儿童百日咳发病特点及诊断中联合呼吸道病毒检测的临床意义分析

Clinical analysis of children with pertussis and significance of respiratory virus detection in the combined diagnosis

目的 分析儿童百日咳的发病特点及诊断中联合呼吸道病毒检测的必要性,提高临床医生对儿童百日咳的认识,及早完善病原学诊断并规范治疗.方法 临床资料回顾性分析2015年1月至2016年12月在首都儿科研究所附属儿童医院感染门诊及住院的195例疑似百日咳患儿临床资料.结果 195例疑似百日咳患儿均完成呼吸道分泌物百日咳鲍特菌核酸检测,其中172例同时完成呼吸道7种病毒[呼吸道合胞病毒（RSV）、腺病毒（ADV）、流感病毒A（INFA）、流感病毒B（INFB）、副流感病毒Ⅰ型（PIV Ⅰ）、副流感病毒Ⅱ型（PIVⅡ）、副流感病毒Ⅲ型（PIVⅢ）]直接免疫荧光检测.（1）百日咳核酸检测阳性80例（阳性率41.0％）,男47例,女33例,年龄从1月龄至10岁,全部病例均有阵发性咳嗽（100.0％）,伴痉挛性咳嗽50例（62.5％）,咳嗽后呕吐9例（11.2％）,咳嗽后青紫22例（27.5％）,咳嗽后吸气性吼声13例（16.2％）,伴明显呼吸困难4例（5.0％）,胸X线片诊断为肺炎18例（22.5％）,并发百日咳脑病1例（1.2％）;（2）完成呼吸道病毒检测的172例中病毒病原阳性69例（检出阳性率40.1％）,其中RSV阳性32例（18.6％）,PIVⅢ阳性29例（16.8％）;（3）80例百日咳核酸检测阳性病例中,66例完成了呼吸道病毒检测,阳性9例（9/66,13.6％）,其中7例为PIVⅢ混合感染,临床表现为咳嗽后青紫6例,呼吸困难2例,肺部X线片诊断为肺炎3例,临床症状较普通百日咳患儿表现突出;（4）以确诊病原为分组依据,单纯百日咳组57例,RSV感染组32例,单纯PIVⅢ感染组22例,单纯百日咳组、RSV感染组、单纯PIVⅢ感染组痉挛性咳嗽分别为35例（61.4％）、7例（21.9％）、8例（36.4％）,单纯百日咳组发生率高于其他2组（x2=12.850、4.013,P＜0.05）,3组吸气性吼声分别为11例（19.3％）、1例（3.1％）、0例,单纯百日咳组发生率高于其他2组（x2=4.596、4.932,P＜0.05）,3组呼吸困难分别为2例（3.5％）、11例（34.4％）、0例,RSV感染组发生率高于其他2组（x2=15.654、9.487,P＜0.01）.结论 儿童百日咳并不少见,主要以未接种或未完成全程疫苗接种的小婴儿为主,最常见的临床表现为阵发性痉挛性咳嗽,合并PIVⅢ感染可加重百日咳临床表现,早期行呼吸道分泌物百日咳鲍特菌核酸检测有助于诊断百日咳,RSV及PIVⅢ是类百日咳综合征患儿的主要病原,同时行呼吸道病毒检测有利于鉴别诊断,指导用药.

Objective To analyze the clinical data of children with pertussis and explore the necessity of respiratory virus detection in the combined diagnosis so as to improve the clinician＇s understanding and standardize the diagnosis and treatment of pertussis in children.Method Clinical data and laboratory examination of 195 suspected pertussis children between Jan.2015 and Dec.2016 in Children＇s Hospital Affiliated to Capital Institute of Pediatric were analyzed retrospectively.Result The nasopharyngeal secretions were collected from 195 suspected pertussis children,PCR was employed to detect the nucleic acid of Bordetella pertussis.Meanwhile,172 of 195 cases were screened for antigens of 7 common respiratory viruses by direct immunofluorescence （DIF） （respiratory syncytial virus （RSV）,adenovirus （ADV）,influenza virus A and B,parainfluenza viruses type Ⅰ-Ⅲ）.（1） Eighty cases were positive in pertussis nucleic acid detection （positive rate was 41.0%）,47 males and 33 females,age ranged from one month to ten years,all of them had paroxysmal cough （100.0%）,50 cases with spasmodic cough （62.5%）,9 cases with vomiting after cough （11.2%）,22 cases with cyanosis after cough （27.5%）,13 cases with roaring after cough （16.2%）,4 cases with dyspnea（5.0%）,18 cases were diagnosed as pneumonia by chest radiography （22.5%） and 1 case was diagnosed as pertussis encephalopathy（1.2%）;（2） 172 cases of respiratory virus DIF detection were completed and 69 of them were positive（positive rate was 40.1%）,including 32 cases positive for RSV （18.6%）,29 cases for PIV Ⅲ（16.8%）;（3） In 80 confirmed pertussis children,66 cases of respiratory virus DIF detection were completed and 9 were positive （9/66,13.6%）,including 7 cases positive for PIV Ⅲ.The clinical manifestations were cyanosis after cough （6 cases）,dyspnea （2 cases） and pneumonia were diagnosed by chest radiography in 3 cases,the clinical symptoms of these children were more prominent than children with general pertussis;（4） Patients were divided into three groups according to the pathogens：57 cases in single pertussis group,32 cases in RSV infection group,22 cases in single PIV Ⅲ infection group.The cases of spasmodic cough in Pertussis group was 35 （61.4%）,RSV infection group was 7（21.9%）,single PIVⅢinfection group was 8 （36.4%）,compared with the other two groups,the incidence of spasmodic cough were higher in Pertussis group （x2 =12.850,4.013,P 〈 0.05）.The cases of roaring in Pertussis group was 11 （19.3%）,RSV infection group was 1 （3.1%）,single PIVⅢ infection group was 0,and the incidence were higher in Pertussis group （x2 =4.596,4.932,P 〈 0.05）.The cases of dyspnea in Pertussis group was 2 （3.5%）,RSV infection group was 11 （34.4%）,single PIVⅢ infection group was 0,and the incidence was higher in RSV infection group （x2 =15.654,9.487,P 〈 0.01）.Conclusion Pertussis is common in children,especially in unvaccinated or incompletely vaccinated infants.The typical clinical manifestation is paroxysmal spasmodic cough;complicated with PIV Ⅲ infection is a risk factor for sever pertussis.Early detecting of Bordetella by PCR is helpful for the diagnosis of pertussis,RSV and PIV Ⅲ are the main pathogen for Pertussis-like syndrome.The detection of respiratory virus is helpful for differential diagnosis and medication guidance.