TRNG I HC TN C THNG KHOA KHOA HC NG DNG

SERMIN AS NHM 2 07SH1D

VIBRIO CHOLERAE
NM HC 2008-2009
1

H TN
1 2 3 4 5 6 7 8 9 NGUYN QUNH DAO CHU NGC THY DUNG TH DUYN THI QUC HIN EM CAO DNG HOI GIANG TRN TR HU NGUYN TH LAN HNG NGUYN TH MAI HNG NGUYN PHNG H

MSSV
072404S 072408S 072417S 072418S 072420S 072423S 072426S 072427S 072429S

VIBRIO CHOLERAE

I. PHN LOI
_V.cholerae thuc ging Vibrio, h Vibrionaceae, thuc phn nhm gamma ca proteobacteria. V.cholerae l loi bao gm cc vi khun gy v khng gy bnh t c s ging nhau v cu trc DNA v cc tnh cht sinh hc khc, c nh gii phu hc ngi Filippo Pacini (1812-1893) xc nh gy bnh t nm 1854, tuy vy khm ph ca ng khng c cng nhn n khi Robert Koch (1843-1910) nghin cu c lp sau 30 nm v cng b v s phn lp vi khun V.cholerae trong ngi mang bnh t, v xc nhn chng l nguyn nhn gy ra bnh t cng nh phng php phng chng bnh vo nm 1883.

Filippo Pacini (1812-1893)

Robert Koch (1843-1910)

_Cn c vo s khc nhau ca khng nguyn thn (O), V.cholerae c phn chia thnh hn 100 nhm. _Da vo tnh cht sinh hc, V.cholerae c chia lm 2 sinh tp: Vibrio cholerae sinh tp c in v vibrio cholerae sinh tp Eltor Nhng c im ca tp El Tor gip n khng nh kh nng gy nguy him cao hn so vi typ c in bao gm: (1) T l nhim El Tor thp hn nhiu so vi t l nhim tp c in; (2) Thi gian mang trng sau khi b bnh do El Tor di hn so vi trng hp nhim tp c in; (3) El Tor c kh nng tn ti ngoi mi trng tt hn, di hn tp c in. Chnh v vy El Tor c kh nng gy dch ti c nhng ni Tp c in tng "tung honh"! _Hu ht cc chng vi khun t u khng c c tnh. Chng Bengal gy thnh dch c nh danh l O1. Da vo thnh phn khng nguyn v (O antigen), V.cholerae O1 chia lm 3 tp huyt thanh (serotype): Ogawa, Inaba v Hikojima. Mi chng trong 3 loi ny c kh nng th hin c tnh ca chng c in hay ca El Tor. -Tp Ogawa c khng nguyn A v B -Tp Inaba c khng nguyn A v C -Tp Hikojima c khng nguyn A, B, C 3

_Trong ch c 2 tp Ogawa v Inaba thnh bnh. Tp Hikojima thng him gp. _Trc nm 1992, cn nguyn ca tt c v dch t u bt ngun t nhm O1. Nm 1992 xut hin 1 nhm huyt thanh mi, gy tiu chy cp c c ch ging vi V.cholerae O1, l V. cholerae O139 "Bengal". V mt di truyn, O139 "Bengal" hnh thnh t El Tor nhng cu trc khng nguyn ca chng cng bin i. V.cholerae 9 khng c cc gen kim sot qu trnh tng hp khng nguyn ging nh O1, v vy n khng b ngng kt bi khng huyt thanh khng O1. Do c tnh khng nguyn O c th ca Bengal O139 nn c th khng c min dch sau khi bnh.

Do 1 s yu t nht nh cc dng non O1 v non O139 khng gy bnh sau khi trao i thng tin di truyn vi chng O1 v O139 s chuyn thnh dng gy bnh

II. C IM SINH HC
_Vi khun hnh que cong, Gram m, kch thc 0,3-0,61,5m, khng c v khng hnh thnh bo t, c 1 tin mao u v c kh nng di ng mnh. _Hiu kh, pht trin tt trong mi trng kim (pH 8,5-9,5) v nng NaCl cao (3%) nhit 37oC _Tnh cht sinh ho: ln men khng sinh hi, cha 1 s enzyme dch ho gelatin, kh nitrat thnh nitrit,phn gii tryptophan thnh idol, ln men ng glucose, sucrose,manose _Sc khng: Bn vi nhit , sy kh, tia x, cc phn ng acid v cht st trng, thng cht sau 15 pht 56oC. trong d dy cht nhanh bi dch mt, HNO2 ca d dy. _Trong mi trng m, lnh, pH kim vi khun sng lu hn. Tn ti trong phn v nc thi, nc ging, sng rch khong 14 ngy, nc bin l 6 ngy, nc h l 5 ngy v c th tn ti trong sa n 20 ngy.

