余进侵袭性真菌病诊断进展

Dept.Dermatology,PekingUniversityFirstHospitalandResearchCenterforMedicalMycology,PekingUniversityDept.Dermatology,PekingUniversityFirstHospitalandResearchCenterforMedicalMycology,PekingUniversity侵袭性真菌病诊断进展北京大学第一医院北京大学真菌和真菌病研究中心余进Dept.Dermatology,PekingUniversityFirstHospitalandResearchCenterforMedicalMycology,PekingUniversityDept.Dermatology,PekingUniversityFirstHospitalandResearchCenterforMedicalMycology,PekingUniversity侵袭性真菌病的诊断方法传统诊断方法—真菌直接镜检—真菌培养血清学方法分子生物学方法Dept.Dermatology,PekingUniversityFirstHospitalandResearchCenterforMedicalMycology,PekingUniversityDept.Dermatology,PekingUniversityFirstHospitalandResearchCenterforMedicalMycology,PekingUniversity新型检查方法•真菌细胞壁成分–（1-3）-β-D-葡聚糖检测（G试验）•真菌抗原检查–半乳甘露聚糖（galactomannan)抗原（GM试验)–隐球菌荚膜多糖抗原（乳胶凝集试验）–甘露聚糖/甘露聚糖抗体（M/AM)•真菌DNA的检测Dept.Dermatology,PekingUniversityFirstHospitalandResearchCenterforMedicalMycology,PekingUniversityDept.Dermatology,PekingUniversityFirstHospitalandResearchCenterforMedicalMycology,PekingUniversityβ-（1-3）-D-葡聚糖检测Dept.Dermatology,PekingUniversityFirstHospitalandResearchCenterforMedicalMycology,PekingUniversityDept.Dermatology,PekingUniversityFirstHospitalandResearchCenterforMedicalMycology,PekingUniversityBG检测的特点•可检测多种致病真菌感染–念珠菌,曲霉,肺孢子菌,镰刀菌,地霉,组织胞浆菌,毛孢子菌等–不能用于检测隐球菌和接合菌感染•阳性结果代表存在侵袭性真菌感染•真菌对数生长期释放量最大,可被体内葡聚糖酶降解(glucanase)•每周检测2次Dept.Dermatology,PekingUniversityFirstHospitalandResearchCenterforMedicalMycology,PekingUniversityDept.Dermatology,PekingUniversityFirstHospitalandResearchCenterforMedicalMycology,PekingUniversity（1-3）-β-D-葡聚糖(BG)检测方法•colorimetric–Fungitec-G(JapanSeikagaku)–Fungitell/Glucatell(USAssociatesofCapecod.)•turbidimetric–WakoPureChemicals–GKT-5MSet动态真菌检测试剂盒(国内金山川公司)Dept.Dermatology,PekingUniversityFirstHospitalandResearchCenterforMedicalMycology,PekingUniversityDept.Dermatology,PekingUniversityFirstHospitalandResearchCenterforMedicalMycology,PekingUniversity假阳性问题•污染（无热源的试管、枪头和蒸馏水等）•血液透析、腹膜透析•纱布或其他医疗物品（外科手术）•某些品牌的静脉制剂（白蛋白、凝血因子、免疫球蛋白等）•抗肿瘤多糖（香菇多糖）•某些细菌败血症患者（尤其是链球菌败血症）•对策:动态监测葡聚糖的变化Dept.Dermatology,PekingUniversityFirstHospitalandResearchCenterforMedicalMycology,PekingUniversityDept.Dermatology,PekingUniversityFirstHospitalandResearchCenterforMedicalMycology,PekingUniversity抗生素的影响•假阳性：阿莫西林/克拉维酸平均值1339+1798pg/ml•头孢他定17+26•健康志愿者18+13Dept.Dermatology,PekingUniversityFirstHospitalandResearchCenterforMedicalMycology,PekingUniversityDept.Dermatology,PekingUniversityFirstHospitalandResearchCenterforMedicalMycology,PekingUniversity国产Gtest•试剂质量•缺少大样本、不同高危因素人群应用方面的研究•确诊病例少•敏感度60-70%