Shorr Andrew F, Susla Gregory M, O'Grady Naomi P
Pulmonary and Critical Care Medicine Service, Walter Reed Army Medical Center, Washington, DC 20307, USA.
Chest. 2004 Jan;125(1):260-71. doi: 10.1378/chest.125.1.260.
Pulmonary complications remain a major cause of both morbidity and mortality in immunocompromised patients. When such individuals present with radiographic infiltrates, the clinician faces a diagnostic challenge. The differential diagnosis in this setting is broad and includes both infectious and noninfectious processes. Rarely are the radiographic findings classic for one disease, and most potential etiologies have overlapping clinical and radiographic appearances. In recent years, several themes have emerged in the literature on this topic. First, an aggressive approach to identifying a specific etiology is necessary; as a corollary, diagnostic delay increases the risk for mortality. Second, the evaluation of these infiltrates nearly always entails bronchoscopy. Bronchoscopy allows identification of some etiologies with certainty, and often allows for the exclusion of infectious agents even if the procedure is otherwise unrevealing. Third, early use of CT scanning regularly demonstrates lesions missed by plain radiography. Despite these advances, initial therapeutic interventions include the use of broad-spectrum antibiotics and other anti-infectives in order to ensure that the patients is receiving appropriate therapy. With the results of invasive testing, these treatments are then narrowed. Frustratingly, outcomes for immunocompromised patients with infiltrates remain poor.
肺部并发症仍然是免疫功能低下患者发病和死亡的主要原因。当这些患者出现影像学浸润时，临床医生面临诊断挑战。这种情况下的鉴别诊断范围很广，包括感染性和非感染性过程。影像学表现很少是某一种疾病的典型表现，大多数潜在病因的临床和影像学表现相互重叠。近年来，关于这个主题的文献中出现了几个主题。首先，必须采取积极的方法来确定具体病因；相应地，诊断延迟会增加死亡风险。其次，对这些浸润灶的评估几乎总是需要进行支气管镜检查。支气管镜检查能够确定某些病因，即使该检查未发现其他异常，也常常能排除感染病原体。第三，早期使用CT扫描经常能发现胸部X线平片遗漏的病变。尽管有这些进展，但初始治疗干预措施包括使用广谱抗生素和其他抗感染药物，以确保患者接受适当的治疗。根据侵入性检查的结果，再缩小这些治疗范围。令人沮丧的是，有浸润灶的免疫功能低下患者的预后仍然很差。
