免疫正常的重症病人之巨細胞病毒感染

Cytomegalovirus Infection in Immunocompetent Critically Ill Patients

研究顯示住在加護單位的重症病人巨細胞病毒（cytomegalovirus, CMV）感染發生率為0～35%，重症病人一旦發病CMV，會增加器官功能障礙、院內感染、呼吸器留置、加護病房住院天數與死亡發生率。目前文獻尚無針對原本無免疫異常之重症病人CMV發病的治療指引，且臨床醫師對於此類病人之CMV檢測與治療亦無共識。已有實證統計經組織切片確診的CMV肝炎，給予有效的抗病毒藥物，能改善預後，提升存活機率。但是臨床上仍有許多醫師疑慮給予非免疫功能低下的重症病人抗病毒藥物，是否徒增暴露骨髓抑制的風險。我們也有臨床經驗發現一些重症病人的延遲性消退之肺炎或結腸潰瘍與出血，最後卻意外診斷為CMV感染性疾病，而部分病人也不幸地因無適當治療而病逝。有鑑於此，筆者回顧免疫功能正常的重症病人CMV發病的相關文獻，特別針對重症病人CMV發病的致病機轉、診斷、發生率、高危險因子和治療與否，做綜合性討論，並整合常見CMV發病的案例報告，包括腸炎、肺炎、肝炎和腦炎，以供臨床相關醫療團隊之警覺與參考。

Integrated studies have shown that the incidence of cytomegalovirus (CMV) infection ranges from 0% to 35% among critically ill patients hospitalized in an intensive care unit (ICU). It has also been found that critically ill patients infected with CMV have increased risk of organ dysfunction, nosocomial infection, and mortality, and experience more ventilator indwelling days and ICU hospitalization days. Guidelines for the treatment of CMV infection specific to critically ill and non-immunocompromised patients have been lacking. Furthermore, there has been no consensus among clinicians regarding the optimal detection and treatment of CMV. There is clinical evidence that the administration of antiviral drugs to patients with biopsy-and histology-proven CMV pneumonia can improve outcomes and increase the chances of survival. Many physicians, nonetheless, remain concerned about the risk of bone marrow suppression caused by antiviral drugs in non-immunocompromised critically ill patients. Some patients in our institution with delayed-resolution pneumonia or colonic ulcers with bleeding were eventually diagnosed with unexpected CMV infection. Unfortunately, without the necessary treatment, some of these patients died. Therefore, we reviewed the literature on CMV infections in critically ill non-immunocompromised patients. We undertook a comprehensive discussion, particularly focusing on the pathogenesis, diagnosis, incidence, and risk factors of CMV infection, and whether treatment is advisable for critically ill patients. We also integrated the literature reporting cases of common CMV infections including colitis, pneumonitis, hepatitis, and encephalitis hoping to raise awareness and provide a reference for relevant medical teams.