A pulmonary source of infection in patients with sepsis-associated acute kidney injury leads to a worse outcome and poor recovery of kidney function

BACKGROUND:Hospital mortality rates are higher among patients with sepsis-associated acute kidney injury(SA-AKI)than among patients with sepsis.However,the pathogenesis underlying SA-AKI remains unclear.We hypothesized that the source of infection affects development of SA-AKI.We aim to explore the relationship between the anatomical source of infection and outcome in patients with SA-AKI.METHODS:Between January 2013 and January 2018,113 patients with SA-AKI admitted to our Emergency Center were identifi ed and divided into two groups:those with pulmonary infections and those with other sources of infection.For each patient,we collected data from admission until either discharge or death.We also recorded the clinical outcome after 90 days for the discharged patients.RESULTS:The most common source of infection was the lung(52/113 cases,46%),followed by gastrointestinal(GI)(25/113 cases,22.1%)and urinary(22/113,19.5%)sources.Our analysis showed that patients with SA-AKI had a significantly worse outcome(30/52 cases,P<0.001)and poorer kidney recovery(P=0.015)with pulmonary sources of infection than those infected by another source.Data also showed that patients not infected by a pulmonary source more likely experienced shock(28/61 cases,P=0.037).CONCLUSION:This study demonstrated that the source of infection infl uenced the outcome of SA-AKI patients in an independent manner.Lung injury may influence renal function in an asyet undetermined manner as the recovery of kidney function was poorer in SA-AKI patients with a pulmonary source of infection.     

米卡芬净在造血干细胞移植二级预防中的临床应用分析

目的 探讨米卡芬净在有侵袭性真菌感染(invasive fungal infection,IFI)病史的患者行造血干细胞移植(haematopoietic stem cell transplantation,HSCT)时二级预防(secondary anti-fungal prophylaxis,SAP)的有效性和安全...     

肺心病患者睡眠低氧血症特点及氧疗和无创正压通气的应用价值

1 Subjects and method 12 patients of pure pulmonary heart disease,10 males,2 females,aged form 54～ 70 years old(mean age:60 years old).Among these patients,there were 9 cases with long term smoking history,7 cases with chronic bronchitis and pulmonary emphysema,1 case with remote pulmonary tuberculosis,1 case with chronic bronchiectasis,2 cases with pulmonary interstitial fibrosis,1 case with chronic organized pneumonia.Weighing index(21～ 24)kg/m2.Sleep hypoxencic follow international sleep medical diagnosis criterion and pulmonary heart disease follow diagnosis and treatment standard of COPD made by respiratory China Medical College.     

126例青春期女性盆腔包块的病因及诊治分析

Objective To explore the clinical characteristics,causes,diagnosis and treatment of pelvic mass in adolescents caused by gynecologic diseases. Methods One hundred and twenty-six adolescents with gynecologic diseases presented as pelvic mass were retrospectively reviewed. Results The average age of all patients was 17. 6 years,ranging from 10. 0 to 19. 0 years. Ectopic pregnancy was found in 38 patients(30. 2%) ,the average age of the patients was 18.6 ±0.5 years, ranging from 17.0 to 19.0 years. Ovarian neoplasm was found in 35 patients (27. 8%) ,the average age of the patients was 17. 1 ± 2. 1 years, ranging from 10. 0 to 19. 0 years. Twenty cases (57. l%)had germ cell tumor, eighteen with mature teratomas, one with endodermal sinus tumor and one with immature teratoma. Thirteen cases(37. 2%)had epithelial ovarian tumors;eight with serous cystadenomas,three with mucinous cystadenoma, one with mucinous cystadenoma complicated with serous cystadenoma and one with borderline mucinous cystadenoma. Two cases had simple cyst of the ovary (5. 7%) . Congenital abnormality of reproductive tract was found in 14 patients (11. 1%), the average age was 14. 7 ±2. 2 years, ranging from 13.0 to 19. 0 years. Seven had imperforate hymens, two had rudimentary horn of uterus,four had atresia of vagina,one had atresia of vagina complicated with rudimentary horn of uterus,and one had oblique septum of vagina. Corpus luteum rupture was found in 11 patients (8. 7%) , the average age was 18. 1 ± 1. 9 years, ranging from 13. 0 to 19. 0 years. 116 patients underwent operative treatment and 10 patients underwent conservative therapy. Conclusions According to the stage of adolescents, main causes of pelvic mass in adolescents are different Main causes of pelvic mass in early adolescents are tumorous disease. Congenital abnormalities of reproductive tract are usually in middle adolescents. The gonads develop closely mature in late adolescent period; main causes of pelvic mass are ectopic pregnancy, ovarian neoplasm and physiologic ovarian cyst Surgery is the main therapy of pelvic mass in adolescents.     

