Dị ứng miễn dịch lâm sàng

V i du: chlorprom azin lieu cao se lam ha huyet ap va co the tu vong.. Da May day, phu Quincke, san ngura, viem da tiep xuc, man cam anh sang, do da toan than, hong ban nhiem sic co dinh

X d CtfNG BI HE TH6NG TIEN TRIEN

t _

I O jNH NG H IA

X o c u n g bi he th o n g (X C B H T ) la m ot ben h 11/ m ien dich m an tin h , kh o n g ro can ngu yen, 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 do s y tic h luy co la g e n , lien q u a n den nhieu he c o qua n bao gom ong tie u hoa, tim , p ho i, th a n va m ach m au

II c h A n d o a n

1 C h in d o a n x a c d jn h

a Trieu c h irn g la m s a n g

- Da: d a y c im g da, phu ne, voi hoa, roi loan s lic to da

- K h o p : vie m k h o p , s u n g , nong, do, bien dan g,

- K h am d a u chi: p h a t hien tim , n h o t h oa c hoai tu dau chi (hoi c h u n g R a yn a u d )

- Phoi: ho kh a n , ran no, ran am , hpi c h u n g d o n g dac,

- Tim m a ch : co th e co ta n g h u ye t ap, roi loan nhip tim , tie n g cp m a n g tim , ca c tie n g th o i 6 tim , c£ c

bieu hien su y tim p h a i (g a n to, tTnh m ach co noi, .)

- Tieu hoa: n u o t n g h e n , roi lo an tie u hoa, hoi c h u n g tra o n g u g c

- T han: bieu hie n v ie m ca u th a n , hpi c h u n g th a n h u (H C T H ), su y th a n (phu, dai it, dai do, th ie u nieu,

vo nieu)

b T rieu c h irn g c a n la m s a n g

- C o ng th u c m au: co th e co hong cau (H C ) giam , h e m o g lo b in g ia m , b a ch cau (B C ) tang, toe d p I3ng

m au tang

- D in h lu g n g u re ta n g , c re a tin in tang, kali m a u ta n g tro n g tru o n g h g p co suy than

- T o n g pha n tic h n u o c tieu: p ro te in nieu, HC, BC, tru nieu tro n 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 y e t th a n h : a lb u m in giam , g lo b u lin tang

- D o c h u c n a n g phoi: FV C , F E V 1

- C h u p X q u a n g tim phoi, C T scan long n g u c (neu nghi n g d co to n th u o n g pho i ke)

- Sieu am D o p p e r m ach chi, m ach than: hep m ach, giam toe do dong chay tron g don g m ach, tTnh m ach

+ X o c u n g da: d a y da, c u n g da doi x u n g o ngo n tay, g o c c a c k h o p lien d o t h o a c k h d p d ot ban tay

T o n th u o n g da co th e lien qua n den to a n bo ban tay, co, n g u c , b un g, m at

Ton thu’O’n g d a u c h i do xo> c irn g b i H in h a n h ton th m y n g p h o i k e d o x o c u n g bi

- Tieu ch u a n phu:

+ X o c u n g d a u chi: c a c ton th u ’o n g da m o ta tre n g id i han d ngo n tay

+ Seo lom h o a c m a t Id p m o de m dau ngo n tay, ngon chan: hau q u a c u a t i c m a ch hoSc nho i m au.+ X o h o a hai d a y phoi: h in h anh m d dan g lu d i h o a c not, h in h to o n g h o a c h in h k in h m d d hai day pho i tre n p him th a n g h o a c p him C T scan long n g u c

* C h an d o a n xa c d in h khi co 1 tieu chu a n c h in h h oa c £ 2 tieu c h u a n phu

2 C h a n d o a n p h a n biet

a Viem k h & p d a n g th a p

- V ie m s u n g , nong, d o dau nh ie u k h d p , d ac biet la ca c k h d p ngo n tay, ban n g o n tay.

- C d n g k h d p b u o i sang

- Y e u to d a n g th a p (R h e u m a to id fa cto r) du’o n g tin h d xap xi 8 0 % b e n h nha n

- C h a n d o a n x a c d in h khi co s 4 /7 tie u ch u a n tro n g ban g tie u c h u a n c h a n d o a n v ie m k h d p d a n g thap cua H oi T h a p k h d p hoc H o a Ky nam 1987

b L u p u s b a n d d h e th o n g

- Ban d o h in h canh b u d m d m at, dau k h d p , rung toe.

- X e t n g h ie m kh a n g th e kh a n g nha n pho i h op , kha n g d s -D N A d u o n g tin h

- C h a n d o a n x a c d jn h khi co > 4/11 tieu chua n cua H oi T h a p k h d p h p c H o a K y na m 1997

d u y tri d lieu 5- 1 0 m g/ngay

+ It ta c d u n g tro n g kie m so a t b e n h va n h ie u ta c d u n g phu nen tra n h s u d u n g k e o dai

H A N 0

- C y c lo p h o s p h a m id :

+ C h i dinh: ton th u o n g pho i ke cua x o c u n g bi he th o n g tie n trie n (X C B H T T T ) kh o n g dap u n g v o i cac th u o c khac

+ Lieu lu g n g : uon g 1- 2 m g /k g /2 4 g io hoac tru ye n tTnh m ach 3 - 4 tu a n m o t lan, m oi lan 500 - 1000m g,

g iam lieu khi co s u y th a n T h o i gian dieu tri > 6 thang

+ T h e o doi d ie u tri: C T M 1 tuan/Ia n, xet ng h ie m c h u c nang gan th a n tr u o c die u tri va 1 th a n g /la n tron g th o i gian d ie u tri N g u n g dieu tri neu S LB C < 1.5G /I, TC < 100G /I, HC nieu (+) Bu dich toi da trong

th o i gian dieu tri de ta n g th a i th u o c

- C y c lo s p o rin A:

+ C h i dinh: to n th u o n g p h o i ke cua XC BH T TT

+ Lieu lu g n g : 2 - 5 m g /k g /2 4 g io , uong chia 2 lan tro n g > 6 th a n g

