累及神经系统手足口病患儿临床特征及危重症危险因素分析

目的 探讨重症和危重症手足口病患儿典型的临床体征和辅助检查指标，丰富卫生部《手足口病诊疗指南》（2008年版）的内容。方法 以2008年5～12月在广州市妇女儿童医疗中心儿童医院住院治疗的累及神经系统手足口病重症和危重症患儿为研究对象。对临床特征和辅助检查结果进行汇总分析，比较重症组和危重症组神经、呼吸和循环系统表现，以及辅助检查结果的差异，Logistic回归分析重症进展为危重症的危险因素。结果 142例患儿进入分析，其中男88例，女54例；<3岁110例（77.5％）。重症组75例，危重症组67例。①高热82例(57.7％)，热程(5.68±3.19) d；典型皮疹88例（62.0％）；②神经系统主要表现：肢体震颤107例(75.4%)、精神差93例(65.5%)、烦躁86例(60.6%)、双膝反射活跃或亢进79例(55.6%)、惊跳78例(54.9%)、呕吐73例(51.4%)；③循环和呼吸系统主要表现：心率增快35例(24.6%)、CRT 3~5 s 34例(23.9%)、呼吸浅快31例(21.8%)、呼吸节律不规则29例(20.4%)、血压升高21例(14.8%)、CRT>5 s 19例(13.4%)、肺出血9例(6.3%)；④辅助检查：WBC>12×109·L-1 55例(38.7%)、血糖升高90例(63.4%)、胸部X线片提示肺部渗出性病变36例(25.4%)；⑤危重症组颈抵抗、肌张力增高或减低、抽搐、肢体无力、眼球运动异常、心率增快、血压升高、CRT 3~5 s或>5 s、呼吸浅快、呼吸节律不规则和肺部渗出性病变发生率均显著高于重症组；⑥多因素Logistic回归分析显示，心率增快（OR=17.918,95%CI:4.634~69.284）、CRT>5 s(OR=8.985, 95%CI: 1.568~51.488)、颈抵抗(OR=8.467,95%CI: 1.964~36.513)和肺部渗出性病变(OR=7.692, 95%CI:2.345~25.235)是重症患儿进展为危重症的危险因素；⑦治疗和预后：6例死亡，136例治愈或好转出院，随访6～12个月，未发现明显的智力落后、继发性癫及肢体瘫痪。结论 肢体震颤、精神差、烦躁、惊跳、呕吐及膝反射活跃或亢进是神经系统病变的早期症状和体征；心率增快、CRT>5 s、颈抵抗及肺部渗出性病变是手足口病重症患儿进展为危重症的高危因素。

Clinical features and critical illness risk factors of children with hand, foot and mouth disease of neurological involvement

Objective To explore the typical clinical features and assistant examination indexes of intensive care children with hand, foot and mouth disease (HFMD), enrich Guide for the Diagnosis and Treatment of Hand, Foot and Mouth Disease established by Ministry of Health of the People′s Republic of China in 2008, and provide the reference for the clinical diagnosis and treatment of HFMD.Methods The sick children with HFMD of neurological involvement treated in Guangzhou Women and Children's Medical Center from May to December in 2008, were recruited and divided into the severe illness and the intensive care groups according to their status. The information on fever, rash and clinical manifestations of nervous, respiratory and circulatory systems, and the laboratory examination data were summarized and analyzed. The difference was analyzed on the clinical manifestation and the laboratory examination between the two groups. Then the high risk factors of critical illness were analyzed by logistic regression analysis.Results One hundred and forty-two recruited cased with HFMD of neurological involvement included 88 males and 54 females, 110 younger than 3 years old cases (77.5%), 67 in the intensive care group and 75 in the severe ill group. ① 82 cases were with high fever (57.7%), and the fever duration was (5.68±3.19) d, 88 cases presented typical rash (62.0%). ② The major neurological features included limb tremor (75.4%, 107/142), fatigue (65.5%,93/142), restlessness (60.6%, 86/142), irritation (54.9%, 78/142), vomiting (51.4%, 73/142) and double knee reflex hyperactivity (55.6%,79/142). ③ The clinical manifestations of circulatory and respiratory systems included tachycardia (24.6%, 35/142), hypertension (14.8%, 21/142), capillary refill time being more than 5 seconds (13.4%, 19/142), tachypnea (21.8%, 31/142), respiratory rhythm abnormality (20.4%, 29/142), pneumorrhagia(6.3%, 9/142). ④ Among all 142 cases, there were 55 cases (38.7%) with a peripheral blood WBC count of more than 12×10~9·L~(-1), 90 cases (63.4%) with blood glucose level of more than 6 mmol·L~(-1), and 36 cases (25.4%) whose chest X-ray showed lung exudative lesion. ⑤ Between the intensive care group and the severe illness group, there was significant difference in cervical rigidity, hypermyotonia or hypomyotonia, convulsion, limb weakness, eye movement abnormality, tachycardia, high blood pressure, capillary refill time being more than 3 or 5 seconds, tachypnea, respiratory rhythm abnormality and lung exudative lesion. ⑥ Multivariate logistic regression analysis showed that tachycardia (OR=17.918, 95%CI: 4.634-69.284), capillary refill time being more than 5 seconds (OR=8.985, 95%CI: 1.568-51.488), cervical rigidity (OR=8.467, 95%CI: 1.964-36.513), and lung exudative lesion (OR=7.692, 95%CI:2.345-25.235) were the high risk factors of intensive care children with HFMD of neurological involvement. ⑦ Except for the conventional treatments, 43 cases in the intensive care group were treated with respirator by the tracheal intubation. 136/142 cases well recovered and had no sequelae affirmed by the follow-up survey after 0.5-1 year, and 6 cases died.Conclusions The early symptoms and signs of neurological complications caused by HFMD include limb tremor, fatigue, restlessness, irritation, vomiting and double knee reflex hyperactivity. The high risk factors of critical illness associated with HFMD are tachycardia, capillary refill time being more than 5 seconds, cervical rigidity and lung exudative lesion.