目的:本文报道一例罕见的重症原发免疫性血小板减少症(ITP)患者治疗过程中合并EDTA、肝素钠、枸橼酸钠抗凝剂同时依赖性假性血小板减少的病例,分析与探讨其病因,为临床工作提供处理预案及经验指导。方法:通过静脉采血同时送EDTA-K2抗凝管、肝素钠抗凝管和枸橼酸钠(1:9)抗凝管至血细胞分析仪进行PLT计数,手指末梢血采血立即手工稀释计数法作为对比。回顾性分析该例临床资料,结合文献复习探讨其发生可能的原因。结果:该例ITP患者使用EDTA-K2抗凝管、肝素钠抗凝管、枸橼酸钠(1:9)抗凝管的PLT计数分别为6.00 × 109/L、9.00 × 109/L、7.00 × 109/L,手指末梢血校正手工稀释计数为PLT 32.00 × 109/L。患者ITP出血评分5分,重症ITP合并EDTA、肝素钠、枸橼酸钠抗凝剂同时依赖性假性血小板减少诊断明确,其原因可能与自身免疫性疾病及EDTA螯合、诱导血小板活化等机制相关,临床发生率极低,很容易误诊、漏诊,影响后续治疗,需要予以关注。结论:对于重症ITP患者治疗后血小板仍低的情况,除考虑治疗效果不理想外同时需要考虑合并EDTA、肝素钠、枸橼酸钠抗凝剂依赖性假性血小板减少的可能,需结合临床表现及时手工计数校正,可以减少临床误诊、漏诊。Objective: This article reports a rare case of severe primary immune thrombocytopenia (ITP) complicated with EDTA, sodium heparin, and sodium citrate anticoagulant-dependent pseudothrombocytopenia during treatment, shares and discusses its etiology, and provides treatment plans and experience guidance for clinical work. Methods: Venous blood was collected and sent to the blood cell analyzer for PLT counting in EDTA-K2 anticoagulant tubes, sodium heparin anticoagulant tubes, and sodium citrate (1:9) anticoagulant tubes. Finger-end blood sampling and immediate manual dilution counting were used as a comparison. The clinical data of this case were retrospectively analyzed, and the possible causes of its occurrence were discussed in combination with literature review. Results: The PLT counts of the ITP patient using EDTA-K2 anticoagulant tube, heparin sodium anticoagulant tube, and sodium citrate (1:9) anticoagulant tube were 6 × 109/L, 9 × 109/L, and 7 × 109/L, respectively. The PLT count of fingertip blood corrected for manual dilution was 32 × 109/L. The ITP bleeding score of the patient was 5 points, and the diagnosis of severe ITP combined with EDTA, heparin sodium, and sodium citrate anticoagulant-dependent pseudothrombocytopenia was clear. The cause may be related to autoimmune diseases and EDTA chelation, induction of platelet activation and other mechanisms. The clinical incidence is extremely low, and it is easy to misdiagnose
目前免疫检查点抑制剂针对恶性肿瘤有较好的疗效,但其引起的重度免疫相关的不良反应较少。1例70岁的男性肺鳞癌患者经治1月后出现视物模糊,上眼睑提肌无力,眼球运动障碍,颈部肌肉无力,无法平卧等临床症状,结合实验室检查及临床症状考虑为重症肌无力合并免疫相关性心肌炎,立即予以甲强龙联合丙种球蛋白治疗等综合治疗,后患者症状明显改善。结合该患者的诊疗方案我们得出结论,在应用卡瑞利珠单抗等抗PD-1治疗时,应监测患者肝肾功能、心肌酶谱、神经系统功能等指标,一旦出现免疫相关不良反应累及神经系统及心脏时,应立即并永久停药,并给予足够的皮质类固醇和免疫球蛋白治疗,同时可联合溴吡斯的明减少后遗症的发生。我们报道此例卡瑞利珠单抗治疗后诱发重症肌无力合并免疫相关性心肌炎通过治疗好转的病例,同时进行文献回顾,以期为重度免疫相关不良反应诊治提供一些治疗策略参考。At present, immune checkpoint inhibitors have a good effect on malignant tumors, but they cause few severe immune-related adverse reactions. A 70-year-old male patient with lung squamous cell carcinoma developed blurred vision, weakness of the levator muscle of the upper eyelid, eye movement disorder, neck muscle weakness, and inability to lie down one month after treatment. Combined with laboratory tests and clinical symptoms, the patient was considered as myasthenia gravis combined with immune-related myocarditis. Based on the diagnosis and treatment plan of this patient, we conclude that liver and kidney function, myocardial enzyme spectrum, and nervous system function should be monitored during the application of anti-PD-1 therapy such as Camrelizumab. Once immune-related adverse reactions occur involving the nervous system and heart, the drug should be stopped immediately and permanently, and adequate corticosteroid and immunoglobulin should be given. It can be combined with pyridostigmine bromide to reduce the occurrence of sequelae. We report a case of myasthenia gravis complicated with immune-related myocarditis induced by Camrelizumab and review the literature in order to provide some treatment strategies for the diagnosis and treatment of severe immune-related adverse reactions.
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