儿童暴发性心肌炎58例临床分析与随访

发布时间：2018-05-20 19:03

本文选题：儿童 + 暴发性心肌炎　；参考：《山东大学》2014年硕士论文

【摘要】：研究目的本研究旨在总结与分析58例儿童暴发性心肌炎(AFM)的临床特点、治疗措施及临床转归,为临床诊断与治疗AFM提供宝贵经验。研究对象与方法选择自2003年1月至2014年2月期间在山东大学附属省立医院小儿心脏科住院的58例AFM患儿,其中男33例,女25例,年龄为2月-17岁,平均9.0±5.0岁。将AFM患儿的临床表现、病原学、心肌损伤标志物包括心肌肌钙蛋白(cTn)与肌酸激酶同工酶质量(CKMB_Mass)、氨基末端脑钠肽前体(NT-pro BNP)、心电图、经胸超声心动图、心脏磁共振、治疗措施及转归等资料进行统计分析,并对部分指标在死亡的患儿(死亡组)与治愈的患儿(治愈组)之间进行比较。所有患儿进行门诊及电话随访,随访时间4月-70月,平均22.5±13.8月,失访率10.3%(6/58)。结果 1.58例AFM患儿发病时间2小时～14天,平均121.0±100.8小时,住院时间为2小时～50天,平均25.7±8.5天,表现为急性心力衰竭者56例,心源性休克18例,阿斯综合征14例,室性心动过速1例,室颤1例,Ⅲ度房室传导阻滞(AVB)15例,高度AVB1例；其中植入临时起搏器者10例,植入永久起搏器2例,治愈率为87.9%(51/58),死亡率8.6%(5/58),8例转为扩张型心肌病。 2.所有患儿发病前2周内均有前驱感染,前驱感染为呼吸道感染者29例,消化道感染者23例,不明原因发热者6例,首发症状以胸闷、胸痛及乏力多见。 3.58例AFM患儿中56例行cTn检测,均升高(100%),恢复正常时间为17～50天,平均25.5±5.8天。51例行CKMB_Mass检查,33例(64.7%)升高。cTn升高的阳性率显著高于CKMB_Mass (χ2=23.8, P0.05)。死亡组患儿cTn与治愈组之间无统计学差异(P均0.05)；死亡组患儿CKMB_Mass明显高于治愈组(66.9±102.7ng/ml vs.28.5±31.5ng/ml, t=2.04, P0.05)。 4.58例AFM患儿中38例行NT-pro BNP检测,均升高,为9941.5±10655.0pg/ml。死亡组患儿NT-pro BNP显著高于治愈组(27815.0±10070.4pg/ml vs.9421.2±10655.0pg/ml, t=2.98, P0.05). 5.58例AFM患儿检测病毒阳性者30例,其中EB病毒20例(34.5%),柯萨奇病毒7例(12.1%),巨细胞病毒5例(8.6%),单纯疱疹病毒3例(5.2%),细小病毒2例(3.4%),腺病毒1例(1.7%),甲型H1N1病毒感染1例(1.7%),其中有9例为两种病毒混合感染。 6.58例患儿心电图均异常,其中31例呈急性心肌梗死样改变；3例病理性Q波；24例AVB,其中Ⅲ度15例,高度1例,Ⅱ度5例,Ⅰ度3例；4例阵发性室上性心动过速；1例室性心动过速；1例室颤；6例QRS低电压。死亡组患儿病理性Q波(40%,2/5)明显多于治愈组(2.0%,1/51)(P0.05)。 7.58例AFM患儿中57例行经胸超声心动图检查,54例(94.7%)异常,表现为心腔扩大者32例,心肌动度减低48例,心肌变薄13例,心肌增厚8例,心肌回声增强10例,心包积液23例,二尖瓣反流40例,三尖瓣反流35例及附壁血栓2例；左室射血分数(LVEF)降低者49例,为18.0%～58.0%,平均39.6±9.6%。死亡组患儿LVEF明显低于治愈组(29.0±6.95%vs.43.67±12.29%,t=3.06,P0.05)。 8.58例AFM患儿中15例行心脏磁共振检查,11例(73.3%)异常,其中T2加权像增强信号者1例,局部心肌延迟强化信号10例,心包积液4例,局部心肌变薄8例,局部心肌增厚4例,心肌动度减低4例。 9.58例AFM患儿中42例应用大剂量静脉用免疫球蛋白(IVIG)(2kg·-1),IVIG治疗的AFM患儿治愈率(97.6%,40/41)明显高于未使用IVIG的患儿(73.3%,11/15)(P0.05)。 10.58例AFM患儿中36例给予糖皮质激素治疗,其中应用地塞米松者8例(0.5～1mg·kg-1),应用大剂量甲基强的松龙治疗28例(15～30mg·kg-1)。使用糖皮质激素治疗的AFM患儿治愈率(97.1%,34/35)与未使用糖皮质激素治疗的患儿(80.9%,17/21)之间无统计学差异(P0.05)。结论 1.儿童暴发性心肌炎起病急,病情凶险,病死率高,首发症状以胸闷、胸痛及乏力多见。 2.暴发性心肌炎患儿肌钙蛋白的阳性检测率高于肌酸激酶同工酶。 3.EB病毒、柯萨奇病毒、巨细胞病毒、单纯疱疹病毒、细小病毒及腺病毒是儿童暴发性心肌炎较常见病原,其中EB病毒更为常见。 4.肌酸激酶同工酶与氨基脑钠肽前体显著升高、心电图显示病理性Q波、左室射血分数显著减低的暴发性心肌炎患儿死亡率高。 5.心脏磁共振成像检查可显示暴发性心肌炎患儿病变心肌T2加权像异常高信号与钆延迟增强信号,为临床安全、有效及无创的心肌炎检测手段之一。 6.大剂量静脉注射免疫球蛋白可降低暴发性心肌炎患儿的死亡率。
[Abstract]:research objective
