儿童难治性肺炎支原体肺炎临床特征及血清白介素-17水平的意义分析.pdf

Mod Diagn Treat现代诊断与治疗2023 Jun 34渊12冤*院天津市卫生健康科技项目渊项目编号ZC20090冤曰天津市卫生健康委中医中西医结合科研项目渊项目编号2021092冤儿童难治性肺炎支原体肺炎临床特征及血清白介素-17 水平的意义分析赵久龄1袁叶菁2袁王欣2袁高巧营3渊1.天津市儿童医院/天津大学儿童医院中医科袁天津 300134曰2.天津市中西医结合医院/天津市南开医院儿科曰3.天津市中西医结合医院/天津市南开医院中西医结合研究所袁天津 300100冤ClinicalCharacteristicsofRefractoryMycoplasmaPneumoniaePneumonia in Children and Significance of Serum Interleukin-17LevelsZHAO Jiuling1,YE Jing2,WANG Xin2,GAO Qiaoyin3(1.Department of Traditional Chinese Medicine,TianjinChildrensHospital/ChildrensHospitalofTianjinUniversity,Tianjin300134;2.DepartmentofPediatrics,TianjinIntegratedTraditionalandWesternMedicineHospital/TianjinNankaiHospital,Tianjin300100;3.InstituteofIntegrated Chinese and Western Medicine,Tianjin Integrated Traditional and Western Medicine Hospital/TianjinNankai Hospital,Tianjin 300100,China)Abstract:ObjectivesTo analyze the clinical characteristics of Refractory Mycoplasma Pneumoniae Pneumonia(RMPP)in children and significance of serum interleukin-17(IL-17).MethodsA retrospective analysis wasconducted on 412 children with community-acquired pneumonia hospitalized in Tianjin Childrens Hospital fromJuly 2019 to December 2021.Among them,there were 126 cases of Mycoplasma Pneumoniae Pneumonia(MPP)with complete data,including 87 cases of NRMPP and 39 cases of RMPP.The clinical characteristics and relatedlaboratory examination indexes of the two groups were statistically analyzed.ResultsThere was no significantdifference in age,gender,and highest body temperature between the two groups(P跃0.05).RMPP chest X-ray mainlysuggests segmental pneumonia or lobar pneumonia,and the incidence of Pleural effusion in RMPP group wassignificantly higher than that in NRMPP group(P约0.05).There was no significant difference in white blood cellcount,neutrophil percentage,lymphocyte percentage,hemoglobin,platelet and procalcitonin(PCT)between NRMPPgroup and RMPP group in acute phase(P跃0.05).There were significant differences in the levels of IL-17,C-reactiveprotein(CRP)and Lactate dehydrogenase(LDH)between the two groups(P约0.05).ROC curve analysis showed thatthe AUC of IL-17 was 0.814,and the diagnostic efficacy of IL-17 was higher.The optimal diagnostic threshold was9.55pg/ml,the sensitivity was 72.4%,and the specificity