肾移植术后受者新型隐球菌感染的临床分析

龙成美; 杨华; 李新长; 张钰; 杨锦然

doi:10.3969/j.issn.1674-7445.2019.04.014

肾移植术后受者新型隐球菌感染的临床分析

doi: 10.3969/j.issn.1674-7445.2019.04.014

330006 南昌，江西省人民医院移植科（龙成美、杨华、李新长、杨锦然）；南昌大学附属九江医院骨科（张钰）

基金项目:

江西省科技计划项目 20151BBG70069

详细信息

作者简介:
龙成美，男，1973年生，博士，副主任医师，研究方向为器官捐献及移植工作、肾脏病基础与临床研究，Email：ddlongchm19@163.com

通讯作者:
李新长，男，1966年生，学士，主任医师，研究方向为器官捐献及移植工作、肾脏病基础与临床研究，Email：lxzh863@126.com

中图分类号: R617, R392.4
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出版历程
- 收稿日期: 2019-04-08
- 网络出版日期: 2021-01-19
- 刊出日期: 2019-07-15

Clinical analysis of infection in recipients after renal transplantation

Department of Transplantation, Jiangxi Provincial People's Hospital, Nanchang 330006, China

More Information

Corresponding author: Li Xinchang, Email:lxzh863@126.com

摘要

摘要: 目的分析肾移植术后患者新型隐球菌感染的临床特点。方法回顾性分析9例肾移植术后新型隐球菌感染受者的临床资料，包括受者的感染部位、临床表现、真菌学、组织病理学、影像学检查结果及治疗经过和转归。结果 9例肾移植受者术后常规应用他克莫司（FK506）+吗替麦考酚酯（MMF）+泼尼松三联免疫抑制治疗。发病中位时间为术后6（1~13）年。其中单纯隐球菌性脑膜炎1例、隐球菌性脑膜炎合并隐球菌肺炎5例、单纯隐球菌肺炎2例、皮肤隐球菌病1例。隐球菌肺炎临床多表现为发热、咳嗽、咳痰、气促及胸痛等症状，胸部CT示结节、胸腔积液等。主要经肺穿刺活组织检查（活检）及肺泡灌洗液墨汁负染色确诊。隐球菌性脑膜炎患者临床表现以发热、阵发性头痛伴呕吐症状居多，主要经血培养及脑脊液墨汁负染色确诊。皮肤隐球菌病表现为右肩部包块，经皮肤活检确诊。所有患者分别给予两性霉素B、氟康唑等规范抗真菌治疗，免疫抑制剂减量治疗。9例受者中1例死亡，其余受者预后情况良好。结论肾移植术后受者新型隐球菌感染多发生于术后中晚期，临床症状缺乏特异性，对怀疑隐球菌病者应及时做血培养、肺穿刺活检、脑脊液等检查以确诊。规范抗真菌治疗可降低病死率。
- 肾移植 /
- 隐球菌病 /
- 新型隐球菌 /
- 组织病理学检查 /
- 氟康唑 /
- 两性霉素B /
- 伏立康唑 /
- 肾功能
Abstract: Objective To analyze the clinical characteristics of the recipients infected with cryptococcus neoformans after renal transplantation. Methods Clinical data of 9 patients infected with cryptococcus neoformans after renal transplantation were retrospectively analyzed, including the infection site, clinical manifestations, mycological, histopathological, imaging examination results, treatment process and clinical prognosis. Results Nine recipients were treated with routine triple immunosuppressive therapy of tacrolimus (FK506) + mycophenolate mofetil (MMF)+prednisone. The median time of onset was 6 years (1-13 years) after operation. Among them, 1 case was diagnosed with cryptococcal meningitis, 5 cases of cryptococcal meningitis complicated with cryptococcal pneumonia, 2 cases of cryptococcal pneumonia and 1 case of cutaneous cryptococcal infection. Cryptococcal pneumonia was clinically manifested as fever, cough, expectoration, shortness of breath and chest pain, etc. Chest CT demonstrated the signs of nodules and pleural effusion, etc. The diagnosis was mainly confirmed by lung biopsy and negative ink staining of the alveolar lavage fluid. Clinical manifestations of cryptococcal meningitis primarily included fever and paroxysmal headache accompanied by vomiting, which was mainly confirmed by blood culture and negative ink staining of the cerebrospinal fluid. Cutaneous cryptococcal infection was characterized by a mass in the right shoulder, which was confirmed by skin biopsy. All patients were given with standard antifungal therapy including amphotericin B and fluconazole, and immunosuppressive therapy at a reduced dosage. Among 9 recipients, 1 recipient died, and the other recipients obtained excellent clinical prognosis. Conclusions Cryptococcus neoformans infection dominantly occurs in the middle and late stage after renal transplantation presenting with non-specific clinical symptoms. Blood culture, lung biopsy and cerebrospinal fluid examination should be timely performed to validate the diagnosis of this disease. Standard anti-fungal therapy can reduce the mortality rate.
- Renal transplantation /
- Cryptococcosis /
- Cryptococcus neoformans /
- Histopathological examination /
- Fluconazole /
- Amphotericin B /
- Voriconazole /
- Renal function