The purpose of this study is to summarize and analyze the clinical features, treatment and clinical outcomes of 58 cases of fulminant myocarditis (AFM) in children, and to provide valuable experience for clinical diagnosis and treatment of AFM.
Research objects and methods
From January 2003 to February 2014, 58 children with AFM were hospitalized in the Department of pediatric cardiology, the affiliated Provincial Hospital of Shandong University, including 33 males and 25 females. The average age was -17 years old and 9 + 5 years old. The clinical manifestations, etiology, and myocardial damage markers included cardiac muscle troponin (cTn) and creatine kinase isoenzyme (CKMB_M) in the children of AFM (CKMB_M Ass), the amino terminal brain natriuretic peptide precursor (NT-pro BNP), electrocardiogram, transthoracic echocardiography, cardiac magnetic resonance, treatment and prognosis were statistically analyzed, and some indexes were compared between the dead children (death group) and the cured children (cured group). All the children were followed up by the outpatient and telephone, and the follow-up time was -70 month of April. The average loss rate was 10.3% (6/58), with an average of 22.5 + 13.8 months.
Result
The onset time of 1.58 cases of AFM was 2 hours to 14 days, the average was 121 + 100.8 hours, the time of hospitalization was 2 hours to 50 days, the average was 25.7 + 8.5 days. 56 cases of acute heart failure, 18 cases of cardiogenic shock, 14 cases of ASP syndrome, 1 cases of ventricular tachycardia, ventricular fibrillation (AVB), high AVB1 cases, and high AVB1 cases; Of the 10 pacemakers, 2 were implanted permanent pacemakers. The cure rate was 87.9% (51/58), the mortality rate was 8.6% (5/58), and 8 cases were dilated cardiomyopathy.
2. all children had prodromic infection in the first 2 weeks, 29 cases of respiratory tract infection, 23 cases of digestive tract infection and 6 cases of unexplained fever. The first symptoms were chest tightness, chest pain and fatigue.
Of the 3.58 cases of AFM, 56 cases were detected by cTn (100%), the normal time was 17~50 days, the average of 25.5 + 5.8 days.51 routine CKMB_Mass examination, 33 (64.7%) elevated.CTn positive rate was significantly higher than CKMB_Mass (x 2=23.8, P0.05). There was no statistical difference between the death group and the treatment group (P 0.05); CKMB_Mass in the death group. It was significantly higher than that in the cured group (66.9 + 102.7ng/ml vs.28.5 + 31.5ng/ml, t=2.04, P0.05).
