侵袭性深部真菌病的实验室诊断

1、现在学习的是第一页，共31页条件致病菌 致病性双相真菌 l念珠菌 组织胞浆菌l曲霉 球孢子菌l隐球菌 芽生菌l接合菌 马内菲青霉l镰刀菌 孢子丝菌l暗色真菌l酵母菌l毛孢子菌l枝顶孢霉现在学习的是第二页，共31页侵袭性真菌病(IFD)主要包括：l念珠菌病l隐球菌病l侵袭性曲霉病现在学习的是第三页，共31页现在学习的是第四页，共31页l广谱抗生素应用l入住ICUl血液系统肿瘤病人（粒缺、骨髓移植）l器官移植lHIV感染l应用皮质激素l糖尿病l静脉插管现在学习的是第五页，共31页美国美国49家医院血液分离病原菌及死亡率家医院血液分离病原菌及死亡率次序次序病原菌病原菌菌株菌株数数% 死亡率死亡率(%

2、)1凝固酶阴性葡萄球菌凝固酶阴性葡萄球菌3,908 31.9212金黄色葡萄球菌金黄色葡萄球菌1,928 15.7 253肠球菌肠球菌1,354 11.1 324念珠菌念珠菌934 7.6 405大肠艾希菌大肠艾希菌7005.7 246克雷伯菌克雷伯菌6625.4277肠杆菌属肠杆菌属5574.5288假单胞菌属假单胞菌属5424.4339沙雷菌属沙雷菌属1771.42610草绿色链球菌草绿色链球菌1731.423Edmond et al. Clin. Infect. Dis. (1999). 29:239-244现在学习的是第六页，共31页78798081828384858687888990

3、919202468Aspergillus spp.Candida spp.All otherPrevalence at Autopsy %Prevalence of invasive aspergillosis at necropsy at JW Geothe University Hospital,Frankfurt,Germany(Lancet ,2000;335:2076)现在学习的是第七页，共31页54.84%12.9%3.23%9.68%19.35%国内西南医院尸解资料，国内西南医院尸解资料，(1971-2000)，郝飞教授提供，郝飞教授提供CryptococcusMucorCand

4、idaAll others现在学习的是第八页，共31页侵袭性真菌病的流行病学特点危险因素不断增多，发生率逐年增高趋势，确切资料有待收集整理白念珠菌仍然是最常见临床分离致病菌 非白念珠菌增加（带来的问题）曲霉已成为重要的致死真菌现在学习的是第九页，共31页l形态学检查：经验？阳性率？l培养+鉴定：时间长，敏感性？l血清学检查：敏感性？特异性？l分子生物学检查：标准化？现在学习的是第十页，共31页GM试验：试验：血浆、血清、血浆、血清、BAL、胸、胸水、水、CSF，用于曲霉检测；，用于曲霉检测；G试验试验: 用于曲霉、念珠菌检测，用于曲霉、念珠菌检测，对隐球菌、接合菌无意义；对隐球菌、接合菌无意义

5、；乳胶凝集试验乳胶凝集试验: 检测隐球菌；检测隐球菌；现在学习的是第十一页，共31页现在学习的是第十二页，共31页Marr and Leisenring Clin Infect Dis 2005; 41:S381现在学习的是第十三页，共31页Musher et al. J Clin Microbiol 2004: 42(12): 5517-22敏感性敏感性 (%)特异性特异性 (%)阳性预测阳性预测 (%)阴性预测阴性预测 (%)血清血清47937382BAL8510010088Becker et al. Br J Haematol 2003; 121: 448现在学习的是第十四页，共31页u

6、可作为推定诊断的标准可作为推定诊断的标准;uGM: 检测半乳甘露聚糖，对检测半乳甘露聚糖，对曲霉曲霉感染诊断特感染诊断特异性强，假阳性反应可以在青霉菌属中出现；异性强，假阳性反应可以在青霉菌属中出现；部分含青霉烷砜衍生物的抗菌药物可以诱发部分含青霉烷砜衍生物的抗菌药物可以诱发阳性反应；阳性反应；uG试验试验: 检测检测(1,3)-D-葡聚糖，在很多真菌中葡聚糖，在很多真菌中都可以出现阳性反应，但在隐球菌、接合菌、都可以出现阳性反应，但在隐球菌、接合菌、毛霉、根霉呈阴性反应；毛霉、根霉呈阴性反应；现在学习的是第十五页，共31页Prospective utility of (1-3)-B-D-Gl

7、ucan (BG), galactomannan (GM) and anti-Candidaalbicans germ tube antibodies (CAGT) for the diagnosis of invasive fungal disease (IFD) in haemato-oncology adult patientsA. Alhambra1, M.S. Cutara2, J.M. Moreno1, A. Del Palcio Perez-Medel1, I. Moragues3, J.Pontn3, A. Del Palacio11Hospital Universitario

