糖皮质激素治疗一例2019冠状病毒病(COVID-19)危重型患者炎症反应动态观察

Dynamic inflammatory response in a critically ill COVID-19 patient treated with corticosteroids

目的:探讨糖皮质激素治疗对2019冠状病毒病(COVID-19)危重型患者炎症反应和临床预后的影响。方法:回顾性分析浙江省首例COVID-19危重型患者的流行病学史、诊疗经过和患者预后。患者于入院第2天开始采用甲泼尼龙80 mg治疗,其后适时调整剂量,累计使用13 d。动态监测激素治疗前后患者淋巴细胞亚群(CD4^+T、CD8^+T、NK细胞、B细胞)和淋巴细胞因子(IL-2、IL-4、IL-6、IL-10、TNF-α、γ干扰素)变化情况。结果:入院第1天,患者外周血CD3+T、CD4^+T、CD8^+T、NK细胞数较正常值范围明显降低;随着病情改善,CD3^+T、CD8^+T和CD4^+T细胞数量逐渐恢复,呈线性增长趋势(线性拟合方程:Y=18.59X+109.4,P<0.05)。入院第2天,患者IL-6、IL-10显著高于正常值,γ干扰素处于正常高值,随后迅速降低;IL-2、IL-4、TNF-α均在正常值范围。入院第6、7天,患者IL-6、IL-10首次降至正常值范围。入院第18天,患者痰液病毒核酸检测首次阴性,粪便病毒核酸检测仍为阳性;入院第20天,患者痰液和粪便病毒核酸检测均为阴性。入院第34天,患者痊愈出院,出院时肌力评分44分,日常生活能力评分90分。结论:缺少有效抗病毒药物的情况下,COVID-19危重型患者早期使用合适剂量的糖皮质激素能够迅速减轻炎症反应程度、改善临床症状,但这在一定程度上会减少T细胞数量,须及时调整剂量。

Objective:To investigate the effect of corticosteroids therapy on the inflammatory response in a critically ill coronavirus disease 2019(COVID-19)patient.Methods:A 55-year old female patient with critical ill COVID-19 was admitted in Taizhou Hospital on January 19,2020.The patient was treated with methylprednisolone 80 mg on the 2nd day after admission.Thereafter,the dose was adjusted in a timely manner and the therapy lasted for 13 days.The peripheral lymphocyte subsets(CD3^+T,CD4^+T,CD8^+T,NK cells,B cells),as well as serum levels of lymphocyte factors(IL-2,IL-4,IL-6,IL-10,TNF-α,IFN-γ)were dynamically monitored.Results:On D1 of admission,the numbers of peripheral blood CD3+T,CD4^+T,CD8^+T,and NK cells were significantly lower than the normal range.With the improvement of the disease,the numbers of CD3+T,CD8^+T and CD4+T cells gradually recovered and showed a linear growth trend(linear fitting equation:Y=18.59X+109.4,P<0.05).On D2 of admission,the patient's IL-6 and IL-10 levels were significantly higher than normal values,IFN-γwas at a normal high value,and then rapidly decreased;IL-2,IL-4,and TNF-αwere all in the normal range.On the D6 and D7,the IL-6 and IL-10 decreased to the normal range for the first time.On the D18,the sputum virus nucleic acid test was negative for the first time,and the fecal virus nucleic acid test was still positive;on the D20 the sputum and fecal virus nucleic acid test were both negative.On D34,the patient recovered and was discharged.At the discharge the muscle strength score of the patient was 44 and the daily life ability evaluation was 90.Conclusion:In the absence of effective antiviral drugs,early use of appropriate doses of corticosteroids in critically ill patient with COVID-19 can quickly alleviate inflammatory response and improve clinical symptoms,however,it may reduce the number of T cells,and to adjust the dose in time is necessary.