原发性肺隐球菌病12例临床分析

目的探讨免疫功能无异常的原发性肺隐球菌病患者cT征象及CT引导下经皮肺穿刺活检在诊断中的价值。方法回顾性分析浙江大学医学院附属邵逸夫医院经病理证实的12例原发性肺隐球菌病患者的临床资料。结果（1）12例患者的CT征象均为单肺叶发病,其中单发结节4例,局限性多发混杂的结节和（或）肿块和（或）肺实变8例,此外还可见支气管充气征／小泡征（9例）、空洞（2例）和“晕”征（4例）。（2）9例行CT引导下经皮肺穿刺活检,其中7例病理学确诊。（3）12例患者中7例行手术切除,术后2例行氟康唑治疗,余5例未用药,其中1例术后5个月发生隐球菌性脑膜炎;另5例用氟康唑治疗。结论免疫功能无异常者时有发生肺隐球菌病的可能;肺隐球菌病的临床症状与影像学表现明显不相称;大多数肺隐球菌病的CT主要征象为局限性多发混杂的结节和（或）肿块和（或）肺实变,如同时有支气管充气征／小泡征、晕征,则具有特征性;尽早采用CT引导下经皮穿刺活检将有助于该病的早期诊断;氟康唑治疗该病效果好,有助于预防严重并发症的发生。     

21例原发性肺隐球菌病诊治体会

目的通过回顾性分析21例原发性肺隐球菌病例,提高肺隐球菌病的诊治水平。方法回顾性分析2005年1月-2012年12月期间收治的21例肺隐球菌病患者的临床资料。结果 21例患者临床表现均缺乏特异性;肺部CT表现:61.9%表现为单发或多发结节、肿块影,23.8%表现为肺部浸润实变影,15.7%为混合病灶。所有患者血清乳胶凝集试验均呈阳性。确诊患者11例,其中开胸手术确诊2例,TBLB确诊1例,CT引导肺穿刺活检确诊7例,穿刺液培养阳性1例;临床诊断10例。所有患者均未合并隐球菌脑膜炎。在接受氟康唑和氟胞嘧啶治疗3月后,所有患者肺部病灶均明显吸收。结论原发性肺隐球菌病临床表现无特异性,确诊主要依靠病理,应优先考虑采用CT引导下经皮肺穿刺活检术获取病理组织;血清乳胶凝集试验对诊断具有重要价值,结合患者的影像学表现和治疗反应可进行临床诊断。     

21 例原发性肺隐球菌病诊治体会简

目的 通过回顾性分析21例原发性肺隐球菌病例,提高肺隐球菌病的诊治水平.方法 回顾性分析2005年1月-2012年12月期间收治的21例肺隐球菌病患者的临床资料.结果 21例患者临床表现均缺乏特异性;肺部CT表现：61.9%表现为单发或多发结节、肿块影,23.8%表现为肺部浸润实变影,15.7%为混合病灶.所有患者血清乳胶凝集试验均呈阳性.确诊患者11例,其中开胸手术确诊2例,TBLB确诊1例,CT引导肺穿刺活检确诊7例,穿刺液培养阳性1例;临床诊断10例.所有患者均未合并隐球菌脑膜炎.在接受氟康唑和氟胞嘧啶治疗3月后,所有患者肺部病灶均明显吸收.结论 原发性肺隐球菌病临床表现无特异性,确诊主要依靠病理,应优先考虑采用CT引导下经皮肺穿刺活检术获取病理组织;血清乳胶凝集试验对诊断具有重要价值,结合患者的影像学表现和治疗反应可进行临床诊断.     

肺隐球菌病17例临床分析

目的 提高对肺隐球菌病的临床诊疗水平.方法 回顾分析上海瑞金医院2009年1月至2011年10月收治的17例肺隐球菌病病例的临床资料,对其临床特点、影像学表现、实验室检查、治疗方法进行综合分析.结果 本组肺隐球菌病患者中,有临床症状者14例,主要表现为咳嗽、咳痰、发热、胸痛、气急.其余3例体检发现.影像学主要表现为肿块结节型或片状渗出影.所有患者血清乳胶凝集试验均为阳性.17例患者均经病理确诊为肺隐球菌病,其中14例经CT引导下经皮肺穿刺活检证实.所有患者均接受抗真菌治疗,疗程2至6月,15例患者治愈或显效.结论 肺隐球菌病临床表现缺乏特异性,血清乳胶凝集试验对本病的诊断价值较高.本病确诊依靠病理,同时应优先考虑CT引导下经皮肺穿刺活检获得病理组织.药物治疗需要足够疗程.     

