单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,2019/9/30,#,EFISG,European Society of Clinical Microbiology and Infection Diseases,ESCMID Fungal Infectious Study Group,Only for internal learning or discussion,forbidden for any other purpose,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 10,th,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,2014 ESCMID曲霉菌病治疗指南-慢性肺曲霉病2014,1,Present by,David Denning,ECCMID 10,th,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(CFPA),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 ECCMI,2,Present by,David Denning,ECCMID 10,th,May 2015 in Barcelona,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,pulmonary aspergillosis(CFPA),曲霉菌肉芽肿,Aspergillus nodule(s),Present by David Denning ECCMI,3,Present by,David Denning,ECCMID 10,th,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 fibrosing pulmonary aspergillosis(CFPA),Present by David Denning ECCMI,4,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 microbiological 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）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).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;actinomycosis.Active bacterial infection,including mycobacterial infection and/or malignancy may occur concurrently.Mycobacterial infections or malignancy may mimic CPA.,Present by,David Denning,ECCMID 10,th,May 2015 in Barcelona,慢性肺曲霉菌病-诊断标准需要满足以下条件：1.1 CT影像学,5,慢性肺曲霉菌病,-,气道标本的诊断,Respiratory specimen diagnosis of CPA,Present by,David Denning,ECCMID 10,th,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,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,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-气道标本的诊断Present by Davi,6,慢性肺曲霉菌病,-,抗原检测,Antigen diagnosis of CPA,Present by,David Denning,ECCMID 10,th,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,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,dat