儿童感染后闭塞性细支气管炎25例临床分析

发布时间：2018-05-21 08:30

本文选题：闭塞性细支气管炎 + 高分辨力CT　；参考：《山东大学》2012年硕士论文

【摘要】：研究背景： 1901年德国病理学家Lange首次提出闭塞性细支气管炎(bronchiolitis obliterans, BO)的概念。B0是慢性气流阻塞的临床综合征,主要由小气道的炎性病变引起。诊断B0的金标准是肺活检,但是在儿科肺活检非常困难,且不一定能够取到病变部位,可能得不到有意义的结果。B0在儿科相对少见,临床医生对其认识不足,国内外也缺乏大样本的研究。因此,B0的流行病学、发病机制、有效治疗及预后等仍不十分清楚。近年来,随着高分辨力CT(high-resolution CT, HRCT)的应用,B0的临床诊断率有了大幅度的提高。儿童B0以感染引起的最多见,即感染后闭塞性细支气管炎(post-infectious bronchiolitis obliterans, PIBO)。B0严重影响患儿的身体健康,给患儿家庭和社会带来精神和经济负担,正日益引起儿科医生的重视。研究目的：观察儿童PIBO的临床特点,分析其病原学、影像学特点及免疫学改变,总结早期临床识别和干预治疗对PIBO的影响,为PIBO的临床诊断和治疗提供依据。研究方法：收集2010年9月～2011年11月在山东省立医院小儿呼吸综合科临床诊断为PIBO的患儿25例。年龄6月-36月。男18例,女7例。按临床诊断PIBO并开始治疗时患儿的咳嗽及喘息时间将患儿分为病程12周(A组)和病程≥12周(B组)两组。收集患儿的临床资料,包括年龄、性别、入院时咳嗽及喘息情况、查体肺部听诊情况、既往治疗情况、有无湿疹史、出生史、家族中过敏史等。病原学检测,包括血培养、痰培养、九项呼吸道感染病原体IgM抗体(腺病毒、嗜肺军团菌、肺炎支原体、Q热立克次体、肺炎衣原体、呼吸道合胞病毒、甲型流感、乙型流感、副流感病毒123型)、肺炎支原体抗体、结核抗体、曲霉菌抗原测定、真菌D-葡聚糖定量、EB病毒系列、尿CMV-DNA定量等。检测血T细胞亚群包括CD3+、CD4+、CDS+、CD4/CD8水平,检测血免疫球蛋白IgG, IgA, IgM, IgE及补体C3、C4水平,检测血常规、肝功、心肌酶谱等。行胸部X-RAY及HRCT检查。对6例咳嗽、喘息持续时间长(均12周)、临床治疗效果欠佳的患儿行纤维支气管镜检查,并行肺泡灌洗治疗,送检肺泡灌洗液细菌培养及抗酸染色。给予抗感染、激素(静脉、口服及吸入激素)、支气管扩张剂、大环内酯类(阿奇霉素或依托红霉素)以及钙剂、维生素D等治疗。2～12周后定期门诊复查,记录其咳嗽、喘息情况。6月后复查胸部HRCT,观察其改善情况。对部分统计结果以均数±标准差表示,采用SPSS19.0统计软件进行分析处理,两样本均数的比较采用t检验,以P0.05表示差异有统计学意义。研究结果： 1.临床特点患儿年龄6月～36月,其中6月～12月为好发年龄,有14例(56%)。男孩发病率高于女孩,男18例(72%),男女比例2.57：1。 25例患儿在临床诊断为PIBO时均有咳嗽及喘息,20例伴有痰鸣。咳嗽、喘息持续时间7周～17周,其中12周13例(52%),≥12周12例(48%)。5例(20%)伴有发热。3例(12%)伴有皮疹,经涂片检查证实为皮肤念珠菌感染。1例(4%)有鸡胸,8例(32%)有方颅。10例(40%)有口唇发绀,10例(40%)吸气三凹征阳性。25例(100%)入院时双肺闻及喘鸣音,23例(92%)闻及痰鸣音,6例(24%)闻及水泡音。14例(56%)有轻度贫血,12例(48%)有不同程度的肝功损害,9例(36%)有不同程度的心肌损害。所有患儿均在院外以“支气管炎、支气管肺炎或支气管哮喘”反复输液治疗。4例(16%)曾因呼吸衰竭行机械通气。6例(24%)曾用1-2天的静脉激素治疗症状减轻,停用后在短期内反复。25例(100%)均曾用支气管扩张药物治疗,喘息未见减轻或仅有轻微减轻。 2例(8%)有早产史,2例(8%)出生体重2.5Kg。15例(60%)有湿疹史。12例(48%)有家族中过敏史。 2.病原学：肺炎支原体感染8例(32%),腺病毒感染7例(28%),肺炎链球菌感染4例(16%),乙型流感病毒感染3例(12%),曲霉菌感染3例(12%),呼吸道合胞病毒感染1例(4%),巨细胞病毒感染1例(4%),麻疹病毒感染1例(4%),凝固酶阴性葡萄球菌感染1例(4%)。其中7例(28%)为2种或3种病原的混合感染,包括肺炎支原体与麻疹病毒混合感染1例,肺炎支原体与曲霉菌混合感染1例,肺炎支原体与凝固酶阴性葡萄球菌混合感染1例,腺病毒与乙型流感病毒混合感染1例,腺病毒与曲霉菌混合感染1例,肺炎链球菌与曲霉菌混合感染1例,肺炎支原体、腺病毒与乙型流感病毒混合感染1例。