曲霉性骨髓炎：流行病学、临床表现、治疗和预后。
Aspergillus osteomyelitis: epidemiology, clinical manifestations, management, and outcome.
机构信息
Weill Cornell Medical Center of Cornell University, New York, NY, USA; National and Kapodistrian University of Athens, Athens, Greece; Center for Osteoarticular Mycoses, Hospital for Special Surgery, New York, NY, USA; International Osteoarticular Mycoses Study Consortium, USA.
Center for Osteoarticular Mycoses, Hospital for Special Surgery, New York, NY, USA; International Osteoarticular Mycoses Study Consortium, USA; Université Paris-Descartes, Sorbonne Paris Cité, APHP, Service des Maladies Infectieuses et Tropicales, Hôpital Necker-Enfants Malades, Centre d'Infectiologie Necker-Pasteur, Institut Imagine, Paris, France; Unité de Mycologie Moléculaire, Institut Pasteur, Paris, France.
出版信息
J Infect. 2014 May;68(5):478-93. doi: 10.1016/j.jinf.2013.12.008. Epub 2013 Dec 27.
BACKGROUND
The epidemiology, pathogenesis, diagnosis, and management of Aspergillus osteomyelitis are not well understood.
METHODS
Protocol-defined cases of Aspergillus osteomyelitis published in the English literature were reviewed for comorbidities, microbiology, mechanisms of infection, clinical manifestations, radiological findings, inflammatory biomarkers, antifungal therapy, and outcome.
RESULTS
Among 180 evaluable patients, 127 (71%) were males. Possible predisposing medical conditions in 103 (57%) included pharmacological immunosuppression, primary immunodeficiency, and neutropenia. Seventy-three others (41%) had prior open fracture, trauma or surgery. Eighty (44%) followed a hematogenous mechanism, 58 (32%) contiguous infections, and 42 (23%) direct inoculation. Aspergillus osteomyelitis was the first manifestation of aspergillosis in 77%. Pain and tenderness were present in 80%. The most frequently infected sites were vertebrae (46%), cranium (23%), ribs (16%), and long bones (13%). Patients with vertebral Aspergillus osteomyelitis had more previous orthopedic surgery (19% vs 0%; P = 0.02), while those with cranial osteomyelitis had more diabetes mellitus (32% vs 8%; P = 0.002) and prior head/neck surgery (12% vs 0%; P = 0.02). Radiologic findings included osteolysis, soft-tissue extension, and uptake on T2-weighted images. Vertebral body Aspergillus osteomyelitis was complicated by spinal-cord compression in 47% and neurological deficits in 41%. Forty-four patients (24%) received only antifungal therapy, while 121 (67%) were managed with surgery and antifungal therapy. Overall mortality was 25%. Median duration of therapy was 90 days (range, 10-772 days). There were fewer relapses in patients managed with surgery plus antifungal therapy in comparison to those managed with antifungal therapy alone (8% vs 30%; P = 0.006).
CONCLUSIONS
Aspergillus osteomyelitis is a debilitating infection affecting both immunocompromised and immunocompetent patients. The most common sites are vertebrae, ribs, and cranium. Based upon this comprehensive review, management of Aspergillus osteomyelitis optimally includes antifungal therapy and selective surgery to avoid relapse and to achieve a complete response.
背景
曲霉性骨髓炎的流行病学、发病机制、诊断和治疗尚不清楚。
方法
对已发表的英文文献中曲霉性骨髓炎的病例进行了回顾性分析，研究了合并症、微生物学、感染机制、临床表现、影像学表现、炎症标志物、抗真菌治疗和预后。
结果
在 180 例可评估的患者中，127 例（71%）为男性。103 例（57%）存在潜在的易患医学病症，包括药物免疫抑制、原发性免疫缺陷和中性粒细胞减少症。另外 73 例（41%）有先前的开放性骨折、外伤或手术史。80 例（44%）为血源播散性感染，58 例（32%）为相邻感染，42 例（23%）为直接接种。77%的患者为曲霉病的首发表现。80%的患者有疼痛和压痛。最常感染的部位是椎体（46%）、颅骨（23%）、肋骨（16%）和长骨（13%）。椎体曲霉性骨髓炎患者既往骨科手术更多（19% vs 0%；P=0.02），而颅骨骨髓炎患者糖尿病（32% vs 8%；P=0.002）和头颈部手术（12% vs 0%；P=0.02）更多。影像学表现包括溶骨性病变、软组织延伸和 T2 加权图像摄取。47%的椎体体部曲霉性骨髓炎并发脊髓压迫，41%的患者出现神经功能缺损。44 例（24%）仅接受抗真菌治疗，121 例（67%）接受手术和抗真菌治疗。总死亡率为 25%。中位治疗时间为 90 天（范围：10-772 天）。与单独接受抗真菌治疗的患者相比，接受手术联合抗真菌治疗的患者复发率更低（8% vs 30%；P=0.006）。
结论
曲霉性骨髓炎是一种使人虚弱的感染，影响免疫抑制和免疫功能正常的患者。最常见的部位是椎体、肋骨和颅骨。基于这项全面的综述，曲霉性骨髓炎的最佳治疗方法包括抗真菌治疗和选择性手术，以避免复发和获得完全缓解。
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