特征性临床表现结合BALF多病原检测对儿童难治性肺炎的诊断价值
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摘要
目的探讨儿童难治性肺炎不同病原感染与特征性临床表现的关系。方法回顾性分析1109例难治性肺炎患儿的支气管肺泡灌洗液(BALF)多病原学检测结果,其中772例病原学检测阳性,根据病原学检测结果分为单纯肺炎支原体(MP)感染组(A组,489例)、单纯细菌感染组(B组,65例)、单纯病毒感染组(C组,88例)和混合感染组(D组,130例),比较四组患儿临床症状、实验室检查及肺部影像学结果。结果 1109例难治性肺炎患儿BALF病原阳性检出率为69.61%。MP检出率为52.39%;总细菌检出率为12.80%,肺炎链球菌居首;总病毒检出率为15.33%,博卡病毒居首;混合感染占11.72%,以MP混合病毒感染最常见。A组年龄较大,易发生咳嗽,发热病程长,易导致血清肌酸激酶同工酶MB>3.7 U/L,发生大叶性肺炎及肺不张;B组特应性体质所占比例高,血中性粒细胞百分比最高,CRP>40 mg/L的发生率高;C组血ALT>35 U/L的发生率较高,肺部影像学呈支气管肺炎改变的比例高达74.70%;D组年龄较小,病情较重,住院时间长,血乳酸脱氢酶水平高,较易发生肺不张。结论 MP、细菌、病毒以及混合感染都可以导致难治性肺炎,其中导致难治性肺炎第一位病原是MP。不同病原体感染所致的难治性肺炎各有特征性临床表现。
Objective To explore the relationship between different pathogenic infections and characteristic clinical manifestations in the children with refractory pneumonia.MethodsBronchoalveolar lavage fluid(BALF) pathogen detection results and clinical data of 1109 children with refractory pneumonia were retrospectively analyzed.According to the positive results of different pathogens,children were divided into four groups of A [simple Mycoplasma pneumoiae(MP) infection,489 cases],B(simple bacterial infection,65 cases),C(simple virus infection,88 cases) and D(a mixture of two or more infection pathogens,130 cases).Clinical features and laboratory tests were compared among the four groups.Results The pathogen positive rate of BALF specimens from 1109 children with refractory pneumonia was 69.61%.The positive rate of MP was 52.39%.The positive rate of bacteria was 12.80%,of which streptococcus pneumoniae was the first bacterial pathogen.The positive rate of virus was 15.33%,of which bocavirus was the first viral pathogen.Mixed infections accounted for 11.72% and MP mixed virus infection was the most common.In group A,the patients were older,coughed more frequently,and had longer duration of fever.The incidence of elevated creatine kinase isoenzyme MB was higher.The main pulmonary radiographic presentation was labor pneumonia and atelectasis.In group B,more patients had specific constitution.The levels of neutrophils proportion and the incidence of C-reaction protein greater than 40 mg/L were higher.In group C,the incidence of elevated ALT was higher and the main pulmonary radiographic presentations were bronchopneumonia(74.70%).In group D,the patients were younger and had more serious illness and longer duration of hospitalization.Blood level of lactate dehydrogenase was higher.The proportion of atelectasis in pulmonary radiographic presentation was significantly higher.ConclusionMP,bacteria,viruses and mixed infections can all lead to refractory pneumonia,of which MP is the first pathogen of refractory pneumonia.Refractory pneumonia caused by different pathogens has certain characteristic clinical manifestations.
Objective To explore the relationship between different pathogenic infections and characteristic clinical manifestations in the children with refractory pneumonia.MethodsBronchoalveolar lavage fluid(BALF) pathogen detection results and clinical data of 1109 children with refractory pneumonia were retrospectively analyzed.According to the positive results of different pathogens,children were divided into four groups of A [simple Mycoplasma pneumoiae(MP) infection,489 cases],B(simple bacterial infection,65 cases),C(simple virus infection,88 cases) and D(a mixture of two or more infection pathogens,130 cases).Clinical features and laboratory tests were compared among the four groups.Results The pathogen positive rate of BALF specimens from 1109 children with refractory pneumonia was 69.61%.The positive rate of MP was 52.39%.The positive rate of bacteria was 12.80%,of which streptococcus pneumoniae was the first bacterial pathogen.The positive rate of virus was 15.33%,of which bocavirus was the first viral pathogen.Mixed infections accounted for 11.72% and MP mixed virus infection was the most common.In group A,the patients were older,coughed more frequently,and had longer duration of fever.The incidence of elevated creatine kinase isoenzyme MB was higher.The main pulmonary radiographic presentation was labor pneumonia and atelectasis.In group B,more patients had specific constitution.The levels of neutrophils proportion and the incidence of C-reaction protein greater than 40 mg/L were higher.In group C,the incidence of elevated ALT was higher and the main pulmonary radiographic presentations were bronchopneumonia(74.70%).In group D,the patients were younger and had more serious illness and longer duration of hospitalization.Blood level of lactate dehydrogenase was higher.The proportion of atelectasis in pulmonary radiographic presentation was significantly higher.ConclusionMP,bacteria,viruses and mixed infections can all lead to refractory pneumonia,of which MP is the first pathogen of refractory pneumonia.Refractory pneumonia caused by different pathogens has certain characteristic clinical manifestations.
引文
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[16] Deng MH,Lin CW,Sun YN,et al.Role of E-selectin for diagnosing myocardial injury in paediatric patients with Mycoplasma pneumoniae pneumonia[J].Ann Clin Biochem,2017,54(1):49-54.
