耐甲氧西林金黄色葡萄球菌感染致坏死性肺炎临床特点12例分析

Clinical analysis of 12 cases with methicillin-resistant staphylococcus aureus necrotizing pneumonia in children

目的分析儿童耐甲氧西林金黄色葡萄球菌(MRSA)感染导致坏死性肺炎的临床特征,对临床诊治提供参考依据。方法回顾性分析2009年1月-2015年5月收治的12例MRSA感染致坏死性性肺炎患儿的病史资料。结果12例患儿中,男5例、女7例,年龄9月~3岁,中位年龄23月,均为急性起病,既往体健,热程12~36d,住院天数28~70d。均表现为高热、咳嗽及感染中毒症状。5例发病时即为脓毒血症,7例以发热、咳嗽入院,8例有呼吸困难,6例伴有皮疹。10例可闻及细湿啰音,所有病例均有不同程度的胸腔积液,2例合并金黄色葡萄球菌皮肤烫伤样综合征,2例在病程中合并深部软组织脓肿,无合并急性骨髓炎或化脓性关节炎病例。外周血白细胞总数(14.8×109/L^42.36×109/L)、中性粒细胞(78.8%~91.9%)。C反应蛋白(68~140mg/L),血沉(52~114mm/h)及降钙素原(0.8~3.7ng/ml)。胸腔积液检查外观均为粘稠黄色,细胞数明显升高(5 800~12 560)×106/L,蛋白35~60g/L药敏试验显示所有病例均对万古霉素敏感,对青霉素、苯唑西林、红霉素及头孢类抗生素耐药。病初胸部影像学表现为肺纹理增粗或肺大片状高密度灶,迅速进展成为多发囊泡影或空腔。所有病例应用万古霉素或利奈唑胺控制感染及对症治疗,胸腔积液多者给予胸腔闭式引流或胸腔清脓术。所有病例随访半年,于6个月左右复查肺部CT基本完全恢复,无进行肺叶切除病例,预后较好。结论MRSA感染致坏死性肺炎多见3岁以内儿童,发病急、进展迅速,临床上以高热、咳嗽、肺组织坏死为特点,及时积极治疗预后较好。

Objective To analyse the clinical effect of methicillin-resistant staphylococcus aureus（MRSA） necrotizing pneumonia in children. Method A retrospective analysis was performed based on the clinical records,laboratory data and treatment effects which were collected from 12 cases with CA-MRSA necrotizing pneumonia. Results Of the 12 cases,5 cases were male and 7 female. The median age was 23 months （8 months-3 years old） and they were healthy before admis- sion. They were febril for 12-36 days and hospital day was 28-70 days. The general condition of all cases were poor,all had high fever and cough. Dyspnea was found in eight children. Fine tales were found on 10 cases. Sighs of pleural effusion were discovered by physical examination and chest X-ray. During the course of admission, 2 children complicated with deep soft tissue abscess,2 cases complicated with staphylococcus scalded skin syndrome and the other complicated with sepsis syndrome. WBC count was （14.8 - 42.36） × 10^9/L and neutruophil was 78.8 % - 91.9 % in peripheral blood routine test. E- rythrocyte sedimentation rate was 52- 114 mm/h and C-reactive protein was 68- 140 mg/L. The pleural effusion biochemis- try and routine test revealed a WBC count of （5 800-12 560）× 10^6/L,protein of 35-60 g/L. Pleural effusion culture and （or） blood culture in all cases was positive for MRSA. Chest CT revealed high density lesions in the area of lobar consolicat- ed were found a week later. All cases were treated with vancomycin. After a followed up of more than 6 months, chest CT showed that almost lesions in lungs recovered during 6 months. No cases received pneumonectomy. Conclusions MRSA necrotizing pneumonia is more common in children younger than 3 years old. Pathogenesis of acute and rapid progress,clini- cally characterized by high fever,coughing and lung tissue necrosis. If diagnosed and treated promptly, the prognosis of MR- SA necrotizing pneumonia is relatively well.