay c trc, phng theo kinh nghim, da trn bi cnh khi u ca nhim trng v ph khng sinh, s nhy cm k tng a phng. X l ng vo (rt sonde, thay catheter, dn lu m..). 2. X tr khi c kt qu xt nghim 2.1. nh gi li khng sinh dng Tu theo kt qu vi khun v khng sinh . 20

2.2. nh gi hiu qu iu tr Da vo tnh trng ton thn, nhit , bch cu mu v cc nhim trng th pht. - Nu st vn tip tc sau 3 ngy iu tr, cn phi cy mu li. Cc kh nng c th: * Kt qu cy mu vn nh ln trc: Sai lm trong dng thuc (liu thp, thuc khng thm oc nhim trng cha th dit ngay c sau 3 ngy: vim ni tm mc. * Kt qu vi khun ging nh cy ln u, nhng khng sinh khc: Vi khun t bin, tr n khng sinh (vi fluoroquinolone, fosfomycine, rifampicine, acide fusidique, cephalo sporin th h 3) v hay gp i vi mt s vi khun nh t cu, P. aeruginosa, Enterobacter, robacter) * Cy mu c kt qu vi khun khc ln u : bi nhim. * Cy mu m tnh: nhim trng su cha dn lu, vim tnh mch vng tim truyn, nhim t yt khi tnh mch su SC NHIM KHUN

L bin chng cp tnh, nng (c th t vong) ca nhim trng, c th cu c nu pht hin phn ring trong bi ny. I. NHC LI NH NGHA Nh ni trn, sc nhim trng gm : - Nhim trng c biu hin ton thn (sepsis ) - H huyt p: Huyt p tm thu < 90mm Hg hay gim hn 40mm Hg so vi huyt p tm thu lc b mch (o trc tip bng thit b xm nhp vo ng mch ni vi mt monitoring). Khng tm t - H huyt p ko di t nht 1 gi b lng dch. Hay: Phi dng thuc vn mch mi duy tr c huyt p tm thu 90 mm Hg hay huyt p ng mch trung bnh 70 mm Hg Ranh gii gia nhim trng ton thn nng v sc nhim trng rt mong manh, v th iu tr t l mt hnh thc phng sc nhim trng. Bn cht ban u ca sc nhim trng l sc gim t trng thch ng, s tin sang giai on sc lnh hay sc gim phn b mu (hypokinetic shoc toan mu, thiu niu, ri lon thc..). II BNH NGUYN 1.Cc yu t khi u Gii phng cc thnh phn ca tc nhn gy bnh nh cc mnh ca vch t bo vi khun (peptid ), ngoi v ni c t (vi khun Gram m), trong thnh phn lipopolysaccharide (LPS) vi l

de A c nghin cu nhiu nht. 2. ch tc ng 2.1. V th dch Hin tng hat ha b th, gii phng C3a v C5a v yu t ng mu XII. 2.2. V t bo Hot ha i thc bo, t bo n nhn, gii phng cc cytokin (TNF,IL1,IL6,IL8 ). 3. Hu qu Hot ha qu trnh ng mu, lin quan n nng ca tnh trang nhim trng. Hot ha cc bch cu trung tnh, dnh vo nhau v dnh vo t bo ni mc. Qu trnh ny a 21

Gii phng cc cht ca mng t bo nh acid arachidonic, cc gc t do v cc men thuc tiu ni m mao mch, gy tng tnh thm mao mch v dn mch, trn lm sng biu hin bi sc gi Di tc ng ca ni c t v t bo ni m b tn thng, nhiu cht trung gian hot ha. bo (ri c quan), gii thch giai on lm sng, tin trin, kh nng hi phc hay khng ca Suy tun hon cp: L hu qu ca gim th tch tuyt i (dch thm ra ngoi lng mch) v t v do tim khng b tr ni do tc dng inotrope (-) ca nhiu cht trong mu cha xc nh III. LM SNG C in ngi ta chia thnh 2 giai on: sc nng v sc lnh Triu chng Sc nng (hyperkinetic) Sc lnh (hypokinetic) Nhp tim mch nhy mnh mch yu Huyt p Bnh thng, p rng hiu p kp Du vn h (Marbrure) u gi + Suy tim trn lm sng + u chi Nng, kh, ti mu tt Lnh, vn cm thch Nc tiu (t sonde theo di l tt) Bnh thng hay gim < 20ml/gi Bng 2: Phn bit sc nng v sc lnh trong sc nhim trng IV. X TR 1. Chn on sc nhim trng giai on sm thng rt kh chn on, tng ng vi giai on trc y gi l sc nng. kit sc, lo lng , thay i hnh vi bun nn, th nhanh. Huyt p s bo ng hay xc nh Tuy nhin c trng hp sc xy ra t ngt vi triu chng nhim c nng ngay t u (t ba lnh) Nu b kp v dch, thng hi phc nhanh v khng qua giai on suy tim Hin nay, lactate mu l mt xt nghim thng c x dng nghi ng c thiu Oxy ca cc biu hin ton thn nng v sc nhim trng. C th theo s sau y ( ca GS Bruyant Nguyn, i hc Loma Linda, Hoa k) 2. Xc nh bn cht sc v loi tr nguyn nhn khng phi nhim trng 22

Cn tm cc triu chng lin quan n nhim trng (hi chng nhim trng ton thn nng, nh hit, tng hay gim bch cu hay p ng vim ton thn, nu l du hiu duy nht th khng 3. nh gi hu qu ca sc 3.1. Lm sng nh gi mc h huyt p, tun hon ngoi vi, chc nng thn (v niu, cn thm phn - chy t hi chng ARDS, cn th my), thn kinh (m kh qun, t sonde d dy, h hp h tr), tiu o thiu mu cc b). 3.2. Cn lm sng nh gi cc ri lon chuyn ha (Tng lactate mu > 2mmol/L, in gii , cre gan ( mt, tiu t bo gan, suy gan), chc nng cm - ng mu ton b (DIC, tiu si huyt) 4. Xc nh nguyn nhn nhim trng Cy mu. Tm vi khun ng vo, cc nhim di tr (nhum soi, cy bnh phm). 5. Xt nghim khc ty theo gi lm sng. C ch Nguyn nhn Lm sng Cn lm sng Nghn mch mu v tim Thuyn tc phi au ngc, suy tim phi, vim TM

ECG, Phim phi, kh mu, phng x phi, chp mch mu phi Suy tim Chn p do trn dch Nhi mu c tim Lon nhp Mch nghch l, suy tim phi hay ton b au ngc, suy tim ton b ECG, siu m ECG, trophonin, siu m ECG Gim th tch tht s hay tng i Chy mu Phn v Vim tu cp Xanh, chy mu ra ngoi da, ph Quincke au bng Cng thc mu

Amylase mu Bng 3: Mt s xt nghim ty theo bnh cnh lm sng V. IU TR C TH Sau khi khm v cn nhc chn on mt cch nhanh chng, cn tin hnh iu tr ngay lp tc, khng ch i cc kt qu. 1. iu chnh huyt p Trc tin, phi b dch trong vng 20 pht, di hng dn ca p lc tnh mch trung tm. C o ngi ln hay 20ml/kg cho tr. Nu huyt p vn tip tc thp hay kp, hoc ci thin t, t Nu vn tht bi, c th dng thuc vn mch nh Dopamin 10-20 g/kg/pht tng dn 2-5g/kg m Nu khng c hiu qu, cn xem li tt c cc xt nghim lin quan nh hng iu tr. phi v ng mch phi bt. Nu cc thng s chng t b dch cha , tip tc b dch. Nu pht km Dobutamin 5-15 g/kg/pht. Nu khng ci thin c th dng Adrenaline 0,5-5g/kg/pht. tr em, qu trnh cng tng t, tuy nhin cn cn nhc khi cc thng s cho bit c th do h, c th dng Noradrenalin (0,5-5g/kg/pht) km theo Dobutamin hay khng (5-15 g/kg/pht) h dng mt mnh Adrenaline 0,55g/kg/pht. 2. iu tr nhim trng Nu thnh cng, x dng khng sinh theo kinh nghim v tip tc theo di, khi c kt qu khn theo di. 23

Cu hi n tp 1. Trnh by cc khi nim v mang trng, nhim trng c triu chng v nhim trng khng c 2. Trnh by cc nh ngha theo quy c v hi chng p ng vim ton thn (SIRS), sepsis sepsis nng, h huyt p (trong nhim trng), sc nhim trng v hi chng suy a ph tng. 3. Phn bit vng trng huyt v nhim trng huyt. 4. nh ga t bo khng c cung cp oxy, trong sc hin nay ngi ta thng xt nghi ICU hin i). 5. Trnh by li s chn on sepsis nng/sc nhim trng. 24 Bi 4.

Mc tiu ST K O DI CHA R NGUYN NHN

Ts, BsCK1 Nguyn L 1. Sinh vin bit v nm vng nh ngha quy c th no l st ko di cha r nguyn nhn. 2. Trong kh nng v phng tin sn c ty theo mi trng, c th x tr hp l trc mt t Ni dung

I. NH NGHA Nm 1961, Petersdorf v Beeson nh ngha st ko di cha r nguyn nhn nh sau: - Nhit bnh nhn lun lun trn 38,2 C d o bt k lc no. - St ko di trong sut t nht 3 tun. - Tin hnh mi khm xt lm sng v cn lm sng trong phm vi c th c mt bnh vin, nhn. St ko di cha r nguyn nhn (SKDCRNN) v vy c th phn bit c vi nhng trng hp t 4 gi. nh ngha ny c cng nhn v x dng rng ri trn ton th gii trong 30 nm v c xem n nay, vi s tin b ca Y hc, Durack v Street ngh cch phn loi mi v st ko di Phn loi st ko di cha r nguyn nhn c im Tnh trng bnh nhn ang nm vin. Khi vo khng st. ang cn sn sc c bit Ti bnh vin Gim bch cu Nhim HIV C

BC trung tnh < 500/mm3 hay l s gim xung mc ny trong vi ngy Khng nh vi Western Blot (+) Tt c nhng ngi khc st ko di trn 3 tun Thi gian t khi mc n khi khm bnh 3 ngy l 3 tun 3 ngy 3 ngy. Nu ngoi tr

3 ngy hay n khm 3 ln tip nhau (ngoi tr) Mt s nguyn nhn minh ha Vim tc TM nhim trng, vim xoang, vim i trng gi mc, st do thuc Nhim Lao, trng quanh lymphoma, do thuc hu mn. Nhim nm Candida, Aspergillus

ARV, nhim phc hp Mycobacteria khng in hnh

Nhim trng. Bnh

tnh, cc bnh gy vim, do thuc.

Bng 4: Phn loi st ko di cha r nguyn nhn Tuy nhin trong bi cnh knh t -x hi v nn y hc ca nc ta, p dng nh ngha c in trong bi ny, ch cp n st ko di cha r nguyn nhn c in. 25

Hi chng vim: Gi l hi chng vim cn lm sng khi c : VSS tng ( >16mm n ng, >25mm green, hoc >7mm nam gii, >16mm n gii theo phng php Wintrobe. Ngai ra, ngi ta cn lu rng mt s protein cng gia tng, ph bin nht l protein C ph II.CC BC CHN AN SKDCRNN 1. Tin s Hi bnh s v tin s cn thn l mt khu c bn trong chn an. Cn xc nh 7 im sau : - Cc thuc x dng - C i du lch u khng ? - C tip xc vi ng vt. - Ngh nghip - Li sng - Tin s bnh - Triu chng hin c. Mt s thuc c th gy st,nht l mt s khng sinh. Trong trng hp ny st bin mt tron , v xut hin li khi thuc c tip tc dng. Du lch n nhng vng dch t ca st rt, st vng c th gi n cc bnh ny. Tip xc (bnh do Ricketsia, bnh Sodoku) Mt s ngh nghip c th to iu kin mc mt s bnh c st nh chn nui chim c th mc Li sng cng nh hng n mt s bnh nh nghin ht c th dn n AIDS. Tin s c th gi cho mt nguyn nhn st. V d : tin s si mt gi n mt nhim tr Nhng triu chng hin ti rt quan trng nh hng chn an. Tuy nhin theo nh ngha RNN thng rt ngho nn v khng cho php hng n mt cch r rt mt bnh no. 2. Phn tch din tin cn st Phn tch din tin cn st thng rt hu ch cho chn an. V d st thnh tng cn km t ca nhim trng huyt, st c chu k thng gp trong st rt 3. Khm lm sng t m v tan din Rt c ch cho chn an nguyn nhn st. Cn ch c st cn khng ? c ting thi tim kh h, hch c ln khng ? Khm tuyn gip lai tr hoc cnh gac cc bnh v tuyn gip (cn tai mi hng tm cc bnh c th gy st vng ny, nu cn tham kho thm kin ca c 4. Xt nghim cn lm sng : Ty theo trang b v phng tin ca c s. Tuy nhin, mt cch tng qut, trong tun u ti st huyt , t bo vi trng nc tiu, cy mu. Ch cy mu phi c tin hnh trc khi giang mai, Yersinia, c Brucellose nu c yu t dch t gi , v virus CMV, in di protein lng cc men transaminase, Phosphatase kim, phosphatase acid nam 26

gii. Chp X quang mt s c quan nghi ng c th b bnh nh phi, rng, xoangSiu m ni t cng cho php pht hin mt s bnh gy st (Vim ni tm mc bn cp chng hn). Kt qu ca mt s xt nghim cn phi l gii mt cch thn trng v khng thiu trng hp thc bch cu thng o ngc, phosphatase kim thng tng, yu t thp dng tnh mc du rng hp m tnh gi. V d : Phim phi c th bnh thng trong nhiu tun trong mt ca lao Trong nhng trng hp kh khn, i khi ta phi tin hnh mt s xt nghim gy phin phc, ty , ni soi, hoc nhng xt nghim tn km nh chp in tan ct lp 5. iu tr th Nhiu trng hp ta tin hnh iu tr th theo hng c nghi ng nhiu nht. Chin lc i a phng. V d nc ta, c th iu tr th st rt, thng hn, Trong trng hp nghi h vi khng sinh thch hp. 6. M thm d Nhiu trng hp c nhng triu chng nghi ng nhng khng xc nh c bn cht ca bnh ta lng, ng trn quan im v quyn li ca bnh nhn m quyt nh. III. NHNG NGUYN NHN C TH DN N SKDKRNN 1. Nhim trng

1.1. Nhim trng tan th 1.1.1. Do vi khun - Nhim trng huyt do cc cu khun Gram dng : T cu, lin cu, ph cu. - Nhim trng huyt do cc vi khun Gram m nh Thng hn, E.coli,Listeria - Lu, giang mai - Leptospirose, bnh Lyme - Lgionellose - Dch hch v cc bnh do cc chng Yersinia khc - Lao - Nhim vi khun Whitmore - Bnh Hansen. - Ricketsia - Nhim Mycoplasma 11.1.2. K sinh trng - St rt - Toxoplasmose - Leishmaniose - Trypanosomiase - Cc bnh do giun sn (sn mng,amip ni tng..) 1.1.3. Nm - Nhim Candida - Nhim Cryptococcus 27 - Histoplasmose 1.1.4. Virus - Epstein Barr - Cytomegalovirus - HIV 1.2.Nhim trng ti ch 1.2.1. h tim mch - Vim ni tm mc - Vim mng ngai tim - Vim tc tnh mch (no, tnh mch ca..) - Phnh ng mch nhim trng 1.2.2. h h hp - Cc bnh vim phi, c bit lu n cc bnh phi co Chlamydiae, do Legionelle, do Pneusmocystis carinii - Vim mng phi c m. 1.2.3. bng - p xe gan - Vim quanh gan (do Chlamydiae) - p xe di c hanh - Vim ti mt, vim rut ha, vim ti tha Meckel, vim i trng sigma. - p xe lch - p xe thn, vim i b thn,Vim ty quanh thn. - p xe vng chu, vim vi trng, - Vim tuyn tin lit. 1.2.4. Thn kinh - p xe no - Vim mng no - Vim ngoi mng cng 1.2.5. Xng - Vim xng, vim xng-khp - Vim a ct sng 1.2.6. Vim xoang, vim li, rng. 2. Do u - Cc u lympho dng Hodgkin hay khng phi Hodgkin. - Ung th mu (leukemia) - Bnh Histiocytose

- Cc khi ung th khc : tin pht nh K thn, K i trng, K phi, hoc t ni khc di cn - Cc u lnh tnh (U c trn ng tiu ha) 3. Cc bnh c bn cht vim. - Bnh Horton, bnh Takayasu - Vim mch mu hai t, bnh Wegener. 28 - Lupus ban ri rc. - Bnh vim c-b nhiu ni (Polydermatomyosite) - Thp khp cp - Vim a khp thp - Vim cng ct sng - Bnh Still - Bnh Crohn - Bnh Whipple - Sarcoidose - Bnh Bercet 4. Nhng nguyn nhn khc - Do thuc - Bnh huyt khi-thuyn tc - Vim gan do ru - Cng gip - U nhy - Cc bnh phi do lng ng min dch - Phnh ng mch ch - X ha sau phc mc - U x t cung (hai t v trng) - Ti hp th mt u mu - St gi v. Cu hi n tp 1. Phn bit st vi tng thn nhit c tnh (do say nng, say nng...). 2. Cc bnh nhim trng cp nguy him c biu hin u tin l st hay gp Vit Nam 3. Khi no th dng thuc h nhit trong mt trng hp st cp tnh? 4. Trnh by nh ngha c in v st ko di cha r nguyn nhn. 5. Trnh by cc nguyn nhn gy st thng gp trn mt s c a c bit: nhim HIV, gim 29 Bi 5. HI CHNG VNG DA TRONG CC BNH NHIM TRNG

Mc tiu BsCK2,Ths H th Thu Vng 1.Trnh by c triu chng lm sng v cn lm sng ca hong m nhim khun. 2 .Chn on sm nguyn nhn gy hong m nhim khun. 3. Ch nh kp thi iu tr h tr v nguyn nhn. 4. Xc nh c cc bin php phng bnh Ni dung

I. I CNG Hong m l biu hin lm sng ca tnh trng tng nng bilirubin trong mu trn mc bnh a .Hong m nhim khun thng cn thit c mt chn on nguyn nhn khn trng nhm c bi II. C CH HONG M 1. Tng sn xut bilirubin Do tn huyt nhiu hn bnh thng c th gp trong st rt, nhim trng huyt,... 2. Ri lan qu trnh thu nhn bilirubin vo t bo gan Gp trong vim gan nhim c do thuc (Rifamycin, novobiocin... ). 3. Ri lan qu trnh lin hp do thiu enzyme glycoronyl Gp trong vim gan, x gan, vng da tr s sinh. 4. Ri lan qu trnh vn chuyn bilirubin vo ng mt Gp trong x gan, vim gan nhim c thuc (INH, oestrogen, halothane... ). 5. Tng sinh ng mt - Vim gan qun mt - Tt nghn ng mt - Chn p ng mt: gp trong x gan, si mt, u ng mt, vim c vng odi, u u ty, III. PHN LAI NGUYN NHN HONG M 1. Theo bilirubin mu 1.1.Tng bilirubin trc tip Nguyn nhn ch yu l cc bnh l t ng mt trong gan tr xung 2.2. Tng bilirubin gin tip Nguyn nhn c th l cc bnh l t t bo gan tr ln, nhng thng l trc gan 1.3. Tng bilirubin hn hp Thng gp trong vim gan cp hoc mn 2. Theo v tr 2.1. Hong m trc gan 30

Do hng cu v nhiu, gii phng nhiu huyt sc t. Nguyn nhn c th do :st rt, nhim tr 2.2. Hong m ti gan Do tn thng t bo gan, lm cho mt cc vi ti mt qun d thm vo cc vi ti huyt qun, thng t bo gan, cc vi ti mt qun cng c th b tn thng, tit nhiu cht nhy, lm th Nguyn nhn c th do: vim gan do virus, nhim xon khun, nhim trng mu .... 2.3. Hong m sau gan Do cn tr c gii trong hoc sau gan lm cho mt khng xung c ng tiu ha, li trong thng gp l tc mt do si IV. LM SNG 1. Hi bnh 1.1. Tin s c nhn - Bnh l gan mt ( si mt ), tin s hang m tng thi k, cn au qun gan. - Ngh nghip: tip xc vi ha cht, sc vt, li vng m ly, sng sui. - Nhng thuc s dng gn y, ru - Tin s mi y: phu thut, sy thai, no ph thai, sinh , truyn mu hoc sn phm ca 1.2. Tnh cht ca vng da 1.3. Tin triu: Nhc u, au khp, ban 1.4. Du hiu i km: nga nhiu ( mt), au bng (si mt), au c (leptospirose) 1.5. Tin trin ca st: St cn c rt run kiu st rt, st gim khi xut hin vng da 2. Khm thc th: Nhm tm kim: 2.1. Cc du hiu nng ca bnh - S ri lan huyt ng: mch, huyt p, mu sc da, lng nc tiu. - S suy thoi t bo gan: hi chng xut huyt, bnh l no gan, din c ca gan gim, hi - Hi chng mng no kt hp thiu niu, v niu (leptospirose). - Nhng du hiu huyt tn cp ( da xanh, da nim mc nht, mch nhanh, lch ln...). 2.2. Cc du hiu khc -Tnh trng gan ( ln, mt , tnh cht, b mt gan, phn hi gan tnh mch c, ti mt l - Du hiu tng p lc tnh mch ca - Du hiu mt: da mt vng, nga, phn bc mu, nc tiu m mu, mch chm... 3. Cn thm khm mt cch tan th cho php ngi thy thuc c ci nhn tng qut V. CN LM SNG 1. Bilan nhim trng Cy mu, cy nc tiu, chc d nc no ty nu c hi chng mng no. Tm k sinh trng st

Cc phn ng huyt thanh ty theo tnh hung 2. Chc nng gan, tnh trng mt - Hy hai t bo gan: SGOT, SGPT - mt: Tng bilirubin kt hp, phosphatase kim 31

- Suy t bo gan: t prothrombin gim, yu t V, fibrinogen, ng mu, albumin mu gim. 3. Huyt tn Tng bilirubin t do, t bo li, st huyt thanh, haptoglolin. Hemoglobin nc tiu (+). 4. Thm d v gan - Siu m gan: C ch li khi c hin din ca hi chng mt. - Chp ct lp:c th nh gi tnh trng ch m gan, ng mt, ty tng, lch, ti mt... - Chp ng mt: + Chp thng + C ung hoc tim thuc cn quang + Chp ng mt ngc dng + Chp ng mt trong khi soi bng - Ghi hnh gan bng ng vi phng - Soi bng - Sinh thit gan 5. Xt nghim min dch hc - Cc phn ng huyt thanh chn on vim gan siu vi nh :Tm HBsAg, anti-HBs, anti-HBc, ant ti-HCV. - Cc khng th t mim nh khng th khng nhn, khng th khng c trn. - in di Globulin min dch. VI. CHN ON NGUYN NHN + Chn on sm tin lng v iu tr kp thi v chuyn bnh nhn ng tuyn. + Cn phn loi cc nguyn nhn ca hi chng hong m: - Hi chng hong m do huyt tn: St rt, nhim trng huyt do vi khun k kh... - Hi chng hong m do tc mt: Si ng mt. - Hi chng hong m do vim gan: vim gan siu vi. + Chn on c mt s nguyn nhn gy hong m nhim khun thng gp: 1. Vim ng mt trong gan - Lm sng: tam chng: au, st, vng da mt. + au h sn phi hoc thng vi, au t nhin hoc khi n hay th su, au lan ln vai, th + St cao t ngt, giao ng hay km rt run. + Vng da v nim mc kiu mt. Cng c nhng trng hp khng in hnh: khng vng da, khng au, ch st n thun. - Xt nghim: Bch cu tng, a nhn trung tnh tng, cy mu c th (+) (a s E.coli). Siu V tr ch tc c th xc nh bng chp ng mt ngc dng. a s nguyn nhn l si, c khi l khi u bn ngoi hay trong ng mt, c khi do sn l gan, giun a... 2. Nhim trng mu Vng da gp khong15%, ch yu trong nhim trng mu do vi khun gr (-) bt ngun t ng ti h nhim trng huyt c th km theo hang m nhng mc khc nhau, gan to 30-50%, xy ra 32

trng huyt din bin trong 10-20 ngy song song vi tin trnh nhim trng, tin lng thng nng. Xt nghim: bilirubin kt hp t ng km du hai t t bo gan h n l suy gan. 3. St rt Trong st rt thng c th c hang m nh, hong m r thng gp th st rt i Hemog 3.1. St rt i Hemoglobin + Lm sng: khi t ngt bun nn, nn ra dch nh mt, au vng hng, nhc u. thi k tan pht bnh nhn st lin tc hay tng cn, cn st i i vi t tn huyt. N chng trung thnh ca bnh, xut hin t 6-12 gi sau khi i tiu en, lc u c th nh sau Bnh c th a n thiu mu v suy thn, th nng t l t vong ln n 20-30% + Xt nghim: Hb niu (+),Hng cu niu (-), k sinh trng st rt (+) hoc (-) 3.2. St rt th gan mt

Ngoi cc triu chng lm sng v cn lm sng ca st rt, bnh nhn c vng da v mt, tiu gan c th khng nghim trng lm, biu hin lm sng ca suy gan him gp. Trng hp nng tng cao, thi gian Prothrombin ko di. 4. Nhim Leptospira L bnh ca sc vt hoang di v gia sc lan truyn cho ngi, c c im lm sng a dng, biu hin tn thng cng lc nhiu c quan, ch yu l gan, thn, mng no. Bnh thng gp vng nhit i, c bit vng nng thn, rung ry, khu chn nui. Lm sng bao gm 5 hi chng chnh, trong hi chng nhim trng l c bn + Hi chng nhm trng: St cao 39-40 t ngt, c th km rt run, mt nhiu, chn n, li t nhin v tng khi s nn nht l c bp chn, c i. Kt mc mt xung huyt, da c th + Hi chng gan mt: vng da thng l mu cam ging mu lu chn, gan ln v au, i khi lch ln. + Hi chng thn: Ure, creatinin mu tng, nc tiu c albumin, hng cu, bch cu, tr niu + Hi chng mng no: L biu hin quan trng trong giai an min nhim, dch no ty: bch 00 mm3) + Hi chng xut huyt: Chy mu cam, ban xut huyt... 5. Vim gan siu vi Bnh thng gp ti gan do HAV, HBV, HCV, HDV, HEV, HGV... gy ra. 5.1. Lm sng Lm sng ca vim gan siu vi thay i, c th khng c triu chng hoc c th vng da v m hay th mn tnh. Vim gan siu vi th cp in hnh din qua 4 giai an: + Thi k bnh: Thay i ty theo lai virus gy bnh + Thi k khi pht: St l du hiu thay i, thng bnh nhn st nh, mt mi, u oi, ch vim gan siu vi B, C ) pht ban gp trong 5 - 15%, nn ma, au h sn phi, tiu t v m 33

+ Thi k tan pht: Bnh nhn ht st, mt mi v chn n hn. - Vng da - vng mt l du quan trng xut hin 4 - 10 ngy sau khi triu chng khi pht v ko di 2 - 8 tun sau gim dn, nc tiu m mu, phn bc mu, c th nga. - Gan ln va v au nh lc khm, lch c th ln trong 5 - 25% trng hp + Thi k hi phc: Bnh nhn cm gic khe, cc du hiu lm sng hu nh khng cn na, tu r v bnh thng, cn khang vi tun na mi c tnh trng hi phc v xt nghim. 5.2 Cn lm sng - Hi chng hy hai t bo gan: SGPT, SGOT tng 5-10 ln tr ln so vi tr s bnh thng, t l SGOT / SGPT < 1 - Hi chng mt: Bilirubin tng, ch yu bilirubin trc tip, sc t mt, mui mt nc tiu dng tnh. - T prothrombin bnh thng th thng thng, nu t l gim < 30% tin lng nng. VII. IU TR Cn iu tr h tr v iu tr nguyn nhn kp thi: 1. iu tr h tr Ty theo bnh cnh lm sng: - H nhit: Khng nn x dng mt cch h thng nht l khi cha tm ra nguyn nhn. - Chng chong nu c - Chuyn mu khi c thiu mu cp - Phng chng suy thn cp. 2. iu tri nguyn nhn - Nhim trng huyt, vim ng mt : Dng khng sinh. - St rt: Dng thuc khng st rt nh: Artesunate. Mefloqiune... - Nhim Leptospira :Khng sinh Penicillin 100.000 v/kg/ngy x 5 - 7ngy, Tetracyclin, dox ycyclin 100mg x 2 vin/ngy X7ngy VIII. PH NG BNH Ty theo nguyn nhn Cu 1. 2. 3.

hi n tp Trnh by c ch v phn loi vng da theo v tr Trnh by cc du hiu nng ca hi chng vng da trong cc bnh nhim trng. Nu vi ng Nu mt s xt nghim chn on nguyn nhn thng gp ca hi chng vng da nhim kh

4. 5. 34

Trc mt bnh nhn c vng da cn hi g chn on nguyn nhn iu tr h tr hi chng vng da nhim khun

6. Bi 6. HI CHNG ST PHT BAN NHIM TRNG

Mc tiu Ts, BsCK1 Nguyn L 1. Khm v ghi nhn y cc d kin lin quan n mt trng hp st pht ban. 2. C nh hng chn an v cho cc xt nghim cn thit xc nh nguyn nhn st pht ban. Ni dung

C rt nhiu bnh c biu hin st v pht ban. Bn thn t n cng bao hm nhiu hnh mao mch hay phn ng ca da) biu hin da v nim mc. Do , st pht ban thng l mt c Tuy nhin a s nguyn nhn gy st pht ban l vi sinh vt, trong nh bnh sm s gip g gim ly lan cho cng ng, v cao hn na , c th gip ngi bnh that cht trong mt s xut huyt do no m cu. Cc hnh thc biu hin khc nhau ca cc lai ban s gip ngi thy thuc gii hn li cac lm sng v dch t, trong nhiu trng hp, c th cho chn an kh chnh xc trong nhng t I. MT S NGUYN TC KHM MT BNH NHN ST PHT BAN 1. Mt s vn cn lu - Tnh trng min dch hin ti ca bnh nhn. Tin s v chng nga. - Cc thuc x dng trong vng mt thng trc ngy c ban. - C tip xc vi ng vt g ? ( vt nui hay ngai nh). C b ng vt hay cn trng t - Du lch : c n vng no c cc bnh a phng c bit ang lu hnh ? - C tip xc vi ngi no c bnh tng t ? - C nguy c mc bnh ly qua ng tnh dc ? - Bnh nhn c chch ma ty v dng chung kim tim vi ngi khc khng ? - Bnh nhn c bt thng hay bnh tim mch ? Bnh nhn ang dng thit b tr gip nhn to hn to, catheter..) 2. Khm biu hin ban 2.1. Phn lai ban - Ban khng xut huyt (thng gi l ban , hng ban) - Ban xut huyt ( t ban : purpura) - Ban dng bng nc hay mn m. 2.2. Ban ni ln th no so vi b mt da ? (hnh thi ni dy: eruption) - Dt (macule): nm phng so vi mt da, vng thay i sc t gii hn tng i r. 35

- Sn (papule) : ni ln khi mt da, ng knh ban < 5mm - Mng (plaque) : ni ln khi mt da, ng knh > 5mm. C dng cao nguyn, b mt phng s u - Nt (nodule) : ni khi mt da, ng knh > 5mm, nhng b mt cong, khng phng nh mang. - My ay (wheals hay urticaria, hives) : dng sn hay dng mng. C th tp hp li thnh My ay c in ( khng do mao mch) thng ch xut hin 24-48 gi ri ln. - Mn nc : vesicule ( < 5mm) v bng nc : bullae (>5mm) : nhng ti c cha dch ni ln - Mn m (Pustule) : l mn hay bng m dch cha l m. - T ban chm : khng s thy g ln mt da, do xut huyt. Gm: ban xut huyt lm tm (Pet 3mm v mng xut huyt (echymose) ng knh > 3mm. - T ban ni: g ln mt da, do vim thnh mch mu (vasculitis), sau xut huyt. 2.3. Mt s vn khc Cng cn xc nh thi im xut hin ban so vi st v mt s triu chng khc. Xc nh v

tan thn. C i xng ? Qu trnh lan t thn ra t chi hay ngc li. Tc lan ca ban ( vng, ban mc cng ln hay ln lt ? c cc ban cc tui khc nhau khng ? C ni ban t ? C li so hy du vt g trn da khi ban mt i khng ? 2.4. Khm tan din Khm tt c cc c quan v h thng khc pht hin cc triu chng khc. i khi rt quyt si..) II. PHN LAI V MT S C IM THEO NGUYN NHN phm vi bi ny, ch cp n mt s bnh tan thn c st v pht ban. Nhng biu hin b itis) hay chc (impertigo) c dnh cho gio trnh da liu. Chng ti cng ch trnh by mt Nhng trng hp khc, ngi c c th tham kho thm ti liu lin quan. C nhiu cch C th phn lai theo nguyn nhn: virus, vi trng, nm, d ng, do cc nguyn nhn khng nhi hn lai theo tnh cht v phn b ca ban. Thit ngh nh th thun tin hn cho chn an. 1. Ban dt sn, ch yu mc thn : l lai st pht ban ph bin nht. - Si: thng mc u tin chn tc, sau lan dn xung thn v t chi. Nhng khng c n ring r, nhng v sau tp hp li ngy cng nhiu, khin ta c cm gic nh s vo vi mt trong m. Ch ng lm vi du Fordyce (tuyn b lc ch,khng c mng chung quanh v - Si c (rubella) : Cng khi pht t chn tc nh si. Nhng khi lan xung thn th ban huyt vm ming khu ci ( du Forchheimer) gi , nhng khng c hiu v c th gp bn hn do EB. Hch sau tai, sau c c n chm, vim khp hay gp ngi ln. Cn trnh ly cho o thai nhi. - Mt s enterovirus nh Echovirus hay Cosxackie, s nhim HIV, nhim trng n nhn do EBV c an tng t nh si, km theo ni hch v vim hng. 36

- Hng ban nhim trng (erythema infectiosum) : do parvovirus B19 gy ra. Thng gp tr t ui. Hng ban c nh trng, mu sng xut hin ma sau khi h st km vi vng da quanh mi m phn ng sau mt ci tt. Hm sau, thn xut hin ban lan ta, thng c nga. Ban ny mt mng li, c th thay i sc khi thay i nhit , ko di chng 3 tun. ngi l i m b nhim virus ny. - Ngai ban xut hin t ngt (exanthem subitum), cn gi l o ban (roseola), ch yu gp thng c mu hng sng, kch thc 2-3mm, dng dt hay dng sn xut hin ban u thn, c bin mt sau 2 ngy. - Ban do phn ng thuc cng rt hay gp v khng th phn bit c vi ban do mt s virus. nhng khng phi lc no cng phn bit c. Da vo tin s c dng thuc, tan trng khng tun sau khi ngng thuc. Ban do d ng thuc thng gp mt s c a. Nhng ngi nhi mide, nhng bnh nhn nhim virus Epstein - Barr thng ni ban khi dng Ampicilline. - Ban do st m: phn b ch yu thn. C tin s vo vng dch t a phng v thng tm hch vng b m cn. T vong ln n 30% nu khng c iu tr kp thi. tsutsumaguchi. - Ban do Leptospirose :Ban thng c dng dt sn, km theo xung huyt kt mc, chy mu k im mng no nc trong. Trng hp nng (bnh Weil) ban xut huyt, km theo hi chng hin i xng v khu tr xng chy. - Bnh Lyme : Ban di chuyn mn tnh (erythema chronicum migrans) l mt bnh mi pht hin . Cha c pht hin nc ta. - Ban thng hn : xut hin thn ri lan ra cc chi. L nhng chm hng, 2-4 mm.

- Ban vng (Erythema marginatum) trong thp tim: thng kh ln, xut hin ri mt i theo tng t cp ca thp tim. Thng xut hin thn hay gc chi. C th xu - Ban ca mt s bnh to keo : ban lupus ban thng c hnh cnh bm mt, nhng cng c Still : thng c mu nh c hi. 2. Ban ch yu mc chi Loi ny thng xut hin cc chi. Sau , c th lan vo thn hay khng. - St do Ricketsia ricketsi vng ni Hoa k : (Rocky moutain spotted fever) : Mc du c tsia khc thng c ban mc ch yu thn. Lai ny thng xut hin ban cc chi trc. L pht hin sm. Tuy nhin nc ta t gp, tr du khch hay Vit kiu v nc. - St v pht ban trc xng chy : mt dng nhim xon khun Leptospira. Bnh cnh thng t ri t hi phc. - Giang mai thi k 2: ban thng xut hin tan thn, nhng ch yu lng bn tay, lng bn

rng ri. Tin s c th c sng giang mai. - Si khng in hnh: Thng gp ngi c chng nga si, nhng vi lai vaccine virus ch hin u tin cc u chi ri lan vo thn, c th chuyn thnh dng bng nc hay - Bnh l mm long mng ngi do virus Coxsackie A16: mm, xut hin nhng bng nc, n ban u xut hin nhng vng ban 37

dng sn, 0,25cm. V sau cng bin thnh cc bng nc. - Hng ban a dng: nhiu nguyn nhn: thuc (sulfa, h peni, h phenyltoin), nhim trng (he coplasma pneumoniae). Ban i xng u gi, khyu tay, lng bn tay, bn chn, c th lan ta . Ban thng l mt vng , bao quanh bi mt vng sng v bn ngai c th c mt vng b - Vim ni tm mc nhim trng: Thng do lin cu, t cu...Th bn cp :xut hin cc nt tay hay ngn chn. Ban xut huyt da v nim mc. Hoc c tng mng xut huyt nh. Th thng Janeway l nhng ban dt hay xut huyt, khng au lng bn tay hay lng bn c 3. Hng ban bong vy Cc ban v sau thng c hin tng bong vy. - Tinh hng nhit (Scarlatine fever) : Nguyn nhn ban u thng do ngai c t gy st A, . Cc ban thng l hu qu th pht. c im ban : ban , n mt. Xut hin u tin mt an da nht mu. Da rp nh khi s vo giy nhm. nhng np ln da, c cc ng ban ( nh du ty (strawberry tongue). Ban thng bong vy vo tun th 2. Hu ht gp tr 2-10 do lin cu nhm A. - Ban trong bnh Kawasaki : ban d dng nh tinh hng nhit hay hng ban a dng. Cng c l ,vim kt mc, ph bn tay, bn chn. V sau bong vy. Gp tr < 8 tui. Km theo hch c, guyn nhn cha r. - Ban do sc c t lin cu nhm A: ging ban tinh hng nhit. C th gp vim cn hai t ( s), nhim trng huyt, vim phi lin cu. T vong 30%. - Ban trong sc do t cu (SSS): thng do c t t cu 1 v c t rut B, C. Ban lan t mc. Bong vy sau 7-10 ngy. - Ban trong hi chng bong da do t cu (Staphylococcal scalded-skin syndrome) : Thng do t cu type phage II. Ch yu gp tr con v ngi ln suy gim min dch. Ban xut hi au. giai an bong vy, khi n vo, ban d dng to thnh mt bng nc ( du Nikolsky). hng nhit, nhng khng c hnh nh li dy ty hay mng trng quanh ban. - Hi chng da bong vy: Thng n ng > 50 tui, c mt bnh da mn tnh nh vy nn, thng bong vy, xen k tn thng vi bnh da c sn. - Hai t da nhim c: ban lan ta, c khuynh hng hnh thnh cc bng nc. Du Nikolsky da t cu ch nh hng n lp nng, y tn thng tan b lp thng b. Nguyn nhn th 4. Cc ban dng bng nc - Thy u : Ban u dng dt, ri sn ri thnh bng nc. ng knh 2-3mm trn mt , nhng cng gp ngi ln. Bnh thng lnh tnh. Nhng ngi ln hay tr suy gim min - Ban do Rickettsialpox : Do Ricketsia akari nh thy u. Nhng thng tm thy vt en do - Ban do nhim Vibrio vulnificus v P. aeruginosa: gp nhng ngi suy gim min dch. Ban huyt trong bi cnh nhim trng nng. 5. Ban dng my ay My ay c in thng khng km theo st. Nu c st, my ay thng c ngun gc do vim c nh my ay c in, thng bin 38

mt trong 24 gi, my ay c st ko di n 5 ngy. Nguyn nhn c th l bnh huyt thanh, s bnh c tnh cng c my ay km vi st. 6. Ban dng nt - Ban do nhim nm lan ta : Thng gp bnh nhn suy gim min dch. V d : nhim Candi da tropicalis) vi st, au c, ban dng nt.Cc thng tn ca Crytococcus hay Penicillum ma c th ging ht u nhy ly (molluscum contagium). Hai t cc nt gi nhim Aspergillosi s. - Hng ban nt (Erythema nodosum) : biu hin bi cc nt ban di da, khng let, ln, mu h i di nhng i khi cng c chi trn. Hay gp ph n t 15-30 tui. Km theo au khp (5 trng, do thuc. - Hi chng Sweet: Biu hin cc nt ph, n au to cm gic nh mt bng nc. Thng xut thng gi n hng ban nt nhiu hn.Thng gp ngi 30-60 tui , a s ph n. 7. Ban xut huyt

- Nhim khun huyt cp do no m cu : Ban u l nhng chm xut huyt nh, s lng tng bng nc. Ban ch yu mc thn v cc chi. Nhng cng c xut hin mt, bn tay, bn ch yt c tnh. Hay gp tr em v nhng ngi ct lch hay gim b th ( C5-C8). - Ban xut huyt c tnh trong hi chng Waterhouse-Friderichson : L nhng mng xut huyt, r rt, hnh sao. Nhanh chng bin thnh mng nc xut huyt, ri hai t. - Ban nhim khun no m cu mn tnh: c nhiu dng ban. Dng dt sn, dng nt, dng ban xu vi tm mu xanh xm nht. Thng chi di. - Nhim lu cu lan ta: Dng sn (1-5 mm) ri bin thnh mn m xut huyt vi mt li hai Him hn, c khi dng bng nc xut huyt Cc tn thng (thng s lng < 40) thng phn - Ban xut huyt do enterovirus : nguyn nhn l echovirus 9 v Coxsackievirus A9. c im: ban xut huyt ri rc, c th dng dt sn, mn nc hay my ay. - Ban do st xut huyt Dengue : Ban xut huyt lm tm. - Ban do gim tiu cu (thrombotic thrombocytopenic purpura): dng ban xut huyt lm tm c r nguyn nhn. Cu hi n tp 1. Phn loi cc loi ban theo quan im Ty y? 2. K mt s bnh nhim virut c biu hin ban ton thn hay gp Vit Nam. 3. Phn bit hng ban v t ban. 4. K mt s bnh nguy him n tnh mng c biu hin ban da. 5. Thy u c xp vo loi ban no, bn cht c ging hng ban hay t ban khng? 39 Bi 7.

Mc tiu NHIM TRNG NHIM C THC N

Ts, Bs Trn xun Chng 1. Xc nh c nguyn nhn v mt s yu t dch t hc ca bnh. 2. Trnh by c cc triu chng lm sng v cc xt nghim. 3. X l ban u, chuyn ln tuyn trn ng lc v kp thi. 4. Xc nh c cc bin php phng bnh

I. I CNG Ni dung Nhim trng nhim c thc n l nguyn nhn gy tiu chy cp thng gp, ngay cc nc c mc sng cao, do n ph i thc n b nhim vi khun hay c t cu chng. II. NGUYN NHN 1. Nhim trng nhim c thc n do Salmonella Type huyt thanh thng gp l S. Typhi murium, S. Enteritidis, s lng vi khun gy khun, thc n b nhim thng gp l trng khng c nu chn. 2. Nhim trng nhim c thc n do t cu

Nhim trng nhim c thc n do ngoi c t t cu, thc n thng b ly nhim bi ngi mang t cu vng (nht, chn m..), thi gian nung bnh t 1-6 gi 3. Nhim trng nhim c thc n do cc vi khun khc qua trung gian c t - Clostridium perfringens: thng do n tht khng c nu chn hay thc n hm li kh bnh 8 -12 gi. - Clostridium botulinum. III. DCH T HC 1. Phng thc ly truyn Ch yu l ng phn ming , do ung nc hoc n thc n b nhim bn 2. Ngun bnh - Ngui bnh - Ngi lnh mang trng : y l ngun ly quan trng 3. Tui : c th gp tr ln v ngi ln . 4. Gii : Khng c s khc bit gia nam v n 5. Ma: Bnh thng xy ra vo ma nng. 6. Tnh hnh kinh t, x hi Bnh thng xy ra cc nc nhit i, km pht trin, iu kin v sinh km. 7 . Yu t nguy c 40

- C a: Tr nh, tr suy dinh dng, ngi suy gim min dch. - Tp qun n ung thiu v sinh : n thc n cha c nu chn, hm li nhiu ln, khng c thi quen ra tay trc khi n v sau khi i cu. - iu kin v sinh km - S dng ngun nc khng sch IV. SINH L BNH 1. Do vi khun sinh c t Staphylococus, C. Perfringens sn xut ra ngoi c t trong thc n gy bnh cnh vim d d khun hot ha h adenylcyclase ca t bo rut gy tng s bi tit ca nc v in g ong lng rut hin din mt lng ln cc dung dch c p lc thm thu cao vt qu kh nn chy nhiu. Chc nng hp thu ca rut non v i trng vn cn nguyn vn. 2. Do vi khun xm nhp vo thnh rut. Vi khun bm dnh, xm nhp vo trong thng b, gy nn cc tn thng i trng, dn t, hng cu, bch cu. Phn thng lng l do nh hng trc tip n s hp thu ca i 3. C ch phi hp Salmonella c th gy i chy bng c ch phi hp: do c t v xm nhp V. LM SNG 1. Nhim trng nhim c thc n do Salmonella Pht bnh thng t ngt, thi gian bnh thng t 12-36 h, phn lng, thi, km st cao, chng ko di 2-3 ngy ri khi nhanh. 2. Nhim trng nhim c thc n do t cu Bnh khi cp tnh vi: bun nn, nn ma, i cu phn lng, ton nc, s lng nhiu, ph mu, nhiu ln trong ngy. Bnh nhn thng khng st hoc st nh, au bng t hn so v nn ma, c th gy mt nc nhanh v nng, c bit tr nh v ngi gi. Bnh nhn d b mt nc, c khi gy try mch, bnh thng tin trin thun li. Cy phn nh. Nguyn nhn C. Perfringens Thc n Sa, cc cht c s,Trng,Tht, bin Tht, sn phm ca tht (ng hp) Thi gian bnh (12 gi) St Ngn (6-12 gi) Di (12-36 gi) (-)

Staphylococus Sa, tht, sn phm ca tht

Salmonella spp.

Ng

(+) (++) ( ) Tiu chy (++) Bng 5: Phn bit nguyn nhn theo triu chng VI. CN LM SNG 1. Quan st trc tip mt mu phn ti 41

(+) Nn ma ( ) (+++) (+)

C th cho php nh hng chn on trong mt s trng hp. 2. Soi phn Tm bch cu hoc vi khun .C bch cu khi i chy do tc nhn xm nhp nim mc rut, m t g xm nhp nim mc rut hoc do c t rut. 3. Cy phn xc nhn tc nhn gy bnh chnh cn s dng nhiu loi mi trng hiu kh, k kh, y nhin rt kh, v khi cy phn (+) li c th do tc nhn gy bnh khc. 4. Cc xt nghim khc Nhm hng dn tr liu trong cc trng hp nng nh: Hct, ure mu, in gii , d tr VII. IU TR 1. Nguyn tc iu tr + iu chnh, ngn nga, chng mt nc v in gii v ri lon thng bng kim toan. + iu tr nhim trng rut bng khng sinh nu cn. + Bo m dinh dng y theo yu cu iu tr trong v sau khi ht a chy. + iu tr triu chng v bin chng nu c 2. B dch v in gii nh gi lng nc mt s khi, thng da vo lm sng v cn nng. 2.1.B nc v in gii, iu chnh thng bng kim toan: ty thuc vo mt nc v lo - Mt nc nh hoc trung bnh ( cn ung c) cho ung dung dch in gii ORS - Mt nc nng hay trung bnh nhng i nhiu khng ung c: i vi ngi ln: Chuyn cc dung dch ng trng nh Ringer lactat, dung dch mui ng tr h quay (ngi ln c th chuyn 1 lt trong vng 10- 15 pht). Sau iu chnh dch truyn 2.2. iu tr duy tr Sau khi b s lng nc mt s khi, cn b s nc mt thm sau khi nhp vin, v lng nc cn thit cho nhu cu bnh thng ca c th 3. iu tr nhim khun + i vi vi khun sinh c t: Khng iu tr khng sinh. + i vi Salmonella: c th dng cc khng sinh nh: Bactrime, Acid Nalidixic, tuy nhin hin nay khng sinh thng dng cc Fluoroquinolones nh: - Ofloxacine 0,2g x 2 vin / ngy - Ciprofloxacine 0,5g x 2-3 vin / ngy 4. Bo m dinh dng y trong v sau khi ht tiu chy 5. iu tr triu chng v bin chng - Thuc cm a chy - Thuc hp ph ( kaolin, than hot... ) khng c tc dng 42

- Thuc phin v dn xut phin: Lm gim au nhng lm chm thi vi khun nguy him v g - H st bng lau mt , lau m , cn thn khi dng thuc h st tr nh - Chng co git: Nu km st cao th phi h nhit . Mt nc v ri lon in gii th ph - Trnh dng cc thuc nng huyt p, tr tim, cortcoide VIII. PH NG BNH 1. V sinh n ung v v sinh thc phm - Khng n cc thc n sng tr nhng rau qu ti c th bc v v n ngay sau khi bc - un nu thc n cho n khi chn - n thc n khi cn nng hoc un li hon ton trc khi n - Gi thc n chn v bt a sch cch ly vi thc phm v bt a c th b nhim. - Ra tay bng x phng trc khi nu n, trc khi n ung , trc khi cho tr n v sau k hin, hiu qu v thch hp mi ni - Khng rui bu vo thc n bng cch y lng bn,

2. Pht hin v iu tr ngi mang mm bnh 3. Nc ung - Ngun cung cp nc phi bo m sch, khng b nhim bi cc ngun nc bn ngm vo - Bo qun cc ngun nc, ngn khng cho sc vt li gn - Cha nc trong cc thng sch, y np kn, dng go c cn di mc nc. - Nc ung phi c un si ngui 4. V sinh cc nh n tp th, cc ni ch bin thc n cng cng - Bp nu n phi bo m h thng mt chiu - Kim tra sc khe nh k nhn vin nu n v phc v n ung - Qun l nhn vin mc bnh nhim trng mn tnh, nht l nhim trng ng rut, da . 5. H x - Cn c h x hp v sinh, tt c mi ngi trong nh phi i cu vo h x , phi gi cho - Nu khng c h x th cn phi x l phn xa nh , ng i hoc ni tr em hay chi a, xa ngun nc s dng t nht 10 m. 6. Gio dc nhn dn hiu cc bin php phng bnh Cu hi n tp 1. K tn nhng tc nhn ph bin gy nhim trng nhim c thc n Vit Nam ? 2. Nu c im c ch bnh sinh ca vi khun sinh c t ? 3. Triu chng lm sng nhim trng nhim c thc n do Salmonella ? 4. K tn cc khng sinh c th dng iu tr nhim trng nhim c thc n do Salmonella 5. Nu cc bin php v sinh cng cng d phng nhim trng nhim c thc n ? 43 Chng 2. CC BNH DO NHIM KHUN Bi 8. BNH VIM MNG NO M

Mc tiu Ths, BsCK1 ng th Nga 1. Lit k c tn v tn 2. Phn tch c cc iu .3. Chn on xc nh lm 4. Phn bit c cc bin 5. S dng khng sinh ng 6. Hng dn cch d phng Ni dung

sut mc cc tc nhn gy vim mng no m thng gp. kin lm d v cc yu t nguy c gy vim mng no m sng bnh vim mng no m i dch no ty mt s bnh vim mng no thng gp trong iu tr vim mng no m mt s bnh vim mng no m thng thng

I . I CNG nh ngha: Vim mng no m ch tnh trng khi bt k mt phn no ca t chc mng no b ca mng no s lan ta i khp ni biu hin trn lm sng mt hi chng nhim trng v hi T chc mng no bao ph ton b no, sng no, no tht v ty sng; bo gm mng cng, khoa g di nhn. Do v tr tip cn ca no v mng no nn i khi bnh l mng no cng c th Khi lm sng c biu hin ca hi chng mng no th chnh l mt tnh trng cp cu cn p yn nhn. Vic iu tr tr s tng t l t vong v i khi cn li di chng II. NGUYN NHN ngi trng thnh S. pneumoniae l tc nhn gy vim mng no thng gp nht, k n l N ia monocytogene. ngi trn 60 tui tc nhn gy bnh c th tm thy l cc trc khun gra tr em Hemophilus influenza, Streptococcus pneumoniae, Neiseria. meningitidis l cc n guyn nhn gy vim mng no thng gp. Tr s sinh streptococcus nhm B cng nh trc khun coli v Listeria monocytogene cng l nguyn nhn hay gp.

