间断发热 轻咳

1病例资料患儿男,5个月。因"间断发热伴轻咳1月余"于2012-10-18就诊于北京儿童医院。患儿无明显诱因发热,体温最高38.7℃,多低于38.0℃,可自行降至正常,热峰约2次/d,伴轻咳,痰不多,遂于当地妇幼医院住院治疗,脑脊液常规及生化未见明显异常,X线胸片提示肺炎,心脏彩超未见明显异常,血常规示白细胞12.8×109/L,淋巴细胞0.363,中性粒细胞0.480,血小板655×109/L,血红蛋白     

感染性心内膜炎28例

目的 总结小儿感染性心内膜炎(IE)临床表现特点及治疗经验,以利于早期诊断和治疗。方法对1980~2002年住院28例IE患儿的临床表现、诊断、治疗、及预后进行回顾性分析。结果 临床表现以发热、心脏杂音多变、心力衰竭、贫血、白细胞增高和血沉加快为主.血培养阳性9例(32.1％)。发现心内赘生物22例(78.6％)。6例行外科手术治疗,手术后均治愈。治愈20例(71.4％),自动出院2例,死亡6例。结论 先天性心脏病(CHD)患儿出现不明原因长时间发热,无基础心脏病感染发热患儿发现心脏杂音,均应及时做连续规范血培养及超声心动图检查,以利于早期诊断和治疗。IE患儿经抗生素治疗后心内赘生物不消失或出现顽固性、进行性心衰时应进行外科手术治疗,及时采用手术治疗对改善这类患儿预后有重要意义。     

真菌性食管炎一例

患儿,男,5岁,因“反复发热伴皮疹1个月”入当地医院诊治,入院后血常规提示白细胞（5.8 ～ 16.9）×109/L,中性粒细胞百分比（62.5～81.3）％,CRP 28 mg/L.类风湿因子、结核菌素试验、抗核抗体、抗线粒体抗体、抗HIV、血培养均阴性.X线胸片、腹部B超、心脏彩超未见异常.骨髓涂片提示增生性骨髓象.诊断为反复上呼吸道感染、病毒疹,先后给予头孢曲松钠、阿奇霉素、利巴韦林输液治疗15d,患儿仍持续发热,伴皮疹加重及关节痛,诊断幼年类风湿性关节炎,给予甲强龙20 mg静脉滴注,1次/d,5d后患儿热峰下降,出院后继续口服泼尼松治疗,体温正常.     

单中心十年收治感染性心内膜炎患儿临床分析

目的 探讨单中心10年来收治的感染性心内膜炎(infective endocarditis,IE)患儿的临床特点、病原菌分布等情况,为临床诊治提供参考.方法 回顾性分析中国医科大学附属盛京医院2006年10月至2016年10月儿科病房住院治疗的30例确诊 IE 患儿的临床及病原学资料.结果30例IE 患儿中,男18例,女12例,年龄2个月~13岁.IE就诊原因分别为发热21例(70.0%),呼吸系统症状4例(13.3%),神经系统症状4例(13.3%),水肿2例(6.7%),新发心脏杂音1例,心前区不适1例,血三系减少1例.基础疾病所占比例最高的是先天性心脏病17例(56.7%),其中6例为先天性心脏病术后患儿.30例患儿心脏彩超均发现赘生物,血细菌培养阳性15例(50.0%),病原菌分布:金黄色葡萄球菌6例(40.0%),肺炎链球菌4例(26.7%),粪肠球菌2例(13.3%),血链球菌1例,咽颊炎链球菌1例,表皮葡萄球菌1例.入院时C-反应蛋白升高25例(83.3%),其中8例C-反应蛋白>100 mg/L.结论 IE早期临床症状多不典型,发热是IE的常见就诊原因,先天性心脏结构异常易并发IE,革兰阳性球菌是主要致病原,单纯抗感染治疗效果不佳者可联合手术治疗.     

