摘 要
目的：回顾性分析支气管肺炎患儿各项免疫功能指标，为临床小儿支气管肺炎的免疫治疗提供理论依据。
方法：收集 2017 年 5 月 1 日-2019 年 4 月 30 日吉首大学第一附属医院（湘西自治州人民医院）儿科病房支气管肺炎 216 例，依据研究对象感染病原体不同，将他们分为细菌性肺炎组（n=68），病毒性肺炎组（n=109），支原体肺炎（Mycoplasma pneumoniae pneumonia，MPP）组（ｎ＝39），根据研究对象的病情严重程度不同，再分为重症组（ｎ＝51）和普通组（ｎ＝165），依据研究对象是否有喘息症状和（或）肺部是否有哮鸣音，又可分为喘息组（n=132）及非喘息组（n=84），216例病例均采用免疫速率散射比浊法和流式细胞技术法检测血清免疫球蛋白 A（Immunoglobulin A，IgA）、免疫球蛋白 M（ImmunoglobulinM，IgM）、免疫球蛋白 G（Immunoglobulin G，IgG）、补体 C3、补体 C4 及淋巴细胞亚群百分比结果，进而比较不同病原体感染，以及患儿病情严重程度、是否合并喘息与免疫功能变化的关系。
结果：1.患儿的一般资料：细菌性肺炎组年龄在 1 月至 10 岁之间，病毒性肺炎组年龄在 1 月 13 天至 11 岁之间，支原体肺炎组年龄在 3 月 29 天至 6 岁之间，三组均以婴幼儿期为主，在比较三组患儿的平均年龄、不同年龄阶段发生率时，差异均无统计学意义（P>0.05）；重症组年龄在 1 月至 6 岁之间，婴幼儿期发生者占 90.2%，在学龄前期发生者占 9.8%，普通组年龄在 1 月 25 天至 11 岁之间，婴幼儿期发生者占 70.3%，在学龄前期发生者占 26.1%，两组均以婴幼儿期为主，在比较两组患儿的平均年龄、不同年龄阶段发生率时，差异均有统计学意义（P<0.05）；喘息组年龄在 1 月至 10 岁，婴幼儿期发生者占 83.3%，学龄前期发生者占 15.2%，非喘息组年龄在 2 月至 11岁，婴幼儿期发生者占 61.9%，学龄前期发生者占 33.3%，两组均以婴幼儿期为主，在比较两组患儿的平均年龄、不同年龄支气管肺炎发生率时，差异均有统计学意义（P<0.05）；然而不同病原体感染者及病情轻重者在性别上比较，差异均未见统计学意义（P>0.05）。2.比较细菌性肺炎、病毒性肺炎、支原体肺炎三组患儿各项免疫功能指标，结果表明细菌组与病毒组血清 IgA 水平均低于支原体组，而病毒组血清 IgM 水平低于支原体组，差异存在统计学意义（P<0.05），比较 IgG、补体 C3、补体 C4、CD4+T、CD8+T 细胞百分比、CD4+/CD8+比值、B 细胞、自然杀伤细胞（natural killer cell，NK）时差异无统计学意义(P>0.05）。3. 比较普通组与重症组免疫功能，结果表明普通组 IgA、IgG、补体 C3、CD8+T 细胞均高于重症组，普通组 B 细胞低于重症组，差异有统计学意义（P<0.05），比较 IgM、补体 C4、NK 细胞、CD4+T 细胞、CD4+/CD8+比值时差异均无统计学意义（P>0.05）。4.经比较喘息组与非喘息组免疫功能，结果表明喘息组 IgA、IgG、CD8+T细胞低于非喘息组，非喘息组的 CD4+/CD8+比值、CD4+T 细胞低于喘息组，差异均存在统计学意义（P<0.05）， IgM、补体 C3、补体 C4、B 细胞、NK 细胞比较，差异无统计学意义（P>0.05）。
进一步对患儿进行所感染的病原体分层分析发现：1.在细菌性肺炎患儿中，重症组的 B 细胞高于普通组，补体 C3 低于普通组，喘息组的 CD8+T 细胞低于非喘息组，差异有统计学意义（P<0.05），其余各项指标比较无统计学意义（P>0.05）。2.在病毒性肺炎患儿中，重症组的 IgA、IgG、NK 细胞、CD8+T 细胞低于普通组，CD4+/CD8+比值远超过普通组，喘息组的 IgA、IgG、CD8+T 细胞低于非喘息组，喘息组的 CD4+/CD8+比值高于非喘息组，差异有统计学意义（P<0.05）；其余各项指标均未见明显统计学意义（P>0.05）。3.在支原体肺炎患儿中，重症组的 B 细胞高于普通组，而 CD4+T 细胞低于普通组，差异有统计学意义（P <0.05），其余各项指标均未见明显统计学意义（P> 0.05）；喘息组与非喘息组间所有指标比较均未见统计学意义（P> 0.05）。
结论：1.不同病原体感染的支气管肺炎患儿与年龄和性别无关，但支气管肺炎严重程度与年龄有关，重症肺炎更易发生在 3 岁以下儿童，且伴有喘息症状的支气管肺炎多出现在 3 岁以下儿童。2.免疫功能紊乱与感染的病原菌种类相关。3.支气管肺炎患儿的免疫功能紊乱与病情的严重程度相关。4.伴有喘息症状的支气管肺炎患儿体内存在免疫功能紊乱。
关键词：儿童；支气管肺炎；感染；细胞免疫；体液免疫。
ABSTRACT
Objective ： A retrospective analysis was made on the immune function indexes of children with bronchopneumonia, which provides theoretical basis for immunotherapy of pediatric bronchopneumonia. Methods：Researchers collected 216 cases of bronchopneumonia in the pediatric ward of the First Affiliated Hospital of Jishou University (xiangxi Prefecture People's Hospital) from May 1, 2017 to April 30, 2019. In terms of the different infection pathogens of the researchsubjects, they were pided into bacterial pneumonia group (n = 68), viral pneumonia group (n = 109), and mycoplasma pneumonia group (n = 39);In terms of whether the subjects had wheezing symptoms and/or wheezing in the lungs, they were further pided into the wheezing group (n=132) and the non-wheezing group (n=84). All 216 cases were tested for serum immunoglobulin A (IgA), immunoglobulin G (IgG),immunoglobulin M (IgM), the results of complement C3, complement C4and lymphocyte subsets by the methods of immunization rate scattering turbidimetric and flow cytometry technology, and then compare the infection of different pathogens, and the relationship between the severity of the disease and the changes in immune function in children.
