中华儿科杂志
中華兒科雜誌
중화인과잡지
Chinese Journal of Pediatrics
2009年
10期
730-734
,共5页
张晓艳%赵顺英%钱素云%胡英慧%曾津津%江载芳
張曉豔%趙順英%錢素雲%鬍英慧%曾津津%江載芳
장효염%조순영%전소운%호영혜%증진진%강재방
儿童%曲霉菌病%诊断%治疗
兒童%麯黴菌病%診斷%治療
인동%곡매균병%진단%치료
Children%Aspergillosis%Diagnosis%Treatment
目的 总结非血液病患儿侵袭性肺曲霉病(IPA)的诊断和治疗.方法回顾性分析2002年6月-2008年7月期间北京儿童医院确诊或临床诊断的21例非血液病患儿发生IPA的高危因素、临床和影像学表现、微生物学检查、病理学检查以及治疗和预后.结果 确诊5例,临床诊断16例,其中急件IPA 13例,慢性坏死性肺曲霉病8例.高危因素:确诊原发性免疫缺陷病6例,可疑原发性免疫缺陷病3例;使用广谱抗生素、糖皮质激素5例;有肺部基础疾病3例;白细胞减少1例;3例患儿无明显宿主因素.临床和影像学表现:所有患儿均有发热、咳嗽.所有的急性IPA患儿影像均可见双肺多发结节样或刚块状实变阴影,伴空洞形成,10例有"空气新月征".所有的慢性坏死性肺曲霉病患儿均可见单侧肺大叶实变伴有局部胸膜肥厚,实变区有空洞形成.微生物学检查:急性IPA和慢性坏死性肺曲霉病患儿痰和(或)支气管肺泡灌洗液培养的总阳性率分别为72.1%和22.4%.所有培养阳性的痰液和(或)支气管肺泡灌洗液直接涂片均发现有大量典型的曲霉菌丝.病理学检查:3例慢性坏死性肺曲霉病患儿行肺活检,病理学检查结果 均提示肺组织坏死,有肉芽肿性炎症,PAS染色找到曲霉菌丝和孢子.治疗和预后:15例采用两性霉素B、伏立康唑、伊曲康唑及卡泊芬净单用或联合应用,12例治疗有效;3例治疗无效死亡,该3例患儿均发生肺外播散.6例患儿未接受治疗,均死亡.两性霉素B的不良反应主要为寒战、高热、低钾血症和一过性的BUN升高.患儿对伏立康唑、卡泊芬净耐受性好,未发现明显不良反应.结论 发生于非血液病儿童的IPA绝大多数有高危因素或环境暴露史,影像学表现有相对的提示性.宿主(危险)因素和影像学表现是临床考虑IPA的重要线索,蕈复痰液病原学检查是临床诊断的关键.早期两性霉素B、伏立康唑、伊曲康唑单用或联合用药可控制病情.
目的 總結非血液病患兒侵襲性肺麯黴病(IPA)的診斷和治療.方法迴顧性分析2002年6月-2008年7月期間北京兒童醫院確診或臨床診斷的21例非血液病患兒髮生IPA的高危因素、臨床和影像學錶現、微生物學檢查、病理學檢查以及治療和預後.結果 確診5例,臨床診斷16例,其中急件IPA 13例,慢性壞死性肺麯黴病8例.高危因素:確診原髮性免疫缺陷病6例,可疑原髮性免疫缺陷病3例;使用廣譜抗生素、糖皮質激素5例;有肺部基礎疾病3例;白細胞減少1例;3例患兒無明顯宿主因素.臨床和影像學錶現:所有患兒均有髮熱、咳嗽.所有的急性IPA患兒影像均可見雙肺多髮結節樣或剛塊狀實變陰影,伴空洞形成,10例有"空氣新月徵".所有的慢性壞死性肺麯黴病患兒均可見單側肺大葉實變伴有跼部胸膜肥厚,實變區有空洞形成.微生物學檢查:急性IPA和慢性壞死性肺麯黴病患兒痰和(或)支氣管肺泡灌洗液培養的總暘性率分彆為72.1%和22.4%.所有培養暘性的痰液和(或)支氣管肺泡灌洗液直接塗片均髮現有大量典型的麯黴菌絲.病理學檢查:3例慢性壞死性肺麯黴病患兒行肺活檢,病理學檢查結果 均提示肺組織壞死,有肉芽腫性炎癥,PAS染色找到麯黴菌絲和孢子.治療和預後:15例採用兩性黴素B、伏立康唑、伊麯康唑及卡泊芬淨單用或聯閤應用,12例治療有效;3例治療無效死亡,該3例患兒均髮生肺外播散.6例患兒未接受治療,均死亡.兩性黴素B的不良反應主要為寒戰、高熱、低鉀血癥和一過性的BUN升高.患兒對伏立康唑、卡泊芬淨耐受性好,未髮現明顯不良反應.結論 髮生于非血液病兒童的IPA絕大多數有高危因素或環境暴露史,影像學錶現有相對的提示性.宿主(危險)因素和影像學錶現是臨床攷慮IPA的重要線索,蕈複痰液病原學檢查是臨床診斷的關鍵.早期兩性黴素B、伏立康唑、伊麯康唑單用或聯閤用藥可控製病情.
