Research clinical, subclinical characteristics and hs-CRP, Procalcitonin, Interleukin 6 in severe viral pneumonia in children under 5 years old

anism of co-infection, secondary infection 1.9. Inflammatory markers 1.9.1. Hs-CRP 1.9.2. Procalcitonin 1.9.3. Interleukin 6 1.9.4. Roles and mechanisms of some biological markers 1.10. Research situation of viral pneumonia and inflammatory markers in children 1.10.1. Researches in the world. In 1986, Mullis K. and et al. proposed the basic method for running PCR, a process in which DNA can be artificially multiplied by multiple replications by DNA polymerase. In 2011, Ruuskanen O. and et al. published a reasearch on viral pneumonia by PCR that showed the co-infection with viruses and bacteria in one third of cases. Huijskens E.G. and et al. has studied and evaluated the diagnoses of viral pneumonia in children by real-time PCR. In the 1990s, the number of drugs used to treat viral infections increased, especially antiretroviral drugs. Amantadine, the first systemic antiviral drug, was used in 1966. Ribavirin, Aerosol (1985), Alfa Interferon (1986), Foscarnet (1991), Rimantadine (1993) and Fomivirsen (1998). Researches and understanding of the physiological and pathophysiological role of cytokine have gained significant achievements. Cytokine is involved in many biological processes in the body such as embryogenesis, reproduction, hematopoiesis, immune response, inflammation. 1.10.2. Researches in Vietnam. After the application of real-time PCR and real-time PCR, there have been many researrches on viruses causing respiratory diseases in children in recent years. However, rsearsches go into each virus such as Adenovirus, respiratory syncytial virus, H1N1 flu causing bronchitis in children. Tran Anh Tuan's study (2012) on the role of viruses in acute bronchiolitis in children. Research on application of xTAG multi-PCR technique to diagnose the causes of respiratory infections in children at National Children’s Hospital in 2012-2013 to identify the infection status of 18 common viruses, and it also shows co-infection between viruses and bacteria. Vietnam has conducted a number of marker tests that reflect the condition of inflammation. In 2007, author Bui Binh Bao Son and et al. published a research on blood PCT concentration in 50 children from 2 months to 5 years old suffering pneumnia. In addition, there are also other researches related to PCT such as research on PCT characteristics in the diagnosis of neonatal sepsis by Tran Thi Lam and et al. research on the role of PCT in diagnosing the differences between pus meningitis and encephalitis aseptic in children published by author Tran Kiem Hao and et al. in 2014. Research on prognostic value of TNF-α, IL-β, IL-6 and IL-10 in septic shock in 74 children by Phung The Nguyen and et al. at Children's Hospital 1. Research on IL-concentration 6, TNF-α in serum of 30 pediatric patients with autoimmune arthritis in polyarthritis in National Children’s Hospital by Le Quynh Chi . Chapter 2 SUBJECTS AND METHODS 2.1. Research subjects Patients, from 1 month to under 5 years old, have been diagnosed with severe viral pneumonia according to WHO-2013 standards and treated at National Children’s Hospital from February 2015 to February 2017. 2.1.1. Criteria for selecting research subjects 2.1.1.1. Diagnosis of pneumonia 2.1.1.2. Diagnosis of severe viral pneumonia The Children have a cough or difficulty in breathing accompanied by at least one of the following main symptoms: - Cyanosis or SpO2 <90%. - Severe respiratory distress (moaning and heavy chest recession ...) - Signs of pneumonia with severe general signs: + Unable to drink or breastfeed. + Coma or not awake. + Convulsions. - Some or all other signs of pneumonia. - Inflammation of the upper respiratory tract syndrome. - Symptoms in the lungs: wheezing, rapid breathing, shortness of breath. Lungs have moist or moist rales, snoring rashes. - X-ray: image of pneumonia - Finding the virus in nasal fluid, dysentery, phlegm 2.1.2. Exclusion criteria - Children under 1 month of age and older than 5 years. - Patients with non-viral pneumonia (eg pneumonia after drowning, choking oil, pneumonia ...). - Patients with pneumonia do not have severe signs. -Patients with chronic, congenital diseases (such as: airway malformation, congenital lung disease, liver failure, kidney failure ...). - Patients are eligible to participate in the study but the family does not agree to participate. 