换血治疗婴儿重症百日咳合并高白细胞血症1例报道

百日咳是由百日咳鲍特菌感染引起的急性呼吸道传染病。其典型的临床表现为无热痉挛性咳嗽,大部分预后良好,少部分并发重症肺炎、百日咳脑病、高白细胞血症、肺动脉高压,预后不良,甚至死亡。有研究者认为出现以上严重并发症,需要入住重症监护室（NICU/PICU）治疗的病例即为重症百日咳病例^[1]。目前,对于具有明显高白细胞血症的重症百日咳患儿,较为推荐的降白细胞措施即为换血治疗,但国内相关报道较少。2018年11月上海儿童医学中心首次报道采用换血治疗1例6月龄的重症百日咳女婴,但该患儿在接受换血术前已存在多器官功能衰竭,最终死亡^[2]。我院NICU收治1例30日龄的百日咳男性患儿,合并明显的高白细胞血症,经换血治疗,白细胞明显下降,效果理想,患儿好转出院。结合国内外已有百日咳合并高白细胞血症及换血治疗的相关文献,将本病例报告如下,以期加深儿科医师对换血疗法的认识,为伴发高白细胞血症的重症百日咳患儿的救治提供思路。     

换血疗法在儿童重症百日咳肺炎中的临床应用

目的:了解换血疗法在儿童重症百日咳肺炎中的应用情况。方法:收集2019年1月至2020年3月入住湖南省儿童医院重症监护病房应用换血疗法的重症百日咳肺炎患儿4例,总结重症百日咳肺炎的临床特点和换血疗法在重症百日咳肺炎中的疗效及预后。结果:4例患儿中,3例好转出院,1例死亡。4例患儿换血前白细胞计数、淋巴细胞计数、中性粒细...     

婴幼儿重症百日咳研究进展

百日咳是一种具有高度传染性的呼吸道疾病, 尽管疫苗的广泛接种使得百日咳发病大幅度降低, 但是近30年来出现了"百日咳再现", 局部地区出现了百日咳暴发。未接种或未完成全程免疫接种的婴儿百日咳感染较重。由于小婴儿症状不典型易出现漏诊、误诊, 不能及时诊治, 易发展为重症百日咳, 甚至死亡。因此, 现就近年来重症百日咳的相关研究作一综述, 为重症百日咳的临床诊治、预防和基础研究提供参考。     

儿童百日咳临床特征及重症百日咳危险因素分析

目的旨在研究儿童百日咳临床特征、发生重症百日咳的危险因素。方法回顾性分析2019年1月至2020年3月入住湖南省儿童医院重症监护病房、呼吸科、急诊综合科确诊百日咳患儿的临床资料及实验室检查结果。按年龄大小分为年龄≤3个月组58例、年龄>3个月组64例, 按痰培养结果分为痰培养阴性组63例、痰培养阳性组59例, 按是否完成百白破疫苗接种分为完成疫苗接种组19例、未完成疫苗接种组103例, 按病情严重程度分为重症百日咳组28例与非重症百日咳组94例, 比较两组的临床特点, 同时对发生重症百日咳的危险因素进行分析。结果年龄≤3个月组住院天数及气促、呼吸暂停、咳嗽后紫绀、心率下降、细菌感染的发生率均高于年龄>3个月组(P<0.05)。痰培养阳性组呼吸衰竭发生率、心力衰竭发生率均高于痰培养阴性组(P<0.05)。重症百日咳组住院天数、住院费用、发热发生率、喘息发生率、峰值白细胞计数、峰值淋巴细胞计数、细菌感染发生率等13项指标均高于非重症百日咳组(P<0.05)。4例进行换血治疗, 其中1例死亡。发热、喘息、咳嗽后紫绀、白细胞计数>20×109/L是重症百日咳...     

