非获得性免疫缺陷综合征患者肺隐球菌病42例影像学特征及诊断方法

The characteristics of CT imaging and diagnosis of pulmonary cryptococcosis in 42 cases with nonacquired immune deficiency syndrome

目的提高非AIDS肺隐球菌病（PC）的临床诊断水平。方法收集2003—2008年复旦大学附属中山医院呼吸科确诊的42例非AIDS的PC资料，总结分析其临床表现、胸部CT征象和诊断方法。结果42例非AIDS的PC患者均无禽鸟或其粪便接触史，免疫健全者占71．4％（30／42）。影像学以多发性结节病灶（67．9％）最常见，胸膜下分布为主（67．9％），可伴空洞形成（50％）。亦可见团块和（或）实变（31．4％）或斑片（2．9％）病灶。无创检查如痰、支气管肺泡灌洗液（BALF）、支气管镜吸出物阳性检出率分别为4．3％、8．3％、6．3％，有创检查包括经支气管镜肺活检、经皮细针穿刺肺活检、手术切除肺组织活检阳性检出率则分别达64．7％、64．3％、100％。14例经病理或培养确诊的PC，同时行血清乳胶凝集试验，结果均阳性。结论PC在免疫健全者中常见。禽鸟或其粪便接触史对此病的鉴别诊断意义不大。影像学表现多样化且变化较慢，除胸膜下多发性结节外，尤其应警惕团块和（或）实变或斑片表现。创伤性检查如经支气管镜或经皮肺穿刺活检可提高非手术病例的临床诊断率。血清隐球菌抗原检测是PC较理想的早期无创性诊断及病情随访和疗效评价的重要手段之一。

Objective To further elucidate the CT characteristics and diagnostic approaches to nonacquired immune deficiency syndrome patients with puhnonary cryptococcosis. Methods The histories of forty-two puhnonary cryptococcosis （PC） patients diagnosed in Zhongshan Hospital from 2003 -2008 were collected and analyzed for demography data, underlying conditions, clinical symptoms, chest CT and diagnostic studies. Results None of the 42 PC patients had avian or its feces contacting history, and 71.4% （30/42） of them were immunocompetent. The most frequent CT lesions were multiple nodules （67.9%） with peripheral predominance （67.9%）, and cavitations （50%） often presented within them. Masses/consolidation （31.4%） and patching lesions （2.9%） could exist occassionally. Positive detection rates of non-aggressive examinations including sputum, bronchoalveolar lavage fluid and bronchofibroscope aspiration were 4. 3% , 8.3% and 6.3% respectively, while those of aggressive approaches including transbronchial lung biopsy （TBLB）, thin needle aspiration biopsy （TNAB） and pneumonectomy by surgery were 64.7%, 64. 3% and 100% respectively. Non-aggressive serum eryptocoecus antigen test was performed in 14 patients who had been diagnosed by histopathology or pathogen culture, and all of them were positive. Conclusion Our study suggests that PC is common in immunoeompetent population. Avian or its feces contacting is not so important as used opinion to PC differential diagnosis. CT characteristics of PC are diversifonn and always change very slowly. Besides the most frequent multiple nodules with subpleural predominance, pulmonary lesions can present as masses, consolidation or patchings. Aggressive techniques such as TBLB and TNAB are benefit to clinical diagnosis of PC, and non-aggressive serum cryptococcus antigen test may be promising for its early diagnosis as well as clinical course follow-up and therapeutic effect evaluation.