慢性阻塞性肺疾病急性加重期合并侵袭性肺曲霉菌病23例临床分析

目的探讨慢性阻塞性肺疾病急性加重期(AECOPD)合并侵袭性肺曲霉菌病(IPA)的危险因素及临床特点。方法回顾分析2008年5月至2010年6月浙江大学医学院附属第一医院收治的慢性阻塞性肺疾病急性加重期合并侵袭性肺曲霉菌病患者的临床资料。结果 23例患者中,确诊7例,临床诊断16例。平均年龄(68.3±4.32)岁。其中22例使用广谱抗生素和15例长期使用激素,12例1年内住院>3次,11例年龄>70岁。病灶出现在双上肺占52.1%,双肺多发占21.7%,双下肺占13.0%,位于右中叶和左舌叶共占13.0%;其中5例(21.7%)出现晕征,4例(17.3%)出现"新月"征。结论使用广谱抗生素、长期激素治疗、频繁住院等是慢性阻塞性肺疾病合并肺曲霉菌的危险因素,患者临床表现缺乏特异性,胸部CT表现有一定特征性,结合患者有危险因素及实验室检查,有助于早期诊断和早期治疗,改善患者预后。     

慢性阻塞性肺疾病合并肺曲菌病一例及文献复习

目的:提高对慢性阻塞性肺疾病合并侵袭性肺曲菌病(COPD合并IPA)临床特点、诊断及治疗的认识.方法:回顾性分析2011年4月收治的一例COPD合并IPA患者的临床资料及诊治经过,并复习相关文献.结果:男患,“咳嗽、咳痰30余年,气短3年,加重1月余”入院,肺部CT示双肺多发结节影、空洞影,经抗炎、抗念珠菌治疗无效,CT下肺结节病灶活检病理示肺曲菌.抗曲菌治疗后症状好转、肺部影像明显吸收.结论:COPD合并IPA正逐渐引起重视,临床特征无明显特异性,肺部影像以结节影、空洞影多见,早期常规治疗无效时应积极抗曲菌治疗,可明显改善症状,降低死亡率,病理活检是确诊的依据.     

侵袭性肺曲霉病10例临床分析

目的:提高对侵袭性肺曲霉病(IPA)的认识,早期诊断、早期治疗.方法:回顾性对我院10例侵袭性肺曲霉病的临床资料并进行分析.结果:10例患者均符合侵袭性肺曲霉病的诊断,6例患者通过纤支镜活检确诊,4例通过刷检及痰培养结果临床诊断,纤支镜下主要表现为粘膜充血水肿、息肉样肿物或伪膜性气道支气管炎,经伊曲康唑口服治疗,10例患者均能达到临床治愈.结论:侵袭性肺曲霉病症状不典型,纤支镜检查对早期诊断有重要意义,对于轻中症患者,伊曲康唑口服治疗经济有效.     

侵袭性曲霉菌病13例临床特点分析

目的分析侵袭性肺曲霉病(IPA)的临床特点,提高对本病的认识。方法对13例确诊的IPA患者的临床资料进行回顾性分析。结果 IPA患者中存在基础疾病或危险因素者占69.2%(9/13);临床表现包括咳嗽、黄痰(13/13)、高热(11/13)、胸闷或呼吸困难(7/13)和咯血(2/13)等;92.3%(12/13)患者有高白细胞血症,WBC大多为(15~30)×109;10例G试验检测的患者中有9例出现阳性;影像学检查:肺内多发空洞及"空气新月征"9例(69.2%),"晕轮征"2例(15.4%),支气管炎表现6例(46.2%),胸腔积液3例(23.1%),颅内播散病灶1例;气管镜检查以粘膜水肿、脓痰、管腔坏死物为主;9例患者痰培养或肺泡灌洗液培养阳性(占69.2%),所有患者病理检查均见曲霉菌丝。所有患者均接受抗真菌药物治疗,4例好转出院,9例恶化放弃治疗或死亡。结论 IPA是临床严峻挑战;掌握该病的临床特点、实验室检查和胸部影像特征,及时的气管镜、组织病理检查有助于IPA确诊。临床医师应高度重视曲霉病。     

