本文選題：閉塞性細(xì)支氣管炎 + 高分辨力CT��； 參考：《山東大學(xué)》2012年碩士論文

【摘要】：研究背景： 1901年德國病理學(xué)家Lange首次提出閉塞性細(xì)支氣管炎(bronchiolitis obliterans, BO)的概念。B0是慢性氣流阻塞的臨床綜合征,主要由小氣道的炎性病變引起。診斷B0的金標(biāo)準(zhǔn)是肺活檢,但是在兒科肺活檢非常困難,且不一定能夠取到病變部位,可能得不到有意義的結(jié)果。B0在兒科相對少見,臨床醫(yī)生對其認(rèn)識(shí)不足,國內(nèi)外也缺乏大樣本的研究。因此,B0的流行病學(xué)、發(fā)病機(jī)制、有效治療及預(yù)后等仍不十分清楚。近年來,隨著高分辨力CT(high-resolution CT, HRCT)的應(yīng)用,B0的臨床診斷率有了大幅度的提高。兒童B0以感染引起的最多見,即感染后閉塞性細(xì)支氣管炎(post-infectious bronchiolitis obliterans, PIBO)。B0嚴(yán)重影響患兒的身體健康,給患兒家庭和社會(huì)帶來精神和經(jīng)濟(jì)負(fù)擔(dān),正日益引起兒科醫(yī)生的重視。 研究目的： 觀察兒童PIBO的臨床特點(diǎn),分析其病原學(xué)、影像學(xué)特點(diǎn)及免疫學(xué)改變,總結(jié)早期臨床識(shí)別和干預(yù)治療對PIBO的影響,為PIBO的臨床診斷和治療提供依據(jù)。 研究方法： 收集2010年9月～2011年11月在山東省立醫(yī)院小兒呼吸綜合科臨床診斷為PIBO的患兒25例。年齡6月-36月。男18例,女7例。按臨床診斷PIBO并開始治療時(shí)患兒的咳嗽及喘息時(shí)間將患兒分為病程12周(A組)和病程≥12周(B組)兩組。 收集患兒的臨床資料,包括年齡、性別、入院時(shí)咳嗽及喘息情況、查體肺部聽診情況、既往治療情況、有無濕疹史、出生史、家族中過敏史等。 病原學(xué)檢測,包括血培養(yǎng)、痰培養(yǎng)、九項(xiàng)呼吸道感染病原體IgM抗體(腺病毒、嗜肺軍團(tuán)菌、肺炎支原體、Q熱立克次體、肺炎衣原體、呼吸道合胞病毒、甲型流感、乙型流感、副流感病毒123型)、肺炎支原體抗體、結(jié)核抗體、曲霉菌抗原測定、真菌D-葡聚糖定量、EB病毒系列、尿CMV-DNA定量等。 檢測血T細(xì)胞亞群包括CD3+、CD4+、CDS+、CD4/CD8水平,檢測血免疫球蛋白IgG, IgA, IgM, IgE及補(bǔ)體C3、C4水平,檢測血常規(guī)、肝功、心肌酶譜等。 行胸部X-RAY及HRCT檢查。 對6例咳嗽、喘息持續(xù)時(shí)間長(均12周)、臨床治療效果欠佳的患兒行纖維支氣管鏡檢查,并行肺泡灌洗治療,送檢肺泡灌洗液細(xì)菌培養(yǎng)及抗酸染色。 給予抗感染、激素(靜脈、口服及吸入激素)、支氣管擴(kuò)張劑、大環(huán)內(nèi)酯類(阿奇霉素或依托紅霉素)以及鈣劑、維生素D等治療。2～12周后定期門診復(fù)查,記錄其咳嗽、喘息情況。6月后復(fù)查胸部HRCT,觀察其改善情況。 對部分統(tǒng)計(jì)結(jié)果以均數(shù)±標(biāo)準(zhǔn)差表示,采用SPSS19.0統(tǒng)計(jì)軟件進(jìn)行分析處理,兩樣本均數(shù)的比較采用t檢驗(yàn),以P0.05表示差異有統(tǒng)計(jì)學(xué)意義。 研究結(jié)果： 1.臨床特點(diǎn) 患兒年齡6月～36月,其中6月～12月為好發(fā)年齡,有14例(56%)。男孩發(fā)病率高于女孩,男18例(72%),男女比例2.57：1。 25例患兒在臨床診斷為PIBO時(shí)均有咳嗽及喘息,20例伴有痰鳴�？人�、喘息持續(xù)時(shí)間7周～17周,其中12周13例(52%),≥12周12例(48%)。5例(20%)伴有發(fā)熱。3例(12%)伴有皮疹,經(jīng)涂片檢查證實(shí)為皮膚念珠菌感染。1例(4%)有雞胸,8例(32%)有方顱。10例(40%)有口唇發(fā)紺,10例(40%)吸氣三凹征陽性。25例(100%)入院時(shí)雙肺聞及喘鳴音,23例(92%)聞及痰鳴音,6例(24%)聞及水泡音。14例(56%)有輕度貧血,12例(48%)有不同程度的肝功損害,9例(36%)有不同程度的心肌損害。 所有患兒均在院外以“支氣管炎、支氣管肺炎或支氣管哮喘”反復(fù)輸液治療。4例(16%)曾因呼吸衰竭行機(jī)械通氣。