Dị ứng miễn dịch lâm sàng

X d CtfNG BI HE TH6NG TIEN TRIEN t _ I O jNH NG HIA X o c u n g bi he th o n g (X C B H T ) la m ot benh 11/ m ien dich m an tin h , khon g ro can nguyen, d#c tru n g ve lam sang b o i tin h tra n g d a y va c u n g da s y tich luy colagen , lien quan den nhieu he c o quan bao gom ong tieu hoa, tim , phoi, than va m ach m au II chAn an C h in d o an xac djnh a Trieu c h irn g la m s a n g - Da: day c im g da, phu ne, voi hoa, roi loan s lic to da - K h op: vie m k h o p , s u n g , nong, do, bien dang, - K ham dau chi: p h a t hien tim , n h o t hoac hoai tu dau chi (hoi c h u n g R a ynaud) - Phoi: ho khan, ran no, ran am , hpi c h u n g dong dac, - Tim m ach: co th e co tang huyet ap, roi loan nhip tim , tie n g cp m ang tim , cac tieng thoi tim , c£c bieu hien suy tim phai (gan to, tTnh m ach co noi, ) - Tieu hoa: n u o t ngh en, roi loan tieu hoa, hoi c h u n g trao n g u g c - Than: bieu hien vie m cau than, hpi c h u n g than h u (H C T H ), suy than (phu, dai it, dai do, thieu nieu, vo nieu) b Trieu c h irn g ca n la m s a n g - C ong th u c m au: co th e co hong cau (H C ) giam , h e m o g lo b in giam , bach cau (B C ) tang, toe dp I3ng m au tang - D inh lu g n g ure ta ng, cre a tin in tang, kali m au tang tron g tru o n g h g p co suy than - Tong phan tic h n u o c tieu: protein nieu, HC, BC, tru nieu tron g tru o n g h g p co ton th u o n g thSn - D ie n di p ro te in h u ye t thanh: a lbum in giam , g lobulin tang - D o c h u c nang phoi: FVC, F E V - C h up X q u a n g tim phoi, C T scan long n g u c (neu nghi n g d co ton th u o n g phoi ke) - Sieu am D o p p e r m ach chi, m ach than: hep m ach, giam toe dong chay dong m ach, tTnh m ach - D ie n ta m - Noi soi da day - ta trang - K h ang th e khan g nhan (A N A ) d u o n g tin h dac hieu v o i x o c u n g bi c Tieu c h u a n c h a n d o an cu a H o i th ap kh& p h p c H o a K y n a m 1980 - Tieu c h u a n ch in h : + X o c u n g da: day da, c u n g da doi x u n g o ngon tay, goc cac k h o p lien d ot hoa c k h d p dot ban tay T on th u o n g da co th e lien quan den toan bo ban tay, co, n g u c, bung, m at H U O N G d A n c h A n b o A n v A b i £ u t r i b En h 766 Ton thu’O’n g d au c h i xo> c irn g b i N Q i khoa H in h a n h ton th m yn g p h o i k e x o c u n g bi - Tieu chua n phu: + X o c u n g dau chi: ca c ton th u ’o n g da m o ta tren g id i han d ngon tay + Seo lom hoa c m at Idp m o dem dau ngon tay, ngon chan: hau qua cu a t i c m ach hoSc nhoi m au + X o hoa hai day phoi: hin h anh m d dang lu d i hoa c not, h in h to ong h o a c h in h kin h m d d hai day phoi tren phim th a n g hoa c phim C T scan long ngu c * C han doan xac dinh co tieu chuan ch in h hoac £ tieu ch u a n phu C h an d o an phan biet a Viem kh& p d a n g th ap - V iem su n g , nong, dau nhieu kh d p , dac biet la cac k h d p ngon tay, ban n go n tay - C d n g k h d p buoi sang - Y e u to dang th a p (R h e u m a to id facto r) du’o n g tin h d xap xi 80% b en h nhan - C han doan xac dinh co s 4/7 tieu chua n tron g bang tieu chua n ch a n d o a n vie m k h d p dang thap cua Hoi T h a p k h d p hoc H oa Ky nam 1987 b L u p u s b an dd h e th o n g - Ban h inh canh b u d m d m at, dau kh d p , rung toe - X e t ngh iem khan g th e khan g nhan phoi hop, khang d s-D N A d u o n g tin h - C han doan xac djn h co > 4/11 tieu chuan cua Hoi T h a p k h d p hpc H o a Ky nam 1997 c Viem da co, vie m da ccy - D a u c o , yeu c o chu yeu cac c o d goc chi, co the kem th e o cac m a n g ban tim d da - X et ngh iem m en c o tro n g m au tang cao - T h u d n g co n gu yen nhan ac tin h > 50% cac tru d n g hop III l£ U TR| N g u yen t§c d i§ u trj: dieu trj kiem soat benh phoi h o p dieu trj trie u c h u n g P h u xm g p h ap d i§ u trj a C ac th u o c k ie m s o a t b en h - G lu co co rtico id : + M e th ylp re d n iso lo n , p re d n iso lo n hoa c p re d n iso n 1,5 -2 m g /kg /2 g id , g ia m dan lieu 10m g /tu a n va tri d lieu 5- 10m g/ngay + It ta c d un g tro n g kie m so a t benh va nhieu ta c dung phu nen tra n h s u d un g ke o dai H uong d An c h A n o o A n v a e i£ u t r i bEnh N i khoa 767 - C yclo p h o sp h a m id : + C h i dinh: ton th u o n g phoi ke cua x o cu n g bi he th o n g tien trie n (X C B H T T T ) khon g dap u n g v o i cac th u o c khac + Lieu lu g n g : uong 1- m g /kg /2 g io hoac truyen tTnh m ach - tuan m ot lan, m oi lan 500 - 1000m g, giam lieu co suy than T h o i gian dieu tri > thang + T he o doi dieu tri: C T M tuan/Ian, xet nghiem c h u c nang gan than tru o c dieu tri va thang/la n th o i gian dieu tri N g u n g dieu tri neu S LB C < 1.5G /I, TC < 100G/I, HC nieu (+) Bu dich toi da th o i gian dieu tri de tang thai thuoc - C yclo sp o rin A: + C h i dinh: ton th u o n g phoi ke cua XC BHTTT + Lieu lu g n g : - m g /kg /2 gio , uong chia lan tron g > thang + T he o doi d ieu tri: H A hang tuan X et nghiem c h u c nang than tru o c die u trj va thang/lan, m u c loc cau than th a n g /la n tro n g th o i gian dieu tri b D ie u tri trie u ch u ’n g - Hoi c h u n g R a ynaud: + Tranh tie p xu c v o i khoi th u o c la, tranh lanh, g iu am toan bo c o the, dac biet ban ta y va tranh c&c sang chan ta m li + T huoc: th u o c ch e n kenh calci d u o n g uong (dac biet la n ifed ipin) co hieu qua tot nhat Neu khong hieu qua co the d un g th e m ilo prost truye n tTnh m ach, prazosin uong hoa c nitro g lyce rin dan tai cho + Khi co lo et dau chi: dam bao vo trung, tranh boi nhiem vung ton th u o n g P hau thuat loai bo to c h u c hoai tu va c i t cut la n h u n g giai phap cuoi cung - Ton th u o n g da: + Han che t im vi co th e lam kho da + S u dung kem lam am da c h u a lanolin + C o lch icin co th e co hieu qua v o i trieu c h u n g calci hoa d u o i da - Trieu c h u n g c o x u o n g khop : + T h u o c ch o n g vie m khon g steroid (N S A ID s) co hieu qua tron g phan Ion tru o n g hgp + T ru o n g h g p co vie m c o hoac vie m gan - bao hoat djch khong dap u n g v d i N S A ID s co the dung glu co co rtico id lieu th a p (p re d n iso n 10 - 20m g/ngay) Can phoi h g p phuc hoi c h u c nang + Neu g lu c o c o rtic o id khon g hieu qua co the phoi h g p them m e th o tre xa t - Trieu c h u n g tie u hoa: + N h u n g benh nhan co roi loan nhu dong th u c quan nen d u o c an nhieu b u a nho va nam cao dau sau an, tra n h an ve dem C an n h lc dung them cac th u o c khan g acid (n h u cim etidin, om eprazol) + N h u n g tru o n g h g p co tru o n g bung, tieu chay, sut can, giam hap thu roi loan nhu dong ruot non can dieu tri b ln g cac th u o c khang sinh rong n h u trim e th o p rim -s u lfa m e th o x a z o l, m e tro n id a zo l hoac cip rofloxacin m oi d o i tuan C an bo sung vitam in va m uoi khoang -T rie u c h u n g tim phoi: + V iem p h o i ke: g iai d o a n s o m can d u g c d ieu trj b in g g lu c o c o rtic o id va cac th u o c u c che m ien djch (dac b ie t la c y c lo p h o s p h a m id ) T rong giai doan cuoi, to c h u c x o p h a t trie n nhieu, can n h ic vie c g he p phoi + Tang ap d on g m ach phoi d o n thuan: th d oxy lien tuc, s u d un g chon g dong va dieu trj suy tim phai co the cai th ie n to t cac trie u c h u n g C an nha c s u dung ilo p ro st tru ye n tin h m ach 768 H i/< n g d a n c h a n o o A n v A d iE u t r i b £ n h NO i khoa + C a c bieu hien tran dich m ang tim , suy tim , roi loan nhip tim d ieu tri tu o n g t u n h u n g bieu hien n£y tron g cac benh li khac - T on th u o n g than: + D ung th u o c lo i tie u neu co suy than + Neu co suy than nang khon g dap u n g Igi tieu can can n h ic loc m au s d m hoSc lien he g he p thgn + Khi co cao huye t ap can dieu tri ap b