乙肝病毒相关慢加急性肝功能衰竭患者中侵袭性肺曲霉病的危险因素分析

目的探讨乙肝病毒相关慢加急性肝功能衰竭(HBV-ACLF)患者中侵袭性肺曲霉病(IPA)的发生率、危险因素及预后。方法回顾性分析2015年1月~2017年1月住院的283例HBV-ACLF患者临床资料,根据住院期间是否并发IPA将患者分为IPA组和对照组。结果在纳入研究的283例HBV-ACLF患者中,住院期间并发IPA 39例,发生率13.78%。IPA组和对照组患者在2型糖尿病、肺部基础病,入院时基线TBiL水平、MELD评分,糖皮质激素使用、广谱抗生素使用,股静脉置管,住院楼层比较上存在统计学差异(P0.05)。对单因素分析中存在统计学差异的因素进行logistic回归分析,结果显示,HBV-ACLF患者肺部曲霉菌感染发生的危险因素为:2型糖尿病(OR=8.981,P=0.002)、肺部基础疾病(OR=8.525,P=0.000)、糖皮质激素使用超过3d(OR=8.856,P=0.000)、广谱强效抗生素使用超过1周(OR=9.823,P=0.000)。HBV-ACLF并发IPA后,病死率达79.48%。结论 HBV-ACLF患者住院过程中易合并IPA。2型糖尿病、肺部基础疾病、真菌感染发生前糖皮质激素使用、广谱抗生素使用等可能是肺部曲霉菌感染的危险因素。HBV-ACLF患者一旦并发IPA,病死率极高。     

23例儿童霍奇金淋巴瘤临床分析(英文)

目的:分析儿童青少年霍奇金淋巴瘤(HL)患者的病理特征、临床表现及其预后影响因素。方法:收集青岛大学医学院附属医院血液儿科2001年5年至2013年8月收治的23例经病理确诊的儿童青少年HL患者的临床资料,采用Fisher确切概率法等进行各组间差异检验。结果:确诊病例共23例,中位年龄7.5岁,男:女发病比例=6.7:1,Ⅰ期、Ⅱ期、Ⅲ期、Ⅳ期分别占13.0%、26.2%、30.4%、30.4%;结节性淋巴细胞为主型(NLPHL)1例(4.3%),经典型HL22例(95.7%):混合细胞型(MC)10例(43.5%),淋巴细胞为主型(LP)11例(47.9%),结节硬化型(NS)1例(4.3%);受累部位以颈部淋巴结最多见,其次依次为纵隔、腹腔及腹膜后、脾、骨骼、肺组织等,其中巨大纵隔肿块者2例;具有B症状者8例(34.7%)。化疗2个疗程评估总有效率为100%,完全缓解(CR)率69.6%,部分缓解(PR)率30.4%。Ⅰ期和Ⅱ期患者CR率100%,明显高于Ⅲ期和Ⅳ期患者(50%),P0.05;23例患者7例复发,复发率Ⅲ期和Ⅳ期患者为46.2%,Ⅰ期和Ⅱ期患者为11.1%,前者高于后者(P=0.0098);有B症状与无B症状患者之间复发率有显著统计学差异(P=0.019);2例有巨大包块患者皆复发;各病理分型与疾病的复发间差异无统计学意义(x2=2.695,P0.05)。结论:儿童霍奇金淋巴瘤预后相对较好,但Ⅲ期和Ⅳ期、合并B症状及大肿块或大纵隔肿瘤的患者复发率高,应依据疾病危险度分层治疗,以期更好的预后。     

慢性阻塞性肺疾病合并侵袭性肺曲霉病的病理生理特点及其诊断策略

近年来,慢性阻塞性肺疾病患者侵袭性肺曲霉病的发病率不断上升,早期诊断对改善临床预后极为重要。慢性阻塞性肺疾病患者支气管-肺功能和结构损害,并经常接受激素治疗等特点导致患者合并侵袭性肺曲霉病时临床和CT表现不典型,有关侵袭性肺曲霉病的实验室诊断敏感性和(或)特异性降低,给诊断带来了困难。本文试从慢性阻塞性肺疾病合并侵袭性肺曲霉病的病理生理特点入手探讨其诊断上的一些问题。     

