慢性肾脏病者伴肺孢子虫肺炎漏诊分析  

Analysis of missed diagnosis in chronic kidney diseases complicated with pneumocystis carinii pneumonia

作　　者：宋岩[1] 姚凤华[1] 李冀军[1] 陈凤锟[1] 纪殿忠[1] 赵长征[1] 

机构地区：[1]解放军总医院第一附属医院肾内科,北京100048

出　　处：《临床肾脏病杂志》2010年第2期65-67,F0002,共4页Journal Of Clinical Nephrology

摘　　要：目的探讨慢性肾脏病者伴肺孢子虫肺炎（PCP）漏诊原因。方法回顾性分析3例漏诊的慢性肾脏病伴PCP患者的临床症状、影像学及实验室检查资料，并分析漏诊原因。结果本组3例，IgA肾病2例，肾淀粉样变性病1例。临床表现为发热、咳嗽、胸闷，2例出现Ⅰ型呼吸衰竭，1例出现低氧血症。3例均应用激素治疗，2例同时应用环磷酰胺（CTX）。2例诊断为肺部急性细菌性感染，1例诊断为肺部支原体感染。入院时3例X线征象均不典型，2例有典型CT征像。确诊时2例有典型X线征象，3例有典型CT征象。3例常规痰培养均未发现伊氏肺孢子菌，支气管肺泡灌洗液吉姆萨染色涂片发现伊氏肺孢子菌或痰聚合酶链反应（PCR）法检测伊氏肺孢子菌虫体DNA（＋）。给予卡泊芬净及复方磺胺甲噫唑治疗均治愈。结论PCP是接受激素和（或）CTX治疗的慢性肾脏病患者肺部机会感染之一，早期胸部X线和CT征像常不典型，典型的X线或CT征像对PCP的诊断具有重要意义。接受激素和（或）免疫抑制剂治疗的慢性肾脏病患者若出现发热、抗细菌感染治疗效果不佳，应尽早行痰或支气管肺泡灌洗液吉姆萨染色找伊氏肺孢子菌或PCR法检测伊氏肺孢子菌虫体DNA。Objective To discuss the missed diagnosis of chronic kidney diseases complicated with pneumocystis carinii pneumonia（PCP）. Methods The clinical symptom,imaging findings and la boratory data of 3 cases of chronic glomerular disease with PCP were analyzed. Results There were 2 cases of IgA nephropathy and one case of renal amyloidosis. The clinical manifestations included fever, cough,and chest tightness. Two patients had type I respiratory failure and one had hypoxemia. They all accepted hormone therapy, while two accepted cyclophosphamide （CTX） simultaneously. Two patients were diagnosed as pulmonary bacterial infection and one patient as mycoplasma infection. At admission,X ray findings were not typical in three patients and CT imaging findings were typical in two patients. After definite diagnosis,X-ray findings were typical in two patients and CT imaging findings typical in three patients. Pneumocystis carinii were not found by sputum culture in 3 patients, but they were found by bronchoalveolar lavage fluid sputum Giemsa stain,and sputum was positive for DNA detected by polymerase chain reaction （PCR）. Three patients were cured with caspofungin and compound sulfamethoxazole. Conclusions PCP is one of pulmonary opportunistic infections in patients receiving hormone and CTX therapy. The early chest X-ray and CT findings are not typical and could be diag nosed as lung bacteria and mycoplasma infection. Typical X-ray or CT findings are important for diagnosis. When patients with chronic kidney diseases receiving hormone and immunosuppressive therapy are fever and antibiotics are ineffective, sputum Giemsa stain and sputum PCR should be done as soon as possible.

关 键 词：肾疾病 肺炎 肺囊虫性 糖皮质激素 

分 类 号：R692[医药卫生—泌尿科学]