D ng min dch lm sng 2005

T gia th k 20, chuyn ngnh D ng - Min dch lm sng c hnh thnh nhiu
nc cng nghip (Hoa K, c, Anh, Php v.v.v), v s ngi bnh rt ln, ngy cng tng.
Vic chn on v iu tr khi cha t kt qu mong i, ngoi ra nhng trng hp cp
cu theo chuyn ngnh ny (sc phn v, hen ph qun, ph Quincke, d ng thuc ) hay
xy ra, i hi thy thuc x l nhanh, ng, kp thi.

Lnh o B Y t nc ta (GS. Phm Ngc Thch, GS. V Vn Cn) sm quan tm n

chuyn ngnh D ng - Min dch lm sng, nn t nm 1960 c ngi i hc v t chc
n v D ng i hc Y H Ni (9/1969). Nm 1980, B Y t quyt nh thnh lp B
mn D ng i hc Y H Ni v Khoa D ng - MDLS Bnh vin Bch Mai tin hnh
ging dy (bc i hc v Sau i hc), kt hp nghin cu khoa hc v iu tr ngi bnh.

1. i cng v cc phn ng v bnh d ng - GS.TSKH. Nguyn Nng An

2. D nguyn - GS.TSKH. Nguyn Nng An
3. Hen ph qun -GS.TSKH. Nguyn Nng An
4. D ng thuc -GS.TSKH. Nguyn Nng An
5. Sc phn v -PGS.TS. Phan Quang on
6. My ay - ph Quincke -PGS.TS. Phan Quang on
7. D ng thc n -TS. Nguyn Vn on
8. Vim da atopi v vim da d ng tip xc -TS. Nguyn Th Vn
9. Vim mao mch d ng -TS. Nguyn Vn on
10. Lupus ban h thng -BSCKII. Trng Thanh Lan
11. X cng b TS. Nguyn Th Vn
12. Ti liu tham kho
Theo ch o ca B Y t v trng i hc Y H Ni, B mn D ng bin son Bi ging
D ng - Min dch lm sng cho i tng sinh vin Y5, thi lng ging 20 tit v 48 tit
thc hnh. Phn thc hnh s c bin son thnh tp ring. Rt mong vic bin son Bi
ging D ng - MDLS s gip ch cho sinh vin v c s gp kin ca cc bn ng
nghip ln ti bn sau s c hon chnh hn.

H Ni, ngy 25 thng 12 nm 2005

 i c-ng v cc phn ng v bnh d ng mt s khi
nim v cc phn ng v bnh d ng

Mc tiu hc tp:
1. Hiu -c s pht hin cc hin t-ng d ng kinh in, bn cht ca cc
phn ng v bnh d ng.
2. Nm -c nh ngha, phn loi, c ch cc p hn ng d ng.
3. Hiu r p ng min dch trong cc phn ng v bnh d ng, cc yu t
tham gia
p ng min dch trong vim d ng.

1. vi NT V LCH S PHT HIN CC HIN TNG d NG

1.1. Nhng nhn xt u tin
Hin t-ng d ng -c bit t lu i, vi nhng khi nim khc nhau.
Hippocrate (460-377 TCN) thi c La M, c l l ng -i u tin ch n
biu hin d ng do
thc n ng-i bnh: sau ba n, xut hin my ay, mn nga, ri lon tiu
ho, ph n mt vi vng trn c th. ng gi y l nhng bnh c ng
(idiosyncrasie).
Areteus (87-130) phn bit cn kh th do thay i thi tit v cn kh th
do lm vic qu sc. Ngy nay, ai cng bit l hai bnh khc nhau: tr -ng
hp th nht l hen ph qun d ng v tr-ng hp sau l cn hen tim. Galen
(126 -199) l-u nhng tr-ng hp chy mu nghim trng ng -i bnh sau
khi tip xc vi hoa hng. Hin
t-ng ny mi n th k 16 mi -c nhiu thy thuc khc ch , nh -
Helmont (1577-1644) B v Botalius (1530 -1582) . T nh, Helmont mc
bnh hen ph qun. Da vo kinh nghim bn thn, ng cho rng qu trnh
bnh l din ra trong ph qun. ng thng bo nhiu tr-ng hp kh th
(hen ph qun) do thc n (c) v bi nh. Botalius m t t m hi chng d
ng vi ho a hng: nga v chy n-c mt, ht hi lin tc nhiu ln, nhc
u, i khi ngt th v hn m.
Bostock (1773-1846) Anh nghin cu nh h -ng ca thi tit, kh hu
trong c ch bnh sinh ca cc bnh d ng. Sc kho ca ng tt v ma
ng, nh -ng st km r rt v ma h, nht l vo ma hoa n: mi mt lc
no cng sp xung, n -c mt chy gin gia v nh nng mt tri, nng
ngc. Nm 1828, Bostock m t lm sng ca bnh bnh st ngy ma,
nh-ng nguyn nhn ch -a bit r. Mi n nm 1873, Blackley (1820-1900)
mi lm th nghim b, ng tm -c nguyn nhn bnh l phn hoa
cy, c (b , thng, liu, bch d -ng, c ui mo, c ui tru, c lng
nhung..)
Chu u v chu M, hng nm c n cui thng 5, u thng 6, khi hoa
n khp ni, cng l ma bnh do phn hoa: vim mng kt hp, vim mi d
ng, hen ngy ma; st ngy ma v.v.., t l mc bnh kh ln nh - M -
3% dn s (Criep, 1966).
Ng-i u tin lm th nghim b tr- c Blackley l Salter ( 1823 - 1871). Mt
hm,
ng ang ngi ngh ngoi thnh ph, trn i l con mo ang nm ng.
Bng ng thy kh th, nga mt. B con mo v vut ve n, i tay ng ni
mn nga v nga khp ng-i. Theo ng, nguyn nhn ca hi chng ny do
lng mo. Bng th nghim b, ng xc nh -c iu ny. Tip tc cng
vic ca Salter, ngoi cc th nghim b, Blackley cn dng cc th nghim
kch thch (nim mc mi, mng kt hp) pht hin nhiu loi phn hoa,
bi lng sc vt l d nguyn.
Bi lng, biu b sc vt (nga, cu, ch, m o..) l nhng d nguyn mnh,
gy nn hen ph qun v mt s bnh d ng khc cng nhn cc nh my
thuc da, nng tr- ng chn nui, x nghip g vt, nh my lng v, cc nh
chn nui sc vt th nghim, cc tr-ng ua nga
Cho n th k 19, vic gii thch c ch bnh sinh ca cc hin t -ng,
phn ng v bnh d ng cn gp nhiu kh khn.
Nhng cng trnh nghin cu v sc phn v, bt u t Magendie, t kt
qu r rt trong cc th nghim ca Richet (1850 -1935) v Portier (1866 -
1963), tip tc pht trin nhiu nm sau, t c s khoa hc cho d ng hc
v m ra giai on pht trin mnh m ca mn khoa hc ny trong th k va
qua.
2. Mt s hin t-ng d ng kinh in trn thc nghim

2.1. Sc phn v - mt hin t-ng khoa hc quan trng

Nm 1839, Magendie tim mt liu albumin vo tnh mch th, khng c phn
ng g xy ra. Vi tun sau, ln tim th 2 lm con vt cht. Nhiu nh vi
sinh vt v sinh hc mt s n-c c nhng nhn xt t-ng t: Behring c
khi nghin cu tc dng ca
c t bch hu i vi chut lang nm 1893; Flexner M - tim huyt thanh
ch cho th; Arloing v Courmont Php - tim huyt thanh la cho ng -i.
Nm 1898, Richet v Hefricourt Php nghin cu tc dng huyt thanh l -n
i vi ch th nghim. Ln tim th hai (sau ln tim th nht vi tun l)
gy t vong cho nhiu con vt th nghim. My nm sau, Richet (1850 -
1935) v Portier (1866 -1963) tip tc cng trnh nghin cu trn, tm hiu
kh nng min dch ca ch i vi c t ca hn bin trong chuy n i
kho st gn o Cp Ve, trn con tu mang tn hong t Alice II. Bin bn th
nghim ghi li nh- sau:
Ngy 14 thng 1 nm 1902, ch Neptune -c tim mt liu c t ca hn
bin vng d-i da (0,lmg c t/kg cn nng ca con vt th nghim). N
eptune l con ch to v khe. Khng c phn ng g. Bn tun sau, ngy 10
thng 2 nm 1902, tim ln th 2 vi liu l-ng nh- tr-c. Mi ng-i hy vng c
2
tnh trng min dch ca ch i vi
c t.
Mt cnh t-ng bt ng xut hin: ch Neptune lm vo mt cn sc trm
trng, kh th, nn ma, co git, mt thng bng, a i ba bi v cht sau
25 pht.

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Sau ny, vo dp k nim ln th 60 ngy pht hin sc phn v (1962)
Portier k li nh- sau: Khi s kin khoa hc mi -c xc nh l c tht,
Richet ngh ti t tn. Qu tht ti ch-a kp ngh n iu ny. Richet
tin n bng en, hi ti: T Hy lp bo v l g?. Ti bit t ny khi cn l
sinh vin, nh -ng khi y qun khuy. Richet kh nhc Phylaxis. Ti bn thm tin
t ph nh a - Aphylaxis. Nh-ng thut ng ny nghe khng ku lm, v vy
chng ti quyt nh gi l Anaphylaxis, (phn v, khng c bo v) i lp
vi trng thi min dch (Immunit).
Phn v l mt mu hnh nghin cu d ng trn thc nghim. Nhng nm
sau , ng-i ta bit thm mt s hin t -ng d ng khc.
2.2 Hin t-ng Arthus
Nm 1903, nh sinh hc Php Arthus ( 1862 - 1945 ) thng bo mt hin t -ng
mi.
ng tim huyt thanh nga (5ml) nhiu ln vo vng d- i da th, mi ln cch
nhau 6 ngy. Ba ln tim u khng c phn ng g. Cc ln tim th 4,5,6
lm xut hin thm nhim ngy mt rn chc v ko di hn, c ph n
v lan xung cc t chc d-i da. n ln tim th 7, thm nhim tr thnh
hoi t vi din bin bnh l tr tr, lu lnh. y l hin t-ng phn v ti
ch c tnh c hiu.
2.3 Hin t-ng Schultz-dale
Nm 1910, Schultz ( c) v Dale ( Anh) nm 1913 lm th nghim nh-
sau: hai
ng mn cm chut lang ci bng lng trng trng (hoc huyt thanh nga).
Sau 3 -4 tun l, ly on hi trng hoc sng t cung ca chut lang ny,
nui trong bnh c dung dch Tyrode. Khi cho mt vi git d nguyn c
hiu ni trn (lng trng trng, huyt thanh nga nng rt nh (l/10.000
-1/100.000), on hi trng hoc sng t cung s co tht li. y l hin t-ng
phn v invitro theo ph-ng php mn cm tch cc. Schultz lm th
nghim ny bng on hi trng, cn Dale thy rng sng t cung ca chut
lang mn cm c nhy cm 1500 ln ln hn vi d nguyn, so vi th
nghim trn t cung chut bnh th-ng.
Phn v invitro -c gi l hin t-ng Schullz-Dale
2.4 Hin t-ng phn v th ng
Sc phn v l hnh thi phn v tch cc, v liu mn cm bng huyt
thanh nga lm hnh thnh khng th trong c th con vt th nghim.
Cc tc gi Xakharp (1905), Rosenau v Anderson (1907) Nicolle (1910)
chng minh kh nng mn cm th ng bng huyt thanh. Th nghim tin
hnh nh - sau: tim mt liu d nguyn (lng trng trng) vo chut lang A.
Ba tun sau, ly huyt thanh ca chut lang A ti m cho chut lang B. Trong
4
huyt thanh ny c khng th phn v. Sau liu mn cm ny, sm nht
l sau 4 gi, trung bnh sau 24 -28 gi, tim liu d nguyn lng trng trng
(liu quyt nh) vo tnh mch chut lang B s thy xut hin bnh cnh
sc phn v (phn v th ng), tuy nhin mc sc yu hn so vi
ph-ng php mn cm tch cc.

5
Hin t-ng phn v th ng l mt bng chng quan trng ca thuyt th
dch gii thch c ch cc phn ng ph.
Nhng nm sau, ng-i ta chng minh -c kh nng to -c phn v invitro
th
ng. Ly mt on hi trng (hoc sng t cung) ca chut lang ci bnh th
-ng, t trong huyt thanh chut lang A ( mn cm) trong thi gian 2 gi.
Sau - a on hi trng vo bnh Schultz-Dale c dung dch sinh l (
hoc dung dch Tyrode). Cho mt vi git d nguyn (lng trng nng
1/1000 -1/100), on hi trng s co tht li mt cch c hiu: l hin t
-ng Schultz-Dale th ng (phn v th ng invitro).
2.5 Hin t-ng Prausnitz - Kustner
Nm 1921, Prausnitz v Kustner chng minh kh nng mn cm th ng
ng -i. Th nghim tin hnh nh- sau: Kustner b d ng vi c. Prausnitz ly
huyt thanh ca Kustner, tim 0,05-01ml huyt thanh ny vo da cng tay mt
ng -i kho mnh. 24 gi sau, ng tim 0,02ml chit dch c vo cng tay hm
tr -c. Xut hin phn ng ti ch mnh m. N chng t khng th d ng ca
ng- i bnh (Kustner) gn vo t bo da ca ng-i kho v kt hp vi d
nguyn c hiu.
Mt s tc gi khc, Urbach (1934), Moro (1934) c i bin ph-ng php
Prausnitz - Kustner, m ta gi l "phn ng kiu khong cch". Theo dng ci
bin ny, tim 0,05ml huyt thanh ng-i mc bnh d ng vo trong cng tay
tri ca mt ng -i kho, cn d nguyn (nghi ng) th tim vo vng da i xng
c a cnh tay phi.
Phn ng Prausnitz - Kustner -c ng dng pht hin d nguyn v
khng th d ng trong chn on v iu tr mt s bnh d ng.
2.6. Hin t-ng Ovary (phn v th ng da)
Tin hnh nh- sau: Mn cm chut A (chut lang, chut c ng trng) bng d
nguyn, v d huyt thanh nga (0,2 -0,5ml). n thi gian mn cm ti -u,
git chut A, ly ht mu, phn lp huyt thanh. Tim 0,l -0,2ml huyt thanh
ny cho chut B (trong da). T 3-12 gi sau , tim cht xanh Evan (hoc
cht mu kh c) vo tnh mch chut B.
c phn ng sau 35-40 pht. Phn ng d-ng tnh nu vng da (quanh ni
tim trong da) c mu xanh. Xanh Evan gn vo protein ca huyt t- ng
khuch tn ra, v tng tnh thm mao mch. o -ng knh vng bt mu,
c th nh mc phn ng.
3. Phn loi cc phn ng d ng

3.1 Ba giai on trong cc phn ng d ng

Theo A (1978), cc phn ng d ng l bnh l vim do s kt hp d
nguyn vi khng th d ng ( IgE, IgG). S kt hp ny tri qua 3 giai on:

6
 Giai on th 1 c tn l giai on mn cm bt u t khi d nguyn lt
vo c th ng-i bnh (qua h h hp, h tiu ho, tip xc, tim truyn) cho
n khi hnh thnh khng th d ng, ch yu l IgE, IgE gn vo mng cc
t bo: mast, eosinophil, basophil.

7
 Giai on th 2 cn gi l giai on sinh ho bnh xy ra khi d nguyn tr
li c th ng-i bnh, kt hp vi IgE trn mng cc t bo k trn, gii phng
mt s trung gian ho hc (mediators) tin pht: histamin, serotonin, bradykinin,
PAF (Platelet activating factor - Yu t hot ho tiu cu), ECF (eosinophil
chemotactic factor - yu t ho ng ng eosinophil) v mt s mediators th
pht nh- prostaglandines, leucotrienes, neuropeptides:
Trong giai on th 2, c s tham gia ca mt s enzymes (hista minase,
tryptase, chymase). S tng hp cc mediators, (Leucotrienes, Prostaglandines)
l nhng sn phm chuyn ho ca Axit Arachidonic (AA) do tc ng ca
phospholipase A2. Cyclo oxygenase chuyn dng (AA) thnh Prostaglandin,
cn 5 lipo oxygenase chuy n AA thnh Leucotrienes (xem s 1).
PAF - acther

Lysophospholipid
Leucotri nes
Phospholipase A2

Acid Prostaglandines
arachidonic
Mng phospholipid

S 1 : S tng hp cc Leucotrines v Prostaglandines

C 2 loi leucotrienes : Loi 1 l LTB-4 c tc dng ha ng ng v kt dnh
neutrophil vo ni mc thnh mch; loi 2 l L TC4, LTD-4. LTE4 lm tng tnh
thm thnh mch, co tht ph qun.
Cc Prostaglandines c tc ng n ph qun : PGD2 co tht ph qun,
PGE4 gin ph qun.
Trong giai on th 2 , cn c s tham gia ca mt lot cc cytokines l nhng
phn t nh -c gii phng t cc t bo T, i thc bo, t bo mast.
Giai on th 3 l giai on sinh l bnh vi nhng ri lon chc nng (co
tht ph qun, ban , ph n) hoc tn th-ng t chc (tan v hng cu,
bch cu v.v...) do tc
ng ca cc mediators k tr n n cc t chc hoc t bo t-ng ng.
3.2. D ng loi hnh tc th v loi hnh mun
Cc phn ng d ng chia thnh 2 loi hnh :
Cc phn ng d ng loi hnh tc th (gi tt: d ng tc th, d ng th
dch), v cc phn ng d ng loi hnh mun (gi tt : d ng mun, d
ng t bo).
Cc c im ca hai nhm ny (d ng tc th v d ng mun -c tm
8
tt trong bng 1 d-i y :

9
 Bng 1 : So snh nhng c im ca hai loi hnh d ng
c im D ng tc th D ng mun
Hi chng lm sng St ngy ma, hen, bnh Lao, bnh do Brucella,
in hnh huyt thanh, ph vim da tip xc v.v...
Quincke
D nguyn Phn hoa, huyt thanh, Vi khun, virus, nm,
cc dung dch protein, k sinh trng, ha cht
thc phm n gin, t chc v
t bo
ng vt
Khng th d ng C trong huyt thanh Khng c trong
huyt
thanh
Thi gian xut hin 5-20 pht, c khi nhanh Khng sm hn 5-6 gi,
phn ng hn (hng giy) chm trung bnh 24-72 gi
nht sau 3-4 gi.
Hnh nh t chc hc Thm nhim bch cu Thm nhim bch cu
a n nhn
nh
Ch bng mi tr-ng
n
t bo
Truyn mn cm th ng Bng huyt thanh,
i khi
bng mi tr-ng t bo
Cc cht trung gian ha C vai tr quan Lymphotoxin, yu t
hc (mediators) trng (histamin, truyn li, yu t c
serotonin, ch di tn i thc
leucotrienes, bo ...
prostaglandines)
Tc dng nhim c Khng c C
ca d nguyn
Tc dng ca R rt Khng r rt
ph-ng php mn
cm
Khng histamin Corticoid, ACTH, cc
Cc cht c ch phn cht c ch min
ng d ng dch
3.3. Cc loi hnh d ng theo Gell v Coombs
Gell v Coombs (1964) phn loi c 4 loi hnh d ng (hnh 1, 2, 3, 4)

Ch thch : S kt hp d
nguyn (DN) vi IgE ph v cc
10
 ht trong t bo mast, gii
phng hng lot mediators
gy vim (histamin,
serotonin).

Hnh 1 : C ch loi hnh I

11
 Loi hnh 1 (loi hnh phn v, loi hnh IgE) : D nguyn (phn hoa, huyt
thanh, lng v, bi nh) khng th l-u ng IgE gn vo t bo. Hnh thi lm
sng : sc phn v, cc bnh d ng atopi nh- vim mi, st ma, hen ph
qun do phn hoa, my ay, ph Quincke. Ng-i bnh c c a hoc th
tng d ng. D nguyn kt hp khng th trn mng t bo mast, phn hu
cc ht ca t bo ny, gii phng cc cht trung gian ho hc (histamin,
serotonin, bradykinin). Cc cht tr ung gian ho hc ny, nht l histamin lm co
tht mch no (au u, chng mt, hn m ...), co tht ph qun (gy
ph n nim mc ph qun), ph n lp d-i da, kch thch cc tn cng thn
kinh lp d-i da (nga) co tht v gin ng mch ln, lm st huyt p (Hnh
1).

Ch thch :
Hapten gn vo t
bo, sinh khng th. S
kt hp DN + K.th c
s tham gia ca b th
tiu t bo.
Hnh 2 : C ch loi hnh
II

Loi hnh II (loi hnh gy c t bo) : D nguyn (hapten), hoc t bo

gn t rn mt hng cu, bch cu. Khng th (IgG) l-u ng trong huyt
thanh ng-i bnh. S kt hp d nguyn vi khng th trn b mt hng cu
(bch cu), hot ha b th v dn n hin t-ng tiu t bo (hng cu).
in hnh cho loi hnh II l bnh thiu m u tn huyt, gim bch cu, gim
tiu cu do thuc (Hnh 2).
Loi hnh III (loi hnh Arthus, loi hnh phc hp min dch) : D nguyn l
huyt thanh, ha cht, thuc. Khng th kt ta (IgM, IgG1, IgG3). D nguyn
kt hp vi khng th kt ta, vi iu kin tha d nguyn trong dch th, to
nn phc hp min dch, lm hot ha b th. Cc phc hp ny lm tn
th-ng mao mch, c trn. Hin t-ng Arthus l in hnh ca loi hnh III
(hnh 3).
Bnh cnh lm sng thuc loi hnh III gm cc bnh d n g sau : bnh
huyt thanh, vim khp dng thp, vim cu thn, ban xut huyt dng thp
(hi chng Schoenlein Henoch), bnh phi do nm qut (aspergillus), vim nt
quanh ng mch, lupus ban
h thng, x cng b...
Hin t-ng Arthus v cc bnh d ng l oi hnh III xy ra do s kt ta ca cc
12
phc hp min dch (d nguyn + khng th) trong bch cu a nhn. Do hot
ha b th lm v cc ht trong bch cu, gii phng cc men ca lysosom
lm t hoc hoi t huyt qun. S thm nhim bch cu ht cn do b th
-c hot ha, nht l phc hp C5, 6, 7 gn vo cc thnh phn C1,2,4 sau khi
cc thnh phn ny gn vo phc hp min dch (d nguyn, khng th).

13
 Ch thch :
Phc hp DN (d nguyn)
+ K.th l-u ng trong
huyt qun c s tham
gia ca b th, gy
vim mch v tn th-ng
ni mc thnh mch.

Hnh 3 : C ch loi hnh III

D nguyn khu vc tha DN kt hp vi khng th d ng trong lng mch
thnh mt phc hp, hot ha b th, lm tn th-ng mch, t bo c trn.
Loi hnh IV l loi hnh d ng mun do cc d nguyn : vi khun, virus,
ha cht, nha cy vi cc bnh : lao, phong, vim da tip xc v.v... (hnh 4).

Ch thch :
T bo lymph T mn
cm lm nhim v
khng th d ng. S
kt hp DN (trn mt t
bo) lm hnh thnh t
bo T mn cm
gii phng cc
cytokines tiu t bo.
Hnh 4 : C ch loi hnh
IV

4. Dch t hc cc bnh d ng
4.1. Theo s liu nghin cu mi y ca Beasley v cng s (ISAAC, 2004)
30% dn s cc n-c pht trin c mt hoc nhiu hn cc bnh d n g (xem
bng 2).
Bng 2 : l-u hnh cc bnh d ng cc n-c ph-ng Ty
l-u hnh %

He 10
n 15%
Vim mi d 20
ng 22%
Vim da 10
atopi 12%

D ng sa 3%
Tnh
b trng mn 35
cm 40%
Ch thch : l-u hnh l t l % dn s c bnh m t thi im nht
14
nh

15
4.2. Gn 40% dn s nhiu n-c ph-ng Ty c tnh trng mn cm vi mt
hoc nhiu hn cc d nguyn hay gp (bi nh, phn hoa, thc n v.v...).
l-u hnh cc bnh d ng c xu th tng 2 -4 ln trong 2 thp k va qua
(1980 - 2000) theo ISAAC (International Study Allergy and Asthma Childhood),
cc n-c pht trin ph-ng Ty, cng nh- cc n-c khu vc ng Nam - Ty
Thi Bnh d-ng. Nguyn nhn ch yu ca s gia tng l-u hnh cc
bnh d ng l do qu
trnh th ha, cng nghip ha v hc i li sng ph-ng Ty cc n-c
ang pht trin.
4.3. l-u hnh cc bnh d ng Vit Nam
Trong nhng nm 2000 -2002, theo nhng s liu kho st trn 8000 ng-i 6
tnh thnh ph ca Vit Nam (H Ni, TP. H Ch Minh, Hi Phng, Ho
Bnh, Ngh An, Lm ng) cc bc s B mn D ng v Khoa D ng -
Min dch lm sng Bnh vin Bch Mai pht hin t l mc cc bnh
d ng nh- sau:
Hen 4,9%
D ng thuc 8,73%
My ay, Ph Quincke 11,68%
Vim mi d ng 10,97%
D ng thi tit 9,81%
D ng do thc n 6,02%
Theo nhng nghin cu mi y nht ca Ch-ng trnh Hen ph qun S Y t
H Ni (2004) t l cc bnh hen v vim mi d ng tip tc gia tng trong
dn c-. S liu
ang -c x l, t l hen trn 5%. T l hc sinh ni thnh mc hen ph qun
l 12,56%, vim mi d ng l 15,8% .

5. p ng min dch trong cc phn ng v bnh d ng

Thc cht phn ng d ng l Vim do s kt hp ca d nguyn vi khng th
d ng (hoc lympho bo mn cm), c s tham gia ca nhiu yu t sau
y :
5.1. D nguyn lt vo c th dn n s hnh thnh khng th d ng
(hoc lympho bo mn cm) xem hnh 5 d-i y :

16
Hnh 5. Qu trnh hnh thnh khng th d ng

17
 5.2. Khng th d ng l cc globulin min dch (5 loi) do t bo lympho B
v t-ng bo (plasmocyte) sn sinh.
Mi phn t khng th c 2 chui nng v 2 chui nh.

IgA - phn t l-ng = IgG

hng s 9 - 14s, c 10% -ng
1% IgA l IgA tit dch (IgAs). IgAs trong nim dch (ph qun, h
tiu ha) v trong n-c ming

IgG : 70% cc globulin min dch, phn t l-ng 150.000 hng s lng 7S,
2,5%
-ng, c 4 loi IgG1, IgG2, IgG3, IgG4.

IgM : c 5 phn t khng th, phn t l-ng 900.000; 10% cc globulin min
dch l-u ng, l cc khng th ng-ng kt.

IgD : 1% cc globulin min dch , chc nng ch-a r.

IgE : Khng th d ng quan trng nht, phn t l-ng 190.000, hng s

lng 8S. Tr l-ng IgE trong huyt thanh ng-i 0,05 0,4 mg/l.

Hnh 7. IgA c chui J

Hnh 6. Phn t globulin min
dch IgG

Hnh 8. Phn t IgM ( 5 phn t) Hnh 9. S iu ha v tng hp IgE t

Th2
t bo B t bo plasma IgE

18
5.3. Cc t bo vim : i thc bo, t bo T v B, t bo mast, eosinophil, t
bo biu m, t bo ni m v.v...
Cc t bo vim gii phng cc cytokines, mediator s th pht (xem hnh 10).

Hnh 10. T bo vim v cc mediators

Ch
thch :
LT (leucotrines)
PG
(prostaglandines)
MBP (Major Basic Protein)
ECP (Eosinophil Chemotactic Factor)
EPO (Eosinophil Peroxidase)
TXA2 (Thromboxane A2)
HETE (Hydroxyeicosatetranoic acid)

5.4. Tc dng cytokines trong p ng min dch v c ch cc bnh d

ng
Cytokines l nhng protein ha tan gp phn iu ha p ng min dch,
-c sn sinh t cc t bo gy vim (i thc bo, cc t bo : Th1; Th2; B;

19
mast; eosinophil) lm chc nng thng tin gia cc t bo. Ngun gc v tc
dng ca cc cytokines trong c ch cc bnh d ng -c ghi nhn trong
bng d-i y :

20
 Bng 4: Cytokines v c ch cc bnh d ng

Cytokines Ngun gc Tc dng

IL1 B/c n nhn, TB Hot ha, tng sinh cc tb T, B, gin
mch,
khng virus, khng U
IL2 tb T, eosinophile Tng sinh tb T, hot ha tb B, tb NK, TB
IL3 tb T, tb Bit ha, tng tr-ng b/c n nhn, tb
mast, mast
eosinophile
IL4 tb T, tb Kch thch, bit ha tb B sn sinh IgE
mast, v IgG, c ch d ng t bo
eosinophil, basophil Tng tr-ng tb B, hot ha + tng sinh
IL5 tb T, tb eosinophi, basophil.
mast,
eosinophil
IL6 tb T, TB Bit ha tb B t-ng bo sn sinh
IgE IL7 ty x-ng Tng sinh, hot ha tb B v eosinophile
IL8 b/c n nhn, TB Ho ng ng v hot ha neutrophil
IL9 tb T Tng tr-ng tb T v tb mast
IL10 tb T, tb mast c ch s tng hp cc cytokines v tng
sinh tb mast
IL11 ty x-ng Tng tr-ng tb B
IL12 i thc bo, b/c Tng sinh v hot ha tb NK
n nhn
IL13 tb T Kch thch tb B sn sinh IgE, c ch Th1
IL14 tb T Kch thch sn sinh IgE
IL15 i thc bo Tng tr-ng v tng sinh cc tb T, B
IL16 tb T, tb hot ho b/c n nhn, tb T
mast,
eosinophil
IL18 TB, tb biu m hot ho tb B sn xut IFN
GMCSF tb T, biu m Tng tr-ng, bit ha b/c n
nhn
IFN tb T Ho ng ng, kch thch, hot ho i
thc bo
TGF T chc lin kt c ch tb T, B; kch thch; hot ha i
thc
b
o
TNF v Bch cu, t bo Tng sinh cc tb T, B; ha ng ng +
biu hot ha b/c trung tnh, tb NK, khng
m virus v u.

5.5. Vai tr cc t bo T v B sn sinh cc cytokines ch yu trong p

ng min dch
21
 Bng 5 : Vai tr cc t bo T v B
p ng min Cytokines kch Cytokines c
dch thch ch
T bo T IL1, IL2, IL6, IL8, IL12, IL10, IL4, TGF
T bo IL15, IFN, TNF TGF
B IL1, IL2, IL5, IL6, IL7,
D IL10, IL11, IFN IFN, IL12
ng IL3, IL4, IL5, IL13, IL14

22
5.6. Cc phn t kt dnh (Adhesion molecules)
Cc phn t kt dnh l nhng phn t prtein trn b m t cc mng t bo,
c chc nng gn kt cc t bo vi nhau trong cc m, t chc v to iu
kin cho cc t bo di tn n v tr vim d ng.
Cc phn t kt dnh c 3 loi : globulin min dch; integrines v selectines,
nh-ng ch yu l cc globulin min dch (ICAM1 ICAM2 - ICAM3
(Intercellular adhesion molecule 1, 2, 3)

Hnh 11 : Eosinophil trong lng

mch, do tc ng ca yu t ho
ng
ng (ECP) chuyn ng n ni
mc thnh mch, y c cc
phn t kt dnh (AM) lm cho
eosinophil di t n qua ni mc thnh
mch. Cc mediators t t bo
mast (Histamin, ECP) v cc
cytokines IL 1 (t TB) TNF (t t
bo mast) l nhng yu t ho ng
ng c nh h-ng n cc
phn t kt dnh (AM).

