中华危重病急救医学
中華危重病急救醫學
중화위중병급구의학
Chinese Critical Care Medicine
2015年
8期
630-634
,共5页
中东呼吸综合征%冠状病毒%临床治疗%抗病毒药物
中東呼吸綜閤徵%冠狀病毒%臨床治療%抗病毒藥物
중동호흡종합정%관상병독%림상치료%항병독약물
Middle East respiratory syndrome%Coronavirus%Treatment%Anti-viral drug
目的：报告中国首例输入性中东呼吸综合征（MERS）患者的救治经过，探讨MERS的临床特点及治疗方案。方法2015年5月28日广东省惠州市中心人民医院重症医学科收治了中国首例输入性MERS患者，通过患者的临床资料及治疗经过，分析MERS的临床特点及治疗方案。结果输入性MERS患者男性，43岁，韩国人，因背部酸痛7 d、发热2 d入院。①病例特点：患者7 d前出现背部酸痛，无发热，无咳嗽、咳痰，被韩国疾病控制部门列为“中东呼吸综合征冠状病毒”（MERS-CoV）可疑感染者但未予特殊诊治；2 d前出现发热，体温最高达39.7℃，无畏寒、寒战，无咳嗽、咳痰，无气促，无腹痛、腹泻，无尿频、尿急，无咽痛；有明确MERS患者接触史，为韩国第二代人传人病例。②辅助检查：2015年5月29日中国疾病预防控制中心（中国CDC）对3份咽拭子标本进行病毒核酸检测显示均呈阳性，血清、痰液、粪标本也呈阳性。通过全基因组序列扩增与测定序列分析结果推测该病毒株可能来自沙特阿拉伯的Jeddah和Riyahh地区。入院时患者血液检查提示：白细胞偏低（3.22×109/L），中性粒细胞比例偏高（0.73），血小板偏低（81×109/L）。入院时患者床旁X线胸片提示：双下肺少量渗出性病灶。③治疗措施：给予呼吸湿化吸氧仪加强氧疗（吸入氧浓度0.50～0.80，可耐受时设定流量为60 L/min），入院第20天改为鼻导管低流量吸氧，第24天停用；利巴韦林2.0 g口服负荷剂量后改为600 mg、8 h 1次（q8h），入院第10天减为600 mg、12 h 1次（q12h），第13天停用；入院第4天加用头孢曲松钠2.0 g、每日1次（qd）抗感染，第7天改为美罗培南2.0 g、q8h，2周后停用；静脉注射人免疫球蛋白20 g、qd，共用7 d，入院第8天加用胸腺肽α1治疗，2周后停用；干扰素每周1次（仅用1次）；同时给予护肝及继续口服甲硫咪唑抗甲状腺功能亢进等对症治疗。④患者入院后出现咳嗽、无痰，后出现咳少量黄黏痰，见少许血丝，随后转为干咳无痰；出现过短暂活动后轻度气促、腹泻；无胸闷胸痛、呼吸困难等症状；入院第18天咳嗽消失。入院第5天出现双下肺叩诊浊音，后逐渐恢复清音；入院第5天出现肩胛下区和肩胛间区细湿啰音，双下肺呼吸音弱，3 d后啰音消失，5 d后右下肺呼吸音增强，18 d后恢复正常。入院后第1周患者仍持续发热，最高体温39.5℃；第2周体温开始恢复正常。广东省疾病预防控制中心（广东CDC）复查病毒核酸显示：咽拭子在入院后第3天即转阴；血清标本在入院后第8天转阴；2周后粪标本转阴；痰液标本转阴最迟，直至出院前5 d才转阴。患者氧合指数随治疗逐渐升高，入院第15天超过300 mmHg（1 mmHg＝0.133 kPa）。床旁X线胸片提示：入院第1周胸部渗出迅速增多，第2周开始逐渐吸收，但直至出院仍未完全吸收。结论本例患者病程短、急性起病，以发热为主要表现，无呼吸道症状，入院后出现高热、咳嗽、气促、腹泻等临床表现；治疗后患者痰液病毒检测消失，但X线胸片显示渗出并未完全吸收，可能是病毒性肺炎渗出病灶吸收延迟的原因；病原学方面，本例患者痰液标本转阴最迟，说明肺部病毒的清除相对缓慢。该患者尚属我国首例输入性MERS，有关MERS的临床特点有待于更多的病例分析总结，治疗方案尚需进一步探索。
目的：報告中國首例輸入性中東呼吸綜閤徵（MERS）患者的救治經過，探討MERS的臨床特點及治療方案。方法2015年5月28日廣東省惠州市中心人民醫院重癥醫學科收治瞭中國首例輸入性MERS患者，通過患者的臨床資料及治療經過，分析MERS的臨床特點及治療方案。結果輸入性MERS患者男性，43歲，韓國人，因揹部痠痛7 d、髮熱2 d入院。①病例特點：患者7 d前齣現揹部痠痛，無髮熱，無咳嗽、咳痰，被韓國疾病控製部門列為“中東呼吸綜閤徵冠狀病毒”（MERS-CoV）可疑感染者但未予特殊診治；2 d前齣現髮熱，體溫最高達39.7℃，無畏寒、寒戰，無咳嗽、咳痰，無氣促，無腹痛、腹瀉，無尿頻、尿急，無嚥痛；有明確MERS患者接觸史，為韓國第二代人傳人病例。②輔助檢查：2015年5月29日中國疾病預防控製中心（中國CDC）對3份嚥拭子標本進行病毒覈痠檢測顯示均呈暘性，血清、痰液、糞標本也呈暘性。通過全基因組序列擴增與測定序列分析結果推測該病毒株可能來自沙特阿拉伯的Jeddah和Riyahh地區。入院時患者血液檢查提示：白細胞偏低（3.22×109/L），中性粒細胞比例偏高（0.73），血小闆偏低（81×109/L）。入院時患者床徬X線胸片提示：雙下肺少量滲齣性病竈。③治療措施：給予呼吸濕化吸氧儀加彊氧療（吸入氧濃度0.50～0.80，可耐受時設定流量為60 L/min），入院第20天改為鼻導管低流量吸氧，第24天停用；利巴韋林2.0 g口服負荷劑量後改為600 mg、8 h 1次（q8h），入院第10天減為600 mg、12 h 1次（q12h），第13天停用；入院第4天加用頭孢麯鬆鈉2.0 g、每日1次（qd）抗感染，第7天改為美囉培南2.0 g、q8h，2週後停用；靜脈註射人免疫毬蛋白20 g、qd，共用7 d，入院第8天加用胸腺肽α1治療，2週後停用；榦擾素每週1次（僅用1次）；同時給予護肝及繼續口服甲硫咪唑抗甲狀腺功能亢進等對癥治療。