2.2. Research methods 2.2.1. Research design Described cross section research 2.2.2. Research sample size: - Formula to calculate study sample size Where: n: Sample size p: The incidence of viral pneumonia (p = 0.597). Z21-α/2: 1.96 with 95% confidence Δ: Accuracy, Δ = 0.05. - According to calculations, the number of samples needed is n>192 patients. - In this research, a sample size of 202 children was selected - Methods to choose convenient samples. 2.2.3. Research parameters 2.2.3.1. General characteristics of the research subjects - Age, gender - History: obstetrics, nourishment, immunization, disease, treatment. 2.2.3.2. Clinical: - Check and find signs of the whole body: temperature, breathing rate, heart rate, weight, SpO2 ... - Examination of functional symptoms: cough, wheezing, runny nose - Physical examination of respiratory symptoms + Difficulty breathing, chest shrinkage, fluttering nose, nodding head with breathing, intercostal muscle pull, receding concave: yes or no + Listen to lung rales: yes or no - Subclinical: Blood counts, hs-CRP, PCT, IL-6, Blood gases + Chest X-ray - Microbiological tests: + Adenovirus, Rhinovirus: performed by real-time PCR + Influenza A, B, RSV: implemented by rapid test method or RT-PCR + Transplanting count, classify bacteria and make antibiotics. 2.2.4. Criteria for evaluating research parameters 2.2.4.1. Evaluating clinical symptoms 2.2.4.2. Evaluating subclinical results - Radiographs of the heart and lungs: + The fuzzy image has localized system in 1-2 lung lobes. + The watermark does not have a scattered system in the area of the lungs and around the navel, asymmetry. + Sometimes the image is grid or nodular lesions, sometimes the blur is very small, not more than one lung segment, less dense, gathering like butterfly wings in pulmonary edema. + In children, there may be enlarged swollen umbilical lympho nodes. - Virus test: 2.2.4.3. Treatment results: * Discharge: - No respiratory depression - Children eat well, are overall good condition - Blood test, chest X-ray examination is stabel - Children may take medicine or have completed a course of injections of antibiotics - Parents understand the signs of pneumonia, risk factors and when is to return to the hospital. * Support, reduction: patients with stable condition , can be treated at home. * Department transfer, hospital transfer: Patients who get rid of severe pneumonia, suffer other diseass must be transferred to other department or hospital. * Death: the patients die at the hospital or request to die. 2.2.5. How to conduct 2.2.5.1. Clinical - Built up medical sample that is appropriate for the research subjects . Develop research consent form. - Patients are closely monitored for changes in daily clinical symptoms and early detection of possible complications. - Each patient has a separate record with all information related to the thesis. 2.2.5.2. Subclinical - Quantification of hs-CRP was determined by turbidity measurement using Olympus AU 2700. - PCT quantification was determined by luminescent immunization method, running on ADVIA Centaur machine of Siemens. - Quantifying IL-6 when patients are hospitalized with BioRad's Bio-Plex Protein Array System. - Test for finding the primary causes: Quick Test or RT-PCR for Influenza A, B, RSV, Adenovirus, Rhinovirus 2.3. Methods of data analyzing and processing Data were processed by STATA 14.0 software The statistical algorithms are used in this thesis as follows: - Avergae sample calculation (X), standard deviation (SD), median, T-student test, Multiple average comparision, test ꭓ2, Fisher, two median comparision, calculating sensitivity, specificity, cut-point by analyzing ROC curve, evaluating correlation coefficient 2.4. Medical ethics: - The management board of the National Hospital of Pediatrics and Department of Respiratory granted permission for post-graduate student to carried out this research. - Patient's parents are informed of the purpose and content of the research, in order to ensure the commitment and acceptance of the patient's family. - Patients are guaranteed the rights of comprehensive examination and evaluation. Their personal information is maintained safely. - Special tests IL-6 are self-funded by post-graduate student. 