Cơ xương khớp

VIEM KH0P DANG THAP I O Al CU’O’NG V iem k h d p dang th a p (rh e u m a to id arth ritis) la benh tu m ien, dien bien m an tinh Benh du’o c dac tru n g b d i tin h tran g vie m cac k h d p nho n h d co tin h chat doi x d n g , co dau hieu c d n g k h d p buoi sang va thu’d n g co m at cua yeu to dang th a p huyet doi co ton thu’o n g noi tang D a y la m ot cac benh k h d p m an tin h thu’d n g gap nhat T i le m ic benh vao khoa ng 0,3 - 1% dan so td n g quoc gia V e lam sang, benh gap chu yeu d nu1g id i, tuoi trung men, benh th u ’d n g dien bien m an tinh xen ke cac d o i viem cap tinh M uc dich dieu tri nham kiem soat qua trin h viem kh d p , tri tinh trang on dinh benh, tranh cac d o i tien trien li chAn o o An C han doan xac djn h benh viem k h d p dang t h ip - V iem k h d p dang th a p du’O’c chan doan theo tieu chuan cua Hoi T h a p k h d p hoc My - A m erican C ollege o f R h e u m a to lo g y (A C R ) nam 1987 Noi dung cua tieu chua n nhu’ sau: + C d n g k h d p buoi sang keo dai tren m ot gid + V iem it nha t tro n g 14 vi tri kh d p sau: dot ngon tay gan, ban ngon tay, co tay, khuyu, goi, co chan, ban ngon chan (hai ben) + Trong do, co it nha t m ot k h d p th u o c cac vi tri sau: dot ngon ta y gan, ban ngon tay, co tay + Co tin h chat doi xd n g + H at du’d i da + Yeu to dang th a p hu ye t th a n h d u'ong tinh + X quang dien h in h d khoi xu’o n g co tay (h in h bao m on, m at chat kh o a n g dau xu’ong ) T h d i gian dien bien cua benh it nhat phai tuan - C han doan xac dinh co it nhat tron g yeu to - X et nghiem can lam sang can lam: + Te bao m au ngoai vi, toe m au lang, protein C phan d n g (C R P ) - Yeu to dang th a p (R F), anti C C P (khang the cyclic citru llin a te d p e p tid e ) neu co dieu kien - C hup X q u a n g k h d p ban co tay th in g va cac k h d p ton th u ’o n g C h up tim phoi th in g C han doan phan biet a L u p u s b an h e th o n g T h u ’d n g gap d nu’ tre tuoi Bieu hien dau k h d p nho nhd T h u 'd n g co kem th e o sot keo dai va ton thu’o n g nhieu tang (ban hin h canh bu’d m d m at, lo et hpng, pro te in nieu, suy than, giam bach cau, tran dich da m ang ) C h in doan benh lupus ban he th o n g th e o tie u c h u in A C R 1997 b X o 1c irn g bi T hu’d n g gap d n d , tru n g nien Bieu hien viem cac k h d p nho n h d d ban tay T h u d n g co hoi c h d n g 610 H uong dAn ch An oo An v a o i £u tri b £n h N oi k h o a R aynaud Ton thu’a n g da co gia tri chan doan: da day, c u n g , roi loan s ic to C han doan theo tieu chuan A C R 1980 v a i benh x a c u n g bi c Th o h o a kh& p T hu’a n g gap a nu, trun g nien Bieu hien s u n g dau k h o p (thu’a n g g a p k h a p goi hoa c cac k h o p ngon xa hai ben) K h o p dau kieu c o hpc, co dau hieu pha ri kh o p C o th e co ca c hat H e berden, B o uchat toan trang khon g th a y doi X e t ngh iem m au va dich khap : khong co hoi ch u ’ng viem , yeu to dang thap th u o n g am tinh d G u t m a n tinh Thu’a n g gap o nam g ia i, tuoi trun g nien S a n g dau cac k h o p nho n h a a ban tay chan doi x u n g hai ben Tien s u co d o t s u n g dau cap tin h ngon chan cai C o the co hat tophi C h an d oa n th e o tieu chuan chan doan cua B e n n e tt va W ood 1968 e Thap k h a p cap G ap a n g u a i tre tuoi (tha nh thieu nien) S a n g dau cac k h o p n h o , vie m cap tin h , kieu di chuyen, C han doan xac dinh th e o tieu chua n Jone s cai tien nam 1992 III O l£U TR! BENH VIEM KHO ’P DANG TH AP N g u ye n t i c d ie u tri th u o c Ket h a p nhieu nhom thuoc: th u o c dieu tri trieu c h a n g (th u o c g ia m dau chon g vie m ) va it nhat 02 nhom th u o c chon g th a p k h a p ta c dung cham ta giai doan dau cu a b en h tre n n gu yen t i c so nhom th u o c va lieu th u o c toi th ie u co hieu qua R ieng co rticoid th u a n g c h i d un g tro n g cac d o t tien trien cua benh C a c th u o c dieu trj trieu c h a n g co the giam lieu hoac n g u n g h ln C a c th u o c dieu tri c a ban th a o n g dung keo dai nhieu nam , tham chi suot doi D ieu trj to an than a G lu c o c o rtic o id - C h i djnh: tron g d o t tien trien cua benh c h o d o i th u o c die u trj c o ban co hieu qua ho3c tru o n g h a p phu th u o c corticoid - Lieu lu a n g va cach dung + B o i tien trien nang (co ton th a o n g noi tang, sot, vie m nhieu k h o p ): tru ye n tTnh m ach 80-125m g m e th yl-p re d n iso lo n pha tron g 25 m l dung djch N atri clo ru a 0,9% tro n g 3-5 Sau tri uong 1.52 m g /kg /2 g ia tin h th e o p re d nisolon + O a t tien trien th o n g th a o n g : lieu -1 ,5m g /kg/24 g ia G iam dan % /tu a n Khi a lieu cao chia uong 2/3 sang, 1/3 chieu Khi a lieu < m g /n g a y uong m ot lan vao luc g ia sang , sau an T h a o n g sau 1-2 th a n g co the thay bang th u o c chon g vie m khong steroid + T o n g h o p phu th u o c co rtico id tri lieu - ,5 m g /2 g ia keo dai + T o n g h o p dung g lu co co rtico id lieu cao hoa c keo dai, can bo sung cac th u o c sau: > Kali: 1-2 gam kali clo rid ho a c 2-4 vien K a leorid 600 m g m oi > V ita m in D 0 IU va gam calci m oi > H an che ta c d y n g khon g m ong m uon tre n da da y-ta trang: nen d un g nh o m a c che b o m proton (o m e pra zol, p a n to p zo l, ) > B ip h o sp h o n a t (F o sa m a x, F o sa m a x plus): d a ng loang x u o n g co rtico id b Thu oc c h o n g viem k h d n g s te ro id - C h i djnh: giai d oa n k h o p vie m m u c v u a phai, hoa c th a y th e co rtico id - C h on m ot tron g so th u o c sau (lu u y tu y e t doi khon g phoi h o p th u o c tro n g nh o m vi khon g t§ng tac dung dieu trj m a lai co n hieu ta c dung khon g m ong m uon): H u On g d An c h An o o An v A b i £ u t r i b En h NOi khoa 611 + D iclo fe n a c (V oltaren) vien 50m g: vie n/n gay chia lan sau an no C o the s u dung dang ong tiem bap m g /n g a y tro n g - dau benh nhan dau nhieu, sau chuye n sang d u o n g uong + M eloxicam (M o b ic) vien 7,5m g: -2 vie n/n gay sau an no hoac dang ong tiem b ip 15m g/ngay x 2-3 neu benh nhan dau nhieu, sau chuyen sang du’a n g uong + Piroxicam (Felden) vien hay ong 20m g, uong vien/ngay uong sau an no hoac tiem b ip ong 2-3 dau benh nhan dau nhieu, sau chuyen sang du’O’ng uong + C e lecoxib (C e le b re x) vie n 200m g, lieu den vie n /n g a y sau an no Khong nen dung cho benh nhan co tien s u benh tim m ach va