呼吸重症监护病房侵袭性肺曲霉病临床特点及预后分析
Clinical characteristics and prognosis of invasive pulmonary aspergillosis in the respiratory intensive care unit
孙辉明 1王永萍 1袁冬梅 1陈晨 1陈菲 1吴冠楠 1徐小勇 1赵蓓蕾1
作者信息
- 1. 210002 解放军南京总医院呼吸与危重症医学科
- 折叠
摘要
目的 总结呼吸重症监护病房(ICU)侵袭性肺曲霉病(IPA)的临床特点及转归,为早期诊断和治疗提供帮助.方法 回顾性分析2015年5月至2018年4月在呼吸ICU诊断为IPA的17例患者的临床特点、治疗及转归.结果 17例患者的基础疾病多为慢性呼吸道疾病(14例,其中11例为慢性阻塞性肺疾病).IPA确诊1例,临床诊断13例,拟诊3例.所有患者住院期间均应用过广谱抗生素,6例在入院前3周及住院期间全身应用过糖皮质激素.主要临床症状有咳嗽咳痰、呼吸困难、发热等,其中4例出现咯血.8例影像学表现为片状渗出影,4例有多发结节影伴空洞,2例有沿支气管多发小结节,1例为左肺上叶实变影.16例接受伏立康唑单独或联合卡泊芬净抗曲霉治疗,14例行伏立康唑血药浓度检测,4例在正常范围,10例升高(2例明显升高,>10 μg/L),用药后患者胆红素均无明显升高;伏立康唑血药浓度升高者,丙氨酸氨基转移酶(ALT)和天冬氨酸氨基转移酶(AST)升高4例,血药浓度正常者ALT和AST升高2例.血药浓度升高与患者预后无明确相关性.8例好转出院,9例因病情恶化放弃治疗而死亡.8例患者接受机械通气治疗(6例有创,2例无创),其中7例最终放弃治疗而死亡.结论 慢性呼吸道疾病合并IPA临床特点多不典型,但病情危重,病死率高,危重患者可能更易出现伏立康唑血药浓度升高.对有全身应用糖皮质激素史,临床出现咯血、气促,影像学表现渗出样变、结节样变和/或空洞,规范抗感染治疗无效者,应积极寻找IPA的证据,早期诊断,规范治疗,可改善患者的预后.
Abstract
Objective To demonstrate the clinical characteristics and prognosis of invasive pulmonary aspergillosis (IPA) in respiratory intensive care unit (ICU), for early diagnosis and treatment. Methods The clinical features, treatment and outcome of 17 patients diagnosed as IPA in RICU from May 2015 to April 2018 were analyzed retrospectively. Results The basic diseases of 17 patients were mostly chronic respiratory diseases (14 cases, while 11 cases were chronic obstructive pulmonary disease). One case was proven by IPA criteria, 13 cases were probable and 3 cases were possible. All patients were treated with broad-spectrum antibiotics during hospitalization, and 6 patients were treated with glucocorticoids (oral/intravenous) within 3 weeks of admission and during hospitalization. The main clinical symptoms included cough sputum, dyspnea and fever, among which 4 cases had hemoptysis. Infiltrates were seen in 8 cases, multiple nodules with cavitary lesions in 4 cases, multiple small nodules along the bronchi in 2 cases, and left upper lobe consolidation in the proven case. Sixteen patients were treated with voriconazole alone or in combination with caspofungin. Fourteen patients were tested for voriconazole serum concentration, while 4 were in normal range, 10 were elevated (2 cases were significantly elevated, ＞10 μg/L). Serum concentration of bilirubin did not increase significantly in all paitents after treatment. Serum concentrations of alanine aminotransferase (ALT) and aspartate aminotransferase (AST) were elevated in 4 cases with elevated serum concentration of voriconazole and 2 cases with normal serum concentration of voriconazole. Patients with elevated voriconazole concentration did not show significant difference in prognosis compared with those with normal concentration. Eight cases were improved and discharged and 9 gave up and died due to the worsening of the disease. Eight patients received mechanical ventilation (6 cases were invasive and 2 cases were non-invasive), 7 of them eventually gave up treatment and died. Conclusions The clinical features of chronic respiratory diseases with IPA are atypical, however, the patient is critically ill with high mortality. Elevated serum concentration of voriconazole might be more common in severe patients. For those who have a history of systemic application of glucocorticoids, clinical symptoms with hemoptysis, short of breath, radiology with infiltrates, nodular and/or with cavity, and with no response to antibiotics, clinicians should actively seeking evidence of IPA, for early diagnosis, standardized treatment, and improve the prognosis of patients with chronic respiratory diseases complicated with IPA.
关键词
重症监护病房/曲霉菌病/早期诊断/预后/回顾性研究Key words
Intensive care units/Aspergillosis/Early diagnosis/Prognosis/Retrospective studies引用本文复制引用
出版年
2018
NETL
NSTL
维普
万方数据