肺泡灌洗液病毒检测对造血干细胞移植后肺炎患者临床诊治的意义

Clinical value of PCR for viral detection of bronchoalveolar lavage fluid in the diagnosis and treatment of pneumonia after allogeneic hematopoietic stem cell transplantation

目的探讨肺泡灌洗液（BALF）病毒检测在异基因造血干细胞移植（allo-HSCT）后常规病原学检查阴性肺炎患者诊治中的意义。方法回顾性分析2015年5月至2017年3月行allo-HSCT后出现肺部病变，并行支气管镜检查有完整BALF病原学检查结果的患者临床资料，比较单纯病毒检测阳性患者与所有病原学检查阴性患者的临床特点及转归。结果71例患者因发生肺部病变行BALF病原学检查。临床诊断单纯病毒相关性肺部病变15例（检出率为21．13％），未发现任何病原学证据患者19例，两组肺部病变中位发生时间分别为移植后176（49～1376）d和移植后196（57～457）d（z=-0．191，P=0．864），两组患者在一般临床情况及表现上差异均无统计学意义。肺炎发病后100d肺炎的归因死亡率分别为13．3％（2／15）和26．3％（5／19）（z=0．864，P=0．426），应用大剂量糖皮质激素（等效剂量≥250mg／d甲泼尼龙）治疗的患者与未用激素或应用常规剂量激素组患者的死亡率分别为60．0％（6／10）和4．2％（1／24）。病毒检出组2例死亡患者均为早期应用大剂量糖皮质激素，而11例未用激素或晚期应用患者均存活。结论对于allo-HSCT后常规病原学检查均阴性的肺炎患者，应重视病毒感染的可能，BALF病毒检查可提高诊断率，并对治疗有指导意义。

Objective To analyze the clinical value of real-time PCR for virus detection in the diagnosis and treatment of patients after allo- HSCT who had no infection evidence of pneumonia using routine pathogen detection panel. Methods The clinical data of 71 episodes with acute lung injury from May 2015 to March 2017 after allo-HSCT in hematology department of Peking University People＇ s Hospital （PKUPH） were retrospectively analyzed. PCR for virus detection and other routine pathogen detection tests were performed on bronchoalveolar lavage fluid （BALF） samples. Results Among 71 episodes with acute lung injury, a total of 15 patients were diagnosed as lower respiratory tract disease merely associated with virus （detection rate of 21,13% ）, 19 episodes were absent of lower respiratory tract infection. The median time from allo-HSCT to the occurrence of lung injury were 176 （49-1 376） d and 196 （57-457） d respectively （z=-0.191, P= 0.864）. There were no statistical differences for baseline characteristics and clinical features between two groups. The 100-day attributable mortalities were 13.3% （2/15 ） and 26.3 % （ 5/19 ） （y2 = 0.864, P = 0.426）. Patients with low- dose steroids treatment had favorableoutcome than those with high-dose steroids treatment （the dose of methylprednisolone≥250 mg/d as standard） [4.2% （1/24） vs 60.0% （6/10）]. In patients with detectable virus in BALF, 2 patients died with early high-dose steroids treatment, while 11 patients survived with no steroids treatment or late application. Conclusions Virus infection should he considered in post-HSCT pneumonia patient with negative result using routine pathogen detection panel. Expanding virus detection panel by PCR in BALF could increase diagnostic precision and might be instructive to treatment.