溃疡性结肠炎合并巨细胞病毒感染的临床特点分析

Clinical features analysis of ulcerative colitis complicated with cytomegalovirus infection

目的分析UC合并巨细胞病毒（CMV）感染患者的临床特征、临床结局和预测因素。方法纳入2004年5月至2014年11月诊断为UC且筛查过CMV感染的120例住院患者，筛选出31例中重度UC合并CMV感染患者。分析UC合并CMV感染患者的人口学资料、临床特征、内镜下表现、治疗等情况，并与同期住院的CMV筛查阴性的60例中重度UC患者进行比较。使用Mann-Whitney U检验等进行统计学分析，并应用Logistic回归分析UC并发CMV感染的危险因素。结果120例UC患者中，轻度或缓解期29例，CMV筛查均阴性；中重度91例，其中CMV感染31例（34.1%），31例中20例为糖皮质激素难治。31例UC合并CMV感染患者的中位年龄为39岁（22岁，51岁），中位病程为24.0月（6.0月，42.0月），短于未合并CMV感染患者的36.0月（13.5月，84.0月），差异有统计学意义（U＝639.5，P＝0.015）；广泛结肠型23例（74.2%），重度26例（83.9%），均多见；29例（93.5%）曾使用糖皮质激素治疗，12例（38.7%）曾使用免疫抑制剂治疗，6例（19.4%）曾使用英夫利西单克隆抗体治疗。与UC未合并CMV感染患者相比，UC合并CMV感染患者的发热、腹痛、体质量下降多见，且5例出现肝功能轻度异常，内镜下表现为纵行溃疡、不规则溃疡、深大溃疡、凿洞样溃疡和虫蚀样溃疡等。25例采用糖皮质激素治疗的UC合并CMV感染患者中，11例（44.0%）无效；39例采用糖皮质激素治疗的UC未合并CMV感染患者中，8例（20.5%）无效；前者需行补救治疗的比例高于后者，差异有统计学意义（χ^2＝4.026, P＝0.045）。多因素Logistic回归分析显示，Hb≥100 g/L（OR＝0.144, 95%CI0.040～0.516, P＝0.003）是CMV感染的保护因素，发病前1个月使用糖皮质激素（OR＝8.946, 95%CI 2.459～32.541, P＝0.001）是CMV感染的危险因素。结论使用糖皮质激素和免疫抑制剂治疗的UC患者易合并CMV感染，而CMV感染可加重UC的病情，对于这类患者，应注意筛查并监测CMV感染，及时进行抗病毒治疗。

Objective To analyze the clinical features, clinical prognosis and predictive factors of ulcerative colitis （UC） complicated with cytomegalovirus （CMV） infection. Methods From May 2004 to November 2014, 120 hospitalized patients diagnosed as UC and screened for CMV infection were enrolled. A total of 31 patients with moderate to severe UC accompanied by CMV infection were screened out. Demographics, clinical features, endoscopic appearance and treatment of patients with UC complicated with CMV infection were analyzed, and compared with 60 moderate to severe UC patients without CMV infection at the same period of hospitalization. Mann Whitney U test was performed for statistical analysis. Logistic regression analysis was used to analyze risk factors of UC complicated with CMV infection. Results Among 120 patients with UC, 29 were mild or in remission period, whose CMV screening tests were all negative. Ninety-one were moderate to severe, 31 patients （34.1%） of them had CMV infection, and 20 of 31 patients were steroid-refractory. Among the 31 patients with UC complicated with CMV infection, median age was 39 years （22 years, 51 years）, median disease duration was 24.0 months （6.0 months, 42.0 months） which was shorter than that of patients without CMV infection （36. 0 months （13.5 months, 84.0 months））, and the difference was statistically significant （U=639.5, P=0. 015）. A total of 23 patients （74.2%） had extensive colitis and 26 patients （83.9%） had history of severe colitis. A total of 29 patients （93.5 %） had history of corticosteroids treatment, 12 patients （38.7 %） had history of immunosuppressive agents treatment, and six patients （19.4 %） had history of infliximab treatment. Compared with UC patients without CMV infection, fever, abdominal pain and weight loss were more common in UC patients with CMV infection. Five CMV-infected patients had mild liver dysfunction. Endoscopic appearance was longitudinal ulceration, irregular ulceration, large deep ulceration, punchedout ulceration and worm-like ulceration. Among the 25 CMV infected patients who were treated with corticosteroids, 11 patients （44.0%） had no response. Among the 39 CMV-negative patients who were treated with cortieosteroids, eight patients （20.5%） had no response. The rate of patients who needed rescue therapy of the former was higher than that of the latter, and the difference was statistically significant （χ^2=4. 026, P=0. 045）. The results of multivariate Logistic regression analysis showed that hemoglobin over 100 g/L（OR=0. 144, 95M confidence interval （CI） 0. 040 to 0. 516,P=0. 003） was a protective factor of CMV infection, however corticosteroids use within a month before the onset （OR= 8. 946, 95%CI 2. 459 to 32. 541, P=0. 001） was a risk factor. Conclusions UC patients treated with eortieosteroids and immunomodulator therapy may predispose UC patients to CMV infection, on the other hand, CMV infection can exacerbate the severity of UC. CMV infection should be screened and monitored in UC patients, and anti-viral therapy should be taken in time in case of CMV infection.