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病例:抽丝剥茧,他是肺炎链球菌肺炎吗?

2018-01-29 朱越燕(浙江省人民医院院感科) SIFIC感染官微

患儿男性,16个月,因“咳嗽1周,发热2天”入院。

病情简介:

患儿男性,16个月,因“咳嗽1周,发热2天”入院。

现病史:1周前出现咳嗽,阵发性,痰液黄色,口服药物治疗(具体不详),症状无好转,2天前出现发热,体温最高达40.6℃,伴寒战、门诊检查血常规:白细胞计数:10.39×10^9/L,中性粒细胞分类:64.9%,肺炎支原体IgM弱阳性,副流感病毒抗体弱阳性,胸片示右肺肺炎,予以静脉滴注阿奇霉素针2天症状无缓解,改用头孢呋辛针治疗1天,体温峰值较前下降,间隔时间延长,于2017年11月10日入院,病程中无咯血,无气促等。

既往史:足月顺产,无先天性疾病。

入院检查:

体格检查:T:38.8℃, P:92次/分,R:22次/分,神志清楚,精神软,心率:92次/分,律齐,右肺叩诊实音,双肺呼吸音粗,可闻及中小水泡音,腹软,肝脾触诊不满意。

实验室检查:

血常规:白细胞计数:10.39×10^9/L,中性粒细胞分类:64.9%;

C反应蛋白:300mg/L

血沉:120mm/h

降钙素原:15.08ng/ml

血气分析:PH  7.44  PO2:77mmHg,PCO2:20mmHg

肺炎支原体抗体IgM阴性;

肝、肾功能、心肌酶谱指标均正常

影像检查:

2017年11月10日胸部CT提示:右肺实变影,少量胸腔积液。

入院诊断及治疗方案:

入院诊断社区获得性肺炎

诊断依据:(1)男性幼儿;(2)症状表现为发热、干咳;(3)入院查体:T38.5℃,右肺叩诊实音,双肺呼吸音粗,右肺可闻及中小水泡音。(4)辅助检查:血常规:WBC:10.39×10^9/L,N%:64.9%;C反应蛋白:300mg/L;降钙素原:15.08ng/ml;血气分析:PH 7.44  PO2:77mmHg,PCO2:20mmHg,胸部CT提示:右肺实变影。

入院治疗方案:予以美罗培南针抗感染,甲基强龙针抗炎,丙种球蛋白加强支持治疗及止咳化痰补液对症处理。

病情变化:

2天后患儿体温降至正常,复查C反应蛋白:94mg/L,2017年11月10日痰培养结果示耐青霉素肺炎链球菌(PRSP)++++:对青霉素、阿莫西林、红霉素、四环素、复方新诺明耐药;对头孢噻肟、头孢曲松、美罗培南中介;对左氧氟沙星、莫西沙星、利奈唑胺、万古霉素、氯霉素敏感。鉴于患儿病情好转,感染指标较前下降,结合药敏试验,继续原有治疗方案。患儿无发热,偶咳嗽,2017年11月17日复查C反应蛋白:9.83mg/L,降钙素原:0.233ng/ml,复查胸部CT提示右肺实变影,内坏死明显,右侧气胸,考虑为坏死性肺炎,患儿家属要求自动出院。



分析:

纵观病程,患儿起病急骤,症状表现为高热、咳嗽,右肺可闻及中小水泡音,辅助检查提示白细胞,C反应蛋白及降钙素原等炎症指标均升高明显, 2017年11月10日胸部CT提示右下肺实变,由肺部外周向内进展,并有少量胸腔积液,经过美罗培南抗感染及激素抗炎治疗后复查C反应蛋白、降钙素原均明显下降,11月17日复查胸部CT右肺实变区出现多发空洞,并出现右侧气胸,符合典型的坏死性肺炎表现。患者病程中曾行痰培养提示肺炎链球菌++++。结合病史,该患儿社区获得性肺炎诊断明确,病情进展快,C反应蛋白及降钙素原指标升高明显,并且血气分析氧分压偏低:77mmHg,提示轻度氧合障碍,二氧化碳分压:22mmHg,提示过度通气,考虑为重症。

那么患儿痰培养肺炎链球菌是否为责任病原菌呢?肺炎链球菌肺炎的临床表现又是怎么样的呢?我们知道,肺炎链球菌是寄居在口腔及鼻咽部的正常菌群,机体免疫功能受损时入侵人体而致病。

