侵袭深部真菌病的实验室诊断

,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,侵袭深部真菌病的实验室诊断,侵袭深部真菌病的实验室诊断,第1页,侵袭性真菌病致病菌,条件致病菌,致病性双相真菌,念珠菌 组织胞浆菌,曲霉,球孢子菌,隐球菌 芽生菌,接合菌 马内菲青霉,镰刀菌 孢子丝菌,暗色真菌,酵母菌,毛孢子菌,枝顶孢霉,侵袭深部真菌病的实验室诊断,第2页,侵袭性真菌病,(IFD),主要包含：,念珠菌病,隐球菌病,侵袭性曲霉病,侵袭深部真菌病的实验室诊断,第3页,高危人群,+,高危原因,=IFD,侵袭深部真菌病的实验室诊断,第4页,IFD,高危人群和高危原因,广谱抗生素应用,入住,ICU,血液系统肿瘤病人（,粒缺、骨髓移植）,器官移植,HIV,感染,应用皮质激素,糖尿病,静脉插管,侵袭深部真菌病的实验室诊断,第5页,侵袭深部真菌病的实验室诊断,第6页,尸体解剖中侵袭性真菌感染发生率,78,79,80,81,82,83,84,85,86,87,88,89,90,91,92,0,2,4,6,8,Aspergillus,spp.,Candida,spp,.,All other,Prevalence at Autopsy%,Prevalence of invasive aspergillosis at necropsy at JW Geothe University Hospital,Frankfurt,Germany(Lancet,;335:2076),侵袭深部真菌病的实验室诊断,第7页,54.84%,12.9%,3.23%,9.68%,19.35%,我国西南医院尸解资料，,(1971-),，郝飞教授提供,Aspergillus,Cryptococcus,Mucor,Candida,All others,侵袭深部真菌病的实验室诊断,第8页,侵袭性真菌病流行病学特点,危险原因不停增多，发生率逐年增高趋势，确切资料有待搜集整理,白念珠菌依然是最常见临床分离致病菌,非白念珠菌增加（带来问题）,曲霉已成为主要致死真菌,侵袭深部真菌病的实验室诊断,第9页,真菌感染试验诊疗方法及问题,形态学,检验：,经验？阳性率？,培养,+,判定：时间长，敏感性？,血清学检验：,敏感性？特异性？,分子生物学检验：,标准化？,侵袭深部真菌病的实验室诊断,第10页,真菌抗原、细胞壁成份检测,GM,试验：,血浆、血清、,BAL,、胸水、,CSF,，用于曲霉检测；,G,试验,:,用于曲霉、念珠菌检测，对隐球菌、接合菌无意义；,乳胶凝集试验,:,检测隐球菌；,侵袭深部真菌病的实验室诊断,第11页,新生隐球菌乳胶凝集试验,侵袭深部真菌病的实验室诊断,第12页,血清,GM,作为诊疗早期标志物,Marr and Leisenring Clin Infect Dis;41:S381,侵袭深部真菌病的实验室诊断,第13页,在,BAL,中检测,GM,作为早期诊疗标志,Musher et al.,J Clin Microbiol,:42(12):5517-22,敏感性,(%),特异性,(%),阳性预测,(%),阴性预测,(%),血清,47,93,73,82,BAL,85,100,100,88,Becker et al.,Br J Haematol,;121:448,侵袭深部真菌病的实验室诊断,第14页,关于,GM,试验与,G,试验,可作为推定诊疗标准,;,GM:,检测半乳甘露聚糖，对,曲霉,感染诊疗特异性强，假阳性反应能够在青霉菌属中出现；个别含青霉烷砜衍生物抗菌药品能够诱发阳性反应；,G,试验,:,检测,(1,3)-D-,葡聚糖，在很多真菌中都能够出现阳性反应，但在隐球菌、接合菌、毛霉、根霉呈阴性反应；,侵袭深部真菌病的实验室诊断,第15页,Prospective utility of,(1-3)-B-D-Glucan(BG),galactomannan(GM)and anti-Candida,albicans germ tube antibodies(CAGT),for the diagnosis of invasive fungal disease(IFD)in haemato-oncology adult patients,A.Alhambra1,M.S.Cutara2,J.M.Moreno1,A.Del Palcio Perez-Medel1,I.Moragues3,J.,Pontn3,A.Del Palacio1,1Hospital Universitario Doce de Octubre,MADRID,Spain 2Hospital Universitario Severo,Ochoa,LEGANES,Spain 3Universidad del Pais Vasco,BILBAO,Spain,侵袭深部真菌病的实验室诊断,第16页,Invasive Candidiasis,S SP PPV NPV,CAGT(%)57 93 44 96,BG(%)77 86 39 97,Invasive Aspergillosis,S SP PPV NPV,GM(%)92 94 73 98,BG(%)57 84 42 91,侵袭深部真菌病的实验室诊断,第17页,CONCLUSIONS,The incidence of IFD correlated directly and significantly(x2 p=0.0005)with risk stratification group:highest proportion in the high-risk group.,Since all the biomarkers have inherent limitations,a better diagnosis yield is achieved,combining the biomarkers.,All three biomarkers