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 ( 380 C) hay h nhit ( 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

c

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 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 i