肠道病毒71型感染首发肺水肿与肺出血三例报告

Three cases of enterovirus 71 infection with pulmonary edema or pulmonary hemorrhage as the early clinical manifestation

目的了解肠道病毒71型首发肺水肿或肺出血的暴发性致死性的临床特征。方法回顾分析3例的临床表现，化验检查，诊断，治疗转归等。结果此3例均死亡，病初仅有发热、呕吐等非特异性症状，均无手足口臀部皮疹，发病后1—2d病情迅速恶化，突发口唇发绀，呼吸急促。3例均误诊，因考虑感染性休克而扩容。均未能早期认识肺出血，直至出现口鼻吐血性液、全身发绀等才行气管插管，气管内均见大量血性泡沫液。3例血糖显著升高和肌张力降低，2例心动过速，1例高血压。3例胸片双侧或单侧渗出性病变，心影不大，3例外周血白细胞均升高，3例咽拭子、气管分泌液和1例脑脊液样本均检测到肠道病毒71型。结论婴幼儿首发肺水肿或肺出血患儿，符合肠道病毒71型感染特点，发生神经源性肺水肿或肺出血，急诊医生对该类疾病认识和处理不足。婴幼儿病初仅发热伴呕吐，数天后突发口唇发绀，呼吸急促，心动过速，高血压或低血压，肌张力低下，应高度怀疑该病，警惕肺水肿、肺出血。及时告知预后不良，扩容将迅速加剧病情恶化，应严格控制液体，早期气管插管正压通气，积极心功能支持。

Objective To recognize the clinical features of the enterovirus 71 （EV71） infection with pulmonary edema or pulmonary hemorrhage as a fulminant and often fatal illness. Methods We retrospectively reviewed the medical records of the three cases with EV71 infection for clinical manifestation, laboratory data, medications, outcome etc. Results All the cases were infants and they all died. These infants had no skin or mucosal lesions, however, they had sudden onset of cyanosis and tachypnea 1 to 2 days after the onset of the febrile disease with vomiting. All these 3 cases were misdiagnosed and were treated for shock on admission. Pulmonary hemorrhage was not considered in any of the cases on admission. All the cases received tracheal intubation when foamy secretions were discharged from mouth and nose of the patients and notable cyanosis was noted. After intubation, all had pink foamy fluid flew out from the endotracheal tube. The patients had hyperglycemia and limb weakness, two had tachycardia, and hypertension was found in one case. Chest X-ray showed bilateral or unilateral widespread air space opacity, but the cardiac size and shape were normal. All the patients had leucocytosis. EV71 infection was confirmed by detection of specific sequences of the virus in throat swab and tracheal secretions samples and in one case in cerebrospinal fluid sample. Conclusion Pulmonary ederma or pulmonary hemorrhage occurred in the 3 cases with EV71-infected infants. The initial presentation was often nonspecific with fever and vomiting, and sudden appearances of cyanosis, tachypnea, tachycardia, hypertension or hypotension, limb weakness may suggest pulmonary edema or hemorrhage. Excessive fluid resuscitation may deteriorate the illness, on the contrary, fluid restriction and inotropic agents, and early intubation with positive pressure mechanical ventilation may be the proper treatment.