儿童2009甲型H1N1流感相关神经系统并发症报道

报道儿童2009甲流H1N1流感相关神经系统并发症的临床特征。方法　对深圳市儿童医院2009 - 11 - 04 - 2010 - 01 - 19因2009甲型H1N1流感住院,并发神经系统并发症的21例患儿进行前瞻性调研,对其临床特征及转归进行总结。结果　在150例儿童危重症2009甲型H1N1流感住院患儿中,神经系统并发症的发生率为14.0%（21/150）,其中脑病18例（85.7%）,惊厥2例（9.5%）,脑炎1例（4.7%）。男14例,女7例;年龄中位数为5岁。12例（57%）入住ICU监护,6例（28.5%）接受气管插管及机械通气。17例80.9%）痊愈出院,1例仍在住院,3例（14%）死于脑病。结论　2009甲型H1N1流感相关神经系统并发症发生率高,严重脑病患儿可以导致死亡。随着2009甲型H1N1流感的流行,这一结果应该引起广泛关注。     

Myocarditis in a pediatric case of pandemic 2009H1N1 influenza

We report a 6‐year‐old boy with no major disease history or allergic conditions initially presented with pneumonia, progressed to acute respiratory distress syndrome and acute myocarditis caused by pandemic 2009H1N1 influenza diagnosed with RT‐PCR testing, successfully managed with mechanical ventilation and percutaneous cardiopulmonary support system. Marked transient elevation of IgE in acute phase of the disease and the subsequent diagnosis of atopic asthma in our patient suggested a possible role of an underlying allergic condition in the clinicopathological process. Critically ill 2009H1N1‐infected patient with acute respiratory failure should carefully be physiologically monitored together with serial assessment of biomarkers aiming at a favorable cardiac outcome by giving the timely diagnosis and intervention.     

Factors associated with hypoxemia in children infected with pandemic H1N1 2009 influenza virus

Background: Hypoxemia was found to be a major cause of death from pandemic H1N1 2009 influenza (pH1N1) infection. There are limited data on factors associated with hypoxemia in children infected with pH1N1 influenza virus. Methods: Factors associated with hypoxemia were investigated using univariate and multivariate analysis in 76 hospitalized pediatric patients with laboratory‐confirmed H1N1 influenza virus infection at Gyeongsang National University Hospital in Jinju, South Korea, from August 2009 to January 2010 by retrospective chart review. Results: Hypoxemia occurred in 17 children (22%), of whom three were admitted to an intensive care unit and one died. Hypoxemic patients were significantly more likely to have a higher respiratory rate, pulse rate, white blood cell count (WBC), and C‐reactive protein level, as well as a longer hospital stay. Respiratory rate and WBC count at admission were independently associated with hypoxemia as determined on multivariate analysis, and this association was found to be clinically significant. Conclusion: Although a higher WBC count and respiratory rate may not be specific for pHINI but represent the degree of disease severity for any infectious respiratory disease in general, clinicians can use these parameters at admission as useful, early indicators of disease severity in pediatric pH1N1 infection.     

Acute disseminated encephalomyelitis following 2009 H1N1 influenza vaccine

Acute disseminated encephalomyelitis (ADEM) is an immune‐mediated inflammatory disorder of the central nervous system. We describe a previously healthy 2‐year‐old boy with ADEM, who exhibited high fever, lethargy, and recurrent seizures at 25 days after H1N1 influenza vaccination. To our knowledge, there has been only one report of ADEM following the 2009 H1N1 influenza vaccine, although such vaccination is accompanied with optic neuritis apart from this case. Thus, this is the first case of ADEM without optic neuritis, following the 2009 H1N1 influenza vaccination. Although vaccine‐associated ADEM remains rare, the increasing number of influenza vaccinations might increase the incidence of ADEM. We still need to pay attention to the occurrence of ADEM and treat patients with steroid therapy.     

Treatment with oseltamivir and prone positioning for a 9‐year‐old boy with ARDS caused by pandemic H1N1 2009 influenza

Here we report the case of a 9‐year‐old boy with acute respiratory distress syndrome (ARDS) caused by novel H1N1 swine‐origin influenza virus A. A diagnosis of ARDS caused by a novel influenza A (H1N1) virus was made on the basis of chest X‐ray and computed tomography together with low oxygenation index (OI) and the detection of novel influenza A (H1N1) virus from tracheal secretion samples. Oseltamivir phosphate and prone positioning were effective in the treatment of ARDS in this case. These findings suggest that anti‐viral drugs and prone positioning can play an important role in the improvement of ARDS caused by novel H1N1 swine‐origin influenza virus A.     

