重症“不明原因”社区获得性肺炎的临床特征及血清细胞因子的初步分析

发布时间：2018-07-11 12:58

本文选题：重症肺炎 + 不明原因肺炎　；参考：《北京协和医学院》2013年硕士论文

【摘要】：目的：对成人重症“不明原因”社区获得性肺炎的临床表现、病原体检测、病情严重程度等方面进行综合分析,探讨其病原学及临床特点。采集患者血清进行细胞因子测定,初步分析治疗前后其细胞因子水平的变化规律。方法：收集2012年4月至2013年4月,北京协和医院急诊科重症监护病房收治的符合重症“不明原因”社区获得性肺炎诊断标准的患者。记录人口统计学资料、病史资料、病情评分、治疗用药等。采集患者入院后第1、3、5、7天血液标本,分离血清测定TNF-α、IL-1β、IL-6、IL-8、IL-10、可溶性细胞间黏附分子、可溶性E-选择素浓度,分析患者治疗前后其血清细胞因子的变化。结果：①最终入选重症“不明原因”社区获得性肺炎20例,男性11例,女性9例,平均年龄为(41.9±15.1)岁,所有病例均出现发热及咳嗽,病例高发时间为1月至4月。②所有入选病例均符合急性呼吸窘迫综合征柏林诊断标准,重度ARDS患者(9例)与轻、中度ARDS患者相比,LIS、SOFA评分更高、氧合指数更低、需要更高的PEEP水平,使用机械通气时间更长,差异有统计学意义(P0.05)。③入选病例中8例明确病原体,均为病毒感染,其中7例为腺病毒,1例为鼻病毒。腺病毒感染患者以男性多见,但差异无统计学意义(P=0.20)。病毒性肺炎患者与不明原因肺炎患者入院时各项评分及临床表现无显著差异。④20例患者病程初期均无细菌及真菌感染证据,病程后期13例病例合并细菌感染,均出现在机械通气患者中,其中2例合并真菌感染。⑤20例病例中累及两个或两个以上肺叶者占55%,影像学表现为实变影、散在团块影、广泛磨玻璃影,病毒性肺炎与不明原因肺炎患者的影像学表现无显著差异。⑥入院后第1、3、5、7天患者体内TNF-α呈上升趋势；IL-6于第3天出现显著下降,差异有统计学意义(P0.05)：IL-8、IL-10第3天达高峰,后期逐渐下降；可溶性E-选择素及sIC AM-1持续处于较高水平。结论：①病毒成为重症“不明原因”社区获得性肺炎的主要病原体之一,冬春季节需高度警惕病毒性肺炎。②根据临床特征、病情严重程度及影像学表现不能区分病毒性肺炎和不明原因肺炎。③对重症“不明原因”肺炎患者进行病毒筛查尤为重要,确诊依靠病原学证据。④序贯器官衰竭评分有助于判断病情严重程度。⑤IL-6对治疗反应较好,在早期对预后判评有一定价值。IL-1β、IL-8与病情变化相一致。⑥在疾病严重情况下,TNF-α持续升高与病情严重程度相关。
[Abstract]:Objective: to analyze the clinical manifestation, pathogen detection and severity of adult severe "unknown cause" community acquired pneumonia, and to explore its etiology and clinical features. The changes of cytokine levels before and after treatment were preliminarily analyzed. Methods: from April 2012 to April 2013, the patients in the intensive care unit of emergency department of Beijing Union Union Hospital who met the criteria for the diagnosis of severe "unknown cause" community-acquired pneumonia (CPAP) were collected. Record demographic data, medical history, disease score, medication and so on. The blood samples were collected on the 1st day of admission, and the serum levels of TNF- 伪, IL-1 尾, IL-6, IL-8 and IL-10, soluble intercellular adhesion molecules and soluble E- selectin were measured, and the changes of serum cytokines before and after treatment were analyzed. Results Twenty patients with severe "unknown cause" community-acquired pneumonia, 11 males and 9 females, with an average age of (41.9 卤15.1) years, had fever and cough. The time of high incidence was from January to April .2 all the selected cases were in accordance with the Berlin diagnostic criteria for acute respiratory distress syndrome. The patients with severe ARDS (9 cases) had higher score and lower oxygenation index than those with mild and moderate ARDS. The need for higher peep level, the use of mechanical ventilation time longer, the difference was statistically significant (P0.05) in the selected cases 8 cases identified pathogens, all of them were viral infection, 7 cases were adenovirus 1 case is rhinovirus. Male patients with adenovirus infection were more common, but the difference was not statistically significant (P0. 20). There was no significant difference in scores and clinical manifestations between patients with viral pneumonia and those with unexplained pneumonia at admission. There was no evidence of bacterial and fungal infection in 420 patients at the beginning of the disease course, and 13 cases were complicated with bacterial infection in the late stage of the disease. All of them appeared in mechanical ventilation patients, of which 2 cases were complicated by fungal infection. 55 cases were involved in two or more lobes of lung. The imaging manifestations were solid change, scattered mass shadow, and widely ground glass shadow. There was no significant difference between the imaging manifestations of viral pneumonia and unexplained pneumonia. 6 the TNF- 伪 in patients with viral pneumonia showed an increasing trend on the 7th day after admission, and IL-6 decreased significantly on the 3rd day, and the difference was statistically significant (P0.05). The TNF- 伪 level reached the peak on the 3rd day after admission (P0.05). The content of soluble E- selectin and sIC AM-1 remained at high level. Conclusion the virus of 1 is one of the main pathogens of severe "unknown cause" community-acquired pneumonia. In winter and spring, it is necessary to be on high alert for viral pneumonia .2 according to the clinical characteristics. It is particularly important that the severity of the disease and the imaging findings can not distinguish viral pneumonia from unexplained pneumonia. 3. It is particularly important for patients with severe "unknown cause" pneumonia to be screened for viruses. Depending on the etiological evidence, the score of Sequential Organ failure was helpful to judge the severity of the disease, and the response of IL-6 to the treatment was better. Early prognostic evaluation. IL-1 尾 -IL-8 is consistent with the changes of the disease. 6 in the case of serious disease, the sustained increase of TNF- 伪 is related to the severity of the disease.
【学位授予单位】：北京协和医学院
【学位级别】：硕士
【学位授予年份】：2013
【分类号】：R563.1

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