获得性免疫缺陷综合征合并内脏利什曼病并发噬血细胞综合征一例

doi:10.3877/cma.j.issn.1674-1358.2024.02.009

中华实验和临床感染病杂志(电子版) ›› 2024, Vol. 18 ›› Issue (02) : 117 -121. doi: 10.3877/cma.j.issn.1674-1358.2024.02.009

病例报告

获得性免疫缺陷综合征合并内脏利什曼病并发噬血细胞综合征一例

刘杰¹, 宋世会¹, 邹诗¹, 骆名其¹, 梁科²^,^†(

)

^1. 430071　武汉市，武汉大学中南医院感染科
^2. 430071　武汉市，武汉大学中南医院感染科；430071　武汉市，武汉大学中南医院医院感染管理办公室；430071　武汉市，中国医学科学院武汉感染性疾病及肿瘤研究中心；430071　武汉市，感染性疾病精准防控与诊治湖北省工程研究中心

收稿日期:2023-08-22 出版日期:2024-04-15
通信作者: 梁科
基金资助:
中国医学科学院中央级公益性科研院所基本科研业务费专项资金(No. 2020-PT320-004); 武汉大学中南医院科技创新培育基金(No. cxpy2017043); 武汉大学创新平台支撑项(No. PTXM2020008)

A case of acquired immune deficiency syndrome with visceral leishmaniasis complicated with hemophagocytic syndrome

Jie Liu¹, Shihui Song¹, Shi Zou¹, Mingqi Luo¹, Ke Liang²^,^†()

^1. Department of Infectious Diseases, Zhongnan Hospital of Wuhan University, Wuhan 430071, China
^2. Department of Infectious Diseases, Zhongnan Hospital of Wuhan University, Wuhan 430071, China; Department of Nosocomial Infection Management, Zhongnan Hospital of Wuhan University, Wuhan 430071, China; Wuhan Research Center for Infectious Diseases and Cancer, Chinese Academy of Medical Sciences, Wuhan 430071, China; Hubei Engineering Center for Infectious Diseases Prevention, Control and Treatment, Wuhan 430071, China

Received:2023-08-22 Published:2024-04-15
Corresponding author: Ke Liang

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引用本文：

刘杰, 宋世会, 邹诗, 骆名其, 梁科. 获得性免疫缺陷综合征合并内脏利什曼病并发噬血细胞综合征一例[J]. 中华实验和临床感染病杂志(电子版), 2024, 18(02): 117-121.

Jie Liu, Shihui Song, Shi Zou, Mingqi Luo, Ke Liang. A case of acquired immune deficiency syndrome with visceral leishmaniasis complicated with hemophagocytic syndrome[J]. Chinese Journal of Experimental and Clinical Infectious Diseases(Electronic Edition), 2024, 18(02): 117-121.

目的

探讨宏基因组学测序（mNGS）在获得性免疫缺陷综合征（AIDS）合并利什曼病诊治中的价值，提高临床对利什曼病的认知及诊疗水平。

方法

回顾性分析2021年12月28日武汉大学中南医院收治的1例AIDS合并内脏利什曼病（VL）并发噬血细胞综合征患者的临床资料及诊疗经过。

结果

该患者因发热入院，入院后辅助检查提示外周血粒系、红系、巨核系细胞减少、肝肾功能不全、低纤维蛋白原血症、炎症指标水平明显升高，骨髓细胞学提示噬血现象，常规检查诊断不明确且经验性抗感染治疗无效，送检外周血mNGS检出利什曼原虫序列1 262条（杜氏利什曼原虫序列80条，婴儿利什曼原虫20条），最终诊断为AIDS合并内脏利什曼病、噬血细胞综合征，予以葡萄糖酸锑钠（0.6 g/d静脉注射，疗程为10 d）及比克替拉韦/恩曲他滨/丙酚替诺福韦（50 mg/200 mg/25 mg口服）抗HIV治疗后好转出院，院外随访未见复发。

结论

mNGS具有重要诊断价值，尤其对常规检查诊断不明的AIDS患者。AIDS患者尽早启动HARRT，对改善患者预后、预防VL复发具有重要意义。

关键词: 利什曼病, 噬血细胞综合征, 获得性免疫缺陷综合征

Objective

To investigate the potential benefits of metagenomics next-generation sequencing (mNGS) on diagnosis for patients with acquired immune deficiency syndrome (AIDS) and Leishmaniasis, and to improve the diagnostic and therapeutic understanding of leishmaniasis.

