Ebook nhiễm khuẩn hệ thần kinh phần 1

Benh truyen nhiem than kinh, neu khong diiOc dieu tri sOm, benh nhan co the bi tii vong hoac di chiing nang ne, trO thanh tan phe.. - Thifdng ton than kinh khu tru: mat van dong ngon ngu

Chu bien: GS TS HO HOU LtfONG

NHIEM KHUAN HE THAN KINH

CHU BlfiN: GS TS HO HUU LlTONG

NHIEM KHUAN

HE THAN KINH

GS.TS N g u yin Van Mui

TS Phan Viet Nga

L0 1 NOI DAU

Nhiem khuan than kinh dang la mot van de thdi sU, cap bach cua Y hoc va cua cac chuyen khoa Than kinh,Truyen nhiem, Hoi siic cap ciiu, Phuc hoi chtic nang , dang thu hut

sii quan tarn nghien ciiu cua cac thay thuoc trong nhieu linh vile dieu tri, du phong

Benh truyen nhiem than kinh, neu khong diiOc dieu tri sOm, benh nhan co the bi tii vong hoac di chiing nang ne, trO thanh tan phe

Muon dieu tri sdm cac benh nhiem khuan th in kinh thi phai phat hien benh s6m

Muon phat hien benh s6m can phai co kien thilc va kinh nghiem ve cac benh nhiem khuan than kinh

Cuon sach nay gi6i thieu nhiing kien th\ic va kinh nghiem cua cac tac gia ve cac benh nhiem khu&n than kinh thUdng gap

Chung toi hy vong cuon sach nay co the gop phan vao viec giang day, nghien ciiu va dieu tri benh nhiem khuan than kinh de phuc vu siic khoe cho nhan dan

Ha noi ngay 1 - 8 - 2005

C ac ta c gia

MUC LUC

Nhutng thUdng ton than kinh gap trong nhiem

Viem da re - day than kinh cap ti'nh nguyen phat 185

VIEM NAO VIRUT

I DAI ClfONG VE VIEM NAO VIRUT

Viem nao virut (VNVR) la mot qua trinh benh ly viem xay

ra d to chiic nhu mo nao, do nhieu loai virut co ai ltfc vdi te bao than kinh gay ra Dac diem lam sang da dang, nhiing chu yeu

la hoi chufng nao cap, gay roi loan y thiic vdi nhieu miic do khac nhau

1 Cac loai virut gay benh viem nao (theo Tyler K.L.,1998)

1.1 Cac loai virut thutfng gap

Cac virut Arbo

Cac virut diidng ruot (Entero virutes)

- Virut Herpes simplex (HSV: Herpes simplex virut)

- Virut quai bi

1.2 Cac loai virut it gap

CMV (Cytomegalo virut)

EBV (Epstein barr virut)

HIV(Human immuno-deficiency virut)

Virut sdi

Virut thuy dau (VZV: Varicella zoster virut)

1.3 Cac loai virut hiem gap

1.4 Sap xep cac loai gay viem nao theo mua

- Mua he den dau mua thu: virut Arbo, virut diidng ruot

- Mua thu - dong: LCMV

- Mua dong - xuan: virut quai bi

- Khong theo mua: HIV, HSV

2 NhCrng dac diem chung ve lam sang, can lam sang cua VNVR

2.1 Hoi chung nhiSm khuan - nhiSm doc

ThUOng co nhieu bieu hien khac nhau tuy theo can nguyen Tuy nhien da so' co sot, mot so trUOng hdp co bach cau mau ngoai vi tang va ty le bach da nhan tang (hay gap trong VNVR do virut Arbo)

2.2 Nhutig roi loan ve tam - than kinh

Thifdng rat da dang vdi nhfing roi loan chmh sau:

- Thay doi ve y thtic: tuy theo mute do benh, co the gap Id

md, ngu lim, ban hon me va hon me

Roi loan tam than: me sang, mat dinh hifdng, ao giac, loan than, roi loan cii chi va nhan cach

- Co cdn co giat kieu dong kinh: thifdng gap d 50% so benh nhan nang, co the co giat cuc bo hoac toan than

- Thifdng ton than kinh khu tru: mat van dong ngon ngut, that dieu, bai hoac liet nhe, tang phan xa gan xUOng, xuat hien phan xa benh ly bo thap (+), rung giat cd, liet cac day than kinh van nhan, day VII

Cac trieu chilng do thifdng ton true dudi doi - tuyen yen (roi loan than kinh thvfc vat) nhif: roi loan dieu hoa than nhiet, tang tiet mo hoi, dai thao nhat

2.3 Xet nghiem djch nao tuy

2.3.1 Te bao trong dich nao tuy:

- Hau het (85% trUdng hdp) co tang nhe te bao (tren 5 den vai chuc te bao/m m 3), chu yeu la te bao lympho Tuy nhien, d lan choc ong song that lufng dau tien (giai doan s6m) hoac d benh nhan suy giam mien dich khong thay tang te bao trong dich nao tuy Khoang 10% so' benh nhan co so liidng

te bao lympho trong dich nao tuy ldn hdn 500/mm3, so' it co the

>1000/mm3 (hay gap trong viem nao ngvfa mien Dong, viem nao California, viem nao do virut quai bi va do LCMV )

- Mot so" VNVR khong tang te bao lympho, thifdng gap

do EBV, CMV va HSV

- Mot so viem nao co tang bach cau trung ti'nh trong DNT (hay gap trong viem nao ngiia mien Dong, viem nao do virut ECHO 9 va mot so' virut dtfdng ruot khac) Tuy nhien, nhufng triidng hdp xet nghiem dich nao tuy co bach cau trung

ti'nh tang cham (sau >48 gid), can phan biet vdi cac can nguyen

do vi khu&n, hoac cac can nguyen khac

- Mot so" triidng hdp (khoang 20% trUdng hdp VNVR do HSV, CTFV va viem nao California) trong DNT co the co hong cau >500 te bao/mm3

2.3.2 X et nghiem sinh hoa trong dich nao tuty:

- Protein: thiidng tang nhe

Glucose: thUdng la binh thUdng, doi khi tan g nhe.

