Ebook nhiễm khuẩn hệ thần kinh phần 2

VIEM

TUY

CAP

I. D A I C lfO N G
1. Ljch sur

C) the ky thii XIX, hau het cac benh d tuy song deu diidc
goi la viem tuy. Morton Prince da viet trong Dercum’s
Textbook of Nervous Disease nam 1895, de cap tdi viem tuy
chan thiidng, viem tuy chen ep... Cung vdi thdi gian, sii hieu
biet ve cd che benh sinh cua benh than kinh da cd nhieu biidc
tien bo, cac benh ly ve thudng ton tuy do cac nguyen nhan
khac bi loai bo ra khdi bang phan loai nay va chi cdn lai thuat
ngii viem tuy. Nhiing cho den ngay nay sii lien quan giiia viem
va nhiem khuan cdn chiia ro rang. Mot vai virut cham khac
thiidng cd the pha huy cac te bao than kinh nhiing khong xuat
hien cac te bao viem. Ngay nay trong thiic te thuat ngii benh
tuy (myelopathy) hay diidc dung hdn.
2. Thuat ngCr

Tuy song la ndi cd the xay ra qua trinh viem, mot so" can
nguyen tap trung pha huy cac neuron, so" khac tham gia qua
trinh pha huy mang te" bao hoac chat trang va cd the gay hoai
tii ca chat xam va chat trang. Thuat ngut dUdc chap nhan hien
tai cho tat ca cac benh ly tuy nay la benh ly tuy song
(myelopathy). Ngoai ra cdn cd mot so" thuat ngii chuyen biet
khac diidc sii dung de chi ra chi'nh xac hdn sii phan bo" cua qua
trinh viem nhii sau:

103


Neu thiidng ton gidi han d chat xam la viem tuy xam
(poliomyelitis).
- Thiidng
(leucomyelitis).

ton

d

chat

tr&ng

la

viem

tuy

trang

Toan bo khu viic cat ngang cua tuy deu bi thudng ton
diidc goi la viem tuy ngang (myelitis transversa).
Neu thiidng ton d nhieu ndi va lan rong qua pham vi
chieu dai la viem tuy rai rac (diffuse hoac disseminated
myelitis).

-

T huat ngii viem tuy - m ang tuy (meningomyelitis) la

dung trong trUdng hdp co sii phoi hdp cua viem mang tuy va
tuy song.

Co the phoi hdp viem tuy song vdi viem day than kinh
thi giac, goi la viem tuy thi than kinh (neuromyelitis optica).
-

Cac dang benh ly viem tuy cap cdn cd the phoi hdp mot

so o viem dong thdi cd d tuy song va d trong nao, goi la viem

nao - tuy cap tinh (encephalomyelitis acute).
Cd the phoi hdp viem tuy vdi viem re than kinh tuy
song goi la viem re tuy song (myeloradiculiis).
- Mot dang viem tuy dac biet khac la viem tuy leo (liet
leo Landry).
3. Khai niem ve the benh
- Viem tuy cap dUdc de cap khi cac trieu chiing benh xuat
hien nhanh va dat giai doan toan phat trong vong vai ngay.
Ban cap la benh tien trien trong khoang thdi gian tii 2
den 6 tuan.
- Viem tuy man tinh vdi thdi gian hdn 6 tuan ke tii khi
khdi phat tdi khi phat trien day du benh canh lam sang.
104

4. Nguyen nhan
Viem tuy cap bao gom nhiing thiidng ton cap ti'nh d tuy
song, co the la tien phat hoac thii phat, do virut hoac vi khuan
gay nen.
-

Nhiem khuan:

+

Tien phat: virut dai, poliovirut, Arbo virut.

+ Thii phat: do virut bach hau, cum, sdi, vi khuan ly, phe
cau, tu cau, lien cau, hoac do cac benh nhiem trung phiic tap
khac nhii triic khuan giang mai, thiidng han, ly va cac loai
nhiem khuan huyet khac gay nen.
Nhilm doc: arsen, chi, thuy ngan va cac kim loai nang
khac.
5. Dac diem thudng ton
Hinh anh thiidng ton benh ly theo qua trinh tien trien cua
benh gom 3 giai doan:
5.1. Nhun tuy do
Giai doan b it dau cua viem, bieu hien sung huyet phu ne
tuy, gian mach, xuat huyet nho, nhiing te bao than kinh bi
thiidng ton tan nhan, tao khong bao, vd te bao. Cac sdi true bi
huy myelin. Ve mat dieu tri chi co the lam tuy hoi phuc d giai
doan nhun tuy do.
5.2. Nhun tuy trdng
Cac te bao va to chiic than kinh bi hoai tii, te bao than
kinh bi pha vd hang loat, sdi true bi pha huy.

