急性白血病合并肺部感染的影像学特点与临床资料的回顾性分析

发布时间：2018-04-11 08:45

本文选题：急性白血病 + 肺部感染　；参考：《河北医科大学》2012年硕士论文

【摘要】：目的：急性白血病（Acute Leukemia，AL）是血液系统的常见病及多发病。患者由于自身免疫缺陷、应用化疗药物和使用糖皮质激素等,使感染成为最常见并发症和致死原因之一，而肺部感染又是最常见的感染部位。由于AL本身或治疗等原因会出现血小板减少或者凝血异常而致易出血，使得肺活检受到限制。因此，肺CT检查，特别是高分辨率CT检查可以给临床诊治提供参考。我们逐一分析66例患者的临床资料及肺部不同微生物感染的CT影像特点和临床抗感染治疗疗效，籍此总结肺CT影像特征与抗感染治疗有效和有效药物的相关性，从而为肺部感染临床早期诊断及特异性治疗提供依据。方法：收集本院2010年8月-2011年12月间收治的66例AL并发肺部感染的临床及肺CT资料，临床资料主要收集姓名、性别、年龄、住院天数、AL类型、化疗方案、骨髓缓解情况、临床表现、肺部病变影像特征、胸腔积液情况、粒缺持续时间、合并其他部位感染、入院前感染史、出院情况、G实验、C-反应蛋白、有无低白蛋白血症、痰培养或涂片、血培养等，肺CT资料来自影像科。我们把66例给予抗真菌治疗的57例患者按照侵袭性肺部真菌感染（Invasive pulmonary fungal infection，IPFI）的疗效标准对患者进行评价，把57例患者分为抗真菌治疗有效组和抗真菌治疗无效组，把痊愈+显效+进步的患者归为抗真菌治疗有效组，把无效+死亡归为抗真菌治疗无效组，分析抗真菌治疗有效组与各影像特征之间有无相关性；根据细菌感染疗效标准把66例患者分为抗细菌治疗有效组和抗细菌治疗无效组，把痊愈+显效+进步的患者归为抗细菌治疗有效组，把无效的患者归为抗细菌治疗无效组，分析抗细菌治疗有效组与各影像特征之间有无相关性。把66例患者的影像特征按单一影像特征分为结节影、斑片影、磨玻璃影、实变影、空洞影、条索影和棉絮状阴影，针对这些影像特征和抗微生物治疗有效药物的关系，我们采用χ2检验对其进行统计学分析。结果： 1将66例AL患者的肺部感染部位分为两肺及单侧肺，在统计学分析有统计学意义的抗真菌治疗有效的结节影、空洞影及结节影合并空洞影的患者中，对结节影与肺部部位的相关性进行统计学分析，，没有统计学意义（p＞0.05）。在统计学分析有统计学意义的抗细菌治疗有效的条索影、条索影合并斑片影、条索影合并磨玻璃影的患者中，对条索影与肺部部位的相关性进行统计学分析，没有统计学意义（p＞0.05）。 2我们收集的66例AL患者肺部感染的影像学特点共有11种。根据这11种影像特点，再针对单一影像特点进行分析。将肺部感染的影像分为结节影、斑片影、实变影、磨玻璃影、条索影、棉絮状阴影、空洞影七种。抗真菌治疗有效的患者中经统计学分析后显示结节影、空洞影及结节影合并空洞影与抗真菌治疗有效的患者有相关性（结节影：p=0.005，空洞影：p=0.013，结节影合并空洞影：p=0.037），而斑片影、实变影、磨玻璃影、条索影、棉絮状阴影与抗真菌治疗有效的患者均没有相关性（p＞0.05）。另外，结节影合并胸腔积液及结节影合并咳嗽和咳痰与抗真菌治疗有效的患者有相关性（结节影合并胸腔积液：p=0.010，结节影合并咳嗽和咳痰：p=0.034），结节影合并斑片影、实变影、磨玻璃影、晕征、近胸膜与抗真菌治疗有效的患者均没有相关性（p＞0.05），斑片影合并实变、磨玻璃影、胸腔积液、咳嗽和咳痰与抗真菌治疗有效的患者均没有相关性（p＞0.05），空洞影合并实变、胸腔积液、咳嗽和咳痰与抗真菌治疗有效的患者均没有相关性（p＞0.05），实变影合并磨玻璃影与抗真菌治疗有效的患者没有相关性（p＞0.05）。本研究提示肺部CT的结节影、空洞影及结节影合并空洞影可能与真菌感染有关。