25例中有4例(16%)未查到明确病原。 3.影像学特点胸部X-RAY显示肺纹理增粗、紊乱25例(100%),斑片状浸润影17例(68%),肋膈角模糊2例(8%),合并肺不张2例(8%),合并肺实变3例(12%)。胸部HRCT显示双肺斑片状或磨玻璃样密度增高影25例(100%),马赛克灌注征22例(88%),伴局限性肺气肿3例(12%),伴局限性肺不张3例(12%),伴肺实变3例(12%),伴胸腔积液2例(8%),伴胸膜增厚5例(20%),伴胸廓畸形1例(4%)。出院后6月复查胸部HRCT,结果：1例磨玻璃影及马赛克灌注征较确诊PIBO时范围增大、病变更明显,9例磨玻璃影或马赛克灌注征较确诊PIBO时范围减小、病变减轻,15例马赛克灌注征及磨玻璃影无明显变化。 4.免疫学改变：血T细胞亚群显示CD3+降低4例(16%),CD4降低5例(20%),CD8升高19例(76%),CD4/CD8降低17例(68%)。血免疫球蛋白、补体显示IgG降低5例(20%),IgA降低4例(16%),IgM升高1例(4%),IgE升高5(20%),补体3降低3例(12%),补体4升高2例(8%)。 5.纤维支气管镜检查及治疗：6例行纤维支气管镜检查的患儿均未发现气道结构异常或异物,且均可在部分肺叶见到不同程度的附壁痰液或痰栓阻塞,其中1例有左下叶外基底段亚段闭塞。灌洗治疗后4例症状和体征减轻,1例曲霉菌感染和1例曲霉菌合并腺病毒感染的患儿仍有反复的咳嗽、喘息,其中1例再次行灌洗治疗。肺泡灌洗液培养及抗酸染色仅1例培养出凝固酶阴性葡萄球菌。 6.治疗及转归所有患儿随访时间最短者6月,最长者12月,其中10例现已无咳嗽、喘息等症状,其余15例咳嗽、喘息较治疗前明显减轻,仅在呼吸道感染或剧烈活动时可出现。目前无死亡病例。患儿出院3个月后随访,有20例(80%)平时无咳嗽、喘息,仅在呼吸道感染或剧烈活动时有咳嗽、喘息,且每次咳嗽、喘息的持续时间缩短,其中4例治疗42～56天(平均51.20±5.46天)后咳嗽、喘息消失。5例(20%)与治疗前相比咳嗽、喘息减轻不明显,受凉或轻微活动时即可再次出现,复查时肺部喘鸣音仍然存在,其中4例多次因咳嗽、喘息加重住院。6个月后随访,25例(100%)治疗后平时无咳嗽、喘息,仅在呼吸道感染或剧烈活动时有咳嗽、喘息,其中7例经治疗42-165天(平均124.32±40.78天)后咳嗽、喘息消失。分别统计病程12周组(A组)和病程≥12周组(B组)患儿出院后3月内、6月内咳嗽及喘息发作次数,并进行t检验,结果有统计学差异,表明表明早期诊断和干预能明显减少患儿的咳嗽、喘息发作次数。结论： 1.PIBO好发于小于1岁的婴儿,且男孩发病率高于女孩。 2.肺炎支原体和腺病毒感染是儿童PIBO的主要病因。 3.PIBO患儿的胸部X-RAY无特异性改变,HRCT典型表现为斑片状或磨玻璃样密度增高影、马赛克灌注征,有部分可合并肺气肿、肺不张、肺实变、胸腔积液、胸膜增厚等表现。 4.婴幼儿免疫功能的不完善,以及佝偻病、贫血、个人湿疹史、家族过敏史等可能是导致PIBO的危险因素。 5.早期临床识别和治疗能显著减轻PIBO患儿的反复咳嗽、喘息等临床症状,改善患儿的生活质量,在一定程度上改变PIBO的预后。
[Abstract]:Research background:
In 1901, German pathologist Lange first proposed that the concept.B0 of bronchiolitis obliterans (BO) is a clinical syndrome of chronic airflow obstruction, which is mainly caused by inflammatory lesions of the small airway. The gold standard for diagnosing B0 is a lung biopsy, but it is very difficult in pediatric lung biopsy and can not be taken to the site of the lesion. .B0 is relatively rare in pediatrics, lack of understanding in pediatricians and lack of large sample studies at home and