A Clinical Feture Ananlysis Of Severe HFMD

Objective:The goal to explore the clinical features and the treatment of the severe hand foot and mouth disease, and related risk factors affectin g prognosis.Methods:The clinical data of 127children with severe HFMD seen fr-om January 2009 to December 2014 in Children’s Hospital of Chongqing Medical University were analyzed retrospectively. According to the progn osis,127 children were divided to survival group and death group. Risk fa ctors of severe HFMD related death were respectively analyzed by using s ingle factor analysis(X2 test, t test, rank and inspection), and did the unco nditional logistic regression. Telephone follow-up some survival cases.Results:There were 5097 children admitted in Children’s Hospital of Chongqing Medical University with hand foot and mouth disease from 20 09 to 2014,of which 127 were severe HFMD, accounting for 2.49%.The p roportion of the children who were under 5years old was96.85%(123/127), most of the were boys(61.42%,78/127),and the ratio of boy and girl was 1. 59:1.The fatality rate was 70.87(90/127).The peak season was from Marc h to July (69.29%,88/127) and October to November(14.17%,18/127).Th e death peak was from March to July (64.44%,58/90) and October to Nov ember(17.78%,16/90). Most of the them were without a clear history of ex posure. Severe HFMD has an acute onset and a rapid progression. The mo st common clinical manifestation was fever(98.43%,125/127),and there w ere 92.91%(118/127) of the them with the body temperature above 39℃,s ome of them were ultrahyperpyrexia(5.51%,7/127).There were 124 childr en had rash(97.62%,124/127) and 109 of them were typical papule or pap ulovesicle(85.83%,109/127).The most common distribution pattern of ras h was hand with foot type(29.84%,37/124).The rash of the survival grou p was more and easy to be found.The rash of the death group was scarce and latent. The most common nervous system of severe HFMD were distu rbance of consciousness (96.85%,123/127),the pupil light reflex slow o r loss(86.61%,110/127),vomiting(69.29%,88/127),startle or limb jitter(66. 14%,84/127), meningeal irritation sign(26.77%,34/127), Babinski sign(2 4.41%,31/127) and convulsion(15.75%,20/127).The most common respir atory system manifestations were pulmonary rales(90.55%,115/127),pul monary edema or pulmonary hemorrhage(63.78%,81/127) and pneumoni a(40.94%,52/127). The most common circulation system manifestations were increased heart rate(97.64%,124/127),peripheral circulatory disturba nce(88.98%,113/127),cyanosis(55.12%,70/127) and hypotension (48.03 %,61/127).In auxilliary examination, there were 73 cases of blood glucos e≥ 11.1mmol/L (57.94%,73/126),92 cases of lactic acid> 2.1 mmol/1 (73.02%,92/126),94 cases of CK-MB>5U/L (74.02%,94/127),27 ca ses of ALT>50 U/L (21.26%,27/127),57 cases of AST>55U/L (44.88 %,57/127) and 86 cases of LDH>330U/L(6.72%,86/127).In the blood gas analysis, there were 63 cases with acid poisoning(49.61%,63/127) an d 77 cases with electrolyte disturbance(60.63%,77/127).The common ele ctrolyte disorder were hypokalemia(30.71%,39/127),hyponatremia(29.92 %,38/127),hypocalcemia(18.11%,23/127) and hyperkalemia(10.24%,13/ 127).The abnormal rate of cerebrospinal fluid examination was 61.90%(l 3/21),the most common was the raise of glucose level(42.86%,9/21),cell number(28.75%,6/21) and protein level(23.81%,5/21).There were 88 cas es had the etiology of EV71(69.29%,88/127),62 of them were positive(70. 45%,62/88).There were 50 cases had the etiology of EVU(39.37%,50/12 7),46 cases were positive(92%,46/50).Seven cases were single EVU posit ive(14%,7/50),of which 6 cases were dead(12%,6/50).There were 51 cas es had the etiology of CoxA16(40.16%,51/127) and all of them were neg ative. The change of chest X-ray were pneumonia(46.67%,35/75),lung ma rkings increased(20%,15/75),pulmonary exudative lesions(17.33%,13/7 5),lung consolidation(6.67%,5/75) and lung atelectasis(6.67%,5/75).The most common change of cranial MRI was brainstem encephalitis(88.89% ,8/9).Sinus tachycardia is the most common change in electrocardiogram. Some cases had ventricular flutter (0.79%,1/127) and ventricular fibril lation (0.79%,1/127) in death group. The abnormal rate of EEG was 80. 