肾移植受者卡氏肺囊虫肺炎的肺泡损伤

Alveolar damage of pneumocystis carinii pneumonia in renal transplantation recipients

目的 通过观察肾移植后卡氏肺囊虫肺炎 (PCP)患者的肺泡超微结构改变 ,探讨其与病原学的关系。方法 对可疑PCP的肾移植受者 ,进行支气管肺泡灌洗 (BAL)和 (或 )经支气管肺组织活检 (TBLB) ,以发现卡氏肺囊虫为确诊依据 ,通过光镜和电镜下的观察 ,结合其临床特点 ,分析病原体与宿主肺泡病理反应的关系。结果 确诊PCP 2 3例 ,发病距肾移植时间平均 5 6个月 ,发病至就诊时间平均 5 5d ;临床以发热、呼吸困难为主要症状 ,胸部CT表现为两肺弥漫性肺间质及肺泡改变。通过BAL检查发现卡氏肺囊虫者 18例 ,通过TBLB电镜检查发现卡氏肺囊虫者 14例 ,虫体以滋养体与包囊两种形式存在。肺组织光、电镜检查 :可见Ⅰ型上皮细胞变性、Ⅱ型细胞增生、Ⅰ型和Ⅱ型上皮细胞脱落、上皮细胞脱落后其下的基底膜暴露于肺泡腔等 ;肺间质及肺泡内出现少量炎症细胞 ;肺泡腔内见少量蛋白样物质渗出 ,部分可见空泡样细胞及泡沫样组织 ;肺间质中可见不同程度胶原纤维增生 ,肺泡间隔增宽。结论 肾移植后PCP患者存在明显的肺泡损伤 ,以肺泡内渗出、炎症细胞浸润、上皮细胞受损及间质纤维组织增生为特征 。

Objective To study the alveolar ultrastructural changes and the interaction between Pneumocystis carinii (PC) and alveoli in Pneumocystis carinii pneumonia(PCP) patients after renal transplantation Methods Twenty seven patients with suspected PCP after renal transplantation were examinated by bronchoscopy with bronchoalveolar lavage(BAL) and transbronchial lung biopsy(TBLB) The BAL fluid was centrifuged and the sediments were stained for PC Cases for which electron microscope showed alveolar tissue in TBLB specimen were included Then the clinical features,PC,alveolar epithelial damage,exudate in alveolar space,inflammatory cell infiltration,and fibrous tissue in the interstitial space were analyzed and evaluated Results Twenty three cases were studied The mean time from renal transplantation to onset of illness was 5 6 months,and that from onset of illness to hospitalization was 5 5 days Clinical features included fever,dyspnea,unproductive cough,and scanty chest signs,to hypoxemic respiratory failure Chest CT showed diffuse lung interstitial changes in 22 of the 23 cases,9 with consolidation After treatment with SMZco,the fever resolved in 1 5 days,and the general state of the patients became better,and 19 patients were dischaged within 1 month PC in BAL fluid was found by special staining in 18 patients ,while PC was found by electron microscope in 14 patients In most cases PC was few in the lung tissue, but in 3 cases abundant PC filled the alveolar space PC was seen in two forms,the cyst and the trophozoite Electron and light microscopes showed alveolar exudate,inflammation in interstitium and alveolar space, interstitial fibrosis,and alveolar epithelial damage in all patients Conclusion In PCP patients after renal transplantation there was marked alveolar damage, which was the major pathological change in the lung