Cac benh do vi khuan:
3.1. Lao (Mycobacterium tuberculosis)
Lam sang: Benh lao co the xuat hien o bat cu giai doan nao trong qua trinh nhiem HIV, bieu hien lam sang phu thuoc vao muc do suy giam mien dich.
Lao phoi:
- Trong giai doan som cua nhiem HIV, khi mien dich con tuong doi binh thuong, benh nhan thuong co cac trieu chung sot, ho, met moi, gay sut, ra mo hoi dem...
- Trong giai doan muon cua nhiem HIV, co suy giam mien dich, benh nhan ho it, chu yeu sot va gay sut.
Lao ngoai phoi: Thuong gap khi benh nhan co so TCD4 thap. Benh nhan thuong co bieu hien sot keo dai, gay sut, di kem voi bieu hien tai co quan bi ton thuong.
- Lao hach: thuong bieu hien cap tinh. Hach co mat do chac, thuong doi xung hai ben, ton tai keo dai.
- Lao mang phoi: ho, tuc nguc, tran dich mang phoi...
- Lao mang ngoai tim: dau tuc nguc, tran dich mang ngoai tim.
- Lao mang nao: dau dau va sot tang dan, dau mang nao, co the co roi loan tinh than va dau than kinh khu tru khi benh dien bien keo dai.
- Lao mang bung: dau tuc bung, tran dich mang bung.
- Lao ruot: dau tuc bung, di ngoai phan long, co the co dau hieu tac ruot, di ngoai phan mau; tham kham co the phat hien khoi u trong o bung.
- Lao ke: sot, met moi, gay sut; cac trieu chung ho hap khong noi bat; co the co trieu chung o cac co quan khac nhu tieu hoa, than kinh...
- Cac dang lao hiem gap: lao cot song (benh Pott), u lao o nao, ap-xe thanh nguc...
Chan doan:
- X-quang phoi: hinh anh thay doi tuy thuoc vao giai doan suy giam mien dich.
+ Giai doan mien dich con tuong doi binh thuong: ton thuong tham nhiem hoac hang lao o thuy tren.
+ Giai doan suy giam mien dich: ton thuong lan toa hoac tham nhiem dang not-luoi o thuy duoi cua ca hai phoi kieu lao ke; sung hach ron phoi hoac hach trung that.
+ Cac ton thuong khac: tran dich mang phoi, tran dich mang tim.
+ Phim X-quang trong giai doan suy giam mien dich nang co the khong co ton thuong.
- Soi dom tim AFB: Xet nghiem thuong duong tinh o nhung benh nhan co mien dich con tuong doi tot va ton thuong phoi dien hinh. Trong giai doan suy giam mien dich nang, xet nghiem co the am tinh ngay ca trong truong hop benh phoi hoat dong.
- Soi phe quan va xet nghiem AFB dich rua phe quan-phe nang neu co dieu kien.
- Choc hut hoac sinh thiet hach bi ton thuong, soi tim AFB, xet nghiem te bao hoac to chuc hach de tim ton thuong lao.
- Xet nghiem dich nao tuy, dich mang phoi, dich mang bung va dich mang ngoai tim khi co bieu hien benh, lam cac xet nghiem sinh hoa, te bao va vi khuan hoc nhu soi AFB, PCR, ELISA de chan doan lao.
- Phan lap M.tuberculosis tu dom va cac benh pham khac va lam khang sinh do neu co dieu kien.
- Mantoux co the am tinh o nhung benh nhan bi suy giam mien dich nang hoac lao nang.
- Chup cat lop vi tinh so nao va cac tham do hinh anh khac khi co chi dinh va co dieu kien.
Dieu tri:
Dieu tri benh lao o benh nhan nhiem HIV noi chung khong khac biet so voi nhung benh nhan khong bi suy giam mien dich. Chu y:
- Tat ca cac benh nhan dong nhiem lao/HIV phai duoc hoi chan voi chuyen khoa lao va dieu tri theo che do DOT.
- Khong dung thiacetazone do co nhieu tac dung phu.
- Streptomycin (S/SM) van la thuoc co hieu qua nhng khong nen su dung o nhung noi dieu kien vo trung khong bao dam de tranh lay nhiem HIV qua bom kim tiem.
