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肺曲霉菌病的外科治療

目的探討肺曲霉菌病的臨床特點與外科治療原則。方法回顧分析32例肺曲霉菌病患者的臨床資料和手術治療結果，手術施行采用標準后外側切口肺葉切除術6例，楔形切除術3例，胸腔鏡或胸腔鏡輔助改良后外側微創小切口楔形切除術15例，肺葉切除術6例，肺段切除術2例。結果21例無肺原發疾病，11例有肺原發疾病。痰菌檢查陽性率為13．3％（2／15），術前診斷符合率為28．1％（9／32）；術后并發癥發生率為15．6％（5／32），其中切口皮下積液、肺膨脹不良各2例，氣胸1例；隨訪32例，隨訪10～160個月，無咯血或血痰、肺曲霉菌病復發或播散。結論肺曲霉菌病多數無肺原發疾病和癥狀，無論有否癥狀均應手術治療，而微創外科手術治療并發癥少且較輕，是首選的治療方法。

Detection of Invasive Aspergillosis by Serum Galactomannan Test: A Systematic Review

Objective　To assess the quality of current domestic literature about enzyme-linked immunosorbent assay (ELISA) for invasive aspergillosis diagnosis by detecting Aspergillus galactomannan (GM) antigen, and to analyze the sources of bias and variability, as well as the diagnostic ability of different thresholds. Methods　Both computer-based online search and manual retrieval were employed to identify relevant articles. The statistical information and quality of science were assessed and classified. The data were analyzed using Meta Disc 1.4 software. The best cutoff value for defining a positive test result was selected by summarizing the following statistical indicators as sensitivity, specificity, likelihood ratio (LR) and summary receiver operating characteristic curve (SROC curve), and by calculating the area under the curve (AUC) as well. Results　A total of 20 studies among 2658 literatures were included in accordance with the inclusion criteria, and were divided into different groups based on different cutoff values. Though heterogeneity tests showed no threshold effect, and there were other reasons of heterogeneity. So the data were analyzed by random effects model. The results showed that, compared with other groups, the one with cutoff value set at 0.7 (AUC=0.9456, Q= 0.884 6) showed the best accuracy in diagnosing. Conclusion　ELISA detection of Aspergillus GM antigen with cutoff value set at 0.7 has important significance in the early diagnosis of invasive aspergillosis, and it can be conducive to reduce mortality in patients at high risk for Aspergillus infection.

Completely Video-assisted Thoracopic Surgery for Pulmonary Aspergilloma: A Case Control Study

ObjectiveTo discuss the possibility and safety of video-assisted thoracoscope surgery for pulmonary aspergilloma. MethodsWe retrospectively analyzed the clinical data of 39 patients with pulmonary aspergilloma in Beijing Chaoyang Hospital between June 2009 and May 2014. The patients were divided into two groups according to their operation method including a conventional thoracotomy surgery group (open group, n=11) and a video-assisted thoracoscope pneumonectomy group (VATS group, n=28). There were 8 male patients and 3 female patients with age of 29-64 (50.7±9.7) years in the open group. There were 13 male patients and 15 female patients with age of 20-75 (55.4±15.3) years in the VATS group. We compared clinical effectiveness between the two groups. ResultsThe operations of all patients were performed successfully. There were statistical differences between the two groups in the average length of operative time (P=0.001), the loss of intraoperative blood (P=0.005), and the score of pain (P=0.001). There was no statistical difference in lead flow of postoperative chest (P>0.05) and the time of hospitalization (P>0.05). ConclusionVideo-assisted thoracoscope surgery in the treatment of pulmonary aspergilloma could be feasible, safe, and effective based on our study. It is worth of clinical application and popularization．

狼瘡性腎炎合并肺部多重真菌感染一例

Effects of Aspergillus fumigatus spores on airway inflammation and airway responsiveness on asthmatic rat model