2.5. Research process flowchart Chapter 3 RESEARCH RESULTS From February 2015 to February 2017, the research was conducted in 202 patients with severe viral pneumonia who were treated in the National Children’s Hospital. 3.1. Research clinical and subclinical characteristics of severe viral pneumonia in children under 5 years old. 3.1.1. Some common characteristics of pediatric patients 3.1.1.1. Age and gender - 124 male and 78 female. Male/female ratio = 1.59/1 - Patients are mostly under 12 months of age (76.7%). The average age is 8.4 months, the lowest is 1 month and the highest is 48.7 months 3.1.1.2. Time of illness: mainly from February to April (46.0%). 3.1.1.3. Obstetric history: The proportion of children who are underweight at birth (<2500g) is 19.8%. There are 19.8% of premature. 3.1.1.4. History of nutrition and vaccination: 33.7% of children were malnourished, only 74.3% of children were vaccinated according to the schedule. 3.1.1.5. History of illness: 25.7% of children have respiratory illness. 3.1.1.6. History: The average number of days of being ill before having treatment in hospital is 6.89 days, There are 71.8% of children with number of day of being ill ≤ 7 days, 41.1% are inpatient and 26.2% are outpatient before being treated in the hospital. 3.1.2. Clinical and subclinical characteristics 3.1.2.1. Clinical characteristics: - 71.8% of children have fever symptoms - The rate of children having cough is 100%, runny nose is 39.6%; wheezing is 83.7%. - Physical symptoms, the most common ones are tachypnea, thoracic receding, moist lung in 100%; 3.1.2.2. Subclinical characteristics: - The average concentration of IL-6 in the researched group is 28.2 ± 81.7 (pg / ml), the lowest value is 0, the highest value is 500. - The average concentration of PCT is 1.7 ± 4.2 (ng / ml), the lowest value is 0.01, the highest value is 44.0. - Average hs-CRP value in theresearched group is 15.6 ± 31.5 (mg / dl), median is 4.2, the minimum value is 0.1, the highest value is 273. Figure 3.3. Lung X-ray damage (n = 202) Comment: 149 patients with fuzzy lesions, 43 patients with interstitial lung lesions, 10 patients with other injuries - hs-CRP concentration > 6 mg/l is 43.1%; PCT concentration >0.5 ng/ml is 50.0%. - 19.3% had moderate respiratory failure and 8.9% had severe respiratory failure. 3.1.2.3. Virus and bacterial characteristics The majority of children has RSV (36.1%), followed by Influenza A (24.3%) and Adenovirus (19.8%). The percentage of children suffered Influenza B is thelowest at 6.9%. There are 149 children infected with the virus, 53 children (26.2%) are infected with bacteria or/and viruses. Table 3.13. Co-infection characteristics (n = 53) Virus 1 BC 2 BC 3 BC 1 VR 1 BC 1 VR 1 BC 2 VR Grand Total Total Total Total Total Total Total Total RSV 8 2 1 2 1 0 14 Influenza A 5 0 0 6 0 2 13 Adenovirus 6 0 1 3 2 0 12 Rhinovirus 7 0 0 0 3 0 10 Influenza B 4 0 0 0 0 0 4 Comment: Among 14 children with RSV co-infection, 8 out of 14 cases infecte withonly 1 bacteria. 6 In 13 children who suffers Influenza A co-infection the number of children co-infected with 1 virus, 6 out of 13, the highest rate.. - The highest incidence of H. influenza co-infection (45.2%), followed by K. pneumoniae and P. aeruginosa (with 19.1%). The lowest are B. cepacia and S. aureus (with 2.4% equals 1 case). 