诺卡菌病34例临床分析

Clinical analysis of 34 cases of nocardiosis

目的分析诺卡菌病的临床症状、影像学、实验室检查及诊断、治疗情况,为临床工作提供参考。方法收集并分析2012—2021年郑州大学第一附属医院确诊为诺卡菌感染并肺部受累患者的临床资料。结果共34例患者纳入研究,其中20例存在免疫功能低下,14例免疫功能正常的患者中8例有肺部基础疾病;病变仅累及肺部的有23例,两个部位受累的有8例,其中肺部受累基础上播散至皮肤4例、中枢神经系统2例、血液2例,三个及以上部位受累的有3例。临床常见症状依次是发热、咳嗽、咯黄脓痰,播散至中枢神经系统可出现头痛、脑膜刺激征,播散至皮肤可出现局部硬结等。多数患者白细胞计数、中性粒细胞绝对值、中性粒细胞/淋巴细胞比值、降钙素原、C反应蛋白、红细胞沉降率等可不同程度升高,淋巴细胞亚群CD3、CD4、CD4/CD8可不同程度降低。常见的胸部影像学表现依次为结节影、不同形态高密度影,如片状、斑片状、团块状、条索状高密度影、空洞、实变等。34例患者中通过临床标本培养确诊20例、宏基因组二代测序技术(mNGS)确诊4例,通过培养和mNGS同时确诊7例、肺组织活检病理确诊3例。治疗上单用磺胺类3例,另31例以磺胺类为基础联合治疗。5例病情恶化后自动出院或死亡,29例均好转出院。结论诺卡菌病好发于免疫功能低下的患者,常累及肺部、皮肤、中枢神经系统等,临床症状常不典型,磺胺类药物是治疗的首选药物,由于耐药率相对较低,早期、足量、足疗程治疗一般预后较好。

Objective To review the clinical manifestations,imaging signs,laboratory tests,diagnosis,and treatment of nocardiosis for better clinical management.Methods The clinical data of patients who were diagnosed with Nocardia infection and lung involvement from 2012 to 2021 in the First Affiliated Hospital of Zhengzhou University were collected and analyzed.Results A total of 34 patients were included,of which 20 were immunocompromised.Overall,8 of the 14 immunocompetent patients had underlying lung disease.Nocardiosis affected lungs alone in 23 patients.Eight patients had nocardiosis at two body sites,including spread to skin in 4 cases,to central nervous system in 2 cases,and to blood in 2 cases.Three patients had Nocardia infection at 3 or more bode sites.The common clinical symptoms were fever,productive cough with yellow purulent sputum,even headache and meningeal irritation in case of involving central nervous system.Local induration was found in case of spread to skin.White blood cell count,neutrophils count,neutrophil/lymphocyte ratio,procalcitonin,C-reactive protein,erythrocyte sedimentation rate slightly increased in most patients.The lymphocyte subsets CD3,CD4,CD4/CD8 slightly decreased.Nodular,patchy,lumpy,and strip-shaped high-density opacities,cavities,and consolidation were the common findings on chest imaging examination.Nocardiosis was confirmed by culture in 20 of 34 patients,by metagenomic next-generation sequencing(mNGS)in 4 patients,by both culture and mNGS in 7 patients,and by pathological examination of lung biopsy in 3 cases.Three patients were treated with sulfonamides alone,and the remaining 31 patients were treated with sulfonamide-based combination therapy.Five patients left hospital voluntarily or died after deterioration.The remaining 29 patients were improved after treatment.Conclusions Nocardiosis occurs especially in immunocompromised patients,usually affecting lungs,skin,and central nervous system. The clinical symptoms are often atypical. Sulfonamides are the first choice treatment for nocardiosis. Early, adequate, and full-course treatment generally results in good outcome due to relatively low resistance level of Nocardia.