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目的通过观察3例儿童2009年新型甲型H1N1流感病毒急性坏死性脑病(ANE)脑组织病理性改变,探讨ANE脑组织可能的免疫病理反应。方法对2009年11月至2010年1月深圳儿童医院3例因ANE死亡患儿脑组织行HE染色形态学观察、髓鞘染色、小胶质细胞石蜡切片染色及免疫组织化学EliVision法检测分析。结果 ANE患儿脑组织小胶质细胞棘突消失变为圆形,髓鞘染色证实脑实质神经纤维呈脱髓鞘改变,经Naomenke及Feigin染色法证实小胶质细胞处于激活状态,免疫组化发现ANE患儿小胶质细胞产生TNF-α和IFN-α,脑组织未见淋巴细胞、中性粒细胞浸润。结论小胶质细胞异常增生可能是导致ANE发病的原因之一。     

八例儿童重症甲型H1N1流感病例临床分析

目的 分析儿童重症甲型H1N1流感病例的临床特征.方法 总结8例重症甲型H1N1流感病例的临床表现和诊治经过.结果 8例患儿均否认传染病接触史.4例有基础疾病,分别为肾病综合征、先天性甲状腺功能低下症、支气管哮喘及贫血.8例均有咳嗽和发热,咳嗽有痰,高热为主(5例),均有气促,出现在病程0.5～6 d,且进行性加重,3～24 h后出现呼吸衰竭;X线胸片为局限性渗出病变,类似支原体肺炎表现;血常规示7例中性粒细胞比例升高,6例CRP明显升高;均伴有呼吸衰竭,2例并发中毒性脑病.8例患儿均予抗病毒药物和脏器支持治疗,均使用了丙种球蛋白,部分患儿使用了皮质激素治疗,6例需要呼吸机支持,机械通气时间3～6 d,无一例死亡.结论 儿童重症甲型H1N1流感多是以严重低氧血症为突出表现的重症肺炎,经过及时有效的干预可避免严重急性呼吸窘迫综合征的发生,降低病死率.     

Neurologic adverse events following influenza A (H1N1) vaccinations in children

Background: Since the monovalent pandemic influenza A (H1N1) vaccine was recommended worldwide in October 2009, there has been a shortage of pediatric clinical data for post‐vaccine neurologic adverse events (NAE), including Guillain–Barré syndrome. We reviewed pediatric NAE data following H1N1 vaccinations and for patients with peripheral neuropathy, we followed their progress. Methods: In our single‐center study, we retrospectively reviewed 14 cases of children who visited the Division of Pediatric Neurology in the Department of Pediatrics of Chonnam National University Hospital due to NAE following monovalent influenza A (H1N1) vaccination between November 2009 and March 2010. Results: Clinical diagnoses for major NAE included: polyneuropathy in the extremities (11/14, 78.6%), sensory mononeuropathy with numbness in the left fibula area (1/14, 7.1%), Bell's palsy (1/14, 7.1%) and recent‐onset acute headache only (1/14, 7.1%). Therefore, most patients were diagnosed as having peripheral neuropathy (13/14, 92.9%), and two met the Brighton Collaboration Guillain–Barré syndrome definition criteria for level 3 (the lowest level of diagnostic certainty). Conclusions: Post‐vaccine NAE were mainly motor weakness due to polyneuropathy, which had a good prognosis of complete improvement within a few months without sequelae.     

Oseltamivir-resistant 2009 H1N1 influenza pneumonia during therapy in a renal transplant recipient

The emergence of oseltamivir-resistant 2009 H1N1 influenza virus (conferred by the H275Y substitution in NA) during therapy or prophylaxis in immunocompromised patients is a serious concern. The optimal therapy for immunosuppressed patients with oseltamivir-resistant 2009 H1N1 influenza virus is unknown and few options exist. We report a 10-yr-old recipient of kidney transplant who was hospitalized with oseltamivir-resistant 2009 H1N1 influenza pneumonia complicated by severe respiratory failure, ARDS, and renal failure requiring institution of ECMO and CRRT. On presentation, treatment with oseltamivir (second course) and broad-spectrum antibiotics was initiated. Immunosuppressive agents were stopped on hospital day (d) 2. On hospital d 7, given his critical status, immunocompromised state, and difficulty in obtaining intravenous zanamivir, after obtaining ethical approval and parental consent, he was treated with intravenous peramivir (through an Emergency Investigational New Drug Application) for two wk. He tolerated the regimen well and his clinical status improved gradually. Several factors may have contributed to virus clearance and survival including recovery of the immune system, aggressive critical care support, and administration of peramivir. Ongoing surveillance is essential to monitor how oseltamivir-resistant H275Y mutant viruses may evolve in the future.     