목적 총결비혈액병환인침습성폐곡매병(IPA)적진단화치료.방법회고성분석2002년6월-2008년7월기간북경인동의원학진혹림상진단적21례비혈액병환인발생IPA적고위인소、림상화영상학표현、미생물학검사、병이학검사이급치료화예후.결과 학진5례,림상진단16례,기중급건IPA 13례,만성배사성폐곡매병8례.고위인소:학진원발성면역결함병6례,가의원발성면역결함병3례;사용엄보항생소、당피질격소5례;유폐부기출질병3례;백세포감소1례;3례환인무명현숙주인소.림상화영상학표현:소유환인균유발열、해수.소유적급성IPA환인영상균가견쌍폐다발결절양혹강괴상실변음영,반공동형성,10례유"공기신월정".소유적만성배사성폐곡매병환인균가견단측폐대협실변반유국부흉막비후,실변구유공동형성.미생물학검사:급성IPA화만성배사성폐곡매병환인담화(혹)지기관폐포관세액배양적총양성솔분별위72.1%화22.4%.소유배양양성적담액화(혹)지기관폐포관세액직접도편균발현유대량전형적곡매균사.병이학검사:3례만성배사성폐곡매병환인행폐활검,병이학검사결과 균제시폐조직배사,유육아종성염증,PAS염색조도곡매균사화포자.치료화예후:15례채용량성매소B、복립강서、이곡강서급잡박분정단용혹연합응용,12례치료유효;3례치료무효사망,해3례환인균발생폐외파산.6례환인미접수치료,균사망.량성매소B적불량반응주요위한전、고열、저갑혈증화일과성적BUN승고.환인대복립강서、잡박분정내수성호,미발현명현불량반응.결론 발생우비혈액병인동적IPA절대다수유고위인소혹배경폭로사,영상학표현유상대적제시성.숙주(위험)인소화영상학표현시림상고필IPA적중요선색,심복담액병원학검사시림상진단적관건.조기량성매소B、복립강서、이곡강서단용혹연합용약가공제병정.
Objective To explore diagnosis and treatments of invasive pulmonary aspergillosis (IPA) in children with non-hematologic diseases. Method Twenty one patients without hematological malignancy were diagnosed with proven or possible IPA from July 2002 to June 2008. The risk factors, clinical manifestations, chest radiographic findings, microbiological and histopathological evidence, diagnostic procedures, treatment and prognosis were retrospectively reviewed. Result Five children had proven IPA, and 16 patients had possible IPA. Thirteen children were classified as having acute invasive pulmonary asergillosis (AIPA), eight children as having chronic necrotizing pulmonary aspergillosis (CNPA). Definitive diagnosis of primary immunodeficiency (PID) was made in 6 children (4 with chronic granulomatous disease, 2 with cellular immunodeficiency); three children were suspected of having PID. Corticosteroids and multiple broad-spectrum antibiotics had been administered in 5 patients (3 of these 5 patients also had invasive mechanical ventilation). Two children had underlying pulmonary disease. Three patients had unknown risk factors. Among these three patients, two had history of environmental exposure. Fever and cough were present in all the children. Fine rales were found in nineteen children. Six children had hepatosplenomegaly. The common roentgenographic feature of AIPA in 13 patients was nodular or mass-like consolidation with multiple cavity. "air-crescent" was seen in 10 of patients with AIPA. Lobar consolidation with cavity and adjacent pleural thickening was found in all children with CNPA. The positive rate of sputum and/or BALF culture in MPA and CNFA were 72.1% and 22.4%, respectively. A large number of septate hyphae on wet smear were found in all of the children whose sputum and/or BALF culture were positive. Lung biopsy was performed in 3 children with CNPA, and necrosis, granulomatous inflammation, as well as septate, branching hyphae were observed on histopathologic examination. Fifteen children were treated with anti-fungal therapy (amphotericin B, voriconazole, traconszole and caspofungin used alone or in combination), symptoms and lung lesions resolved in 12 children. Three children died. Six children did not receive anti-fungal therapy and died. The side effects of amphotericin B include chill, fever, hypokalemia and transient increase in BUN, none of which needed discontinuation of the antifungal therapy. Children had a good tolerance to fluconazole and caspofungin, there were no apparent side effects. Conclusion Most of the children without hematologic diseases who suffered from invasive pulmonary aspergillosis had risk factors or exposure history. Roentgenographic findings were relatively characteristic for invasive pulmonary aspergillosis. Risk factors and roentgenographic findings were clues to consider clinically invasive pulmonary aspergillosis. Sputum culture was the key point to clinical diagnosis. The patients in whom the antifugal therapy was initiated early had a good outcome.