Objective To explore the effects of Aspergillus fumigatus（A. fumigatus） spores on airway inflammation and responsiveness in asthmatic rats.Methods Seventy male Wistar rats were randomly divided into Ⅰ and Ⅱ groups（n=35 in each group），then Group Ⅰ and Group Ⅱ were subdivided into a normal control group（n=5），an asthma group（n=10），a spores-treated control group（n=10），and a spores-treated asthma group（n=10）.The rats were sensitized to ovalbumin（OVA） and challenged with aerosol OVA to establish the asthma model.The effects of A. fumigatus spores on asthmatic rats before and after OVA aerosol challenging were investigated in Group Ⅰ and Group Ⅱ，respectively.The parameters associated with bronchial epithelial damage were observed by total protein concentration in BALF measured by BCA method.Total and differential cell counts in BALF were also counted.The airway resistance and airway responsiveness were calculated by transpulmonary pressure and gas flow rate.Results In Group Ⅰ，the total protein in BALF in the asthma group treated with A. fumigatus spores before OVA challenging（Group CA） was increased remarkably compared to the asthma group（Group A1）[（1.125±0.254）μg/mL vs（0.825±0.173）μg/mL，Plt;0.01].The nonspecific airway resistances induced by different concentration of acetylcholine in Group CA ［（0.997±0.196）cm H2O?mL-1?s-1，（1.123±0.142）cm H2O?mL-1?s-1，（1.130±0.197）cm H2O?mL-1?s-1］were increased significantly compared to Group A1 [（0.655±0.089）cm H2O?mL-1?s-1，（0.687±0.048）cm H2O?mL-1?s-1，（0.821±0.043）cm H2O?mL-1?s-1]（all Plt;0.05）.In Group Ⅱ，however，the above parameters in the asthma group treated with A. fumigatus spores after OVA challenging（Group AC） were not dramatically increased compared with the asthma group（Group A2）（all Pgt;0.05）.The differences in the total and differential cell counts in BALF in Group CA were not remarkable compared to other subgroups in Group Ⅰ（all Pgt;0.05）.But the BALF neutrophil count in Group AC was increased obviously compared to Group A2 ［（2.488±0.420）×106 vs （0.936±0.459）×106，Plt;0.05］.Conclusion These data indicate that exposure to A. fumigatus spores before challenging causes aggravated epithelial damage and increased airway resistance in an asthma rat model.

侵襲性肺遲緩曲霉病一例報道

目的 通過本病例及綜述以提升對侵襲性肺遲緩曲霉病早期病原學診斷的重視，并為治療方案提供參考依據。方法 回顧我科診治的1例COVID-19感染后繼發的侵襲性肺遲緩曲霉病患者的臨床資料，復習既往文獻總結分析肺遲緩曲霉病的臨床表現、診斷及治療用藥方案。結果 患者79歲，老年男性，咳嗽、咳痰伴呼吸困難4月余。胸部CT提示：雙肺數個結節灶，部分結節內空洞形成；散在實變影。G實驗、GM結果陰性。氣管鏡肺泡灌洗液送檢mNGS查見遲緩曲霉菌。給予伏立康唑治療后效不佳，且繼發肝功能異常，調整為艾沙康唑治療后臨床癥狀及肺部影像學征象好轉。復習文獻，共有12例個案報道，其中8例存在免疫抑制狀態，4例合并慢性阻塞性肺病，6例為器官移植術后。臨床選藥以伏立康唑和兩性霉素B居多，雖經治療仍有66.7%（8例）患者在確診后7周內死亡。結論 本例為國內外首次使用艾沙康唑成功治療侵襲性肺遲緩曲霉病的報告。侵襲性肺遲緩曲霉病屬于罕見病，免疫抑制狀態是其高危因素。該病進展迅速，具有高度耐藥性，預后差，病死率高，早期病原學診斷尤為關鍵。

無哮喘的變應性支氣管肺曲霉病一例

目的 報道并分析1例變應性支氣管肺曲霉病（allergic bronchopulmonary aspergillosis，ABPA）的臨床特點、診斷及治療方法。方法 結合文獻資料分析我科2019年診治的1例ABPA的病例。結果 該患者診斷明確，治療稍有曲折。ABPA常發生于肺部有基礎疾病者，尤其是支氣管哮喘或囊性纖維化者。臨床表現主要是咳嗽、咳痰、喘息、胸悶；實驗室檢查血清總IgE水平和曲霉特異性IgE水平上升，以及嗜酸性粒細胞數增加；胸部影像學表現為反復的肺部游走性浸潤影和中心性支氣管擴張等。治療包括糖皮質激素和抗真菌治療，對于不能耐受糖皮質激素的患者，抗IgE抗體治療有益。結論 臨床上ABPA容易誤診、誤治，特別是無哮喘病史時，其診斷更加困難。因此早期診斷和正確治療可以減少ABPA造成的肺損傷，改善患者的預后。

