异基因造血干细胞移植后合并结核病的临床分析

Clinical diagnosis of tuberculosis after allogeneic hematopoietic stem cell transplantation:a retrospective study

目的探讨异基因造血干细胞移植(hematopoietic stem cell transplantation,HSCT)后合并结核病(tuberculosis,TB)的临床特征及治疗疗效。方法研究共纳入16例异基因造血干细胞移植后合并结核病患者。回顾性分析16例患者的临床特点、实验室检查及治疗疗效。结果16例结核病患者的发病时间为HSCT后20 d~2 a,以1 a内发病多见。15例为继发型肺结核,1例为血行播散型肺结核;单纯肺结核9例,合并肺外结核7例。发热、咳嗽、咳痰为首要的临床表现。3例治愈,4例仍在治疗中,2例因Ⅳ级骨髓抑制或重度肝功能损害中断治疗,1例失访,6例死亡。结论异基因造血干细胞移植患者并发结核病时,临床症状不具有特异性,常规病原学检查阳性率低,纤支镜检查、分子生物学检查及结核分枝杆菌γ-干扰素释放试验检查可显著提高诊断率。移植后早期要重视结核病的发生。在治疗异基因造血干细胞移植后并发结核病的患者时应当注重合理选择抗结核药物,以减轻骨髓毒性为重点,兼顾应用免疫抑制剂与抗结核药物,个体化治疗,降低患者的药物不良反应。

Objective To investigate the clinical characteristics and therapeutic efficacy of tuberculosis(TB)after allogeneic hematopoietic stem cell transplantation(HSCT).Methods The clinical characteristics,laboratory tests and therapeutic efficacy of 16 patients with TB after HSCT were retrospectively analyzed.Results The TB in the 16 patients break out 20 days to 2 years after HSCT,the majority occurring within 1 year.They were classified into 15 cases of secondary tuberculosis and 1 case of disseminated tuberculosis,or into 9 cases of pulmonary tuberculosis and 7 cases of extrapulmonary tuberculosis according to different types.The primary clinical manifestations were fever,cough and expectoration.Three cases were cured and four cases were under treatment.Two cases were respectively discontinued due to grade 4 myelosuppression or severe liver function damage.One case fell out of touch during follow-up,and six cases died.Conclusion TB infection after HSCT shows non-specific clinical symptoms and low positive rate by routine pathogenic examination.However,the diagnosis rate can be significantly improved by fiberoptic bronchoscopy,molecular biological examination and mycobacterium tuberculosis interferon-γrelease assays(IGRAs).Attention should be paid to the occurrence of tuberculosis in the early stage after transplantation.For the treatment of patients with TB after HSCT,anti-tuberculosis drugs must be rationally select to alleviate the toxicity of bone marrow and strike a balance with immunosuppressive agents based on personalized medicine for the purpose of reducing adverse side effects.