纤支镜检查对菌阴性肺结核的诊断价值

目的探讨纤支镜检查技术对菌阴性肺结核的诊断价值。方法通过回顾性分析153例痰涂片、痰培养和PCR分析均为结核杆菌阴性疑诊为肺结核最终确诊为肺结核的患者病例资料。观察肺结核病灶在纤支镜下的表现,并于镜下行组织活检、刷检、组织盲检,支气管肺泡灌洗液涂片及PCR检查和痰结核分枝杆菌涂片检查。结果回顾性分析发现肺结核纤支镜下改变主要为粘膜充血肿胀(23.5%)、粘膜溃疡糜烂(19.6%)、粘膜表面灰白色苔状物或豆腐渣样物质覆盖(15.7%)和支气管瘢痕或狭窄(13.1%)。纤支镜下组织活检、刷检、组织盲检,支气管肺泡灌洗液涂片及PCR检查和痰结核分枝杆菌涂片检查,诊断为肺结核的患者占最终明确诊断为肺结核的百分比分别为41.2%(63/153),47.1%(72/153),11.1%(17/153),56.9%(87/153),55.6%(85/153)和32.0%(49/153)。结论菌阴性肺结核镜下改变多样无特征性,纤支镜检查技术对菌阴性肺结核的明确诊断具有重要价值,多种纤支镜技术联合能够明显提高菌阴性肺结核的诊断率。     

经纤支镜治疗支气管结核的疗效观察及护理体会

目的探讨经纤支镜治疗支气管结核的疗效及护理配合措施。方法选择我院2012年10月~2013年12月确诊支气管结核患者72例,随机分为两组,对照组按常规方案进行抗结核治疗;治疗组在常规抗结核治疗的基础上,通过纤支镜灌洗并向病变部位注入药物。经纤支镜镜下治疗3个月、抗结核治疗1年以及随访1年,通过肺部CT,纤支镜刷检找抗酸杆菌,纤支镜直视下观察支气管黏膜改变,症状体征等方面比较临床疗效。结果经纤支镜灌洗及滴药治疗后,治疗组总有效率为97%,明显优于对照组的80%。结论经纤支镜局部治疗能促进病灶吸收,改善气道通气,提高患者生活质量。同时,充分的术前准备、术中密切观察及配合,是确保手术顺利完成的重要环节。     

侵袭性肺曲霉菌患者血清半乳甘露聚糖动态变化及与CT影像学关系

目的观察侵袭性肺曲霉菌感染患者抗真菌治疗前后肺泡灌洗液及血清中半乳甘露聚糖(GM)的水平变化、CT影像学特征及血清中性粒细胞数与GM试验阳性率之间的关系,患者血清中性粒细胞值与GM试验阳性率之间的关系。方法连续性纳入60例确诊侵袭性肺曲霉菌感染患者,观察抗真菌治疗前后肺泡灌洗液和血清GM试验动态水平变化。单因素Logistic回归分析CT侵犯肺叶数、空气新月征、晕轮征、血清中性粒细胞值与GM的关系。结果抗真菌治疗前患者肺泡灌洗液GM平均值均高于血清GM平均值(0.62±0.08mg/L,60.0%;0.51±0.07mg/L,31.6%)。同抗真菌治疗前比,患者抗真菌治疗后1个月、2个月、3个月、6个月肺泡灌洗液GM值快速降低(P0.05),而血清GM数值缓慢降低,仅在第3个月、第6个月降低(P0.05)。患者CT侵犯肺叶数、晕轮征与肺泡灌洗液、血清中性粒细胞值GM试验阳性率显著相关。结论肺泡灌洗液及血清GM试验可作为IFD疾病诊断及治疗的重要辅助指标。CT影像学特征、血清中性粒细胞值与GM试验阳性率显著相关。     

