老年肺部疾病患者并发真菌感染相关因素的临床研究（附49例临床报告）

目的：探讨我院呼吸内科病房老年肺部疾病患者并发真菌感染发病的相关因素,分析其易患因素、临床特征和治疗。方法：采用回顾性调查方法对2002年1月至2008年6月收住内科的经微生物检查证实49例继发真菌感染的患者进行分析,并与同期无真菌感染的肺部疾病患者（对照组）比较。结果：在呼吸内科病房中,老年患者院内肺部真菌感染发生率为3.78%,主要感染部位为泌尿系（21.8%）,呼吸道（26.9%）,消化道（40.9%）。慢性阻塞性肺疾病（49.8%）是继发院内肺部真菌感染最常见的基础疾病,其感染因素为长期使用广谱抗生素（96.2%）和糖皮质激素（33.2%）、营养状况不良（58.3%）出现低蛋白血症及合并糖尿病、白细胞减少和侵袭性诊疗操作等。肺部真菌感染的临床表现无特异性,确诊需结合痰培养,组织病理学和临床表现来确定,感染菌种以白色念珠菌为主,占62.6%。氟康唑治疗有效率91.4%。研究组与同期无真菌感染的肺部疾病患者（对照组）比较：病死率分别为6.12%和0.82%,两组治疗无效的病例（恶化和死亡病例）比较差异有显著性。结论：院内真菌是呼吸系统疾病继发感染的重要病原体,而白色假丝酵母菌是院内肺部真菌感染的主要致病菌,宿主免疫状态、感染播散和疾病严重程度是影响预后的因素。该研究认为老年肺部疾病患者并发真菌感染的相关因素和影响预后的因素对其预防、诊断、治疗、改进预后和生存质量有重要的临床意义。除有效的抗真菌治疗外,积极的综合治疗有助于提高真菌感染的治愈率。     

Aztreonam in the treatment of severe urinary tract infections in pediatric patients.

Aztreonam was administered to 30 patients, ages 0.03 to 15.4 years, with severe and in 21 cases complicated urinary tract infections caused by members of the family Enterobacteriaceae and Pseudomonas aeruginosa which were resistant to ampicillin and susceptible to the study drug in vitro. A mean dose of 47.7 mg/kg was given intramuscularly every 12 h to 26 patients. In four patients with renal insufficiency, the dose was reduced according to pharmacokinetic data. Permanent urine sterilization and clinical cure were achieved in 22 patients, 13 of whom had urological malformations. In two patients with P. aeruginosa and Proteus mirabilis infections, the treatment failed. Another patient had an Escherichia coli reinfection 21 days after the end of therapy. Four patients with various urological abnormalities had gram-positive superinfections, and two patients had gram-negative superinfections during and at the end of therapy: all six had indwelling ureteric splints or pyelostomy as predisposing conditions. No adverse clinical effects were observed. Some transient and slight or moderate alterations were observed at the end of treatment: eosinophilia (nine cases), elevation of hepatic enzymes (eight cases), prolongation of prothrombin time (three cases), and neutropenia (one case). A pharmacokinetic study was performed in six patients with normal renal function and in seven patients with various degrees of renal insufficiency. The elimination half-life of the drug was inversely correlated with the glomerular filtration rate. At the dosage used, aztreonam proved effective for severe urinary tract infections caused by members of the family Enterobacteriaceae in pediatric patients.     

乳腺肿物超声引导粗针活检组织学诊断准确性探讨

目的探讨乳腺肿物超声引导粗针活检(CNB)病理组织学诊断的准确性及其影响因素.方法结合临床资料,对72例乳腺穿刺活检标本和开放性活检标本的病理组织学诊断进行比较和分析.结果临床送检的72例乳腺CNB标本的病理组织学诊断分别为:浸润性癌43例,原位癌/非典型增生3例,良性病变20例,未见明显病变6例.CNB与开放性活检的病理诊断符合率为90%,kappa＝0.798(P＜0.01).乳腺恶性病变CNB病理诊断的敏感性为92%,特异性为100%.CNB漏诊原因分别为临床取材失误2例,病理诊断3例,临床处理不当1例.CNB诊断较困难的病变主要是原位癌、早期浸润性导管癌和浸润性小叶癌.结论超声引导下粗针活检是一种敏感性高和特异性很强的乳腺病变诊断方法,对少数特殊类型乳腺病变的诊断存在着一定的局限性.     

