淹溺后侵襲性肺曲霉病3例附文獻復習
發(fā)布時間：2018-11-29 10:07
【摘要】：1.目的 本文旨在總結淹溺后侵襲性肺曲霉病(IPA)的臨床表現(xiàn)及病情進展特點,提高對其的認識和診斷水平。 2.方法 收集2010年1月到2012年3月在浙江大學醫(yī)學院附屬第一醫(yī)院收治的3例淹溺后IPA患者的完整資料,包括臨床表現(xiàn)、實驗室指標、影像學表現(xiàn)及病原學結果,進行分析；同時查找美國國立圖書館PubMed、中國期刊網(wǎng)全文數(shù)據(jù)庫、萬方數(shù)據(jù)資源系統(tǒng)、維普期刊在線數(shù)據(jù)庫的相關文獻,進行文獻復習。 3.結果 3例淹溺患者中,男性1例,女性2例,年齡分別為24、26和44歲；既往均無基礎性疾��；1例因交通意外,1例因遭遇傷害事故,1例因誤跌入河中溺水；淹溺后3例患者均因急性呼吸窘迫(ARDS)行氣管插管機械通氣,并接受廣譜抗生素及糖皮質(zhì)激素同時治療。臨床癥狀均表現(xiàn)為發(fā)熱、咳嗽咳痰、胸悶氣急,1例有胸痛,且病程中體溫升高與病情進展相平行。實驗室檢查：3例均有超敏C反應蛋白升高,肝功能異常,低白蛋白血癥明顯；3例痰液、氣管鏡活檢、肺泡灌洗液真菌鏡檢或培養(yǎng)均為陰性；血培養(yǎng)1例葡萄球菌,1例銅綠假單胞菌。影像學動態(tài)變化：3例患者早期(淹溺后8-12天)呈多發(fā)結節(jié)、實變或大片團塊影,內(nèi)見“空氣支氣管征”,腫塊或結節(jié)周緣可見“暈征”,中期(淹溺后19-22天)團塊中出現(xiàn)空洞型病灶,后期(淹溺后26-31天)團塊中出現(xiàn)的“新月征”、“洞中球征”。 以"near-drowning"及'aspergillosis"為檢索詞,未設定時間限制,搜索PubMed數(shù)據(jù)庫,共得到8篇淹溺后IPA的病例報道；以“淹溺／溺水”和“侵襲性肺曲菌病”為檢索詞,搜索中國期刊網(wǎng)全文數(shù)據(jù)庫,萬方數(shù)據(jù)庫,獲得2篇共4例資料完整的國內(nèi)淹溺后IPA的病例報道。12例病例中,7例確診,5例是臨床診斷,結合本文3例病例：淹溺患者大多在淹溺后5-15天內(nèi)病情加重；影像學上表現(xiàn)相似,均有雙側肺實變、多發(fā)性結節(jié)、空洞形成,可見新月征。 4.結論 溺水后IPA的發(fā)生即與直接吸入大量曲菌有關,亦與各種危險因素下機會性感染有關,廣譜抗生素的使用大大地增加了條件致病性真菌感染的風險。對病情進展快的危重患者實驗室手段難以揭示病原學,且難以實施有創(chuàng)性的組織病理學檢查,應及早進行臨床綜合診斷。肺部影像特點對于IPA的診斷及病情估計有重要的指導意義。在循證醫(yī)學原則指導下,進行個體化的聯(lián)合優(yōu)化抗真菌治療,有效阻止曲霉菌的增殖和侵襲,從而改善危重患者預后。
[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.
【學位授予單位】：浙江大學
【學位級別】：碩士
【學位授予年份】：2012
【分類號】：R519
本文編號：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.
【學位授予單位】：浙江大學
【學位級別】：碩士
【學位授予年份】：2012
【分類號】：R519
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，本文編號：2364705
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