Lytructrung_Y 5

8/14/2019 Lytructrung_Y 5

1/39

L TRC TRNG

i tng: Y 5

Bs Phm Th L Hoa


2/39

MC TIU

1.Nu c tm quan trng ca bnh do Shigella

2.K c im vi sinh chnh ca vi trng Shigella

3.Trnh by triu chng chn on bnh & bin chng

4.K cc khng sinh iu tr c hiu

5.Trnh by bin php phng cho c nhn & cng ng


3/39

I. I CNG HC l = fn m mu, mt rn, au bng qun (Hipocrate)

Cui TK 19: phn bit 2 tc nhn l: amp vi trng

(nhn din E. histoliticanm 1859 & Shigellanm 1906)

Roger (1913) phn bit 2 bnh cnh l:

gy dch nh t, tri lnh, bnh tm thn: do Shigella

cabnh l t vo ma nng: doamp

Dch trong lch s: lin quan n cc trn chin, trong tri

lnh. Thit hi do l trc trng vt xa thit hi do chin tranh.


4/39

I. I CNG

T TK 20: Shigella yu t R khng thuc truyn qua

plasmid, gy dch khp ni, nng, t vong cao

Trung M: 1969-73

Bangladesh: u 70s

Nam : gia 80s

Trung Phi: cui 70s n 90s (Zaire Rwanda, Burundi)

cc nc Nam Phi (Zambia, Malawi, Mozambique,

Zimbabwe)


5/39

I. I CNG

Hin nay: ang bng pht; 5-15% tiu chy tr em cc

nc ang pht trin.

nh hng: Bnh nng, bin chng t vong.

Bnh ko di: mt protein qua rut ln.

Vc xin: c OMS xc nh t cui 1990s, cha p dng

rng ri


6/39

II. TC NHN GY BNH

Vi trng Shigella: gia nh Enterobacteriacea, gram m,

khng di ng, khng sinh nha bo, khng c nhung mao, ch

c khng nguyn thn O. Chia 40 serotp & subtype. Nhn

din thnh 4 nhm huyt thanh (4 serogroup):

Nhm A: S.dysenterie, gm 13 serotp.

Nhm B: S.flexnerie, gm 6 serotp (chia 15 subtype)Nhm C: S.boydii, gm 18 serotp

Nhm D: S.sonnei, 1 serotp.


7/39

II. TC NHN GY BNH

Vi trng ch gy bnh trn ngi.

Gy bnh thc nghim trn kh.

Kh nng xm ln: test Sereny (vim kt mc th )

Kh nng lan trn trn nim mc: th nghim to plaque

trn t bo Hela, phi g (di ng kiu Olm - Organelle

like movement & polymer ho actin)


8/39

II. TC NHN GY BNH

c lc ca mt chng Shigella

quy nh bi cc gen /nhim sc th & plasmid

lin quan vi:

Kh nng xm nhp

Kh nng lan trn v sinh sn ni bo

Kh nng sinh c t Shigatoxin


9/39

II. TC NHN GY BNH

KH NNG XM NHP V LAN TRN NI BO

Bi nhm gen (IPAs, virF, mxi) trn

plasmid 120-140 megadalton.

Chu tc dng iu ha bi cc gen(vac B, C, Kcp A) trn nhim sc th

Biu hin cc gen iu ha chu nh hng ca nhit ,p lc thm thu v mt s yu t khc.


10/39


11/39

II. TC NHN GY BNH

Ngoi c t:

SHIGATOXIN dogen stx AB, cu to A-B.

c ch tng hp protein

gy apoptosis.

SHET-1 (do cc locus trn nhim sc th ca S. flexneri 2a)

SHET-2(do cc locus trn plasmid ca Shigella& E.coli)gy tit nc v in gii vo lng rut

Ni c t lipopolysaccharide: gy sc ni c t

KH NNG TIT C T CA VI TRNG


12/39

III. DCH T HC:

1. Tnh hnh l trc trng cc nc trn th gii:

250 triu ca/nm (OMS 1999)

90% nc ang pht trin (3.5/100 dn

so vi 6.5/100.000 dn nuc cng nghip)2. Chng gy bnh:

S. dysenterie:gy bnh trc TC I.

S.flexnerie: T sau TC I

S.sonnei: Sau TC II nc cng nghip


13/39

III. DCH T HCOMS, 1999

ncang pht trin

nccng nghip

S.dysenterie** 6% 1%,

S.flexnerie 60% 16%

S.boydii 6% 2%

S.sonnei 15%* 77%

* ? Pleisiomonas shigelloidesc KN O ging S.sonnei).

* * (nuc ngho & vng chin tranh: S.dysenterie 1)


14/39

III. DCH T HC3. Thay i theo ma:

Ma nng (thiu nc ung & sinh hot)Mt s vng: nuc ma gip Shigella nc).

4. Ngun bnh:

Ngi:Bnh cp (103- 109 VT/g phn).

