GM-CSF and HMGB1 level were associated with the clinical characteristics and prognosis of childhood refractory mycoplasma pneumoniae pneumonia

GM-CSF and HMGB1 level were associated with the clinical characteristics and prognosis of childhood refractory mycoplasma pneumoniae pneumonia | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research article GM-CSF and HMGB1 level were associated with the clinical characteristics and prognosis of childhood refractory mycoplasma pneumoniae pneumonia Lianfu Cao, Haijiao Lin, Hongjun Yu, Yongji Wang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-18708/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: To analyze the relationship between granulocyte-macrophage colony-stimulating factor (GM-CSF) and high mobility group box 1 (HMGB1) level in alveolar lavage fluid with the clinical characteristics and prognosis of children refractory mycoplasma pneumoniae pneumonia (MPP), so as to provide reliable targets for clinical diagnosis and treatment. Methods: A total of 106 children diagnosed with MPP and prepared for bronchoalveolar lavage therapy were selected in this study, which were divided into 2 groups according to clinical diagnosis: those showing clinical and radiological deterioration despite appropriate antibiotic therapy for ≥7 days were classified into refractory MPP group (n=47), while the others were classified into non-refractory MPP group (n=59). The data of physical examination, treatment and outcome were collected. In addition, the GM-CSF and HMGB1 levels in alveolar lavage fluid during each bronchoalveolar lavage therapy were detected by ELISA kits. Results: There was no significant difference in age, sex, course of fever, the highest temperature, WBC, L, PLT, ALT, AST, CK-MB, D-D, CK, IgG, IgA, IgM, C3, and C4 between refractory MMP group and non-refractory MMP group on admission (P＞0.05). The levels of N, CRP, PCT, and LDH in refractory MPP group were higher than those in non-refractory MPP group, the difference had statistical significance (P＜0.05). Both GM-CSF and HMGB1 levels were positively correlated with traditional indicators N, CRP, PCT and LDH (r=0.611-0.785, P<0.05). ROC analysis results showed that CRP, GM-CSF and HMGB1 had predictive value for refractory MPP attack (AUC=0.636, 0.657, 0.651, P<0.05). Logistic regression analysis results showed GM-CSF and HMGB1 were independent factors for refractory MPP (B＞1.0, P28 d) and poor prognosis of refractory MPP (AUC=0.782-0.825, P < 0.05). Conclusion: The level of GM-CSF and HMGB1 in alveolar lavage fluid is closely related to the occurrence and development of refractory MPP, which can be used as an auxiliary indicator for clinical diagnosis and prognosis evaluation, and has certain guiding significance for its clinical treatment. Pulmonology infantile pneumonia granulocyte-macrophage colony-stimulating factor high mobility group box 1 mycoplasma pneumoniae refractory pneumonia Figures Figure 1 Figure 2 Figure 3 Backgrounds Mycoplasma pneumoniae (MP) is one of the most common causes of community-acquired pneumonia (CAP) in children and young adults, with ability to cause local epidemics[ 1 ]. In general, Mycoplasma pneumoniae pneumonia (MPP) is mild and self-limiting, which could be rapidly improved by macrolide treatment. However, in recent years, the incidence of refractory MPP characterized by rapid development, long course of disease and severe pulmonary lesions has been increasing year by year[ 2 ]. In addition to improving the treatment methods, how to improve the early diagnosis rate and win the best treatment opportunity is also a focus of current researches[ 3 ]. Several mechanisms, including direct cytotoxicity, intracellular colonization, adsorption effect to respiratory epithelial cells, and causing immune dysfunction has been reported as so far, in which immune dysfunction, especially adaptive immune dysfunction is considered to be the most important factor to promote the development of refractory MPP[ 4 ]. Despite being only a subsystem in the more basic and all-compassing system maintaining integrity, the adaptive immune system plays a key role in recognizing pathogens and distinguishing dead cells, thus clear harmful substances and block secondary damage[ 5 ]. It is reported that pathogen-associated molecular pattern molecules (PAMPs) and damage- associated molecular pattern molecules (DAMPs) are the most important adjuvants for adaptive immune system[ 6 ]. PAMPs has been identified galore, while there are only two types of typical DAMP as so far: high mobility Group Box 1 (HMGB1) protein and adenosine triphosphate proteins (ATP)[ 7 ]. HMGB1 is a kind of highly conserved encoded non-histone, nuclear DNA-binding protein widely found in eukaryotic cells. In addition to its classical role such as DNA recombination and cell differentiation, HMGB1 also sever as an inflammatory factor to participate in anti-pathogen activities. Granulocyte macrophage colony stimulating factor (GM-CSF) was first detected in Lung tissue from mice cultured in vitro after LPS stimulation. Recent years, a few studies focused on GM-CSF expression in children with MPP, and found GM-CSF played an important role in the inflammatory response conducted by neutrophil in acute and severe MPP[ 8 ]. Liu Y, et al. [ 9 ] found the GM-CSF level of MPP Children was associated to the duration of fever and might be a good marker for prognosis. It was reported that the bronchial epithelium could produce GM-CSF in the stimulation of MP, which serve as a proinflammatory cytokines to recruit and activates neutrophils. Meanwhile, GM-CSF could also modulate oxidative stress activity through a priming phenomenon of human neutrophil respiratory burst. Otherwise, we noticed that both HMGB1 and GM-CSF has important effect on toll like receptor 2 -the main receptor to identify mycoplasma. In this study, we analyzed their relationship with patient clinical characteristics and prognosis, as a result, we found both GM-CSF and HMGB1 have prognostic value in determining disease status of refractory MPP. Methods Study population A total of 106 children (including 47 refractory MMP) diagnosed with MPP and prepared for bronchoalveolar lavage therapy registered by the Affiliated Hospital of Changchun University of Traditional Chinese Medicine from July 2014 to November 2015 were selected for this study. All children had been diagnosed with the disease in accordance with the Guidelines for the management of community-acquired pneumonia in children. The refractory MMP cases were defined as those showing clinical and radiological deterioration despite appropriate antibiotic therapy for ≥ 7 days[ 10 ]. Children with congenital heart diseases, hereditary metabolic diseases, neurological disorders, bronchopulmonary dysplasia, and immunodeficiency were excluded. This research was conducted in compliance with the principles of the Declaration of Helsinki and approved by the ethics committee of Affiliated Hospital of Changchun University of Traditional Chinese Medicine. Written informed consent was provided by all enrolled individuals. Clinical data collection Clinical parameters before and during the treatment were collected from patient medical records, including age, sex, course of fever, the highest temperature, white blood cell count (WBC), lymphocyte count (L), neutrophil count (N), blood platelet count (PLT), C-reaction protein (CRP), procalcitonin (PCT), D -dimer (D-D), aspartate aminotransferase (AST), alanine transaminase (ALT), lactate dehydrogenase (LDH), creatine kinase (CK), creatine kinase isoenzyme (CK-MB), immunoglobulin (IgA, IgM and IgG), complement (C3 and C4), and multi detector computed tomography (MSCT) data. Treatment methods All children received a Bronchoalveolar lavage therapy defined by Guidelines for the management of community-acquired pneumonia in children consistent with the individual condition of each patient. In this study, the children in non-refractory MMP group accepted bronchoalveolar lavage therapy only once, while those in refractory MMP group accepted 2 to 4 times according to individual condition. The lavage fluids we used was prepared with 50 ml saline, 80,000u gentamicin, and 5 mg dexamethasone. Cases with localized pulmonary lesions was douched in the suspicious bronchopulmonary segment, while cases with diffuse interstitial pulmonary lesions was douched in the right middle lobe or left lingulaoflung. In addition, all children were given supportive treatment such as sensitive antibiotic, antitussive, anticonvulsant, sputum aspiration, parenteral nutrition, etc. Quantification of GM-CSF and HMGB1 level in bronchoalveolar lavage fluid (BALF) BALF was extracted after bronchoalveolar lavage therapy, and the cells in the BALF samples was separated by a centrifuge at 200 g for 10 min at 4 ℃, then stored at -80 ℃. The levels of HMGB1 and GM-CSF in those cells were quantified by ELISA kits purchased from Shanghai Meilian Biotechnology Co. Ltd (Shanghai, China) in a week. The experimental procedure is strictly carried out according to the instructions, in a word, each standard or sample was placed into the appropriate wells of 96-well plates, and incubated with biotinylated detection antibody adequately. Then, HRP-streptavidin solution was added and incubated, each plate was again inverted and washed prior to the addition of 100 µl of ELISA Colorimetric TMB Reagent. The absorbance was measured using a Universal Microplate Spectrophotometer at 450 nm. Prognostic assessment methods Most children in non-refractory MMP group got good prognosis and discharged from hospital in 7 to 15 days, so we mainly observed the effect of refractory MMP group. The hospital stay time and pulmonary function on discharge were assessed. Those with respiratory dysfunction such as pulmonary fibrosis, unilateral hyperlucent lung syndrome and asthma., etc. were classified into poor prognosis. Statistical analysis Statistical analyses were performed using SPSS software (version 22.0). All normally distributed quantitative variables are expressed as means ± SD, the remainder were expressed as median (IQR) values. ANOVA and LSD-t tests were performed to compare differences among groups for normally distributed variables, and Mann-Whitney U tests were performed for variables not normally distributed. Categorical data are expressed as percentages, and chi-square tests were performed to compare differences between groups. Kruskal–Wallis H test was performed for comparisons between groups with ranked data. In addition, ROC curve analysis was used to ascertain the predicted value of BALF HMGB1 and GM-CSF for the occurrence of refractory MMP and poor prognosis of refractory MMP. Results Clinical characteristics of children in refractory MPP group and non-refractory MPP group before treatment The clinical characteristics of children before treatment were shown in Table 1 . There was no significant difference in age, sex, course of fever, the highest temperature, WBC, L, PLT, ALT, AST, CK-MB, D-D, CK, IgG, IgA, IgM, C3, and C4 between refractory MPP group and non-refractory MPP group. The