血液病患者伴发肺部侵袭性真菌感染临床分析及伊曲康唑疗效观察
发布时间：2018-07-29 09:07
【摘要】：研究背景及目的：近年来,随着医疗技术的进步和病原体自身适应外界环境因素的影响,侵袭性真菌感染在临床中逐渐增多,特别是恶性血液病患者由于机体免疫功能低下,接受化疗药物治疗、使用广谱抗生素、激素和联用免疫抑制剂等因素更易发生真菌感染,尤其是肺部侵袭性真菌感染。真菌感染不仅极大影响恶性血液病患者的治疗效果,严重者更可以直接导致死亡。由于肺部真菌感染临床表现缺乏特异性,不易获得病原学结果,早期诊断较困难,同时患者原发病病情复杂,易误诊或漏诊,如诊断及治疗不及时,导致死亡率增加。因此探讨血液病伴发肺部侵袭性真菌感染的宿主因素、临床特点、影像学表现及诊断和治疗,观察伊曲康唑疗效,提高对该病的认识,有重要临床意义。方法：本研究通过对2010年3月～2012年1月,回顾性分析山东大学齐鲁医院我科116例用伊曲康哗治疗血液病伴发肺部真菌感染住院患者临床资料,其中男61例,女55例,年龄16～77岁,平均年龄49.7岁,总结肺真菌病的宿主因素、临床特征、影像学特点、诊断、抗真菌治疗及观察伊曲康唑疗效。 结果： 1.116例肺部侵袭性真菌感染患者中,MM患者37例,重型再障患者5例,ITP患者4例,AML患者31例,ALL患者16例,NHL患者15例,MDS患者8例。 2.116例肺部侵袭性真菌感染患者临床特点,以发热(94.5%)、胸闷气促(35.6%)、咳嗽、咳痰(65.8%)、低氧血症(57.5%)为主要表现,肺部干湿性Up音61.5%为重要体征。 3.116例患者中,痰培养曲霉菌23例,念珠菌28例,未分类真菌11例。 4.影像学表现呈多样性,胸膜下结节35例(30.2%),非特异性毛玻璃样改变30例(25.9%),肺部大结节(直径1cm)23例(19.8%),日晕征14例(12.1%)、新月征13例(11.2%),胸膜渗出性改变8例(6.9%),空洞样改变10例(8.6%),肺实变7例(6.0%)。 5.116例患者中,临床诊断62例,拟诊54例。6.116例患者.静脉应用伊曲康唑治疗均在2周以上评价疗效,其中有效78例,临床有效率67%,无效38例(33%),死亡16例,死亡率14%。 结论： 1.患者多合并血液系统恶性肿瘤,接受化疗后多伴有中性粒细胞减少,部分中性粒细胞缺乏,免疫功能状态一般较差,IFI机率较大。 2.侵袭性真菌感染临床表现不典型,除发热、咳嗽咳痰、胸闷急呼吸困难外,少部分患者还表现为恶心呕吐、腹泻等消化道症状,乏力、盗汗等消耗症状,当患者出现呼吸系统外其他不典型症状时,不能排除真菌感染。 3.影像学表现复杂多变,典型的“新月征”表现者少,应结合其临床表现、宿主因素及病史、病原学检查综合分析判断是否有真菌感染,以便正确及时做出诊断。 4.患者多合并恶性疾病及高危因素,化疗后骨髓抑制期,或恶性肿瘤终末期,一般情况差,无法耐受如气管镜、手术等检查方法获取病理结果,痰培养及血培养最简单常用,但阳性率低。 5.早期诊断IFI并早期起始经验性抗真菌治疗是治疗成功关键。IFI临床表现无特异性,如患者具备宿主危险因素,经广谱强有力抗生素治疗无效,参考影像学证据和实验室检查结果,即应起始抗真菌治疗。 6.目前缺乏IFI治疗期间进行有效评估并对病原体数量做定量测定病原学标志,发热与否不是评价抗真菌治疗是否有效的标准,必须依赖于临床表现、影像学证据、实验室检查来评估治疗效果好与坏。 7.血液系统疾病合并IFI患者,伊曲康唑早期抗真菌治疗,有效率高,安全性好,应用期间要注意监测肝脏功能。
[Abstract]:Research background and purpose: in recent years, with the progress of medical technology and the influence of the pathogen itself to the external environmental factors, invasive fungal infection is increasing in clinical, especially for patients with malignant hematological diseases, due to the low immune function of the body, the treatment of chemotherapeutic drugs, the use of broad-spectrum antibiotics, hormones, and combined immunosuppressants. Fungal infection, especially in the lung invasive fungal infection. Fungal infection not only greatly affects the treatment effect of patients with malignant hematopathy, but the serious patients can lead to death. Because of the lack of specificity in the clinical manifestations of pulmonary fungal infection, it is difficult to obtain the results of etiology. Early diagnosis is difficult and the patients have primary disease. The disease is complicated, easily misdiagnosed or missed diagnosis, such as the diagnosis and treatment is not timely, resulting in increased mortality. Therefore, it is important to explore the host factors, clinical features, imaging manifestations, diagnosis and treatment of the pulmonary invasive fungal infection of the blood diseases, and to observe the curative effect of itraconazole and improve the understanding of the disease. Methods: This study passed to 2 From March to January 2012 from 010 years to January 2012, the clinical data of hospitalized patients with hematological diseases and pulmonary fungal infection were retrospectively analyzed in our department of Qilu Hospital of Shandong University, including 61 cases of male, 55 women, 16~77 years old and 49.7 years old. The host factors, clinical features, imaging characteristics, diagnosis and antifungal treatment of pulmonary fungal disease were summarized. Treatment and observation of itraconazole.
