【作者】 姚佳峰；

【导师】 韩明哲；

【作者基本信息】 中国协和医科大学 ， 内科学， 2009， 博士

【摘要】 【目的】1.研究血清半乳甘露聚糖(galactomannan,GM,以下简称为GM试验)试验对血液病患者并发侵袭性曲霉病(invasive aspergillosis,IA)的早期诊断价值,并初步探讨动态监测IA患者抗真菌治疗前后血清GM水平与疗效的关系;2.探讨接受造血干细胞移植(hematopoietic stem cell transplantation,HSCT)治疗的患者在移植早期内动态监测血清半乳甘露聚糖水平对于早期诊断IA的临床应用价值,并分析移植早期内IFI发生的危险因素。【方法】1.研究对象分类按照我国血液病或恶性肿瘤患者侵袭性真菌感染的诊断标准与治疗原则(修订版),将入选患者分为确诊、临床诊断和拟诊IFI。对于可排除IFI患者归为对照组。2.采用双夹心酶联免疫吸附法(enzyme linked immunosorbent assay,ELISA)检测血清GM。具体操作严格按照试剂盒说明书进行,每一次操作均对试剂盒提供的阳性及阴性对照血清进行检测。【结果】1.对血液病患者并发IA的GM检测结果提示将单次≥0.7或连续两次≥0.5同时作为阳性界定值时,敏感性、特异性、阳性预测值、阴性预测值分别为88%、88.7%、64.7%、96.9%;在未加入GM检测结果前,仅17例临床诊断IA患者,其中4例出现主要影像学表现,阳性率为23.5%(4/17),186例拟诊IA患者中(160例患者有影像学资料)中主要影像学表现者24例,阳性率15%。而GM试验的阳性率分别为92.3%和85.7%。加入GM值后,临床诊断病例增至59例。GM阳性较痰培养结果提前平均5.9±4.3d(1-12d),比CT证据提早出现平均6.94±5.35d(0-15d);有效患者的GM水平随着治疗呈波动性下降,无效患者GM水平无变化或有升高;通过对排除IA患者的用药分析发现静脉应用哌拉西林-他唑巴坦假阳性率可达30%左右;而IA患者应用棘白霉素类抗真菌药物后血清GM水平早期略有上升,但总体呈下降趋势;2.45例接受HSCT患者经分析15例为拟诊IFI,其中13例为IA。在13例拟诊IA患者中有13例GM(+),其中9例连续2次及以上GM(+),中位感染时间移植后+11d(-2-+21)d,1例发生在预处理期间,12例发生在造血干细胞输注后,主要分布于+7-+21d。阳性出现时间较出现临床症状平均提前6.75(3-11)d;45例接受HSCT患者中27例出现至少1次GM(+),14例为假阳性,假阳性率43.8%(14/32)。其中13例出现连续2次及以上GM(+),4例为假阳性,假阳性率12.5%(4/32)。分析14例患者假阳性发生具体时间分别为7例为预处理后造血干细胞输注前出现,7例为造血干细胞输注后出现(其中6例进行检测前应用过哌拉西林-他唑巴坦),GM假阳性出现中位时间为+1(-8-+21)d;经logist回归进行多因素分析得出,IFI病史者P＜0.05,HR=9.113,为HSCT患者移植后早期IFI发生的危险因素;HSCT患者移植后1个月内IFI的累积发生率为33.3%(15/45)。【结论】1.GM试验对于侵袭性曲霉病感染的早期诊断具有重要意义。将I≥0.7或连续两次≥0.5两种界定值同时应用,与单用一种界定值相比,既可提高试验的灵敏度,又能达到理想的特异度。与其他诊断性的辅助检查相比,对于IA的早期诊断阳性检出率及检出时间方面,GM试验均明显优于主要影像学表现及直接微生物学证据。同时依据此标准(一定程度上)可以评价系统性抗真菌治疗效果。2.动态监测血清GM抗原水平有利于HSCT患者IA早期诊断,且以连续两次GM(+)为诊断标准,可明显减低假阳性率。HSCT患者预处理后GM假阳性发生率极高,而移植后1个月内IA多发生在+7天后,两者具有较明显的时间分布性。将标本采集时间间隔缩至每周2次更利于IA的早期诊断。同时对监测时间范围内的IFI发生的危险因素进行分析,结果显示既往有IFI病史者IFI发生率明显增高,有明显统计学差异。更多还原

