摘要
目的探讨急性白血病患者并发侵袭性肺部真菌感染(IPFI)的临床特点。方法对2005年1月至2010年1月共54例并发IPFI的急性白血病患者的临床特征进行回顾性分析。结果 54例IPFI患者确诊4例,临床诊断35例,拟诊病例15例。住院天数>14 d(P=0.02)、使用含激素的联合化疗方案、广谱抗生素使用时间>7 d、中性粒细胞缺乏时间>5 d、合并全身性疾病如糖尿病是发生IPFI的高危易感因素。其临床表现无特异性包括稽留热或不规则发热、咳嗽咳痰,部分患者表现为单纯胸闷或呼吸困难。影像学改变复杂多变:临床考虑曲霉菌感染者胸部CT呈多发或散在斑片影、结节影或两者同时存在,或伴空洞形成,并且病灶靠近胸膜处;临床考虑为念珠菌属感染者,多表现为肺部弥漫斑片影,或合并存在小结节影,但是很少伴有空洞形成。菌种分布提示近5年来曲霉菌属感染的比例明显上升,占43.6%(而1998年1月至2005年1月曲霉菌属感染仅占19.4%),念珠菌属构成比明显下降。治疗药物主要选用针对曲霉菌属的抗真菌治疗药物,包括二性霉素B脂质体、伏立康唑等,平均抗真菌治疗疗程15～30 d,治愈22例,明显好转25例,仅7例患者死亡(13%)。结论急性白血病患者具有IPFI发生的多种高危因素,具有临床表现无特异性、影像学改变复杂多变、曲霉菌属感染比例明显上升等特点,经验治疗和抢先治疗是目前最主要的治疗策略。为了进一步减少IPFI的病死率,建议在高分辨CT的基础上,开展真菌血清免疫学(G/GM试验)等研究,以期早期诊断,早期治疗。
Objective To investigate the clinical characteristics of the acute leukemia patients which combined with invasive pulmonary fungal infections（IPFI）.Methods Fifty-four patients of IPFI during Jan 2005 to Jan 2010 were enrolled in this investigation,of which clinical manifestation,fungal spectrum,treatment and outcome were observed retrospectively.Results The hospitalized day longer than 14 days,chemotherapy approaches combined with glucocorticoids,broad-spectrum antibiotics using 7 days and agranulocytosis persistence 5 days,associated with general conditions such as diabetes mellitus were all the high risk factors for IPFI in hematological malignancies.The symptoms of IPFI were non-specific and mostly presented with fever,cough,emptysis,and dyspnea,etc.The common imaging features which varied with different fungal species,included multiple nodules,infiltrates and consolidations,or cavities（especilly in aspergillus infection）,or diffused lesions in bilateral lungs（especilly in Candida albicans infection） were found in most IPFI patients.The most common fungal subtypes were aspergillus which morbidity increased to 43.6% in these 5 years,but the incidence of Candida albicans infection were decreased to 35.9%.The the main drugs for treatment of IPFI were liposomal amphotericin B and voriconazole,with an average course of 15 to 30 days,and 22 cases cured,25 cases significantly improved,only 7 patients died（13%）.Conclusion The occurrence of IPFI combined with acute leukemia correlated with multiple high risk factors.It is characterized with no specific clinical manifestations,complexable changes in imaging findings,and significantly increased proportion of Aspergillus species.Nowadays,Empirical treatment and preemptive therapy are the most important treatment strategies in our department.To further reduce the mortality IPFI,it is recommended to carry out fungal serological（G / GM test） and other research,combined with high-resolution chest CT,to perform the early diagnosis and early treatment.
出处
《安徽医学》
2011年第10期1691-1695,共5页
Anhui Medical Journal
