肾移植术后耶氏肺孢子菌肺炎的临床表现及诊治分析

目的 分析探讨肾移植术后耶氏肺孢子菌肺炎(pneumocystis jiroveci pneumonia, PJP)的发病情况及临床诊治情况。方法 回顾性分析2015年1月至2021年7月首都医科大学附属北京友谊医院收治的肾移植术后PJP患者的临床表现、实验室及影像学结果以及诊治过程。结果 本研究共收录肾移植术后耶氏肺孢子菌肺炎患者34例,其中男性21例,女性13例。感染时间为肾移植术后8.5(6.0,18.0)月;主要临床表现为发热31例(占91.2%)、干咳14例(占41.2%)及喘憋13例(占38.2%);相关感染指标中(1,3)-β-D葡聚糖[147.7(60.0,258.7)pg/mL]、乳酸脱氢酶[(393.94±107.94) U/L]及C-反应蛋白[30.5(12.8,57.5)mg/L]明显升高,与出院时结果差异有显著统计学意义(P<0.01);病原学检查以痰耶氏肺孢子菌PCR检测为主,阳性率为56.7%,肺泡灌洗液(BALF)PCR、痰液、肺泡灌洗液及血液的宏基因组二代测序(macrogenomic next-generation sequencing, mN...     

艾滋病与慢性肾脏病患者耶氏肺孢子菌肺炎的临床特征比较

目的：回顾性分析艾滋病(AIDS)与慢性肾脏病(CKD)患者耶氏肺孢子菌肺炎(PJP)临床特征及预后。方法：纳入2018年10月至2022年4月东部战区总医院国家肾脏疾病临床医学研究中心收治的CKD合并PJP患者,以及同期南京市第二医院感染病科收治的AIDS合并PJP患者,比较分析两类患者的临床及影像学特征和预后。结果：CKD组79例,AIDS组31例。CKD组患者PJP症状出现到确诊时间短,入院时氧合指数、血液总淋巴细胞计数、白蛋白、球蛋白、CD3⁺T、CD8⁺T数值更低,血液总中性粒细胞计数、乳酸脱氢酶、CD4⁺T、C反应蛋白、降钙素原、白细胞介素6、血清真菌G值更高(P<0.05),支气管肺泡灌洗液中耶氏肺孢子菌(PJ)碱基序列数少于AIDS组,但细菌种类更多(P<0.05)。CKD组胸部CT显示磨玻璃样病变比例低,斑片状阴影比例高(P<0.01)。CKD和AIDS组患者90 d生存率分别为69.62%和93.55%(P=0.01)。结论：与AIDS患者相比,发生PJP的CKD患者PJ负荷低,但炎...     

艾滋病患者耶氏肺孢子菌肺炎的影像学分析

目的通过对艾滋病（AIDS）患者耶氏肺孢子菌肺炎（PCP）的影像学特点分析,提高PCP的诊断水平。方法回顾性分析45例AIDS患者PCP的胸部x线、cT表现。结果45例均表现为两肺弥漫性病变,呈两肺网状合并斑片状、小片状、大片状、结节状及两肺磨玻璃状改变。少见的合并表现有少量胸腔积液、肺气囊、肺大泡、结节灶、空洞、气胸。4例胸片两肺未见异常。结论胸部x线及CT对AIDS患者PCP具有重要的诊断价值。     

