儿童系统性红斑狼疮并发肺孢子菌肺炎的高危因素

系统性红斑狼疮是儿童常见的自身免疫性疾病之一, 糖皮质激素及免疫抑制剂是其治疗的主要药物, 长期使用上述药物将导致免疫功能低下, 容易并发肺孢子菌肺炎。肺孢子菌肺炎起病隐匿、进展迅速、可危及患儿生命, 预防性治疗可降低其发病率和病死率。现就儿童系统性红斑狼疮并发肺孢子菌肺炎的高危因素进行综述, 以期早期识别并及时预防肺孢子菌肺炎。     

儿童非人类免疫缺陷病毒感染重症耶氏肺孢子菌肺炎七例并文献复习

目的总结儿童非人类免疫缺陷病毒(HIV)感染的耶氏肺孢子菌肺炎(PCP)的临床特征及治疗情况。方法回顾性分析2015年5月1日至2021年5月1日在香港大学深圳医院PICU和咸阳彩虹医院PICU住院的7例非HIV感染的重症PCP患儿病例,观察其高危因素、临床表现、实验室检测指标、肺部影像学特征、治疗及转归等。结果7例PCP患儿,男4例,女3例,年龄13~85个月,平均(42.4±26.8)个月,均存在基础疾病,以血液系统恶性肿瘤最为多见;6例患儿有应用复方磺胺甲口,恶唑(TMP-SMX)预防PCP治疗史,其中4例自行停药2~4周发生PCP。7例患儿均存在低氧性呼吸衰竭,氧合指数(OI)30.6±3.4;临床表现为发热、干咳、进行性呼吸困难,早期肺部均未闻及湿啰音,乳酸脱氢酶[(745.7±317.0)U/L]和β-D-葡聚糖[(513.8±225.0)pg/mL]均升高,胸部CT显示双肺弥漫性间质性改变伴肺内多发性渗出。7例患儿均在入院3 d内开始抗耶氏肺孢子菌治疗,其中5例采用静脉TMP-SMX,2例口服TMP-SMX+卡泊芬净,疗程21 d,抗耶氏肺孢子菌同时应用糖皮质激素治疗;2例患儿在PCP治疗3 d后出现病情加重,其中1例死亡,另1例继续用药6 d后开始临床好转,其余5例在治疗3~7 d后开始出现临床好转,最终6例治愈,1例死亡。结论非HIV感染的PCP患儿均存在免疫受损的高危因素,TMP-SMX可有效预防PCP的发生;对于重症PCP患儿,尽早静脉应用TMP-SMX联合糖皮质激素治疗可降低病死率,在无静脉TMP-SMX情况下,也可口服TMP-SMX+卡泊芬净替代。     

儿童肺部孢子菌感染的诊治进展

肺孢子菌肺炎是一种机会性感染,近年来移植技术和免疫抑制剂等药物的广泛应用使非人类免疫缺陷病毒感染的继发免疫缺陷患儿肺孢子菌肺炎发病率增加,预防和早期诊治对降低病死率尤为重要。该文对儿童肺孢子菌肺炎的诊治进展进行了概述。     

肺炎患儿外周血超敏C反应蛋白、降钙素原及细胞免疫指标变化及意义

目的观察肺炎患儿外周血超敏C反应蛋白(hs-CRP)、降钙素原(PCT)、T淋巴细胞亚群及CD4+CD25+调节性T细胞(regulatory T cell,Treg)水平变化,探讨其与儿童肺炎的关系。方法入选细菌性肺炎38例、支原体肺炎29例和病毒性肺炎25例,共92例肺炎患儿,应用免疫散射比浊法、酶联荧光分析法和流式细胞术检测患儿外周血hs-CRP、PCT、T淋巴细胞亚群(CD3+、CD4+、CD8+、CD4+/CD8+)和CD4+CD25+Treg细胞水平(CD4+CD25+Treg占CD4+T细胞百分比),并与30例正常对照儿童进行比较。结果肺炎患儿的CD3+、CD4+T淋巴细胞水平、CD4+/CD8+比值均低于正常对照儿童,差异均有统计学意义(P<0.01);细菌性肺炎、支原体肺炎患儿的CD8+T淋巴细胞、hs-CRP水平均高于正常对照儿童,差异均有统计学意义(P<0.01);病毒性肺炎患儿的CD8+T淋巴细胞、hs-CRP水平与正常对照儿童的差异均无统计学意义(P>0.05);细菌性肺炎患儿的PCT水平、PCT阳性率均高于支原体肺炎和病毒性肺炎患儿,差异均有统计学意义(P<0.01);肺炎患儿的CD4+CD25+Treg细胞水平均高于正常对照儿童,差异均有统计学意义(P<0.01)。结论 hs-CRP、PCT为儿童肺炎鉴别诊断提供了一定参考依据,PCT诊断早期细菌感染的特异性优于hs-CRP;免疫损伤在儿童肺炎中起了一定作用。     