肺普通裂褶菌感染并肺不张1例并文献复习

普通裂褶菌(Schizophyllum commune,S.commune)是一种丝状真菌,为条件致病菌,引起人深部侵袭性感染国内报道罕见。我院收治了1例免疫功能正常患者肺部感染S.commune,广东人,既往体健,临床表现为反复出现的非刺激性咳嗽、咳黄白色黏液痰,胸部CT示右肺上叶肺不张并黏液栓,纤支镜下可见右肺上叶黏液栓堵塞及大量黄色脓性分泌物,肺泡灌洗液培养出S.commune,给予伊曲康唑抗真菌治疗1周后症状好转出院,出院后继续服用伊曲康唑3个月,随访复查胸部CT示病灶吸收,右肺上叶完全复张,提示抗真菌治疗有效。     

纤维支气管镜在肺不张诊断与治疗中的意义

目的:探讨纤维支气管镜(纤支镜)在肺不张的诊断及治疗中的意义.方法:对经X线、CT诊断为肺不张的67例患者行纤支镜检查和治疗.结果:纤支镜病因诊断符合率为98.5%.其中肺癌38例(56.7%),炎症19例(28.4%),结核9例(13.4%),异物阻塞1例(1.5%).病变部位以右上叶16例最多(23.9%),接着依次为右肺下叶(19.4%),右肺中叶(17.9%).对肺不张患者经纤支镜吸痰、灌洗、局部给药、取出异物等治疗后,患者症状均有不同程度的改善,且炎症、结核、异物所致的肺不张肺叶均有不同程度复张,呼吸功能改善.结论:纤支镜对肺不张的诊断及治疗具有重要意义,且经纤支镜辅助治疗可促进肺复张.     

罕见的侵袭性肺枝孢样枝孢霉病1例

报道1例由枝孢样枝孢霉引起的肺部感染,患者女,52岁,主因"反复咳嗽、咳痰1年余,加重伴气短3周"就诊。根据肺泡灌洗液液基薄层形态学检查、G实验、真菌培养及药物敏感实验的结果诊断为"侵袭性肺枝孢样枝孢霉病",经伊曲康唑0.4g/d抗真菌治疗、头孢他啶抗细菌感染治疗后,病情好转出院。     

磷脂酶D缺失对小鼠抗烟曲霉感染过程的影响研究

目的揭示宿主磷脂酶D(phospholipase D,PLD)应对烟曲霉感染过程中的重要作用和可能机制。方法应用滴鼻方式使野生小鼠和磷脂酶D双基因敲除小鼠(pld1~(-/-)pld2~(-/-))感染烟曲霉孢子后,取小鼠肺组织、抽取支气管肺泡灌洗液,应用组织匀桨与菌落计数的方法检测小鼠肺组织中烟曲霉负荷,采用eBioscience公司的多因子检测试剂盒检测肺泡灌洗液中炎症因子分泌情况;分离两种小鼠的骨髓细胞并诱导分化为成熟巨噬细胞(BMDM),制霉菌素法检测其吞噬和杀死烟曲霉孢子的能力。结果感染烟曲霉孢子6 h后,pld1~(-/-)pld2~(-/-)小鼠肺部真菌负荷显著高于野生小鼠,其肺泡灌洗液和肺泡巨噬细胞中均存在大量孢子,肺泡灌洗液中炎症因子浓度显著升高;体外实验证明pld1~(-/-)pld2~(-/-)小鼠的BMDM细胞吞噬和杀死烟曲霉孢子的能力显著减弱。结论小鼠pld1基因和pld2基因同时敲除导致其巨噬细胞的吞噬和杀死烟曲霉孢子的能力显著减弱,进而可能降低小鼠抗烟曲霉感染的能力。同时机体可能通过分泌大量的炎症因子以招募其他免疫细胞杀灭烟曲霉孢子。     

