侵袭性肺曲霉菌病11例临床分析

Clinical analysis of 11 patients with invasive pulmonary aspergillosis

目的探讨侵袭性肺曲霉菌病(IPA)的危险因素、临床表现、诊断和治疗特点。方法回顾性分析2006年1月至2010年10月收治的11例IPA的基础疾病、危险因素、临床表现、实验室及影像学特征、治疗和预后情况。结果 11例IPA患者确诊2例,临床诊断9例。3例患者无特殊病史,其余8例均有基础疾病。主要症状为发热、咳嗽、咯痰、咯血、胸闷和气喘。痰涂片3例、痰培养1例、肺泡灌洗液1例、胸水1例均查见曲霉菌。1,3-β-D-葡聚糖试验(G试验)及半乳甘露聚糖试验(GM试验)阳性6例。1例支气管镜活检、1例经皮肺活检病理形态学及特殊染色结果符合曲霉菌感染。影像学表现呈多样性。11例患者均接受抗真菌药物治疗,目前仍在治疗中2例,7例随诊,失访2例。6例选用伏立康唑、3例选用伊曲康唑、2例选用卡泊芬净作为初始治疗,均有疗效。结论 IPA与基础疾病及长期使用大剂量广谱抗生素、大剂量糖皮质激素等因素密切相关,主要临床表现不典型,病情进展迅速,病死率极高。诊断有赖于病理学及病原微生学结果,但随着高分辨率CT及G试验与GM实验在临床中的开展,使早期拟诊成为可能,早期予以经验性抗真菌治疗,可明显提高IPA的治愈率。

Objective To investigate risk factors,clinical manifestations,diagnosis and treatment of the invasive pulmonary aspergillosis（IPA）.Methods Retrospective study on the basic diseases,risk factors,clinical characteristics,laboratory and imaging features,treatment and prognosis of 11 cases with IPA referred to our hospital from January 2006 to November 2010 was carried out.Results Of 11 IPA cases,2 cases were diagnosed definitely,and 9 were diagnosed clinically.Eight cases had basic diseases while the other 3 cases had not.The main symptoms were fever,cough,expectoration,hemoptysis,chest distress and dyspnea.Aspergillus was found in sputum smears（3 cases）,sputum culture（1 case）,bronchoalveolar lavage fluid（1 case） and hydrothorax（1 case）.Six cases were positive for both galactomannan test（GM test） and 1,3-β-D-glucan test（G test）.The results of pathomorphology and special stain by transbronchoscopic lung biopsy（1 case） and percutaneous lung biopsy（1 case） conformed to aspergillus infection.The imaging features were varied.All of 11 cases accepted antimycotic treatment,and 2 cases of them were still under the treatment.Seven cases were followed-up and 2 cases were lost.The drugs for primary therapy of IPA included voriconazole（6 cases）,itraconazole（3 cases） and caspofungin（2 cases）,and all of them had therapeutic effect.Conclusions IPA is closely related to basic diseases,long-term use of mega-dose broad-spectrum antibiotics,mega-dose glucocorticoid and else.IPA has the features of untypical clinical manifestations,fast advancement and high mortality.The diagnosis of IPA bases on the results of pathology and pathogenic microoganisms.Recently,the applications of high resolution CT,G test and GM test in clinic make the impressional diagnosis of aspergillus infection possible.The experiential antimycotic treatment in early stage would elevate the cure rate of IPA.