Miller W T, Sais G J, Frank I, Gefter W B, Aronchick J M, Miller W T
Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia 19104.
Chest. 1994 Jan;105(1):37-44. doi: 10.1378/chest.105.1.37.
To evaluate the clinical and radiographic features of pulmonary aspergillosis as they present in AIDS patients; in particular, to determine similarities and differences between Aspergillus infection in patients with AIDS vs those without AIDS.
Six new cases of confirmed or probable pulmonary aspergillosis were discovered during a search of hospital records. These are reviewed with 30 previously reported cases with special attention to radiographic appearance of disease and how radiographic appearance influences clinical outcome.
Symptoms of pulmonary aspergillosis in AIDS were nonspecific, most often including fever, cough, and dyspnea, and less commonly, chest pain or hemoptysis. Major risk factors for the development of pulmonary aspergillosis in patients with AIDS were steroid administration and neutropenia. Neutropenia was often a complication of therapies for AIDS, in particular, ganciclovir and zidovudine. Radiographic appearance of disease could be divided into three general categories. One third of the patients (13/36) presented with cavitary upper lobe disease resembling noninvasive or chronic necrotizing aspergillosis. Fatal hemoptysis occurred in 42 percent of patients with this form of disease. Twenty-two percent (8/36) of the cases presented as a nondescript focal alveolar opacity similar to invasive aspergillosis. In several patients, the focal infiltrate remained stable for several months, a feature that is unusual for aspergillosis in non-AIDS patients. The air crescent sign was present in none of the 36 reported cases. Patients with only focal disease had the best prognosis of patients with pulmonary aspergillosis. Bilateral alveolar or interstitial disease similar to invasive aspergillosis was present in 23 percent (9/36) of the patients. Bilateral disease appears to be a marker for disseminated infection and was associated with a high mortality due to aspergillosis. Two new forms of bronchial aspergillosis (5/36 cases) have been described previously. These patients presented with either obstructing fungal casts or bronchial pseudomembranes demonstrated bronchoscopically. In some patients with the bronchial forms of aspergillosis, transient alveolar opacities were seen on chest radiographs. These opacities may represent regions of atelectasis due to airway obstruction. One patient who had bilateral pneumothoraces without parenchymal opacities did not correspond to any of the three previously mentioned categories. Mortality due to aspergillosis was greater than 50 percent among AIDS patients. Death was subsequent to fatal hemoptysis or widespread pulmonary or systemic infection.
Unlike other risk groups that tend to contract only one form of pulmonary aspergillosis, AIDS patients can develop the whole spectrum of aspergillosis-related pulmonary disorders, including chronic cavitary, invasive, and bronchial forms of aspergillosis. Clinical symptoms are nonspecific and major risk factors include neutropenia, which is often a side effect of various therapies for AIDS, and steroid administration. Patients with the chronic cavitary form of disease have an unusually high mortality due to fatal hemoptysis. Patients with bilateral pulmonary infiltrates and aspergillosis have a high mortality due to disseminated infection.
评估肺曲霉病在艾滋病患者中的临床及影像学特征；尤其要确定艾滋病患者与非艾滋病患者曲霉感染之间的异同。
通过查阅医院记录发现6例确诊或疑似肺曲霉病的新病例。将这些病例与30例先前报告的病例一起进行回顾，特别关注疾病的影像学表现以及影像学表现如何影响临床结局。
艾滋病患者肺曲霉病的症状不具特异性，最常见的包括发热、咳嗽和呼吸困难，较少见的有胸痛或咯血。艾滋病患者发生肺曲霉病的主要危险因素是使用类固醇和中性粒细胞减少。中性粒细胞减少常是艾滋病治疗的并发症，尤其是更昔洛韦和齐多夫定治疗。疾病的影像学表现可分为三大类。三分之一的患者（13/36）表现为上叶空洞性病变，类似于非侵袭性或慢性坏死性曲霉病。42%患有这种疾病形式的患者发生致命性咯血。22%（8/36）的病例表现为类似于侵袭性曲霉病的不明确局灶性肺泡实变。在一些患者中，局灶性浸润在数月内保持稳定，这一特征在非艾滋病患者的曲霉病中并不常见。36例报告病例中均未出现空气新月征。仅患有局灶性疾病的患者是肺曲霉病患者中预后最好的。23%（9/36）的患者出现类似于侵袭性曲霉病的双侧肺泡或间质性疾病。双侧疾病似乎是播散性感染的标志，并且与曲霉病导致的高死亡率相关。先前已描述了两种新的支气管曲霉病形式（5/36例）。这些患者经支气管镜检查显示有阻塞性真菌栓子或支气管假膜。在一些患有支气管型曲霉病的患者中，胸部X线片上可见短暂的肺泡实变。这些实变可能代表由于气道阻塞导致的肺不张区域。1例有双侧气胸而无实质病变的患者不符合上述三种类型中的任何一种。艾滋病患者中曲霉病导致的死亡率超过50%。死亡继发于致命性咯血或广泛的肺部或全身感染。
与其他往往仅感染一种肺曲霉病形式的风险群体不同，艾滋病患者可发生一系列与曲霉病相关的肺部疾病，包括慢性空洞性、侵袭性和支气管型曲霉病。临床症状不具特异性，主要危险因素包括中性粒细胞减少（常是艾滋病各种治疗的副作用）和使用类固醇。患有慢性空洞性疾病形式的患者因致命性咯血而死亡率异常高。患有双侧肺部浸润和曲霉病的患者因播散性感染而死亡率高。