超声心动图联合脑钠肽检测评价急性肺栓塞溶栓治疗效果

Objective To explore the value of combined echocardiography and brain natriuretic peptide (BNP) levels in acute pulmonary embolism (APE) treated by thrombolysis.Methods Echocardiography,pulmonary ventilation-perfusion imaging and plasma BNP levels were performed before thrombolysis and 24 - 48 h after thrombolysis in 31 patients with diagnosis of APE and signs of right ventricular pressure overload.Results Twenty-six patients with thrombolysis effective,after thrombolysis,the pulmonary artery systolic pressure decreased from (57.3 ± 18.2)mm Hg to (40.4 ± 15.4)mm Hg (P= 0.003) ,the right ventricular diastolic diameter reduced from (40.6 ± 6.1)mm to (35.4 ± 6.0)mm (P ＜0.01) ,the pulmonary artery diameter reduced from (27.2 ± 4.9)mm to (22.5 ± 4.4)mm (P = 0.004) ,the left ventricular diastolic diameter increased from (42.4 ± 7.2)mm to (43.1 ± 6.9)mm (P = 0.42),septal contradiction were reduced from 20 cases to 10 cases (P = 0.02),plasma BNP levels decreased from (278.8 ± 43.3)ng/L to (119.1 ± 40.4)ng/L (P = 0.000 01).Five patients with thrombolysis ineffective,there were no significant changes before and after thrombolytic therapy in the parameters of echocardiography,however,plasma BNP levels increased from (431.8 ± 57.7) ng/L to (496.4 ± 70.3) ng/L(P = 0.03).Plasma BNP levels and pulmonary artery systolic pressure had a better relationship(r = 0.62,P ＜0.01).Conclusions The pulmonary perfusion and right ventricular function in patients with APE can be rapidly improved by thrombolytic therapy.Combined echocardiography and the BNP levels is a sensitive index in the hemodynamic changes of thrombolytic therapy,and can evaluate the treatment accurately.     

晚期非小细胞肺癌放射治疗联合靶向治疗效果分析

目的 评价放疗联合表皮生长因子受体-酪氨酸激酶抑制剂(EGFR-TKI)靶向治疗Ⅳ期非小细胞肺癌(NSCLC)的疗效及安全性.方法 26例NSCLC患者.其中骨转移16例,脑转移10例.放疗部位包括肺原发灶及骨、脑转移灶,放疗期间同时服用吉非替尼250 mg每天1次,或厄洛替尼150 mg每天1次,直至肿瘤进展或出现不可耐受的副作用.结果 所有患者在放疗期间均能完成放疗联合靶向治疗,12例患者出现腹泻,8例伴发呕吐,12例合并有皮疹.放疗前按美国东部肿瘤协作组(ECOG)评分平均为3分,放疗后为2分.骨转移局部控制率为93.8%(15/16),脑转移灶控制率为70.0%(7/10),肺部6个月局部控制率为84.6%(22/26).结论 针对Ⅳ期NSCLC,姑息性放疗联合靶向治疗是有效而安全的治疗方法,其对生存时间的影响需要进一步观察.

Abstract：

Objective To evaluate the efficacy and safety of radiation combined with targeted therapy of EGFR-TKI in the patients with stage IV non-small cell lung cancer ( NSCLC). Methods There were 17 female and 9 male patients with NSCLC enrolled into this study, which included 19 adenocarcinoma, 4 alveolar carcinoma and 3 uncertain carcinoma according to the iconography findings. Sixteen patients suffered from single or multiple bone metastasis,and 10 cases with brain metastasis. Gefitinib 250 mg or Erlotinib ISO mg per day were administrated during and after the process of radiation until the disease progressed. Results All patients had complete combined therapy, 12 of them suffered from diarrhea, 8 from emesia and 12 from erythra. The average score of ECOG improved from 3 to 2 after combined therapy. The bone metastasis control rate was 93.8% ,brain metastasis control rate was 70.0% , and the 6-month local lung lumps control rate was 84. 6%. Conclusion Palliative radiation combined with targeted therapy of EGFR-TKI is an effect and safe therapy for the patients with the stage IV of NSCLC, but the influence on survival shall be observed in further study.     

