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中华妇幼临床医学杂志(电子版)

中华妇幼临床医学杂志(电子版) ›› 2021, Vol. 17 ›› Issue (02) : 234 -242. doi: 10.3877/cma.j.issn.1673-5250.2021.02.016

所属专题： 文献；

论著

儿童暴发性心肌炎临床特点分析
任兴琼1,2,1,2, 邵淑冉1,1, 张楠俊1,1, 王川1,1, 周开宇1,†,1()   
  • 收稿日期:2020-12-10 修回日期:2021-03-10 出版日期:2021-04-01
  • 通信作者: 周开宇

Analysis of clinical characteristics of fulminant myocarditis

Xingqiong Ren1,2,1,2, Shuran Shao1,1, Nanjun Zhang1,1, Chuan Wang1,1, Kaiyu Zhou1,1,†()   

  • Received:2020-12-10 Revised:2021-03-10 Published:2021-04-01
  • Corresponding author: Kaiyu Zhou
  • Supported by:
    Key Research & Development Project of Sichuan Science and Technology Department(2020YFS0101, 2019YJ0024, 2021YJ0211, 2021YFS0094); National Key Program of Ministry Science and Technology in China " Prevention and Controlling Researches on Reproductive Health and Major Birth Defects"(2018YFC1002301)
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任兴琼, 邵淑冉, 张楠俊, 王川, 周开宇. 儿童暴发性心肌炎临床特点分析[J/OL]. 中华妇幼临床医学杂志(电子版), 2021, 17(02): 234-242.

Xingqiong Ren, Shuran Shao, Nanjun Zhang, Chuan Wang, Kaiyu Zhou. Analysis of clinical characteristics of fulminant myocarditis[J/OL]. Chinese Journal of Obstetrics & Gynecology and Pediatrics(Electronic Edition), 2021, 17(02): 234-242.

目的

探讨儿童暴发性心肌炎(FM)的临床特点及其危险因素。

方法

选择2010年1月至2020年10月，四川大学华西第二医院及成都市妇女儿童中心医院收治的53例FM患儿为研究对象，根据FM患儿预后，将其分为死亡组(n＝23)和幸存组(n＝30)。比较2组FM患儿一般临床资料(年龄、入院前病程等)，入院前及入院时临床症状，实验室检查结果，心电图及影像学检查结果，治疗结局等。采取受试者工作特征(ROC)曲线，对预测FM患儿死亡指标进行ROC曲线分析，并计算曲线下面积(AUC)。本研究遵循的程序符合2013年新修订的《世界医学协会赫尔辛基宣言》要求，并与患儿监护人签署临床研究知情同意书。

结果

①2组FM患儿性别构成比、入院前病程等一般临床资料比较，差异均无统计学意义(P>0.05)。②53例患儿中，入院24 h内死亡为16例(16/23，69.6%)，入院72 h内死亡为20例(20/23，87.0%)。入院前以胃肠道症状最多见(38/53，71.7%)，其次为呼吸道症状(25/53，47.2%)和发热(20/53，37.7%)。2组患儿年龄，住院时间，入院前有呼吸道症状和神经系统症状者所占比例，入院时低血压、微循环障碍和意识障碍者所占比例及收缩压、舒张压分别比较，差异均有统计学意义(P<0.05)。③实验室检查：2组患儿血乳酸、血清Ca2+，动脉血pH值、碱剩余、凝血酶原时间(PT)、国际标准化比率(INR)、活化部分凝血酶原时间(APTT)比较，差异均有统计学意义(P<0.05)。④53例患儿中，50例接受心脏彩色多普勒超声检查，2组患儿左心室收缩功能下降、心包积液所占比例比较，差异均有统计学意义(P<0.05)。2组患儿入院时心电图结果显示Ⅲ°房室传导阻滞(AVB)所占比例比较，差异有统计学意义(P<0.05)。⑤2组患儿均接受综合治疗，其中临时心脏起搏器使用率、血管活性药物评分(VIS)比较，差异均有统计学意义(P<0.05)。⑥血乳酸、动脉血pH值及碱剩余、血清Ca2+、INR、APTT和VIS对预测FM患儿死亡的AUC分别为0.776(95%CI：0.621～0.890，P<0.001)、0.804(95%CI：0.664～0.905，P<0.001)、0.829(95%CI：0.692～0.922，P<0.001)、0.702(95%CI：0.559～0.821，P＝0.016)、0.753(95%CI：0.602～0.869，P＝0.001)、0.791(95%CI：0.644～0.898，P<0.001)和0.890(95%CI：0.774～0.959，P<0.001)。

