摘要目的 探讨不同体液巨细胞病毒(CMV) DNA实时荧光定量(RT)-PCR检测在免疫正常婴儿CMV肺炎中的诊断价值.方法 回顾性分析2016年1月1日至2018年2月5日广东省妇幼保健院儿童重症医学科诊断的免疫正常婴儿CMV肺炎的临床资料,包括肺泡灌洗液(BALF)、尿液、血液和脑脊液CMV DNA载量,血液免疫球蛋白(Ig)M CMV,丙氨酸转氨酶(ALT),胸片和胸部增强CT,合并感染情况,临床表现和治疗情况.结果 926例接受肺泡灌洗治疗的婴儿中,34例为免疫正常CMV肺炎.CMV肺炎患儿尿液CMV DNA、血液CMV DNA及IgM CMV、ALT异常的阳性率分别为100.0％(34/34例)、61.8％(21/34例)、52.9％(18/34例)、20.6％(7/34例).血液CMV DNA与IgM CMV阳性率比较差异无统计学意义(x2=0.5,P＞0.05),均低于尿液CMV DNA阳性率,差异均有统计学意义(x2=16.1、20.9,均P＜0.05).ALT异常的阳性率低于尿液CMV DNA、血液CMV DNA和IgM CMV的阳性率,差异均有统计学意义(x2=44.8、11.9、7.7,均P＜0.05).行脑脊液RT-PCR检测10例,均为阴性.BALF、尿液和血液中CMV DNA载量的中位数分别为170.0×105copies/L、130.0×105 copies/L和6.0×105 copies/L.BALF与尿液中CMV DNA载量的中位数比较差异无统计学意义(U=561,P＞0.05).BALF与血液中CMV DNA载量呈正相关(r=0.35,P＜0.05),BALF CMV DNA载量与年龄呈负相关(r=-0.42,P＜0.05),尿液与血液中CMV DNA载量呈正相关(r=0.52,P＜0.05).无论血液IgM CMV阳性与否,BALF CMV DNA载量比较差异无统计学意义(U=92,P＞0.05).影像学以肺间质改变为主.34例免疫正常CMV肺炎婴儿症状持续超过2周18例(52.9％),20例(58.8％)并感染,均予更昔洛韦诱导治疗,病毒尿症转阴率为55.9％(19/34例).并细菌、支原体感染时加用抗生素治疗,均临床表现改善出院.结论 BALF RT-PCR检测可快速、敏感、特异地诊断CMV肺炎.尿液RT-PCR取材方便、安全,与BALF的阳性率及病毒载量均较好相符,可考虑作为CMV感染筛查和监测病毒载量的手段.血液CMV DNA载量和血液IgM CMV反映病毒播散和免疫反应能力,不建议单独作为诊断CMV肺炎的手段.

abstractsObjective To investigate the value of Cytomegalovirus(CMV) DNA real-time quantitative-polymerase chain reaction(RT-PCR) in different body fluids for diagnosing CMV pneumonia in immunocompetent infants.Methods The clinical data of immunocompetent infants with CMV pneumonia who were treated in Pediatric Intensive Care Unit of Guangdong Women and Children's Hospital from January 1st,2016 to February 5th,2018 were retrospectively analyzed.The clinical data included CMV DNA load of bronchoalveolar lavage fluid (BALF),urine,blood and cerebrospinal fluid(CSF);blood immunoglobulin(Ig) M CMV,alanine aminotransferase (ALT),X-ray and CT test of chest,combined infection,clinical manifestation and treatment.Results Nine hundred and twenty-six infants received bronchoalveolar lavage by bronchoscope,and 34 cases were diagnosed as immunocompetent with CMV pneumonia.The infants with CMV pneumonia:the positive percentage of urine CMV DNA,blood CMV DNA,blood IgM CMV and ALT elevation were 100.0％ (34/34 cases),61.8％ (21/34 cases),52.9％ (18/34 cases) and 20.6％ (7/34 cases),respectively.There was no difference in positive percentage between blood CMV DNA and blood IgM CMV (x2 =0.5,P ＞ 0.05).Both the positive percentages of blood CMV DNA and blood IgM CMV were lower than those in the urine CMV DNA,and the differences were statistically significant (x2 =16.1,20.9,all P ＜0.05).The positive percentages of ALT elevation were lower than those in the positive percentage of urine CMV DNA,blood CMV DNA and blood IgM CMV,and the differences were statistically significant (x2 =44.8,11.9,7.7,all P ＜ 0.05).Ten patients' CSF CMV DNA were tested,and they were all negative.The median load of CMV DNA in BALF,urine and blood was 170.0 × 105 copies/L,130.0 x 105 copies/L and 6.0 x 105 copies/L.There was no difference in median load between BALF and urine (U =561,P ＞ 0.05).BALF CMV DNA load and blood CMV DNA load had a weak positive correlation (r =0.35,P ＜ 0.05),BALF CMV DNA load and age had a negative correlation (r =-0.42,P ＜ 0.05),and urine CMV DNA load and blood CMV DNA load had a positive correlation (r =0.52,P ＜ 0.05).No matter whether blood IgM CMV was positive,BALF CMV DNA load had no differences (U =92,P ＞ 0.05).The main radiographic signs were pulmonary interstitial lesions.Thirty-four immunocompetent infants with CMV pneumonia,18 patients (52.9％) with symptoms lasted for over 2 weeks,20 patients (58.8％) had complicated infections.They all received inductive treatment of Ganciclovir,55.9％ (19/34 cases) patients' urine CMV DNA turned to be negative.When patients got combined infections by bacteria or mycoplasma,antibiotics were used.All discharged patients had symptoms relieved and signs improved.Conclusions BALF RT-PCR is instant,sensitive and distinctive method to diagnose CMV pneumonia.Urine RT-PCR gets specimens conveniently and safely,its positive percentage and DNA load are present well according to BALF,and is suitable for screening and monitoring CMV infection.Blood CMV DNA load and blood IgM CMV indicate viral dissemination and immunocompetence,but it is not recommended for diagnosing CMV pneumonia solely.