Common oral lesions: Part I. Superficial mucosal lesions

Common superficial oral lesions include candidiasis, recurrent herpes labialis, recurrent aphthous stomatitis, erythema migrans, hairy tongue, and lichen planus. Recognition and diagnosis require taking a thorough history and performing a complete oral examination. Knowledge of clinical characteristics such as size, location, surface morphology, color, pain, and duration is helpful in establishing a diagnosis. Oral candidiasis may present as pseudomembranous candidiasis, glossitis, or perlèche (angular cheilitis). Oral candidiasis is common in infants, but in adults it may signify immune deficiency or other illness. Herpes labialis typically is a mild, self-limited condition. Recurrent aphthous stomatitis most often is a mild condition; however, severe cases may be caused by nutritional deficiencies, autoimmune disorders, or human immunodeficiency virus infection. Erythema migrans is a waxing and waning disorder of unknown etiology. Hairy tongue represents elongation and hypertrophy of the filiform papillae and most often occurs in persons who smoke heavily. Oral lichen planus is a chronic inflammatory condition that may be reticular or erosive. Certain risk factors have been associated with each of these lesions, such as poor oral hygiene, age, tobacco use, and alcohol consumption, and some systemic conditions may have oral manifestations. Many recommended therapies for oral lesions are unsupported by randomized controlled trials.     

Fish breeder granuloma: infection caused by Mycobacterium marinum and other atypical mycobacteria in the human. Analysis of 8 cases and review of the literature

Granulomatous lesions of the skin and tendon sheaths after exposure to fish tank or aquarium water are frequently caused by non-tuberculous so-called atypical mycobacteria. Mycobacterium marinum is the species most often isolated from such lesions. Rarely, other non-tuberculous species of mycobacteria may be isolated. In contrast to swimming-pool granuloma as the epidemic form of Mycobacterium marinum infection of man, fish tank granuloma seems to be a rare sporadic human disease that is often misdiagnosed. We report eight cases of fish tank granuloma. Five patients had sporotrichoid lesions, and one patient had a singular lesion. Three patients presented with tenosynovitis. Culture-proven Mycobacterium marinum infection was found in four patients, in one patient the causative organism isolated from the biopsy specimen was identified as Mycobacterium kansasii. In three patients with typical appearance of the lesions and exposure to fish tank water, biopsy specimens for culture were not available, and the diagnosis was histopathologically confirmed. Surgical treatment had an unfavourable outcome in two of three patients. Conservative antimicrobial therapy was evaluated in six patients. Similar to published reports, the treatment with rifampicin in combination with other agents seemed to be a useful therapy. Complete remission was, however, also achieved with doxycycline monotherapy. Microbiological diagnosis should be attempted in suspected cases of fish tank granuloma, and, if therapy is indicated, we strongly suggest primary medical treatment.     

Small bowel enema and diagnosis of chronic nonischemic disturbance of superior mesenteric venous blood flow

Chronic nonischemic disturbance of mesenteric venous blood flow is reported in 11 patients with a mean age of 19 years. This entity, rarely discussed n the literature, is different from acute thrombosis and chronic thrombotic forms with portal hypertension or hypercoagulopathy. In eight patients this syndrome was secondary to organic lesions of different origin: mesenteric vein squeezed by fibrous bands or an abnormal jejunal artery (four cases), lymphoma involving the distal superior mesenteric veins (three cases), hemangioma causing microthrombi (one case). In three patients no etiology or predisposing factor was found. All patients presented with rectal hemorrhage. Small bowel enema showed a constant pattern in 11 patients: small nodules, modified by compression or peristalsis, involving the mesenteric border of the jejunoileal segment, and associated with thick, straight but regular folds. Mesenteric varices were suspected and led to angiographic studies which were normal in three cases, confirmed varices in eight cases, and thrombosis in four cases. Laparotomy was normal in three cases and established the etiological diagnosis in eight cases. Varices were shown in six cases. Arteriography and laparotomy were unable to reach a complete diagnosis.     