艾滋病合并肺部感染12例临床分析

目的:探讨艾滋病(AIDS)合并肺部感染的临床特点、实验室检查及影像学特征。方法:回顾性分析我院2008年1月-2012年4月期间确诊的12例AIDS合并有肺部感染患者的病例资料。结果:发病以男性为主(11例),临床症状以发热、咳嗽、胸闷等为主,实验室检查血沉明显增快、中性粒细胞升高,2例合并有梅毒螺旋体感染,5例合并有乙肝病毒感染,1例合并丙肝病毒感染,氏肺孢子虫肺炎发生率41.67%(5/12);影像学检查主要表现为双肺弥漫性病变,肺门部位为主的毛玻璃样改变。结论:AIDS合并肺部感染患者早期不易诊断,应进一步提高对AIDS的临床症状及影像学认识提高对AIDS的早期诊断率,如存在高危因素者应及时进行艾滋病病毒抗体检测以明确诊断。     

慢性肺曲霉菌病55例临床分析

目的分析慢性肺曲霉菌病(CPA)临床特点,为诊断和治疗提供依据。方法回顾性分析55例临床诊断CPA患者的临床资料、影像学特征及实验室检查。结果在诊断为CPA55例患者中,34例诊断为慢性空洞性肺曲霉病,15例亚急性侵袭性肺曲霉菌病,4例单纯性肺曲霉菌球,2例曲霉菌结节。在CPA患者中合并慢性阻塞性肺疾病29例(52.7%),恶性肿瘤6例(10.9%)、肺结核5例(9.1%)、哮喘4例(7.3%)、支气管扩张4例(7.3%)、间质性肺疾病1例(1.8%)。CPA患者最常见症状是咳嗽(94.5%)、咳痰(81.8%)、咯血(54.5%)和发热(36.4%)。最常见胸部CT扫描异常是空腔(96.4%)、结节(63.6%)、渗出或实变(7.3%)和胸膜增厚(5.5%)。结论 CPA患者多合并慢性阻塞性肺疾病、恶性肿瘤、肺结核、哮喘、支气管扩张、间质性肺疾病,慢性空洞性肺曲霉病是CPA患者最常见的类型。积极寻找病原学和影像学证据,必要时行肺穿刺及肺切除手术,尽早开始抗真菌治疗,改善CPA患者的预后。     

肺隐球菌病41例临床分析

目的总结分析41例肺隐球菌病患者的临床特点。方法回顾性分析我院(2003年1月～2006年10月)41例肺隐球菌病的临床、影像学表现,免疫学检查、病理及抗真菌治疗疗效。结果①41例肺隐球菌病,男28例,女13例,有基础疾病者18例,有临床症状者22例,影像学表现为结节肿块型27例,肺炎型8例,混合型6例。②有基础疾病的18例患者中有临床症状者15例;影像学表现为肺炎型8例,混合型4例,结节肿块型6例;并发隐球菌脑膜炎2例。无基础疾病患者23例,多无临床症状或临床症状较轻,多表现为结节肿块型(21例),无并发症,预后较好。③抗真菌药物治疗36例,治愈34例,好转2例(有效率100%)。都使用氟康唑治疗,疗程2周～2年不等。结论免疫功能正常的肺隐球菌病患者病变局限,多为结节肿块型,并发症少,预后好;免疫功能异常者多表现为肺炎型或混合型,易出现全身播散。肺隐球菌病单用氟康唑抗真菌治疗效果好,应为首选。     

Invasive pulmonary aspergillosis in AIDS.

Aspergillosis is a fungal infection rarely observed in Cuba during the first years of the AIDS epidemic. However, the increase in aspergillosis cases diagnosed by autopsy in recent years, led us to study the epidemiological, clinical, radiological and anatomopathological characteristics of this disease among the Cuban AIDS patients. A total of 307 autopsies were reviewed, seven of them had invasive pulmonary aspergillosis (2.2%). The disease was predominant in men and in the white race. Neutropenia and drugs use were the risk factor more frequently observed. Clinical manifestations were those unspecific and common to other opportunistic infection of the respiratory system. The more common radiological picture were bilateral nodular infiltrates and cavitary lesions in the upper lobes (two cases). The anatomopathological diagnosis was based on the morphological characteristics of the agent and in the angioinvasive features of the pulmonary lesions. We suggest that aspergillosis should be considered in the differential diagnosis of opportunistic respiratory events of AIDS patients in advanced stages.     