3.2. Evaluating the relationship between hs-CRP, PCT, IL-6 and clinical, subclinical, treatment results, viral etiology in viral pneumonia in children under 5 years old. 3.2.1. Relationship between clinical, subclinical characteristics and etiology. - 100% of children had cough, fever, runny nose had statistically significant differences between virus groups with p <0.01. The percentage of children with Influenza B and Influenza A group has the highest fever, respectively, 100.0% and 94.4%; lowest in RSV group with 39%. The rate of children with runny nose in Influenza A and B group are highest with 80.6% and 70.0% respectively, the lowest in the Adenovirus group with 17.9%. + 100% of children have rapid breathing, chest concave, moist lung in the lungs. - Symptoms of tachycardia with statistically significant differences between virus groups with p = 0.02. - X-ray images showed that the percentage of children in RSV group, Rhinovirus with interstitial lesions accounted for the highest with 47.5% and 37.5%, the lowest was in the Adenovirus group (21.4%). Meanwhile, blurred lesions were found in Adenovirus group (75.0%), Influenza A (66.7%) and Influenza B (70.0%), Rhinovirus group (43.7%). The differences between these groups are statistically significant (p<0.05). Apnea is seen in 1 child with Adenovirus and 2 children with Rhinovirus. Characteristics of the test index by mere virus groups - The Adenovirus group has the highest leukocyte index (median = 12.4 G/L). There was a statistically significant difference between leukocytes, lymphocytes and viral groups with p = 0.04 - Influenza B group has the highest neutrophil index, the lowest is Rhinovirus group. Differences between Influenza A group and RSV group; between Influenza A group and Rhinovirus group; between RSV group and Adenovirus group; and between Adenovirus and Rhinovirus group were statistically significant (p <0.01). The highest rate of children with hs-CRP> 6-10 mg/l in the Influenza B group is 80.0%; the lowest in Rhinovirus group with 12.5%. The difference between the two groups is statistically significant (p 0.5 ng / ml in the Influenza B group was also highest with 90.0%; lowest in Rhinovirus group with 31.3%. The difference between the two groups is statistically significant (p <0.05). 3.2.2. Clinical and subclinical characteristics in pediatric patients with severe viral co-infection - 100% of patients have symptoms of cough, tachypnea, chest concave, moist lung in the lungs The co-infection group only had a higher number of white blood cells than the co-infection group. The co-infection group of bacteria and viruses has a higher number of white blood cells than the co-infected group. The difference was statistically significant (p <0.05). Hs-CRP was highest in the co-infection group only, followed by the virus co-infection group, and lowest in the co-virus and bacterial co-infection group. PCT increased the highest in the co-infection group only, followed by virus and bacterial co-infection group, the lowest group was only co-infected with virus. IL-6 has the highest increase in the co-infection group with both virus and bacteria. - The co-infection group has a higher rate of children with fever, cyanosis than the non-co-infected group, with statistical significance (p <0.05 - There was no difference in lung X-ray lesion between the virus-infected group alone and the co-infected group (p>0.05). - In the group of pediatric pneumonia patients, the number of leukocytes, neutrophils, hs-CRP and PCT was statistically significantly higher (p<0.05) compared to the group of patients infected with virus alone. . - The percentage of pediatric patients in the co-infection group with the number of white blood cells (28.3%) and the proportion of neutrophils (35.8%) was higher than the simple group (p<0.05). - The proportion of pediatric patients in hs-CRP co-infection group> 6-10 mg/l was 54.7%, higher than in the simple group of 38.9% (p 0.5 ng / ml were found in 66.0% of pediatric patients compared to 44.3% in the simple group (p<0.05). Figure 3.3: ROC curve of hs-CRP and PCT values ​​in distinguishing between purely viral pneumonia and viral pneumonia co-infection Children with fever symptoms had significantly higher neutrophils, hs-CRP, PCT and IL-6, which were statistically higher than those without fever (p<0.05). Meanwhile, in the group of children with