1例内脏利什曼病严重肺部感染的诊疗分析

doi:10.12140/j.issn.1000-7423.2025.06.020

摘要/Abstract

摘要：

患者，女，38岁，山西省临汾市乡宁县人，农民。2016年诊断肾病综合征，2021年诊断为系统性红斑狼疮。2024年10月反复发热就诊于风湿免疫科，化验示全血细胞三系减少、白蛋白球蛋白比例倒置、免疫球蛋白IgG升高、凝血异常、心磷脂抗体阳性、脾大等，痰真菌培养示白假丝酵母菌感染。患者10月29日胸部CT示双肺散在炎症，伴右下叶空洞形成。10月31日行骨髓穿刺，骨髓象示巨核细胞1个，整片分布血小板，全髓涂片可见利什曼原虫无鞭毛体（利杜小体），遂转入感染病科。11月5日血清送至山西省疾病预防控制中心，内脏利什曼病rK39免疫层析试纸检测阳性。11月6日骨髓病原微生物宏基因组二代测序（mNGS）检出利什曼原虫属DNA序列数66 596条，其中婴儿利什曼原虫序列数1 668条，相对丰度为52.02%。予持续吸氧、输注去白悬浮红细胞、抗感染、补液、纠正低蛋白血症、止血等对症治疗，11月4日予两性霉素B胆固醇硫酸酯复合物50 mg静脉泵入；11月5日调整为100 mg；11月6日再调整为150 mg（足剂量）。患者不适症状逐渐缓解后出院。12月9日复查，抗原虫疗效佳，未查见利杜小体，肺部空洞消失。随访，患者未再复发。

关键词: 内脏利什曼病, 肺部感染, 组织胞浆菌病, 两性霉素B胆固醇硫酸酯复合物, 系统性红斑狼疮, 宏基因组二代测序

Abstract:

The patient was a 38-year-old female farmer from Xiangning County, Linfen City, Shanxi Province. She was diagnosed with nephrotic syndrome in 2016 and systemic lupus erythematosus in 2021. In October 2024, the patient was admitted to the Department of Rheumatology and Immunology due to recurrent fever. Laboratory tests revealed pancytopenia, inverted albumin-globulin ratio, elevated IgG levels, coagulation abnormalities, positive anticardiolipin antibodies and splenomegaly, and sputum fungal cultures indicated Candida albicans infection. Chest CT scans on October 29 showed scattered inflammation in bilateral lungs with cavity formation in the right lower lobe. On October 31, bone marrow punctures displayed one megakaryocyte and widespread platelet distribution in blood marrow smears, and Leishmania amastigotes (Leishman-Donovan bodies) were observed across whole bone marrow smears, prompting patient’s transfer to the Department of Infectious Diseases. On November 5, serum samples were sent to Shanxi Provincial Center for Disease Control and Prevention, where the rK39 rapid immunochromatographic test yielded a positive result. On November 6, metagenomic next-generation sequencing (mNGS) of bone marrows detected 66 596 Leishmania species DNA sequences, including 1 668 L. infantum sequences with relative abundance of 52.02%. Symptomatic treatments were therefore given, including continuous oxygen therapy, transfusion of leukoreduced red blood cells, anti-infection therapy, fluid replacement, correction of hypoalbuminemia, and hemostasis. On November 4, amphotericin B cholesterol sulfate complex was administered intravenously at 50 mg via an intravenous pump, and the dose was adjusted to 100 mg on November 5 and further escalated to the 150 mg (full dose) on November 6. The patient was discharged after the discomfort symptoms gradually subsided. A follow-up examination on December 9 showed excellent antiprotozoal efficacy, with no Leishmania amastigotes detected and the pulmonary cavities disappeared. Subsequent follow-ups indicated no recurrence in the patient.

Key words: Visceral leishmaniasis, Pulmonary infection, Histoplasmosis, Amphotericin B cholesterol sulfate complex, Systemic lupus erythematosus, Metagenomic next-generation sequencing

中图分类号:

R531.6

靳萱, 刘元丽, 邓春青. 1例内脏利什曼病严重肺部感染的诊疗分析[J]. 中国寄生虫学与寄生虫病杂志, 2025, 43(6): 874-877.

JIN Xuan, LIU Yuanli, DENG Chunqing. Diagnosis and treatment of a case with visceral leishmaniasis complicated by severe pulmonary infection[J]. Chinese Journal of Parasitology and Parasitic Diseases, 2025, 43(6): 874-877.