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5.3. X o h o a
To chtic than kinh bi hoai tti diidc thay bang to chtic xd,
xen ke cac te bao than kinh dem. Day la sii seo hoa d vi tri to
chtic tuy bi thiidng ton.
II. VIEM TUY NGANG CAP
Viem tuy ngang cap (VTNC) la the lam sang thudng gap
nhat cua viem tuy cap. Trong thiic te thiidng hay gap viem tuy
ngang d doan tuy phinh that liing, doan tuy ngiic, rat it khi
gap d doan tuy co.
Nguyen nhan chu yeu tien phat do virut cung co the thii
phat nhiing hiem (sau cum, sdi...).
1. Lam sang
1.1. Hoi chitng nhiem khuan
Benh thudng khdi phat cap tinh bang hoi chting nhiem
khuan. Sot cao d cac mtic do khac nhau (tuy nhien cung co
triidng hdp sot khong ro) kem theo dau cac day than kinh d
khu viic bi viem, dau lan trong khoanh doan da do re than
kinh cua cac khoanh tuy do chi phoi. Sau mot vai ngav xuat
hien trieu chting than kinh khu tru.
1.2. Hoi chitng thitctng ton than kinh khu tru
Tuy theo khu viic tuy bi thiidng ton ma co nhting trieu
chting tiidng ting, dau hieu lam sang phat trien dien hinh cua
mot thiidng ton cat ngang tuy song.
Roi loan van dong: kieu diidng dan truyen, liet phan cd
the du'cli mtic tuy thiidng ton, giai doan dau liet mem (dac diem
quan trong), triidng liic cd phan chi liet giam, giai doan sau

chuyen sang liet ciing.
106


Roi loan ve phan xa: phan xa gan xUdng m at (tiidng
iing phan chi liet), phan xa da bung mat.
Roi loan cam giac: mat cam giac kieu diidng dan
truyen, mat toan bo cac loai cam giac diidi khoanh tuy thiidng
ton, ngay tren vung thiidng ton mat cam giac la vung tang
cam.
Roi loan cd vong: thiidng xuat hien sdm d da so’ benh
nhan bieu hien la bf dai, dai kho, den khi liet nang chuyen
sang dai dam.
Roi loan dinh dudng, thiic vat: benh nhan cd roi loan
dinh diidng tram trong d khu vUc bi thiidng ton, bieu hien lam
sang la loet diem ty sdm, loet rong, sau va rung long toe.
Tat ca cac trieu chiing tren chiing to tinh chat cua mot
liet mem la hau qua cua mot giai doan soc tuy nang ne.
2. Xet nghiem
Dich nao tuy: nhieu triidng hdp khong thay doi dang
ke, mot so" cd bieu hien tang albumin, bach ciu N, L.
Mau: cd the tang to"c do mau lang, thay ddi cong thiic
bach cau.
Cay khuan: cay DNT hoac cay mau ft khi phan lap
diidc vi khuan.
Chan doan huyet thanh dac hieu cung ft triidng hdp
xac dinh diidc ro loai virut gay benh.
3. Chan doan
3.1. Chan doan xac djnh
Chan doan viem tuy ngang cap cd ban diia vao lam sang.

107


Chan doan dinh khu can cti vao cac trieu chting than kinh
(roi loan van dong, cam giac...).
3.2. Chan doan phan biet
3.2.1. Phan biet vdi roi loan tuan hoan tup:

Co trUdng hdp viem tuy cap khdi phat dot ngot bang liet
hai chan, roi loan cam giac va roi loan cd vong kieu dot quy
tuy song, vi vay can chan doan phan biet vdi tac dong mach
tuy song. Sif kien nay thifdng chi xay ra d khu vUc cua dong
mach tuy song trUdc. Dong mach nay cung cap mau cho 2/3
trifdc cua tuy, tif nuoi dudng chi b in g mot so' nhanh mach mau
rat han che. Trong khi dong mach tuy song sau difdc cung cap
bdi so lifdng nhanh mach mau d nhieu mtic khac nhau. Hoi
chting dong mach tuy trUdc thifdng xay ra do tac mot trong
nhting mach nuoi. Benh thifdng xay ra d ngifdi huyet ap cao,
vtia xd dong mach, chan thifdng, chup dong m ach.....
Benh canh lam sang dien hinh la khdi phat cap tfnh, bieu
hien la: liet, m at phan xa, giai doan soc tuy se het sau mot vai
ngay hoac tuan, tien trien thanh liet m em vdi phan xa gan
xUdng nhay va phan xa da gan chan dao ngifdc. Them vao do,
roi loan cam giac phan ly (mat cam giac dau, nhiet do, nhUng
cdn cam giac sau va cam giac tif the vi cot sau dufdc nuoi dudng
bdi dong mach tuy song sau).

3.2. Phan biet vdi u tuy
Cd the viem tuy gia u, trieu chting than kinh tien trien

nang dan len, nhUng trong u tuy tien trien cham hdn.

Dau la benh canh noi bat, d nhieu benh nhan benh khdi
phat bat thifdng vdi cac trieu chting cua mot thifdng ton ngoai
tuy nhif dau re, dau khu tru d lifng, hoac dau lan toa d mot chi
va vdi dac tfnh tang len khi ho hoac keo cang re.

108


Roi loan van dong co the xay ra, liet ciing sdm, loet muon
va nhe hdn.
Co nghen tac lUu thong DNT, xet nghiem DNT co phan ly
albumin - te bao, chup tuy can quang thay vi tri tuy bi chen ep.
3.3.3. Giang m ai tuy' song:

ThUdng ton: chu yeu gay thudng ton cot sau tuy song,
(hay gap la thifdng ton bo Goll va cac re sau vung tuy that
lifng- cung.
Trieu chiing lam sang: roi loan cam giac chu quan va
khach quan; dau la trieu chiing dien hinh cua benh, tfnh chat
cua dau rat dac biet: benh nhan dau d mot vung nhu kim nhon
cham chfch, dau nhif dien giat hoac set danh, cdn dau xuat
hien tii nhien hay do kich thich.
Roi loan cam giac khach quan chu yeu hai chi dudi,
mat cam giac sau. Benh nhan di bang mat, do do khi khong co
anh sang benh nhan khong the di lai difdc.
G iam trUdng liic cd va m at phan xa gan xUdng (do
thudng ton re sau cua cung phan xa khoanh tuy).

