山东济宁^60Co辐射事故受照人员的临床救治

Medical management of irradiated patients in a radiation accident in Jining, Shangdong Province

目的总结和探索肠型放射病和极重度骨髓型放射病临床诊治经验。方法中国山东济宁^60Co辐射事故中2例病人受到意外照射。综合估算，病例A受照剂量20～25Gy，诊断为“肠型放射病”；病例B受照剂量9～15Gy，诊断为“极重度骨髓型放射病”。经联合预处理，2例分别行单倍体和HLA相合外周血造血干细胞移植。结果2例患者均移植成功，供体完全植活，三系血细胞和骨髓造血重建成功，均无移植排斥和移植物抗宿主病。病例A于照后33d（d33）死于败血症和多脏器功能衰竭，病例B于d75死于心衰为主的多脏器功能衰竭。结论骨髓和外周血染色体及牙齿ESR检查等对超大剂量放射病诊断有重要价值。HLA相合及半相合外周造血干细胞移植救治急性放射病是完全可能和可行的。感染和多脏器功能衰竭仍然是病人的主要死亡原因。应加强对促进辐射损伤修复和多脏器功能衰竭的救治研究。

Objective To summarize the experience of diagnosis and treatment from the extremely severe bone marrow form of acute radiation sickness and intestinal form of acute radiation sickness. Methods A nuclear accident occurred in China on October 21 st, 2004. Two individuals were accidentally irradiated by a ^60 Co source. The two patients were estimated at more than 20-25 Gy and 9-15 Gy of γ-rays exposures, respectively, and were diagnosed as the intestinal form of acute radiation sickness （patient A） and the extremely severe bone marrow form of acute radiation sickness （patient B）, respectively. After urgent preparative regimen based on low- dose fludarabine, antilymphocyte globulin and cyclophosphamide, the two patients received HLA-haploidentical （patient A） or HLA-identical （patient B） peripheral blood stem cell transplantation （PBSCT）, respectively. Cyclosporin A combined mycophenolate mofetil regimen was used for the prevention of graft-versus-host disease （GVHD）. Bone marrow mesenchymal stem cells from donor were injected to bone marrow of patient A additionally. Results Both peripheral blood and bone marrow examinations showed hemopoietic recovery after PBSCT. Neither of the two patients showed obvious clinical signs specific to GVHD. Patient A died of septicemia and multi-organ failure on the 33rd day after exposure, while patient B died of multi-organ failure with predominant heart failure on the 75th day after exposure. Conclusions Chromosome analysis of bone marrow and peripheral blood, and electron spin resonance measurement of tooth enamel play a very important role in diagnosis of the very high dose radiation disease. It is possible and feasible to treat acute radiation sickness using HLA-haploidentical or HLA-identical PBSCT. The death of patients is mainly due to infection and multi-organ failure.