两性霉素B成功治疗不规则毛霉引起的皮肤慢性毛霉病1例

患者,女,44岁,面部红斑、丘疹16年,溃疡、结痂8年。皮肤科检查：面部弥漫肿胀性红斑、大片状境界清晰的溃疡和坏死性焦痂。双眼睑外翻,右眼失明。真菌直接镜检、培养及分子生物学菌种鉴定,确诊为不规则毛霉所导致的皮肤慢性毛霉病,予两性霉素B静脉滴注治疗,皮损明显改善,遗留萎缩性瘢痕。     

鼻眶脑毛霉菌病16例临床病理分析

目的探讨鼻眶脑毛霉菌病(ROCM)的临床与病理特征,提高对该病的认识和病理诊断水平。方法回顾分析首都医科大学附属北京同仁医院1998～2008年16例ROCM患者的病历资料。用HE、PAS和GMS染色显示组织病变特点及真菌的形态特征,对1例石蜡组织行透射电镜观察。结果 14例(87.5%)有基础疾病,2例(12.5%)无特殊病史。死亡5例(31.3%),3例死于ROCM,2例死于原发病。CT示鼻腔鼻窦软组织密度影16例,MRI示眶内(15例)和颅内(5例)异常信号影。真菌培养7例阳性(43.8%)。组织病理:16例均见组织凝固性坏死、真菌性血管炎及肉芽肿,骨质破坏9例,外周神经纤维坏死7例。特殊染色菌丝形态均符合毛霉目真菌;透射电镜见菌丝形态不规则,菌壁电子密度高。结论 ROCM主要见于糖尿病和血液系统恶性肿瘤者,亦见于无基础疾病者。常见致病菌为根霉和毛霉。在病变组织中找到符合毛霉目真菌形态特点的菌丝可确诊。对临床症状、影像学、真菌培养及病理学表现等多方面进行综合分析可明确诊断。     

多变根毛霉致面部皮肤毛霉病1例

报道1例由多变根毛霉引起的面部皮肤毛霉病.患者男,65岁,面部结节斑块伴痒半年余.皮损组织病理检查示真皮中下层有炎细胞及多核巨细胞浸润,并见粗大较短的无隔菌丝.经真菌培养和分子生物学鉴定,菌种鉴定为多变根毛霉.皮损经短时两性霉素B治疗后好转.     

心脏移植术后并发肺毛霉病5例治疗经验分析

目的 对心脏移植术后肺毛霉感染患者的感染特点、诊疗经过及转归进行分析总结。方法 回顾性总结分析2018年5月至2022年10月于郑州市第七人民医院就诊的5例心脏移植术后肺毛霉感染患者的临床特点、诊疗经过及转归。结果 5例患者中有2例患者经组织病理确诊,3例患者经mNGS辅助诊断,所有患者均采用药物治疗,其中有4例患者死亡,死亡率75%,死亡患者平均生存时间131 d。结论 心脏移植术后肺毛霉病危险因素多、进展迅速、死亡率高,尽早诊断、规范治疗是改善预后的关键,宏基因二代测序或许可作为早期诊断方法之一。     

