【作者】 杨婷；

【导师】 陈乐蓉；

【作者基本信息】 南昌大学 ， 临床医学硕士（专业学位）， 2023， 硕士

【摘要】 目的:提高临床医生对肺孢子菌肺炎合并巨细胞病毒感染的认识,并比较分析HIV-PCP(Human immunodeficiency virus infection with Pneumocystis pneumonia,HIV-PCP)合并CMV(Cytomegalovirus,CMV)组与NH-PCP(Non human immunodeficiency virus infection with Pneumocystis pneumonia,NH-PCP)合并CMV组之间的临床特征,为临床诊疗提供参考。方法:收集2018年1月至2022年12月江西省胸科医院收治的肺孢子菌肺炎合并巨细胞病毒感染患者的临床资料,基于人类免疫缺陷病毒(Human immunodeficiency virus,HIV)感染状态分为HIV-PCP合并CMV组与NH-PCP合并CMV组,对两组患者一般资料、临床表现、影像学表现、实验室结果、诊断方法、合并感染、治疗方案等进行回顾性分析。采用SPSS 26.0进行统计分析。结果:(1)、本研究共纳入50例患者,其中HIV-PCP合并CMV组有30例,NHPCP合并CMV组有20例;两组患病人群均以男性患病更为多见;NH-PCP合并CMV组患者年龄更年长(P<0.05);NH-PCP合并CMV组患者起病至入院就诊的时间间隔明显更短(P<0.05);HIV-PCP合并CMV组患者住院天数明显更长(P<0.05)。(2)、NH-PCP合并CMV组患者基础疾病多见于实体瘤、肾脏疾病、自身免疫性疾病。(3)、临床表现以咳嗽、胸闷、发热最多见,差异无统计学意义(P>0.05);NH-PCP合并CMV组呼吸困难更常见(P<0.05);HIV-PCP合并CMV组口腔鹅口疮更常见(P<0.05);胸部影像学表现以磨玻璃影、斑片状影、云雾状影、结节状影、网格样影最多见,较为少见的是实变影、空洞影、蜂窝样影、胸腔积液、胸膜增厚等,两组差异均无统计学意义(P>0.05)。(4)、有43例患者经m NGS技术明确病原体感染,其余7例为临床诊断;HIV-PCP合并CMV组更多见合并马尔尼菲蓝状菌感染(P<0.05);NH-PCP合并CMV组更多见合并曲霉菌感染(P<0.05)。(5)、NH-PCP合并CMV组C反应蛋白(CRP)水平明显升高(P<0.05);NH-PCP合并CMV组血氧水平表现更差(P<0.05);HIV-PCP合并CMV组所有患者CD4+T淋巴细胞计数均出现降低,且显著低于NH-PCP合并CMV组(P<0.05);NH-PCP合并CMV组CD8+T淋巴细胞计数明显降低,其CD4/CD8比值显著高于HIV-PCP合并CMV组(P<0.05);两组血浆(1,3)-β-D-葡聚糖(BDG)检测总体阳性率为42.22%,差异无统计学意义(P>0.05)。(6)、所有患者入院后均接受复方磺胺甲噁唑(TMP-SMX)抗PCP治疗,其中有33例患者单独接受TMP-SMX抗PCP治疗,有12例患者接受TMP-SMX联合卡泊芬净治疗,两组疗效比较,差异无统计学意义(P>0.05)。所有患者均接受更昔洛韦抗CMV治疗,有15例治疗期间更改为膦甲酸钠治疗。有44例患者使用了糖皮质激素治疗,两组疗效比较,差异有统计学意义(P<0.05)。有46例患者接受氧疗或机械通气,其中,NH-PCP合并CMV组更多患者需要无创或有创机械通气治疗(P<0.05);NH-PCP合并CMV组患者的总体死亡率为35%。结论:NH-PCP合并CMV组患病人群相对老年化,病情进展更快,低氧血症更严重,更多患者需要无创或有创机械通气,病死率相对更高,其基础疾病多见于实体瘤、肾脏疾病和自身免疫性疾病。更多还原

