两种曲霉菌相关性哮喘临床诊治特点对比分析
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摘要
目的提高对两种曲霉菌相关性哮喘——变应性支气管肺曲霉病(ABPA)和真菌致敏性严重哮喘(SAFS)的认识,减少误诊和漏诊。方法回顾性对比分析23例ABPA患者和7例SAFS患者的临床资料。结果 ABPA患者和SAFS患者哮喘病史、喘息、胸闷气急等哮喘发作症状、嗜酸性粒细胞百分比、C反应蛋白(CRP)、血清总IgE、烟曲霉特异性IgE、PaCO_2、HCO_3~-比较差异均有统计学意义(均P<0.05)。SAFS患者CT表现无特异性,而ABPA患者胸部CT表现为中心性支气管扩张、黏液栓、迁移性肺浸润影等。糖皮质激素联合抗真菌治疗ABPA和SAFS效果明显。然而ABPA和SAFS治疗后复发率高,尤其是ABPA,7例患者在治疗过程或停药后复发。结论 SAFS较ABPA更易被误诊、漏诊,对于严重、难治性哮喘合并或不合并胸部CT表现异常的患者,均应常规行真菌学相应检查。激素联合抗真菌治疗对于ABPA和SAFS均有显著疗效,但两者均易复发,定期随访对于早期发现疾病进展、反复十分必要。
Objective To analyze the clinical features of allergic bronchopulmonary aspergillosis(ABPA) and severe asthma with fungal sensitation(SAFS). Methods The clinical data of 23 ABPA patients and 7 SAFS patients diagnosed in our hospital from 2010 to 2017 were retrospectively analyzed. Results There was lack of characteristic clinical manifestations in ABPA and SAFS, the common symptoms and signs were cough and expectoration, chest irritation, wheeze, fever, wheezing rale and moist crackles. The symptoms of asthma in SAFS patients were more common, such as chest irritation and wheeze. In laboratory tests, the eosinophils, CRP, IgE, and aspergillus specific IgE levels of ABPA were significantly higher than those of SAFS patients before treatment. There was lack of characteristic imaging findings in SAFS patients, while the chest CT showed centricity bronchiectasis, mucus plugs, mobile lung infiltrating shadows in ABPA patients. The efficacy of glucocorticoid combined with antifungal therapy was definite for ABPA and SAFS patients. However, ABPA and SAFS had a high recurrence rate after treatment, especially ABPA, and 7 patients relapsed after treatment or drug withdrawal. Conclusion SAFS is more susceptible to misdiagnosis than ABPA, mycology examination should be taken for patients with severe, refractory asthma with or without chest radiographic abnormality. The combination of hormone and antifungal therapy shows significant curative effects for both ABPA and SAFS patients, but the disease is prone to relapse, and regular follow-up is necessary for early detection of disease progression and recurrence.
Objective To analyze the clinical features of allergic bronchopulmonary aspergillosis(ABPA) and severe asthma with fungal sensitation(SAFS). Methods The clinical data of 23 ABPA patients and 7 SAFS patients diagnosed in our hospital from 2010 to 2017 were retrospectively analyzed. Results There was lack of characteristic clinical manifestations in ABPA and SAFS, the common symptoms and signs were cough and expectoration, chest irritation, wheeze, fever, wheezing rale and moist crackles. The symptoms of asthma in SAFS patients were more common, such as chest irritation and wheeze. In laboratory tests, the eosinophils, CRP, IgE, and aspergillus specific IgE levels of ABPA were significantly higher than those of SAFS patients before treatment. There was lack of characteristic imaging findings in SAFS patients, while the chest CT showed centricity bronchiectasis, mucus plugs, mobile lung infiltrating shadows in ABPA patients. The efficacy of glucocorticoid combined with antifungal therapy was definite for ABPA and SAFS patients. However, ABPA and SAFS had a high recurrence rate after treatment, especially ABPA, and 7 patients relapsed after treatment or drug withdrawal. Conclusion SAFS is more susceptible to misdiagnosis than ABPA, mycology examination should be taken for patients with severe, refractory asthma with or without chest radiographic abnormality. The combination of hormone and antifungal therapy shows significant curative effects for both ABPA and SAFS patients, but the disease is prone to relapse, and regular follow-up is necessary for early detection of disease progression and recurrence.
引文
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[11]陈娟,崔学范.血清CEA在评估变应性支气管肺曲霉菌病治疗疗效中的临床意义[J].环球中医药, 2015, 8(s1):261-262.