超声对乳腺占位性病变的诊断价值及引导下活检的应用

目的探讨乳腺占位性病变超声诊断及超声引导下活检的临床意义。方法利用超声对临床诊断为乳腺肿块的208例患者检查及超声引导下细针抽吸细胞学活检。结果乳腺肿块检查以二维超声检查为主,频谱多普勒、彩色多普勒血流图起协助作用,乳腺肿块以良性肿瘤为多发。本组208例,其中囊性增生102例,腺瘤样增生51例,纤维腺瘤49例,肉芽肿性乳腺炎2例,乳腺癌4例。其中误诊3例。结论超声对乳腺占位性病变诊断及引导下活检具有较高的临床诊断意义,正确认识有利于临床治疗,减轻患者痛苦,为治疗疾病争取时间。     

Esophageal biopsy findings in the acquired immunodeficiency syndrome (AIDS): clinicopathologic correlation in 20 patients

We reviewed 20 esophageal biopsy specimens from 180 adult patients with the acquired immunodeficiency syndrome (AIDS). Ten (50%) showed superficial Candida infection, and four revealed esophagitis due to cytomegalovirus. Candida was never invasive, even though it was associated with significant ulceration. Esophageal candidiasis did not necessarily imply the presence of oral candidiasis, and conversely, oral candidiasis did not imply esophageal candidiasis. Odynophagia was associated with significant histologic ulcerations in eight of ten patients. In the patients who had odynophagia, biopsy was almost equally likely to show Candida or viral cytopathic effect. We discuss the clinicopathologic implications of these findings.     

^18F-FDG PET/CT显像在颅内占位性病变诊断中的价值

目的 探讨18F-F DG P ET/CT显像在颅内占位性病变诊断中的价值。方法 回顾性分析48例颅内占位性病变病人的颅脑及体部18F-F DG P ET/CT显像及临床随访结果。结果 P ET/CT诊断脑转移瘤29例,经手术、内镜或穿刺病理学证实原发灶者24例,病理确诊脑转移瘤未明确原发灶者4例,病理证实为结核1例;PET/CT诊断颅内原发恶性肿瘤19例,病理证实为淋巴瘤8例,胶质瘤5例,2例随访中发现原发灶证实为转移瘤,余4例临床随访1年均未见颅外恶性病灶。结论 颅内占位性病变病人行18F-F DG PET/CT显像可有效发现原发病灶,并根据体部及颅脑显像特点初步判定转移性肿瘤和原发性肿瘤。     

An open multicentre study of the efficacy and safety of a single dose of fluconazole 150 mg in the treatment of vaginal candidiasis in general practice

The efficacy and tolerability of fluconazole given as a single oral dose of 150 mg were assessed in 1,017 patients in general practice presenting with signs and symptoms of vaginal candidiasis. At the review visit 7-14 days after treatment, about 95 per cent of patients reported being either cured or improved. High vaginal swabs taken from 43 patients out of 50 who failed following treatment revealed Candida albicans in 17 (1.8 per cent). Efficacy in patients with predisposing factors (oral contraceptives, antibiotics and recurrent vaginal candidiasis - four episodes or more in previous year) was not significantly different from that in those without these factors. Of patients who had received previous intravaginal therapy for vaginal candidiasis, 88 per cent preferred fluconazole, 10 per cent previous therapy and two per cent had no preference. Investigators assessed efficacy after fluconazole as excellent or good in 91 per cent and tolerability as excellent or good in 91 per cent of patients. Significant adverse effects were reported in less than one per cent of patients.     

Intramuscular myxoma: sonographic appearance and sonographically guided needle biopsy.

The sonographic appearances of four intramuscular myxomas were reviewed. These tumors appeared as well-defined, ovoid masses surrounded by normal muscle. The echogenicity was decreased in all cases, and the presence of small fluid-filled clefts and cystic areas was noted in three of the four lesions. Color Doppler examination was performed in two cases and was negative. Sonographically guided fine-needle aspiration biopsy yielded a thick myxoid substance. Large-core cutting needle biopsy allowed establishment of the diagnosis in one of the two cases in which it was performed. The differential diagnosis of a well-demarcated intramuscular mass with multiple fluid-filled clefts or cystic areas should include intramuscular myxoma.     

