【作者】 蔡闯； 卓超； 吴璐璐； 杨新云； 钟淑卿； 钟南山；

【Author】 CAI Chuang~*,ZHUO Chao~*,WU Lu-lu~*,YANG Xin-yun,ZHONG Shu-qing~*,ZHONG Nan-shan~*. * Guangzhou Institute of Respiratory Disease,the First Affiliated Hospital of Guangzhou Medical University, Guangzhou,510120,China

【机构】 广州医学院第一附属医院广州呼吸疾病研究所； 广州医学院第一附属医院药剂科；

【摘要】 目的探讨难治性侵袭性肺曲霉菌病(IPA)的诊断及补救治疗。方法根据临床、胸部放射影像学及病原学特点,结合文献复习,讨论1例伏立康唑初始治疗失败、伊曲康唑静脉滴注及序贯治疗获部分缓解的难治性IPA的诊断及治疗经过。结果 1例IPA患者,伏立康唑静脉滴注治疗7天,发热、气促症状未缓解,肺部渗出、空洞病灶无明显吸收,符合难治性IPA诊断标准。患者痰培养分离出烟曲霉菌,药敏试验提示对伏立康唑、伊曲康唑敏感。伊曲康唑200mg静脉滴注2/日(疗程14天)及伊曲康唑口服液序贯治疗获部分缓解,未观察到显著不良反应。结论对伏立康唑初始治疗失败的IPA,如药敏试验提示不存在交叉耐药,补救治疗可选择伊曲康唑。应警惕伏立康唑药代动力学变异性对临床疗效的影响,尤其对于体外药敏敏感而临床疗效不佳的侵袭性真菌感染。更多还原

【Abstract】 Objective To explore the diagnosis and salvage therapy of refractory invasive pulmonary aspergillosis(IPA).Methods Based on clinicoradiological findings and microbiological study,the diagnosis and treatment of one case of IPA refractory to initial voriconazole therapy but responsive to itraconazole salvage therapy was discussed,along with literature review.Results 7-day course intravenous voriconazole initial therapy failed to improve fever and dyspnea as well as pulmonary infiltrates and cavitary lesions associated with IPA,qualifying this case as refractory IPA.The isolated Aspergillus fumigatus strains from sputum were susceptible to itraconazole and voriconazole.Intravenous itraconazole(200mg bid,for 14 days) with sequential oral itraconazole solution achieved partial response without significant side effects. Conclusions For IPA unresponsive to initial voriconazole therapy,if no cross-resistance between the two azoles is detected by in vitro susceptibility test,sequential itraconazole therapy might be an option.The impact on clinical efficacy due to voriconazole pharmacokinetic variability should be highlighted,especially for invasive fungal infections with poor response but good susceptibility profile.更多还原