以大疱样皮疹为特征的手足口病病原学及临床特点分析

Pathogenic and clinical presentation of bullous rash in hand, foot and mouth disease

目的回顾性分析西安地区2013至2014年皮疹形态以大疱表现为特征的手足口病患儿的病原及其临床特点。方法收集2013年1月至2014年12月西安市儿童医院224例以广泛的皮肤黏膜大疱反应为特征的、临床诊断为手足口病的患儿标本，以实时荧光定量PCR法进行手足口病病毒核酸检测并分型，对其临床特点、实验室检查及后期随访进行总结分析。结果在皮疹形态以大疱改变为特点的、临床诊断为手足口病的224例患儿的标本中，柯萨奇病毒A6型（CA6）阳性207例，占92．4％，肠道病毒71型（EV71）阳性4例，占1．8％，柯萨奇病毒A16型（CA16）阳性10例，占4．5％，4例肠道病毒核酸检测均阴性。220例肠道病毒核酸阳性病例中，男130例，女90例；男女比为1．44：1，〈5岁203例，占92．3％。血常规检查白细胞升高75例，占34．1％；超敏c反应蛋白（hsCRP）升高者200例，占90．9％；心肌酶CK—MB偏高者35例，占15．9％，肝功能检查丙氨酸转氨酶（ALT）升高者15例，占6．8％。共有187例患儿出现发热，占85．O％。所有病例均未出现脑炎、心肌炎等严重并发症。病程极期皮疹均表现为大疱或大囊泡样改变，痒感明显，伴面部斑丘疹。疱疹液吸收或破溃后出现结痂和大片脱皮，基底新出皮肤无渗出，后期随访无明显色素沉着。在后期追踪随访过程中，CA6阳性病例中有52例（25．1％）距离手足口病发病期约2～4周内出现了指（趾）甲脱落剥离症状，脱甲数量1—8个，平均4．3个，甲板由里向外脱落并伴随新甲长出，脱落后的甲床未见明显结构异常，新生甲板无增生，表面光滑度存在，无肥厚，未留其他后遗症。结论皮疹形态以大疱表现为特点的手足口病主要由CA6引起，该病原所致的以大疱表现为特点的手足口病皮疹伴明显痒感，皮疹后期可出现结痂和脱皮，部分病例可出现脱甲病。

Objective To investigate the pathogenic and clinical presentation and laboratory tests of bullous rash in hand, foot and mouth disease （HFMD） in Xi＇an from January 2013 to December 2014 by retrospective analysis. Method A total of 224 specimens were collected from clinically diagnosed HFMD cases who were characterized by widespread mucocutaneous bullous reactions in Xi＇an Children＇s Hospital from January 2013 to December 2014, the identification and subtyping of the isolates were conducted with real-time fluorescent quantitative RT-PCR. A retrospective analysis was performed to analyze the clinical presentation, laboratory tests and late follow-up problems of the HFMD. Result In the clinically diagnosed HFMD cases who were characterized by widespread mueocutaneous bullous reactions, 207 were caused by eoxsaekievirus A6 （ CA6 ） , accounting for 92.4% of all cases with bullous, 4 were caused by enterovirus 71 （ EV71 ） , accounting for 1.8% , 10 were caused by coxsackievirus A16 （CA16） , accounting for 4. 5% ; 4 cases were negative for these viruses. In the cases positive for intestinal virus nucleic acid, 130 were male, 90 were female; male to female ratio was 1.44： 1, 203 were 〈5 years old, accounting for 92. 3%.Leukocytosis was found in 75 cases （34. 1% ） ; high-sensitivity C-reactive protein （hsCRP） increased in 200 cases （90. 9% ）; elevated myocardial enzyme CK-MB was found in 35 cases （15.9%）, alanine aminotransferase increased in 15 cases （6. 8% ）; 187 cases had fever （85.0%）. None of the cases had serious complications such as encephalitis or myocarditis. In the course of the critical phase bullous rash or large vesicle-like changes, obvious itching, and facial rash appeared. After the fluid in the bullae was absorbed or the bullae ruptured or became ulcerated, scar formation and large areas of exfoliation occurred, with no effusion on the newly formed epithelium in the base, without significant pigmentation on later follow- up. In the late follow up process, 52 cases in CA6-positive patients （25.1% ） developed onychomadesis within 2 -4 weeks after onset, 1 to 8 nails, an average of 4. 3 fell off, new nails grew, the nail bed showed no structural abnormalities and hyperplasia after falling off, the surface was smooth, had no hypertrophy, left no sequelae. Conclusion The pathogen in HFMD characterized by widespread bullous reactions was mainly the CA6, this kind of HFMD was mainly mild type, with significant itching, later the bullae may have scar formation and skin exfoliation, in some cases onychomadesis may occur.