新型冠状病毒肺炎康复期感染肺孢子菌肺炎一例并文献复习

Infection of Pneumocystis pneumonia during convalescence of COVID-19:One case report and literature review

目的探讨新型冠状病毒肺炎(COVID-19)合并肺孢子菌肺炎(PCP)的临床特点。方法分析1例COVID-19康复期经肺泡灌洗液病理检测确诊为PCP患者的病历资料,并进行相关文献检索及复习。结果共检索到99篇文献,其中19篇为COVID-19合并PCP的病例报道。COVID-19合并PCP多发生于重症合并有T细胞免疫功能抑制患者,2例康复期患者出现PCP。临床多表现为发热、干咳、不同程度的呼吸困难,实验室检查可有血清1,3-β-D-葡聚糖升高,胸部影像学表现为多肺叶磨玻璃浸润影、细小网状改变,可出现实变、囊肿样病变及气胸等表现。CT不易区分COVID-19是否合并PCP,联合痰/肺泡灌洗液Grocott银染色、免疫荧光镜检、聚合酶链反应、血清1,3-β-D-葡聚糖可有效提高肺孢子菌检测准确率。复方磺胺甲口恶唑(TMP/SMZ)为PCP治疗的首选药物,采用氨苯砜、克林霉素、卡泊芬净治疗也可获得较好的临床效果。结论重症COVID-19患者及其康复期存在合并PCP的风险,但早期识别困难。PCP治疗首选药物为TMP/SMZ,也可采用氨苯砜、克林霉素、卡泊芬净联合治疗。

Objective To investigate the clinical characteristics of COVID-19 complicated with Pneumocystis pneumonia(PCP).Methods Medical record of a patient with PCP confirmed by pathological examination of bronchoalveolar lavage fluid during convalescence period of COVID-19 were analyzed,the relevant literatures were searched and reviewed.Results A total of 99 literatures were retrieved,19 of which were case reports of COVID-19 combined with PCP.COVID-19 combined with PCP mostly occurred in critically ill patients with T-cell immunosuppression,and PCP occurred in 2 convalescent patients.Most clinical manifestations were fever,dry cough and dyspnea in varying degrees,laboratory examination showed elevation of serum 1,3-β-D-glucan,chest imaging showed multi-lobe ground-glass infiltration,small reticular changes,consolidation,cyst-like lesions and pneumothorax.It was difficult for CT to distinguish whether COVID-19 was complicated with PCP,combined with sputum/bronchoalveolar lavage fluid Grocott’s silver staining,immunofluorescence microscopy,polymerase chain reaction and serum 1,3-β-D-glucan,the accuracy of Pneumocystis detection could be effectively improved.Compound sulfamethoxazole(TMP/SMZ)was the first choice for the treatment of PCP,dapsone,clindamycin and capofungin also had effective clinical efficacy.Conclusion Patients with severe COVID-19 and their convalescence period are at risk of PCP,but early identification is difficult.TMP/SMZ is the first choice for PCP treatment,combination therapy with dapsone,clindamycin and caspofungin can also be adopted.