本文選題：兒童 + 暴發(fā)性心肌炎��； 參考：《山東大學(xué)》2014年碩士論文

【摘要】：研究目的 本研究旨在總結(jié)與分析58例兒童暴發(fā)性心肌炎(AFM)的臨床特點、治療措施及臨床轉(zhuǎn)歸,為臨床診斷與治療AFM提供寶貴經(jīng)驗。 研究對象與方法 選擇自2003年1月至2014年2月期間在山東大學(xué)附屬省立醫(yī)院小兒心臟科住院的58例AFM患兒,其中男33例,女25例,年齡為2月-17歲,平均9.0±5.0歲。將AFM患兒的臨床表現(xiàn)、病原學(xué)、心肌損傷標志物包括心肌肌鈣蛋白(cTn)與肌酸激酶同工酶質(zhì)量(CKMB_Mass)、氨基末端腦鈉肽前體(NT-pro BNP)、心電圖、經(jīng)胸超聲心動圖、心臟磁共振、治療措施及轉(zhuǎn)歸等資料進行統(tǒng)計分析,并對部分指標在死亡的患兒(死亡組)與治愈的患兒(治愈組)之間進行比較。所有患兒進行門診及電話隨訪,隨訪時間4月-70月,平均22.5±13.8月,失訪率10.3%(6/58)。 結(jié)果 1.58例AFM患兒發(fā)病時間2小時～14天,平均121.0±100.8小時,住院時間為2小時～50天,平均25.7±8.5天,表現(xiàn)為急性心力衰竭者56例,心源性休克18例,阿斯綜合征14例,室性心動過速1例,室顫1例,Ⅲ度房室傳導(dǎo)阻滯(AVB)15例,高度AVB1例；其中植入臨時起搏器者10例,植入永久起搏器2例,治愈率為87.9%(51/58),死亡率8.6%(5/58),8例轉(zhuǎn)為擴張型心肌病。 2.所有患兒發(fā)病前2周內(nèi)均有前驅(qū)感染,前驅(qū)感染為呼吸道感染者29例,消化道感染者23例,不明原因發(fā)熱者6例,首發(fā)癥狀以胸悶、胸痛及乏力多見。 3.58例AFM患兒中56例行cTn檢測,均升高(100%),恢復(fù)正常時間為17～50天,平均25.5±5.8天。51例行CKMB_Mass檢查,33例(64.7%)升高。cTn升高的陽性率顯著高于CKMB_Mass (χ2=23.8, P0.05)。死亡組患兒cTn與治愈組之間無統(tǒng)計學(xué)差異(P均0.05)；死亡組患兒CKMB_Mass明顯高于治愈組(66.9±102.7ng/ml vs.28.5±31.5ng/ml, t=2.04, P0.05)。 4.58例AFM患兒中38例行NT-pro BNP檢測,均升高,為9941.5±10655.0pg/ml。死亡組患兒NT-pro BNP顯著高于治愈組(27815.0±10070.4pg/ml vs.9421.2±10655.0pg/ml, t=2.98, P0.05). 5.58例AFM患兒檢測病毒陽性者30例,其中EB病毒20例(34.5%),柯薩奇病毒7例(12.1%),巨細胞病毒5例(8.6%),單純皰疹病毒3例(5.2%),細小病毒2例(3.4%),腺病毒1例(1.7%),甲型H1N1病毒感染1例(1.7%),其中有9例為兩種病毒混合感染。 6.58例患兒心電圖均異常,其中31例呈急性心肌梗死樣改變；3例病理性Q波；24例AVB,其中Ⅲ度15例,高度1例,Ⅱ度5例,Ⅰ度3例；4例陣發(fā)性室上性心動過速；1例室性心動過速；1例室顫；6例QRS低電壓。死亡組患兒病理性Q波(40%,2/5)明顯多于治愈組(2.0%,1/51)(P0.05)。 7.58例AFM患兒中57例行經(jīng)胸超聲心動圖檢查,54例(94.7%)異常,表現(xiàn)為心腔擴大者32例,心肌動度減低48例,心肌變薄13例,心肌增厚8例,心肌回聲增強10例,心包積液23例,二尖瓣反流40例,三尖瓣反流35例及附壁血栓2例；左室射血分數(shù)(LVEF)降低者49例,為18.0%～58.0%,平均39.6±9.6%。死亡組患兒LVEF明顯低于治愈組(29.0±6.95%vs.43.67±12.29%,t=3.06,P0.05)。 8.58例AFM患兒中15例行心臟磁共振檢查,11例(73.3%)異常,其中T2加權(quán)像增強信號者1例,局部心肌延遲強化信號10例,心包積液4例,局部心肌變薄8例,局部心肌增厚4例,心肌動度減低4例。 9.58例AFM患兒中42例應(yīng)用大劑量靜脈用免疫球蛋白(IVIG)(2kg·-1),IVIG治療的AFM患兒治愈率(97.6%,40/41)明顯高于未使用IVIG的患兒(73.3%,11/15)(P0.05)。 10.58例AFM患兒中36例給予糖皮質(zhì)激素治療,其中應(yīng)用地塞米松者8例(0.5～1mg·kg-1),應(yīng)用大劑量甲基強的松龍治療28例(15～30mg·kg-1)。使用糖皮質(zhì)激素治療的AFM患兒治愈率(97.1%,34/35)與未使用糖皮質(zhì)激素治療的患兒(80.9%,17/21)之間無統(tǒng)計學(xué)差異(P0.05)。 結(jié)論 1.兒童暴發(fā)性心肌炎起病急,病情兇險,病死率高,首發(fā)癥狀以胸悶、胸痛及乏力多見。 2.暴發(fā)性心肌炎患兒肌鈣蛋白的陽性檢測率高于肌酸激酶同工酶。 3.EB病毒、柯薩奇病毒、巨細胞病毒、單純皰疹病毒、細小病毒及腺病毒是兒童暴發(fā)性心肌炎較常見病原,其中EB病毒更為常見。 4.肌酸激酶同工酶與氨基腦鈉肽前體顯著升高、心電圖顯示病理性Q波、左室射血分數(shù)顯著減低的暴發(fā)性心肌炎患兒死亡率高。 5.心臟磁共振成像檢查可顯示暴發(fā)性心肌炎患兒病變心肌T2加權(quán)像異常高信號與釓延遲增強信號,為臨床安全、有效及無創(chuàng)的心肌炎檢測手段之一。 6.大劑量靜脈注射免疫球蛋白可降低暴發(fā)性心肌炎患兒的死亡率。
