肺移植术后侵袭性支气管曲霉病20例临床分析

lnvasive tracheobroncial aspergillosis in donation after citizen＇s death for lung transplantation： a series of 20 cases

目的探讨公民逝世后器官捐献（DCD）供者供肺移植术后侵袭性支气管曲霉病（ITBA）的临床特点和防治策略。方法回顾性分析2015年1月至2016年6月间137例DCD供者供肺移植的临床资料，ITBA诊断依据典型的气管镜下黏膜损害表现及支气管活检组织病理学或肺泡灌洗液培养结果证实曲霉感染。结果术后20例受者发生ITBA，发生率为14．60％，发生时间为术后（22．45±17．70）d（7-70d），其中烟曲霉19例（95％），黄曲霉1例（5％）。20例受者中，免疫抑制剂使用20例，低蛋白血症6例，巴利昔单抗使用3例，术前存在曲霉定植3例，持续的中性粒细胞减少1例，以及鼻窦曲霉1例。治疗上分别予卡泊芬净、米卡芬净、伏立康唑、泊沙康唑、两性霉素B全身用药，联合两性霉素B或其脂质体雾化吸入，制霉菌素漱口，并结合气管镜下介入治疗。20例发生ITBA的受者中，5例出现吻合口或气道狭窄，其中1例死亡；此外有2例受者因非ITBA因素死亡；其余17例受者经治疗后均好转。所有受者均未发生吻合口瘘或裂开、侵袭性肺真菌病等严重并发症。结论ITBA的诊断主要通过支气管镜，肺泡灌洗液半乳甘露聚糖（GM）试验有助于指导诊断；预防性治疗要兼顾安全性；球囊扩张可作为气道介入治疗的重要手段之一，但不宜过早过多应用。

Objective To investigate clinical features and therapeutic strategies of invasive tracheobroncial aspergillosis （ITBA） in donation after citizens death （DCD） for lung transplantation. Methods From January 2015 to June 2016, 137 patients underwent lung transplantation from DCD donors. The clinical data were reviewed retrospectively. The diagnosis of ITBA was made by typical bronchoscopy findings, bronchial biopsy or bronchoalveolar lavage fluid glactomannan test. Results Twenty cases （14. 60%） were diagnosed as having ITBA. The time for diagnosis of ITBA was （22. 45 ±17. 70） days （7-70 days） postCtransplant. Aspergillus fumigatus was the most common pathogen （n = 19）. The risk factors of ITBA included immunosuppressive agents （n = 20）, hypoproteinemia （n = 6）, basiliximab （n = 3）, preoperative aspergillus colonization （n = 3）, neutropenia （n = 1）, as pergillus infection of the sinus （n = 1）. Therapeutic strategies included intravenous caspofungin, micafungin, voriconazole, posaconazole, amphotericin B, nebulized amphotericin B or amphotericin B liposome, gargled mycostatin, combined with interventional bronchoscopy. Five cases developed anastomotic or airway stenosis,one of them died,and two died due to non ITBA factors. The rest 17 cases recovered after treatment. No patient suffered from severe complications including anastomotic dehiscence, anastomotic fistula and invasive pulmonary fungal disease. Conclusion Bronchoscopy is the most important diagnostic method for ITBA. Bronchoalveolar lavage fluid glactomannan test helps to guide diagnosis. Safety needs to be taken into account in antifungal prophylaxis. Balloon dilatation should not be conducted prematurely as one important method of interventional bronchoscopy.