腐生性肺曲霉病临床特点探讨

发布时间：2018-03-12 11:52

本文选题：腐生性　切入点：肺曲霉球病　出处：《浙江大学》2012年硕士论文　论文类型：学位论文

【摘要】：背景腐生性肺曲霉病是曲霉菌感染的最主要形式,由腐生菌寄生于肺部原有空洞性病变形成,主要通过烟曲菌形成肺曲菌球(PA)或慢性坏死性肺曲菌病(CNPA),因肺内病变可发生大咯血,常危及生命,外科手术是目前普遍可接受的能唯一治愈肺曲霉病的方式。目的探讨腐生性肺曲霉菌病的临床特点、影像学特征、手术方式及术后并发症,病理学特点,随访资料,以期通过本研究提高对该病的认识水平,帮助我们掌握外科手术适应征及最佳手术时机,以便于恰当选择手术病人,使病人从外科手术中最大程度获益,控制围手术期并发症及死亡率在可接受水平。方法对浙江大学附属第一医院心胸外科及呼吸内科2006年～2011年间确诊的50例腐生性肺曲霉菌病住院病例进行回顾性研究,对比分析27例慢性坏死性肺曲菌病和23例肺曲霉球的基础疾病、临床特点、实验室检查、影像学特征、病理学特点和治疗方法及预后。结果腐生性肺曲霉病好发于中老年患者,且都好发于肺部原有空洞或者囊性空腔等结构性病变处,如空洞型肺结核及空洞性支气管扩张等。单因素分析证实慢性坏死性肺曲菌病和肺曲霉球在性别,年龄,临床症状方面无显著性差异。影像学上,CNPA和肺曲霉球均可出现空气新月征,均好发于两肺上叶,但前者有胸膜增厚,空洞周围浸润阴影、厚壁空洞和洞壁不规则等特征,对比分析证实两者在影像学特征上存在显著性差异。病理学上,CNPA和肺曲霉球都可见锐角分支、有隔膜的曲霉菌丝,但前者有组织出血、坏死、微脓肿和炎性反应细胞浸润等特征,对比分析证实两者在病理学特征上存在显著性差异。单因素分析后证实大咯血,体重减轻,是术后并发症危险因素。5年累计生存分析,PA组为88%,CNPA组为81.3%,多因素通过COX风险比例回归分析证实年轻,无大咯血是生存预后有利因素。结论组织病理学是鉴别肺曲菌球(PA)或慢性坏死性肺曲菌病(CNPA)金标准,空气新月征,是腐生性肺曲霉病特征性CT表现,大咯血是腐生性肺曲霉病术后独立危险因素。在可手术患者中,无症状患者亦推荐早期手术治疗,可阻止发生大咯血,提供理想的可永久治愈机会。单纯肺曲菌球,手术切除完整,术后无症状患者不推荐常规预防性抗真菌治疗,而慢性坏死性肺曲菌病术后需预防性抗曲菌治疗,存在肺内多发病灶亦需抗曲菌治疗。
[Abstract]:Background Aspergillus pneumoniae is the main form of aspergillus infection. Pulmonary aspergillosis (PAA) or chronic necrotizing pulmonary aspergillosis (CNPAA) is mainly formed by aspergillus fumigatus. Because massive hemoptysis can occur in the lung, surgical operation is the only commonly accepted way to cure pulmonary aspergillosis. Objective to investigate the clinical, imaging, operative and postoperative complications, pathological features and follow-up data of pulmonary aspergillosis in order to improve the understanding of the disease. It helps us to grasp the surgical adaptation sign and the best time of operation, so as to select the patients properly, to maximize the benefits of surgery, and to control the perioperative complications and mortality at acceptable level. Methods A retrospective study was conducted on 50 cases of atrophic pulmonary aspergillosis diagnosed in the Department of Cardiothoracic surgery and Department of Respiratory Medicine in the first affiliated Hospital of Zhejiang University in 2006. A comparative analysis was made of 27 cases of chronic necrotizing pulmonary aspergillosis and 23 cases of pulmonary aspergillosis. The clinical features, laboratory findings, imaging features, pathological features, treatment methods and prognosis were compared and analyzed. Results Pulmonary aspergillosis was more common in middle-aged and elderly patients, and most of them occurred in structural lesions such as the original cavity or cystic cavity of the lung. Univariate analysis showed that chronic necrotizing pulmonary aspergillosis and pulmonary aspergillosis were found in sex, age, and age. There was no significant difference in clinical symptoms. Both CNPA and Aspergillus pulmonis appeared air crescent sign on imaging, which occurred in both upper lobes of lung, but the former was characterized by pleural thickening, infiltration and shadow around cavity, thick wall cavity and irregular wall, etc. The contrast analysis showed that there was a significant difference in the imaging characteristics between the two groups. Both CNPA and Aspergillus pneumoniae could be seen in pathology with an acute angle branch with membranous aspergillus, but the former had tissue bleeding and necrosis. The pathological characteristics of microabscess and inflammatory response cell infiltration were significantly different from those of the control group, and the results of univariate analysis showed significant hemoptysis and weight loss. 5 years cumulative survival analysis was 81.3% in PA group. Multiple factors were confirmed by proportional regression analysis of COX risk. No hemoptysis was a favorable factor for survival and prognosis. Conclusion histopathology is the gold standard for differentiating pulmonary aspergillosis (PAA) from chronic necrotizing pulmonary aspergillosis (CNPA). The air crescent sign is the characteristic CT manifestation of pulmonary aspergillosis. Massive hemoptysis is an independent risk factor for postoperative pulmonary aspergillosis. Among operable patients, asymptomatic patients also recommend early surgical treatment to prevent massive hemoptysis and provide an ideal permanent cure. Postoperative asymptomatic patients do not recommend routine prophylactic antifungal therapy, while chronic necrotic pulmonary aspergillosis needs preventive anti-aspergillus treatment, and multiple pulmonary lesions also need anti-aspergillus treatment.
【学位授予单位】：浙江大学
【学位级别】：硕士
【学位授予年份】：2012
【分类号】：R519

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