④患者入院後齣現咳嗽、無痰，後齣現咳少量黃黏痰，見少許血絲，隨後轉為榦咳無痰；齣現過短暫活動後輕度氣促、腹瀉；無胸悶胸痛、呼吸睏難等癥狀；入院第18天咳嗽消失。入院第5天齣現雙下肺叩診濁音，後逐漸恢複清音；入院第5天齣現肩胛下區和肩胛間區細濕啰音，雙下肺呼吸音弱，3 d後啰音消失，5 d後右下肺呼吸音增彊，18 d後恢複正常。入院後第1週患者仍持續髮熱，最高體溫39.5℃；第2週體溫開始恢複正常。廣東省疾病預防控製中心（廣東CDC）複查病毒覈痠顯示：嚥拭子在入院後第3天即轉陰；血清標本在入院後第8天轉陰；2週後糞標本轉陰；痰液標本轉陰最遲，直至齣院前5 d纔轉陰。患者氧閤指數隨治療逐漸升高，入院第15天超過300 mmHg（1 mmHg＝0.133 kPa）。床徬X線胸片提示：入院第1週胸部滲齣迅速增多，第2週開始逐漸吸收，但直至齣院仍未完全吸收。結論本例患者病程短、急性起病，以髮熱為主要錶現，無呼吸道癥狀，入院後齣現高熱、咳嗽、氣促、腹瀉等臨床錶現；治療後患者痰液病毒檢測消失，但X線胸片顯示滲齣併未完全吸收，可能是病毒性肺炎滲齣病竈吸收延遲的原因；病原學方麵，本例患者痰液標本轉陰最遲，說明肺部病毒的清除相對緩慢。該患者尚屬我國首例輸入性MERS，有關MERS的臨床特點有待于更多的病例分析總結，治療方案尚需進一步探索。
목적：보고중국수례수입성중동호흡종합정（MERS）환자적구치경과，탐토MERS적림상특점급치료방안。방법2015년5월28일광동성혜주시중심인민의원중증의학과수치료중국수례수입성MERS환자，통과환자적림상자료급치료경과，분석MERS적림상특점급치료방안。결과수입성MERS환자남성，43세，한국인，인배부산통7 d、발열2 d입원。①병례특점：환자7 d전출현배부산통，무발열，무해수、해담，피한국질병공제부문렬위“중동호흡종합정관상병독”（MERS-CoV）가의감염자단미여특수진치；2 d전출현발열，체온최고체39.7℃，무외한、한전，무해수、해담，무기촉，무복통、복사，무뇨빈、뇨급，무인통；유명학MERS환자접촉사，위한국제이대인전인병례。②보조검사：2015년5월29일중국질병예방공제중심（중국CDC）대3빈인식자표본진행병독핵산검측현시균정양성，혈청、담액、분표본야정양성。통과전기인조서렬확증여측정서렬분석결과추측해병독주가능래자사특아랍백적Jeddah화Riyahh지구。입원시환자혈액검사제시：백세포편저（3.22×109/L），중성립세포비례편고（0.73），혈소판편저（81×109/L）。입원시환자상방X선흉편제시：쌍하폐소량삼출성병조。③치료조시：급여호흡습화흡양의가강양료（흡입양농도0.50～0.80，가내수시설정류량위60 L/min），입원제20천개위비도관저류량흡양，제24천정용；리파위림2.0 g구복부하제량후개위600 mg、8 h 1차（q8h），입원제10천감위600 mg、12 h 1차（q12h），제13천정용；입원제4천가용두포곡송납2.0 g、매일1차（qd）항감염，제7천개위미라배남2.0 g、q8h，2주후정용；정맥주사인면역구단백20 g、qd，공용7 d，입원제8천가용흉선태α1치료，2주후정용；간우소매주1차（부용1차）；동시급여호간급계속구복갑류미서항갑상선공능항진등대증치료。④환자입원후출현해수、무담，후출현해소량황점담，견소허혈사，수후전위간해무담；출현과단잠활동후경도기촉、복사；무흉민흉통、호흡곤난등증상；입원제18천해수소실。입원제5천출현쌍하폐고진탁음，후축점회복청음；입원제5천출현견갑하구화견갑간구세습라음，쌍하폐호흡음약，3 d후라음소실，5 d후우하폐호흡음증강，18 d후회복정상。입원후제1주환자잉지속발열，최고체온39.5℃；제2주체온개시회복정상。광동성질병예방공제중심（엄동CDC）복사병독핵산현시：인식자재입원후제3천즉전음；혈청표본재입원후제8천전음；2주후분표본전음；담액표본전음최지，직지출원전5 d재전음。환자양합지수수치료축점승고，입원제15천초과300 mmHg（1 mmHg＝0.133 kPa）。상방X선흉편제시：입원제1주흉부삼출신속증다，제2주개시축점흡수，단직지출원잉미완전흡수。결론본례환자병정단、급성기병，이발열위주요표현，무호흡도증상，입원후출현고열、해수、기촉、복사등림상표현；치료후환자담액병독검측소실，단X선흉편현시삼출병미완전흡수，가능시병독성폐염삼출병조흡수연지적원인；병원학방면，본례환자담액표본전음최지，설명폐부병독적청제상대완만。해환자상속아국수례수입성MERS，유관MERS적림상특점유대우경다적병례분석총결，치료방안상수진일보탐색。
