Respiratory Pathogens Screening and Clinical Characteristics Analysis for Pediat

时间：2024-09-03

MAI Ai,LUO Ya-sha,ZHONG Guo-yu,WEI Feng-gui,CHEN De-hui,WEI Xiao-ping,ZHOU Qiang,LIN Yong-ping

1.Department of ENT,the First Affiliated Hospital of Guangzhou Medical University，Guangzhou,Guangdong Province,510120 China; 2.Department of Laboratory,Guangdong Provincial Maternity and Child Care Center,Guangzhou,Guangdong Province,511442 China; 3.Department of Pediatrics,the First Affiliated Hospital of Guangzhou Medical University,Guangzhou,Guangdong Province,510120 China;4.Department of Clinical Laboratory,the First Affiliated Hospital of Guangzhou Medical University,Guangzhou,Guangdong Province,510120 China;5.The Second Affiliated HospitalClinical Laboratory of Guangzhou University of Chinese Medicine, Guangzhou,Guangdong Province,510120 China

Respiratory Pathogens Screening and Clinical Characteristics Analysis for Pediatric Acute Rhinosinusitis Patients

MAI Ai1,LUO Ya-sha2,ZHONG Guo-yu3,WEI Feng-gui3,CHEN De-hui3,WEI Xiao-ping4,ZHOU Qiang5,LIN Yong-ping4

Objective Acute upper respiratory tract infection (AURI)is a common disease in most pediatric outpatients,and viral etiologies have been shown to play an important role.However,the URI infection following to result most pediatric sinus infections,which is known to damage the nasal/sinus epithelial cells and cilis.Therefore,the pathogens screening and clinical characteristics analysis were conducted to determine the prevalence of viruses in acute rhinosinusitis (ARS)and controls groups.Methods Nasal swab(NS) samples were collected from 564 pediatric outpatients,which were 259 ARS patients(group I),219 AURIs patients(group II)and 86 controls(group III)respectively.Multiplex PCR was used to identify respiratory viruses in each group and the pathogens were compared with each other.Results The datas were shown that infected with respiratory viruses would increase 3.104-fold risk become RS (RR=3.104,95%CI=2.134～4.517).Only RV and ADV had a higher rate in group I than group II(P＜0.05),the rest pathogens shown no significant difference either(P＞0.05).RV infection rate in group Ia(ARS only)was absolutely higher than other groups(P＜0.01), ADV was more prevalent in the AURI population with ARS(group Ib)(P＜0.05).Effusion of immune cells have been found in 49.6% group I samples by cell smearing analysis,which nearly equal to the pathogen detection rate of group I(47.4%).Conclusion This investigation proved that RV and ADV contribute more on ARS development,especially RV,which made children have more chance developing to ARS with the neutrophils and lymphocyte effusion in nasal mucosa.Further studies should be done to generalize the research by incresing sample capacity and collecting ARS patients from different hospital during continuous seasons.

Acute sinusitis in Children；Rpathogens;Screenin

Acute rhinosinusitis(ARS)is a common problem in children with acute upper respiratory tract infections(AURIs), while AURIs is the largest number of disease in pediatric outpatients.Recent evidence shows that most URIs are caused by viruses,but the viral screening and clinical characteristics analysis for pediatric of acute RS are not well understood.Since rhinitis and sinusitis in pediatric patients are often a continuous disease according to the anatomical characteristics in children[1],it is not possible to distinct rhinitis from sinusitis on clinical espression individually.Recognition of history and symptoms are important to establish a diagnosis of RS due to which is still often under-diagnosed in practical pediatric.Research has shown that the the most common RS symptoms were rhinorrhea,cough,post-nasal drip and nasal congestion,and most symptoms and signs in acute and chronic RS were similar[2].In addition,RS is a multifactorial disease,which is the several predisposing factors changes with increasing age[3-4].Therefore,more continued research in these fields should be done to determine the most safe and effective methods to prevent and treat RS in children.