B gen vi khun v s sn sinh c t: _c t ng rut ca vi khun l sn phm ca ctxAB gene . ctxA m ho cu phn A, ctxB m ho cu phn B. Thng tin ca cc gene ny c chuyn v cng mt mRNA sau khi sao m (chng l thnh phn ca mt operon). _ Qu trnh sao m ca ctxAB c iu ho bi nhiu yu t bao gm c cc tn hiu mi trng trong vi khun ang tn ti nh nhit , pH, tnh thm thu, cc amino acid. Mt s gene khc ca phy khun cng c iu ho theo c ch tng t nh cc gene trong tcp operon. tcp c cho l quyt nh qu trnh tng hp "roi" hay "lng" ca vi khun. Chnh v vy m c ctx v tcp u chu nh hng ca cc yu t mi trng. _ mRNA ny c hai v tr kt hp vi ribosome pha u 5' cc on gene tng ng. V tr kt hp ribosome ca cu phn B c kh nng hot ng mnh hn t nht 7 ln so vi v tr kt hp ribosom ca A chnh v th m lng sn phm ca qu trnh dch m (cc protein) ca B s gp vi ln potein ca A. T l protein A v B m bo c lc ca vi khun l 1A:5B. Sau khi c tng hp, protein A v B kt hp vi nhau ti v tr gia mng t bo v mng ngoi ca ribosom. Lng protein B cn d s c tit ra khi t bo. Tuy nhin thnh phn A phi c kt hp vi 5B c vn chuyn ra ngoi t bo. Thnh phn A nguyn vn (cha kt hp vi B) s trng thi bt hot v c gi li bng cch hnh thnh hai phn A1 v A2 ni vi nhau bng lin kt disulfide. Khi c t vi khun kt hp vi GM1 receptor ca t bo vt ch, thnh phn A1 c gii phng (bng cch ct lin kt disulfide) v xm nhp vo t bo. C ch xm nhp ca A1 cha c bit r. C gi thit cho rng 5 n v cu phn B (5B) to thnh mt khe trn mng t bo gip A1 xm nhp. _Cc protein c xc nh lin quan n qu trnh iu ho cc gene ni trn bao gm ToxR, ToxS v ToxT. ToxR l mt protein mng vi 2/3 amino acid nm trong t bo cht. T hp hai protein ToxR (ToxR dimer) kt hp vi vng khi s ca ctxAB v hot ho qu trnh sao m. ToxS protein c cho l c chc nng p ng vi cc tn hiu mi trng, lm thay i hnh thi v c th thay i qu trnh bt cp ca ToxR qua xc tin sao m. ToxS ng vai tr nh b phn cm bin, phosphoryl ho v chuyn ToxR sang trng thi kt hp vi DNA. ToxT l protein trong t bo cht c chc nng hot ho tcp opeon dn n tng hp thnh phn ca tcp pili. Biu hin ca ToxT chu nh hng ca ToxR. V vy, ToxR l mt protein iu ho thc hin chc nng "khi mo" h thng iu khin. ToxR cng c cho l tng tc vi ToxS thc hin chc nng nhn bit cc thay i ca yu t mi trng v chuyn cc tn hiu ( mc phn t) n nhim sc th dn n qu trnh sao m ca cc gene gip vi khun gn kt vi mng t bo v sn xut c t.

