非人类免疫缺陷病毒感染患儿并发肺孢子菌肺炎的临床特点

Clinical characteristics of pneumocystis carinii pneumonia in children without human immunodeficiency virus infection

目的探讨儿童非人类免疫缺陷病毒(HIV)感染患儿并发肺孢子菌肺炎(PCP)的临床特征及预后。方法 2017年1月至2020年12月, 湖南省儿童医院收治非HIV感染合并PCP病例35例, 按照出院时预后分为存活组和死亡组, 比较两组的临床特点, 并分析影响预后的因素。结果 35例患儿年龄1个月~15岁, 男24例, 女11例。基础疾病中原发性免疫缺陷病7例(20.0%), 自身免疫性疾病5例(14.2%), 肾脏疾病4例(11.4%)。18例(51.4%)患儿诊断前长期使用激素治疗, 13例使用免疫抑制剂治疗。临床表现主要为气促或呼吸困难、咳嗽、发热等, 肺部异常呼吸音少。外周血淋巴细胞计数<1.5×10^(9)/L 18例;乳酸脱氢酶(LDH)明显增高, 平均(654.94±57.66)U/L;真菌D葡聚糖增高13例;P/F值下降, 平均(121.29±23.25) mmHg, 16例P/F<200 mmHg;CD4细胞<500个/μL 15例, <200个/μL 8例。肺部影像学主要表现为实变影或斑片状影、弥漫性磨玻璃影, 3例伴有胸腔积液, 1例伴有气胸。最终存活22例, 死亡13例, 病死率37.1%。存活组和死亡组住院天数、CD4细胞数、真菌D葡聚糖、P/F、有创机械通气使用率比较差异有统计学意义(P<0.05)。Logistic多因素分析显示, P/F值下降是影响非HIV感染患儿合并PCP预后的独立危险因素(OR=0.996, 95%CI 0.975~1.000)。结论非HIV感染患儿合并PCP的临床表现缺乏特异性, 病死率高, 当怀疑诊断时应结合外周血淋巴细胞数、CD4细胞数、真菌D、LDH及血气分析结果, 尽早查高分辨率CT, 及时使用复方磺胺甲唑治疗。P/F值下降是影响非HIV患儿并发PCP预后的独立因素。

Objective To investigate the clinical characteristics and prognosis factors in children with pneumocystis carinii pneumonia(PCP)without human immunodeficiency virus(HIV)infected.Methods From January 2017 to December 2020,35 non-HIV infected patients with PCP were admitted to Hunan Children′s Hospital.According to the prognosis at discharge,they were divided into survival group and death group.The clinical characteristics of two groups were compared,and the prognostic factors were analyzed.Results The age of 35 patients ranged from 1 month to 15 years,including 24 males and 11 females.Seven patients(20.0%)had primary immunodeficiency,5 patients(14.2%)had autoimmune disease,and 4 patients(11.4%)had renal disease.Eighteen patients were treated with long-term hormone and 13 patients were treated with immunosuppressive agents before the onset of the disease.Clinical symptoms included shortness of breath or dyspnea,cough,fever and so on,while with few pulmonary signs.Peripheral blood lymphocyte count was less than 1.5×10^(9)/L in 18 cases.The median LDH was(654.94±57.66)U/L;Fungal D-glucan increased in 13 cases.The median P/F was(121.29±23.25)mmHg,and P/F was less than 200 mmHg in 16 cases.CD4 cells were less than 500/μL in 15 cases and less than 200/μL in 8 cases.The imaging findings were mainly consolidation or patellar shadow,diffuse ground glass shadow,3 cases with pleural effusion,and 1 case with pneumothorax.Twenty-two cases survived and 13 died,with a mortality rate of 37.1%.There were statistically significant differences in hospitalization days,CD4 cell count,Fungal D-glucan,P/F,ICU admission and invasive mechanical ventilation between two groups(P<0.05).Logistic multivariate analysis showed that decreased P/F value was an independent risk factor affecting the prognosis of non-HIV infected children with PCP(OR=0.006,95%CI 0.975-1.000).Conclusion The clinical manifestations,laboratory examinations and imaging examinations of non-HIV infected patients with PCP lack specificity.When a diagnosis is suspected,high-resolution CT should be performed based on the results of peripheral blood lymphocyte count,CD4 cell count,fungal D,LDH,and blood gas analysis results as soon as possible,compound sulfamethoxazole should be used timely.Decreased P/F value is an independent factor affecting the prognosis of non-HIV children with PCP.