I. DAI c u a N G
V ie m xu 'o n g tu y n h ie m kh u a n (O s te o m y e litis ) hay co t tu y v ie m la tin h tra n g n h ie m tru n g ca p hay m an tin h cua xu’o n g , th u ’o n g la cu a vo h oa c tu y xu’o n g do vi kh u a n sin h m u k h o n g d a c hieu (kh o n g phai do lao, pho ng, nam , ki sin h tru n g ) g ay nen.
C o hai du’d n g lay n hiem ch in h : vie m xu’o n g tuy nhie m khu a n th e o du’d n g m a u c h ie m 2 0 % ca c tru d n g h o p , chu yeu g a p d tre em (th u ’d n g ton th u o n g d xu’o n g dai), sau d o la n h u ’ng n g u d i Idn d a n g truyen th u o c du’d n g tTnh m a ch (th u ’d n g ton th u ’o n g d co t song du’d i d a n g v ie m d o t so n g d ia dem ). V e nguyen nhan, tre n 9 5% tru ’d n g h o p g ay ra do d uy n ha t m ot loai vi kh u a n , hay g a p n h a t la tu cau va n g (khoang 50% tru’d n g h g p ). C a c vi kh u a n thu’d n g g a p kh a c bao go m lien cau tan h u y e t n h o m B, E s c h e ric h ia coli hay gap d nhom tre s o sinh; lien cau nho m A hay gap d nho m tre Id n tu o i h o n . T rong vie m dot song d ia dem , E. c o li va c a c tru e khu a n du’d n g ruot kh a c ch ie m k h o a n g 2 5 % tru ’d n g h g p . Tu cau vang, tru e khua n m u xa n h h ay g a p tro n g vie m xu’o n g tu y nhie m kh u a n d b e n h n h a n d a n g tru y e n m au tro n g benh vie n va thu’d n g khu tru d c a c xu ’o n g cung , xu’o n g d c don h o a c co t so n g ; tro n g khi do, S a llm o n e lla va ty cau vang la n g u ye n nha n c h in h tro n g vie m xu’o n g tu y nhie m k h u a n c a p tin h vi tri xu’o n g dai tro n g nhom benh nha n bi c a c b e n h li m au.
V ie m xu ’o n g tu y du’d n g ke can ch ie m k h o a n g 8 0% ca c tru ’d n g h g p , ch u ye u xa y ra d n g u d i Idn.
Bao go m sau ch a n th u ’o n g tr y c tiep, sau ch a m c d u , bi can h o a c sau p h a u th u a t, th a y k h d p gia hoac tu o n hiem khu a n pha n m e m ke can g ay ra. V e ngu ye n nhan: tre n 5 0% la d o tu cau vang, d o n g th d i ty cau va n g cung la n g u ye n nha n can ban cua vie m xu’o n g tu y n h ie m kh u a n sau pha u th uat. Tuy nhien.
khac v d i d u ’d n g m au, vie m xu ’o n g tu y du’d n g ke can th u ’d n g p h a n lap d u g c nhieu vi kh u a n tai o nhiem khua n n h u ty cau va n g , ty cau da, vi khua n G ra m am cung n h u c a c vi kh u a n ai kh i khac. V ie m x u o n g tu y n hiem kh u a n sau p h a u th u a t h o a c sau nhie m kh u a n p h a n m e m v u n g hau hgng, xo a n g tieu hoa hoa c tie t nieu co th e d o n h ie u vi kh u a n yem kh i va ai khi. N h ie m k h u a n d o tru e kh u a n m u xanh th u d n g sau dam phai dinh.
II. c hAn d oAn
1. C h a n d o a n x a c d jn h : d u a va o trie u c h u n g lam sang , can la m sang.
a. L a m s a n g
Co hai the la viem x u o n g tuy nhiem khuan d x u o n g ngo ai bien va vie m d ot song d ia de m nhiem khuan.