非人类免疫缺陷病毒感染儿童重症肺孢子菌肺炎七例临床分析

目的:探讨小儿肺孢子菌肺炎(pneumocystis jirovecii pneumonia,PCP)的临床特征,提高儿科医师对该病的认识。方法:回顾性分析西安市儿童医院儿童重症监护病房(pediatric intensive care unit,PICU)2019年1月至12月收治的7例非人类免疫缺陷病毒感染PCP患...     

难治性肺炎支原体肺炎5例

目的 探讨难治性肺炎支原体肺炎的临床特点.方法 2003年12月-2006年1月首都医科大学附属北京友谊医院儿科住院的难治性肺炎支原体肺炎患儿5例.男4例,女1例;年龄6～13岁.对5例患儿的临床表现、实验室检查、胸片检查及治疗进行回顾性分析.结果 肺炎支原体肺炎5例患儿均以发热、咳嗽起病,呈稽留高热,体温40.0～40.7℃,咳嗽剧烈,患侧肺部叩诊浊音,呼吸音减低.5例ESR增快(53～107mm/1h),CRP升高(270～1600mg/L);2例行细胞免疫功能检查CD4 /CD8 降低;胸片示左中下肺野大片状阴影3例,右中下肺野大片状阴影2例,均并胸腔积液.5例均并心电图异常改变,3例表现为T波低平,2例表现为左前分支传导阻滞,心肌酶CK-MB、肌钙蛋白T均正常.5例咽拭子肺炎支原体培养阳性,体外药物敏感性试验证实为耐药菌感染.5例均予大环内酯类药物治疗.其中1例加用甲泼尼龙治疗,热程缩短.随访2～3个月,全部病例肺部炎性反应吸收,1例并胸膜肥厚.结论 耐药肺炎支原体感染诊治困难,对大环内酯类抗生素治疗不敏感不能排除肺炎支原体肺炎,应行病原学检查及耐药基因检测,同时需寻找有效的药物控制耐药菌感染.     

经肺泡灌洗液高通量测序诊断婴儿肺孢子菌肺炎1 例并文献复习

目的探讨肺孢子菌肺炎的病因、临床表现、病原学诊断和治疗。方法回顾分析1例肺孢子菌肺炎患儿的临床资料。结果患儿,男,2个月20天,临床表现为慢性咳嗽、气促、烦躁、低氧血症;肺部影像呈双肺弥漫性浸润改变;经支气管镜术取肺泡灌洗液进行宏基因高通量测序后证实为肺孢子菌感染。确诊后予甲氧苄胺嘧啶-磺胺甲噁唑(TMP-SMZ)治疗,临床症状基本消失,肺部 CT明显好转。结论肺泡灌洗液行宏基因高通量测序可诊断肺孢子菌肺炎。     

肺孢子菌肺炎的诊断与治疗

肺孢子菌肺炎(PCP)是在细胞免疫功能障碍时由尹氏肺孢子菌引起的肺部机会感染,在HIV感染者和非HIV感染的免疫抑制宿主的临床表现有所不同。诊断PCP的金标准是在肺实质或下呼吸道分泌物中证实肺孢子菌的存在,甲氧苄啶-磺胺甲唑是首选治疗药物,采用合适的预防用药方案可明显降低PCP的发病率。     

