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目的:总结播散型组织胞浆菌病(disseminated histoplasmosis,DH)临床特点及治疗经过,以提高对该病的诊治能力,并为流行病学调查提供循证医学证据。方法:收集重庆医科大学附属第一医院2008年至2014年经骨髓及病理确诊的DH 6例,对其临床表现、诊治过程及转归等资料进行回顾性分析。结果:6例DH病人HIV阴性,无免疫受抑制基础疾病;主要表现为发热、乏力、消瘦、肝脾肿大,血细胞减少、肝酶升高,胸、腹部影像学异常;依赖骨髓涂片、淋巴结活检确诊;6例病人中初始接受两性霉素B治疗(amphotericin B deoxycholate,Am B)4例、两性霉素B脂质体(liposomal amphotericin B,L-Am B)及伏立康唑各1例,后2例均在1周后改为Am B;Am B日剂量为0.50~0.65 mg/kg时病人耐受良好;总疗程23~60 d,临床效果显著;其后4例病人接受伊曲康唑胶囊巩固治疗15 d~6个月。6例病人均临床痊愈,随访1~7年无复发。结论:所有DH病人为重庆本地居民,无外地旅居史,提示重庆可能为DH自然疫源地之一;DH在免疫正常人群属于少见病,临床表现及常规检查均无特异性,极易误诊、漏诊,对发热待查病人常规行骨髓、淋巴结活检可提高确诊率;在经济欠发达地区,Am B可作为中-重度DH首选药物,及时治疗预后好。
Objective: To summarize the clinical features and treatment of disseminated histoplasmosis (DH) in order to improve the diagnosis and treatment of the disease and provide evidence-based medical evidence for epidemiological investigation. Methods: Six cases of DH diagnosed by bone marrow and pathology were collected from the First Affiliated Hospital of Chongqing Medical University from 2008 to 2014. The clinical manifestations, diagnosis, treatment and prognosis were retrospectively analyzed. Results: Six patients with DH were HIV negative and had no immune suppression. The main manifestations were fever, fatigue, emaciation, hepatosplenomegaly, cytopenia, elevated liver enzymes, thoracic and abdominal abnormalities. Dependent on bone marrow smear, Lymph node biopsy was performed. In the 6 patients, 4 patients were initially treated with amphotericin B deoxycholate (Am B), 1 patient with liposomal amphotericin B (L-Am B) and voriconazole 2 patients were changed to Am B after 1 week; Am B daily dose 0.50 ~ 0.65 mg / kg patients were well tolerated; total course of 23 ~ 60 d, the clinical effect was significant; followed by 4 patients received itraconazole Capsule consolidation treatment 15 d ~ 6 months. Six patients were clinically recovered, no follow-up of 1 to 7 years of recurrence. Conclusion: All DH patients are local residents in Chongqing, and have no history of living outside the country, suggesting that Chongqing may be one of DH natural foci. DH is a rare disease in normal immune population, and has no specific clinical manifestations and routine examination. Misdiagnosis, routine examination of patients with fever, bone marrow, lymph node biopsy can improve the diagnosis rate; in economically underdeveloped areas, Am B can be used as the first choice for moderate-severe DH drugs, timely treatment of good prognosis.