levels of N, CRP, PCT, and LDH in refractory MPP group were all higher than those in non-refractory MPP group, the difference between groups had statistical significance ( P ༜0.05). Table 1 The basic data compare between children with and without refractory MMP. Clinical characteristics Refractory MMP group (n = 47) Non-refractory MMP group (n = 59) χ 2 /t P Age (IQR, months) 35 (24, 66) 31 (24, 59) -1.314 0.185 Male [n(%)] 23 (48.9%) 32 (54.2%) 0.294 0.587 Course of fever (IQR, d) 8 (4, 12) 4 (3, 6) -1.217 0.224 The highest temperature ≥ 40 ℃ [n (%)] 11 (23.4%) 9 (15.3%) 1.135 0.287 WBC (IQR, 10 9 /L) 9.22 (4.35, 25.25) 8.65 (5.01, 23.52) -0.757 0.449 N (IQR, 10 9 /L) 5.55 (2.15, 13.25) 4.82 (2.22, 11.12) -2.070 0.038 L (IQR, 10 9 /L) 3.02 (1.84, 9.25) 3.37 (2.01, 10.36) -1.283 0.199 PLT (IQR, 10 9 /L) 322.5 (85.3, 488.2) 313.2 (102.3, 451.3) -1.141 0.254 CRP (IQR, mg/L) 25.34 (15.52, 52.31) 11.54 (6.33, 43.62) -2.563 0.010 PCT (IQR, µg/L) 6.53 (1.52, 28.62) 7.15(1.44, 22.63) -2.178 0.029 ALT (IQR, U/L) 22.13 (18.25, 84.6) 25.24 (15.25, 75.62) -1.512 0.131 AST (IQR, U/L) 34.35 (29.38, 44.25) 36.25 (30.24, 42.15) -0.998 0.318 LDH (IQR, U/L) 322.33 (125.32, 382.63) 302.52 (116.85, 335.21) 2.308 0.023 D-D (mean ± SD, mg/L) 3.36 ± 0.83 3.12 ± 0.91 1.402 0.164 CK (mean ± SD, U/L) 201.35 ± 46.52 185.63 ± 40.36 1.861 0.066 CK-MB (mean ± SD, U/L) 12.25 (6.35, 18.35) 8.22 (6.02, 16.21) -0.016 0.987 IgG (mean ± SD, g/L) 9.15 ± 2.35 9.28 ± 2.52 0.272 0.786 IgA (mean ± SD, g/L) 0.81 ± 0.21 0.88 ± 0.19 1.798 0.075 IgM (mean ± SD, g/L) 1.35 ± 0.26 1.46 ± 0.31 1.947 0.054 C3 (mean ± SD, g/L) 1.26 ± 0.25 1.32 ± 0.28 1.149 0.253 C4 (mean ± SD, g/L) 0.32 ± 0.08 0.35 ± 0.10 1.673 0.097 WBC: white blood cell count; PLT: blood platelet count; L: lymphocyte count, N: neutrophil count; CRP: C-reactive protein; PCT: procalcitonin; D-D: D -dimer; AST: aspartate aminotransferase; ALT: alanine transaminase; LDH: lactate dehydrogenase; CK: creatine kinase; CK-MB: creatine kinase isoenzyme; IgA: A type immunoglobulin; IgM: M type immunoglobulin; IgG: G type immunoglobulin; C3: complement 3; C4: complement 4; BALF: bronchoalveolar lavage fluid; GM-CSF: granulocyte-macrophage colony-stimulating factor; HMGB1: high mobility group box 1. The relationship between BALF HMGB1 and GM-CSF with clinical characteristics of MPP The levels of BALF HMGB1 and GM-CSF in refractory MPP group were all higher than those in non-refractory MPP group, the difference between groups had statistical significance ( P ༜0.05). Both GM-CSF and HMGB1 levels were positively correlated with traditional indicators N, CRP, PCT and LDH ( r = 0.611–0.785, P < 0.05). Their scatter plots and associated lines were shown in Fig. 1 . The relationship between BALF HMGB1 and GM-CSF with refractory MMP attack We analyzed the diagnostic efficiency of N, CRP, PCT, LDH, HMGB1, and GM-CSF for refractory MPP. ROC analysis results (Fig. 2 and Table 2 ) showed that CRP, GM-CSF and HMGB1 had predictive value for refractory MPP attack ( AUC = 0.636, 0.657, 0.651, P 1.0, P < 0.05). Table 2 ROC analysis results for each index to predict the occurrence of refractory MMP. Indexes Area Sig. 95% C.I. OOP sensitivity specificity Lower Upper N 0.508 0.891 0.395 0.620 3.395 0.660 0.390 CRP 0.636 0.016 0.529 0.744 17.330 0.745 0.610 PCT 0.523 0.684 0.411 0.635 24.980 0.298 0.780 LDH 0.559 0.297 0.448 0.670 413.090 0.468 0.695 HMGB1 0.657 0.006 0.552 0.762 6.760 0.532 0.712 GM-CSF 0.651 0.008 0.539 0.763 6.745 0.468 0.949 N: neutrophil count; CRP: C-reactive protein; PCT: procalcitonin; LDH: lactate dehydrogenase; HMGB1: high mobility group box 1; GM-CSF: granulocyte-macrophage colony-stimulating factor; OPP: optimum operating point Table 3 Logistic regression analysis results for the occurrence of refractory MMP. Indexes B S.E. Wald Sig. Exp(B) 95% C.I.for EXP(B) Lower Upper HMGB1 0.664 0.250 7.057 0.008 1.943 1.190 3.173 GM-CSF 0.755 0.303 6.217 0.013 2.128 1.175 3.854 N -0.772 0.284 7.380 0.007 0.462 0.265 0.806 CRP 0.069 0.048 2.076 0.150 1.071 0.976 1.176 PCT -0.095 0.087 1.209 0.271 0.909 0.767 1.077 LDH -0.131 0.137 0.914 0.339 0.878 0.671 1.147 Constant -0.554 0.664 0.696 0.404 0.575 -- -- N: neutrophil count; CRP: C-reactive protein; PCT: procalcitonin; LDH: lactate dehydrogenase; HMGB1: high mobility group box 1; GM-CSF: granulocyte-macrophage colony-stimulating factor; OPP: optimum operating point The relationship between BALF HMGB1 and GM-CSF with prognosis of refractory MPP The hospital stay time of refractory MPP group were 16 to 37 days. There were 7 cases of poor prognosis in all, including 1 pulmonary fibrosis, 1 cryptogenic organizing pneumonia, 1 unilateral hyperlucent lung syndrome, and 1 asthma. The BALF HMGB1 and GM-CSF level decreased with the treatment, and the levels at 2nd bronchoalveolar lavage therapy had predictive value for long hospital stay (> 28d) and poor prognosis of refractory MPP (Fig. 3 ). Discussion Serum specific antibody test is the most common clinical method for the diagnosis of MP infection, but the MP antibody usually appears a week after the attack of disease, and children’ MP antibody appears even later because of their poor and not fully developed immune system function[ 11 ]. The delay in clinical diagnosis contributes greatly to disease progression and the attack of refractory MPP. With the progression of refractory MPP, some cases might develop into long-term respiratory dysfunction or life-threatening complications[ 12 , 13 ]. More and more studies focused on finding new methods or new biochemical markers for early diagnosis of refractory MPP in recent years. For example, Zhang Y, et al. [ 2 ] compared the clinical data between 145 refractory MPP patients and 489 general MMP patients, and found CRP, LDH, and IL-6 might be the significant predictors of children refractory MPP. Liu T, et al. [ 14 ] claimed serum lactate dehydrogenase isoenzymes 4 plus 5 had better sensitivity compared to traditional index LDH for refractory MPP. Cheng S, et al. [ 15 ] develop a nomogram for predicting refractory MPP, in which high fever, albumin, and LDH served as important factors. We measured BALF HMGB1 and GM-CSF in this study for two reasons: the BALF sample derived directly from the lower respiratory tract, which means a less chance of pollution, and a closer distance to the lesion. Several studies pointed out that BALF culture has higher pathogen detection rate than sputum culture[ 16 ]. We also considered the anti-pathogen activities of immune system after MP infection, HMGB1 is mainly released by mononuclear macrophages and dendritic cells and plays a role in the adaptive immune phase[ 17 ], while GM-CSF is mainly released by activated T cells and play role in the cellular immune phase. After released outside the cell, both of them plays a synergistic role with various pro-inflammatory factors and forms a positive feedback loop to amplify the inflammatory response. Besides BALF HMGB1 and GM-CSF, we found 4 traditional biochemical markers difference between refractory MPP and non-refractory MPP: N, CRP, PCT, LDH. We also found there were a good correlation between GM-CSF and HMGB1 levels with those traditional indicators N, CRP, PCT and LDH ( r = 0.611–0.785, P < 0.05). Serve as immune cells, neutrophils play an important role in anti-pathogens[ 18 ]. Increased neutrophils in peripheral blood and alveolar lavage fluid are important clinical features of mycoplasma pneumonia[ 19 ]. CRP and PCT are both inflammatory markers commonly used in clinic. A retrospective study involved 119 children with community-acquired pneumonia revealed that PCT on admission is correlated to inflammatory response degree, while CRP on admission is a predictor of lobar consolidation[ 20 ]. Neeser, et al.[ 21 ] found CRP/PCT ratio could provide reliable information to help discriminating MPP from streptococcus pneumoniae. Several studies claimed PCT concentrations in children hospitalized with CAP had ability to distinguish typical bacteria (eg, Streptococcus pneumoniae and Staphylococcus aureus) and atypical bacteria (Mycoplasma pneumoniae and Chlamydophila pneumoniae) [ 22 – 24 ]. LDH occurs in the blood when tissues and organs are damaged, so it is used to be a biomarker to evaluate disease severity of MPP in clinic[ 25 ]. There was evidence that LDH is an easily accessible biological marker that has been associated with several pulmonary disorders[ 26 , 27 ]. A prospective cohort study of 300 children with refractory pneumonia and 353 with general pneumonia showed serum LDH with a cutoff of 379 U/L could be used to predict refractory MPP at early stage of hospitalization [ 28 ]. In brief, the traditional markers N, CRP, PCT, and LDH have good predictive value for the occurrence and development of MPP, and the correlation between BALF HMGB1 and GM-CSF with them indicate a potential value of HMGB1and GM-CSF in MPP evaluation. After Logistic analysis and ROC analysis, we found CRP, GM-CSF and HMGB1 had predictive value for refractory MPP attack, and GM-CSF and HMGB1 were independent factors for refractory MPP. The results further confirmed their important diagnostic value. In addition, we found the BALF HMGB1 and GM-CSF level decreased with the treatment. Considering that the number of cases decreased greatly at 3rd bronchoalveolar lavage therapy, we analyzed the prognostic evaluation effect of BALF HMGB1 and GM-CSF level in the first two treatments. The results showed the levels at 2nd bronchoalveolar lavage therapy had predictive value for long hospital stay (> 28d) and poor prognosis of refractory MPP. A few studies have showed HMGB1 might be a reliable biochemical marker for prognosis evaluation of MPP and community acquired pneumonia [ 29 , 30 ], which consistent with our study. The clinical studies about BALF GM-CSF in MPP are limited quantity. Previous studies have shown that GM-CSF plays a vital role in neutrophil inflammation in M. A proper GM-CSF secretion is beneficial for lung protection, while increased GM-CSF in pulmonary could causes alveolar macrophage accumulation, which contribute to a lung parenchymal injury derived excessive immune inflammatory response[ 31 ]. This may be one of the reasons for GM-CSF level lead to poor prognosis. Conclusions In conclusion, the level of GM-CSF and HMGB1 in alveolar lavage fluid is closely related to the occurrence and development of refractory MPP, which can be used as an auxiliary indicator for clinical diagnosis and prognosis evaluation, and has certain guiding significance for its clinical treatment. Abbreviations Granulocyte-macrophage colony-stimulating factor GM-CSF High mobility group box 1 HMGB1 Mycoplasma pneumoniae pneumonia MPP Mycoplasma pneumoniae MP Community-acquired pneumonia CAP Damage- associated molecular pattern molecules DAMPs Pathogen-associated molecular pattern molecules PAMPs Adenosine triphosphate proteins ATP White blood cell count WBC Lymphocyte count L Neutrophil count N Blood platelet count PLT C-reaction protein CRP Procalcitonin PCT D-dimer D-D Aspartate aminotransferase AST Alanine transaminase ALT Lactate dehydrogenase LDH Creatine kinase CK