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1、,2014 ESCMID曲霉菌病治疗指南-慢性肺曲霉病,2014 ESCMID Aspergillus Guideline-Chronic Pulmonary Aspergillosis,Present by David W.Denning United Kingdom,ECCMID 10th May 2015 in Barcelona,),欧洲临床微生物与感染性疾病学会(ESCMID,European Society of Clinical Microbiology and Infectious Diseases),滨州医学院附属烟台海港医院 急诊科 王功军,Present by David
2、 Denning,ECCMID 10th May 2015 in Barcelona,慢性肺曲霉菌病-疾病分类 Chronic Pulmonary Aspergillosis - subsets,单发曲霉球 Simple/single Aspergilloma 曲霉肉芽肿病 Aspergillus nodule(s) 慢性空腔曲霉菌病/复杂曲霉球病 Chronic Cavitary Pulmonary Aspergillosis/Complex Aspergilloma (CCPA) 慢性纤维化肺曲霉菌病 Chronic Fibrosing Pulmonary Aspergillosis (C
3、FPA) 亚急性侵袭性/半侵袭性/慢性坏死性肺曲霉菌病 Subacute invasive(SIA)/Semi-Invasive/Chronic Necrotizing Pulmonary Aspergillosis (CNPA) 注：真菌球（曲霉球）可出现在以上除曲霉菌肉芽肿之外的任意一种情况中 fungal balls (aspergilloma) may be seen in any of these conditions, except Aspergillus nodule,Present by David Denning,ECCMID 10th May 2015 in Barcelo
4、na,慢性曲霉菌病临床表现分类 Clinical phenotypes of chronic Aspergillus spp diseases,单发曲霉球 Single/simple aspergilloma,慢性坏死性/亚急性肺曲霉菌病 Chronic necrotizing pulmonary aspergillosis (CNPA) or subacute Invasive aspergillosis (SAI),慢性空腔性肺曲霉菌病 Chronic cavitary pulmonary aspergillosis (CCPA),慢性纤维化肺曲霉菌病 Chronic fibrosing
5、pulmonary aspergillosis (CFPA),曲霉菌肉芽肿 Aspergillus nodule(s),Present by David Denning,ECCMID 10th May 2015 in Barcelona,不同类型的慢性曲霉菌病 Different patterns of CPA,曲霉菌肉芽肿Aspergillus nodule(s),单发曲霉球 Single/simple aspergilloma,慢性空腔性肺曲霉菌病 Chronic cavitary pulmonary aspergillosis (CCPA),慢性纤维化肺曲霉菌病 Chronic fibr
6、osing pulmonary aspergillosis (CFPA),慢性肺曲霉菌病-诊断标准 Chronic Pulmonary Aspergillosis Diagnostic criteria,需要满足以下条件：,1.1 CT影像学表现为肺部真菌球 或 胸腔内空腔，或支气管扩张 Characteristic CT appearance of a fungus ball in a pulmonary or pleural cavity, or dilated bronchus,+,1.2 任何与曲霉菌感染相关的直接或间接的微生物证据 Any direct or indirect mic
7、robiological evidence of Aspergillus infection (see below). ,或：,2.1 影像学特征持续表现为慢性肺曲霉菌病（包括空腔，胸膜增厚，严重的纤维化或肉芽肿） Radiological features consistent with chronic pulmonary aspergillosis (including cavity(ies), pleural thickening, extensive fibrosis or nodule),+,2.2 患者的临床表现和影像学证据至少存在3个月以上时间注意半侵袭性/慢性坏死性肺曲霉病的疾
8、病疗程相对CPA较短，可逐渐演化成慢性肺曲霉病 Clinical or radiological evidence of at least 3 months disease (sometimes inferred) Note shorter durations of disease may be seen in SIA/CNPA, which becomes CPA because of its chronicity,+,2.3 获得与曲霉菌感染相关的组织病理或微生物证据或免疫学证据（如：肺活检中组织病理发现曲霉样菌丝或经皮肺穿刺培养阳性；肺泡灌洗液抗原强阳性；IgG抗体阳性/曲霉沉淀素阳性）
9、呼吸道分泌物培养或PCR方法检测曲霉样性 Histological or microbiological or immunologic evidence of Aspergillus infection (e.g.histological evidence of Aspergillus-like hyphae in lung biopsy or Aspergillus culture from a percutaneous cavity aspiration; strongly positive BAL antigen; positive IgG antibody/precipitins).
