儿童暴发性心肌炎12例临床分析

doi:10.12372/jcp.2023.23e0168

摘要/Abstract

摘要：

目的分析儿童暴发性心肌炎（FM）的临床特点，为儿科医师临床决策提供参考。方法回顾性分析2019年10月至2022年10月在儿科重症监护病房（PICU）住院治疗的FM患儿临床资料。结果纳入FM患儿12例，男5例、女7例，中位年龄10.0（5.6~12.6）岁，起病至就诊中位时间5.0（3.0~6.0）天，中位住院时间12.0（11.0~16.8）天。12例患儿就诊时症状无特异性，11例合并循环系统症状，1例仅有消化道症状。8例以消化系统症状起病，5例以神经系统症状起病，其中2例同时有消化道症状和神经系统症状，1例以呼吸系统症状起病。所有患儿心肌肌钙蛋白I （cTnI）、脑钠肽（BNP）和乳酸脱氢酶（LDH）均升高，中位cTnI水平为5.5（1.4~12.6）ng/L，中位BNP水平为1 1630.0（6 440.0~28 152.0）pg/mL，中位LDH水平为642.0（465.5~1 194.3）U/L;11例心肌肌钙蛋白T（cTnT）升高（1例未测），中位cTnT水平为1.2（0.3~3.9）ng/L;9例血清肌酸激酶（CK）和肌酸激酶同工酶（CK-MB）升高，中位CK水平为348.5（99.3~674.8）U/L，中位CK-MB水平为35.4（24.5~97.2）U/L。10例患儿D-二聚体升高，中位D-二聚体水平为1.7（0.6~3.3）mg/L。所有患儿入院后心电图和彩色多普勒超声心动图均异常。3例患儿应用体外膜肺氧合（ECMO）。10例（83.3%）患儿好转后出院，2例死亡。结论儿童FM起病症状不典型;心肌酶、心电图和超声心动图的阳性率高;ECMO是救治FM的有效手段。

关键词: 暴发性心肌炎, 临床特点, 治疗, 预后, 儿童

Abstract:

Objective To analyze the clinical characteristics of fulminant myocarditis (FM) in children, and to provide references for the clinical decision-making of pediatricians. Methods The clinical data of children with FM who were hospitalized in the pediatric intensive care unit (PICU) from October 2019 to October 2022 were retrospectively analyzed. Results Twelve children with FM (5 boys and 7 girls) were included. The median age was 10.0 (5.6-12.6) years, the median time from onset of disease to treatment was 5.0 (3.0-6.0) days, and the median length of hospital stay was 12.0 (11.0-16.8) days. Twelve patients had no specific symptoms, 11 had circulatory symptoms, and 1 had gastrointestinal symptoms only. The onset symptoms were as follows: 8 children had digestive symptoms, 5 children had neurological symptoms, 2 children had both digestive and neurological symptoms, and 1 child had respiratory symptoms. The levels of myocardial troponinⅠ(cTnⅠ), brain natriuretic peptide (BNP) and lactate dehydrogenase (LDH) were elevated in all children. The median cTnⅠ level was 5.5 (1.4-12.6) ng/L, the median BNP level was 11630.0 (6440.0-28152.0) pg/mL, and the median LDH level was 642.0 (465.5-1194.3) U/L. The myocardial troponin T (cTnT) level was elevated in 11 patients (1 child undetected), and the median cTnT level was 1.2 (0.3-3.9) ng/L. The levels of serum creatine kinase (CK) and creatine kinase isoenzyme (CK-MB) were elevated in 9 patients, the median CK level was 348.5 (99.3-674.8) U/L, and the median CK-MB level was 35.4 (24.5-97.2) U/L. The D-dimer levels were elevated in 10 patients, and the median D-dimer level was 1.7 (0.6-3.3) mg/L. Electrocardiogram and echocardiography were abnormal in all patients after admission. Three patients were treated with extracorporeal membrane oxygenation (ECMO). Ten patients (83.3%) were discharged after improvement, and 2 died. Conclusions The onset symptoms of FM in children are atypical. The positive rates of myocardial enzyme, electrocardiogram and echocardiography were high. ECMO is an effective method to treat FM.

Key words: fulminant myocarditis, clinical feature, treatment, prognosis, child

孙娟, 李海英, 贾沛生, 王怀立. 儿童暴发性心肌炎12例临床分析[J]. 临床儿科杂志, 2023, 41(9): 692-696.

SUN Juan, LI Haiying, JIA Peisheng, WANG Huaili. Clinical analysis of fulminant myocarditis in 12 children[J]. Journal of Clinical Pediatrics, 2023, 41(9): 692-696.

图/表 1

表1

FM患儿12例心电图和超声心动图情况"

病例号	心电图	超声心动图
1	窦性心动过速、不完全右束支传导阻滞	EF26%，左室壁弥漫性搏动异常，左心收缩和舒张功能下降，心包积液（少量），心动过速
2	三度房室传导阻滞	EF49%，右心大，左室壁搏动整体减弱，三尖瓣中度关闭不全，左心功能下降
3	一度房室传导阻滞、左前分支传导阻滞、完全性右束支传导阻滞、ST-T改变	EF58%，全心增大、室壁增厚，全心功能减低，二、三尖瓣轻度关闭不全，心包积液（少量）
4	三度房室传导阻滞、加速性交界性逸搏心律、完全性右束支传导阻滞	EF约56%，二尖瓣、三尖瓣轻度关闭不全，左室舒张功能下降
5	三度房室传导阻滞、加速型室性逸搏心律	EF56%，左室轻度增大，左室收缩和舒张功能下降
6	室性心动过速，二度~高度房室传导阻滞、偶发室性期前收缩	EF约51%，左室前壁搏动幅度减弱，三尖瓣少量反流，心包积液（微量），左室舒张功能下降
7	窦性心动过速、不完全性右束支阻滞、ST 段压低	EF16%，心脏收缩及舒张功能明显下降，左心增大，右心室增大，肺动脉瓣轻度反流，心包积液
8	窦性心动过速、干扰性房室脱节或二度房室传导阻滞、完全性右束支传导阻滞，频发加速型室性逸搏伴逸搏心律、QT及QTc间期延长	左室壁节段性搏动异常、二尖瓣轻度关闭不全、左心收缩功能低下
9	窦性心动过速、三度房室传导阻滞、加速型室性逸搏心律	EF17%，全心增大，左室壁运动幅度弥漫性减弱，二尖瓣、主动脉瓣轻度关闭不全，三尖瓣中度关闭不全，左心收缩功能下降，心包积液
10	双侧心房、左心室肥大，QT间期延长、ST-T改变	EF30%，左室壁搏动普遍明显减弱，左心收缩及舒张功能减低（左室收缩功能明显减低），左心形态饱满
11	一度、二度Ⅰ型房室传导阻滞、完全性左束支传导阻滞	EF约43%，左心增大（左室显著），左室壁运动普遍减弱且不协调，左室心尖部肌小梁稍增多，左心收缩功能减低，卵圆孔未闭
12	Ⅰ、aVL导联呈QS型，可见胚胎r，伴ST段抬高，V3-V6导联ST段抬高，Ⅱ导联基本正常，Ⅲ、V1导联ST段压低	左室后壁增厚，心包积液（少量）

表1

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