肺移植后侵袭性肺曲霉菌病的诊治一例

目的总结双肺移植后侵袭性肺曲霉菌病的诊疗体会。方法1例双肺移植患者,术后8个月肺部发生嗜麦芽寡养单胞菌和黄曲霉菌感染,胸部X线片显示双肺呈浸润性病变,以右肺为主,应用伊曲康唑抗曲霉菌治疗,应用头孢哌酮/舒巴坦抗嗜麦芽寡养单胞菌治疗。结果用药6d后痰真菌培养结果转阴,患者症状逐步好转;头孢哌酮/舒巴坦抗嗜麦芽寡养单胞菌治疗效果不佳,后换用替卡西林/克拉维酸后痰细菌培养转阴。在维持血他克莫司(FK506)浓度在有效水平的基础上,FK506的用量从6mg/d减至0.5mg/d。结论CT在侵袭性肺曲霉菌病诊断中的价值优于X线片;应用伊曲康唑治疗侵袭性肺曲霉菌病有效,同时应注意血FK506浓度的监测。     

肝移植术后肺曲霉菌感染的诊治

目的：探讨肝移植术后肺曲霉菌感染的诊治方法。方法：肝移植术后患者常规进行痰培养,应用二性霉素B、伊曲康唑和氟康唑等抗真菌药物治疗,回顾性分析了3例肺部曲霉菌感染患者的诊治经过。结果：54例肝移植患者有3例发生肺曲霉菌感染,治愈1例,死亡2例。结论：（1）过度免疫抑制是导致肺曲霉素感染的重要因素。（2）二性霉素B治疗肺曲霉感染有效。（3）为降低二性霉素B的毒副作用和增强疗效,治疗方法上可采用渐进性给药、间断性给药、低浓度给药、联合给药,真菌培养阴性后用伊曲康唑巩固治疗2-3周。     

肾移植术后侵袭性肺曲霉菌病的诊治

目的 探讨肾移植受者侵袭性肺曲霉菌感染的诊断与治疗. 方法肾移植术后侵袭性肺曲霉菌病患者10例.男7例,女3例.年龄28～56岁,平均43岁.感染发病时间为术后平均59 d.患者低氧血症和呼吸困难严重.10例均行纤维支气管镜、肺部CT检查和血清半乳甘露聚糖(GM)抗原检测.其中纤维支气管镜取分泌物培养阳性3例,肺部CT检查有明显影像学特征6例,血清GM抗原检测阳性5例.应用伊曲康唑和两性霉素B脂质体治疗,剂量为伊曲康唑第1天400mg静脉滴注,第2天起200 mg静脉滴注,共14 d;两性霉素B脂质体治疗剂量为50 mg加入5%葡萄糖注射液500 ml中慢速静脉滴注约8 h,共14～28 d.结果 3例应用伊曲康唑治愈,5例应用两性霉素B脂质体治愈,2例死亡.结论 侵袭性肺曲霉菌感染是肾移植术后肺部感染的严重并发症,早期诊断与正确治疗可降低病死率.     

肝移植术后肺部真菌感染的诊断和治疗

目的探讨肝移植术后肺部真菌感染的早期诊断及治疗方法。方法回顾分析20例肝移植术后肺部真菌感染患者的临床资料,分析其原发病、免疫状态、感染真菌的种类及抗真菌药物的应用。结果20例患者念珠菌感染17例,死亡2例,曲霉菌感染3例,死亡2例。氟康唑、伊曲康唑、两性霉素B治疗有效率70％,伏立康唑、卡泊芬净治疗有效率100％。结论肝移植术后真菌感染高发,以危重患者为主要目标人群,发生早,病情重。诊断分三级,达到临床诊断即应及早治疗。治疗以伏立康唑为首选,严重感染者联合应用卡泊芬净效果良好。     

两性霉素B脂质体治疗肝、肾联合移植后肺曲霉菌感染一例

我院于2002年12月施行同种异体肝、肾联合移植1例，术后患者发生严重的肺部曲霉菌感染，给予两性霉素B脂质体治疗21d后痊愈，肝、肾功能无明显损害，报告如下。     

对张晓宁读者来信的答复

曲霉菌已经成为包括器官移植患者在内的免疫功能低下人群致命性感染的一项重要病因，特别是侵袭性曲菌病在移植术后一旦发生，更是具有较高的病死率。在国内，用于治疗侵袭性曲菌病的抗真菌药物药物包括两性霉素B及其脂质剂型、三唑类的伏立康唑、伊曲康唑、泊沙康唑以及棘白菌素类的卡泊芬净和米卡芬净等。正如张晓宁医生提出的氟康唑对于曲霉菌的治疗是无效的。     

肾移植术后肺部曲霉菌感染

肺部真菌感染为肾移植术后较常见并发症之一,主要致病菌有念珠菌、曲霉菌、隐球菌.其中侵袭性肺曲霉病的病死率最高,已引起人们的关注.我们对肾移植术后肺部曲霉菌感染的流行病学、致病因素、诊断及治疗进行综述.     

