Application of metagenomic next-generation sequencing technology in mycobacterium tuberculosis infection after allogeneic hematopoietic stem cell transplantation
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摘要: 目的 探讨宏基因二代测序(metagenomic next-generation sequencing，mNGS)技术在异基因造血干细胞移植后结核分枝杆菌(mycobacterium tuberculosis，MTB)感染中的应用。方法 收集2018年1月至2020年5月采用mNGS诊断的11例异基因造血干细胞移植后MTB感染患者的临床资料，回顾性分析患者的临床特征及治疗转归。结果 11例患者中男6例，女5例；中位年龄45(28~56)岁；结核类型主要为肺结核(9例，81.8%)，另外结核性脑膜炎和结核菌血症各1例；移植后并发MTB感染的中位时间为4.1(1.1~12.1)个月。临床表现：以发热和呼吸道症状最常见，其中发热7例，呼吸道症状8例，1例结核性脑膜炎患者表现为发热、头痛和癫痫。实验室检查：11例患者中3例(27.3%)涂片抗酸染色阳性(2例肺泡灌洗液，1例脑脊液)；9例(81.8%)外周血T-SPOT阳性；5例(45.5%)Xpert阳性(4例肺泡灌洗液，1例脑脊液)；1例(9.1%)外周血MTB-PCR阳性。通过mNGS均检测出MTB序列数(1~154)。影像学表现：肺部CT表现为斑片状渗出影7例，纵隔旁团块影1例，多发粟粒状结节影1例，头颅MRI发现1例结核性脑膜炎患者大脑多发结节病灶。预后：经过积极治疗后9例患者获得MTB感染的治愈；1例患者MTB感染经积极治疗后未获得病情控制，死于肺部严重混合感染；另外1例患者死亡原因为MTB感染，总体治愈率为81.8%(9/11)。结论 mNGS技术可以明显提高异基因造血干细胞移植后MTB的检出率，为临床早期精准治疗提供重要的病原学依据。
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关键词:
- 结核分枝杆菌感染 /
- 异基因造血干细胞移植 /
- 宏基因二代测序 /
- 诊断
Abstract: Objective To explore the application of metagenomic next-generation sequencing(mNGS) technology in mycobacterium tuberculosis(MTB) infection after allogeneic hematopoietic stem cell transplantation.Methods The clinical data of 11 patients with MTB infection after allogeneic hematopoietic stem cell transplantation diagnosed by mNGS from January 2018 to May 2020 were retrospectively analyzed.Results Of the 11 patients, there were 6 males and 5 females. The median age was 45(28-56) years old. The main type of tuberculosis was pulmonary tuberculosis(9 cases, 81.8%). Other types included 1 case of tuberculous meningitis and 1 case of tuberculous bacteremia. The median duration of MTB presentation after transplantation was 4.1 months(range 1.1-12.1 months). The clinical manifestations were mainly fever and respiratory symptoms, including 7 cases of fever, 8 cases of respiratory symptoms, and 1 case of tuberculous meningitis with fever, headache and epilepsy. Laboratory examination: Three out of 11 patients(27.3%) showed positive acid-fast staining on smears(2 cases of bronchoalveolar lavage fluid and 1 case of cerebrospinal fluid); 9 cases(81.8%) were T-SPOT positive in peripheral blood; 5 cases(45.5%) were Xpert positive(4 cases of bronchoalveolar lavage fluid and 1 case of cerebrospinal fluid); 1 case(9.1%) had positive