58例艾滋病合并马尔尼菲青霉菌病病人临床特征分析

目的分析艾滋病(AIDS)合并马尔尼菲青霉菌病病人的临床特征。方法采用回顾性分析方法,对2014年1月至2016年12月出院的58例AIDS合并马尔尼菲青霉菌病病人的临床表现、辅助检查和实验室资料进行分析。结果 58例病人中发热占94.8%,咳嗽占70.7%,特征性皮疹占46.6%,腹痛占39.7%,脾大占55.2%,腹腔淋巴结肿大占51.7%,贫血占81.0%。CD4~+T淋巴细胞(简称CD4细胞)计数中位数为10个/μL,50个/μL的占85.7%。血培养马尔尼菲青霉菌阳性47例,阳性率81.0%,其他组织、体液培养和病理阳性11例,占19.0%。GM试验阳性91.7%(44/48),G试验阳性72.0%。两性霉素B联合伊曲康唑序贯治疗占79.3%。好转出院49例(84.5%),恶化出院9例(15.5%)。结论 AIDS合并马尔尼菲青霉菌病好发于CD4细胞50个/μL的病人,临床表现复杂多样。诊断依靠病原菌的培养及组织病理,抗真菌治疗效果好。     

伏立康唑治疗AIDS合并马尔尼菲青霉菌病的疗效与安全性

目的探讨单用伏立康唑(VO)及VO序贯两性霉素B(AMB)治疗艾滋病(AIDS)合并马尔尼菲青霉菌病(PSM)的疗效与安全性。方法前瞻性观察36例确诊AIDS合并PSM病人,单用VO及VO序贯AMB方案治疗后的疗效及不良反应。结果 36例病人中,男性28例,女性8例,平均年龄34.5岁。血和骨髓培养均发现马尔尼菲青霉菌(PM),抗真菌前83.3%存在肝功能受损,41.67%存在肾功能损害,50.0%发生严重贫血,19.4%外周血白细胞≤3×109/L,27.8%血小板≤50×109/L。初始治疗使用VO,治疗14天后复查血和骨髓培养PM情况:20例(55.6%)均转阴,16例(44.4%)仍阳性。复查PM转阴者继续使用VO,阳性者则改用AMB。36例病人使用VO 14天后临床症状好转,肝肾功能、血常规及血清钾改善(P0.05),未出现严重药物不良反应。16例序贯治疗病人使用AMB 14天后,血和骨髓培养均转阴,肝肾功能、血常规及血清钾无明显变化(P0.05),未发生明显不良反应。结论 VO治疗AIDS合并PSM多器官损害病人具有较好的疗效和安全性,并能改善病人一般情况,为进一步使用AMB根除PM创造机会。     

两性霉素B、氟康唑和伊曲康唑治疗AIDS合并马尔尼菲青霉病疗效的Meta分析

目的采用Meta分析评价两性霉素B、氟康唑与伊曲康唑对AIDS合并马尔尼菲青霉病(penicilliosis marneffei,PSM)的治疗效果。方法检索Cochrane图书馆、美国国立医学图书馆Pub Med数据库、美国Ovid数据库、荷兰医学文摘数据库、万方数据库、中国知网CNKI全文数据库和中国生物医学文献数据库,按照Cochrane协作网推荐的纳入标准筛选文献并进行质量评价,采用Stata 12.0进行Meta分析。结果纳入文献6篇,AIDS合并PSM共893例,其中两性霉素B治疗467例,氟康唑治疗152例,伊曲康唑治疗274例。Meta分析结果显示:两性霉素B治疗好转率高于氟康唑[OR=7.138(95%CI 1.761~28.932),P0.05],病死率低于氟康唑[OR=0.507(95%CI 0.294~0.875),P0.05],差异均具有统计学意义;两性霉素B与伊曲康唑对比,治疗好转率[OR=0.777(95%CI 0.498~1.212),P0.05]和病死率[OR=1.427(95%CI 0.890~2.287),P0.05]差异均无统计学意。结论两性霉素B治疗AIDS合并PSM效果优于氟康唑,与伊曲康唑比较疗效无明显差异。今后应积累更多前瞻性资料进一步证实。     

