克雷伯杆菌所致肝脏巨大气性脓肿一例报告

目的:分析克雷伯杆菌导致肝脓肿的的可能原因和发病机理,提高诊断的准确性,并对临床治疗提供帮助.方法:本文报道了本院收治的一例肝内罕见巨大气性脓肿,详细分析了其影像学表现特点及临床表现、辅助检查等情况.结果:本病例细菌培养结果为克雷伯杆菌.患者经积极治疗后病情好转.结论:肺炎克雷伯杆菌引起的肝脓肿发病率呈上升趋势,并已经成为细菌性肝脓肿最常见的致病菌.克雷伯杆菌所致的肝脓肿除了有细菌性肝脓肿的普遍表现外,还有其独特的特点.另外,糖尿病是克雷伯杆菌肝脓肿常见的基础疾病,糖尿病患者的肝脓肿往往进展迅速,且早期症状及CT表现多不典型,因此对于感染入院的糖尿病患者应该警惕克雷伯杆菌肝脓肿的发生.     

高毒力肺炎克雷伯菌致病及耐药分子机制研究进展

近年来,肺炎克雷伯菌已成为医院内感染及社区获得性感染的常见致病菌,临床标本分离率仅次于大肠埃希菌。根据毒力特征差异,肺炎克雷伯菌可分为经典肺炎克雷伯菌和高毒力肺炎克雷伯菌2种类型。高毒力肺炎克雷伯菌是引起化脓性肝脓肿的主要病原菌,其感染可出现内源性转移,包括眼、肺和中枢神经系统;此外还与原发性肝外感染有关,包括菌血症、肺炎和软组织感染。值得关注的是,高毒力肺炎克雷伯菌除了导致患者出现严重感染外,目前已出现了碳青霉烯耐药高毒力株,这将为临床诊疗带来更多的挑战。本文就高毒力肺炎克雷伯菌的流行现状、毒力因子(包括荚膜多糖、铁载体系统以及毒力基因)、耐药现状及其主要机制等方面的研究现状进行综述,以期为以后的深入研究提供参考。     

高毒力肺炎克雷伯菌的毒力机制研究进展

肺炎克雷伯菌是一种常见的革兰阴性杆菌,是第二大容易引起院内感染的细菌。高毒力肺炎克雷伯菌(HvKP)又称高黏性肺炎克雷伯,是从传统肺炎克雷伯菌中分离出来的具有高毒力、高黏性的侵袭性细菌,其表现出的高毒力会引起健康人发生侵袭性感染,严重者会危及生命。目前,临床实验室主要通过拉丝实验与传统的肺炎克雷伯菌相鉴别。研究发现,Hv KP的高黏性与其K1、K2、K57等血清型,编码荚膜相关基因及铁载体相关。对HvKP的毒力增强因素以及该菌引起的肝脓肿做简要综述。     

肺炎克雷伯菌血流感染的临床回顾性分析

目的探讨肺炎克雷伯菌血流感染的临床特点、治疗方案和预后。方法对诸暨市人民医院2014年3月-2015年9月诊断为肺炎克雷伯菌血流感染的住院患者临床资料进行回顾性分析。结果 66例肺炎克雷伯菌血流感染患者平均年龄64.6岁,检出前平均住院5.7d。13例(19.7%)合并有其他细菌感染,49例(74.2%)合并其他系统感染。肺炎克雷伯菌血流感染多见于糖尿病(33.3%)、实体肿瘤(30.3%)等免疫力低下疾病,最常见于肝胆外科(24.2%)、内分泌科(16.7%)等科室。患者预后好转47例(71.2%),APACHEⅡ评分为13.78±4.33;死亡19例(28.8%),APACHEⅡ评分为21.10±7.45,两组评分差异有统计学意义(P0.05)。合并其他感染状况与合并神经系统疾病状况病死率更高(P0.05)。结论肺炎克雷伯菌血流感染多见于糖尿病、实体肿瘤等免疫力低下的危重疾病患者,多发生在医院内环境的外科手术操作的科室,容易合并其他系统感染。APACHEⅡ评分可作为判断肺炎克雷伯菌血流感染预后的重要指标。控制其他感染情况可有助于临床防控肺炎克雷伯菌血流感染,改善其预后。     

