儿童细菌性坏死性肺炎与肺炎支原体坏死性肺炎的临床特征与预后分析

Clinical characteristics and prognosis of bacterial necrotizing pneumonia and Mycoplasma pneumoniae necrotizing pneumonia in children

目的探讨儿童细菌性坏死性肺炎与肺炎支原体坏死性肺炎的临床特征与预后情况的异同。方法回顾性分析2016年1月至2019年1月菏泽市妇幼保健院收治的坏死性肺炎患儿共80例,根据病原菌情况分为儿童细菌性坏死性肺炎组(BNP组28例)与肺炎支原体坏死性肺炎组(MPNP组52例),比较两组患儿的症状、体征、实验室及影像学检查结果、诊治过程及预后转归情况,分析BNP的独立影响因素。结果BNP组与MPNP组患儿性别、年龄等差异无统计学意义(P值均>0.05)。BNP组病原菌分别来源于肺炎链球菌、金黄色葡萄球菌、铜绿假单胞菌,以肺炎链球菌较为多见。两组患儿均有发热、咳嗽咳痰、食欲不振、精神萎靡等症状,发热天数分别为1~39 d和3~41d,差异无统计学意义(P>0.05);BNP组出现气促现象患儿占71.43%(20/28),而MPNP为9.62%(5/52)例,差异具有统计学意义(χ2=6.185,P<0.05),但两组在呼吸音减弱及肺部湿啰音发生频率(15/28比23/52)差异无统计学意义(P>0.05)。BNP组患儿的白细胞计数(white blood cell,WBC)、C反应蛋白(C-reactive protein,CRP)、降钙素原(procalcitonin,PCT)、白细胞介素-10(interleukin-10,IL-10)明显高于MPNP组[(22.40±14.25)×10^(9)/L比(9.72±2.30)×10^(9)/L、(160.73±28.94)mg/L比(90.82±25.75)mg/L、(3.68±8.29)μg/L比(0.53±0.22)μg/L、(11.30±3.16)ng/L比(4.88±1.57)ng/L];BNP组中性粒细胞、肿瘤坏死因子α(tumor necrosis factorα,TNF-α)和γ干扰素(interferon,IFN-γ)明显低于MPNP组[(0.70±0.08)×10^(9)/L比(0.79±0.16)×10^(9)/L、(2.38±1.24)ng/L比(2.68±1.86)ng/L、(4.94±2.11)ng/L比(11.62±2.81)ng/L],差异具有统计学意义(t值分别为16.982、18.627、10.697、20.694、4.281、6.873、9.184,P值均<0.05),80例患儿中检出胸腔积液72例,其中BNP组25例,MPNP组47例,两组胸腔积液的细胞计数[(5200.94±4.15)×10^(6)/L比(816.39±4.32)×10^(6)/L]、乳酸脱氢酶(lactic dehydrogenase,LDH)[(3917.62±246.81)U/L比(2256.49±312.35)U/L]以及葡萄糖水平[(0.44±0.11)mmol/L比(5.94±0.59)mmol/L],差异具有统计学意义(t值分别为125.682、4.152、9.857,P值均<0.05);所有患儿均出现NP表现,在出现坏死的时间[(14.85±3.26)d比(18.61±4.49)d]及胸腔积液分隔的发生率(37.50%比4.17%)差异均具有统计学意义(t值分别为6.884、7.152,P值均<0.05);经单因素分析后,将上述有差异的指标绘制ROC(receiver operating characteristic)得出当WBC≥17.45×10^(9)/L,中性粒细胞>0.842×10^(9)/L,CRP>157.4 mg/L,DG二聚体<176.2ng/mL,PCT≥1.511μg/L,胸腔积液细胞学计数≥2629×10^(6)/L,胸腔积液葡萄糖<3.71 mmol/L时,提示患儿可能为BNP感染。结论NP病情严重、病程长,若能及时接受合理的对症干预,可获得理想预后,临床应关注NP患儿WBC、中性粒细胞、CRP、DG二聚体、PCT、胸腔积液细胞学计数与葡萄糖等指标,有助于区分鉴别BNP和MPNP。