一种引致人体原发性皮肤毛霉病的非高温根毛霉属真菌

由石家庄中国人民解放军白求恩国际和平医院皮肤科李成龙大夫提供的一株人体皮肤病菌经我们研究鉴定为毛霉目(Mucorales)毛霉科(Mucoraceae)根毛霉属(Rhizomucor)的一个种,并定名为多变根毛霉新种(Rhizomucor variabilis Zheng & G.-q.Chen sp. nov.)。据李大夫介绍,这株菌是从一名居住在江苏农村到该医院看病的女病人的手上病部分离的。这个病人没有一般真菌病病人所患有的其他疾病如糖尿病、白血病等等。她也没有患有其他毛霉病,因此她的皮肤毛霉病是原发性的而不是继发性的。我们查阅文献结果,国内由根毛霉属真菌引致的毛霉病过去仅有过一次肺部感染的报道;国外则有过较多次数的由根毛霉引致的人体毛霉病,主要为肺部疾病并可引致继发性的皮肤病,尚未见有由根毛霉属引起的原发性皮肤毛霉病的报道。无论国内、外引起人体毛霉病的根毛霉均为微小根毛霉[Rhizomucor pusillus(Lindt) Schipper,包括Mucor pusillus Lindt,Mucor parasiticus Lucet & Costanin等异名]一种。因此,本病例为我国第二例由根毛霉弓l起的人体毛霉病及第一例由根毛霉引起的人体皮肤毛霉病,同时又是全世界第一例由根毛霉属除微小根毛霉以外的另外一个种引起的人体毛霉病,很可能还是全世界第一例由根毛霉引起的人体原发性皮肤毛霉病。多变根毛霉与根毛霉属内所有过去已报道过的种都有显著差异。它的最适生长温度为24-30℃,最低9℃,最高38℃;其他种均为高温真菌,它们的最高生长温度可达55℃或更高。形态方面,多变根毛霉也与属内其他已知种明显不同。它的菌落高达4-8 mm并呈鲜明的浅黄色;其他已知种菌落低矮,除奈尼塔尔根毛霉(Rhizomucor nainitalensis Joshi)外全部为深暗灰色,奈尼塔尔根毛霉菌落色泽虽然较浅,但为浅灰或灰黄色,与多变根毛霉的鲜明黄色不同。它的假根异常发达并可从菌体的各个部位如菌丝、匍匐丝、孢子枝、孢子囊、囊轴上长出;其他已知种的假根一般都不发达且从未见有从孢子枝、孢子囊、囊轴等处长出的描述。它的孢子枝的分枝常常长于主枝;其他已知种则分枝长度一般不超过主枝。它的囊轴形状多变:球形、近球形、扁球形、卵形、椭圆形、梨形等等,两边对称或不对称,溢缩或不绕缩,纵向深裂或不作纵向深裂;其他已知种的囊轴形状通常为倒卵形至梨形的规则形状。它的囊领明显;其他已知种的囊领均很不明显至缺如。它的孢囊孢子形状和大小变化都较大,卵形、椭圆形、矩圆形、近球形、近三角形或其他各种不规则形状,长度范围2.5-16.5 μm;其他已知种除上面已经提到过的奈尼塔尔根毛霉外,它们的孢囊孢子形状仅限于卵形、椭圆形、近球形等较规则的形状,长度范围总是在3-6 μm范围内,奈尼塔尔根毛霉的孢囊孢子形状虽然多变,但其决度亦在3-6 μm的范围内。此外,多变根毛霉的孢子囊、囊轴、孢囊孢子等各种构造均较大;其他已知种则较小,其中肿梗根毛霉[Rhizomucor tauricus (Milko & Schkurenko) Schipper]虽亦较大,但除此之外与多变根毛霉迥异。多变根毛霉未见有接合孢子,将我们保存的全部微小根毛霉菌株与它分别配对时,或将我们的几对别的属的(+)(-)测试菌株与它分别配对时,均未见形成接合孢子或有任何反应。     

又一种引致人体原发性皮肤毛霉病的非商温根毛霉属真菌

一年多以前,我们报道了一种引致人类原发性皮肤毛霉病的病原真菌Rm6并定名为多变根毛霉((Rhizomucor variabilis Zheng & G.-q. Chen)。最近我们又发现了它的另外一个变种Rm7。它是北京医科大学第一医院的王端礼教授分离的,原编菌号4873。Rm7的病人和Rm6的情况很相近。她也是一个女病人,来自农村,患的同样是原发性皮肤病而没有患有其他的毛霉病或其他疾病,她的病也没有传染给她的家人。不同的是,她来自我国北部的河北省而不是南部的江苏省;她的病史更长,达16年之久;她的病部在脸上而不是在手上,并造成进食困难。Rm7和Rm6的培养物相似,也是亮黄色,但比较低矮。它与Rm6一样是非高温真菌,最适、最高、最低温度同样分别是24-30, 38,和9℃形态上的亲缘性也是显而易见的:两者都有匍匐菌丝和较发达的假根;孢子枝也是假轴分枝;孢子囊壁也是缓慢消解;有很不规则形状的囊轴;有明显的囊领;都有大量厚垣孢子。Rm7与Rm6的主要区别在于:(1)假根只从匍匐菌丝和气生菌丝上长出而不从孢子枝、孢子囊或囊轴等各处长出;(2)孢子枝可连续分枝达7次之多;(3)孢子枝在分枝处往往有一个隔膜;(4)往往在10天以上的培养物中才出现不规则形状的囊轴;(5)从未见有囊托;(6)孢囊孢子形状较规则,较短而不超过11 μm;(7)孢子囊和囊轴均较小,直径相应不超过70及30 μm.因此,我们将Rm7鉴定为Rm6的一个变种,并定名为较规则多变根毛霉新变种(Rhizomucor variabilis var. regularior Zheng & G.-q. Chen var.nov.)。这样,在根毛霉属内可以承认的共计5种6分类群。     

