你以为流感就是带来感冒?其实更可怕的是“心”

2018-02-06 小郭 检验医学网

自2017年进入冬季以来,流感来势汹汹,全国报告的流感爆发数显著高于往年同期,无论北方省份还是南方省份的医院病例数都急剧上升,尤其儿科更是爆满。冬季是流感高发季节,今冬气候异常,易感人群增多。


自2017年进入冬季以来,流感来势汹汹,全国报告的流感爆发数显著高于往年同期,无论北方省份还是南方省份的医院病例数都急剧上升,尤其儿科更是爆满。冬季是流感高发季节,今冬气候异常,易感人群增多。

流感病毒分为甲、乙、丙三型:

甲型:抗原变异性最强,感染人类和其他动物,引起中、重度疾病,侵袭所有年龄组人群,常引起世界性大流行,如曾一度流行的“H1N1猪流感”、“H7N9禽流感”和主导本次流感疫情的“H3N2型流感”。甲型流感不同亚型之间无交叉免疫,可反复发病。

乙型:变异性较弱,仅感染人类,一般引起轻微的疾病,主要侵袭儿童,可引起局部暴发。

丙型:抗原性较稳定,仅引起婴幼儿感染和成人散发病例。

2018年第3周,中国国家流感中心发布的流感监测周报显示,中国南、北方省份流感活动均处于冬季流行高峰水平,但北方省份已经连续两周下降,南方省份却依然处于上升趋势。目前检测到的流感病毒以B(Yamagata)系和甲型H1N1为主。

然而,可怕的不是流感本身,而是其并发症:

流感病毒进入人体后会释放毒素,对身体抵抗力较弱人群的体内器官造成器质性的损害,并引起多种继发性感染。

流感最常见的并发症是肺炎,还有胃肠道症状、肌肉炎、心脏损害、神经系统并发症等。易发生并发症人群为5岁以下儿童和老年人。其中最严重的是继发肺炎球菌肺炎,而对心脏的损伤不分年龄限制,也需值得关注。

英国医学期刊《柳叶刀:传染病》网络版上曾刊登:英国科研人员对有关心脏病的39项研究进行了分析,发现了流感和心脏病之间存在稳定的关联。该研究发现,超过一半的流感意外死亡病例都是由心脏病发作引起。

流感导致的心脏损伤不常见,但却可能导致死亡等严重后果。本文就来介绍下流感与几种常见的心肌损害疾病。

流感相关病毒性心肌炎

病毒感染后,如果过度劳累、过度饮酒、营养不良等人体抵抗力降低,病毒可侵蚀心肌细胞,使其大面积水肿、坏死,从而诱发心肌炎。流感相关病毒性心肌炎多发生在病毒感染的4-7天,临床表现复杂多样,差异很大,轻症患者可以没有明显症状,而重症患者可发生心力衰竭、心源性休克甚至发生猝死。

病毒性心肌炎最常见的症状是气短,由于容易被当做流感的症状而被忽视。在病毒流行感染期约有5%患者发生心肌炎。大部分患者经治疗可获得痊愈。

临床上,因为“死扛”感冒引发心肌炎的案例并不少见。流感病毒、柯萨奇病毒等常见病毒,这类病毒对心肌细胞有很强的“亲和力”。

流感与暴发性心肌炎

暴发性心肌炎是心肌炎最为严重和特殊的类型,主要特点是起病急骤,病情进展极其迅速,患者很快出现血液动力学异常(泵衰竭和循环衰竭)以及严重心律失常,并可伴有呼吸衰竭和肝肾功能衰竭,早期病死率极高。该病通常由病毒感染引起,在组织学和病理学上与普通病毒性心肌炎比较并没有特征性差别,更多的是一项临床诊断。该病在急性期病情异常严重,死亡风险高,但度过危险期后患者预后良好。

由于检测方法的原因,仅可在10%-20%的急性心肌炎患者心肌组织中检测到病毒基因,主要包括柯萨奇病毒、腺病毒和流感病毒。近些年,流感病毒尤其是高致病性流感病毒较为常见。在冬春季发病较多,长期疲劳更易发病。由于诊断难度大,易误诊、漏诊,常引起医疗纠纷。

媒体报道中常提到,某某学生感冒后跑步、某某职员感冒后坚持工作,突然猝死,多是由于暴发性心肌炎。

流感病毒感染与急性心肌梗死

急性心肌梗死(AMI)的病理变化基础是动脉粥样硬化(AS),多年来,人们一直认为动脉粥样硬化的发生与高血压、高血脂、糖尿病、肥胖、吸烟等危险因素密切相关。但这些传统的危险因素并不能解释所有患者的发病。

流感病毒感染与急性心肌梗死的关系最早在1900年欧美的流感大流行时被发现。在流感流行期间大约有30%的心肌梗死与上呼吸道感染有关。流感活跃一直被作为冬季心肌梗死发病高峰期的原因。
流感病毒感染能促进动脉粥样硬化形成,不稳定斑块破裂,血栓形成,最终增加冠心病的住院率和死亡率。而接种流感疫苗已证实可减少急性心肌梗死的复发,因此,提倡在流感病毒流行季对65岁以上有心肌梗死患者接种流感疫苗,从而降低心脏事件及脑卒中的发生率。

