1例肾移植术后患者肺部感染耶氏肺孢子菌与新型隐球菌的诊疗分析

Analysis of Diagnosis and Treatment of Pulmonary Infection with Pneumocystis Jirovecii and Cryptococcus Neoformans in One Patient after Renal Transplantation

目的:分析肾移植术后患者肺部感染耶氏肺孢子菌与新型隐球菌的诊断和治疗过程,为临床此类免疫抑制患者真菌感染的诊治提供参考。方法与结果:一肾移植术后长期服用免疫抑制剂患者因“胸闷气促、纳差20余天”来院就诊,临床结合胸部CT检查结果,考虑其为社区获得性肺炎;入院后,患者血常规、生化常规和血气分析除肌酐水平较高外无明显异常,但2 d后隐球菌荚膜多糖抗原检测回报阳性,(1,3)-β-D-葡聚糖试验呈阳性,肺泡灌洗液的涂片和六胺银染色均发现隐球菌样真菌孢子和少量耶氏肺孢子菌,并且肺泡灌洗液的二代测序(next-generation sequencing,NGS)检查提示真菌阳性(新型隐球菌、耶氏肺孢子菌),遂确定患者的诊断为新型隐球菌和耶氏肺孢子菌所致真菌性肺炎,随即予以氟康唑和复方磺胺甲噁唑;近1周后,患者肌酐水平持续升高,为减小对患者肾功能的影响,遂决定减小氟康唑的剂量和减少复方磺胺甲噁唑的用药频次;又18 d后,考虑患者胸闷气促症状明显好转,且肌酐水平较前明显降低,遂准予患者出院;3个多月后,患者复查胸部CT显示,病灶明显吸收或好转。结论:临床上肺部混合真菌感染较为少见,并且对于免疫低下患者稍有不慎更是极为凶险,故完善检查以及早明确诊断,对患者的治疗和预后是极为重要的。

Objective:To analyze the diagnosis and treatment process of pulmonary infection with Pneumocystis jirovecii and Cryptococcus neoformans in patients after renal transplantation,and provide a reference for the diagnosis and treatment of fungal infections in such immunosuppressed patients in the clinical practice.Methods and Results:One patient who had been taking immunosuppressants for a long time after renal transplantation visited the hospital due to"chest tightness,shortness of breath,and poor appetite for more than 20 days".According to the chest CT result,the patient was considered to have community-acquired pneumonia.After admission,the patient's routine blood test,routine biochemical test,and arterial blood gas analysis showed no obvious abnormalities except for a high creatinine level.However,2 days later,the cryptococcal capsular polysaccharide antigen test reported positive result,the(1,3)-β-D-glucan test reported positive result.Cryptococcal fungal spores and a small amount of Pneumocystis jirovecii were found in the smear and methenamine silver staining of the alveolar lavage fluid.The next-generation sequencing(NGS)on alveolar lavage fluid showed positive fungi(Cryptococcus neoformans and Pneumocystis jirovecii).Therefore,the patient was diagnosed with fungal pneumonia caused by Cryptococcus neoformans and Pneumocystis jirovecii,and fluconazole and compound sulfamethoxazole were given immediately.After about one week,the patient's creatinine level continued to rise.In order to reduce the impact on the patient's renal function,the dosage of fluconazole and the dosing frequency of compound sulfamethoxazole were reduced;then after 18 days,the patient's symptoms of chest tightness and shortness of breath had been relieved obviously,and the creatinine level was significantly decreased,so the patient was allowed to be discharged.After more than 3 months,the patient's chest CT showed that the lesions were significantly absorbed or improved.Conclusion:Mixed pulmonary fungal infection is relatively rare in clinical practice,and it is extremely dangerous for immunocompromised patients if it is not well managed.Therefore,it is extremely important to complete the examinations and make an early definite diagnosis for the treatment and prognosis of patients.