儿童肺结核、结核性脑膜炎引起噬血细胞综合征1例  

A case of hemophagocytic syndrome caused by pulmonary tuberculosis and tuberculous meningitis in children

作　　者：王汝琼 林道炯 曾玫 战跃福 周琼花 林意 Wang Ruqiong;Lin Daojiong;Zeng Mei;Zhan Yuefu;Zhou Qionghua;Lin Yi(Infection Department of Hainan Women and Children's Medical Center,Hainan Haikou 570311,China;Infection Department of Shanghai Fudan University Affiliated Pediatric Hospital,Shanghai 201102,China;Radiology Department,Shenzhen Longgang District Third People's Hospital,Guangdong Shenzhen 518100,China)

机构地区：[1]海南省妇女儿童医学中心感染科,海南海口570311 [2]复旦大学附属儿科医院感染传染科,上海201102 [3]深圳市龙岗区第三人民医院放射科,广东深圳518100

出　　处：《新发传染病电子杂志》2024年第5期68-72,共5页Electronic Journal of Emerging Infectious Diseases

基　　金：海南省临床医学中心建设项目(琼卫医函【2021】75号)。

摘　　要：肺结核(pulmonary tuberculosis)是我国常见的慢性传染性疾病,在儿童多见原发综合征。结核性脑膜炎(tuberculous meningitis,TBM)是儿童肺外结核中最危重的疾病,具有病情进展快、早期诊断难、易误诊误治、遗留后遗症、病死率高等特点,严重威胁患儿的生命健康。噬血细胞综合征(hemophagocytic lymphohistiocytosis,HLH)是异常免疫激活导致的过度炎症反应和组织破坏综合征,主要发生于儿童,典型的临床表现为发热、肝脾肿大、血细胞减少、肝功能损害伴噬血现象、铁蛋白升高、低纤维蛋白原血症。如患儿同时存在肺结核、TBM及HLH,那么尽早明确诊断并给予正确治疗对患者的预后非常重要。本文报道1例10岁儿童,因反复发热、咳嗽就诊。既往体健,无基础疾病。此次发病初步诊断为肺炎,外院治疗无好转,骨髓穿刺提示噬血细胞,病情加重入海南省妇女儿童医学中心诊治。入本院后诊断为重症肺炎、HLH,按照指南方案治疗HLH,并予抗细菌、真菌感染治疗,丙种球蛋白支持治疗等。患儿症状无缓解,病情仍进行性加重,进一步检查脑脊液宏基因组学第二代测序(metagenomics next-generation sequencing,mNGS)结果提示结核分枝杆菌阳性,痰液GeneXperts(结核和利福平耐药快速分子鉴定)阳性,给予四联抗结核治疗。患儿后期出现脑疝,放弃治疗后死亡。通过此病例探讨肺结核、结核性脑膜炎引起HLH的临床表现、影像学改变、病原学检查及诊疗过程,提高临床医生对儿童重症结核病诱发HLH的认识。Pulmonary tuberculosis is a common infectious disease in China,and primary syndrome is more common in children.Tuberculous meningitis is the most critical disease among children with tuberculosis,which is progressing rapidly,with high disability and mortality rates.Hemophagocytic syndrome(HLH)is a group of diseases with rapid progress and high mortality,and its incidence rate is high in children.If the patient also has pulmonary tuberculosis,tuberculous meningitis,and hemophagocytic syndrome,early diagnosis and correct treatment are crucial for the patient's prognosis.This article reports a 10-year-old child who sought medical attention due to recurrent fever and cough.Previously healthy with no underlying diseases.The preliminary diagnosis of this illness is pneumonia,and there has been no improvement after active treatment in an external hospital.Bone marrow puncture shows hemophagocytic cells,and the condition worsens and is transferred to our hospital.After admission to our hospital,the diagnosis was severe pneumonia and HLH.HLH was treated according to the guidelines,and antibiotics,fungal infections,and immunoglobulin support therapy were given.The symptoms of the patient did not improve,but the condition continued to worsen.Further examination showed positive Mycobacterium tuberculosis in the cerebrospinal fluid and positive sputum X-pert(rapid molecular identification of tuberculosis and rifampicin resistance).Four combination anti tuberculosis treatment was given,but the patient developed brain herniation in the later stage and died after giving up treatment.This article discusses the clinical manifestation,imaging changes,pathogenic examination,diagnosis and treatment process of hemophagocytic syndrome caused by pulmonary tuberculosis and tuberculous meningitis,so as to improve clinicians'understanding of HLH induced by severe tuberculosis in children.

关 键 词：肺结核 结核性脑膜脑炎 噬血细胞综合征 

分 类 号：R739.85[医药卫生—肿瘤] R512.91[医药卫生—临床医学]