肺隐球菌病的临床特点及诊治分析

目的分析肺隐球菌病的临床特点、诊断、治疗及预后。方法回顾分析23例确诊肺隐球菌病患者的高危因素、临床表现、影像学特点、确诊方法及治疗转归。结果原发性肺隐球菌病21例（91．3％）,继发性2例（8．7％）,合并基础疾病5例（21．7％）。主要症状为咳嗽13例（56．5％）和胸痛9例（39．1％）。影像学主要表现为单发或多发结节／肿块18例（78．3％）,主要分布在肺下叶（12例）。10例经皮穿刺肺活检确诊,12例经外科手术组织病理学确诊。行氟康唑治疗20例中（外科切除病灶10例）,18例痊愈。结论原发性肺隐球菌病较为常见,影像学特点对诊断有一定的提示意义。经皮穿刺肺活检是经济、安全、有效的确诊措施,氟康唑治疗疗效较好。     

原发性肺隐球菌病10例临床分析

目的总结分析10例原发性肺隐球菌病患者的临床特点。方法分析我院10例原发性肺隐球菌病患者的临床、影像学表现、实验室检查、病理及确诊方法、疗效等。结果①10例原发性肺隐球菌病,男6例,女4例,有基础疾病者2例,有临床症状者8例,主要表现为胸痛、咳嗽、咳痰、痰中带血、发热,影像学表现为结节肿块型1例,肺炎型4例,混合病变型5例,全部病例均经病理确诊。②治疗采用手术切除病灶和(或)氟康唑治疗。1例行手术切除后口服氟康唑,另9例均行氟康唑治疗,治愈6例,好转4例,有效率100%,疗程1～12月不等。结论原发性肺隐球菌病临床和影像学表现不典型,呈多样性,应积极行肺活检以协助诊断,肺隐球菌病单用氟康唑抗真菌治疗效果良好。     

53例非免疫缺陷肺隐球菌病的诊疗分析

目的通过总结53例非免疫缺陷肺隐球菌病患者的临床特征,提高对非免疫缺陷肺隐球菌病的认识。方法回顾性分析2011年4月至2017年2月行CT引导下经皮肺穿刺活检或外科手术病理证实的肺隐球菌病患者的临床资料。结果共53例患者,其中男30例,女23例;年龄20-86岁,平均51岁;其中31例合并有基础病;所有患者均未行器官移植术,且HIV指标均为阴性。胸部CT扫描表现为实变渗出灶、结节状、团块状以及混合型。1例行胸腔镜手术切除治疗,经手术病理证实。52例经CT引导下经皮肺穿刺活检病理证实。53例患者中47例予以氟康唑、6例予以伊曲康唑治疗,疗程6-12个月,随访6个月-33个月。肺部病灶均有不同程度的吸收。结论非免疫缺陷肺隐球菌病的临床表现无特异性,胸部CT扫描多表现为多发或单发结节和肿块。49例乳胶凝集试验阳性,阳性率达92.4%。在随访中,治疗后的乳胶凝集定量试验滴度较治疗前明显下降。随访51例患者中,46例氟康唑治疗中,治愈30例,好转16例;而5例伊曲康唑治疗后均为好转。     

免疫功能正常肺隐球菌病23例诊断分析

目的提高临床医师对肺隐球菌病的认识。方法回顾分析2000年1月-2016年2月期间收治的23例肺隐球菌病的临床资料。结果 23例患者临床表现均缺乏特异性;胸部CT表现:59.7%为单发或多发结节、团块影,21.4%为肺部浸润实变影,18.9%为混合病灶。经穿刺活检病理确诊10例、术后病理确诊2例、支气管镜活检病理确诊1例;乳胶凝集试验阳性13例,其中病理与乳胶凝集试验均阳性的5例;脑脊液隐球菌墨汁染色阳性2例。结论肺隐球菌病临床、影像、缺乏特异性;病理检查为金标准、但易漏诊;乳胶凝集试验特异性高,可弥补病理检查不足。     

