【摘要】：目的：總結(jié)暴發(fā)性心肌炎（Fulminant myocarditis，F(xiàn)MC）患兒的臨床診斷特點(diǎn)和治療措施，為小兒FMC的及時(shí)診斷和治療提供臨床依據(jù)。 方法：回顧性分析重慶醫(yī)科大學(xué)附屬兒童醫(yī)院1998年6月-2012年10月臨床診斷FMC并收治住院的70例兒童的臨床資料，從一般情況、臨床表現(xiàn)、輔助檢查結(jié)果、治療方法及預(yù)后等方面進(jìn)行歸納分析。應(yīng)用SPSS19.0統(tǒng)計(jì)軟件分析。 結(jié)果： 1.一般資料：70例FMC患兒，男性36例（51.43%），女性34例（48.57%），年齡7天至14歲，平均發(fā)病年齡（4.99±4.21）歲，起病后就診時(shí)間最短15分鐘，最長(zhǎng)15天，3天內(nèi)就診46例。 2.臨床表現(xiàn)：67例（95.71%）有明確的前驅(qū)感染史，首發(fā)癥狀以心外表現(xiàn)多見，其中呼吸系統(tǒng)（28.57%）與消化系統(tǒng)（27.14%）最常見，臨床表現(xiàn)多以活動(dòng)量下降（85.71%）、發(fā)紺（67.14%）、面色蒼白（74.28%）等非特異性癥狀為主要表現(xiàn)，以心音低鈍（95.71%）、律不齊（45.71%）為主要體征，易合并充血性心力衰竭（78.57%）、心源性休克（62.86%）、持續(xù)性室性心動(dòng)過(guò)速（32.86%）或阿斯綜合征（32.86%）等危急重癥。 3.輔助檢查： （1）病原學(xué)檢查：柯薩奇病毒B組最常見。 （2）心肌酶譜與肌鈣蛋白：本組病例94.44%（51/54）心肌酶譜有不同程度的異常，其中74.07%（40/54）肌酸激酶同功酶MB型（MBisoenzyme of creatine kinase，CK-MB）升高，31.11%（14/45）的患兒肌鈣蛋白異常。治愈組CK-MB、谷草轉(zhuǎn)氨酶、乳酸脫氫酶較死亡組低，治療后的肌酸激酶、CK-MB、谷草轉(zhuǎn)氨酶、乳酸脫氫酶、α-羥丁酸脫氫酶水平較治療前降低，差別均有統(tǒng)計(jì)學(xué)意義（P0.05）。 （3）心電圖（ECG）：以ST-T改變、T波改變及各型心律失常多見，異常比例93.85%（61/65）。 （4）心臟彩色超聲心動(dòng)圖（UCG）：93.10%（27/29）患兒出現(xiàn)不同程度的異常，治愈組左室短軸縮短率水平較死亡組高（P0.05），治療后的左室射血分?jǐn)?shù)、左室短軸縮短率水平均較治療前升高（P0.05）。 4.治療情況：以綜合、對(duì)癥為主。糖皮質(zhì)激素使用率為77.14%，使用組的治愈率（55.10%）比未使用組（8.33%）高（P0.05）；靜脈丙種球蛋白（IVIG）使用率22.86%，同樣，使用組的治愈率（68.75%）比未使用組（37.78%）高（P0.05）。 5.預(yù)后：70例患兒中，28例（40.00%）治愈，33例（47.14%）死亡，9例因自動(dòng)放棄且失訪而預(yù)后不詳。 結(jié)論： 1.小兒FMC起病急、病情進(jìn)展快，多數(shù)有病毒感染的前驅(qū)癥狀，臨床表現(xiàn)多樣，，首發(fā)癥狀以心外表現(xiàn)為主，其中呼吸消化系統(tǒng)多見，因而早期診斷困難，可迅速出現(xiàn)心力衰竭、心源性休克、阿斯綜合征或嚴(yán)重心律失常等并發(fā)癥，病死率高。 2.病原學(xué)以柯薩奇病毒B組最常見，CK-MB、肌鈣蛋白升高是心肌炎的重要特征之一，ECG、UCG結(jié)果雖無(wú)特異性表現(xiàn)，但亦能為該病的診斷提供重要的臨床依據(jù)。 3.FMC患兒早期綜合使用糖皮質(zhì)激素和IVIG治療及積極的搶救對(duì)癥治療，可能可以使搶救成功率提高。
[Abstract]:Objective: to summarize the clinical diagnosis and treatment of fulminant myocarditis (Fulminant myocarditis,FMC) in order to provide clinical basis for the timely diagnosis and treatment of infantile FMC. Methods: the clinical data of 70 children with FMC diagnosed from June 1998 to October 2012 in affiliated Children's Hospital of Chongqing Medical University were retrospectively analyzed. Treatment methods and prognosis were summarized and analyzed. SPSS19.0 statistical software was used to analyze. Results: 1. General data: 70 children with FMC, 36 males (51.43%) and 34 females (48.57%), aged from 7 days to 14 years old, the average onset age was (4.99 鹵4.21) years. 46 cases were treated in 3 days. 2. Clinical manifestations: 67 cases (95.71%) had a clear history of preemptive infection, and the first symptoms were mostly extracardiac, among which the respiratory system (28.57%) and digestive system (27.14%) were the most common. The main clinical manifestations were decreased activity (85.71%), cyanosis (67.14%), pale complexion (74.28%), low heart tone (95.71%) and irregular rhythm (45.71%). It is easy to be complicated with congestive heart failure (78.57%), cardiogenic shock (62.86%), persistent ventricular tachycardia (32.86%) or ASAS syndrome (32.86%). 