血液病患者合并阿萨希毛孢子菌菌血症3例并文献回顾

毛孢子菌属是一类有“念珠菌样”特征,在自然界广泛存在的一类条件致病真菌。该类菌可以引起人类皮肤浅部感染、过敏性肺炎,在免疫损伤患者中可引起侵袭性感染,其中阿萨希毛孢子菌在毛孢子菌属中最为常见[1]。恶性血液病患者由于免疫功能受损,长期接受化疗药物并易行静脉置管,是真菌感染的好发人群,有文献报道,毛孢子菌是引起恶性血液病患者播散性感染的除念珠菌属外第二位的酵母菌[2],死亡率可高达75%以上[3]。     

致肝脓肿高毒力肺炎克雷伯菌的表型及分子特征

目的 探究导致肝脓肿高毒力肺炎克雷伯菌的分子特征。方法 用VITEK-2细菌鉴定仪鉴定2014年1月至2016年1月丽水市中心医院肝脓肿患者脓肿穿刺液中分离的细菌。应用拉丝试验鉴定菌株的高黏性,用多位点序列分型(MLST)和血清型分型(K分型)对菌株进行分子分型,并用S1核酸酶脉冲场凝胶电泳(S1-PFGE)对菌株质粒谱进行分析。结果 57例肝脓肿患者接受肝脏脓肿穿刺引流并做脓液培养。44例患者的脓液培养到不同的致病菌,培养阳性率为77.2%。在培养到的44株病原菌中,其中2株为大肠埃希菌,产酸克雷伯菌、金黄色葡萄球菌各1株,而肺炎克雷伯菌为40株,占肝脓肿致病菌的90.9%。40株肺炎克雷伯菌中,拉丝阳性率为67.5%(27/40),K1为主要血清分型,占62.5%(25/40),其次为K2型,占17.5%(7/40)。ST23为主要ST分型,占47.5%(19/40),其次为ST86和ST65,各占7.5%(3/40)。同时发现一些未报道过的致肝脓肿肺炎克雷伯菌新ST分型,如ST218、ST1941、ST76、ST2159、ST660和ST485。40株致肝脓肿肺炎克雷伯菌中总共检测到12种质粒谱,包括带有一个质粒、多个质粒或不带质粒的谱型。其中带有一个近220 kb的质粒谱为主要谱型,共涉及19株菌,占47.5%,12株菌带有一个质粒,大小为140～250 kb。4株菌带有2个或3个质粒,5株菌不含有质粒。结论 拉丝试验和血清学分型不能鉴定所有的高毒力肺炎克雷伯菌;高毒力肺炎克雷伯菌很多为ST23型,但其进化整体上较为分散;高毒力肺炎克雷伯菌菌株可以不携带质粒。     

产超广谱β-内酰胺酶肺炎克雷伯菌血流感染的耐药性、危险因素及临床结局分析

本研究旨在分析107例肺炎克雷伯菌血流感染患者的临床资料,探讨产超广谱β-内酰胺酶(extended-spectrumβ-lactamase,ESBL)肺炎克雷伯菌血流感染的耐药特点、危险因素及临床结局,为防治产ESBL肺炎克雷伯菌血流感染提供临床理论参考。选取2012年1月—2016年6月于深圳市南山区人民医院住院且血培养肺炎克雷伯菌阳性的107例患者,根据药敏结果分成产ESBL血流感染组(20例)和非产ESBL血流感染组(87例)。107例患者血流感染主要继发于肺部感染(38.32%)及泌尿系感染(14.02%),细菌对碳青霉烯类抗生素敏感性好。单因素及logistic回归分析结果显示,医院内感染和入院前有外伤史为产ESBL肺炎克雷伯菌血流感染的危险因素。总体肺炎克雷伯菌血流感染病死率为17.76%,产ESBL组与非产ESBL组之间病死率无显著性差异(25%vs.16.09%)。结果提示,产ESBL不是预测肺炎克雷伯菌血流感染患者死亡的独立危险因素。     

