血栓性肺栓塞八例临床特征分析

目的分析儿童血栓性肺栓塞(PTE)临床特征以提高对该病的认识和诊治能力。方法回顾性分析浙江大学医学院附属儿童医院2014年3月至2019年3月收治的8例PTE患儿(男4例、女4例)的临床表现、实验室检查、影像学特点和诊治情况。结果8例PTE患儿年龄9小时龄~14岁10月龄。发热4例、咳嗽加剧4例、气促3例、胸痛2例、腹痛和背痛1例、咯血2例、发绀1例、下肢水肿2例。肺部局部呼吸音降低2例、痰鸣音3例、胸膜摩擦音1例。超声发现胸腔积液5例。6例血浆D-二聚体水平升高(0.66~9.96 mg/L),5例超敏C反应蛋白升高(10.78~78.00 mg/L)。胸部增强CT提示肺动脉或静脉充盈缺损,其中肺动脉栓塞7例、肺静脉栓塞1例。原发病包括肺炎支原体肺炎4例、肾炎2例和先天性心脏病术后2例。7例患儿接受抗凝治疗后痊愈,1例因家长拒绝进一步治疗自动出院。结论对于有肺炎支原体肺炎、免疫紊乱、长期激素治疗、心血管有创操作等高危因素的患儿,出现发热、咳嗽加重、呼吸急促、胸痛和腹背痛伴胸腔积液等,要注意PTE可能,尽早行胸部增强CT检查以确诊。抗凝可以作为儿童PTE首选治疗方法。     

Zatorowość płucna w praktyce pediatrycznej – opis przypadku

Venous thromboembolic disease is a rare condition in the pediatric population. In the current paper the case of a 17-year-old patient with pulmonary embolism was presented. The patient was admitted to the hospital with signs and symptoms of respiratory infection. The pneumonia was diagnosed and standard doses of antibiotics were introduced, however, no improvement was observed. Because of lingering increase of D-dimer plasma concentration and constant chest pain, laboratory examinations were extended and finally the diagnosis of pulmonary embolism was established. A clinical data, diagnostics and treatment of the patient with pulmonary embolism were presented in this case report. Attention is drawn to the importance of risk factors of thromboembolic disease in pediatric patients.     

Pulmonary embolism in children

Unlike in adults, pulmonary embolism (PE) is an infrequent event in children. It has a marked bimodal distribution during the paediatric years, occurring predominantly in neonates and adolescents. The most important predisposing factors to PE in children are the presence of a central venous line (CVL), infection, and congenital heart disease. Clinical signs of PE are non-specific in children or can be masked by underlying conditions. Diagnostic testing is necessary in children, especially with the lack of clinical prediction rules. Recommendations for tests are derived from adult studies with ventilation/perfusion (V/Q) scintigraphy being well established. There exists an increasing role for computerised tomography pulmonary angiography (CTPA) and magnetic resonance pulmonary angiography (MRPA). Thrombotic events in children are initially treated with unfractionated heparin (UFH) or low molecular weight heparin (LMWH). For the extended anticoagulant therapy LMWH or vitamin K antagonists can be used with duration of treatment recommendations extrapolated from adult data. Mortality rates for PE in children are reported to be around 10%, with death usually related to the underlying disease processes. Exact data about recurrence risk in children is unknown. Because of the difference in aetiology, presentation, diagnostic methods and treatment between adults and children further research is necessary to assess the validity of recommendations for children.     

Anticoagulation therapy: indications, monitoring, and complications

Anticoagulation for thromboembolic disease and bleeding, the main complication of anticoagulation therapy, are uncommon but are potentially life- or limb-threatening conditions that may present in the pediatric emergency department. Thromboembolic disease in children usually occurs as a complication of vascular access, primarily in children with congenital heart disease or cancer. However, complications of anticoagulation therapy used in the treatment of venous thromboembolism, pulmonary embolism, and blocked central venous catheter; arterial thromboembolism, including arterial ischemic stroke, Kawasaki disease, and after cardiac surgery, may warrant a visit to n the pediatric emergency department. Anticoagulation therapy may take the form of unfractionated heparin, low-molecular weight heparin, vitamin K antagonists, acetylsalicylic acid, or thrombolytic therapy. Monitoring anticoagulation therapy in children is very important and follows adult guidelines. Anticoagulant dosing may be adjusted based on activated partial thromboplastin time, anti-factor Xa level, and international normalized ratio.     

