CAJ | 학술논문

目的分析肺炎链球菌坏死性肺炎临床特点及诊断治疗要点.方法回顾性分析北京儿童医院20例肺炎链球菌坏死性肺炎的临床、影像学表现、治疗及预后.结果 20例患儿男9例,女11例,年龄(27.9±15.8)个月,既往体健；热程(27.7±13.5)d；住院天数为(36.5±8.3)d；全部病例一般状况差,均表现为发热(高热19例,中等热1例)、咳嗽,16例有呼吸困难；18例在肺部病变侧闻及细湿啰音,其中4例伴有散在喘鸣音,2例有痰鸣音,全部病例均有胸腔积液体征.血常规提示白细胞(16.2～60.95)×109/L,中性粒细胞0.705～0.872;CRP80 ～＞ 160mg/L;血沉44～ 109mm/1 h；胸腔积液常规、生化提示:白细胞6400× 106/L～满视野无法计数,多核细胞0.51 ～0.9,糖0.02 ～ 1.8 mmol/L,蛋白32～51 g/L,乳酸脱氢酶5475 IU/L～高于检测范围；胸腔积液培养(其中2例合并血培养)均为肺炎链球菌；病初肺部影像学为双肺或单侧肺大叶高密度均匀病灶,大约1周左右大叶实变内可见单一或多发低密度病灶,伴随或之后出现囊泡影或多发空腔,后期可出现肺大泡,全部病例均合并胸腔积液,7例合并包裹性液气胸.合并中耳炎2例、心功能不全2例.17例应用万古霉素或替考拉宁、利奈唑胺；18例行胸腔闭式引流术,3例胸腔清脓术；随访半年以上,预后较好,均未行肺切除术.结论肺炎链球菌坏死性肺炎多见于婴幼儿,病后一般状况差,高热、热程长,咳嗽伴有呼吸困难.血白细胞、中性粒细胞比值及CRP明显升高,胸腔积液提示脓胸表现.病初肺部影像学为大叶高密度病灶,之后逐渐出现低密度病灶及空腔,后期可出现肺大泡、包裹性液气胸.及时治疗后大多数预后比较好.
목적 분석폐염련구균배사성폐염림상특점급진단치료요점.방법 회고성분석북경인동의원20례폐염련구균배사성폐염적림상、영상학표현、치료급예후.결과 20례환인남9례,녀11례,년령(27.9±15.8)개월,기왕체건；열정(27.7±13.5)d；주원천수위(36.5±8.3)d；전부병례일반상황차,균표현위발열(고열19례,중등열1례)、해수,16례유호흡곤난；18례재폐부병변측문급세습라음,기중4례반유산재천명음,2례유담명음,전부병례균유흉강적액체정.혈상규제시백세포(16.2～60.95)×109/L,중성립세포0.705～0.872;CRP80 ～＞ 160mg/L;혈침44～ 109mm/1 h；흉강적액상규、생화제시:백세포6400× 106/L～만시야무법계수,다핵세포0.51 ～0.9,당0.02 ～ 1.8 mmol/L,단백32～51 g/L,유산탈경매5475 IU/L～고우검측범위；흉강적액배양(기중2례합병혈배양)균위폐염련구균；병초폐부영상학위쌍폐혹단측폐대협고밀도균균병조,대약1주좌우대협실변내가견단일혹다발저밀도병조,반수혹지후출현낭포영혹다발공강,후기가출현폐대포,전부병례균합병흉강적액,7례합병포과성액기흉.합병중이염2례、심공능불전2례.17례응용만고매소혹체고랍저、리내서알；18례행흉강폐식인류술,3례흉강청농술；수방반년이상,예후교호,균미행폐절제술.결론 폐염련구균배사성폐염다견우영유인,병후일반상황차,고열、열정장,해수반유호흡곤난.혈백세포、중성립세포비치급CRP명현승고,흉강적액제시농흉표현.병초폐부영상학위대협고밀도병조,지후축점출현저밀도병조급공강,후기가출현폐대포、포과성액기흉.급시치료후대다수예후비교호.
Objective Streptococcus pneumoniae necrotizing pneumonia (SPNP) was reported elsewhere but not in China yet.Inappropriate treatment due to poor recognition of this disease could influence its prognosis.This paper presents the clinical characteristics,diagnosis and treatment of SPNP hoping to elevate pediatrician's recognition level for this disease. Method Clinical manifestations,radiological findings,treatment and prognosis of 20 patients (9 boys,11 girls) who had been hospitalized with SPNP in Beijing Children's Hospital from 2004 -2011 were retrospectively analyzed.Result The patients included in this study aged from 9 months to 6 years [(27.9 ± 15.8) m] and were healthy before admission.They were febrile for 8 to 50 days [(27.7 ± 13.5 ) d] and hospital day was 24 - 55 days [( 36.5 ± 8.3 ) d].The general condition of all subjects was relatively poor and they all had fever and cough.One child had moderate fever and nineteen children had high fever.Dyspnea was found in sixteen children.Fine rales were found on auscultation in 18 children,among whom diffuse wheeze appeared in 4 children,and wheezy phlegm was found in two children.Signs of pleural effusion were discovered in all cases by physical examination and chest X-ray.White blood cell (WBC) count was 16.2-60.95 × 109/L and neutrophil was 70.5％ - 80.2％ in peripheral blood routine test.Erythrocyte sedimentation rate (ESR) was 44 - 109 mm/h [(69.6 ± 16 ) mm/h] and C-reactive protein (CRP) was 80 - ＞ 160 mg/L.The pleural effusion biochemistry and routine test revealed a WBC count of 6400 × 106/L -too much to count,polykaryocyte of 51％ -90％,glucose of 0.02 - 1.8 mmol/L,protein of 32-51 g/L and LDH of 5475 IU/L-or higher.Pleural effusion culture in all cases and blood culture in 2 cases was positive for Streptococcus pneumoniae.Chest X-ray or CT revealed high density and well-distributed lobar consolidation in one lung or two lungs initially.Single or multiple low density lesions in the area of lobar consolidation were found a week later,accompanied by multiple cystic shadow or cavity at the same time or afterwards.Bulla of lung appeared later.Pleural effusions were found in all patients. Seven cases complicated with hydropneumothorax,two with otitis media,one with heart failure,one with cardiac insufficiency.Seventeen patients were treated with vancomycin or teicoplanin or linezolid two with amoxicillin and clavulanate potassium. Other two patients had been treated with meropenem and cephalosporin antibiotics respectively before admission,and they had been at recovery stage when they were hospitalized.Thoracic close drainage and thoracoscopy were performed respectively in 18 cases and 3 cases,respectively.After a follow up of more than 6 months,chest CT showed that almost all lesions in lungs recovered during 4-6 months. No one received pneumonectomy.Conclusion SPNP has special manifestations.The incidence in infants is higher.Patients' general condition is poor and febrile course is relatively long. All patients manifested fever and cough,with a presence of dyspnea in most of them. WBC,neutrophil and CRP elevated apparently. The characteristic of pleural effusion indicates empyema.In early stage,the chest X-ray and CT showed high-density lobar lesions,followed by low-density lesions and cyst gradually.Bulla of lung and/or hydropneumothorax may appear at the late stage.But if diagnosed and treated promptly,the prognosis of SPNP was relatively good.