恶性血液病并发军团菌肺炎12例临床分析.pdf
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1、3648plus pomalidomide and low-dose dexamethasone versus pomalid-omide and low-dose dexamethasone in patients with relapsed andrefractory multiple myeloma(ICARIA-MM):a randomised,mul-ticentre,open-label,phase 3 study J.Lancet,2019,394(10214):2096-2107.杨二青,等21RICHARDSON PG,SAN-MIGUELJ,BEKSAC M,et al.U
2、pdatesfrom ICARIA-MM,a phase 3 study of isatuximab(Isa)plus po-malidomide and low-dose dexamethasone(Pd)versus Pd in re-lapsed and refractory multiple myeloma(RRMM)J.J Clin On-col,2021,39(15 Suppl):8017.恶性血液病并发军团菌肺炎12 例临床分析(编校:巩森淼)恶性血液病并发军团菌肺炎12 例临床分析杨二青,米瑞华,陈琳,王琳,魏旭东郑州大学附属肿瘤医院血液科,河南郑州450 0 0 8【摘要】目
3、的:通过对恶性血液病并发军团菌肺炎患者的临床特点及诊疗转归分析,提高对该疾病的认识。方法:回顾性分析我院血液科2 0 2 1年0 3月至2 0 2 2 年0 8 月收治的12 例恶性血液病并发军团菌肺炎患者的临床资料,包括临床特征、影像学表现、治疗及转归等。结果:12 例患者中,男性4例,女性8 例,中位年龄55(14 8 9)岁;急性髓系白血病(acute myeloid leukemia,A M L)5例,急性淋巴细胞白血病(acutelymphoblasticleukemia,ALL)2例,骨髓增生异常综合征(myelodysplastic syndrome,MDS)1例,T淋巴母细胞白
4、血病/淋巴瘤(Tlymphoblastic leukemia/lymphoma,T-ALL/LBL)1例,多发性骨髓瘤(multiplemyeloma,MM)3例;通过肺泡灌洗液、肺组织活检和血液宏基因组二代测序明确诊断。临床表现有高热(12/12)、咳嗽(8/12)、咳痰(6/12)、呼吸困难(5/12)、寒战(3/12)、胸痛(3/12)、呼吸衰竭(3/12)。C反应蛋白12 例均升高,6 例降钙素原明显升高,6 例血钾下降,8 例血钠下降。胸部CT影像呈快速进展,表现为结节状、条索状或斑片状高密度影,融合成片或实变,可伴肺不张、胸腔积液、胸膜增厚等。发生于化疗后骨髓抑制期11 例,治疗药
5、物首选喹诺酮类和大环内酯类抗生素,8 例好转,4例死亡。结论:恶性血液病合并军团菌肺炎以化疗后骨髓抑制期出现较多,临床表现及影像学表现不典型,病死率高,同时出现低钾血症、低钠血症及广谱抗生素、抗真菌药物治疗无效的肺炎时应警惕军团菌肺炎可能,应尽早寻找病原菌并针对性治疗有利于患者的预后。【关键词】血液肿瘤;军团菌;肺炎;治疗;预后【中图分类号】R732【文章编号】16 7 2-4992-(2 0 2 3)19-36 48-0 5Clinical analysis of 12 cases of hematological malignancies with legionella pneumonia
6、YANG Erqing,MI Ruihua,CHEN Lin,WANG Lin,WEI XudongDepartment of Hematopathy,the Affiliated Cancer Hospital of Zhengzhou University,Henan Zhengzhou 450008,China.Abstract】O b j e c t i v e:T o e n h a n c e t h e u n d e r s t a n d i n g o f l e g i o n e l l a p n e u mo n i a i n p a t i e n t s w
7、i t h h e ma t o l o g i c a l ma l i g-nancies by analyzing the clinical characteristics and diagnostic outcomes.Methods:We retrospectively analyzed theclinical data included clinical characteristics,imaging manifestations,treatments,and outcomes of 12 patients with he-matological malignancies comp
8、licated by legionella pneumonia admitted to the Hematology Department of our hospitalfrom March 2021 to August 2022.Results:Of the 12 patients,4 were male and 8 were female,with a median age of 55(14 89)years old.There were 5 cases of acute myeloid leukemia(AML),2 cases of acute lymphoblastic leukem
