慢性阻塞性肺疾病急性加重期合并侵袭性肺曲霉病的研究进展

COPD急性加重期(AECOPD)患者合并呼吸衰竭时常需住院或进入ICU治疗.虽然病毒和细菌感染是引起AECOPD的主要原因,但近来人们发现真菌感染也可能是COPD患者病情急剧恶化的原因之一.     

慢性阻塞性肺疾病合并侵袭性肺曲霉病病例报告并文献回顾

目的:结合文献总结慢性阻塞性肺疾病(COPD)合并侵袭性肺曲霉病(IPA)患者的临床特征,提高早期诊治水平。方法:对1例经支气管镜肺活检确诊的重度COPD合并IPA患者的临床资料进行分析,并回顾复习有关文献。结果:COPD合并IPA患者严重呼吸困难多见。本例患者胸部CT可见中央型支气管扩张、小结节影、不典型渗出影,血清半乳甘露聚糖抗原检测(GM试验)及1.3-β-D葡聚糖检测(G试验)阳性。经支气管镜肺活检病理学检查见曲菌丝及炎症细胞浸润。结论:COPD合并IPA诊断困难,病死率高,综合分析临床表现、影像学、微生物学及血清学检查结果是提高诊断率、改善预后的有效手段。若临床情况允许,应尽早进行支气管镜等有创检查确定诊断。     

慢性阻塞性肺疾病合并侵袭性肺曲霉病的危险因素及诊断进展

慢性阻塞性肺疾病（COPD）是常见的慢性呼吸系统疾病.侵袭性肺曲霉病（IPA）是肺曲霉病的一种类型,其危害最大,病死率最高.近年来,侵袭性肺曲霉病作为一种严重的机会性真菌感染,在COPD患者报道日益增多,除恶性肿瘤、器官移植外,COPD已成为IPA的第3位易患因素.据文献报道10％以上的COPD患者并发侵袭性肺曲霉病,5％以上合并IPA.另外有研究表明,全球约1％～2％ COPD患者死于IPA,而COPD合并IPA的病死率高达72％ ～ 95％.现将COPD合并IPA等风险因素研究及诊断进展综述如下.     

慢性阻塞性肺疾病合并侵袭性肺曲霉菌病的研究进展

近年来,慢性阻塞性肺疾病(COPD)合并侵袭性肺曲霉菌病(IPA)发病率不断增高,该类患者预后差、病死率高,早期诊断、及时治疗是改善其预后的重要措施。本文结合相关文献对COPD合并IPA的发病机制、临床特征、实验室检查、诊断及治疗等进行综述,为临床医生早期诊断和及时治疗该病提供参考。     

慢性阻塞性肺疾病急性加重合并侵袭性气管支气管曲霉病1例报告

正1、病历资料患者女,70岁,家庭妇女,主因"反复咳嗽、咳痰伴胸闷、气短40余年,加重10余年,再发伴双下肢浮肿2天"入院时间2015年12月17日。患者40年前无明显诱因反复出现咳嗽咳痰伴胸闷气短,不伴胸痛、咯血等症状,上述症状数年一次,可自行缓解,未予重视及规律诊治。10余年前患者上述症状     

重症慢性呼吸道疾病合并侵袭性肺曲霉病的临床特点

目的 总结重症慢性呼吸道疾病(CRD)合并侵袭性肺曲霉病(IPA)的临床特点,为早期诊断和治疗提供依据.方法 分析2004年10月至2007年2月在北京朝阳医院呼吸科重症监护室(RICU)住院的149例痰或BALF分离出曲霉的CRD患者资料.以SPSS 10.0统计软件进行数据处理,所有计量资料以均数±标准差表示,计数资料以例数表示.计量资料采用t检验,计数资料采用X2检验.结果 149例CRD患者中共收集16例IPA病例(COPD 11例,COPD合并支气管哮喘4例,支气管扩张症1例),其中3例确诊,10例临床诊断,3例拟诊.12例在人RICU前使用过大量糖皮质激素,15例使用广谱抗生素.15例临床表现为严重气道痉挛,9例行无创通气失败,14例因严重呼吸衰竭而需有创机械通气.12例X线胸片可见明显渗出影.外周血白细胞及中性粒细胞比例在疾病后期迅速增高;早期气管镜检查可见气道黏膜充血、水肿、糜烂,气道痉挛,痰液黏稠,后期气道黏膜可出现伪膜;早期真菌病原学检查阳性率低(2/12),后期阳性率高(10/12);早期治疗的患者存活率高(4/4),晚期治疗效果差(11/12),由呼吸衰竭迅速进展为多脏器衰竭是最主要的死亡原因.结论 CRD合并IPA并不少见,预后差.根据临床特点进行早期诊断及经验性治疗可改善患者的预后.     