was 71.8%.ConclusionsRMPP in children is mostlymanifested as segmental or lobar pneumonia,and the serum levels of IL-17 and LDHwere different from those ofNRMPP.Serum IL-17 can be used as one of the indicators for early prediction of RMPP.Keywords:Refractorymycoplasmapneumoniaepneumonia;Interleukin-17;Inflammatoryfactor;Clinicalcharacteristics摘要院目的分析儿童难治性肺炎支原体肺炎渊RMPP冤的临床特征及血清白介素-17渊IL-17冤的意义遥方法回顾性分析2019年7月至2021年12月于天津市儿童医院住院的社区获得性肺炎患儿412例袁其中研究数据资料齐全的肺炎支原体肺炎渊MPP冤病例126例袁包括NRMPP87例和RMPP39例遥统计分析2组病例的临床特征和相关实验室检查指标遥结果两组年龄尧性别及最高体温方面等比较袁差异无统计学意义渊P跃0.05冤曰RMPP胸片以节段性肺炎或大叶性肺炎为主袁且合并胸腔积液发生率高于NRMPP组袁差异有统计学意义渊P约0.05冤遥急性期NRMPP组与RMPP组在白细胞计数尧中性粒细胞百分比尧淋巴细胞百分比尧血红蛋白尧血小板和降钙素原渊PCT冤指标比较袁差异无统计学意义渊P跃0.05冤曰而两组IL-17尧C反应蛋白渊CRP冤及乳酸脱氢酶渊LDH冤水平比较袁差异有统计学意义渊P约0.05冤遥 ROC曲线分析袁IL-17的AUC为0.814袁IL-17诊断效能更高袁其最佳诊断界值为9.55 pg/ml袁灵敏度72.4%袁特异度71.8%遥结论儿窑论著窑1739窑窑Mod Diagn Treat现代诊断与治疗2023 Jun 34渊12冤肺炎支原体渊Mycoplasma pneumoniae袁MP冤是儿童呼吸道感染袁尤其是大于 5 岁儿童社区获得性肺炎渊Community acquired pneumonia袁CAP冤常见病原体之一遥 文献报道袁肺炎支原体肺炎渊Mycoplasma pneu鄄moniae pneumonia袁MPP冤占儿童肺炎的 40%以上袁流行季节比例更高咱1暂遥 肺炎支原体感染造成的病情严重程度不一袁轻者呈自限性袁重者可以造成重症肺炎尧急性呼吸窘迫综合征尧胸腔积液等肺内疾患甚至累及神经尧关节尧肝脏和心脏等多个肺外系统咱2暂遥 儿童 MPP 的治疗袁首选阿奇霉素尧红霉素等大环内酯类抗生素遥 成人有报道可以广泛应用的喹诺酮类和四环素类抗生素袁在儿童用药均有限制遥随着国内外文献报道难治性肺炎支原体肺炎渊Refractory My鄄coplasma pneumoniae pneumonia袁RMPP冤的病例越来越多袁这类病例的治疗袁大多需要及时应用糖皮质激素或/和静脉丙种球蛋白等袁甚至纤维支气管镜来治疗咱3暂遥 因此袁能否在早期及时预测和判断肺炎支原体儿童是否属于 RMPP 有重要意义遥 本研究旨在通过比较儿童 MPP 相关临床和实验室检查指标袁探讨RMPP 的临床特征袁以及白介素渊Interleukin袁IL冤-17对其早期预测的作用意义遥 报道如下遥1资料与方法1.1一般资料回顾性分析 2019 年 7 月至 2021 年12 月期间天津市南开医院儿科住院的社区获得性肺炎患儿共 412 例袁其中病毒性肺炎 39 例尧细菌性肺炎 77 例尧肺炎支原体肺炎 201 例尧其他病原体或病原体不明确的病例 95 例遥 在 201 例 MPP 病例中袁研究数据资料齐全的共 126 例袁包括非难治性支原体肺炎渊Non-refractory Mycoplasma pneumoniae pneu鄄monia袁NRMPP冤87 例和 RMPP 39 例均纳入研究遥 本研究已获得天津市南开医院医学伦理委员会批准渊审批号院NKYY-YXKT-IRB-2021-041-01冤遥1.2相关诊断标准MPP 的诊断同时符合以下标准咱4暂院渊1冤具有发热尧咳嗽等呼吸道感染表现遥渊2冤胸片检查示支气管肺炎尧间质性肺炎尧节段性肺炎或大叶性肺炎尧肺门淋巴结肿大等袁甚至伴有肺不张尧胸腔积液尧坏死性肺炎等遥 渊3冤单次血清 MP-IgM 抗体逸1颐160 或短期复查结果明显升高者遥 RMPP 的诊断标准为院符合 MPP 诊断袁正规使用大环内酯类抗生素1 周以上袁仍有发热且病情或影像持续加重遥1.3排除标准符合下列情况之一者均予以排除院渊1冤通过血清学或呼吸道分泌物检测明确合并其他病原体感染者遥 渊2冤如患儿合并哮喘尧严重的心肝肾和造血系统疾病袁或有其他基础疾病者遥1.4方法采用回顾性队列研究方法袁从数据库调取出院诊断为野肺炎支原体肺炎冶相关病例袁根据上述 MPP 和 RMPP 诊断标准及病例排除标准袁将病例分为 NRMPP 组和 RMPP 组遥 收集两组病例患儿的一般数据院包括年龄尧性别尧住院期间最高体温尧住院天数尧肺部影像学表现等袁以及实验室指标院包括白细胞计数渊White blood cell袁WBC冤尧中性粒细胞百分比渊Percentage of neutrophils袁Neutrophils%冤尧淋巴细胞百分比渊Percentage