儿童急性白血病併发曲霉菌病的临床诊断和治疗——附7例临床病例报告

目的探讨儿童急性白血病患者曲霉菌感染,尤其是肺曲霉菌病的临床特点及其诊断和治疗。方法对我院血液肿瘤病房7例曲霉菌病进行回顾性分析,观察其发病时间、诱因,临床症状及X线、CT表现及治疗效果。通过血或痰等分泌物培养,X线及CT检查等诊断。所有粒细胞缺乏的发热患者积极抗生素治疗的基础上予大扶康预防或经验治疗,3~7天无效者改用两性霉素B。结果诊断曲霉菌肺炎6例,曲霉菌鼻窦炎2例(1例合并肺炎)。鼻窦炎1例鼻窦冲洗液培养为曲霉菌。另1例口唇坏死组织切片见大量菌丝及孢子。曲霉菌肺炎主要根据肺部CT特征性改变及治疗转归临床诊断。2例原发病未缓解者死亡,其它5例均经两性霉素B治疗好转。两性霉素B副作用主要有:寒战、高热、低钾血症及一过性肾功能损害,均无需停药。结论深部曲霉菌感染临床表现不典型,诊断困难,肺部CT检查对其早期发现、及早治疗有重要意义。曲霉菌肺炎典型CT改变为球形或团块状阴影,伴“晕轮征”或“新月征”。以胸膜为基底的楔形实变影提示发生致命性咯血的可能。两性霉素B疗效肯定,副作用可耐受。原发病的缓解及粒细胞恢复也是真菌感染能否治愈的重要因素。

Clinical diagnosis and treatment of invasive aspergiliosis in children with acute leukemia

Objective To evaluate the characteristics and outcome of children with leukemia who developed aspergillosis.Methods We reviewed the medical records of all patients treated at our department of Hematology/Oncology from January 2000 to December 2004 for aspergillosis. Results Among the 7 patients studied,we found 6 cases of pulmonary aspergillosis and 2 case of nasosinusitis(1 of which was concomitant of pulmonary aspergillosis).Culture of drainage from accessory nasal sinus yielded aspergillus,and hyphae and spores were found in the necrotic tissue of the lip of 1 case.Pulmonary aspergillosis diagnosed mainly by the typical imaging manifestation,positive reaction to treatment of amphotericin B(AmB) and failure of treatment by fluconazole(Diflucan).The side effections of AmB include chill,fever,hypokalemia and transient increase in BUN,none of which need discontinue therapy.Conclusions It is important for patient of neutropenia fever to be checked by CT as soon as possible to find out aspergillosis and treat it timely.The typical CT exhibition of pulmonary aspergiilosis include nodules or masses with "halo si gn"or "air crescent sign". Characteristics of angioinvasive aspergillosis is "halo design" and pleura-based wedge-shaped areas of consolidation found by CT and high risk of mortal hemoptysis.The curative effect of AmB is affirmed and we haven't found life-threatening side-effect in children.The remission of primary disease and recovery of immune function are also key factors for the cure of aspergillosis.