实体瘤患儿行自体外周血干细胞移植治疗中真菌感染情况

目的通过对31例实体瘤患儿行自体外周血干细胞移植(auto-PBSCT)治疗中真菌感染的情况进行分析,总结其临床特点、诊断与治疗经验。方法回顾性分析2006年5月-2009年12月本院儿科收治的31例实体瘤患儿行auto-PBSCT治疗过程中防治真菌感染的过程。结果 1.Ⅳ期进展期神经母细胞瘤患儿2例行自体外周血干细胞移植过程中经微生物学检查明确并肺部真菌感染,其中1例并脑、肝真菌感染;2例患儿血培养均为近平滑假丝酵母菌;4例患儿行肺部CT检查,表现为密度增高、渗出炎症阴影;1例进展期神经母细胞瘤患儿明确真菌感染后应用氟康唑、两性霉素B脂质体、伏立康唑静脉滴注抗真菌治疗有效,体温正常,度过骨髓抑制期,原发病获得部分缓解;1例进展期神经母细胞瘤患儿因存在颅内、骨骼、脊髓、肺、肝多发转移肿瘤,于自体外周血造血干细胞移植9 d后骨髓抑制期死亡。2.部分缓解期Ⅳ期神经母细胞瘤1例及进展期肝母细胞瘤1例患儿表现为发热、咳嗽、抽搐,怀疑侵袭性真菌感染,给予氟康唑、两性霉素B、伏立康唑治疗后好转度过骨髓抑制期,原发病获得部分缓解。3.余27例实体瘤患儿auto-PBSCT治疗中应用氟康唑预防真菌感染,临床未发生侵袭性真菌感染,1例进展期Ⅳ期神经母细胞瘤患儿因有多脏器转移,且有原发心脏损害,大剂量化疗后骨髓抑制期免疫耐受差,导致多脏器衰竭死亡。余26例实体瘤患儿顺利度过骨髓抑制期,病情获得缓解。结论实体瘤患儿auto-PBSCT治疗中易并真菌感染,需结合病史、血培养、G试验及CT、MRI等影像学检查做出诊断,经验性应用氟康唑、伏立康唑、两性霉素B等可防治真菌感染,原发病严重未缓解者预后差。

Clinical Analysis of Invasive Fungal Infections in Autologous Peripheral Blood Stem Cell Transplantation in Children with Solid Tumor

Objective To analyze the clinical characteristics of invasive fungal infections in 31 children with solid tumor after autologous peripheral blood stem cell transplantation(auto-PBSCT),and to share the experience on diagnosis and treatment.Methods The diagnosis and treatment of invasive fungal infection were retrospectively reviewed in 31 children with solid tumor,after auto-PBSCT from May 2006 to Dec.2009 in Beijing Tongren Hospital Affiliated to Capital Medical University.Results 1.Two cases of neuroblastoma patients in stage Ⅳ after auto-PBSCT had been diagnosed as pulmonary fungal infections by microbiological examination,including 1 patient with head and liver fungal infections too;blood cultures were fungal positive(candida parapsilosis) in 2 patients;pulmonary CT scan showed higher density of nodules in 4 cases;amphotericin B liposome and voriconazole were applied in 1 case with parapsilosis candida infection and the patient successfully recovered and got partial remission through the transplantation.While the other patients with stage Ⅳ neuroblastoma with parapsilosis Candida infection died of disease metastasis to the brain,bone,spinal cord,lung,liver,after being treated with fluconazole,voriconazole.2.One case with partial remission of stage Ⅳ neuroblastoma and 1 case with advanced liver neuroblastoma developed fever,cough,convulsions,and then invasive fungal infection was suspected,and fluconazole,amphotericin B,voriconazole were used for controlling infection,and they got partial remission for primary disease.3.Fungal prevention with fluconazole was given to the rest of 27 cases of children with solid tumor after auto-PBSCT and nobody had been diagnosed as invasive fungal infections,none for possible infection.One patient with advanced stage Ⅳ neuroblastoma died of multiple organ metastasis and primary cardiac damage.Conclusions The children with solid tumor after auto-PBSCT are likely to get invasive fungal infections,and they need a combined procedures,including medical history review,laboratory detections such as blood culture,G test and CT scan as well as MRI scan.Once the invasive fungal infection is diagnosed,even for possible infection,empirical antifungal therapy might be necessary,and medications of fluconazole,voriconazole,amphotericin B are the most common medications for such infections.The prognosis is poor in cases of the worsening primary disease.