摘要
目的探讨以皮疹为主要表现的急性移植物抗宿主病(aGVHD)在免疫监控指导下的精准诊疗效果。方法回顾1例因高危急性髓系白血病接受非血缘脐血移植、其后出现顽固性皮疹的患儿的临床资料及诊治过程,以“造血干细胞移植”“免疫重建”和“急性移植物抗宿主病”的中英文为检索词,对以下数据库的相关论文进行检索:PubMed、Web of Science、CNKI、万方数据知识服务平台,收集检索到的病例资料并进行分析。结果该例1岁9月龄女性患儿成功获得造血重建,移植后22 d患儿头部、后颈部出现密集红色丘疹(面积约19%)、瘙痒明显,口服他克莫司、外用激素类药物后皮疹无好转(面积>90%),此时监测CD3^(+)细胞、CD8^(+)细胞、CD3^(+)CD69^(+)细胞、CD3^(+)HLADR^(+)细胞比例明显升高,调节性T细胞(Treg)比例下降。免疫指标支持T淋巴细胞活化,考虑Ⅱ度aGVHD(皮肤3级),遂予加强免疫抑制治疗方案。期间患儿皮疹有消退,但仍反复,并伴皮肤明显脱屑,复查CD3^(+)细胞、CD8^(+)细胞、CD3^(+)HLA-DR^(+)细胞比例仍偏高,遂再次调整治疗方案、加强抗排斥,患儿皮肤aGVHD好转。定期监测原发病完全缓解、植入比例100%、免疫重建稳定,随访至移植后32个月,患儿无病存活。检索到相关文献9篇,均论证了早期CD3^(+)细胞、CD8^(+)细胞、活化T淋巴细胞比例升高以及Treg下调与aGVHD发生相关。结论对异基因造血干细胞移植术后患者的免疫状态进行动态监测,有利于评估其免疫重建情况及疾病状态(如aGVHD),有助于制定合理的免疫抑制治疗方案,使患者获得良好预后。
Objective To explore the effect of the precise diagnosis and treatment of a case of acute graft-versus-host disease(aGVHD)with rash as the main manifestation under the guidance of immune monitoring.Methods Clinical data and diagnosis and treatment of a child with high-risk acute myeloid leukemia who developed intractable rash after receiving unrelated umbilical cord blood transplantation were retrospectively analyzed.Using the keywords of“hematopoietic stem cell transplantation”“immune reconstitution”and“acute graft-versus-host disease”,relevant literatures were searched from PubMed,Web of Science,CNKI and Wanfang databases,and relevant cases were collected and analyzed.Results Hematopoietic reconstruction was successfully achieved in this 1 year 9 months old girl.On day 22 after transplantation,the skin of head and back neck of the patient showed dense red papules(approximately 19%in area),with obvious itching.Under the treatment of oral tacrolimus and topical hormone drugs,the rash was not alleviated(area>90%).Meanwhile,the proportion of CD3^(+)cells,CD8^(+)cells,CD3^(+)CD69^(+)cells and CD3^(+)HLA-DR^(+)cells was significantly increased,and the proportion of Treg cells was decreased.The immune indexes supported T lymphocyte activation,then diagnosis of gradeⅡaGVHD(skin grade 3)was made,and the immunosuppressive regimen was strengthened.During this period,the skin rash of the child subsided,but recurred,and accompanied by obvious skin desquamation.The proportion of CD3^(+)cells,CD8^(+)cells,and CD3^(+)HLA-DR^(+)cells remains relatively high,supporting the diagnosis of aGVHD.Therefore,the anti-GVHD regimen was adjusted and strengthened,and the aGVHD of the child’s skin was mitigated.Regular monitoring showed that the primary disease was completely relieved,the implantation rate was 100%,and the immune reconstitution was stable.During 32-month follow-up after transplantation,the child obtained disease-free survival.Nine relevant literatures were retrieved,all of which demonstrated that the increased proportion of early CD3^(+)cells,CD8^(+)cells,activated T lymphocytes and Treg downregulation were associated with the occurrence of aGVHD.Conclusion The dynamic monitoring of the immune status of patients after allogeneic hematopoietic stem cell transplantation is helpful to evaluate their immune reconstitution and disease status(such as,aGVHD),thereby assisting clinicians to formulate a reasonable immunosuppressive regimen and bring favorable prognosis to patients.
作者
吴正宙
詹丽萍
阙丽萍
吴晓君
徐宏贵
黄科
Wu Zhengzhou;Zhan Liping;Que Liping;Wu Xiaojun;Xu Honggui;Huang Ke(Department of Pediatrics,Sun Yat-sen Memorial Hospital,Sun Yat-sen University,Guangzhou 510120,China)
出处
《新医学》
CAS
2024年第3期208-213,共6页
Journal of New Medicine
基金
广州市科技计划项目(2023A04J2085)。
关键词
造血干细胞移植
脐血
急性移植物抗宿主病
免疫监控
免疫重建
Hematopoietic stem cell transplantation
Cord blood
Acute graft-versus-host disease
Immune monitoring
Immune reconstitution
