NHÂN MỘT TRƯỜNG HỢP VIÊM NÔI TÂM MẠC DO NẤM TRÊN VAN NHÂN TẠO Phm Quang Tun, Nguy  Yn, Nguy Khoa Ni Tim Mch-BVTW Hu TÓM TẮT B 56 tui, nhp vin phu thung mch ch loi c. Sau phu thut hin st cao. Cy catheter  ch cho kt qu Staphylococus non coagulas, c  n mi l . Bu tr  u tr  c . Bc ct qu c nhau 4  y Candida parapsilosis. B u tr vi thum Fluconazole. Sau 8 tuu tr bn chu thut, bnh n nh ra vin. Kt lun: VNTMNK do nm trng ch u tr n phm khi kt qu c   SUMMARY CASE REPORT: INFECTIVE ENDOCARDITIS CAUSED BY CANDIDA PARAPSILOSIS ON PROSTHETIC VALVES A 56-year-old woman was hospitalized for an operation of replacement of aortic- mitral mechanical valves. 10 days after the operation, the patient got a high fever. Staphylococcus was found on the venous catheter but the blood culture was negative for 9 times in three consecutive days. The patient was under antibiotic treatment but the status was not improved. Positive blood culture of Candida parapsilosis was done twice. The patient was given thereafter with Fluconazole. She was discharged after 8 weeks under this treatment with neither complication nor re-operation. Conclusion: fungus searching should be considered if the blood culture result is negative for the bacterial species and the bacterial antibiotics is not effective. MỞ ĐẦU  VNTMNK  bi van tim ng, chim khong 0.5% mm cn phn khi VNTMNK b u tr u trng mc phi ti bnh vin. Hi cha VNTMNK do n khun. Mt phn bng xng hu phu hay do nhiu bnh phi hp. ng rn chng nht ca VNTM do n   c, bao gm tc ngh    n ngo   m c ch lng thi l hn ch liu tr ni khoa phi kt hp vi phu thut. BÁO CÁO TRƯỜNG HỢP LÂM SÀNG B 56 tui, tin s h ng mch ch, h hu tr nc, b ng mch chp vin ghi nhng bnh v huyu chng nhi ng suy tim nh. Bc phu thung mch ch  hu thut hi 0C - 40 0C c. Bnh c .  tt c m : CTM, VSS, CRP, cc tiu, cy dch vt m, cy catheter   ng hu phu m thay van ng nhi nng n. Sc chuyn n Khoa Ni Tim mch. Ghi nhn ti Khoa Ni Tim Mch: Mch: 80 l: 39 0C . Tn s th 28 l Ching 60 kg. t mi bn, v mt nhi Bt. Kt mc mt trng nhm xut huyt  2 c.  c. Mu, bng thi.  nh,  ng. Phi ran m  i. n. Ting, tiu t chu buu lc nhc ti.  n b m c 1. CTM 13/01 01/02 09/02 14/02 17/03 01/04 04/05 18/05 Bch cu 6,22 17,68 17,98 24,71 9,47 6,09 7,61 4,47 Hng cu 4,03 3,69 2,55 3,9 2,92 2,9 2,8 3,7 Hb 13 11,7 8,5 11,9 8,9 9,1 9,0 11 HCT 38,4 34,2 23,15 33,64 28,3 26,97 7,97 30,0  l: 13/01 01/02 09/02 14/02 17/03 01/04 04/05 18/05 Ure 5,9 11,3 48 35,4 2,5 5,0 9,1 8 Creatinin 64 195 412 111 45 69 118 111 CRP 66.5 54,3 22,1 6,7 VSS 1 h 122 96 76 50 2 h 136 131 112 80 3. INR: -3,5 4. ECG:  kc bit 5. XQ phi: khng c tn thng.   IA quan trng mch ch  a IM quan tr n p nhc SM (2D)= 2,2 cm 2 mm, VG ln= 40 mm IT= 2/4, PAPS= 40 mmHg  gim, EF= 46%    Gradt qua VM tt ng tt   Gradt VA max= 95 mmHg    Chm EF= 50%      tt Gradient qua VM max= 13 mmHg    Gradient qua VA max= 28 mmHg    Cho tn, EF= 55% Cho tn, EF= 55% ng ngang VG   N ng thc 9,3x14,2 mm N  PAPs= 41 mmHg EF= 56% 7. Cy dch vt m  8. C 9. Cn: > 9 l h cho kt qu  10. Cm: Kt qu n vi Candida parap 4/04. Bc ch u tr the c ki  u tr ng c nhii cu tr trng bc cm. Sau 5   t qu  u v       u tr  ng VNTMNK do n    m      chuy  ch. Sau 7    t st. Bp tp, sau 7 tum bn n nh, cc thc hin th u tr m cho kt qu  i 3 mu th. ghic thc hi v ng, lm nhiu so vc, bch cng, XQ phi, c biy EF ci thin, khi. Bo tun th ng u B t BÀN LUẬN Mt bc m o, khi i chng nhi mt s  c vt m, nhit, VNTMNKi, nhit niu do n bi chng nhim u t m, nhim khun huyt m cy dch vt m y Catheter tnh mu cho kt qu u tr ng nhim khun vt m  nhiu tr ng bi thin. Bm tra pht hin khc cn, mi l h cho kt qu i vi khuu tr  VNTMNK c  u tr ng nhi vi thin. Bp tc cc bim n t qu cu tr thung nhii thi Dn cha Duke c 2003. ng dn v ch NK c  dng b  nhng hp VNTMNK. n