肾移植后肺毛霉病三例临床分析

Post-kidney-transplant pulmonary mucormycosis： analysis of three cases

目的探讨肾移植后肺毛霉病的临床特点、影像学表现、诊断和治疗方法。方法收集经肺组织活检病理证实的肾移植后肺毛霉病3例的相关资料，其中男性2例，女性1例，年龄为39～54岁。均因“尿毒症”接受肾移植，1例合并糖尿病，分别于肾移植后6个月、2年及6年发病。症状有发热、咳嗽、痰中带血及胸痛等。CT影像学表现，2例早期为多发不规则块状影，1例早期为双肺弥漫性浸润影；均较快进展为多发厚壁空洞；1例伴胸水。3例均经CT引导下经皮肺穿刺病理检查确诊。结果3例中，例1采用伊曲康唑治疗1年，治愈，停药8个月后复发；例2伊曲康唑治疗21d，显效，因移植肾发生排斥反应，加强免疫抑制后毛霉播散，死亡；例3经伊曲康唑治疗，显效，仍在随防中。结论肾移植受者并发肺毛霉病的诊治困难；对可疑病例应及时行经皮肺穿刺等组织活检术；可选用伊曲康唑抗毛霉治疗；早期诊断、把握好免疫功能状态是改善预后、减少复发的关键。

Objective To investigate the clinical features, radiology, diagnosis and treatment of post- kidney-transplant pulmonary mucormycosis. Method Three cases of post-kidney-transplant pulmonary mucormycosis were successfully diagnosed by histopathologic examinations. The clinical features of the cases were analyzed. The patients consisted of 2 males and 1 female, aged 39 to 54 years. All patients were subjected to renal transplantation due to uremia, one was complicated with with diabetes, and pulmonary mucormycosis occurred 6 months, 2 years and 6 years after kidney transplant respectively. Fever, cough, bloody sputum and chest pain were the main clinical manifestations. Multiple irregular massive or diffuse infiltrates in the lungs were the early CT findings. In a shoot time, multiple thick-walled cavities oceurred in the pulmonary lesions. Pleural effusion was found in one patient. The lung specimens of patients were obtained by CT-gnided percutaneous biopsy. Result The first patient was cured after one year therapy by Itraconazole,but recurred after 8 months. The second patient had a marked effect after a 21-day therapy by Itraconazole, but died of disseminated mucor for excessive immunosuppressant against the renal transplantation rejection. The third patient also had a marked effect, and was still in follow up. Conclusion The post-kidney-transplant pulmonary mucormycosis is difficult in diagnosis and treatment. CT-guided percutaneous biopsy is one of effective ways for diagnosis. Itraconazole appears to be effective in treatment of pulmonary mucormycosis. Farly diagnosis and an appropriate immune function are the keys to improve prognosis and reduce recurrence.