Sau phu thut thn kinh cc tc nhn gp tn sut cao l Staphylococcus aureus, Pseudomonas osa v trc khun gram m. Ngi nhim HIV, ngoi tc nhn gy vim mng no thng gp l n ia monocytogene. III. DCH T HC Bnh xy ra ma lnh, cao im l ma xun - ma thu. Ti M hng nm 10/105 ngi mc, tro T l ny cao hn 3-4 ln cc nc pht trin. 44

Bnh kh ph bin nc ta, v cc yu t gy vim vo mng no qua mu t cc nhim tin ph bin do vim mng no ch yu l do vi khun, khong 10 % trng hp vim mng no kh tr.Theo bo co ca vin V sinh dch t trung ng trong 10 thng u nm 2002 c nc ta no m cu t l t vong khong 2%. 1 Cc yu t nguy c 1.1 Ngoi cnh - Nhim trng ng h hp trn, vim phi - Cc nhim trng cnh mng no: Vin xoang sng, xoang bm , xoang trn - Vim tai gia , vim tai xng chm. - Abces no - Vim ni tm mc , huyt khi tnh mch , t catheter tnh mch - Chn thng s no 1.2 Ni ti - Cc tnh trng bnh l ton thn: i ng, suy dinh dng, gim min dch, iu tr corti i thi k 2, - C a + Nam mc nhiu hn n + S sinh v tr nh , ngi gi yu mc nhiu hn tr ln v ngi ln + Ngi b ct lch d b vim mng no do ph cu , haemophilus influenza type B v trc khun gram (-) 1.3. Mi trng: Hemophilus influenza, Neiseria. meningitidis c th gy dch vim mng no nh tr, mu gio . 2 Tn sut mc bnh theo nhm tui tui ngi ln Tc nhn gy bnh Haemophylus influenza Neisseria meningitidis S. pneumonia E. coli Streptococcus Staphylococcus Listeria monocytogenes Vi khun khng xc nh 0- 2 % 0-1 1-4 30-50 40-60 2-5 2-10 5-10 40-50 % 20-30 10-30 1-4 2-5 1-2 1-2 5-10 5% 25-40 40-50 S sinh < 2 thng > 2 th- 6 tui

> 6 tui &

5-10 1-3 5-10 5 5-10 Bng 6: Tn sut mc bnh theo nhm tui 45

IV. C CH BNH SINH Tc nhn gy bnh thng t nhim tin pht t ng h hp trn, phi, ni tm mc, da, ch im xoang, vim tai gia, vim tai xng chm ... vo mu, vt qua hng ro mch nu no ri Vim mng no do vi khun xy ra khi cc yu t c sinh bnh vt qua c ch khng ca c - Tc nhn gy vim mng no kt dnh c v nh khu trn b mt biu m nim mc ngi bn - Xm nhp v sng st trong lng mch mu. - Vt qua hng ro mu no. - Sng c trong dch no ty. kt dnh v nh khu trn b mt biu m nim mc, tc nhn gy bnh phi sn xut cc pro au khi gn v xm nhp c vo biu m nim mc, vi khun i vo v sng trong lng ni mch h ln trnh h thng b th lu hnh khi b tiu dit . Nu vi khun c tim nng i tnh HI, E.Coli), th s tm cch lt qua hng ro mu no vo trong dch no ty. Bnh thng n c bit hot ng ca globulin min dch v b th dng nh khng c hiu qu. Mc khc hi t ra km hu hiu ngay c khi hng ro mu no b ph v trong vim mng no do vi khun. hn gy bnh khi vt qua c hng ro mu no s pht trin v lan trn rt nhanh. Chnh s s ri lon tnh thm ca mng no khi b vim khin cho bnh cnh lm sng ca vim mng no che chn nn tc nhn gy vim khng xm nhp trc tip vo m no, tuy nhin cc phn k cn g tri li, khi vi khun i vo mng no qua dng mu t no th cng c bnh cnh vim no V. GII PHU BNH - Phn ng vim mng nui, mng nhn v dch no ty lm cho mng no dy ra. Trong vim m uanh mch mu v mng nui c th b x rch . Cc cu trc cnh no cng c th c nhng tha h mng nui c th to thnh mch lu v tc mch - Nh c mng nui che chn nn tc nhn gy vim khng xm nhp trc tip vo m no, tuy nh huyt, ph n . - Cc bin i khc c th gp l: + Trn dch mng cng + Vim ng mch no + Vim tc tnh mch v no + Vim tc mao mch lp v mng no k cn vi mng no vim + ng ty sng cng c th cha dch vim, dch vim hin din khoang di nhn + Tn thng cc dy thn kinh s no xy ra ni tch t nhiu dch vim, hoc vim (nh kinh s no ). + Ph no, tng p p ni s thng do: 46

Cht t bo Tng tnh thm mao mch do cc cytokin Tng p lc thy tnh (ph no k) do tc nghn ti hp thu dch no ty . Do tng tit ADH b VI. TRIU CHNG LM SNG Lm sng chung ca vim mng no biu hin u tin v ph bin l hi chng nhim trng v h - St cao t ngt , hoc st cao t t , c khi du hiu st rt kn o - Hi chng mng no thng gm cc triu chng: Du c nng:Nhc u Nn To bn Du thc th : thm khm c th pht hin: Cng c, Kernig (+), Brudzinski(+), Vch mng no Din bin vim mng no rt phc tp, mt t l thp tin trin mn tnh v c tnh hi qui nh vim mng no lao, nm, leptospira, amip, toxoplasma, him hn Listeria monocytogenes . VII. LM SNG MT S VIM MNG NO M THNG GP 1 Vim mng no do no m cu - Bnh c th thnh dch v xut hin theo ma nht l mu lnh. - ng xm nhp thng l mi hng - Du mng no c km theo vi tnh trng nhim trng ton thn , c bit vi ban xut huy n xut huyt hoi t km chong. Tuy nhin c khong 20-40% s bnh nhn c vim mng no m

khun huyt do no m cu do chn on phi da vo vic tm vi khun trong dch no ty. - Cn lm sng Cng thc mu: s lng bch cu tng, tng bch cu a nhn trung tnh. Nc no ty: tng s lng bch cu, a nhn trung tnh tng, mu sc c khi c nh nc vo cu khun - ngi ln iu tr p ng tt vi Penicilline G (300.000v/ kg/ 24h ) hoc Ampicilline 200mg/kg/24gi, ng tnh mch, chia u mi 4 gi . Nu d ng vi Penicilline G c th dn g /kg/24 gi, chia u mi 6 gi; hoc Ceftriaxone 2g -4g/24gi, chia u mi 12 gi. Thi gi hi ht st t 5- 7 ngy. 2 Vim mng no do ph cu - ng vo: Cc nhim trng tai mi hng nh vim xoang, vim tai, vim phi , chn thng s do ph cu c th khi pht nh mt bnh nguyn pht khng c du hiu bo trc ca bt k m vim ni tm mc do ph cu cng c th a n vim mng no do chnh tc nhn ny. - VMN m do ph cu i khi rt nng, cc bin chng nh hn m, ri lon thn kinh thc vt, ha mng no, tc nghn nc no tu v t vong. - Cn lm sng: Nc no ty c, c t bo thoi ha v ln song cu khun Gram(+) hnh ngn c khi 6 - 8 g/l. 47

- iu tr p ng tt vi Ampicilline 150- 200 mg/kg/ 24gi, ng tnh mch, chia u mi 4 hay th bng Ceftriaxone 2g -4g/24gi chia u mi 12 gi. Chloramphenicol cng l thuc c no m do ph cu khi bnh nhn d ng vi Betalactam. - Nu iu tr tch cc bnh thng hi phc tt. 3 Vim mng no do Listeria monocytogenes - Ngoi du hiu vim mng no c th km du hiu no; hay gp ngi gi, ngi suy dinh d no c th biu hin trong mt thng sau sinh, lm sng c th c st hoc khng, i khi c rung ng - Lm sng ging nh bnh cnh vim mng no cp - Nc no ty th khng c s bin i v sinh ha, hoc khi pht t t nh mt vim mng n thy Listeria trong nc no ty; c cc du hiu ca no v cc dy thn kinh s no. - Thuc chn la: Ampicilline 200mg/kg/24gi (ngi ln), chia u mi 4 gi; mt loi thuc amethxazol - trimethoprim ng tnh mch; phi chc d ty sng sau 48 gi kim tra kt q huc i vi Listeria l 2 tun l 4 Vim mng no do Haemophylus influenza - H. influenza l nguyn nhn ph bin nht ca bnh do vi khun tr em. Vim mng no chi H. influenza xm nhp. Bnh phn ln tr em t 2 -6 tui. T l t vong khong 5%. - ng vo hay gp l tai mi hng. Lm sng thng m trong vng vi ngy ri t tr nn ging nh vim mng no m do bt k nguyn nhn no; di chng nhiu v thn kinh v tri gi - iu tr: Trc y thuc chn la l Ampicilline, nhng H.influenza ngy cng khng vi th l Cephlosporin th h III c th Cefotaxime (2-12g/24gi, chia u mi 6 gi), hoc cef 4g/24gi, chia u mi 12 gi). Vi H.influenza, d dng khng sinh liu nhng nghi cn vi i, do , trc khi ra vin nn dng mt liu Rifampicine 20 mg/ kg / 24 gi x 4 ngy ung hc nh. 5 Vim mng no do t cu - Thng th pht sau nhim khun da, phi, hay sau phu thut tim mch, s no... - Biu hin lm sng rm r km ri lon tinh thn kinh, - Dch no ty c, bch cu cao, soi ti v nhum gram c th pht hin t cu gy bnh - iu tr kh khn. Thuc u tin c chn la l Vancomycin v Cefotaxim hoc Fluroquinolon, song song phi hp iu tr nhim trng tin pht trit . VIII. CHN ON GIN BIT 1. Vim mng no lao - Thng th pht sau mt bnh lao khng iu tr ng phc - Lm sng: Hi chng mng no t r nt, xut hin t t, vi nhc u, st nh, km n, mt cm hoc kch thch, mt ng, mt i khi c du tn thng cc dy thn kinh s no nh lc - Cn lm sng: Chp film phi, lm IDR l bt buc. 48

- Chc ty sng: p lc tng, nc vng chanh, trong; c khi m nh. Protein tng 0,5 -2 g/l l- : gim. Glucose: bnh thng hoc gim t. Tm vi khun lao trong dch no ty cho kt qu un mc tr. C th lm PCR tm vi khun lao.

- iu tr: dng phc khng lao. 2 Vim mng no virus - Lm sng l mt hi chng mng no vi dch no ty trong, tng lympho. - Da vo yu t dch t ca tng tc nhn v lm sng nh Myxovirus (cm, quai b, si) hoc Enterovirus (bi lit, coxsackie), hoc Herpes - zona, Rubeole, Mononucleose infect ieus. - Hi chng mng no rm r, t ngt vi nhc u d di, nn ma, c khi km du hiu ca n thi gian... - Cn lm sng: nc no tu trong, p lc tng, c khi m nh v t bo tng , a s l bch otein bnh thng hoc tng nh . - iu tr: khng c iu tr chng virus c hiu ngoi tr vim mng no do Herpes, cn li ch iu tr h st, gim au. 3 Vim mng no do nm - Gp trn ngi suy gim min dch , hoc s dng corticoide ko di . - Hay gp l Cryptococcus neoformans, din bin phc tp, nhc u ko di. - Chc d ty sng c th phn lp c Cryptococcus neoformans, hay gp nhng bnh nhn AIDS. Ngoi ra him hn c th gp vim mng no do Candida albicans. 4 Mt s bnh cnh khc - Abces no - Chn thng vo u gy t mu di mng cng - Chy mu di mng nhn - Bnh no do chuyn ha. IX. THI X TR Phi nh rng vim mng no l mt cp cu ni khoa, cn chn on sm, iu tr tch cc 1 Nguyn tc iu tr - Khng sinh dit khun - iu tr h tr - Phi theo di din bin v nh gi kt qu iu tr 2 iu tr c th - Khng sinh: bt buc trong iu tr vim mng no m. Theo khng sinh khi xc nh c th da vo lm sng, tn sut mc bnh chn khng sinh. Thuc phi c hiu vi tng loi it khun; nn dng ng tnh mch vi liu cao duy tr sut thi gian iu tr. - Thi gian dng khng sinh: Trong qu trnh iu tr cn theo st din bin lm sng v dch khng thun li th sau 36 - 48 gi chc li dch no tu; nu thnh phn dch no ty din b sinh hoc thay i khng sinh thch hp. Ngng khng sinh khi lm sng din bin tt km the n tr v bnh thng , bch cu <10 t bo ch yu l lymphocyte. - iu tr h tr: Bnh nhn c th c cc ri lon khc i km do : 49

+ Cn bng nc, in gii. + X tr cp cu khi c ri lon thn kinh thc vt nghim trong e da tnh mng bnh nhn n ri lon thn nhit... + Chng co git: bng Diazepam hoc Phenobarbital + Corticoide: dng cho trng hp hn m hoc ri lon tri gic ko di nghi ng c tng p 0,5mg/kg/24gi dng 4 ngy song song vi khng sinh. X. BIN CHNG V TIN LNG 1. Bin chng - Suy h hp, suy tun hon do ph no gy tt kt. - Tng p lc ni s - Bi nhim do nm lu, ri lon nc , in gii - Trn dch di mng cng, t m di mng cng . - Abces no, vim no tht, no ng thy tr nh 2.Tin lng - Tui cng nh hoc cng gi , suy dinh dng, hoc gim min dch cng xu. - Thi gian t lc c triu chng n lc iu tr cng mun cng xu - Loi vi khun gy bnh 3. Di chng - ic: Ph bin nht (do ph cu 37%, no m cu 10%, HI 5- 20 %) - Ri lon nhn cch vi nhiu mc khc nhau - Ri lon th gic

- Ring tr em di chng v sau gm chm pht trin tinh thn , ngn ng XI. PH NG BNH Nc ta, vim mng no ch yu do nhim trng v vy phng mt s bnh nhim trng s gim t ch t l di chng v t vong. C th mt s vim mng no gy dch c th phng bng khng s 1 i vi Haemophylus influenza - Vaccine d phng : C th phng nhim HI bng vaccine. Tt c tr di 5 tui u phi c h gim dn do c min dch t nhin - Thuc: phng vim mng no m do HI bng thuc ch khi trong tp th nh tr hay mu gio c 1 thng hoc gia nh c tr < 4 tui hoc ph n c thai sng chung vi tr b vim mng n e 20 mg/kg/24 h x 4 ngy. Phng bng thuc cng dng cho nhng ngi c tip xc vi bnh nh g mt liu duy nht 5 mg/kg/2 ln /ngy hoc ceftriaxone liu duy nht 200mg tnh mch/tim b line ch c tc dng dit HI hu v hin nay HI c khuynh hng khng thuc ny. 2 i vi no m cu - Vaccine hin nay c 3 loi vaccine polysaccharide ca no m cu l : mt thnh phn A, 2 thnh phn A v C, 4 thnh phn A,C,Y v W135) + Tr < 2 tui dng 1 liu vaccine duy nht type C c th hiu qu phng bnh 70 % trong 6- 9 thng. 50

+ Tr > 2 tui c tip xc vi bnh nhn nhim no m cu th ngoi chng nga vaccine phi u cc loi vaccine ny p ng min dch yu. - Thuc: Thuc phng dng cho ngi tip xc vi bnh nhn. Rifampicine ung mt liu duy nh gy hoc ceftriaxone mt liu 200mg tim tnh mch hoc tim bp. Cu hi n tp 1. Hy trnh by tn v tn sut xut hin ca cc tc nhn gy vim mng no m thng gp. 2. Gii thch cc iu kin lm d v cc yu t nguy c gy vim mng no m. 3. Hy m t cch chn on lm sng vim mng no m 4. Hy phn tch tnh cht dch no ty mt s vim mng no thng gp 5. Trnh by cch thc iu tr vim mng no m 51 Bi 9.

Mc tiu BNH L TRC KHUN

BsCK2,Ths H th Thu Vng 1. Xc nh c nguyn nhn, dch t hc ca bnh, ch n tnh trng khng thuc 2. M t lm sng, cn lm sng v cc bin chng chnh 3. Chn la phc iu tr thich hp 4. Trnh by c cc bin php phng bnh

I. I CNG

Ni dung L trc khun l bnh nhim khun cp tnh rut do trc khun Shigella gy ra, y l mt b g cc loi bnh tiu chy v l mt bnh ph bin cc nc nhit i ang pht trin nh n ao c ni ln n 15%. Biu hin bnh l thay i t th tiu chy nh n cc th bnh nng II. NGUYN NHN 1. c im vi khun Shigella l mt loi trc khun gram m, khng di ng, thuc h Enterobacteriaceae. Da vo O v cc c tnh sinh ha, ngi ta chia l 4 nhm chnh A,B,C,D. Khng nguyn O c hiu t nguyn K l khng nguyn b mt, mi nhm chnh c phn ra nhiu type huyt thanh - Nhm A: S. dysenteriae, nhm ny bao gm 10 type huyt thanh khc nhau, trong S. dysente e type 1 ( trc khun Shiga) c mt ngoi c t hot tnh mnh gy bnh nng hn cc type kh - Nhm B : S. flexneri c 8 nhm huyt thanh - Nhm C: S. boydii, bao gm 18 type huyt thanh, v mt sinh ha n rt gn vi nhm B, nn tn ti phn ng cho vi nhm B - Nhm D : S. sonnei, ch c mt type huyt thanh nhng c nhiu sinh type . 2. c t Cc loi Shigella c ni c t c hot tnh sinh hc ging nh ni c t ca cc loi enterobacteriaceae khc Ngoi ra S. dysenteriae I ( trc khun Shiga) cn tit ra ngoi c t vi mt lng ng k c t ny c kh nng c ch khng phc hi s sinh tng hp protein ca t bo, c tc dn Shigella flexneri v sonnei cng sinh ngoi c t nhng s lng t hn . Ngoi c t gm 2 bn n v l phn gn dnh v phn hot ha. Sau khi c tit ra, c t n ) mng t bo. Sau phn hot 52

ha c chuyn vo bn trong t bo v ngn cn s tng hp protein phn 60 S ca ribosome trong bo tng . 3. Sc khng S lng vi khun thi ra trong phn ngi b l khong106 - 108 vi khun / gram phn. Hin n nterie tn ti bao lu mi trng bn ngoi. Ring loi S. sonnei c th sng trong o qun rong nc n 6 thng, trong cc thc n t 3 tun n 6 thng. nhit < 25 chng c t ngy trong sa, trng, chng c th tn ti 3 ngy trong nc bin III. DCH T HC 1. Phn b a d v tnh hnh bnh tt Bnh do Shigella thy khp th gii, hin nay vn cn l bnh quan trng ti cc nc thiu v inh dng ph bin v l bnh nng e da t vong nhiu hn cc loi tiu chy khc. Trn th mc bnh v khong 600 ngn trng hp t vong . Chng vi khun S. flexneri 230 S.dysenteria 1 99 S. dysenteria 2 -10 13 S. boydii 31 S. sonnei 12 Tng s 9 Bng 7: Tnh hnh l trc trng nhp vin trong 5 nm ti Dhaka, Bangladesh S bnh nhn vo vin 2319 10 1251 8 132 10 303 10 145 8 4150 385 S bnh nhn t vong

T l t von

 cc nc pht trin bnh l trc trng thng gii hn trong cc tp th nh nh nh tr , tt nhanh chng cc nc ang pht trin cc v dch ln l mi e da cho ngnh y t. T l t vong ca l t vong. Hai chng ph bin gy l trc trng cc nc ang pht trin l S. dysenteria v trc nm 1968 chng S. flexneri l chng ph bin, t 1968 n 1980 l chng S. dysenteria v t 1980 neri tr thnh chng u th, l do ti sao c s chuyn chng hin nay cha r . C nhiu v dch xy ra chu phi, , M la tinh do S. dysenteria type 1. V dch chu M v 1973 c 500.000 ngi mc bnh 20.000 bnh nhn t vong c l do s trm trng ca bnh v Gn y mt lot dch l xy ra mt s nc ti min ng, Trung v Nam Phi bao gm Rwa Zimbawe, Swaziland , Mozambique . 2. Phng thc ly truyn L ng ming, ch cn 10-100 vi khun cng gy bnh ngi ln tnh nguyn mnh kho. N 105 vk th c th gy bnh 75 %. iu ny cho thy tnh cht ly truyn ca l trc trng Bnh thng ly truyn trc tip t ngi sang ngi qua trung gian tay bn hoc vt dng b hc n nc ung. Rui ng vai tr quan trng trong c ch truyn bnh 53

3. Yu t nguy c Tnh trng v sinh km, ch ng c, c bit ni c nhiu tr em suy dinh dng, s mt m 4. Ngun bnh Ngi l ngun bnh duy nht, c th ngi bnh, ngi ang thi k hi phc, ngi lnh mang khun ko di t 7-12 ngy. Tuy vy nhng trng hp mn tnh, c bit nhng tr suy di ko di hn 1 nm 5. Tui - gii i tng mc bnh thng gp l tr em 1- 4 tui ngi ln bnh thng xy ra n hn nam c l do tip xc gn gi tr em . 6. Ma Ti vng c dch lu hnh th bnh c cao im vo ma h thu 7. Tnh hnh khng thuc S. dysenteria khng mt s khng sinh nh sulfamide, streptomycin, tetracyclin, chloramphe nicol. Ngoi ra, t l khng Ampicilline, cotrimoxazol, acide nalidixic tng ln. IV. SINH BNH HC Do tnh cht khng vi acid d dy, shigella d dng xm nhp vo ng tiu ha. Sau th hun vo rut non v n xm nhp vo t bo thng b rut gi, tng sinh trong ni bo gy Giai on ny tng ng vi thi k khi pht vi cc triu chng nhim trng khng c hiu Sau lp t bo thng b cha vi khun b hu hoi v bong ra to nn nhng lot nng, t cht nhy v bch cu a nhn. Giai on ny bnh nhn thi nhiu vi trng theo phn ra ngoi Tn thng lc u khu tr i trng Sigma v trc trng sau c th lan ln phn trn c on b khung i trng, lan n on cui ca hi trng, tiu chy do ri lon hp thu nc, Vai tr khng ca c th i vi Shigella hin nay cha c r. Acid d dy v mt cha p rut trong lc b bnh c xem l c ch chnh ca thi khun. Cc loi thuc cm tiu chy, lm cn tr thi khun l nguyn nhn gy ra cc bin chng nghim trng. Vi khun ch bnh t pht trin ca vi khun .IgA cng c xem l yu t bo v ca c th chng li l. Cc khn c pht hin thy trong huyt thanh 1- 2 tun sau khi b bnh. p ng min dch t bo tr Kho st trong ng nghim cho thy cc Lymphocyte mang b phn th Fc, cc n bo v bch c lla vi s hin din ca khng huyt thanh Shigella . Khi b bnh, nim mc rut gi b let lan rng vi cht xut tit cha t bo nim mc rut thng let trng ging nh mng gi. Cc t bo ni mc mao ng mch va mao tnh mch b trn thnh mch. Vi khun c th thy c trong t bo cht 54

tr em nhim S. dysenteria type 1 vi vim i trng nng c th xut hin hi chng huyt v lng ng cc cc fibrin gy tc mch mu cu thn ). Tr b m chng li l trc trng t yu t chng nhim trng. V . LM SNG V TH LM SNG 1. Th in hnh 1.1. Thi k bnh : Khng c triu chng lm sng, thng ko di 12- 72 gi ( trung bnh 1- 5 ngy ). 1.2. Thi k khi pht : Bnh khi pht t ngt vi cc triu chng khng dc hiu nh st c

hc u, mt mi, bing n, bun nn km theo tiu chy v au bng 1.3. Thi k ton pht : Bnh din bin thnh bnh cnh l y i cu phn nhy mu vi bnh nhn mun i cu nhng khng i c, mt rn do co tht c trn hu mn. Mt rn nhiu g gy lit c vng hu mn lm hu mn gin rng. i cu nhiu ln trong ngy t 20-60 ln/ ngy, phn t, c nhy mu, v sau khng c cht phn. Trong thi k ny bnh nh mi, th trng suy sp, mt hc hc, mi kh li vng bn. 1.4. Thi k li sc: thng sau 1-2 tun , nu khng iu tr bnh cng c th t ci thin. h a n hn m v t vong 2. Th nng ti cp Xy ra vi st cao run lnh, l m, i cu ra mu t, ngi suy kit, ri lon nc v in vong thng do S. dysenteria type 1. 3. Th l ko di hay th l suy kit Trong mt s v dch, c mt s bnh nhn b l ko di trn 2 tun, thng l tr suy dinh d do S. dysenteria type 1. Lc u hi chng l rt in hnh tr i cu phn nhy mu, mt rn rn nhiu n ni sa trc trng, c vng hu mn b lit v hu mn n rng. Nhng bnh nhn . St trong th ny tht thng lc cao lc nh, lc h thn nhit. Din bin th ny a n mu, nhim trng mu v hi chng huyt tn ure mu cao. 4 Th khng in hnh 4.1. Th a chy Trong th ny, triu chng a chy l chnh bnh khi vi au bng qun, st cao > 39 C, trng nhim c, sau tiu chy xut hin, phn khng thi, v sau phn c th t mu. Th vi t l 1045 % nu km theo st cao. Tuy vy cng c trng hp tr khng st cao nhng vn co git. C th khin nhm vi mt s bnh l ca h thn kinh trung ng nh vim mng no m, vim no git i khi xy ra trc khi tiu chy hay a phn mu gy kh khn cho chn on ban u. T nh hn m, th khng u hoc ngng th ging nh thy trong hi chng Reye, hoc l m l trng c khi gp nhy mu gip hng ti chn on ) 55

Trc y ngi ta cho rng cc triu chng ny l do c t ca Shigella gy ra, nhng hin hp ngi ta ghi nhn c h Calci v Natri mu cng nh thy bin i v t bo v protein t do Shigella rt him gp. Trong th tiu chy c th km theo du mt nc. 4.2. Th nh (thng do nhim S. sonnei) Biu hin vi tiu chy nh hoc khng c triu chng r ch au bng m , a chy thong qua v bnh t gii hn . VI. CN LM SNG 1. Cng thc mu t c gi tr chn on, bch cu tng vi a nhn trung tnh tng, i khi km phn ng tu gy tng bch cu mu > 30.000 bc/mm3 mu ( him gp).. 2. Xt nghim phn T l phn lp vi trng t phn ti thp nn cn cy phn 3 ngy lin tc, kt qu (+ ) t chng lm sng, t l cao nht l trong 3 ngy u ca bnh v ko di vi tun nu khng i 3. Soi trc trng Thy hnh nh vim lan ta cp tnh nim mc trc trng vi nhng lot cn c xut huyt. 4 . Huyt thanh chn on: t c gi tr chn on trn thc t - Phn ng min dch hunh quang trc tip - Phn ng ngng kt : VII. CHN ON PHN BIT c t ra vi nhng bnh vim i trng c cc triu chng st, i cu phn c mu v c b 1. E .Coli: c 1 s nhm E.coli gy hi chng l - EIEC (E.Coli Entero-invasive) bnh xy ra tr em, ngi ln, vi hi chng l tng t nh l trc khun. - EHEC (E. Coli Entero Hemorragique colitis): gy i chy phn nhy mu. 2. Yersinia Yersinia enterolytica hin din trong nhiu thc n nh rau, tht, sa... Bnh cnh lm s g tiu chy c st v au bng vng h chu phi, c khi c mu trong phn c th xy ra vng , sau giai on nhim trng c th pht hin hng ban dng nt hay vim khp dng thp, tr chn on da vo cy phn, cn huyt thanh chun on c gi tr th ngoi ng tiu vng hi manh trng. 3. Campylobacter jejuni

Hin din trong ng tiu ha ca nhiu ng vt v gia cm, ly sang ngi qua ng tiu ha m sng trong iu kin v sinh km. Thi gian bnh 1-3 ngy, lm sng biu hin i chy c st, phn thng c mu km au b 4. Vim i trng mng gi (do Clostridium difficile ) 56

Thng xy ra trong lc ang dng mt s khng sinh ko di hay sau khi ngng khng sinh. Lm -40 C km ton thn suy sp, au bng d di v a chy c khi km mu v mng nim mc ung tnh tng. Chn on da vo: soi i trng, c th quan st thy nim mc i trng xu dng nhng mng nh trng vng t vi mm n vi cm. 5. L amip Do Entamoeba histolytica, khng st, ton thn t thay i, s ln i cu thng < 15 ln / ngy, phn thnh khun km nhy mu bm phn v cui bi c vi git mu. V lm sng i khi rt kh phn bit l trc trng vi cc nguyn nhn k trn, tuy vy phn pht trin c xem do Shigella (v bnh ph bin hn ). VIII. BIN CHNG Thng t xy ra ngay c trng hp khng iu tr tr tr nh v ngi gi . 1. Bin chng ti ch 1.1. Hoi t rut: Bnh nhn i cu ra mt cht dch nng mi km mng hoi t mu xm hay m 1.2.xut huyt : Bnh nhn i cu ra mu ti nhiu gy thiu mu cp 1.3. Thng i trng gy vim phc mc ( t gp ) 1.4. Ri lon vi khun ch (do l ko di hoc dng khng sinh ko di ) . 1.5. Sa trc trng 2. Bin chng ngoi rut 2.1. Suy dinh dng tr em, l bin chng thng gp ca l trc khun, tn thng let trong tn thng, do nhu cu c th lm lnh vt let v do chn n khi b bnh. Thng gp bin c l bnh tiu chy gy suy dinh dng thiu m nhanh nht. 2.2.Mt nc v in gii nht l h Natri mu, c th gy suy tun hon , suy thn 2.3. Vng khun huyt: Bin chng vi t l 8% nhng bnh nhn b l ti Dhaka, Bangladesh, Shigella dysenteria type 1 hn cc chng khc v t vong cao (20-50 %) c bit i vi tr inh dng v ngi gi. 2.4. Hi chng huyt tn ure mu cao. Bin chng ny xy ra vi S. dysenteria typ 1 (cng c th vi S. flexneri) v thng xut hi th 1, trong khi hi chng l bt u n nh. Hi chng ny c lin quan n vai tr ca hagic E coli cng c c t tng t nh shigatoxine v cng gy huyt tn ure mu tng). Bi da ti xanh, tiu t v dn dn v niu gy suy thn, thiu mu, suy tim, xt nghim cho th g thc bch cu c hnh nh gi bach cu cp, tiu cu gim . Cc bin chng nh vim phi, vim m o, vim kt gic mc v pht ban t gp. Hi chng Re mt c th gp ngi c khng nguyn tng hp HLA - B 270 (hi chng ny do chlamydia, be gella nhng hay xy ra ng thi vi l trc khun). IX. IU TR 1. iu tr c hiu 57

ngi mnh khe, bnh c th t gii hn. Khng sinh c vai tr rt ngn thi gian bnh v khng sinh ngm qua nim mc rut. Vi cc khng sinh nh sulfamide, streptomycin, tetracyclin, chloramphenicol khng nn dng v l khng thuc qu cao, cn ampicilline th ch nhy vi a phng, c th dng cotrimoxa ic trong khi i kt qu khng sinh . Do c im khng nhanh vi khng sinh ang dng, v an ton hn. Hin mt s khng sinh mi c hiu qu tt trong iu tr l trc khun nh: + Nhm fluoroquinolon: Liu lng : ngi ln, dng 1 trong cc lai sau : - Ofloxacin 200mmg x 2 vin/ ngy - Ciprofloxacin 500 mmg x2 -3 vin / ngy Cc fluoroquinolone iu tr l trc trng ngi ln vi hiu qu tt, nhng tr em cha c nh gi v gy tn thng sn xng v chm tng trng xng sc vt th nghim. + Nhm cephalosporin th h 3: - Cefixime 8 mg/kg/ngy, ngi ln 400 mg/ngy - Ceftriaxone 50 mg /kg /ngy, ngi ln 2g/ngy Ngoi ra trong trng hp khng thuc c th dng:

Azithromycin: 12 mg/kg ngy th nht, 6 mg/kg x 4 ngy tip theo Thi gian iu tr khng sinh l 5 ngy . 2. iu tr triu chng - Bi hon nc v in gii: Trong giai on khi pht tiu chy t d dn n ri lon n vi dung dch ORS ung sm hoc chuyn dch nu mt nc v in gii nng. Trong trng hp alvesin, chuyn mu nu mt mu nhiu. - Khng c dng cc thuc lm gim nhu ng rut v gim au, cc loi dn xut t cy thu khun v ko di thi gian bnh m cn c th lm cho bnh nng thm, lm c ch h hp, lit nhiu, mt rn nhiu, e da sa trc trng c th cho thuc an thn nh diazepam - H nhit khi st cao , km theo thuc an thn phng co git. 3. Ch n Bnh nhn n cht dinh dng, gio dc nhn dn b tp qun n king khi b a chy ni ch dinh dng nhanh nht. X. TIN LNG T vong t xy ra i vi tr khe mnh, tr ln hay ngi ln tri li tr suy dinh dng, t mt nc v ri lon in gii nng, suy thn, vng khun huyt l nhng yu t tin lng n XI . PH NG BNH 1. Gio dc y t Qun chng phi c thng v cch ly truyn v cch phng chng s ly truyn , c th tuyn truyn gio dc ti nh, c s y t, trng hc 2. Ra tay bng x phng 58

C th l bin php hu hiu nht phng chng s ly nhim, vic ny cn c khuyn khch u khi ra ry cho mt a tr khi i cu sau khi phn ca tr, trc khi nu n v trc k bn tay. 3. An ton thc phm - Khng n thc n sng tr nhng rau qu ti c th bc v v n ngay sau khi bc - un nu thc n cho n khi chn - n thc n khi cn nng hoc un li hon ton trc khi n - Gi thc n nu v bt a sch cch ring vi nhng thc phm sng v nhng bt a c - Ra k tay bng x phng trc v sau nu n - Khng rui bu vo thc n bng cch y lng bn. 4. Nc ung sch Nc cung cp bng h thng ng phi c clor ha cn thn vi hm lng cho php . Khi dng ly nc phi c bo v trnh cho ngi v sc vt lm nhim, khng c cho n vi 10 m v phi di ngun nc. Khi ngun nc ti ch chc chn b nhim phi cung cp n c th tr nc trong cc chum vi c np y khng cho sc vt n gn v dng 1 go ging c 5. Thi phn Phi bo m x l an ton cc cht thi ca ngi, phi c h thng h x thch hp vi iu Gio dc y t cn nhn mnh n vic tng ngi phi s dng ng cc h x k c tr con, c ni khng c h x vic phng u phi thc hin trong nhng ni quy nh v phi chn phn 6. Phng chng s ly lan ti cc c s y t Cung cp y nc v x phng ra tay Ra tay bng x phng trc v sau khi khm bnh. Khng c phn nhng nhn vin y t phc phc v vic n ung chung. Phi phn bnh nhn vo nh v sinh, thng xuyn git gi v ty u qun o , vi tr 7. Khng dng khng sinh phng chng l trc trng, vic ny khng t ra c kt qu m cn lm tng khng thuc v lm cho vic iu tra bnh tr nn kh khn. 8. Vaccine - Cc vaccine cha vi khun cht thng khng c hiu qu. - Ngi ta nghin cu 1 loi vaccine cha vi khun sng gim kh nng gy bnh bng cch l 1 phn nhim sc th t E.coli sang shigella .Tuy nhin cc phng php ny cha cho kt qu Cu hi n tp 1. Vai tr ca c t trong bnh sinh ca l trc khun 59 2. Nu mt ch n c th cho mt bnh nhn l trc khun v gii thch 3. Lm sng ca l trc khun th ko di

4. Chn on phn bit l trc khun v l amip 5. iu tr mt trng hp l trc khun c try tim mch 60 Bi 10. BNH DCH T

Mc tiu 1. Phn tch c cc c im dch t hc ca bnh dch t 2. Gii thch cch gy bnh ca vi khun t Ths, BsCK1 ng thi Nga 3. M t lm sng mt bnh nhn dch t v nh gi mt nc , ri lon in gii 4. Ch nh cc xt nghim c gi tr chn on xc nh. 5. iu tr c bnh t v tuyn truyn phng chng bnh dch t Ni dung

I. I CNG Bnh dch t l mt bnh nhim trng nhim c cp tnh ca ng tiu ha, c th lan trn thnh dch ln gy ra do Vibrio - cholera ch yu nhm O1 v O139 Lm sng c trng l tiu chy d di km nn ma dn n hu qu mt nc in gii, nu k II. TC NHN GY BNH Tc nhn gy bnh do Vibrio cholera. Vi khun ny l loi trc khun gram (-), hnh hi cong nh du phy, di ng c nh c mt lng u . Vibrio cholera c khng nguyn thn O v khng nguyn lng H. Cn c vo tnh c hiu ca kh ia vi khun t ra lm 6 nhm k hiu O1-O6 . Vi khun gy bnh nm nhm O1. N gm c hai t o Cholera v Vibrio Eltor v ba nhm huyt thanh Inaba, Ogawa, v Hikojma. Ngoi ra cn nhm thanh mi serotype O139 c th gy bnh n v Banglades. Vi khun t c sc khng yu, b tiu dit nhit 55oC/1gi v 80oC/5 pht . ngoi c nc nhim mn c th 3- 50 ngy. Khng sng c trong sa chua, ru vang, mi trng kh Nui cy c khi c106 vi khun/g phn. Mi trng nui cy thng l canh thang, pepton ki ui, hoc thch TCBS (Thiosulfat Citrate Bile Salt). c t vi khun t: Vibrio Cholera sn xut c t rut gi l choleragen (ging nh cholera thnh phn A: Phn hot c (Active) B: Phn gn dnh (Binding) Phn B ca c t gn vi th th GM1 ( ganglioside) b mt t bo biu m nim mc rut, sau phn A s xm nhp vo t bo biu m rut . S c mt ca phn A trong t bo s men adenylcyclase (c thnh t bo nim mc rut), lm cho ATP (c trong t bo nim mc r g. Khi AMP vng gia tng th t bo biu m rut s tng thi in gii qua mng t bo vo l 61 c t rut (+) Adenylcyclase ATP

AMPC Thi Na+, Cl-, HCO3-,H2O S c ch gy a chy trong t

III. DCH T Bnh t c t lu trn th gii, bt ngun t chu th sng Hng (n ) v c nhiu i dch xy ra . Ngy nay nh c vaccine v bin php kim dch cht ch do bnh xy ra c Trong 3 thp nin cui ca th k 20, i dch ln th 7 trn ton cu xy ra, do V. Chole an trn t n v ng nam sang chu Phi, Trung, ng, Nam chu u v cc o Ty Thi B Nm 1991 dch t nhm V. Cholera O1, serotype Inaba biotype Eltor lan n Peru v hu ht Phi. M, c ri rc vi trng hp do ngi du lch t chu M la tinh hoc Chu mang sa Nm 1992 c 358.581 trng hp mc bnh v t vong 3871 trng hp trong 14 nc Bc v Nam Phi Nm 1993 dch xy ra do V. Cholera O1, biotype Eltor. Tng s c 376.845 ngi mc v 6781 trng hp t vong /78 nc. T l t vong l 1,8%. y l con s cc nc c t cao nh 1993 xut hin serotype non O1 l do V. Cholera O139 ( Bengal), c phn lp t nm 1992 , li xut hin ti 7 nc chu . . - Theo WHO nm 2001 chu c 10.340 trng hp, t vong 138 ; chu Phi c 173.359 trng hp , t vong 2590; chu M c 535trng hp, khng t vong ; chu u c 58 tr - Vit nam bnh t c ghi nhn u tin nm 1862 qun i vin chinh Php xm lc nc - Ring Vit nam theo thng k ca vin V sinh dch t Trung ng nm 2002 th t nm 1999 dch t xy ra trn ton lnh th. Tc nhn gy bnh c phn lp trong cc v dch l V l Inaba v Ogawa. T nm 1996 t l mc lun lun di 0,85/100.000 dn. Tn s mc cao nh . Tuy nhin nm 2000 min Bc c dch xy ra Ngh an, Thi bnh, Nam nh, nhng min Nam no. 1.Ngun bnh a s ngi ang mc bnh thi mt lng ln vi khun ra mi trng xung quanh .y l ngun un gieo rc vi khun tn phm vi rng ln 2. Cch ly truyn Bnh c th ly truyn theo hai cch: - Gin tip: L ch yu, thng do: + Ngun nc b nhim vi khun: ngun nc b nhim vi khun ng mt vai tr ch yu trong c nh vo ngun nc m dch lan ra nhanh 62

chnh v pht trin thnh nh cao ngay vo tun l th 2. Nu x l tt ngun nc, th dch + Thc n: cng ng mt vai tr ng k nh rau sng bn phn ti trong v dch khng x l - Trc tip: t gp, ch xy ra nhn vin y t, ngi nui bnh hoc nhn vin khm lim t 3. Cc yu t nguy c - Bnh thng xut hin vng dn c ng c, iu kin v sinh km, nc khan him - Ngi c t dch vi nh ct d dy, teo nim mc d dy, hoc pH dch v cao - Ti vng dch lu hnh, tr em d mc bnh hn ngi ln, v ngi ln c min dch mc bnh ca mi ngi v mi gii nh nhau - Ngi c nhm mu O c nguy c mc bnh cao hn 4. Ma

nc ta dch xy ra vo ma kh nng t thng 5 n thng 8 khi nc ao h cn kit, nc sng b nhim mn, nhng cng c khi tn pht vo ma ng. Dch c xu hng xy ra 4 n nht l tr b giun sn v suy dinh dng. IV. SINH L BNH Qu trnh gy bnh ca vi khun t c th chia lm 3 giai on: 1. Vt qua hng ro dch v Vi khun vo c th qua ng tiu ha . Mt phn ln b tiu dit d dy bi pH acide khun vt qua, v thc n c th trung ha tm thi acide dch v . 2. Vi khun sinh sn v pht trin t trng v rut non Phy khun t sng trong mi trng kim cho nn t trng l mt mi trng thch hp cho s gi vi khun s bao ph ton b b mt ca t trng v sau lan nhanh xung rut non. Khi v rin mnh hn, bm cht vo thnh rut n n tn y cc nhung mao, nhng khng xm nhp g 3. Sn xut c t Vo n rut non vi khun pht trin v sn xut c t. c t t vo trong t bo nim mc bin i ln : - T bo crypt (hang): tng thi in gii v nc d di. - T bo goblet (tit nhy): tng tit cc cht nhy (lm sng thy cc ht ln cn trng). C ) khng b nh hng, do kh nng hp thu nc v in gii vn nguyn vn, nhng khi khi lng nc v in gii tit ra nhiu vt qu kh nng t

iu chy trn lm sng . Dch tit ra trong lng rut non l mt th dch c xem nh gn ng trng so vi huyt t cu, bch cu ; protein < 200 mg % v nc . Tiu chy nhiu a n hu qu gim th tch tun hon, chong v t vong. Thnh phn in gii trong phn c khc nhau ty la tui, nhn chung tr em mt nhiu K+ cn ngi ln th mt nhiu HCO3Min dch trong t l mt loi min dch khng bn. S hnh thnh khng th c xut hin b g khun v khng th khng c t . Da trn tnh cht ny ngi ta sn xut c 2 loi vacc e c t (s dng phn B ca c t) 63

V. GII PHU BNH - Rut: cc quai rut mu tm, trn vi th lp biu b vn nguyn vn. - Thn: Tn thng l hu qu ca s mt nc khng b c - Gan: c th to ra, ti mt c th cha mt cht dch mu en rt qunh, c khi tm thy vi - Cc c quan khc: Ch tm thy mt tnh trng kit nc trm trng VI. LM SNG C nhiu hnh nh lm sng khc nhau t nh n nng 1.Th in hnh 1.1 Thi k bnh: Vi gi n vi ngy, trung bnh 4 gi n 1 ngy khng c triu chng c bit. 1.2 Thi k khi pht: t ngt, bnh nhn c th thy kh chu, si bng, bun nn v nn, km tiu chy. Lc u n Ton thn khng st, khng au bng (tr ngi gi), c khi cm thy gai rt v au bng lm rm. 1.3 Thi k ton pht Nn ma, tiu chy t v kit nc - Tiu chy xi x: Phn ton nc c l hoc trong c vi ht trng ln nhn nh ht go. V 6/g phn. S ln c th 5-7 ln/ngy hoc 20- 30 ln/ngy. Mi ln c th ln n 1 lt nc. 8- 8,5). Lng nc mt ti a trong 24 gi u sau gim i - Nn: nhiu tng ng vi tiu chy. Nn xut hin sm l do c t t tc dng ln b ph ong cht nn cng cha nhiu vi khun . - Kit nc v ri lon in gii: l hu qu ca nn v tiu chy . Lm sng rt r vi: * Da kh, casper (+), mt trng . * Mt kh, khng c nc mt * Hng kh, ni thu tho, th nhanh nng * Chut rt cc c (c bng th phi chn on phn bit vi au bng) * Mch nhanh nh, huyt p tt kp, try mch hon ton, i t hoc v niu. Bnh nhn v Cn c vo s mt nc, c th chia lm 3 x tr * 1: Du mt nc nh, casper (+) kht nc. Mch nhanh nhng huyt p n nh. Mt < 5% * 2: Nn ma, tiu chy nhiu, casper (++), mch 100 ln /pht, huyt p ti a 70- 80 m g lng, hoc 70- 80 ml/kg * 3: Try mch hon ton . Mt > 10 % trng lng hoc 100- 120 ml /kg. V niu, ri lon nhp th, tim nhanh nh, thc l m, u m thiu oxy t bo. Tin trin: 1 v 2 c iu tr hi phc nhanh sau 3- 4 gi. th nng nu b dch nha Da hng, chi m, casper (-), mch, huyt p n nh, tiu c. Khng iu tr t vong cao > try mch . VII. CN LM SNG 1. Xt nghim c hiu Phn lp vi khun t phn v cht nn - Soi ti phn: 64

* Knh hin vi thng khng thy vi khun t, ch thy phn khng c HC, BC . * Knh hin vi nn en: Chn on nhanh thy vi khun di ng dng rui bay . Chn on ty chuyn bit cho tng type - Cy: Chn on (+) sau 24 gi 2 Cc xt nghim khc CTM: HC tng, BC tng

Hct: tng T trng huyt tng tng Ri lon v in gii : Na+ bnh thng hoc gim. K+ lc u tng sau gim (nhng s tng nu c suy thn cp), d tr kim gim . pH phn kim Chn on sm da vo: Bnh xy ra trong v dch, nn ma d di, tiu chy t, phn ton n , khng au bng. Cc du hiu ny phi c tuyn truyn rng ri trong cng ng bng cc p sm trng hp t u tin kp thi c bin php ngn nga khng cho dch xy ra VIII. CHN ON GIN BIT 1. Cc bnh tiu chy nhim khun - Nhim trng nhim c thc n do t cu vng: Lm sng gn ging nhng phn thi, tc dng g nn nhiu hn v c th try mch. - Nhim salmomella hoc shigella: Phn lng, thi, c au bng v c v mt nhim trng, c s - a chy do Vibrio parahemolyticus, Vibrio minicus ... Lm sng gn ging t nhng tc dng h hn v thi gian tiu chy ngn hn, c st c au bng . 2. Cc bnh tiu chy khng nhim khun - St rt c tnh th tiu ha - Ng c: Arsenic, nm, sn, thy ngn. - Tng ur mu... IX. IU TR Cn phi nhanh chng, khn trng, ng quy cch. Nguyn tc iu tr - Cp cu try tim mch: b nc v in gii. C th b bng nc hoa qu,nc cho, dung dch ORS, - Khng sinh c hiu. Tetracycline l thuc u tin c ch riti cng ng khi c dch xy ra, ngoi tr tr nh v ph 1 B nc v in gii C hai giai on mt nc cn c quan tm l lng nc mt 1.1 Xc nh lng nc mt tnh lng dch b Tng ng I 50 ml / kg 6- 9 % 60-80 ml/kg III > 10 % 100- 120ml / kg Bng 8: mt nc v lng dch b 65 100-110 ml/kg B < 5 % 40- 50 ml/kg II 70- 80 ml /kg

ng ung hoc tuyn tnh mch

la iu tr t. y l lai n c thai thi thay bng ampici

trc khi iu tr v trong khi

Mt

1.2 Chn dch: Thnh phn phn t c khc nhau gia ngi ln v tr em Nng mEq/l Thnh phn Na+ K+ ClHCO3Phn t ngi ln 135 15 10 0 45 Phn t tr em 105 25 90 30 Mt dung dch thay th cn phi bo m cung cp Na+: 130 -155mEq/l, Cl-: 90 - 110 mEq/l, vi p lc thm thu 250-290 mosmol/l HCO3-: 28 - 52 mEq/l K+: 15- 20 mEq/l V chc nng hp thu ca nim mc rut vn tt v glucose s chim ch lin kt ca phn B huyn co nn ung sm dung dch ORS. Ngoi ra, tr em mt K+ rt quan trng, ngoi vic u nn kt hp ung km KCl nu dch khng cha K+.

Dung dch ORS c cho trong 4 h u Tui 2-4 tui 5-14 tui Trng lng (kg) 9 16-29,9 Lng (ml) 200 dch ORS 200-400 1200-2200 2200-4000 400-600 600-800 800-1 < 4 th >15 tui < 5 > 30 4-11 th 5-7,9 12-23 th 8- 0,9 11-15,

1.3 Cc giai on b dch - Giai on 1: B nhanh li khi lng tun hon, c th truyn 2-3 dy. Tr em c th b h bt c, gim tc dch truyn (1/2 lng nc mt b trong 1- 2 h u, 1/2 cn li tron im, ph mn tnh gim tc dch truyn . - Giai on 2: Dch duy tr: Nn nh bnh nhn vn tip tc nn v tiu chy trong giai on r dch vi tc nhanh hay chm ty theo din bin lm sng (c th > 100 git/pht) ng git/ pht v bnh nhn d try mch tr li v trnh suy thn do gim cung lng tun hon q Khi HA, M tr v bnh thng bnh nhn nn nn cho ung ORS. Ngng truyn khi ti tnh da , phn st vng (thng khong 12- 24 gi sau khi b dch ) Nn nh khng dng cc thuc nng HA nh: Isuprel hoc dopamin, corticoide... 2 Khng sinh Khng sinh c hiu iu tr vi khun t l: Khng sinh Tr em Liu lng Ngi ln 12,5mg/kg x 4l/j x 3j 300 mg liu duy nht (160+800)ng x2l/j x3j 100mg x4l/j x3j 500m

Chn la u tin Tetracyline g x4l/j x 3j Doxycycline Liu duy nht 6mg/kg Khi khng vi Tetrcyline IMP-SMX 5mg+25mg/kg x2l/j x3j Furazolidone 1,25mg/kg x4l/j x3j Hu ht kim tra phn (-) sau 48 gi C th dng Chlorocide, Bactrim, Ampicilline... 3. iu tr triu chng 66

Khng nn cm tiu chy bng cc thuc lm gim nhu ng rut nh morphin, atro uc loi hp ph nh pectin, kaoline, than hot... v lng nc mt vn tip tc tit ra tro oi, nn khng tnh c lng nc mt thc s. C th dng aspirin, indomethacine, chlopromazin... gim s bi xut nc, in gii qua c Cc tai bin cn ch trong khi iu tr t - Co git do truyn nhiu nc qu - Suy tim tri, OAP do tha nc hoc vn tc truyn qu nhanh - Chong dch truyn - Gim K+ gy lit rut v ngng tim 4.Vn nui dng - Vn tip tc cho tr b m hoc b bnh. - Khi ngng nn ma, ch tit thc bnh thng khng thay i IX.PH NG BNH 1 Gio dc sc khe Gio dc sc khe cho dn chng l iu thit yu trong phng chng bnh t. Cc thng tin qu vng cn quan tm bng cc phng tin truyn thng i chng hoc ph bin ti trng hc, c 2 Gim st t Theo quy nh ca t chc y t th gii (WHO 1969) th c quan ph trch y t quc gia phi b t ti ni ca mnh cho t chc y t th gii cng nhanh cng tt v bo co s trng hp m gip vic gim st ti a phng c thc hin d dng, bo co phi y chi tit sau

- Tui - V tr a l/ a ch - Nhp vin hay khng nhp vin - Kt qu iu tr Cc thm tra v dch t hc ca v dch cn phi cho nhng thng tin chi tit v ngun ly v 3 phng s lan truyn rng ri ca bnh t - Cch ly dch, kim tra dch v kim sot bin gii khi ang c dch xy ra mt vng no

- Hn ch tp trng ng ngi nh trong cc tang l, hi h, hp ch trong vng dch t ang e da, v dch c th lan rt nhanh qua thc n, nc ung. Nu cn thit phi t chc php bo m cung cp nc sch, nu n an ton v x l phn hp v sinh - Cung cp nc v v sinh: Bo m cho mi ngi c y h thng x l phn v nc ung h thng phn phi nc v h thng nc ti nng thn bng clo v iod . V sinh thc phm: * Trnh khng thc n, nc ung b nhim bi phn, khng n tri cy, rau sng gn t chn . * Khng nn n thc n c ch bin hay thu hoch ti vng nc b nhim nh s, hn, tm * Cc thc n p lnh hay ng lnh ch hn ch sinh sn ca vi khun t nhng li ko di s * Cc thc n c th xem l an ton, t c nguy c cha Vibrio Cholera nh: 67

Thc n chua pH < 4,5 Thc n un nng, tit trng, ng hp. Hoc cc thc n cha t nc nh: Rau kh, sa bt, thc n bo qun bng mui nh c mui, 4 Chng nga Ngy nay c ba loi vaccine t ung cho thy an ton v hiu qu. Nhng vaccinee ny c ph h. Mt loi vaccine kt hp gia xc ton phn Vibrio cholera O1 vi phn B ca c t t ti t led Whole Cell V cholera O1 with purified recombinant B- Subnit of cholera toxin ). Kt qu th nghim Bangladesh, Colombia, Peru, Sweden thy an ton v hiu lc bo v 85 2 ln ung cch nhau 1 tun. Bangladesh hiu lc bo v gim nhanh sau 6 thng tr nh, n tr ln v ngi ln sau 2 nm. Mt bin th ca vaccine WC/rBS khng cha phn c t B ti t hp c sn xut v th Vi h nghim Vit Nam t 1992 - 1993 thy hiu qa bo v khong 66% trong 8 thng cc nhm it Nam. Mt loi khc l CVD - 103 -HqR c th nghim nhiu ni vi mt liu duy nht cho thy hiu Trn ngi tnh nguyn M cho thy 1 liu vaccine ung duy nht hiu qu bo v n 95% ch 65% chng li Vibrio cholera El Tor sau 3 thng. Thng 5/1999 WHO triu tp mt cuc hp bn v gi tr s dng ca vaccine t ung v a Vaccine t ung WC/rBS nn c xem nh l mt cng c ngn chn bnh t trong cng g 6 thng v khng va tri qua mt v dch, bao gm c nhng cng ng c nguy c cao nh ng g cc khu chut ca thnh ph. Mt l t nht l 2 triu liu vaccine t ung WC/rBS nn c trang b s dng trong nhng vng c nguy c cao, c s ny cn c b sung kp thi. L vaccine ny c nh gi bi mt nhm c vn cc nc qua theo di tng trng hp e Vic s dng vaccine t t l ny nn c lin kt chc ch nh gi nh hng ca 10.5 Ha d phng Trc y ngi ta c p dng bin php ha d phng rng ri bng khng sinh cho cng ng mun hn ch vic lan truyn bnh t v bnh thng lan truyn rt mnh trc khi ha d ph ngy sau ngun ung d dng b nhim bnh . c hiu qu ti a, ha d phng chn lc phi thc hin nhanh trong khi trng hp u ti ung, sinh hot chung vi bnh nhn u phi ung thuc. Khng sinh v liu dng d phng cng ng dch t Thuc u tin l doxycycline ung 1 liu duy nht 300 mg: ngi ln v 6 mg /kg tr em. Cu hi n tp 1. Trnh by cc c im dch t hc ca bnh dch t 2. M t c ch bnh sinh ca vi khun t

3. M t bnh cnh lm sng, nh gi mt nc, ri lon in gii do bnh dch t gy ra. 4. M t cch iu tr bnh dch t. 5. Tm tt cch phng chng bnh dch t 68 Bi 11. BNH THNG HN

Mc tiu BsCK2, Ths Phan Qun 1. Xc nh c tm quan trng, tnh ph bin ca bnh i vi i sng nhn dn. 2. M t cc c im chnh ca tc nhn gy bnh, cch ly v cc yu t nguy c. 3. Gii thch triu chng lm sng, bin chng bng c s gii phu bnh v sinh l bnh. 4. Chn on lm sng sm, mun, cc bin chng, v cc th lm sng 5. iu tr c th bnh thng thng v m t cch thc phng chng bnh. Ni dung

I. I CNG Vi khun Salmonella gy bnh ngi gm cc bnh cnh chnh nh nhim khun khu tr, vim d dy - rut cp tnh, nhim khun huyt, bnh thng hn - ph thng hn. Vim d cc nc ang pht trin, th n bnh thng hn - ph thng hn. Trong phm vi bi ny ch - rut cp tnh (cn gi nhim trng - nhim c thc n) c trnh by mt bi ring trong khun khu tr v nhim khun huyt cc bn c th tham kho thm u trong cc gio trnh oi nc di tiu nhim Salmonella khng gy bng thng hn (Salmonella spp.). 1.nh ngha Thng hn - ph thng hn, bnh nhim khun - nhim c ton thn do Salmonella typhi, Salm A,B,C gy ra. Ly theo ng tiu ha, c bnh cnh lm sng phong ph: st, nhc u, thng chng. L bnh xy ra quanh nm, cao im vo ma h - thu, gy dch. 2.Tc nhn gy bnh Thuc nhm Salmonellae (Salmonella group), trc khun, c lng, di ng, i kh v k kh ty g lu trong mt. Khng nguyn H (lng vi khun), khng nguyn O (thn vi khun) l ni c t c gii phng g nguyn b mt, phn nh c tnh vi khun, cho php trnh s thc bo, c Salmonella typh yphi C, Salmonella Dublin, gn ging khng nguyn O. Vi khun thng hn tn ti lu mi tr 3.Dch t hc 3.1. Phn b v t l Nc ta bnh lu hnh nng min Nam, nht l ng bng sng Cu Long, mt s tnh duyn hi dch xy ra. Phn b s mc bnh nm 1995: min Nam 90,9%; min Trung 5,2%; min Bc 3,5%; Ty Nguyn 0,4%. Nm 1986 - 1995 t l mc chung l 0,01 %. T l cht/mc 0,3%. Trn th gii bnh gp cc nc ang pht trin ; cc nc pht trin bnh tn pht hoc nhp tc hoc do dn nhp c. T l chung 0,36%, cc nc ang pht trin 0,5%. Bnh hay gp tui thanh thiu nin, lao ng (10 - 40), cng ln tui bnh cng t. 69

Ngi lnh mang mm bnh gp n, t l nam / n: 1/4, 85% ngi lnh mang mm bnh > 50 tu 3.2. Cch thc ly truyn: c 2 cch ly Trc tip: do tip xc trc tip cc cht thi ca bnh nhn c vi khun nh phn, nc tiu, bnh nhn. Gin tip: cch ly ch yu, thc n, nc ung nhim khun. Rui ng vai tr ly truyn bn khun; thc phm nh c, s, hn, rau, tht, trng, sa b nhim khun.

