HLA半相合骨髓移植后并发肺结核四例

目的 探讨HLA半相合骨髓移植后并发肺结核的诊断与治疗.方法 4例白血病患者,采用阿糖胞苷、环磷酰胺及直线加速器全身照射进行预处理,然后接受HLA半相合未去T淋巴细胞骨髓移植.移植后采用环孢素A、短程甲氨蝶呤、霉酚酸酯、抗CD25单克隆抗体和抗胸腺细胞球蛋白预防移植物抗宿主病.4例均获造血重建.4例分别于移植后150 d、120 d、47 d和43 d出现高热,伴轻度咳嗽,痰少,或干咳无痰;肺部CT检查,均有异常改变,但无特征性;结核菌素试验及结核菌素抗体试验均呈阴性反应;既往均无结核病史及接触史.例1经开胸肺活检病理诊断为增殖性肺结核,另3例抗结核治疗有效,确立肺结核诊断.采用利福平、链霉素、吡嗪酰胺及异烟肼抗痨治疗9～12个月.结果 4例患者经抗结核治疗,体温下降,肺部病灶明显缩小、吸收,除1例因急性移植物抗宿主病死亡外,其余3例患者均存活.治疗期间,维持原免疫抑制方案,1例血环孢素A浓度一度较低,增加CsA剂量后恢复至正常范围.结论 HLA半相合骨髓移植后并发的结核感染,其临床表现不典型,肺部CT表现无特征性,应注意与其它感染相鉴别,抗结核治疗有效.

Pulmonary tuberculosis in HLA-haploidentical bone marrow transplantation recipients:report of 4 cases

Objective To investigate the diagnostic and treatment modalities of pulmonary tuberculosis in patients after HLA-haploidentical bone marrow transplantation(BMT).Methods Four patients with leukemia received HLA-haploidentical bone marrow grafts without T Lymphocyte depletion after preconditioning with cytosine arabinoside,eyelophosphamide and total body irradiation with a linear accelerator.Graft versus host disease was prevented by the administration of a combination of immunosuppressive drugs including eyclosporine A,short-course MTX,mycophenolate mofetil,antiCD25 monoclonal antibody and ATG.All four cases achieved hematopoietic reconstruction and presented high fever complicated with mild cough with little or no sputum on day 43,47,120,and 150 after transplantation respectively.CT scan of the lungs showed abnormalities without any characteristic lesions.They were devoid of tuberculosis history and negative for both tuberculosis skin and antibody tests.One case was diagnosed as proliferative pulmonary tuberculosis by histological examination on the lung biopsy after thoracotomy.The other 3 cases were diagnosed by empiric anti-tuberculosis treatment,which included a combination of Rifampin,streptomycin sulfate,pyrazinamide and isonicotinyl hydrazide and persisted for 9 to 12 months.Results After anti-tuberculosis treatment,the temperature of all 4 patients recovered to normal and the foci dwindled or disappeared as identified by CT scan.Three patients survived and one died of acute graft versus host disease.Immunosuppressive therapy was continued during anti-tuberculosis treatment.and the serum 1evel of cyclosporine A was reduced in one patient and reached tO the normal range after a dose raise.Conclusion The clinical features and CT scan examination of pulmonary tuberculosis are atypical in patients after HLA-haploidentical BMT.which might result in confusion with other pulmonary infections.Good response to treatment with standard anti-tuberculosis drugs may provide supportive information for differentiaI diagnosis.