AIDS合并巨细胞病毒视网膜炎患者眼免疫重建炎症反应综合征的临床表现及治疗

孔文君; 魏文斌; 谢连永; 陈超; 杜葵芳

doi:10.3760/cma.j.cn115989-20200317-00179

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中华实验眼科杂志

• 临床研究 •

ENGLISH ABSTRACT

AIDS合并巨细胞病毒视网膜炎患者眼免疫重建炎症反应综合征的临床表现及治疗

作者及单位信息

出版日期： 2021 -07 -10 ·

DOI： 10.3760/cma.j.cn115989-20200317-00179

Clinical manifestation and treatment of ocular immune reconstitution inflammatory response syndrome in acquired immunodeficiency syndrome patients with cytomegalovirus retinitis

Authors Info & Affiliations

Kong Wenjun

Department of Ophthalmology, Beijing You'an Hospital, Capital Medical University, Beijing Infectious Eye Disease Diagnosis And Treatment Center, Beijing 100069, China

Wei Wenbin

Department of Ophthalmology, Beijing Tongren Hospital, Capital Medical University, Beijing Ophthalmology and Visual Sciences Key Lab, Beijing Infectious Eye Disease Diagnosis And Treatment Center, Beijing 100730, China

Xie Lianyong

Department of Ophthalmology, Beijing You'an Hospital, Capital Medical University, Beijing Infectious Eye Disease Diagnosis And Treatment Center, Beijing 100069, China

Chen Chao

Department of Ophthalmology, Beijing You'an Hospital, Capital Medical University, Beijing Infectious Eye Disease Diagnosis And Treatment Center, Beijing 100069, China

Du Kuifang

Department of Ophthalmology, Beijing You'an Hospital, Capital Medical University, Beijing Infectious Eye Disease Diagnosis And Treatment Center, Beijing 100069, China

Published： 2021 -07 -10 ·

DOI： 10.3760/cma.j.cn115989-20200317-00179

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摘要

目的探讨获得性免疫缺陷综合征(AIDS)合并巨细胞病毒视网膜炎(CMVR)的眼免疫重建炎症反应综合征(IRIS)患者眼部特征及治疗预后。

方法采用系列病例观察研究方法，纳入2016年2月至2018年12月于首都医科大学附属北京佑安医院确诊为AIDS合并CMVR的IRIS患者15例17眼，患者均为男性，年龄21～43岁，记录患者最佳矫正视力(BCVA)，采用非接触眼压计测量眼压，采用裂隙灯显微镜检查眼前节，采用彩色眼底照相和光相干断层扫描(OCT)法观察眼底表现，采用逆转录PCR反应检测发生眼IRIS时房水中巨细胞病毒脱氧核糖核酸(CMV-DNA)含量，采用流式细胞仪检测高效抗逆转录病毒治疗(HAART)前和发生眼IRIS时外周血CD4 ⁺ T淋巴细胞计数，所有患者随访3～25个月，平均15个月，IRIS眼HAART时间为17～104 d，平均(66.1±27.4)d。对IRIS眼出现眼前节炎症反应患者进行抗炎和扩瞳治疗，严重玻璃体混浊者给予曲安奈德4 mg玻璃体腔注射，黄斑水肿者给予康柏西普0.50 mg玻璃体腔注射。

结果17眼中9眼出现眼前节炎症反应，11眼出现不同程度的玻璃体混浊，2眼出现黄斑水肿。15眼房水CMV-DNA测定结果为阴性(<500拷贝/ml)。发生眼IRIS时，外周血CD4 ⁺ T淋巴细胞计数为67(51，99)个/μl，高于HAART治疗前的17(6，20)个/μl，差异有统计学意义( Z＝-4.48， P<0.01)。15例AIDS患者中2例合并肺结核。治疗后患眼平均BCVA为0.50(0.35，0.60)，明显高于治疗前的0.30(0.10，0.55)，差异有统计学意义( Z＝-2.34， P＝0.019)。

结论AIDS合并CMVR患者的眼IRIS可累及眼前后节，眼部对症治疗效果显著。

关键词：获得性免疫缺陷综合征/治疗;眼免疫重建炎症反应综合征/治疗;临床表现;疗效

ABSTRACT

ObjectiveTo investigate the ocular characteristics and treatment prognosis of ocular immune reconstruction inflammatory syndrome (IRIS) in patients with cytomegalovirus retinitis (CMVR) complicated with acquired immunodeficiency syndrome (AIDS).

