免疫受损患者肺部感染的诊断

随着肿瘤化放疗技术的进步及患者生存期延长、器官移植的发展、艾滋病病毒(HIV)感染和艾滋病(AIDS)的出现,近年来免疫受损(ICH)患者明显增加.肺是免疫受损患者最为常见的感染靶器官.因此,ICH并发肺部感染是目前临床所面临的一大挑战和难题,探讨其诊断思路显得尤为必要.     

继发性非人类免疫缺陷病毒免疫受损宿主的肺部感染

免疫受损宿主（immunocompromised host，ICH），也被译为免疫低下宿主，指免疫应答或其它防御机制削弱或改变者.近年来，随着肿瘤放化疗技术的发展，器官移植的突破，糖皮质激素等免疫抑制药物在胶原性疾病等其它一些慢性疾病中的广泛应用，以及人类免疫缺陷病毒（human immunodeficiency virus，HIV）的出现和流行，免疫损害宿主的数量较前有了明显增加.感染成为影响这类患者病程和愈后的最主要因素，其中又以肺部感染最常见.各项报道显示在ICH肺部并发症中感染约占3/4，而病死率可达39%.如此高的发病率和病死率不得不引起临床医生的警惕，因此在ICH患者出现发热，肺部浸润等症状时，必须做到早期诊断，早期治疗，以挽救患者的生命.有报道显示，诊断时间是影响免疫损害宿主肺部感染预后情况的一项重要因素 .本文主要针对非HIV感染的免疫受损宿主肺部感染加以叙述。     

X线平片与CT对HIV肺部感染的诊断价值比较

目的探讨X线平片与CT用于人体免疫缺陷病毒(HIV)并发肺部真菌感染的诊断价值。方法随机抽取2014年7月-2016年7月,60例在我院接受诊断治疗的HIV肺部感染患者资料,对肺部真菌感染进行分组诊断,对照组(X线平片检查)、观察组(CT检查);结合诊断结果,对比2组患者肺部真菌感染的阳性率,对真菌感染者提出科学的治疗方案。结果本次60例肺部真菌感染患者,真菌培养100%阳性,2组诊断结果中,观察组43例阳性,阳性率71.7%,对照组6例阳性,阳性率10%;CT检查明显优越X线平片检查。从真菌分布来看,本次检出60珠真菌,白色假丝酵母菌42例,占70%,热带假丝酵母菌10例、光滑假丝酵母菌6例、毛霉菌属1例、曲霉菌属1例。结论 CT检查用于HIV肺部真菌感染诊断效果更高,为感染症状治疗提供了临床参考依据,值得推广。     

糖皮质激素联合免疫抑制剂治疗肾脏疾病并发肺部机会性感染的诊断与治疗

目的 了解糖皮质激素联合免疫抑制剂治疗肾脏疾病并发肺部机会性感染的特点和治疗经验.方法 回顾性总结2007年2月互2008年5月解放军总医院肾脏科和急诊科收治的11例应用糖皮质激素联合免疫抑制剂治疗后出现严重肺部感染的肾脏疾病患者,分析患者的临床资料和随访结果.结果 所有患者呼吸系统症状均在治疗8周后出现,进行性呼吸困难为主要临床表现,5例患者出现呼吸衰竭,肺部影像学显示为两肺局灶性或弥漫性毛玻璃样病变,免疫学检查显示患者免疫功能基本正常,病原学检查所有患者血清人类免疫缺陷病毒(HIV)抗体阴性,1例患者血清巨细胞病毒IgM抗体阳性,1例痰培养烟曲霉菌阳性,其余患者未查到病原体,患者分别给予抗病毒和抗真菌感染或二者联合治疗,根据患者呼吸衰竭严重程度辅以无创或有创呼吸机辅助呼吸,最终2例患者死亡,其余患者病情好转出院,随访1个月至1年肺功能恢复正常.结论 肾脏病患者应用糖皮质激素联合疫抑制剂治疗过程中要警惕肺部机会性感染的发生,及时诊断和早期行综合治疗有利于改善患者预后.     