Urine antigen detection of blastomycosis in pediatric patients

Blastomycosis is an uncommonly recognized disease in pediatric patients. We describe 4 cases of pediatric blastomycosis that presented to our children's hospital, 2 with isolated pulmonary blastomycosis and 2 with disseminated blastomycosis. Because of variable clinical presentations and morbidity if treatment is delayed, physicians must maintain a high index of suspicion and obtain appropriate diagnostic tests promptly. For the first time, we report the effect of therapy on Blastomyces antigen clearance. In our experience, the urine antigen detection for B. dermatitidis is useful for diagnosis and follow up during therapy.     

Focal nodular hyperplasia of the liver after intensive treatment for pediatric cancer: is hematopoietic stem cell transplantation a risk factor?

Focal nodular hyperplasia (FNH) is a benign hepatic lesion very rarely described in the pediatric population. It has been reported more frequently in patients treated for pediatric cancers with chemotherapy or hematopoietic stem cell transplantation. The use of high dosage of alkylating agents, the occurrence of venous occlusive disease, graft-versus-host disease, and other variables linked to the hematopoietic stem cell transplantation procedure can represent risk factors for the development of FNH in the pediatric age. The discovery of hepatic nodules in the follow-up of patients treated for malignancies suggests recurrence of disease and raises a diagnostic dilemma. Here we describe possible risk factors, clinical and radiological findings of eight pediatric patients who developed focal nodular hyperplasia after hematopoietic stem cell transplantation. The aim of this report is to provide useful diagnostic tools to facilitate accurate diagnosis of FNH and suggest a correct management of this benign lesion during postcancer follow-up.     

Oral benadryl and central venous catheter abuse-a potentially "lethal combination"

This article describes the potential for lethal abuse of central venous catheters in oncology patients and its effects especially on the cardiovascular system. Central venous catheters are frequently used to provide immediate vascular access allowing patients to obtain lifesaving therapy or have painless blood-drawing procedures. However, they may also serve as a vehicle for abuse and misuse of medications increasing the potential for morbidity and mortality. We present a unique instance where a pediatric patient attempted suicide by self-injecting crushed diphenhydramine (Benadryl) capsules into her central venous catheter. The patient developed acute but transient ST segment elevation and echocardiographic evidence of severe pulmonary hypertension. She was treated symptomatically with oxygen and diuretics over a period of weeks, while her pulmonary hypertension completely resolved. The injection of oral medications into the central circulation is typically associated with transient pulmonary hypertension and clinical features of pulmonary embolism, especially in preparations containing talc. Although the pulmonary hypertension can be transient, it could be fatal. Physicians must be alert to the potential for abuse and misuse of central venous catheters especially in the chronically ill pediatric patients.     

Calcified pulmonary thromboembolism in a child with sickle cell disease: value of multidetector CT in patients with acute chest syndrome

The incidence of pulmonary embolism in children is not clearly known, but is believed to be low. Risk factors for pulmonary thromboembolism include central venous catheter, malignancy, surgery, infection, trauma, and congenital hypercoagulable disorders. Children with sickle cell disease are prothrombotic and are at an increased risk of thromboembolism. The incidence of this event is unknown because these children are often not thoroughly imaged. We report here a case of a calcified pulmonary thromboembolism in a child with sickle cell disease and emphasize the use of multidetector CT in detection of pulmonary thromboembolism in children with sickle cell disease.     

儿童肺血管栓塞性疾病

近年来,儿童肺血管栓塞性疾病在临床的发生率有所增长。儿童肺栓塞跟成人不同,其临床表现无明显特异性,血流动力学不稳定少见,容易误诊漏诊,病死率较高。治疗上大部分经验来自于成人,儿科医生对本病的药物使用经验不足。该文对儿童肺栓塞的流行病学、风险因素、临床表现、诊断、治疗、预防及预后等方面的诊治进展进行综述,以提高临床医生对本病的认识,做到早诊断、早治疗,降低病死率。     

Venous thromboembolism in infancy and childhood.