婴幼儿重症支原体肺炎28例临床分析

目的　了解婴幼儿重症支原体肺炎的发病特点 ,提高其诊断与治疗水平。方法　采用回顾性研究方法对本院收治的 2 8例婴幼儿重症支原体肺炎病例进行临床分析。结果　本组重症支原体肺炎 2 2例 (79% )的患儿起病急 ,以咳嗽、喘息为主症 ,并很快出现呼吸困难及发热 ;所有的患儿均有程度不同的肺外症状 ;3例并发肺不张。结论　婴幼儿重症支原体肺炎病情重、变化快 ,肺外症状多见 ,有 3例合并肺不张 ,应引起临床重视。     

病毒性肺炎患儿自然杀伤细胞亚群、T细胞亚群及血IL-2、IL-4、INF-γ变化的研究

目的 探讨病毒性肺炎患儿自然杀伤(NK)细胞亚群、T细胞亚群及血IL-2、IL-4、INF-γ的动态变化及临床意义.方法 采用流式细胞术测定32例病毒性肺炎患儿急性期(肺炎起病2?d内)、恢复期(肺炎起病5?d内)外周血NK细胞亚群、T细胞亚群,用ELISA法测定血IL-2、IL-4、INF-γ水平,用乳酸脱氢酶释放法测定NK细胞活性变化,并与30例健康对照组儿童进行比较.结果 (1) 病毒性肺炎患儿CD16+CD56+、CD16+NK细胞在急性期分别为(0.73±0.17)%、(0.39±0.2)%,恢复期分别为(1.47±0.22)%、(0.89±0.14)%;急性期与恢复期比较,恢复期CD16+CD56+、CD16+NK细胞明显升高(P<0.01),但均显著低于对照组(P<0.01).两组NK细胞亚群变化与其活性改变呈正相关.病毒性肺炎患儿CD56+NK细胞与健康儿童差异无显著性(P>0.05).(2) 与对照组相比,病毒性肺炎患儿的急性期、恢复期IL-2、IL-4均无明显改变,差异无显著性(P>0.05);急性期INF-γ无明显改变,差异无显著性(P>0.05),而恢复期INF-γ[(28.10±1.38)?μg/L]明显高于急性期[(22.78±1.19)?μg/L],差异有非常显著性(P<0.01).(3) 与对照组相比,病毒性肺炎患儿CD4+、CD4+/CD8+T细胞计数在急性期与恢复期均无明显改变,差异无显著性(P>0.05).病毒性肺炎急性期、恢复期CD8+T细胞均低于对照组,差异有显著性(P<0.05),但病毒性肺炎急性期、恢复期间差异无显著性(P>0.05).结论 病毒性肺炎患儿NK细胞活性降低,活性与亚群数目呈正相关;病毒性肺炎患儿抑制性T细胞功能低下.病毒性肺炎急性期NK细胞激活是多因素共同作用的结果 .     

An outbreak of Pneumocystis carinii pneumonia in children with malignancy

An outbreak of Pneumocystis carinii pneumonia (PCP) in three patients within a 6 week period was reported. Two patients had acute lymphoblastic leukaemia and one had brain-stem glioma. They shared common features of immuno-suppression and absence of cotrimoxazole prophylaxis and had been nursed in the same room. The severity of PCP and its response to treatment may be related to the degree of immunosuppression. Because of the morbidity and mortality of PCP, chemoprophylaxis should be given to all at-risk cases. Furthermore, isolation of patients with PCP should be considered in view of increasing evidence of nosocomial transmission.     

Pneumocystis carinii in children with severe pneumonia at Mulago Hospital, Uganda

The prevalence of Pneumocystis carinii pneumonia (PCP), its clinical and radiological features and the outcome in 121 children aged 2-60 months presenting with severe pneumonia over a 2-month period at Mulago Hospital, Kampala are described. Children presenting with severe pneumonia had sputum induction using 3% hypertonic saline. The sputum was stained using PCP monoclonal antibodies and viewed with fluorescent microscopy. Twenty children with confirmed PCP were compared with 101 without PCP. The prevalence of PCP was 16.5%, and 12 (60%) were < 6 months of age. Eighteen (42%) of 43 children infected with HIV had PCP and two of 78 not infected with HIV. The outcome in children with PCP was poor with a case fatality rate of 40% compared with 20% in those without HIV. Radiological findings were non-specific. Clinical features associated with PCP included: HIV-positive infants with a small head circumference, AIDS, a clear chest on auscultation and elevated LDH levels. PCP occurs in one in six children < 5 years with severe pneumonia in Mulago Hospital. In developing countries where investigations for PCP are not routinely available, infants suspected of PCP should be treated as an emergency.     

