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骨髓培养在儿童侵袭性真菌病中的诊断意义

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骨髓培养在儿童侵袭性真菌病中的诊断意义

AthesisdissertationsubmittedtoZhengzhouUniversityforthedegreeofMasterdoctorTheSignificanceOfBoneMarrowCultureOntheDiagnosisOfInvasiveFungalDiseaseInChildrenByYuzhenLiSupervisorProf.ShaoPengDepartmentofPediatricsTheFirstAffiliatedHospitalMay,2013原创性声明本人郑重声明所呈交的学位论文,是本人在导师的指导下,独立进行研究所取得的成果。除文中已经注明引用的内容外,本论文不包含任何其他个人或集体已经发表或撰写过的科研成果。对本文的研究作出重要贡献的个人和集体,均已在文中以明确方式标明。本声明的法律责任由本人承担。学位论文作者杏玉嗲日期2。B年争月仰日学位论文使用授权声明本人在导师指导下完成的论文及相关的职务作品,知识产权归属郑州大学。根据郑州大学有关保留、使用学位论文的规定,同意学校保留或向国家有关部门或机构送交论文的复印件和电子版,允许论文被查阅和借阅本人授权郑州大学可以将本学位论文的全部或部分编入有关数据库进行检索,可以采用影印、缩印或者其他复制手段保存论文和汇编本学位论文。本人离校后发表、使用学位论文或与该学位论文直接相关的学术论文或成果时,第一署名单位仍然为郑州大学。保密论文在解密后应遵守此规定。学位论文作者奎玉珍日期2。15年g月11日摘要骨髓培养在儿童侵袭性真菌病中的诊断意义背景和目的研究生李玉珍导师彭韶教授郑州大学第一附属医院河南郑州450052摘要侵袭性真菌病invasivefungaldisease,IFD是指致病真菌侵入人体深部组织、血液,并在其中生长、繁殖所导致的组织、器官损害和功能障碍的疾病。在过去的20年时间,IFD的发病率逐渐升高,这可能与广谱抗生素、糖皮质激素及其它免疫抑制剂、抗肿瘤药物的普遍应用,气管插管、导管留置等侵入性诊疗技术的开展,以及临床医生对IFD的认识和诊断水平的不断提高有关。儿童IFD具有起病隐匿、发病时间较长、临床表现缺乏特异性症状和体征、死亡率高等特点,严重威胁着儿童的健康和生命安全。因此,如何对真菌感染患者做出快速、准确的诊断和有效的治疗,已成为所有儿科医生必须面对的考验之一。病原学培养和鉴定对诊断感染性疾病具有重要的意义,但由于其阳性率低,常常被许多临床医生所忽视。我们在长期的临床工作中观察到,对怀疑IFD的患儿进行骨髓培养,其阳性率较血培养高,骨髓培养对儿童IFD的诊断有一定的意义。目前国内外尚缺乏关于这一方面的资料,为此本研究总结我院近年来疑似IFD患儿的骨髓培养、痰培养和血培养结果,并对三者进行比较,从而探讨骨髓培养对儿童IFD的诊断意义。摘要方法选择2010年10月.2012年10月在我院儿内科、儿童重症监护病房PICU发热持续7天以上,具有真菌感染宿主/危险因素如有基础性疾病、应用免疫抑制剂、接触真菌环境等,且抗生素治疗效果差的住院病人进行骨髓培养和血培养,呼吸系统受累者进行痰培养,根据病情选择实验室检验、影像学和组织病理学检查,记录患者一般资料和检查结果,直至患者体温恢复正常,临床表现和体征好转,实验室指标好转,或排除诊断侵袭性真菌病,或家属要求出院。总结研究对象的一般情况,记录真菌培养结果。运用统计学方法对血培养和骨髓培养结果进行比较,并分别计算痰培养、血培养和骨髓培养的灵敏度、特异度、阳性和阴性预测值。分别绘制痰培养、骨髓培养和血培养诊断儿童IFD的ROC曲线,对比曲线下面积。牯甲当日7尺共76例患者入选本次研究。1原发性疾病为血液系统恶性疾病者18例,原发性疾病治疗需长期服用激素者29例,儿童危重症者9例,异体造血干细胞移植受者2例。既往体健,无反复感染病史和基础疾者18例。36例患者曾接触过鸡群、鸽群等真菌环境。所有患者均于外院或本院给予广谱抗生素应用5.7天,效果不佳。276例患者中,确诊病例22例,临床诊断病例7例,拟诊病例4例,共33例。排除诊断IFD43例。333例IFD患者器官受累情况为肺28例85%,肝脾18例54%,淋巴结14例42%,肠道14例42%,神经系统1例1%。476例患者共培养出49株真菌。骨髓培养阳性共15例血培养阳性6例,其中1例白色念珠菌考虑定植或污染可能性大痰培养阳性26例尿液培养阳性2例。真菌类型以念珠菌最多,占43/49例88%,且以白色念珠菌为主,为22/49例45%新型隐球菌和烟曲霉菌分别为4/49例8%和2/49例4%。5骨髓培养和血培养阳性率相比较,两者的差异具有统计学意义f5.06,P0.05。6分别计算痰培养、骨髓培养和血培养的灵敏度、特异度、阳性预测值和阴性预测值,痰培养为53.57%、68.57%、57.69%和64.86%骨髓培养为45.45%、100%、100%和70.49%血培养为15.15%、97.67%、83.33%和60.00%。痰培养和骨髓培养的灵敏度较高,骨髓培养和血培养的特异度较高。II摘要7应用SPSSl7.0分别绘制骨髓培养、痰培养和血培养诊断儿童IFD的ROC曲线,骨髓培养诊断IFD的AUC为0.788,95%CI为0.6620.915。痰培养诊断IFD的AUC为O.631,95%CI为0.4880.774。血培养诊断IFD的AUC为O.596,95%CI为0.4480.744。痰培养和血培养的ROC曲线均位于骨髓培养ROC曲线的下方,提示骨髓培养对儿童IFD的诊断性优于痰培养和血培养的诊断性。结论1儿童IFD的不良预后率较高,临床表现和体征缺乏特异性,念珠菌仍为儿童IFD最常见的致病菌。2骨髓培养特异性高,对儿童侵袭性真菌病具有确诊价值,且其诊断性优于痰培养和血培养,可以提高真菌病原学的检出率。3真菌药敏试验结果为临床治疗提供了有价值的信息。