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Шупер В.А., Шупер С.В., Вагина Ю.И., Гаврилов А.А. Особенности дифференциальной диагностики грибковых поражений легких (клинический случай)
31.07.2014, 18:21

Резюме
Шупер В.А., Шупер С.В., Вагина Ю.И., Гаврилов А.А. Особенности дифференциальной диагностики грибковых поражений легких (клинический случай).
В работе представлен краткий обзор современной литературы по диагностике и лечению аспергиллеза легких. Описан клинический случай диагностики и лечения вероятного аспергиллеза легких в терапевтическом отделении.
Ключевые слова: аспергиллез легких, аспергиллема, диагностика, лечение.
Резюме
Шупер В.О., Шупер С.В., Вагіна Ю.І., Гаврилов А.О. Особливості диференційної діагностики грибкових уражень легенів (клінічний випадок).
У роботі представлений короткий огляд сучасної літератури по діагностиці і лікуванню аспергільозу легенів. Описаний клінічний випадок діагностики і лікування вірогідного аспергільозу легенів у терапевтичному відділенні.
Ключові слова: аспергільоз легенів, аспергільома, діагностика, лікування.
Summary
Shuper V.A., Shuper S.V., Vagina Yu.I., Gavrilov A.A. Features of the differential diagnoses of the fungal lung diseases (the clinical case).
The brief review of modern literature on diagnostics and treatment of Pulmonary aspergillosis is presented in the work. The clinical case of diagnostics and treatment of credible Pulmonary aspergillosis in a therapeutic department is described.
Key words: Pulmonary aspergillosis, Aspergilloma, diagnostics, treatment.

Рецензент: д.мед.н. Г.П. Победьонна

УДК 616.24-022-08

ДУ «Луганский государственный медицинский университет»

 

State Establishment "Lugansk State Medical University"

shooper@inbox.ru

sergej-shuper@yandex.ua

Fungal lung infections are fairly common, but their timely diagnosis in routine medical practice is difficult due to the presence of mixed infections, masking symptoms by comorbidities of the patient, needing to use a significant amount of instrumental and laboratory studies.

Aspergillosis should be noted among the most common fungal lung lesions.
Aspergillosis is a second frequency after Candida fungal infection, in most cases it is caused by Aspergillus fumigatus (90%), and A. flavus, A. niger, A. terreus, A. nodulans. Aspergillus can penetrate the lung tissue as saprophytes, allergens or invasive pathogen. However, the disease due to the invasion of these fungi in the tissues of the body is rare and, above all, with severe immunosuppression.

According to various sources incidences of pulmonary aspergillosis are from 0.4% to 1.5 % in the world population. Among the predisposing factors COPD, tuberculosis, pulmonary fibrosis, using of immunosuppressive therapy, diabetes, alcoholism, exhaustion and chemotherapy identify prevalence. Fungal infection is confirmed with a positive histology or positive culture obtained by bronchoalveolar lavage, or fungemia and clinical presentation of lung tissue destruction.

In our practice we are faced with a case of suspected pulmonary aspergillosis in patients admitted for treatment at the therapeutic department with a diagnosis of community-acquired pneumonia of right lung upper lobe.

Patient S. , 62 years old, complained of expressed general weakness, cough with scanty greenish sputum, dyspnea due to little physical exertions, chest pain in the right side of the thorax when coughing and deep breathing, fever up to 380. By the moment of admission, these symptoms were reported during a week, patient used NSAID’s for self-treatment.

History of patient’s life revealed TB-specialist’s supervision for 10 years due to pulmonary tuberculosis, operation in 2005 due to laryngeal cancer (permanent tracheostomy), then receiving of the radiation therapy. Patient worked as a welder.
An objective examination attention was attracted by severe cachexia, pale skin and sclera. Lungs auscultation reveled diminished breathing, moist finely rales in the upper part of the right lung, respiratory rate was 24 per min. Heart sounds were muffled and rhythmic, HR = PS = 96 bpm, BP 150\90 mm Hg. The liver was palpated by 3 cm under the costal arch.

Patient was examined in a hospital: CBC (Hb - 123 g\l, RBC - 3.97 * 1012/l, CI - 0.9, WBC - 15.5 * 109/l, stab - 23 %, segmented - 70 %, lymphocytes - 3% , monocytes - 4%, ESR - 46 mm\h); Blood glucose level - 3.9 mmol\l;
Urine test (specific gravity  - 1027, proteinuria – 0,133 g\l, WBC - 4-5 in f/v);
Sputum test (color - gray, texture – viscous, nature – muco-purulent, leukocytes - all sight, erythrocytes - 2-5 in f\v, Alveolar macrophages - single, TB - thrice negative); Biochemical blood test (bilirubin - 15 mmol\l, ALT - 0.46 nmol\l, urea - 11.8 nmol\l , creatinine - 141 mcmol\l, total protein - 58 g\l, albumins - 26 g\l).
Chest X-ray revealed increased capacity of right lung lover lobe, suspected pneumonia. Patient was conducted according to the protocol of pneumonia treatment (antibiotics of broad spectrum – cephalosporins of III generation, macrolides, and fluoroquinolones of III generation, NSAID’s, surfactant syntheses stimulators, immune stimulators, mucolitics and expectorants).

In two weeks after hospitalization clinical condition of patient improved but without positive X-ray dynamics. Antibacterial (cephalosporins of IV generation) and anti-inflammatory therapy was continued. In for weeks of treatment X- ray revealed formation of the cavities in the inflamed area of right lung. CT scan of the lungs found two cavities d = 2 cm and 3 cm, with the presence of free-ranging sequestration in the infiltration of the right upper lobe; in the upper lobe of the left lung - local fibrotic changes of the lung tissue with a cavity with thick walls and sequestration. Bronchoscopy did not find tumors or metastases, Cytology conclusion: against inflammatory elements presents of bronchial epithelial cell proliferation with moderate atypia, WBC - 14-16 in f\v. Flora - cocci. Mycobacterium tuberculosis and atypical cells are negative.

Repeated consultation thoracic surgeon, pulmonologist, phthisiatrician: upper lobar right sided pneumonia with formation of lung abscess, prolonged duration, cystic formation of the upper lobe of the left lung (aspergilloma).

Anti-inflammatory therapy was continued, assigned specific therapy of aspergillosis - itraconazole. X-ray examination noted pronounced strong positive dynamics in resorption of the infiltrative changes, however, retaining cavity with sequestration in the upper lobe of the left lung. 2 months after the start of treatment the patient was discharged in satisfactory condition with Diagnosis: upper lobar right sided pneumonia with formation of lung abscess due to immunocompromised state, prolonged duration. Aspergilloma of the left upper lobe (?). Condition after combined treatment of laryngeal cancer (2005), constant tracheostomy. Cachexia.  It was recommended to continuo clinical supervision by therapeutics, pulmonologist, oncologist residence with dynamic X-ray control every 2-3 months.

Thus, the diagnosis of pulmonary aspergillosis, aspergilloma remains unproven, however, most likely on the basis of the differential diagnosis, resulting of the positive effect from the antifungal therapy. Confirmation of the diagnoses was difficult due to severe general condition of the patient. Opportunity and invasive diagnostic procedures will be determined by the dynamics of the disease and the patient's condition.

Alertness of the practitioners for possible fungal lung disease in patients with secondary immunodeficiency and insufficient clinical benefit from the use of standard treatment of pneumonia (as in our clinical observation) will help to solve the complex diagnostic problems in such cases.

 

Литература

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