abroad. Therefore, the epidemiology, pathogenesis, effective treatment and prognosis of B0 are still not very clear. In recent years, with the application of high resolution CT (high-resolution CT, HRCT), the clinical diagnostic rate of B0 has been large The increase of amplitude. The most common cause of children's B0 infection, namely, post-infectious bronchiolitis obliterans (PIBO).B0, seriously affects the health of the children, bringing the mental and economic burden to the family and society of the children, and is increasing the attention of the pediatrics doctor.
The purpose of the study is:
To observe the clinical characteristics of PIBO in children, analyze its etiology, imaging features and immunological changes, summarize the effect of early clinical identification and intervention therapy on PIBO, and provide the basis for the clinical diagnosis and treatment of PIBO.
Research methods:
From September 2010 to November 2011, 25 children were diagnosed as PIBO in the pediatric respiratory Comprehensive Department of Shangdong Province-owned Hospital. The age was -36 months in June. There were 18 males and 7 females. According to the clinical diagnosis of PIBO, the children's cough and wheezing time were divided into two groups (group A) and disease course more than 12 weeks (group B).
The clinical data of children were collected, including age, sex, cough and wheezing at admission, pulmonary auscultation, past treatment, history of eczema, birth history, and allergy history in the family.
Pathogenic detection, including blood culture, sputum culture, nine respiratory tract infection IgM antibodies (adenovirus, Legionella pneumophila, Mycoplasma pneumoniae, Q Rickettsia, Chlamydia pneumoniae, respiratory syncytial virus, influenza A, B influenza, parainfluenza virus 123), Mycoplasma pneumoniae, tuberculosis antibody, Aspergillus antigen, and fungal D- Portuguese. Sugar quantitative, EB virus series, urine CMV-DNA quantitative and so on.