Objective To investigate the clinical characteristics and prognosis of bacterial necrotizing pneumonia and Mycoplasma pneumoniae necrotizing pneumonia in children.Methods A total of 80 children with necrotizing pneumonia admitted to Heze maternal and child health hospital from January 2016 to January 2019 were analyzed retrospectively.According to the pathogenic bacteria,they were divided into bacterial necrotizing pneumonia(BNP)group(n=28)and Mycoplasma pneumoniae necrotizing pneumonia(MPNP)group(n=52).The symptoms,laboratory and imaging examination results,diagnosis and treatment process and prognosis of the two groups were compared,the independent influencing factors of BNP were analyzed.Results There was no significant difference in children's gender or age between BNP and MPNP groups(all P values>0.05).The pathogens in BNP group were Streptococcus pneumoniae,Staphylococcus aureus,Pseudomonas aeruginosa,respectively,and Streptococcus pneumoniae was more common.Children in both groups had symptoms of fever,cough and expectoration,poor appetite,and listlessness,and the number of febrile days ranged from 1 to 39 D and from 3 to 41 D,respectively(P>0.05);71.43%(20/28)children presented with shortness of breath phenomenon in BNP group compared with 9.62%(5/52)MPNP,which was statistically significant(χ2=6.185,P<0.05),but there was no significant difference between the two groups in the reduction of breath sounds and the frequency of lung wet rales(15/28 vs 23/52)(P>0.05).The white blood cell count(WBC),C-reactive protein(CRP),procalcitonin(PCT),interleukin-10(IL-10)in the children in BNP group were significantly higher than those in MPNP group[(22.40±14.25)×10^(9)/L vs(9.72±2.30)×10^(9)/L,(160.73±28.94)mg/L vs(90.82±25.75)mg/L,(3.68±8.29)μg/L vs(0.53±0.22)μg/L,(11.30±3.16)ng/L vs(4.88±1.57)ng/L.Neutrophils,tumor necrosis factor in BNP groupα(tumor necrosis factorα,TNF-α)andγinterferon(IFN-γ)was significantly lower than that in the MPNP group[(0.70±0.08)×10^(9)/L vs(0.79±0.16)×10^(9)/L,(2.38±1.24)ng/L vs(2.68±1.86)ng/L,(4.94±2.11)ng/L vs(11.62±2.81)ng/L],lactate dehydrogenase(LDH)[(3917.62±246.81)U/L ratio(2256.49±312.35)U/l]as well as glucose level(0.44±0.11)mmol/L vs(5.94±0.59)mmol/L),the differences were statistically significant(t-values were 125.682,4.152,9.857,both P values<0.05);All children developed NP manifestations,and the differences were statistically significant in the time to the appearance of necrosis[(14.85±3.26)d vs(18.61±4.49)d]and the incidence of pleural effusion septation(37.50%vs.4.17%)(6.884,7.152,P<0.05,respectively);After univariate analysis,the ROC(receiver operating characteristic)was plotted for the above differentially expressed indexes to obtain the maximum value when WBC≥17.45×10^(9)/L,neutrophils>0.842×10^(9)/L,CRP>157.4 mg/L,DG dimer<176.2 ng/mL,PCT≥1.511μg/L,pleural effusion cytology count≥2629×10^(6)/L,and pleural fluid glucose<3.71 mmol/L,suggesting that the child may be BNP infection.Conclusion NP is severe and has a long disease course,and the ideal prognosis can be achieved if reasonable symptomatic intervention can be received in a timely manner,the clinic should focus on the WBC,neutrophils,CRP,DG dimer,PCT,pleural effusion cytology count with glucose and other indicators,which can help to distinguish BNP from MPNP.