免疫抑制肺炎_培训课件.ppt

PCP-Patients at Risk AIDS at CD4 200. Congenital and acquired defects in cellular immunity. Organ transplantation recipients. Chemotherapy. Corticosteroids. Malnutrition. Premature birth. Symptoms of Disease--PCP ‘Triad of symptoms’ Non-productive, dry cough Breathless-ness (dyspnea) Fever Fujii, T. et al. Journal of Infection and Chemotherapy. 2007; 13:1-7 Diagnosis /overview/fungi1.html Giemsa stain Gomori methenamine Silver stain AIDS和非AIDS的PCP比较 临床表现 非AIDS AIDS 呼吸困难 常见 常见 咳嗽 常见 常见 进展速度 快（7-12d) 渐进（2-5w） 低氧血症 严重 不严重 胸片 双肺弥漫性间质浸润 不对称或双侧间质浸润 治疗反应 快（3-5d） 慢（5-9d） 复发 少见 常见 对再次治疗反应 好 肺损伤 治疗副作用 通常较轻 常见，可严重 Empiric treatment Difficult because of the broad differential diagnosis Aggressive early diagnostic procedures should precede antimicrobial therapy 几个问题 如何达到治疗效果又避免不必要和盲目的联合治疗 ICH：发热+肺浸润：感染，非感染 如何掌握ICH感染时的糖皮质激素和免疫抑制剂的使用：短暂停用或减量 非感染因素引起多需加用或加大糖皮质激素用量，鉴别非常重要 Imaging approach The degree and type of immunosuppression may have an impact Normal chest exam and CXR is possible（10%） Diffuse perihilar infiltrates PCP, CMV, Legionella Pulmonary nodules Fungi, Nocardia, mycobacteria Cavitary lesions TB, invasive pulmonary aspergillosis CT- pulmonary infiltratets infection and noninfectious: hemorrhage, drug-induced lung disease, pulmonary edema,pulmonary embolism febrile pneumonitis: drug-induced ,acute eosinophilic pneumonia ,OP, pulmonary vasculitis Differential diagnosis of pulmonary infiltrates in ICH 感染因素 Bacteria: 绿脓，金葡 Fungi: 曲霉，毛霉，PCP，念珠菌属 Viruse: CMV,VZV,RSV influenza Mycobacteria 非感染因素 Pulmonary edema Progression of underlying disease Radiation toxicity Drug-induced disease DAH BOOP Secondary alveolar proteinosis TRALI(Transfusion-related acute lung injury) 34/M,AML, 结节，实变，磨玻璃，胸水， RSV 36/F, allogeneic bone marrow transplantation 磨玻璃和磨玻璃样结节 CMV 23/M, neutropenia following bone marrow transplantation 磨玻璃和实变 Candida albicans 47/F, allogeneic bone marrow transplantation Halo sign +pleural effusion IA 25/F, neutropenia(760/mm) following bone marrow transp