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一文搞懂非HIV感染血液病患者卡氏肺孢子菌肺炎的诊疗方案

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作者:天津市胸科医院 小可真


人们熟知卡氏肺孢子菌肺炎(PCP)是HIV感染患者最常见的机会性感染,也是此类患者主要死因,但PCP最早是在具有先天免疫缺陷、恶性肿瘤化疗后及器官移植后接受免疫抑制剂后中发现,而随着相关疾病的发病率升高,伴随PCP的发生风险也逐渐增加。本文总结最新指南与大家共同学习血液病患者PCP的诊疗方案。


1.临床表现与严重程度分级


表1 PCP临床表现与严重程度分级


2.PCP治疗开始时机


一旦高度怀疑卡氏肺孢子菌感染应立即开始治疗,无需等待实验室检查结果。


高危患者合并以下情况高度怀疑感染卡氏肺孢子菌:


(1)伴以下临床症状和体征:①呼吸困难和(或)咳嗽②发热(偶尔可不出现)③低氧血症(偶尔可不出现)④胸痛(罕见);


(2)首选胸部CT检查,放射检查改变符合PCP特征;


(3)伴或不伴原因未明的血清乳酸脱氢酶升高。


3.治疗方案


表2非HIV患者PCP治疗方案

    注:TMP:甲氧苄啶;SMX:磺胺甲恶唑


4.预后不良因素


表3非HIV血液病患者PCP预后不良因素

注:ECOG PS:东部肿瘤协作组的绩效评分;HSV:单纯性疱疹病毒;CMV:巨细胞病毒;BAL:支气管肺泡灌洗;ARDS:急性呼吸窘迫综合征


参考文献:


[1]Maschmeyer G, Helweg-Larsen J, Pagano L, et al. ECIL guidelines for treatment of Pneumocystis jirovecii pneumonia in non-HIV-infected haematology patients. J Antimicrob Chemother. 2016 ;71:2405-13. 


[2]Kojicic M, Li G, Hanson AC, et al. Risk factors for the development of acute lung injury in patients with infectious pneumonia. Crit Care 2012; 16: R46.


[3]Alanio A, Hauser PM, Lagrou K, et al. ECIL guidelines for the diagnosis of Pneumocystis jirovecii pneumonia in patients with haematological malignancies and stem cell transplant recipients. J Antimicrob Chemother 2016; 71: 2386–96.


[4]Cordonnier C, Cesaro S, Maschmeyer G et al. Pneumocystis jirovecii pneumonia: still a concern in patients with haematological malignancies and stem cell transplant recipients. J Antimicrob Chemother 2016; 71: 2379–85.


[5]Maertens J, Cesaro S, Maschmeyer G et al. ECIL guidelines for preventing Pneumocystis jirovecii pneumonia in patients with haematological malignancies and stem cell transplant recipients. J Antimicrob Chemother 2016; 71: 2397–404.


[6]Li MC, Lee NY, Lee CC et al. Pneumocystis jiroveci pneumonia in immunocompromised patients: delayed diagnosis and poor outcomes in non-HIV-infected individuals. J Microbiol Immunol Infect 2014; 47: 42-7.


更多指南详情》》》非HIV感染血液病患者的耶氏肺孢子菌肺炎(PCP)的ECIL治疗指南

 

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