Clinical and Experimental Pediatrics

대한소아청소년과학회 (The Korean Pediatric Society)
권호 표지
DOI QR코드

DOI QR Code

소아 가막성 대장염: 단일 대학병원의 경험

Pseudomembranous colitis in children: Experience of a university hospital in Korea

  • 박재현 (계명대학교 의과대학 소아과학교실) ;
  • 강경지 (계명대학교 의과대학 소아과학교실) ;
  • 강유나 (계명대학교 의과대학 병리학교실) ;
  • 김애숙 (동국대학교 의과대학 소아과학교실) ;
  • 황진복 (계명대학교 의과대학 소아과학교실)
  • Park, Jae Hyun (Department of Pediatrics, Keimyung University School of Medicine) ;
  • Kang, Kyung Ji (Department of Pediatrics, Keimyung University School of Medicine) ;
  • Kang, Yu Na (Department of Pathology, Keimyung University School of Medicine) ;
  • Kim, Ae Suk (Department of Pediatrics, Dongguk University College of Medicine) ;
  • Hwang, Jin-Bok (Department of Pediatrics, Keimyung University School of Medicine)
  • 투고 : 2009.09.08
  • 심사 : 2009.10.19
  • 발행 : 2010.02.15
PDF 다운로드
⟨ 이전 논문 다음 논문 ⟩

초록

목 적 : 가막성 대장염(pseudomembranous colitis, PMC)은 소아에서는 드문 질환으로 항생제의 사용이 늘어나면서 증가하고 있을 것으로 추정되고 있다. 저자들은 세균성 장염의 소견을 보인 소아 PMC의 발병 빈도와 임상 특성에 관한 단일 대학 병원의 경험을 소개하고자 한다. 방 법 : 2003년 11월부터 2007년 7월까지 동산의료원 소아과에 입원한 환자 중 최근 1개월 이내에 항생제 사용의 병력을 가지면서 세균성 장염 증상을 보인 환자에서 직장 내시경 및 조직생검을 시행하여 조직학적으로 PMC로 확진된 연속해서 모아진 환자를 대상으로 하였다. 결 과 : 직장 내시경 및 조직 검사를 시행한 22례 중 11례(50.0%)에서 PMC로 진단되었다. 소아 PMC 환자의 연령은 2개월에서 12세로, 1세 이하가 5례(45.5%)를 차지하였다. 혈성 설사 6례(28.6%), 복통 혹은 보챔 6례(28.6%), 수양성 혹은 점액성 설사 5례 (23.8%), 구토 2례(9.5%), 열 2례(9.5%)가 관찰되었다. 항생제는 병합 사용된 경우를 포함하여 총 18건이 관찰되어, 페니실린 계열 10건(55.6%), 마크로라이드 5건(27.8%), 세팔로스포린 2건(11.1%), 아미노글라이코사이드 계열 사용이 1건(5.6%)이었다. 항생제 사용 기간은 3일에서 14일로 다양하였다. 항생제 노출에서 증상 발현까지의 기간은 5일에서 21일이었다. 대변 Clostridium difficile 독소 A 검사는 PMC 환자 전례에서 음성이었다. 가막성을 기준으로 한 가막성 대장염의 내시경 소견은 1단계(18.2%, 2), 2단계(27.3%, 3), 3단계(36.4%, 4), 4단계(18.2%, 2)였다. 추적 관찰 중 전례에서 재발은 관찰되지 않았다. 결 론 : 소아의 가막성 대장염은 드물지 않으며, 영아기에도 호발한다. 특히 항생제를 사용 중이거나 사용 병력을 가진 환자에서 세균성 장염의 소견을 보일 때 직장 내시경 검사 및 조직 생검을 이용한 적극적인 진단적 접근이 필요할 것으로 판단된다.

Purpose : Pseudomembranous colitis (PMC) occurs rarely in children, but its incidences are increasing due to frequent antibiotic use. We investigated the incidence and clinical characteristics of PMC accompanied by bacterial enteritis-like symptoms in children. Methods : Between November 2003 and July 2007 at the Department of Pediatrics, Dongsan Medical Center, we analyzed the medical records of consecutive patients who received antibiotics in the past 1 month, developed bacterial enteritis-like symptoms, and were diagnosed with PMC based on sigmoidoscopy examination and histological findings. Results : Among 22 patients who underwent sigmoidoscopy and biopsy examinations, 11 (50%) were diagnosed with PMC. These 11 patients were aged 2 months-12 years, among whom 5 patients (45.5%) were less than 1 year old. The clinical symptoms were bloody diarrhea (28.6%), abdominal pain or colic (28.6%), watery or mucoid diarrhea (23.8%), vomiting (9.5%), and fever (9.5%). The antibiotics used were penicillins (55.6%), macrolides (27.8%), cephalosporins (11.1%), and aminoglycosides (5.6%). The period of antibiotic use was 3-14 days. The interval between the initial antibiotic exposure and the onset of symptoms was 5-21 days. The results of stool examination of all patients were negative for Clostridium difficile toxin A. Patient distribution according to the degree of PMC was as follows: grade I, 18.2% (2 cases); grade II, 27.3% (3); grade III, 36.4% (4); and grade IV, 18.2% (2). PMC did not recur in any case.Conclusion : PMC is not a rare disease in children. If pediatric patients receiving antibiotics manifest symptoms like bacterial enteritis, PMC should be suspected. Endoscopy and biopsy should be applied as aggressive diagnostic approaches to detect this condition.