关键词骨髓培养血培养儿童侵袭性真菌病IIIAbstractTheSignificanceBoneMarrowCultureOntheDiagnosisOfInvasiveFungalDiseaseInChildrenPostgraduateLIYuzhenSupervisorPENGShaoDepartmentofPediatrics,theFirstAffiliatedHospitalofZhengzhouUniversityZhengzhou450052,ChinaAbstractBackgroundand0bjectivePathogenicfungusinvadingthedeeptissueofbodyandbloodcangrowandreproduce,resultinginthedamageanddysfunctionofourorgans.Inthepast20years,theincidenceofIFDincreasedgradually,whichmaybeassociatedwithwidespreaduseofbroad.spectrumantibiotics,corticosteroidsandotherimmunosuppressiveagents,anticancerdrugs,invasivetechnologydevelopmentsuchastrachealintubation,indwellingcatheterandothers,aswellastheimprovementofdiagnosticlevelonIFD.IFDinchildrenhappenobscurely,butlastlonger,whichislackofspecificsymptomsandsigns,withahighmortalityrate,threatingtochildrenshealthandsafety.Therefore,howtomakearapidandaccuratediagnosisoffungalinfectioninpatientshasbecomeaseriouschallengefora11pediatricians.Cultureandidentificationoftheetiologyhasimportantsignificanceinthediagnosisofinfectiousdiseases.However,itisoftenneglectedeasilybymanycliniciansbecauseitspositiverateislow.Wehaveobservedthatinclinicwork,bonemarrowculturepositiverateamongthesuspectedIFDpatientsishigherthanbloodculture,SOthebonemarrowculturehasacertainsignificanceindiagnosisoffungalinfectioninpediatricpatients.Thereisnostudyandinformationonthisathomeandabroad.Inthisstudy,wesummarizedthesputumIV垒坚垡一一一culture.bonemarrowcultureandbloodcultureinourhospitalinrecentyears锄ongchild僦suspectedwithIFD,andcomparedtheresults,SOastoexplorethediagnosticsignificanceoflFDtrainingonchildrensbonemarrowMethodsAccordingtotheinclusio。ncriteria,childrenwhoweresuspectedofsufferingnDminvasive缸19a1infectioninpediatricintensivecareunitPICUoftheFirstAffiliatedHospitalofZhengzhouUniversitywereenrolledinthisstudy.Theyallweretakenbloodandbloodmarrowtocultureinthisstudy.Childernwithespiratorysysteminv01veIIlentweretakensputumculture.Werecordedtheinformationandtheclinicalmanifest撕onofthechildrenalluntiltheirtemperaturereturnedtonormal,otherclinicals卿tomsandsignsimproved,laboratoryindicatorsgotbetter,beingexcludedmedia{毋osisofinvasivefungaldisease,orterminationthetreatmentaskedbvtheir陆nilymembers.Accordingtotherecord,wesummarizedandgenerallzedtnegeneralcaSeoftheresearchedobject,recordedtheresultsoffungalcultureThenwecomDaredtheresultsofbloodculture,sputumcultureandbonemarrow叫lturebYuseingofStatiSticalmethods,a11dcalculatedthesensitivity,specificity,PoslnVepredictivevalueandnegativepredictivevalueofthembothretrospectively.WiththehelpofStatisticalsoftwareSPSS17.0,wecoulddrowtheROCofcurvebonem舡owculture,spl】t11mcultureandbloodcultureinthediagnosisofIFDinchildren,a11dmadecomparisonsofareaunderthecurveeach.ResultsAtotalof76patientswereenrolledinthisstudy.IAmongthem,th饿w盯eI萏caseswhoweresu鼢ingfrommalignantbloodsystemdiseases,29caseswhowereundergoingthetreatmentofprimarydiseasesrequiringlongtermuseo士homones,ycaSesofchildrenwithcriticalillness,2caseswhowerealreadytakenallogenelchematoDoieticstemcelltransplantation,and18caseswhowerein900dhealth,withoutr印eatinginfectionhistoryandbasicdisease,and36patientshadcontactwithchickens,dove,eta1.AllofthepatientshadalreadybeenadministeredNAbstractbroadspectrumantibioticsinthehospitalfor57days,buttheeffectwaspoor.276patientswithconfirmedcasesin22cases,7casesofclinicallydiagnosedcases,suspectedcases,4casesof33cases.ExcludethediagnosisIFD43example.333casesofpatientswiⅡlIFDorganinvolvementwerelungin28cases85%,liverandspleenin18cases54%,lymphnodesin14patients42%,intestinalin14patients42%,nervoussystemcases1%.4Therewerecultured49strainsoffungi.Bonemarrowcultureswerepositivein15cases,including13casesof13/15thetimerequiredfor72h.BloodcultureWaspositivein6cases,thedetectiontimeis96h.SputumcultureWaspositivein26casesurinecultureswerepositivein2Cases.Candidafungiisthemostcommontypes,43/49cases88%,andCandidaalbicansWasthemainspecies,22/49cases45%CryptococcusneoformansandAspergillusfumigatuswere4/49cases8%and2/494%caseseach.5Comparedwithbonemarrowcultureandbloodcultureresults,thedifferenceWasstatisticallysignificant∥5.06,P0.05.6Resultsofsensitivity,specificity,positivepredictivevalueandnegativepredictivevalueforbonemarrowculture,sputumcultureandbloodculturewere45.45%、100%、100%and70.49%53.57%、68.57%、57.69%and64.86%15.15%、97.67%、83.33%and60.00%respectively.Sputumcultureandbonemarrowculturehaveahighersensitivity,andbonemarrowcultureandbloodculturehasahigherspecificity.7WiththeapplicationofSPSS17.0Statisticalsoftware,wedrowedtheROCcurveofthebonemarrowculture,sputumcultureandbloodcultureonthediagnosisofIFD,AUCofbonemarrowcultureWasO.788,95%CIWas0.662~0.915.AUCofsputumcultureWasO.631,95%CIWas0.488~0.774.AUCofbloodcultureWasO.596,95%CIWas0.448~O.744.TheROCcurveofbonemarrowcultureandsputumculturewerebelowtheROCcurveofbloodculture,prompRingthatthevalueofbonemarrowcultureonthediagnosisIFDinchildrenWasbetterthanthatoftheothersConclusions1ThebadprognosisinchildrenwithIFDrateishigh,andtheclinicalmanifestationsandsignsarelackofspecificity.CandidaalbicanisstillthemostVIAbstractcommonpathogeninIFDinchildren.2Bonemarrowculturehasahie,hspecificity,andthediagnosisvalueisbetterthanthesputumcultureandbloodculture,whichCanimprovethedetectionoffungalpathogens.3Fungalsusceptibilitytestresultsprovidevaluableinformationforclinicaltreatment.rKeywordsbonemarrowculturebloodculturechildreninvasivefungaldiseaseVII

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