重症肝损伤在幼年特发性关节炎全身型并发巨噬细胞活化综合征中的诊断意义

Severe hepatic injury for predicting the development of macrophage activation syndrome in systemic juvenile idiopathic arthritis

目的 通过分析10例以重症肝损伤为特征的继发于幼年特发性关节炎全身型（soJIA）的巨噬细胞活化综合征（MAS）的临床资料,提高对该病的认识水平.方法 回顾性分析南京医科大学附属南京儿童医院风湿免疫科10例继发于soJIA的MAS（soJIA/MAS）患儿临床资料,包括MAS临床表现、实验室特征、治疗及预后,并综合文献进行分析讨论.结果 10例患儿女性6例,发生MAS的年龄为1.5 ～9.5岁,平均（5.2±2.6）岁.发生MAS时10例患儿均无全身症状,以重症肝损伤为突出表现.其中肝肿大10例,脾肿大2例,所有患儿肝功能指标显著升高（中位数：ALT 1 445 U/L,AST 885 U/L）,总胆红素增高（中位数145.5μmol/L）,其中2例并发中枢神经系统功能障碍,2例伴皮肤黏膜出血,2例合并肺部感染.10例血小板计数均低于正常值或预警值（≤262×10^9/L）,10例血清铁蛋白明显升高（中位数：17 329 mg/mL）,5例（5/5）可溶性CD25（中位数：3 140 U/ml）显著升高.9例患儿骨髓穿刺可见到组织细胞和吞噬现象,1例行肝穿刺活检提示汇管区炎症和大量单核细胞浸润.9例患儿给予大剂量激素冲击、丙种球蛋白和环孢霉素A治疗,8例患儿治疗后好转,2例患儿随访12个月后发生严重肺间质病变.结论 soJIA出现重症肝损伤同时伴有血小板降低等其他实验室指标异常,应警惕发生MAS,给予大剂量激素冲击和环孢霉素治疗可改善soJIA/MAS预后.

Objective To analyze the clinical features and laboratory data of 10 patients with macrophage activation syndrome （MAS） complicating systemic onset juvenile idiopathic arthritis （soJIA）,which were characterized by acute severe liver injury.Methods Data of 10 patients with soJIA/MAS from Nanjing Children＆#39;s Hospital were collected retrospectively.The clinical features,laboratory findings,treatment,outcomes and prognosis were analyzed.Results In the total 10 patients,female （6/10） outnumbered male.Their age ranged from 1.5 to 9.5 years old （average 5.2＆#177;2.6）.The most remarkable clinical manifestations were severe liver injury without systemic features,representing as hepatomegaly （10/10）,splenomegaly （2/10） and strikingly increased transaminase （10/10,median：ALT 1 445 U/L,AST 885 U/L）.Central nervous system dysfunction and hemorrhages were recorded in 20% of the patients.Two patients had pulmonary infection.Laboratory data showed that platelet count was less than normal or precaution value （10/10,≤262＆#215;10g/L）.Hyperferritinaemia （10/10,median：17 329 mg/ml） and soluble CD25 elevation （median：3 140 U/ml） were common in the soJIA/MAS patients.Evidence of macrophage hemophagocytosis was found in 90% of the patients （9/10） who underwent bone marrow aspiration.Pathological findings of liver biopsy from 1 patient revealed massive infiltration of mononuclear cells in the portal tracts.Nearly all patients （9/10） received intravenous pulse methylprednisolone therapy,combined with cyclosporine A and high-dose intravenous immunoglobulin.Eight patients had good outcome.Only 2 patients were complicated with severe interstitial lung disease during 12-months follow-up.Conclusion MAS should be considered when patients with soJIA represents acute severeliver injury without systemic features combined with other laboratory data.Intravenous pulse methylprednisolone and cyclosporine A therapy may improve the prognosis of soJIA/MAS.