| [Background and Objectives]In recent years, fungal infections rised because of the extensive use of broad-spectrum antibiotics, HIV infection, radiotherapy and chemotherapy of tumor, organ transplant, increased use of Glucocorticoids and immunosuppressive agents, and so on. The incidence of cryptococcosis increasingly rise. In foreign country, it had become the most common complications of AIDS and the leading cause of death in AIDS patients. The Common pathogens of pulmonary fungal infection are Aspergillus, Cryptococcus and Candida. In recent years, domestic and foreign studies have shown that pulmonary cryptococcal infection was the second cause of pulmonary fungal infection. Previous study of pulmonary cryptococcosis often focus on AIDS patients and solid organ transplant recipients. While the study of immunocompetent hosts was very little. The clinical symptoms of pulmonary cryptococcosis in immunocompetent hosts were mild, it had non-specific signs, and the etiology detection rate was very low. So the rate of misdiagnosis was very high. Diagnosis of PC depends on surgical excision and invasive biopsy to obtain histopathologic evidence or etiological evidence of blood and sterile cavity fluid. The former was traumatic to the patients and the latter had a very low positive rate. So how to improve the diagnosis of pulmonary cryptococcosis become important in clinical.This study had analyzed the clinical characteristics, epidemiology status quo, imaging characteristics and diagnostic methods of pulmonary cryptococcosis in the immunocompetent patients. In order to improve the clinician’s level of dia-gnosis and treatment of pulmonary cryptococcosis. [Methods]The medical records of91adult patients diagnosed with pulmonary cryptococcosis at Nanfang Hospital affiliated to Southern Medical University and the First Affiliated Hospital of Guangzhou Medical college between2006and March2011were reviewed retrospectively. Reference to the consensus revised definitions draft VI of EORTC/MSG in2005, and the diagnostic criteria and therapeutic principle of invasive pulmonary fungal infection(protocol)of China in2006, all of the cases were diagnosed by pathology, microbiology, or coherence examination. The exclusion criteria includes:(1) the AIDS patients,(2) solid organ transplant or bone marrow transplant recipient,(3) Other immune deficiency disease. Schedule tables were made to record the detail information of each patient with pulmonary cryptococcosis. Include the following information:(1) the general condition of the patients:sex, age, admission department, initial diagnosis, definite time required, hospital day etc.(2) The host factors:history of exposure, The basic disease and related treatment.(3) clinical manifestations, sign, chest CT, laboratory tests, the cryptococcal latex agglutination test results;(4) diagnostic method. Related data were compared according to host factors, the cryptococcal latex agglutination test results and imaging classification types. To describe the normal distribution measurement information as Mean±standard deviation, t test. Count data is described as the ration (%), and the χ2test was used to compare proportions. Statistical analysis was conducted using SPSS for Windows(version13.0). Significance was defined as P<0.05with two-sided analysis.[Results](1)91patients were enrolled. The mean(±SD)age of them was (46.05±12.57)years(range,19to71years), most males’ age was between30-60years old; for female was40-70years old. And75.82%of all patients were in the age between30 and60years. The patients consisted of54males and37females. There was significant difference of age number between male and female(t=2.723,P=0.008).(2) From the year2006to2011, the annual number of patients diagnosed with pulmonary cryptococcosis was increased. Most of the patients were in the inpatient department of Respiratory Medicine and Thoracic Surgery.(3)82cases(90.1%) had no history of exposure. Only6patients had definite history of exposure,50%among them had washed Sauna bath. There were birds contact history in only1cases. Among the patients who had underlying diseases, diabetes mellitus is the most common risk factor(n=13;14.29%), and others were the use of steroid hormones (n=7;14.58%), chronic hepatitis B(n=5;5.49%), connective tissue disease (n=6;6.59%), malignant tumor(n=3;3.30%), recent history of operation patients(n=11;12.08%), the patients with based diseases which influence host immune function ratio was32.97%.(4)22patients(24.18%)were asymptomatic, who had abnormal chest radiographs during a routine physical examination.69patients(75.82%)complained of respiratory or other symptoms, as follows:cough(n=55;60.44%), expectoration(n=41;45.05%), fever(n=19;20.88%), chest pain(n=33;36.26%), dyspnea(n=21;23.08%) and weakness(n=12;13.19%).34patients had mild abnormal signs include:rales, diminished breath-sounds. All symptoms were mild and the signs were not obvious. Very few patients had neurologic symptoms such as headache, vomit, stiff neck.