混合型肺曲霉病21例临床特征分析

Clinical characteristics of 21 cases of mixed types of pulmonary aspergillosis

目的提高对混合型肺曲霉病(MTPA)的认识和诊治水平。方法回顾性分析2013年1月至2021年7月广西医科大学第一附属医院呼吸与危重症医学科收治的21例MTPA的临床资料。结果21例MTPA分别为变应性支气管肺曲霉病(ABPA)+侵袭性肺曲霉病(IPA)或曲霉球+IPA重叠类型,95.2%有肺内结构性病变;ABPA+IPA重叠3例,平均年龄(38.0±14.4)岁,有哮喘病史66.7%;曲霉球+IPA重叠18例,平均年龄(54.8±11.5)岁,均无哮喘病史(0%),2组年龄、哮喘病史差异有统计学意义(P<0.05)。临床症状:ABPA+IPA组,咳嗽咳痰(100%),呼吸困难(66.7%);曲霉球+IPA组,咳嗽咳痰(100%),咯血(61.1%)。11例(11/19)血GM检测阳性,10例(10/12)BALF GM检测阳性。影像学表现:ABPA+IPA组,肺内结节、肿块、高密度影(100%),牙膏征、指套征(66.7%),支气管扩张(100%),晕轮征(33.3%);曲霉球+IPA组,肺内结节、肿块、高密度影(94.4%),空气新月征(44.4%),支气管扩张(50.0%),空洞(88.9%),晕轮征(22.2%),2组比较,仅牙膏征、指套征差异有统计学意义(P<0.05)。治疗及转归:ABPA+IPA组,3例(100%)均经抗真菌联合全身激素治疗后好转;曲霉球+IPA组,单纯抗真菌治疗9例(50.0%),单纯肺叶切除术2例(11.1%),肺叶切除术联合抗真菌治疗7例(38.9%),好转16例(88.9%),恶化2例(11.1%)。结论MTPA较罕见,肺内结构性基础疾病是其主要宿主因素之一;ABPA与IPA重叠主要症状为咳嗽咳痰、呼吸困难,曲霉球与IPA重叠主要症状为咳嗽咳痰、咯血;GM检测有助于诊断重叠IPA类型的MTPA;胸部影像学对MTPA的诊断有重要意义;抗真菌联合全身激素治疗是治疗ABPA重叠IPA的有效手段;曲霉球与IPA重叠患者的治疗需个体化,单纯抗真菌治疗或手术联合抗真菌治疗效果好。

Objective To improve the understanding,diagnosis,and treatment of mixed types of pulmonary aspergillosis(MTPA).Methods The clinical data of 21 patients with MTPA treated at Department of Respiratory Medicine,First Affiliated Hospital of Guangxi Medical University from January 2013 to July 2021 were analyzed retrospectively.Results Of the 21 MTPA patients included in this study,3 had allergic bronchopulmonary aspergillosis(ABPA)+invasive pulmonary aspergillosis(IPA)and 18 had aspergilloma+IPA;95.2%had intrapulmonary structural lesions.For patients with ABPA+IPA,they had an average age of(38.0±14.4)years and 66.7%had a history of asthma.For patients with aspergilloma+IPA,they had an average age of(54.8±11.5)years and none had a history of asthma.There were significant differences in age and asthma history between the two groups(P<0.05).In the ABPA+IPA group,the main symptoms were cough and sputum(100%)and dyspnea(66.7%);in the Aspergilloma+IPA group,cough and sputum(100%)and hemoptysis(61.1%)were common.Eleven(11/19)cases were positive for blood galactomannan(GM)detection and ten(10/12)were positive for bronchoalveolar lavage fluid GM detection.Regarding imaging manifestations the ABPA+IPA group mainly showed pulmonary nodules,masses,or highdensity shadows(100%),toothpaste sign,finger sleeve sign(66.7%),bronchiectasis(100%),and halo sign(33.3%),while the aspergilloma+IPA group often had pulmonary nodules,masses,or high-density shadows(94.4%),air crescent sign(44.4%),bronchiectasis(50.0%),cavity(88.9%),and halo sign(22.2%);only the toothpaste sign and finger sleeve sign were statistically different between the two groups(P<0.05).With regard to treatment and outcome:the 3 cases(100%)in the ABPA+IPA group were improved after antifungal therapy combined with systemic hormone therapy.In the aspergilloma+IPA group,9 cases(50.0%)were treated with antifungal drugs,2(11.1%)were treated by lobectomy,and 7(38.9%)were treated by lobectomy and antifungal therapy;16 cases(88.9%)were improved,and 2(11.8%)were worsened.Conclusion MTPA is rare,and underlying pulmonary structural diseases are one of the main host factors.The main symptoms of ABPA+IPA are cough,sputum,and dyspnea,while those for ABPA+IPA are cough,sputum,and hemoptysis.GM detection is helpful in the diagnosis of overlapping IPA type MTPA.Chest imaging plays an important role in the diagnosis of MTPA.Antifungal therapy combined with systemic hormone therapy is an effective method to treat ABPA+IPA.The treatment of patients with aspergilloma+IPA needs to be individualized.Simple antifungal therapy or operation combined with antifungal therapy is effective.