키워드

참고문헌

  1. Brook I. Pseudomembranous colitis in children. J Gastroenterol Hepatol 2005;20:182-6 https://doi.org/10.1111/j.1440-1746.2004.03466.x
  2. Cleary RK. Clostridium difficile-associated diarrhea and colitis: clinic manifestations, diagnosis, and treatment. Dis Colon Rectum 1998;41:1435–49 https://doi.org/10.1007/BF02237064
  3. Kim J, Smathers SA, Prasad P, Leckerman KH, Coffin S, Zaoutis T. Epidemiological features of Clostiridium difficile-associated disease among inpatients at children's hospitals in the United States, 2001-2006. Pediatrics 2008;122;1266-70 https://doi.org/10.1542/peds.2008-0469
  4. Kim BC, Yang HR, Jeong SJ, Lee KH, Kim JE, Ko JS, et al. Clostridium difficile colitis in childhood: associated antibiotics. J Korean Pediatr Gastroenterol Nutr 2002;5:143-9
  5. Zwiener RJ, Belknap WM, Quan R. Severe pseudomembranous enterocolitis in a child: case report and literature review. Pediatr Infect Dis J 1989;8 876-82 https://doi.org/10.1097/00006454-198912000-00010
  6. Park JH, Bae WY, Lee JH, Park DH, Lee SH, Chung IK, et al. The relationship between endoscopic degrees and prognostic factors in pseudomebranous colitis. Korean J Gastrointest Endosc 2006;32:260-5
  7. Price AB, Davies DR. Pseudomembranous colitis. J Clin Path 1977;30:1-12 https://doi.org/10.1136/jcp.30.1.1
  8. McFarland LV, Brandmarker SA, Guandalini S. Pediatric Clostridium difficile: a phantom menace or clinical reality? J Pediatr Gastroenterol Nutr 2000;31:220-31 https://doi.org/10.1097/00005176-200009000-00004
  9. Ramaswamy R, Grover H, Corpuz M, Daniels P, Pitchumoni CS. Prognostic criteria in Clostridium difficile colitis. Am J Gastroenterol 1996;91:460-4
  10. Wanahita A, Goldsmith EA, Musher DM. Conditions associated with leukocytosis in a tertiary care hospital with particular attention to the role of infection caused by Clostridium difficile. Clin Infect Dis 2002;34:1585-92 https://doi.org/10.1086/340536
  11. Hookman P, Barkin JS. Clostridium difficile associated infection, diarrhea and colitis. World J Gastroenterol 2009;15:1554-80 https://doi.org/10.3748/wjg.15.1554
  12. Gerding DN, Johnson S, Peterson LR, Mulligan ME, Silva J Jr. Clostridium difficile-associated diarrhea and colitis. Infect Control Hosp Epidemiol 1995;16:459–77 https://doi.org/10.1086/648363
  13. Bartlett JG. The pseudomembranous enterocolitis and antibiotic- associated colitis. In: Sleisenger MH, Fordtran JS, editors. Gastrointestinal disease. 5th ed. Philadelphia : WB Saunders Co, 1993:1174-89
  14. Burgner D, Siarakas S, Eagles G, McCarthy A, Bradbury R, Stevens M. A prospective study of Clostridium difficile infection and colonization in pediatric oncology patients. Pediatr Infect Dis J 1997;16:1131-4 https://doi.org/10.1097/00006454-199712000-00006
  15. Starr J. Clostridium difficile-associated diarrhoea: diagnosis and treatment. BMJ 2005;331:498-501 https://doi.org/10.1136/bmj.331.7515.498
  16. Wenzl TG, Kusenbach G, Skopnik H. Pseudomembranous viral colitis. J Pediatr Gastroenterol Nutr 2000;30:472 https://doi.org/10.1097/00005176-200004000-00026
  17. Olofinlade O, Chiang C. Cytomegalovirus infection as a cause of pseudomembrane colitis: a report of four cases. J Clin Gastroenterol 2001;32:82-4 https://doi.org/10.1097/00004836-200101000-00019
  18. Savidge TC, Pan WH, Newman P, O'brien M, Anton PM, Pothoulakis C. Clostridium difficile toxin B is an inflammatory enterotoxin in human intestine. Gastroenterology 2003;125:413-20 https://doi.org/10.1016/S0016-5085(03)00902-8
  19. von Eichel-Streiber C, Boquet P, Sauerborn M, Thelestam M. Large clostridial cytotoxins— a family of glycosyltransferases modifying small GTP-binding proteins. Trends Microbiol 1996;4:375-82 https://doi.org/10.1016/0966-842X(96)10061-5
  20. Biddle WL, Harms JL, Greenberger NJ, Miner PR Jr. Evaluation of antibiotic-associated diarrhea with a latex agglutination test and cell culture cytotoxicity assay for Clostridium difficile. Am J Gastroenterol 1989;84:379-82
  21. Holmes R, Byrne WJ. Relapsing pseudomembranous colitis. J Pediatr Gastroenterol Nutr 1986;5:314-5 https://doi.org/10.1097/00005176-198603000-00027
  22. Bartlett JG, Tedesco FJ, Shull S, Lowe B, Chang T. Symptomatic relapse after oral vancomycin therapy of antibioticassociated pseudomembranous colitis. Gastroenterology 1980;78:431-43
  23. Nair S, Yadav D, Corpuz M, Pitchumoni CS. Clostridium difficile colitis: factors influencing treatment failure and relapse-a prospective evaluation. Am J Gastroenterol 1998;93:1873-6

피인용 문헌

  1. 소아에서 발생한 Clostridium difficile 관련 질환의 역학과 임상양상: 지역사회감염과 원내감염의 비교 vol.13, pp.2, 2010, https://doi.org/10.5223/kjpgn.2010.13.2.146
  2. Skeletal Muscle Na + Channel Disorders vol.2, pp.None, 2010, https://doi.org/10.3389/fphar.2011.00063
  3. Clostridium difficileInfections in Children vol.34, pp.2, 2010, https://doi.org/10.12771/emj.2011.34.2.3