5.7. p ng min dch v vim d ng

Thc cht cc phn ng d ng l vim d ng vi c ch phc tp hn so vi
bt c loi hnh d ng theo cch phn loi ca Gell v Coombs (hnh
1,2,3,4)
Vim d ng l s kt hp cc khng th d ng vi phn d nguyn trn b
mt cc t bo mast v eosinophil, c s tham gia ca cc t bo T, B v cc
cytokines do cc t bo T, B sn sinh; ng l-u p ng d ng sm v p
ng d ng mun.
C ch vim d ng c th tm tt trong hnh 12 v cc p ng d ng sm
v mun tm tt trong hnh 13.

DN

DN

Th2

VK,VR Th1 23
Hnh 12 : C ch vim d ng

24
 p ng d ng sm p ng d ng mun

Hnh 13: p ng d ng sm v mun

p ng min dch trong cc phn ng v bnh d ng c s tham gia ca
nhiu yu t khc nhau:
- Vai tr ca d nguyn s hnh thnh khng th d ng
- Cc t bo vim, ch yu l TB, tb Th 2, tb B, t-ng bo, tb mast, eosinophil.
- Mediators tin pht (histamin, tryptase, PAF, ECP)
- Mediators th pht (cytokines, ECP, EPO, MPB,
PG, LT) Cytokines bao gm IL 1 - IL18, GMCSF, INF,
TNF.
Phn t kt dnh c 3 loi, ch yu l ICAM 1, ICAM2, ICAM3.
Phn ng d ng thc cht l vim mn tnh do s kt hp ca DN+KT d
ng qua 3 giai on.
Trong vim d ng c p ng d ng sm v p ng d ng mun.

Cu hi t l-ng gi

1. Vic pht hin sc phn v c ngha g?

2. Nu nhng hin t-ng d ng kinh in?
3. Phn loi cc phn ng d ng ?
4. Phn bit d ng tc th v d ng mun.
5. Nhng yu t tham gia p ng min dch trong cc phn ng v bnh
d ng ?
6. Phn bit mediators tin pht v mediators th pht?
7. Chc nng ca cytokines v interleukines?
8. Vim d ng khc vim nhng c im g?

25
9. Phn bit p ng d ng sm v mun?

26
 D nguyn

Mc tiu hc tp:
1. Nm vng cc c im ca d nguyn
2. Hiu cch phn loi d nguyn
3. Nm -c nhng d nguyn hay gp trong bnh nguyn v bnh sinh cc bnh
d ng.
4. Trnh by -c vai tr v phn loi t d nguyn trong cc bnh t min.

1. i c-ng :

1.1. nh ngha
D nguyn l nhng cht c tnh khng nguyn, khi lt vo c th, sinh ra cc
khng th d ng nh- IgE, IgG, IgM nhng bnh nhn c yu t di truyn,
c a d ng trong mi tr-ng sng v sn xut, c hng vn lo i d nguyn
khc nhau, chng l nguyn nhn gy nn nhiu bnh d ng h h hp v
cc h c quan khc.
1.2. My c im ca d nguyn:
D nguyn c tnh khng nguyn ngha l c kh nng kch thch c th sinh
ra khng th v kt hp c hiu vi khng th . S kt hp ny to nn
tnh trng d ng.D nguyn c th l nhng phc hp: protein, protein +
polysacarit, protein + lipit; lipit + polysaccrit; protein + ho cht n gin.
Nhng phc hp ny c tnh khng nguyn y . Mt vi protein khng c
tnh khng nguyn, hoc c tnh khng nguyn khng hon ton. Mt s
phc hp lipit + polysaccarit c tnh khng nguyn mnh, nh- ni c t ca
nhiu vi khun gram m. Phn ln cc protein ca ng-i, ng vt v mt vi
loi polysaccarit c tnh khng nguyn hon ton. Hu ht cc polysaccarit,
mt vi loi lipit v ho cht n gin c tnh khng nguyn khng hon ton.
l nhng hapten c chc nng l nhm cu thnh khng nguyn ca phn
t protein, v d nhn amin thm, lm cho cu trc d nguyn c nhng thay
i nht nh.
Landsteiner K (1936) dng dy ni azoprotein v mt vi k thut khc
tm hiu tnh c hiu ca d nguyn. Tnh c hiu ny do mt cu trc
c bit trn b mt phn t ca d nguyn. Theo Landsteiner, vic gn
cc nhn thm vo protein lm cho protein c tnh khng nguyn mi.
Cu trc ho hc, v tr cu thnh khng nguyn, cch sp xp axid amin
trong dy polypeptit l iu kin quyt nh tnh c hiu ca khng

27
nguyn l sinh ra khng th, c th phn ng vi khng th . iu ny gii
thch s tn ti ca phn ng d ng cho. Dn chng l cc phn ng d
ng gia cc cht : anhydrit xitraconic; clorua

28
ftalic; O.clorua clorobenzoil; clorua picrin. Mn cm chut lang bng anhydrit
xitraconic, lm th nghim b vi c lorua ftalic, anhydrit. Mayer (1954) cho rng
tc dng gy mn cm ca cc ho cht do sn phm chuyn ho ca cc cht
ny trong c th. Nh- tr-ng hp paraphenylendiamin, acid paraamonbenzoic,
sunfanilamit, procain chuyn ho trong da v t chc thnh am in quinonic
hoc dn xut phenylhydroxylamin, cc cht chuyn ho kt hp vi protein,
chng c tc dng mn cm da v t chc, cc ho cht amino, nitro, diazo,
COHN 3. Nhng nhm cu thnh t-ng t ca phn t protein s l cc nhm
phenol, cacboxyl... . Nhng gc hot
ng ca protein, kt hp vi d nguyn l: - COOH - SH - NH2 - NHCNH2
Tnh khng nguyn ca d nguyn ph thuc vo mt s iu kin:
* C bn cht l i vi c th . Phn t d nguyn khng -c ging bt c
thnh phn no ca c th. y l iu kin tuyt i cn thit i vi d
nguyn. C th khng bao gi tng hp khng th chng li nhng thnh phn
ca bn thn n, tr mt vi tr-ng hp ngoi l.
*Phn t l-ng ca d nguyn phi ln. Cc cht c phn t l-ng nh khng
c t nh khng nguyn. Theo quy lut, ch c nhng cht c phn t l-ng
ln hn 10.000 -
20.000 mi bt u c tnh khng nguyn, nh-ng tnh khng nguyn ny cn
yu, ngay vi cc cht c trng l-ng phn t nh hn 40 nghn. Nhng cht c
cu trc ho hc phc tp, phn t l-ng cng ln hn (hn 600.000) tnh khng
nguyn cng mnh. Tuy nhin cng c nhng ngoi l. V d dextran c phn
t l-ng 100.000, nh-ng tnh khng nguyn ca cht ny kh yu.
Mt s ho cht c phn t l-ng nh (clorua picrin, focmol ...) vn c tnh
khng nguyn v gy nn tnh trng d ng nh- vim da tip xc. Cc cht ny
lm bin cht protein ca c th. Chnh cc protein bin cht ny mi c tnh
khng nguyn y , cn cc ha cht k trn ch tham gia vi t- cch l
hapten.
Bn cht v cu trc ho hc ca d nguyn: hu ht cc protein u c tnh
khng nguyn, tr mt s t gelatin, fibrinogen, casein. Tnh khng nguyn ca
protein ph thuc vo cu trc ho hc, v tr cc nhm ho hc nht nh
trong protein.
Chit dch ca giun sn (giun a, giun ch....) c tnh khng nguyn cc
mnh, cng nh- mt s protein v c t vi khun. Protein ngun gc thc vt
(phn hoa, tri qu, nha cy) cng l nhng d nguyn mnh i vi ng vt
c v. Phn t d nguyn protein c nhiu dy peptit cu thnh. Mi dy
polypeptit gm nhiu axid amin ni vi nhau bng nhm - C-NH =O

29
D nguyn c cu trc ho hc l polysaccarit, lipit, acid nucleic c tnh khng
nguyn khng ng u, ni chung l yu.

30
1.3. Phn loi d nguyn
D nguyn chia lm 2 nhm ln (S 1)
- D nguyn t mi tr-ng bn ngoi lt vo c th l d nguyn ngoi sinh.
- D nguyn hnh thnh trong c th l d nguyn ni sinh (t d nguyn)
S 1
D nguyn

D nguyn ngoi sinh D nguyn ni

sinh (T d
nguyn)
2. D nguyn ngoi sinh
D nguyn ngoi sinh li chia lm 2 th nhm (s 2)
* D nguyn ngoi sinh khng nhim trng v
* D nguyn ngoi sinh nhim trng.
2.1. D nguyn ngoi sinh khng nhim trng.
D nguyn ngoi sinh khng nhim t rng bao gm :
* Bi nh, bi -ng ph, bi th- vin. Bi nh -c nghin cu nhiu hn c,
c nhiu thnh phn phc tp, hot cht ch yu l cc con mt (ve) trong bi
nh (xem hnh 1) c nhiu loi mt trong bi nh, hay gp hn c l
Dermatophagoides pteronyssinus, Dermatophagoides farinae, tip theo l cc
loi mt khc.
Trong 1g bi nh c t 50 - 500 con mt. Nng mt t 2mcg n 10mcg
trong 1g bi nh l yu t nguy c gy mn cm, dn n gy hen ng-i .
Bi nh cng c th gy vim mi d ng vi l-u hnh kh cao ( trn 20%
dn s).

31
Hnh 1 : Mt Dermatophagoides pteronyssinus trong bi nh (knh hin
vi in t)

32
 S 2: Phn loi d nguyn ngoi
sinh
D Nguyn ngoi sinh

Khng nhim trng

Ho cht Thc Nhim trng

Bi nh
Bi -ng phm
ph
Thuc
(Khng
Biu b, lng sc vt sinh,
(ch, mo, nga ) Ngu Ngu Vi Nm Vi
sulfamid, n n thc khu ru
huyt thanh, n vt n s
Phm vacxin) g
hoa vt
(cy,
c)

: Cc d nguyn l biu b, vy da, lng sc vt T bo ng vt lt vo

c th theo nhiu -ng khc nhau v c tnh khng nguyn. Chng l nguyn
nhn ca nhiu phn ng v bnh d ng hay gp. Nhng d nguyn
ngun ng vt ph bin l biu b, lng v, bi lng gia sc (nga, ch,
cu, mo) cn trng (o ng mt, ong v, b-m, chu chu, b hung, rp v.v...).
Vy da, mng vut, m ca nhiu ng vt khc, b lng sc vt (cu, chn)
l trang sc, qun o, lng g, lng vt, lng chim lm gi
m. Hot cht cc d nguyn k trn ch-a r. Thnh phn ch y u ca tc,
lng v, vy da, l cht sng c nhiu nguyn t S (l-u hunh) trong cc phn
t axid amin (xystein, methionin). Cht sng khng tan trong n-c v khng
chit xut -c bng Coca.L-u nhng d nguyn ca mo, ch (lng, biu
b), n-c bt ca m o l nhng nguyn nhn gy cc bnh d ng -ng h
hp ng-i (xem hnh 2).

33
Hnh 2. Lng v n-c bt ca mo c th gy vim mi d ng v
hen

34
Trong vy da nga c 2 thnh phn: thnh phn c sc t v thnh phn
khng c sc t. Theo Silwer (1956) trong vy da nga c loi d nguyn
protein (phn t l-ng 40 nghn) cn Stanworth (1957) tm thy 7 thnh phn
protein, trong c mt thnh phn protin c tnh khng nguyn mnh nht
v kt ta trong dung dch ammoni sunfat 55- 85% bo ho. Trong in di,
thnh phn protein ni trn di chuyn trong vng bta-globulin, c 9% hexoza
dng galactoza, monoza m phn t l-ng l 34 nghn.
Ng-i ta hay gp cc hi chng d ng (hen, vim mi, my ay, chm) do
lng v, lng sc vt, vy da ng vt, trong cng nhn cc trang tri chn
nui (b, cu, ln), x nghip g vt, nh my chn nui sc vt th nghim
(chut bch, chut cng, th, kh, g sng). Nhiu ng-i mc qun o c lng
b d ng: o mng t c lng, o lng, khn qung lng, tt tay lng . o len
an, m c lng chim cng c th l nguyn nhn gy bnh, c nhiu
thng bo v nhng ng-i bnh hen ph qun do lng chim (vt, bch yn, b
cu).
Nc ong (ong mt, ong v) l d-c liu qu cha bnh. Trong nc ong c
2 loi protein: Protein I c 18 axit amin, c c tnh, khng c enzym, phn t
l-ng l 35 nghn, lm tan hng cu, gim huyt p ngoi vi, tc ng n
thnh mch v gy nn phn ng vim ti ch. Protein II c 21 axit amin v 2 loi
enzym: hyaluronidaza v photpholipaza A. Hyaluronidaza lm tiu cht c bn
ca t chc lin kt, to iu kin cho nc ong lan truyn trong da v d-i da,
tng tc dng ti ch ca nc. Photpholipaza A tch lexitin thnh my thnh
phn khc nhau, trong c sn phm
isolexitin lm tan huyt v tiu t bo. Chnh thnh phn protein II l nguyn
nhn lm gim ng mu khi nhiu con ong t mt lc. Hoa K hng
nm c trn 500 tr-ng hp sc phn v t vong do ong t. Ch-a r bn cht
ca protein III.
B-m, rp, chu chu, b hung c ng l nhng d nguyn hay gp khi
b-m vy cnh, lp phn trn thn vung ra, ri xung -c gi cun i xa. l
nhng d nguyn rt mnh. Nhng ng-i b d ng c th ln cn hen, vim
mi d ng, my ay, mn nga.
D nguyn l phn hoa : Phn hoa th-ng c mu vng i khi mu tm
hoc mu khc. Cc ht phn dnh lin nhau thnh khi phn nh- hoa lan,
hoa thin l. Nhn qua knh hin vi, ta thy: ht phn c hai nhn: nhn ngoi
ho cutin, rn khng thm, tua ta nhng ci gai, mo v.v... Tng qung c
nhng ch trng gi l l ny mm. Mng trong bng xenluloza dy ln pha
tr-c cc l ny. Kch th-c ca mng ht phn thay i theo tng loi cy, c,
trung bnh t 0,01 - 0,02 mm.
Phn hoa gy bnh c kch th-c rt nh, d-i 0,05mm; l-ng phn hoa ln ng
ha l thuc v cc cy c trng nhiu a ph-ng, th phn nh gi. Mt
35
gc la cho ti 50 triu ht phn; ht phn thng th-ng c hai qu bng nh
cha y kh hai bn, nn rt nh v bay xa khi c gi, mt cm Ambrosia
cho 8 t ht phn trong 1 gi, mi nm Hoa K c ti mt triu tn ht phn loi
ny.

36
 Hnh 3. Phn hoa Ambrosia
c tnh khng nguyn rt
mnh

Cc nh d ng hc Hoa K, Php, Nga v nhiu n-c khc, quan tm n

phn hoa cc loi Ambrosia v bnh do phn hoa gy ra mc nghim
trng. Heyl (1982)
phn tch phn hoa Ambrosia v pht hin nhiu thnh phn khc nh-:
protein 24,4%, xenluloza 12,2%, pentoza 7,3%, dextrin 2,1% photpho
0,37%, tro thc vt
5,4%.
Sau phn hoa Ambrosia, phn hoa h la l d nguyn gy bnh hay gp.
H la c 313 loi vi 3300 loi do gi th phn, kch th-c ht phn t 0.01 -
0.02mm, ng ch l cc loi ht phn: c ui mo, c chn vt, loi hoa
ng c, loi mch en... Phn hoa mt s cy khc nh- phn cy bch
d-ng c kch th- c 0.02mm; phn cy si 0,02mm v nhiu loi cy c khc
nh- c ca g, phn cc loi hoa hng cc, th-c d-c, layn, o, t linh
h-ng... c ht phn nh hn 0.05mm. l nguyn nhn ca nhiu hi chng
d ng do phn hoa (vim mi ma, st ma,vim k t mc ma xun,hen
ma),m i khi chn on nhm l cm.
D nguyn l thc phm: D ng vi thc phm -c bit t my nghn
nm tr-c y vi tn gi bnh "c ng" (idiosyncrasie) c nhiu biu hin
mc khc nhau, t nh n nng, m hay gp l cc bnh sau y:
Vim mi, vim da, my ay, ph Quincke, hen ph qun, sc phn v. Thc
phm chia lm 2 loi hnh: ngun ng vt (tm, cua, tht, c) v ngun gc
thc vt (rau qu), trong c nhng cht cn ch l trng sa v bt tr
em.
D ng vi trng hay gp hng ngy vi cc biu hin: ban, my ay, kh
th, ri lon tiu ho. Cc loi trng g vt, ngan... c nhng khng nguyn
chung. Hot cht ca trng l lng trng trng v ovmucoit trong lng .
37
Sa b l nguyn nhn d ng tr em, chim t l trung bnh 0,3 -0,5% nht
l tr s sinh v la tui mu gio. y l loi protein "l" vo c th sm nht.
Sa b c nhiu thnh phn khc nhau nh-: -lactoglobulin (A v B), -
lactoalbumin, casein ( ,,) trong c -lactoglobulin c tnh khng nguyn
mnh. Sa b c th l nguyn nhn

38
ca nhiu hi chng d ng: sc phn v, cn kh th, ph n nim mc mi,
hen, ri loi tiu ho, nn ma, co tht mn v, vim i trng, hi chng d dy
- t trng,my
ay, ph Quincke .
Thc phm ngun thc vt bao gm nhiu loi c kh nng gy d ng t
265 loi nm n h la: bt m, bt go, la m, ng khoai v.v.. v du cc
cy cng nghip (da, lc) v cc loi qu (cam, qut, chanh, o, l, mn, d-a
hu, d-a b, u , da v.v...), nhiu loi rau (mng ti, dc mng, khoai ty,
c ph, sn,, c chua...).
Thc phm ngun gc ng vt c nhiu loi l nhng d nguyn mnh nh-
tht g, vt, tru, b, ln, th ch, nhi v tht tm cua, c, c, nhng v.v...
Mt s bnh ko nh- scla, ko vng, ung nh- n-c chanh, n-c cam, bia
v.v...
gy d ng.
D nguyn l thuc: Nhng tai bin d ng thuc xy ra ngy mt nhiu s
dng thuc khng ng ch nh. Theo thng k ca OMS 17 n-c trn th
gii, d ng vi khng sinh, c bit vi Penicilli n, Streptomycin, Tetracyclin
v.v... l nhiu nht. Ngoi ra, cc thuc khc nh- Sulfamid, an thn, gim au,
h nhit, vitamin v.v...cng gy nn nhng tai bin ng tic.
Nhng biu hin d ng do thuc trn lm sng rt a dng. Hay gp nht
l cc triu chng mt mi, bn chn, kh th, chng mt, st, mch nhanh,
mch chm, tt huyt
p v.v... S tai bin do huyt thanh, vacxin cc loi cng xy ra do tim chng
ch-a
ng s , liu l-ng. Tai bin sau tim vacxin phng di xy ra vi t l
1/16.000 - 1/17.000 v c xu h-ng tng thm.
Bnh cnh ca d ng thuc rt phong ph, c th l nguyn nhn sc phn
v, bnh huyt thanh, vim da tip xc, hen, da ton thn, hi chng
Stevens -Johnson, hi chng Lyell.
D nguyn l ho cht: Nhiu ho cht n gin c kh nng gn vi protein
v tr thnh d nguyn hon chnh mi c tnh khng nguyn mnh v l
nguyn nhn ca nhiu hi chng v bnh d ng. Hng nm, cng nghip c
thm hng vn ho cht mi, trong s c nhiu cht l d nguyn, ng ch
nhng ho cht sau y: nhm cc kim loi nng (kn, crm, bch kim),
nhm ho cht hu c tng hp hoc t nhin; nhm du ngun thc vt,
nhm cc phn bn ho hc, thuc tr su, dit c, cc cht du sn v.v...
Bng 1: Mt s d nguyn l ho cht

39
 Ho cht Biu hin d ng
Phn bn ho hc c nit Vim da th chm, vim mng tip
hp, vim mi, ri lon tiu ho, hen
Phn bn ho hc c ure Ri lon h hp, d ng da ton
dinitrtoluen Nitrat, vi, kali, ure thn Vim da tip xc
Phn bn ho hc photphat Ri lon h hp v d ng da
Phn bn kali Chm
Phn bn thin Hen
nhin Cc thuc tr
su: Hen, vim mng tip
DD (Dicloropropan, hp
Dicloropropen) Cloropicrin Vim mi, hen,
chm Vim mng
Axid xyanhydric v mui
Hydrocacbua khng c halogen tip hp Chm,
vim da atopi

40
 Sulfua Chm, ri lon tiu
cacbon ho
c:
Hu thm (diclorobenzen) Hen, ph Quincke
vng DDT Hng ban
c brom, c l-u hunh, c nit Chm
c photphat Hen, vim kh
qun Aramit Chm

2.2. D nguyn ngoi sinh nhim trng

Trong nhm ny cc loi d nguyn th-ng gp l vi khun, virus, nm, k sinh
trng.
Vi khun c cu trc khng nguyn. V d: lin cu khun tan huyt nhm
A : v vi khun c axid hyaluronic, vch vi khun c 3 loi protein: M, T, R, trong
, M l khng nguyn mnh. Sau vch vi khun l lp cacbonhydrat c chui
polysaccarit -N- axetylglucosamin (30%) v ramnoza (60%), tip theo l lp
mucopetit c N - axetylglucosamin, axit N-axetylmuraminic, alanin, lysin, glyxin
(Hnh 4).

Hnh 4 : S cu trc khng

nguyn ca lin cu khun tan
huyt nhm A
1- V vi khun, c axit hyaluronic
2- Vch vi khun, c 3 loi protein M.T,R
3- Lp cacbohydrat c chui polysaccarit
- N-axetylglucosamin v ramnoza
4- Lp mucopetit c N-axetylglucozamin,
axid N-axetylmuraminic...
5- Mng bo t-ng

Ph cu khun c 2 loi khng nguyn: Polysaccarit gy d ng tc th,

nucleoprotein gy d ng mun.
c t bch hu c cc c im ca phn v nguyn.
Trong cc bnh d ng -ng h hp, ng-i ta pht hin trong ph qun
hay gp cc vi khun Neisseria catarrhalis, lin cu khun xanh, Klebsiella,
ph cu khun v.v...cn trong hng l t cu khun vng, t cu khun
trng v.v...
Nhiu d nguyn t ngun vi khun -c s dng chn on. Antraxin (d
41
nguyn t trc khun than) l phc hp nucleosaccarit + protein; dysenterin l
dung dch protein cc vi khun Flexner hoc Sonne; Brucellin l n-c lc canh
khun Brucella; Lepromin

42
l khng nguyn ly t bnh phm ng-i phong. Phn ng Shick tin hnh
bng c t bch cu.
D nguyn l virus: Virus c nhiu cu trc khng nguyn, mn cm v tc
ng
n c th theo nhng quy lut nht nh, l nguyn nhn ca nhiu phn
ng d ng trong mt s bnh do virus (si, herpes, quai b, vim no tu cp
tnh, bnh di v.v.. .). Nhng virus hay gp trong mt s bnh d ng:
Arbovirus. VRS (Virus Respiratory Synticial) Rhinovirus, Coronavirus v.v....
Virus c 3 loi khng nguyn: khng nguyn hu hnh l nhng vng virus nguyn
vn, c axit nucleic v protein ca bo t-ng tron g virus, khng nguyn ho tan
l thnh phn khng nguyn b mt c tnh c hiu theo nhm, khng
nguyn ng-ng kt hng cu c bn cht lipoprotein.
D nguyn l nm: Trong thin nhin c khong 8 vn loi nm nh-ng ch c
hn mt nghn loi c kh nng gy d ng. C th phn bit : nm "hon
chnh" v nm "khng hon chnh".
Nm "khng hon chnh" c 2 nhm: Nhm nm khng c dnh bo t mu
sm. Chnh loi nm c dnh bo t mu sm c tnh khng nguyn mnh,
l nguyn nhn ca nhiu phn ng v bnh d ng nh- vim mi, hen ph
qun, d ng da. ng ch d nguyn l cc nm sau y: Pnicillium,
Aspergillus, Alternaria, Hermodendrum, Cladosporium, Trichophyton, Candida
v.v... (Xem hnh 5,6,7,8) bo t nm nm trong bi -ng ph, bay trong khng
kh, mt khc nhau theo tng loi nm v theo ma, tuy quanh nm lc no
cng c.

Hnh 7 Hnh 8
Hnh 5 Hnh 6 Nm Nm
Nm Nm Alternaria Aspergillus
Penicillium Cladosporium
D nguyn t mi tr-ng sng v lao ng l mt trong nhng yu t g y

43
bnh d ng. Vai tr d nguyn trong c ch sinh cc bnh d ng c th tm
tt trong hnh 9 d-i
y:

44
 Hnh 9 : D nguyn v bnh d ng

3. D nguyn ni sinh (t d nguyn)

3.1. i c-ng
D nguyn ni sinh ( th-ng gi l t d nguyn): T d nguyn l nhng
d nguyn hnh thnh trong c th. Protein ca c th trong nhng iu
kin nht nh, tr thnh protein "l" i vi c th v c y nhng
c im ca d nguyn. Nhng iu kin l: nh h-ng ca nhit
cao, thp; tc ng ca vi khu n, virus v c t ca chng; nh h-ng
ca cc yu t l ho nh- axid, baz, tia phng x v.v... T d nguyn -ng
nhin c tnh khng nguyn, c kh nng lm hnh thnh cc t khng th. T
d nguyn v t khng th c vai tr r rt trong c ch nhiu phn ng, hi
chng min dch bnh l (nh-c c, v sinh do mt sn xut tinh trng...)
trn lm sng l cc bnh t min (vim no tu,thiu mu tn huyt, bnh
tuyn gip...).
Khi no trong c th xut hin tnh trng t d ng? Tnh trng ny xut
hin cng vi cc t d nguyn. T d nguyn l nhng thnh phn ca t bo
v t chc ca bn thn c th, trong nhng iu kin nht nh, to ra
nhng t khng th v lymph bo mn cm chng li bn thn c th, cui
cng l xut hin tnh trng t d ng ( min dch bnh l) dn n s hnh
thnh cc hi chng v bnh t min nhiu h c quan (h ni tit, h
mu, h thn kinh v.v...).
3.2. Phn loi t d nguyn (d nguyn ni sinh)

T d nguyn c 2 phn nhm: t d nguyn l t bo t nhin v t d ngu yn

l t bo bnh l (xem s 3).
45
 S 3 : Phn loi t d nguyn

T d nguyn

(A)
T bo t nhin
nguyn pht (nhn
(B)
mt, t bo: thn
kinh,
tuyn gip, tinh trng..
Th pht t
bnh
bo
l

(B1)
B2
Khng nhim
trng (do bng, Nhim trng
phng x, nhim
lnh

B2a B2b
Phc hp Trung gian
(t bo + vi (V d: bnh
khun, t bo + di)
c t VK) V
d: Thp tim

Thc cht ca hi chng t d ng : lymph bo mn cm v t khng th

chng li cc t chc ca bn thn c th, gy tn th-ng cho cc t chc
ny. Hi chng t d ng l: hi chng sau nhi mu c tim; lon d-ng gan
cp trong vim gan nhim trng; trong cc bnh phng x, bng v.v...
Cc t d nguyn nhm A l cc t bo nguyn pht bnh th-ng (nhn mt,
t bo thn kinh...). v tr cch bit vi h mu khi c chn th-ng, i vo
mu, gp t bo lymph ln u, tr thnh t d nguyn, lm xut hin t
khng th.
Cn cc t d nguyn nhm B c 2 th nhm. Th nhm th nht (B1) l cc
t bo bnh l do cc yu t l ho (bng, phng x) l t d nguyn th ph t
khng nhim trng.
Cc t d nguyn th pht nhim trng (nhm B 2) c th phn 2 loi:
46
 Phc hp (B2a) do s kt hp t bo + vi khun hoc c t vi khun, nh-
trong bnh thp tim.
Trung gian (B2b) nh- trong bnh di

47
T d nguyn th pht nhim trng trung gian hnh thnh trong t bo thn
kinh do tc
ng ca virus bnh di n t bo ny. N c bn cht hon ton khc vi
bn cht ca virus, cng nh- ca t bo thn kinh.
Nhim virus c th dn n s hnh thnh nhng d nguyn c phn ng
cho vi t chc ca bn thn c th, hu qu l pht sinh bnh t min (t
d ng).
Nhiu tc gi Fridman W.H Daeron M. (1995) nhn mnh: cc bnh t min c
2 loi: tnh c hiu i vi 1 c quan, hoc vi nhiu c quan.

Khi t d nguyn c phm vi hn

ch, bnh t min cng c phm
vi thu hp. Hnh 10 dn chng
mt s bnh t min c hiu
i vi 1 c quan hoc vi nhiu
c quan.
Nhng nm gn y (1995,
2000) cc tc gi Wallace D.J,
Metger A., Ashman R.F thng bo
vai tr nhiu yu t khc (gen
HLA, yu t d truyn, tia U.V,
t bo TCD8, T c ch trong c
ch bnh sinh nhiu bnh t
min, cng vi vai tr cc t d
nguyn v t khng th (khng th
khng nhn, v.v...).

Hnh 10: Mt s bnh t min c hiu theo c quan

Cu hi t l-ng gi

1. D nguyn l g? C my loi ?
2. D nguyn c nhng c im g?
3. Cc d nguyn ngoi sinh khng nhim trng ph bin nht l nhng loi g?
4. Hot cht ca bi nh l g ?
5. Nhng phn hoa l d nguyn phi c nhng c im g?
6. Nhng thc n l d nguyn c th gy nhng bnh g ?
7. Vai tr vi khun v virus gy cc bnh d ng ?
8. Cch phn loi t d nguyn ?

48
9. Vai tr t d nguyn v t khng th trong cc bnh t min ?

49
 HEN PHE QUN (HEN)

Mnc tiu hoc tp

1. Hieu dwoc khi nim mi ve hen, nhung nguyn nhn gy hen, co che hen
2. Biet cch chan don, dieu tr% v x l cc con hen
3. Nam vung phc do 4 bc, cch s dcng thuoc cat con v dn phng hen.