[17] 于春琳,赵德育.肺炎支原体肺炎免疫功能与其病情的相关性[J].江苏医药,2017,43(19):34-36.
[18] 王永,宁大米,韩明峰.支气管局部灌洗治疗难治性肺炎32例疗效观察[J].临床医学,2012,32(1):44-45.
[19] 中华医学会儿科学分会呼吸学组,《中华儿科杂志》编辑委员会.儿童社区获得性肺炎管理指南(2013年修订)[J].中华儿科杂志,2013,51(10/11):745-752,856-862.
[20] 潘蔚,刘军生,刘云香,等.乙型流感性肺炎和社区获得性肺炎病例比较分析[J].解放军预防医学杂志,2015,33(1):92.
[21] 任立歆,郭伟,董汉权,等.支气管肺泡灌洗液细菌培养及药敏试验在儿童难治性肺炎诊治中的价值[J].中华实用儿科临床杂志,2013,28(4):258-260.
[22] Kawamata R,Yokoyama K,Sato M,et al.Utility of serum ferritin and lactate dehydrogenase as surrogate markers for steroid therapy for Mycoplasma pneumoniae pneumonia[J].J Infect Chemother,2015,21(11):783-789.
[2] Wang X,Zhong LJ,Chen ZM,et al.Necrotizing pneumonia caused by refractory Mycoplasma pneumonia pneumonia in children[J].World J Pediatr,2018,14(4):344-349.
[3] Wang M,Wang Y,Yan Y,et al.Clinical and laboratory profiles of refractory Mycoplasma pneumoniae pneumonia in children[J].Int J Infect Dis,2014,29:18-23.
[4] 黄宝兴,邓继岿,王红梅,等.1693例难治性肺炎患儿支气管肺泡灌洗液病原体培养分析[J].中国感染控制杂志,2015,14(6):379-382.
[5] Robert S,Lhommet C,Brun CL,et al.Diagnostic performance of multiplex PCR on pulmonary samples versus nasopharyngeal aspirates in community-acquired severe lower respiratory tract infections[J].J Clin Virol,2018,108:1-5.
[6] Lu AZ,Shi P,Wang LB,et al.Diagnostic value of nasopharyngeal aspirates in children with lower respiratory tract infections[J].Chin Med J (Engl),2017,130(6):647-651.
[7] 胡亚美,江载芳.诸福棠实用儿科学[M].7版.北京:人民卫生版社,2002:1108.
[8] 陆敏,陆权,车大钿,等.纤维支气管镜在小儿难治性肺炎诊治中的价值[J].临床儿科杂志,2008,26(9):811-815.
[9] Shin JE,Cheon BR,Shim JW,et al.Increased risk of refractoy Mycoplasma pneumoniae pneumonia in children with atopic and sensitization and asthma[J].Korean J Pediatr,2014,57(6):271-277.
[10] YazIcI S,Güne? S,Kurtulu?-?okboz M,et al.Allergen variability and house dust mite sensitivity in pre-school children with allergic complaints[J].Turk J Pediatr,2018,60(1):41-49.
[11] 梁坤,张慧玉,田玲,等.细胞因子IL-6、IL-10在难治性肺炎患儿肺泡灌洗液中的变化及意义[J].临床儿科杂志,2014,32(4):336-338.
[12] 苏亚楠.乌鲁木齐市单中心小儿难治性肺炎的危险因素分析[D].乌鲁木齐:新疆医科大学,2017.
[13] von Eiff M,Roos N,Glaser J,et al.Bronchoscopic diagnosis of therapy refractory pneumonia[J].Pneumologie,1990,44(Suppl 1):548-549.
[14] Yan Y,Wei Y,Jiang W,et al.The clinical characteristics of corticosteroid-resistant refractory Mycoplasma Pneumoniae pneumonia in children[J].Sci Rep,2016,6:39929.
[15] Xu JJ,Shu LH.Clinical characteristics of refractory Mycoplasma pneumoniae pneumonia in children[J].Zhongguo Dang Dai Er Ke Za Zhi,2018,20(1):37-42.
[16] Deng MH,Lin CW,Sun YN,et al.Role of E-selectin for diagnosing myocardial injury in paediatric patients with Mycoplasma pneumoniae pneumonia[J].Ann Clin Biochem,2017,54(1):49-54.
[17] 于春琳,赵德育.肺炎支原体肺炎免疫功能与其病情的相关性[J].江苏医药,2017,43(19):34-36.
[18] 王永,宁大米,韩明峰.支气管局部灌洗治疗难治性肺炎32例疗效观察[J].临床医学,2012,32(1):44-45.
[19] 中华医学会儿科学分会呼吸学组,《中华儿科杂志》编辑委员会.儿童社区获得性肺炎管理指南(2013年修订)[J].中华儿科杂志,2013,51(10/11):745-752,856-862.
[20] 潘蔚,刘军生,刘云香,等.乙型流感性肺炎和社区获得性肺炎病例比较分析[J].解放军预防医学杂志,2015,33(1):92.
[21] 任立歆,郭伟,董汉权,等.支气管肺泡灌洗液细菌培养及药敏试验在儿童难治性肺炎诊治中的价值[J].中华实用儿科临床杂志,2013,28(4):258-260.
[22] Kawamata R,Yokoyama K,Sato M,et al.Utility of serum ferritin and lactate dehydrogenase as surrogate markers for steroid therapy for Mycoplasma pneumoniae pneumonia[J].J Infect Chemother,2015,21(11):783-789.
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