接合菌病及實(shí)驗(yàn)室診斷

1、接合菌病及診斷第一醫(yī)院真菌和真菌病研究中心余進(jìn)Dept. Dermatology, Peking University First Hospital and Research Center for Medical Mycology, Peking University常見(jiàn)致病接合菌根霉Rhizopus克銀漢霉瓶霉被孢霉蛙糞霉毛霉Mucor毛霉目Mucorale接合菌Zygomycota蟲(chóng)霉目Entomophthorales根毛霉Rhizomucor共頭霉屬囊托霉屬科克霉犁頭霉Lichtheimmiaor Myoclaadius (Absidia)耳霉Dept. Dermatology, Pek

2、ing University First Hospital and Research Center for Medical Mycology, Peking University接合菌比例上升Dept. Dermatology, Peking University First Hospital and Research Center for MedicKontoyiannis DP,cology, Peking University. JInfectDis. 2005;191:1350Incidence per 1000 Patient Days0,7Aspergillus0,210,6Zyg

3、omycetes0,180,50,150,40,120,30,090,20,060,10,03002000 2001 2002 2003 2004Year毛霉目真菌重要的醫(yī)學(xué)真菌常見(jiàn)屬：根霉 Rhizopus黃梗霉Lichtheimia(犁頭霉Absidia) 根毛霉Rhizomucor毛霉Mucor少見(jiàn)屬： Saksenaea， Syncephalastrum，Cunninghamela，CokeromycesDept. Dermatology, Peking University First Hospital and Research Center for Medical Mycology

4、, Peking University毛霉?。╩ucormycosis）分布于自然界和腐爛植物中條件致病菌：相對(duì)罕見(jiàn)，次于念珠菌、曲霉易感因素生前診斷難，治療效果差，預(yù)后差Dept. Dermatology, Peking University First Hospital and Research Center for Medical Mycology, Peking University途徑吸入孢子，肺和鼻竇是最常見(jiàn)的部位經(jīng)皮途徑，皮膚創(chuàng)傷，注射器污染，繃帶污染食用被孢子污染的蚊蟲(chóng)叮咬Dept. Dermatology, Peking University First Hospital a

5、nd Research Center for Medical Mycology, Peking University免疫抑制(中性粒細(xì)胞缺乏,糖皮質(zhì)激素治療,移植, HIV)代謝問(wèn)題 (, 未,去鐵胺治療,慢性酮癥酸的)代謝性酸皮膚軟組織破損 (燒傷,外傷接種,手術(shù)傷口)其它(靜脈吸毒,早產(chǎn)兒, 營(yíng)養(yǎng)不良)Dept. Dermatology, Peking University First Hospital and Research Center for Medical Mycology, Peking University臨床類(lèi)型鼻腦(44-49%)皮膚(1016%) 肺(1011%)播散性

6、(611.6%)消化道 (211%)其他:腎臟等Dept. Dermatology, Peking University First Hospital and Research Center for Medical Mycology, Peking University鼻腦毛霉病rhino-orbital-cerebral mucormycosis最常見(jiàn)70%由根霉屬引起，多見(jiàn)于米根霉和小孢根霉一半以上的患者有表現(xiàn)一側(cè)頭痛，鼻內(nèi)疼痛和發(fā)熱波及上腭，患側(cè)腭部有黑色焦痂，鼻中隔穿孔或硬腭穿孔波及眼眶，引起眶周或鼻周持續(xù)性腫脹波及第2、4、6對(duì)顱神經(jīng)時(shí)，可出現(xiàn)瞳孔散大、固定、凸眼或上瞼下垂，甚至失明

7、波及大時(shí)，可在顱內(nèi)引起栓塞和壞死，伴腦DD軟Dept. D化ermatology, Peking University First Hospital and Research Center for Medical Mycology, Peking University肺毛霉病pulmonary mucormycosis惡性血液病37%，腦毛霉病吸入空氣中或巴管播散后引起32%，僅次于鼻鼻竇中的孢子，或行、淋非特異性：持續(xù)性高熱、咳嗽、和胸痛胸片：浸潤(rùn)、多發(fā)結(jié)節(jié)、實(shí)變，空洞少見(jiàn)高分辨率CT痰培養(yǎng)Dept. Dermatology, Peking University First Hospital

8、 and Research Center for Medical Mycology, Peking University胃腸毛霉病gastrointestinal mucormycosis多發(fā)生于營(yíng)養(yǎng)不良的嬰兒或兒童無(wú)特異性，有腹痛、嘔血、黑便，嚴(yán)重可形成壞死性胃炎或腸道潰瘍等最常見(jiàn)的部位是胃（占該型的95%以上），其次是大腸慢性消化道潰瘍是重要的基礎(chǔ)疾病胃鏡檢查可見(jiàn)表淺或深在的潰瘍，表面覆以厚層污苔，嚴(yán)重的深部損害可形成穿孔或鏡可見(jiàn)到綠色或黑色的中心壞死區(qū)；結(jié)腸Dept. Dermatology, Peking University First Hospital and Research C