甲型H1N1流感重症患儿12例临床资料分析

目的探讨甲型H1N1流感患儿的临床特点及治疗。方法对2009-11-04—2009-12-24桂林市人民医院收治的12例甲型H1N1流感重症患儿的临床资料进行回顾性分析。结果12例患儿均有发热,其中10例以呼吸道症状起病,如咽痛、咳嗽、咳痰等流感样症状;1例以消化系统症状(腹泻)起病;1例以神经系统症状起病;2例伴明显喘憋、呼吸困难;3例双肺闻及痰鸣音、湿啰音,2例闻及喘鸣音。12例患儿白细胞计数增高4例,降低3例;中性粒细胞比例增高4例,降低4例;淋巴细胞比例增高4例,降低2例;血小板计数降低1例,增高1例。6例丙氨酸转移酶(ALT)增高,7例天冬氨酸转移酶(AST)增高,7例乳酸脱氢酶(LDH)增高,7例肌酸激酶(CK)增高,3例肌酸激酶同工酶(CK-MB)增高。随着患儿病情好转,白细胞、肝功、心肌酶恢复正常。结论甲型H1N1流感重症患儿多以呼吸道症状发病,主要靶器官是肺,常合并细菌、支原体感染,出现各种并发症累及多脏器功能。以神经系统症状起病患儿进展迅速、病情凶险。     

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目的探讨甲型H1N1流感患儿的临床特点及治疗。方法对2009-11-04—2009-12-24桂林市人民医院收治的12例甲型H1N1流感重症患儿的临床资料进行回顾性分析。结果12例患儿均有发热,其中10例以呼吸道症状起病,如咽痛、咳嗽、咳痰等流感样症状;1例以消化系统症状(腹泻)起病;1例以神经系统症状起病;2例伴明显喘憋、呼吸困难;3例双肺闻及痰鸣音、湿啰音,2例闻及喘鸣音。12例患儿白细胞计数增高4例,降低3例;中性粒细胞比例增高4例,降低4例;淋巴细胞比例增高4例,降低2例;血小板计数降低1例,增高1例。6例丙氨酸转移酶(ALT)增高,7例天冬氨酸转移酶(AST)增高,7例乳酸脱氢酶(LDH)增高,7例肌酸激酶(CK)增高,3例肌酸激酶同工酶(CK-MB)增高。随着患儿病情好转,白细胞、肝功、心肌酶恢复正常。结论甲型H1N1流感重症患儿多以呼吸道症状发病,主要靶器官是肺,常合并细菌、支原体感染,出现各种并发症累及多脏器功能。以神经系统症状起病患儿进展迅速、病情凶险。     

儿童血液病并发绿脓杆菌败血症的临床特点分析

目的研究儿童血液病并发绿脓杆菌败血症的临床特点及治疗效果。方法回顾性总结了1995～2005年入院的24例儿童白血病或再生障碍性贫血患儿并发绿脓杆菌败血症的临床资料,并结合血培养、药敏试验结果综合分析。结果①绿脓杆菌败血症主要发生于中性粒细胞低下的住院病人;②起病急、发展快、病情重,100%的患儿有发热,87.5%有寒战,25.0%出现感染性休克,8.3%出现DIC,20.8%出现坏疽性深脓疱;③药敏监测显示对碳青霉烯类、头孢他定等有较高的敏感率;④24例患儿中治愈22例,死亡2例,患儿在24h内应用碳青霉烯类抗感染治疗,可明显缩短发热时间和病程;中性粒细胞绝对值(ANC)<0.5×109/L、持续时间≥7d的患儿,发热持续时间及感染灶恢复时间较ANC<0.5×109/L、持续时间<7d的病人明显延长。结论绿脓杆菌败血症在粒细胞低下的血液病患儿进展极其迅速,及时有效的抗生素应用是改善预后的关键。     

急性白血病患儿并发耐碳青霉烯类抗生素败血症的临床特点

目的：研究儿童急性白血病发生耐碳青霉烯类抗生素败血症的临床表现特点、病原菌分布、合并其他感染部位、治疗及预后,为临床合理使用抗生素提供参考依据。方法回顾性分析2011年12月至2015年9月在北京儿童医院血液肿瘤中心住院的45例急性白血病合并革兰阴性菌败血症患儿,药敏结果提示碳青霉烯类抗生素耐药,分析其临床资料及药敏试验结果。结果45例患儿均有发热,其中有8例患儿持续发热,37例患儿发热天数为1~27 d,平均(6.1±5.2)d。45例患儿中26例感染发生于中性粒细胞缺乏阶段,中性粒细胞绝对值<0.5×109/L,中性粒细胞缺乏时间2~79 d,平均(15.2±16.2) d。中性粒细缺乏组发热持续时间平均(7.5±5.8)d,不伴中性粒细缺乏组,发热持续时间平均(3.7±2.5)d,两组比较差异有统计学意义( P＝0.011)。45例患儿中有23例同时伴有其他部位感染,感染灶以肺部、消化道、口腔及肛周为主。全部患儿送检血培养标本总量711份,其中耐碳青霉烯类抗生素的耐药菌共162株,耐药菌标本中以铜绿假单胞菌、肺炎克雷伯杆菌、阴沟肠杆菌及大肠埃希菌为主要致病菌。45例中36例抗感染治疗有效,9例抗感染治疗无效(死亡及放弃)。结论耐碳青霉烯类抗生素败血症的革兰阴性菌以铜绿假单胞菌、肺炎克雷伯杆菌、阴沟肠杆菌及大肠埃希菌为主要致病菌。中性粒细胞缺乏是影响抗感染治疗转归的重要因素。     

