激素治疗并发重症肺部感染患者的临床分析

Severe pulmonary infection as a complication of glucocorticosteroids therapy in patients with nephrotic syndrome

目的:探讨肾病综合征(NS)患者糖皮质激素(GC)治疗后并发重症肺部感染的临床特点。方法:选取2011年4月至2012年4月南京军区南京总医院全军肾脏病研究所ICU收治的11例在GC治疗后并发重症肺部感染和急性呼吸窘迫综合征(ARDS)的NS患者,回顾性分析其临床特点,GC治疗剂量及疗效,肺部感染的临床表现,免疫功能、病原学特点、治疗经过和预后。结果:11例患者中男7例、女4例,平均年龄28.5±12.7岁(16～50岁),均予足量GC诱导治疗,其中甲泼尼龙8例(48mg/d),泼尼松3例(50～60mg/d)。GC治疗8周内均达到完全缓解予减量,但在GC治疗13±2周时并发重症肺部感染,以发热和胸闷为首发症状,体温达39.9±0.8℃(38.9～41.2℃),伴咳嗽、少痰。病情进展急剧,突出表现为呼吸困难,氧合指数均<200,平均117.7±42.1(57.5～200)。病初肺部体征少,无明显干湿啰音,胸部CT或胸片提示双肺弥漫性间质性炎症。体液免疫检查示血清IgG、IgM正常,而细胞免疫功能低下,外周血淋巴细胞总数偏低(538.8±165.5/μl),其中CD4+T淋巴细胞计数明显减低,为133.3±45.4个/μl。病原学检查阳性率低,影像学检查提示间质性肺炎,临床疑诊为耶氏肺孢子虫肺炎。患者均予辅助机械通气、复方磺胺甲噁唑联合米卡芬净、甲泼尼龙及抗感染、对症支持治疗,6例行连续性肾脏替代治疗(CRRT),1例联合体外膜肺氧合(ECMO)治疗,最终8例痊愈,3例死亡或放弃;平均ICU住院时间为18±7d(11～33d),平均总住院时间24±14d(13～55d)。结论:激素治疗敏感的NS患者,在肾脏病完全缓解、激素减量过程中仍可继发严重细胞免疫缺陷和重症肺部感染,病情进展快且病死率高,需引起重视。

Objective：To investigate the clinical features of severe pulmonary infection in patients treated with glucocorticosteroids for their renal injury. Methodology：Eleven patients with nephrotic syndrome who admitted to ICU because of severe pulmonary infection as well as ARDS was retrospectively reviewed. The clinical features of renal injure, time and efficacy of GC therapy, the clinical manifestations of pulmonary infection, immune function, pathogenic characteristics,treatment through and prognosis were investigated. Results：They were 7 males and 4 females with an average age of 28.5± 12. 7 years old ranged froml6 to 50. All patients with biopsy-proved podocytopathy, Among them, 8 cases used full-dose methylprednisolone （48 mg/day） ,and 3 cases used prednisone （50 to 60 mg/day）. At the 8th week, 11 patients （100%） had total remission. However, all of them developed pulmonary infection after taking glucocorticosteroids within 9 -16 weeks,with an average time of 13 ±2 weeks. They complained of progressive dyspnea and fever,cough and a little white sputum. Their temperature was higher at 39. 9 ± 0. 8℃ （38. 9 to 41.2℃）. Rapid progression was observed in the patients, with difficulty breathing and severe bypoxemia as the significant symptoms. The oxygenation indices were below 200 with an average of 118 ±42. 1 （57.5 to 200）. Coarse breath sounds was heard initially and a few wet and dry tales later onlung auscultation. Chest CT or chest radiography was suggestive of bilateral diffuse interstitial inflammation. Laboratory examination revealed a lower level of cellular immune function and reduced count of peripheral blood lymphocytes （539 ± 166μ1）, as well as significantly decreased CIM- ＋ T lymphocyte count at （133 ± 45.4）μ1, lgG and IgM levels were with the normal range. All patients were given suspected diagnosis of pneumocystis carinii pneumonia and need ventilatory support therapy. The triple therapy of antiinfection drugs was SMZ, micafungin and methylprednisolone. Six patients required continuous renal replacement therapy （CRRT） ,one of them given extracorporeal membrane oxygenation therapy （ECMO）. After therapy,g（72.7% ） patients recovered and 3 （27.3%） died or gave up treatment. The average ICU stay was 18 ±7.0 days （11 to 33） ,and the overall average length of stay （24± 14） days （ 13 to 55 ）. Conclusion： steroid-sensitive patients who were treat with glucoeorticosteroids for their podocyte injury may appears severe puhnonary infections even though they had complete remission. Regard to immunodeficiency, the disease can rapidly progress and mortality is high.