1. ai cwong ve hen
* Hen l bnh dwoc ni den t lu di, 5000 nam trwc dy, nhung hieu biet ve hen phe qun
dwoc tch luy ngy mt nhieu, nhat l may thp k va qua, dwoc sn quan tm to ln ca
nhieu chuyn ngnh y hoc (d% ng hoc, mien d%ch hoc, phoi hoc, nhi khoa, ni khoa...), v ket
qu dieu tr% chwa dat ket qu mong muon, t l t vong cao.
1.1. Vi dng l%ch su
* Thi ky co dai:
- Ngwi Trung Quoc (3000 TCL) d thng bo ve hen
- Hippocrate: (400TCL) de xuat v gii thch thut ngu asthma (th vi v)
- Celsus (the k 1) cc thut ngu dyspnea, asthma
- Areteus (the k 1) m t con hen - Galen (the k 2) bnh do phan hoa.
* Thi ky trung co: (T the k 3 den the k 17) khng c ti liu v tien b
- Helmont (1615): kh th do ma hoa
- Floyer (1698): kh th do co that phe qun
- Cullen (1777): Con kh th ve dm, vai tr di truyen v thi tiet trong qu trnh sinh bnh
hen.
* Thi ky cn v hin dai:
- Laennec (1860) - thng bo hen do lng mo
- Blackley (1873) - hen v mt so bnh do phan hoa
- Widal (1914) de xuat Thuyet d% ng ve hen
- Besanoon (1932) ai hi Hen ton cau lan th I
- Nhieu tc gi (1936-1945) pht hin thuoc khng Histamin
- Burnet, Miller, Roitt (1962-1972) vai tr tuyen c, cc te bo T v B trong Hen
Ishizaka (1967) pht hin IgE
T nam 1975 den nay, nhieu tc gi nghin cu pht hin mt so mediators trong hen nhw
prostaglandines, leucotrienes, cytokines.
- Cc thuoc cat con hen (salbutamol, terbutalin fenoterol)

27
- Cc thuoc dn phng hen (corticoid kh dung: beclometason, budesonide, fluticason)
- Cc thuoc phoi hop trong dieu tr% hen: cwng beta 2 tc dnng ko di (salmeterol,
formoterol) + corticoid kh dung (fluticason, budesonid) dwoc s dnng trong phc do 4 bc
theo GINA (chwong trnh quoc te phng chong hen 2000,2005).
2. %nh nghia, d lwu hnh, nguyn nhn, phn loai hen:
2.1. C nhieu d%nh nghia hen.
* %nh nghia cua OMS (1974)
Hen l bnh c nhung con kh th do nhieu nguyn nhn v ke c do gang sc, km theo dau
hiu lm sng tac nghen phe qun.
* %nh nghia cua Hi phoi My (1975):
Hen l bnh c dc diem gia tang tnh phn ng dwng h hap do nhieu nguyn nhn khc
nhau.
* %nh nghia cua Charpin (1984):
Hen l mt hi chng c nhung con kh th ve dm, hi chng tac nghen v tang tnh phn
ng phe qun do nhieu yeu to kch thch khc nhau.
* %nh nghia theo Chwong trnh quoc te phng chong hen (2002)
Hen l bnh l vim man tnh dwng th (phe qun) c sn tham gia ca nhieu loai te bo,
nhieu chat trung gian ho hoc (mediators), cytokines vv...Vim man tnh dwng th, sn gia
tang dp ng phe qun vi cc dot kh kh, ho v kh th lp di lp lai, cc bieu hin ny
nng ln ve dm hoc sng sm gii han dwng th lan to, thay doi v hoi phnc.
2.2. Ve d lwu hnh v tu vong cua hen
lwu hnh hen thap nhat: 1,4% dn so Uzobekistan, 15 nwc c d lwu hnh <6%(Trung
quoc, Vit nam...), 16 nwc c d lwu hnh 6-9%(PhanLan, Indonexia...), 14 nwc c d lwu
hnh 9-12% (Malaysia, Thi Lan, Philippin, i Loan...), 14 nwc c d lwu hnh 12-20%(
Colombia, Braxin,H Lan, Anh...)
lwu hnh hen cao nhat Peru 28%
Theo wc tnh ca To chc y te the gii (2004), hin nay trn the gii c 300 triu ngwi hen.
en nam 2025, con so ny se tang ln 400 triu ngwi. ng Nam Chu l khu vnc c d
lwu hnh gia tang nhanh nhat. Malaixia 9.7%, Indonexia 8.2%, Philippin 11,8% Thi Lan
9.2%, Singapore 14,3%, Vit Nam (2002) khong 5%, con so ny tiep tnc gia tang.
* Ty l Hen tre em
T l Hen tr em d tang 2-10 lan mt so nwc Chu Thi Bnh Dwong, Australia.

Bng 1: Ty l Hen tre em mt so nwc.

28
 Nwc 1984 1995

Nht 0.7% 8%

Singapore 5% 20%

Indonexia 2.3% 9.8%

Philippin 6% 18.5%

Malaixia 6.1% 18%

Thi Lan 3.1% 12%

Vit Nam 4% 11.6%

* Tu vong do Hen:
Trn pham vi ton cau, t vong do Hen c xu the tang r rt. Moi nam c khong 200.000
trwng hop t vong do hen (Beasley, 2003), 85% nhung trwng hop t vong do hen c the
trnh dwoc bang cch chan don sm, dieu tr% k%p thi, tin lwong dng dien bien ca bnh.
Ph ton do hen ngy mt tang, bao gom chi ph trnc tiep (tien, thuoc, xt nghim, vin ph) v
chi ph gin tiep (ngy ngh vic, ngh hoc, gim nang suat lao dng, tn phe, chet sm). Theo
To chc Y te the gii(1998), hen gy ton ph cho nhn loai ln hon chi ph cho 2 can bnh
hiem ngho ca the k l lao v HIV/AIDS cng lai.
2.3. Nhung nguyn nhn chnh gy Hen.
- Hng nghn loai d% nguyn (bni nh, phan hoa, lng th, vi khuan, virus, thnc pham, nam,
moc...)
- Tnh trang gang sc qu mc...
- Cm cm, nhiem lanh
- Cc chat kch thch: khi cc loai, nhung chat c mi v% dc bit (nwc hoa, my pham...)
- Thay doi nhit d, thi tiet, kh hu, khng kh lanh
- Nhung yeu to nghe nghip: bni (bng, len...) ho chat..
- Thuoc men (aspirin, penicillinv.v...)
- Cm xc m tnh: lo lang, stress...
2.4. Nhung yeu to kch pht con hen
- Nhiem trng dwng h hap, dng ch vai tr cc virus:
Virus (Arbovirus, VRS (Virus Respiratory Syncitial), Rhinovirus, Adenovirus, Coronavirus.
- Suy dinh dwng, d nhe cn (<2,5kg).
- nhiem mi trwng (trong nh, ngoi nh)

29
- Hwong khi cc loai, dc bit l khi thuoc l (trong khi thuoc l c hng tram thnh phan
lm pht sinh con hen). Tr nh rat nhay cm vi khi thuoc l.
2.5. Phn loai hen (so do 1):
C nhieu cch phn loai hen: theo nguyn nhn, theo mc d nng, nhe ca hen.
*Phn loai theo nguyn nhn: hen khng d% ng v hen d% ng
- Hen d% ng c 2 loai:
Hen d% ng khng nhiem trng do cc d% nguyn:
- Bni nh, bni dwng pho, phan hoa, bieu b lng sc vt (ch, mo, ngna vv...). khi bep
(than, ci...), hwong khi, thuoc l.
- Thc an (tm, cua), aspirin...
Hen d% ng nhiem trng do cc d% nguyn :
- Virus (Arbovirus, Rhinovirus, VRS (Virus Respiratory Syncitial), Coronavirrus).
- Nam moc (Penicillum, Aspergillus, Alternaria...).
Hen khng d% ng do cc yeu to: di truyen, gang sc, roi loan tm than, roi loan ni tiet,
thuoc (aspirin, penicillin..), cm xc m tnh manh (stress)
So do 1: Phn loai hen d% ng v khng d% ng

Hen

Khng d% ng D% ng

Khng nhiem trng (hen atopi, hen Nhiem trng

do bni nh, bieu b lng sc vt, (virus, nam moc...)
thc an.v.v...)

Phn loai hen theo bc nng nhe

C 4 bc hen theo mc d nng , nhe (Xem bng 2)

Bng 2. Phn loai 4 bc hen

Mc d con
Triu chng Triu chng hen nh Dao dng
Bc hen PEF, FEV
ban ngy ban dm hwng hoat PEF
dng
I Khng gii
Nhe, ngat <1 lan/tuan 2lan/thng han hoat >80% 20%
qung dng the lnc
II >1lan/tuan >2lan/ngy C the nh 60%-80% 20%-30%

30
 Nhe, dai hwng hoat
dang dng the lnc
nh hwng
III
Hng ngy >1lan/tuan hoat dng the 60% >30%
Trung bnh, lnc
Thwng
IV Gii han hoat
xuyn lin Thwng c 60% >30%
Nng dng the lnc
tnc

3. Nhung hieu biet mi ve co che hen

Nhung nghin cu mi nhat ve hen, cho thay co che pht sinh ca bnh ny rat phc tap, c
sn tham gia ca 3 qu trnh bnh l v nhieu yeu to khc nhau:
3.1. Ba qu trnh bnh l trong hen

So do 2 : Ba qu trnh bnh l trong hen

Yeu to nguy co
(lm pht sinh bnh hen)

Vim man tnh phe qun

Co that co tron
phe qun

Tang dp ng
dwng th Yeu to nguy co
(gy con hen cap)
Triu chng
HEN

3.2. Trong co che bnh sinh cua hen c nhieu yeu to tham gia:
Trwc het l nhieu loai te bo vim. Nhung te bo ny (te bo mast, eosinophil, dai thnc bo,
te bo bieu m, te bo ni mac, te bo lymph T v B) lai gii phng hng loat chat trung gian
ho hoc khc nhau.
Nhm chat trung gian ho hoc (mediators) dwoc gii phng trong co che bnh sinh hen, bao
gom cc mediators tin pht (histamin, serotonin, bradykinin, PAF, ECF...) v cc mediators
th pht (leucotrienes, prostaglandines, neuropeptides, cytokines; interferons (cc yeu to tang
trwng te bo v bach cau hat, bach cau don nhn (G-CSF, GMCSF) yeu to hoai t u
(TNF)). Xem bng 4 bi ai cwong.
Ngoi cc chat trung gian ho hoc ke trn, cn cc phn t ket dnh (Adhesion, molecules:
ICAM1, ICAM2, VCAM v nhieu enzymes (histaminase, tryptase, chymase) tham gia co che
hen.

31
 3.3. Co che hen, thnc chat l co che vim d% ng trong bnh sinh cua hen, c the tm
tat trong so do 3.

So do 3: Vim trong hen phe qun

4. Chan don hen:

4.1. Chan don xc d%nh:
Trong nhieu trwng hop, chan don xc d%nh hen khng kh khan
Khi no nghi den hen? Khi c mt trong 4 triu chng sau:
- Ho thwng tang ve dm;
- Th rt, kh kh ti pht;
- Kh th ti pht;
- Cm gic nng ngnc ti pht

32
Cc triu chng trn xuat hin hoc nng ln ve dm v sng sm lm ngwi bnh thc giac,
hoc xuat hin sau khi vn dng, gang sc, xc dng, thay doi thi tiet, tiep xc vi mt so d%
nguyn dwng h hap (khi bni, phan hoa)..
- C tien s bn thn hoc gia dnh mac cc bnh d% ng nhw hen, chm, vim mui d% ng,
vim ket mac ma xun.
- e chan don hen, can khai thc tien s, bnh s, khm lm sng, tham d chc nang h
hap, X quang phoi v cc xt nghim dc hiu khc.
- C the chan don xc d%nh neu thay con hen dien hnh dwoc m t nhw sau:
- Tien triu: Hat hoi, so mui, nga mat, buon ng, ho khan...
- Con kh th: Kh th chm, kh th ra, c tieng c c, tieng rt (bn thn bnh nhn v
ngwi xung quanh c the nghe thay), kh th tang dan, c the km theo v mo hi, kh ni.
Con c the ngan 5-15 pht c the ko di hng gi hng ngy hoc hon. Con hen c the tn hoi
phnc dwoc, ket thc bang kh th gim dan, ho v khac dm trong, qunh dnh.
- Nghe phoi trong con hen thay c ran rt ran ngy. Ngoi con hen phoi hon ton bnh
thwng.
- o chc nang thng kh phoi gip cho khang d%nh kh nang hoi phnc phe qun, bieu hin
bang tang >15% (hoc >200ml) FEV1, hoc lwu lwong dnh (LL) sau ht 400mcg
salbutamol 10 den 20pht.
- Chnp Xquang phoi v ghi din tim c the gip cc thng tin cho chan don phn bit.
4.2. Chan don phn bit:
- Khi chan don hen can ch tham khm dwng h hap trn de chan don phn bit hen vi;
amidan qu pht tr em, cc tac nghen do u chn p kh qun, bnh l thanh qun...
- Cc tac nghen khu tr kh phe qun nhw khoi u chn p, d% vt dwng th.. vi tieng th rt
co d%nh v khng dp ng vi thuoc gin phe qun.
- Hen tim: l bieu hin ca suy tim tri do hep h 2 l hoc cao huyet p. Can hi tien s,
khm lm sng, chnp X quang phoi v ghi din tim, siu m tim gip cho xc d%nh chan don.
- Bnh phoi tac nghen man tnh: thwng ngwi bnh trn 40 tuoi c ht thuoc l thuoc lo,
ho khac dm nhieu nam. o chc nang thng kh c roi loan tac nghen khng hoi phnc hon
ton vi thuoc gin phe qun.
4.3. Chan don nguyn nhn gy hen v cc yeu to kch pht con hen
Chan don dc hiu: Tm nguyn nhn (d% nguyn gy bnh), xc d%nh IgE ton phan v IgE
dc hiu sau khi d khai thc tien s d% ng v lm cc th nghim lay da, th nghim kch
thch vi cc d% nguyn dc hiu.
Lm sng c the dn don dwoc cc yeu to kch pht (gy con hen, lm con hen nng hon)
sau dy: lng sc vt; hwong khi cc loai; khi than, ci; bni dm giwng, goi; bni nh; ho
chat; phan hoa; thay doi thi tiet; cm cm; chay, nhay, d bng v cc loai hnh the thao c
the gy hen do gang sc.

33
 4.4. Chan don phn bc hen:
Phn bc hen ch can dna vo 1 dc tnh thuc bc cao nhat ca bnh nhn mc d cc dc
tnh khc c the bc nhe hon (xem bng 2).
Phn bc hen c nghia quan trong trong vic ch d%nh dieu tr% duy tr. Tuy nhin can ch
mt so diem sau dy:
- Tat c moi trwng hop moi bc deu c the b% con hen nng v nguy hiem tnh mang do vy
vic chuan b% x tr cc con hen cap deu can dwoc dt ra vi moi trwng hop bnh nhn.
- Phn bc c the thay doi trong qu trnh dieu tr%, c thay thuoc v bnh nhn deu can lwu
de c sn dieu chnh thch hop. Neu trong 1 thng hen chwa kiem sot dwoc can tang bc, v
neu hen dwoc kiem sot on d%nh trong 3 thng th c the th gim bc dieu tr% de tm che d
toi thieu kiem sot dwoc.
5. ieu tr% hen
5.1. Thuoc dieu tr% hen c 3 nhm chnh :
Thuoc cat con (gin phe qun)
Trong cc thuoc cat con, c may loai sau
- Thuoc cwng 2 tc dnng nhanh v tc dnng ko di
Thuoc cwng 2 tc dnng nhanh cat con sau 3-5 pht nhwng ch ton tai trong co the ngwi
bnh hen 4 gi (goi tat l SABA=short acting beta 2 agonist); salbutamol, terbutalin.
Thuoc cwng 2 tc dnng ko di, ton tai trong co the 12 gi (goi tat: LABA=Long acting
beta 2 agonist): salmeterol, formoterol.
- Thuoc khng cholinergic (Ipratropium) cat con sau 1 gi
- Thuoc corticoid uong (prednisolon 5mg), cat con sau 6 gi
- Theophyllin vin 100mg hin nay t dng v lieu dieu tr% hen v v lieu gy dc gan ke nhau.
Trong cc thuoc cat con ni trn, tot nhat l cc thuoc cwng beta2 tc dnng nhanh.
Thuoc dn phng hen c may loai:
- Thuoc corticoid dang kh dung (goi tat ICS = Inhaled corticosteroid): beclometason,
budesonide, fluticason
- Ngoi corticoid dang kh dung, thuoc dn phng hen cn c: LABA, thuoc khng
leucotrien(Montelukast, Zarfirlukast) nhwng dn phng hen tot nhat l corticoid kh dung
(ICS)
- Thuoc phoi hop: LABA + ICS l thuoc c nhieu wu diem nhat de dat kiem sot hen trit de.
5.2. Mnc tiu dieu tr% hen theo GINA(chwong trnh phng chong hen ton cau nam
2002, 2004):
- Khng c cc triu chng hen (hoc gim toi da)
- Khng cap cu, khng nhp vin (t khi xy ra)
- Khng dng thuoc cat con (hn huu)

34
- Khng ngh hoc, khng ngh vic
- Lwu lwong dnh gan nhw bnh thwng
- Khng c phn ng phn ca thuoc
5.3 Nhung thay doi co bn trong dieu tr% hen
Corticoid ht (ICS) l thuoc tot nhat khng vim trong hen. ICS c tc dnng:
+ Gim sn gia tang dp ng qu mc ca dwng th vi cc yeu to gy hen.
+ Kiem sot tnh trang vim dwng th.
+ Lm gim triu chng ca hen.
+ Lm gim so con hen nng den toi thieu.
+ Ci thin chat lwong cuc song ca ngwi hen.
Cch tiep cn dieu tr% hen hin nay (Xem bng 3 v bng 5)
"Bat dau bang lieu cao, roi gim dan khi tnh hnh dwoc ci thin". Khi dau vi lieu
800mcg/ngy, mt khi triu chng hen d ci thin th gim lieu den mc thap nhat m van
dm bo kiem sot dwoc bnh.
nhung bnh nhn hen chwa dwoc kiem sot tot vi corticoid ht, th khng nn tang lieu
thuoc ny, m ket hop vi mt thuoc khc (nhw LABA) se c hiu qu hon l tang lieu ICS.
Sn ket hop ICS vi LABA (thuoc gin phe qun cwng beta 2 tc dnng di) trong cng 1 dnng
cn ht ("2 trong 1") l bwc tien ln trong dieu tr% hen, v n gip kiem sot hen mt cch hiu
qu bang mt liu php don gin, liu php ket hop LABA + ICS (Seretide v Symbicort)
trong mt dnng cn ht, c hiu qu twong dwong vi dng 2 thuoc trong 2 dnng cn ht ring
bit, vi kh nang ngan nga con hen nng, ci thin chat lwong cuc song bnh nhn,
linh dng ve hm lwong thuoc, gip don gin hovic dieu tr% bnh hen. Hin nay, c 2 loai
thuoc phoi hop trong dieu tr% hen : Salmeterol (Seravent) + Fluticason (Flixotide) = Seretide
v Symbicort = Formoterol + Pulmicort
Liu php dieu tr% ket hop LABA + ICS se l nen tng cho dieu tr% hin hen trong twong lai
15 -20 nam ti.
Bng 3: Thuoc dieu tr% hen theo phc do 4 bc.

Thuoc cat
Bc Dn phng di han Gio dnc y te
con
1 SABA khi - Khng can dieu tr% dn phng Hwng dan cc van de can bn ca
can - Khi phi dng thuoc cat con hen
2lan / tuan th dng nhw bc 2 - Hwng dan cch s dnng cc
dnng cn
- Hwng dan cch nhn biet cc triu
chng nng v khi no can phi nhp
vin.
2 SABA khi ICS lieu thap
can

35
3 SABA khi ICS lieu trung bnh + LABA SABA = Cwng 2 tc dnng
can ngan;
4 SABA khi ICS lieu cao + LABA CS uong LABA = Cwng 2 tc dnng di;
can hay tim truyen ICS = corticosteroid ht;
CS=corticosteroid;
Anti LT = antileukotrien

Bng 4 : Bc dieu tr%

Tang v gim bc dieu tr%

Tang bc Gim bc
Ch d%nh Kiem sot v on d%nh dwoc triu chng t nhat
Khng kiem sot dwoc triu chng trong 1 3 thng
thng vi mc dieu tr% hin tai
X tr - Lieu toi thieu c hiu qu de trnh tc dnng
- Trnh yeu to kch pht phn
- m bo sn tun th dieu tr%, s dnng thuoc
dng cch
- Lieu cao ICS phoi hop vi LABA

Bng 5 : ieu tr% hen theo phc do 4 bc

ieu tr% dn phng- Duy tr lu di ieu tr% cat con

Thuoc gin phe qun tc dnng
Bc 1
ngan: Cwng 2 dang ht khi
Nhe Khng can dieu tr% dn phng
can, nhwng < 1 lan/ tuan hoc
(cch qung)
Cromoglycat.
Thuoc gin phe qun tc dnng
Bc 2
Bat dau dieu tr% dn phng vi lieu thap ngan: Cwng 2 dang ht.
Nhe Khng nn dng qu 3lan/
Corticoid, kh dung
(dai dang) ngy
Thuoc gin phe qun tc dnng
Bc 3
Bat dau dieu tr% dn phng vi lieu va ngan: Cwng 2 dang ht neu
Trung bnh can. Nhwng khng qu 3lan/
Corticoid, kh dung
(dai dang) ngy
ieu tr% hng ngy: Thuoc gin phe qun tc dnng
Corticoid dang ht: 800-2.000mcg. Thuoc ngan: Cwng 2 dang ht.
Bc 4 gin phe qun tc dnng ko di: Cwng 2
Nng dang ht tc dnng ko di v/hoc
(dai dang) Theophyllin phng thch chm v/hoc
Cwng 2 dang uong. Corticoid dang uong
hoc tim

36
 So do 4 : ieu tr% hen tai nh

nh gi mc d nng nhe ca Hen

Dna vo lm sng: kh kh, ho, kh th, rt lm long ngnc
Lwu lwong dnh (PEF):<80% tr% so bnh thwng

ieu tr% ban dau

Thuoc cwng 2 tc dnng ngan, dang ht
toi da 3lan/ gi, hoc kh dung 1 lan

p ng tot (nhe) p ng khng tot lam Khng dp ng (nng)

PEF > 80% dp ng vi (va) PEF60%. Dng thuoc
thuoc cwng 2 ko di PEF=60-80% dp ng vi cwng 2 triu chng
dwoc 4 gi. thuoc cwng 2 dwi 3 gi. khng gim hoc tang
ieu tr% tiep vi thuoc ieu tr% tiep thuoc cwng ln. ieu tr% nhac lai
cwng 2 3-4 gi/ lan 2 dang ht kh dung thm: thuoc cwng 2 ht hoc
trong 2-3 ngy tiep. Corticoid x%t hoc uong kh dung lieu cao hon.
Thm: Corticoid uong

Lin h vi bc si de en khm bc si ngay Vo bnh vin cap

c hwng dan dieu tr% de dieu tr% k%p thi cu ngay

37
 So do 5: ieu tr% hen tai bnh vin
nh gi mc b hen:
Khai thc tien s, bnh s, lm sng (kh kh, kh th, co ko long ngnc nhp tim,
nhp th, bo luu lung bnh, FEV1, SaO2, kh mu).

ieu tr ban bau:

* Thuoc cung 2 tc dnng ngan hang ht, kh dung 20-30pht/lan trong 1 gi.
*Th oxy cho ben khi SaO2 bat trn 95%
*Corticoid bung ton thn (neu khng bp ng ngay, hoc truc b bnh nhn b
dng Corticoid hoc cn hen nng)

nh gi lai:
Khm lm sng, bo luu lung
bnh, SaO2, SpO2, bin tim,
kh mu v xt nghim khc.

Hen phe qun mc b va: Hen phe qun mc b nng:

PEF: 60-80%
Lm sng: kh th va, co rt long ngnc
nhe
Thuoc cung 2 dang ht moi gi c the
dng Corticoid uong. Tiep tnc bieu tr 1-3
gi neu tien trien tot ln.
PEF: 60%
Lm sng: kh th nng, co rt long ngnc manh,
tien s c nguy c cao (nng). Tnh trang khng
kh ln sau bieu tr ban bau.Dng thuoc cung 2
1 gi/1lan hoc lin tnc. Dng khng Cholinergic
dang xt, th Oxy, dng Corticoid ton thn cung
2 dang tim.

p ng tot: p ng khng tot lam: Khng bp ng: sau 1 gi

Duy tr tot sau 60pht bieu tr ban Sau 1-2 gi. Bnh nhn c bnh nhn c nguy c cao.
bau nguy c cao Lm sng: l m, l lan.
Khm lm sng bnh thung Lm sng t nhe ben va. PEF< 50%
PEF>70% khng suy h hap. PEF: > 50-70% PCO2 > 45mmHg
SaO2 >95% SaO2 khng kh ln PO2 < 60mm Hg

Xuat vin:
Tiep tnc bieu tr thuoc cung 2
dang ht. C the dng Corticoid
dang xt hoc uong. Hung dan
dng thuoc bng phc bo, bng
ky thut. Theo di st
Tiep tnc bieu tr tai bnh vin.
Thuoc cung 2 dang ht
khng Cholinergic dang xt
Corticoide - uong hoc tim. C
the dng Aminophylin tim chm
TM. Theo di PEF, SaO2, mach,
nong b. Theophyllin (neu c)
ieu tr cap cu: Thuoc cung 2
ht khng Cholinergic ht.
Corticoide tim TM. Th O2, c
the dng Aminophyllin tim TM
chm (neu can). C the bt ni
kh qun, th my

Kh hn Khng kh hn

Xuat vin (neu PEF >70%). Chuyen cap cu cham sc bc bit

Tiep tnc bieu tr thuoc vin. neu khng b sau 6-12 gi
Siro hay dang xt

38
 Cu hi tn lwong gi

1. Hen l g?
2. V sao d lwu hnh hen ngy cng tang ?
3. Nhung nguyn nhn gy hen hay gp nwc ngoi? nwc ta?
4. V sao goi hen l gnh nng ton cau?
5. Phn loai hen c may cch?
6. Khi nim mi ve hen c t bao gi? Ni dung ch yeu l g?
7. Cch dieu tr% dn phng hen l ch yeu? Tai sao? Dng thuoc g?
8. Cat con hen bang thuoc g?
9. Phc do 4 bc l g?
10. Hen c the dieu tr% hon ton? Tai sao?

39
 D ng thuc

Mc tiu hc tp
1. Bit phn bit cc tai bin d ng thuc vi cc tai bin khc do thuc gy ra.
2. Hiu r nhng thuc hay gy d ng v c ch d ng thuc.
3. Bit r nhng biu hin lm sng d ng thuc, cch chn on, x l v
d ph ng cc tai bin d ng thuc.

1. i c-ng
Theo cch phn loi ca nhiu tc gi (Charpin, 1981, Vervloet, 1995) nhng
tai bin do dng thuc c th bao gm nhiu nhm vi cc nguyn nhn sau
y:
- Qu liu
- Tnh trng khng dung np thuc
- Tnh trng c ng (idiosyncrasie)
- Tc dng ph
- Cc phn ng d ng hay gp hn c v c c ch min dch do s kt
hp d nguyn (thuc) vi khng th d ng.
2. Nhng c ch d ng thuc

Bt k thuc no cng c th gy d ng. Phn t thuc c th l protin

hoc hapten khi vo c th c th gy ra tnh trng mn cm c th, lm
hnh thnh cc khng th IgE hoc t bo T k c, hu qu l pht sinh phn
ng d ng trn lm sng.
C ch d ng thuc: Thuc kt hp vi phn t protin kch thch d ng
tc th vi IgE hoc d ng mun vi t bo T. D ng thuc c th l mt
trong 4 loi hnh (type) d ng theo cch phn loi ca Gell v Combs (bng
1).
Bng 1: Phn loi min dch bnh l ca d ng thuc

Loi hnh d ng V d Th lm sng in

thuc hnh
Loi hnh I (d ng tc
th) Betalactam,Insuli Sc phn v, my
n ay, ph Quincke
Loi hnh II (gy c t bo)
Methyldop Thiu mu tn huyt,
a xut huyt gim tiu
Loi hnh III (phc Globulin khng
hp lymph cu
min dch) Bnh huyt thanh,
Kem corticoid
Loi hnh IV (d ng vim mch
Cht cn quang,
mun) Loi hnh d ng aspirin Vim da tip xc
gi hiu 41 Ban, sc phn v, co
tht ph qun, vim
mi
Ngoi 4 loi hnh d ng (I, II, III, IV) theo Gell v Coombs, cn mt loi hnh
d ng gi hiu (pseudoallergic) do cc thuc; aspirin, chng vim khng
steroid (non steroid anti inflammatory drug NSAID).
3. Nhng thuc hay gy d ng

Theo nhng thng k ca T chc Y t Th gii (1990) 17 n-c cho thy tt

c cc loi thuc u c th gy d ng, nhi u nht l khng sinh. Trong cc
khng sinh gy d ng, penicillin ng hng u, t l sc phn v do dng
penicillin l 1/70000.
an Mch, c 10 triu ng-i dng khng sinh c 1 ng-i t vong do sc phn v.

Hoa K, t 1954-1960, t l t vong do d ng khng sinh tng 12 ln.

Lin X (c), trong 10 nm 1971 -1980, xy ra 12238 tai bin do dng
thuc, trong d ng vi khng sinh l 9400 tr-ng hp (71,05%), hng nm c
2/1 triu ng-i t vong do d ng vi khng sinh.
Hurwite (1969) cho bit d ng thuc chim 2,9% cc tr-ng hp vo vin iu
tr. Arsdel (1978) cho bit ti 10% s ng-i dng Sulfamid b d ng vi loi
thuc ny. Kt qu iu tra c bn ca B mn D ng i hc Y H Ni
nhng nm 1980 -1984 H Ni cho thy t l d ng thuc l 2,5% v c xu
h-ng gia tng cao trong nhng nm gn y, tng 2-3 ln, t ti 8,73% (2000 -
2001).
Nghin cu v tnh hnh d ng thuc Khoa D ng - MDLS Bnh vin
Bch Mai nhng nm t 1980-1991 v 1991-1994 cho thy s ng-i d ng vi
khng sinh ch im t l cao nht (80,3%), tip theo l thuc chng vim, gim
au, h st... (bng 2). Trong s nhng ng-i b d ng vi khng sinh, s d
ng vi penicillin v ampicillin chim t l cao nht (bng 3 v 4).
Bng 2: T l ng-i bnh b d ng thuc

TT Tn thuc gy d Ng-i T l
ng bnh %
1 Khng sinh v Sulfamid 237 80,3%
chm
25 8,5
2 Chng vim, gim au, h
st 10 3,4

3 Vitamin 7 2,4

4 An thn 6 2,0

5 Vacxin, huyt thanh 5 1,7

6 Thuc ng y 2 0,7

7 Thuc chng d ng 3 1,0

42 295 100%
8 Cc thuc khc
Tng s
 Bng 3: S ng-i bnh b d ng khng sinh

S T l % T l
TT Tn khng bnh trong %
sinh
nhn khng sinh chung
1 Penicillin
86 36,3 29,2
2 Ampicillin
45 19 15,2
3 Streptomycin
38 16 13
4 Tetracyclin
30 12,6 10,2
5 Sulfamid chm
17 7,2 5,7
6 Cloramphenicol
10 4,2 3,4
7 Rifampicin
4 1,7 1,3
8 Gentamycin
3 1,3 1
Tng
cng 237 100% 80,3
Bng 4: Tnh hnh d ng khng sinh ti Khoa D ng -
MDLS Bnh vin Bch Mai 1981 -1990 v 1991-
1994

Tn khng 1981- 1991-

sinh 1990 1994
S l-ng T l S l-ng T l
% %
Penicillin 86 32
36,3 21,34
Ampicillin 45 72
19 48
Streptomycin 38 5
16 3,34
Tetracyclin 30 6
12,6 4
Sulfamid chm 17 15
7,2 10
Cloramphenico 10 4
4,2 2,66
l Rifampicin 4 6
1,7 4
Gentamycin 3 6
1,3 -4
Khng sinh 4 4
khc 1,7 2,66
237 150
100% 100%
4. Mt s c im d ng thuc

Tnh khng nguyn khng ng u gia cc loi thuc , do bn cht cu

trc ho hc, phn t l-ng ca thuc, s chuyn ho ca thuc trong c th, s
hnh thnh cc sn phm trung gian v s lin kt ca cc sn phm trung gian
ny vi thnh phn protein ca c th.