+ T h e o d o i d ie u tri: d o H A hang tuan X e t ng h ie m c h u c nang th a n tru o c d ie u trj va 1 th a n g /la n , m u c loc cau th a n 3 th a n g /la n tro n g th o i gian dieu tri

+ T h u o c c h o n g v ie m k h o n g ste ro id (N S A ID s) co hieu qua tro n g pha n Ion tru o n g h gp

+ T ru o n g h g p co v ie m c o h oa c vie m gan - bao hoat djch kho n g d a p u n g v d i N S A ID s co th e dung

g lu co co rtico id lieu th a p (p re d n is o n 10 - 2 0 m g /n g a y ) Can pho i h g p phu c hoi c h u c nang

+ N eu g lu c o c o rtic o id kh o n g hieu q u a co th e pho i h g p th e m m e th o tre x a t

- Trieu c h u n g tie u hoa:

+ N h u n g b e n h n h a n co roi loan nhu don g th u c qua n nen d u o c an n h ie u b u a nho tro n g ngay va nam cao dau sau an, tra n h an ve dem C an n h lc dun g th e m ca c th u o c kh a n g acid (n h u cim e tid in ,

om eprazol)

+ N h u n g tru o n g h g p co tru o n g bun g, tieu chay, sut can, g iam hap thu do roi loan nhu don g ruot non can dieu tri b ln g c a c th u o c khan g sinh p h o 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 z o l h oa c cip ro flo xa cin m oi d o i 2 tuan C a n bo sung v ita m in va m uoi kh oa ng

-T rie u c h u n g tim phoi:

+ V ie m p h o i ke: g ia i d o a n s o m can d u g c d ie u trj b in g g lu c o c o rtic o id va c a c th u o c u c ch e m ien djch (d a c b ie t la c y c lo p h o s p h a m id ) T ro n g g ia i d o a n cu o i, khi to c h u c x o p h a t trie n n h ie u , can n h ic vie c g h e p p ho i

+ Tan g ap d o n g m a ch pho i d o n th u a n : th d oxy lien tuc, s u d u n g c h o n g don g va die u trj suy tim phai

co the cai th ie n to t c a c trie u c h u n g C a n n h a c s u d u n g ilo p ro s t tru y e n tin h m ach

7 6 8 H i / < 3 n g d a n c h a n o o A n v A d i E u t r i b £ n h NO i k h o a

+ C a c bieu hien tra n d ich m a n g tim , su y tim , roi loan nhip tim d ie u tri tu o n g t u n h u n g b ie u h ie n n£y

6 tro n g c a c b e n h li khac

- T o n th u o n g than:

+ D ung th u o c lo i tie u neu co su y than

+ Neu co su y th a n n a n g kh o n g d a p u n g Igi tie u can can n h ic loc m a u s d m hoSc lien he g h e p thgn + K hi co ca o h u ye t ap ca n dieu tri ha ap b ln g ca c th u o c ch e n ke n h ca lci, ire ch e a n g io te n s in II hoSc

u c che m e n c h u y e n (neu kh o n g co hep d o n g m ach th a n h o a c su y th a n nan g)

TAl LIEU TH A M KHAO

3 A n to n y T.H Lin, P h ilip J C le m e n ts , D aniel E F u rs t (2003) “ U p d a te o n d is e a s e -m o d ify in g

a n tirh e u m a tic d ru g s in the tre a tm e n t o f sys te m ic s c le r o s is R h e u m D is C lin N A m 29, pp 4 0 9 - 426.

4 S a p a d in A N , F le is c h m a je r R (2 0 0 2 ) “ 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.

5 V a len tin i G , B la c k C (2002) “ S yste m ic s c le ro s is ” B est P ra ctice & R e se a rch C lin ica l R h e u m a to lo g y

16, 5, pp 8 0 7 - 816.

6 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 ia g n o s tic

and T h e ra p e u tic C rite ria C o m m itte e (1980) "P re lim in a ry c rite ria fo r th e c la s s ific a tio n o f s y s te m ic

s c le ro s is (s c le ro d e rm a )” A rth ritis R h e u m 2 3 :5 8 1 - 90.

DI UNGTHUOC

I DjNH NGHlA

Di u n g th u o c (d ru g a lle rg y) la pha n u n g qua m ire, b at thu’d n g , co hai ch o c o th e n g u d i benh khi dung hoac tie p x u c v d i th u o c (co s u ket h g p di ngu yen v d i kha n g th e h oa c yeu to tu o n g d u o n g ), do da co giai doan m an cam Di u n g th u o c kho n g phu th u o c va o lieu lu g n g thuoc, co tin h m an ca m cheo, v d i m p t so trieu c h u n g va hoi c h u n g la m sang nhat dinh, th u d n g co bieu hien ngo ai da va rat n g u a Neu dun g lai

th u o c do h oa c ho h a n g v d i no th i phan u n g di u n g se xay ra nang h o n va co th e t u vong

II PHAN BIET Dj U N G TH U O C V Q I M 0 T SO PHAN U N G CO HAI KHAC DO THUO C

- D ac u n g th u o c (idiosyncrasy): la tinh trang m ot ca the nhay cam bat th u d n g , dac biet va bat n g d vd i m ot loai thuoc nao do v d i lieu lu g n g rat thap so v g 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 do phenyltoin hay suy tuy x u o n g do chloram phenicol,

- K h ong d u n g n a p th u o c (in to le ra n ce ): d ay la pha n u n g kich liet, d a c b ie t cua c o th e doi v d i m ot loai

th u o c v d i lieu b in h th u d n g , co khuyn h h u d n g di tru ye n Trieu c h u n g lam sang g io n g ngo d oc th u o c chi xay ra rieng b ie t tre n m o t so it n g u d i, ben h khon g p ha t trie n m a n h h o n hay n gu y hiem h o n khi dung lai

ch in h th u o c do V i du: uon g m ot vai g io t th u o c a tro p in co th e lam gian d o n g t ir h o a c ha h u ye t ap, hay ngu keo dai 16 g id sau khi uong 1 vie n th u o c kha n g hista m in