儿童急性呼吸窘迫综合征的诊治进展

儿童急性呼吸窘迫综合征（ARDS）是儿科重症监护室重症患者死亡的重要原因。尽管随着肺保护性通气策略的实施,儿童ARDS的预后有所改善,但中重度ARDS救治成功率仍低。鉴于与成人相比,儿童ARDS的流行病学、治疗和预后有差异,2015年国际儿科急性肺损伤共识会议第一次赋予儿童ARDS定义。提高对儿童ARDS的早期识别,规范临床管理,仍是儿科重症医学的重要挑战。该文对儿童ARDS的定义、流行病学特点和管理方案进行综述。     

儿童百日咳临床特征及重症百日咳危险因素分析

目的　分析儿童百日咳临床特征及重症百日咳发生的危险因素,为临床诊治提供参考。方法　以首都儿科研究所中心实验室为检测中心,回顾性分析2019年1月至12月确诊的114例百日咳住院患儿病例资料。根据是否合并其他病原感染,分为单纯百日咳组73例,混合感染组41例;根据病情程度分为普通百日咳组100例,重症百日咳组14例。组间进行单因素比较,同时行二元Logistic回归分析重症百日咳的危险因素。结果　（1）百日咳好发于秋冬季共66例（62.2%）。患儿以≤6月龄为主,共79例（69.3%）。未免疫89例（78.1%）,免疫25例（21.9%）。（2）单因素分析比较得出,混合感染组较单纯百日咳组更易出现血氧下降、三凹征、发热、肺部湿啰音（P＜0.05）;重症组中有早产史、咳嗽后青紫、三凹征、发热、肺部湿啰音、肺炎和混合感染患者占比高于普通组（P＜0.05）;混合感染组、重症组较单纯百日咳组、普通组住院时间更长（P＜0.05）;重症组白细胞峰值较普通组高（P＜0.05）,Logistic回归分析显示白细胞峰值高是重症百日咳的危险因素（OR＝1.096,P＜0.05）。（3）114例确诊患儿均使用大环内酯类抗生素治疗,10例（8.8%）患儿在病程7 d内用药,33例（28.9%）在病程8～14 d用药,余均＞病程14 d用药,其中5例重症患儿＞病程21 d用药。（4）≤4月龄的重症百日咳患儿易并发肺炎、百日咳脑病、心肺衰竭等严重并发症,其中8例患儿行有创通气治疗。经积极治疗,1例患儿死亡,余均好转出院。结论　≤6月龄、未免疫的小婴儿百日咳发病多见,常需住院治疗,小月龄的百日咳患儿并发症发生率更高。合并感染、延迟用药可能会加重百日咳病情,延长住院时间。监测血白细胞峰值有助于病情程度的判断。     

白细胞单采术治疗小儿重症百日咳合并高白细胞血症一例并文献复习

目的探讨白细胞单采术治疗小儿重症百日咳合并高白细胞血症的安全性及效果。方法回顾性分析首都儿科研究所附属儿童医院PICU收治的1例恶性百日咳合并高白细胞血症患儿的救治结果。结果患儿1岁9个月,合并高白细胞血症、百日咳脑病的重症百日咳,给予无创呼吸机辅助通气,阿奇霉素联合头孢哌酮舒巴坦静点抗感染,外周血白细胞进行性升高,最高达103.04×109/L,在白细胞快速上升期,应用2次白细胞单采术,患儿白细胞水平明显下降,未出现不良反应。入院第6天撤离呼吸机,入院第15天患儿白细胞下降至13.9×109/L,咳嗽较前好转,一般情况好,住院15 d出院,未出现其他并发症。结论合并高白细胞血症的重症百日咳幼儿,在白细胞快速上升期,可采用白细胞单采术治疗,可以缩短住院时间,减少并发症,改善预后。     

儿童重症哮喘86例救治体会

目的 总结重症儿童哮喘治疗经验.方法 对86例重症儿童哮喘的治疗进行回顾性分析.结果 本组患儿86例,死亡3例,治愈率96.5%,病死率3.5%.结论 提高重症儿童哮喘的救治成功率关键是正确使用药物,个体化用药,及早诊治,快速平喘,并应重视积极消除病因或诱因,准确判断病情,及时治疗并发症等环节.     

