非人类免疫缺陷病毒感染者卡氏肺孢子虫所致机械通气相关性肺炎五例

目的提高临床对非人类免疫缺陷病毒(HIV)感染者罹患卡氏肺孢子虫(PC)所致机械通气相关性肺炎(VAP)的认识。方法回顾性分析我院南楼临床部2000年10月-2003年10月收治的5例非HIV感染者PC所致VAP的临床资料。结果5例患者均为男性,年龄71-93岁,均有严重的基础疾病,均因肺部感染诱发严重呼吸衰竭,经人工气道长期应用机械通气,机械通气期间反复发生VAP,并因此长期反复应用多种广谱抗生素。5例患者均有发热,大多伴有明显的呼吸道症状,4例肺部听诊可闻及湿罗音。5例患者中有4例x线胸片显示两肺弥漫性斑片影,另1例右肺密度普遍增加;2例有网状纹理,2例胸水增加。5例患者中有4例痰找PC和PCPCR阳性;另1例痰PCPCR阳性,痰找PC阴性。5例患者HIV抗体均阴性。确诊PCP后,5例患者在原有治疗的基础上加用或单用复方新诺明(SMZeo),4例治愈,复查痰找PC和PCPCR均阴性,目前尚未发现有重新阳性者。1例死亡。结论老年、反复应用广谱抗生素或糖皮质激素、恶性肿瘤晚期者,即使没有HIV感染,在长期应用呼吸机期间,发生PC所致VAP是可能的。     

艾滋病并发结核病的相关性及肺部X线表现

目的 探讨艾滋病(HIV／AIDS)并发肺结核病的肺部X线表现特点。方法 分析确诊艾滋病并发肺结核病患者l3例临床肺部X线表现。结果 HIV抗体阳性l3例；末梢血白细胞总数正常或降低；血、痰培养结核菌阳性5例．纤支镜检查并组织学证实结核5例，PPD试验阴性。肺部X线表现为片状融合性渗出病灶．10例位于肺下叶．3例位于上叶尖后段．密度均匀者8例．密度不均匀者5例；均未见空洞形成。结论 HIV感染后,CD4^-T淋巴细胞明显减少．导致发生活动性结核。结核病也可使HIV感染者发展为AIDS。其肺部片状肺炎样改变应警惕并发肺结核病的可能。     

老年肺曲霉菌病5例临床分析

目的 对5例老年肺曲霉菌病进行临床分析，以提高临床对老年高危患者肺曲霉菌病的认识。方法 对我院南楼呼吸科2005年11月至2006年10月收治的5例肺曲霉菌病的临床资料进行分析。结果 5例患者均为男性，年龄68～86岁，1例表现为间断痰中带血，胸部CT呈现游走性肺浸润影，诊断为“变应性支气管肺曲菌病”，经糖皮质激素及伊曲康唑治疗后，治愈。其余4例患者体温均〉38．0℃，均有慢性基础疾病，有长期使用多种广谱抗生素病史；长期应用糖皮质激素，长时间使用机械通气，长期全胃肠外营养等情况各3例；3例患者的咯血及痰中带血，胸片均存在肺部浸润影；1例连续2次痰培养为曲霉菌；1例痰病理可见大量曲霉菌团；2例生前无微生物学及组织病理学依据，尸检时组织病理学可见曲霉菌。4例患者被确诊为“侵袭性肺曲菌病”。2例生前确诊患者，应用抗真菌治疗后，痰菌转阴。结论 高龄老年患者，长期应用广谱抗生素和（或）糖皮质激素，长期机械通气，长期胃肠外营养的患者，应警惕肺曲霉菌感染的可能性。     