糖尿病与非糖尿病患者社区获得性高毒肺炎克雷伯菌肝脓肿临床及病原学特征比较

高毒力肺炎克雷伯菌(hypervirulent Klebsiella pneumoniae,HvKP)造成侵袭性感染已在全球范围内被广泛报道，其感染者主要集中在患有糖尿病(diabetes mellitus,DM)、慢性肝病等基础疾病的社区人群，且容易发生全身迁徙性感染。本研究收集了本院2013年1月～2018年12月社区获得性肺炎克雷伯菌肝脓肿患者377名，男性占65.8%，其中49.6%有DM。DM患者易发生眼部及中枢神经系统(central nervous system,CNS)感染，治疗过程中更需要持续的局部脓肿引流，其中血糖控制差的患者继发血流感染(bloodstream infections,BSI)的比率更高。共获得HvKP菌株219株，K1/K2血清型占总数81.7%,K2型患者发生BSI的比率高于K1型。PCR检测结果表明，毒力基因(rmpA、areo、kfu、allS、iroN、magA、uge、wcaG)在K1/K2型菌株的携带率明显高于non-K1/K2型，ST23和ST65是最常见的多位点序列分型(multilocus sequence typing, MLS...     

糖尿病性肾病患者泌尿系感染的菌群分布及耐药性

目的探讨糖尿病性肾病患者泌尿系感染的菌群分布及耐药性。方法选取在温岭市第一人民医院就诊的糖尿病性肾病合并泌尿系感染患者共109例,所有患者均收集清洁中段尿进行尿培养及药物敏感试验,分析糖尿病性肾病合并泌尿系感染患者的病原菌分布特点及耐药情况。结果糖尿病性肾病泌尿道感染患者109例共检测出152株病原菌,G~-菌104株,最常见的3种为大肠埃希菌、肺炎克雷伯菌和变形杆菌;G~+菌43株,最常见的3种为金黄色葡萄球菌、肠球菌和表皮葡萄球菌;真菌5株,均为白色念珠菌。主要G~-菌对万古霉素、亚胺培南及阿米卡星的耐药率较低,主要G~+菌对万古霉素、哌拉西林/他唑巴坦、阿莫西林/克拉维酸钾的耐药率较低,真菌对两性霉素B耐药率较低。结论糖尿病性肾病泌尿系感染以G~-菌为主,常规抗生素耐药率高,临床医师应根据耐药性检查及安全性选择合适的抗生素。     

噬菌体治疗肺炎克雷伯菌感染的研究进展

肺炎克雷伯菌是肠杆菌科家族中的一员,在各种环境中广泛存在,可导致诸如奶牛乳房炎在内的多种动物疫病,引起人类的肺炎、尿路感染、菌血症、伤口性感染和化脓性脓肿在内的多种临床感染。该菌对抗生素的耐受日趋严重,而且高毒力菌株不断出现,给该菌的防控带来了巨大挑战。噬菌体是一种裂解细菌的病毒,因其具有治疗耐药细菌感染的潜力而备受关注,世界各地均有使用噬菌体成功治疗耐药细菌感染的案例。本文基于国内外对肺炎克雷伯菌及其噬菌体的研究数据,综述了肺炎克雷伯菌的流行病学调查情况和噬菌体在治疗肺炎克雷伯菌感染方面的应用,以期为基于肺炎克雷伯菌噬菌体的抗菌研究和临床应用提供参考。     