Roi loan than kinh thiic vat.
Thay doi trong dich nao tuy: te bao tang, protein tang,
chu yeu la globulin.
3.2.4. X o nao - tup rai rac:

Thuoc benh thoai hoa myelin, thudng ton bieu hien rai rac
d nao, tuy song, d tieu nao, day than kinh thi giac. Benh tien
trien tiing ddt mot va rat hiem gap d Viet Nam.
L am sang: bang lam sang rat da dang, thudng phoi hdp
m ay hoi chiing nhU: hoi chiing thap, hoi chiing tieu nao, roi
loan cam giac, roi loan mat va tien dinh.

109


Dac biet can phan biet la cac triidng hdp thiidng ton benh
ly khu tru d tuy song. Benh thiidng xuat hien d tuoi thanh va
trung nien, dien bien co tfnh chat tuan tien. Co the ca trong
qua trinh benh chi co trieu chiing liet hai chi dudi.
3.2.5. N goai ra cdn phan biet vdi:

Chan thiidng tuy song.
-

Cac benh ly cua cot song gay chen ep tuy.

4. Dieu trj
Dung khang sinh.
Dung corticoid.
-

Vitamin nhom B.

- Thuoc kich thich tang ciidng dan truyen than kinh nhii
Nivalin.
Nuoi diidng: chu y tang thanh phan dam.
Chong loet: dem lot diem ty, trd minh 1 - 2 gid mot lan,
lau sach da.
Chong nhiem trung dudng tiet nieu: khong dat sonde
neu benh nhan dai dam, neu benh nhan bi dai thi cho dat
sonde 2 -3 ngay rut ra, cho benh nhan tap di tieu tien, dan ltfu
niidc tieu kin, vo trung. Neu da nhiem khuan bang quang phai
riia bang Rivanol l% o hoac dung dich thuoc tim 4%o.
Tap van dong, cham ciiu, xoa bop, dieu tri ly lieu.
5. Tien trien va tien lirdng
Neu dieu tri sdm, tich ciic, san soc ho ly tot thi benh nhan
cd the hoi phuc mot phan. Da cd triidng hdp cd di chiing bai
hoac liet hai chi diidi, roi loan cd vong hoi phuc tot, nhUng
110


cung co trUdng hdp khong hoi phuc dUdc. NhUng benh nhan tu
vong la do suy kiet va boi nhiem.

III. VIEM TUY LEO CAP (HOI CHL/NG LANDRY)
Viem tuy leo cap (Landry) co dac diem lam sang khdi phat
giong viem tuy ngang cap, nhUng tien trien nhanh chong hang
ngay hang gid, lan dan tti thap len cao va co the thUdng ton len
hanh nao, gay tti vong nhanh do suy thd, truy tim mach. Tien
lUdng de dat, ty le tti vong cao.

1. Lam sang
Khdi phat thudng thudng ton d tuy lung, vdi bieu hien liet
mem hai chi dudi, trong vong mot vai ngay liet len hai chi
tren.
Benh nhan trd thanh liet mem tti chi, cd the thay phan xa
benh ly bo thap d hai chi dudi. Mtic do mat cam giac cung lan
dan tti chan len bung, ngUc, len chi tren va len cd. Roi loan cd
vong kieu trung Udng, ltic dau thudng la bi dai tieu tien, sau
dai dam ng&t quang. Ddi khi thudng ton hai ben tuy khong
dong deu, ben nay nang hdn ben kia hoac sdm hdn ben kia, tao
nen mot hoi chting kieu Brown - Sequard.
Sau dd benh tiep tuc tien trien: benh nhan dau d co, gay
roi liet cac cd d co, thUdng ton day than kinh hoanh, bieu hien
kho thd; thudng ton nhan day than kinh IX, X, XII, bieu hien:
noi kho, nghen, sac, mat phan xa hong - hau, liet van dong
lUdi. Cuoi cung roi loan nhip tim va benh nhan tti vong do truy
tim mach.
Mtic do liet va roi loan cam giac luc dau cang nang thi
tien trien cang nhanh va tien lUdng cang xau, benh nhan cd
the chet trong vai ngay.

Ill


Nhiing trUdng hdp nhe, miic do thudng ton khong n&ng,
dUdc ciiu chiia kip thdi, benh nhan khong tii vong thi sau
10 - 15 ngay bat dau trieu chiing hoi phuc mot phan, da so de
lai di chiing, thUdng de lai di chiing bai hoac liet ciing hai chi
dudi. O chi tren co the phuc hoi tot hdn, co the con di chiing
liet hai chi dudi kieu trung Udng ket hdp bai hai chi tren hoac

mot chi tren kieu ngoai vi (do thudng ton d phinh co), bieu
hien: liet m em , teo cd, m at phan xa gan xUdng, hiem gap liet
ngoai vi d hai chi dudi (thudng ton phinh that lung).

Roi loan cd vong co the dUdc phuc hoi, benh nhan dai tieu
tien chu dong dUdc.
Rat hiem trUdng hdp hoi phuc hoan toan khong de lai di
chiing gi.

