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侵袭性肺曲霉菌感染诊治进展

随着社会老龄化, 抗肿瘤药物、免疫抑制剂和器官移植等治疗的广泛开展, 在危重患者中广谱抗生素药物的长期应用, 与之伴随的是真菌感染发生的逐年增多, 其中侵袭性曲霉菌感染因其感染隐匿, 难以诊治和高死亡率等特点被临床医生所重视。按我国医院感染监控网分析, 医院真菌感染率从1993 ～1996 年的13. 9% 上升至1998 ～1999 年的17. 1% 、1999 ～2000 年的24. 4% 。侵袭曲霉菌病特别是肺部曲霉菌感染多发生在有严重基础疾病的患者,预后差, 病死率达50% ～100% [ 1 ] 。本文回顾相关研究文献中关于侵袭性肺曲霉菌诊治进展, 高危人群, 目前诊断检测技术的临床价值, 抗曲霉菌药物特点和治疗现状。

肺曲霉菌病的外科治疗

目的探讨肺曲霉菌病的临床特点与外科治疗原则。方法回顾分析32例肺曲霉菌病患者的临床资料和手术治疗结果，手术施行采用标准后外侧切口肺叶切除术6例，楔形切除术3例，胸腔镜或胸腔镜辅助改良后外侧微创小切口楔形切除术15例，肺叶切除术6例，肺段切除术2例。结果21例无肺原发疾病，11例有肺原发疾病。痰菌检查阳性率为13．3％（2／15），术前诊断符合率为28．1％（9／32）；术后并发症发生率为15．6％（5／32），其中切口皮下积液、肺膨胀不良各2例，气胸1例；随访32例，随访10～160个月，无咯血或血痰、肺曲霉菌病复发或播散。结论肺曲霉菌病多数无肺原发疾病和症状，无论有否症状均应手术治疗，而微创外科手术治疗并发症少且较轻，是首选的治疗方法。

长期服用糖皮质激素及免疫抑制剂致肺曲霉菌感染一例

Completely Video-assisted Thoracopic Surgery for Pulmonary Aspergilloma: A Case Control Study

ObjectiveTo discuss the possibility and safety of video-assisted thoracoscope surgery for pulmonary aspergilloma. MethodsWe retrospectively analyzed the clinical data of 39 patients with pulmonary aspergilloma in Beijing Chaoyang Hospital between June 2009 and May 2014. The patients were divided into two groups according to their operation method including a conventional thoracotomy surgery group (open group, n=11) and a video-assisted thoracoscope pneumonectomy group (VATS group, n=28). There were 8 male patients and 3 female patients with age of 29-64 (50.7±9.7) years in the open group. There were 13 male patients and 15 female patients with age of 20-75 (55.4±15.3) years in the VATS group. We compared clinical effectiveness between the two groups. ResultsThe operations of all patients were performed successfully. There were statistical differences between the two groups in the average length of operative time (P=0.001), the loss of intraoperative blood (P=0.005), and the score of pain (P=0.001). There was no statistical difference in lead flow of postoperative chest (P>0.05) and the time of hospitalization (P>0.05). ConclusionVideo-assisted thoracoscope surgery in the treatment of pulmonary aspergilloma could be feasible, safe, and effective based on our study. It is worth of clinical application and popularization．

无哮喘的变应性支气管肺曲霉病一例

目的 报道并分析1例变应性支气管肺曲霉病（allergic bronchopulmonary aspergillosis，ABPA）的临床特点、诊断及治疗方法。方法 结合文献资料分析我科2019年诊治的1例ABPA的病例。结果 该患者诊断明确，治疗稍有曲折。ABPA常发生于肺部有基础疾病者，尤其是支气管哮喘或囊性纤维化者。临床表现主要是咳嗽、咳痰、喘息、胸闷；实验室检查血清总IgE水平和曲霉特异性IgE水平上升，以及嗜酸性粒细胞数增加；胸部影像学表现为反复的肺部游走性浸润影和中心性支气管扩张等。治疗包括糖皮质激素和抗真菌治疗，对于不能耐受糖皮质激素的患者，抗IgE抗体治疗有益。结论 临床上ABPA容易误诊、误治，特别是无哮喘病史时，其诊断更加困难。因此早期诊断和正确治疗可以减少ABPA造成的肺损伤，改善患者的预后。

