慢性坏死性肺曲霉病

慢性坏死性肺曲霉病是曲霉菌引起的一种慢性肺组织坏死的过程,常发生于原有基础肺病和轻度免疫抑制的患者。其临床表现无特异性,与肺结核和肺曲霉球非常相似,确诊依赖于组织病理检查和真菌培养。药物治疗可选择两性霉素B和伊曲康唑,手术治疗仅有部分患者获益。     

慢性坏死性肺曲霉病与肺曲霉球临床病理比较分析

目的 了解慢性坏死性肺曲霉病(CNPA)与肺曲霉球的临床表现、影像学和病理学特点.方法 回顾性分析2000至2004年浙江大学附属第一医院手术和病理证实的8例CNPA和26例肺曲霉球患者的临床表现、影像学和病理资料.结果 CNPA和肺曲霉球在发病年龄上差异无统计学意义,且都好发于陈旧性肺结核与肺脓肿患者.8例CNPA患者均有咳嗽、咳痰,7例咯血,5例伴全身中毒症状.26例肺曲霉球患者中,最常见的症状为咯血,有25例,咳嗽、咳痰17例,2例伴有全身中毒症状.影像学上,CNPA和肺曲霉球均可出现空气新月征,有提示性诊断意义,但前者空洞周围有浸润阴影、洞壁较厚和洞壁不规则等特征.病理学上,CNPA和肺曲霉球都可见锐角分支、有隔膜的曲霉菌丝,但前者的特点是肺组织内有曲霉菌丝侵袭、组织坏死和肉芽形成,曲霉菌只在空洞或扩张成囊的支气管内生长,不侵犯肺组织.结论 组织病理检查是鉴别CNPA和肺曲霉球的金标准,临床和影像学检查也有一定价值.     

慢性坏死性肺曲霉病的诊断与治疗

目的 探讨慢性坏死性肺曲霉病（CNPA）的诊断与治疗。方法本研究包括8例2000年至2004年间在浙江大学医学院附属第一医院经病理证实的慢性坏死性肺曲霉病住院病例，结合文献分析其临床表现、影像学、诊断和治疗方法。结果CNPA是少见的一种肺曲霉病。最常见的症状是咳嗽、咳痰（8／8）、咯血（7／8）和全身中毒症状（5／8）。“空气新月征”有提示性诊断意义，在本组共发现4例，实变阴影也较为多见（5／8）。CNPA的病理特点是肺组织内曲霉菌丝侵袭、组织坏死和肉芽形成。结论CNPA的临床表现无特异性，影像学检查在其诊断中起重要作用，其诊断需要病理依据支持。所有CNPA患者都需要系统抗真菌药物治疗，对于病程迁延和反复咯血者可以考虑手术切除。     

17例肺曲霉病临床分析

目的探讨肺曲霉病的临床特征、诊断及治疗方法。方法收集武汉大学人民医院和中南医院呼吸科和胸外科2003年-2009年间17例肺曲霉病确诊病例,对其病例特点进行分析。结果 17例患者中男性13例,女性4例,平均年龄44.3岁。确诊方法：手术病检确诊8例,经纤维支气管镜病检确诊9例。基础疾病：肺癌4例,急性白血病1例,支气管扩张2例,空洞性肺结核1例,AIDS 1例,肺大疱1例,肺囊肿1例。症状方面：咯血8例（痰中带血丝或少量咯血7例,日咯血量大于100 m l1例）,咳嗽咳痰6例,干咳3例,胸痛3例,呼吸困难4例,发热4例（高热1例,低热3例）。1例是在健康体检时胸片发现左上肺占位手术后确诊。X线影像学表现：占位性病变7例（其中4例与肺癌并存）,肺实变5例,多发结节4例,空洞形成3例,典型＂新月征＂仅1例。手术前均被误诊为肺结核或肺癌。结论肺曲霉病临床表现无特异性,痰培养阳性率不高,高分辨率CT检查在诊断中起重要作用,确诊需要病理依据。肺曲霉病患者易被误诊为肺结核、肺癌或并发于肺结核或肺癌。手术既可确诊又可切除病灶。     