43
 Tnh mn cm cho gia cc thuc c cu trc ho hc gn ging nhau
nh- Penicillin v Ampicillin, Sulfamid v Procain... gy nn nhng tai bin
bt ng cho thy thuc.
Tnh a gi (polyvalent) ca d ng thuc -c th hin nhng mc
khc nhau, mt loi thuc c th gy ra nhiu triu chng lm sng v ng-c
li, mt hi chng lm sng c th do nhiu loi thuc. V d, Penicillin c th
gy ra sc phn v, bnh huyt thanh, vim da tip xc, hen, da ton
thn, hi chng Stevens -Johnson, hi chng Lyell... Ng-c li, sc phn v
khng phi ch do khng sinh m cn do nhiu loi thuc v cc sn phm
khc (Vitamin B1, B12, Procain, Vacxin, huyt thanh, trng,sa, nc cn
trng...).Ng-i bnh d ng vi thuc th-ng hay km theo cc bnh d ng
khc (d ng thi tit, d ng thc n, hen v.v...).
Yu t di truyn, c a v th tng d ng ca ng-i bnh v cch s
dng thuc c vai tr rt quan trng trong c ch bnh sinh d ng thuc
(vn ny s -c cp trong mc nhng yu t nguy c d ng thuc).
5. Nhng biu hin lm sng d ng thuc.

5.1. Nhng biu hin lm sng ca d ng thuc rt phong ph v a

dng (bng 5), cc biu hin ny c th xut hin ton thn, hoc tng h
c quan (da, phi, gan, thn, mu...).
Bng 5: Nhng biu hin lm sng d ng thuc

V tr xut Biu hin lm

hin sng
Ton Sc phn v, h huyt p, st, vim mch, s-ng hch,
bnh huyt thanh
thn Da My ay, ph Quincke, sn nga, vim da tip xc,
mn cm
nh sng, da ton thn, hng ban nhim sc c
nh, hi chng Stevens-Johnson, hi chng Lyell.
Ph
i Kh th, vim ph nang

Gan Vim gan, tn th-ng t bo gan

Tim Vim c tim

Th Vim cu thn, hi chng thn h-
n Ban xut huyt gim tiu cu, thiu mu tn huyt,
gim bch cu trung tnh.
5.2.
Mu Mt s bnh cnh lm sng hay gp do d ng thuc
+ My ay
- My ay th-ng l biu hin hay gp v ban u ca phn ln cc tr-ng
hp d ng thuc.
- Cc loi thuc u c th gy my ay, hay gp hn l do khng sinh,
huyt thanh, vacxin, thuc chng vim, gim au, h st...

44
- Sau khi dng thuc t 5 - 10 pht n vi ngy, bnh nhn c cm gic nng
bng, nga, trn da ni ban cng sn ph. Sn c mu hng, xung quanh vin
, hnh th trn, bu dc, to bng ht u, ng xu, c th lin kt thnh
tng mng, cng gi cng tin trin nhanh v lan rng. Tr-ng hp nng, km
theo vi my ay c th au bng,
au khp, chng mt, bun nn, au u, mt mi, st cao...
+ Ph Quincke

- Ph Quincke l mt dng my ay khng l, nguyn nhn c th do nhiu loi thuc

khc nhau gy nn nh- khng sinh, huyt thanh, h st...

- Chng vim, gim au, h st...

- Ph Quincke th-ng xut hin nhanh sau khi dng thuc nhng vn g da
mng, mi, c, quanh mt, bng, cc chi, b phn sinh dc... Kch th-c ph
Quincke th-ng to, c khi bng bn tay, nu gn mt c th lm mt hp
li, mi lm mi s-ng to bin dng, mu da ph Quincke bnh th-ng hoc
hng nht, i khi phi hp vi my
ay, tr-ng hp ph Quincke hng, thanh qun, bnh nhn c th nght th;
rut, d dy, gy au qun bng; no, gy au u...
+ Sc phn v
- Sc phn v l tai bin d ng nghim trng nht, d gy t vong. Kh
nhiu loi thuc c th gy sc phn v nh- khng sinh, huyt thanh,
thuc chng vim, gim
au, h st, tinh cht gan, mt s loi vitamin, thuc gy t...
- Bnh cnh lm sng ca sc phn v kh a dng, th-ng c th xy ra sau
khi dng thuc t vi giy n 20 -30 pht, khi u bng cm gic l th-ng
(bn chn, hong ht, s cht...). Sau l s xut hin nhanh cc triu
chng mt hoc nhiu c quan nh- tim mch, h hp, tiu ho, da.... vi
nhng biu hin nh- mch nhanh, nh, huyt
p tt, khng o -c, kh th, nga ran khp ng-i, au qun bng, a i
khng t ch. Th ti cp ng-i bnh hn m, nght th, ri lon tim mch,
ngng tim v t vong sau t pht.
+ Chng mt bch cu ht
- Chng mt bch cu ht c th xut hin sau khi bnh nhn dng cc loi
thuc nh- Sulfamid, Penicillin liu cao, Streptomycin, Cloramphenicol,
Pyramidon, Analgin... vi bnh cnh lm sng in hnh: st cao t ngt,
sc kho gim st nhanh, lot hoi t nim mc mt, ming, hng, c quan
sinh dc; vim phi, vim tc tnh mch, nhim khun huyt, d dn ti t
vong.
+ Bnh huyt thanh
45
- Bnh huyt thanh l mt loi tai bin d ng hay gp, gy ra do cc loi
khng sinh nh- Penicillin, Ampicillin, Streptomycin.... v mt s thuc khc nh-ng
t -c ch . Bnh xut hin t ngy th 2 n ng y th 14 sau khi dng
thuc, bnh nhn mt mi chn n, mt ng, bun nn, au khp, s-ng nhiu
hch, st cao 38 - 390, gan to hn

46
bnh th-ng, my ay ni khp ng-i, nu pht hin kp thi, ngng ngay
thuc, cc triu chng trn s mt dn.
+ Vim da d ng
- Vim da d ng thc cht l chm (eczema), th-ng tn c bn l mn
n-c km theo c nga v tin trin qua nhiu giai on. Vim da d ng
th-ng xy ra nhanh t gi sau tip xc vi thuc, ng-i bnh thy nga d di,
ni ban , mn n-c, ph n cc vng da h, vng tip xc vi thuc.
+ da ton thn
- da ton thn th-ng xy ra do thuc nh- Penicillin, Ampicillin,
Streptomycin, Sulfamid, Cloramphenicol, Tetracyclin, cc thuc an thn, gim
au h st... bnh xut hin 2-3 ngy, trung bnh 6-7 ngy, i khi 2-3 tun
l sau khi dng thuc. Bnh nhn thy nga khp ng-i, st cao, ri lon tiu
ho, ni ban v tin trin thnh da ton thn, trn da c vy trng, kch
th-c khng u, t ht phn n ht d-a, cc k tay k chn nt chy n-c vng,
i khi bi nhim c m.
+ Hi chng Hng ban a dng c bng n-c (Hi chng Stevens -
Johnson) xem hnh 2 v 3.
- Do cc thuc nh- : Penicillin, Streptomycin, Sulfamid chm, Tetracyclin thuc
an thn, thuc chng vim, gim au, h st... Sau khi dng thuc vi gi n
15 -20 ngy, bnh nhn thy mt mi, nga khp ng-i, c cm gic nng
ran, st cao, ni ban , ni cc bng n-c trn da, cc hc t nhin (mt,
ming, hng, b phn sinh dc) dn ti vim lot, hoi t nim mc cc hc ny,
c th km theo tn th-ng gan thn, th nng c th gy t vong.
+ Hi chng Lyell (Hi chng hoi t tiu th-ng b nhim c - Toxic
epidermal
necrolysis) xem hnh 4.
- L tnh trng nhim c da nghim trng nht gy ra do cc thuc nh-
Sulfamid chm, Penicillin, Ampicillin, Streptomycin, Tetracyclin, Analgin,
Phenacetin... Bnh din bin vi gi n vi tun sau khi dng thuc, bnh
nhn cm thy mt mi, bng hong, mt ng, st cao, nga khp ng-i, trn
da xut hin cc mng , i khi c cc chm xut huyt, vi ngy sau,
c khi sm hn, lp th-ng b tch khi da, kh
ng ti l trt ra tng mng (du hiu Nikolski d-ng tnh), t-ng t nh- hi
chng bng ton thn, cng vi tn tht da c th vim gan, thn, tnh trng
ng-i bnh th-ng rt nng, nhanh dn ti t vong.
5.3. Nhng yu t nguy c gy d ng thuc.
Ng-i s dng thuc c c a, tin s d ng , bn thn v gia nh
(b, m, anh ch em rut, con ci) tng b d ng thuc hoc c bnh d

47
ng (vim mi d ng, hen, d ng thc n, ho cht, d ng tim chng
v.v...).
Tui v gii c vai tr r rt trong bnh sinh d ng thuc: n nhiu hn nam,
tui 20 - 40.

48
 Dng thuc c nhm c hiu (NH2, CONH2, NHOH, COOH...) d gn
vo gc hot ng ca phn t prtin c th (COOH, SH, NH 2, NHCNH2).
S dng thuc khng ng ch nh , dng nhiu loi thuc cng lc, dng
thuc ko di; kt hp nhiu loi mt ln, khng bit chng c th mn cm
cho, t-ng tc, t-ng k, phn ch nh vi nhau (xem cc bng 6, 7, 8, 9).
Bng 6: Mn cm cho trong d ng thuc

Thuc Nhng thuc ging nhau v c tnh KN

Peniclllin Bicilllin, Phenoxymethyl penicillin, Penicillin G, cc loi Penicillin
bn tng hp: Methycillin, Ampicillin, Oxacillin.
Levomycllin Syntomycin (Chloramphenicol)
Streptomyci Colimycin
n Neomycin Kanamycin, Monomycin
Colimycin Gentamycin, Dicain, Axit Para amino benzoic
Sulfamid Novocain, Dicain, Axit Para amino benzoic
Amidopyrin Butadion, Analgin, Antipyrin, Reopyrin
(Pyramidon
) Aminazin, Phenergan
Medinal, Luminal,
Plpolphene
Theophedrin
Veronal
Bng 7: Phn ng t-ng tc khng sinh (A) vi thuc B

Khng sinh Thuc Biu

(A) B hin
Cephalospori R-u ethylic Ng-i nng, ra m hi, tim p
n Chlorocid nhanh, chng mt, dng (A)
cai nghin r-u
Sulfamid
Griseofulvin
Corticoid, (A) lm gim (B)
Rifampicin Theophyllin
(A) tng tnh c ca (B)
Erythromycin Theophylli
Tng c tnh trn thn v thnh
Aminoglucosi n Lasix gic
d Rifampicin Quinidin (A) lm gim tc dng (B)
Tetracyclin Polymycin Tng c tnh vi thn
Mui st (ung) (A) v (B) gim tc dng ln nhau:
Hydroxyt nhm Ung cch (A) 3 gi.

49
 Bng 8: Phn ng t-ng k ca khng sinh (khng trn ln)

Streptomyci Ampicillin, Penicillin G,

n Procain
Vitamin C Tetracyclin Aminophyllin,
Penicillin G , ,
Erythromycin, Lyncomycin, Streptomycin Nabic
a,
Tetracycllin Aminophyllin, Ampicillin, Penicillin G, Chlorocid,
phc
hp vitamin B, vitamin B12, Heparin, Methycillin,
Oxacillin, Amphotericin
Gentamycin Ampicillin, Penicillin G, Erythromycin, Babica,
Chlorocid,
Lasix, Heparin, Carbenicillin
Clindamycin Aminophyllin, Ampicillin, Barbiturat, Calci
gluconat,
Bng 9: Phn
Magnesi sulfat,ch nh ca thuc
Tobramycin

1. Betalactam Allopurinol
2. Isoniazid Carbamazepin
3. Rifampicin Thuc nga thai
4. Macrolid Ergotamin
5. Trimethoprim Methotrexat
6. Corticoid Erythromycin
7. Cc khng Histamin R-u, cn

6. Chn on, pht hin sm d ng thuc.

Nhng ph-ng php n gin, d lm d phng v pht hin sm d ng
thuc.
Tr-c ht l khai thc tin s d ng
Lm r cc cu hi
A. Ng-i bnh dng thuc no lu v nhiu nht?
B. Loi thuc gy phn ng? Biu hin?
C. Nhng bnh tr-c y v hin nay: Vim phi, Vim ph qun, Vim hng,
Vim tai, ho g, Vim mi, Vim xoang mi, Hen, s t ma, My ay, Ph
Quincke., thp (khp, tim), lao, bnh do nm, bnh thn kinh v tm thn,
tiu -ng, HA cao v.v...
D. tim chng nhng loi vacxin v Huyt thanh no?
E. nh h-ng ca cc yu t nhim lnh, c hi, thc phm, stress, thay i
ni v lm vic, cn trng t, tip xc vi phn hoa, ho cht, gia sc.

50
F. B m, con ci, anh ch em rut: Ai c nhng phn ng v bnh k trn (A,
B, C, D, F).
Test ly da
Nh git khng sinh (Pencillin, Streptomycin) nng 1/10 vn, 1/vn.
Ly kim
t gc 450v ly ng-c ln. Sau 10 - 20 pht, c kt qu.
Test kch thch
Test nh mi.
Nh mt git d nguyn vo mt bn mi. Phn ng d-ng tnh xut hin khi
c ht hi, nga mi, kh th mt bn mi.
Test kch thch d-i l-i
Ngm 1/4 vin thuc, hoc gc c tm thuc. Sau 10 - 15 pht, nu ng-i
bnh c: ph l-i, ph mi, ban, my ay l th nghim d-ng tnh. Khi
ng-i bnh cn sc ming loi b thuc.
Cc phn ng in vitro phng th nghim (xem tp thc hnh d ng),
ch yu l:
+ Phn ng phn hu t bo mast
+ Phn ng tiu bch cu c hiu
+ Phn ng xc nh IgE c hiu v ton phn.
7. iu tr d ng thuc.

Nguyn tc chung
- Khng bnh nhn tip xc vi thuc gy d ng cho h, hn ch
dng cc thuc khc.
- S dng cc thuc chng d ng: Khng Histamin anti H1 th h 2 (cetirizin,
fexofenadin, astemizol, loratadin...). Tr-ng hp d ng thuc nng hn: kt
hp dng corticoid (prednisolon, methyl prednisolon) tim truyn, phi hp vi cc
thuc cha triu chng.
- B n-c v in gii (khi c yu cu), thuc li tiu.
- Chng bi nhim (nu c), la chn khng sinh thch hp m bo s dng
hp l, an ton.
D phng sc phn v (xem bi sc phn v)
X l cc tr-ng hp: da, hi chng Stevens - Johnson, hi chng Lyell. X
l nh- vi cc tr-ng hp nng do d ng thuc, ch cng tc h l.
8. D phng d ng thuc.

Tuyn truyn s dng thuc an ton, hp l trong cn b y t, dng thuc

ng ch
nh, ng liu. Hn ch nn t iu tr trong nhn dn.
Tr-c khi s dng thuc, kim tra cht l-ng thuc; khai thc tin s d ng,
th test theo thng t- b y t, chun b ti chng sc.
Tim khng sinh phi dng dng c ring.
51
9. Mt s hnh nh d ng thuc

Hnh 1. Hng ban nhim sc c nh do Tetracycl in (

mi)

Hnh 2 . Hng ban a dng do d ng thuc Penicillin, c bng

n-c

52
Hnh 3 . Hi chng Stevens-Johnsons do thuc nh mt clorocid

Hnh 4. Hi chng Lyell do Ampicillin

53
 Cu hi t l-ng gi

1. V sao d ng thuc xy ra ngy cng nhiu?

2. Nhng thuc no hay gy d ng?
3. D ng thuc c nhng c ch g l ch yu?
4. Phn loi d ng do thuc?
5. V sao ni lm sng d ng thuc rt phong ph v a dng?
6. Nhng yu t nguy c gy d ng thuc l nhng yu t g?
7. C th d phng v pht hin sm d ng thuc khng?
8. Nhng thuc dng iu tr, x l d ng thuc?
9. Hi chng Stevens Johnson c nhng biu hin g?
10. Hi chng Lyell - Bnh cnh lm sng - iu tr nh- th no?

54
 Sc phn v (SPV)

Mc tiu hc tp :
1. Hiu -c c ch bnh sinh ca sc phn v (SPV).
2. Nm -c cc nguyn nhn gy SPV.
3. Nm chc cc triu chng lm sng ca SPV
4. Bit cch x l sc phn v v cc bin php d phng SPV.

1. Vi nt i c-ng

Sc phn v (SPV) l tai bin d ng nghim trng nht, d gy t vong nu

khng
-c chn on v x l kp thi. Tnh cht nguy kch ca SPV gy hoang
mang cho mi ng-i k c thy thuc v thn nhn bnh nhn. Bnh xut
hin nhanh, ngay lp tc hoc 30 pht sau khi dng thuc, th test, b ong
t hoc sau khi n mt loi thc
n l. Triu chng bnh xut hin cng sm th bnh cng nng, t l t
vong cng cao. Cc -ng -a thuc vo c th: tim tnh mch, tim bp, d-i
da, trong da, ung, xng, bi ngoi da, nh mt, t m o.v.v u c th
gy SPV, tuy nhin -ng tim tnh mch l nguy him nht. Cc loi thuc,
nht l cc thuc khng sinh l nguyn nhn chnh gy SPV. V vy SPV l
mt cp cu cn -c x tr nhanh, kp thi v d dn n t vong do suy
h hp cp v tt huyt p.
Vy SPV l g? l mt dng ca phn ng d ng typ nhanh (typ reagin,
typ phn v) pht sinh khi c s xm nhp ln th hai ca d nguyn vo
c th. SPV c c
im tt huyt p, h thn nhit, tru tim mch, tng tnh thm thnh mch v
co tht c trn. Tuy nhin trong thc t c nhiu tr-ng hp bnh nhn mi
dng thuc ln
u nh-ng b SPV l do h b mn cm tr-c vi mt loi d nguyn no
c cu trc ging vi cu trc ca thuc, v d ng-i bnh b nhim
nm penicillinum t mi tr-ng do n hoc ht phi loi nm ny.
2. C ch v nguyn nhn gy sc phn v

2.1. C ch bnh sinh : Phn ng qu mn tc th th-ng ko theo s gii

phng cc cht trung gian ho hc (mediator) t t bo mastocyte v basophil
m c ch l do s kch thch ca d nguyn vi khng th IgE.
D nguyn l nhng cht c bn cht khng nguyn hoc khng khng nguyn
c kh nng gy nn trng thi d ng (kch thch to khng th c hiu
IgE).
Khng th IgE l khng th qu an trng nht tham gia c ch d ng -c
55
Coca pht hin nm 1925. Cc reagin ca ng-i l IgE -c Ishizaka tm ra nm
1967. Trong cc bnh d ng hm l-ng IgE trong huyt thanh tng rt cao.
Kt qu s kt hp ca d nguyn vi khng th IgE trn mng t bo
mastocyte l hng lot cc cht trung gian ho hc -c gii phng theo s
d-i y:

56
 C ch sc phn v (c ch d ng typ I)

D
nguyn Ni gn D
IgE nguyn

Tng hp
IgE
Mastocyt
e

IL-4/IL-13
Gii phng
mediators

Hen ph qun, my
Plasmocyt ay,
e vim mi d ng, sc phn
v

Hnh nh t bo mast ang phng thch histamin

v cc cht trung gian ho hc (nh chp qua k nh hin vi in t)

Kt qu ca phn ng d ng nu trn l hng lot cc cht trung gian ho hc

(mediators) -c thot ra t t bo mastocyte v basophil nh- histamin,
serotonin, bradykinin, leucotrien, cht tc dng chm ca phn v (SRS -A:
slow reacting substances of anaphylaxis), cc Prostglandines, yu t hot ho
tiu cu (PAF: platelet activating factor) v.v cc cht ny lm gin mch,
co tht c trn ph qun, my ay, ph Quincke v.v gy nn bnh cnh
lm sng ca SPV.
Sau y l tc dng sinh l ca mt s cht trung gian ho hc t t bo
mastocyte v basophil trong sc phn v:
57
2.1.1.Histamin: Kch thch receptor H 1 : - Co mch
- Gin mch, ph nim mc ph qun
- Tng tnh thm thnh mch, tng tit dch
- Co tht c trn ph qun
- My ay, ph Quincke, ban .
Kch thch receptor H 2 : - Gin mch
- Tng nhp tim
- Tng co bp c tim
- Tng tit dch d dy
2.1.2. Serotonin : c vai tr quan trng trong phn ng SPV ca ng-i v ng
vt. Cht ny gy co tht c trn ph qun , tng tnh thm thnh mch, co
tht cc mch mu tim, phi, no, thn, kch thch cc u mt thn kinh gy
nga.
2.1.3. Bradykinin: co c trn chm hn histamin, gin mch, h huyt p, tng
tnh thm thnh mch.
2.1.4. Cc Prostaglandines : co tht c trn ph qun, tng tnh phn ng
ph qun (PGD2 gy co ph qun).
2.1.5. PAF (yu t hot ho tiu cu): ng-ng kt tiu cu, kch thch tiu
cu gii phng histamin v cc mediators khc, lm tng tnh thm thnh
mch, co tht c trn v ph qun.
2.1.6.SRS.A: tng tnh thm thnh mch v sn sinh IL 1, co tht ph qun.
2.1.7.Leucotrien : - Co c trn ph qun
- Tng tc dng ca histamin
Sc phn v xy ra nhiu c quan ni tng trong c th do s tc ng ca
cc cht trung gian ho hc k trn:
- Trn h tim mch lm gin mch, tt huyt p, tru tim mch.
- Trn h h hp : co tht ph qun gy nght th
- Trn h thn kinh: co mch no gy au u, hn m.
- Trn h tiu ho: tng tit dch, tng nhu ng rut gy ra a chy, au
bng. Lm ri lon vn ng c trn bng quang, hu mn gy i a khng
t ch.
- Trn da: gy my ay, ph Quincke, mn nga.
2.2. Nguyn nhn gy sc phn v : C rt nhiu nguyn nhn, trong
thuc l nguyn nhn hng u, tip n l thc n, nc cn trng.
2.2.1. Danh mc cc thuc gy sc phn v : SPV v nhng tai bin do d
ng thuc xy ra ngy mt nhiu vi nhng hu qu nghim trng nhiu tr-ng
hp t vong. Cc thuc khi vo c th (u l hapten) phi kt hp vi protein
trong huyt thanh hoc m mi tr thnh d nguyn hon chnh c c
tnh khng nguyn gy nn phn ng phn v. Cc thuc gy SPV ngy cng
nhiu, sau y l nhng thuc hay gp:
58
Penicillin Streptomycin
Ampicillin Vancomycin

59
 Amoxycillin Chloramphenicol
Cephalosporin Tetracyclin
Claforan Trimazon
Neomycin Nevigram
Kanamycin Erythromycin
Lincomycin Polymycin
B Gentamycin
2.2.1.2. Cc thuc chng vim khng steroid: salicylat, colchicin,
mofen, indomethacin.
2.2.1.3. Cc vitamin: vitamin C tim tnh mch l nguyn nhn gy SPV hay
gp n-c ta, tip sau l vitamin B1, B12 dng tim.
2.2.1.4. Cc loi dch truyn: glucose, nutrisol, alvesin, bestamin, tryphosan.
2.2.1.4. Thuc gy t:procain, novocain, Lidocain, thiopental.
2.2.1.5. Thuc cn quang c it : visotrat
2.2.1.6. Cc hormon : insuline, AC TH, vasopressin.
2.2.1.7. Cc loi vacxin, huyt thanh: vacxin phng di, phng un vn, huyt
thanh khng bch cu, un vn.
2.2.1.8. Cc thuc c phn t l-ng thp: dextran, gamma globulin, dch trit
ph tng.
2.2.1.9. Cc enzym: trypsin, chymotrypsin.
2.2.1.10. Cc thuc khc: visceralgin, Aminazin, paracetamol, efferalgan -codein.
2.2.2.Cc nguyn nhn khc gy sc phn v
2.2.2.1. Thc n : C nhiu loi thc n ngun gc ng vt, thc vt, gy
SPV nh-: c thu, c ng, xi gc, tm, tp, c, trng, sa, nhng, da, khoai
ty, soi, lc, u nnh, cht ph gia.v.v
2.2.2.2. Nc cn trng: sc phn v xy ra do ong t, rn, nhn, b cp cn.
Bnh cnh lm sng ca SPV do cn trng v do cc nguyn nhn khc (thuc
- thc phm) v c bn ging nhau.
3. c im lm sng ca sc phn v:
Sc phn v lin quan n phn ng qu mn tc th c th xy ra nhng
ng-i b mn cm, c th tng d ng (atopy) phn ng qu mn tc th c
th xy ra ti ch hoc ton thn tt c cc loi vi c im hay gp n
ht l co tht c trn ph qun v tng tnh thm thnh mch.
Triu chng lm sng ca SPV rt a dng, xut hin nhiu c quan ni
tng.
nng ca sc ph thuc vo mc nhy cm ca tng c th, s l-ng v
tc hp th cc d nguyn hay cht l vo c th, mt khc ch yu ph
thuc vo thi gian x tr iu tr ng. Nhng du hiu sm cn l-u : nga
bn tay, chn, t mi, l-i, kh th, nhp tim nhanh, cm gic bn chn, ht

60
hong.
Cc triu chng lm sng hay gp cc c quan:

61
3.1. H h hp: ph thanh hu, dy thanh i, ph kh qun, co tht kh
qun, ph qun, nghe phi c ran rt, ran ngy ging nh- hen ph qun.
Bnh nhn thy kh th, ngt, tm, suy h hp cp, gim thng kh ph
nang. Mt vi tr-ng hp c th c ph phi cp do tn th-ng tng tnh thm
thnh mch.
3.2. H tun hon v huyt ng : tnh trng gin mch th-ng c sm trong
SPV do hu qu tc dng ca cc cht trung gian ho hc, gin mch, tng tnh
thm thnh mch nhanh dn n gim th tch tun hon (th tch mu to
n phn v th tch plasma u gim r rt trong SPV), nhp tim nhanh
hoc lon nhp, p lc ng mch gim do gim th tch tng mu.
S thiu xy mu, gim th tch tun hon dn n toan mu v gim co bp
c tim l giai on nng ca SPV. V th cp c u gim th tch mu l mt
yu t chnh trong SPV.
3.3. Thn kinh: au u, chng mt, run chn tay, l m, vt v, ni lm
nhm, co git ton thn, c th ngt xu hoc hn m.
3.4. Tiu ho: cc cht gy SPV l thc n, hoa qu v thuc ung, bnh nhn
au bng d di, nn, bun nn, a chy, i a khng t ch, c khi chy
mu tiu ho.
3.5. Ngoi da: My ay ton thn, ph Quincke, hoc ban nga.
3.6. Ton thn: c th c st, v m hi, rt run, mt l v.v
Nhng triu chng chung l nh- vy, nh-ng tu theo mc tin trin, SPV
-c chia ra 3 mc din bin khc nhau: nh, trung bnh, nng:
- Din bin nh: vi nhng triu chng au u, s hi, chng mt, c th
c ni my
ay, mn nga, ph Quincke, nn hoc bun nn, au bng, i a khg t
ch, nhp tim nhanh, huyt p tt, kh th.
- Din bin trung bnh: bnh nhn hong ht, s cht, chong vng, nga ran
khp ng-i, kh th, co git, i khi hn m, au bng, da tm ti, nim mc
nht, ng t gin, mch nhanh nh, huyt p tt hoc khn g o -c.
- Din bin nng: xy ra ngay trong nhng pht u tin vi tc chp
nhong. Ng-i bnh hn m, nght th, da tm ti, mch huyt p khng o
-c, t vong sau vi pht, hn hu ko di vi gi.
D din bin nh hay trung bnh, nng u phi dng ngay adrenalin.
Ch nhng din bin mun xy ra sau SPV nh- vim c tim d ng, vim
thn, vim cu thn. Nhng bin chng ny c th dn n t vong. C
tr-ng hp SPV -c x l nh-ng 1-2 tun sau xut hin hen ph
qun, my ay, ph Quincke ti pht nhiu ln.
Tm li SPV l hu qu ca thiu oxy mu, gin mch, tng tnh thm thnh
mch t cp tnh v co tht c trn ph qun. V vy nguyn nhn t vong
nhanh l do co tht ph qun gy suy h hp v tt huyt p ko di.
mt tr-ng hp SPV do ampicillin
Bnh nhn n, 24 tui, vo bnh vin ph sn Hi Phng vi l do chuyn d
ln 1, thai thng nh-ng v i non. Tin l-ng -ng d-i kh v c du
62
hiu suy thai.
Bnh nhn -c m vi mch 95 ln/pht, huyt p 120/80mmHg, v l y
-c thai nhi 3400g c mt vng rau qun c. Sau m tnh trng sn ph v
thai nhi n nh. Bc

63
s trc ch nh cho tim Ampicillin 1g (3 l) tim tnh mch 23h, 6h, 12h
chng nhim khun. Tr-c khi tim bnh nhn -c th test ly da m tnh vi
amp icillin. Sau khi tim Ampicillin vo tnh mch -c 3 pht, bnh nhn thy
kh chu, nga ton thn, ch ni vi bc s l kh th ri hn m ngay. Da
ton thn tm ti, c bit l vng mt v u chi. Huyt p khng o
-c, mch khng bt -c. Bnh nh n
-c kp trc t ni kh qun, bp bng, ng thi tim Adrenalin 1mg trc
tip vo tnh mch lin tc ti ng th 30 th bt -c mch nhanh, nh, huyt
p 40/20mmHg. Tip tc duy tr truyn Adrenalin tnh mch: 10 ng/ln +
50ml glucose 5% (5 -6 ng/gi),
1 gi sau sc huyt p bnh nhn tng dn n 120/60 mmHg, c lc vt ln
180/110mmHg, c lc huyt p ti a li gim d-i 90mmHg, nht l lc thay
dch truyn mi. Sau khi dng Adrenalin -c phi hp truyn dopamin,
solumedrol tnh mch km theo th my PEEP: 5cm H2O. Sau sc 5 gi bnh
nhn c nhp th n nh, ch nh thi th my, mch 120 ln/pht; huyt
p 100/60mmHg. Sau 7 gi sc bnh nhn tnh, gi bit, mch 125 ln/pht,
huyt p 100/50 mmHg, SpO 2: 98%, n-c tiu 3000ml. Ch nh gim liu
Adrenalin truyn 1mg/gi. Nh- vy tng liu Adrenalin s dng l 80 ng v
cu sng sn ph. (cng trnh NCKH Hi ngh khoa hc chuyn ngnh d ng
- min dch lm sng - NXB Y hc 2004. trang 92 -95).
4. Chn on SPV
Phi nhanh chng, kp thi, ch yu da vo s xut hin nhanh trong vng
vi pht ca cc triu chng k trn sau khi tip xc vi d nguyn gy phn
ng phn v (thuc, thc n, ho cht dng hay b cn trng t). Tuy
nhin chn on s gp kh khn khi cc triu chng ny khng nh- ch
c ni my ay hoc co tht ph qun cp trn mt bnh nhn hen. V vy
khi chn on cn l-u ti tt c cc triu chng nht l tru tim mch, huyt
p tt sau khi -a thuc hoc d nguyn l vo c th.
5. iu tr sc phn v.
5.1. Nguyn tc:
- Khn cp, ti ch v dng ngay Adrenalin.
Phi dng ngay adrenalin cng nhanh cng tt v adrenalin lm thay i
ngay tc khc cc du hiu nng do SPV gy ra nh- co tht ph qun v
tt huyt p bng cch lm tng cAMP trong t bo mast v basophil. S tng
cAMP s c ch gii phng cc cht trung gian ho hc t nhng t bo ny.
Adrenalin cn kch thch trn h v . Kch thch 1 ca Adrenalin lm
tng lc co bp c tim, tng khi l-ng tun hon v iu ho nhp tim. Kch
thch lm tng sc cn ngoi vi, tng p lc tm tr-ng, tng t-i mu ti ng
mch vnh, kt qu Adrenalin lm tng l-u l-ng tim, tng huyt p, tng c-ng
vn chuyn oxy ti cc t chc.
5.2. Phc cp cu sc phn v (theo thng t- 08 ngy 4 -5-1989 ca B Y
t).
5.2.1. X tr ngay ti ch
* Ngng ngay tip xc vi d nguyn!
(thuc ang dng tim, ung, bi, nh mt, mi)
* Cho bnh nhn nm ti ch
64
* Dng thuc:
- Adrenalin l thuc c bn chng sc phn v.