- Keo dai thoi gian dung thuoc trong cac truong hop lao nang ngoai phoi hoac lan toa nhu lao mang nao, lao ke, lao cot song co bien chung than kinh tuy thuoc vao muc do benh (co the keo dai toi 18 thang).
- Than trong khi dieu tri ket hop lao va cac thuoc khang retrovirus do kha nang tuong tac thuoc giua rifamycin voi cac thuoc uc che men sao chep nguoc non-nucleoside va cac thuoc uc che men protease (xem Phu luc 9: Tuong tac cua cac thuoc ARV).
- Theo doi dap ung dieu tri de phat hien khang thuoc va theo doi sau dieu tri de phat hien tai phat hoac tai nhiem.
Phac do dieu tri benh nhan lao moi:
- Cong thuc: 2SHRZ/6HE: Su dung 4 loai thuoc streptomycin, isoniazid (H/INH), rifampicin (R/RMP) va pyrazinamid (Z/PZA) hang ngay trong 2 thang dau, 6 thang tiep theo dung 2 loai thuoc isoniazid va ethambutol (E/EMB) hang ngay.
- Chi dinh: Tat ca cac truong hop benh nhan lao moi.
Phac do dieu tri lai:
- Cong thuc: 2 SHRZE / 1 HRZE / 5 H3R3E3 Su dung 5 loai thuoc S, H, R, Z, E lien tuc trong 2 thang dau, thang thu 3 dung 4 loai H, R, Z, E (khong tiem S) hang ngay; 5 thang tiep theo dung 3 lan mot tuan voi 3 loai H, R, E.
- Chi dinh: Cong thuc nay dung cho cac truong hop that bai hoac tai phat cua cong thuc dieu tri benh nhan lao moi.
Bang 3: Lieu toi uu cua cac thuoc chua lao thiet yeu
Ten thuoc
Lieu luong hang
ngay (mg/kg)
Lieu cach quang (mg /kg)
3lan / tuan
2 lan / tuan
Isoniazid
5 (4-6 )
10 (8-12 )
15 (13-17 )
Rifampicin
10 ( 8-12 )
10 (8-12 )
10 (8-12 )
Pyrazinamid
25 ( 20-30 )
35 (30-40 )
50 (40-60 )
Ethambutol
15 ( 15- 20 )
30 (25-35 )
45 (40-50 )
Streptomycin
15 (12-18 )
15 (12-18 )
15 (12-18 )
Mot so dieu can chu y o tre em:
Nhiem lao co the xay ra trong bat cu giai doan nao cua qua trinh nhiem HIV. Tre nho co nguy co mac benh cao va thuong bi lao lan toa.
Cong thuc dieu tri lao tre em: 2 HRZ/4 HR
Dung 3 loai thuoc H, R, Z hang ngay trong 3 thang dau, 4 thang tiep theo voi 2 loai H, R. Doi voi nhung the lao nang nhu lao mang nao, lao ke, lao xuong khop, co the bo xung Streptomycin trong 2 thang tan cong.
Mot so dieu can chu y o phu nu co thai:
- Chup phoi co tam chan o phan bung la tuong doi an toan cho thai nhi.
- Lao phoi va lao ngoai phoi trong thoi ky mang thai co the dan toi de non, can nang khi sinh thap, va roi loan phat trien bao thai, nhat la khi benh nhan khong duoc dieu tri, benh keo dai cho den giai doan cuoi cua thai ky.
- Cac thuoc INH, RMP, PZA va EMB co the su dung an toan cho phu nu co thai. Chu y theo doi chuc nang gan khi dieu tri INH. Tre sinh ra tu nhung nguoi me dieu tri RMP trong thoi ky mang thai co the co bieu hien xuat huyet va can duoc dieu tri du phong bang vitamin K 10mg sau khi sinh.
- Khong dung streptomycin va kanamycin cho phu nu co thai do co kha nang gay doc cho day than kinh so VIII cua tre, gay diec bam sinh.
3.2. Benh do MAC va cac mycobacteria khong dien hinh
Lam sang: Benh thuong xuat hien o giai doan suy giam mien dich nang, TCD4 < 100 te bao/mm3.
