耶氏肺孢子菌肺炎临床特征分析

Clinical features of Pneumocystis jirovecii pneumonia

目的分析耶氏肺孢子菌肺炎(PJP)患者的临床特征、实验室指标与影像学特点,为该病的临床诊治提供依据。方法纳入2017年5月至2020年8月中日友好医院就诊的154例PJP患者。收集患者的临床症状、实验室检查和预后情况,并将患者分为死亡组(51例)与存活组(103例),采用t检验、非参数检验、卡方检验等统计学方法比较死亡组与存活组实验室检查结果的差异。结果154例PJP患者中男性89例,女性65例,年龄(53.7±14.8)岁。其中,1个月内使用免疫抑制剂的患者占85.7%(132/154),肾脏疾病患者27.9%(43/154),结缔组织病患者33.1%(51/154)。临床症状方面,发热81.8%(126/154),咳嗽59.7%(92/154),呼吸困难52.6%(81/154)。实验室检查,乳酸脱氢酶(LDH)561.0(434.3,749.0)IU/L,91.3%(95/104)患者LDH升高;CD4+T淋巴细胞<400个/μl和<200个/μl的患者分别占88.0%(95/108)和57.4%(62/108);74.4%(67/90)PJP患者(1,3)-β-D葡聚糖试验(BG)>100.0 ng/L。影像学检查,CT检查90%(117/130)患者可见双肺弥漫性磨玻璃/网格影。死亡组患者LDH 690.5(528.8,932.3)IU/L,高于存活组502.5(381.8,657.0)IU/L(Z=-3.375,P=0.001);死亡组的白细胞计数9.8(5.8,12.6)×109/L高于存活组的7.3(5.0,10.1)×109/L(Z=-2.392,P=0.017);死亡组淋巴细胞比例5.3(3.2,9.3)%,低于存活组9.6(5.6,17.2)%(Z=-3.262,P=0.001);死亡组年龄(69.8±14.5)岁,高于存活组(50.6±14.0)岁(t=-3.756,P=0.001);死亡组患者动脉氧分压均值(64.8±17.7)mmHg(1 mmHg=0.133 kPa),低于存活组(73.2±20.5)mmHg(t=2.345,P=0.021);死亡组患者合并细菌/曲霉菌感染为55.1%(27/51),高于存活组21.5%(22/103)(χ^(2)=15.372,P=0.001)。结论长期使用免疫抑制剂/糖皮质激素者易发生PJP;CD4+T淋巴细胞、LDH、BG可作为辅助临床诊断PJP的重要参考指标;年龄、LDH、白细胞计数、淋巴细胞比率、动脉氧分压及是否合并细菌和/或曲霉感染与PJP患者预后关系密切。

Objective The clinical features,laboratory indices,and imaging data of patients with Pneumocystis jirovecii pneumonia(PJP)were described and analyzed,aiming to provide helpful information for the diagnosis and treatment of PJP.Methods A retrospective study were conducted with data from 154 PJP patients who visited China-Japan Friendship Hospital from May 2017 to August 2020.Their clinical characteristics,laboratory and imaging data,and clinical outcomes were collected for analysis.The patients were further divided into the death group(51 cases)and the survival group(103 cases).The differences between the groups were compared by using t-test,nonparametric test,and chi-square test.Results Of the 154 PJP patients,there were 89 males and 65 females,with a mean age of(53.7±14.8)years.Among them,85.7%(132/154)were on immunosuppressive/glucocorticoids agents within the past month.Besides,27.9%(43/154)and 33.1%(51/154)had kidney diseases and connective tissue diseases,respectively.The major clinical manifestations in these patients involved fever 82.9%(126/154),cough 59.7%(92/154),and dyspnea 52.6%(81/154).For the laboratory data,the lactate dehydrogenase(LDH)was 561.0(434.3,749.0)IU/L and the value increased in 91.3%(95/104)of the patients.The CD4+T-cell lymphocytes in 88.0%(95/108)and 57.4%(62/108)of patients were lower than 400/μl and 200/μl,respectively.Furthermore,(1,3)-β-D glucan(BG)increased in 74.4%(67/90)of PJP patients(≥100.0 ng/L).For the imaging results,chest computed tomography(CT)showed diffuse ground-glass shadows/grid shadows in 90%(117/130)patients.Compared with the survival group,higher LDH[690.5(528.8,932.3)IU/L vs 502.5(381.8,657.0)IU/L,Z=-3.375,P=0.001],white blood cell count(WBC)[9.8(5.8,12.6)×109/L vs 7.3(5.0,10.1)×109/L,Z=-2.392,P=0.017],and age[(69.8±14.5)years vs(50.6±14.0)years,t=-3.756,P=0.001]were found in the death group.Lower lymphocyte ratio[5.3(3.2,9.3)%vs 9.6(5.6,17.2)%,Z=‒3.262,P=0.001]and oxygen partial pressure(PaO2)levels[(73.2±20.5)mmHg vs(64.8±17.7)mmHg(1 mmHg=0.133 kPa),t=2.345,P=0.021]were also observed in the death group.Furthermore,in the death group,the bacterial and fungal infection rate was higher than the rates in the survival group[55.1%(27/51)vs 21.5%(22/103),χ^(2)=15.372,P=0.001].Conclusions Long-term use of immunosuppressive agents or glucocorticoids predispose to PJP.CD4+T-lymphocytes,LDH,and BG might be used as important auxiliary examinations for PJP patients.Age,LDH,WBC,lymphocyte ratio,PaO2 and possible combinations with bacterial or fungal infections are more closely related to the prognostic of PJP patients.