Gio trnh Bnh nhim

86

VIM HNG

BS. Nguyn Vn K

Mc tiu hc tp

1. Nu c cc nguyn nhn, c im lm sng v phng php chn on

vim hng

2. Trnh by c cch x tr, iu tr cc trng hp vim hng

Ni dung

I. NH NGHA

Vim hng l tnh trng vim amidan v/hoc vim hu hng, gy au rt hng t

nhin hoc khi nut thc n, ung nc. y l triu chng thng gp trong bnh

truyn nhim, thng c th gy nhiu bin chng, i khi nng.

II. NGUYN NHN (Bng 1 v 2)

i vi tt c cc la tui, hn 50% trng hp vim hng l do virus.

1. Vim hng -ht

Thng gp nht, do cc nguyn nhn:

Virus: l tc nhn gy bnh thng nht, gm Rhinovirus, Coronavirus,

Adenovirus, Myxovirus influenzae v para-influenzae, RSV, EBV (Epstein-

Barr virus), hoc HIV (him).

- Vi khun: chnh l Lin cu khun nhm A -tn huyt (chim # 15% tt c

trng hp vim hng), him hn l Lin cu khun nhm B, C, F, G,

Neisseria gonorrhoeaes ...

Bng 1: Tc nhn vi sinh gy vim hng

VI

SINH VT

VIM HNG -

HT

VIM HNG

GI MC

VIM HNG

MN NC

VIM HNG

LOT

Virus

Rhinovirus,

Coronavirus,

Adenovirus, M.

influenzae v para-

influenzae, RSV,

EBV, HIV

EBV

Echo, Coxackie

(Enterovirus)

HSV, VZV

Vi khun

Lin cu A -tn

huyt

Lin cu khun B, C,

F, G

C.diphteriae

F. necrophorum

+1 loi Borrelia

T. pallidum

2. Vim hng gi mc

- Virus: EBV l nguyn nhn thng nht gy bnh tng n nhn nhim trng.

- Vi khun: Corynebacterium diphteriae (bch hu).

Gio trnh Bnh nhim

87

3. Vim hng mn nc

- Virus: l tc nhn gy bnh duy nht, gm Herpes simplex (HSV), Virus thu

u-zona (VZV), hoc Enterovirus (Echo, Coxackie virus).

4. Vim hng lot

Vi khun: do kt hp cu vi khun k kh, Fusobacterium necrophorum v

mt xon khun thuc loi Borrelia, hoc do Treponema pallidum (giang

mai).

Bng 2: Nguyn nhn nhim trng cu vim hng cp

VI SINH VT HI CHNG/ BNH T L (%)

Nhim virus:

Rhinovirus (100 types & 1 subtype)

Coronavirus (> 3 types)

Adenovirus (types 3, 4, 7, 14, 21)

HSV (types 1 & 2)

Parainfluenza virus (types 1-4)

Influenza virus (types A & B)

Coxackie virus A

EBV

CMV

HIV-1

Nhim vi khun:

Streptococcus -hemolytic nhm A

Streptococcus -hemolytic nhm C

Vi khun k kh hn hp

Neisseria gonorrhoeae

Corynebacterium diphteriae

Corynebacterium ulcerans

Corynebacterium hemolyticum

Yersinia enterocolitica

Treponema pallidum

Nhim Chlamydia:

Chlamydia pneumoniae

Nhim Mycoplasma:

Mycoplasma pneumoniae

Mycoplasma hominis (type 1)

Khng bit

Cm thng

Cm thng

St vim hngkt mc, bnh h hp

cp

Vim li, ming, hu hng

Cm thng, tc thanh qun

Cm

Vim hng mn nc

Tng n nhn nhim trng

Tng n nhn nhim trng

S nhim HIV

Vim hng/amidan, tinh hng nhit

Vim hng/amidan

Vim li, hng (Vim hng Vincent)

Vim/pxe quanh amidan

Vim hng

Bch hu

Vim hng, bch hu

Vim hng, ban dng tinh hng

Vim hng, vim rut (nongi)

Giang mai k II

Vim phi / ph qun / hng

Vim phi / ph qun / hng

Gy vim hng ngi tnh nguyn

20

5

5

4

2

2

< 1

< 1

< 1

< 1

1530

510

< 1

< 1

< 1

1

< 1

< 1

< 1

< 1

Khng r

Gio trnh Bnh nhim

88

III. LM SNG

Cc triu chng c nng (s mi, ho ...) xy ra nhanh, kt hp au rt hng t

nhin vi nut au, v i khi vi au tai trong bnh cnh st. Cng st thay

i tu theo nguyn nhn. tr em thng c nn ma hoc au bng.