41例肾移植术后肺部感染临床分析

目的探讨肾移植术后肺部感染的临床表现、病原体、治疗及转归。方法对41例肾移植术后肺部感染患者临床资料进行回顾性分析。结果主要临床表现为发热、咳嗽、气促，仅21例（51．2％）可闻及肺部音。多数患者（24例，58．5％）X片或CT表现为双肺受累，10例（24．4％）有双肺间质性改变。病原体17例（41．5％）为细菌，其次为真菌、病毒、支原体和结核杆菌。经治疗后34例患者（82．9％）治愈，3例（7．3％）无效，4例（9．8％）死亡。结论肾移植术后肺部感染临床表现无特异性，病原体主要为革兰阴性菌和条件致病菌，经积极有效的治疗后能取得较好的疗效。     

肺部感染的诊断与治疗 免疫受损患者肺部感染的诊断

随着肿瘤化放疗技术的进步及患者生存期延长、器官移植的发展、艾滋病病毒 (HIV)感染和艾滋病 (AIDS)的出现 ,近年来免疫受损 (ICH)患者明显增加。肺是免疫受损患者最为常见的感染靶器官。因此 ,ICH并发肺部感染是目前临床所面临的一大挑战和难题 ,探讨其诊断思路显得尤为必要。1　 ICH的认定对疑及 ICH患者 ,首先需要鉴别其感染系在有 ICH情况下所致或其他状况时引起。如属 ICH,则须区分其受损的类型 ,如原发性或继发性 ,特异性或非特异性 ,细胞、体液或联合 ICH。体液 ICH的诊断标准为 :反复细菌感染 ;血液中免疫球蛋白含量…     

AIDS合并肺部感染116例临床分析

目的探讨AIDS合并肺部感染的临床特点。方法回顾性分析我院临床确诊的116例合并肺部感染的AIDS患者的临床表现、实验室资料、影像学表现及治疗预后。结果最常见的是细菌性肺炎(54例,46.6%),其次是肺结核(40例,34.5%)、肺孢子菌肺炎(14例,12.1%)、马尔尼菲青霉菌肺炎(3例,2.6%)、隐球菌肺炎(2例,1.7%)、淋巴细胞间质性肺炎(2例,1.7%)和巨细胞病毒性肺炎(1例,0.9%)。死亡12例(10.3%),另有12例(10.3%)因病情加重自动出院。结论肺部感染是AIDS的主要机会性感染,病原学的复杂性导致诊疗更加困难,影像学检查可能有助于诊断。AIDS患者如发生肺部感染,尤其是合并其他并发症时,预后不良。     

艾滋病患者肺部感染136例临床分析

目的探讨HIV/AIDS合并肺部感染的临床特点。方法回顾性分析我院临床确诊的136例HIV/AIDS肺部感染临床表现,以及免疫功能,影像学表现。结果 HIV/AIDS肺部感染最常见的类型是肺结核,共73例（占53.7%）,其次是PCP33例（占22.8%）和细菌性肺炎23例（占21.3%）。其临床特点、X线和CT表现具有一定的特征。结论肺部感染是艾滋病患者晚期的主要机会性感染。临床表现复杂多样,诊断困难,治疗效果差,预后差。     

