| BackgroundPulmonary fungal disease(PFD)refers to the related diseases caused by acute and chronic inflammation or pathological damage of lung tissue caused by fungi directly invading the lung or its bronchus.It is the most common deep fungal disease,which is common in people with underlying diseases or immune dysfunction.In recent years,due to the wide application of broad spectrum antibiotics,immunosuppressants,antitumor drugs,glucocorticoids and cytotoxic drugs,the rise of in vivo interventional therapy,the extensive development of organ transplantation and hematopoietic stem cell transplantation,as well as malignant tumors,diabetes and autoimmune diseases,immunodeficiency disease,such as the quantity of HIV/AIDS patients,the incidence of pulmonary fungal diseases are constantly increasing.Studies have shown that pulmonary fungal diseases not only tend to occur in immunocompromised patients,but also gradually increases in immunocompetent patients,with longer treatment cycle,more drug-related adverse reactions,higher mortality and poor prognosis.Wang et al.reported that among 187 patients with pulmonary fungal diseases diagnosed by pathology in Peking Union Medical College Hospital from 2001 to 2015,aspergillus was the most common pathogen,followed by cryptococcus,mucor,histoplasma,candida and pneumocystis.The multicenter retrospective study conducted by Liu et al.showed that the most common pathogen was aspergillus,followed by candida,cryptococcus,pneumocystis and mucor.At present,the literature reports on the distribution of strains are inconsistent.At present,most studies at home and abroad focus on immunocompromised pulmonary fungal diseases,while there are relatively few studies on immunocompetent pulmonary fungal diseases.Due to the lack of specific clinical and imaging manifestations,clinicians have limited knowledge of pulmonary fungal diseases in immunocompetent patients.Compared with immunocompromised patients,immunocompetent patients with pulmonary fungal diseases are more difficult to diagnose and more likely to be misdiagnosed,resulting in some patients may receive unnecessary antibiotics and surgical treatment.Therefore,this paper discusses the differences of bacterial distribution and clinical characteristics of patients with pulmonary fungal diseases in different immune states diagnosed by pathology,so as to provide more theoretical basis and reference for clinicians to improve their understanding of pulmonary fungal diseases and for the early diagnosis and treatment of such patients.ObjectiveThis study aims to investigate the distribution,clinical characteristics,treatment plan and prognosis of patients with pulmonary fungal diseases in different immune states,so as to provide a theoretical basis for clinicians to improve their understanding and early diagnosis and treatment of pulmonary fungal diseases.Method1.A total of 256 inpatients with pathological diagnosis of pulmonary fungal diseases who were admitted to the First Affiliated Hospital of Zhengzhou University from January 2018 to October 2021 were selected as the research objects.According to the different immune status of the patients,they were divided into immunocom promised group(n=129)and the immunocompetent group(n=127).2.Retrospective analysis of strains distribution,age,gender,basic disease,drug application(wide-spectrum antibiotics,cytotoxic drugs,glucocorticoids,antitumor drugs,etc.),individual history,clinical symptoms,signs,hematological indicators(blood routine,liver function,inflammatory indicators,fungi indicators),microbiology examination(tissue culture,metagenomics next generation sequencing,sputum culture,dyed light microscopy,bronchoalveolar fluid lavage culture,etc.),chest CT examination,bronchoscopy,treatment plan,adverse drug reactions and prognosis.3.SPSS 23.0 statistical software and GraphPad Prism 8.0 were used to analyze and plot the data in this study.Normally distributed measurement data are expressed as mean ± standard deviation,non-normally distributed measurement data are expressed as median(P25,P75)and interquartile range(Q),and categorical variables are expressed as counts or percentages.The t-test was used to compare the normally distributed measurement data between two independent groups with equal variance,the Mann-Whitney U test was used to compare the non-normally distributed measurement data between groups,and the χ2 test or corrected χ2 test or fisher’s exact probability method was used to compare the categorical variables between groups.P<0.05 was considered statistically significant.Result1.Analysis of species distribution of PFDPathologically diagnosed pulmonary fungal diseases pathogens in 256 cases were aspergillus in 155 cases(60.5%),cryptococcus in 67 cases(26.2%),mucor in 29 cases(11.3%),pneumocystis in 3 cases(1.2%),candida in 1 case(0.4%)and actinomycetes in 1 case(0.4%).In this study,there were 129 cases in the immunocompromise group and 127 cases in the immunocompetent group,and the immunocompetent group accounted for 47.9%of all patients.The incidence of underlying diseases and pulmonary mucormycosis in the immunocompromise group was higher than that in the immunocompetent group,and the incidence of pulmonary cryptococcosis