1、兒童嗜肺軍團菌肺炎合并肺炎支原體感染的臨床研究基金項目：國家自然科學基金資助項目（批準號：10971168）。何志慧， 周玉福， 石遠濱（400700重慶，重慶市第九人民醫(yī)院兒科）【摘 要】 目的 對兒童嗜肺軍團菌(Legionella pneumophila, Lp)肺炎合并肺炎支原體(Mycoplasma pneumoniae，MP)感染的臨床特征進行研究總結，為臨床防治積累資料 。 方法 收集本院2010年1月2012年1月收治的225例Lp感染、其中有98例合并MP感染的肺炎患兒的臨床資料，對其臨床特征作回顧性對比分析。結果 LP與MP混合感染所致兒童肺炎多見于城鎮(zhèn)學齡前期兒童, 與單

2、獨LP感染肺炎組比較：混合感染組多表現(xiàn)為熱峰高、熱程長，出現(xiàn)肺部陽性體征、心率增快、頸淋巴結腫大和肝臟增大的發(fā)生例數(shù)顯著增多，差異有統(tǒng)計學意義（P0.05）；輔助檢查出現(xiàn)胸片大片斑片影及胸腔積液表現(xiàn)，出現(xiàn)WBC增高、CRP增高、心電圖陽性表現(xiàn)（心動過速ST-T改變）、CK-MB增高、肝功異常的例數(shù)顯著增多，差異有統(tǒng)計學意義（P0.05）；所需治療時間顯著延長，差異有統(tǒng)計學意義（P0.05）。結論 兒童LP肺炎合并 MP混合感染可群體發(fā)病，常表現(xiàn)為肺部癥狀體征重、更易合并肺外多器官及多系統(tǒng)的損害。應積極開展大樣本、多中心的研究以獲得我國感染現(xiàn)狀的可靠資料，從而為臨床防治提供思路和對策。【關鍵詞】

3、兒童 嗜肺軍團菌 肺炎支原體 肺炎The clinical research of childhood legionella pneumophila pneumonia combined with mycoplasma pneumoniae infection HE Zhihui, ZHOU Yufu , SHI Yuanbing(Department of Pediatrics, The Ninth Peoples Hospital of Chongqing, Chongqing 400700, China) Abstract Objective To summarize the clini

4、cal features of childhood legionella pneumophila pneumonia (Lp) combined with mycoplasma pneumoniae (Mp) infection ,to accumulate materials for the clinical prevention and treatment. Methods Clinical data of 255 cases infected with childhood legionella pneumophila pneumonia (in which 98 cases combin

5、ed with Mp infection) admitted to The Ninth Peoples Hospital of Chongqing from January 2010 to January 2012 were collected, and their clinical features were compared and analyzed. Results Childhood pneumonia due to LP and MP mix infection is more common in urban preschool children. Compared with the

6、 LP pneumonia group, most in mixed infection group have performance of: high thermal peak, long thermal path. And there is a significant increase in the number of cases for positive signs of lung, heart rate increase, enlargement of lymph nodes and liver (P0.05). And with auxiliary examination have

7、performance of : large areas of plaques shadow and pleural effusion in Chest X-ray, WBC increase, CRP increase, ECG positive (tachycardia / ST-T changes), CK-MB increase, cases with liver function abnormal were significantly increased (P0.05). And the required treatment time was significantly prolon

8、ged, the difference was statistically significant (P 1：16為陽性。其中僅符合LP實驗室血清學診斷標準的患兒共127例，既符合LP又符合MP實驗室血清學診斷標準的患兒共98例，該225例患兒皆不符合其他檢測指標的實驗室血清學診斷標準。將225例病例分為2組，其中LP組127例， LP+MP組98例，兩組病人一般資料詳見表1。1.2 方法 分別對比分析兩組患兒的主要臨床表現(xiàn)以及主要輔助檢查結果，兩組患兒均應用降溫、保持呼吸道通暢、對癥及阿奇霉素抗感染、營養(yǎng)心臟/肝臟等綜合治療措施。出院標準：臨床癥狀體征消失及各項輔助檢查正?；蚝棉D。表1 LP

