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【检验临床面对面】当取完整淋巴结送检遇到APTT延长

时间:2019-03-13       作者:检验视界网      浏览量:5379 次

作者:张家红 宋鉴清,中国医科大学附属第一医院检验科


前言


凝血常规是术前的筛查实验,临床医生都要根据患者的凝血指标予以术前评估。这样做的目的无非是预防手术时出血不止,然而,凝血指标延长就有出血倾向吗?特别是APTT单独延长时?接下来,一例5岁患儿淋巴结肿大诊断过程带给您答案。


案例经过


患儿男,5岁,以发现颈部淋巴结肿大半年,间断发热、咳嗽1个月为主诉入院(1月3日)。


现病史:患儿半年前无明显诱因发现颈部淋巴结肿大,无局部发热,无触痛,当时伴有发热,家属携患儿就诊于当地医院给予静点抗生素后热退,2个月内反复共3次,均静点抗生素后发热好转,但淋巴结肿大未见好转,家属未做处置,1个月前患儿再次出现发热,体温最高39.9℃,发热间隔12小时左右,无寒战,无抽搐,口服退热药后热退,伴有咳嗽,有痰不易咳出,就诊于当地医院诊断肺炎支原体肺炎,给予红霉素、炎虎宁、沐舒坦静点1周,咳嗽好转,仍有发热,就诊于当地某医院完善血检测提示CRP:95g/L,并有颈部淋巴结逐渐增大,建议到上级医院就诊。家属携患儿就诊于**市儿童医院,完善颈部超声考虑淋巴瘤,建议穿刺。家属为求进一步系统诊治收入我院儿科,患儿近来无腹痛,无皮疹,精神状态可,饮食可,二便正常。


既往史:既往体健,否认肝炎、结核病史及接触史。


个人史:第1胎,足月正常产,出生无窒息,生后母乳喂养,按时添加辅食,按时接种疫苗,生长发育同正常同龄儿。


家族史:父母体健。


查体:T36.6℃,P110次/分,R 21次/分,血压90/42mmHg。神志清楚,呼吸平稳,未见皮疹及出血点,瞳孔双瞳孔等大正圆,D=3mm,双侧光反应灵敏,鼻扇(-),口唇略苍白,咽充血,双侧扁桃体I°大,未见脓点,颈强无,三凹征(-),肺脏叩诊未叩,听诊双肺呼吸音粗,未闻及干、湿啰音,心音有力,律齐,各瓣膜听诊区未闻及杂音,腹平,全腹无压痛,肝脾肋下未触及,四肢末梢温暖,毛细血管再充盈时间<3秒,脊柱四肢无畸形,活动自如,未见手足镯,双下肢水肿无,神经系统四肢肌力、肌张力正常。双膝腱反射正常,双巴氏征阴性。初步诊断:淋巴结肿大原因待查,淋巴瘤?


实验室检查:WBC 14.35×109/L,HGB 96g/L,PLT 526×109/L,CRP167.9 g/L,APTT80.2S, APTT纠正实验未纠正,ESR 81mm/h,肺炎支原体抗体1:320。


诊疗计划:1.完善血常规、凝血因子、狼疮抗凝物、肝肾功、离子、心肌酶、血沉、CRP、胸片等检查;2.完善颈部淋巴结穿刺。


患儿穿刺前已经检测三次凝血四项,APTT分别为82.6S、77.9S、80.2S,Rosner指数23.7>11.0为未纠正,1:1混合血浆孵育后APTT延长2.8秒。虽然患儿既往无出血史和家族史,但临床医生还是持谨慎态度,这种情况下能否穿刺、取完整淋巴结,能否造成出血不止。由于淋巴结穿刺送检病理的组织材料太小,病理室建议结合临床取完整淋巴结送检。实验室结合APTT纠正实验结果给出意见,建议检测狼疮抗凝物,可以穿刺,取完整淋巴结,不会造成过多出血。


实验室又做如下主要检查: APTT62.3s,PT13.8s;狼疮抗凝物质检测:ndRVVT-R 1.37(参考值<1.2),第2次APTT纠正实验未纠正,抗心磷脂抗体、风湿抗体系列、血浆凝血因子活性II、V、VII、VIII、IX、XI、vWF、肾功、血离子、血糖、铁蛋白、T-SPOt大致正常;骨髓像提示:未见特征性血液病改变;完整淋巴结病理提示:


1.L-L3(颈部淋巴结):经典霍奇金淋巴瘤(混合细胞型)。

2.免疫组化结果:CK(-),CyclinD1(散在+),Bcl-6(散在+),MUM1(灶状+),CD15(散在+),CD30(散在+),Ki-67(约30%+),CD68(+),ALKP80(-),EMA(-),CD3(+),CD20(灶状+),Pax-5(灶状+),Bcl-2(灶状+),CD21(灶状+),CD23(灶状+),CD10(-),CD5(+)。

3.分子病理结果:EVB*(+)。


1.jpg

图1 显微镜下淋巴结组织病理切片


讨论


APTT延长不外乎以下几种情况:1.内源性凝血因子缺乏;2.含有凝血抑制物(包括抗磷脂抗体和凝血因子抗体);3.应用肝素。本案患儿连续多次APTT单独延长(见图2),没有出血表现并排除应用肝素,两次APTT纠正实验均未纠正(Rosner指数>11.0为未纠正,Rosner指数<11.0为纠正),2次1:1混合血浆孵育后APTT分别延长2.8秒、4.2秒(>3.0秒提示存在时间温度依赖性凝血抑制物如Ⅷ因子抑制物,见图3),且凝血因子大致正常,因此可以判断该凝血抑制物为抗磷脂抗体。该患儿的抗心磷脂抗体、抗β2糖蛋白-Ⅰ抗体阴性,狼疮抗凝物的检测阳性(见图4),可进一步诊断血浆中含有狼疮抗凝物,干扰APTT实验,导致结果升高。


2.jpg

图2 患儿住院期间检测的凝血四项


3.jpg

图3 患儿两次纠正实验


4.jpg

图4 患儿狼疮抗凝物检测


5.png

图5 APTT延长分析流程图


那么,狼疮抗凝物阳性为什么会使APTT延长呢?


