摘要
目的总结变应性支气管肺曲霉病(ABPA)的临床特征,分析其漏诊原因。方法回顾性分析2014年10月至2017年11月就诊于山东大学齐鲁医院并确诊ABPA的患者临床资料,包括一般资料及外周血嗜酸粒细胞计数、血清总IgE、烟曲霉特异性抗体(sIgE、sIgG及sIgM)、肺功能以及胸部CT等指标,对血清总IgE、sIgE与第一秒用力呼气量(FEV1)占预计值的百分比(FEV1预计值%)及FEV1与用力肺活量(FVC)的比值(FEV1/FVC)的相关性进行分析。总结患者的临床特征,分析其漏诊原因。结果ABPA患者共计46例,其中男21例,女25例,年龄(48.3±13.2)岁。首次出现症状后就诊即确诊者仅2例(4.3%),其余44例(95.7%)确诊前反复治疗多年,最长达40年。确诊前被误诊为支气管哮喘(简称哮喘)26例(56.5%),支气管扩张(支扩)13例(28.3%),肺炎4例(8.7%),肺结核3例(6.5%),肺癌4例(8.7%);ABPA患者常见的症状包括咳嗽、咳痰、喘息、胸闷、发热、体重减轻、胸痛等;37例(80.4%)外周血嗜酸粒细胞计数增高;37例(80.4%)血清总IgE>1 000 U/ml,9例(19.6%)总IgE<1 000 U/ml;sIgE、sIgG及sIgM的阳性率分别为100.0%、89.1%及54.3%;46例均行肺功能检查,35例(58.7%)伴阻塞性通气功能障碍,5例(10.9%)伴混合性通气功能障碍;5例(10.9%)肺通气功能正常,1例(2.2%)伴限制性通气功能障碍。患者均行胸部CT检查,其中支扩28例(60.9%),黏液栓8例(76.1%)(其中4例为高密度黏液栓),其他非典型影像学10例(21.7%)。血清总IgE、sIgE与FEV1预计值%及FEV1/FVC均无相关性。结论ABPA的主要特征为反复发作的喘息,游走性的肺部阴影和支扩。漏诊原因主要为:症状不典型性、诱发疾病的多样性、早期不典型的影像学改变、筛查指标使用的限制及误区、肿瘤标志物的干扰及混合类型的曲霉菌病的存在。真菌致敏的程度与哮喘发作的严重程度无关。
Objective To summarize the clinical features of allergic bronchopulmonary aspergillosis (ABPA) and analyze the common causes of missed diagnosis. Methods The clinical data of patients with ABPA who were admitted into Qilu Hospital of Shandong University from October 2014 to November 2017 were retrospectively analyzed, including baseline data, eosinophil count in peripheral blood, serum total IgE, A. fumigates-specific antibody (sIgE, sIgG and sIgM), pulmonary function tests and chest CT, etc. Then the correlations between serum total IgE, sIgE and forced expiratory volume in one second (FEV1) as percentage of predicted value (FEV1%pred) was conducted, as well as that between serum total IgE, sIgE and FEV1/forced vital capacity (FEV1/FVC). The clinical features of the patients were summarized and the causes of missed diagnosis were analyzed. Results There were 46 patients with ABPA (21 males and 25 females, 48.3±13.2 years old) in total. Only 2 cases (4.3%) were diagnosed after the first symptom onset, and 44 cases (95.7%) were treated repeatedly for many years before being diagnosed. The misdiagnoses were asthma (26 cases, 56.5%), bronchiectasis (13 cases, 28.3%), pneumonia (4 cases, 8.7%), pulmonary tuberculosis (3 cases, 6.5%), and lung cancer (4 cases, 8.7%). Common symptoms of ABPA included cough, expectoration, wheezing, chest tightness, fever, weight loss, chest pain, etc. Peripheral blood eosinophil count increased in 37 patients (80.4%). Serum total IgE in 37 patients (80.4%) were higher than 1 000 U/ml, and 9 cases (19.6%) were less than 1 000 U/ml. The positive rate of sIgE, sIgG and sIgM was 100.0%, 89.1% and 54.3%, respectively. All patients underwent pulmonary function tests and 35 cases (76.1%) had obstructive ventilation dysfunction, 5 cases (10.9%) with mixed ventilation dysfunction, 5 cases (10.9%) were normal and 1 case (2.2%) with restrictive ventilation dysfunction. All patients underwent Chest CT examination, 28 cases (60.9%) showed bronchiectasis, 8 cases (17.4%) manifested mucus plugs (among them, 4 cases with high-attenuation mucus) and 10 cases (21.7%) had other atypical imaging. Serum total IgE and sIgE had no correlations with FEV1%pred and FEV1/FVC. Conclusions ABPA is characterized by recurrent episodes of wheezing, fleeting pulmonary opacities and bronchiectasis. The main reasons of misdiagnosis in ABPA patients were: atypical symptoms, variety of predisposing diseases, early atypical imaging changes, limitations and misunderstandings of screening indicators, interference with tumor markers, and the presence of pulmonary aspergillus overlap syndrome. The severity of asthma attacks is not related to the degree of fungal sensitization.
作者
邹敏芳
李硕
杨燕
曹丽丽
潘云
孙恩华
董亮
Zou Minfang;Li Shuo;Yang Yan;Cao Lili;Pan Yun;Sun Enhua;Dong Liang(Department of General Medicine,Qilu Hospital of Shandong University,Jinan 250012,China;Department of Respiratory and Critical Care Medicine,Qilu Hospital of Shandong University,Jinan 250012,China;Department of Otolaryngology,Qilu Hospital of Shandong University,Jinan 250012,China;Department of Bacterial Culture Clinical Laboratory,Qilu Hospital of Shandong University,Jinan 250012,China)
出处
《中华医学杂志》
CAS
CSCD
北大核心
2019年第16期1221-1225,共5页
National Medical Journal of China
基金
国家自然科学基金(81770029)
山东省重点研发计划(2017GSF218056)
济南市科技计划(201821056).
关键词
曲霉菌病
变应性支气管肺
哮喘
疾病特征
诊断
Aspergillosis, allergic bronchopulmonary
Asthma
Disease attributes
Diagnosis
