HIV阴性急性白血病患者化疗后并发耶氏肺孢子菌肺炎1例报告及文献复习

摘要

目的:探讨人类免疫缺陷病毒 (HIV) 阴性血液病患者并发耶氏肺孢子菌肺炎 (PCP) 的临床特点, 分析其高危因素、治疗方法、预后和预防措施.方法:1例18岁女性急性髓系白血病患者, 在巩固化疗血象恢复正常后出现胸闷、憋气, 血氧饱和度下降, 胸部CT提示双肺出现弥漫磨玻璃影, 经抗细菌治疗5d无效, 出现干咳, 血氧饱和度进行性下降至75％, 复查胸部CT示双肺磨玻璃影范围增大, 考虑为PCP, 予复方磺胺甲恶唑 (TMP/SMZ) 1g、每6h1次联合卡泊芬净治疗.结果:治疗2d后患者症状无改善, 转至ICU, 经支气管肺泡灌洗确诊PCP, 予TMP/SMZ 2g、每8h1次联合卡泊芬净抗PCP, 同时予双水平气道正压 (Bipap) 通气, 5d后症状改善, 停呼吸机辅助呼吸, 继续治疗5d后好转出院, 院外单用TMP/SMZ 2g、每8h1次, 共口服36d痊愈停药.结论:HIV阴性急性白血病化疗患者要注意PCP的预防.未行预防的血液病患者, 一旦在非粒细胞缺乏期出现疑似PCP的临床表现, 要考虑PCP诊断.及早行经验性抗PCP治疗, 一旦发生呼吸衰竭及时转入ICU是减少死亡和改善预后的关键.%Objective:To discuss the clinical characteristics of the Pneumocystis jirovecii pneumonia (PCP) in the non-HIV-infected blood disease patients, and to analyze its risk factors, treatment methods, prognosis and prevention measures.Methods:A female patient aged 18years old was confirmed as acute myeloid leukemia (AML) , and experienced dyspnea, chest congestion and hypoxaemia during the recovery period of hemogram after chemotherapy.The chest CT showed the bilateral lung diffuse ground glass density images.The patient had a dry cough and the oxygen saturation was gradually decreased to 75％5dafter antibacteriological treatment.A repeat chest CT showed enlarged diffuse ground glass density images on both lungs.Considering about the possibility of PCP, the patient received oral trimethoprim/sulfamethoxazole (TMP/SMX) 1g, once every 6h, in combination with caspofungin.Results:Two days later, the symptoms of the patients were not improved.The patient was transferred to ICU and was diagnosed PCP by bronchoalveolar lavage.The patient was switched to oral TMP/SMX2g, once every 8h, in combination with caspofungin.Meanwhile, the patient received bi-level positive airway pressure ventilation (Bipap) for the increased work of breathing.Five days later, the symptoms of the patients were improved and the Bipap was stopped.The patient got better and discharged 5dlater.The patient continuely received oral TMP/SMX 2g, once every 8hfor 36d.Conclusion:Prevention of PCP should be focused, in the non-HIV-infected blood disease patients receiving chemotherapy.Diagnosis of PCP should be considered in these patients without prevention who once have suspected clinical manifestation of PCP in non-granulocytic phase.Early empirical treatment of PCP and ICU management in the non-HIV-infected blood disease patients with acute respiratory failure are the keys to reduce death and improve the prognosis of PCP.