儿童甲型H1N1流感的流行病学及其治疗进展

甲型H1N1流感是一种急性人畜共患的呼吸道传染性疾病,儿童作为容易感染的群体,其防治显得格外重要.目前的治疗药物主要有神经氨酸酶抑制剂和M_2离子通道阻滞剂两类.该文主要综述了甲型H1N1流感的特点、药物治疗和免疫预防的最新研究进展及中医的治疗,以提高大家对甲型H1N1流感的认识.     

儿童重症甲型H1N1流感43例临床分析

目的 探讨小儿重症甲型H1N1流感的临床特点及治疗.方法 回顾分析2009年11月 - 2010 年1月长春市儿童医院收治的43例重症甲型H1N1流感患儿的临床特点及治疗情况.结果 43例均为本土病例,男32例,女11例;年龄最大13岁,最小6个月.重症43例中有8例危重症.有明确甲型H1N1流感接触史者7例.均以呼吸道感染为首发症状、体征,包括发热、咳嗽、喘息和肺部啰音、双肺阴影等改变,均以呼吸系统损害为重.危重症可出现呼吸衰竭、多脏器衰竭,部分出现肺水肿、肺出血,病情危重.所有患儿均参照卫生部颁布的<甲型H1N1流感诊疗方案>进行治疗,全部治愈出院.结论 儿童重症甲型H1N1流感主要表现为呼吸系统症状、体征,大部分经过良好,但危重症病例病情进展迅速,病势凶险,很快出现呼吸衰竭,可伴有各个脏器受损,应及时应用机械通气治疗.     

Novel inpatient surveillance in tertiary paediatric hospitals in New South Wales illustrates impact of first-wave pandemic influenza A H1N1 (2009) and informs future health service planning

Aim: To document the impact of pandemic influenza A H1N1 (2009) in New South Wales (NSW) children's hospitals. Methods: A novel surveillance system, Paediatric Active Enhanced Disease Surveillance (PAEDS), identified hospitalised children <15 years with laboratory‐proven influenza (1 June–30 September 2009) in the three children's hospitals in NSW: Children's Hospital at Westmead (CHW), Sydney Children's Hospital, John Hunter Children's Hospital. Clinical characteristics, management and complications were documented, and at CHW comparison made with 2007 data. Results: The 324 children identified represented 1802 hospital bed‐days and 230 PICU bed‐days. Most (73.1%) children had H1N1, one had an oseltamivir‐resistant isolate. Median age was 2.5 years: 65% were <5 years. Although 80.9% had cough, 8.0% had no respiratory symptoms. Complications occurred in 34.6%, of whom 56% were previously healthy. Only 50% received antivirals. Forty children (12.3%) were admitted to PICU: one child with H1N1 died. At CHW, comparison between 2009 and 2007 showed nearly twice the total number of admissions (226 vs. 122) and PICU admissions (22 vs. 13), but no deaths either year. Vomiting was more frequent in 2009 than 2007 (38.5% vs. 13.1%; P = 0.0001) as were neurological complications (11.4% vs. 2.4%; P = 0.0027) but length of hospital and PICU stay were similar. Conclusions: PAEDS is a valuable surveillance tool that documented the impact of the H1N1 (2009) pandemic in NSW children's hospitals. High numbers of complications, often in previously well children, suggest an important role for early diagnosis, antiviral therapy and influenza vaccination. Observed regional differences identify areas potentially at greater risk in a subsequent wave.     

Critical findings of severe influenza A (H1N1) pneumonia in children

Background: Pandemic influenza A (H1N1) causes severe pneumonia in children. The mechanism of development of respiratory failure in pneumonia patients remains unknown. This report describes clinical features of childhood influenza A pneumonia. Methods: The clinical and laboratory findings of 31 H1N1 pneumonia patients hospitalized in Iwata City Hospital from 1 October 2009 to 31 January 2010 were reviewed. Intubation and mechanical ventilation were required due to respiratory failure in eight patients, who were classified as the intubation group. Other patients without mechanical ventilation were classified as the non‐intubation group. Clinical features and laboratory findings were compared between the two groups. Results: The median age was 6.3 years (range, 3–10 years). The male to female ratio was 22:9. Clinical manifestations of tachycardia, tachypnea and cyanosis were significant findings in the intubation group at admission. Lymphocytopenia was observed in both groups. Leukocytosis with neutrophilia was the risk factor for intubation. Conclusions: Tachycardia, tachypnea, cyanosis and leukocytosis with neutrophilia, could be useful predictors at admission to identify high‐risk influenza A (H1N1) pneumonia in children.     