烟曲霉再鉴定、标准化CSP分型及体外药物敏感性

目的 了解烟曲霉复合体临床株菌种分布,经典烟曲霉临床株CSP基因型及对常见抗真菌药物敏感性状况.方法 菌株来源:北京大学真菌和真菌病研究中心保存分离自125名患者的162株烟曲霉复合体菌株.通过形态学,最高生长温度及分子生物学测序分步鉴定;对CSP基因进行扩增、测序,采用国际化命名体系进行CSP分型;采用微量液基稀释法测定经典烟曲霉对伊曲康唑(ITC)、两性霉素B(AMB)、伏立康唑(VRC)及卡泊芬净(CAS)的敏感性.结果 所有烟曲霉复合体菌株均为经典烟曲霉;共分为16个CSP基因型,最常见为t04A、t03和t01;分离自4名患者的13株菌对ITC的MICs≥4 μg/mL,其中2株菌AMB和VRC的MICa分别为4μg/mL和16 μg/mL.CAS的MECs最高为4μg/mL,仅1株.结论 未检出烟曲霉相关新种;经典烟曲霉临床株共16个CSP基因型,分布与国际研究结果基本一致,其中5个为新型.我国经典烟曲霉临床株ITC耐药率为3.2％,个别菌株AMB,VRC和CAS耐药.     

支气管灌洗液SIRT-1、TGF-β1及PINP水平与肺结核患者支气管狭窄发生风险的关系及其预测价值分析

摘要 目的：探讨支气管灌洗液中沉默信息调节因子1（SIRT-1）、转化生长因子-β1（TGF-β1）及I型前胶原N端前肽（PINP）水平与肺结核患者支气管狭窄发生风险的关系，并分析三指标预测肺结核发生支气管狭窄的价值。方法：选择2020年2月至2023年2月江苏大学附属宜兴医院收治的187例肺结核患者，根据是否发生支气管狭窄分为狭窄组（86例）和非狭窄组（101例）。检测并比较两组支气管灌洗液SIRT-1、TGF-β1及PINP水平和肺功能。Pearson相关性分析支气管灌洗液SIRT-1、TGF-β1及PINP水平与肺功能的相关性。多因素Logistic回归模型分析肺结核患者发生支气管狭窄的影响因素。受试者工作特征（ROC）曲线分析支气管灌洗液SIRT-1、TGF-β1及PINP水平预测肺结核患者发生支气管狭窄的价值。结果：狭窄组肺不张、呼吸困难比例、支气管灌洗液TGF-β1、PINP水平高于非狭窄组（P＜0.05），SIRT-1水平、第1秒用力呼气量（FEV1）、用力肺活量（FVC）、最大呼气峰流速（PEF）低于非狭窄组（P＜0.05）。支气管狭窄肺结核患者的支气管灌洗液SIRT-1水平与FEV1、FVC、PEF呈正相关（P＜0.05），TGF-β1、PINP水平与FEV1、FVC、PEF呈负相关（P＜0.05）。多因素Logistic回归分析，结果显示，呼吸困难、高水平TGF-β1、高水平PINP是肺结核患者发生支气管狭窄的危险因素（P＜0.05），高水平SIRT-1则是保护因素（P＜0.05）。支气管灌洗液SIRT-1、TGF-β1及PINP单独检测预测肺结核患者发生支气管狭窄的曲线下面积（AUC）为0.736、0.799、0.730，联合检测支气管灌洗液SIRT-1、TGF-β1及PINP预测的AUC为0.861，高于单独指标检测的预测效能。结论：支气管狭窄肺结核患者的支气管灌洗液中SIRT-1水平降低，TGF-β1、PINP升高，且与肺功能下降以及支气管狭窄发生风险增加有关，支气管灌洗液SIRT-1、TGF-β1及PINP水平检测对肺结核患者发生支气管狭窄具有一定预测价值，且联合检测的预测效能更高。     

一次性防污染标本刷重复使用的可能性研究

本文报告纤支镜用一次性防污染标本刷重复使用的方法及其可靠性试验结果。重复使用的方法：初次使用后用清水认真洗涤，７５％酒精浸泡消毒二小时，灭菌盐水浸泡半小时后凉干，在外套管末端重新置入一聚乙二醇保护塞，或同时在纤支镜吸引孔末端亦加入保护塞。重复使用可靠性的验证：１、用１０＾５－１０＾１０的大肠杆菌液污染毛刷并用上述方法消毒处理，反复１５次试验，刷洗涤液无细菌生长。     