Creatine kinase isoenzyme CK-MB Immunoglobulin A IgA Immunoglobulin M IgM Immunoglobulin G IgG Complement 3 C3 Complement 4 C4 Multi detector computed tomography MSCT Declarations Ethics approval and consent to participate This research was conducted in compliance with the principles of the Declaration of Helsinki and approved by the ethics committee of Affiliated Hospital of Changchun University of Traditional Chinese Medicine. Written informed consent was provided by all enrolled individuals and the parent’s patient has given their parental consent for this study. Consent for publication Approval. Availability of data and materials The data used to support the findings of this study are available from the corresponding author upon request. Competing interests None of the authors of the present manuscript have a commercial or other association that might pose a conflict of interest. Funding None. Authors’contributions LC and YW conceived the study. HL acquired data. HY performed the statistical analysis. LC drafted the manuscript. All authors read and approved the manuscript prior to submission. Acknowledgements Not applicable. References [1] I.A. Yoon, K.B. Hong, H.J. Lee, K.W. Yun, J.Y. Park, Y.H. Choi, W.S. Kim, H. Lee, B.W. Eun, Y.M. Ahn, E.Y. Cho, H.J. Cho, E.H. Choi, Radiologic findings as a determinant and no effect of macrolide resistance on clinical course of Mycoplasma pneumoniae pneumonia, BMC infectious diseases, 17 (2017) 402. [2] Y. Zhang, Y. Zhou, S. Li, D. Yang, X. Wu, Z. Chen, The Clinical Characteristics and Predictors of Refractory Mycoplasma pneumoniae Pneumonia in Children, PloS one, 11 (2016) e0156465. [3] L. Wang, S. Lu, Z. Feng, L. Li, B. Niu, J. Shuai, L. Cao, G. Li, J. Liu, The early examination of combined serum and imaging data under flexible fiberoptic bronchoscopy as a novel predictor for refractory Mycoplasma pneumoniae pneumonia diagnosis, Medicine, 96 (2017) e9364. [4] J.J. Xu, L.H. Shu, [Clinical characteristics of refractory Mycoplasma pneumoniae pneumonia in children], Zhongguo dang dai er ke za zhi = Chinese journal of contemporary pediatrics, 20 (2018) 37-42. [5] R. Chaudhry, A. Ghosh, A. Chandolia, Pathogenesis of Mycoplasma pneumoniae: An update, Indian journal of medical microbiology, 34 (2016) 7-16. [6] J.A.S. Quaresma, Organization of the Skin Immune System and Compartmentalized Immune Responses in Infectious Diseases, Clinical microbiology reviews, 32 (2019). [7] M.E. Bianchi, M.P. Crippa, A.A. Manfredi, R. Mezzapelle, P. Rovere Querini, E. Venereau, High-mobility group box 1 protein orchestrates responses to tissue damage via inflammation, innate and adaptive immunity, and tissue repair, Immunological reviews, 280 (2017) 74-82. [8] F. Pandolfi, S. Altamura, S. Frosali, P. Conti, Key Role of DAMP in Inflammation, Cancer, and Tissue Repair, Clinical therapeutics, 38 (2016) 1017-1028. [9] Y. Liu, X. Zhang, Y. Wang, C. Zhu, M. Fan, X. Dou, C. Hao, Y. Yan, W. Ji, G. Gu, J. Lou, Z. Chen, The role of granulocyte macrophage colony stimulating factor in hospitalized children with Mycoplasma pneumoniae pneumonia, Journal of infection and chemotherapy : official journal of the Japan Society of Chemotherapy, 24 (2018) 789-794. [10] J. Liu, F. Zhao, J. Lu, H. Xu, H. Liu, X. Tang, H. Yang, J. Zhang, S. Zhao, High Mycoplasma pneumoniae loads and persistent long-term Mycoplasma pneumoniae DNA in lower airway associated with severity of pediatric Mycoplasma pneumoniae pneumonia, BMC infectious diseases, 19 (2019) 1045. [11] X. Zhang, Z. Chen, W. Gu, W. Ji, Y. Wang, C. Hao, Y. He, L. Huang, M. Wang, X. Shao, Y. Yan, Viral and bacterial co-infection in hospitalised children with refractory Mycoplasma pneumoniae pneumonia, Epidemiology and infection, 146 (2018) 1384-1388. [12] Y.J. Choi, J.H. Jeon, J.W. Oh, Critical combination of initial markers for predicting refractory Mycoplasma pneumoniae pneumonia in children: a case control study, Respiratory research, 20 (2019) 193. [13] Y. Xu, L. Yu, C. Hao, Y. Wang, C. Zhu, W. Ji, Y. Li, G. Li, Z. Chen, Y. Yan, Plasma soluble B7-H3 levels for severity evaluation in pediatric patients with Mycoplasma pneumoniae pneumonia, International immunopharmacology, 73 (2019) 163-171. [14] T.Y. Liu, W.J. Lee, C.M. Tsai, K.C. Kuo, C.H. Lee, K.S. Hsieh, C.H. Chang, Y.T. Su, C.K. Niu, H.R. Yu, Serum lactate dehydrogenase isoenzymes 4 plus 5 is a better biomarker than total lactate dehydrogenase for refractory Mycoplasma pneumoniae pneumonia in children, Pediatrics and neonatology, 59 (2018) 501-506. [15] S. Cheng, J. Lin, X. Zheng, L. Yan, Y. Zhang, Q. Zeng, D. Tian, Z. Fu, J. Dai, Development and validation of a simple-to-use nomogram for predicting refractory Mycoplasma pneumoniae pneumonia in children, Pediatric pulmonology, (2020). [16] M. Wang, Y. Wang, Y. Yan, C. Zhu, L. Huang, X. Shao, J. Xu, H. Zhu, X. Sun, W. Ji, Z. Chen, Clinical and laboratory profiles of refractory Mycoplasma pneumoniae pneumonia in children, International journal of infectious diseases : IJID : official publication of the International Society for Infectious Diseases, 29 (2014) 18-23. [17] S. Manti, T.J. Harford, C. Salpietro, F. Rezaee, G. Piedimonte, Induction of high-mobility group Box-1 in vitro and in vivo by respiratory syncytial virus, Pediatric research, 83 (2018) 1049-1056. [18] E.H. Aitken, A. Alemu, S.J. Rogerson, Neutrophils and Malaria, Frontiers in immunology, 9 (2018) 3005. [19] J. Li, H. Zhu, Y. Bai, C. Ma, G. Zhang, W. Feng, C. Liu, Hemilagglutinin -3 expression in RMPP airway inflammation is associated with mycoplasma pneumoniae load and neutrophils level (in Chinese), Journal of clinical pulmonary medicine, 25 (2020). [20] L. Agnello, C. Bellia, M. Di Gangi, B. Lo Sasso, L. Calvaruso, G. Bivona, C. Scazzone, P. Dones, M. Ciaccio, Utility of serum procalcitonin and C-reactive protein in severity assessment of community-acquired pneumonia in children, Clinical biochemistry, 49 (2016) 47-50. [21] O.L. Neeser, T. Vukajlovic, L. Felder, S. Haubitz, A. Hammerer-Lercher, C. Ottiger, B. Mueller, P. Schuetz, C.A. Fux, A high C-reactive protein/procalcitonin ratio predicts Mycoplasma pneumoniae infection, Clinical chemistry and laboratory medicine, 57 (2019) 1638-1646. [22] C.M. Nascimento-Carvalho, M.R. Cardoso, A. Barral, C.A. Araujo-Neto, S. Guerin, A. Saukkoriipi, M. Paldanius, R. Vainionpaa, P. Lebon, M. Leinonen, O. Ruuskanen, D. Gendrel, Procalcitonin is useful in identifying bacteraemia among children with pneumonia, Scandinavian journal of infectious diseases, 42 (2010) 644-649. [23] A. Julian-Jimenez, J. Timon Zapata, E.J. Laserna Mendieta, R. Parejo Miguez, M. Flores Chacartegui, P. Gallardo Schall, [Ability of procalcitonin to predict bacteremia in patients with community acquired pneumonia], Medicina clinica, 142 (2014) 285-292. [24] C. Stockmann, K. Ampofo, J. Killpack, D.J. Williams, K.M. Edwards, C.G. Grijalva, S.R. Arnold, J.A. McCullers, E.J. Anderson, R.G. Wunderink, W.H. Self, A. Bramley, S. Jain, A.T. Pavia, A.J. Blaschke, Procalcitonin Accurately Identifies Hospitalized Children With Low Risk of Bacterial Community-Acquired Pneumonia, Journal of the Pediatric Infectious Diseases Society, 7 (2018) 46-53. [25] R. Kawamata, K. Yokoyama, M. Sato, M. Goto, Y. Nozaki, T. Takagi, H. Kumagai, T. Yamagata, Utility of serum ferritin and lactate dehydrogenase as surrogate markers for steroid therapy for Mycoplasma pneumoniae pneumonia, Journal of infection and chemotherapy : official journal of the Japan Society of Chemotherapy, 21 (2015) 783-789. [26] C.Y. Ding, L. Peng, Y.X. Lin, L.H. Yu, D.L. Wang, D.Z. Kang, Elevated Lactate Dehydrogenase Level Predicts Postoperative Pneumonia in Patients with Aneurysmal Subarachnoid Hemorrhage, World neurosurgery, 129 (2019) e821-e830. [27] Y. Ding, C. Chu, Y. Li, G. Li, X. Lei, W. Zhou, Z. Chen, High expression of HMGB1 in children with refractory Mycoplasma pneumoniae pneumonia, BMC infectious diseases, 18 (2018) 439. [28] A. Lu, C. Wang, X. Zhang, L. Wang, L. Qian, Lactate Dehydrogenase as a Biomarker for Prediction of Refractory Mycoplasma pneumoniae Pneumonia in Children, Respiratory care, 60 (2015) 1469-1475. [29] H. Lu, N. Zeng, Q. Chen, Y. Wu, S. Cai, G. Li, F. Li, J. Kong, Clinical prognostic significance of serum high mobility group box-1 protein in patients with community-acquired pneumonia, The Journal of international medical research, (2019) 300060518819381. [30] W. Song, H. Tan, S. Wang, Y. Zhang, Y. Ding, Association of High Mobility Group Box Protein B1 Gene Polymorphisms with Pneumonia Susceptibility and Severity, Genetic testing and molecular biomarkers, 23 (2019) 3-11. [31] T. Suzuki, C. McCarthy, B.C. Carey, M. Borchers, D. Beck, K.A. Wikenheiser-Brokamp, D. Black, C. Chalk, B.C. Trapnell, Increased Pulmonary GM-CSF Causes Alveolar Macrophage Accumulation. Mechanistic Implications for Desquamative Interstitial Pneumonitis, American journal of respiratory cell and molecular biology, 62 (2020) 87-94. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-18708","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research article","associatedPublications":[],"authors":[{"id":432206,"identity":"96564fe9-d601-4b9b-8fa8-e932188538e1","order_by":1,"name":"Lianfu Cao","email":"","orcid":"","institution":"Affiliated Hospital of Changchun University of Traditional Chinese Medicine","correspondingAuthor":false,"prefix":"","firstName":"Lianfu","middleName":"","lastName":"Cao","suffix":""},{"id":432207,"identity":"09cb1916-77a6-4a07-a8d0-2d0b81f2e699","order_by":2,"name":"Haijiao Lin","email":"","orcid":"","institution":"Affiliated Hospital of Changchun University of Traditional Chinese Medicine","correspondingAuthor":false,"prefix":"","firstName":"Haijiao","middleName":"","lastName":"Lin","suffix":""},{"id":432208,"identity":"0bddc939-1055-4c7b-a287-bab621843d3b","order_by":3,"name":"Hongjun Yu","email":"","orcid":"","institution":"Affiliated Hospital of Changchun University of Traditional Chinese Medicine","correspondingAuthor":false,"prefix":"","firstName":"Hongjun","middleName":"","lastName":"Yu","suffix":""},{"id":432209,"identity":"a713f505-7deb-4af1-b58a-b9357ac64326","order_by":4,"name":"Yongji Wang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6ElEQVRIiWNgGAWjYBACgwMMDMw8QAZjM4MBwwcDGzvStDDOKEhLJkoL4wwom5nnwyHGBoJajp89/OJDxR275nbmbZ9tDA4wM7AfProBnxazM3lpFglnniU3NrMVz84xuMPHwJOWdgOvlgM5ZgaJbYeTGZt5jJlzDJ4xM0jwmOHXcv4NkhYLg8OMDYS02N/IMX4A1GIH1sJAjBbLG2/MGBLOHE5gBPqFsccgLZmNkF8MzucYf0ioOGxv2H94M8OPPzZ2/OyHj+HVAgRsEkAicWMDjEtAOQgwfwD5SZ4IlaNgFIyCUTBCAQBW+E89bMQcjwAAAABJRU5ErkJggg==","orcid":"","institution":"Affiliated Hospital of Changchun University of Traditional Chinese Medicine","correspondingAuthor":true,"prefix":"","firstName":"Yongji","middleName":"","lastName":"Wang","suffix":""}],"badges":[],"createdAt":"2020-03-20 16:29:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-18708/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-18708/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":699706,"identity":"3e540df1-1c5c-4afd-b538-5853dd9f2f96","added_by":"auto","created_at":"2020-03-24 