重症慢性阻塞性肺疾病合并侵袭性支气管肺曲霉病确诊病例的临床特点

目的探讨重症慢性阻塞性肺疾病（COPD）合并侵袭性支气管肺曲霉病（IBPA）确诊病例的临床特点。方法回顾性分析北京朝阳医院呼吸重症监护室（RICU）2006年4月至2012年8月收治的7例COPD合并IBPA确诊病例的病史、实验室检查、气管镜及影像学资料。结果7例COPD合并IBPA确诊患者入RICU前多有大剂量糖皮质激素（6／7）和多种广谱抗菌药物（7／7）应用史。临床最常见的表现为对大剂量糖皮质激素及广谱抗菌药物治疗无效的发热、持续气道痉挛所致呼吸困难和双肺广泛哮鸣音。7例患者中，5例为曲霉性气管支气管炎（ATB）合并侵袭性肺曲霉病（IPA），患者支气管镜下主要表现为气道黏膜严重充血、水肿、糜烂及气道痉挛，并伴有气道内伪膜形成，胸部影像学提示由最初大致正常迅速进展为渗出影或实变影，在临床上均发生呼吸衰竭并迅速进展为多脏器功能衰竭而死亡。存活的2例患者仅存在气道病变，且均在出现胸部渗出影前开始抗真菌治疗，病情好转。结论 重症COPD合并IBPA病情进展迅速，如不能及时诊断并尽早治疗，患者单纯ATB迅速进展为肺实质受累的IPA而死亡。早期支气管镜检查及气道黏膜活检有助于建立诊断和指导治疗。

Clinical features of invasive bronchial-pulmonary aspergillosis in critically ill patients with chronic obstructive pulmonary diseases

Objective To investigate the clinical features of invasive bronchial-pulmonary aspergillosis （IBPA） in critically ill patients with chronic obstructive pulmonary diseases （COPD）. Methods Clinical data of 7 COPD patients complicated with IBPA from respiratory intensive care unit （RICU） in Beijing Chaoyang Hospital during April 2006 and August 2012 were retrospectively analyzed. Results All patients were treated with several kinds of broad-spectrum antibiotics and 6 patients were also treated with large dose of corticosteroids before their admission to RICU. The most frequent clinical manifestations were fever, persistent bronehospasm induced dyspnea and bilateral wheezing which were unresponsive to large doses of corticosteroids and broad-spectrum antibiotics. In 5 patients with both aspergillus tracheobronchitis （ATB） and invasive pulmonary aspergillosis （IPA）, bronchoscopy showed tracheobronchial inflammation, bronchospasm, phlegm and bronchial pseudomembrane formation. All these 5 patients had a rapid progression from normal to infiltrates or consolidation in chest X-ray, and died of respiratory failure or multiple organ failure. The other 2 cases were diagnosed with ATB and received prophylactic antifungal treatments before infiltrates were shown on their chest X-ray. Both of them survived. Conclusions In COPD patients combined with IBPA, ATB may progress rapidly to IPA which affect lung parenchyma and lead a high mortality. Bronehoscopy and bronchial mucous biopsy may be helpful in earlydiagnosis and treatment.