126例青春期女性盆腔包块的病因及诊治分析

Objective To explore the clinical characteristics,causes,diagnosis and treatment of pelvic mass in adolescents caused by gynecologic diseases. Methods One hundred and twenty-six adolescents with gynecologic diseases presented as pelvic mass were retrospectively reviewed. Results The average age of all patients was 17. 6 years,ranging from 10. 0 to 19. 0 years. Ectopic pregnancy was found in 38 patients(30. 2%) ,the average age of the patients was 18.6 ±0.5 years, ranging from 17.0 to 19.0 years. Ovarian neoplasm was found in 35 patients (27. 8%) ,the average age of the patients was 17. 1 ± 2. 1 years, ranging from 10. 0 to 19. 0 years. Twenty cases (57. l%)had germ cell tumor, eighteen with mature teratomas, one with endodermal sinus tumor and one with immature teratoma. Thirteen cases(37. 2%)had epithelial ovarian tumors;eight with serous cystadenomas,three with mucinous cystadenoma, one with mucinous cystadenoma complicated with serous cystadenoma and one with borderline mucinous cystadenoma. Two cases had simple cyst of the ovary (5. 7%) . Congenital abnormality of reproductive tract was found in 14 patients (11. 1%), the average age was 14. 7 ±2. 2 years, ranging from 13.0 to 19. 0 years. Seven had imperforate hymens, two had rudimentary horn of uterus,four had atresia of vagina,one had atresia of vagina complicated with rudimentary horn of uterus,and one had oblique septum of vagina. Corpus luteum rupture was found in 11 patients (8. 7%) , the average age was 18. 1 ± 1. 9 years, ranging from 13. 0 to 19. 0 years. 116 patients underwent operative treatment and 10 patients underwent conservative therapy. Conclusions According to the stage of adolescents, main causes of pelvic mass in adolescents are different Main causes of pelvic mass in early adolescents are tumorous disease. Congenital abnormalities of reproductive tract are usually in middle adolescents. The gonads develop closely mature in late adolescent period; main causes of pelvic mass are ectopic pregnancy, ovarian neoplasm and physiologic ovarian cyst Surgery is the main therapy of pelvic mass in adolescents.     

泊沙康唑与伏立康唑预防异基因造血干细胞移植后侵袭性真菌感染的疗效和安全性

目的 比较泊沙康唑与伏立康唑预防异基因造血干细胞移植（allo-HSCT）后侵袭性真菌感染（IFI）的疗效及安全性差异。方法 回顾性分析2019年6月-2021年6月于我院行allo-HSCT且应用泊沙康唑或伏立康唑进行真菌预防的104例患者（泊沙康唑组54例，伏立康唑组50例），对比两组移植后180 d内IFI发生率、药物不良反应发生率等相关指标。结果 泊沙康唑组和伏立康唑组IFI发生率分别为7.4%(4例)和20.0%(10例)，差异无统计学意义（P=0.085）；在IFI高危风险的患者中，两组IFI发生率为10.0%(3例)和34.9%(9例)，差异有统计学意义（P=0.047）；两组药物不良反应发生率为7.4%(4例)和18.0%(9例)，差异无统计学意义（P=0.091）。结论 泊沙康唑较伏立康唑可进一步降低allo-HSCT后高危风险患者的IFI发生率，且未增加药物相关不良反应发生率。     

异基因造血干细胞移植后患者预防性抗真菌治疗的研究进展

真菌感染,特别是侵袭性真菌病(IFD)为导致异基因造血干细胞移植(allo-HSCT)后患者死亡的主要原因之一.多项研究结果证实,应用预防性抗真菌治疗可降低allo-HSCT后患者真菌感染相关死亡率及IFD发生率.合理有效的预防性抗真菌治疗,需要根据allo-HSCT后患者既往真菌感染史及其免疫特点,选择有效的预防性抗真菌用药及其疗程.笔者拟就allo-HSCT后患者预防性抗真菌治疗的临床应用进展进行综述.     