14:44:38","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":2299249,"visible":true,"origin":"","legend":"The scatter plots and associated lines of BALF HMGB1 and GM-CSF with N, CRP, PCT, and LDH. A：BALF HMGB1 levels compare between refractory MPP and non-refractory MPP. B: The correlation lines between BALF HMGB1 with N, CRP, PCT, LDH. C: BALF GM-CSF levels compare between refractory MPP and non-refractory MPP. D: The correlation lines between BALF GM-CSF with N, CRP, PCT, LDH.","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-18708/v1/Figure 1.jpg"},{"id":699707,"identity":"9d79cc64-0ee0-4496-aa4b-4ec6602d0f48","added_by":"auto","created_at":"2020-03-24 14:44:38","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":140497,"visible":true,"origin":"","legend":"ROC analyze results for N, CRP, PCT, LDH, BALF HMGB1 and GM-CSF to predict refractory MPP attack. A：ROC analyze for traditional indexes N, CRP, PCT, and LDH. B: ROC analyze for BALF HMGB1 and GM-CSF.","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-18708/v1/Figure 2.jpg"},{"id":699708,"identity":"f1039956-e9e7-4e84-83a2-d346f3813a58","added_by":"auto","created_at":"2020-03-24 14:44:38","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":729769,"visible":true,"origin":"","legend":"Changes of BALF HMGB1 and GM-CSF in treatment and their predictive value for prognosis. A：BALF HMGB1 change trend in the bronchoalveolar lavage therapy. B: BALF GM-CSF change trend in the bronchoalveolar lavage therapy. C: ROC analyze results for BALF HMGB1 and GM-CSF at 2nd bronchoalveolar lavage therapy to predict poor prognosis; AUC=0.768, 0.825, P=0.025, 0.007. D: ROC analyze results for BALF HMGB1 and GM-CSF at 2nd bronchoalveolar lavage therapy to predict long hospital stay time; AUC=0.782, 0.798, P=0.002, 0.001.","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-18708/v1/Figure 3.jpg"},{"id":13495106,"identity":"75c38771-c9a2-4173-b698-5e65c7db40b5","added_by":"auto","created_at":"2021-09-16 22:43:52","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":698008,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-18708/v1/2a230f0e-580e-4d72-9bba-703bd212b643.pdf"}],"financialInterests":"","formattedTitle":"GM-CSF and HMGB1 level were associated with the clinical characteristics and prognosis of childhood refractory mycoplasma pneumoniae pneumonia","fulltext":[{"header":"Backgrounds","content":" \u003cp\u003eMycoplasma pneumoniae (MP) is one of the most common causes of community-acquired pneumonia (CAP) in children and young adults, with ability to cause local epidemics[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In general, Mycoplasma pneumoniae pneumonia (MPP) is mild and self-limiting, which could be rapidly improved by macrolide treatment. However, in recent years, the incidence of refractory MPP characterized by rapid development, long course of disease and severe pulmonary lesions has been increasing year by year[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In addition to improving the treatment methods, how to improve the early diagnosis rate and win the best treatment opportunity is also a focus of current researches[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Several mechanisms, including direct cytotoxicity, intracellular colonization, adsorption effect to respiratory epithelial cells, and causing immune dysfunction has been reported as so far, in which immune dysfunction, especially adaptive immune dysfunction is considered to be the most important factor to promote the development of refractory MPP[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite being only a subsystem in the more basic and all-compassing system maintaining integrity, the adaptive immune system plays a key role in recognizing pathogens and distinguishing dead cells, thus clear harmful substances and block secondary damage[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. It is reported that pathogen-associated molecular pattern molecules (PAMPs) and damage- associated molecular pattern molecules (DAMPs) are the most important adjuvants for adaptive immune system[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. PAMPs has been identified galore, while there are only two types of typical DAMP as so far: high mobility Group Box 1 (HMGB1) protein and adenosine triphosphate proteins (ATP)[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. HMGB1 is a kind of highly conserved encoded non-histone, nuclear DNA-binding protein widely found in eukaryotic cells. In addition to its classical role such as DNA recombination and cell differentiation, HMGB1 also sever as an inflammatory factor to participate in anti-pathogen activities.\u003c/p\u003e \u003cp\u003eGranulocyte macrophage colony stimulating factor (GM-CSF) was first detected in Lung tissue from mice cultured in vitro after LPS stimulation. Recent years, a few studies focused on GM-CSF expression in children with MPP, and found GM-CSF played an important role in the inflammatory response conducted by neutrophil in acute and severe MPP[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Liu Y, et al. [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] found the GM-CSF level of MPP Children was associated to the duration of fever and might be a good marker for prognosis. It was reported that the bronchial epithelium could produce GM-CSF in the stimulation of MP, which serve as a proinflammatory cytokines to recruit and activates neutrophils. Meanwhile, GM-CSF could also modulate oxidative stress activity through a priming phenomenon of human neutrophil respiratory burst. Otherwise, we noticed that both HMGB1 and GM-CSF has important effect on toll like receptor 2 -the main receptor to identify mycoplasma. In this study, we analyzed their relationship with patient clinical characteristics and prognosis, as a result, we found both GM-CSF and HMGB1 have prognostic value in determining disease status of refractory MPP.\u003c/p\u003e "},{"header":"Methods","content":" \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy population\u003c/h2\u003e \u003cp\u003eA total of 106 children (including 47 refractory MMP) diagnosed with MPP and prepared for bronchoalveolar lavage therapy registered by the Affiliated Hospital of Changchun University of Traditional Chinese Medicine from July 2014 to November 2015 were selected for this study. All children had been diagnosed with the disease in accordance with the Guidelines for the management of community-acquired pneumonia in children. The refractory MMP cases were defined as those showing clinical and radiological deterioration despite appropriate antibiotic therapy for \u0026ge;\u0026thinsp;7 days[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Children with congenital heart diseases, hereditary metabolic diseases, neurological disorders, bronchopulmonary dysplasia, and immunodeficiency were excluded. This research was conducted in compliance with the principles of the Declaration of Helsinki and approved by the ethics committee of Affiliated Hospital of Changchun University of Traditional Chinese Medicine. Written informed consent was provided by all enrolled individuals.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eClinical data collection\u003c/h2\u003e \u003cp\u003eClinical parameters before and during the treatment were collected from patient medical records, including age, sex, course of fever, the highest temperature, white blood cell count (WBC), lymphocyte count (L), neutrophil count (N), blood platelet count (PLT), C-reaction protein (CRP), procalcitonin (PCT), D -dimer (D-D), aspartate aminotransferase (AST), alanine transaminase (ALT), lactate dehydrogenase (LDH), creatine kinase (CK), creatine kinase isoenzyme (CK-MB), immunoglobulin (IgA, IgM and IgG), complement (C3 and C4), and multi detector computed tomography (MSCT) data.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eTreatment methods\u003c/h2\u003e \u003cp\u003eAll children received a Bronchoalveolar lavage therapy defined by Guidelines for the management of community-acquired pneumonia in children consistent with the individual condition of each patient. In this study, the children in non-refractory MMP group accepted bronchoalveolar lavage therapy only once, while those in refractory MMP group accepted 2 to 4 times according to individual condition. The lavage fluids we used was prepared with 50\u0026nbsp;ml saline, 80,000u gentamicin, and 5\u0026nbsp;mg dexamethasone. Cases with localized pulmonary lesions was douched in the suspicious bronchopulmonary segment, while cases with diffuse interstitial pulmonary lesions was douched in the right middle lobe or left lingulaoflung. In addition, all children were given supportive treatment such as sensitive antibiotic, antitussive, anticonvulsant, sputum aspiration, parenteral nutrition, etc.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eQuantification of GM-CSF and HMGB1 level in bronchoalveolar lavage fluid (BALF)\u003c/h2\u003e \u003cp\u003eBALF was extracted after bronchoalveolar lavage therapy, and the cells in the BALF samples was separated by a centrifuge at 200\u0026nbsp;g for 10\u0026nbsp;min at 4 ℃, then stored at -80 ℃. The levels of HMGB1 and GM-CSF in those cells were quantified by ELISA kits purchased from Shanghai Meilian Biotechnology Co. Ltd (Shanghai, China) in a week. The experimental procedure is strictly carried out according to the instructions, in a word, each standard or sample was placed into the appropriate wells of 96-well plates, and incubated with biotinylated detection antibody adequately. Then, HRP-streptavidin solution was added and incubated, each plate was again inverted and washed prior to the addition of 100\u0026nbsp;\u0026micro;l of ELISA Colorimetric TMB Reagent. The absorbance was measured using a Universal Microplate Spectrophotometer at 450\u0026nbsp;nm.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003ePrognostic assessment methods\u003c/h2\u003e \u003cp\u003eMost children in non-refractory MMP group got good prognosis and discharged from hospital in 7 to 15 days, so we mainly observed the effect of refractory MMP group. The hospital stay time and pulmonary function on discharge were assessed. Those with respiratory dysfunction such as pulmonary fibrosis, unilateral hyperlucent lung syndrome and asthma., etc. were classified into poor prognosis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eStatistical analyses were performed using SPSS software (version 22.0). All normally distributed quantitative variables are expressed as means\u0026thinsp;\u0026plusmn;\u0026thinsp;SD, the remainder were expressed as median (IQR) values. ANOVA and LSD-t tests were performed to compare differences among groups for normally distributed variables, and Mann-Whitney U tests were performed for variables not normally distributed. Categorical data are expressed as percentages, and chi-square tests were performed to compare differences between groups. Kruskal\u0026ndash;Wallis H test was performed for comparisons between groups with ranked data. In addition, ROC curve analysis was used to ascertain the predicted value of BALF HMGB1 and GM-CSF for the occurrence of refractory MMP and poor prognosis of refractory MMP.