隐球菌病9例临床特征及治疗分析

目的了解儿童隐球菌病的临床特征,探讨其诊治方法。 方法回顾分析2004—2006北京儿童医院收治的9例隐球菌病患儿的临床资料。 结果急性起病2例,亚急性或慢性起病7例。发热8例,头痛、呕吐5例,咳嗽4例,皮肤黄疸3例。脑膜刺激征阳性5例,肝大、脾大各4例,淋巴 结肿大5例。视乳头水肿3例。白细胞、C反应蛋白均增高,脑脊液异常5例。 肺CT异常8例。血清隐球菌抗原均阳性。1例放弃治疗;8例出院时 临床症状消失,病原学检查阴性。 结论儿童隐球菌病临床表现多样,无特异性体征,误诊率高。对于中枢神经系统感染或多脏器损害且经抗结核、抗感染治疗无效者,应考虑该病可 能。确诊依赖于脑脊液墨汁染色、血清或脑脊液乳胶凝集试验,组织病理及病原培养。     

恶性组织细胞病一例

患儿女 ,1岁 7个月。主因面色苍白半年渐加重伴发热2 0ｄ入院。患儿半年前患“上感”时化验血红蛋白低 (具体值不详 ) ,面色稍苍白 ,给予抗贫血药口服。 2 0ｄ前患儿出现发热 ,体温在 3 9～ 40℃ ,伴轻咳 ,面色苍白加重。 7ｄ前在某医院查血白细胞 1× 10 9/Ｌ ,血红蛋白 81ｇ/Ｌ ,血小板 14× 10 9/Ｌ。行骨髓检查 ,提示增生性贫血。给予抗感染等治疗不见好转而来我院。患儿有结核病接触史 ,但已接种卡介苗。体检 :体温 3 6 5℃ ,呼吸 2 8次 /ｍｉｎ ,脉搏 140次 /ｍｉｎ ,体重 10ｋｇ。精神差 ,面色苍白 ,皮肤未见出血点、皮疹、黄染 ,浅…     

Meningococcal infections in children: a review of 100 cases

One hundred children with meningococcal infection diagnosed from January 1, 1985, to February 29, 1988, were reviewed. Clinical manifestations ranged from fever alone to fulminant septic shock with purpura fulminans. Twenty-nine percent of the children presented without skin lesions. Of the 55 patients with meningitis, 6 lacked cerebrospinal fluid abnormalities on initial lumbar puncture but cerebrospinal fluid cultures were positive. An overall case fatality rate of 10% was noted with the following poor prognostic indicators identified: hypothermia; seizures or shock on presentation; a total peripheral white blood cell count less than 5000/mm3; a platelet count less than 100,000/mm3; and the development of purpura fulminans. Meningococcal infections remain an important cause of morbidity and mortality in children. Infections caused by Neisseria meningitidis (including meningitis) should be considered even in the absence of skin lesions or cerebrospinal fluid abnormalities.     

Linezolid-induced reversible bicytopenia in a 4-year-old boy with methicillin-resistant Staphylococcus aureus bacteremia

The authors report on a 4-year-old child with the diagnosis of tetralogy of Fallot (TOF) and infective endocarditis. Methicillin-resistant Staphylococcus aureus (MRSA) was isolated from the blood culture of the patient. While receiving imipenem, amikacin, and linezolid therapies, the boy's general condition improved, acute phase reactants decreased, and his blood culture became negative for MRSA. On his follow-up echocardiography, the vegetation had also disappeared. However, he developed progressive bicytopenia following linezolid therapy for 5 weeks. During linezolid therapy, his hemoglobin level decreased from 12.1 to 5.3 g/dL and his platelet count from 242 × 10⁹ to 14 × 10⁹/L. His white blood cell count (WBC) did not decrease during linezolid therapy. Six days following termination of linezolid therapy, his hemoglobin had increased to 8.2 g/dL and platelet count to 192 × 10⁹/L. Thus, it should be kept in mind that linezolid may induce cytopenias in children. If these side effects of linezolid are known, unnecessary laboratory investigations may be prevented and cessation of the drug may be sufficient for reversal of the cytopenias.     

Uses and technique of pediatric lumbar puncture.