- D o c tinh cua th u o c (drug toxicity): xay ra d bat ki n g u d i nao hoac nhieu n g u d i khi cung dung m ot khoi

lu g n g thuoc kha Idn hoa c v d i lieu thap khi 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 th u o c co doc tin h cao V i du: chlorprom azin lieu cao se lam ha huyet ap va co the tu vong

- T ac dun g phu cu a th u o c (sid e effe ct): la ta c dong kho n g m o n g m u o n do th u o c, co th e doan tru d c

d u g c v d i m o t loai th u o c n ha t djnh, ngo ai ta c dun g trj lieu ch in h V i du: a tro p in g ay kho m ieng aspirin va

th u o c ch o n g v ie m k h o n g ste ro id g a y loet da day,

- T ac d u n g th u p h a t cu a th u o c (se c o n d a ry effect): bieu hien lam sa n g g io n g nhau se xay ra tren nhu’ng n g u d i cu n g d u n g m o t loai th u o c nao do lieu cao, keo dai V i du: hoi c h u n g gia C u sh in g sau khi dung co rtic o id h o a c lo a n kh u a n , n hiem nam , th ie u v ita m in sau d u n g kh a n g sinh,

III B |£U HIEN LAM SANG D| U N G TH U O 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

Toanthan Soc phln ve, ha huyet ap, sot, viem mach, sung hach, benh huyet thanh.

Da May day, phu Quincke, san ngura, viem da tiep xuc, man cam anh sang, do da toan than, hong ban nhiem sic co dinh, hoi

chung Stevens-Johnson, hoi chirng Lyell.

Phoi Kho thd, viem phe nang.

Gan Viem gan, ton thuong te bao gan.

Than Viem cau than, hoi chirng than hu.

Mau Ban xuat huyet giam tieu ciu, thieu mau tan huyet, giam bach cau hat.

X u a t hien sau khi d u n g th u o c vai p hu t hoa c vai g id , c h a m h o n so v d i m a y day, b ie u hie n tro n g da va

to c h d c du’d i da co td n g d a m s u n g ne, du’d n g kin h td 2 - 1 0cm , th u ’d n g x u a t hie n d n h d n g v u n g da co

to c h d c long leo: m oi, co, q u a n h m at, bung, bo pha n sinh due, th a n h q u a n , ruot, da day, nao, td cung

P hu Q u in c k e thu’d n g kh o n g sot, kho n g n g d a , m au da it th a y doi

3 S 6 c p h an ve

Lam sang cua s o c pha n ve kha da dang, th u ’d n g x a y ra c h o p n h o a n g sa u d u n g th u o c td va i giay den 2 0 -3 0 phut, k h d i d a u b ln g cam g ia c la thu’d n g (bon ch o n , h o a n g hot, so’ ch e t, .) S a u d o la s y

x u a t hien n ha nh c a c trie u c h d n g d m o t h oa c nhieu c o qua n n h u tim m a ch , h o hap, tie u hoa, da, v d 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 qua n bung, d a i tie u tie n kh o n g t u chu, m a ch nhanh, nho, h u ye t ap tu t h o a c kh o n g do d u g c , kho th d T h e toi cap n g u d i ben h hon m e, n g h e t th d , roi lo an tim

m ach, n g u n g tim va tu vo n g sau it phut

4 C h d n g m i t b ac h c i u h at

S o t ca o d o t ngot, s d c kh o e g iam sut nha nh, lo et hoai tu n ie m m a c m at, m ie n g , hpn g, c o q u a n sinh due; vie m phoi, vie m t i c tin h m a ch , nhie m khua n huyet, de dan td i t u vo n g

5 B e n h h u y lt th a n h

D o tie m h u ye t th a n h h o a c c a c p ro te in di the, xu a t hien tu n g a y th d 2 d e n n g a y th d 14 sau khi dung

th u o c B e n h nha n m e t m oi, chan an, m a t ngu, buon non, dau k h d p , s u n g n h ie u hach , so t ca o 38°C - 39°C , co th e vie m gan, v ie m than, co th e co m ay day to a n th a n

xu a t hien tre n th a n m in h va m at T o n th u o n g c h u ye n m a u g io n g ba m m a u va lui d a n sau m o t vai tuan

9 H 6 n g ban n h iim s i c c 6 dinh

B e nh x u a t hien sau vai g id h o a c vai n ga y sau d u n g th u o c N g u d i b e n h so t nhe, m e t m oi tre n da

xu a t hien n h ie u ban luc d a u do, sau m au sam , d m oi, td chi, th a n m in h B e n h se x u a t hien d c h in h vi tri

do neu n h d n g lan sau lai d u n g th u o c do h o a c ca c th u o c g io n g no

H A A A A e i £ u £ N

10 H d n g ban da dan g

S au dun g th u o c, ngu-oi ben h thu’d n g m et m oi, sot va xu a t hien nhieu d a n g ton th u o n g da: ban do,

s in , m un n u o c , bon g n u o c , th u d n g co ban hin h bia b ln , tien trie n ca p tin h to a n than

c h im x u it huye t, sau d o Id p th u o n g bi tach khoi da, khe don g td i la tro t ra tu n g m ang D ien tic h da ton

th u o n g > 30% da c o the, co th e vie m gan, than, tin h tra n g n g u d i b e n h th u d n g r i t nang, nha nh dan td i

tu vong

v c hAn o oAn Dj Cp n g t h uOc

- C o q u a trin h d u n g th u o c

- P han u n g di u n g x a y ra sau d u n g thuoc

- C o c a c trie u 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 u a n trp n g )

- Tien s u di u n g (tie n s u di u n g th u o c h oa c di u n g ca nhan, gia d in h )

- X e t n g h ie m (XN ): co m p t X N (+) trd len tu y th e o th e lam sang h o a c loai pha n u n g (phan u n g th o £ t hat (d e g ra n u la tio n ) te b a o m ast, tieu bach cau d ac hieu, te st ch u ye n d a n g lym p h o bao, RAST, .)