than h o n o n g u o i cao tuoi c C ac th u o c g ia m d au C hi djnh theo s o bac th a n g cua To c h u c Y te the g io i C ac th u o c th u o n g d u o c s u dung: - P a race tam ol: 2-3 g a m /n g a y chia lan - P a race tam ol ket h o p v o i codein (E fferalgan C odein) - vien/ngay - P a race tam ol ket h o p v o i d e xtro proxyphe n (D i-antanvic): uong 4-6 vien/ngay - F locta phen in (Id a c vien 200 m g) uong 2-6 vie n/n gay; th u o c d u o c ch i djnh tron g tru o n g h o p benh nhan co ton th u o n g te bao gan, suy gan d N h d m th u o c c h o n g th ap kh& p tac d u n g ch a m (D is e a s e -m o d ify in g a n tirh e u m a tic d rugs -D M A R D s) - T huoc chong sot ret tong h o p + H ydroxychloroquin (Plaquenil vien 200m g 1-2 vien hoac chloroquin lieu 250m g/ngay (vien 250m g) + Chong chi djnh: benh nhan co thai, n g u d i co suy giam G 6P D hoac co ton th u o n g gan + Tac dung khon g m ong m uon: chan an, non, dau th u o n g vj, sam da, kho da, viem to c h u c lu o i o vong m ac C an kiem tra thj lu c, soi day m at m di thang va khong dung qua nam - M ethotrexat + Lieu dung: 10 -2 m g /tu a n , tiem bap hoac uong T h u o n g dung d u o n g uong b i t dau b ln g lieu 10mg; uong vien (2 ,5 m g /vie n ) va o m ot nhat djnh tuan T h u o c co hieu qua sau 1-2 thang Co the chinh lieu th e o dap u n g cua benh Trong tru o n g h o p th u o c kem hieu qua hoac kem dung nap dung d u o n g tiem b ip (ong tiem 10 hoac 15m g) m oi tuan m ot m ui nhat + Chong chi djnh: bach cau, suy gan than, ton th u o n g phoi m an tinh + Tac dung khon g m ong m uon: th u o n g gap loet m ieng, non, buon non C o the gay doc te bao gan va + N h im han che ta c dung khong m ong m uon cua m e th o tre xa t can bo sung acid folic, lieu bang lieu m ethotrexat (vien 5m g, 02 vie n /tu a n chia tuan dung lieu 10m g m eth otrexa t/tu an - S ulfasala zin (S a la zo p yrin ) + C hi djnh: dung benh nhan co chong chi djnh v o i m e th o tre xa t hoa c dung phoi h o p cung vo i m ethotrexat tron g the it dap u n g v o i m e th o tre xa t d o n doc + Lieu lu o n g : lieu 2-3 gam /ngay + Tac dung khon g m ong m uon: roi loan tieu hoa, chan an, ban ngo da, bong n u o c , loet m ieng, protein nieu, hoi c h u n g than h u , viem tuyen giap trang, giam tieu cau, bach cau, huye t ta n , - C yclospo rin A (N eoral; S a n d im u n e ) + C hi djnh: vie m k h o p dang th a p the nang, khong dap u n g v o i m e th o tre xa t + Lieu: b i t dau bang lieu ,5m g/kg /n gay, chia lan Sau 4-8 tuan neu khong co hieu qua tang 0.51m g/kg/ngay tron g 1-2 thang; cho den dat 5m g/kg/ngay Lieu an to a n th u o n g dung la 2-3 m g /kg / Than tron g v o i benh nhan co suy giam c h u c nang than + Biet d u o c : N e ora l vie n 25m g va 100m g; S a n d im u n e ong 100m g 612 H u Ong dan chan e C ac tac n h a n sin h h o c (cac th u o c lpc An v A d i Eu t r i b E n h NOl khoa ch e cyto kin ) La cac tac nhan gay chen hoa c tu o n g ta c v o i cac c h u c nang cua cac cyto kin hoat dong tron g c o che benh sinh cua vie m k h o p d an g thap C ac th u o c th u o n g dung: - E n ta n e rce p t-E n b re l: ong 25m g Lieu 25m g lan/tuan hoa c m g /tu a n , tiem d u o i da - In flixim a b -R e m ica d e : ong 100m g, lieu 3m g/kg/lan tru ye n tTnh m ach ch a m (it nhat tro n g g io ) vao tuan 0; 2; 6, sau n h lc lai m oi tuan - Chi dinh: vie m k h o p d an g th a p nang, khang v o i dieu tri th o n g th u o n g - T ac dung khon g m ong m uon: lao va cac nhiem khuan c o hoi - R itu xim ab (M a b T h e , R ituxan ): thuoc u c che te bao B + C hi dinh: ta t ca cac benh nhan viem k h o p dang thap v o i m uc d ich ngan n g u a ton th u o n g khop co the c h u a tu n g dieu tri v o i m e th o tre xa t hoac khong dap u n g v o i m e th o tre xa t + Lieu: 0 -1 0OOmg/lan truye n M oi lieu trin h lan truyen cach 02 tuan Ket h o p vcri m ethotrexat, K hoang cach g iu a lieu trin h tiep th e o la 6-12 thang + C ach dung: pha 500 m g rituxim ab 500m l NaCI 9% , truye n tTnh m a ch ch a m (X g io t/p h u t) Sau 30 phut neu khon g co phan u n g bat th u d n g co the cho truye n nhanh h o n , X X -X X X giot/phu t Nen cho m e th ylp re d n iso lo n (80m g) tiem tTnh m ach tru d c truye n ritu xim a b 30 p h u t de han che tac dung phu cua th u o c n h u sot, ret run, huye t ap + C h ong chi dinh: tin h tra n g suy giam m ien dich nang hoa c n h u n g n g u d i d an g bi nhiem trung nSng hoac d u o c biet qua m an cam v d i bat c u th a n h phan nao cua thuoc C a c p h u c n g p h a p k h a c - D ieu tri tai cho: tiem co rticoid tai cac k h d p vie m sau da dieu tri toan than - Phuc hoi c h u c nang: n h im lam giam c u n g va dau kh d p , cho n g d in h kh d p ; kh uye n kh ich benh nhan tu van dong va tu phu c vu cac sinh hoat cua ban than - Noi soi ru a kh d p : ch i dinh vie m m ot vai kh d p keo dai kh o kiem soat - D ieu tri ngoai khoa: c i t bo m ang hoat dich (hien it d u o c ch i dinh), th a y k h d p nhan tao khdp giam c h u c nang nang Tom ta t p h a c d ie u tri viem k h o p d an g thap tai Viet N a m Ket hop dong thoi nhdm thuoc dudi day: T h u o c chon g viem - C o rticoid lieu cao, n g in ngay, sau giam lieu dan (th u d n g kh o a n g 1-2 thang) - H oac th u o c chon g vie m khong steroid T h u o c giam dau - P a ce ta m o l hoac cac che pha m ket h o p khac T h u o c chon g th a p k h d p tac dung cham - H y d ro xych lo ro q u in ho a c ch lo ro q u in (doi v d i the nhe) - M e th o tre xa t + c h lo ro q u in d u o c lu a chon hang dau - S a la zo p yrin ch i djnh khong dung nap m eth otrexa t - M e th o tre xa t + c h lo ro q u in + salazopyrin - M e th o tre xa t + c y clo sp o rin A - R ituxim ab H u Ong d An ch An oo An v A d i Eu t r i b En h N i khoa 613 IV THEO DOI VA PHONG BENH - G iao dye benh nhan dieu tri th u o c th u d n g xuyen n h im tran h cac d o i tien trien - T h e o doi n h im d u phdng cac tac dung khong m ong m uon cua thuoc + V e lam sang: th e o doi can nang hang thang va kham m it m oi thang H ang kiem tra huyet ap, nhiet do, cac trieu c h u n g da d ay-ta trang, tin h trang nhiem khuan + V e xet nghiem : kiem tra dinh ki m oi thang can xet ngh iem dien giai do, d u d n g m au, c h u c nang gan, than, te bao m au ngoai vi, toe m au lin g , protein C phan u n g (C PR ) - H u d n g dan benh nhan luyen tap