182例天疱疮患者合并感染状况的回顾分析

【摘要】 目的 分析天疱疮患者合并感染的情况和并发感染的危险因素及其对预后的影响。方法 回顾性分析2011年5月至2017年5月于第四军医大学西京皮肤医院住院治疗的182例天疱疮患者的临床资料,分析感染发生率与年龄、病情严重程度、合并症、糖皮质激素最大用量、住院时间及住院费用的关系。采用SPSS 22.0软件,Logistic回归分析首次住院天疱疮患者并发感染的危险因素。结果 182例首次住院患者中,82例（45.05%）出现感染,取77例患者皮损分泌物培养出107株病原菌,其中金黄色葡萄球菌60株（56.07%）,58株对青霉素耐药（96.67%）。182例中,低蛋白血症患者14例,11例发生感染,无低蛋白血症患者168例中69例（41.07%）发生感染。轻度天疱疮患者27例中4例（4.81%）、中度90例中34例（37.7%）、重度65例中42例（67.69%）发生感染。Logistic回归分析显示,低蛋白血症患者感染发生率高于无低蛋白血症患者（OR = 5.559,95% CI 1.053 ~ 29.347,P = 0.043）;与轻度天疱疮患者相比,中度（OR = 4.676,95% CI 1.276 ~ 17.123）、重度（OR = 16.529,95% CI 4.183 ~ 65.314）天疱疮患者感染的发生率均明显升高（P < 0.05或 < 0.001）。性别、疾病类型以及是否合并高血压病、糖尿病对天疱疮患者感染发生率的影响差异无统计学意义（均P > 0.05）。随访145例患者,完全治愈33例,临床治愈67例,好转23例,复发或加重10例,死亡12例。死亡患者中,3例因肺炎、2例因天疱疮加重伴皮肤感染、1例因败血症去世。结论 病情重、低蛋白血症是天疱疮患者感染的危险因素,细菌感染是天疱疮患者常见的合并症,重症感染是导致天疱疮患者死亡的原因之一。     

天疱疮患者感染危险因素分析

目的探讨天疱疮患者感染的危险因素。方法回顾性分析2012-2017年本科58例住院的天疱疮患者的临床特点、感染部位、病原体,分析可能的易感因素。结果有39例发生感染,感染率67.24%;单因素分析显示寻常型天疱疮、口腔受累、病情重、合并糖尿病、低蛋白血症的患者感染率更高,差异有统计学意义(P0.05);病情重、合并糖尿病的患者院感率也更高,差异有统计学意义(P0.05);单独糖皮质激素和糖皮质激素联合环磷酰胺治疗的患者感染率和院感率差异均无统计学意义(P0.05)。多因素分析显示口腔受累(OR=12.373)、病情重(OR=11.300)、合并糖尿病(OR=17.268)、低蛋白血症(OR=8.699)是感染的独立危险因素;病情重(OR=8.390)、合并糖尿病(OR=4.109)也是院感的独立危险因素。结论天疱疮患者病情严重程度、合并糖尿病、低蛋白血症、口腔黏膜损害是感染的危险因素,环磷酰胺的应用没有增加感染的风险。     

天疱疮149例临床分析

目的 总结天疱疮发病的临床规律和特点,探寻最佳治疗方案,为科学治疗天疱疮和改善预后提供依据。方法 回顾性分析1994年4月-2011年1月昆明医学院附属二院皮肤科收治的149例天疱疮住院患者的临床资料。结果 男71例,女78例;平均年龄(46.24±13.10)岁。轻症26例,中症58例,重症65例。轻、中和重症天疱疮患者激素治疗初始用量分别为(42.15±11.60)mg,(76.94±25.80mg)和(104.02±14.31)mg(P<0.05);重症患者中激素联合免疫抑制剂组病情缓解率(82.05%,32/39)高于激素组(57.69%,15/26,P<0.05)。结论 天疱疮好发于中年人,无性别差异。口腔/头皮受累常提示病情严重;激素用量根据病情严重程度而定,激素联合免疫抑制剂治疗优于单用激素;感染是其主要并发症;疾病类型、病情严重程度及是否合并低蛋白血症是影响预后的重要因素。     

