Liu Jin-rong, Xu Bao-ping, Li Hui-min, Sun Ji-hang, Tian Bao-lin, Zhao Shun-ying, Jiang Zai-fang
Respiratory and Infectious Diseases Center, Capital Medical University, Beijing, China.
Zhonghua Er Ke Za Zhi. 2012 Jun;50(6):431-4.
Streptococcus pneumoniae necrotizing pneumonia (SPNP) was reported elsewhere but not in China yet. Inappropriate treatment due to poor recognition of this disease could influence its prognosis. This paper presents the clinical characteristics, diagnosis and treatment of SPNP hoping to elevate pediatrician's recognition level for this disease.
Clinical manifestations, radiological findings, treatment and prognosis of 20 patients (9 boys, 11 girls) who had been hospitalized with SPNP in Beijing Children's Hospital from 2004-2011 were retrospectively analyzed.
The patients included in this study aged from 9 months to 6 years [(27.9 ± 15.8) m] and were healthy before admission. They were febrile for 8 to 50 days [(27.7 ± 13.5) d] and hospital day was 24 - 55 days [(36.5 ± 8.3) d]. The general condition of all subjects was relatively poor and they all had fever and cough. One child had moderate fever and nineteen children had high fever. Dyspnea was found in sixteen children. Fine rales were found on auscultation in 18 children, among whom diffuse wheeze appeared in 4 children, and wheezy phlegm was found in two children. Signs of pleural effusion were discovered in all cases by physical examination and chest X-ray. White blood cell (WBC) count was 16.2 - 60.95×10(9)/L and neutrophil was 70.5% - 80.2% in peripheral blood routine test. Erythrocyte sedimentation rate (ESR) was 44 - 109 mm/h [(69.6 ± 16) mm/h]and C-reactive protein (CRP) was 80 - > 160 mg/L. The pleural effusion biochemistry and routine test revealed a WBC count of 6400×10(6)/L-too much to count, polykaryocyte of 51% - 90%, glucose of 0.02 - 1.8 mmol/L, protein of 32 - 51 g/L and LDH of 5475 IU/L-or higher. Pleural effusion culture in all cases and blood culture in 2 cases was positive for Streptococcus pneumoniae. Chest X-ray or CT revealed high density and well-distributed lobar consolidation in one lung or two lungs initially. Single or multiple low density lesions in the area of lobar consolidation were found a week later, accompanied by multiple cystic shadow or cavity at the same time or afterwards. Bulla of lung appeared later. Pleural effusions were found in all patients. Seven cases complicated with hydropneumothorax, two with otitis media, one with heart failure, one with cardiac insufficiency. Seventeen patients were treated with vancomycin or teicoplanin or linezolid two with amoxicillin and clavulanate potassium. Other two patients had been treated with meropenem and cephalosporin antibiotics respectively before admission, and they had been at recovery stage when they were hospitalized. Thoracic close drainage and thoracoscopy were performed respectively in 18 cases and 3 cases, respectively. After a follow up of more than 6 months, chest CT showed that almost all lesions in lungs recovered during 4-6 months. No one received pneumonectomy.
SPNP has special manifestations. The incidence in infants is higher. Patients' general condition is poor and febrile course is relatively long. All patients manifested fever and cough, with a presence of dyspnea in most of them. WBC, neutrophil and CRP elevated apparently. The characteristic of pleural effusion indicates empyema. In early stage, the chest X-ray and CT showed high-density lobar lesions, followed by low-density lesions and cyst gradually. Bulla of lung and/or hydropneumothorax may appear at the late stage. But if diagnosed and treated promptly, the prognosis of SPNP was relatively good.
肺炎链球菌坏死性肺炎（SPNP）在其他地区有报道，但中国尚未见报道。对此病认识不足导致的不恰当治疗可能影响其预后。本文介绍SPNP的临床特征、诊断及治疗，希望提高儿科医生对此病的认识水平。
回顾性分析2004年至2011年在北京儿童医院住院治疗的20例SPNP患儿（男9例，女11例）的临床表现、影像学表现、治疗及预后。
本研究纳入的患儿年龄9个月至6岁[（27.9±15.8）个月]，入院前均健康。发热8至50天[（27.7±13.5）天]，住院天数24至55天[（36.5±8.3）天]。所有患儿一般状况相对较差，均有发热和咳嗽。1例中度发热，19例高热。16例患儿有呼吸困难。18例听诊有细湿啰音，其中4例有弥漫性哮鸣音，2例有喘息性痰鸣音。所有病例体格检查和胸部X线检查均发现胸腔积液征象。外周血常规检查白细胞（WBC）计数为16.2 - 60.95×10⁹/L，中性粒细胞为70.5% - 80.2%。红细胞沉降率（ESR）为44 - 109 mm/h[（69.6±16）mm/h]，C反应蛋白（CRP）为80 - >160 mg/L。胸腔积液生化及常规检查显示白细胞计数6400×10⁶/L - 多至无法计数，多核细胞51% - 90%，葡萄糖0.02 - 1.8 mmol/L，蛋白32 - 51 g/L，乳酸脱氢酶（LDH）5475 IU/L或更高。所有病例胸腔积液培养及2例血培养肺炎链球菌阳性。胸部X线或CT最初显示一侧或双侧肺叶高密度、分布均匀的实变影。1周后在肺叶实变区域发现单个或多个低密度病灶，同时或之后伴有多个囊状阴影或空洞形成。后期出现肺大疱。所有患儿均有胸腔积液。7例合并液气胸，2例合并中耳炎，1例合并心力衰竭，1例合并心功能不全。17例患儿使用万古霉素或替考拉宁或利奈唑胺治疗，2例使用阿莫西林克拉维酸钾治疗。另外2例患儿入院前分别使用美罗培南和头孢菌素类抗生素治疗，入院时已处于恢复期。18例和3例患儿分别进行了胸腔闭式引流和胸腔镜检查。随访6个月以上，胸部CT显示肺部几乎所有病灶在4至6个月内恢复。无一例接受肺切除术。
SPNP有特殊表现。婴儿发病率较高。患儿一般状况差，发热病程相对较长。所有患儿均有发热和咳嗽，多数伴有呼吸困难。白细胞、中性粒细胞及CRP明显升高。胸腔积液特征提示脓胸。早期胸部X线和CT显示肺叶高密度病灶，随后逐渐出现低密度病灶和囊肿。后期可能出现肺大疱和/或液气胸。但如果及时诊断和治疗，SPNP预后相对较好。