8、 Doce de Octubre, MADRID, Spain 2Hospital Universitario SeveroOchoa, LEGANES, Spain 3Universidad del Pais Vasco, BILBAO, Spain现在学习的是第十六页，共31页Invasive Candidiasis S SP PPV NPVCAGT (%) 57 93 44 96BG (%) 77 86 39 97Invasive Aspergillosis S SP PPV NPVGM (%) 92 94 73 98BG (%) 57 84 42 91现在学习的是第十七页，共31页CO

9、NCLUSIONS The incidence of IFD correlated directly and significantly (x2 p=0.0005) with risk stratification group: highest proportion in the high-risk group.Since all the biomarkers have inherent limitations, a better diagnosis yield is achieved combining the biomarkers. All three biomarkers share h

10、igh negative predictive value and can exclude reasonably IFD in haematology adult patients treated with wide spectrum antifungals.现在学习的是第十八页，共31页Evaluation of two serologic test for diagnosis invasive AspergillosisC. Castro, A. Romero, A. Aller, T. Gonzalez, A. Gonzlez, E. Martn-MazuelosH. U. Valme,

11、 SEVILLA, Spain现在学习的是第十九页，共31页A total of 236 sera from 51 patients in risk of IA were tested for GM using Platelia Aspergillus kit (Bio Rad, France) which 36 sera (10 patients) were tested for BG also using Fungitell kit (Associates of Cape Cod., USA). Patients were attended at the University Hospit

12、al of Valme from Seville from January of 2008 to December 2008. Patients with GM index 0.5 in two consecutive samples have been marked as GM positive and samples with results 80pg/ml were marked as BG positive. All GM positive patients were classified according to EORTC/MSG criteria (2008) for proba

13、bility of IA.现在学习的是第二十页，共31页lFrom 51 patient studied, 16 of them showed at least one positive specimen (33 sera). lOnly 6 patients showed two consecutive positive results (0.5 GM test) and they show clinical signs or microbiological criteria for AI proven (3 patients) and probable (3 patients). 现在学习

14、的是第二十一页，共31页lThe BG assay were used in parallel with GM in 36 sera which 26 showed positive result from 9 patients, (3 with AI proven and 6 AI probable). l3 patients showed positive results before for BG test ( 3,5 days) and 6 patients presented simultaneously both antigens. Never the GM test was th

15、e first serological test to show a positive result.lG试验阳性的9名患者中，G试验单独阳性的有3个病人，两种抗原同时阳性有6个病人，未出现单独GM试验阳性的情况。现在学习的是第二十二页，共31页ConclusionCalculating significant sensitivity for both detection methods was not feasible due to a low number of proven/probable AI. BG detection showed positive results before

16、GM test and present the great advantage to be a “panfungal”antigen. BG detection should be used with other techniques for detection of invasive Aspergillosis infections.现在学习的是第二十三页，共31页现在学习的是第二十四页，共31页 病例选择病例选择 深部真菌感染患者深部真菌感染患者35例，年例，年 龄龄1288岁，来自我院岁，来自我院2004年年1月到月到5月住院患者，月住院患者，均经培养证实存在深部真菌感染，感染部位包均经

17、培养证实存在深部真菌感染，感染部位包括呼吸道、泌尿道、血液及静脉插管引起的系括呼吸道、泌尿道、血液及静脉插管引起的系统性感染。正常健康对照组统性感染。正常健康对照组30人，来自我院健人，来自我院健康查体者。康查体者。第四军医大学第四军医大学 现在学习的是第二十五页，共31页l正常对照组血浆1-3-D葡聚糖含量最高为7.29 pg/ml ，最低为0.45 pg/ml，平均值为2.832.57pg/ml；l深部真菌感染组血浆1-3-D葡聚糖含量最高为168.9 pg/ml，最低为14.93pg/ml，平均值为54.0636.13 pg/ml。l经SPSS统计软件T-检验分析，对照组与深部真菌感染组1-3-D葡聚糖平均值差异非常显著（t=7.741,P0.001）。 现在学习的是第二十六页，共31页l入选的深部真菌感染患者均经细菌培养证实为念珠菌感染，包括白色念珠菌23株、热带念珠菌8株、季也蒙念珠菌1株、克柔念珠菌1株和光滑球拟假丝酵母菌2株，无隐球菌感染。l如以10 pg/ml为cutoff值，则阳性率为100%; 以20 pg/ml为cutoff值，则阳性率为91.4。l葡聚糖检测可在拟诊早期