侵袭性气管支气管曲霉病8例临床分析
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摘要
目的探讨非经典免疫功能缺陷者气管支气管曲霉病的临床特点、胸部CT及支气管镜表现、治疗及预后。方法回顾性分析2016年1月-2018年5月漳州正兴医院、厦门大学附属东南医院收治的8例非经典免疫功能缺陷者气管支气管曲霉病临床资料。结果 8例患者,男7例,女1例;5例有慢性阻塞性肺疾病(COPD),3例无基础病;临床症状主要是呼吸困难,发热,咳嗽、咯痰,其中呼吸困难尤为突出。血清半乳甘露聚糖(GM)值升高5例、正常3例,肺泡灌洗液GM值均升高。胸部CT影像主要表现是气管支气管管壁增厚,树芽征,沿支气管分布片状影或结节影,气管支气管僵硬。支气管镜检查表现主要是气管支气管管壁白色伪膜或白色结节状物,气管支气管黏膜充血,单发或多发黏膜表面溃疡,受侵犯的气道黏膜外观不规则并管腔狭窄。培养以烟曲霉为主。病理检查见曲霉菌丝及孢子。主要采用伏立康唑抗真菌治疗,7例治愈,1例死亡。结论气管支气管曲霉病临床表现无特异性,容易延误诊断。支气管镜检查对气管支气管曲霉病及早诊断起决定性作用。早期诊治对本病预后非常重要;危重患者联合抗真菌治疗能提高患者治愈机会。
Objective To examine the clinical manifestation, chest CT images, bronchoscopy findings, management and prognosis of tracheobronchial aspergillosis in patients with common variable immunodeficiency disease. Methods The patients with tracheobronchial aspergillosis and common variable immunodeficiency disease were identified in Zhangzhou Zhengxing Hospital and Xiamen University Affiliated Dongnan Hospital from January 2016 to May 2018. The clinical data of the 8 identified patients were reviewed retrospectively. Results Of the 8 patients(male 7, female 1), 5 had underlying disease(chronic obstructive pulmonary disease). The main clinical symptoms included dyspnea, fever, cough, and expectoration, especially dyspnea. Glucomannan(GM)level increased in serum in 5 cases, and increased in bronchoalveolar lavage in all cases. Chest CT images showed thickening of tracheal wall, tree-in-bud sign, patchy or nodular opacities along bronchi, and tracheobronchial stiffness. Bronchoscopy showed white pseudomembrane or white nodules on tracheal or bronchial wall. Tracheal and bronchial mucosa were congested with single or multiple ulcers on mucosal surface. The mucosa of the involved airway was irregular in appearance associated with luminal stenosis.Aspergillus fumigatus was the most frequently isolated pathogen. Aspergillus filaments were found in pathological examination.Most of the patients received treatment with voriconazole. As result, 7 patients were cured and 1 died. Conclusions The clinical manifestation of tracheobronchial aspergillosis is not specific. So the diagnosis is easily delayed. Bronchial examination plays a decisive role in early diagnosis of tracheobronchial aspergillosis.Early diagnosis and treatment are very important for improving the outcome of the disease. Combined antifungal therapy can increase the chance of cure in critically ill patients.
Objective To examine the clinical manifestation, chest CT images, bronchoscopy findings, management and prognosis of tracheobronchial aspergillosis in patients with common variable immunodeficiency disease. Methods The patients with tracheobronchial aspergillosis and common variable immunodeficiency disease were identified in Zhangzhou Zhengxing Hospital and Xiamen University Affiliated Dongnan Hospital from January 2016 to May 2018. The clinical data of the 8 identified patients were reviewed retrospectively. Results Of the 8 patients(male 7, female 1), 5 had underlying disease(chronic obstructive pulmonary disease). The main clinical symptoms included dyspnea, fever, cough, and expectoration, especially dyspnea. Glucomannan(GM)level increased in serum in 5 cases, and increased in bronchoalveolar lavage in all cases. Chest CT images showed thickening of tracheal wall, tree-in-bud sign, patchy or nodular opacities along bronchi, and tracheobronchial stiffness. Bronchoscopy showed white pseudomembrane or white nodules on tracheal or bronchial wall. Tracheal and bronchial mucosa were congested with single or multiple ulcers on mucosal surface. The mucosa of the involved airway was irregular in appearance associated with luminal stenosis.Aspergillus fumigatus was the most frequently isolated pathogen. Aspergillus filaments were found in pathological examination.Most of the patients received treatment with voriconazole. As result, 7 patients were cured and 1 died. Conclusions The clinical manifestation of tracheobronchial aspergillosis is not specific. So the diagnosis is easily delayed. Bronchial examination plays a decisive role in early diagnosis of tracheobronchial aspergillosis.Early diagnosis and treatment are very important for improving the outcome of the disease. Combined antifungal therapy can increase the chance of cure in critically ill patients.