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参考文献(25)

[1]	许书添, 谢红浪, 陈劲松, 等.肾移植术后新生隐球菌病的临床特点及转归[J].肾脏病与透析肾移植杂志, 2012, 21(1):19-23.DOI: 10.3969/j.issn.1006-298X.2012.01.004. XU ST, XIE HL, CHEN JS, et al. Clinical features and outcomes of renal transplant patients with cryptococcosis[J]. Chin J Nephrol Dial Transplant, 2012, 21(1):19-23. DOI: 10.3969/j.issn.1006-298X.2012.01.004.
[2]	KLEINERT JM, LIM HB. Cryptococcal infection[J]. J Hand Surg Am, 1995, 20(3):517-518. doi: 10.1016/S0363-5023(05)80126-1
[3]	陈莉萍.实体器官移植术后隐球菌病的研究进展[J].器官移植, 2018, 9(1):9-15.DOI: 10.3969/j.issn.1674-7445.2018.01.002. CHEN LP. Research progress of cryptococcosis after solid organ transplantation [J]. Organ Transplant, 2018, 9(1):9-15. DOI: 10.3969/j.issn.1674-7445.2018.01.002.
[4]	周颖杰, 李光辉.隐球菌病处理临床实践指南:2010年美国感染病学会更新[J].中国感染与化疗杂志, 2010, 10(3):161-166. http://d.old.wanfangdata.com.cn/Periodical/zgkgrhlzz201003001 ZHOU YJ, LI GH. Clinical practice guidelines for the management of cryptococcal disease: 2010 update by the Infectious Diseases Society of America[J]. Chin J Infect Chemother, 2010, 10(3):161-166. http://d.old.wanfangdata.com.cn/Periodical/zgkgrhlzz201003001
[5]	张园, 王静梅, 剡根强.新生隐球菌病研究进展[J].动物医学进展, 2007, 28(12):63-67.DOI: 10.3969/j.issn.1007-5038.2007.12.015. ZHANG Y, WANG JM, SHAN GQ. Progress on cryptococcosis neoformans[J]. Progress Vet Med, 2007, 28(12):63-67. DOI: 10.3969/j.issn.1007-5038.2007.12.015.
[6]	朱伯成, 潘搏, 葛国军, 等.移植肾功能衰竭患者播散性新生隐球菌病1例并文献复习[J].中国真菌学杂志, 2017, 12(5):295-297.DOI: 10.3969/j.issn.1673-3827.2017.05.010. ZHU BC, PAN B, GE GJ, et al. A patient with renal allograft failure and disseminated cryptococcosis: a case report[J]. Chin J Mycol, 2017, 12(5):295-297. DOI: 10.3969/j.issn.1673-3827.2017.05.010.
[7]	DAHDAL S, KALICKI R, VON STEIGER N, et al. Disseminated cryptococcal infection in a patient who had kidney transplant: discrepancy between clinical symptoms and microbiological findings[J]. BMJ Case Rep, 2017:bcr-2017-219234.DOI: 10.1136/bcr-2017-219234.
[8]	GUIMARÃES LF, HALPERN M, DE LEMOS AS, et al. Invasive fungal disease in renal transplant recipients at a Brazilian center: local epidemiology matters[J]. Transplant Proc, 2016, 48(7):2306-2309. DOI: 10.1016/j.transproceed.2016.06.019.
[9]	梁丽玲, 梁志欣, 陈良安.肺隐球菌病临床诊治进展[J].中华医院感染学杂志, 2017, 27(6):1437-1440. DOI: 10.11816/cn.ni.2016-170299. LIANG LL, LIANG ZX, CHEN LA. Progress of clinical diagnosis and treatment of pulmonary cryptococcosis[J]. Chin J Nosocomiol, 2017, 27(6):1437-1440. DOI: 10.11816/cn.ni.2016-170299.
[10]	PERSONETT HA, LAUB MR. Review of infectious disease prophylaxis in solid organ transplantation[J]. Crit Care Nurs Q, 2017, 40(4):383-398. DOI: 10.1097/CNQ.0000000000000175.
[11]	陈静丹, 盛吉芳.隐球菌性脑膜炎的诊断与治疗[J].中国微生态学杂志, 2018, 30(3):344-349. DOI: 10.13381/j.cnki.cjm.201803024. CHEN JD, SHENG JF. Cryptococcal meningitis: diagnosis and treatment[J]. Chin J Microecology, 2018, 30(3):344-349. DOI: 10.13381/j.cnki.cjm.201803024.
[12]	YANG YL, CHEN M, GU JL, et al. Cryptococcosis in kidney transplant recipients in a Chinese university hospital and a review of published cases[J]. Int J Infect Dis, 2014, 26:154-161. DOI: 10.1016/j.ijid.2014.05.028.
