ICU中以脓毒症和难治性高乳酸血症为临床表现疑诊淋巴瘤3例并文献复习  

Suspected lymphoma with sepsis and refractory hyperlactatemia as clinical manifestations in ICU:report of 3 cases and review of literature

作　　者：骆艳妮[1] 张静静[1] 侯彦丽[1] 李佳媚[1] 韩俊丽[1] 王岗[1] 王小闯[1] Luo Yanni;Zhang Jingjing;Hou Yanli;Li Jiamei;Han Junli;Wang Gang;Wang Xiaochuang(Department of Critical Care Medicine,the Second Affiliated Hospital of Xi'an Jiaotong University,Xi'an 710004,China)

机构地区：[1]西安交通大学第二附属医院重症医学科,西安710004

出　　处：《白血病．淋巴瘤》2024年第4期214-219,共6页Journal of Leukemia & Lymphoma

摘　　要：目的探讨重症监护室(ICU)中以脓毒症和难治性高乳酸血症为临床表现疑诊淋巴瘤的诊治。方法回顾性分析2019年7月至2022年7月西安交通大学第二附属医院ICU收治的3例以脓毒症和难治性高乳酸血症为主要临床表现的疑诊淋巴瘤患者临床资料。3例患者均接受针对脓毒症的常规治疗后持续高乳酸血症不能纠正。结果1例63岁男性患者,给予碳酸氢钠并连续性肾脏替代治疗,乳酸水平持续>15.0 mmol/L,腹部CT及磁共振成像示肝脾大、脾梗死,骨髓穿刺及流式细胞术检查示异常单克隆B淋巴细胞,疑诊淋巴瘤,但因病情危重未行骨髓活组织检查;经会诊及家属同意给予试验性化疗,乳酸水平降至1.6 mmol/L。1例60岁男性患者,出现脓毒性休克,加强抗感染治疗后循环稳定,乳酸水平仍未正常,患者持续发热且三系细胞低,最终经PET-CT、骨髓穿刺活组织检查明确为弥漫大B细胞淋巴瘤。1例70岁男性患者以皮疹伴发热入院,起初考虑感染导致的脓毒症,血液宏基因组二代测序示巨细胞病毒阳性,且符合噬血细胞综合征诊断;予化疗并抗感染治疗后症状好转,乳酸水平下降后再次升高,最终确诊为外周T细胞淋巴瘤。3例患者均因病情进展死亡。结论对于ICU中以脓毒症合并难治性高乳酸血症为临床表现的患者,当合并三系细胞减少时要高度怀疑淋巴瘤,且初期继发脓毒症会干扰原发病的诊治,常规方式纠正乳酸水平无效是其特点,化疗是关键,侵犯肝脾后患者死亡率高。Objective To explore the diagnosis and treatment of suspected lymphoma with sepsis and refractory hyperlactatemia as clinical manifestations in the intensive care unit(ICU).Methods The clinical data of 3 suspected lymphoma patients with sepsis and refractory hyperlactatemia as the main clinical manifestations in ICU of the Second Affiliated Hospital of Xi'an Jiaotong University from July 2019 to July 2022 were retrospectively analyzed.The 3 patients had persistent hyperlactatemia that could not be corrected after receiving conventional treatment for sepsis.Results One 63-year-old male patient was given sodium bicarbonate and continuous renal replacement therapy,but the lactate level continued to be>15.0 mmol/L.CT and magnetic resonance imaging of the abdomen suggested hepatosplenomegaly and splenic infarcts,and bone marrow aspiration and flow cytometry suggested the presence of abnormal monoclonal B lymphocytes,and he was suspected to have lymphoma;however,bone marrow biopsy was not performed because of the critical condition.The experimental chemotherapy was given,and the lactate level reduced to 1.6 mmol/L.One 60-year-old male patient developed septic shock,the circulation was stabilized after intensive anti-infective treatment,but the lactate level was still abnormal.The patient continued to have fever and low trilineage cells.Finally,the patient was clearly diagnosed as diffuse large B-cell lymphoma by PET-CT and bone marrow aspiration biopsy.One 70-year-old male patient was admitted to the hospital with a rash accompanied by fever,and initially,sepsis due to infection was considered,and the next-generation sequencing of the blood macro-genome suggested cytomegalovirus positive,the patient was consistent with the diagnosis of hemophagocytic syndrome.The symptoms improved after chemotherapy and anti-infective treatment,but the lactate level decreased and then increased again,and the patient was finally diagnosed as peripheral T-cell lymphoma.All 3 patients died due to the disease progression.Conclusions For pa

关 键 词：脓毒症 高乳酸血症 淋巴瘤 重症监护病房 

分 类 号：R459.7[医药卫生—急诊医学]