肾移植术后隐球菌感染的临床分析

Clinical analysis of cryptococcal infection after renal transplantation

目的分析并探讨肾移植术后患者隐球菌感染的临床特点,以便更好地预防、诊断和治疗。方法回顾性分析2016年6月至2021年6月武汉大学人民医院住院治疗的6例肾移植术后隐球菌感染患者的基本临床资料。结果6例肾移植术后发生隐球菌感染的患者中,男性3例,女性3例,平均年龄为(31~49)岁,发病中位时间为术后1(0~6)年。其中4例为隐球菌肺炎,1例为隐球菌性脑膜炎,1例为肺脑合并感染。采用血液和脑脊液隐球菌培养、血清和脑脊液隐球菌荚膜抗原检测、纤支镜肺泡灌洗液高通量测序、支气管镜取活组织病检等方法来确诊。发生感染后,5例患者给予氟康唑等规范抗真菌治疗,1例多重耐药患者给予泊沙康唑治疗,抗感染过程中均调整免疫抑制剂用量。6例患者中5例经治疗后预后情况良好,1例患者因出现脓毒血症、感染性休克、呼吸循环衰竭而死亡。结论肾移植术后隐球菌感染好发于肺部和脑部,多预后不良,患者由于临床症状不典型,容易漏诊及误诊,因此移植术后应注意防治感染,同时防范供者源性感染。胸部影像学多表现为肿块、斑片、结节等,无特异性表现。血和脑脊液隐球菌荚膜多糖抗原灵敏度和特异度高,有助于早期诊断。隐球菌感染病程较长,治疗上应早期、足量、长疗程给药。

Objective To analyze and discuss the clinical characteristics of cryptococcal infection in patients after renal transplantation for better prevention,diagnosis and treatment.Methods The basic clinical data of 6 patients with cryptococcal infection after renal transplantation who were hospitalized in People's Hospital of Wuhan University from June 2016 to June 2021 were retrospectively analyzed.Results Among the 6 patients with cryptococcal infection after kidney transplantation,The male to female ratio was 3/3,the age was(31~49)years,and the median time of onset was 1(0~6)year.Four cases were cryptococcal pneumonia,1 case was cryptococcal meningitis and 1 case was cryptococcal pneumonia combined with cryptococcal meningitis.Cerebrospinal fluid and blood cryptococcus culture,serum and cerebrospinal fluid cryptococcus capsular antigen detection,high throughput sequencing of bronchoscopic alveolar lavage fluid,bronchoscopy biopsy and other methods were used to confirm the diagnosis.After infection,5 patients were given standard antifungal therapy such as fluconazole,and 1 patient with multiple drug resistance was given posaconazole.The dosage of immunosuppressant was adjusted during the anti-infection process.Five of the six patients had a good prognosis after treatment,and one patient died due to sepsis,septic shock,and respiratory and circulatory failure.Conclusion Cryptococcal infections after kidney transplantation tend to occur in the lungs and brain,and often have a poor prognosis.The patients are prone to overlooked and misdiagnosed due to atypical clinical symptoms.Therefore,attention should be paid to prevention and treatment of infections after transplantation and to prevent donor-derived infections.Chest imaging mostly showed lumps,patches,nodules,and so on without specific manifestations.The sensitivity and specificity of Cryptococcus capsular polysaccharide antigen in blood and cerebrospinal fluid are high,which is helpful for early diagnosis.Cryptococcal infection has a long course of disease,so early,sufficient,and long course of treatment should be given.