儿童非HIV型肺孢子菌肺炎8例临床分析

目的提高对儿童非HIV型肺孢子菌肺炎认识,以期早期预防、诊断、治疗及提高疗效。方法回顾近3年共8例儿童非HIV型肺孢子菌肺炎的临床诊治经过,并进行相关文献复习。结果8例患儿中有7例为小于1岁婴儿(中位数月龄:4月),1例为3岁肾病综合症患儿;男女比例为5:3;发病前有使用糖皮质激素类药物史6例;8例患儿均通过肺泡灌洗液病原学高通量基因检测查出为耶氏肺孢子菌感染;症状分析为发热5例,气促5例,肺部湿啰音6例,喘鸣音1例;呼吸困难需呼吸机通气4例;病程大于1月者8例;肺部影像学提示斑片状渗出6例,伴有胸腔积液、气胸、肺实变者各2例,肺不张者1例;伴有动脉血氧分压下降5例;8例患儿均血生化检查乳酸脱氢酶升高大于350 U/L,平均值1214 U/L;血清1-3β葡聚糖升高(大于33.5 ng/L)者3例;免疫功能血TBNK检查NK细胞比例减少者3例;免疫五项检查C3补体下降者4例;8例患儿均合并其他病原体感染,合并有巨细胞病毒感染7例;合并呼吸道合胞病毒及人类疱疹病毒5型感染各4例;合并真菌感染3例;合并革兰阳性球菌感染5例,流感2例;腺病毒1例;治疗上,8例患儿均接受口服复方磺胺甲恶唑治疗,予抗真菌治疗7例,人免疫球蛋白治疗6例,更昔洛韦治疗4例,其中口服磺胺药后好转5例,2例死亡患儿均在住院期间有持续使用糖皮质激素(甲强龙>1周或>2 mg/kg)治疗,因怀疑免疫缺陷病转院1例。结论儿童非HIV型肺孢子菌肺炎病程长,确诊难度大;小婴儿使用糖皮质激素类药物时应更谨慎;临床有发热、气促、肺部湿啰音及动脉血氧分压下降,血乳酸脱氢酶升高,1-3β葡聚糖升高,胸片提示斑片状渗出等特点,伴有免疫性疾病或激素用药史者需警惕本病,常有多种病原体混合感染,以巨细胞病毒多见;部分患儿可经复方磺胺甲恶唑治疗后好转。     

耶氏肺孢子菌肺炎的临床特征分析

目的 分析耶氏肺孢子菌肺炎患者的临床特点,以提高对此类疾病的认识,做到早诊早治。方法 选择2017年3月1日至2022年3月1日,空军军医大学第二附属医院收治的耶氏肺孢子菌肺炎患者43例,按是否感染HIV分为非HIV感染组17例,HIV感染组26例。分析两组患者性别、年龄、吸烟史,基础疾病,既往用药,临床症状、实验室检查、胸部CT资料及治疗、疗效。结果 非HIV感染组年龄(52.29±13.59)岁大于HIV感染组(39.42±12.55)岁;两组患者性别,临床症状,起病时间,白细胞总数、淋巴细胞总数及胸部CT表现差异无统计学意义(P>0.05),吸烟史、起病时间小于1周、既往用药基础疾病、合并症,静滴丙种球蛋白、使用机械通气及疗效差异有统计学意义(P<0.05)。非HIV感染组,胸部CT表现、起病时间、治疗中激素使用、丙种球蛋白使用无统计学意义(P>0.05),机械通气使用有统计学意义(P<0.05)。结论 中年,有吸烟史,基础疾病,服用激素或免疫抑制剂患者,在小于1周内出现双肺弥漫性病变后应考虑耶氏肺孢子菌肺炎可能,静滴丙种球蛋白有可能疗效亦不佳,使用机械通...     

艾滋病合并耶氏肺孢子菌肺炎及马尔尼菲青霉病56例临床分析

艾滋病（AIDS）患者免疫功能极度低下,容易并发各种机会性感染,有些甚至是多种感染混合存在,给诊断和治疗带来极大的困难,病死率高。近年来,我院发现AIDS合并耶氏肺孢子菌肺炎（PCP）及马永尼菲青霉病（PSM）56例。现将56患者的临床资料分析如下。     

肺孢子菌肺炎的治疗研究进展

<正>耶氏肺孢子菌(Pneumocyctis Jirovecii,PJ)是一种非典型真菌,具有宿主特异性,是一种机会性致病菌^[1]。肺孢子菌肺炎(Pneumocystis Jirovecii pneumonia,PJP)为人类免疫缺陷病毒(HIV)患者最常见的机会性感染和急性呼吸衰竭的主要原因,针对HIV的高活性抗逆转录病毒治疗降低了PJP的发生率^[2]。随着恶性肿瘤新型治疗方法的进步、骨髓或实体器官移植的普遍开展、自身免疫性疾病接受免疫抑制治疗的逐渐增多,PJP在非HIV免疫抑制患者中的发生率逐渐升高,此类患者的治疗及管理成为临床医师不容忽视的问题。     