侵袭性肺曲霉病的研究进展

正侵袭性肺曲霉病(invasive pulmonary aspergillosis,IPA)是指曲霉菌菌丝生长侵入肺实质而引起的感染性疾病;其最常见的感染患者为恶性血液病以及实体器官和造血干细胞移植的患者~([1])。由于烟曲霉菌的血培养通常显阴性,并且通过支气管肺泡灌洗从下呼吸道取样来进行曲霉菌的培养通常不够灵敏,所以IPA的诊断比较复杂。近年来,非培养的诊断方法不断发展起来,包括成像检查,PCR技术,抗原检测     

伏立康和唑伊曲康唑治疗慢性阻塞性肺疾病合并侵袭性肺曲霉病的对照研究

目的 探讨应用伏立康唑对照伊曲康唑治疗慢性阻塞性肺疾病合并侵袭性肺曲霉病患者的临床疗效.方法 收集中山大学附属第一医院及中山大学附属江门医院2005年1月～2012年8月收治的确诊为慢性阻塞性肺疾病合并侵袭性肺曲霉病,且初始时选用伏立康唑或伊曲康唑治疗的患者43例,分为伏立康唑组(24例)和伊曲康唑组(19例),对两组患者的临床资料进行回顾性分析.结果 两组患者,使用广谱抗生素、肺功能、营养状态等影响因素及临床症状、体征等比较差异均无统计学意义.伏立康唑组患者治愈或好转率(79.17％)明显高于伊曲康唑组(52.63％,P＜0.05).伏立康唑补救治疗有效率为60.00％ (3/5).结论 初始选用伏立康唑治疗慢性阻塞性肺疾病并发侵袭性肺曲霉病的疗效明显优于伊曲康唑.     

Invasive pulmonary aspergillosis in patients with chronic obstructive pulmonary disease

Background

Invasive pulmonary aspergillosis (IPA) is an infection often occurring in neutropenic patients and has high mortality rates. In recent years, it has been reported that the incidence of IPA has also increased in patients with chronic obstructive pulmonary disease (COPD). The purpose of this study is to investigate the clinical and demographic characteristics and treatment responses of IPA in patients with COPD.

Methods

Seventy-one patients with a positive culture of Aspergillus from lower respiratory tract samples were examined retrospectively. Eleven (15.4%) of these patients, affected with grade 3 or 4 COPD, had IPA.

Results

Aspergillus hyphae were detected in lung biopsy in three (27.3%) out of 11 patients and defined as proven IPA; a pathological sample was not taken in the other eight (72.7%) patients, and these were defined as probable IPA. Aspergillus isolates were identified as six cases of Aspergillusfumigatus and three of Aspergillusniger in nine patients, while two isolates were not identified at species level. While five patients required intensive care unit admission, four of them received mechanical ventilation. The most common finding on chest X-ray and computed tomography (CT) (respectively 63.6%, 72.7%) was infiltration. Amphotericin B was the initial drug of choice in all patients and five patients were discharged with oral voriconazole after amphotericin B therapy. Six patients (54.5%) died before treatment was completed.

Conclusions

IPA should be taken into account in the differential diagnosis particularly in patients with severe and very severe COPD presenting with dyspnea exacerbation, poor clinical status, and a new pulmonary infiltrate under treatment with broad-spectrum antibiotics and steroids.

     

Invasive pulmonary aspergillosis in patients with chronic obstructive pulmonary disease.

Aspergillus spp. cultured in specimens from the airways of chronic obstructive pulmonary disease (COPD) patients are frequently considered as a contaminant. However, growing evidence suggests that severe COPD patients are at higher risk of developing invasive pulmonary aspergillosis (IPA), although IPA incidence in this population is poorly documented. Some data report that COPD is the underlying disease in 1% of patients with IPA. Definitive diagnosis of IPA in COPD patients is often difficult as tissue samples are rarely obtained before death. Diagnosis is therefore usually based on a combination of clinical features, radiological findings (mostly thoracic computed tomography scans), microbiological results and, sometimes, serological information. Of 56 patients with IPA reported in the literature, 43 (77%) were receiving corticosteroids on admission to hospital. Breathlessness was always a feature of disease and excess wheezing was present in 79% of patients. Fever (>38 degrees C) was present in only 38.5%. Chest pain and haemoptysis were uncommon. Six out of 33 (18%) patients had tracheobronchitis observed during bronchoscopy. The median delay between symptoms and diagnosis was 8.5 days. The mortality rate was high: 53 out of 56 (95%) patients died despite invasive ventilation and antifungal treatment in 43 (77%) of them. In chronic obstructive pulmonary disease patients, invasive pulmonary aspergillosis currently carries a very poor prognosis. Outcome could perhaps be improved by more rapid diagnosis and prompt therapy with voriconazole.     