心、肺联合移植一例报告

目的对1例心、肺联合移植术进行总结分析。方法对1例患先天性心脏病、室间隔缺损合并艾森曼格综合征者施行同种异体原位心、肺联合移植术,手术在中低温、体外循环下进行。术后对受者进行密切监护,积极防治排斥反应和感染。结果术中体外循环时间240min,升主动脉阻断时间125min;患者术后第7、203d发生移植肺急性排斥反应,第177、228d发生移植心急性排斥反应,均经治疗逆转;第9d发生肺部及胸腔感染,经抗感染治疗痊愈;第265d发生肺部毛霉菌感染,经两性霉素B治疗后症状控制;目前受者的心功能为Ⅰ级,超声心动图提示心脏结构及瓣膜功能基本正常,肺部感染的临床表现基本消失,生活自理。结论良好的心肺保护、细致的外科操作和正确的围手术期处理是心、肺联合移植成功的关键。     

肺曲菌病手术治疗2例

例1女,15岁.阵发性咳嗽,咳白色粘痰伴右肩部刺痛半月.X线胸片诊断为右上肺空洞型肺结核.抗痨治疗4周后复查,X线胸片提示右上肺仍可见一约4cm×4cm的圆形空洞.1991年8月全麻下行剖胸探查,术中行右肺上叶后段楔形切除术.术后病理:右肺上叶后段曲菌病.随访5年,恢复良好,无复发.     

肝移植术后侵袭性曲菌病的防治

目的探讨原位肝移植术后侵袭性曲菌病的防治。方法回顾性分析2000年1月至2005年1月完成的576例原位肝移植的临床资料,总结术后侵袭性曲菌病的预防和治疗经验。结果9例患者术后并发侵袭性曲菌病,发病率为1.74%(9/576),首发感染部位为肺部8例,中枢神经系统感染1例。6例患者停用免疫抑制治疗,3例患者将他克莫司(FK506)或CsA降低到最低有效血药浓度。6例患者选用两性霉素B脂质体(其中1例先试用氟康唑)、3例首选伊曲康唑进行治疗。5例肺部感染患者痊愈,2例因肺部感染无法控制死亡,2例因并发多器官曲霉菌感染死亡。结论早发现并及时调整免疫抑制治疗方案,早期、足量和足程使用抗真菌药物,积极行手术治疗是降低肝移植术后侵袭性曲菌病发病率和病死率的根本措施。     

肺移植术后气道吻合口狭窄的原因和治疗

目的探讨肺移植术后气道吻合口狭窄的原因及预防和治疗方法。方法2003年1月至2005年8月，对11例重度肺气肿患者成功地实施了同种异体单肺移植手术，9例存活良好，气道吻合均采用端端支气管吻合（膜部连续软骨部间断缝合）方法。术后有4例发现霉菌感染以及其中2例出现支气管吻合口狭窄。结果2例分别于术后1个月、7个月发现支气管吻合口狭窄，置人镍钛网状支架后症状改善。结论气道吻合口狭窄与支气管缺血、霉菌感染以及吻合技术等多方面因素有关。气道支架置人治疗吻合口狭窄效果显著。     

Antifungal Prophylaxis with Voriconazole or Itraconazole in Lung Transplant Recipients: Hepatotoxicity and Effectiveness

Invasive fungal infections (IFI) are common after lung transplantation and there are limited data for the use of antifungal prophylaxis in these patients. Our aim was to compare the safety and describe the effectiveness of universal prophylaxis with two azole regimens in lung transplant recipients.
This is a retrospective study in lung transplant recipients from July 2003 to July 2006 who received antifungal prophylaxis with itraconazole or voriconazole plus inhaled amphotericin B to compare the incidence of hepatotoxicity. Secondary outcomes include describing the incidence of IFI, clinical outcomes after IFI and mortality.
Sixty-seven consecutive lung transplants received antifungal prophylaxis, 32 itraconazole and 35 voriconazole and inhaled amphotericin B. There were no significant differences between groups in the acute physiology and chronic health evaluation (APACHE) score at the time of transplantation, demographic characteristics, comorbidities and concomitant use of hepatotoxic medications. Hepatotoxicity occurred in 12 patients receiving voriconazole and inhaled amphotericin B and in no patients receiving itraconazole (p < 0.001). There was no significant difference between groups with regard to the percentage of transplants with IFI, but one case of zygomycosis occurred in a transplant treated with voriconazole. Voriconazole prophylaxis after lung transplantation was associated with a higher incidence of hepatotoxicity and similar clinical effectiveness when compared to itraconazole.     