原发性肺隐球菌病临床与病理对照观察

目的探讨原发性隐球菌病（PC）的临床表现与病理变化特点。方法对23例肺原发性肺隐球菌病临床及病理资料进行对比分析,组织化学染色及光镜观察。结果23例中8例术前经肺穿刺活检明确诊断,15例开胸探查,病理证实为此真菌病,病理诊断5例为粘液胶样病变,炎性肉芽肿病变12例,结节状纤维肉芽肿病变6例,所有病例均检出新型隐球菌并行手术病灶切除,粘液卡红（Mc）,过碘酸雪夫染色（PAS）及六胺银（GMS）组织化学染色隐球菌呈阳性。术后3例并发隐球菌性脑膜炎,占本组病例13％（3／23）,本组病例术后经6周～3个月不同疗程的抗真菌治疗,术后随诊3个月～1年,均无隐脑及肺部复发。结论PC的临床与影像学表现均无特异性,肺穿刺活检病理检查有助于此病的诊断,术后应常规抗真菌治疗,以防发生隐脑与肺部复发。     

肺活检确诊肺隐球菌病4例并文献复习

目的提高对肺隐球菌病的认识。方法回顾性分析2008年1月～2009年3月期间经肺活检病理确诊的4例肺隐球菌病患者的临床资料。结果男性3例,女性1例,年龄24～58岁。农民2例（其中1例曾经种蘑菇7年）,小商贩和教师各1例。1例8年前因右肺球孢子菌病行右下叶肺切除术。4例人类免疫缺陷病毒（HIV）抗体检测均阴性。胸部X线和CT检查：4例均为双肺多发斑片状、斑点状、结节或团块状阴影,伴有透亮区3例。诊断及病理：经纤支镜肺活检病理示隐球菌性肉芽肿3例,其中过碘酸雪夫（PAS）染色阳性1例;经皮肺活检病理示隐球菌性肉芽肿1例。治疗和随访：4例患者住院41～119天;经抗真菌治疗6个月,患者症状均缓解或减轻,复查胸部CT示病灶均有吸收好转。结论经纤支镜和经皮肺活检是确诊肺隐球菌病简便、易行、微创的方法。     

A clinicopathological study of pulmonary cryptococcosis--chest CT and pathologic correlation]

We reviewed the clinicopathological features in 12 patients (7 males and 5 females; mean age 54 yr) with pulmonary cryptococcosis. Eleven of the patients were asymptomatic and the disease was detected by chest radiograph abnormalities. The underlying systemic disease had been diagnosed as diabetes mellitus in two. Chest CT scans showed a solitary nodule in 9 of the 12 patients, multiple nodules in 2, and infiltration in 1. The nodular diameter was less than 2 cm in 10 of the 12. All nodules were located in the subpleural region. On the chest CT, cavitary nodules, scattered nodules, or both, and spiculated nodules were difficult to distinguish from pulmonary tuberculosis and primary lung cancer, respectively. According to McDonnell's pathological classification of pulmonary cryptococcosis, the resected 8 lungs revealed peripheral pulmonary granuloma in 5 and granulomatous pneumonia in 3. It is important to perform a pathological examination for the diagnosis of pulmonary cryptococcosis to avoid misdiagnosis as lung cancer or pulmonary tuberculosis.     

病理确诊的肺隐球菌病38例临床分析

目的 探讨肺隐球菌病的临床特点、影像学表现、病理特征、治疗方法及预后。方法收集南京军区福州总医院2003年3月至2010年2月经病理确诊的38例肺隐球菌病患者的临床资料,并对相关资料进行分析。结果 38例均为社区获得性肺炎,其中男29例,女9例,年龄21～70岁,平均(47±13)岁。38例中伴基础疾病者9例。流式细胞分析CD4细胞正常20例。影像学表现：35例病变靠近胸膜,以下肺部受累多见,其中左下肺21例,右下肺23例;单发结节影11例,多发结节影16例,多发斑片状影3例,肿块伴多发结节5例,弥漫性肺实质浸润影3例;4例患者行18F-脱氧葡萄糖正电子发射计算机断层显像(PET-CT)检查,病灶均有较高的标准化摄取值（SUV值）。经皮肺穿刺活检确诊33例,开胸手术确诊1例,胸腔镜手术确诊3例,淋巴结活检确诊1例。治愈34例,显效3例,死亡1例。结论 在门诊就诊的肺部阴影患者中,肺隐球菌病应作为诊断及鉴别诊断的疾病之一。肺隐球菌病的影像学表现具有病灶多发、靠近胸膜及多位于下肺部等特点,但临床表现无特异性。经皮肺穿刺活检是确诊的有效方法之一。     