聯合檢測半乳甘露聚糖和（1→3）-β-D葡聚糖在診治侵襲性曲霉菌感染中的研究進展

近年隨著廣譜抗生素和免疫抑制劑的使用，侵襲性真菌感染（invasive fungal disease，IFD）的發病率逐年上升。其中侵襲性曲霉病（invasive aspergillosis，IA）在IFD中比例逐年增高。侵襲性曲霉菌感染在血液科和重癥加強治療病房（ICU）最為常見，其次為呼吸內科、感染科和免疫科，IA為免疫功能低下患者致死率高的主要原因，造血干細胞移植（HSCT）患者中IA的發病率為2%~26%，在血液病和造血干細胞移植患者中IA死亡率高達70.0%~90.0%。造成死亡率高的主要原因是在病程早期不能對IA進行可靠診斷，往往使患者延誤治療而死亡。因此，選擇正確、合適的早期診斷方法對疾病的預后具有決定性意義。傳統的診斷方法如影像學、真菌直接鏡檢、培養及組織病理學檢查的敏感性不高，檢出率低，難以用于早期診斷。因此，新的診斷方法對IA的治療至關重要。血清學診斷方法是應用免疫和生化方法檢測血清或其他體液中的真菌細胞壁和胞質成分，分為抗原和抗體檢查兩類。但由于IFD多繼發于嚴重免疫受損患者，往往缺乏可檢測到的抗體，或者抗體的產生變化較大，因此以檢測真菌抗原為主。目前半乳甘露聚糖（GM）和（1→3）-β-D葡聚糖（BG）成為真菌檢查中非常重要的兩個抗原。

Clinical characteristics of patients with Coronavirus Disease 2019-associated pulmonary mucormycosis

ObjectiveTo analyze the clinical characteristics, prognosis and predisposing factors of coronavirus disease 2019 (COVID-19) associated pulmonary mucormycosis (CAPM), so as to improve people's understanding of the disease.MethodsFrom from September 1, 2021 to July 31, 2024, 11 patients with CAPM who were hospitalized in Beijing Chaoyang Hospital affiliated to Capital Medical University were retrospectively collected, and 22 patients with non-CAPM were included after matching according to the ratio of 1:2. The clinical manifestations, laboratory examinations, imaging features, tracheoscopy, treatment and prognosis of the two groups were analyzed. ResultsThe average age of patients in CAPM group was 59.5 ± 10.6 years, with 81.8% of males; diabetes mellitus (90.9%) was the most common complication. In CAPM group, the median time after the occurrence of mucor after COVID-19 was 13.0 (10.0, 24.0) days. The utilization rate of glucocorticoids in the CAPM group was 63.6% (7/11), which was significantly higher than that in non-CAPM group [13.6% (3/22)], and the difference between the groups was statistically significant (P=0.006). The C-reactive protein level in CAPM group was significantly higher at 93.90 (75.00, 129.00) mg/L than that in non-CAPM group at 26.10 (4.83, 114.03) mg/L, with a statistically significant difference (P=0.040). The CD4+T lymphocyte counts and B lymphocyte counts in CAPM group were 223.00 (66.75, 336.75)/μL and 32.00 (21.75, 55.25)/μL, respectively, which were significantly lower than those in the non-CAPM group 394.00 (206.00, 610.00)/μL and 112.50 (56.00, 159.25)/μL, with statistical differences between the groups (P=0.040, P=0.040). In terms of imaging, the main imaging findings were the involvement of multiple lobes in both groups. 63.6% (7/11) of patients with pulmonary aspergillosis in CAPM group were significantly higher than those(4/22, 18.2%) in non-CAPM group (P=0.017). The incidence of dyspnea in CAPM group was significantly higher than that in non-CAPM group (90.9% vs. 50.0%, 0.027%).ConclusionThe proportion of glucocorticoid use and the proportion of pulmonary aspergillosis in CAPM group are significantly higher, and they are in a more serious state of immunosuppression. Once combined with pulmonary aspergillus , the mortality rate is higher.

Role of aspergillus infection in bronchiectasis and its diagnosis and treatment

Bronchiectasis is a heterogeneous disease characterized by abnormal expansion of the bronchi, manifested by cough, sputum, and recurring lung infections. As one of the common fungi of lung infection, aspergillus can not only appear as the outcome of the disease in bronchiectasis, but also as an inducement to participate in the disease progression, and ultimately complicate the course of bronchiectasis. This article describes the susceptibility factors and pathogenic mechanisms of aspergillus in bronchiectasis, and further introduces the diagnosis and treatment status of bronchiectasis combined with aspergillus infection, aiming to clarify the effect of aspergillus infection on bronchiectasis and provide new thinking directions for its clinical diagnosis and treatment.