肺孢子菌肺炎31例临床分析

目的探讨研究肺孢子菌肺炎患者的临床特点、影像学表现及治疗方法。方法分析在我院诊断的肺孢子菌肺炎的31例患者的临床资料。结果 31例患者中HIV/AIDS患者28例,非AIDS患者3例,其中男性22例,女9例,年龄23~75岁。主要临床表现为咳嗽,气促者28例(90.3%),发热25例(80.6%),咳痰17例(54.8%),乏力,纳差15例(48.3%),胸痛8例(25.8%),腹泻4例(12.9%),反复皮疹3例(9.6%)。3例患者行无创通气,1例因严重肺部感染,低氧血症,行有创机械通气。31例患者胸部CT均表现为典型的双肺弥漫性磨玻璃影,所有患者均选用复方磺胺甲基异噁唑治疗,对吸空气时血氧分压PaO2低于70 mmHg患者给予激素治疗。结论当AIDS患者或免疫抑制患者出现发热,咳嗽,呼吸困难,低氧血症,其胸部CT提示典型的双肺弥漫性磨玻璃影,需考虑PCP的可能,但其病原学检查困难,治疗以复方磺胺甲基异噁唑及激素治疗为主。     

2158例MTB/HIV双重感染患者治疗转归及影响因素分析

目的 分析MTB/HIV双重感染患者治疗转归情况及影响因素,为有效防控MTB/HIV双重感染疫情提供科学依据。方法 收集2017—2019年四川省结核病定点医疗机构诊断并登记为MTB/HIV双重感染且接受治疗的2249例患者。排除无原因及时间停止治疗、诊断变更、单耐药或耐多药的情况,最后纳入2158例。收集患者的人口学特征(性别、年龄、民族、职业)、患者发现方式(患者来源、首诊机构级别)与患病特征(有无并发其他结核、是否重症、HIV阳性检查时间、病原学检查结果、耐药情况、治疗分类、确诊AIDS年限)等,分析患者的治疗转归情况及影响因素。 结果 2158例患者中,治愈442例、完成疗程1505例,治疗成功率为90.22%(1947/2158),不良结局率为9.78%(211/2158),包括非结核死亡134例(6.21%)、丢失22例(1.02%)、因结核死亡16例(0.74%)、因药物不良反应停止治疗13例(0.60%)、失败7例(0.32%)、转入耐多药治疗1例(0.05%)、其他18例(0.83%)。多因素分析结果显示,与首诊机构为市级的患者相比,到县级就诊的患者发生不良结局的风险较小(OR=0.525,95%CI:0.288~0.955);与病原学检查结果为阴性及无病原学结果的患者相比,病原学检查为阳性的患者发生不良结局的风险是其1.433倍(OR=1.433,95%CI:1.053~1.951)。 结论 MTB/HIV双重感染患者中以市级为首诊机构、病原学检查阳性的患者不良结局发生率较高,应加强对到市级医疗机构首诊、病原学检查为阳性的患者的健康教育、疗效观察,并及时调整治疗方案,以提高MTB/HIV双重感染患者的治疗成功率,改善患者的预后。     

Prognostic factors of non-HIV immunocompromised patients with pulmonary infiltrates

STUDY OBJECTIVES: To assess the outcome and the prognostic factors in 200 non-HIV immunocompromised patients with pulmonary infiltrates (PIs). DESIGN: Prospective observational study. SETTING: An 800-bed university hospital. PATIENTS: Two hundred non-HIV immunocompromised patients (hematologic malignancies, 79 patients; hematopoietic stem cell transplants [HSCTs], 61 patients; and solid-organ transplants, 60 patients). METHODS: Investigation of prognostic factors related to mortality using a multiple logistic regression model. RESULTS: Specific diagnosis of the PI was obtained in 78% of the cases (infectious origin was determined in 74%). The overall mortality rate was 39% (78 of 200 patients). Patients with HSCT had the highest mortality rate (53%). A requirement for mechanical ventilation (odds ratio [OR], 28; 95% confidence interval [CI], 9 to 93), an APACHE (acute physiology and chronic health evaluation) II score of > 20 (OR, 5.5; 95% CI, 2 to 14.7), and a delay of > 5 days in establishing a specific diagnosis (OR, 3.4; 95% CI, 1.2 to 9.6) were the variables associated with mortality at the multivariate analysis. The subgroup analysis based on underlying disease confirmed the prognostic significance of these variables and the infectious etiology for the PI. CONCLUSIONS: Mortality in immunocompromised patients is high, particularly in patients undergoing HSCT. Achieving an earlier diagnosis potentially may improve the mortality rate of these patients.     

