Maschmeyer Georg, Donnelly J Peter
Department of Haematology, Oncology and Palliative Care, Klinikum Ernst von Bergmann, Potsdam, Germany.
Department of Haematology, Radboud University Medical Centre, Nijmegen, The Netherlands.
Br J Haematol. 2016 Apr;173(2):179-89. doi: 10.1111/bjh.13934. Epub 2016 Jan 5.
Pulmonary complications affect up to 40% of patients with severe neutropenia lasting for more than 10 d. As they are frequently associated with fever and elevation of C-reactive protein or other signs of inflammation, they are mostly handled as pneumonia. However, the differential diagnosis is broad, and a causative microbial agent remains undetected in the majority of cases. Pulmonary side effects from cytotoxic treatment or pulmonary involvement by the underlying malignancy must always be taken into account and may provide grounds for invasive diagnostic procedures in selected patients. Pneumocystis jirovecii (in patients not receiving co-trimoxazole as prophylaxis), multi-resistant gram-negative bacilli, mycobacteria or respiratory viruses may be involved. High-risk patients may be infected by filamentous fungi, such as Aspergillus spp., but these infections are seldom proven when treatment is initiated. Microorganisms isolated from cultures of blood, bronchoalveolar lavage or respiratory secretions need careful interpretation as they may be irrelevant for determining the aetiology of pulmonary infiltrates, particularly when cultures yield coagulase-negative staphylococci, enterococci or Candida species. Non-culture based diagnostics for detecting Aspergillus galactomannan, beta-D-glucan or DNA from blood, bronchoalveolar lavage or tissue samples can facilitate the diagnosis, but must always be interpreted in the context of clinical and imaging findings. Systemic antifungal treatment with mould-active agents, given in combination with broad-spectrum antibiotics, improves clinical outcome when given pre-emptively. Co-trimoxazole remains the first-line treatment for Pneumocystis pneumonia, while cytomegalovirus pneumonia will respond to ganciclovir or foscarnet in most cases. The clinical outcome of acute respiratory failure can also be successful with proper intensive care, when indicated.
肺部并发症影响多达40%的严重中性粒细胞减少持续超过10天的患者。由于它们常与发热、C反应蛋白升高或其他炎症迹象相关，大多按肺炎处理。然而，鉴别诊断范围广泛，多数病例中仍未检测到致病微生物。必须始终考虑细胞毒性治疗的肺部副作用或潜在恶性肿瘤的肺部累及情况，这可能为特定患者进行侵入性诊断程序提供依据。可能涉及耶氏肺孢子菌（未接受复方新诺明预防的患者）、多重耐药革兰氏阴性杆菌、分枝杆菌或呼吸道病毒。高危患者可能被丝状真菌如曲霉属感染，但开始治疗时这些感染很少得到证实。从血液、支气管肺泡灌洗或呼吸道分泌物培养物中分离出的微生物需要仔细解读，因为它们可能与确定肺部浸润的病因无关，特别是当培养物产生凝固酶阴性葡萄球菌、肠球菌或念珠菌属时。基于非培养的检测血液、支气管肺泡灌洗或组织样本中曲霉半乳甘露聚糖、β-D-葡聚糖或DNA的诊断方法有助于诊断，但必须始终结合临床和影像学表现进行解读。当进行抢先治疗时，使用对霉菌有活性的药物进行全身性抗真菌治疗并联合广谱抗生素，可改善临床结局。复方新诺明仍然是肺孢子菌肺炎的一线治疗药物，而巨细胞病毒肺炎在大多数情况下对更昔洛韦或膦甲酸钠有反应。如有指征，适当的重症监护也可使急性呼吸衰竭的临床结局取得成功。
