慢性肺曲霉病的诊断与管理 江西省人民医院呼吸内科童波 2019 1 目录 慢性肺曲霉病的定义 慢性肺曲霉病的临床表现类型 慢性肺曲霉病的诊断 慢性肺曲霉病的管理 总结 2019 2 目录 慢性肺曲霉病的定义 慢性肺曲霉病的临床表现类型 慢性肺曲霉病的诊断 慢性肺曲霉病的管理 总结 2019 3 DefinitionsofCPA ThemostcommonformofCPAisCCPA Untreateditmayprogresstochronicfibrosingpulmonaryaspergillosis CFPA LesscommonmanifestationsofCPAincludeAspergillusnoduleandsingleaspergilloma Alltheseentitiesarefoundinnon immunocompromisedpatientswithpriororcurrentlungdisease Subacuteinvasivepulmonaryaspergillosis formerlycalledchronicnecrotisingpulmonaryaspergillosis isamorerapidlyprogressiveinfection 3months usuallyfoundinmoderatelyimmunocompromisedpatients D DENNINGETAL ESCMID ERSGUIDELINES EurRespirJ2015 2019 4 目录 慢性肺曲霉病的定义 慢性肺曲霉病的临床表现类型 慢性肺曲霉病的诊断 慢性肺曲霉病的管理 总结 2019 5 PresentbyDavidDenning ECCMID10thMay2015inBarcelona 慢性曲霉菌病临床表现分类ClinicalphenotypesofchronicAspergillussppdiseases 单发曲霉球Single simpleaspergilloma 慢性坏死性 亚急性肺曲霉菌病Chronicnecrotizingpulmonaryaspergillosis CNPA orsubacuteInvasiveaspergillosis SAI 慢性空腔性肺曲霉菌病Chroniccavitarypulmonaryaspergillosis CCPA 慢性纤维化肺曲霉菌病Chronicfibrosingpulmonaryaspergillosis CFPA 曲霉菌肉芽肿Aspergillusnodule s CCPA是最常见的CPA类型CCPA不治疗可进展为CFPA曲霉结节与单纯性曲霉肿较少见免疫功能受损患者常见SAIA 2019 6 CPA的分类与定义 CCPA 慢性空洞型肺曲霉病 CFPA 慢性纤维性肺曲霉病 SAIA 亚急性侵袭性曲霉病 慢性坏死性 半侵袭性曲霉病 D DENNINGETAL ESCMID ERSGUIDELINES EurRespirJ2015 2019 7 Single simple pulmonaryaspergillomaisasinglefungalballinasinglepulmonarycavity Thereisnoprogressionovermonthsofobservationandveryfew ifanypulmonaryorsystemicsymptomsandserologicalormicrobiologicalevidenceimplicatingAspergillusspp Simpleaspergillomathatdevelopedwithinapost tuberculouscicatricialatelectasisoftheleftupperlobewithsaccularbronchiectasis Surgicalresectionbyvideo assistedthoracicsurgerywasperformedbecauseofrecurrenthaemoptysisandarequirementforanticoagulanttherapy D DENNINGETAL ESCMID ERSGUIDELINES EurRespirJ2015 2019 8 CCPA formerlycalledcomplexaspergilloma usuallyshowsmultiplecavities whichmayormaynotcontainanaspergilloma inassociationwithpulmonaryandsystemicsymptomsandraisedinflammatorymarkers overatleast3monthsofobservation Untreated overyears thesecavitiesenlargeandcoalesce developingpericavitaryinfiltratesorperforatingintothepleura andanaspergillomamayappearordisappear ThusserologicalormicrobiologicalevidenceimplicatingAspergillusspp isrequiredfordiagnosis Chroniccavitarypulmonaryaspergillosisshowingmarkedprogressionbetweena 2007andb 2012 Chestradiographspriorto2007 i e 1990s showed upperlobefibrosis withoutafirmdiagnosis Alargecavitywithpleuralthickeningisvisibleontheleftinbothimages withadditionalsmallcavitiesinferiorlyin2012 andcontractionoftheleftupperlobe Therightsideshowsintervaldevelopmentofalargecavity withsomepleuralthickening Neithercavitycontainsafungalball a b 2019 9 Imagingshowingchroniccavitarypulmonaryaspergillosisshowinganaxialviewwitha lungandb mediastinalwindowsattheleveloftherightupperlobe Multiplecavitiesarevisiblewithafungusballlyingwithinthelargestone Thewallofthecavitiescannotbedistinguishedfromthethickenedpleuraortheneighbouringalveolarconsolidation Theextrapleuralfatishyperattenuated whitearrows thedilatedoesophagusshouldnotbeconfusedwithacavity a b 2019 10 CFPAisoftenanendresultfromuntreatedCCPA ExtensivefibrosiswithfibroticdestructionofatleasttwolobesoflungcomplicatingCCPA leadingtoamajorlossoflungfunction Usuallythefibrosisissolidinappearance butlargeorsmallcavitieswithsurroundingfibrosismaybeseen SerologicalormicrobiologicalevidenceimplicatingAspergillusspp isrequiredfordiagnosis Oneormoreaspergillomasmaybepresent Imagingofchronicfibrosingpulmonaryaspergillosiscomplicatingchroniccavitarypulmonaryaspergillosis whichfollowedtuberculosis withmildchronicobstructivepulmonarydisease Completeopacificationofthelefthemi thoraxdevelopedbetweenFebruary1998 whenaleftupperlobecavitywithafluidlevelwaspresent andMay1999 Multipleleftlungautopsypercutaneousbiopsiesshowedevidenceofchronicinflammation butnogranulomasorfungalhyphae 2019 11 Oneormorenodules 3cm whichdonotusuallycavitate areanunusualformofCPA Theymaymimiccarcinomaofthelung metastases cryptococcalnodule coccidioidomycosisorotherrarepathogensandcanonlybedefinitivelydiagnosedonhistology NodulesinpatientswithrheumatoidarthritismaybepurerheumatoidnodulesorcontainAspergillus Tissueinvasionisnotdemonstrated althoughnecrosisisfrequent Sometimeslesionslargerthan3cmindiameterareseenandmayhaveanecroticcentre Thesearenotwelldescribedintheliteratureandarebestdescribedas masslesionscausedbyAspergillusspp SuccessiveaxialviewswithinthelungwindowshowingAspergillusnodules ofvariablesizeandborders andafungusballfillingacavitywithawallofvariablethicknessinapatientwithpre existingbronchiectasisandcicatricialatelectasisofthemiddlelobe Aspergillusnodule s 2019 12 Subacuteinvasiveaspergillosis SAIA waspreviouslytermedchronicnecrotisingorsemi invasivepulmonaryaspergillosis SAIAoccursinmildlyimmunocompromisedorverydebilitatedpatientsandhassimilarclinicalandradiologicalfeaturestoCCPAbutismorerapidinprogression SAIAtypicallyoccursinpatientswithdiabetesmellitus malnutrition alcoholism