急性上呼吸道感染是儿科门诊中就诊数量最多的疾病，而急性鼻窦炎是小儿急性上呼吸道感染中的常见问题。最新研究表明大多数的上呼吸道感染是由病毒引起的，但对小儿急性鼻窦炎的病毒筛查和临床特点分析尚不明确。根据儿童的解剖特点，鼻炎和鼻窦炎在儿科患者中往往是一种连续性疾病，因此，两者的临床表现难以区分。由于鼻窦炎在目前的儿科就诊患儿中容易漏诊，所以对其疾病史和症状的认知对诊断该疾病很重要的。研究表明最常见的鼻窦炎症状是流鼻涕，咳嗽，鼻塞，鼻后滴流，急性鼻窦炎和慢性鼻窦炎的大多数症状和体征相似。此外，鼻窦炎是由多因素引起的疾病，随着年龄的增加多种诱因也随之改变。因此，应该开展更多关于该领域的研究来决定预防和治疗小儿鼻窦炎的最安全最有效的方法。

Viral etiologies have shown virus play an important role in the AURI pediatric which following to result most sinus infections,was known to damage the nasal/sinus epithelial cellsandcilis[5].After samples were collected from control groups without ARS,the respiratory pathogens rate was compared with that in ARS subjects.These data proved that some specific virus would made children have more chance developing to ARS with plenty of neutrophils effusion in nasal mucosa.

病毒病因学表明病毒在小儿急性上呼吸道感染中起很大作用，会导致进一步的鼻窦感染，而鼻窦感染会损伤鼻窦黏膜上皮细胞。从没有患急性鼻窦炎的对照组中采集样本之后，该研究将患有急性鼻窦炎的受试组的呼吸系统病原体感染率与其相比较。研究数据表明一些特定的病毒会增加儿童感染急性鼻窦炎的风险，并且鼻黏膜会有大量的中性粒细胞渗出。

MATERIALS AND METHODS

Patient population.Five hundred sixty-four pediatric out-patients were recruited between July 2013 and June2014 at 1st Affiliated Hospital of Guangzhou Medical University,China,of whom with a ARS diagnosis were divided into group I(259),including a subgroup Ia (95)only with ARS and a subgroup Ib(164)both with ARS and AURIs.The other 219 simple AURIs children who didn’t have any nasal symptoms were divided into group II,and group III(86)were control volunteers who have neither ARS nor AURIs.All rhinosinusitis patients met the established diagnostic criteria[6]for ARS,which the most common symptoms were rhinorrhea, cough,post-nasal drip and nasal congestion,and the persistent symptoms for more than 10 days but less than 4 weeks. The diagnosis of AURIs is usually made from the history and presenting symptoms,which can include cough,wheeze and fever,among others,also the persistent symptoms for more than 10 days but less than 4 weeks.Asthma and allergic disease were excluded from the study.All the legally authorized representatives of children provided informed consent.

1 资料与方法

1.1 研究对象

选取该院564例儿科门诊病人，收取时间是2013年7月—2014年7月，并根据诊断结果将患者分为3组。I组有259例病人，包括Ia组（仅患有急性鼻窦炎）95例患者和Ib组（同时患有急性鼻窦炎和急性上呼吸道感染）164例患者；其他219例没有鼻症状的儿童被分为II组；III组作为健康对照组，共86名。所有的鼻窦炎患者均符合诊断标准。鼻窦炎的常见症状是流鼻涕，咳嗽，鼻塞，鼻后滴流，症状持续时间是10 d～4周；而通常根据既往和现有的症状对急性上呼吸道感染进行诊断，包括咳嗽、气喘、发热。该研究不包括哮喘与过敏性疾病患者；所有的知情同意书均向儿童的法定监护人出示。

Specimens collection.Nasal swab(NS)samples were collected from five hundred sixty-four participants from July 2013 to June 2014.To obtain nasal specimen,a Dacron swab with a plastic shaft(Copan,Italy)was placed 2 to 2.5 cm into the right nostril and rotated three times against the surface of the nasal cavity.Specimens were placed into transport tubes containing 2 mL of sterile phosphate-buffered saline medium. The samples were frozen immediately after collection and stored at-80°C until use.In addition,455 of these children had also been done with nasal secretions cell analysis by smearing observation.