天疱疮113例糖皮质激素的初始剂量与预后分析

目的探讨天疱疮患者治疗用糖皮质激素的初始剂量的缓解率和影响因素的相关性。方法对本科2000年1月～2007年10月住院的113例天疱疮患者的临床资料进行回顾性分析。结果113例患者中男61例,女52例,发病年龄11～72岁;12例轻度患者缓解7例,68例中度患者缓解55例,33例重度患者缓解22例,皮损严重程度与缓解率差异无统计学意义(P<0.25),40～60岁最多(67例),其缓解率为86.57%,高于≤40岁组的59.26%和>60岁组的52.63%,有和无口腔黏膜损害者的缓解分别为60.46%和82.86%;伴或不伴有低蛋白血症者的缓解率分别为56.25%和81.48%;差异,均有统计学意义(P均<0.01)。结论糖皮质激素的初始剂量治疗天疱疮损缓解率与患者年龄、黏膜受累情况、血浆蛋白高低相关。单纯依据皮损面积确定糖皮质激素的剂量并不能有效的控制皮损。     

45例大疱性类天疱疮初次住院患者临床回顾性分析

目的总结45例初次住院的大疱性类天疱疮患者的临床特点及治疗经验。方法分析2009年8月—2014年12月45例住院治疗的大疱性类天疱疮患者临床表现、组织病理、免疫病理、治疗方案及并发症等方面的情况。结果 45例住院患者86.67%为老年人,均表现为瘙痒性紧张性大疱,普通组织病理表现为表皮下水疱,直接免疫荧光检查见IgG和(或)C3在基膜带呈线状沉积。6例患者转科或自动出院,入院时均存在低白蛋白血症。余39例患者好转或临床治愈出院,总有效率为86.67%。39例患者中9例单纯使用糖皮质激素治疗,30例糖皮质激素联合免疫抑制剂治疗(主要为甲氨蝶呤)。单纯糖皮质激素治疗组的住院天数显著少于糖皮质激素联合免疫抑制剂治疗组(P0.05)。糖皮质激素联合使用免疫抑制剂治疗感染发生率更高(P0.05)。结论系统使用糖皮质激素是大疱性类天疱疮患者住院治疗的首选,视病情联合免疫抑制剂治疗可以增加疗效,但感染发生率会增加,要警惕低白蛋白血症的危险性。     

天疱疮58例临床分析

目的探讨天疱疮的发病情况及临床特点,总结治疗经验,以期改善其治疗及预后。方法回顾性分析58例天疱疮住院病例。结果58例天疱疮患者均符合典型临床表现,经糖皮质激素或联用免疫抑制剂治疗有效。结论对天疱疮应正确诊断,早期、足量、规则用药,糖皮质激素和免疫抑制剂仍为目前最主要的治疗药物。     

