发热伴血小板减少综合征患者临床特征及预后分析

Clinical Features and Prognosis of Patients with Fever with Thrombocytopenia Syndrome

目的分析发热伴血小板减少综合征(SFTS)流行病学、临床特征及预后,并进一步明确预后不良独立性风险因素,以期为SFTS预防及诊疗提供关键指导。方法以2021年3月~2022年11月经联勤保障部队第九九〇医院感染科收治的869例SFTS病例作回顾性分析,运用描述流行病学方案分析SFTS流行特点及临床特征,且根据预后情况分为预后良好组(n=754例)、预后不良组(n=115例),收集两组人口学信息、临床特征(包括临床表现及实验室指标)行单因素及Logistic回归模型多因素分析明确预后不良独立性风险因素。结果869例SFTS病例中2021年收治412例(47.41%)、2022年收治457例(52.59%);男376例,女493例,男女比例1:1.31;发病年龄中位数61岁,60~69年龄段发病率最高,达35.44%(308/869);发病时间分布于4~11月,以5~8月为发病高峰期,尤以5月发病率最高,达24.28%(211/869);信阳市下辖8县2区中以商城县、光山县发病率居1、2位,占比依次为28.65%(249/869)、22.90%(199/869),固始县最低,占比为1.96%(17/869);发病人群中职业以农民为主,占比达94.02%(817/869),其他职业5.98%(52/869);852例(98.04%)于发病2周内存在户外活动或劳作史,302例(34.75%)明确有蜱叮咬史;869例SFTS病例均因急性发作前来就诊,就诊时间1-18d,平均(5.45±2.10)d,首发症状以发热为主,占比99.54%(865/869),其次为食欲不振、恶心、呕吐、乏力及淋巴结肿大等,部分病例存在腹泻、肌肉酸痛、咳嗽咳痰及皮疹。若病情严重者,还可引发早期出血及神经系统症状;869例SFTS病例中WBC下降857例(98.62%),PLT下降854例(98.27%),HGB下降157例(18.07%);尿蛋白阳性532例(61.22%);尿潜血阳性72例(8.29%);LDH升高843例(95.74%)、CK升高627例(72.15%)、AST升高857例(98.62%),ALT升高561例(64.56%),ALB下降415例(47.76%),Tn I上升316例(36.36%)、Scr上升165例(18.99%)、BUN上升184例(21.17%);PT延长89例(10.24%),APTT延长406例(46.72%),FIB降低149例(17.15%)、D-D升高431例(49.60%);PaO_(2)降低167例(19.22%)、PaCO_(2)升高152例(17.49%);高SFTSV载量278例(31.99%);869例SFTS病例中重症例数214例,重症率24.63%,经救治后死亡115例,死亡率13.23%;除性别、WBC、HGB、尿蛋白、尿潜血及FIB外,两组年龄、合并症、就诊时间、早期出血、神经系统症状、PLT、AST、ALT、ALB、LDH、CK、Tn I、Scr、BUN、PT、APTT、D-D、PaO_(2)、PaCO_(2)及SFTSV载量比较,差异有统计学意义(P<0.05);经Logistic回归模型多因素分析结果显示:影响预后不良独立性风险因素为年龄、就诊时间、早期出血、神经系统症状、AST、ALT、LDH、CK、APTT、D-D、PaO_(2)、PaCO_(2)及SFTSV载量。结论SFTS流行特征明显,且临床特征典型,尤需对高龄、就诊时间延迟、出现早期出血或神经系统症状、生化,凝血,血气分析指标异常及SFTSV高载量患者诊治引起重视,有利于降低预后不良风险。