2.4 Di chung do VNVR

Neu benh nhan VNVR khong tvf vong co the de lai nhieu loai di cluing khac nhau, trong do chu yeu la cac di chiing ve tarn than kinh

Khoang 80% viem nao ngila mien Dong co di chiing nang ve than kinh

- VNVR it gay di chiing: EBV, California, viem nao ngUa Venezuela

- Ty le va nnic do di chiing phu thuoc vao tuoi, tinh trang y thiic cua benh nhan khi vao vien: benh nhan hon me sau, Glasgow < 6 diem thi de til vong hoac de lai nhilng di chiing nang; benh nhan ^ 30 tuoi va it ro'i loan y thilc thildng khoi hoac chi co di chiing nhe

3 Nhurng xet nghiem chan doan can nguyen

3.1 Xet nghiem tim can nguyen trong dich nao tuy

- Phan lap virut trong dich nao tuy thildng khong ket qua

Ky thuat PCR (khuyech dai acid nhan virut) trong dich nao tuy: hien nay dang dUdc sU dung rong rai va difdc xem nhii

mot ky thuat cO ban trong chan doan VNVR d cac nifdc tien tien, dac biet VNVR do CMV, EBV, virut thuy dau va virut difdng ruot.

Tim khang nguyen trong dich nao tuy: nhiing trifdng hop nghi ngd VNVR do HSV co the tim khang nguyen glycoprotein cua HSV trong dich nao tuy Nhifng xet nghiem nay can phai lam sdm trong tuan dau cua benh

- Phat hien khang the dac hieu chong virut trong dich nao tuy va trong huyet thanh Cac xet nghiem nay can dUOc lam 2 lan, cach nhau 2 tuan de xac dinh bien dong cua khang the Khi phat hien thay khang the dac hieu chong virut typ IgM trong dich nao tuy va trong huyet thanh cung co gia tri chan doan Chi so" khang the dac hieu chong virut trong dich nao tuy so vcfi trong huyet thanh khi > 1,5 lan cung co gia tri chan doan

з.2 Ghi dien nao do (EEG), chup cat I dp vi tinh (CT Scan) va chup cong huong tCf(MRI)

Cac ky thuat nay chi co gia tri dinh hudng cac thUOng ton

0 nao la lan toa hay cuc bo Vi vay, chi co the giup cho hUOng chan doan nghi ngd la VNVR, chii khong co gia tri chan doan xac dinh Tuy nhien, cac ky thuat nay co the rat co gia tri trong chan doan phan biet vcfi cac benh ly khac cua nao (nhu

и, ap xe, xuat huyet nao ).

C3 benh nhan VNVR, cac ky thuat EEG, CT Scan, MRI co the thay cac hinh anh sau:

EEG: giai doan cap co the co nhiing song gai nhon xuat hien co chu ky tren nen song gai cham, bien do thap Cac song nay thifdng gap d thuy thai dufdng Giai doan ban cap thay xuat hien song delta va theta

CT Scan: co the thay nhiing vung giam ty trong khong dong deu, ranh gidi khong ro, hap thu cham, kich thifdc ldn lan

toa, cac khe cuon nao ldn Cac thifdng ton thifdng d rai rac hai ban cau, nhifng gap nhieu d thuy thai difdng.

- MRI: co the thay dau hieu tang dam d cac thuy tran, thai difdng

3.3 Sinh thiet nao

Trifdc khi co ky thuat PCR thi sinh thiet nao difdc coi la

"tieu chuan vang" de chan doan xac dinh VNVR, nhat la VNVR do HSV Hien nay ky thuat nay it difdc ap dung To chifc nao sau khi sinh thiet difdc kiem tra mo benh hoc va sieu cau true Ket qua chinh xac tren 95% Nhifng ky thuat nay gay nhieu tai bien: 0,5 - 2% (chay mau, phu ne tai cho, dong kinh cuc

bo, nhilm khuan ) va co the gay tii vong do ky thuat (0,2%)

4 Dieu trj VNVR

4.1 Dieu trj dac hieu

Bang cac thuoc chong virut Tuy nhien, hien nay cung chUa that sif co thuoc co tac dung tot vdi cac loai virut va cung

da co hien tifdng virut khang vdi cac thuoc chong virut Mot so" thuoc da difdc ap dung la:

4.1.1 Aciclovir:

- Chi dinh tuyet doi trong VNVR do HSV Ngoai ra VNVR nang do EBV va VZV thi aciclovir con co tac dung ifc che DNA polymerase cua virut

- Lieu dung: lOmg/kg x 3 lan/ngay x 14 ngay, pha trong dich truyen tinh mach cham Aciclovir co do pH kiem nen khi truyen phai theo doi chat che, khong de thuoc thoat ra ngoai (do vd tinh mach hoac kim truyen chech ra ngoai ) Khi thuoc chech ra ngoai se gay viem tai cho Khong tiem dudi da hoac bap thit

Tac dung phu cua aciclovir: khi tiem bap hoac diidi da gay viem tai cho (9%), gay tang ure va creatinin mau (5%), giam tieu cau (6%), roi loan tieu hoa (7%: buon non, non, ia long), nhiem doc than kinh (1%: ngu lim, mat cam giac dau, roi loan dinh hudng, lu lan, kich thich vat va, ao giac, run cd

va co giat)

- Hien nay, da co bieu hien virut khang aciclovir do virut thay doi men thymidin kinase va DNA polymerase, nhat la d nhiing benh nhan suy giam mien dich

4.1.2 G anciclovir va foscarnet natri:

La nhiing thuoc diidc chi dinh dieu tri VNVR do CMV Ganciclovir va foscarnet natri co tac dung lie che canh tranh vdi DNA polymerase cua virut

Lieu dung cua ganciclovir: 5mg/kg nang x 2 lan/ngay, pha trong dich truyen tinh mach cham (lieu tan cong) Sau do duy tri lieu 5 mg/kg/ngay Khi co suy than phai giam lieu, khi

co giam bach cau hat va tieu cau thi phai ngulng thuoc

Lieu foscarnet natri: 60 mg/kg nang x 3 lan/ngay, truyen tinh mach cham x 14 - 21 ngay, sau do giam xuong lieu duy tri: 60 - 120mg/kg nang/ngay Foscarnet natri co the gay thiidng ton than, gay giam calci, magie, kali va co the roi loan nhip tim, co giat

4.2 Dieu tri trieu chung

Benh nhan phai diidc dieu tri, theo doi d cac buong cap cilu hoi siic Dac biet chu y theo doi, xii tri cap ciiu ve ho hap

va tuan hoan

Chong phu nao tich ciic bang cac bien phap

Ha nhiet do khi sot cao

An than, chong co giat

- Bat dong benh nhan tai giufdng, theo doi, san soc de phong viem phoi, loet, viem tac tinh mach, nhiem khuan cho dat catheter

II VIEM NAO DO VIRUT ARBO

1 NhOrng dac diem chung cua VNVR Arbo

1.1 Nhutig dac diem ve dich tS hoc

Dac diem djch t l h<?c chinh cac virut Arbo gay viem nao

(theo Peters C.J., 1998)