1.2 标本采集

从2013年7月—2014年6月，在564例研究对象中收集鼻腔黏膜拭子样本。将一塑料轴涤纶拭子（Copan，意大利）置入右鼻孔2～2.5 cm，然后沿鼻腔表面旋转3次；将标本置于包含2 mL无菌磷酸盐缓冲盐水培养基的透明管中，标本采集后立即冷冻并贮藏在-80°C直到使用。此外，对其中455例儿童的鼻分泌物涂片，并进行细胞染色分析。

Pathogen screening.After vortex shocked and centrifuged,aqueous phase were recover for nucleic extracted by QIAamp viral RNA kit(Qiagen),according to the manufacturer’s instructions.Super Script III Reverse Transcriptase (Invitrogen)was used to synthesize cDNA.Each cDNA was added to a multiplex PCR reaction system,at a final volume of 25 μL,including 12.5 μL Premix Taq (TaKaRa),4 μL primer mix,5.5 μL dd H2O and 3 μL cDNA.Samples were subjected to initial denaturation at 94°C for 5 min;35 cycles of 94°C for 30 s,56°C for 30 s,and 72°C for 30 s;and a final extension at 72°C for 3 min.The products were visualized by electrophoresis on 3%agarose gel.The multiplex PCR system included 4 groups for viral screening,parainfluenza viruses 1,2,3,and 4,influenza viruses A and B,res-piratory syncytial viruses (RSV),rhinoviruses (RV)and enteroviruses(EV),coronaviruses 229E,NL63 and OC43,adenovirus(ADV),human metapneumovirus(HMPV),and human bocaviruses[7-9]were included.

1.3 病因筛查

对样本进行旋涡震荡、离心，提取上清液，按照试剂盒说明书进行操作。使用逆转录酶III(Invitrogen)合成cDNA，按试剂盒要求配置25 μL反应体系。PCR的反应条件为94°C 5 min，35个循环（94°C 30 s，56°C 30 s、72°C 30 s），72°C 3 min进行最终扩增。PCR产物通过2%琼脂糖进行凝胶电泳。多重PCR反应体系对以下病毒进行筛查，包括副流感病毒1、2、3、4，流感病毒A和 B，呼吸道合胞病毒，鼻病毒，肠病毒，冠状病毒229E、NL63和OC43，腺病毒，肺炎病毒和人博卡病毒。

Analysis of cells in nasal secretions.455 nasal secretion samples from these children were smeared to slide and dyed by Wright's stain after them dried,observed and imaged through microscrope.A sample would be considered to positive as if immune cells were observed under the microscope. Serum C reaction protein level and peripheral blood white cells analysis.

352CRP and WBC clinical laboratory test results of the children were collected though the hospital information system.

1.4 鼻分泌物细胞分析

对455个鼻分泌物样本进行滑动涂片及瑞氏染色，干燥后通过显微镜观察，如果显微镜下可见免疫细胞，则该样本就被视为阳性样本。

Statistical analysis.Pearson’s chi-squared tests and Fisher’exact tests were used to compare the positive rate of viruses and cells in nasal secretions for different groups,risk ratios(RR)and 95%confidence intervals(CI)were also calculated.ANOVA was used to compare the serum CRP level and blood white cells counts in each group.Statistical analysis was performed using SPSS version 19.0 and a P value＜0.05 was regarded as significant.

1.5 血清C反应蛋白水平和外周血白细胞分析

通过医院检验信息系统收集352例儿童的CRP和WBC临床实验室结果。

1.6 统计方法

使用SPSS 19.0统计学软件对本研究数据进行分析。对不同组间的鼻分泌物病毒和细胞的阳性率分别应用χ2检验和Fisher精确检验法比较，同时计算风险率（RR）和95%置信区间（CI）。对每组的血清CRP水平和白细胞数目应用ANOVA法进行比较。以P＜0.05为差异具有统计学意义。

RESULTS

The study recruited five hundred sixty-four pediatric out-patients from July 2013 to June 2014,including 259 children with ARS,219 with AURIs and 86 control subjects.The mean age of all subjects was(3.61±2.55)years. Age and gender were not shown differences among the three groups.

Pathogen etiologies.179 (31.7%)positive for one or more pathogens of all samples were detected,and the positive rate for group I (44.4%),group II (27.4%)and group III (4.7%)were significant different(P＜0.001).It was shown that infected with respiratory viruses would increase 3.104-fold risk become rhinosinusitis(RR=3.104,95%CI=2.134～4.517). The most prevalent virus was rhinovirus,24 samples (9.3%) were positive in group I and 9(4.1%)in group II(P＜0.05, RR=2.27);secondarily,16 samples(6.2%)were adenovirus positive in group I and 4(1.6%)in group II(P＜0.05,RR= 3.374),the rest pathogens shown no significant difference in group I and II(Table 1).Four viruses have been detected in group III were RSV,MP,IFA and ADV respectively.While, PIV3,PIV4,NL63,229E and MPV haven’t been detected in this study.