[13]	王雪静, 王燕平, 徐尚志, 等.肺隐球菌病25例临床诊治分析[J].中国乡村医药, 2018, 25(4):5-6. DOI: 10.3969/j.issn.1006-5180.2018.04.002. WANG XJ, WANG YP, XU SZ, et al. Clinical diagnosis and treatment of 25 cases of pulmonary cryptococcosis [J]. Chin J Rural Med Pharm, 2018, 25(4):5-6. DOI: 10.3969/j.issn.1006-5180.2018.04.002.
[14]	吕军, 张洪, 马延贺.肺隐球菌病CT征象分析[J].实用放射学杂志, 2017, 33(3):382-384, 388. DOI: 10.3969/j.issn.1002-1671.2017.03.015. LYU J, ZHANG H, MA YH. CT analysis of pulmonary cryptococcosis[J]. J Pract Radiol, 2017, 33(3):382-384, 388. DOI: 10.3969/j.issn.1002-1671.2017.03.015.
[15]	傅顺金, 许攀峰, 周华, 等.52例肺隐球菌病的临床及影像特点与隐球菌荚膜抗原检测结果的关系[J].中华医院感染学杂志, 2018, 28(22):3397-3400, 3409. DOI: 10.11816/cn.ni.2018-173575. FU SJ, XU PF, ZHOU H, et al. Clinical and imaging characteristics of 52 patients with pulmonary cryptococcosis and their association with result of cryptococcal capsular antigen test[J]. Chin J Nosocomiol, 2018, 28(22):3397-3400, 3409. DOI: 10.11816/cn.ni.2018-173575.
[16]	郑娜, 王威, 张家堂, 等.颅内隐球菌感染对脑屏障通透性的影响[J].解放军医学院学报, 2017, 38(7):668-670. DOI: 10.3969/j.issn.2095-5227.2017.07.018. ZHENG N, WANG W, ZHANG JT, et al. Influence of intracranial cryptococcal infection on brain barrier permeability[J]. Acad J Chin PLA Med Sch, 2017, 38(7):668-670. DOI: 10.3969/j.issn.2095-5227.2017.07.018.
[17]	王俊杰, 王露霞, 李林海.原发性皮肤隐球菌病一例[J].实用皮肤病学杂志, 2017, 10(2):116-118. DOI: 10.11786/sypfbxzz.1674-1293.20170218. WANG JJ, WANG LX, LI LH. A case of primary cutaneous cryptococcosis[J]. J Pract Dermatol, 2017, 10(2):116-118. DOI: 10.11786/sypfbxzz.1674-1293.20170218.
[18]	CHAKRADEO K, PAUL CHIA YY, LIU C, et al. Disseminated cryptococcosis presenting initially as lower limb cellulitis in a renal transplant recipient - a case report[J]. BMC Nephrol, 2018, 19(1):18. DOI: 10.1186/s12882-018-0815-7.
[19]	NELSON GE, NEOFYTOS D, FISCHER M, et al.A 70-year-old kidney transplant recipient presenting with persistent leg cellulitis[J]. Clin Infect Dis, 2014, 59(5):688, 743-744. DOI: 10.1093/cid/ciu489.
[20]	FISHMAN JA. Infection in organ transplantation[J]. Am J Transplant, 2017, 17(4):856-879. DOI: 10.1111/ajt.14208.
[21]	GASSIEP I, MCDOUGALL D, DOUGLAS J, et al. Cryptococcal infections in solid organ transplant recipients over a 15-year period at a state transplant center[J].Transpl Infect Dis, 2017, 19(1). DOI: 10.1111/tid.12639.
[22]	SKOLNIK K, HUSTON S, MODY CH. Cryptococcal lung infections[J]. Clin Chest Med, 2017, 38(3):451-464. DOI: 10.1016/j.ccm.2017.04.007.
[23]	MARQUES S, CARMO R, FERREIRA I, et al. Cryptococcosis in renal transplant recipients: a single-center experience[J]. Transplant Proc, 2016, 48(7):2289-2293. DOI: 10.1016/j.transproceed.2016.06.006.
[24]	王芳, 黄琛, 杜艳, 等.36例新型隐球菌性脑膜炎的临床分析[J].中国抗生素杂志, 2019, 44(2):273-276.DOI: 10.3969/j.issn.1001-8689.2019.02.023. WANG F, HUANG C, DU Y, et al. Clinical analysis of 36 cases of cryptococcus neoformans meningitis[J].Chin J Antibiot, 2019, 44(2):273-276.DOI: 10.3969/j.issn.1001-8689.2019.02.023.
[25]	宋旸, 矫黎东, 王宪玲, 等.新型隐球菌脑膜炎24例临床分析[J].北京医学, 2017, 39(5):464-467.DOI: 10.15932/j.0253-9713.2017.05.007. SONG Y, JIAO LD, WANG XL, et al. Cryptococcus neoformans meningitis: a clinical analysis of 24 cases[J]. Beijing Med J, 2017, 39(5):464-467. DOI: 10.15932/j.0253-9713.2017.05.007.