V iru t

Tru ng gian truyen benh va vat chu chinh

Tg u benh (n gay)

T y le thu benh

Tuoi mac benh

%

ch et

Di chung

1 2 3 4 5 6 7 Xuan - He

Nga

- Ixodes

pe rsulcatus

- Dong vat co vu

7-14 ■ moi tuoi 20 nhieu

Pow assan - Ixodes coo kei

moi tuoi gan

10 hiem

Ghi chu:

(*): Benh nhe d ngifdi tre, nang hdn d ngifdi lcfn tren 40 tuoi

(**): Moi liia tuoi, nhifng d trong vung dich thi tre em mac cao hdn

(***): Ngifdi 16n: 1/1000, tre em: 1/50, sd sinh: 1/1

1.2 C a c h e benh sinh, giai p h iu benh ly

Cac virut Arbo gay viem nao noi chung deu co cd che benh sinh tifdng til nhau Cac con trung khi hut mau ngifdi difa virut vao cd the Virut theo difdng mau den xam nhap va gay thifdng ton he thong than kinh trung ifdng, dac biet la cac

te bao bieu mo cua he khiiu giac va cac bao ngoai mach

- Hinh anh giai phau benh thiidng gap la hoai ttf cac neuron than kinh, viem cac te bao than kinh dem va tham nhilm te bao lympho quanh mach mau Cac vung lan can co hien tiidng "tang tiidi mau" vdi bieu hien tang sinh mach mau

va co hien tiidng giam tieu thu oxy

1.3 Nhung bieu hien lam sang chung cua VNVR Arbo

Cac bieu hien lam sang cua viem nao virut Arbo thiidng khac nhau theo nhom tuoi Tuy nhien thiidng co nhiing bieu hien chinh sau:

Khdi phat: thiidng co sot, chong mat; mot so" co the dau

Sau do: dau dau, non, dau hieu mang nao (+), sd anh sang Nang hdn co the Id md, roi loan y thiic, mat dinh hii6ng, ban hon me va hon me

- Trieu chiing pho bien la run cd, mat phan xa da bung, liet cac day than kinh so nao, liet nhe nvia ngUdi hoac khu tru tai mot chi, kho nuot Co giat hay gap thiidng xuyen va cung

can nguyen cua benh la virut La Crosse Virut La Crosse co

13 nhom huyet thanh (serogroup), mot so" nhom co kha nang

gay benh cho ngifdi nhif virut Jamestown Canyon, virut Inkoo,

virut Trivittatus Virut Jamestown Canyon thifdng gay

ra nhiing viem nao nang d ngifdi 16n vdi cac bieu hien roi loan

ho hap

2.2 Dac diem dich te

Trung gian truyen benh la giong muoi Aedes, trong do

chu yeu la muoi A triseriatus Gan day, thay muoi A

albopictus cung dong vai tro truyen benh rat quan trong gay

viem nao cho loai ho d chau A va truyen benh viem nao cho

chuot

Nguon benh chu yeu trong tti nhien la loai soc chuot d

Nam Hoa Ky Muoi Aedes vifa la trung gian truyen benh, viia

la nguon benh vi muoi co the truyen virut cho ddi sau qua

triing

Benh gap nhieu d cac thang 6 - 9 hang nam

6 nhiing vung co benh lifu hanh, ty le khang the tim thay trong huyet thanh > 20% Benh thifdng gap ft tre em < 15

tuoi

2.3 Dac diem lam sang

Co the gap mot so" tien trieu nhif: sot, nhiic dau, ngu

lim, buon non va non

Co giat: gap d 58% so" benh nhan

Hon me: 1/3 so" benh nhan

- Nhiing trieu chiing than kinh hay gap la: cdn dong kinh cuc bo, bai n ia ngifdi, run cd, mua vdn, mat van dong

ngon ngii, Babinski (+)

- Xet nghiem: bach c&u mau ngoai vi thifdng tang cao (co the den 20000/mm3), cong thiic bach cau chuyen trai.

- Dich nao tuy: te bao thifdng tang (30 - 500/mm3), chu yeu la lympho, nhifng so it benh nhan bach cau trung tinh co the chiem 25 - 90% Protein binh thifdng hoac tang nhe, glucose binh thifdng

- Tien trien: l't thay co di chiing, chi khoang 10% benh nhan co cdn dong kinh tai phat, mot so it tre co thieu nang tinh than va roi loan nhan cach

2.4 Chan doan

Phan lap virut tif nao tii thi

- Tim khang the dac hieu chong virut ldp IgM trong huyet thanh va trong dich nao tuy

3 VNVR Saint Louis

- Nguon benh trong tU nhien la chim

- Trung gian truyen benh viem nao St Louis la muoi

Culex 0 Hoa Ky, muoi C Tarsalis truyen benh d cac vung nong thon mien Tay va Trung Hoa Ky, muoi C.Pipiens va C.Quinquefasciatus truyen benh d cac vung thanh thi mien Trung va Dong Hoa Ky

- Benh thtfdng xay ra vao mua he: thang 6 den thang 10 hang nam

- Mifc do benh tang theo liia tuoi: benh thUdng nhe d tre

em va thanh thieu nien, benh nang hdn va tif vong nhieu d ngifdi ldn tuoi.

- Bieu hien lam sang thifdng gap la: sot, dau dau, lu lln ,

me sang Kham thay co ciing gay, giam trufdng life cd, tang phan xa gan xifdng, run va giat cd NhiJng trifdng hdp nang co

18

liet day than kinh so nao, liet niia ngifdi va co giat Benh nhan thifdng bi dai va trong nifdc tieu co the thay khang nguyen virut.