2. Dieu trj
Dieu tri viem tuy leo cap giong nhu dieu tri viem tuy
ngang cap. Dieu can chu y d day la phat hien sdm the benh
nay, khi cd kho thd thi phai ho trd ho hap kip thdi, hoi siic tich
ciic cho benh nhan.
IV. VIEM TUY THj THAN KINH (BENH DEVIC)
La mot the dac biet cua viem tuy ngang cap. Bieu hien cua
viem ket hdp day than kinh thi giac vdi viem tuy ngang. The
benh nay ve lam sang, phat trien va dieu tri tUdng tii nhu
viem tuy ngang cap.
Thudng ton dac hieu la thoai hoa bao myelin cua sdi than
kinh, gap d day than kinh thi giac chu yeu d giao thoa thi giac.
Trong nhieu trUdng hdp day la giai doan dau cua bieu hien xd
nao tuy rai rac.
Thudng ton bat cii ndi nao cua tuy song, nhUng phd bien
nhat la tuy song nguc.

112


1. Lam sang

Khdi phat tUdng doi dot ngot, trieu chting giam thi liic va
liet 2 chi diidi co the cung xuat hien, hoac trieu chting thi giac
xuat hien trUdc chting vai ngay hay vai tuan.
Roi loan thi giac dUdc bieu hien b&ng tu nhien giam thi liic
d mot hay ca hai ben, thiidng co am diem trung tam va thu hep
thi trUdng, gai thi co hien tUdng phu viem , giam thi liic tti nhe
tdi mu han vdi toe do tUdng ddi nhanh.
Sau 1 - 2 ngay hoac 1 tuan cd trieu chting cat ngang tuy
song, cd trieu chting roi loan van dong va roi loan cam giac
kieu dudng dan truyen, roi loan cd vong.
Cd the cd trieu chting ve nao: dau dau, roi loan y thiic nhe,
cd the cd co giat kieu dong kinh, cd khi la dong kinh tuy song
(co cting 2 chi dudi, dau ddn).
2. Xet nghiem
Xet nghiem DNT: da so' la trong gidi han binh thudng, so it
cd tang albumin nhe.
3. Tien trien
Ket qua dieu tri tUdng doi kha quan sii phuc hoi trUdc tien
la day than kinh thi giac dudi tac dung cua corticoid. Mot so de
lai di chting giam thi liic, teo gai thi.
V. VIEM TUY XAM CAP (BENH BAI LIET)
Con ngUdi da biet benh viem tuy xam tti hang the ky nay.
Nam 1840 Jacob Heine da mo ta benh canh lam sang dau tien.
Nam 1890 Medin da bo sung nhting hieu biet ve dich te hoc
cua benh. Dau the ky 20 Landsteiner, Popper, Flexner, Levis
da xac dinh dUdc benh do virut gay ra. Ngay nay ngUdi ta da
biet v i r u t gay benh bai liet la Poliovirut.
113

Dac diem cua virut bai liet: co ai ti'nh cao vdi te bao
th in kinh van dong (nhat la nhiing te bao than kinh van dong
ldn), pha huy te bao than kinh d siing trUdc tuy song va than
nao, phan huy chat nhiem sac va ton tai trong te bao difdi
dang bao quan lia acid va gay hoai tii te bao, chiing co the keo
theo viem mang tuy vung ke can. virut bai liet con co the xam
lan tan cong te bao sOfng sau tuy song, cac te bao hach than
kinh va cac to chiic than kinh trung lidng (nhiing rat hiem).
Diidng xam nhap: virut bai liet xam nhap vao cd the
qua diidng mieng, chung sinh san d hong, ruot va to chiic
lympho bao cua amidan, sau do vao hach co va mac treo ruot
roi vao mau (thdi gian chung d trong mau rat ngan), vao giai
doan nay chiing khong gay trieu chiing lam sang. Sau do
chung xam nhap vao to chiic than kinh bang con dudng nao
thi y kien cua cac tac gia con chua thong nhat. Da so cac tac
gia cho rang co hai con dudng xam nhap la qua hang rao
mach mau - nao va qua synap than kinh - cd.
1. Djch te
Benh liiu hanh tren khap the gidi, nhat la cac vung nong, co
the xay ra vao moi thdi ky nhiing thudng vao cuoi ha sang thu.
Cd the xay ra le te (sporadic), dia phiidng (endemic),
nhUng cung cd the xay ra thanh dich (epidemic).

Tuoi rat hiem gap diidi 6 thang tuoi: thiidng gap trong giai
doan 5 - 1 0 tuoi, nhUng noi chung cd the gap d moi liia tuoi.
C) Viet Nam trong vong 10 nam tu! nam 1979 den 1988
tinh hinh bai liet tre em d nUdc ta da giam xuong kha nhieu
tuy nhien ty le mac benh van tiidng doi cao. Dac biet d mien
Nam cao khoang gap 10 lan hdn d mien Bac. Mac dau ty le tii
vong do bai liet khong ldn lam nhiing dieu quan trong hdn la