share,high negative predictive value,and can exclude reasonably IFD in haematology adult patients treated with wide spectrum antifungals.,侵袭深部真菌病的实验室诊断,第18页,Evaluation of two serologic test for diagnosis invasive Aspergillosis,C.Castro,A.Romero,A.Aller,T.Gonzalez,A.Gonzlez,E.Martn-Mazuelos,H.U.Valme,SEVILLA,Spain,侵袭深部真菌病的实验室诊断,第19页,A total of 236 sera from 51 patients in risk of IA were tested for,GM,using Platelia Aspergillus kit(Bio Rad,France)which 36 sera(10 patients)were tested for,BG,also using Fungitell kit(Associates of Cape Cod.,USA).,Patients were attended at the University Hospital of Valme from Seville from January of to December.,Patients with,GM index 0.5 in two consecutive samples,have been marked as GM positive and samples with results,80pg/ml were marked as BG positive,.All GM positive patients were classified according to EORTC/MSG criteria()for probability of IA.,侵袭深部真菌病的实验室诊断,第20页,GM test,From 51 patient studied,16 of them showed at least one positive specimen(33 sera).,Only 6 patients showed two consecutive positive results(0.5 GM test)and they show clinical signs or microbiological criteria for AI proven(3 patients)and probable(3 patients).,侵袭深部真菌病的实验室诊断,第21页,BG assay,The BG assay were used in parallel with GM in 36 sera which 26 showed positive result from 9 patients,(3 with AI proven and 6 AI probable).,3 patients showed positive results before for BG test(3,5 days)and 6 patients presented simultaneously both antigens.Never the GM test was the first serological test to show a positive result.,G,试验阳性,9,名患者中，,G,试验单独阳性有,3,个病人，两种抗原同时阳性有,6,个病人，未出现单独,GM,试验阳性情况。,侵袭深部真菌病的实验室诊断,第22页,Conclusion,Calculating significant sensitivity for both detection methods was not feasible due to a low number of proven/probable AI.,BG detection showed positive results before GM test and present the great advantage to be a,“panfungal”antigen.BG detection should be used with other techniques for detection of invasive Aspergillosis infections.,侵袭深部真菌病的实验室诊断,第23页,真菌细胞壁结构示意图,侵袭深部真菌病的实验室诊断,第24页,深部真菌感染患者血浆,1-3-D,葡聚糖检测,病例选择 深部真菌感染患者,35,例，年 龄,12,88,岁，来自我院,年,1,月到,5,月住院患者，均经培养证实存在深部真菌感染，感染部位包含呼吸道、泌尿道、血液及静脉插管引发系统性感染。正常健康对照组,30,人，来自我院健康查体者。,第四军医大学,侵袭深部真菌病的实验室诊断,第25页,检测结果,正常对照组血浆,1-3-D,葡聚糖含量最高为,7.29 pg/ml,，最低为,0.45 pg/ml,，平均值为,2.832.57pg/ml,；,深部真菌感染组血浆,1-3-D,葡聚糖含量最高为,168.9 pg/ml,，最低为,14.93pg/ml,，平均值为,54.0636.13 pg/ml,。,经,SPSS,统计软件,T-,检验分析，对照组与深部真菌感染组,1-3-D,葡聚糖平均值差异非常显著（,t=7.741,P,0.001,）。,侵袭深部真菌病的实验室诊断,第26页,讨论,入选深部真菌感染患者均经细菌培养证实为念珠菌感染，包含白色念珠菌,23,株、热带念珠菌,8,株、季也蒙念珠菌,1,株、克柔念珠菌,1,株和光滑球拟假丝酵