替比夫定少见不良反应:横纹肌溶解症

An unusual reaction to telbivudine:rhabdomyolysis

1例26岁男性患者,因双下肢肌痛、胸闷和心悸入院治疗。患者入院时尿少,呈酱油色,BP 80/50 mm Hg,HR 120次/min。实验室检查:CK906 U/L,CK-MB 100 U/L,ALT310 U/L,AST369 U/L;尿常规:WBC 1 493.2/μl,RBC 193.1/μl,管型65/μl,病理性管型(+),胆红素(++),潜血(++),蛋白(++),比重1.030;血气分析:pH值6.9,PO264 mm Hg。考虑为代谢性酸中毒,给予5%碳酸氢钠静脉滴注。追问病史,患者有慢性乙型肝炎史,并服用替比夫定600 mg,1次/d,共11个月余。查血肌红蛋白>500 ng/ml,诊断为替比夫定相关横纹肌溶解症。给予血液滤过,甲泼尼龙及其他对症治疗,并停用替比夫定,改为恩替卡韦。住院第2天,患者CK峰值为1300 U/L,CK-MB 61 U/L,ALT512 U/L,AST579 U/L。4 d后尿量恢复正常,肾功能逐渐恢复正常。住院第12天,患者双下肢肌痛明显好转,四肢肌力达Ⅳ级,CK 144 U/L,CK-MB 15.1 U/L,ALT57 U/L,AST34 U/L,电解质正常。

A 26-year-old man was hospitalized with myalgia in his lower extremities, chest distress and palpitation. On admission, he had oliguria, dark urine, a BP of 80/50 mm Hg, and a heart rate of 120 beats/min. Laboratory test results were as follows： CK 906 U/L, CK-MB 100 U/L, ALT 310 U/L, AST 369 U/L. Urinalysis revealed the following results： WBC count 1493.2μl, RBC count 193. 1/μl, cast 65/μl , pathologic cast （ ＋ ）, bilirubin （ ＋ ＋ ）, occult blood （ ＋ ＋ ）, protein （ ＋ ＋ ）, specific gravity 1. 030. Blood gas analysis revealed a pH of 6.9 and a PO2 of 64 mm Hg, which was considered to be metabolic acidosis. An IV infusion of sodium bicarbonate 5% was given. A review of his medical history showed that he had a history of chronic hepatitis B and received telbivudine 600 mg once daily for 11 months and more. Laboratory test showed his blood myoglobin level was more than 500 ng/ml. The man was diagnosed with telbivudine-associated rhabdomyolysis and treated with hemofihration, methylprednisolone, and symptomatic therapy. Telbivudine was discontinued and changed to entecavir. The second day of hospitalisation, he had a peak CK level of 1300 U/L, a CK-MB level of 61 U/L, a ALT level of 512 U/L, and a AST level of 579 U/L. Four days later, his urine volume normalized, renal function gradually returned to within normal ranges. On day 12 of hnspitalisation, his myalgia in the lower extremities markedly improved and his muscle strength recovered to grade Ⅳ ; he had a CK level of 144 U/L, a CK-MB level of 15.1 U/L, a ALT level of 57 U/L, a AST level of 34 U/L, and normal electrolyte levels.