原发性肺隐球菌病的诊疗——附4例报告

目的探讨肺隐球菌病的临床特征、诊断和治疗,以提高对本病的认识。方法对2003年1月至2005年12月在本院呼吸科确诊的4例原发性肺隐球菌病患者的临床资料进行回顾性分析。结果4例患者,男3例,女1例,年龄31～41岁,平均36.5岁。临床表现:低至中度发热4例,咳嗽3例,咳白色粘痰1例,胸闷3例,气促2例,胸痛2例,盗汗2例,肺部呼吸音减低3例,肺部湿啰音2例跋裱П硐治铝⑿灾卓橛埃崩喾⒅卓橛埃忱?病变分布于双侧下肺3例,其中1例合并有双上肺病变,单侧下肺1例。4例均经皮肺穿刺病理确诊,全部经抗真菌药物(两性霉素B,氟康唑)治疗获得理想效果。结论原发性肺隐球菌病多发于无基础疾病的中青年,开始症状较轻,以肺部单发或多发块状阴影为多,易被漏诊、误诊,氟康唑治疗效果良好。     

Current status of cryptococcosis in Canada

The concurrent use of microscopic, cultural, histopathologic and immunologic procedures enabled us to diagnose 91 cases of cryptococcosis, belonging to cutaneous, pulmonary, meningeal and disseminated types, from the time this mycosis was first reported in Canada in 1953 to the present. These cases occurred predominantly in Quebec (43%) followed by Alberta, British Columbia, Ontario, Saskatchewan, Manitoba, New Brunswick and Newfoundland. It is not known whether any Cryptococcus neoformans infections have occurred elsewhere in Canada. The clinical and laboratory findings indicate that infections occurred in debilitated as well as nondebilitated individuals. Nearly 25% of the infections were seen in individuals having the acquired immune deficiency syndrome (AIDS) in provinces of Alberta, British Columbia, Ontario and Quebec. In some of the AIDS cases, the latex agglutination (LA) test demonstrated exceptionally high titres of circulating cryptococcal antigen (1:256 to 1:32,768). Cr. neoformans infections occurred more commonly in males than in females, and there were 11 fatal cases of cryptococcosis. The incidence of Cr. neoformans in Canada is probably higher than our data suggest because cryptococcosis is not notifiable in Canada and underreporting is likely.     

442例咯血患者误诊原因回顾性分析

目的:分析442例咯血患者误诊的原因。方法:观察并记录442例咯血患者的年龄、性别、X线及纤支镜检查结果、初步诊断和最后诊断,分别计算各种疾病的误诊率,并分析误诊原因。结果:误诊率较高的前5位疾病分别为:肺曲菌病(79.8%),支气管内膜结核(75%),肺隐球菌病(71.43%),肺栓塞(61.5%),支气管结核合并肺癌(51.84%)。结论:咯血可由多系统多器官疾病引起,这些疾病往往缺乏特异性的症状和体征,在诊断时必须仔细鉴别才能避免误诊。     

对14例免疫功能基本正常儿童肺隐球菌病的再认识

目的深入认识儿童肺隐球菌病的表现、诊断进展、治疗和预后,以提高对儿童肺隐球菌病的诊断和治疗水平,防止发生全身播散。方法回顾分析2005-01—2006-06北京儿童医院收治的免疫功能基本正常的14例肺隐球菌病患儿的临床资料。结果14例患儿最小年龄为1岁8个月。症状主要为长期发热,咳嗽不重或持续时间较短暂。肺部查体12例正常,2例闻及干啰音和中水泡音?级廾飨灾卸局⒆础?例伴有间断腹痛,查体时有肝和(或)脾肿大。从发病到确诊至少23d,最长为5个月。实验室检查:13例外周血白细胞和中性粒细胞升高、C反应蛋白(CRP)明显升高。肺部影像学表现:11例患儿表现为双肺弥漫或散在小结节影,并有胸膜下分布。3例未发生肺外播散,11例伴有肺外隐球菌病(播散性隐球菌病)。病原学检查:8例找到隐球菌孢子。12例进行血清隐球菌荚膜多糖抗原检查,仅1例阴性,其余2例单独肺隐球菌病患儿以及9例播散性隐球菌病患儿全部阳性。动物接触史:6例有接触鸽子史,5例无动物接触史,3例接触家鸡。在11例伴有肺外隐球菌病的患儿中,9例静脉联合应用二性霉素B和氟康唑等治疗,病情控制,改为口服氟康唑继续治疗。1例在确诊前死亡,未行抗真菌治疗。在3例单独的肺隐球菌病患儿中,2例静脉应用二性霉素B;1例静脉应用氟康唑治疗病情控制,改为口服氟康唑继续治疗。结论儿童肺隐球菌病可发生于免疫功能正常的儿童,可无动物接触史,尽管长期发热、外周血白细胞和中性粒细胞升高、CRP升高,无特异性,但临床进展缓慢,咳嗽不重、无明显中毒症状、嗜酸性粒细胞升高,IgE升高是其相对特异的临床表现。双肺弥漫或散在小结节影,和(或)纵隔、肺门淋巴结肿大,为影像学表现。除隐球菌培养外,血肺隐球菌抗原检测有助于诊断。二性霉素B和(或)氟康唑治疗可控制隐球菌病。     