- Xet nghiem: so" lifdng bach cau tang, cong thiic bach cau chuyen trai; dich nao tuy: te bao tang (vai tram te bao/mm3, chu yeu bach cau lympho), glucose binh thifdng

- Ty le tik vong chung khoang 7%; benh nhan > 60 tuoi tii vong co the len den 20%

- Neu khong til vong: phuc hoi thifdng cham Benh nhan ldn tuoi thifdng co di chufng roi loan cam giac, giam tri nhd, suy nhifdc

va run cd keo dai

4 VNVR Tay song Nile, VNVR Thung lung Murray va VNVR Rocio

Virut viem nao Tay song Nile, virut viem nao Thung lung Murray, virut Rocio deu thuoc nhom virut Flaviviridae (cung nhom nay con co virut St Louis, virut viem nao Nhat Ban )

- Benh VNVR Tay song Nile: benh difdc lifu hanh trong thien nhien giuta cac loai chim hoang dai, do muoi Culex la trung gian truyen benh Benh thifdng gap ci chau Phi, Trung Dong, phia Nam chau Au va chau A Benh canh lam sang thifdng la sot va co thifdng ton he than kinh trung ifdng, doi khi gay viem mang nao nifdc trong va viem nao nang Benh gap ca d tre em va ngifdi ldn

Trieu chiing lam sang thifdng gap la: dau dau, dau nhiic ho mat, dau rat hong, non, buon non, dau khdp, sifng dau

Australia va New Zealand Virut Rocio gay ra viem nao dia phiidng tai Brazil vao nhiing nam 1975 -1977, nhiing sau do khong thay xuat hien Ca hai virut nay deu co vat chu la chim

va trung gian truyen benh la muoi Culex Benh canh lam sang tiidng tii benh viem nao Nhat Ban

5 VNVR Trung Au va VNVR xuan - he Nga

- Hai loai virut nay deu gay benh d chau Au va co nhieu dac diem giong nhau Virut gay viem nao Trung Au co vector truyen benh la loai ve Ixodes ricinus Benh lay truyen benh tii ban dao Scandinavia tdi Ural Virut gay viem nao xuan he Nga (hay con goi la virut viem nao vien dong do ve truyen) co vector truyen benh la ve Ixodes persulcatus, benh lay truyen benh tCf chau Au qua Ural den Thai Binh Diidng

- Benh hay xay ra vao mua xuan den dau mua he, it gap cuoi he

- Chi mot so ft dong vat co xiidng song mac dong thdi ca hai loai virut nay Ngiidi bi lay benh do bi ve dot hoac doi khi

do an phai suta cua de, ciiu nhiem virut chiia diidc nau ky

- Thdi gian nung benh cua hai loai virut khoang 7 - 14 ngay hoac dai hdn

- Lam sang VNVR mien Trung Au la: thiidng co sot, dau moi cd khdp trong 2 den 4 ngay tuy thuoc vao giai doan nhiem virut huyet Sau do co the chi d mile do viem mang nao nhe, gap d nhiing benh nhan tre tuoi; hoac thiidng ton than kinh trung lidng nang nhii hon me, co giat, rung giat cd keo dai

7 - 10 ngay Nang hdn co the gap liet cd ho hap Da so benh nhan hoi phuc, chi mot so ft de lai di chiing

- VNVR xuan - he Nga thiidng nang hdn Ty le tii vong cao va co nhieu di chiing, nhat la di chiing liet cac neuron than kinh van dong d cac cd til chi, than minh va co

Chan doan: giai doan sdm co the phan lap diidc virut tii mau Co the phat hien diidc khang the ldp IgM trong huyet thanh va hoac trong dich nao tuy.

Khong co thuoc dieu tri dac hieu Hien nay da co v&cxin bat hoat virut diidc san xuat tai Ao, Diic va Nga, sif dung vacxin thay co hieu gia khang the cao

6 VNVR Powassan

- Virut Powassan gay benh cho mot so" loai dong vat co xifdng song nho thong qua vector truyen benh la ve Ixodes cookei Mot so loai ve khac (nhif Ixodes dammini) cung co the truyen benh

- Benh gap d mien Dong Canada va Hoa Ky

- VNVR Powassan thiidng gap d tre em, vao cac thang 5 den 10 hang nam

Thdi ky nung benh khoang mot tuan, benh thiidng nang va de lai nhieu di chiing

7 VNVR ngtfa mien Dong

- Benh diidc phat hien lan dau d nhiing vung dam lay doc theo bd bien phia Dong Hoa Ky cho tdi tan bang Michigan

- Benh viem nao ngiia mien Dong d ngiidi thiidng xay ra tii thang 6 den thang 10 hang nam Vat chu chinh la chim, vector truyen benh la muoi Culiseta melanura Ngoai ra, muoi Aedes albopictus cung da diidc xac dinh la vector truyen benh trong thiic nghiem

- Virut nay thiidng gay benh cho ngUa Ngiia co the lay benh cho ngiidi qua muoi dot, nhiing ngiia it co vai tro quan trong trong sii nhan len cua virut

- VNVR ngiia mien Dong la mot trong nhiing benh do virut Arbo gay ra co benh canh nang ne nhat Benh tien trien nhanh, ram ro, ty le tii vong cao, de lai nhieu di chiing Hinh anh giai ph&u benh ly cua nao cho thay nhiing thiidng ton hoai tii lan tran va tham nhiem bach cau neutro trong cac te nao cung nhii tang bach cau neutro trong dich nao tuy, nhat la vao ngay 1 - 3 cua benh Xet nghiem mau ngoai vi cung thay bach cau tang, cong thiic bach cau chuyen trai.

- V&cxin virut bat hoat bdi formalin diidc sii dung chu yeu cho nhan vien phong thi nghiem, nhiing chiia diidc ap dung rong rai cho cong dong

8 VNVR ngira mien Tay

Chu ky liiu hanh benh trong thien nhien la nuoi Culex tarsalix va chim, chu yeu la chim se Ngiia va ngUdi chi la bi lay nhiem ngau nhien

Benh thiidng xay ra vao thang 6 den thang 10 hang nam Trong nhiing nam 1930- 1950 benh thiidng gap d mien Tay va mien Trung Hoa ky (giong benh viem nao St Louis) Nhiing gan day benh da bi thu hep va it pho bien Nam 1987 d Hoa Ky co 41 benh nhan, nhiing tii nam 1988 - 1995 chi co 4 benh nhan mac benh vien nao ngiia mien Tay

- La benh VNVR co bieu hien cua thiidng ton lan toa dien hinh Benh co the gap d moi liia tuoi, nhiing thiidng xay

ra d liia tuoi tre, dac biet la tre dudi 2 tuoi Ty le tii vong cao, d tre nho va ngiidi rat gia 1/3 so" triidng hdp co co giat trong giai doan cap va thiidng co di chiing cdn dong kinh ve sau Tre diidi

1 tuoi, sau khi mac benh thiidng co bieu hien di chiing liet cd van dong hoac sa sut tri tue

- Ty le tre nam: tuoi 5 - 9 thiidng mac benh cao gap 2 lan

so vdi nii cung liia tuoi Dieu nay diidc giai thfch bdi 2 ly do: do dac diem sinh hoc gidi tinh va do tre nam thiidng hay bi phdi nhiem nhieu hdn

- Vacxin bat hoat bdi formalin diidc sii dung de bao ve cho cac nhan vien phong thi nghiem, chiia diidc ap dung cho cong dong.

