嚴重之粟粒狀肺結核合併巨細胞病毒感染：一病例報告

Severe Miliary Tuberculosis Co-infected with Cytomegalovirus Infection: A Case Report

蘇思憓(Szu-Huei Su) ； 余文良(Wen-Laing Yu)

《內科學誌》 24卷3期 (2013/06) Pp. 220-226

https://doi.org/10.6314/JIMT.2013.24(3).08

摘要

據統計重症病人巨細胞病毒感染發生率為0-36%，且通常發生於入住加護病房後4至12天之間。研究指出重症病人巨細胞病毒感染，其呼吸器留置與加護病房住院天數都高於無巨細胞病毒感染病人。然而文獻僅表示免疫功能不全病人，如：癌症、器官移植與後天免疫不全症候群，檢測巨大細胞病毒去氧核醣核酸定量擴增試驗為陽性，即要及早治療，方能降低死亡率。對於原本非明確免疫功能不全之重症病人，若巨大細胞病毒去氧核醣核酸定量為陽性者，是否投予抗病毒製劑則尚無定論。本病人為74歲男性，因發燒與呼吸困難至本院急診，當時呼吸衰竭放置氣管內管，住入加護病房。住院後因胸部X光影像呈現雙側肺野呈瀰漫性粟粒狀的浸潤，痰液抗酸性細菌染色與肺結核菌之去氧核醣核酸定量擴增試驗均為陽性，故以肺結核為治療方向。然而病人血氧濃度持續不穩定，雙側肺炎未見改善。因血液與痰液之巨大細胞病毒去氧核醣核酸定量擴增試驗亦呈現陽性，故吾人思考活動性巨細胞病毒感染的可能性，投予ganciclovir治療5日後，病人仍宣告不治。面對如此危及生命之嚴重病例，吾人有感於治療之困難，故提醒粟粒狀肺結核與巨細胞病毒合併感染的可能性，並建議應可嘗試及早檢測、及早治療，以控制巨細胞病毒感染的惡化程度，進而爭取治癒的機會。

關鍵字

肺結核 ； 巨細胞病毒 ； 再活化 ； 重症病人

並列摘要

Cytomegalovirus (CMV) infection occurs in 0 to 36% of critically ill patients, mostly between 4 and 12 days after intensive care units (ICUs) admission. Research reported that the ICU stay and mechanical ventilation days of the critically ill patients with CMV infections were longer than those without CMV infections. Studies have suggested that immunocompromised patients such as cancer patients, organ transplant recipients and acquired immunodeficiency syndrome with positive CMV- polymerase chain reaction (PCR) results should be early initiated with anti-CMV therapy to reduce mortality. However, it remains controversial to treat the ICU patients without immunosuppression when the CMV-PCR results were positive. The 74 years old man was brought to the Emergency Room of the hospital due to fever and short of breath. He was intubated for acute respiratory failure and was admitted to the ICU. The CXR showed diffuse miliary lesions over bilateral lung fields. The acid-fast bacilli stain and tuberculosis (TB)-PCR of the sputum both showed positive, so he was mainly given anti-TB therapy. But the patient continued with instability of oxygen saturation, and bilateral pneumonia has not improved. Meanwhile, the CMV-PCR of the sputum and blood showed positive, thus active CMV infection was suspected and ganciclovir infusion was initiated. But after5 days of ganciclovir therapy, the patient still passed away. We recognized a difficult-to-treat case while facing such a severely life-threatening illness, therefore, we remind the possible co-infection of milary tuberculosis and CMV infection and suggest a trial of early diagnosis and early initiation of therapy to control progressive worsening of CMV infection, in order to cure the illness.

並列關鍵字

Pulmonary tuberculosis ； Cytomegalovirus ； Reactivation ； Critically ill patient