AECOPD继发肺侵袭性真菌感染临床特征及预后

目的探索慢性阻塞性肺病急性加重（acute exacerbation of chronic obstructive pulmonary disease，AECOPD）继发侵袭性肺真菌感染的早期诊断方法，以及影响预后的因素。方法查阅2000—2008年因AECOPD入院继发肺真菌感染病例，符合侵袭性肺部真菌感染的诊断标准与治疗原则（草案）者，调阅CT及X档案，记录住院期间抗生素和皮质激素使用史、真菌培养和药敏试验、基础病等进行分析。结果AECOPD合并肺侵袭性真菌感染25例，死亡4例。其病原学分析显示：白假丝酵母菌16例（64％），光滑假丝酵母菌4例（16％），热带假丝酵母菌2例（8％），克柔假丝酵母菌1例（4％），曲霉菌2例（8％）。胸部CT改变以结节影、结节晕轮征、团块影以及空洞为主，分别为：20、17、14和8例次，其中结节晕轮征具有特征性；X线胸片以支气管肺炎样改变、团块影、空洞和支气管炎改变为主，分别为16、14、5、5例次。预后分析提示：机械通气、抗生素使用时间超过7d、同时使用抗生素种类超过3种、大剂量激素和合并呼吸衰竭等基础病是AECOPD继发肺侵袭性真菌感染预后不良的因素。结论AECOPD继发肺真菌感染预后差，病死率高（16％），早期胸部CT以及痰检对及早发现肺侵袭性真菌感染有价值。合理使用抗生素，严格掌握AECOPD使用皮质激素以及机械通气的适应证，对改善预后有积极作用。

Clinical Characteristics and Prognosis of AECOPD Complicated with Invasive Pulmonary Fungal Infection

Objective This study aims to evaluate the early diagnostic methods and the prognosis of the acute exacerbation of chronic obstructive pulmonary disease （AECOPD） complicated with invasive pulmonary fungal infection （IPFI）. Methods Patient records showing AECOPD and lung fungi infection from the year 2000-2008 were retrospectively analyzed. Computer tomographic films, chest X-ray films and the history of antibiotic and corticosteroid usages were re-analyzed according to the Diagnosis Standard for the Invasive Infection with Fungi. Results of sputum fungal culture and the underlying diseases were studied. Results 25 cases were found to meet the diagnostic criteria and 4 patients were died of pulmonary fungal infection. The number of cases with fungal infection was 16 for C. a/b/carts, 4 for C. glabrata, 2 for C. tropicalis, 1 for Monilia krusei and 2 for aspergillus. Chest CT findings included globular nodules （20 cases）, nodules with halo sign （17 cases）, masses （14 cases） and cavity （8 cases）. A halo surrounding the nodule is the characteristic feature in the chest CT films. There are also chest x-ray films showing bronchial pneumonia or masses. Factors associated with poor prognosis are the patients with a history of mechanic ventilation, more than 7 days＇ antibiotics usage, given more than 3 antibiotics at one time, receiving a high dose of corticosteroids and with complicated respiratory failure. Conclusion AECOPD with IPFI has a poor prognosis and a high death rate （16%）. Early chest CT and sputum test can improve the IPFI diagnosis. To improve the outcome of IPA, antibiotics, corticosteroids and mechanical ventilation should be used.