The blood T cell subsets were detected, including CD3+, CD4+, CDS+, CD4/CD8 levels, the detection of blood immunoglobulin IgG, IgA, IgM, IgE and complement C3, C4 level, detection of blood routine, liver function, myocardial enzyme spectrum and so on.
X-RAY and HRCT examinations were performed on the chest.
In 6 cases of cough and long duration of wheezing (all 12 weeks), children with poor clinical treatment were treated with fiberoptic bronchoscopy, alveolar lavage, and bacterial culture and acid staining of alveolar lavage fluid.
Administration of anti infection, hormone (intravenous, oral and inhaled hormone), bronchodilator, macrolide (azithromycin or erythromycin), calcium, vitamin D and other treatment for.2 to 12 weeks, regular outpatient reexamination, record the cough,.6 months after.6 reexamination of the chest HRCT, to observe the improvement.
Some statistical results were expressed with mean standard deviation, and SPSS19.0 statistical software was used for analysis and processing. T test was used for the comparison of the average number of two samples. The difference was statistically significant by P0.05.
The results of the study:
1. clinical characteristics
The age of the children ranged from June to 36 months, and from June to December, there were 14 cases (56%). The incidence of boys was higher than that of girls, and 18 cases (72%) were male. The ratio of male to female was 2.57:1.
25 cases had coughing and wheezing in the clinical diagnosis of PIBO, 20 cases were accompanied by phlegm and phlegm, cough, and the duration of wheezing for 7 weeks to 17 weeks, 12 weeks 13 cases (52%), 12 cases (48%) in 12 weeks (48%) (20%) with fever.3 cases (12%) accompanied by rash, and.1 cases of Candida albicans (4%) with chicken chest by smear examination Cyanosis of the lips, 10 (40%) positive.25 cases of inspiratory three depression (100%) had double lung smelling and wheezing sound, 23 (92%) heard and phlegm sound, 6 (24%) heard and.14 cases (56%) had mild anemia, 12 (48%) had different degree of liver damage, 9 cases (36%) had different degree of myocardial damage.
All children were treated with repeated infusion of "bronchitis, bronchopneumonia, or bronchial asthma" in the treatment of.4 cases (16%).6 cases (24%) with respiratory failure (24%) had been treated with 1-2 days of intravenous hormone treatment, and after the discontinuation of.25 cases (100%) had been treated with bronchiectasis. A slight reduction.
2 cases (8%) had preterm labor history, 2 cases (8%) had birth weight 2.5Kg.15 cases (60%) had eczema history,.12 cases (48%) had family allergy history.
2. etiology: Mycoplasma pneumoniae infection (32%), adenovirus infection in 7 cases (28%), Streptococcus pneumoniae infection in 4 cases (16%), influenza B virus infection 3 cases (12%), Aspergillus infection 3 cases (12%), respiratory syncytial virus infection 1 cases (4%), cytomegalovirus infection, measles virus infection cases, coagulase negative staphylococcus infection cases. 7 cases (28%) were mixed infection of 2 or 3 pathogens, including mixed infection of Mycoplasma pneumoniae and measles virus, 1 cases of Mycoplasma pneumoniae and Aspergillus mixed infection, 1 cases of Mycoplasma pneumoniae and coagulase negative staphylococcus, 1 cases of mixed infection of adenovirus and Japanese influenza virus, 1 cases of mixed infection of adenovirus and Aspergillus, 1 cases of adenovirus and Aspergillus, pneumonia, pneumonia, pneumonia, and pneumonia. Mixed infection of Streptococcus and Aspergillus in 1 cases, Mycoplasma pneumoniae, adenovirus and influenza B virus mixed infection in 1 cases, 4 cases (16%) in.25 cases, no definite pathogen was found.
3. imaging features
Chest X-RAY showed a thickening of lung texture, disorder in 25 cases (100%), patchy infiltration in 17 cases (68%), blurred costal angle in 2 cases (8%), pulmonary atelectasis in 2 cases (8%) and pulmonary consolidation in 3 cases (12%).