tranh dinh va bien dang khdp TAI LIEU T H A M K H A O Tran N goc An (2000), “D ie u tri benh viem kh o p d a n g thap", D ie u tri hoc Noi khoa tap I, Nha x u lt ban Y hoc Ha Noi, tr 206-212 N g uyen Thj N g o c Lan (2009), “C han doan va d ieu tri nhCrng b e n h c o xuxrng kh o p th u v n g g $ p '\ Nha xuat ban Y hoc Ha Noi, tr 88 - 110 C ro n ste in BN (2005), “L o w -D o se m e th o tre xa te : A M a in s ta y in the T reatm ent o f R h e u m a tio d A rth ritis ” P h a rm a co l Rev, 2005, 57: 163-172 F leisch m an n R M (2008), “S a fety o f B io lo g ic T he rap y in R h e u m a tio d A rth ritis a n d O th e r A u to im m u n e D isia se s: F o cu s on R ituxim ab", S em in A rth ritis R heum 00 M ar 11 Tanya D and E len a M, “R h e u m a tio d A rth ritis: A n O ve rv ie w o f N e w a n d E m e rg in g Therapies", J Clin P h arm acol 2005; 45;751 VIEM COT SONG DINH KH0P I DAI C U m iG V iem cpt song d in h k h d p (V C S D K ) la m pt benh vie m k h d p m an tin h hay gap nha t tron g nhom benh li cot song the huye t th a n h am tinh Benh V C S D K co m oi lien he chat che v d i yeu to khang nguyen bach cau H L A -B 27 (80 - 90 % ) cua he thong khang nguyen hoa h o ’P to c h d c , benh th u ’d n g gap d nam gidi (80 - 90% ), tre tuoi (du’d i 30 tuoi chiem ti le 80% ) B enh anh hu*dng nhieu den c h d c nang van dong kh d p , kha nang lao dong, sinh hoat, chat lu p n g song cua n g u d i benh va la ngu yen nhan gay tan phe neu khon g d u p e ch a n d oa n va dieu tri kip thdi N guyen nhan cua benh V C S D K hien c h u a ro li c h An o o An C han d o an xac djnh D u a vao tieu chua n chan doan N e w York nam 1984: • Tieu chua n lam sang - Tien s u hay hien tai co dau vung t h it lu n g hay vung lu n g - t h lt lu n g keo dai tren thang - H an che van dong t h lt lu n g d ca tu the cui, ng u a , ngh ie n g va quay - D o gian long n g u c giam • Tieu chua n X q uang - V iem k h d p cung chau m ot ben d giai doan III hoac IV V ie m k h d p cu n g ch a u hai ben tu giai doan II trd len - C han doan xac djnh benh V C S D K co m ot tieu chu a n lam sang va m o t tieu chua n Xquang - N ham chan doan benh va th e o doi tien trien cua benh can lam th e m ca c xe t n gh iem ve phan irng vie m (toe m au lin g , pro te in C phan u n g ) - T rong giai doan s d m cua benh de g iiip chan doan xac djnh neu co dieu kie n chi d u p e them xet ngh iem H L A -B d u o n g tin h > 80% tru d n g h o p ), chup cong h u d n g t u (M R I) k h d p cung ch§u Cac th a n h vien tron g gia d in h co the m lc cac benh li tron g nho m benh li co t song th e huye t th a n h am tinh (viem cot song d in h kh d p , vie m k h d p vay nen, vie m k h d p phan irn g ) C h an d o an phan biet - C a c benh cpt song: vie m dot song d ia dem vi khuan, lao: tin h tra n g n hiem khuan, ton th u o n g than dot va d ia dem tren phim X q uang - T ho hoa cp t song: gap d n g u d i Idn tuoi, h inh anh gai x u o n g th a n d o t song, cac xet nghtem ve phan u n g vie m b inh th u d n g - C&c benh li k h d p ngoai vi: lao k h d p hang (benh nhan dau va han ch e van dpng th u d n g m dt ben k h d p hang, ton th u o n g x u o n g va k h d p tren phim , co the co lao p ho i phoi h o p ), th o a i hoa k h d p h^ng (cac xet ngh iem ve phan u n g vie m b in h th u d n g , ton th u o n g gai x u o n g ) H ucJng dAn ch A n o o A n vA ei£u t r i bEnh NOi khoa 615 III l£ u TR! M uc d ich dieu tri: kie m soat tin h trang dau va viem , tri c h u c nang van dong cua cac khap , cot song va phong tranh bien dang k h d p va cot song V an don g lieu phap - T u v a n , h u d n g dan cho n g u d i benh cac bai tap van dong k h d p va cot song, tham gia cac hoat dong the due (bai, di bo, di xe dap ) phu h a p v d i tinh trang benh va giai doan benh - H u d n g dan benh nhan tap th d , n im dung tu the (khdng dung goi cao, khdng nam dem m em , khdng nam co kh d p goi ) - D ieu tri va t li tri lieu: ch ieu tia hong ngoai, sieu am , tam n u d e khoang ndng, t im bun, xoa bop D i§u trj th u d c • T huoc giam dau: cd the lu a chpn m ot cac th u d c giam dau: -A c e ta m in o p h e n (pa ce ta m o l, D olodon, T ylenol ) 0,5g x - vie n /2 gid - F locta fen ine (Ida rac) 0 m g x vie n/2 gid • T hu oc chon g vie m khdn g steroid: cd the lu a chon m ot tron g cac loai th u o c khang viem khdng steroid sau phu th u o c va o d a p u n g cua thuoc, tin h trang benh va kha nang kinh te cua n g u d i benh (lu u y tuyet doi khdng phoi h a p th u o c nhdm vi khdng tang tac dung dieu tri m a lai co nhieu tac dung khdng m ong m uon): - D iclofena c (V oltaren) vie n 50m g x vie n/n gay chia hoa c vien 75m g x vie n /n g a y sau an no Cd the s u dung dang ong tiem b ip 75 m g /n g a y - dau benh nhan dau nhieu, sau dd chuyen sang d u d n g uong - M eloxicam (M o b ic) vie n 7,5m g x vie n/n gay sau an no hoac dang ong tiem b ip 15m g/ngay x - neu benh nhan dau nhieu, sau dd chuyen sang d u d n g uong - P iroxicam (F e ld e n ) vien hay ong 20m g, uong vien/ngay, uong sau an no hoac tiem b ip ong - nga y dau benh nhan dau nhieu, sau dd chuye n sang d u d n g uong - C e lecoxib (C e le b re x) vie n 200m g lieu den vie n /n g a y sau an no K hdng nen dung cho benh nhan cd tien s u benh tim m ach va than tron g h a n d n g u d i cao tuoi • T huoc tac dung ch a m (dieu tri c a ban): - S u lfasala zin (S a la zo p yrin e ) 1000 - 0 m g /2 gid - M eth otrexa t 7,5 - 15m g/tuan: doi v d i tru d n g h a p viem cot song d in h k h d p the kh d p ngoai vi • T hu oc corticoid: D ieu trj co rtico id tai cho: tiem kh d p , tiem cac diem bam gan (h yd ro co rtiso n acetat: 125m g/5m l, D epo - m edrol 40 m g /m l ) D ieu trj co rtico id to a n th a n tron g cac tru d n g h a p benh tien trien nang khdn g dap u n g v d i cac thuoc chong viem khdn g ste ro id hoa c tru d n g h a p benh nhan phu th u o c co rtico id , lieu dung - 1,5m g/kg/24 g id va giam lieu dan th e o tin h tran g tien trien va dap u n g cua benh nhan - N hdm th u o c sinh hoc m d i: cac khan g the d a n dong chon g yeu to hoai tu u T N F a np (R em icade, E ntanecept ) dieu trj cac tru d n g h a p khang v d i cac th u o c dieu trj - T h u o c dieu trj phoi h a p th u o c gian c a + Benh nhan cd dung th u o c m e th o tre xa t: acid fo lic 5m g x vie n /tu a n + Benh nhan cd bieu hien viem da day-h a n