- Nhorri cac virut gay dich dong vat dia phiidng (enzootic virutes): gom cac subtype ID, IE, IF va cac typ II, III, IV, V, VI

9.1 Nhom cac virut gay dich cho dong vat lan tran

- Cho den nay, nhom virut nay chiia ro nguon benh trong thien nhien va trung gian truyen benh Ngiidi ta chi thay diidc benh xay ra mot cach dinh ky cho ngiia va ngiidi d chau My Dich thay d Venezuela, Colombia, Ecuador, Peru va mot so" quoc gia Nam My khac Chu ky dich 10 nam mot lan tii

1930 den 1969 Sau do, dich lan ra cac vung Trung My va Mehico Nam 1972, benh lan den Texas (Hoa Ky) Tii 1993 -

1995, benh it xuat hien Tii 1995, benh lai xay ra d Mehico, Colombia va Venezuela

- Ty le ngiidi nhiem virut co bieu hien lam sang khoang

10 - 60% Da so" benh nhan co sot, nhiing chi co so" it ngiidi co bieu hien cua viem nao, bieu hien than kinh cung it gap Trong mot nghien ciiu tren 8500 benh nhan, co 4% (chu yeu

la tre em) co thiidng tori than kinh va 300 ngiidi ta vong

- Hien nay co vacxin song giam doc hie hoac vacxin bat hoat Nhiing hien m6i chi sii dung han che cho nhan vien phong thi nghiem

9.2 Nhom cac virut gay dich cho dong vat dia phi/Ong

Cac virut do an nau trong thien nhien, nguon benh la cac loai dong vat gam nham va vector truyen benh la muoi Culex

- Benh thiidng gap d bang Florida (Hoa Ky) va vung bd bien Dai Tay Difdng cua Trung My

- Bieu hien lam sang chu yeu cua benh la sot cap ti'nh giong cum, dau dau dii doi, dau ho m&t, non, sung huyet ket mac va hong Sau 3-5 ngay sot, nhat la tre em, co bieu hien thifdng ton he than kinh trung ifdng (tif ngu ga den mat dinh hif6ng, co giat, liet, hon me va tU vong)

III VIEM NAO NHAT BAN (JAPANESE ENCEPHALITIS)

Vao nhiing nam 1933-1936 cac nha nghien ciiu Nhat Ban

da tim ra virut gay benh va chCfng minh r^ng virut nay difdc truyen qua muoi dot

Cac vu dich viem nao Nhat Ban difdc thong bao cac nif6c nhif: Nhat Ban, Trung Quoc, Trieu Tien, Mien Dien, Philippin, Lien Xo, Thai Lan, Viet Nam va cac vung khac thuoc chau Uc

va chau Phi

d Viet Nam, benh diidc phat hien tuf nhiing nam 60 cua the ky XX, dich xay ra hang nam Theo thong bao tinh hinh dich thi d Viet Nam, benh viem nao Nhat Ban liiu hanh rong rai khap ca niidc, nhiing dac biet nghiem trong d vung dong bang song Hong va trung du Bac bo v6i ty le mac hang nam tii

6 - 10/100.000 dan

2 Mam benh

Virut viem nao Nhat Ban thuoc virut Arbo ho Flaviviridae, giong Flavi virut Virut co dang hinh cau, kich thiidc 40 - 50 nanomet Ve mat cau true, virut viem nao Nhat Ban gom ba phan la: phan loi co ARN, sdi ddn; phan capsid bao quanh loi

la nucleoprotein va phan vo boc ngoai cau tao bdi glycoprotein Khang nguyen glycoprotein co tinh ngiing ket hong cau va hoat tinh trung hoa, nen diidc ilng dung trong cac phan ling chan doan huyet thanh

Virut phat trien d te bao phoi ga va to chiic nuoi cay d

pH = 7,9 va tot nhat d pH = 8 Virut khong chiu nhiet, chung

bi bat hoat d 56°C trong 30 phut; d 70°C trong 10 phut, 100°C trong 2 phut Trong trang thai dong lanh virut co the ton tai trong vai nam Ducfi tac dung cua aceton, con va ete, virut chet sau 3 ngay Dung dich lysol 5% diet virut trong 1 phut Mot so dong vat co man cam vdi virut viem nao Nhat Ban la: khi, chuot bach va mot so loai chuot dong, mot so loai muoi va nhieu loai chim

3 Djch te hoc

Viem nao Nhat Ban la benh co o dich thien nhien Trong thien nhien cac o chila virut la cac sue vat nhii ldn, ngiia va cac loai chim (trong do, ldn va chim la vat chu chinh); mot so' dong vat khac co the la o chila virut nhiing vdi ty le thap hdn nhii trau, bo, de, cufu, cho va khi O Viet Nam, Vien Ve sinh

dich t§ trung lidng da phan lap diidc virut viem nao Nhat Ban trong loai chim Lieu dieu (Garrulax perspicillatus - Gmelin).

Virut diidc truyen giu!a cac vat chu vdi nhau va truyen sang ngiidi nhd giong muoi Culex Co 17 loai muoi Culex, trong

do C Tritaeniorhynchus va C Vishnui la vector chu yeu Ngoai ra con co the cac giong muoi khac nhii giong Aedes (chiing A Togoi, A Japonicus), c o tai lieu noi ca den Anopheles Maculipennis, giong Mansonia cung co kha nang truyen benh

Chu ky truyen benh viem nao Nhat Ban dUdc minh hoa theo sd do sau:

Siic thu benh cao vcfi tre em dtfdi 10 tuoi Ngiidi ldn ty le co khang the cao do vay it mac benh hdn

Ty le mac benh viem nao Nhat Ban d vung dong bang cao hdn vung riing nui va d nong thon cao hdn thanh pho

Sau khi bi benh de lai mien dich chac chan va viing ben

4 Co che' benh sinh va thi/dng ton giai phau benh ly

Virut diidc muoi truyen vao mau, chung phat trien 0 trong mau va di kh&p cd the Nhd hiicing tinh than kinh, virut xam nhap vao cac te bao than kinh, sinh san va phat trien nhanh 0

do Sau khi da dat dUdc mat do cao d cac te bao than kinh, virut lai tu! do xam nhap lan thif 2 vao mau Nhiem virut lan thti hai d mau bat dau gay nen phan ting sot, tren lam sang no tiidng Cfng vdi sii b&t dau giai doan cap tmh cua benh