结论

儿童FM临床特点缺乏特异性，死亡多见于病程早期出现呼吸困难、意识障碍、微循环障碍、左心室射血分数(LVEF)降低、高乳酸血症、依赖大剂量血管活性药物患儿。死亡患儿多集中在入院72 h内，尤其是入院24 h内，对FM高危患儿应尽早给予密切监测及积极机械循环支持。

关键词: 心肌炎, 疾病特征, 预后, 猝死, 心脏, 危险因素, ROC曲线, 儿童
Objective

To investigate clinical characteristics and risk factors of fulminant myocarditis (FM) in children.

Methods

From January 2010 to October 2020, a total of 53 children with FM who were admitted in West China Second University Hospital, Sichuan University and Chengdu Women′s and Children′s Central Hospital were selected into this study. According to their prognosis, they were divided into death group (n=23) and survival group (n=30). The general clinical data (age, course of disease before admission), clinical symptoms before and after admission, and results of laboratory examination, electrocardiogram and imaging examination, treatment outcomes between two groups were compared. The receiver operating characteristics (ROC) curves were drawn, and ROC curves of different indicators to predict death of FM children were analyzed, and area under the curve (AUC) was calculated. This study met the requirements of the World Medical Association Declaration of Helsinki revised in 2013. Informed consent was obtained from each participates.

Results

①There were no significant differences in general clinical data, such as gender composition ratio and the course of illness before admission between two groups (P>0.05). ②Among 53 FM children, 16 (16/23, 69.6%) died within 24 h after admission, and 20 (20/23, 87.0%) died within 72 h after admission. Top 1 clinical symptom of them before admission was gastrointestinal symptoms (38/53, 71.7%), followed by respiratory symptoms (25/53, 47.2%) and fever (20/53, 37.7%). The age, duration of hospital stay, systolic blood pressure, diastolic blood pressure, and proportion of respiratory symptoms and nervous system symptoms before admission, and proportion of hypotension, microcirculation disturbance and consciousness disturbance at admission were compared between two groups, all of these differences were statistically significant (P<0.05). ③There were significant differences between two groups in blood lactate, serum Ca2+ , artery blood pH value and base excess, prothrombin time (PT), international normalized ratio (INR), activated partial thromboplastin time(APTT) (P<0.05). ④There were significant differences between death group (n=20) and survival group (n=30) in ratio of left ventricular function decline and pericardial of fusion by color Doppler echocardiography(P<0.05). There were significant differences between two groups by electrocardiogram in ratio of Ⅲ° atrioventricular block (AVB) (P<0.05). ⑤After comprehensive treatment, and differences between two groups of temporary pacemaker utilization rate and vasoactive-inotropic store (VIS) were statistically significant (P<0.05). ⑥The AUC of blood lactate, artery blood pH value and base excess, serum Ca2+ , INR, APTT and VIS for predicting death of FM children were 0.776 (95%CI: 0.621-0.890, P<0.001), 0.804 (95%CI: 0.664-0.905, P<0.01), 0.829 (95%CI: 0.692-0.922, P<0.001), 0.702 (95%CI: 0.559-0.821, P=0.016), 0.753 (95%CI: 0.602-0.869, P=0.001), 0.791 (95%CI: 0.644-0.898, P<0.001), and 0.890 (95%CI: 0.774-0.959, P<0.001).

Conclusions

The clinical characteristics of children with FM lack specificity, and death of FM children are more common in early onset complicated with dyspnea, disturbance of consciousness, circulatory disturbance, decrease of left ventricular ejection fraction (LVEF), hyperlactacidemia, dependence on large-dose vasoactive drugs. Children who died were mostly within 72 h of admission, especially within 24 h of admission. Children with high risk of FM should be closely monitored and actively supported by mechanical circulation as soon as possible.