Pulmonary Aspergillus Overlap Syndromes

Background

Broadly, there are three main categories in pulmonary aspergillosis: chronic forms of aspergillosis; allergic bronchopulmonary aspergillosis; and invasive aspergillosis (IPA). IPA has been further subdivided into angioinvasive and airway-invasive aspergillosis. Aspergillus overlap syndromes is defined as the occurrence of more than one form aspergillus disease in a single individual.

Objectives

To help clinicians correctly deal with AOS.

Methods

Retrospectively study the clinical findings of nine patients presenting with AOS.

Results

Four cases were diagnosed as angioinvasive aspergillosis complicated with ABPA, three cases as IPA overlap aspergilloma, and two cases as ABPA with AWIA. All the patients presented with cough and expectoration. In three patients with IPA overlap aspergilloma, two had hemoptysis, two had wheezing and fever. All of patients with IPA overlap ABPA had wheezing, dyspnea, and fever, three had sputum plugs, two had hemoptysis, and five patients had mucopurulent discharge and rhonchi in auscultation. Their total IgE ranged from 129 to 2124 IU/ml (676.5 ± 557.33 IU/ml). Fungal culture in sputum showed A. Fumigatus in three patients. All the six patients with IPA overlap ABPA applied steroid therapy and antifungal therapy. Three of them received two or more antifungal drugs successively, and three received combinational therapy. All the patients improved except one diagnosed ABPA overlap IPA.

Conclusions

Clinical manifestation of AOS is not typical. Poor first-line therapeutic effects and complicated diagnosis criteria require clinicians to be aware of AOS when facing patients with aspergillosis.

     

非粒细胞减少患者肺曲霉病22例回顾性分析

目的提高对非粒细胞减少患者肺曲霉病的认识及诊疗水平。方法回顾性分析22例非粒细胞减少患者肺曲霉病的临床、影像学及实验室资料,随诊其转归。结果22例肺曲霉病（PA）患者,男性12例,女性10例,平均年龄（56．3±21．4）岁。确诊、临床诊断各8例,拟诊6例。侵袭性肺曲霉病（IPA）11例,单纯性曲霉球6例,慢性坏死性肺曲霉病（CNPA）5例。常见基础疾病为继发型肺结核（8／22）、糖尿病或类固醇性糖尿病（6／22）、高血压病（5／22）、慢性阻塞性肺疾病（5／22）,4例系原发社区感染。常见临床症状咳嗽咳痰（18／22）、咯血（11／22）、气促（7／22）。影像学表现为肺部渗出或实变病灶9例、空洞改变及典型曲霉球12例,结节或肿块1例。首选药物治疗依次为伏立康唑（10／22）、卡泊芬净（4／22）、伊曲康唑（3／22）。结论非粒细胞减少伴IPA好发于糖尿病、慢性阻塞性肺疾病,亦可发生在免疫功能正常患者。单纯曲霉球多继发或并发于肺结核。应注意鉴别CNPA与单纯曲霉球。IPA临床表现缺乏特征性。影像改变未见典型晕征及空气半月征,肺外播散少见,药物治疗首选伏立康唑。     

肺曲霉病40例的临床分析

目的：探讨肺曲霉病的临床表现、影像学特点、诊断和治疗,以提高对本病的认识。方法：回顾性分析本院2002年1月-2009年4月经病理确诊为肺曲霉病住院患者40例,总结其临床表现、影像学特点、诊断及治疗情况。结果：40例肺曲霉病患者中,曲菌球23例、侵袭性肺曲霉病17例。合并有基础疾病者36例（90．0％）：其中,肺结核15例（37．5％）,支气管扩张6例（15．0％）。肺曲霉病的主要症状为咳嗽32例（80．0％）,咳痰25例（62．5％）,咯血24例（60．0％0。影像学表现多样,肿块结节型23例（57．5％）,渗出型12例（30．0％）空洞样病灶12例（30．0％）,“洞中球征”和“晕征”各8例（20．0％）。所有病例均经过病理检出,手术切除后病理检出26例（65．0％）,纤维支气管镜下活检栓出12例（30．0％）,CT引导下经皮肺穿刺活检检出2例。本组病例中,26倒在病理诊断前被初诊误诊,误诊率高达65．0％,初诊为肺结核13例（32．5％）,肺癌8例（20．0％）,细菌感染3例,支气管扩张并感染2例。26例（65．0％）经外科手术切除,随访均无复发;10例（25．O％）经抗真菌药物治疗,9例痊愈或显效。结论：肺曲霉病多继发于肺部基础疾病,临床表现以咳嗽、咳痰、反复间断咯血为主,缺乏特异性;影像学表现复杂多样。曲菌球和侵袭性肺曲霉病的发病危险因素、临床表现、影像学以及治疗方法均有不同。肺曲霉病误诊率高,确诊有赖于组织病理学;外科治疗和抗真菌药物治疗有较好的疗效。     