\u003c/p\u003e \u003c/div\u003e "},{"header":"Results","content":" \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eClinical characteristics of children in refractory MPP group and non-refractory MPP group before treatment\u003c/h2\u003e \u003cp\u003eThe clinical characteristics of children before treatment were shown in Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. There was no significant difference in age, sex, course of fever, the highest temperature, WBC, L, PLT, ALT, AST, CK-MB, D-D, CK, IgG, IgA, IgM, C3, and C4 between refractory MPP group and non-refractory MPP group. The levels of N, CRP, PCT, and LDH in refractory MPP group were all higher than those in non-refractory MPP group, the difference between groups had statistical significance (\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003eP\u003c/span\u003e༜0.05).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cdiv class=\"SimplePara\"\u003eThe basic data compare between children with and without refractory MMP.\u003c/div\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eClinical characteristics\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eRefractory MMP group (n\u0026thinsp;=\u0026thinsp;47)\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003eNon-refractory MMP group (n\u0026thinsp;=\u0026thinsp;59)\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003eχ\u003csup\u003e2\u003c/sup\u003e/t\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003eP\u003c/div\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eAge (IQR, months)\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e35 (24, 66)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e31 (24, 59)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e-1.314\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.185\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eMale [n(%)]\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e23 (48.9%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e32 (54.2%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.294\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.587\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eCourse of fever (IQR, d)\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e8 (4, 12)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e4 (3, 6)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e-1.217\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.224\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eThe highest temperature\u0026thinsp;\u0026ge;\u0026thinsp;40 ℃ [n (%)]\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e11 (23.4%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e9 (15.3%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e1.135\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.287\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eWBC (IQR, 10\u003c/span\u003e\u003csup\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e9\u003c/span\u003e\u003c/sup\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e/L)\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e9.22 (4.35, 25.25)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e8.65 (5.01, 23.52)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e-0.757\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.449\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eN (IQR, 10\u003c/span\u003e\u003csup\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e9\u003c/span\u003e\u003c/sup\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e/L)\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e5.55 (2.15, 13.25)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.82 (2.22, 11.12)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e-2.070\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.038\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eL (IQR, 10\u003c/span\u003e\u003csup\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e9\u003c/span\u003e\u003c/sup\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e/L)\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e3.02 (1.84, 9.25)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e3.37 (2.01, 10.36)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e-1.283\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.199\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003ePLT (IQR, 10\u003c/span\u003e\u003csup\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e9\u003c/span\u003e\u003c/sup\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e/L)\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e322.5 (85.3, 488.2)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e313.2 (102.3, 451.3)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e-1.141\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.254\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eCRP (IQR, mg/L)\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e25.34 (15.52, 52.31)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e11.54 (6.33, 43.62)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e-2.563\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.010\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003ePCT (IQR, \u0026micro;g/L)\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e6.53 (1.52, 28.62)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e7.15(1.44, 22.63)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e-2.178\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.029\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eALT (IQR, U/L)\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e22.13 (18.25, 84.6)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e25.24 (15.25, 75.62)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e-1.512\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.131\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eAST (IQR, U/L)\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e34.35 (29.38, 44.25)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e36.25 (30.24, 42.15)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e-0.998\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.318\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eLDH (IQR, U/L)\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e322.33 (125.32, 382.63)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e302.52 (116.85, 335.21)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e2.308\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.023\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eD-D (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD, mg/L)\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e3.36\u0026thinsp;\u0026plusmn;\u0026thinsp;0.83\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e3.12\u0026thinsp;\u0026plusmn;\u0026thinsp;0.91\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e1.402\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.164\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eCK (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD, U/L)\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e201.35\u0026thinsp;\u0026plusmn;\u0026thinsp;46.52\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e185.63\u0026thinsp;\u0026plusmn;\u0026thinsp;40.36\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e1.861\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.066\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eCK-MB (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD, U/L)\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e12.25 (6.35, 18.35)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e8.22 (6.02, 16.21)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e-0.016\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.987\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eIgG (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD, g/L)\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e9.15\u0026thinsp;\u0026plusmn;\u0026thinsp;2.35\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e9.28\u0026thinsp;\u0026plusmn;\u0026thinsp;2.52\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.272\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.786\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eIgA (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD, g/L)\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.81\u0026thinsp;\u0026plusmn;\u0026thinsp;0.21\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.88\u0026thinsp;\u0026plusmn;\u0026thinsp;0.19\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e1.798\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.075\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eIgM (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD, g/L)\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e1.35\u0026thinsp;\u0026plusmn;\u0026thinsp;0.26\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e1.46\u0026thinsp;\u0026plusmn;\u0026thinsp;0.31\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e1.947\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.054\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eC3 (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD, g/L)\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e1.26\u0026thinsp;\u0026plusmn;\u0026thinsp;0.25\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e1.32\u0026thinsp;\u0026plusmn;\u0026thinsp;0.28\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e1.149\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.253\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eC4 (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD, g/L)\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.32\u0026thinsp;\u0026plusmn;\u0026thinsp;0.08\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.35\u0026thinsp;\u0026plusmn;\u0026thinsp;0.10\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e1.673\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.097\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eWBC: white blood cell count; PLT: blood platelet count; L: lymphocyte count, N: neutrophil count; CRP: C-reactive protein; PCT: procalcitonin; D-D: D -dimer; AST: aspartate aminotransferase; ALT: alanine transaminase; LDH: lactate dehydrogenase; CK: creatine kinase; CK-MB: creatine kinase isoenzyme; IgA: A type immunoglobulin; IgM: M type immunoglobulin; IgG: G type immunoglobulin; C3: complement 3; C4: complement 4; BALF: bronchoalveolar lavage fluid; GM-CSF: granulocyte-macrophage colony-stimulating factor; HMGB1: high mobility group box 1.