儿童难治性肺炎支原体肺炎97例临床特征分析

Clinical Features Analysis of Refractory Mycoplasma Pneumoniae Pneumonia in 97 Children

目的：分析总结难治性肺炎支原体肺炎（RMPP）患儿临床特征。方法：回顾性分析我院呼吸科2013年1月-2015年12月收治的643例肺炎支原体肺炎（MPP）患儿,根据初始给予阿奇霉素静滴5~7d是否有反应分为MPP组和RMPP组。比较两组患儿临床表现、实验室检查、影像学特征,寻找RMPP各独立相关因素的临界值。结果：643例患儿中RMPP组97例,MPP组546例。两组间热程、中性粒细胞比例、淋巴细胞比例、CRP、血清铁蛋白、谷丙转氨酶、谷草转氨酶、乳酸脱氢酶、FDP、D二聚体差异均有统计学意义（P均〈0.05）。RMPP组混合感染率明显高于MPP组（χ^2=30.290,P〈0.01）;前者肺部影像学常提示肺部大片高密度均匀实变影（常超过2/3肺叶）,常伴有胸腔积液、肺不张、坏死性肺炎等;支气管镜下RMPP组患儿常有黏膜糜烂、溃疡、管腔内胶冻样坏死物、塑型痰栓等;RMPP组各系统肺外并发症发病率均高于MPP组（P均〈0.05）。经ROC曲线下面积计算得出C反应蛋白、血清铁蛋白、乳酸脱氢酶、中性粒细胞比率为RMPP有价值的预测指标,临界值分别为47mg/L、263μg/L、506U/L和0.78。RMPP组的D二聚体水平显著高于MPP组。结论：当MPP患儿接受常规大环类酯类抗生素治疗5d以上无效,CRP≥47mg/L,血清铁蛋白≥263μg/L,乳酸脱氢酶≥506U/L,中性粒细胞比例≥0.78,胸部影像学进展,提示为RMPP,应及时予甲泼尼龙抗炎治疗,持续肺不张者予儿科软式支气管镜治疗;并常规予凝血功能检查,如果提示血液高凝应予抗凝治疗。

Objective：To analyze and summarize the clinical features of refractory Mycoplasma pneumoniae pneumonia（RMPP）.Methods：Retrospective analysis was performed on the clinical data of 643 children with MPP who were hospitalized in respiration department of our hospital during January 2013 and December 2015.According to the reaction to intravenous treatment of Azithromycin in 10mg/（kgod）for 5~7days,the subjects were divided into MPP and RMPP groups.The clinical manifestations,laboratory examination and imaging characteristics of two groups were compared.The critical values of each independent factors related with RMPP had been detected.Results：In 643 cases,97cases had no response to Azithromycin treatment were recruited into the RMPP group,while another 546 cases with response into the MPP group.Between two groups,the duration of fever,percentage of neutrophils（N）and lymphocyte（L）,Creactive protein（CRP）,serum ferritin（SF）,glutamic-pyruvic transaminase（AST）,glutamic-oxalacetic transaminase（ALT）,actic dehydrogenase（LDH）,FDP,DDR were statistically significant（P〈0.05）.The mixed infection rate of RMPP group was significantly higher than MPP group（χ^2=30.290,P〈0.01）.The chest radiograph of RMPP demonstrated large high-density homogeneous consolidation（always more than two-thirds of lungs）,and usually coexists with pleural effussion,atelectasis,necrotizing pneumonia and so on.Through flexible bronchoscope,manifestations of RMPP always showed as mucosal erosion,mucosal ulceration,tremelloid sphacelus,plastic sputum bolt.As compared to MPP,RMPP has higher rations of extra-pulmonary complications（P 0.05）.Calculated by the area under the ROC curves,the CRP,SF,LDH,and N were the prediction indicators of RMPP.The cut off value was 47mg/L,263μg/L,506U/L,and 0.78 respectively.Conclusion：RMPP is suggested when the MPP children has no response to routine erythromycin treatment lasted at lest 5days,CRP≥47mg/L,SF≥263μg/L,LDH≥506U/L,N≥0.78,and chest radiograph shows more than two-thirds of lung dense consolidation.The anti-inflammatory therapy of methylprednisolone should be considered as early as possible,and continuous pulmonary atelectasis should be treated by pediatric fiberoptic bronchoscopy treatment.We suggests Routine examination of blood coagulation should be acted,if the prompt blood coagulation should be treated with anticoagulation.