Sii bien doi benh ly ro ret nhat d he thong than kinh Tren kinh hien vi ngiidi ta co the thay nhiing bien doi la: phu ne mang nao va to chiic nao, cac dong mach va tinh mach nao dan rong va 11 mau, xuat huyet dom nho d to chiic nao va mang mem Trong to chiic nao va dac biet la vung doi thi, the van va

ca siing amon co nhiing o nhun nao va xuat huyet

Trong cac cd quan noi tang deu co il mau, co nhieu dom xuat huyet d niem mac va thanh mac, thoai hoa to chiic cd tim, gan, than va phat sinh viem phoi do'm Viem xuat huyet va thoai hoa mang nao - tuy va ca chat nao - tuy Ngoai phu ne va xuat huyet dom ra con thay tham nhiem quanh cac huyet quan cua to chiic nao, tuy song, tao nen cac u hat nho quanh huyet quan va cac te bao than kinh vdi sii tao nen cac o hoai tii

va nhun nao nho Nhiing thay doi benh ly nang nhat xay ra d vung doi thi, chat xam, nhan do, the tran va tieu nao

5 Lam sang

5.1 The thong thu&ng dien hinh

5.1.1 Thdi ky nung benh:

- Keo dai tii 5 - 14 ngay, trung binh la 1 tuan

5.1.2 Thai ky khdi phat:

Benh khdi phat rat dot ngot bang sot cao 39 - 40°C hoac hdn Benh nhan dau dau, dac biet la vung tran, dau bung, buon non va non Ngay trong 1 - 2 ngay dau cua benh da xuat hien ciing gay, tang triidng liic cd, roi loan sii van dong nhan cau Ve tam than kinh co the xuat hien lu lan hoac mat y thiic Nhiing ngay dau phan xa gan xiidng tang, sung huyet, dan mach rd O mot so tre nho tuoi, ngoai sot cao co the thay di long, dau bung, non giong nhii nhiem khuan - nhiem doc an uong

Tom lai: trong thdi ky khdi phat dac diem noi bat cua benh

la sot cao dot ngot, hoi chiing mang nao va roi loan y thiic tii nhe den nang (ly bi, kich thfch, vat va, u am, mat y thiic hoan toan)

Thdi ky khdi phat cua benh tUdng ling vdi luc virut viidt qua hang rao mach mau - m ang nao vao to chiic nao va gav nen phu ne nao.

5.1.3 Thdi ky toan p h a t (tii ngay thil 3 - 4 den ngay thil 6 - 7cua benh):

Bii6c sang ngay thil 3 - 4 cua benh, cac trieu chiing cua thdi ky khdi phat khong giam ma lai tang len Tii me sang kich thi'ch va u am luc dau, dan dan benh nhan di vao hon me sau dan

Cac trieu chiing roi loan than kinh thiic vat cung tang len:

va nhieu mo hoi, da luc do luc tai; roi loan nhip thd va tang tiet trong long khi phe quan, do vay khi nghe phoi co the thay nhieu ran rft, ran ngay va ca ran no; mach d benh nhan thiidng nhanh va yeu

Noi bat trong giai doan toan phat la sii xuat hien cac trieu chiing thiidng ton nao noi chung va thiidng ton than kinh khu tru Benh nhan cuong sang, ao giac, kich dong, tang trUdng luc

cd kieu ngoai thap lam cho benh nhan nam co quap Trong trifdng hdp thifdng ton he thong thap nang co the thay co giat

9,cling hoac giat rung cac cd mat va cd chi hoac bai, liet ciing O mot so benh nhan xuat hien trang thai dinh hinh, giut nguyen tif the (catalepsia)

Do roi loan chufc nang hypothalamus lam cho mach nhanh 120-140 lan/phut, tang ap luc dong mach va co mach ngoai vi.Cac day than kinh so nao cung co the bi thiidng ton, dac biet la cac day van nhan (III, IV, VI) va day VII

Roi loan trung khu ho hap dan tdi thd nhanh nong, xuat tiet nhieu d khi phe quan va co the thay viem phoi dom hoac viem phoi thuy

Ve xet nghiem: ngay til nhiing ngay dau bach cau thiidng tang cao 15.000 - 20.000/mm3, trong do bach cau da nhan trung tinh tang tdi 75 - 85%, bach cau ai toan va lympho bao giam Toe do mau lang hau het d cac benh nhan tang (tdi

20 - 30mm/gid dau)

Xet nghiem dich nao tuy: ap life dich nao tuy tang, dich trong vat, protein tang nhe (60 - 70mg%); te bao tang nhe (dif6i 100 te bao/mm3) luc dau la bach cau da nhan, ve sau la lympho

Soi day mat trong giai doan cap tinh thiidng thay xung huyet gai thi, doi khi thay ca phu ne va xuat huyet Benh nhan roi loan nhan cam mau sac va anh sang, thi trufdng bi thu hep

Thdi ky nay tiidng ilng vdi thdi ky virut xam nhap vao cac

te bao nao gay huy hoai cac te bao than kinh

Tom lai: thdi ky toan phat cua benh viem nao Nhat Ban

d iin ra ngan Do thifdng ton cac te bao than kinh, hypothalam us va roi loan cac trung khu difdi vo da lam cho

benh nhan rdi vao trang thai hon me sau v6i sii roi loan cac chiic nang song Do vay benh nhan thiidng tii vong trong vong

7 ngay dau Nhiing benh nhan vUdt qua diidc thdi ky nay thi tien liidng tot hdn

5.1.4 Thdi ky lui benh vdi nhumg bien chimg va di chimg (tii ngay thti 7- 8 trd di):

Thong thiidng budc sang tuan thil 2 cua benh, benh nhan

dd dan, nhiet do giam til sot cao xuong sot nhe va vao khoang tii ngay thil 10 trd di nhiet do trd ve binh thiidng neu nhii khong co boi nhilm vi khuan khac Cung vcfi nhiet do, mach cung cham dan ve binh thUdng, thd khong roi loan Hoi chiing nao - mang nao cung dan dan mat: benh nhan til hon me dan dan tinh, triidng liic cd giam dan va khong con nhiing cdn co cilng Benh nhan het non va dau dau, gay mem, cac dau hieu mang nao cung trd ve am tinh

Trong khi hoi chiing nhiem trung nhiem doc va hoi chiing nao - mang nao giam dan thi cac thiidng ton than kinh khu tru lai ro hdn triicfc Benh nhan co the bai va liet chi hoac liet cac day than kinh so nao hoac roi loan sii phoi hdp van dong v.v Thdi ky nay co the xuat hien nhiing bien chiing sdm nhii: phe quan phe viem hoac viem phe quan boi nhiem, viem be than, bang quang boi nhiem do phai thong dai hoac dat sonde dan lUu, loet va viem tac tinh mach do n&m, roi loan dinh diidng Nhiing di chiing sdm co the gap la: bai hoac liet niia ngiidi, mat ngon ngii, mua giat, mua vdn, roi loan phoi hdp van dong, giam tri nhd nghiem trong, roi loan tam than

