肺隐球菌病临床误诊讨论

A Study of Clinical Misdiagnosis of Pulmonary Torulosis

目的探讨肺隐球菌病的临床特点及诊治方法,以减少误诊。方法对我院近期收治的1例肺隐球菌病误诊病例的临床资料进行回顾性分析,并复习相关文献。结果患者因阵发性左侧背部疼痛,伴发热及咳嗽、咳痰1个月入院。曾于外院就诊,经肺部CT检查诊断为肺炎、肺结核不能排除,给予相应治疗病情加重转入我院。入院后行肺部CT检查示左肺多发渗出伴实变、下叶为著;隐球菌乳胶凝集试验(+),效价1∶480;纤维支气管镜肺活组织病理检查倾向隐球菌感染;免疫组织化学检查示CD68(组织细胞+),PAS(+),六胺银(+),抗酸(-);气管镜肺泡灌洗液检查找到新型隐球菌。确诊肺隐球菌病,予氟康唑及左氧氟沙星治疗3周后,复查胸部CT与入院时胸部CT比较肺部病灶明显吸收,出院。结论对临床表现为肺部多发渗出病灶、持续低热,且抗感染治疗效果不佳的患者应高度警惕肺隐球菌病,及时行病理检查、隐球菌乳胶凝集试验及肺泡灌洗液检查等,以减少误诊误治。

Objective To analyze the clinical characteristics of pulmonary torulosis and its diagnostic methods,so as to reduce misdiagnosis rate. Methods One misdiagnosed case of pulmonary torulosis was retrospectively analyzed,and relevant literatures were reviewed. Results The female patient had been diagnosed as having pneumonia（with / without TB） with pulmonary CT in another hospital. Her condition deteriorated after corresponding treatment,and then she was admitted to our hospital for cough,sputum with fever for one month,and lung CT examination showed multiple exudation with consolidations in left lung,especially in lower lobe. Cryptococcal latex agglutination test（＋）,titers of 1∶ 480 parallel; bronchoscopy transbronchial lung biopsy（TBLB） had a tendency of cryptococcal infection. Immunohistochemistry showed CD68（epithelial cells ＋）,PAS（＋）,six methenamine silver（＋）,tuberculosis（-）. Bronchoalveolar lavage fluid inspection reported： Cryptococcus neoformans（＋）. The patient was diagnosed as having pulmonary cryptococcosis,and underwent Levofloxacin and Fluconazole treatment. After 3 weeks of treatment,the second lung CT showed that lung lesions were significantly absorpted,and then the patient was discharged from the hospital. Conclusion Patients with multiple pulmonary exudative lesions,sustained low fever refractory to treatment should be highly suspected as having pulmonary cryptococcosis. Pathology,cryptococcal latex agglutination test,and bronchoalveolar lavage fluid cryptococcal examination are of important significance in the process of diagnosis.