9、enter for Medical Mycology, Peking University皮膚接合菌病cutaneous zygomycosis最輕的一型，急性皮膚率低，預(yù)后較好伴有嚴(yán)重基礎(chǔ)病發(fā)熱, 腫脹, 組織壞死, 梗死,黑色焦痂慢性皮膚肉芽腫不伴有嚴(yán)重基礎(chǔ)病性肉芽腫胰島素注射部位 , 導(dǎo)管處, 傷口表面、移植 (肝),骨髓移植, 燒傷,Dept. Dermatology, Peking University First Hospital and Research Center for Medical Mycology, Peking University播散型毛霉病disseminate

10、d mucormycosis可繼發(fā)于上述4型，累及兩個(gè)或多個(gè)肺毛霉病易于出現(xiàn)腦部播散腦最常見(jiàn)，脾、心和皮膚多發(fā)梗死最常見(jiàn)于中性粒細(xì)胞減少癥或淋巴瘤患者，伏立康唑預(yù)防應(yīng)用時(shí)率高，90% ，100%Dept. Dermatology, Peking University First Hospital and Research Center for Medical Mycology, Peking University其它型毛霉病心臟、腹膜、腎、骨髓等Dept. Dermatology, Peking University First Hospital and Research Center for

11、 Medical Mycology, Peking University診斷高?；颊撸R床表現(xiàn)，使用抗細(xì)菌或唑類(lèi)抗真菌影像學(xué) 微生物學(xué)（泊沙康唑除外）無(wú)效組織病理尤為重要診斷Dept. Dermatology, Peking University First Hospital and Research Center for Medical Mycology, Peking University治療基礎(chǔ)疾病，糾正酸和水電解質(zhì)紊亂，某些的影響外科手術(shù)重要，盡可能采用 可顯著降低率 70%10%早期應(yīng)用有效的抗真菌Dept. Dermatology, Peking University First

12、Hospital and Research Center for Medical Mycology, Peking University抗真菌兩性霉素B及其脂泊沙康唑（posaconazole) 伊曲康唑比前二者效差用藥 兩性霉素B+泊沙康唑 兩性霉素B+卡泊芬凈 泊沙康唑+卡泊芬凈Dept. Dermatology, Peking University First Hospital and Research Center for Medical Mycology, Peking University輔助治療高壓氧鐵鰲合劑（非去鐵胺）IFN-r, GM-CSFDept. Dermatology

13、, Peking University First Hospital and Research Center for Medical Mycology, Peking University預(yù)后與預(yù)防鼻腦毛霉?。?0%90%） 、肺毛霉病（65%）和播散型毛霉病預(yù)后差，率高積極治療基礎(chǔ)疾病，杜絕醫(yī)源性因素是重要的環(huán)節(jié)環(huán)境：高危人群盡量遠(yuǎn)離空氣中散布大量孢子的環(huán)境Dept. Dermatology, Peking University First Hospital and Research Center for Medical Mycology, Peking University接合菌病的診斷D

14、ept. Dermatology, Peking University First Hospital and Research Center for Medical Mycology, Peking University接合菌診斷臨床癥狀高危因素影像學(xué)表現(xiàn)體征臨床診斷微生物學(xué)組織病理學(xué)診斷確診、擬診或排除Dept. Dermatology, Peking University First Hospital and Research Center for Medical Mycology, Peking University免疫抑制(中性粒細(xì)胞缺乏,糖皮質(zhì)激素治療,移植, HIV)代謝問(wèn)題 (,

15、 未,去鐵胺治療,慢性酮癥酸的)代謝性酸皮膚軟組織破損 (燒傷,外傷接種,手術(shù)傷口)其它(靜脈吸毒,早產(chǎn)兒, 營(yíng)養(yǎng)不良)Dept. Dermatology, Peking University First Hospital and Research Center for Medical Mycology, Peking University臨床癥狀和體征病史無(wú)特異性某些癥狀或體征有提示意義患者出現(xiàn)復(fù)視頜面部、眶周、鼻旁出現(xiàn)壞死性焦痂中性粒細(xì)胞缺乏患者出現(xiàn)胸膜疼免疫受損患者出現(xiàn)壞死性皮疹使用抗細(xì)菌 唑除外）無(wú)效或唑類(lèi)抗真菌（泊沙康Dept. Dermatology, Peking Univers