6例(24%)曾用1-2天的靜脈激素治療癥狀減輕,停用后在短期內(nèi)反復(fù)。25例(100%)均曾用支氣管擴(kuò)張藥物治療,喘息未見減輕或僅有輕微減輕。 2例(8%)有早產(chǎn)史,2例(8%)出生體重2.5Kg。15例(60%)有濕疹史。12例(48%)有家族中過敏史。 2.病原學(xué)：肺炎支原體感染8例(32%),腺病毒感染7例(28%),肺炎鏈球菌感染4例(16%),乙型流感病毒感染3例(12%),曲霉菌感染3例(12%),呼吸道合胞病毒感染1例(4%),巨細(xì)胞病毒感染1例(4%),麻疹病毒感染1例(4%),凝固酶陰性葡萄球菌感染1例(4%)。其中7例(28%)為2種或3種病原的混合感染,包括肺炎支原體與麻疹病毒混合感染1例,肺炎支原體與曲霉菌混合感染1例,肺炎支原體與凝固酶陰性葡萄球菌混合感染1例,腺病毒與乙型流感病毒混合感染1例,腺病毒與曲霉菌混合感染1例,肺炎鏈球菌與曲霉菌混合感染1例,肺炎支原體、腺病毒與乙型流感病毒混合感染1例。25例中有4例(16%)未查到明確病原。 3.影像學(xué)特點(diǎn) 胸部X-RAY顯示肺紋理增粗、紊亂25例(100%),斑片狀浸潤影17例(68%),肋膈角模糊2例(8%),合并肺不張2例(8%),合并肺實(shí)變3例(12%)。 胸部HRCT顯示雙肺斑片狀或磨玻璃樣密度增高影25例(100%),馬賽克灌注征22例(88%),伴局限性肺氣腫3例(12%),伴局限性肺不張3例(12%),伴肺實(shí)變3例(12%),伴胸腔積液2例(8%),伴胸膜增厚5例(20%),伴胸廓畸形1例(4%)。出院后6月復(fù)查胸部HRCT,結(jié)果：1例磨玻璃影及馬賽克灌注征較確診PIBO時(shí)范圍增大、病變更明顯,9例磨玻璃影或馬賽克灌注征較確診PIBO時(shí)范圍減小、病變減輕,15例馬賽克灌注征及磨玻璃影無明顯變化。 4.免疫學(xué)改變：血T細(xì)胞亞群顯示CD3+降低4例(16%),CD4降低5例(20%),CD8升高19例(76%),CD4/CD8降低17例(68%)。血免疫球蛋白、補(bǔ)體顯示IgG降低5例(20%),IgA降低4例(16%),IgM升高1例(4%),IgE升高5(20%),補(bǔ)體3降低3例(12%),補(bǔ)體4升高2例(8%)。 5.纖維支氣管鏡檢查及治療：6例行纖維支氣管鏡檢查的患兒均未發(fā)現(xiàn)氣道結(jié)構(gòu)異�；虍愇�,且均可在部分肺葉見到不同程度的附壁痰液或痰栓阻塞,其中1例有左下葉外基底段亞段閉塞。灌洗治療后4例癥狀和體征減輕,1例曲霉菌感染和1例曲霉菌合并腺病毒感染的患兒仍有反復(fù)的咳嗽、喘息,其中1例再次行灌洗治療。肺泡灌洗液培養(yǎng)及抗酸染色僅1例培養(yǎng)出凝固酶陰性葡萄球菌。 6.治療及轉(zhuǎn)歸 所有患兒隨訪時(shí)間最短者6月,最長者12月,其中10例現(xiàn)已無咳嗽、喘息等癥狀,其余15例咳嗽、喘息較治療前明顯減輕,僅在呼吸道感染或劇烈活動(dòng)時(shí)可出現(xiàn)。目前無死亡病例。 患兒出院3個(gè)月后隨訪,有20例(80%)平時(shí)無咳嗽、喘息,僅在呼吸道感染或劇烈活動(dòng)時(shí)有咳嗽、喘息,且每次咳嗽、喘息的持續(xù)時(shí)間縮短,其中4例治療42～56天(平均51.20±5.46天)后咳嗽、喘息消失。5例(20%)與治療前相比咳嗽、喘息減輕不明顯,受涼或輕微活動(dòng)時(shí)即可再次出現(xiàn),復(fù)查時(shí)肺部喘鳴音仍然存在,其中4例多次因咳嗽、喘息加重住院。6個(gè)月后隨訪,25例(100%)治療后平時(shí)無咳嗽、喘息,僅在呼吸道感染或劇烈活動(dòng)時(shí)有咳嗽、喘息,其中7例經(jīng)治療42-165天(平均124.32±40.78天)后咳嗽、喘息消失。 分別統(tǒng)計(jì)病程12周組(A組)和病程≥12周組(B組)患兒出院后3月內(nèi)、6月內(nèi)咳嗽及喘息發(fā)作次數(shù),并進(jìn)行t檢驗(yàn),結(jié)果有統(tǒng)計(jì)學(xué)差異,表明表明早期診斷和干預(yù)能明顯減少患兒的咳嗽、喘息發(fā)作次數(shù)。 結(jié)論： 1.PIBO好發(fā)于小于1歲的嬰兒,且男孩發(fā)病率高于女孩。 2.肺炎支原體和腺病毒感染是兒童PIBO的主要病因。 3.PIBO患兒的胸部X-RAY無特異性改變,HRCT典型表現(xiàn)為斑片狀或磨玻璃樣密度增高影、馬賽克灌注征,有部分可合并肺氣腫、肺不張、肺實(shí)變、胸腔積液、胸膜增厚等表現(xiàn)。 4.嬰幼兒免疫功能的不完善,以及佝僂病、貧血、個(gè)人濕疹史、家族過敏史等可能是導(dǎo)致PIBO的危險(xiǎn)因素。 5.早期臨床識(shí)別和治療能顯著減輕PIBO患兒的反復(fù)咳嗽、喘息等臨床癥狀,改善患兒的生活質(zhì)量,在一定程度上改變PIBO的預(yù)后。
