摘要目的 观察外周血CD14+单核细胞HLA-DR异常表达对手足口病(HFMD)免疫功能状态的评估,以及对病情严重程度评估和临床预后的指导价值.方法 招募2017年6月至2018年10月在我院就诊的普通型HFMD患儿100例,重型和危重型HFMD患儿分别为80例和32例,40例健康体检儿童为对照组.入组病例根据外周血单核细胞HLA-DR表达测定值,分为DR抑制组(HLA-DR<30％)和DR正常组(HLA-DR>30％).流式细胞术检测CD14+单核细胞HLA-DR阳性表达和淋巴细胞亚群细胞绝对计数,免疫透射比浊法检测血浆IgG、IgM、IgA水平;酶联免疫吸附试验(ELISA)检测血浆炎症因子IFN-γ 和IL-10浓度;小儿危重病例评分(PCIS)及第三代小儿死亡危险评分(PRISMⅢ)用于病情评估.结果 (1)普通型、重型和危重型HFMD患儿单核细胞HLA-DR阳性表达存在显著性差异(F=47.102,P<0.05),危重型HLA-DR表达水平降低更显著(P<0.05);(2)DR抑制组外周血CD14+单核细胞、CD3+T细胞、CD4+T细胞、CD8+T细胞、B细胞、NK细胞数量均明显低于DR正常组和对照组,重型和危重型HFMD免疫细胞数量减少更明显(P<0.05);(3)DR抑制组、DR正常组和对照组相比,体液免疫指标IgG、IgA、IgM水平未见显著性差异(P>0.05);(4)DR抑制组血浆IFN-γ 浓度均低于DR正常组,IL-10血浆浓度高于DR正常组,IFN-γ/IL-10比值均低于DR正常组和对照组(P<0.05);HLA-DR表达水平与IL-10血浆浓度呈明显负相关(r=-0.704,P<0.05),与IFN-γ/IL-10比值显著正相关(r=0.773,P<0.05);(5)DR抑制组PCIS评分显著低于DR正常组,PRISMⅢ评分高于DR正常组;HLA-DR表达与PCIS评分正相关(r=0.715,P=0.00),与PRISMⅢ评分负相关(r=-0.610,P=0.00);(6)DR抑制组HFMD病例肺水肿、肺出血、心肺衰竭发生率以及死亡率显著高于DR正常组,差异有统计学意义(P<0.05).结论 重型和危重型HFMD患儿存在细胞免疫功能紊乱和CD14+单核细胞HLA-DR的异常表达,HLA-DR表达检测可用于重症HFMD患儿细胞免疫功能状态评估,CD14+单核细胞HLA-DR低表达与HFMD病情严重程度和临床不良预后密切相关.

abstractsObjective To investigate the value of abnormal expression of HLA-DR on peripheral blood monocytes in evaluating the immune function status, clinical prognosis and severity of patients with&nbsp;hand, foot and mouth disease (HFMD). Methods From June 2017 to October 2018, 100 cases of mild HFMD, 80 cases of severe HFMD, 32 cases of critical HFMD and 40 healthy children (control group) were recruited in this study. The patients were divided into two groups, lower DR group (DR-L, HLA-DR expres-sion<30％ ) and normal DR group (DR-N,HLA-DR expression>30％ ) according to the HLA-DR expression on monocytes. Flow cytometry was used to detect the CD14+ monocytes expressing HLA-DR and the absolute count of lymphocyte subsets. Immunoturbidimetry was used to detect the levels of IgG, IgM and IgA in plas-ma samples. Enzyme-linked immunosorbent assay (ELISA) was performed to detect the levels of IFN-γ and IL-10 in plasma samples. Pediatric critical illness score ( PCIS) and the pediatric risk of mortality Ⅲ(PRISM Ⅲ) were used to estimate the severity of HFMD. Results ① There were significant differences in HLA-DR expression on monocytes among children with mild, severe and critical HFMD (F = 47. 102, P<0. 05). Patients with critical HFMD had the lowest HLA-DR expression (P<0. 05). ② The numbers of CD14+ monocytes, CD3+T cells, CD4+T cells, CD8+T cells, B cells and NK cells in peripheral blood of the DR-L group were significantly lower than those of the DR-N group and the normal group, especially in pa-tients with severe or critical HFMD (P<0. 05). ③ There was no significant difference in the level of IgG, IgA or IgM among the DR-L, DR-N and control groups (P>0. 05). ④ Compared with the DR-N group, the DR-L group showed decreased IFN-γ level and increased IL-10 level in plasma (P<0. 05). The ratio of IFN-γ/ IL-10 of the DR-L group was lower than that of the DR-N group and control group (P<0. 05). HLA-DR expression was negatively correlated with the concentration of IL-10 in plasma (r= -0. 704, P<0. 05), and positively correlated with the IFN-γ/ IL-10 ratio (r = 0. 773, P<0. 05). ⑤ Compared with the DR-N group, the DR-L group showed lower PCIS and higher PRISM Ⅲ. HLA-DR expression was positively corre-lated with PCIS (r=0. 715, P=0. 00) and negatively correlated with PRISM Ⅲ (r = -0. 610, P = 0. 00).⑥ The incidence of pulmonary edema, pulmonary hemorrhage and cardiopulmonary failure and the mortality of HFMD patients in the DR-L group were significantly higher than those in the DR-N group (P<0. 05).Conclusions Patients with severe or critical HFMD had cellular immune dysfunction and abnormal HLA-DR expression on CD14+ monocytes. Assessing the expression of HLA-DR on monocytes could be used to evaluate the cellular immunity of patients with severe or critical HFMD. Lower expression of HLA-DR on CD14+ monocytes might be associated with severe HFMD and poor prognosis.