无基础疾病及免疫缺陷的慢性坏死性肺曲霉病三例

曲霉(aspergillus)广泛存在于自然界,因机体的免疫状态、肺脏结构基础及孢子吸入量的不同,导致临床表现各异的肺曲霉病.临床上通常将肺曲霉病分为变应性支气管肺曲霉病(allergic bronchopulmonary aspergillosis,ABPA)、侵袭性肺曲霉病(invasive pulmonary aspergillosis,IPA)和曲霉球 (aspergilloma,fungal ball)[1].慢性坏死性肺曲霉病(chronic necrotizing pulmonary aspergillosis,CNPA)又称为半侵袭性肺曲霉病(semi-invasive pulmonary aspergillosis),20世纪80年代由Gefter等[2 ]和Binder等[3]首先报道.目前认为是一种局限性侵袭性肺曲霉病,常发生于原有肺部基础疾病的患者,如尘肺、COPD、肺癌、肺结核、肺叶切除术后、肺囊性纤维 化或轻度免疫功能缺陷的患者,如长期服用糖皮质激素、糖尿病、嗜酒、高龄、营养不良及慢性肉芽肿[1.3].现报道3例无基础疾病及免疫功能缺陷的CNPA病例.     

侵袭性肺曲霉病49例临床分析

目的 通过分析侵袭性肺曲霉病(IPA)病例,提高IPA临床诊治水平.方法 回顾性分析49例IPA患者的人口学资料、宿主因素、基础疾病、胸部CT表现、微生物检验、组织病理学检查、治疗和转归.结果 49例IPA患者确诊19例(38.8%),临床诊断30例(61.2%).3例(6.1%)无宿主因素,与1PA相关的宿主因素和基础疾病25例(51.0%),关系不肯定的基础疾病2l例(42.9%).胸部CT表现:结节29例次,斑片影15例次,团块12例次,实变10例次,空洞34例次,晕征19例次,支气管充气征18例次,新月征6例次,双肺影33例次,多发病灶38例次.痰真菌培养阳性率为26.5%(13/49),支气管肺泡灌洗液真菌培养阳性率为66.7%(10/15),曲霉半乳甘露聚糖试验阳性率为30.6%(11/36),肺组织病理检查阳性率为90.5%(19/21).烟曲霉为主要病原菌81.0%(17/21).抗真菌药物初始治疗有效率为50%(21/42).结论 IPA患者胸部影像学表现以双肺、多发、结节影、空洞为主,晕征、新月征少见.侵袭性诊断技术具有较好的诊断价值.     

关注非经典免疫抑制宿主的非典型肺曲霉病

肺曲霉病包括曲霉属真菌引起的侵袭性肺病和非侵袭性肺病,前者指侵袭性肺曲霉病（invasive pulmonary aspergillosis,IPA）及侵袭性气管支气管曲霉病,后者指曲霉真菌抗原和曲霉毒素引起的变态反应性支气管肺病及肺曲霉球。曲霉球多发生于肺结核、肺囊肿、肺脓肿、肺癌空洞及支气管扩张和肺囊性纤维化等结构破坏性肺病,曲霉菌呈局部定植寄生状态,多数患者无症状,少数患者可有反复少量咯血,偶尔发生大咯血,支气管动脉栓塞或手术切除曲霉球为有效治疗。变态反应性肺曲霉病,临床表现类似哮喘,对激素及口服伊曲康唑治疗反应良好。     