9、ia(ALL),1 case of myelodysplastic syndrome(MDS),1 case of T lymphoblastic leukemia/lymphoma(T-ALL/LBL),and 3 cases of multiple myeloma(MM).The diagnoses were confirmed through bronchoalveolar lavage fluid,lung【收稿日期】2022 11-17【修回日期】2023-05-12【基金项目】国家自然科学基金面上项目(编号:8 2 17 0 151);河南省医学科技攻关计划联合共建项目(编号:LH
10、GJ20210185)【作者简介】杨二青(1997 一),女,河南三门峡人,硕士研究生,主要从事恶性血液病综合治疗研究。E-mail:【通信作者】魏旭东(196 3一),男,河南郑州人,主任医师,博士,博士生导师,主要从事血液病基础和临床研究。Ema i l:w e i x u d o n g 6 3 12 【文献标识码】AD0I:10.3969/j.issn.1672-4992.2023.19.022现代肿瘤医学2 0 2 3年10 月第31卷第19期tissue biopsy,and blood next generation sequencing.Clinical symptoms in
11、cluded high fever(12/12),cough(8/12),sputum production(6/12),dyspnea(5/12),chills(3/12),chest pain(3/12),and respiratory failure(3/12).Labora-tory tests showed that C-reactive protein was increased in all 12 cases,procalcitonin was significantly increased in 6cases,serum potassium was decreased in 6
12、 cases,and serum sodium was decreased in 8 cases.The imaging manifesta-tions were rapidly progressive,showing nodular,cord or patchy high-density shadows,fused into patches or consolida-tion,accompanied by atelectasis,pleural effusion,pleural thickening.The majority of cases(11/12)occurred duringthe
13、 bone marrow suppression period following chemotherapy.Quinolones and macrolides were the preferred antibioticchoices,and 8 cases showed improvement and 4 cases resulted in death.Conclusion:Legionella pneumonia in patientswith hematological malignancies is more commonly observed during the bone marr
14、ow suppression period fllowingchemotherapy.The clinical and imaging manifestations are atypical,and the mortality rate is high.When pneumoniaoccurs with hypokalemia,hyponatremia,and ineffective treatment with broad-spectrum antibiotics and antifungaldrugs,legionella pneumonia should be considered.Ea
15、rly identification of the pathogen and targeted treatment can im-prove the prognosis of patients.Key words hematological malignancies,legionella,pneumonia,treatment,prognosis化疗后免疫抑制、黏膜屏障破坏、糖皮质激素及广谱抗生素的应用等使肺部感染成为恶性血液病的常见并发症。自197 6 年军团菌首次被发现以来,其被认为是社区获得性肺炎(communitya c q u i r e d p n e u mo n i a,CA
16、P)的常见原因,是医院获得性肺炎的少见原因。军团菌肺炎进展迅速,可在短期内导致死亡,大部分患者死亡于呼吸衰竭,其次为休克和急性肾功能衰竭,病死率约5%30%,由于其临床表现及影像学表现不典型,易造成误诊及漏诊2 。恶性血液病并发军团菌肺炎在国内仅有散在报道。本中心诊治了12 例恶性血液病并发军团菌肺炎患者,现报道如下并进行文献复习,旨在提高对该疾病的认识。1资料与方法1.1病例资料收集收集我院血液科2 0 2 1年0 3月至2 0 2 2 年0 8 月诊断为恶性血液病合并军团菌肺炎的12 例患者的临床资料。本研究符合伦理委员会所制定的伦理学标准,受试对象(或其监护Tab.1Clinical d
17、ata of 12 patients with malignant hematological diseases complicated with legionella pneumoniaAgeCaseGender(years)1Female2Female3Male4Female5Female6Female7Female8Female9Male10Male11Female12MaleMODERN ONCOLOGY,Oct.2023,VOL.31,No.19人)均知情同意。1.2方法收集患者的基础资料(性别、年龄、基础疾病、疾病诊断)、临床表现、实验室检查、影像学检查、诊断方法、治疗及转归等。2