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eThe relationship between BALF HMGB1 and GM-CSF with clinical characteristics of MPP\u003c/h2\u003e \u003cp\u003eThe levels of BALF HMGB1 and GM-CSF in refractory MPP group were all higher than those in non-refractory MPP group, the difference between groups had statistical significance (\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003eP\u003c/span\u003e༜0.05). Both GM-CSF and HMGB1 levels were positively correlated with traditional indicators N, CRP, PCT and LDH (\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003er\u003c/span\u003e\u0026thinsp;=\u0026thinsp;0.611\u0026ndash;0.785, \u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003eP\u003c/span\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Their scatter plots and associated lines were shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003ch2\u003eThe relationship between BALF HMGB1 and GM-CSF with refractory MMP attack\u003c/h2\u003e \u003cp\u003eWe analyzed the diagnostic efficiency of N, CRP, PCT, LDH, HMGB1, and GM-CSF for refractory MPP. ROC analysis results (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) showed that CRP, GM-CSF and HMGB1 had predictive value for refractory MPP attack (\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003eAUC\u003c/span\u003e\u0026thinsp;=\u0026thinsp;0.636, 0.657, 0.651, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Logistic regression analysis results (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e) showed that GM-CSF and HMGB1 were independent influencing factors for refractory MPP (\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003eOR\u003c/span\u003e\u0026thinsp;\u0026gt;\u0026thinsp;1.0, \u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003eP\u003c/span\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cdiv class=\"SimplePara\"\u003eROC analysis results for each index to predict the occurrence of refractory MMP.\u003c/div\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cdiv class=\"SimplePara\"\u003eIndexes\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cdiv class=\"SimplePara\"\u003eArea\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cdiv class=\"SimplePara\"\u003eSig.\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e95% C.I.\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cdiv class=\"SimplePara\"\u003eOOP\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cdiv class=\"SimplePara\"\u003esensitivity\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cdiv class=\"SimplePara\"\u003especificity\u003c/div\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eLower\u003c/span\u003e\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eUpper\u003c/span\u003e\u003c/div\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eN\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.508\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.891\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.395\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.620\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003e3.395\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.660\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.390\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eCRP\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.636\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.016\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.529\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.744\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003e17.330\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.745\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.610\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ePCT\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.523\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.684\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.411\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.635\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003e24.980\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.298\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.780\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eLDH\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.559\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.297\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.448\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.670\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003e413.090\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.468\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.695\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eHMGB1\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.657\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.006\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.552\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.762\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003e6.760\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.532\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.712\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eGM-CSF\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.651\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.008\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.539\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.763\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003e6.745\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.468\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.949\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003eN: neutrophil count; CRP: C-reactive protein; PCT: procalcitonin; LDH: lactate dehydrogenase; HMGB1: high mobility group box 1; GM-CSF: granulocyte-macrophage colony-stimulating factor; OPP: optimum operating point\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cdiv class=\"SimplePara\"\u003eLogistic regression analysis results for the occurrence of refractory MMP.\u003c/div\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cdiv class=\"SimplePara\"\u003eIndexes\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cdiv class=\"SimplePara\"\u003eB\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cdiv class=\"SimplePara\"\u003eS.E.\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cdiv class=\"SimplePara\"\u003eWald\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cdiv class=\"SimplePara\"\u003eSig.\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cdiv class=\"SimplePara\"\u003eExp(B)\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cdiv class=\"SimplePara\"\u003e95% C.I.for EXP(B)\u003c/div\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cdiv class=\"SimplePara\"\u003eLower\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cdiv class=\"SimplePara\"\u003eUpper\u003c/div\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eHMGB1\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.664\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.250\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e7.057\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.008\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003e1.943\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cdiv class=\"SimplePara\"\u003e1.190\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cdiv class=\"SimplePara\"\u003e3.173\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eGM-CSF\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.755\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.303\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e6.217\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.013\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003e2.128\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cdiv class=\"SimplePara\"\u003e1.175\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cdiv class=\"SimplePara\"\u003e3.854\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eN\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e-0.772\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.284\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e7.380\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.007\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.462\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.265\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.806\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eCRP\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.069\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.048\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e2.076\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.150\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003e1.071\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.976\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cdiv class=\"SimplePara\"\u003e1.176\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ePCT\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e-0.095\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.087\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e1.209\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.271\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.909\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.767\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cdiv class=\"SimplePara\"\u003e1.077\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eLDH\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e-0.131\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.137\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.914\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.339\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.878\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.671\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cdiv class=\"SimplePara\"\u003e1.147\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eConstant\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e-0.554\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.664\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.696\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.404\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.575\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cdiv class=\"SimplePara\"\u003e--\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cdiv class=\"SimplePara\"\u003e--\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003eN: neutrophil count; CRP: C-reactive protein; PCT: procalcitonin; LDH: lactate dehydrogenase; HMGB1: high mobility group box 1; GM-CSF: granulocyte-macrophage colony-stimulating factor; OPP: optimum operating point\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003ch2\u003eThe relationship between BALF HMGB1 and GM-CSF with prognosis of refractory MPP\u003c/h2\u003e \u003cp\u003eThe hospital stay time of refractory MPP group were 16 to 37 days. There were 7 cases of poor prognosis in all, including 1 pulmonary fibrosis, 1 cryptogenic organizing pneumonia, 1 unilateral hyperlucent lung syndrome, and 1 asthma. The BALF HMGB1 and GM-CSF level decreased with the treatment, and the levels at 2nd bronchoalveolar lavage therapy had predictive value for long hospital stay (\u0026gt;\u0026thinsp;28d) and poor prognosis of refractory MPP (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e "},{"header":"Discussion","content":" \u003cp\u003eSerum specific antibody test is the most common clinical method for the diagnosis of MP infection, but the MP antibody usually appears a week after the attack of disease, and children\u0026rsquo; MP antibody appears even later because of their poor and not fully developed immune system function[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The delay in clinical diagnosis contributes greatly to disease progression and the attack of refractory MPP. With the progression of refractory MPP, some cases might develop into long-term respiratory dysfunction or life-threatening complications[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. More and more studies focused on finding new methods or new biochemical markers for early diagnosis of refractory MPP in recent years. For example, Zhang Y, et al. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] compared the clinical data between 145 refractory MPP patients and 489 general MMP patients, and found CRP, LDH, and IL-6 might be the significant predictors of children refractory MPP. Liu T, et al. [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] claimed serum lactate dehydrogenase isoenzymes 4 plus 5 had better sensitivity compared to traditional index LDH for refractory MPP. Cheng S, et al. [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] develop a nomogram for predicting refractory MPP, in which high fever, albumin, and LDH served as important factors.\u003c/p\u003e \u003cp\u003eWe measured BALF HMGB1 and GM-CSF in this study for two reasons: the BALF sample derived directly from the lower respiratory tract, which means a less chance of pollution, and a closer distance to the lesion. Several studies pointed out that BALF culture has higher pathogen detection rate than sputum culture[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. We also considered the anti-pathogen activities of immune system after MP infection, HMGB1 is mainly released by mononuclear macrophages and dendritic cells and plays a role in the adaptive immune phase[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], while GM-CSF is mainly released by activated T cells and play role in the cellular immune phase. After released outside the cell, both of them plays a synergistic role with various pro-inflammatory factors and forms a positive feedback loop to amplify the inflammatory response. Besides BALF HMGB1 and GM-CSF, we found 4 traditional biochemical markers difference between refractory MPP and non-refractory MPP: N, CRP, PCT, LDH. We also found there were a good correlation between GM-CSF and HMGB1 levels with those traditional indicators N, CRP, PCT and LDH (\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003er\u003c/span\u003e\u0026thinsp;=\u0026thinsp;0.611\u0026ndash;0.785, \u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003eP\u003c/span\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003eServe as immune cells, neutrophils play an important role in anti-pathogens[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Increased neutrophils in peripheral blood and alveolar lavage fluid are important clinical features of mycoplasma pneumonia[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. CRP and PCT are both inflammatory markers commonly used in clinic. A retrospective study involved 119 children with community-acquired pneumonia revealed that PCT on admission is correlated to inflammatory response degree, while CRP on admission is a predictor of lobar consolidation[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Neeser, et al.[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] found CRP/PCT ratio could provide reliable information to help discriminating MPP from streptococcus pneumoniae. Several studies claimed PCT concentrations in children hospitalized with CAP had ability to distinguish typical bacteria (eg, Streptococcus pneumoniae and Staphylococcus aureus) and atypical bacteria (Mycoplasma pneumoniae and Chlamydophila pneumoniae) [\u003cspan additionalcitationids=\"CR23\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. LDH occurs in the blood when tissues and organs are damaged, so it is used to be a biomarker to evaluate disease severity of MPP in clinic[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. There was evidence that LDH is an easily accessible biological marker that has been associated with several pulmonary disorders[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. A prospective cohort study of 300 children with refractory pneumonia and 353 with general pneumonia showed serum LDH with a cutoff of 379\u0026nbsp;U/L could be used to predict refractory MPP at early stage of hospitalization [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. In brief, the traditional markers N, CRP, PCT, and LDH have good predictive value for the occurrence and development of MPP, and the correlation between BALF HMGB1 and GM-CSF with them indicate a potential value of HMGB1and GM-CSF in MPP evaluation. After Logistic analysis and ROC analysis, we found CRP, GM-CSF and HMGB1 had predictive value for refractory MPP attack, and GM-CSF and HMGB1 were independent factors for refractory MPP. The results further confirmed their important diagnostic value.\u003c/p\u003e \u003cp\u003eIn addition, we found the BALF HMGB1 and GM-CSF level decreased with the treatment. Considering that the number of cases decreased greatly at 3rd bronchoalveolar lavage therapy, we analyzed the prognostic evaluation effect of BALF HMGB1 and GM-CSF level in the first two treatments. The results showed the levels at 2nd bronchoalveolar lavage therapy had predictive value for long hospital stay (\u0026gt;\u0026thinsp;28d) and poor prognosis of refractory MPP. A few studies have showed HMGB1 might be a reliable biochemical marker for prognosis evaluation of MPP and community acquired pneumonia [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], which consistent with our study. The clinical studies about BALF GM-CSF in MPP are limited quantity. Previous studies have shown that GM-CSF plays a vital role in neutrophil inflammation in M. A proper GM-CSF secretion is beneficial for lung protection, while increased GM-CSF in pulmonary could causes alveolar macrophage accumulation, which contribute to a lung parenchymal injury derived excessive immune inflammatory response[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. This may be one of the reasons for GM-CSF level lead to poor prognosis.\u003c/p\u003e "},{"header":"Conclusions","content":" \u003cp\u003eIn conclusion, the level of GM-CSF and HMGB1 in alveolar lavage fluid is closely related to the occurrence and development of refractory MPP, which can be used as an auxiliary indicator for clinical diagnosis and prognosis evaluation, and has certain guiding significance for its clinical treatment.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eGranulocyte-macrophage colony-stimulating factor\u0026nbsp;\u0026nbsp; GM-CSF\u003c/p\u003e\n\u003cp\u003eHigh mobility group box 1 \u0026nbsp;\u0026nbsp;HMGB1\u003c/p\u003e\n\u003cp\u003eMycoplasma pneumoniae pneumonia \u0026nbsp;\u0026nbsp;\u0026nbsp;MPP\u003c/p\u003e\n\u003cp\u003eMycoplasma pneumoniae\u0026nbsp;\u0026nbsp; MP\u003c/p\u003e\n\u003cp\u003eCommunity-acquired pneumonia \u0026nbsp;\u0026nbsp;\u0026nbsp;CAP\u003c/p\u003e\n\u003cp\u003eDamage- associated molecular pattern molecules \u0026nbsp;\u0026nbsp;\u0026nbsp;DAMPs\u003c/p\u003e\n\u003cp\u003ePathogen-associated molecular pattern molecules\u0026nbsp;\u0026nbsp;\u0026nbsp; PAMPs\u003c/p\u003e\n\u003cp\u003eAdenosine triphosphate proteins \u0026nbsp;\u0026nbsp;\u0026nbsp;ATP\u003c/p\u003e\n\u003cp\u003eWhite blood cell count \u0026nbsp;\u0026nbsp;\u0026nbsp;WBC\u003c/p\u003e\n\u003cp\u003eLymphocyte count \u0026nbsp;\u0026nbsp;\u0026nbsp;L\u003c/p\u003e\n\u003cp\u003eNeutrophil count \u0026nbsp;\u0026nbsp;\u0026nbsp;N\u003c/p\u003e\n\u003cp\u003eBlood platelet count\u0026nbsp;\u0026nbsp; PLT\u003c/p\u003e\n\u003cp\u003eC-reaction protein \u0026nbsp;\u0026nbsp;\u0026nbsp;CRP\u003c/p\u003e\n\u003cp\u003eProcalcitonin \u0026nbsp;\u0026nbsp;\u0026nbsp;PCT\u003c/p\u003e\n\u003cp\u003eD-dimer\u0026nbsp;\u0026nbsp; D-D\u003c/p\u003e\n\u003cp\u003eAspartate aminotransferase \u0026nbsp;\u0026nbsp;\u0026nbsp;AST\u003c/p\u003e\n\u003cp\u003eAlanine transaminase\u0026nbsp;\u0026nbsp; ALT\u003c/p\u003e\n\u003cp\u003eLactate dehydrogenase \u0026nbsp;\u0026nbsp;\u0026nbsp;LDH\u003c/p\u003e\n\u003cp\u003eCreatine kinase \u0026nbsp;\u0026nbsp;\u0026nbsp;CK\u003c/p\u003e\n\u003cp\u003eCreatine kinase isoenzyme\u0026nbsp;\u0026nbsp; CK-MB\u003c/p\u003e\n\u003cp\u003eImmunoglobulin A\u0026nbsp;\u0026nbsp;\u0026nbsp; IgA\u003c/p\u003e\n\u003cp\u003eImmunoglobulin M\u0026nbsp;\u0026nbsp; \u0026nbsp;IgM\u003c/p\u003e\n\u003cp\u003eImmunoglobulin G\u0026nbsp;\u0026nbsp; \u0026nbsp;IgG\u003c/p\u003e\n\u003cp\u003eComplement 3\u0026nbsp;\u0026nbsp; C3\u003c/p\u003e\n\u003cp\u003eComplement 4\u0026nbsp;\u0026nbsp; C4\u003c/p\u003e\n\u003cp\u003eMulti detector computed tomography \u0026nbsp;\u0026nbsp;\u0026nbsp;MSCT\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was conducted in compliance with the principles of the Declaration of Helsinki and approved by the ethics committee of Affiliated Hospital of Changchun University of Traditional Chinese Medicine. Written informed consent was provided by all enrolled individuals and the parent\u0026rsquo;s patient has given their parental consent for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eApproval.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data used to support the findings of this study are available from the corresponding author upon request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone of the authors of the present manuscript have a commercial or other association that might pose a conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo;contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLC and YW conceived the study. HL acquired data. HY performed the statistical analysis. LC drafted the manuscript. All authors read and approved the manuscript prior to submission.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003cp\u003e[1] I.A. Yoon, K.B. Hong, H.J. Lee, K.W. Yun, J.Y. Park, Y.H. Choi, W.S. Kim, H. Lee, B.W. Eun, Y.M. Ahn, E.Y. Cho, H.J. Cho, E.H. Choi, Radiologic findings as a determinant and no effect of macrolide resistance on clinical course of Mycoplasma pneumoniae pneumonia, BMC infectious diseases, 17 (2017) 402.\u003c/p\u003e\n\u003cp\u003e[2] Y. Zhang, Y. Zhou, S. Li, D. Yang, X. Wu, Z. Chen, The Clinical Characteristics and Predictors of Refractory Mycoplasma pneumoniae Pneumonia in Children, PloS one, 11 (2016) e0156465.\u003c/p\u003e\n\u003cp\u003e[3] L. Wang, S. Lu, Z. Feng, L. Li, B. Niu, J. Shuai, L. Cao, G. Li, J. Liu, The early examination of combined serum and imaging data under flexible fiberoptic bronchoscopy as a novel predictor for refractory Mycoplasma pneumoniae pneumonia diagnosis, Medicine, 96 (2017) e9364.\u003c/p\u003e\n\u003cp\u003e[4] J.J. Xu, L.H. Shu, [Clinical characteristics of refractory Mycoplasma pneumoniae pneumonia in children], Zhongguo dang dai er ke za zhi = Chinese journal of contemporary pediatrics, 20 (2018) 37-42.\u003c/p\u003e\n\u003cp\u003e[5] R. Chaudhry, A. Ghosh, A. Chandolia, Pathogenesis of Mycoplasma pneumoniae: An update, Indian journal of medical microbiology, 34 (2016) 7-16.