Results: 1. General information of the child patients: The bacterial pneumonia group is between 1 month and 10 years old, the viral pneumonia group is between 1 month plus 13 days and 11 years old, and the mycoplasma pneumonia group is between 3 months plus 29 days and 6 years old. The three groups were dominated by infants and young children. There was no statistically significant difference in the average age of the three groups and the incidence of bronchopneumonia at different ages (P> 0.05); The severe group was between 1 month and 6 years old, with 90.2% occurring in infants and young children, and 9.8% occurring in preschool age. The general group was between 1 month plus 25 days and 11 years old, with 70.3% of those in infants and young children, and 26.1% of those in preschool age. The two groups were mainly infants and young children, and the differences in the mean age and the incidence of bronchopneumonia at different age stages were statistically significant (P<0.05). The wheezing group was from 1 month to 10 years old, and 83.3% occurred in infancy and early childhood, and 15.2% occurred in preschool age. The non-wheezing group was aged from 2 month to 11 years old, 61.9% occurred in infancy, and preschool age accounted for 33.3%. The two groups were mainly infants and young children, and the differences in the mean age and the incidence of bronchopneumonia at different age stages were statistically significant (P<0.05). However, there was no statistically significant difference in gender between patients with different pathogens and those with severe disease (P> 0.05). 2. The results showed that the serum IgA level of bacterial pneumonia group and viral pneumonia group were lower than that of mycoplasma pneumonia group by comparing the immune function indexes of the three groups of children with bacterial pneumonia, viral pneumonia and mycoplasma pneumonia. The serum IgM level of the viral pneumonia group was lower than that of the mycoplasma pneumonia group, and the difference was statistically significant (P<0.05). here was no statistically significant difference between IgG, complement C3,complement C4, CD4+T cells, CD8+T cells, CD4+/CD8+ratio, B cells,and natural killer cells (NK) (P>0.05).3. Comparing the immune function of the normal group and the severe group, the results showed that the IgA,IgG, complement C3, CD8+T cells of the normal group were higher than the severe group, and the B cells of the normal group were lower than the severe group, the difference was statistically significant (P <0.05).
