肺泡灌洗液在诊断真菌性肺炎中的价值

The Value of Bronchoalveolar Lavage in Diagnosis of Fungal Pneumonia

目的探讨支气管镜肺泡灌洗液病原菌检查在诊断肺部真菌感染、区分是肺部定植菌还是真正的肺部真菌感染中的价值。方法回顾分析2009年1月1日至2013年12月31日上海交通大学医学院附属新华医院呼吸内科通过肺泡灌洗液找到真菌的患者,对其临床表现、影像学改变、支气管镜肺泡灌洗液病原菌检查和组织病理学进行综合分析。结果肺泡灌洗液中找到真菌60例,最常见的真菌为曲霉、念珠菌和隐球菌。其中27例(45.00%)经肺组织病理学检查确诊为肺部真菌感染,33例(55.00%)为肺部定植菌。曲霉35例(58.33%),其中12例(34.28%)为致病菌,23例(65.72%)为定植菌;念珠菌13例(21.67%),其中3例(23.08%)为致病菌,10例(76.92%)为定植菌;10例隐球菌和2例肺孢子菌均为致病菌。肺泡灌洗液找到曲霉、念珠菌首先需考虑定植菌,这些病例往往因肺部肿块或支气管内新生物经活检最后确诊为肺部肿瘤。12例诊断为肺孢子菌感染和隐球菌肺炎的患者均有影像学改变:两肺多发磨玻璃样渗出影,肺内多发结节影、肺实质内有团块样影。肺泡灌洗液诊断和组织病理学诊断吻合率为45%。结论曲霉和念珠菌是肺泡灌洗液中最常见的病原菌。支气管镜肺泡灌洗液细胞学检查是诊断肺部真菌感染的重要方法之一,必须结合临床表现、支气管镜检查和肺组织病理结果作出正确诊断与治疗。

Objective To explore the value of bronchoscopy alveolar lavage cytology in diagnosis of pulmonary fungus infection and distinguishing colonization from true fungal infections. Methods A retrospective analysis was conducted on the patients with positive fungi results in bronchoalveolar lavage cytology admitted in Shanghai Xinhua Hospital between January 2009 and December 2013. Clinical,radiological,bronchoalveolar lavage and histopathology findings were recorded and analyzed. Results Fungi were found in alveolar lavage fluid in 60 cases. The most common fungal organism identified was Aspergillus,followed by Candida and Cryptococcosis. Twenty-seven cases（ 45. 00%） by lung biopsy pathology were diagnosed as pulmonary fungal infection and 33 cases（ 55. 00%） were diagnosed as lung bacteria colonization. Aspergillus was found in 35 cases（ 58. 33%）,as pathogenic bacteria in 12 cases（ 34. 28%）,and colonization bacteria in 23 cases（ 65. 72%）. Candida was found in 13 cases（ 21. 67%）,as pathogenic bacteria in 3 cases（ 23. 08%）,and colonization bacteria in 10 cases（ 76. 92%）. Ten cases of Cryptococcus and 2 cases of pulmonary sporozoan were all as pathogenic bacteria. Most cases of Aspergillus and Candida in cytological specimens presented as a pulmonary mass or endobrochial growth and were diagnosed as carcinomas in biopsy specimens,so bacteria colonization should be considered in these cases first of all. All cases of Pneumocystis with bilateral ground glass infiltrates and cryptococcosis with parenchymal mass lesion in radiology represented true infection. The coincidence rate of bronchoscopy alveolar lavage cytology and histopathology was 45%. Conclusions Aspergillus and Candida species are the most common fungal organisms in the bronchoscopy alveolar lavage. Fluid cytological examination is an important diagnostic modality for pulmonary mycoses,however it is important to correlate with clinical,bronchoscopy and biopsy findings for accurate diagnosis and appropriate management.