VI D I^ U TR|

1 O i§u trj s o c p h a n ve

P h a c d o c ip c u u s o c p h a n ve (th e o th o n g tu 08 ngay 4 -5 -1 9 9 9 cu a B o Y te)

a X lp tri n g a y ta i c h o

- N g u n g n g a y tie p x u c v d i dj n g u ye n (th u o c dan g tiem , uong, boi, nho m it, m ui).

- C h o ben h n h a n n im tai cho

- D ung th u o c: a d re n a lin la th u o c c o ban de chon g soc pha n vp

+ A d re n a lin d u n g d jch 1/1.000, ong 1m l = 1mg, tie m d u d i da n g a y sau khi x u it hien soc phan ve v d i lieu n h u sau: 1/2 - 1 o n g d n g u d i Idn K h ong q u a 0,3 m l d tre em (ong 1m l (1 m g ) + 9m l n u d e c i t = 10m l sau do tie m 0 ,1 m l/k g ) H o a c a d re n a lin 0 ,0 1 m g /k g cho ca tre em lan n g u d i Idn

+ T ie p tu c tie m a d re n a lin lieu n h u tre n 10-15 p h u t/la n cho den khi h u ye t ap trd lai b in h th u d n g

- U im , d i u t h ip , ch a n cao, th e o doi h u ye t ap 10-15 p h u t/la n ( n im n g h ie n g neu co non)

Neu so c q u a nan g de d o a tu vong , ngo ai d u d n g tie m d u d i da co th e tie m a d re n a lin dun g djch

1/1 0 0 0 0 (pha lo a n g 1/1 0) q u a tin h m ach, b o m q u a ong noi kh i q u a n h o a c tie m q u a m ang nhan giap

7 7 2 H U d N G D A N C H A N O O A N V A B l f U T R| B E N H NOl K H O A

+ B op bon g a m b u co oxy

+ D a t ong noi kh i qu a n , th o n g kh i nha n tao M d khi q u a n neu co phu th a n h m on

+ T ru ye n tin h m a ch c h a m d ia p h y llin 1 m g /k g /g id h o a c te rb u ta lin 0 ,2 ^ g /k g /p h u t

C o th e dung:

+ T erbutalin 0 ,5 m g (1m l), 1 ong du’d i da d ngu’d i Idn va 0,2 m l/1 0 k g d tre em T ie m lai sau 6 -8 g id neu kho n g d d kho th d

+ X it hon g te rb u ta lin , s a lb u ta m o l m oi lan 4 -5 nhat bop, 4 -5 lan tro n g ngay

- T h ie t lap m o t du’d n g tru y e n tTnh m ach: a d re n a lin de d u y tri h u ye t ap b i t d a u 0 ,1 p g /k g /p h u t, dieu chinh toe d o th e o hu ye t ap (2m g a d re n a lin /g id ch o ngu’d i Idn 55kg )

- C a c th u o c khac:

+ M e th y lp re d n is o lo n 1 - 2 m g /k g /4 g id h oa c h yd ro c o rtis o n h e m is u c c in a t 5 m g /k g /g id tie m tin h m ach (co th e tie m bap d tu y e n c a s d ) D ung lieu cao h a n neu soc n a n g (g a p 2 -5 lan)

- NaC I 0 ,9 % 1-2 lit d n g u ’d i Idn, kh o n g qua 1 0 m l/kg d tre em

- D ip h e n h y d ra m in 2 5 m g h o a c d im e d ro l 10m g x 2 ong, tie m b ip hay tin h m ach

c D ie u tri p h o i h g p

- U o ng th a n h oa t 1 g /kg can nang neu di ngu ye n qua d u ’d n g tie u hoa.

- B a ng ep chi p h ia tre n c h o tie m (neu di ngu ye n th e o du’d n g tie m )

- C h u y:

+ T h e o doi b e n h nha n it n ha t 24 g id sau khi h u ye t ap da on dinh

+ S au khi s a c im nen ta n d u n g du’d n g tie m tin h m a ch dui

+ N eu h u ye t ap van kh o n g len sau khi tru ye n du dich va a d re n a lin , th i co th e tru y e n th e m huye t tu’a n g , a lb u m in (hoSc m a u neu m at m au) hoSc bat ki dun g dich ca o p h a n tu* san co

+ D ie u d u ’d n g vie n co th e d u n g a d re n a lin du’d i da th e o p h a c do khi y, b a c s i kh o n g co mSt

- K h a n g sin h h is ta m in H i: c h lo p h e n ira m in , p h e n e rg a n , h e x o fe n a d in (T elfast), c e tiriz in (C ezil Z yrte c),

lo ra ta d in (C la rity n e ), d e s lo ra ta d in (A e riu s), le v o c e c tiriz im (X yza l)

+ T h e nhe, vi du: c h lo p h e n ira m in 4m g x 2 v ie n /n g a y x 3 - 5 n g a y h o a c T e lfa st 1 80 m g, uon g 1 v ie n /

n ga y x 3 - 5 ngay

+ N ang: d im e d ro l 10m g, tie m b i p 2 - 4 ong x 3 - 5 ngay Sau d o d u n g uon g: c h lo p h e n ira m in 4m g x

2 v ie n /n g a y h o a c d e s lo ra ta d in (A e riu s), le v o c e c tiriz im (X yza l) 5m g, lo ra ta d in (C la rity n e ), c e tirizin (C e zil,

Z y rte c ) 10m g x1 v ie n /n g a y x 3 - 5 ngay

- C h ong n h ie m trung:

+ Tai cho: th a y vai trai g iu d n g hang ngay V e sinh ca c hoc tu nhien th u d n g xuyen Boi dun g dich

C a ste lla n i v a o n h u n g vu n g da bi loet tra t G lyce rin borat: boi m oi C h i tra h yd ro c o rtis o n va o m it neu khong loet g ia c m ac, th o n g th u d n g hay tra dung dich C B2 n ga y 2-4 lan