患者通常为原先健康的青壮年或老人与婴幼儿。起病多急骤,突发高热、寒战、肌肉酸痛,体温常在数小时内升高达39℃—40℃,脉率增快,可有患侧胸痛,咳嗽或深呼吸时加剧,痰少,可带血或呈铁锈色,早期肺部体征无明显异常,肺实变时叩诊浊音,触诊触觉语颤增强并可闻及支气管呼吸音,消散期可闻及湿啰音,影像学早期仅见肺纹理增粗或受累的肺段、肺叶稍模糊,随病情进展,肺泡内充满炎性渗出物,表现为大片炎症浸润阴影或实变影,并可见支气管充气征,肋膈角可见少量胸腔积液,消散期,炎性浸润逐渐吸收,多数病例在3—4周完全消散,但在儿童期,该病原是CAP最常见的细菌病原,可导致重症肺炎、坏死性肺炎。

儿童坏死性肺炎一般为侵袭性细菌感染所致,Sawicki等认为感染触发了强烈的炎症反应导致坏死性肺炎发生。Hsieh等则认为感染菌分泌毒素递质引起血管炎和血管血栓形成,影响支气管和肺的血供,进一步发展为坏死性肺炎,坏死性肺炎的病原菌主要为金黄色葡萄球菌和肺炎链球菌,儿童坏死性肺炎多合并败血症,且易合并有胸腔积液、气胸、支气管胸膜瘘等并发症。或许炎症损伤之后的肺泡、胸膜易脆性改变与气胸、支气管胸膜瘘发生有关。并且儿童坏死性肺炎多伴有白细胞升高,以中性粒细胞比例升高为主,可引发炎症因子风暴损伤致病,C反应蛋白明显升高。

综上所述,从患儿的临床表现及影像学表现,符合肺炎链球菌肺炎的表现,而痰培养为肺炎链球菌++++是否就可以确诊呢?对于肺炎链球菌感染的病原学检查,2009年英国胸科学会(BTS)的CAP指南认为社区治疗的CAP患者不必常规进行性病原学检查,除非经验治疗无效,而对于所有中重度CAP患者均应行病原学检查,并可根据严重程度选择检查范围;而2007年美国感染病学会/美国胸科协会(IDSA/ATS)制定的CAP指南却建议门诊CAP患者根据病情也可以选择常规行病原学诊断。

对于严重的CAP,IDSA/ATS与BTS菌强烈推荐行血培养、痰培养检查,并且血培养应在抗生素使用之前进行,尤其是肺炎链球菌血培养结果容易受抗生素的影响,即使在抗生素使用前即行血培养,检出病原菌的可能性也仅为4%—15%;BTS指南建议若CAP诊断明确且患者较轻,可以不做血培养。肺炎链球菌肺炎菌血症患者的痰标本培养肺炎链球菌阳性率为40%-50%[4],痰液标本检测的干扰因素主要包括痰液标本是否合格、之前是否使用过抗菌药物及送检是否及时,对于培养出的肺炎链球菌还需要区分是定植还是感染。

痰标本革兰染色在CAP诊断中的价值一直饱受争议,它的敏感性与特异性在不同情况下差别较大,但是由于肺炎链球菌形态的特殊性,在CAP患者的合格脓痰标本中若发现大量的革兰阳性双球菌可以诊断为肺炎链球菌肺炎。因此痰标本革兰染色在肺炎链球菌肺炎的诊断中有重要的作用,此项检查出结果较快且价格相对较低。此外,肺炎链球菌尿抗原检测也有助于判断是否存在肺炎链球菌感染,敏感度为50%—80%,特异度超过90%。鉴于肺炎链球菌感染后该试验可持续阳性1-6个月,且对肺炎链球菌无症状的携带者,特别是婴幼儿,该检测也经常呈阳性反应,因此该检测推荐用于成人,对于儿科病人价值有限,不推荐用于6岁以下幼儿。

若肺炎链球菌肺炎肺炎合并胸腔积液并能够进行穿刺者,均应进行诊断性胸腔穿刺,抽取胸腔积液进行常规、生化及病原学检查。

因此,对于肺炎链球菌肺炎的病原学诊断标准可参照我国CAP诊断和治疗指南,确定标准如下:

血液或胸腔积液培养到肺炎链球菌;