Pulmonary infections diagnosed by BAL: a 12-year experience in 1066 immunocompromised patients

Bronchoalveolar lavage (BAL) is a useful tool in the diagnosis of pulmonary infections in immunocompromised patients. We aimed to compare the spectrum of infectious pulmonary complications diagnosed using BAL in a large consecutive cohort of immunocompromised patients. The diagnostic yield of 1066 BAL specimens was analyzed in 4 different groups of immunocompromised patients (HIV; solid organ transplants; high-dose chemotherapy and/or stem cell transplants; other immunosuppressive therapy) suffering from fever, respiratory symptoms and/or infiltrates on chest X-ray. Specimens were analyzed for bacteria, mycobacteria, fungi, Pneumocystis jiroveci, cytomegalovirus (CMV) and other viruses. Two time periods were compared (1992-1996; 1997-2003). The overall diagnostic yield of BAL was 34% for bacteria, 22% for CMV, 15% for P. jiroveci, 6% for other viruses, 6% for mycobacteria and 2% for aspergillus. There were significant changes in the pattern of opportunistic infections between the 2 time periods. Mycobacterial infections decreased considerably in the HIV group (17.9 vs. 8.5%, P=0.02), while the incidence of P. jiroveci decreased mainly in the transplant group (32.6 vs. 7.9%, P<0.00001). This study demonstrates a changed pattern of pulmonary infections in immunocompromised patients diagnosed by BAL. The overall diagnostic yield of BAL remains high in immunocompromised patients with respiratory symptoms.     

Characterization of Cytomegalovirus Lung Infection in Non-HIV Infected Children

Cytomegalovirus (CMV) is a prevalent pathogen in the immunocompromised host and invasive pneumonia is a feared complication of the virus in this population. In this pediatric case series we characterized CMV lung infection in 15 non-HIV infected children (median age 3 years; IQR 0.2–4.9 years), using current molecular and imaging diagnostic modalities, in combination with respiratory signs and symptoms. The most prominent clinical and laboratory findings included cough (100%), hypoxemia (100%), diffuse adventitious breath sounds (100%) and increased respiratory effort (93%). All patients had abnormal lung images characterized by ground glass opacity/consolidation in 80% of cases. CMV was detected in the lung either by CMV PCR in bronchoalveolar lavage (82% detection rate) or histology/immunohistochemistry in lung biopsy (100% detection rate). CMV caused respiratory failure in 47% of children infected and the overall mortality rate was 13.3%. Conclusion: CMV pneumonia is a potential lethal disease in non-HIV infected children that requires a high-index of suspicion. Common clinical and radiological patterns such as hypoxemia, diffuse adventitious lung sounds and ground-glass pulmonary opacities may allow early identification of CMV lung infection in the pediatric population, which may lead to prompt initiation of antiviral therapy and better clinical outcomes.     

The Diagnostic Yield,Safety, and Impact of Flexible Bronchoscopy in Non-HIV Immunocompromised Critically Ill Patients in the Intensive Care Unit

Background

Flexible bronchoscopy (FB) and bronchoalveolar lavage (BAL) have major roles in the evaluation of parenchymal lung diseases in immunocompromised patients. Given the limited evidence, lack of standardized practice, and variable perception of procedural safety, uncertainty still exists on what constitutes the best approach in critically ill patients with immunocompromised state who present with pulmonary infiltrates in the era of prophylactic antimicrobials and the presence of new diagnostic tests.

Objective

To evaluate the diagnostic yield, safety and impact of FB and BAL on management decisions in immunocompromised critically ill patients admitted to the intensive care unit (ICU).

Methods

A prospective, observational study of 106 non-HIV immunocompromised patients admitted to the intensive care unit with pulmonary infiltrates who underwent FB with BAL.