- Toan than: tin h tra n g n h ie m tru n g n h u sot, ret run, m oi kho, lu d i ban, h o i th d hoi.
- Tai cho:
+ T h e vie m x u o n g tu y n h ie m kh u a n d n g o a i bien: v d i d o i cap th u d n g g a p d tre em , s u n g non g do dau nhieu p h a n m e m ta i cho. T ru d n g h g p vie m tie n trie n m a n tin h trie u c h u n g ta i c h o am i, dau, tie t dich dai d in g , co th e h in h th a n h lo ro tu x u o n g ra n g o a i da, c h a y m u h ay th o a t ra m a n h x u o n g chet. V tem
H i / O n g d A n c h a n d o A n v A b i E u t r i b £ n h Npi k h o a 6 8 3
c o th e lan ra to chipc xu n g q u a n h g ay vie m co , ap xe c o hay vie m k h o p n hiem khuan.
+ V ie m d o t song dTa de m (la dang pho bien nhat cua vie m xu’o n g tu y nhie m kh u a n th e o du’o n g m au d n g ird i Ion). V i tri ton thu-ong th u ’o n g gap d cot song th a t lu n g (50% ), co t song n g u c (3 5 % ) va cot song co. trie u chipng dau am i, co c o canh song, han che van don g co t song, co th e co trie u c h u n g chen ep th a n kin h n h u liet tip chi h ay liet hai chi d u d i, roi loan dai tieu tie n ,... do ca c bien chipng chen ep cua o ap xe h o a c xep, tr u o t d o t song. C o th e co lo ro canh co t song ch a y dich mu.
b. T h a m d o c a n la m s a n g - C h an d o a n h in h anh:
+ X q u a n g x u o n g ngo ai bien: la th a m d o th u d n g quy. C o th e th a y hin h anh s u n g ne phan m em , dau hieu phan ipng m a n g x u o n g , h in h anh tieu x u o n g , co th e co b d vie n d a c x u o n g q ua nh o tieu x u o n g hoac m anh x u o n g chet. T ru d n g h o p vie m dTa dem d o t song dien h in h la h in h anh hep khe lien dot song, dot song bi bao m o n n h a m n h d d c h6 tie p giap v d i dTa de m ton th u o n g .
+ C h u p ca t Id p vi tin h : ch i d in h tro n g ch a n doan n h u n g ton th u o n g vie m x u o n g d n h u n g vi tri kho xac dinh b d i c h u p X q u a n g th u d n g q uy n h u x u o n g sg, x u o n g chau , co t song h o a c nhCpng ton th u o n g viem x u o n g s d m m a c h u p X q u a n g c h u a ro hoac de dan h gia ca c ton th u o n g pha n m em phoi h g p , d ac biet khi co tie m th u o c can qu a n g .
+ C h u p co n g h u d n g tip: chi dinh tron g tru d n g h g p vie m d ot song dTa de m h oa c khi vie m x u o n g m a nghi n g d co to n th u o n g pha n m em kem theo. C o th e th a y ro ton th u o n g d o t song, dTa dem , cac ap xe c o canh co t song , a p xe tu y song , ap xe tru n g th a t va ton th u o n g pha n m e m khac.
+ S ieu am : p h a t hien s u n g ne phan m em , dich kh d p , ca c ap xe c o kem theo.
- C h g c hut b in g kim m il h oa c d u d i h u d n g dan cua sieu am , m an huynh q u a n g ta n g sang h oa c ch u p cat Idp vi tin h lay b e n h p h a m soi tu o i, nhu om gram , nuoi ca y tim vi khua n, lam kha n g sinh do.
- C h up xa h in h x u o n g 3 pha (dung te c h n e tiu m 9 9 m ) de ch a n d o a n s d m vie m x u o n g tu y nhiem khuan tro n g 2 4 -4 8 g id dau.
