28例原发性肺隐球菌病临床特征分析

目的：探讨原发性肺隐球菌病(pulmonary cryptococcosis，PC)的临床表现、术前误诊原因及诊疗方法。方法：回顾性分析2008-2013年中南大学湘雅二医院收治的28例经病理组织学确诊的PC患者的临床资料。结果：28例PC患者中19例无宿主因素，无1例患者近期有鸽子接触史。PC影像学表现以单发或多发结节肿块影为主，亦有斑片渗出影表现。8例18F-脱氧葡萄糖正电子发射断层扫描 (18F-fluorodeoxyglucose positron emission tomography/computed tomography，18F-FDG PET/CT)显像均示脱氧葡萄糖异常聚集，其中7例考虑恶性病变，1例考虑结核瘤，无1例考虑肺部真菌病。28例病理均表现为肉芽肿性病变，过碘酸希夫染色、六胺银染色下均可见新型隐球菌。27例患者接受外科肺叶切除术，1例患者接受单纯抗真菌药物治疗，随访中仅1例患者病情控制不佳。结论：大部分PC患者无明显免疫功能损害，其临床症状多样且与患者的免疫状态有关。PC影像学表现与恶性肿瘤难以鉴别， 即使18F-FDG PET/CT显像亦不能获得明显诊断倾向。特殊PC人群外科肺叶切除后仍需系统抗真菌治疗。氟康唑和伊曲康唑治疗仍是经典的内科治疗手段。

Clinical characteristics of primary pulmonary cryptococcosis in 28 patients

Objective: To determine the clinical characteristics, causes of pre-operative misdiagnosis and therapy of pulmonary cryptococcosis. Methods: We retrospectively analyzed the clinical data of 28 patients suffering from pulmonary
cryptococcosis from 2008 to 2013 in the Second Xiangya Hospital of Central South University. All patients were diagnosed pathologically. Results: Of the 28 patients, 19 had no clear host factors. No patient was exposed to pigeons recently. The imaging findings showed that most patients had solitary, multiple nodules, masses, and patches. 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDGPET/CT) showed abnormal accumulation of fluorodeoxyglucose. Seven patients demonstrated malignancy and 1 demonstrated tuberculosis. None was considered as pulmonary fungus diseases. Microscopically, cryptococcosis granuloma formation was found in all patients and cryptococcosis neoformans were detected by Periodic acid-schiff and Grocott methenamine silver staining methods in the histopathological examination, respectively. Twenty-seven patients underwent lobectomy, and 1 had the medical antifungal drugs treatment. During the follow-up, symptoms in only 1 patient were not controlled. Conclusion: Most pulmonary cryptococcosis patients have no evident immunocompromise. Clinical presentation of pulmonary cryptococcosis varies and is often related to the immune status of patients. Radiological manifestation of pulmonary cryptococcosis is indistinguishable from malignant tumor, and even 18F-FDG-PET imaging does not help to get a clear diagnosis. After surgical resection of the lung, systemic antifungal treatment is still necessary for special population. Systemic therapy of both fluconazole and itraconazole is classic choice for pulmonary cryptococcosis.