儿童肾病综合征并自发性细菌性腹膜炎临床分析

Clinical analysis of spontaneous bacterial peritonitis in children with nephrotic syndrome

目的探讨肾病综合征（Ns）并自发性细菌性腹膜炎（SBP）患儿的临床特征。方法回顾性总结2010年1月至2014年6月在首都医科大学附属北京儿童医院肾内科住院的11例Ns合并SBP患儿的临床表现、实验室资料和治疗情况。结果11例Ns患儿共发生12例次SBP，其中1例患儿发生2次。男9例，女2例；发病年龄2岁11个月～14岁11个月。9例患儿接受糖皮质激素和／或免疫抑制剂治疗。11例患儿均有不同程度的腹痛，其中7例起病缓，全腹胀痛不伴反跳痛和腹肌紧张。出现发热10例，腹胀8例，腹泻5例，呕吐4例。2例患儿病程中突然出现休克。全部患儿存在高度水肿，其中5例表现为腹水迅速增加，利尿剂治疗无效。11例患JL#I-周血白细胞计数和C反应蛋白均升高。血清清蛋白水平明显降低。CD4辅助细胞比例和血IgG水平降低。腹水外观混浊呈脓样，中性粒细胞计数升高。2例患儿腹水培养和血培养肺炎链球菌阳性，均应用抗生素治疗。9例患儿应用单一抗生素治疗，疗程7～10d。2例血培养阳性的危重患儿抗生素疗程4周。5例患儿采用腹腔穿刺放液治疗。11例患儿腹膜炎全部治愈。2例肾病复发患儿在腹膜炎治愈后尿蛋白转阴。结论SBP在Ns患儿表现不典型，甚至缺少腹膜激惹征，容易漏诊导致病情突然恶化，需要临床医师予以重视。SBP亦会导致NS复发，腹膜炎的治愈有助于原发病的缓解。

Objective To explore the clinical feature of spontaneous bacterial peritonitis （SBP） in children with nephrotic syndrome （NS）. Methods Eleven cases of SBP in children with NS from Department of Nephrology, Beijing Children＇s Hospital Mfiliated to Capital University of Medical Science between January 2010 and June 2014 were analyzed retrospectively. The clinical features, laboratory data and efficacy of therapy were reviewed. Results In this study, 12 episodes of primary peritonitis were detected in 11 patients. One patient had 2 attacks. There were 11 ca- ses including 9 boys and 2 girls. The age of the patients ranged from 2 years and llmonths to 14 years and 11 months. Nine cases of them received steroid therapy and/or eytotoxic drugs. Peritonitis was characterized by abdominal pain, mild abdominal pain occurred in 7 cases with slow onset. Ten cases had fever of varying degrees,8 cases had abdominal distention ,5 cases had diarrhea and 4 cases had nausea and vomiting. Shock signs were present suddenly in 2 cases be- fore therapy of antibiotics. Apparent edema and severe ascites were present in all cases. Five of them were presented with increasingly rapid severe ascites and showed no response to diuretic drugs. Blood investigation showed leukocytosis and high C - reactive protein. Serum albumin levels and IgG and CD4 ratio were very low in all cases. Ascites were like cloudy pus with raised neutrophil cells. Streptococcus pneumonia was positive in both blood culture and ascites culture in 2 cases. Cephalosporin was used empirically to all cases for 7 to 10 days in 9 cases and 4 weeks in 2 cases with posi- tive blood culture. Paracentesis to release ascites fluid was performed in 5 eases with constant ascites. Eleven cases re- covered from peritonitis completely. The proteinuria was negative in 2 cases after they recovered from peritonitis. Conclusions SBP was atypical in children with NS and sometimes patients might have to abdominal pain and rebound tenderness, which may be ignored and may induce deterioration suddenly and clinicians should be aware of it clearly. SBP could lead to relapse of NS and the cure of SBP by treatment could help the children recover from NS.