淹溺后侵袭性肺曲霉病3例附文献复习
发布时间：2018-11-29 10:07
【摘要】：1.目的 本文旨在总结淹溺后侵袭性肺曲霉病(IPA)的临床表现及病情进展特点,提高对其的认识和诊断水平。 2.方法 收集2010年1月到2012年3月在浙江大学医学院附属第一医院收治的3例淹溺后IPA患者的完整资料,包括临床表现、实验室指标、影像学表现及病原学结果,进行分析；同时查找美国国立图书馆PubMed、中国期刊网全文数据库、万方数据资源系统、维普期刊在线数据库的相关文献,进行文献复习。 3.结果 3例淹溺患者中,男性1例,女性2例,年龄分别为24、26和44岁；既往均无基础性疾病；1例因交通意外,1例因遭遇伤害事故,1例因误跌入河中溺水；淹溺后3例患者均因急性呼吸窘迫(ARDS)行气管插管机械通气,并接受广谱抗生素及糖皮质激素同时治疗。临床症状均表现为发热、咳嗽咳痰、胸闷气急,1例有胸痛,且病程中体温升高与病情进展相平行。实验室检查：3例均有超敏C反应蛋白升高,肝功能异常,低白蛋白血症明显；3例痰液、气管镜活检、肺泡灌洗液真菌镜检或培养均为阴性；血培养1例葡萄球菌,1例铜绿假单胞菌。影像学动态变化：3例患者早期(淹溺后8-12天)呈多发结节、实变或大片团块影,内见“空气支气管征”,肿块或结节周缘可见“晕征”,中期(淹溺后19-22天)团块中出现空洞型病灶,后期(淹溺后26-31天)团块中出现的“新月征”、“洞中球征”。 以"near-drowning"及'aspergillosis"为检索词,未设定时间限制,搜索PubMed数据库,共得到8篇淹溺后IPA的病例报道；以“淹溺／溺水”和“侵袭性肺曲菌病”为检索词,搜索中国期刊网全文数据库,万方数据库,获得2篇共4例资料完整的国内淹溺后IPA的病例报道。12例病例中,7例确诊,5例是临床诊断,结合本文3例病例：淹溺患者大多在淹溺后5-15天内病情加重；影像学上表现相似,均有双侧肺实变、多发性结节、空洞形成,可见新月征。 4.结论 溺水后IPA的发生即与直接吸入大量曲菌有关,亦与各种危险因素下机会性感染有关,广谱抗生素的使用大大地增加了条件致病性真菌感染的风险。对病情进展快的危重患者实验室手段难以揭示病原学,且难以实施有创性的组织病理学检查,应及早进行临床综合诊断。肺部影像特点对于IPA的诊断及病情估计有重要的指导意义。在循证医学原则指导下,进行个体化的联合优化抗真菌治疗,有效阻止曲霉菌的增殖和侵袭,从而改善危重患者预后。
[Abstract]:1. Objective to summarize the clinical manifestations and progression of invasive pulmonary aspergillosis (IPA) after drowning in order to improve the understanding and diagnosis of the disease. 2. Methods from January 2010 to March 2012, the complete data of 3 patients with IPA after drowning in the first affiliated Hospital of Zhejiang University Medical College were collected and analyzed, including clinical manifestations, laboratory indicators, imaging findings and etiological results. At the same time, we search the full text database of PubMed, Wanfang data resource system, and the online database of WIP periodicals in the National Library of the United States, and review the literature. 3. Results among the 3 drowning patients, 1 male and 2 female, aged 24 to 26 and 44 years old, had no basic diseases, 1 case suffered from traffic accident, 1 case suffered from injury accident, 1 case fell into the river and drowned by mistake. After drowning, all the patients were treated with extensive antibiotics and glucocorticoid because of acute respiratory distress (ARDS). The clinical symptoms were fever, cough and expectoration, acute chest tightness, chest pain in one case, and the elevation of body temperature in the course of the disease was parallel to the progression of the disease. The results of laboratory examination were as follows: all of the 3 cases had elevated hypersensitive C-reactive protein, abnormal liver function and obvious hypoalbuminemia, while sputum, tracheoscopy biopsy and alveolar lavage fluid fungi were negative in 3 cases. One case of staphylococcus and one case of Pseudomonas aeruginosa were cultured in blood. Dynamic changes of imaging: early stage (8-12 days after drowning) showed multiple nodule, consolidation or mass shadow, "air bronchus sign" and "halo sign" around the mass or tubercle. In the middle stage (19-22 days after drowning), the cavity lesion appeared in the mass, and in the late stage (26-31 days after drowning), the "crescent sign" and "ball sign in the hole" appeared in the mass. "near-drowning" and 'aspergillosis "were used as the key words, and no time limit was set to search the PubMed database. Eight cases of IPA after drowning were reported. With "drowning / drowning" and "invasive pulmonary aspergillosis" as the key words, the full text database and Wanfang database of China Journal Network were searched, and 2 cases of IPA after drowning were reported in China. Among the 12 cases, 7 cases were confirmed. 5 cases were clinically diagnosed, combined with 3 cases in this paper: most of the drowning patients became worse within 5-15 days after drowning; Imaging findings were similar, with bilateral pulmonary consolidation, multiple nodules, cavitation, and crescent sign. 4. Conclusion the occurrence of IPA after drowning is related to direct inhalation of aspergillus and opportunistic infection under various risk factors. The use of broad-spectrum antibiotics greatly increases the risk of opportunistic fungal infection. It is difficult to reveal etiology and carry out invasive histopathological examination by laboratory methods for critical patients with rapid progress of the disease. Comprehensive clinical diagnosis should be carried out as soon as possible. Pulmonary imaging features are of great significance in the diagnosis and evaluation of IPA. Under the guidance of Evidence-based Medicine, individualized combined and optimized antifungal therapy was carried out to effectively prevent the proliferation and invasion of Aspergillus and thus improve the prognosis of critical patients.
