HIV阴性肺隐球菌病60例临床特征分析并文献复习

Analysis of Clinical Features of 60 Cases of HIV-Negative Pulmonary Cryptococcosis and Literature Review

目的探讨人类免疫缺陷病毒(HIV)阴性肺隐球菌病(PC)的临床特征、诊治及预后。方法回顾性分析郑州大学第一附属医院2010年5月至2019年5月经组织病理或病原菌确诊的60例HIV阴性PC患者的临床资料。结果共60例患者,男32例,女28例,男女比例为1.14∶1。平均年龄为(50.55±11.96)岁。4例有禽粪或潮湿环境接触史,所患基础疾病中糖尿病15例(45.45%)。18例患者无临床症状,42例因不同的呼吸道症状就诊,其中咳嗽32例(76.19%),咳痰23例(54.76%),发热9例(21.43%),胸痛6例(14.29%),胸闷5例(11.90%),咯血2例(4.76%),气喘1例(2.38%),呼吸困难1例(2.38%)。38例G实验结果中阳性5例(13.16%),13例GXM结果中阳性6例(46.15%)。影像学特征:结节或肿块影35例(58.33%),浸润影11例(18.33%),混合病变14例(23.33%),伴随征象中淋巴结肿大16例(26.7%)。48例(80.00%)初治诊断为其他疾病。53例经CT引导下经皮肺穿刺组织病理活检确诊,4例经手术切除肺组织病理活检确诊,2例经支气管镜下组织病理活检确诊,1例经肺泡灌洗液发现隐球菌病原体确诊。氟康唑治疗39例,21例好转,2例治愈。伏立康唑治疗4例,3例好转,1例治愈。伊曲康唑治疗1例,好转。伏立康唑序贯氟康唑治疗1例,好转。氟康唑序贯伏立康唑治疗6例,5例好转,1例无效。两性霉素B序贯伏立康唑治疗1例,好转。氟康唑联合两性霉素B治疗1例,好转。手术切除治愈2例。结论HIV阴性PC好发于中青年男性,环境暴露隐匿,糖尿病是其发病常见的风险因素,临床及影像学表现缺乏特异性,容易误诊,对疑似病例应尽早行组织病理活检明确诊断。

Objective To explore the clinical features,diagnosis,treatment and prognosis of human immunodeficiency virus(HIV)-negative pulmonary cryptococcosis(PC).Methods The clinical data of 60 HIV-negative PC patients diagnosed by histopathology or pathogenic bacteria from May 2010 to May 2019 in the First Affiliated Hospital of Zhengzhou University were retrospectively analyzed.Results There were a total of 60 patients,32 males and 28 females.The male to female ratio was 1.14∶1.The average age was(50.55±11.96)years old.Four cases had a history of exposure to poultry manure or humid environment,and 15 cases(45.45%)of the underlying diseases were diabetes.Eighteen patients were asymptomatic,and 42 patients presented with different respiratory symptoms,including 32 cases of cough(76.19%),23 cases of sputum(54.76%),9 cases of fever(21.43%),6 cases of chest pain(14.29%),5 cases of chest tightness(11.90%),2 cases of hemoptysis(4.76%),1 case of asthma(2.38%),and 1 case of dyspnea(2.38%).Of the 38 cases of G test results,5 cases(13.16%)were positive,and 6 cases(46.15%)of the 13 cases of GXM results were positive.Imaging features:35 cases(58.33%)of nodules or masses,11 cases(18.33%)of infiltration,14 cases(23.33%)of mixed lesions,16 cases(26.7%)of accompanying signs of lymph node enlargement.Forty-eight cases(80.00%)were initially diagnosed as other diseases.Fifty-three cases were diagnosed by CT-guided percutaneous lung biopsy,4 cases were confirmed by surgical resection of lung tissue pathology biopsy,2 cases were confirmed by bronchoscopy histopathological biopsy,1 case was confirmed by alveolar lavage fluid with cryptococcal pathogens.In 39 cases treated with fluconazole,21 cases improved and 2 cases were cured.Four cases were treated with voriconazole,3 cases were improved and 1 case was cured.One case was treated with itraconazole and got better.One case was treated with voriconazole followed by fluconazole and got better.Among 6 cases were treated with fluconazole followed by voriconazole,5 cases were improved and 1 case was failed.One case was treated with amphotericin B sequential voriconazole and got better.One case was treated with fluconazole combined with amphotericin B and got better.Two cases were cured by surgical resection.Conclusion HIV-negative PCs tend to occur in young and middle-aged men,with hidden environmental exposure.Diabetes is a common risk factor for their onset.The clinical and imaging findings lack specificity and are easy to be misdiagnosed.Suspected cases should be diagnosed by histopathological biopsy as soon as possible.