HIV阴性免疫损害成人的卡氏肺孢子虫肺炎

为了解卡氏肺孢子虫肺炎(PCP)在病人中的危险性及评估化学预防的可能作用,作者于90年1月至93年4月应用间接免疫荧光法在悉尼对1002份住院病人的呼吸道标本(包括咳痰、诱生痰、支气管肺泡灌洗液、肺活检标本),进行肺孢子虫检测。确诊的PCP为92例,其中HIV阳性者64例,HIV阴性者28例。HIV阴性患者中肾移植者9例,肝移植者6例,与血液系统有关的恶性肿瘤患者4例(多发性骨髓瘤2例,Hodgkin′s病1     

长期住院机械通气老年患者卡氏肺囊虫肺炎的诊治

目的提高对老年人长期住院机械通气患者卡氏肺囊虫(PC)肺炎的认识。方法对5例长期住院的老年机械通气PC肺炎患者进行回顾性临床分析。结果5例PC肺炎患者由临床表现、胸部X线和CT征像、血气分析、痰PC多聚酶链反应法(PCR)检测(+)或姬姆萨染色找到PC而确诊肺炎。5例中4例长期机械通气,占同期>15d机械通气121例的41%,占>6个月机械通气28例的143%,机械通气时间越长,PC肺炎发病率越高。复方新诺明(SMZco)是治疗PC肺炎首选药物,本组剂量为口服980mg,2次/d,2～3周为1个疗程。所有患者均有效而无副反应。结论PC肺炎是老年人长期住院机械通气肺机会感染之一,痰PCR(+)或痰姬姆萨染色找到PC而确诊,并与其他肺机会性感染相鉴别。为维持较好的疗效和减少副作用,SMZco在老年患者剂量应略小于年轻人。     

艾滋病合并耶氏肺孢子虫(菌)肺炎的实验室诊断

采用吉氏染色法检查艾滋病患者有耶氏肺孢子虫(菌)肺炎临床表现者痰液和支气管肺泡灌洗液(BALF)中的耶氏肺孢子虫(菌)。抽取部分留痰患者(500例)血液,检测CD4+淋巴细胞。结果显示,痰液标本耶氏肺孢子虫(菌)的阳性率(46.8%,845/1 806)显著低于BALF标本(55.8%,106/190)(P<0.05)。耶氏肺孢子虫(菌)阳性患者有临床症状的比例(96.6%,816/845)显著高于阴性者(64.0%,615/961)(P<0.05)。患者血液中CD4+淋巴细胞数量越少,耶氏肺孢子虫(菌)阳性率越高,CD4+细胞数量>200×106/L组、200×106/L～100×106/L组和<100×106/L组的耶氏肺孢子虫(菌)阳性率分别为12.0%(6/50)、39.0%(39/100)和54.6%(191/350)(P<0.05)。吉氏染色法是较好的检查耶氏肺孢子虫(菌)的方法,简单易行,容易推广,但需积累经验。     

99例AIDS患者痰液卡氏肺孢子虫PCR检测结果分析

目的 采用巢式PCR检测对AIDS患者痰液标本进行卡氏肺孢子虫检测,为AIDS患者合并卡氏肺孢子虫肺炎的临床诊断提供参考价值.方法 将我院感染科2008年1月至10月收治的具有呼吸道症状的99例AIDS患者痰液标本进行收集,将痰标本进行镜检,巢式PCR扩增卡氏肺孢子虫基因,并且对99例患者进行临床诊断和实验室诊断.结果 99例AIDS患者中,临床诊断卡氏肺孢子虫仅2例;油镜下观察到卡氏肺孢子虫4例;PCR痰阳性共43例,取其中4例成功扩增出耶氏肺孢子菌基因.结论 采用巢式PCR对AIDS患者痰液标本进行检测,可以早期诊断卡氏肺孢子虫,减少卡氏肺孢子虫肺炎患者的漏诊率.     