Bnh hi phc (103 VT/g phn 6 tun)

Ngi mang trng mn: him (AIDS)

Ngun nc: (nhim phn: vi trng sng 6 thng)

nc ging nc h ao nc sui

Clor ha nc git c VT, nga ly Shigellaqua nc.


15/39

III. DCH T HC

5. Cm th

Tr < 6 th c KT chng LPS /sa m

Tr 1-5 tui: cha thc v sinh

thiu min dch mc phi

6. ng ly truyn

Tip xc trc tip: ca l t (t l ca th ft cao, tr nh 60%)

Gin tip: v dch (rui, d.c v sinh, thc n, ngun nc)Quan h tnh dc ng gii nam.


16/39

III. DCH T HC

iu kin gy dch: Thiu nc sch.

VS mi trng km (phn, rc, rui)

Tp th ng ( tip xc trc tip, iu kin VS)

thc VS c nhn km (thiu gio dc y t, tri giam, t nn,

tm thn, chm pht trin)

C a km dinh dng, gim min dch.


17/39

IV. C CH BNH SINH

12 gi sau: tng sinh RN 107

-109

vt/ml:st, au bng, tiu lng, c cn co tht

Sau vi ngy, khng cn VT RN:

st gim, au vng bng di. Giai n mun: tn thung n an cui RG. Mt VT

cao nht b mt nim mc, gim dn n lp lamina

propia: mt rn, tiu lt nht, mc i cu gi.tn thng: microabces lot nim mc


18/39

IV. C CH BNH SINH:

Qu trnh xm nhp Quat bo M trnh by cho TB di nmc RG.

TB tit IL-1 gy t tp BCN di nim mc.

Khi TB cht, phng VT vo di mng y. IL-1 lm thay i tnh cht cu ni lin bo, VT xm nhp

t t lng rut v t di mng y.


19/39

IV. C CH BNH SINH:


20/39

1. gn vo protein INTEGRIN ca tb M nm RG

2. trnh by cho i thc bo. Tng sinh trong TB3. phng thch IL-1 vim v t tp BCN

4. phng VT vo di nm, xm nhp th ft qua mng y

5. BCN chui qua cu lin bo

6. bin i tnh cht lin bo, xm nhp th ft VT qua nmc


21/39

IV. C CH BNH SINH Qu trnh lan trn trong nim mc


22/39

IV. C CH BNH SINH Tc dng ca Shigatoxin

1. c ch tng hp protein: Shigatoxinc tit khi VT pht

trin trong nim mc.

Shigatoxingn vo glycolipid(Gb3) ca nm RG

Cu to A ni bo ha, tc dng

60S, ngn cn gn adenosinln si protein ang thnh lp, c

ch sinh tng hp protein.


23/39

IV. C CH BNH SINH Tc dng ca Shigatoxin

2. Shigatoxingy tit cc cytokin (TNF, IL-1, IL8) gy tn

thng ni mc trong cc hi chng HUS, nhim c thn

kinh.

3. Biu l cm th th vi c t (IL-1, IL-8) ging vai tr ca

Lipopolysaccharide ca vi trng (t tp BC, biu l receptor

vi c t).


24/39

IV. C CH BNH SINHp ng min dch sau nhim Shigella

p ng dch th:

KTh IgA xut hin vi ngy sau, ko di nhiu tun.

Gm: khng th chng lipopolysaccharidekhng th chng c t polypeptid

Bo v: c hiu cho tng serotype

c th bo v cho gia cc serotype.

Min dch t bo cng c vai tr chng nhim trng.


25/39

IV. TRIU CHNG LM SNG

Thay i ty chng VT, c a:

Bnh nng (km sc, hi chng EKIRI, HUS) ngi gi,

tr nh thng, nh cn, SDD hay do nhim S. dysenterie1

1. Thi k bnh: 24 72 gi2. Thi k khi pht: 1-2 ngy vi:

HCNT: St cao, mt mi, au u, mi ton thn.

HC tiu ha:Tiu lng vng, c th nhiu nc (ngi gi,

tr qu nh).


26/39

IV. TRIU CHNG LM SNG

3. Thi k ton pht

Ton thn: HCNT Tng trng

Du mt nc nh. Mt nc nhiu do n km, st cao.

Tiu ha:

Tiu chy nhiu ln (c th 20-60 ln).

Phn t dn v c nhy, mu.

au bng di rn, dc khung i trng.

Mt rn, thn hu mn, sa trc trng (ng.gi, tr con)

Khm bng mm, au khi khm h chu tri


27/39

V. BIN CHNG1. Bin chng thn kinh: sm (c gng, RLTG, cogit) do:

St cao. Ri lan chuyn ha ng.

H natri mu: do mt qua rut hay SiADH

Nhim c TK (HC EKIRI)Hi Chng EKIRI: tng thn

nhit, co git, hn m, nhim

c nng, nng nhng khng

di chng.

