尖端赛多孢子菌肺部感染的临床特征及预后分析

Clinical manifestations and outcomes of pulmonary infection by Scedosporium apiospermum

目的分析尖端赛多孢子菌引起的肺部感染的临床特征、治疗及预后,为临床诊断和治疗提供依据。方法收集2018年1月—2021年12月在复旦大学附属中山医院感染病科治疗的尖端赛多孢子菌肺部感染的患者共8例,回顾性分析患者的临床特征、影像学表现、治疗及预后。结果8例患者中,男性3例,女性5例,平均年龄58(27~76)岁。经MALDI-TOF MS鉴定,6例为尖端赛多孢子菌,2例为波氏假阿利什菌。8例患者中1例无基础疾病;1例有系统性硬化症合并肺间质病变、糖尿病,长期服用强的松10 mg/qd、赛可平0.5 g/qd;其余6例伴有肺部基础疾病。最常见的临床症状为咳嗽,其余依次为咳痰、痰血/咯血、发热、气急、消瘦。患者的平均BMI为19.5(15.6~23.2)kg/m^(2),4例患者BMI<18.5 kg/m^(2)。实验室检查方面,所有患者的白细胞计数、中性粒细胞计数、降钙素原均正常;红细胞沉降率(erythrocyte sedimentation rate,ESR)平均为32 mm/h(4例升高);高敏C反应蛋白(high sensitivity C-reactive protein,hs-CRP)平均为24.8 mg/L(5例升高)。G试验和GM试验阴性。患者的CD4淋巴细胞计数平均为512.8(226.0~943.0)/μL,5例CD4淋巴细胞计数<500/μL。患者的胸部CT表现多样:支气管扩张(5例)、结节(3例)、实变(3例)、空洞(2例)、胸膜增厚(2例)、树芽征(2例),各种影像学表现往往合并存在。所有患者均首选伏立康唑治疗,4例患者服药后出现肝功能不全、幻视予停药或调整为泊沙康唑治疗。随访至治疗开始后6个月,所有患者的临床症状均明显好转;影像学上,5例病灶好转吸收,2例病灶相仿,1例病灶增多,考虑为合并胞内分枝杆菌感染所致。结论尖端赛多孢子菌肺部感染的临床症状和影像学表现缺乏特异性,仅炎症标志物ESR和hs-CRP轻度升高,G试验和GM试验阳性率低,因此早期诊断困难。治疗首选伏立康唑,患者总体预后良好。

Objective To summarize the clinical characteristics and outcomes of localized pulmonary infection by Scedosporium apiospermum(S.apiospermum)in order to provide evidence for diagnosis and treatment.Methods We reviewed 8 patients diagnosed with S.apiospermum pulmonary infection from Jan 2018 to Dec 2021 at the department of infectious disease of Zhongshan Hospital,Fudan University.The clinical data,radiological findings,treatment and prognosis of the patients were analyzed retrospectively.Results Among the 8 patients,there were 3 males and 5 females,with an average age of 58(27-76)years.Identified by MALDI-TOF MS,6 cases were S.apiospermum and 2 cases were S.boydii.There was 1 case had systemic sclerosis with pulmonary interstitial disease and diabetes,treated with Prednisone 10 mg/qd and Mycophenolate Mofetil 0.5 g/qd,6 cases were accompanied by underlying pulmonary diseases,and 1 case had no underlying disease.The most common clinical symptoms were cough,followed by sputum production,haemoptysis,fever,dyspnea and weight loss.The mean BMI was 19.5(15.6-23.2)kg/m^(2),and the BMI was less than 18.5 kg/m^(2) in 4 cases.The white blood cell counts,neutrophil counts and procalcitonin(PCT)were normal in all patients.The average value of erythrocyte sedimentation rate(ESR)and high sensitivity C-reactive protein(hs-CRP)were 32 mm/h(increased in 4 cases)and 24.8 mg/L(increased in 5 cases).G test and GM test were negative.The average CD4 lymphocyte count of patients was 512.8(226.0-943.0)/μL,and the counts of 5 cases were<500/μL.The chest CT findings were diverse:bronchiectasis(5 cases),nodules(3 cases),consolidation(3 cases),cavities(2 cases),pleural thickening(2 cases),and tree bud sign(2 cases),and various imaging findings often existed in combination.All the patients were treated with voriconazole,and 4 patients developed liver insufficient and visual hallucination after taking the medicine were stopped or adjusted to posaconazole.Follow up for 6 months after the start of treatment,the clinical symptoms of all patients were significantly improved.In imaging,5 cases were absorbed,2 cases were similar,and 1 case was deteriorated,which was considered to be caused by mycobacterium infection.Conclusion The clinical and imaging manifestations of localized pulmonary infection by S.apiospermum are non-specific,inflammation markers ESR and hs-CRP are only slightly elevated,and the positive rates of G test and GM test are low,which make early diagnosis difficult.All the patients were treated with voriconazole and the overall prognosis is good.