67例成人巨噬细胞活化综合征的临床特征及治疗转归

Clinical characteristics and treatment outcomes of macrophage activation syndrome in adults: A case series of 67 patients

目的:探讨巨噬细胞活化综合征患者的特征及转归。方法:纳入3个中心自2007年1月至2017年12月住院诊断的巨噬细胞活化综合征患者67例,回顾其主要临床特征、实验室数据、治疗及转归情况,并分析与缓解及死亡的可能相关因素。结果:67例确诊巨噬细胞活化综合征的患者平均年龄为(36.1±16.3)岁,诊断巨噬细胞活化综合征时结缔组织病的中位病程为8个月。巨噬细胞活化综合征潜在的结缔组织病中56.7%为成人Still病,30.0%为系统性红斑狼疮。所有患者均有发热,82.1%有脾大。实验室指标异常以高铁蛋白血症最为常见(100.0%),其次为血清可溶性白细胞介素-2受体升高(93.2%)。成人Still病继发巨噬细胞活化综合征组谷丙转氨酶、D-二聚体、血清铁蛋白及C反应蛋白均显著高于系统性红斑狼疮继发巨噬细胞活化综合征组,而动态红细胞沉降率显著降低。所有患者均使用了糖皮质激素治疗,91.0%加用了丙种球蛋白,64.2%加用环孢素A,46.3%加用依托泊苷。治疗8周时完全缓解率为47.8%,治疗16周时死亡率为22.4%。与未达到完全缓解组的患者比较,达到完全缓解组的脾大发生率更低(71.9%vs.91.4%,P=0.037),血碱性磷酸酶、谷氨酰转肽酶、总胆红素、直接胆红素更低。死亡患者巨噬细胞活化综合征的诊断年龄(P=0.014)、结缔组织病诊断年龄(P=0.017)均显著高于存活组,血小板水平显著低于存活组(P=0.018)。Logistic回归分析显示,使用环孢素A显著降低巨噬细胞活化综合征的死亡风险(P=0.004)。结论:结缔组织病继发巨噬细胞活化综合征以成人Still病和系统性红斑狼疮最多见,二者实验室指标差异有统计学意义;年龄增长及血小板低是死亡相关危险因素,使用环孢素A治疗可能降低死亡风险。

Objective:To described the clinical and laboratory features and outcome of 67 macrophage activation syndrome(MAS).Methods:A total of 67 MAS patients from three centers from January 2007 to December 2017 were enrolled.Clinical and laboratory features,and response to therapy were analyzed.Predictive factors for remission and survival were explored.Results:We identified a mean age of(36.1±16.3)years at diagnosis of MAS and a median connective tissue disease(CTD)duration of 8 months prior to MAS development.Among 67 MAS patients identified,underlying diseases included adult-onset Still’s disease(AOSD)in 56.7%and systemic lupus erythematosus(SLE)in 30.0%.Fever and splenomegaly were found in 100.0%and 82.1%of the patients,respectively.Ferritinemia and elevation of serum soluble interleukin-2 receptor was seen in 100.0%and 93.2%of the patients.Serum levels of alanine aminotransferase,D-dimer,ferritin and C reactive protein were significantly higher in MAS associated with the AOSD patients than in MAS associated with the SLE patients.A significant decrease of erythrocyte sedimentation rate was found in MAS associated with AOSD,as compared with MAS associated with SLE.The most commonly used therapy was corticosteroids,which were initially administered in 100.0%of the patients.Intravenous immunoglobulin(IVIG)was administered in 91.0%,cyclosporine A in 64.2%,and etoposide in 46.3%of the patients,respectively.The induction therapy yielded a complete remission(CR)at the end of week 8 in 47.8%of the MAS patients.The overall mortality rate at the end of week 16 was 22.4%.The median serum levels of gamma-glutamyltransferase,alkaline phosphatase,total bilirubin and direct bilirubin were significantly lower in the patients who achieved complete remission at the end of week 8 than in those who did not,and splenomegaly was significantly less frequent(71.9%vs.91.4%,P=0.037).Both the mean age at diagnosis of MAS and the mean age at diagnosis of underlying CTD of the deceased patients were elder than those of the survived population(P=0.014 and P=0.017,respectively).The platelet count was significantly less in the deceased population as compared with the living population(P=0.018).No addition of cyclosporine A(P=0.004)was identified as risk factors associated with death in Logistic regression analysis.Conclusion:MAS secondary to connective tissue disease is most common with AOSD and SLE.In terms of laboratory findings,there were considerable differences between the patients with underlying SLE and those with AOSD.Advanced age and low platelet counts are significant predictive factors for death,while treatment with cyclosporine may reduce the risk.