聚合酶链反应方法检测诱导排痰标本对卡氏肺孢子虫肺炎的诊断价值

目的 评价聚合酶链反应方法检测诱导排痰标本中卡氏肺孢子虫DNA对卡氏肺孢子虫肺炎（PCP）的诊断意义。方法 分别用姬姆萨和六胺银（GMS）两种染色方法和mt-rRNA-PCR方法检测痰液中的卡氏肺孢子虫。结果 化学染色法检测16例临床拟诊PCP的患者痰标本。结果 8例阳性,20例非PCP患者痰标本均为阴性,化学染色方法的敏感性和特异性分别为50％和100％。PCR方法检测16例临床拟诊PCP患者痰液中卡氏肺孢子虫,14例阳性,20例非PCP患者痰标本均为阴性,mt-rRNA-PCR方法的敏感性和特异性分别为88％和100％。结论 姬姆萨和GMS两种细胞化学染色方法联合检测痰标本卡氏肺孢子虫,特异性高,但敏感性偏低。mt-rRNA-PCR检测痰标本中卡氏肺孢子虫DNA方法敏感性高于化学染色法且特异性高,更适于临床应用。     

11例肺炎型肺癌的误诊及其影像学特点分析

目的探讨肺炎型肺癌误诊原因和其影像学特点。方法分析11例被误治为其他疾病的肺炎型肺癌患者的临床资料,分析讨论误诊误治经过和影像学（x线摄片、cT扫描）特点。结果肺炎型肺癌的临床表现主要是咳嗽、咳痰,x线表现致密浸润阴影、斑片状阴影,cT扫描大片状致密阴影和小结节影等。9例患者被误诊为局灶性肺炎,2例被误诊为肺结核,经抗炎、抗结核等治疗无好转,后经反复痰液脱落细胞学检查、纤支镜活检、经皮肺穿刺活检等措施确诊。结论肺炎型肺癌极易误诊为局灶性肺炎,确诊需结合影像学检查、纤支镜活检、痰脱落细胞学检查、经皮肺穿刺活检等综合措施。     

原发性呼吸道淀粉样变四例

例 1　 患者女 ,4 9岁。因反复咳嗽 咳痰 咯血 2 0余年 ,喘憋伴声音嘶哑 10年于 1999年入院。患者入院前 7年曾因声音嘶哑于我院行声带息肉摘除术。体检 :声音嘶哑 ,听诊闻及右肺呼吸音较左肺低 ,双肺可闻及呼气性哮鸣音。血常规、肝肾功能、类风湿因子、抗中性粒细胞胞浆抗体、血浆蛋白电泳、免疫球蛋白定量、尿本周蛋白及自身免疫性疾病相关血清学检查均未见异常。反复多次痰脱落细胞学检查及痰找抗酸杆菌均阴性。心电图、肝肾超声检查未见异常。胸部X线示双肺纹理增重、紊乱 ;CT示右肺中叶片状模糊影。肺功能检查示阻塞性通气功能障…     

A case of Pneumocystis jiroveci pneumonia that presented with cavity and cystic changes in a malignant thymoma patient]

A 53-year-old man had received various chemotherapy and steroid treatments for malignant thymoma. He had demonstrated persistent fever since the beginning of January 2006, and chest radiograph showed consolidation in the left middle lung fields. Bacterial pneumonia was suspected, but antibiotics were not effective. He was referred and admitted to our hospital on January 16. Chest radiograph and CT scan on admission showed diffuse ground-glass opacities, consolidation with cavity, and cystic changes. Pneumocystis jiroveci Pneumonia was diagnosed by examination of alveolar lavage. This patient was regarded as immunodeficient because of steroid treatment, low counts of CD4-positive lymphocytes, and the complication of hypogammagloblinemia. We reported this case of a non-HIV patient with atypical images demonstrating Pneumocystis jiroveci pneumonia.     

