内脏利什曼病62例的流行病学及临床特征分析

Epidemiological and clinical features of 62 patients with visceral leishmaniasis

目的分析内脏利什曼病患者流行病学及临床特征,以提高对该病的认识和规范化诊疗。方法回顾性分析2010年1月至2020年12月兰州大学第一医院收治的62例内脏利什曼病患者的临床资料和诊治过程。比较儿童患者与成人患者的临床症状及天冬氨酸转氨酶、乳酸脱氢酶、降钙素原等指标。统计学比较采用χ^(2)检验。结果62例患者中,男性患者为31例(50.0%),其中儿童38例(61.3%),成人24例(38.7%)。长期居住于陇南市者32例(51.6%),居住于甘南藏族自治州者11例(17.7%),47例(75.8%)从发病至确诊时间>30 d。所有患者均有发热、畏寒,34例(54.8%)有乏力、纳差,30例(48.4%)有咳嗽、咳痰,10例(16.1%)有头痛、头晕;45例(72.6%)出现脾肿大,40例(64.5%)贫血,29例(46.8%)肝肿大;32例(51.6%)并发呼吸道感染,11例(17.7%)并发噬血细胞综合征,10例(16.1%)并发肝功能异常。60例患者接受治疗,其中14例经治患者入院前接受过至少1个疗程的锑剂单药治疗后复发。46例接受标准锑剂方案单药治疗,14例接受标准锑剂联合两性霉素B治疗,其中13例因肾功能受损而停用两性霉素B,50例患者随访至少半年无复发。儿童脾肿大和肝肿大比例分别为86.8%(33/38)和65.8%(25/38),高于成人患者的50.0%(12/24)和16.7%(4/24),差异均有统计学意义(χ^(2)=10.03、14.26,均P<0.050);儿童患者中从发病至确诊时间>30 d者为33例(86.8%),而成人为14例(58.3%),两组患者中不同发病至确诊时间所占比例的差异有统计学意义(χ^(2)=6.52,P=0.011)。儿童患者中天冬氨酸转氨酶、乳酸脱氢酶和降钙素原升高比例均高于成人患者[76.3%(29/38)比45.8%(11/24)、94.3%(33/35)比71.4%(15/21)、73.9%(17/23)比5/17],差异均有统计学意义(χ^(2)=5.97、3.89、7.82,均P<0.050)。结论内脏利什曼病患者并发症较多且重,早诊断、早治疗及规范化治疗是提高治愈率及减少不良结局的重要措施。锑剂治疗失败患者可考虑两性霉素B单药或者联合锑剂再治疗,但应密切监测肾损伤等不良反应。

Objective To analyze the epidemiological and clinical features of patients with visceral leishmaniasis(VL),and to improve the understanding of the disease and standardize the diagnosis and treatment.Methods The clinical data and diagnosis and treatment process of 62 patients with VL admitted to The First Hospital of Lanzhou University from January 2010 to December 2020 were retrospectively analyzed.The clinical symptoms and laboratory data,including aspartate aminotransferase(AST),lactate dehydrogenase(LDH)and procalcitonin(PCT)were compared between children and adults.Chi-square test was used for statistical analysis.Results Of the 62 patients,31(50.0%)patients were males,38(61.3%)patients were children and 24(38.7%)were adults.There were 32 cases(51.6%)living in Longnan City,and 11 cases(17.7%)living in Gannan Tibetan Autonomous Prefecture.Forty-seven cases(75.8%)had a delay over 30 days from onset to diagnosis.All patients had fever and chills,34 cases(54.8%)had fatigue and poor appetite,30(48.4%)had cough and expectoration,10 cases(16.1%)had headache and dizziness,45 cases(72.6%)had splenomegaly,40 cases(64.5%)had anemia,and 29 cases(46.8%)had hepatomegaly.There were 32 cases(51.6%)accompanied with respiratory infection,11 cases(17.7%)accompanied with hemophagocytic lymphohistiocytosis and 10 cases(16.1%)accompanied with abnormal liver function.Of the 60 patients who received treatment,14 were recurrent cases who had received at least one course of pentavalent antimony monotherapy before admission.Forty-six patients received standard antimony monotherapy,14 patients received standard antimony combined with amphotericin B therapy.Thirteen patients discontinued amphotericin B due to impaired renal function,and 50 patients were followed up for half a year without recurrence.The proportions of splenomegaly and hepatomegaly in children were 86.8%(33/38)and 65.8%(25/38),respectively,and the corresponding numbers in adults were 50.0%(12/24)and 16.7%(4/24),respectively.The differences were statistically significant(χ^(2)=10.03 and 14.26,respectively,both P<0.050).Thirty-three cases(86.8%)in children and 14 cases(58.3%)in adults had a delay over 30 days from onset to diagnosis.The difference was statistically significant(χ^(2)=6.52,P=0.011).The proportions of patients who had elevated AST,LDH and PCT were 76.3%(29/38),94.3%(33/35)and 73.9%(17/23)in children,respectively,while 45.8%(11/24),71.4%(15/21)and 5/17 in adults,respectively,and the differences were all statistically significant(χ^(2)=5.97,3.89 and 7.82,respectively,all P<0.050).Conclusions Patients with VL are tend to have complications and be severe.Early diagnosis and standardized treatment are important measures to improve the prognosis.Patients who have failed antimony treatment can be treated with amphotericin B or combination therapy,but kidney injury and other adverse reactions should be closely monitored.