2 结果

该研究在2013年7月—2014年6月收集564例儿科门诊患者，包括259例患有ARS的儿童，219例患有AURIs的儿童和86名健康对照患儿。所有研究对象的平均年龄是（3.61±2.55）岁，3组间年龄和性别差异无统计学意义。

2.1 病原学病因

该研究样本中，其中179例（31.7%）测得有1种以上病

原感染，其中I组（44.4%），II组（27.4%）和III组（4.7%），3组间的阳性率差异具有高度统计学意义（P＜0.001），提示感染了呼吸道病毒的患儿有3.104倍的风险会进一步发

展为鼻窦炎(RR=3.104,95%CI=2.134～4.517)。其中最常见的是鼻病毒，I组有24例是阳性（9.3%），II组有9例是阳性(4.1%)（P＜0.05,RR=2.27）；其次是腺病毒，I组有16例阳性(6.2%)，II组有4例阳性(1.6%)（P＜0.05,RR=3.374）；其余的病原体在两组间的差异无统计学意义，见表1。在III组中发现4种病毒，分别是RSV，MP，IFA和ADV，此外，该研究中并未检测出PIV3,PIV4,NL63,229E和 M PV。

Table 1 Comparison of pathogen detection rate between group I with II[n(%)]

表1 I组和II组病原菌检测率的比较[n(%)]

According to the above results,RV and ADV positive rate shown difference in group I and II,so we compared their detection rate in group Ia,Ib and group II further,the results both shown difference rate of RV and ADV among group Ia, Ib and II(P＜0.05).RV infection rate in Ia was absolutely higher than the other groups(P＜0.01),however,ADV was more prevalent in the AURI population with RS(group Ib) (P＜0.05)(Table 2).

根据上述结果，I组和II组的RV和ADV阳性率差异有统计学意义（P＜0.05）；再进一步的比较Ia组、Ib组和II组的检测率，结果表明3组间的RV和ADV的检测率差异有统计学意义（P＜0.05），其中Ia组的RV感染率明显高于其他组（P=0.01）。然而，ADV在同时患有AURI和RS的患儿中更为常见（Ib组），P＜0.05，见表2。

Table 2 Comparison the positive rate of RV and ADV among group Ia,Ib and II[n(%)]

表2 Ia组,Ib组和II组的RV与ADV阳性率比较I[n(%)]

Cell smears analysis.455 samples were analyzed the cells of nasal secretions,epithelial cells have been found in every sample.Immune cells(neutropils,lymphocyte or monocyte)also been observed in 140 smear samples,113(49.6%) in group I,22 (13%)in group II and 5(8.6%)in group III, which has significant difference among three groups(P= 0.000).Addictional,immune cells were also positive in 78 samples(74.3%)of group I in which PCR were positive(P= 0.000).Figure 2 was shown several pictures of the smears.

2.2 细胞涂片分析

对455例鼻腔分泌物样本进行涂片分析，每一个样本在显微镜下均可见鼻黏膜上皮细胞，其中的140例涂片样本中可同时观察到免疫细胞（中性粒细胞，淋巴细胞和单核细胞）（图 2），包括I组的 113例 (49.6%),II组的 22 (13%)和III组的5(8.6%)，并且3组间差异有统计学意义（P=0.000）。此外，I组有78例样本(74.3%)的免疫细胞在PCR检测中同样也是阳性（P=0.000）。

Figure 2 Images for the scrape content smear(×1000)

图2 鼻腔分泌物涂片的显微镜下图像(×1 000)

Serum CRP and WBC analysis.352 children have been tested serum CRP and white blood cells count examinations, the values of these tests were compared among each group by ANOVA,CRP level and monocyte of rhinosinusitis patients were higher than other children,white blood cells analysis shown no significant difference in each group(table 3).