IFD在异基因造血干细胞移植后感染的护理进展

侵袭性真菌病(invasive fungal disease, IFD),又称侵袭性真菌感染。IFD在异基因造血干细胞移植(allogeneic hematopoietic stem cell transplantation,allo-HSCT)患者中并不少见,随着免疫抑制剂的应用,IFD也在增加。总结侵袭性真菌病在异基因造血干细胞移植后感染特点、临床表现和护理措施,以指导临床护理。     

异基因造血干细胞移植后侵袭性真菌感染及其危险因素分析

本研究分析异基因造血干细胞移植（allo—HSCT）后患者侵袭性真菌感染（IFI）的发生及其高危因素。选择自2000年1月至2007年3月在我院行allo—HSCT患者180例，随访至2007年10月31日，用Kaplan—Meier和Cox回归模型方法，分析了IFI的发生率及其相关的危险因素。结果表明，35例（19、5％）患者在HSCT后发生了IFI，确诊1例，临床诊断34例；其中曲霉菌感染18例（51、4％），念珠菌感染17例（48．6％）。IFI组1年的存活率为34．3％．无IFI组1年的存活率为53．8％，存在显著性差异。在单因素分析中，与IFI的发生率增加有关的因素包括移植前真菌定植或感染、非血缘供者allo—PBHSC或allo—BMHSC移植、急性GVHD发生、广泛性慢性GVHD、应用甲基泼尼松龙。在多因素分析时，非血缘供者异基因外周血或骨髓干细胞移植、急性GVHD发生及移植前真菌感染或定植使IFI发生危险增加（RR分别为：1．589、2、399、1．410）。结论：IFI是allo—HSCT的常见并发症，也是主要致死原因之一，对移植前真菌感染或定植、非血缘供者allo-PBHSC或allo—BMHSC移植及发生急性GVHD的高危患者有必要早期采取干预性治疗。     

异基因造血干细胞移植后发生巨细胞病毒感染的临床分析

本研究总结巨细胞病毒(CMV)感染的发生及治疗。对北京军区总医院血液科2010年1月至2012年1月140例异基因造血干细胞移植(allo-HSCT)患者的临床资料进行了回顾性分析。结果表明,140例allo-HSCT中48例患者发生移植后CMV感染,发生率为34.3%,首次检出CMV-DNA阳性中位时间为移植后45(33-68)d,CMV定量范围为1.25×103-5.5×106,其中2例为CMV相关性间质性肺炎,5例为CMV相关性出血性膀胱炎。发生移植物抗宿主病(GVHD)患者共65例,其中合并CMV感染32例,占49.2%。应用更昔洛韦、膦甲酸钠抗CMV治疗45(33-68)d后CMV-DNA转阴,有效率为100%。共有12例患者治疗过程中出现一过性的白细胞和血小板减少。结论:allo-HSCT后较易发生CMV感染,发生GVHD的患者CMV感染发生率也较高,更昔洛韦、膦甲酸钠对allo-HSCT后CMV感染的治疗效果可靠,且不良反应少。     

异基因造血干细胞移植后并发肺部真菌感染6例临床分析

目的探讨异基因造血干细胞移植(allo-HSCT)后患者发生肺部真菌感染的发病原因及防治措施。方法对6例发生肺部真菌感染的allo-HSCT后患者的临床表现,影像学,微生物学,血象,免疫抑制剂和糖皮质激素的使用以及免疫功能状态,有无移植物抗宿主病(GVHD)和广谱抗生素的应用情况进行了临床统计和分析。结果6例患者均有体温>38℃;不同程度的呼吸道症状;肺部CT除曲霉菌感染有典型表现外一般无特殊改变。患者多有白细胞和中性粒细胞减少、使用免疫抑制剂和糖皮质激素及发生慢性GVHD,加上广谱抗生素的应用使得真菌感染率增加。4例治愈,2例死亡。结论对于allo-HSCT后具有真菌感染高危因素患者应给予高度重视,治疗真菌同时可给予增强免疫功能的治疗。     