Clinical characteristics and epidemiology of pulmonary pseudallescheriasis

BackgroundSome members of the Pseudallescheria (anamorph Scedosporium) have emerged as an important cause of life-threatening infections in humans. These fungi may reach the lungs and bronchial tree causing a wide range of manifestations, from colonization of airways to deep pulmonary infections. Frequently, they may also disseminate to other organs, with a predilection for the brain. In otherwise healthy patients, the infection is characterized by non-invasive type involvement, while invasive and/or disseminated infections were mostly seen in immunocompromised patients.AimsWe reviewed all the available reports on Pseudallescheria/Scedosporium pulmonary infections, focusing on the geographical distribution, immune status of infected individuals, type of infections, clinical manifestations, treatment and outcome.Results and conclusionsThe main clinical manifestations of the 189 cases of pulmonary pseudallescheriasis reviewed were pneumonia (89), followed by fungus ball (26), and chest abscess (18). Some patients had more than one type of invasive pulmonary manifestations. Among patients with pneumonia, several cases of pneumonia associated with near-drowning (10/89, 11.2%) have also been reported in immunocompetent hosts. Major underlying conditions for non-invasive pulmonary infection were preexisting lung cavities and medical immunosuppression for invasive pulmonary infection. Saprobic airway colonization was mostly seen in patients with mucosal dysfunction, i.e. patients with cystic fibrosis. The mortality rate was closely related to the infection type, being 26.8% in non-invasive type (fungus balls) and 57.2% in invasive type.     

Do Neutrophils Play a Role in Establishing Liver Abscesses and Distant Metastases Caused by Klebsiella pneumoniae?

Serotype K1 Klebsiella pneumoniae is a major cause of liver abscesses and endophthalmitis. This study was designed to identify the role of neutrophils in the development of distant metastatic complications that were caused by serotype K1 K. pneumoniae. An in vitro cellular model was used to assess serum resistance and neutrophil-mediated killing. BALB/c mice were injected with neutrophils containing phagocytosed K. pneumoniae. Serotype K1 K. pneumoniae was significantly more resistant to serum killing, neutrophil-mediated phagocytosis and intra-cellular killing than non-K1 isolates (p<0.01). Electron microscopic examination had similar findings as in the bioassay findings. Intraperitoneal injection of neutrophils containing phagocytosed serotype K1 K. pneumoniae led to abscess formation in multiple sites including the subcutaneous tissue, lung, and liver, whereas no abscess formation was observed in mice injected with non-K1 isolates. The resistance of serotype K1 K. pneumoniae to complement- and neutrophil-mediated intracellular killing results in the dissemination of K. pneumoniae via the bloodstream. Escape from neutrophil intracellular killing may contribute to the dissemination and establishment of distant metastases. Thus, neutrophils play a role as a vehicle for helping K. pneumoniae and contributing to the establishment of liver abscess and distant metastatic complications.     

Review of hepatic abscess from Klebsiella pneumoniae. An association with diabetes mellitus and septic endophthalmitis.

I present the only comprehensive review of hepatic abscess from Klebsiella pneumoniae. The world literature contains 46 individually reported cases and 3 large studies of K pneumoniae liver abscess. The source of the abscesses frequently was not found. Diabetes mellitus was a frequent underlying condition and may predispose patients to the development of liver abscess with this organism. The exact mechanism is unclear, and further investigation is necessary. In addition, extrahepatic metastases, such as septic endophthalmitis, often occurred with serious complications, particularly in patients with diabetes. The association between K pneumoniae liver abscess and diabetes is so close that a search for underlying diabetes mellitus is warranted in all patients with K pneumoniae liver abscess. Fortunately, earlier diagnoses and better treatment modalities have improved the outcome for these patients.     

