It is reported that a man in Zhangzhou, Fujian Province went to the hospital for about a week because of cough and chest discomfort. At first, from the examination image, the doctor treated the man according to common pneumonia, but after a week or so of treatment, the patient's lung condition not only did not improve, but became more serious.
After that, a puncture biopsy was performed and the diagnosis was pulmonary mycosis. According to the doctor's inquiry, patients come home from work every day, "smell smelly socks first." Although they used to be healthy, they often stayed up late to take care of their babies, and their immunity declined, which eventually led to fungal infection in the lungs.
According to the doctor, socks and shoes are easy to breed fungi for people with tinea pedis. In addition, pulmonary mycosis develops very rapidly, which is not found in time, with high mortality and expensive treatment.
Invasive pulmonary fungal infection (IPFI) is a bronchopulmonary disease caused by fungal infection, including primary and secondary pulmonary fungal infections. Primary IPFI is more common in community-acquired infections. The host can avoid the risk factors of fungal infection, and the clinical process is relatively mild and less dangerous. Clinical treatment requires that the treatment method should be selected as soon as possible after diagnosis. Secondary IPFI is mostly hospital-acquired infection, and the host has clear high-risk factors of fungal infection. The clinical process is sudden and dangerous, which requires comprehensive analysis and judgment, timely treatment (empirical treatment) or clinical diagnosis and treatment. The clinical manifestations of pulmonary fungal infection are often nonspecific and easy to be misdiagnosed.
The common fungi that cause IPFI are Candida, Aspergillus, Cryptococcus, Conjugates (mainly Mucor) and Pneumocystis.
1. The chest X-ray and CT imaging features of invasive pulmonary aspergillus infection are: nodular consolidation with increased subpleural density in the early stage, and halo sign around the focus a few days later. After about 10 ~ 15 days, the lung consolidation area became liquefied and necrotic, and cavitation shadow or crescent sign appeared. (2) The chest CT imaging features of pneumocystis pneumonia are ground-glass interstitial lesions of both lungs with hypoxemia. Secondary characteristics: (1) Symptoms and signs of pulmonary infection; (2) New pulmonary infiltrative shadows appeared on imaging; (3) The fever lasted for 96h, but it was ineffective after active antibacterial treatment.
On 20 1 1 year, the American Thoracic Society (ATS) issued a new version of the treatment guidelines for adult pulmonary fungal infections, introducing new drugs, new treatment methods and emerging fungal species.
Antifungal drugs
Polyenes: Amphotericin B deoxycholate is still the first choice for the treatment of severe fungal infections, and its lipid preparation (liposomal amphotericin B and amphotericin B lipid complex) has less nephrotoxicity (A Ⅱ), so it is recommended for patients with renal insufficiency or taking multiple nephrotoxic drugs at the same time (D Ⅱ).
Triazoles: including ketoconazole, itraconazole, fluconazole, voriconazole and posaconazole. Because they are easy to interact with other drugs, the plasma concentration of these drugs should be monitored (Aⅱ), and the dose of fluconazole should be halved for patients with renal insufficiency (Bⅲ).
Echinococcus is a brand-new antifungal drug, which mainly acts by inhibiting the activity of 1, 3-β- glucan synthase, and then destroying the fungal cell wall. At present, there are caspofungin, micafungin and anifungin available in clinic.
histoplasmosis
For patients with normal immune function, anti-fungal therapy (DI and B ⅲ) is not recommended for pulmonary nodules and most bronchial stones. For patients with hemoptysis, bronchoscopy or surgical intervention (B ⅱ) is feasible. For patients with fibrous mediastinitis, itraconazole (200 mg, bid) 12 weeks (c Ⅲ) can be given, and if it improves, the treatment can be extended to 12 months (c Ⅲ). Anti-fibrosis drugs or systemic glucocorticoid (D Ⅱ) are not recommended. If there are complications, it is recommended to place endovascular stent (B Ⅱ).
Patients with symptoms and progressive diseases were treated with itraconazole (200 mg, bid) 12 weeks (B ⅲ). For patients with severe pulmonary histoplasmosis, it is suggested to give amphotericin B 0.7 mg/(kg d) until the symptoms improve or the cumulative dose reaches 2 g (bi). Itraconazole 200 mg, bid, 65438 02 weeks (B Ⅱ). For severe patients with diffuse pulmonary infiltration or a large number of granulomatous mediastinitis, systemic glucocorticoid adjuvant therapy (C ⅱ) was given.
For immunocompromised hosts, mild to moderate patients were given itraconazole (200 mg, tid) and changed to 200 mg, bid after 3 days, and the treatment lasted 12 months (CI). Patients with severe progressive dissemination were given amphotericin B 0.7 ~1.0 mg/(kg d) until the symptoms improved or the cumulative dose reached 2g (b Ⅱ), followed by itraconazole (200 mg, bid) 12 months (CI).
For AIDS patients with progressive disseminated histoplasmosis, after itraconazole treatment 12 months, itraconazole (200 mg, bid) was continued until effective immune reconstruction (CD4 cells >: 200 cells/μ l) (C Ⅱ), and the level of polysaccharide antigen (B Ⅲ) in urine and blood was detected several times a year.