在抗细菌治疗有效的患者中经统计学分析发现条索影、条索影合并斑片影和条索影合并磨玻璃影与抗细菌治疗有效的患者有相关性（条索影：p=0.006，条索影合并斑片影：p=0.008，条索影合并磨玻璃影：p=0.042）。另外，条索影合并胸腔积液、咳嗽和咳痰与抗细菌治疗有效的患者有相关性（p值均为：p=0.008），而结节影、斑片影、实变影、磨玻璃影、棉絮状阴影、空洞影以及它们合并出现均与抗细菌治疗有效的患者没有相关性（p＞0.05）。本研究提示肺部CT的条索影、条索影合并斑片影、条索影合并磨玻璃影、条索影合并胸腔积液、咳嗽和咳痰可能与细菌感染有关。 3按照IPFI的疗效标准，我们收集的66例患者中，有57例给予了抗真菌治疗，在抗真菌治疗有效的22例中，其中痊愈4例，显效10例，进步的8例；本研究显示抗真菌治疗总有效率为38.6%，伏立康唑治疗有效的12例，占54.5%。按照IPFI治疗疗效标准评价药物有效率时，用痊愈+显效／全部病例计算药物有效率，在抗真菌治疗有效的患者中结节性真菌感染的患者应用伏立康唑治疗有效的7例，显效的4例，有效率为57.1%。根据细菌感染疗效标准收集的66例患者均应用了抗细菌药物治疗，其中抗细菌治疗有效的14例，其中痊愈1例，显效6例，进步7例；本研究显示抗细菌治疗总有效率为21.2%，在抗细菌治疗有效的14例中碳青霉烯类抗生素治疗有效的7例，占50%。按照细菌治疗疗效标准评价药物有效率时，用痊愈+显效／全部病例计算药物有效率，在抗细菌治疗有效的患者中有条索影的细菌感染患者应用碳青霉烯类抗生素治疗有效的5例，显效的2例，有效率为40%。 4AL合并肺部感染CT影像特征和有效药物的关系：66例患者中57例给予了抗真菌治疗，抗真菌治疗有效的22例，伏立康唑为主要有效药物，在抗真菌治疗有效的患者中结节影、空洞影及结节影合并空洞影与肺部真菌感染有相关性，我们发现应用伏立康唑治疗真菌结节统计学分析有统计学意义（p=0.000），而空洞影及结节影合并空洞影未发现有统计学意义的药物（P值均为：p＞0.05）。收集的66例患者均应用了抗细菌药物治疗，其中抗细菌治疗有效组14例，碳青霉烯类抗生素为主要有效药物。在抗细菌治疗有效的患者中条索影与肺部细菌感染有相关性，我们发现应用碳青霉烯类抗生素治疗细菌条索影统计学分析有统计学意义（p=0.004）,而条索影合并磨玻璃影、条索影合并斑片影、条索影合并胸腔积液、咳嗽和咳痰未发现有统计学意义的药物（P值均为：p＞0.05）。结论： 1在AL患者的肺部感染部位中两肺感染为肺部感染的主要部位，占肺部感染的57.6%，但研究提示抗真菌及细菌有效的患者的肺部影像特点与肺部部位没有相关性。 2在AL合并肺部感染的患者中肺部出现结节影、空洞影及结节影合并空洞影时应考虑真菌感染，当患者肺部出现条索影、条索影合并磨玻璃影、条索影合并斑片影以及条索影合并胸腔积液、咳嗽和咳痰时应考虑细菌感染。 3AL合并肺部感染的患者中结节性真菌感染应用伏立康唑治疗有效率最高，为57.1%，可选用伏立康唑治疗。肺部感染的患者中出现条索影时应用碳青霉烯类抗生素治疗有效率最高，为40%，可选用碳青霉烯类抗生素治疗。 4抗感染疗效评估中侵袭性肺部真菌感染的患者中治疗总有效率为38.6%，细菌感染患者治疗总有效率为21.2%。
[Abstract]:Objective : Acute leukemia ( AL ) is one of the most common and most common diseases in the blood system . Because of its own immune deficiency , it is one of the most common complications and causes of death , and pulmonary infection is the most common infection site .