Detection of Aspergillus fumigatus hyphae in respiratory secretions by membrane filtration, fluorescent labelling and laser scanning

The detection of Aspergillus fumigatus hyphae in bronchoalveolar lavage fluid (BAL) and sputum is diagnostically useful in patients at risk of invasive aspergillosis. We report a dedicated enzymatic-chemical sample pretreatment that allows the application of a previously described solid phase cytometry (SPC) method for detection of A. fumigatus hyphae in sputum and BAL samples. Non-specific detection of fungal hyphae by SPC is based on a 'viability' staining using carboxyfluorescein diacetate. For a specific detection of A. fumigatus hyphae by SPC, viability staining is combined with a pre-incubation at 45 degrees C, immunofluorescent labelling and microscopic recognition of the characteristic hyphal morphology. Low numbers of A. fumigatus hyphae (2-10 hyphae/sample) have now been demonstrated in spiked sputum using the non-specific and specific staining in 2.5 and 8.5 h, respectively.     

支气管结石合并肺部盖尔森基兴奴卡菌感染1例

本文旨在通过对1例支气管结石伴盖尔森基兴奴卡菌肺炎患者的诊治过程进行回顾,并对相关文献进行复习,以提高临床医师对此类疾病的认识。该患者为结石性体质,胸部计算机断层扫描(computed tomography,CT)提示支气管内高密度影;无痛纤维支气管镜下确诊支气管内膜结石,给予患者支气管镜下碎石、取石,并送病理科行切片活检,同时行痰涂片、痰培养寻找病原体。结果成功在肺泡灌洗液中培养出盖尔森基兴奴卡菌,针对盖尔森基兴奴卡菌感染给予敏感药物治疗3个月后痊愈。支气管结石伴盖尔森基兴奴卡菌肺炎极其罕见,尤其局限于呼吸系统感染者更为少见。此类疾病需考虑支气管内膜结石所致支气管扩张等结构性疾病存在,导致局部抵抗力低下,从而引起条件致病菌盖尔森基兴奴卡菌感染。针对此类患者,建议及早行纤维支气管镜检查并完善灌洗液涂片、抗酸染色、灌洗液培养以获得病原学证据,为治疗赢得时间。控制盖尔森基兴奴卡菌感染后,需及早行纤维支气管镜下碎石等治疗,以纠正局部结构改变,减少再次感染机会。     

Pneumocystis carinii pneumonia: detection of parasites in sputum and bronchoalveolar lavage fluid by monoclonal antibodies.

Diagnosis of pneumocystis pneumonia is based on identifying Pneumocystis carinii cytochemically in material from the lung. The silver methenamine staining methods most commonly used are technically difficult and lack specificity. The diagnostic value of immunocytological identification of the parasite was evaluated by using mouse monoclonal antibody 3F6, specific for human pneumocystis, to identify P carinii in bronchoalveolar lavage fluid and sputum by immunofluorescence and was compared with that of other variables. Bronchoalveolar lavage was performed on 25 patients positive for HIV antibody with clinically suspected pneumocystis pneumonia and 40 patients negative for HIV antibody who presented with interstitial disorders of the lung. Lavage fluid showed pneumocystis only in the patients positive for antibody, the parasite being detected in 19 by immunofluorescence and in 17 by a modified silver methenamine staining method. Chest x ray films obtained at the time of bronchoscopy showed interstitial or alveolar shadowing in 17 of the 19 patients, but clinical symptoms and the presence of antibodies to pneumocystis did not seem to be predictive. Sputum samples were collected during 43 episodes of clinically suspected pneumocystis pneumonia in patients positive for HIV antibody. Pneumocystis was detected consistently more commonly by immunofluorescence than the silver strain in sputum collected routinely and induced by inhalation of saline. In 17 patients bronchoalveolar lavage followed sputum collection, and the sensitivity of detection of pneumocystis in immunofluorescence in sputum compared with lavage fluid was 57% (8/14). Immunofluorescence was suitable for specimens fixed in ethanol and seemed highly specific and more sensitive than the standard cytochemical methods for identifying pneumocystis.     