[Abstract]:research objective
The purpose of this study is to summarize and analyze the clinical features, treatment and clinical outcomes of 58 cases of fulminant myocarditis (AFM) in children, and to provide valuable experience for clinical diagnosis and treatment of AFM.
Research objects and methods
From January 2003 to February 2014, 58 children with AFM were hospitalized in the Department of pediatric cardiology, the affiliated Provincial Hospital of Shandong University, including 33 males and 25 females. The average age was -17 years old and 9 + 5 years old. The clinical manifestations, etiology, and myocardial damage markers included cardiac muscle troponin (cTn) and creatine kinase isoenzyme (CKMB_M) in the children of AFM (CKMB_M Ass), the amino terminal brain natriuretic peptide precursor (NT-pro BNP), electrocardiogram, transthoracic echocardiography, cardiac magnetic resonance, treatment and prognosis were statistically analyzed, and some indexes were compared between the dead children (death group) and the cured children (cured group). All the children were followed up by the outpatient and telephone, and the follow-up time was -70 month of April. The average loss rate was 10.3% (6/58), with an average of 22.5 + 13.8 months.
Result
The onset time of 1.58 cases of AFM was 2 hours to 14 days, the average was 121 + 100.8 hours, the time of hospitalization was 2 hours to 50 days, the average was 25.7 + 8.5 days. 56 cases of acute heart failure, 18 cases of cardiogenic shock, 14 cases of ASP syndrome, 1 cases of ventricular tachycardia, ventricular fibrillation (AVB), high AVB1 cases, and high AVB1 cases; Of the 10 pacemakers, 2 were implanted permanent pacemakers. The cure rate was 87.9% (51/58), the mortality rate was 8.6% (5/58), and 8 cases were dilated cardiomyopathy.
2. all children had prodromic infection in the first 2 weeks, 29 cases of respiratory tract infection, 23 cases of digestive tract infection and 6 cases of unexplained fever. The first symptoms were chest tightness, chest pain and fatigue.