- X e t n g h ie m te b a o m a u ngo ai vi phat hien tin h tra n g viem : ba ch cau m au b in h th u d n g h oa c tang nhe, m au lang va C R P (p ro te in C pha n u n g ) th u d n g tang. C a y m au, nuo i ca y tim vi k h u in lam khan g sinh do.
C h an d o a n x a c din h khi co it n ha t 2 tro n g 4 tieu c h u a n sau:
- X e t n g h ie m d ich h ilt tu x u o n g ton th u o n g co mu.
- C a y m au h o a c b e n h p h a m lay tip x u o n g ton th u o n g d u o n g tin h v d i vi khua n.
- Lam sang die n h in h v d i s u n g dau nong do pha n m em tai cho.
- D au hieu tre n ch u p X q u a n g h oa c chup c i t Id p vi tin h , ch u p cong h u d n g tip co tie u x u o n g , phan u n g m ang x u o n g die n h in h h o a c h in h anh vie m d ot song dTa dem .
2. C h a n d o a n p h a n b ie t: d u a va o c a c d a c d iem lam sang, ch a n doa n h in h anh va xet ngh iem - T ru d n g h g p ton th u o n g x u o n g ngo ai bien: pha n biet v d i c a c v ie m p h a n m em , vie m k h d p nhiem khua n h ay v ie m k h d p vo khua n, benh gut hay gia g ilt, cac g a y x u o n g , nho i m au x u o n g . u x u o n g lanh tin h hay ac tin h , nho i m a u x u o n g ,...
- T ru d n g h g p v ie m d o t song dTa dem : phan biet v d i u tu y song x a m lan dot song , n hiem khu a n tu y song, v ie m dTa d e m d o t song do lao, ca c roi loan d ia d e m co t song vo k h u a n n h u th o a i hoa, benh S c h e u e rm a n n , u x u o n g lanh tin h hay ac tin h , nhoi m au th a n d ot s o n g ,,..
3. C h a n d o a n n g u y e n n h a n : phan lap vi khua n d u a v a o C a y m au hay ca y ben h pha m C o th e p h a n la p d u o c nhieu vi khua n tai o nhiem khua n
6 8 4 HuOn g dAn c hAn o oAn vA o iCu t r i b£n h No i k h o a
III. D ltU TR|
1. N g u y e n t i c
C han d o a n b e n h s o m , d u n g n ga y kh a n g sinh, d in lu’u m u va to c h u c hoa i ti> (neu co), b at dong x u o n g khi can de tra n h g a y xu’o n g . T h u c hien n g a y ca y m au, c iy d ich h ut t u xucrng to n th u crn g (neu co the), soi tu o i, n h u o m g ra m tim vi kh u a n tru ’d c khi ch o kh a n g sinh. L u a c h o n k h a n g sin h ban dau d u a vao ket q u a n h u o m g ra m (am h ay d u o n g ), lu a tuoi, d u d n g lay n h ie m d e d u d o a n vi k h u in g a y benh (phan dai c u o n g ).
K h ang sinh th u o c n h o m diet khua n, lieu cao, k h d i dau dun g d u d n g tin h m ach. Khi co ket q u a khang sinh do, die u tri th e o ke t q u a dap u n g va kh a n g sinh do.
2. D ie u trj cu th e a. D ie u t r i k h a n g s in h
• Khi c h u a co kh a n g sin h do: tro n g da so tru d n g h o p nen d u n g k h a n g sin h nh o m c h o n g tu cau vang lieu cao (o xa cillin , n a fcillin , c e fa zo lin h oa c v a n c o m y c in ) n h u trin h b a y d d u d i, neu ngh i n g d nhiem khuan G ra m am can ket h g p v d i th u o c th u o c nho m c e p h a lo s p o rin th e he 3 h o a c a m in o g ly c o s id hoac flu o ro q u in o lo n . Khi lam sang ngh i n g d n hiem khu a n do c a c vi kh u a n sau:
- D o tu cau vang:
+ O xa cillin (h o a c c lo x a c illin ) 2 g /la n d u n g d u d n g tin h m a ch (T M ), n g a y d u n g 4 lan ca ch 6 g id . T h d i gian dung d u d n g T M it n h a t 2 tu a n , neu dap u n g to t co th e c h u y e n u o n g 1 g /la n , 4 la n/n gay. to n g th d i gian 4 -6 tuan.