101例艾滋病合并马尔尼菲青霉病的临床研究

目的 探讨艾滋病合并马尔尼菲青霉病的流行病学、临床特点及治疗方案.方法 回顾性分析2003年1月至2006年12月,广州市第八人民医院收治的101例确诊为艾滋病合并马尔尼菲青霉病患者的资料.结果 艾滋病合并马尔尼菲青霉菌感染病例近年来逐年增加,呈多部位播散感染;临床表现以发热、贫血、消瘦、咳嗽、咳痰、皮疹、脾大为主,外周血CD4 淋巴细胞计数多数(91.09%)＜50个/μl;特征型皮疹具有一定诊断意义,皮肤活检、血培养、骨髓培养阳性率高;应用伊曲康唑和两性霉素B疗效较好,长时间二级预防联合高效抗逆转录病毒治疗可降低复发率.结论 马尔尼菲青霉菌已成为广东地区艾滋病机会性感染的主要病原之一,临床表现无特异性,主要发生于CD4 淋巴细胞计数＜50个/μl的患者,确诊需多部位取材培养或活检,治疗推荐使用伊曲康唑、两性霉素B.     

艾滋病合并马尔尼菲青霉病不同疗程的临床效果观察

目的探讨艾滋病(AIDS)合并马尔尼菲青霉病(PM)的有效治疗方案,提高AIDS合并PM的诊疗水平,降低病死率。方法选取AIDS合并PM患者62例,分为疗程10周组和12周组,两组均给予两性霉素B和/或伊曲康唑及抗艾滋病病毒治疗(ARV),治疗结束后观察两组的复发率及病死率。结果治疗疗程10周组与12周组的复发率及病死率差异无统计学意义(P0.05)。结论 AIDS合并PM治疗疗程10周组与12周组疗效大致相同。     

在北方诊治的艾滋病合并马尔尼菲青霉菌病27例临床观察

目的总结艾滋病(AIDS)合并马尔尼菲青霉菌病的临床特点及治疗转归情况。方法回顾性资料分析。结果 2006年2月-2011年2月,北京地坛医院感染中心确诊27例艾滋病合并马尔尼菲青霉菌病患者。临床表现以发热、咳嗽、盗汗、贫血、皮疹、腹痛、多部位淋巴结肿大为主;皮疹具有特征性,皮肤活检、血培养阳性率高;胸片或胸部CT主要表现为肺野斑片状或斑点状浸润阴影、弥漫粟粒样结节改变。患者的CD4+淋巴细胞计数均<100个/μL。3例痊愈出院,22例好转出院,2例死亡。结论马尔尼菲青霉菌病是我国南方常见的艾滋病机会性感染之一,但近年在北方就诊的患者中也并不少见。确诊需多次血培养及皮肤等部位的活检,该病易误诊为肺结核和淋巴结核,治疗上单独使用伊曲康唑也可达到满意疗效。     

艾滋病合并马尔尼菲青霉菌病患者预后因素分析

目的 探讨影响AIDS合并马尔尼菲青霉菌病(PSM)预后的因素.方法 165例经病原学确诊的AIDS合并PSM患者.根据预后分成生存组和死亡组.应用Logistic回归,分析25个可能影响疾病预后的临床和实验室指标,筛选出独立预后因素.结果 AIDS合并PSM患者中,生存组121例,死亡组44例,病死率为26.7%.单因素分析显示,影响AIDS合并PSM预后的因素包括皮疹、细菌和(或)其他真菌性肺炎、CMV感染、败血症、肾功能损伤、PLT减少、Hb、CD4~+T淋巴细胞计数、Alb、伊曲康唑(ITR)序贯疗法及高效抗反转录病毒治疗(HAART).多因素分析显示,去除各因素之间相互混杂的影响,筛选出细菌或其他真菌性肺炎(OR=6.539;95%CI 2.312,18.498)、败血症(OR=15.307;95%CI 1.473,42.462)及PLT减少(OR=7.763;95%CI 2.658,22.675)是AIDS合并PSM死亡的危险因素,而ITR序贯疗法((OR=0.088;95%CI 0.013,0.611)与HAART(OR=0.084;95%CI 0.026,0.269)是其保护性因素.结论 合并细菌或其他真菌性肺炎、败血症与PLT减少是AIDS合并PSM预后不良的危险因素,ITR序贯疗法和HAART则可减少死亡风险,改善预后.     