肾病综合征合并卡氏肺孢子菌肺炎3例报告并文献复习

目的分析肾病综合征合并卡氏肺孢子菌肺炎（PCP）的临床和影像学表现。方法对3例肾病综合征合并PCP患者的临床资料进行分析,并进行相关文献复习。结果3例皆以发热、咳嗽、进行性呼吸困难为首发症状,影像学表现为双肺弥漫性磨玻璃影;2例合并呼吸衰竭;3例均痰中找到卡氏肺孢子菌;治疗药物包括复方磺胺甲嗯唑,克林霉素及卡泊芬净;2例治愈,1例死亡。结论肾病综合征合并PCP时,有典型的临床和影像学表现;肾病综合征患者免疫抑制治疗后出现进行性低氧血症应考虑PCP的可能性,需早期诊断、早期治疗。     

肾移植术后合并卡氏肺孢子菌肺炎1例报告并文献复习

目的探讨肾移植术后卡氏肺孢子菌肺炎的临床。方法介绍1例确诊卡氏肺孢子菌肺炎并Ⅰ型呼吸衰竭的肾移植术后患者的临床资料并文献复习。结果患者肾移植术后免疫抑制剂持续治疗5月时,出现发热、咳嗽、咳痰、胸闷、气喘及呼吸困难,血液检查中性粒细胞比例增高,伴严重低氧血症,胸部CT显示两肺弥漫性渗出性病变伴间质改变,痰涂片找到卡氏肺孢子菌。予复方新诺明（SMZco）、甲基强的松龙、调整免疫抑制剂应用及其它支持对症治疗,15 d痊愈出院。结论肾移植术后合并卡氏肺孢子菌肺炎是常见机会性感染,及时诊断和治疗可取得满意的效果。     

咽喉部马尔尼菲青霉感染合并卡氏肺孢子菌肺炎一例并文献复习

目的提高临床医师对马尔尼菲青霉感染合并卡氏肺孢子菌肺炎的认识及诊断水平。方法对1例青年男性患者马尔尼菲青霉感染合并卡氏肺孢子菌肺炎的诊疗经过进行分析、讨论并复习中外文献。结果咽喉部马尔尼菲青霉感染通过咽喉部专科检查、痰培养找到马尔尼菲青霉生长,病理活检证实;卡氏肺孢子菌肺炎通过胸部CT征象及卡氏肺孢子菌(PC)聚合酶链反应(PCR)阳性确诊。马尔尼菲青霉感染合并PCP治疗选用伊曲康唑、SMZ/TMP同时口服碳酸氢钠,疗效满意。结论对反复咽喉部溃疡难以愈合的患者建议痰培养、局部组织活检及肺部影像学检查,尽早明确诊断,恰当治疗。     

Multiple pneumatocoeles and bilateral tension pneumothoraces complicating Pneumocystis pneumonia in AIDS

Pneumatocoele and pneumothorax are uncommon complications of Pneumocystis carinii pneumonia. We report a patient with the Acquired Immune Deficiency Syndrome who developed multiple bilateral pneumatocoeles which we demonstrate to have ruptured leading to the subsequent bilateral tension pneumothoraces and to death. The computerised tomographic appearances, and histopathology of these unusual complications are presented. The literature on these manifestations is reviewed and management discussed.     

