成人感染相关性噬血细胞综合征32例临床分析

Clinical analysis of 32 adult patients with infection-associated hemophagocytic syndrome

目的分析成人感染相关性噬血细胞综合征(IAHS)患者的临床特征,以期提高临床医师对IAHS的诊治能力。方法回顾性分析2014年7月至2019年11月昆明医科大学第一附属医院重症医学科收治的32例成人IAHS患者的临床资料。收集患者的一般情况、临床表现、实验室指标、影像学检查结果、病原学检测结果和临床转归,并根据确诊28 d预后分为存活组和死亡组。比较两组患者的临床资料;将单因素分析中差异有统计学意义的变量进行多因素Logistic回归分析;绘制受试者工作特征曲线(ROC),分析单因素分析中差异有统计学意义的变量对成人IAHS患者28 d预后的预测价值。结果32例成人IAHS患者中,男性17例(占53.1%),女性15例(占46.9%);细菌感染18例,以鲍曼不动杆菌和大肠埃希菌居多;病毒感染14例,以EB病毒为主。28 d总病死率为62.5%(20/32)。①与存活组(12例)比较,死亡组(20例)患者白细胞计数(WBC)、中性粒细胞计数(NEU)、淋巴细胞计数(LYM)、血小板计数(PLT)和氧合指数(OI)更低,天冬氨酸转氨酶(AST)、K^+、血清铁蛋白(SF)和乳酸脱氢酶(LDH)更高〔WBC(×10^9/L):3.90±3.36比9.57±6.48,NEU(×10^9/L):2.69±2.09比7.01±6.34,LYM(×10^9/L):0.36(0.23,0.84)比1.24(0.61,2.36),PLT(×10^9/L):51.15±27.60比108.42±80.26,OI(mmHg,1 mmHg=0.133 kPa):134.0(77.5,192.0)比292.0(187.0,329.0),AST(U/L):254.00(67.80,452.50)比85.50(38.38,111.25),K^+(mmol/L):4.06(3.65,4.51)比3.52(3.26,3.76),SF(μg/L):6290.0(1851.0,13904.8)比1777.1(1228.5,3486.3),LDH(μmol·s^-1·L^-1):19.3(11.9,27.0)比9.8(6.9,11.1),均P<0.05〕,就诊后发热时间更长〔d:13.5(9.0,17.2)比6.0(2.5,8.0),P<0.01〕,皮肤发绀发生率更高(40.0%比0%,P<0.05);而两组间其他临床资料比较差异均无统计学意义。②多因素Logistic回归分析显示,OI降低且LDH升高为成人IAHS患者28 d死亡的危险因素〔优势比(OR)分别为0.967和1.007,均P<0.05〕。③ROC曲线分析显示,WBC、NEU、AST、SF、LDH和OI对成人IAHS患者28 d预后均有一定预测价值(均P<0.05),以OI和LDH的ROC曲线下面积(AUC)最大,均为0.847。当OI的最佳截断值为145.5 mmHg时,敏感度为63.2%,特异度为100%;当LDH的最佳截断值为13.4μmol·s^-1·L^-1时,敏感度为72.2%,特异度为91.7%。结论成人IAHS患者OI<145.5 mmHg和LDH>13.4μmol·s^-1·L^-1可提示其28 d预后不良。

Objective To analyze the clinical feature of adult patients with infection-associated hemophagocytic syndrome (IAHS), and to improve the ability of clinicians to diagnose and treat IAHS.Methods A retrospectively study was performed. The clinical data of 32 adult patients with IAHS admitted to the intensive care unit (ICU) of the First Affiliated Hospital of Kunming Medical University from July 2014 to November 2019 were analyzed. The general data, clinical manifestations, laboratory results, imaging findings, pathogen and clinical outcomes were collected, and the patients were divided into survival group and death group according to the 28-day prognosis. The clinical data between the two groups were compared, and multivariate Logistic regression analysis was used to analyze the variables with statistical significance in univariate analysis. The receiver operating characteristic (ROC) curve was drawn to analyze the predictive value of variables with statistical significance in univariate analysis for 28-day prognosis of adult patients with IAHS.Results Among 32 adult patients with IAHS, there were 17 males (53.1%) and 15 females (46.9%). Eighteen patients were bacterial infection, most of which were Acinetobacter baumannii and Escherichia coli;14 patients were viral infection, mainly EB virus;and the overall 28-day mortality was 62.5% (20/32). ① Compared with the survival group (n = 12), the levels of white blood cell (WBC), neutrocyte (NEU), lymphocyte (LYM), platelet (PLT) and oxygenation index (OI) in the death group (n = 20) were lower, while the levels of aspartate aminotransferase (AST), K^+, serum ferritin (SF) and lactate dehydrogenase (LDH) were higher [WBC (×10^9/L): 3.90±3.36 vs. 9.57±6.48, NEU (×10^9/L): 2.69±2.09 vs. 7.01±6.34, LYM (×10^9/L): 0.36 (0.23, 0.84) vs. 1.24 (0.61, 2.36), PLT (×10^9/L): 51.15±27.60 vs. 108.42±80.26, OI (mmHg, 1 mmHg = 0.133 kPa): 134.0 (77.5, 192.0) vs. 292.0 (187.0, 329.0), AST (U/L): 254.00 (67.80, 452.50) vs. 85.50 (38.38, 111.25), K+ (mmol/L): 4.06 (3.65, 4.51) vs. 3.52 (3.26, 3.76), SF (μg/L): 6 290.0 (1 851.0, 13 904.8) vs. 1 777.1 (1 228.5, 3 486.3), LDH (μmol·s^-1·L^-1): 19.3 (11.9, 27.0) vs. 9.8 (6.9, 11.1), all P < 0.05]. In death group, duration of having a fever after admission was prolonged [days: 13.5 (9.0, 17.2) vs. 6.0 (2.5, 8.0), P < 0.05] and the incidence of cyanosis was higher (40.0% vs. 0%, P < 0.05). There was no significant difference in other indicators between the two groups. ② Multivariate Logistic regression analysis showed that low OI combined with high LDH were risk factors for 28-day mortality of adult patients with IAHS [odds ratio (OR) was 0.967 and 1.007, respectively, both P < 0.05].③ It was shown by ROC curve analysis that WBC, NEU, AST, SF, LDH and OI had predictive value for 28-day prognosis of adult patients with IAHS (both P < 0.05), and the area under ROC curve (AUC) of OI and LDH was higher, that was both 0.847. When the best cut-off of OI was 145.5 mmHg, the sensitivity was 63.2%, and the specificity was 100%. When the best cut-off of LDH was 13.4 μmol·s-1·L-1, the sensitivity was 72.2%, and the specificity was 91.7%.Conclusion OI < 145.5 mmHg, and LDH > 13.4 μmol·s^-1·L^-1 were significant predictors for poor 28-day prognosis of adult patients with IAHS.