Result:
Of the 1.116 patients with invasive pulmonary fungal infection, 37 cases were MM, 5 cases of severe aplastic anemia, 4 cases of ITP, 31 AML patients, 16 ALL patients, 15 cases of NHL, and 8 of MDS patients.
2.116 cases of pulmonary invasive fungal infection were characterized by fever (94.5%), chest tightness (35.6%), cough, expectoration (65.8%), hypoxemia (57.5%), and dry and wet Up tone 61.5% as an important sign.
Among the 3.116 patients, sputum cultures were Aspergillus in 23 cases, Candida in 28 cases, and unclassified fungi in 11 cases.
The 4. images showed diversity, sub pleural nodule in 35 cases (30.2%), non specific hair glass changes in 30 cases (25.9%), pulmonary nodules (diameter 1cm) 23 cases (19.8%), corona sign 14 cases (12.1%), crescent sign 13 cases (11.2%), pleural exudative change 8 cases (6.9%), cavity like changes in 10 cases, pulmonary consolidation cases.
Of the 5.116 patients, 62 cases were diagnosed and 54 cases of.6.116 were diagnosed. Intravenous itraconazole was used to evaluate the curative effect over 2 weeks. Among them, 78 cases were effective, clinical effective rate was 67%, 38 cases were invalid (33%), death 16 cases, death rate of 14%.
Conclusion:
1. patients were combined with malignant tumor of the blood system. After chemotherapy, most of them were accompanied by neutrophils, some neutrophils were lacking, the immune function was generally poor, and the probability of IFI was large.
2. the clinical manifestations of invasive fungal infection were atypical, except fever, cough and expectoration, chest tightness and sudden breathing difficulties. A few patients also showed symptoms of nausea, vomiting, diarrhea and other digestive tract symptoms, fatigue, sweating and other symptoms. When the patients appeared other atypical symptoms outside the respiratory system, the fungal infection could not be excluded.
The 3. imaging features are complex and changeable, and the typical "crescent sign" shows few. It should be combined with the clinical manifestation, the host and the medical history, and the etiology examination to determine whether there is any fungal infection in order to make a correct and timely diagnosis.
4. patients combined with malignant disease and high risk factors, after chemotherapy, bone marrow depression, or malignant tumor end-stage, general situation is poor, can not tolerate such as trachea, surgery and other examination methods to obtain pathological results, sputum culture and blood culture is the simplest common, but the positive rate is low.
5. early diagnosis of IFI and early initial empirical antifungal therapy are the key.IFI clinical manifestations of successful treatment, such as patients with host risk factors, effective broad spectrum antibiotic therapy, reference imaging evidence and laboratory results, that is, antifungal treatment should be initiated.
6. the current lack of effective evaluation of IFI and quantitative etiological markers for the number of pathogens. Fever is not a criterion for evaluating the effectiveness of antifungal therapy. It must rely on clinical, imaging, and laboratory tests to assess the good and bad effects of the treatment.
7. in patients with hematologic diseases and IFI, itraconazole is effective in early antifungal therapy. It is effective and safe. Liver function should be monitored during application.