cac di chiing than kinh rat kho hoi phuc ve mat van dong nen

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chien ludc cua To chtic Y te the gidi la tien tdi thanh toan
benh nay tren toan the gidi.
2. Lam sang
Benh khdi dau giong nhiem khuan cap, 25% trUdng hdp
cac trieu chting khdi phat mat di sau 36 - 48 gid, sau dd benh
nhan thay stic khoe hoi phuc 2 - 3 ngay. Tiep theo la sot ddt 2,
kem theo hoi chting mang nao: dau dau tang dan, dau cd xuat
hien va thudng khu tru d gay va that lung, cd the cd roi loan y
thtic nhe. ThUdng sau khi cd trieu chting than kinh dau tien
khoang 3-5 ngay thi liet xuat hien. NhUng cung cd khi liet la
trieu chting than kinh xuat hien dau tien hoac rat muon (sau
2-3 tuan). ThUdng ton van dong tien trien nhanh trong vong
3-5 ngay. Liet thudng khu tru d tti chi, cung cd khi cd than
cung thudng ton. Nhting trUdng hdp nang cac cd ho hap va cd
hoanh cung bi liet. Thong thudng trieu chting sot ton tai 4 - 7
ngay, sau dd than nhiet giam dan va trd ve binh thudng.
3. Xet nghiem
3.1. Dich nao tuy
Trong dich nao tuy thudng thay tang te bao, tti 10 - 200 bach
cau/mm3, hiem khi tdi tren 500 bach cau/mm3. O giai doan sdm cua
benh, ty le bach cau da nhan so vdi lymphocyt thudng cao nhUng
chi trong vai ngay ty le dd se dao ngUdc. Protein nao tuy tang vtia,
trung binh khoang 40 - 50mg/100mm3 nhUng cung cd trUdng hdp
mtic protein tang cao hdn ntia va ton tai trong nhieu tuan. Cdn
lUdng glucose nao tuy trong ranh gidi binh thudng.

5.3.2. Phan lap virut:

Lay phan cua benh nhan ngay khi mdi khdi phat va trong
cac thdi gian tiep theo. NgUdi ta thudng sti dung nuoi te bao
cua ngUdi hoac cua khi de theo ddi sU phat trien cua virut bai

115


liet. Co the phat hien dUdc virut bai liet d benh nhan trong
vong 2 tuan dau vdi ty le 80% nhUng sang 2 tuan tiep do chi
dat dUdc ty le 20%.

5.3.3. H uyet thanh hoc:

Cac khang the trung hoa thifdng xuat hien sdm va co the
phat hien dUdc ngay sau khi benh nhan vao vien. Can lay mau
kep de thif phan ting huyet thanh va qua dd danh gia dUdc
hieu gia khang the.
4. Chan doan
6 da so" cac trifdng hdp chan doan cd the de dang, can ci(
vao liet mem tien trien khong doi xting, thay ddi dich nao tuy.
Trong nhting trUdng hdp khong dien hinh hoac mdi d giai doan
khdi phat, neu benh nhan mdi dUdc tiem chung hoac d vung
dang cd dich can sdm nghi tdi viem tuy xam.

Dich nao tuy thay cd tang ap luc, tang te bao, tang dam
nhe (neu liet nang cd the tang 1 - 3g/l). LUu y te bao tang sdm
(trUdc khi liet) va giam nhanh, trong khi dd dam tang muon va
ton tai nhieu tuan sau.

5. Dieu trj
Dieu tri viem tuy xam nhu dieu tri viem tuy ngang.
Hien nay chua cd phUdng phap dieu tri dac hieu nen can
phai dieu tri trieu chting. Van de quan trong la trong giai doan
cap, ngay tai giUdng benh da phai de phdng cac bien dang tu
the. O cac giai doan sau can day manh phuc hoi chtic nang.
6. Tien lUdng
Gan 10% tti vong trong giai doan dau cua benh do suy thd,
suy ho hap va bien chting phoi.
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The co thiidng ton hanh nao co ty le tti vong cao nhat (tren
50%).
Tien liidng xau neu co liet rong, liet tien trien cham va co
cac ddt gay liet them cac nhom cd mdi.
Sii phuc hoi phu thuoc vao mtic do lan rong va mtic do
nang ne cua liet.
Mot so" benh nhan co hoi chting Postpolio bieu hien bang
cac trieu chting: yeu cd tai phat, teo cd tien trien va rung giat
bo sdi cd. Hay con goi la teo cd tien trien sau viem tuy xam.
7. Phdng benh
Can sti dung vicxin phong bai liet cho tat ca cac tre em va
trong cac vu dich. Co hai loai vacxin hien nay: loai vacxin bat
hoat vdi formalin va loai vacxin Sabin. Niidc ta thiidng xuyen
thiic hien chiidng trinh tiem chung md rong phdng 6 benh pho
bien, trong dd cd benh bai liet tre em.
VI. VIEM NAO - TUY DO TIEM VACXIN PHONG BENH DAI
Khi tiem vacxin phdng benh dai cd the gay nen viem nao tuy. Trieu chting thiidng xuat hien sau khi tiem lan cuoi ciing
va cd the sau khi tiem vacxin khoang 1 - 2 thang.

Cd 3 the lam sang chinh:
Liet leo cap tinh: benh canh giong nhii benh tuy leo cap
ti'nh neu d tren. Benh nhan sot, dau dau, tang ki'ch thich, sau
2 - 3 ngay xuat hien liet 2 chi diidi, sau dd liet len hai chi tren
va liet len hanh nao, de doa ti'nh mang cua benh nhan.
The viem tuy that liing: benh canh lam sang giong nhut
viem tuy ngang cap.

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The viem nhieu day than kinh: bieu hien hay gap la
thiidng ton cac day than kinh so nao nhii day VII, III, IV, V
va cac day than kinh nhii day tru, day quay, day than kinh
hong to.
Thiidng kem theo cac trieu chiing nao chung nhii nhiic
dau, chong mat, buon non, non, co giat,v.v...
VII. MOT SO THE VIEM TUY CAP KHAC
1. Viem tuy cap mot phan
Thiidng ton khong c&t ngang hoan toan tuy song, do vay
trieu chiing lam sang bieu hien khong mat dan truyen cua tuy
song mot cach toan bo.
Neu thiidng ton ngang 1/2 tuy song se gay hoi chiing
Brown - Sequard. Benh nhan mat toan bo cam giac sau va tinh
vi ben thiidng ton va kem theo liet mia ngUdi. Ben doi dien thi
mat cam giac nhiet, dau.
ThUdng ton d mep xam triidc d vung phinh co se co bieu
hien phan ly cam giac, mat cam giac dau va cam giac nong,
lanh; con xuc giac va cam giac sau, khu tru d hai tay va nUa
tren ngiic hinh canh biidm.