Khm hu hng cho php chn on khi thy cc triu chng vim thay i tu

th:

1. Vim hng -ht

Trong vim hng , hu b vim, ph, nhng khng tit dch r, hai amydale to.

Trong vim hng ht, amidan b ph mt lp trng lm tm, d bc v bao ph

lp nim mc sung huyt. C mt hoc nhiu hch to i km, di gc xng

hm.

Kh phn bit vim hng do lin cu khun vi vim hng do virus:

1.1. Vim hng do lin cu khun: khi pht t ngt, st > 39o C, nut au

d di, hai amydale sng to hoc ht, hch c to i km, au v pht ban

dng tinh hng ban. t s mi v ho (nh vim hng do virus).

C th gy bin chng ti ch nh: vim ty quanh amygdale, pxe thnh sau

hu ...; bin chng ton thn nh: hi chng vim sau khi nhim lin cu (bnh

thp, vim cu thn cp), bin chng nhim c (tinh hng ban, hi chng sc

nhim c).

Hnh 1 . Vim hng do nhim Streptococcus

1.2. Vim hng do virus: khi pht t t, st, hng ph nh v , c ho, s

mi, khan ting (nhng cng c trong 1/4 1/3 vim hng do lin cu khun),

au c, mt mi. Thng ly lan thnh dch.

Vim hng do Adenovirus thng km vim kt mc ( trng hp).

St v vim hng khng xut tit thng thy vi tun sau khi nhim HIV.

Triu chng thng gim sau 3 hoc 4 ngy v a s khi sau 1 tun.

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89

2. Vim hng gi mc

Khm thy mt lp gi mc mu xa c hoc hi xm trn ln trn amydale.

Hnh 2 . Vim hng gi mc

2.1. Tng n nhn nhim trng: xy ra chnh thanh thiu nin. Vim

hng trc tin l ht (rt au), ri pht trin dn thnh gi mc, khng dnh

v thng cha li g, kt hp vi ban xut huyt vm ming. St, c hch

to lan to, gm c hch c sau, mt mi ko di. lch to trong trng hp.

C th gy bin chng: ti ch nh ph n huamydale; ton thn nh thiu

mu tn huyt, xut huyt gim tiu cu, tn thng thn kinh.

2.2. Bch hu hng: gi mc lan rng, xm ln c li g, dnh v khng

bc c. Hch to nm di gc xng hm. C th gy bin chng: ti ch

nh nght th, suy h hp cp, v bin chng do c t nh vim c tim,

tn thng thn kinh.

3. Vim hng mn nc

C nhng mn nc nh, trn nim mc vim hu hng, v nhanh li cc vt

st nh, ph mt lp hi trng v bao quanh bi mt qung vim.

3.1. S nhim herpes: xy ra tr em v thanh nin, vim hng thng kt

hp vi vim liming lan to, gy bin chng vim nomng no hoc hng

ban a dng. c im cu nhim virus Herpes l c nhiu mn nc v cc

vt lot nng trn vm hu.

3.2. Nhim virus Coxsackie A (Herpangina): xy ra tr nh t 1 7 tui,

trong cc v dch ma h. Vi nhng triu chng: st, au c, vim hng hu

v sang thng mn nc trn vm hu, gia li g v amygdale. Din bin

tt trong vi ngy.

3.3. Thu u: nt u (mn nc) mc hu hng, hnh dng nh ngoi

da, khi v thnh vt lot, ng vy.

3.4. Zona hu: mn nc ch mt bn v nm trong vng thn kinh s IX

hoc s V.

Gio trnh Bnh nhim

90

4. Vim hng lot

C vt lot amygdale, i khi lan n vm ming, hoc phn sau hu hng.

4.1. Vim hng Vincent: thng gp nht. Triu chng lm sng gm: st

va, hi th hi, nut au mt bn, khm hng thy mt vt lot su c bao

ph bi mng hi xm, khng dnh, mm khi s v hch to i km. C th gy

bin chng ho m ti ch, vim ty quanh amygdale, tc tnh mch cnh vi

nguy c lp mch nhim trng v nhi mu phi.

