摘要目的 探讨重症与危重症甲型H1N1 流感的临床特点、实验室检查结果、胸部CT影像表现和治疗,分析其与预后的关系.方法 回顾性分析2018年11月至2019年2月南宁市第四人民医院收治的54例成人重症和危重症甲型H1N1 流感患者的临床资料.所有患者咽拭子甲型H1N1流感病毒核酸检测结果均为阳性,确诊为甲型H1N1流感.收集患者的性别、年龄、病程、基础疾病、症状、体温、住院时间,以及胸部CT检查和实验室检查结果;同时记录患者的治疗情况及预后.结果 54例患者中重症组38例,危重症组16例.两组患者均有发热、咳嗽、呼吸困难等临床表现,CD4+ T淋巴细胞计数均低于正常参考值(410～1 590/μL).重症组胸部CT表现为单肺或双肺野散在斑片状高密度灶及磨玻璃状密度增高影,经抗病毒、抗菌药物、吸氧治疗,全部治愈出院.危重症组从发病到入院时间长,病情进展快,呼吸困难的表现更为明显,胸部CT表现为双肺大片状模糊并实变影,密度不均匀.与重症组相比,危重症组患者肌酸激酶(CK)、乳酸脱氢酶(LDH)、C-反应蛋白(CRP)和降钙素原(PCT)升高更为显著〔CK(U/L):704.50(908.50)比146.00(220.75),LDH(U/L):614.50(492.25)比217.00(142.75),CRP(mg/L):85.65(56.13)比18.80(50.63),PCT(μg/L):1.30(5.00)比0.10 (0.16),均P＜0.01〕;白细胞计数(WBC)、中性粒细胞比例升高也更为显著〔WBC(×109/L):12.37±7.63比8.29±3.32,中性粒细胞比例:0.81±0.11比0.75±0.11〕,但差异无统计学意义(均P＞0.05).危重症组经治疗好转出院9例,治愈好转率56.25% ;死亡7例,病死率43.75%,其中2例〔获得性免疫缺陷综合征(AIDS)、尿毒症各1例〕入院时已合并多器官功能衰竭(MOF)放弃机械通气治疗,3例并发急性肾衰竭放弃血液透析, 1例鼻咽癌放疗术后,1例慢性肾衰竭尿毒症期合并多重耐药菌感染、MOF.结论 重症与危重症甲型H1N1流感均表现为发热、咳嗽、呼吸困难,且均表现为不同程度的器官功能障碍;重症患者以肺部病变为主,危重症患者则表现为心、肺、肾等多器官功能损害且病灶进展迅速;有慢性基础疾病与合并MOF是危重症甲型H1N1流感患者死亡的主要原因.

abstractsObjective To investigate the clinical features, laboratory results, chest CT imaging manifestations and treatments of severe and critical influenza A (H1N1), and to analyze the relationship with the prognosis. Methods The clinical data of 54 adult patients with severe and critical H1N1 admitted to the Fourth People's Hospital of Nanning from November 2018 to February 2019 were analyzed retrospectively. Throat swab specimens of the patients were determined for nucleic acid detection of influenza A (H1N1) virus, and all of the patients were confirmed. The gender, age, course of disease, underlying diseases, symptoms, body temperature, hospital stays, chest CT findings and laboratory results were collected, and the treatments and prognosis were recorded. Results Of 54 patients, 38 patients were enrolled in severe group, and 16 in critical group. Fever, cough, sputum, shortness of breath and so on could be found in the two groups. The CD4+ T lymphocytes were less than normal reference value (410-1 590/μL) in both groups. The chest CT findings manifestations of severe group were scattered patchy shadows and ground glass appearance, all of them were cured and discharged after antiviral, antibiotics, and oxygen treatment. In critical group, the time in hospital was longer, the disease progresses varied faster, the shortness of breath was more apparent, and a large patch of fuzzy and real change shadows on both lungs could be found from CT findings. Compared with the severe group, creatine kinase (CK), lactic dehydrogenase (LDH), C-reactive protein (CRP) and procalcitonin (PCT) levels in the critical group were increased more significantly [CK (U/L): 704.50 (908.50) vs. 146.00 (220.75), LDH (U/L): 614.50 (492.25) vs. 217.00 (142.75), CRP (mg/L):85.65 (56.13) vs. 18.80 (50.63), PCT (μg/L): 1.30 (5.00) vs. 0.10 (0.16), all P < 0.01], white blood cells count (WBC) and neutrophil ratio were also increased more significantly [WBC (×109/L): 12.37±7.63 vs. 8.29±3.32, neutrophil ratio:0.81±0.11 vs. 0.75±0.11] without statistical differences (both P > 0.05). Nine patients in critical group were cured with cure rate of 56.25%. Seven patients died with mortality of 43.75%, including 2 patients with acquired immunodeficiency syndrome (AIDS) and uremia respectively, who had multiple organ failure (MOF) on admission and waive the mechanical ventilation treatment; 3 patients complicated with acute renal failure but abandon hemodialysis; 1 patient with nasopharyngeal carcinoma radiotherapy after operation; and 1 patient with chronic renal failure uremia period combined multiple drug-resistant bacteria infection, and died from MOF finally. Conclusions The patients with severe and critical influenza A (H1N1) show fever, cough, dyspnea, and organ dysfunction in varying degrees. Severe patients were mainly pulmonary lesions, while critical patients show MOF such as heart, lung and kidney, and the lesions progressed rapidly. The major cause of death for critical influenza A (H1N1) may be chronic underlying diseases and MOF.