65
Adrenalin dung dch 1/1.000, ng 1ml =1mg, tim d-i da nga y sau khi xut
hin sc phn v vi liu nh- sau:
1/2 - 1 ng ng-i ln.
Khng qu 0,3ml tr em (ng 1ml (1mg) + 9ml n-c ct = 10ml sau tim 0,1
ml/kg).
Hoc Adrenalin 0,01mg/kg cho c tr em ln ng-i ln.
- Tip tc tim Adrenalin liu nh- trn 1 0-15 pht/ln cho n khi huyt p tr
li bnh th-ng.
* m, u thp chn cao, theo di huyt p 10 -15
pht/ln. (nm nghing nu c nn).
Nu sc qu nng e do t vong, ngoi -ng tim d-i da c th tim
Adrenalin dung dch 1/10.000 (pha long 1/1 0) qua tnh mch, bm qua ng
ni kh qun hoc tim qua mng nhn gip.
5.2.2.Cc bin php khc
Tu theo iu kin trang thit b y t v trnh chuyn mn k thut ca
tng tuyn c th p dng cc bin php sau:
* X tr suy h hp:
Tu theo tuyn v mc kh th c th s dng cc bin php sau y:
- Th oxy mi, thi ngt.
- Bp bng ambu c oxy.
- t ng ni kh qun, thng kh nhn to. M kh qun nu c ph thanh
mn.
- Truyn tnh mch chm Aminophyllin 1mg/kg/gi hoc Terbutalin
0,2mcg/kg /pht. C th dng:
- Terbutaline 0,5mg, 1 ng d-i da ng-i ln v 0,2ml/10kg tr em. Tim li sau
6 - 8 gi nu khng kh th.
- Xt hng Terbutalin, Salbutamol mi ln 4 -5 nht bp, 4-5 ln trong ngy.
* Thit lp mt -ng truyn tnh mch
Adrenalin duy tr huyt p bt u bng 0,1mg/kg/pht, iu chnh tc
theo huyt p (khong 2mg Adrenalin/ gi cho ng-i ln 55kg).
* Cc thuc khc
- Methylprednisolon 1 -2mg/kg/4 gi hoc:
- Hydrocortison hemisuccinat 5mg/kg/gi tim tnh mch (c th tim bp
tuyn c s). Dng liu cao hn nu sc nng (gp 2 -5 ln).
- NaCl 0,9% 1-2 lt ng-i ln, khng qu 10ml/kg tr em.
- Diphenhydramin 1-2mg, tim bp hay tnh mch.
5.2.3.iu tr phi hp
- Ung than hot 1g/kg cn nng nu d nguyn qua -ng tiu ho.
66
- Bng p chi pha trn ch tim hoc -ng vo ca nc c.
* Ch :
- Theo di bnh nhn t nht 24 gi sau khi huyt p n nh.
- Sau khi s cu nn tn dng -ng tim tnh mch i (v tnh mch to, nm
pha trong ng mch i, d tm) .
- Nu huyt p vn khng ln sau khi truyn dch v adrenalin, th c th
truyn thm huyt t-ng, albumin (hoc mu nu mt mu) hoc bt k
dung dch cao phn t no sn c.
- iu d-ng vin c th s dng adrenalin d-i da theo phc khi y, bc s
khng c mt.
- Hi k tin s d ng v chun b hp thuc cp cu sc phn v tr-c khi
dng thuc l cn thit.
6. Nhng bin php hn ch d ng thuc v SPV
6.1. Tuyn truyn vic s dng thuc hp l, an ton ng ch nh.
6.2. Tr-c khi k n thuc, ng-i thy thuc phi khai thc k tin s d ng
ca ng-i bnh. ng-i bnh c tin s d ng vi thuc, thc n, s rt d
b d ng khi dng thuc.
Phi d phng SPV trn nhng bnh nhn c mn cm, cn nhc v liu
l-ng, -ng dng v tc hp ph ca thuc dng trong iu tr v chn
on. Khi mt bnh nhn
c tin s phn ng phn v vi mt thuc no d nh cng phi c
gng trnh dng li, cn hiu r cc phn ng cho gia cc loi thuc (v d:
penicillin v cephalosporin u c chung vng lactam).
6.3. Tr-c khi tim khng sinh phi th test ly da, test m tnh mi -c tim.
Phi chun b sn thuc v dng c cp cu SPV.
6.4. Khi ang tim thuc, nu thy c nhng cm gic khc th-ng (bn chn,
ht hong, s hi ) phi ngng t im v kp thi x l nh- sc phn v).
6.5. Sau khi tim thuc ng-i bnh ch 10 -15 pht phng SPV xy
ra mun hn.
6.6. Ni dung hp thuc cp cu sc phn v:
Adrenalin 1mg - 1ml : 2 ng
N-c ct : 10ml : 2 ng
Bm kim tim v khun : 10ml ; 2 ci, 1ml : 2 ci
Hydrocortison hemisuccinat 100mg hoc methyl prednisolon (SoluMedrol
40mg hoc depersolon 30mg : 2 ng).
Ph-ng tin kh khun (bng, bng gc cn)
Dy garo
Phc cp cu SPV
Cc trang thit b khc: tu theo iu kin trang thit b y t v trnh
chuynmn ca tng tuyn, cc phng iu tr nn c cc thit b y t
67
sau:

68
 Bm xt Salbutamol hoc Terbutalin
Bng ambu v mt n.
ng ni kh qun
Than hot

Cu hi t l-ng gi

1. nh ngha sc phn v?
2. Trnh by c ch bnh sinh ca sc ph n v
3. Hy nu nhng tc dng sinh l ca cc cht trung gian ho hc.
4. Trnh by cc nguyn nhn gy sc phn v.
5. Cc triu chng lm sng ca sc phn v.
6. Chn on sc phn v
7. Nguyn tc iu tr sc phn v. Ti sao adrenalin li l thuc u
tay trong
iu tr sc phn v?
8. Hy trnh by th t cc b-c trong x l sc phn v.
9. Hy nu nhng bin php hn ch d ng thuc v sc phn v.
10.Ni dung hp cp cu sc phn v gm nhng th g?

69
 My ay - ph quincke

Mc tiu hc tp:
1. Nm -c cc nguyn nhn gy My ay ph Quincke hay gp.
2. Trnh by -c c ch bnh sinh My ay ph Quincke.
3. Nm vng hnh nh lm sng v bit cch iu tr My ay ph
Quincke.

Trong cc bnh d ng th My ay v Ph Quincke l bnh ph bin v

hay gp nht, t l mc bnh ny trong cng ng dn c- n-c ta khong
19 -24%. Cc bnh ny do nhiu nguyn nhn gy nn, triu chng lm sng
ca My ay ch yu biu hin ngoi da, tin trin tng t nhiu vng
trn c th th Ph Quicke c th xut hin khng nhng trnda m cn nim
mc cc c quan ni tng (thanh qun, d dy, rut v.v )
1. Phn loi my ay : C 2 cch phn loi:
1.1. Theo din bin lm sng
- My ay cp: xut hin vi pht sau khi ti p xc vi d nguyn, ko di
nhiu gi, nhiu ngy, th-ng d-i 6 tun.
- My ay mn : xut hin trong thi gian trn 6 tun, c th ko di trong
nhiu nm. Theo nghin cu ca nhiu tc gi, My ay mn tnh th-ng
khng r nguyn nhn.
1.2. Theo nguyn nhn: My ay c c ch d ng v khng d ng.
1.2.1. My ay d ng : Do rt nhiu nguyn nhn gy nn, tr-c ht l cc
loi thuc, tip n l thc n, ho m phm, bi, nm mc, lng sc vt, v.v
1.2.1.1. Thuc l nguyn nhn chnh gy My ay trong cc
tr-ng hp d ng thuc. Tt c cc loi thuc v cc -ng -a thuc vo c
th nh- ung, tim, xng, ht, t d-i l-i, bi ngoi da v.v u c th
gy My ay - Ph Quincke. Trong cc thuc gy My ay- Ph Quincke,
ng u l nhm khng sinh, tr ong nhm ny th Beta- lactam chim t l
cao nht, tip n l nhm Cyclin, Macrolid, Chloramphenicol, Aminosid,
Quinolon, khng sinh chng nm, chng lao.v.v
Cc thuc chng vim khng Steroid (NSAID) (Aspirin, Decolgen, Mofen,
Profenid, Diclofenac.v.v..), cc vitamin (vitamin B1, B2, B12, PP, C ), cc loi
vacxin, huyt thanh, cc thuc cha tiu ho, thn kinh, cc loi gim au, gy
t, gy m, thuc
iu tr b-u c, thuc chng st rt, thuc trnh thai, thuc iu tr tiu
-ng, thuc cn quang c iod, thuc h huyt p, cc thuc c ngun gc
ng vt, thc vt. ng l-u nht l cc thuc chng d ng cng gy d
ng nh- cc loi glucocorticoid: Prednisolon, Dexamethason, Hydrocortison,
Flucinar.v.v , cc thuc khng histamin tng hp: Clarityne, Theralen, Pamin,
Promethazin, Pipolphen v.v
Cc loi thuc u l hapten, khi vo c th chng c th kt hp vi protein
huyt thanh hoc protein cc m v tr thnh cc d nguyn (DN) hon chnh
70
(khng nguyn ton phn). Cc khng nguyn ny kch thc h c th to khng
th (KT) d ng v gy nn trng thi mn cm vi thuc.

71
Ng-i ta pht hin -c cc nhm c hiu ca mt s ho cht c th
gn -c vo protein c th nh-:
NH2-NO-N= ; -CONH2, -NHOH, -COOH, -OH.
V cc nhm c hiu trn phn t protein c th kt hp vi ho cht: -
COOH, -SH, - NH2, -NHCNH2, -NH-
1.2.1.2. Nguyn nhn l thc n
C nhiu thc n ngun gc ng vt, thc vt gy My ay - Ph Quincke,
c loi thc n c kh nng gii phng histamin: Tm, cua, c, c, lng trng t
rng, ph tng
ng vt c v, nc ong, da, du ty, c chua, ng cc, ht d, lc, r-u, vng,
ko socola.v.v C loi thc n lm giu histamin nh-: Pho mt, cc loi c, tht
hun khi, xc xch, ung ln men, c chua, ci xoong, hp, d-a bp ci,
d-a chut, khoai ty.v.v Cc loi thc n giu protein d gy My ay - Ph
Quincke hn cc loi thc
n khc.
1.2.1.3. Nguyn nhn l ho cht :
Tr-c ht phi k n cc loi m phm: phn, son, n-c hoa, thuc nh rng,
x phng cc loi, thuc nhum tc, thuc nhum mng tay, mng chn v.v
Cc loi ny l nguyn nhn chnh gy My ay, nht l ph Quincke mt
cho ph n. Trong cng nghip thc phm sn xut hp, bnh ko, thc n
ng-i ta s dng nhiu thuc nhum mu c nguy c gy My ay nh-
Tartrazin, v mt s cht khc.
1.2.1.4. Cc nguyn nhn khc : Bi nh, bi bng, len, bi th- vin, bi kho
Cc loi phn hoa, nm mc, biu b lng sc vt v.v cng l nhng tc
nhn gy My ay - Ph Quincke.
1.2.2. My ay khng d ng : y l dng My ay, Ph Quincke xy ra
khng theo c ch d ng. Tr-ng hp ny th-ng do cc yu t vt l (nng,
lnh, nh nng mt tri, p lc, chn thng ) gy nn.
C ch c th do cc t bo mast t chc d-i da ca nhng c th qu
mn cm, cc t bo ny d dng thot bng (degranulation), phng thch
cc cht ho hc trung gian khi tip xc vi nhng yu t nu trnv gy nn
bnh cnh lm sng ca My ay - ph quincke.
2. C ch bnh sinh
Theo phn loi ca Gell v Coombs, c ch bnh sinh My ay - Ph
Quincke thuc phn ng d ng typ nhanh (typ I).
C ch phn ng d ng typ I
Khi d nguyn lt vo c th, d nguyn b cc t bo trnh din khng
nguyn tip nhn. Cc t bo ny truyn c im cu trc ca d
nguyn n t bo Th 2. Th2 d-i tc ng ca IL4 v IL13 (interleukin 4,13) lm
t bo lympho B bit ho thnh plasmocyte. T bo plasmocyte ny tng
hp khng th IgE. Cc KT IgE gn trn b mt t bo mast nh tn cng Fc
(constant - fragment) nm domenC 4 v gy nn trng thi mn cm ca c
th.

72
Khi d nguyn lt vo c th ln th hai, ngay lp tc cc KT ny lin kt vi
DN ph hp nh tn cng khc ca IgE - Fab (antigen - binding fragment), khi
mt phn t IgE c th kt hp vi 2 phn t d nguyn. Chnh v kh nng
ny nn mt phn t DN mt vi v tr quyt nh c th lin kt vi mt
vi phn t IgE to thnh vng ni

73
gia chng vi nhau. S to thnh phc hp DN - IgE trn b mt t bo nh
Fc - receptor gy nn hin t-ng thot bng (degranulation) t t bo mast
gii phng hng lot cc cht trung gian ho hc (mediators): histamin,
serotonin, baradykinin, leucotriens, prostaglandin, cht tc dng chm ca
phn v SRS.A (Slow reacting substance of anaphilaxis).v.v Cc cht ny,
c bit l histamin lm tng tnh thm thnh mch, gy ph n, ban d-i
da v kch thch cc tn cng thn kinh cm gic d-i da gy nga.
Ngy nay nhiu tc gi xc nh rng cn nhiu t bo khc nh- t bo
n nhn, bch cu i toan, tiu cu cng tham gia phn ng d ng typ I.
Trn b mt c c t bo ny cng c cc receptor dnh cho Fc ca IgE. DN
kt hp vi IgE ny cng lm gii phng hng lot cc cht trung gian ho hc
khc nhau c tc dng chng vim.
Theo phn loi kinh in, phn ng d ng typ I xy ra ngay trong na gi
u tin hoc sm hn na. Phn ng d ng cng c th xy ra mun hn
t 4 n 8 gi sau khi tip xc vi DN, tuy nhin mc biu hin ca phn
ng mun c th khc nhau.
Nhm cc bnh d ng atopy (hen ph qun, bnh phn hoa, vim mi d
ng, vim da d ng, My ay, ph Quincke, d ng thuc.v.v..) th-ng c
nng IgE ton phn tng cao, i khi rt cao. Cng vi s tng nng ca
IgE ton phn, th c mt s l-ng IgE c hiu, cc KT ny l KT kt hp vi
DN ph hp. Trong rt nhiu tr-ng hp cng vi s tng IgG ton phn ng-i ta
cn thy s c mt ca IgG4 cng c kh nng gn trn b mt t bo mast
v basophil.
KT IgE l-u hnh -c tng hp rt nhanh, na i sng ca chng t 2 -4 ngy.
Khi IgE gn trn t bo tn ti lu hn nhiu, khong 28 ngy.
Cc t bo sn xut IgE thuc loi c i sng di. Cc t bo ny ch yu
cc t chc lympho ca nim mc, cc hch lympho (mng pay -e), cc hch
lympho ph qun.
3. Hnh nh lm sng
3.1. My ay d ng:
Sau khi dng thuc, thc n hoc tip xc vi d ng uyn (nhanh c th vi
pht, chm c th hng ngy) ng-i bnh c cm gic nng bng, rm ran mt
vi ch trn da nh- cn trng t, rt nga v nhng vng xut hin nhng
sn ph mu hng hoc
-ng knh vi milimet n vi centimet, ranh gii r, mt chc, hnh trn
hoc bu dc, xut hin nhiu ni, c th ch khu tr u, mt c, t
chi hoc b ton thn. Nga l cm gic kh chu nht, xut hin sm,
th-ng lm ng-i bnh mt ng, cng gi cng lm sn ph to nhanh hoc
xut hin nhng s n ph khc. Cc triu chng km theo i khi c kh th,
au bng, au khp, chng mt, bun nn, st cao. My
ay d ti pht trong thi gian ngn, ban va mt i xut hin tr li. My
ay mn tnh th-ng ko di nhiu thng, c khi nhiu nm, rt kh chu cho
sinh hot v lao
ng.
3.2. My ay tip xc:

74
Khi tip xc vi nhng cht khc nhau nh- amoni, persulfat (dung dch un
tc), alehyt cinnamic, acid benzoic (th-ng thy trong m phm v thc
phm) v cc ho cht khc c th gy ni My ay ti ch trong vng vi
pht n vi gi. Cc cht nu trn hoc khi mang gng tay cao su latex l
nhng nguyn nhn th-ng gp ca My
ay tip xc bn tay. V c ch n c th xy ra d-i dng phn ng min
dch hoc khng min dch, cc phn ng ny th-n g nh.

75
3.3. My ay do cn trng t.
y l My ay dng sn do tng mn cm vi cc vt t ca mt s cn trng
nh- mui, mng, b cht, mt, kin, ong, su rm.v.v Triu chng l nhng
dt hoc nt sn t thnh tng m ch yu vng da trn, c bi t l tay,
chn v vng u, mt, c, rt nga v th-ng b gi try x-c.
3.4. My ay vt l.
My ay vt l -c c tr-ng bi nhng dt sn xy ra sau mt tc nhn vt l
no
. Chng xy ra khong 50% s bnh nhn My ay mn tnh. Loi My
ay ny c th chia ra cc dng nh- sau:
3.4.1.Chng da bn , My ay do sc p hoc rung ng.
Cc tnh trng ny c th do sang chn c hc nh- c xt (v d ln da), sc p
v rung
ng. Chng da bn c triu chng lm xut hin nhng dt, sn nga
khong 5-10 pht sau khi ch nh ln da, phn ng ny cng c th xy ra
nhng ni qun o c xt vo da lm da rt nga. My ay mun do sc p
xy ra sau mt gi tr ln khi mt vng trn c th phi chu sc p ko di,
mc qun o b st l mt nguyn nhn chnh hay gp ca My ay mun
do sc p - cc dt, sn trong dng My ay ny tn ti dai dng. My ay do
rung ng t gp hn, trong triu chng s-ng, nga tay l chnh, v d
khi nm cht tay iu khin my cn cu, li xe t v.v
3.4.2. My ay do lnh: triu chng xy ra trong vng vi pht b lnh da.
Thi tit lnh, n-c lnh, hoc cm nm vt lnh th-ng lm khi pht bnh
vi cc biu hin sn s-ng hoc ti, nga ni tip xc vi lnh.
3.4.3. My ay do nng : Cc sn hoc ti, nga th-ng xut hin nhng
vng da h do phi nhim vi nh nng mt tri hoc do nng.
3.5. My ay do gng sc : do tng tit cholinergic khi vn ng mnh, cc
sn th-ng nh (2-4mm), nga v xung quanh c qung . Chng c th xy
ra bt c ni n o trn c th v xut hin trong vng vi pht sau khi c
kch thch.
3.6. My ay mn tnh khng r nguyn nhn : l th bnh hay gp, hay ti
pht v khng tm -c nguyn nhn gy bnh. Biu hin lm sng l nhng
dt hoc sn s-ng n, mu hng hoc ti nht.
My ay mn tnh ch yu xy ra ng-i ln, c n 40% s bnh nhn My
ay mn tnh ko di hn 6 thng, n 10 nm sau vn s b ni My ay.
Bnh c xu h-ng din bin lui bnh ri li ti pht, triu chng nng hn v
m. My ay mn tnh th-ng gy cho ng-i bnh cm gic kh chu, bun
bc, nh h-ng n sinh hot v lao ng, hc tp.
D-i y l bng cu hi dng cho ng-i bnh b My ay:
- Thi gian xut hin ca My ay < 6 tun 6 tun
- Kch th-c ca sn, My ay
- Mu sc ..................................................................
- B ngoi ca da sau khi sn ln ..........................
76
- S ln ni sn...........................................................
- C s-ng n mt (m mt, mi) ming

77
- Tn th-ng xut hin khi :
dng thuc
Thc n
Tip xc bi nh
Ho cht (ph gia, latex, m
phm) cn trng t
Ch xt
p
Gng
sc
Nng
Lnh
Nhng trong n-c m hoc n-c
lnh nh nng mt tri
- C triu chng i km st
Nga
au bng
au u
3.7. Ph Quincke:
Ph Quincke l bnh d ng c c im ph cc b da v d-i da do
nhiu nguyn nhn gy nn. Bnh ny do H.Quincke m t ln u tin vo
nm 1882. ng vit: Trong da v t chc di da ca ngi bnh xut hin
tng m s-ng n, -ng knh t 2-10cm, th-ng cc vng da trn khp, trn
thn mnh, mt, c bit mi mt v mi. Mu sc nhng m s-ng n
khng c g c bit, c th nh- mu da bnh th-ng, i khi hi ti
hc hi hng, c th nga hoc cm gic cng da. Ming, thanh qun
s-ng, ph n, du hiu ny xut hin nhanh chng sau mt vi gi, gy kh
th, i khi nguy kch. Ng- i bnh mt mi v kht, c bit khng st.
Bnh ti pht nhiu ln cng ti nhng vng xut hin tr-c y trn c th.
Ph Quincke l mt bnh rt ph bin, t l mc bnh ny mt s n-c l
25 -30%. Vit Nam theo kt qu nghin cu ca Nguyn N ng An v cng
s mt s vng dn c- H Ni, Hi Phng, Ho Bnh, NghAn, TP. H Ch
Minh, Lm ng l 20%. Bnh gp mi la tui, nhiu nht nhm tui t
19 -40, n mc nhiu hn nam. nhng ngi c th tng d ng t l mc
bnh khong 25 -60%.
Ph Quincke th-ng i km vi My ay nh-ng cng c nhiu tr-ng hp ch c
ph Quincke n thun.
78
Nhng v tr hay gp khi b ph Quincke l mi, mi mt, c, nim mc ming,
hng, thanh qun, rut v.v

79
Ph Quincke in hnh th-ng gp thy mt vi hai mi mt s-ng mng,
i mi to, da mt cng n, lm bin dng khun mt, c th km theo au
u, bun nn.
Ph Quincke thanh qun l nguy him nht, nhiu n-c t l mc khong
25% cc tr-ng hp Ph Quincke. Khi b ph Quincke thanh qun triu chng
xut hi n u tin l ho khan, ni ging khn, sau xut hin kh th c
th th vo v th ra, v mt tm ti, bnh nhn ht hong, lo lng.
Khi b ph Quincke nim mc ph qun gy nn triu chng kh th kiu hen,
nghe phi c ran rt, ran ngy.
Cc tr-ng hp trn u phi -c nhanh chng cp cu. Tr-ng hp hay gp
na l Ph Quincke nim mc -ng tiu ho vi triu chng bun nn, ri nn
ra thc n, sau nn ra c mt. Lc u au bng cp khu tr, sau lan ra
khp bng, km theo c tng nhu ng rut, a chy, c khi km theo ban My
ay ngoi da.
Ph Quincke -ng tit niu c triu chng ca vim bng quang cp, i
but, i rt. Ph Quincke nim mc t cung cng c cc triu chng t-ng t,
ch 2 triu chng
au bng d-i, ra mu d nhm vi cha n goi d con.

Mt s nh minh ho

Hnh 1 : Bnh nhn V Th N.

Ph Quincke do ung Analgin
80
 Hnh 2 : My ay do ung ampicillin

4. Chn on my ay - ph Quincke
4.1. Chn on xc nh : Khng kh khi da vo cc biu hin lm sng.
b-c
u xc nh s b nguyn nhn gy bnh ng-i thy thuc cn khai thc t
m tin s d ng bn thn, gia nh ng-i bnh, tr-c tin phi hi k ng-i
bnh cc loi thuc, thc n, ho m phm.v.v.. dng tr-c khi b My ay -
Ph Quincke. nh h-ng ca lao ng gng sc, mi tr-ng sng v lm vic.
iu kin nh , thi gian xut hin cn My ay u tin. Mi quan h gia
My ay - Ph Quincke vi ch n, ngh nghip, ma trong nm. Cc bnh
nhim khun mn tnh nh- vim i trng, vim gan mt, vim -ng tit niu,
vim xoang.v.v lin quan n s xut hin
My
ay, ph Quincke. Xem xt k hnh thc bn ngoi ca tn th-ng: kch
th-c, mu sc, v tr ca cc sn My ay trn c th.
4.2. Chn on nguyn nhn : xc nh nguyn nhn gy bnh phi d
ng cc ph-ng php chn on d ng c hiu, bao gm: khai thc tin s
d ng c nhn v gia nh, test ly da, test kch thch vi d nguyn nghi
ng, phn ng in vitro xc nh khng th d ng trong huyt thanh ng-i
bnh.
i vi My ay do yu t v t l lm th nghim vi n-c nng, cc tc
ng trn da (th-ng l mt tr-c trong cng tay).
5. iu tr my ay - ph quincke
5.1. Nguyn tc iu tr :
B-c u tin trong iu tr My ay d l My ay d ng hoc khng d
ng l lm gim triu chng bng cch cho dng thuc khng histamin H 1.
Trong tt c mi tr-ng hp, ngoi tr nhng tr-ng hp nng nht, nn bt
u vi cc thuc khng histamin H1 t hoc khng gy bun ng hay cn gi
l cc thuc th h th hai nh- loratadine, fexofenadin hay cetirizine. Trn lm
sng fexofenadine hon ton khng gy bun ng v rt hiu qu,
81
loratadine cng khng gy bun ng liu thng th-ng, trong khi cetirizine
c gy bun ng trn khong 20 -30% bnh nhn, y l cht chuyn ho
ca hydroxyzine, mt thu c khng histamin c tc dng gy ng cao.

82
Nhng bnh nhn My ay mn tnh hay b nga vo bui ti, nga cng
xy ra ban ngy nh-ng t l thp hn, do bui ti nn cho dng cc thuc
khng histamin gy bun ng nh- Hydroxizin, Cholorpheniramin. Vi M y ay
mn tnh s kt hp gia thuc khng histamin H 1 v H2 nh- Cimetidin c th c
tc dng cng lc v hiu qu hn khi dng thuc khng histamin H 1 n
thun.
C ch tc dng ca thuc khng histamin H 1 l lm gim s l-ng, kch th-c
v thi gian tn ti ca sn My ay v gim nga. Thuc khng histamin H 1
th h th nht v th hai c hiu qu t-ng t nh- trong iu tr My ay
mn tnh, tuy nhin thuc khng histamin th h th nht gy bun ng nn
ngy nay t -c s dng.
Vi cc thuc khng histamin th h th hai c nhiu -u im v-t tri :
- Hp thu nhanh, khi pht tc dng nhanh
- Hiu qu iu tr cao
- Khng nhn thuc hoc ht tc dng nhanh sau khi ngng thuc.
- Khng tch lu thuc, khng gy t-ng tc thuc.
- Khng hoc t cn chnh liu nhng i t-ng c bit (suy gan, suy
thn, ng-i gi).
- Tc dng ko di cho php dng thuc 1 ln/ngy.
- t hoc khng c tc dng ph.
- Khng gy bun ng.
Trong tr-ng hp dng thuc khng histamin m khng kim sot -c bnh th
nn phi hp vi cc thuc Corticoid dng tim hoc ung.
5.2. iu tr c hiu : Loi b d nguyn gy bnh bng cch khng dng
cc loi thuc, thc n, ho m phm.v.v gy My ay - ph Quincke,
chuyn ni , lm vic v.v
Khi vn phi tip xc vi cc d n guyn gy bnh tc l khi khng loi b -c
d nguyn th tin hnh ph-ng php iu tr gim mn cm c hiu. Tuy
nhin ph-ng php ny t -c p dng i vi ng-i bnh My ay - ph
Quincke.
Nu My ay do lnh cn ch mc m, i gng tay, tt, tm nng, hn ch
ra lnh qu sm cng phn no hn ch -c My ay. Ch khng i tm
sng, bin mt mnh phng xut hin My ay cp, co tht ph qun
rt nguy him. Vi My ay do nng cng hn ch n mc ti a tc ng
ca nh nng mt tri ln da.
5.3. iu tr triu chng
5.3.1.My ay
i vi My ay ch c biu hin nh khu tr tay, chn, mt, thn mnh,
c th ch dng mt trong cc thuc khng histamin tng hp sau: Astemizol
10mg ngy ung 1 vin, Loratadin 10mg x 1 vin, Fexofenadin 180mg x 1 vin.
My ay ton thn kt hp Corticoid + khng histamin.
Cc glucocorticoide th-ng dng dng tim truyn hoc ung. Cc thuc hay
83
-c s dng Depersolon 30mg, Methylprednisolon 40mg, hoc cc thuc dng
vin Prednisolon 5mg, Methylprednisolon 4mg v 16 mg.

84
Vi My ay mn tnh nn dng kt hp glucocorticoid, khng histamin H1 v
khng histamin H2. Trong tr-ng hp ny khng histamin H2 lm tng v ko di
tc dng ca khng histamin H1.
5.3.2.Ph Quincke : Thuc vn dng l Corticoid dng tim t ruyn hoc ung
kt hp vi khng histamin H1.
Vi cc tr-ng hp gy kh th do ph Quincke nng mt, ph thanh qun
nn dng ngay Adrenalin 1mg tim d-i da 1/3mg.
Ngoi vic dng thuc, ng-i bnh cn -c bit nhng kin thc v nhng
tc nhn c th lm cho My ay nng thm hoc ti pht nh- ung r-u,
nhim trng, n cc thc n tanh, vn ng qu sc v.v d phng.

Cu hi t l-ng gi

1. C my cch phn loi My ay?

2. Trnh by cc nguyn nhn gy My ay d ng?
3. Trnh by cc nguyn nhn gy My ay khng d ng?
4. Hy nu c ch bnh sinh ca My ay.
5. M t triu chng My ay do d ng thuc.
6. M t triu chng v cc th ph Quincke.
7. S khc nhau gia My ay - ph Quincke v mt lm sng l g?
8. Hy m t cc hnh thi lm sng ca My ay?
9. Chn on My ay - Ph Quincke?
10. iu tr My ay - Ph Quincke?

