诊断学理论与实践 ›› 2021, Vol. 20 ›› Issue (06): 515-521.doi: 10.16150/j.1671-2870.2021.06.001
• 专家论坛 • 下一篇
许晓倩, 卿恺, 张苏江
收稿日期:2021-11-08
出版日期:2021-12-25
发布日期:2021-12-25
Received:2021-11-08
Online:2021-12-25
Published:2021-12-25
中图分类号:
许晓倩, 卿恺, 张苏江. 造血干细胞移植后非感染性肺部并发症的诊治进展[J]. 诊断学理论与实践, 2021, 20(06): 515-521.
表1
2011年美国胸科协会颁布的IPS诊断标准
| Ⅰ：广泛肺泡损伤的证据 a. 常规胸片或计算机断层显示多叶浸润 b. 肺炎症状和体征（咳嗽、呼吸困难、呼吸急促、肺部闻及啰音） c. 肺部生理异常的证据 1. 肺泡与动脉血氧差增加 2. 新增的或限制性肺功能试验异常加剧 Ⅱ：无活动性下呼吸道感染 a. 支气管肺泡灌洗液检查细菌性病原体阴性,包括抗酸杆菌、诺卡菌和军团菌 b. 支气管肺泡灌洗检查,非致病性细菌微生物阴性 1. 病毒和真菌的常规培养 2. 巨细胞病毒和呼吸道合胞病毒培养 3. 巨细胞病毒包涵体、真菌和卡氏肺囊虫的细胞学检查 4. CMV、RSV、HSV、VZV、流感病毒、副流感病毒、腺病毒和其他生物的抗体直接荧光染色 c. 其他生物或试验阴性 1. 人偏肺病毒、鼻病毒、冠状病毒和疱疹病毒的聚合酶链反应 2. 衣原体、支原体和曲霉的聚合酶链反应 3. 曲霉菌血清半乳甘露聚糖酶联免疫吸附试验 d. 如病情许可经支气管活检 Ⅲ：无心功能障碍、急性肾功能衰竭或医源性液体超载这些可导致肺功能不全的因素 |
表2
HSCT后IPS的临床疾病谱（按原发性组织损伤部位分类）
| 肺实质 | 血管内皮 | 气道上皮 |
|---|---|---|
| 急性呼吸窘迫综合征 | 移植期呼吸窘迫综合征 | 隐源性机化性肺炎 |
| 迟发性肺毒性综合征 | 弥漫性肺泡出血 | 闭塞性细支气管炎 |
| 急性间质性肺炎 |
表3
造血干细胞移植后BOS的诊断标准
| FEV1/FVC≤0.7 FEV1≤75%预测值且与基线相比至少下降10%,支气管扩张剂使 用后无明显反应 小气道疾病的其他证据（至少1/3） 胸部高分辨率计算机断层扫描显示空气滞留、小气道增厚或支气管扩张 残余容积120%,或残余容积/肺活量增加 狭窄性毛细支气管炎的病理证实 无呼吸道感染 通过适当的临床、放射学、微生物学检查(窦吸、上呼吸道、病毒筛检、痰培养或支气管肺泡灌洗 |
表4
常见非感染性肺部并发症的临床特点
| 分类 | 好发时间 | 危险因素 | 检查 | 影像学 | 临床表现 | 治疗 |
|---|---|---|---|---|---|---|
| PERDS | 植入期,多在 移植后2周 | 女性、GM-CSF | HRCT | 弥漫性磨玻璃样 阴影,胸腔积液 | 低氧血症伴 发热、皮疹 | 糖皮质激素,预后好 |
| DAH | 移植后11~21 d | 药物、感染、GVHD | 支气管肺泡灌洗 | 早期磨玻璃样阴影和 实变伴空气支气管征, 后期铺路石改变 | 低氧血症、咯血、 咳白痰 | 针对病因治疗,通气 支持及激素,预后差 |
| COP | 移植后2~15个月, 中位108 d | 女供男、HLA 配型 不合、急慢性 GVHD | HRCT及肺功能 | 肺有实变或斑片影,可 伴有磨玻璃样和结节 样改变 | 发热、干咳和 呼吸困难 | 糖皮质激素 |
| BOS | 移植后第3个月 至2年 | 移植前低FEV1/FVC、 急或慢性GVHD、无 关或女性供体、 | HRCT及肺功能 | 马赛克征、气体闭陷 征、外周支气管管壁 增厚和扩张 | 气流阻塞的 相关症状 | 免疫抑制剂,FAM 方案 |
| PPFE | 移植后数月至数年 | 预处理放化疗及 GVHD | HRCT及肺功能 | 上叶纤维化伴胸膜下 及胸膜下增厚伴缩窄、 体积缩小及牵引性 支气管扩张 | 干咳、呼吸困难 | 肺移植 |
| TALS | 继发于BOS、COP 及ILD | 慢性GVHD、男性、移植时年龄<38岁和使用他 克莫司 | 胸片、CT | 气胸 | 胸痛、呼吸困难 | 胸腔闭式引流 |
| 肺动脉高压 | 移植后2~6个月 | 放化疗损伤 | 超声心动图、 右心导管术 | 右心室增大,肺弥漫 性磨玻璃样改变 | 右心衰症状 | 类前列腺素、内皮 素受体拮抗剂等 |
| PTLD | 移植后前6个月 | 去T细胞移植物、抗胸 腺细胞球蛋白使用、 GVHD等 | 血EB拷贝数、 PET/CT及活检 | PET/CT检查出现 高代谢病灶 | 发热、淋巴结 肿大及呼吸 系统症状 | 免疫抑制剂减停 及利妥昔单抗 |
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