h ta trang: o m e p zo n m g /2 gid + B enh nhan d u n g corticoid, cd loang x u a n g : ca lcito n in (M ia ca lcic, R o ca lcic) -1 00U I/24 g id (tiem b ip ho$c xjt m ui), b ip h o sp h o n a t (F osam ax, A le n ta ) m g /tu a n , ca lci 0,5-1 g/24 gid 616 H u o n g d a n c h A n o o A n v a biEu t r i bEnh Ndi khoa + B enh nhan co th o a i hoa kh d p th u phat: diacerin (A rtro d a r) 50 - 0 m g/25h , g lu co sa m in sulfat (V iartril-s, B o sam in, Lubrex-F ) 1g-1,5g/24 gid, ch o n d ro itin 0,5-1 g/ngay * P hau th u a t ch inh hinh: T hay k h d p hang, th a y k h d p goi, giai phong kh d p d inh hoa c k h d p bi bien dang IV PHONG BENH - G iao due va hu>dng dan benh nhan, n g u d i nha benh nhan cd n h u n g hieu biet ve benh de th u c hien d ung lieu trin h dieu tri va th e o ddi qua trin h dieu tri - A p dung cac bien p p dieu tri n h im han che dr c h u n g benh: cho n g teo c o \ d in h kh d p nang cao chat lu o ’ng song cua benh nhan tAi lieu tham khAo K h an M A (2 0 ), “U p d a te on s p o n d y lo a rth ro p a th ie s ”, A n n In te r M ed Ju n 18 2002: 136 (12): 96 - 907 R e veill JD , B a llE J , K han M A (2001), “H L A -B a n d g e n e tic p re d is p o s in g fa cto r in s p o n d y lo a rth ro p a th ie s ”, C u rr O pin R h eum ato l Jul 2001; 13 (4): 72 R e veill JD , A rn e tt FC (2005), “S p o n d ylo a rth ritis upd a te on p a th o g e n e s is a n d m anage m e nt", Ann J M ed Jun 2005; 118(6): 592 603 B rau n J, S ie p e r J (2007), “A n k y lo s in g s p o n d y litis ”, Lancet, A p ril 21 200 7; 369 (9570): 1379 - 90 VIEM KH0P PHAN tfNG I DAI CLFQNG V iem k h d p phan u n g (V K P U ) la m ot benh viem kh d p vd khuan xuat hien sau nhiem khuan chu yeu la nhiem khuan tie t nieu sinh due, hd hap, tieu hoa, B enh gay ton th u o n g d k h d p va cac c o quan khac n h u m at, he tiet nieu sinh due, he tieu hoa, th u d n g gap d lu a tuoi tre, ti le m lc benh d nam va n u n h u C o che benh sinh cua benh V K P U c h u a d u o c biet ro V K P U la m ot tin h tran g viem k h d p vd khuan xay sau m ot nhiem khua n nao dd c o the m a khdng tim thay vi khuan tai kh d p Yeu to gen g iu vai trd quan tron g tro n g benh sinh cua benh V K P U , cd 30-70% benh nhan V K P U d u o n g tin h v d i yeu to khang nguyen bach cau H LA -B 27 II chAn An C han doan xac djnh a A p d u n g tieu c h u a n chan doan cua A m o r (1983) - V iem vd khua n m ot ho a c vai k h d p khdng doi xung -T ie u chay hoa c cd hoi c h u n g li - V iem m ang tie p h o p m at - V iem nieu, vie m co t u cung - V iem loet tro t niem m ac, da - C o dja H L A -B (+) hoa c cd tien s u gia dinh benh viem cot song d in h khdp - C ac xet ngh iem tim th a y ta c nhan gay benh tru e tiep hoac gian tiep Benh V K P U d u o c chan doan cd 4/7 trieu c h u n g tren b Tieu c h u a n c h a n d o an cu a n h d m b en h li co t s o n g the h u y e t th an h am tinh ch a u A u (1990) - D au, vie m d ot song - H oac vie m m a n g hoa t djch k h d p (chu yeu la k h d p d chi d u d i va khdn g doi x u n g ) C d kem theo m ot cac hoi c h u n g sau day: + C d tien s u gia d in h benh vie m cot song d inh khdp + V iem k h d p vay nen + Benh li ruot + D au vung chau hong + Benh li p n m em q ua nh kh d p + V iem k h d p cu n g chau + V iem nieu d a o sin h due c The d a c b ie t cu a V K P If: hoi c h u n g R e ite r chan doan cd tam c h u n g : viem kh d p , viem nieu dao va viem ket m a c m it HUONG 618 d An ch An oo A n VA O l f u TRI BfNH N O I KHOA C h an doan phan biet - V iem k h d p nhiem khuan: vie m k h d p m ot d o n doc, tin h tra n g nhiem khua n, xet ngh iem dich khdp, cay m au, - B enh G ut: vie m k h d p cap tinh, tien trien tu n g d o i, dap u n g v d i co lch icin , - V iem k h d p dang th a p th e m ot kh d p : th u ’d n g gap d n u g id i, tuoi trun g nien, vie m k h d p tien tnen tu n g d o i, yeu to dang th a p du’O’ng tin h , - V iem k h d p tro n g cac benh suy giam m ien dich m lc phai (A ID S ): th e tra n g suy kiet, xet nghiem HIV du’a n g tinh, cd tien s u ngh ien ch ich m a tuy, III l£ u TR! T h u o c g iam dau C d the lu a chon m ot tron g cac th u d c giam dau -A c e ta m in o p h e n (p a ce ta m o l, D olodon, Tylenol, ) 0,5g x 2-4 vie n /2 gid - F lo cta fe n in (Id a c) 200 m g x vie n/2 gid T h u d c ch d n g viem kh d n g steroid C hon m ot tron g so th u o c sau (lu u y tu ye t doi khdng phoi h a p th u o c tro n g nhd m vi khdng t§ng tac dung dieu tri m a lai cd nhieu tac dung khdng m ong m uon): - D iclo fe n a c (V oltaren) vie n 50m g x vie n /n g a y chia hoa c vien m g x vie n /n g a y sau an no Cd the s u dung dang ong tiem b ip m g /n g a y tron g 2-3 dau benh n n dau nhieu, sau dd chuyen sang d u d n g uong - M e lo xica m (M ob ic) vie n ,5m g x vie n /n g a y sau an no ho a c dang ong tie m b ip 15m g/ngay x 2-3 neu benh nhan dau nhieu, sau dd chuye n sang d u d n g uong - P iro xica m (F e ld e n ) vien hay ong 20m g, uong vie n /n g a y uong sau an no hoa c tiem b ip ong 2-3 dau benh nhan dau nhieu, sau dd ch uye n sang d u d n g uong - C e le co xib (C e le b re x) vie n 200 m g lieu den vie n /n g a y sau an no K h d n g nen dung cho benh nhan cd tien s u benh tim m ach va than tron g h a n d n g u d i cao tuoi T h u d c tac d u n g ch am - S u lfa sa la zin (S a la zo p yrin ) 0 -2 0 m g /2 g id , dieu tri keo dai 1-3 thang - M e th otrexa t: ,5 -2 m g /tu a n : dieu tri keo dai 1-3 thang: tro n g tru d n g h a p vie m nhieu kh d p va ton th u o n g k h d p nang - T h u o c u c che yeu to hoai tu u T N F alpha: in flixim a b (R e m ica d e ): c h i dinh tron g tru d n g h o p benh ton th u a n g k h d p nang ne hoa c khang dieu trj v d i cac loai th u o c ch o n g vie m khdn g stero id va corticoid T h u d c co rtic o id - C o rticoid: d ieu trj co rtico id toan than tron g cac tru d n g h a p b en h tie n trie n nang khong dap ung v d i cac th u o c chon g vie m khdn g stero id hoa c tru d n g h a p b en h nhan phu th u o c co rtico id lieu dung -1 ,5 m g /kg /2 g id va g iam lieu dan th e o tin h tran g tien trien va dap u n g cu a benh nhan C hi d>eu tn co rtico id toan than tron g th d i gian ngan, kiem soat d u a c benh phai ch u ye n sang dieu trj th u o c chong vie m khdn g sterroid D ie u trj co rtico id tai cho: tiem kh d p , tiem cac diem bam gan (h