输入性恶性疟疾重症病例研究

Research on severe cases of imported falciparum malaria

目的研究输入性恶性疟疾重症病例的临床表现、诊断及治疗。方法对2009年11月—2018年3月收治的89例输入性恶性疟疾重症病例的流行病学资料、临床特点、诊断方法、治疗措施进行总结。统计流行病学资料;统计发热、寒战、肌肉疼痛、头痛等患者占所有病例的百分比;统计贫血、黄疸、少尿或无尿、肝脾肿大、意识障碍等患者占所有病例的百分比;依据WHO第三版重症疟疾标准对所有病例进行评估;统计各分型病例占所有病例的百分比;了解显微镜下疟原虫密度、形态;采用疟疾快速诊断试剂(胶体金法),进行检测,并与显微镜镜检结果进行比较分析;对照青蒿素类药物蒿甲醚与青蒿琥酯的疗效;总结血液透析、血液灌流、血浆置换、血浆吸附例数。结果全部病例均有国外生活史及蚊虫叮咬史。所有患者均有不同程度的发热(100.0%),寒战、肌肉疼痛、头痛患者分别占所有病例的96.6%、94.4%、92.1%;贫血、黄疸、少尿或无尿、肝脾肿大、意识障碍分别占100.0%、79.8%、30.3%、28.1%、11.2%;分型以急性肝损伤、高原虫血症、急性肾功能衰竭多见,分别占79.8%、62.9%、30.3%。所有病例外周血涂片入科前均查到疟原虫,环状体(小滋养体)73例(82.0%),大滋养体14例(15.7%),配子体2例(2.3%)。抗原检测(快速诊断试验,RDT)36例(入科治疗后),阳性25例(其中镜检阴性4例),阴性11例。疟原虫镜检阳性32例。应用蒿甲醚后7 d镜检阴转率93.8%,青蒿琥酯7 d镜检阴转率100.0%。血液透析、血液灌流、血浆置换、血浆吸附等支持对症治疗86例痊愈。3例在入院前因诊断不清而延误治疗,导致入院后经抢救无效死亡。结论流行病学史的详细调查对早期诊断及治疗预后至关重要;镜检与RDT检测结果要依据治疗前后结果进行综合分析。青蒿素类抗疟治疗安全、有效,无抗药性,重症病例青蒿琥酯首选。血液透析、血液灌流、血浆置换、血浆吸附及支持对症治疗,对抢救重症疟疾患者效果良好。

Objective To study the clinical manifestations, diagnosis and treatment of severe imported cases of falciparum malaria. Methods The epidemiological data, clinical characteristics, diagnostic methods and treatment measures of 89 severe cases of faleiparum malaria admitted from November 2009 to March 2018 were summarized. Statistical epidemiologieal data; Statistics of the percentage of all cases with fever, chills, muscle pain, headache and so on; Statistical the percentage of all cases with anemia, jaundice, oliguria or anuria, hepatosplenomegaly, disturbance of consciousness; According to the WHO Third Edition Severe Malaria Standard to evaluate all cases severe malaria; Statistical case classification as a percentage of all cases; To understand the microscopic parasite density and form; malaria rapid diagnostic reagents （colloidal gold）, testing, and comparing with the results under microscope analysis; Comparison of artemisinin, artemether and arteseed effect; Conclusion hemodialysis, blood perfusion, plasma exchange, plasma adsorption cases.Results All cases were with foreign life history and history of mosquito bites, all patients had different degrees of fever （100.0%）, chills, muscle pain, headache, respectively 96.6%, 94.4%, 92.1% of all cases; Anemia, jaundice, oliguria or anuria, hepatosplenomegaly, disturbance of consciousness were accounted for 100.0%, 78.9%, 30.3%, 28.1%, 11.2% of all cases; Classification with acute liver injury, P. falciparum parasitaemia, acute renal failure, accounted for 79.8%, 62.9% and 30.3% respectively. All cases of peripheral blood smear into the division before the check to the malaria parasite, doughnut （small nourish body） 73 cases （82.0%）, 14 eases（15.7%） big nourishes the body, gametophyte in 2 cases（2.3%）, respectively. Antigen detection （rapid diagnostic tests, RDT） 36 cases （after treatment）, and positive for 25 cases （including microscopy negative 4 cases）, negative 11 cases. 32 cases were positive of microscopic examination of the malaria parasite. 7 days after the application of artemether microscopy negative turn rate 93.8%, microscopic examination of the artesunate 7 days negative turn rate was 100.0%. After blood dialysis, blood perfusion, plasma exchange and plasma adsorption support symptomatic treatment, 86 cases recovered. 3 cases of delay due to unclear diagnosis treatment before hospital, cause death disables via rescue after admission. Conclusion The detailed investigation of the history of epidemiology in early diagnosis and treatment prognosis is essential; Microscopy and RDT test results to make a comprehensive analysis on the basis of the results before and after the treatment. Artemisinin-based antimalarial treatment is safe, effective, no drug resistance, severe cases artesunate preferred. Blooddialysis, blood perfusion, plasma exchange and plasma adsorption and support symptomatic treatment, to rescue patients with severe malaria is good effect.