Duke cc chn c chm Candida parapsilosis. vi vi khun c gii m nm. To do nm xut hi c gi m t l ry thp khoc g  VNTMNK sm. C. Garzoni [10]    ng h    nh  gii cho th        sis chim khong 17%. V u tr n pht ra c th u tr ni n vi thum hay kt hp ngoi khoa. ng dng dn ca hip hi bnh nhi   2004 cho ki     mc Candida rng          u tr vi phu thut thay van nhi               fluorocytosine liu dung np tn sau phu thut, nu u thuu tr t c ch n c bing hp nhim khun nu t m dung np tc hi        u h u nhy cm vi t  i m. Theo khuyc la ch i vi thn cao, ng ch ng b suy thn c u tr  ng ha chn. i        . Thu  m mi c J P Talang s  c mng hu tr    phu thut. Trong tt c m k   n lo  V u tr phu thun thi ng dnh ch nh phu thui vc do nm ng dn ca hip hi bnh nhi 2004 cho kii c Candida r  u tr vi phu thut thay van nhi. u tr tt vn phm kt hp vi phu thut li. Tn u thu  t tuu tr  ng nhii thin, mc chp nhn lng nhiu, n t  n ln    gi ng hu tr   n phu thut l   ng hp phi phu thut li m     Talarmin v ng s ng hp VNTMNK do nm (6 do Candida albicans, do Candida parapsilosis), ng hp dung thut hp thay van sau 4-6 tuu tr  kh ng hi ch m, 1 tng hp t  2 do nhim khun nng hu cho kt qu tn phu thut. Ligia C Pierrotti [11] nhng hp VNTMNK do nm t 1995-2000, mt s u tr nc vi thumt s phi hp vi phu thut. T ng h l t 30 b  liu). T l t vong gi  ng s bc do nu thut van (68.3% so vu thut , p=0.2). T l t vong  bu tr ni hu tr ni ngou xp x 50%. T l t vong t gia VNTMNK bin chn chu tr ni khoa hay phi hp ni ngoi khoa. T  ng: Can thip phu thui thin t l t i bu tr  n KẾT LUẬN VNTMNK do nm t trong nhng chc  nhng b o hoc ci vi khu liu tm cn phc s dng st qu ci  u tr ngot trong tng hp c th. Ch ti thng b mt ng hp vim ni tm mc do nm trn van nhn to iu tr th cng bng phng ph ni khoa, tuy nhin kt qu lu d cn phi c theo d bnh nhn tip tc. TÀI LIỆU THAM KHẢO 1. Hu      c nhim khun, Giáo trình sau đại học Tim mạch họci hc Hu, tr. 89-105. 2. Phm Nguy  c nhim khun, Bệnh học tim mạch tập 2, Nxb Y h H - 315. 3. Nguyc nhim khun, Siêu âm tim từ căn bản đến nâng caoi hc Hu, tr. 157-167. 4. Hi Tim Mch Hc Vit Nam (2008), Khuya Hi Tim mch Vit Nam hc Vit Nam v ch c nhim khun, Khuyến cáo 2008 về các bệnh lý tim mạch và chuyển hóa, Nxb Y hc, tr. 52-71. 5. Karcher AW. Infective endocarditis. In: Zipes DP, Libby P, Bonow RO, Braunwald E, eds.  th edition. Elsevier Saunders 2005: 1633-1658. 6. Guidelines on the prevention, dianogis, and treatment of Infective endocarditis (new version 2009). The Task Force on the prevention, dianogis, and treatment of Infective endocarditis of the European Society of Cardiology (ESC). Eur Heart J 2009; 30: 2369-2413. 7. Infective endocarditis: Dianogis, antimicro-bial therapy, and management of complication: A statement for healthcare professionals from the Com-mittee on rheumatic fever, endocarditis, and Kawasaki disease, Council on cardiovascular disease in the young, and the Councils on clinical cardiology, stroke, and cardiovascular surgery and anesthesia, American Heart Association. Circulation 2005; 111:e 394-e 434. 8. Talarmin J P et al (2008), Candida endocarditis: role of new antifungal agents, Article first published online. 9(2002), Fungal endocarditis, 1995-2000. Chest 2002; 122: 302-310. 10. Garzoni C, Nobre VA and Garbino J (2007), Candida parapsilosis endocarditis: a comparative review of the literature, Eur J Clin Microbiol Infect Dis. 11. Ligia C -2000. Chest 2002; 122: 302-310. . NHÂN MỘT TRƯỜNG HỢP VIÊM NÔI TÂM MẠC DO NẤM TRÊN VAN NHÂN TẠO Phm Quang Tun, Nguy  Yn, Nguy. ng s ng hp VNTMNK do nm (6 do Candida albicans, do Candida parapsilosis), ng hp dung thut hp thay van sau 4-6 tuu tr . ti bnh vin. Hi cha VNTMNK do n khun. Mt phn bng xng hu phu hay do nhiu bnh phi hp. ng