心脏移植术后早期感染的防治

目的 探讨、总结心脏移植术后感染的特点与预防和治疗经验。方法对2000年5月至2003年4月36例同种异体原位心脏移植患者的临床资料及感染情况进行观察、分析。结果术后随访7～41个月,所有患者均存活,仅2例(6％)患者于术后2、13个月发生感染,均为肺部巨细胞病毒感染,经静脉应用更昔洛韦后治愈。结论良好的预防措施可以明显降低心脏移植术后感染的发生率,发生感染后早期诊断和治疗十分重要。     

Randomized controlled trial of oral itraconazole solution versus intravenous/oral fluconazole for prevention of fungal infections in liver transplant recipients

BACKGROUND: Liver transplant recipients at high risk for serious fungal infections frequently receive fluconazole or an amphotericin B preparation for antifungal prophylaxis. Because of concerns about fungal resistance with fluconazole, safety with amphotericin B, and the cost of lipid formulations of amphotericin, alternative prophylactic regimens are needed. In this randomized, controlled trial, we compared the efficacy and safety of oral itraconazole solution with intravenous/oral fluconazole for prevention of fungal infections. METHODS: Adult liver transplant recipients were randomized to receive either oral itraconazole solution (200 mg every 12 hr) or intravenous/oral fluconazole (400 mg every 24 hr). Each study drug was started immediately before transplant surgery and continued for 10 weeks after transplantation. Patients were evaluated for fungal colonization, proven invasive or superficial fungal infection, drug-related side effects, and death. RESULTS: Fungal colonization decreased from baseline to week 8 after transplantation in both the itraconazole patients (67% to 25%, P<0.001) and the fluconazole patients (77% to 30%, P<0.001). Proven fungal infection developed in 9 (9%) of 97 itraconazole patients and in 4 (4%) of 91 fluconazole patients (P =0.25). The number of proven invasive fungal infections (seven with itraconazole [7%], three with fluconazole [3%]) and proven superficial fungal infections (two with itraconazole [2%], one with fluconazole [1%]) were also similar in both groups of patients. Organisms causing infection were (four patients), (three patients), and species (two patients) in the itraconazole group and (two patients), (one patient), and species (one patient) in the fluconazole group. Mortality from fungal infection was very low and occurred in only 1 (0.5%) of 188 patients. Except for more frequent gastrointestinal side effects (nausea, vomiting, diarrhea) with itraconazole, both itraconazole and fluconazole were well tolerated and not associated with any hepatotoxicity. Mean trough plasma concentrations of itraconazole were greater than 250 ng/mL throughout the study and were not affected by H -receptor antagonists or antacids. CONCLUSION: Oral itraconazole solution has adequate bioavailability in liver transplant recipients for effective antifungal prophylaxis. Similar to fluconazole, prophylactic oral itraconazole decreases fungal colonization and is associated with a low incidence of serious or fatal fungal infections. Except for gastrointestinal side effects, oral itraconazole solution is well tolerated and has no significant hepatotoxicity.     

Native lung pneumonectomy for invasive pulmonary aspergillosis following lung transplantation: a case report.

Pulmonary aspergillosis occurs most commonly as a consequence of immunosuppression in recipients of pulmonary transplantation and is associated with a high mortality. It affects the native lung more commonly than the transplanted lung in single lung transplant patients. Infection often progresses despite aggressive medical therapy. The cornerstone of treatment of acute, semi-invasive, and invasive pulmonary aspergillosis (IPA) is medical, with intravenous amphotericin B, and oral itraconazole either as isolated or combined therapy. While newer, and more expensive liposomal forms of amphotericin B have been used to enhance tissue penetration and minimize renal toxicity, an appreciable improvement in clinical outcome has not been reported. The role of surgery in localized pulmonary aspergillus infection is well recognized, but remains undefined in immunosuppressed patients. We report a case where a pneumonectomy was performed for progressive, refractory angioinvasive aspergillosis in a lung transplant recipient whose disease progressed despite conventional antifungal therapy.     

Efficiency and Safety of Inhaled Amphotericin B Lipid Complex (Abelcet) in the Prophylaxis of Invasive Fungal Infections Following Lung Transplantation

Background

Invasive fungal infections (IFIs) in patients undergoing lung transplantation (LT) are associated with significant mortality. Previous studies have shown the efficacy of aerosolized amphotericin B deoxycholate and oral fluconazole for antifungal prophylaxis. Evolving data show a potential advantage of prophylaxis with lipid-based formulations of amphotericin B in the prevention of IFIs. We reviewed the incidence of IFIs among patients receiving aerosolized amphotericin B lipid complex (ABLC) in LT.