According to IgM, complement C4, NK cells, CD4+T cells, CD4+/CD8+ratio comparison, the difference was not statistically significant (P>0.05).4. By comparing the immune function between the wheezing group and the non-wheezing group, the results showed that the IgA, IgG, and CD8 +T cells in the wheezing group were lower than those in the non-wheezing group. Statistical significance (P <0.05). Compared with IgM, complement C3, complement C4, B cells and NK cells, thedifferences were not statistically significant (P> 0.05).
Further stratified analysis of the infected pathogens in the children revealed that: 1. For children with bacterial pneumonia, the B cells in the severe group were higher than the normal group, the complement C3 was lower than the normal group, and the CD8 +T cells in the wheezing group were lower than those in the non-wheezing group, the difference was statistically significant (P <0.05); No statistical significance was found in the comparison of other indexes (P>0.05). 2. For children with viral pneumonia, the IgA, IgG, NK cells, and CD8 +T cells in the severe group were lower than those in the normal group, the ratio of CD4 + /CD8 + far exceeded that in the normal group, and the IgA, IgG, and CD8+T cells in the wheezing group were lower In the wheezing group, the CD4 +/CD8+ratio in the wheezing group was higher than that in the non-wheezing group, and the difference was statistically significant (P <0.05); There was no obvious statistical significance in other indexes (P> 0.05). 3. For children with mycoplasma pneumonia, the B cells in the severe group were higher than the normal group, and the CD4 +T cells were lower than the normal group, the difference was statistically significant (P <0.05);No statistical significance was found in the other indexes (P> 0.05);There was no statistically significant difference in all indexes between the wheezing group and the non-wheezing group (P> 0.05).
Conclusions:1. Children with bronchopneumonia infected by different pathogens have nothing to do with age and gender, but the severity of bronchopneumonia depends on age. Severe pneumonia is more likely to occur in children under 3 years old, and bronchial pneumonia with wheezing symptoms mostly occurs in children under 3 years old.2. There is a certain relationship between immune dysfunction and the pathogen species of infection. 3. The immune dysfunction of children with bronchopneumonia is related to the severity of the disease. 4. Children with bronchopneumonia by wheezing symptoms have immune dysfunction.
