临床医生如何看待真菌感染与定植.pptVIP

例2.肝移植患者 IPA 误诊的原因 The diagnosis of IPA in non-neutropenic critically ill patients is difficult signs and symptoms are non-specific. A positive result of a culture of a respiratory specimen or positive findings of a direct microscopic examination only one-half of patients with IPA. The predictive value of a positive culture result depends largely on whether the patient is immunocompromised and ranges from 20% to 80%. IPA的危险因素 GM 抗原的敏感性与特异性 Correlates with fungal burden in animal and clinical studies Sensitivity and specificity Limitations in non-neutropenic patients (SOT) Detected in CSF, bronchoalveolar lavage (BAL) fluid IPA高风险病人 的诊治策略 38 patients probable (n = 28) proven (n = 10) . 37% patients ≥2 risk factors for IA. All probable IA were diagnosed by BAL. Proven IA was reached by positive histopathologic and culture results of samples autopsy (n = 4) percutaneous (n = 3) transbronchial biopsy (n = 3). HRCT 分类 Airway invasive aspergillosis 气道侵袭性曲霉病 Aspergillus bronchiolitis （“tree-in-bud” pattern） Aspergillus bronchopneumonia（air-space consolidation） angioinvasive aspergillosis 血管侵袭性曲霉病 “halo” of ground-glass “air-crescent sign” 气道侵袭性曲霉病 血管侵袭性曲霉病 HRCT与 GM 在 IPA的相关性 研究结论（1） Serum GM levels may be lower in patients with airway IA than in those with an angioinvasive form. （气道侵袭性曲霉病的血清GM水平比血管侵袭性曲霉病低） HRCT findings of airway IA are very similar to those of others infection such as viral infection. （气道侵袭性曲霉病的HRCT影像学表现与其他感染，比如病毒感染非常近似） 研究结论（2） A lower or even negative GM result does not effectively exclude airway invasive fungal disease. （GM水平低或阴性不能除外气道侵袭性曲霉病） Given the very high sensitivity of HRCT and the high specificity of the serum GM in these patients were both complementary tests in the diagnosis of IA. （HRCT的高敏感性和GM的高特异性对于IPA诊断具有辅助作用） 小结（1） 重视危险因素 IPA的危险因素包括：结缔组织病、使用激素治疗、肝衰竭、CRRT治疗，与传统的危险因素明显不同。 越来越多的证据表明，COPD已成为IPA最主要的危险因素，其次是自身免疫性疾病、实体器官移植、肝硬化。 ICU患者气道分离出曲霉菌不论是定植或侵袭，都是不良预后的指标，和高死亡率相关，应予以重视。 小结（2） 正确认识影像学与GM 目前很多IA的GM多用于