儿童急性外源性类脂性肺炎的临床特征及随访研究

Clinical characteristics and follow-up study of acute exogenous lipoid pneumonia in children

目的分析儿童急性外源性类脂性肺炎(ELP)的临床特征和随访结果。探讨其诊断策略、治疗方式及危险因素。方法对2013年5月至2018年5月广州医科大学附属广州市妇女儿童医疗中心收治的41例ELP住院患儿的临床特点、影像学表现、支气管肺泡灌洗液(BALF)检测结果、治疗方式及预后进行总结和分析,并复习相关文献。结果1.共41例患儿,其中男29例,女12例;发病年龄4~53个月,多数3岁以内发病(35/41例,85.4%),以1~2岁为主(23/41例,56.1%)。2.误服油脂包括灯油/香油11例、白电油7例、电蚊香油5例、润滑油5例、石蜡油4例、汽油/柴油3例、煤油和鱼肝油各2例、缝纫机油和性质不清各1例。3.临床表现主要为咳嗽(26/41例,63.4%)、气促(23/41例,56.1%)、发热(17/41例,41.5%)、发绀伴低氧血症(15/41例,36.6%)、喘息(9/41例,22.1%)、呼吸窘迫(9/41例,22.1%)、肺出血(6/41例,14.7%)、喂养困难和/或一过性呕吐(4/41例,9.8%),无症状7.3%(3/41例)。4.胸部X线主要表现为双肺渗出性改变或肺实变,胸部高分辨CT(HRCT)最常见征象为局部或广泛渗出,可伴肺实变(18/41例,43.9%)。受累部位最常见为双下肺叶(8/41例,19.5%),其次为右下叶(3/41例,7.3%)、右中叶(2/41例,4.8%)和左下叶(2/41例,4.8%)。其他征象包括肺囊泡改变、过度通气、磨玻璃样改变及小结节形成等。5.共7例患儿因呼吸衰竭需要机械通气支持治疗,所有患儿行经支气管镜支气管肺泡灌洗(BAL)。所有患儿痊愈出院,无一例死亡,住院时间为(11.67±4.90)d,合并腺病毒感染者住院时间为(19.25±5.93)d。9例患儿随诊失访(其中8例轻症,1例重症),余患儿症状均在1周~1个月消失,21例在出院1个月内肺部影像恢复正常,7例出院3个月恢复正常,4例在6个月后恢复正常。结论急性ELP临床表现和肺部影像无特异性。重症患儿肺部影像多肺叶受累,可出现肺实变和囊泡改变。多数患儿预后良好,并感染尤其是腺病毒感染可能是急性ELP患儿病情加重的高危因素。BAL能同时起诊断和治疗作用,BAL联合局部/全身糖皮质激素治疗对重症急性ELP有效。

Objective To analyze the clinical features and follow-up results of children with acute exogenous lipoid pneumonia(ELP),and to investigate the diagnosis strategy,treatment and risk factors of ELP.Methods The clinical features,imaging manifestations,results of bronchoalveolar lavage fluid(BALF),treatment methods and prognosis of 41 ELP inpatients in Guangzhou Women and Children′s Medical Center,Guangzhou Medical University from May 2013 to May 2018,were summarized and analyzed,and the related literature was reviewed.Results(1)Among 41 patients,29 cases were male and 12 cases were female.The age of onset ranged from 4 to 53 months.Most of them(35/41 cases,85.4%)were less than 3 years old,and the majority were aged 1 to 2 years(23/41 cases,56.1%).(2)The grease taken by children by accident included perfume oil(11 cases),white electric oil(7 cases),electric mosquito oil(5 cases),lubricating oil(5 cases),paraffin oil(4 cases),gasoline/diesel oil(3 cases),kerosene(2 cases),cod-liver oil(2 cases),sewing machine oil(1 case),and unclear oil(1 case).(3)The main clinical manifestations were cough(26/41 cases,63.4%),shortness of breath(23/41 cases,56.1%),fever(17/41 cases,41.5%),cyanosis with hypoxemia(15/41 cases,36.6%),wheezing(9/41 cases,22.1%),respiratory distress(9/41 cases,22.1%),pulmonary hemorrhage(6/41 cases,14.7%),feeding difficulties and transient vomiting(4/41 cases,9.8%).Some cases showed no symptoms(3/41 cases,7.3%).(4)Chest X-ray mainly showed bilateral pulmonary exudative changes or pulmonary consolidation.The most common sign of high-resolution computerized tomography(HRCT)was local or extensive exudation,often accompanied by pulmonary consolidation(18/41 cases,43.9%).The most common affected sites were bilateral lower lobes(8/41 cases,19.5%),followed by right lower lobes(3/41 cases,7.3%),right middle lobes(2/41 cases,4.8%)and left lower lobes(2/41 cases,4.8%).Other signs included alveolar changes,hyperventilation,ground glass changes,and nodule formation.(5)Seven children needed mechanical ventilation due to respiratory failure,and all patients underwent bronchoalveolar lavage(BAL).All patients recovered without death,with(11.67±4.90)days of hospitalization,and the hospitalization time of ELP patients with adenovirus infection was(19.25±5.93)days.Nine of them were lost to follow-up(8 cases were mild and 1 case was severe).The symptoms of the remaining children disappeared within 1 week to 1 month.The lung images of 21 cases returned to normal within 1 month after discharge,7 cases returned to normal within 3 months after discharge,and 4 cases returned to normal after 6 months.Conclusion The clinical manifestations and lung imaging of children with acute ELP have no specificity.Pulmonary imaging of severe patients shows multiple lobes involved,and consolidation and vacuolar changes may occur.Most patients have a favorable prognosis.Co-infection,especially adenovirus infection,may be a risk factor for acute ELP in children.BAL can play a role in both diagnosis and treatment,and its combination with local/systemic glucocorticoid therapy is effective for severe acute ELP.