重症程序性细胞死亡蛋白-1抑制剂致心肌炎的临床特点分析

Clinical analysis of the severe programmed death 1 inhibitor myocarditis

目的:探讨重症的程序性细胞死亡蛋白-1抑制剂相关心肌炎临床特点,为临床诊治提供参考。方法:回顾分析我院2018年1月至2021年1月间,16例诊断程序性细胞死亡蛋白-1抑制剂相关心肌炎患者的资料,对其中10例普通心肌炎患者和6例重症患者的一般资料、实验室及辅助检查、治疗方式及转归等进行比较。结果:重症心肌炎组与普通组在性别、年龄、BMI、PD-1抑制剂用药持续时间、PD-1抑制剂累积使用剂量、起病至就诊时间及既往病史等,差异无统计学意义(P> 0.05)。重症组以乏力、心悸症状为主,普通组以乏力、胸闷为主,重症组心悸者占66.7%,发生率显著高于普通组(P<0.05)。重症组cTnI为2.26(0.64,3.63)μg/L,显著高于普通心肌炎组(P<0.05);两组NT-pro BNP、肌红蛋白、CK-MB、肝肾功能等,差异无统计学意义(P>0.05)。普通组心电图可见I度房室传导阻滞,重症组可见完全性右束支传导阻滞及左前分支阻滞。33.3%重症组患者超声心动图可见严重心功能不全,普通组均无异常。两组心肌炎患者均出现累积其他靶器官(甲状腺、肝脏、肾上腺等)现象,但两组靶器官不良反应发生率差异无统计学意义(P>0.05)。普通组患者均得到转归,重症组患者有3例死亡。结论:PD-1抑制剂相关心肌炎的临床症状多不典型,容易使临床大夫误诊、漏诊,尽早识别存在高危因素的重症患者,及时给予有效治疗。

Objective: Analysis the clinical features and treatment of the severe programmed death 1 inhibitors related myocarditis. Methods: Selected 16 patients from the Beijing Tsinghua Changgung Hospital,from January 2018 to January 2021, to compared the 10 cases of ordinary myocarditis with the 6 cases of severe myocarditis in the patients’ general condition, laboratory and auxiliary examination and treatment plans.Results: There was no difference between the severe group and ordinary group in sex, age,BMI, duration of PD-1 inhibitors,cumulative dose of PD-1 inhibitor,onset to visit time, and medical history(P>0.05).The main clinical symptoms of the severe group were fatigue and palpitations, and the ordinary group were fatigue and chest tightness. The incidence of palpitations was 66.7% in severe group, with a significantly higher incidence than that in ordinary group(P>0.05). There were no differences in NT-pro BNP, MYO, CK-MB, liver function and renal function in the two groups(P>0.05).Atrioventricular block was happened in ordinary group, and completed right bundle branch with or without the left anterior branch block were happened in severe group.Echocardiography indicated the incidence of cardiac insufficiency was 33.3% in severe group, and no significant abnormalities were observed in the ordinary group.Both groups had accumulated other target organs(thyroid, liver, adrenal glands, etc.),however, there was no significant difference in the incidence of target reactions in two groups(P>0.05).All patients in ordinary group were cured, three patients died in severe group. Conclusions: A lack of specificity in the clinical manifestations of PD-1 inhibitor myocarditis, it’s easy to misdiagnose and miss diagnosis, the severe programmed death 1inhibitor myocarditis had severe clinical conditions and rapid progress and poor prognosis. Clinicians should raise the awareness of the disease, learn to identify patients with high risk factors timely, take effective measures.