Hnh . Vim hng Vincent

4.2. Sng giang mai: mt vt lot nng, t au, cng khi thm khm hu.

Trng hp vim hng lot dai dng, bt tr vi khng sinh liu php, phi tm

mt bnh v mu, bnh khng c bch cu ht, hoc bnh bu tng sinh.

IV. CHN ON

Hi chng lm sng i khi cn c xc nh chn on bng cc xt nghim:

- Cng thc mu: BC > 12.000 /mm3 trong vim hng do lin cu khun.

- Soi, cy pht hng: lin cu khun, trc khun bch hu (cy trn mi trng

Loeffler), Neisseria gonorrhea (c th tm thy trn mi trng Thayer

Martin hoc mi trng thch hp khc), vim hng Vincent c chn on

bng pht nhum Crystal violet, thy nhiu Fusobacteria v xon khun.

- Cy mu: khi nghi ng nhim trng huyt sau vim hng.

- Tests chn on nhanh: Streptococcus A (chuyn bit nhng khng nhy

lm),

- Phn ng huyt thanh: giang mai (VDRL), tng n nhn nhim trng (Paul

Bunnel), nhim HIV (ELISA, Western Blot ...).

V. IU TR

1. iu tr c hiu

1.1. Vim hng do lin cu khun nhm A: dng cc loi penicilline (V,

ampi, ), macrolide (erythromycine, ), hoc cho ung cephalosporine th

Gio trnh Bnh nhim

91

h 1 (cefadroxil, cefaclor, ) trong 10 ngy. Bt u iu tr trong vng 1

tun sau khi khi pht s nga bnh thp v sau (penicilline l thuc duy

nhat chng minh nga c bnh thp).

1.2. Bch hu: dng ngay (c khi nghi ng) SAD v penicilline G trong 14

ngy.

1.3. Vim hng Vincent: dng penicilline V trong 10 ngy. C th dng

penicilline V phi hp vi metronidazole, hoc Clindamycine n c. Khi

d ng vi cc lactamine, thay bng mt metronidazole.

1.4. Sng giang mai: dng penicilline G, hoc cc cycline, erythromycine.

1.5. Vim hng do siu vi (EBV, mn nc, ): amantadine cho sm c hiu

qu i vi virus cm tp A. Acyclovir v foscarnet c gi tr trong iu tr

vim hng do nhim virus nhm Herpes.

2. iu tr triu chng

- Ngh ngi.

- Sc hng vi nc mui m.

- Cho ung thuc gim au, h st: i vi tr em t 612 tui, ibuprofen tt

hn acetaminophen.

TI LIU THAM KHO

1. APPIT. Angines. Dans Maladies Infectieuses et Tropicales, E. Pilly, 17

dition, 2M2, 2000, Chapitre 14 (p. 135 138).

2. APPIT. Infections ORL. Dans LE POPI, 4 dition, Chapitre 22.

3. Jack M. Gwaltney, Jr. Pharyngitis. In Mandell, Douglas and Bennetts

Principles and Practice of Infectious Diseases, 4th edition, 1995, Chapter

40 (pp566571).

4. Marlene durand, Michael Joseph, Ann Sullivian Baker. Infections of the

upper respiratory tract. In Harrisons Principles of Internal Medicine, 14th

edition, 1998, Chapter 30.

Gio trnh Bnh nhim

92

CU HI TRC NGHIM

1. Tc nhn gy vim hng mn nc thng l:

A. Vi khun

B. Virus

C. Rickettsia

D. K sinh trng

E. Tt c a, b, c, d

2. Vim hng lot thng gp nht l:

A. Vim hng do lin cu khun

B. Vim hng Vincent

C. Sng giang mai

D. Vim hng do virus

3. Vi khun chnh gy vim hng ht l:

A. T cu vng

B. No m cu

C. Lin cu khun nhm A tn huyt

D. Ph cu

4. Bnh no c cc c im sau: xy ra chnh thanh thiu nin. Vim hng

trc tin l ht, ri pht trin dn thnh gi mc, khng dnh v thng cha

li g, kt hp vi ban xut huyt vm ming. C hch to lan to, gm c hch

c sau.

A. Vim hng do lin cu khun

B. Vim hng do virus

C. Tng n nhn nhim trng

D. Vim hng Vincent

P N: 1. B 2. B 3. C 4. C