儿童肺炎支原体肺炎合并肺栓塞9例临床分析并文献复习

Clinical analysis of 9 cases of mycoplasma pneumoniae pneumonia complicated with pulmonary embolism in children and literature review

目的分析儿童肺炎支原体肺炎(MPP)合并肺栓塞(PE)的临床特点及治疗方法。方法回顾性分析2018年1月至2021年12月期间天津市儿童医院呼吸科确诊的9例MPP并发PE患儿的一般资料、临床表现、实验室检查及影像学特点、治疗及预后等病例资料,并进行文献复习。结果9例MPP合并PE患儿发病年龄3~8岁,中位年龄7.5岁,PE距起病中位时间为14 d。所有患儿均为难治性肺炎支原体肺炎(RMPP),其中胸痛3例、咯血1例、呼吸困难5例,不典型部位放射痛6例;9例患儿CRP、D⁃二聚体、纤维蛋白原(FIB)均呈不同程度升高,7例患儿PLT计数、IL⁃6水平升高;9例患儿均筛查血栓性疾病相关指标,其中狼疮抗凝物(LA)阳性5例,抗心磷脂抗体(ACA)阳性5例,抗β2⁃糖蛋白抗体IgM阳性3例;蛋白S活性降低3例,凝血因子ⅤⅢ升高3例;9例患儿中6例抗核抗体阳性;所有患儿CT肺动脉造影提示栓塞部位充盈缺损,均合并胸腔积液;9例患儿的支气管肺泡灌洗液耐药突变位点2063/2064阳性。所有患儿使用利伐沙班序贯低分子肝素抗凝治疗后预后均良好,其中2例合并心脏栓塞者进行溶栓治疗;随访0.5~9个月,9例患儿栓子均缓慢吸收,无血栓复发,自身抗体及血栓性疾病指标恢复正常。结论MPP合并PE多为RMPP病例,发生PE时间并不一定与疾病极期重合,多数患者会出现一过性自身抗体阳性导致凝血与抗凝纤溶系统失衡;MPP合并PE经及时治疗预后良好,利伐沙班用于儿童肺栓塞具有较好疗效。

Objective To analyze the clinical characteristics and treatment of mycoplasma pneumoniae pneumonia(MPP)complicated with pulmonary embolism(PE)in children.Methods The general data,clinical manifestations,laboratory tests,imaging features,treatment and prognosis of 9 cases of children with MPP complicated with PE treated during Jan.2018 and Dec.2021 were retrospectively analyzed,and relevant literature was reviewed.Results The me⁃dian age of patients was 3⁃8 years,with a median of 7.5 years;the median days from onset to PE was 14 days.All cases were refractory MPP(RMPP).Chest pain occurred in 3 cases,hemoptysis in 1 case,dyspnea in 5 cases,and ra⁃diating pain at atypical sites in 6 cases.The C⁃reactive protein(CRP),D⁃dimer and fibrinogen(FIB)increased in all cases;the platelet(PLT)count and IL⁃6 levels increased in 7 cases.Screening of thrombophilia⁃related indexes showed 5 cases of positive lupus anticoagulant(LA),5 cases of positive anti⁃cardiolipin antibody(ACA),3 cases of positive anti⁃β2⁃glycoprotein antibody IgM,3 cases of reduced protein S activity,3 cases of elevated coagulation factor VIII,and 6 cases of positive antinuclear antibody.CT pulmonary arteriogram showed filling defects at the embolization site with pleural effusion.All cases were positive for bronchoalveolar lavage fluid resistance mutation site 2063/2064.After treatment with sequential low⁃molecular heparin anticoagulation plus rivaroxaban,all patients recovered well,and 2 children with cardiac embolism received thrombolysis.During the follow⁃up of 0.5⁃9 months,all children had slow absorption of emboli,no recurrence occurred,and the autoantibodies and thrombophilia indexes returned to normal.Conclusion MPP complicated with PE is mostly RMPP cases.The onset of PE does not necessarily coincide with the extreme stage of disease.Most patients will have transient autoantibody positivity,leading to imbalance of coagulation and anticoagulation fibrinolytic system.Timely treatment will result in good prognosis,and rivaroxaban is effective in the treatment of the disease.