信迪利单抗致免疫相关肺炎的临床特征及案例分析

Clinical characteristics and case analysis of immune-related pneumonia induced by sindilizumab

目的总结4例信迪利单抗致免疫相关肺炎患者的临床症状、影像学、实验室检验指标、治疗方案和随访情况,为此类患者的治疗提供参考。方法回顾4例免疫相关肺炎患者的治疗过程,结合文献分析该类患者的治疗特点。结果4例患者发生免疫相关肺炎之前使用信迪利单抗治疗的时间依次为6.4、10.5、5.3、3.9个月,中位时间5.85个月。3例患者初始临床症状为胸闷、气短、咳嗽及乏力,1例无明显临床症状。4例患者胸部电子计算机断层扫描(CT)呈斑片状高密度影,其中1例患者行电子支气管镜检查,发现有肉芽样新生物增生,其余3例未行电子支气管镜检查。4例患者初始中性粒细胞比率轻度升高,超敏C反应蛋白升高,降钙素原基本正常,痰细菌和真菌培养、G/GM试验结果均呈阴性。治疗方案中,4例免疫相关肺炎患者停用信迪利单抗,初始使用甲泼尼龙琥珀酸钠或联合吗替麦考酚酯治疗有效。患者出院序贯口服糖皮质激素,在逐渐减量并停药后或治疗过程中出现了免疫相关肺炎复发,合并肺部感染,其中3例治疗无效,死于免疫相关肺炎合并感染性肺炎导致的呼吸衰竭,1例患者病情缓解。结论糖皮质激素或联合吗替麦考酚酯可有效治疗信迪利单抗致免疫相关肺炎,但再次复发风险较高,且常合并感染性肺炎,死亡率高。故临床治疗信迪利单抗致免疫相关肺炎时,糖皮质激素需逐渐减量、足疗程使用。

Objective To summarize the clinical symptoms,imaging,laboratory test indicators,treatment plans and follow-up of 4 patients with immune-related pneumonia induced by sindilizumab,so as to provide references for the treatment of such patients.Methods The treatment process of 4 patients with immune-related pneumonia was reviewed,and the treatment characteristics of these patients were analyzed based on the literatures.Results The treatment time with sindilizumab before immune-related pneumonia in 4 patients was 6.4,10.5,5.3,3.9 months,with a median of 5.85 months.The initial clinical symptoms of 3 patients were chest tightness,shortness of breath,cough and fatigue,and a patient did not have obvious clinical symptoms.The chest computed tomography(CT)of 4 patients showed patchy high density shadows.A patient underwent electronic bronchoscopy and was found granulation like neoplasia,while the other 3 patients did not underwent electronic bronchoscopy.In 4 patients,the initial neutrophil ratio increased slightly,the hypersensitive C-reactive protein increased,the procalcitonin was basically normal,and the sputum bacterial and fungal culture,and G/GM test results were negative.In the treatment plans,4 patients with immune-related pneumonia stopped using sindilizumab and were initially effectively treated with methylprednisolone or combined with mycophenolate mofetil.After discharge,all patients were given sequential oral administration of glucocorticoids;after gradual reduction and withdrawal of medication or during treatment,immune-related pneumonia recurred and were complicated with pulmonary infection;among them,3patients died of respiratory failure caused by immune-related pneumonia complicated with pulmonan infection,and a patient was in remission.Conclusion Glucocorticoid or combined with mycophenolate mofetil can effectively treat immunerelated pneumonia induced by sindilizumab,but the risk of recurrence is high and often complicated with infectious pneumonia infection,with high mortality.Therefore,in the clinical treatment of immune-related pneumonia induced by sindilizumab,the glucocorticoid should be gradually reduced and treated in full course.