异基因造血干细胞移植后的巨细胞病毒肠炎24例分析

Cytomegalovirus enteritis after allogeneic hematopoietic stem cell transplantion

目的分析异基因造血干细胞移植（allo—HSCT）后巨细胞病毒（CMV）肠炎的临床特点、诊断方法和危险因素。方法总结北京市道培医院2007年8月至2009年7月确诊的24例CMV肠炎患者的一般临床资料和内窥镜、组织病理学和病毒学检查结果，以及CMV肠炎与CMV病毒血症和移植物抗宿主病（GVHD）的关系。结果87．5％的患者年龄≥18岁，诊断CMV肠炎的中位时间为allo—HSCT后第63天。内窥镜下的肠黏膜表现对区分单纯CMV肠炎和肠炎合并GVHD没有鉴别意义。用于诊断的方法包括组织病理学（32．1％）和病毒学（92．9％）检查。肠黏膜标本中每10。个单个核细胞的CMVDNA定量大于10^5时更有诊断价值。在死亡和存活两组患者中进行了下列危险因素的比较：移植类型、预处理方案、更昔洛韦预防病毒天数、确诊肠炎前有无Ⅱ～Ⅳ度急性GVHD、GVHD确诊时间、是否使用≥1mg／kg的甲泼尼龙治疗GVHD、GVHD距离确诊肠炎的时间、肠炎前是否有CMV血症、确诊肠炎的时间、肠黏膜CMVDNA定量，差异均无统计学意义。结论进行内窥镜检查并通过组织病理学和病毒学检查确诊是CMV肠炎诊断中的决定性因素，最好进行全结肠检查并到达回肠末端。PCR方法能明显提高CMV检出率。对那些无法进行肠镜检查的患者，采用粪便检测CMVDNA能够对诊断提供帮助。

Objective To analyse the clinical features, diagnostic methods and risk factors of eyto- megalovirus（CMV） enteritis after allogeneic hematopoietic stem cell transplantation（allo-HSCT）. Methods Analysis was made on 24 cases of CMV enteritis after allo-HSCT in Beijing Daopei Hospital from Aug. 2007 to Jul. 2009, including clinical data, endoscopic diagnosis, histopathological and virological results, and the association between CMV enteritis with viremia and graft-versus-host disease（GVHD）. Results 87.5% of the patients were over 18 years old. The median time to diagnosis of CMV enteritis was 63 days after HSCT. The mucosal lesions in enteroscopic examination had no significant differences between CMV enteritis and gastrointestinal GVHD complicated with the enteritis. The methods used in diagnosis included histopathology （32.1%） and virology （92.9%）. The copies of CMVDNA in mucosal samples greater than 105/106 PBNC was better diagnosis. A number of risk factors were compared between the survival and death groups ： type of transplant, conditioning regimen, the time span of gancielovir prophylaxis therapy, grade Ⅱ- ⅣGVHD before enteritis, the time of diagnosis as GVHD, using MP≥ 1 mg/kg to treat GVHD, the time between GVHD and enteritis, CMV viremia before enteritis, the time of diagnosis as enteritis, CMVDNA quantitation, and there were no any statistic differences. Conclusion Cytomegalovirus enteritis should be carefully diagnosed by histopathology and virology through endoscopic examination. It is better to undertake pan-colon endoscopy as well as terminal ileum examination for more accurate diagnosis. PCR can significantly improve the detection rate. CMVDNA detection in patients＇ stool may be helpful to diagnosis, especially for those patients who can not stand the endoscopy examination.