9、組與LP+MP組患兒一般資料 組別n男女年齡范圍平均年齡（歲）農村城鎮(zhèn)平均住院天數(shù)（天）LP組12769584個月-12歲2.92.557708.81.39LP+MP組9844549月-8歲3.12.1207810.71.701.3 統(tǒng)計學分析采用SPSS15.0 統(tǒng)計軟件對數(shù)據進行統(tǒng)計處理。計量資料均值以均數(shù)標準差(s)表示，其中率的比較用檢驗，兩樣本均數(shù)比較用t檢驗，以p0.05為差異有統(tǒng)計學意義。結果2.1 一般資料從表1可知，兩組發(fā)病年齡均以學齡前期兒童為主。從病人分布來看，LP組中城鎮(zhèn)患兒占55.1（70/127例），LP+MP組城鎮(zhèn)患兒占79.6（78/98例）,兩組相比有統(tǒng)計學差

10、異（=14.718，P0.001）。而從住院的平均時間來看，LP組（8.81.39天）較LP+MP組（10.71.70天）顯著縮短（t= -2.921, P0.05）。主要臨床表現(xiàn)兩組病人的臨床表現(xiàn)比較結果顯示：LP組與LP+MP組有咳嗽、腹痛及吐瀉、皮疹表現(xiàn)的發(fā)生例數(shù)的差異比較無統(tǒng)計學意義（P0.05）；而LP+MP組有發(fā)熱、熱峰高（40）、熱程長（5天）、肺部陽性體征、心率增快、頸淋巴結腫大和肝臟增大的發(fā)生例數(shù)與LP組比較顯著增多，差異有統(tǒng)計學意義（P0.05），詳見表2。表2 LP組與LP+MP組患兒主要臨床表現(xiàn)比較 n 組別n咳嗽發(fā)熱熱峰（40）熱程（5天）腹痛、吐、瀉肺部陽性體征心率

11、增快頸淋巴結腫大肝臟增大皮疹LP組1271271027456439723211913LP+MP組989898786534894632269X2-21.70311.47610.9990.0178.04821.6217.9804.6280.069p-0.0010.0010.0010.8960.0058mg/L）、心電圖陽性表現(xiàn)（心動過速ST-T改變）、CK-MB增高（24及100U/L）、肝功異常（ASTALT）的發(fā)生例數(shù)與LP組比較顯著增多，差異有統(tǒng)計學意義（P8mg/L）心電圖CK-MB（U/L）肝功紋理增多大片斑片影胸腔積液41020心動過速ST-T改變24100AST異常ALT異常LP組1

12、2712746225812165552345122016LP+MP組9898661216483478644570324536X2-21.43810.7930.4194.9539.87519.27610.74420.28428.68318.93324.51018.134p-0.001.0010.5180.0260.0020.0010.0010.0010.0010.0010.0018mg/L）、心電圖陽性表現(xiàn)（心動過速ST-T改變）、CK-MB增高（24及100U/L）、肝功異常（ASTALT增高）的例數(shù)與LP組比較顯著增多。以上結果提示LP與MP混合感染所致肺炎較重、更易合并肺外系統(tǒng)的損害，臨床

13、中如遇到肺炎病兒熱峰高、熱程長、胸片示大片斑片影及胸腔積液且合并存在肺外癥狀體征表現(xiàn)時，應高度警惕LP與MP混合感染可能。LP與MP混合感染及單獨LP感染兩組患兒經降溫、保持呼吸道通暢、對癥及阿奇霉素抗感染、營養(yǎng)心臟/肝臟等綜合治療措施后，皆臨床癥狀體征消失，各項輔助檢查正常或好轉出院，提示目前的抗感染措施仍為有效。從住院的平均時間來看，LP+MP組（10.71.70天）較LP組（8.81.39天）顯著延長，提示混合感染的治療難度較大、需要恢復時間長。有研究顯示LP在培養(yǎng)的人巨噬細胞中增生更加迅速, 提示嗜肺軍團菌的毒力可能因發(fā)生變異更強21。成人LP肺炎有引起ARDS及死亡病例的報道22，國

14、外有報道MP肺炎也有趨向難治的傾向23，國內亦有兒童難治性MP肺炎的報道24，故今后對兒童LP肺炎及混合MP感染的治療及預防仍顯得任重道遠應受到更多關注 。綜上所述，兒童LP肺炎合并 MP混合感染多見于城鎮(zhèn)學齡前兒童，可群體發(fā)病，常表現(xiàn)為熱峰高、熱程長、肺部癥狀體征重、更易合并肺外多器官及多系統(tǒng)的損害。對此，臨床醫(yī)務人員和防疫部門應給予重視，積極開展大樣本、多中心的研究以獲得我國感染現(xiàn)狀的可靠資料，從而為臨床防治提供思路和對策。 參考文獻1 McDade J E, Shepard C C, FraserD W, et al. Legionnairesdisease, isolation of

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