免疫抑制宿主肺奴卡菌病二例并文献复习

Pulmonary nocardiosis in immunocompromised host： report of 2 cases and review of the literature

目的了解肺奴卡菌感染的临床特征、影像学特点、病原学特点及其耐药情况。方法分析2006-2008年中山大学附属第三医院呼吸科收治的2例肺奴卡菌病患者的临床特点、影像学所见、病原学特点及耐药情况，并结合1982年以来国内报道的具有完整资料的32例奴卡菌病病例进行复习。结果34例奴卡菌病中，肺奴卡菌病26例，死亡4例；多器官感染11例，其中肺部＋皮肤7例，肺部＋皮肤＋脑3例，肺部＋脑1例。26例肺奴卡菌病患者均出现咳嗽；34例中发热27例，5例为间歇发热，22例为持续发热；11例（11／26）肺奴卡菌病患者并发皮肤或颅内播散，14例免疫功能缺陷患者中8例出现播散，3例死亡；12例免疫功能正常者中3例播散，1例死亡。检出星形奴卡菌14株，巴西奴卡菌4株，未分型奴卡菌8株；播散者中星形奴卡菌感染8例，巴西奴卡菌2例；影像检查发现胸腔积液8例，块状影7例，浸润影6例，空洞6例，结节5例。奴卡菌对磺胺、阿米卡星、头孢噻肟、头孢三嗪、米诺环素、氟喹诺酮类及利奈唑胺敏感。结论免疫功能抑制是肺奴卡菌病的高危因素；星形奴卡菌最常见，较易播散；影像学检查以胸腔积液、块状影、浸润和空洞多见；磺胺类药物耐药率上升，可根据药敏结果联合用药；免疫功能抑制患者预后差。

Objective To investigate the clinical, imaging and pathogenic features of pulmonary nocardiosis and the drug resistance of Nocardia. Methods The clinical and radiological data of ：2 cases of pulmonary nocardiosis in this hospital were presented, and 32 cases reported in the Chinese literature since 1982 were reviewed. Results Among the 34 cases of Nocardia infections, there were 26 cases of pulmonary nocardiosis, and 4 of whom died. Multiple organ infection occurred in 11 patients, including 7 with pulmonary and skin infections, 3 with pulmonary, skin and intracranial infections, and 1 with pulmonary and intracranial infections. All patients with pulmonary nocardiosis had cough. Of the 34 cases, 27 had fever,including intermittent fever in 5, and sustained fever in 22 cases. Of the 11 cases of pulmonary nocardiosis complicated with skin or intracranial dissemination, 8 patients were immunocompromised and 3 were immunocompetent （ X2 = 2. 08, P 〉 0. 05 ）. Three cases died in the immunocompromised group and 1 died in the immunocompetent group. Nocardia asteroides was identified in 14 cases, Nocardia brasiliensis in 4 cases,and the other 8 were not classified. In the patients with complicated skin or intracranial infections, 8 were caused by Nocardia asteroids, and 2 were caused by Nocardia brasiliensis. Chest X-ray or CT imaging of the lungs showed pleural effusion in 8, masses in 7, infiltrates in 6, cavities in 6, and nodular lesions in 5 cases. Antimicrobial susceptibility testing showed that Nocardia was sensitive to sulfonamide, amikacin,cefotaxime, ceftriaxone, minocycline, fluoroquinolones, and linezolid. Conclusions Immunosuppression is the most important predisposing factor for pulmonary noeardiosis. The most common pathogenic bacterium is Nocardia asteroids, which is frequently associated with disseminated lesions. The radiographic abnormalities of the lung show pleural effusion, masses, infiltration or cavity. With the increasing rate of resistance of Nocardia to the sulfonamide, the combination of antibiotic regimen according to susceptibility testing needs to be considered. Poor outcome is mostly found in immunocompromised hosts.