全球首例甲型H10N8禽流感病毒感染导致重症肺炎死亡病例分析

A report of first fetal case of H10N8 avian influenza virus pneumonia in the world

目的报告全球首例人感染甲型H10N8禽流感病例的救治经过，对比其与人感染H7N9禽流感的病例特点，给临床诊疗提供依据。方法2013年11月30日江西省南昌市出现首例人感染甲型H10N8禽流感死亡病例，分析其临床病症及流行病学调查，并与以往人感染H7N9禽流感的临床病症进行比较分析。结果73岁女性患者，因咳嗽、咳痰、胸闷3d，发热1d，于2013年11月30日入住南昌大学第三附属医院呼吸科；12月2日因病情加重转入重症医学科重症监护病房（ICU）；12月5日病情进展出现器官功能衰竭（MOF）；12月6日08：30出现心脏停搏，抢救无效死亡。①流行病学调查：该患者为老年人，有多种慢性病（高血压、冠心病、重症肌无力等）、免疫功能受损（胸腺瘤切除术后）等易感因素；且在就诊前1周有活禽经营市场暴露史，发病前患者家中有感冒症状者；传播途径为经呼吸道传播，与人感染H7N9禽流感相似。②临床表现：该患者有流感样症状，如咳嗽、发热（39．1℃），但没有头痛、肌肉酸痛，2-3d出现重症肺炎并进行性加重，伴呼吸窘迫，从气管插管内吸出大量血水样痰（2000mL／24h），病情迅速进展，出现急性肾损伤、急性呼吸窘迫综合征（ARDS）、脓毒性休克及意识障碍等，与人感染H7N9禽流感相似。③辅助检查：该患者除淋巴细胞比例降低（0．070）、天冬氨酸转氨酶（AST）轻度升高（57u／LJ）、C-反应蛋白（CRP）升高（〉200mg／L）外，血小板、肌酸激酶、乳酸脱氢酶、丙氨酸转氨酶、肌红蛋白均不升高，白细胞总数略升高（10．34x109／L），这与人感染H7N9禽流感病例特征不相符。肺部感染实变影进行性扩展；与H7N9禽流感一致。④诊疗：依据患者临床表现、肺部感染实变影进行性增大、有流行病学史，故考虑甲型禽流感可能。虽然在早期就给予治疗量的奥司他韦抗病毒，以及积极的呼吸、循环支持和抑制免疫反应等综合治疗，但患者最终因呼吸衰竭、休克而死亡。⑤经中国疾病预防控制中心（CDC）证实，该患者为甲型H10N8禽流感，与该患者密切接触者经南昌市及中国CDC多次筛查均未感染。结论人感染甲型H10N8禽流感与人感染H7N9禽流感并不完全雷同，很难从传统的实验室指标得到提示；临床病症及流行病学史是诊断的要件。参照人感染H7N9禽流感治疗方案给予神经氨酸酶抑制剂治疗H10N8禽流感患者并未逆转肺部的恶化进程。中国CDC检测发现甲型H10N8禽流感病毒导致人感染和传播的风险低。

Objective To report the treatment process of the first case of human pneumonia resulted from HION8 avian influenza virus infection in the world for providing the data for clinical diagnosis and treatment. Methods On November 30, 2013, the first case of human infection with HION8 avian influenza virus was discovered in Nanchang City, Jiangxi Province. Its clinical symptoms and epidemiology were analyzed and compared with the characteristics of human infection with H7N9 avian influenza virus. Results A 73-year old female patient complaining of cough and chest tightness for 3 days and fever for 1 day was admitted to the Department of Respiratory Diseases of the Third Affiliated Hospital of Nanchang University on November 30, 2013. As the illness became worse, the patient was transferred into Intensive Care Unit （ ICU ） of the Department of Critical Care Medicine on December 2. The patient＇s condition deteriorated, manifesting multiple organ failure （MOF） on December 5. At 08：30 on December 6, cardiac arrest occurred, and the patient died after inefficient resuscitation. ① Epidemiological investigation ： the patient was an elderly woman, suffering from a variety of chronic diseases （hypertension, coronary heart disease, myasthenia gravis, etc ） and impaired immune function （undergone thymectomy）, all of them were predisposing factors for deterioration of her health. She had visited the live poultry market one week before admission, and developed symptoms of influenza. The transmission route was the respiratory tract, which was similar to H7N9 avian influenza. ② Clinical manifestations： the patient had flu-like symptoms, such as cough and fever （39.1 °C ）, but no headache or myalgia. Two days later pneumonia accompanied with respiratory distress developed and a large amount of bloody sputum was sucked out throughtracheostomy tube （2 000 mL/24 h ）. Acute kidney injury, acute respiratory distress syndrome （ARDS）, septic shock, and unconsciousness occurred, all of which was consistent with the diagnosis of H7N9 avian influenza. ③ Auxiliary examination： with the exception of a decrease in lymphocyte ratio （0.070）, aspartate aminotransferase （AST） was slightly increased （57 U/L）, C- reactive protein （CRP） was elevated （〉200 rag/L）, but the platelet count, creatine kinase, lactate dehydrogenase, alanine aminotransferase and myoglobin were not increased, while leucocyte count was increased slightly （ 10.34 ~ 109/L）. The changes in above indexes did not match the characteristics of H7N9 avian influenza. However, the aggravated consolidation of the lung conformed to that of H7N9 avian influenza. ④ Diagnosis and treatment： according to the clinical manifestations, aggravation of consolidation of the lung, and epidemiological evidence, the diagnosis of avian influenza was considered. Though therapeutic dose of osehamivir was given as antiviral treatment for the early therapy, and other therapeutic measures such as energetic respiratory and circulatory support, and immunosuppressant therapy were given, the patient eventually died from respiratory failure and shock. ⑤ The Chinese disease prevention and control center （CDC） confirmed that, the patient was infected H 10N8 avian influenza virus. No person with close contact with the patient was infected, as screened by Nanchang City and Chinese CDC. Conclusions Human infection with H10N8 avian influenza was not exactly the same as that of HTN9. It was difficult to get true information from the conventional laboratory examinations, while the clinical characteristic and epidemiology were essential for the diagnosis. Referring to the treatment regime for human infection with H7N9 avian influenza virus, therapeutic dose of neuraminidase inhibitors could not reverse deterioration of pulmonary pathology. Chinese CDC found that the risk of human infection and transmission of H10N8 avian influenza virus through personal contact was low.