3.3. Cc yu t nguy c Mi trng b nhim nng, cung cp khng nc sch cho nhn dn. Vn v sinh thc phm khng an ton. Tp qun sinh hot , v sinh km. Tp qun n ung ca mt s b phn dn c cn lc hu, d lm cho bnh ly lan. Nguyn nhn thuc khng acid ko di. Ngi mang mm bnh trong cng ng cha c nghin cu v x l m II. SINH L BNH Sau khi n, vi khun Salmonella vt qua hng ro ca d dy ti rut non. Qua thc nghim bnh, m 105 vi khun gy bnh lm sng chng 27%, ngi tnh nguyn cho thy: ngi nhim mc bnh. Cc nghin cu ng vt gi rng Salmonella xm nhp vo phn trn ca rut non, ri vo chng v thong qua s bt u theo thi k bnh. Cc vi khun Salmonella ny b cc i th vn cn sng. Bt u thi k khi pht, vi khun huyt tn ti lu. Do cha c khng th c ong dng cn sng, do cc vi khun ny pht trin v nhn ln trong i thc bo nh vo c yn Vi), gip cho vi khun khng s thc bo, Khi lng vi khun trong i thc bo t m y gii gii phng ni c t thc y tnh trng min dch qua trung gian t bo, c bit l vim ton thn to nn tnh trng st ko di trn lm sng. Tip n vi khun xm nhp vo t hy mu tiu ha, thng rut... Khi xm nhp ti mt, cc mng Peyer vi khun li vo lng rut, nn tun th 2 cy phn dn dng tnh. Ni c t vi khun lipopolysaccharide (LPS) gp phn gy st, h BC, v cc triu chng ton gian ca cytokin phng thch ra t cc n nhn i thc bo, khi c th b nhim Salmonella. li ln 2. III.C TH BNH Bnh nh hng n nhiu c quan, nh gy tn thng r nt rut, hch mc treo. 1.Rut Thng gp on 30 cm cui hi trng, him khi i trng, thng tn ch yu l cc nang giai on: 1.1. Giai on thm nhim Trong giai on khi pht, nim mc b xung huyt vim long, cc nang bch huyt kn, cc mn ca nim mc, c mu hng, lc u cn cng sau mm nhn. 1.2. Giai on lot T sau ngy th 10, vng gia mng Peyer bt u hot t, lot rng hnh bu dc, c lc dy d gy xut huyt v thng rut. 70

1.3. Giai on ha so Thng xy ra vo tun th 4, tng sinh v pht trin t chc ht, nhng khng bao gi gy h 2.Cc c quan khc 2.1. D dy Chy mu khu tr lot rt him khi xy ra. 2.2. Lch Sng mu ta, cc tiu th Malpighi cng din bin qua 3 giai an trn: thm nhp bch c tr, ha so. 2.3. Gan Thng sng, t tp t bo mn ch m gan, phn ng vim ng mt, c th c p xe nh tr 2.4. Tim Vim c tim, c tim nht mu v c chm xut huyt ri rc, thoi ha ht, thoi ha m, hoc thoi ha hyalin. IV. LM SNG 1.Th bnh in hnh 1.1. Thi k bnh Thng l 15 ngy, ngn di ph thuc vo lng vi khun xm nhp, khng triu chng. 1.2. Thi k khi pht Trung bnh 1 tun, bnh c tnh cht tng dn. - nh hung ton thn : nhc u, mt mi, mt ng. - St: lc u nh, tng dn ln trong vng 4-7 ngy, sng thp chiu cao, chnh 0,5 - 10C, s lnh run. - Ri lon tiu ha: chn n, to bn, bun nn. - Chy mu cam: 1- 2 ln. - Khm lm sng: li hoc trng bn, bng chng nh, din lch dc, mch nhit phn ly (

du c in) hin nay t gp. 1.3. Thi k ton pht Bt u tun th 2, ko di 2 - 3 tun. - Nhc u, tai, lng tai. - Du hiu ton thn: ngi rt mt, mt ng. - St: mc ti a 39,5 - 410C, lin tc dng cao nguyn, sng chiu chnh nhau 0,50C. - Ri lon tiu ha: phn lng vng, c khi en, 2 -3 ln/ngy, c khi tiu chy nhiu ln, c - Du Tuphos: v mt bt ng, ng ngc, nhn chm chm mt khng nhp nhy, thnh thong n - Khm lm sng: + Mch nhit phn ly (him gp). + Bng chng, c ch h chu phi, lch to mm, gan to nh, n au. + y phi phi g c; hoc vi ran ph qun, c khi c 2 phi; ho khan. + Hng ban c th gp, 3 dng: Ban dt: gp lng, ngc, tay, chn l mt m hng ban c gii hn r rng. Ban bo tm: g , khng bao gi qu 30 nt. Ban dng si: nh si, mc mt lc t u xung chn. + Lot hng Duguet: 71

lot tr trc mn hu, i xng, bu dc, y sch, nut khng au, hng khng , khng + Mch nhanh, tim nhanh, c khi ting tim m (vim c tim). + Li kh bn. 1.4. Thi k lui bnh Bnh nhn c iu tr khng sinh sau 3 ngy (ti thiu) - 7 ngy (ti a) nhit h dn, k li sc ngn. Nu bnh nhn khng c iu tr s thi k lui bnh ko di, hi phc ko 2.Th lm sng 2.1. Th khi pht bt thng - Khi pht t ngt: st cao 39 - 400C, lnh run, au mi ton thn nh cm, do nhim mt l > thng hn). - C khi st vi hm km theo rt run, ri xut huyt tiu ha, hoc thng rut lm cho bnh - C khi khi u bng st, km du hiu vim ph qun, rut tha vim, vim ng mt trong 2.2. Th bnh theo tui, c a - Thng hn ph n c thai: c nguy c sy thai, sinh non, cc du hiu bng thng kh - Ngi ln tui: bnh t khi gp, thng l nng, st t hay c bin chng try tim mch, bi - Tr nh: him gp < 6 thng tui, kh chn on lm sng, cy mu kh, cy phn thun li. - Tr ln: mch nhanh, him c du Tuphos, khng li b m sng, st tht thng, i lng hn im. Kh chn on lm sng. 2.3.Th phi hp Bnh thng hn c th phi hp vi mt bnh khc, lm cho bnh cnh lm sng phc tp thm, kh chn on. Hay gp l phi hp vi st rt, l trc trng.... V. TIN TRIN V TIN LNG Din bin t nhin khng iu tr, bnh nhn c th t vong trong thi k ton pht do mt s th bnh nng, nu tin trin thun li sau thi k ton pht cc triu chng gim dn, th in chng. T khi c khng sinh tr liu (1948, chloramphenicol), din bin bnh c rt ngn nhng i pht 7 - 15 ngy sau khi ngng thuc . Trc thi i khng sinh t l t vong cao, ty theo nhm kinh t x hi. Khi c Chloram phe <1% ti cc nc pht trin, cc nc chm pht trin t l ny cao hn. Nc ta, t l r VI. BIN CHNG 1.Bin chng tiu ha 1.1.Xut huyt tiu ha Lot cc mng Peyer lm v mch mu ; xut huyt nh i cu phn en ; xut huyt nng phn c anh nht, mch nhanh, huyt p h, c th t vong nu khng pht hin, iu tr kp thi. Xu rut. 1.2.Thng rut Cn phn bit gi thng gp thng hn nng, iu tr mun ; do nh hng thn kinh giao c hc: gi thng khng c lim hi. - Thng rut th kch lit (sthenic form) 72

Thng rm r, au bng di hoc h chu phi, bng chng, phn ng thnh bng (+). Khm: b

b trung i tin, vng c trc gan mt, huyt p tt, mch nhanh, nhit h, bnh nh hi di c honh ; x tr: m cp cu, hi sc ni khoa. - Thng rut th m (asthenic form) Triu chng khng r, kh pht hin: bng chng nh, au khng nhiu, khu tr khng r, mch g sc: mt my hc hc, da lnh, rm rp m hi. Phi chp X quang tm lim hi khi nghi thn 1.3. Cc bin chng tiu ha khc v c quan k cn - Thng hn th i trng: a chy nhiu ln, au bng, bng chng. - Vim rut tha, vim phc mc. - Vim gan nhim trng, vim ng mt trong gan, vim ti mt. 2. Bin chng tim mch 2.1. Vim c tim Nhp tim nhanh, ting tim m, lon nhp, ting nga phi, vim c tim gy suy tim cp, tin l ko di, T v ST o ngc, QRS in th thp. 2.2. Try tim mch Nhit tt, huyt p h, mch nhanh, chn tay lnh, da nht nht, v m hi, mt my hc h tin lng nng. 2.3. Cc bin chng him gp khc Vim mng ngoi tim, ni tm mc; vim ng mch chi di, tnh mch (thng chi tri). 3. Bin chng thn kinh 3.1. No vim thng hn Bin chng nng, nh hng n no gia, thnh no tht, cc nhn xm trung ng, vng trn b 3.2. Vim mng no thng hn Thng gp tr em hn l ngi ln, c khi nc no ty trong, tng lymph hoc m c, c i ch l phn ng mng no. 4. Cc bin chng him gp khc 4.1. H hp Vim ph qun, vim ph qun phi; trn dch mng phi (gp tr em). 4.2. Vim xng, vim khp. 4.3. Vim thn, vim a c, vim dy thn kinh th gic. VII.CHN ON 1. Chn on lm sng 1.1. Chn on lm sng giai on sm (thi k khi pht): Thng kh, da vo mt s triu c - St tng dn, km mt mi tng dn, nhc u, mt ng, mi kh li bn. - To bn ri sau i lng. - Khm khng thy biu hin nhim trng r nt mt b phn c th no. - Bnh nhn sng vng dch lu hnh. - Bch cu mu gim hoc bnh thng, lymph tng tng i. 1.2. Chn on lm sng thi k ton pht Khi triu chng ca bnh xut hin cng lc cng r nt hn nh m t phn lm sng. 1.3. Chn on khi c cc bin chng Xut huyt tiu ha, thng rut, vim c tim, vim no. Xy ra, khi bnh cnh lm sng ko d 2. Chn on bng xt nghim 73

2.1. Cng thc mu Bch cu gim hoc thng, 4-5 x 109/L, gim Neutrophile (40-50%), nh hng chn on. 2.2. Cy mu T l (+) 80-90% tun u, 50% tun th 2, v sau t l thp (cy mu trc dng KS). 2.3. Cy phn Kt qu (+) cao tun th 2; chn on bnh v pht hin ngi mang mm bnh (sau 1 nm (+)). 2.4. Cy ty xng Kt qu (+) cao, thm ch sau khi dng khng sinh mt thi gian ngn. 2.5. Phn ng Widal - Ti thiu xt nghim 2 ln xc nh ng lc khng th. - Khng th O (+) ngy th 7-10, tn ti trong vng 3 thng. - Khng th H (+) ngy th 12 -14, tn ti nhiu nm. O c gi tr hn H. Nng khng th O = 1/100, H = 1/200 l (+) ngi cha chng nga. Tuy nhin, c th (+) v (-) gi, v c trng hp cy mu (+) m Widal (-) hoc Widal (+) nh Widal c th (+) trong vi bnh: do cc Rickettsia, mt s bnh gan mn tnh, mt s nhim kh phn ng Widal c gi tr nh hng chn on m thi.

Tm li, chn on xc nh bnh thng hn: + Bnh cnh lm sng + Cy mu hoc cy phn hoc cy ty (+). + Bnh cnh lm sng + Widal (+) vi ng lc khng th cao. 3.Mt s k thut chn on mi (ch tham kho thm): cha dng ph bin nc ta. 3.1. Phng php ELISA - Tm khng th khng Lipopolysaccharide ca Salmonella (typhi-paratyphi A,B,C) v khng th khng Porines. - Tm khng - khng nguyn bao Vi pht hin ngi mang mm bnh mn tnh. 3.2. Phng php ngng kt hng cu th ng tm khng - khng nguyn bao Vi. 3.3. Phng php PCR (phn ng chui polymerase) Lng DNA vi khun trong cc mu nghim (mt, mu, phn) s c khuych i xc nh. 4.Chn on phn bit Trn thc t c nhiu tnh trng lm sng c din bin gn ging thng hn. 4.1.Giai on sm ca bnh (thi k khipht) - St siu vi: St t ngt, au mi ton thn, bch cu bnh thng hoc gim, khng din bin ko di. - St m (Orientia tsutsugamushi): Khi pht t ngt; xung huyt kt mc, da; pht ban; mt mi; vt lot vng kn: tht lng, cline, chloramphenicol. - St rt tin pht: Khi pht t ngt, st lin tc, ri lon tiu ha, tm KST st rt, yu t dch t. - Nhim trng cp cc mc khc nhau ti cc b phn c th. 4.2. Giai on ton pht Phn bit mt s trng hp c th gy st ko di. - Cc nung m su (p xe gan, vim quanh thn...) - Cc trng hp nhim trng huyt: cy mu, nhim tin pht, di bnh th pht, sc. - Lao phi: st tht thng, ho ko di, X quang phi, VS, cy mu (-), IDR. Hoc lao ni kh - Vim ni tm mc cp, bn cp: d nhm vi thng hn nu khng c kt qu cy mu. 74

VIII. IU TR V D PH NG 1. iu tr 1.1. Thuc c tr phng th nghim vi khun thng hn nhy cm nhiu khng sinh, trn c th vi khun sng n mi dng iu tr. Cc thuc c in Chloramphenicol, Bactrime, Ampiciline. Thuc mi nh Cep h h II (cefuroxim), III (cefotaxim...); fluoroquinolon rt hiu qu. Tuy nhin, nc ta mt vi khun thng hn khng acid nalixidic, khi dng Fluoroquinolone thi gian ct st di hn thng 3 ngy). Thuc c hai dng ung v tim, ch dng mt thuc khng phi hp. 1.2. Liu lng 1.2.1. Ni cha b khng thuc kinh in: vn c th dng cc thuc sau (r, d kim). - Chloramphenicol: Ngi ln: 1 - 1,5 g/ngy, ung 2 ln (sng - chiu). Tr em : 50 mg/kg/ngy, ung 2 l - Ampiciline hoc Amoxiciline: 50 - 100 mg/kg/ngy /ngy/ 4 ln. - Co-trimoxazol: (Trimethoprim - Sulfamethoxazol): 50 mgTri. + 10 mg Sulfa. /kg/ ngy / ung 4 ln, Tt c cc thuc trn u dng lin tc trong 14 ngy. 1.2.2. Vng b khng thuc kinh in: Dng thuc mi - Pefloxacine 400mg; Ofloxacine 200mg; Ciprofloxacine 500mg. Dng 1 trong 3 loi trn, ngy 2v x 7 -10 ngy, ung 2 ln (sng-chiu). - Cefuroxim 1,5g/ngy x 10 ngy (vin 250mg), ung 3 ln /ngy. - Rocephine 1- 2g/ngy hoc Ceftriaxone 1- 2g/ngy x 10 ngy, tim bp 2 ln /ngy. Ht st s 4 ngy iu tr. Ph n c thai, tr < 15 tui, dng Cephalosporine th h 2 - 3. Khng dng Fluoroquinolone. r theo vng, s chp nhn ca bnh nhn theo kh nng chi tr. Tuy nhin, thuc mi c li h ngi mang mn bnh do dit sch vi khun 2.iu tr triu chng, chm sc v n ung

2.1. Try tim mch, vim c tim Gim liu KS hoc ngng, hi sc tim mch, Hydrocortison hemisuccinate 100 mg/ngy x 2-3 ngy 2.2. No vim hoc nhim c nng Nhim c nng dng Hydrocortison hemisuccinate 100 mg/ngy x 2-3 ngy. No vim: Dexamethazo mg/kg, sau 30 pht 1mg/kg c 6 gi/ln/ 24 gi (tim tnh mch 1-2 ngy) + khng sinh (Harri 2), theo mt s tc gi nc ngoi th hiu qu cu sng 50% trng hp no vim thng hn. 2.3. Chy mu tiu ha nng Truyn 1 - 2 n v mu, chm bng. 2.4. Kit sc, suy kit do m lu Huyt tng, m thy phn, polyvitamin. Chm sc v sinh rng ming hng ngy. 2.5. Ch n ang st th n lng, xp nghin. Ht st cho n nho, cho, xp ri n c dn nhng trnh c 3.Phng bnh 3.1. Khi cha c bnh (d phng cp 0) - Tng cng gim st dch ti cc dch c, cc vng c nguy c cao (ng dn c; v sinh k ). 75

- Bo co u n bnh trong khu vc theo quy nh B Y t. - Tng cng ci thin cung cp nc sinh hot, x l cht thi bnh vin, kim tra bin php nh mi trng. - Tng cng cng tc tuyn truyn, gio dc v sinh phng bnh cng ng, n chn, ung chn c nhn-cng ng. 3.2. Vi bnh nhn (d phng cp 1) - iu tr dt im, liu thuc, trnh iu tr d dang d thnh ngi mang mm bnh. - Pht hin, qun l v iu tr ngi lnh mang mm bnh. 3.3. Khi c dch - Bin php t chc + Thnh lp ban ch o chng dch cca tnh, thnh ph. + T chc i lu ng, trang b thuc men, ha cht, phng tin, h tr ni c dch. - Bin php k thut: + Gim st pht hin, iu tr sm cc ca bnh u tin c pht hin ti bnh vin; pht hi + Thng bo cho c quan y t d phng cng cp, c bin php chng dch v h tr. - Cc bin php v sinh mi trng, tham gia chng dch ca cng ng . + X l phn: x l vi bt hoc ha cht phn bnh nhn trc khi vo h thng chung. + Kh nc sinh hot bng Chloramin B nng chlore 0,3mg/l, nc ging cng vy. + Gii quyt rc: vi bt, dit rui, x l rc cng cng. + V sinh thc phm n ung. + Ly mu thc phm, nc phn lp vi khun, c bit, khu vc c bnh nhn. + Kim tra, thanh tra v sinh thc phm thng xuyn, t xut. + Tuyn truyn n chn, ung chn. + Xt nghim phn cc i tng: ngi phc v n ung, ch bin thc phm, c nui dy tr, bnh. - Vc xine phng bnh: C 2 loi vc xin phng bnh (ung v tim). C th dng vc xin cho ngi tip xc bnh nhn, cc i tng vng nguy c cao, dch c

Cu hi n tp 1. M t cc c im chnh v dch t hc bnh thng hn nc ta. 2. M t cc c im chnh tc nhn gy bnh, cch ly, yu t nguy c ca bnh thng hn. 3. M t gii phu bnh, sinh l bnh gii thch triu chng v du hiu lm sng thng h 4. Trnh by chn on lm sng sm, mun, bin chng, v cc th lm sng bnh thng hn. 5. M t iu tr th thng thng v th nng bnh thng hn. 76 Bi 12.

BNH ST M

Mc tiu BsCK2, Ths Phan Qun 1. M t tnh cht ca tc nhn gy bnh, ng ly, c im cn trng trung gian, i tng 2. M t lm sng,gii thch mt s triu chng bnh bng c s gii phu bnh v sinh l bn 3.Chn an bnh st m th thng thng. 4.M t cc cch thc iu tr. 5. M t cch thc phng chng bnh st m. Ni dung

I. I CNG Bnh st m c mt trn 1.000 nm trc Nht, Trung Quc. Sau ny bnh c xp vo nhm bnh do Rickettsia, mt ngi M nghin cu v sau ng cht v bnh ny khi nghin c ketts (1871-1910). Hin nay, do cu trc di truyn c s sai bit vi nhm cc rickettsia, n ring, c gi l Orientia tsutsugamushi v cng thuc h Rickettsia. Cn trng trung gian Nm 1906 Kitashima v Miyajima xc nh c tc nhn gy bnh v thnh cng trn thc nghim yt thanh ca bnh nhn st m ngng kt dch nui cy vi khun Proteus OX- K (Khng ngng k h nhn mc cc Rickettsia khc). 1.nh ngha St M, bnh cp tnh do Orientia tsutsugamushi (O.T.), tc nhn gy bnh ly truyn qua vt khi pht t ngt, gm st 40-410C, kt mc-da xung huyt, pht ban, ngi mt nhiu, thn . c bit ni m t c sn , sau ng vy en. Bnh c th t vong do bin chng phi, ti 2.Tc nhn gy bnh Orientia tsutsugamushi (O.T.) gy bnh st M, trung gian gia virus v vi khun, ging vi kh c lp v, bo tng, v cc ht vi bn trong, mt khc ging virus v y l loi vi khun ht trin v tn ti bn trong nhn ca t bo ch. Cui cng ngi ta xp vo lp vi khun gram m a dng (pleomorphis), v c kh nng sao ch ch, cc phn t cu thnh tng t vi khun gram m khc. Chng nhy cm vi khng sinh. O.T. c nhiu dng, nhng 3 dng KARP, GILLIAM, KATO c s dng khng nguyn rng ri. Hnh dng O.T. ging cc Rickettsia khc, do sng ni bo bt buc cho nn pht trin tt tr tt nht l phi g-vt ; tim vo tin phng mt th, kh, chut nht. Tim vo tinh hon v ghim. Chut nht trng nhy cm vi O.T. v dng chn on sinh vt hc. 77

O.T. pht trin tt trong iu kin kh hu, a l nhit i v bn nhit i vi nhit ti > 1300mm), m cao (> 85%), cy ci rm, nhiu sng sui, rng ni rm rp. 3.Dch t hc Ngi ta ghi nhn st m c mt rt sm, nhiu ti liu m t bnh ht sc phong ph nhiu n sng Nht Bn; Tsutsugamushi, gi thng hn, st bi rm (scrub typhus). Trn th gii, c ng Nam , Nht Bn, cc qun o Ty Thi Bnh Dng, c bit l vng Quc, Triu Tin, i Loan, Ty Tng, v pha bc Lin Bang X Vit c, Tn Guinea, yn hi pha bc bang Queensland ti pha ng Australia. Nc ta, theo Bi i, bnh c mt vng Ty Bc, Sn La, Ngh Tnh, Mc Chu. Nam v tuyn vn ghi lnh M mc bnh. Nh vy, da vo sinh thi, c im kh hu, t liu, cho thy nc ta c s lu hnh ca b hiu, nhng do nhiu l do khc nhau m chn on nhm vi bnh khc nh thng hn, st rt, hun mu, st dengue..., nu khng ch . Ti min Trung, trn thc t lm sng nhiu trng hp bnh xut hin. Bnh theo ma, vng a l r. Khu vc trin sng, vng bn sn a nhiu bi rm v di nhi ngi hay lui ti d nhim bnh. 3.1. Cn trng trung gian l u trng m Trombicula (acarien), ngoi c mu nhung hoc cam ti, u trng m cha m trng thnh sang th h u trng m. Trng ca m b nhim tn ti trong t m nhiu cht mn, thnh u trng ri b vo cc bi g (loi c v hoc chim) khi c iu kin, trn thn cc ng vt ny vi ngy ri ri xung

m trng thnh. Khi chu k ny c tip tc, th s truyn O.T. qua trng s m bo cho t O.T. nhn ln trong tuyn nc bt u trng m vi lng ln, v vy d gy nhim cho vt nh Cn lu , ch c u trng m mi t ngi v sc vt v ch t mt ln trong chu k sng, ngi, u trng m thng bm vo cng, i ri di chuyn n nhng ni kn, c m hi m, cch chch vi vo da. u trng m khng n mu, khi t chng bm nc bt vo vt t tron tein lm tiu cc t bo vt ch ri to nn mt cht nho c cht dinh dng m u trng g t mn tip tc chu k sng. u trng m t vo ban mai v lc tri sp ti. khu vc kh hu nng m, bnh xy ra quanh nm (nc ta), tri li vng lnh nh Nht Bn th hay gp vo ma thu. 3.2. Vt ch Vt ch cha tc nhn gy bnh rt a dng, m loi gm nhm ng vai tr c bn duy tr O.T. khng r, to iu kin ly nhim cho vec t truyn bnh (u trng m), ch yu l chut Ratt khc, th cng c th l ni lu gi mm bnh. Loi chim nhim t nhin, cng c th dng thc nghim, c bit l chim s, chng mang mm b ombicula, do m chng lm lan to O.T. 78

v vec t truyn bnh cho cc qun o trn i dng, ni m chng lu tr trong qu trnh d M trng thnh c xem l vt ch th yu v c cha O.T. 3.3. Cc yu t nguy c - Nhng ngi lm nng nghip, lm nghip, cng tc kim lm..., c iu kin tip xc cn tr bi rm. - Nhng ngi tham quan du lch vo vng bnh lu hnh. - Nhng ngi cha tip xc dch d mc bnh hn nhng ngi trong vng dch lu hnh. II. C TH BNH 1. Ti v tr b u trng m t O.T. nhn ln v pht trin, ri lan to. y, c vt lot hoi t, nh hng n lp t b g. 2. Hch bch huyt Lin quan ti v tr u trng m t; hch v tinh sng,hoi t trung tm ca hch. C th s o m nh cc vi khun sinh m). 3. Mch mu O.T. c i tnh vi cc t bo ni mc mch mu, gy thng tn ni mch, xung quanh cc mch ging mao mch) c bit l mch da,c tim, no, phi. 4. Phi Ngi ta tm thy tn thng trong lng mch vi hin tng thuyn tc v chy mu, cc t b v thnh mch b ph n, thnh ph nang dy ln, khoang gia cc ph nang c hin tng xut 5. C tim T bo mono xm nhp khe c tim v hoi t khu tr, vim k c tim, mao mch nh ca c tim b 6. No Ri rc c phn ng vim quanh mch no v tng sinh t bo m, cc mao mch ca t chc no o nhi mu li ti. 7. Lch Lch sng to v c cc bin i nh trong nhim khun mu, km theo hoi t khu tr. 8. Gan Gan sng, xung huyt, hoi t khu tr. 9. Thn C vi khu vc thn xung huyt, v thn nht mu v sng. Bng k thut hunh quang, ngi ta c th pht hin ra O.T. trn t chc no, phi, c tim v III. BNH SINH - SINH L BNH O.T. pht trin v nhn ln ti v tr u trng m t; sau mt thi gian bnh chng thm n vo mu, thng l vi gi trc khi pht bnh, chng li tip tc xm nhp cc t bo ni m cc bin i ti mch mu, gy vim, xung huyt v pht ban. Trng hp nng (giai on sm), gy suy tun hon ngoi bin, thng xut hin trong tun lu thng, cha c hin tng tng thm mao mch, hoc thot dch ra khong gian bo. V li, i on mun), c thng tn tng sinh v thuyn tc xut hin trong cc mao mch nh, kt qu 79

hin tng hoi t v tng thm mao mch t nhiu gy gim th tch mu, ph n khong khe qu nht l giai on mun trn bnh nhn nng.

Bnh cn biu hin ph v thiu mu c tim, trn t chc hc v in tim, i khi lon nhp x Kt qu ca suy tun hon ngoi bin gp trong cc trng hp bnh nng, gy thiu niu, v n tinin mu; gim protid mu, natri mu; ph v hn m. C khi ri lon chc nng gan hoc c Cc nghin cu v cc t bo b nhim O.T., cc i thc bo trn t chc nui cy, ngi ta yt tng vo khong gian bo. Nguyn nhn ny l do cc t bo ni mc mao mch v i thc in (nht l PG1 v PG2) v Leucotrienes. Bnh c min dch khng bn, d mc li, dn bn a t mc v nh hn dn ngoi lai, c chn IV. LM SNG 1.Th bnh in hnh 1.1. bnh Trung bnh 10-15ngy, c nt sn do u trng m t, c th gp t 10-90% trng hp, tu no khc. 1.2. Khi pht Khi pht t ngt vi cn rt run, st cao, ngi mt mi ton thn, nhc u nhiu vng tr ; sau thi gian ngn ri vo thi ton pht. 1.3. Ton pht - St: st cao 40-410C, dng cao nguyn trong vi 3 ngy u, sau gim, ri tip tc tng 39-400C v duy tr mc y trong 2-3 tun, nhit sng thp chiu cao. - Tim mch: nhanh (bnh nng), chm (th nh). C th tru tim mch (mch nhanh, h huyt p, c tim hay gp (tim nhanh, ting tim m), c khi ngoi tm thu. - H hp: biu hin vim ph qun (nh), vim phi khng in hnh do O.T. (nng). - Thn kinh: nhc u nhiu, s nh sng, mt ng; bnh nng c du kch ng, vt v, m sn tu bnh thng. Nu vim mng no thng l nng. - Tiu ho: li kh, xung quanh, trng hoc en chy gia. i khi tiu chy hoc xut - Da v kt mc: xung huyt; pht ban gp 2/3 trng hp, xut hin ngy th 4-7, khi u hi. Loi ban dt sn i khi bin thnh mng nc, thng mt i khi n; chm xut huyt (th n mn hu, hng. Ti vt t xut hin mng nc, sau hoi t v hnh thnh mt lp vy 5mm, xung quanh hi , c khi nga-au nh, c sng hch khu tr km theo nhng khng ho m lng, l rn, nch, ngc, di tai.... - Tit niu: i dm, b i, albumin v tr niu, ur mu bnh thng, him khi vim thn. - Hch ton thn: i khi c gp, r nht l c, nch v bn, hi rn, n au nh, hch kh hc. 1.4. Lui bnh Sau 14-30 ngy, nhit gim nhanh, bnh nhn cm thy d chu, i nhiu. Ngi cn yu v di nhiu tun ti nhiu thng. Bnh nh thi k ny ngn hn. 2. Th bnh khng in hnh 80

Khng c nt lot, khng pht ban v ch st trong vng 5-10 ngy, kh chn on. Mt s th iu hin vim phi khng in hnh c kh th, th bnh vim c tim,v.v.. V. TIN LNG & BIN CHNG Tin trin nng nh tu a phng, tui bnh nhn (tui cao bnh nng). T l t vong mt s ni nh Indonesia-i Loan 5-20%, Nht 20-60%; M Lai 15%, Vit Nam 0,6% (th nh). Nguyn nh thng do tru tim mch, vim c tim, xut huyt, bi nhim phi, bin chng vim no- mng n Nu c pht hin v iu tr sm bnh gim st nhanh trong vng 12, 24-48 gi; thi k hi VI. CHN ON 1.Lm sng Ch yu da vo tnh cht khi pht t ngt vi - St cao lin tc - Nt lot, km sng hch v tinh (nt lot l du in hnh trong bnh st m, tuy nhin c on) - Xung huyt kt mc, da; pht ban - Sng hch ton thn - Vim c tim 2.Cn lm sng - Bch cu mu: thng khng tng, thay i t 3-22 x 109 / mL, lymphocte > 70%. - Chn on min dch hc: + Khng th hunh quang gin tip (Indirect Fluorescent Antibody: IFA): Dng khng th KARP, LIAM, KATO pht hin khng nguyn (kh nhy). Bnh nhn c nng 1: 40 t ngy th 9 ca h 2. Gi tr (+) tu thuc tng phng th nghim c th 1 : 640 hoc 1 : 1280, nhng nu

in dch c th gim (xt nghim chun ca WHO, nhng do kh v k thut, cha p dng rng). + Min dch gin tip Peroxidase ( indirect Immunologic Peroxidase: IIP) l phng tin h tr rng khng c dng ph bin. - Phn ng Weil Felix: Phn ng (+) vi OX-K bt u t ngy 5 sau st, hiu gi cao nht vo tun th 4. Cc trng hp c hiu gi ngng kt vi OX-K trn 1 : 160 v ho long, hoc ln 2 gp ln u 4 ln u c gi tr chn on, vi 2 ln cch nh - Phn lp O.T.: Ly mu bnh nhn lc st cao, tim phc mc chut, nu trong vng 13-16 ng ng mu c O.T.. Nhum t thit gan, lch, hch bng giemsa, soi knh hin vi s pht hin O.T chuyn tip 2-3 chut mi pht hin (+). 3.Dch t hc Bnh nhn ang sinh sng, lm vic, hoc vo vng bnh lu hnh. VII. IU TR 1.Nguyn tc iu tr - iu tr c hiu cng sm cng tt. - Chng ch nh cc thuc c Sulfonamide v s lm cho bnh nng thm. - Trong trng hp c sng hch ton thn, hch v tinh th cn iu tr ko di chng ti - iu tr h tr, nht l trng hp nng s gp phn lm gim cc bin chng v t l t vo 2.iu tr thc t 2.1. iu tr c hiu 81

- Nu iu tr sm, trc khi pht ban th rt hiu qu, nhit tr v bnh thng trong v , c xut huyt th p ng chm hn. - Thuc c hiu lc Chloramphenicol; Tetracyclin (Doxycyclin); cn Azithromycin c tc dng v O.T. khng Tetracyclin trn ng nghim, ng dng c hiu qu lm sng. - Liu lng: Chloramphenicol 30 mg/ kg/ ngy; Tetracyclin 20-30 mg/ kg/ ngy; Doxycyclin 100mg x 2 vin / ngy (ngi ln). Ch dng mt thuc; dng 7 ngy; khi hch sng dng 14 ngy. Khng bnh nng v c iu kin dng tnh mch (vd: bnh km theo vim mng no) Ch : Fluoroquinolone khng hiu qu vi O.T. ch vi Rickettsia conorii (Mediterranean spotted fever). 2.2. iu tr h tr - Dch truyn: Glucose hoc Ringers Lactate nhm hi phc nc & in gii, lng tun hon; cn lu trng hp vim phi, vim c tim khng truyn nhiu. - Ch n ung: nn n xp, cho long khi cn st, m bo cht dinh dng. - V sinh rng ming, lau sch ton thn hng ngy, trnh lot cho cc trng hp nng. - Thiu mu do xut huyt tiu ho, nn truyn mu ti. - Trng hp nng hoc c bin chng (tim, phi, thn kinh...) v nht l cc ca iu tr mu steroid liu cao, ngn ngy : Hydrocortison: 100 mg / ngy x 3 ngy, c th thay bng Depersolon. VIII. PH NG & CHNG BNH ST M 1.Khi cha mc bnh: c cc hng d phng nh sau 1.1. Dit vt ch v cn trng trung gian Ti khu vc dn c sinh sng, c quan n v ng chn, nhn vin y t cn quan tm dch lu c nhiu bi rm v sng sui. Chut v cc loi gm nhm: ni c dch lu hnh, ni lao ng cn pht ng phong tro dit n ho cht. Cn t chc pht quang, lm sch c v bi rm quanh nh , pht quang ri t tp trung, c rng (Trung quc p dng c hiu qu khng c m tn ti n 40 ngy). Cng vic ny cn tin hnh thng xuyn. 1.2. Bo v c nhn, hn ch, trnh u trng m t Khi lao ng, di chuyn n vng c bi rm cn ct cht ng qun tay o, hoc mang dy c b Thi gian ngh sau lao ng, ngh dc ng, khng nn nm hoc b o qun trn c rm. Sau lao ng hoc vo cc khu vc trn nn tm ngay trong ngy, lau sch ngi nht l cc vng kn (bn, nch, tht lng, c...) 1.3. Vaccine Trong th chin II, cc tc gi Anh, M xut loi vc xin Rickettsia cht, khng hiu qu. Nm 1952, cc nh khoa hc M lai nghi dng vc xin cht kt hp khng sinh, xut ny k sinh th bnh nh nhng khng to min dch bn c. 1.4. iu tr d phng

Ngay sau khi b u trng m t ung 1 ln 2gram chlorocid hoc 1.5 gram Tetracyclin, sau 1 ln, trong thi gian 4 tun, th bnh nh hoc khng pht ra. Tt nht, bnh mi chm dng 2. Khi c ngi mc bnh 82

Cn pht hin sm iu tr, nht l vng bnh lu, hnh nhn vin y t cn quan tm n b heo di cc bin chng c th xy ra.

Cu hi n tp 1. M t tnh cht tc nhn gy bnh, ng ly, c im cn trng trung gian, i tng ngu c mc bnh. 2. Trnh by v sinh l bnh ca bnh st m 3. M t cc im chnh gii phu bnh ca bnh st m 4. Trnh by v sinh l bnh v gii thch din trin lm sng ca bnh st m. 5. M t cch thc iu tr bnh st m. 83 Bi 13.

Mc tiu BNH NHIM NO M CU

Ts, BsCK1 Nguyn L 1.Chn on sm v chuyn kp thi nhng bnh nhn nhim no m cu nng. 2. Bit cch iu tr v phng bnh no m cu cho nhn dn. Ni dung

Nhim trng huyt v vim mng no m do no m cu l hai bin chng nng v hay gp nht c m cu c tin trin rt nhanh, c th gy t vong nhanh chng trong vng 24 gi mt ngi t I TC NHN GY BNH Da trn bn gen, ngi ta xp no m cu vo nhm -proteo cterium c lin h n cc h ria, Kingella, v Methylomonas, xa hn l cc h Vibrio, Haemophilus, v Escherichia coli. Theo c in ngi ta xp loi no m cu da trn cc h thng phn loi huyt thanh, cn c , cc protein chnh mt ngoi mng t bo (major outer-membrane : OMP) ti cc l thng uyt thanh), cc OMP khc (cc phn type huyt thanh), cc lipo-oligosaccharide (LOS, type mi dch). V d : mt chng no m cu c k hiu l B:2b:P1.5:L3,7,9 ngha l : chng ny thuc nhm uyt thanh (2b), phn nhm (P1.5), v type min dch (L3,7,9). No m cu c xp thnh cc nhm huyt thanh ty thuc vo tnh khng nguyn ca polysaccha hau ca cc carbohydrate. Trn th gii c 5 nhm huyt thanh (A, B, C, Y v W135) gp trong h cnh ca no m cu. Cc chng thuc nhm A, thng gy nhng v dch ln trong na u th hi vng h sa mc Sahara (Phi chu) v mt s a phng khc nhng nc ang pht tri y thnh dch nhng nc k ngh ho. Hoa k v Canada, trong sut thp nin 1990, nhm rc, cn nhm C thng gy dch bc pht. Nhm Y mi c pht hin gn y v chim gn 1/3

nhng ngi gc Phi, c sn mt bnh mn tnh. Nhm Y v W 135 cng hay gp nhng bnh nhn Xp loi theo nhm huyt thanh c khuyt im l khng theo di c qu trnh thay i nhm tng hp v vi khun c th chuyn i t vi khun ny sang vi khun khc, v do chng c ay c nhiu phng php xp loi khc tt hn, cho php theo di qu trnh thay i ca cc c hanh v c cc phn type huyt thanh c xc nh bi khng nguyn ca cc OMP c hiu khc ultilocus) gip phn loi vi khun theo cc type in di. Ngoi ra cn c phng php xp lo 84

trong trng xung in hoc phng php khuych i chui gen bng PCR. Cc phng php ny no m cu. Chng hn trong v dch Nepal t 1983 - 1984, ln u ngi ta tm c phc hp dng vi uyt thanh A. Chng ny lan n Mecca, sau ti vng di sa mc Sahara v n vng chu Ph huyt thanh B phn lp ln u Na uy vo thp nin 1970, sau gy nhng v dch chu u Bc Thi bnh Dng. Phc hp ET -37 (cn gi l ET- 24) thuc nhm huyt thanh C tng gy b rc Canada v Hoa k, v thng kt hp vi t l mc bnh v t vong cao. II. DCH T HC Bnh no m cu ph bin ton th gii, thnh tng ca ri rc hay nhng v dch nh lng, x, tp th, c quan, nhng cng cng c th thnh nhng v dch ln. Mc du c khn cu vn l mt nguyn nhn gy vim mng no v nhim trng nng hng u trn th gii, gy o mnh bnh thng. No m cu l tc nhn gy bnh duy nht trong s nhng vi khun gy vim mng no c th gy Tnh chung, hng nm c n 300.000 n 500.000 trng hp vim mng no trn ton th gii d v dch ln !). T s bnh mi hng nm ca vim mng no do no m cu chim t 1 - 2/100.00 ri rc, t 5 - 10/ 100.000 nhng vng c dch nh v t 10 cho n > 1000 ca /100.000 tro hay i dch. Vng ai h sa mc Sahara n nay vn l vng c ri rc v bng thnh nhiu 6 -1997 ghi nhn hn 300.000 ngi bnh trong 30.000 t vong do vi khun nhm A. Nhng v v cc t bc pht do nhm A hay C cng c ghi nhn chu u, Hoa k, Canada, Trung quc, and, Cuba, Braxin, Chil, rp Saudi, v Nam Phi t 1990. Trong nhng nm 200 -2002, nhng v dch vim mng no do nhm W135 thng kt hp vi nhng t hnh hng c m cu h sa mc Sahara. Nhng trng hp u tin ca dch vim mng no do no m cu thng xy ra do nhng tip x cho ngi th hai l 400 1000 /100.000 thnh vin trong gia nh. Ly lan trng hc cng c ghi nhn, nhng t l rong cc v dch lng i hc, t l ly lan cao nht nhng sinh vin c x. Nhng tr t khi c trng hp mc bnh u tin, nhng cng c trng hp ko di n vi thng sau. Vi khun no m cu c trong mi hu (ngi mang vi khun) v c th tn ti hng thng. Tron 10 % ngi bnh thng c mang vi khun ny. Nhng yu t thun li ly no m cu l sng vi khun, nh hay c quan cht chi, ht thuc l ch ng hay th ng v tin s c nhim t g nguy c vim mng no do no m cu. Ngi l ngun bnh duy nht. Vi khun thng khu tr vng mi hu. Ly truyn ch yu qua ( doanh tri qun i, tri giam..), cc khu ph ng c, v sinh km l nhng iu kin thu No m cu nhm A, trc y thng gy dch. Hin nay u th thuc v nhm B v C. Nhm B thng gy bnh tr nh. Nhm C nhm tr ln v ngi tr tui. III. BNH NGUYN T nim mc mi, no m cu c th xuyn qua cc t bo ny, lch qua thnh mch vo mu. dit ngay. Nu 85

khng, vi khun s sinh si ny n, to nn nhim trng huyt v theo mu n cc ni khc tr qua hng ro mch no, n u tin no tht ri lan n khoang di nhn), da, khp, thn Nhim no m cu cn ty thuc vo c a bnh nhn. a s u c khng th chng no m cu. V sau, c min dch t nhng chng khng gy bnh c khng nguyn tng t . Nhng ngi c h min dch khng tan vn thng d nhim no m cu : thiu mt thnh phn gim -globulin mu, ct lch ( hay lch mt chc nng). Nhim cm cng l mt yu t thun l IV. LM SNG 99% biu hin ca nhim no m cu l nhim trng huyt (NTH), vim mng no m hay phi hp nhng c quan khc rt t gp. Thng thng, bnh nhn c triu chng h hp trc khi c bn 1.Nhim trng huyt 30-40% nhim trng huyt n thun khng c km thm vim mng no. Bi cnh lm sng rt kh h, bun nn, nn, ni ban, au khp, au c. St thng cao ( 39-41 C) mc du trong trn

h nhit. Ban l mt triu chng quan trng ( gp 3/4 cas) c th dng dt sn, xut huyt thng xut hin sm ngay sau pht bnh, ng knh 2-10 mm, mu hng, phn b tha tht thn v cc chi. gia c th c chm xut huyt. nng, ban ny c th bin thnh xut huyt. Ban xut huyt c ng knh 1-2 mm thng c ming v kt mc. Nhng ca tng i nng, ban xut huyt t li thnh mt bng xut huyt Ban xut huyt lan rng, h huyt p, gim tun han ngai vi, khng c vim mng no km theo l nhng ch im tin lng xu.

ha

Tr v

nh 1 : Ban xut huyt trong nhim no m cu 1.1.Nhim trng huyt c tnh (Hi chng Waterhouse- Frederichsen). Chim 10-20% vi c im tin trin nng rt nhanh : cc ban xut huyt lan rng thnh cc m mch (DIC), v suy nhiu c quan. ng lu l bnh nhn c th vn tnh to d rng h huy Cc ban xut huyt ln nhanh, gy tn thng da, nim mc, c vn, tuyn thng thn v i k , gp phn vo tnh trng sc. Ri lan tan thn gm toan mu, ri lan in gii, thiu ni l t vong rt cao, ln n 50-60% ngay c cc trung tm hi sc tin tin. 86

nh 2 : Ban xut huyt hnh sao trong nhim trng huyt c tnh do no m cu

1.2.Nhim trng huyt mn Chim 1-2% gm : tng t st hi quy, ban dt sn, au khp ko di hng tun hay hng thng ban xut huyt. Gia nhng t, bnh nhn gn nh bnh thng. Tuy nhin, nu khng iu tr 2.Vim mng no. Thng kt hp vi nhim trng huyt. Khi bnh c tnh cht tan thn, cc triu chng mng n cc bnh nhn sau u xut hin cc triu chng in hnh ca vim mng no 3.Cc biu hin khc ca nhim no m cu. t gp. C th vim khp, vim phi, vim xoang, vim tai gia, vim kt mc, vim ni tm m o. 4. Bin chng Chim 5% nhng ngi that cht. H hp : thng c bi nhim VK khc, nht l khi c th my. Thn kinh : vim no, p xe no, co git, du thn kinh khu tr, ph no, dch di m kinh s no (ic). V. CN LM SNG Phn lp c vi khun trong mu, dch no ty, dch khp, cc dch cc xoang nh mng n ban xut huyt. PCR tm DNA vi khun : c hiu v nhy nhng t tin. Cng thc mu : thng c bch cu tng cao, ch yu bch cu a nhn trung tnh. Tuy nh tnh, bch cu li gim. Ty theo tnh trng v giai an ca sc, ta c cc xt nghim v to cho m.. 87

VI. CHN AN Giai an sm : rt kh phn bt vi bi cnh mt nhim virus, nht l khi khng c vi hng gi l ban hng sng nh trong thng hn. Khi ban tr thnh ban xut huyt th cc ban do cc bnh virus, Mycoplasma .. Chn an xc nh nh vo phn lp c vi khun trong bnh phm. Ch : phn lp vi ch l ngi mang vi khun. VII. IU TR Do tnh cht nghim trng v tin trin nhanh ca bnh, cn iu tr ngay khi nghi ng, hoc lp tc. Ly ngay cc bnh phm cn thit (cy mu, dch no ty..) sau iu tr ngay k 1.iu tr nguyn nhn: Khng sinh liu php Khi khng phn bit c no m cu vi cc nguyn nhn gy bnh khc, nht l trong vi

osporine th h ba nh cefotaxime hay ceftriaxone. Liu: cefotaxime 150-200mg/kg/ngy TM ( ti a 12 g), Ceftriaxone : 75-100 mg/kg/ngy TM (ti a 5g). Tuy nhin, khi bit chc no m cu v cn nhy cm vi penicilline th Penicilline G vn l 0.000-300.000 UI/kg/ngy TM. (Ti a 24 triu UI). Khi bnh nhn d ng vi Penicilline, c loramphenicol 75-100mg/kg/6 gi TM. Ti a 4g/ngy. 2.iu tr nng Phi lun lun cnh gic v din tin ca khng tin lng trc c v din tin rt nhanh. , mch, nhit trung tm v ngai bin, lu lng nc tiu, tnh trng ti mu, thng kh tham kho thm bi sc nhim trng. VIII. PH NG BNH Nc ta cha x dng rng ri vaccine no m cu. Phng bnh ch yu cho nhng ngi sng g tp th, nhn vin y t sn sc ngi bnh) Thuc dng : Rifammycine 10 mg/kg/12 gi ( ti a 600mg/12 gi) trong 2 ngy i vi nhng ng h nhn. Vi tr < 1 tui : dng liu 5 mg/kg. Ngi ln c th dng Ofloxacine 400mg/ngy thay cho Rifampin. Ph n c thai : dng ceftriaxone 250mg TB mt ln duy nht. Tr < 12 tui cng c th dng 5mg. Cu hi n tp 1. K cc i tng c nguy c nhim no m cu nng 2. Trnh by lm sng v cn lm sng cc th nhim trng huyt do no m cu 3. Chn on xc nh nhim no m cu 4. Cc nguyn tc iu tr nhim trng huyt ti cp do no m cu 5. Phng bnh cho cng ng khi xy ra dch do no m cu. 88 Bi 14. BNH NHIM T CU

Mc tiu 1. M t c mt s hnh thi lm sng nhim t cu hay gp 2. Lit k c cc bin chng do nhim t cu gy ra Ths, BsCK1 ng th Nga 3. Pht hin sm v x tr ng cc bin chng do nhim t cu 4. Tuyn truyn phng nhim t cu Ni dung

I. I CNG T cu ch yu l t cu vng, l mt tc nhn gy bnh quan trng ngi, n nh c da v nim mc ca k ch. Nu hng ro bo v da v nim mc b ph v do chn thng ht trin, nh c thnh abces. Mc d nhng nhim trng di da khng nguy hi, t gii hn, nhng cng c trng hp t cu lot cc biu hin ton thn nng n vi nhiu bin chng nguy him. II. BNH NGUYN 1 c tnh T cu thuc h Micrococcaceae l mt loi cu khun Gr (+), ng knh 0,7-1,2 nm, i kh thch mu n mc thnh cc khun lc c ng knh 1-4mm, trn nhn, bng v c bao bc xun T cu c sc khng kh vng, 40oC gi nguyn sinh lc trong 3 thng, b tiu dit mi t , thuc st khun thng thng nh: Iode.. Chng gy bnh ch yu l t cu vng v chng c c lc cao. T cu trng cng hin din

s tr nn gy bnh nh vim ni tm mc hoc nhim trng huyt 2.Cu trc t bo Ba thnh phn chnh ca vch t bo vi khun t cu vng l: Peptidoglycan, Phosphat Containing Polymer v Protein A. 3.Cc yu t gy bnh ca t cu 3.1 c lc ca t cu Phc hp peptidoglycane lm vch ca vi khun vng chc kh b ph v v c th hot ho b t ch sinh shock v CIVD. Ngoi ra t cu cn sn sinh nhiu enzym m chinh enzym ny gp phn ca vi khun nh : nuclease, protease, lipase, catalase, hyalurmidase, lisozime, l t m se, ct te dehydrogen se. T cu cn sn xut ra mt lng ln ngoi c t lm ri lon nhiu chc nng nghim trng n erotoxin, epidermolytic toxin A v B, TSST1 (Toxic Shock Syndrome Toxin group 1) 3.2 Sc khng ca vt ch Khi hng ro da v nim mc b tn thng vi khun t cu xm nhp vo, hn 50% nhim truing t cu t chc su u bt ngun t biu b, mt s nh t ng h hp, tiu 89

him khi t ng niu sinh dc. Bnh nhn bnh vin th t cu vng c th c a vo m uc. Ti nhim trng c phn ng vim hoi t ti ch, phn ln t cu b bch cu a nhn trun ung quanh tc nghn, fibrine lng ng chung quanh v sau t bo x lm thnh v bc, a es bao gm: phn trung tm cha bch cu, vi khun cht cng vi dch tit, chung quanh c khng sinh. Khi c th gim sc khng, t cu vo h thng bch huyt ri vo mu n n e tim, c tim, gan, lch, no.. Mt s t cu vng c th sng trong thc bo nn bnh kh i Tt c cc la tui u c th b nhim t cu nhng c bit l ngi gi v tr em th th III. MT S H NH THI LM SNG NHIM T CU HAY GP 1 Cc nhim trng nng 1.1. Da - Chc l: c bng nc trong, sau vi gi c kh v li vy vng nh sp ong, nga. Th - Nht sau khi c m th t chc xung quanh b hoi th nu nht cm li gi l hu bi (gp vai ) - Chn m - Vim nang lng - Vim bch mch, vim mao mch 1.2. T chc di da - Thng gp l vim m t bo (cellutite) - Nhim t cu cc ng tuyn nht l tuyn m hi nch, chung quanh hu mn, sinh dc 1.3. Nim mc - Vim hch hnh nhn - Vim xoang - Vim tai - Nht tin nh mi 2. Cc nhim t cu c quan 2.1 Nhim khun huyt Nhim khun huyt do t cu khng hn l s sinh sn ca vi khun trong mu m ch l s lan lt sau vo cc ni tng (vng khun huyt) to thnh cc di bnh ti cc c quan. Tm l vng khun huyt. Vng khun huyt do t cu c th bt ngun t bt c mt nhim khun ti ch no, nhng tr oc xy ra sau phu thut xng, thn kinh, tim mch, h hp, tit niu, hoc cc th thut m kh qun, khai kh qun, v thng thng a s l do can thip khng ng cc nht (nn n Lm sng ca vng khun huyt : Hay gp vi: - St dao ng, rt run, c khi st lin tc - Lch to - Trn da c pht ban, i khi thy cc microabces - Tin lng nng v tin trin khng lng trc c, shock xy ra khong 8-10%, c bit l gy shock. 2.2 Vim ni tm mc 90

y c xem nh l mt bin chng ca nhim khun huyt do t cu. Valve 2 l v valve ng

Lm sng biu hin vi: - St dao ng, rt run, c khi st lin tc - Lch to - Xut hin cc ting tim bnh l bt thng. - Thiu mu - Bnh tin trin nng vi cc bin chng suy tim, tc mch nhiu ni - Siu m c th pht hin c cc m si trn cc valve. 2.3 Vim phi v t cu phi mng phi - tr ln v ngi ln khe mnh, vim phi do t cu thng xy ra sau khi mc mt bnh n us khc. Bnh khi pht t ngt vi st cao, ho, au ngc, khc m c th c ln mu hoc m - tr nh vim phi do t cu thng biu hin bng st cao v ho. Sau hnh thnh cc tn c mc hi nc trn phim chp X quang. Mt i khi cc abces cnh l tng v vo mng - T cu thng c tr cc ph qun ca tr em b bnh x ha nang v c th gy nn cc 2.4 Cc bnh cnh khc ca nhim t cu c quan - Xng khp: (xa khuu gn u) nh xng chy, xng i, cnh tay, c tay, vim a m, v - No mng no: Abces no, vim mng no m. - Vim c. - Tit niu, sinh dc: vim tinh hon, vim ty quanh thn, abces tuyn lit tuyn 3 Nhim trng nhim c thc n - Vi khun gy bnh bi mt loi c t rut trong thc phm b nhim mm bnh, a s c l - Thi gian bnh ngn khong 1-6 gi sau khi n, bnh nhn nn , au bng, a chy - Bnh khi sau 12 gi. 4 Cc bnh gy ra do c t t cu 2.1 Hi chng bong da: SSSS ( Staphylococus Scalded Skin Syndrome) - Do nhim t cu c men gy trc vy (epidermatolysine) hoc c t gy trc vy ( exfolicetin toxin) hay gp tr s sinh, tr cn b, him gp ngi ln - Bnh khi u vi nhim trng di da ti ch; khu tr hay lan to, pht ban dng scalatin nc ri v ra li da trn ng khi dng tay ch nh da bong ra ngay 2.2 Hi chng sc c t TSST1: (Toxic Shock Syndrome Toxin group I) - Pht hin u tin do Tood, nm 1978 m t trn tr em - Lm sng: st cao, ban rm nng da (sunburn rash) hoc bong vy, huyt p h; phn lp IV. CHN ON Chn on xc nh : - Tm vi khun thng tn v cy mu ( cn cn thn khi khi ly bnh phm v t cu hin di - Chn on xc nh khi cy mu (+) nhiu ln hoc tm thy vi khun trong phn , hoc nc thit xng, nc ra ni kh qun. V. IU TR 1.T cu da v nim mc - St trng da v lm v sinh, nu mn nht hay ti i ti li hoc vng c nguy c dng: * Cephalosporine th h I : c th Cephalexin 1,5g - 2g/ ngyx 7 ngy 91 * Hoc Oxacilline 2g / ngy x 7ngy 2.Nhim t cu nng - Nguyn tc cy bnh phm v lm khng sinh trc khi cho khng sinh. - Thuc dng bng ng tnh mch hay tim bp. Thng l Chng khng sinh Penicillinase : Penicillin G :4 triu n v/4h Gentamycine 1mg/kg/8h Cephalosporin th h I Nu d ng Penicilline hoc nhim t cu khng Methiciline Vancomycine 0,5g/6h 3.Nhim khun huyt Phi hp khng sinh l bt buc - Nu cn nhy cm vi Penicillin : Penicillin (M) + Gentamycine - Nu d ng Penicillin : Cephalosporin th h I + Gentamycine - Nu t cu khng Methicicline Glycopeptide (vancomycine) + Aminoside Phosphomycine + Rifamycine Fluoroquinolone + Glycopeptide hoc Aminoside 4 Nhim khun nng vim ni tm mc nhim khun

thay

bng

Glycopeptide (vancomycine) + Aminoside Phosphomycine + Aminoside 5 Thi gian iu tr nhim khun huyt c khu tr Tim: 4 tun Phi: 4 - 6tun Ni tm mc: 6 tun Xng khp: 6 tun - 3 thng VI. PH NG BNH 1. C nhn Ngi lnh mang t cu khng gy nguy him cho bn thn. Ngi b nht hoc mang t cu m 2. Tp th - Cch li bnh nhn c nhim t cu - Dng thuc st trng iu tr nhim trng da ti ch - Kim tra u n nhn vin k ngh thc phm pht hin ngi mang mm bnh - Tn trng quy ch thanh trng khi phu thut - Khng dng khng sinh sai ch nh trnh chng t cu a khng khng sinh - Dng khng sinh lun chuyn, dnh cc khng sinh mnh iu tr trng hp nng. Cu hi n tp 1. Trnh by cc c im sinh vt hc v cc yu t gy bnh ca t cu. 4. Trnh by mt s hnh thi lm sng nhim t cu hay gp. 5. M t v gii thch cc cc bin chng do nhim t cu gy ra. 6. Trnh by cch chn on v cc bin chng do nhim t cu gy ra. 4. Trnh by cch thc iu tr v phng bnh do t cu gy ra. 92 Bi 15.

Mc tiu BNH UN VN

Ts, Bs Trn xun Chng 1.M t c cc c im chnh ca tc nhn gy bnh v vn. 2.Trnh by c cc triu chng lm sng, th lm sng, 3.Chn on c v tin lng c cc th bnh un vn 4.M t c cch thc iu tr bnh, bin chng v cch Ni dung

Un vn (Tetanus, Tetanos) l mt ri lon thn kinh, c trng bi tng trng lc c v cc spasmin. Bnh un vn c nhiu dng, bao gm un vn ton thn, un vn cc b, un vn s si I.NGUYN NHN Vi khun gy bnh l Clostridium tetani, k kh, Gram(+), thng tn ti khp ni quanh chng ta di dng bo t, rt kh tiu dit. Bo t c th tn ti nhiu nm trong nhi uc dit khun v un si di 20 pht. Khi nhim vo c th v c iu kin thun li, bo t ysin v Tetanospasmin gy bnh.

tm quan trng ca bnh un

cc bin chng bng kin thc sinh l v bin chng. thc d phng.