2009甲型H1N1流感儿童胸X线片表现

目的 总结儿童2009甲型H1N1流感的胸部X线影像特点.方法 选取2009年5月1日至2010年1月31日经首都儿科研究所病毒研究室病原学检测确诊且影像学资料完整的2009甲型H1N1流感患儿235例,按病情分为轻度组(172例)、中度组(49例)、重度组(14例),对患儿发病至首次拍片时间以及首次胸X线片影像表现进行比较.三组间性别、影像表现差异使用χ2检验.患儿年龄及发病至首次拍片时间的比较使用非参数检验.结果 各组患儿年龄、性别差异无统计学意义(P＞0.05).3组发病至拍摄胸X线片的时间分别为:轻度组(5.91±1.64)d,中度组(3.60±1.43)d,重度组(1.21±0.41)d,3组间差异有统计学意义(χ2=13.368,P＜0.01).首次胸X线片影像异常率:轻度组79.7%,中度组91.8%,重度组100.0%,在胸X线片表现上,各组出现肺纹理粗重、模糊(轻度组55.2%,中度组83.7%,重度组78.6%),肺实变(轻度组34.3%,中度组69.4%,重度组100.0%),肺过度充气(轻度组22.1%,中度组44.9%,重度组50.0%)以及磨玻璃密度影(轻度组0.6%,中度组2.0%,重度组14.3%)的比例差异均有统计学意义(P＜0.01).重度组病灶分布广、不对称,累及多个肺叶.结论 儿童2009甲型H1N1流感首次胸X线片出现异常时间、异常率、胸X线片表现严重度与临床病情严重程度成正比.

Abstract：

Objective To evaluate chest radiographic findings of children with 2009 influenza ( H1N1 ) virus infection. Method Data of 235 patients who had microbiologically confirmed H1N1 infection and available chest radiograph obtained between May 1st 2009 and Jan. 31st 2010 were retrospectively analyzed. The final study group was divided on the basis of clinical course [group 1 mild, outpatients without hospitalization ( n = 172 ); group 2 moderate, inpatients with brief hospitalization ( n = 49 ); group 3 severe, ICU admission (n = 14)]. Four pediatric radiologists reviewed all the chest radiographs of lung parenchyma, airway, pleural abnormalities and also anatomic distribution of the disease. Result No significant sex or age differences were found among the study groups ( P ＞0.05 ). The mean interval between the onset of clinical symptom and the initial chest radiography was (5.91 ± 1. 64) days (group 1 ), (3.60 ±1.43 ) days ( group 2) and ( 1.21 ± 0.41 ) days ( group 3 ), respectively. The differences among the three groups were significant statistically ( χ2 = 13.368, P ＜ 0.01 ). The ratio of abnormality presented at initial chest X-ray was 79.7% in group 1,91.8% in group 2 and 100% in group 3. Radiographically, there were prominent peribronchial markings ( group 1, 55.2%; group 2, 83.7%; and group 3, 78.6% ),consolidation ( group 1, 34.3%; group 2, 69.4%; and group 3, 100.0% ), hyperinflation ( group 1,22.1%; group 2, 44.9%; and group 3, 50.0% ) and ground glass opacity ( group 1, 0.6%; group 2,2.0%; and group 3, 14.3% ) in the chest radiographs. The differences of presenting were statistically significant (P ＜0.01 ). In the severe group, the lesions distributed diffusely and asymmetrically with multi lobe involvements. Conclusion In children with 2009 influenza A H1N1 viral infection, the interval between the onset of clinical symptom and initial chest radiography, the ratio of abnormality presented at initial chest X-ray film and the severity of chest film are parallel to their clinical situation.     

An influenza Epidemic among Institutionalized Children at the Time of Replacement from A(H3N2)to A(H1N1): Observation of 32 Cases Including 3 Cases of Probable Simultaneous Infection with A(H1N1) and A(H3N2)

An influenza epidemic occurred in Fukuoka, southern part of Japan in January, 1978 in which both influenza virus A(H1N1) and A (H3N2) were isolated. Thirty-two institutionalized children with influenza were studied at the time of this shift from A (H3N2) to A (H1N1). Fourteen virus strains were isolated. Thirteen strains belonged to influenza virus A (H1N1) (A/USSR/92/77-like strain) and one a mixed strain of A (H1N1) and A (H3N2) (A/Texas/77-like strain). The hemagglutination inhibition (H1)tests of paired sera indicated that of the 32 Children, 27 Showed a significant increasein HI antibody titers for influenza virus A (H1N1). 2 for A (H3N2) and the remaining 3, including the case from which the mixed virus strain was isolated, for both A (H1N1) and A (H3N2). These offers 3 cases were thought to be probably infected simulataneously with both influenza virus A (H1N1) and A (H3N2). Clinical manifestations due to influenza virus A (H1N1) were moderate and the 3 cases of probable simultaneous infection with both influenza virus A (H1N1) and A (H3N2) did not show two clinical episodes but rather a single episode with clinical manifestations similar to the cases with single virus infection.