两性霉素B治疗COPD合并侵袭性肺曲霉菌病的相关性研究

目的对比两性霉素B与伊曲康唑治疗C0PD合并侵袭性肺曲霉菌病(IPA)的临床疗效、不良反应及治疗费用。方法对比研究我院两性霉素B治疗COPD合并IPA的52例患者诊疗过程与伊曲康唑治疗COPD合并IPA的25例患者诊疗过程。结果两性霉素B治疗COPD合并IPA有效率70.2%,不良反应发生率53.1%,主要是低血钾(44.7%),寒战发热(31.9%),中位疗程29天,治疗经费1820元,7例中途放弃治疗(14.9%);伊曲康唑治疗COPD合并IPA有效率68.4%,不良反应发生率10.5%,均为轻度肝功能异常(5.3%),中位疗程26天,治疗经费28000元,6例中途放弃治疗(24%)。结论与伊曲康唑相比,两性霉素B治疗COPD合并IPA疗效肯定,不良反应发生率高,但无严重不良反应,且治疗经费低,患者能坚持治疗,是较为安全有效的一线抗真菌药物。     

播散性马尔尼菲篮状菌病合并肺隐球菌病1例并文献复习

本文报道1例无免疫缺陷的非获得性免疫缺陷综合征宿主, 以发热、呼吸道症状、多发淋巴结肿大、皮下脓肿、肺部阴影伴骨质破坏为主要临床表现, 经肺组织活检病理找到隐球菌后, 给予氟康唑抗真菌治疗, 病情进展, 最终通过脓性分泌物培养出马尔尼菲篮状菌, 肺组织病理同时找到隐球菌与马尔尼菲篮状菌, 最终确诊为播散性马尔尼菲篮状菌病合并肺隐球菌病, 经两性霉素B序贯伊曲康唑治疗后好转。本文可引起临床对无免疫缺陷的非获得性免疫缺陷综合征宿主同时感染多种机会性真菌的重视, 并提高临床诊治水平。     

恶性血液病合并侵袭性真菌感染73例治疗分析

目的探讨恶性血液病患者合并侵袭性真菌感染(IFI)应用氟康唑、伊曲康唑和两性霉素B治疗的结果及其影响因素。方法选择南方医科大学附属南方医院1992-01~2004-10收治的恶性血液病合并IFI患者73例,单用常规剂量的氟康唑33例、伊曲康唑26例、两性霉素B14例;氟康唑治疗无效者改用伊曲康唑9例和两性霉素B6例,伊曲康唑治疗无效改用两性霉素B和脂质体两性霉素B16例,47例同时应用了粒细胞集落细胞刺激因子(G-CSF)治疗至白细胞正常,37例联合静脉注射丙种球蛋白。结果73例IFI总的治愈率和有效率分别为53·4%和63·0%,在各诊断组间差异无显著性意义(P>0·05)。单用氟康唑治疗组的有效率显著低于伊曲康唑和两性霉素B治疗组,分别为39·4%、53·9%和57·1%(P<0·05);用氟康唑治疗无效改用伊曲康唑或两性霉素B治疗的有效率分别为77·8%和83·4%。结论伊曲康唑和两性霉素B治疗IFI的疗效相似,明显高于氟康唑;两性霉素B的副反应多。抗真菌的有效率在确诊组、临床诊断组和拟诊组之间差异无显著性意义。     

