发热、头痛、皮肤紫癜2例  

A report of two children with fever, headache, and purpura

作　　者：徐洪波[1] 谭梅[1] 路健[1] 田茂强[1] 陈艳[1] 

机构地区：[1]遵义医学院附属医院小儿内科,贵州遵义563003

出　　处：《中国当代儿科杂志》2017年第9期999-1002,共4页Chinese Journal of Contemporary Pediatrics

摘　　要：该研究2例学龄期患儿于春季急性起病,表现为发热、头痛、呕吐、意识障碍,以及皮肤紫癜、脑膜刺激征阳性。外周血白细胞及中性粒细胞均增高、血红蛋白及血小板不同程度降低;CRP明显增高;脑脊液白细胞数增高达数百或上千、且以中性粒细胞为主,脑脊液蛋白增高,糖、氯化物正常。其中1例头颅CT示右侧小脑、双侧大脑多发血肿。骨髓细胞学提示感染性骨髓象,血培养、骨髓培养均提示金黄色葡萄球菌(MRSA)。患儿抗感染治疗过程中出现心脏杂音,并且血红蛋白及血小板进行性下降,心脏彩超发现主动脉瓣赘生物形成,确诊为感染性心内膜炎(IE)。根据药敏试验改为万古霉素抗感染治疗,1例6周后痊愈,1例放弃治疗死亡。儿童IE起病隐匿,临床表现多样,建议对于不明原因发热患儿要注意动态观察心脏杂音,及时行心脏彩超排除IE;以化脑为表现的患儿伴有难以用血小板减少解释的皮肤、黏膜出血时,也应警惕IE。In this study, two school-aged children had an acute onset in spring and had the manifestations of fever, headache, vomiting, disturbance of consciousness, purpura and ecchymosis, and positive meningeal irritation sign. There were increases in peripheral white blood cells and neutrophils, but reductions in the hemoglobin level and platelet count in the two children. They had a significant increase in C-reactive protein. There were hundreds or thousands of white blood cells in the cerebrospinal fluid, mainly neutrophils. Increased protein contents but normal levels of glucose and chloride in the cerebrospinal fluid were found. Head CT scan showed multiple hematomas in the right cerebellum and both hemispheres in one child. Bone marrow cytology indicated infection in the bone marrow, and both blood culture and bone marrow culture showed methicillin-resistant Staphylococcus aureus（MRSA）. Both patients had cardiac murmurs and progressive reductions in the hemoglobin level and platelet count during treatment, and echocardiography showed the formation of vegetation in the aortic valve. Therefore, the patients were diagnosed with infectious endocarditis（IE）. Vancomycin was used as the anti-infective therapy based on the results of drug sensitivity test. One child was curedafter 6 weeks, and the other child was withdrawn from the treatment and then died. Dynamic monitoring of cardiac murmurs should be performed for children with unexplained fever, and echocardiography should be performed in time to exclude IE. IE should also be considered for children with purulent meningitis and skin and mucosal bleeding which cannot be explained by the reduction in platelet count.

关 键 词：发热 头痛 紫癜 心脏杂音 感染性心内膜炎 儿童 

分 类 号：R725.4[医药卫生—儿科]