巨細胞病毒感染併發嚴重橫紋肌溶解症和吞嚥障礙：個案報告及文獻回顧

背景：巨細胞病毒（Cytomegalovirus, CMV）好發於免疫功能不全的病人，患者初次感染後它會潛伏在器官或細胞內，當患者免疫力降低或失調時，病毒會再度活化。橫紋肌溶解症（Rhabdomyolysis）是因人體肌肉細胞壞死，受損或受傷的肌肉迅速溶解而導致急性腎臟受損或多重器官衰竭。回顧相關文獻，患者因巨細胞病毒感染引發嚴重橫紋肌溶解症的案例很少，巨細胞病毒會導致嚴重吞嚥障礙甚至更少見。病例報告：一名35歲女性，入院前兩個月因四肢肌肉痠痛無力、頭痛、進食困難和發燒至急診就診。離院四天後，症狀未改善，實驗室檢查顯示患者C反應蛋白數值升高，肝指數異常，全血球計數及白血球分類顯示主要為淋巴球，診斷感染性單核球血症（Infectious mononucleosis）。一周後症狀仍持續，門診檢驗後診斷為巨細胞病毒型肝炎（Cytomegaloviral Hepatitis）。一個月後患者因全身不舒服、肌肉痠痛、心搏過速、茶色尿液、肝功能異常和吞嚥困難安排住院。住院期間患者被診斷為巨細胞病毒感染引發橫紋肌溶解症，但隨著橫紋肌溶解症的惡化，最後導致患者四肢無力和嚴重吞嚥障礙，需依賴鼻胃管攝取營養。安排電視螢光錄影攝影檢查並使用鋇劑作為濃稠液體，在側面像中，患者吞嚥兩毫升的鋇劑，口腔準備期結果顯示咀嚼食團能力不足、攪拌食團能力不足及形成食團能力不足。咽部期則出現嚴重的障礙，包括咽部收縮力量不佳、會厭軟骨閉合不足、喉部上提不足、較多食團殘留在會厭谿（vallecula）及梨狀竇（pyriform sinus）且吞嚥中出現嗆入（penetration）現象。在前後像中，患者咽部肌群整體肌無力，且吞嚥後較多食團殘留在雙側梨狀竇。出院後兩周，患者已可從口進食單一質地的食物，並在出院後一個月後患者拔除鼻胃管。結論：巨細胞病毒很少會引發橫紋肌溶解症，而因病毒感染引發橫紋肌溶解症併發嚴重吞嚥障礙的情況也很少。雖然嚴重橫紋肌溶解症經常會導致急性腎臟衰竭，本案例顯示也可能造成嚴重的吞嚥障礙。因此，因病毒誘發橫紋肌溶解症的吞嚥障礙患者，建議接受吞嚥評估並提供合適的吞嚥訓練，有助於改善或減緩其吞嚥障礙的症狀。

關鍵字

巨細胞病毒（Cytomegalovirus）；橫紋肌溶解（Rhabdomyolysis）；吞嚥障礙（Dysphagia）；螢光吞嚥攝影檢查（Video fluoroscopic swallowing study, VFSS）

並列摘要

Cytomegalovirus(CMV) is a common virus that usually occurs in immunocompromised patients. After primary infection with CMV, the virus becomes latent in multiple organs and can later be reactivated during severe immune system dysregulation. Rhabdomyolysis is a disease of human muscle cell necrosis, and the rapid dissolution of damaged or injured muscles may lead to acute kidney injury or multiple organ failure. After reviewing relevant literature, patients with severe rhabdomyolysis caused by CMV infection are rarely reported and even less commonly, CMV leads to severe dysphagia. The patient was a 35-year-old woman without underlying disease. Two months before hospitalization,she visited the emergency department due to four limbs muscle weakness, headache, dysphagia and intermittent fever. Four days later, symptoms persisted, and lab data showed increased C-reactive protein, abnormal liver function, and complete blood cell and differential count that was lymphocyte-dominant. Infectious mononucleosis was diagnosed. One week later, symptoms persisted, and lab data showed immunoglobulin (Ig)M-positive. Cytomegaloviral hepatitis was diagnosed. She was admitted to our hospital because of persistent general malaise, soreness, tachycardia, tea-colored urine, abnormal liver function and swallowing difficulties 1 month later. During hospitalization, rhabdomyolysis was diagnosed concomitant with the CMV infection. With the rhabdomyolysis-associated deterioration, the patient developed quadriplegia and severe dysphagia, and she required a nasogastric tube for nutrient intake. A video fluoroscopic swallowing study (VFSS) with barium as a thickening liquid was used to assess her swallowing function. In the lateral view of VFSS, she swallowed 2 mL of barium. The oral phase showed insufficient chewing, insufficient mixing bolus and insufficient bolus formation. Severe swallowing dysfunction of pharyngeal phase was noted, including poor pharyngeal constriction, poor epiglottis closure, poor laryngeal elevation, much residuein the vallecula and pyriform sinus, and the presence of penetration during swallowing. In the anterior–posterior view, the pharyngeal muscle group showed general weakness and much residue in bilateral pyriform sinus after swallowing. Two weeks after discharge, the patient attempted oral intake with a single consistency, and the nasogastric tube was removed 1 month later. Cytomegalovirus has rarely been reported as a cause of rhabdomyolysis and severe dysphagia with virus-induced rhabdomyolysis is also rare. Severe rhabdomyolysis often leads to acute renal failure, and this case report shows that it may also cause severe dysphagia. Thus, swallowing assessment followed by suitable swallowing training could be recommended for those patients with viral-induced rhabdomyolysis with swallowing difficulties, helping improve or relieve the symptoms of swallowing disorders.

並列關鍵字

cytomegalovirus ； rhabdomyolysis ； dysphagia ； video fluoroscopic swallowing study

參考文獻

1. Jain M, Duggal S, Chugh TD. Cytomegalovirus infection in non-immunosuppressed critically ill patients. J Infect Dev Ctries 2011;5:571-9.

3. Cannon MJ, Schmid DS, Hyde TB. Review of cytomegalovirus seroprevalence and demographic characteristics associated with infection. Rev Med Virol 2010;20: 202-13.

4. Crough T, Khanna R. Immunobiology of human cytomegalovirus: from bench to bedside. Clin Microbiol Rev 2009;22:76-98.

6. Wong WM, Wai-Hung Shek T, Chan KH, et al. Rhabdomyolysis triggered by cytomegalovirus infection in a heart transplant patient on concomitant cyclosporine and atorvastatin therapy. J Gastroenterol Hepatol 2004;19:952-3.

7. Rosenbek JC, Robbins JA, Roecker EB, et al. A penetration-aspiration scale. Dysphagia 1996;11:93-8.

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巨細胞病毒感染併發嚴重橫紋肌溶解症和吞嚥障礙：個案報告及文獻回顧

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