- Hemolysin t quan trng trn lm sng - Tetanospasmin gy ra cc triu chng ca bnh un vn. Tetanospasmin l mt chui polypepti 1 chui nng (100 kDt) v 1 chui nh (50 kDt). Chui nng gn vo th th t bo thn kinh t bo cn chui nh c ch s phng thch cc cht dn truyn thn kinh. II.DCH T HC - Trc khun un vn c tm thy trong lp nng ca t, trong t giu cht hu c v trong phn mt vi ng vt nh tru , b, nga.., gp vng kh hu nng v m,. - Bnh khng gy dch m l bnh lu hnh a phng, do nhim bo t un vn qua vt thng - Bnh ph bin trn ton th gii, ch yu cc nc ngho, y t lc hu, khng tim phng gii c 9.766.000 trng hp un vn, trong c 309.000 t vong (theo s liu ca T chc Y - Nc ta cha c thng k y trn phm vi ton quc nhng nh chng trnh tim chng m gim r rt. Tuy nhin, t l ngi ln vn cn cao. BVT Hu, s bnh nhn un vn tron 2005 khong 12-15 ngi/ nm, chim 0,3-0,6% bnh nhn Khoa Truyn Nhim. III.SINH L BNH a s vt thng u c nhim bo t un vn. Tuy nhin ch khi c iu kin thun li, thiu Oxy, bo t mi chuyn thnh dng vi khun hot ng. Vi khun un vn khng gy phn ng vim. Chng sn xut ngoi c t Tetanospasmin, c t n c t khng trc tip vo h thn kinh trung ng v khng thm qua hng ro mch mu no. 93

ng, c t ngc dng thn kinh vn ng vo trung ng, n phong ta cc synap c cha G v Glycin l cc cht dn truyn thn kinh. S co cng c ton thn xut hin khi mt s c g ng n ngoi vi. c t un vn cng c tc ng ln h thn kinh giao cm, to nn mt hi chng cng giao c huyt p mnh, mch nhanh, st cao, v nhiu m hi, tng tit m di.. Biu hin lm sng l tnh trng co cng cc c qu mc, tng trng lc c thng xuyn, ri vn ng cc dy s no. C nhai c dy vn ng ngn nht, nn c t vo sm nht . V vy Min dch khng y , c t ch c trung ha mt s ni, gy nn th cc b. c t Tetanospasmin rt c, ch mt lng rt nh gy bnh , nhng khng kch thch c m phi chng nga nh ngi cha mc bnh. IV. LM SNG 1. Th ton thn in hnh - bnh: trung bnh 7-10 ngy; c 15% trng hp < 3 ngy v 10% trng hp > 14 ngy. Thi g lng cng nng. -Khi pht: t khi cng hm (trismus) n khi co cng ton thn, thi gian t vi gi n vi cng hm tng dn n khi kht hm, lan ra cc c vng mt , vng hu hng, vng c lm hn c v mt au kh (risus sardonicu ): trn nhn, lng my xch ln, khe ming b ko tr -Ton pht: cng c lan n cc c c, c lng, c bng ri t chi. Trng lc c tng thng ng bt ng. Bnh nhn thng tng phn x qu mc. Cc c c, c lng co cng gy nn tnh tr nhn n cong ngi, lng ri khi ging, tay co rt, cc c chn dui ra (opisthotonos). Cc kch thch nh nh nh sng, ting ng, s, tim thuc, hoc nhng kch thch t bn tro phn ng do to bn u c th gy nhng cn co git kch pht trn nn co cng y, gy a c th ngt th v cc c h hp co cng ko di. Nhng trng hp bnh nng c ri lon thn kinh thc vt km theo.Biu hin nh: v m hi, g hn : tng hay h huyt p ko di hoc xen k, nhp tim nhanh hoc lon nhp, i khi ngn Bnh un vn din tin ko di v c t gn vo thn kinh rt bn, trung bnh 4-6 tun. Nu nhanh hn. Cc cn co gim tn s. Hm h to dn. Bnh nhn c th ung c ri n tr li xy ra nhiu bin chng. 2. Un vn s sinh a s do nhim khun rn. Xy ra tr s sinh v m khng c min dch chng un vn. Bnh k . Triu chng ban u l kh b, ming chm li ri khng b c. Sau bnh nhn co cng, o suy h hp. T l t vong rt cao, t 70-80%. 3. Un vn cc b Ch biu hin co cng mt s c, khu tr v tr tng ng vi ni xm nhp ca vi khun u tanospasmin. Tin lng thng nh, tuy nhin cng c mt s trng hp tin trin thnh th 4. Un vn th u 94

L mt th c bit ca un vn cc b. Thng do vt thng vng mt c. Biu hin gm cn C th chuyn qua th ton thn.

5. Phn un vn Da vo mc nng ca bnh, ngi ta chia lm 4 : - 1 (nh): cng hm nh n va phi, co cng ton thn, khng c cn co git, khng ri l - 2 ( trung bnh ): cng hm va phi, cn git nh n trung bnh nhng ngn, kh nut nh ln/ pht ). - 3 ( nng ): cng hm nng, co cng ton thn, cn git xut hin t nhin v ko di, kh pht ), nhp tim nhanh > 120 ln/ pht. - 4 ( rt nng ): bnh cnh lm sng nh 3 km ri lon thn kinh thc vt: huyt p cao v mch nhanh xen k vi huyt p thp v mch chm, huyt p cao ko di ( HA t oc huyt p thp ko di ( HA tm thu < 90 mmHg ). V. CHN ON 1. Chn on xc nh Ch yu da vo lm sng vi cc du chng : - Cng hm, khng km theo au vng mt c - Du tng trng lc c ton thn lin tc - Cc cn co git in hnh tng t - Trong mt s trng hp c th pht hin ng xm nhp ca vi khun, thng gp nht l v Trong trng hp un vn cc b, th u, du hiu cng hm gip ta ngh n bnh un vn. N ut, tng phn x cn cng gip chn on. Cc xt nghim cn lm sng ch c gi tr ch im cc bin chng ( bch cu tng trong bi 2. Chn on gin bit - Ch c triu chng cng hm : Phn bit vi cng hm do bnh nhn au khng dm h ming tr vim amidal, p-xe quanh amidal, tai bin rng khn. Thng c thm cc triu chng khc km p-xe, cng hm bui sng trong thp khp ). Dng li lm h ming d dng. - Cng c v cng lng : Cn gin bit vi vim mng no v vim no. - Cn co git ton thn : gin bit vi bnh di ( c biu hin s gi, s nc ), tnh trn ci hoc magne mu thp hoc c du hiu kim h hp ), ng c Strychnin ( tin trin rt nha hy cht c trong d dy v nc tiu), ng c Phenothiazine hoc Metoclopramide( cng hm v vi Hysteria. VI. BIN CHNG 1. Do c t un vn gy co git - suy h hp cp ( co tht thanh hu, cn co ko qu di gy ngt ) - ngng tim t ngt ( him ), tng hay gim huyt p nghim trng - gy xng, nht l xng sng tr nh, rch c, t dy chng, t mu trong bao c (do co 2. Do nm lu - thuyn tc ng mch phi, xp phi - bi nhim: vim phi thu hoc vim ph qun-phi, vim bng quang, nhim trng huyt ( dn - lot d dy t trng 3. Cc tai bin do iu tr 95

- tai bin huyt thanh (dng SAT nga) - tai bin do m kh qun : hp kh qun, n tht kh qun, so li, trn kh di da, trn k - ng c cc thuc an thn v dng qu liu - tai bin do th my ko di. VII. TIN LNG Trc y tin lng da vo: - Thi gian bnh (t khi vi khun xm nhp n triu chng u tin): cng ngn cng nng. ti cp, 3-7 ngy : un vn cp. - Thi gian khi bnh (t khi cng hm n khi co cng ton thn): cng ngn cng nng. Nu d : tng i nh. - ng vo v vi khun: Nu tm c v gii quyt trit , tin lng tt. Nu khng tm gch, ni tng ) : tin lng xu - Tn s cn co git: cng dy cng xu, nu hn 4 cn/ gi km co tht hng, thanh qun gy - Ri lon thn kinh thc vt: st > 40C, mch nhanh > 120 ln/ ph, v nhiu m hi, tng ti Hin nay, tin lng cn phi cn c vo tui (tui > 50 nng hn ngi tr), tnh trng sc y thn, x gan, bnh tim, nghin ru...bnh cng nng),tnh trng min dch ca bnh nhn, c quan trng nht. T l t vong do un vn ngi ln khong 10-20%, ring Khoa Truyn nhim (ngi ln), Bnh vin T Hu, trong cc nm 1996-2005 khong 12-15%.

VIII. IU TR 1. Kim sot cc cn co git Thuc tt nht l Diazepam ( SEDUXEN, VALIUM ), ng tnh mch. Liu dng: khi u 1-2 ng u nu cn tim lp li. Liu ti u c xc nh khi khng ch c cc cn co git ton g bnh nhn v ty theo din bin lm sng, nhng khng qu 7 mg/ kg/ ngy. Khi khng c Diazepam hay dng liu kh cao m khng ch ng c cn git, c th i hay uy nhin, lu dng Phenobarbital c c ch h hp. Cc thuc khng ch cn co git khc nh ronium ch c dng cc trung tm ln, bo m c h hp h tr. 2. Dit vi khun + Penicilline, 3 - 5 triu n v /ngy, tim tnh mch x 10 ngy. + Metronidazole 1 - 2 g/ ngy x 10 ngy, truyn tnh mch, c u im hn v mt l thuyt (k h Penicilline ) ln thc hnh, nhng gi thnh t hn. C th dng ring l hay phi hp c + Nu tm c ng vo, phi m rng, dn lu, ly cc d vt, cc m hoi t v ra bng O 3. Trung ha c t + Globulin min dch un vn t ngi (HTIG : Human tetanus immunoglobulin): Khng gy sc ph uyt thanh, bo v c 8 -14 tun. Liu dng : 500 v tim bp hoc tim tnh mch c hiu q 0 v). + SAT: nc ta hin nay cha c khng huyt thanh ngi, ch c SAT ngun gc t nga. Tuy ga d gy phn ng, bnh huyt thanh v thi gian khng th tn ti trong ngi ngn (ch 1 .000 v tim bp. Phi th phn ng trc khi dng. Nu c d ng, phi gii mn cm bng cc 96

nh tng dn (phng php Besredka). Tuy nhin, d test th m tnh vn c th xy ra phn n 4. Sn sc bnh nhn + Nui dng hoc bng ng tnh mch, hoc nu c th t ng thng d dy. + Bo m nhu cu calo, nc, in gii, protide, lipide, vitamin v mui khong cho bnh nh + Xoay tr chng lot. giai on hi phc, tp v xoa bp cc c, phng cng c v khp + C th dng thuc chng ng phng thuyn tc. 5. Theo di v x tr cc bin chng + Quan trng nht l nguy c ngt th do co tht thanh mn v suy h hp do cc c h hp co khng ch c cn co: m kh qun cp cu v h hp h tr (th my). Mt s tc gi c ch tch cc. + Bin chng ngng tim thng t ngt v kh x tr. Kch thch in hay c hc km theo xoa hn. + H huyt p : truyn dch v dng cc thuc vn mch + Tng huyt p : dng thuc chn alpha - beta nh Labetalol + Theo di cc chc nng thn , bng quang, rut. phng lot, chy mu tiu ha + Pht hin v iu tr bi nhim. IX. PH NG BNH 1. Tim phng + nc ta, tim phng un vn c trin khai trong chng trnh tim chng m rng cho tr ho g v bch hu (DPT). Tim t thng th 2 tr i, ba ln lin tip, cch nhau 1 thng. Tu sau 3-5 nm cha c ch trng. + Ph n c thai c tim phng 2 ln vo qu cui v 1-2 tun trc khi sinh. + Hu hiu nht l tim phng cho ton dn. Tim lin tip 3 mi, cch nhau mt thng, 5 nm nhc li mi ln mt mi, c tc dng phng bnh gn nh sut i. Bnh nhn sau khi khi un + Ci thin cht lng cc nh h sinh c s, nng cao kin thc v sinh cho nhn dn cng l l nhng vng cha tim phng rng ri c. 2. X l vt thng c nguy c un vn Ra sch vt thng bng nc m v trng. Ly sch cc d vt, cc m hoi t. Ph b cc ng sinh. Trong trng hp khng x l trit c, bn cnh khng sinh c th dng SAT (1500-3000 v 0.5ml Anatoxin, tim bp, tim nhc li sau 1 thng v 6 thng ). Cu hi n tp 1. M t cc triu chng ca giai on khi pht bnh un vn. 2. M t cc du hiu ca Hi chng cng giao cm bnh nhn un vn ? 3. Nu mt s bin chng thng gp ca bnh un vn. 4. Trnh by phc kim sot cn co git ca bnh un vn. 5. Trnh by cch x l vt thng phng bnh un vn.

97 Bi 16.

Mc tiu BNH DCH HCH

Ts, Bs Trn xun Chng 1. Xc nh c tm quan trng, nguyn nhn v yu t dch t hc ca bnh. 2. Trnh by c cc triu chng lm sng v cc xt nghim. 3. Chn on sm v tin lng ng. 4. iu tr sm v kp thi. 5. Xc nh c cc bin php phng bnh Ni dung

I. I CNG Dch hch l bnh truyn nhim rt nguy him gy dch, c th gy i dch do trc khun Yersinia pestis gy nn. Hin nay tuy bnh khng cn ph bin nh trc nhng n vn l hng lm tt cng tc chm sc sc khe ban u v iu tra dch t hc bnh c th bc pht anh. II. BNH NGUYN Yersinia pestis l mt cu trc khun Gr (-), sc khng ca Y. pestis tng i km. C 2 loi c t - Ngoa c t: khng chu nhit, ha tan, gm 2 thnh phn, phn A v phn B - Ni c t: chu nhit, khng ha tan C hai loi c t tc dng trn cc mch mu ngoi vi gy c c mu v sc, ni c t c III DCH T HC 1. Yu t ngh nghip Nhng ngi lm ngh c tip xc vi cc loi gm nhm, ng vt hoang di nh ngi lm rng cao hn. 2. Ngun bnh ng vt gm nhm l vt ch mang mm bnh dch hch, c 2 loi ngun bnh : - Vt ch chnh gp trong dch thin nhin, c sc duy tr mm bnh lu di - Vt ch th yu tuy c vai tr trong qu trnh sinh dch nhng ring mt mnh n kh duy tr hiu nhng ngun truyn bnh chnh 3. Cn trng trung gian B cht l cn trng trung gian truyn bnh trong cc ging chut v t chut sang ngi. Tt truyn bnh c bit l Xenopsylla cheopis l mi gii chnh, ngoi ra ngi ta tm thy irritans. IV. SINH L BNH Vi khun dch hch xm nhp vo c th qua da ( ch yu do vt t ca b cht) v nim mc (mng tip hp, nim mc hu hng, ng tiu ha, ng h hp). Sau theo dng bc eo dng bch huyt n cc hch su hoc xa hch khi im, cui cng mi vo mu. Trong mu Qu trnh bnh l c th dng li y. Ngc li nu gan lch khng lc c th vi khun c t ca vi khun dch hch c i tnh vi t chc thn kinh gy li b m sng v cc tn t ni tng. 98

Trong dch hch th phi, vi khun qua mi xm nhp vo nim mc ng h hp trn nhng khn Bnh gy min dch kh bn vng, him khi ti pht. V. LM SNG 1. Th vim hch Chim 90 -95% trong dch hch. 1.1. Thi k nung bnh T 1 n 5 ngy, c th ngn hn (vi gi) hay di hn (8 -10 ngy) nhng t gp. 1.2. Thi k khi pht Trc khi ni hch, bnh khi t ngt ngi khe mnh vi mt mi, kh chu, nhc u, ch hp khi pht bng triu chng nhim c, au nhiu vng sp ni hch . 1.3.Thi k ton pht - Vim hch: bt k ni no ca h thng bch huyt ngoi bin, lin quan n ni b cht hiu ni hch bn (62- 80%) , k l nch (14 -20%), c, di hm, dc c c n chm (1 eo chn rt him, thng ch 1 hch. c im hch vim: au xut hin sm trc khi sng, au cng nhiu bnh cng nng. Khi hch uanh hch b vim dnh nn kh xc nh ranh gii v kch thc. - Hi chng nhim trng nhim c: St, mch nhanh, nhp th tng, ngi l , mt mi, ht 1.4. Thi k lui bnh Hch vim s ha m, t v, chy ra mt cht nc hung hung . Bnh c th khi sau > 1 t in n cc th nng nh nhim trng huyt hay vim phi lm cht nhanh. Nu c iu tr tun iu tr . 2. Th nhim trng huyt 2.1 Tin pht Bnh khi t ngt, kch lit vi st cao 40-410C, kch ng, m sng, nn ma, tiu chy, b au chong nhim trng, ng mu ri rc thnh mch v t vong nhanh chng 2.2 Th pht: sau vim hch Bnh cp tnh nhng t rm r. Tin lng kh quan hn nu c iu tr tch cc. 3. Th phi 3.1 Tin pht Him gp. Nung bnh ngn chng vi gi. St rt cao km rt run, mch tng, bnh nhn mt mi -24 h sau cc biu hin tn thng ngy cng r: au ngc, ho tng cn, khc nhiu m, kh nn t khi nghe rales bnh l . Xquang: Hnh nh c phi hay hnh nh bong bng nh trong t cu phi . 3.2 Th pht Thng gp hn, l bin chng ca th hch khng c pht hin v iu tr kp thi. Chn o hun c mt cht nhy hng. VI. CN LM SNG - Bnh cng nng bch cu cng tng, th nhim trng huyt tin pht bch cu tng rt cao ti 50.000/mm3, N > 80%; c khi bch cu gim 1000/mm3, L >80% - Tiu cu gim trong th nng, nht l khi c hin tng ri lan ng mu. Tm Yersinia pestis trong cc bnh phm nh chc ht hch, mu, m, cht nhy c hng, dc 99

- Soi pht mu ngoi vi (+) :thng gp trong th nhim trng huyt tin pht. Soi pht mu n ong nhim trng huyt th pht. - Cy mu : Thng (+) th nhim trng huyt, vim phi. - Tm khng th trong huyt thanh bnh nhn . VII. CHN ON Dch t hc - Vng dch lu hnh - Mc chut v b cht tng cao - C chut cht t nhin v nhiu - Cha tim phng dch hch Lm sng: Hi chng nhim trng nhim c nng km au vng hch (lc hch cha sng) Cn lm VIII. IU TR 1. Cc bin php x l sm - Phi dng khng sinh sm - Cch ly bnh nhn trm x phng x - Nn t chc iu tr ti ch, nu xt cn phi chuyn sm

iu tr sm khi nghi ng, th thng thng gim t l t vong 40 %, th phi gim 5-10% 2. Phc iu tr 2.1. Th nh: Dng mt khng sinh ung 7 ngy lin tc Tetracycllin hoc Chloramphenicol 40mg /kg /ngy hoc cotrimoxazol 480 mg X 4 vin /ngy. 2.2. Th trung bnh: streptomycine 50mg /kg/ngy tim bp + tetracyclline ung 50mg /kg /ngy hoc chloramphenicol 7-10 ngy lin tc, tr sc, truyn dch nu cn. 2.3. Th nng -Khng sinh dng phi hp 3 khng sinh vi liu nh trn, khi bnh gim 2 th khng sinh sau - Corticoide: Depersolone 30 -60 mg - Bin php hi sc: Truyn dch, th Oxy, tr sc, nng cao th trng, tr tim mch. -Thuc an thn h nhit . - Chm sc bnh nhn: v sinh rng ming, thn th. IX. PH NG BNH V CHNG DCH Cc bin php chng dch hch khi c dch : - Bo co dch khn cp v bt buc - Cch ly bnh nhn hon ton - Cht thi ca bnh nhn nh nc tiu, phn, m, m x l bng nc Javen. - X l t thi bnh nhn dch hch: T thi bc trong vi tm lysol 5% hoc chloramin 3% . Bn trong quan ti phi rc chlorua vi, sau em chn su 1,5 - 2 mt. - Ung thuc phng i tng cho ung thuc phng khn cp l ngi tip xc bnh nhn v ngi sng chung nh b nhin, nghi ngh dch hch. Thng dng Tetracycline 1 g/ngy hay Cotrimoxazol 480 mg x 4 vin /ngy x 7 ngy Nhng ngi tim phng dch dch cha qu 6 thng khng cn ung phng . - Tim chng : c nghin cu t lu nhng hiu lc ca n khng cao. Khi c dch bng pht nn tim phng cho nhn dn cc vng ln cn, khng tim cho ngi sng gim c lc, tim mt ln, to min dch nhanh (5 - 7 ngy sau khi tim) - Dit b cht v dit chut (dit b cht trc dit chut) - y mnh cng tc tuyn truyn nhn dn hiu r s nguy him ca bnh. Cu hi n tp 100 1. Ngun bnh v cn trng trung gian gy bnh dch hch l g ? 2. Nu c im vim hch trong dch hch th hch ? 3. c im lm sng ca dch hch th phi ? 4. Phc iu tr dch hch th nh v trung bnh ? 5. Cc bin php chng dch hch khi c dch ? 101 Bi 17.

Mc tiu BNH NHIM LEPTOSPIRA (LEPTOSPIROSIS)

BsCK2,Ths H th Thu Vng 1. Trnh by c tnh cht ph bin v cc yu t dch t ca bnh nhim Leptospira. 2. M t c triu chng lm sng, cc bin chng thng gp ca bnh nhim Leptospira.

3. Trnh by c cc phng php iu tr bnh nhim Leptospira. 4. M t c cc bin php d phng bnh nhim Leptospira trong cng ng. Ni dung

Nhim xon khun Leptospira l bnh ca sc vt hoang di v gia sc lan truyn cho ngi. B tn thng cng lc nhiu c quan. Hi chng Weil l mt bnh cnh nng ca nhim xon khun, uy thn. I.NGUYN NHN Leptospira l mt loi xon khun thuc h Leptospiraceae, c kch thc rt mnh , trn knh nh chui cu trng, khng bt mu nhum gram thng thng, ch pht hin bng nhum nitrat bc, c nhiu type huyt thanh khc nhau. C n hn 200 type, chia thnh 23 nhm. Ch c mt s type hay gp v gy bnh cho ngi. Tc nhn ictero haemorrhagiae. Mt type huyt thanh c th gy nhiu bnh cnh khc nhau. Ngc li, mt bnh cnh lm sng nhm gy bnh to nn. II. DCH T HC Leptospira l bnh ch yu ca cc ng vt, nht l cc ng vt gm nhm nh chut v gia sc nh ch, heo, tru, b.... Ngi ch mc bnh khi tip xc vi t, nc c xon khun thi ra t nc tiu ng vt hay t mu hoc xc ng vt mc bnh. Bnh thng xy ra vo ma h-thu, lc con ngi phi lao ng hay gii tr ngai tri. Nam m tui hay mc. Nhim xon khun cng l bnh ngh nghip, lin quan n cng vic dm nc v cng nhn v sinh cng rnh, th m, cn b th y ...v thng xuyn tip xc vi ngun bnh III. GII PHU BNH V SINH L BNH Sau khi qua da v nim mc, Leptospira vo mu, lan trn khp c th gy nhng biu hin bnh l nhiu c quan.. Leptospira di chuyn xon c nn c th lch qua cc m lin kt d dng. Ngoi ra, cng pht cht lc canh cy Leptospira, chnh cht ny gip Leptospira xm nhp bt thng vo nhiu c Nhng pht hin v lm sng v m hc trn ngi v ng vt cho thy tnh cht gy bnh ca enzyme v cc cht bin dng khc to ra t s ly gii ca Leptospira Bn cht ca cc ri lan l thng tn mng cc mch mu nh, a n vim mao mch, thot d an gan, thn, c, v t cc mao mch c th gy tn thng cho bt k c quan no khc nh m 102

- Gan: hoi t trung tm cc thy km cc t bo Kuffer phnh to. Tuy nhin khng c hoi t - Thn: Thng c vim thn k v hoi t ng thn. Leptospira thng c tm thy trong ln g thn c l do thiu oxy mu hoc tc ng gy c trc tip ca Leptospira. Cc bin i c mun, c phc hp min dch lu hnh v s lng ng b th ti cu thn, gi vim vi cu t - Leptospira c th tm thy d dng trong dch no tu vo tun u ca bnh, thng lc ch xut hin khi nng khng th trong huyt thanh bt u tng, khi leptospira bin im mng no c l do phn ng khng nguyn- khng th. - C:: Mc d au c xut hin sm v trm trng nhng thay i m hc thng khng ng k. Giai on khi bnh nhiu si c mi c thnh lp. IV. LM SNG Bnh cnh lm sng c th nh hoc rt nng. Th nng c trng bi xut huyt, vng da, suy thn (hi chng Weil) do L.autumnalis, L. bataviae, L. copenhageni...gy ra. Bnh thng din bin theo 2 pha : 1.Pha nhim khun huyt (Acute leptospiremic phase) 1.1.Thi k bnh Trung bnh t 1-2 tun, c th dao ng trong khong 2-26 ngy. 1.2. Thi k khi pht Khi pht thng vi cc triu chng st, nhc u, s nh sng, rt run, v m hi v au c thng c cn rt run. Nhc u c th vng trn, hai bn thi dng, c th vng chm. lng, cng chn. Xo p c lm cn au tng ln. Vng da xut hin 5-7 ngy sau khi khi ph 1.3. Thi k tan pht Cc triu chng trn tip tc pht trin nng hn. Bnh nhn au c nhiu hn, c khi khng . Mt b xung huyt. Trn da thng c ni cc ban dng dt hay dng ban lm tm khu tr c th c chy mu cam, au hng , ho. Cn lm sng : trong giai an tan pht (thng l tun u tin), ta c th tm thy vi khu v tun th hai trong nc tiu. Tuy nhin giai an ny cc xt nghim huyt thanh thn

Cng thc mu cho thy bch cu tng cao, ch yu a nhn trung tnh trong phn ln trng h r mu v creatinine mu tm thi. 1.4. Thi k hi phc tm thi Phn ln cc triu chng bin mt sau 1 tun. Sau 1-3 ngy, cc triu chng xut hin tr li ca bnh. 2.Pha min dch (Immune leptospiruric phase) S bt u pha min dch c lin quan n s xut hin cc khng th. Biu hin hay gp l vi vim c tim v vim no. - Vim mng no: thng c hi chng mng no r, nhng dch no ty trong, khng tm thy vi l lympho nh trng hp vim mng no virus. Tuy nhin trong mu cng thc bch cu c th v tnh. - Suy thn cp : c th xy ra ngay trong giai an tan pht v ko di, khng c giai an niu ri v niu. Xt nghim c th c hemoglobin niu, hng cu, tr ht, cc cn lng ca r mu v creatinin mu tng cao. 103

- Vim gan: Th vim gan cp vi cc triu chng gan to, au. Vng da r do mt . - Xut huyt nhiu ni : biu hin thng di da vi nhng mng rng l mt biu hin nng khi lng tun han. - Hi chng Weil :L th nng nht ca bnh, c trng bi vng da, suy thn, xut huyt v c g trn thng xut hin sau khong 4-9 ngy. Vng da khng c lin quan n hoi t t bo g t ng thn cp, gy ra bi gim th tch tun hon v gim ti mu thn. V. CN LM SNG 1. Cng thc mu: Bch cu thng tng khong 10.000 20.000/mm3, a s a nhn trung tnh, c th bch cu b da cng nng bch cu cng tng cao. Hng cu gim nhiu nu c tn huyt ni mch hoc xut huyt Tiu cu gim, him khi n mc gy xut huyt nng 2. Nc tiu: hemoglobin niu, hng cu, tr ht, cc cn lng ca hng cu v cc mnh ca t 3. Chc nng thn: Ur, creatinin mu thng tng rt cao trong cc trng hp c vng da, ngay c khi bnh nhn c iu tr khng sinh 4. Chc nng gan: SGOT, SGPT thng tng di 5 ln tr s bnh thng. Bilirubin tng thng 5. Chn on vi sinh: + Soi: Phng php quan st trc tip xon khun trong mu hay nc tiu bng soi knh hin v v dc hiu (60,1%) thng thp Mt s phng php nhum nh nhum min dch hunh quang, nhum nitrat bc thng khng c i thp + Phn lp xon khun - Cy mu: Ch dng tnh trong tun u tin ca bnh. - Cy nc tiu: Ch dng tnh sau tun u tin ca bnh v ko rt di v sau v bnh nhn g sau khi khi bnh. C th phn lp c xon khun t dch no tu, dch thm phn phc mc + Cc xt nghim huyt thanh :Cc phng php chn on hay dng hin nay l : - Ngng kt vi th (MAT: microscopic agglutination test) dng tnh khi hiu gi 1/100. Ch p vo tun th hai ca bnh. - Test ELISA ( enzyme-linked immuno-absorbent assay) : nhy nhng t tin. - PCR: c dng pht hin chui DNA ca Leptospira; ch thc hin cc trung tm ln. VI. CHN ON Chn an xc nh nh tm c vi khun trong mu hay trong nc tiu. Ngai ra cn c th xc nh bng cc xt nghim huyt thanh v k thut PCR. 1. Cc du hiu gi trn lm sng : + Tin s c tip xc vi ngun bnh trong vng 1 thng. + Ngh nghip c nguy c nhim xon khun. + Cc triu chng : st, au c, vng da, xung huyt kt mc, suy thn, xut huyt. 2. Xt nghim cn lm sng: - Cy mu : Ch dng tnh trong tun u tin ca bnh. - Cy nc tiu : Ch dng tnh sau tun u tin ca bnh v ko rt di v sau v bnh nh hng sau khi khi bnh. - Cc xt nghim huyt thanh VII. IU TR

1. iu tr nguyn nhn Xon khun nhy cm vi hu ht cc khng sinh thng thng. Trng hp nng nn dng Pnicil illin hoc Erythromycin ng tnh mch. 104

Liu Pnicillin: 6 triu n v/ ngy, chia 4 ln trong 7 ngy. Liu Amoxicillin v Ampicilli x 7 ngy. Trng hp bnh nh c th dng Tetra cyclin, Doxycyclin, Amoxicillin hoc Ampicillin bng ng ung. Tuy nhin khng sinh ch c hiu lc khi dng sm, trong vng 5 ngy k t khi pht bnh. Khi khng sinh thng khng c hiu qu. 2. iu tr triu chng Cn ti lp cn bng nc v in gii. Bnh nhn c hi chng Weil cn c truyn mu v ti c suy h hp, nht l ARDS . VIII. PH NG BNH 1.Cc bin php chung - Dit chut v cc lai gm nhm, trnh tip xc vi nc tiu v ng vt cht. - S dng gng tay, ng bo h khi phi lm vic trong mi trng c nhiu xon khun nh kha g... - Theo di nh k cc ngh nghip c nguy c mc xon khun cao. - Trng hp mi nhim c th dng Doxycyclin, 200mg, liu duy nht mi tun. 2. Tim chng - Vaccine c kh nng bo v chng xon khun vng da xut huyt (L. icterohemorrhagiae) trong 3 nm. Hiu lc bo v xut hin sau ln tim th ba (mi ln cc nhau 15 ngy, 1ml/ln). C th tim phng vaccine cho sc vt: tru b, ch, heo... Cu hi n tp 1. Cc yu t nguy c ca bnh leptospira 2. Lm sng ca bnh leptospira pha min dch 3. Cc xt nghim gip chn on xc nh bnh leptospira 4. iu tr mt trng hp bnh leptospira c suy thn cp 5. Trnh by cc bin php phng bnh do leptospira. 105 Chng 3. CC BNH DO NHIM VIRUS Bi 18. NHIM HIV/ AIDS

Mc tiu Ts,BsCK1 Nguyn L 1. T vn c cho ngi nhim HIV, thn nhn v nhng ngi c nguy c nhim HIV v ng l 2. Theo di v sn sc c hiu qu ngi nhim HIV trong mi giai an Ni dung I. NH NGHA Nhim HIV l tnh trng c virus HIV trong c th. Tuy chm, ca c th, nh h thn kinh trung ng, v c bit h min hay do chnh virus HIV. n nay, l mt bnh cha c thuc iu tr tht s, ch km mt hiu qu do nhiu nguyn nhn khc nhau. II. S LC LCH S Nhng trng hp nhim trng c hi hay u Kaposi do suy gim

nhng chng ngy cng tn cng m dch, lm c th mt dn kh nn

hm c tin trin ca bnh, v

min dch u tin c ghi nhn

Nm 1983, Luc Montagnier (Php) phn lp c HIV 1, nm sau 1984, tm c HIV2. Bnh c nhanh chng lan truyn v pht hin ln lt trn th gii mt cch nhanh chng, cui thp nin 1980, lan n chu mun hn, nhng hin nay c nguy c tng nhanh hn cc c Trn lm sng, nhiu phng thc c gng h thng ha biu hin ht sc a dng ca cn b (1985), ca Walter Reed (1986), ca CDC (1987), ca WHO ri ca CDC ci tin (1993) vi nhng uyt im ring, ln lt ra i gip cho cc nh lm sng, dch t v min dch, thng nh V iu tr, cng c nhng tin b vt bc. Thuc khng HIV u tin (AZT) c th nghim ( ip theo cc nhm thuc khng HIV khc ln lt pht hin. K t 1995, liu php kt hp 3 th u trong vic chn ng tin trin ca bnh, thm ch c hy vng bin nhim HIV thnh mt bn i thnh qu t, tc dng ph v s xut hin virus khng thuc khi dng lu di lm cho hi hiu hn ch. III. TC NHN GY BNH v SINH L BNH I CNG Virus HIV hin nay c pht hin c 2 lai HIV1 v HIV2, khc nhau kh nhiu v mt s khng gy bnh v din tin lm sng khng khc nhau lm. Nhim HIV2 c tin trin n giai an AI 106

C hai lai u l nhng Retrovirus, vi acid nhn l RNA, chng c kh nng tng hp thnh D RNA nh vo mt men c bit gi l men sao m ngc (reverse transcriptase, vit tt l RT). hng han chnh, hay c sai st so vi nguyn bn ban u. iu ny, gip cho virus thay i in chng khc nhau, gip cho virus that khi s tm dit ca h min dch. Virus c bc bi mt lp v ngai, gm cc glycoprotein 120 v glycoprotein 41, c kh nng l nhm CD4 v cc coreceptor khc. Hai coreceptor ni ting ca HIV l nhng th th ca ch trc dng CCR5, mt c cu trc CXCR4. Mt s ngi (thng thuc chng tc Cacause, da trng), khng c th th CCR5, nn m IV, iu ny gii thch nhng trng hp nhim HIV tin trin ko di n 15-16 nm. Mt nhm men quan trng ca virus l cc men tiu proteine (cc protease). Cc men ny gip c irus va c tng hp, nhm li thnh nhng virus han chnh v ph v t bo vt ch ph tip tc tn cng cc t bo ch khc. c ch c nhm men ny s c ch c s nhn ln Virus HIV khng c kh nng tn ti lu ngai cnh. Chng b dit bi nhit > 56 C, v thng nh dung dch cloramin, nc Javel, hi nc nng. Tuy nhin trong c th ngi nhim, virus kh b tiu dit. Chng tn cng cc t bo c mang c i tnh vi chemokin nh cc t bo lympho T gip (c gi l cc t bo CD4+), t bo cell) h thn kinh, cc i thc bo, cc t bo mono v cc t bo lympho vng mm ca h Chng n trong cc hch bch huyt giai an u, kh nng thay i khng nguyn thng xuy g tm cch dit chng. Sau , nh vo chc nng trnh din khng nguyn ca cc i thc bo thch hp, c bit t bo T CD4+, xm nhp v ph hy t bo ny. T bo T CD4+ l t bo quan trng trong iu ha min dch ca c hai h min dch th dch gim dn s lng T CD4+ lm c th mt kh nng min dch vi ngai cnh, dn n nhim tr Bn thn virus HIV cng c th tn cng mt s c quan c nhiu t bo mang receptor CD4 nh bin chng thn kinh quan trng. IV. DCH T HC T nhng pht hin u tin nm 1981 ti Hoa k, bnh nhanh chng lan truyn khp th gii th ty v mi dm.T lan n cho ngi hn phi v tr em ra i t nhng ngi m HIV (+). M nhng ng ny ngy cng hn ch do nhng bin php pht hin HIV trc khi cho mu ngy c Bo co ca WHO vo 31/12/2007: Uc tnh ton th gii c khong 65 triu ngi nhim HIV, t Phn b theo a l nh sau Chu M : 3. 000.000 Chu u : 1. 880.000 trong ng u 1.3 triu Chu Phi vng h sa mac Sahara : 25.000.000 Bc Phi v Trung ng : 480.000 Chu c : 32.000 Chu : ch yu Nam v NA : 7.400.000. 107

Tuy nhin, s ngi nhim mi cc nc pht trin nh Ty u v Bc M ngy cng gim, tro Vng bin Caribe v chu Phi vng h sa mc Sahara vn cn gi mc cao. Vit Nam, bo co ca y ban phng chng HIV/AIDS quc gia c tnh n cui 2007 c khong 400.000 ngui nhim HIV (t l 1/200 dn s). Cc tnh v thnh ph c s ln HCM, H ni, An giang, Hi phng, Qung ninh, Vng tu, ng thp, ng nai, Ngh an, Cn t Ngun ly : Hin nay HIV ch c vt ch l ngi. Cc virus tng t (nh SIV), c th gy b

bnh cho ngi. Ngc li, HIV1 v HIV2 cng khng gy bnh cho cc ng vt khc, k c c h kh tng t nhim HIV ngi v l m hnh tt nghin cu HIV ngi. ng ly truyn: Hin nay, HIV ly qua ba ng : - ng mu: Mu, huyt tng, cc dch c th ngi nhim HIV a trc tip vo mu hay qua in, mc ly ty thuc vo nng virus. Nng ny thay i ty theo giai an ca bnh nh m hi, nc bt, m, nc tiu, phn...c mt virus thp. Ch ly khi c c hi tip nim mc b xy xt. Dch sinh dc v cc dch kn trong c th (dch no ty, dch khp, Nhng tr quan h tnh dc, a s ly qua cc dch ny l tai nn ngh nghip ca ngnh y t Trong thc t, ly truyn qua ng mu ch yu xy ra nhng ngi nghin chch ma ty dn t truyn mu hay cc ch phm ca mu ngy cng t, nhng khng trit tiu hn v khng th s. Cc xy xt qua da v nim mc do dng chung nhng dng c nh dao co ru, dng c ct m nh trng k.. l nhng ng ly cn lu . n nay cha c bng chng ly qua cc cn trn - ng tnh dc: L con ng ly truyn kh ph bin v kh ngn cn do thiu hiu bit. N uy c ln hn khi giao hp qua ng trc trng, sang chn khi giao hp, c bnh hoa liu kh m thng gy nhim cho n nhiu hn. - Ly t m qua con: c th ly trong giai an thai k, trong thi gian chu sinh v trong khi cho con b d rng mt virus trong sa m thp. V. CC GIAI ON NHIM HIV 1. Giai an s nhim Giai an ny tnh t lc virus HIV xm nhp vo n lc c th c khng th chng li HIV ( -6 tun. Trong giai an ny, mt virus rt cao, nn rt d ly nhim. S lng t bo T Giai an ny, bnh nhn c mt s biu hin lm sng ca nhim virus chung chung nh st, a khi biu hin vim phi, ri lan tiu ha, thm ch nhng triu chng thn kinh. Nhng bi thi gian tin n AIDS. Biu hin cng nng, cng nhanh tin n giai an cui. Trong giai an ny, cc xt nghim tm khng th u m tnh v c th cha sn xut. Ch ph sn phm ca HIV (gp 20, gp40..). nc ta, cc xt nghim ny cha ph bin. Cui giai an s nhim, lng virus trong mu gim xung, v khng th khng HIV bt u xu tip virus c th m tnh do lng virus qu thp hay do virus n trong cc hch bch huyt. khng th vn 108 cha dng tnh. Giai an m tnh gi ny gi l giai an ca s.

Biu 1: Din bin s t bo T CD4+ v nng HIV ngi nhim HIV 2. Giai an tim n Sau thi k s nhim, c th bt u to khng th tm dit HIV. Trong giai an ny, virus t erminative zone) ca cc hch bch huyt. Chng thay i khng nguyn v trong cc i th t bo gy c v t bo git. Mt virus lc ny trong mu thp, nhng nguy him v ngi inh hat bnh thng trong x hi, tip tc hat ng tnh dc nn lm tng kh nng truyn b Bn trong c th virus tip tc sinh sn v hy hai dn t bo T4. Sau mt giai an kh d nh nht l 3 nm, di nht c th n 16 nm. Trung bnh 10 nm), lng t bo T4 khng cn c biu hin suy gim min dch. Nng virus trong mu tng dn theo thi gian (do kh n lng T4 giai an ny vn nm trong gii hn bnh thng. Giai an ny c th pht hin h, hin ang x dng nc ta. 3. Giai an tin AIDS (Trc y gi l giai an c biu hin cc phc hp lin quan n AI Giai an ny, bnh nhn thng c cc biu hin lm sng vi nhng hi chng gi n nhim cn 10% trng lng c th M KHNG T M C L DO no khc (lao, cng gip, ung th, i xoang ming, m o, p ng km vi iu tr. Ph n c th lan sn hay K c t cung ti . Zona nhiu vng trn c th, ti pht nhiu ln l mt bnh hay gp giai an ny. Giai a mm3. 4. Giai an AIDS Theo quy nh ca CDC, mi trng hp c T4 < 200/mm3 u xp vo giai an AIDS. H min d v c th. Trn lm sng bnh nhn thng mc cc nhim trng c hi, mt s bnh c tnh c Kaposi). Mt s c cc bin chng do chnh virus HIV gy ra (vim no do HIV..).Cc bnh ny g phn lai ca CDC 1993. Cc bnh c hi 109

thng kh cha, v d khng thuc. Nu cha khi thng hay ti pht, i hi phi ung thu

h nhim trng cng lc cho nn rt kh iu tr v bnh nhn thng t vong . Giai an ny mt virus trong mu rt cao. Nhng do khng cn hat ng c nn nguy c l cho bn cng tim chch hay do tai nn ngh nghip y t. Trong bi cnh nc ta, ngi nhim HIV thng c nhng biu hin nhim trng c hi. Mt s K c t cung xm ln. Nhng u Kaposi, d rt ph bin cc nc, nc ta cha thy bo c cha c phng tin khng nh. V th, y ch cp n nhim trng c hi. VI. NHIM TRNG C HI (NTCH) 1. nh ngha NTCH l nhng bnh ch xy ra trn nhng c a suy gim min dch (leucemie, dng thuc c c giai an AIDS). Trn c th bnh thng cc tc nhn gy bnh thng b h min dch c th Tuy nhin, khi nim ny hin nay c m rng gm c nhng bnh nhim trng nhng bnh nh chng cng c th gy bnh ngi bnh thng nh lao, vim phi vi khun thng thng. iu thng tin trin nhanh chng, p ng chm vi khng sinh c hiu, ti pht nhiu ln.. 2. Mt s bnh c hi hay gp Vit Nam Danh sch bnh c hi trong AIDS rt nhiu, v ngy cng c b sung thm. N ty thuc vo g bnh nhn sng. Chng ti ch k n mt s bnh hay gp nc ta. 2.1. Lao Lao l bnh c hi hng u ngi nhim HIV nc ta. Lao lm tin trin HIV nhanh hn n g ao d lan ta tan thn, kh iu tr v lm xut hin cc chng khng thuc nhiu hn. 2.2. Nm Candida Hay xut hin xoang ming v m o. Tuy nhin khi tnh trng min dch gim, nm lan n t y lan vo nhu m phi ...thm ch gy nhim nm huyt, lan n cc ni tng khc. iu tr r 2.3. Nhim nm Penicillum marnerffei Lai nm ny ch ph bin ng nam , c ngun gc t chut ng (Bambou Rat). Thi Lan cha c cng b chnh thc, nhng pht hin nhiu trng hp c ba min. Thng c biu in d lm vi u nhy ly (Molluscum contagium). iu tr kh khn vi thuc khng nm. T vo nazol tim TM 400mg/ngy khi c nhim nm huyt hay ni tng. Ung thng cho kt qu chm h phi ung thuc phng (Fluconazole sut i cng vi thuc khng HIV. 2.4. Vim phi do P. jeroveci (trc y gi l Pneumocystis carinii ) L bnh c hi ph bin cc nc Chu u v M. nc ta bo co chnh thc ch c 5 tr nhiu trng hp vim phi k, khng p ng vi cc khng sinh ph rng v cc thuc khng C th y l do nhim P. jeroveci. y l mt bnh phng c. Khi bnh nhn c TCD4+ < 200/ ngy d phng. 110

2.5 Tiu chy Do rt nhiu nguyn nhn. Vi cc vi khun thng thng, d c p ng vi Fluoroqu onidazole, bnh thng ti pht nhiu ln vi khong cch rt gn. C trng hp ch p ng 2.6. Vim mng no do nm Crytococcus neoformant Cn cnh gic khi bnh nhn HIV(+) c hi chng mng no. Cn cho xt nghim dch no ty (nh vi Amphotericine B hay Fluconazole. 2.7. Nhim Toxoplasma L mt bnh c th phng c bng cch khuyn bnh nhn khng tip xc vi mo v phn mo. Pyrimethamine. VII. CHN ON 1. Chn on nhim HIV Do tnh cht quan trng v tnh trm trng (khng cha c, chc chn t vong) cho c nhn c h hng rt ln n i sng bnh nhn v mt th cht cng nh tm l, nh hng n uy tn khi kt lun mt ngi nhim HIV. Ch nh v kt qu xt nghim cn ty giai on ca bnh 1.1 Xt nghim pht hin khng th L cc xt nghim ang c x dng ph bin nc ta. Cc xt nghim ny khng pht hin yn bnh nhn xt nghim ln 2, sau 3 thng khng c tip xc vi ngun ly nhim no khc. N hng nhim. Ngc li, tr < 1 tui, m HIV (+), nu xt nghim dng tnh, vn khng kt lun c ch yn qua. Do phi xt nghim li trong nhng nm sau t 18 thng tui tr ln. C ba lai xt nghim pht hin khng th khng HIV ang dng nc ta: Test Serodia : nhy thp, nhng c hiu cao. Ch c gi tr sng lc ban u. Nhng ng , cn xc nh thm bng cc xt nghim khc trc khi khng nh. Ngc li, ngi Serodia ( Test ELISA : pht hin mt lai khng th ty theo kit chn trc. Phn ng ny c nhy ca o vi cc th h XN sau. Tuy nhin vn khng chc chn 100%.

Test Western - Blot : Kt lun ch chc chn 100% khi ngi bnh c xt nghim HIV (+) vi ph - Blot. Phng php ny pht hin mt lot nhiu khng th c hiu chng nhiu lai khng n . Do lai tr c phn ng dng tnh gi. Tuy nhin do xt nghim Western-blot rt t tin, khng th x dng i tr m s ngi nhi ay ngnh Y t quy nh : Vn xem nh l (+) nhng trng hp ELISA (+) 2 ln vi 2 lai kit k khng th khng HIV khc nhau ). Xc sut dng tnh gi khi xt nghim 2 ln vi 2 lai kh sc thp nn him khi gp sai lm trong thc t. 1.2. Xt nghim tm trc tip virus hay cc sn phm virus Ngi ta c th pht hin trc tip s hin din ca virus trong mu hay dch c th bng ph hng php dng gen mi thm d. Cc phng 111

php ny c hiu, cho php pht hin ngay c trong giai an s nhim. Ngai ra, cn dng rus (o nng virus trong mu), pht hin tr s sinh c nhim HIV hay khng. Tuy nhin do , hin nay ch x dng cc trung tm nghin cu quc gia, cha p dng i tr. Cc k thut tm cc protein virus nh p24 (Hin nay test ELISA th h 4 va cho php pht hi ht hin KN p24) c tnh c hiu, nhng khng hng nh. Phn lp virus HIV : chnh xc v c th kho st c nhiu c tnh ca virus. Nhng cha t 2. Chn on giai on ca bnh Mc du tin trin v mt sinh l bnh c 4 giai on, nhng trn thc t lm sng, biu hin v a dng. Do , nhiu phng php xp loi c ngh ph hp hn vi lm sng v dch t Trn thc t lm sng, ngi ta thng chn on giai on nhim HIV da vo mt trong nhng Ni ting nht l cch xp loi ca CDC 1993 dnh cho ngi ln nhim HIV S t bo T CD4+ /mm3 hay t % A > 500 (>29%) B1 200 - 499 (14-28%) B2 < 200 ( <14%) B3 C2 A3 C3 B A1 C1 A2 C

Bng 9: Cch xp loi ca CDC 1993 Nhng bnh nhn thuc vo nhm C v/hay c ch s 3 c xp vo giai on AIDS. Do khun kh c th cc triu chng v bnh c xp vo cc nhm. Ngi c c th tm c d dng trong rt nhiu ti liu lin quan n phn loi giai on nhim HIV trn cc sch Y hc v trn cc trang Web lin quan Nhng bnh nhn xp vo nhm thp hn, d sau c ci thin lm sng, vn khng chuyn n Phng php xp loi ny c u im d theo di, tin lng v d cn nhc x dng thuc khn hi. Tuy nhin tiu chun m s t bo T CD4+ kh thc hin a s cc nc ngho (nh Vit CD4+ qua s lng t bo lympho ngoi vi, qua cc phn ng b, c ng dng mt s ni nh hn rng ri V th, T chc Y t th gii (WHO) gii thiu mt cch xp loi khc, trong khng x dng mc sinh hat ca bnh nhn trong ngy. Cch chia ca WHO ch c 4 giai on. Chng ti k o WHO y v khun kh bi hc . Cc xp loi ca T chc Y t Th gii d dng cho cc nc ngho, thun tin cho dch t hc cc nh lm sng quyt nh dng thuc khng HIV hay cho thuc phng mt s bnh c hi. i vi tr em, do cc c th ring, c c mt bng xp loi khc ca CDC 1993. C th tha VIII. CHM S C V IU TR NGI NHIM HIV Do c qu nhiu vn , trong phm vi bi ny, chng ti ch nu ln mt s nguyn 112 tc chung. Chi tit xin tham kho nhng ti liu lin quan. 1. Nguyn tc : 1.1.Chm sc tan din :

Hin nay chm sc ton din ngi nhim HIV bao gm cc lnh vc : chm sc th cht, chm s x hi v phng bnh. 1.2. V th cht Khm sc khe nh k cho bnh nhn v bt k lc no c bnh. Mc ch theo di gm c : ph dch ca bnh nhn (l tng l m s lng t bo TCD4+), tnh trng virus (nu c iu ki dng. Khi bnh nhn sp ri vo giai an AIDS, c th x dng thuc phng mt s bnh c hi P. carinii, Toxoplasma..), cc thuc khng nm phng mt s bnh v nm..Vn tim vc xanh ph cu, cm, H. influenza.. cho bnh nhn HIV nc ta cha c bn n. Nu c ch nh d cht ch vi bnh nhn, ngi gim h v t chc mng li cp thuc cho bnh nhn. Trnh tn khng liu, t ngng thuc v khng ch li g cho bnh nhn m cn c th chn lc ra h ca cc thuc x dng cho bnh nhn c th iu tr kp thi 1.3. Chm sc tm l Bnh nhn phi c t vn, trnh khng hong tm l vo lc pht hin nhim HIV. Trnh cc p t t) hay x hi (tr th bng cch c gy ly nhim cho ngi khc). Nu c cc biu hin trm cm nguy him, c th hi chn thm vi chuyn khoa tm thn h Khi tm n nh v tm l giai on u, cn gip bnh nhn vt qua cc k th v phn bit cc sng t tin v hu ch hn. 1.4. Chm sc tm linh ng trc bnh khng cha c v d b k th, ban u v nht l lc sp t vong, bnh nh hay khng t gic) nh Cht l g? Sau khi cht ta i v u? C thin ng, a ngc khn yn th lm th no ? Chm sc tm linh gip ngi bnh chp nhn mt cch an bnh nhng au n v tinh thn v th gip h tha th hay bnh tm vi ngi thn, ngi gy au kh cho h Ty theo tn gio ca bnh nhn (hay khng theo tn gio no), to iu kin cho bnh nhn g yu cu, tn trng nhng nim tin v cu nguyn ca h ngay c khi ang Bnh vin, nhng kh i phm ni quy iu tr. Cng khng truyn gio theo tn gio mnh ang theo cho bnh nhn. 1.5. Chm sc x hi To iu kin cho bnh nhn n nh cuc sng. Gi b mt c nhn cho bnh nhn. ng vin b khng b ly nhim. (Xin tham kho thm v k thut t vn). Gii thch cho thn nhn v nhn him HIV i x hp l vi bnh nhn, khng xa lnh, cch ly khng cn thit. Khng phn b li chnh ng theo quy nh ca php lut m ngi nhim c th b tc ot do k th (quy 113

1.6. Phng bnh : Ngi sn sc v thn nhn c th sinh hot vi bnh nhn bnh thng, ngoi tr quan h tnh do v tnh (dng chung dao co ru, bn chi nh rng), bit cch phng h cho c nhn khi p ui (x l bnh phm, o qun, chn mn c dnh mu, dch ca bnh nhn..). ch phng ly l trng hp nhim lao phi khng nhim HIV khc 2.Thuc khng virus HIV n nay c 2 nhm 2.1. Cc thuc c ch men sao chp ngc RT: gm c - Cc thuc tng tranh c cu trc nucleoside : Gm AZT (Zidovudine), Didanosine (ddI), Zalcitabine (ddC), Stavudine (d4T), Lamivudine (3TC), Abacavir (ABC). - Cc thuc khng c cu trc nucleoside: Nevirapine, Efavirenz, Delavirdine. Cc thuc nhm ny d b khng nn khng bao gi c dng mt mnh. Nhiu tc dng ph. 2.2. Cc thuc c ch men protease : c ch giai an trng thnh ca virus. Gm : Indinavir (Crixivan), Ritonavir (Norvir), Saquinavir HGC (In virase), Saquinavir SGC (Fortovase), Nelfinavir (viracept), Amprenavir (Ageneras e), ABT 378/r (Lopinavir/r : Kaletra). Mt s phc phi hp 3 thuc khng HIV - AZT + ddI + Indinavir - AZT + 3TC + Nelfinavir - d4T + ddI + Ritonavir - d4T + 3TC + Efavirenz ( hayNevirapine, Abacavir, Lopinavir) C th thay i nh sau : - AZT + ddC + Amprenavir - DdI + 3TC + Saquinavir... 2.2. Ch nh Do nhng kt qu lm gim nng virus ng k, nhng khng dit c virus, phi hp 3 thu hm ch khng cn cnh gic vi cn bnh. Tuy nhin, trong thc t, dng lu di em n nhi

rng v hin tng khng thuc, nn ch nh hin nay c phn hn ch hn so vi ch nh n ung cho tt c mi ngi nhim HIV d giai an no ang c nhiu bn ci, v cha ng ng. , nhng ch nh sau y c thng nht : 1. Nhng bnh nhn c triu chng ( giai an B v C theo CDC 1993) 2. Bnh nhn khng c triu chng nhng s lng T CD4+ < 350/mm3. 3. Bnh nhn khng triu chng, 350 < T4 < 500/mm3 nhng nng RNA HIV > 30.000 copies/mm3. Nu RNA < 30.000 th ty quyt nh thy thuc. 4. Bnh nhn khng triu chng, T4 > 500 : Hin nay c khuyn co khng nn dng. 3. iu tr phi nhim (tai nn ngh nghip) Nhng ngi c tip xc vi ngun c nguy c nhim HIV (tai nn ngh nghip ca y t, c quan tn cng bi dng c c cha mu hay dch ngi nhim.) Nu c iu kin, XN ngay nng HIV ngun nhim v ngi b nn. Sau x dng thuc kh lai thuc) trong vng 1 114

thng. Sau khi chm dt liu trnh, nn xt nghim tm khng nguyn p24 sau 15 ngy ri sau 1 thng, 3 thng, 6 thng theo di s chuyn i huyt thanh nu c. Ngoi ra cng cn t an ch i kt qu (+) hay (-). IX. PH NG BNH Khi tip xc vi ngi bnh, khng dng chung nhng dng c c kh nng gy tn thng da hay g tay, co ru, bn chi nh rng c bit bm v kim tim. Trng hp nhn vin y t, khi thao tc c kh nng xm nhp vo bnh nhn nhim HIV, cn man rang, knh eo mt, ng, o chong kn. Thanh trng ngay sau khi dng. Khng vt b ba bi c nhn sau dng xong. Dng c phi c ngm cn, cloramin T hay hp hi nc 100 /20 pht. Khng quan h tnh dc vi ngi khng bit c nhim HIV hay khng. Nn nh, bao cao su ch a dc kiu t nhin ( sinh dc-sinh dc), khng an tan khi qu trnh tnh dc c nhng hnh vi ip xc vi dch sinh dc ngi nhim), tip xc ming-sinh dc khng an tan v c th b x m khng bit. Trong truyn mu, tt nht l truyn mu t thn. Truyn mu t ngi khc khng r lai lch, c giai an ca s. Ph n nhim HIV khng nn c thai. Nu c thai, phi dng thuc khng HIV ( AZT, nevirapine thai nhi.). Vn phng bnh cho thai nhi khi m nhim HIV, xin xem chi tit bi HIV v s sn. M nhim HIV khng nn nui con bng sa m. Tuy nhin, ty bi cnh x hi, c nhiu v uy dinh dng do thiu sa m cn cao hn nguy c nhim HIV th vn phi cho con b. Khng nghin ht ma ty (ri s a n giai an chch ma ty), khng x dng chung bm, kim Quyt tm cai ma ty cho c nhn. V mt cng ng, tng cng bi tr ma ty, gip nhng ngi nghin ma ty cai nghin. H an tan cho nhng ngi hnh ngh mi dm v khch hng dng bao cao su.

Cu hi n tp 1.ng dng cc c im phn b HIV trong c th ngi nhim gii thch ti sao khng cn cch ly ngi nhim ra khi cuc sng gia nh v cng ng ? 2. Cc dng c ni soi thng c dit trng bng cch no khi ly truyn HIV? 3. Ti sao vit Nam, khng nn x dng phn ng b tuberculine phng nhim lao cho nhn 4. Trnh by cc nguyn tc chm sc ton din ngi nhim HIV 5. Cc nhm thuc khng HIV. u v khuyt im cho ngi nhim khi dng thuc khng HIV. 115 Bi 19.

