重症支原体肺炎肺炎.ppt

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,支原体抗体,各厂家使用的抗原不完全相同,酶联测定IgM:1-6d,7-25%,7-15d,31-69%,16d以上,33-87%,提示发病后1-2周高于50%,支原体抗体测定,抗体滴度增加者,病情严重,敏感性低于冷凝集实验,5岁以下感染,以咳嗽喘息为主,肺功能下降,开始于年幼儿,5岁以下感染,IgG测定:,7-12月:28%,13-24月:55%,25-60月:67%,流行特征相似于麻疹,敏感人群是年幼儿,各型支原体肺炎,难治性或重症支原体肺炎,难治性支原体肺炎临床表现,（,1）病情重：合理大环内酯类抗生素治疗后仍持续高热、剧烈咳嗽。,（2）,双侧或单侧大叶肺实变，合并少-中量胸腔积液,（3）易合并肺外表现,（4）炎性指标升高,中性粒细胞、血沉和CRP升高,血凝指标也升高。,(5)遗留肺部后遗症,难治性支原体肺炎影像学表现,（1）双侧或单侧大叶肺实变，合并少-中量胸腔积液。,（2）影像学表现为双侧肺弥漫性间质性,浸润。,2005/10/1,难治性支原体肺炎,合并症,急性期,易合并肝、心肌等损害 其他肺外表现,类川崎病样表现,全身炎症反应综合征,肺损伤、ARDS、,肺脓肿（坏死性肺炎）,肺不张,大量胸腔积液,血管栓塞,渗出性多形红斑,死亡,国外儿科文献也报道了重症MPP病例。,表现为肺脓肿（坏死性肺炎），,合并大量胸腔积液、呼衰、DIC等。,Septic shock,necrotizing pneumonitis,and meningoencephalitis caused by Mycoplasma pneumoniae in a child:a case report.,Clin Pediatr(Phila).2009;48(3):320-2.,Mycoplasma pneumoniae is an important causative agent of respiratory infection in childhood.Although the infection caused by M.pneumoniae is classically described as benign,severe and life-threatening pulmonary and extrapulmonary complications can occur.This study describes the first case of septic shock related to M.pneumoniae in a child with necrotizing pneumonitis,severe encephalitis,and multiple organs involvement,with a favorable outcome after lobectomy and systemic corticosteroids.,难治性支原体肺炎,后遗症,慢性期或后遗症期：,持续肺不张,局限性支气管扩张,闭塞性支气管炎,间质性肺炎,文献报道支原体肺炎合并闭塞性支气管炎,Leong MA,Nachajon R,Ruchelli E,et al.,Bronchitis Obliterans Due to Mycoplama pneumonia.Pediatric Pulmonology,.,1997,23(5):375.,重症支原体肺炎与肺结核鉴别,临床+影像表现（本身或并发症）易与肺结核相互误诊,鉴别诊断,症状：发热、咳嗽,影像学表现：淋巴结肿大、空洞,治疗反应:,PPD反应：结核病可阴性，而支原体肺炎可阳性。,重症支原体肺炎诊断,支原体肺炎+重症表现,支原体诊断,抗体检查，但阳性时间延迟。,重症表现：,临床表现、影像学表现,、,性指标升高,量化：持续高热超过7-10天以上，有合并症,依据年龄、咳嗽性质、中毒症状和进展、影像学指标、其他病原学检查。,支愿体肺炎影像学相对特征,细支气管炎、肺间质性病变、肺实质，常混合存在。,表现为间质浸润的线状阴影、网结节；树芽征、小叶中心结节、细支气管壁增厚、,实质浸润。,支原体肺炎发病机制,对肺损伤有直接细胞病理效应,细胞介导免疫反应,细胞因子增多淋巴细胞降低动物实验临床表现,多型性治疗反应,治疗问题,有待根据对发病机制的认识，探讨合理治疗。,（1）直接损害,（2）耐药？,（3）免疫和炎症机制：,炎症指标升高,腺体分泌亢进,治疗,抗生素：,激素：,丙种球蛋白：,清除黏液：支气管镜灌洗等,抗生素,并不是所有耐药，大环内酯类抗生素选择？,联合用药,（,1）,有细菌感染指标,痰液或BALF培养、胸水检查、,病程长，治疗后炎性指标持续升高,（2）重复检查病毒抗体阳性,激 素和丙种球蛋白,激 素,甲强：2mg/kg.d,一般3天，减量,视病情而定疗程。韩国和日本已应用,丙种球蛋白,400,mg/kg.d,一般3天，,Role of Prednisolone Treatment in Severe Mycoplasma pneumoniae Pneumonia in Children,Pediatric Pulmonology 41:263268(2006),Methylprednisolone pulse therapy for refractory Mycoplasma pneumoniae pneumonia in children,J Infect.2008 Sep;57(3):223-8.Epub 2008 Jul 25.Links,OBJECTIVES:To determine the efficacy of methylprednisolone pulse therapy for children with Mycoplasma pneumoniae pneumonia(MP)that is refractory to antibiotic treatment.METHODS:Refractory patients were defined as cases showing clinical and