y d ro c o rtis o n acetat D epo-m edrol, D ip rospan, ) 688 H u o n g d A n c h A n o o A n v A b i £ u t r i b En h Noi khoa - Khi chu’a co ket qua cay m au, dich: dung nga y khang sinh ce p h a lo s p o rin the he d u d n g tin h m ach (TM ) nhu* ce p h o ta xim g /n g a y chia lan (cach g id m ot lan) ho a c ce ftria xo n 1-2g m o t la n /n g a y - Tru’d n g h o p soi tu o i nhu om G ram dich k h d p phat hien vi khua n gram d u o n g : o xa cillin hoSc nafcillin 2g m i g id m ot lan ( g /n g a y) hoac clin d a m ycin 2,4g T M /n g a y chia lan N eu nghi n g d n h ie m tu cau vang khang khang sinh: va n co m ycin g/n g a y chia hai lan (pha g v d i 0 m l dung dich m uoi hoSc d u d n g d in g tru o n g tru ye n tTnh m ach tron g 60 phut) N h u n g benh nhan nghi n h ie m tru n g tru e khua n m il xanh can phoi h o p th e m khan g sinh nhom a m in o g lyco sid (n h u g e n ta m ic in m g /kg /n g a y - d un g m ot lan tiem b ip vao buoi sang hoa c a m ika cin 15 m g /kg /n g a y tiem b ip ho a c pha tru y e n T M ch ia - lan/ngay) - T ru d n g h o p cay m au, dich k h d p d u o n g tin h th i dieu trj th e o khan g sin h d o (h o a c tie p tu c tri khang sinh th e o n h u dieu tri ban dau neu th a y dap u n g tot): + N hiem khua n tu cau vang nhay cam v d i khang sinh thi d un g o x a c illin hoa c nafcillin hoSc clinda m ycin (lieu n h u tren) Tu cau vang khan g m e th icillin thi d un g v a n c o m y c in lieu n h u tren + N h iim khuan phe cau hoa c lien c iu vi khuan nha y v d i p e n icillin: p e n icillin G trieu d o n vi TM m oi g id tron g tuan Do H in flu e n za e va S p n e u m o n ia e kh a n g p e n icillin : ce ftria xo n - 2g m ot lan /ngay hoac ce fo ta xim 1g la n /n g a y tron g tu in + N hiem khua n gram am : khan g sinh the he hoa c TM tro n g - tu a n hoa c th u o c nhom flu o ro q u in o lo n n h u le vo flo xa cin 500 m g T M /u o n g m oi 24 gid + N hiem khuan tru e khua n m u xanh: phoi h o p a m in o g lyco sid (n h u g e n ta m ic in m g /kg /n g a y - dung m ot lan tiem b ip vao buoi sang hoa c a m ika cin m g /kg /n g a y tie m b ip ho a c pha tru ye n TM chia - lan/ngay) v d i m ot khan g sinh p en icillin rong n h u m e zlo cillin 3g TM m oi g id ho a c ce fta zid im 1g moi gid T h d i gian dung tro n g khoa ng tu in , sau dung khan g sinh flu o ro q u in o lo n n h u ciprofloxacin 750m g uong la n /n g a y d o n doc hoa c phoi h o p v d i m ot th u o c nh o m p e n icillin p h o rong n h u tren T h d i gian dieu tri vie m k h d p nhiem khuan: loai vi khua n, nh a y ca m - tin h tra n g khang thuoc Thong th u d n g , khoa ng t u - tu a n tru ye n TM sau c h u ye n sang d u d n g uong b in g khan g sinh thich hgp Lieu trin h dieu trj tu - tuan T h e o doi qua dap u n g lam sang nha t la tin h tran g sot, s u n g dau tai cho, xet nghiem (so lu o n g bach cau, m au lin g , C R P) D ieu tri viem k h o p la u cau - T ru d n g h g p lau cau nha y cam p en icillin co the dung a m o xicillin uong 0 m g /n g a y chia lan hoac dung cip ro flo xa cin uong 0 m g chia hai la n /n g a y (n goai tru) - T ru d n g h g p nghi n g d lau c iu khan g penicillin: k h d i dau ce ftria xo n 1g T M m oi 24 g id ngay, sau chuye n dung c ip ro flo x a c in uong 500m g hai lan/ngay H o a c sp e ctin o m ycin 2g tiem b ip m oi 12 g id /n g a y - Khi nghi n g d boi nhiem C h la m yd ia tra c h o m a tis : phoi h g p khan g sinh uong d o xyc yclin 100m g lan/ hoac te tra cyclin 500 m g x la n /n g a y hoa c e ryth ro m ycin 500 m g x la n /n g a y tron g b C ac b ien p h a p k h a c p h o i hi soi k h d p ru a kh o p : tru o n g h o p sau - nga y dieu tri d un g th u o c ket h o p hut, dan lu u dich khd’p nhieu li n t h it bai hoSc nhiem k h u in k h o p dich m u dac hay co vach ngan khong hut d u o c dich khop - P hau th u a t m o k h o p l i y bo to c h u c nhiem khuan kem nhiem khua n sun k h o p hay x u o n g , nhiem khuan d k h o p nhan ta o hoac nhiem k h u in k h o p d sau n h u k h o p hang, dac biet tre em iv p h Gng b e n h - T h y c hien vo tru n g tu ye t doi lam cac thu thuat, phau th u a t tien hanh tgi khop - D ieu trj tot cac n hiem khua n tgi cac c o quan khac, dac biet tai da, phan m em va x u o n g - D oi v o i benh Igu p ho ng b in g cach th u c hien hanh vi tin h dye an toan TAI LIEU TH A M KHAO Le Ngoc Trong, 06 Khang Chi§n (chu bien), “ Viem k h d p m u va vie m k h d p l$u", H u o n g dan dieu trj, ta p II: h u o n g dan dieu trj m ot so benh nhiem k h u in th u d n g gap, N x u it ban Y hoc, 2006, tra n g 24 - 28 Osmon DR, Steckelberg JM, “O steom yelitis, In fe ctio u s a rth ritis a n d P ro s th e tic - jo in t in fe c tio n ”, C u rre n t d ia g n o s is and tre a tm e n t in in fectious diseases, 1th E dition; M a cG w - H ill/A pple ton and Lange, 200 1; p 160 - 168 Goldenberg DL, “B a c te ria l A rthritis", Textbook o f R heum ato logy, fo u rth Edition, Voi 2; W.B S a u n d e r C o m pa ny, 2003; p 1449 -1 6 Hedstrom S, Lidgren L, “S e p tic a rth ritis a n d o s te o m y e litis ”, R h e u m a to lo g y 2th Edition, Voi 2, M osby, 200 0; p 6/2.1 -6 /2 VIEM CO N H llM KHUAN-AP XE CO I DAI C ir a N G V iem c o nhiem khua n (p yo m yo sitis) la vie m hoac ap xe tai c o van vi khua n sinh m u gay nen Dinh n gh ia loai tr u cac benh li viem c o vo khuan c o che tu m ien tro n g ca c b en h li he th o n g n h u viem da co, vie m da co N g uyen n h a n hay gap nhat la vi khua n G ram du’o n g n h u tu cau d a c biet la tu cau vang, lien cau, vi khuan G ram am n h u E coli, tru e khuan m u xanh va vi khua n ki it g a p h o n D u d n g la y nhiem th u d n g th e o d u d n g tai cho qua cac nhiem khua n d da n h u m un nho t hoSc theo d u d n g m au Benh cd the xu a t hien tu nhien hoac sau chan th u o n g , tie m tru y e n kh d n g vo khuan, cham cu u ; hoac sau bi m un nhot ngoai V iem c o t h lt lu n g ch a u th u d n g xa y sau cac nhiem khuan tie t nieu sinh due, sau vie m d ia dem dot song hoa c sau phau th u a t vu n g tieu khung V iem c o cung th u d n g gap d benh nhan cd suy giam m ien dich (tieu d u d n g , n hiem HIV, d un g co rticoid keo dai, benh m an tin h , ) II c h An o o An C h an doan xac djnh a L a m san g - Toan than: hoi c h u n g nhiem trung: sot, co the kem ret run; m di kh o lu d i ban, h o i th d hdi - Tai cho: vi tri