Mc tiu

BNH VIM GAN VIRUS

BsCK2,Ths Phan Qun 1. Xc nh vai tr quan trng ca vim gan virus i vi sc kho cng ng. 2. Phn bit c cc virus gy vim gan v v cu trc sinh hc, dch t,vi yu t lm sng 3. M t c tin trin lm sng ca vim gan do virus B. 4. M t cch phng v iu tr vim gan virus cp v mn tnh. Ni dung

I. I CNG - Mt bnh nhim c tnh h thng, virus gy bnh i tnh vi gan, gy vim, tn thng t bo gan, thoi ha t bo gan - mt v tng transaminase. Trn c s virus, dch t hc, lm sng hin ngi ta c 5 loi vim gan do 5 virus A,B,D (Delta) virus C, E. Thm 2 virus mi tm thy l G v TTV m vai tr lm sng cha r rt. - Cc virus trn c th gy vim gan cp; virus B, D, v C c th gy vim gan mn tnh, gy n nguyn pht (HCC: Hepato cellular carcirnoma). - Theo Vin y hc lm sng nhit i H ni, nc ta c mt 6 loi virus ni trn, tr TTV. - Trong cc virus gy bnh trn, vim gan virus B l vn nghim trng v: + T l mang thai c HBsAg (+) rt cao (12,7%). + Nguy c ly chu sinh cho con rt cao (44,72%), nu m c HBeAg (+) 96,49%. + Trong dn chng bnh thng khng c bnh gan m HBsAg (+) 10-14%. Anti - HBs (+) 35-37%, c him HBV rt cao. + i tng nguy c cao nhim HBV theo theo th t: Tim chch ma ty, bnh nhn chy thn nhn to nhiu ln, ngi c truyn mu (test sng l - Vim gan do virus C cng nghim trng: + HCV hot ng (HCV - RNA) ngi cho mu (0,8-16,1%), m ta cha c iu kin xt nghim p ngi cho mu v cc mu mu. + Nu cho mu thi im HCV hot ng th nguy c rt ln; c th ly cho ngi khc nu ph + Khng th HCV ngi cho mu cng rt cao (0,8 20,6%). + Nhim HCV qun th 4 - 9%. Rt cao i tng tim chch ma ty (31-87%), bnh nhn chy thn nhn to, hoc truyn mu nhiu ln. - Virus vim gan G mi c pht hin ta. II. CC LOI VIM GAN VIRUS 1. Vim gan do virus A 1.1. Dch t: ngi l vt ch duy nht; ly qua ng tiu ha, do thc n - nc ung nhim mi sinh, kinh t - x hi. Ly cao nht l 2 tun trc khi biu hin lm sng. Ngoi ra, c th ly ng mu (giai on virus huyt). 1.2. Virus vim gan A (HAV) thuc h picornavirus, cu trc RNA khng v. Trong vim gan cp, s huyt xut hin 2 tun trc hong m v c th tn ti vi ngy sau hong m (ngn), i mu, xut hin trong phn 2 tun trc hong m v tn ti 7-10 ngy sau hong m. 1.3. Lm sng: bnh 2- 6 tun. 116

Th bnh cp tnh, in hnh gm: - Giai on tin hong m 1-3 tun ng ch l: + Chn n, n kh tiu, bun nn, tc hoc au h sn phi. + Ngi mt nhiu, mt ng. + Biu hin nh hi chng cm: st, vng u, au mi c khp. + Ni mn. - Giai on hong m: mt - da vng; nc tiu t, m mu; him khi nga. Khm lm sng kh v c khi lch to. Th khng hong m thng gp (90%): khng vng mt - da, nhng tng transaminase (nh hn 1.4. Xt nghim sinh hc: - V gan:

+Hi chng tiu t bo: tng transaminase 20-40 ln (thi k tin hong m c ga tr chn + Hi chng mt: tng bilirubin, ch yu l kt hp. Sc t mt, mui mt trong nc tiu ( + T prothrombine, nu bnh rt nng t P gim nhiu, a s l bnh thng. - V virus: + Khng th khng HAV IgM xut hin sm khi c du hiu lm sng u tin, chng tng nhanh ly bnh, Ri tip tc gim nhng cn cao, lp IgG xut hin mun, tn ti nhiu nm. Min d . + Chn on (giai on cp tnh) da vo IgM anti-HAV bng phng php min dch phng x ho anti - HAV c gi tr chn on dch t. 1.5. Tin trin: - Tt, trong 10-15 ngy, tiu trong, phn m mu, hong m nht dn, cc du lm sng v si di chng. - Mt s trng hp rt him: + Th ko di: tn ti du lm sng v sinh ha nhiu tun, nhiu thng, khng gy vim gan m + Th mt: triu chng nh hong m tc mt c hc, nhng gan khng ln, du nhim trng ( + Th ti pht: c th xy ra sau mt thng, tin lng tt. + Th ti cp: rt him 1/104. 2.Vim gan do virus B 2.1. Dch t: ly ng tim truyn, tnh dc v m ly sang con trong k chu sinh. - Ton th gii, 2 t ngi nhim HBV, 350 triu nhim virus mn tnh, 1,1 triu ngi cht/n h hng th 5. Trn th gii hin c 3 vng dch t: + Vng dch lu hnh thp (Ty u, Bc M, c ): bnh him tr em; 3 - 5% ngi c anti - HBs; 0,1- 0,5% ngi mang HBsAg mn. + Vng dch lu hnh va (a Trung Hi, Trung ng, Nam M, ng u, cc nc thuc Lin X 2 - 7% ngi mang HBsAg mn tnh. + Vng dch lu hnh cao (Trung quc, ng Nam , cn sa mc Sahara): hay gp ly chu sinh tr 95% ngi c anti - HBs; 8-15% ngi mang HBsAg mn tnh. - Virus huyt ko di, cho nn d ly qua tim truyn, mu, cc ch phm ca mu, tim chch nhn to nhiu ln, tim chch ma ty, nhn vin y t nht l ngi lm vic n v thn n - Virus qua cc cht tit ch yu qua sinh dc, nhng nc bt v sa nng virus thp hn, chng 50% trng hp khng tm thy ng vo. - Ly m sang con l nghim trng: Nhim Virus tr s sinh c nguy c gy vim gan mn tnh. m trong 3 thng cui thai nghn hoc trong k sinh , 117

hoc ngi c thai vim gan mn. Ch yu ly bnh lc chu sinh, khi m c HBeAg (+) nguy c l nguy c thp hn (25%) m c HBeAg (- ). 2.2. Virus vim gan B (HBV): h hepadnavirus, virus DNA, c capside - mt v. - HBsAg c mt lp v; cn capside c hnh thnh do kt hp 2 khng nguyn c hiu HBeAg . Tm thy HBsAg, HBeAg trong mu, nhng HBcAg ch c trong t bo gan. - Virus hon chnh c v bao quanh capside gi l tiu th Dane. - Trong capside c acid nhn, v 2 enzyme ng vai tr nhn ln v s trng thnh ca Virus: v proteinkinase. - Khi Virus nhn ln & pht trin trong t bo gan, c th phn ng vi s nhim virus, iu vim gan virus. Ni chung, vic thi loi t bo gan b nhim ty thuc vo c ch min dch lng p ng min dch ny tun th cc yu t quyt nh di truyn (a dng), c 4 mi t + Phn ng min dch mnh: phn ng mnh thi loi virus lu thng trong mu v trong cc gan cp tnh, sau thi gian b bnh s din tin khi bnh hon ton. Phn ng c th qu nn teo gan vng cp, a s t vong. + Phn ng min dch yu nhng cn bng: nhim virus khng triu chng v tin trin khi bn + Phn ng min dch yu v khng cn bng: to nn tnh trng dung np tng phn; kt hp vi BsAg (+) ko di) v s ph hy m thm t chc gan, y l s thi loi mn tnh, ko di nh v tin trin x gan. Chnh qu trnh ko di ny, v di s nh hng cc ng yu t (cofactor ) (v d: cht c, thc phm), t bin t bo gan gy ra ung th gan nguyn pht. + H min dch c th khng phn ng: y l trng thi ngi mang virus khng triu chng, c virus B nhn ln mnh m. 2.3. Lm sng: a dng, nhim virus c th cp tnh, qu cp, hoc mn tnh; thng tn t bo gan cng rt hoc tim tng ton b, hoc hoi t cp hoc vim gan mn tn ti, tn cng, gy x gan ri - Thi k bnh 4-28 tun, a s l 60-120 ngy, nhng c khi n 180 ngy, thng nhim vir

sau: + Th bnh khng triu chng (90%), khng r bnh xut hin lc no. + Hoc th cp c bnh cnh lm sng tng t nh vim gan A. + Tin trin ca bnh ni chung thng ko di nhiu tun. 2.4. Xt nghim sinh hc: - V gan: + Hin tng tiu t bo gan: tng transaminase (ALAT, ASAT) + Khi t Prothrobin > 60% khng c du hiu suy t bo gan. - Cc ch im (markers) virus B khi xt nghim mu: + Virus B khng th nui cy c, ch c 3 khng nguyn: HBsAg, HBcAg, HBeAg, c 3 khng HBs, Anti - HBc, Anti - HBe. + Nh cc Virus c v khc, ch Anti - HBs c tnh bo v (to min dch b sau nhim virus, + Xt nghim v HBsAg v Anti-HBs; HBeAg; Anti-HBc huyt thanh (thc hin thng qui); DNA po ase huyt thanh (thc hin phng xt nghim c bit); HBcAg v HBsAg c trong trong t ch c trong huyt thanh, trong t bo gan. + HBsAg xut hin trong huyt thanh: 1-3 thng sau ly bnh; 2-4 tun trc khi tng transami BsAg tn ti 1- 2 thng, nhng c khi tn ti vi tun sau khi transaminase tr 118

v bnh thng. + Anti - HBc xut hin trong huyt thanh 1-2 tun sau HBsAg xut hin; Anti - HBc IgM, l du hiu s nhim, tn ti vi thng. + HBeAg (+) trong huyt thanh chng t virus ang hot ng, nhn ln mnh m, tin lng xu g bin mt trc HBsAg. S xut hin anti - HBe cha phi l khi bnh, m l yu t tin l Trong 80-90% trng hp, 1 - 3 thng sau khi HBsAg bin mt, th anti- HBs xut hin, cho th v c min dch. Anti - HBs tn ti < 10 nm (nguyn tc chung) sau khi khi vim gan B. Tron anti - HBs xut hin thong qua ri bin mt trong vi thng, ch tn ti anti - HBc lp IgG Chn on mc vim gan B mi y: tm Anti - HBe IgM. 2.5. Tin trin: - Vim gan cp tnh in hnh hoc khng triu chng: Tin tin lnh tnh, trong vi tun transaminase tr v bnh thng, HBsAg bin mt, chng t in v nhn ln, Anti - HBs xut hin l du khi bnh. - Cc th bnh cp tnh khc: + Th mt ko di, th ti pht c th tin trin nh vim gan in hnh cp tnh. + Th cp tnh nng: nh hng gan nng n, t l prothrombin < 50%. + Th vim teo gan ti cp: Him, 1/103 ca vim gan B, t prothrombin 30%, bnh l no gan, iu chng lm sng nh th thng thng, tip n bnh l no gan xut hin ( ri lon thc trin trong 2 tun u ca thi k hong m. C khi, ngay t nhng ngy u ca bnh, xut h hn m, km theo hong m, h ng mu, hi chng tiu t bo gan rt r, km ri lon ng mu.Th bnh ny t vong 80%, nu khng c ghp gan (d vim gan ti pht di chng. - Cc th mn tnh: Gp 10% trng hp, virus tn ti trong t bo gan, mang HBsAg (+) > 6 th u vim gan cp th khng triu chng, hoc biu hin lm sng nh, c bit hay gp 50% ng inh b vim gan. + Ngi mang HBsAg mn tnh khng triu chng: 30% nhng ngi mang HBsAg mn tnh; transamin virus khng nhn ln; HBeAg, HBV DNA; DNA polymerase trong huyt thanh (-); vi th c th cho thy thy tn thng gan dng x ha khng ng k. Tuy nhin, ngi mang HBsAg c th ti ho thit gan; hoc xt nghim transaminase, HBeAg hoc HBV DNA, anti - HBs u n (4 6 thng + Vim gan B mn: HBsAg (+) v tng transaminase > 6 thng. Khi pht hin HBsAg (+) tnh c, th vim gan mn c xc nh khi anti - HBc IgG (+). * Vim gan mn tn ti: 40% nhng ngi mang HBsAg mn tnh, hnh nh sinh thit gan thy t t bo gan ch khu tr khong ca v khng lan ta, c th khi bnh sau 2 - 7 nm tin trin tn ti ko di), c khi tin n vim gan mn tn cng v x gan. * Vim gan mn tn cng: 30% vim gan mn, sinh thit thy c t bo vim thm nhp v hoi t v quanh khong ca, dn ti hoi t cu ni lm tch ra t chc thy gan nh, cui cng gy ** Lm sng: Triu chng vim gan mn thng ngho nn, c khi bnh nhn than phin mt mi, tc h sn p Transaminase tng nh (gp 1,5 - 2 ln gii hn trn bnh thng). Cc xt nghim sinh ha kh in bnh gan. Khng th khng c trn (-) hoc (+) nh. Cc biu hin ngoi gan gp trong vim gan mn tn cng v cng gp th bnh cp

thng thng, nh sng khp, vim cu thn v vim nt quanh ng mch. 119

** Huyt thanh ngi vim gan mn: (1) HBsAg (+), IgM anti-HBc (-), IgG anti-HBc (+): xc nh vim gan mn B mn tnh. (2) HBV NA (+) v tn ti HBsAg (+) > 6 thng: xc nh vim gan B mn tnh. Nhng HBsAg (-) vn cha th loi tr chn on (do t bin o thot), t bo gan b nhim Ag v hoc HBcAg ch trong t bo gan, m c th pht hin bng sinh thit gan v nhum mi Nu vim gan mn m anti-HBc (+) v HBsAg (-), cn biopsie, c bit nu Anti-HBc (+) vi nn vim gan B mn tnh th n. (3) HBeAg (+) ko di l tin lng xu c nguy c vim gan mn tin trin ti x gan (ch , eAg (-)). Tri li, anti-HBe (+), xt nghim sinh ha bnh thng tc l khng cn tn thng Trong trng hp thch hp hn cng thy lc u HBeAg (+) ri chuyn i huyt thanh qua HB +); HBsAg (+) ri chuyn i huyt thanh qua HBsAg (-) v anti-HBs (+). ** Tin trin vim gan mn: - Din tin khi bnh vi chuyn i huyt thanh t nhin 3% - 5%/nm. - Hay gp hn, tin lng thng d dt do cc bin chng (nhng t vim gan ti pht, t nh ng) v nguy c do x gan v ung th gan nguyn pht e da n cuc sng trc mt hoc l Tin trin ca vim gan mn c 3 giai on: + Giai on u: Virus nhn ln & pht trin mnh m (HBV DNA tng trong huyt thanh), tng n , trn sinh thit gan c du hiu vim gan nh. + Giai on hai: vi nm sau, tng ng p ng min dch mnh: tnh trng vim gan tng ln mu sinh thit gan) v virus gim hot ng. L giai on hnh thnh x ha vi x gan ti a h lm virus ngng pht trin & nhn ln v chuyn i huyt thanh mt HBeAg v anti - HBe (+ rng vim gan bin mt (transaminase bnh thng, khng cn hoi t v vim trong gan). + Giai on ba: virus khng nhn ln v khng tin trin vim gan. Giai on ny, c th xut nguyn pht. Cn thit gim st alpha - foetoprotein v siu m gan u n (6 thng/1ln). ), c th xy ra mt vim gan ti hot ng (virus nhn ln, tng transaminase, tn thng t , gim st transaminase v cc khng nguyn ch im virus nhn ln l rt cn thit: - X gan sau vim gan: L bin chng tin trin ca vim gan B mn tn cng, nhng x gan cng c th pht hin nhi do x gan (tng p tnh mch ca, suy t bo gan) cn c tng t ti hot ng vim gan mn t nguy c gy tin trin x gan ngi vim gan mn nh: ln tui, nng virus cao trong HIV, ung ru, transaminase tng cao lin tc, kiu gene C. - Ung th gan nguyn pht: Ni chung, xy ra ngi c x gan trc. vng dch t vim gan B lu hnh cao (Phi chu) ng yu t gy ung th th tn sut ung th gan rt ln: 40-50% s b nhim trong s nhim th gan. Ch yu l u t bo n dng lan ta trong gan. 3. Vim gan virus delta 3.1. Dich t: M t ln u , c mt nhiu ni trn th gii, ch yu a Trung hi, ng u, vi vng n ch yu ngi nghin ma ty, quan h tnh dc ba bi. Ly ging nh HBV do tim chch ma t xc qu mc thn thit gia cc c nhn. 3.2. Virus D (HDV): 120

L virus RNA khng hon chnh, x dng v ca virus vim gan B (HBsAg). Gy bnh bng cch cng sinh vi v HBV c i tnh vi t bo gan. 3.3. Lm sng: - Nhim ng thi virus D v HBV: phn ln trng hp c triu chng nh vim gan B thng th khng tng nguy c tin ti vim gan B mn. Tri li,nhim ng thi 2 virus trn lm tng ng n vng cp. - Ngi vim gan B mn bi nhim HDV: virus D tm thy iu kin thch hp ngi vim gan B ln nhiu v ko di. Bi nhim gy nhiu hu qa: + HDV giao thoa vi sinh tng hp ca HBV, ngi ta thy gim nhy cm, hoc bin mt cc ch huyt thanh v t bo gan chng c v s nhn ln ca HBV (HBV DNA). + HDV lm tng s nghim trng cc tn thng gan. V lm sng, bi nhim HDV gy ra vim gan cp, trong 80% trng hp tin trin qua vim gan im gan B mn 3.4. Mt s im ch :

Nhng ch im huyt thanh mt vim gan D trn bnh nhn mang HBsAg(+). + Phm vi dch t hc: Ngi tim ma ty, quan h tnh dc ba bi, ng tnh luyn i, lin ). + Phm vi lm sng: Vim gan cp qun th ngi nguy c vim gan D, vim gan cp ngi ma mn hoc x gan nhm ngi tr c nguy c vim gan D, vim gan cp ti pht, teo gan vng (+) v tin trin nhanh qua vim gan mn tn cng. 3.5. Tin trin: Nhim HBV, HDV biu hin di 2 dng: + ng nhim HBV/HDV: nguy c teo gan cp 10-20 ln so vi vim gan B cp. + Bi nhim HDV ngi nhim HBV: d tin ti vim gan mn tn cng - x gan. 4. Vim gan virus C (HCV) 4.1. Dch t: Ly qua mu 90%, qua vt liu dnh mu v v trng km, thng gp ngi chch . Ngi khe mnh c th ly qua tnh dc (+/-). 4.2. Tc nhn gy bnh: Virus C thuc h Flavivirus, virus RNA. Khng phn lp c virus m ch tch c gene di tr ong huyt tng ngi b nhim (HCV RNA). 4.3. Lm sng: bnh 4-6 tun, 95% vim gan C cp khng triu chng v khng hong m, thng tng transam hng cng c s dao ng transaminase so mc bnh thng. Sau giai on cp tnh 15-20% tin a teo gan vng cp. Transaminase bnh thng > 6 thng v PCR (-) l khi bnh. 4.4. Huyt thanh: Anti-HCV xut hin mun, 5-6 thng sau nhim (trung bnh 15 tun sau vin gan). Cha c test nti-HCV hoc khng nguyn HCV. Da vo test huyt thanh khng phn bit ngi mang Virus mn h c min dch sau mc vim gan C. Tm HCV RNA trong huyt thanh bng phng php khuch i gene (PCR) phn bit ngi c ti trong mu v ngi vim gan mn tnh khng do HBV m anti-HCV(-). xc nh chn on vim gan C cp, cn loi tr nhim HBV [HBsAg (-) v IgM anti-HBc (-)], loi tr HAV [IgM anti-HAV(-)], loi tr Epstein-Barr virus [IgM anti-VCA ()], loi tr Cytomegalovirus [IgM anti-CMV (-)], tin s khng dng thuc gy c gan. xc nh vim gan C mn tnh, phi loi tr nhim HBV v cc nguyn nhn gy vim gan mn tnh him gp khc.Vim gan t min, do thuc, bnh wilson. 4.5. Tin trin: 121

Nhim HCV c 10 - 15% khi bnh, 20% ngi lnh mang virus, 60 - 70% vim gan mn tnh trong n v 3 - 5% ung th gan nguyn pht/nm. Vim gan C mn tnh khng triu chng vi transamina thng gan ti thiu (sinh thit) 1525%; s cn li vim gan mn tnh tn cng. Trong s vim gan tn cng, x gan xut hin 20% trong thi gian 10 - 20 nm sau vim gan. Cc nguy c ung th gp ngi ln tui, ung HBV. Khi nhim HIV lm tng nng HCV trong mu s tng nguy c ly qua tnh dc v ch y inh, tng tin trin x gan v ung th gan, cc nguy c ny cn tng ln ngi > 45 tui 5. Vim gan virus E (HEV) 5.1. Dch t Ly qua ng tiu ha, bnh hay gp , Phi chu, cc trng hp bnh gp Bc M, u chu c lin quan du lch ti cc vng bnh lu hnh. 5.2. Tc nhn: Virus E thuc h Calicivirus, virus RNA. HEV c thi ra nhiu trong phn. 5.3. Lm sng: Nhim cp thng c hong m vi th bnh in hnh. 5.4. Huyt thanh: Khng c ch im huyt thanh, chn on vim gan E c bn da trn s ly v loi tr cc ng - HAV (-); HBsAg v IgM anti- HBc (-)]. 5.5. Tin trin: Lnh tnh, thng gp th nng ch yu ph n c thai v nht l 3 thng cui thai k (t vong > 10%), bnh khng tin trin mn tnh. 6. Vim gan virus G (HGV) - Pht hin nm 1995, virus c mt trn th gii vi vng lu hnh nng l chu Phi v ng u, cch ly ch yu qua mu, nhng c th ly m sang con, ng tnh dc. - H Flavivirus, cu trc gene RNA-c v. C th pht hin virus bng PCR.

Vai tr gy bnh cha xc nh, ngi ta thy virus nhim kt hp vi HCV, c khi HBV trong cc trng hp vim gan mn tnh 7. Virus TTV Phn lp nm 1997, t l ngi cho mu nhim 1% M, 12% Nht v 36% Thi lan. Pht hin A chui xon i, gn gi vi h Parvovirus, c 2 - 6 genotype khc nhau. Kh nng gy bnh c vim gan cp sau truyn mu hoc vim gan mn tnh. III. D PH NG V IU TR VIM GAN VIRUS 1. D phng 1.1. D phng trc khi nhim l quan trng nht. - Vi HAV: + Ngi ln: tim Havrix (loi ngi ln, virus bt hot) hoc Avaxim Nhn vin y t, ngi dng ng. Nhng ngi cha min dch vo vng dch lu hnh. Nhm nguy c: nghin chch ma tu, ng tnh luyn i, bnh a chy mu truyn mu nhiu ln. Tim 2 mi cch nhau 6 - 12 thng p ng bo v > 95%, ko di t nht 10 nm. + Tr con: trn 1 tui tim Havrix (loi cho tr); hoc vaccine Twinrix (kt hp HBV v HAV), tim 3 mi (ngy 0, cch 1 thng, cch 6 thng). - i vi HBV, HDV dng vaccine d phng + Cc i tng c nguy c cao: Nhn vin y t Truyn mu nhiu ln (ghp tng, bnh a chy mu vv...), ngi chy thn nhiu ln. Tim ch HBsAg (+). 122

Ngi nh c HBsAg (+), tr s sinh c m HBsAg(+). Ngi cha min dch, ngi chm pht trin tr tu. + Vaccine ti t hp gene (Gen Hevac B Pasteur hoc Engrix B). p ng min dch tt; ch 4 g khng th, ch yu ngi ln > 40 tui, ngi suy gim min dch, nghin ru. Vaccine ch , dung np tt. Ty theo tui - gii m hiu lc vaccine khc nhau. Min dch tt ph n, ngi < 40 tui. + Chng nga 3 ln tim bp cch nhau thng 1 ln, hoc ngy 0, thng 1, thng 6. + Nhc li 1 mi sau 5 nm, nu chng nga sau 25 tui v kim tra nng khng th sau 2 th tim nhc li. + Phi hp tim HBIg v chng nga vim gan B (tim bp HBIg 3 ln, 0,1ml/ln x 6 thng/ln, gan B cho i tng mi phi nhim (ngi cha min dch tip cn mu, tai bin ngh nghip, + Khng c vaccine ring i vi vim gan Virus D. - i vi HCV v HEV hin cha c vaccine c hiu. 1.2. Phng nga sau phi nhim : i vi HBV khi m b nhim th phng cho con vo k chu sinh, dng HBIg phi hp vaccine tro inh, v cc tr s sinh nhim c nguy c cao vim gan mn. 2. iu tr 2.1. iu tr vim gan virus cp: ch yu l h tr, dinh dng c vai tr nht nh. - Thc n lng c ch cho bnh nhn bun nn v nn. Hn ch m, m. Hi phc nc - in gi nhn chn n, suy dng: dng vitamin. Hn ch hot ng khi cn triu chng lm sng v xt - Gim st, theo di bnh nhn vim gan cp ch yu da vo ASAT/ALAT iliri in, chc n , t prothrobin nh gi trin trin ca bnh. Khi bnh nhn suy gan cp cho thy gim tra umin, tng bilirubin, gim t Prothrombin; lm sng cho thy mt ng, chn n. 2.2. Suy gan cp (teo gan vng cp) - Ngoi vim gan virus, suy gan cp c th do ng thuc, thiu mu gan nng, c t, gan n nghn, bnh wilson, hi chng Reye. - Lm sng: bnh l no gan, tt huyt p, mch nhanh, vng mt - da m, xut huyt tiu ha suy thn, ri lon in gii - toan kim. + ng mu thng gim < 60mg/dl th cn truyn thm ng. + Khng acid, khng H2 Receptor, duy tr pH d dy > 5 phng chy mu tiu ha. + Chy mu nhiu: truyn huyt tng lnh, mu ti cng nhm. + Bnh nhn c tng p ni s hoc hn m gan giai on III, IV: dng mannitol tnh mch 1g/k tnh mch 100 150ml, L six. + Neomycin 0,25g x 4v- 8v ngy chi 2-3ln/ngy x 5 - 7 ngy, c th metronidazole 1g/ngy x 5 - 7 ngy. Bi nhim, dng khng sinh khng c gan (Amoxicillin). + Tht tho phn 2 ln/ ngy, km theo Lactulose 50% (a ng sorbitol, lactose, galactose )

/ngy (lm nhun trng, tng o thi cc acid hu c khi i trng,c ch vi khun ch, chu v o thi theo phn). + Ghp gan (trng hp do HBV, sau ghp gan c th ti nhim virus ) + Mi y (2004) N-acetyl cysteine (Acemuc) c dng trong suy gan bn cp khng r nguyn n /ngy trong 3 tun ri dng 75mg/ngy/4 ln/ngy (tim TM, nu bnh nhn nn): 7/9 (77%, nhm (17%, nhm chng) khi bnh. Dng trong suy gan cp do dng qu liu paracetamol. - T vong do suy gan tin trin, chy mu tiu ha, nhim trng, ri lon nhp tim, try mch hi chng phi - gan. 2.3. Vim gan virus mn tnh 123

2.3.1. Vim gan B mn tnh - Ch nh dng thuc cho vim gan B mn tnh th hot ng. - Mc tiu iu tr l c ch s hot ng virus cui cng lm ngng tin trin vim gan mn V vy phi iu tr giai on sm Interferon alpha - Tim bp, di da 9 - 10 triu x 3 ln/tun (4 - 6 thng) chuyn i huyt thanh 20 - 30%. - p ng tt bnh nhn c: HBV DNA thp; ALAT tng cao; c tn thng vim-hoi t trong g ; nhim virus khi ln tui. - Hiu qu khi: transaminase bnh thng; cc marker nhn ln ca virus HBV DNA, HBeAg m tn HBe (+); l tng l HBsAg (-) v anti-HBs (+). Tuy nhin c mt s trng hp virus nhn l i ngng thuc. Pegylated interferon alpha 2a hoc 2b (kt hp interferon vi glycol polyethylene, nn thi qua thn chm, dng tun/ln). - Tim bp, di da 180 mcg/tun Peg. interferon alpha 2a (Pegasys) cho thy hiu qu 28% so vi interferon alpha 12%, khi dng 4 - 6 thng. - p ng: mt HBeAg, HBV DNA < 500.000 copies/mL, transaminase bnh thng. Lamivudine - Ung 100mg/ngy, c ch virus nhn ln 80%, nhng xut hin khng do t bin (15%/nm, ch yu dng YMDD), tuy nhin, t bin o thot cha r trn lm sng, khi c t thuc thay th s virus pht trin tr li. Adefovir dipivoxil - Thuc tng t nucleoside, tc dng cnh tranh vi deoxyadenosine triphosphate c ch polymerase DNA v enzyme sao chp ngc ca HBV, chm dt s tng hp chui DNA. - Liu ung 10 mg/ngy, dng 48 tun cng nhm placebo c t l chuyn i anti-HBe tng ng hc hc gan 53% v 25%, khng pht hin nng HBV DNA tng ng l 21% v 0% bnh nhn. Dn dine. Tenofovir - Thuc tng t nucleoside, tc dng c ch HBV v HIV. - Dng cho ngi ng nhim HIV v HBV, gim nng virus > 4 log10 v hiu qu trng hp H Cc thuc khc Hin nay ang iu tr th cc thuc tng t nucleoside: Entecavir, Entricitabine, Clevudine Phi hp thuc - Adefovir phi hp pegylated interferon trong HBV khng Lamivudine. - Bnh nhn x gan mt b do HBV khng dng interferon. Nhng dng Lamivudine, Adefovir hoc ir n thun 2.3.2. Vim gan C mn tnh Ribavirine - Dng ng ung liu 10,6 mg/kg - Thuc c th gy gim hemglobine nh do tn huyt, gim bch cu ngoi bin. Pegylated interferon alpha 2b hoc alpha 2a Thng dng Pegasys (Peg alpha 2a) 180 mcg tim bp hoc di da. Phi hp thuc Thng kt hp hai thuc trn v ribavirine c tc dng hip ng vi interferon. Cho bnh nhn ung paracetamol trnh st do interferon. Cu hi n tp 1. Trnh by nh hng ca vim gan virus i vi sc kho cng ng. 2. M t cu trc sinh hc, dch t, vi yu t lm sng ca cc virus gy vim gan nguyn

pht thng gp. 124 3. Trnh by cc vng lu hnh vim gan B trn th gii v cc hnh thi phn ng ca c th 4. M t tin trin lm sng v biu th cc marker trong vim gan B cp v mn tnh. 5. Trnh by cch thc phng nga v iu tr vim gan virus cp v mn tnh. 125 Bi 20.

Mc tiu BNH NHIM VIRUS DENGUE

BsCK2,Ths Phan Qun 1. Xc nh tm quan trng, tnh ph bin, v phm vi nh hng ca bnh. 2. M t mt s c im tc nhn gy bnh, ng ly, tp tnh cn trng trung gian, cc yu 3. Gii thch c cc th lm sng bng c th bnh hc, bnh sinh-sinh l bnh 4. Phn loi th bnh, m t cc bc iu tr st dengue, dengue xut huyt v th c sc. 5. M t c cch thc phng chng st dengue xut huyt. Ni dung

I. I CNG Bnh dengue c in gm st cao, au khp, au c c bit hn mt th k trc. 1953, ln u xc nhn st dengue xut huyt Phi lut tn, Thi lan (1958), bnh lan ra mt s n 1. nh ngha St dengue v st dengue xut huyt l bnh nhim do virus dengue gy ra, lm sng gm st ca yt. Khc vi st dengue, st dengue xut huyt l bnh cnh nng, c th sc v lin quan ch h tiu cu v c c mu. C th t vong nu khng c iu tr thch hp v kp thi. C 2.Tc nhn gy bnh Virus dengue, h Flaviviridae, nhm Arbovirus (do mui truyn), c 4 type huyt thanh D1, D2 , D3, D4. C 4 type ny u c th gy dch st dengue, st dengue xut huyt. Cc nghin cu cho thy D2 c lin quan ti st dengue xut huyt / dengue xut huyt c sc, D3. Nhim virus dengue ln u to ra min dch bn sut i vi type nhim. Ngoi ra, min d v c tnh bo v nht thi (6 thng). Nh vy, nu nhim ln 2 vi mt type virus dengue kh . 3. Dch t hc 3.1. Vt ch Ngi l vt ch chnh, ngoi ra loi kh rng M lai v Ty Phi cng ng vai tr vt ch. 3.2. ng ly truyn v cn trng trung gian - Ly cho ngi qua mui ci Aedes aegypti t (gin tip), mui nhim virus c kh nng truy s dengue lu hnh trong mu t khi st. Mui cha nhim t, ht mu bnh nhn c virus, viru ong c th mui v truyn bnh sau chng mt tun. - Nc ta, Aedes aegypti l mui truyn bnh chnh, c mt hu ht cc tnh, tr lt, vn ni cao - kh hu lnh pha bc. + Mui Aedes aegypti sng gn nh, trong nh, nc trong v sch (vt thi rn ng nc oc chum vi cha nc, hn non b...). u ni treo o qun, bn t, t khi tng.

+ Mui t ngi nhiu nht lc 9 -10gi sng v hot ng n 17 - 18gi. + Chu k pht trin: trng thnh nhng ri mui trng thnh. + Mui pht trin 20 - 300c, chu k pht trin nhanh 9 ngy, trung bnh 12, chm 20 ngy. 126

- Ngoi ra, ngi ta cn phn lp virus mui Aedes albopictus ti Chu - Thi Bnh Dng, hin xut hin mt s ni trn th gii, k c nc ta. 3.3. S phn b v t l 3.3.1. Trn th gii - Virus dengue c cc nc nhit i, bn nhit i. Cc type huyt thanh lu hnh ng Nam : D1, 2, 3, 4; Ty phi: D1, 2; ng phi: D2; vng bin Carribea: D1, 4; Bc m: D2, 3. - Ln u tin dengue xut huyt Phi lut tn (1953), sau ng Nam , cc qun o Thi Bnh Dng, Trung Quc, Lo, Campuchia, v cc nc khc. - Nm 1956 - 1990 c 3.071.245 ca mc bnh, 51.087 ca t vong (Bo co t 12 nc Chu , cc o Thi Bnh Dng, Cu Ba, Venezuela). 3.3.2. Nc ta - St dengue, st dengue xut huyt quanh nm, dch thng xy ra cui h, u ma ma. Vng ng bng sng Cu Long v cc tnh ven bin min Trung l vng lu hnh cao chim 84% s mc ca c nc. Nm 1997, bnh xy ra ti 50/61 tnh, thnh vi 107.188 ca bnh, 226 cas t vong. S mc tng 19% so vi nm 1996. Nm 1998. Tnh n ngy 16/8 c 84.505 ca bnh v t vong 186. Chu k dch 3-4 nm. - i tng mc bnh ch yu tr t 3- 9 tui, thanh thiu nin v trung nin. Cc tnh pha khi pha Bc, t l ngi ln trong cc v dch 9,6% 38,6%. Khng khc bit gii. Trc y dch thnh ph, th x, nay lan rng n nng thn. 3.4. Cc yu t nguy c dch xy ra - Mt dn cao, v sinh mi trng km, l iu kin tn ti v pht trin mui truyn bnh - thc phng bnh km, vt ba bi vt dng tha, cht thi rn ng nc quanh vn. - Nhit thch hp cho mui Aedes aegypti pht trin (20 - 300C), gi ma lm dch tng. - Ch s nh c b gy Aedes aegypti hoc ch s vt cha c b gy 2% l cho dch lan tru cha b gy). - Ngi giao lu mnh t vng dch n vng khc ni c vect lm dch lan truyn rng. II. C TH BNH - Trng hp t vong do st dengue xut huyt, chy mu da, t chc di da, nim mc ng tiu ha, tim, gan cc mc khc nhau. t khi chy mu no, di mng nhn chy mu t. - Trn dch thanh mc vi protein cao (ch yu albumin) nh mng phi, xoang bng. - Thnh mch (soi di knh hin vi quang hc) thay i khng c ngha, hay gp ti cc c -tnh mch xung huyt v xut huyt xung quanh. Monocyte v lymphocyte xm nhp quanh mch m lng cc ng mch nh c nhng cc mu ng gp bnh nhn ngi ln xut huyt nng. - Ph nang: t bo n nhn thm nhp vo thnh ph nang v t chc khe. - Tim: tng vng c tim xung huyt. - Gan: t bo hoi t khu tr, ph n; theo Innis (1990) c hnh nh t bo lan rng trn t hoi ha hyalin; xoang gan, khong ca t tp nhiu t bo Mono v Neutro. - T chc lymph: tng hot h thng B lymph, tng sinh tng bo, mu bo lymph, mm tng tng sinh s ln nguyn bo min dch. - Khng nguyn virus dengue c t bo gan, lch, tuyn hung, hch bch huyt, t bo Kupffer, t bo lt trong xoang gan, t bo lt ph nang. - Ty xng: thnh phn ty xng b c ch, ci thin sau khi ht st. - Thn: phc hp min dch dng vim cu thn, khi khng li di chng. - Monocyte v lymphocyte xm nhp cc mao mch da; b th, globulin min dch v fibrinogen mch mu da. - Mu sinh thit da bnh nhn st dengue xut huyt soi di knh hin vi in t cho thy tr s lng cc khng bo v cc th m bo, l bng chng gy thot huyt tng t mao mch vo 127 III. BNH SINH - SINH L BNH 1. Cc bin i bnh l trong st dengue 1.1. Tng thm thnh mao mch Thot huyt tng vo khong gian bo v huyt p tt, mch yu v sc. (cn xt 1.2. Cc bin i v tnh trng cm mu:

xut huyt c sc

cc xoang (mng phi, mng bng v.v.), gy c c m nghim Hct, thng tng vo ngy 3-7 sau st, vo l lin quan n 3 yu t ch yu:

- Nhng thay i v thnh mch mu. - S lng v tp trung tiu cu gim (< 100.000/mL ngy th 2-3 sau st, trc Hct tng). - Ri lon ng mu. C 3 yu t ny c st dengue xut huyt/dengue xut huyt c sc, nhng mc khc nhau q 2. Hai gi thuyt v c ch bnh sinh 2.1. Thuyt nhim virus th pht Cn gi tng cng nhim virus do min dch ln u, Halstead xut sau khi nghin cu dch gue ln 2; v ln u nhim mt type khc nn c mt phn min dch cho vi ln 2, phn Fc c t bo n nhn / i thc bo. Phc hp ny thc y virus thm nhp n nhn/i thc bo d nng. T bo n nhn/i thc bo b nhim virus tr thnh ch ca c ch min dch o thi, cc , yu t hot ha tiu cu (PAF) v Urokinase (plasminogen). Chng l cht trung gian ha hc mao mch, hot ha b th, suy tun hon, ri lon thromboplastin t chc, ri lon ng mu. 2.2. Thuyt c lc virus dengue Tnh trng nng st dengue xut huyt / dengue xut huyt c sc xy ra trong nhim virus ti cho thy l chng c c lc mnh hoc yu. Hin nhiu quan im cho l c lc ca chng vir ca bnh. Tm li, quan im khc nhau v bnh sinh st dengue xut huyt cha c thng nht. Duy ch gue gy hu qu tng thm thnh mch, h tiu cu, gy ri lon ng mu cn phi x tr sm . LM SNG bnh 4-6 ngy, c 2 tnh hung: c triu chng, khng triu chng. Loi c triu chng gm 3 dng lm sng: dengue c in, dengue xut huyt, dengue xut huyt c sc. 1.St dengue Bnh cnh l thuc tui, tr con v tr em c th c bnh cnh st khng r nguyn nhn km b Tr ln v ngi ln thng st cao t ngt, au u nhiu, au h mt, au c - khp, pht c n chm, hch trn li cu, gan lch bnh thng. BC gim, c khi tiu cu gim, Hematoc se bnh thng, din bin trong vng mt tun, thi gian hi phc 1-2 tun, mt mi ko di. Chikungunia c bnh cnh lm sng nh st dengue. S khc bit dengue c in (t c xut huyt, khng tng Hct) vi dengue xut huyt (c xut 2. St dengue xut huyt St dengue xut huyt in hnh thng c 4 triu chng lm sng: st cao, xut huyt (c khi ), gim tiu cu nh n nng, ng thi vi c c mu (Hct tng) l du c trng ca st d - Khi pht t ngt, st cao, mt - mt xung huyt, nhc u nhiu, au sau h mt, au c k v hng , kh chu thng v, tc h sn phi, au ton bng hay gp. 128

- St 2-7 ngy, ri nhit bnh thng, gn bnh thng. St 40-41 C, c th km co git. - Du xut huyt: hay gp dy tht (+), c nhng vt bm tm, hoc chy mu ti ni tim chc cc chi, nch, chy mu mi, chy mu chn rng, c khi i mu, hnh kinh ko di, c khi x pht ban da cng gp. - Gan to xut hin sm trong giai an st, t s c cho n 2-4cm di sn, n tc. Khng bnh. Nhng gan to hay gp trong trng hp sc, transaminase tng nh, gan mm, c khi (rt . - Sng hch: trn li cu, dc theo c c n chm; n hi tc, khng da, c khi sng hch Din bin xu xy ra lc h nhit, sau st 3-4 ngy, c khi km du hiu ri lon tun hon v m hi nh, u chi hi lnh, nhp tim nhanh, huyt p hi h do thot huyt tng nh.Vi tr ln, sc c th xy ra din bin ti sc nng nu khng cp cu kp thi s t vong. Mc nng nh ca bnh ty vo vic chn on, x tr sm hoc mun. Gim tiu cu v tng Hct thng c trc sc. 3. St dengue xut huyt c sc Bnh nhn ang st cao, t ngt tng trng xu i vi du hiu tin sc xut hin, thng ngy 3-7 ca bnh: - Thn kinh: Tr hi ly b, vt v, ht hong, quy khc, ngi ln th tnh to. - au bng: nht l au vng gan, c khi au ton bng. - u chi hi lnh, trong khi thn nhit cao. - C th tt nhit . - Ngi nhm nhp m hi trn, mt Sc xut hin: Mch nhanh nh kh bt, huyt p kp bt k mc no, hoc huyt h km theo hm, c khi trn dch mng phi, mng bng, c khi khng c xut huyt da. Bnh nhn sc c v ng th sc su hn, mch khng bt c, huyt p khng o c.

a s bnh nhn vn tnh to cho n giai on cui cng. Khi sc khng c x tr s gy cc bin i: toan chuyn ha, chy mu tiu ha (d dy - rut) v cc c quan khc, c th xut huyt no gy hn m, t vong. Thi k hi phc ca st dengue xut huyt/dengue xut huyt c sc thng l ngn, trng h 2-3 ngy, bnh nhn n ngon tr li l du tin lng tt. Thi k hi phc thng c mch ch V. BIU HIN LM SNG V BIN CHNG HIM GP 1. Thn kinh - St dengue xut huyt km biu hin vim no ( M lai, Min in, Thi lan, Cng ha Dominica, Puerto - Rico) - C khi co git, co cng, ri lon thc, c khi km theo lit (dch no tu bnh thng). 2. Gan Tn thng gan gp tr con (< 12 thng tui), lu ng c thuc do qu liu Paracetamol. 3. Thn Suy thn cp do sc ko di, hi chng tn huyt tng ur mu. 4. ng mu ri rc ni mch C th xy ra trong a s trng hp sc nng, nht l khi c chy mu trn lm sng. VI. X T NGHIM 1. Mu - Tiu cu: < 100.000/ mm3 (ngy th 3-7), tp trung gim. - C c mu (Hct tng ) trong trng hp c sc Hct tng > 20% so vi mc bnh thng. L 2 du c trng trng trong st Dengue xut huyt . 129

- Bch cu mu: thng gim s lng. 2. Mt s thnh phn khc trong mu - Protein mu gim, Natri mu gim. - Transaminase tng nh. - Toan ha mu: trng hp sc ko di. 3. Cc yu t ng mu - Fibrinogen gim, Prothrombin gim; VIII, XII, antithrombin III, alpha - antiplasmi n, u gim; thi gian thromboplastin tng phn ko di. 4. Phn lp virus (thc hin trong nghin cu hoc gim st) Phn lp t huyt thanh, huyt tng, t mu sinh thit - t thit (gan, lch, hch, thymus). Ly mu nghim sm, trong qu trnh bnh, chuyn nhanh n phng th nghim, l xt nghim hc hin phng xt nghim cao cp). 5. Chn on huyt thanh (dng chn on xc nh v nghin cu) C 2 loi p ng min dch p ng tin pht gp ngi cha b nhim hoc chng vc xin chng flavivirus (st vng, vim no Nht Bn ), nng khng th tng chm. p ng th pht gp ngi b nhim hoc chng vc xin nga flavivirus (st vng vim no N 5.1. Phn ng c ch ngng kt hng cu ngng (HI) Da vo kh nng khng th dengue c ch ngng kt hng cu, cn thc hin cng sm cng tt type v 2 mu cch nhau 1-4 tun, hiu gi ln 2 gp 4 ln hiu gi khng th ln u l (+) 5.2. Phn ng c nh b th Phn ng ny khng nhy bng HI, phn ng ny l tin li v ch IgG khng Dengue mi c nh khng th c nh b th ln 2 tng gp 4 ln u, 2 ln ly mu cch nhau < 2 tun th c 5.3. Phn ng trung ha C nhiu loi phn ng trung ha trong chn on nhim dengue, nhng c l c hiu v nhy c i vi nhim tin pht, khng th trung ha n type c pht hin sm trong giai on u rung ha c nng cao, chng li 2 ti 4 type virus dengue. 5.4. Pht hin IgM v IgG v nhng khng th khng dengue khc - Khng th IgM khng dengue c to nn tm thi c trong nhim tin pht, ln th pht; pht hin n c ngha ang nhim hoc va mi nhim dengue. - Khng th IgG khng dengue cng gp trong c nhim tin pht, nhng lng khng th trong n so vi nhim tin pht . Ngi ta c th dng phng php MAC - ELISA ly mu ch mt ln sau ngy th 5 ca bnh. (Ig ELISA). Gn y hn c phng php min dch enzyme (dot enzyme immuno - assay: DEIA) pht hin kh ao (97,3%) VII. CHN ON 1. Chn on lm sng

1.1. Chn on st dengue - Tr: st + pht ban. - Tr ln, ngi ln: + st cao t ngt + Nhc u nng, au h mt. + Xung huyt. + au c khp. 1.2. Chn on st dengue xut huyt (c h tr ca xt nghim) 130

Gm 4 tiu chun: - St: Tnh cht khi pht t ngt, cao, ko di 3-7 ngy. - Nhng biu hin xut huyt: gm t nht dy tht (+), (2,5cm2 c trn 20 chm xut huyt c ng giai on sc nng. Ri (+) c khi rt mnh giai on khi sau sc) hoc mt trong nhng t + Chm xut huyt, m xut huyt, m bm tm. + Chy mu cam, chy mu chn rng. + Nn mu v / hoc a phn en - Gim tiu cu <100.000/mm3 . - C c mu: Hct tng ( > 20% so vi mc bnh thng; hoc chng c khch quan tng tnh th Chn on st dengue xut huyt c sc: Gm cc triu chng ca st dengue xut huyt + du hiu suy tun hon (-mch nhanh v yu; t km theo da lnh, m, ngi vt v). 2.Chn on nng nh ca st dengue xut huyt / c sc I: St + Triu chng ton thn khng c hiu + du dy tht (+) II: I + xut h III: Suy tun hon (mch nhanh, yu; huyt p kp hoc h; da lnh m; vt v) IV: Sc Hin din gim tiu cu, c c mu phn bit st xut huyt dengue I,II vi st dengue rong cc v dch tr em. Mt s lu khi theo di v chn on - S khc bit gia st dengue v st dengue xut huyt ch st dengue khng c tng thm t bnh thng (Hct) hoc khng c trn dch cc mng c th, trong khi st dengue xut huy tng 20% so vi mc bnh thng) hoc c trn dch cc mng c th. - Nhim virus dengue ngi ln, s lng tiu cu mu c th gim < 150.000tc/mm3 v tp trung gim c th gp c trong st dengue ln st dengue xut huyt, thay 100.000tc/mm3 nh tiu chun ca WHO a ra, mi gi l st dengue xut huyt. - Trong qu trnh lm sng ca nhim virus dengue, trong giai on u kh c th phn bit s e xut huyt, nht l khi cc bng chng ti thiu gip chn on cha c y , ngi th engue xut huyt. phn loi st dengue v st dengue xut huyt ch c th thc hin sau c hm dt. 3. Chn on gin bit 3.1. Giai on sm ca st dengue xut huyt Gin bit bnh nhim khun: st rt, nhim cc virus khc vi khi pht t ngt. - Xon khun Leptospira: khi pht t ngt au c t nhin hoc thm khm (c cng chn, i a. - St m: khi pht t ngt, xung huyt ngoi da, au mi c khp, lin quan dch t. - Cm: St, vim long h hp, dch t. - St rt: St lin tc, c khi xung huyt da, kt mc nh, lch to, lin quan dch t. 3.2. Ngy th 3-4 tr i Khi c suy tun hon, km c c mu v h tiu cu c gin bit sc nhim khun no m cu VIII. IU TR 1. Nguyn tc Kp thi, khn trng, y , thch hp. - Ngay t khi st, tt nht nn bi ph nc in gii bng ORS sn c trm y t. 131

- H st khi > 39oC, nht l tr em; p khn t h nhit, hn ch thuc h nhit tr khi c ylique. - Khi sc, hi phc tch cc bng dung dch Ringers, l ct te, N tri cloru 9%o; nu cha n . - Xut huyt nng, gim tiu cu nng c th truyn mu hoc tiu cu khi. - Truyn dch phi theo di v kim tra bng Hct, p lc tnh mch trung tm nu c th.

2. iu tr thc t 2.1. St Dengue xut huyt ( I & II) : iu tr tai tuyn c s. - B nc in gii: + Ung ORS, tr em 150ml/kg/ngy, ngi ln 1-2 gi ung/ngy. C th ung nc tri cy, n + Truyn dch: nn nhiu, khng ung c, ngi hi vt v mt, st cao (1 NaCl 9o/oo + 1.Glucose 5%, 5%, Ringers L cte). Lng dch v tc ty thuc vo lm sng: mch, huyt p, nhp th, Hct. Tr em: Khi u 6-7ml/kg/gi. Lng dch trung bnh 100-120ml/kg/ngy. Ngi ln: 1-1,5 lt/ngy ty trng hp. - H st : st > 390C, trnh co git: + Gim bt o qun, chm khn t. + Paracetamol: Tr < 12 tui liu khng qu 60mg/kg/ngy. Tr ln v ngi ln 300600mg/ln x 3 - 4 ln /ngy. + Khi nhit tt cn p m. - iu tr triu chng khc: + An thn: Seduxen 0,2-0,8mg/kg/ngy, phng co git khi st cao. + Vitamin C. - Ngi ta c th dng thuc nam : c tc dng thanh nhit, lng huyt, ch huyt, gii c, o I&II. Ch ung thuc nam, ngh ngi,n nh (Hng dn ca B y t 4882/YT-YH) L cc tn 12 gram. C nh ni 16 gram. M 16 gram. Trc bch dip (sao en) 16 gram (thay bng l sen sao 12 g). Sn dy c 20 gram (c th thay du). Rau m 16 gram. Gng ti 3 lt. Cch dng: 60ml nc sch, un si 30 pht, ung ngy 3 ln, ung lc cn m (ngi ln). Tr 1-5 tui: 1/3 liu ngi ln 6-13 tui: 1/2 liu ngi ln > 14 tui: bng liu ngi ln. 2.2. St Dengue xut huyt c sc ( III&IV): iu tr ti tuyn cao hn. - Truyn dch: + Vi cc dch nu, tt nht l Ringers L ct e hoc NaCl 9o/oo 20mg/kg/gi. + Truyn n khi huyt p n nh v mch chm, bnh nhn ht vt v, tiu c, sau 1 gi nu ht sc th gim xung cn 10ml/kg/gi ri sau gim xung cn 3ml/kg/gi. + Nu sc ko di: dng Dextran 40, 10ml/kg/gi cho n khi sc ci thin. + Ri duy tr dch ng trng da vo Hematorit. Lu dch tha do ti hp thu dch gian b - Thng bng kim toan: Da vo xt nghim pH mu, HCO3- , b NaHCO3 14o/oo. Khi no ngng chuyn dch ? Khi c nguy c : hi kh th, phi ran m. Tnh trng lm sng n nh: mch, huyt p n nh; HCT ,40%. 132

Nu o c p lc tnh mch trung tm (CVP) t c 5cm H2O, huyt p n nh. Khi CVP 5 - 10 cm H2O, huyt p vn cha ln dng Dopamin 5 mcg/kg/pht hoc Dobutamin 10 mcg/kg/pht. - Oxy: cho th trong trng hp c sc. - Truyn mu: Xut huyt nng - thiu mu: Hct gim m huyt p khng ln cn truyn mu. Xut huyt nn giu tiu cu, hoc tiu cu khi. - Thuc khc: + An thn: khi st cao hoc vt v, Diazepam tr 0,2-0,8mg/kg/ngy,ngi ln 510mg/ngy. + Adrenoxyl (10mg) ngi ln 1-3 vin, tr > 2 tui 1-2 vin: khi chy mu. + Li tiu furosemide khi c du hiu tha dch. - Theo di iu tr sc: + Mch, nhit, huyt p, nhp th, lng tiu 15-30 pht/ln cho n khi ht sc, sau theo + C sc theo di Hct (khi sc 1gi/ ln, ht sc 2 - 3 gi / ln n n nh). + Theo di bi lan dch, ch khng c truyn tha dch. 3. Tip nhn bnh nhn - St dengue xut huyt I: iu tr ti tuyn c s, theo di chuyn , d bo sc. - St dengue xut huyt II: - C chm xut huyt ngoi da: iu tr ti tuyn c s, theo

ut huyt tng ph: s cu bnh x x, chuyn tuyn trn c nhn vin cp cu km theo. - St dengue xut huyt III&IV: - Cp cu ti ch c tng cng tuyn trn. Chuyn bnh khi cp cu, duy tr dch truyn khi chuyn. IX. D PH NG 1. Khi cha c dch, bnh Bin php tt l gim st v phng mui Aedes egypti. 1.1. Phng mui Aedes: bin php hiu qu, nht l qun l mi trng, bng gim st mi tr 3 dng: - Thay i mi trng: thay i lu di ni vect (dn vt ng nc, y kn nc..). - Vn ng mi trng: thay i tm thi, mui khng c iu kin sng-sinh sn (dn vt ng xuyn). - Thay i ni , hnh vi con ngi: gim tip xc con ngi - cn trng trung gian - tc nh gy bnh (nm mn, khng vt rc thi ba bi...) 1.2. Gim st mui Aedes aegypti Da cc ch s sau gim st mt mui Aedes aegypti, nhm dng bin php kp thi. T l phn trm nh c b gy; T l phn trm vt cha nc c b gy; Ch s Breteau = vt trong 1 khong thi gian (phng php nhy nhng tn km). Ti mt s nc nhit i, s vng khng Aedes aegypti vic gim st l quan trng, trnh mui xm nhp. Ch cng, sn bay, nhng ni nhp cnh. 2. Gim st, phng, chng dch bnh 2.1. Gim st st dengue, st dengue xut huyt: Mc ch l pht hin sm v dch, lm t - Gim st cc trng hp st Phng khm im hoc tuyn y t c s c dch c, phi bo s ca st/tun cho c quan y t, - S bnh nhn st > 38 C. Phng php ny c th pht hin t l mi st tng, xc nh n hanh hc. 133

- Ph bin kin thc t chm sc cho dn, khi c ngi mc bnh phng hu qu xu: triu c sc (tiu chun chn on), pha ch ORS ung khi b st. - Nhn vin y t chn on st dengue, st dengue xut huyt. c tnh, nu 100-200 ca st dengue s c 1 bnh nhn sc do st dengue xut huyt vo bnh vin. - Bo co ca bnh Trng hp nghi st dengue xut huyt cn bo co theo h thng. 2.2. Gim st mui Aedes aegypti Thc hin gim st c nc xc nh mt qun th mui, lu hnh theo ma. 2.3. Gim st v virus Phn lp virus t bnh nhn, t mui Aedes aegypti nh type huyt thanh l quan trng. 2.4. Phng chng dengue xut huyt phng dch bng pht, phi khng ch mui, cch ly-iu tr bnh nhn vin. - Khng ch mui khn cp: khi nghi ng c dch cn tin hnh + Truyn thng cho cng ng v c im ca bnh, bin php c nhn dng gim nguy c nhi ui -sinh sn trong nh, ngoi vn. + Khoanh vng khu vc phun - dit mui, ni c bnh nhn, ni mt mui cao. + Chun b trc cc thuc dit mui, cc phng tin phun thuc. - Cch ly v iu tr bnh nhn ti vin gim c ngun ly Mc ch: gim mt mui nhim virus ct ng ly, lc ngi bnh hi phc. Tht bi 3. Phng nga dch st xut huyt Hin cha c vc xin phng bnh, nn bin php phng bnh l phng mui Aedes aegypti t. - Gim st v iu tr theo tuyn. - Gim st v phng mui, qun l mi trng, khng ch bng ha cht, sinh hc (th c, mesocyclops). - D tr nc an ton (y kn chum vi nc), qun l v sinh v cc cht thi rn. - Gio dc sc khe, tuyn truyn y t cng ng, huy ng cng ng tham gia.

Cu hi n tp 1. M t dch t hc ca bnh do virus dengue gy ra nc ta. 2. M t c im tc nhn gy bnh, tp tnh cn trng trung gian, yu t nguy c dch st d 3. Trnh by c th bnh hc, bnh sinh-sinh l bnh st dengue xut huyt 4. Phn loi th bnh, m t cc bc iu tr st dengue, dengue xut huyt v th c sc. 5. Trnh by cch thc phng chng st dengue xut huyt.

