念珠菌关节炎的诊断与治疗——18例报告并文献复习

Candida arthritis:18cases report and literature review

目的分析念珠菌关节炎的临床特征,结合文献复习提高对念珠菌关节炎诊治的认识。方法回顾性分析2008年1月至2018年6月两家医院收治的18例念珠菌关节炎患者,男13例,女5例;年龄(59±8)岁(范围48-71岁)。均行关节积液细菌培养及药敏试验,1例手术患者行术中组织细菌培养及药敏试验。17例患者接受MR检查,人工膝关节置换术后感染的患者接受了膝关节x线检查。分析临床特征、高危因素、临床表现、病原学、治疗方式及预后。结果18例均为膝关节念珠菌关节炎,2例合并糖尿病。1例为骨关节炎全膝关节置换术后继发念珠菌关节炎,16例有3次以上关节腔内糖皮质激素注射史,1例无糖尿病、关节手术及激素应用史。临床表现均为关节肿痛,部分伴有行走受限;外周血白细胞计数增高或正常,C反应蛋白、红细胞沉降率增高;MRI表现为关节积液及滑膜增生;关节镜检查见关节积液浑浊及滑膜增生;关节置换术后感染患者的X线表现为假体周围软组织肿胀、假体周围骨质吸收。培养结果为白色念珠菌2例、非白色念珠菌16例。18例念珠菌对氟康唑、两性霉素B、伏立康唑敏感率均为100%。13例接受手术联合抗真菌药物治疗,4例单纯抗真菌药物治疗,1例放弃治疗。真菌药物疗程6-52周,中位时间12周。应用氟康唑治疗12例、伏立康唑治疗1例、伏立康唑及氟康唑序贯治疗1例、氟康唑治疗联合两性霉素B脂质体全身及关节腔局部用药1例、特比萘芬后改用氟康唑治疗1例、氟胞嘧啶联合氟康唑治疗1例。17例随访3-72个月,末次随访时治愈12例、截肢1例、复发4例。结论文献中念珠菌关节炎的报告比较少见,多发生在人工关节置换术后,且有糖尿病、免疫抑制剂应用的高危人群中。对免疫正常、非术后患者念珠菌关节炎的发生可能与关节腔内多次注射及频繁的关节腔内糖皮质激素应用相关。由于无典型的临床表现,确诊困难,治疗疗程长且预后不佳。

Objective To analyze the clinical features of candida arthritis and to conduct literature review to improve diagnosis and treatment.Methods From January 2008to June 2018,eighteen patients (5females and 13males)with candida arthritis were admitted to two hospitals.The mean age at diagnosis was 59±8(range 48-71years).The diagnosis was determined Based on joint fluid aspirate in all cases and on intra-operative samples in 1patients.Seventeen patients received MR examination;and on epatient who underwent total knee arthroplasty underwent knee X-ray examination.The clinical features,risk factors,61inical manifestations,etiology,treatment and prognosis are recorded.Results Knee joints were involved in all patients/is infection sites.Seventeen patients had risk factors for candida infection,including diabetes mellitus in 2patients,artificial joint replacement in 1,and glucocorticoid injection in the joint cavity in 16.Swelling and pain were presented in all cases.Peripheral blood leukocytes were increased or normal,while C-reactive protein (CRP)and erythrocyte sedimentation rate (ESR)were increased. Magnetic resonance showed joint effusion and slip membrane hyperplasia.Joint turbidit^and synovial hyperplasia were presented by arthroscopy.X-ray demonstrated swelling of soft tissue around the prosthesis and bone absorption around the prosthesis.The most frequent species was nou-candida albicans.Susceptibility to antifungals was tested in all cases.Thirteen patients underwent surgery combined with antifungal therapy,while 4patients only received antifungal therapy and 1patient refused to treat.The du- ration of antifungal therapy was from 6weeks to 52weeks (median,12weeks).Twelve cases were treated with fluconazole and 1 with voriconazole,1with voriconazole and fluconazole,1with fluconazole combined with lipid formulation amphotericin B,1with terbinatine and fluconazole,1with flucytosine combined with fluconazole.Seventeen cases were followed up for 3to 72months.At final follow-up,twelve patients were healed,while 1case was amputated and 4patients relapsed and refused further treatment. Conclusion As a rare disease,candida arthritis is usually happened after artificial joint replacement and in high-risk patients with diabetes and immunosuppressant applications.In immunocompetent patients without surgery,infection may be related to multiple injections into the joint cavity with glucocorticoids.The infection may be difficult to be diagnosed and with poor prognosis. Surgery with long-term antifungal therapy is required.