论文部分内容阅读
目的为临床诊治马尔尼菲青霉菌病(PSM)浆膜侵犯出现的浆膜腔积液提供经验。方法回顾性分析2001年3月至2008年3月在广西医科大学第一附属医院住院确诊为PSM患者(61例)中出现胸膜腔、腹膜腔、心包腔积液或脑脊液异常的10例临床资料。结果(1)临床表现胸腔积液10例,其中同时合并有心包积液2例、腹腔积液5例、脑脊液异常2例。误诊为结核性胸膜炎10例,曾行抗结核治疗,同时误诊为结核性脑膜炎2例,结核性心包炎2例,结核性腹膜炎5例,癌性胸腔积液5例。(2)所有患者均有发热、贫血、乏力、消瘦等症状。其中咳嗽9例,胸痛8例,呼吸困难6例,腹泻2例,腹痛3例。坏死性丘疹5例,皮下脓肿、结节8例,淋巴结肿大9例,肝脾肿大9例,湿性啰音7例。(3)白细胞总数增高9例,以中性粒细胞总数[(17.6±5.3)×109/L]及比值(0.841±0.048)显著增高为主,淋巴细胞比值相对降低(0.976±0.035),但总数正常(1.59±0.7)×109/L。(4)所有患者人免疫缺陷病毒(HIV)阴性,CD4/CD8比值1.19±0.38。(5)A/G倒置10例,胆红素增高6例,肾功能异常5例,红细胞沉降率增快10例,C反应蛋白(CRP)增高10例。(6)所有病例均有病原学依据,其中血培养5例,骨髓培养2例,痰培养1例,脓肿分泌物培养4例,组织病理4例。(7)影像检查肺部有实质性异常10例,肝脾肿大或腹主动脉旁淋巴结肿大9例,溶骨性破坏6例。(8)浆膜腔积液性质为渗出液,表现为混浊的黄色或血性外观,细胞数明显增高,以中性粒细胞为主,蛋白增高。(9)4例抗真菌治疗好转,死亡3例,死于呼吸衰竭、心力衰竭、肝肾功能衰竭。恶化2例、1例未治自动出院。结论PSM浆膜腔侵犯常发生于免疫功能正常者,临床上表现以中性粒细胞显著增高的慢性化脓性感染性疾病,侵犯肺部、腹部器官及脑膜时常常同时伴有胸腹腔积液及脑脊液异常,其性质符合炎症性积液,有效抗真菌治疗可完全吸收,临床转归与全身状态相关。
Objective To provide experience in the diagnosis and treatment of serosal effusion in the clinical diagnosis and treatment of penicillium marneffei (PSM) serosal invasion. Methods A retrospective analysis of 10 cases of pleural cavity, peritoneal cavity, pericardial effusion or cerebrospinal fluid abnormalities in hospitalized patients with PSM (61 cases) admitted to the First Affiliated Hospital of Guangxi Medical University from March 2001 to March 2008 was retrospectively analyzed . Results (1) The clinical manifestations of pleural effusion in 10 cases, of which at the same time combined pericardial effusion in 2 cases, 5 cases of ascites, cerebrospinal fluid abnormalities in 2 cases. Misdiagnosed as tuberculous pleurisy in 10 cases, had anti-TB treatment, while misdiagnosed as tuberculous meningitis in 2 cases, tuberculous pericarditis in 2 cases, tuberculous peritonitis in 5 cases, 5 cases of cancerous pleural effusion. (2) All patients had fever, anemia, fatigue, weight loss and other symptoms. Among them, 9 were coughing, 8 were chest pain, 6 were dyspnea, 2 were diarrhea and 3 were abdominal pain. 5 cases of necrotic papules, subcutaneous abscess, nodules in 8 cases, 9 cases of lymphadenopathy, hepatosplenomegaly in 9 cases, 7 cases of wet rales. (3) The total number of leukocytes increased in 9 cases, with the total number of neutrophils [(17.6 ± 5.3) × 109 / L] and the ratio (0.841 ± 0.048) significantly increased, while the lymphocyte ratio decreased (0.976 ± 0.035) The total number of normal (1.59 ± 0.7) × 109 / L. (4) All patients were negative for human immunodeficiency virus (HIV), with a CD4 / CD8 ratio of 1.19 ± 0.38. (5) A / G was inverted in 10 cases, bilirubin increased in 6 cases, renal dysfunction in 5 cases, erythrocyte sedimentation rate increased in 10 cases and increased C-reactive protein (CRP) in 10 cases. (6) All cases were etiologically based, including 5 blood culture, bone marrow culture in 2 cases, sputum culture in 1 case, abscess secretion in 4 cases, histopathology in 4 cases. (7) Imaging examination There were 10 cases of abnormal lung, 9 cases of hepatosplenomegaly or para-aortic lymph node enlargement and 6 cases of osteolytic destruction. (8) The effusion of serosal cavity is exudative, showing turbid yellow or bloody appearance. The number of cells is obviously increased, mainly neutrophils, and the protein is increased. (9) 4 cases of antifungal therapy improved, 3 died, died of respiratory failure, heart failure, liver and kidney failure. 2 cases of exacerbation, 1 case not discharged automatically. Conclusions The PSM serosal invasion frequently occurs in patients with normal immune function. In clinical manifestations, chronic suppurative infectious diseases with markedly increased neutrophil granuloma are frequently accompanied by pleural and peritoneal effusion when invading the lungs, abdominal organs and meninges Cerebrospinal fluid abnormalities, its nature in line with inflammatory effusion, effective antifungal therapy can be completely absorbed, clinical outcome and systemic status.