ObjectiveTo report the treatment of the first imported Middle East respiratory syndrome (MERS) in China, and to investigate the clinical features and treatment of the patient.Methods On May 28th, 2015, the first patient of imported MERS to China was admitted to Department of Critical Care Medicine of Huizhou Municipal Central Hospital. The clinical features and treatments of this patient were analyzed.Results①A 43 years old male of South Korean nationality was admitted with the complaint of back ache for 7 days and fever 2 days with the following characteristics: back ache 7 days ago, without fever or cough or expectoration. He had been suspected to suffer from infection of Middle East respiratory syndrome coronavirus (MERS-CoV) by the Disease Control Department of South Korea, but no specific treatment was given. He had fever for 2 days with maximum body temperature of 39.7℃. He had no chills, cough, expectoration, short of breath, abdominal pain, diarrhea, frequent micturition, or urgency or pain of urination, and no sore throat. The patient had a history of exposure to MERS-CoV patient. He was considered to be a patient of the second batch of South Korean epidemic.② Auxiliary examination: 3 copies of throat swab specimens for virus nucleic acid detection were performed by the Disease Prevention Control Center of China (China CDC), and they were positive on May 29th, 2015, and also for serum, sputum and stool. Based on the results of whole genome sequence analysis, the virus strains were implicated to be derived from Riyahh and Jeddah regions of Saudi Arabia. On admission, the patient's blood test showed that the white blood cell count was low (3.22×109/L), the proportion of the neutrophils was high (0.73), and that of the platelet was low (81×109/L). On admission, the patient's chest X-ray showed that a small amount of infiltration in the lung.③ Treatment: a high-flow nasal cannula (HFNC) with oxygen concentration of 0.50-0.80 was given, with a flow rate was set at 60 L/min if tolerated. It was changed to a low flow oxygen inhalation nasal cannula on the 20th day, and oxygen treatment was stopped on the 24th day. Ribavirin 2.0 g was given as the first dose, and was switched to 600 mg every 8 h (q8h), and it was reduced to 600 mg q12h after 10 days, and extenuated since the 13th day. Ceftriaxone was added on the 4th day with 2.0 g a day , and it was changed to meropenem 2.0 g, q8h on the 7th day for 2 weeks. Gamma globulin was given for 7 days (20 g, qd). Thymosin-α1 was given on the 8th day for 2 weeks. Interferon was given once a week, but only one dose was used. At the same time symptomatic treatment such as methimazole and liver protection therapy were given.