异基因造血干细胞移植后肺烟曲霉菌病合并闭塞性细支气管炎一例附文献复习

背景：异基因造血干细胞移植是多种血液系统恶性疾病和遗传性疾病的有效治疗方法，但移植后易并发全身多脏器的病变，其中尤以肺部并发症多见。肺部并发症绝大部分为感染性疾病，小部分为非感染性疾病，两者亦可并存，但当移植病患同时发生肺部感染性疾病和非感染性疾病时，如何正确诊断和治疗尤为重要。 目的：报道异基因造血干细胞移植1年后发生肺侵袭性烟曲霉菌病合并闭塞性细支气管炎1例，复习相关文献探讨其预防、临床表现和恰当的治疗方法。 方法：患者异基因造血干细胞移植后373 d出现发热伴咳嗽，活动后胸闷，胸部CT提示右肺上叶前段、中叶及下叶背段可见片状阴影，进一步行右肺上叶病灶穿刺活检、培养。 结果与结论：肺穿刺活检病理提示肺泡扩张，肺泡上皮增生，肺间质增厚，间质细胞增生，并见少许散在的异型淋巴样细胞，肺功能中最大通气量明显下降，残气量增加，肺活量减低，基础第1秒用力呼气容积值为59.27%。肺穿刺物培养提示烟曲霉菌生长。细胞免疫组化提示为T淋巴细胞，:CD3(+)、CD45RO(+)，CD20(－)，CD79a(－)，MPO(－)，CD34血管(－)。患者确诊肺侵袭性烟曲霉菌病合并闭塞性细支气管炎，经注射用醋酸卡泊芬净+注射用伏立康唑抗真菌治疗，甲基泼尼松、硫唑嘌呤、阿奇霉素治疗闭塞性细支气管炎，治疗40 d后复查胸部CT病灶完全吸收。

Pulmonary Aspergillus infection coexisted with obliterative bronchiolitis in a patient at one year following allogeneic hematopoietic stem cells transplantation

BACKGROUND: Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is an effective method for treating multiple malignant hematological diseases and hereditary diseases. However, systematic internal organs disorders, especially pulmonary complications, are commonly following allo-HSCT. How to correctly diagnose and treat the coexistence of pulmonary infectious complications and pulmonary noninfectious complications has great importance. OBJECTIVE: To report a case suffered from pulmonary Aspergillus infection coexisted with obliterative bronchiolitis at 1 year following allo-HSCT, and to discuss the prevention, clinical manifestation and treating method by reviewing related literature. METHODS: At 373 days after allo-HSCT, the patient developed fever, dry cough, shortness of breath and dyspnea on exertion. A high-resolution computed tomography of chest demonstrated that there were alveolar infiltrating in the upper, middle and lower lobe of the right lung, and the focus of infection was performed further biopsy. RESULTS AND CONCLUSION: The histopathological examination of the sample showed alveolus dilatation, epithelial cells hyperplasia, fibrinous obliteration in alveolar space and peribronchiolar lymphocytes inflammation, which were CD3(+), CD45RO(+), CD20(-), CD79a(-), MPO(-), CD34(-). Aspergillus fumigatus could be seen in the cultured biopsied tissue specimen. Pulmonary function test showed that, air flow obstruction with reduction of forced expiratory volume in one second was 59.27%. The patient was diagnosed as invasive pulmonary Aspergillus infection combined with bronchiolitis obliterans and was treated by caspofungin combined with intravenous voriconazole for invasive aspergillosis, methylprednisolone, azathioprine, intravenous immunoglobulin and azithromycin for bronchiolitis obliterans. At 40 days after treatment, the CT examination showed the focus was absorbed completely.