儿童全身播散性隐球菌病临床特征及预后

摘要

Objective To analyze the clinical characteristics and prognosis of disseminated cryptococcosis in children.Methods The data of disseminated cryptococcosis inpatients were reviewed retrospectively at Beijing Children's Hospital,Capital Medical University,from January 2002 to September 2014.The demographic data,clinical manifestations,laboratory findings,imaging,antifungal treatments and outcomes of all the patients were analyzed.Results Overall 25 children with disseminated cryptococcosis were enrolled including 17 boys(68.0％).The average age was 7 years old.Four cases (16.0％) had underlying conditions,among them 1 case had human immunodeficiency virus(HIV)-positive.The median time to diagnosis was 32 (23-47) days,44.0％ of the patients (11 cases) were misdiagnosed,and 8 cases misdiagnosed as tuberculosis.All patients had fever.Other common clinical manifestations included cough (16 cases),headache (10 cases),vomiting (10 cases),altered mental status (6 cases) and stomachache (6 cases).Respiratory system involvement was seen in all cases,central nervous system was involved in 18 cases,other organ involvement included lymph nodes,spleen,liver,kidney,skin,skeleton and costicartilage.Amphotericin B (AmB) + Fluconazole (Flu) ± 5-flucytosine (5-FC) was the most common therapy (15 cases),Flu ± 5-FC for 6 cases,AmB ± 5-FC for 2 cases,Voricanazole (VOR) for 1 case.Sixteen cases (66.7％) got recovery/improved on discharge,8 cases (33.3％) rejected to the advise and discharged with treatment failure,and the HIV-infected patient transferred to a special hospital.Fifteen patients (60.0％) were followed up,and 13 cases (87.0％) showed recovery,but 2 died in the long-term prognosis.Conclusions Disseminated cryptococcosis in children is more common in school-age boys.Most patients are without underlying conditions.Disseminated cryptococcosis can cause multiple organ damage.Patients with prolonged fever,cough,headache,with or without underlying diseases,can be suspected as disseminated cryptococcosis.Blood and cerebrospinal fluid culture for fungus,cryptococcal antigen should be performed for early diagnosis and treatment.%目的 总结儿童全身播散性隐球菌病的临床特征及预后.方法 对2002年1月至2014年9月在首都医科大学附属北京儿童医院住院的全身播散性隐球菌病患儿临床资料进行回顾性分析,包括一般资料、临床表现、实验室检查、影像学检查、治疗及预后等.结果 共有25例患儿诊断为全身播散性隐球菌病,男童占68.0％(17例),平均发病年龄为7岁;有基础疾病者4例(16.0％),其中人类免疫缺陷病毒(HIV)阳性1例(4.0％).确诊时间32(23～47)d;误诊11例(44.0％),其中误诊为结核病8例.患儿均有发热,其他主要临床症状有咳嗽(16例)、头痛(10例)、呕吐(10例)、精神意识改变(6例)、腹痛(6例).患儿均有肺部受累,其次为中枢神经系统受累18例,其他受累器官有淋巴结、脾、肝、肾、皮肤、(软)骨.初始治疗予两性霉素B(AmB)+氟康唑(Flu) ±5-氟胞嘧啶(5-FC)15例;Flu ±5-FC 6例;AmB±5-FC 2例;伏立康唑1例.评估住院期间抗真菌治疗效果:16/24例(66.7％)患儿治疗成功,8/24例(33.3％)治疗失败,HIV阳性患儿转院.远期随访患儿共15例(60.0％),其中13例(87.0％)存活能正常生活,2例(8.0％)死亡.结论 儿童全身播散性隐球菌病多见于学龄期男童,大部分患儿无基础疾病,可累及多脏器.如临床表现为长期发热、咳嗽、头痛、伴或不伴有基础疾病者,应注意考虑到全身播散性隐球菌病的可能,尽早行病原学检测.