摘要
目的分析累及中央气道的真菌感染患者的临床特征。方法本研究为病例系列研究,采用非随机抽样法收集2023年1月至2024年4月于应急总医院呼吸与危重症医学科住院的8例累及中央气道的真菌感染患者为研究对象。收集整理患者的人口统计学特征、病史、临床表现、实验室检查、影像学表现、支气管镜检查、病原学检查、组织病理表现、治疗和转归等临床资料。结果8例累及中央气道的真菌感染患者中,男4例,女4例,年龄22~71岁。单纯毛霉菌感染5例,单纯曲霉菌感染2例,混合感染1例。所有患者均有糖尿病基础病史,合并结核性胸膜炎1例、新型冠状病毒感染1例、慢性胰腺炎1例、慢性肾功能不全1例。主要临床表现为呼吸困难伴咳嗽、咳痰,伴或不伴发热。急性感染期胸部CT显示气管和(或)支气管管壁增厚,管腔狭窄,管腔内可见新生物样物质。支气管镜下早期可见管腔内大量坏死物堵塞管腔,清理坏死物后可见软骨破坏甚至断裂,黏膜糜烂,管壁软化塌陷;后期可见肉芽增生、瘢痕形成,管腔塌陷狭窄。支气管镜下分泌物刷片荧光快速现场评估(ROSE)和组织涂片荧光ROSE的检测阳性率分别为100%(7/7)和66.7%(4/6),8例患者支气管肺泡灌洗液(BALF)培养均阴性,BALF联合组织宏基因组二代测序(mNGS)的检测阳性率为100%(8/8),8例患者组织活检病理均检出真菌。8例患者均给予全身抗真菌、雾化吸入两性霉素B脱氧胆酸盐和支气管镜下局部灌注治疗,并在硬质支气管镜下给予介入治疗,包括二氧化碳冷冻冻取(6例)和(或)圈套器圈套(6例)去除坏死物、支架置入(4例)、球囊扩张(6例)和二氧化碳冷冻冻融(5例)等治疗,所有患者的症状均得到改善。治疗后气促评分、CT下测量气道狭窄程度均较治疗前下降[(0.88±0.64)分比(3.13±0.64)分,(26.3±11.9)%比(92.5±8.9)%,均P<0.05]。结论累及中央气道的真菌感染可导致呼吸困难,严重者可危及生命,支气管镜下分泌物刷片荧光ROSE和组织涂片荧光ROSE、BALF或组织mNGS检测有助于早期病原学诊断,支气管镜检查有助于早期诊断并快速缓解气道狭窄,治疗需全身药物治疗结合支气管镜下介入治疗,管腔狭窄严重的可行气道支架置入。
ObjectiveTo analyze the clinical characteristics of patients with fungal infection involving the central airway.MethodsThis was a case series study.A total of 8 patients with fungal infection involving the central airway who were hospitalized in the Department of Respiratory and Critical Care Medicine of Emergency General Hospital from January 2023 to April 2024 were collected by the non-random sampling.Demographic characteristics,medical history,clinical manifestations,laboratory testing,imaging findings,bronchoscopy,pathogen examination,histopathological manifestations,treatment,and outcomes were collected.ResultsThe data of 8 patients with fungal infection affecting the central airway were collected,including 4 males and 4 females,with the age of 22-71 years.There were 5 cases of mucormycosis,2 cases of aspergillus,and 1 case of mixed infection.All patients had underlying diseases of diabetes,and there were 1 case of tuberculous pleurisy,1 case of coronavirus disease 2019,1 case of chronic pancreatitis,and 1 case of chronic renal insufficiency.The main clinical manifestations were dyspnea with cough and sputum,with or without fever.Chest computed tomography(CT)showed thickening of the tracheal and/or bronchial walls,narrowing of the lumen,and the presence of new biological-like substances within the lumen during the acute infection phase.Bronchoscopy showed a large amount of necrotic material blocking the lumen in the early stage.After cleaning the necrotic material,cartilage damage or even fracture,mucosal erosion,wall softening and collapse could be observed.Granulation hyperplasia,scar formation,collapse and narrowing of the lumen were seen in the later stage.Positivity for the secretion brush and tissue smear fluorescence rapid on-site evaluation(F-ROSE)was 100%(7/7)and 66.7%(4/6),respectively.Negativity for bronchoalveolar lavage fluid(BALF)culture was detected in 8 cases.Positivity for BALF combined with the metagenomic next-generation sequencing(mNGS)in tissue was 100%(8/8),and 8 cases showed positive tissue biopsy.All patients were treated with systemic antifungal therapy,amphotericin B deoxycholate aerosol inhalation and local perfusion under bronchoscope.Bronchoscopic interventional therapy was performed under rigid bronchoscope,including carbon dioxide cryopreservation(6 cases)and/or snare trapping(6 cases)to remove necrotic materials,stent placement(4 cases),balloon dilation(6 cases),and carbon dioxide freezing-thawing(5 cases).The symptoms of all patients were improved.The dyspnea score(0.88±0.64 points vs 3.13±0.64 points)and degree of airway stenosis(26.3%±11.9%vs 92.5%±8.9%)measured under CT significantly decreased compared with pre-treatment values(both P<0.05).ConclusionFungal infection affecting the central airway can lead to breathing difficulties,and can be life-threatening in severe cases.F-ROSE examination of secretion brush or tissue smear,and mNGS detection of BALF or tissue both attributes to the early etiologic diagnosis.Bronchoscopy can help with early diagnosis and rapid relief of airway stenosis.Treatment requires systemic drug therapy combined with bronchoscopic interventional therapy.Stent placement is feasible for severe airway stenosis.
作者
高永平
陈小艳
常鑫
张洁莉
秦芳
王书方
付怀秀
郑敏
荆蕾
周云芝
Gao Yongping;Chen Xiaoyan;Chang Xin;Zhang Jieli;Qin Fang;Wang Shufang;Fu Huaixiu;Zheng Min;Jing Lei;Zhou Yunzhi(Department of Respiratory and Critical Care Medicine,Emergency General Hospital,Beijing 100028,China;Department of Pathology,Emergency General Hospital,Beijing 100028,China;Department of Medical Imaging,Emergency General Hospital,Beijing 100028,China)
出处
《国际呼吸杂志》
2025年第5期390-397,共8页
International Journal of Respiration
关键词
肺疾病
真菌性
肺曲霉菌病
毛霉菌病
中央气道狭窄
支气管镜
介入治疗
Lung diseases,fungal
Pulmonary aspergillosis
Mucormycosis
Central airway stenosis
Bronchoscopes
Interventional therapy