+ Toan than: d u n g kh a n g sinh, neu co dieu kien thi dun g kha n g sinh it co n g u y c a di u n g d u a vao phan u n g pha n huy te bao m a st hoac tieu bach cau d ac hieu T h o n g th u d n g hay dun g khan g sinh ho

m a cro lid (it g a y di u n g )

- D inh d u d n g : neu c h u a lo e t tro t d u d n g tie u hoa, can cho an sup du so lu a n g va ch a t lu a n g (giau protein va vita m in ) N eu co loet tro t d u d n g tieu hoa: cung cap nan g lu a n g q u a d u d n g tTnh m ach Can

th ie t co the tru y e n dam , m d ch o n g u d i benh

b D ie u trj d j u n g th u o c

- G lu c o c o rtic o id : m e th y l-p re d n is o lo n (S o lu -M e d ro l 4 0 m g ) h o a c d e p e rs o lo n 30m g x 2-4 Ip/ngay, tiem tTnh m ach 3-5 n g a y dau, sau do g iam lieu b ln g th u o c uong P re d n iso lo n 5m g x 6 -8 v ie n /n g a y x 3-5 ngay hoac M e d ro l 16m g x 2 v ie n /n g a y x 3-5 ngay C u oi cung p re d n is o lo n 5m g x 2-4 v ie n /n g a y x 3-5 ngay hoac M edrol 16m g x 1 v ie n /n g a y x 3-5 ngay

Neu co ton th u a n g nao, tim m ach, co th e d u n g g lu c o c o rtic o id th e o p h u a n g pha p lieu cao, n g ln ngay ("p u lse th e ra p y ” h o a c “ b o lu s ”): m e th y l-p re d n is o lo n 500-1 OOOmg: pha dich tru ye n dun g dich NaCI0,9% 2 5 0 m l (h o a c d u n g dich g lu co se 5% 2 5 0 m l), tru ye n tTnh m ach X X X g io t/p h u t x 3 ngay, sau do g iam lieu (uong)

- K h ang h is ta m in Hi: d im e d ro l 10m g x 2-4 ong/ngay T iem b ip 3-5 nga y dau, sau do co th e dung

uong C h lo p h e n ira m in 4 m g x 2 v ie n /n g a y h oa c d e s lo ra ta d in (A e riu s), le v o c e c tiriz im (X yza l) 5m g,

lo ratadin (C la rity n e ), c e tiriz in (C ezil, Z yrte c) 10m g, uong 1 v ie n /n g a y x 3-5 ngay

VII BIEN PHAP HAN CH S D| 1>NG TH UO C VA SPV

- T uye n tru y e n v ie c s u d u n g th u o c h a p li, an to a n dun g c h i dinh

- T ru d c khi ke d a n th u o c, n g u d i th a y th u o c pha i khai th a c kT tie n 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 th u o c, th u c an, rat d§ bi dj u n g khi d u n g th u o c P hai d u p h o n g S P V doi v d i

n h u n g b e n h n h a n m a n cam , can n h ic ve lieu lu a n g , d u d n g d u n g va toe d o h ip phu cua th u o c dung trong dieu tri va c h in doa n Khi m o t ben h nhan da co tien s u so c p h a n ve v d i m ot th u o c nao do du nhe cung pha i co g in g tra n h d u n g lai, can hieu ro ca c phan u n g c h e o g iu a c a c loai thuoc

- T ru d c khi tie m k h a n g sin h (p e n icillin , stre p to m y c in ) pha i th u te s t lay da, te s t am tin h m d i d u a c tiem Phai c h u in bi san th u o c va d u n g cu c lp c u u SPV

- Khi d a n g tie m th u o c, neu t h iy co n h u n g cam g ia c k h a c th u d n g (bon chon , hot hoa ng, sa hSi, .) phai n g u n g tie m va kjp th d i x u li n h u soc pha n ve)

- Sau khi tie m th u o c de n g u d i b e n h c h d 10-15 p hu t de de p h o n g S P V xa y ra m u o n h an

- Npi d u n g hop th u o c c ip c u u so c pha n ve:

+ A d re n a lin : 1m g - 1ml: 2 ong

7 7 4 H t f C J N G D A N C H A N o o A n V A O l £ u T RI B f N H NOl K H O A

+ Nu’O’C cat: 10ml: 2 ong.

+ B o m kim tie m vo kh u a n : 10m l; 2 cai, 1ml: 2 cai

+ H y d ro c o rtis o n h e m is u c c in a t 100m g hoa c m e th yl p re d n is o lo n (S o lu M e d ro l 4 0 m g h o a c d e p e rs o lo n 30m g: 2 ong)

+ C on, bong, b a n g g a c vo tru n g

+ D ay garo

+ P h a c d o cap ci>u SPV

tAi l i e u t h a m k hAo

1 N g u y e n V a n D o a n (1 9 9 6 ) "G op p h a n n g h ie n c iru di u n g d o th u o c ta i k h o a D i irn g - M D LS , B e n h

vie n B a ch M a i (1 9 9 1 -1 9 9 5 )" Lua n an pho tien khoa h pc Y -D iro c

2 F o s ter, C o re y ; M istry, N e v ille F.; P e d d i, P a rv in F.; S h a rm a , S h iv a k (2 0 1 0 ) 'A lle rg y a n d

Im m u n o lo g y ” in W a s h in g to n M a n u a l o f M e d ic a l T h e ra p e u tics, C o p y rig h t L ip p in c o tt W illia m s &

W ilkins T he , 33rd E d itio n (8) p.3 5 0 -3 7 0

3 F ritsch P.O., R a m o n R u iz- M a ld o n a d o (2003) “E ryth e m a M u ltiform e , S te v e n s - J o h n s o n S yn d ro m e

a n d Toxic E p id e rm a l N e crolysis" F itzpa trick s D e rm a to lo g y in G e n e ra l M e d ic in e (Vol I): p 5 4 3 - 558.