ln g cac th u o c chen kenh calci, ire che a n g io te n sin II hoSc u c che m en ch u ye n (neu khon g co hep dong m ach than ho a c suy th a n nang) TAl LIEU TH AM KHAO D en to n C.P (2006) “S yste m ic scle ro sis: clin ica l fe a tu re s a n d m a n a g e m e n t” M e d ic in e 34 11, pp -4 8 F u rst D E., P o p e J., C le m e n ts P., O ttaw a M eth o d s G ro u p (2004) "S yste m ic scle ro sis E vid e n ce -b a se d R h eum ato logy Edit by P eter T ug w ell and B e ve rle y S hea B M J P u b lish in g G roup, pp 4 - 494 A n to n y T.H Lin, Ph ilip J C lem en ts, D aniel E F urst (2003) “ U p date on dise a se -m o d ifyin g an tirh e u m a tic dru g s in the trea tm ent o f syste m ic s c le r o s is R heum D is C lin N A m 29, pp - 426 S a p a d in A N , F le is c h m a je r R (2 0 ) “ T re a tm e n t o f S c le ro d e rm a " A rc h D e rm a to l 138, pp 99 - 105 V alentini G , B lack C (2002) “ S ystem ic scle ro sis” Best P ractice & R e search C linical R h eum ato logy 16, 5, pp 807- 816 S u b c o m m itte e fo r S c le ro d e rm a C rite ria o f th e A m e ric a n R h e u m a tis m A s s o c ia tio n D iag n o stic and T h e p e u tic C rite ria C o m m itte e (1980) "P re lim in a ry crite ria fo r the c la s s ific a tio n o f s y ste m ic s c le ro sis (s c le ro d e rm a )” A rth ritis R heum 3:581 - 90 DI UNGTHUOC I DjNH NGHlA Di u n g th u o c (dru g a llergy) la phan u n g qua m ire, bat thu’d n g , co hai cho c o the n g u d i benh dung hoac tiep xuc v d i th u o c (co s u ket h g p di nguyen v d i khang the hoac yeu to tu o n g d u o n g ), da co giai doan m an cam Di u n g th u o c khong phu thuoc vao lieu lu g n g thuoc, co tin h m an cam cheo, v d i m pt so trieu c h u n g va hoi c h u n g lam sang nhat dinh, th u d n g co bieu hien ngoai da va rat ng u a Neu dung lai thuoc hoac ho hang v d i no thi phan u n g di u n g se xay nang h o n va co the t u vong II PHAN BIET Dj U N G TH U O C VQ I M T SO PHAN UN G CO HAI KHAC DO THUO C - Dac u n g thuoc (idiosyncrasy): la tinh trang m ot ca the nhay cam bat th u d n g , dac biet va bat n g d vdi m ot loai thuoc nao v d i lieu lu g n g rat thap so vg i lieu dieu tri, gap d m ot so it n g u d i, khong lien quan den tac dung d u g c li quen biet V i du: tinh trang thieu m au phenyltoin hay suy x u o n g chloram phenicol, - K hong d un g nap th u o c (intole ran ce): day la phan u n g kich liet, dac biet cua c o the doi v d i m ot loai thuoc v d i lieu b in h th u d n g , co khuynh h u d n g di truye n Trieu c h u n g lam sang giong ngo doc thuoc chi xay rieng biet tre n m ot so it n g u d i, benh khong phat trien m anh h o n hay nguy hiem h o n dung lai chinh th u o c V i du: uong m ot vai giot thuoc atropin co the lam gian d on g tir hoa c huye t ap, hay ngu keo dai 16 g id sau uong vien th u o c khang histam in - D oc tinh cua th u o c (drug toxicity): xay d bat ki n g u d i nao hoac nhieu n g u d i cung dung m ot khoi lu g n g thuoc kha Idn hoac vd i lieu thap n g u d i benh gia yeu, suy giam c h u c nang m ot so c o quan (gan, th a n , ) hoac thuoc co doc tinh cao V i du: chlorprom azin lieu cao se lam huyet ap va co the tu vong - Tac dung phu cua th u o c (side effect): la ta c dong khong m ong m uon thuoc, co the doan tru d c d u g c v d i m ot loai th u o c nhat djnh, ngoai tac dung trj lieu chinh V i du: atro p in gay kho m ieng aspirin va thuoc chon g vie m khon g stero id gay loet da day, - Tac dung th u p h a t cua th u o c (seco n d a ry effect): bieu hien lam sang giong se xay tren nhu’ng n g u d i cung dung m ot loai th u o c nao lieu cao, keo dai V i du: hoi c h u n g gia C ushing sau dung co rtico id ho a c loan khuan, nhiem nam , thieu vitam in sau dung khan g sinh, III B|£U HIEN LAM SANG D| UN G TH UO C (Xem bang) B a n g : B ie u h ie n la m s a n g d i ir n g th u o c Vi tri Bieu hien lam sang Toanthan Soc phln ve, huyet ap, sot, viem mach, sung hach, benh huyet May day, phu Quincke, san ngura, viem da tiep xuc, man cam anh sang, da toan than, hong ban nhiem sic co dinh, hoi chung Stevens-Johnson, hoi chirng Lyell Kho thd, viem phe nang Da Phoi Gan Viem gan, ton thuong te bao gan Tim Viem co tim Than Viem cau than, hoi chirng than hu Mau Ban xuat huyet giam tieu ciu, thieu mau tan huyet, giam bach cau hat 770 H ucJng dA n c h A n o o A n vA o i f u t r i bEnh NO i khoa IV M Q T S HQI CHU’NG LAM SANG Dj 1>NG THUO C M ay day La bieu hien hay gap va thu’d n g la bieu hien ban dau cua ca c tru ’d n g h g p di d n g th u o c khac xuat hien va bien m at nhanh T on th u ’o n g c o ban la san phu rat n g d a M ay day ca p < tuan, m an £ tuan P h il Q u in c k e X u a t hien sau d un g th u o c vai phut hoac vai gid , cham h o n so v d i m ay day, bieu hien tro n g da va to c h d c du’d i da co td n g dam s u n g ne, du’d n g kinh td - cm , th u ’d n g x u a t hien d n h d n g vu n g da co to c h d c long leo: m oi, co, q ua nh m at, bung, bo phan sinh due, th a n h qua n, ruot, da day, nao, td cung Phu Q u in c ke thu’d n g khon g sot, khong ng d a , m au da it th a y doi S c phan ve Lam sang cua soc phan ve kha da dang, thu’d n g xay c h o p nh o a n g sau d un g th u o c td vai giay den 20 -3 phut, k h d i dau b ln g cam giac la thu’d n g (bon chon, hoa ng hot, so’ chet, ) S au la s y xuat hien nhanh ca c trie u c h d n g d m ot hoac nhieu c o quan n h u tim m ach, ho hap, tieu hoa, da, vd i n h u n g bieu hien n h u n g d a ran k h lp n g u d i, dau quan bung, dai tieu tie n kho n g t u chu, m ach nhanh, nho, huyet ap tut hoa c khon g d u g c , kho th d T he toi cap n g u d i benh hon m e, ng h e t th d , roi loan tim m ach, n g u n g tim va tu vong sau it phut C h d n g m it bach c iu hat S ot cao d o t ngot, s d c khoe giam sut nhanh, loet hoai tu niem m ac m at, m ieng , hpng, c o q ua n sinh due; vie m phoi, vie m t i c tin h m ach, nhiem khuan huyet, de dan td i t u vong B enh h u y lt th an h Do tie m huye t th a n h hoa c cac protein di the, xuat hien tu nga y th d den nga y th d 14 sau dung thuoc B enh nhan m et m oi, chan an, m at ngu, buon non, dau k h d p , s u n g nhieu hach, sot cao 38°C 39°C , co the vie m gan, vie m than, co the co m ay day toan than V iem da dj d n g t il p xuc T h u d n g xay sau it g id tie p xuc v d i thuoc, n g u d i benh th a y n g d a d u dpi, noi ban do, m un nu d e , phu ne cac vung da hd, vu n g tie p xuc v d i thuoc D o da to an than D o da toan than la tin h tran g da dien rong hoac to a n th a n n h u to m luoc, g o m giai dean: da va bong vay trln g H o ng ban nut Sau m ot vai nga y dung th uoc, benh nhan sot cao, dau m oi to a n th an, x u a t hien n hieu nut to nho noi len m at da, nhan do, an dau vi tri d g iu a tru n g bi va bi, ta p tru n g nhieu d m a t d uo i cua cac chi doi xu a t hien tre n than m in h va m at T o n th u o n g ch uye n m au giong bam m au va lui dan sau m ot vai tuan H n g ban n h iim s i c c dinh B enh xu a t hien sau vai g id ho a c vai sau dung thuoc N g u d i b e n h sot nhe, m e t m oi tre n da xu a t hien nhieu ban luc dau do, sau m au sam , d m oi, td chi, th a n m in h B e nh se xuat hien d ch in h vi tri neu n h d n g lan sau lai d un g th u o c hoa c cac th u o c g iong no H u o n g d An c h An o o An v A ei£u tri b£nh N oi k h o a 771 10 H dng ban da dang Sau dung thuoc, ngu-oi benh thu’d n g m et m oi, sot va xuat hien nhieu dang ton th u o n g da: ban do, s in , m un n u o c , bong n u o c , th u d n g co ban hinh bia b ln , tien trien cap tin h toan than 11 Hoi chu’ng S te v e n s - J o h n so n D a c tru n g cua hpi c h u n g la loet cac hoc tu nhien (tren hoc hay gap d m it va m ieng) va co nhieu dang ton th u o n g da: bong n u d