甲型H1N1流感合并肺炎患者临床和影像学表现分析

目的探讨甲型H1N1流感合并肺炎临床和影像学表现。方法分析本院2009年9～2010年3月临床确诊24例甲型H1N1流感合并肺炎患者临床和影像学资料。结果 18例胸片均表现为肺纹理增多,6例表现为单肺斑片状影。CT显示6例单侧肺部炎性渗出影,12例双侧肺部炎性渗出影,4例弥漫性棉絮状病变;2例实质间质混合渗出。12例甲型H1N1流感合并肺炎患者出院1个月做CT检查,7例完全恢复正常;3例斑片状密度增高影2月后复查CT完全吸收;2例纤维条索影。结论影像学表现对于确定病变范围、病程发展变化和治疗后动态观察具有非常重要的参考价值。     

重症监护室医院获得性肺炎发病及预后危险因素分析

目的 了解教学医院监护室（ＩＣＵ）内获得性肺炎的发病及预后危险因素，为制定相应防治措施作参考。方法 以近２年上海中山医院外科监护室（ＳＩＣＵ）、呼吸监护室（ＲＩＣＵ）及华山医院综合监护室（ＧＩＣＵ）１０８例医院获得性肺炎及同期各ＩＣＵ未发生肺为的５０例患为对象，采用回顾性病例对照分析，用ＳＰＳ软件，作Ｌｏｇｉｓｔｉｃ回归，筛选和分析ＩＣＵ相关危险因素。结果 综合分析医院内获得性肺炎（ＨＡＰ）发病     

Role of CD8 lymphocytes and neutrophilic alveolitis in Pneumocystis jiroveci pneumonia

We described the characteristics of bronchoalveolar inflammatory cells and their correlation with lung injury in patients with Pneumocystis jiroveci pneumonia.We reviewed all cases of patients with Pneumocystis jiroveci pneumonia in newly diagnosed HIV infected patients admitted to a large metropolitan referral hospital during June 2003 to December 2004. Nine patients (5M, 4F) with Pneumocystis jiroveci pneumonia diagnosed with bronchoscopy and cytological examination of bronchoalveolar lavage (BAL) were identified. There was a positive correlation between peripheral CD8 count and BAL neutrophilia and negative correlation with hypoxemia. Although the number patients in this case series is small, our findings suggest that CD8 cells and alveolar neutrophilic inflammation have a role in lung injury in Pneumocystis jiroveci pneumonia. These findings are consistent with data from animal studies.     

Unusual presentation of pneumocystis pneumonia in an immunocompetent patient diagnosed by open lung biopsy

Pneumocystis pneumonia (PCP) is the most common opportunistic infection in acquired immune deficiency syndrome (AIDS) patients. It is a fungal infection with Pneumocystis jiroveci which can be isolated from bronchoalveolar lavage of healthy subjects. The infection occurs mainly in HIV patients; with CD4 lymphocyte count drop to less than 200 cells/μL. PCP has been reported in non-HIV patients with other risk factors such as immunosuppressive medications, malignancies, and other inflammatory conditions. PCP has been rarely reported in immunocompetent subjects. However, in most of these patients, PCP occurred after a period of acute illness with bacterial pneumonia and antibiotic therapy. In this report, we describe a case of PCP in an immunocompetent patient with nonreactive HIV and no immunosuppressive risk factors. The patient had large pulmonary nodules discovered incidentally on chest film as preoperative evaluation for hip surgery. Bronchoalveolar lavage, transbronchial biopsies (TBB), and computed tomography (CT) guided needle biopsy were all negative for P. jiroveci. PCP diagnosis was made after open lung biopsy and wedge resection. To our knowledge, this is the first case of PCP in immunocompetent patient with negative BAL, TBB and CT guided biopsy. The diagnosis of PCP required open lung biopsy and the patient recovered without complications.     

