肾病综合征患者合并播散性奴卡菌感染的临床特征

Clinical characteristics of isseminated nocardiosis in patients with nephrotic syndrome

目的：肾病综合征（NS）患者长期服激素、免疫抑制剂可出现免疫功能缺陷,易继发少见病原菌感染,分析并总结NS合并播散性奴卡菌病患者的临床表现、诊断、治疗及预后。方法：回顾性分析南京军区南京总医院肾脏科近年来收治的9例出现奴卡菌感染的NS患者,对其临床特征进行分析。结果：男性3例,女性6例,平均年龄33.6±9.8岁。9例患者均曾使用激素及免疫抑制剂,出现感染时服泼尼松剂量为34.4±12.6 mg/d。激素治疗至出现感染的中位时间为6月（2~51月）,其中6例感染发生在6个月内。8例患者出现发热,平均38.8℃±1.0℃。白细胞升高8例（8/9）,C反应蛋白升高8例（8/8）,降钙素原轻度升高1例（1/5）。4例（4/7）患者CD4＋T淋巴细胞减低,其中3例〈200个/μl。9例患者均有肺部感染,其中5例表现为孤立或散在的结节状或团块状密度增高影,病灶多贴近胸膜,部分形成空洞。其他部位受累包括皮肤7例、胸腔3例、肝周脓肿2例,颅脑、眼、肾上腺各1例。皮肤脓液及胸水培养阳性率均达到100%。星形、豚鼠、巴西奴卡菌各1例,余6例未能分型。7例患者在诱导治疗时使用复方新诺明（TMP-SMX）,其中2例联合、另有2例单用碳青霉烯类药物,治疗有效率100%。结论：NS患者长期服激素及免疫抑制剂,如出现全身多发脓肿,肺部感染影像学上表现为近胸膜的结节或团块状密度增高影,降钙素原不高,应考虑奴卡菌感染。确诊依赖于细菌学培养,早期诊断及合理用药是奴卡菌病治疗的关键。

Objective： To evaluate the clinical manifestations,diagnosis,treatment and outcome of disseminated nocardiosis in nephrotic syndrome patients. Methodology： Nine cases of culture-proven disseminated nocardial infections diagnosed in recent years were reviewed retrospectively. Their clinical manifestations, treatment and outcomes were analyzed. Results： There were three males and six females with the mean age of 33. 6 ± 9. 8 years. At the onset of Nocardia infection,the mean prednisolone dose was 34. 4 ± 12. 6 mg / d. The median time to develop Nocardia infection after the usage of glucocorticoid was 6 months,and 6 patients within 6 months. 8 patients had fever with the mean body temperature of 38. 8 ℃ ± 1. 0 ℃. White blood cell counts and C-reactive protein in peripheral blood were elevated.Procalcitonin level was slightly increased in one out of the 5 patients who had detected. 4 out of 7 patients had low CD4＋Tcell counts,3 lower than 200 cells per μl. All patients had pulmonary Nocardiosis. Radiologic findings of 5 cases were characterized by isolated or scattered nodules and mass,usually close to the pleura,and cavitation could be found. All them also had disseminated diseases including subcutaneous abscess in 7cases,thoracic cavity in 3,liver in 2,brain in one,ocular in one,and adrenal gland in one case. The positive rate of culture in samples of subcutaneous abscess and pleural fluid reached to 100%. 3 species of Nocardia were indentified： Nocardia otitidiscaviarum（ n = 1）,Nocardia asteroids（ n = 1）,Nocardia brasiliensis（ n = 1）,and the other 6 isolates were not determined. 7 patients were treated with oral TMP-SMX,including 2 patients combining with carbapenem antibiotics,as an induction therapy,and the other 2patients received carbapenem monotherapy. The long-term prognosis was good,with a treatment success rate of 100%.Conclusion： NS patients often receive long-term treatment with glucocorticoid and immunosuppressants,when one suffers with systemic multiple abscess,and lung image is characterized by isolated or scattered nodules and mass,usually close to the pleura, but procalcitonin level is within normal limits or just slightly increased, nocardial infection should be considered. The diagnosis relies on the microbiologic culture. Early diagnosis and specific treatment may have a positive effect on the outcome.