肾移植后患者肺孢子菌肺炎的临床特点分析

Analysis of clinical characteristics of pneumocystis jirovecii pneumonia following kidney transplantation

目的:探讨肾移植后肺孢子菌肺炎(PCP)的临床特点、诊断及治疗方法。方法:本组7例肾移植后患者PCP均经病原学确诊,具有完整的病例资料,并结合国内外相关报道进行文献复习。结果:7例患者中男性5例,女性2例,年龄28～57岁,平均45岁;临床主要表现为发热、干咳、呼吸困难,而肺部体征较少,其特点为"症征不符";动脉血气表现均为低氧血症,严重者为Ⅰ型呼吸衰竭;静脉血乳酸脱氢酶(LDH)和(1,3)-β-D-葡聚糖(G试验)水平均明显升高;胸部高分辨CT(HRCT)表现为双肺弥散性磨玻璃影(GGO)伴或不伴斑片实变影;5例患者行支气管肺泡灌洗液(BALF)六胺银染色可发现肺孢子菌包囊,另外2例在痰中发现肺孢子菌包囊;痰液及BALF肺孢子菌PCR检测均为阳性。经免疫抑制剂减量、磺胺甲恶唑/甲氧苄啶(SMZ/TMP)治疗、机械通气及支持对症后,5例治愈,1例自愈,1例死亡。结论:肾移植后患者PCP具有较为明显的临床特点,血浆LDH和(1,3)-β-D-葡聚糖等检测有助于早期诊断,痰液或BALF六胺银染色是主要的确诊方法;早期免疫抑制剂减量和SMZ/TMP治疗后患者的预后相对较好。

Objective：To describe the clinical characteristics of pneumocystis jirovecii pneumonia（PCP） following kidney transplantation and to evaluate the methods of diagnosis and treatment.Methods：PCP in 7 patients with kidney transplantation was diagnosed and treated in our hospital and the literature on the subject were reviewed.Results：There were totally 7 patients with PCP,5 of them were male and 2 were female.Their ages were between 28-57 years and the average was 45.Most patients presented with fever,dry cough and dyspnea,and almost no rales were heard in lung auscultation.High resolution CT（HRCT） showed diffuse ground glass opacities（GGO） with/without patchy consolidations in most patients.Arterial gas analysis showed obvious hypoxemia and even type 1 respiratory failure.Lactate dehydrogenase（LDH） and（1,3）-β-D-glucan in plasma were elevated in most patients.Pneumocystis jirovecii cysts were found in 5 patients in bronchoalveolar lavage fluid（BALF） and 2 patients in sputum.Polymerase chain reaction（PCR） assays of sputum or BALF specimens were all positive in detecting pneumocystis jirovecii.Reduction of immunosuppressive drugs and administration of SMZ/TMP are the essential treatment of PCP.Five patients were cured and one was died,and another remitted spontaneously without anti-PCP therapy.Conclusion：Patients with PCP and kidney transplantation have some clinical characteristics.The elevations of LHD and（1,3）-β-D-glucan in plasma indicates the diagnosis of PCP;GMS stains of sputum and BALF could ensure the diagnosis of PCP.Reduction of immunosuppressive drugs and administration SMZ/TMP are essential for the treatment of PCP following kidney transplantation.