OBJECTIVES--To review diagnostic and therapeutic indications, contraindications, complications, and technique of pediatric lumbar puncture with emphasis on diagnosis of bacterial meningitis in bacteremia, cellulitis, and fever with seizures and to discuss cerebrospinal fluid findings in partially treated infection and traumatic blood-contaminated spinal tap. RESEARCH DESIGN--Literature review. CONCLUSIONS--We recommend lumbar puncture for children younger than 1 year with bacteremia, children with Haemophilus influenzae type B cellulitis, and children with fever and seizures not classified as simple. Pretreatment with antibiotics rarely changes cerebrospinal fluid characteristics such that a diagnosis of bacterial meningitis would be obscured. In a traumatic spinal tap, the equation to predict cerebrospinal fluid pleocytosis based on the peripheral blood cell count is invalid. When used together, cerebrospinal fluid glucose level, Gram's staining, and observed-to-expected ratio of white blood cells are highly reliable in diagnosing bacterial meningitis.     

儿童屎肠球菌脑膜炎的临床特征分析

目的 总结屎肠球菌脑膜炎患儿的临床特点,以期提高临床诊治水平。方法 对9例屎肠球菌脑膜炎患儿进行临床资料分析。结果 9例患儿均经血液或脑脊液或PICC端培养出屎肠球菌,其中6例（67%）为新生儿,2例（22%）为6个月以内婴儿,1例（11%）为3岁4个月幼儿。56%的患儿起病前存在致病高危因素：肠道感染、脑积水术后安置引流管,以及颅骨骨折、导管相关性感染和母亲围产期感染。以发热、反应差为主要表现,22%的患儿出现抽搐,均无脑膜刺激征及意识障碍。血常规白细胞总数及CRP正常或升高;脑脊液有核细胞正常或轻度升高,蛋白明显升高,糖降低。药敏均提示对万古霉素敏感,且万古霉素治疗有效,1例出现脑积水并发症。结论 屎肠球菌脑膜炎主要见于新生儿及婴儿,存在致病高危因素的比例高,临床特征不典型,对万古霉素敏感。     

Significance of neutrophils in cerebrospinal fluid samples processed by cytocentrifugation

We reviewed medical records of 155 pediatric patients whose cerebrospinal fluid (CSF) samples contained an increased proportion of neutrophils when processed by cytocentrifugation, despite normal CSF total white blood cell count. It was determined that these CSF findings occurred more commonly in patients with bacteremia, peripheral leukocytosis, and increased numbers of red blood cells in the CSF. Pulmonary infiltrates in infants and otitis media in children were also significantly associated. Cytocentrifugation allows the identification of neutrophils in the CSF, even in the absence of central nervous system infection. Infants and children with more than 10 per cent neutrophils in CSF require evaluations for focal and bacteremic infections.     

儿童重症7型腺病毒肺炎45例临床分析

目的 总结儿童重症7型腺病毒肺炎的临床特点，以期为临床的诊断治疗提供经验。方法 回顾性分析2019年2~6月确诊为重症7型腺病毒肺炎患儿的临床资料。结果 45例患儿中男女比为3：2，中位年龄为14个月，均有反复高热、咳嗽、肺部湿啰音，平均热程为14±4 d，发热至呼吸困难的中位时间为8 d，发热至需要呼吸机机械通气的平均时间为11.6±2.5 d。WBC无明显升高，以中性粒细胞为主；血红蛋白、白蛋白轻度下降；血小板、纤维蛋白原正常；天冬氨酸氨基转移酶、乳酸脱氢酶、降钙素原及C反应蛋白均升高。混合病原体检出率为84%。胸部影像学改变以双肺渗出为主（64%）。支气管镜下表现为支气管内膜炎、气管软化、塑形支气管炎。呼吸系统并发症发生率为100%，肺外并发症主要累及循环系统（47%）、消化系统（36%）和神经系统（31%）。16例患儿的给药方案为静脉注射丙种球蛋白（IVIG）每日400 mg/kg，连用5 d，平均热程为16±5 d；29例患儿的给药方案为IVIG每日1 g/kg，连用2 d，平均热程为13±4 d；两种给药方案治疗患儿的平均热程比较差异有统计学意义（P=0.046）。总病死率为11%。结论 儿童重症7型腺病毒肺炎病情重，并发症发生率高，病死率高，需早诊断，早治疗。     