Key words: Myocarditis, Disease attributes, Prognosis, Death, sudden, cardiac, Risk factors, ROC curve, Child
表1 2组FM患儿一般临床资料比较
组别 例数 性别[例数(%)] 入院前病程[d，M(P25～P75]
男 女
死亡组 23 13(56.5) 10(43.5) 2.0(1.0～5.0)
幸存组 30 18(60.0) 12(40.0) 3.0(1.0～5.0)
检验值   χ2＝0.065 U＝340.000
P值   0.799 0.928
表2 2组FM患儿入院前及入院时临床资料比较
组别 例数 年龄[月，M(P25～P75)] 住院时间[d，M(P25～P75] 入院前[例数(%)]
胃肠道症状a 呼吸道症状b 神经系统症状c 心脏骤停
死亡组 23 28.0(6.6～87.0) 0.6(0.3～1.2) 15(65.2) 18(78.3) 4(17.4) 3(13.0)
幸存组 30 97.5(67.2～138.0) 18.5(15.0～23.0) 23(76.7) 7(23.3) 13(43.3) 2(6.7)
检验值   U＝525.500 U＝690.000 χ2＝0.841 χ2＝15.762 χ2＝4.021 χ2＝0.098
P值   0.001 <0.001 0.359 <0.001 0.045 0.754
组别 例数 入院前[例数(%)] 入院时
胸痛或心悸 发热 低血压[例数(%)] 收缩压[mmHg，M(P25～P75)] 舒张压[mmHg，M(P25～P75)] 微循环障碍[例数(%)]d 意识障碍[例数(%)]
死亡组 23 1(4.4) 7(30.4) 16(69.6) 71.0(60.0～89.0) 43.0(26.0～57.0) 18(78.3) 14(60.9)
幸存组 30 7(23.3) 13(43.3) 9(30.0) 95.0(79.5～103.5) 54.5(47.2～64.2) 8(26.7) 6(20.0)
检验值   χ2＝2.330e χ2＝0.922 χ2＝8.178 U＝510.500 U＝478.500 χ2＝13.867 χ2＝9.255
P值   0.127 0.337 0.004 0.003 0.016 <0.001 0.002
表3 2组FM患儿实验室检查结果
组别 例数 cTnI[ng/mL，M(P25～P75)] CK-MB[ng/mL，M(P25～P75)]a LDH[U/L，M(P25～P75)]b ALT[U/L，M(P25～P75)] AST[U/L，M(P25～P75)] 尿素氮[mmol/L，M(P25～P75)]
死亡组 23 2.7(0.8～8.1) 20.8(12.1～65.1) 1 433.0(968.4～3 251.0) 114.0(29.6～1 001.0) 407.3(82.0～1 024.6) 7.8(4.3～10.6)
幸存组 30 8.6(2.5～21.0) 21.5(4.3～51.6) 1 555.5(868.5～2 733.8) 116.0(41.8～447.8) 199.5(65.5～887.8) 7.4(5.4～9.2)
检验值   U＝246.000 U＝235.000 U＝313.500 U＝344.000 U＝280.000 U＝320.000
P值   0.076 0.416 0.872 0.986 0.243 0.654
组别 例数 肌酐[μmol/L，M(P25～P75)] 血乳酸[mmol/L，M(P25～P75)]c CRP[mg/L，M(P25～P75)] 血清K+(mmol/L，±s) 血清Na+(mmol/L，±s) 血清Ca2+(mmol/L，±s)
死亡组 23 50.5(31.0～139.0) 7.1(4.6～15.5) 9.0(5.0～16.0) 4.5±1.2 135.9±6.9 1.9±0.3
幸存组 30 58.0(40.5～70.2) 3.3(2.5～7.5) 13.8(5.5～44.5) 4.1±0.8 134.4±5.2 2.1±0.2
检验值   U＝338.000 U＝98.000 U＝261.500 t＝1.367 t＝0.888 t＝—2.565
P值   0.900 0.002 0.134 0.178 0.379 0.013
组别 例数 pH值(±s)d 碱剩余(mmol/L, ±s)d PT[s，M(P25～P75)]e INR[M(P25～P75)]e APTT[s，M(P25～P75)]e 病原学检查呈阳性[例数(%)]f
死亡组 23 7.2±0.2 -16.0±7.9 21.5(15.8～ 29.3) 1.8(1.4～2.6) 50.7(37.4～57.9) 6(30.0)
幸存组 30 7.4±0.1 -6.0±7.0 14.6(12.4～ 21.4) 1.2(1.1～1.5) 33.9(29.0～42.9) 4(13.8)
