目的 探讨儿童血管迷走性晕厥(vasovagal syncope,VVS)及体位性心动过速综合征(postural tachycardia syndrome,POTS)共患过敏性疾病的临床特点。方法 回顾性分析67例VVS及POTS儿童的临床资料,比较共患过敏性疾病与非共患过敏性疾病患儿的一般情况、症状评估、过敏指标以及直立试验或直立倾斜试验中的血流动力学特点,组间比较采用独立样本t检验或秩和检验,组成比比较采用χ2检验。采用双变量相关分析检验嗜酸性粒细胞百分比及计数与症状评分/晕厥发生频率的相关性。P<0.05为差异有统计学意义。结果 67例患儿中(VVS 43例,POTS 24例)共有21例(31%)共患过敏性疾病,伴随的过敏性疾病包括过敏性鼻炎、支气管哮喘、变应性皮炎及食物过敏,其中以过敏性鼻炎最为常见。过敏组与非过敏组患儿在就诊年龄、性别比例、基础血压方面差异无统计学意义。与非过敏组相比,过敏组的起病年龄(月)较大[11±2 vs. 9±3],病程(月)偏短[8.0(0.1,24.0) vs. 12.0(0.1, 144.0)]。在VVS患儿中过敏组晕厥发生频率(次/月)较非过敏组高[2.50(0.08,30.00) vs. 0.25(0.03,5.00)]。过敏组嗜酸性粒细胞百分比(%)[3.50(0.70,5.90) vs. 1.65(0.30,6.20)]及计数(×109)[0.18(0.05,0.71) vs.0.10(0.02,0.38)]较非过敏组更高,P均<0.05。VVS患儿中,过敏组与非过敏组相比直立倾斜试验阳性反应时间差异无统计学意义。在POTS患儿中,过敏组与非过敏组患儿在直立不耐受症状评分及直立试验中心率增加最大值方面差异无统计学意义。结论 过敏性疾病是VVS及POTS儿童常见的共患病,其中过敏性鼻炎最为常见;具有过敏性疾病的患儿出现直立不耐受表现的起病年龄较大,更可能因短期内发作较为频繁而就诊;VVS合并过敏性疾病时晕厥发生频率更高。
Objective: To explore the clinical characteristics of the co-morbidity of vasovagal syncope (VVS) and postural tachycardia syndrome (POTS) with allergic diseases in children. Methods: A re-trospective analysis was launched to summarize the clinical data of children with VVS and POTS. They were divided into allergic group and non-allergic group according to the history of allergic diseases. The participants’ clinical characteristics were compared between allergic group and non-allergic group using independent sample t test or rank sum test; composition comparisons were completed by Chi-square test. Bi-variate correlation analysis was used to explore the association between eosinophil percentage/count and symptom scores/frequency of syncope episodes. A P value <0.05 was defined as statistically significant. Results: Sixty-seven children complaining of orthostatic intolerance (43 patients diagnosed as VVS and 24 cases diagnosed as POTS) were enrolled. Totally 21 cases (31%) had allergic diseases, including allergic rhinitis, atopic eczema, asthma, as well as food allergy. And allergic rhinitis is the most common co-morbidity. There were no significant differences between the two groups in age, gender ratio, height, body weight and basement blood pressure. Compared with the non-allergic group, the allergic group showed later onset age (year) (11±2 vs. 9±3, P<0.05) of orthostatic intolerance and shorter course of the diseases (month) [8.0 (0.1, 0.1) vs. 24.0 (0.1, 144.0), P<0.05]. The frequency of syncope episodes in the allergic group among VVS children (times per month) [2.50 (0.08, 30.00) vs. 0.25 (0.03, 5.00), P<0.05] was much higher than that in the non-allergic group. Additionally, the eosinophil percentage (%) [3.50 (0.70, 0.59) vs. 1.65 (0.30, 6.20), P<0.001] and eosinophil count (×109) [0.18 (0.05, 0.71) vs. 0.10 (0.02, 0.38), P<0.001] were increased in the allergic group. However, there were no remarkable differences in the results of head-up tilt test in children with VVS or in the maximum change of heart rate during standing test in children with POTS were involved. Conclusion: Allergic diseases are common co-morbidities in children with both VVS and POTS. Allergic rhinitis is the most common co-morbidity. Children with co-morbidity of VVS/POTS and allergic diseases had a later onset of symptoms of orthostatic intolerance, and were more likely to be hospitalized for intensive attacks of symptoms during a short period when compared with those without allergic diseases. Children diagnosed as VVS combined with allergic diseases had more frequent episodes of syncope.
