摘要
目的分析肝衰竭患者并发侵袭性肺曲霉病的临床特征,提高对曲霉病的早期识别。方法回顾性分析上海市公共卫生临床中心2006年1月-2011年5月收治的39例肝衰竭合并侵袭性肺曲霉病(IPA)患者的临床资料;组间均数比较采用t检验或非参数检验,计数资料采用χ2检验。结果肝衰竭合并IPA临床表现不典型,首发症状最常见为发热,发生率为66.7%,早期影像学表现以多发结节或团块影为主,1,3-β-D葡聚糖抗原检测结果均为阴性;发生感染后患者血清总胆红素、血肌酐、国际标准化比率、白细胞及终末期肝病模型(MELD)评分显著升高,而白蛋白、球蛋白、血浆凝血酶原活动度、血红蛋白、血小板值明显下降,病情快速恶化;39例患者中,8例抗真菌治疗有效,肝功能好转后出院,其余31例均在发病后<2个月病死,病死率达79.5%;其中住院期间病死17例,从出现首发症状至病死平均时间为(5.3±4.7)d;发生IPA前存活组人口学特征、肝衰竭分期、病因构成与病死组相比差异无统计学意义,但MELD评分好于病死组,存活组确诊时间及开始有效抗真菌治疗均早于病死组;8例存活患者接受棘白菌素抗真菌治疗,其中2例联用伏立康唑,平均疗程(70.9±26.4)d,未出现肝功能反跳的不良反应,耐受性较好。结论肝衰竭合并侵袭性肺曲霉病后病情快速恶化,病死率极高,但临床表现特异性少,早期诊断困难,应提高对曲霉菌属感染的警惕性,早期诊断及治疗有可能改善患者预后。
OBJECTIVE To analyze the clinical features of invasive pulmonary aspergillosis（IPA） in patients with liver failure and to improve the identification of aspergillosis at an early stage.METHODS Medical records of 39 liver failure patients with IPA admitted in Shanghai public health center from Jan 2006 to May 2011were reviewed.T test or non-parametric test was performed for inter-group comparison of means,and chi-square test was performed for enumeration data.RESULTS The clinical features of IPA with liver failure were atypical.The most common initial symptom was fever,accounting for 66.7%.Early imaging showed multiple nodules or masses shadow with negative results in 1,3-β-D glucan test.The patients′ condition rapidly deteriorated after infection accompanied by significantly increased TB,Scr,INR,WBC and MELD score and significantly decreased Alb,Glb,PTA,HB,and PLT.Among the 39 cases,anti-fungal therapy was only effective in 8 patients who were discharged after improvement of hepatic function,while the other 31 patients were dead within 2 months of onset.The mortality rate was 79.5%.17 patients died during hospitalization with an average time of（5.3±4.7） days from the first symptom to death.There was no statistical significance between the survivors and the dead patients in respect of demographic characteristics,stage of liver failure and constitution of cause before IPA.However,the survivors had better MELD scores and received definite diagnosis and effective anti-fungal therapy earlier than dead patients.All the 8 survivors received a long-term treatment with echinocandin including two cases received combination of viriconazole.The mean therapeutic course lasted for（70.9±26.4） days.No serious adverse drug reactions such as hepatic function relapse were observed.The drugs were well tolerated.CONCLUSION Diseasecondition is rapidly deteriorated after liver failure complicated with IPA,with extremely high mortality.However,specific clinical manifestations are rare,making early diagnosis difficult.Vigilance towards Aspergillus infection should be elevated.Early diagnosis and effective antifungal therapy may improve the prognosis of patients.
出处
《中华医院感染学杂志》
CAS
CSCD
北大核心
2012年第4期705-708,共4页
Chinese Journal of Nosocomiology
关键词
肝功能衰竭
侵袭性肺曲霉病
感染
Liver failure
Invasive pulmonary aspergillosis
Infection