48例儿童骨髓增生异常综合征的细胞学诊断

观察分析儿童MDS外周血象及涂片和骨髓细胞病态改变 ,用血细胞分析仪进行外周血细胞计数和瑞氏染色法进行血及骨髓细胞形态学分析。结果显示 :血细胞计数大多为血红蛋白、白细胞和血小板减少。血涂片染色 ,部分可见原始和幼稚白细胞和 (或 )幼红细胞。骨髓粒、红、巨红三系均有不同程度的病态造血表现 :粒系原始细胞增多 ,比值及形态异常 ;半数以上患者红系过多 ,并有明显形态异常 ;巨核细胞计数减少 ,小巨核检出率为 0 .1 8。我认为 ,儿童MDS至少有两系以上病态改变 ,与成人MDS虽然诊断标准相同 ,但儿童MDS有其发病及诊断特点。     

基于决策曲线和剂量反应分析评估乳酸脱氢酶对儿童难治性肺炎支原体肺炎的预测价值

目的 探讨乳酸脱氢酶（LDH）对儿童难治性肺炎支原体肺炎（RMPP）的预测价值。方法 通过倾向性匹配法获得73例RMPP患儿为难治组,146例非难治性的普通MPP患儿为普通组,利用logistic回归、限制性立方样条模型和决策曲线分析评估LDH对RMPP的临床预测价值。结果 难治组和普通组高热发生率、WBC计数、血小板计数、中性粒细胞百分比及血清C反应蛋白、降钙素原、血红蛋白、白蛋白、谷氨酸-丙酮酸氨基转移酶、天门冬氨酸氨基转移酶、LDH含量的比较差异有统计学意义（P < 0.05）。两组鼻咽抽吸物MP-DNA载量及胸腔积液、肺实变、肺不张、气促、皮肤损害发生率的比较差异有统计学意义（P < 0.05）。多因素logistic回归分析显示,高热、血红蛋白水平、LDH水平、肺实变是RMPP发生的独立预测因素（OR分别为10.097、0.956、1.006、3.756,均P < 0.05）。限制性立方样条分析结果显示,LDH连续性变化与RMPP发生的关联强度呈非线性剂量反应关系（P < 0.01）。决策曲线分析显示LDH对RMPP的预测有重要临床价值。结论 LDH是儿童RMPP发生的独立预测因素,与RMPP发生的关联强度呈非线性剂量反应关系。     

Hematologic predictors of bone marrow recovery in neutropenic patients hospitalized for fever: implications for discontinuation of antibiotics and early discharge from the hospital.

We evaluated the timing and pattern of changes in the complete blood cell count that preceded marrow recovery during 107 consecutive episodes of fever and neutropenia in 64 children with cancer. Four measures derived from serial daily measurement of the complete blood cell count were evaluated: total leukocyte count, absolute neutrophil count, absolute phagocyte count, and platelet count. During 70 (65%) of these 107 episodes, patients were discharged with an absolute neutrophil count of fewer than 500 cells/mm3; 24 patients were discharged from the hospital despite an absolute neutrophil count of fewer than 100 cells/mm3. During all but one of these 70 episodes, however, signs of early marrow recovery were present before discharge; sustained increases were observed in these patients' leukocyte, absolute neutrophil, absolute phagocyte, and platelet counts 2 or more days before their discharge in 41%, 49%, 50%, and 39% of cases, respectively. Although they were neutropenic at discharge, most patients had signs of multilineage marrow recovery at that time; 59 of 70 had increases in three of four of the measurements that we studied. None of the 69 patients who had evidence of marrow recovery at discharge had recurrence of fever. We conclude that children with cancer who were hospitalized for fever during periods of neutropenia have increases in the peripheral blood cell count that herald imminent bone marrow recovery, often several days before the absolute neutrophil count recovers to 500 cells/mm3. Our success in discharging such patients before resolution of neutropenia suggests that further controlled trials are needed to evaluate the safety and feasibility of cessation of antibiotic therapy and early discharge from the hospital.     

Isolated thrombocytopenia in children with acute lymphoblastic leukemia: a rare event in a Pediatric Oncology Group Study

To determine how many children with acute lymphoblastic leukemia were initially referred to a pediatric hematologist because of isolated significant thrombocytopenia ([platelet count less than 50,000/mm3] and an otherwise normal complete blood cell count and physical findings), a retrospective review of the Pediatric Oncology Group's charts was undertaken. Review of the records of 2239 children enrolled in the past two acute lymphoblastic leukemia protocols showed that none of these children had significant thrombocytopenia with no other hematologic or physical manifestations of acute lymphoblastic leukemia when they were first seen by the hematologist. The results suggest that routine bone marrow aspiration in the child with isolated thrombocytopenia may be unnecessary to rule out acute lymphocytic leukemia.