血清CRP和WBC分析：通过ANOVA法对352例儿童的血清CRP和白细胞计数进行检测比较，可见鼻窦炎患儿的CRP水平和单核细胞均高于其他组患儿，而组间的白细胞计数差异无统计学意义，见表3。

TABLE 3 Serum CRP and white blood cells analysis（±s）

Group I (n=162) Group II (n=135) Group III (n=55)FP CRP(mg/L) WBC(×109/L) Neutrophils(%) Lymphocyte(%) Monocyte(%) 12.16±16.93 10.10±4.19 57.07±17.44 32.59±16.10 8.80±2.88 6.69±8.10 9.79±4.33 57.23±19.34 32.99±18.44 8.24±4.19 5.48±9.41 10.61±4.12 52.39±19.25 36.66±18.03 7.64±2.68 8.711 0.678 0.347 1.045 3.213 0.000 0.508 0.261 0.353 0.041

表3 血清CRP和WBC分析（±s）

I组 (n=162)II组 (n=135)III组 (n=55)FP CRP(mg/L) WBC(×109/L)中性粒细胞(%)淋巴细胞(%)单核细胞(%) 12.16±16.93 10.10±4.19 57.07±17.44 32.59±16.10 8.80±2.88 6.69±8.10 9.79±4.33 57.23±19.34 32.99±18.44 8.24±4.19 5.48±9.41 10.61±4.12 52.39±19.25 36.66±18.03 7.64±2.68 8.711 0.678 0.347 1.045 3.213 0.000 0.508 0.261 0.353 0.041

Discussion

Rhinosinusitis(RS)is a common disease among children and complicates 5%～10%of pediatric upper respiratory infections[10].Most patients were first diagnosed as RS at ambulatory pediatric clinics,with similar symptoms such as nasal discharge,fever,and cough.So far,the diagnosis of RS is mainly established on the history and symptoms of patients. Nevertheless, the symptoms or severity are subjective and vary from each individual.Although imaging examination such as X-ray,CT or MRI can assist in diagnosis,the performance of distinguishing ARS from mild or recovered URTI is not sensitive enough[11],and the imaging examination can only confirm the absence of RS when the result is negative[12].While,under-diagnosis or delayed treatment of ARS may lead to CRS or complications,viral infection has been described in many existing studies as vital cause of cold and may be the trigger of RS,combinedsymptoms with the infection information on nasal cavity would contribute to diagnosis of RS.It is known that the procedure of obtaining a nasopharyngealaspirate (NPA) specimen is uncomfortable and frightening to children,it’s also unpleasant for medical staff who have to carry out the process in struggling,crying and coughing children.Many studies have demonstrated that NS might prove suitable for obtaining respiratory viral specimens.The collection of a NS is easy and convenient,it requires no additional devices,and it is less costly and causes less distress for the patient than the NPA[13].Some research considered mucosal scraping as more clinically significant and specific method than nasal lavage fluid,since the turbinate epithelial cells may better reflect sinus mucosa.In addition,nasal lavage fluid might have an increased chance of trapping viruses floating in ambient air,and of containing a more mixed viral infection than the scraping samples[14].Then in clinical practice,the optimal sampling methods must be balanced with patient’s comfort,costs,effectiveness and risk to others to achieve the best cooperation of children[15],so we used nasal swab for collecting sample in outpatient children with ARS.Respiratory tract infections are common in children and diagnosis is usually made from the history and presenting symptoms, which can include cough,wheeze and fever,among others. And viral etiologies are the most common causes for AURI, including RS[16].

3 讨论

鼻窦炎是儿童一种常见疾病，占小儿上呼吸道感染的5%～10%。许多病人在儿科门诊中初步被诊断为鼻窦炎，具有流鼻涕，发热，咳嗽等症状。迄今为止，鼻窦炎的诊断主要是建立在病人的病史和症状的基础上；然而，症状及其轻重程度是主观的并且因人而异。尽管X-ray,CT或者MRI的影像检查有助于诊断，但对于急性鼻窦炎与轻度或恢复中的急性上呼吸道感染的比较仍然不够敏感；同时，急性鼻窦炎诊断不足或延误治疗可能会导致发展为慢性鼻窦炎及其并发症。目前，许多研究把病毒感染描述为感冒的重要起因或者鼻窦炎的诱因，因此，关于鼻腔感染的联合症状将有助于鼻窦炎的诊断。众所周知，获取鼻咽分泌物样本的过程会使儿童感到不舒适和恐惧，同样，面对挣扎，哭泣和咳嗽的儿童，收集标本的医务人员也会手足无措。已经有许多研究表明鼻腔黏膜拭子可能是获取上呼吸道病毒标本的合适手段，该采集方法简单方便，无需额外的装置，成本低廉，比起获取鼻咽分泌物样本更能减少患儿痛苦。由于鼻甲粘膜上皮细胞可以更好地反映鼻窦粘膜，因此一些研究认为与鼻灌洗液相比，黏膜拭子采样是更具体、更有效的临床方法。在临床实践中，最佳的抽样方法必须与病人的舒适度、成本、有效性和风险达到一个平衡，因此，对患有急性鼻窦炎的门诊病人采用这种简便无痛的鼻黏膜拭子的样本采集方法。

