来氟米特相关过敏性肺炎一例及文献复习

Leflunomide associated hypersensitivity pneumonitis:a case report and review of the literatures

目的了解来氟米特相关过敏性肺炎的临床特点,以早期诊断、及时给予恰当治疗、改善患者的预后,提高诊治水平。方法回顾1例来氟米特治疗后发生过敏性肺炎的类风湿关节炎患者的诊治经过,并文献复习。结果患者女,34岁,诊断类风湿关节炎4年,近两年联合使用来氟米特和甲氨蝶呤,咳嗽、进行性气喘1月余,伴发热2d,经验性抗感染治疗无效。CT显示双肺弥漫性分布边缘模糊的小叶中央型结节,部分融合成斑片状、磨玻璃状影,伴空气潴留。外周血白细胞减少,巨细胞病毒DNA升高,肺功能显示重度混合性通气功能减退,弥散量明显降低,血气分析示Ⅰ型呼吸衰竭,经支气管镜肺活检组织病理符合过敏性肺炎。经停用来氟米特、甲氨蝶呤,给予甲泼尼龙、更昔洛韦、对症支持等综合治疗,10d后患者症状完全缓解,外周血巨细胞病毒DNA降至正常范围,CT示双肺病灶几乎完全吸收。结论来氟米特相关过敏性肺炎症状体征无特异性,CT以双肺弥漫性分布的边缘模糊的小叶中央型结节、斑片状、磨玻璃状影及空气潴留为特点,可合并巨细胞病毒感染,甲泼尼龙、更昔洛韦疗效好。来氟米特治疗类风湿关节炎应选择合适的患者,警惕间质性肺病及机会性感染的发生,一旦疑诊,即应尽早取得病理诊断、给予合理治疗,提高治愈率,改善预后。

Objective To learn the clinical characteristics of leflunomide associated hypersensitivity pneumonitis,as to improve the ability of the physicians in dealing with the disease,and to obtain a better outcome for the patients.Methods Report a case of hypersensitivity pneumonitis with the course of its diagnosis and therapy,which was associated with leflunomide in a rheumatoid arthritis (RA) patient.Then review the literatures.Results A 34-year-old woman was hospitalized for cough,progressive dyspnea and fever.She had been diagnosed RA for 4 years and had been treated with leflunomide and methotrexate for 2 years.Empiric antibiotic treatment was not effective.Diffuse centrilobular nodules with edge unsharped,patchy ground glass opacities and air trapping were seen on CT scan.The white cells of her peripheral blood was decreased.The amount of cytomegalovirus (CMV) DNAs was increased.The pulmonary function tests showed a severe impairment of the ventilation function and diffusion capacity for CO along with signs of a severe obstructive and restrictive pulmonary disease.And respiratory failure was achieved.Transbronchial lung biopsy showed the histopathology pattern of hypersensitivity pneumonitis.The patient was treated with methylprednisolone and ganciclovir,with leflunomide and methotrexate disused.She was recovered 10 days later with the CMV DNAs returned to the normal range and the abnormalities on CT scan absorbed premodinantly.Conclusions The symptoms of leflunomide associated hypersensitivity pneumonitis were common.It was characterized by diffuse centrilobular nodules with edge unsharped,patchy ground glass opacities and air trapping on CT scan.It could be complicated with CMV infections.Methylprednisolone and ganciclovir were effective.It's important to chose a fitting RA patient for leflunomide,and to be alerted with interstitial lung disease and opportunistic infections.Once interstitial lung disease was suspected,the histopathology diagnosis should be achieved as early as possible,as to provide proper treatment protocols leading to a better outcome.