類風溼性關節炎患者罹患巨細胞病毒感染症之臨床表現和預測因子

Clinical characteristics and predictors of cytomegalovirus infection in patients with rheumatoid arthritis

目的：描述類風濕關節炎患者罹患巨細胞病毒感染症之臨床表現和預測因子。方法：此回溯性研究納入一家醫學中心於2008年11月至2018年1月間住院且接受過巨細胞病毒聚合酶鍊反應檢驗的類風溼性關節炎患者。接受過兩次以上檢驗的患者，納入病毒量最高的一次。本研究比較巨細胞病毒聚合酶鍊反應檢驗陽性和陰性患者之臨床資訊、表徵、實驗室檢查結果，並以多變項羅吉斯回歸探討類風濕關節炎患者罹患巨細胞病毒感染之預測因子。結果：本研究共收錄61名住院之類風濕性關節炎患者，其中16名被檢驗到有巨細胞病毒感染。巨細胞病毒感染之患者相較於沒有感染者者有較高的全原因死亡率（50.0% vs. 22.2%）。呼吸道症狀（75.4%）、發燒（68.9%）和貧血（47.5%）是最常見之臨床表現。巨細胞病毒IgM於巨細胞病毒感染症之檢驗敏感度為25%（3/12）。臨床診斷之巨細胞病毒肺炎患者中有10位患者接受支氣管肺泡灌洗術，但僅有30%於支氣管肺泡灌洗術中被發現有巨細胞病毒。多變項回歸分析發現三個月內的靜脈類固醇治療和貧血是巨細胞病毒感染的獨立預測因子。結論：住院的類風濕性關節炎患者的巨細胞病毒感染症有高死亡率。近期靜脈類固醇使用和貧血為此感染症之獨立預測因子。臨床醫師應在高危險類風濕患者族群中留意此罕見但嚴重的感染併發症。

Objective: To describe the clinical characteristics and evaluate predictors of cytomegalovirus (CMV) infection in patients with rheumatoid arthritis (RA). Methods: The present retrospective study was performed in a tertiary medical center. Patients with RA who were hospitalized from November 2008 to January 2018 and underwent at least one CMV polymerase chain reaction (PCR) test were enrolled. The first test or the test with the highest copy number was included for each patient. Baseline demographic characteristics, treatments, clinical manifestations, and laboratory data were compared between patients with positive and negative CMV PCR results. Predictors of CMV infection were analyzed using multivariate logistic regression. Results: A total of 108 CMV PCR results were available and attributed to 61 hospitalized patients. Patients with CMV infection (26.2%; 16/61) had significantly higher all-cause mortality than did patients without (50.0% vs. 22.2%, p = 0.036). Overall, respiratory symptoms (75.4%) were the most common clinical manifestation, followed by fever (68.9%) and anemia (47.5%). The sensitivity of CMV IgM for CMV infection was 25% (3/12). Bronchoalveolar lavage was used as an additional diagnostic tool in 45.9% of patients. However, the yielding rate was only 30% (3/10) for clinically diagnosed CMV pneumonia. Multivariate logistic regression identified intravenous (IV) steroid therapy within 3 months and anemia as two independent predictors of CMV infection. Conclusions: CMV infection was associated with high mortality in patients with RA. Recent IV steroid therapy and anemia were independent predictors of CMV infection. Clinicians should be aware of this rare but serious complication in high-risk populations.