[1] 中华医学会儿科学分会心血管学组, 《中华儿科杂志》编辑委员会, 北京医学会儿科学分会心血管学组, 中国医师协会儿科医师分会儿童晕厥专业委员会. 儿童晕厥诊断指南(2016年修订版)[J]. 中华儿科杂志, 2016, 54(4): 246-250.
[2] 杜军保, 陈丽. 不断提高儿童直立不耐受的诊治水平[J]. 中华医学杂志, 2009, 89(28): 1945-1946.
[3] Wieling W, Jardine DL, de Lange FJ, et al. Cardiac output and vasodilation in the vasovagal response: An analysis of the classic papers [J]. Heart Rhythm, 2016, 13(3): 798-805.
[4] Vallejo M,Martínez-Martínez LA, Grijalva-Quijada S, et al. Frequency of migraine in patients with vasovagal syncope [J]. Int J Cardiol, 2014, 171(2): e14-e15.
[5] Zysko D, Melander O, Fedorowski A. Vasovagal syncope related to emotional stress predicts coronary events in later life [J]. Pacing Clin Electrophysiol, 2013, 36(8): 1000-1006.
[6] Reynolds GK, Lewis DP, Richardson AM, et al.Comorbidity of postural orthostatic tachycardia syndrome and chronic fatigue syndrome in an Australian cohort [J]. J Intern Med, 2014, 275(4): 409-417.
[7] Sakuramoto M, Himeno T, Minoguchi K, et al. The prevalence of orthostatic dysregulation complicated with bronchial asthma [J]. Arerugi, 1997, 46(11): 1123-1131.
[8] 中华医学会儿科学分会呼吸学组,《中华儿科杂志》编辑委员会. 儿童支气管哮喘诊断与防治指南(2016年版)[J]. 中华儿科杂志, 2016, 54(3): 167-181.
[9] 赵京, 柏娟, 申昆玲, 等. 北京、重庆、广州三城市中心城区0~14岁儿童过敏性疾病问卷调查[J]. 中华儿科杂志, 2011, 49(10): 740-744.
[10] 中国医师协会儿科医师分会儿童耳鼻咽喉专业委员会, 中华医学会儿科学分会呼吸学组. 儿童普通感冒与变应性鼻炎早期识别和诊治专家共识[J]. 临床儿科杂志, 2017, 35(2): 143-147.
[11] 中华医学会皮肤性病学分会免疫学组. 湿疹诊疗指南(2011年)[J].中华皮肤科杂志, 2011, 44(1): 5-6.
[12] Winker R, Barth A,Dorner W, et al. Diagnostic management of orthostatic intolerance in the workplace [J]. Int Arch Occup Environ Health, 2003, 76(2): 143-150.
[13] Lin J, Jin H, Du J. Assessment of therapeutic biomarkers in the treatment of children with postural tachycardia syndrome andvasovagal syncope [J]. Cardiol Young, 2014, 24(5): 792-796.
[14] Furuta GT, Atkins FD, Lee NA, et al. Changing roles of eosinophils in health and disease [J]. Ann Allergy Asthma Immunol, 2014, 113(1): 3-8.
[15] Swartzendruber JA, Byrne AJ, Bryce PJ. Histamine is required for IL-4-driven eosinophilic allergic responses [J]. J Immunol, 2012, 188(2): 536-540.
[16] Wheatley LM,Togias A. Clinical practice. Allergic rhinitis [J]. N Engl J Med, 2015, 372(5): 456-463.
[17] Grosicki M, Wójcik T, Chlopicki S, et al. In vitro study of histamine and histamine receptor ligands influence on the adhesion of purified human eosinophils to endothelium [J]. Eur J Pharmacol, 2016(777): 49-59.
[18] Shibao C, Arzubiaga C, Roberts LJ 2nd, et al. Hyperadrenergic postural tachycardia syndrome in mast cell activation disorders [J]. Hypertension, 2005, 45(3): 385-390.
[19] Liu M, Yokomizo TA. The role of leukotrienes in allergic diseases [J]. Allergol Int, 2015, 64(1): 17-26.
[20] Sirois P, Kérouac R, Roy S, et al. In vivo effects of leukotriene B4, C4 and D4. Evidence that changes in blood pressure are mediated by prostaglandins [J]. Prostaglandins Med, 1981, 7(5): 363-373.
[21] op denWinkel M, Gmelin L, Schewe J, et al. Role of cysteinyl-leukotrienes for portal pressure regulation and liver damage in cho-lestatic rat livers [J]. Lab Invest, 2013, 93(12): 1288-1294.
