人类免疫缺陷病毒感染与非人类免疫缺陷病毒感染免疫抑制肺孢子菌肺炎合并急性呼吸衰竭患者的临床特点比较

Comparison of clinical features of pneumocystis pneumonia complicated with acute respiratory failure between human immunodeficiency virus-infected patients and non-human immunodeficiency virus-infected immunocompromised patients

目的分析比较重症监护病房(intensive care unit,ICU)内人类免疫缺陷病毒(human immunodeficiency virus,HIV)感染与非HIV感染免疫抑制肺孢子菌肺炎(pneumocystis pneumonia,PCP)合并急性呼吸衰竭(acute respiratory failure,ARF)患者的临床特点及预后影响因素。方法收集2018年5月至2020年10月收治于郑州大学第一附属医院和郑州市第六人民医院ICU的PCP合并ARF患者的临床资料,分为HIV感染PCP组和非HIV感染免疫抑制PCP组。分析两组患者的一般特点、基础疾病等资料,并比较两组患者的实验室检查、治疗和预后等情况。统计学分析采用独立样本t检验、曼-惠特尼U检验和χ2检验,预后危险因素分析采用单因素和多因素logistic回归。结果129例PCP合并ARF患者中,HIV感染者75例,非HIV感染免疫抑制者54例。HIV感染PCP组仅10.7%(8/75)的患者既往接受抗反转录病毒治疗,两组患者均未行PCP预防用药。HIV感染PCP组患者入ICU的急性生理学和慢性健康状况评价(acute physiology and chronic health evaluation,APACHE)Ⅱ评分为(18.7±6.0)分,高于非HIV感染免疫抑制PCP组的(13.1±4.4)分,差异有统计学意义(t=-5.45,P<0.001);两组患者均存在明显低蛋白血症。HIV感染PCP组96.0%(72/75)的患者CD4+T淋巴细胞计数<200/μL,84.0%(63/75)的患者CD4+T淋巴细胞计数<50/μL;非HIV感染免疫抑制PCP患者中CD4+T淋巴细胞计数<200/μL的占比为57.4%(31/54)。HIV感染PCP组的CD4+/CD8+T淋巴细胞比值为0.05(0.02,0.12),低于非HIV感染免疫抑制PCP组的0.96(0.64,1.44),差异有统计学意义(Z=-9.16,P<0.001)。非HIV感染免疫抑制PCP患者在ICU的时间和住院时间分别为10.0(7.0,14.0)d和18.0(11.8,32.5)d,分别长于HIV感染PCP患者的7.0(4.0,9.0)d和13.0(7.0,23.0)d,差异均有统计学意义(Z=-3.58、-2.73,均P<0.050);HIV感染PCP组的病死率为57.3%(43/75),高于非HIV感染免疫抑制PCP组的38.9%(21/54),差异有统计学意义(χ2=4.27,P=0.039)。多因素logistic回归分析显示,乳酸脱氢酶(lactic dehydrogenase,LDH)、C反应蛋白(C-reactive protein,CRP)和APACHEⅡ评分是HIV感染PCP患者不良预后的危险因素[比值比(odds ratio,OR)=1.006、1.015、1.736,均P<0.050],氧合指数、LDH和CD4+T淋巴细胞计数是影响非HIV感染免疫抑制PCP患者预后的独立危险因素(OR=0.970、1.008、0.989,均P<0.050)。结论PCP患者合并ARF后病情重,病死率高。LDH、CRP和APACHEⅡ评分为HIV感染PCP患者不良预后的危险因素,而氧合指数、LDH和CD4+T淋巴细胞计数为影响非HIV感染免疫抑制PCP患者预后的危险因素。

Objective To compare the clinical characteristics and analyze the prognostic factors between human immunodeficiency virus(HIV)-infected patients and non-HIV-infected immunocompromised patients with pneumocystis pneumonia(PCP)complicated with acute respiratory failure(ARF)in intensive care unit(ICU).Methods The clinical data of patients with PCP complicated with ARF admitted in ICU of The First Affiliated Hospital of Zhengzhou University and The Sixth People′s Hospital of Zhengzhou City between May 2018 and October 2020 were retrospectively reviewed.All subjects were divided into HIV-infected group and non-HIV-infected immunocompromised group.General characteristics and underlying diseases of patients in the two groups were analyzed.Laboratory parameters,treatment and outcomes between two groups were compared.Independent sample t test,Mann-Whitney U test and chi-square test were used for statistical analysis,and univariate and multivariate logistic regression models were used to identify the risk factors for the clinical outcome.Results A total of 129 PCP complicated with ARF patients were enrolled,including 75 HIV-infected patients and 54 non-HIV-infected immunocompromised patients.Only 10.7%(8/75)patients of HIV-infected group received anti-retroviral therapy(ART),but none of the patients in either groups had previously received trimethoprim-sulfamethoxazole(TMP-SMX)for PCP prophylaxis.Acute physiology and chronic health evaluation(APACHE)Ⅱscore of HIV-infected group was 18.7±6.0,which was higher than that in non-HIV-infected immunocompromised group(13.1±4.4)when admitted in ICU(t=-5.45,P<0.001).Hypoproteinemia was common in both groups.Ninety-six percent(72/75)of HIV-infected patients had CD4+T lymphocyte counts lower than 200/μL and 84.0%(63/75)of patients had CD4+T lymphocyte counts even lower than 50/μL,while 5.74%(31/54)of patients in non-HIV-infected immunocompromised group had CD4+T lymphocyte counts lower than 200/μL.The CD4+/CD8+T lymphocyte counts ratio was 0.05(0.02,0.12)in HIV-infected group,which was lower than that in non-HIV-infected immunocompromised group(0.96(0.64,1.44)),and the difference was statistically significant(Z=-9.16,P<0.001).The length of ICU stay and hospital stay of non-HIV-infected immunocompromised patients were 10.0(7.0,14.0)days and 18.0(11.8,32.5)days,respectively,which were both longer than those in HIV-infected patients(7.0(4.0,9.0)days and 13.0(7.0,23.0)days,respectively),and the differences were both statistically significant(Z=-3.58 and-2.73,respectively,both P<0.050).The hospital mortality of HIV-infected patients was 57.3%(43/75),which was significantly higher than that in non-HIV-infected immunocompromised patients(38.9%,21/54)(χ2=4.27,P=0.039).Multivariable logistic regression identified that lactic dehydrogenase(LDH),C-reactive protein(CRP)and APACHEⅡscore were the risk factors for the clinical outcome of HIV-infected patients(odds ratio(OR)=1.006,1.015 and 1.736,respectively,all P<0.050).The partial pressure of oxygen in arterial blood/fractional concentration of inspiratory oxygen(PaO2/FiO2),LDH and CD4+T lymphocyte counts were the risk factors for the clinical outcome of non-HIV infected immunocompromised patients(OR=0.970,1.008 and 0.989,respectively,all P<0.050).Conclusions PCP patients with ARF are critically ill with high mortality rate.LDH,CRP and APACHEⅡscore are predictors for prognosis of HIV-infected patients with PCP,while PaO2/FiO2,LDH and CD4+T lymphocyte counts are predictors for prognosis of non-HIV infected immunocompromised patients with PCP.