[Abstract]:Research background:
In 1901, German pathologist Lange first proposed that the concept.B0 of bronchiolitis obliterans (BO) is a clinical syndrome of chronic airflow obstruction, which is mainly caused by inflammatory lesions of the small airway. The gold standard for diagnosing B0 is a lung biopsy, but it is very difficult in pediatric lung biopsy and can not be taken to the site of the lesion. .B0 is relatively rare in pediatrics, lack of understanding in pediatricians and lack of large sample studies at home and abroad. Therefore, the epidemiology, pathogenesis, effective treatment and prognosis of B0 are still not very clear. In recent years, with the application of high resolution CT (high-resolution CT, HRCT), the clinical diagnostic rate of B0 has been large The increase of amplitude. The most common cause of children's B0 infection, namely, post-infectious bronchiolitis obliterans (PIBO).B0, seriously affects the health of the children, bringing the mental and economic burden to the family and society of the children, and is increasing the attention of the pediatrics doctor.
The purpose of the study is:
To observe the clinical characteristics of PIBO in children, analyze its etiology, imaging features and immunological changes, summarize the effect of early clinical identification and intervention therapy on PIBO, and provide the basis for the clinical diagnosis and treatment of PIBO.
Research methods:
From September 2010 to November 2011, 25 children were diagnosed as PIBO in the pediatric respiratory Comprehensive Department of Shangdong Province-owned Hospital. The age was -36 months in June. There were 18 males and 7 females. According to the clinical diagnosis of PIBO, the children's cough and wheezing time were divided into two groups (group A) and disease course more than 12 weeks (group B).