2. Viem simg trudc tuy cap tinh
Virut xam nhap chu yeu vao dau siing triidc tuy song lam
huy hoai cac te bao van dong cua siing triidc.
Viem siing triidc tuy song cap tinh do virut bai liet: benh
bai liet d tre em la mot the benh dien hinh. Ngoai ra viem tuy
do virut khac gay nen ca d ngiidi ldn. Bieu hien lam sang than
kinh giong nhii benh bai liet, yeu liet kieu ngoai bien, liet
mem, triidng liic cd giam va dinh diidng roi loan nhanh vdi
phan iing thoai hoa dien.

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Tom lai viem tuy cap (hay co the goi la benh tuy cap tinh)
do nhieu nguyen nhan gay nen, co nhiing the lam sang khac
nhau, can chu y kham ky ve than kinh de chain doan dinh khu
va chan doan xac dinh benh. Viec dieu tri can chu y khau san
soc ho ly, phuc vu benh nhan.

BENH BAI LIET

I. DAI CLTONG
1. Djnh nghTa
Bai liet la benh truyen nhiem cap ti'nh do virut bai liet gay
ra, benh lay theo diidng ho hap va dudng tieu hoa. Dac diem
lam sang chu yeu la nhiing bieu hien liet mem ngoai vi, khong
co roi loan cam giac kem theo.
Benh do Heine mo ta lan dau tien vao nam 1840, sau do la
Medin (1887) nen con diidc goi la benh Heine - Medin.
2. Mam benh

Virut bai liet (PolioVirut) do Landsteiner va Popper tim ra
nam 1909, la mot virut hinh cau, kich thiidc nho, diidng kinh
8 - 27 nm, co cau tao la ARN va protein, khong co chat beo.
Virut bai liet co 3 typ khang nguyen khac nhau va khong
gay mien dich cheo:
Typ I: dien hinh la chung Brunhilde.
Typ II: dien hinh la chung Lansing.
Typ HI: dien hinh la chung Leon.
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Trong do typ I chu yeu gay benh cho ngUdi d the dien hinh,
typ II gay benh the an va typ III it gay benh hdn.
Virut co tinh chiu diing cao vdi ngoai canh: trong phan
ngifdi chiing song diidc vai ngay den vai tuan, trong niidc co
the tdi 14 ngay. De bi diet bang cac thuoc khu trung thong
thUdng nhU: chloramin B, nUdc oxy gia, thuoc tfm va tia ciic
tim... 6 60°C, virut bi diet trong 30 phut.
3. Nguon benh
La nhiing benh nhan bi benh bai liet. Virut cd d hong va d
phan ngUdi benh trUdc va sau khi khdi phat cd the den 2 tuan
hoac hdn.

Ngoai ra, ngUdi mang virut khong cd trieu chiing lam sang
(ngUdi lanh mang virut) cung la mot nguon lay quan trong.
4. Dudng lay
Bang viec phan lap dUdc virut d hong, ngUdi ta da xac dinh
dUdc virut bai liet lay theo dudng ho hap trong thdi ky diu cua
benh.
NhUng benh lay chu yeu b in g dudng tieu hoa, thong qua

tay va dung cu nhiem ban, vdi vat chu trung gian truyen benh
la ruoi. Virut dUdc thai ra theo phan cua ngUdi benh trong thdi
gian dai (tdi vai thang) va xam nhap vao dudng tieu hoa
(mieng) cua ngUdi lanh.
5. Sure cam thu va mien djch
NgUdi cd siic thu benh cao vdi virut bai liet. Tuoi hay gap
la tre em tii 2 - 8 tuoi, dac biet la tre 2 - 4 tuoi chiem tdi
60 - 80%, tre sd sinh va ngUdi ldn cd the bi nhUng ft hdn va
thudng la khong dien hinh.

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Sau khi bi benh bai liet benh nhan thifdng co mien dich
ben vflng, hiem khi mac lai.

6. Tinh chat djch
Benh thifdng tan phat, doi khi thanh dich d nhiing tap the
nho nhu nha tre, trUdng mau giao, trUdng pho thong cd sd, d
thanh pho nhieu hdn nong thon va hay xay ra vao cuoi mua
xuan, dau mua he hang nam.
Nhd co vacxin Sabin, nhieu nUctc tren the gidi da day lui va
thanh toan tan goc benh bai liet. C) Viet Nam, benh dUdc xep
vao mot trong cac benh nam trong chUdng trinh tiem chung
md rong cho tre em va nUdc ta da tuyen bo" thanh toan benh
bai liet vao nam 2000.
II. CO CHE BENH SINH VA GIAI PHAU BENH LY
1. Cd che benh sinh
Tii khi xam nhap vao cd the den khi vao he than kinh
trung Udng gay benh canh lam sang dien hinh (liet), virut bai

liet phai hai lan vao mau va khu tru d mot so phu tang. Qua
trinh dien bien qua 3 giai doan:
Giai doan xam nhap va tang sinh d dUdng tieu hoa:
virut vao cd the qua hau, hong, trong 24 gid dau da den cac
hach bach huyet quanh hong, vao niem mac tieu trang va tang
sinh d do (co the phan lap dUdc virut d nhay hong va phan
trong giai doan nay).
Giai doan noi tang: tif niem mac dUdng tieu hoa, virut
vao mau (lan 1) sau do den cac noi tang (tim, gan, tuy, thudng
than, ho hap...). Tai day chung tiep tuc tang sinh va gay ra cac
bieu hien lam sang cua thdi ky tien liet.

