重度溃疡性结肠炎合并多种机会性感染——诊疗抉择

Severe ulcerative colitis with multiple opportunistic infections-diagnosis and treatment options

重度溃疡性结肠炎(ulcerative colitis, UC)是一种临床急症,处理不当会危及生命。合并机会性感染时,如何权衡原发病治疗与机会性感染治疗是一道临床难题。本文报道1例妊娠期加重的急性重度UC,同时合并巨细胞病毒(cytomegalovirus, CMV)感染与乙型肝炎病毒(hepatitis B virus, HBV)感染,经多学科讨论,使用英夫利西单抗(Infliximab, IFX)治疗1次后好转,出院后病理提示CMV结肠炎,是否加用抗病毒治疗存在争议,又因患者无法按时诊治,后复诊时行IFX药物监测提示血药浓度低,抗抗体阴性,但症状及肠镜均好转,IFX是否优化存在矛盾,经医患共决策后予以优化,目前达到黏膜愈合。该患者起病时具备多种高危因素并合并机会性感染,经积极治疗后避免了外科手术,预后良好。希望通过本例患者的诊治给临床医师提供借鉴。

Severe ulcerative colitis(UC) is a clinical emergency disease, which is serious and develops rapidly, inappropriate management can cause life-threatening situations.When severe UC is combined with opportunistic infection, it is more difficult to treat, especially how to choose between primary disease treatment and opportunistic infection treatment. This case about an acute severe UC patient who aggravated during pregnancy with cytomegalovirus(CMV) infection and previous hepatitis B virus(HBV) infection. After multidisciplinary discussion, Infliximab(IFX) was treated for 1 time and the patient′s symptoms were significantly improved before discharged. After discharge, pathology suggested CMV colitis, and the use of antiviral therapy was controversial.Affected by the epidemic, neither primary disease nor CMV colitis can be treated as prescribed. The patient come for a follow-up visit, and her symptoms, the colonoscopy were significantly improved, and the pathological CMV immunohistochemistry was negative.However, the serum concentration of IFX was low, test for anti-antibody was negative.Again, there was disagreement over whether to optimize treatment. Finally, we choose the treatment with the patient, and achieved clinical and endoscopic remission. The patient had multiple risk factors associated with opportunistic infections, after active treatment, surgery was avoided and she achieved a good prognosis. We hope that the diagnosis and treatments of this patient will be helpful to clinicians.