The clinical data of children were collected, including age, sex, cough and wheezing at admission, pulmonary auscultation, past treatment, history of eczema, birth history, and allergy history in the family.
Pathogenic detection, including blood culture, sputum culture, nine respiratory tract infection IgM antibodies (adenovirus, Legionella pneumophila, Mycoplasma pneumoniae, Q Rickettsia, Chlamydia pneumoniae, respiratory syncytial virus, influenza A, B influenza, parainfluenza virus 123), Mycoplasma pneumoniae, tuberculosis antibody, Aspergillus antigen, and fungal D- Portuguese. Sugar quantitative, EB virus series, urine CMV-DNA quantitative and so on.
The blood T cell subsets were detected, including CD3+, CD4+, CDS+, CD4/CD8 levels, the detection of blood immunoglobulin IgG, IgA, IgM, IgE and complement C3, C4 level, detection of blood routine, liver function, myocardial enzyme spectrum and so on.
X-RAY and HRCT examinations were performed on the chest.
In 6 cases of cough and long duration of wheezing (all 12 weeks), children with poor clinical treatment were treated with fiberoptic bronchoscopy, alveolar lavage, and bacterial culture and acid staining of alveolar lavage fluid.
Administration of anti infection, hormone (intravenous, oral and inhaled hormone), bronchodilator, macrolide (azithromycin or erythromycin), calcium, vitamin D and other treatment for.2 to 12 weeks, regular outpatient reexamination, record the cough,.6 months after.6 reexamination of the chest HRCT, to observe the improvement.
Some statistical results were expressed with mean standard deviation, and SPSS19.0 statistical software was used for analysis and processing. T test was used for the comparison of the average number of two samples. The difference was statistically significant by P0.05.
The results of the study:
1. clinical characteristics
The age of the children ranged from June to 36 months, and from June to December, there were 14 cases (56%). The incidence of boys was higher than that of girls, and 18 cases (72%) were male. The ratio of male to female was 2.57:1.
25 cases had coughing and wheezing in the clinical diagnosis of PIBO, 20 cases were accompanied by phlegm and phlegm, cough, and the duration of wheezing for 7 weeks to 17 weeks, 12 weeks 13 cases (52%), 12 cases (48%) in 12 weeks (48%) (20%) with fever.3 cases (12%) accompanied by rash, and.1 cases of Candida albicans (4%) with chicken chest by smear examination Cyanosis of the lips, 10 (40%) positive.25 cases of inspiratory three depression (100%) had double lung smelling and wheezing sound, 23 (92%) heard and phlegm sound, 6 (24%) heard and.14 cases (56%) had mild anemia, 12 (48%) had different degree of liver damage, 9 cases (36%) had different degree of myocardial damage.
All children were treated with repeated infusion of "bronchitis, bronchopneumonia, or bronchial asthma" in the treatment of.4 cases (16%).6 cases (24%) with respiratory failure (24%) had been treated with 1-2 days of intravenous hormone treatment, and after the discontinuation of.25 cases (100%) had been treated with bronchiectasis. A slight reduction.
2 cases (8%) had preterm labor history, 2 cases (8%) had birth weight 2.5Kg.15 cases (60%) had eczema history,.12 cases (48%) had family allergy history.
2. etiology: Mycoplasma pneumoniae infection (32%), adenovirus infection in 7 cases (28%), Streptococcus pneumoniae infection in 4 cases (16%), influenza B virus infection 3 cases (12%), Aspergillus infection 3 cases (12%), respiratory syncytial virus infection 1 cases (4%), cytomegalovirus infection, measles virus infection cases, coagulase negative staphylococcus infection cases. 7 cases (28%) were mixed infection of 2 or 3 pathogens, including mixed infection of Mycoplasma pneumoniae and measles virus, 1 cases of Mycoplasma pneumoniae and Aspergillus mixed infection, 1 cases of Mycoplasma pneumoniae and coagulase negative staphylococcus, 1 cases of mixed infection of adenovirus and Japanese influenza virus, 1 cases of mixed infection of adenovirus and Aspergillus, 1 cases of adenovirus and Aspergillus, pneumonia, pneumonia, pneumonia, and pneumonia. Mixed infection of Streptococcus and Aspergillus in 1 cases, Mycoplasma pneumoniae, adenovirus and influenza B virus mixed infection in 1 cases, 4 cases (16%) in.25 cases, no definite pathogen was found.