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Giai doan xam nhap va tang sinh cl than kinh trung
Udng: virut tti cac noi tang vao mau (lan 2) va vao he than
kinh trung ifdng, chu yeu la cac neuron van dong d sting triidc
tuy song.
Ddi vdi the khong dien hinh (khong cd liet), virut chi xam
nhap tdi cac hach bach huyet, niem mac difdng tieu hoa hoac
tdi mau ma khong vao he th in kinh trung ifdng, sau dd bi dao
thai ra ngoai theo phan.
2. Giai phau benh ly
Thifdng ton chu yeu la d sting trifdc tuy song, ngoai ra la d
sting ben, sting sau cung cd the bi viem nhUng thifdng la
thifdng ton nhe va khong dien hinh. Doan tuy co va that lung
la nhting ndi thudng ton hay gap nhat, tiep theo la vung than
nao, cac nhan van dong, tien dinh, he ludi, tieu nao va cac day
than kinh so nao.

- Ve dai the: mang nao - tuy phu ne sung huyet, chat
xam d sting trUdc tuy song cd mau hong hoac mau vang xam,
chat trang sung huyet va cd nhting dam xuat huyet rai rac.
- Ve vi the: thifdng ton sdm nhat d te bao than kinh la
hien tUdng tieu huy the Nissl trong nguyen sinh chat, dan tdi
tinh trang cac neuron bi thoai hoa va phan ting viem quanh
cac neuron, cac mach mau va to chtic dem, dong thdi cd hien
tiidng xam lan cac bach cau da nhan, lympho bao, dai thiic
bao. Hau qua cua sii thoai hoa cac neuron, phan ting viem va
sii xam lan te bao lam teo sting trifdc tuy song, xd hoa to chiic
dem va thanh mach. Tuy nhien, da so" cac thiidng ton diidc
phuc hoi va cac chtic nang than kinh cung cd the dUdc phuc
hoi sau 1 - 2 thang. Mot so" neuron bi thifdng ton nang khong
hoi phuc (tren lam sang the hien b in g cac di chting).

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Cac cd quan ngoai he than kinh cung co the bi virut tan
cong nhu ho hap, tim , gan, than, tieu hoa v.v.. nhUng cac
thUdng ton thUdng nhe va nhanh hoi phuc.

III. LAM SANG
9

'

t

o

1. The thong thudng dien hinh (hay the liet - Paralytic
poliomyelitis)
The nay chiem 1% trong so cac the benh.
1.1. Thdi ky nung benh
Khoang 5 - 35 ngay, trung binh 6 - 20 ngay.
1.2. Thdi ky khdi phat (hay giai doan tien liet)
Tu: 3 - 7 ngay vdi nhieu bieu hien phong phu:
Sot: khdi phat dot ngot, da so" sot nhe, mot so trUdng
hdp sot cao 39 - 40°C, keo dai trong 3 - 4 ngay.
-

Viem long dUdng ho hap tren: ho khan, hat hdi, chay
nUdc m it nUdc mui, giong noi khan.
Roi loan tieu hoa: non, buon non, di ngoai phan tao
hoac long.
Roi loan than kinh thiic vat: tre va nhieu mo hoi, net
mat luc tai luc hong, mach cham (ngUdc lai vdi mach nhanh
khi sot cao).

khoc.

Trang thai tam than kinh: ly bi hoac vat va, hay keu

-

Dau va co ciing cac cd la dau hieu rat sdm va pho bien.
Day la nhUng dau hieu rat cd gia tri de chan doan sdm vi
nhiing cd nao dau se phat trien liet, thudng dau va co ciing cac

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cd vung co, than minh va sau dui lam tre met moi, siic cd yeu,
trUdng luc cd giam, doi khi co hien tUdng co giat nhe d nhiing
cd sau nay se bi liet. Kem theo co bieu hien giam hoac mat
phan xa (khi mat phan xa da bung tdi 80% co liet chi dudi).
Hoi chiing mang nao: nhiic dau nhieu (kem theo non,
buon non). Kham cac dau hieu thiic the: ciing gay (+),
Kernig (+), Brudzinski (+). d tre nho dUdi 18 thang co the
thay thop phong hoac dau hieu Hoyne (+): de tre nam ngiia,
dung 2 tay thay thuoc nang nhe 2 vai tre, dau tre khong
ngoc len dUdc theo.
Xet nghiem dich nao tuy co the thay te bao tang nhe,
protein binh thUdng hoac tang it, glucose va NaCl binh
thudng.
1.3. T h d i k y to a n p h a t (hay giai doan liet)

Dac diem cua liet:
+

Liet nheo ngoai vi, khong doi xOfng.

+

Liet khong theo mot thii tii nhat dinh.

+ Liet xay ra dot ngot va nhanh, thudng xuat hien vao
ngay thii 4 - 7 cua benh, khi nhiet do da ve binh thudng hoac
het sot trUdc do 1 - 2 ngay. Tit khi bat dau co liet den khi liet

khong tien trien mia chi trong vong 48 - 72 gid.
+ Cac cd bi liet thudng yeu, trUdng liic cd giam, mat hoac
giam phan xa gan xUdng va phan xa da, cd teo nhanh. Diem
dang chu y la d cac cd nay khong co nhiing roi loan cam giac
kem theo.
Dinh khu cua liet: tuy theo vi tri thUdng ton co cac the
sau:
+

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The tuy song: chiem 60 - 70% the co liet.


