儿童重症药疹51例临床特征分析

发布时间：2018-06-05 08:47

本文选题：药物不良反应 + 重症药疹　；参考：《重庆医科大学》2012年硕士论文

【摘要】：背景及目的药疹又称药物性皮炎（drug eruption），是药物通过各种途径进入人体后引起的皮肤粘膜炎症反应。其中皮损广泛、粘膜损害明显、可导致严重内脏损害、致死率高者我们称之为重症药疹。重症药疹（severe cutaneous adverse drug reactions SCADRs）包括重症多形红斑型即Steven-Johson syndrome（SJS）、大疱性表皮松解型（drug-induced bullosa epidermolysis）又称中毒性表皮坏死松解型（toxicepidermal necrolysis TEN）、剥脱性皮炎型（exfoliative dermatitis ED）及药物超敏反应综合征（drug hypersensitivity syndrome DHS）。在疾病初期，其皮损表现多样，特别是在儿童，尤其难与感染性疾病引起的皮肤损害相鉴别。加之药疹的检测和识别在临床上无灵敏度高、特异性强的实验室指标，其诊断主要依靠药物接触史及临床表现。故对儿童重症药疹的发病规律及其特点进行分析总结对指导临床诊断及治疗具有重要的意义。本文就我院儿童重症药疹住院病例的临床特点、致敏药物及治疗预后情况进行临床回顾性研究，希望能为早期诊断及治疗疾病提供相关的临床依据。方法对我院2007年1月-2011年12月51例重症药疹住院患儿进行临床回顾性分析，其中包括好发年龄、住院情况、潜伏期、致敏药物、临床表现、治疗方法及转归。男32例，女19例，发病年龄为3月-14.5岁，平均年龄为（6.00±3.64）岁。结果 1.好发年龄：发病的高峰年龄为1-3岁（21.57%）及6-9岁（35.29%），青春期及婴儿期的发病人数相对较少，分别为3.92%、7.84%。男女之比为1.69：1，男性稍高于女性。 2.本研究中，重症药疹病例占全院总住院患儿的比例为0.22‰。2007-2011年，每年的比例分别为0.13‰、0.22‰、0.24‰、0.18‰、0.31‰，整体呈增长趋势。 3.药疹类型：51例儿童重症药疹中常见的临床类型比例依次为SJS(54.90%)，TEN(27.45%)，ED(9.80%)，DHS(7.85%)。 4.潜伏期：SJS、TEN、ED及DHS的平均潜伏期为（5.66±6.45）d、（6.61±9.65）d、（16.00±7.41）d、（18.00±6.97）d，ED及DHS的平均潜伏期较SJS及TEN延长，其比较有明显的统计学差异（F=5.5,P0.05），而ED与DHS比较，其平均潜伏期无明显的统计学差异（F=0.005,P0.05）。 5.致敏药物：常见的致敏药物为抗生素类(39.21%)、解热镇痛类(21.57%)及抗癫痫类药物(17.65%)。其中SJS主要以抗生素为主（57.90%），TEN以抗生素（41.67%）及解热镇痛药（50.00%）为主，ED以抗生素（60.00%）为主，而DHS以抗癫痫类药物（75.00%）为主。抗癫痫药的平均潜伏期较抗生素及解热镇痛药明显延长，其差异有显著的统计学意义（F=19.5,P0.05）。 6.用药原因：感染性疾病(56.85%)是儿童用药后引起重症药疹最主要的原因，尤以上呼吸道感染（43.14%）最为常见。 7.脏器受累：最常见的为肝脏（39.22%），其次为肾脏（5.08%）和肺部（7.84%），心脏受累者（1.96%）少见。粘膜受累主要见于SJS(21例)及TEN（14例），而ED（1例）及DHS粘膜受累少见，DHS嗜酸性粒细胞升高（3例）明显。 8.预后及治疗：治愈32例（62.75%），好转18例（35.29%），死亡1例（1.96%），治愈率高。有病毒感染、粘膜受累、内脏损害的患儿其平均病程分别为（18.86±2.34）d、（15.94±4.39）d、（18.90±2.86）d，无病毒感染、粘膜受累、内脏损害的患儿平均病程分别为（12.38±5.11）d、（8.00±1.93）d、（9.90±2.76）d，有病毒感染、粘膜受累及内脏损害者病程延长，其比较均有统计学意义（P0.05）；激素用量与疾病病程关系不大（相关系数γ=0.23，P0.05）。结论 1.近年来，儿童重症药疹住院病例占总住院患儿的比例呈上升趋势，其多器官受累明显，主要以肝脏损害最为常见，肺部、肾脏、心脏也可发生病变，危害性大，需早期诊断。 2.儿童重症药疹根据其既往药物过敏史、可疑药物接触史、潜伏期及临床皮损等特点，可早期诊断，及时治疗，治愈率高。 3.重症药疹一旦确诊，需立即停止可疑致敏药物，根据病情严重程度及时给予适量糖皮质激素。目前我们不提倡大剂量激素治疗，建议根据病情严重程度，使用适量的激素，，以可控制病情为标准。糖皮质激素联合静脉注射丙种球蛋白（IVIG）治疗可减少激素用量，降低激素副作用的发生。同时丙种球蛋白有一定抗病毒的作用，可用于伴有病毒感染治疗效果不佳者。 4.对于有病毒感染、粘膜受累及内脏功能损害者，需积极予以相关对症支持治疗，以免延长病程。
[Abstract]:Background and objective drug rash, also known as drug dermatitis (drug eruption), is an inflammatory response to the skin and mucous membrane caused by various ways of entering the body. There are extensive skin lesions and obvious mucosal damage, which can lead to severe visceral damage. The high fatality rate is called severe drug rash. The severe drug rash (severe cutaneous adverse drug reactions SCA) DRs) including severe polymorphic erythema, Steven-Johson syndrome (SJS), bullous epidermolysis (drug-induced bullosa epidermolysis), also known as medium toxic epidermal necrosis and loosening (toxicepidermal necrolysis TEN), exfoliative dermatitis (exfoliative dermatitis) and drug hypersensitivity syndrome S). In the early stages of the disease, its skin lesions are diverse, especially in children, especially in the identification of skin damage caused by infectious diseases. In addition, the detection and identification of drug rash in the clinic is highly sensitive and specific, and its diagnosis depends mainly on the history of drug contact and clinical manifestations. The analysis and summary of its characteristics is of great significance for guiding clinical diagnosis and treatment. The clinical features, sensitized drugs and treatment prognosis of hospitalized children with severe drug rash in our hospital are reviewed in this paper, hoping to provide a clinical basis for early diagnosis and treatment of diseases.
Methods the clinical retrospective analysis of 51 cases of severe drug eruption in January 2007 -2011 years in our hospital, including good onset age, hospitalization, latent period, sensitizing drugs, clinical manifestation, treatment and prognosis, 32 men and 19 women, age -14.5 in March, the average age was (6 + 3.64) years old.
Result
