免疫功能正常宿主原发性肺隐球菌病23例临床分析

Clinical analysis on primary pulmonary cryptococcosis in 23 immunocompetent patients

目的提高对免疫功能正常隐球菌病患者的认识。方法回顾性分析2002年1月至2014年5月广西医科大学第一附属医院呼吸内科收治的23例免疫功能正常的肺隐球菌病患者的临床资料,按症状分为急重组与轻微组,归纳其临床特征。结果症状轻微组最常见(19例),多体检发现或偶有轻微咳嗽、胸痛,实验室检查基本正常;单个或多个结节影累及单侧肺(15例)或累及双侧肺(4例),胸膜下多见,甚至呈分叶状、有毛刺、空洞,易被误诊为肺癌。急重组(4例)以畏寒、高热、胸痛为首发症状,白细胞(WBC)及中性粒细胞增高,血红蛋白(Hb)下降,其中呼吸衰竭2例;肺部病灶广泛胸膜下为主,大片渗出、实变影,结节或团块影,易被误诊为细菌性肺炎或肺结核;4例均经皮肺穿刺病理找到隐球菌孢子确诊。23例中抗真菌治疗15例,手术治疗8例。14例治愈,9例好转,其中3例术后肺内播散,治疗后好转。结论免疫功能正常患者肺隐球菌病症状轻微多见,亦可表现为急性进展伴严重炎症反应,及时取得肺部病理找到病原菌是减少误诊的重要手段。手术治疗的患者复发播散的风险高,建议及时规范抗真菌治疗。

Objective To summarize the clinical characteristics of immunocompetent patients with pulmonary cryptococcosis. Methods A total of 23 immtmocompetent patients with pulmonary cryptococcosis were collected from 2002 to 2014 in Respiratory Disease Department of the First Affiliated Hospital of Guangxi Medical Urdversity and divided into the severe symptom group （n= 19） and the mild symptom group （n= 4） in a bid to retrospectively analyze their clinical characteristics. Results 1-he mild symptom was predominated in this study. In this group, patients were usually asymptomatic and found during routine health examinations, or occasionally showed mild cough and chest pain, with basically normal laboratory results. Fifteen patients in the mild symptom group revealed single or multi-nodules on single lobe and 4 on both lobes, subpleurally predominant, and even showed lobulation, speculation or cavitation, which might be easily misdiagnosed as lung cancer. The patients of the severe symptom group initially showed chillness, high fever and chest pain, with an elevated count of white blood cells and neutrophils but decreased hemoglobin levels; respiratory failure occurred in 2 cases. Radiographic findings exhibited extensive pulmonary damages with subpleural predominance, including broad infiltration, consolidations, nodules or lumps that may generally be linked to bacterial pneumonia or pulmonary tuberculosis. All patients in the severe symptom group had been pathologically diagnosed with pulmonary cryptococcosis through percutaneous translung biopsy. Of the 23 patients, 15 were treated with anti-fugal drugs and 8 with chest surgery; 14 were cured and 9 with substantial improvements, including 3 cases with pulmonary dissemination after surgery, but remitted by anti- fungus therapy. Conclusion Pulmonary cryptococcosis in immunocompetent hosts mostly present mild symptoms, but sometimes progresses rapidly and shows severe inflammatory reaction. Timely biopsy is the key means to avoid misdiagnosis. Patients may carry high risks of extrapulmonary dissemination after surgery so timely and standardized anti-fugal therapy is advised.