支气管镜下表现对重症患者侵袭性肺曲霉菌病诊断的辅助作用

Assistant role of manifestations under tracheoscopy in the diagnosis of invasive pulmonary aspergillosis in severe patients

目的探讨支气管镜下表现对重症患者侵袭性肺曲霉菌病(IPA)诊断的辅助作用。方法应用回顾性研究方法,选择滨州医学院附属医院重症医学科2015年1月至2019年12月收治的疑似IPA患者。确诊、临床诊断和拟诊均按照《重症患者侵袭性真菌感染诊断与治疗指南(2007)》的分级标准诊断,符合者纳入IPA组,不符合者上述诊断或其他病原体感染者纳入非IPA组。收集患者的一般资料,记录治疗前后支气管镜下气管和支气管黏膜改变、支气管肺泡灌洗液(BALF)中半乳甘露聚糖肽抗原检测(GM试验)和病原学培养结果。比较各组患者基线情况、支气管镜下表现与胸部CT表现及其动态变化。结果最终142例疑似IPA患者纳入分析,按照IPA分级诊断标准,确诊12例,临床诊断77例,拟诊22例,非IPA 31例。142例患者中有支气管镜下典型气道黏膜损伤表现者60例,其中确诊患者7例(58.3%),临床诊断52例(67.5%),拟诊1例(4.5%),而非IPA者无一例有损伤表现。IPA患者中分别有12例确诊(100%)、73例临床诊断(94.8%)和21例拟诊(95.5%)者进行了胸部CT检查,多为斑片状或条索状密度增高影等非特异性胸部CT表现,具有典型IPA胸部CT表现(晕轮征和空洞或新月征)者分别为确诊组3例(25.0%)、临床诊断组7例(9.0%)、拟诊组0例(0%)。确诊及临床诊断的89例患者中有支气管镜下气道黏膜损伤表现且复查≥3次者35例,均进行了抗曲霉菌治疗,其中16例存活,19例死亡。存活组患者支气管镜下黏膜损伤表现逐渐减轻、临床表现逐步好转;死亡组患者中有16例支气管镜下气道黏膜损伤恶化。结论重症患者支气管镜下气道黏膜损伤的特异性表现对IPA诊断具有重要的提示意义;在重症患者不能及时进行病理或胸部CT检查的情况下,动态观察气道黏膜损伤改变是及时发现患者病情变化、评估抗真菌治疗效果和IPA预后的简单辅助方法。

Objective To evaluate the assistant role of manifestations under tracheoscopy in the diagnosis of invasive pulmonary aspergillosis(IPA)in severe patients.Methods A retrospective study was conducted.The patients with suspected IPA admitted to intensive care unit(ICU)of Affiliated Hospital of Binzhou Medical College from January 2015 to December 2019 were enrolled.The diagnosis,clinical diagnosis and suspected diagnosis were made according to the grading criteria of Guidelines for the diagnosis and treatment of invasive fungal infection in severe patients(2007).Those who met the criteria were enrolled in the IPA group,and those who did not meet the criteria or other pathogens were enrolled in the non-IPA group.The general data of the patients were collected,and the changes of tracheal and bronchial mucosa under tracheal microscope before and after treatment were recorded,as well as the results of galactomannan(GM)test and aetiology culture of bronchoalveolar lavage fluid(BALF).The baseline,bronchoscopy and pulmonary CT manifestations and their dynamic changes were compared in each group.Results A total of 142 patients with suspected IPA were finally enrolled.Among them,12 were pathologically proven IPA,77 were probable IPA,22 were possible IPA,and 31 were undefined IPA.Of the 142 patients,60 had typical manifestations of mucosal injury under bronchoscopy,including 7 proven IPA patients(58.3%),52 probable IPA patients(67.5%),and 1 possible IPA patient(4.5%),but none undefined IPA patient.The patients undergoing lung CT scan were 12 proven IPA patients(100%),73 probable IPA patients(94.8%),and 21 possible IPA patients(95.5%),respectively.Most of the Chest CT showed patchy or strip density increasing and other non-specific manifestations.There were 3 proven IPA patients(25.0%),7 probable IPA patients(9.0%),and 0 possible IPA patient(0%)who had typical IPA CT manifestations(halo sign and cavity or crescent sign).Among the patients of proven IPA and probable IPA(89 cases),there were a total of 35 cases with endoscopic airway mucosal injury and tracheoscopy reexamination≥3 times.All the 35 patients received anti-aspergillus treatment,among which 16 survived and 19 died.Among the 16 patients who survived,the microscopic appearance of mucosal injury was gradually reduced and the clinical manifestations were gradually improved.Of the 19 patients who died,16 had deteriorated endoscopic airway mucosal injury.Conclusions The specific manifestations of severe patients with bronchial mucosal injury are of great significance in the diagnosis of IPA.In the case of severe patients who cannot receive pathological examination or chest CT in time,dynamic observation of the changes of airway mucosal injury is a simple auxiliary method to discover the changes of patients'condition in time,evaluate the effect of antifungal therapy and the prognosis of IPA.