MethodsA serial case-observational study was conducted.Seventeen eyes from 15 male 21-to 43-year-old AIDS patients combined with CMVR, who were diagnosed with IRIS at Beijing You'an Hospital, Capital Medical University from February 2016 to December 2018 were included.The best corrected visual acuity (BCVA) of patients was recorded, and the intraocular pressure and anterior segment was measured with a non-contact tonometer and a slit-lamp microscope, respectively.The ocular fundus was observed by fundus photography and optical coherence tomography (OCT). Reverse transcription polymerase chain reaction was used to measure the cytomegalovirus deoxyribonucleic acid (CMV-DNA) content in the aqueous humor during the occurrence of IRIS.The flow cytometry was employed to determine the peripheral blood CD4 ⁺ T lymphocyte count before highly active antiretroviral therapy (HAART) and during the occurrence of IRIS.All patients were followed for 3 to 25 months, with an average of 15 months.The HAART time of patients was 17 to 104 days, with an average of (66.1±27.4) days.Patients with anterior segment inflammatory reactions were given the anti-inflammatory and mydriatic treatment.Patients with severe vitreous opacity were intravitreally injected with 4 mg of triamcinolone.Patients with macular edema were given 0.5 mg intravitreal injection of conbercept.The study adhered to the Declaration of Helsinki and was approved by an Ethics Committee of Beijing You'an Hospital, Capital Medical University (No.[2017]11). Written informed consent was obtained from each patient prior to any examination.

ResultsAnterior segment inflammation (Tyndall effect, KP, post-iris adhesion) was found in 9 eyes, vitreous opacities to varying degrees in 11 eyes, and macular edema in 2 eyes.The CMV-DNA content was negative (<500 copies/ml) in 15 eyes.The CD4 ⁺ T lymphocyte count in peripheral blood during IRIS was 67 (51, 99) cells/μl, which was significantly higher than 17(6, 20) cells/μl before HAART treatment ( Z=-4.48, P<0.01). Two of the 15 AIDS patients had tuberculosis.The BCVA of the patients was improved from 0.30 (0.10, 0.55) before treatment to 0.50 (0.35, 0.60) after treatment, and the difference was statistically significant ( Z=-2.34, P=0.019).

ConclusionsThe anterior and posterior segment may be involved in IRIS patients with AIDS and CMVR, and the corresponding ocular treatment is effective.

KEYWORDS： Acquired immune deficiency syndrome/treatment;Ocular immune reconstitution inflammatory syndrome/treatment;Clinical manifestation;Treatment effectiveness

Corresponding author: Wei Wenbin, Email: mocdef.3ab61nibnewiew_rt

FUNDING:

You'an Liver Disease and AIDS Fund of China Primary Health Care Foundation（YNKT20160038）

Beijing Ophthalmology & Visual Sciences Key Laboratory（2016YKSJ04）

COPYRIGHTS:

No content published by the journals of Chinese Medical Association may be reproduced or abridged without authorization. Please do not use or copy the layout and design of the journals without permission.

All articles published represent the opinions of the authors, and do not reflect the official policy of the Chinese Medical Association or the Editorial Board, unless this is clearly specified.

引用本文

孔文君,魏文斌,谢连永,等. AIDS合并巨细胞病毒视网膜炎患者眼免疫重建炎症反应综合征的临床表现及治疗[J]. 中华实验眼科杂志,2021,39(07)：626-631.

DOI:10.3760/cma.j.cn115989-20200317-00179

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巨细胞病毒视网膜炎(cytomegalovirus retinitis，CMVR)是获得性免疫缺陷综合征(acquired immune deficiency syndrome，AIDS)患者的常见眼部并发症。随着高效抗逆转录病毒疗法(highly active antiretroviral therapy，HAART)的广泛应用，CMVR已逐渐得到有效控制，较大程度上挽救了患者的视功能 ^{[
1
]}。HAART治疗后患者的免疫功能明显增强，然而患者的机会性感染风险却明显增加，即免疫重建炎症反应综合征(immune reconstitution inflammatory syndrome，IRIS) ^{[
2
]}。IRIS在眼部表现为前葡萄膜炎、玻璃体炎、视神经炎、黄斑囊状水肿或视网膜前膜，严重影响患者视力 ^{[
3
]}。有研究显示，75例AIDS合并CMVR患者中，55例在接受HAART治疗后出现眼IRIS ^{[
4
]}。另有研究显示，在HAART开始后的2～8周IRIS严重程度达峰值 ^{[
5
]}。但目前国内外有关眼IRIS的研究非常有限，对其治疗的探讨更少。本研究拟观察AIDS合并CMVR患者眼IRIS临床表现并探讨其治疗方法及疗效，为眼IRIS的临床诊断和治疗提供参考依据。

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参考文献

参考文献

[1]

Jabs DA ， Van Natta ML ， Holland GN ，et al. Cytomegalovirus retinitis in patients with acquired immunodeficiency syndrome after initiating antiretroviral therapy[J]．Am J Ophthalmol， 2017，174∶23-32. DOI： 10.1016/j.ajo.2016.10.011 .