85
 d ng thc n

Mc tiu hc tp:

1. Nm -c mt s khi nim v d ng v nhng phn ng khng mong mun

do thc
n.
2. Nu -c mt s loi thc n d gy d ng, cc th lm sng v triu
chng th-ng gp.
3. Bit -c mt s ph-ng php chn on v nguyn tc iu tr d ng thc
n

1. i c-ng v d ng thc n

1.1. Lch s: Ngay t rt xa x-a, thi c La M, ng-i ta ch n nhng

biu hin d ng do thc n mt s ng-i sau ba n xut hin my ay,
mn nga, ri lon tiu ho, ph n. Hippocrate gi l " bnh c ng"
(idiosyncrasie). u thp k 20 vi pht minh v sc phn v ca Richet v
Portier gii thch -c c ch cc bnh d ng trong c d ng thc
n.
1.2. Khi nim v d ng thc n: C th hiu n gin d ng th c n l
mt phn ng d th-ng ca c th i vi mt hoc nhiu loi thc n. Cc
triu chng, hi chng lm sng ca bnh xut hin sau khi n . Tnh trng
d ng thc n l kt qu ca mt chui cc phn ng ca h thng min
dch, trong c s kt hp d nguyn v khng th
1.3. Cc phn ng d ng do thc n: D ng thc n l c thc. Vn
quan trng l cn phi phn bit vi cc phn ng d ng gi: khng dung np
thc n, cc phn ng bt li do thc n v ng c thc n.
1.3.1 Khng dung np thc n: phn nh tnh trng bt bnh th-ng trong
chc nng chuyn ho lin quan n kh nng tiu ho thc n ch khng phi
l cc phn ng bt th-ng ca h min dch. Bt dung np lactose c l l
th d in hnh v loi phn ng ny. Do tnh trng thiu ht loi enzym tiu
ho -ng lactose nn cc c th ny mc phi chng khng dung np lactose
trong sa v trong cc ch phm t sa. Bnh nhn s b au tht vng
bng v tiu chy sau khi n sa v nhng ch phm t sa.
1.3.2.Phn ng bt li do thc phm ging nh- phn ng thuc : l phn
ng c tnh cht d-c l xy ra bt c lc no do c cc cht c bit no
trong thc n tc
ng n c th gy phn ng c hi. Cafein trong tr v c ph l th d
in hnh nht v ho cht trong thc n khi dng qu mc, cht ny li gy
au u, chng mt, chong vng, c khi gy ri lon tiu ho. V bn cht tc

86
dng ny n thun l phn ng ho hc khng phi l d ng.
1.3.3. Nhim c thc n : cn gi l ng c thc n, c 2 loi: Do mm
bnh c trong thc n tc ng trc tip ln cc h c quan ca con ng-i
hoc do cc loi ho

87
cht c bit tit ra bi cc mm bnh y gy ra tnh trng ng c. Phn
ng nhim
c tc ng n bt k ng-i no n phi thc n .
2. Cc loi thc n gy d ng

Bt k loi thc phm no cng c th gy d ng. Thc n c ngun gc

ng vt hay gy d ng hn thc n c ngun gc thc vt: sa b, trng
g, tm, cua, c c kh nng gy sc phn v v chng l nhng d nguyn
mnh. Sa b c: beta lactaglobuli n (A v B) anpha lactaglobulin casein
(anpha, gamma), trong bta lactaglobulin c tnh khng nguyn mnh c
th gy ra sc phn v, hen ph qun, vim mi d ng, ri
lon tiu ho, my ay, ph Quincke Lng trng v ovomucoid (trong lng )
trng
g l nhng protein c tnh khng nguyn mnh. Nhng ng-i d ng vi trng
g cng d b d ng vi tht g v nhng vaccin c s dng phi g . Thc
n c ngun gc thc vt: u phng, u nnh, cc loi ht, qu... c th
gy ra nhiu hi chng d ng. Kt qu nghin cu ca chng ti cho thy d
ng i vi c (n-c mn, ngt) cao nht (31,5%), h gip xc (22,9%), gia
sc - gia cm (17,1%) v sa (14%). Thc n c ngun gc thc vt chim
20,0%, trong hoa qu t-i 18,5%, rau 1,4%.
3. Mt s vn lin quan n d ng thc n.

3.1. Cht lm hng thc phm: D ng vi cc cht lm nhim mt s thc

n phi
-c phn bit vi d ng vi chnh thc n y, th d nh- d ng vi phomat,
tri cy t-i, tri cy kh hoc r-u nho c th khng thc s d ng vi bn
thn cc mn ny, m l d ng vi mt s nm mc hin din lm cho thc
n b h- hng, hoc cc mnh xc cn trng ln vo mt s gia v hoc ri
vo cc thc n v cc th ny c th khi ng cc phn ng d ng khin
ng-i ta nhm ln
3.2. Cc cht ph gia: Cht ph gia thc phm l gm bt k cht g -c
trc tip hoc gin tip -a thm vo qu trnh ch bin thc phm v n tr
thnh mt thnh phn ca thc phm ch bin y. Theo S y t cng cng
Hoa K, xp x 2.800 cht
-c c tnh thm vo thc n to hiu qu mong mun. Ngoi ra c n
10.000 ph gia hoc hn hp ph gia c th -c thm vo thc phm trong
quy trnh ch bin, ng gi, hoc tn tr. Mt s ph gia thng dng v
cc loi phn ng th-ng do chng gy ra: Cht aspartame (Nutrasweet),
BHA (Butylated hydroxyanisol) v BHT- BHA(butylated hydrotoluen - butylated
hydroxyanisol), FD v Yellow 5 (Tartrazine), cht dy mi thng dng
monosodium glutamate (MSG), cc mui nitrate
v nitrite -c dng l cht bo qun, cht dy mi v cht to mu, cc cht
parabens, bao gm butyl-, etyl-, metyl- propyl-, cc sulfite, nh- bisulfit,
metabisulfit, patassiumsulfit, sodiumsulfit v sulfurdioxid
88
4. Nhng yu t lin quan n d ng thc n

4.1. Gii v tui : Ch-a c thng k c th hoc thng bo no ch r c s khc

bit v gii d ng thc n. Theo nghin cu ca Kanny- G v cng s th t
l d ng thc n ph n l 50 - 63%, cn Spergel cho bit t l nam n
751 tr em d ng thc n l: nam
70%, n 30%. D ng thc n c th xy ra bt c la tui no, theo nhiu
thng bo th t l gp tr em cao hn. Trung tm Chm sc sc kho ban
u Sharnbrook, UK (1996)

89
cho bit, t l d ng thc n tr em l 8% v d ng thc n ng-i ln l
2%. Nghin cu ca chng ti vi 70 bnh nhn, n (61,4%), nam (38,6 %).
Nhm tui no cng gp d ng thc n, lp tui 10 -19 (22,9%) gp nhiu
hn so vi cc lp tui khc.
4.2 Tin s d ng ca c nhn, gia nh: Nhn t di truyn v nhng
ng-i c tin s c nhn hay gia nh v cc bnh d ng ( c a d ng)
d b d ng thc n hn. Theo Jonathan nghin cu trn 751 tr th t l tr
c tin s d ng gia nh v bn thn l 92%. Nghin cu ca chng ti
c (62,9%) s bnh nhn d ng thc n c tin s d ng c nhn v gia
nh.
4.3 a gii v tp qun n ung: Tu theo a gii m ngun thc n phong
ph v loi g, thm vo l tp qun n ung ca tng vng c th dn ti t
l d ng khc nhau v t l cc loi thc n gy d ng khc nhau. Theo
nhiu nghin cu n- c ngoi th cc thc n ph bin gy d ng Php, Hoa
K, Hn Quc l: trng, c, sa b; Ty Ban Nha ph bin li l hoa qu t-i,
hi sn v rau
5. C ch d ng thc n

D ng thc n in ra vi c 4 c ch theo phn loi ca Gell v

Coombs. Theo phn loi kinh in th d ng thc n cng chia lm 2 nhm
ln: d ng tc th v d ng mun. D ng thc n ch yu l loi hnh d
ng tc th. Thi gian xut hin phn ng rt nhanh, t vi ba pht n vi
gi k t thi im tip xc vi thc n. D nguyn s kt hp vi khng th
d ng(IgE, IgG) trong huyt thanh gn trn mng mastocyte, bch cu i
kim lm gii phng cc cht ha hc trung gian nh- : histamin, serotonin,
nhiu loi bradykinin, leucotrien, yu t hot ho tiu cu,yu t ho h-ng
ng bch cu i toanv gy ra cc biu hin lm sng d ng : ban ,
my ay, sn nga, ph Quincke Kt qu nghin cu ca chng ti cho
thy bnh nhn d ng thc n ch yu thuc loi hnh tc th chim t l
61,4% .
6. Mt s biu hin lm sng hay gp trong d ng thc n

6.1. My ay : My ay l biu hin lm sng hay gp nht ca d ng thc

n (nghin cu ca chng ti l 71,4%). Bnh th-ng xy ra sau khi n vi pht
c khi n vi gi, ng-i bnh c cm gic nng bng, nga, trn da ni ba n
cng sn ph. Sn c mu hng, xung quanh c vim , hnh th trn, bu
dc, to bng ht u, ng xu, c th lin kt vi nhau thnh mng, cng gi
cng tin trin nhanh v lan rng. Tr-ng hp nng, my ay c km theo
kh th, au bng, bun nn, i ngoi phn lng, au u, chng mti
khi my ay l du hiu sm ca sc phn v.
6.2. Ph Quincke: ph Quincke c th do nhiu loi thc n gy ra, th-ng xut
hin nhanh sau khi n , nhng vng da mng : mi, c, quanh mt, bng, b
phn sinh dc, cc chi v.v... Kch th-c ph Quincke th-ng to c khi bng bn
90
tay, nu gn mt lm cho mt hp li lm cho mi s-ng to bin dng, mu
da vng ph Quincke bnh th-ng hoc hng nht, i khi trn lm sng kt
hp vi my ay. Tr-ng hp ph Quincke hng, thanh qun, ng-i bnh c
th b nght th, nu xy ra rut, d

91
dy s gy au bng . Kt qu nghin cu ca chng ti cho thy ph Quincke
chim 17,2% trong cc th lm sng d ng thc n.
6.3. Hen ph qun: Cn hen ph qun cp tnh th-ng xut hin nhanh sau
khi n, cc thc n hay gy hen ph qun c ngun gc ng vt nh- : tm ,c,
trng , sa.. .Bnh nhn c th kh th nh, trung bnh v c th biu hin
kh th d di, tng tit m ri, c c, lc ny nghe phi c rt nhiu rales
rt, rals ng y khp hai ph tr-ng. C
th phi hp vi cc triu chng khc nh- my ay, au bng
6.4. Sc phn v: Sc phn v l bnh cnh lm sng nghim trng nht, d
dn n t vong. Cc thc n c tnh khng nguyn mnh nh- sa, trng, g,
tm, cua, c, cu c th gy nn sc phn v . Bnh cnh lm sng
sc phn v kh a dng. Sc phn v th-ng c th xy ra sau khi n t vi
giy cho n 20 -30 pht, khi u bng cm gic l th-ng : bn chn, ht
hong, s hi... v tip l s xut hin nhanh cc triu chng mt hay
nhiu c quan ch nh- tim mch, h hp, da, tiu ho ..vi cc biu hin :
mch nhanh, nh, huyt p tt, kh th, nga ran khp ng-i,
au qun bng, a i khng t ch, th ti cp ng-i bnh hn m, nght
th, co git, ri lon nhp tim, ngng tim v t vong sau t pht.
6.5. da ton thn: Bnh th-ng xut hin vi gi sau khi n. Bnh nhn
thy nga khp ng-i, st, ri lon tiu ho, ni ban v tin trin thnh da
ton thn, trn da c vy trng, kch th-c khng u t ht phn n ht
d-a, cc k tay, chn c th b nt v chy n-c vng. Khi khi, da tay chn
th-ng bong ra tng mng ln nh- "bt tt rch". Tuy vy, sau da s tr li
trng thi bnh th-ng.
6.6. Ngoi ra cn mt s bnh cnh lm sng khc nh- vim mi d ng,
vim da d ng, hng ban a dng, ban xut huyt...
7. Chn on d ng thc n

Vic u tin v quan trng nht trong chn on thc n gy d ng l khai

thc tin s d ng v bnh s ca bnh nhn, xem xt hon cnh xut
hin bnh (sau khi n , ung hay tip xc) tm ra thc n gy d ng.
T s b nhn nh thc n no l nguyn nhn gy d ng ri tin
hnh cc th nghim nhm chn on xc nh.
7.1. Th nghim thc n: Bnh nhn -c dng cc thc n d-i s gim
st cht ch ca bc s, th-ng trong bi cnh bnh vin, l th nghim c
tnh quyt nh bit r thc n no gy d ng. Th nghim tin
hnh theo mt trong ba cch: cng khai, m n, m kp. Th nghim cng
khai, c bc s v bnh nhn u bit r ang th nghim tc nhn d ng
no, loi th nghim ny c tnh ch quan cao nn t chnh xc nht trong 3
cch th nghim. Trong th nghim m n, ch bnh nhn bit r mnh
ang n mn g nn th nghim c phn khch quan hn. Trong th nghim
m kp, c hai bn u khng bit r, khch quan nht trong 3 cch. Loi
92
thc n nghi ng d ng v cht gi hiu u -c cho vo vin nang ng
cng, c bc s v bnh nhn
u khng bit r vin no l tc nhn gy d ng hay l thuc gi hiu.
Cc triu chng d ng pht sinh -c xem l chng c xc thc v thc n
gy d ng.

93
7.2. Ch n loi tr: Th nghim ny yu cu loi tr hn cc loi thc n
c th gy d ng, ri sau -a chng li vo khu phn n trong mt thi
gian quan st. Nu triu chng d ng vn xy ra trong bi cnh ch
n loi tr kht khe th rt c th cc thc n loi tr khi ch n khng
phi l tc nhn gy d ng. Nh-ng cc triu chng bin mt sau khi loi tr
mt thc n no v sau chng li xut hin khi n tr li th thc n y
chnh l tc nhn gy d ng. Th nghim ny tuy mt nhiu thi gian,
nh-ng n c -u im an ton hn.
7.3. Khi th nghim "nh git" v th nghim trong da: Khi th nghim nh
git cho kt qu d-ng tnh, c ngha l d nguyn rt c kh nng gy sc
phn v. Khi th nghim nh git m tnh th chuyn sang th nghim ly
da, rch b, ni b. Bc s Nelson Lee Novick cho bit th nghim ly da vi
thc n cho kt qu d-ng tnh gi ti 30%. Th nghim tim trong da, ngy
nay t -c s dng, v k hng hiu qu g hn th nghim ly da, m i
lc c th gy phn ng d ng nghim trng e do
n tnh mng.
7.4. Theo di ch s gim bch cu v tiu cu: Khi cc th nghim b cho
kt qu khng r rng th ng-i ta theo di ch s bch cu, tiu c u tr-c v
sau khi cc d nguyn vo c th. S kt hp d nguyn v khng th s phn
hu cc t bo mu.Phn ng d-ng tnh, khi s l-ng ca bch cu gim trn
1000/ml mu, s l-ng ca tiu cu gim qu 15% so vi ln m u.
7.5. Cc ph-ng php phng x min dch: ph-ng php min dch phng x
trn giy(PRIST), hunh quang min dch (RAST) nh l-ng IgE c
hiu qua gip cho chn on chnh xc nguyn nhn d ng, tuy nhin
ph-ng php nay t tin t
-c p dng.
8. iu tr bnh nhn d ng thc n

8.1. iu tr c hiu:
Loi b d nguyn bng cch n theo ch ring, loi b cc thc n gy d
ng trong ch n ung ca ng-i bnh l ph-ng thc iu tr v ngn
chn an ton v hu hiu nht.
Ph-ng php gim mn cm c hiu: - c ch nh khi khng loi b -c
d nguyn. Thc cht ca ph-ng php ny l -a d nguyn gy bnh vo c
th nhiu ln vi liu nh tng dn, lm hnh thnh trong c th nhng
khng th bao vy (IgG 4) ngn cn d nguyn kt hp khng th d ng. Do
b nh d ng khng pht sinh, nu pht sinh ch mc nh
Ngoi ra cn c cc ph-ng php khc: c ch s hnh thnh khng th d ng
, c ch s kt hp d nguyn vi khng th d ng Thc t cc ph-ng php
ny t -c p dng
8.2. iu tr khng c hiu:
94
V hiu ho cc hot cht trung gian: histamin, serotonin, bradykinin, acetylcholin
v.v.. bng cc thuc khng histamin, khng serotonin, tiu acetylcholin
(khng

95
cholin)... Corticoid -c s dng nhiu trong vic iu tr cc bnh d ng,
nh-ng cn thn trng, ch nh ng, dng liu, ngn ngy
iu tr cc ri lon chc nng, tn th-ng t chc, cc triu chng d ng
(my ay, nga, kh th, au bng, h huyt p ...)

Cu hi t l-ng gi

1. Phn bit d ng thc n tht v gi

2. Nu cc loi thc n c th gy d ng
3. Trnh by th lm sng v triu chng th-ng gp ca d ng thc n
4. Nu mt vi ph-ng php kh thi chn on d ng thc n
5. Nu nguyn tc iu tr d ng thc n

96
 Vim da atopi v vim da d ng tip xc

Mc tiu hc tp :
1. Nm -c nh ngha, c ch tn th-ng, cc hnh thi lm sng
ca vim da atopi v vim da d ng tip xc.
2. Hiu -c cc tiu chun chn on bnh vim da atopi v vim da
d ng tip xc
3. Trnh by -c cc bin chng , nguyn tc iu tr vim da atopi v
vim da d ng tip xc.

1. i c-ng
1.1. nh ngha
Vim da atopi v vim da d ng tip xc l nhng biu hin tn th-ng
da trn mt bnh nhn c c a d ng c tr-ng bi nhng du hiu
lm sng ca hin t-ng qu mn tc th vi s c mt ca IgE hoc
hin t-ng qu mn mun vi s tham gia ca t bo T c hiu.
1.2. Phn loi: Tn th-ng da theo c ch d ng -c phn chia theo
nhiu cch, tuy nhin theo nhiu tc gi vic p hn loi theo nguyn nhn
ngoi sinh hoc ni sinh -c nhiu ng-i cng nhn:
+ Vim da atopi l bnh da c c a d ng, kh xc nh -c nguyn
nhn nh-ng lin quan n tui mc bnh ca bnh nhn. Tn xut
gp cc la tui
-c th hin biu 1 :
60% 60%

50%

40%
30%
30%

20%
10%
10% 6%
4%

0%
<1 tui 1-5 tui 6-15 tui 16-25 tui 25-40 tui

Biu 1: Tui mc bnh vim da atopi

+ Vim da d ng tip xc th-ng d pht hin do c tc nhn bn ngoi
r rt. Tuy nhin c hai bnh ny u c chung c ch tng mn cm
nhanh hoc chm.
97
1.3. C ch bnh sinh
1.3.1.Vim da atopi
Theo Gell v Coombs, phn ng d ng c s tham gia ca IgE l hin
t-ng tng mn cm typ I, xy ra nhanh, bn cht ca hin t-ng ny l s
hot ho t bo mast bi vic hnh thnh cc cu ni ca 2 phn t IgE
k nhau trn b mt t bo mast lm thay i cu trc mng t bo
gy hin t-ng thot bng v gii phng cc ho cht trung gian nh-
histamin. Cc yu t ho ng ng, heparin v cc protaze gy ra mt
s biu hin nh- vim da atopi . Tuy nhin vic hot ho cc phospholipase
A2 ti mng t bo mast s hnh thnh acid arachidonic hnh thnh
prostaglandines, thromboxan A2 v leucotrines. Bn thn cc sn phm
ny s gy ra nhiu phn ng d ng khc nhau trong c vim da atopi
cp (hnh 1).
1.3.2.Vim da d ng tip xc:
y l c ch d ng mun. D nguyn tip xc trc tip trn mt da,
chui qua da vo t chc d-i da nh s gn vi t bo Langerhans ca
t chc ni b. Chng vn chuyn cc thng tin v d nguyn nhanh
chng di tn t lp th-ng b n cc hch lympho vng. Ti y cc
thng tin v d nguyn -c truyn cho cc t bo lympho T k c. T
cc thng tin c hiu ny m p ng min dch qua trung gian t
bo -c hnh thnh vi s sn xut rt nhiu lymphokin t t bo
lympho T mn cm. Cc t bo lympho T s n hanh chng di chuyn v
vng da c d nguyn. Cc lymphokin t t bo lympho mn cm s
kch thch, hot ho, kt dnh, ho ng ng i cc t bo khc nh-
bch cu n nhn trung tnh di chuyn n ni c d nguyn theo
-ng ng ngc ri vo mu v cui cng n t chc d-i da. S thm
nhim cc t bo -c thu ht t mch mu n t chc d-i da to
nn tn th-ng t chc hc in hnh ca vim da d ng tip xc.

98
Hnh 1 : C ch min dch ca vim da atopi

99
1.4. T chc hc vng da tn th-ng : S thay i v t chc hc ca
da trong vim da atopi v vim da tip xc -c quan st thy khong 4h
sau khi d nguyn vo c th qua da hoc qua nim mc.

+ Thm nhim bch cu n

Hnh 2 : Thm nhim t bo vim ti
t chc da
nhn xung quanh cc mch mu
ca t chc d-i da.
+ Thm nhim bch cu n
nhn
n lp biu b khong 8h sau
khi d nguyn vo c th gy
ph lp biu b.
+ Thm nhim cc t bo vim
gm s c mt ca c t bo
lympho CD4 v c Lympho CD8.
Cc t bo Langerhans lp
biu b tng cao vo 24h - 48h
sau khi c kch thch d
nguyn.

2. Chn on
Vim da atopi v vim da d ng tip xc u c qu trnh tin trin
lm sng qua 4 giai on:
+ Giai on da: nga nhiu, ban ri rc v ph lp th-ng b.
+ Giai on hnh thnh cc bng n-c
+ Giai on r n-c v bi nhim gy ra tn th-ng chc l.
+ Giai on ng vy: tin trin lu di v hnh thnh mng liken ho.
2.1. Vim da atopi :
2.1.1.Tiu chun chn on:
* Tiu chun chn on theo Hanifin v Rajka:
- Tiu chun chnh: cn c 3 trong 4 tiu chun sau y:
+ Nga
+ Hnh thi v v tr tn th-ng in hnh :
Liken ho ti cc np gp nht l tr em.
Tn th-ng mt v mt dui ca chi
+ Tin trin mn tnh v ti pht
+ Tin s gia nh v bn thn c c a d ng.
- Tiu chun ph: Cn c ti thiu 3 tiu chun sau:
+ Kh da
+ C vy, dy sng

10
0
+ IgE ton phn tng cao

10
1
+ Xy ra tui nh
+ C xu th nhim trng da
+ Vim da d ng tay, chn
+ Chm ho nm v
+ Vim kt mc ti pht
+ Du hiu dy sng hnh nn
+ Nhim sc t xung quanh mt
+ da vng mt
+ Vy phn hng
+ Tn th-ng mt tr-c c
+ Hay phn ng vi len d v cc ho cht
+ D ng thc n
+ Cc triu chng nng ln khi xc ng
+ C du hiu vch da .
* Tiu chun chn on theo Williams
- Tiu chun chnh : nga
- Tiu chun ph: km thm 3 triu chng trong cc triu chng sau
y:
+ Tin s c bnh l da cc np ln da
+ C tin s bn thn bnh hen ph qun v vim mi d ng
+ Kh da trong thi gian tr-c
+ C tn th-ng chm ho cc np gp
+ Bnh bt u tr-c 2 tui
Ph-ng php chn on ny -c n gin hn v d p dng.
2.1.2.Hnh thi lm sng
Vim da d ng tr s sinh
+ L biu hin u tin trn mt c a d ng. Chng th-ng bt u
t 3 thng tui. Tuy nhin 38% cc tr-ng hp bnh bt u t tr-c 3
thng tui v 85% cc tr-ng hp bnh bt u t nm tui u tin.
+ Tn th-ng l cc mng , ph, gii hn r, xen k l cc mn n-c nh li
ti. Cc bng n-c nh ny d dp v, v sau ng vy. Hay bt u
mt, cc vng g cao m, trn, cm. Tn th-ng t in trin ton thn,
tp trung mt dui ca chi. i khi c hnh thi trn nh- ng xu, ranh
gii r.
+ Nga nhiu gy ri lon gic ng ca tr.

10
2
+ Tn th-ng la tui ny hay km bi nhim da gy phn ng ton
thn nh- st - hch to au ngoi vi.

10
3
 Phiu chn on
H tn: corticoid ti ch:
Ngy sinh: Liu/ thng
Ngy khm t ti pht/thng

S trong ngoc dng

cho TE < 2 tui
A ( rng vng tn th-ng)

B. Mc C. Nga + ri
nng lon gic
ng
Tiu Mc im
chun
0 : khng
- da
- Ph c 1 : nh SCORAD: A/5+7B/2+C
- R n-c - ng 2 : va
vy
- Chy s-t da 3 : nng
- Liken ho
- Kh da
3 ngy Nga (0-10) 10
hoc
0 1
m cui 0
RL ng (0-10)
iu tr
0
Khm li
SCORAD: H thng nh gi ca Chu u theo di v th nghim
iu tr vim da atopi i vi tr s sinh < 2 tui

10
4
Vim da atopi tr em:
Sau 2 nm tui, cc tn th-ng c xu th
bn cp v mn tnh, tn th-ng khng
rm r, tin trin t t, ti pht.
+ V tr vn cc np gp nh- khoeo,
khuu c tay, chn, mu bn tay v cc
ngn. i khi lan ra ton thn.
+ Tn th-ng mn n-c, dp v, hnh
thnh mng kh, nga nhiu. Du hiu
kh da tr m trng hn i khi phi hp
sng ho.

Hnh 3: Vim da atopi tr

em
Hnh nh vim da atopi tr ln v ng-i tr-ng thnh
+ Vim da atopi tn ti dai dng t nh
n khi tr-ng thnh. T l chim
khong 10% trong dn c-.
+ Tn th-ng a hnh thi hn. Ngoi
cc hnh thi nu trn, cn c cc
tn th-ng c bit nh- chc, l cc
vng mt c, chm ho tay, gan
bn chn. Hin
t-ng liken ho cc np gp chi cng Hnh 4 :Vim da atopi tr
ph bin. ln v ng-i tr-ng thnh

2.1.3.Nguyn nhn ca vim da atopi

Stress

Yu t Nhi
di m
truyn trng

Vim da
D atopi Kch thch da
ng bng nhiu yu
thc n t (ho cht, nh
sng)

Khng nguyn
10
5
 qua -ng th

S 1 : Nguyn nhn gy vi m da atopi

10
6
2.2. Vim da d ng tip xc
+ L bnh l theo c ch d ng mun c vai tr tham gia ca cc lympho
bo
mn cm gy ra phn ng vim ti
t chc d-i da tip xc vi d
nguyn. D nguyn c vai tr nh-
mt hapten. Tn th-ng t chc
hc ging nh-
trong vim da atopi ni trn.
Tuy nhin, hin t-ng dy sng lp
H.5 th-ng b xy ra sm hn.
+ Hnh thi lm sng ca vim da
d ng tip xc ph thuc vo
tng loi d nguyn, v tr tip
xc vi d nguyn. Tn th-ng c
ranh gii r rt vi vng da lnh,
ch c vng tip xc vi d
nguyn. Ban u l nga sau
H.6 da, ph, xut hin mn n-c ri dp
v, r n-c vng, kh v to mng ti
ni c d nguyn.

Hnh 5: Vim da tip xc do bng

dnh Hnh 6: Vim da tip xc do
gng tay

Hnh 7: Vim da tip xc do giy Hnh 8 : Vim da tip xc vi

Nikel
ca vng eo tay
+ Nguyn nhn : th-ng do tip xc vi cc vt, sn phm, dng hng
ngy
2.3. Mt s ph-ng php chn on c hiu

10
7
Tu bn cht ca d nguyn m ng-i ta c th dn g cc ph-ng php sau
chn on c hiu tm nguyn nhn trong vim da atopi v vim
da d ng tip xc.
+ nh l-ng IgE ton phn : Nng IgE ton phn th-ng tng rt cao
trong cc bnh l d ng cng nh- cc bnh l da d ng.

10
8
+ Test ly da ( Prick test).
+ Phn ng phn hu t bo mast hoc tiu bch cu c hiu nhm
pht hin khng th hoc khng nguyn c hiu thng qua mc v
ca cc t bo trn.
+ Vic xc nh d nguyn gy bnh c bit trong vim da d ng do
tip xc ng-i ta s dng test p. y l k thut n gin, d lm, an
ton v cho kt qu chnh xc : d nguyn nghi ng -c ho trong
vaselin, p trn da trong mt loi
a nh. Sau 24h-48h m ra kim tra vng , nu d-ng tnh s thy
trn da ti vng c d nguyn , nga, sn ph, ranh gii r, c th c
mn n-c. Ng-i ta c th c vo 48h sau ln c th nht c ngha l
96h sau khi tip xc d nguyn. H thng a ng d nguyn p da
-c dng rng ri trn th gii gip chng ta c th lm nhiu d nguyn
mt lc. ( xem hnh 9 v hnh 10).

Hnh 9: a dng d nguyn v Hnh 10: Test p d-ng tnh vi

s d nguyn c th lm cng mt Formaldehyde
thi im

3. Tin trin v bin chng

3.1. Tin trin

+ Trong thi gian u tin trin thnh tng t, c cn cp v cng c t
thuyn gim. Cc yu t tc ng v thc y t ti pht i khi d pht
hin nh- nhim trng mi hng, vim ph qun phi, bi nhim vi khun,
virus, tim phng, trng thi stress, thi tit, thc n, nh h-ng nhiu n
thc y ti pht vi m da d ng.
+ Trong thi gian sau: tin trin mn tnh l phn ln.
Tuy nhin 1/4 s bnh nhn s sinh c thuyn gim bt u t 3 tui
n 5 tui chim 50% trong mt s nghin cu. T l tr em tn ti vim
da atopi n tui tr-ng thnh khong 20% n 25%. Mc rm r v
din tch tn th-ng t ti pht th-ng t l vi mc nng khi bt
10
9
u b bnh.
+ Yu t tin l-ng xu cho vim da atopi ng-i ln l:
Bnh bt u sm (tr-c 1 nm tui)

11
0
 Mc tn th-ng da sau khi sinh (1 thng tui u tin)
Tin s bn thn v gia nh v d ng.
S phi hp vi cc bnh d ng khc nh- hen ph qun, vim mi d
ng.
Bi nhim da v cht l-ng chm sc da.
Cc yu t ny s lm cho tnh trng bnh nng thm hoc hn ch
hiu qu iu tr.
3.2. Bin chng ca vim da atopi v vim da d ng tip xc
3.2.1.Nhim vi khun:

+ Nhim t cu vng l rt hay gp ti cc vng da tn th-ng dp v, r

n-c. Vic xm nhp d dng ca vi khun qua da l do s thay i
thnh phn lipid trn b mt da v tng s kt dnh ca vi khun vi lp
th-ng b.

+ Du hiu lm sng th hin phn ng vim rm r trn da, ty ,

au, mn n-c c dch c, m. Hch ngoi vi to v au. St c th c.
3.2.2.Nhim virus:
+ Tn th-ng gm nhiu bng n-c, au, rt, dch trong hoc c, c
nhiu ch hoi t.
Cc bin chng ny lm nh h-ng n s pht trin ca tr do mc
nng ca tn th-ng, cc bnh l phi hp, ch iu tr thuc ton
thn hoc ti ch khng kim sot tt, nga nhiu, mt ng v thiu
vitamin D.
3.2.3.Phi hp vi mt s bnh l khc
+ Hen, vim mi d ng cng pht trin trn mt c a d ng nh- cc
bnh l vim da atopi hoc vim da d ng tip xc. Hen xut hin
mun hn vim da d ng khong t 3-7 nm. Theo mt s nghin cu th
30% s bnh nh n c vim da d ng c km theo hen. Nguy c c cn
kh th nng ng-i vim da atopi hay vim da d ng tip xc l 50%.
+ D ng thc n, d ng thuc hay gp tr em c vim da atopi . Cc
tn th-ng biu hin da nh- my ay, ph Quincke cng rt hay
gp.
4. iu tr

4.1. Chng vim:

Corticoid ti ch (tr cc tn th-ng c bi nhim) hiu qu iu tr tt
11
1
trong nhiu tr-ng hp, an ton v khng c tai bin ton thn cho
bnh nhn. Liu
iu tr tu vo mc tn th-ng, mt tn th-ng ca m i t ti
pht. Mc
ch ca iu tr ti ch l bo v v hn gn hng ro da bo v c
th. i vi

11
2
tr nh vic dng corticoid ti ch c liu cao s nh h-ng n tuyn
th-ng thn v s pht trin ca tr.
Dng m corticoid (iu tr tt trong cc th dy sng nng) nh-
Diflucortolon, Diprosalic, Betametason, Dermovat bi 1 n 2 ln/24 gi.
Khng dng trn mt v gy teo da, xm da kh phc hi.
4.2. Chng nhim khun:
+ Chm sc da sch bng cc dung dch st trng ti ch Hexamidin,
Cytal (1 tha sp pha trong 5 lt n-c dng tm cho nhng vng tn
th-ng. Tm n-c khong, nng l ph-ng php -c khuyn dng.
+ Khng sinh ton thn nu bi nhim nng (nhm Macrolid hay -c
ch nh v t gy phn ng d ng.
4.3. iu tr kh da
y l giai on iu tr cn thit. Kh da lm tng tnh trng nga, nt
n da s to li vo cho vi khun cng nh- d nguyn. Bn vng lp m d-i
da s gi n-c v hn ch tc ng t bn ngoi.
+ S dng cc dung dch lm mm da giu cht bo nh- du tm
Dermagor, Balnum.
+ Sau khi lm sch da c th bi cc thuc giu cht lipid nh m Atonyl
iu tr u n hng ngy khi c t cp cng nh- khi n nh s
phc hi v ci thin cu trc da.
4.4. iu tr khc: Cc thuc khng Histamin -c s dng nhiu c tc d
ng gim phn ng d ng v gim nga gip cho vic ci thin tnh trng
ton thn.
4.5. iu tr th nng:
+ Mt s th vim da atopi tr nn nng v khng iu tr. Cn l-u
chn on phn bit vi mt s tn th-ng khc nh- suy gim min dch
v mt s bnh l ri lon chuyn ho khc.
+ Ciclosporin: -ng ung vi liu bt u 2 -5mg/kg/24h. Sau gim
liu dn, th-ng dng iu tr cho ng-i ln.