Of the 3.58 cases of AFM, 56 cases were detected by cTn (100%), the normal time was 17~50 days, the average of 25.5 + 5.8 days.51 routine CKMB_Mass examination, 33 (64.7%) elevated.CTn positive rate was significantly higher than CKMB_Mass (x 2=23.8, P0.05). There was no statistical difference between the death group and the treatment group (P 0.05); CKMB_Mass in the death group. It was significantly higher than that in the cured group (66.9 + 102.7ng/ml vs.28.5 + 31.5ng/ml, t=2.04, P0.05).
Of the 4.58 children with AFM, 38 cases were detected by NT-pro BNP and increased. The NT-pro BNP in the 9941.5 + 10655.0pg/ml. death group was significantly higher than that of the cure group (27815 + 10070.4pg/ml vs.9421.2 + 10655.0pg/ml, t=2.98, P0.05).
5.58 cases of AFM were detected in 30 cases of virus positive, including 20 cases of EB virus (34.5%), 7 cases of Coxsackie virus (12.1%), 5 cases of cytomegalovirus (8.6%), 3 cases of herpes simplex virus (5.2%), 2 cases of parvovirus (3.4%), adenovirus 1 cases (1.7%), and H1N1 virus infection.
6.58 cases had abnormal ECG, of which 31 cases had acute myocardial infarction like changes, 3 cases of rational Q wave, 24 cases of AVB, including 15 cases, 1 cases, 5 cases, 3 cases, 4 cases of paroxysmal supraventricular tachycardia, 1 cases of ventricular tachycardia, 1 ventricular fibrillation, 6 cases QRS low voltage. Pathological Q wave (40%, 2/5) of children in death group were significantly more than those in the death group. The cure group (2%, 1/51) (P0.05).
Of 7.58 children with AFM, 57 cases were examined by transthoracic echocardiography, 54 cases (94.7%) were abnormal, including 32 cases of enlargement of heart cavity, 48 cases of myocardial dysfunction, 13 cases of myocardial thinning, 8 cases of myocardial thickening, 10 cases of myocardial echo enhancement, 23 cases of pericardial effusion, 40 cases of mitral regurgitation, three apex regurgitation and peripheral thrombus, and lower left ventricular ejection fraction (LVEF). Of the 49 cases, 18% to 58%, with an average of 39.6 + 9.6%., the LVEF of the death group was significantly lower than that of the cure group (29 + 6.95%vs.43.67 + 12.29%, t=3.06, P0.05).
Of the 8.58 cases of AFM, 15 cases were examined by cardiac magnetic resonance (MRI) and 11 cases (73.3%) were abnormal, including 1 cases of T2 weighted image enhancement signal, 10 cases of local myocardial delayed intensification signal, 4 cases of pericardial effusion, 8 local thinning cases, 4 local myocardial thickening, and 4 myocardial dynamic reduction.
In 9.58 children with AFM, 42 cases were treated with large doses of intravenous immunoglobulin (IVIG) (2kg. -1). The cure rate of AFM in children treated with IVIG (97.6%, 40/41) was significantly higher than that of children without IVIG (73.3%, 11/15) (P0.05).
Of 10.58 children with AFM, 36 were treated with glucocorticoid, of which 8 cases (0.5 ~ 1mg / kg-1) were treated with dexamethasone and 28 cases (15 to 30mg. Kg-1) were treated with high dose methylprednisolone. The cure rate of AFM in children treated with Glucocorticoid (97.1%, 34/35) was not statistically significant between children without glucocorticoid treatment (80.9%, 17/21). Differences (P0.05).
conclusion
1. children with fulminant myocarditis onset acute, dangerous condition, high mortality, the first symptoms are chest tightness, chest pain and fatigue.
2. the positive detection rate of troponin in children with fulminant myocarditis is higher than that of CK.
3.EB virus, Coxsackie virus, cytomegalovirus, herpes simplex virus, parvovirus and adenovirus are common pathogens of fulminant myocarditis in children, and EB virus is more common.
4. the creatine kinase isozymes and aminobrain natriuretic peptide precursors increased significantly. The electrocardiogram showed the pathological Q wave, and the mortality of the children with acute myocarditis with a significant decrease in the left ventricular ejection fraction was high.
5. cardiac magnetic resonance imaging (MRI) can show abnormal high signal and gadolinium delayed enhancement signal of T2 weighted image in the diseased myocardium of children with fulminant myocarditis. It is one of the clinical safety, effective and noninvasive methods for detecting myocarditis.
6. large doses of intravenous immunoglobulin can reduce the mortality of children with fulminant myocarditis.
【學(xué)位授予單位】：山東大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2014
【分類號】：R725.4

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