多发性骨髓瘤并发上消化道侵袭性念珠菌病2例报道及文献复习

摘要/Abstract

摘要： 目的探讨多发性骨髓瘤(Multiple myeloma,MM)并发上消化道侵袭性念珠菌病的临床特点,提高诊治该病的水平。方法回顾分析我科2例多发性骨髓瘤并发上消化道侵袭性念珠菌病的诊治过程,分析、总结治疗经验,并结合文献复习骨髓瘤并发上消化道侵袭性念珠菌感染的易感因素、临床表现、诊断和鉴别诊断及治疗。结果 MM患者1,女性,异基因造血干细胞移植术后4个月发生腹泻伴腹部隐痛,抗移植物抗宿主病(graftversus host disease,GVHD)治疗无效,经胃镜诊断上消化道念珠菌病,予卡泊芬净治愈出院。MM患者2,男性,化疗过程中疾病进展,并出现腹胀、腹痛,对症处理改善,再次化疗时上述症状加重并发肺部念珠菌病,发生急性心、肾功能不全,经胃镜诊断上消化道念珠菌病,予伊曲康唑、米卡芬净治疗,最终因肺部真菌感染加重,治疗无效死亡。结论多发性骨髓瘤并发上消化道侵袭性念珠菌病易发生误诊、漏诊。临床医生需提高对该病的认识,首选电子胃镜明确诊断、判断疗效。

关键词: 多发性骨髓瘤, 念珠菌病, 侵袭性真菌感染

Abstract: Objective To discuss the clinical features of multiple myeloma who complicated with upper gastrointestinal invasive candidiasis, and improve our knowledge about this disease. Methods We retrospectively analysed two patients with multiple myeloma complicated with upper gastrointestinal invasive candidiasis, and reviewed literature about this disease to understanding it's risk factors, clinical fature, diagnosis, differential diagnosis and therapy. Result Case 1 A woman was diagnosed a κ light chain multiple myeloma for which she successfully underwent allo-bone marrow transplant. 4 months later she developed diarrhea and pain of belly, anti GVHD treatment was inefficiency. By electronic gastroscopy she was diagnosed upper gastrointestinal invasive candidiasis, and was cured by infusing caspofungin. Case 2 A man was diagnosed an IgG λ multiple myeloma for which he unsuccessfully underwent chemotherapy. With progression of the disease, he developmented abdominal distension,belly pain, heart failure, renal failure as well as pulmonary candidiasis. By electronic gastroscopy he was diagnose upper gastrointestinal invasive candidiasis.Treating with itraconazole and caspofungin were futility, and soonly died of multi-organic failure and cadidiasis infection. Conclusion We explored the clinical features of the disease and found it's prone to misdiagnosis. Clinician need enhance the knowledge of the disease, and electronic gastroscopy is essential for diagnosis as well as assessment of treatment effect.

Key words: multiple myeloma, gastrointestinal candidiasis, invasive fungal infection

中图分类号:

R519.3

金丽娜, 杜鹃, 袁振刚, 张春阳, 傅卫军, 侯健. 多发性骨髓瘤并发上消化道侵袭性念珠菌病2例报道及文献复习[J]. 中国真菌学杂志, 2013, 8(2): 83-86.

JIN Li-na, DU Juan, YUAN Zhen-gang, ZHANG Chun-yang, FU Wei-jun, HOU Jian. Multiple myeloma complicated with upper gastrointestinal invasive candidiasis：two case reports and literature review[J]. Chinese Journal of Mycology, 2013, 8(2): 83-86.

参考文献

[1] Kumar SK, Rajkumar SV, Dispenzieri A, et al. Improved survival in multiple myeloma and the impact of novel therapies[J]. Blood, 2008,111(5):2516-2520.
[2] Turesson I, Velez R, Kristinsson SY, et al. Patterns of improved survival in patients with multiple myeloma in the twenty-first century: A population-based study[J]. J Clin Oncol, 2010,28(5):830-834.
[3] Kuroki Y, Tsuchida K, Go I, et al. A study of innate immunity in patients with end-stage renal disease: special reference to toll-like receptor-2 and-4 expression in peripheral blood monocytes of hemodialysis patients[J]. Int J Mol Med, 2007,19(5):783-790.
[4] Cecilie B, Ulf-Henrik M, Ola L, et al. Multiple myeloma and infections: a population-based study based on 9,610 multiple myeloma patients[C]//Blood (ASH Annual Meeting Abstracts), 2012,120: 945.
[5] Pagano L,Girmenia C, Mele L, et al. Infections caused by filamentous fungi in patients with heamatologic malignancies. A report of 391 cases by GIMEMA infection program[J]. Heamatologica, 2001, 86(8): 862-870.
[6] Pagano L, Caria M, Candoni A, et al. The epidemiology of fungal infections in patients with hematologic malignancies: the SEIFEM-2004 study[J]. Haematologica, 2006,91(8):1068-1075.
[7] 王彦艳,沈志祥.血液病真菌相关感染[J].国际输血及血液学杂志,2010,33(5):385-386.
[8] Nencioni A, Schwarzenberg K, Brauer KM, et al. Proteasome inhibitor bortezomib modulates TLR4-induced dendritic cell activation[J]. Blood, 2006,108(2):551-558.
[9] Palumbo A, Bringhen S, Caravita T, et al. Oral melphalan and prednisone chemotherapy plus thalidomide compared with melphalan and prednisone alone in elderly patients with multiple myeloma: randomised controlled trial[J]. Lancet, 2006,367(9513): 825-831.
[10] Kliemann DA, Pasqualotto AC, Falavigna M, et a1. Candida esophagitis: species distribution and risk factors for infection[J]. Rev Inst Med Trop Sao Paulo, 2008, 50(5): 261-263.
[11] Weerasuriya N, Snape J. A study of candida esophagitis in elderly patients attending a district general hospital in the UK[J]. Dis Esophagus, 2006, 19, 189-192.
[12] Nicholas K, John K, Lori M. Caspofungin Susceptibility Testing of Isolates from Patients with Esophageal Candidiasis or Invasive Candidiasis: Relationship of MIC to Treatment Outcome[J]. Antimicrob. Angent Chemother, 2005, 49(9). 3616-3623.
[13] 黄蓓晖,李娟,刘俊茹.多发性骨髓瘤合并侵袭性真菌感染的临床特点及易感因素分析[J].中华内科杂志,2009,12(12):1026-1030.
[14] 中国侵袭性真菌感染工作组.血液病/恶性肿瘤患者侵袭性真菌感染的诊断标准与治疗原则(第三次修订)[J].中华内科杂志,2010,49(5):451-454.
[15] 念珠菌病诊断与治疗:专家共识[J].中国感染与化疗杂志,2011,11(2):81-95.
[16] Chen HF, Wu TQ, Li ZY, et al. Extramedullary plasmacytoma in the presence of multiple myeloma: clinical correlates and prognostic relevance[J]. Onco Targets Ther, 2012,5:329-334.
[17] Pappas PG, Kauffman CA, Andes D, et a1. Clinical practice guidelines for the management of candidiasis:2009 update by the Infectious Diseases Society of America[J]. Clin Infect Dis, 2009, 48(5): 503-535.