Efficacy of 99mTc-DTPA lung clearance test in the diagnosis of PCP in HIV-positive patients

The study aims to evaluate the efficacy of technetium-99m diethylenetriaminepentaacetic acid ((99m)Tc-DTPA) lung clearance test in the diagnosis of pneumocystis carinii pneumonia (PCP) in HIV-positive paediatric patients. Twenty HIV-negative patients with no chest symptoms constituted Group A, 25 HIV antibody positive asymptomatic children formed Group B, while 45 HIV antibody positive children with respiratory infections comprised Group C. Group C was subdivided into C(1) (n = 20, documented PCP on microbiology), C(2) (n = 10, tuberculosis) and C(3) (n = 15, bacterial pneumonias). The mean age group of patients in Group A, Group B and Group C was 4.7 +/- 1.9, 4.2 +/- 1.5 and 4.8 +/- 1.7 years, respectively. All patients were subjected to complete blood count, blood culture, chest radiographs, microscopic staining of sputum (PCP stains, Ziehl-Nielsen staining, Gram staining), ABG and Mantoux test. All these patients underwent dynamic lung scans using (99m)Tc-DTPA aerosols and lung clearance was calculated in terms of half-time transfer value (T(1/2)) value. T(1/2) was compared between different groups and lung scan findings were correlated with radiological and microbiological results. Patients with PCP had T(1/2) in the range of 9.02 +/- 1.35, TB 28.2 +/- 3.03 min and other bacterial pneumonias in the range of 20.5 +/- 3.1 min (range for normal individuals was 49.8 +/- 6.13 min). T(1/2) in patients with PCP was found to be significantly lower when compared with T(1/2) in other groups. Patients with PCP had characteristic biphasic curves while the rest had monophasic curves. Some patients with PCP had low T(1/2) values even when chest radiographs and arterial blood gases were normal. (99m)Tc-DTPA lung clearance test is a sensitive, safe and non-invasive diagnostic tool for the early detection of PCP in HIV-positive paediatric patients.     

Intermittent oral trimethoprim/sulfamethoxazole on two non-consecutive days per week is effective as Pneumocystis jiroveci pneumonia prophylaxis in pediatric patients receiving chemotherapy or hematopoietic stem cell transplantation

Pneumocystis jiroveci pneumonia (PCP) is a serious complication in patients receiving chemotherapy or hematopoietic stem cell transplantation. Current recommendations for trimethoprim-sulfamethoxazole (TMP-SMZ) dosing as PCP prophylaxis in immunocompromised patients are based on either daily dosing or dosing three consecutive days per week. We report our experience of prophylaxis with TMP-SMZ twice daily on two non-consecutive days per week in 145 immunocompromised children with hematologic disorders, cancer, or metabolic disorders following chemotherapy or hematopoietic stem cell transplantation. There were no breakthrough cases of PCP. We therefore conclude our prophylaxis regimen is effective against PCP in immunocompromised children.     

Prognostic factors and life expectancy in children with acquired immunodeficiency syndrome and Pneumocystis carinii pneumonia

Eighteen children with the acquired immunodeficiency syndrome (AIDS) were diagnosed as having Pneumocystis carinii pneumonia (PCP) by either open lung biopsy or bronchoalveolar lavage. Seven patients (39%) died during the acute illness. Alveolar-arterial oxygen gradients at the time of presentation and lactate dehydrogenase levels did not distinguish survivors from nonsurvivors. Total lymphocyte and T4 cell counts were low in children who died during the initial PCP infection but had considerable overlap with survivors. Response to phytohemagglutinin was measured in 5 of the 7 patients who died initially. In these patients, the mean phytohemagglutinin response was 1977 cpm. Of the 11 early survivors, 10 died within 27 months after PCP. Mean phytohemagglutinin response was 46,079 cpm in patients who died within 1 year, and 44,768 cpm in those who died later. Only 1 child is still alive 5 years after PCP illness. Children with AIDS and PCP infection have high initial mortality and poor long-term prognosis. Response to phytohemagglutinin is helpful in predicting who will survive initial PCP infection.     

