摘要目的 分析支气管肺泡灌洗液半乳甘露聚糖试验(BALF-GM试验)联合血清GM试验诊断侵袭性肺曲霉病(IPA)的准确性及诊断价值.方法 选择2016年1月至2018年6月济宁医学院附属医院疑似真菌感染患者,其中送检BALF标本190例,送检血清标本4 787例.所有患者按照《肺真菌病诊断和治疗专家共识》的分级标准分为临床确诊IPA、临床诊断IPA、拟诊IPA、排除IPA.分析BALF和血清GM试验结果与临床实际诊断的符合率;绘制受试者工作特征曲线(ROC),评估BALF与血清GM试验单独或联合检测对IPA的诊断价值.对免疫功能正常和免疫功能异常患者进行亚组分析,比较BALF与血清GM试验单独或联合检测的敏感度和特异度.结果 BALF-GM试验阳性率为46.8%(89/190),血清GM试验阳性率为10.4%(497/4 787).有156例患者同时送检了BALF-GM试验与血清GM试验,其中BALF与血清GM试验均阳性44例,与临床确诊的符合率为93.2%(41/44);BALF-GM试验阳性、血清GM试验阴性34例,与临床确诊的符合率为64.7% (22/34);血清GM试验阳性、BALF-GM试验阴性56例,与临床确诊的符合率为48.2%(27/56);BALF与血清GM试验均阴性22例,与临床排除的符合率为90.9%(20/22).ROC曲线分析显示,BALF联合血清GM试验对IPA的诊断价值优于BALF-GM试验或血清GM试验单独检测〔ROC曲线下面积(AUC):0.992比0.983、0.976〕,其敏感度、特异度、阳性预测值(PPV)、阴性预测值(NPV)分别为95.3%、87.0%、93.2%和90.9%.亚组分析结果显示,89例BALF-GM试验阳性患者中,免疫功能正常85例(95.5%),情况未知4例(4.5%);497例血清GM试验阳性患者中,免疫功能正常12例(2.4%),免疫功能异常372例(74.9%),不确定113例(22.7%).ROC曲线分析结果显示,对于免疫功能正常的患者,BALF-GM试验诊断IPA的敏感度高于血清GM试验(95.6%比88.9%);而对于免疫功能异常的患者,血清GM试验诊断IPA的敏感度高于BALF-GM试验(91.8%比89.9%).结论 BALF和血清GM试验结果与临床实际诊断的一致性较高,且两者联合检测对IPA的诊断较单独检测更有临床价值,尤其适用于免疫功能未知的患者.

abstractsObjective To evaluate the accuracy and diagnostic value of bronchoalveolar lavage fluid galactomannan test (BALF-GM) combined with serum GM test on invasive pulmonary aspergillosis (IPA). Methods 190 cases of BALF-GM and 4 787 cases of serum GM specimens suspected of fungal infection in patients admitted to Affiliated Hospital of Jining Medical University from January 2016 to June 2018 were enrolled and analyzed. All patients were classified into clinically confirmed IPA, clinically diagnosed IPA, suspected IPA and excluded IPA according to the classification standard of Expert consensus on diagnosis and treatment of pulmonary mycosis. The coincidence rate of BALF and serum GM test results with clinical diagnosis was analyzed. Receiver operating characteristic (ROC) curve was performed, and the diagnostic value of BALF and serum GM test alone or in combination for IPA was evaluated. Subgroup analysis was performed in patients with normal or abnormal immune function, and the sensitivity and specificity of BALF and serum GM test were compared separately or jointly. Results The positive rate of BALF-GM was 46.8% (89/190), and 10.4% (497/4 787) on serum GM. Among them, 156 patients were both tested on BALF and serum GM. There were 44 cases with both positive in BALF and serum GM, the coincidence rate of clinical definite was 93.2% (41/44). There were 34 cases with positive BALF-GM and negative GM test in serum, and the coincidence rate of clinical definite was 64.7% (22/34). There were 56 cases positive in serum GM and negative in BALF-GM, and the coincidence rate of clinical definite was 48.2% (27/56). BALF and serum GM tests were both negative in 22 cases, and the coincidence rate of exclusion diagnosis was 90.9% (20/22). ROC curve analysis showed that the diagnostic value of BALF-GM test combined with serum GM test for IPA was better than that of BALF-GM test or serum GM test alone [area under ROC curve (AUC): 0.992 vs. 0.983, 0.976]. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were 95.3%, 87.0%, 93.2% and 90.9%, respectively. Subgroup analysis showed that among 89 patients with positive BALF-GM test, 85 cases (95.5%) had normal immune function and 4 cases (4.5%) had unknown condition. Among 497 patients with positive serum GM test, 12 cases (2.4%) had normal immune function, 372 cases (74.9%) had abnormal immune function and 113 cases (22.7%) were uncertain. It was shown by ROC curve analysis that the sensitivity of positive BALF-GM test in diagnosis of IPA in patients with normal immune function was higher than that of positive serum GM test (95.6% vs. 88.9%), while the sensitivity of positive serum GM test in patients with abnormal immune function was higher than that of positive BALF-GM test (91.8% vs. 89.9%). Conclusion The results of BALF and serum GM tests are in good agreement with clinical diagnosis, and the combined detection of BALF and serum GM is more valuable for IPA diagnosis than single detection, especially for patients with unknown immune function.