1. the age of good onset: the peak age of the disease is 1-3 (21.57%) and 6-9 (35.29%). The incidence of adolescence and infancy is relatively low, which is 3.92%, the ratio of 7.84%. to men and women is 1.69:1, and the male is slightly higher than that of the female.
2. in the 2. study, the proportion of severe drug eruptions in the total hospitalized children was 0.22 per thousand.2007-2011 years, the proportion of each year was 0.13 per thousand, 0.22 per thousand, 0.24 per thousand, 0.18 per thousand, 0.31 per thousand, and the overall growth trend.
3. type of drug eruption: 51 cases of severe drug eruption in children were followed by SJS (54.90%), TEN (27.45%), ED (9.80%) and DHS (7.85%).
4. incubation period: the average latency of SJS, TEN, ED and DHS is (5.66 + 6.45) d, (6.61 + 9.65) d, (16 + 7.41) d, (18 + 6.97) d, and the average latency of ED and DHS is higher than that of SJS and TEN.
5. sensitizing drugs: the common sensitizing drugs are antibiotics (39.21%), antipyretic and analgesic (21.57%) and antiepileptic drugs (17.65%). Among them, SJS is mainly antibiotics (57.90%), TEN is mainly antibiotics (41.67%) and antipyretic analgesics (50%), ED is mainly antigenic (60%), and DHS is mainly antiepileptic drugs (75%). Antiepileptic drugs The average incubation period was significantly longer than that of antibiotics and antipyretic analgesics, and the difference was statistically significant (F=19.5, P0.05).
6. reasons for drug use: infectious diseases (56.85%) are the main causes of severe drug eruption after medication in children, especially respiratory tract infections (43.14%).
7. organs were involved: the most common were liver (39.22%), followed by kidney (5.08%) and lung (7.84%), and heart involvement (1.96%). Mucous membrane involvement was mainly seen in SJS (21 cases) and TEN (14 cases), while ED (1 cases) and DHS mucous membrane were rarely involved, DHS eosinophilic Bao Shenggao (3 cases) was obvious.
8. the prognosis and treatment: 32 cases (62.75%) cured, 18 cases (35.29%), 1 cases of death (1.96%), high cure rate. The average course of children with virus infection, mucous membrane involvement, and visceral damage was (18.86 + 2.34) d, (15.94 + 4.39) d, (18.90 + 2.86) d, no virus infection, mucous membrane involvement, and the average course of children's visceral damage was D, respectively. 00 + 1.93) d, (9.90 + 2.76) d, virus infection, mucous membrane involvement and visceral damage prolonged the course of disease, the comparison was statistically significant (P0.05), and the dose of hormone was not related to the disease course (correlation coefficient gamma =0.23, P0.05).
conclusion
1. in recent years, the proportion of children with severe drug rash in the total hospitalized children is on the rise, and the multiple organ involvement is obvious. The most common cases are liver damage, lung, kidney, and heart can also be diseased, and the early diagnosis is needed.
2. children with severe drug eruption can be diagnosed early and treated timely according to their previous drug allergy history, suspected drug exposure history, latent period and clinical skin lesions. The cure rate is high.
3. severe drug rash, once confirmed, should immediately stop suspicious sensitizing drugs and give proper amount of glucocorticoid in time according to the severity of the disease. We do not advocate large dose hormone therapy at present. We suggest that a moderate amount of hormone should be used to control the condition according to the severity of the disease. Glucocorticoid combined with intravenous immunoglobulin (IVIG) is a combination of glucocorticoid and intravenous injection. Treatment can reduce the amount of hormone and reduce the occurrence of side effects of hormone. At the same time, the gamma globulin has a certain antiviral effect, which can be used in patients with poor treatment of virus infection.
4. for patients with viral infection, mucosal involvement and visceral dysfunction, relevant symptomatic and supportive treatment should be actively taken so as not to prolong the course of disease.
【学位授予单位】：重庆医科大学
【学位级别】：硕士
【学位授予年份】：2012
【分类号】：R758.25

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