急性白血病并发慢性播散性念珠菌病的临床研究
A clinical study of chronic disseminated candidiasis in patients with acute leukemia
目的 提高对急性白血病(AL)并发慢性播散性念珠菌血症(CDC)的了解和认识.方法 回顾性分析我科2004年8月至2005年5月初治并完成诱导化疗的119例AL患者,对确诊合并CDC患者的临床表现、实验室和影像学检查、诊断和治疗进行分析总结.结果 119例患者中3例确诊合并CDC,发生率为2.5%,3例均为AL化疗后中性粒细胞缺乏持续时间>15 d的患者,2例患者确诊CDC时粒细胞已恢复正常.3例患者均表现为持续发热、肝脾肿大和肝区叩击痛,2例伴咳嗽、咳痰及呼吸困难.2例患者出现碱性磷酸酶增高,3例CT均发现肝脾内多发低密度病灶,2例伴双肺多发结节状斑片状影,1例行MRI检查发现肝、脾、肾脏多发异常信号.2例血培养及1例肝穿刺活检培养发现热带念珠菌生长.2例采用两性霉素B(AmpB)治疗2周仍持续高热,1例改用AmpB胆固醇复合体(ABCD),1例联合伏立康唑治疗后病情好转;1例确诊后应用ABCD治疗45 d(AmpB累积剂量3.45 g)后症状消失,但停药12 d又出现高热,后经伏立康唑治疗后病灶消失.3例患者在治疗CDC同时均进行化疗.结论 CDC的诊断比较困难,目前主张结合临床表现、微生物学、组织病理学及影像学检查综合判断.AmpB是临床上治疗CDC的基本用药,对不耐受或耐药的患者可以使用脂质体AmpB治疗,伏立康唑对难治复发病例疗效满意,可用于二线治疗.另外,AL并发CDC不影响正常化疗的进行.
更多Objective To deepen the understanding of chronic disseminated candidiasis(CDC)in patients with acute leukemia(AL).Methods CDC was investigated in 119 AL patients who received induction chemotherapy from August 2004 to May 2005.Clinical manifestations,laboratory tests,imaging modalities,diagnosis and treatment were investigated retrospectively.Results Three patients(2.5%) were identified to be suffering from CDC.All the three patients had an absolute neutrophil count (ANC)<0.5 × 109/L for more than 15 days.Two patients had normal ANC when they were diagnosed to have CDC.The common manifestations in these three patients were persistent fever,splenohepatomegalia and percussion pain in hepatic region.Meanwhile,2 of them were accompanied with cough,expectoration and dyspnoea.The abnormal laboratory test observed during the course of infection in two of them was increase of alkaline phosphatase.Computed tomography scan showed multiple hypodense lesions in the liver and spleen in all the three patients:two of them showed multiple nodular patchy shadOW$in lungs.Nuclear magnetic resonance imaging showed multiple abnormal signal in liver,spleen and kidneys in one of the patients.Two patients had positive bleed fungal cultures and histologic examination in one of the patients were positive for Candida tropicalis.Two patients received amphotericin B therapy empirically,but it was replaced by amphotericin B colloid dispersion (ABCD) later in one and combined with voficonazole in another because of unresponsiveness to the drug.One patient took a favorable turn after receiving ABCD therapy for 45 d,which was replaced by voriconazole because of the emergence of fever after disconfinuation of ABCD.All the three patients received further chemotherapy smoothly after the diagnosis of CDC.Conclusion The diagnosis of CDC remains difficult.Fungal blood cultares and histologic examination have been considered in many studies as the golden standard for the diagnosis of CDC.Amphotericin B is the cornerstone of treatment in patients with CDC and lipid formulations of amphotericin B can be used in CDC patients who are intolerant of or refractory to conventional amphotericin B.Voriconazole has a favorable response for refrectory/relapse patients and could be used for second line trectment.The development of CDC in patients with acute leukemia does not preclude further chemotherapy.
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