，特异度70-90%•NPV较高，除外的意义更大•高危人群（血液病化疗后，移植患者）PPV较高，对于一般住院患者PPV较低Dept.Dermatology,PekingUniversityFirstHospitalandResearchCenterforMedicalMycology,PekingUniversityDept.Dermatology,PekingUniversityFirstHospitalandResearchCenterforMedicalMycology,PekingUniversityG试验、candidascore(CS)、colonizationindex(CI)•CS=3:全胃肠外营养×1+外科手术×1+多点定植+严重败血症×2•CI=0.5:培养阳性部位数/全部培养部位数•IC:14;BG(+):13;CS≥3:10;CI≥0.5:7•Candidemic:12;BG阳性早于培养诊断(24to72hrs).•阳性预测值:BG/CS/CI:72.2%/57.1%/27.3%•阴性预测值:BG/CS/CI:98.7%/97.2%/91.7%•败血症时取材的BG检测早期诊断价值高.Posteraroetal.CriticalCare2011,15:R249Dept.Dermatology,PekingUniversityFirstHospitalandResearchCenterforMedicalMycology,PekingUniversityDept.Dermatology,PekingUniversityFirstHospitalandResearchCenterforMedicalMycology,PekingUniversity半乳甘露聚糖抗原检测（GM试验）Dept.Dermatology,PekingUniversityFirstHospitalandResearchCenterforMedicalMycology,PekingUniversityDept.Dermatology,PekingUniversityFirstHospitalandResearchCenterforMedicalMycology,PekingUniversityGM抗原乳胶凝集试验（Pastorex®）(15ng/ml)酶连免疫吸附试验（Platelia®）(1ng/ml)80-9050-90ELISA90-10025-70LA特异度（%）灵敏度（%）Sabettaetal.JID1985;152:946Sabettaetal.JID1985;152:946Ansorgetal.EurJClinMicrobiolInfectDis1994;13:582Ansorgetal.EurJClinMicrobiolInfectDis1994;13:582Verweijetal.JCM1995;33:3150Verweijetal.JCM1995;33:3150Maertensetal.Blood2001;97:1604Maertensetal.Blood2001;97:1604Herbrechtetal.JClinOncol2002;20:1898Herbrechtetal.JClinOncol2002;20:1898Dept.Dermatology,PekingUniversityFirstHospitalandResearchCenterforMedicalMycology,PekingUniversityDept.Dermatology,PekingUniversityFirstHospitalandResearchCenterforMedicalMycology,PekingUniversity侵袭性真菌病的诊断标准EORTC/MSG2008修订版•宿主因素•临床特征•病原学–真菌镜检–真菌培养–组织病理学检查–血清学检查方法（间接证据）•CSF隐球菌抗原阳性——确诊•GM-test,G-test——临床诊断ClinicalInfectiousDiseases2008;46Dept.Dermatology,PekingUniversityFirstHospitalandResearchCenterforMedicalMycology,PekingUniversityDept.Dermatology,PekingUniversityFirstHospitalandResearchCenterforMedicalMycology,PekingUniversityGM试验非确证试验!GM试验阳性不代表必然存在感染，只能提示感染的可能性!Dept.Dermatology,PekingUniversityFirstHospitalandResearchCenterforMedicalMycology,PekingUniversityDept.Dermatology,PekingUniversityFirstHospitalandResearchCenterforMedicalMycology,PekingUniversity•敏感度为0.71，特异度为0.89•血液系统恶性病–敏感度0.7,特异度0.92•骨髓移植患者–敏感度0.82,特异度0.86•实体器官移植患者–敏感度0.22，特异度0.84•肝移植敏感度55.6%•肺移植敏感度30%•ICU敏感度25%•儿童假阳性率高于成人（12.7-44%,0.9-2.5%)GMinSerumDept.Dermatology,PekingUniversityFirstHospitalandResearchCenterforMedicalMycology,PekingUniversityDept.Dermatology,PekingUniversityFirstHospitalandResearchCenterforMedicalMycology,PekingUni