134 Bi 21. BNH C M, C M H5N1 V HI CHNG H HP CP TNH NNG (SARS)

Mc tiu Ts, Bs Trn xun Chng 1. Trnh by c tnh cht chung ca cc tc nhn gy bnh v cch thc ly bnh cm, cm A (H5N1) v SARS 2. M t cch pht hin, chn on v iu tr ban u nhng trng hp cm c bin chng, cm A v SARS.. 3. Trnh by cch t chc phng v chng cc bnh trn cho c nhn v cng ng. Ni dung

I. BNH C M Bnh cm l mt bnh truyn nhim cp tnh ng h hp do virus influenza gy nn. Tuy trong a s trng hp, bnh ch khu tr ng h hp trn vi tin trin lnh tn . Chng thng gy nn nhng v dch, thm ch i dch, do s ngi t vong v cm rt 1. Tc nhn gy bnh Virus cm c tn khoa hc l virus influenza, thuc h Orthomyxoviridae, c phn bit thnh ba typ A,B,C da trn s khc nhau ca cc khng nguyn. Cu trc ca virus cm g - Phn li c cha mt si ARN mang nhng thng tin di truyn. - Phn v c 3 khng nguyn : + Khng nguyn S (Soluble): l khng nguyn ho tan. + Khng nguyn H (Hemaglutinin): gip virus bm dnh vo t bo cm th + Khng nguyn N (Neuraminidase): gip gii phng virus th h sau ra khi t bo. Hai khng ca typ thng c nhng thay i. S thay i khng nguyn c th xy ra t t, to nn nhng v dch nh hay c th t ngt, to nn nhng i ch thay i chm nn him khi gy dch ln. - S ngng kt hng cu xy ra khi virus tip xc vi b mt ca hng cu. Ngi ta da vo h v o nng khng th. 2. Dch t hc - Bnh rt d ly v ly rt nhanh trong cng ng. Trong cc v dch, c n 30-60% dn c trong vng c dch b mc bnh. Cc v dch xut hin khng theo chu k r rng. - ng ly : ch yu l ng h hp. Cc git nc bt rt nh ca ngi bnh d dng lt v tng ng. Ngi bnh c th ly cho ngi khc t 6 ngy trc khi c triu chng cho dn 1 - S thay i khng nguyn (nht l virus typ A) lm gim kh nng min dch ca nhng ngi h trong cng ng, gy nn nhng v dch, thm ch i dch nu s thay i khng nguyn nhi - Bnh thng xy ra vo ma lnh, t cui thu n ma xun nm sau. Dch t n cao im 1hng. 135

- T vong thng xy ra nhng ngi c nguy c b bin chng cao. l nhng ngi gi yu v chuyn ho , c bnh tim phi mn tnh, suy thn mn, nhng ngi suy gim min dch.. 3. Sinh l bnh Sau khi vo c th theo ng h hp, virus bm dnh ri thm nhp vo t bo biu m ca v pht trin ca vi-rt bn trong t bo, vi-rt lm ri lon chuyn ho t bo v ph v t Qu trnh ny xy ra kh nhanh nn ch trong mt thi gian ngn, virus c th lan ton b ni an n tn ph nang. Cc t bo biu m s sung huyt, ph n, hoi t v bong ra. S bong r in st v s mi. Tuy nhin sau khi khi bnh, chng thng c thay th bi cc t bo bi 4. Lm sng

4.1 Th in hnh 4.1.1 Thi gian bnh Ko di 1-3 ngy, trung bnh 48 gi. Bnh khi pht t ngt vi st, n lnh, nhc u, s m 4.1.2 Thi k khi pht Thng t ngt, st cao 39-400C, rt run, nhc u, bun nn, au mi ton thn. 4.1.3 Thi k ton pht: c 3 hi chng: * Hi chng nhim trng: - St : t ngt v tng ln nhanh chng trong nhng ngy u tin, c khi ln n 40 C k ong vng 1 tun. - Mt mi ton thn, chn n, mi kh, li bn. * Hi chng au lan to: - Nhc u: quanh hc mt, vng trn hay thi dng. C trng hp vng chm. Nhc u th vi cn st. - au c khp : au ton thn, nhng r nht l cng chn v vng tht lng. * Du hiu vim long ng h hp trn: Thng c s mi, ho khan, i khi c m, rt hng. - Khm thc th : c khi khng pht hin g. Nhim virus typ B c th gp cc triu chng m mc. - Tin trin : bnh thng t hi phc trong vng 4-7 ngy khi khng c bin chng. Tuy nhin chn n, ho v mt mi cn ko di n 3 tun sau, nht l ngi gi. 4.2. Cm c tnh C biu hin ca hi chng suy h hp cp do virus cm gy ra. Thng gp nhng ngi suy h ai, gi yu hay c suy gim min dch. - Lm sng: th nhanh, tm u chi, phi c ran n hai bn. C th c du suy tim phi v ri im, vim mng ngoi tim, suy thn, suy gan.. - X quang phi : m lan to hai phi. Bnh nhn thng t vong do thiu Oxy nng. 4.3.Bin chng 4.3.1. Bi nhim ph qun-phi do vi khun y l bin chng thng gp nht ca cm. - Tc nhn gy bnh thng l Haemophilus influenza, ph cu, lin cu, t cu vng.., thng tnh. - Triu chng bo hiu thng l st tng tr li sau khi gim xung 1-2 ngy. Bnh nhn h phi c nhiu ran n, c th c hi chng c phi hoc vim ph qun. - C th dng khng sinh phng bi nhim nhng ngi c nguy c. 136

4.3.2. Bi nhim Tai-Mi-Hng Him gp hn, ch yu tr em, bao gm: - vim tai gia - vim xoang - vim thanh qun 4.3.3. Bin chng khc Rt him gp, gm c : - vim c tim, vim mng ngoi tim - vim mng no lymph c hoc khng km du hiu vim no - sy thai ph n c thai - Hi chng Reyes : ph no, h ng huyt, tn thng t bo gan v thn. Thng ch gp - Hi chng Guillain - Barre 5. Chn on 5.1. Chn on Chn on cm thng da vo : 5.1.1 Lm sng - Cc triu chng nhim virus ni chung : st cao t ngt, mt mi, chn n.. - Hi chng au - Du hiu vim long ng h hp trn. 5.1.2 Yu t dch t : C nhiu ngi cng mc bnh trong vng bnh nhn ang sng. 5.1.3 Chn on xc nh + Phn lp virus : c th phn lp virus trong dch xut tit mi hng hay kh qun, cy trn + Chn on huyt thanh: phng php c ch ngng kt hng cu (Hemagglutination inhibition) lement fixation). Cn ly mu 2 ln, cch nhau 7-10 ngy. Kt qu (+) khi hiu gi t 1/1280

2 tng gp 4 ln so vi ln u. Cc phng tin chn on xc nh bng phng php huyt thanh hc hay phn lp virus rt nghin cu dch t hc, phc v cng tc d bo v lm vaccine. 5.2 Chn on bin chng Da vo cc triu chng lm sng v cc xt nghim lin quan. 5.3 Chn on gin bit - Trn lm sng, rt kh phn bit vi cc bnh do cc loi virus khc nh virus parainfluenz adenovirus.. gy ra. Ch yu da vo yu t dch t. - Phn bit vi vim phi do Mycoplasma, Chlamydia, vim hng do cc vi khun..C thng khng t gii hn v p ng vi khng sinh thch hp. 6. iu tr 6.1 Nguyn tc - Khng c iu tr c hiu. Ch yu iu tr triu chng v cc bin chng. - Nng cao th trng bnh nhn . 6.2 iu tr c th - Ngh ngi, n ung v b nc cho bnh nhn. Ch hot ng tr li dn dn khi hi phc, - Nu bnh nhn st cao : h nhit bng Paracetamol 500 mg x 3-4 ln/ ngy. Khng dng Aspiri xut c Salicylate khc, nht l cho tr em. - Vitamin C, 1 -2 g/ ngy. - Cc thuc iu tr triu chng (khng histamin, long m, gim ho..): ch dng khi cn thi sau xng c c th dng Codeine, 16 - 64 mg mi 4 -6 gi. 137

- i vi cc bnh nhn c nguy c cao ( tr s sinh, ngi gi, ngi c suy h hp mn tnh nh phng bi nhim. - Thuc chng virus c hiu : Ribavirin, Amantadine v Rimantadine ch c hiu lc nhng kh virus cm typ A v phi dng rt sm ngay sau khi nhim virus . - iu tr cc bin chng : Khng sinh thch hp nu c bi nhim vi khun ( ch yu khng ). Bo m h hp. Trng hp hi chng Reyes: truyn Glucose, chng ph no. - iu tr cm c tnh : + Theo di v iu tr ti phng Hi sc cp cu. + Hi sc h hp v cc bin php khc : th Oxy, th my, cn bng nc-in gii, khng sinh. 7. Phng bnh - Tuyn truyn rng ri kin thc v cm cho nhn dn. c bit nhn mnh n kh nng ly la in chng cao khi mc cm. - Cch ly bnh nhn nghi cm. Khng cho nhng ngi c bnh tim mch mn tnh, gi yu..tip xc, c th d phng bng Amantadine ( hay Rimantadine ) 200 mg/kg/ngy x 3-7 ngy. Kh nng 70% i vi virus cm A, nhng khng c hiu qu i vi virus B. Thuc khng virus mi Rib dung, t ra c hiu qu tt trong d phng v iu tr bnh cm. - Trn th gii, ngi ta thng chng nga vaccine vo u ma thu (trc ma dch hng nm) irus cm gy dch nhng nm trc, thng c hiu qu bo v tt (khong 65 - 70%). Thi gian thng t gii hn v t l t vong khng cao nn vaccine cm khng c a vo chng trnh rus th ngi chng nga vn c th mc cm. II. BNH C M A (H5N1) 1. Gii thiu Bnh cm g xut hin ln u tin Hng Kng nm 1997 v mt s nc khc sau . Rin gy ra. y l mt bnh c kh nng gy dch nh ti a phng cng nh dch ln nhiu vn hn nui ni ring cng nh cho nn kinh t ni chung v gy nguy him n tnh mng ca ng 90 bnh nhn nghi b cm H5N1, trong c 21 trng hp t vong. 2. Tc nhn gy bnh Tc nhn gy bnh l virus cm, thuc h orthomyxoviridae. Virus c 3 type, type A thay i k nhanh v gy hu ht cc v dch cm. V ca virus c cha hai protein hemagglutinin (H) v (N). Hin c 15 ph type ca H (c k hiu H1-H15) v 9 ph type N (N1-N9). Virus cm hin l loi H5N1. 3. Dch t hc v c ch bnh sinh 3.1. Dch t hc - Ngun bnh: + Ngi ang nhim virus. + G hoc gia cm mc bnh: ngi ta nghi ng c s ly lan khi tip xc vi gia cm mc bnh

- ng ly: + ng h hp, do nc bt ca ngi nhim virus khi ho, ht hi. + Do tip xc vi nc bt ca ngi bnh hoc vi gia cm b bnh ri a vo mi, ming ng + Thi gian ly: 1 ngy trc khi c triu chng v ko di 3-7 ngy sau khi khi bnh. 138

3.2. C ch bnh sinh: Tng t c ch bnh sinh ca cc bnh cm thng thng. 4. Triu chng lm sng v cn lm sng Xem phn triu chng lm sng bnh cm. 5. Chn on 5.1. Chn on Chn on cm thng da vo : - Cc triu chng nhim vi-rt ni chung : st, mt mi, chn n.. - Tn thng ng h hp, suy h hp cp. - X quang phi: c hnh nh m lan ta c hai phi. - Yu t dch t: C tip xc vi bnh nhn cm H5N1 hoc vi gia cm b mc bnh. 5.2. Chn on xc nh : + Phn lp virus: bng k thut PCR c th phn lp virus trong dch xut tit mi hng hay k + Chn on huyt thanh: bng phng php c ch ngng kt hng cu hoc phng php C nh 6. iu tr 6.1.iu tr cm thng thng - Ngh ngi ti ging, n ung v b nc cho bnh nhn. Ch c hot ng tr li dn d - Nu bnh nhn st cao: h nhit bng Paracetamol 500 mg x 3-4 ln/ ngy. Khng dng Aspirin xut c salixylat khc, nht l cho tr em. - Vitamin C, 1 -2 g/ ngy. - Cc thuc iu tr triu chng (khng histamin, long m, gim ho..) : ch dng khi tht c v au sau xng c c th dng Codein, 16-64 mg mi 4 -6 gi. - i vi cc bnh nhn c nguy c cao (tr s sinh, ngi gi, ngi c suy h hp mn tnh, phng bi nhim. - iu tr nguyn nhn: Dng thuc khng virus Tamiflu (Oseltamivir). Liu dng: vin 75mg x 2 ln/ngy trong 5 ngy. - iu tr cc bin chng : Khng sinh thch hp nu c bi nhim vi khun ( ch yu khng ). Bo m h hp. 6.2. iu tr cm c suy h hp - Cho th Oxy, th my, cn bng nc-in gii, khng sinh. - Xt nghim: cng thc mu, kh mu, in gii ..., chp X quang phi hng ngy. 7.Phng bnh - Tuyn truyn rng ri cc kin thc v cm cho nhn dn. c bit nhn mnh n kh nng l a cm cht hng lot khng r l do. - Tt c gia cm trong phm vi 3 km quanh ni c dch u phi c tiu hu. Tuyt i khng g khc. Gia cm hoc tht gia cm u phi c kim dch trc khi bn ra th trng. - Tt c bnh nhn b cm hoc nghi b cm do H5N1 u phi c cch ly tuyt i. III. HI CHNG H HP CP TNH NNG (SARS) 1. Gii thiu Hi chng h hp cp tnh nng (Severe acute respiratory syndrome, vit tt l SARS) hay cn vim ng h hp cp, l mt bnh truyn nhim cp tnh do virus gy ra, c kh nng gy dc ut hin ln u vo thng 11.2002 Qung ng (Trung Quc), sau nhanh chng lan rng ra T thng 11.2002 n 07.08.2003 dch lan rng n 29 nc v vng lnh th. Tng s bnh nh ong; ring nc ta c 63 bnh nhn SARS v c 5 bnh nhn t vong. 139

Bnh c t l t vong cao, cha c thuc iu tr c hiu v cha c vaccine. Dch SARS hnh tr x hi ca nhiu nc. Theo c tnh dch SARS gy thit hi hn 150 t -la M 2. Tc nhn gy bnh Tc nhn gy bnh l mt loi coronavirus, thuc h coronaviridae, mt loi ARN virus. SARS c s c cu trc phn t ging 60-70% loi coronavirus trc y. Coronavirus kinh in thng g ch yu ngi trng thnh. SARS coronavirus l loi rt mnh, c kh nng ph hu t chc trc y. SARS-CoV c th sng st bn ngoi c th tng i bn vng, nht l trong iu kin nhit

3-4 ngy trn cc vt liu g, vi, giy, kim loi, da; 4-5 ngy trong nc bt v cht thi tn ti vi c lc cao 4-20 0C trong 5 ngy. Tia cc tm v cc ho cht kh trung y t trong vng 60 pht. 3. Dch t hc v c ch bnh sinh 3.1. Dch t hc - S lu hnh bnh: Ch trong vng 9 thng, bnh SARS lan truyn nhanh chng ra 29 nc c 5 chu lc. iu ny cho thy kh nng pht tn v lan truyn ton cu ca bnh. minh l c mt nhiu khu vc trn th gii. Nh vy kh nng lu hnh rng ri ca SARS-Co h nhiu dch bnh ng h hp khc, khu vc chu vi mt dn c ng v nhiu yu t t pht v l ni lu hnh thng xuyn nht ca dch bnh SARS. - cha: Ngi ta cho rng ngun gc ca cc tc nhn gay bnh SARS l sc vt hoang d.Cc him trn 300 mu mu t cy hng ni xy ra dch SARS ca tnh Qung ng v pht hin ging nh SARS-CoV c phn lp ngi mc bnh. - Ngun ly: Bnh nhn SARS ang trong giai on khi pht v ton pht l ngun bnh nguy hi coronavirus khng c triu chng cng l ngun ly bnh trong cng ng. - ng ly: ng h hp: nc bt v dch tit ng h hp ca bnh nhn khi ni, ho, khc. ng tip hn c th lm nhim b mt phng bnh hay trong nh cng cc vt dng c nhn, t qua tay n 3.2. C ch bnh sinh Phn ln coronavirus nhn ln cc t bo biu m ca ng h hp v gy nn cc triu chn t bo ca vt ch, iu khin t bo tng hp nhng thnh phn khng nguyn, cc v, cc en cc virus mi v tip tc tn cng cc t bo khc. Qu trnh ny xy ra kh nhanh nn ch trong mt thi gian ngn, virus c th lan ton b ni g. Cc t bo biu m s sung huyt, ph n, hoi t v bong ra. S trao i kh gia mng-ma rong mu gim i nhanh chng. cc khong k c s tng tit gy vim khong k. 4. Triu chng lm sng v cn lm sng 4.1. Lm sng 4.1.1 Thi gian bnh: 7-10 ngy, c th dao ng trong khong 3-14 ngy. Trong Thi gian virus cha ghi nhn trng hp ly bnh. Do ngi ta thy rng khi tip xc vi ngi bn th coi nh khng b ly nhim SARS. 140

4.1.2 Thi gian khi pht: trung bnh 1 tun sau khi tip xc vi ngun ly. * Triu chng ton thn: - St cao t ngt, thng st lin tc trn 380C, i khi rt run. Thi gian st ko di 5-15 ngy, trung bnh 10 ngy. Mt , mch nhanh, n km. - au u v au mi cc c, au sau hc mt. C th sng hch ngoi bin. - Mt mi, n ung km - Nhc u, chng mt -Tiu chy: mt s bnh nhn a chy 3-4 ln/ngy, phn lng vng, khng nhy mu. * Triu chng h hp: C mt hoc nhiu triu chng sau: - Ho: thng ho khan, c th c m trng. - Kh th: th nhanh, nng, trn 25 ln/pht. C cc du hiu suy h hp cp. - Nghe phi c th c nhiu ran rt, ran ngy hoc ran m mt bn hoc hai bn phi. Mt s - Rung thanh v g u bnh thng. Nh vy biu hin tn thng phi bnh nhn SARS l c trng ca vim phi khng in hnh. 4.1.3 Thi k hi phc: Sau khong 10-15 ngy bnh nhn ht st, ht ho, n ng bnh thng. Hnh nh tn thng phi dn dn thu nh li v mt i. 4.2. Cn lm sng - CTM: S lng BC v TC bnh thng hoc gim. BC tng khi c bi nhim vi khun. S lng t - Kh mu: gim Oxy mu nng vi SpO2di 90% hoc PaO2 di 60 mmHg, PaCO2 bnh thng hoc tng. - S lng T CD4, T CD3 gim. - Transaminase tng khong 2-6 ln. Chc nng thn bnh thng. - X quang phi: c hnh nh vim phi k, lc u khu tr, sau lan to. T ngy u c nh thng tin trin nhanh tng ngy. Sau 1-2 ngy lan n 1/2 hoc 2/3 phi. Trng hp nn cho bnh nhn kh th v suy h hp nng. Tn thng phi l nhng m thm nhim khong k hoc nhng m m ranh gii khng r rt

5. Chn on 5.1. Yu t dch t Ngi bnh vng dch lu hnh hoc c nghi ng tip xc 5.2. Lm sng C triu chng st v kh th nh trn. 5.2.1 Trng hp nghi ng SARS: - St cao t ngt (>380C) - au c, au mi ton thn - C mt hoc nhiu triu chng h hp (ho, au ngc, au - Trong tin s 10 ngy trc c tip xc vi ngi b 5.2.2 Trng hp c kh nng b SARS: - St cao t ngt (>380C) - au c, au mi ton thn - C mt hoc nhiu triu chng h hp (ho, au ngc, au - X quang phi c vim phi hoc c hi chng h hp cp - Trong tin s 10 ngy trc c tip xc vi ngi b 141

vi ngi bnh SARS. Nhn vin y t

hng, th nhanh, kh th) vim ng h hp cp hoc cht m

hng, th nhanh, kh th)

vim ng h hp cp hoc cht m

5.3. Cn lm sng C hnh nh X quang phi c trng. Chn on xc nh bng phn lp virus trong mu, m, dch ph qun bng phn ng chui poly hin khng th ca viru s bng cc phng php th nghim min dch men (ELISA), min dch h FA). 5.4 Chn on phn bit Khi b vim phi do SARS cn phn bit vi: 5.4.1 Vim phi thu do vi khun (ph cu, lin cu, t cu) y l loi vim phi in hnh, c cc triu chng lm sng ch yu nh: - St cao t ngt 39-400C, rt run - au ngc d di - Ho c m, m c m hoc c mu mu r st - Kh th, th nhanh v nng - Khm thc th c hin tng ng c phi - Bch cu mu tng, a s l a nhn trung tnh. X quang c hnh nh vim phi thu. 5.4.2 Vim phi khng in hnh do virus: Rt nhiu loi virus ng h hp c th gy vim p - Triu chng lm sng: st cao t ngt, ho, nhc u, mt mi, s mi. Nghe phi c ran rt - X quang: c tn thng phi hnh mng li, thm nhim thu phi, rn phi m. - Bch cu mu bnh thng hoc gim. 6. iu tr 6.1. Nguyn tc - Mi trng hp c pht hin bnh hoc nghi ng mc bnh u phi nhp vin v cch ly hon ton. - Ch yu l iu tr triu chng. Pht hin v x tr kp thi tnh trng suy h hp. - Thng bo ngay tt c nhng trng hp bnh c pht hin v Trung tm Y t d phng ca - Phng iu tr bnh nhn: Khng c dng my iu ho nhit . tt c cc ca s phng ph s nc, ngi ta ng kn ca phng v dng my c p lc m thng kh, y khng kh tr 6.2. iu tr nguyn nhn Ribavirin 400mg tim TM 3 ln/ngy trong 3 ngy hoc n khi tnh trng bnh nhn ci thin, dng ng ung, 2400 mg/ ngy, chia 2 ln. Mt s nc c dng Oseltamivir (Tamiflu), vin 75 mg, ung 2 ln/ ngy hoc Amantadin 100 mg x 2 vin/ ngy. Tuy nhin cho n nay ngi ta vn cha chng minh c cc thuc ny c tc dng khng virus LS cc bnh nhit i khng dng thuc khng virus cho tt c bnh nhn SARS, k c nhng b 6.3. iu tr triu chng - Dng thuc gim ho nu c ho khan nhiu. Nh mi bng Naphazolin. - H st: Paracetamol, 2g/ngy cho ngi ln, 50-60mg/kg cn nng/ngy cho tr. 6.4. iu tr h tr - Methylprednisolon tim TM , liu 1mg/kg/ngy khi c suy h hp hoc tnh trng nhim trng g nn qu 5 ngy. - C th dng Gammaglobulin truyn TM 200-400mg/kg, ch dng mt ln. Hoc albumin 20% x 100m ruyn TM ba ngy mt ln.

6.5. Dinh dng - m bo dinh dng. Ung nhiu nc hoa qu. 142

- Truyn dch NaCl 0,9%, Ringer lactate, Glucose 5%, m.. tu tnh trng bnh nhn. 6.6. iu tr suy h hp cp - Bo m thng kh, th Oxy qua ng sonde mi hoc mt n. Lu lng 4-10 l/pht. - Theo di lin tc SpO2 hoc PaO2. - t ni kh qun v th my khi c ri lon thc, th nhanh qu 35 l/pht hoc chm di 7,25. 7. Phng bnh 7.1. Phng bnh trong bnh vin - Bnh nhn mc bnh hoc nghi ng mc bnh SARS phi lp tc c cch ly nhng khu vc ri h phi phng ring, khng chung phng vi ngi nghi ng mc bnh. - Cho bnh nhn sc ming bng dung dch st khun ng mi hng. - Tt c bnh nhn phi mang khu trang tiu chun nh N95. Mi th thut, xt nghim u ph - Cm ngi nh v khch n thm khu cch ly. - Nhn vin y t chm sc bnh nhn SARS phi mc o chong bo h (o giy, dng mt ln), mang khu trang N95, knh bo h hoc mt n che mt, gng tay. - Dng c dng cho ngi bnh phi c ra v ty u bng x phng v ho cht kh khun hng 7.2. Phng bnh trong cng ng - Tuyn truyn trn cc phng tin thng tin i chng v dch SARS, cc triu chng thng t - Thnh lp cc khu vc cch ly cc vng c dch, cng hng khng quc t, cng bin, ca k phi c theo di, kim tra v cch ly nu mang mm bnh. Kim tra nhit bng my o th tai. Cu hi n tp 1. Trnh by mt s c im dch t hc ca virus cm. 2. Trnh by triu chng lm sng v cn lm sng ca cm c tnh. 3. Trnh by nguyn tc iu tr bnh cm. 4. Th no l mt trng hp nghi ng SARS ? 5. Trnh by cc nguyn tc iu tr bnh SARS. 143 Bi 22. BNH RUBELLA

Mc tiu BsCK2,Ths Phan Qun 1. M t c c im, tnh cht ly, bnh sinh ca virus rubella 2. Xc nh c tnh nghim trng ca bnh i vi ph n c thai. 3. M t c lm sng v chn on gin bit rubella mc phi vi mt s bnh pht ban. 4. M t c hnh thi rubella bm sinh. 5. M t cch thc phng nga rubella Ni dung I. I CNG Bnh virus, c pht ban hoc khng, d ly, min dch bn sau mc bnh, lnh tnh, gp tr em thi k 2, ng ngi l thai ph mc bnh tng nguy c thai nhi d tt bm sinh. 1. Tc nhn gy bnh Virus RNA, rubivirus, h togaviridae. Gn ging alphavirus, phn bit cu trc khng nguyn

(hemagglutinine, khng nguyn c nh b th), v ca phn ng huyt thanh c hiu. 2. Tn sut bnh v nhm nguy c Dch t hc ca bnh thay i nh chng nga rng cho tr. Trc y, dch tin trin theo v dch ln xut hin cch y 30 nm, trong thi gian ngi ta thy s sinh mc d tt b a bm sinh (v dch nm 64 65 M, Anh nm 1978). Tr tr s sinh v tr con, bnh gp ha min dch (10% qun th ngi ln). 3. Ni cha virus v s ly nhim - Nhim cp tnh, ch tn ti ngi. C c mt min dch xc nh. Bnh ly qua khng kh ubella bm sinh). - Ni cha virus gm: + Ngi nhim virus khng hoc c triu chng, virus tn ti hng ca h 7 10 ngy trc pht ban v 10 15 ngy s u pht n (v th bin php cch ly khng hiu qu). + Tr s sinh mc rubella bm sinh, rt ly v thi virus t 4 - 6 thng, d c khng th tru - Bnh ly yu hn si: 50% tr 10 tui, 75% v thnh nin, 90% ngi ln khng min dch. II. BNH SINH bnh 14 23 ngy (trung nh 14 18 ngy) s u khi xm nhp mi hng. Virus huyt 8 ngy trc pht ban v bin mt cng vi ban, khi c min dch. Min dch bn, IgMc hiu 3 thng, ri IgG xut hin. Nu nhim rubella ln 2 s khng c virus huyt, khng triu chng, m IgG tng nhanh v c khi tng IgM. III. RUBELLA MC PHI 1. Lm sng Rubella khng biu hin triu chng, hoc khng r, ch pht ban thong qua. Khi pht ngn (1 2 ngy) v khng r, st nh, au c khp, hch c sau tai, c sau v d iu tun. Pht ban khng hng nh. Khi u mt v lan rng trong 24 gi n thn v chi trn. Ban d sn, c bit mt, i khi dng scarlatine ngy th 2, c bit mng v gc i; mt vo ngy th 3 khng du vt. 144

Ni ban (c nt xut huyt vm hu, vim kt mc, chy mi nh), lch sng nh. St, < 3805C, bin mt t ngy th nht sau pht ban. 2. Chn on xc nh Huyt : gim bch cu a nhn, i khi tng lymph a kim, c khi tng tng bo (5 10%) gip nh hng chn on. Huyt thanh tng quan chn on chc chn l bng chng chuyn i huyt thanh. Lng khng nhanh trong 2 tun k tip. gii thch kt qu ng cn xt nghim 2 ln cch nhau 10 ng th ln 2 tng gp 4 ln u. Nu xt nghim huyt thanh mt ln khng gii thch c kt q l ng thi trong cng mt phng xt nghim, phi gi li 2 mu huyt thanh t nht 6 thng 3. Chn on gin bit - Trc mt pht ban dng si cn gin bit vi mt s bnh c pht ban: + Tinh hng nhit: Ch chn on lm sng, bng chng sinh hc khng chc, khng c bng chn him ban u. Yu t gi : tui (tr), vim hng cp c trc, pht ban khng c khong d bong mng da cc u chi. Hay gp th khng in hnh. Tinh hng nhit lin cu do phu thut au nhng ngoi ban quanh vt m trc khi lan ton thn. + Si: tr 3 7 tui, cc yu t chn on nh s ly lan v cha chng nga, vim long h pht ban si, du Koplik trc pht ban. Ban pht bt u u mt, ri thn mnh n t ch hin th ht st, ch mt t ban. Huyt thanh chn on IgM ch dng th bnh khng in + Pht ban ma xun (exanthme subit): tr con s nhim virus herps type 6 (HHV6), ch yu st km pht ban, gy min dch, c im ch gp tr 6 thng 3 tui, khng l ban, t ngt 39 400C. St 3 ngy ri ht. Ban xut hin ch yu c v thn, bin mt nhanh lun lun gim. Cha c chn on sinh hc. + S nhim HIV: ban dt sn thn, mt, c, gp s nhim HIV c triu chng, trung bnh 10 n au c, au khp, lot hng v hoc lot sinh dc, sng hch, him hn l a chy, nm ming anh HIV m tnh v chn on da vo khng nguyn P24 hoc HIV RNA mu. + S nhim Epstein - Barr virus: pht ban dng si t nhin ch gp 5 10% trong cc trng nhim khun. Tri li, khi mc bnh v dng ampicillin s gy pht ban dng si hoc tinh hn h cu n nhn nhim khun (tng n nhn a kim gi chn on) v test huyt thanh xc nh chn on. + Pht ban do enterovirus: cc enterovirus khng gy bnh bi lit nh ECHO (entero cyto huma rphanan) hoc Coxsackie, gy pht ban dng rubella kn o, xy ra cc v dch nh ma h.

nhim trng khng c hiu: gi cm, a chy, au u, au c. i khi, ch yu l vim mng u tr lin sn, gy kh th, nhng khng c du hiu triu chng ca phi, X quang phi bnh ) kh gi . C th phn lp virus trong phn, him hn trong nc no tu. Nhiu type huyt yn nhn gy bnh (ECHO1 9, 11, 14, 18, 19, 25, 30, Coxs ckie B1 6). c hiu: "pht ban Boston do virus ECHO16 c gy dch v hi chng vim mng no - pht ban do ECHO9 iu hin pht ban c xut huyt v us 71: st, pht ban tay - chn - ming, a chy, vim no - mng no, hn m. + Ngoi ra, cc virus c th gy pht ban: virus vim gan B, adenovirus, virus cm, myxovirus, arbovirus,. Mt s vi khu n cng gy pht ban,. Mt s k sinh trng. - Trng hp sng hch c km du nhim trng cn gin bit bnh c triu chng tng t: + Tng bch cu n nhn nhim khun do virus Epstein B rr. 145

+ Do cytomeg lovirus. + S nhim HIV giai on sng hch ton thn. + Nhim cc adnovirus. + Vim hch do cc vi khun sinh m, lao. 4. Tin trin v bin chng 4.1. Vim a khp bnh nhn v thnh nin, ngi ln v c bit l ph n. Xut hin ngy th 2 tr i. Cc tay, khp thi dng hm, cng nh khp c tay, u gi. Vim khp c th bng pht mt t 5 30 ngy khng di chng. Hi chng au c tn ti him gp, m ch yu gp con gi tr. 4.2. Xut huyt gim tiu cu sau pht ban. Him (1/3.000), hay gp tr hn ngi ln, xut hin 10 15 ngy s u pht n chm dt. M rng hp tiu cu gim rt thp. Hi phc 2 4 tun hoc ngn hn khi dng corticoid. C th ca rubella. 4.3. Vim no mng no Him hn (1/5.000 1/25.000) so vi vim no do si, xut hin ngy th 2 4 s u pht n v hn kinh (co git, ri lon thc, cc chuyn ng bt thng, tht iu) v vim mng no. di chng. 4.4. Cc bin chng khc Vim gan tiu t bo va phi v vim thn kinh (thn kinh to) him gp. 5. iu tr n thun iu tr triu chng. IV. RUBELLA BM SINH Nhim virus rubella m - con hay gp, c nhng vn t nh trong vic chn on v thi tr liu (chm dt thai k hay khng ?) Tng quan s ly qua nhau thai vi d tt bm sinh trong 3 thng u thai nghn. Rubella bm iu vn nghim trng tri li ngi ln mc bnh th lnh tnh. 1. Cc d kin dch t hc Tn s Rubella bm sinh trong cc v dch trn qun th gim ng k nh d phng. Nm 1998, thnh ph ca Php, tn s mi nhim Rubella hng nm trong qu trnh thai nghn l 3,7/105 tr s sinh v tn s d dng bm sinh do Rubella l 0,41/105 tr s sinh. S tun mang thai S % d dng hoc khuyt tt 0 8 85% 9 12 52% 13 20 16% > 20 tr ln 0% Bng: Xc xut nhim m - con tng quan trc tip vi th gian mang thai

Trong khi mt s ly bnh mun khng bo v khi Rubella tin trin bm sinh. 2. Thai nhi chm pht trin Ngi ta c th gp hai bnh cnh nh sau 1.1. Hi chng d dng (cn gi l hi chng Gregg) Gregg m t nm 1941. Pht hin vo lc sinh, v di chng Rubella bm sinh ch c th xc n Thc ra, nhiu tn thng tin trin ko di. Cc khim khuyt v tri gic hoc tm thn - v pht trin vn ng v

tm thn ca tr, c khi ch pht hin c tui i hc. Mt, c quan thnh gic, tim, h thn kinh trung ng l cc c quan b nh hng chn lc. C vi nhau. 146

- Tn thng tn mt: ch yu c thu tinh th hai bn. C th thy mt nh, tng nhn p (g - Thng tn thnh gic: ic, thng mt bn, him khi ic hon ton. y l mt gim thnh - Tim bm sinh: c th tt c, nhng thng l tn ti ng thng ng tnh mch v teo hp - Thng tn thn kinh: chng u nh, chm pht trin tinh thn. - Cc d dng bm sinh khc: rt him, nht l rng (hypoplasie, agnsie de certaines dents, micrognathie). 1.2. Rubella bm sinh tin trin Tng ng vi nhim virus mn tnh ton thn. Virus tn ti cc c quan v hng, gp tr hng). Ni chung chng kt hp vi cc d dng c pht hin khi sinh. S tn ti virus dn n c th thoi lui hoc tn ti vi nhiu di chng. Rubella tin trin lc sinh nh cu no km pht trin (pondrale) v ton b bt thng kt xut huyt gim tiu cu, vim gan c gan lch to vi hong m, vim mng no tng lymph , vim c tim, vim phi k, tn thng xng trn X qu ng (cc dy trc mtaphysaire mt c . V sau, ngi ta c th pht hin cc bt thng v thn kinh, chm pht trin tm thn - vn bella tin trin. Tin lng xa rubella bm sinh d dt, nht l lin quan pht trin tm th tng lai. 3. Chn on Thng l cc bng chng hi cu v bnh cnh d dng ca a tr. Trng hp rubella s sinh - Phn lp virus tr s sinh (hng, nc tiu, nc no tu). - Hin din IgM c hiu lc sinh hoc mt chn on huyt thanh (+) trong vng 6 thng. 4. Phng nga Khng c iu tr c hiu, ch c th chm dt thai k trnh sinh ra a tr d dng hoc Xc nh huyt thanh rubella ph n: khm tin hn nhn, khm thai (thai 3 thng u) 4.1. Phng nga cho thai ph huyt thanh (-) hoc khng bit c min dch cha - Cc ph n ny cn c theo di c bit 3 thng u thai nghn v nhiu vn t ra tro + tip xc mt ngi nghi l rubella. + Nghi ng cc triu chng pht ban mt ph n. Ch chn on bng huyt thanh: xut hin mt chuyn i huyt thanh vi IgM c hiu. Cn ti thi im ti cng phng xt nghim vi k thut tin cy c. - Chn on rubella thai nhi ch thc hin bng cch tm IgM mu cung rn c chc ht di ca thai k. - Cui cng cn phi: + Phng ly cho cc nhn vin chuyn nghip nht l ph n tr lm vic mi trng d ly n + Hiu lc ca globulin min dch cn bn ci. + Ch nh chm dt thai k khi xc nh nhim virus rubella 3 thng u thai nghn. - Cc bin php trn s khng cn na khi chng nga c tin hnh cho mi qun th. 4.2. Chng nga trong qun th nc ngoi ngi ta c lch chng theo qui nh + Chng nga c nhn 147

Dng cho ph n tui sinh , hoc xt nghim khng th m tnh, hoc ngi khng c bin ph i ngoi hn nhn tng m khng kim tra khng th trc mang thai. Do vaccine virus sng gim i mt thng trc v 2 thng sau chng nga. Cnh gic v chng nga c th gy qui thai, ch y cha thy trng hp rubella bm sinh no do chng nga. - Tng cng chng trnh chng nga di dng chng nga ton dn, vi cc mc ch: + Ngn nga s lu hnh virus d ly cho thai ph: chng nga cho tr em hai gii; vi phm vi bao ph tng ln c th khi u vic loi tr bnh rubella. + Duy tr v tng cng chng nga cho tr gi 11 13 tui - Cch tin hnh tim chng tr em: + T 12 thng tui tr i, chng nga c phi hp Si Qu i - Rubella: liu th nht (p P H emophilus c tim v tr khc) + Gia 3 n 6 tui, chng nga mi th 2 Si Qu i - Rubella. + Gia 11 n 13 tui, tip tc tim phng Si Qu i - Rubella vi tr cha c tim ph

V. PH NG NGA - Ch c th phng nga bng bin php chng nga. - C th, chng nga trc mang thai cho ph n tui sinh trnh nguy c cho thai nhi. - Tp th, dng vaccine rng ri tr em lm mt s lu hnh virus v trnh ly cho thai ph. 1. Chng nga Vaccine sng gim c lc (plotkin RA 27/3), c th ch tim mt mi di da hoc bp tht, r phi hp khng nguyn si v quai b (ROR Vax, Priorix), c th c kt hp vi cc thuc ch CG. - Vc xin dung np tt: st nh, au khp v pht ban thong qua ngi ln < 5%. - To min dch hiu lc ti a (97%) sau chng bn v n nh. Tim nhc li khng c li d bnh; khi khng cn nguy him. 2. Chng trnh tim chng - t 2 mc ch: + p dng rng ri cho tr em hai gii gim ni cha virus, trnh ly cho thai ph. + Bo v ph n tr cha min dch (tin hn nhn) trc mang thai ln u hoc ngay sau sinh. - c p dng cho tr c 2 gii: + Chng nga cho tt c tr tui 12 thng 24 thng, phi hp vi vaccine Si, Quai b ri c tui (ROR Vax, Priorix); + Chng cho tr 2 10 tui cha c chng, c khi tui nh tr hoc tui tiu hc; + Chng cho tr 12 13 tui, hoc l chng ln u hoc l chng li ln 2; c th vi liu + Chng nga cho ph n tr, c ngh vi trng hp thch hp (t vn tin hn nhn hoc huyt thanh trc (c bit yu cu vi nhn vin y t). ph n tr, chng nga cn kim s i thng sau chng nga. Tuy nhin, cha c trng hp rubella bm sinh no do chng nga gy Cu hi n tp 1.Trnh by c im, tnh cht ly, bnh sinh ca virus rubella 2. M t tnh nghim trng ca bnh rubella i vi ph n c thai. 3. Trnh by lm sng v chn on gin bit rubella mc phi vi mt s bnh pht ban. 4. M t cc hnh thi rubella bm sinh. 5. Cch thc phng bnh rubella 148 Bi 23.

Mc tiu BNH VIM NO NHT BN

Ths, BsCK1 ng th Nga 1. M t c nh ngha , tm quan trng ca bnh vim no Nht bn 2. M t c dch t , lm sng , cn lm sng chnh ca bnh vim no Nht bn 3. Trnh by c nguyn tc iu tr , phng bnh chnh trong bnh vim no Nht bn Ni dung

I.I CNG 1.nh ngha Vim no Nht Bn l mt bnh truyn nhim cp tnh do mt loi virus c i tnh vi nhu m n in hi chng nhim trng v ri lon thn kinh nhiu mc khc nhau, iu ng lo ngi l ng cao. 2.Tm quan trng L bnh c bit hn 100 nm trc y . Cui th k XIX lin tip cc v dch xy ra c v t l t vong ti 60 %. Bnh nh hng ti sc khe cng ng, nhng bnh nhn sng st thn , vn ng, kh nng thch ng vi i sng gia nh v x hi b ri lon. ngi ln mt kim ch, o gic, mt cc k nng tinh vi trong ngh nghip. tr em c nhng ri lo inh, chm bit ni, khng th ha hp v tip thu bi hc nh cc em cng lp. Ngoi ra tr c kh nng thch ng vi x hi cng kh khn hn. Do vy vim no Nht Bn l bnh c tm qua hng c hiu c hiu qu v c cc bin php iu tr thch hp gim ti a cc di chng II. DCH T HC 1.Tc nhn gy bnh Virus Vim no Nht bn thuc nhm arbovirut nhm B, h Togaviridae, ging Flavivirus, kch 22 nm. C cu trc ARN; pht trin t bo phi g v t chc nui cy; khng chu nhit , c pht , 100oC trong 2 pht . 2.ng ly truyn Virus c truyn qua mui , ngi l k ch tnh c, ngun ly ch yu l ngi bnh, ln, n . 3.Mt s c im dch t hc vim no Nht bn B - dch thin nhin: Vim no Nht bn B c khp ni , virus lu hnh trong cc dch c lp c virus t chim liu iu . - Cn trng trung gian truyn bnh : Trong thin nhin virus c truyn t cc vt ch vi n ging Culex (cc chng C.pipiens, C.tritaeniarhynchus, C.bitaeniarhynchus..) l ch yu , ng oi ra cn c th c c ging Aedes (A. togoi, A. Japonicus) c kh nng truyn bnh. - Vit nam loi mui Culex tritaeniarhynchus sinh si mnh vo ma h (nht l t thng 3 h vo bui chp ti . Loi mui ny c mt cao 149

vng ng bng v trung du , n l vt ch trung gian truyn bnh ch yu bnh vim no Nht bn nc ta. Sc cm th cao vi tr em di 10 tui , ngi ln t l c khng th cao do vy t mc bnh ni v nng thn cao hn thnh ph. Sau khi b bnh li min dch chc chn v vng b III . LM SNG 1. Triu chng lm sng th thng thng in hnh 1.1.Thi k nung bnh Ko di t 5 n 14 ngy , trung bnh l 1 tun 1.2.Thi k khi pht Bnh thng khi pht rt t ngt vi st cao 39oC - 40 oC hoc hn . Bnh nhn au u, c Ngay trong 1 -2 ngy u ca bnh xut hin cng gy, tng trng lc c, ri lon s vn l ln hoc mt thc. Nhng ngy u phn x gn xng tng, xung huyt gin mch r. mt u bng, nn. Tm li trong thi k khi pht c im ni bt ca bnh l st cao t ngt , hi chng mng no v ri lon thc t nh n nng (li b, kch thch, vt v, u m, mt th hon ton) Thi k khi pht ca bnh tng ng vi lc virus vt qua hng ro mch mu no vo t chc no v gy tn thng nn ph n no. 1.3.Thi k ton pht T ngy th 3 -4 n ngy th 6 -7 ca bnh. Thi k ny tng ng vi thi k virus xm nhp nh Bc sang ngy th 3 -4 ca bnh cc triu chng ca thi k khi pht khng gim m li tng dn bnh nhn di vo hn m su dn. Cc triu chng ri lon thn kinh thc vt cng tng l lon nhp th v tng tit trong lng kh qun do vy khi nghe phi c th thy nhiu ran rt thng nhanh v yu . Ni bt trong giai on ton pht l s xut hin cc triu chng tn thng no ni chung v hn cung sng, o gic, kch ng, tng trng lc c kiu ngoi thp lm cho bnh nhn nm thp nng c th thy co git cng hoc git rung cc c mt v c t chi hoc lit, lit c nh hnh, gi nguyn t th. Do ri lon chc nng vng di i lm cho mch nhanh 120 -14

co mch ngoi vi. Cc dy thn kinh s no cng b tn thng, c bit l cc dy vn nhn ( trung khu h hp dn ti th nhanh nng, xut tit nhu kh ph qun v c th thy vim p Soi y mt trong giai on cp tnh thng thy xung huyt gai th, i khi thy c ph n v mu sc v nh sng, th trng b thu hp Tm li thi k ton pht din ra ngn , bnh nh m su vi ri lon cc chc nng sng . Do vy bnh nhn thng t vong trong vng 7 ngy h tin lng tt hn. 1.4.Thi k lui bnh T ngy th 7, 8 tr i, lm sng xut hin nhng bin chng v di chng . Thng thng bc nhit gim t st cao xung st nh v vo khong ngy th 10 tr i nhit tr v bnh vi nhit , mch cng chm dn v bnh thng, nhp th khng ri lon. Hi chng no - m tnh, trng lc c gim dn v khng cn nhng cn co cng. Bnh nhn ht nn v au u, c 150

Trong khi hi chng nhim trng , nhim c v hi chng mng no gim dn th cc tn thng v lit chi hoc lit cc dy thn kinh s no hoc ri lon s phi hp vn ng. Thi k n im ph qun, vim phi hoc vim ph qun - phi do bi nhim hoc phi h hp vin tr, ht uang do thng tiu hoc t sonde dn lu; lot v vim tc tnh mch do nm lu v ri lon h gp l bi hoc lit na ngi, mt ngn ng, ma git, ma vn, ri lon phi hp vn n T cui tun th 2 tr i l thi k ca nhng bin chng v di chng mun. Nhng bin chng bng quang, lot nhim trng, ri lon giao cm, ri lon chuyn ho. Nhng di chng mun c oc thm ch hng chc nm m thng gp l ng kinh v parkinson 1.5. Tin lng Bnh c t l t vong cao (25 - 80 %). T vong thng xy ra trong 7 ngy u khi bnh nhn c g triu chng tn thng hnh no. T vong gai on sau ch yu do cc bin chng c bit hn qua khi c th li nhng di chng sut i m hay gp l ri lon tm thn 2. Mt s th khng in hnh 2.1. Th n Khng c biu hin lm sng 2.2 Th ct Ch c hi chng nhim khun , nhim c 3.Th vim mng no Gp tr ln v thanh nin , din bin ging vim mng no do virus khc IV. CN LM SNG 1.Bch cu mu ngoi vi Nhng ngy u bch cu thng cao 15 000 - 20 000 /ml , trong bch cu a nhn trung tnh au bch cu tr v bnh thng 2.Bin lon nc no ty p lc dch no tu tng, dch trong, protein tng nh (60 - 70 mg %), t bo tng nh (thn l bch cu a nhn, v sau nhanh chng chuyn sang lympho, glucoza trong dch no tu t tha (phn bit vi bin lon nc no ty do cc nguyn nhn khc nh vim mng no m , vim mn 3.Phn lp virus Trong 2 -3 ngy u, bnh phm l mu, dch no tu hoc no t thi mi cht trong vng 2 gi 4.Huyt thanh chn on Phn ng kt hp b th (dng tnh t tun th 2) hoc phn ng ngng kt hng cu v phn u). Phng php min dch men (ELISA) l phng php c p dng rng ri c nhy v V. CHN ON 1.Chn on xc nh Lm sng : Hi chng nhim trng - nhim c ton thn nng + Hi chng thn kinh + Ri lon thn kinh thc vt nng Cn lm sng: xt nghim c hiu, Phn lp virus hoc phn ng huyt thanh Dch t : ni c dch lu hnh 2.Chn on phn bit Vim no th pht sau si , cm , thu u , ho g .. thng khi t li di chng Hi chng no cp : do ri lon chuyn ho dn ti h ng huyt , ri lon nc in g 151 Vim mng no m hoc vim mng no lao VI.IU TR 1.Nguyn tc iu tr Khng c thuc chng virus c hiu

iu tr triu chng l ch yu Nng cao th trng Pht hin kp thi iu tr phng cc bin chng 2. iu tr c th Chng ph no: Truyn dung dch u trng nh dung dch Glucose 10 - 20 -30 % Cc thuc li tiu nh Manitol 20 % 1- 2 g/ kg tc nhanh. Trng hp ph no nng c co git th dng corticoid: Dexamethason 10 mg tim tnh mch , sau mi 5 gi tim 4 mg An thn: Seduxen qua sonde hoc tim bp hoc tim tnh mch . Nu bnh nhn c co git denal H nhit: thuc h nhit qua sonde d dy hoc t hu mn loi paracetamol 0,5g x 2 -3 ln / ngy Hi sc h hp v tim mch : Th oxy , ht m di , h hp vin tr khi ri lon nhp t , iu chnh nc , in gii kp thi Phng bi nhim v dinh dng chng lot: Khng sinh ph rng, v sinh thn th, rng mi g lot, ch dinh dng: bo m m, vitamin qua sonde d dy VII.PH NG BNH Tim chng vaccinee phng bnh Tuyn truyn cc bin php phng bnh cho nhn dn , v sinh mi trng 1.Vaccinee Mc ch chnh ca vaccinee l to c min dch c hiu bo v sc khe Hai loi vaccine bt hot c s dng chng vim no Nht bn, mt loi sn xut t vi us mc trn t bo thn chut Hamster con thun chng. Tim 2 ln cch nhau 7 - 14 ngy, sau mi th 3, c mi 3 -4 nm tim nhc li. Tim chng phng nga l bin php gim st gim s ngi nhy cm nht l nhng ngi i t vng khng c dch n vng c dch nh chu , c hng cho tr t 3 n 15 tui 2. Bin php d phng cng ng Khng ch vector truyn bnh l iu kh thc hin i vi vim no Nht bn B.Bin php p d min dch cho ln con d phng nhim virus mu. nc ta nn dit mui Culex tritaeniarhynchus, chng mui t c nhn (d thc hin, t tn nh ca, ng nm mn, che ph da bng qun o v bi thuc xua mui, c th dng nhng bin p , dit hoc to min dch d phng i vi vt ch t nhin v bo v ngi bng phng php an trn virus i xa Cu hi n tp 1. Trnh by nh ngha, tm quan trng ca bnh vim no Nht bn 2. Trnh by v dch t hc bnh vim no Nht Bn. 3. M t lm sng bnh vim no Nht bn. 4. M t cn lm sng ca bnh vim no Nht Bn. 5. Trnh by nguyn tc iu tr, cch phng bnh bnh vim no Nht bn 152 Bi 24. BNH DI

Mc tiu 1. Chn on c bnh di. 2. Bit cch x tr khi mt ngi b ng vt nghi di cn. Ts, BsCK1 Nguyn L 3. Bit c mt s lai vaccine, cch phng di trc v sau khi nhim virus di.

Ni dung

I. NH NGHA Di l mt bnh nhim virus di h thn kinh trung ng. Bnh nh hng n cc ng vt c i c trng hp truyn bnh qua ng h hp hoc qua ng ghp c quan. Bnh nng thng g II. NGUYN NHN Virus di thuc nhm rhadovirus, ging lyssavirus. Ra ngai c th ng vt, virus rt d ch bi x phng, ether, cc dn xut ammoniac ha tr 4. III. DCH T Di l bnh ca ng vt mu nng, c xng sng, ngi ch l vt ch tnh c. C ba dng d 1.Dch hoang d Truyn ch yu qua nc bt cc ng vt hoang d. Ty theo vng m c mt vt ch thin nhi 2.Dch ng ph Ch yu do ch nh . 3.Dch do di Nam M. IV. NG TRUYN BNH Ch yu truyn qua nc bt ng vt b nhim bnh . Him hoi truyn qua bi cha phn di c virus. ng vt mc bnh c th truyn virus 5-7 ngy trc khi c triu ch? Virus ch yu truyn qua vt cn, co. Him c trng hp truyn qua trung gian vt. Virus lnh. V. LM SNG Biu hin lm sng ca di c th chia thnh 4 giai an: tin triu; giai an vim no; gia cung no, to ra hnh nh lm sng c trng cho di; cht hay rt him, hi phc. 1. Giai an tin triu Giai an ny ko di t 1 n 4 ngy, vi cc du hiu st, nhc u, mt mi, au c, mt hng v ho khan. Triu chng gi n di gi tr nht l d gic v git c ti ch hay qua 153

Nhng cm gic ny c th lin h n s nhn ln ca virus hch sng lng ca dy thn kin g ny ln n 50 - 80 %. 2. Giai an vim no Giai an ny thng c bo hiu bi nhng thi k vn ng qu mc, kch ng v bt an. git , lit khu tr dn dn xut hin. Cc thi k l ln thng xen k vi nhng thi k h trin, thi k minh mn cng lc cng ngn dn v sau cng bnh nhn ri vo hn m. y l a n s nhy qu mc vi cc kch thch nh nh sng chi, ting ng n o, s m v nga Khm thc th c th pht hin bnh nhn st cao, c th n 40,6 . Km theo cc du hiu r bt thng, tng tit nc mt, nc bt, m hi, h huyt p theo t th, Cc triu chng l y (+) l nhng du hiu thng gp. Lit dy thanh m cng l triu chng kh c th. 3. Giai an ri lan chc nng cung no Giai an ny xy ra ch mt thi gian ngn sau giai an vim no. Lit cc dy thn kinh s lit mt, vim thn kinh th v c bit l kh nut.. Kt hp hin tng tng tit nc bt S nc, co tht khng t v gy au d di ca c hanh, , cc c h hp ph, c hu, c t di. Tn thng nhn amydale hnh no biu hin vi cng cng dng vt v xut tinh t nh g tm h hp b nh hng , bnh nhn s t vong v ngng th.. Cc triu chng ni bt ca ri lan chc nng cung no, khi xy ra sm thng cho php phn hi cng bo hiu bnh s xu dn nhanh chng. Thi gian trung bnh t khi xut hin cc du i cht l 4 ngy. Lu nht l 20 ngy. 4. Giai on cht hay hi phc Hu ht bnh nhn t vong. Mt vi trng hp c hi sc thnh cng v that cht. Tuy nhi may mn phi tri qua nhiu bin chng nh: hi chng tng tit ADH khng thch hp, i nht hi chng ARDS, chy mu tiu ha, gim tiu cu, v lit rut. Hi phc rt him, v xy ra 5. Cc th khc ca di 5.1. Lit tun tin dng Landry- Guilliam Barr Th lit thng hay gp nhng bnh nhn mc di t di (Nam M), sau c tim vaccine. Th 5.2. Di do ghp gic mc. Trong ngi cho c triu chng ca th lit dng Guilliam Barr. Sau khi t vong, no ng

egri. V ngi ta phn lp c virus di mt ngi cho c gi ng lnh. IV. CN LM SNG Giai an u ca bnh, cc xt nghim mu v sinh ha khng c g bt thng. Tuy nhin, v xut hin. Bch cu hi tng (12.000 17.000/mm3), nhng cng c trng hp bch cu bnh thng hay rt tng (c trng hp n 3 154

Cng nh cc virus khc, chn an dc hiu bnh di da vo : - Phn lp c virus trong dch tit ca c th.(nc bt, dch no ty) hay trong m mc b - Huyt thanh chn an giai an cp. - Pht hin khng nguyn ca virus trong cc m b nhim. - Pht hin acide ca virus (ARN) bng phng php PCR. Cc mu no do sinh thit hay ly sau khi bnh nhn cht, thng c dng : - Tim vo chut phn lp vi rut. - Dng phng php khng th hynh quang pht hin khng nguyn ca virus. - Xt nghim t bo hc v m hc vi knh hin vi thng thng v knh hin vi in t ( t - Pht hin ARN ca virus vi k thut PCR. K thut tim vo chut v phng php khng th hynh quang nhy v ng tin cy. Tuy nhin v xut hin khng th chng virus, qu trnh t v trng ha c th xy ra v hai k thut Cn xc nh s hin din virus hoc trc tip bng huyt thanh hc hoc bng cch xc nh k bnh nhn ang cn sng . Bnh phm ly t sinh thit da, gic mc hay nc bt. Nu bnh nhn khng c tim phng di, hiu gi khng th trung ha tng gp 4 ln cho php th chn an da vo s hin din ca khng th trung ha dch no ty. Tim phng sau khi th trung ha trong dch no ty, nu c cng ch mc hiu gi thp (< 1/64). Hiu gi khn g chng dch no ty thng rt cao, t 1/200 n 1/160.000. V. CHN AN GIN BIT Rt kh phn bit gia di v nhng vim no khc. Chng c duy nht ngh n di l c ti Ngai ra ta cn phi phn bit vi cc bnh cnh khc nh : - Hysterie phn ng sau khi b ng vt cn. -Hi chng Landry/Guilliam - Barr. - Bi lit. - Vim no d ng sau khi tim huyt thanh phng di. Bin chng ny xy ra khi dng vacccine c di, thng xy ra 1 n 4 tun sau khi tim vaccine. VI. IU TR Trc mt bnh nhn n khm nghi ng di, ta phi xc nh nhng yu t sau : - Bnh nhn c tip xc trc tip vi nc bt hay cc cht khc c kh nng hin din virus - Bnh nhn c trong vng dch lu hnh ca di khng ? - Tnh trng khi bnh nhn b ng vt tn cng : ng vt c b khiu khch hay khng khi c Trong trng hp b ng vt cn, tt nht l gi ng vt li theo di. Nu ng vt b 155

Nu khng bt c ng vt, tt c cc con vt khng bit tung tch, khng c chng nga di hay i hnh vi t ngt, hoc c kh nng tip xc vi ng vt khc b di u phi xem nh Trng hp gia sc cn v c th theo di c, nn theo di trong 10 ngy. Nu con vt cht virus di bng phng php khng th hynh quang. Nu ng vt vn sng v khe mnh, km th vng v di, c th xem nh bnh nhn khng b nhim virus di trng thi gian b cn. Tuy n hnh cao, nn git con vt xt nghim no tm virus. VII. PH NG BNH 1. Phng bnh sau khi tip xc vi virus di. Gm c : sn sc vt thng ti ch , tim vaccine phng di v nu c iu kin, dng khng 1.1. Sn sc vt thng ti ch Rt quan trng trong phng chng di. Ra vt thng vi x phng. Ch xt mnh. Sau ra l ay bng ha hc u quan trng nh nhau. Cc hp cht ammonium ha tr 4 nh benzalkonium chl 4 % hay Bromide cetrimonium 1% u c th bt hat virus di. Tuy nhin, Benzakonium 0,1% kh qu bng dung dch x phng 20 %. Ngai ra, ngi ta dng thm khng sinh v gii c t un 1.2. Min dch th ng vi huyt thanh chng di Huyt thanh chng dI c th t nga hay t ngi. Globulin min dch c ngun gc ngi tt thanh.Liu dng: 20UI/kg vi huyt thanh ngi (40UI/kg vi huyt thanh nga), chia lm hai tim trc tip vo quanh vt thng. Phn cn li tim mng. 1.3. Min dch ch ng vi vaccine chng di

 cc nc pht trin, ngi ta thng dng vaccine sn xut t t bo lng bi ca ngi. V s di Pitman - Moure, bt hat vi propiolactone. Hoc vaccine ca i hc Michigan, dng ch di Kissling cy trn t bo lng bi ca kh Rhesus, bt hat vi nhm. C hai lai u c h ca c hai lai vaccine ny rt him. Ch 1/650 ngi c mn nga. St, nhc u thng nh ng ti ch tim nh sng, da, cng vng tim chim 15 -20 % bnh nhn. cc nc ang pht trin, cc lai vaccine sn xut t t bo phi g, chut hamster, t b Cc vaccine ny c v an tan, c tnh khng nguyn v c hiu qu phng bnh. Cch dng : vi vaccine phng di lai t bo lng bi, ngi ta tim 5 ln, mi ln 1ml. Liu u tin tim cng sm cng tt sau khi b nhim virus. V tr tim tt nht l c t vo cc ngy th 3, 7, 14 v 28. T chc y t th gii cng a ra cc liu trnh 21 v 90 S phi hp gia vc xanh v khng huyt thanh chng di, s to nn khng th trung ha viru v c hiu qu rt cao trong phng chng di. Tht bi trong phi hp rt him gp. Tuy nhin e, t l tht bi cao hn, nht l khi vt cn su v nguy him. V l do kinh t, cc nc ang pht trin, ngi ta thng dng vaccine theo ng tim tr Phi hp khng huyt thanh chng di vi liu trnh tim vaccine trong da c chng minh l 156

Liu trnh vaccine trong da gm : Ngy u tin tim vaccine trong da 8 v tr. Ngy th b v 91 mt v tr. T chc Y t th gii a ra mt liu trnh khc : Tim trong da hai v tr vo cc ngy u gy 21 v 90. 2. Phng bnh trc khi tip xc vi virus di Nhng ngi c nguy c cao tip xc vi virus di nh th y, nhng ngi thm him hang ng, di, nhng ngi lm cc ngh c tip xc thng xuyn vi ng vt, cn phi tim phng vac bi ngi l tt nht. Tim ba ln, tim bp (1ml) hay tim trong da (0,1 ml) vo cc ngy 0,7,21 v cn thn c th vo ngy th 28. Nhng cc vaccine iu ch bng cch hp ph th khng tim trong da c. Cn kim tra hiu gi khng th trung ha sau khi tim vaccine. Khng nn dng Choloroquin ng thi vi vaccine v n ngn cn s p ng to khng th ca Ty theo mc nguy c, cn kim tra huyt thanh nh k , khang cch t 2 n 6 nm. Khi h 5, cn tim nhc li. Liu nhc li ch 1 ln 1ml tim bp hay 0,1 ml trong da. Vi nhng ngi c tim phng khi c nguy c nhim virus di, ch dn tim li hai mi v th ba. Khng huyt thanh khng dng trong trng hp ny. Tim nhc li vaccine thng c tc dng ph, gy st, nhc u, au c, au khp chng 20 % ne nhc li c phn ng nh l phn ng ca phc th min dch gm : ni my ay, vim khp, dema). Cc phn ng ny thng t gii hn v c lin quan n s hin din ca albumin ngi ia tng khng th IgE vi khng nguyn ny. Nhng ngi cng tc c nguy c cao phi c kim tra hiu g khng th nh k, v tim nhc li bt c lc no hiu gi khng th thp. Nhng ngi t c nguy c cao th khng cn phi kim tra thng xuyn, nhng phi tim nhc vi virus di. 3. Phng bnh chung cho cng ng Phng bnh di cho cng ng nc ta ch yu l phng di cho ch. tim phng di nh k cho ch nh, hng nm. Vn ng ch nui ch dn ch i tim nh k v Vn ng, tuyn truyn ch nui ch c bin php hu hiu khng cho ch cn ngi khc ( xch c dy dn. Khi ch b? bnh, nht l khi c biu hin hung d, thay i thi , hnh vi, t cn tham kho kin ca th y v nu cn phi git. Nhng ngi c nguy c d b di nh bc s th y cn c tim phng trc. Cu hi n tp 1. Trnh by cc yu t c th nh hng n thi gian bnh ca bnh di. 2. Cc ng ly truyn ca bnh di. 3. X l tc thi mt trng hp b ng vt nghi di cn. 4 . Phng bnh di trc khi phi nhim cho cc i tng no? 5. Cc nguyn tc phng bnh di cho cng ng. 157 Bi 25.