引文
[1]FRANQUET T,MüLLER N L,OIKONOMOU A,et al.Aspergillus infection of the airways:computed tomography and pathologic findings[J].J Comput Assist Tomogr,2004,28(1):10-16.
[2]KRENKE R,GRABCZAK E M.Tracheobronchial manifestations of aspergillus infections[J].Scientificworldjournal,2011,11:2310-2329.
[3]XU X Y,SUN H M,ZHAO B L,et al.Diagnosis of airwayinvasive pulmonary aspergillosis by tree-in-bud sign in an immunocompetent patient:case report and literature review[J].J Mycol Med,2013,23(1):64-69.
[4]MOHAN A,GULERIA R,MUKHOPADHYAYA S,et al.Invasive tracheobronchial aspergillosis in an immunocompetent person[J].Am J Med Sci,2005,329(2):107-109.
[5]PATTERSON T F,THOMPSON G R 3rd,DENNING D W,et a1.Practice guidelines for the diagnosis and management of aspergillosis:2016 update by the Infectious Diseases Society of America[J].Clin Infect Dis,2016,63(4):el-e60.
[6]王继旺,查王健,黄茂,等.经可弯曲气管镜治疗阻塞型气道侵袭性曲霉病并呼吸衰竭二例[J].中华结核和呼吸杂志,2013,36(9):702-704.
[7]赵伟业,刘菁,刘学东.曲霉气管支气管炎4例临床分析[J].中国感染与化疗杂志,2017,17(1):19-23.
[8]WU N,HUANG Y,LI Q,et al.Isolated invasive Aspergillus tracheobronchitis:a clinical study of 19 cases[J].Clin Microbiol Infect,2010,16(6):689-695.
[9]KARNAK D,AVERY R K,GILDEA T R,et al.Endobronchial fungal disease:an under-recognized entity[J].Respiration,2007,74(1):88-104.
[10]王虹,万毅新,王晓平,等.气道侵袭性曲霉病1例并文献复习[J].国际呼吸杂志,2011,31(24):1845-1848.
[11]朱亚茜,马淑萍,杜岩,等.气道侵袭性曲霉病一例[J].中华结核和呼吸杂志,2017,40(12):948-950.
[12]ZHENG X,SHAO J,XU J.Airway obstruction due to invasive tracheobronchial aspergillosis[J].Am J Med Sci,2016,352(2):218.
[13]李玉苹,陈成水,叶民,等.无免疫缺陷者侵袭性气道肺曲霉病的支气管镜和胸部CT表现[J].中华结核和呼吸杂志,2009,32(6):439-443.
[14]叶健,王利民,黄晟,等.阻塞性支气管曲霉病一例[J].中华结核和呼吸杂志,2005,28(11):806-807.
[15]李云,张亮,杨蕾,等.气道侵袭性肺曲霉菌病MSCT表现[J].实用放射学杂志,2018,34(4):529-532.
[16]PARK S Y,LIM C,LEE S O,et al.Computed tomography findings in invasive pulmonary aspergillosis in non-neutropenic transplant recipients and neutropenic patients,and their prognostic value[J].J Infect,2011,63(6):447-456.
[17]KIM J H,LEE H L,KIM L,et al.Airway centered invasive pulmonary aspergillosis in an immunocompetent patient:case report and literature review[J].J Thorac Dis,2016,8(3):E250-254.