III. CHU TRNH SNG

_NGUN LY NHIM Do dng ngun nc nhim vi khun gy bnh. Do tip xc gin tip hay trc tip vi ngun cht thi ca ngi bnh (phn, nc thi, cht nn),cc ngun thc phm nhim khun khng c nu chn k nh rau qu, c sng, nc , c bit l cc loi hi sn gip xc (tm, cua, s.). Tiu biu nn dch t xy ra M vo thp nin 1970s bt u t s v cua b nhim khun vnh Mexico. Ngoi ra, ngun truyn bnh cn xut pht t nhng ngi lnh mang mm bnh. Bnh thng bc pht nhng khu dn c c mc thu nhp thp, nhim mi trng nng, thc v sinh cha cao. Rui nhng, rc ng, nc ao t, gin, thc phm i thiu l nhng tc nhn gy bng pht bnh. Bo l cng l 1 phng tin lan truyn vi khun n cc vng xa hn. Cc nghin cu gen mi y cho thy mc d ly nhim ca 1 ngi i vi bnh t cn ph thuc vo nhm mu. Ngi c nhm mu O d ly nhim nht trong khi ngi c nhm mu AB c kh nng khng c nhiu nht. Gia 2 thi cc ny l nhng ngi c nhm mu A v B, v nhm mu A c kh nng khng V.cholerae nhiu hn nhm mu B _Trong iu kin t nhin,V.cholerae thng gy bnh cho ngi. Khi theo nc ung hay thc n vo trong d dy, vi khun chu tc ng ca dch d dy c pH thp (mi trng axit). Bnh thng, pH d dy xp x 3, gy cht nhanh chng cho V.cholerae v 1 s vi khun khc. Nhng th nghim trn ng vt v ngi tnh nguyn cho thy V.cholerae gy tiu chy nu cho ung Natri Cabonat ngay trc khi ung dung dch cha V.cholerae. Trn thc t, bnh t thng gp nhng ngi c acid ca dch v gim hoc mt. i vi ngi bnh thng th thc n phi c kh nng trung ho bt acid ca dch v th vi khun mi c kh nng gy bnh c. 6

_Sau khi qua khi tc ng ca dch v d dy,nhng vi khun sng st s tip tc xung rut non. rut non,nh pH thch hp, vi khun c kh nng tn ti v pht trin rt tt. Do kh nng "t bi", vi khun c th chuyn ng ngc chiu vi nhu ng rut tip cn vi nim mc rut nh c im ho hng ng ca chng. Phy khun c kh nng khng tc ng ca mui mt, xm nhp qua lp mng nhy trn nim mc rut. Qu trnh xm nhp c h tr bi men tan nhy v cc men phn ct protein thnh cc peptide.Khi bm vo nim mc rut, vi khun hu nh khng xm nhp su vo m rut v khng gy tn thng cho nim mc rut, nhng li tit ra c t rut LT (thermolabile toxin). c t sinh ra gn vo nim mc rut non lm t bo gim hp th Na+, tng tit nc v Cl- gy tiu chy cp tnh. Sau vi khun theo cht thi ca ngi bnh ra ngoi mi trng, pht tn i nh nc v tip tc xm nhp vo c th khc. IV. C CH GY BNH 1. c t ca phy khun tip xc vi b mt mng t bo. Kh nng gn kt v c nh vo t bo nim mc c th c h tr bi cc "si lng" ca chng kt li thnh b mt u vi khun. Cc si ny c gi l Tcp pili (toxin coregulated pili: cc si phi hp iu ho c t). Chui amino acid ca Tcp pili tng t nh N-methylphenylalamine pili ca Pseudomonas v Neisseria. Vi khun cn c kh nng tng hp hai protease c tn chitinase v mucinase. Chitinase l sn phm tit c kh nng lm bin i chitin - thnh phn cu to lp v cng ca cc loi gip xc trong c tm, cua bng cch b gy cc lin kt glycosidic v gip vi khun xm nhp qua c lp v vo c th nhng ng vt ny. Mucinase l mt protease khng c hiu nhng c tc dng h tr cho vi khun khi xm nhp vo ng tiu ha ca ngi. Mt c t khc ca vi khun c tn Zone Occludans Toxin (ZOT) c tc dng ln cc t chc k gn kt cc t bo biu m thnh rut to iu kin cho vi khun c nh v sn xut c t trong ng tiu ha ca ngi. 2. Cc thnh phn lin kt (B) gn vi oligosaccharide ca mt th quan c bit c tn monosialosyl ganglioside (GM1 ganglioside); 3. Thay i dng ca th quan: Vibrio cholerae sn xut men tan nhy v cht gip n xm nhp vo t bo ng thi tc ng lm GM1 ganglioside c trn b mt cc t bo nim mc chuyn thnh monosialosyl c th nhn c t, gip cu phn A tip xc vi mng t bo. Ngoi ra, men tan nhy ca Vibrio cholerae cn gip chng phn gii cc protein nh fibronectin, lactoferrin v phn gii chnh c t ca n 4. Cu phn A xm nhp vo t bo; 5. Lin kt dissulfide ca cu phn A chu tc ng ca glutathione trong t bo dn n gii phng tiu phn A1 v A2; 6. A1 thu phn NAD gii phng ADP-Ribose v nicotinamide, 7