鼻-眶-脑真菌病及其诊疗对策

鼻-眶-脑真菌病（Rhino—orbital—cerebral mycosis,ROCM）是一组累及面部、鼻、眼眶及脑的真菌感染。该病发展迅速,病死率高达80％,并常致失明、眼球坏死、面瘫等后遗症,给患者身心造成极大伤害。早期认识及正确处理该病,是预防并发症、降低病死率的关键。ROCM多由接合菌感染所致,早期可表现为头痛、单侧视力减退、眼睑下垂、外展受限等症状,疾病的后期,常出现单侧视力丧失、疼痛性眼肌麻痹及面瘫;影像学表现为鼻窦炎、海绵窦、颈内动脉等血管的阻塞;组织病理以炎细胞浸润、肉芽肿、血管炎及真菌性血栓形成、动脉栓塞为主要特征。     

中鼻甲手术治疗鼻窦炎的临床疗效

为了研究中鼻甲手术处理对治疗患者鼻窦炎的临床疗效,本研究选取2013年3月至2018年3月在我院进行鼻内镜手术的患者400例,根据术中对中鼻甲处理情况分为观察组和对照组,每组200例,观察组行中鼻甲成形术,对照组行中鼻甲切除术;观察2组患者治疗一年后的疗效、Lund-Kennedy评分、主观症状VAS评分、嗅觉变化及并发症。研究显示,观察组的治疗有效率(90.50%)与对照组(88.50%)无显著差异(p=0.514)。两组患者治疗1年后的Lund-Kennedy总评分均显著降低,并且观察组的Lund-Kennedy总评分显著低于对照组(2.24 vs.2.75,p<0.05)。对于Lund-Kennedy评分的各个单项评分,治疗后观察组的息肉、瘢痕和结痂显著低于对照组(p<0.05)。治疗1年后观察组的鼻塞评分显著低于对照组(2.22 vs.3.43,p<0.05),而两组的脓涕评分差异无统计学意义(2.25 vs.2.76,p>0.05)。治疗1年后,两组嗅觉功能评分均显著降低,但两组评分之间差异无统计学意义(1.78 vs.1.81,p>0.05)。两组患者的并发症发生率无统计学差异(p>0.05)。本研究表明,中鼻甲是否切除不影响患者的治疗效果和嗅觉功能,然而,与中鼻甲切除术相比,中鼻甲成形术后患者具有较少的息肉、瘢痕、结痂、鼻腔干燥现象,并且可显著改善鼻塞主观症状。     

毛霉病的防治策略与研究进展

毛霉病是一种进展迅速、病死率高的罕见侵袭性真菌病,近年来其发病率呈整体上升趋势。自2019年12月以来,2019冠状病毒病(corona virus disease 2019,COVID-19)在全世界广泛流行并引发第六次国际公共卫生事件,在此背景下印度大规模暴发了毛霉病。本文就毛霉病流行病学、病原学、临床表现、诊断治疗等方面的研究进展进行综述。对于临床可疑毛霉病患者,应尽早完成影像学、真菌病原学及分子生物学检查,以期实现毛霉病的早期诊断、早期治疗,改善患者临床转归及预后。     

鼻内镜下鼻窦炎合并中鼻甲外侧壁切除术的临床疗效观察

目的:探讨鼻内镜下行鼻窦炎手术同时行中鼻甲外侧壁切除的疗效。方法:选择本院2009年6月至2013年7月的行鼻内镜下鼻窦炎手术的慢性鼻窦炎患者160例,随机分为观察组和对照组.对照组行单纯的鼻窦炎开放手术,观察组在对照组治疗的基础上行中鼻甲外侧壁切除术。比较两组术后临床疗效、换药平均次数、SNOT-20评分及不良反应等。结果:对照组术后平均换药次数显著高于观察组(P0.05);对照组治疗总有效率为72.50%,显著低于观察组92.50%,差异具有统计学意义(P0.01);两组治疗前SNOT-20评分比较无统计学差异(P0.05),治疗后SNOT-20评分,组内比较均低于治疗前(P0.05);观察组治疗后SNOT-20总分显著低于对照组(P0.05);两组不良反应发生率无显著差异(P0.05)。结论:鼻内镜下鼻窦炎手术中实施中鼻甲外侧壁切除的临床疗效显著,既不破坏鼻腔解剖结构,又保证了中鼻道的宽大,安全性较高,值得在临床推广应用。     

Comparison between effects of various partial inferior turbinectomy options on nasal airflow: a computer simulation study

Partial inferior turbinectomy is typically performed on patients suffering from chronic nasal obstruction due to hypertrophy of inferior turbinates and is refractory to other more conservative treatments. The effects of the various options of incision performed on the inferior turbinate in terms of the resulting nasal airflow pattern are examined using computational fluid mechanics. The pressure drops across the severely blocked nose and healthy nose models were found to be 32.3 and 12.3 Pa, respectively, whereas the pressure drops across the nasal cavity following one-third turbinate resection, total turbinate resection and front-end resection were obtained as 5.8, 6.1 and 30.5 Pa correspondingly. Based on the total pressure drop results, the one-third resection option seems to be better than the front-end surgery and the total turbinate resection.     