Treatment of recurrent vulvovaginal candidiasis

Vulvovaginal candidiasis is considered recurrent when at least four specific episodes occur in one year or at least three episodes unrelated to antibiotic therapy occur within one year. Although greater than 50 percent of women more than 25 years of age develop vulvovaginal candidiasis at some time, fewer than 5 percent of these women experience recurrences. Clinical evaluation of recurrent episodes is essential. Patients who self-diagnose may miss other causes or concurrent infections. Known etiologies of recurrent vulvovaginal candidiasis include treatment-resistant Candida species other than Candida albicans, frequent antibiotic therapy, contraceptive use, compromise of the immune system, sexual activity and hyperglycemia. If microscopic examination of vaginal secretions in a potassium hydroxide preparation is negative but clinical suspicion is high, fungal cultures should be obtained. After the acute episode has been treated, subsequent prophylaxis (maintenance therapy) is important. Because many patients experience recurrences once prophylaxis is discontinued, long-term therapy may be warranted. Patients are more likely to comply when antifungal therapy is administered orally, but oral treatment carries a greater potential for systemic toxicity and drug interactions.     

Histopathologic features of the L-tryptophan-related eosinophilia-myalgia (fasciitis) syndrome.

Study of 18 biopsy specimens in 11 patients with L-tryptophan-related eosinophiliamyalgia (fasciitis) syndrome showed hyaline sclerodermoid changes. Dermal scleroderma was found in eight of nine punch biopsy specimens and eight of nine excisional biopsy specimens. Fascial scleroderma was found in eight excisional biopsy specimens. One specimen obtained by excision had no fascia present. Eleven biopsy specimens showed edema of the dermis, and 13 showed dilated lymphatic structures; thus, the clinical picture of edematous sclerosis was confirmed. Mucinous fasciitis was present in five excisional biopsy specimens, in conjunction with a large number of macrophages in four. Dermal mucinosis was present in 11 biopsy specimens. Lymphocytic and macrophage inflammation was minimal in 14 biopsy specimens and pronounced in only 4. Plasma cells were present in eight cases. Eosinophils were present in substantial numbers in three biopsy specimens and only occasionally in four. Eosinophilic spongiosis was observed in one patient. Lymphocytic inflammation was noted around a single muscle spindle and around large nerve trunks in three patients. No relationship was established between these pathologic features and the duration or dose of tryptophan, prednisone treatment, or duration of symptoms. Pathologic features of the L-tryptophan syndrome consist of hyaline sclerodermoid collagen in the dermis, the septa, and the fascia. Edema, focal mucinosis, and macrophage inflammation may be features that identify this event.     

Esophageal candidiasis. Managing an increasingly prevalent infection

Esophageal candidiasis is an opportunistic infection that is being recognized increasingly often in certain patients, including those who have a neoplastic disease, are undergoing protracted antibiotic therapy, or hae acquired immunodeficiency syndrome (AIDS). Impaired cell-mediated immunity may predispose the patient to esophageal mucosal colonization, whereas chemotherapy-induced granulocytopenia may predispose to disseminated candidiasis. Esophageal candidiasis should be suspected in susceptible patients with complaints of substernal odynophagia or dysphagia. The diagnosis is confirmed by endoscopically directed mucosal biopsy. Esophagitis from other causes (eg. herpes simplex virus, cytomegalovirus, or bacterial infection) may develop concomitantly with esophageal candidiasis. Treatment is determined by the clinical and immune status of the patient. Amphotericin B (Fungizone) is administered to immunocompromised patients at risk for disseminated or deeply invasive candidiasis and is indicated in nongranulocytopenic patients whose symptoms prevent reliable administration of oral antifungal agents. Ketoconazole (Nizoral) may be administered to clinically stable nongranulocytopenic patients with esophageal candidiasis limited to the mucosa. Patients with AIDS and a history of esophageal candidiasis usually benefit from long-term suppression with an oral antifungal agent.     