7. Mt trong cc protein Gs hoc Ns c tc dng iu ho h thng ca adenylate cyclase c mt pha trong mng t bo di xc tc ca tiu phn A1 s gn vi ADP-Ribose hnh thnh dng lin kt protein vi ADP-Ribose (GsADPR), gy c ch hot ng ca GTPase v gi adenylate cyclase trng thi hot ng; . 8. Adenylate cyclase l mt enzyme lin kt vi mng t bo v c kh nng xc tc qu trnh chuyn ATP (adenosine triphosphate) thnh dng AMP vng (cyclic adenosine monophosphate-cAMP). Bnh thng adenylate cyclase c hot ho bi protein iu ho v GTP. Thi gian hot ho adenylate cyclase thng ngn do mt protein khc (c gi l Gi) c kh nng thu phn GTP lm mt kh nng hot ho adenylate cyclase ca GTP.Vic c ch hot ng ca GTPase lm GTP khng b thu phn tip tc thc hin chc nng hot ho adenylate cyclase dn n hnh thnh hm lng cao hn bnh thng ca cAMP. cAMP kch thch t bo "bm" ion Cl- vo lng rut. Do mt ion Cl- nn nc, Na+, v cc cht in gii khc nh K+, Cl-, HCO3- s ra khi t bo (theo chiu gradient). Chnh v vy cc t bo chu tc ng ca c t V.cholerae nghim nhin tr thnh nhng chic "my bm" chuyn

nc vo lng rut dn n tiu chy, mt cht in gii

V. BNH T
_Ngun gc Bnh t (Cholera) l mt nhim trng ng rut do vi khun Vibrio cholerae gy ra. Bnh t xut hin chu khong 600 nm trc Cng nguyn, c ngun gc t n , ghi nhn u tin trong y hc l nm 1563 v i dch nm 1817-1821. Vo khong nm 1831, bnh t ln u tin lan truyn vo chu u lm gn 40.000 ngi

cht Php (1832) v 70.000 ngi cht Anh (nm 1848-1849), cp i sinh mng 1/8 dn s London (1854). Dch t vo Peru nm 1991 v ly sang Ecuado, Colombia, Mexico v Nicaragua lm 12.000 trong s 400.000 ngi bnh Nam M lc thit mng. _Triu chng - Tiu chy lin tc, nn i nhiu, c th gy t vong do tnh trng mt nc nu khng iu tr kp thi. - Nhim vi khun t bt u bng thi k bnh sau tng dn n giai on ton pht. + Thi k bnh: bt u t gi th 4 ko di n 4 - 5 ngy sau khi nhim vi khun t, trung bnh vo khong 36 - 48 gi. + Thi k khi pht: Vo ngy hm sau khi b nhim (t gi th 24 - 4, bnh khi pht t ngt vi cc triu chng nh au bng (t), tiu chy lc u c phn nhng sau l phn lng + Thi k ton pht biu hin vi 4 triu chng tiu biu: - Tiu chy xi x hng chc ln trong ngy, mi ln tiu chy c lt nc. Do , trong vng 6 - 8 ting giai on ton pht, bnh nhn c th b mt n 20 lt nc. 9

Phn ca bnh t c m t l rt c hiu vi mu trng c nh nc vo go, khng m mu, khng hi thi nhng c mi tanh nng. Tiu chy lc ny km au bng t v khng mt rn. i khi bnh nhn i tin khi cha kp vo nh v sinh. Do i a chy nng nn c th b mt nc, cc cht in gii, bicarbonat, v cc ion trong vng mt hai ngy. Hin tng ny xy ra do c t ng rut ca vi khun hot ho enzyme xc tc adenylate cyclase trong cc t bo biu m nim mc rut, bin cc t bo ny thnh "nhng chic bm" thc hin "bm" nc cng cht in gii t trong mu v cc m vo trong rut lm c th nhanh chng b mt nc, thiu niu, toan huyt v b sc. Phn ca ngi bnh c cc t bo biu m ca rut, cc mng nhy (phn nc go) v ng thi c nhiu vi khun. Mt ion trm trng c th dn n bin chng tim mch. - Nn i thng xut hin sau tiu chy, lc u nn ra thc n nhng v sau th nn ra dch vng (do dch mt). C th c cm gic bun nn km theo tiu chy - Hu qu ca tiu chy v i ma l tnh trng mt nc vi cc triu chng nh da kh, nhn nheo, mt tnh n hi, h mt trng su, l , mi kh, tiu rt t, chut rt v cc biu hin co git. - Cc du hiu ton thn khc nh tay chn lnh, tot m hi, nhp th nhanh, tim p rt yu, mch nhanh. T l cht ca bnh rt cao (c th ti 50-60%) nu bnh nhn khng c iu tr kp thi. - i vi thai ph, t c th gy sy thai rt nhanh. i vi tr em cng th, tnh trng mt nc rt d gy ra cc bin chng no b khi h thn kinh ca tr cha pht trin hon chnh. S lng vi khun trong phn cho php xc nh bnh nng nh hay ngi lnh mang mm bnh: + Nu c 103-105 vi khun/1g phn: ngi lnh mang mm bnh + Nu c 106-109 vi khun/1g phn: biu hin bnh nh + Nu c 1010-1012 vi khun/1g phn: biu hin bnh nng