3. imaging features
Chest X-RAY showed a thickening of lung texture, disorder in 25 cases (100%), patchy infiltration in 17 cases (68%), blurred costal angle in 2 cases (8%), pulmonary atelectasis in 2 cases (8%) and pulmonary consolidation in 3 cases (12%).
25 cases (100%), 22 cases of mosaic perfusion syndrome (88%), 3 cases of localized emphysema (12%), 3 cases of limited pulmonary atelectasis (12%), 3 cases of pulmonary atelectasis (12%), 3 cases of pulmonary atelectasis (12%), 2 cases of pleural effusion (8%), pleural thickening (8%), pleural thickening and thoracic malformation in June. After discharge, the chest HRCT was reviewed in June. The range of ground glass shadow and mosaic perfusion sign was larger than that of PIBO, and the lesions were more obvious. 9 cases of grinding glass shadow or mosaic sign were less than diagnosed PIBO, and the lesions were relieved. There was no obvious change in 15 cases of mosaic perfusion and glass shadow.
4. immunological changes: the blood T cell subgroup showed 4 cases (16%), 5 CD4 decreased (20%), CD8 increased 19 cases (76%), CD4/CD8 decreased in 17 cases (68%). The blood immunoglobulin, IgG decreased in 5 cases (20%), IgA decreased 4 (16%), IgM increased in 1 cases, IgE raised cases, complement decreasing cases.
5. fiberoptic bronchoscopy and treatment: 6 cases of children with fiberoptic bronchoscopy were not found abnormal airway structure or foreign body, and there were different levels of sputum or phlegm obstruction in some pulmonary lobes, of which 1 cases had subsegment subsegment occlusion in the left inferior lobe. 4 cases were relieved of symptoms and signs and 1 Aspergillus infection after lavage treatment. 1 cases of Aspergillus complicated with adenovirus infection still had repeated cough and wheezing, of which 1 cases were treated again with lavage. Only 1 cases of coagulase negative Staphylococcus were cultured with alveolar lavage fluid and acid staining.
6. treatment and prognosis
The shortest follow-up time of all children was in June and the oldest in December. 10 of them had no cough, wheezing and other symptoms, the other 15 cases were relieved obviously before the treatment, only when respiratory infection or violent activities were available. No death cases were present.
After 3 months of discharge from hospital, 20 cases (80%) had no cough, wheezing, only cough, wheezing, coughing, and short duration of wheezing in respiratory tract infection or intense activity. 4 cases were treated for 42~56 days (mean 51.20 + 5.46 days) after cough and.5 cases (20%) were coughing compared with before treatment. The pulmonary wheezing sound still existed at the time of reexamination, of which 4 cases were followed up for.6 months after coughing and wheezing, 25 cases (100%) had no cough and wheeze after treatment, only cough and wheezing in respiratory tract infection or violent activity, 7 of them were treated for 42-165 days (mean 124.32 + 40.78 days) after 42-165 days. The wheeze disappeared.
The number of coughing and wheezing episodes in the 12 weeks group (group A) and the group of 12 weeks (group B) were statistically different, and the results were statistically different. The results showed that early diagnosis and intervention could significantly reduce the number of cough and wheezing episodes in children.
Conclusion:
1.PIBO occurs in infants younger than 1 years old, and the incidence of boys is higher than that of girls.
2. Mycoplasma pneumoniae and adenovirus infection are the main causes of PIBO in children.
There were no specific changes in the chest X-RAY of the 3.PIBO children. The typical manifestations of HRCT were plaque or increased glass like density, and mosaic perfusion syndrome. There were some emphysema, atelectasis, pulmonary consolidation, pleural effusion, pleural thickening, and so on.
4. the imperfections of infants' immune function, rickets, anemia, history of personal eczema and family allergy may be the risk factors of PIBO.
5. early clinical identification and treatment can significantly reduce the clinical symptoms such as recurrent cough and wheezing in children with PIBO, improve the quality of life of the children and change the prognosis of PIBO to a certain extent.
【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】：2012
【分類號(hào)】：R725.6

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