symptoms of runny nose, IL-6 is higher than the group without symptoms, the value is statistically significant with p<0.05. * Using Spearman correlation coefficient for quantitative variables distributed non-standard, the results show that: - There is a negative correlation between hs-CRP and Hb, and a positive correlation between hs-CRP and the number of white blood cells and neutrophils. - There is a positive correlation between PCT and the number of white blood cells, neutrophils, mono leukocytes and hs-CRP. - There is a negative correlation between IL-6 and lymphocytes, and there is a positive correlation between IL-6 and neutrophils, hs-CRP and PCT. Figure 3.4. The linear regression equation shows the relationship between hs-CRP and PCT Explain the regression equation: "When the hs-CRP concentration increased by 1 mg/l, the PCT concentration increased by 0.0296 ng/ml" with the average correlation coefficient r = 0.3530. - Differences in treatment time between influenza A and RSV groups, Adenovirus, Rhinovirus; between influenza B and RSV, Adenovirus and Rhinovirus; between RSV and Adenovirus group; and between Adenovirus and Rhinovirus group were statistically significant (p <0.05). - The rate of children recovered from influenza B is the highest at 85.7%; The lowest is influenza A group with 67.3%. There was no difference in treatment results between groups (p <0.05). - Increased IL-6 levels are associated with an increased risk of death in pediatric patients. Significant relationship with p <0.05 (according to the Mann-Whitney test). Figure 3.5. ROC curve of IL-6 value in distinguishing between mortality and non-mortality rate - At the cut-off value of 2.4 ng/ml, the difference between mortality and non-mortality of IL-6 has a sensitivity of 57.14% (95% CI) and specificity 88.24% (95% CI). - The area under the curve (AUC) of IL-6 is 0.6993 with a 95% confidence interval of 0.456 - 0.942. CHAPTER 4 DISCUSSION 4.1. Research clinical and subclinical characteristics of severe viral pneumonia in children under 5 years old. 4.1.1. Some common characteristics of pediatric patients 4.1.1.1. Age and gender Our research results show that pneumonia is common in children under 12 months old. The disease is more prevalent in boys than in girls, similar to the researched that is carried out by Quach Ngoc Ngan and et al. in children from 2 months to 5 years old at Can Tho Children Hospital in 196 children with 48% under 12 months old; the male/female ratio is 1.9/1 4.1.1.2. Time of illness Research results show that the disease occurs in all months of the year, the peaked time is spring (from February to April). Research of Prel J.B et al. shows that Adenovirus pneumonia tends to increase as temperature rises. 4.1.1.3. History of obstetrics Malnutrition is a major cause of immunodeficiency. Micronutrient deficiency causes poor growth, intellectual impairment, and increased mortality and susceptibility to infections, leading to pneumonia. 4.1.1.4. History of illness According to Smyth A., a number of comorbidities increase the risk of viral pneumonia: congenital heart disease, respiratory malformation. This study showed that 65.4% of children without common illness, while 25.7% of children often have respiratory disease. 4.1.1.5. History features Average number of days of being hospitalized is higher in patients with co-infection. 4.1.2. Clinical and subclinical characteristics 4.1.2.1. Clinical characteristics of the disease 46.4-64.4% of children with acute lower respiratory tract infection shows fever symptoms majority of which have fever ≤ 380C in all groups of viruses, symptom of cough is found in 100% of patients; over 66.7% of patients shows signs of wheezing and at least 75.3% of patients shows signs of upper respiratory tract inflammation. 4.1.2.2. Subclinical characteristics - X-ray characteristics Huijskens E.G. and et al. showed lung damage in 23.8% of cases and often manifested interstitial lesions on both sides of the lung. Respiratory X-ray images showed that children with mostly blind lesions were 61.4%. 