心脏损伤的早期识别

急性心肌梗死可以从临床、心电图、生物标志物、病理特征等几个方面来诊断。心律失常是病毒性心肌炎、急性心肌梗死的最常见体征之一,但疾病早期患者症状复杂,且隐藏在流感症状之下,如依靠心电图诊断漏诊率较高。心脏超声心动图等影像学诊断方法需要有经验的影像医生进行,属于主观诊断,受影响因素多,而且X线、CT等方法不能实现床旁快速诊断。早期识别除基本的临床体征、心电图、超声等检测,心脏标志物的检查是较可靠、客观和快速的诊断方法,而且在急性心肌梗死全球定义中心肌肌钙蛋白(cTnl或cTnT)阳性也是必备的诊断指标。

《病毒性心肌炎临床路径》(2010年版)以CK-MB升高或心肌肌钙蛋白阳性作为临床诊断依据之一。

在2017年新发布的《成人暴发性心肌炎诊断与治疗中国专家共识》中指出实验室检查:
① 肌钙蛋白、肌酸激酶及其同工酶、乳酸脱氢酶、天门冬氨酸氨基转移酶以及肌红蛋白等升高,其中以肌钙蛋白最为敏感和特异,心肌酶谱改变与心肌梗死差别在于无明显酶峰,提示病变为渐进性改变,持续性增高说明心肌持续进行性损伤和加重,提示预后不良。
② B型利钠肽(BNP)或N末端B型利钠肽原(NT-proBNP)水平通常显著升高,提示心功能受损严重,是诊断心功能不全及其严重性、判断病情发展及转归的重要指标,尤其是对于合并重症肺炎者有重要鉴别诊断价值,但BNP或NT-proBNP的升高与心肌损伤相比有一定滞后,因此发病极早期检查正常或仅有轻度增高者,短期内需要复查。
③ 血常规检查中性粒细胞早期常不升高,但2-3天时可升高,另外在合并细菌感染时也升高,如果中性粒细胞降低则是预后不良的表现;单核细胞增多;血小板持续性降低预后不良。


(点击可查看大图)

国赛生物Kemilo酶促化学发光分析仪,以崭新的精准POCT检测理念,造型小巧、操作便携,为临床诊断心脏损伤提供精准的检测结果。

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    2018-02-07 15991890016白熊

    学习了

    0

  2. [GetPortalCommentsPageByObjectIdResponse(id=286015, encodeId=2a55286015ae, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=64, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20221028/11610bd349304a3a86a2c437d4cf0b47/30aeaebb323a43c193abde39a65e8ce0.jpg, createdBy=957a2221566, createdName=15991890016白熊, createdTime=Wed Feb 07 20:21:54 CST 2018, time=2018-02-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=285840, encodeId=b2fe285840a9, content=学习了.谢谢, beContent=null, objectType=article, channel=null, level=null, likeNumber=51, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/icyLhIGqru6gIknBJqfuPhRvIvBCic3jbz4PVDcMREDl6iaWw7opPo99JEXWc0tmIrGaXGPP0y58DKDiajZfV2qR3qXdCgwIyhVq/0, createdBy=d71a1955931, createdName=QFXL123456, createdTime=Wed Feb 07 07:06:57 CST 2018, time=2018-02-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=285833, encodeId=3c1828583342, content=非常好.非常实用, beContent=null, objectType=article, channel=null, level=null, likeNumber=58, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/10/21/9461f3b3c9f14e1d844256cdd08f2cf3.jpg, createdBy=a30f1426910, createdName=swfzhanggui, createdTime=Wed Feb 07 06:29:21 CST 2018, time=2018-02-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=285695, encodeId=b3c32856950a, content=学习了受益匪浅, beContent=null, objectType=article, channel=null, level=null, likeNumber=50, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/ajNVdqHZLLDicHg2ldsSNmib46PmdzpO7CQEmPjuULp1v45zPWwMYhrnXgvl3OtmUCZSQfgITWn96X9moL94nUGA/0, createdBy=28072041016, createdName=131****1460, createdTime=Tue Feb 06 19:21:53 CST 2018, time=2018-02-06, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=285690, encodeId=d2f12856905e, content=学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=60, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=ba101609906, createdName=happsf, createdTime=Tue Feb 06 18:32:21 CST 2018, time=2018-02-06, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=285683, encodeId=331a285683e6, content=^_^^_^^_^, beContent=null, objectType=article, channel=null, level=null, likeNumber=20, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/vi_32/Swp2ehfHpiciczeTntUyQOlIGMzQ705ic67sdMTVMbwTv7KbmlUvxrGvRSvQZjPkz7ib5tEDfIaORgczPtmHDpwojg/0, createdBy=c54b2163125, createdName=wqkm, createdTime=Tue Feb 06 17:34:15 CST 2018, time=2018-02-06, status=1, ipAttribution=)]
    2018-02-07 QFXL123456

    学习了.谢谢

    0

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    2018-02-07 swfzhanggui

    非常好.非常实用

    0

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    2018-02-06 131****1460

    学习了受益匪浅

    0

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    2018-02-06 happsf

    学习

    0

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    2018-02-06 wqkm

    ^_^^_^^_^

    0

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