(1,3)-β-D葡聚糖、半乳甘露聚糖联合降钙素原检测对侵袭性真菌感染的诊断价值

目的 探讨血清中(1,3)-β-D葡聚糖[ (1,3) β-D-glucan,G]和半乳甘露聚糖(galactomannan,GM)联合降钙素原(procalcitonin,PCT)检测对患者侵袭性真菌感染(invasive fungal infections,IFI)的临床诊断价值。方法 选取徐州市中心医院2017年1月至2018年6月收治的具有高危IFI因素的住院患者447例,根据血培养结果分成实验室诊断组和非实验室诊断组。分别采用定量检测、比色法及电化学发光法对血清中G、GM和PCT的含量进行检测,评价三者联合检测对IFI的早期诊断价值。结果 447例患者中实验室诊断组51例,非实验室诊断组396例。51例患者中G试验阳性39例,GM试验阳性14例,PCT阳性41例。G试验、GM试验、PCT检测的敏感性为76.47%、27.45%和80.39%;特异性为76.77%、87.12%和66.67%;阳性预测值为29.77%、21.54%和23.70%;阴性预测值为96.20%、90.31%和96.35%;阳性似然比为3.29、2.13和2.41;阴性似然比为0.31、0.83和0.29;Youden指数为0.53、0.15、0.47。三者联合检测的敏感性为94.12%、特异性为62.88%、阳性预测值为24.62%,阴性预测值为98.81%,阳性似然比为2.54,阴性似然比为0.09,Youden指数为0.57。三者联合检测的敏感性均高于G试验、GM试验、PCT单独检测及G/GM联合试验,差异具有统计学意义(χ2值分别为6.331、47.545、4.320和5.299,P值均<0.05)。三者联合检测的特异性均低于G试验、GM试验单独检测及G/GM联合试验,差异具有统计学意义(χ2值分别为18.127、62.061和16.754,P值均<0.05),但与PCT单独检测相比差异无统计学意义(χ2=1.245,P>0.05)。结论 G、GM以及PCT三者联合检测可显著提高IFI检出的敏感性,并且对IFI的诊断排除有很大的价值,从而降低假阳性率和假阴性率,为IFI的早期诊断提供一定的依据。     

Opportunistic fungal infections in persons living with advanced HIV disease in Lagos,Nigeria; a 12-year retrospective study

IntroductionNigeria has a large estimated burden of AIDS-related mycoses. We aimed to determine the proportion of patients with AIDS-related opportunistic fungal infections (OFIs) at an urban antiretroviral treatment (ART) centre in Nigeria.MethodsA retrospective analysis of a cohort of ART-naïve, HIV-infected patients, assessed for ART eligibility and ARTexperience at the PEPFAR outpatient clinic at Lagos University Teaching Hospital over a 12-year period (April 2004-February 2016) was conducted.ResultsDuring this period, 7,034 patients visited the clinic: 4,797 (68.2%) were female; 6161 patients had a recorded baseline CD4 count, and the median CD4 count was 184 cells/µl (IQR, 84–328). A baseline HIV-1 viral load (VL) was recorded for 5,908 patients; the median VL was 51,194 RNA copies/ml (IQR, 2,316–283,508) and 6,179/7046(88%) had initiated ART. Some 2,456 (34.9%) had a documented opportunistic infections, of whom 1,306 (18.6%) had an opportunistic fungal infection. The total number of OFI episodes was 1,632: oral candidiasis (n=1,473, 90.3%), oesophageal candidiasis (n=118; 8%), superficial mycoses (n=23; 1.6%), Pneumocystis pneumonia (PJP) (n=13; 0.8%), and cryptococcal meningitis(CM) (n=5; 0.4%). 113 (1.6%) were known to have died in the cohort.ConclusionApproximately 1 in 5 HIV-infected patients in this retrospective cohort, most of whom had initiated ART, were clinically diagnosed with an OFI. Improved access to simple accurate diagnostic tests for CM and PJP should be prioritised for this setting.     

Successful lung transplant in a child with cystic fibrosis and persistent Blastobotrys rhaffinosifermentans infection

Fungal respiratory infections in patients with CF are a significant concern both pre‐ and post‐lung transplantation (LTx). Fungal infection is associated with increased mortality post‐LTx, and in the past decade, the prevalence of fungal colonization in Canadian pediatric patients with CF has increased. The emergence of novel fungal pathogens is particularly challenging to the transplant community, as little is known regarding their virulence and optimal management. We present a case of a successful double‐lung transplant in a pediatric patient with CF who was infected pretransplantation with a novel yeast, Blastobotrys rhaffinosifermentans. This patient was treated successfully with aggressive antifungal therapy post‐transplantation, followed by extended fungal prophylaxis. The significance of fungal colonization and infection in children with CF pre‐ and post‐LTx is reviewed.     

伊曲康唑预防急性白血病患儿侵袭性真菌感染的临床研究

目的：评价伊曲康唑口服液在急性白血病（AL）患儿化疗后粒细胞缺乏伴感染时侵袭性真菌感染（IFI）预防性治疗的效果。方法回顾性分析2009年6月-2013年6月我院收集的AL化疗后伴粒细胞缺乏的213例患儿,将其分为伊曲康唑早期预防组和晚期预防组。伊曲康唑早期预防组（330例次）在粒细胞缺乏伴发热应用广谱抗生素同时服用伊曲康唑口服液;对照组（191例次）在粒细胞缺乏出现发热、经广谱抗生素应用72 h 后发热无改善者加用伊曲康唑口服液,比较两组患儿IFI发生率。结果伊曲康唑早期预防组和对照组各有7例和18例发生IFI,发生率分别为2.12％和9.42％,两组IFI发生率差异有显著性（P＜0．01）。结论 AL化疗后粒细胞缺乏患儿在发热早期进行预防性口服伊曲康唑可以有效降低IFI的发生率。     

Surgical resection for persistent localized pulmonary fungal infection prior to allogeneic hematopoietic stem cell transplantation: Analysis of six cases

ObjectiveAlthough invasive fungal disease (IFD) is an important complication in allogeneic hematopoietic stem cell transplantation (HSCT), the clinical significance of surgery, including the role of surgical resection for persistent pulmonary fungal disease prior to allogeneic HSCT in the current era with a variety of available antifungal agents, is controversial. We investigated the role of surgical resection.MethodsWe retrospectively investigated six patients who underwent surgical resection of suspected pulmonary fungal disease prior to allogeneic HSCT between April 2007 and June 2016 at our medical center.ResultsWe present six patients who underwent surgical resection of suspected pulmonary fungal disease prior to allogeneic HSCT. In our case series, three of four patients who were given a presurgical diagnosis of possible IFD were given a proven diagnosis after surgery, including two cases of invasive aspergillosis (IA) and one case of mucormycosis. All surgeries were performed by video-assisted thoracic surgery (VATS) for lobectomy without major complications. Recurrence of IFD was not observed after allogeneic HSCT in any of the six patients.ConclusionOur experience indicated that surgical resection of persistent localized pulmonary lesions of IFD before allogeneic HSCT was helpful for obtaining a definitive diagnosis and might be useful for reducing recurrence after HSCT.