骨髓培养在儿童侵袭性真菌病中的诊断意义

A thesis(dissertation)submitted toZhengzhou Universityfor the degree of Master(doctor)The Significance Of Bone Marrow Culture On the DiagnosisOf Invasive Fungal Disease In ChildrenBy Yuzhen LiSupervisor：ProfShao PengDepartment of PediatricsThe First Affiliated HospitalMay，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(invasive fungal disease，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57天，效果不佳。(2)76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。(3)33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)。(4)76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4349例(88)，且以白色念珠菌为主，为2249例(45)；新型隐球菌和烟曲霉菌分别为449例(8)和249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(f=506，P005)。(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5357、6857、5769和6486；骨髓培养为4545、100、100和7049；血培养为1515、9767、8333和6000。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SPSSl70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0788，95CI为0662-0915。痰培养诊断IFD的AUC为O63 1，95CI为0488-0774。血培养诊断IFD的AUC为O596，95CI为0448-0744。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IIIAbstractThe Significance Bone Marrow Culture On theDiagnosis Of Invasive Fungal Disease In ChildrenPostgraduate：LI Yu-zhenSupervisor：PENG ShaoDepartment of Pediatrics，the First Affiliated Hospital of Zhengzhou UniversityZhengzhou 450052，ChinaAbstractBackground and 0bjectivePathogenic fungus invading the deep tissue of body and blood can grow andreproduce，resulting in the damage and dysfunction of our organsIn the past 20 years，the incidence of IFD increased gradually,which may be associated with widespreaduse of broadspectrum antibiotics，corticosteroids and other immunosuppressiveagents，anticancer drugs，invasive technology development such as tracheal intubation，indwelling catheter and others，as well as the improvement of diagnostic level on IFDIFD in children happen obscurely,but last longer,which is lack of specific symptomsand signs，with a high mortality rate，threating to childrens health and safetyTherefore，how to make a rapid and accurate diagnosis of fungal infection in patientshas become a serious challenge for a11 pediatriciansCulture and identification of theetiology has important significance in the diagnosis of infectious diseasesHowever，itis often neglected easily by many clinicians because its positive rate is lowWe haveobserved that in clinic work，bone marrow culture positive rate among the suspectedIFD patients is higher than blood culture，SO the bone marrow culture has a certainsignificance in diagnosis of fungal infection in pediatric patientsThere is no studyand information on this at home and abroadIn this study,we summarized the sputumIV垒!坚垡 一一一culturebone marrow culture and blood culture in our hospital in recent years锄ongchild僦suspected with IFD，and compared the results，SO as to explore the diagnosticsignificance of lFD training on childrens bone marrowMethodsAccording to the inclusio。n criteria,children who were suspected of sufferingnDminvasive缸19a1 infection in pediatric intensive care unit(PICU)of the First AffiliatedHospital of Zhengzhou University were enrolled in this studyTheyall were takenblood and blood marrow to culture in this studyChildern with espiratory systeminv01veIIlent were taken sputum cultureWe recorded the information and the clinicalmanifest撕on of the children all until their temperature returned to normal，otherclinical s卿toms and signs improved，laboratory indicators got better,beingexcluded me dia毋osis of invasive fungal disease，or termination the treatment askedbv their陆nily membersAccording to the record，we summarized and generallzed tnegeneral caSe of the researched object，recorded the results of fungal cultureThenwecomDared the results of blood culture，sputum culture and bone marrow叫lture bYuseing of StatiStical methods，a11d calculated the sensitivity,specificity,PoslnVepredictive value and negative predictive value of them both retrospectivelyWiththehelp of Statistical software SPSS 1 70，we could drow the ROC of curvebone m舡owculture，spl】t11m culture and blood culture in the diagnosis of IFD in children，a11dmade comparisons of area under the curve eachResultsA total of 76 patients were enrolled in this study(I)Among them，th饿w盯e I萏cases who were su鼢ing from malignant blood system diseases，29 cases who wereundergoing the treatment of primary diseases requiring long-termuse o士homones，ycaSes of children with critical illness，2 cases who were alreadytaken allogenelchematoDoietic stem cell transplantation，and 1 8 cases who were in 900d health，without r印eating infection history and basic disease，and 36 patients had contactwith chickens，dove，et a1All of the patients had already been administeredNAbstractbroad-spectrum antibiotics in the hospital for 5-7 days，but the effect was poor(2)76patients with confirmed cases in 22 cases，7 cases of clinically diagnosed cases，suspected cases，4 cases of 33 casesExclude the diagnosis IFD 43 example(3)33cases of patients wil IFD organ involvement were：lung in 28 cases(85)，liver andspleen in 1 8 cases(54)，lymph nodes in 1 4 patients(42)，intestinal in 1 4 patients(42)，nervous system cases(1)(4)There were cultured 49 strains of fungiBonemarrow cultures were positive in 15 cases，including 13 cases of(1315)the timerequired for72hBlood culture Was positive in 6 cases，the detection time is96hSputum culture Was positive in 26 cases；urine cultures were positive in 2 CasesCandida fungi is the most common types，4349 cases(88)，and Candida albicansWas the main species，2249 cases(45)；Cryptococcus neoformans and Aspergillusfumigatus were 449 cases(8)and 249(4cases)each(5)Compared with bonemarrow culture and blood culture results，the difference Was statistically significant(=506，P005)(6)Results of sensitivity,specificity,positive predictive value andnegative predictive value for bone marrow culture，sputum culture and blood culturewere 4545、100、100and 7049；5357、6857、5769and 6486；1515、9767、8333and 6000respectivelySputum culture and bone marrowculture have a higher sensitivity,and bone marrow culture and blood culture has ahigher specificity(7)With the application of SPSS 1 70 Statistical software，wedrowed the ROC curve of the bone marrow culture，sputum culture and blood cultureon the diagnosis of IFD，AUC of bone marrow culture Was O788，95CI W