Study on pulmonary cryptococcosis disclosed by chest radiographic screening in Nagasaki Prefecture]

We conducted a retrospective investigation of 20 cases of pulmonary cryptococcosis discovered by chest radiographic screening in Nagasaki Prefecture among 2,011,577 persons over a period of 9 years, Apr. 1989-Mar. 1998. Eight males and 12 females between 15 and 72 years of age(mean: 46.6 years) were diagnosed as having pulmonary cryptococcosis. The mean detectability of pulmonary cryptococcosis by screening was 0.99 per 10(5) persons: 1.30 for residents, 0.51 for school children and 0.80 for workers. Chest radiography showed shadows of solitary nodules in 9 patients, multiple nodules in 4, infiltration in 4 and others in 3. Cavities were noted in 7. However, it was difficult to distinguish between pulmonary cryptococcosis from pulmonary tuberculosis and pulmonary cancer based on radiographic data alone. Final diagnoses for 11 and 3 patients, respectively, were made using TBLB or BAL, and lung biopsy. Sixteen patients each underwent an Eiken-Latex agglutination test (serum cryptococcus antigen test) and 15 (93.8%) had positive results. The serum antigen level thus appears to be a useful indicator in the supplementary serological diagnosis of pulmonary cryptococcosis.     

肺内恶性孤立性小结节的CT征像特征分析与诊断

目的通过对肺内恶性孤立性小结节CT影像特征的分析,不断提高CT对恶性孤立性肺结节的检出率。方法全面、系统地回顾、分析134例肺内孤立性小结节患者的临床资料。结果 134例肺内孤立性小结节患者中,病检恶性80例(59.70%);病检和CT均诊断为恶性者78例,CT与病检符合率为97.5%,病检确诊为恶性而CT征像不支持者2例(2.50%),CT诊断为恶性,而首次病检不支持,再次病检支持者1例(1.25%);81例结节≥2.0 cm者,恶性75例(92.59%);53例结节2 cm者,恶性3例(5.66%);右肺结节恶性率为73.21%,明显高于左肺的43.59%(P0.05);恶性结节CT影像表现中胸膜凹陷征、引流线征、血管集束征、毛刺征、棘突征、分叶征、空泡和细支气管充气征,征像所占比例明显高于良性结节(P0.05);85.90%的恶性结节病例表现为3种以上基本影像征像并存。结论肺内孤立性结节恶性率高,其发病的部位和影像表现均具有其一定的特征性,CT诊断具有较高的检出率,在CT诊断过程中,要紧紧围绕结节的部位和影像征像进行仔细分析鉴别,对一时难以定论的结节要积极开展动态观察,以提高恶性孤立性肺结节的检出率,减少误诊和漏诊。     

Clinical features and high-resolution CT findings of pulmonary cryptococcosis in non-AIDS patients

The objective of this study was to clarify clinical and high-resolution computed tomography (HRCT) characteristics in non-AIDS patients with pulmonary cryptococcosis. We analyzed the medical records and HRCT scans in 22 patients with pulmonary cryptococcosis from 1988 to 2003. Thirteen patients (59%) were immunocompetent and nine (41%) were immunosuppressed, seven of whom had diabetes mellitus. No patients exhibited extrapulmonary involvement. Nineteen patients (86%) were asymptomatic. Radiography revealed incidental chest abnormality in all but two patients. The typical HRCT findings were solitary or multiple nodules in the subpleural area. Cavitation was present in 30% of the patients who had nodules. The most frequently applied and reliable diagnostic procedure was video-assisted thoracoscopic surgery (VATS). Treatment included antifungal therapy alone in 11 patients, surgery alone in eight including four treated by VATS, surgery plus antifungal therapy in two and none in one. Patients who underwent surgery alone did not develop any relapse. The majority of non-AIDS patients with pulmonary cryptococcosis present with incidental chest radiographic abnormalities. The most common HRCT findings are solitary or multiple nodules with or without cavitation in the subpleural areas of the lung. VATS is a useful tool for both diagnosis and treatment of isolated pulmonary cryptococcosis.     