(5) The chest CT demonstrated abnormal findings in all patients. The most common radiologic finding was single or multiple nodules or masses(n=52;57.14%), the next was patchy infiltrates (n=25;27.47%), the remaining presented widespread and mixed patterns (n=14;15.38%). The lesion distributed mainly on the right lung(40.7%) and more common in the lower lobe(40.7%) than in the upper lobe. There were significant deviations. The geographic distribution of the nodule or mass lesions mainly on the unilateral lung(71.15%) and especially the right lung(42.30%); The patchy infiltrates could be seen on all lung lobes, and the widespread and mixed patterns in bilateral lung, with ill-defined margins. There were also significant deviations of the number of lesions(χ2=20.761, P=0.000) and the involved lung lobe distribution (χ2=21.942, P=0.000). There were no significant deviations of the lesion type and the morphologic characteristics between the groups with or without host factors(χ2=5.104, P=0.277).The concomitant signs of Chest CT were variegated.26cases had air bronchogram sign,22cases had torn grain,22cases had cavity,17cases had pleural indentation sign and7cases had pleural effusion. multiple nodules or masses and widespread and mixed patterns were more seen in patients with host factors. single nodules or masses were more seen in patients without host factors. There were not significant difference between the two groups.(6) The initial misdiagnosis rate was60.44%(55/91). Most of them were misdiagnosed as lung cancer, pneumonia etc.25patients suspected lung cancer had thoracoscopy or open chest operation. The main diagnostic methods were VATS, TBLB(43cases) and TNAB. And the positive rate of TBLB was65.12%.(7) The leukocyte counts of the patients range from3.12～19.77(8.24±3.42)×10/L,73cases(80.22%)were normal; the neutrophilic granulocyte counts range from1.76～16.29(5.58±3.25)×109/L. And the counts of neutrophilic granulocyte count of al1patients were over1.5×109/L. ESR, C-reactive protein may increase, but they had no specificity.34cases had immunologic test and in which13cases had abnormal results. Lung tumor marker was positive in39.06%patients, most was mild high, Only3patients had two different tumor markers elevated, none of them were more than two times above the normal value. All patients were not HIV positive.(8) Pathogenic microbiology examination:22cases had sputum culture examination with11cases had positive results. Including Candida albicans, Streptococcus, Escherichia coli etc. No Cryptococcus neoformans.10cases had tissue culture, one case was Cryptococcus neoformans-positive.3cases BALF culture and none was positive.(9)48cases had the latex agglutination test for pulmonary Cryptococcus, and64.58%were positive. The specificity of the latex agglutination test is85.71%. The submission rate of internal medicine was76.79%, significantly higher than that of the surgical(14.29%). There was significant difference between the two groups ((x2=33.756, P=0.000).The latex agglutination test positive group often used TBLB as diagnostic methods (64.52%). Meanwhile the group without latex agglutination test often used thoracoscope as diagnostic methods (76.74%). There were significant difference between these two groups (χ2=50.562, P=0.000). There were significant difference between LA test positive group and LA test negative group(x2=17.135, P=0.004) in diagnosis methods.[Conclusion](1) The incidence of pulmonary cryptococcosis had increased tendency in the HIV-negative hosts. The disease mainly involves young and middle-aged. It was more to be seen in the males than the females.(2) Most of the patients had no history of exposure.(3) PC are subacute or chronic infection. The main clinical manifestations of this disease are non-specific, include mild respiratory symptoms and low-grade fever, or asymptomatic, with no specificity and no signs. The imaging features can be classified to3types:nodule or mass type, patchy infiltrates type, and widespread or mixed patterns type. The former two types are more common in clinical. The lesion often occur in the right lower lung. There were no significant difference of the lesion type between the groups with or without host factors.(4) The flexible bronchofiberscope and TNAB had smaller trauma than the surgery, and with a high positive ratio, which can be chosen rely on the location of the lesions. Non-surgical examination has significance to the diagnosis of pulmonary cryptococcosis. The positive rate of respiratory tract etiology in pulmonary cryptococcosis of is very low, its clinical diagnostic value is small.(5) The sensitivity and specificity of the latex agglutination test for cryptococcus neoformans are high. It could be used as an early noninvasive diagnostic and screening methods. This test combined with tumor marker examination can increase the level of the differential diagnosis of lung cancer. So patients can avoid surgery or larger invasive examination. |
PDF Full Text Request