非免疫缺陷原发性肺隐球菌病21例临床分析

目的总结肺隐球菌病的临床资料,提高其诊疗水平。方法收集确诊的21例原发性肺隐球菌病患者的临床资料,对临床表现、实验室检查、影像学检查、病理学检查及治疗进行回顾。结果男性15例,女性6例。有基础疾病4例,无基础疾病17例。肺部症状不典型,有咳嗽、咳痰、发热、咯血、胸痛等;其影像学表现常见结节影、块影、片影等,可伴有空洞、毛刺等;孤立结节影6例,病灶累及双肺15例。初期误诊为肺癌行手术切除7例,误诊为结核4例,误诊为普通肺炎7例。17例抗真菌治疗有效,4例抗真菌治疗后行肺叶切除。结论肺隐球菌病临床及影像学表现不特异,无明显免疫缺陷者也可发病,常误诊为肺癌、肺结核、肺炎,确诊多依赖病理活检。多数患者抗真菌治疗有效,少数需手术治疗。     

肺隐球菌病与肺曲霉菌病临床特点对比分析

目的：探讨肺隐球菌病(pulmonary cryptococcosis,PC)和肺曲霉菌病(pulmonary aspergillosis,PA)的临床特点的差异,为这两种疾病的临床鉴别提供依据,减少误诊或漏诊。方法回顾性分析2011年1月至2014年12月共4年期间广西医科大学第一附属医院经病理分别确诊为PC (29例)、PA (39例)患者的临床资料,从人口学特征、临床表现、影像学资料进行对比分析。结果 PC 组中18例存在宿主因素(3例)和(或)基础疾病(15例),基础疾病中肺外基础疾病占12例;27例出现临床症状,最常见咳嗽、咳痰;影像学表现结节团块型最多,获取组织病理最多的方法为手术肺活检(19例),其次为经皮肺穿刺活检9例。PA 组中32例存在宿主因素(24例)和(或)基础疾病(32例),反复应用抗生素占18例,基础疾病中肺结核等肺部基础疾病占24例;33例出现临床症状,最常见咳嗽、咯血;影像学表现混合型最多,21例伴空洞形成,14例表现为空气新月征;获取病理方法手术肺活检最多。PC 组中结节团块型、伴胸膜增厚、支气管充气征、病灶分布于左肺下叶、行经皮穿刺肺活检的病例数与 PA 组比较差异有统计学意义(P <0.05);而 PA 组在反复抗生素应用、合并肺结核基础疾病、咯血、伴钙化影、近邻支气管扩张、薄壁不规则空洞、空气新月征与 PC组比较差异有统计学意义(P <0.05)。结论 PC 和 PA 患者宿主免疫因素及基础疾病有所不同,两组间症状无特异性,PA 出现咯血更常见,PC 影像主要表现为结节团块型及支气管充气征,多伴胸膜增厚,而 PA 以混合型为主,空气新月征和曲霉球为 PA 的特征性表现。     

肺真菌感染的CT征象分析

目的探讨肺真菌感染的MSCT影像学特征及诊断价值。方法回顾性分析肺真菌性感染患者11例,所有病例均行MSCT检查。结果结节位于左肺6例、右肺3例、双肺多发2例。10例为空洞、空腔内病灶呈圆形或类圆形,结节上缘可见＂新月征＂,周围可见＂气环征＂,其中1例结节内部可见点条样含气影,形成＂球内含气征＂。1例表现为肺内肿块,内可见空洞,但空洞内未见内含物或结节,肿块轮廓模糊,可见＂晕征＂。结论寄生于肺部空洞、空腔内真菌感染表现多种多样,若病灶内具有＂新月征＂、＂气环征＂,是CT的典型表现和诊断的可靠依据;而＂含气征＂和＂晕征＂等征象,对本病具有一定的提示作用。     

