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  • 郑楷炼,张优,王琼娅,徐莹,王辉,孔祥毓,李奕,董宇超.糖皮质激素联合大剂量免疫球蛋白成功治疗重型新型冠状病毒肺炎1例临床经验分析[J].第二军医大学学报,2020,41(2):181-185    [点击复制]
  • ZHENG Kai-lian,ZHANG You,WANG Qiong-ya,XU Ying,WANG Hui,KONG Xiang-yu,LI Yi,DONG Yu-chao.Severe coronavirus disease 2019 successfully treated with glucocorticoid and high-dose intravenous immunoglobulin: a case report and analysis of clinical experience[J].Acad J Sec Mil Med Univ,2020,41(2):181-185   [点击复制]
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糖皮质激素联合大剂量免疫球蛋白成功治疗重型新型冠状病毒肺炎1例临床经验分析
郑楷炼1△,张优2△,王琼娅3,徐莹3,王辉4,孔祥毓5,李奕6*,董宇超6*
0
(1. 海军军医大学(第二军医大学)长海医院普通外科, 上海 200433;
2. 海军军医大学(第二军医大学)长海医院肾内科, 上海 200433;
3. 武汉市汉口医院消化科, 武汉 430014;
4. 解放军 905 医院呼吸内科, 上海 200052;
5. 海军军医大学(第二军医大学)长海医院消化内科, 上海 200433;
6. 海军军医大学(第二军医大学)长海医院呼吸与危重型医学科, 上海 200433
共同第一作者
*通信作者)
摘要:
目的 报道1例重型新型冠状病毒肺炎(COVID-19)应用糖皮质激素联合免疫球蛋白救治成功的病例,分享重型COVID-19的临床治疗经验。方法和结果 患者为武汉市医务工作者,起病前曾多次接触COVID-19患者,2020年1月16日起无明显诱因出现咳嗽伴少许白黏痰,1月22日出现发热(最高38.5℃)并入院治疗,查CT示双肺散在少量渗出,予口服奥司他韦、静脉输注莫西沙星及头孢哌酮舒巴坦钠、加强营养等治疗。1月26日出现胸闷气急,咽拭子检测示严重急性呼吸综合征冠状病毒2(SARS-CoV-2)核酸阳性,CT示双肺渗出较前增加。1月28日气急加重,输注甲泼尼龙(40 mg,每天1次)和人免疫球蛋白(10 g,每天1次)治疗。1月30日体温升高至40.7℃,气急进一步加重,脉搏血氧饱和度(SpO2)降至83%(吸氧量10 L/min),淋巴细胞计数降至0.5×109/L,调整甲泼尼龙剂量(40 mg,每12 h 1次)及人免疫球蛋白剂量(20 g,每天1次),增加胸腺法新(1.6 mg,皮下注射,每天1次)等治疗,体温恢复正常,胸闷气急逐渐好转。1月31日SpO2 88%(吸氧量10 L/min),复查胸部CT提示双肺大片渗出影。2月2日SpO2 95%(吸氧量5 L/min),开始逐渐减少甲泼尼龙用量。2月3日复查胸部CT提示肺部炎症较前好转,2月4日及9日复查咽拭子示SARS-CoV-2核酸阴性。结论 早期及轻型COVID-19患者应尽量避免使用糖皮质激素,当患者出现呼吸衰竭失代偿时可适当使用糖皮质激素降低免疫指标,但剂量不宜过高,必要时可予大剂量免疫球蛋白帮助平衡免疫功能。
关键词:  新型冠状病毒肺炎  糖皮质激素  免疫球蛋白  救治经验
DOI:10.16781/j.0258-879x.2020.02.0181
投稿时间:2020-02-15修订日期:2020-02-17
基金项目:
Severe coronavirus disease 2019 successfully treated with glucocorticoid and high-dose intravenous immunoglobulin: a case report and analysis of clinical experience
ZHENG Kai-lian1△,ZHANG You2△,WANG Qiong-ya3,XU Ying3,WANG Hui4,KONG Xiang-yu5,LI Yi6*,DONG Yu-chao6*
(1. Department of General Surgery, Changhai Hospital, Naval Medical University(Second Military Medical University), Shanghai 200433, China;
2. Department of Nephrology, Changhai Hospital, Naval Medical University(Second Military Medical University), Shanghai 200433, China;
3. Department of Gastroenterology, Hankou Hospital, Wuhan 430014, Hubei, China;
4. Department of Respiratory Medicine, No. 905 Hospital of PLA, Shanghai 200052, China;
5. Department of Gastroenterology, Changhai Hospital, Naval Medical University(Second Military Medical University), Shanghai 200433, China;
6. Department of Respiratory and Critical Care Medicine, Changhai Hospital, Naval Medical University(Second Military Medical University), Shanghai 200433, China
Co-first authors.
* Corresponding authors)
Abstract:
Objective To report a case of severe coronavirus disease 2019 (COVID-19) that had been successfully treated with glucocorticoid and intravenous immunoglobulin therapy. Methods and results The patient was a healthcare provider in Wuhan City who was taking care of COVID-19 patients before the onset of the disease. He started to cough with a little white sticky sputum on January 16, 2020 and had a fever on January 22 (up to 38.5℃) before admission. CT results showed mild exudation in both lungs. Oral oseltamivir and intravenous moxifloxacin, cefoperazone and sulbactam sodium were given in addition to nutritional support. On January 26, the patient had chest tightness and shortness of breath. A swab test was positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) nucleic acid, and chest CT results showed moderate exudation in both lungs. On January 28, shortness of breath worsened and intravenous methylprednisolone (40 mg, qd) and immunoglobulin (10 g, qd) were given. On January 30, shortness of breath further worsened; he had a body temperature of 40.7℃, pulse oxygen saturation (SpO2) of 83% with oxygen inhalation at 10 L/min, and lymphocyte count of 0.5×109/L. The dose of methylprednisolone and immunoglobulin were adjusted to 40 mg, q12h and 20 g, qd, respectively. Subcutaneous injection of thymalfasin (1.6 mg, qd) was added. Then the body temperature returned to normal, and symptoms such as chest tightness and shortness of breath were gradually improved. On January 31, SpO2 was 88% with oxygen inhalation at 10 L/min and a chest CT results revealed large amount of exudation in both lungs. On February 2, SpO2 was 95% with oxygen inhalation at 5 L/min and the dose of methylprednisolone was then gradually reduced. A chest CT results on February 3 revealed improved lung inflammation, and a throat swab on February 4 and 9 was negative for SARS-CoV-2 nucleic acid. Conclusion Glucocorticoid should be used with caution in patients with early and mild COVID-19. However, appropriate dosage of glucocorticoid can be used to modulate lung inflammation in patients with decompensated respiratory failure. Additionally, large dose of immunoglobulin can be given if necessary.
Key words:  coronavirus disease 2019  corticosteroids  immunoglobulin  therapeutic experience