A retrospective study of Scottish hospital inpatients aged 15 years or less has revealed, over a 4-year period, 36 cases of venous thrombosis or phlebitis. Of these 10 were considered to have deep venous thrombosis; 2 cases were associated with obvious pulmonary embolism and 2 cases developed chronic venous insufficiency. change in the coding allocations are proposed. There are "high risk" situations in childhood disease in which a diagnosis of venous thromboembolic disease should be considered and investigated.     

VENOUS THROMBOEMBOLISM IN THAI CHILDREN

This is a retrospective study of 24 pediatric venous thromboembolism (VTE) patients with or without pulmonary embolism, conducted in Bangkok, Thailand, between 1981 and 2005. The incidence rate of VTE in Thai children was 3.9/10,000 hospital admissions per year. The median age was 11.7 years. Seventy-five percent of the patients had at least one associated medical condition accounting for the VTE; the two most common conditions, however, were infection and malignancy. Pulmonary embolism occurred in 29% of patients. Observed outcomes of VTE in this series included death (13%), postphlebitic syndrome (13%), and recurrence (26%). Genetic risk factors were explored in 19 patients, and no factor V Leiden or prothrombin 20210 mutations were detected. Protein C deficiency was found in 4 patients.     

Venous thromboembolism in Thai children

This is a retrospective study of 24 pediatric venous thromboembolism (VTE) patients with or without pulmonary embolism, conducted in Bangkok, Thailand, between 1981 and 2005. The incidence rate of VTE in Thai children was 3.9/10,000 hospital admissions per year. The median age was 11.7 years. Seventy-five percent of the patients had at least one associated medical condition accounting for the VTE; the two most common conditions, however, were infection and malignancy. Pulmonary embolism occurred in 29% of patients. Observed outcomes of VTE in this series included death (13%), postphlebitic syndrome (13%), and recurrence (26%). Genetic risk factors were explored in 19 patients, and no factor V Leiden or prothrombin 20210 mutations were detected. Protein C deficiency was found in 4 patients.     

Venous thromboembolic disease in the pediatric intensive care unit.

Long recognized to be a major source of morbidity in the adult population, venous thromboembolism is being increasingly recognized in the pediatric age group. Pediatric intensive care unit patients are exposed to multiple risk factors for venous thromboembolism. Prothrombotic tendencies may be inherited or acquired, secondary to either the underlying disease or selected therapeutic interventions. In children in whom venous thromboembolism is diagnosed, the most commonly identified risk factor is the presence of a central venous catheter. Many cases are not diagnosed until autopsy. Because current treatment recommendations are extrapolated from adult studies, further investigation is needed to define the optimal treatment and prophylaxis regimens in critically ill children.     

儿童肺炎支原体相关凝血功能障碍与血栓形成

肺炎支原体感染引起凝血功能障碍与血栓形成,主要累及深静脉、肺和脑等器官。中心静脉置管是发生深静脉血栓形成最重要的危险因素。肺炎支原体肺炎肺实变范围超过肺组织2/3是发生肺动脉栓塞的高风险。血液D-二聚体(>5 mg/L)升高是预测血栓风险的独立危险因子,敏感性较高。彩色多普勒超声和CT血管成像等检查是确定血栓形成的主要方法。肺炎支原体感染相关深静脉血栓形成或肺动脉栓塞宜采用个体化的抗凝与溶栓治疗。     

Clinical and radiographic spectrum of septic pulmonary embolism.

