儿童坏死性肺炎临床特征分析及随访研究(附80例报告)

Clinical characteristics analysis and follow-up study of children with necrotizing pneumonia:A report of 80 cases

目的分析坏死性肺炎儿童的临床特征、治疗及预后,提高对其认识和诊治水平。方法回顾性分析2014年1月至2019年12月在苏州大学附属儿童医院诊断为坏死性肺炎患儿的病因、临床表现、实验室检查、影像学改变、并发症、治疗方法、随访情况。结果80例儿童坏死性肺炎患儿,男39例,女41例,年龄为3.4(1.5,8.2)岁。所有患儿均有高热、咳嗽、咳痰,热峰为39.9(39.2,40.0)℃,热程为13.4(7.0,16.0)d,住院时间为20.0(16.0,29.8)d。外周血白细胞计数为18.3(13.0,22.6)×109/L,中性粒细胞比例为83.5(75.7,89.5)%,C反应蛋白为105.0(41.8,183.3)mg/L,降钙素原为0.4(0.2,2.9)ng/L,血沉为21.0(10.3,47.8)mm/h,乳酸脱氢酶为525.4(365.3,792.0)U/L,纤维蛋白原为5.2(3.8,6.3)g/L,D-二聚体为2040.5(890.0,5351.3)μg/L。病原体检出率为71.3%(57/80),其中细菌为41.3%(33/80),肺炎支原体为28.8%(23/80),病毒为25.0%(20/80),前5位的病原体依次为肺炎支原体占28.8%(23/80)、肺炎链球菌占27.5%(22/80)、金黄色葡萄球菌占11.3%(9/80)、博卡病毒和鼻病毒各占7.5%(6/80)、腺病毒占6.3%(5/80)。混合感染率为26.3%(21/80),以肺炎链球菌混合流感病毒常见。55例患儿出现肺部并发症,主要是胸腔积液、脓胸、支气管胸膜瘘、气胸,经抗生素、糖皮质激素、丙种球蛋白等药物治疗,支气管肺泡灌洗、胸腔闭式引流等对症支持治疗,临床症状缓解出院。62.5%(50/80)的患儿随访了3个月~1年,患儿均无明显呼吸道症状,复查胸部CT或胸片,10例有少许斑片影,2例遗留纤维条索影,3例遗留肺空腔病变,其余肺部病灶均消失。结论儿童坏死性肺炎常见病原菌为肺炎支原体、肺炎链球菌、金黄色葡萄球菌,少数为博卡病毒、腺病毒、流感病毒,其病情重,常合并胸腔积液,经积极抗感染、抗炎及对症支持等治疗,预后良好,极少部分遗留肺结构的破坏。

Objective To explore the clinical features,treatment and prognosis of children with necrotizing pneumonia,and to improve the awareness and the level of diagnosis and treatment.Methods Make a retrospective analysis of the etiology,clinical manifestations,laboratory examinations,imaging changes,complications,treatment methods,and follow-up of children diagnosed with necrotizing pneumonia in the Children’s Hospital of Soochow University from January 2014 to December 2019.Results There were 80 children with necrotizing pneumonia in children,39 males and 41 females,aged 3.4(1.5,8.2)years old.All children had high fever,cough,and sputum expectoration.The heat peak was 39.9(39.2,40.0)℃,the heat duration was 13.4(7.0,16.0)days,and the hospital stay was 20.0(16.0,29.8)days.WBC count in peripheral blood was 18.3(13.0,22.6)×109/L;neutrophil ratio was 83.5(75.7,89.5)%;C-reactive protein was 105.0(41.8,183.3)mg/L;calcitonin was 0.4(0.2,2.9)ng/L;erythrocyte sedimentation rate was 21.0(10.3,47.8)mm/h;lactate dehydrogenase was 525.4(365.3,792.0)U/L;fibrinogen was 5.2(3.8,6.3)g/L.The D-dimer was 2040.5(890.0,5351.3)μg/L.The pathogen detection rate was 71.3%(57/80),among which bacteria was 41.3%(33/80).Mycoplasma pneumoniae was 28.8%(23/80),and virus was25.0%(20/80).The top five pathogens in turn were:Mycoplasma pneumoniae accounting for 28.8%(23/80),Streptococcus pneumoniae accounting for 27.5%(22/80),Staphylococcus aureus accounting for 11.3%(9/80),Boca virus and rhinovirus accounting for 7.5%(6/80),and adenovirus accounting for 6.3%(5/80).The mixed infection rate was 26.3%(21/80),and influenza viruses mixed with Streptococcus pneumoniae was common.A total of 55 cases of children had pulmonary complications,which mainly were pleural effusion,empyema,bronchopleural fistula and pneumothorax.After drug treatment with antibiotics,glucocorticoids,gamma globulin,and symptomatic treatment of bronchoalveolar lavage and closed chest drainage,clinical symptoms were relieved and the patients were discharged.About 62.5%(50/80)of the children were followed up for 3 months to 1 year.None of the children had obvious respiratory symptoms.Re-examination by chest CT or chest X-ray,10 cases had a little patchy shadow,2 cases had fiber stripe shadow left,and 3 cases were left with lung cavity lesions,but the remaining lung lesions disappeared.Conclusion The common pathogens in children with necrotizing pneumonia are Mycoplasma pneumoniae,Streptococcus pneumoniae,and Staphylococcus aureus,while a few are boca virus,adenovirus and influenza virus.Its condition is serious,often complicated by pleural effusion:after active anti-infection,anti-inflammation and symptomatic treatment,the prognosis is good,and very few have destruction of lung structure.