重症手足口病合并神经源性肺水肿11例临床研究

Hand-foot-mouth disease combined with neurogenic pulmonary edema in children:11 cases report

目的总结重症手足口病合并神经源性肺水肿的临床特点和有效治疗方法。方法回顾分析11例重症手足口病合并神经源性肺水肿患儿的诊断与治疗经过,包括临床表现、实验室、影像学和神经电生理学检查。结果 11例患儿均有手足口病接触史,临床表现为发热伴皮疹、易惊、肺水肿;4例入院时Glasgow昏迷量表评分≤7分;5例头部MRI显示脑桥和延髓长T_1、长T_2信号影,2例脑桥长T_2信号影,1例延髓长T_1、长T_2信号影;9例超声心动图射血分数≥41.50%。均予气管插管呼吸机辅助通气、降低颅内压、合理应用血管活性药物、激素、静脉注射免疫球蛋白并辅以营养神经和心肌等对症支持治疗,合并呼吸机相关肺炎者联合应用抗生素。3例(3/11)完全康复,5例(5/11)转入康复科继续康复治疗,3例(3/11)死亡。结论重症手足口病合并神经源性肺水肿起病急骤,发展迅速,病死率较高。予气管插管呼吸机辅助通气、降低颅内压、合理应用血管活性药物、激素和静脉注射免疫球蛋白可以改善预后,治疗成功的关键在于积极气管插管呼吸机辅助通气,正确处理神经源性循环功能障碍。

Objective To analyze clinical presentations of children＇s neurogenic pulmonary edema due to severe hand-foot-mouth disease （HFMD）, and inquire the effective treatment. Methods The clinical data of 11 children diagnosed as neurogenie pulmonary edema associated with severe HFMD in our hospital were retrospectively analyzed. The clinical manifestation, laboratory examination, imaging and neuropsyehologieal examination were analyzed. Results All patients were younger than 5 years, and all contacted with severe HFMD. They presented with fever, skin rash, irritability and pulmonary edema. Glasgow Coma Scale （GCS） score of 4 cases was ≤ 7 on admission; head MRI of 5 cases showed long T, and T2 signals in pons and medulla, 2 cases showed long T2 signal in pons, and one case showed long T1 and T2 signals in medulla; eehocardiography ejection fraction （EF） of 9 cases was ≥ 41.50%. Patients were treated by tracheal intubation assisted ventilation, decreasing intracranial pressure, rational vasoaetive agents, eorticosteroids, intravenous immunoglobulin （IVIg） assisted by nerve cells nutrition and myocardial support. Antibiotic therapy was used when combined with breathing machine related pneumonia. After treatment, 3 cases （3/11） died, 3 cases （3/11） were cured and 5 cases （5/11） had paralysis sequelae and referred to rehabilitation. Conclusions Neurogenic puhnonary edema combined with severe HFMD has acute onset, rapid proceeding and high mortality. Tracheal intubation assisted ventilation, decreasing intraeranial pressure, rational vasoaetive agents, cortieosteroids and IVIg can improve the prognosis. The key points of treatment are early tracheal intubation assisted ventilation and proper treating of neurogenic circulation dysfunction.