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目的研究肝、肾移植术后患者隐球菌感染的临床特征。方法选取2010年1月到2015年7月来浙江大学医学院附属第一医院就诊的肝、肾移植术后并确诊为隐球菌感染的患者,对其临床特征进行回顾性分析。结果研究周期内有23例患者符合入组要求,其中肾移植术后21例、肝移植术后2例。对23例患者进行分析,发现单纯隐球菌肺炎6例(占26.0%)、单纯隐球菌性脑膜炎6例(占26.0%)、隐球菌性脑膜炎合并隐球菌肺炎8例(占34.7%)、隐球菌败血症2例(占8.6%),皮肤隐球菌感染1例(占4.3%)。所有隐球菌肺炎均经肺穿刺病理确诊,临床表现以发热,咳嗽咳痰,气急症状居多。胸部CT表现为结节、空洞、肿块、渗出等。所有隐球菌脑膜炎患者中9例经脑脊液培养出新生隐球菌、7例脑脊液墨汁染色见隐球菌,其中3例培养及涂片均为阳性。临床表现以头痛、发热、呕吐症状居多,1例并发癫痫,1例并发意识障碍。所有患者分别给予氟康唑、两性霉素B、氟胞嘧啶针、伏立康唑等抗真菌治疗,其中3例隐球菌脑膜炎患者予两性霉素B鞘内注射。经1~6个月治疗后,总体预后情况良好(好转22例,死亡1例)。结论肝、肾移植术后患者因免疫抑制剂的长期使用,隐球菌感染值得重视,其临床症状不典型,易误诊及漏诊,通过对其主要症状及影像学特点判断,结合肺穿刺活检、脑脊液检查、血培养等检查手段,可明显提高隐球菌感染的检出率,从而做到早诊断,早治疗,降低病死率。
Objective To study the clinical features of patients with cryptococcosis after liver and kidney transplantation. Methods From January 2010 to July 2015, we retrospectively analyzed the clinical features of patients with cryptococcal infection after liver and kidney transplantation and the first affiliated hospital of Zhejiang University School of Medicine. Results Twenty-three patients met the inclusion criteria during the study period, including 21 after renal transplantation and 2 after liver transplantation. Of 23 patients, 6 (26.0%) had cryptococcal pneumonia, 6 (26.0%) had cryptococcal meningitis, 8 had cryptococcal meningitis (34.7%) with cryptococcal pneumonia, , Cryptococcal septicemia in 2 cases (8.6%) and skin cryptococcal infection in 1 case (4.3%). All cryptococcal pneumonia were diagnosed by pulmonary biopsy, clinical manifestations of fever, cough and sputum, the majority of shortness of breath and urgency. Chest CT showed nodules, voids, lumps, exudation and so on. Among all the patients with cryptococcal meningitis, 9 cases of Cryptococcus neoformans were cultured by cerebrospinal fluid and 7 cases of cryptococcosis were seen by cerebrospinal fluid ink stain. Three of them were positive in culture and smear. Clinical manifestations of headache, fever, vomiting mostly, 1 case of complicated epilepsy, 1 case of concurrent disturbance of consciousness. All patients were given fluconazole, amphotericin B, flucytosine needle, voriconazole and other antifungal therapy, of which 3 cases of cryptococcal meningitis to amphotericin B intrathecal injection. After 1 to 6 months of treatment, the overall prognosis was good (improvement in 22 cases, 1 death). CONCLUSIONS: Long-term use of immunosuppressive agents in patients with liver and kidney transplantation is of great importance to cryptococcal infections. The clinical symptoms are not typical, and are easily misdiagnosed and missed. According to its main symptoms and imaging features, combined with pulmonary biopsy, cerebrospinal fluid Examination, blood culture and other inspection methods can significantly improve the detection rate of cryptococcal infection, so as to early diagnosis and early treatment, reduce mortality.