肝衰竭患者合并侵袭性肺曲霉菌病临床分析

目的 了解肝衰竭患者合并侵袭性肺曲霉菌病的危险因素、临床特征和预后,提高对肝衰竭合并侵袭性肺曲霉菌病的认识.方法 对15例肝衰竭合并侵袭性肺曲霉菌病患者的临床资料,包括基础疾病、住院时间、ICU住院时间、激素和抗生素使用情况、临床表现、诊断分层、治疗情况以及预后等进行回顾性分析.结果 全部患者存在慢性乙型肝炎基础疾病,均无粒细胞减少或缺乏.患者MELD评分(37.13±11.03)分.其中46.7％( 7/15)的患者有激素使用史；60％( 9/15)的患者有广谱抗生素(1种或多种)治疗史；60％( 9/15)的患者曾行血液净化治疗；33.3％( 5/15)的患者有CD4+T细胞减少或比例失调；临床表现无明显特异性；所有患者皆有肺部影像学检查阳性改变；73.3％( 11/15)的患者GM试验阳性；20％( 3/15)的患者治疗后好转；80％( 12/15)的患者治疗无效；40％( 6/15)的患者诊断后7d内死亡.结论 肝衰竭患者存在多个并发侵袭性肺曲霉菌病的危险因素；并发侵袭性肺曲霉菌病是肝衰竭患者病情急剧恶化的原因之一；早期CT结合GM试验检查可能提高早期诊断率；早期有效的抗真菌治疗可能改善本病的预后.

A clinical analysis on invasive pulmonary aspergillosis in patients with hepatic failure

Objective To explore the risk factors, clinical characteristics, and prognosis of invasive pulmonary aspergillosis （ IPA ） in patients with hepatic failure. Methods The clillical data of 15 patients with hepatic failure complicated with IPA were analyzed retrospectively. Results All the patients had an underlying discarder that was chronic hepatitis B, but had no granulocytopenia or agranulocytosis. The MELD score was （ 37.13 ± 11.03 ）46.7% （ 7/15 ） of the patients had history of hormone uses ; 60% （ 9/15 ） had history of broad-spectrum antibiotic uses （ single or mulitple ） 60% （ 9/15 ） of patients received previous blood purification. 33.3% （ 5/15 ） had a reduction in CD4＋ T cells or ratio imbalance. Clinical manifestations lacked of obvious specificity. Roentgenographic examination of the lungs showed changes in all the patients; GM test was positive in 73.3% （ 11/15 ） of the patients. 20% （ 3/15 ） of the patients improved after treatment; 80% （ 12/15 ） did not repond to therapies; and 40% （ 6/15 ） were dead within 7 days after diagnosis. Conclusions Patients with hepatic failure have multiple risk factors of invasive pulmonary aspergillosis. IPA is one of the reasons for deterioration in patients with hepatic failure. Early CT examination combined with GM tests can increase the early diagnostic rate. Early effective antifungal therapy can improve the prognosis of the disease.