e , dien tich da ton th u o n g < % dien tich da c o the, co the kem theo ton th u o n g gan than, the nang co the gay tu vong 12 Hoi ch u ’ng Lyell La tin h tra n g nhiem d o c hoai tu da nghiem nhat dac tru n g b d i d iu hieu N ikolsky d u o n g tin h (de tupt da), ti le tu vong cao Benh nhan qua m et m oi, sot cao, tren da x u it hien cac m ang hoSc c h im x u it huyet, sau Idp th u o n g bi tach khoi da, khe dong td i la tro t tu n g m ang D ien tich da ton th u o n g > 30% da c o the, co the vie m gan, than, tin h trang n g u d i benh th u d n g r i t nang, nhanh dan td i tu vong v chAn ooAn Dj Cp n g thu Oc - C o qua trin h d un g thuoc - Phan u n g di u n g xay sau dung thuoc - C o cac trieu c h u n g , hpi c h u n g cua di u n g th u o c (n g u a la d iu hieu q ua n trpng) - Tien s u di u n g (tien s u di u n g th u o c hoac di u n g ca nhan, gia dinh) - X et ngh iem (XN ): co m pt XN (+) trd len th e o the lam sang hoa c loai phan u n g (phan u n g tho£t hat (d e g n u la tio n ) te bao m ast, tieu bach cau dac hieu, test chuye n dang lym ph o bao, RAST, ) VI D I^U TR| O i§u trj s o c phan ve P hac c ip c u u soc phan ve (the o thong tu 08 -5 -1 9 cua B o Y te) a X lp tri n g a y ta i cho - N g u n g nga y tie p xuc v d i dj ngu yen (thu oc dang tiem , uong, boi, nho m it, m ui) - C ho benh nhan n im tai cho - D ung thuoc: a d re n a lin la th u o c c o ban de chong soc phan vp + A d re n a lin d un g djch 1/1.000, ong 1m l = 1mg, tiem d u d i da nga y sau x u it hien soc phan ve v d i lieu n h u sau: 1/2 -1 ong d n g u d i Idn Khong qua 0,3m l d tre em (ong 1m l (1m g) + 9m l n u d e c i t = 10m l sau tiem 0,1 m l/kg ) H o ac a d re n a lin 0,0 m g /kg cho ca tre em lan n g u d i Idn + Tiep tu c tie m a d re n a lin lieu n h u tren 10-15 phu t/lan cho den huye t ap trd lai b inh th u d n g - U im , d iu t h ip , ch a n cao, th e o doi huye t ap 10-15 phu t/lan ( n im ngh ieng neu co non) Neu soc q u a nang de doa tu vong, ngoai d u d n g tiem d u d i da co th e tie m adre n a lin dung djch / 0 0 (pha lo ang / ) q u a tin h m ach, b o m qua ong noi quan hoa c tie m qua m ang nhan giap b C ac b ie n p h a p k h a c T uy th e o dieu kien tra n g th ie t bi y te va trin h dp ch uye n m on k i th u a t cua tu n g tu ye n co the ap dgng c&c bien phap sau: - X u tri suy ho h ip : tu y th e o tu ye n c a s d va m u c kho th d co th e s u dung cac bien phap sau day: + T h d oxy m ui, thoi ngat 772 H U d N G D A N C H A N O O A N V A B l f U TR| B E N H NOl KHOA + Bop bong am bu co oxy + D a t ong noi quan, th o n g nhan tao M d quan neu co phu th a n h m on + Truyen tin h m ach ch a m d ia p h yllin m g /k g /g id hoa c te rb u ta lin ,2 ^g /k g /p h u t C o th e dung: + T erbutalin 0,5m g (1m l), ong du’d i da d ngu’d i Idn va 0,2 m l/1 kg d tre em Tiem lai sau -8 g id neu khong d d kho th d + X it hong te rb u ta lin , sa lb u ta m o l m oi lan 4-5 nhat bop, -5 lan tro n g - T h ie t lap m ot du’d n g tru ye n tTnh m ach: adre n a lin de tri huye t ap b i t dau ,1 p g /kg /p h u t, dieu chinh toe th e o huyet ap (2m g a d re n a lin /g id cho ngu’d i Idn 55kg) - C a c th u o c khac: + M e th ylp re d n iso lo n - m g /kg /4 g id hoac hydro co rtiso n h e m is u ccin a t m g /k g /g id tie m tin h m ach (co th e tiem bap d tu ye n c a sd ) D ung lieu cao h a n neu soc nang (gap 2-5 lan) - NaCI 0,9% 1-2 lit d ngu’d i Idn, khon g qua 10m l/kg d tre em - D ip h e n h yd m in 25m g hoa c d im ed rol 10m g x ong, tie m b ip hay tin h m ach c D ie u tri p h o i h g p - U ong than hoat 1g/kg can nang neu di nguyen qua du’d n g tieu hoa - B ang ep chi p h ia tren ch o tiem (neu di nguyen theo du’d n g tiem ) - C hu y: + T h e o doi benh nhan it nhat 24 g id sau huye t ap da on dinh + Sau s a c im nen tan dung du’d n g tiem tin h m ach dui + N eu huyet ap van khon g len sau truye n du dich va a d re n a lin , thi co th e tru ye n th e m huyet tu’a n g , a lb u m in (hoSc m au neu m at m au) hoSc bat ki dung dich cao phan tu* san co + D ie u du’d n g vie n co the dung adre n a lin du’d i da theo pha c y, bac s i khon g co mSt M ot sd th e lam san g dj lm g th u d c M ay day, phu Q u incke, benh huye t thanh, da toan than, cac loai hong b a n , ): hai loai th u o c ch inh dieu tri: -G lu c o c o rtic o id (m e th yl-p re d n iso lo n , dep erso lon , M edrol, ce le sto n , d e xa m e th a so n , p re d n is o lo n ), lieu dung phu th u o c va o th e lam sang va loai thuoc + T he nhe, vi du: uong p re d n iso lo n 5m g x - v ie n /n g a y x - n ga y ho a c M e d ro l 16m g x vien/ x -5 + T he nang, vi du: d e p e rso lo n 30m g hoa c m e th yl-p re d n iso lo n (S o lu -M e d ro l) m g x - lo/ng ay x - Sau dung th u o c uong: p re dnisolon 5m g x - v ie n /n g a y x - nga y ho a c M e d ro l 15m g x vie n /n g a y x 3-5 - K hang sinh hista m in H i: ch lo p h e n ira m in , p he nergan, h e xo fe n a d in (T elfast), ce tirizin (C ezil Z yrte c), lo ratadin (C la rityn e ), d e slo ta d in (A erius), le vo ce ctirizim (X yzal) + The nhe, vi du: c h lo p h e n ira m in 4m g x v ie n /n g a y x - ng a y h oa c T elfa st 180m g, uong vie n / x - + N ang: d im e d ro l 10m g, tiem b ip - ong x - Sau d un g uong: c h lo p h e n ira m in m g x v ie n /n g a y hoa c d e s lo ta d in (A e rius), le vo ce ctirizim (X yzal) 5m g, lo ta d in (C la rityn e ), ce tirizin (C ezil, Z yrte c) 10m g x1 v ie n /n g a y x - H u o n g dA n c h A n d o A n vA o ifu t r i b£nh NOi 773 khoa Hoi chu’ng S te v e n s - J o h n so n va Lyell a B o i p h u n u a c , d ien giai, dinh d u a n g , ch o n g n h iem tru n g (g io n g d ieu trj bon g) - Boi phu n u d e , dien giai: dung dich glucose 5% 500ml - 2000ml/ngay hoa c dung dich NaCI 0.9%: truyen tin h m ach 3-5 co the dua vao tien trien lam sang va lu’O’ng n u d e tieu de dieu chinh lu a n g dich truyen D u a va o dien giai de boi phu cac chat dien giai - C hong nhiem trung: + Tai cho: th a y vai trai g iu d n g hang V e sinh cac hoc tu nhien th u d n g xuyen Boi dung dich C a stellan i va o n h u n g vung da bi loet tra t G lycerin borat: boi m oi C h i tra hydro co rtiso n vao m it neu khong loet giac m ac, th o n g th u d n g hay tra dung dich C B 2-4 lan + Toan than: dung khan g sinh, neu co dieu kien thi dung khang sinh it co ngu y c a di u n g d u a vao phan u n g phan huy te bao m ast hoac tieu bach cau dac hieu Thong th u d n g hay dung khang sinh ho m acrolid (it gay di u n g ) - D inh d u d n g : neu c h u a lo et tro t d u d n g tieu hoa, can cho an sup du so lu a n g va chat lu a n g (giau protein va vitam in ) N eu co loet tro t d u d n g tieu hoa: cung cap nang lu a n g q u a d u d n g tTnh m ach Can thiet co the tru ye n dam , m d cho n g u d i benh b D ie u trj d j u n g th u o c - G lu co co rtico id : m e th yl-p re d n iso lo n (S o lu-M edrol 40m g) hoa c d e p e rso lo n 30m g x 2-4 Ip/ngay, tiem tTnh m ach 3-5 nga y dau, sau giam lieu b ln g th u o c uong P re dn isolon 5m g x -8 vie n /n g a y x 3-5 hoac M edrol 16m g x v ie n /n g a y x 3-5 C uoi cung pre d n iso lo n 5m g x 2-4 vie n /n g a y x 3-5 hoac M edrol 16m g x v ie n /n g a y x 3-5 Neu co ton th u a n g nao, tim m ach, co the dung g lu co co rtico id th e o p h u a n g phap lieu cao, n g ln ("pulse th e p y ” hoa c “ b o lu s”): m e th yl-p re d n iso lo n 500-1 OOOmg: pha dich truye n dung dich NaCI 0,9% 25 m l (h o a c d un g dich g lucose 5% 250m l), truye n tTnh m ach X X X g io t/p h u t x ngay, sau giam lieu (uong) - K hang h ista m in Hi: d im e d ro l 10m g x 2-4 ong/ngay Tiem b ip 3-5 nga y dau, sau co the dung uong C h lo p h e n ira m in 4m g x vie n /n g a y hoac d e slo ta d in (A