Til cuoi tuan thil 2 trd di la thdi ky cua nhiing bien chiing

va di chiing muon Nhiing bien chiing muon co the gap la phe viem, viem be than - bang quang, loet nhiem trung, roi loan giao cam, roi loan chuyen hoa Nhiing di chiing muon co the xuat hien sau vai nam hoac tham chi hang chuc nam ma thiidng gap la dong kinh va Parkinson

5.1.5 Tien IL/Ong benh:

Benh co ty le tii vong cao (25-80%), tii vong thiidng xay ra trong 7 ngay dau khi benh nhan co hon me sau, co giat va nhiing trieu chiing thifdng ton than nao Tii vong d giai doan sau chu yeu do cac bien chiing dac biet nhu viem phoi, suy kiet Nhiing benh nhan qua khoi co the de lai nhiing di chiing suot ddi, hay gap la roi loan tarn than

5.2 Mot so the khong dien hinh

5.2.1 The an:

Khong phai trifdng hdp nao virut xam nhap vao cd the cung gay benh Ngifdi ta thay sau cac vu dich, so" ngifdi khong mac benh ma v ln co dap ling mien dich chiem ty le rat cao (gap hang tram lan so ngifdi mac benh) Do la the an

5.2.2 The cut:

Chi co hoi chiing nhiem khuan, nhiem doc: sot cao, xung huyet da, niem mac, nhiic dau Ngoai ra khong co trieu chiing

gi cua hoi chiing nao - mang nao

5.2.3 The viem m ang nao:

Gap d nhiing tre lcfn tuoi va thanh nien Benh dien bien giong nhif viem mang nao do virut khac

- Hoi chiing than kinh: luc dau la nhiing dau hieu cua thiidng ton nao lan toa, ve sau co the co nhiing bieu hien cua hoi chiing than kinh khu tru, co hoi chiing mang nao va thay doi dich nao tuy.

Roi loan than kinh thiic vat nang: da luc dau la xung huyet do va sau thay doi that thUdng (luc do, luc xanh tai), va

mo hoi, roi loan ho hap va tuan hoan

6.1.2 X et nghiem dac hieu:

Phan lap virut (trong 2 - 3 ngay dau) til mau, dich nao tuy hoac til nao til thi (m6i chet trong 2 gid)

Phan ilng huyet thanh: co the lam phan ilng ket hdp

bo the (diidng tinh tii tuan thil 2) hoac phan ilng ngiing ket hong cau va phan ilng trung hoa (diidng tmh keo dai nhieu thang sau) Phtfdng phap mien dich men ELISA la phiidng phap diidc ap dung rong rai co do nhay va do dac hieu cao

6.1.3 Dich te:

Ndi co o dich liiu hanh (chu y vung ven song Day, dong bang song Hong ) Benh thiidng phat sinh vao mua he (thang 5,6,7,8) va d tre nho (til 2 - 3 tuoi den 10 - 12 tuoi)

6.2 Chan doan phan biet

6.2.1 Viem nao th ir phat:

Mot so benh truyen nhiem co the gay viem nao thil phat nhii: sdi, cum, thuy dau, ho ga Tren cd sd cua benh chinh sau

do xuat hien them cac trieu chiing viem nao, song thtfdng chi

co bieu hien lan toa cua mot hoi chiing nao cap, khong co trieu chiing than kinh khu tru va khi khoi ft de lai di chiing

6.2.2 H oi chirng nao cap:

Hoi chiing nao cap do nhieu nguyen nhan gay ra Vi du: do roi loan chuyen hoa dan t<3i giam dudng mau (hon me ha diidng huyet), do roi loan niidc va dien giai nang, tre suy dinh diidng nang co roi loan tuan hoan nao cap Hoi chiing nao cap do roi loan chuyen hoa cung co hon me nhifng it thay hoi chiing than kinh khu tru, dich nao tuy it khi co thay doi

6.2.3 Viem m ang nao mu hoac viem m ang nao lao:

Khong co hoi chiing nao, dich nao tuy co bien doi manh

7 Dieu trj

Hien nay chifa co thuoc dieu tri dac hieu, do vay noi dung dieu tri chu yeu la: chong phu ne nao, dieu tri trieu chiing va chong boi nhiem

7.1 Chong phu nao

- Truyen cac dich ifu trifdng de lam tang ap liic tham thau, rut nif6c d to chiic te bao va khoang gian bao vao long mach Truyen tinh mach dung dich glucose 10 - 20 - 30% Glucose chi gay giam ap liic d khoang nao tuy trong mot thdi gian ngan (khong qua 35 - 40 phut) Do vay neu khong xen ke sif dung cac dich ldi nieu khac thi se gay hien tiidng tai phu cua to chiic te bao nang hdn trifdc

Cac thuoc ldi tieu: lam giam phu manh hdn va thdi gian keo dai trong 2 - 10 gid Co the truyen mannitol 20% lieu tii 1 - 2g/kg the trong, truyen vdi toe do lcin (co the cho chay thanh dong)

Trong nhiing trifdng hdp phu nao nang co co giat thi dung corticoid Tot hdn ca la dung dexamethason la loai glucocorticoid tong hdp, tac dung cham va hieu qua h ln g dinh

Dexamethason phat huy tac dung chong phu ne nao sau

12 - 18 gid; lieu dung lOmg tiem tinh mach, sau 5 gid lai tiem 4mg bap thit

7.2 An than cat con giat

Seduxen co the cho qua sonde hoac tiem bap thit va tinh mach Co the dung dung dich liet hach truyen tinh mach nho giot: Aminazin + thiantan + spartein (lieu lifdng Aminazin 3-7

m g/lkg the trong/24 gid)

Neu benh nhan co co giat nhieu thi dung Gardenal

2 - 3 lan/24 gid), hoac vien dan Efferalgan (1 - 2 vien dan /24 gid khi sot cao)

7.4 Hoi s u t ho hap va tim mach

Thd oxy, lau hut ddm dai, san sang ho hap vien trd khi roi loan nhip thd nang hoac ngufng thd

Bo sung ntfdc dien giai kip thdi theo hematocrit va dien giai do Dung thuoc trd tim mach ouabain, spartein, khi can thiet co the dung cac thuoc van mach nhtf Aramine, noradrenalin