- Cac bieu hien chinh: Sot, gay sut, ra mo hoi ve dem; hach to, dau bung, di ngoai long, cac bieu hien o gan, phoi.
Chan doan:
- Soi dom, to chuc hach, tuy xuong hoac phan thay truc khuan khang con khang toan (chan doan phan biet voi lao).
- Cay mau va cac benh pham khac trong cac moi truong dac hieu de phan lap mycobacteria.
- X-quang phoi: ton thuong ke o thuy duoi ca hai phoi.
- Tang phosphatasa kiem.
Dieu tri: dieu tri keo dai (it nhat 1 nam) bang mot trong cac phac do duoi day. Dung dieu tri khi benh nhan duoc dieu tri ARV co so TCD4 >100 te bao/mm3 trong 3-6 thang.
- Phac do uu tien: Clarithromycin uong 500mg x 2 lan/ngay + Ethambutol uong 15mg/kg/ngay.
- Phac do thay the:
+ Azithromycin uong 600mg/ngay + Ethambutol ± Rifabutin uong 300mg/ngay; hoac
+ Azithromycin uong 600mg/ngay + Ethambutol ket hop voi amykacin tiem tinh mach 10-15mg/kg/ngay hoac ciprofloxacin 500-700mg x 2 lan/ngay.
Mot so dieu can chu y o tre em:
- Cac trieu chung chinh: sot keo dai, cham lon, ra mo hoi dem, thieu mau, gan lach to, Tieu chay keo dai, viem hach lympho don doc hoac benh o phoi.
- Chan doan phan biet voi lao neu tim thay AFB trong benh pham choc hut hoac sinh thiet hach.
- Dieu tri bang phoi hop 3-4 thuoc trong thoi gian keo dai. Phoi hop uu tien la azithromycin 10-12 mg/kg/ngay uong mot lan, hoac clarithromycin 7,5-15 mg/kg/ngay uong chia 2 lan voi ethambutol 15-25 mg/kg/ngay uong mot lan va rifamicin 10-20 mg/kg/ngay uong mot lan.
3.3. Benh do phe cau
Lam sang:
- Viem phoi: ho, sot, tuc nguc, kho tho, tim tai.
- Viem tai giua: sot cao, dau tai, non.
- Viem xoang: sot, nhuc dau, dau vung xoang, ngat mui.
- Nhiem trung huyet: sot cao kem ret run, tinh trang toan than nang, co the co roi loan tinh than. Tan suat nhiem trung huyet cao hon so voi ngoi khong nhiem HIV.
- Viem mang nao: sot, non, cung gay, co giat, lo mo.
Chan doan:
- X-quang: viem phoi, thuong la viem phoi thuy.
- Bach cau mau tang cao, bach cau hat trung tinh tang.
- Cay mau, dich phe quan, mu tai hoac dich nao tuy phat hien phe cau.
- Nhuom Gram dich phe quan, dich nao tuy phat hien song cau gram (+) hinh nen.
Dieu tri:
- Phe cau nhay cam voi penicillin: Penicilin G 400.000 don vi/kg moi 6 gio, keo dai 7 - 10 ngay.
- Phe cau khang penicillin: Cefotaxime 200 - 300mg/kg moi 8 gio tiem tinh mach, hoac ceftriaxone 50-80 mg/kg/ngay chia 2 lan.
3.4. Benh do tu cau vang
Lam sang: Nhiem tu cau vang thong xay ra o benh nhan co tiem chich ma tuy. Cac bieu hien chinh:
- Viem da,viem nang long: mun mu ngoai da, nhot.., benh nhan co the co sot.
- Nhiem trung huyet: sot cao, ret run, tinh trang nhiem trung toan than.
- Viem co, ap-xe co, viem khop, viem cot tuy xuong: benh nhan co sot; cac vung co viem sung nong do dau; cac khop bi ton thuong sung dau, han che van dong...
- Viem phoi, ap-xe phoi, viem mu mang phoi: sot, ho, kho tho; nghe phoi co ran am, tieng co mang phoi...