Methods : The clinical and pulmonary CT data of 66 cases of AL complicated with pulmonary infection were collected from Aug . 2010 to December 2011 . The clinical data mainly collected name , sex , age , hospitalization days , AL type , chemotherapy regimen , bone marrow response , clinical manifestation , pulmonary lesion imaging characteristics , pleural effusion , sputum culture or smear , blood culture , etc .
According to the standard of bacterial infection , 66 patients were divided into anti - bacterial treatment effective group and anti - bacterial treatment ineffective group , and the patients who recovered + obvious + progress were classified as anti - bacterial treatment effective group , and the invalid patients were classified as anti - bacterial treatment ineffective group .

Results :

1 The lung infection site of 66 patients with AL was divided into two lungs and one - sided lung , and the correlation between nodule shadow and lung was analyzed statistically without statistical significance ( p > 0.05 ) . There was no statistical significance ( p > 0.05 ) .

There was no correlation ( p > 0.05 ) in the patients with effective anti - fungal therapy ( p > 0.05 ) . In addition , there was no correlation between cord shadow and pleural effusion , cough and sputum and anti - bacterial therapy ( p = 0.008 ) , while nodule shadow , patch shadow , real image , ground glass , cotton wool shadow , cavity shadow and their combination appeared to have no correlation with the patients with effective anti - bacterial treatment ( p > 0.05 ) .

3 According to the standard of IPFI , 57 of the 66 patients collected were treated with antifungal agents . Among the 22 cases effective in antifungal therapy , 4 cases were cured , 10 cases were markedly effective and 8 cases were improved ;
In this study , the total effective rate of antifungal therapy was 38.6 % , 12 cases were effective , 54.5 % . In the patients with antifungal therapy , the total effective rate was 54.5 % . In the patients with antifungal therapy , the effective rate was 57.1 % .
In this study , the total effective rate of anti - bacterial treatment was 21.2 % , 7 cases were effective in 14 cases of anti - bacterial treatment , 7 cases were effective , and 50 % .

The relationship between CT image characteristics and effective drug of 4AL combined with pulmonary infection : Of the 66 patients , 57 of 66 patients were treated with antifungal therapy , 22 with effective antifungal therapy , and V - oliganazol as the main effective drugs . We found that there was statistical significance ( p = 0.000 ) in the treatment of fungal nodules in patients with antifungal therapy , while the cavity shadow and nodule shadow were not found to be statistically significant ( P > 0.05 ) . All the 66 patients collected were treated with anti - bacterial drugs , in which 14 patients were treated with anti - bacterial treatment , and Carbapenem antibiotics were the main effective drugs . In the patients with anti - bacterial treatment , there was statistical significance ( p = 0.004 ) .

Conclusion :

1 In AL patients , the lung infection was the main part of the lung infection , accounting for 57.6 % of the lung infection , but the study suggested that the pulmonary imaging characteristics of the patients with antifungal and bacterial infection were not related to the lung part .

2 In patients with AL combined with pulmonary infection , the pulmonary nodule , cavity shadow and nodule shadow should be taken into account for fungal infection , and bacterial infection should be taken into account when the patient ' s lungs were accompanied by a cord shadow , a cord shadow combined with a glass shadow , a cord shadow combined patch shadow , and a cord shadow combined with pleural effusion , cough and sputum .

The most effective rate was 57.1 % in patients with pulmonary infection and 57.1 % in patients with pulmonary infection . The most effective rate was 40 % in patients with pulmonary infection , and could be treated with Carbapenem antibiotics .

In patients with invasive pulmonary fungal infection , the total effective rate was 38.6 % in patients with invasive pulmonary fungal infection , and the total effective rate was 21.2 % in patients with bacterial infection .

【学位授予单位】：河北医科大学
【学位级别】：硕士
【学位授予年份】：2012
【分类号】：R519;R733.71

【参考文献】