Then with the advantages on sensitivity,specificity and rapidly,multiplex PCR was used to detecting the common respiratory pathogens.Accordingly,our study screened the existence of 15 common respiratory viruses on nasal cavity of 564 children.Finally,the total positive rate for these 16 pathogens shown significant difference on each group,which means the children who suffered respiratory viruses infection would have more chance (3.104-fold)turn to ARS.Only RV and ADV had a higher rate in group I than group II(P＜0.05). However,distinguishing ARS and AURI absolutely is hard, ARS always be an early stage or a complication of AURI,so it is still difficult to evaluate viral infection would be a key reason for RS or just as a common cause for URI with

rhinosinuisitis or sinusitis complication.In our investigation, there is a difference on viral positive rate between the population of ARS patients and the AURI children without nasal symptoms,we can see that RV infection rate in group Ia(ARS only)was absolutely higher than other groups,ADV was more prevalent in the AURI population with ARS than which without ARS,it’s prove that RV and ADV contribute more on ARS development,especially RV.

由于多重PCR检测方法的敏感性、特殊性和快速性方面的优势，临床上用于检测常见的呼吸道病原体，因此，该研究采用该检测方法对564例儿童的鼻腔进行常见呼吸道病毒的筛查。最终，16种病原菌的总阳性率在组间差异有统计学意义，这意味着感染了这部分呼吸道病毒的儿童有3.104倍的机会发展为急性鼻窦炎。I组与II组比较，有更高的RV和ADV感染率（P＜0.05）。然而，急性鼻窦炎与急性上呼吸道感染的鉴别很困难，前者总是后者的早期阶段或是其并发症，因此，病毒感染是鼻窦炎的一个关键原因。在该次调查中，急性鼻窦炎与没有鼻部症状的急性上呼吸道感染儿童的病毒阳性率之间存在差别，我们可以发现仅患有急性鼻窦炎组的RV感染率明显高于其他组患儿；伴有急性鼻窦炎症状的急性上呼吸道感染患儿与没有鼻窦炎症状的患儿比较，ADV的检出更常见。研究表明，RV和ADV促进了ARS的发展，尤其是RV。

Effusion of immune cells have been found in 49.6% group I samples by cell smearing analysis,which nearly equal to the pathogen detection rate of group I(47.4%).The data of this research showed that 78 (74.3%)in 105 PCR positive samples were immune cells observed,it means viral infection was related to the immune cells effusion on the nasal mucosa.It is suggest that a cell-mediated immune response will be activated after viral infection,mainly dominated by neutrophils,Van[17]found the same results. Epithelialcellscan inducetheproduction ofseveral cytokines after viral infected,deposition in the nose the virusistransported to the posteriornasopharynx and attaches to some specific receptor,then reduces the release of proinflammatory cytokines such as IL-1 beta,platelet activating factor and IL-8,initiates the host immune response by enhancing the recruitment of more immune effector cells into the inflammation site[18],that’s the reason why nasalmucosa and secretionswere teeming with neutrophils and(or)lymphocyte,monocyte.On the other hand,nasal epithelial cells and cilia damaged[19],cytokine increased and several inflammatory pathways induced can provide an environment for bacteria to adhesion,and make the ARS step into secondary bacterial infection or chronic diseaseworsestill.In case of rhinoviruses infection,ICAM-1 was a specific receptor as a trigger of a serial cascade reactions has been proved[20].Matrix metalloproteinase-2, matrix metalloproteinase-9,and vascular endothelial growth factor expression can also be upregulated by rhinoviruses, which may contribute to the pathogenesis of nasal polyps formation in patients with chronic rhinosinusitis[20]. Adenovirus is one of the most common viral reason to cause children upper respiratory tract infections,the patients presented common symptoms including fever(97.9%),cough and rhinitis(74%)[21],but the pathogenesis mechanism was still unclear.Some studies revealed[22]that the increasing counts of neutrophil and monocyte had been seen in peripheral blood within a couple of days after inoculation,

but we only found the increase of monocyte,in addition to barriers defence and a cell-mediated immune response,soluble chemical factors such as C-reactive protein concentrations were shown increased slightly in our study.

