50例获得性免疫缺陷综合征合并耶氏肺孢子菌肺炎患者急诊处置分析

Analysis of emergency management of 50 acquired immunodeficiency syndrome patients with pneumocystis carinii pneumonia

目的提高对获得性免疫缺陷综合征(AIDS)合并耶氏肺孢子菌肺炎(PCP)急诊处置能力。方法对2017年11月至2019年2月首都医科大学附属北京地坛医院感染病急诊收治的50例AIDS合并PCP患者流行病学特点、临床表现、实验室指标检查、影像学特征等临床资料进行总结。给予入组患者甲氧苄氨嘧啶磺胺甲基异噁唑(TMP-SMZ)或联合糖皮质激素治疗,分别于治疗前、治疗后6 h、12 h、24 h、48 h和72 h抽取动脉血进行血气分析,监测治疗前后不同时间点氧分压(PaO2)、肺泡-动脉氧分压差(A-aDO2)和氧合指数(OI)动态变化,评估急诊处置效果。结果50例患者中36例有明确的流行病学史,以发热、干咳和进行性呼吸困难为主要表现;外周血淋巴细胞及CD4+T淋巴细胞计数显著降低;胸部CT主要表现为弥漫性磨玻璃影。支气管肺泡灌洗液六胺银染色阳性9例。47例患者给予TMP-SMZ联合静脉或口服糖皮质激素治疗,其余3例单独给予TMP-SMZ治疗。经急诊处置后,患者PaO2和OI随治疗时间延长而提升,而A-aDO2随治疗时间延长而降低。结论AIDS合并PCP有典型的流行病学特点、临床和影像学表现,一旦临床考虑合并PCP,应尽早使用TMP-SMZ,以降低病死率。TMP-SMZ联合糖皮质激素治疗重症PCP患者疗效确切。

Objective To improve the emergency management of acquired immunodeficiency syndrome(AIDS)patients complicated with pneumocystis carinii pneumonia(PCP).Methods From November 2017 to February 2019,the clinical data including epidemiology,clinical symptoms,laboratory examination and imaging features of 50 AIDS patients complicated with PCP admitted to Beijing Ditan Hospital,Capital Medical University were collected and analyzed,respectively.All patients were treated with trimethoprim sulfamethoxazole(TMP-SMZ)or glucocorticoid.Blood gas analysis was performed before treatment and after 6 h,12 h,24 h,48 h and 72 h of treatment,respectively.Dynamic changes of oxygen partial pressure(PaO2),alveolar artenal oxygen partial pressure difference(A-aDO2)and oxygenation index(OI)at different time points before and after treatment were analyzed to evaluate the effect of emergency treatment.Results Among the 50 csaes,36 cases had a clear epidemiological history characterized by fever,dry cough and progressive dyspnea.The absolute counts of T lymphocytes and CD4+T lymphocytes in peripheral blood were significantly declined.The computed tomography(CT)of chest indicated diffuse ground glass opacity.Nine cases were methenamine silver-stained positive in bronchoalveolar lavage fluid.There were 47 cases who were treated with TMP-SMZ combined with intravenous or oral glucocorticoid,while the remaining 3 cases with treatment of TMP-SMZ alone.After emergency management,PaO2 and OI increased with the treatment time,whereas A-aDO2 decreased.Conclusions AIDS complicated with PCP had typical epidemiological characteristics,clinical and imaging manifestations.TMP-SMZ should be used as early as possible to reduce the mortality once clinical PCP is considered.TMP-SMZ combined with corticosteroid is effective in the treatment of patients with severe PCP.