5. Phng bnh

+ Gio dc cho bnh nhn, cha m bnh nhn v c ch, cc hnh thi
tn th-ng, mc , nguyn nhn gy bnh, qu trnh tin trin mn

11
3
tnh, s phi hp c th c vi mt s bnh khc, theo di v kin tr iu
tr ca bnh nhn.

11
4
+ Kt qu test p, test ly da v kt qu chn on trong phng th
nghim s l nhng thng tin cn cho bnh nhn bit.
+ Thng bo danh sch mt s sn phm, d nguyn th-ng gy bnh
bnh nhn bit cch phng trnh tip xc.
+ Ng-i c vim da d ng tip xc cn -c theo di v qun l
phng trnh tip xc li bng mi cch nht l ti ni lm vic. Nu kh
ng -c th cn s dng cc bin php bo h lao ng hn ch n
mc thp nht s tip xc vi d nguyn.
+ Pht hin v iu tr cc bnh d ng km theo nh- hen, vim mi d
ng v
iu tr cc nhim trng v rng, tai mi hng.

Cu hi t l-ng gi

1. Trnh by c ch bnh sinh ca vim da atopi v vim da d ng tip

xc.
2. Trnh by hnh thi tn th-ng t chc hc ca vim da atopi v vim
da d ng tip xc.
3. Nu qu trnh tin trin lm sng ca vim da atopi v vim da d
ng tip xc.
4. Trnh by tiu chun chn on vim da atopi theo Hanifin v Rajka.
5. Trnh by cc tiu chun trong chn on vim da atopi ca Williams.
6. M t cc hnh nh lm sng ca vim da atopi v vim da d ng tip
xc.
7. Trnh by cc ph-ng php chn on c hi u cc bnh l da d
ng
8. Tin trin v bin chng ca vim da atopi v vim da d ng tip
xc.
9. Nu cc ph-ng php iu tr vim da atopi v vim da d ng tip
xc.
10. Trnh by cc ph-ng php phng bnh.

11
5
 Vim mao mch d ng (VMMD-)

Mc tiu hc tp:
1. Nm -c triu chng chnh ca bnh
2. Bit chn on phn bit -c vi mt s bnh khc
3. Bit -c tin l-ng bnh
4. Nm -c mt s ph-ng php iu tr

1. Vi nt v lch s vim mao mch d ng (hichngSchoenleinHenoch)

Ln u tin Heberden (1801) thng bo mt tr-ng hp bnh nhn 5 tui
b au bng, nn, phn en, au khp, xut huyt dng chm nt hai chn
v c mu trong n-c tiu. Sau Willan m t tr-ng hp t-ng t vi tiu
purpura urticans.
Nm 1837 Schnlein m t tnh trng gi l peliosis rheumatica vi cc biu
hin
au khp, xut huyt in hnh. 37 nm sau (1874) hc tr c ca Sch
nlein l Henoch m t hi chng mi gm xut huyt, au b ng d di, a
phn en ngoi nhng biu hin t-ng t: thp khp cc khp c tay, bn
ngn tay, c chn.
Nhng nm 1895-1914 Osler cng b Anh nhiu bi bo v cc biu
hin ca vim mao mch d ng (VMMD) c lin quan n cc hin t-ng d
ng. S au Frank ngh -c s dng rng ri M, cc tc gi chu
u v Nht thch dng tn ng-i tm ra hi chng Schnlein- Henoch.
Nm 1969, Berger pht hin s lng ng vng gian mch cc phc hp ca
IgA trong bnh thn IgA tin pht ging nh- vim thn do VMMD. Nm 1980,
Conley dng k thut khng th n dng pht hin s lng ng gian mch
trong bnh Berger v ch yu l d-i lp IgA1. Hai nm sau, Sevenson thng
bo s xut hin ng thi IgA v C3 trong cc mch ca da, rut v cc vng
gian mch mt ng-i ln b VMMD.
2. dch t hc
2.1. Tui: VMMD xut hin mi la tui, nh-ng ch yu tr 2 -16 tui. T
l tr em/ng-i ln thay i t 16 - 22.
2.2. Gii: Bnh gp nhiu nam hn n, ng-i ln t l gii tnh cng ging
nh- t r em: t l nam/n = 1,5/1. Mt s tc gi thng bo nam n c t l
ngang nhau, nh-ng theo mt nghin cu ca Nht th n li chim -u th.
2.3. Ma: C th gp cc thng trong nm, nh-ng hay xy ra vo ma ng
xun.
2.4. Chng tc: Bnh gp cc chng tc, mt s n-c nh- Anh, Php, Phn
Lan, Nht, Singapore, i Loan s l-ng bnh nhn gp nhiu so vi Bc
M, Chu Phi. Ti Nam M s l-ng bnh nhn b vim cu thn do VMMD
him gp hn, trong khi t l bnh nhn b vim cu thn khu vc

11
6
ny rt cao. VMMD cng nh- bnh thn IgA tin pht ng-i da en rt him
mc. S khc nhau trn c th do c mi tr-ng v chng tc.

11
7
3. nguyn nhn v sinh bnh hc

3.1. Nguyn nhn: Nguyn nhn ca VMMD n nay ch-a r, th-ng khi
pht sau nhim trng -ng h hp vi tun tr-c khi bnh bt u. S pht
hin lin cu khun trong hng v s tng t l streptolysine O gp phn sinh
bnh ca lin cu khun. Ngoi ra, mt s vi khun khc cng b nghi ng l
nguyn nhn nh-: t cu khun, trc khun lao, varicella, adenovirus,
nmMt s bnh nhn sau khi dng thuc, tim phng vacxin, cn trng t.
3.2. C ch bnh sinh: Qua mt s nghin cu thc nghim trn m hnh
ng vt v cc quan st ng-i cho thy: phc hp min dch c th l c
ch ch yu tro ng biu hin ca cc bnh vim mch nh, tuy nhin s khu tr
phc hp min dch (PHMD) l-u hnh cc v tr mch c bit ca cc
bnh vn cn l suy on. S pht hin lng
ng PHMD cha IgA, C3, t lng ng IgG v properdin ti cc vng gian
mch mao mch da, hng trng ca cc tr em b vim thn do VMMD kt
hp vi cc quan st thy nng IgA huyt thanh tng trong giai on cp ca
bnh, cc kt qu thu -c ny gp phn gii thch cn nguyn min dch.
3.2.1. M hnh ng vt: Mt bnh ging VMMD l Purpura hemorragica
-c quan st thy nga ngay sau mt nhim trng -ng h hp trn do
Streptococcus equi. Bnh ny bao gm mt xut huyt trn da vi hin t-ng
vim mch Leucocytoclastic, th-ng c vim cu thn, tng IgA huyt thanh v
xu t hin PHMD l-u hnh m thnh phn bao gm cc khng nguyn ca
Streptococcus v cc IgA c hiu.
3.2.2. Phc hp min dch cha IgA: Vo nm 1971 Trygstad v Stiehm
quan st thy s tng IgA huyt thanh lin quan n d-i lp IgA1 50% s
bnh nhn t r em ca h. Hai ng cng nht thy s ging nhau v lm sng
gia hi chng VMMD vi cc bnh l cu thn trn thc nghim, trong c
bnh thn do IgA tin pht, s ging nhau ny dn n gi thit cho rng
VMMD d-ng nh- l mt bnh c lin quan n lng ng PHMD cha IgA 1
cc mch mu v cu thn.
4. Biu hin lm sng

VMMD l mt bnh h thng, triu chng u tin xut hin sau nhim
trng -ng h hp trn vi cc biu hin: mt mi, st nh, ri lon tiu ho,
tip l ban c hiu v cc triu chng lm sng khc.
4.1. Biu hin da: Xut huyt l triu chng u tin gp trn 50%
cc tr-ng hp giai on tin trin.
- V tr: mt dui t chi ( xem hnh 1), quanh 2 mt c trong v ngoi, i,
mng, cnh tay, cng tay; t gp thn mnh, i khi tai, ng tai, mi, b
phn sinh dc ngoi.
- Tnh cht: khng nga; tn th-ng l ban xut huyt do thnh mch c dng
chm, nt, th-ng l g cao hn mt da (do thm nhim) c th c my ay,
bng n-c hoc bm mu v ban hoi t; tn th-ng b nh hung bi t- th
ng (tng ln bi t- th
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8
ng); c th pht hin ph: ph mm, n lm th-ng khu tr da u, vng
quanh h mt, tai, mu tay, mu chn, gt, i khi b phn sinh dc, ph hay
gp tr nh; tn th-ng c tnh i xng.

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9
 Hnh 1 : Bnh nhn VMMD ban xut huyt mt dui 2
chi d-i

4.2. Biu hin tai khp gp trong 75% cc tr-ng hp

- V tr: cc khp gn k vi v tr ca ban xut huyt : c chn, gi, khuu,
him khi c tay v bn tay. Vai, ngn chn v ct sng cng c khi b nh
h-ng.
- Tnh cht: au khp, vim khp mc trung bnh, hn ch c ng; tn
th-ng th-ng i xng; ph quanh khp, i khi au gn phi hp; tn
th-ng khp -c
iu tr khi trong vi gi hoc v i ngy, c th ti pht; khng lm bin
dng khp; tn th-ng c c th thy, sinh thit c c th pht hin cc tn
th-ng hoi t trn mt
ng mch c.
4.3. Tiu ho: gp trong 3766% cc tr-ng hp, i khi l khi u ca bnh.
- au bng vng quanh rn t d di, lin tc, tri ln khi n vo, c th au
th-ng v lan to hoc khu tr, phi hp vi nn v bun nn. Thi gian au
ko di vi gi hoc vi ngy, hay ti pht.
- Xut huyt tiu ho c biu hin nn ra mu, phn en hoc phn c mu,
km theo
au bng d di.
- Lng rut cp v th-ng v tr hi - hi trng l bin chng trm trng
nht ca tn th-ng -ng tiu ho c th quan st thy trong 5% cc tr-ng
hp.
- C th xy ra tc rut, nhi mu, hoc thng i trng, gin i trng.
- C th vim tu cp.
4.4. Tn th-ng thn: gp trong 25 - 50% trong giai on cp. i mu i
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th hoc vi th, protein niu, tr-ng hp protein niu ko di th-ng phi hp
vi i mu vi th, i khi c bch cu niu m khng c nhim trng, xut
hin s au 1 n vi tun hoc mun hn mt vi biu hin khc:
- Hi chng thn h- khng n thun c cc biu hin: protein niu > 3g/24h
ng-i ln v > 40mg/m2 c th/h tr em; phi hp vi albumin mu < 30g/l; du
hiu khng n

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1
thun biu hin bng s t ng huyt p hoc suy thn
- Hi chng vim thn cp cng c th gp (-c xc nh bng s xut hin
i mu v protein niu < 3g/24h ng-i ln, < 40mg/m 2/h tr em ng thi
c th c hoc khng suy thn v tng huyt p phi hp).
- Mt s tr-ng hp tr em c hi chng vim cu thn tin trin nhanh(protein
niu s l-ng nhiu mt cch khng n nh, i mu v c bn l s h- hng
nhanh chng chc nng thn). Nhng bnh nhn c hi chng ny th c tin
l-ng rt xu.
- Suy thn mn l du hiu nng ca bnh.
4.5. Triu chng ti cc c quan khc him gp hn nh-:
- Vim tinh hon: tinh hon au v s-ng, th-ng t khi sau vi ngy.
- Tim: vim c tim, vim mng ngoi tim; nhi mu c tim trn ng mch vnh
bnh th-ng c lin quan n cc vim mch nh ca c tim; ri lon nhp tim;
suy tim sung huyt do VMMD.
- Phi: Xut huyt trong cc ph nang l bin chng rt him trong VMMD,
nh-ng rt nng. Du hiu ny khng bao gi l triu chng m u ca
bnh; trn dch mng phi t huyt v xut huyt.
- Thn kinh trung -ng: C th ch l au u hoc ri lon hnh vi; tr-ng
hp nng hn, c chy mu mng no, co git hoc hn m.
- Mt: Vim mch vng mc vi xut huyt y mt quan st thy mt s
bnh nhn.
5. Chn on
5.1. Chn on xc nh: da vo lm sng l ch yu, da vo cc triu
chng y
v in hnh nh-: ban xut huyt do mch da, au khp, biu hin tiu
ho, thn.
Nm 1990 Hi thp khp Hoa K (ARA) -a 4 tiu chun chn on VMMD
(chn on VMMD nu bnh nhn c t 2 tiu chun tr ln)
1. Ban xut huyt thnh mch.
2. Tui < 20 khi bt u bnh
3. au bng: lan to tng ln sau cc ba n, th-ng xuyn a ra mu.
4. Hnh nh vim mch leucocytoclastic trn sinh thit da.
5.2. Chn on phn bit:
Ban xut huyt: phn bit vi xut huyt do nhim trng: nhim trng
huyt do no m cu; xut huyt gim tiu cu: s l-ng tiu cu gim;
Luput ban h thng: nu ban kt hp vi au khp; vim nt quanh ng
mch
Vim khp: Phn bit vi bnh Kawasaki, biu hin lm s ng ch yu l
ban nim mc phi hp vi hch to nhiu ni.
Biu hin bng: Cn phn bit vi cc cp cu ngoi khoa v i khi mt
phu thut m bng thm d l cn thit khng tin trin thnh lng
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2
 rut hoc vim phc mc.
Thn: C th chn on nhm vi vim thn do lin cu khun trong tr-ng
hp tng t l Streptolysin O v tm thy lin cu thanh qun.

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3
6. Tin trin v tin l-ng

6.1. Da: Tn th-ng da th-ng ko di 2 3 tun sau m dn i v c

th ti pht vi t mi, cc t ni tip nhau ko di khong 3 thng hoc c
th lu hn k t khi bt u pht bnh.
6.2. Khp: Cc triu chng v khp xut hin thong qua v mt i khng
li di chng.
6.3. Tiu ho: Triu chng m u v i khi l bin chng nguy him nh-
lng rut, tc rut thng ng tiu ho, gin i trng c tr-ng hp phi cp cu
ngoi khoa.
6.4. Thn: a s l khi hon ton, mt s t tin trin thnh suy thn mn l
giai
on cui cng ca cc loi tn th-ng thn, do mc nng ca tn
th-ng thn l yu t quyt nh tin l-ng ca bnh. Biu hin thn chung
ca VMMD trn lm sng l:
- Hng cu niu hoc protein niu hay gp hn l c hai, trong 20%
gp i mu
i th.
- Mt s tr-ng hp biu hin vim thn cp vi triu chng: thiu niu, ph,
tng huyt p, nit phi protein nh- ure v creatinin trong mu tng cao.
Khong 10% cc tr-ng hp c tn th-ng thn vi hi chng thn h- l du
hiu tin trin khng thun li. Bnh nhn c tin l-ng nng (nguy c tin
trin thnh suy thn mn: Hi chng thn h- hoc ch yu l c protein niu
qu 1g/24h trn lm sng; Chc nng thn b suy gim mt cch nhanh chng
ngay t u; Tui > 50, tng huyt
p; Trn vi th tng sinh t bo c trong v ngoi mch vi bin dng hnh lim
km theo).
7. Mt s vn v iu tr

Khng c liu php iu tr c hiu, ch yu l iu tr triu chng, cc

bin php
iu tr bao gm:
7.1. Ngh ngi : Ngh ngi 1- 2 thng, n nh (chia nhiu ba, hn ch cht
x) nht l cc tr-ng hp c biu hin h tiu ho.
7.2. Gim au v khng vim khng steroid: Thuc gim au (paracetamol
v dn cht) s dng trong cc tr-ng hp au khp, au c, st. Khng vim
khng steroid: S dng iu tr au khp nhiu khng p ng vi gim
au thng th-ng. Khng dng trong cc tr-ng hp c biu hin tiu ho phi
hp.
7.3. Corticoid : Liu dng: prednisolon 1 - 2mg/kg cn nng/ngy trong 3 - 4
tun sau
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4
 dng cch ngy hoc gim dn liu. C th dng n c hoc kt hp
vi cc thuc c ch min dch khc. Vi cc tr-ng hp tn th- ng thn nng
nh- vim cu thn c hi chng thn h- c th dng bolus corticoid liu 500 -
1000mg methyl prednisolon/24h trong 3 ngy lin tip sau gim xung liu
thng th-ng 2mg/kg/24h v gim liu dn, ph-ng php ny c tc dng tt
lm ci thin c c triu

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5
chng trn lm sng cng nh- trn vi th, gim tng liu corticoid cng nh- thi
gian nm vin.
7.4. Cc thuc c ch min dch: dng trong cc tr-ng hp tn th-ng thn
nng nh- vim thn cu thn c tng sinh ngoi mch nh h-ng ti > 75% s c
u thn. Cc ch phm hay -c dng l Azathioprin liu 3 - 4mg/kg/24h
phi hp vi corticoides gim dn liu trong 6 thng n
1 nm, hoc c th dng Cyclophosphamid.
7.5. Khng sinh: Penicillin i khi tc dng tt trong tr-ng hp c nguyn nhn
l nhim khun lin cu.
7.6. Ghp thn: p dng cho cc tr-ng hp suy thn giai on cui tuy nhin c
ti pht li vim thn do VMMD mt s tr-ng hp bnh nhn -c ghp
thn.
7.7. Cc bin php khc: -c s dng cho d hiu qu ch-a r rng: Lc
huyt t-ng, khng Histamin -c dng nh-ng hiu qu ch-a -c chng minh,
thuc chng co tht dng b sung trong cc tr-ng hp tn th-ng h tiu ho.

Cu hi t l-ng gi

1. Trnh by vn dch t hc trong bnh VMMD

2. Gii thch c ch bnh sinh ca V MMD
3. Nu cc triu chng v 4 tiu chun chn on VMMD
4. Trnh by cc bin chng c th gp ca VMMD
5. Nu cch iu tr thng th-ng v cc bin php c th p dng trong iu
tr VMMD.

12
6
 lupus ban h thng (SLE)

Mc tiu hc tp:
1. Hiu -c cc yu t tham gia vo c ch bnh sinh
2. Nm -c cc triu chng lm sng, xt nghim chn on bnh,
chn on phn bit
3. Thuc 11 tiu chun chn on ca ARA 1982
4. Bit cch iu tr
I. i c-ng:

Lupus c y hc bit n t u th k XIX, nhng mi ch c coi l

bnh ngoi da khng nguy him. Nm 1828, BieHe miu t ban ri rc i
xng v phn bit Lupus tn thng su vi tn thng b mt. Nm
1845, Hebra m t tn th-ng ngoi da nh- hnh cnh b-m mt. Danh t
Lupus ban c Cazenave a ra nm 1851 vi hai th: th nh tn
th-ng ngoi da v th nng km theo cc tn th-ng ni tng.
n nm 1872 Kaposi chia Lupus ban h thng (SLE) thnh hai th lm
sng: Lupus dng a v Lupus dng lan to. dng lan to m Kaposi miu
t ngoi nhng biu hin ngoi da cn c cc tn th-ng khc nh- mu, thn
kinh, ni tng km theo st m ng gi l sc nhim c.
Nm 1895 - 1904, Osler l ng-i u tin m t nhng biu hi n ton thn ca
bnh Lupus ban : vim khp, vim phi v cc biu hin thn, h thn
kinh ng thi ng cng thng bo nhng tn th-ng ni tm mc v ngoi
tm mc trong nhm bnh c bit c ban xut hin.
Na u th k XX ghi nhn nhng biu hin m hc ca bnh: cc tn
th-ng cu thn -c thy trn 23 ca bnh v ti nm 1942 Klemperer v
Bachs -a h-ng nghin cu theo bnh Collagenoses.
Nm 1948, Hargraves v cng s pht hin ra t bo LE. Nm 1950, Hassik
tm ra yu t min dch c vai tr quan trng trong s hnh thnh t bo LE,
quan im v mt bnh t min -c hnh thnh.
Cui cng s pht hin khng th khng nhn do Coons v Frion nm 1957
dn n s tm ra mt lot cc t khng th khc, nh du mt mc quan
trng khng nh Lupus ban l mt bnh t min.
S xut hin v tc dng tt ca corticoid ko di i sng bnh nhn v
gip cho tin l-ng ca bnh nhn thay i rt nhiu (Hench 1948 - 1949)
Dubois -a ra nh ngha: bnh Lupus l mt hi chng nguyn nhn k hng
r, c tr-ng bi tn th-ng nhiu c quan ni tng, c nhng t tin trin
nng xen k t lui bnh. Chn on bnh da trn s c mt ca cc khng
th khng nhn v t bo Hargraves trong huyt
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7
thanh ca bnh nhn lupus. Nm 1968 Hi khp hc Hoa K (ARA) -a ra 14
tiu chun chn on v ngy nay ch cn 11 tiu chun. Ch cn c 4/11
tiu chun l chn
on d-ng tnh.
T l mc bnh lupus hng nm rt kh xc nh. Theo mt s ti liu
nghin cu, t l
dao ng t 1 n 10 ca mi trong 100.0 00 dn (1955-1975) ti M v
cc n-c Bc u.
2. c ch Bnh sinh

2.1. Cc bt th-ng v min dch

2.1.1.Cc t khng th
2.1.1.1. Khng th khng cu trc ca nhn:
- Khng th khng nhn (ANA) t l d-ng tnh cao ti 90% nh-ng c
hiu thp v ANA c th gp trong cc bnh khc nh- s cng b, vim
a khp dng thp.
c bit gp d-ng tnh t 1 - 3% ng-i bnh th-ng, nht l ng-i gi.
- Khng th khng ADN gm 03 type:
+ Type I : Khng th khng ADN t nhin chui kp (ds ADN, db ADN, n
ADN), t l gp l 60-70%, c hiu cao.
+ Type II : Khng th khng c ADN chui n v chui kp.
+ Type III : Khng th khng ADN chui n (n -ADN), t l gp l 30%
- Khng th khng Histone : gp trong cc tr-ng hp Lupus do thuc.
- Khng th khng nucleoprotein khng ho tan, -c pht hin bng t bo
Hargraves.
2.1.1.2. Khng th khng cc khng nguyn ho tan:
- Khng th khng Sm (tn ca bnh nhn -c pht hin u tin), t l
gp l 30 - 40%
- Khng th khng RNP (khng nguyn t-ng ng l ribonucleo -protein) :
nhy v c hiu kh cao. Hai khng th Sm v RNP th-ng i km vi
nhau tuy khng nguyn khc nhau.
- Khng th khng SSA (khng Ro) gp 30% trong bnh Lupus ban h
thng, 60% trong hi chng Sjogren Gougerout. Rt c hiu chn
o n Lupus bm sinh.
2.1.1.3. Khng th khng cc t bo:
- Khng th khng hng cu: nghim php Coombs d-ng tnh t l gp

12
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60% trong bnh Lupus v th-ng gy ra biu hin thiu mu trn lm sng.

12
9
- Khng th khng bch cu: bch cu ngoi vi gim. Cc nghin c u cho thy
ch yu l lymphocyte b tn th-ng, mt phn nh l bch cu a nhn
trung tnh.
- Khng th khng tiu cu: l cc khng th khng li cc khng nguyn trn
b mt tiu cu, gy biu hin gim tiu cu mc nh & va; c th
gp xut huyt gi m tiu cu.
2.1.1.4. Khng th khng photpholipit : trn lm sng -c biu hin bng phn
ng giang mai d-ng tnh gi.
2.1.1.5. Khng th khng vi c quan:
- Khng th khng Riboxom: khi xut hin khng th ny th-ng c biu
hin tm thn.
- Khng th chng b my Golgi: rt t gp
2.1.2.Cc phc hp min dch
- Phc hp min dch l-u hnh: gp trong h tun hon
- Phc hp lng ng: trong cc m, cc t chc d-i da, mng y cu thn.
2.1.3.B th
Cc phc hp min dch (PHMD) khi lng ng s hot ho b t h theo con
-ng kinh in. S hot ho s gii phng ra cc mnh C 3a C5a. y l
yu t ho ng
ng, s li ko cc bch cu a nhn trung tnh, i thc bo n thc bo
phc hp min dch. Trong qu trnh thc bo s gii phng ra nhng cht gy
vi m nhng ni c PHMD lng ng.
Khi phn ng vim din ra kch thch qu trnh oxy ho to ra cc gc t do, cc
ion c
c tnh rt mnh vi m lin kt.
Ngoi cc t bo, gc t do gy tn th-ng cn c cc enzyme tiu protein c
ngun gc t nhiu t bo khc nhau tham gia vo qu trnh hu hoi m, cc
t chc lin kt
2.2. Cc yu t nguyn nhn
2.2.1.Yu t bm sinh (Di truyn)
C tnh cht gia nh vi t l mc bnh tng ln nhng ng-i cng huyt
thng, c bit th h th nht. Yu t di tr uyn cng r tr s sinh
cng trng, chim t l 63% trong khi tr s sinh khc trng t l mc l
10%.
Ngy nay vi k thut tin tin ng-i ta th-ng thy Lupus kt hp vi HLA DR 2
v HLA DR3.
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0
2.2.2.Yu t mc phi
2.2.2.1.Virus: Khi so snh nhng ng-i tr tui b Lupus vi ng-i lnh th thy
tn sut huyt thanh nhim Epstein Barr tng ln r rt, tuy nhin mi c
gng phn lp

13
1
virus bnh nhn Lupus u tht bi. c gi thuyt coi virus nh- mt yu
t khi pht gen trong c th gy ri lon h min dch.
2.2.2.2. Thuc: Cc thuc iu tr lao (INH, Rifampixin), h p (Hydralazin,
Procainamid), chng co git (Phenintoin ), thuc chng th thai l nhng
nguyn nhn gy Lupus ban .
2.2.2.3.Hoc mn gii tnh : Gp n nhiu hn nam (8 -9/1), tn sut cao
la tui sinh . Qu trnh thai nghn nh h-ng r rng ti bnh, c bit l
03 thng cui thi k mang thai.
2.2.2.4. Tia cc tm
3. Lm sng

3.1. St: Th-ng st nh 37 5 C - 37 6 C, nh-ng cng c tr-ng hp st cao ti

39 - 40 C. St ko di khng r nguyn nhn, km theo cc triu chng ton
thn nh- gy st, mt mi, km n.
3.2. Biu hin da v nim mc
- Ban hnh cnh b-m mt. Ban thnh mng, vy mn c khi ph n,
kh- tr hai cnh mi, g m v d-i cm (xem hnh 2).
- C th gp ban vng tr-c ngc, l-ng, u ngn tay xung quanh
mng.
- Da nhy cm vi nh sng.
- Lot ming, hng (xem hnh 1).
- Rng tc c th lan to hoc kh- tr thnh mng.
3.3. Cc biu hin c x-ng khp
- au c, au khp l du hiu hay gp v th-ng l du hiu khi pht
bnh.
- Vim khp n thun: C th gp mt hay nhiu khp, c th di chuyn
t khp ny sang khp khc. Khng c cng khp bui sng, khng c s-ng nng
, khng c bin dng x-ng khp. Trn X -quang khng c hnh nh mn
x-ng, gai x-ng hoc hp dnh khe khp. C th gp bin dng ngn tay
hnh thoi, hoc bin dng c trc khp hnh thnh mt bnh thp kiu
Jaccoud, nh-ng rt t gp.
- Hoi t x-ng v khun: Th-ng gp cc trn x-ng i, li cu x-ng i,
thn x-ng chy hoc u x-ng cnh tay m khng phi do corticoid.
- Vim c, lon d-ng c: C th thy xm nhp bch cu qua sinh thit c
v c tng men c qua xt nghim.
- Vim khp nhim trng: Th-ng gp khp gi, do cc chng vi khun sinh
m gy nn.
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2
3.4. Biu hin ti thn
Ch yu l tn th-ng cu thn, th-ng l nguyn nhn gy t vong ca
bnh. Tn th-ng thn c c im sau:
- L tn th-ng sm trong cc tn th-ng ni tng
- Khng c s ph hp gia tn th-ng thn vi bnh cnh lm sng.
- Khng c s ph hp gia gii phu bnh vi biu hin lm sng.
Cc biu hin hay gp: ph, i t, protein niu, c th c hng cu, bch
cu, tr niu. Th-ng c vim cu thn cp, hi chng thn h- v suy thn.
Tn th-ng cu thn trn hnh nh sinh thit thn gm:
- Loi I : Thn bnh th-ng v quang hc, khng c lng ng min dch
hunh quang
- Loi II : Vim cu thn gin mch
- Loi III: Vim cu thn on v tng sinh
- Loi IV: Vim cu thn tng sinh lan ta
- Loi V : Vim cu thn ngoi mng
- Loi VI: Vim thn s ho
Trn lm sng, tn th-ng thn -c biu hin:
- Hi chng vim cu thn cp: i mu i th hoc vi th, i t hoc v
niu km theo ure v creatinin tng nhanh, c th dn ti suy thn cp.
- Hi chng thn h-:
+ Ph to
+ Protein/ niu trn 3,5g/ 24h
+ Protein mu gim d-i 60g/l trong Albumin gim d-i 30g/l.
+ Tng Lipit (Triglycerin, cholesterol)
- Suy thn mn: v niu, huyt p cao, thiu mu, ph, creatinin mu tng cao
cc mc khc nhau. y l nguyn nhn gy t vong.
- Tn th-ng bng quang: r t him gp, biu hin ch yu l vim bng
quang (thnh bng quang dy ln). y l loi tn th-ng nng vi tin l-ng t
vong cao khi xut hin.
3.5. Biu hin tim mch
3.5.1.Biu hin tim:
- Vim ngoi tm mc l biu hin hay gp nht trong cc tn th -ng tim,
chim 20
40%. Trn dch mng ngoi tim th-ng khng nhiu ti mc gy p
tim.
- Vim ni tm mc kiu Libman -Sacks: Si cc van tim v vch tht. Lm
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3
sng nhiu khi kh pht hin, pht hin nh siu m tim gp 15 - 20%
cc tr-ng hp

13
4
 Osler.
- Vim c tim: Trn lm sng gp 10 15%, c biu hin ri lon nhp,
block dn truyn, t gp lon nhp hon ton.
3.5.2.Biu hin h mch:
- Hi chng Raynaud gp 20 30%
- Tn th-ng mch vnh: Biu hin bng cn au tht ngc hoc nhi mu
c tim.
- Huyt khi tnh mch: Gp trong 8 20% tr-ng hp, th-ng d gy tc
mch, hay gp vng tnh mch cc chi, nh-ng cng c th tnh mch
cc tng hay tnh mch ch th-ng lin quan n cc cht chng ng l-u
hnh.
3.6. Biu hin h h hp
- Vim mng phi: c th b mt hoc hai bn, gp trong thi k tin trin
ca bnh vi t l 25-50%. C trn dch mng phi n-c thanh t, s l-ng
dch th-ng khng nhiu.
- Tn th-ng nhu m: kh pht hin v c nhiu biu hin lm sng khc
nhau.
+ Vim phi Lupus: triu chng rt n o, cp tnh nh-ng t l gp khng
cao.
+ Chy mu ph nang: l tn th-ng rt nng gy suy h hp cp v dn
ti t vong nhanh chng, X quang phi c hnh nh phi trng.
3.7. Biu hin h thn kinh tm thn
- au u, co git kiu ng kinh ton th hoc cc b l nhng triu
chng hay gp.
p ng tt vi thuc chng co git v corticoid.
- Ri lon tm thn l mt trong nhng biu hin nng ca bnh, tin l-ng
xu. Cn phn bit vi ri lon tm thn do corticoid.
Ngoi ra c th gp vim no, vim mng no, hi chng vim tu ct ngang.
3.8. Biu hin mu v t chc sinh mu
- Thiu mu gp t nht 50% bnh nhn, c th l biu hin khi pht
ca bnh.
- Gim tiu cu cng l biu hin hay gp
- Ri lon ng mu vi nguy c tng ng gy huyt khi tnh mch.
- Lch v hch to nhiu a im
3.9. Biu hin h tiu ho
- Th-ng gp l chn n, bun nn, nn trong t tin trin ca bnh. Chy
mu tiu ho gp 1,5 - 6,3% trong c nguyn nhn do thuc (corticoid),
13
5
 cng c lot rut non, i trng do thiu mu cc b.
- Gan to gp 8-12% bnh nhn, th-ng khng au khi khm tr mt vi
tr-ng hp trong giai on tin trin ca bnh.
Ngoi ra trn lm sng c th gp vim tu, hi chng au bng gi ngoi
khoa d gy chn on nhm.