【Abstract】 Objective1.To evaluate the value of serum galactomannan(GM) detection for early diagnosis of invasive aspergillosis(IA) in patients with hematological disease,and to explore the relationship between dynamic detection of serum GM level and anti-fungal treatment outcomes.2.To explore the cinical value on Dynamic detection of serum galactomannan for IA patients after early phase of hematopoietic stem cell transplantation(HSCT),and to analysis the risk factors of IFI in these patients.Methods1.According to the diagnostic criteria of invasive fungal infections in China,the suspicious IFI patients with hematological disease could be divided into proven、clinical and possible IFI patients.The group of excluded IFI patients was control group.2.The serum GM concentration of all the patients was detected by Platelia Aspergillus double-sandwich enzyme linked immunosorbent assay (PADSELISA).And the sensitivity,specificity and predictive values were calculated.Results1.The sensitivity、specificity、positive predictive values and negative predictive values of the PADSELISA were 88%、88.7%、64.7%and 96.9% respectively by using the cut-off value of single≥0.7 and/or consecutive≥0.5.Before GM test,there were 17 clinical IA patients,among which 4 patients had major CT imaging with positive rate of 23.5%.24 patients had major CT imaging in 186 possible IA patients with positive rate of 15%(total 160 patients had CT imaging).The positive rate of GM test were 92.3%and 85.7%respectively.After GM test,there were 59 clinical IA patients.GM positive results ahead sputum culture positive result 5.9 ±4.3d(1-12d),and ahead CT results 6.94±5.35d(0-15d);A progressive reduction of GM level was found in survivors,however,the patients of poor prognosis showed higher antigen titres.The GM false positive rate was about 30%in control group patients who using intravenous injection piperacillin-Tazobactam.The GM level of IA patients after using echinocandin was up in 1 day,and slowed down since that.2.There were total 15 possible IFI patients,in which 13 IA patients among the 45 HSCT patients.13 IA patients with 1 GM(+),and 9 IA patients with 2 consecutive GM(+).Median time of IA infection was +11d(-2-+21)d,1 IA patient was infected after pretreatment,while 12 IA patients happened after HSCT,mainly between +7-+21d.GM positive results ahead clinical symptoms 6.75(3-11)d.There were 27 patients at least 1 GM(+) among 45 HSCT patients.14 patients were GM false positive.The GM false positive rate was 43.8%(14/32).There was 13 patients who had consecutive GM(+).4 patients were GM false positive.The GM false positive rate was 12.5%(4/32).Analysing 14 false positive patients,7 patients happened after pretreatment and before HSCT,and 7 happened after HSCT(6 patients had piperacillin-Tazobactam before test).Median time of false positive was +1(-8-+21)d.By using logist-regression:IFI history increasing infection risk(P<0.05,OR=9.113).The add up happen rate of IFI in HSCT patiens during 1 month after HSCT was 33.3%(15/45).Conclusions1.The PADSELISA for GM detection is a reliable method for early diagnosis and treatment of IA in patients with hematological disease.Comparing with single value,sigle≥0.7 and/or consecutive≥0.5 both be used could increase the sensitivity and had no obviouse decrease on specificity. Comparing with other diagnostic accessory examination,for example,major CT imaging and direct microbiological,GM test had obviouse advantage on the positive rate and time.We can estimate the anti-fungal effect by dynamic detection of serum galactomannan.2.Dynamic detection of serum galactomannan after early phase of hematopoietic stem cell transplantation had clinical value on IA early diagnostic.GM false positive rate could be decreased by using consecutive GM(+).The high false positive rate usually happened after pretreatment,while IA infection mostly happened after +7d.That would be good to early diagnosis of IA that having serum sample twice 1 week.IFI history was IFI risk factor by using multi-regression.更多还原