检验值   t＝—4.625 t＝—4.641 U＝120.000 U＝122.000 U＝103.000 χ2＝1.046g
P值   <0.001 <0.001 0.004 0.004 0.001 0.306
表4 2组FM患儿心电图及影像学检查结果
组别 例数 心脏彩色多普勒超声a
心脏长大[例数(%)] 左心室收缩功能下降[例数(%)] LVEF[%，M(P25～P75)] FS[%，M(P25～P75)] 心包积液[例数(%)] 瓣膜反流[例数(%)] 室间隔或室壁增厚[例数(%)]
死亡组 23 12(60.0) 15(75.0) 39.3(26.0～53.5) 19.1(12.0～27.8) 3(15.0) 8(40.0) 2(10.0)
幸存组 30 19(63.3) 14(46.7) 58.0(40.2～61.2) 30.0(19.8～32.2) 15(50.0) 11(36.7) 10(33.3)
检验值   χ2＝0.057 χ2＝3.955 U＝204.000 U＝197.500 χ2＝6.380 χ2＝0.057 χ2＝2.417
P值   0.812 0.047 0.106 0.059 0.012 0.812 0.120
组别 例数 心电图
T波改变[例数(%)] 完全右束支传导阻滞[例数(%)] 完全左束支传导阻滞[例数(%)] 室性逸搏心律[例数(%)] 室性早搏[例数(%)] 室性心动过速[例数(%)] 心室颤动[例数(%)]
死亡组 23 14(60.9) 3(13.0) 2(8.7) 5(21.7) 6(26.0) 6(26.0) 1(4.3)
幸存组 30 23(76.7) 7(23.3) 0(0) 8(26.7) 11(36.7) 3(10.0) 1(3.3)
检验值   χ2＝1.542 χ2＝0.354c — χ2＝0.171 χ2＝0.669 χ2＝1.385c —
P值   0.214 0.552 0.184 0.679 0.413 0.239 1.000
组别 例数 心电图
房性早搏[例数(%)] 房性心动过速[例数(%)] 心房颤动[例数(%)] Ⅰ°AVB[例数(%)] Ⅱ°AVB[例数(%)] Ⅲ°AVB[例数(%)] 异常Q波[例数(%)] 胸部X射线摄片或CT检查[例数(%)]b
死亡组 23 0(0) 2(8.7) 1(4.3) 1(4.3) 1(4.3) 4(17.4) 2(8.7) 7(38.9)
幸存组 30 3(10.0) 1(3.3) 0(0) 3(10.0) 1(3.3) 15(50.0) 3(10.0) 17(56.7)
检验值   — — — χ2＝0.061c — χ2＝6.019 χ2＝0.000c χ2＝1.422
P值   0.249 0.573 0.434 0.805 1.000 0.014 1.000 0.233
表5 2组FM患儿治疗情况比较
组别 例数 安置临时心脏起搏器[例数(%)] 血液净化[例数(%)] 心脏电复律[例数(%)] VIS[分，M(P25～P75)] ECMO[例数(%)]
死亡组 23 3(13.0) 3(13.0) 6(26.1) 30.0(15.0～55.0) 1(4.3)
幸存组 30 13(43.3) 6(20.0) 2(6.7) 5.0(5.0～15.0) 2(6.7)
检验值   χ2＝5.668a χ2＝0.090a χ2＝2.466a U＝76.000 χ2＝0.000a
P值   0.017 0.765 0.116 <0.001 1.000
表6 预测FM患儿死亡指标的ROC曲线分析比较
指标 ROC曲线 最佳临界值 敏感度(%) 特异度(%) 约登指数
AUC AUC 95%CI P值
血乳酸(mmol/L) 0.776 0.621～0.890 <0.001 3.60 60.9 89.5 50.4
pH值 0.804 0.664～0.905 <0.001 7.18 96.2 50.0 46.2
碱剩余(mmol/L) 0.829 0.692～0.922 <0.001 —5.20 61.5 95.4 56.9
血清Ca2+(mmol/L) 0.702 0.559～0.821 0.016 1.94 83.3 68.2 51.5
INR 0.753 0.602～0.869 0.001 1.31 65.4 78.9 44.3
APTT(s) 0.791 0.644～0.898 <0.001 36.30 73.1 84.2 57.3
VIS(分) 0.890 0.774～0.959 <0.001 20.00 96.7 65.2 61.9
图1 血清Ca2+、INR、VIS和APTT预测FM患儿死亡的ROC曲线
图2 碱剩余、血乳酸和pH值预测FM患儿死亡的ROC曲线
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