儿童危重肠道病毒71型感染分期与个体化监护治疗探讨

目的 探讨肠道病毒71型( enterovirus,EV71)感染重症病例的临床表现分期、监护及治疗措施.方法 2010年5月至2011年9月我院重症医学科共收治EV71感染重症病例45例.持续监测生命体征,危重患儿监测动脉血压、中心静脉压、混合静脉血氧饱和度、动态无创心功能和尿量等.根据临床表现,将患儿分为3个阶段:(1)神经系统受累阶段;(2)呼吸系统受累阶段;(3)循环系统受累阶段(代偿期及失代偿期).根据不同阶段,采用个体化救治措施及监护.结果 45例患儿中,38例治愈出院,治愈率为84.4％;死亡7例,全部为循环功能衰竭患儿.38例患儿中19例局限于神经系统受累;12例病情止步于呼吸系统受累阶段,7例为循环系统受累阶段.结论 早期识别EV71感染重症病例,积极控制高热、合适的液体治疗、控制高血压、早期呼吸支持,防止患儿发生循环功能衰竭是救治关键.进行分阶段、个体化综合救治可能有效治疗重症EV71感染.     

婴幼儿重症百日咳死亡相关因素分析

目的探讨婴幼儿重症百日咳死亡相关因素。方法回顾分析2015年1月1日至2019年10月31日收治的婴幼儿百日咳25例病死病例(死亡组)及80例同期收治的重症存活病例(存活组)的临床资料。结果死亡组男性5例(20.0%),中位发病日龄77天,20例(80.0%)未接种百日咳疫苗;存活组男性47例(58.8%),中位发病日龄83天,63例(78.8%)未接种疫苗。与存活组相比,死亡组男性少、痉挛性咳嗽发生率低、肺实变(或肺不张)发生率高、外周血白细胞(WBC)增多更显著、肺动脉高压发生率高、使用丙种球蛋白比例低,差异均有统计学意义(P0.05)。多元logistic回归分析发现,男性、使用丙种球蛋白(OR=0.03、0.03)为重症百日咳死亡的保护因素,WBC最高值高、肺动脉高压(OR=1.10、13.31)为死亡的危险因素,有痉挛性咳嗽患儿死亡概率更小(OR=0.02)。预测死亡的WBC最高值的最佳临界值为55.37×10~9/L,AUC=0.83(95%CI:0.73～0.93)P0.001。结论未接种疫苗、高WBC血症、肺动脉高压明显增加婴幼儿重症百日咳的病死率,使用丙种球蛋白、早期换血减轻高WBC血症可能改善其预后,慎用激素。     

Pertussis in practice in 2007]

Universal vaccination of infants against pertussis has transformed the epidemiology of the disease. Pertussis has however become frequent, although not often diagnosed, in adolescents and adults and thus contributes to permanent transmission of Bordetella pertussis in France and contamination of young infants at risk of severe disease. Control of transmission of pertussis in France necessitates reinforcement of vaccination with late boosters in adolescents and adults and, in addition, education of physicians to recognize and treat early cases of pertussis, especially in adolescents and adults with a persistent or chronic cough, and to take appropriate prophylactic measures (antibiotics and recall vaccination) of those in contact with confirmed cases. Effective treatment does little to reduce symptoms but it does reduce transmission. Macrolides are the recommended treatment for pertussis.     

婴儿百日咳的流行病学意义及其临床特点

婴儿百日咳是社区百日咳持续传播的明确证据。婴儿是百日咳健康威胁最严重的群体,也是百日咳社区网状传播的重要节点,预防婴儿百日咳是疫苗免疫等防控措施的核心。目前国内报道百日咳虽然以婴儿百日咳病例为主,但实际发生的婴儿百日咳病例更多,临床上还需提高警惕和加强认识,普及相关实验室检测。在重视识别婴儿百日咳的基础上,及时诊治、随访观察和规范管理百日咳患儿的密切接触者,才能减少和阻断百日咳的社区传播。[中国当代儿科杂志,2022,24 (9):955-959]     

百日咳并发症

百日咳感染者可出现多种并发症，常见并发肺炎、球结膜下出血等，严重并发症，如肺动脉高压、脑病等可能危及生命。低年龄患儿缺乏百日咳特征性的临床表现，因此提高对百日咳并发症的认识，有助于及时诊断和治疗百日咳，对改善预后有着积极意义。但目前还没有百日咳并发症的诊治规范，不同报告使用的诊断名称、依据和报告数据等存在很大差异。该文就文献报道的百日咳并发症，包括呼吸系统并发症（肺炎、肺动脉高压、气胸及纵膈或皮下气肿）、骨折、疝气、循环系统并发症、神经系统并发症（惊厥、脑病及出血和血肿）、泌尿系统并发症、继发感染等进行了全面综述，希望为临床诊治和研究百日咳并发症，以及早日促成百日咳并发症的规范诊治提供参考。     