经纤维支气管镜或人工气道吸引的标本培养的肺炎链球菌浓度≥10^5cfu/ml(半定量培养++),支气管肺泡灌洗液(BALF)标本≥10^4 cfu/ml(+—++),防污染毛刷或防污染BALF标本≥10^3cfu/ml(+);

肺炎链球菌尿抗原检测阳性(儿童除外)。

有意义的诊断如下:

合格痰标本培养到肺炎链球菌中度以上生长(≥+++);

合格痰标本肺炎链球菌少量生长,同时涂片镜检查见成对排列的阳性球菌;

3d内多次培养到肺炎链球菌。

该患儿痰培养肺炎链球菌++++,有意义,结合病史及影像,诊断肺炎链球菌肺炎,但仍需与其他病原菌鉴别:

肺结核:如果是肺结核,肺内大片实变渗出,必定有周围支气管的部播散,该患儿病灶清楚,未见周围侵袭,可排除结核。

支原体肺炎:据文献报道,肺炎支原体也可引起大叶性肺炎,支原体肺炎白细胞不高或轻度增高,中性粒细胞轻度增高,治疗首选大环内酯类抗菌药物,但是该患儿入院后检测肺炎支原体抗体阴性,并且应用阿奇霉素针不显效,故基本可排除支原体肺炎。

金黄色葡萄球菌肺炎:小儿坏死性肺炎常见病原菌是肺炎链球菌和金黄色葡萄球菌,但小儿金葡菌肺炎影像表现有其特殊性,一般以两肺多发渗出病变为主,病灶易变,容易形成肺气囊,与该患儿影像表现不符,加之患儿痰培养肺炎链球菌++++,故可排除金葡菌肺炎。

患儿诊断基本考虑肺炎链球菌肺炎,那么治疗是否合理呢?根据《儿童社区获得性肺炎管理指南(2013修订)》,儿童青霉素不敏感肺炎链球菌(PNSSP)尤其青霉素耐药肺炎链球菌(PRSP)对治疗结局究竟有无影响?多数研究认为只要使用适当剂量的青霉素或阿莫西林依然有效。为了提醒临床医生不要过份关注实验室的最小抑菌浓度(MIC)值而忽视了患者的实际情况,避免在初始治疗时就选择广谱抗菌药物,2008年美国临床和实验室标准化委员会(CLSI)修订了SP青霉素折点判定标准,口服青霉素沿用原先标准,即敏感(S)≤0.06mg/L,中介(I)0.12—1mg/L,耐药(R)≥2mg/L;而对胃肠道外使用青霉素的折点标准:非脑膜炎标本(呼吸道、血流)来源菌株S≤2mg/L,I 4mg/L, R≥2mg/L,R≥8mg/L。

对于肺炎链球菌抗菌药物治疗,PSSP(青霉素敏感肺炎链球菌)首选青霉素或阿莫西林,PISP(青霉素中介肺炎链球菌)首选大剂量青霉素或阿莫西林,PRSP(青霉素耐药肺炎链球菌)首选头孢曲松、头孢噻肟,备选万古霉素或利奈唑胺。结合此案例,患儿为青霉素耐药肺炎链球菌,选择头孢曲松或头孢噻肟比较合适,但估计因患者病情重,所以临床医生选用了美罗培南。经过初始治疗后评估患儿体温下降,C反应蛋白、降钙素原指标明显下降,说明治疗有效,但患者胸部CT提示右下肺病灶内出现多发空洞,并有气胸,这是肺炎过程中的表现,并非治疗无效,而且儿童支气管胸膜瘘一如果面积不大,可自愈。

关于激素的应用,CAP患儿无常规使用糖皮质激素的指征,更不能将糖皮质激素作为“退热剂”,但出现下列情况可以短疗程(3-5天)使用糖皮质激素:喘憋明显伴呼吸道分泌物增多;中毒症状明显的呼吸道重症肺炎,例如合并休克、脓毒血症、缺氧中毒性脑病、急性呼吸窘迫综合征者、胸腔短期有大量渗出者;肺炎高热持续不退伴过度炎性反应者。有细菌感染者必须在有效抗菌药物使用的前提下家用糖皮质激素。该患儿病情进展快,缺氧,故短期应用激素是有利于病情好转的。

