63例免疫功能正常患者肺隐球菌病的治疗和预后

Treatment and prognosis of 63 cases of immunocompetent patients with pulmonary cryptococcosis

目的探讨免疫功能正常患者肺隐球菌病的临床特征、治疗方法及预后,为临床提供参考。方法回顾性分析2012年1月-2017年12月医院63例免疫功能正常的肺隐球菌病患者的临床资料,对其临床特征、影像学表现、治疗过程及预后进行分析。结果 32例免疫功能正常的肺隐球菌病患者起病时无临床症状,31例有临床症状的患者主要表现为咳嗽、咳痰、发热等。在有创检查中,CT引导下经皮肺穿刺的病理阳性率为91.30%(21/23),经支气管镜肺活检阳性率为57.69%(15/26);血清隐球菌乳胶凝集试验有较高的阳性率(93.44%)。免疫功能正常的肺隐球菌病患者影像学表现多样,伴随症状多为支气管充气征(31.03%),其次为毛刺(24.14%)和空洞(18.97%)。患者炎症标记物[C-反应蛋白(CRP)、血沉(ESR)]多为正常(84.48%、87.76%)。47例患者完成治疗,其中30例氟康唑治疗有效,1例伊曲康唑治疗有效,6例伏立康唑治疗有效,10例两性霉素B或两性霉素B脂质体治疗有效;31例治愈,16例好转。氟康唑治疗有效的患者中,18例使用日剂量0.4g自始至终;5例患者在使用两性霉素B或两性霉素B脂质体过程中出现不同程度肾功能损害。结论三唑类药物对免疫功能正常的肺隐球菌病通常有效,三唑类耐药时可使用两性霉素B或两性霉素B脂质体;免疫功能正常的肺隐球菌病预后良好。

OBJECTIVE To analyze the clinical features,treatment and prognosis of the immunocompetent patients with pulmonary cryptococcosis,so as to provide references for clinical practice.METHODS The clinical data of 63 cases of immunocompetent patients with pulmonary cryptococcosis from Jan.2012 to Dec.2017 were retrospectively analyzed.The clinical features,imaging,treatment and prognosis were analyzed.RESULTS Totally 32 patients had no clinical symptoms,and among the rest 31 patients,the major clinical symptoms included cough,expectoration and fever.The positive rate of pathology of the CT-guided percutaneous needle biopsy was 91.30%（21/23）,and that of the fiber bronchoscope with transbronchial lung biopsy was 57.69%（15/26）.The positive rate of the latex cryptococcal antigen agglutination tests reached 93.44%.The imaging of immunocompetent patients with pulmonary cryptococcosis was various.Most common incidental signs were air bronchogram（31.03%）,followed by speculation（24.14%）and cavity（18.97%）.The inflammation markers（C-reactive protein（CRP）and erythrocyte sedimentation rate（ESR））of the patients were mostly common（84.48% and 87.76%）.Among the 47 patients who had completed the treatment,30 patients were effective in the treatment of fluconazole,1 patient was effective in the treatment of itraconazole,6 patients were effective in the treatment of voriconazole and 10 patients were effective in the treatment of amphotericin B or amphotericin B liposome.Totally 31 patients got recovery and 16 patients got improved.Totally 18 patients used daily dose of 0.4 g from beginning to end among the 30 patients who used fluconazole effectively.A total of 5 patients had renal impairment among the 10 patients who used amphotericin B or amphotericin B liposome.CONCLUSION The triazole antifungals are always effective to immunocompetent patients with pulmonary cryptococcosis.Amphotericin B or amphotericin B liposome can be used while triazoles are resistant.The prognosis of pulmonary cryptococcosis is always favorable.