18、结果2.1临床资料12 例恶性血液病合并军团菌肺炎患者中,男性 4 例,女性8 例,中位年龄55(14 8 9)岁。急性髓系白血病(acutemyeloidleukemia,AML)5例,急性淋巴细胞白血病(acutelymphoblasticleukemia,ALL)2例,骨髓增生异常综合征(my-elodysplastic syndrome,MDS)1例,T淋巴母细胞白血病/淋巴瘤(T lymphoblastic leukemia/lymphoma,T-ALL/LBL)1 例,多发性骨髓瘤(multiplemyeloma,MM)3例(见表1)。1例有慢性乙型病毒性肝炎病史,1例有胃底间质瘤
19、手术史,2 例有高血压病病史。表112 例恶性血液病合并军团菌肺炎患者的临床资料DiseasePeriod of time54AML56AML52AML30AML65AML59MDS15ALL24ALL14T-ALL/LBL70MM89MM65MM 3649.Modern 0ncology 2023,31(19):3648-3652Clinical manifestationTreatmentFever,chils,cough,expectoration,Myelosuppression stagebloody sputum,poor appetiteMyelosuppresion stage
20、Fever,coughMyelosuppression stageFever,cough,chest pain,hemoptysisFever,chills,headache,pharyngalgia,Myelosuppresion stageMyelosuppression stageMyelosuppression stageMyelosuppresion stageMyelosuppreson stageFever,dyspnea,hypoxemia,respiratory failureMoxiloxacin+azthromycinMyelosuppression stageMoxil
21、oxacin+azithromycinchest pain,dyspneaMyelosuppresion stageFever,dyspnea,respiratory failureFever,cough,bloody sputum,dyspnea,Pre chemotherapyrespiratory failureFever,fatigue,cough,expectoration,Myelosuppression stageDays of medicationMoxilloxacin+azithromycin14Moxifloxacin21Moxiloxacin12Moxiloxacin1
22、4nausea,vomitingFever,cough,expectoration,bloody sputumFever,chlls,faigue,por apetiteFever,cough,blody sputum,chest pain,dyspneaFever,cough,expectoration,poor appetiteOutcomeImprovementImprovementImprovementImprovementMoxifloxacin14Moxifloxacin3Moxifloxacin 7 days,Moxifloxacin+azithromycinazithromyc
23、in 10 days3Moxiloxacin 31 days,azithromycin 14 daysMoxifloxacin+azithromycin1Moxifloxacin+azithromycin2Moxiloxacin 18 days,Moxifloxacin+azithromycinazithromycin 7 daysImprovementDeathImprovementDeathImprovementDeathDeathImprovement3650.2.2临床表现12例患者均有高热,3例寒战,2 例乏力,1例咽痛,1例头痛,2 例纳差,8 例咳嗽(其中2 例为干咳),6 例咳
24、痰,4例痰中带血,3例胸痛,1例咯血,5例出现呼吸困难,3例呼吸衰竭,11例发生于化疗后骨髓抑制期(见表1)。2.3实验室检查11例患者白细胞计数(whiteblood cell count,W BC)、中性粒细胞计数(neutrophil count,Neu)明显降低,12 例C反应蛋白(Cr e a c t i v e p r o t e i n,CRP)及降钙素原(procalcitonin,Laboratory examinationWBC(10/L)Neu(10%/L)CRP(mg/L)PCT(ng/mL)TBLB(mol/L)ALT(U/L)AST(U/L)Cer(mol/L)K+
25、(mmol/L)Na+(mmol/L)Pro-BNP(pg/mL)注:ALT:谷丙转氨酶;AST:谷草转氨酶。Note:ALT:Glutamic pyruvic transaminase.AST:Glutamic oxaloacetic transaminase.2.4影像学表现12例患者影像学均有斑片状高密度影表现,8 例有条索状阴影,5例有结节状影。9例有多个肺叶感染,7 例出现实杨二青,等PCT)均升高(其中6 例降钙素原明显升高),4例总胆红素(total bilirubin,TBLB)升高,3例肌酐(creatinine,Ccr)升高,6例血钾下降,2 例血钾升高,8 例血钠下降,1
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