\u003c/p\u003e\n\u003cp\u003e[6] J.A.S. Quaresma, Organization of the Skin Immune System and Compartmentalized Immune Responses in Infectious Diseases, Clinical microbiology reviews, 32 (2019).\u003c/p\u003e\n\u003cp\u003e[7] M.E. Bianchi, M.P. Crippa, A.A. Manfredi, R. Mezzapelle, P. Rovere Querini, E. Venereau, High-mobility group box 1 protein orchestrates responses to tissue damage via inflammation, innate and adaptive immunity, and tissue repair, Immunological reviews, 280 (2017) 74-82.\u003c/p\u003e\n\u003cp\u003e[8] F. Pandolfi, S. Altamura, S. Frosali, P. Conti, Key Role of DAMP in Inflammation, Cancer, and Tissue Repair, Clinical therapeutics, 38 (2016) 1017-1028.\u003c/p\u003e\n\u003cp\u003e[9] Y. Liu, X. Zhang, Y. Wang, C. Zhu, M. Fan, X. Dou, C. Hao, Y. Yan, W. Ji, G. Gu, J. Lou, Z. Chen, The role of granulocyte macrophage colony stimulating factor in hospitalized children with Mycoplasma pneumoniae pneumonia, Journal of infection and chemotherapy : official journal of the Japan Society of Chemotherapy, 24 (2018) 789-794.\u003c/p\u003e\n\u003cp\u003e[10] J. Liu, F. Zhao, J. Lu, H. Xu, H. Liu, X. Tang, H. Yang, J. Zhang, S. Zhao, High Mycoplasma pneumoniae loads and persistent long-term Mycoplasma pneumoniae DNA in lower airway associated with severity of pediatric Mycoplasma pneumoniae pneumonia, BMC infectious diseases, 19 (2019) 1045.\u003c/p\u003e\n\u003cp\u003e[11] X. Zhang, Z. Chen, W. Gu, W. Ji, Y. Wang, C. Hao, Y. He, L. Huang, M. Wang, X. Shao, Y. Yan, Viral and bacterial co-infection in hospitalised children with refractory Mycoplasma pneumoniae pneumonia, Epidemiology and infection, 146 (2018) 1384-1388.\u003c/p\u003e\n\u003cp\u003e[12] Y.J. Choi, J.H. Jeon, J.W. Oh, Critical combination of initial markers for predicting refractory Mycoplasma pneumoniae pneumonia in children: a case control study, Respiratory research, 20 (2019) 193.\u003c/p\u003e\n\u003cp\u003e[13] Y. Xu, L. Yu, C. Hao, Y. Wang, C. Zhu, W. Ji, Y. Li, G. Li, Z. Chen, Y. Yan, Plasma soluble B7-H3 levels for severity evaluation in pediatric patients with Mycoplasma pneumoniae pneumonia, International immunopharmacology, 73 (2019) 163-171.\u003c/p\u003e\n\u003cp\u003e[14] T.Y. Liu, W.J. Lee, C.M. Tsai, K.C. Kuo, C.H. Lee, K.S. Hsieh, C.H. Chang, Y.T. Su, C.K. Niu, H.R. Yu, Serum lactate dehydrogenase isoenzymes 4 plus 5 is a better biomarker than total lactate dehydrogenase for refractory Mycoplasma pneumoniae pneumonia in children, Pediatrics and neonatology, 59 (2018) 501-506.\u003c/p\u003e\n\u003cp\u003e[15] S. Cheng, J. Lin, X. Zheng, L. Yan, Y. Zhang, Q. Zeng, D. Tian, Z. Fu, J. Dai, Development and validation of a simple-to-use nomogram for predicting refractory Mycoplasma pneumoniae pneumonia in children, Pediatric pulmonology, (2020).\u003c/p\u003e\n\u003cp\u003e[16] M. Wang, Y. Wang, Y. Yan, C. Zhu, L. Huang, X. Shao, J. Xu, H. Zhu, X. Sun, W. Ji, Z. Chen, Clinical and laboratory profiles of refractory Mycoplasma pneumoniae pneumonia in children, International journal of infectious diseases : IJID : official publication of the International Society for Infectious Diseases, 29 (2014) 18-23.\u003c/p\u003e\n\u003cp\u003e[17] S. Manti, T.J. Harford, C. Salpietro, F. Rezaee, G. Piedimonte, Induction of high-mobility group Box-1 in vitro and in vivo by respiratory syncytial virus, Pediatric research, 83 (2018) 1049-1056.\u003c/p\u003e\n\u003cp\u003e[18] E.H. Aitken, A. Alemu, S.J. Rogerson, Neutrophils and Malaria, Frontiers in immunology, 9 (2018) 3005.\u003c/p\u003e\n\u003cp\u003e[19] J. Li, H. Zhu, Y. Bai, C. Ma, G. Zhang, W. Feng, C. Liu, Hemilagglutinin -3 expression in RMPP airway inflammation is associated with mycoplasma pneumoniae load and neutrophils level (in Chinese), Journal of clinical pulmonary medicine, 25 (2020).\u003c/p\u003e\n\u003cp\u003e[20] L. Agnello, C. Bellia, M. Di Gangi, B. Lo Sasso, L. Calvaruso, G. Bivona, C. Scazzone, P. Dones, M. Ciaccio, Utility of serum procalcitonin and C-reactive protein in severity assessment of community-acquired pneumonia in children, Clinical biochemistry, 49 (2016) 47-50.\u003c/p\u003e\n\u003cp\u003e[21] O.L. Neeser, T. Vukajlovic, L. Felder, S. Haubitz, A. Hammerer-Lercher, C. Ottiger, B. Mueller, P. Schuetz, C.A. Fux, A high C-reactive protein/procalcitonin ratio predicts Mycoplasma pneumoniae infection, Clinical chemistry and laboratory medicine, 57 (2019) 1638-1646.\u003c/p\u003e\n\u003cp\u003e[22] C.M. Nascimento-Carvalho, M.R. Cardoso, A. Barral, C.A. Araujo-Neto, S. Guerin, A. Saukkoriipi, M. Paldanius, R. Vainionpaa, P. Lebon, M. Leinonen, O. Ruuskanen, D. Gendrel, Procalcitonin is useful in identifying bacteraemia among children with pneumonia, Scandinavian journal of infectious diseases, 42 (2010) 644-649.\u003c/p\u003e\n\u003cp\u003e[23] A. Julian-Jimenez, J. Timon Zapata, E.J. Laserna Mendieta, R. Parejo Miguez, M. Flores Chacartegui, P. Gallardo Schall, [Ability of procalcitonin to predict bacteremia in patients with community acquired pneumonia], Medicina clinica, 142 (2014) 285-292.\u003c/p\u003e\n\u003cp\u003e[24] C. Stockmann, K. Ampofo, J. Killpack, D.J. Williams, K.M. Edwards, C.G. Grijalva, S.R. Arnold, J.A. McCullers, E.J. Anderson, R.G. Wunderink, W.H. Self, A. Bramley, S. Jain, A.T. Pavia, A.J. Blaschke, Procalcitonin Accurately Identifies Hospitalized Children With Low Risk of Bacterial Community-Acquired Pneumonia, Journal of the Pediatric Infectious Diseases Society, 7 (2018) 46-53.\u003c/p\u003e\n\u003cp\u003e[25] R. Kawamata, K. Yokoyama, M. Sato, M. Goto, Y. Nozaki, T. Takagi, H. Kumagai, T. Yamagata, Utility of serum ferritin and lactate dehydrogenase as surrogate markers for steroid therapy for Mycoplasma pneumoniae pneumonia, Journal of infection and chemotherapy : official journal of the Japan Society of Chemotherapy, 21 (2015) 783-789.\u003c/p\u003e\n\u003cp\u003e[26] C.Y. Ding, L. Peng, Y.X. Lin, L.H. Yu, D.L. Wang, D.Z. Kang, Elevated Lactate Dehydrogenase Level Predicts Postoperative Pneumonia in Patients with Aneurysmal Subarachnoid Hemorrhage, World neurosurgery, 129 (2019) e821-e830.\u003c/p\u003e\n\u003cp\u003e[27] Y. Ding, C. Chu, Y. Li, G. Li, X. Lei, W. Zhou, Z. Chen, High expression of HMGB1 in children with refractory Mycoplasma pneumoniae pneumonia, BMC infectious diseases, 18 (2018) 439.\u003c/p\u003e\n\u003cp\u003e[28] A. Lu, C. Wang, X. Zhang, L. Wang, L. Qian, Lactate Dehydrogenase as a Biomarker for Prediction of Refractory Mycoplasma pneumoniae Pneumonia in Children, Respiratory care, 60 (2015) 1469-1475.\u003c/p\u003e\n\u003cp\u003e[29] H. Lu, N. Zeng, Q. Chen, Y. Wu, S. Cai, G. Li, F. Li, J. Kong, Clinical prognostic significance of serum high mobility group box-1 protein in patients with community-acquired pneumonia, The Journal of international medical research, (2019) 300060518819381.\u003c/p\u003e\n\u003cp\u003e[30] W. Song, H. Tan, S. Wang, Y. Zhang, Y. Ding, Association of High Mobility Group Box Protein B1 Gene Polymorphisms with Pneumonia Susceptibility and Severity, Genetic testing and molecular biomarkers, 23 (2019) 3-11.\u003c/p\u003e\n\u003cp\u003e[31] T. Suzuki, C. McCarthy, B.C. Carey, M. Borchers, D. Beck, K.A. Wikenheiser-Brokamp, D. Black, C. Chalk, B.C. Trapnell, Increased Pulmonary GM-CSF Causes Alveolar Macrophage Accumulation. Mechanistic Implications for Desquamative Interstitial Pneumonitis, American journal of respiratory cell and molecular biology, 62 (2020) 87-94.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"infantile pneumonia, granulocyte-macrophage colony-stimulating factor, high mobility group box 1, mycoplasma pneumoniae, refractory pneumonia ","lastPublishedDoi":"10.21203/rs.3.rs-18708/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-18708/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground:\u0026nbsp;To analyze the relationship between\u0026nbsp;granulocyte-macrophage colony-stimulating factor (GM-CSF)\u0026nbsp;and high mobility group box 1 (HMGB1) level in alveolar lavage fluid with the clinical characteristics and prognosis of children refractory mycoplasma pneumoniae\u0026nbsp;pneumonia (MPP), so as to provide reliable targets for clinical diagnosis and treatment. \u003c/p\u003e\u003cp\u003eMethods: A total of 106 children diagnosed with MPP and prepared for bronchoalveolar lavage therapy were selected in this study, which were divided into 2 groups according to clinical diagnosis: those showing clinical and radiological deterioration despite appropriate antibiotic therapy for ≥7 days were classified into refractory MPP group (n=47), while the others were classified into non-refractory MPP group (n=59). The data of physical examination, treatment and outcome were collected. In addition, the GM-CSF and HMGB1 levels in alveolar lavage fluid during each bronchoalveolar lavage therapy were detected by ELISA kits. \u003c/p\u003e\u003cp\u003eResults: There was no significant difference in age, sex, course of fever, the highest temperature, WBC, L, PLT, ALT, AST, CK-MB, D-D, CK, IgG, IgA, IgM, C3, and C4 between refractory MMP group and non-refractory MMP group on admission (P＞0.05). The levels of N, CRP, PCT, and LDH in refractory MPP group were higher than those in non-refractory MPP group, the difference had statistical significance (P＜0.05). Both GM-CSF and HMGB1\u0026nbsp;levels were positively correlated with traditional indicators N, CRP, PCT and LDH (r=0.611-0.785, P\u0026lt;0.05). ROC analysis results showed that CRP, GM-CSF and HMGB1 had predictive value for refractory MPP attack (AUC=0.636, 0.657, 0.651, P\u0026lt;0.05). Logistic regression analysis results showed GM-CSF and HMGB1 were independent factors for refractory MPP (B＞1.0, P\u0026lt;0.05). ROC analysis results showed that GM-CSF and HMGB1 at 2nd\u0026nbsp;bronchoalveolar lavage therapy had predictive value for long hospital stay (\u0026gt;28 d) and poor prognosis of refractory MPP (AUC=0.782-0.825, P\u0026nbsp;\u0026lt; 0.05). \u003c/p\u003e\u003cp\u003eConclusion: The level of GM-CSF and HMGB1 in alveolar lavage fluid is closely related to the occurrence and development of refractory MPP, which can be used as an auxiliary indicator for clinical diagnosis and prognosis evaluation, and has certain guiding significance for its clinical treatment.\u003c/p\u003e","manuscriptTitle":"GM-CSF and HMGB1 level were associated with the clinical characteristics and prognosis of childhood refractory mycoplasma pneumoniae pneumonia","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2020-03-24 14:44:37","doi":"10.21203/rs.3.rs-18708/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"921dc659-8268-4030-9723-5f47280ff855","owner":[],"postedDate":"March 24th, 2020","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":74027,"name":"Pulmonology"}],"tags":[],"updatedAt":"2020-09-11T16:33:10+00:00","versionOfRecord":[],"versionCreatedAt":"2020-03-24 14:44:37","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-18708","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-18708","identity":"rs-18708","version":["v1"]},"buildId":"_2-kVJe1T_tPrBINL-cwx","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}