慢性阻塞性肺疾病合并侵袭性肺曲霉病的临床分析及动物模型的建立

发布时间：2018-02-09 03:54

  本文关键词： 慢性阻塞性肺疾病 侵袭性肺曲霉病 临床特征 动物模型　出处：《吉林大学》2017年硕士论文　论文类型：学位论文

【摘要】：目的:1、通过分析24例COPD合并IPA患者的资料,总结分析其临床特征,为早期诊断及治疗提供帮助。2、为进一步研究COPD合并IPA的发病机制,探讨其动物模型的建立方法。方法:1、收集2010年12月-2016年09月期间就诊于吉林大学第二医院患者的临床资料,其中COPD合并IPA患者24例,单纯COPD患者24例,包括:(1)一般资料和相关病史:年龄、性别、吸烟指数、基础疾病、既往住院次数及糖皮质激素与广谱抗生素的应用情况;(2)临床表现和相关治疗:症状、体征、胸部影像学表现、气管镜结果、实验室检查及病原学检测结果、入院后接受的治疗、住院天数及患者的转归。回顾性统计分析两组患者上述临床资料。2、COPD合并IPA小鼠模型的建立:选取野生型(WT)C57BL/6小鼠16只,将小鼠进行编号,随机分为2组,分别为正常对照组(8只)和实验组(8只)。实验组小鼠给予口鼻暴露有机玻璃染毒箱熏烟,30min/次,间隔15min,4次/d,持续16周;其后给予小鼠甲泼尼龙100mg/kg*d,共5d;次日将小鼠经气管穿刺方法给予1×106CFU/ml的孢子混悬液30ul,然后保持小鼠直立状态3~5min,缝合颈部皮肤,成功接种后小鼠给予万古霉素15mg/kg 1/日、头孢他啶150mg/kg 1/日、庆大霉素5mg/kg隔日1次,预防混合感染。正常对照组不予熏烟,在玻璃箱内吸入空气,相同时间内应用等量生理盐水代替甲泼尼龙及孢子混悬液,其余同实验组。实验过程中观察一般情况包括精神状态、活动、进食情况,每2周称量体重。在成功感染72h后统一处理实验组及正常对照组小鼠,包括体重测量、小鼠肺功能检测、肺组织病原学培养及病理学检查。结果:1、临床资料分析:(1)两组患者在年龄、性别上无统计学差异(P0.05)。(2)COPD合并IPA组吸烟指数、平均住院天数明显高于COPD组(P0.05)。(3)分析两组患者一般资料,在口服或静脉激素治疗≥7d、广谱抗生素应用≥14d、1年住院次数≥2次、诊断前入住ICU、白蛋白32g/L、血红蛋白115g/L的情况上,COPD合并IPA组较COPD组常见(P0.05),而在合并症方面,存在高血压、冠心病、糖尿病的情况上两组之间无明显差异(P0.05)。(4)两组患者均存在咳嗽,其他主要临床症状包括咳痰、痰中带血、发热、呼吸困难、胸痛及干湿Up音,两组临床表现比较无显著差异(P0.05)。(5)比较两组患者白细胞总数及中性粒细胞百分比,COPD合并IPA组患者(11.072±6.10,78.758±14.77)均明显高于COPD组(7.829±2.75,65.308±12.34),差异有统计学意义(P=0.0240.05,P=0.0010.05)。(6)COPD合并IPA组相关实验室及影像学检查阳性率:GM实验(54.17%),G实验(83.33%),痰培养(87.5%);培养出菌株中烟曲霉19例(79.17%),黑曲霉3例(12.5%),黄曲霉2例(8.3%);斑片渗出影(66.67%),结节影(含“晕轮征”)(34.78%),段叶不张或实变影17.39%),单发或多发空洞(17.39%);双肺磨玻璃样改变(13.04%),“空气新月征”(4.34%),胸腔积液(34.78%)。(7)COPD合并IPA组治疗方面:联合广谱抗生素同时,分析初始抗真菌治疗及疗效,结果显示伊曲康唑、伏立康唑、两性霉素B、卡泊芬净和联合治疗组之间疗效无显著差异(P0.05)。最终17例(70.83%)病情好转出院(包含拟诊患者2例),院内确定临床死亡患者4例,出院后随访死亡患者3例,共7例(29.17%)患者死亡。2、COPD合并IPA小鼠模型的建立:(1)体重变化:于第4周开始实验组小鼠较对照组小鼠体重明显降低,差异显著(P0.05)。(2)肺功能:实验组小鼠气道总阻力(R)、气道阻力(Rn)、呼吸系统弹性阻力(E)(2.100±0.310,0.889±0.183,63.070±10.464)较对照组(1.536±0.135,0.636±0.127,48.037±6.092)明显增加,而呼吸系统顺应性(C)较对照组明显降低(0.016±0.004与0.023±0.003),差异均有统计学意义(P0.05)。(3)肺组织匀浆培养:实验组小鼠肺组织匀浆培养曲霉菌菌落呈蓝绿色,正常对照组培养阴性。(4)组织病理学:实验组小鼠肺组织切片在显微镜下可观察到充血水肿的肺泡组织,炎症细胞浸润,肺泡组织结构破坏,肺气肿形成,肺泡间可见分隔且分叉呈45°夹角真菌菌丝,符合COPD合并IPA的病理特征;对照组未见上述变化。结论:1、COPD合并IPA通常发生在老年患者,且相对COPD患者吸烟指数高,住院时间长。2、应用激素、抗生素,反复住院、ICU治疗,营养不良在COPD合并IPA患者中存在比例高,一定程度上影响疾病的发生及进展。3、COPD合并IPA患者症状不典型,相关实验室及影像学检查结果特异性及敏感性均不高,但反复痰培养对于诊断仍有重要意义。4、对临床诊断及拟诊患者,早期应用标准抗真菌治疗方案仍能使患者获益,同时应结合患者病情进行综合治疗,对于重症患者的抗真菌治疗仍是难点。5、在单纯被动吸烟法制作COPD模型的基础上给予甲泼尼龙引起免疫抑制,其后应用气管穿刺法接种烟曲霉孢子混悬液的方法可成功建立COPD合并IPA小鼠模型。
