免疫正常人群播散型组织胞浆菌病的诊断和治疗(附6例分析及文献复习)  

Diagnosis and treatment of disseminated histoplasmosis in immunocompetent patients:analysis and literature review of 6 cases

作　　者：彭凤英[1] 

机构地区：[1]重庆医科大学附属第一医院感染科,重庆400016

出　　处：《重庆医科大学学报》2016年第4期404-408,共5页Journal of Chongqing Medical University

摘　　要：目的:总结播散型组织胞浆菌病(disseminated histoplasmosis,DH)临床特点及治疗经过,以提高对该病的诊治能力,并为流行病学调查提供循证医学证据。方法:收集重庆医科大学附属第一医院2008年至2014年经骨髓及病理确诊的DH 6例,对其临床表现、诊治过程及转归等资料进行回顾性分析。结果:6例DH病人HIV阴性,无免疫受抑制基础疾病;主要表现为发热、乏力、消瘦、肝脾肿大,血细胞减少、肝酶升高,胸、腹部影像学异常;依赖骨髓涂片、淋巴结活检确诊;6例病人中初始接受两性霉素B治疗(amphotericin B deoxycholate,Am B)4例、两性霉素B脂质体(liposomal amphotericin B,L-Am B)及伏立康唑各1例,后2例均在1周后改为Am B;Am B日剂量为0.50~0.65 mg/kg时病人耐受良好;总疗程23~60 d,临床效果显著;其后4例病人接受伊曲康唑胶囊巩固治疗15 d^6个月。6例病人均临床痊愈,随访1~7年无复发。结论:所有DH病人为重庆本地居民,无外地旅居史,提示重庆可能为DH自然疫源地之一;DH在免疫正常人群属于少见病,临床表现及常规检查均无特异性,极易误诊、漏诊,对发热待查病人常规行骨髓、淋巴结活检可提高确诊率;在经济欠发达地区,Am B可作为中-重度DH首选药物,及时治疗预后好。Objective：To refine diagnostic ability and therapeutic decisions of clinicians and to come up with some evidence for epidemiological survey of disseminated histoplasmosis（DH）. Methods：A retrospective descriptive study was conducted between 2008 and2014 in the First Affiliated hospital of Chongqing Medical University. The clinical signs,epidemiology,diagnosis,treatment,and outcomes of 6 DH patients confirmed by direct examination of bone marrow smear or lymph node biopsy were retrospectively analyzed.Results：The 6 patient were HIV negative and their CD4 lymphocyte counts were normal. The main clinical signs noted in 6 patients were fever,weight loss,lassitude,lymphadenopathy,hepatosplenomegaly. Laboratory abnormalities including pancytopenia,elevated γ-glutamine transferase（GGT）,alkaline phosphatase（ALP）were common findings. Cultures of blood,bone marrow were all negative. Of the 6 DH cases,5 were confirmed by direct examination of bone marrow smears,1 was confirmed by biopsy of the right axillary lymph node,which revealed necrotizing granulomas,periodic acid-schiff stains were positive for fungi. Antifungal therapy were started on amphotericin B（Am B）in 4 patients,and started on liposomal amphotericin B（L-Am B）or voriconazole in another 2 patients,respectively. Then the 2 latter patients were subsequently switched on day 7 to Am B secondary economic hardship or having no improvement of symptoms. Six patients with gradual escalation up to 0.5-0.65 mg/kg/day for 23-60 days;all of the patient＇s symptoms were found to be significantly improved or disappeared. After that,4 patients transitioned to oral itraconazole of 200 mg for 15 days-6 months.The patients all cured;all patients have been followed up 1-7 years without relapse. Conclusion：Chongqing may be one of the natural epidemics zone of DH. The observed clinical and biological signs of DH do not differ from the literature;clinical symptoms of DH are unspecific and mimicking the features of tuberculosis;the clinicians should therefo

关 键 词：组织胞浆菌病 诊断 治疗 两性霉素B 伏立康唑 

分 类 号：R379.9[医药卫生—病原生物学]