+ H o a c c e p h a z o lin 1 -2 g /lin T M nga y 3 lan ca ch nha u 8 g id it n h a t tro n g 2 tu a n , sau ch u ye n d u d n g uong c e p h a le xin 1 -2g/lan , n ga y d u n g 4 lan, to n g th d i gia n 4 -6 tuan.
+ H o ac c lin d a m y c in 6 0 0 m g /la n TM , n ga y dun g 3-4 lan. Sau do, c h u y e n uon g c lin d a m y c in 300- 4 5 0 m g /la n , n ga y uon g 4 lin , to n g th d i gian kh o a n g 4 -6 tuan.
+ T ru d n g h g p tu c iu va n g kha n g m e th icillin : v a n c o m y c in 1 g /lan p h a 1 0 0 m l d u n g dich m uoi hay d u d n g d in g tru a n g tru y e n T M tro n g 60 phut, ngay 2 lan ca ch 12 g id , sau d o c h u y e n uon g nfam picin 30 0 m g /la n , uong n ga y 2 lan (neu co b in g c h u n g vi kh u a n n ha y ca m ), to n g th d i g ia n 4 - 6 tu in .
- Do nhiem lien cau beta tan m au: b e n zyl pen icillin (p e nicillin G ) 2 trie u U l/la n TM , n ga y 4 lan trong 2-4 tu in . Neu lam sang cai th ie n thi ch u ye n uong a m o xicillin 1 g/lan, n ga y uong 3 lan, to n g th d i gian 4-6 tuan.
- D o nhie m S a lm o n e lla : c ip ro flo x a c in 7 5 0 m g /la n uon g, n ga y 2 lan c a c h 12 g id , tro n g 6 tu a n (chong ch i dinh d phu n u co thai).
- D o nhie m tru e kh u a n d u d n g ru o t E n te ro b a c te ria c e a e : p e fla cin 1 3 m g /kg /n g a y, TM h o 3 c uong chia 2-3 lan, ket h g p kh a n g sin h nh o m a m in o g ly c o s id (n h u g e n ta m ic in 3 m g /k g /n g a y - dun g m ot lan tiem b ip vao b u o i sang h o a c a m ik a c in 1 5 m g /k g /n g a y tie m b ip h o a c pha tru y e n T M ch ia 1-3 la n /n g a y hoSc ce ftria x o n 1-2 g /n g a y TM , n g a y 1 lan h oa c tic a rc ilin 2 0 0 m g /k g /n g a y T M ch ia 3 lan h o a c fosfo rnycin 2 0 0 m g /k g /n g a y T M ch ia 3 lan.
• Khi co kha n g sin h do: die u tri th e o kh a n g sinh do h o a c v in tie p tu c d u y tri th u o c kh a n g sinh tarcrc do neu co hieu qua.
T h d i gian die u trj: tu 4 den 6 tu a n tro n g d o th u d n g 2-4 tu a n d a u d u n g k h a n g sin h d u d n g tTnh m ach.
c3n c u va o d a p u n g la m sang n h a t la tin h tra n g sot, s u n g dau ta i ch o , xe t n g h ie m th e o doi so lu o n g b ach cau, m au lin g , C R R
b. C a c b ie n p h a p k h a c p h o i h g p v d i d ie u trj k h a n g s in h
- H a sot g ia m dau b ln g p a ra c e ta m o l lieu tu 1- 3g/ngay, m oi lan 0,5-1 g kh i so t cao, dau n h ie u NSng cao the tra n g b ln g an uong. nuo i d u d n g q u a ong th o n g h ay d u d n g tTnh m ach.