异基因造血干细胞移植后重症胃肠道出血15例分析

目的分析异基因造血干细胞移植(alloHSCT)后重症胃肠道(GI)出血的临床特征、原因、治疗和转归。方法观察并分析15例白血病患者在alloHSCT后发生的急性(导致失血性休克)或亚急性(需要连续2d以上每日输注≥1U红细胞)胃肠道失血。结果15例患者共发生17次重症GI出血事件,发生时间分为早期(1周内)、中期(1～2个月)、晚期(4～7个月)。早期出血均有呕血和便血,中、晚期出血以便血为多见。出血发生时,绝大多数患者血小板<50×109/L。出血原因:预处理不良反应2例次;移植物抗宿主病(GVHD)或伴有(或疑诊)肠道巨细胞病毒(CMV)和真菌感染因素11例12例次;CMV肠炎1例次;消化性溃疡出血2例次;不明原因1例次。经过输注血小板、红细胞和新鲜血浆以及H2受体阻滞剂和奥美拉唑等支持治疗,由GVHD或伴有(或疑诊)CMV肠炎所致的出血同时予以免疫抑制剂和(或)抗病毒药等针对出血病因的治疗,最终8例9例次出血得以控制,8例患者持续出血直至死亡,主要死因为难治的急性GVHD和(或)相关合并症。结论alloHSCT后重症GI出血的主要原因为预处理不良反应和GVHD或伴有(或疑诊)CMV肠炎,前者多为自限性,预后良好,后者治疗难度较大,具有高度的病死率。     

异基因造血干细胞移植术后巨细胞病毒感染的临床研究

本研究探讨异基因造血干细胞移植（allogenic hematopoietic stem cell transplantation,allo-HSCT）后的巨细胞病毒感染及其相关因素.对2004年1月1日至2014年3月31日在本院血液科行allo-HSCT的108例受者病例进行回顾性分析,统计allo-HSCT后及其随访期内巨细胞病毒（cytomegalovirus,CMV）的感染发生率、中位发生时间并分析移植后受者CMV感染的相关高危因素及CMV病死亡率等指标.结果表明：纳入入选标准的108例allo-HSCT受者,其CMV感染率为52.78％（57/108）,首次检出CMV感染的中位时间为44（3-308）d,主要集中在移植后30-100 d;单因素分析显示,CMV感染的发生率与供受者人类白细胞抗原（human leucocyte antigen,HLA）配型、预处理方案中未使用抗人胸腺细胞免疫球蛋白（anti-human thymus globulin,ATG）、移植后粒细胞缺乏时间＞10 d及移植物抗宿主病（graft-versus-host disease,GVHD）等因素有关,与受者年龄、性别、原发疾病种类、原发疾病到移植间隔时间、原发疾病分级、干细胞来源、供者性别、供受者ABO血型是否相同及移植季节等因素均无关;多因素分析显示：粒细胞缺乏时间＞10 d和GVHD是CMV感染的高危因素.移植后因CMV病的死亡率为58.82％（10/17）,其中CMV间质性肺炎（CMV-interstitial pneumonia,CMV-IP）死亡率最高,占CML病死亡病例的60％（6/10）.结论：CMV是allo-HSCT术后常见的感染病毒之一,移植时最好选择亲缘、H-LA配型全相合的供者,在预处理方案中加用ATG,移植后将粒细胞缺乏时间控制在10 d以内以及预防GVHD的发生均有可能减少CMV感染发生率;积极加强CMV感染的抢先治疗有可能减少CMV病的发生率和死亡率.     

小儿异基因造血干细胞移植后早期真菌感染的临床观察

目的观察儿童异基因造血干细胞移植（allo-HSCT）后早期侵袭性真菌感染（IFI）的发生情况,对其发生率、死亡率与伊曲康唑注射液、粒细胞刺激因子（G-CSF）之间的关系进行分析,为临床能够更好地预防和治疗IFI提供参考。方法对2008年3月至2010年2月我院收治的87例儿童异基因造血干细胞移植患者早期IFI发生情况进行回顾性调查分析。87例病例分为4组,分别为伊曲康唑注射液＋使用G-CSF预防组4例、非伊曲康唑注射液＋使用G-CSF预防组31例、伊曲康唑注射液＋未使用G-CSF预防组48例和非伊曲康唑注射液＋未使用G-CSF预防组4例,比较各组间早期IFI率和早期死亡率的差异。结果非伊曲康唑注射液＋使用G-CSF预防组与伊曲康唑注射液＋未使用G-CSF预防组之间其早期IFI率和早期死亡率均有统计学差异（P值均〈0.05）;而其它各组相互之间的早期IFI率和早期死亡率均无统计学差异（P值均〉0.05）。伊曲康唑副作用少。结论静脉注射伊曲康唑预防儿童异基因造血干细胞移植患者早期IFI是一种安全、有效的方法。儿童allo-HSCT术后早期应用G-CSF的临床价值有待进一步总结。     