【Abstract】 Objective:To improve clinicians’ understanding of Pneumocystis pneumonia combined with cytomegalovirus infection and to compare and analyze the clinical characteri-stics between HIV-PCP combined with CMV group and NH-PCP combined with CMV group to provide reference for clinical diagnosis and treatment.Methods:The clinical data of patients with Pneumocystis pneumonia combined with cytomegalovirus infection admitted to Jiangxi Chest Hospital from January 2018 to December 2022 were collected and divided into HIV-PCP combined with CMV group and NH-PCP combined with CMV group based on human immunodeficiency virus infection status,and the general data,clinical manifestations,imaging findings,laboratory results,diagnostic methods,co-infections,and treatment plans of the two groups were retrospectively analyzed.SPSS 26.0 was used for statistical analysis.Results:(1)、A total of 50 patients were included in this study,including 30 patients in the HIV-PCP-combined CMV group and 20 patients in the NH-PCP-combined CMV group;both groups were more frequently affected by men;patients in the NH-PCPcombined CMV group were older(P < 0.05);patients in the NH-PCP-combined CMV group had a significantly shorter time interval between onset of disease and hospital admission(P < 0.05);the number of days of hospitalization was significantly longer in the HIV-PCP combined with CMV group(P < 0.05).(2)、The underlying diseases in the NH-PCP combined with CMV group were mostly seen in solid tumors,renal diseases,and autoimmune diseases.(3)、The most common clinical manifestations were cough,chest tightness and fever,with no statistically significant differences(P > 0.05);dyspnea was more common in the NH-PCP combined with CMV group(P < 0.05);oral thrush was more common in the HIV-PCP combined with CMV group(P < 0.05);chest imaging manifestations were most common with ground glass,patchy,cloudy,nodular and gridlike shadows.Less common were solid shadow,cavity shadow,honeycomb shadow,pleural effusion,pleural thickening,etc.The differences between the two groups were not statistically significant(P > 0.05).(4)、Pathogenic infections were clearly identified by metagenomic nextgeneration sequencing technology in 43 patients,and the remaining 7 cases were clinically diagnosed;combined Bluefinella marcescens infections were more common in the HIV-PCP combined with CMV group(P < 0.05);combined Aspergillus infections were more common in the NH-PCP combined with CMV group(P < 0.05).(5)、The C-reactive protein level was significantly higher in the NH-PCP combined with CMV group(P < 0.05);the blood oxygen level performed worse in the NH-PCP combined with CMV group(P < 0.05);the CD4+ T lymphocyte count was reduced in all patients in the HIV-PCP combined with CMV group and was significantly lower than that in the NH-PCP combined with CMV group(P < 0.05);the CD8+ T lymphocyte count was significantly lower in the NH-PCP combined with CMV group(P < 0.05);and the CD4/CD8 ratio was significantly higher in the NH-PCP combined with CMV group.The CD8+ T-lymphocyte count was significa-ntly lower in the NHPCP combined with CMV group,while the CD4/CD8 ratio was significantly higher than that in the HIV-PCP combined with CMV group(P < 0.05).The overall positive rate of plasma(1,3)-β-D-glucan(BDG)assay was 42.22% in both groups,and the difference was not statistically significant(P > 0.05).(6)、All patients received compound sulfamethoxazole(TMP-SMX)anti-PCP treatment after admission,among which 33 patients received TMP-SMX anti-PCP treatment alone and 12 patients received TMP-SMX combined with caspofungin treatment,the difference in efficacy between the two groups was not statistically significant(P > 0.05);all patients received ganciclovir anti-CMV treatment,with All patients received ganciclovir anti-CMV treatment,with 15 changing to phosphonate therapy during treatment;44 patients were treated with glucocorticoids,and the difference was statistically significant when comparing the efficacy of the two groups(P < 0.05);46 patients received oxygen therapy or mechanical ventilation,of which more patients in the NH-PCP combined with CMV group required noninvasive or invasive mechanical ventilation(P < 0.05);the overall mortality rate of patients in the NH-PCP combined with CMV group was overall mortality rate was 35%.Conclusion:The NH-PCP combined with CMV group has a relatively older population with more rapid disease progression,more severe hypoxemia,more patients requiring noninvasive or invasive mechanical ventilation,and a relatively higher morbidity and mortality rate,and their underlying diseases are mostly seen in solid tumors,renal diseases and autoimmune diseases.更多还原