关于儿童CAP合并胸腔积液的治疗:欧美国家前瞻性研究发现,有2%-12%的CAP患儿并发有胸腔积液,最常见于细菌性肺炎(包括肺炎链球菌肺炎、化脓性链球菌及金黄色葡萄球菌等)患者中。当出现脓胸时,在充分有效的抗感染治疗基础上需要脓液的引流。感染性胸腔积液的引流可以减少发热、炎症和住院天数。另外,积液的多少和患儿呼吸窘迫的程度也是决定治疗方案的重要因素。少量积液往往对抗菌药物治疗反应良好,通常不需要进一步的干预。大量积液(受累面积超过胸腔的1/4)伴有呼吸窘迫时应及时予以引流。包裹性积液引流困难可局部给予纤维蛋白溶解剂改善引流,包括尿激酶或组织型纤溶酶原激活物,有条件者可予电视胸腔镜手术。该患儿胸腔积液量少,对抗菌药物治疗反应好,故未进一步干预。

体会:

对于感染患者,综合临床表现、实验室检查、影像表现及微生物检验多维度判断病情十分重要,有利于抗菌药物精准治疗,该患儿痰培养为肺炎链球菌++++,是有意义的,但是最好同时行痰涂片革兰氏染色检查及血液培养检查,同时患儿的动态胸部影像变化也为诊断提供了帮助。

知识点拓展:

肺炎链球菌感染概述:

肺炎链球菌又称肺炎双球菌,1881年首次由法国的巴斯德(Louis  Pasteur)和美国的G.M.Sternberg分别从患者痰液中分离出来,属细菌界、厚壁菌门、杆菌纲、乳杆菌目、链球菌科、链球菌属、肺炎链球菌种,基于表型特征和分类学考虑,肺炎链球菌目前归入缓症链球菌群。肺炎链球菌是常见的条件致病菌,尝寄居于正常人鼻咽部,目前已知的亚型有90多个,多数不致病或致病力弱,仅一部分(约20—30个亚型)有致病力,常在人体营养不良,抵抗力下降时发病。肺炎链球菌感染性疾病可分为侵袭性和非侵袭性两类,侵袭性肺炎链球菌性疾病是指肺炎链球菌侵入与外环境无直接相通,原本无菌的部位和组织所致感染,主要包括脑膜炎、菌血症和菌血症性肺炎等。在侵袭性链球菌性疾病中80%—90%为菌血症性肺炎、5%—10%是脑膜炎,不足5%为胸膜炎和关节炎等。

肺炎链球菌的微生物学特点及致病机制

肺炎链球菌为具有多糖荚膜的革兰染色阳性球菌,兼性厌氧,菌体呈矛头或瓜籽仁装,常以钝端相对、尖端向外成对或成短链排列,无鞭毛和芽孢。肺炎链球菌在机体内或含血清的培养基上有较厚的荚膜,人工培养后荚膜逐渐消失。革兰染色时荚膜不着色,表现为菌体周围透明环。

肺炎链球菌不产生重要毒素,其侵袭力主要与荚膜、溶血素、神经氨酸酶有关。荚膜能抵抗人体内吞噬细胞的吞噬作用而大量繁殖;溶血素可与被感染者细胞膜上的胆固醇结合,进而形成空洞起到杀伤细胞的作用;神经氨酸酶能分解细胞膜糖蛋白和糖磷脂的N-乙酰神经氨酸,与肺炎链球菌在鼻咽部和支气管粘膜上定植、繁殖和扩散有关。荚膜是最主要的致病因素,如果失去荚膜,其毒力和致病性将削弱或丧失。

肺炎练球菌感染的流行病学:

肺炎链球菌感染性疾病常见于营养不良人群、社会经济水平低者及发展中国家,各季节均可发生,温带地区以冬季和春季发病较高。该病多呈散发流行,但在封闭人群中(如养老院/幼儿园等)可暴发流行。据2012年WHO报道,每年有超过120万人死于肺炎链球菌感染,其中70—100万人为5岁以下儿童,在能通过疫苗预防的病原菌中其病死率最高。

肺炎链球菌感染的临床表现:

自然条件下,该菌定植在10%—40%的人鼻咽部,全球有5%—10%的健康成人、20%—40%的健康儿童是肺炎链球菌携带者。因为正常人呼吸道有多种防止肺部感染的保护机制如咳嗽反射、纤毛运动、巨噬细胞吞噬作用等,故一般情况下肺炎链球菌并不引起发病。仅当进入气道的细菌数量太大、或呼吸道正常防御功能遭受损害时才引起发病。