单倍体相合异基因造血干细胞移植治疗重型再生障碍性贫血疗效回顾性分析

本研究旨在观察单倍体相合异基因造血干细胞移植（allo-HSCT）对重型再生障碍性贫血（SAA）的疗效,评价其安全性.21例SAA患者（13例SAA-Ⅰ,8例SAA-Ⅱ）接受单倍体相全合allo-HSCT,供者为患者相关亲属（父母供子女12例,同胞供者9例）.预处理方案包括环磷酰胺、氟达拉滨及抗胸腺细胞球蛋白（ATG）.移植后给予短程甲氨蝶呤、吗替麦考酚酯及环孢素A预防移植物抗宿主病（GVHD）.植入成功后定期监测供体细胞嵌合率,观察感染、GVHD等合并症的发生率、严重程度及患者的长期生存率.结果表明：中位随访16（3-46）个月,21例患者中15例生存,生存率为71.4％;1例患者因植入失败而在移植后43 d死于真菌败血症,2例患者分别于移植后6d及10 d因肺部感染死亡,1例患者于移植后3个月出现排斥,后接受了第二次移植（同一供者）,于移植后17d死于肺部感染,2例患者分别于移植后35 d及52天死于Ⅳ度肠道GVHD,GVHD的累积发生率为66.7％（14/21）,其中Ⅲ度以上5例.结论：单倍体相合allo-HSCT治疗SAA的效果明显,并发症较少,安全性较好.     

伊曲康唑治疗血液系统恶性肿瘤伴发真菌感染临床观察

目的观察伊曲康唑治疗血液系统恶性肿瘤患者伴发真菌感染的效果。方法选择我院2004年2月至2009年6月收治的恶性血液病合并侵袭性真菌感染患者(IFI)31例并分为两组,A组17例,予伊曲康唑注射液静脉注射2 d后改口服液续贯治疗,B组14例,予伊曲康唑注射液静脉注射14 d后改口服液续贯治疗。结果A组与B组IFI患者有效率分别为64.7%和64.3%。结论恶性血液病合并侵袭性真菌感染者应用改良伊曲康唑方案治疗有效,节约了医疗费用,其抗感染疗效与免疫力恢复速度密切相关。     

肺侵袭性真菌感染患者临床与影像学特征对真菌病原体的提示

目的：探讨肺侵袭性真菌感染（IFI）的临床与影像学特征对真菌病原体的提示意义。方法于2013年10月至2015年10月在新疆医科大学第一附属医院呼吸 ICU 按序收集免疫抑制合并肺 IFI 的患者资料。IFI 诊断标准包括危险因素、临床表现、HRCT 特征与血清 GM试验或 G 试验阳性,符合2008年欧洲癌症研究治疗组织／真菌病研究组（EORTC ／MSG）临床诊断（probable diagnosis）的定义标准,并且抗真菌治疗有效。采用χ2检验比较酵母菌和霉菌患者不同临床与影像学特征的差异性。采用 Logistic 回归模型进行判别分析,以准确率评价判别效果。结果有143例纳入,支气管肺泡灌洗液（BALF）分离酵母菌108例（75.5％）和霉菌35例（24.5％）。危险因素主要包括糖尿病62例（43.4％）、慢性肺疾病46例（32.2％）、使用广谱抗生素（≥14 d）51例（35.7％）、恶性肿瘤33 例（23.1％）、使用糖皮质激素（≥14 d ）33 例（23.1％）、慢性肾病肾脏替代治疗23 例（16.1％）和免疫性疾病15例（10.5％）。这些危险因素在两类真菌病原体分布差异的比较结果显示,使用广谱抗生素（≥14 d）多见于酵母菌感染（P ＜0.05）,而有慢性肺疾病则有利于霉菌的产生（P ＜0.05）。纳入研究后合并细菌感染和使用机械通气的患者,酵母菌比霉菌多发（分别 P ＜0.05）。胸部 HRCT 表现为支气管肺炎-肺实变76例（53.1％）、块状影42例（29.4％）,小结节35例（24.5％）,大结节27 例（18.9％）,胸腔积液27 例（18.9％）,晕轮征20 例（14％）,以及空洞14 例（9.8％）等。这些影像学特征在两类真菌分布差异的比较结果显示,胸腔心包积液多出现在霉菌感染（P ＜0.05）。Logistic 回归模型判别两类真菌的结果显示,使用广谱抗生素（≥14 d）、机械通气和胸腔心包积液的判断价值大（均 P ＜0.05）,预测判别的准确率为77.6％。结论对于免疫抑制合并肺 IFI 患者,多数危险因素、临床和 HRCT 主要特征不能提示真菌病原体,而且 BALF 分离的非隐球菌之类酵母菌可能是伴随菌或定植菌。     