AIMS: To review the clinical presentation, radiographic findings, and outcome of therapy in children with septic pulmonary embolism. METHODS: Retrospective analysis of patients in a tertiary paediatric facility in northern Taiwan. RESULTS: Ten children were identified with septic pulmonary emboli in a four year retrospective chart review between 1998 and 2001. Seven were immunocompetent, two were premature infants, one had beta thalassemia major. Seven had community acquired staphylococcal infections and bacteraemia, of which six were methicillin resistant Staphylococus aureus (MRSA) isolates. Five had soft tissue infections, two bone infections, one suppurative otitis media, one catheter related infection, and one unknown foci of infection. Multiple and bilateral nodular pulmonary parenchymal lesions were common on plain chest radiographs, but chest computed tomography scans showed the additional findings of a "vessel sign" and central cavitations, confirming the existence of septic pulmonary embolism. CONCLUSIONS: Community acquired MRSA infections occurred in seven patients with septic pulmonary embolism but without predisposing high risk factors. Critically ill children with skin, soft tissue, or bone infections, when associated with septic pulmonary embolism in an area with a high rate of MRSA, should be empirically treated with glycopeptides (such as vancomycin or teicoplanin) before susceptibility results are known, in order to minimise morbidity and avoid mortality.     

Foreign body aspiration in childhood]

Damage to the airways and lung parenchyma from aspiration is a common clinical problem with diagnostic and therapeutic challenges. The insult may be acute or chronic. The amount of concentration, chemical composition, and size of particles vary, and the lesion produced may be reversible or irreversible. Death may be immediate or late. Recovery may be complete, or crippling pulmonary disease may follow. In this review is reported on the aspiration of foreign bodies or liquids into the respiratory tract. Specialty: in infancy, esophageal foreign bodies may cause mainly respiratory symptoms. Adequate diagnosis and therapy are discussed.     

A six-year old with fatal pulmonary embolism

Pulmonary thromboembolism is rarely recognized in young children, even in hospital settings. All current management decisions for children with deep vein thrombosis (DVT) are directly extrapolated from treatment recommendations for adults with no further validation. We report the case of a 6-y-old child presenting with deep vein thrombosis of the leg veins and fatal pulmonary embolism. The fatal outcome in our case highlights the need for more epidemiological studies in children, not only to predict the recurrence of pulmonary emboli but also to prepare standard treatment guidelines for the management of DVT and pulmonary emboli in children. We speculate that there may be a role for temporary inferior vena cava filters in young children with extensive DVT of the legs. CONCLUSIONS: This case highlights the need for more epidemiological studies to predict the recurrence of pulmonary emboli and effective guidelines for the management of paediatric DVT and pulmonary emboli in children.     

Acute Pulmonary Embolism in a Neonate: Precipitation During Cardiac Catheterization and Successful Treatment

This report illustrates the rare occurrence of a pulmonary embolus in a neonate during cardiac catheterization. The patient was a term newborn who underwent repair of obstructed infradiaphragmatic total anomalous pulmonary venous connection. Postoperative risk factors for pulmonary embolism included severe pulmonary hypertension unresponsive to nitric oxide therapy, an indwelling venous catheter, and young age. Successful management was achieved by initial mechanical fragmentation with streptokinase infusion and monitoring by serial lung perfusion scans.     

Clinical and radiographic spectrum of septic pulmonary embolism

Aims: To review the clinical presentation, radiographic findings, and outcome of therapy in children with septic pulmonary embolism. Methods: Retrospective analysis of patients in a tertiary paediatric facility in northern Taiwan. Results: Ten children were identified with septic pulmonary emboli in a four year retrospective chart review between 1998 and 2001. Seven were immunocompetent, two were premature infants, one had ß thalassemia major. Seven had community acquired staphylococcal infections and bacteraemia, of which six were methicillin resistant Staphylococus aureus (MRSA) isolates. Five had soft tissue infections, two bone infections, one suppurative otitis media, one catheter related infection, and one unknown foci of infection. Multiple and bilateral nodular pulmonary parenchymal lesions were common on plain chest radiographs, but chest computed tomography scans showed the additional findings of a "vessel sign" and central cavitations, confirming the existence of septic pulmonary embolism. Conclusions: Community acquired MRSA infections occurred in seven patients with septic pulmonary embolism but without predisposing high risk factors. Critically ill children with skin, soft tissue, or bone infections, when associated with septic pulmonary embolism in an area with a high rate of MRSA, should be empirically treated with glycopeptides (such as vancomycin or teicoplanin) before susceptibility results are known, in order to minimise morbidity and avoid mortality.