16、ity First Hospital and Research Center for Medical Mycology, Peking University影像學(xué)診斷早期CT檢查肺、鼻竇常見(jiàn)表現(xiàn) 結(jié)節(jié) 反向暈征（Reversed halo signs)或暈征（halo signs） 楔形浸潤(rùn)影 胸膜滲出Dept. Dermatology, Peking University First Hospital and Research Center for Medical Mycology, Peking UniversityRHS（反向暈征）由于肺梗死周邊毛霉病中更常見(jiàn)重于中心Dept. Derm

17、atology, Peking University First Hospital and Research Center for Medical Mycology, Peking UniversityReversed Halo Sign and Pulmonary Zygomycosis189 確診或臨床診斷真菌性132 肺曲霉病37 肺毛霉病20 肺鐮刀菌病8名患者出現(xiàn)RHS(4%)7 名肺毛霉病1名 肺曲霉病Dept. Dermatology, Peking University First Hospital and Research Center for Medical Mycolog

18、y, Peking UniversityHS（暈征）肺梗死周邊肺泡周邊性壞死無(wú)炎癥細(xì)胞浸潤(rùn)IPA更常見(jiàn)Dept. Dermatology, Peking University First Hospital and Research Center for Medical Mycology, Peking University肺曲霉病與肺接合菌病臨床和影像學(xué)差異臨床差異 鼻竇累及 伏立康唑預(yù)防治療影像學(xué)差異 多發(fā)結(jié)節(jié)（>=10個(gè)） 胸膜滲出Dept. Dermatology, Peking University First Hospital and Research Center for M

19、edical Mycology, Peking University病原診斷微生物學(xué)Dept. Dermatology, Peking University First Hospital and Research Center for Medical Mycology, Peking University微生物學(xué)特征-顯微鏡下形態(tài)直接涂片10%KOHDept. Dermatology, Peking University First Hospital and Research Center for Medical Mycology, Peking University微生物學(xué)特征-培養(yǎng)特點(diǎn)血培

20、養(yǎng)陽(yáng)性罕見(jiàn) 組織培養(yǎng)陽(yáng)性率低 避免組織勻漿 剪碎或切碎組織 35-37C培養(yǎng)可提高陽(yáng)性率生長(zhǎng)快速霉樣菌落Dept. Dermatology, Peking University First Hospital and Research Center for Medical Mycology, Peking University鑒定要點(diǎn)出現(xiàn)產(chǎn)孢結(jié)構(gòu) 孢子囊、孢囊梗、假根、囊托-分屬 溫度試驗(yàn)、孢子囊孢子、孢囊梗長(zhǎng)度、厚壁孢子等-分種DNA序列比對(duì)Dept. Dermatology, Peking University First Hospital and Research Center for M

21、edical Mycology, Peking UniversityAbsidia,Mucor,Rhizomucor,Rhizopus的孢子囊特征犁頭霉:*接合孢子附屬絲*孢囊下分隔*無(wú)臨床致病Lichtheimia(“橫梗霉”)*圓錐狀囊軸*沒(méi)有孢囊下分隔根毛霉* 囊托 -* 假根 +根霉 :* 囊托 +* 假根 +毛霉* 囊托 -* 假根 -其他:微生物學(xué)特征-組織病理表現(xiàn)HE、PAS、GMS染色均可見(jiàn)典型表現(xiàn)：無(wú)分隔或者分隔少的寬大菌絲，壁薄，易折疊，90度分支Dept. Dermatology, Peking University First Hospital and Research

22、 Center for Medical Mycology, Peking UniversityInvasive zygomycosis免疫組化和原位雜交ImmunohistochemicalPASISHDept. Dermatology, Peking University First Hospital and Research Center for Medical Mycology, Peking University新型診斷技術(shù)基于DNA的核酸擴(kuò)增技術(shù)基于蛋白質(zhì)的質(zhì)譜技術(shù) (MALDI-TOF） 代謝產(chǎn)物 LC-MS (soluble) GC-MS (volatile organic co

23、mpounds VOCs)EIA Galactofuranose Epitope-based cell wall components Other cell wall epitopesDept. Dermatology, Peking University First Hospital and Research Center for Medical Mycology, Peking University診斷-組織新鮮/冰凍組織福爾固定石蠟包埋組織SequencingRFLP提取DNAPCRRLBDept. Dermatology, Peking University First Hospital and Research Center for Medical Mycology, Peking University新鮮/冰凍組織敏感性和特異性較好正確鑒定種屬Dept. Dermatology, Peking University First Hospital and Research Center for Medical Mycology, Peking University福爾方法固定石蠟包埋組織 PCR+Sequencing( ITS1) Semi-nested PCR(18SrRNA) Real-time PC