通过细胞涂片分析发现，I组49.6%的样本中有免疫细胞的渗出，与PCR方法检测的I组病原检测率比例大致相同(47.4%)。研究数据表明，105个PCR阳性样本中78个样本检测出免疫细胞(74.3%)，这就意味着病毒感染和鼻粘膜免疫细胞渗出是相关的。有学者也发现了同样的结果，上皮细胞被病毒感染后，也会产生多种细胞的渗出，鼻内病毒沉积输送至后鼻咽并且依附于某个特定的受体，随后会发生IL-1β、血小板活化因子和IL-8前炎性细胞活素的释放减少，通过使炎症部位吸附更多的免疫效应细胞启动宿主免疫反应，这就是鼻粘膜和分泌物充满中性粒细胞和（或）淋巴细胞和单核细胞的原因。另一方面，鼻黏膜上皮细胞与纤毛的损伤，细胞因子的增加，若干炎症途径为细菌依附提供了环境，导致急性鼻窦炎发展为继发性细菌感染或使慢性疾病加重。

Above all,the investigation found that RV and ADV make children have more chance developing to ARS with the neutrophils and lymphocyte effusion in nasal mucosa,and then trigging the immune cascade reactions at the nasal local site,serum C-reactive protein concentrations and monocyte will increase slightly in peripheral blood which is different from the sharp increasing when bacterium infection.

On the other hand,there were some shortcomings in this study,sample capacity was small and patients were recruited from a single hospital,which may limit the generalizability of the research and pending in further study.

该调查发现，RV和ADV更容易使儿童发展成为在鼻粘膜内有中性粒细胞和淋巴细胞渗出的急性鼻窦炎，从而导致鼻部出现一系列免疫反应。此外，周围血液的血清C反应蛋白浓度和单核细胞会有轻微增加，这有别于急性细菌感染的病例。

另一方面，该研究仍存在不足，样本容量小，而且仅仅只从一家医院获取门诊患儿的样本，这使调查研究的普及受限，因此，有待在未来的研究中进一步完善。

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[2]Poachanukoon O,Nanthapisal S,Chaumrattanakul U.Pediatric acute and chronic rhinosinusitis:comparison of clinical characteristics and outcome of treatment[J].Asian Pac J Allergy Immunol,2012,30(2):146-151.

[3]van der Veken P J,Clement P A,Buisseret T,et al.CT-scan study of the incidence of sinus involvement and nasal anatomic variations in 196 children[J].Rhinology,1990,28 (3):177-184.

[4]Yaniv E,Oppenheim D,Fuchs C.Chronic rhinitis in children[J].Int J Pediatr Otorhinolaryngol,1992,23(1):51-57.

[5]Pedersen M,Sakakura Y,Winther B,et al.Nasal mucociliary transport,number of ciliated cells,and beating pattern in naturally acquired common colds[J].Eur J Respir Dis Suppl,1983,128(Pt 1):355-365.

[6]Fokkens W J,Lund V J,Mullol J,et al.European Position Paper on Rhinosinusitis and Nasal Polyps 2012[J].Rhinol Suppl,2012(23):291-298.

[7]Brittain-Long R,Nord S,Olofsson S,et al.Multiplex realtime PCR for detection of respiratory tract infections[J].J Clin Virol,2008,41(1):53-56.

[8]Aguilar J C,Perez-Brena M P,Garcia M L,et al.Detection and identification of human parainfluenza viruses 1,2,3, and 4 in clinical samples of pediatric patients by multiplex reverse transcription-PCR[J].J Clin Microbiol,2000,38(3): 1191-1195.

[9]Zhang G,Hu Y,Wang H,et al.High incidence of multiple viral infections identified in upper respiratory tract infected children under three years of age in Shanghai,China[J]. PLoS One,2012,7(9):e44568.

[10]Wald E R.Sinusitis in children [J].N Engl J Med, 1992,326(5):319-323.

[11]Gwaltney J J.Acute community-acquired sinusitis[J].Clin Infect Dis,1996,23(6):1209-1225.

[12]Brook I.Acute sinusitis in children[J].Pediatr Clin North Am,2013,60(2):409-424.