非粒细胞缺乏患者肺曲霉菌病 16 例临床研究简

目的 探讨非粒细胞缺乏肺曲霉菌病患者的临床表现、影像学特点及诊断治疗方法.方法回顾性分析16例确诊的肺曲霉菌病患者的临床资料.结果 曲霉菌球菌病3例,变态反应性支气管肺曲霉菌病1例,侵袭性肺曲霉菌病12例.主要症状为咳嗽、咯痰、发热、咯血、胸闷和气喘,肺部体征不明显.胸部CT表现：双肺多发病灶13例,单病灶3例.所有患者均接受抗真菌药物治疗,死亡6例皆为侵袭性肺曲霉菌病患者.结论 曲霉菌球菌病病情发展缓慢,部分病人需要手术切除病灶;变态反应性支气管肺曲霉菌病情时轻时重,早期常误诊为支气管哮喘;侵袭性肺曲霉菌病情进展迅速,死亡率高,降低病死率有赖于早期诊断及抢先治疗.     

Superinfection of chronic necrotizing pulmonary aspergillosis by Mycobacterium tuberculosis.

A 63-year-old woman with chronic necrotizing pulmonary aspergillosis complicated by active pulmonary tuberculosis is reported. A small infiltrative shadow appeared, but no definite diagnosis was made. Six years later the shadow was found to have increased in size; chest CT revealed a fungus ball, while a transbronchial lung biopsy revealed aspergillus hyphae. The intrabronchial inoculation of amphotericin B proved ineffective, and a lobectomy was performed. Histopathologic findings showed necrotic granulomas containing aspergillus and some acid-fast bacilli. While the superinfection of healed tuberculous lesions by Mycobacteria or Aspergillus species is well documented, their coexistence is rare.     

Two cases of pulmonary aspergillosis successfully treated with combinated micafungin and itraconazole therapy

We report 2 cases of pulmonary aspergillosis treated successfully by combining micafungin and traconazole. Case 1: A 51-year-old man with hemoptysis and dyspnea on effort treated for pulmonary tuberculosis and aspergillosis was found on chest CT on admission to have a fungus ball in the left upper lobe and increasing consolidation around the cavity of both lung fields. Bronchoscopy proved positive for aspergillus PCR in bronchial lavage. He was diagnosed with chronic necrotizing pulmonary aspergillosis, based on clinical and radiological findings and the positive reaction for aspergillus PCR. He was treated with micafungin alone at first, this proved ineffective, so itraconazole was added, resulting in improvement. Case 2: A 24-year-old woman with stabilized Hodgkin's disease (mixed). She had suffered from a cough and back pain, and chest CT showed increasing consolidation inside and around a giant bulla. She was diagnosed with chronic necrotizing pulmonary aspergillosis, based on isolation for Aspergillus sp. in sputum culture and a positive reaction for Aspergillus antigen in bronchial lavage and Aspergillus antibody in serum. She was treated with the combined micafungin and itraconazole, which rapidly improved symptoms and radiological findings. Pulmonary aspergillosis therapy is often difficult, because delivery of the drug to the infection site is limited and drug tolerance is poor. We found that combination micafungin and itraconazole therapy is tolerable and effective in these cases.     

Bronchopulmonary aspergillosis: new developments

Bronchopulmonary aspergillosis are in the news. Invasive pulmonary aspergillosis raise early diagnostic problems and prevention problems in immunocompromised patients. These infections are no unusual in chronic obstructive pulmonary disease. The diagnosis between aspergilloma and chronic necrotizing pulmonary aspergillosis can be difficult. In allergic bronchopulmonary aspergillosis, epidemiology and therapy are questionable. Real progress has been made due to thoracic computed tomographic scan and mycological methods. Better use of amphotericin B, of amphotericin B lipid formulations and of azole antifungal agents, combined with surgical resection if necessary should improve aspergillosis prognosis.     

