【作者】 何川；

【导师】 刘霆；

【作者基本信息】 四川大学 ， 内科学， 2007， 硕士

【摘要】 目的人巨细胞病毒(HCMV)是人疱疹病毒科属DNA病毒，在发达国家感染率可达30～70％。在正常人体内通常呈潜伏感染，而在免疫功能低下时则可能出现HCMV活跃复制，进而发展为HCMV疾病(如间质性肺炎、肠炎、视网膜炎等)，是异基因造血干细胞移植(allo—HSCT)患者发病和死亡的重要原因。目前的常规预防方案是预防性治疗(universal prophylaxis)，即对移植前HCMV血清学阳性的所有患者都进行抗病毒治疗，这能够有效减少HCMV疾病的发生，但长期用药可造成骨髓抑制，并且增加治疗费用。抢先治疗(preemptive therapy)是指对发现有活动性HCMV感染的患者在HCMV疾病出现之前开始的抗病毒治疗，可以避免不必要的治疗，减轻抗病毒药物的副作用，降低费用。这需要依赖快速、敏感、可靠的活动性HCMV感染的监测手段。本研究采用荧光定量PCR法(FQ—PCR)监测allo—HSCT患者HCMV-DNA拷贝数，了解allo—HSCT患者移植后HCMV感染状况，并根据HCMV-DNA拷贝数判断患者是否存在HCMV的活跃复制，从而决定是否需要抢先治疗。探讨抢先治疗和预防性治疗相比较的优越性，同时比较血浆荧光定量PCR和白细胞荧光定量PCR检测有无差别。方法2004年9月～2006年4月在华西医院血液科层流病房住院行异基因造血干细胞移植的23例患者，移植前采用FQ-PCR法和血清学法同时进行血浆HCMV-DNA、白细胞HCMV-DNA、血清HCMV-IgG和HCMV-IgM检测。移植后两周开始采用血浆和白细胞FQ-PCR法对患者进行定点连续监测，每两周采血一次，至移植后半年。如患者血浆HCMV-DNA＞10~3拷贝／ml则开始抢先治疗，方案为更昔洛韦5mg／kg，q12h，至HCMV-DNA＜10~3拷贝／ml。并采用配对χ~2法对血浆和白细胞FQ-PCR检测结果进行统计学比较。结果23例allo—HSCT患者移植前22例血清学HCMV-IgG阳性，1例HCMV-IgM阳性，血浆和白细胞FQ-PCR均为阴性。移植后14例患者出现血浆FQ-PCR阳性，16例出现白细胞FQ-PCR阳性，13例血浆和白细胞FQ-PCR均阳性。14例血浆FQ-PCR阳性患者中11例接受了抢先治疗，2例发生HCMV疾病(间质性肺炎)，9例血浆FQ-PCR阴性患者均未发生HCMV疾病。结论本研究提示：HCMV活跃感染是allo—HSCT患者移植后常见并发症，容易出现的时间是移植后30～60天；荧光定量PCR是早期检测allo—HSCT患者HCMV活跃感染的有效方法，根据HCMV—DNA拷贝数而开始的抢先治疗与传统的预防性治疗相比，HCMV疾病的发病率无差异，减少了常规预防性应用抗病毒药物的副作用，避免了不必要的治疗，降低了治疗费用。和血浆FQ-PCR相比，白细胞FQ-PCR的检出率更高，但血浆FQ-PCR检测更简便、易行。更多还原

【Abstract】 Objective Human cytomegalovirus(HCMV) is a member ofβhuman herpesvirus with double-stranded linear DNA. In developed countries the overall seroprevalence is 30-70%. Following primary infection, the virus establishes latent infection in health adult. Virus reactivation occurs when the immune function are suppressed. Some cases may develop into HCMV disease(i.e. interstitial pneumonia, enteritis, retinitis) .HCMV remains a major cause of morbidity and mortality in allogeneic hematopoietic stem cell transplant(allo-HSCT) recipients. The common strategy is universal prophylaxis, means all seropositive recipients are given antiviral prophylaxis. This can significantly reduce HCMV disease. But it is a high-cost strategy and may lead to marrow suppression. Preemptive therapy means antiviral treatment is initiated when HCMV reactivation is detected. The advantages for this management of HCMV infection include avoiding unnecessary therapy, reducing the number of patients exposed to antiviral toxicity, andmaximizing the cost:benefit ratio. It depends on the quick, sensitive and reliable method which can monitor HCMV reactivated infection. The objective of this study is to monitor the copies of HCMV-DNA in allo-HSCT recipients by Fluorescent Quantitative PCR(FQ-PCR) assay, to learn about the infection condition in allo-HSCT recipients, to decision if the reactivated infection is existed and preemptive therapy is needed. Above all,to investigate the superiority of universal prophylaxis and preemptive therapy and to make a comparison between plasma FQ-PCR and leukocytic FQ-PCR.Methods A total of 23 patients underwent allogeneic hematopoietic stem cell transplantation at West China Hospital from September 2004 to April 2006. They were tested by plasma FQ-PCR, leukocytic FQ-PCR and serological assay before transplantation. Recipients were routinely monitored by plasma FQ-PCR and leukocytic FQ-PCR every 2 weeks(from engraftment to day +180). Preemptive therapy was initiated when HCMC-DNA> 10~3 copies/ml by plasma FQ-PCR with intravenous GCV 5mg/kg/twice daily until HCMC-DNA<10~3/ml copies. Statistical analysis of plasma FQ-PCR and leukocytic FQ-PCR was performed by chi-square test.Results Among 23 patients, 22 were positive for HCMV-IgG and 1 was positive for HCMV-IgM. None was found to be positive by plasma and leukocytic FQ-PCR before transplantion.14 patients were found to be positive by plasma FQ-PCR and 16 were by leukocytic FQ-PCR post transplantation. Among 14 plasma FQ-PCR positive patients, 11 initiated preemptive therapy. Two of these 11 patients developed into HCMV disease (interstitial pneumonia). HCMV disease had no evidence in 9 plasma FQ-PCR negative patients.Conclusion This study indicates that HCMV infection is one of common complications in allo-HSCT recipients, which occurs mostly during 30 to 60 days after transplantation. FQ-PCR is a useful method for early and rapid detection of HCMV infection in allo-HSCT recipients. Preemptive therapy based on copies of HCMV-DNA can reduce HCMV diseases just like universal prophylaxis. At the same time, it also can reduce the side effects of antiviral drugs, avoid unnecessary therapy and maximize the cost : benefit ratio. Leukocytic FQ-PCR has higher positive ratio than plasma FQ-PCR. But plasma FQ-PCR is simple and easy to carry out.更多还原