erius), le vo ce ctirizim (X yzal) 5m g, loratadin (C la rityn e ), ce tirizin (C ezil, Z yrtec) 10m g, uong vie n /n g a y x 3-5 VII BIEN PHAP HAN CH S D| 1>NG THUO C VA SPV - Tuyen tru ye n vie c s u dung th u o c h a p li, an toan dung ch i dinh - T ru d c ke d a n th uoc, n g u d i thay th u o c phai khai thac kT tien s u di u n g cua n g u d i benh O' n g u d i benh co tien s u di u n g v d i thuoc, th u c an, rat d§ bi dj u n g dung th uoc Phai d u phong S P V doi v d i n h u n g benh nhan m an cam , can n h ic ve lieu lu a n g , d u d n g dung va toe h ip phu cua thuoc dung dieu tri va c h in doan Khi m ot benh nhan da co tien s u soc phan ve v d i m ot th u o c nao du nhe cung phai co g in g tran h dung lai, can hieu ro cac phan u n g ch e o g iu a cac loai thuoc - T ru d c tie m khan g sinh (penicillin , stre p to m ycin ) phai th u te st lay da, te st am tin h m d i d u a c tiem Phai c h u in bi san th u o c va dung cu c lp c u u SPV - Khi dang tie m th uoc, neu t h iy co n h u n g cam giac khac th u d n g (bon chon, hot hoang, phai n g u n g tie m va kjp th d i x u li n h u soc phan ve) - Sau tie m th u o c de n g u d i benh c h d 10-15 phut de de p ho ng S P V xay m uon han - Npi dung hop th u o c c ip c u u soc phan ve: + A d re n a lin : 1m g - 1ml: ong sa hSi, ) 774 H t f C J N G D A N C H A N o o A n V A O l £ u TRI B f N H NOl KHOA + Nu’O’C cat: 10ml: ong + B o m kim tiem vo khuan: 10m l; cai, 1ml: cai + H yd ro co rtiso n h e m is u ccin a t 100m g hoac m eth yl pre d n iso lo n (S o lu M e d ro l m g hoa c d e p e rso lo n 30m g: ong) + C on, bong, bang gac vo trun g + D ay garo + P hac cap ci>u SPV t A i l ie u t h a m k h A o N g u yen V a n D o a n (1996) "G op p h a n ng h ie n c iru di u n g th u o c ta i kh o a D i irn g - M D LS , B e nh vie n B a ch M a i (1 991-199 5)" Luan an tien khoa hpc Y -D iro c F oster, C o rey; M istry, N e ville F.; P eddi, P arvin F.; S h a rm a , S h iv a k (2010) 'A lle rg y and Im m u n o lo g y ” in W ash in g to n M a n u a l o f M e d ic a l Therapeutics, C o p y rig h t L ip p in c o tt W illia m s & W ilkins The, 33rd E dition ( ) p.350-370 Fritsch P.O., R am on R u iz- M ald o n ad o (2003) “E rythem a M ultiform e, S te ve n s- Jo h n so n S yndrom e a n d Toxic E p id e rm a l N ecrolysis" Fitzpatrick s D e rm atolog y in G e n e l M e d icin e (Vol I): p543- 558 G ru ch alla R.S (2003) “D ru g allergy" J A lle rg y clin im m unol (Vol 111, No 2): p - 559 H o c k e tt K.C (2 004) “S teven s- John son S yndrom e a n d Toxic E p id e m ia l N e crolysis: O ncologic considerations" C lin J O ncol N urs (Vol , No 1): p27-30 O Joh n M a, D avid M C lin e (2007), 'A n a p h yla xis a n d acute a lle rg ic reactions", E m ergency M edicine M anual, th Edition S e ct.2, C opyright, T he M cG raw -H ill C o m pa nies S h ep h erd G M , M D (2003) “H yp e rse n sitivity R e actions to D rugs: E va lu a tio n M a n a g e m e n t' The M ount Sinai Journal o f M edicine (Vol 70, No 2): p113-25 784 H lt O n g d A n c h A n d o A n v A o i £ u t r i b £ n h N O i k h o a thuoc can qua ng), th u c an (hai san, tru n g , su a , lac, ), noc tru n g (kien, ong), long sue vat (chb, m eo), cac yeu to vat li (n h u nong, lanh, anh n in g ), hoa chat, Phu Q u in c k e thucrng xuat hien tron g vong vai phut den vai g io sau tie p xuc v o i di nguyen gay benh, m ot so it tru o n g h o p co the xuat hien toi cap tron g vong vai giay - Khai thac tien s u di u n g cua benh nhan va gia d inh n g u o i b en h cu n g th u d n g p h a t hien d u o c cac benh di u n g khac di kem n h u cham , vie m m ui di ung , viem ket m ac di u n g , hen phe quan, D ac diem can lam sang - Test lay da v d i cac dj nguyen co the cho ket qua d u o n g tin h v d i n h u n g di n g u ye n m a n g u d i benh m an cam - X e t nghiem dinh lu o n g IgE dac hieu v d i cac di ngu yen nghi n g d co th e xac d inh d u o c ch in h xac loai di ngu yen m a n g u d i benh m an cam - C ac xet ngh iem m au va n u d e tieu thong th u d n g it co bien doi d cac b en h n n phu Q uincke C h an d o an xac dm h C hu yeu d u a va o cac bieu hien lam sang va hoi tien s u benh, lu u y m oi lien q u a n g iu a s u xuat hien cua phu Q u in c ke v d i tien s u tiep xuc cac yeu to la C h an doan phan biet - V iem m o te bao: th u d n g bieu hien s u n g , nong, do, dau tai vu n g ton th u o n g , kem th e o co sot cao, the tran g n h iim trung - Phu suy tim : xu a t hien tu tu , kem th e o cac bieu hien kh a c cu a suy tim n h u gan to, tin h m ach co noi, kho th d g an g s u e va n im , t iin s u co m ic cac b en h tim m ach - Phu bach huyet: phu c u n g , khon g n g u a , chi co cam g ia c dau tu c , ta p tru n g d hai chi d u d i, xu a t hien tu tu , gap d n h u n g n g u d i co tien s u loi ruong th u d n g xuyen - Phu benh than: x u it hien tu tu tre n n h u n g benh nhan co tie n s u b en h th a n , phu tra n g , phu m em, i n lom, xet nghiem c h u c nang than co bien loan - V iem t i c tTnh m ach: tai vung ton th u o n g th u d n g co ca m gia c dau tu c , da co m au tim do, co the co dam hoai tu , sieu am D o p p le r m ach co the p h a t hien ch o vie m t i c tin h m ach - V iem da co : th u d n g co noi ban d m at va than m inh, dau yeu c o , s o t ke o dai, xe t n g h ie m co t§ng m en cre a tim in kin ase (C K) III D l£ u TR! D ieu trj phu m ach co> c h i dj u n g a D ie u trj d ac h ie u - T ranh tie p xuc hoa c loai bo cac yeu to da d u o c biet gay b en h h o a c lam nang benh: n g u n g dung thuoc, th u c an, ch u ye n cho d , doi nghe, tra n h nong, lanh, anh n in g m a t trd i, - C an n h ic dieu tri g iam m an cam dac hieu neu khon g t h i loai bo d u o c di n g u ye n gay benh b D ie u trj trieu c h tin g C a c nhom th u o c chu yeu de kiem soat trieu c h u n g gom : a d re n a lin (e p in e p h rin ), cac th u o c khan g histam in va g lu co co rtico id -A d re n a lin : + C hi dinh cho t i t ca cac tru d n g h o p phu Q u in cke c o che di u n g co phu ne d u d n g ho h a c hoac tut huyet ap H u O n g d A n c h A n d o A n v A p i £ u tr i b £ n h 785 NOI khoa + Lieu dung: ,3 - , m g tiem b ip , nhac lai sau 15 - 20 p h u t neu can, tru’d n g h o p nang n h lc lai sau - phut N eu khon g d a p u n g , tiem TM - 5m l dung dich a d re n a lin 1/1 0 0 hoa c b o m qua m ang n h in g iap hoa c noi kh i quan C o the pha loang ong a d re n a lin 1m g v d i 3m l dung djch m uoi sinh li de d un g tro n g ca c tru’d n g h o p co phu ne du’d n g ho h ip tren - T h u o c khan g h ista m in H i: + C h i djnh: tro n g t i t ca cac tru ’d n g h o p phu Q u in c ke c ip va m an tin h c o che di dng + Lieu lu’o n g , cach dun g: xe m bang B a n g C a c th u o c k h a n g h is ta m in H1 tro n g d ie u tri p h u m a c h d i irn g Thuoc Lieu lugng cach dung Yeu cau giam lieu Chlorpheniramin NL:4mgx3-4 lan/ngay TE: 0,35mg/kg/24 gia Khong Diphenhydramin NL: 25-50mg x 3-4 lan/ngay TE: 5mg/kg/24 gid Suy gan Doxepin NL: 25-50mg x lan/ngay Suy gan Hydroxyzin NL: 25-50mg x lan/ngay TE: 2mg/kg/24 gio Suygan Ketotifen NL: 2mg x lan/ngay TE > tuoi: 1mg x lan/ngay Khong The he ( it h o a c k h d n g g a y Acrivastin NL: 8mg x lan/ngay Khong buo n n g u ) Cetirizin NL va TE > tuoi: 5-10mg x lan/ngay TE < tuoi: 5mg/ngay Suy gan, suy than Desloratadin NL: 5mg x lan/ngay Suy gan, suy than Ebastin NL: 10-20mgx lan/ngay Suy gan, suy than Fexofenadin NL: 60mg x lan/ngay hoac 180mg x lan/ngay Suythan Levocetirizin NL:5mgx1 lan/ngay Suy gan, suy th§n Loratadin NL va TE > 30kg: lOmgx lan/ngay TE < 30kg: 5mg/ngay Suygan Mizolastin NL: lOmg x lan/ngay Suythan The h e (g d y b u o n n g u ) * NL: n g u d i Id n ; TE: tre em - G lu