【学位授予单位】：山东大学
【学位级别】：硕士
【学位授予年份】：2012
【分类号】：R519;R55
本文编号：2152190
[Abstract]:Research background and purpose: in recent years, with the progress of medical technology and the influence of the pathogen itself to the external environmental factors, invasive fungal infection is increasing in clinical, especially for patients with malignant hematological diseases, due to the low immune function of the body, the treatment of chemotherapeutic drugs, the use of broad-spectrum antibiotics, hormones, and combined immunosuppressants. Fungal infection, especially in the lung invasive fungal infection. Fungal infection not only greatly affects the treatment effect of patients with malignant hematopathy, but the serious patients can lead to death. Because of the lack of specificity in the clinical manifestations of pulmonary fungal infection, it is difficult to obtain the results of etiology. Early diagnosis is difficult and the patients have primary disease. The disease is complicated, easily misdiagnosed or missed diagnosis, such as the diagnosis and treatment is not timely, resulting in increased mortality. Therefore, it is important to explore the host factors, clinical features, imaging manifestations, diagnosis and treatment of the pulmonary invasive fungal infection of the blood diseases, and to observe the curative effect of itraconazole and improve the understanding of the disease. Methods: This study passed to 2 From March to January 2012 from 010 years to January 2012, the clinical data of hospitalized patients with hematological diseases and pulmonary fungal infection were retrospectively analyzed in our department of Qilu Hospital of Shandong University, including 61 cases of male, 55 women, 16~77 years old and 49.7 years old. The host factors, clinical features, imaging characteristics, diagnosis and antifungal treatment of pulmonary fungal disease were summarized. Treatment and observation of itraconazole.
Result:
Of the 1.116 patients with invasive pulmonary fungal infection, 37 cases were MM, 5 cases of severe aplastic anemia, 4 cases of ITP, 31 AML patients, 16 ALL patients, 15 cases of NHL, and 8 of MDS patients.
2.116 cases of pulmonary invasive fungal infection were characterized by fever (94.5%), chest tightness (35.6%), cough, expectoration (65.8%), hypoxemia (57.5%), and dry and wet Up tone 61.5% as an important sign.
Among the 3.116 patients, sputum cultures were Aspergillus in 23 cases, Candida in 28 cases, and unclassified fungi in 11 cases.
The 4. images showed diversity, sub pleural nodule in 35 cases (30.2%), non specific hair glass changes in 30 cases (25.9%), pulmonary nodules (diameter 1cm) 23 cases (19.8%), corona sign 14 cases (12.1%), crescent sign 13 cases (11.2%), pleural exudative change 8 cases (6.9%), cavity like changes in 10 cases, pulmonary consolidation cases.
Of the 5.116 patients, 62 cases were diagnosed and 54 cases of.6.116 were diagnosed. Intravenous itraconazole was used to evaluate the curative effect over 2 weeks. Among them, 78 cases were effective, clinical effective rate was 67%, 38 cases were invalid (33%), death 16 cases, death rate of 14%.
Conclusion:
1. patients were combined with malignant tumor of the blood system. After chemotherapy, most of them were accompanied by neutrophils, some neutrophils were lacking, the immune function was generally poor, and the probability of IFI was large.
2. the clinical manifestations of invasive fungal infection were atypical, except fever, cough and expectoration, chest tightness and sudden breathing difficulties. A few patients also showed symptoms of nausea, vomiting, diarrhea and other digestive tract symptoms, fatigue, sweating and other symptoms. When the patients appeared other atypical symptoms outside the respiratory system, the fungal infection could not be excluded.
The 3. imaging features are complex and changeable, and the typical "crescent sign" shows few. It should be combined with the clinical manifestation, the host and the medical history, and the etiology examination to determine whether there is any fungal infection in order to make a correct and timely diagnosis.
4. patients combined with malignant disease and high risk factors, after chemotherapy, bone marrow depression, or malignant tumor end-stage, general situation is poor, can not tolerate such as trachea, surgery and other examination methods to obtain pathological results, sputum culture and blood culture is the simplest common, but the positive rate is low.
5. early diagnosis of IFI and early initial empirical antifungal therapy are the key.IFI clinical manifestations of successful treatment, such as patients with host risk factors, effective broad spectrum antibiotic therapy, reference imaging evidence and laboratory results, that is, antifungal treatment should be initiated.
6. the current lack of effective evaluation of IFI and quantitative etiological markers for the number of pathogens. Fever is not a criterion for evaluating the effectiveness of antifungal therapy. It must rely on clinical, imaging, and laboratory tests to assess the good and bad effects of the treatment.
7. in patients with hematologic diseases and IFI, itraconazole is effective in early antifungal therapy. It is effective and safe. Liver function should be monitored during application.
【学位授予单位】：山东大学
【学位级别】：硕士
【学位授予年份】：2012
【分类号】：R519;R55
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