ECCMID 曲霉菌指南简介 慢性肺曲霉菌病感染

EFISGEuropeanSocietyofClinicalMicrobiologyandInfectionDiseasesESCMIDFungalInfectiousStudyGroupOnlyforinternallearningordiscussion,forbiddenforanyotherpurposeEFISGEuropeanSocietyofClinicalMicrobiologyandInfectionDiseasesESCMIDFungalInfectiousStudyGroupOnlyforinternallearningordiscussion,forbiddenforanyotherpurpose2014ESCMID曲霉菌病治疗指南-慢性肺曲霉病2014ESCMIDAspergillusGuideline-ChronicPulmonaryAspergillosisPresentbyDavidW.Denning[UnitedKingdom]ECCMID10thMay2015inBarcelona)欧洲临床微生物与感染性疾病学会(ESCMID,EuropeanSocietyofClinicalMicrobiologyandInfectiousDiseases)滨州医学院附属烟台海港医院急诊科王功军EFISGEuropeanSocietyofClinicalMicrobiologyandInfectionDiseasesESCMIDFungalInfectiousStudyGroupOnlyforinternallearningordiscussion,forbiddenforanyotherpurposePresentbyDavidDenningECCMID10thMay2015inBarcelona慢性肺曲霉菌病-疾病分类ChronicPulmonaryAspergillosis-subsets•单发曲霉球Simple/singleAspergilloma•曲霉肉芽肿病Aspergillusnodule(s)•慢性空腔曲霉菌病/复杂曲霉球病ChronicCavitaryPulmonaryAspergillosis/ComplexAspergilloma(CCPA)•慢性纤维化肺曲霉菌病ChronicFibrosingPulmonaryAspergillosis(CFPA)•亚急性侵袭性/半侵袭性/慢性坏死性肺曲霉菌病Subacuteinvasive(SIA)/Semi-Invasive/ChronicNecrotizingPulmonaryAspergillosis(CNPA)注：真菌球（曲霉球）可出现在以上除曲霉菌肉芽肿之外的任意一种情况中–fungalballs(aspergilloma)maybeseeninanyoftheseconditions,exceptAspergillusnoduleEFISGEuropeanSocietyofClinicalMicrobiologyandInfectionDiseasesESCMIDFungalInfectiousStudyGroupOnlyforinternallearningordiscussion,forbiddenforanyotherpurposePresentbyDavidDenningECCMID10thMay2015inBarcelona慢性曲霉菌病临床表现分类ClinicalphenotypesofchronicAspergillussppdiseases单发曲霉球Single/simpleaspergilloma慢性坏死性/亚急性肺曲霉菌病Chronicnecrotizingpulmonaryaspergillosis(CNPA)orsubacuteInvasiveaspergillosis(SAI)慢性空腔性肺曲霉菌病Chroniccavitarypulmonaryaspergillosis(CCPA)慢性纤维化肺曲霉菌病Chronicfibrosingpulmonaryaspergillosis(CFPA)曲霉菌肉芽肿Aspergillusnodule(s)EFISGEuropeanSocietyofClinicalMicrobiologyandInfectionDiseasesESCMIDFungalInfectiousStudyGroupOnlyforinternallearningordiscussion,forbiddenforanyotherpurposePresentbyDavidDenningECCMID10thMay2015inBarcelona不同类型的慢性曲霉菌病DifferentpatternsofCPA曲霉菌肉芽肿Aspergillusnodule(s)单发曲霉球Single/simpleaspergilloma慢性空腔性肺曲霉菌病Chroniccavitarypulmonaryaspergillosis(CCPA)慢性纤维化肺曲霉菌病Chronicfibrosingpulmonaryaspergillosis(CFPA)EFISGEuropeanSocietyofClinicalMicrobiologyandInfectionDiseasesESCMIDFungalInfectiousStudyGroupOnlyforinternallearningordiscussion,forbiddenforanyotherpurpose慢性肺曲霉菌病-诊断标准ChronicPulmonaryAspergillosis–Diagnosticcriteria需要满足以下条件：1.1CT影像学表现为肺部真菌球或胸腔内空腔，或支气管扩张CharacteristicCTappearanceofafungusballinapulmonaryorpleuralcavity,ordilatedbronchus,+1.2任何与曲霉菌感染相关的直接或间接的微生物证据AnydirectorindirectmicrobiologicalevidenceofAspergillusinfection(seebelow).,或：2.1影像学特征持续表现为慢性肺曲霉菌病（包括空腔，胸膜增厚，严重的纤维化或肉芽肿）Radiologicalfeaturesconsistentwithchronicpulmonaryaspergillosis(includingcavity(ies),pleuralthickening,extensivefibrosisornodule)+2.2患者的临床表现和影像学证据至少存在3个月以上时间[注意半侵袭性/慢性坏死性肺曲霉病的疾病疗程相对CPA较短，可逐渐演化成慢性肺曲霉病]Clinicalorradiologicalevidenceofatleast3monthsdisease(sometimesinferred)[NoteshorterdurationsofdiseasemaybeseeninSIA/CNPA,whichbecomesCPAbecauseofitschronicity],+2.3获得与曲霉菌感染相关的组织病理或微生物证据或免疫学证据（如：肺活检中组织病理发现曲霉样菌丝或经皮肺穿刺培养阳性；肺泡灌洗液抗原强阳性；IgG抗体阳性/曲霉沉淀素阳性）呼吸道分泌物培养或PCR方法检测曲霉样性HistologicalormicrobiologicalorimmunologicevidenceofAspergillusinfection(e.g.histologicalevidenceofAspergillus-likehyphaeinlungbiopsyorAspergillusculturefromapercutaneouscavityaspiration;stronglypositiveBALantigen;positiveIgGantibody/precipitins).RespiratorytractcultureorPCRpositiveforAspergillusissupportive.排除：对于特定地区或游历该地区患者需要排除组织胞浆菌，球孢子菌和副球孢子菌感染；以及排除肺放线菌病。排除活动性细菌感染，包括分枝杆菌感染伴或不伴恶性肿瘤。分枝杆菌感染可能与真菌感染相似Exclusionofhistoplasmosis,coccidioidomycosisandparacoccidiodomycosisinendemicareasorthosewithpertinenttravelhistory;actinomycosis.Activebacterialinfection,includingmycobacterialinfectionand/ormalignancymayoccurconcurrently.MycobacterialinfectionsormalignancymaymimicCPA.PresentbyDavidDenningECCMID10thMay2015inBarcelonaEFISGEuropeanSocietyofClinicalMicrobiologyandInfectionDiseasesESCMIDFungalInfectiousStudyGroupOnlyforinternallearningordiscussion,forbiddenforanyotherpurpose慢性肺曲霉菌病-气道标本的诊断RespiratoryspecimendiagnosisofCPAPresentbyDavidDenningECCMID10thMay2015inBarcelona患者人群Population目的Intention干预手段InterventionSoRQoE文献Reference备注Comment在非免疫抑制患者中伴有空腔/结节肺浸润CavitaryornodularpulmonaryinfiltrateinNon-immunocompromisedpatients诊断或排除慢性肺曲霉菌病DiagnosisOrexclusionofCPA确诊或排除其他病原体TodocumentorExcludeotherpathogens直接镜检发现菌丝Directmicroscopyforhyphae组织病理Histology（气道分泌物）真菌培养Fungalculture（respiratorysecretion）（经皮肺穿刺）真菌培养Fungalculture(transparietalaspiration)（气道分泌物）曲霉菌PCRAspergillusPCR(respiratorysecretion)细菌培养BacterialcultureAAABCCIIIIIIIIIIIIItUffredi,2003Denning,2003;Horvath,1994Denning,2013;Duddy,2012Horvath,1994慢性曲霉菌病中病理能够将半侵袭性曲霉菌病（SAIA）/慢性坏死性肺曲霉菌病与慢性空腔性肺曲霉菌病区分开来。镜检阳性是一个感染的强指证。细菌培养平板的敏感性叫真菌平板的敏感性较低。PCR的敏感性较培养高EFISGEuropeanSocietyofClinicalMicrobiologyandInfectionDiseasesESCMIDFungalInfectiousStudyGroupOnlyforinternallearningordiscussion,forbiddenforanyotherpurpose慢性肺曲霉菌病-抗原检测AntigendiagnosisofCPAPresentbyDavidDenningECCMID10thMay2015inBarcelona患者人群Population目的Intention干预手段Interve