in the immunocompromise group was lower than that in the immunocompetent group(P<0.05).2.Clinical characteristics of PFD with different immune status(1)Baseline analysis:The age and the proportion of glucocorticoid/immunosuppressant application history in immunocompromise group was higher than those in immunocompetent group(57years old vs.53 years old,P=0.022;31.0%vs.0.0%,P<0.001).The top three underlying diseases were hypertension in 64 cases(25.0%),diabetes in 60 cases(23.4%);and pulmonary underlying diseases in 45 cases(17.6%),including bronchiectasis,chronic obstructive pulmonary disease,old tuberculosis,and bronchial asthma.The incidence of hypertension,diabetes,solid malignant tumor,cirrhosis,autoimmune disease,chronic kidney disease,and hematological diseases in the immunocompromised group was higher than that in the immunocompetent group(33.3%vs.16.6%,P=0.002;46.6%vs.0.0%,P<0.001;25.6%vs.0.0%,P<0.001;19.4%vs.0.0%,P<0.001;15.5%vs.0.0%P<0.001;8.5%vs.0.0%,P=0.001;7.0%vs.0.0%,P=0.007).(2)Clinical features:Pulmonary fungal disease is the most common clinical symptoms to cough,and the number of fever cases in the immunocompromised group was higher than that in the immunocompetent group(45.0%vs.26.8%;P=0.002).(3)Laboratory test results:The proportion of blood glucose,erythrocyte sedimentation rate,C-reaction protein,Procalcitonin in the immunocompromised group higher than the immunocompetent group(5.33mmol/L vs.4.77mmol/L,P<0.001;31mm/h vs.12mm/h,P<0.001;8.22mg/L vs.3.14mg/L,P=0.001;0.05ng/ml vs.0.031ng/ml,P<0.001),the percentage of hemoglobin,lymphocytes,total protein,albumin in the immunocompromised group were lower than those in the immunocompetent group(121g/L vs.129g/L,P<0.001;1.31×109/L vs.1.69×109/L,P=0.004;(65.11±7.55)g/L vs.(68.43±6.56)g/L,P<0.001;38.2g/L vs.41.4g/L,P<0.001).(4)Chest CT features and bronchoscopy:The most common lesions were multiple lobes,the most common CT finding were tuberous mass type.The number of cases with multi-lobe distribution in immunocompromised group was higher than that in immunocompetent group(P<0.05),the incidence of single lobe distribution,"air crescent sign" and "aspergilloma" in immunocompromised group was lower than that in immunocompetent group(P<0.05).Bronchoscopy:The incidence of neoplasms in the immunocompromised group was higher than that in immunocompetent group(P<0.05).(5)Diagnostic methods:All 256 patients underwent histopathological diagnosis,including 153 cases of CT-guided percutaneous lung biopsy,70 cases of transbronchial lung biopsy,32 cases of postoperative pathology,and 1 case of thoracoscopy.155 cases were sent for fungal culture,and 32 cases were positive for culture.The rates of submission and positive culture were 60.5%and 20.6%,respectively.The histopathological diagnosis of fungi was consistent with the traditional fungal culture.A total of 14 patients underwent metagenomic sequencing,and fungal sequences were detected in 8 patients.The fungal species detected by metagenomic sequencing were consistent with those detected in pathological lung tissue.(6)Misdiagnosis:Among the 256 patients with PFD,184(71.9%)were misdiagnosed as other diseases,mainly as other types of pneumonia or lung cancer.(7)Treatment plan:The treatment plan adopts drug therapy,surgery or surgery combined with drug therapy,and drug therapy is the main one.The proportion of immunocompromised group combined with drugs is higher than that of immunocompetent group(P<0.05),and the proportion of immunocompromised group monotherapy patients is lower than immunocompetent group(P<0.05).(8)Adverse drug reactions:During the hospitalization of 256 patients with PFD,243 patients received antifungal drugs,and 50 patients had drug-related adverse reactions.The main adverse reactions included gastrointestinal reactions,liver function damage,renal function damage and electrolyte disturbance.(9)Prognosis and follow-up:To telephone follow-up of 256 cases of PFD,36 cases died,the mortality rate was 14.1%,23 cases were lost to follow-up,45 cases deteriorated,188 cases improved,and 45 cases who received surgical treatment improved.Conclusion1.This study collected the pathological diagnosis of PFD,rounding out the top three is pulmonary aspergillosis,pulmonary cryptococcosis and pulmonary mucormycosis.Due to different immune status,pulmonary cryptococcosis is more likely to occur in immunocompetent patients,and pulmonary mucormycosis is more likely to occur in immunocompromised patients.2.Most patients with pulmonary fungal diseases have underlying diseases,and the clinical manifestations are nonspecific.Cough is the most common clinical symptom,and fever is common in immunocompromised patients.Multiple nodules and masses are the most common chest radiographic features in patients with PFD.The lesions in the immunocompromised group are extensive and those in the immunocompetent group are limited,"air crescent sign","aspergilloma" in the common immunocompetent patients.PFD are mainly treated with drugs.The immunocompromised group received multi-drug combination therapy,and the immunocompetent group received mono-drug therapy.Patients who undergo surgery may have a better prognosis. |
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