图/表 2

参考文献 20

[1]	汪俊云, 高春花. 《黑热病诊断标准》解读[J]. 中国血吸虫病防治杂志, 2017, 29(5): 541-543.
	Wang JY, Gao CH. Interpretation of diagnostic criteria for kala-azar[J]. Chin J Schisto Control, 2017, 29(5): 541-543. (in Chinese)
[2]	魏志云, 罗小飞, 于颖洁, 等. 2019—2023年山西省黑热病流行病学特征及时空聚集性分析[J]. 预防医学情报杂志, 2025, 41(9): 1167-1171.
	Wei ZY, Luo XF, Yu YJ, et al. Epidemiological characteristics and spatio-temporal clustering of leishmaniasis in Shanxi Province from 2019 to 2023[J]. J Prev Med Inf, 2025, 41(9): 1167-1171. (in Chinese)
[3]	Georgiadou SP, Stefos A, Spanakos G, et al. Current clinical, laboratory, and treatment outcome characteristics of visceral leishmaniasis: Results from a seven-year retrospective study in Greece[J]. Int J Infect Dis, 2015, 34: 46-50.
[4]	崔银风, 张莉芸, 许珂, 等. 误诊为系统性红斑狼疮的黑热病一例[J]. 中华风湿病学杂志, 2022, 26(1): 39-41, I0002.
	Cui YF, Zhang LY, Xu K, et al. A case of kala-azar misdiagnosed as systemic lupus erythematosus[J]. Chin J Rheumatol, 2022, 26(1): 39-41, I0002. (in Chinese)
[5]	Akkuzu G, Ozkara S, Ozgur DS, et al. Visceral leishmaniasis in a patient with systemic lupus erythematosus: Dilemma in diagnosis and management[J]. Int J Rheum Dis, 2023, 26(4): 769-773.
[6]	Sheng LP, Lin BZ, Han LN, et al. Case report: Visceral leishmaniasis misdiagnosed as systemic lupus erythematosus in a 36-year-old migrant worker[J]. Front Med (Lausanne), 2025, 12: 1614790.
[7]	李杰, 李霞, 杨桂. 组织胞浆菌病误诊黑热病1例[J]. 中国寄生虫病防治杂志, 1998(4): 91.
	Li J, Li X, Yang G. Histoplasmosis misdiagnosed as kala-azar: A case report[J]. J Pathog Biol, 1998(4): 91. (in Chinese)
[8]	陈栖栖, 邬锐, 周乔, 等. 黑热病免疫学异常的临床特点分析[J]. 实用医院临床杂志, 2016, 13(3): 54-56.
	Chen XX, Wu R, Zhou Q, et al. The clinical features of immunological abnormalities of kala-azar patients[J]. Pract J Clin Med, 2016, 13(3): 54-56. (in Chinese)
[9]	谢孝泉, 蒋术侠. 以肾损害为突出表现的黑热病12例分析[J]. 临床误诊误治, 1994, 7(4): 161-162.
	Xie XQ, Jiang SX. Analysis of 12 cases of kala-azar with renal damage as the prominent manifestation[J]. Clin Misdiagnosis Mistherapy, 1994, 7(4): 161-162. (in Chinese)
[10]	Tolaj I, Mehmeti M, Gashi H, et al. Visceral leishmaniasis in Kosovo: A case of misdiagnosis and diagnostic challenges[J]. IDCases, 2023, 32: e01768.
[11]	鲁卓林, 刘力, 孙燕燕. 氯喹和羟氯喹的应用进展[J]. 国际生物医学工程杂志, 2020, 43(4): 330-334.
	Lu ZL, Liu L, Sun YY. Research progress in application of chloroquine and hydroxychloroquine[J]. Int J Biomed Eng, 2020, 43(4): 330-334. (in Chinese)
[12]	Bazmani A, Moshaverinia A, Razmi G. Simultaneous application of thymoquinone and hydroxychloroquine suppresses autophagy and disrupts the autophagosomal trench engulfed Leishmania major[J]. Iran Biomed J, 2024, 28(5 & 6): 255-264.
[13]	《中华传染病杂志》编辑委员会. 中国利什曼原虫感染诊断和治疗专家共识[J]. 中华传染病杂志, 2017, 35(9): 513-518.
	Editorial Board of the Chinese Journal of Infectious Diseases. Expert consensus on diagnosis and treatment of Leishmania infection in China[J]. Chin J Infect Dis, 2017, 35(9): 513-518. (in Chinese)
[14]	Freire ML, de Avelar DM, Pedras MJ, et al. Impact of age and immune status on the accuracy of rapid diagnostic tests for visceral leishmaniasis in Brazil[J]. PLoS Negl Trop Dis, 2025, 19(6): e0013087.
[15]	谢垒, 王瑶, 马威, 等. 宏基因组二代测序技术诊断骨髓涂片阴性婴幼儿黑热病3例报告[J]. 临床儿科杂志, 2023, 41(11): 859-862.
	Xie L, Wang Y, Ma W, et al. Diagnosis of three cases of bone marrow smear-negative infantile kala-azar by metagenomics next-generation sequencing[J]. J Clin Pediatr, 2023, 41(11): 859-862. (in Chinese)
[16]	宏基因组分析和诊断技术在急危重症感染应用专家共识组, 童朝阳, 宋振举. 宏基因组分析和诊断技术在急危重症感染应用的专家共识[J]. 中华急诊医学杂志, 2019, 28(2): 151-155.
	Expert consensus group on the application of metagenomic analysis and diagnostic techniques in critical and severe infections, Tong ZY, Song ZJ. Expert consensus on the application of metagenomic analysis and diagnosis technology in acute and critical infection[J]. Chin J Emerg Med, 2019, 28(2): 151-155. (in Chinese)
[17]	Zhao R, He GL, Xiang L, et al. Metagenomic next-generation sequencing assists in the diagnosis of visceral leishmaniasis in non-endemic areas of China[J]. Front Cell Infect Microbiol, 2025, 15: 1517046.
[18]	Zhang XG, Liu YQ, Zhang MM, et al. Case report: Diagnosis of visceral leishmaniasis using metagenomic next-generation sequencing and bone marrow smear[J]. Front Cell Infect Microbiol, 2022, 12: 1095072.
[19]	牟丽娉, 姚瑜. 解读美国传染病学会2007年修订版组织胞浆菌病临床治疗指南[J]. 国外医药(抗生素分册), 2008(3): 125-139.
	Mou LP, Yao Y. Interpretation of the revised 2007 guidelines for clinical treatment of histoplasmosis of American Society of Infectious Diseases[J]. World Notes on Antibiotics, 2008(3): 125-139. (in Chinese)
[20]	Calvopi?a M, Toro M, Bastidas-Caldes C, et al. A fatal case of disseminated histoplasmosis by Histoplasma capsulatum var. capsulatum misdiagnosed as visceral leishmaniasis-molecular diagnosis and identification[J]. Pathogens, 2023, 12(9): 1112.