免疫监控指导治疗脐血移植后急性移植物抗宿主病一例并文献复习  

Treatment of acute graft-versus-host disease after umbilical cord blood transplantation under the guidance of immune monitoring:a case report and literature review

作　　者：吴正宙 詹丽萍[1] 阙丽萍[1] 吴晓君 徐宏贵[1] 黄科[1] 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)

机构地区：[1]中山大学孙逸仙纪念医院儿科,广州510120

出　　处：《新医学》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)。

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 increas

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 

分 类 号：R457.7[医药卫生—治疗学]