Thiidng ton tuy co: liet cd co, vai, gay, chi tren (cd vai)
va cd hoanh.
ThUdng ton tuy that lung: liet cac cd bung dudi va chi
dudi.
+ The hanh tuy: thudng ton hanh tuy ddn thuan hiem
gap ma thifdng ket hdp vdi thiidng ton tuy song. Cac bieu hien
thifdng ton hanh tuy:
Roi loan ho hap: nac nhieu, kho thd, roi loan nhip thd.
Roi loan tuan hoan: mach khong deu hoac truy mach, roi
loan nhip tim, huyet ap dao dong va cd xu hiidng giam.
Roi loan than kinh thiic vat: sot cao, va nhieu mo hoi,
da tim tai.
Day la the rat nang, tii vong cao (50 - 90%).
+ The tuy song - hanh tuy: la thudng ton phoi hdp 2 the
tren, chiem 15 - 25% cac the cd liet.
+ The nao: cd the ddn thuan hoac phoi hdp vdi thudng ton

hanh tuy - tuy song. Neu la the nao lan toa ddn thuan thudng
rat kho phan biet vdi viem nao do cac loai virut khac. Day la the
hiem gap, tien trien keo dai va de lai nhieu di chiing.
Cac trieu chiing khac:
+ Dau hieu dau cd: tang len khi bat dau liet, keo dai vai
ngay sau dd giam dan, kem theo dd dau dau, tinh tao hdn, an
ngu kha hdn, dd met mdi.
+

Xet nghiem:
Bach cau mau ngoai vi binh thudng hoac cd the tang
trong mot vai ngay, sau dd ve binh thudng.

.

Xet nghiem dich nao tuy: te bao tang (thudng tang vai
chuc den vai tram bach cau, nhUng hiem khi tdi 1000
bach cau/mm3), tang cao nhat vao tuan 2 - 3 cua benh.

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Cong thiic te bao: luc dau chu yeu la bach cau da nhan
trung tinh, sau vai ngay bach cau lympho chiem tfu the dan va
trd ve binh thiidng tvf tuan thii 4 cua benh. Protein trong dich
nao tuy co the tdi 1 - 2 g/1, cao nhat vao tuan thii 3 va trd ve
binh thiidng sau 1 - 2 thang. Khoang 10% so triidng hdp co
dich nao tuy binh thiidng. Tuy nhien, te bao tang va protein
tang khong lien quan den miic do benh.
Phan lap virut: tii mau (triidc khdi phat 2 - 3 ngay va

sau khdi phat 1 - 2 ngay), tii nhay hong (triidc khdi
phat va keo dai 10 ngay sau khdi phat), tii phan (triidc
khdi phat va keo dai tdi khi hoi phuc).
Huyet thanh chan doan: phan iing ket hdp bo the va
phan iing trung hoa.
1.4. Thdi ky hoi phuc va di chung
Hoi phuc sdm: trong 6 tuan dau cua benh, cac cd bi liet
phuc hoi nhanh, giam va het dau, chi de lai mot so" it cd va
nhom cd bi liet hoan toan. Dd la do da so cac neuron than kinh
chi phoi cac cd liet luc dau chi bi phu ne va roi loan chiic nang,
sau dd hoi phuc.
Hoi phuc muon: sau 6 tuan tdi 2 - 3 nam, cd cd bi liet
giam cham va khong ro rang, nhieu cd bi liet hoan toan.
-

Di chiing: la nhiing thiidng ton khong hoi phuc sau 3 nam.

2. Mot so the lam sang khac
2.1. The khong trieu chung lam sang
The nay chiem tdi 80 - 85% cac the benh. Chan doan xac
dinh diia vao viec phan lap virut tu! phan benh nhan va sii cd
mat cua khang the trong huyet thanh.
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2.2. The nhe (abortive poliomyelitis)
Chiem 4 - 8%, bieu hien bang trieu chiing viem long dudng
ho hap tren, roi loan tieu hoa va mot so' trieu chiing giong cum
(sot, dau khdp). Chan doan cung phai dUa vao phan lap virut
va phan iing huyet thanh.

2.3. The khong liet (non paralytic poliomyelitis)
Chiem 10%, benh nhan co cac trieu chiing: cua thdi ky tien
liet (d the liet), noi bat la hoi chiing mang nao va cac dau hieu
kich thich mang nao nhiing khong cd liet.
IV. CHAN DOAN
1. Chan doan xac djnh dira vao
Lam sang: sot cao, dau cd.
Liet nheo ngoai vi khong doi xiing: xay ra dot ngot, giam
phan xa gan xiidng va khong cd roi loan cam giac kem theo.
- Xet nghiem: phan lap virut tii mau, nhay hong, phan
theo tiing thdi ky benh. Phan iing trung hoa hoac phan dng
ket hdp bo the vdi hieu gia khang the lan hai tang cao hdn lan
thii nhat.
Dich te: tuoi de mac benh (2 - 8 tuoi) va cd nhieu tre
trong mot tap the ciing bi tUdng tu.

2. Chan doan phan biet
2.1. Thai ky tien liet
Benh cum va nhiem virut diidng ho hap do virut khac:
sot cao lien tuc tdi 4 - 7 ngay, thiidng cd ret, nhiem doc nang hdn,
dau dau dii doi, benh dien bien nhanh trong vong 7 - 1 0 ngav.
127