艾滋病肝脓肿患者临床特征的对照分析

Case-control analysis of liver abscess in patients with acquired immunodeficiency syndrome

目的比较肝脓肿在艾滋病和非艾滋病患者中的临床特征及预后。方法以2013年1月-2018年8月于北京佑安医院治疗的84例艾滋病肝脓肿患者(艾滋病组)和70例非艾滋病肝脓肿患者(对照组)为研究对象,回顾性对照分析两组患者的临床表现、实验室指标、影像学表现、病原学结果、治疗与疗效及预后情况等。结果与对照组相比,艾滋病组男性比例更高,发病年龄更小(均P<0.05)。发热是两组患者最常见症状,但艾滋病组患者入院后发热持续时间较长(P<0.05)。艾滋病组腹痛、咳嗽、体重减轻的发生率均高于对照组(均P<0.05),但WBC计数、中性粒细胞比例、CRP升高的发生率均低于对照组(均P<0.05)。以右叶、单发肝脓肿为主是两组影像学表现的共同特点,但艾滋病组单发肝脓肿比例较高,病灶呈分叶/分隔的比例较低(均P<0.05)。艾滋病组肝脓液及血液培养共检出病原菌9株,其中葡萄球菌5株,肺炎克雷伯菌1株,真菌3株;对照组检出病原菌38株,其中革兰阴性菌30株,占78.9%(主要为肺炎克雷伯菌),革兰阳性菌8株,占21.1%(主要为链球菌和葡萄球菌)。艾滋病组合并肝外真菌感染、肝外结核、扁桃体炎的比例明显高于对照组,对照组合并2型糖尿病、脂肪肝的比例高于艾滋病组(均P<0.05)。艾滋病组与对照组肝脓肿治疗有效率分别为89.3%和97.1%,差异无统计学意义(P>0.05)。艾滋病组内经皮抽吸/引流/手术治疗患者院内病死率明显低于单纯抗生素治疗患者(P<0.05)。艾滋病组与对照组院内病死率分别为6.0%及1.4%,不良预后(治疗无效+院内死亡)率分别为10.7%及2.9%,差异均无统计学意义(均P>0.05)。艾滋病组不良预后的独立危险因素包括:出现脓毒性休克、呼吸衰竭、气腔形成;对照组不良预后的独立危险因素为发生呼吸衰竭。结论艾滋病肝脓肿患者临床表现缺乏特异性,诊断依靠影像学及病原学检查,抗感染药物联合经皮穿刺抽吸/引流治疗可能有利于改善患者预后。

Objective To analyze the clinical and prognostic characteristics of liver abscess in patients with acquired immunodeficiency syndrome(AIDS)by comparing with those without AIDS.Methods A total of 154 patients with liver abscess(84 in AIDS group,70 in non-AIDS group),admitted to Beijing You-an Hospital between January 2013 and August 2018,were included to analyze the clinical manifestations,imaging features,etiologies,therapeutic effects and prognostic factors of liver abscess in AIDS patients.Results AIDS group showed significantly higher proportion of males and younger age of onset than non-AIDS group(all P<0.05).Fever was the most common symptom in both groups,but the duration of fever after admission was longer in AIDS group than in non-AIDS group(P<0.05).Patients in AIDS group showed significantly higher incidence of abdominal pain,cough and,weight loss than those in non-AIDS group(all P<0.05).Elevated WBC count,neutrophils percentage,and C-reactive protein level in AIDS group were significantly lower than in non-AIDS group(all P<0.05).Imaging study showed single rightlobe liver abscess in most cases regardless of AIDS.However,the frequency of multiple liver abscesses and lobulation/septation was lower in AIDS group(P<0.05).Nine strains of pathogens were isolated from liver pus and blood culture in AIDS group,including Staphylococcus(5 strains),Klebsiella pneumoniae(1 strain),and fungus(3 strains).Thirty eight strains of pathogens were isolated in non-AIDS group,of which 78.9%were Gram negative bacteria(mainly Klebsiella pneumoniae)and 21.1%Gram positive bacteria(mainly Streptococcus and Staphylococcus).The prevalence of type 2 diabetes mellitus and fatty liver in AIDS group was significantly lower than that in non-AIDS group(all P<0.05).The efficacy rate was 89.3%and 97.1%,respectively(P>0.05).AIDS patients treated with percutaneous aspiration and drainage or surgery showed significantly lower in-hospital mortality than those treated with antimicrobial agents only(P<0.05).The in-hospital mortality was 6.0%in AIDS group and 1.4%in non-AIDS group.Poor outcome(treatment failure and in-hospital death)was documented in 10.7%and 2.9%of patients,respectively(all P>0.05).The predictors of poor outcome were septic shock,respiratory failure,and air cavity formation in AIDS group,but respiratory failure in non-AIDS group.Conclusions The clinical features of liver abscess in AIDS patients are not specific.The diagnosis is dependent on imaging and etiologic findings.Antimicrobial agents in combination with percutaneous aspiration and drainage may be conducive to better outcomes.