[Abstract]:Objective: 1. By analyzing the data of 24 cases of COPD patients with IPA, analyze the clinical characters of summary, provide help for the early diagnosis and treatment of.2, to further study the pathogenesis of COPD with IPA, to explore the methods to establish the animal model. Methods: 1, December 2010 -2016 during 09 months of treatment in patients with clinical data the second hospital of Jilin University, including 24 cases of COPD patients with IPA, patients with COPD of 24 cases, including: (1) general information and History: age, gender, smoking index, basic disease, previous hospitalizations and glucocorticoid application of hormone and antibiotics; (2) the clinical manifestations and treatment. The symptoms, signs, chest X-ray manifestation, bronchoscopy results, results of laboratory examination and treatment of pathogens, after accepting admission, hospitalization days and the prognosis of patients. Retrospective statistical analysis of two groups of patients with the clinical data of.2, COPD And the establishment of IPA mice model: selection of wild type (WT) 16 C57BL/6 mice, then the mice were numbered, randomly divided into 2 groups: normal control group (8 rats) and experimental group (8 rats). The mice in experimental group were given oral nasal exposure of organic glass box smoke exposure, 30min/, interval 15min /d, 4, 16 weeks after mice were given methylprednisolone; 100mg/kg*d, 5D; the next day the mice were given 1 methods of tracheal puncture * 106CFU/ml spore suspension of 30ul, and then stay upright mouse 3~5min, neck skin suture, successfully inoculated mice were given vancomycin 15mg/kg 1/, ceftazidime 150mg/kg 1/ the next day, gentamicin 5mg/kg 1 times, the prevention of mixed infection. The control group was given fumigation, inhalation of air in the glass box, the same time the application of normal saline instead of methylprednisolone and spore suspension, the rest of the experimental group were observed during the experiment. Including the mental status, activity, eating, weight every 2 weeks. After successful infection after 72h unified treatment of the experimental group and normal control group of mice, including weight measurement, mouse pulmonary function testing, culture and pathological examination of lung tissue pathogen. Results: 1. Clinical data analysis: (1) patients in the two groups there was no significant difference in age, gender (P0.05). (2) COPD combined with IPA group smoking index, average hospitalization days was significantly higher than COPD group (P0.05). (3) analysis of the general data of the two groups of patients, in the oral or intravenous steroid therapy than 7d, broad-spectrum antibiotics 14d more than 1 years, more than 2 times of hospitalization the diagnosis, before ICU admission, albumin 32g/L, hemoglobin 115g/L cases, compared with the COPD group COPD combined with IPA group (P0.05), and the complications, hypertension, coronary heart disease, diabetes cases no significant difference between the two groups (P0.05). (4) there were two patients with cough and other major 涓村簥鐥囩姸鍖呮嫭鍜崇棸,鐥颁腑甯﹁��,鍙戠儹,鍛煎惛鍥伴毦,鑳哥棝鍙婂共婀縐p闊，

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