4 G ru c h a lla R S (2 0 0 3 ) “D ru g allergy" J A lle rg y clin im m u n o l (Vol 111, No 2): p 5 4 8 - 559.

5 H o c k e tt K C (2 0 0 4 ) “S te ve n s- Jo h n so n S yn d ro m e a n d Toxic E p id e m ia l N e cro lysis: O n co lo g ic

co n sid e ra tio n s" C lin J O ncol N urs (Vol 8, No 1): p27-30

6 O Jo h n M a, D avid M C lin e (2007), 'A n a p h y la x is a n d a cu te a lle rg ic re a ctio n s ", E m e rg e n cy M edicine

M anual, 6th E dition S e ct.2, C o pyright, T h e M cG ra w -H ill C o m p a n ie s

7 S h e p h e rd G M , M D (2003) “H y p e rs e n s itiv ity R e a ctio n s to D ru g s: E v a lu a tio n M a n a g e m e n t' T he

M o u n t S inai Jo u rn a l o f M e d ic in e (Vol 70, No 2): p113-25

LUPUS BAN DO HE THONG

I OjNH N G H lA

B enh lu pus ban do he th o n g (syste m ic lupus e ry th e m a to s u s - S L E ) la m ot benh t y m ien, tro n g do

ca c te bao va to chi>c bi ton th u ’a n g b d i s u lang don g ca c tu kha n g th e ben h li va p h u c h a p m ien dich

- T on th u a n g da: ban d o h in h canh b u d m , ban dan g dia, lo et m ieng, phu,

- K h dp: dau k h d p (co s u n g , nong, do, co hoac khon g kem th e o tra n dich), co th e tai p ha t nhieu lan

- T rieu c h u n g noi tang:

+ Tim m ach: trie u c h u n g vie m m ang ngo ai tim , tran dich m a n g ngo ai tim (co th e co ep tim ), vie m npi tam m ac, vie m c a tim , ta n g h u ye t ap (HA), co the co bieu hien su y tim , (gan to, tin h m ach co noi, nhip

n g u a phi, .)

+ Phoi: co bieu hien vie m m ang phoi co hoa c khon g kem th e o tra n dich m ang phoi, vie m phoi ke, tru d n g h o p n a n g c h a y m au phe nang

+ T han, tie t nieu: co th e co ca c dau hieu vie m cau than, hoi c h u n g th a n h u (H C T H ), suy th a n (phu,

co tru d n g , dai it h o a c vo nieu, .)

+ Tieu hoa: non, b u o n non, tieu chay, dau bung, trie u c h u n g ban t i c ruot th u d n g x u a t hien tro n g d p t bung phat

+ T h a n kinh, ta m th a n : co giat, roi loan tam than

+ C o th e co trie u c h u n g h u ye t hpc (thieu m au, xu a t h u ye t g iam tieu ca u ) h oa c vie m m ach

b T rieu c h tin g c a n la m s a n g

- X e t n g h ie m c a ban:

+ C o ng th u c m au: hon g cau (H C ) giam , h e m o g lo b in (H b) g ia m khi co th ie u m au, co the co bach cau (BC ) giam , tieu ca u (T C ) giam

+ Toe do lin g m au: ta n g cao

+ M en gan: AST, A L T ta n g tro n g giai doa n hoat dong benh

+ Ure ta n g , c re a tin in ta n g khi co suy than, dien giai do co th e co ta n g kali, g ia m natri m au

+ T o n g p h a n tic h n u d e tieu: p ro te in nieu cao, HC, BC nieu khi co to n th u a n g than

+ D ie n ta m do: nh jp nha nh, d ie n th e ngo ai bien th ip ,

+ C h up X q u a n g tim phoi: co the t h ly hinh anh tran djch m ang phoi, tra n djch m a n g tim , viem phoi k e , + Sieu am bu n g : co th e t h ly gan to, hin h anh th a n teo nho, ranh g id i vo th a n , tu y th a n kho n g ro d nhu’ng tru d n g h p p su y th a n m an,

- X e t n g h ie m c h u y e n khoa:

+ K h a n g th e kh a n g nha n (A N A ) d o n ha y cao n h u n g do d a c hieu k h o n g cao doi v d i lupus

7 7 6 H U O N G D A N C H A N O O A N V A D l f U TRI B t N H NOl K H O A

+ K h ang th e k h a n g ds - D N A d ac hieu v d i lupus

+ S ieu am tim : co th e th a y h in h anh tran dich m ang ngo ai tim , EF g ia m khi co su y tim

- Ban h in h ca n h b u d m d m at: co djnh, p h in g h oa c g o len m a t da, lan to a hai ben m a

- Ban dan g dia: h in h tro n g d len m at da, lorn d g iu a co th e ke m th e o se o te o da

- N h a y c a m anh sang : khi tie p xu c v d i anh sang co th e g a y ban d o x u a t hien

- L oe t m ieng : b a o g o m lo e t m ieng , m ui hpng do th a y th u o c q u a n sa t thay

- V ie m k h d p : m o t h o a c n h ie u k h d p ngoai bien v d i c u n g kh d p , s u n g h o a c tra n djch

- R oi lo an h u ye t hpc: th ie u m au tan m au; h o a c g iam b ach cau d u d i 4 G /L ; h o # c g ia m ly m p h o bao

d u d i 1 ,5G /L h o a c g ia m tie u cau d u d i 10OG/L khi khon g co sai lam tro n g d u n g th u o c

- R oi loan m ie n dich: x u a t hien kha n g th e kh a n g d s-D N A , kh a n g S m v a /h o a c kh a n g p h o s p h o lip id

+ Y e u to d a n g th a p (rh e u m a to id fa cto r) d u a n g tin h a xa p xi 8 0 % b e n h nha n

+ C h an d o a n xa c d jn h khi co > 4/7 tieu ch u a n tro n g b a n g tie u ch u a n ch a n d o a n v ie m k h d p d a n g th a p cua H oi T h a p k h d p h pc H oa Ky nam 1987

- X a c u n g bi:

+ G ia i doa n d a u co th e c h i co bieu hien dau kh d p , ton th u a n g noi ta n g , k h a n g th e k h a n g n h a n d u a n g tin h n h u SLE

+ Khi b e n h tie n trie n ton th u a n g sam da, day da, c u n g da, m a t sa c to d a n g a y ca n g ro h a n

+ C h an d o a n x a c d jn h khi co 1 tieu ch u a n ch in h h o a c > 2 tie u c h u a n p h u tro n g b a n g tie u ch u a n chan

- Lieu lu’a n g tu y tu n g loai th u o c va tu y th e o m d c do cap tin h cua benh.