10、Respiratory tract culture or PCR positive for Aspergillus is supportive.,排除：,对于特定地区或游历该地区患者需要排除组织胞浆菌，球孢子菌和副球孢子菌感染；以及排除肺放线菌病。排除活动性细菌感染，包括分枝杆菌感染伴或不伴恶性肿瘤。分枝杆菌感染可能与真菌感染相似 Exclusion of histoplasmosis, coccidioidomycosis and paracoccidiodomycosis in endemic areas or those with pertinent travel history; ac
11、tinomycosis. Active bacterial infection, including mycobacterial infection and/or malignancy may occur concurrently. Mycobacterial infections or malignancy may mimic CPA.,Present by David Denning,ECCMID 10th May 2015 in Barcelona,慢性肺曲霉菌病-气道标本的诊断 Respiratory specimen diagnosis of CPA,Present by David
12、 Denning,ECCMID 10th May 2015 in Barcelona,患者人群 Population,目的 Intention,干预手段 Intervention,SoR,QoE,文献 Reference,备注 Comment,在非免疫抑制患者中伴有空腔/结节肺浸润,Cavitary or nodular pulmonary infiltrate in Non-immunocompromised patients,诊断或排除慢性肺曲霉菌病,Diagnosis Or exclusion of CPA,确诊或排除其他病原体,To document or Exclude other
13、pathogens,直接镜检发现菌丝,Direct microscopy for hyphae,组织病理,Histology,（气道分泌物）真菌培养,Fungal culture （respiratory secretion）,（经皮肺穿刺）真菌培养,Fungal culture (transparietal aspiration),（气道分泌物）曲霉菌PCR,Aspergillus PCR (respiratory secretion),细菌培养,Bacterial culture,A,A,A,B,C,C,II,II,III,II,II,IIt,Uffredi, 2003,Denning,
14、2003;,Horvath, 1994,Denning, 2013; Duddy, 2012,Horvath, 1994,慢性曲霉菌病中病理能够将半侵袭性曲霉菌病（SAIA）/慢性坏死性肺曲霉菌病与慢性空腔性肺曲霉菌病区分开来。 镜检阳性是一个感染的强指证。 细菌培养平板的敏感性叫真菌平板的敏感性较低。 PCR的敏感性较培养高,慢性肺曲霉菌病-抗原检测 Antigen diagnosis of CPA,Present by David Denning,ECCMID 10th May 2015 in Barcelona,患者人群 Population,目的 Intention,干预手段 Inte
15、rvention,SoR,QoE,文献 Reference,备注 Comment,在非免疫抑制患者中伴有空腔/结节肺浸润,Cavitary or nodular pulmonary infiltrate in Non-immunocompromised patients,诊断或排除慢性肺曲霉菌病,Diagnosis Or exclusion of CPA,肺泡灌洗液抗原,Antigen （BAL）,血清学抗原检测,Antigen （Serum）,痰培抗原检测,B,C,II,II,Izumikawa, 2012,Izumikawa,2012; Kono,2013; Shin,2014,血清和肺泡
16、灌洗液的抗原检测已经建立研究，但痰液的抗原尚未涉及,Antigen（Sputum）,No data,慢性肺曲霉菌病-抗体检测 Aspergillus antibody diagnosis of CPA,Present by David Denning,ECCMID 10th May 2015 in Barcelona,患者人群 Population,目的 Intention,干预手段 Intervention,SoR,QoE,文献 Reference,备注 Comment,在非免疫抑制患者中伴有空腔/结节肺浸润,Cavitary or nodular pulmonary infiltrate in Non-immunocompromised patients,诊断或排除慢性肺曲霉菌病,Diagnosis Or exclusion of CPA,曲霉抗体IgG,Aspergillus IgG antibody,Aspergillus IgM antibody,Aspergillus IgA a