The immunoneuroendocrine role of melatonin

Abstract: A tight, physiological link between the pineal gland and the immune system is emerging from a series of experimental studies. This link might reflect the evolutionary connection between self-recognition and reproduction. Pinealectomy or other experimental methods which inhibit melatonin synthesis and secretion induce a state of immunodepression which is counteracted by melatonin. In general, melatonin seems to have an immunoenhancing effect that is particularly apparent in immunodepressive states. The negative effect of acute stress or immunosuppressive pharmacological treatments on various immune parameters are counteracted by melatonin. It seems important to note that one of the main targets of melatonin is the thymus, i.e., the central organ of the immune system. The clinical use of melatonin as an immunotherapeutic agent seems promising in primary and secondary immunodeficiencies as well as in cancer immunotherapy. The immunoenhancing action of melatonin seems to be mediated by T-helper cell-derived opioid peptides as well as by lymphokines and, perhaps, by pituitary hormones. Melatonin-induced-immuno-opioids (MHO) and lymphokines imply the presence of specific binding sites or melatonin receptors on cells of the immune system. On the other hand, lymphokines such as -γ-interferon and interleukin-2 as well as thymic hormones can modulate the synthesis of melatonin in the pineal gland. The pineal gland might thus be viewed as the crux of a sophisticated immunoneuroendocrine network which functions as an unconscious, diffuse sensory organ.     

Changes in connexin43, the gap junction protein of astrocytes, during development of the rat pineal gland

Abstract: The abundance of gap junctions between rat pineal astrocytes formed by connexin43 (Cx43) was studied during development. Levels and distribution of Cx43 were measured by immunoblotting and indirect immunofluorescence, respectively. The amount of Cx43 in cells located within the gland was low until about the 7th postnatal day and increased to adult values between the 14th and 21st days postpartum. Although astrocytes, recognized by their vimentin immunoreactivity, were scarce before birth, they were abundant by the 7th postnatal day suggesting that the low levels of Cx43 found at this age corresponded to a low expression of this protein. Localization of the immunoreactivity to Cx43 and vimentin showed a close correlation, indicating that mature or immature pineal astrocytes form gap junctions made of Cx43. Since Cx43 levels attained their adult values at about the time the innervation and the functional state of the gland reached maturity (2–3 weeks after birth), it is proposed that astrocyte gap junctions are involved in the function of the adult rat pineal gland.     

Response of rat pineal melatonin to calcium, magnesium, and lithium is circadian stage dependent

Abstract: Herein we documented the response of pineal melatonin production to electrolytes known to be effective on pineal function in view of a possible circadian stage dependence. We studied the release of melatonin by perifused rat pineal glands at 2 different circadian stages corresponding to the middle of the light and dark periods, i.e., respectively, 7 and 19 HALO (Hours After Light Onset, L:D = 12:12). The initial efflux rates were, as expected, much higher in the perifusates of glands removed from rats sacrificed during the dark phase than of those removed during the light phase. After 3 hr of perifusion, melatonin release reached similar levels which were found constant up to the 8th hr of perifusion, whatever the circadian stage. Perifusion of the glands with physiological concentrations for the rat of calcium (5.2 mmol/1) and magnesium (1.34 mmol/1) resulted in a stimulatory effect on the pineal glands removed from rats sacrificed in the middle of the dark period (19 HALO), whereas no effects were observed on the pineal glands removed from rats sacrificed during the light (7 HALO). Lithium (0.28 and 0.55 mmol/1) was ineffective on melatonin release in pineal glands removed 7 and 19 HALO. Our results show differences in the initial efflux rates of melatonin and in the response of perifused pineal glands to calcium and magnesium according to the circadian stage.     

Conservative management of perforated duodenal diverticulum： A case report and review of the literature

Duodenal diverticula are a relatively common condition. They are asymptomatic, unless they become complicated, with perforation being the rarest but most severe complication. Surgical treatment is the most frequently performed approach. We report the case of a patient with a perforated duodenal diverticulum, which was diagnosed early and treated conservatively with antibiotics and percutaneous drainage of secondary retroperitoneal abscesses. We suggest this method could be an acceptable option for the management of similar cases, provided that the patient is in good general condition and without septic signs.     