of lymphocyte袁Lymphocyte%冤尧血红蛋白渊Hemoglobin冤尧血小板渊Platelet冤尧C 反应蛋白渊C-reactive protein袁CRP冤尧降钙素原渊Procalcitonin袁PCT冤尧乳酸脱氢酶渊Lactate dehydrogenase袁LDH冤尧IL-17 等遥1.5统计学处理采用 SPSS 17.0 统计学软件进行处理遥 计量资料采用渊x依s冤表示袁行 t 检验曰计数资料采用n渊%冤暂表示袁行 字2检验曰非正态分布的计量资料采用中位数渊P25-P75冤表示袁用 Mann-Whitney U检验进行比较曰对 IL-17尧LDH尧CRP 等炎症标志物诊断试验分析采用 ROC 曲线分析袁计算 ROC 曲线下面积渊Area under the curve袁AUC冤尧灵敏度和特异度遥P约0.05 示差异有统计学意义遥2结果2.1NRMPP 组与 RMPP 组在症状特征上的比较两组在年龄尧性别及最高体温方面比较袁差异无统计学意义渊P跃0.05冤遥 但 RMPP 胸片表现与 NRMPP 比较袁以节段性肺炎或大叶性肺炎为主袁且更易合并胸腔积液袁住院时间更长袁差异有统计学意义渊P约0.05冤遥 见表 1遥2.2两组在急性期实验室检查上的比较急性期袁NRMPP 组与 RMPP 组在 WBC尧中性粒细胞百分比渊Neutrophils%冤尧淋巴细胞百分比渊Lymphocyte%冤尧血红蛋白渊hemoglobin冤尧血小板渊platelet冤和降钙素原渊PCT冤指标比较袁差异无统计学意义渊P跃0.05冤曰而两组 CRP尧LDH 和 IL-17 水平比较袁差异有统计学意义渊P约0.05冤遥 见表 2遥2.3ROC 曲线分析通过 ROC 曲线渊图 1冤分析 IL-17 的 AUC 为 0.814袁其最佳诊断界值为 9.55 pg/ml袁其灵敏度 72.4%袁特异度 71.8%遥 其次为 LDH 的 AUC童RMPP多表现为节段性或大叶性肺炎袁更易合并胸腔积液袁且血清IL-17和LDH较NRMPP有差异曰血清IL-17可作为早期预测RMPP的指标之一遥关键词院难治性肺炎支原体肺炎曰白介素-17曰炎症因子曰临床特征中图分类号院R725.6文献标志码院A文章编号院1001轧8174渊2023冤12轧1739轧031740窑窑Mod Diagn Treat现代诊断与治疗2023 Jun 34渊12冤表1NRMPP组与RMPP组在临床特征上的比较临床特征NRMPP组(n=87)RMPP组(n=39)t/字2P年龄渊岁冤性别男女最高体温渊益冤住院天数肺炎类型支气管肺炎大叶性/节段性肺炎胸腔积液8.8依2.8503739.0依0.89.3依2.166212渊2.3冤8.7依2.8231639.1依0.813.1依2.210299渊23.1冤0.0960.0250.995-9.06728.37514.5910.9240.8740.6950.0000.0000.000为 0.778袁其最佳诊断界值为450IU/L袁其灵敏度73.6%袁特异度 69.2%遥 结果提示血清 IL-17 诊断价值更高遥见表 3遥3讨论肺炎支原体肺炎是儿童常见的 CAP 类型之一袁主要在 5 岁及 5 岁以上儿童发生袁但有报道袁5 岁以下低龄儿童的发病率亦不少见遥 临床表现无明显特异性袁胸片可呈多种表现袁除了引起呼吸道肺内疾患袁还可引起肺外多器官多系统损害遥自 2004 年袁日本学者 Matsuoka M 等咱5暂系统报道了大环内酯类耐药肺炎支原体渊Macrolide-re鄄sistant Mycoplasmae pneumonia袁MRMP冤的基因和表型以来袁中国大陆尧台湾和欧美地区局先后有相关文献报道袁尤其是亚洲国家和地区袁甚至出现了高达90%的耐药率咱6-8暂遥由于肺炎支原体的直接侵犯袁感染后引起体液和细胞免疫异常袁造成肺部和机体的过强炎症反应以及 MRMP 耐药基因片段的存在等因素袁引起重症肺炎支原体肺炎和难治性肺炎支原体肺炎咱9暂遥因此袁早期识别 RMPP 对临床有重要的指导意义遥目前对 MPP 的免疫机制研究袁除了常规的WBC尧CRP尧ESR 等炎症指标袁还有 LDH尧IL-17 等炎症因子遥LDH 主要由活化的巨噬细胞和单核细胞产生袁 正常情况下袁是参与和维护机体正常免疫应答和炎症反应的关键因子遥但在 MP 感染时袁LDH 不仅在导致局部肺组织损伤袁高浓度的 LDH 还可引起肺外脏器组织损伤袁从而干扰机体的免疫调节袁由此参与影响MPP 儿童的发病及免疫反应过程咱10暂遥 IL-17 是一种促炎因子袁主要由 TH17 分泌袁少部分也由 NK 细胞等多种细胞分泌袁通过产生各种炎性细胞因子和中性粒细胞浸润袁从而诱导 Th17 型宿主反应袁在各种感染性疾病的免疫调控中起到关键作用咱11-12暂遥本研究中袁NRMPP 组与 RMPP 组在儿童在年龄尧性别和最高体温等比较均无统计学差异渊P跃0.05冤袁但值得注意的是 RMPP 儿童更多出现节段性或大叶性肺炎袁且多可引起胸腔积液遥对于常规实验室检查指标袁NRMPP 与 RMPP 儿童在血红蛋白尧血小板方面的比较均无显著差异袁在常见的炎症指标 WBC 和PCT 的比较上也无明显差异袁故其对于 RMPP 的预测没有特异性遥 本研究发现 IL-17 的 AUC 最高袁诊断效能最大袁优于 LDH 和 CRP遥IL-17 最佳诊断界值为 