系统性红斑狼疮患者医院感染的临床特点及影响因素

目的探讨系统性红斑狼疮(SLE)患者发生医院感染的临床特点及影响因素,为预防控制医院感染的发生提供参考。方法采取床旁调查和查阅住院病历相结合的方法,根据2001年卫生部《医院感染诊断标准》,将295例SLE患者是否符合医院感染标准分为医院感染组与对照组进行相关因素分析。结果呼吸道及皮肤黏膜是SLE患者最常见的感染部位,其感染率分别为45.6%和18.4%。最常见细菌感染(57.6%),革兰阴性菌、革兰阳性菌分别占38%和19.6%,其中铜绿假单胞菌、鲍氏不动杆菌、大肠埃希菌、金黄色葡萄球菌分别占13.0%、8.7%、5.4%、5.4%;其次为疱疹病毒感染(20.7%);真菌感染占16.3%,其中白色假丝酵母菌占8.7%。使用糖皮质激素治疗后真菌感染率为40.0%,明显高于疱疹病毒及结核感染率,差异有统计学意义(P0.05);低蛋白血症患者普通细菌感染率为63.3%,明显高于真菌、疱疹病毒和结核感染率,差异有统计学意义(P0.05);白细胞减少患者结核感染率为9.1%,与其他组的结核感染率比较,差异无统计学意义(P0.05);从影响医院感染相关因素看,SLE患者住院时间、两个以上器官受损、感染前使用过抗生素治疗、使用糖皮质激素及免疫抑制剂治疗、低蛋白血症和24 h尿蛋白3.5 g是医院感染的主要危险因素,其感染率明显高于对照组。结论呼吸道及皮肤黏膜是SLE患者最常见的感染部位,医院感染病原体以革兰阴性菌为主,其次为革兰阳性菌。通过缩短住院时间、有效控制病情、谨慎使用糖皮质激素和免疫抑制剂、合理使用抗生素、防止多器官功能损伤等有可能减少SLE患者医院感染的发生。     

天疱疮患者桥粒芯糖蛋白抗体水平和疾病活动度关系及变化规律分析

目的 研究56例天疱疮患者疾病严重程度和桥粒芯糖蛋白1（Dsg1）和桥粒芯糖蛋白3（Dsg3）酶联免疫吸附试验（ELISA）指数之间的关系,探讨Dsg ELISA指数在不同型别天疱疮中转归的规律。 方法 用ELISA测定36例寻常型天疱疮和20例落叶型天疱疮患者治疗前、病情缓解且糖皮质激素开始减量时、糖皮质激素减量至相当于初始量1/2时、维持治疗开始时以及随诊2年时体内Dsg1和Dsg3 ELISA指数。 结果 Dsg ELISA指数与天疱疮疾病活动度相关,在疾病缓解时,Dsg ELISA指数下降,与治疗前差异均有统计学意义（P < 0.01）。在患者病情稳定使用维持量糖皮质激素、疗程到2年时,落叶型天疱疮中10例（50%）、寻常型天疱疮中7例（19.4%）Dsg1 ELISA指数出现阴性,只有1例（2.7%）寻常型天疱疮患者Dsg3 ELISA指数阴性。 结论 Dsg ELISA指数和天疱疮患者疾病严重程度相关,可能是一种评估病情的有用指标,可对治疗的有效性作出评价。     

大疱性类天疱疮疾病严重程度与BP180抗体水平关系的研究

目的 研究大疱性类天疱疮患者临床疾病严重程度和BP180抗体滴度之间的关系.方法 用BP180NC16a-ELISA分别测定大疱性类天疱疮患者治疗前,病情缓解、糖皮质激素开始减量时和糖皮质激素减量至相当于泼尼松0.5 mg·kg^-1·d^-1时,体内BP180抗体滴度,观察其与患者病情严重程度的一致性.结果 在治疗前,19例大疱性类天疱疮患者的BP180 ELISA平均A值为0.520(0.832～0.372);在病情得到控制、糖皮质激素准备减量时,其BP180 ELISA平均A值为0.405(O.723～0.204);在病情缓解、糖皮质激素减至相当于泼尼松0.5 mg·kg^-1·d^-1时,其BP180 ELISA平均A值为0.215(0.412～0.093).结论 BP180抗体的滴度与大疱性类天疱疮患者疾病严重程度相关,是一种评估疾病病情的有用手段,也可对治疗的有效性作出评价.     

天疱疮43例临床资料分析

目的 探讨天疱疮各型的临床特征和治疗方法 .方法 对43例天疱疮住院患者的临床资料进行回顾性分析.结果 35.71%的寻常型天疱疮患者出现口腔、外阴黏膜损害,14.29%红斑型天疱疮患者出现口腔溃疡,1例增殖性天疱疮患者表现为近3年口腔黏膜破溃.直接免疫荧光确诊阳性72.72%.糖皮质激素治疗为首选,糖皮质激素联合免疫抑制剂治疗疗效好.结论 直接免疫荧光为诊断天疱疮的常用方法 ,天疱疮的分型是影响激素用量的重要因素,糖皮质激素联合免疫抑制剂是目前治疗此病的主要方法 .     