异基因造血干细胞移植后的巨细胞病毒肠炎24例分析

目的 分析异基因造血干细胞移植(allo-HSCT)后巨细胞病毒(GMV)肠炎的临床特点、诊断方法和危险因素.方法 总结北京市道培医院2007年8月至2009年7月确诊的24例CMV肠炎患者的一般临床资料和内窥镜、组织病理学和病毒学检查结果,以及CMV肠炎与CMV病毒血症和移植物抗宿主病(GVHD)的关系.结果 87.5%的患者年龄≥18岁,诊断CMV肠炎的中位时间为allo-HSCT后第63天.内窥镜下的肠黏膜表现对区分单纯CMV肠炎和肠炎合并GVHD没有鉴别意义.用于诊断的方法包括组织病理学(32.1%)和病毒学(92.9%)检查.肠黏膜标本中每106个单个核细胞的CMV DNA定量大于105时更有诊断价值.在死亡和存活两组患者中进行了下列危险因素的比较:移植类型、预处理方案、更昔洛韦预防病毒天数、确诊肠炎前有无Ⅱ～Ⅳ度急性GVHD、GVHD确诊时间、是否使用≥1 mg/kg的甲泼尼龙治疗GVHD、GVHD距离确诊肠炎的时间、肠炎前是否有CMV血症、确诊肠炎的时间、肠黏膜CMV DNA定量,差异均无统计学意义.结论 进行内窥镜检查并通过组织病理学和病毒学检查确诊是CMV肠炎诊断中的决定性因素,最好进行全结肠检查并到达回肠末端.PCR方法能明显提高CMV检出率.对那些无法进行肠镜检查的患者,采用粪便检测CMVDNA能够对诊断提供帮助.

Abstract：

Objective To analyse the clinical features, diagnostic methods and risk factors of cytomegalovirus(CMV) enteritis after allogeneic hematopoietic stem cell transplantation(allo-HSCT).Methods Analysis was made on 24 cases of CMV enteritis after allo-HSCT in Beijing Daopei Hospital from Aug.2007 to Jul.2009, including clinical data, endoscopic diagnosis, histopathological and virological results, and the association between CMV enteritis with viremia and graft-versus-host disease(GVHD).Results 87.5% of the patients were over 18 years old.The median time to diagnosis of CMV enteritis was 63 days after HSCT.The mucosal lesions in enteroscopic examination had no significant differences between CMV enteritis and gastrointestinal GVHD complicated with the enteritis.The methods used in diagnosis included histopathology (32.1%) and virology (92.9%).The copies of CMVDNA in mucosal samples greater than 105/106 PBNC was better diagnosis.A number of risk factors were compared between the survival and death groups: type of transplant, conditioning regimen, the time span of ganciclovir prophylaxis therapy, grade Ⅱ - Ⅳ GVHD before enteritis, the time of diagnosis as GVHD, using MP≥1 mg,/kg to treat GVHD, the time between GVHD and enteritis, CMV viremia before enteritis, the time of diagnosis as enteritis, CMVDNA quantitation, and there were no any statistic differences.Conclusion Cytomegalovirus enteritis should be carefully diagnosed by histopathology and virology through endoscopic examination.It is better to undertake pan-colon endoscopy as well as terminal ileum examination for more accurate diagnosis.PCR can significantly improve the detection rate.CMVDNA detection in patients' stool may be helpful to diagnosis, especially for those patients who can not stand the endoscopy examination.