发热伴惊厥患儿脑脊液结果及症状学鉴别诊断

Cerebrospinal fluid results and semeiology differentiation of febrile children with convulsions

目的分析发热伴惊厥患儿的临床资料和脑脊液(CSF)等辅助检查结果,为临床识别中枢神经系统(CNS)感染及其病原学提供诊断依据。方法回顾性收集2016年1月至2018年12月上海交通大学医学院附属上海儿童医学中心神经内科收治的64例发热伴惊厥患儿的临床资料,根据CSF常规和/或生化检查结果分为正常组(44/64例,69%)和异常组(20/64例,31%),对2组患儿年龄、性别、临床症状、体征及辅助检查等进行对比分析,采用Logistic回归分析探讨CSF结果异常的独立危险因素;将20例CSF结果异常的患儿,根据CSF糖水平分为糖正常组(12/20例,60%)和糖降低组(8/20例,40%),比较2组间发热时间、血炎症指标及CSF常规、生化指标的差异。结果多因素非条件Logistic回归分析显示:精神状态改变(OR=435.99,P=0.010)、异常神经系统体征(OR=65.25,P=0.023)及呕吐(OR=20.56,P=0.048)为CSF结果异常的高危因素;CSF检查结果异常患儿中,平均发热持续时间:糖降低组为12.50(7.75~16.75)d,糖正常组为4.00(3.00~5.75)d;CSF中蛋白:糖降低组为3000(1745~3000)mg/L,糖正常组为648(469~1734)mg/L;红细胞沉降率:糖降低组为71.50(56.00~97.50)mm/1 h,糖正常组为20.50(12.00~26.00)mm/1 h;血降钙素原:糖降低组为2.76(0.90~20.72)g/L,糖正常组为0.23(0.03~1.00)g/L;血C反应蛋白水平:糖降低组为123.00(33.00~177.75)mg/L,糖正常组为12.50(4.25~57.75)mg/L,2组间以上指标比较差异均有统计学意义(均P<0.05)。结论在发热伴惊厥患儿中,若同时伴随精神状态改变、异常神经系统体征和/或呕吐,提示可能存在CNS感染,需要尽早进行CSF等辅助检查进行确诊;再如CSF检查结果异常者,CSF中糖水平的降低则高度提示细菌性CNS感染的可能性,需要及时开展其他病原学检查以证实,并尽早应用抗生素等治疗。

Objective To analyze the clinical characteristics,cerebrospinal fluid(CSF)and other auxiliary examination results of febrile children with convulsions in order to provide the evidence for clinical recognition of central nervous system(CNS)infection and its etiology.Methods The clinical data of 64 fever patients with convulsions admitted at the Department of Neurology,Shanghai Children′s Medical Center,Shanghai Jiaotong University School of Medicine were analyzed retrospectively.According to the results of the routine biochemical examination of CSF,they were divided into 2 groups as CSF normal group(44/64 cases,69%)and CSF abnormal group(20/64 cases,31%).Their age,gender,clinical manifestations,physical symptoms and auxiliary examination results were compared between the two groups.Logistic regression analysis was performed to explore the independent risk factors of abnormal CSF results.Twenty children with abnormal CSF results were divided into the normal glucose group(12/20 cases,60%)and the glucose reduction group(8/20 cases,40%)according to the glucose level of CSF.The fever duration,serum inflammation markers,CSF routine and biochemical indexes of the two groups were compared.Results According to Logistic multivariate unconditional regression analysis,the mental state change(OR=435.99,P=0.010),abnormal neurological signs(OR=65.25,P=0.023)and vomiting(OR=20.56,P=0.048)were the high risk factors of abnormal CSF results.Among the children with abnormal CSF results,in the glucose reduction and normal glucose groups,the fever duration was 12.50(7.75-16.75)d and 4.00(3.00-5.75)d,respectively;the level of CSF protein were 3000(1745-3000)mg/L and 648(469-1734)mg/L,respectively;the erythrocyte sedimentation rate(ESR)was 71.50(56.00-97.50)mm/1 h and 20.50(12.00-26.00)mm/1 h,respectively;the procalcitonin level was 2.76(0.90-20.72)g/L and 0.23(0.03-1.00)g/L,respectively;the C-reactive protein(CRP)level was 123.00(33.00-177.75)mg/L and 12.50(4.25-57.75)mg/L,respectively.The fever duration,CSF protein level,ESR,procalcitonin level and CRP level were statistically different between the glucose reduction and normal glucose groups(all P<0.05).Conclusions In fever children with convulsions,vomiting,the mental state change,and abnormal neurological signs are the high risk factors of abnormal CSF results,suggesting the possibility of CNS infections and the need of early diagnosis by CSF and other auxiliary examinations.In addition,a low level of CSF glucose in children with abnormal CSF results may be a potential and powerful clue for purulent meningitis.Timely etiological tests are required for confirmation,and antibiotics treatments should be applied as early as possible.