慢性肺曲霉病的诊断与管理

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,慢性肺曲霉病的诊断与管理,江西省人民医院呼吸内科 童波,目录,慢性肺曲霉病的定义,慢性肺曲霉病的临床表现类型,慢性肺曲霉病的诊断,慢性肺曲霉病的管理,总结,目录,慢性肺曲霉病的定义,慢性肺曲霉病的临床表现类型,慢性肺曲霉病的诊断,慢性肺曲霉病的管理,总结,D,efinitions of CPA,The most common form of CPA is,CCPA,.Untreated it may progress to chronic fibrosing pulmonary aspergillosis(,CFPA,).Less common manifestations of CPA include,Aspergillus nodule,and,single aspergilloma,.All these entities are found in non-immunocompromised patients with prior or current lung disease.,Subacute invasive pulmonary aspergillosis,(formerly called chronic necrotising pulmonary aspergillosis)is a more rapidly progressive infection(3 months)usually found in moderately immunocompromised patients.,D.DENNING ET AL.,ESCMID/ERS GUIDELINES,.,Eur Respir J 2015,.,目录,慢性肺曲霉病的定义,慢性肺曲霉病的临床表现类型,慢性肺曲霉病的诊断,慢性肺曲霉病的管理,总结,Present by,David Denning,ECCMID 10,th,May 2015 in Barcelona,慢性曲霉菌病临床表现分类,Clinical phenotypes of chronic,Aspergillus spp diseases,单发曲霉球,Single/simple aspergilloma,慢性坏死性,/,亚急性肺曲霉菌病,Chronic necrotizing pulmonary,aspergillosis(CNPA)or subacute,Invasive aspergillosis(SAI),慢性空腔性肺曲霉菌病,Chronic cavitary pulmonary,aspergillosis(CCPA),慢性纤维化肺曲霉菌病,Chronic fibrosing,pulmonary aspergillosis(CFPA),曲霉菌肉芽肿,Aspergillus nodule(s),CCPA,是最常见的,CPA,类型,CCPA,不治疗可进展为,CFPA,曲霉结节与单纯性曲霉肿较少见,免疫功能受损患者常见,SAIA,CPA,的分类与定义,CCPA-,慢性空洞型肺,曲霉病,;CFPA-,慢性纤维性肺,曲霉病,;,SAIA-,亚急性侵袭性曲霉病,/,慢性坏死性,/,半侵袭性曲霉病,分 类,定 义,单纯性曲霉肿,非免疫功能受损的患者存在含有真菌球的单一肺部空洞，且血清学或微生物学证据提示曲霉属,(,Aspergillus spp.,),感染，无症状或仅有轻微症状，在至少,3,个月的观察期内未出现影像学进展,CCPA,存在,1,个或多个含有,1,个曲霉球或不规则腔内结构的肺部空洞,(,薄壁或厚壁,),，且血清学或微生物学证据提示曲霉属感染，有明显的肺部和,/,或系统症状，在,至少,3,个月的观察期内出现,明显的影像学进展,(,新空洞、空洞外周浸润增加、或纤维化增加,),CFPA,CCPA,并发出现的至少,2,个肺叶出现严重的纤维化破坏并导致大部分肺功能丧失。单个存在空洞的肺叶出现严重纤维化破坏仅代表影响该肺叶的,CCPA,。通常纤维化表现为肺部实变，但也可表现为周围出现纤维化的较大空洞,曲霉结节,一种少见的,CPA,类型，出现,1,个或多个形成或不形成空洞的结节。可与结核球、肺癌、球孢子菌病以及其他疾病相似，只有通过组织学检查才能确诊。尽管常出现坏死，但不会出现组织浸润。,SAIA/CNPA,在,1-3,个月内出现的侵袭性曲霉病,，常发生在存在,轻度免疫功能受损,的患者之中，存在多种影像学特征，包括空洞形成、结节、“脓肿形成”的进展性实变等。受累肺部组织活检可见菌丝，,微生物学检查结果与侵袭性曲霉病一致,，特别是血液,(,或呼吸道液体,),曲霉半乳甘露聚糖抗原阳性,D.DENNING ET AL.,ESCMID/ERS GUIDELINES,.,Eur Respir J 2015,.,Single(simple)pulmonary aspergilloma,is a single fungal ball in a single pulmonary cavity.There is no progression over months of observation and very few,if any pulmonary or systemic symptoms and serological or microbiological evidence implicating Aspergillus spp.,Simple aspergilloma that developed within a post-tuberculous cicatricial atelectasis of the left upper lobe with,saccular bronchiectasis,.Surgical resection by video-assisted thoracic surgery was performed because of recurrent haemoptysis and a requirement for anticoagulant therapy.,D.DENNING ET AL.,ESCMID/ERS GUIDELINES,.,Eur Respir J 2015,.,CCPA,formerly called complex aspergilloma,usually shows multiple cavities,which may or may not contain an aspergilloma,in association with pulmonary and systemic symptoms and raised inflammatory markers,over at least 3 months of observation.Untreated,over years,these cavities enlarge and coalesce,developing pericavitary infiltrates or perforating into the pleura,and an aspergilloma may appear or disappear.Thus serological or microbiological evidence implicating Aspergillus spp.is required for diagnosis.,Chronic cavitary pulmonary aspergillosis showing marked progression between,a)2007,and,b)2012,.Chest radiographs prior to 2007(i.e.1990s)showed“upper lobe fibrosis”,without a firm diagnosis.,A large cavity with pleural thickening is visible on the left in both images,with additional small cavities inferiorly in 2012,and contraction of the left upper lobe.The right side shows interval development of a large cavity,with some pleural thickening.Neither cavity contains a fungal ball.,a),b),Imaging showing,chronic cavitary pulmonary aspergillosis,showing an axial view with a)lung and b)mediastinal windows at the level of the right upper lobe.Multiple cavities are visible with a fungus ball lying within the largest one.The wall of the cavities cannot be distinguished from the thickened pleura or the neighbouring alveolar consolidation.The extra pleural fat is hyperattenuated(white arrows).*:the dilated oesophagus should not be confused with a cavity.,a),b),*,*,CFPA,is often an end result from untreated CCPA.Extensive fibrosis with fibrotic destruction of at least two lobes of lung complicating CCPA,leading to a major loss of lung function.Usually the fibrosis is solid in appearance,but large or small cavities with surrounding fibrosis may be seen.Serological or microbiological evidence implicating Aspergillus spp.is required for diagnosis.One or more aspergillomas may be present.,Imaging of chronic fibrosing pulmonary aspergillosis complicating chronic cavitary pulmonary aspergillosis,which followed,tuberculosis,with mild chronic obstructive pulmonary disease.Complete opacification of the left hemi-thorax developed between February 1998,when a left upper lobe cavity with a fluid level was present,and May 1999.Multiple left lung autopsy percutaneous biopsies showed evidence of chronic inflammation,but no granulomas or fu