9.55pg/ml袁其灵敏度 72.4%袁特异度 71.8%遥 由此可见 IL-17 可作为 RMPP 预测的理想指标遥 但本研究为回顾性研究袁样本量尚不足够充分袁各组病例检查访视节点没有统一标准袁存在一定的局限性袁下一步可进行相关大样本前瞻性的研究遥表3IL-17和CRP尧LDH的ROC曲线图分析指标Cutof鄄fvalueAUCSE95%CISensi鄄tivitySpeci鄄ficityPIL-17CRPLDH9.5515.754500.8140.7710.7780.0420.0460.0430.7320.8970.6820.8600.6940.8620.7240.6320.7360.7180.6920.6920.0000.0000.000注院Cutoff value袁界值曰AUC袁area under curve袁曲线下面积曰SE袁standard error袁标准误曰CI袁confidence interval袁可信区间曰Sensitivity袁敏感度曰Specificity袁特异度遥表2NRMPP组与RMPP组在急性期实验室检查上的比较实验室检查NRMPP组(n=87)RMPP组(n=39)zPWBC渊伊109/L冤Neutrophils%Lymphocyte%Hemoglobin渊g/L冤Platelet渊伊109/L冤CRP渊mg/L冤PCT渊ng/ml冤LDH渊IU/L冤IL-17渊pg/ml冤8.5渊7.19.7冤61.3渊46.264.9冤26.4渊20.340.3冤123渊118132冤254渊170294冤12.0渊7.417.0冤0.16渊0.080.38冤387渊328455冤8.4渊6.210.6冤8.1渊6.89.1冤56.8渊46.564.9冤26.5渊20.435.1冤121渊118129冤252渊177322冤22.8渊15.033.5冤0.15渊0.100.30冤529渊438681冤12.8渊8.720.4冤-0.818-0.195-0.499-1.107-0.195-4.851-0.074-4.979-5.6260.4130.8450.6180.2680.8450.0000.9410.0000.000图1ROC曲线图1741窑窑Mod Diagn Treat现代诊断与治疗2023 Jun 34渊12冤*院江西省卫生健康委员会课题赣卫科教字渊2021冤17号202211464暂多频振动排痰对重症肺炎合并呼吸衰竭患者护理干预研究*涂文萍渊江西省中西医结合医院 江西 南昌 330006冤Study on Nursing Intervention of Multi-frequency Vibration Expec鄄toration in Patients with Severe Pneumonia Complicated with Respi鄄ratory FailureTU Wenping(Jiangxi Hospital of Integrated Traditional Chinese and Western Medicine,Nanchang 330006 Jiangxi,China)Abstract:ObjectivesTo investigate the effect of multi-frequency vibration expectoration on patients with severepneumonia complicated with respiratory failure.MethodsA total of 60 patients with severe pneumonia complicatedwith respiratory failure admitted to the Department of Critical Care Medicine in the Emergency Department of ourhospital from December 2021 to June 2022 were selected as the research objects.The patients were divided intoobservation group and control group randomly,with 30 cases in each group.The observation group was treated withmulti-frequency vibration mechanical expectoration,and the control group was treated with artificial physical expec鄄toration.The hospitalization time and mechanical ventilation time of emergency ICU were compared between the twogroups.The blood gas analysis indexes were compared before treatment and on the 1st and 7th day after treatment.The heart rate,mean arterial pressure and expectoration effect were compared before treatment and 5 minutes after综上所述袁儿童 RMPP 多表现为节段性或大叶性肺炎袁更易合并胸腔积液袁且血清 IL-17 和 LDH 较NRMPP 有差异曰血清 IL-17 可作为早期预测 RMPP的指标之一遥参考文献咱1暂Gao LW,Yin J,Hu YH,et al.The epidemiology of paediatric My鄄coplasma pneumoniae pneumonia in North China:2006 to 2016咱J暂.Epidemiol Infect,2019,147:e192.