Chronic patients were given itraconazole (200 mg, BId) 12 ~ 24 months (bi), and amphotericin B(Bⅱ) was the first choice for the initial treatment of severe patients.
Systemic glucocorticoid adjuvant therapy (BI) is recommended for immunocompromised patients with severe pulmonary histoplasmosis and diffuse pulmonary infiltration.
sporotrichosis
According to lung imaging and oxygenation, patients with mild to moderate degree were given itraconazole (200 mg, bid) for 3 ~ 6 months (B ⅲ). The critically ill patients were given amphotericin B 0.7 mg/(kg d) until their condition improved or the cumulative dose reached 2 g, and then itraconazole (200 mg, bid) was given for 3 ~ 6 months (B ⅲ).
blastomycosis
Mild and moderate patients were given oral itraconazole 200 mg, bid, and the course of treatment was 6 months (A Ⅱ) for those with perfect immunity and 12 months for those with immunodeficiency.
Severe patients were given amphotericin B 0.7 ~1.0 mg/(kg d) until the symptoms improved (B Ⅱ), and then itraconazole (200 mg, bid). The course of treatment was 6 months (B Ⅱ) for patients with normal immune function and 65438 02 months for patients with low immune function. Amphotericin B lipid preparation is the first choice for patients with renal failure.
For patients with bone invasion, it is suggested that the course of itraconazole should be extended to 12 months (C Ⅱ); For patients with central nervous system involvement, triazole monotherapy (D ⅱ) is not recommended. The former is given amphotericin B 0.7 mg/(kg d) until its cumulative dose reaches 2 g (B ⅱ), while the latter is given amphotericin B 0.7 mg/(kg d) combined with intravenous or oral fluconazole 400~800 mg/d until symptoms improve (D ⅱ). Patients with AIDS should continue to take fluconazole (400 mg, qd) for a long time until immune reconstruction (A ⅱ).
coccidioidomycosis
For most patients with normal immune function, if there are no other risk factors of disseminated infection, antifungal therapy is not recommended (B ⅱ); For those with moderate or severe clinical symptoms or symptoms lasting for 6 weeks, it is suggested to give triazole antifungal drugs for 3~6 months, and if there is no improvement, the course of treatment can be extended (B Ⅱ).
For immunocompromised patients, when the immunosuppression is significant (chemotherapy, systemic glucocorticoid therapy, CD4 cells
Disseminated patients need treatment regardless of their immune function. Patients without meningeal involvement should be treated with fluconazole (400 mg/d) or itraconazole (400 mg/d) 1 year until clinical improvement and stability (b Ⅱ); Itraconazole is the first choice for patients with bone involvement; For severe or refractory patients, liposomal amphotericin B 5 mg/(kg d) or amphotericin B 0.7 ~1.0 mg/(kg d) can be given until clinical improvement, followed by fluconazole (400 mg/d) or itraconazole (400mg/d) 1 year (. For patients with meningitis, it is suggested to use fluconazole (400~ 1000 mg/d) or itraconazole (400~600 mg/d) for life (b Ⅱ). For meningitis patients who have failed to treat with triazole, it is suggested to use amphotericin B intrathecal injection (B ⅲ) selectively.
cryptococcosis
For patients with normal immune function, fluconazole was given 400 mg/d at first, and it was reduced to 200 mg/d (A Ⅱ) six months after clinical improvement. Or itraconazole 400 mg/d for 6 months (b ⅱ); If there is a huge lesion or the lesion does not subside after drug treatment, selective surgical resection (C ⅲ) is recommended.
Patients with disseminated or central nervous system involvement were treated with amphotericin B 0.7 ~1.0 mg/(kg d) combined with flucytosine100 mg/(kg d) for 2 weeks, and then treated with fluconazole or itraconazole (400 mg/d) for 8 ~/kloc-0. For patients with increased intracranial pressure, if no definite brain mass is found by CT or MRI, it is suggested that cerebrospinal fluid drainage (A Ⅱ), repeated lumbar puncture, lumbar drainage, ventriculoperitoneal shunt, temporary lateral ventriculostomy and mannitol treatment (A Ⅲ) are also feasible.
Aspergillus disease
Treatment of allergic bronchopulmonary aspergillosis with prednisone; If there are still many acute attacks of asthma, it is suggested to give long-term corticosteroid treatment with a dose of 7.5 mg/d (B ⅲ); Itraconazole (200 mg, BId) can also be administered 16 weeks (bi).
For patients with pulmonary aspergillosis, except for patients with suspected invasive lesions (B ⅲ), antifungal therapy (D ⅱ) is not recommended; For patients with massive hemoptysis, it is suggested to perform emergency bronchial artery embolization (B Ⅱ) or consult thoracic surgery (B Ⅱ). For allergic pneumonia, antifungal therapy is not recommended, and glucocorticoid therapy is given when necessary, and the dose can reach 60 mg/d, 1 month (B ⅲ).
For the invasive patients with immune deficiency, it is suggested to treat them with voriconazole intravenously until their clinical symptoms improve, and then take voriconazole 200 mg (the first choice) or itraconazole 400~600 mg/d orally until the clinical symptoms and imaging changes subside or stabilize (AI). For patients with refractory invasive pulmonary aspergillosis with limited focus, surgical resection (C ⅲ) is recommended after the failure of active antifungal treatment.