- N S A ID d o c v d i gan va th a n can tra n h s u dung ch o n h u n g ben h nha n lu p u s co vie m than

2 T h u o c k h a n g s o t re t to n g h g p : (ch lo ro q u in , h yd ro x y c h lo ro q u in )

- T a c d u n g d ie u tri ban do, nhay ca m anh sang, dau kh d p , vie m kh d p , rung toe

- Lieu tu 2 0 0 -4 0 0 m g /n g a y uong sau b u a an

- C h ong c h i d in h v d i b e n h nha n vie m gan, th a n va phu n u co thai

- C an kham m it tru d c dieu trj va 6 th ang/la n trong qua trin h dieu tri vi th u o c co d oc tin h v d i vong mac

d u g c c h i d in h tro n g c a c tru ’d n g h g p co ton th u ’a n g noi ta n g h oa c tro n g d o t cap

- Lieu ca o d u ’d n g tin h m a ch (p u lse th e ra p y): m e th y lp re d n is o lo n 2 5 0 - 100 0 m g /n g a y, tru ye n tTnh

m ach tro n g 30 phu t, tru y e n 3 n ga y lien tiep, sau do ch u ye n ve lieu tru n g b in h Lieu cao du’d n g tin h m ach

th u d n g d u g c c h i d in h de die u tri tan cong tro n g ca c tru’d n g h a p b e n h n a n g d e doa s y song h o a c khon g d£p d n g v d i lieu th o n g th u ’d n g

- T h e o doi d ie u trj: h u ye t ap, du’d n g m au, ca lci m au, c o rtis o l m au, te s t A C T H , ca c trie u c h d n g cua viem lo et da d a y - ta tra n g , do m at do xu’o n g (neu co dieu kien)

• C a c th u o c d c c h e m ien djch

- M e th o tre x a t, c y c lo p h o s p h o m id , a za th io p in , m y c o p h e n o la t m o fe til,

+ C h i dinh: k h o n g d a p d n g v d i c o rtico id ; pho i h g p v d i co rtic o id de han ch e ta c d u n g phy

- M e th o tre xa t:

+ C h i djn h c h o c a c tru ’d n g h g p lu p u s co vie m da va v ie m k h d p cap

+ Lieu lu g n g 7 ,5 m g uong 1 la n /tu a n co th e ta n g len td i 2 0 m g uon g 1 la n /tu a n , g ia m lieu doi v d i

+ T a c d u n g p h y: n h ie m kh u a n , nhie m virus, u c che tu y x u a n g , g ia m b a ch cau, th ie u m au, g ia m tieu cau, v ie m b a n g q u a n g c h a y m au, ung th u b a n g qu a n g , non, tie u chay, khoi u ca c tin h , vo sinh, .-A z a th io p rin :

+ C h i d jnh: v ie m th a n lu pus, dieu trj d u y tri vie m th a n lu p u s sau khi da d ie u trj p u lse m e th y lp re d n is o lo n

va b o lu s c y c lo p h o s p h a m id

+ L ie u lu g n g : 2 -3 m g /k g /n g a y uong, g ia m lieu neu do th a n h th a i c re a tin in < 5 0 m l/p h u t

- D u y tri ch e do an n ha t 2 -3g m uoi/nga y, han ch e da m 0 ,6 - 0 ,7 g /k g ca n n a n g c o the.

- C o rtico id lieu ca o d u d n g tin h m ach (P u lse th e ra p y ) h o a c c y c lo p h o s p h a m id d u o n g tin h m a ch 500-

1 0 0 0 m g /m2 da c o th e 1 la n /th a n g tro n g 6 th a n g dau, 1 la n/3 th a n g tro n g 6 th a n g tie p theo C h o n g chi dinh ch o n h u n g tru d n g h g p suy th a n nang do 3, d o 4 T h e o doi die u tri: C T M 1 tu a n /Ia n , x e t ng h ie m

c h u c nang gan th a n tr u d c dieu tri va 1 th a n g /la n tro n g th d i gia n d ie u tri N g u n g die u tri neu S L B C < 1.5G /L, T C < 100 G /L, HC nieu (+) Bu dich toi da tro n g th d i g ia n die u tri d e ta n g th a i th u o c

- D ung th u o c ha h u ye t ap khi co ta n g huye t ap

- D ung th u o c Igi tie u d uy tri th e tic h n u d e tie u 24 g id k h o a n g 1 5 0 0 m l (ch u y bu du kali), tru ye n

a lb u m in khi can

- D u ng th u o c k ic h th ic h san sin h hon g cau e ry th ro p o ie tin (E p o kin , E p re x)

- C h a y th a n nha n ta o khi co c h i dinh

- Neu tran dich so lu g n g v u a va it dieu tri corticoid; m e th y lp re d n is o lo n 0 ,5 -2 m g /k g /n g a y tie m tin h m ach.

