非洲输入性疟疾患者血脂水平与疾病严重程度的相关性分析

Correlation between blood lipid levels and disease severity in imported malaria patients from Africa

目的探讨非洲输入性疟疾患者的临床特点,以及其血脂水平与疾病严重程度的相关性。方法收集2018年1月1日至2021年1月31日广州医科大学附属市八医院收治的172例非洲输入性疟疾患者的临床资料,回顾性分析患者的一般情况、临床症状、实验室检查、治疗和预后。统计学方法采用两独立样本t检验、曼-惠特尼U检验和二分类多因素logistic回归分析。结果172例患者中,重症39例,非重症133例;感染虫种以恶性疟原虫为主,共153例(89.0%);重症患者均为恶性疟。与非重症组相比,重症组患者的白细胞计数、三酰甘油均升高,差异均有统计学意义(Z=2.397、4.368,均P<0.05);血红蛋白、血细胞比容、血小板计数、高密度脂蛋白胆固醇、载脂蛋白AⅠ、载脂蛋白AⅠ/载脂蛋白B均降低,差异均有统计学意义(Z=-4.473、-4.464、-4.750、-4.826、-5.488、-4.419,均P<0.01);总胆固醇、低密度脂蛋白胆固醇均降低,差异均有统计学意义(t=3.817、5.285,均P<0.01)。高密度脂蛋白胆固醇、低密度脂蛋白胆固醇、三酰甘油、载脂蛋白AⅠ、载脂蛋白AⅠ/载脂蛋白B的受试者操作特征曲线下面积分别为0.754、0.727、0.730、0.789、0.733(均P<0.01)。当约登指数最大时,载脂蛋白AⅠ的最佳截断值为0.535 g/L,其对重症疟疾预测的灵敏度为79.5%,特异度为68.4%。载脂蛋白AⅠ[比值比(odds ratio,OR)=0.013,95%可信区间(confidence interval,CI)0.002~0.086,P<0.01]对重症疟疾有独立预测价值,根据最佳截断值分层,载脂蛋白AⅠ<0.535 g/L时的重症疟疾发生风险是载脂蛋白AⅠ≥0.535 g/L时的8.396倍(OR=8.396,95%CI 3.557~19.820,P<0.01)。重症患者病死率为2.6%(1/39)。结论非洲输入性疟疾患者以恶性疟原虫感染为主,重症患者病死率高,血脂中的高密度脂蛋白胆固醇、低密度脂蛋白胆固醇、三酰甘油、载脂蛋白AⅠ、载脂蛋白AⅠ/载脂蛋白B对重症疟疾的预测价值较高,其中载脂蛋白AⅠ对重症疟疾有独立预测价值。血脂变化有助于尽早识别重症疟疾,提高治愈率,降低死亡风险。

Objective To explore the clinical characteristics of imported malaria from Africa,and the correlation between blood lipids and disease severity.Methods The clinical data of 172 imported malaria patients from Africa were collected from January 1,2018 to January 31,2021 in Guangzhou Eighth People′s Hospital,Guangzhou Medical University.The general conditions,clinical symptoms,laboratory tests,treatment and prognosis of the patients were analyzed retrospectively.The independent samples t-test,Mann-Whitney U test and binary multivariate logistic regression analysis were used for statistical analysis when appropriate.Results A total of 172 patients were divided into 39 severe cases and 133 non-severe cases in this study.The main infection species was Plasmodium falciparum,with a total of 153 cases(89.0%),and the severe cases were all falciparum malarias.Compared with the non-severe group,the white blood cell count and triacylglycerol level were increased in the severe group.The differences were both statistically significant(Z=2.397 and 4.368,respectively;both P<0.05).The hemoglobin,hematocrit,platelet count,high-density lipoprotein cholesterol,apolipoprotein A(ApoA)Ⅰand ApoAⅠ/apolipoprotein B(ApoB)were significantly decreased in the severe group.The differences were all statistically significant(Z=-4.473,-4.464,-4.750,-4.826,-5.488 and-4.419,respectively;all P<0.01).The total cholesterol and low-density lipoprotein cholesterol were also reduced in the severe group.The differences were both statistically significant(t=3.817 and 5.285,respectively;both P<0.01).The area under receiver operator characteristic curve of high-density lipoprotein cholesterol,low-density lipoprotein cholesterol,triacylglycerol,ApoAⅠ,and ApoAⅠ/ApoB were 0.754,0.727,0.730,0.789 and 0.733,respectively(all P<0.01).When the Youden index was at its maximum,the best cut-off value of ApoAⅠwas 0.535 g/L with sensitivity of the prediction for severe malaria of 79.5%and the specificity of 68.4%.ApoAⅠhad independent predictive value for severe malaria(odds ratio(OR)=0.013,95%confidence interval(CI)0.002 to 0.086,P<0.01),and stratified according to the best cut-off value,the risk of severe malaria when ApoAⅠ<0.535 g/L was 8.396 times of ApoAⅠ≥0.535 g/L(OR=8.396,95%CI 3.557 to 19.820,P<0.01).The case fatality rate of severe malaria was 2.6%(1/39).Conclusions The imported malaria patients from Africa are mainly infected with Plasmodium falciparum and the case fatality rate of severe malaria is high.The high-density lipoprotein cholesterol,low-density lipoprotein cholesterol,triacylglycerol,ApoAⅠ,ApoAⅠ/ApoB of blood lipids show higher predictive value for severe malaria,among which,ApoAⅠhas independent predictive value for severe malaria.Changes in blood lipids will help to identify severe malaria as early as possible,improve the cure rate,and reduce the risk of death.