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目的:总结临床和影像学等不同表现的儿童重症肺炎支原体肺炎（MPP）的临床表型。方法:回顾性队列研究。纳入2016年1月至2023年10月在首都医科大学附属北京儿童manbet官网登录 呼吸中心临床部二病区住院的505例MPP患儿的临床、影像学和实验室数据等资料。根据是否遗留下气道闭塞分为重症和非重症组，分析组间的临床和影像学特征；根据重症组影像学表现为单个肺叶≥2/3的肺实变（大叶实变）的患儿是否发生肺组织坏死分为肺组织坏死亚型及肺组织未坏死亚型，比较两个亚型的临床表现、支气管镜下表现和全血C反应蛋白（CRP）等炎症指标。组间比较采用独立样本 t检验、非参数检验或 χ2检验。对两个亚型的CRP等炎症指标进行单因素受试者工作特征（ROC）曲线分析。 结果:505例MPP患儿中，男254例、女251例，起病年龄（8.2±2.9）岁。重症组233例，其中影像学表现为大叶实变206例，弥漫性细支气管炎27例；非重症组272例，影像学表现均有斑片、云絮影或单个肺叶<2/3的不均匀实变或局限性细支气管炎。206例大叶实变患儿中，肺组织坏死亚型88例、肺组织未坏死亚型118例；持续高热206例（100.0%），支气管镜下存在炎性分泌物阻塞和塑形性支气管炎203例（98.5%）。88例肺组织坏死亚型中呼吸困难42例（47.7%），合并中-大量胸腔积液39例（44.3%），病程中明确合并肺栓塞35例（39.8%），另有34例（38.6%）高度可疑，支气管镜下可见气道较为广泛的黏膜坏死46例（52.3%）；肺组织坏死亚型的全血CRP水平高于肺组织未坏死亚型［131.5（91.0，180.0）比25.5（12.0，43.1）mg/L， U=334.00， P<0.001］，称为“肺实变-不张-坏死型”。118例肺组织未坏死亚型中呼吸困难27例（22.9%），中-大量胸腔积液0例，支气管镜下可见塑形性支气管炎65例（55.1%），可见气道黏膜少量坏死32例（27.1%），称为“肺实变-不张型”。ROC曲线分析示病程第6~10天的全血CRP 67.5 mg/L对于在大叶实变患儿中识别出“肺实变-不张-坏死型”的灵敏度0.96，特异度0.89，曲线下面积0.97。 结论:儿童重型MPP的影像学表现为大叶实变或弥漫性细支气管炎，其中大叶实变可分为“肺实变-不张-坏死型”和“肺实变-不张型”两个亚型，病程第6~10天的全血CRP 67.5 mg/L可作为两个亚型的早期区分指标。

Objective:To investigate and summarize pediatric patients with severe Mycoplasma pneumoniae pneumonia (MPP) presenting with varied clinical and chest imaging features in order to guide the individualized treatment. Methods:This was a retrospective cohort study. Medical records of clinical, imaging and laboratory data of 505 patients with MPP who were admitted to the Department Ⅱ of Respirology Center, Beijing Children′s Hospital, Capital Medical University from January 2016 to October 2023 and met the enrollment criteria were included. They were divided into severe group and non-severe group according to whether lower airway obliterans was developed. The clinical and chest imaging features of the two groups were analyzed. Those severe cases with single lobe ≥2/3 consolidation (lobar consolidation) were further divided into subtype lung-necrosis and subtype non-lung-necrosis based on whether lung necrosis was developed. Comparison on the clinical manifestations, bronchoscopic findings, whole blood C-reactive protein (CRP) and other inflammatory indicators between the two subtypes was performed. Comparisons between two groups were achieved using independent-sample t-test, nonparametric test or chi-square test. Univariate receiver operating characteristic (ROC) curve analyses were performed on the indicators such as CRP of the two subtypes. Results:Of the 505 cases, 254 were male and 251 were female. The age of the onset was (8.2±2.9) years. There were 233 severe cases, among whom 206 were with lobar consolidation and 27 with diffuse bronchiolitis. The other 272 belonged to non-severe cases, with patchy, cloudy infiltrations or single lobe <2/3 uneven consolidation or localized bronchiolitis. Of the 206 cases (88.4%) severe cases with lobar consolidation, 88 harbored subtype lung-necrosis and 118 harbored subtype non-lung-necrosis. All 206 cases (100.0%) presented with persistent high fever, among whom 203 cases (98.5%) presented with inflammatory secretion obstruction and plastic bronchitis under bronchoscopy. Of those 88 cases with subtype lung-necrosis, there were 42 cases (47.7%) with dyspnea and 39 cases (44.3%) with moderate to massive amount of pleural effusion. There were 35 cases (39.8%) diagnosed with lung embolism during the disease course, of which other 34 cases (38.6%) were highly suspected. Extensive airway mucosal necrosis was observed in 46 cases (52.3%), and the level of their whole blood CRP was significantly higher than that of subtype non-lung-necrosis (131.5 (91.0, 180.0) vs. 25.5 (12.0, 43.1) mg/L, U=334.00, P<0.001). They were regarded as subtype "lung consolidation-atelectasis-necrosis". Of those 118 cases with subtype non-lung-necrosis, 27 cases (22.9%) presented with dyspnea and none were with moderate to massive amount of pleural effusion. Sixty-five cases (55.1%) presented with plastic bronchitis and localized airway mucosal necrosis was observed in 32 cases (27.1%). They were deemed as subtype "lung consolidation-atelectasis". ROC curve analyses revealed that whole blood CRP of 67.5 mg/L on the 6-10 th day of disease course exhibited a sensitivity of 0.96, a specificity of 0.89, and an area under the curve of 0.97 for distinguishing between these two subtypes among those with lobar consolidation. Conclusions:Pediatric patients with severe MPP present with lobar consolidation or diffuse bronchiolitis on chest imaging. Those with lobar consolidation harbor 2 subtypes as "lung consolidation-atelectasis-necrosis" and "lung consolidation-atelectasis". Whole blood CRP of 67.5 mg/L can be applied as an early discriminating indicator to discriminate between these two subtypes.