急性早幼粒细胞白血病患者小孢根霉变种感染1例

报道1例由小孢根霉变种导致的皮肤毛霉病.患者女,30岁.因患急性早幼粒细胞白血病,化疗后继发口腔颌面部小孢根霉变种感染,表现为发热、右侧颊黏膜水肿,皮损中央溃疡、焦痂,周边组织炎性水肿,以面颊部、颌下区为中心明显肿胀,逐渐累及右侧颈部及右下颌,进行性加重.坏死组织涂片镜检显示有粗大、无分隔直角菌丝,真菌学检查鉴定为小孢根霉,分子测序证实为小孢根霉变种.给予两性霉素B、伊曲康唑静脉滴注和手术清创,坏死组织连续3次真菌培养均未培养出小孢根霉变种,患者体温逐渐恢复正常,治疗2周后颔面部肿胀明显减退,浅表淋巴结未触及肿大,4周后额部及右眼睑肿胀已完全消退,伤口结痂愈合.随访2 a,右侧颌下可见长约2 cm手术疤痕,未见皮肤毛霉病复发.     

Myocardial infarct in disseminated mucormycosis: case report with special emphasis on the pathogenic mechanisms

A case of myocardium infarction in generalized mucormycosis is reported in a patient suffering from chronic renal failure and receiving a cadaver kidney transplant. At autopsy we found a recent necrotic myocardium, coronary vessels occluded by mucor hyphae and a striking absence of inflammatory cells, chiefly neutrophils. Ultrastructural studies revealed thick-walled fungus that participate in the thrombus and cross the coronary artery in a corkscrew pattern, without important cellular degeneration. Thin-walled irregularly branching structures were observed occluding the microcirculation of still preserved cardiac areas. These structures could be originated from the fungus cells that had lost their thick laminated wall, leaving the plasmatic membrane as external coat. Special emphasis is given to the relation between the poor coronary vascular protection against mucormycosis and the neutrophilic disfunction. The lungs are the main site of primary infection. This disease is underdiagnosed in vivo and leads always to death.     

Acute dysphagia after carp fish meal: a case report

An 80-year-old man was admitted to the emergency department with acute dysphagia symptoms of 8 hours' duration. The problem began after a carp fish meal. Prominent symptoms included inability to swallow, mild dyspnea, and cough. Laboratory evaluation and fiber-optic examination of the upper aerodigestive tract was normal except for accumulation of saliva in the hypopharynx. Examination with a flexible esophagoscope revealed a total blockage of the lumen of the lower esophagus due to impaction of carp fish roe (column-like formation). With careful maneuvers and water pressure we were able to relieve the obstruction. No other lesion was detectable and no further interventions were needed. Patient follow-up was uneventful.     

An extensive review on antifungal approaches in the treatment of mucormycosis

During the period of COVID-19, the occurrences of mucormycosis in immunocompromised patients have increased significantly. Mucormycosis (black fungus) is a rare and rapidly progressing fungal infection associated with high mortality and morbidity in India as well as globally. The causative agents for this infection are collectively called mucoromycetes which are the members of the order Mucorales. The diagnosis of the infection needs to be performed as soon as the occurrence of clinical symptoms which differs with types of Mucorales infection. Imaging techniques magnetic resonance imaging or computed tomography scan, culture testing, and microscopy are the approaches for the diagnosis. After the diagnosis of the infection is confirmed, rapid action is needed for the treatment in the form of antifungal therapy or surgery depending upon the severity of the infection. Delaying in treatment declines the chances of survival. In antifungal therapy, there are two approaches first-line therapy (monotherapy) and combination therapy. Amphotericin B ( 1 ) and isavuconazole ( 2 ) are the drugs of choice for first-line therapy in the treatment of mucormycosis. Salvage therapy with posaconazole ( 3 ) and deferasirox ( 4 ) is another approach for patients who are not responsible for any other therapy. Adjunctive therapy is also used in the treatment of mucormycosis along with first-line therapy, which involves hyperbaric oxygen and cytokine therapy. There are some drugs like VT-1161 ( 5 ) and APX001A ( 6 ), Colistin, SCH 42427, and PC1244 that are under clinical trials. Despite all these approaches, none can be 100% successful in giving results. Therefore, new medications with favorable or little side effects are required for the treatment of mucormycosis.