7.5 Ngan ngira boi nhiem va dinh difdng, chong loet

- Dung khang sinh pho rong tuy theo trong lifdng cd the

Thifdng xuyen lau rOfa da, ve sinh rang mieng,

dai, dung dem cao su bdm hdi de vao cac diem ty va

xuyen thay doi tif the cho benh nhan

Che do dinh difdng cho benh nhan phai dam

dam va cac vitamin, cho an qua sonde 4 lan/ngay

VIEM MANG NAO

I PHAN LOAI VIEM MANG NAO

1 Mot so phan loai thong thifdng

Tuy theo muc dich, co rat nhieu cach phan loai viem mang nao (VMN) khac nhau Dudi day la mot so cach phan loai thifdng sik dung

1.1 Phan loai theo can nguyen

- VMN do vi khuan (VMN mu): nhieu loai vi khuan co the gay VMN mu Cac vi khuan thifdng gap la: mang nao cau

H Influenzae, tu cau (Staphylococci), E Coli, lien c&u nhom B (Streptococcus nhom B)

- VMN do lao

VMN do virut: nhieu loai virut co the gay VMN: virut quai bi, sdi, cac virut Arbo, Coxackie, ECHO, Herpes, EBV, HIV

VMN do ky sinh trung: nhieu loai ky sinh trung co the gay VMN, song benh canh thifdng gap la ket hdp viem nao -

dat voi thtfdng

bao du

mang nao Cac loai ky sinh trung thUdng gap la: cac loai amip, Toxoplasma, Tripanosoma, ky sinh trung sot ret, giun xoan

- VMN do nam nhii Cryptococcus neoformans

- VMN do Rickettsia

- VMN do cac can nguyen khac, nhu can nguyen do thuoc (thuoc gay te tuy song, gay te ngoai mang ciing, thuoc penicillin ); cac benh ly u nao, xuat huyet di*6i nhen, benh nao do chi v.v co bieu hien giong VMN

Tren thiic te lam sang, VMN mu (do vi khuan) va VMN lao diiOc chu y nhat

1.2 Phan loai theo mau sac dich nao tuy

- VMN mu

- VMN niidc trong (VMN thanh dich)

1.3 Phan loai theo loai te bao chiem da so trong dich nao tuy

- VMN tang bach cau da nhan (neutrophil - gap trong VMN do vi khuan)

- VMN tang te bao limpho (gap trong VMN do lao, VMN

do virut, VMN do vi khuan da dieu tri )

- VMN tang te bao ai toan (eosinophil)

1.4 Phan loai theo c a c h e benh sinh

- VMN tien phat

- VMN thil phat (sau nhiem khuan tai cho, nhiem khu&n huyet )

Trong thifc te lam sang, ngifdi ta thifdng phan loai cac can nguyen gay VMN theo cac dang hinh thai cua dich nao tuy Bang phan loai dif6i day thifdng difdc ting dung trong chan doan lam sang

2 Bang phan loai umg dung

Bang phan loai can nguyen VMN theo cac dang hinh thai djch nao tuy

DNT Bach cau

(ml)

Glucose (mmol/l)

> 40%

glucose mau

VMN dang u hat, do:

- Lao

- Nam

- Cac n h ilm khuan khac (nhiem Mycoplasma, VMN

do Listeria, do giang mai, benh Lyme, VMN do Rickettsia, benh Leptospira, SRAT the nao, giun xoin, benh Toxoplasma, Benh Tripanosoma )

- Benh nao do nhiem doc (benh nao do chi, do thuoc )

- Viem nao sau tiem vacxin

II VMN DO VI KHUAN

1 NhGmg dac diem chung ve VMN do vi khuan

1.1.Can nguyen vi khuan gay VMN mu

1.1.1 Phan lo a i theo m ite do pho bien:

- Nhiing vi khuan gay VMN mu thifdng gap: mang nao cau, H Influenzae, phe cau

- Nhiing vi khuan gay VMN mu it gap: E Coli, tu cau, lien cau

38

Nhiing vi khuan gay VMN mu hiem gap: Proteus, triic khuan mu xanh, Salmonella, Listeria, Klebsiella

1.1.2 Phan lo a i theo Ufa tuoi:

- Cac nghien ciiu cua cac tac gia tren the gidi phan chia cac liia tuoi rat khac nhau Tuy nhien, co the khai quat chung nhif sau:

- Tre sd sinh (< 2 thang tuoi): triic khuan difdng ruot (E Coli ), Streptococcus nhom B, Listeria Monocytogenes

- Tren 2 thang - 18 tuoi: H Influezae, mang nao cau, phe cau, E Coli, tu cau

- Tif 18 - 50 tuoi: mang nao cau, phe cau

Tren 50 tuoi: phe cau, L Monocytogenes

Dudi day la nghien ciiu ve can nguyen gay VMN mu cua mot so" tac gia de tham khao:

Can nguyen vi khuan gay VMN mu theo liia tuoi (ty le %)

Vi khuan Theo Shield, 1983 Theo Roos va cs, 1991

< 2 thang tuoi

2 thang

- 6 tuoi > ?

tuoi

1 thang

1 thang -15 tuoi

>15 tuoi

H Influezae 1-2 40-60 5 0-3 40-60 1-3 N.

Can nguyen vi khuan thiidng gap gay VMN mu theo liia tuoi co the diidc mo hinh hoa nhii sau:

Can nguyen vi khuan thUdng gap gay VMN mu theo cd dja

(gay VMN mu thirphat)

1.1.3 Phan loai can nguyen theo co dia:

- Nghien rifdu

- Dai difdng

- Viem tai giOa

- Giam sire de khang MD

- Sau mo cat lach

- Sau chan thUdng, VT so nao

- Sau p h lu thuat than kinh

- Co benh van hai la

Phe cau, Listeria Phe cau, Listeria, S.Aureus Phe cau, TK di/dng ruot, S Aureus Listeria

Listeria, H Influenzae Phe cau, TK difdng ruot, S Aureus,

H Influenzae

S Aureus, trifc khuan Gram (-)

S Epidermidis, S Aureus

1.2 Difdng xam nhap cua vi khuan vao mang nao

Tuy theo sii xam nhap cua vi khuan vao mang nao, ngUdi

ta chia thanh hai loai VMN:

1.2.1 VMN mu nguyen phat:

Do mang nao cau tu mui hong xam nhap vao mang nao

1.2.2 VMN mu th i/ phat:

Co the do cac nguyen nhan sau:

- Vi khuan tu o viem gan mang nao, mang tuy xam nhap vao nhii: o viem tai, viem xUdng chum, viem xiidng so, viem xoang, viem hoc mat, viem cd doc theo cot song Mam benh