35.6% had interstitial lung damage. - Subclinical laboratorial characteristics - Laboratory features + Hemoglobin and leukocytes According to Ruuskanen O. and et al., showing that the white blood cell count <10G/L is often suggestive of viral cause. An increased white blood cell count indicates that the child has a bacterial infection but 75.6% of the children do not have an increased number of white blood cells but still have the infection. Even 9.0% of children with neutropenia. + hs-CRP The proportion of pediatric patients with hs-CRP levels> 6 mg / l is 43.1%. This result is consistent with the study of Dao Minh Tuan and et al. with the highest hs-CRP <6 mg / dl ratio with 43.75%. + PCT Many studies also show that PCT can shorten diagnosis time, distinguish bacterial or viral infections, monitor response to antibiotic treatment and control foci better than other markers such as hs-CRP. + IL-6 Endeman H. and et al. Showed that in acute pneumonia Interleukin (IL-1, IL-6, IL-8 and IL-10) acted as an acute stage protein. Cytokine levels were significantly higher in patients with acute pneumococcal pneumonia. - Characteristics of virus and bacterial infection + The prevalence of severe pneumonia by virus groups The viruses that cause bronchitis are common such as Influenza virus, RSV, Adenovirus, Rhinovirus. + Co-infection status: Pavia A.T. and et al. research in 58 out of 58 patients identified the cause of pneumonia, 65% of patients infected on 1 virus, bacterial co-infection was 35%. 4.1.3. Clinical and subclinical characteristics according to the virus groups in pediatric patients infected by a single virus 4.1.3.1. Demographic characteristics 4.1.3.2. Clinical characteristics - Pneumonia caused by RSV D’Elia C. and et al. showed that wheezing is one of the functional symptoms with high sensitivity and specificity of 85% and 65% in diagnosis of ARIs caused by RSV. Our research results showed that 39% of RSV infected children had fever, 89.8% of wheezing children. - Pneumonia caused by Adenovirus Adenovirus bronchitis is often acute, prone to epidemics, rapid progression, causing complications of respiratory failure and death. The disease is often severe and persistent, the number of days of hospitalization lasts. - Rhinovirus pneumonia Rhinovirus is identified in 3-45% of children with community pneumonia. On the other hand, some studies suggest that Rhinovirus can multiply at body temperature and infect cells of the lower respiratory tract. - Pneumonia caused by Influenza A and Influenza B Pneumonia in influenza patients can be either viral or secondary to bacterial superinfection, common to S. pneumococcus or H. influenza 4.1.3.3. Subclinical characteristics - X-ray characteristics According to Kern S. and et al when studying X-ray images of 108 children with upper respiratory infections due to RSV found that: normal images were 30%, pneumonia 32%, bronchitis 26%, stasis 11%, collapsed lung 5%. - White blood cell characteristics - Hemoglobin and platelet characteristics - Characteristics hs-CRP According to a study by Li L. and et al, the group of severe Adenovirus pneumonia was 2.54 mg/l. Research by Garcia-Garcia M.L. and et al., pneumonia virus in the community showed that the average hs-CRP value in RSV group was 32.2 ± 46.1 mg/l, Rhinovirus was 81 ± 109 mg/l - PCT characteristics Because of the high specificity of PCT in response to severe systemic infections, appropriate PCT is used to guide treatment and evaluate prognosis. PCT has the ability to effectively detect bacterial co-infection and is an important indicator to keep in mind during child care. - IL-6 specification IL-6 is an important indicator for assessing viral infections. 4.1.4. Clinical and subclinical characteristics in pediatric patients who are infected with bacteria and virus Symptoms such as fever, tachycardia, and runny nose were different between the groups of children infected with the virus alone. Analysis of subclinical characteristics also showed that there was no significant difference between the three groups on lung X-ray characteristics, subclinical indicators such as Hb, hs-CRP, PCT or IL- 6. The co-in