- Neu tra n d ich n h ie u co dau hieu ep tim cap pha i ch p c th a o m a n g tim , p h o i h g p v d i co rtic o id lieu

0 ,5 -2 m g /k g /n g a y tie m tin h m ach

tAi l i e u t h a m k hAo

1 A m e ric a n C o lle g e o f R h e u m a to lo g y ad hoc c o m m itte e on s y s te m ic lu p u s E ry th e m a to s u s

g u id e lin e s (1 9 9 9 ) “G u id e lin e s fo r re fe rra l a n d m a n a g e m e n t o f s y s te m ic lu p u s e ry th e m a to s u s in

adults, A rth ritis <S R h e u m a tis m " Vol 42, N o 9 S e p te m b e r, pp 1 7 8 5 -9 6

T u y th e o th d i g ia n d iin bien, m a y d a y d u o c ch ia th a n h 2 dan g la m ay day cap tin h (dien bien < 6

tu a n ) va m ay d a y m an tin h (dien bien > 6 tuan)

- M ot d ac tru n g c o ban tre n lam sang cua ton

th u o n g m a y d ay la xu h u d n g th a y doi kich th u d c

va h in h th a i rat nha nh, m oi ton th u o n g d o n le

th u d n g x u a t hien va bien m at tro n g vo n g m ot vai

g id , it khi ton tai q u a 8 g id va co th e di c h u ye n tu

vi tri nay sang vj tri khac Noi ch u n g , ton th u o n g

m a y d ay th u d n g xu a t hien ve ch ie u toi va sang

s d m g iam dan va o buoi sang va buo i tru a D a c tru n g nay co th e khien cho v ie c chan d o a n m ay

d a y tre n lam sang gap kho khan vi tai th d i d ie m ben h nhan di kham co th e kh o n g co ton th u o n g

th u c th e tre n da

- M ay day cap tin h th u d n g xu a t hien sau khi tiep xu c v d i dj nguyen gay benh tu vai p hu t den vai

g id , keo dai m ot vai ngay den m ot vai tu a n (n h u n g

d u d i 6 tuan) N g uyen nhan gay benh th u d n g gap

la do ca c loai th u c an (n h u tom cua ca tru n g ,

su a .) thuoc phan hoa long sue va t M ay

d a y m an tin h keo dai it n h a t 6 tuan m o t so tru d n g

II c h A n o o a n

1 D a c d ie m lam sa n g

h o p co th e dien ra d a i d in g tro n g nhieu nam va kh o n g ro can n g u ye n g a y ben h M o t so yeu to n h i/ th a y doi th d i tiet, d o uon g co con, th a y doi n h ie t do m oi tru’d n g d o t ngot, a n h n ln g m a t trd i, gai h o a c co sat, ti

de, m a c du khon g pha i la n g u ye n nhan gay ben h n h u n g co th e k ic h p h a t kh o n g d a c hieu tn e u c h d n g cua ca m a y d ay ca p va m a n tin h

- K hai th a c tie n s u cua ngu’d i ben h co th e tim th a y m oi lien q u a n g iu a s y x u a t hien cua m a y day va vie c tiep xu c v d i c a c yeu to la n h u th u o c, th d c an, hoa chat, noc con tru n g , lo ng sue vat, N g oai ra khai th a c tie n s d dj d n g cu a ben h nhan va gia d in h ngu’d i ben h cu n g co th e p h a t hien d u o c ca c ben h di

d n g kh a c di kem n h u ch a m , vie m m ui dj u n g , vie m ket m a c dj u n g , hen p h e qu a n ,

2 D a c d iem can lam s an g

- Test lay da v d i c a c dj n g u ye n co th e ch o ket qua d u o n g tin h v d i nhCrng d| n g u ye n m a n g u d i benh

- T ranh tie p xu c h o a c loai bo ca c ye u to da d u o c b ie t gay b e n h h o a c la m n a n g benh: n g u n g dung

th u o c, th u c an, c h u ye n ch o d , doi nghe, tra n h nong, lanh, anh n ln g m a t trd i,

- C an nha c die u trj g ia m m a n ca m d a c hieu neu kho n g th e loai bo d u o c dj n g u y e n g a y benh

2 D ie u trj trie u c h d n g

C a c nh o m th u o c chu ye u de kiem so a t trie u c h u n g gom : a d re n a lin (e p in e p h rin ), c a c th u o c khan g

h ista m in , th u o c kh a n g le u k o trie n e va g lu c o c o rtic o id

a T h u o c k h a n g h is ta m in H1

- C hi djn h la lu a ch p n dau tie n tro n g ta t ca ca c th e m a y day

- Lieu lu p n g , c a ch d un g: xe m b a n g 1

H i / O n g d A n c h A n d o A n v A d i £ u t r i b £ n h N 0 i k h o a 781

B a n g 1 Cac th u o c k h a n g h is ta m in H1

The he 1 (gay buon ngu) Chlorpheniramin NL: 4mg x 3-4 lan/ngay

gay buon ngu)

Cetirizin NL va TE > 6 tuoi: 5-10mg x 1 lan/ngay

TE < 6 tuoi: 5mg/ngay

Suy gan, suy than

Fexofenadin NL: 60mg x 2 lan/ng hy hoac 180mg x 1 lan/ngay SuythSn

Loratadin NL va TE > 30kg: lOmg x 1 lan/ngay

Famotidin Ngirdi Idn: 40mg/ngay uong hoac tiem TM

Tre em: 0,5 -1 mg/kg/ngay Tong lieu khdng virgt qua 40mg/ngay.

Ranitidin Ngirdi Idn: 150mg uong 6 - 8 gid/lan khdng vum qua 600mg/ngay.

Treem: > 12 tudi: 1,25 - 2,5mg/kg uong 12 gid/lan khdng vi/gt qua 300mg/ngay Cimetidin Ngudi Idn: 300 - 800mg uong 6 - 8 gid/lan

Tr£ em: 20 - 40mg/kg/ngay uong chia ra 6 gid/lan.

c G lu c o c o rtic o id

- C h i djnh: p h o i h o p v o i th u o c kh a n g H i va H2 de g ia m trie u c h u n g tro n g c a c tru o n g h o p m ay d ay

n |n g kh6ng d a p u n g v o i ca c th u o c ke tren

- Lieu lu o n g , c a ch dun g: nen d u n g lieu tru n g b in h , m o t d o t n g in n ga y de han che ta c dun g phu C o

th e dung p re d n is o n h o a c p re d n is o lo n h o a c m e th y lp re d n is o lo n uong 4 0 - 6 0 m g /n g a y ( 6 n g u d i Ion) h oa c

1 m g /kg /n g a y ( 0 tre e m ) tro n g 5 -7 ngay