radiological deterioration despite appropriate antibiotic therapy for 7 days or more.We identified 6 such children(male/female:3/3)aged 3-9 years who were treated between 1998 and 2006.During the same period,190 children with MP were admitted to our institution.RESULTS:Common laboratory findings of the patients included cytopenia,elevated serum lactate dehydrogenase and ferritin levels,and elevated urine beta(2)-microglobulin levels,suggesting complication of hypercytokinemic condition.We initiated intravenous methylprednisolone at a dose of 30 mg/kg on 10.2+/-2.8 clinical days and administered it once daily for 3 consecutive days.Fever subsided 4-14 h after initiation of steroid pulse therapy in all patients.This dramatic effect was accompanied by rapid improvement of radiological abnormalities including infiltrates and pleural effusion,followed by improvement of laboratory abnormalities.There were no adverse events of steroid therapy.CONCLUSIONS:This is the first case-series study showing an effect of 3-day methylprednisolone pulse therapy on refractory MP in children.This therapy is apparently an efficacious and well-tolerated treatment for refractory MP.,支气管镜灌洗,肺高密度实变阴影并肺不张,高热、痰液粘稠,减少闭塞，减少肺不张。,黏液纤毛系统损害,给予相应药物,44,粘液纤毛清除防御系统,传导性气道共有的组织学结构,纤毛细胞,粘液层,浆液层,浆液分泌腺,杯状细胞,粘液毯,粘液毯:粘液层和浆液层,形成粘液毯:杯状细胞和分泌腺,运输粘液:纤毛柱状上皮细胞及纤毛,抗凝治疗,D-二聚体升高纤维蛋白原升高,抗凝治疗,治 疗,耐药无治疗失败或病情进展,比较阿奇霉素与红霉素或阿莫西林治疗儿童CAP疗效及安全性的随机研究研究设计,随机、对照研究,110名1-14岁的儿童CAP患者入选，106名完成研究,分组,典型肺炎患儿,阿奇霉素组（n=23）：10mg/kg，每天1次，3天,阿莫西林组（n=24）：75mg/kg/天，分3次服用，7天,非典型肺炎患儿,阿奇霉素组（n=33）：10mg/kg，每天1次，3天,红霉素组（n=26）：50mg/kg/天，分3次服用，14天,所有患儿在第3、7、14天接受随访，进行疗效评估,Pediatr Pulmonol.2003;35:9198.,比较阿奇霉素与红霉素或阿莫西林治疗儿童CAP疗效及安全性的随机研究研究结果,阿奇霉素与阿莫西林疗效比较（典型CAP组患者）,Pediatr Pulmonol.2003;35:9198.,阿奇霉素组（n=23）,阿莫西林组（n=24）,P值,第3天,发热（,38,）,8.7%,12.5%,NS,第7天,发热（,38,）,0.0%,0.0%,NS,胸片改善75%,81.0%,60.9%,0.009,第14天,发热（,38,）,0.0%,0.0%,NS,胸片改善75%,100%,100%,NS,NS：无显著差异,比较阿奇霉素与红霉素或阿莫西林治疗儿童CAP疗效及安全性的随机研究结论,阿奇霉素短疗程方案可有效治疗儿童社区获得性肺炎（典型或非典型），与阿莫西林或红霉素长疗程治疗疗效相当,阿奇霉素安全性良好，服用方便，对于可能的呼吸道病原菌具有良好的抗菌活性,Pediatr Pulmonol.2003;35:9198.,阿奇霉素治疗儿童CAP的疗效及安全性研究设计,多中心、随机、双盲、平行对照研究,456名6个月至16岁的儿童CAP患者入选，其中420进行疗效分析,分组,阿奇霉素组（n=33）：第1天阿奇霉素干混悬剂10mg/kg，第2-5天5mg/kg，单剂服用,对照组（n=26）：5岁及以下患儿，阿莫西林/克拉维酸40mg/kg/天，分3次服用，10天；5岁以上患儿，红霉素40mg/kg/天，分3次服用，10天,所有患儿在第2-5天、15-19天、治疗后4-6周接受随访临床评估,Pediatr Infect Dis J.1998;17(10):865-71.,阿奇霉素治疗儿童CAP的疗效及安全性结论,阿奇霉素每天1次，5天治疗儿童社区获得性肺炎疗效与阿莫西林/克拉维酸、红霉素每天3次，10天治疗相似,阿奇霉素不良反应发生率显著低于对照组药物,Pediatr Infect Dis J.1998;17(10):865-71.,沙眼衣原体肺炎,女，12天，咳嗽4天，无发热。外周血白细胞不高。,沙眼衣原体肺炎,男，28天，咳嗽1周，发i热3天，体温38.5。外周血白细胞不高,沙眼衣原体肺炎诊断和治疗,诊断,临床特征：6个月以下婴儿、无热肺炎、中毒症状不重、病情迁延、典型者咳嗽类似百日咳。半数病程中合并结膜炎。,抗体检查：,治疗,红霉素,谢 谢 ！,请 指 教！,