vie m c o cd the tai m ot hay nhieu c o C a c trie u c h u n g th u d n g qua ba giai doan: giai doan dau c o ton th u o n g su n g , dau va cang tai vung ton th u o n g , cd th e kem dd hoa c khdng G iai doan hai th u d n g xay sau -2 ngay, c o s u n g ndng dd, an m em h o n giai d o a n dau, ch o c cd the cd mu G iai doan ba neu khdn g dieu trj tich c u c d cac giai doan tren, nh ie m kh u a n cd th e phat trien ap xe da o, toan than cd the soc, suy da phu tang - T ru d n g h o p vie m c o d vj tri sau, dac biet doi v d i c o t h lt lu n g ch a u trie u c h u n g s u n g ndng rat kho phat hien C hu yeu benh nhan dau tai vung th a t lu n g hoa c ho ch a u ben ton th u o n g chan han che dong ta c d uo i tron g cac dong tac van dong k h d p hang (gap, gia n g , khep, xoay) van b in h th u d n g b C ac x e t n g h ie m can lam sa n g - Sieu am c o (dung dau dd tan so cao tu 5-2 M H z) la th a m dd h in h anh lu a chon hang dau cd the thay h inh anh c o phu ne m at cau true s o i c o bieu hien vie m ho a c cac o cd cau true am hon h o p hay am bieu hien o mu - C h oc tham dd m u h oa c d u d i h u d n g dan cua sieu am lay b en h ph a m m u lam xe t ngh iem te bao hoc thay bach cau da nhan th o a i hoa, soi tu o i nhu om gram tim vi khua n gay benh N uoi cay benh pha m mu phan lap vi khuan, lam khan g sinh - X q u a n g quy u d c : cd th e th a y b on g c o to h o n h o a c kh i tro n g c o T ru d n g ho’p ke m vie m x u o n g tu y n h ie m khua n se th a y h in h a n h ton th u o n g vie m x u o n g T ru d n g h o p vie m c o t h l t lu n g c h a u cd H i/ O n g d A n c h A n o o A n v A p i E u t r i b £ n h N p i k h o a 691 th e kem ton th r o n g vie m dTa dem d ot song (khe dTa dem hep, huy x u 'o n g ve hai p h ia dien k h d p -h in h anh soi gu-ong) - C h up c i t Idp vi tinh: ch i dinh tru ’d n g h o p tren lam sang nghi n g d viem c o d v| tri sau nhu 1c o that lu n g chau m a sieu am khdng ro hoac nghi n g d cd vie m xu’o n g kem theo C hup c i t Idp vi tinh cdn cd ta c dung hu’d n g dan choc hut o ap xe - C hup cong hu’d n g ti>: phat hien sd m viem c o v d i nhay rat cao C h i dinh sieu am nghi ngd, chu’a k h ln g dinh cd vie m c o hoac cd nghi n g d viem dTa dem dot song kem theo - C ay m au, cay dich ch o c o viem cd the du’o n g tinh - T e bao m au ngo vi: so lu’o n g bach cau tang, ti le bach cau trun g tin h tang, toe m au lin g tang, protein C phan d n g (C R P ) tang c C h an d o an x a c dm h D y a vao lam sang cd bieu hien su n g , ndng, dd, dau tai c o ket h o p sieu am c o (hoac chup c i t Idp vi tin h hay chup cong hu’d n g td ) cd bieu hien viem , ch o c hut c o cd mu, nuoi cay m au/m u du’o n g tinh C han doan phan biet - U co, sarcom co: c o su n g , khdng cd trieu c h u n g viem tren lam sang va xet nghiem C hoc hut khdng cd m u, xet ngh iem te bao va sinh thiet m d benh hoc cho chan doan xac dinh - D oi v d i viem c o th a t lu n g chau can phan biet v d i ton thu’o n g k h d p hang, dam quanh ruot th d a , viem lao - C hay m au tro n g c o (chan thu’o n g , benh m au ) C han doan n g u yen nhan D y a vao cay m au hay mu III DIEU TRj N g u yen t ic C han doan benh sd m , dung khang sinh du’d n g tTnh m ach, dan lu-u m u cd o ap xe T h y c hien cay m au, cay m u, soi tu o i dich nhuom G ram tim vi khua n tru ’d c ch o khang sinh L y a chon khang sinh ban dau d y a vao ket qua nhuom gram (am hay d u ’o n g ), du’d n g lay nhiem de d y doan vi khuan gay benh (phan dai cu’a n g ) D idu trj kh an g sinh a Trw &ng h o p chu’a cd k h a n g sin h - C h u’a dinh hu’d n g du’a c vi khuan gay benh: oxacillin 1-2g tie m T M /lan, lan tron g hoac cloxacillin lieu tu ’a n g ty , sau 1-2 tuan dung du’d n g TM se ch uye n sang du’d n g uong - T ru’d n g h o p nghi n g d tu cau hay lien cau nhay cam v d i m e th icillin : dung oxa cillin hoac cloxacillin lieu nhu’ tren H o a c c e p h a zo lin g/lan TM , hai lan hoac n a fcillin 1-2g T M /lan, lan trong 1-2 tuan, sau dd ch uye n uong oxacillin hay clo xacillin -6g/ngay - N ghi n g d n hiem tu cau vang khang khang sinh: va n co m ycin g /n g a y ch ia hai lan (pha 1g v d i 100m l dung dich m uoi h o a c du’d n g dang tru 'o n g truye n tTnh m ach tro n g 60 phut) - N ghi n g d d o phe cau hoac lien cau nhay v d i penicillin: p e n icillin G trie u d o n vi TM m oi g id tuan D o H in flu e n z a e v a S p n e u m o n ia e khang penicillin: ce ftria xo n 1-2g m ot lan/ngay, hoac cefotaxim 1g x lan/ngay - T ru’d n g h o p nghi n g d vi khuan G ram am: dung khan g sinh ce p h a lo sp o rin the he du’d n g tTnh m ach (T M ) nhu' c e p h o ta x im 3g/ngay, chia lan (cach g id m ot lan) hoa c ce ftria xo n 1-2g m ot lan/ngay, 692 H uong pan chan d o An v a o i Cu t r i b £ n h NOi khoa hoac th u o c nhom flu o ro q u in o lo n nhu- le vo flo xa cin 500m g T M /u o n g m oi 24 gicr - N h u n g benh nhan nghi n g o nhiem trun g try c khuan m u xanh: phoi h o p a m in o g ly c o s id (n h u g e n ta m icin 3m g/kg/n gay D ung m ot lan tiem b lp v£o buoi sang ho a c a m ika cin 15m g/kg/n gay tie m b ip hoac pha truye n TM chia - la n/n gay) v d i m ot khang sinh p e n icillin p h o rong nhu- m e zlo cillin 3g TM m oi gid , hoac ce fta zid im 1g m oi g id T h d i gian dung tro n g kh o a n g tuan, sau d un g khan g sinh flu o ro q u in o lo n n h u c ip ro flo xa cin 750 m g uong la n /n g a y d o n doc ho a c phoi h o p v d i m ot th u o c nhom pen icillin rong nhu 1tren b T rw a n g h o p cd k h a n g s in h D ung th u o c th e o khan g sinh hoac tiep tu c tri dieu tri th e o ph a c d o ban dau neu benh nhan dap d n g tot c T h d i g ia n d ie u trj N hin chun g t d 3-4 tuan, tron g 1-2 tuan dau dung khan g sin h d u d n g tTnh m ach, sau chuyen sang du’d n g uong C an th e o doi tien trien lam sang, so lu’o n g bach cau, toe d o m au lin g , CRP, sieu am c o de qu ye t dinh co tie p ty c dieu tri n u a hay khong Dieu trj phoi ho’p - Ha sot giam dau b ln g p a ce ta m o l lieu t d 1- 3g/ngay, m oi lan 0,5-1 g sot cao, dau nhieu Nang cao th e tra n g b ln g an uong, nuoi du’d n g qua ong th o n g hay du’d n g tTnh m ach - C h o c hut dan lu’u m u du’d i hu’d n g dan cua sieu am hoa c ch u p c i t Id p vi tin h tro n g ca c tru d n g hop viem c o hoa m u, d a c biet o ap xe d sau nhu> ap xe c o t h lt lu n g chau Dieu tri