[12]王颖.变应性支气管肺曲霉菌病治疗效果中血清CEA的评估分析[J].中国现代药物应用, 2017, 11(14):62-63. DOI:10.14164/j.cnki.cn11-5581/r.2017.14.034.
[13]Pasqualotto AC, Powell G, Niven R, et al. The effects of antifungal therapy on severe asthma with fungal sensitization and allergic bronchopulmonary aspergillosis[J]. Respirology, 2009, 14(8):1121-1127.DOI:10.1111/j.1440-1843.2009.01640.x.
[14]Denning DW, O'Driscoll BR, Powell G, et al. Randomized controlled trial of oral antifungal treatment for severe asthma with fungal sensitization:The Fungal Asthma Sensitization Trial(FAST)study[J]. Am J Respir Crit Care Med, 2009, 179(1):11-18. DOI:10.1164/rccm.200805-737oc.
[15]彭娟,韩锋锋,杨天芸,等.变应性支气管肺曲霉病四例临床分析并文献复习[J].中国呼吸与危重监护杂志, 2015, 14(5):456-461. DOI:10.7507/1671-6205.2015112.
[2]Thilagar LB, Mckay SA. Allergic Bronchopulmonary Aspergillosis[J].Dis Mon, 2008, 54(8):547-564. DOI:10.1016/j.disamonth.2008.05.004.
[3]Denning DW, O'Driscoll BR, Hogaboam CM, et al. The link between fungi and severe asthma:a summary of the evidence[J]. European Respiratory Journal, 2006, 27(3):615-626. DOI:10.1183/09031936.06.00074705.
[4]中华医学会呼吸病学分会哮喘学组.支气管哮喘防治指南(2016年版)[J].中华结核和呼吸杂志, 2016, 39(9):675-697. DOI:10.3760/cma.j.issn.1001-0939.2016.09.007.
[5]李琳.真菌致敏与严重支气管哮喘[J].中华哮喘杂志(电子版),2011,5(2):125-129. DOI:10.3969/j.issn.1674-3911.2011.02.012.
[6]周巧龙,李斌,许兴钢,等.慢性变态反应性支气管肺曲霉菌病25例CT表现及临床分析[J].浙江医学, 2015, 37(5):427-429.
[7]马艳良,张为兵,余兵,等.支气管哮喘患者中变应性支气管肺曲霉病的检出及临床特点初步调查[J].中华结核和呼吸杂志, 2011, 34(12):909-913. DOI:10.3760/cma.j.issn.1001-0939.2011.12.009.
[8]Greenberger PA. When to suspect and work up allergic bronchopulmonaryaspergillosis[J].AnnAllergyAsthmaImmunol,2013,111(1):1-4. DOI:10.1016/j.anai.2013.04.014.
[9]Homma T, Kurokawa M, Matsukura S, et al. Anti-IgE therapy for allergic bronchopulmonary aspergillosis[J]. Journal of Microbiology Immunology&Infection, 2013, 49(3):459-463. DOI:10.1016/j.jmii.2013.10.003.
[10]Noguchi T, Yamamoto K, Moriyama G, et al. Evaluation of serum levels of carcinoembryonic antigen in allergic bronchopulmonary aspergillosis[J]. J Nippon Med Sch, 2013, 80(6):404-409. DOI:10.1272/jnms.80.404.
[11]陈娟,崔学范.血清CEA在评估变应性支气管肺曲霉菌病治疗疗效中的临床意义[J].环球中医药, 2015, 8(s1):261-262.
[12]王颖.变应性支气管肺曲霉菌病治疗效果中血清CEA的评估分析[J].中国现代药物应用, 2017, 11(14):62-63. DOI:10.14164/j.cnki.cn11-5581/r.2017.14.034.
[13]Pasqualotto AC, Powell G, Niven R, et al. The effects of antifungal therapy on severe asthma with fungal sensitization and allergic bronchopulmonary aspergillosis[J]. Respirology, 2009, 14(8):1121-1127.DOI:10.1111/j.1440-1843.2009.01640.x.
[14]Denning DW, O'Driscoll BR, Powell G, et al. Randomized controlled trial of oral antifungal treatment for severe asthma with fungal sensitization:The Fungal Asthma Sensitization Trial(FAST)study[J]. Am J Respir Crit Care Med, 2009, 179(1):11-18. DOI:10.1164/rccm.200805-737oc.
[15]彭娟,韩锋锋,杨天芸,等.变应性支气管肺曲霉病四例临床分析并文献复习[J].中国呼吸与危重监护杂志, 2015, 14(5):456-461. DOI:10.7507/1671-6205.2015112.