1株盾叶薯蓣植物内生烟曲霉菌的分离鉴定

从药用盾叶薯蓣地下茎组织中分离内生菌。选取盾叶薯蓣地下茎核心组织,32℃恒温孵育,分离菌株;依据形态学、分子生物学特征鉴定菌株;通过纸片扩散法检测分离株与同种植物内生Bcillus subtilis SWB8菌株的拮抗作用。结果显示,孵育48 h后,培养基表面呈现扁平、白色或深绿色绒毛状菌落,显微镜下见孢子囊和圆形分生孢子;ITS序列分析显示,分离株ITS基因序列与GenBank数据库中烟曲霉菌同源性为100%,鉴定为烟曲霉菌(A.fumigatus YHY01)。拮抗实验显示,其与B.subtilis SWB8菌没有明显相互抑制现象。首次从盾叶薯蓣植物中分离出A.fumigatus,推测其与B.subtilis SWB8菌株间存在共生关系。     

Crystals occurring in pulmonary cytology specimens. Association with Aspergillus infection

Birefringent needlelike crystals in rosette or wheat-sheaf-like arrangements were found in pulmonary cytology specimens from 11 of 65 patients who had either sputum cultures positive for Aspergillus or histologically confirmed pulmonary aspergilloma. No crystals were found in specimens from 60 control patients with and without known fungal disease. The crystals were most often associated with A. niger infection (45.4%), followed by A. flavus (16%). Crystals were also observed in one case of A. fumigatus infection and in one case in which the species was not determined. In two cases, crystals were found more than one year before sputum cultures became positive; in one of these patients, a fungus ball was not identified by X ray until five years after the first appearance of the crystals in the sputum. Sixty-four percent of the patients with crystals also showed moderate to severe cytologic atypia. The crystals are thought to be calcium oxalate. We conclude that the presence of birefringent needlelike crystals with rosette or wheat-sheaf-like arrangements in pulmonary cytology specimens is a reliable marker for the presence of Aspergillus infection, which may be detected before cultures are positive or a fungus ball is evident on X ray.     

μ-chain-deficient mice possess B-1 cells and produce IgG and IgE, but Not IgA, following systemic sensitization and inhalational challenge in a fungal asthma model

Allergic bronchopulmonary aspergillosis is often difficult to treat and results in morbidity associated with chronic airway changes. This study assessed the requirement for B cells and their products in the allergic pulmonary phenotype in a murine model of fungal allergic asthma that mimics allergic bronchopulmonary aspergillosis. C57BL/6 and μMT mice (assumed to lack peripheral B cells) were sensitized with Aspergillus fumigatus extract and challenged with two inhalation exposures of live conidia to induce airway disease. Airway hyperresponsiveness after methacholine challenge, peribronchovascular inflammation, goblet cell metaplasia, and fibrotic remodeling of the airways was similar between μMT mice and their wild-type counterparts (C57BL/6). Surprisingly, even in the absence of the μ-chain, these μMT mice produced IgE and IgG Abs, although the Abs induced did not have specificity for A. fumigatus Ags. In contrast, IgA was not detected in either the lavage fluid or serum of μMT mice that had been exposed to A. fumigatus. Our findings also reveal the existence of CD19(+)CD9(+)IgD(+) B-1 cells in the lungs of the μMT animals. These data show the μMT mice to have a developmental pathway independent of the canonical μ-chain route that allows for their survival upon antigenic challenge with A. fumigatus conidia, although this pathway does not seem to allow for the normal development of Ag-specific repertoires. Additionally, this study shows that IgA is not required for either clearance or containment of A. fumigatus in the murine lung, as fungal outgrowth was not observed in the μMT animals after multiple inhalation exposures to live conidia.     