- Viem mang nao, ap-xe nao, viem tac tinh mach nao, ap-xe ngoai mang cung: benh nhan co sot, dau dau, co the co dau than kinh kh tru, liet van dong va roi loan co tron...
- Viem noi tam mac: sot kem ret run, co the co bieu hien tac mach dau chi, thieu mau; nghe tim co tieng thoi o cac o van.
Chan doan:
- Cay mau, dom, mu ap-xe va cac benh pham khac de phan lap tu cau vang gay benh.
- Nhuom Gram cac benh pham dom, mu ap-xe, dich mang phoi… co the thay cac cau khuan Gram (+) xep thanh dam.
- X-quang phoi: hinh anh nhieu o ap-xe, co the co tran dich mang phoi.
- Sieu am tim: sui van tim, co the co tran dich mang ngoai tim, ap-xe co tim...
- Chup cat lop vi tinh so nao, chup cong huong tu cot song neu nghi ngo cac bien chung he than kinh trung uong va cot song neu co dieu kien.
Dieu tri: Tot nhat lua chon khang sinh theo khang sinh do. Lieu luong khang sinh, duong dung va thoi gian su dung phu thuoc vao vi tri va muc do nhiem trung.
- Phac do uu tien: Cac thuoc penicillin chong tu cau (methicillin, oxacillin..) hoac cephalosporin the he I (cephazolin, cephalothin..) tiem truyen, lieu trung binh 100mg/kg can nang/ngay + mot aminoglycoside (gentamycin, netilmycin…).
Thuoc uong: cephalexin 500mg x 4 lan/ngay. Chi dinh cho nhung truong hop nhiem tu cau nhe, khong lan toa.
- Phac do thay the: Chi dinh khi S.aureus khang methicillin. Dung vancomycin truyen tinh mach 1g x 2 lan/ngay ± mot aminoglycoside (gentamycin, netilmycin..) hoac rifamycin uong 300mg x 2 lan/ngay.
Mot so dieu can chu y o phu nu co thai: Khong dung cac thuoc aminoglycoside do co kha nang gay diec bam sinh o tre.
3.5. Cac benh tieu chay do vi khuan
Nguyen nhan thuong gap: Salmonella, Shigella, Campylobacter va mot so vi khuan duong ruot khac.
Lam sang:
- Sot, di ngoai nhieu lan phan nuoc hoac co nhay mau kem theo; co the co dau quan bung, mot ran.
- Benh thuong dien bien nang, keo dai va hay di kem voi nhiem khuan huyet; co the co cac o di benh o cac co quan khac nhu phoi, khop, gan mat, tuy xuong.
- Nguoi benh co the mang khuan keo dai va bi benh tai phat.
Chan doan:
- Soi phan co hong cau va/hoac bach cau (tieu chay xam nhap)
- Cay mau
- Cay phan
- Cay mu hoac dich tu o di benh
Dieu tri:
- Salmonella: Ciprofloxacin uong 500mg x 2 lan/ngay hoac ofloxacin uong 200-300mg/ngay x it nhat 14 ngay. Cac thuoc thay the: cephalosporin the he III tiem tinh mach (ceftazidime, cefoperazone..) 50mg/kg/ngay x it nhat 14 ngay, neu benh nhan bi di ung hoac khong dung nap fluoroquinolone.
- Shigella: ciprofloxacin uong 500mg x 2v/ngay x 5 ngay. Thuoc thay the: ceftriaxone tiem tinh mach 50mg/kg/ng x 5 ngay, chi dinh khi benh nhan co thai, bi di ung hoac khong dung nap fluoroquinolone.
- Campylobacter: erythromycin uong 500mg x 4 lan/ngay hoac ciprofloxacin uong 500mg x 2 lan/ngay trong 5-7 ngay.
- Trong truong hop khong phan lap duoc vi khuan gay benh, co the cho dieu tri theo kinh nghiem bang ciprofloxacin hoac mot thuoc quinolone moi khac. Theo doi dap ung voi dieu tri (sot, tinh trang phan) va theo doi sau dieu tri de phat hien tinh trang mang khuan keo dai va tai phat benh. Benh nhan nhiem trung huyet hoac mang khuan keo dai can duoc dieu tri keo dai (nhieu tuan) hoac dieu tri duy tri bang ciprofloxacin uong 500mg x 2 lan/ngay (nhiem salmonella).
