不明原因发热患者病原学临床分析

Etiological study on patients with fever of unknown origin

目的明确不明原因发热(FUO)人群的病原学检查结果情况。方法回顾性收集306例FUO病例的临床资料,对病原学检查结果进行分析。结果 306例FUO病例中,感染性疾病202例(66.0%),为FUO的首要病因;风湿免疫类病38例(12.4%);肿瘤性疾病20例(6.5%);其他疾病22例(7.2%);到出院时原因仍未明24(占7.8%)。306例FUO患者中病原学总的阳性率为72.5%,病原菌培养的阳性率为34.6%,病原体血清抗体的阳性率为43.5%,血病原体核酸的阳性率为6.2%,标本涂片镜检查病原体阳性率为18.3%,标本的病理学检查中病原体阳性率为1.6%。306例FUO患者中总的抗生素的使用率为94.1%。将风湿免疫病、肿瘤性疾病、其他疾病和最终仍原因不明合并成非感染组,与感染性疾病组进行比较,结果显示,感染组病原学总的阳性率显著高于非感染组(χ2=24.9,P<0.01);病原学检出的阳性率中细菌的阳性率最高,为57.5%,其中结核杆菌的阳性率为22.9%,其次为病毒,为48.3%,真菌的阳性率为11.1%,支原体的阳性率为8.8%,衣原体的阳性率为6.5%,寄生虫的阳性率为1.0%。可疑的感染灶中,肺部最常见(45.4%),其次是淋巴结(12.4%),然后是血液(4.2%),少见的感染部位有腹腔(1%)、胆道(1%)、肝脏(0.7%)、颅内(0.7%)、心内膜(0.7%)、泌尿道(0.3%),还有相当一部分病例找不到可疑的感染灶(11.4%)。结论 FUO的诊治过程中,病原学的检查的意义在于,阳性结果能够提示感染的相关诊断,尤其是结合感染灶时;阴性结果可以协助排除感染的相关情况,为确诊感染以外的疾病提供相关的证据。在FUO中,无论引起发热的原发病因是感染因素还是非感染因素,都需要完善病原学的相关检查,以明确原发感染或继发感染的病原学情况。

Objective To analyze the etiological factors of patients with fever of unknown origin（ FUO）. Methods The clinical data of306 patients with FUO hospitalized in this hospital during January 2003 to August 2013 were retrospectively analyzed. Results Among them,202 cases were suffered with infectious diseases（ 66%）,38 cases（ 12. 4%） suffered with connective tissue diseases,20 cases（ 6. 5%） with malignancies,22 cases（ 7. 2%） with other kinds of diseases,and the etiology of 24 cases（ 7. 8%） could not be confirmed until their discharge from the hospital. Among these 306 FUO cases,the rate of positive etiological determination was 72. 5%,the positive rate of pathogenic cultures was34. 6%,the positive rate of antibodies in plasma was 43. 5%,the positive rate of blood nucleic acid of pathogens was 6. 2%,the positive rate of pathogens in smear examinations was 18. 3%,and the positive rate of pathological examination of specimens was 1. 6%. Among these 306 FUO cases,the total rate of application of antibiotics was 94. 1%. The cases with rheumatoid disease,neoplastic diseases,other kinds of diseases caused fever and ultimately unknown causes were listed in non-infectious diseases group. The results of non-infectious disease group were compared with those of infectious disease group. The results showed as follows： the positive rate of pathogens in infectious disease group was significantly higher than that of non-infectious disease group（ χ^2= 24. 9,P〈0.01）. The positive rate of pathogenic detection was highest in bacterial disease group,and its rate was 57. 5%. Among these bacterial disease groups,the positive rate of mycobacteria tuberculosis was 22. 9%. The positive rate of viral diseases was 48. 3%. The positive rate of fungal infection was 11. 1%. The positive rate of mycoplasma infection was 8. 8%,and it in chlamydial infection was 6. 5%. The positive rate of parasitic diseases was 1. 0%. Among the suspicious foci of infection,lung was the most common site（ 45. 4%）,the second one was lymph glands（ 12. 4%） and the third one was blood stream. The rare infection sites included abdominal cavity（ 1%）,biliary tract（ 1%）,liver（ 0. 7%）,intracranial sites（ 0. 7%）,cardiac intima（ 0. 7%） and urinary tract（ 0. 3%）. There were considerable number of cases（ 11. 4%） could not find out suspicious foci. Conclusion In the process of diagnosis and treatment of FUO,the significance of etiological examination lies in important place,the positive results can prompt the diagnosis of infection,especially when combined with the foci of infection. The negative results can help to exclude the infection,thus they can provide the evidence for diseases other than confirmed infections. In FUO,regardless the primary cause of fever is infection or non infectious factors,it needs to raise the level of relevant etiological examination,in order to clarify the etiology of primary infection or secondary infection.