侵袭性肺迟缓曲霉病一例报道

目的 通过本病例及综述以提升对侵袭性肺迟缓曲霉病早期病原学诊断的重视，并为治疗方案提供参考依据。方法 回顾我科诊治的1例COVID-19感染后继发的侵袭性肺迟缓曲霉病患者的临床资料，复习既往文献总结分析肺迟缓曲霉病的临床表现、诊断及治疗用药方案。结果 患者79岁，老年男性，咳嗽、咳痰伴呼吸困难4月余。胸部CT提示：双肺数个结节灶，部分结节内空洞形成；散在实变影。G实验、GM结果阴性。气管镜肺泡灌洗液送检mNGS查见迟缓曲霉菌。给予伏立康唑治疗后效不佳，且继发肝功能异常，调整为艾沙康唑治疗后临床症状及肺部影像学征象好转。复习文献，共有12例个案报道，其中8例存在免疫抑制状态，4例合并慢性阻塞性肺病，6例为器官移植术后。临床选药以伏立康唑和两性霉素B居多，虽经治疗仍有66.7%（8例）患者在确诊后7周内死亡。结论 本例为国内外首次使用艾沙康唑成功治疗侵袭性肺迟缓曲霉病的报告。侵袭性肺迟缓曲霉病属于罕见病，免疫抑制状态是其高危因素。该病进展迅速，具有高度耐药性，预后差，病死率高，早期病原学诊断尤为关键。

Clinical characteristics of patients with Coronavirus Disease 2019-associated pulmonary mucormycosis

ObjectiveTo analyze the clinical characteristics, prognosis and predisposing factors of coronavirus disease 2019 (COVID-19) associated pulmonary mucormycosis (CAPM), so as to improve people's understanding of the disease.MethodsFrom from September 1, 2021 to July 31, 2024, 11 patients with CAPM who were hospitalized in Beijing Chaoyang Hospital affiliated to Capital Medical University were retrospectively collected, and 22 patients with non-CAPM were included after matching according to the ratio of 1:2. The clinical manifestations, laboratory examinations, imaging features, tracheoscopy, treatment and prognosis of the two groups were analyzed. ResultsThe average age of patients in CAPM group was 59.5 ± 10.6 years, with 81.8% of males; diabetes mellitus (90.9%) was the most common complication. In CAPM group, the median time after the occurrence of mucor after COVID-19 was 13.0 (10.0, 24.0) days. The utilization rate of glucocorticoids in the CAPM group was 63.6% (7/11), which was significantly higher than that in non-CAPM group [13.6% (3/22)], and the difference between the groups was statistically significant (P=0.006). The C-reactive protein level in CAPM group was significantly higher at 93.90 (75.00, 129.00) mg/L than that in non-CAPM group at 26.10 (4.83, 114.03) mg/L, with a statistically significant difference (P=0.040). The CD4+T lymphocyte counts and B lymphocyte counts in CAPM group were 223.00 (66.75, 336.75)/µL and 32.00 (21.75, 55.25)/µL, respectively, which were significantly lower than those in the non-CAPM group 394.00 (206.00, 610.00)/µL and 112.50 (56.00, 159.25)/µL, with statistical differences between the groups (P=0.040, P=0.040). In terms of imaging, the main imaging findings were the involvement of multiple lobes in both groups. 63.6% (7/11) of patients with pulmonary aspergillosis in CAPM group were significantly higher than those(4/22, 18.2%) in non-CAPM group (P=0.017). The incidence of dyspnea in CAPM group was significantly higher than that in non-CAPM group (90.9% vs. 50.0%, 0.027%).ConclusionThe proportion of glucocorticoid use and the proportion of pulmonary aspergillosis in CAPM group are significantly higher, and they are in a more serious state of immunosuppression. Once combined with pulmonary aspergillus , the mortality rate is higher.