co co rtico id : + C h i djnh: tro n g ca c tru ’d n g h o p phu m ach cap va m an tin h de g ia m trie u c h d n g va d u phong trieu c h d n g tai lai + Lieu lu g n g , ca ch dung: nen dung lieu trun g binh, m p t d o t n g in nga y de han che ta c dgng phy Co the d un g p re d n is o n hoa c p re d n iso lo n h oa c m e th ylp re d n iso lo n uong 40 - m g /n g a y (d ngu’d i Idn) hoac m g /k g /n g a y (d tre e m ) tro n g -7 - C a c bie n p h a p dieu tri ho tro khac: - D a t noi kh i q u a n hoa c m d kh i q ua n neu tin h tran g phu ne d u d n g ho h ip gay de doa tin h m ang n g u d i benh va kh o n g dap u n g v d i th u o c d o n thuan c C a c c h i s o c an th eo d d i - T in h tra n g lam sang 786 H u C n g dAn chA n b o A n v A oi£u t r i bEnh NO i khoa - C ong thu’c m au (ti le BC toan) - Toe m au lang - N ong khan g th e IgE dac hieu (neu co the) d T a i k h a m - Phu m ach cap tin h : sau 3-5 - Phu m ach m an tinh: sau 2- tuan TAl LIEU TH A M KHAO P o w ell R J., Du Toit G L., S id d iq u N., et al “B S A C I g u id e lin e s fo r the m a n a g e m e n t o f chronic u rtica ria a n d a n g io o e d e m a " C lin E xp A lle rg y 2007, 37, p -6 K ap lan A P A n g io o e d e m a W orld A lle rg y O rg a n iza tio n Ju n e 200 8, p 103-113 F erd m an R M "U rtica ria a n d A n g io e d e m a " C lin Ped E m erg M ed 20 , 8, p 72-80 F rig as E., P a rk M A "A cute U rticaha a n d A n g io e d e m a D ia g n o s tic a n d T re a tm e n t C o n side ratio ns" A m J C lin D e rm a to l 2009; 10 (4), p 239-250 T e m in o V.M , P e e b le s R S “ The S p ectrum a n d T reatm e nt o f A n g io e d e m a " A m J M ed 200 8, 121, 4, p 282 -28 VIEM MACH DI• tfNG • I DINH NG HIA V iem m ach di u n g (S ch o n le in - H enoch) la m ot benh li vie m m ach he th o n g khong ro can nguyen, co ton thu’a n g ca c m ach nho lin g dong p h u c h a p m ien dich IgA, lien quan chu yeu den da, than, ruot va khap II chAn O OAN C h a n d o a n x a c d jn h a B ieu h ie n la m s a n g - V iem m ach S ch o n le in - H enoch thu’a n g bieu hien v a i trieu chu’ng kinh dien la noi ban xuat huyet, dau kh a p , dau bung va ton thu’a n g than - Ban xu a t huyet: g a p a hau het cac benh nhan, h a i noi g a tren m at da, an kin h khong m at m au, khong ng u a , kho n g dau, co the co hoai tu va bong nu’a c tron g m ot so it tru’a n g h a p (th u a n g gap a n g u a i tru’a n g th a n h ) O' n g u a i la n va tre la n tuoi, ban th u a n g tap trun g a vung th a p cua tay va chan (dau hieu di ung), n h u n g a tre nho, ban th u a n g tap trun g a lu n g , m ong va dui C a c ban xuat huyet th u a n g da h in h thai, co the dang cham not hoac lien ket v a i th a n h m ang, dam , ton tai 5-10 ngay, nhat dan m au va m a t di khong de lai di c h u n g C ac ban xuat hu ye t m a i co th e lien tu c xuat hien 4-8 tuan - O au k h a p /v ie m k h a p : gap a 50 - 80% benh nhan, chu yeu a k h a p goi va co chan, keo dai 3-7 ngay, khong doi x u n g va khon g gay bien dang khap - O au bung: xay a h a n 50% so benh nhan, th u a n g dau quan tu n g c a n , chu yeu a vung quanh ron va th u a n g vj, gay xuat huye t a phu c m ac va m ac treo B ieu hien dau bung th u a n g xuat hien vong tu a n sau noi ban xuat huyet, co the kem th e o buon non, non, tieu chay va dai tien m au hoac phan den - Ton th u a n g than: xay a 40 - 50% so benh nhan, th u a n g bieu hien vie m cau than m u c nhe va hau het cac tru a n g h a p deu hoi phuc hoan toan M ot so it tru a n g h a p co the bieu hien vie m cau than tien trien nhanh, hoi c h u n g th a n h u hoa c viem cau than m an dan den suy than m an Ton th u a n g thgn tron g vie m m ach S ch o n le in - H e noch th u a n g xu a t hien sau k h a i pha t benh - tuan hay gap a n h u n g benh nhan co xuat huye t tieu hoa va ban xuat huye t dai d in g keo dai qua thang, rat it gSp a tre d u a i tuoi V ie m cau than m an va suy than giai doan cu o i tro n g vie m m ach S ch o n le in - H enoch th u a n g gap a n g u a i tru a n g thanh, it gap h a n a tre em - C ac bieu hien th u a n g gap kh a c tron g vie m m ach S ch o n le in - H e n o ch la sot nhe, m et m oi, dau n h u c b ip chan va s u n g ne hai c ln g chan N g oai ra, chay m au cam , long ruot, x u lt h u ye t phoi, tinh hoan, nao, nhoi m au nao, co giat cung la n h u n g bieu hien hiem co the gap tro n g vie m m ach S ch o n le in - H enoch b B ie u h ie n can la m sa n g - Tang so lu o n g bach cau da nhan trun g tinh - So lu a n g tieu cau va cac xet ngh iem dong cam m au b in h th u a n g - T a n g nong CRP 788 H u O n g dA n c h A n o o A n vA oi£u t r i bEnh N oi k h o a - X e t nghiem n u ’O’C tie u co protein nieu, hong cau nieu va tru hong cau d n h u n g benh nhan co ton thu’o n g cau than - T an g nong IgA tro n g m au - M o benh hoc: m iu sin h th ie t da hoac than co hinh anh hoai tu d an g fib rin cua th a n h m a ch m au, phu ne te bao noi m o th a n h m ach va xam nhap bach cau da nhan tru n g tin h N h uom m ien dich huyn h q ua ng m o sinh th ie t co tin h tran g lang dong IgA va bo the c Tieu c h u a n c h a n d o an Tieu chua n cua Lien d oa n phong chon g benh k h d p chau A u (2 ) ch a n d oa n xac d inh vie m m ach S ch onle in - H e noch co ban xuat huyet dang cham not noi g d tren m a t da va it nhat m ot tro n g cac tieu chua n sau day: - D a u bung lan toa - Sinh thiet ton thu’a n g da va m ach m au co lin g dong IgA - V iem k h d p (cap, bat ki k h d p nao) hoac dau khdp - T on th u ’a n g than (hong cau nieu hoa c protein nieu) C h a n d o a n p h a n b ie t Khi khong co du cac tieu chua n chan doan xac dinh benh, th e o bieu hien lam sang, can phan biet v d i m ot so benh li sau: - C ac ngu yen nhan dau bung ngoai khoa: co the co phan d n g th a n h bun g, cam d n g p hu c m ac, khong co cac bieu hien tre n da va k h d p cua vie m m ach di dng - N hiem trun g nao m o cau: sot, the tran g nhiem trung, ban xuat hu ye t da h in h thai, khon g co tin h chat phan bo d vung th a p nhu' tro n g vie m m ach di dng - T h a p tim : sot, khon g co ton th u 'a n g da dac tru>ng cua vie m m ach di d n g , kh a m lam sang va sieu am tim co bieu hien ton th u a n g van tim va c a tim , tang nong C R P m au - X u a t h u ye t g ia m tie u ca u vo can: ban xu a t hu ye t da h in h th a i, th u d n g d a n g m a n g , co th e phan bo to a n th an, th u d n g kem th e o xu a t h u ye t niem m ac va noi ta n g n h u c h a y m a u ch a n rang tie u hoa, rong huye t, - Lup us ban he thong: sot keo dai, ban canh b u d m , dau k h d p , rung toe, vie m lo et m ieng , - P han u'ng thuoc: ban xu a t huyet xu a t hien sau dung th u o c, th u d n g co n g u a , co th e kem th e o ton th u a n g niem m ac ca c hoc tu nhien n h u m ieng, m it, - V iem kh d p dang thap: sot keo dai, s u n g dau k h d p doi x u n g , co bien d an g k h d p , th u d n g kho n g co dau bung va khong co ban x u lt huyet ngoai da - V ie m noi tam m ac n hiem k h u ln : sot cao, bieu hien n hiem tru n g , ton th u a n g van tim tre n lam sang va sieu am tim ill e i £ u TRj N g u y e n ta c d ie u trj - K h ong co dieu tri dac hieu - P h u o 'n g phap dieu tri chu yeu: chon g viem + dieu tri trie u c h u n g P h u a n g p h a p d ie u tr i a C a c b ien p h a p d ie u tri b ao ton D u a c ch i dm h ch o t i t ca cac benh nhan N h u n g tru d n g h o p ch i co ban chi c in dieu tri b ln g cac bien phap nay: - N g h i n g a i tai g iu d n g tron g do1 c lp - V ita m in C lieu cao (1 -2 g /n g a y uong hoac tiem tin h m ach) - Bu dich x u it huyet d a n th u a n co the H u O n g d An c h An o o A n v A o i £u tri b £n h N O i k h o a 789 b D ie u tri c h o n g viem • T h u