peripheral blood MTB-PCR. The MTB sequence number of all the patients were detected by mNGS(between 1-154). Image findings: The chest CT showed patched shadow in 7 cases, mass shadow near mediastinum in 1 case, multiple miliary nodular shadow in 1 case. Brain MRI revealed multiple nodular lesions in one patient with tuberculous meningitis. After active treatment, 9 patients were cured of MTB infection, and 1 patient died of severe mixed infection in the lungs without control, the other one died of MTB infection, with an overall cure rate of 81.8%(9/11).Conclusion mNGS technology can significantly improve the detection rate of MTB after allogeneic hematopoietic stem cell transplantation, providing important pathogenic basis for early and precise clinical treatment. -
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表 1 11例经mNGS诊断allo-HSCT后MTB感染患者的临床特征及转归
例号 性别 年龄/岁 基础疾病 移植类型 预处理方案 干细胞来源 临床表现 结核类型 GVHD 合并感染 1 男 47 Ph+ALL 同胞全相合 改良BU+CY 外周血 发热、咳嗽、咳痰 肺结核 皮肤cGVHD CMV 2 女 35 AML 同胞全相合 改良BU+CY 外周血 发热、头痛、癫痫 结核性脑膜炎 无 无 3 女 35 MDS-EB2 单倍体 改良BU+CY 骨髓+外周血+第三方脐血 咳嗽、咳痰 肺结核 无 无 4 男 30 Ph+ALL 同胞全相合 改良BU+CY 外周血 发热 肺结核 皮肤cGVHD CMV、肺炎克雷伯杆菌 5 男 53 AML 单倍体 改良BU+CY 骨髓+外周血+第三方脐血 发热、咳嗽、咳痰 肺结核 皮肤、肠道、肝脏aGVHD 无 6 女 46 Ph+ALL 无关全相合 改良BU+CY 外周血 咳嗽、咳痰 肺结核 皮肤cGVHD 无 7 女 52 AML 单倍体 改良BU+CY 骨髓+外周血+第三方脐血 咳嗽、咳痰 肺结核 无 肺炎支原体 8 男 28 T淋母细胞淋巴瘤 单倍体 改良BU+CY 骨髓+外周血+第三方脐血 发热、咳嗽、咳痰 肺结核 无 CMV、曲霉菌 9 男 30 ALL 单倍体 TBI+CY 骨髓+外周血+第三方脐血 发热 结核菌血症 无 CMV 10 男 56 AML 单倍体 改良BU+CY 骨髓+外周血+第三方脐血 发热、咳嗽、咳痰 肺结核 皮肤、肠道、肝脏aGVHD CMV、耶氏肺孢子菌 11 女 45 AA-PNH 单倍体 改良BU+CY 骨髓+外周血+第三方脐血 咳嗽、咳痰 肺结核 无 无 例号 T-SPOT 其他检查 mNGS样本 mNGS检测MTB序列数 影像学 诊断距移植时间/月 治疗 转归 1 阳性 抗酸染色阳性
Xpert阳性肺泡灌洗液 10 右上肺斑片渗出影 2.7 HRE 存活 2 阳性 抗酸染色阳性
Xpert阳性脑脊液 5 大脑多发结节病灶 3.5 HRZML 存活 3 阳性 抗酸染色阴性
Xpert阴性肺泡灌洗液 6 双肺斑片渗出影 4.4 HRtEZL 存活 4 阳性 抗酸染色阳性
Xpert阳性外周血肺泡灌洗液 5、24 双肺斑片渗出影 6.5 HREML 存活 5 阳性 抗酸染色阴性
Xpert阴性外周血肺泡灌洗液 6、135 双肺斑片渗出影及条索影 5.6 HZML 死亡 6 阴性 抗酸染色阴性
Xpert阴性肺泡灌洗液 7 双肺斑片渗出影 12.1 HEML 存活 7 阴性 抗酸染色阴性
Xpert阴性肺泡灌洗液 11 双肺斑片渗出影及条索影 11.8 HEM 存活 8 阳性 抗酸染色阴性
Xpert阳性外周血肺泡灌洗液 2、3 两肺弥漫性分布粟粒状微小结节影 2.7 HEML 死亡 9 阳性 MTB-PCR阳性 外周血 13 无 1.1 HEZML 死亡 10 阳性 抗酸染色阴性
Xpert阴性肺泡灌洗液 154 双肺斑片渗出影及条索影 4.1 HEML 死亡 11 阳性 抗酸染色阴性
Xpert阳性肺泡灌洗液 1 左上肺纵隔旁团块影，临近肺野散在片状模糊影 3.1 HEZM 存活 Ph+ALL：Ph阳性急性淋巴细胞白血病；AML：急性髓系白血病；MDS-EB2：骨髓增生异常综合征伴原始细胞增多-2；AA-PNH：再生障碍性贫血-阵发性睡眠性血红蛋白尿；CMV：巨细胞病毒；H：异烟肼；R：利福平；E：乙胺丁醇；Z：吡嗪酰胺；M：莫西沙星；Rt：利福喷丁；L：利奈唑胺。 
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