【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
本文编号：2364705
[Abstract]:1. Objective to summarize the clinical manifestations and progression of invasive pulmonary aspergillosis (IPA) after drowning in order to improve the understanding and diagnosis of the disease. 2. Methods from January 2010 to March 2012, the complete data of 3 patients with IPA after drowning in the first affiliated Hospital of Zhejiang University Medical College were collected and analyzed, including clinical manifestations, laboratory indicators, imaging findings and etiological results. At the same time, we search the full text database of PubMed, Wanfang data resource system, and the online database of WIP periodicals in the National Library of the United States, and review the literature. 3. Results among the 3 drowning patients, 1 male and 2 female, aged 24 to 26 and 44 years old, had no basic diseases, 1 case suffered from traffic accident, 1 case suffered from injury accident, 1 case fell into the river and drowned by mistake. After drowning, all the patients were treated with extensive antibiotics and glucocorticoid because of acute respiratory distress (ARDS). The clinical symptoms were fever, cough and expectoration, acute chest tightness, chest pain in one case, and the elevation of body temperature in the course of the disease was parallel to the progression of the disease. The results of laboratory examination were as follows: all of the 3 cases had elevated hypersensitive C-reactive protein, abnormal liver function and obvious hypoalbuminemia, while sputum, tracheoscopy biopsy and alveolar lavage fluid fungi were negative in 3 cases. One case of staphylococcus and one case of Pseudomonas aeruginosa were cultured in blood. Dynamic changes of imaging: early stage (8-12 days after drowning) showed multiple nodule, consolidation or mass shadow, "air bronchus sign" and "halo sign" around the mass or tubercle. In the middle stage (19-22 days after drowning), the cavity lesion appeared in the mass, and in the late stage (26-31 days after drowning), the "crescent sign" and "ball sign in the hole" appeared in the mass. "near-drowning" and 'aspergillosis "were used as the key words, and no time limit was set to search the PubMed database. Eight cases of IPA after drowning were reported. With "drowning / drowning" and "invasive pulmonary aspergillosis" as the key words, the full text database and Wanfang database of China Journal Network were searched, and 2 cases of IPA after drowning were reported in China. Among the 12 cases, 7 cases were confirmed. 5 cases were clinically diagnosed, combined with 3 cases in this paper: most of the drowning patients became worse within 5-15 days after drowning; Imaging findings were similar, with bilateral pulmonary consolidation, multiple nodules, cavitation, and crescent sign. 4. Conclusion the occurrence of IPA after drowning is related to direct inhalation of aspergillus and opportunistic infection under various risk factors. The use of broad-spectrum antibiotics greatly increases the risk of opportunistic fungal infection. It is difficult to reveal etiology and carry out invasive histopathological examination by laboratory methods for critical patients with rapid progress of the disease. Comprehensive clinical diagnosis should be carried out as soon as possible. Pulmonary imaging features are of great significance in the diagnosis and evaluation of IPA. Under the guidance of Evidence-based Medicine, individualized combined and optimized antifungal therapy was carried out to effectively prevent the proliferation and invasion of Aspergillus and thus improve the prognosis of critical patients.
【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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