Pertussis: diagnosis, clinical aspects and therapy

Isolation of the causative agent remains the "gold standard" for the early diagnosis of pertussis. For this purpose, the nasopharynx is swabbed with a calcium alginate swab. Cephalexin-containing charcoal horse blood medium is used for the transport of the swabs to the bacteriology laboratory. As an alternative, the isolation of bordetellae can be performed at the paediatrician's office by direct inoculation of charcoal horse blood agar plates. Long-lasting cough of unknown aetiology is the main field for pertussis serology (ELISA). Even today, severe courses of whooping cough requiring hospitalization are not rare, especially in infants. Erythromycin (given in high doses for 14 days) is the antibiotic of choice for pertussis. As an alternative to the macrolides, cotrimoxazole may be administered or amoxycillin. Salbutamol and the corticosteroids have been shown to be useful for the symptomatic treatment of severe pertussis in infants.     

Pertussis in adults.

A survey was conducted of 89 households in each of which at least one patient with culture-confirmed pertussis had been detected. The source of infection was found to be an adult in 10 (11.2%) of the 89 households, and the rate of secondary attack was 19 (10.3%) of 185. Furthermore, a laboratory study disclosed 17 adults with subclinical pertussis; the subclinical infection rate was 17 (25.0%) of 68. When compared with pertussis in young children, the adult illness was generally less severe and had different clinical features. Adult pertussis showed neither leukocytosis nor lymphocytosis, but it produced anti-pertussis toxin antibody more quickly and higher levels of anti-filamentous hemagglutinin and agglutinin antibodies, and showed stronger growth inhibition of Bordetella pertussis. Although adult pertussis is usually unrecognized because of its different clinical and laboratory features, it is a significant health threat that requires some measures for disease control.     

新生儿百日咳 17 例临床分析

目的探讨新生儿百日咳的临床表现、诊断、治疗及预后。方法回顾性分析经百日咳鲍特菌聚合酶链反应确诊为百日咳的17例新生儿患者的临床资料。结果 17例患儿中,男8例、女9例,早产儿2例,发病日龄15~27 d。13例患儿有咳嗽患者接触史,4例早期有鼻塞、流涕等症状,5例有典型痉挛性咳嗽,1例咳嗽伴有鸡鸣样回声,6例咳嗽剧烈有面色通红,7例咳嗽剧烈时伴口唇发绀,2例住院前曾出现全身青紫,7例咳嗽后有吐奶,3例有发热。15例患儿外周血白细胞计数升高,为(12.57~79.63)×109/L,淋巴细胞比例为45.1%~75.2%。百日咳PCR拷贝数为7.12×10~2~1.04×10~8/m L。17例患儿均予静脉滴注红霉素治疗,均有明显好转,无死亡病例。结论对于有明确咳嗽患者接触史、出现阵发性咳嗽,外周血白细胞升高,并以淋巴细胞为主的新生儿需警惕百日咳可能,应及早行相关检查。     

Malignant pertussis in the young infant]

Pertussis remains in France the first cause of bacterial, infectious death in infant aged 10 days to 2 months. It is especially in this age group that malignant pertussis occurs. CASE REPORT: A 40-day-old infant was admitted in the intensive care unit with symptoms of bronchiolitis along with a 200 bpm permanent tachycardia. He presented a marked leukocytosis with lymphocytosis. On the second day, convulsions and coma occurred, followed rapidly by respiratory failure, with a subsequent deterioration due to the development of severe pulmonary hypertension. Circulatory failure caused the infant's death on the beginning of the 5th day. Pertussis was confirmed by PCR on nasopharyngeal swab. Intra-familial contamination was most likely. COMMENTS: Malignant pertussis is characterized by the very young age of patients, permanent tachycardia sine materia, dyspnea with early respiratory failure, frequent neurological symptoms, severe hyperleukocytosis and hyperlymphocytosis, and deep hyponatremia with oliguria and edema. Mortality remains superior to 75% despite the various treatments and life support measures that have been attempted. Adult pertussis, which represents one third of the cases of prolonged cough in this age group, is the main source of contamination of non-immunized young infants. This mode of transmission stresses the importance of the generalization of pertussis vaccine booster in early adolescence, which is recommended in France since 1998. Its extension towards the adult age is under study.     

