新型冠状病毒奥密克戎变异株感染危重型儿童神经系统并发症临床及影像分析

Clinical and imaging analysis of neurological complications in critically ill children infected with SARS-CoV-2 Omicron

目的总结深圳地区新型冠状病毒(新冠病毒)奥密克戎变异株第一轮感染高峰期间有神经系统并发症的危重型患儿相关临床预后指标及影像特征。方法回顾分析2022年12月12日至31日深圳市儿童医院收治的确诊为新冠病毒奥密克戎变异株感染的11例有神经系统并发症危重型患儿的临床资料。收集与肝实质损害、组织细胞损伤、炎症、凝血功能相关的实验室检查结果,评估CT/磁共振成像(MRI)影像征象,比较住院期间不同预后患儿CT/MRI评分、急性坏死性脑病严重程度量表(ANE-SS)评分及总评分(CT/MRI评分+ANE-SS评分)的差异。结果11例患儿中,男性7例,女性4例;年龄10个月~16岁;急性坏死性脑病(ANE)5例,急性暴发性脑水肿(AFCE)6例;住院期间存活3例,死亡8例,均死于多器官功能障碍综合征(MODS),其中ANE 2例,AFCE 6例。11例患儿均发热(>38.5℃),其中3例超高热(>41℃);发病48 h内均出现意识障碍,9例发生惊厥。8例死亡患儿均伴随多系统受累,表现为休克、呼吸衰竭、弥散性血管内凝血(DIC)、肝衰竭、肾衰竭或心肌损害,肝实质损害指标〔丙氨酸转氨酶(ALT)、天冬氨酸转氨酶(AST)〕、组织细胞损伤指标〔肌酸激酶(CK)、乳酸脱氢酶(LDH)〕、炎症指标〔降钙素原(PCT)、白细胞介素-6(IL-6)、血清铁蛋白(SF)〕、凝血功能指标(D-二聚体)及血糖(Glu)均不同程度升高;其中6例AFCE患儿PCT呈特异性升高、3例AFCE患儿PLT呈特异性减少,2例ANE患儿ALT和LDH明显升高。影像分析显示,6例AFCE患儿均可见蛛网膜下腔出血、基底节区及丘脑病变,5例ANE患儿均可见丘脑病变。8例死亡患儿ANE-SS评分2~7分(其中6例≥5分),3例存活患儿ANE-SS评分0~2分;8例死亡患儿CT/MRI评分1~4分(其中6例为4分),3例存活患儿CT/MRI评分1~2分(其中2例为1分);8例死亡患儿总评分6~10分(其中6例≥8分),3例存活患儿总评分1~4分。结论深圳地区新冠病毒奥密克戎变异株感染危重型患儿影像表现包括ANE和AFCE,进展迅速且死亡风险较大。高热(>40℃)、伴惊厥/意识障碍、合并多器官功能衰竭在此类患儿发生ANE及AFCE时出现频率较高;AFCE患儿PCT特异性升高、PLT特异性减少;预后差(死亡)多见于年龄<4岁,ALT、AST、CK、LDH、PCT、D-二聚体、Glu、IL-6指标明显升高,PLT明显减少时。ANE及AFCE的影像学表现中共性征象为背侧丘脑受累;AFCE可出现蛛网膜下腔出血。ANE-SS评分、CT/MRI评分和二者总评分越高,患儿死亡风险越大。

ObjectiveTo summarize clinical predictors and imaging characteristics of critically ill children infected with SARS-CoV-2 Omicron with neurological complications in Shenzhen during the peak of the first round of infections.MethodsThe clinical data of 11 critically ill children with neurological complications infected with SARS-CoV-2 Omicron in Shenzhen Children's Hospital from December 12 to 31,2022,were retrospectively collected and analyzed.Laboratory test results related to liver parenchymal injury,histiocytic injury,inflammation,and coagulation function were collected,and imaging characteristics including CT and/or magnetic resonance imaging(MRI)were analyzed.The differences in CT/MRI score,acute necrotizing encephalopathy severity scale(ANE-SS)score and total score(CT/MRI score+ANE-SS score)were compared between the two groups with different prognosis during hospitation.ResultsAmong 11 children,7 were male and 4 were female.The age ranged from 10 months to 16 years.There were 5 cases of acute necrotizing encephalopathy(ANE)and 6 cases of acute fulminant cerebral edema(AFCE).During hospitalization,3 patients survived and 8 patients died of multiple organ dysfunction syndrome(MODS),including 2 cases of ANE and 6 cases of AFCE.All cases had fever(>38.5℃),and 3 cases had ultra-high fever(>41℃).Within 48 hours of onset,all cases had disorders of consciousness and 9 cases had seizures.The 8 dead children had complications with multisystem involvement,including shock,respiratory failure,disseminated intravascular coagulation(DIC),liver failure,renal failure or myocardial damage,and the laboratory predictors related to hepatocellular injury[alanine aminotransferase(ALT),aspartate aminotransferase(AST)],histocyte injury[creatine kinase(CK),lactate dehydrogenase(LDH)],inflammation[procalcitonin(PCT),interleukin-6(IL-6),serum ferritin(SF)],coagulation function(D-dimer)and blood glucose(Glu)increased in different quantities,of which PCT was specifically increased in 6 cases with AFCE,PLT was specifically decreased in 3 cases with AFCE,and ALT and LDH were significantly increased in 2 cases with ANE.Imaging analysis showed subarachnoid hemorrhage,basal ganglia and thalamus lesions in all 6 cases with AFCE,while thalamus lesions in all 5 cases with ANE.The ANE-SS score of 8 deceased children ranged from 2 to 7(of which 6 cases were≥5),and the ANE-SS score of 3 surviving children ranged from 0 to 2.Eight dead children had a CT/MRI score of 1-4(of which 6 cases were 4),and 3 surviving children had a CT/MRI score of 1-2(of which 2 cases were 1).The total score of 8 deceased children was 6-10(of which 6 cases≥8),and 3 surviving children was 1-4.ConclusionsThe neurological complications of critically ill children infected with SARS-CoV-2 Omicron in Shenzhen progressed rapidly to ANE and AFCE,with high mortality.High fever(>40℃),convulsion/disturbance of consciousness,and multiple organ failure were the most common symptoms in ANE and AFCE cases.PCT increased and PLT decreased specifically in AFCE cases.Poor prognosis(death)was more common in age<4 years old,predictors of ALT,AST,CK,LDH,PCT,D-dimer,Glu,IL-6 increased significantly,PLT decreased significantly.The common imaging feature of ANE and AFCE is the involvement of dorsal thalamus,a new imaging sign of AFCE(subarachnoid hemorrhage)was found.The higher the ANE-SS score,CT/MRI score and total score,the greater the risk of death.