Keywords: children ； bronchopneumonia ； infection ； cellular immune；humoral immune。
前言
尽管儿童支气管肺炎的管理已经取得极大进展，但该病的发病人数及死亡人数仍居高不下。支气管肺炎不但严重危害儿童身心健康，而且消耗了巨大的医疗资源，给家庭、社会带来巨大压力及责任。引起儿童肺炎的病原体呈多样性，大多数是由细菌所引发，其中独居首位的是肺炎链球菌。还有金黄色葡萄球菌、溶血性链球菌、流感嗜血杆菌、大肠杆菌、肺炎克雷伯菌等。当然，由病毒引起的肺炎亦是不可忽视的，引起病毒性肺炎的主要病原体包括呼吸道合胞病毒、各型流感病毒、腺病毒等。多位专家认为国内各种病毒肺炎的总发病例数有增多趋势，同时两种甚至更多病毒的混合感染在临床上也有不少。该病多见于 2 岁以下婴幼儿，局部症状主要为咳嗽，全身症状主要为发热等，呼吸困难等表现在小婴儿中也不少见，肺部听诊可有固定中细湿啰音。MPP 发病年龄多集中在学龄前儿童，婴幼儿亦多，本病全年多发，发病率达儿童肺炎的 20% [1],其主要临床症状为发热和刺激性干咳，肺部体征不明显，部分可没有肺部体征。体征与剧烈刺激性咳嗽、发热等临床症状不一致，是 MPP 的特征之一。支气管肺炎在春夏秋冬四季中均有发病，尤其在冬春严寒季候及天气骤变时、室内居住拥挤、透风不佳、空气污染，易致肺部炎症。此外，如若患有先天性心脏病、免疫缺陷病等，及低出生体重儿亦可致该病[2]。
众所周知，支气管肺炎的疾病严重程度取决于宿主自身能力和病原微生物的挑战[3]，然而免疫功能的作用不容忽视。研究发现，伴有原发和继发性免疫缺陷儿童更易受肺部感染。因目前国内外免疫抑制药物广泛使用而带来的继发性免疫缺陷发生率逐年上升。在评估机体免疫功能状况时，免疫水平情况很重要，而且免疫水平可辅助了解患儿病情严重程度、预后与转归，最终帮助临床医师进一步遏制与治疗疾病，从而缩短支气管肺炎的病程[4]。目前的研究多集中在支气管肺炎免疫学发病机制上，但对于不同病原体感染患儿其免疫功能状态与病情严重程度、有无合并喘息等合并症，及临床转归仍缺乏系统性研究,故本研究从临床实践出发，通过回顾性分析不同病原体感染和不同病情支气管肺炎患儿免疫功能指标的变化，为临床小儿支气管肺炎的免疫治疗提供理论依据。
1 、材料与方法。
1.1 、研究对象。
1.1.1、 一般资料。
选取 2017 年 5 月 1 日-2019 年 4 月 30 日吉首大学大学第一附属医院儿科病房支气管肺炎 216 例，包括男性 146 例，女性 70 例；细菌性肺炎组（n=68），包括男性 39 例，女性 29 例；病毒性肺炎组（n=109），包括男性 78 例，女性31 例；MPP 组（n=39），包括男性 29 例，女性 10 例；根据严重情况分为普通组（n=165），包括男性 112 例，女性 53 例；重症组（n=51），包括男性 34 例，女性 17 例，依据是否有喘息症状及肺部是否有哮鸣音又可分为喘息组（n=132），男性 93 例，女性 39 例，及非喘息组（n=84）,男性 53 例，女性 31 例。
1.1.2 、纳入标准。
1 年龄在 1 月-14 岁；2 诊断为支气管肺炎；3 完善抽血采集呼吸道九项病原体检查（肺炎支原体、肺炎衣原体、副流感病毒、甲型流感、乙型流感、呼吸道合胞病毒、腺病毒、嗜肺军团菌、Q 热立克次体）、肺炎支原体（Mycoplasma pneumoniae，MP）血液学、EB病毒检测、外周血淋巴细胞亚群百分比、各项免疫球蛋白及补体检查；4 完善痰培养和（或）肺泡灌洗液检查；5 完善血培养。
1.1.3 、排除标准。
1 年龄小于 1 月和年龄大于 14 岁；2 有先天性免疫缺陷病；3 既往用过任何免疫抑制剂；4 有心、肝、脑等重要脏器疾病；5 既往诊断为支气管哮喘；6 淋巴结核压迫；7 支气管异物。
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1.2 、诊断标准
1.3 、研究方法
1.4 、统计学方法
2 、结果
2.1 、基本资料
2.1.1 、不同病原体感染病例之间基本资料比较
2.1.2 、普通肺炎组与重症肺炎组病例之间基本资料比较
2.1.3、 喘息组与非喘息组病例之间基本资料比较.
2.2、 免疫功能指标
2.2.1 、不同病原体感染组免疫功能比较
2.2.2 、普通肺炎组与重症肺炎组免疫功能比较
2.2.3 、喘息组与非喘息组患儿免疫功能比较
2.3 、细菌性肺炎患儿免疫功能指标
2.3.1、 重症组与普通组免疫功能比较
2.3.2、 喘息组与非喘息组免疫功能比较
2.4、 病毒性肺炎患儿免疫功能指标
2.4.1 、重症组与普通组免疫功能比较
2.4.2 、喘息组与非喘息组免疫功能比较
2.5 、支原体肺炎患儿免疫功能指标
2.5.1、 重症组与普通组免疫功能比较
2.5.2、 喘息组与非喘息组免疫功能比较
3 、讨论
4、 结 论
1.不同病原体感染的支气管肺炎患儿与年龄和性别无关，但支气管肺炎严重程度与年龄有关，重症肺炎更易发生在 3 岁以下儿童，且伴有喘息症状的支气管肺炎多出现在 3 岁以下儿童。
2.免疫功能紊乱与感染的病原菌种类相关。
3.支气管肺炎患儿的免疫功能紊乱与病情的严重程度相关。
4.伴有喘息症状的支气管肺炎患儿体内存在免疫功能紊乱。
参 考 文 献.