Inhaled corticosteroids in chronic obstructive pulmonary disease and disseminated aspergillosis

Inhaled corticosteroids are widely used in patients with chronic obstructive pulmonary disease (COPD), although their efficacy is still being debated. Due to local and systemic effects, such therapy can have an immunosuppressive action and opportunistic infections can occur. In the present case, a 74-year-old man treated with inhaled corticosteroids for 5 years developed disseminated aspergillosis. No other immunosuppressive factor was found. To our knowledge, only a few cases of lung aspergillosis in such patients have been described in the literature. However, the risk-to-benefit ratio of this treatment must be reassessed.     

COPD继发曲霉菌感染危险因素分析

目的分析慢性阻塞性肺病继发曲霉菌感染的危险因素。方法采用回顾性病例对照分析方法,收集我院呼吸内科住院期间慢性阻塞性肺病继发曲霉菌感染36例作为感染组,随机抽取同期呼吸内科住院的无曲霉菌感染慢性阻塞性肺病患者36例作为对照组,对比分析两组患者的临床资料。结果血清白蛋白水平、机械通气、侵入性操作及使用激素是引起曲霉菌感染的主要诱因,两组间比较差异有统计学意义（P〈0.05）。结论血清白蛋白水平、机械通气、侵入性操作及使用激素是慢性阻塞性肺病继发曲霉菌感染的危险因素。     

Allergic bronchopulmonary aspergillosis in a patient with chronic obstructive pulmonary disease

Allergic bronchopulmonary aspergillosis (ABPA) is a debilitating lung disease which occurs as a result of interplay between a variety of host and environmental factors. It occurs in certain susceptible individuals who develop hypersensensitivity to the colonised Aspergillus species. ABPA is a complicating factor in 2% of patients with asthma and is also seen in patients with cystic fibrosis. Asthma and chronic obstructive pulmonary disease (COPD) are known to share key elements of pathogenesis. It is well known that ABPA can occur in patients with asthma, but it has recently been reported in patients with COPD as well. We report a 55-year-old male ex-smoker who presented with complaints of exertional breathlessness and productive cough for five years and an episode of haemoptysis four days prior to presentation. Spirometery showed airflow obstruction which was not reversible with bronchodilators. Chest CT scan revealed paraseptal emphysema along with central bronchiectasis (CB) in the right upper lobe and bilateral lower lobes. A type I skin hypersensitivity reaction to Aspergillus species was elicited. He fulfilled the serological criteria for ABPA and was diagnosed as having concomitant COPD and ABPA-CB. The patient was initiated on therapy for COPD along with oral corticosteroids, on which he had remarkable symptomatic improvement.     

慢性阻塞性肺疾病合并侵袭性肺曲霉菌病的危险因素分析

目的探讨慢性阻塞性肺疾病(COPD)合并侵袭性肺曲霉菌病(IPA)的危险因素。方法采用病例对照研究方法,选取2015-05～2018-05该院呼吸内科住院的COPD合并IPA的住院患者24例为病例组,以年龄为匹配因素(±2岁),按1∶2的比例选取同期住院的COPD患者48例为对照组,采用条件Logistic回归分析对COPD合并IPA的危险因素进行分析。结果单因素分析结果显示COPD频繁急性加重、糖尿病、慢性肾功能不全、应用广谱抗生素≥2周、应用糖皮质激素为COPD合并IPA的危险因素(P0.10);采用条件Logistic分析,糖尿病、应用广谱抗生素≥2周、应用糖皮质激素为COPD合并IPA的独立危险因素(OR=7.384,6.681,32.354,P0.05)。结论糖尿病、应用广谱抗生素≥2周、应用糖皮质激素为COPD合并IPA的独立危险因素。     

Invasive pulmonary aspergillosis

Invasive pulmonary aspergillosis (IPA) is the most common fungal pulmonary infection in severely immunocompromised patients. Aspergillus species are commonly isolated from the soil, plant debris, and the indoor environment, including the hospital. Phagocytosis is the main host defense against Aspergillus conidia and hyphae. The diagnosis of IPA is based on clinical, radiological, and mycological data. Clinical signs have a low specificity. The most typical computed tomographic (CT) findings are nodules with or without the halo sign or the air crescent sign. Sensitivity of microscopy and culture of noninvasive collected samples is low. Galactomannan and nucleic acid detection in serum or in bronchoalveolar lavage (BAL) fluid help to confirm the diagnosis. Crude mortality is high and strongly correlated with the underlying condition, stage of the underlying disease, and extension of the aspergillosis. Optimal therapeutic strategies include the prevention of contamination in patients at high risk, early initiation of antifungal therapy, surgery in some instances, and, importantly, treatment of the underlying condition to restore whenever possible a certain degree of immunocompetence. Voriconazole has demonstrated better efficacy and safety than amphotericin B deoxycholate. The improved survival observed with voriconazole makes it a new reference for the first-line therapy of IA. Lipid formulations of amphotericin B, caspofungin, micafungin, and posaconazole are other therapeutic options in the event of failure of or contraindication to voriconazole. The main indication for surgery is prevention of severe hemoptysis when the lesion is adjacent to a large vessel.