Results

FB and BAL established the diagnosis in 38 (33%) of cases, and had a positive impact on management in 44 (38.3%) of cases. Escalation of ventilator support was not required in 94 (81.7%) of cases, while 18 (15.7%) required invasive and 3 (2.6%) required non-invasive positive pressure ventilation after the procedure. Three patients (2.6%) died within 24 h of bronchoscopy, and 46 patients (40%) died in ICU. Significant hypoxemia developed in 5% of cases.

Conclusion

FB can be safely performed in immunocompromised critically ill patients in the ICU. The yield can be improved when FB is done prior to initiation of empiric antimicrobials, within 24 h of admission to the ICU, and in patients with focal disease.

     

Respiratory viruses and severe lower respiratory tract complications in hospitalized patients

BACKGROUND: Acute respiratory viral infections are generally self-limited in healthy subjects but can lead to severe complications in immunocompromised hosts. We report the clinical impact of acute lower respiratory tract viral infections in hospitalized patients. MATERIALS AND METHODS: Of 1,001 fiberoptic bronchoscopies performed during a period of 5 years, 33 BAL samples were positive for respiratory viruses by cell culture. The main diagnosis, length of hospitalization, response to initial treatment, and the mortality rate at 30 days were analyzed. Spirometry performed before and after infection was compared in lung transplant recipients. RESULTS: The following respiratory viruses were identified in 33 cases: influenza A or B (n = 13), parainfluenza virus 1-3 (n = 7), rhinovirus (n = 5), respiratory syncytial virus (n = 4), and adenovirus (n = 4). All cases were immunocompromised patients who acquired new respiratory symptoms and/or radiologic abnormalities suggesting a pulmonary infection. Twenty-five patients (74%) did not respond to initial broad-spectrum antibiotics, and 11 patients (33%) required intensive care for respiratory failure. The overall mortality rate at 1 month was 24%. In patients with a sole viral pathogen identified in their BAL, the mortality rate was 39%. In lung transplant recipients (n = 10), the mean FEV(1) decreased from 2.2 to 1.9 L/s before and during the infection episode, respectively (p < 0.01); 3 months later, 60% of the patients had still not completely recovered to baseline values. CONCLUSION: Respiratory viruses recovered in BAL samples of immunocompromised patients are associated with severe lower respiratory complications. In lung transplant recipients, we observed a persisting impairment of pulmonary function.     

中国大陆肺孢子虫肺炎回顾性研究

目的 分析中国大陆1959-2006年间肺孢子虫肺炎（PCP）的流行特点和趋势，为PCP的防治提供依据。方法 利用互联网资源，从中国生物医学文献系统web版（CBM）等数据库搜索PCP病例报告，排除重复报道及不可信病例，（1）从基础疾病等多个角度对比分析21世纪前、后我国PCP流行特点和趋势，（2）从HIV／AIDS患者的机会感染频率的角度分析文献报道的HIV感染者或AIDS患者中PCP的发病情况。结果 （1）1959-2006年文献报道的PCP共384例，1959-2000年报道的有100例，其中HIV／AIDS相关PCP13例（占13％）；非HIV相关PCP87例，主要涉及抗肿瘤化疗41例（41％），肾移植15例（15％）及其他原因导致免疫机能低下者24例（24％）等。2001-2006年间报道了284例，其中HIV／AIDS相关PCP160例（占56．3％）。（2）在检获的HIV／AIDS患者合并PCP11份文献中，报道了1985-2006年诊断的AIDS患者共1249例，其中合并PCP163例（13．1％）。结论 21世纪以前，我国大陆PCP的基础疾病主要是非HIV感染者（87％）；21世纪以后主要为HIV／AIDS患者（56．3％）。但中国大陆AIDS患者合并PCP的发牛率仅为13．1％（163／1249）。     