Clinicopathologic study of various lung diseases with bronchiolitis obliterans organizing pneumonia (BOOP) pattern in open lung biopsy]

The histologic findings of BOOP are nonspecific, and the diagnosis of idiopathic BOOP is one of exclusion. We studied the clinicopathologic features of various lung diseases with histopathological appearance of bronchiolitis obliterans organizing pneumonia (BOOP) pattern in open lung biopsy specimens. The 17 patients with BOOP pattern studied included idiopathic BOOP (n = 7), unclassified interstitial pneumonia (n = 1), collagen vascular disease (n = 3, RA 1, PM/DM 2), hypersensitivity pneumonitis (HP, n = 2), eosinophilic pneumonia (EP, n = 1), multiple lung abscesses (n = 1), limited form of Wegener's granulomatosis (n = 1), and pneumocystis carinii pneumonia associated with adult T cell leukemia (n = 1). There were no differences in clinical symptoms, laboratory data, respiratory function, and cytological findings in bronchoalveolar lavage fluid (BALF) between cases of idiopathic BOOP and other lung diseases. The duration of clinical symptoms was less than one year in 16 patients (one case had no symptoms). Chest X-rays showed bilateral patchy, nodular, or reticular shadows in all cases. Multiple patchy migratory shadows were only observed in cases of idiopathic BOOP or EP. Organizing pneumonia was recognized in the transbronchial lung biopsy specimens of all patients with idiopathic BOOP, HP or EP. Regarding prognosis, relapses occurred in idiopathic BOOP (n = 5), polymyositis, EP, limited form of Wegener's granulomatosis, and Pneumocystis carinii pneumonia. Four patients with idiopathic BOOP relapsed when steroid therapy was decreased or stopped. These findings indicate that idiopathic BOOP should be differentiated from other lung diseases, and these patients should be followed for a long period of time.     

卡氏肺囊虫肺炎临床诊治的初步体会

目的提高对卡氏肺囊虫肺炎（ＰＣＰ）的认识。方法回顾性分析６例ＰＣＰ患者资料。结果６例ＰＣＰ基础疾病为白血病、淋巴瘤、肾移植和溶血性贫血。临床表现为呼吸困难、咳嗽和发热。Ｘ线表现为双肺弥漫性肺泡性或间质性改变或无改变。治疗首选复方新诺明（ＳＭＺｃｏ）和氨苯砜。３例并发呼吸衰竭，表现与成人呼吸窘迫综合征（ＡＲＤＳ）相似的低氧血症、肺内分流和顺应性下降。持续气道正压通气／呼气末正压通气（ＣＰＡＰ／ＰＥＥＰ）为常用模式。顽固性低氧血症可试用高水平（＞１４７ｋＰａ）ＰＥＥＰ治疗。结论卡氏肺囊虫肺炎并发急性呼吸衰竭者预后差，争取早期诊断与治疗是提高生存率的关键。     

Characterization of Cytomegalovirus Lung Infection in Non-HIV Infected Children

Cytomegalovirus (CMV) is a prevalent pathogen in the immunocompromised host and invasive pneumonia is a feared complication of the virus in this population. In this pediatric case series we characterized CMV lung infection in 15 non-HIV infected children (median age 3 years; IQR 0.2–4.9 years), using current molecular and imaging diagnostic modalities, in combination with respiratory signs and symptoms. The most prominent clinical and laboratory findings included cough (100%), hypoxemia (100%), diffuse adventitious breath sounds (100%) and increased respiratory effort (93%). All patients had abnormal lung images characterized by ground glass opacity/consolidation in 80% of cases. CMV was detected in the lung either by CMV PCR in bronchoalveolar lavage (82% detection rate) or histology/immunohistochemistry in lung biopsy (100% detection rate). CMV caused respiratory failure in 47% of children infected and the overall mortality rate was 13.3%. Conclusion: CMV pneumonia is a potential lethal disease in non-HIV infected children that requires a high-index of suspicion. Common clinical and radiological patterns such as hypoxemia, diffuse adventitious lung sounds and ground-glass pulmonary opacities may allow early identification of CMV lung infection in the pediatric population, which may lead to prompt initiation of antiviral therapy and better clinical outcomes.