o c cho n g vie m khong steroid (N S A ID s): - D an xuat: n ap roxe n, diclofena c, ibuprofen, - C hi dinh: cac tru’d n g ho’p ch i co ban xuat huyet va dau kh o p d o n thuan D ung m ot d o i - hoac den trie u c h u n g on dinh - Lieu lu’ong : + N a proxen: n g u o i Ion va tre em > 12 tuoi: 200 - 500m g x - lan m oi ngay, toi da 1500m g/ngay Tre em > tuoi: m g/kg x lan m oi G iam lieu tron g suy gan + D iclofenac: 50 - 75m g uong lan/ngay; khong uong cung s u a va tron g bOa an + Ibuprofen: n g u o i Ion: 20 -8 0 m g uong - lan m oi (toi da ,4g/ngay) Tre em: 30 - m g / kg/ngay chia - lan (toi da m g/kg/ngay) - Han che s u dung benh nhan co xuat huye t tieu hoa hoac suy than hoa c suy gan nang • G lu co co rtico id (pre dniso n, prednisolon, m eth ylp re d n iso lo n , ): - C hi dinh: tro n g cac tru o n g h o p co dau bung, ton th u o n g than, dau k h o p va ban xuat huyet khong dap u n g v o i cac th u o c ch o n g vie m khong steroid d o n thuan hoac v o i cac bieu hien nang va hiem gap cua benh n h u ton th u o n g than kinh, ton th u o n g phoi, D ung s o m g lu co co rtico id d n h u n g benh nhan ch u a co ton th u o n g th a n co the han che d u o c s u xu a t hien cua cac ton th u o n g qua trin h tien trien cua benh - Lieu dung: k h o i dau 1m g/kg/ngay, giam dan lieu, th o i gian s u dung th u o c vao dap u n g cua n g u d i benh, d a c biet ton th u o n g than T h d i gian dieu trj m oi d o t khong nen keo dai qua thang - T he o doi ta c dung phu: huyet ap, m at x u o n g , d u d n g m au, nong calci m au, cortisol m au, test AC TH , cac trieu c h u n g vie m loet da day - ta trang, [1], • C ac th u o c u c che m ien djch (U C M D ): - Dan xuat: a za th io p rin , cyclo p h o sp h a m id , cyclo sporin, - C hi djnh: d un g phoi h o p v d i glu co co rtico id benh nhan co ton th u o n g than khong dap u n g v d i glu co co rtico id d o n thuan, dac biet la hoi c h u n g than h u va vie m cau than tien trien nhanh [3, 4], - Lieu dung: + A za th io p rin : uong m g /kg /2 g id - thang + C yclo p h o sp h a m id : uong - 2m g /kg /2 g id tron g - tuan + C yclospo rin: - m g /kg /2 g id , uong chia lan - thang - T he o doi d o c tinh: + A zathioprin: cong th u c m au (C TM ) va c h u c nang gan tru d c dieu trj va lan/tuan thang dau, sau - lan/thang N g u n g thuoc neu so lu o n g bach cau (S LB C ) < 1.5G /L, TC < 100G /L, HC nieu (+) + C yclo p h o sp h a m id : C T M la n/tuan tron g th d i gian dieu trj, xet n gh iem (X N ) c h u c nang gan than tru d c dieu trj va th a n g /la n N g u n g dieu trj neu S LB C < 1.5G /L, TC < 100G /L, HC nieu (+) Bu > 200 0m l n u d c /2 gid + C yclospo rin: H A hang tuan, XN c h u c nang than tru d c dieu trj va th a n g /la n , m u c b e cau than thang/lan • C ac p h u o n g phap dieu trj khac: m ot so p h u o n g p p dieu trj sau day co the d u o c s u dung d n h u n g benh nhan co ton th u o n g noi tang nang khong dap u n g v d i cac th u o c dieu trj tren: - C o rticoid lieu cao: m e th ylp re d n iso lo n (pulse th e p y) 0 m g /n g a y tro n g ngay, s u dung d nhu’ng benh nhan co hoi c h u n g than h u khon g dap u n g v d i co rtico id lieu th o n g th u d n g - Im m u n o g lo b u lin tin h m ach lieu cao - Loc huye t tu o n g - G hep than c D ie u t r j trie u c h ir n g : [2,3] - Suy than: d un g th u o c Igi tieu, an nhat, han che djch H u O n g d A n c h A n o o A n v a o i Eu t r i b e n h N o i k h o a 790 - D a u bung: dung th u o c giam dau, an than - X u at huye t tieu hoa: th u o c d c che tie t dich vi (o m e p zo l, cim e tid in , nitid in), th u o c cam m au (transam in , ) va boc niem m ac da day Han che toi da vie c s ir dung g lu c o c o rtic o id va cac th u o c chon g vie m khong steroid - D a u kh d p : dung cac th u o c chon g vie m giam dau toan th a n hoa c tai cho T h e o d o i d ie u trj a Cctc c h i so can th eo d d i - H uyet ap - S y xu a t hien cac trie u c h d n g lam sang: ban xuat huye t ngoai da, dau k h d p , dau bung, non m au, di ngoai phan den - Toe lin g m au - Tong phan tic h nu’d c tieu: hong cau nieu, protein nieu - X et ngh iem c h d c nang than ure, creatinin, kali m au - N ong IgA tron g m au (neu co the) b T h a i g ia n tai k h a m - N eu khon g co ton th u ’o n g than: th e o doi th a n g /la n tron g thang - N eu co ton thu’o n g than: th e o doi th ang/la n cho den on dinh XN nu’d c tie u va c h d c nang than B a n g L ira ch o n d ieu trj tro n g viem m a c h S c h o n le in - H e n o c h Lua chon dieu tri Bieu hien DTbao ton NSAID Corticoid uong ngan Corticoid TM C orticoid lie u cao C orticoid + l/CMD Gan huyet tuo ng BanXH 3cm thuan X Ban XH+ dau khop X Ban XH +sung ne cang chan X X Dau bung nang X X Dau bung + non X Ton thuong tinh hoan X Hoi chung than hir X VCTtien trien nhanh X X X Xuat huyet phoi X X X X X X X X * VCT: vi6m c iu th$n; DT: d iiu tri: NSAID : thudc chdng viem khdng steroid: TM: tinh m ach; WCMD: u c c h i m iin dich TAl L ie u THAM KHAO W e is s P.F., F e in s te in J A , L u a n X., e t al “E ffe c ts o f C o rtic o s te ro id on H e n o c h - S ch o n le in P u rp u : A S ys te m a tic R eview " P e d ia trics 2007, 120; p 107 -1 R o b e rts P.F., W a lle r T.A , B rin k e r T.M., e t al “H e n o c h - S ch o n le in P u rp u : A R e v ie w A rtic le ' S o uth ern M e d ica l Jo u rn a l 2007, 100; ; p 821-24 R e am y B.V., W illia m s P.M “H enoch-S chonleln P u rp u " A m Fam P hysician 2009, 80(7), p.6S7-704 G o n z a le z L.M , J a n n ig e r C K , S c h w a rtz R A P e d ia tric H e n o c h - S ch o n le in pu rp u , n te m a tio n a l Jo u rn a l o f D e rm a to lo g y 2009, 48, p 1157-1165 O zen S., P is to rio A , lu s a n S.M , e t al 'E U L A R /P R IN T O /P R E S criteria fo r H e n o c h -S c h o n le m purpura, c h ild h o o d p o lya rte ritis nodosa, ch ild h o o d W e g e n e r g n u lo m a to s is a n d c h ild h o o d Takayasu artentis: A n ka 2008 P a rt II: F in a l cla ssifica tio n criteria" A n n R h eum D is 2010, 69, p 798-8C VIEM G A N T l/M ilN I.O A I CIFCTNG Bieu hien benh chu yeu la tin h trang tang a m in o tra n sfe se m au va co hin h anh m o hoc viem quanh khoang cu a B enh tien trien v o i ton thu’o n g hoai tu b lc cau, nhieu thuy va tien trien den x o gan Neu khong du’o c dieu tri vie m gan tu m ien (V G T M ) co ti le tu vong cao (50% benh nhan V G T M m u’c nang chet vong nam ) C han doan V G T M chu yeu la loai tru cac ngu yen nhan khac cua viem gan hoac dang uong ru o u rat nhieu D a c diem quan cua V G T M la hay gap o n u (ti le n u /n a m la 4/1), tang g a m m aglobulin va hien dien tron g m au tu khang the II SINH LY BENH C h u a tim can n gu yen gay benh C o nhieu yeu to d u o c d u a d u a tre n nen tang benh li m ien dich Cac yeu to di truye n, virus, hoa chat, horm on co the la can nguyen cua benh III TRIEU CHU’NG LA M SANG V G T M co th e g a p a m oi lu a tuoi va o ca hai g io i, tuoi hay gap - tuoi H o i b e n h G ay sut, m et m oi, dau tu c s u o n phai K h a m la m s a n g C o the th a y va n g m it, vang da, gan to, lach to, co tru o n g G iai doan nSng h o n co bieu hien hon m e tang ure m au X e t n g h ie m m a u C o the thay tang g a m m a g lo b u lin e B ilirubin > 3m g/dL, p h o sp h a ta se kie m > lan, A S T > 1000U /L C&c xet n gh iem m ien dich dinh lu o n g tu khang the giup chan doan xac dinh cung n h u phan loai the viem gan: khan g th e khan g tieu vi the gan than typ (LK M -1 ), khan g th e khan g tu o n g bao gan typ (LC -1), khang th e khan g thu the g lyco p ro te in tren m ang te bao gan n g u o i chau A (A S G P R ), khang the khang ty lap th e (A M A -M ), khan g the khang c o tro n (S M A ), khan g the khan g tu o n g bao bach cau da nhan trung tin h (A N C A ), khan g th e khan g KN g a n /g a n -tu y hoa tan (anti S L A /LP ) V G TM co th e ket h o p v o i n h u n g benh sau: - V iem tuyen giap tu’ m ien, benh Basedow - V iem loet dai tra n g m an tinh - X o c u n g bi, vie m k h o p dang thap - V ie m m ach, hong ban nut -T a n m au (C o o m b s +), xuat hu ye t giam tieu cau vo can 792 IV H i/O n g d A n c h A n o o A n v A o i £ u t r i b E n h NOi khoa c h An d o a n v a pha n lo C h an doan Do khong co tieu chua n “vang " chan doan V G T M , nen chan d oa n chu yeu b ln g p h iro n g phap loai tri> cac ngu yen nhan gay vie m gan m an khac Sau day la tie u ch u a n chan doan cua nho m nghien ci>u V G T M the g io i dipa nam 1999 (bang 1) B a n g Tinh d iem chan d o a n V G TM Danh sach Yeu to Diem Globulin hoac immunoglobulin G tren rmifc binh thudng >2,0 1,5-2,0 1,0-1,5 60 g/ngay +2 -2 Danh sach Yeu to Diem Gidi m +2 Men gan Tl le phosphatase kiem (ALP)/ aspartat aminotransferase (hoac alanin aminotransferase) 3,0 +2 -2 Hieu gia khang the khang nhan, SMA, hoac LKM1 >1:80 1:80 1:40 < 1:40 Cacti; khang the khac +1 + -5 -3 -3 +2 G hi chu: Tdng d iim A > 15 hoSc > cho c h in d o in x ic dinh VGTM trv v c hoSc sau d iiu tri, tuxyng im g MSt khdc d iim giua 10-15 v i 12-17 cho c h in d o in cd t h i xay ho$c tru d c sau tri h€u tuo ng u n g AM A (k h in g t h i k h in g ti th i), LKM-1 (k h in g t h i k h in g t iiu vi t h i gan-th$n), SMA (k h in g t h i k h in g c o tron) P h an loai (bang 2) B a n g P h an lo a i V G TM Lam s a n g -x e t nghiem Typ Typ i Typ Ti/khang the SMA, ANA Anti-actin Anti-LKM P450IID6 SLA/LP Tuoi 10-20 va 45-70 2-14 30-50 Nu" (%) 78 89 90 Benh ty mien kem theo (%) 41 34 58 Cac tir khang the khac Anti-actin, Anti-SLA Anti-ASGPR, pANCA Khang the khang-LC1 Khangthekhang-ASGPR AMA, SMA ANA, Anti-ASGPR y-globulin tang Trung binh-nhieu Nhe Trung binh HlfO NG d An ch An oo A n VA p i Eu tri b En h NQ 793 i khoa B a n g (T iep) Lam s a n g -x e t nghiem Typ Typ Typ Immunoglobulin A J Khong Co the Khong HLA B8, DR3, DR4 B14, DR3, C4AQ0 Khong ro 0^p Ung corticosteroid Rat tot Trung binh Rat tot Tien trien xagan 45% 82% 75% V chAn ooAn PH AN BIET - X a du’a n g m a t tie n phat: lam sang, sinh hoa, m o benh hpc nhu* vie m gan tu m ien nhu’ng thu’a n g ket h a p v a i vie m loet dai tra n g m an tinh C han doan qua chup du’a n g m at va sinh th ie t gan v a i hinh anh tham nhiem te bao lym p h o cyte va x a du’a n g m at - V iem du’a n g m a t tu m ien: tang sp h a ta se kiem , y-g lu ta m yltra n sp e p tid a se , tra n sam inase M o benh hpc co hin h anh ton th u ’a n g khoang cu a , tham nhiem lym ph o bao, tu a n g bao va vie m d u a n g m at Phan biet v a i x a d u a n g m at tron g gan tien phat khong co khan g the khan g A M A va khang p yruvat d e h yd ro g e n a se KT: anti A N A va SM A D a p u n g co rticosteroid - V iem gan virus: vie m gan A, B, C th u a n g co tang tra n sa m in a se , bilirub in, y-globulin, IgG va sp h a ta se kie m ca o h a n V G T M va hinh anh m o benh hpc la hoai tu n hieu phan thuy gan tron g a viem gan tu m ien chu yeu la ton th u a n g viem te bao gan ngoai co ket h a p v a i benh khac (viem tuyen giap, vie m lo e t dai tran g m an tinh, ) cung yeu to H L A -D R 4, H LA B , A1, khang the khang SM A, khang A N A th u a n g gap h a n (92% so v a i 22% ) cac khan g th e tre n co hieu gia thap viem gan virus - V iem gan m an tin h can ngu yen an: th u a n g co khang the khan g S M A , khan g LK M H in h anh m o benh hpc dien h in h n h u V G T M C o yeu to H L A -B , H L A -D R 3, H L A - A l- B - D R D a p u n g v a i thuoc corticoid VI TlSN TRIEN V A TIEN LU’O’NG C ac ch i so tien lu a n g d u a vao: X e t n g h ie m sin h hoa den kham - A S T > 10 lan c h i so bin h th u a n g : 50% tu vong sau nam -A S T > lan c h i so b in h th u a n g + G G T > lan ch i so b in h th u a n g ; 90% t u vo n g sau 10 nam - A S T < 10 lan c h i so b in h th u a n g + G G T < lan chi so bin h th u a n g ; % x a gan sau 15 nam ; 10% tu vong sau nam M o b en h h pc den kham - H oai t u kh o a n g cu a : 17% x a gan sau nam - H oai tu' b lc cau: 82% x a gan sau nam ; 45% tir vong sau nam - X a gan: 58% t u vo n g sau nam vu b i£ u t r ! C h i djn h dieu trj: phu th u o c m u c hoat dong cua benh (xem b an g 3) 794 H u O n g d a n c h A n d o A n vA d i£ u t r i b£ n h NOi k h o a B a n g C h i dinh d ieu tri V G TM Tuyet doi Tucrng doi - AST > 10 lan chi so binh thudng hoac - AST > lan chi so binh thudng va y-globulin > lan chi so binh thudng vdi -Mo hpc: hoai tir lan toa -Trieu chUng (met mdi, dau co, vang da) - AST va/hoac y-globulin < - Ton thuong chu yeu quanh khoang cua • P hac dieu tri v a i n g u a i la n Tan cong: dieu tri tan cong keo dai it nhat thang Hai loai th u o c ch in h d u a c s u dung la co rtico id s (p re d n iso n ) va azathiprin B a n g D ieu tri tan c d n g Prednisolon don thuan (mg/ngay) Prednisolon (mg/ngay) Azathioprine (mg/ngay) Tuan 60 30 50 Tuan 40 20 50 Tuan 30 15 50 Tuan 30 15 50 Duy tri 20 10 50 Thdi gian Prednisolon phoi hop azathioprine B a n g The k h o n g dap Ceng Prednisolon dem thuan (m g/ngay) Prednisolon phoi hap azathioprine Prednisolon (m g/ngay) A za th io p rin e (m g/ngay) 60x thang 30x1 thang 150x thang 20 10 50 - C ach giam lieu: + Lieu p p phoi hap : giam pre d n iso lo n m g/th ang va a z a th io p rin m g /th a n g + P re dn isolon d a n th u a n 10m g/thang - Lieu tri benh da on djnh keo dai 12-18 thang + Lieu phap phoi hap : p re d n iso lo n 10m g/ngay, a za th io p rin 50m g/ngay + P re d n iso lo n d a n thuan: 20m g/ngay C ac th u o c khac D u a c chi djnh benh nhan khan g hoac co chon g chi djnh v a i cac th u o c tren C a c th u o c co the chi djnh tron g cac tru a n g h a p gom : - M yco p h e n o la t m ofetil - In te rfe ro n -a - C yclospo rin - FK -506 -A c id u rso d e o xych o lic - P o lyu n sa tu re d p h o sp h a tid ylch o lin - A rgim n th ia z o lid in e c a rb o x y la t - Tinh chat h o rm on tu ye n uc H u O n g dAn chA n b o A n va oi£u t r i bEnh NO i 795 khoa T h e o d o i d i§ u tr j (xem bang ) B a n g Theo d o i x e t n g h iem tro n g d ieu tri VG TM Test Truac dieu trj Trong dieu trj (4 tuan) Sau dieu trj Thuyen giam tuan X4 thang Kham lam sang + + + + + Sinh thiet gan + - + - - Cong thUcmau + + + + + Men aminotransferase + + + + + Bilirubin + + + + + Dong mau + + + + + Tukhangthe + +/- + +/- +/- ChUc nang tuyen giap + +/- + +/- +/- VIII TOM TA T V G TM la benh gan m an tin h dac tru'ng b a i tin h trang vie m te bao gan m a can nguyen chu’a ro Benh co yeu to di tru ye n v a i benh canh lam sang da dang V G T M chia typ C han doan chu yeu d y a vao m o benh hpc, ta n g g a m m a g lo b u lin m au, co t y khang the dac hieu va chan doan loai tri> cac nguyen nhan viem gan khac D ie u tri chu yeu bang p re d nisone d a n thuan hoa c phoi h p p a za thioprin M M F co vai tro quan trp n g tro n g tru ’a n g h a p khang dieu tri thong thu’a n g gBH gBM EIISSiem m aaiiBM ESSge ^ TAl Lieu TH A M KHAO F e ld m a n , F rie d m a n , S le is e n g e r S le is e n g e r & F o r d tra n ’s G a s tr o in te s tin a l a n d L iv e r D is e a s e , P a th o p h y s io lo g y , D ia g n o s is , M a n a g e m e n t 7th Edition C h a p te r 75 A u to im m u n e H epatitis C za ja , A lb e r t J “C u rre n t C o n ce p ts in A u to im m u n e H e patitis" A n n a ls o f H e p a to lo g y 2005: 4(1): Ja n u a ry-M a rch : 6-24 C za ja , A lb e r t J “T reatm e nt C h a lle n g e s a n d In v e s tig a tio n a l O p p o rtu n itie s in A u to im m u n e H epatitis" H e p a to lo g y 2005: 