肾移植术后肺孢子菌肺炎13例临床分析

Clinical analysis of pneumocystis pneumonia after kidney transplantation: a report of 13 cases

目的探讨肾移植术后肺孢子菌肺炎(pneumocystis carinii pneumonia,PCP)的临床诊治经验。方法回顾性分析2020年1月至2022年1月广西医科大学第二附属医院收治的通过宏基因组二代测序(metagenomics next-generation sequencing,mNGS)确诊PCP的13例肾移植受者的临床资料。其中,女性3例,男性10例;年龄(46±10)岁;术后发病中位时间为10(2~21)个月;临床表现为发热11例,咳嗽7例,咳痰6例,气促11例。采用配对t检验,对受者入院及出院时的实验室检查结果进行对比分析。结果13例PCP肾移植受者均通过肺泡灌洗液/静脉血mNGS检测确诊。入院时G试验、LDH检测、总T淋巴细胞绝对计数(CD3+Abs)、抑制/细胞毒T淋巴细胞计数(CD3+CD8+Abs)、辅助/诱导T淋巴细胞绝对计数(CD3+CD4+Abs)分别为(543.27±440.49)pg/ml、(529.98±222.43)U/L、(191.92±119.42)个/μl、(87.33±50.59)个/μl、(106.92±87.42)个/μl,与出院时的(69.58±50.21)pg/ml、(285.38±46.62)U/L、(888.58±672.99)个/μl、(336.83±305.21)个/μl、(520.08±388.76)个/μl比较,差异均有统计学意义(P<0.001、P=0.002、0.006、0.017、0.005)。13例均采用复方磺胺甲恶唑+卡泊芬净联合方案进行治疗,治愈12例,另1例治疗21 d后因感染性休克而死亡。结论mNGS检测是早期确诊PCP的重要方法之一;复方磺胺甲恶唑+卡泊芬净的抗感染效果良好;免疫功能监测对于抗感染及免疫抑制剂方案的调整具有重要意义。

Objective To explore the clinical characteristics of pneumocystis carinii pneumonia(PCP)after kidney transplantation.Methods From January 2020 to January 2022,clinical data were retrospectively reviewed for 13 renal transplant recipients with pneumocystis pneumonia diagnosed by metagenomics next generation sequencing(mNGS).There were 3 females and 10 males with an age range of(46±10)years.The median time of postoperative onset was 10(2-21)months;The major clinical manifestations included fever(n=11),cough(n=7),expectoration(n=6)and dyspnea(n=11).Paired t-test was employed for analyzing the laboratory results at admission and discharge.Results The diagnosis was confirmed by the detection of NGS in alveolar lavage fluid or venous blood.The levels of G test,LDH test,total T lymphocyte absolute count(CD3+Abs),inhibitory/cytotoxic T lymphocyte count(CD3+CD8+Abs)and auxiliary/induced T lymphocyte absolute count(CD3+CD4+Abs)were(543.27±440.49)pg/ml,(529.98±222.43)U/L and(191.92±119.42)/μl,(87.33±50.59)/μl and(106.92±87.42)/μl at admission and(69.58±50.21)pg/ml,(285.38±46.62 U/L),(888.58±672.99)/μl,(336.83±305.21)/μl and(520.08±388.76)/μl at discharge.The differences were statistically significant(P<0.001,P=0.002,0.006,0.017,0.005).All of them received compound sulfamethoxazole and caspofungin.Except for one death due to septic shock after 21-day treatment,12 cases were cured.Conclusions mNGS test is one of the important tool for an early diagnosis of PCP.Combined use of compound sulfamethoxazole and caspofungin is an effective anti-infective regimen.And immune function monitoring is vital for adjusting antibiotic and immunosuppressive regimens.