H i f 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 N p i k h o a 685
- K hi k h a n g sin h co ta c dun g (tren lam sang, xet n g h ie m ), neu b e n h nha n con dau nhieu thi co the pho i ho’p v o i th u o c c h o n g vie m g iam dau nhu1 d ic lo fe n a c 10O m g /ng ay ch ia 2 lan h o a c m e lo x ica m 15m g/
n ga y d e g ia m dau, ch o n g vie m (khong dung ngay ca c th u o c tre n khi ch u ’a d a n h gia du’o c ta c dung cua kh a n g sinh).
- T ru 'd n g h o p vie m d o t song d ia dem : m ac ao nep co t song th a t lu n g , han che van dong cot song khi dau nhieu.
- B at d o n g ta m th d i vu n g xu’o n g vie m n hiem de tra n h dau hay g l y xu’o n g khi van dong, d ac biet khi viem xu’o n g lan rong.
c. P h o i ho>p d ie u trj n o i k h o a v & i d ie u trj p h a u th u a t
- C ot tu y vie m xu’o n g n g o a i vi kem ap xe ngo ai xu’o n g - d u ’d i m a n g xu’o n g hoa c kem vie m k h d p nhiem khua n h o a c k h o n g cai th ie n trie u c h d n g sau 3-5 n ga y du dieu tri dung.
- V ie m d ia d e m d o t song co co t song m at v u n g h oa c co trie u c h d n g chen ep th a n kinh hoac ap xe c o canh co t so n g lan rong kh o n g th e giai q u ye t b ln g dan lu’u du’d i da.
L w u y : tru 'd n g h o p v ie m xu’o n g tu y nhiem khua n m an tin h can d u n g kh a n g sin h th ic h h o p tru’d c khi phau th u a t nhieu n g a y d e kh o n g ch e tin h tra n g nhie m kh u a n . T ro n g pha u th u a t, chu y nao bo ton thu’o n g viem , to c h d c m u, c a c m a n h xu’o n g chet, sau do tie p tu c d u n g th u o c d u ’d n g tin h m a ch 4 -6 tu a n sau m o.
IV. PHONG BENH
T h u c hien vo tru n g tu y e t d o i khi lam ca c thu th u a t, pha u th u a t tie n han h ta i kh d p . D ie u tri to t c a c n h ie m kh u a n tai ca c c o qua n khac, d a c biet ta i da, p h a n m em .
mmmmmmmmmmummmmmsmmmmmmmMmmmmmumaBBm
t A i l i e u t h a m k h A o
1. Le N g o c T rp n g , D 6 K h a n g C h i§n (ch u b ien), "V iem x u v n g tu y x u v n g d u v n g m a u ”, H u’d n g dan dieu trj, ta p II: hu’d n g dan d ie u trj m o t so benh nhie m kh u a n th u ’d n g gap; N ha xu a t ban Y hoc, 200 6; tra n g 32-39.
2. P a s o n e t J, M a g u ire JH , “O s te o m y e litis ”, H a rris o n ’s P rin c ip le s o f In te rn a l M e d ic in e 16th E dition;
M a c G ra w - H ill P ro fe s io n a l, 200 5; p 8 1 8 - 822.
3 .0 s m o n D R ,S te c k e lb e rg J M , O sfeom ye//f/s, In fe c tio u s a rth ritis a n d P ro s th e tic -jo in tin 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 fe c tio u s d ise a se s, 1th E d ition; M a c G ra w - H ill/A p p le to n and Lange, 2001;
p 160 -16 8.
4. H e d s tro m S, L id g re n 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 E d ition, Voi 2;
M osby, 2 0 0 0 ; p 6 /2 .1 -6 /2 .1 0 .