phiu thuat C h i dinh dieu tri khan g sinh dung tron g 3- nga y ket h g p ch g c hut m u t h i t bai hoSc o £p xe c o lan rong/co hoai tu hoa c co bien c h u n g vie m x u o n g IV ph Gng benh G iu ve sinh da sach se, dieu tri tic h c u c cac nhiem khua n da n h u m yn nhot t A i l ie u t h a m k h Ao Le Ngoc Trong, D6 Khang Chi§n (chu bien), “ Viem ccr ho a m u", H u d n g dan dieu tri, ta p II: h u d n g dan dieu tri m g t so benh n hiem khua n th u d n g gap; N xu a t ban Y hoc, 2006, tran g 14-18 Mark Wilhelm, Randall Edson, “S kin a n d S o ft-tissu se in fection", C u rre n t d ia g n o s is and trea tm ent in in fe ctio u s d ise a se s, 1th E d ition; M a cG w - H ill/A p p le to n and Lan ge, 200 1; p 50-159 UNG THU DI CAN XUONG I OAl CUQNG Ung thu” di can x u a n g la m ot hau qua nghiem tron g cua ung th u noi chung Tat ca cac loai ung th u deu co the di can va o x u o n g , song gap chu yeu tu cac ung th u bieu m o n h u ung th u vu (n u ), ung th u tien liet tuyen (nam ), ung th u phoi, ung th u da day, ung th u tuyen giap, II ch An d o An Can d u a vao cac trieu c h u n g lam sang va can lam sang sau: Bieu hien lam sang D au x u o n g k h o p , d a c biet dau tai cot song t h lt lu n g m u c nang, toan than gay sut can, co th e th a y hach ngoai vi hoa c di can c o quan khac tren benh nhan da d u o c chan doan ung th u nguyen pha t hoac c h u a d u o c chan doan ung th u nguyen phat Xet nghiem - Bilan viem (toe lin g C R P ): th u o n g tang - Bilan p h o sp h a ta se (calci m au p h o sp h o ta se kiem ): th u d n g tang, dac biet co huy x u o n g nhieu, thieu mau - C ac m a rke r ung th u : co the tang cao th e o tu n g loai ung th u nguyen phat Xquang xuang H inh anh o tieu x u o n g , ket dac x u o n g hoa c hon hop, doi ch i th a y h inh anh loang x u o n g d o n thuan Tuy nhien, da th a y ton th u a n g tren X q u a n g quy u a c thi benh nhan da d giai doan m uon Xa hinh xuang C o nhay rat cao n h u n g dac hieu c h u a cao H inh anh dien h inh cua ung th u di can x u a n g la tang hoat tin h phong xa da o v d i h inh dang, kich c d va ti khac nhau, phan bo khong doi x u n g , khong deu, rai rac tre n toan bo he thong x u o n g dac biet tren cot song, x u o n g s u d n Khi o ton th u o n g la d o n doc, can ch u p S P E C T (chup ba pha) de phan tich dac tin h o ton th u a n g qua ba pha huye t dong hoac chup P E T de pha t hien ung th u d giai doan s d m ca H~inh anh ung th i/d i can xuang dien hinh ve vi tri va c h u c nang cua khoi u Cong hudng tip hoac cat Idp vi tinh C o ch in h xac ca o h o n ve hinh anh ton th u o n g Tuy nhien kho th u c hien d u o c toan than va gia th a n h d lt 694 H u Cj n g d A n c h A n d o A n v A e i f u t r i b E n h N o i k h o a Sinh thidt xuxmg - Sinh thiet xu’o n g du’d i hu’d n g d in cua C T lay m o benh hoc xe t n gh iem giai phau benh cSltctc coi la tieu chuan vang Tuy nhien, co the th u c hien sinh thiet m u neu d vj tri nong n h u gai ch a u tn /d c tren M o benh hoc co nhay khon g cao va co the cho ket qua am tin h gia sinh th ie t khon g d i/o c dung to c h d c ung th u \ - C an th u c hien cac th a m khac de chan doan ung th u n gu yen phat T uy nhien, cung co n h d n g tru’d n g h o p khong th e pha t hien du’o c ung th u nguyen phat ill o i£ u t r ! - M uc d ic h d ie u tri + D ieu tri trieu ch d n g : giam dau, dieu tri gay xu’o n g , tang calci m au, nang ca o s d c de khang td nang cao chat lu’o n g cu o c song + N gan chan va /h o a c lam giam qua trin h huy xu’ong , lam cham q u a trin h tie n trien cua benh Oi§u trj trieu chdng - G iam dau: - D ie u tri giam dau th e o bac thang giam dau cua W H O B a c 1: p a ce ta m o l (lieu n g u d i Idn 0 m g -1 0 m g /c d m oi -6 g id neu can va khon g qua 4000m g/ ngay, lieu cho tre em < 12 tu o i la 10-15m g/kg can n a n g /c d m oi 4-6 g id ) B a c 2: p a ce ta m o l + code in (E fferang an codein, U ltracet (3 ,5 m g tra m a d o l + 325 m g acetam in ophen ) lieu dung 1-2 v ie n /c d 4-6 g id va khong qua vien/ngay, dung khon g qua ngay, giam lieu d nhdng benh nhan suy gan, suy than, n g u d i gia) B a c 3: m orp hin hoa c cac dan xuat cua m orp hin (m orphin su lp h a t 10m g, lieu th e o td n g m d c dau cua benh nhan, co th e s d dung dang uong hoa c tiem , lieu dao d on g -3 m g /c d m oi g id neu can) - D ung th u o c chon g vie m khon g steroid cung co ta c dung cho n g vie m va g ia m dau tron g ung th ir di can xu ’ong C hon m ot tron g so th u o c sau (lu’u y tu ye t doi khon g phoi h o p th u o c tron g nhom vi khong tang ta c dung dieu tri m a lai co nhieu ta c dung khong m ong m uon): + D iclofena c (V o lta re n ) vie n 50m g x vie n /n g a y chia ho a c vie n m g x vie n /n g a y sau an no Co the s d dung dang ong tie m b ip m g /n g a y tron g 2-4 dau benh nhan dau nhieu, sau chuyen sang du’d n g uong + M eloxicam (M ob ic) vien 7,5m g x vie n /n g a y sau an no hoa c d an g ong tie m b ip 15m g/ngay x - neu benh nhan dau nhieu, sau ch uye n sang du’d n g uong + P iro xicam (F e ld e n ) vien hay ong 20m g, uong v ie n /n g a y uong sau an no hoa c tie m b ip ong - dau benh nhan dau nhieu, sau c h u ye n sang du’d n g uong + C e le co xib (C e le b re x) vie n 200m g, lieu den v ie n /n g a y sau an no K h o n g nen dung cho benh nhan co tien s d benh tim m ach va than tron g h o n d n g u d i cao tuoi - Ket h o p th u o c chon g tra m cam d n h d n g benh nhan co bieu hien lo lin g hay tra m cam nhieu thuoc am itrip tylin 25m g, lieu 1-4 vie n/n gay, d o g m a til 50m g, 2-6 vien - D ieu tri tang calci m au + Truyen dich pha loang: dung dich natri clrorid 9%o 3- lit/n g a y (2 0 -3 0 m l/g id va tri n ird c tteu 0 -2 0 m l/g id ) v d i dieu kien huyet ap cho phep T ruyen dich qua tin h m ach trun g ta m la to t n h lt + L o i tieu: dung nho m fu ro se m id 20m g (tiem tin h m ach), s d d un g tron g va sau tru ye n drch + C alcitonin: tiem b ip hoa c tru ye n tin h m ach pha v d i natri clro rid 9%o co ta c dung calci m au rat H i / th e v u i g a p o n g u ’d’i tre n tu o i, y e u c o k h o n g d o i xu n g , yeu co ngon chi, sin h th ie t c o co ca c kh d n g bao cd vien va b i t m a u b a z o tro n g te bao C h in d o a n p h a n b ie t V iem da c o va vie m da c o can phan biet v d i m ot so tin h tra n g benh li - Y eu c o tien trien