当机体突然受凉、淋雨、疲劳和酒醉等均可降低抵抗力,当病人免疫力降低或菌群失调时,其可直接侵入鼻窦、支气管甚至肺泡引起肺炎等。

肺炎链球菌是社区获得性肺炎的常见病原菌,临床症状为突然发病、高热、寒战、胸膜剧烈疼痛、咳铁锈色痰。10%—20%的患者可于高热期伴发菌血症。

其病理表现最初为肺泡内有大量纤维蛋白渗出液,继之是红细胞和白细胞向肺泡内渗出,最终导致病变部位肺组织实变。病变通常仅累及单个肺叶,故称为大叶性肺炎。肺炎链球菌也可侵入机体其他部位,引起中耳炎、鼻窦炎、胸膜炎、腹膜炎、心内膜炎及化脓性脑膜炎等,尤其是呼吸道病毒感染者或婴幼儿、老年体弱者。

肺炎链球菌肺炎的影像学表现:

急性肺炎链球菌肺炎典型的影像学表现包括跨越肺段的均质性病变,但仅

仅累及一个肺叶(大叶性肺炎)。由于实变起始于肺的外周部的气腔,故其总是贴近脏层胸膜表面或叶间部。偶尔,感染可表现为球形病灶(球形肺炎),与成人相比,该类型更多见于儿童。另外,约1/3病人表现为斑片状实变影(支气管肺炎)。病情严重者,可出现空洞性坏死、脓肿、支气管胸膜瘘、胸腔积液等表现。

肺炎链球菌病原学诊断:

从无菌体液中直接培养到肺炎链球菌,是确切诊断肺炎链球菌感染的金标准方法。除此之外,肺炎链球菌尿抗原检测也有助于判断是否存在肺炎链球菌感染,敏感度为50%—80%,特异度超过90%。鉴于肺炎链球菌感染后该试验可持续阳性1-6个月,且对肺炎链球菌无症状的携带者,特别是婴幼儿,该检测也经常呈阳性反应,因此该检测推荐用于成人,对于儿科病人价值有限,不推荐用于6岁以下幼儿。

肺炎链球菌感染的治疗

IDSA/ATS的成人社区获得性肺炎治疗共同指南强烈推荐大环内酯抗菌药物作为门诊治疗的单一药物方案。但考虑到在一些地区,如亚洲国家,肺炎链球菌对大环内酯类抗菌药物的耐药率的增加,应用该推荐方案时应保持谨慎。头孢呋辛也被IDSA/ATS指南推荐用于有抗菌药物耐药风险的肺炎链球菌感染患者的治疗。然而,在对头孢呋辛有高耐药率的地区,如亚洲地区,也不应选择这种推荐。

在美国和欧洲的指南中,氟喹诺酮类药物也被推荐作为CAP患者可供选择的治疗方法。考虑到全球许多地区肺炎链球菌对氟喹诺酮类药物较低的耐药率。在社区获得性肺炎诊断准确的基础上,可以谨慎低选用该类药物。

在我国,肺炎链球菌对克林霉素、红霉素、磺胺甲恶唑的耐药率也较高,均超过50%,对万古霉素、利奈唑胺以及氯霉素的耐药率较低,必要时可选择万古霉素、氯霉素、利奈唑胺等耐药性较低的抗菌药物,以提高肺炎链球菌感染的治疗效果。

无并发症的肺炎链球菌肺炎疗程为7-10天,抗菌药物一般用至热退且体温平稳,全身症状明显改善以及呼吸道症状部分改善后3-5天。

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    2018-01-30 虈亣靌

    诊疗进展值得借鉴

    0

  4. 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    2018-01-30 131****1460

    学习了受益匪浅

    0

  5. 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    2018-01-30 神功盖世

    0

  6. 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topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=ba101609906, createdName=happsf, createdTime=Tue Jan 30 08:30:01 CST 2018, time=2018-01-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=283407, encodeId=34f228340e54, content=学习学习学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=74, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NfNLvzZhgPxRkia1DP5MpwEgtXo1XhXA11xD6MWKxunAZFXKSNic0fWHUQx83oNHPlRMxxIctM83QKeCLkJpMibibiaC/0, createdBy=7e581734408, createdName=深海的鱼, createdTime=Tue Jan 30 06:49:32 CST 2018, time=2018-01-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=283402, encodeId=49672834025a, content=好, beContent=null, objectType=article, channel=null, level=null, likeNumber=49, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, 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    2018-01-30 happsf