Mot so dieu can chu y o tre em va phu nu co thai:
Cac thuoc fluoroquinolone co the gay roi loan phat trien sun o bao thai va dong vat chua truong thanh tren thuc nghiem. Tren thuc te, chua phat hien thay tac dung tuong tu o tre duoc dieu tri cac thuoc fluoroquinolone va tre sinh ra tu nhung nguoi me dung cac thuoc nay trong thoi ky mang thai. Cac thuoc fluoroquinolone co the su dung o tre em va phu nu co thai, neu chung salmonella gay benh khang voi cac thuoc khac.
3.6. Benh do Klebsiella pneumoniae
Lam sang: Sot, viem phoi, ap-xe phoi, tran mu mang phoi, shock nhiem khuan, nhiem trung duong tiet nieu, duong mat.
Chan doan:
- Soi dom: cau truc khuan Gram (-) co vo
- Phan lap vi khuan gay benh tu dom, mau va cac benh pham khac.
- X-quang phoi co hinh anh ton thuong phoi (tham nhiem phoi, ap-xe phoi, tran dich mang phoi).
Dieu tri: Lua chon khang sinh tren co so xet nghiem khang sinh do. Lieu dung va thoi gian dieu tri phu thuoc vao vi tri nhiem trung va dap ung voi dieu tri.
- Phac do uu tien: cephalosporin the he III (ceftazidime) dong tinh mach lieu trung binh 100mg/kg/ngay ± mot aminoglycoside (amikacin tiem bap 500-1000mg/ngay).
- Phac do thay the: ciprofloxacin uong 500-750mg x 2 lan/ngay.
Mot so dieu can chu y o tre em va phu nu co thai: Xem phan benh do salmonella.
3.7. Giang mai
Lam sang:
- Giang mai thoi ky I: sang giang mai co dien, di kem voi hach tai cho. Co the co nhieu vet loet, phu ne lan toa va dau.
- Giang mai thoi ky II: Bieu hien lam sang da dang, bao gom ban tren da dang dat, san, san co vay, gap ca o long ban tay va ban chan; san phi dai (condyloma lata) o sinh duc, hau mon; ton thuong mang o niem mac sinh duc, hau mon; sot; rung toc; noi hach toan than; viem mang nao, v.v..
- Giang mai kin: benh nhan khong co bieu hien lam sang, chi co xet nghiem huyet thanh duong tinh.
- Giang mai thoi ky III: gom giang mai, giang mai than kinh, giang mai tim mach, va co the o cac co quan khac. Giang mai than kinh co the xuat hien som, khong co trieu chung, chi bieu hien bang bien loan dich nao tuy; benh nhan thuong co viem mang bo dao kem theo.
- Giang mai bam sinh: bong nuoc tren da, viem xuong-sun xuong va mang xuong, gan lach hach to, vang da, thieu mau, va cac di tat khac nh sut moi, ho ham ech.
Chan doan:
- Tim xoan khuan giang mai trong dich ton thuong thoi ky I va II, soi hien vi nen den.
- Xet nghiem huyet thanh: RPR, VDRL. Can lam dinh luong khang the de theo doi hieu qua dieu tri. Nhung benh nhan nghi giang mai co huyet thanh am tinh can duoc lam cac xet nghiem khac nhu sinh thiet, soi hien vi nen den, khang the huynh quang hoac PCR benh pham tu ton thuong.
- Moi benh nhan dong nhiem giang mai/HIV can duoc tham kham ve than kinh va mat. Nhung benh nhan co trieu chung than kinh va mat, benh nhan giai doan kin muon va khong ro giai doan can duoc choc do tuy song de loai tru giang mai than kinh. Dich nao tuy co the bien loan nhe (protein binh thuong hoac tang nhe, te bao chu yeu la bach cau don nhan). Can chan doan phan biet voi viem mang nao do HIV. Nen lam VDRL, RPR dich nao tuy; neu nghi ngo duong tinh gia, can lam TPHA.
