- 期刊
Clinical Features of Pulmonary Nocardiosis: Experience with 30 Cases
土壤絲菌之肺部感染－三十個病例的經驗
摘要
土壤絲菌(Nocardia)是一種革蘭氏陽性桿菌。它會造成局部或系統性的感染，而呼吸道是最常見的傳染途徑。本研究的目的在於評估肺部土壤絲菌感染的誘發因子、臨床表現、X光影像特徵、治療方式和結果。我們針對1992至2003年之間於成功大學附設醫院所診斷的30個病歷做分析。他們都有肺炎的X光影像證據，而且至少有一個呼吸道檢體培養出土壤絲菌。病人的平均年齡是68歲，男女的比例為23:7。其中43.3%的病人有既存的肺部疾病，例如慢性阻塞性肺病、氣喘、支氣管擴張或肺癌。而且他們多數(70.0%)都有免疫不全的狀況，例如長期使用類固醇、惡性腫瘤、糖尿病等。呼吸困難、發燒及咳嗽是主要的症狀。在胸部X光影像特徵方面，以肺實質化佔大多數(80%)，而腫塊、節結或混合實質化及節結則較少。檢體的培養平均需要19天，菌種以Nocardia asteroides佔多數(56.7%)。有20位病人在診斷後接受抗生素治療；處方以TMP/SMX為主。其餘的10位病人因為死亡、失聯或病情改善而未接受治療。瀰散性的感染只發生在兩位病人，一例為腦膿瘍；另一例為菌血症。九位病人(30.0%)於當次住院死亡；他們大多於疾病早期就有呼吸衰竭或休克的情形。由上述的觀察結果可知，肺部的土壤絲菌感染雖然少見，嚴重者卻可能致死。它的診斷不易且費時。對於免疫不全且有肺炎的病人，Nocardia應該被納入鑑別診斷。
並列摘要
Nocardia is a Gram-positive aerobic bacillus that can cause localized or disseminated infection, with major transmission via the respiratory tract. In order to further understand the consequences of this bacillus, this study sought to evaluate the predisposing factors, clinical features, radiographic findings, treatment, and outcome of patients with pulmonary nocardiosis. We reviewed 30 cases of pulmonary nocardiosis diagnosed in our hospital between 1992 and 2003. All of the cases had evidence of pneumonia on the chest radiograph, and at least I airway specimen with a positive culture for Nocardia species. The mean age of the patients was 68 years, and the male to female ratio was 23:7. Many of the patients had preexisting lung illness (43.3%), such as chronic obstructive pulmonary disease (COPD), asthma, bronchiectasis, or lung cancer. In addition, most of the patients had conditions that might impair immunity (70.0%), including long-term steroid use, hematologic or solid organ malignancy, diabetes mellitus, and other. Dyspnea, fever, and cough were the most common symptoms. The most common pattern on the chest radiographs was consolidation (80.0%). Other patterns included mass, nodules, and mixed consolidation and nodules. The mean period needed for culture was 19 days. Nocardia asteroides accounted for most of the isolated species (56.7%). Twenty patients received treatment after the diagnosis of pulmonary nocardiosis, either during hospitalization or after discharge. Most of them received trimethoprim/sulfamethoxazole (TMP/SMX). The other 10 patients, whose diagnosis of pulmonary nocardiosis was made after discharge, did not receive treatment because of death, lost to follow-up, or disease improvement on their own. Disseminated infection occurred in 2 patients only; 1 with brain abscess and the other with bacteremia. Nine patients (30%) died during hospitalization. Most of them developed early respiratory failure and septic shock, which may have contributed to mortality. In conclusion, pulmonary nocardiosis is a rare condition, but may be fatal. The diagnosis is time-consuming and not easy. However, clinicians should take pulmonary nocardiosis into the differential diagnosis of pneumonia in patients who are immunocompromised.