    学习

    0

  7. [GetPortalCommentsPageByObjectIdResponse(id=1443196, encodeId=35e8144319669, content=<a href='/topic/show?id=49ae8219357' target=_blank style='color:#2F92EE;'>#肺炎链球菌#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=59, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=82193, encryptionId=49ae8219357, topicName=肺炎链球菌)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=69f05034104, createdName=12498e0fm79暂无昵称, createdTime=Wed Jan 31 14:23:00 CST 2018, time=2018-01-31, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1624049, encodeId=e43b1624049c7, content=<a href='/topic/show?id=69699666026' target=_blank style='color:#2F92EE;'>#链球菌#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=53, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=96660, encryptionId=69699666026, topicName=链球菌)], attachment=null, authenticateStatus=null, createdAvatar=null, 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createdAvatar=https://wx.qlogo.cn/mmopen/ajNVdqHZLLDicHg2ldsSNmib46PmdzpO7CQEmPjuULp1v45zPWwMYhrnXgvl3OtmUCZSQfgITWn96X9moL94nUGA/0, createdBy=28072041016, createdName=131****1460, createdTime=Tue Jan 30 08:58:20 CST 2018, time=2018-01-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=283465, encodeId=5ead28346587, content=阅, beContent=null, objectType=article, channel=null, level=null, likeNumber=90, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/vi_32/fhZdOu27e88Voqh19n8eF8cLplo8L4nicKtH0WnE3KFELXns5XDu8rsiceK2HHDZc2SEStia5VV3Pia2QLMVqlWbHw/0, createdBy=6e012139475, createdName=神功盖世, createdTime=Tue Jan 30 08:49:54 CST 2018, time=2018-01-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=283453, encodeId=d7482834536a, content=学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=82, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=ba101609906, createdName=happsf, createdTime=Tue Jan 30 08:30:01 CST 2018, time=2018-01-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=283407, encodeId=34f228340e54, content=学习学习学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=74, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NfNLvzZhgPxRkia1DP5MpwEgtXo1XhXA11xD6MWKxunAZFXKSNic0fWHUQx83oNHPlRMxxIctM83QKeCLkJpMibibiaC/0, createdBy=7e581734408, createdName=深海的鱼, createdTime=Tue Jan 30 06:49:32 CST 2018, time=2018-01-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=283402, encodeId=49672834025a, content=好, beContent=null, objectType=article, channel=null, level=null, likeNumber=49, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=6d551998554, createdName=1e1c07bdm01(暂无匿称), createdTime=Tue Jan 30 06:24:49 CST 2018, time=2018-01-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=283389, encodeId=3dba28338922, content=很好, beContent=null, objectType=article, channel=null, level=null, likeNumber=52, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2018/01/15/8213228fe923915543544ad3da7e1c64.jpg, createdBy=6bd82014262, createdName=秀红, createdTime=Tue Jan 30 06:14:31 CST 2018, time=2018-01-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=283380, encodeId=ebfd283380b7, content=好好好好好好好好, beContent=null, objectType=article, channel=null, level=null, likeNumber=49, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, 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    2018-01-30 深海的鱼

    学习学习学习

    0

  8. 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  9. 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topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=ba101609906, createdName=happsf, createdTime=Tue Jan 30 08:30:01 CST 2018, time=2018-01-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=283407, encodeId=34f228340e54, content=学习学习学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=74, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NfNLvzZhgPxRkia1DP5MpwEgtXo1XhXA11xD6MWKxunAZFXKSNic0fWHUQx83oNHPlRMxxIctM83QKeCLkJpMibibiaC/0, createdBy=7e581734408, createdName=深海的鱼, createdTime=Tue Jan 30 06:49:32 CST 2018, time=2018-01-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=283402, encodeId=49672834025a, content=好, beContent=null, objectType=article, channel=null, level=null, likeNumber=49, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, 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    2018-01-30 秀红

    很好

    0

  10. 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createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/08/29/bbc5cc0eed9b8d17623d2fd49dbdf19a.jpg, createdBy=79522135794, createdName=yjs木玉, createdTime=Tue Jan 30 05:10:28 CST 2018, time=2018-01-30, status=1, ipAttribution=)]
    2018-01-30 yjs木玉

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