Presence of immunoreactive growth hormone and prolactin in the ovine pineal gland

Abstract: The use of antisera raised against bovine growth hormone (GH) and ovine prolactin (PRL) enabled the detection of related immunoreactive (ir) sequences of proteins in ovine pineal tissue. The isolation of PRL-like ir-material was accomplished using a 0.25 M ammonium sulphate (pH 5.5) extraction followed by ethanol precipitation, whereas the resulting 2.0 M ammonium sulphate (pH 7.0) precipitate contained a GH-like immunoreactivity. Gel chromatography of the GH-like immunoreactivity (Sephadex G-100) indicated the presence of several GH-like fragments ranging in the M_r range of 7,000 to 55,000. Analyses of the PRL-like ir-material found in pineal tissue on HPLC using a TSK 545-DEAE column led to the resolution into a single peak of immunoreactivity. A single peak of activity was also observed following chromatofocusing and hydrophobic interaction chromatography of the ir-peak from the TSK 545-DEAE column. The PRL-like ir-material inhibited the binding of [¹²⁵I]ovine PRL-S14 to anti-ovine PRL antibodies without showing an affinity for binding to anti-rat PRL or anti-bovine GH antibodies. Scatchard analysis of the binding of pineal PRL-like ir-material and pituitary ovine PRL-S14 to liver membranes from day-20 pregnant rats revealed similar affinity constants (K_a of 4.7 ± 0.2 × 10⁹ M^-1). In addition, the replication of Nb 2 Node rat lymphoma cells was stimulated by pineal PRL-like ir-material, an effect known to be specific for lactogenic hormones. The pineal PRL-like immunoreactivity appeared on sodium dodecyl sulfate polyacrylamide gels as a single major band of M_r 24,000. The functional status of PRL-and GH-like ir-material in the ovine pineal remains to be determined, but evidence is presented that the overall protein synthesis rate of the rat pineal responded to circulating concentrations of PRL.     

Microbiology of human immunodeficiency virus anorectal disease

PURPOSE: Individuals who are seropositive for the human immunodeficiency virus are at high risk for opportunistic infection and anorectal disorders. Little prospective information is available regarding anorectal pathogens in these patients. METHODS: One hundred sixty-three HIV-seropositive patients presented to the colorectal clinic between 1989 and 1992. Forty-seven (29 percent) patients were thought to have an infectious process and were prospectively studied using a standardized multiculture protocol. RESULTS: Mean age was 33 (range, 19–59) years. All were male; high-risk behavior accounted for 87 percent of HIV transmissions. Presenting complaints included anorectal pain (79 percent), pus per anum (28 percent), and blood per anum (26 percent). Examination revealed perianal tenderness (60 percent), condyloma (38 percent), perianal ulcers (38 percent), and anal fissures (34 percent). Sixty-six sets of cultures were performed; 28 patients had one set, 15 had two sets, and 4 had three sets. Thirty-two of these 47 patients (68 percent) had positive cultures including herpes (50 percent), cytomegalovirus (25 percent),Neisseria gonorrhoeae (16 percent), chlamydia (16 percent), acidfast bacilli (2 percent), and others (9 percent). Six of 32 patients with positive cultures had more than one organism cultured. Sixteen (50 percent) patients with positive cultures were treated medically, 8 (25 percent) were treated surgically and 8 (25 percent) were treated with both modalities. Sixty-one procedures were performed on 17 patients for condylomata. Eighteen patients had 20 procedures for abscesses, 50 percent of whom had positive cultures for other than common bowel flora; all improved. Fourteen patients underwent 33 procedures for perianal fistulas.Mycobacterium fortuitum was cultured from one patient who required 13 procedures for abscesses and fistulas. Forty-five (96 percent) patients were followed for an average of 12.5 months ±2.9 SEM (range, 1–94 months). Symptoms were improved or resolved in 22 of 32 (69 percent) patients with positive cultures and in 11 of 13 (84 percent) with negative cultures. CONCLUSIONS: Specific pathogens may often be identified in human immunodeficiency virus-seropositive patients with anorectal disorders if aggressively sought. Although patients without specific pathogens identified may be expected to improve with planned empiric treatment, positive identification allows more directed therapy.