肝移植术后耶氏肺孢子菌肺炎5例诊治经验总结

Managements of Pneumocystis jirovecii pneumonia after liver transplantation:a report of 5 cases

目的总结原位肝移植术后早期耶氏肺孢子菌肺炎(Pneumocystis jirovecii pneumonia,PJP)的诊治经验,探讨发病的危险因素及治疗方案的优化。方法回顾性分析西安交通大学第一附属医院外科重症医学科2020年12月至2023年12月收治的5例肝移植术后PJP病人的临床资料,从疾病临床表现、早期诊断、治疗方案制定、治疗过程监测、病情转归等方面总结诊治经验。结果5例病人中男性3例,女性2例,均通过宏基因组二代测序(metagenomics next generation sequencing,mNGS)技术证实耶氏肺孢子菌感染,血清1,3-β-D葡聚糖定量检测(G试验)、乳酸脱氢酶(lactate dehydrogenase,LDH)阳性率均为100%;经口气管插管接呼吸机辅助呼吸2例,其中1例死亡,1例自动出院;3例病人接受无创呼吸机或经鼻高流量吸氧辅助,最终康复。结论将肺泡灌洗液早期送检mNGS可快速明确病原体,弥补传统检验缺陷;G试验、LDH在PJP中升高显著,对该病原体感染诊断具有较高的敏感性,但不具备特异性;治疗过程中,需根据病人免疫状态、器官功能状态及临床表现动态调整免疫抑制剂方案、抗生素剂量以达到治疗目标;接受有创机械通气病人病死率高。

Objective To summarize the managements of Pneumocystis jiroveci pneumonia(PJP)in an early stage after orthotopic liver transplantation(LT),explore the risk factors for an onset of disease and optimize its therapeutic outcomes.Methods From December 2020 to December 2023,the relevant clinical data were retrospectively reviewed for 5 PJP patients after LT.The diagnostic and therapeutic experiences were summarized from the aspects of clinical manifestations,early diagnosis,treatment planning,process monitoring and disease outcomes.Results There were 3 males and 2 females.A definite diagnosis of PJP was made by metagenomic next generation sequencing(mNGS).The positive rates of serum(1,3)-β-D-glucan assay(G assay)and lactate dehydrogenase(LDH)were both 100%.Two patients received oral endotracheal intubation and ventilator-assisted breathing.One case died while the remainders were discharged smoothly.Three patients received non-invasive ventilation or nasal high-flow oxygen inhalation assistance and eventually recovered.Conclusion Early detection of mNGS in bronchoalveolar lavage fluid may quickly identify the pathogens and compensate for the deficiencies of traditional testing methods.The levels of G assay and LDH are markedly elevated in PJP.With a high sensitivity in diagnosing the pathogen of infection,it is not specific.During treatments,it is necessary to dynamically adjust immunosuppressive regimens and antibiotic doses based upon immune status,organ function status and clinical manifestations.Mortality rate of patients on invasive mechanical ventilation remains high.