裂隙淋巴细胞辅助诊断儿童百日咳的临床价值

目的 探讨外周血涂片裂隙淋巴细胞对辅助早期诊断百日咳的意义。方法 采集107例疑似百日咳患儿的鼻咽拭子和外周血。采用PCR-流式荧光杂交法进行百日咳杆菌核酸检测,根据结果分为百日咳组（n=52）和非百日咳组（n=55）;百日咳组按年龄分为<1岁组（n=42）和≥1岁组（n=10）,按病情严重程度分为轻症组（n=45）和重症组（n=7）。采用全自动血细胞分析仪对各组患儿进行外周血细胞计数测定,血涂片后行瑞氏染色和过氧化物酶染色,显微镜下观察各组患儿裂隙淋巴细胞并计数。结果 裂隙淋巴细胞呈圆形,胞体较小,胞浆量少,胞核上有切迹或裂缝;过氧化物酶染色为阴性,细胞学分类属淋巴细胞。百日咳组患儿白细胞计数、淋巴细胞比例、血小板计数、裂隙淋巴细胞比例均明显高于非百日咳组（P < 0.001）。百日咳组患儿中,<1岁组患儿淋巴细胞比例、血小板计数、裂隙淋巴细胞比例均明显高于≥1岁组患儿（P < 0.05）;重症组患儿上述血细胞计数及细胞比例均高于轻症组,但差异无统计学意义（P > 0.05）。结论 裂隙淋巴细胞联合外周血细胞计数可为百日咳患儿的早期诊断提供新思路。     

Inaccurate diagnosis in infants with pertussis. An eight-year experience

A review was conducted of all patients seen at Upstate Medical Center, Syracuse, NY, from June 1975, to June 1983, whose nasopharyngeal specimens were positive by specific Bordetella pertussis-fluorescent antibody stain. Sixty-one patients were identified; 46 were hospitalized and 15 were outpatients. The age and immunization status of the two groups were compared. Admission diagnosis, indices of illness severity, and clinical course were assessed for the hospitalized patients. Review of the house officers' initial differential diagnoses disclosed that pertussis was considered in the diagnosis in only 45% of the cases. Bronchiolitis was the next most commonly listed diagnosis. Frequent vomiting and severe coughing were the most helpful clinical findings leading to an accurate diagnosis. Abnormal chest roentgenograms and elevated white blood cell counts were present in a minority of our patients, whether the initial diagnosis was correct or not. Younger and less-immunized patients had more severe and prolonged clinical courses. This study demonstrates that the diagnosis of pertussis is often missed or delayed because clinical findings are similar to those of other respiratory infections in infancy. Suspicion of the diagnosis in children with nonspecific respiratory illness is required for early diagnosis, treatment, and prevention of spread to susceptible individuals.     

百日咳患儿临床特点及危险因素分析

目的 探讨百日咳患儿的临床特点及感染的危险因素。方法 回顾性对比分析253例百日咳住院患儿（百日咳组）与同期314例咳嗽住院患儿（对照组）的临床资料及免疫功能相关实验室指标结果。百日咳鲍特菌DNA检测采用实时荧光PCR法。收集两组患儿疫苗免疫、可疑患者接触史及住址分布的信息行百日咳危险因素分析。结果 对两组患儿进行23项典型临床指标比较,结果百日咳组患儿仅10项典型临床指标不同于对照组（P < 0.05）。两组患儿并发症中,仅百日咳组心肌炎发生率低于对照组（P < 0.05）。百日咳组患儿血清球蛋白、IgM水平显著低于对照组（P < 0.05）。百日咳组患儿百白破联合疫苗未免疫、未及时免疫及可疑患者接触史比率显著高于对照组（P < 0.05）;疫苗未免疫、未及时免疫、可疑患者接触史是百日咳感染的危险因素（P < 0.05）。结论 百日咳患儿常不具备典型的临床特征,实时荧光PCR法检测百日咳鲍特菌DNA有助于不典型百日咳患儿的早期诊断。婴幼儿应及时进行百日咳疫苗免疫接种,并与可疑患者做好隔离防护,降低百日咳发生率。