血液病患者伴發(fā)肺部侵襲性真菌感染臨床分析及伊曲康唑療效觀察
發(fā)布時(shí)間：2018-07-29 09:07
【摘要】：研究背景及目的：近年來(lái),隨著醫(yī)療技術(shù)的進(jìn)步和病原體自身適應(yīng)外界環(huán)境因素的影響,侵襲性真菌感染在臨床中逐漸增多,特別是惡性血液病患者由于機(jī)體免疫功能低下,接受化療藥物治療、使用廣譜抗生素、激素和聯(lián)用免疫抑制劑等因素更易發(fā)生真菌感染,尤其是肺部侵襲性真菌感染。真菌感染不僅極大影響惡性血液病患者的治療效果,嚴(yán)重者更可以直接導(dǎo)致死亡。由于肺部真菌感染臨床表現(xiàn)缺乏特異性,不易獲得病原學(xué)結(jié)果,早期診斷較困難,同時(shí)患者原發(fā)病病情復(fù)雜,易誤診或漏診,如診斷及治療不及時(shí),導(dǎo)致死亡率增加。因此探討血液病伴發(fā)肺部侵襲性真菌感染的宿主因素、臨床特點(diǎn)、影像學(xué)表現(xiàn)及診斷和治療,觀察伊曲康唑療效,提高對(duì)該病的認(rèn)識(shí),有重要臨床意義。方法：本研究通過(guò)對(duì)2010年3月～2012年1月,回顧性分析山東大學(xué)齊魯醫(yī)院我科116例用伊曲康嘩治療血液病伴發(fā)肺部真菌感染住院患者臨床資料,其中男61例,女55例,年齡16～77歲,平均年齡49.7歲,總結(jié)肺真菌病的宿主因素、臨床特征、影像學(xué)特點(diǎn)、診斷、抗真菌治療及觀察伊曲康唑療效。 結(jié)果： 1.116例肺部侵襲性真菌感染患者中,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例肺部侵襲性真菌感染患者臨床特點(diǎn),以發(fā)熱(94.5%)、胸悶氣促(35.6%)、咳嗽、咳痰(65.8%)、低氧血癥(57.5%)為主要表現(xiàn),肺部干濕性Up音61.5%為重要體征。 3.116例患者中,痰培養(yǎng)曲霉菌23例,念珠菌28例,未分類真菌11例。 4.影像學(xué)表現(xiàn)呈多樣性,胸膜下結(jié)節(jié)35例(30.2%),非特異性毛玻璃樣改變30例(25.9%),肺部大結(jié)節(jié)(直徑1cm)23例(19.8%),日暈征14例(12.1%)、新月征13例(11.2%),胸膜滲出性改變8例(6.9%),空洞樣改變10例(8.6%),肺實(shí)變7例(6.0%)。 5.116例患者中,臨床診斷62例,擬診54例。6.116例患者.靜脈應(yīng)用伊曲康唑治療均在2周以上評(píng)價(jià)療效,其中有效78例,臨床有效率67%,無(wú)效38例(33%),死亡16例,死亡率14%。 結(jié)論： 1.患者多合并血液系統(tǒng)惡性腫瘤,接受化療后多伴有中性粒細(xì)胞減少,部分中性粒細(xì)胞缺乏,免疫功能狀態(tài)一般較差,IFI機(jī)率較大。 2.侵襲性真菌感染臨床表現(xiàn)不典型,除發(fā)熱、咳嗽咳痰、胸悶急呼吸困難外,少部分患者還表現(xiàn)為惡心嘔吐、腹瀉等消化道癥狀,乏力、盜汗等消耗癥狀,當(dāng)患者出現(xiàn)呼吸系統(tǒng)外其他不典型癥狀時(shí),不能排除真菌感染。 3.影像學(xué)表現(xiàn)復(fù)雜多變,典型的“新月征”表現(xiàn)者少,應(yīng)結(jié)合其臨床表現(xiàn)、宿主因素及病史、病原學(xué)檢查綜合分析判斷是否有真菌感染,以便正確及時(shí)做出診斷。 4.患者多合并惡性疾病及高危因素,化療后骨髓抑制期,或惡性腫瘤終末期,一般情況差,無(wú)法耐受如氣管鏡、手術(shù)等檢查方法獲取病理結(jié)果,痰培養(yǎng)及血培養(yǎng)最簡(jiǎn)單常用,但陽(yáng)性率低。 5.早期診斷IFI并早期起始經(jīng)驗(yàn)性抗真菌治療是治療成功關(guān)鍵。IFI臨床表現(xiàn)無(wú)特異性,如患者具備宿主危險(xiǎn)因素,經(jīng)廣譜強(qiáng)有力抗生素治療無(wú)效,參考影像學(xué)證據(jù)和實(shí)驗(yàn)室檢查結(jié)果,即應(yīng)起始抗真菌治療。 6.目前缺乏IFI治療期間進(jìn)行有效評(píng)估并對(duì)病原體數(shù)量做定量測(cè)定病原學(xué)標(biāo)志,發(fā)熱與否不是評(píng)價(jià)抗真菌治療是否有效的標(biāo)準(zhǔn),必須依賴于臨床表現(xiàn)、影像學(xué)證據(jù)、實(shí)驗(yàn)室檢查來(lái)評(píng)估治療效果好與壞。 7.血液系統(tǒng)疾病合并IFI患者,伊曲康唑早期抗真菌治療,有效率高,安全性好,應(yīng)用期間要注意監(jiān)測(cè)肝臟功能。
[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.
【學(xué)位授予單位】：山東大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2012
【分類號(hào)】：R519;R55
本文編號(hào)：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.
【學(xué)位授予單位】：山東大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2012
【分類號(hào)】：R519;R55
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，本文編號(hào)：2152190
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