④ Patient began to cough at admission, and it disappeared on the 18th day. There was no sputum at first, then a small amount of sputum with a little blood appeared after the admission. Then there was cough without sputum. Mild shortness of breath and diarrhea after exertion were noticed. He had no chest pain, difficulty in breathing or other symptoms. There was dullness on percussion in both sides of chest, and it disappeared gradually. Fine moist rales were detectable in scapular area and interscapular area on the 5th day, and they disappeared after 3 days. Breath sounds on both sides was weak, and it became more obvious in the right lung after 5 days, and returned to normal after 18 days. He had a sustaining fever for 1 week with the maximum temperature of 39.5℃, then the body temperature returned to normal. The viral nucleic acid test as performed by the Center for Disease Control of Guangdong (CDC, Guangdong) showed that the pharyngeal swab cultured turned negative on the 3rd day, that of serum specimens turned negative on the 8th day, that of stool specimen after 2 weeks, and it was persistently positive for sputum culture until 5 days before discharge. The oxygenation index gradually increased, and it was over 300 mmHg (1 mmHg = 0.133 kPa) after 15 days. Pleural effusion was rapidly increased during the first week as shown by chest X-ray films, and it began to be absorbed gradually in the second week, but it was not completely absorbed until discharge.Conclusions The disease course of the reported patient was short, with an acute onset, with fever as the chief complaint, but there were no respiratory symptoms, though there were high fever, cough, shortness of breath, diarrhea and other clinical symptoms after admission. Virus in sputum disappeared after treatment, but pleural effusion was not completely absorbed. Negative test for virus in sputum was late, indicating that clearance of virus was slow from the lungs. It is the first case of MERS in China, therefore, the clinical manifestations and the treatment strategy need to be further explored.