85%(38/47) and the most common change was increased activity of 69 wave. In the treatment, most children had mannitol(99.21%,126/127),me chanical ventilation assisted breating(92.13%,117/127),gamma globulin(7 8.74%,100/127),hormone(97.64%,124/127) and vasoactive drugs, includ ing milrinone(97.32%,19/112), esmolol(47.32%,53/112) and sodium nitr oprusside(46.43%,52/112).In 127cases,42 children died in the hospital,48cases died after leave hospital and the mortality rate was 70.87%(90/127).22 cases recovered w ell and 15 cases improved. Some recovered cases were followed up,3 chil dren had a good recovery, without neurological sequelae;2 cases grow up slow; one case had peroneal injury and improved after rehabilitation.one c ase had swallowing dysfunction.In the comparison, the mortality of girl was higher than boy. The ons et to admission time(P<0.05),, come on critical time(P<0.05),, the hos pitalization time (P<0.05), thermal process(P<0.05),,the number of rus h(P<0.05), disturbance of consciousness (P<0.05),the pupil light refl ex slow or loss (P<0.05), lung wet rales (P<0.05), pulmonary hem orrhage (P<0.01), peripheral circulatory disturbance (P<0.05), hea rt rate (P<0.05), hypotension (P<0.05), white blood cell count(P <0.05),blood glucose(P<0.01),blood lactate(P<0.01),AST(P<0.05) a nd LDH(P<0.05), the incidence of acid poisoning(P<0.01),lung exudati ve lesion (P<0.05),ARDS (P<0.05), sinus tachycardia (P<0.0 5), the use of ventilator(P<0.05),gamma globulin(P<0.05), vasoactiv e drugs(P<0.05) and milrinone(P<0.05) were significant statistical diffe rence between survival group and death group. There were no statistical di fference in age(P>0.05),the distribution of the rash(P>0.05), vomiting(P >0.05),limb jitter(P>0.05),headache(P>0.05),cyanosis(P>0.05),tachy cardia(P>0.05),platelet(P>0.05),CK-MB(P>0.05),ALT(P>0.05),electr olyte disorder(P>0.05), abnormal rate of cerebrospinal fluid(P>0.05),po sitive rate of EV71(P>0.05),pneumonia(P>0.05),head CT or MRI(P>0. 05),EEG(P>0.05),hormone(P>0.05),esmolol (P>0.05),sodium nitro prusside (P>0.05) and the species of vasoactive drugs (P>0.05) we re not significant difference between the two group.Single factor analysis suggested that severe HFMD death risk factors are gender, fever, conscious disturbance, pupil light reflex slow, hypotens ion,heart rate, peripheral circulatory disorders, pulmonary rales, pulmon ary hemorrhage, white blood cell count, blood glucose, blood lactate, acid poisoning and lung exudative lesions, gamma globulin content and vasoac tive drugs. The girl children, blood glucose, blood lactate, heart rate, perip heral circulatory disorders and gamma globulin content were screened out as an independent risk factor for death in Logistic regression analysis. Lu ng exudative lesions and ARDS have too many missing values, were not i ncluded in the analysis.Conclusion:Severehand foot and mouth diseasehas an acute onset, ra pid progression and high mortality. It occurs mainly in male children unde r 5 years old, with peak incidence during March to July and October to No vember. The mortality of girl were higher than boys.There were no signifi cant difference in age between the two group.The most common clinical manifestations were fever, rash, disturbance of consciousness, pulmonary rales, pulmonary hemorrhage, peripheral circulation disturbance and hypo tension. The site and the number of the rash involving had correlation wit h prognosis. The fewer parts rash involving, the worse the prognosis was. The risk factors in severe HFMD patients have gender, fever, disturbance of consciousness, heart rate, peripheral circulatory disorders,white blood cell count, blood glucose,blood lactate, acid poisoning, lung exudative 1 esions and ARDS, gamma globulin content and vasoactive drugs. The ind ependent risk factors for mortality in severe HFMD patients were girl chil dren, blood glucose,blood lactate, heart rate, peripheral circulatory disorde rs and gamma globulin content.