Pneumocystis jirovecii pneumonia in kidney transplantation

Pneumocystis jirovecii pneumonia (PCP) remains an important cause of morbidity and mortality in immunocompromised renal transplant recipients. In recent years, PCP outbreaks in renal transplant centers have been reported in many countries. Person‐to‐person transmission between PCP patients and other recipients lacking prophylaxis is one of the possible sources of infection. To prevent infection, effective prophylaxis in susceptible patients is recommended. Trimethoprim‐sulfamethoxazole (TMP‐SMX) is the most effective drug for PCP prophylaxis, but its recommended duration of use after transplantation varies among the different guidelines. The European Renal Association recommends a prophylaxis period of 4 months after transplantation, the American Society of Transplantation (AST) 6–12 months, and the Kidney Disease Improving Global Outcomes guidelines 3–6 months. Lifelong prophylaxis with TMP‐SMX is not recommended in renal transplant recipients; however, in many cases, PCP has occurred after the recommended prophylaxis periods after transplantation. In this minireview, we discuss the risk factors including environmental‐nosocomial exposure; state‐of‐the‐art diagnosis, treatment, prophylaxis and isolation; and references to the AST 2009 guidelines with the aim of integrating our experience with PCP outbreaks into recent reports, and we discuss how renal transplant recipients can be protected from PCP.     

艾滋病合并重症卡氏肺孢子虫肺炎25例临床病例分析

目的探讨艾滋病(AIDS)合并重症肺孢子虫肺炎(PCP)的临床特点、诊断和治疗。方法分析重庆市公共卫生救治中心收治的25例AIDS合并重症PCP患者的临床资料。结果发热、咳嗽、进行性呼吸困难是最常见的临床症状,CD4+T淋巴细胞数为:2～68个/ul;典型影像表现是肺部磨玻璃影;25例重症PCP患者经过复方磺胺甲基异噁唑联合强的松治疗,如合并其他机会感染予以相应的治疗,14例好转,11例死亡,死亡患者大都同时合并其他病原菌感染。结论 AIDS合并重症PCP患者病情重,常合并多种病原菌及多系统感染,疗效欠佳,故采用合理有效的抗HIV治疗措施以减少其发病。     

肾移植受者合并重症肺孢子菌肺炎的危险因素及预后分析

目的 分析肾移植受者合并重症肺孢子菌肺炎(PCP)的早期危险因素及预后.方法 收集2010年6月-2020年6月安徽省立医院诊治的65例肾移植受者合并PCP的临床资料,分别根据病情严重程度和预后情况分组,采用多因素Logistic回归分析与重症以及预后不良患者相关的危险因素.并对患者进行长期随访,采用Kaplan-Me...     

Recurrence of Pneumocystis carinii pneumonia in an HIV-infected patient: apparent selective immune reconstitution after initiation of antiretroviral therapy

Although several studies have reported that it is safe to discontinue secondary Pneumocystis carinii pneumonia (PCP) prophylaxis in patients infected with HIV who experience a sustained immune response as a result of antiretroviral therapy, we describe a patient who developed recurrent PCP <3 months after discontinuing trimethoprim-sulfamethoxazole prophylaxis. He developed disease despite a sustained CD4 T-cell count above 200 cells/microL for more than 3 years while on antiretroviral therapy, as well as an apparent immune reconstitution against disseminated Mycobacterium avium complex (MAC) and Histoplasma capsulatum, for which he also discontinued therapy but without adverse effects. Thus, although increasing evidence continues to indicate that HIV-infected patients receiving combinations of antiretroviral therapies may regain specific immunity against opportunistic infections, our patient's experience suggests that this immune recovery may be selective and incomplete.     

Can the course of high dose cotrimoxazole for Pneumocystis carinii pneumonia in AIDS be shorter? A possible solution to the problem of cotrimoxazole toxicity

Fifty consecutive patients with confirmed PCP received a high dose of cotrimoxazole for 14 d, or until development of intolerance, directly followed by reduced dose maintenance therapy. Seven individuals died during the high dose course. Twenty (47%) of the 43 survivors showed toxicity reactions that necessitated dose reduction to maintenance level on average after 9.6 d. Thirteen of these 20 individuals tolerated the reduced dose, and seven did not. No further cases of toxicity were observed. In 43 survivors only one early relapse (day 17) was observed in a patient who had received full dose treatment for 14 d. We conclude (1) that extending high dose cotrimoxazole therapy beyond 2 weeks is usually unnecessary, provided that reduced dose maintenance therapy is given directly, and (2) that dose reduction on appearance of toxicity signs during the second week of treatment is safe and allows two-thirds of patients to be maintained on cotrimoxazole with satisfactory results.