25 cases (100%), 22 cases of mosaic perfusion syndrome (88%), 3 cases of localized emphysema (12%), 3 cases of limited pulmonary atelectasis (12%), 3 cases of pulmonary atelectasis (12%), 3 cases of pulmonary atelectasis (12%), 2 cases of pleural effusion (8%), pleural thickening (8%), pleural thickening and thoracic malformation in June. After discharge, the chest HRCT was reviewed in June. The range of ground glass shadow and mosaic perfusion sign was larger than that of PIBO, and the lesions were more obvious. 9 cases of grinding glass shadow or mosaic sign were less than diagnosed PIBO, and the lesions were relieved. There was no obvious change in 15 cases of mosaic perfusion and glass shadow.
4. immunological changes: the blood T cell subgroup showed 4 cases (16%), 5 CD4 decreased (20%), CD8 increased 19 cases (76%), CD4/CD8 decreased in 17 cases (68%). The blood immunoglobulin, IgG decreased in 5 cases (20%), IgA decreased 4 (16%), IgM increased in 1 cases, IgE raised cases, complement decreasing cases.
5. fiberoptic bronchoscopy and treatment: 6 cases of children with fiberoptic bronchoscopy were not found abnormal airway structure or foreign body, and there were different levels of sputum or phlegm obstruction in some pulmonary lobes, of which 1 cases had subsegment subsegment occlusion in the left inferior lobe. 4 cases were relieved of symptoms and signs and 1 Aspergillus infection after lavage treatment. 1 cases of Aspergillus complicated with adenovirus infection still had repeated cough and wheezing, of which 1 cases were treated again with lavage. Only 1 cases of coagulase negative Staphylococcus were cultured with alveolar lavage fluid and acid staining.
6. treatment and prognosis
The shortest follow-up time of all children was in June and the oldest in December. 10 of them had no cough, wheezing and other symptoms, the other 15 cases were relieved obviously before the treatment, only when respiratory infection or violent activities were available. No death cases were present.
After 3 months of discharge from hospital, 20 cases (80%) had no cough, wheezing, only cough, wheezing, coughing, and short duration of wheezing in respiratory tract infection or intense activity. 4 cases were treated for 42~56 days (mean 51.20 + 5.46 days) after cough and.5 cases (20%) were coughing compared with before treatment. The pulmonary wheezing sound still existed at the time of reexamination, of which 4 cases were followed up for.6 months after coughing and wheezing, 25 cases (100%) had no cough and wheeze after treatment, only cough and wheezing in respiratory tract infection or violent activity, 7 of them were treated for 42-165 days (mean 124.32 + 40.78 days) after 42-165 days. The wheeze disappeared.
The number of coughing and wheezing episodes in the 12 weeks group (group A) and the group of 12 weeks (group B) were statistically different, and the results were statistically different. The results showed that early diagnosis and intervention could significantly reduce the number of cough and wheezing episodes in children.
Conclusion:
1.PIBO occurs in infants younger than 1 years old, and the incidence of boys is higher than that of girls.
2. Mycoplasma pneumoniae and adenovirus infection are the main causes of PIBO in children.
There were no specific changes in the chest X-RAY of the 3.PIBO children. The typical manifestations of HRCT were plaque or increased glass like density, and mosaic perfusion syndrome. There were some emphysema, atelectasis, pulmonary consolidation, pleural effusion, pleural thickening, and so on.
4. the imperfections of infants' immune function, rickets, anemia, history of personal eczema and family allergy may be the risk factors of PIBO.
5. early clinical identification and treatment can significantly reduce the clinical symptoms such as recurrent cough and wheezing in children with PIBO, improve the quality of life of the children and change the prognosis of PIBO to a certain extent.
【学位授予单位】：山东大学
【学位级别】：硕士
【学位授予年份】：2012
【分类号】：R725.6

【参考文献】