摘要
目的分析诺卡菌感染病例的临床特点，提高对该病的诊治水平。方法回顾性分析北京协和医院1990年1月至2010年1月收治的26例诺卡菌感染病例的临床资料。结果26例中，男10例，年龄29～80岁，平均（52±14）岁；女16例，年龄15～71岁，平均（42±17）岁。其中增殖性疾病2例，慢性肾病3例（1例接受肾移植），糖尿病、胸部外伤史及库欣综合征各1例，无基础病、自身免疫病及慢性肺部疾病者各6例；26例中11例曾服用过糖皮质激素。临床表现为中高度发热25例，咳嗽22例，咳痰19例，胸膜炎性胸痛10例，咯血8例，肺部湿性哕音10例，5例合并皮肤感染，4例合并颅内脓肿。影像学表现为肺部斑片状及实变影21例，空洞10例。合并胸腔积液13例，双侧胸部受累15例。26例中仅4例经合格痰培养确诊，胸腔积液培养阳性8例，BALF培养阳性2例，支气管镜下吸取物培养阳性1例，皮下脓肿液培养阳性4例，CT引导下经皮肺穿刺组织培养阳性7例，颅内病变部位组织培养阳性1例；细菌培养结果显示，巴西诺卡菌9例，星形诺卡菌6例，豚鼠耳炎诺卡菌1例及未能分类的诺卡菌10例；药敏试验结果遗失10例，7株耐磺胺甲嚼唑／甲氧苄啶。治疗及转归：5例单用磺胺甲嘧唑／甲氧苄啶治疗，1例单用米诺环素治疗，其余均为2种及以上药物的联合治疗（包括磺胺甲瑶唑／甲氧苄啶、阿米卡星、头孢呋辛、头孢曲松、阿莫西林＋克拉维酸、链霉素、左氧氟沙星、环丙沙星、米诺环素和亚胺培南等）。4例死亡，2例复发，其余20例均治愈。结论机体抵抗力下降的患者，尤其是使用糖皮质激素者，出现中高度发热及呼吸系统症状、合并皮肤感染及颅内脓肿、胸部影像学显示斑片状或实变影，特别是合并空洞及胸腔积液时，应警惕诺卡菌感染的可能；尽早获取病原学及药敏试验结果，并给予早期、足疗程治疗，可以改善患者的预后。
Objective To describe the clinical characteristics of nocardiosis. Method The clinical and radiological data of 26 patients with nocardosis admitted into Peking Union Medical College Hospital from 1^st January 1990 to 1 ^st January 2010 were retrospectively analyzed. All of the patients had our microbiology laboratory identified nocardia species in one or more clinical specimens. Results Nocardiosis was diagnosed in 10 men, aged from 29 to 80 years, mean （52 ± 14）years, and in 16 women, aged from 15 to 71 years, mean （42 ± 17）years. No cases were identified in children. Six patients had no significant underlying conditions, while the other patients had at least one underlying condition, including autoimmune diseases （ n = 6 ）, chronic lung disease （ n = 6）, neoplastic disease （ n = 2 ）, chronic renal disease （ n = 3 ）, diabetes mellitus （ n = 1 ）, chest crush injuries （ n = 1 ） and Cushing＇ s syndrome （ n = 1 ）. Eleven cases had been receiving corticosteroids. The most common manifestations were moderate to high fever （ n = 25 ）, cough （ n = 22）, expectoration（ n = 19） , pleuritic chest pain （ n = 10 ）, hemoptysis （ n = 8 ） and moist rales（ n = 10）. Some of them had subcutaneous（ n = 5） and brain abscess（ n = 4）. Blood tests showed elevated ESR in 14 cases and decreased albumin levels in 14 cases. Patchy infiltrates or consolidation （ n = 21 ） and cavitations（ n = 10） were the main manifestations of chest radiology. Pleural effusions（ n = 13 ） were common complicated manifestations. Thoracic lesions were always bilateral （n = 15 ）. Only 4 patients were diagnosed by sputum culture. The other patients were diagnosed by culture of specimens obtained invasively：8 positive pleural effusions, 2 positive bronchioalveolar lavage culture, 1 positive bronchial washings, 4 positive abscesses,7 positive lung tissues, and 1 positive brain abscess. Nocardia brasiliensis （n = 9） and Nocardia asteroids（ n = 6） were the main species. There was one case with Nocardia otitisdiscaviarium infection and the other cases with Nocardia undifferentiated. Result of antimicrobial susceptibility was unavailable in l0 cases. Among the other 16 results, 7 strains of nocardia were resistant to trimethoprim sulfamethoxazole （TMPco）. Six cases were treated with a single drug, 5 cases with trimethoprim-sulfamethoxazole and 1 with minocycline. The other patients were given combination treatment,including trimethoprim-sulfamethoxazole, amikacin, cefuroxime, ccftriaxone, amoxicillin- clavulanic acid, streptomycin, evofloxacin, ciprofloxacin, minocycline and imipenem. Four patients died, 2 patients relapsed and the other 20 cases cured. Conclusions For immunosuppressed patients, nocardia infections should be considered when they had moderate to high fever and respiratory manifestations, especially accompanied with subcutaneous and/or brain abscess, and the chest radiology showed patchy infiltrates and/or consolidations. Further specific microbiological studies and sufficient therapy should be obtained as quickly as possible.
出处
《中华结核和呼吸杂志》
CAS
CSCD
北大核心
2010年第9期651-655,共5页
Chinese Journal of Tuberculosis and Respiratory Diseases
关键词
真菌
感染
诺卡菌
Fungi
Infection
Nocardiosis