Of the 4.58 children with AFM, 38 cases were detected by NT-pro BNP and increased. The NT-pro BNP in the 9941.5 + 10655.0pg/ml. death group was significantly higher than that of the cure group (27815 + 10070.4pg/ml vs.9421.2 + 10655.0pg/ml, t=2.98, P0.05).
5.58 cases of AFM were detected in 30 cases of virus positive, including 20 cases of EB virus (34.5%), 7 cases of Coxsackie virus (12.1%), 5 cases of cytomegalovirus (8.6%), 3 cases of herpes simplex virus (5.2%), 2 cases of parvovirus (3.4%), adenovirus 1 cases (1.7%), and H1N1 virus infection.
6.58 cases had abnormal ECG, of which 31 cases had acute myocardial infarction like changes, 3 cases of rational Q wave, 24 cases of AVB, including 15 cases, 1 cases, 5 cases, 3 cases, 4 cases of paroxysmal supraventricular tachycardia, 1 cases of ventricular tachycardia, 1 ventricular fibrillation, 6 cases QRS low voltage. Pathological Q wave (40%, 2/5) of children in death group were significantly more than those in the death group. The cure group (2%, 1/51) (P0.05).
Of 7.58 children with AFM, 57 cases were examined by transthoracic echocardiography, 54 cases (94.7%) were abnormal, including 32 cases of enlargement of heart cavity, 48 cases of myocardial dysfunction, 13 cases of myocardial thinning, 8 cases of myocardial thickening, 10 cases of myocardial echo enhancement, 23 cases of pericardial effusion, 40 cases of mitral regurgitation, three apex regurgitation and peripheral thrombus, and lower left ventricular ejection fraction (LVEF). Of the 49 cases, 18% to 58%, with an average of 39.6 + 9.6%., the LVEF of the death group was significantly lower than that of the cure group (29 + 6.95%vs.43.67 + 12.29%, t=3.06, P0.05).
Of the 8.58 cases of AFM, 15 cases were examined by cardiac magnetic resonance (MRI) and 11 cases (73.3%) were abnormal, including 1 cases of T2 weighted image enhancement signal, 10 cases of local myocardial delayed intensification signal, 4 cases of pericardial effusion, 8 local thinning cases, 4 local myocardial thickening, and 4 myocardial dynamic reduction.
In 9.58 children with AFM, 42 cases were treated with large doses of intravenous immunoglobulin (IVIG) (2kg. -1). The cure rate of AFM in children treated with IVIG (97.6%, 40/41) was significantly higher than that of children without IVIG (73.3%, 11/15) (P0.05).
Of 10.58 children with AFM, 36 were treated with glucocorticoid, of which 8 cases (0.5 ~ 1mg / kg-1) were treated with dexamethasone and 28 cases (15 to 30mg. Kg-1) were treated with high dose methylprednisolone. The cure rate of AFM in children treated with Glucocorticoid (97.1%, 34/35) was not statistically significant between children without glucocorticoid treatment (80.9%, 17/21). Differences (P0.05).
conclusion
1. children with fulminant myocarditis onset acute, dangerous condition, high mortality, the first symptoms are chest tightness, chest pain and fatigue.
2. the positive detection rate of troponin in children with fulminant myocarditis is higher than that of CK.
3.EB virus, Coxsackie virus, cytomegalovirus, herpes simplex virus, parvovirus and adenovirus are common pathogens of fulminant myocarditis in children, and EB virus is more common.
4. the creatine kinase isozymes and aminobrain natriuretic peptide precursors increased significantly. The electrocardiogram showed the pathological Q wave, and the mortality of the children with acute myocarditis with a significant decrease in the left ventricular ejection fraction was high.
5. cardiac magnetic resonance imaging (MRI) can show abnormal high signal and gadolinium delayed enhancement signal of T2 weighted image in the diseased myocardium of children with fulminant myocarditis. It is one of the clinical safety, effective and noninvasive methods for detecting myocarditis.
6. large doses of intravenous immunoglobulin can reduce the mortality of children with fulminant myocarditis.
【学位授予单位】：山东大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R725.4

【参考文献】