天疱疮160例临床分析以及死亡病例原因分析

目的总结天疱疮的临床特点、治疗方法及死亡原因。方法对161例天疱疮临床资料进行回顾性分析。结果常见诱因和加重因素为不规则使用激素和精神因素,抗Dsg1/3的阳性率为89%,轻、中、重型的激素使用量和住院天数差异有统计学意义,死亡常见于寻常型和重型天疱疮,肺炎为死亡常见的原因。结论规则使用激素和加强患者心理教育可减少疾病复发,抗Dsg1/3可作为天疱疮常规检查,病情分型影响激素的用量,感染是死亡的常见原因。     

Early treatment of pemphigus does not improve the prognosis A review of 53 patients

Background With the introduction of systemic steroids to control pemphigus vulgaris the prognosis and survival of these patients has changed dramatically. However, in contrast to their beneficial effects, in a once almost inevitably fatal disease, the steroid therapy has created other problems, including cases of mortality. Objective To analyze the possible factors influencing the course and prognosis of the disease and to review the steroid complications in our patients. Methods 53 patients with pemphigus, admitted to the Department of Dermatology of Ichilov Hospital between 1965 and 1989, were studied. Results The total mortality rate of 26.4% (14 patients of 53) in the present study is within the range found by others. A long pretreatment period did not lead to a worse prognosis. Patients with a pretreatment period longer than 6 months had a lower mortality rate than patients with a pretreatment period shorter than 6 months. The age of the patient played a role in determining the outcome of the disease as patients older than 60 years had a worse prognosis compared with patients younger than 50 years, 37.5% of the patients over 60 years died, as compared with a mortality rate of zero in patients younger than 50. This is in accordance with data found by others. Adjuvant therapy with azathioprine was found to improve the prognosis. Patients receiving azathioprine in addition to steroids had a significantly lower mortality rate and fewer exacerbations. Patients with involvement of the mucosa alone had a higher mortality rate than patients with involvement of the skin only and those with involvement of both skin and mucosa had the highest mortality rate. Conclusions Early treatment of pemphigus does not improve the prognosis. Therefore, immediate high-dose treatment in every case of pemphigus doesn't seem absolutely essential any more.     

天疱疮或大疱性类天疱疮合并单纯疱疹病毒感染8例临床特征及治疗分析

目的回顾分析天疱疮/大疱性类天疱疮(BP)合并单纯疱疹病毒(HSV)感染的临床特征及治疗方法。方法回顾分析2016—2021年在武汉市第一医院住院治疗的天疱疮/BP合并HSV感染病例的临床特征及治疗和随访情况。结果 8例天疱疮/BP合并HSV感染患者中, 男2例, 女6例, 年龄(50.6 ± 8.3)岁, 包括5例寻常型天疱疮, 1例落叶型天疱疮, 2例BP。7例合并HSV-1感染, 1例合并HSV-2感染。8例均因天疱疮或BP接受系统糖皮质激素及免疫抑制剂治疗, 并对治疗抵抗入院, 其中7例表现为原发病灶加重或复发, 1例表现为全身皮损增加。HSV感染位于躯干4例, 口腔4例, 头皮3例, 面部2例。皮疹表现为不规则的糜烂面, 伴血痂, 部分为中央有脐凹的脓疱, 7例伴有皮疹处明显疼痛。发生HSV感染时, 6例天疱疮患者抗Dsg1抗体均下降, 5例寻常型天疱疮中4例抗Dsg3抗体下降;2例BP患者中1例抗BP180抗体降低, 1例升高。予足量足疗程抗病毒治疗(伐昔洛韦或更昔洛韦治疗7 ～ 14 d), 所有患者HSV感染均被控制, 自身免疫性大疱性皮肤病严重程度评分较抗病毒治疗前均...     