Methods

We undertook a retrospective review of the results of our antifungal protocol in a cohort of 60 LT patients. We analyzed the efficiency, safety, and tolerability of 50 mg of aerosolized ABLC administered postoperatively for IFI prophylaxis once every 2 days for 2 weeks and then once per week for at least 13 weeks. In addition, these transplanted patients received fluconazole (200 mg/d) during the first 21 days posttransplant. The prophylaxis-related efficiency and safety were quantified for IFIs and adverse events (AEs) for 6 months after study drug initiation.

Results

Prophylaxis was efficient in 59 (98.3%) patients. Only one patient developed a possible IFI, due to Aspergillus fumigatus. Four patients presented nausea and vomiting as an AE, although aerosolized amphotericin B was ongoing.

Conclusions

Nebulized ABLC was effective, safe, and well tolerated for the prophylaxis of aspergillosis in lung transplant patients during the early posttransplant period.     

肺移植术后的结核感染一例

目的 探讨肺移植后结核杆菌感染的诊断与治疗。方法 １例接受左单肺移植的患者术后１３个月发生胸壁结核感染,曾疑为急性排斥反应而予以激素冲击治疗,后经左前胸季肋部局部肿块穿刺抽吸物（脓液）涂片及培养,发现结核杆菌而诊断为胸壁结核脓肿,后又发生混合感染,给予抗结核药头及头孢他定治疗,同时行脓肿切开引流。结果 经治疗,患者的病情迅速得到控制,体温恢复正常,３个月后伤口愈合。结论 肺移植后发生结核病,其症状     

Voriconazole Prophylaxis in Lung Transplant Recipients

Lung transplant recipients have one of the highest rates of invasive aspergillosis (IA) in solid organ transplantation. We used a single center, nonrandomized, retrospective, sequential study design to evaluate fungal infection rates in lung transplant recipients who were managed with either universal prophylaxis with voriconazole (n = 65) or targeted prophylaxis (n = 30) with itraconazole ± inhaled amphotericin in patients at high risk (pre- or posttransplant Aspergillus colonization [except Aspergillus niger ]). The rate of IA at 1 year was better in lung transplant recipients receiving voriconazole prophylaxis as compared to the cohort managed with targeted prophylaxis (1.5% vs. 23%; p = 0.001). Twenty-nine percent of cases in the targeted prophylaxis group were in patients colonized with A. niger who did not receive itraconazole. A threefold or higher increase in liver enzymes was noted in 37–60% of patients receiving voriconazole prophylaxis as compared to 15–41% of patients in the targeted prophylaxis cohort. Fourteen percent in the voriconazole group as compared to 8% in the targeted prophylaxis group had to discontinue antifungal medications due to side effects. Voriconazole prophylaxis can be used in preventing IA in lung transplant recipients. Regular monitoring of liver enzymes and serum concentrations of calcineurin inhibitors are required to avoid hepatotoxicity and nephrotoxicity.     

Antifungal Prophylaxis and Treatment Among Lung Transplant Recipients in Early Postoperative Stage: A Single-Center Study

BackgroundLung transplantation remains the only feasible option for certain patients with end-stage lung disease. Lifelong immunosuppression increases the risk of infection, including fungal infections. The aim of this study was to assess the effect of antifungal prophylaxis and treatment among lung transplant recipients in the early postoperative stage.MethodsThis retrospective analysis included 127 patients who underwent lung transplantation between 2014 and 2021 in the lung transplant ward, 65.35% of whom were males. The most common indication for lung transplantation was cystic fibrosis (n = 59; 46.46%). All of the patients were receiving inhaled amphotericin B. Within this group there were patients who also were treated with intravenous caspofungin, intravenous/oral voriconazole, or both.ResultsThe difference in the efficacy against Candida spp. between caspofungin and voriconazole in the early post-transplant period was not statistically significant (χ₂ = 0.5, P = .477). Moreover, the difference in the efficacy against Candida spp. between itraconazole and voriconazole during the first post-transplant year was not statistically significant (χ₂ = 0.46, P = .496).ConclusionCaspofungin and voriconazole are proper and relatively efficient antifungal prophylaxis and treatment options after lung transplantation. There was no significant difference between voriconazole and caspofungin as antifungal agents used in the early post-transplant stage. There was no significant difference between voriconazole and itraconazole as antifungal agents used during the first post-transplant year. Further research on this issue is required.