重症监护病房内非粒细胞缺乏患者合并侵袭性肺曲霉菌病38例临床特征及预后分析

Analysis of clinical manifestations and prognosis of 38 cases of invasive pulmonary aspergillosis in non-neutropenic patients in intensive care unit

目的探讨重症监护病房(ICU)内非粒细胞缺乏(非粒缺)患者合并侵袭性肺曲霉菌病(IPA)的临床特征及预后因素。方法回顾性收集2017年2月至2019年2月中日友好医院呼吸与危重症医学科四部(MICU)非粒缺合并IPA患者的临床资料,分析其临床特征和预后因素。结果该研究共纳入38例非粒缺IPA患者。主要临床表现有难治性发热和退热48 h后再发热。影像学方面最常见CT征象的为斑片影和实变,晕征和空气新月征相对少见。气管镜下以支气管黏膜充血、水肿,痰液粘稠多见。痰培养和肺泡灌洗液GM试验的阳性率为分别47.4%、52.9%。此外,有22例患者合并流感病毒感染。预后方面19例好转出院,10例死亡,9例因放弃治疗预后不佳。存活组和死亡组之间在BMI、合并冠心病比率、影像学出现空洞的比率、有创通气支持率、血管活性药物使用率方面存在统计学差异。结论ICU内非粒缺IPA患者的临床表现、影像学均缺乏特异性,当出现反复发热、肺部渗出影、常规抗感染治疗无效时需警惕IPA可能,尤其在合并重症流感时。BMI偏低、合并冠心病、肺部影像出现空洞、需要机械通气和血管活性药物治疗的患者预后不佳。

Objective To investigate the clinical manifestations and prognostic factors in invasive pulmonary aspergillosis(IPA)in non-neutropenic populations in intensive care unit(ICU).Methods Retrospectively collect clinical data of patients diagnosed with IPA among non-neutropenic patients in the Department of Respiratory and Critical Care Medicine(MICU)of the China-Japan Friendship Hospital from February 2017 to February 2019,and analyze their clinical characteristics and prognostic factors.Results A total of 38 non-neutropenic patients with IPA were included in this study.The main clinical symptoms included refractory fever and recurring fever at 48 hours after fever relief.The most common CT signs were patchy shadows and consolidation,while halo signs and air crescent signs were relatively rare.Tracheoscopy showed bronchial mucosal hyperemia and edema and sticky sputum were more common.The positive rates of sputum culture and GM test of alveolar lavage fluid were 47.4% and 52.9%.Moreover,22 patients had influenza virus infection.In terms of prognosis,19 patients were discharged from the hospital,10 died,and 9 patients gave up treatment and had poor prognosis.There were significant differences between the survival and the death group in terms of BMI,the rate of complicating coronary heart disease,the ratio of cavity in imaging,rate of invasive ventilation support,and rate of vasoactive drug use.Conclusions The clinical manifestations and imaging of non-neutropenic IPA patients in the ICU lack specificity.When patients have refractory fever,pulmonary exudation,and don’t respond to conventional anti-infective therapy,it is necessary to be alert to the possibility of IPA,especially when it is complicated with severe influenza virus infection.The prognosis of patients is poor when they are with low BMI,coronary heart disease,cavities in lung images,and need mechanical ventilation and vasoactive drug treatment.