【作者】 刘洋；

【导师】 邢丽华；

【作者基本信息】 郑州大学 ， 内科学（呼吸病学）（专业学位）， 2022， 硕士

【摘要】 目的探讨非人类免疫缺陷病毒(human immunodeficiency virus,HIV)感染免疫功能低下宿主重症巨细胞病毒肺炎的临床特征和预后危险因素。方法收集并回顾性分析2018年12月至2021年12月期间64例非HIV感染免疫功能低下且确诊为重症巨细胞病毒性肺炎患者的临床资料,包括性别、年龄、基础疾病,血常规、降钙素原(procalcitonin,PCT)、C-反应蛋白(C reactive protein,CRP)、乳酸脱氢酶(lactate dehydrogenase,LDH)、T淋巴细胞亚群、血气分析等实验室检验结果,急性生理与慢性健康Ⅱ(acute physiology and chronic health evaluationⅡ,APACHEⅡ)评分、肺炎严重指数(pneumonia severity index,PSI)、CURB-65(Confusion,Urea,Respiratory rate,and Age65,CURB-65)评分等疾病严重程度评分。根据患者出院28天转归分为存活组和死亡组。应用SPSS 23.0统计软件进行数据分析。结果1.共纳入非HIV感染免疫功能低下重症巨细胞病毒性肺炎患者64例,其中男性33例(51.6%),女性31例(48.4%),平均年龄(55.1 ± 14.4)岁。存活组34例,平均年龄(53.9±13.9)岁,男性21例(61.8%),女性13例(38.2%);死亡组30例,平均年龄(56.4±15.1)岁,男性12例(40.0%),女性18例(60.0%)。两组患者性别、年龄均无统计学意义(均P>0.05)。2.免疫功能低下相关基础疾病以免疫结缔组织病23例(35.9%)、肾脏疾病17例(26.6%)、血液系统恶性肿瘤11例(17.2%)为主,其中共有43例(67.2%)患者接受糖皮质激素治疗,31例(48.4%)接受免疫抑制剂治疗。3.临床症状主要为发热41例(64.1%)、咳嗽29例(45.3%)、胸闷25例(39.1%)、呼吸困难21例(32.8%)、咳痰20例(31.3%)。胸部影像学特征主要为:双肺弥漫磨玻璃影40例(62.5%)、双肺斑片状密度增高影31例(48.4%)、结节影24例(37.5%)、纵隔淋巴结肿大17例(26.6%)、网格影12例(18.8%)、实变影8例(12.5%)、空洞8例(12.5%)。4.APACHE Ⅱ、PSI、CURB-65 在死亡组中分值分别为(23.2±1.2)、(140.7±5.3)、2.0(2.0,3.0),均高于存活组(18.1±1.2)、(115.2±6.9)、1.0(1.0,2.0),两组间差异有统计学意义(均P<0.05)。APACHE Ⅱ评分、PSI评分分级、CURB-65评分的AUROC分别为 0.722(%95 CI:0.595-0.826)、0.678(%95 CI:0.550-0.790)、0.774(%95 CI:0.652-0.869)(均P<0.05)。5.两组血常规中淋巴细胞计数均低于正常范围,死亡组0.5(0.3,0.8)× 109/L明显低于存活组0.9(0.4,1.7)× 109/L,具有统计学意义(P<0.05)。T淋巴细胞亚群(CD3+T淋巴细胞、CD4+T淋巴细胞、CD4+/CD8+T淋巴细胞比值)在死亡组分别为 351.3(218.0,536.6)、116.5(76.4,190.5)、0.6(0.4,1.0)均明显低于存活组622.0(329.1,1031.7)、282.0(138.8,427.0)、1.0(0.7,1.8),差异具有统计学意义(均P<0.05)。两组LDH水平均高于正常范围,死亡组1079.5(816.0,1666.3)U/L明显高于存活组553.0(400.0,822.5)U/L,差异具有统计学意义(P<0.05)。中性粒细胞计数、PCT、CRP、ESR等炎症指标无明显统计学意义(均P>0.05)。6.64例患者总体死亡率为46.9%。呼吸衰竭、多器官功能衰竭综合征、ARDS在死亡组分别为30例(100%)、15例(50.0%)、14例(46.7%),存活组分别为27例(79.4%)、4例(11.8%)、7例(20.6%),两组间差异具有统计学意义(均P<0.05)。两组氧合指数均明显下降,死亡组为88.7(57.1,135.1)明显低于存活组172.6(104.3,205.2)(P<0.05)。机械通气、应用血管活性药物在死亡组比例分别为86.7%、56.7%明显高于存活组20.6%、20.6%(均P<0.05)。死亡组住院时长为(18.2±14.0)显著短于存活组(29.6±20.9)天(P<0.05)。7.多因素logistic回归分析显示,CURB-65、LDH是非HIV感染免疫功能低下宿主重症巨细胞病毒性肺炎的独立危险因素(OR=2.883、1.002,均P<0.05)。结论1.非HIV免疫功能低下宿主重症巨细胞病毒性肺炎患者病情危重,病死率局。2.非HIV免疫功能低下宿主重症巨细胞病毒性肺炎淋巴细胞计数、CD4+T淋巴细胞减少,死亡风险高。3.APACHE Ⅱ、PSI、CURB-65评分对于非HIV感染免疫功能低下宿主重症巨细胞病毒性肺炎预后具有预测价值;CURB-65、LDH是非HIV感染免疫功能低下宿主重症巨细胞病毒性肺炎预后相关独立危险因素。更多还原