VI. MIN DCH V CHUN ON

1. MIN DCH _C ch khng khng c hiu - acid ca dch v l yu t khng rt quan trng ngn chn V.cholerae. H vi khun bnh thng cng tham gia vo c ch khng khng c hiu nh cnh tranh vi V.cholerae. _C ch khng c hiu -Bnh t to kh nng min dch kh vng bn. Nghin cu cho thy khong 90% s ngi mc bnh khng mc li. Thi gian bo v ko di khong 3 nm. -Vai tr ch cht trong min dch c hiu l min dch tit, do cc globulin min dch (IgA, IgG, IgM) ti lp nim mc rut tit ra c kh nng lm ng vn v lm mt kh nng di ng ca vi khun. i vi c V.cholerae O1 v O139 u c 2 loi khng th c vai tr bo v: khng th chng khng nguyn lng hay chng cc thnh phn lp v vi khun LPS v khng th chng c t rut LT: Khng th chng LPS kh nng v hiu ha qu trnh kt dnh ca vi khun vo cc t bo biu m thnh rut (mt qu trnh c tnh c hiu cao). Khng th chng LT ngn c t ny gn vo th th GM1. -Tuy nhin, cc khng th ny c tnh c hiu khc nhau, nn ngi min dch vi V.cholerae O1 vn mc bnh do V.cholerae O139. 2. CHUN ON a. Chun on trc tip 10

Bnh phm l phn v cht nn. Cn xt nghim trong vng 2 gi, nu mun hn th phi cy vo mi trng bo qun. _ Nhum soi hoc ti: Tin hnh soi ti, quan st tnh di ng ca V.cholerae. Nhum soi m bch cu trong phn, ngi mc bnh c s lng bch cu rt t, khong 5 bch cu trong 1 vi trng ( phng i 400) _K thut khng th hunh quang trc tip: Cho kt qu nhanh v tnh c hiu cao, thng dung p dng kim dch ca khu. _Nui cy phn lp: Thng dng mi trng pepton kim, thch kim, TCBS (Thiosulfate Citrat Bilesalt Sucrose)

b. Chun on huyt thanh Trn thc t khng lm chun on huyt thanh v cho kt qu chm. VII. PHNG PHP CHA TR & PHNG NGA 1. Phng bnh +Khng c hiu: V sinh n ung, dng nc sch, dit rui, chun on sm, cch li bnh nhn, x l phn v cht nn ca ngi bnh. Khi c dch t, phi thng bo ngay v kp thi thc hin cc bin php bao vy dch. X l v sinh khu vc c nhim phn bnh nhn bng cloramin B 10%. Ty trng vt dng c nhn bng nc Javen, nc si, cloramin 2%, khng nn dng vi bt kh trng. +c hiu: Hin c 2 loi vacxin s dng theo ng ung: vacxin ung gim ng lc v vacxin cht. 11

Vacxin phng t c dng nc ta l vacxin bt hot gm O1 v O139, a vo c th theo ng ung. Sau khi b nhim vi khun c th pht hin khng th khng c t, khng khng nguyn v (O), khng nguyn lng (H) trong mu. Vaccin (c cc thnh phn khng nguyn) dn n lm tng lng khng th. Khng th chng li khng nguyn O s ha tan t bo vi khun vi s hin hin ca b th v cc thnh phn khc trong huyt thanh. Lng khng th cao nht sau 8-10 ngy pht bnh, gim dn v tr v trng thi ban u sau khong 2-7 thng. 2. iu tr -B nc v cht in gii bng dung dch oresol, tim truyn natri clorua 0,9% hay dung dchringer lactate nu b mt nc v cht in gii nhiu hn 5% trng lng c
th.

V.cholerae cn nhy vi 1 s loi khng sinh thng thng nh: tetracycline, chloramphenicol, aureomycin, streptomycin, hoc bactrin... Nhng cng xut hin kh nng vi khun khng thuc.

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