m an tin h hoa c ban cap cac benh li ve th a n kinh n h u te o c o ton th u a n g tuy, benh x o hoa cot ben, loan du’d n g c o , benh c o ch u ye n hoa, b en h c o roi loan noi tie t n h u c u d n g hoac suy giam , cu’d n g vd th u g n g than, benh n h u o c co C a c dau hieu ve than kinh van dong cac xet nghiem horm on, dien c o va sinh th ie t c o cd the g iiip phan biet cac benh li - Yeu c o cap tin h ca c benh li than kinh n h u hoi c h irn g G u illa in -B a rre , vie m tu y c i t ngang, nhiem doc than kinh, vie m tu y virus cac benh li yeu c o th u ’d n g kem dau hieu dau, co rut co Cac viem c o chuye n hoa, virus, vi khuan, ki sinh trun g K hai th a c tie n s ir, kham lam sang va cac xet nghiem ve vi sinh va t cd the g iiip phan biet - B enh li c o th u o c g a y b d i m ot so th u o c n h u AZT, ca c th u o c m d m au, ch o ro q u in e co lch icin e , ca rb im a z o le , m o t sd th u o c ch e n th a n kin h c o n h u p a n c u ro n iu m B ieu hien lam sang cd rat giong vie m da c o K h a i th a c kT bie u hien lam sang va d a c bie t tie n s ir d u n g th u o c cd th e g iup xac djnh chan doan - Y eu c o dau c o hoa c benh kh d p M ot sd tin h tran g benh li n h u dau c o thap, cac benh viem kh d p cd the gay dau va yeu c o lan toa ho a c gan vj tri k h d p ton th u o n g K ham lam sang, cac xet n gh iem ve vie m va m ien djch g iiip chan d oa n cac benh D a c biet sinh th ie t c o ch o ket qua b in h th u a n g H i/O n g d A n c h A n o o A n vA p i £ u t r i b En h N p i k h o a 701 III Ol£u TR! M u c tie u d i§ u trj - N h im cai thien c a lu c c a qua cai thien v a tri c h irc nang van d on g tron g sinh hoat hang - G iam cac trieu c h irn g ngoai c o nhu sot, cac ton thu’a n g da, nuo t kho, noi kho, kho th o D a n h g ia t r u a c d ie u trj - N h im th e o doi va danh gia dap irn g dieu tri - D anh gia c a lu c q u a kham th u c the va s ir dung cac p h u a n g phap dinh lu o n g vi du danh gia th o i gian n g u o i benh th u c hien lan d u n g day tir tu the ngoi ghe - X q uang phoi, c h irc nang ho hap, cac xet nghiem m en c o (CK, a ldola se, SGOT, SGPT, LD H) C a c b ie n p h a p k h o n g d u n g th u d c - N g hi n g o i tai g iu o n g xen ke v o i cac bai tap thu dong tro n g giai doan viem c a nang n h im tri c h irc nang van d on g va tra n h co c irn g - N gay cac trie u c h irn g d u o c cai thien can ap dung cac bai tap tic h cue C a c th u d c d i4 u trj - C o rtico ste ro id : p re d n is o lo n e d u o n g uong d u o c c h i dinh s o m v o i lieu 1m g/kg/ngay Sau 3-4 tuan v£ cac trieu c h irn g d u o c cai thien co the giam lieu 5-1 Omg m oi 3-4 tuan cho den lieu thap nhat co hieu qua V o i cac tru o n g h a p nang co the b i t dau b ln g d u a n g tru ye n tin h m ach N eu sau thang dieu trj bang p re d n iso lo n e m a kh o n g co s u cai thien ve cac trieu c h irn g thi can ch i dinh cac thuoc ire che m ien dich C o rtico ste ro id d u o n g tai cho chi dinh tron g cac tru d n g h o p co ton th u a n g da viem da co -A z a th io p rin (im u n ): lieu 2-3m g/kg /n gay K hong dung cho phu n u co thai hoac s ip co thai Can theo doi cong th irc bach cau, nhat la cac tru d n g h o p dung lieu cao, cd suy gan, than - M eth otrexa t: d u d n g uong lieu 10-20m g/kg/tu an, d u d n g tiem d u d i da hoa c tTnh m ach tu 15-50m g/ tuan C an th e o ddi bach cau, c h irc nang gan, than, c h irc nang ho hap tron g qua trin h dieu tri N g irng thuoc bach cau d u d i 0 /m m hoac cd ton th u o n g gan than, tru d c cd thai thang - C y c lo p h o sp h a m id : tru ye n tTnh m ach, lieu 0,5-1 m g hang th a n g tron g thang, dung phoi h o p v d i m esna tru ye n tin h m a ch (tha m khao pha c dieu tri cyclo p h o sp h a m id ) T h a n trpn g v d i cac tru d n g h o p suy than T ac d u n g phu cd the gay giam bach cau, suy buong trirn g , vie m bang quang chay m au, vd tinh trung C an th e o doi co n g th irc m au, tieu cau, h e m a to crit tron g q u a trin h d ieu tri - C yclo sp o rin A (biet d u p e N eoral, S a n d im m u m ): lieu: 2-5 m g /kg /n g a y, ch ia lan dung d o n doc hoac phoi h p p v d i m e th o tre xa t - M yco p h e n o la t m ofe til (C ellC e pt): lieu k h d i dau g a m /n g a y tro n g th a n g dau, sau g am /ngay th a n g tiep, lieu tri 0,5-3 g a m /n g a y tron g 1-3 nam C h ii y ta c d un g phu non, buon non, tieu chay, dau bung C a n th e o doi c h irc nang gan, kiem tra m en gan m ot th a n g sau dieu tri va n h lc lai sau 3-4 th£ng - V d i c£c ton th u a n g da tron g viem da c o cd the can n h ic dieu tri b ln g ch lo ro q u in C ac lin g dong ca lci th u d n g kho die u tri M pt so th u o c n h u bisp h o sp h o n a t, co lch icin , p ro b e n e cid , th u o c chen kenh calci cd th e ngan ch a n vie c h inh cac ton th u o n g m d i ket qua c h u a ro rang - V ie m c o th e vu i th u d n g dap irn g kem v d i cac th u o c ire che m ien dich Phoi h o p co rtico ste o id v d i aza th io p rin ho a c m e th o tre x a t cd ket qua tron g m ot so tru d n g h p p H i/O n g d A n c h A n d o a n vA o iE u t r i bE nh N O i k h o a 702 M o t s b ie n p h a p d ie u trj tich e y e co t h e d u ’ O’c a p d u n g - C ac th u o c dieu tri th e o c o che sinh hoc n h u retuxim ab, eta n e rce p t, inflixim ab -T ru y e n im m u n o g lo b u lin m ien dich - Loc huyet tu o n g IV PHONG BENH - Tranh cac nhiem khuan, virus, ki sinh trung la cac yeu to co th e lam k h d i p h a t benh - D ung cac th u o c dieu tri benh can than va dung ch i dinh, th e o doi cac ta c dung phu tron g qu£ trinh dieu tri TAl LIEU TH AM KHAO T a n im o to K , N a k a n o K, K a n o S, M o ri S, U e k i H , N is h ita n i H , S a to T, K iu c h i T, O h a s h i Y "C lassification crite ria fo r p o ly m y o s itis a n d d e rm a to m yo sitis" J R h e u m a to l, 1995 A pr; 22 (4) 6 74 E rratum in: J R h e u m a to l 1995 Sep; 22 (9): 1807 H o c h b e rg , M C , e t al., “R h e u m a to lo g y", ed 2007: M osby D a la k a s , M C , “P o lym yo sitis, D e rm a to m yo sitis, a n d In clu s io n B o d y M yositis, in H arrison's P rin cip le s o f In te rn a l M edicine", Fauci, A S., et al., E ditors 2008, M cG w -H ill M c P h e e , S J., M A P a p a d a k is , a n d L M , Tierney, “C u rre n t M e d ic a l D ia g n o s is & Treatm ent", 47th ed 00 : M cG raw -H ill