13
6
3.10. Biu hin mt
- Vim vng mc, vim kt mc xung huyt.
- Tc ng mch vng mc, vim thn kinh th gic, hi chng x teo tuyn
l, teo t chc lin kt mt.
4. Cc biu hin cn lm sng

4.1. Cc xt nghim khng c hiu

- Cng thc mu: Gim nh 3 dng hng cu, bc h cu, tiu cu. Mu lng
tng cao
- in di protein: T l A/G o ng-c, -globulin tng cao.
- Tng phn tch n-c tiu: Protein T bo Tr niu
4.2. Cc xt nghim c hiu
- Khng th khng nhn ANA, ds ADN
- T bo Hargraves
- Khng th khng photpholipit: khng th khng Cardiolipin gy phn ng gi
vi giang mai.
- Sinh thit da bng min dch hunh quang thy c lng ng cc
globulin min dch v cc b th ni lin da th-ng b.
- Sinh thit thn.
5. Tiu chun chn on ca hi khp hc hoa k (ARA) 1982

5.1. Ban hnh cnh b-m mt

5.2. Ban dng a
5.3. Nhy cm nh sng
5.4. Lot ming
5.5. Vim a khp
5.6. Vim mng tim hoc mng phi
5.7. Tn th-ng thn: Protein/niu > 0,5 g/24 h ; hng cu niu; tr niu
5.8. Tn th-ng thn kinh tm thn
5.9. Ri lon v mu
- Thiu mu huyt tn
- Bch cu d-i 4000/ mm3
- Tiu cu d-i 100.000/ mm3
5.10. Ri lon min dch
- ANA; ds ADN
- T bo Hargraves
- Khng th khng Sm
10
0
- Phn ng giang mai d-ng tnh gi ko di trn 6 thng v trong 6 thng
phi khng c biu hin ca bnh giang mai
5.11. Khng th khng nhn hiu gi bt th-ng
Ch cn 4 trong 11 tiu chun l chn on d-ng tnh.
6. Cc th bnh

6.1. Mn tnh: lnh v tn th-ng ch kh- tr ngoi da, khng c tn th-ng ni

tng.
6.2. Cp tnh: nng v c tn th-ng ni tng
Tuy nhin t mn tnh c th chuyn thnh cp tnh n u c nhng yu t
thun li nh- stress, d ng thuc
7. Chn on phn bit

7.1. St ko di trong mt s bnh khc nh- ung th-, nhim trng, st rt, st
virus
7.2. Lupus kinh Lupus hnh a: lnh tnh v tn th-ng ch kh- tr ngoi
da
7.3. Vim khp dng thp: trong giai on u nu ch c au khp v st rt
d nhm. Tuy nhin trong vim khp dng thp tn th-ng khp rt c
tr-ng, km theo c bin dng x-ng khp.
7.4. X cng b h thng tin trin: chn on d-ng tnh c cng da
ton thn v hi chng Raynaud
8. iu tr

8.1. Cc thuc chng vim khng phi steroid

-c dng trong giai on u ca bnh v tc dng chng vim, gim au, h
st. Th-ng s dng thuc thuc cc nhm Salicylic, Indomethacin, Pyrazol,
Ibuprofen.
8.2. Thuc chng st rt
-c s dng iu tr Lupus t cui th k XX. Rt c hiu qu trong iu
tr tn th-ng da cc tr-ng hp lupus kinh cng nh- cc triu chng ton thn
khc (st, mt mi, gy st ). Liu iu tr th-ng bt u t 200mg 2 ln
trong mt ng y, sau mt thng khng c p ng c th tng liu 600mg trong
mt ngy. Liu duy tr l 200mg. Tuy nhin thuc chng st rt c tc dng ph
ln mt nn khuyn bnh nhn khm mt 2 ln trong mt nm.
8.3. Corticoid
-c -a vo iu tr Lupus t 1950. C tc dng chng vim v c ch min
dch r rt.
Trong giai on u ca bnh, dng liu thp t 5 -15mg/24h, sau h liu
c 15 ngy h 1mg. Trong cc tr-ng hp nng, dng liu t 1 -2mg/kg/24h.
C th dng
101
-ng ung hoc tim truyn. Dng liu tn cng lc di 2-3 tun, sau c
7 ngy gim liu mt ln, mi ln 5 -10mg. Theo di kt qu iu tr da trn
lm sng, xt nghim v cc tc dng ph ca thuc.

102
8.4. Thuc c ch min dch
Trong cc tr-ng hp c tn th-ng cu thn nh-ng dng corticoid liu c ao vn
khng c tc dng c th dng cc thuc c ch min dch.
Cyclophosphamid dng -ng ung, liu l-ng t 1 -4mg/kg/24h. Ng-i ta thy
c tin trin tt sau khi iu tr 10 tun bng Cyclophosphamid. Tuy nhin
trong qu trnh
iu tr phi theo di chc nng thn v khi dng thuc c th c t bng
pht bnh nng hn.
8.5. iu tr triu chng
- Khng sinh nu c nhim trng
- An thn nu c tn th-ng h thn kinh
- Chng ng nu c vim tc tnh mch
- H p trong tr-ng hp tn th-ng thn nng
- Cc thuc bi ti ch nh- kem Betnovat, kem Betamethason.
9. Tin l-ng

Khng r rng, bnh ko di nhiu nm, phi dng thuc lin tc v theo s
ch dn ca bc s.

Mt s hnh nh minh ho

Hnh 1 : Lupus ban h Hnh 2: Lupus ban h

thng Vim lot thng ban hnh cnh b-m
ming

103
 Cu hi t l-ng gi

1. Hy k tn cc t khng th tham gia vo c ch bnh lupus.

2. Trnh by vai tr ca cc t khng th trong c ch bnh SLE.
3. Trnh by cc phc hp min dch v b th trong c ch b nh SLE.
4. Hy nu cc yu t nguyn nhn lm pht sinh bnh SLE.
5. Trnh by cc xt nghim c hiu v khng c hiu chn on SLE.
6. Trnh by cc biu hin lm sng ca bnh SLE.
7. Hy k 11 tiu chun chn on theo ARA 1982.
8. Chn on phn bit Lupus ban vi mt s bnh khc.
9. iu tr Lupus ban h thng.
10.Hy nu c im tin trin bnh SLE.

104
 x cng b (XCB)
Mc tiu hc tp:
1. Nm -c nh ngha, phn loi v c ch bnh sinh ca bnh XCB.
2. Trnh by -c biu hin lm sng v cc xt nghim trn bnh nhn XCB.
3. Hiu -c nguyn tc c bn trong iu tr bnh XCB.

1. i c-ng

1.1. nh ngha

XCB l bnh c tn th-ng ton b t chc lin kt, vi tn th-ng nhiu

c quan khc nhau c tr-ng bng cc tn th-ng ng mch, mao mch
nh gy x cng v lm tc nghn cc mch mu da, ng tiu ho, tim, phi ,
thn v cc c quan khc nhau.
Tn th-ng da th-ng kh- tr, ti xut hin s tng sinh nhiu cht to keo
t chc lin kt d-i da. Tn th-ng ni tng l iu kin tin l-ng.
1.2. Phn loi
1.2.1.Th tn th-ng da lan to :
+ Hi chng Raynaud t nht c 1 nm tr-c khi c tn th-ng da.
+ Tn th-ng da gc chi v thn mnh
+ Hay gp v c khi c rt sm :
Tn th-ng t chc k ca phi
Suy thn
Tn th-ng d dy, rut non mt cch lan ta.
Tn th-ng c tim
+ Dn v ph hu cc mao mch.
1.2.2.Th tn th-ng khu tr:
+ C hi chng Raynaud t nhiu nm tr-c.
+ Tn th-ng da kh- tr u ngn (t ngn tay ln n c tay hoc t
ngn chn
n u gi), i khi cng da kh- tr vng d-i x-ng n).
+ C nguy c tng p lc ng mch phi mun.
+ C hoc khng c :
Tn th-ng t chc k ca phi
au dy thn kinh tam thoa
+ X ho v dn cc mao mch t chc d-i da.
+ Hi chng CREST: bao gm 4 du hiu sau y:

105
 -Hi chng Raynaud
-Vi ho
-X cng ngn chi
- Dn mch v x cng thc qun.
1.3. Dch t hc
L bnh him gp, tn sut gp thay i gia cc nghin cu. Nh-ng
ng-i ta nhn thy rng ti M c t 2,3 n 16 tr-ng hp pht hin mi trong
1 triu dn mi nm.
Bnh bt u th-ng t 40 - 50 tui, n xut hin sm hn khong 30 -
39 tui. Tr-c tui 20, ng-i ta gp vi t l 10% cc tr-ng hp nghin cu. T
l t vong hng nm trung bnh M khong 2,1 n 2,8 trn 1 triu dn. T
l ny thay i tu theo tui.
T l t vong trung b nh M khong t 2,1 n 2,8/1 triu dn. T l ny
thay i tu theo tui ca bnh nhn.
Phn ln bnh nhn t vong c thi gian tin trin trung bnh 5 nm. y l
thi gian cho mt qu trnh tn th-ng ni tng tin trin.
1.4. C ch bnh sinh
X cng b l bnh c c ch phc tp . Tuy nhin t nhiu c ch bit
qua nghin cu v s tham gia ca nhiu loi t bo, v nhiu phn t (khng
th, hot cht trung gian) Ng-i ta m hnh ho c ch bnh sinh ca x
cng b nh- sau (s 1) :

- Tn Ri lon Ri lon chuyn

th-ng min ho
mch mu dch cht to keo

X cng b

Ri lon Ge Yu t
nhim sc n mi tr-ng
th

S 1 : M hnh ho c ch bnh sinh ca x cng b

1.4.1.Bnh l v cht to keo

+ Tng l-ng cht to keo ngoi t bo nh- protoglycanes, fibronectin, laminin
to nn cc tn th-ng v gii phu bnh hc c bn ca XCB l x
106
cng da v dy da.

107
+ Nghin cu qua knh hin vi in t ng-i ta nhn thy xut hin s tch
t ca cc si fibrin xen qun vi cc si to keo . iu ny lm bin i cu
trc ca da do tng lng ng v bm dnh.
1.4.2.Bnh l tn th-ng mch mu
.+ Trong XCB tn th-ng cc mch mu c kch c nh (50 500 microns). Hi
chng Raynaud rt hay gp (90 95% s bnh nhn), y -c coi l s
tn th-ng vi mch ch yu trong x cng b.
+ C s tng sinh cc t bo ni m, lm dy t chc trung m, x ho th
pht v lng ng cht to keo gy ra tc vi mch do hp lng mch nh.
+ Thoi ho nhn v hoi t nhn cc t bo ni mch. Mt i tnh trng lin
kt cht ch ca thnh mch. Tng qu trnh thm thu thnh mch gy ra
ph, thm nhim t bo vim.
1.4.3.Bnh l h min dch
+ Cc t bo ca h min dch nh- lympho, i thc bo v cc cytokines
khc nhau
u tham gia trong c ch tn th-ng ca mch mu v t chc lin
kt.
+ Phi hp vi cc tn th-ng v gen ring bit tc ng mt cch gin tip
bng cch kch thch cc nguyn bo si v cc t bo ni m.
+ Trung tm tn th-ng da l s thm nhim cc t go T - CD4 v T
CD8, nhiu nht vng xung quanh mch mu v thn kinh.
+ Kch thch cc lympho B sn xut mt l-ng ln khng th, ch yu l cc t
khng th.

2. chn on x cng b lan to

2.1. Tiu chun chn on

Tiu chun chn on da vo cc tiu chun lm sng ca hi khp Hoa k
(ARA)
i vi XCB h thng.
Tiu chun chnh:
* X cng da vng chi: da cng cng, dy, n khng lm.
Tiu chun ph:
* Cng ngn chi: cng cc ngn tay hoc chn, hn ch gp, dui cc ngn
tay.
* Chm ln so vng da ngn chi.
* X phi vng y.
(L-u : Cn c 1 tiu chun chnh v 2 tiu chun ph).
108
2.2. Triu chng lm sng th-ng
gp:
2.2.1.Hin t-ng Raynaud (xem hnh
1)
+ Gp 95% cc tr-ng hp bnh
nhn XCB v 4% n 5% trong
dn c-. L du hiu c tr-c t vi
thng hoc vi nm tr-c khi c x
cng b. Tin trin mt cch m
thm. Hnh 1: Du hiu Raynaud giai on
tm
+ y l ri lon qu trnh vn
mch
u chi do tc ng ca l nh v
tin trin trong 3 giai on.
Giai on u trong vi pht, xy ra nhanh mt hoc nhiu ngn ca 2 bn
tay lm
u ngn trng, lnh v gim cm gic. y l giai on cn cho chn on.
Giai on 2: Vng chi tm li v au do tr mu h tiu tnh mch.
Giai on 3: Bn tay tr li hng do gin n cc mao qun. Bn tay tr nn
nng hn.
Hin t-ng Raynaud ngy cng xut hin nhiu, gn li, v r nt cng vi qu
trnh tin trin ca bnh. Giai on nng bn tay lun lnh, tm v gim
cm gic.
2.2.2. Tn th-ng da v nim mc (da, nim mc, mng) tri qua 3 giai on:
ph, cng , teo da, mt cc np trn da.
+ Da vng trn, quanh mt phng, mt np nhn, mi mng cng, khun mt
v cm.
+ Da cng vng ngn, dy ln to thnh mng d a kh, dnh st vo lp su
lm hn ch gp dui, gim tit m hi, rng lng, mng kh cng, gy v
c kha. Nhiu khi c teo da r ngn.
+ Lot v hoi t u ngn do lon d-ng v tc mch , i khi phi tho t
ngn i vi tr-ng hp nng v au. Lot c th gp cc vng da khc do
lon d-ng (hnh 2).
+ Lot ming, p xe rng li cng l du
hiu hay gp. Hn ch m ming do
cng, c hnh kha da quanh ming.
+ Xut hin vng mt sc t trn da (30%),
i khi xut hin vng calci ho d-i da
u ngn hoc vng da cng tay,
109
c, u gi. S lng ng calci ny
khng lm thay i mu da, tuy
nhin c mt
chc, khng u v c th c lot.
Hnh 2 : Hnh nh lot u
chi

110
2.2.3. Tn th-ng h tiu ho (xem bng 1)

Bng 1 : Bnh l h tiu ha trong x cng b

Min Thc D dy Ru
g qun t

Lot Tro ng-c thc qun Gim nhu Nhim

ming ng khun
Vim gai l-i Gim nhu Dn d Lot hnh t
ng dy trng
Dn mao Hp thc thc Gim nhu
mch qun n ng

Ri lon v Lot thc Lot d Lot rut

nut qun dy non

Teo gai l-i Chy mu d Thng

dy rut
Abcs rng Hoi t
rut

2.2.4.Tn th-ng thn

L nguyn nhn t vong ca XCB . Cc tn th-ng th-ng l:
+ Suy thn cp (gp vi tn sut t 15 20%)
+ Protein niu n thun km tng HA, thiu mu.
+ T chc hc ca thn tn th-ng :
Qu sn lp ni mch cc ng mch lin thu.

Hoi t dng fibrin ti cc tiu ng mch.

Tng sinh cc t bo mng y cu thn.

C th pht hin s lng ng ca C3a v IgM bng ph-ng php min

dch hunh quang trn thnh m ch mu tn th-ng gy ra thiu mu cc b ti
cc vng v thn, gy x ho n v cu thn. Tn th-ng th-ng lng l, m
thm , nh-ng tin l-ng rt nng. Suy thn l nguyn nhn chnh gy t vong.

+ Nguyn nhn ca tn th-ng thn ch yu l do gim th tch mu n

thn mt mt do x cng ng mch thn c bit cc mch mu nh,
mt khc c s bi tit Renin ti t chc cn cu thn gy co mch v gim
l-u l-ng ti thn. (xem s 2)

111
 Tn
Co mch th-ng
thn
mch mu
nh

Gim l-u l-ng Hp v tc cc

ng Tc vi
tun hon mch
thn mch lin thu

Bi tit Thiu oxy t Hi chng tan mu

Renin bo v
tng ure mu

Bi tit Hoi t vng

angiotensin v
II thn kh- tr

Protein niu
Tng HA tng
ure mu suy
thn
S 2 : Sinh l bnh ca tn th-ng thn trong XCB

2.2.5.Tn th-ng phi

X phi do x ho t chc k l bin chng hng u trong x cng b.
Biu hin kh th khi gng sc, ho khan khng khc m, gim r ro ph
nang y phi.
XQ phi cho thy hnh nh li giai on u, sau xut hin cc nt
m xen ln, tp trung vng rn phi tri di xung y phi. i khi xut
hin hnh nh bng kh do dn ph nang.
Chp ct lp phi cho thy r tn th-ng giai on sm khi XQ cn trong
gii hn bnh th-ng.
Thm d qu trnh thng kh phi cho php pht hin sm du hiu x t
chc k ca phi, tr-c khi c du hiu ca XQ phi, qu trnh x phi s gy
ra ri lon thng kh hn ch (gim cc th tch kh ca phi).
+ Tng p lc ng mch phi: o p lc ng mch phi l cn thit trong
cc tr-ng hp XCB . y l bin chng mun v l nguyn nhn t vong.
2.2.6.Tn th-ng tim
+ Du hiu lm sng khng c hiu cho ring XCB l kh th gng
sc, hi hp, tc ngc, tm mi v u chi.
+ Tn thung tim hay gp:
Vim mng ngoi tim c th cp hoc tin trin mn tnh. i vi th
112
mn tnh

113
th-ng khng c triu chng, ch pht hin trn siu m tim C th km
theo trn dch mng ngoi tim vi s l-ng va hoc nhiu.
Bnh c tim trong XCB rt hay gp do ri lon tun hon vi mch ca ng
mch vnh nui d-ng c tim. Do qu trnh x cng mao mch, co tht, hp
mao mch gy gim qu trnh t-i mu ca c tim. Tnh trng ny -c ci thin
khi iu tr bng cc thuc chn Calci nh- Nifdipine.
Ri lon dn truyn t ng gy ra cc ri lon v nhp, bloc nhnh, bloc nh
tht.
2.2.7. Tn th-ng x-ng v khp : Gp t 45% - 90% cc bnh nhn b XCB
h thng tin trin. y i khi l du hiu u tin ca bnh.
+ au, vim nhiu khp i xng, cng khp vo bui sng lm ng-i ta th-ng
ngh
n vim khp dng thp.
+ Th-ng au, vim cc khp t, bn ngn, c tay, khp gi, c th s-ng,
nng, km theo.
+ Vim bao hot dch ti khp au, trn dch khp, thm nhim nhiu t bo
n nhn v lympho.
+ Hn ch vn ng, c cm gic co cng khi vn ng. iu ny i khi cn
do cng da lm nng thm.
+ Trn XQ khp ng-i ta c th quan st thy dy ln ca phn mm quanh
khp, hp khp, long x-ng, hu u x-ng trong khp.
2.2.8.Tn th-ng c
+ Bt u bng au c tng dn ln.
+ Tng cc men c va phi trong huyt thanh nh-ng l du hiu rt c
ngha.
+ Sinh thit c tm thy x ho t chc k, gim -ng knh cc si c, gim
s l-ng mao mch trong t chc c. Tuy nhi n sinh thit c khng phi l
th thut -c khuyn dng v sau sinh thit c hin t-ng chm qu trnh ln
so bnh nhn XCB 2.2.9. Tn th-ng h ni tit
+ Suy tuyn gip hoc c-ng gip c th gp.
+ C khng th khng gip tm thy trong nhng bnh nhn suy gip.
+ Suy tuyn cn gip do x ho tuyn gy ra.
+ Teo tuyn th-ng thn -c m t trong XCB c th do qu trnh iu tr
corticoides ko di hoc do chnh XCB gy ra.
2.2.10. Tn th-ng thn kinh
+ C th gy tn th-ng dy tam thoa vi cc t riu chng: d cm, au, i
xng do tn th-ng 2 nhnh d-i ca dy thn kinh ny. Th-ng khng c
ri lon vn ng.

114
+ C th c tn th-ng h thn kinh trung -ng, ri lon tm thn km theo.
Ng-i ta cng m t n cc du hiu tn th-ng thn kinh ng oi bin. Cc
tn th-ng thn kinh cng nng ln khi c s gim vitamin B12 do qu trnh
km hp thu, calci ho trong tu hoc chn p tu.

115
+ Tn th-ng h thn kinh t ng rt hay gp trong cc tn th-ng d dy
v rut gy ra ri lon v nhu ng ca d dy v rut.
2.3. Xt nghim
2.3.1 Cc khng th khng nhn trong XCB:
Ng-i ta pht hin -c mt s khng th khng nhn nh- : Anti
Histon
etrong XCB , tuy nhin vic xc nh hiu gi trong chn on bnh cn cn
-c nghin cu nhiu.
2.3.2.Cc xt nghim khc
+ Hi chng vim trn xt nghim: tng tc mu lng, tng globuline, tng
Ferritin, tng CRP.
+ Thiu mu, thng th-ng l thiu mu hng cu nh, nh-c sc, i khi c
thiu mu tan mu t min.
+ Sinh thit da: hnh nh tng sinh cc nguyn bo si, cht to keo, dy thnh
mao mch d-i da, tn th-ng lp t bo ni m, hnh nh tc vi mch, thm
nhim cc t bo vim xung quanh mch mu.
2.4. Tin trin v tin l-ng
+ Tin trin ca XCB h thng rt khc nhau v kh nhn thy truc -c. Tin
l-ng chung ph thuc vo s tn th-ng ni tng. Yu t tiu l-ng xu l
mc tn th-ng thn v tim , n cn ph thuc vo s lan to nhanh
chng ca tn th-ng da.
+ Yu t tiu l-ng bnh -c cp nhiu l tn th-ng phi vi FEV1
<70% so vi gi tr l thuyt v cc du hiu xut hin sm ca vim mng
ngoi tim hoc ri lon sc t da ngay ln u khm bnh.
2.5. Chn on phn bit
C nhiu tn th-ng cng da rt gn vi tn th-ng da trong XCB.
2.5.1 Cng da ph nim : bnh him gp, n c mt s c im sau:
+ Lng ng nhiu cc phn t mucopolysacarides lp th-ng b, trung b.
+ Gia tng nhiu nguyn bo si ti t chc d-i da.
+ Nhiu sn c -ng knh 2 3mm da c tay, mt mu tay, cnh tay
v mt.
Th-ng phi hp vi cng da ton th.
+ Chn on da vo sinh thit da.
2.5.2.Teo cng da bm sinh
+ Hi chng Werner: bnh c tnh gia nh. Xut hin teo da th ging

116
XCB, teo c,
c thu tinh th 2 bn, phi hp cc bnh l v ng mch. Trn da c
nhiu vt lot, lon d-ng chn hay phi hp vi long x-ng v i -ng.

117
2.5.3.Cc bnh phi hp
+ Hi chng Gougerot Sjogren: th-ng gp vi t l thp t 1,4 7,8%
nhng bnh nhn , ng-i bnh th-ng c ph i tuyn mang tai, gim
tit dch n-c bt. Ti tuyn c thm nhim cc t bo lympho.
+ Vim da c : Tn th-ng c km vi XCB l rt hay gp. Thng th-ng c tng
men c (CK, CKMP, GOT, GPT ). Trn lm sng c hin t-ng yu c, ri
lon in c, c biu hin vim c khi sinh thit c. i khi cn c biu
hin lm sng ca vim da c.
+ Lupus ban : Trong bnh l ny cng hay gp cc triu chng chung ca
XCB nh-
au c au khp. Tuy nhin khng th khng DNA gp trong Lupus ban
h thng vi tn sut cao hn.
+ Hi chng Shapr: l hi chng bao g m cc du hiu ca hi chng
Raynaud, ngn tay cng, au khp khng bin dng v vim c, trong huyt
thanh xut hin khng th khng nhn ho tan typ anti RNP vi hiu gi
cao, khng th ny t c trong XCB.
3. iu tr XCB ton th

3.1. iu tr ton thn

3.1.1.Khng dng thuc
+ Cai thuc l nhm chn qu trnh tc ng n phi v mch mu.
+ Tp th lc hng ngy c bit tp th th-ng xuyn nhm ci thin thng
kh ca phi.
+ Xoa bp, phc hi chc nng bng cc ph-ng php tm nng, bc paraff ine
nhm phc hi vn ng, trnh co cng c, chng teo c, tng c-ng tun
hon mao mch ni tn th-ng.
3.1.2.Corticoid theo -ng ton thn: nhm mc ch
+ Lm thay i cu trc si to keo.
+ Gim phn ng vim ti da, khp, c v phi.
+ iu tr trong nhng th XCB c km vim a c , vim da c , lupus ban
v trong nhng th nng ca XCB kh- tr.
+ Corticoid khng phi l ph-ng tin ch yu nhm iu tr cc tn th-ng
ni tng nng v gp vo vic quyt nh tin l-ng ca XCB.
+ Liu dng hng ngy 0,5 1mg/kg/24, gim liu sau .
3.1.3. Corticoid ti ch:
M Dermovat hoc Betamethason bi trn da 1 ln/24h trong th tn thung
118
da khng nng v khng qu su.

119
3.1.4. D Pnicillamin l thuc iu tr vim khp dng thp, cng c th
s d ng
iu tr XCB. N c ch qu trnh tng hp cht to keo ca t chc lin kt.
Liu dng hng ngy t 300-600mg. Thi gian c th n 6 thng. Ng-i ta c
th phi hp vi corticoid trong iu tr
XCB. Tc dng khng mong mun hay gp khi dng
D - Pnicillamin l : ri lon tiu ho, gim tiu cu, gim bch cu, lon sn
tu, suy thn, nh-c c v d ng vi cc thnh phn ca thuc.
3.1.5.Methotrexat.
-c s dng vi mc ch c ch sn xut cc cht to keo t cc nguyn bo
si. Ng-i ta nhn thy s ci thin c ngha v mc tn th-ng da,
din tch tn th-ng da, s ci thin nhu ng ca thc qun v hi chng
Raynaud. Ngoi ra thay huyt t-ng phi hp vi cyclophosphamid cng -c
cp n trong iu tr XCB ton th.
3.2. iu tr tu theo mt s tn th-ng
3.2.1. iu tr hi chng Raynaud: ch yu l iu tr tn th-ng mch mu
ngoi vi, ngn chn qu trnh sn xut qu nhiu t chc si v cht to keo.
+ i vi th nh:
Nn trnh tip xc lnh, trnh chn th-ng d gy lot.
Trnh dng cc thuc d gy hi chng Raynaud hoc lm cho n nng ln:
Bta bloquant, casin, nicotin, cocain v cc thuc co mch khc.
V sinh da trnh lot, trnh bi nhim. i vi cc th lot nng c th dng
m khng sinh ti ch. Khi tay b m cn -c lm kh.
Dng m nitroglycrine (Lenitral) trn vng da ngn ti v tr 2 cnh bn ca
ngn ni c ng mch nh i qua nhm lm dn mao mch nh, ci
thin s t-i mu
n ngn
chi.
+ i vi th nng:
c ch knh calci -c dng ph bin v c hiu qu: Nifedipin t 20mg
n 80mg/ngy trong thi gian di. Bin chng hay gp l gim tr-ng lc
c tm v nn gy tro ng-c thc qun, d dy v vy cn phi hp thm
thuc anti H2.
Aspirin -c dng nhm chng ng-ng tp tiu cu.
3.2.2.iu tr khp
+ Gim au, chng vim khng steroid hoc liu thp ca corticoid ( 5-
10mg/ngy).
120
+ Vn ng liu php, vt l tr liu, chnh hnh thay th nu bin dng v
hn ch vn
ng.
3.2.3.Tn th-ng tim
+ Cc thuc chn knh calci lm ci thin r nt s t-i mu cho c tim do gim
co

121
 tht mch mu nh.
+ Cortiroid -c dng trong trn dch hoc nim mng ngoi tim phi hp.
3.2.4.iu tr b my tiu ho
+ iu tr tn th-ng thc qun l ch yu:
Dng thuc khng acid rt c hiu qu trong tn th-ng nim mc thc qun.
n ba nh, nhiu ba
Primpran -c dng trong vic ci thin vn ng thc qun.
3.2.5.iu tr cn co mch thn
y l tn thung cp tnh d gy t vong. C th iu tr bng
propranolon km thm cc thuc chng ng mu. Gim HA bng thuc c ch
men chuyn.
Nhm thuc captopril (Lopril) c hiu qu trong iu tr co mch thn v
tng p
ng mch phi trong XCB.
3.2.6.iu tr cc biu hin phi
Khng c iu tr tht hiu qu cho x phi. Tn th-n g th-ng nng
dn v kh hi phc, trong th nh c th dng D pnicillamin, vi th
nng dng Methotrexat.
Vi cc thuc corticoid, D pnicillamin v cc thuc c ch min dch
ci thin
-c dung tch sng trn thm d chc nng h hp.
Trong tr-ng hp x phi c th dng corticoid 20mg/24h sau
gim liu v 125mg Methotrexat trong 3 thng.

Cu hi t l-ng gi

1. Trnh by tiu chun chn on XCB theo tiu chun chn on ca Hi

khp Hoa k nm 1982.
2. Phn loi XCB v nu r cc d u hiu ca hi chng CREST
3. M t qu trnh ri lon h thng to keo ca t chc lin kt trong bnh
XCB
4. Biu hin tn th-ng mch mu trong XCB l g? Nhng s thay i v
t chc hc ca mch mu.
5. Trnh by thay i ca h min dch trong x cng b .
6. Qu trnh tin trin ca hi chng Raynaud v cch pht hin.
7. M t tn th-ng da v nim mc trong XCB

122
8. Trnh by cc du hiu lm sng ca tn th-ng ni tng trong XCB
9. iu tr v phng bnh XCB
10. iu tr hi chng Rayna ud trong bnh XCB.

123
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