Tissue invasion by Entamoeba histolytica: evidence of genetic selection and/or DNA reorganization events in organ tropism

Entamoeba histolytica infection may have various clinical manifestations. Nine out of ten E. histolytica infections remain asymptomatic, while the remainder become invasive and cause disease. The most common form of invasive infection is amebic diarrhea and colitis, whereas the most common extra-intestinal disease is amebic liver abscess. The underlying reasons for the different outcomes are unclear, but a recent study has shown that the parasite genotype is a contributor. To investigate this link further we have examined the genotypes of E. histolytica in stool- and liver abscess-derived samples from the same patients. Analysis of all 18 paired samples (16 from Bangladesh, one from the United States of America, and one from Italy) revealed that the intestinal and liver abscess amebae are genetically distinct. The results suggest either that E. histolytica subpopulations in the same infection show varying organ tropism, or that a DNA reorganization event takes place prior to or during metastasis from intestine to liver.     

Lipopolysaccharide O1 antigen contributes to the virulence in Klebsiella pneumoniae causing pyogenic liver abscess

Klebsiella pneumoniae is the common cause of a global emerging infectious disease, community-acquired pyogenic liver abscess (PLA). Capsular polysaccharide (CPS) and lipopolysaccharide (LPS) are critical for this microorganism's ability to spread through the blood and to cause sepsis. While CPS type K1 is an important virulence factor in K. pneumoniae causing PLA, the role of LPS in PLA is not clear. Here, we characterize the role of LPS O antigen in the pathogenesis of K. pneumoniae causing PLA. NTUH-K2044 is a LPS O1 clinical strain; the presence of the O antigen was shown via the presence of 1,3-galactan in the LPS, and of sequences that align with the wb gene cluster, known to produce O-antigen. Serologic analysis of K. pneumoniae clinical isolates demonstrated that the O1 serotype was more prevalent in PLA strains than that in non-tissue-invasive strains (38/42 vs. 9/32, P<0.0001). O1 serotype isolates had a higher frequency of serum resistance, and mutation of the O1 antigen changed serum resistance in K. pneumoniae. A PLA-causing strain of CPS capsular type K2 and LPS serotype O1 (i.e., O1:K2 PLA strain) deleted for the O1 synthesizing genes was profoundly attenuated in virulence, as demonstrated in separate mouse models of septicemia and liver abscess. Immunization of mice with the K2044 magA-mutant (K(1) (-) O(1)) against LPS O1 provided protection against infection with an O1:K2 PLA strain, but not against infection with an O1:K1 PLA strain. Our findings indicate that the O1 antigen of PLA-associated K. pneumoniae contributes to virulence by conveying resistance to serum killing, promoting bacterial dissemination to and colonization of internal organs after the onset of bacteremia, and could be a useful vaccine candidate against infection by an O1:K2 PLA strain.     

Pleuropulmonary manifestations of hepatic amebiasis.

Pleuropulmonary manifestations of hepatic amebiasis occurred in 30 patients; 18 (60%) presented with at least 1 pulmonary complaint and 10 (33%) had multiple pulmonary symptoms. In 14 patients (47%), abnormalities were found on examination of the chest. In 16 chest roentgenograms (53%), there was at least 1 abnormality: right-sided pleural effusion (9 patients) and elevated right hemidiaphragm (8 patients) were the most common. All patients were treated with metronidazole (Flagyl) and had resolution of the amebic liver abscess and pulmonary disease. Pleuropulmonary disease is a common complication of amebic liver abscess. The clinical presentation and chest roentgenograms are virtually diagnostic and obviate the need for invasive procedures to confirm the diagnosis. Pleuropulmonary disease resolves with amebicidal treatment of the hepatic abscess.     