Role of germination in murine airway CD8+ T-cell responses to Aspergillus conidia

Pulmonary exposure to Aspergillus fumigatus has been associated with morbidity and mortality, particularly in immunocompromised individuals. A. fumigatus conidia produce β-glucan, proteases, and other immunostimulatory factors upon germination. Murine models have shown that the ability of A. fumigatus to germinate at physiological temperature may be an important factor that facilitates invasive disease. We observed a significant increase in IFN-γ-producing CD8(+) T cells in bronchoalveolar lavage fluid (BALF) of immunocompetent mice that repeatedly aspirated A. fumigatus conidia in contrast to mice challenged with A. versicolor, a species that is not typically associated with invasive, disseminated disease. Analysis of tissue sections indicated the presence of germinating spores in the lungs of mice challenged with A. fumigatus, but not A. versicolor. Airway IFN-γ(+)CD8(+) T-cells were decreased and lung germination was eliminated in mice that aspirated A. fumigatus conidia that were formaldehyde-fixed or heat-inactivated. Furthermore, A. fumigatus particles exhibited greater persistence in the lungs of recipient mice when compared to non-viable A. fumigatus or A. versicolor, and this correlated with increased maintenance of airway memory-phenotype CD8(+) T cells. Therefore, murine airway CD8(+) T cell-responses to aspiration of Aspergillus conidia may be mediated in part by the ability of conidia to germinate in the host lung tissue. These results provide further evidence of induction of immune responses to fungi based on their ability to invade host tissue.     

Pulmonary pseudallescheriasis in a patient with healed tuberculosis

Pulmonary pseudallescheriasis in an immunocompetent patient without a pre-existing cavity or cyst is a rare phenomenon. We report a case of invasive pulmonary pseudallescheriasis in a lobectomised patient treated for tuberculosis. Filamentous fungi with pyriform conidia were seen in the bronchoalveolar lavage fluid .The fungus was identified as Pseudallescheria boydii on culture.     

烟曲霉与宿主细胞相互作用规律的初步研究

目的研究烟曲霉侵入宿主细胞过程中的基本规律及宿主细胞肌动蛋白骨架的变化情况。方法利用表达绿色荧光的烟曲霉ATCC13073,研究烟曲霉侵入上皮细胞和被巨噬细胞吞噬随时间的变化规律。结果烟曲霉侵入吞噬细胞和非吞噬细胞的量随时间呈现完全不同的规律,烟曲霉侵入上皮细胞A549能力较弱,在7h后侵染量才有明显的增加,为原始接种量的（0.09±0.01）%。前3h,鼠巨噬细胞J774吞噬量迅速升高,然后侵染量缓慢下降。烟曲霉侵入宿主细胞过程中会引起宿主细胞肌动蛋白骨架的重排,侵入过程中伴有吞噬杯的形成。结论巨噬细胞吞噬烟曲霉和烟曲霉侵入上皮细胞规律有明显不同,侵入过程都伴随肌动蛋白骨架的重排。     

Enhanced pulmonary allergic responses to Aspergillus in CCR2-/- mice

Allergic responses to Aspergillus species exacerbate asthma and cystic fibrosis. The natural defense against live Aspergillus fumigatus spores or conidia depends on the recruitment and activation of mononuclear and polymorphonuclear leukocytes, events that are dependent on chemotactic cytokines. In this study, we explored the relative contribution of the monocyte chemoattractant protein-1 receptor, CCR2, in the pulmonary response to A. fumigatus conidia. Following sensitization to soluble A. fumigatus Ags, mice lacking CCR2 due to targeted deletion were markedly more susceptible to the injurious effects of an intrapulmonary challenge with live conidia compared with mice that expressed CCR2 or CCR2+/+. CCR2-/- mice exhibited a major defect in the recruitment of polymorphonuclear cells, but these mice also had significantly more eosinophils and lymphocytes in bronchoalveolar lavage samples. CCR2-/- mice also had significant increases in serum levels of total IgE and whole lung levels of IL-5, IL-13, eotaxin, and RANTES compared with CCR2+/+ mice. Airway inflammation, hyper-responsiveness to spasmogens, and subepithelial fibrosis were significantly enhanced in CCR2-/- mice compared with CCR2+/+ mice after the conidia challenge. Thus, these findings demonstrate that CCR2 plays an important role in the immune response against A. fumigatus, thereby limiting the allergic airway inflammatory and remodeling responses to this fungus.