【Abstract】 ObjectiveTo explore the clinical features and prognostic risk factors of severe cytomegalovirus pneumonia in immunocompromised hosts without human immunodeficiency virus(HIV)infection.MethodsA retrospective study collected and analyzed the clinical data of 64 non-HIV-infected immunocompromised patients diagnosed with severe cytomegalovirus pneumonia between December 2018 and December 2021.Collected gender,age,underlying disease,blood routine test(BRT),procalcitonin(PCT),C-reactive protein(CRP),lactate dehydrogenase(LDH),T lymphocyte subsets,and blood gas analysis(BG).Disease severity was scored using the acute physiology and chronic health evaluation Ⅱ(APACHE Ⅱ)score,the Pneumonia Severity Index(PSI),and the CURB-65(Confusion,Disease severity scores such as Urea,Respiratory rate,and Age65).The patients were divided into a survival group and a death group according to the 28-day outcome after discharge from hospital.The data were analyzed with the SPSS(version 23.0)statistical package.Results1.A total of 64 non-HIV-infected immunocompromised patients with severe cytomegalovirus pneumonia were included,including 33(51.6%)males and 31(48.4%)females,aged(55.1±14.4)years old.There were 34 cases in the survival group,with an average age of(53.9±13.9)years,21(61.8%)males and 13(38.2%)females.30 cases in the death group,with an average age of(56.4±15.1)years,and 12(40.0%)males,and 18(60.0%)females.There were no significant differences in gender and age between the two groups(both P>0.05).2.The underlying diseases related to low immune function were immune connective tissue diseases(23,35.9%),renal diseases(17,26.6%),hematological malignancies(11,17.2%),and solid malignancies(5,7.8%).In total,43(67.2%)patients received glucocorticoid therapy and 31(48.4%)received immunosuppressive therapy.3.The main clinical symptoms were fever(41,64.1%),cough(29,45.3%),chest tightness(25,39.1%),dyspnea(21,32.8%),and expectoration(20,31.3%).Chest pain was present in 4 patients(6.25%).The main imaging features of the chest were:diffuse ground-glass opacity in the double lung(40,62.5%),patchy increased density in the double lung(31,48.4%),nodular opacity(24,37.5%),mediastinal lymphadenopathy(17,26.6%),grid shadows(12,18.8%),consolidation shadows(8,12.5%),and cavity(8,12.5%).4.The APACHE II,PSI,and CURB-65 in the death group were(23.2±1.2),(140.7± 5.3),2.0(2.0,3.0),which were higher than those in the survival group(18.1±1.2),(115.2± 6.9),1.0(1.0,2.0)(all P<0.05).AUROC of APACHE Ⅱ score,PSI score classification and CURB-65 score were 0.722(%95 CI:0.595-0.826),0.678(%95 CI:0.550-0.790),0.774(%95 CI:0.652-0.869)(all P<0.05).5.The lymphocyte counts in the blood routine of both groups were low,and the death group was 0.5(0.3,0.8)×109/L,which was significantly lower than the survival group 0.9(0.4,1.7)×l09/L(P<0.05).T lymphocyte subsets(CD3+T lymphocytes,CD4+T lymphocytes,CD4+/CD8+T lymphocyte)in the death group were 351.3(218.0,536.6),116.5(76.4,190.5),and 0.6(0.4,1.0),the survival group were 622.0(329.1,1031.7),282.0(138.8,427.0),1.0(0.7,1.8)(all P<0.05).LDH of the two groups were higher than the normal range,and the death group was 1079.5(816.0,1666.3)U/L significantly higher than the survival group 553.0(400.0,822.5)U/L(P<0.05).There was no significant statistical significance in neutrophil count,PCT,CRP,ESR and other inflammatory indicators(all P>0.05).6.The mortality of 64 patients was 46.9%.The incidence rates of respiratory failure,multiple organ failure syndromes,and ARDS in the death group were all higher than those in the survival group(all P<0.05).The oxygenation index of both groups decreased obviously,the death group was 88.7(57.1,135.1)significantly lower than the survival group 172.6(104.3,205.2)(P<0.05).The proportion of mechanically ventilated patients in the death group(86.7%)was significantly higher than that in the survival group(20.6%)(P<0.05).17(56.7%)patients in the death group were treated with vasoactive drugs,which was much higher than that in the 7(20.6%)patients in the survival group(P<0.05).The length of hospital stay in the death group was(18.2±14.0)significantly shorter than that in the survival group(29.6±20.9)days(P<0.05).7.Multivariate logistic regression analysis showed that CURB-65,LDH were independent risk factors for the patients(OR=2.883,1.002,P<0.05).Conclusions1.Non-HIV-infected immunocompromised hosts with severe cytomegalovirus pneumonia are critically ill and have a high mortality rate.2.Non-HIV-infected immunocompromised hosts with severe cytomegalovirus pneumonia who have decreased lymphocyte counts and CD4+T lymphocytes,are at high risk of death.3.APACHE Ⅱ,PSI and CURB-65 scores have predictive value for the prognosis of severe cytomegalovirus pneumonia in non-HIV-infected immunocompromised hosts.CURB-65 and LDH are independent risk factors associated with the prognosis of the patients.更多还原