Aspergilosis pulmonar invasiva en el enfermo con enfermedad pulmonar obstructiva crónica

Invasive pulmonary aspergillosis (IPA) is a common infection in immunocompromised patients with hematological malignancies or allogenic stem cell transplantation, and is less frequent in the context of chronic obstructive pulmonary disease (COPD).Mucociliary activity impairment, immunosuppression due to the inhibition of alveolar macrophages and neutrophils by steroids, and receiving broad-spectrum antibiotics, play a role in the development of IPA in COPD patients. Colonized patients or those with IPA are older, with severe CODP stage (GOLD ≥ III), and have a higher number of comorbidities. The mortality rate is high due to the fact that having a definitive diagnosis of IPA in COPD patients is often difficult. The main clinical and radiological signs of IPA in these types of patients are non-specific, and tissue samples for definitive diagnosis are often difficult to obtain.The poor prognosis of IPA in COPD patients could perhaps be improved by faster diagnosis and prompt initiation of antifungal treatment. Some tools, such as scales and algorithms based on risk factors of IPA, may be useful for its early diagnosis in these patients.     

国产血清半乳甘露聚糖检测试剂对侵袭性肺曲霉菌病的诊断价值评估

目的：评估国产血清半乳甘露聚糖（Galactomannan,GM）检测试剂对侵袭性肺曲霉菌病的诊断价值。方法根据血液病/恶性肿瘤患者侵袭性真菌病的诊断标准与治疗原则（第四次修订版）[1]收集临床确诊侵袭性肺曲霉菌病（inva-sive pulmonary aspergillosis,IPA）、临床诊断IPA、拟诊IPA、排除IPA四组病例。采用天津贻诺琦公司酶联免疫吸附法（ELISA）试剂检测纳入的86例患者血清标本的GM浓度,分析其敏感性、特异性、阳性预测值（PPV）、阴性预测值（NPV）。结果86例病例中,临床诊断27例、拟诊12例、排除47例。在3种不同的阳性判断标准下,敏感性：9444%、9630%、6296%;特异性：5625%、4576%、6441%;PPV：4474%、4483%、4474%;NPV：9643%、9643%、7917%。统计学分析证实标准1（即血清GM值〉095μg/L为阳性,〈075μg/L为阴性,075~095μg/L为灰区,未将灰区加入计算）在3种判断标准中最优,故选择其为最终判断标准。结论该血清GM检测试剂盒诊断性能较好,可以用于侵袭性肺曲霉菌病的辅助诊断。     

Galactomannan-Based and PCR-Based Assays in Bronchoalveolar Lavage to Diagnose Invasive Aspergillosis: Current Status and Future Prospects

Invasive pulmonary aspergillosis (IPA) is a life-threatening complication in patients receiving chemotherapy or undergoing allogeneic haematopoietic stem cell transplantation for acute leukemia. The existing tools to diagnose IPA lack specificity or sensitivity, or both; the search for improved diagnostic tools for IPA has focused on novel serologic and molecular methods. Aspergillus Galactomannan enzyme-linked immunosorbent assay (GM) analyses showed sensitivity rates in serum samples ranging in a wide span; testing GM in bronchoalveolar lavage (BAL) originated from the primary site of the infection seems to be more sensitive in patients with IPA. Other novel diagnostic markers to detect fungal DNA directly in clinical samples, rapidly, early, sensitively and specifically, are provided by polymerase chain reaction (PCR) based assays; higher sensitivity and specificity rates have been observed for BAL samples in IPA, even under antifungal treatment. The clinical place value of a diagnostic approach combining PCR and GM in BAL is unclear.