41: 207-215 VIEM DA DI tfNG I O Al C U O N G V iem da di u n g bao gom viem da atopi va viem da di u n g tiep xuc D a y la nhu’ng bieu hien ton th u a n g da tren m ot benh nhan co c a dia di u n g dac tru n g b a i n h u n g dau hieu lam sang cua hien tu a n g qua m an tu c thi v a i s u co m at cua IgE hoac hien tu a n g qua m an m uon v a i s u tham gia cua te bao T dac hieu II CH AN O OAN V iem da atopi va vie m da di u n g tiep xuc deu co qua trin h tien trien lam sang qua giai doan: - G iai doan da: n g u a nhieu, ban rai rac va phu la p th u a n g bi - G iai doan h inh th a n h cac bong n u a c - G iai doan ri n u a c va boi nhiem gay ton th u a n g choc la - G iai doan dong vay: tien trien lau dai va hinh m ang liken hoa V iem da atopi a Tieu c h u a n ch a n d o a n T h e o tieu chua n chan doan cua W illia m s (2000) -T ie u chu a n ch in h : ng u a - Tieu chua n phu: kem them trieu c h u n g cac trieu c h u n g sau day: + Tien s u co benh li da a cac nep lln da + C o tien s u ban than benh hen phe quan va viem m ui dj ung + K ho da tro n g th a i gian tru a c + C o ton th u a n g ch a m hoa a cac nep gap + B enh b i t dau tru a c tuoi P h u a n g p p chan d oa n d u a c d a n gian h a n va de ap dung b N g u y e n n h a n cu a viem da a to p i - K ich u n g b a i cac di n gu yen qua da - P han u n g tie p xuc v a i di nguyen ho hap, d u a n g an, uong - Do ap lu c, anh sang va cac yeu to vat li khac V iem da dj u n g tiep xuc - La benh li th e o c a che di u n g m uon gay phan u n g vie m tai n a i tie p xuc v a i di nguyen + Tien trien qua giai doan n h u da noi a tren + N g uyen nhan: th u a n g tiep xuc v a i cac vat, san ph a m co m a b in g niken, hoa chat, dung hang M ot s p h u a n g p h ap chan doan dac hieu - Test lay da (P rick test) - P han u n g th o a t hat te bao m a st hoac tieu bach cau dac hieu n h im p h a t hien khan g the hoac khan g ngu yen dac hieu th o n g qua m u c v a cua cac te bao tren Hl fCJ NG d A n c h A n d o A n v A p i E u t r i bEnh N O i k h o a 797 - Test ap la kT th u a t d a n gian, de lam, an toan va cho ket qua ch in h xac - D in h lu’a n g IgE toan phan va IgE dac hieu v a i di nguyen III t i£ n t r i£ n v a b i£ n c h u n g Tien trien - T rong th a i gian dau tien trien th a n h tu n g d o t, co c a n cap va cung co d o t th u ye n giam - T rong th a i g ian sau: tien trien m an tin h la phan la n - Y eu to tien lu a n g xau ch o vie m da atopi a n g u a i la n la: + Benh b i t dau s a m (tru a c nam tuoi) + M u c ton th u a n g da sau sinh (1 thang tuoi dau tien) + Tien s u ban th a n va gia d in h ve dj ung + S u phoi h a p v a i cac benh di u n g khac n h u hen phe quan, vie m m ui d| ung + Boi nhiem da va ch a t lu a n g cham soc da Bi6n c h u n g cua viem da atopi va viem da dj u n g tiep xuc a N h ie m vi k h u a n - N h iim tu cau va n g tai cac vung da ton th u a n g dap va , ri n u a c - Dau hieu lam sang th e hien phan u n g viem ram ro tren da, tay do, dau, m un n u a c co djch due, mu Hach ngoai vi to va dau S o t co the co ton th u a n g nhiem khua n lan rong b N h ie m viru s Ton th u a n g g o m n hieu bong n u a c , dau, rat, dich hoa c due, co nhieu cho hoai tu IV l£ u TR! C h ong viem - C orticoid tai ch o (tru ca c ton th u a n g co boi nhiem ) hieu qua dieu trj to t tron g nhieu tru a n g hap , an toan va khon g co tai bien toan than cho benh nhan K hong dung tren m at vi gay teo da, xam da kho phuc hoi + Kem m o m e ta s o n (E lo m e t) typ 5g, 15g, 20g Boi da den la n /n g a y tro n g tuan + Kem E u m o va te (clo b e ta s o n ) 0,05% typ 5g Boi toi da la n /n g a y u u tie n cho cham va vie m da dj un g d a n thuan + Kem D e rm ovat 0,05% typ 15g boi lan/ngay tuan danh cho cac liken p h ln g va kho da nhieu + Kem Loca to p ,1 % typ 30g boi la n/n gay u u tien cho vie m da di u n g tie p xuc co ri n u a c C h ong boi n hiem - C ham soc da sach bang cac dung djch sat trun g tai cho C yte a l (1 th ia sup pha tro n g lit n u a c dung tam cho n h u n g vu n g ton th u o 'n g T am n u a c khoang, nong la p h u a n g p p d u o 'c kh uye n dung - Kem B e tn o va t 0,1% boi la n /n g a y tron g tuan dieu trj - M a T ride rm typ 5g, 15g boi la n /n g a y tron g tuan ke ca boi n hiem nam - M a B ivid e rm typ 5g boi la n /n g a y tron g tuan u u tien boi nh ie m tu cau D ieu trj kho da - D ay la giai doan dieu trj can thiet K ho da lam tang tin h tra n g ngu'a, n u t ne da se tao loi vao cho vi khuan cung n h u dj nguyen Ben v u n g la p m a d u a i da se g iu n u a c va han che tac dong tu ben ngoai S u dung cac dung djch lam m em da giau chat beo bao ve da: + Kem B rid ge H eel Balm typ 30g, 75g boi la n/n gay m oi d o t tuan + K em A d e rm a skin care cream typ 50m l xoa la n /n g a y u u tien cho tre nho va s o sinh + Kem A d e rm a - E xo m eg a typ 20 m l xoa la n /n g a y bao ve va d u a n g I m da - D ieu trj deu dan hang co d o t cap cung n h u on djnh se ph u c hoi va cai thien cau true da H U O N G D A N C H A n o o A n V A D | £ u TRI B f N H N O l K H O A 798 D ieu trj khac C ac th u o c khan g hista m in d u a c s u dung nhieu co tac dung giam p n u n g d| irn g va giam n g u a giup cho vie c cai th ie n tin h tra n g to a n than: - D e slo ta d in (A erius): + N g u a i la n va tre em (TE ) > tuoi: 5m g x vien/ngay + TE -1 tuoi siro m l/n g a y (2,5 m g/nga y) + TE - tuoi siro ,5 m l/n g a y (1 ,25m g/ngay) - Loratadin (C la rityne ): - N g u a i la n va TE > 12 tuoi: 5m g/1 vien/ngay + TE - tuoi, > 30kg 10m l/nga y hay th ia ca phe + TE < 30kg m l/n g a y hay th ia ca phe - M a E u rax 10% boi lan/ngay - M a p h e n e rg a n 2% typ 10g boi lan/ngay D ieu trj th e nang - C o rticoid: dung d u a n g toan than tron g m ot so tru a n g h a p v a i lieu d un g 0,5-1 m g /kg /2 g ia roi giam lieu va th e o doi cac ta c dung phu neu co - C yclo sp o rin : d u a n g uong v a i lieu b i t dau - 5m g /kg /2 gia Sau g ia m lieu dan, th u a n g dung dieu trj cho n g u a i la n va can co y kien cac bac s i ch uye n khoa - P co to p ic (T accolim us) 0,03% - boi da la n/n gay tron g tu a n (1 d o t) V PHONG BENH - G iao due cho benh nhan, cha m e benh nhan ve c a che, cac h inh th a i ton th u a n g , m u c do, nguyen nhan gay benh, qua trin h tien trie n m an tin h , s u phoi h a p co th e co v a i m o t so b en h khac, can th e o doi va kien tri dieu tri cua benh nhan - Ket qua te st ap, te st lay da va ket qua chan doan tron g p ho ng th i n g h ie m se la n h u n g th o n g tin can th ie t cho benh nhan biet - T ho ng bao d an h sach m ot so san pham , di ngu yen th u a n g gay b en h de b en h nhan biet cach phong tran h tiep xuc - N g u a i co vie m da di u n g tie p xuc can d u a c th e o doi va quan li de p ho ng tra n h tie p xuc lai b in g moi cach nhat la tai n a i lam viec N eu khong d u a c thi can s u dung cac bien p p bao ho lao dong tfe han che den m u c th a p nhat s u tie p xuc v a i di nguyen - P hat hien va dieu tri cac benh di u n g kem th e o n h u hen, vie m m ui di u n g va dieu tri cac o nhiem trung ve rang, tai m ui hong T A l L IE U T H A M k h A o B o u s q u e t J., D u tau G , G rim fe ld A., Y ves de P ro s t (2000), “ D e la d e rm ite a to p iq u e a /' a s th m e ', e xp a n sio n s c ie n tifiq u e F rancaise, p29-65 K e lso JM *A d m in is tra tio n o f in flu e n za va ccin e s to p a tie n t w ith e g g a l l e r g y J.A IIe rg y.C lin Im m u n o l 2010; 125: p800-2 R anceF "A llergie a lim e n ta ire a I'o e u fd e p o u le chez I'enfant" R e alties p e d ia triq u e 01 0,1 48 p55-55 S ic h e re r S H ,S a m p s o n H A ‘F o o d a lle rg y \ J A lle rg y C lin Im m u n o l 20 , 125 p 16-25