1例重症手足口病合并病毒性脑炎患儿的药学监护

Pharmaceutical care on a child with severe hand-foot-mouth disease and viral encephalitis

1例4岁男性患儿,因高热、头晕、双上肢抖动明显、口腔内多枚疱疹,EV71RNA阳性,诊断为重症手足口病合并病毒性脑炎。临床药师参与治疗方案的评估,对患儿实施药学监护:入院时,患儿体质虚弱,为防止严重不良反应发生,甘露醇使用最小剂量0.5 g.kg-1,在治疗第5天时,患儿出现排尿困难,及时停药,恢复良好;入院后,立即给予患儿静脉注射免疫球蛋白,总量2 g.kg-1,分3天给予,患儿精神状态好转,无不良反应发生;该患儿病情进展较快,根据指南采用糖皮质激素冲击治疗,给予甲泼尼龙10 mg.kg-1.d-1,连用3天,为了预防大剂量激素可能出现的不良反应,同时使用奥美拉唑肠溶片(10mg,qd)4 d抑制胃酸分泌,保护胃黏膜;抗生素选择方面,由于患儿免疫力低下,白细胞计数高,不除外细菌感染,经验使用头孢曲松(1 g,qd)3 d,3 d后评价疗效不佳,遂换为阿奇霉素(0.2 g,qd)共3 d,3 d后患儿感染控制好。1周治疗后,患儿症状显著改善,康复出院。

One 4-year-old male patient with the symptoms of high fever, dizziness, significant jitter in upper limbs, multiple oral herpes, and EV71RNA positive was diagnosed with severe hand-foot-mouth disease complicated with viral encephalitis. Clinical pharmacists involved in the assessment of treatment protocols and carried out a series of pharmaceutical care on this patient. When the patient was admitted to hospital, he was weak, and the mannitol was used with the minimum dose （0.5 g·kg-1 ） in order to prevent serious adverse events. In the fifth day of treatment, the patient developed dysuria, so the medication was promptly discontinued, after that he recovered well. He was intravenously given the total amount of 2 g.kg-1 of human immunoglobulin （pH 4） which was divided into three days after admission, and the mental state of this patient improved without adverse reactions. According to the rapid progression of the patient＇s condition and the guidelines, steroid pulse therapy was applied with methylprednisolone 10 mg-kg-1.d-1 for three days, and omeprazole enteric-coated tablets （10 mg once daily for 4 days） were used to inhibit gastric acid secretion for protecting the gastric mucosa and preventing the adverse reaction caused by large doses of corticosteroid. Considering the low immunity and high white blood cell count of the patient, empirical use of ceftriaxone （1 g, qd for 3 days） was selected for potential bacterial infection, while the efficacy was poor when evaluated after three days, and then ceftriaxone was replaced by azithromycin （0.2 g, qd for 3 days）, 3 days later the infection was controlled. One week later, the symptoms significantly improved and the patient discharged.