Do Shigellanhm A , B, hay

C (ncCN)


28/39

V. BIN CHNG

2. Hi chng tn huyt-ur huyt(HUS):bin chng nng, do S.

dysenterie1, xut hin t tun th hai:tn huyt, vng da, thiu mu

thiu niu

ng mu ni mchgim tiu cu.

3. Nhim trng huytdo

Shigella

cc Enterobacter khc


29/39

V. BIN CHNG

4. Tiu ha:Sa trc trng

Phnh to i trng nhim c(Toxic megacolon) km lit rut

Thng rut gi hay hi trng

5. Suy dinh dngdo mt m qua lot, do n ung km, do

tng d ha.


30/39

V. BIN CHNG

Do nhim S.dysenterie1

1. Nhim trng huyt

2. Hi chng tn huyt-ur huyt(HUS)

3. Tiu ha:

Satrc trng Phnh toi trng nhim c(Toxic megacolon)

Thng rut gi hayhi trng

Do flexneri HC EKIRI (sm)

Vim kt mc, vim khp (Reiter), vim phi, Vim bng

quang, m o (domin dch)


31/39

VI. CN LM SNG

1. Cy phn, cy pht trc trng: thc hin ngay sau khi lymu (hoc gi trong Carry-Blair, nc mui m glycerol).

Mi trng chuyn bit va: Mac-Conkey

Mi trng chuyn bit cao:

DCA (Desoxycholate Citrate Agar)

XLD (Xylose Lysin Desoxycholate)

HEA (Hektoen Enteric Agar).

2. Soiphn:c nhiu BC a nhn (>50 BC/ 40X).


32/39

VI. CN LM SNG

3. Testchn on nhanh

Tm S. dysenterie1 fn:

Nhum KT hunh quang

Tm Shigatoxintrong phn

k thut min dch men -Enzym Immuno Assay

Tm gen c lc trong phn xc nh chng gy bnh c

c lc.

k thut PCR vi an d DNA

k thut ELISA dng khng th n dng


33/39

VII. CHN ON PHN BIT

1. Tiu chy nhim trng do vi trng xm ln khc:E.coli (EIEC, EHEC,..) Campylobacter

Vibrio parahemolyticus Salmonella spp

Yersinia enterocolitica

2. L amp cp v nng ngi gim min dch.

3. Lng rut, thot v nght tr con.

4. Bu i trng hay gp ngi gi.


34/39

VIII. IU TR

1. B nc v in gii

Quan trng ngi gi, tr nh

Mt nc nh & trung bnh:

ORS. iu chnh mt nc, toan chuyn ha, h kali

Mt nc nng:

Lactate Ringer nh fc CDD

2. Dinh dng

Cho n sm, thc n d tiu, ch lng.

Ba n b sung giai an hi phc


35/39

VIII. IU TR

3. Khng sinh: (c ch nh khi c d kin chng minh

nhim trng xm ln) ung 5 ngy

OMS: tiu chn chn KS cho mt cng ng tu d kin

v nhy cm ca VT trong khu vc:

cn dit c 80% chng S dysenterie 1

dng ng ung

chi tr c.


36/39

VIII. IU TR

KS hiu qu in vitro nhng khng tc dng in vivo

Nitrofurantoin Aminoglycoside

Amoxicilline Cefalosporin th h 1 v

Cc khng sinh c t l khng thuc cao cc nc ang

pht trin nh:

Chloramphenicol Tetracycline Streptomycine

Sulfamide Ampicilline Cotrimoxazole

ch cn dng vng khng khng thuc.


37/39

VIII. IU TR: Khng sinh 5 ngy

Tn Thuc Liu ngi ln Liu tr con

Ampicillin 500mg x 4 25mg/kg x 4TrimethoprimSulfamethoxazol 960mg x 2 24mg/kg x 2

A.Nalidixic 500mg x 4 15mg/kg x 4

FluoroquinoloneCiprofloxacin 500mg x 2 10mg/kg x 2

Norfloxacin 400mg x 2

Enoxacin 200mg x 2Azithromycin 500mg N1 10mg/kg N1

250mg N2,3,4 5mg/kg N2,3,4

Pivamdinocilin(USA) 400mg x 4 25mg/kg x 4


38/39

IX. PHNG NGA1. Tng sc khng

Khuyn khch b m 24 thng

Phng & iu tr suy dinh dung.

2. Chng ly trc tip

Cung cp nc sch, bo m chlor

Ci thin iu kin v sinh (cu tiu hp v sinh)

Gio dc thc VS c nhn, VS n ung (nga ly qua

phn, ra tay sau khi i tiu).Cch ly, theo di, iu tr ngi bnh & tip xc.


39/39

IX. PHNG NGA3. Chng ly gin tip

kim sot v sinh thc phm

dit rui nhng

v sinh mi trng.

4. iu tr KS sm trnh suy dinh dng do mt m.

5. Vc xin:cha p dng rng ri do:

serotype

thnh phn KN (Ohay Lipopolysaccharide)

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Lytructrung_Y 5