咱2暂Chang Q,Chen HL,Wu NS,et al.Prediction Model for Severe My鄄coplasma pneumoniae Pneumonia in Pediatric Patients by Admis鄄sion Laboratory Indicators咱J暂.J Trop Pediatr,2022,68(4):059.咱3暂Tong L,Huang S,Zheng C,et al.Refractory Mycoplasma pneumoniaePneumonia in Children:Early Recognition and Management咱J暂.JClin Med,2022,11(10):2824.咱4暂中华医学会儿科学分会呼吸学组,叶中华实用儿科临床杂志曳编辑委员会.儿童肺炎支原体肺炎诊治专家共识(2015年版)咱J暂.中华实用儿科临床杂志,2015,30(17):1304轧1308.咱5暂Matsuoka M,Narita M,Okazaki N,et al.Characterization and molec鄄ular analysis of macrolide-resistant Mycoplasma pneumoniae clin鄄ical isolates obtained in Japan 咱J暂.Antimicrob Agents Chemother,2004,48(12):4624轧4630.咱6暂Leng M,Yang J,Zhou J.The molecular characteristics,diagnosis,and treatment of macrolide-resistant Mycoplasma pneumoniae inchildren咱J暂.Front Pediatr,2023,11:1115009.咱7暂Lee JK,Choi YY,Sohn YJ,et al.Persistent high macrolide resis鄄tance rate and increase of macrolide-resistant ST14 strains a鄄mong Mycoplasma pneumoniae in South Korea,2019-2020 咱J暂.JMicrobiol Immunol Infect,2022,55(5):910轧916.咱8暂Kim K,Jung S Kim M,et al.Global Trends in the Proportion ofMacrolide-Resistant Mycoplasma pneumoniae Infections:A Sys鄄tematic Review and Meta-analysis咱J暂.JAMA Netw Open,2022,5(7):e2220949.咱9暂Zhu H,Cai Y,Slimmen LJM,et al.Galacto-Oligosaccharides as anAnti-Infective and Anti-Microbial Agent for Macrolide-Resistantand-Sensitive Mycoplasma pneumoniae咱J暂.Pathogens,2023,12(5):659.咱10暂Lee E,Choi I.Clinical Usefulness of Serum Lactate Dehydroge鄄nase Levels in Mycoplasma pneumoniae Pneumonia in Children咱J暂.Indian J Pediatr,2022,89(10):1003轧1009.咱11暂Zhang Z,Dou H,Tu P,et al.Serum cytokine profiling reveals dif鄄ferentimmuneresponsepatternsduringgeneralandsevereMycoplasma pneumoniae pneumonia咱J暂.Front Immunol,2022,13:1088725.咱12暂Zhao J,Ji X,Wang Y,et al.Clinical Role of Serum Interleukin-17A in the Prediction of Refractory Mycoplasma pneumoniaePneumonia in Children咱J暂.Infect Drug Resist,2020,13:835轧843.收稿日期院2023轧03轧131742窑窑