3. Auxiliary examination: (1) Pathology examination: Coxsackie virus B group is the most common. (2) Myocardial enzyme spectrum and cardiac troponin: in this group, 94.44% (51 / 54) of the patients had abnormal myocardial zymogram, 74.07% (40 / 54) creatine kinase isoenzyme MB type (MBisoenzyme of creatine kinase,CK-MB increased. 31.11% (14 / 45) of children had abnormal cardiac troponin. The levels of creatine kinase, CK-MB, aspartate aminotransferase, lactate dehydrogenase and 偽 -hydroxybutyrate dehydrogenase in the cured group were lower than those in the dead group, and the levels of creatine kinase, CK-MB, glutamic oxaloacetic transaminase, 偽 -hydroxybutyrate dehydrogenase were decreased after treatment. The difference was statistically significant (P0.05). (3) ST-T, T wave and arrhythmias were the most common changes in (ECG):, and the abnormal rate was 93.85% (61 / 65). (4) (UCG): of cardiac color echocardiography was 93.10% (27 / 29) in children with different degrees of abnormality. The shortening rate of left ventricular short axis in the cured group was higher than that in the dead group (P0.05), and the left ventricular ejection fraction (LVEF) after treatment was significantly higher in the cured group than in the dead group (P0.05). The shortening rate of left ventricular short axis was higher than that before treatment (P0.05). 4. Treatment: comprehensive, symptomatic. The utilization rate of glucocorticoid was 77.14%, the cure rate in the use group (55.10%) was higher than that in the non-use group (8.33%) (P0.05). The utilization rate of intravenous immunoglobulin (IVIG) was 22.86%. Similarly, the cure rate in the use group (68.75%) was higher than that in the untreated group (37.78%) (P0.05). 5. Prognosis: among 70 cases, 28 cases (40.00%) were cured, 33 cases (47.14%) died. Conclusion: 1. Children with FMC have urgent onset and rapid progress. Most of them have the precursor symptoms of virus infection, and their clinical manifestations are diverse. The first symptoms are mainly extra-cardiac symptoms, in which the respiratory and digestive system is more common, so early diagnosis is difficult, and heart failure can occur rapidly. Cardiogenic shock, ASAS syndrome or severe arrhythmia and other complications, high mortality. 2. Coxsackie virus group B is the most common etiology. The elevation of CK-MB, troponin is one of the important characteristics of myocarditis. Although the results of ECG,UCG have no specific manifestation, they can provide important clinical basis for the diagnosis of the disease. Early comprehensive use of glucocorticoid and IVIG and active rescue therapy in children with 3.FMC may improve the success rate of rescue.
【學(xué)位授予單位】：重慶醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2013
【分類號(hào)】：R725.4

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