儿童侵袭性肺曲霉病的临床分析

Invasive pulmonary aspergillosis in children:clinical analysis of nine patients

目的探讨儿童侵袭性肺曲霉病(IPA)的诊断及治疗。方法选择2004年1月至2016年7月于四川大学华西第二医院确诊或临床诊断的9例IPA患儿为研究对象。回顾性分析IPA患儿的宿主高危因素、临床表现、影像学表现、实验室检查结果、病理学检查结果、治疗及预后。结果 9例IPA患儿中,确诊为4例,临床诊断为5例;男性患儿为5例,女性为4例;年龄为5个月~12岁。7例患儿存在宿主高危因素,3例合并肺结核。咳嗽、发热和肺部湿啰音是IPA患儿最常见的临床表现,仅2例出现咯血。确诊时最常见的胸部影像学表现是结节影和斑片影,仅3例出现晕轮征,无一例出现空气新月征。血培养结果均呈阴性,痰液和支气管肺泡灌洗液(BALF)培养呈阳性者分别为2例和4例。3例患儿行肺活组织检查。8例患儿单用伏立康唑、伊曲康唑或米卡芬净,1例采用伏立康唑与两性霉素B脂质体联合治疗。所有患儿随访半年以上,7例痊愈,2例仍在治疗中。结论儿童IPA缺乏特异性临床表现和影像学改变,反复多次痰液和(或)BALF培养是诊断IPA的关键。早期使用抗真菌治疗可控制IPA。

Objective To investigate the diagnosis and treatment of invasive pulmonary aspergillosis （IPA） in children. Methods From January 2004 to July 2016, nine children with proven IPA or possible IPA in West China Second University Hospital, Sichuan University were included into this study. The risk factors, clinical manifestations, chest radiographic findings, microbiological and pathological evidence, treatment and prognosis were retrospectively reviewed in nine patients. Results Among nine patients （four boys, five girls）, four cases were proven IPA, and five cases were possible IPA. The risk factors were found in seven cases. Pulmonary tuberculosis coexisted in three cases. Cough, fever, moist rales were the most common manifestations, and only two cases had hemoptysis. The most common chest imaging was nodules and patchy shadow. Halo sign was found in three cases, and air crescent sign was not found. Blood culture was negative in all nine patients. The positive children of sputum and bronchoalveolar lavage fluid （BALF） culture were two cases and four cases, respectively. Lung biopsy was conducted in three cases. Eight cases were treated with anti-fungal therapy （voriconazole, itraconazole, micafungin used alone）, and only one case was treated with combination therapy （voriconazole and liposomal amphotericin B）. Seven cases recovered, and two cases are still receiving treatment. Conclusions The clinical manifestations and chest imaging of IPA are nonspecific. Repeated sputum and BALF culture are essential to clinical diagnosis of IPA.The patients in whom the antifungal therapy are initiated early have a good outcome.