新型隐球菌性脑膜炎合并肺隐球菌病10例临床分析

目的:探讨新型隐球菌性脑膜炎(CM)合并肺隐球菌病(CP)的临床及影像学特点。方法:对10例经病原学检查证实的CM合并CP的临床资料进行回顾性分析。结果:(1)8例男性,2例女性,年龄4～62岁,平均(31.3±23.2)岁。病程14～120天,平均(40.0±39.7)天。(2)首发症状发热8例、头痛6例、咳嗽咯痰2例、胸痛1例。(3)有基础疾病者8例,其中慢性乙型病毒性肝炎6例、矽肺并肺结核2例、营养不良1例、鼻窦炎1例。(4)9例均被误诊为结核感染。1例误诊为肺癌。(5)胸片表现为两肺散在分布小片状、小结节阴影,边缘模糊、内见不规则低密度区;CT示两肺广泛分布斑片状和斑点状密度增高影、大小不等的空洞或类圆形边缘光滑高密度结节。(6)应用二性霉素B(AMB)联合氟康唑(FCZ)静滴和AMB鞘内注射治疗,治愈6例,好转4例。结论:CM合并CP临床症状和影像学均缺乏特异性,提高对CP影像学的认识有利于早期诊断。     

A case of necrotizing glomerulonephritis presenting with nephrotic syndrome associated with pulmonary cryptococcosis

We describe a 68-year-old man with necrotizing glomerulonephritis who presented with nephrotic syndrome accompanied by pulmonary cryptococcosis. He developed rheumatoid arthritis in July 1999 and was treated with low-dose prednisolone. He was admitted to our hospital on November 22 following the appearance of bilateral leg edema in October 2000. Laboratory tests at presentation revealed nephrotic syndrome with renal impairment. Renal biopsy specimens revealed necrotizing glomerulonephritis with crescent, but immunofluorescence study showed lack of staining for immunoglobulins or complement components. Chest X-ray and CT showed abnormal shadows in the right upper lung field, and Cryptococcus neoformans was isolated in a transbronchial lung biopsy. After the diagnosis of pulmonary cryptococcosis was made, the patient was treated with 200mg/day fluconazole. The pulmonary abnormal shadows immediately improved and urinary protein excretion dramatically decreased. A second renal biopsy, performed about 2 months after the first biopsy, showed disappearance of crescent. Electron microscopic examination of the second renal biopsy showed partial effacement of foot processes without electron-dense deposits. Our findings suggest that necrotizing glomerulonephritis with nephrotic syndrome in this patient represented pauci-immune T-cell-mediated injury related to pulmonary cryptococcosis.     

Combined therapy of interleukin 12 and interleukin 18 against cryptococcus neoformans infection in a murine model

Objective To explore adverse effects of comloined treatment of interleukin-12 (IL-12) and interleukin-18 (IL-18) against cryptococcosis in a murine model.Methods Infected mice were treated with a combination of IL-12 and IL-18. Their body weight and intake of water and food were observed and recorded. Serum levels of leptin were detected with an enzyme-linked immuno sorbent assay (ELISA).Results In the combined treatment group, the intake volume of water and food were reduced,leading to weight loss and undetectable levels of leptin in the serum. These adverse effects were more profound in mice that had received higher doses of cytokines, which sometimes led to a fatal outcome.There was a significant difference compared with the control group. Neutralization of endogenous tumor necrosis factor-α (TNF-α) by its specific mAb did not alter the wasting effect of this treatment.Conclusions The combined IL-12/IL-18 treatment may cause a number of adverse effects independent of TNF-α and leptin synthesis. Further investigations for resolving these adverse effects are required before clinical application of these cytokines.     

Pulmonary infection with capsule-deficientCryptococcus neoformans

Summary A case of bilateral lobar pneumonia due toCryptococcus neoformans is presented. The capsule-deficient fungal organisms within tissue were suggestive ofHistoplasma capsulatum. Cultures grewCryptococcus neoformans and there was cryptococcal antigen in the serum. Pulmonary cryptococcosis and the occurrence of unencapsulated cryptococci are reviewed. The important role both culture and the latex agglutination test for cryptococcal antigen play in the differential diagnosis of systemic fungal infections with over-lapping histopathology are discussed.     

Case Reports. Pulmonary cryptococcosis associated with cryptococcal meningitis in non-AIDS patients

We report four cases of pulmonary cryptococcosis associated with cryptococcal meningitis in non-HIV infected patients. All four patients had no apparent symptoms and signs of focal lesions that necessitate evaluation for the pulmonary lesion. Two out of four patients had radiologic evidence of pulmonary cavitation and mass lesions simultaneously, an uncommon finding in non-AIDS patients. Diagnostic and therapeutic problems of pulmonary cryptococcosis associated with cryptococcal meningitis are discussed.