移植肾活检：病理及组织学的早期诊断价值

背景：移植肾活检病理学组织学早期诊断意义重大,单中心回顾性研究临床诊断与治疗较少。目的：通过对肾功能不全移植肾进行常规穿刺病理活检,根据病理诊断采取相应临床治疗方式,观察治疗效果,同时明确移植肾穿刺病理活检的安全性以及在临床诊治中的意义及其重要性。方法：选取解放军第309医院器官移植中心202例肾移植患者为研究对象,其中80例为肾移植后移植肾功能延迟恢复,122例肌酐不明原因升高。在B超引导下应用活检穿刺针行移植肾穿刺活检,对活检组织标本予以相应染色和病理组织学观察,并进行相应的临床治疗。结果与结论：穿刺组织中,除3例（1.5%）由于组织少难以诊断,其余病理诊断移植肾正常12例（5.9%）,缺血再灌注损伤合并（或）急性肾小管坏死28例（13.9%）,轻度钙调磷酸酶抑制剂类免疫抑制剂急性毒性损伤22例（10.9%）,轻度钙调磷酸酶抑制剂类免疫抑制剂慢性毒性损伤12例（5.9%）,超急性排斥反应1例（0.5%）,疑为急性排斥反应29例（14.4%）,急性T细胞性排斥反应34例（16.8%）,急性抗体介导性排斥反应19例（9.4%）,慢性T细胞介导排斥反应16例（7.9%）,慢性T细胞介导排斥反应伴急性T细胞介导性排斥反应12例（5.9%）,慢性抗体介导性排斥反应3例（1.5%）,高血压因素4例（2.0%）,间质纤维化和肾小管萎缩,未发现特定致病因素所致病变2例（1.0%）,缺血性坏死2例（1.0%）,移植后肾病复发3例（1.5%）,C4d免疫组化染色阳性23例（11.4%）,未发现患者及移植肾的不良反应。     

Minilaparoscopy-guided spleen biopsy in systemic disease with splenomegaly of unknown origin

With the advent of a minimally invasive laparoscopy technique, the advantages of diagnostic laparoscopy are being rediscovered. We report here on four patients with systemic disease of unknown origin and splenomegaly, in whom minilaparoscopy-guided splenic biopsy yielded a definitive diagnosis. Four patients with unclear systemic disease were studied using diagnostic minilaparoscopy and guided spleen biopsy, after failure of diagnostic work-up. Minilaparoscopic spleen biopsy revealed the diagnosis of a B-cell non-Hodgkin's lymphoma in two cases. In one patient, who had a history of Still's disease, the spleen biopsy showed granulocytic infiltration in the spleen typical of an acute episode of Still's disease. One patient with a known immunodeficiency syndrome (stage C III) showed multiple hypodense lesions in the spleen. Biopsy allowed a diagnosis of mycobacterial infection, with identification of Mycobacterium tuberculosis. No major complications occurred in any of the four cases; post-biopsy bleeding was observed in three of the four, but was easily managed by argon plasma coagulation or application of fibrin glue, or both. We recommend the use of spleen biopsy as a diagnostic tool in splenopathy of unknown origin if previous diagnostic methods have failed to yield a definitive diagnosis.     

Predictive factors for pancreatic cancer in patients with chronic pancreatitis in association with K-ras gene mutation