原发性肺隐球菌病52例临床及影像学表现和病理特征

目的 探讨原发性肺隐球菌病(pulmonary cryptococcosis,PC)的临床表现、病理特征、影像学特点及术前误诊原因.方法 回顾分析1998-2008年上海市中山医院收治的52例PC患者的临床、影像学及病理资料.结果 52例PC患者中,男36例,女16例,年龄17～80岁,中位年龄48岁.临床症状较轻,首发症状依次为咳嗽、咳痰及胸痛等.52例中13例既往有慢性疾病或肿瘤病史,其中肝癌并肝移植术后、糖尿病、结核及慢性活动性肝炎各2例,垂体瘤及结节病各1例,糖尿病合并肝痛及肺结核、糖尿病合并结核性胸膜炎及糖尿病合并高血压各1例.45例患者行胸部CT扫描,其中单发或多发结节团块37例,空洞4例,大叶实变3例,弥漫混合性病变1例;CT诊断为恶性肿瘤27例,肺炎15例,结核3例.49例光镜下表现为肉芽肿性病变,3例表现为纤维结缔组织病灶,Grocott六胺银及黏液卡红染色病灶内均可见新型隐球菌.结论 免疫功能正常者亦有发生PC的可能;临床及影像学表现缺乏特征性,且临床症状与影像学表现不符,易误诊为肺癌、肺炎或肺结核;诊断有赖于病理组织学检杳;CT引导下经皮肺穿刺等非开胸肺切除的方法有助于该病的早期诊断.     

Clinical investigation of 15 patients with pulmonary cryptococcosis--clinical comparison of HTLV-I carriers and non-carriers]

We investigated 15 pulmonary cryptococcosis patients. The group had a mean age of 51.7 years, and 6 (40%) of the patients were women. Cryptococcosis was primary in 13 patients and secondary in 2 (diabetes mellitus and smoldering adult T-cell leukemia). Eight patients were asymptomatic and 9 patients were detected by medical examinations. Dry cough was the most common symptoms. On chest radiographs, 5 patients showed solitary nodules, 4 patients showed infiltrative shadows, and 4 patients showed multiple nodules. The right lower lobe was the predominant location of solitary nodules, and the left upper and middle lung fields were the predominant locations of infiltrative shadows. Transbronchial lung biopsy was the method of diagnosis for 9 patients, and open lung biopsy for the others. Eleven patients were treated with fluconazole, and the mean treatment period was 7 months. Four patients underwent, resection procedures only, and experienced no recurrence. Five patients were positive for HTLV-I (one had smoldering ATL) and 5 were negative. Eighty percent of the HTLV-I positive patients had some symptoms and 80% of the HTLV-I negative patients were asymptomatic. HTLV-I positive patients showed various pulmonary shadows and 80% of the HTLV-I negative patients showed solitary nodules. The pulmonary lesions in HTLV-I positive patients were more extensive than those in HTLV-I negative patients (p < 0.05). We postulate the possible existence of subtle immunological abnormalities, including abnormalities of cellular immunity, in HTLV-I carriers.     

Six cases of primary pulmonary cryptococcosis]

Six patients with asymptomatic primary pulmonary Cryptococcosis are reported. In all of the patients, the disease was detected by annual chest X-ray during mass screening for lung cancer or during follow-up for pulmonary tuberculosis or gastric cancer. The chest X-ray findings consisted of a solitary pulmonary nodule in 4 patients and multiple pulmonary nodules in 2. Only one patient who could not be histologically diagnosed by bronchofiberscopy underwent surgical resection. However, the other 5 patients were histologically diagnosed by transbronchial biopsy with bronchofiberscopy. They were treated with oral antifungal agents, namely flucytosine (5-FC) and/or fluconazole, with marked improvement of chest X-ray findings. These results indicate that transbronchial biopsy with bronchofiberscopy and oral administration of antifungal agents instead of initial surgical resection are useful in the diagnosis and treatment of primary pulmonary cryptococcosis.