Cutaneous Cryptococccosis Due to Cryptococcus gattii in Immunocompetent Hosts: Case Report and Review

Cutaneous cryptococcosis caused by C. gattii, in immunocompent patients is a rare manifestation of disease, and may be one of the first manifestations of disseminated cryptococcosis. We report a case of disseminated cryptococcosis caused by Cryptococcus gattii presenting as cutaneous lesions in an immunocompetent patient. Previously to our report, only five cases of cutaneous involvement by Cryptococcus gattii in immunocompetent patients have been reported in the literature. Risk factors for C. gattii infection included exposure to the eucalypt reservoirs in tropical and subtropical areas. Skin involvement corresponded to the disseminated form of cryptococcosis in the majority of patients, and commonly affected the face and neck with different morphologies including papules, pustules, plaques, ulcers, subcutaneous masses, cellulitis or acneiform lesions. Due to the severity of this infection and the life threatening condition that it represents, clinicians must be aware that cutaneous involvement may be one of the first manifestations of disseminated cryptococcosis caused by C. gattii especially in patients living and coming from endemic areas.     

麦默通微创手术结合导管冲洗负压引流治疗乳房脓肿的临床效果观察

目的：探讨麦默通微创手术结合导管冲洗负压引流治疗乳房脓肿的临床效果。方法：选择2007年10月~2012年9月在我院治疗的180例乳房脓肿患者,全部在超声定位引导下行麦默通微创手术结合导管冲洗负压引流治疗,并观察其临床效果。结果：180例乳房脓肿患者完全恢复,住院天数6~10天,无1例并发乳瘘。常规病理结果均符合临床诊断。1~2年随访中,临床检查及乳腺B超检查均未发现复发迹象。结论：麦默通微创手术结合导管冲洗负压引流技术治疗乳房脓肿,切口隐蔽,操作简便,治疗彻底,可减少由于反复穿刺引起的感染,尤其适用于脓腔直径较大、位置较深、细针反复穿刺无效或复发者;术后换药冲洗简单易行,换药次数降低,明显减轻了患者痛苦;拔管后切口无需缝合,瘢痕小,并能维持乳房良好形态,提高了病人术后的生活质量,符合当今女性的审美要求。     

The Importance of a Proper Aetiological Diagnosis in the Management of Patients with Invasive Mycoses: A Case Report of a Brain Abscess by <Emphasis Type="Italic">Scedosporium apiospermum</Emphasis>

Scedosporium apiospermum is a saprobic fungus responsible for many different clinical manifestations. Although it affects mostly immunocompromised patients, pulmonary and disseminated scedosporiosis have also been reported in immunocompetent subjects. It often causes subcutaneous mycetoma, despite its preferential tropism to CNS. The authors describe a fatal case of a S. apiospermum brain abscess in a 58-year-old female. She was affected by chronic liver disease and idiopathic pulmonary fibrosis and had been treated with corticosteroid therapy for a long time. She recovered in a neurosurgery unit, wherein TC scan and cerebral MRI revealed an expansive left temporo-parietal process with vasogenic oedema. A stereotactic puncture of the lesion was carried out, and pus of brain abscess was evacuated. Empirical antifungal therapy was initiated with liposomal amphotericine B based on the clinical suspicion of Zygomycetes infection; after 3 days, posaconazole was added. The correct aetiological diagnosis arrived too late and the patient was treated with no specific therapy. This fatal case confirms the necessity of having a fast and correct aetiological diagnosis to improve the patient’s outcome.     

7例不典型肺真菌病的临床分析

目的 肺部真菌感染往往症状不典型,肺部影像学表现多样,缺乏特异性,为早期诊断和治疗带来困难。尤其足近年来无免疫缺陷人群中也出现肺部真菌感染．使临床判断更加复杂。方法 对我院于2006年上半年收治的7例无免疫缺陷的肺部真菌感染病例,从发病特点、临床表现、影像学、病原学、诊断依据以及治疗策略等方面对其进行了详细分析。结果 7例肺真菌病患者均无明显免疫缺陷,肺部影像学表现多样。通过血清学、肺活检、痰培养等方法确诊,对治疗反应均较好。结论 肺真菌病的临床表现趋向复杂多样,临床医生应予以高度重视。