Objective To analyze the epidemiology,clinical features and prognosis of severe fever with thrombocytopenia syndrome(SFTS),and further identify the independent risk factors for poor prognosis,in order to provide key guidance for the prevention and diagnosis of SFTS.Method A retrospective analysis was conducted on 869 cases of SFTS admitted to the Department of Infection of the 99th Hospital of the Joint Logistic Support Force from March 2021 to November 2022.The epidemiological and clinical characteristics of SFTS were analyzed by descriptive epidemiological protocol.According to the prognosis,the patients were divided into good prognosis group(n=754 cases)and poor prognosis group(n=115 cases).Demographic information,clinical features(including clinical manifestations and laboratory indicators)of the two groups were collected and univariate and Logistic regression model multivariate analysis was performed to identify independent risk factors for poor prognosis.Results Of the 869 SFTS cases,412(47.41%)were admitted in 2021 and 457(52.59%)in 2022.There were 376 males and 493 females,with a male to female ratio of 1:1.31;The median age of onset was 61 years old,and the highest incidence rate was 35.44%(308/869)between 60 and 69 years old.The onset time was from April to November,and the peak period was from May to August,with the highest incidence in May(24.28%,211/869).Among the 8 counties and 2 districts under the jurisdiction of Xinyang City,Shangcheng County and Guangshan County ranked first and second,accounting for 28.65%(249/869)and 22.90%(199/869),respectively.Gushi County was the lowest,accounting for 1.96%(17/869).Farmers were the main occupations,accounting for 94.02%(817/869),other occupations 5.98%(52/869).852 cases(98.04%)had a history of outdoor activities or work within 2 weeks of onset,and 302 cases(34.75%)had a definite history of tick bites.All 869 cases of SFTS came to the clinic due to acute attack,with a mean of(5.45±2.10)d from 1 to 18d.The first symptoms were mainly fever,accounting for 99.54%(865/869),followed by loss of appetite,nausea,vomiting,fatigue and lymph node enlargement.In some cases,diarrhea,muscle soreness,cough,phlegm,and rash were present.In severe cases,it can also cause early bleeding and neurological symptoms;Among 869 cases of SFTS,WBC decreased by 857 cases(98.62%),PLT decreased by 854 cases(98.27%)and HGB decreased by 157 cases(18.07%).Urine protein positive in 532 cases(61.22%);Urinary occult blood was positive in 72 cases(8.29%).LDH increased in 843 cases(95.74%),CK increased in 627 cases(72.15%),AST increased in 857 cases(98.62%),ALT increased in 561 cases(64.56%),ALB decreased in 415 cases(47.76%).TnⅠincreased in 316 cases(36.36%),Scr increased in 165 cases(18.99%)and BUN increased in 184 cases(21.17%).PT was prolonged in 89 cases(10.24%),APTT was prolonged in 406 cases(46.72%),FIB was decreased in 149 cases(17.15%)and D-D was increased in 431 cases(49.60%).PaO_(2)decreased in 167 cases(19.22%)and PaCO_(2)increased in 152 cases(17.49%).278 cases(31.99%)had high SFTSV load;Among 869 cases of SFTS,214 cases were in severe condition,with a severe rate of 24.63%.115 cases died after treatment,with a mortality rate of 13.23%.In addition to gender,WBC,HGB,urinary protein,urinary occult blood and FIB,age,complications,time of visit,early bleeding,neurological symptoms,PLT,AST,ALT,ALB,LDH,CK,TnⅠ,Scr,BUN,PT,APTT,D-D,PaO_(2),PaCO_(2)and SFTSV load were compared between the two groups.The difference was statistically significant(P<0.05).Multivariate analysis of Logistic regression model showed that the independent risk factors affecting poor prognosis were age,time of visit,early bleeding,neurological symptoms,AST,ALT,LDH,CK,APTT,D-D,PaO_(2),PaCO_(2)and SFTSV load.Conclusions The prevalence of SFTS is obvious,and the clinical characteristics are typical.Especially,attention should be paid to the diagnosis and treatment of patients with advanced age,delayed treatment time,early bleeding or neurological symptoms,abnormal biochemical,coagulation,blood gas analysis indexes,and high SFTSV load,which is conducive to reducing the risk of poor prognosis.