骨髓细胞形态学检查及骨髓培养确诊马尔尼菲篮状菌感染一例并文献复习  

A case report of bone marrow smear and culture for the diagnosis of Talaromyces marneffei infection and literature review

作　　者：杨丹 孙兴成 黄正霞 张燕 秦琴 张伟 YANG Dan;SUN Xingcheng;HUANG Zhengxia;ZHANG Yan;QIN Qin;ZHANG Wei(Department of Hematology, The First Affiliated Hospital of the Naval Medical University, Changhai Hospital, Shanghai 200433,P.R.China;Department of Physical Emergency, The First Affiliated Hospital of the Naval Medical University, Changhai Hospital, Shanghai 200433,P.R.China;Department of Pathogenic Microorganism, The First Affiliated Hospital of the Naval Medical University, Changhai Hospital, Shanghai 200433, P.R.China;Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of the Naval Medical University, Changhai Hospital,Shanghai 200433, P.R.China)

机构地区：[1]海军军医大学附属第一医院长海医院血液内科,上海200433 [2]海军军医大学附属第一医院长海医院急诊内科,上海200433 [3]海军军医大学附属第一医院长海医院微生物室,上海200433 [4]海军军医大学附属第一医院长海医院呼吸与危重症医学科,上海200433

出　　处：《中国呼吸与危重监护杂志》2019年第3期236-240,共5页Chinese Journal of Respiratory and Critical Care Medicine

基　　金：国家自然科学基金(81700175);海军军医大学校级教改基金(JYC2017027)

摘　　要：目的回顾分析1例骨髓检查确诊马尔尼菲篮状菌(TM)感染的临床诊疗思路,探讨骨髓细胞形态学检查及骨髓病原学培养在诊断中的作用和意义。方法回顾性分析1例通过骨髓细胞形态学检查及骨髓培养明确诊断的累及多器官的播散型TM感染病例,并通过检索1990年至2018年国内外相关病例报告对TM感染进行文献复习和分析。结果患者男性,23岁,以"反复咳嗽,伴发热"起病,全身多部位浅表淋巴结肿大,胸部CT未见异常,抗感染治疗效果欠佳。后出现进行性腹痛,全身散在分布多部位丘疹,意识减退,血三系进行性下降,于我院行骨髓穿刺术,术后30 min患者出现循环及呼吸功能衰竭,行心肺复苏术成功后,家属即要求转回当地治疗。后HIV初筛结果回报阳性,因骨髓细胞涂片及病原学培养均提示TM而确诊。文献复习共检索TM感染病例2 855例,其中通过血液及骨髓病原学培养确诊的病例占多数,且骨髓培养阳性率显著高于血液培养阳性率,分别为72.4%及66.8%(P=0.007)。骨髓细胞涂片镜检与骨髓培养相比,误诊及漏诊率可达27.6%。通过骨髓相关检查确诊TM感染的患者HIV阳性率最高(95.7%)。结论骨髓细胞形态学检查及病原学培养对TM感染的诊断临床意义重大,对可疑HIV阳性的患者,伴发热、淋巴结肿大、血象异常时需进行TM感染的鉴别。Objective To explore the clinical diagnosis and treatment of Talaromyces marneffei(TM) infection by bone marrow examination, and to clarify the important role and significance of bone marrow smear and pathogenic examination. Methods Retrospective analysis was conducted on a case of disseminated TM infection that was clearly diagnosed through bone marrow related examination. Literature review of TM infection was conducted by retrieving relevant case reports at home and abroad from 1990 to 2018. Results The patient was a 23-year-old man with recurrent cough and onset of fever, superficial lymph node enlargement in multiple parts of the body, no abnormal chest CT sign,and poor efficacy in anti-infection treatment. The patient developed progressive abdominal pain, accompanied by systemic papulosis, decreased consciousness, and progressive decline of blood cells. The patient underwent bone marrow puncture surgery in our hospital, and developed circulatory and respiratory failure half an hour after surgery. TM was confirmed bybone marrow smear and pathogenic culture. In the literature review, 2 855 cases of TM infection were retrieved, among which the majority of cases were confirmed through blood and bone marrow related examination. The positive rate of bone marrow culture was significantly higher than that of blood culture(72.4% and 66.8%, respectively,P=0.007). Compared with bone marrow culture, the misdiagnosis and missed diagnosis rate of bone marrow smear microscopy was 27.6%. Patients diagnosed with TM infection by bone marrow examination had the highest HIV positive rate(95.7%). Conclusions The examination of bone marrow cells and the culture are of great clinical significance for the diagnosis of TM infection. TM infection should be identified in patients suspected of HIV positive with fever, lymph node enlargement and abnormal blood routine.

关 键 词：马尔尼菲篮状菌 骨髓细胞形态学 骨髓培养 

分 类 号：R519[医药卫生—内科学]