异基因造血干细胞移植后肺部侵袭性真菌感染现行诊断标准的应用价值

  目的 分析我国现行血液病/恶性肿瘤患者侵袭性真菌感染诊断标准的可操作性,提高对异基因造血干细胞移植（allo-HSCT）后肺部侵袭性真菌感染特点的认识。方法 回顾性分析连续收治的51例allo-HSCT后肺部侵袭性真菌感染病例的临床特点。结果 肺部侵袭性真菌感染共占同期收治allo-HSCT后肺部感染病例的42.1%（51/121）。确诊1例（2.0%）,临床诊断24例（47.1%）,拟诊26例（51.0%）。使用免疫抑制剂、糖皮质激素和存在移植物抗宿主病为主要宿主因素。2种或2种以上宿主因素同时存在的病例占66.7%(34/51)。94.1%(48/51)病例的肺部高分辨CT表现为结节和（或）斑片影。真菌抗原检测阳性率相对较高［(1,3)-β-D葡聚糖（G）试验阳性率58.6%,半乳甘露聚糖（GM）试验阳性率33.3%］。20例（39.2%）患者伴有动脉血氧分压和氧饱和度下降。结论 使用免疫抑制剂、糖皮质激素和存在移植物抗宿主病为主要宿主因素,肺部高分辨CT表现以结节和（或）斑片影多见,真菌抗原检测是支持临床诊断的主要因素。     

肺真菌病59例病原学和影像学分析

目的：探讨肺真菌病的病原学分布和影像学特征。方法收集肺真菌病59例,均经支气管镜、经皮肺穿刺活检或手术切除送病理学确诊,分析其病原学分布和影像学特征。结果59例病理学确诊肺真菌病患者中,肺曲霉病24例（40．7％）,肺隐球菌病24例（40．7％）,肺毛霉病5例（8．5％）,肺念珠菌病4例（6．8％）,组织胞浆菌病2例（3．4％）,合并放线菌肺炎1例（1．7％）。胸部影像学改变包括肺部肿块23例（39．0％）,渗出性病变23例（39．0％）,结节8例（13．6％）,支气管肿物3例（5．1％）,空洞病变1例（1．7％）,弥漫性病变1例（1．7％）。误诊为肺炎12例（20．3％）,肺结核7例（11．9％）,肺癌4例（6．8％）。结论病理学确诊的肺真菌病以肺曲霉病和肺隐球菌病为多见,影像学表现主要以肺部肿块影和渗出性病变为主。肺真菌病影像学表现多种多样、缺乏特征性,诊断应尽早取得病理学依据。     

继发性免疫抑制患者肺部感染病原及死亡相关因素分析

目的探讨继发性免疫抑制患者（ＩＣＨ）肺部感染的病原体分布及影响预后的相关因素。方法对１９８６年１２月～１９９６年１２月期间经病原学和（或）病理学确诊的ＩＣＨ并发肺部感染８０例进行回顾性分析。结果病原体（除巨细胞病毒）分布：普通细菌４５例（５６％），结核杆菌２３例（２９％），真菌９例（１１％），卡氏肺囊虫３例（４％）。ＩＣＨ并发肺部感染的病死率，年龄＜６０岁为４８％，≥６０岁为６７％，并发菌血症的病死率为８６％，无菌血症的病死率为４５％，白细胞计数＞１０×１０９／Ｌ和＜４０×１０９／Ｌ的病死率分别为６７％，８７％，（４０～１０）×１０９／Ｌ病死率为２３％，弥漫性病灶和局限性病灶病死率分别为６５％和２３％（Ｐ＜０．０５，Ｐ＜０．０１）。ＩＣＨ并发肺部感染的病死率在年龄、有无菌血症、白细胞计数高低、病灶累及范围方面差异有显著性。病死率在性别、基础疾病、病原体种类、混合感染方面差异无显著性（Ｐ＞０．０５）。结论细菌是ＩＣＨ肺部感染最常见的病原体之一，在我国ＩＣＨ肺结核的激活和复燃应引起足够重视。