Dysfunction of natural killer cells in human immunodeficiency virus-infected children with or without Pneumocystis carinii pneumonia.

The development of Pneumocystis carinii pneumonia (PCP) in human immunodeficiency virus (HIV)-infected children with normal T-cell numbers is contrary to previous experience with HIV-infected adults, in whom low CD4+ T-cell numbers predict susceptibility to PCP. To determine whether PCP in HIV-infected children reflects a qualitative T-cell or other immune defect, we studied four HIV-infected children who also had PCP and 10 others without PCP for T-cell and natural killer (NK) cell function. Most of the HIV-infected children had normal T-cell numbers for age, and all had CD4+ T-cell numbers greater than those predictive of PCP in HIV-infected adults. All HIV-infected children had normal T-cell function in vitro. The HIV-infected children as a whole had deficient NK cell cytolysis. We obtained a significant interactive effect of age by health status for NK cell function between patients and age-matched control subjects. All HIV-infected children with defective NK cell function failed to enhance their NK cell cytolysis when their mononuclear cells were stimulated with recombinant interferon alfa (r-IFN-alpha). This NK cell defect in HIV-infected children may facilitate the development of secondary infection.     

Pneumocystis carinii pneumonia in South African children infected with human immunodeficiency virus

BACKGROUND: Pneumocystis carinii pneumonia (PCP) has been regarded as uncommon in HIV-infected patients in Africa, but diagnostic difficulties and geographic variability may partly account for this. There is little information on the incidence of PCP in HIV-infected children in Africa. AIM: To investigate (1) the incidence and associated features of PCP in African HIV-infected children and (2) the usefulness of sputum induction and nasopharyngeal aspirates (NPAs) for diagnosis of PCP. METHODS: HIV-infected children hospitalized with pneumonia were prospectively enrolled in a 1-year study in South Africa. History, examination, chest radiology and blood tests (including HIV testing) were performed. Sputum induction (5% NaCl nebulization) or nondirected bronchoalveolar lavage in intubated patients was performed for P. carinii identification using immunofluorescence and silver stain; immunofluorescence was also done on nasopharyngeal aspirates (NPAs). RESULTS: Of 151 HIV-infected children [47% female; median age, 9 (range, 3 to 23) months], 87 had been previously diagnosed with HIV whereas 64 (42.4%) were found to be HIV-positive at the time of admission. PCP occurred in 15 children (9.9%; 95% confidence interval, 5.9 to 15.5) and was the AIDS-defining infection in 13 of 64 (20.3%; 95% confidence interval, 11.8 to 31.5). Only 1 of 59 children receiving prophylaxis (1.7%) developed PCP compared with 14 of 92 (15.2%) not taking prophylaxis [relative risk, 0.11 (0.02 to 0.82), P = 0.007]. PCP-infected children were younger [3 (range, 3 to 4) vs. 10 (range, 4 to 24) months, P < 0.001] and presented with more severe pulmonary disease as indicated by a higher respiratory rate [63 (range, 60 to 73) vs. 50, (range, 40 to 60) P < 0.001], heart rate [160 (range, 136-180) vs. 140 (range, 120-152) P = 0.025] and a greater incidence of cyanosis (53% vs. 26%, P = 0.025). Clinical signs of HIV infection, occurring in 96% of children, were equally prevalent in both groups. High serum lactate dehydrogenase was the only laboratory investigation that distinguished PCP-infected from uninfected children [626 (range, 450 to 1098) vs. 307 (range, 243 to 465) units/l], P < 0.001. No radiologic features were found to be diagnostic of PCP. P. carinii was identified in 9 sputa and 6 bronchoalveolar lavage specimens, but all corresponding NPAs were negative. Seven of 15 (47%) children with PCP died while hospitalized compared with 24 of 136 (18%) without PCP [relative risk, 1.21 (range, 0.99 to 1.47), P = 0.008]. CONCLUSION: PCP is an important pathogen in HIV-infected infants in South Africa and is associated with a high mortality. Induced sputum is effective for obtaining lower respiratory tract secretions for diagnosis of PCP but an NPA is not useful.