重症患者侵袭性肺曲霉病5例临床诊治分析

Analysis of the diagnosis and treatment of 5 cases of critically ill patients with pulmonary invasive aspergillosis

目的加强临床医师对侵袭性肺曲霉病(invasive pulmonary aspergillosis,IPA)的临床表现、影像学诊断和治疗的认识,提高救治成功率。方法对本科2010年1月至2014年7月收治的5例重症患者IPA病例进行临床分析。结果该组患者多具有应用激素及广谱抗菌药物的高危因素,临床表现多样,4例行肺部CT检查,其中3例肺部CT分别呈现典型征象如曲霉球伴晕轮征、实变区域空洞形成及空气新月征。2例有微生物学依据。5例患者均予静脉用伏立康唑抗真菌治疗,3例病变吸收而治愈,1例治疗好转,1例因感染加重并发多脏器功能衰竭死亡。结论重症监护病房内的非粒缺重症患者IPA临床表现不典型,但典型的肺部影像学表现是IPA临床诊断的重要依据之一,结合高危宿主因素及其他次要特征,依据笔者的临床经验,对重症患者可以考虑及早开始经验性治疗。

Objective To raise clinicians’ awareness of clinical manifestations, imaging diagnosis and treatment of invasive pulmonary aspergillosis （IPA） so as to improve the treatment success rate.Method Five critically ill cases admitted to our department from January 2010 to July 2014 with invasive aspergillosis infection were observed.Result The appliance of glucocorticoid and broad spectrum antibiotics was a high risk factor for this group of patients who had multiple clinical manifestations. Four patients underwent lung CT scan, three of whom presented typical signs separately such as aspergilloma with halo sign, air-crescent sign and hollow shape in consolidation area. The data of two cases were on the basis of microbiological testing. The five patients all received antifungal therapy using voriconazole powder for infusion solution; three patients’ lesions in lungs were absorbed and cured; one patient’s condition improved but one died from multiple organ failure caused by aggravating infection.Conclusion Non-neutropenic critically ill patients with IPA in the intensive care unit （ICU） usually have no typical signs, but the typical signs in the lung CT image are one of the most important bases of clinical diagnosis of IPA infection. Considering the high-risk host factors and other secondary clinical features of IPA, clinicians should start the empiric therapy as early as possible according to the clinical experience, especially for those critically ill patients.