Dieu tri:
- Giang mai moi trong 2 nam dau (Giang mai I, Giang mai II, Giang mai kin som): Benzathine penicilin G 2,4 trieu don vi, tiem bap mong lieu duy nhat, moi ben mong 1,2 trieu don vi, hoac procain penicilin G tan trong nuoc, tiem bap 1,2 trieu don vi /ngay, x10 ngay.
- Neu benh nhan di ung voi penicilin va khong co thai: Doxycyclin 100mg, uong 2 lan/ngay trong 15 ngay, hoac erythromycin 500mg, uong 4 lan/ngay x 15 ngay, hoac ceftriaxone 1g tiem bap hoac tiem tinh mach moi ngay x 8-10 ngay.
- Giang mai muon o nguoi lon: Benzathine penicilin G 2,4 trieu don vi, tat ca 4 lan moi lan 2,4 trieu moi ben mong 1,2 trieu, cach nhau 1 tuan (tong lieu 9,6 trieu don vi), hoac procain penicillin G tan trong nuoc, tiem bap 1,2 trieu don vi/ ngay x 3- 4 tuan.
- Giang mai than kinh: Penicillin G tinh the tan trong nuoc, tiem tinh mach 4-6 gio tiem mot lan, moi lan 2 trieu don vi. Tong lieu trong ngay 8-12 trieu don vi. Dot dieu tri 3 tuan, hoac procain penicillin G tan trong noc, tiem bap 1,2 trieu don vi/ngay + Probenecid 500mg uong 4 lan/ngay. Dieu tri trong 3 tuan.
- Giang mai o phu nu co thai: Dieu tri nhu lieu dung cho nguoi lon khong co thai theo phac do neu tren va o tat ca cac giai doan cua thai.
Neu benh nhan di ung voi Penicillin: Erythromycin 500mg uong 4 lan/ngay trong 15 -30 ngay.
- Giang mai bam sinh:
+ Giang mai bam sinh som < 2 tuoi, dich nao tuy binh thuong: benzathine penicillin G 50.000 don vi/kg can nang tiem bap lieu duy nhat.
+ Dich nao tuy bat thuong: benzyl penicillin 50.000 don vi/kg can nang tiem tinh mach hoac tiem bap 2 lan trong 10 ngay, hoac procain penicillin G 50.000 don vi/kg can nang trong 10 ngay.
+ Giang mai bam sinh muon, tre tren 2 tuoi: DNT binh thuong - benzyl penicillin 30000 don vi/kg tiem bap lieu duy nhat; DNT bat thong - benzyl penicillin 20.000 – 30.000 don vi/kg/ngay chia 2 lan trong 14 ngay; hoac erythromycin 7,5 - 12,5 mg/kg uong 4 lan/ngay trong 30 ngay neu benh nhan di ung voi penicillin.
+ Tre cung can duoc dieu tri khi me bi giang mai ma chua duoc dieu tri du huyet thanh (-) va khong co trieu chung benh hoac me da duoc dieu tri bang thuoc khong phai penicillin.
3.8. Nhiem Haemophilus influenzae type B
Lam sang:
- Viem hong cap hoac viem phoi: ho, sot, kho tho.
- Viem tai giua (o tre lon hon): sot, dau tai, dau dau, non.
- Viem mang nao: sot, dau dau, non, cung gay.
- Nhiem trung mau: sot, nhiem trung nhiem doc, o nhiem trung thu phat.
Chan doan:
- X-quang: Viem phe quan phoi.
- Dich nao tuy bien loan kieu viem mang nao mu, soi co vi khuan Gram (-).
- Cay mau, dich phe quan, dich nao tuy.
Dieu tri:
- Ampicillin 200 - 300mg/kg/24 gio tiem tinh mach chia 4 lan ket hop voi chloramphenicol 100mg/kg/24 gio tiem tinh mach chia 3 lan; hoac
- Cefotaxime 200mg/kg tiem tinh mach 8 gio mot lan; hoac
- Ceftriaxone 100mg/kg tiem tinh mach 12 gio mot lan.
Dieu tri keo dai 10 - 14 ngay.
Trả lời kèm Trích dẫn