[13]Meerhoff T J,Houben M L,Coenjaerts F E,et al.Detec-tion of multiple respiratory pathogens during primary respiratory infection:nasal swab versus nasopharyngeal aspirate using real-time polymerase chain reaction[J].Eur J Clin Microbiol Infect Dis,2010,29(4):365-371.

[14]Cho G S,Moon B J,Lee B J,et al.High rates of detection of respiratory viruses in the nasal washes and mucosae of patients with chronic rhinosinusitis[J].J Clin Microbiol, 2013,51(3):979-984.

[15] Sung R Y,Chan P K,Choi K C,et al.Comparative study of nasopharyngeal aspirate and nasal swab specimens for diagnosis of acute viral respiratory infection[J].J Clin Microbiol,2008,46(9):3073-3076.

[16] Subauste M C,Jacoby D B,Richards S M,et al.Infection of a human respiratory epithelial cell line with rhinovirus. Induction of cytokine release and modulation of susceptibility to infection by cytokine exposure[J].J Clin Invest, 1995,96(1):549-557.

[17]Van Cauwenberge P B,Vermeiren J S,van Kempen M J. Viral rhinitis and asthma[J].Curr Opin Allergy Clin Immunol,2001,1(1):21-25.

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[19]Pedersen M,Sakakura Y,Winther B,et al.Nasal mucociliary transport,number of ciliated cells,and beating pattern in naturally acquired common colds[J].Eur J Respir Dis Suppl,1983,128(Pt 1):355-365.

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[22] Hansen J G,Hojbjerg T,Rosborg J.Symptoms and signs in culture-proven acute maxillary sinusitis in a general practice population[J].Apmis,2009,117(10):724-729.

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小儿急性鼻窦炎呼吸道病原体筛查与临床特征分析

麦艾1，罗娅莎2，钟帼钰3，卫凤桂3，陈德辉3，魏小平4，周强5，林勇平4

1.广州医科大学附属第一医院耳鼻喉科，广东广州 510120；2.广东省妇幼保健院检验科，广东广州 511442；3.广州医科大学附属第一医院儿科，广东广州 510120；4.广州医科大学附属第一医院检验科，广东广州 510120；5.广州中医药大学第二附属医院检验科，广东广州 510120

目的急性上呼吸道感染（URI）是儿科门诊最常见的疾病之一，其病毒学病因发挥着重要的作用。由于病毒对鼻腔、鼻窦上皮细胞及纤毛的损害，URI的感染多数会进一步导致小儿的鼻窦炎感染。因此，通过病原体筛选和临床特征分析，来比较急性鼻窦炎（ARS）组与对照组的病毒发生率。方法对该组564例儿科患者进行鼻粘膜拭子采样，其中259例为ARS患儿（I组），219例为急性URI患儿（II组），86名为对照组（III组）。应用多重PCR技术对每组的呼吸道病毒及病原体进行比较。结果感染了呼吸道病毒的患儿进一步发展为鼻窦炎（RS）的风险将增加3.104倍（RR=3.104,95%CI=2.134～4.517）。 I组中的鼻病毒（RV）与腺病毒（ADV）含量均高于II组（P＜0.05），其余的病原体在两组间的差异无统计学意义（P＞0.05）。Ia组（单纯ARS组）中RV的感染率明显高于其他组（P＜0.01）；与其他组比较，ADV的感染率在Ib组（急性URI伴ARS）患儿中更常见（P＜0.05）。鼻腔分泌物的涂片分析结果显示，49.6%的I组样品中可见免疫细胞的渗出，此结果几乎与该组的病原体检出率（47.4%）相等。结论小儿急性URI发展为ARS的的患者中，病毒RV与ADV担当了比较重要的作用，特别是RV，这部分患儿的鼻腔分泌物中可见中性粒细胞和淋巴细胞的渗出。应该通过不同的采样医院，在连续季节收集更多的ARS样本量，以便更好地推广该研究。

小儿急性鼻窦炎；呼吸道病原体；筛查

R765.4+1

A doi 10.11966/j.issn.2095-994X.2016.02.03.08

（

）

2016-07-20；

2016-08-15

广东省科技计划项目（2011B061300038）。

麦艾（1972.1-），女，广东台山人，博士研究生，副主任医师，研究方向：鼻科学研究。

林勇平（1973.12-），男，广东人，博士，副教授，研究方向：临床病毒学检验，Email：lin_y_p@hotmail.com。