Mc tiu BNH THU U

Ts, Bs Trn xun Chng 1. Trnh by c tnh cht ph bin v cc yu t dch t ca bnh thy u. 2. M t c triu chng lm sng v cc bin chng ca bnh thy u. 3. Trnh by c cc phng php iu tr bnh thy u . 4. Trnh by c cc bin php d phng bnh thy u trong cng ng.

I. NH NGHA Ni dung Bnh Thu u l bnh truyn nhim rt hay ly, do mt loi virus gy ra. Bnh c trng bng . Bnh c bi Richard Morton bc s ngi Anh thng bo ln u nm 1694 v c gi l Chi II. TC NHN GY BNH Tc nhn gy bnh l Herpes varicellae hay Varicella-Zostervirus (VZV), thuc h Herpesvirus, c phn lp nm 1952. S d virus c tn nh trn v khi ngi ta phn lp vir Zona (Zoster) th thy chng hon ton ging nhau. Theo gi thuyt ca Hope-Smpon a ra n g min dch tin pht ca k ch i vi virus, cn bnh Zona l do s ti hot ng ca viru atent form) cc hch ca thn kinh cm gic. III. DCH T HC Bnh Thu u ch ngi. Mi la tui u c th mc, nhng 90% bnh nhn l tr em 1-14 tui. Tr em < 1tui v ngi ln > 19 tui ch < 3% s bnh nhn. Tuy nhin cc nc nhit i tn sut bnh ngi ln thng cao hn. Bnh xy ra khp ni trn th gii, c bit nhng ni dn c ng c nh nh tr, trng trng hp mc bnh Thu u . Bnh thng xy ra vo cui ng, u xun, cao im l vo c ng ly ch yu l ng h hp qua nhng bt nc bn ra t ngi bnh, mt s t ly do t khi c pht ban v ko di cho n khi cc nt u ng my (7-8 ngy). C th b nhim VZV m khng c biu hin lm sng. Thu u gy min dch vnh vin sau khi nhn b bnh ln hai. IV. C CH BNH SINH Sau khi xm nhp vo c th theo ng h hp, virus tng sinh ti y ri n h vng ni m ri i vo mu n gy tn thng da v c quan ni tng. Ti da v nim mc, cc hnh to, cha nhiu dch tit, ng thi xut hin nhiu t bo a nhn khng l cha nhiu hiu bch cu a nhn, t bo thoi ho, fibrin v rt nhiu virus. Virus cng c th ly qua tip xc trc tip vi ngi b Thu u hoc Zona. V. TRIU CHNG LM SNG V CN LM SNG 1. Lm sng - Thi k bnh: thay i t 10-21 ngy, trung bnh 15 ngy. - Thi k khi pht: Bnh nhn c th st nh, mt mi, nhc u, i khi c au bng nh. C th xut hin nhng nt hng ban, kch thc vi mm ni trn nn da bnh 158 thng. Thi k ny di khong 24 gi. thiu nin v ngi ln triu chng thng nng hn. Bnh nhn b suy gim min dch thng st cao hn v thi gian khi pht di hn.

- Thi k ton pht: Trn da mt, u, nim mc, c, lng ni nhng nt u hnh trn hoc h -10 mm, lc u cha mt cht dch trong, sau khong 24 gi th ho c. Chng mc nhiu t hng nhiu la tui khc nhau : dng pht ban, dng nt u trong, nt u c, dng ng m ngy u tin; chi di l ni cui cng c cc nt u. Nt u c th mc nim mc ming, ng h hp, tiu ho, tit niu, m o, gy ra cc tr Bnh nhn thng b nga nh, c th st nh hoc khng st. S lng nt u cng nhiu bnh Nhng ngi suy gim min dch hoc dng thuc c ch min dch ko di c bnh cnh nng n au c. Nt u thng mc nhiu, ko di, dng xut huyt. Cc bin chng thng gp l nhim trng da do vi khun Gram (-), vim phi, vim hch, tn t n, thn kinh trung ng... - Thi k hi phc: Sau mt tun, nt u ng my, kh v rng i, khng so. 2. Cn lm sng - Cng thc mu : bch cu bnh thng hoc tng nh. - Huyt thanh chn on : C th pht hin khng th khng virus Thu u bng cc phng php sau : + Test Kt hp b th + Phng php Min dch hunh quang trc tip + Test ELISA v test FAMA (Fluorescent antibody to membrane antigen ) - Phn lp virus t dch nt u. VI. BIN CHNG 1. Bi nhim Thng gp nhim trng da do Lin cu v T cu vng. Bin chng xy ra do nt u b v hoc u u (varicella gangrenosa ) do Lin cu nhm A gy ra l mt bin chng rt nng . 2. Vim phi Chim t l 20-30% ngi ln v ngi b suy gim min dch, him gp tr em. Bnh nhn s quang c hnh nh tm nhun dng nt v vim phi m k. 3. Hi chng Reye Gp tr ung Aspirin trong giai on u mc. giai on hi phc hi chng Reye xut hin gic, kch thch hoc hn m, co git do ph no. Bnh nhn c th c xut huyt ni tng, x yt v Transaminase mu. 4. Vim no Triu chng thng gp l tht iu, rung git nhn cu, ma vn, nhc u, c th c co git gy v ko di vi tun, c khi n mt thng. Dch no tu c Protein v bch cu tng, a s 5-25%. Cc bin chng thn kinh khc c th gp l vim mng no, p-xe no hoc tu sng. 5. D tt bm sinh Tr em c m b Thu u trong 3 thng cui ca thai k, sau khi sinh ra c th b d tt bm thng mt, co git, chm pht trin tr tu... VI. CHN ON 1. Chn on xc nh 159

Da vo cc c im lm sng v kt qu CLS nh nu phn trn. 2. Chn on phn bit Bnh Thu u cn chn on phn bit vi cc bnh sau : 2.1 Zona: Cng do VZV gy ra. Thng gp ngi ln tui v nhng ngi c tnh trng suy gim min dch: nhim HIV, bnh Hodgkin, Lymphoma, ang iu tr bng cc thuc c ch MD... Lm sng: a dng: zona ngc, zona mt, sau tai, u... - ngc: thng gp nht. Cc nt phng thng ch xut hin mt bn, dc theo cc dy TK li Sau chng tr nn trn v to hn, nm thnh tng nhm. Dch c sau 5 ngy v ln sau 10 n Zona ngc gy au n cho bnh nhn. Vng da ti ch thng gim cm gic. Tin trin: 2-3 tu - mt: Thng gp ngi gi. Tn thng mt trong ba nhnh ca dy TK th gic. C th vi Bin chng thng gp: au ko di sau zona. 2.2 Nt u do HSV (Herpes Simplex Virus): Nhim trng do HSV thng gp trn nhng vng da c , vim da d ng. Bnh nhn thng khng st, s lng v kch thc nt u nh hn. Chn o 2.3 Chc l (Impertigo): Do Lin cu tan mu bta nhm A gy nn. Bnh thng xy ra tr em b tn thng do gh, chm...ri b nhim trng dn n vic to ra nt u. VII. IU TR Bnh Thu u tr bnh thng ni chung lnh tnh v t gii hn, khng cn iu tr c hiu. V sinh thn th tt c th hn ch bi nhim. Tr nh cn c ct mng tay v

1. iu tr triu chng - Gim nga bng cc loi Antihistamin ( Promethazine, Chlorpheniramine...) - Gim au, h st bng Paracetamol. Khng dng Aspirin tr em. 2. iu tr nguyn nhn Dng cc thuc chng virus nh Vidarabine , Acyclovir, Interferon alpha... - Vidarabine (Adenine arabinoside) : Liu dng : 15mg/kg/ngy, tim TM. C c tnh thn kinh v khng hi phc nn t c dng. - Acyclovir (Acyclo-guanosine): hiu qu chng VZV nhng bnh nhn c c a min dch bnh vng 24 gi sau khi khi pht. Acyclovir gip gim st, gim cc triu chng ton thn, gim an xut hin cc nt u mi. Khng nn iu tr cho tr di 6 tui b Thu u cha c bin Liu dng : 7,5-10 mg/kg/ ngy, tim TM mi 8 gi. Thi gian iu tr : 5-7 ngy. - Interferon alpha : c s dng trong iu tr Thu u nhng hiu qu cha c nghin cu y . 3. iu tr bin chng Dng khng sinh trong cc trng hp bi nhim. Bnh nhn c hoi t Thu u phi c iu g/kg/ngy, tim TM mi 4 gi kt hp vi ct lc. VIII. PH NG BNH - Cch ly bnh nhn cho n khi cc nt u ng my. Bnh Thu u rt kh phng nga v bnh c th ly 24-48 gi trc khi c nt u. - Chng nga : 160

+ To min dch th ng: Globuline min dch (VZIG) c th c s dng cho nhng ngi tip hoc c cc yu t nguy c nh tr b suy gim min dch mc phi, ph n c thai, bnh c t .. Liu dng : 125 n v / 10kg, tim bp. Liu ti a 625 v. Thuc ch hiu qu khi dng trong 96 gi sau khi tip xc v c th lp li sau 4 tun. + To min dch ch ng : Ch dng cho nhng ngi b suy gim min dch. Vaccine lm bng v min dch khong 85-95%; thi gian c min dch ko di 10 nm. Bin chng him gp l Thu Cu hi n tp 1. ng ly v thi gian ly bnh ca thy u ? 2. Nu c im ca cc nt u trong bnh thy u ? 3. Nu cc bin chng thng gp trong bnh thy u ? 4. Nguyn tc iu tr bnh thy u ? 5. Nu cc bin php d phng bnh thy u ? 161 Bi 26.

Mc tiu BNH QUAI B

BsCK2,Ths H th Thu Vng 1. Trnh by c tnh cht ph bin v cc yu t dch t ca bnh quai b. 2. M t c cc hnh thi lm sng khc nhau ca bnh quai b. 3.Trnh by c cc phng php iu tr cc biu hin ca bnh quai b. 4. Trnh by c cc bin php d phng bnh quai b trong cng ng.

Ni dung Quai b l mt bnh nhim virus ton thn cp tnh c trng bi sng tuyn mang tai v cc amyxovirus gy nn. Bnh thng gp tr em v thanh thiu nin; bnh ch mc mt ln. Ngoi biu hin vim tuy vim tu, vim mng no... I.TC NHN GY BNH Nguyn nhn gy bnh quai b l vius thuc h Paramyxovirus c hnh cu, khng u,ng kn lp li hnh xon c kn cha chui RNA c bc trong mt lp v lipid v protein. Virus qua hng nguyn S xut pht t mng nhn v khng nguyn V t hemaggglutinin b mt. Khng nguyn cu. Hin nay ngi ta ch bit 1 typ huyt thanh Virus quai b rt nhy cm vi mi trng bn ng vng, tn ti 40C trong vi ngy, - 650C t vi thng n nhiu nm II. DCH T HC Bnh thng xy ra cui ma Xun, c bit vo thng 4 v 5. Ly t ngi ny sang ngi khc bt. Bnh thng d ly lan nhng ni tp trung nhiu ngi nh vn tr, trng hc, doanh Thi gian ly truyn: Nguy c ly truyn cao nht t 6 ngy trc khi khi pht v ko di ang tai. Ly cao nht khong 2-4 ngy sau khi bnh khi pht. Ngi ta phn lp c virus tr ngy sau khi khi pht, d cho thi k ly nhim c khi ngn hn. i tng: nam nhiu hn n. Bnh him tr < 2 tui do chng cn c bo v bi cc khng hiu nin), t gp ngi cao tui. Bnh gy min dch bn vng, d c hay khng c triu ch Vit Nam t l mc bnh quai b cn kh cao, tuy nhin c chiu hng gin dn, nm 2002, ti bnh vin bnh nhit i c 121 trng hp quai bi nhp vin v khng ghi nhn t vong III.SINH BNH HC Virus quai b xm nhp vo c th qua ng h hp. Trong sut thi k bnh (khong 12-25 ngy) virus pht trin, nhn ln trong biu m ng h hp trn v cc t chc , virus theo ng mu n cc c quan khc nh mng no, tuyn sinh dc, ty, tuyn c, gan, ng ng, ring tuyn nc bt c l th pht sau nhim virus mu. giai on ton pht, viru 162

cc c quan tuyn v c quan thn kinh. Virus c thi ch yu qua nc bt, nhng cng ca bnh. IV.GII PHU BNH Nhng thay i bnh l c ghi nhn ti tuyn mang tai trong sut thi k quai b cp gm ph v xut tit cc si tng dch. ng tuyn cha y t bo hoi t v neutrophiles. Nhng tn thng tng t cng c tm thy cc c quan khc nh ty v tinh hon. Trong b thy c nhng vng nhi mu v phn ng vim nng n, hu ht nhng vng ny c hin tng t Khi no b thm nhim, th vim no mng no tin pht vi tiu hy t bo thn kinh hoc th ra. V. LM SNG C khong 1/3 trng hp nhim virus quai b khng c triu chng. - Thi k bnh: trung bnh 18-21 ngy (thay i t 12-25 ngy) - Thi k khi pht: trung bnh 24 - 36 gi. Ton thn: mt mi, chn n, au nhc mnh my, di vi ngy trc khi sng tuyn mang tai - Ton pht: Bt u sng tuyn mang tai, st gim (chng 380C), au u, c th c cc biu 1. Biu hin cc c quan tuyn 1.1 Vim tuyn nc bt mang tai v cc tuyn nc bt khc L biu hin lm sng thng gp nht ( khong 70 % trng hp ).Thng t ngt sau thi k au 1 - 3 ngy ( c ti liu : 2 - 6 ngy ) v gim dn sau 7 - 10 ngy. u tin ch c sng bn kia. Sng c 2 tuyn chim 2/3 trng hp, mt i khi km sng tuyn nc bt di hm Tuyn mang tai sng t tai n di hm v lan ra tn g m, mt rnh trc v sau tai. Vng g vim tuyn mang tai nhim trng, c tnh n hi v khng li u n ngn tay. Bnh nhn c cm gic au tai, nht l khi n hoc ung cc thc n c v chua do nghn ng W thy ming cc l ng tuyn nc bt c th tr nn , ph n v c nhng im xut huyt n Sau 1 tun tuyn mang tai gim au v nh dn, cc triu chng au hng, kh nut gim v t 1.2 Vim tinh han-mo tinh han Xy ra 20-30% nam gii sau tui dy th b quai b , him gp tr nh. Trong s ny ch /3 trng hp xy ra trong tun l u.

Tan thn: St cao 39-410C, n lnh, nn ma, au vng bu, au lan ln bng v i. Thm kh sng to gp 3-4 ln bnh thng. Cc triu chng ny bin mt sau 1-2 tun . Gn 85% trng h inh han. C 0,5% trng hp teo tinh han v thng l 1 bn, nu teo xy ra 2 bn c th nh dch. 1.3 Vim ty Gp ngi ln v tr em. Xy ra ngy th 3-7 sau sng tuyn mang tai. Bnh nhn st 39-400C hng nh. Phn ln trng hp thng hi phc hon ton sau mt tun. Him gp bin chng sc 163

1.4 Vim tuyn v v vim bung trng Xy ra n sau tui dy th: Vim tuyn v (7-30%) Vim bung trng (5%): Triu chng gm: st, nn ma , au bng au h chu. Khm vng h ch v sinh t gp. 2. Biu hin cc c quan thn kinh 2.1. Vim mng no Gp 5 - 10 % trng hp quai b, xy ra 3-10 ngy sau sng tuyn mang tai (c khi 2-3 tun sau). Lm sng thng c mt hi chng mng no c st. Cc triu chng ny gim dn , khng li di chng. Dch no ty c nhng bin i bt thng c th ko di khang 1 thng: Protein bnh thng 500/mm3, a s l Lympho, c khang 20-25% trng hp c Neutrophile tng. 2.2. Vim no Vim no quai b t xy ra hn, tn sut 0,5%, nam > n, xy ra 7-10 ngy sau sng tuyn mang cng lc. Lm sng : hi chng nhim trng, hi chng mng no v cc du hiu tn thng no oc co git. Bnh tin trin c khi rt nng v li di chng vn ng v/hoc tm thn, n 1,5% trng hp). 3. Cc biu hin khc - Vim c tim v mng ngoi tim, - Vim khp, Ri lan chc nng thn. - Vim tuyn gip bn cp, tn thng tuyn c - Biu hin mt: Vim tuyn l, thn kinh th gic, mng b o, kt mc, vng mc, tc tn - Tn thng gan: t triu chng lm sng, thng ch ri lon chc nng gan - H hp: Vim thanh kh ph qun, vim phi k, thng gp tr di 5 tui 4. Quai b ph n c thai Trong 3 thng u ca thai k c th gy sy thai, d dng bo thai. Cn trong 3 thng cui c g gy qui thai ca virus quai b cn cha r. VI. CHN AN V CHN ON GIN BIT 1. Chn on - tuyn y t c s : Ch yu da vo lm sng v dch t : Bnh nhn c cc triu chng nhi hon...Trong gia nh hoc lp hc c ngi b quai b trc vi ngy hoc ang b... - tuyn tnh, trung ng: Chn on da vo lm sng, dch t, kt qu xt nghim: + CTM: Trong quai b ch c BC gim nh km tng cc t bo lympho. Trng hp c vim tinh hon hoc tn thng cc c quan khc bch cu c th tng v + Amylase mu v niu : Tng trong vim ty v vim cc tuyn nc bt + Phn lp virus: Virus c th phn lp c t mu, cht tit c hng, nc bt, t ng St + Test ELISA, Min dch phng x, Test c nh b th cho php xc nh hm lng cc khng t . 2. Chn on gin bit - Trng hp c sng tuyn mang tai ta cn gin bit vi vim tuyn mang tai do 164

nhim cc virus khc (coxaskievirus, virus cm v ph cm) hoc vi khun (c m chy ra l do t cu hoc lin cu ) hoc vim hch bch huyt gc hm do bch hu. - Phn bit vim tinh han do quai b v mt s vim tinh han do nhim khun hay gp l: lu a, thy u , Brucellose...hoc xon tinh hon. VII. IU TR Cha c iu tr c hiu, tc dng ln virus quai b. Ch yu l iu tr cc triu chng xu 1.Trng hp ch c sng tuyn nc bt n thun - V sinh rng ming, trnh thc n qu chua, n lng nh,giu nng lng. - Ngh ngi ti ging khi cn st, c th dng cc thuc Paracetamol hoc Aspirin khng vim, gim au v h st. Trnh dng cc thuc khng vim nonsteroid tr em.

- C th dng thm vitamine C 1-2 g/ngy/ung. 2.Trng hp c vim tinh han - Ngh ngi tuyt i ti ging, chm lnh, mc qun lt b st.. - Dng thuc gim au v chng vim nh Aspirin v thuc khng vim non-steroid. - Vn dng corticoid ch t ra khi c vim no hoc mng no quai b hoc c vim tinh han trm trng , vim ty . 3.Trong cc trng hp vim ty Cho bnh nhn ngh ngi, truyn dch, nhn n, dng cc thuc gim au, chng nn. 4. Vim no - mng no Bnh nhn phi c iu tr phng cp cu. VIII. D PH NG 1.D phng tp th Tuyn truyn cho cng ng bit cc du hiu nghi ng quai b v cch phng bnh. Ngi mc q khi lm sng c triu chng sng tuyn mang tai, nht l khi bnh nhn trong cc tp th n .v.v. 2.To min dch ch ng Vc xin quai b c hiu qu bo v > 95% trng hp c tip xc vi ngun bnh. Vc xin c h dng n c hoc kt hp vi si v Rubella (MMR: Mump, Measle, Rubella). i tng chng r em, thanh thiu nin v ngi ln u c th chng nga quai b. 3.Min dch th ng Dng globuline min dch chng quai b. Ch hiu qu trong 4 ngy u sau nhim virus. Liu d kg cn nng, tim bp cho i tng cha c min dch hoc ph n c thai.tip xc ngi bnh Cu hi n tp 1. Trnh by cc yu t dch t ca quai b 2. c im vim tuyn nc bt ca quai b 3. Trnh by mt s biu hin thng gp ngoi vim tuyn nc bt ca quai b 4. iu tr mt trng hp quai b c vim tinh hon 5. Trnh by cc bin php phng bnh c hiu ca quai b 165 Chng 4. CC BNH DO NHIM K SINH TRNG Bi 27. BNH ST R T THNG

Mc tiu Ths, BsCK1 ng th Nga 1. M t cc chu trnh ca tc nhn gy bnh v c ch bnh sinh ca bnh st rt 2. Chn on sm bnh st rt trong cng ng v phn bit vi mt s bnh khc 3. Phn bit tc dng ca cc thuc iu tr st rt thng thng 4. Hng dn thc hin cng tc phng chng st rt trong cng ng . Ni dung

St rt l mt bnh ly thng gp v l mt vn lu tm cho cc nc sng gia khong 60 h do k sinh trng Plasmodium gy nn v c truyn t ngi ny sang ngi khc qua vt t khong 2 t 700 triu ngi sng trong vng dch t st rt v khong 400 triu ngi st rt ngi cht I. TC NHN GY BNH, VECT TRUYN BNH 1 Tc nhn gy bnh 1.1 Loi Plasmodium

C chng 140 loi Plasmodium, nhng ch 4 loi gy bnh cho ngi l P.falciparum, P.vivax, P v P. ovale. Plasmodium falciparum l nguyn nhn gy st rt nng v t vong. nc ta P. falciparum 70 - 80% P. malariae 1% P. vivax 20 - 29% P. ovale (nc ta khng c, chu Phi). 1.2.Chu trnh pht trin Plasmodium pht trin 2 giai on: giai on hu tnh mui, giai on v tnh ngi. - Giai on hu tnh Mui Anopheles ci t ngi mang k sinh trng st rt ht mu, vo trong d dy mui mu ao t ci (gametocytes), khi hng cu b hy s phng thch ra dng cc phi t (gametes), c thnh hp t (zygotes); hp t pht trin thnh non ng (ockinites) ri nang (ocytes), d dy ln ln ri thnh cc t bo hnh kim c gi l thoa trng (sporozoites), chng khi mui t chng s vo c th ngi. Giai on ny ngn hay di ty vo nhit mi trng, mui v loi k sinh trng, trung bnh khong 7-21 ngy. - Giai on v tnh: c 2 chu k. * Chu k ngoi hng cu: 30 pht sau khi vo c th, cc thoa trng xm nhp vo t bo gan, trophozoites), ri th phn lit (schizontes), chng ph v t bo gan v thnh cc tit trn cc (merozoites) vo mu xm nhp hng cu. Chu k ny di 5-7 ngy vi P. falciparum, 10 vax . + i vi cc tiu th hoa ca P. falciparum sau khi vo mu khng tn ti trong gan na, cho pht xa. 166

+ i vi cc tiu th hoa cc ca P. vivax mt s vo mu mt s cn tn ti trong t bo ga chu k hng cu, gy cc t ti pht xa. * Chu k hng cu: Cc tiu th hoa cc vo mu s xm nhp hng cu, ri pht trin thnh t h hoa cc. Cc tiu th hoa cc ph v hng cu (gy st) ri vo mu v xm nhp hng cu k nhiu hn trong mu nu khng iu tr. Chu k ny thay i 24 - 48 gi cho P. falciparum (c ; 36-48 gi cho P. vivax (cn st cch nht lnh tnh) 2.Vect truyn bnh: Mui Anopheles ci l vect truyn bnh v l vt ch tm thi. Trn th gii, c chng 60/40 Nc ta c 4/50 loi truyn bnh: - A. minimus: vng nc chy ni rng su trong c nc. - A. dirus (balabacensis): vng rng t ranh gii Ngh An, Thanh Ha vo min Nam - A. sundaicus: Vng bin nc l Nam b. - A. subpictus: Di Linh, Lm ng Nhn chung, nhng loi mui ny sng vng ni, va trong nh, va ngoi tri. Sinh sn thuc dit mui thng dng nh malathion, DDT. Anopheles ci t v ht mu ngi, ri u mt ni tiu ha v ch trng chn, bay tm ch na m v sng 22gi - 4gi). Mi ln mui chng 100 - 200 trng, trng pht trin thnh b gy - lng qu ri mui trng thnh. nhit ti u 20 -300C, mui Anopheles sng chng 4 tun l, thi gian ny cho Plasmod k hu tnh mui (khong 10 -16 ngy). iu ny gip cho Anopheles tr thnh trung gian tr thi. II. DCH T HC 1. ng ly truyn Bnh st rt ly truyn qua nhiu ng - Mui t l ch yu - Truyn mu b nhim k sinh trng. - Dng chung kim chch c dnh mu mang KSTSR khng tit trng (rt him, ngi s dng m - Qua nhau thai m c KSTSR (+) c m t mt s nc. 2. Cc yu t nguy c 2.1.Mi trng t nhin & sinh hc - Nhit mi trng: ti u 20 - 300C - m mi trng: > 50% - Ma: trc, trong, sau ma ma (nc ta t thng 4 - 10 hng nm) - V tr a l: ni i, cao nguyn, rng rm hoc ven bin nc l, ph hp vi iu kin s - S nhy cm ca vect i vi ha cht ang s dng 2.2.Yu t kinh t - x hi

- Tui v gii: mi la tui v mi gii u c kh nng mc bnh - Phong tc tp qun: thi quen ng khng c mn, ng ry ca ng bo dn tc, di chuyn a - Mc sng: ngho nn, lc hu, thiu n, dinh dng km, n tm b. - Ngh nghip: ngh nghip d tip xc vect nh lao ng vng rng ni, khch du lch. - Nhng hot ng c kh nng tng st rt: o h ao, pht trin thy li, thy in, khai h 167

- Cc yu t lm d cho bnh nng: ph n c thai, tr em, ngi cao tui, nghin ma ty, suy III. MIN DCH ST R T Trong 30 nm qua, do tm kim vc xin hiu lc m min dch st rt c nghin cu su hn. 1. Min dch t nhin - Ngi khng mc bnh do cc loi Plasmodium chim, b st v gm nhm. - Ngi c HbF, HbS v HbC (homozygous C) c min dch t nhin vi P. falciparum. - Ngi Phi chu v M da en thiu khng nguyn hng cu nhm Duffy - l yu t khng t nhi im P. vivax. 2.Min dch th c - p ng min dch thu c khi mc st rt c 2 tnh cht chnh l tnh ghi nh v tnh c dch ghi li cc thng tin. Khi tip xc ln 2, h min dch p ng l nh thng tin ghi nh con di 6 thng tui c min dch th ng qua nhau thai t m, trong thi gian ny nu tr chng lm sng do c th c khng th v tr t to c khng th, sau 6 thng tr ht khng - S nhim KST lin tc s to cho c th mt p ng min dch i vi st rt m ngi ta Trong ln s nhim vai tr min dch ch yu l hin tng thc bo. Trong ln ti nhim, mi hn nh cc lympho T c mn cm vi khng nguyn t trc. Ngoi ra cn c s ng gp t hng th, nht l IgG, IgM v IgA. Tuy nhin IgG tng cao hn IgA v tn ti lu hn. Trong IgG cao s chng li cc tiu th hoa cc xm nhp hng cu, do KST d dng b cc i - c tnh trng min dch ny, h lin vng ni m c th phi hot ng ht sc tch cc, ai tr c bit trong bnh st rt, lch l ni tp trung v dit cc hng cu b nhim KSTSR B cng cc cht gy c t bo khc. - Nh c hin tng tin min dch, lng KSTSR s duy tr mc thp trong mt thi gian di in dch c hiu cho tng loi Plasmodium. - Qu trnh hnh thnh min dch ny i hi mt thi gian kh di phi vi nm v i hi ph thch min dch th tnh min dch s gim dn v xut hin triu chng lm sng (gp ngi gim ngi mang bnh c tnh, ct lch, suy gan hoc mang thai...Nh vy, min dch th c bn. IV. T NH H NH K SINH TRNG KHNG THUC 1. Xc nh nhy v khng thuc - Nhy cm: Sau 48 gi iu tr, mt k sinh trng gim 75% so vi ngy u, ri sch hn ng 28 ngy sau iu tr. - Khng: I (RI): sch k sinh trng nh trng hp nhy cm, nhng xut hin li trong 28 ngy. II (RII): mt k sinh trng gim 75% sau 48 gi, nhng khng ht hn trong tun u. III (RIII): mt k sinh trng khng gim m tng trong 48 gi u, hoc gim < 75% 168

2. K sinh trng khng thuc trn th gii Hu ht cc vng st rt lu hnh trn th gii c k sinh trng khng thuc cc mc kh o thng bo ca WHO,1994). - Plasmodium falciparum khng thuc Khng vi quinin c pht hin 1910 Brazil. Khng vi Proguanil v pyrimethamin t u nhng nm 1950. * Khng vi Chloroquine 1960 bin gii Columbia v Venezuela, tip n Thi lan nm 1961. Khng vi Amodiaquin 1961 Brazil. Fancidar Thi lan 1980. Khng vi Mefloquin Thi lan nm 1982 v tng nhanh v sau, v c khng cho vi halofantri Khng vi Artemisinin v dn cht ch thy trn m hnh ng vt th nghim 1985 (P. Bergei). - Plasmodium vivax khng thuc

Khng vi Fansidar c thng bo nm 1979. Khng vi Chloroquin c thng bo ln u 198 hng bo 1996). Cha thy thng bo khng quinin hoc mefloquin 3 Nguyn nhn khng thuc 3.1 Nguyn nhn ch yu - p lc thuc: dng nhiu mt loi thuc trong thi gian di cng ng rng s to iu ki gy ra khng thuc tng ln. Hin tng khng c th mt i sau mt thi gian ngng dng. - Di bin ng dn c: lm cc chng khng thuc lan ra. 3.2 Hu qu khng thuc - Kh iu trt tit cn - Bnh st rt d din tin nng - Kh khn phng cc v dch st rt - Chi ph iu tr v phng bnh rt tn km 4 Bin php phng chng khng thuc 4.1 Nga khng - Hng dn v gim st iu tr ng liu ti c s - Truyn thng cng ng bit t chn on v hng dn iu tr liu thuc - Tng cng kim tra KST bnh nhn v iu tr tit cn, liu, khng p dng iu tr p - La chn phc nhy cm, dng liu - Gim st k sinh trng khng thuc. 4.2 Bin php x tr i vi k sinh trng khng thuc - Tm phc chng khng (ti u l phi hp thuc - Qun l tt ngun bnh, trnh mm bnh khng thuc lan truyn - y mnh iu tr tit cn, ngng dng thuc b khng - Nghin cu sn xut thuc mi. V. LM SNG 1. Lm sng st rt in hnh 1.1. bnh Thay i ty loi k sinh trng; 7-10 ngy i vi P. falciparum, 14-17 ngy i vi P. vivax, i khi lu hn. Khng triu chng. 1.2.Khi pht Trong st rt tin pht (mc bnh ln u) c th khi pht theo nhiu cch: - St cao lin tc. 169

- St nh, c cm gic n lnh, - St nh, nhc u v tng dn (biu hin nh thng hn) - St cn, c chu k (t gp). Qua giai on ny, bnh i vo thi k ton pht, hoc cn st c th dt nhng vn tn ti k s xut hin st cn tr li 1.3.Ton pht c im cn st: cn st rt c 3 giai on v c tnh chu k - Rt run: hoc l ch cm gic n lnh dc xng sng v vai, cn rt run c th t 15 pht n 1 gi, tng ng giai on cng giao cm. - Giai on nng: nhit tng cao 39 - 400C, c th t 30 pht n vi gi. - Giai on v m hi: nhit gim, v m hi, d chu. Gia 2 cn st, bnh nhn vn bnh thng, c th sinh hot. Cn st c chu k. Vi P. falcip nht nhng P. vivax l st cn cch nht lnh tnh. Tuy nhin trong thc t lm sng c khi c c hai loi trn, do hai chu k ca KSTSR gi u nhau, iu ny c cng ng khoa hc - Ton thn: + Nhiu t hng cu b ph v s gy thiu mu, vng mt, tiu vng. + Gan, lch thng to ra. - Din bin: Nu khng c iu tr tch cc bnh s din bin nng, 85% do P. falciparum, n ariae c th ng nn c th chuyn sang ti pht gn hoc xa. Nu iu tr v phng bnh tt hng hi phc tt khng li di chng, nht l khi bnh nhn ra khi vng dch t st rt 2.St rt nhng c a c bit 2.1.Ph n c thai Khi mang thai c tnh trng gim min dch, nn rt d bc pht bnh hoc d ti pht nu c d h ng huyt khi mc bnh do P. falciparum v dng quinin. Khi chuyn d, tuy lng KSTS i sinh nhng bnh nhn li d chuyn sang st rt c tnh, chuyn d ko di, xut huyt, suy thai, sinh non, cng gp tr s sinh thiu cn, hoc st rt bm sinh.

2.2 Tr em Lm sng st rt tr em thng a dng, triu chng t r nt nht l tr nh, c th st, thng ko di, suy dinh dng v thiu mu, d mc st rt c tnh. 2.3.Nghin ma ty v suy gim min dch C th gp st rt th gi lnh, st khng r thng km tiu chy v h ng huyt, ko mu 3. Bin chng - Bin chng trc mt: Khi nhim P. falciparum d xy ra st rt c tnh nu khng iu tr - Nu lu trong vng dch t st rt. B ti pht v ti nhim nhiu ln s dn n mt s Gan: Ri loan chc nng gan. Lch: lch to l c trng ca bnh nhn st rt trng din. V vy lch to c s dng g chc nng qu mc trong p ng min dch c th dn n bin chng cng lch. Ton thn: ph, thiu mu, suy dinh dng, thiu vitamin... VI. CHN ON 1 Cn lm sng - Cng thc mu: hng cu gim, Hb bnh thng hoc gim. Bch cu bnh thng, c th tng b hiu). 170

- Ko mu tm KSTSR trn git c v git n. - Chn on huyt thanh: Ch c gi tr nghin cu hn l chn on v iu tr. 2 Chn on sm da vo - Bnh s: tm yu t dch t st rt - Lm sng: cn st in hnh, gan lch to, thiu mu - Ko mu tm KSTSR. - Test nhanh (tm Pf. HRP2 i vi P. falciparum; cn (+) 14 - 21 ngy sau iu tr thnh cn 3 Chn on phn bit t ra nht l khi k sinh trng m tnh. St dengue, cm cm, nhim trng huyt, thng hn, vi leptospira, nhim trng ng gan mt,v.v. C khi phi iu tr th loi tr khi khn 4 nh ngha ca bnh 4.1 Xc nh ca st rt : C k sinh trng st rt trong mu: - Nhum gim sa (+). - Hoc test nhanh (+) i vi P. falciparum. Bao gm: - St rt thng - St rt c tnh - Ngi mang k sinh trng lnh trong 7 ngy qua v hin khng st. 4.2 Ca st rt lm sng (nghi st rt) t ra i vi bnh nhn khng c xt nghim mu, cha c kt qu xt nghim hoc xt nghi - Hin ang st ( 37,50C) hoc st trong 3 ngy va qua. - Khng gii thch st do cc nguyn nhn khc. - ang hoc qua li vng st rt trong 6 thng gn y. - p ng tt vi thuc st rt trong vng 3 ngy. VII . IU TR 1. Nguyn tc - Chn on sm, iu tr sm, liu lng. - iu tr nguyn nhn: ct cn sm, tit cn tt, chng ti pht v chng ly lan. - iu tr ton din - Dng thuc an ton, ng liu trnh khng thuc 2. Cc thuc chng st rt 2.1 Quinin - Thuc r, t b khng, dit tt cc th v tnh trong hng cu, ung hp thu hon ton, gi, bn hy 10 gi. - Thuc c th gy tai, chng mt, nhc u, nn, i Hb (ngng thuc ngay), h ng huyt - Liu: 10 mg/kg mi 8 gi . Hoc 1,5-2 g/ ngy, tng liu < 15 g/ t tn cng. 2.2. Choroquine (nhm 4 amino quinolein) - Vin chloroquin diphosphate 0,25g (150mg base chloroquin) hoc dung dch (0,2g) tim bp, tnh mch. Chloroquin sulphate (Nivaquin) vin 0,1g. Amodiaquine vin 0,2g. - Thuc dit th v tnh trong hng cu, nhng hin b P. falciparum khng nhiu ni tr t P. vivax v P. malariae. - Tng liu mi t tn cng < 2,5g. Ung 4v-4v-2v. Tnh mch hoc tim bp thng thng 0,6g

2.3. Primaquin (Nhm 8 aminoquinolein: vin 13,2mg, cha 7,5mg base): - Thuc dit giao bo (chng ly) liu duy nht 30mg (4 vin/ ngy) chia 1 hoc 2 ln. - Chng th ng P.vivax (chng ti pht) liu 7,5 mg x 2vin / ngy x 10 ngy 171

- Tc dng ph: i Hb ngi gim men G6PD, n km, nn, tm mi. Khng dng cho ph n c 2.4. Tetracycline: Dit th v tnh trong cu nhng ct st v sch k sinh trng chm, d b khng nn phi /ngy x 7 ngy, hoc doxycycline 100 mg/ngy x 7 ngy. 2.5. Nhm Diamino pyrimidin i din pyrimethamin, thng phi hp vi sulphamide chm (fansidar = sulphadoxine + pyrimet ). Tc dng yu v chm, tc dng ch yu trn th v tnh ngoi hng cu. 2.6.Mefloquin (quinoleine methanol) - Dn xut 4 amino quinolein; vin 250mg. Tc dng tt vi v tnh trong hng cu v thoa trng P. falciparum. - Liu duy nht 1250- 1500 mg/ngy chia 3 ln: gi u 750 mg, cch 8 gi 500 mg, 8 gi sau 2 3-2-1). Khi phi hp artesunate th liu trnh nh sau: 3 ngy u liu artesunate l 4v - 2v th 3 dng mefloquin 3 vin (750mg) liu duy nht. - Tc dng ph (lin quan liu lng) gm: bun nn, chng mt, c khi ri lon tm thn v c nn chng ch nh dng chung vi cc thuc c ch (hoc c ch calci). Khng dng cng quini h. 2.7. Halofantrin Thuc tan nhanh trong m, vin 250mg, 500 mg. Ung khi i, tc dng gn ging mefloquin. Li 3 ln cch nhau 6 gi, liu duy nht, t nng nh 6 7 gi. (quinghaosu v dn cht) Quinghaosu c ly t cy Artemisina annual (Trung quc, rng Ty bc nc ta). Tc dng di v tnh trong hng cu, thuc tt nh lm sch nhanh k sinh trng mu, t tc dng ph v r o bo, chng hng cu nhim k sinh trng kt dnh lin bo ni mch v to hoa hng Hin nay thuc dng rt hiu qu iu tr st rt. Tuy nhin, thi gian bn hu nhanh, nn d ti l - Artesunate (theo pht mi ca B Y t nm 08/2003) + Vin 50 mg x 4 vin / ngy u; cc ngy sau ung 2 vin/ny (6ngy) (liu 800mg) + ng 60 mg, dung mi Bicarbonate natri 5%. Tim tnh mch: 1 ml dung mi ho thuc lc k on ton sau thm 5ml mui ng trng. Nu tim bp khng cn thm dung dch mui ng tr au tim nhc li 1,2mg/kg (1 ng); sau mi ngy tim 1 ng cho n khi bnh nhn tnh ri chuyn sang ung 2.9 Vin st rt CV-8 Thuc dng iu tr st rt khng bin chng t l khi bnh cao, t ti pht. Vin CV8 c 4 thnh phn: 32mg dihydroartemisimin (DHA) + 320mg piperaquin phosphat + 90mg tr imethoprim + 5mg primaquin phosphat. Liu ngi ln: 4 vin/ngy u chia 2 ln: 2vin gi th i th 8; 2 ngy sau mi ngy ung 2 vin (tng 8 vin). 3. iu tr c th Cc thuc iu tr st rt sn c ti y t c s, pht min ph, d thc hin cng ng. 3.1. iu tr ct cn Dng thuc dit k sinh trng v tnh trong hng cu. Nn phi hp 2 thuc trnh P. falciparum khng thuc. - Vi P. falciparum ct cn st l tit cn: u tin l quinine, artesunate hoc CV-8 - Vi P. vivax dng chloroquine hiu qu tt (tuy nhin, khi khng nm chc k sinh trng, nn iu tr nh P. falciparum) 172 3.2. iu tr tit cn t ra i vi P. vivax, P. ovale: chng ti pht xa bng primaquin 7,5mg x 2v/ngy x 10 ngy dit th ng. 3.3. Chng ly lan Primaquin 7,5mg x 4v/ngy, liu duy nht khi c giao bo trong mu. 3.4 Nng cao th trng Ch n giu dinh dng: m, ng, m v vitamin. Truyn mu ti ch khi hng cu v th tch huyt cu gim qu nng.

3.5. iu tr triu chng H nhit v an thn t ra khi st cao v c nguy c co git nht l tr em. iu tr cc tri VIII. PH NG CHNG ST R T Tc hi ca st rt i vi kinh t - x hi rt ln. Nu u t mt cch tha ng th vic phng chng s c hiu qu. phng chng st rt tt cn tin hnh cc bin php sau: 1.Tuyn truyn gio dc cng ng tham gia phng chng st rt ti vng bnh lu hnh, tuyn truyn gio dc l bi do cn c s phi hp lin ngnh, dng mi phng tin truyn thng i chng. 2.Nng cao sc kho cng ng Cn ci thin ch dinh dng, ch lao ng ca dn sng vng st rt lu hnh, nht l kho ca nhn dn, nng cao i sng vt cht tinh thn, pht trin sn xut 3.Vc xin phng st rt: hin ti vn cha c v xin s dng. 4.Ha d phng Ung thuc phng (ha d phng tp th): bin php khng c tn thnh, v dng thuc ko d thuc, chi ph cao, khng c iu kin dng thuc lin tc... Cho nn, ung phng ch p dng ngi cha c min dch st rt hoc vo vng st rt trong mt thi gian ngn: ngi i cng 50 mg x 1v / tun. Dng 2 tun trc lc vo, lc v 6 tun sau khi ra khi vng dch. 5. Cc bin php phng chng vect Ni chung, cc bin php phng chng vect cn p dng ni c vect, cc bin php thch h 5.1. Ci to mi trng Lm v sinh ngoi cnh, khi thng cng rnh, lp cc ao t nc ng, pht quang, v sinh ch sng. Vic pht trin kinh t - x hi i km pht trin cc h thng thy li, xy h cha n bnh pht trin, v vy, cn theo di v gam st cht ch mt mui, b gy, nht l khi vng , c bin php khng ch thch hp. 5.2. Bo v c nhn Bin php c dng rng ri v d thuyt phc nht: nm mn , rm, vng tm permethrine. Nu rt c thi quen nm mn tm s gim c t l mc bnh. 5.3.Bin php sinh hc dit b gy, lm gim mt vect nhng vng st rt khng n nh. Bin php ang c c (trm c, r phi, by mu, sn st... ) th vo ao h, cc ni c nc. 5.4 Phun thuc tn lu Hin nay vect khng nhanh cc thuc phun. Bin php ny trong thc t gim s lan truy h. Thuc phun phi an ton, khng mi v 173

vt phun c nhn dn chp nhn, ga c hp l vi iu kin kinh t ca dn vng st rt. v d: nh phi kn, c din phun, tng nh phi ph hp vi tn lu ca ha cht. Do cn ca WHO. Trong y t cng ng, phun tn lu cn chn thuc tan trong nc, thuc hin ang d hin ang c gng gim dn phun ha cht tn lu; ch thc hin cc bnh vng trng im, bng permethrine. Tm li: St rt l mt vn ln ca cc nc trong vng nhit i. Vic chn on bnh s in s khng ch c bnh st rt n mc thp nht. Cu hi n tp 1. M t cc chu trnh ca tc nhn gy bnh st rt 2. Trnh by c ch bnh sinh ca bnh st rt 2. M t cch chn on sm v chn on gin bt bnh st rt. 3. Lit k v phn bit tc dng ca cc thuc iu tr st rt thng 4. Trnh by cch hng dn cng tc phng chng st rt. 174 Bi 28.