狼疮抗凝物(LA)是抗磷脂抗体(主要有狼疮抗凝物、抗心磷脂抗体、抗β2糖蛋白-Ⅰ抗体)家族成员之一,是一组能与负电荷磷脂及磷脂蛋白质复合物相结合的lgG/IgM型免疫球蛋白。LA可作用于凝血酶原复合物(Xa、Va、Ca2+及磷脂)和Tenase复合体(IXa、Ⅷa、Ca2+及磷脂),导致磷脂依赖的凝血试验时间(如APTT、DRVVT、SCT等)延长[1]。而我们所用的APTT检测原理是将标准数量的兔脑磷脂和特定激活物(我室所用试剂含有的激活物是硅土)加到血浆中,经过孵育后,加入适当浓度的钙离子,测定其纤维蛋白凝块形成的时间,因此用APTT监测血浆凝固要具备三个条件:磷脂、激活物、钙离子,三者缺一不可。当血浆中含有抵抗磷脂的LA且所用试剂的激活物是对LA敏感的硅土时,血浆凝固时间势必会延长,其实这是LA对磷脂依赖的体外实验的影响。在体内,LA可激活血小板和(或)通过β2糖蛋白-Ⅰ结合,诱导黏附分子、组织因子表达及补体活化而产生血栓前状态,促进血栓形成[2],也是不明原因习惯性流产、死胎、易栓性疾病及某些自身免疫性疾病的危险信号[3]。Pengo等[4]指出,同种型(最常见的是IgG)的中高滴度aCL和aβ2GPI的存在与阳性LA的患者具有高血栓形成风险。LA也存在于恶性肿瘤、感染、使用药物等患者体内,正常人也会出现一过性LA阳性[5、6]。大多数医生认为含有LA是一种良性疾病,常有短暂的病程,缺乏明显的临床问题[7]。本例患儿EB病毒感染、淋巴瘤并使用药物可能是导致LA阳性原因,因此,虽然患儿APTT明显延长、但LA阳性且无出血倾向,有创性检查不会有出血不止的问题??啥曰级ㄆ谒娣?,治疗原发病同时定期检测LA。


关于LA的研究多在成年人群中进行,儿科年龄组有关LA的资料较少,LA检测的重要性日益凸显。对于单独APTT延长的大多数患者而言,无出血表现、无既往出血史或家族史、未使用抗凝药物,可考虑其体内含有凝血抑制物,可行APTT纠正实验判别下一步方向,需要时再行狼疮抗凝物检测予以确认?;褂?,1.当患者FⅫ、激肽释放酶原(PK)、高分子量激肽原(HMWK)缺乏时同样没有出血表现且APTT延长;2. LA阳性有出血表现者见于抗磷脂综合征血小板减少和儿童低凝血酶原血症-狼疮抗凝物综合征。但是上述情况罕见。


结语


对于本例患儿的确诊,只有行完整淋巴结切除术做病理诊断才是金标准,但APTT显著延长有创检查能否出血不止,临床医生寻求了实验室的帮助。实验室根据APTT、APTT纠正实验、LA、凝血因子等的检测结果给予完整解读,至此打消了医生不敢手术的顾虑。临床需要实验室的检验结果,实验室也要很好地予其解读,更好地辅助临床。当前,检验项目繁多,临床与实验室不再是独立的个体,而是你中有我,我中有你的融合关系,沟通是重要的桥梁,桥梁搭建好了,问题就容易解决。


在此感谢儿科、病理科各老师提供的帮助!


参考文献

[1]寿玮龄, 陈倩, 吴卫, 等. 不同狼疮抗凝物检测试验的临床诊断效能研究[J]. 中华医学杂志, 2015, 95: 2760-2765.

[2]李洋, 吕明恩, 薛峰, 等. 狼疮抗凝物二例报告并文献复习[J]. 中华血液学杂志, 2016, 37: 130-133.

[3]谢波, 徐升强, 崔天盆. 狼疮抗凝物实验室规范化检测进展[J]. 临床检验杂志, 2016, 34: 144-146.

[4]V. Pengo, A. Tripodi, G. Reber, et al. Update of the guidelines for lupus anticoagulant detection. Subcommittee on Lupus Anticoagulant/Antiphospholipid Antibody of the Scientific and Standardisation Committee of the International Society on Thrombosis and Haemostasis[J]. J Thromb Haemost, 2009, 7: 1737-40.

[5]A. Tincani, M. Taraborelli and R. Cattaneo. Antiphospholipid antibodies and malignancies[J]. Autoimmun Rev, 2010, 9: 200-2.

[6]E. Peker, K. Kavakli, C. Balkan, et al. Incidence and clinical importance of lupus anticoagulant in children with recurrent upper respiratory tract infection[J]. Clin Appl Thromb Hemost, 2011, 17: 220-4.

[7]C. Kallanagowdar, A. Chauhan, M. V. Puertolas, et al. Prevalence and Resolution of Lupus Anticoagulant in Children[J]. Ochsner J, 2016, 16: 172-5.


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