支气管哮喘合并侵袭性肺曲霉菌病5例并文献复习

目的 提高对支气管哮喘患者合并侵袭性肺曲霉菌病的诊断及治疗.方法 分析2010年1月至2011年5月在我院呼吸科住院的5例支气管哮喘并侵袭性肺曲霉菌病患者的病例资料,同时结合相关文献进行复习.结果 5例患者确诊2例,临床诊断3例.痰培养4例查见曲霉菌,2例支气管镜检查病理形态学及特殊染色结果符合曲霉菌感染.影像学表现呈多样性.5例患者均接受伏立康唑治疗,其中2例死亡.结论 支气管哮喘患者合并侵袭性肺曲霉菌病临床表现缺乏特异性.早期诊断和尽早抗曲霉菌治疗可降低死亡率.     

Pulmonary aspergilloma, diagnosis and treatment

Pulmonary aspergilloma is a saprophytic form of aspergillosis, and the diagnosis is usually based on radiological findings such as thickened cavitary wall and fungus ball, and on positive serum antibody. Up to 58% of the patients with aspergilloma in Japan have medical history of tuberculosis. Serum anti-Aspergillus antigen is almost always positive in aspergilloma patients but aspergillus antigen is usually negative. Massive hemoptysis can be a fatal complication of aspergilloma, and the most common complication was respiratory failure according to our study. Surgical resection is the only promising intervention to cure the aspergilloma, however, low pulmonary function does not allow operation. Antifungal treatment is chosen for those who are out of operation indication, but the efficacy of antifungal treatment against aspergilloma is controversial. Some patients with aspergilloma show progressive form, and we define such aspergillosis as CNPA, chronic necrotizing aspergillosis, although the original entity of CNPA by Binder et al. is different. We make a diagnosis of CNPA only if all the following entity meets, 1; progressive shadows in radiological findings regardless of the presence of aspergilloma, 2; have some symptoms such as cough, sputum, hemosputum, hemoptysis or fever, 3; proof of Aspergillus attribution by mycological or pathological examination, 4; positive systemic inflammatory reaction, 5; neglect of other etiology of pulmonary diseases. Since CNPA is usually progressive, patients with CNPA should be treated with antifungals.     

国内20年肺曲霉菌病临床资料汇总分析

目的 了解20年来国内报道的肺曲霉菌病的流行病学特征、临床特点、影像学特点、确诊方法、误诊情况、治疗及预后,为临床医师快速准确地诊断本病提供重要线索.方法 回顾性分析1988～2007年国内有关肺曲霉菌感染的文献资料,统计分析并总结了293例肺曲霉菌病患者的临床资料.结果 293例患者中肺曲霉球型181例(61.8%),侵袭件肺曲霉菌病107例(36.5%),变应性支气管肺曲霉菌病5例(1.7%).肺曲霉菌病好发于有肺部基础疾病及其他基础疾病的患者,男、女比例2:1;其临床表现无特异性,而影像学表现呈多样性,临床易误诊,误诊率为74.6%;确诊主要靠呼吸道分泌物涂片、培养以及病理学检查;治疗手段包括手术切除和抗真菌药物的应用.结论 肺曲霉菌病的临床表现缺乏特异性,极易导致误诊,给临床诊断带来困难,必须加深对其认识.     

Chronic necrotizing pulmonary aspergillosis and ankylosing spondylarthritis

Fibro-bullous disease is a late complication of ankylosing spondylarthritis. Its radiologic features frequently mimics tuberculosis or excavated neoplasm. About 50 to 65% of patients with ankylosing spondylarthritis have chronic aspergillus colonization of their airways. Pulmonary aspergillosis infection occurs in 10 to 30% during evolution. We report two cases of patients with spondylarthritis who developed chronic necrotizing pulmonary aspergillosis. Diagnosis was based on serology, mycologic examination of expectoration and in one case on histology obtain by transbronchial biopsies. Pulmonary complications due to aspergillus species frequently reveal an associated fibro-bullous disease in patients with ankylosing spondylarthritis. This can be reported to diminished chest wall movements in such patients. Treatment is based on administration of anti-fungal drugs. In case of medical treatment failure, thoracic surgery may be indicated.