天疱疮合并单纯疱疹病毒感染的研究进展

【摘要】 病毒感染是天疱疮常见的并发症之一,近年来天疱疮合并病毒感染的相关研究主要集中于单纯疱疹病毒（HSV）。有研究显示,HSV感染会对天疱疮患者的病程、治疗效果甚至皮损形态等产生影响。但由于现有研究在样本量、检验方式等方面存在较多差异,故HSV在天疱疮患者中的发生率及对天疱疮临床特征的总结在各研究结果中差异较大。本文就天疱疮合并HSV感染的发生率及临床特征做一综述,以提高临床医生对该病的认识并为诊治提供依据。     

Treatment of pemphigus vulgaris with pulse intravenous cyclophosphamide.

BACKGROUND--Although corticosteroids have dramatically altered the prognosis in pemphigus vulgaris, morbidity and mortality from systemic corticosteroid side effects remains high. While immunosuppressive agents have been successfully used in pemphigus vulgaris, there is a high incidence of side effects with these agents as well. Particularly bothersome are reports of increased risk of malignancy with long-term use of immunosuppressive agents. For these reasons, we used a protocol that includes low-dose oral cyclophosphamide coupled with pulse intravenous cyclophosphamide in two patients with recalcitrant pemphigus vulgaris. OBSERVATIONS--Both patients responded well to monthly doses of intravenous cyclophosphamide with rapid decrease in the frequency and severity of blistering, resulting in resolution of their disease after 7 and 10 months, respectively. CONCLUSIONS--Pulse doses of immunosuppressive agents appear to be successful in the treatment of pemphigus vulgaris. High-dose steroid therapy can be tapered with the use of this treatment. Because monthly intravenous doses of cyclophosphamide lead to a substantially reduced cumulative dose, when compared with standard oral regimens, the risk of developing malignancy may also be reduced. Further studies using larger groups of patients are needed to evaluate the efficacy of pulse intravenous cyclophosphamide in pemphigus vulgaris. Long-term follow up will be necessary to compare the incidence of malignancy in patients receiving pulse doses of immunosuppressive agents with that in patients receiving continuous oral treatment.     

Therapy of pemphigus. Critical remarks based on 44 clinical cases

The results are evaluated of therapy administered between 1957 and 1983 to 44 patients with pemphigus (28 pemphigus vulgaris, 5 pemphigus vegetans, 11 pemphigus seborrhoicus). The mean initial steroid dosage was 87 mg prednisone equivalent per day. The 5-year survival rate was 83%. Fifteen patients who were additionally treated with azathioprine during the initial phases of the disease had a 5-year survival rate of 100%. However, after having the disease for 5 years 41% of all pemphigus patients have to be rehospitalized. This percentage is only 21% in the group requiring less than 100 mg prednisone per day initially. Mortality related to pemphigus or infection occurs significantly earlier than cardiovascular deaths. The prognosis for survival is relatively good, but the prognosis for recovery remains uncertain. Combined therapy with corticosteroids and azathioprine in the early stages of the disease resulted in a 5-year survival rate of 100%, and is therefore recommended. However, even this therapeutic modality does not change the uncertain prognosis regarding recovery.     

Disseminated cellulitic cryptococcosis in the setting of prednisone monotherapy for pemphigus vulgaris

Cryptococcal infections are seen mainly in immunocompromised hosts. The cutaneous manifestations of infection can include papules, plaques, nodules, vesicles, ulcers, ecchymosis, and, rarely, cellulitis. Cryptococcal meningitis is a life-threatening complication of this disease. Pemphigus vulgaris is a rare auto-immune blistering disease that can also be life-threatening. Treatment of pemphigus commonly entails both corticosteroids and steroid-sparing agents. We present a case of disseminated cryptococcal infection in a patient with pemphigus vulgaris treated with high dose corticosteroids as monotherapy. This case provides an opportunity to discuss the difficulty of managing two potentially mortal conditions in which the treatment of pemphigus vulgaris may exacerbate the disseminated cryptococcal infection.