BACKGROUND AND STUDY AIMS: Chronic pancreatitis is considered to be a predisposing factor for pancreatic ductal adenocarcinoma (PAC). The purpose of this study was to examine the prognostic value of a finding of mutated (K- ras) gene in predicting the development of PAC in patients with chronic pancreatitis. PATIENTS AND METHODS: The pancreatic duct brushings of 146 patients with chronic pancreatitis were examined in order to identify K- ras gene mutations. A total of 112 patients were followed up (median duration 42 months) using clinical evaluation, serum CA19 - 9 levels, and imaging studies. RESULTS: One or more K- ras mutations were found in 57 of the 146 patients with chronic pancreatitis (39 %). Patients harboring K- ras mutations had a higher incidence of persistent alcohol consumption ( P = 0.041) and of prior rupture of the main pancreatic duct ( P = 0.040). A finding of nuclear atypia in brushing cytology was also more common in patients with K- ras mutation ( P = 0.048). Out of the 112 patients who were followed up, PAC occurred in four of the 44 patients who had a K- ras mutation, but in none of the 68 patients with the wild genotype ( P = 0.022). PAC occurred in three of the 25 patients who did not have pancreatic calcifications ( P = 0.034) and in four of the 54 patients who had demonstrated exocrine insufficiency, but in none of the 58 patients with preserved exocrine function ( P = 0.051). Using stepwise logistic regression, the absence of calcifications, the presence of exocrine insufficiency, and the presence of K- ras mutation were identified as independent predictive factors for cancer development in all patients with chronic pancreatitis. CONCLUSIONS: K- ras gene mutations occur in chronic pancreatitis and are associated with evolution towards PAC. The absence of pancreatic calcifications and the presence of exocrine insufficiency were identified as additional predictive factors for the development of PAC.     

Laparoscopic findings in hereditary haemorrhagic telangiectasia (Osler-Weber-Rendu disease)

The laparoscopic findings observed in eight patients with hereditary haemorrhagic telangiectasia are reported. Clinical signs or laboratory data suggestive of liver involvement were present in all cases and constituted the main indication for laparoscopic examination. Characteristic vascular lesions distributed at random were found in four cases. Numerous oval, round or polygonal areas of 0.5 to 1.5 cm in diameter were observed on the external surface of the liver. They were of a reddish or pink colour, flat or slightly raised, and made up of a dense vascular meshwork. In one patient macronodular cirrhosis was associated with the vascular lesions. In the remaining four cases laparoscopic examination did not show striking vascular changes, although the liver biopsy revealed a fatty liver in three cases and micronodular cirrhosis with intense inflammatory activity, steatosis and Mallory bodies in one case. In these cases the accompanying hepatic lesions could probably not be aetiopathogenically related to Osler's disease.     

Myocardial infarction and antiphospholipid antibodies in SLE and related disorders

The clinical and serological findings in 13 patients with myocardial infarction and antiphospholipid antibodies (the 'lupus anticoagulant', antibodies to cardiolipin, antibodies to phosphatidylethanolamine (one patient] seen by our unit and other units from 1984 to 1989, are presented (eight males and five females, ages ranging from 20 to 52 years). Five suffered myocardial infarction before the age of 30; four of these five were in their early 20s. Other risk factors such as excessive smoking (greater than 20 cigarettes a day) (two patients), long-term treatment with steroid (one) and use of oral contraceptives (one) were present. One patient had demonstrated a plasminogen activator deficiency and one a deficiency of protein C. Two patients developed myocardial infarction six to eight weeks after warfarin was discontinued for recurrent deep vein thrombosis. Six patients had SLE as defined by the revised 1982 criteria, three suffered from 'lupus-like' disease, while four patients conformed to a 'primary' antiphospholipid syndrome.     

Colon endosonography. Initial experiences in clinical use

For the first time we report about a new diagnostic technique, the endoluminal ultrasound of the colon. It enables us to examine the whole colon by an ultrasound endoscope. The ultrasound frequency of the instrument (XCF-UM2, Olympus Optical/Aloka, Japan) is 7.5 MHz, the roundview is approximately 320 degrees. The mean advantage is the combination of endoscopic inspection including biopsy and endoluminal ultrasound. First clinical experience was gained at a total of 27 examinations. It was possible to demonstrate the normal colonic wall (n = 10) in the entire large bowel, neighbouring organs could be visualized clearly and reproducibly in most cases. Pathologic findings (four carcinomas, eight polyps, five anastomoses) were correctly diagnosed by endosonography with a sensitivity of 100% and a specificity of 96%. In two cases the histopathologic work-up of the resected specimens confirmed the ultrasonographic diagnosis of malignancy, while the endoscopic biopsy indicated benign wall lesions. This suggests that endosonography may be superior to histological diagnosis by biopsy in some cases.