Mc tiu BNH ST R T C TNH

Ths, BsCK1 ng th Nga 1. Xc nh c cc i tng v iu kin c nguy c cao xy ra st rt c tnh 2. Phn tch c cc bin i ca hng cu trong bnh cnh st rt c tnh 3. D bo cc du hiu chnh trn lm sng ca st rt c tnh. 4. Phn loi cc th lm sng ca st rt c tnh. 5. Gio dc, kin ton mng li y t a phng gim t l st rt c tnh. 6. Thit k pht iu tr mt s th lm sng ca st rt c tnh. Ni dung

I.I CNG St rt c tnh l mt tnh trng nhim KST st rt nng n c nhiu bin chng nhiu c quan quan trng nh no, gan, thn, phi...nguy c t vong cao. St rt c tnh do Plasmodium falciparum gy ra v vect truyn bnh l mui Anopheles ci. II. DCH T HC Nguy c xy ra st rt c tnh (SRAT) nhng iu kin sau: Ngi cha c min dch, cha b st rt ln no hoc mc di 6 ln (t l 97,2%) Dn tc kinh chim a s hn dn tc t ngi (t l 93,4%) Ngi mi vo vng dch t st rt di 6 thng d b hn ngi sng lu (t l 81, Tui 16 -30 (t l 74%) Lm rng ry, lao ng nng hoc ang di chuyn hnh qun Nh xa trm x hoc pht hin mun v iu tr mun ang c dch st rt xy ra trong vng chim t l 51,2% III. C CH BNH SINH 1. Cc c im ca P. falciparum khi xm nhp vo hng cu - Plasmodium Falciparum c kh nng xm nhp vo hng cu mi la tui: non, tr, gi, do nhim KST. Mt KST cng cao cng c nhiu bin chng - Khi xm nhp vo c th, KSTSR c kh nng gii phng ra c t, bn cht c t l glycosyl - phosphotidin - inotide - lipide lm hng cu d v - So vi cc loi Plasmodium khc th trong mt hng cu s lng cc merozoide (tiu th hoa th ln n 16 -32 merozoide/1 hng cu trong khi i vi P.vivax ch l 6 - 12 merozoide - Khi xm nhp vo bn trong hng cu mt s KSTSR nh P. Falcifarum to nn cc nt li (kno cu. Cc nt ny s gn vo cc receptor tng ng b mt cc lin bo ni mc ca mch mu t bo ni mc mch mu gy nn tc mch nht l no Cc protein nt li lm chc nng nh Pf.EMP1 ( Plasmodium Falciparum Erythrocyte Menbranous Protein 1) Pf.EMP 2 ( Pla smodium Falciparum Erythrocyte Menbranous Protein 2) Pf.HRP1 ( Plasmodium Falcip arum Histidin Rich Protein 1) 175 Pf. HRP 2 ( Plasmodium falciparum Histidin Rich Protein 2) - Hng cu b nhim KSTSR (th tropozoide gi ) c th dnh cc hng cu khng mang KSTSR to ra hin tng hoa hng d gy tc mch (khng xy ra vi P. vivax). 2. Cc bin i chnh ca hng cu khi b nhim KSTSR - B mt hng cu xut hin cc n li nn khng trn, d dnh v gy tc mch. - n hi mng HC gim - mt kh nng mm do nn kh n mao mch su. - Mng hng cu tng tnh thm i vi Natri lm cho hng cu d v gy tn huyt - bn ca mng hng cu gim st do khi th phn lit pht trin nhiu d v hng cu, C th tm tt c ch bnh sinh ca SRAT nh sau:

P.falciparum

Lm v cc HC b nhim KSTSR Gii phng c t To hoa hng Kt dnh

Ph hu hng cu khng mang KST c ch h hp t Lp mch v bo ng mu ni mch

Thiu Oxy c quan

Bng 10: Tm tt c ch bnh sinh 3. Bin i cc c quan 3.1 Ton thn - St: do tc dng ca sc t st rt v c t KST tit ra tc ng ln trung tm iu nhit t cc i thc bo khi phn hy mnh vn hng cu v KSTSR. - Thiu mu: V hng cu hng lot m c ch ni trn - H ng huyt: do + Tng nhu cu s dng oxy v glucose ca c th . + Tng nhu cu glucose do phn hy glucose theo con ng ym kh. + Gan khng to c glucose t glycogen v tn to glucose t cc cht khc. + Vic s dng quinine s kch thch o langerhan ca ty tit insulin gy h glucose mu. + n ung km. - CIVD: Nghn mch to iu kin cho CIVD cc trng hp nng. Trong cc trng hp ny ph km vi gim tiu cu v fibrin cng nh gim prothrombin gy chy mu nng. 3.2 Cc c quan: Ni chung l do hin tng thiu oxy do c ch bnh sinh m t trn. 176

- No: c 3 thng tn chnh l tc nghn cc mao mch, ph n v xut huyt quanh cc mao m + Nghn mch l hin tng ph bin nht, nhng hu nh khng li di chng khi khi bnh + Thiu oxy no lm cho qu trnh chuyn ha glucose no chuyn sang con ng ym kh sn huyn ha d dang trong lactate gia tng d di trong st rt c tnh th no, phn nh qu actate. + Trong cc trng hp nng s thiu oxy lu s dn n hin tng ph n v xut huyt quanh h nhn t vong - Thn: Thng tn ng thn do i Hb. Thiu oxy gy hoi t v thn, lm ri lon chc nn - Gan: Tng hot h thng vng ni m thc bo, phn nh qua s tng sinh cc t bo kuffe khong ca. Nghn mch gy thiu mu, thiu oxy, cc t bo phnh to, hoi t km mt t b trung tm - Phi: Do c tnh ca KST cng cc cht lymphokine ca i thc bo gii phng ra s gy t

h gy ph phi. IV. CC TH LM SNG pht hin sm mt st rt thng c nguy c chuyn sang st rt c tnh, phi theo di cc du hiu u tin: St lin tc ko di koc nhiu cn k tip nhau, v m hi nhiu Mt ng nng > 2 ngy, nhc u nhiu . Ri lon tinh thn nh thong qua hoc thnh thong mt nh hng khng gian, thi gian Li b hoc kch thch vt v. Mt KST cao: 1 -10 KST/ vi trng. Nn nhiu hoc a chy. T chc y t th gii a ra cc tiu chun chn on SRAT bao gm: 1. Trong SRAT th no phi hn m t nht giai on 2 (glasgow 7 im cho ngi ln v 2 2. Co git ton thn > 2 cn /ngy 3. Thiu mu : Hematocrit < 15 - 20 % hoc hemoglobin <5 -6 g/l 4. Suy thn: S lng nc tiu < 400ml/24 gi, hoc 12 ml / kg /24 gi 5. Ph phi vi du hiu suy h hp cp. 6. H ng huyt: Glucose mu < 2,2 mmol/ lit ( 0,4 mg%) 7. Try tim mch. 8. Chy mu hay ng mu ri rc ni mch. 9. Toan chuyn ha. 10. i Hb khi lng ln Ngoi ra cn c cc tiu chun ph, nhng khi nhng tiu chun ph ny ng ring r th khn 1. Tri gic u m, cha hn m 2. 2. Mt k sinh trng trong mu: > 5%. 3. Vng da: bilirubin mu > 50 mmol/l hoc > 30 mg%. 4. St cao > 41oC hay h nhit < 36oC. 1.St rt c tnh th no nc ta, st rt no chim 55% trong s st rt c tnh. Gi st rt c tnh th no khi b ) km du thn kinh ni bt l co git. 1.1 Thi k khi pht - C th t ngt st cao lin tc hoc st cn, nhng nhiu cn lin tc k tip nhau. - Ri lon tri gic, ri lon thc, li b hoc kch thch cung sng. 177

1.2 Thi k ton pht - St vn tip din - Cc du hiu thn kinh ni bt vi li b ri i vo hn m, co git. - Hn m thng trng thi nm yn, gim trng lc c, nhng khi c tnh trng tn thng dui, chn dui) hoc co cng mt no (2 tay co, 2 chn dui, lng un cong, mt ngc nhn l - Co git: thng xy ra cn co git ton thn ngn theo kiu ng kinh hoc cc du tn th nu hi phc khng li di chng. - Cc du hiu ton thn khc + Ri lon h hp: tng tit m gii, ri lon nhp th, m ri lon tun hon . + Tit niu: Tiu t, ure creatinin mu c th tng. + Gan, lch c th ln, vng da nh. - Cn lm sng: + Cng thc mu: hng cu gim, c th thy hng cu non mu ngoi vi. Bch cu bnh thn + Ko mu tm KSTSR + C ri lon v men gan: SGOT, SGPT tng, bilirubin tng 1.3 Tin trin v tin lng - Din bin tt khi + ang hn m bnh nhn t ngt la ht vt v + Cc phn x (gn xng, da bng, da bu, m mt) gim hoc mt xut hin tr li . + Nhit h dn, mch v huyt p n nh + Bnh nhn tiu nhiu hn - Din bin xu khi + Hn m ngy cng xu hn v ko di trn 3 ngy km mt phn x nut + Co git nhiu km nhng cn ngng th tm ti + St cao lin tc hoc h thn nhit km ri lon tun hon, huyt p tt kp. + i t hoc v niu

+ Nn nhiu, ra dch nu hoc mu Thng t vong trong tnh trng suy h hp hoc suy tun hon 2. St rt c tnh th i Hb Thng xut hin sau cn tn huyt t ngt, gii phng lng ln Hb t do, nc tiu c Hb (lc u mu hng, v sau mu nu en) km theo thiu mu cp v vng mt nh. St rt i Hb thng xut hin nhng bnh nhn sng vng dch t st rt hoc b st rt rong trng hp ny cc hng cu cha k sinh trng st rt bin dng thay i cu trc v c lm v hng lot cac hng cu nhim v khng nhim k sinh trng st rt Bnh nhn thiu G6PD mc st rt c th i Hb khi iu tr quinine hoc primaquine. Lm sng - Khi pht t t vi st khng r hoc t ngt vi st cao, nn ma nhiu ra nc vng xanh - Ton pht: St lin tc hoc thnh cn, thiu mu lm sng nhanh nh nim mc mt nht mu, g vi cc t tn huyt km mt mi, suy nhc; nc tiu t vng sm chuyn sang mu nu en - Gan, lch to ra - Cm gic au m vng lng km nn i. Nu tnh trng tn huyt trm trng c th tt mch v huyt p, thiu niu, ri v niu. Thng t vong trong bnh cnh suy thn Cn lm sng - Mu: Hng cu gim, bch cu bnh thng c khi tng cao ch yu neutrophiles Hct gim. C th khng thy k sinh trng st rt. 178

- Nc tiu: Hb niu (+), khng c hng cu nguyn vn, sc t mt (+) - Ure, creatinine mu tng (nhiu hay t ty mc tn thng thn) - Bilirubin ton phn tng trong ch yu l bilirubine gin tip. - G6PD c khi gim hoc mt hon ton. Din bin v bin chng - Nu iu tr ng, tch cc cc t tn huyt gim i nc tiu trong dn v lui bnh - Bin chng thng gp v nng nht l suy thn cp do vim tc ng thn; t vong do ri lo mu, toan chuyn ha. 3. St rt c tnh th gan mt - Sau thi k khi pht, bnh cnh lm sng nng n vi st cao, da mt vng m, nn nhiu, - Gan to, au tc - Xt nghim chc nng gan cho thy: Bilirubin tng, t l prthrombin gim, SGPT, SGOT tng. Cc xt nghim ny x hi phc khi khi bnh . 4. St rt c tnh th phi Ch yu l du hiu ph phi vi kh th, tm ti, th nhanh 40 -50 l/ph, khc m c bt hn v nh ht. Tin lng chung: theo GS. Trnh kim nh (bnh vin Ch Ry) nh gi tin lng chung nh sa Nhm I: SRAT th no n thun, t vong 0 -10% Nhm II: Th ph tng n thun: t vong 0 -20 %. Nhm III: SRAT th no+ bin chng 1 ph tng t vong 0 -20 %. Nhm IV: SRAT th no + > 2 ph tng: t vong 50%. V. IU TR V D PH NG SRAT l mt bin chng nng do P. falciparum .V cha c vaccine phng st rt v bin php ha d phng tp th khng p dng trong vng c dch st rt lu hnh, do l - Nng cao mc sng ca ngi dn vng dch t st rt gim nguy c mc bnh - Ci thin ch lao ng hp l. - vng bnh lu hnh, gio dc qun chng phng chng bnh gim t l mc. - T chc v kin ton mng li y t c s pht hin trng hp bnh, iu tr ng - - C s theo di v qun l i tng c KSTSR (+) v iu kin lm vic, sinh hot ca h. K - Ti n v iu tr, SRAT cn chm sc, iu tr sm, ng gim t l t vong. Nguyn t - Phi lm gim v dit KSTSR trong mu cng sm cng tt bng thuc khng st rt nh quinin con v ph n c thai - Chm sc v hi sc nh mt cp cu ni khoa: chng ph no, co git, suy thn, suy h hp, , cn bng in gii toan kim, chng bi nhim. iu tr c th 1. SRAT th no 1.1 Chm sc theo di - Bnh nhn hn m: t t th nm nghing, ht m gii ng th thng thong. - Chng let cc im tip xc bng xoa bp, thay i t th hoc k m hi. - V sinh hng ngy 1.2 iu tr nguyn nhn: Cc thuc chng st rt l phng tin c sn trm x, r tin, d

Dng thuc khng st rt: Thuc ngh c dng u tin l Quinine v Artesunate ( dit KST nhanh v t khng ) giai on u thuc hon ton ng tnh mch 179

- Quinine chlohydrate hoc dichlohydrat: 8 -10 mg /kg /8h pha vo dung dch glucose 5% hoc chlorua natri 9%O chuyn TM XXX /1 pht. Ln u tin c th dng liu ti 20mg/kg nu cha dng quinin trc . Tip tc trong 2-3 ngy u . Khi ra khi hn m, chuy ung cho tng liu(<13,2 g). - Artesunate: Trong st rt c tnh lun lun phi phi hp artesunate vi mt loi thuc kh g ng tim bp, tim tnh mch hoc ung qua sonde d dy hoc nht hu mn . Thng th d TM, tng liu <400 mg. Gi th 1: 2ng. Sau c 24 gi tim 1 ng n khi bnh nhn tnh th hc ca B Y t) - C th dng Artesunate: vin n t hu mn: 100mgx3 vin/ngy n khi bnh nhn tnh th 1.3. iu tr h tr - Chng co git: Phenobarbital 0,2g x 1 ng tim bp khi ln cn Seduxen 10 mg x 1 ng TM - Chng ph no: bng cc dung dch u trng glucose 20% hoc manitol 20% - Chng suy h hp do ng m di v ph phi. - B dch v cn bng in gii: ch bnh nhn lun lun b e da bi hin tng ph phi, nc do st cao, nn, nh hng n tun hon. Do bnh nhn phi c theo di bng in hng l Ringer, glucose 5%, chlorua natri 9%o, c th dng glucose 10 % nu c nguy c h - Chng bi nhim nht l khi nm lu v c can thip cc th thut nh t sonde, t cathet inh c ph khun rng. 2.iu tr st rt i huyt sc t bnh nhn i Hb cn hi tin s, bnh s, dng thuc v xt nghim tm KSTSR. - Nu bnh nhn ang iu tr vi mt thuc st rt no v i ra Hb th xem xt li v ng ghim tm men G6PD . Nu khng thy thiu men G6PD th c th tip tc dung quinine, artesuna - Lun lun theo di mu sc v s lng nc tiu mi 8 gi v tng lng nc tiu 24 gi, c gng duy tr lng nc tiu t 1,2 -1,5 l / 24 gi. - Phi lun lun nh nguy c cao ca SRAT i Hb l vim tc ng thn dn n suy thn do bng: - Thuc li tiu: ch s dng sau khi b dch m khng c nc tiu hoc tiu t. Thuc . Sau nu vn khng c nc tiu th ty tnh hnh m tng dn liu 80 mg, 160 mg... - Nu vn v niu c th hoi t ng thn cp cn theo di ure, creatinine mu, in gii cn. - Corticoide: c th kim sot c cn tn huyt, dng Depersolon 100 mg hoc hydrocortisol hemisucsinate 200 mg/ ngy, cho n khi nc tiu trong. - Vic truyn mu tt nht nn kim tra hng cu v Hct thng xuyn, khi thy 2 tr s ny t HC <2 triu) phi t ra ngya nn truyn mu ti. - Cn bng nc - in gii v toan kim: da bilan nc, kim ha nc tiu trnh Hb kt ta lng ng ti ng thn. Tm li SRAT l mt bin chng nng ca st rt P. falciparum, chn on sm, iu tr ng, st rt s gim t l t vong SRAT. Cu hi n tp 1. Trnh by cc iu kin v cc i tng c nguy c cao st rt c tnh. 180

2. Trnh by cc bin i hng cu trong st rt c tnh v cc d bo st rt c tnh trn l 3. Phn loi v m t cc th lm sng st rt c tnh. 4. Trnh by cch gio dc, kin ton mng li y t nhm gim t l st rt c tnh. 5. Thit k pht iu tr mt s th lm sng ca st rt c tnh. 181 Bi 29.

Mc tiu BNH L AMIP

BsCK2,Ths H th Thu Vng 1. Xc nh c nguyn nhn v mt s c im dch t hc ca l amip 2. M t c lm sng, cn lm sng v bin chng ca l amip cp v mn 3. Chn an sm v iu tr ng phc phng bnh din sang mn tnh. 4. Xc nh c cc bin php phng bnh

I. I CNG Ni dung Bnh amp l mt bnh ph bin nc ta cng nh trn th gii v l mt bnh quan trng v Nhim Amip l tnh trng mang Entamoeba histolytica c hay khng c triu chng lm sng. The th gii , bnh amip c phn loi nh sau : - Bnh amip khng triu chng - Bnh amip c biu hin lm sng: + Bnh amip rut: L amip, Vim i trng mn, U Amip, Vim rut tha do Amip + Bnh amip ngoi rut: Bnh Amip gan, phi, no, lch, da ... L amip l tnh trng nhim t E. histolytica, II. BNH NGUYN 1. Hnh thi Entamoeba gy bnh cho ngi tn ti ba dng: 1.1 Th hot ng n hng cu ng knh 30-40 micromet sng trong vch i trng, tng trng tt di iu kin k kh, s pht trin, tm thy trong phn bnh nhn l cp tnh, c gi tc, trong t bo cht c khn 1.2. Th khng n hng cu Tm thy trong phn ngoi giai on cp tnh, ng knh 14-16 micromet, cc gi tc di chuy hng c hng cu, ch c vi trng v glycogen. 1.3. Th bo nang (kn) ng knh 10-15 micromet, hnh cu, chit quang, kn non c mt nhn, kn trng thnh c 4 nhn . 2 . H thng enzym Amip c gy hoi t m nh enzym tiu hy protein t chc (hot tnh ging pepsine,trypsine, ). Th dng bo gy c bch cu, nh vy m chng mi vt qua hng ro t chc lympho ru 3. c tnh sinh bnh ca Entamoeba histolytica 182

Sau khi nut, kn amip vo n rut non nguyn vn, khng b tc dng ca dch v.Ti rut n mng bc kn b v ra, bo nang 4 nhn bin thnh 8 nhn, t phn chia ra thnh 8 Amip. Th khng n hng cu k sinh trn nim mc rut, n vi trng v cc b thc n, c th chuy sang th n hng cu III. DCH T HC 1. S phn b a d Bnh Amip l mt bnh ph bin nc ta cng nh trn ton th gii, nm 1981 t chc Y t t ngi mang kn amip trong phn. Trc y s ngi mang kn amip cn cao hn v c xp th

Hin t l nhim Entamoeba histolytica trn th gii khong 10 % ( 1-69 %), hng nm c khon 0 b nhim vi 30.000 - 40.000 ngi t vong. cc x nhit i, t l nhim amip 25-40%, c Chu, Nam M, Ai cp, Vin ng, Mecico t l 25-40%, Colombia (Medellin) ,50% Costa Rica( ose 72%). vng n i mc sinh hot cao (u Chu, Bc M ) s ngi b nhim di 5%, Vi n 25%, theo thng k ca thnh ph H Ch Minh trung bnh 8%.Thng k ca bnh vin Vit t hin cu khoa hc tp II, 1996) Triu chng lm sng khc nhau tlin quan n mt s yu t nh: vng kh hu n i thng n hu Phi), sc khng ca c th, tu thuc chng amip, cc yu t dinh dng, cc vi khun Khu vc Amip gan % Chu 14 Chu Phi Nam M 1 Chu u 1 2-5 0,1 Nhim amip % 3-47 25 2-11 5 2-72 1 2 Bnh amip %

Bng 11:T l nhim Entamoeba histolytica, mc bnh khc nhau cc vng trn th gii. 2. Tui - gii Tuy cc la tui u c th mc bnh nhng hay gp cc la tui 15-65 (81%), nhiu nht 20uvelle caledonic 76-79) 3. Tnh hnh kinh t - x hi Bnh thng gp x nng vng nhit i, c bit cc nc c iu kin sinh hot thp km, khc do tnh trng v sinh ngoi cnh thp ( cha gii quyt t t phn nc rc ), n ung k 4. Ngun bnh Ngi mang kn amip l ngun ly duy nht: ngi bnh, ngi va khi bnh, ngi lnh mang k ong phn ca bnh nhn va c th dng bo, va kn .Th dng bo d b tiu hy, tri li Marion v Sweetsir nghin cu trn 1000 lnh M th tm thy 168 ca c amip trong - Ngi lnh mang kn amip khng triu chng : 76,2% - Bnh amip kinh nin : 20,2 % - L amip cp : 3,6 % 5. Phng thc ly truyn 5.1 Ly gin tip 183

L ng ly ph bin, mt ngi bnh c th thi qua phn vi triu kn c khi 300 triu kn h 1 kn. Trong ngoi cnh kn sng rt lu, trong phn lng 12 ngy, trong t 10-20 ngy, t Nc di 50 , ha cht chlor, iode nng thp khng dit c kn. Ngi nhim amip khi nut phi kn trong thc n b nhim, nc ung khng chn. Rui, cn tr nguy him. Thy 3/4 rui trong nh ngi b l amip c mang kn (Frye v Meleney (1936)). Kn c th sng chn rui 48gi. 5.2.Ly trc tip T ngi sang ngi do tay bn, kn c th tn ti 5 pht bn tay, 45 pht di mng tay. mang kn amip nhng t khi truyn bnh cho ngi. 5.3.Ly qua ng tnh dc Thng xy ra nhng qun th ng tnh luyn i nam. 6. C th cm th Trong cc vng kh hu nng v m, nhim amip kh trnh, c ngi sau khi nut kn nhng khn trng, c l do thng bng trong mi trng rut khng b ri lon ( vai tr vi khun ch khng th ca rut), c ngi b ti nhim nhiu ln v mang amip mt thi gian di nhng kh ngi s tr thnh ngi bnh sau khi nut kn 1 thi gian di hay ngn ty vo mt s iu h, suy gim min dch.... 7. Hnh thi dch - Vng bnh amip lu hnh, v sinh phn nc km, bnh c th bc pht thnh dch nh, c bi thong c th pht thnh dch ln nu gp iu kin thun li no nh v dch nm 1933

o nc cha kn amip . - Vng n i bnh ch c tnh cht tn pht l t . 8.Yu t nguy c - Chng amip: Nhiu tc gi cho rng chng amip vng ng Nam c c tnh cao hn cc vng Bc Phi, cc chng amip ni a vng n i thng khng c c lc - S ri lon vi khun ch rut . - S suy gim sc khng ca c th . IV. BNH SINH V GII PHU BNH C th tm thy trong lng rut c th kn ln th hot ng ca amip, nhng ch c th hot Trn ng vt, cc hin tng nh ph hy lp nhy, vim lan to v v hng ro biu m rut nim mc rut gi. Th ny tip xc vi cc t bo tit nhy v biu m ca rut gi nh cht -inhibiting lectin). Tn thng rut sm nht l cc vt vi lot nim mc manh trng, rut gi sigma, hay trc tr vim v cc t bo biu m. Soi trc trng pht hin cc vt lot nh vi b chng ln nhau, lot n xung tn nim mc, to nn hnh nh c in hnh cc o, trong c th tm thy am g giai on cp c th c s xm nhim cc t bo trung tnh, nhng hu ht trng hp ng 184

l do b th hot ng ca amp thc bo. Cc vt lot c iu tr s lnh v khng ln Him hn, c th to thnh khi gi l u amp trong lng rut. Lp nim mc bc quanh mng v h dy, ph v xut huyt. U amp l do phn ng thnh lp m ht u th km vi mt t m s Mt s yu t gy c gip E. histolytica c th xm nhp cc biu m gia cc tuyn. Mt enz nase c th thoi ha colagen, cc cht n hi, IgA tit v cc thnh phn b th gy phn v cng ph v cc cu ni glycoprotein gia cc t bo biu m nim mc rut. Amp cn ly gii , lympho v cc t bo biu m ca rut gi v gan. Tc dng gy tiu t bo ca amp i hi n s gii phng phospholipase A v cc peptide to l thng mng t bo. p xe gan lun lun xy ra sau khi c nhim amp rut d c th khng c triu chng. Cc mc iu cc thnh mch v thnh lp huyt khi.. E. histolytica n gan qua tnh mch ca, v c qua trung gian b th, nh n c th tn ti khi vo mu. E. dispar b ly gii bi b th ip amp vo gan chut hamster, thy c xm nhim cc t bo vim, ch yu l a nhn trung t h s b ly gii khi tip xc trc tip vi amp. Cc enzyme trong t bo trung tnh gii phn cc t bo gan. Vng hoi t c bao quanh bi mt vng mng cc m gan xung huyt. Cht ho p thng c m t c mu s c la, mc du mu sc c th thay i v thng l cc mnh v Nhim amip khng gy min dch, nhng mc l hay p xe gan nhiu ln cng t gp. Cc khng t gi khng th lin quan n thi gian mc bnh hn l trm trng ca bnh. Nghin cu trn t bo ng vai tr quan trng hn trong bo v vt ch mc du bnh nhn AIDS khi nhim a V. LM SNG V TH LM SNG Bnh amip c th c hoc khng triu chng, c khi bin mt t nhin. V vy kh xc nh th kn c th khng mc bnh hay bnh pht sau vi tun, vi thng hay vi nm, cng v lu bi chng a dng kh chn on bnh nguyn l amip . 1. Th cp din 1.1. Thi k bnh : kh xc nh 1.2. Thi k khi pht Thng m thm, khng st hay st nh (nu c bi nhim), ton thn t thay i, c th a ch 1.3.Thi k ton pht: in hnh vi hi chng l Ton thn t thay i, c th st nh, khng c du hiu mt nc 185

Hi chng l : - au bng qun, mt rn . - Tnh cht phn: lc u bnh nhn c th i cu phn lng v sau phn nhiu nhy ln m u i phn thnh khun, nhy mu bm xung quanh v cui cng c vi git mu. ngi gi v tr suy dinh dng, hi chng l khng in hnh, c khi ch i cu mu. 1.4. Thi k lui bnh Bnh c th t n nh v ti pht khi gp yu t thun li 1.5. Giai on di chng Bnh c xu hng mn tnh nu khng pht hin v iu tr kp thi, d gy di chng vim i trng mn. 2. Bnh l amip th ti cp (c tnh) Gp c th suy gim min dch, hoc suy kit vi tn thng hoi t lan khp i trng

- Hi chng nhim trng nhim c ton thn nng vi st cao c khi h thn nhit, tng trng h. - au bng d di, nn nhiu, i tin khng t ch, hu mn gin rng, i cu ra cht nc nhy thi ln mu. Gan c th ln v au, bng chng c phn ng thnh bng nh. 3. Bnh l amip mn tnh 3.1. iu kin xut hin - Bnh Amip khng c chn on - Bnh Amip khng c iu tr trit 3.2. Lm sng 3.2.1. Th l: Cm gic nng bng, nhng cn au bng qun sau n hay cm lnh, i cu 5-6 ln/ngy phn nhy mu km mt rn, ngi gy da kh, suy nhc, n ung km . 3.2.2. Th tiu chy: thng au bng m bui sng ri i cu phn nho c dnh nhy hoc t g, c khi phn nhy mu, ton thn gy st. 3.2.3. Th to bn: Thng gp ngi ln tui b l amip trong tin s, th trng tt, t nhy mu. 3.2.4. Th xen k to bn vi a chy: Bnh tin trin dai dng tng t to bn xen k vi t 3.3. Biu hin thn kinh ca bnh amip mn Cc qu trnh vim v let mn tnh i trng lan dn n cc m ri thn kinh mt tri, v hp thu ca rut. Ngoi ra cn c th qua trung gian giao cm v dy ph v m gy nn c hay h huyt p, co tht mch mu ngoi vi... c th biu hin nh: - Bnh d dy rut : au bng vng thng v, chua, i tin ri lon. - au h sn phi. - i but, i rt. - Kh th, nh trng ngc, au vng trc tim, c khi c ngoi tm thu, huyt p h. - Suy nhc c th v ri lon tm thn. 4. Th phi hp: L amp v l trc trng vi 2 kh nng 4.1. Hai bnh song hnh din bin cp tnh Hi chng nhim trng, nhim c ton thn. 186

Hi chng l hoi t: au bng nhiu, nn ma d di, i tin nhiu ln ton m mu hoc nc hung hung nh nc ra tht, hi thi. 4.2. L amip bi nhim Shigella: St cao, hi chng l gia tng mc nng, sau khi iu tr iu ha vn ko di, xt nghim phn th y c amip. VI. CN LM SNG 1. Phn Xt nghim phn nhiu ln sau ung sulfat magnesium, nu c iu kin nn xt nghim li sau tun, 1 thng/ln trong 6 thng v 6 thng/ln trong 2 nm. C th pht hin ngi lnh mang kn, gim ti pht v gim chuyn th mn tnh . 1.1. Soi ti Tm thy amip th dng bo n hng cu di ng, hng cu ng m, bch cu, kn amip 1-4 nhn, tinh th Charcot Leyden. Th dng bo d b tiu hy, tri li kn amip c sc sng cao nn cc th amip rut nng t th dng bo hot ng d cht trong phn. Do dch t hc bnh amip phc tp v nhng ng hng c triu chng nn t c s quan tm ca cc t chc y t. 1.2. Cy phn Trn cc mi trng khc nhau, tm thy cc dng amip v cc vi trng bi nhim Gram(-), mm(+), vi trng, k sinh, nm. 2. Ni soi trc trng - Hnh nh vim trc trng lan ta, r rt nht khong 13 - 20 cm cch l hu mn, nim mc ri rc tng ch c im bm tm. - Tn thng let in hnh: dng vt cu, cc o, gia nhng vng nim mc tn thng l vng nim mc bnh thng. 3. Xquang rut gi: Khng c hnh nh c hiu, c th thy cc hnh nh do bin chng ca l rut, xon rut... 4. Huyt thanh chn on: Amip xm nhp lm xut hin khng th c hiu, pht hin bng phng php min dch hc nh : - Phn ng khuych tn kt ta trn thch. - Min dch hunh quang gin tip . - Phn ng ngng kt hng cu gin tip...

VII. CHN ON 1. Chn on sm da vo - Tin s - Lm sng - Tm kn amip trong phn , xt nghim ny c th pht hin bnh sm khi cha c triu chng km nn c th chi tr c 2. Chn on phn bit 2.1. L trc trng: Bnh cnh cp tnh vi st cao, tnh trng nhim trng, nhim c, ri lo - i cu rt nhiu ln 20 - 30 l/ngy. - Cy phn c Shigella. - Soi trc trng c tn thng lan ta. 2.2. Hi chng gi l do E.coli. 187

2.3.Hi chng gi l do cc loi virus ECHO, coxackie. 2.4. Hi chng gi l do u x t cung , ung th i trng, u x tin lit tuyn. VIII. BIN CHNG 1. Ti rut 1.1. Thng rut gy vim phc mc, c th xy ra th trung bnh hay th nng, bnh nhn st thnh bng. 1. 2. Xut huyt tiu ha: do tn thng mch mu, i khi rt trm trng, i hi phi chuy sm cng tt. 1.3. U amip, tc rut, lng rut, xon rut do u. 1.4. Vim i trng hoi t. 1.5. Sa trc trng. 2. Ngoi rut 2.1. Abces gan: giai on u l vim gan nu khng iu tr th chuyn sang abces gan. 2.2. Amip phi, mng phi: amip t gan qua c honh, c th qua ng mu hay bch mch. Lm - Vim y phi phi cp hay bn cp . - Abces phi ri thng vo ph qun gy khc c m ... phn ng mng phi, trn dch mng ph 2.3. Tn thng ngoi tm mc - Do v m abces gan vo mng tim. - Vim ngoi tm mc phn ng hay c m. 2.4. Bnh amip no 2.5. Bnh amip lch: Vim quanh lch tng ng vi tn thng amip gc i trng tri. 2.6. Bnh amip da : xut pht t 1 bnh amip rut hoc gan . - Quanh hu mn: vt let ni g, y bn, cha nhiu cht hoi t. - Quanh cc vt m abces gan hay mng phi do amip. 2.7.Bnh amip sinh dc- tit niu Vim bng quang, abces quanh thn do amip t gan n , bnh amip dng vt, m o, t cung. IX. TIN LNG Bnh amip thng p ng tt vi iu tr thch hp, tuy nhin t l ti pht kh cao (35%) s hng bin chng t l t vong <1%. Vim phc mc do thng rut amip hay pxe gan v t l t p th ti cp t l t vong > 70 % . Bnh nng tr nh, ngi gi, ph n mang thai . X. IU TR 1. Cc nhm thuc iu tr amip 1.1 Thuc dit amip khuych tn 1.1.1 Emetin: Tc ng n amip trong thnh rut, khng tc dng vi amip trong lng rut . - c tnh i vi tim: c th gy au ngc, kh th, vim c tim nhim c, ri lon nhp tim . Thn ki Ri lon tiu ha: nn ma, tiu chy. 188

- Liu lng v cch dng: 1mg/kg/24 gi tim di da su, tng liu khng qu 1cg/kg. - Chng ch nh : bnh tim, bnh thn, thai nghn (3 thng u) tr di 1 tui. Dehydroemet tin v t i hn, liu 1-2 mg/kg/ngy. 1.1.2. Amino chloroquin : Trc y c dng iu tr abces gan .Liu 1g/ngy trong 2 ngy sau 0,5 g /ngy trong 19 ngy tip theo (iu tr phi hp) 1.2.Thuc dit amip khng khuych tn

1.2.1. Thuc c arsen: Stovarsol, Bemarsol. Liu 2 g/ngy x 10 ngy. 1.2.2. Dn xut c iod ca Quinolein tc dng va dit trng va dit kn amip. - iodoquin 650 mgX 2 ln/ ngy X 20 ngy. - irexiode 210 mg X 4-6 vim/ ngy X 15 -20 ngy. 1.2.3. Diloxanid furoate ( Furamide). Dng cho bnh nhn c kn trong phn . Vin 0,5g X3 vin/ngy. 1.2.4. Khng sinh: - Paramomycine (humatin) Khng b hp thu nim mc rut, khng gy nhim c, tc dng va dit trng va dit amip /ngy X 10 ngy. - Oxytetracyclin ( tetracycline). Liu 2g/ngy X 10 ngy. - Erythromycine : dng trong bnh l xm ln c bit tr em. 1.3. Thuc dit amip ton din: 5-nitro- Imidazole L 1 khng sinh dit amip v kn hu hiu, t c, dng cho amip trong v ngoi rut. 1.3.1. Metronidazole (Flagyl, klion, vagyl): r tin, d kim, hp thu tt. Liu: Tr em 35-50 mg/kg/24 gi X 10 ngy Ngi ln: 750 mg X3 ln / ngy. c tnh: Thn trng dng ngi c bnh thn kinh trung ng , bnh gan nng, hn ch i v huc trong sa tng ng nng trong huyt tng ) thuc c kh nng gy u bu cho tr Tc dng ph: Ri lon tu ha: bun nn, chn n, i ma, tiu chy, au thng v. Nhc u, chng mt, d cm chi, au khp, mt ng, pht ban, ni m ay . 1.3.2. Cc thuc sau Metronidazole Tinidazole (Fasigyn) 2 g/ ngy X 3-5 ngy. Secnidazol e (Flagentyl) 2 g liu duy nht. Ornidazole (Tiberal) 1,5g/ngy X 3-5 ngy. Cc thuc ny c hot tnh vi amip th hot ng, th minuta v kn, thi gian bn hy ko d hai sau thng th 3 c th dng. 2. p dng thc t 2.1. Amip i trng cp Dng Metronidazole, cn au gim sau 24- 48 gi, phn tr v bnh thng sau 2-3 ngy, amip b hn sau 3-6 ngy, tn thng trc trng thnh so sau 10- 15 ngy. Cui t kim tra phn n hi iu tr thm thuc dit amp khng khuych tn trnh ti pht hay chuyn sang mn tn 2.2. Ngi mang kn trong phn khng triu chng iu tr bng: Diloxanide furoate, Diidohydroxyquin, Metronidazole, Paramomycine. 189

2.3.Bnh amip gan iu tr bng Metronidazole thm iodoquinole hay dehydroemetin hay Chloroquin 2.4. Bnh amip i trng mn Phi xc nh bnh nhn cn mang amip hay khng, cn xt nghim phn nhiu ln sau khi ung t tm tn thng. Nu cn amip, cho thuc dit amip ton din. Thm thuc bng nim mc rut, ubtilis, Lactobacillus. 3. Ch n King thc n nhiu bt, ng, nhiu cellulose, cc thc n m bnh nhn d ng. XI. PH NG BNH - V sinh phn rc , qun l vic dng phn trong nng nghip. - Xy cc h x hp v sinh - X l tt nc thi v nc ung, chlor v iode nng ung c th khng dit amip, - V sinh thc phm, n ung, ra tay sch trc khi n, n chn ung chn, ra sch rau sng d lm, c cng ng chp nhn. - Dit rui dn d thc hin, chi tr v chp nhn. - Khng cn ung thuc phng v khng c hiu lc thit thc. - Vaccine cha c ng dng trong thc t - Xt nghim thm d, pht hin ngi lnh mang kn nht l ngi lm ngh ch bin thc n, amip lu hnh, phi c bin php iu tr, qun l ngi mang k sinh trng. - Nng cao i sng v trnh vn ha trong cng ng. - Gio dc v sinh phng bnh. Cu hi n tp 1.Trnh by cc hnh thi amip rut ngi v vai tr ca mi th

2.Cc yu t nguy c 3.Trnh by lm sng 4.Cc xt nghim cn 5.Nu cc bin chng MC LC

ca l amip v iu ca th thng gp nht ca l amip thit chn on l amip ngoi rut ca l amip

Chng 1. I CNG Trang 1. i cng bnh nhim trng - truyn nhim................................................. ....................1 2. Nguyn tc x dng KS trong bnh nhim khun.............................................. ...................9 3. Nhim khun - sc nhim khun.......................................................... .................................14 4. St ko di cha r nguyn nhn........................................................... ..............................24 5. Hi chng vng da trong cc bnh nhim trng.............................................. ....................29 6. Hi chng st pht ban nhim trng....................................................... ..............................34 7. Nhim trng nhim c thc n............................................................. ..............................39 Chng 2. CC BNH DO NHIM KHUN 8. Bnh vim mng no m................................................................. ....................................43 9. Bnh l trc khun................................................................... ............................................51 10. Bnh dch t...................................................................... ..................................................60 11. Bnh thng hn..................................................................... ............................................68 12. Bnh st m...................................................................... .................................................76 13. Bnh nhim no m cu................................................................. .....................................83 14. Bnh nhim t cu................................................................... ............................................88 15. Bnh un vn...................................................................... ................................................92 16. Bnh dch hch.................................................................... ................................................97 17. Bnh nhim leptospira ......................................................... ...........................................101 Chng 3. CC BNH DO NHIM VIRUS 18. Nhim HIV/AIDS................................................................ .............................................105 19. Bnh vim gan virus............................................................ ............................................115 20. Bnh nhim do virus dengue...................................................... ......................................125 21. Bnh cm (gm H5N1) v SARS......................................................... ............................134 22. Bnh rubella.................................................................. ....................................................143 23. Bnh vim no Nht Bn............................................................... ..................................148 24. Bnh di........................................................................ ....................................................152

25. Bnh thu u....................................................................... ...........................................157 26. Bnh quai b.................................................................... ..................................................161 Chng 4. CC BNH DO NHIM K SINH TRNG 27. Bnh st rt thng................................................................... ........................................165 28. Bnh st rt c tnh.................................................................. ..........................................174 29. Bnh l Amp...................................................................... ..............................................181 Ti liu tham kho.................................................................... ............................................182 190 TI LIU THAM KHO

Bi 1. i cng bnh nhim trng - truyn nhim 1. Bi i. 2002. Bnh hc truyn nhim. Nh Xut Bn Y Hc, H Ni. 2. Phan Qun. 2002. i cng bnh nhim trng-truyn nhim. Trong: Bi ging bnh truyn nhi Trng i Hc Y Khoa Hu). 3. E. PILLY. 2004. Maladies Infectious et Tropicales. APPIT,19e dition. Paris. 4. Hoeprich P.D., Jordan M.C., Allan R.R .1994. Infectious Diseases. J.B. Lippin cott Company, fifth Edition. Philadelphia. 5. Jawetz E., Melnick J.L., Adelberg E.A. .1989. Medical Microbiology. A Lange M edical Book, eighteen edition. California. Bi 2. Nguyn tc x dng khng sinh trong bnh nhim khun 1. Bi i. 2002. Bnh hc truyn nhim. Nh xut bn Y hc. H ni. 2. B Y t. 2005. Ti liu tp hun: S dng thuc hp l trong iu tr. H Ni. 3.Simon, Stille. 2000. Antibiotika -Therapie in klinik und praxis. 10.Auflage, S hattauer, Stuttgart, NewYork. Bi 3. Nhim khun v sc nhim khun Ting Anh 1. Annane D et al. 2002. Effect of treatment with low doses of hydrocortisone an d fludrocortisone on mortality in patients with septic shock. JAMA 288:862, 2002 2 Bernard gr et al. 2001.Efficacy and safety of recombinant human activated prot ein C for severe sepsis. N Engl J Med 344:699, 2001. 3.Hotchkiss RS, Karl IE. 2003. The pathophysiology and treatment of sepsi s. N Engl J Med 348:138, 2003 4. Munford RS, Pugin J.. 2001. Normal responses to injury prevent systemic infla mmation and can be immunosuppressive. Am J Respir Crit Care Med 163:316, 2001 5. Robert S. Munford. 2005. Harrisons Priciple of internal medicine 16th editio n. Severe Sepsis and Septic Shock. McGraw - Hill. NewYork. USA Ting Php 1. M. Garr et Rmy. 2001. tat septicmique et choc infectieux. Maladies infectieuses. E. PILLY. Appit. Paris. Bi 4. St ko di cha r nguyn nhn Ting anh 1. Aduan R et al .1978. Prolonged fever of unknown origin. Clin Res 26:558A, 197 8 2. Hirschmann JV.1997. Fever of unknown origin in adults. Clin Infect Dis 24:291 , 1997 3. Jeffrey A. Gelfand Michael V. Callahan .2005. Fever of Unknown Orgin. Harris ons Priciple of internal medicine 16th edition. McGraw - Hill. NewYork. 4.. Kazanjian PH .1992. Fever of unknown origin: Review of 86 patients treated i n community hospitals. Clin Infect Dis 15:968, 1992 5. O Grady NP et al. 1998. Practice guidelines for evaluating new fever in criti

cally ill adult patients. Clin Infect Dis 26:1042, 1998. Ting php 1. Garr M. et Rmy. 2001. Fivres (abord diagnostic et conduit tenir). Maladies infec tieuses. PILLY.Appit. Paris. France Bi 5. Hi chng vng da trong cc bnh nhim trng 1. Berk P.D., Wolkoff A.W..2001. Bilirubin metabolism and the yperbilirubinemias , Harrison s Principles of internal medecine, 15 th Edition, McGraw - Hill. NewYork,USA 2. E.Pilly. 2002. Ictres fbriles d origine infectieuse, Maladies infectieuses et tropicales, Appit, Paris, France 3. Herlong H.F. 1998. Approach to the patient with infection of the liver, Infec tious Diseases, 2nd edition, USA 191 Bi 6. Hi chng st pht ban nhim trng Ting anh 1. Cherry JD. 1992. Contemporary infectious exanthems. Clin Infect Dis 16:199, 1 992. 2. Elaine T. Kaye, Kenneth M. Kaye. 2005. Fever and Rash. Harrisons P riciple of internal medicine 16th edition. McGraw - Hill. NewYork. USA 3. Levin S, Goodman LJ. 1995. An approach to acute fever and rash (AFR) in the a dult. Curr Clin Top Infect Dis 15:19, 1995 4. Weber DJ et al. 2000. The acutely ill patient with fever and rash, in Princip les and Practice of Infectious Diseases, vol 1, 5th ed, GL Mandell et al (eds). Philadelphia, Church ill Livingstone, 2000. Ting php 1. Garr M.et Rmy. 2001. Infection cutanes. Maladies infectieuses. E. Pilly.Appit. Paris, France. 2. Garr M. et Rmy. 2001. Eruption cutanes dorigine infectieuse. Maladies infectieuse s. E. Pilly .Appit. Paris, France. 3. Garr M. et Rmy. 2001. Purpura infectieux . Maladies infectieuses. E. Pilly.Appi t. Paris, France. Bi 7. Nhim trng nhim c thc n 1. Bi i. 2002. Bnh hc Truyn Nhim. Nh xut bn Y hc. H ni. 2. Nguyn Duy Thanh. 1991. Bnh truyn nhim, S y t Hu Giang. 3. Nguyn th Thu Tho. 1997. Bnh truyn nhim. B mn Truyn nhim trng HYD TP HCM. Nh h H Ch Minh. 4. E.Pilly. 2002. Intoxication alimentaire. Maladies infectieuses et tropicales , Appit, Paris, France 5. Reed S.L. 1998. Harrison s Principles of internal medecine, 14 th Edition, Mc Graw - Hill. NewYork. USA Bi 8. Bnh vim mng no m 1. E.Pilly. 2002. Conduite tenir devant un syndrome mning. Maladies inf ectieuses et tropicales.APPIT,18e dition. Paris. France 2. Roos K.L., Tyler K.L.. 2001. Bacterial meningitis and other suppurative infec tions. Harrisons Principles of Internal Medicine. 15 th Edition, McGraw - Hill. NewYork,USA 3. The Washington Manual of Medical Therapeutics. 2001. Meningitis. NewYork. USA Bi 9. Bnh l trc khun 1. Bi i. 2002. L trc khun cp, Bnh hc truyn nhim. Nh xut bn y hc. H ni 2. Phm Th L Hoa. 1997. Bnh l trc trng, Bnh truyn nhim, B mn Truyn nhim trng HYD TP HCM. Nh xut bn y hc, thnh ph H Ch Minh. 3. Gerald T. Keusch. 2001. Shigellosis. Harrison s Principles of internal medec

ine, 15 th Edition, McGraw - Hill. NewYork,USA 4. Gerald T. Keusch. 1998. Shigella, Infectious Diseases, 2nd edition, USA 5. E.Pilly. 2002. Diarrhes Infectieuses. Maladies infectieuses et tropica les.APPIT,18e dition. Paris. France Bi 10. Bnh dch t 1. Gerald T., Keusch, Matthew K, Waldor. 2001. Cholera and other vibrioses. Harr ison s Principles of internal medecine, 15 th Edition, McGraw - Hill. NewYork,USA 2. Cecil texbook of Medicine.1998 3. E.Pilly. 2002. Diarrhees infectieuses. Maladies infectieuses et tropi cales.APPIT,18e dition. Paris. France 4. Weekly epidemiological record 2000. 5. Tp ch y hc d phng. S 3 - 2002 Bi 11. Bnh thng hn 1. Nguyn Hu Bnh. 1991. Bnh Thng Hn. Bch Khoa Th Bnh Hc 1. Trung Tm Quc Gia Bin Son T in Bch Khoa Vit Nam. H Ni. 2. Phan Qun. 2002. Bnh thng hn. Trong: Bi ging bnh truyn nhim (B mn Truyn Nhim). Trng i Hc Y Khoa Hu). 3. Christopher M. Parry et al. 2002. Typhoid Fever. The N Engl J Med, vol. 347, No.22. November 28. 192 4. Gerald T. Keusch. 2001. Salmonellosis. Harrisons Principle of Internal Medicin e. Mc Graw- Hill, 15 th edition, NewYork, USA Bi 12. Bnh st m 1. Bi i. 2002. Bnh hc truyn nhim. Nh Xut Bn Y Hc, H Ni. 2. anp V.M.J. Muravi M.I. ch bin, Bi i dch. 1968.Trm V Sinh Phng Dch, Phng Chng St M. Nh Xut Bn Y Hc v Th Dc Th Thao. H ni. 3. E. PILLY. 2002. Maladies Infectious et Tropicales. APPIT,18e dition. Paris. Fr ance 4. Golvan Y.-J..1983. lments de Parasitologie Mdicale. Flammarion, Paris. France 5. Hoeprich P.D., Jordan M.C., Ronald A.R. 1994. Infectious Diseases. J.B. Lippi ncott Company, fifth Edition. Philadelphia. USA 6. Jawetz E., Melnick J.L., Adelberg E.A. 1989. Medical Microbiology. A Lange Me dical Book, eighteen edition. California. 7. Manson - Bahr P.E.C. and Bell D.R..1987. Mansons Tropical Diseases. Balliere Tindall, nineteenth Edition. Philadelphia. USA Bi 13. Bnh nhim no m cu Ting anh 1. Centers for Disease Control and Prevention 2000: Prevention and control of me ningococcal disease: Recommendations of the Advisory Committee on Immunization P ractices (ACIP). MMWR 49(RR-7):1, 2000 2. Stephens D.S., Munford R.S., Wetzler L.M..2005. Meningococcal infection. Harr isons Priciple of internal medicine 16th edition. McGraw - Hill. NewYork. USA 3. Johansson L et al.. 2003. CD46 in meningococcal disease. Science 301:373, 200 3 4. Rosenstein NE et al..2001. Meningococcal disease. New England Journal of Medi cine. 344:1378, 2001. Ting php 1. Garr M. et Rmy. 2001. Infection meningoccoque. Maladies infectieuses. E. Pilly. Appit. Paris, France. Bi 14. Bnh nhim t cu 1. E. PILLY. 2002. Maladies Infectious et Tropicales. APPIT,18e dition. Paris. Fr ance 2. Hoeprich P.D., Jordan M.C., Allan R.R .1994. Infectious Diseases. J.B. Lippin

cott Company, fifth Edition. Philadelphia. 3. Parsonnet J., Deresiewicz R.L. 2001. Staphylococcal infections. Harrisons pri nciples of internal medicine 15th edition CD - ROM.http://www.harrisonsonline.com/ Bi 15. Bnh un vn 1. Bi i. 2002. Bnh hc truyn nhim. NXB Y Hc, H Ni. 2. Abrutyn E. 2001. Tetanus. In: Harrison s The Principle of Internal Medicine,M c Graw-Hill, 15 th edition, NewYork, USA 3. Sutter R.W. et al.. 1998. Tetanus. In: Infectious Diseases (Paul D. Hoeprich et al), pp.1175-85. J.B. Lippincott Company. USA Bi 16. Bnh dch hch 1. Nguyn Trn Chnh. 1997. Bnh dch hch. Bnh truyn nhim, B mn truyn nhim trng H YD TP HCM. Nh xut bn y hc, TP H Ch Minh. 2. Bi i. 2002. Bnh dch hch. Trong: Bnh hc truyn nhim, NXB Y hc, H Ni 3. Grant L. Campbell D.T. Dennis. 2001. Plague and other Yersinia inf ectious, Harrison s Principles of internal medecine, Mc Graw-Hill, 15 th edition, NewYork, USA 4. E.Pilly. 2002. Peste. Maladies infectieuses et tropicales. APPIT,18e dition. P aris. France Bi 17. Bnh nhim leptospira 1. Bi i. 2002. Bnh do Leptospira, Bnh hc Truyn nhim, NXB Y hc, H Ni. 2. Nguyn th L. 1997. Bnh nhim Leptospira, Bnh truyn nhim, B mn truyn nhim trng H YD TP HCM. Nh xut bn y hc, TP H Ch Minh. 3. Faine, Solly. 1994. Leptospirosis. In: Infectious diseases (Hoeprich P.D., Jo rdan M.C., Allan R.R ). J.B. Lippincott Company, fifth Edition. Philadelphia. USA 193

4. Speelman, Peter.2001. Leptospirosis, Harrisons Principles of internal medicine . Mc Graw-Hill, 15 th edition, NewYork, USA Bi 18. Nhim HIV/AIDS Ting vit 1. Phan th thu Anh v Nguyn th Chnh. 1995. Nhng bin i min dch c th nhim HIV, hp pht hin . Nhim HIV/AIDS, i hc Y H ni, NXB Y hc tr. 37-52. 2. B mn Sinh l bnh i hc Y H Ni. 1981. Nhng k thut c bn dng trong min dch hc Nh xut bn Y hc H ni tr. 283. 3. Lu th Minh Chu.2003. Tnh hnh nhim dch HIV/AIDS ti Vit Nam, Tp hun chn on, i ti thnh ph H ch Minh 10/3/2003. 4. L huy Chnh. 1995. Virus gy hi chng suy gim min dch ngi nhim HIV/AIDS , Nhim , NXB Y hc, tr. 26-34. 5. Davis B. 2003. Tng quan v nhng hi chng lm sng thng gp ngi nhim HIV, Bng chn on, iu tr v chm sc HIV/AIDS, Thnh ph H ch Minh.10/3/2003. 6. Duncombe. 2003. Kinh nghim v iu tr d phng, Bng ting Vit, Hi tho xy dng h HIV/AIDS, H ni 21/01/2003. 7. Kakut. 2003. Bnh lao v nhim HIV, Bng ting Vit, Tp hun chn on, iu tr v ch h H ch Minh, 10/3/2003. 8. Kasper. 2003. Sinh hc c s ca nhim HIV, Bng ting Vit, Tp hun chn on, iu tr h ph H ch Minh,10/3/2003. 9. Phm ng Khoa, Nguyn vn v cc cng s. 1997. Nghin cu s lng lympho bo mang mt s nhm thanh nin Vit Nam , Y hc Vit Nam, 1997(3), tr.61-4. 10. Lng Ngc Khu. 2003. Cng tc qun l, iu tr nhim HIV/AIDS ti Vit Nam, Tp hun AIDS, Thnh ph H ch Minh,10/3/2003. 11. Kaplan J. 2003. iu tr nhim trng c hi ngi ln trn th gii, Bn dch ting Vi CH ngi nhim HIV/AIDS, H ni 21/01/2003. 12. Kaplan J. (2003), iu tr v d phng nhim khun c hi, Bng ting Vit, Tp hun ch IDS, Thnh ph H ch Minh, 10/3/2003. 13. Kantipong P. 2003. Tnh hnh chm sc v iu tr nhim trng c hi Thi Lan, B xy dng hng dn iu tr NTCH ngi nhim HIV/AIDS, H ni

21/01/2003. 14. Trn vn Sng & Nguyn Xun Nghim. 1995. Bnh lao v nhim HIV/AIDS , Nhim HIV/AIDS, i hc Y H ni, NXB Y hc tr. 118-24. 15. Selwyn P. 2003. Chm sc v h tr bnh nhn HIV/AIDS, Tp hun chn on, iu tr v c h H ch Minh, 10/3/2003. 16. Selwyn P.2003. Nghin ma tu v AIDS. Chm sc v d phng, Bng ting Vit, Tp hun ch IV/AIDS, Thnh ph H ch Minh, 10/3/2003. Ting Anh 17. Ada G. L. 2000. An immunologists view of HIV infection , Textbook of AIDS medi cine, 2nd edit. William and Wilkins, USA, pp. 87-100. 18. Ambinder R. S. , Major E. O. 2000. Clinical aspects of AIDS-related lymphoma , Textbook of AIDS medicine, 2nd edit. William and Wilkins, USA, pp. 451-6. 19. Clerq E. D. , Balzarini J.. 2000. Nucleoside and non-nucleoside r everse transcriptase inhibitors active against HIV , Textbook of AIDS medicine, 2nd edit. William and Wilkins, USA, pp. 815-47. 194 20. Barber Y. , Rubio C. , Fernander E.. 2000. Host genetic Background at the C CR5 chemokine receptor and vitamin D receptor loci and HIV1 disease pr ogression among HIV-seropositive infection drug users , Journal of Infectious Di seases 2000(183), pp. 1279-88 21. Benette J. E. 2001. Diagnosis and treatment of Fungal Infection : Candidiasi s . Harrisons Principle of Internal medicine, 15th edit. Mac Graw Hill, USA, pp. 54-56. Ting Php 22. Agut H., Calvez V., Gautheret-Dejean A. 2001. Virologie mdicale et infection V IH , VIH 2e dit. 2001. DOIN, France pp. 12-7 . 24. Amiel C. 2001. Histoire naturelle immunologique , Impact mdecine, guide dinfe ction VIH 2001 pp. 79-84. 25. Barre-Sineussi F. 2001. Virologie fondamentale de linfection VIH , VIH 2 e dit. 2001. DOIN, France pp. 3-8 26. Bouchaud O., Fontanet A., Niyongabo T. 2001. Particularits de linfection VIH e n zone tropicale . VIH 2e dit. 2001. DOIN, France pp. 62-8. 27. Charmo G., Maslo C. 1996. Classifications de linfection HIV. Prise en charge d es individus sropositifs , Le Practicien face au SIDA, 2e dit. pp. 23-4 28. Carcelain G., Autran B. 2001. Mcanismes immuno-pathologiques de linfection VIH , VIH 2e dit. 2001. DOIN, France pp. 21-33. 29. Godeau B., Bierling P. 2001. Manifestation hmatologiques de linfection VIH , VIH 2e dit. 2001. DOIN, France pp. 159-66. 30. Hoen B. 2001. Primo-infection VIH , VIH 2e edit. 2001. DOIN, France pp. 71-74. 31. Huer D. 1993. Gneralits de la rponse immunitaire humorale , Immunologie pp. 179-8 8. 32. Jacomet C. 2001. Test biologiques , Impact mdecin. Guide infection VIH 2001, pp . 87-98. Bi 19. Bnh vim gan virus 1. E. PILLY. 2004. Maladies Infectious et Tropicales. APPIT,19e dition. Paris. Fr ance 2. Lok A.S.F., McMahon B.J.2004. Chronic hepatitis B: Update of recommadations. AASLD. Hepatology, March 2004. 3. Olsen S.K., Brown R.S.2006. Chronic Hepatitis B With Worsening Liver Function Tests on Antiviral Therapy: A Clinical Conundrum. Ann Intern Med 2006;144:705-714,770-771

. Bi 20. Bnh nhim do virus dengue 1. quang H, Trn nguyn c v cng s. 1998. Gp Phn Phng Chng Ch ng Dch St Xut Huyt Dengue ti Tuyn C S. Thi S Y Dc Hc 8/1998, trang 203-206. 2. Phan Qun. 2002. Bnh nhim virus dengue. Trong: Bi ging Bnh truyn nhim do b mn Tryun Nhim Trng i Hc Y Khoa Hu bin son. 3. Phm Song. 1991. ng g Xut Huyt. Trong: Bch Khoa Th Bnh Hc. Trung Tm Quc Gia Bin Son T in Bch Khoa Vit Nam, H Ni 1991. 1. trang150-154. 4. Henchal E.A., Robert Putnak (1990). The Dengue Virus. Clinical Microbiology R eviews. Oct. 1990. 5. Halstead S.B. Dengue. 1994. In: Infectious Diseases (Paul D.Hoeprich, M. Coli n Jordan, and Allan R. Ronald). J.B. Lippincott Company, Fifth edition, Philadelphia, 1994. 6. WHO. 1997. Dengue Hemorragic Fever / Diagnosis, Treatment, Prevention and Con trol, 2 nd edtion, Geneva: WHO. 1997. Bi 21, Bnh cm (gm H5N1) v SARS 1. B Y t. 2003. Hng dn tm thi chn on, x tr v phng ly nhim hi chng h hp c 2. B Y t. 2005. Dch t, lm sng, iu tr v phng chng bnh vim ng h hp cp (SARS 3. Dolin R. 2001. Influenza. In: Harrisons The Principle of Internal Medicine. Mc Graw-Hill, 15 th edition, NewYork, USA 4. E. PILLY. 2002. Grippe. In: Maladies infectieuses et tropicale. E. Pilly. A PPIT.18 e edition. Appitt. Paris. France 195

5. Loletta K.Y.S. et al. 2003. Development of a standard treatment protocol f or severe acute respiratory syndrome. The Lancet, vol 361, May 10, pp.1615-1617. Bi 22. Bnh rubella 1. E. PILLY. 2004. Maladies Infectious et Tropicales. APPIT,19e dition. Paris. Fr ance 2. Ezike E. Rubella.2004. You are in: eMedicine Specialties Last Updated: Novem ber 2, 2004. At: http://www.emedicine.com/cgi-/foxweb.exe/screen@d:/em/ga ?book=ped&authorid=6883&topicid=2025 Bi 23 Bnh vim no Nht Bn 1. Bnh hc truyn nhim. Trng i hc y khoa Hu . Vim no nht bn. Nguyn th thanh Bn 2. Bi i , Nguyn vn Mi, Nguyn Hong Tun. 2002. Sch gio khoa Bnh hc truyn nhim . 349 -355 3. Robert S. Munford .1998. Arboviroses. In: Harrisons Principles of Internal Med icine. 976 - 980 4. E. Pilly. 2002. Arborviroses. Maladies infectieuses et tropicales.18 edition. . 433 -435. Bi 24 Bnh di Ting Anh 1. Centers for Disease Control and Prevention. 2003. Human rabiesIow , 2002. MMWR 52:47, 2003. 2. C thleen A. H nlon L wrence Corey. 2005. R ies. In: H rrisons Priciple of in tern l medicine (K sper, Br unw rd, F uci, H user, Longo, J meson) 16th edition . Pp. 155 - 60. McGr w - Hill. NewYork. USA 3. J ckson AC et l. 2003. M n gement of r ies in hum ns. Clin Infect Dis 36:60 , 2003 Ting Php 1. Garr M. et Rmy. 2001. Rage. In: Maladies infectieuses. E. Pilly .Appit. pp 5215.. Bi 25. Bnh thu u 1. Bi i. 2002. Bnh thu u. Bnh hc truyn nhim, NXB Y hc, H Ni. 2. Cao ngc Nga. 1997. Bnh Thu u. Trong: Bnh truyn nhim, NXB Y hc, 1997, tr.337-347. 3. E. PILLY.2002. Infections a Herpes virus. In: Maladie infectieuses et tropica les. APPITT. Paris. France. pp.442-457.

Bi 26. Bnh quai b 1. Bi i. 2002. Bnh quai b. Trong: Bnh hc Truyn nhim, NXB Y hc, H Ni. tr.191-196. 2. Pomeroy C., Jordan M.C. 1998. Mumps. In: Infectious Diseases (P. H oeprich et al). J.B.Lippincott Company. USA, pp. 829 - 834 3. Fonquernie L., Bouhour D. 1998. Les oreillons. In: INTERNAT-Maladies infect ieuses, Paris. France, pp. 207 - 212 4. Gerschon A. 2001. Mumps. In: Harrisons Principles of Internal Medicine. Mc Gra w-Hill, 14 th edition, NewYork, USA, pp. 1127-1128. Bi 27. Bnh st rt thng 1. Bnh st rt: bnh hc , lm sng v iu tr. D n quc gia phng chng st rt. B y t 2000 2. Hng dn chn on v iu tr st rt. D n quc gia phng chng st rt. B y t. H n 3. Nicholas J. White, Joel G. Breman. 2002. Malaria and bebesiosis: Diseases cau sed by red blood cell parasites. In: Harrisons Principles of Internal Medi cine. Mc Graw-Hill, 14 th edition, NewYork, USA 4. Zoonoses and arthropod-borne diseases. The Washington Manual of Medical Thera peutics. 2001 5. E.Pilly. 2002. Paludisme. Maladies Infectieuses et tropicales. APPITT. Paris, France. 6. Oxford Handbook of Tropical Medicine. 1999. Bi 28. Bnh st rt c tnh 1. Bnh st rt (2000). Bnh hc, lm sng v iu tr. D n quc gia phng chng st rt. B H ni 2. Hng dn chn on v iu tr st rt. 2003. D n quc gia phng chng st rt. B y t 196

3. Nicholas J. White, Joel G. Breman. Malaria and bebesiosis. 2002. Diseases cau sed by red blood cell parasites. Harrisons Principles of Internal Medicine. 4. Oxford Handbook of Tropical Medicine. 1999. 5. Paludisme .Maladies Infectieuses. E.Pilly 2002 6. Tropical Disease Reseach. Progress 1997-1778 7. Zoonoses and arthropod-borne diseases. The Washington Manual of Medical Thera peutics. 2001 Bi 29. Bnh l amip 1. Bi i. 2002. Bnh do amip, Bnh hc truyn nhim, tr: 49- 55. Nh xut bn y hc, H Ni 2. Nguyn Duy Thanh. 1991. Bnh amip, Bnh truyn nhim, tr: 101- 136, S y t Hu Giang 3. Christopher D., Huston. 2000. Amebiasis, Conn s current Therapy, p: 56-58 4. Reed S.L. 2001. Amebiasis and Infection with free- living Amoeba, Harriso n s Principles of internal medecine, Mc Graw-Hill, 14 th Edition, p: 1199 -1202. USA 5. Reed S.L. 1998. Entamoeba histolytica and other intestinal amoeba, Infectious Diseases, 2nd edition, p: 2393- 95. USA 6. E.Pilly. 2002. Amibiase. In: Maladies infectieuses et Tropicales. APPITT, pp: 446 -448. Paris, France