手术联合抗真菌药物治疗肝移植术后颅内曲霉菌感染:附1例报告并文献复习

Combined surgical resection and antifungal therapy for intracranial aspergillosis after liver transplantation :a case report and literature review

目的探讨肝移植术后曲霉菌感染及颅内曲霉菌感染患者的病因、临床表现、诊断及治疗。方法回顾性分析天津市第一中心医院1例经典原位肝移植术后并发颅内曲霉菌感染患者的临床资料、诊断及治疗经过,并进行文献复习。结果患者于移植术后1个月无明显诱因出现肌肉抽搐,抽搐时意识清晰,磁共振成像(MRI)提示:右侧额叶可见占位病变,病灶中心呈长T1长T2信号影,周围可见环形等T1短T2信号影,增强后病灶呈环形强化,中心未强化,周围低密度影未见强化,诊断为颅内曲霉菌感染。患者停用吗替麦考酚酯(MMF)及激素,单用他克莫司(FK506)抗排斥反应,且FK506血药浓度维持在较低水平,同时应用卡泊芬净抗真菌治疗,2周后查头颅MRI见右侧额叶脓肿无明显变化。为治愈颅内感染,患者于全麻下行右额叶脓肿切除术,术中可见坚韧的脓肿壁,大小约1.5 cm×2.0 cm,脑脓肿完整切除后送病理,术后病理回报:颅内曲霉菌感染。术后继续给予卡泊芬净抗真菌治疗,并定期复查头颅CT。颅内脓肿切除术后患者未再发抽搐、高热。术后1个月复查头颅CT显示,颅脑术后改变较前好转,右侧额颞部皮下组织肿胀较前减轻,其他无异常。患者痊愈后出院。结论由于颅内曲霉菌感染抗真菌药往往在局部难以达到有效的抑菌浓度,对于肝移植术后孤立的颅内曲霉菌感染病灶,联合应用局部手术切除和抗真菌药物,同时减少抗排斥反应药物的剂量,可能是理想的治疗方案。

Objective To investigate the etiology,clinical presentation,diagnosis and treatment of Intracranial aspergillosis after liver transplantation. Methods Clinical data, diagnosis and treatment of one case with intracranial aspergillosis after liver transplantation were analyzed and correlative literatures were reviewed. Results The patient suffered muscle twitching without obvious cause one month after liver transplantation with clear consciousness. Magnetic resonance image(MRI)of head showed space-occupying lesion with long T1 long T2 signal in the centre and iso T1 short T2 signal around in the right frontal lobe. After enhancing,the lesion showed ring-enhancement with center and low density shadow around no reinforced. Intracranial aspergillosis was diagnosed. Then monotherapy of tacrolimus(FK506)was used with withdrawl of mycophenolate mofetil(MMF)and glucocorticoid. The serum FK506 concentration was maintained at a low level,and caspofungin was administrated for intracranial aspergillosis. The MRI of head showed no obvious changing in the right frontal lobe abscess after two weeks. In order to cure the intracranial infection,the patient underwent resection of the right frontal lobe abscess after general anesthesia. During the operation,an abscess with tough wall with the size of 1.5 cm×2.0 cm was seen,which was sent to the Department of Pathology after resection. The pathological findings revealed intracranial aspergillosis. After operation,we continued to administrate caspofungin to treat intracranial aspergillosis,and reviewed head CT scan regularly. The patient did not suffer recurrent convulsion and high fever after resection. One month later, head CT scan showed better postoperative brain change and the subcutaneous tissue swelling of the right cranial frontal reduced without other abnormalities. Then the patient was discharged after recovery. Conclusion Due to intracranial aspergillosis infection,it is difficult to achieve effective inhibitory concentration of antifungal agent. So when the transplant recipient was infected with isolated intracranial aspergillosis,combining local resection with antifungal agent and reducing the dose of anti-rejection drugs may be the ideal treatment.