白血病患者巨细胞病毒性视网膜炎的临床特点和疗效观察

Clinical characteristics and treatment of cytomegalovirus retinitis in leukemia

目的 观察白血病患者合并巨细胞病毒（CMV）性视网膜炎（CMVR）的临床特征和疗效。 方法 回顾性病例分析。临床检查确诊的白血病合并CMVR患者7例13只眼纳入研究。其中，男性5例10只眼，女性2例3只眼；平均年龄（33.20±20.37）岁。造血干细胞移植手术后6例，慢性粒细胞白血病1例。均有CMV-DNA血清阳性病史。行造血干细胞移植手术的6例患者中，伴有不同程度排斥反应4例，均口服或静脉滴注糖皮质激素治疗；无排斥反应，未使用糖皮质激素治疗2例。慢性粒细胞白血病的1例患者，行化学药物治疗18次，长期服用苯丁酸氮芥和糖皮质激素治疗。患者均行最佳矫正视力（BCVA）、裂隙灯显微镜、间接检眼镜、眼底彩色照相检查，以及外周血CD4＋T细胞计数。给予全身静脉滴注更昔洛韦或膦甲酸联合玻璃体腔注射更昔洛韦治疗。治疗后随访3～14个月。 结果 7例13只眼中，双眼者6例12只眼，单眼者1例1只眼。BCVA手动～1.0。所有患眼眼前节均可见角膜后沉着物、Tyndall。手术后未合并排斥反应、未使用糖尿病皮质激素治疗者4只眼，玻璃体明显混浊；视网膜下方可见黄白色浸润灶，血管呈白线状。合并排斥反应及慢性粒细胞白血病者9只眼，玻璃体均轻度混浊。其中，视网膜不规则黄白色坏死灶及放射状出血7只眼；视网膜中度颗粒状灰白色混浊斑、未见出血及血管鞘2只眼。治疗后视网膜病灶消退，出血明显吸收；治疗时未发生视网膜脱离、视网膜出血或视神经毒性等与治疗方式和药物相关的并发症。7例患者中，死亡3例，失访1例。 结论 白血病合并CMVR主要表现为进行性坏死性视网膜炎，多伴有出血及血管炎。静脉给予更昔洛韦和（或）膦甲酸联合玻璃体腔注射更昔洛韦有效治疗白血病合并CMVR。

Objective To observe the clinical characteristics and treatment of cytomegalovirus retinitis （CMVR） in leukemia patients. Methods This is a retrospective analysis. Seven leukemia patients （13 eyes） with CMVR were studied. All patients underwent examinations of visual acuity, slit lamp microscope, ophthalmoscope, color fundus photography, peripheral blood CD4＋T cell count and serum/aqueous CMV-DNA test. All patients were treated with ganciclovir or zoledronic acid combined with intravitreal injection of ganciclovir. The follow-up period was 3-14 months. Results Six patients were treated with hematopoietic stem cell transplantation and 1 patient was with chronic leukemia. All patients were CMV-DNA positive for serum, and 18.5% （2/7） for aqueous humor. CMVR in leukemia patients showed mild anterior segment inflammation, ocular fundus with irregular yellowish-white retinal necrosis and radial hemorrhage （7 eyes）. Some （2 eyes） also shoed gray and white granular retinal infiltrates. Intravenous ganciclovir/zoledronic acid combined with intravitreal injection of high concentration ganciclovir was an effective treatment, while systemic corticosteroids were effective in reducing vitreous opacity. Conclusions CMVR is characterized by progressive necrotic retinitis with hemorrhage and vasculitis. Intravenous ganciclovir/zoledronic acid combined with intravitreal injection of ganciclovir is effective in the treatment of CMVR with leukemia.