Methods

The clinical records, diagnosis and treatment of a patient with AIDS complicated by hemophagocytic syndrome due to visceral leishmaniasis (VL) admitted to Zhongnan Hospital of Wuhan University on December 28th, 2021 were reviewed, retrospectively.

Results

The patient was admitted to hospital presenting with fever. After admission, the laboratory investigations revealed peripheral blood pancytopenia, hepatorenal dysfunction, hypofibrinogenemia and markedly elevated inflammatory markers. Hemophagocytic syndrome was confirmed by bone marrow biopsy. However, no positive pathogens were found after various etiological examinations, and antibiotic therapy was ineffective. Total of 1 262 sequences of Leishmania parasites (80 sequences of Leishmania donovani and 20 sequences of Leishmania infantum) were identified from the peripheral blood of the patient through mNGS. Ultimately, a diagnosis of AIDS with concurrent visceral leishmaniasis and hemophagocytic syndrome was established. After sodium antimony gluconate (0.6 g/d, intravenous injection during a course of 10 d) and buctillavir/emtricitabine/propofol tenofovir (50 mg/200 mg/25 mg, oral) for anti-HIV treatment, the patient were improved and discharged, and no recurrence was observed during the follow-up.

Conclusions

mNGS is proved to be an effective diagnostic method, especially for patients with HIV/AIDS who cannot be conclusively diagnosed through conventional laboratory tests. HAART at an early stage of AIDS patients is of significant importance for improving the prognosis and preventing the recurrence of VL.

Key words: Leishmaniasis, Hemophagocytic syndrome, Acquired immune deficiency syndrome

图1 患者腹部CT变化注：A、B、C：锑剂治疗前、治疗第7天及治疗后1个月肝脾肿大；D、E、F：锑剂治疗前、治疗第7天及治疗后1个月腹膜后淋巴结肿大

图2 患者外周血mNGS检测结果注：序列数：高通量测序数据中唯一比对到某属或某种的特异性序列数量；相对丰度：将病原体根据细菌、真菌、病毒和寄生虫进行分类，计算该病原体所在属在相应分类中基因组的相对比例

表1 患者实验室指标

实验室指标	入院时	葡萄糖酸锑钠治疗				出院1个月后
实验室指标	入院时	第1天	第2天	第6天	第10天	出院1个月后
WBC（G/L）	2.10	1.70	3.76	1.40	2.87	4.71
HGB（g/L）	102.0	100.0	89.3	86.0	81.7	101.0
PLT（G/L）	50.0	113.0	104	131	169	196
ALT（U/L）	217	72	60	51	50	34
AST（U/L）	499	146	1120	116	86	28
TBil（μmol/L）	99.3	37.0	35.1	29.5	23.0	17.4
BUN（mmol/L）	15.35	7.50	8.00	4.65	3.44	7.50
Scr（μmol/L）	234.9	178.0	94.5	78.9	87.3	114.6
FIB（mg/dl）	125	101	91	118	125	—
PCT（ng/ml）	2.66	—	—	0.66	0.23	—
CD4⁺ T细胞（个/μl）	211	—	—	—	—	672

表1 患者实验室指标

实验室指标	入院时	葡萄糖酸锑钠治疗				出院1个月后
实验室指标	入院时	第1天	第2天	第6天	第10天	出院1个月后
WBC（G/L）	2.10	1.70	3.76	1.40	2.87	4.71
HGB（g/L）	102.0	100.0	89.3	86.0	81.7	101.0
PLT（G/L）	50.0	113.0	104	131	169	196
ALT（U/L）	217	72	60	51	50	34
AST（U/L）	499	146	1120	116	86	28
TBil（μmol/L）	99.3	37.0	35.1	29.5	23.0	17.4
BUN（mmol/L）	15.35	7.50	8.00	4.65	3.44	7.50
Scr（μmol/L）	234.9	178.0	94.5	78.9	87.3	114.6
FIB（mg/dl）	125	101	91	118	125	—
PCT（ng/ml）	2.66	—	—	0.66	0.23	—
CD4⁺ T细胞（个/μl）	211	—	—	—	—	672

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A case of acquired immune deficiency syndrome with visceral leishmaniasis complicated with hemophagocytic syndrome