[18]陈林桂,黄怡.气管镜在侵袭性气管支气管曲霉菌病诊治中的应用价值[J].临床肺科杂志,2018,23(6):1062-1068.
[19]DE PAUW B,WALSH T J,DONNELLY J P,et al.Revised definitions of invasive fungal disease from the European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and the National Institute of Allergy and Infectious Diseases Mycoses Study Group(EORTC/MSG)Consensus Group[J].Clin Infect Dis,2008,46(12):1813-1821.
[2]KRENKE R,GRABCZAK E M.Tracheobronchial manifestations of aspergillus infections[J].Scientificworldjournal,2011,11:2310-2329.
[3]XU X Y,SUN H M,ZHAO B L,et al.Diagnosis of airwayinvasive pulmonary aspergillosis by tree-in-bud sign in an immunocompetent patient:case report and literature review[J].J Mycol Med,2013,23(1):64-69.
[4]MOHAN A,GULERIA R,MUKHOPADHYAYA S,et al.Invasive tracheobronchial aspergillosis in an immunocompetent person[J].Am J Med Sci,2005,329(2):107-109.
[5]PATTERSON T F,THOMPSON G R 3rd,DENNING D W,et a1.Practice guidelines for the diagnosis and management of aspergillosis:2016 update by the Infectious Diseases Society of America[J].Clin Infect Dis,2016,63(4):el-e60.
[6]王继旺,查王健,黄茂,等.经可弯曲气管镜治疗阻塞型气道侵袭性曲霉病并呼吸衰竭二例[J].中华结核和呼吸杂志,2013,36(9):702-704.
[7]赵伟业,刘菁,刘学东.曲霉气管支气管炎4例临床分析[J].中国感染与化疗杂志,2017,17(1):19-23.
[8]WU N,HUANG Y,LI Q,et al.Isolated invasive Aspergillus tracheobronchitis:a clinical study of 19 cases[J].Clin Microbiol Infect,2010,16(6):689-695.
[9]KARNAK D,AVERY R K,GILDEA T R,et al.Endobronchial fungal disease:an under-recognized entity[J].Respiration,2007,74(1):88-104.
[10]王虹,万毅新,王晓平,等.气道侵袭性曲霉病1例并文献复习[J].国际呼吸杂志,2011,31(24):1845-1848.
[11]朱亚茜,马淑萍,杜岩,等.气道侵袭性曲霉病一例[J].中华结核和呼吸杂志,2017,40(12):948-950.
[12]ZHENG X,SHAO J,XU J.Airway obstruction due to invasive tracheobronchial aspergillosis[J].Am J Med Sci,2016,352(2):218.
[13]李玉苹,陈成水,叶民,等.无免疫缺陷者侵袭性气道肺曲霉病的支气管镜和胸部CT表现[J].中华结核和呼吸杂志,2009,32(6):439-443.
[14]叶健,王利民,黄晟,等.阻塞性支气管曲霉病一例[J].中华结核和呼吸杂志,2005,28(11):806-807.
[15]李云,张亮,杨蕾,等.气道侵袭性肺曲霉菌病MSCT表现[J].实用放射学杂志,2018,34(4):529-532.
[16]PARK S Y,LIM C,LEE S O,et al.Computed tomography findings in invasive pulmonary aspergillosis in non-neutropenic transplant recipients and neutropenic patients,and their prognostic value[J].J Infect,2011,63(6):447-456.
[17]KIM J H,LEE H L,KIM L,et al.Airway centered invasive pulmonary aspergillosis in an immunocompetent patient:case report and literature review[J].J Thorac Dis,2016,8(3):E250-254.
[18]陈林桂,黄怡.气管镜在侵袭性气管支气管曲霉菌病诊治中的应用价值[J].临床肺科杂志,2018,23(6):1062-1068.
[19]DE PAUW B,WALSH T J,DONNELLY J P,et al.Revised definitions of invasive fungal disease from the European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and the National Institute of Allergy and Infectious Diseases Mycoses Study Group(EORTC/MSG)Consensus Group[J].Clin Infect Dis,2008,46(12):1813-1821.