1 year, pneumonia 3 months, antibiotics can not cure?

1Medical history profile Male, 49 years old, Jiangsu, 2018-11-06 into Zhongshan Hospital infection department main complaint: cough cough sputum 1 year, chest pain 7 months of current medical history: November 2017 patients without obvious causes of coughing cough, sputum yellow is not easy to cough, no fever, no night sweats, chest pain, asthma, blood, etcIn March 2018 consciously right front chest pain, the range is about the size of the palm, the seizure of swelling pain, the inhalation phase aggravated, each time lasts several minutes, after rest self-improvement, 1-2 times a week, no other discomfort, still not pay attention to, also did not do electrocardiogramThe post-chest pain is progressively aggravated, with an extended duration of up to half an hour2018-08-06 in the local hospital, check chest CT: right lung upper lobe bronchial stenosis, right lung upper lobe obstructive inflammation and immobility, even if the lymph nodes swelling, anti-infection treatment 3 days (specific drugs unknown) after chest pain no improvement; 08-10 Re-examination: CRP 10.63mg/L, ESR 120mm/H, Pneumonia mycoplasma antibody IgM (-);2018-08-14 local line ultrasound-guided lung puncture biopsy, pathology report: pulmonary fibrosis tissue growth and edema, small amount of lymphocytic immersion, alveolar cavity tissue cell reaction, alveolar epithelial hyperplinter, surface interthelocutan cell growth; Left oxyoxyfluorosacin, azithromycin and other anti-infection treatment, 09-21 review of chest CT: right lung upper leaf multi-immersion real ity, part of the previous absorption, part of the previous new appearance, right lung upper leaf after bronchosindicatal dilation, vertical and right lung door multiple lymph nodes show2018-10-08 Follow-up: CRP 0.64mg/L, ESR 42mm/H, bronchoscopy examination: right lung upper leaf open tube cavity narrow, mucosal hematomaedema, residual tube cavity smooth; biopsy pathology: A large number of lymphatic cells, plasma cells and eosinophils in the inherent membrane of the bronchial mucous membrane were immersed in, in line with the inflammatory performance, and the lung function suggested that the ventilation function was mildly restricted with obstruction of the airways, the dispersion function was impaired, the airway resistance increased, and then continued to be treated with the anti-infection of left oxyphofluoasinAfter treatment there is still intermittent cough ingepsoconsopus, chest pain slightly alleviated, but there are still seizures, and the right upper limb lift when chest pull pain, for a clear diagnosis and further treatment income of my departmentDuring the course of the patient's body temperature is normal, the spirit is OK, appetite sleep can be, two will be no abnormal, no significant fluctuations in weightPast history: 2015 has a history of pneumonia, anti-infection treatment after 1 month improved, after a review of chest CT promptbrond dilation, not treated; Deny the history of raw food, deny the mold environment, poultry and wildlife contact history2Admission examination (2018-11-06) (physical examination)T 37.5 degrees C, P 96bpm, R 20 times/min, BP130/78mmHg;double lung breathing sound coarse, not as clearasableThe tip of the heart is not as murmured as it isThe abdomen is flat and soft, no tenderness anti-jumping painThere is no visible edema in the lower limbsLaboratory Examinations Blood Routines: Hb 115g/L; WBC 4.30x10/9/L; NE 39.9%; Eos 9.0%; Inflammatory Markers: hs-CRP 32.9mg/L; ESR 85mm/H; PCT 0.04ng/mL; urine routine and fecal routine s-OB: both negative; liver and kidney function, blood clotting: no obvious abnormalities; tumor markers: CEA 6.5ng/mL; CYFRA21-1 3.5ng/mL;; myocardial enzyme spectrum: no obvious abnormalities; autoantibodies: ANA (-), ANCA (-), anti-GBM antibodies (-); anti-CCP 34.8U/mL; immunoglobulin set: IgE 6177 IU/mL, C3, C4 are normal; cell immunity examination: normal; sputum bacteria, fungal culture: negative; blood culture; negative; pneumonia mycoplasma antibodies (-); respiratory pathogens: all (-); heliococcal membrane antigen: (-); G test: 1-3-beta-D glutarides: negative; T-SPOT: A/B:0/0; blood analysis (no oxygen absorption) :PaO2 79mmHg; 11-06 echocardiogram: no obvious abnormalities in resting state; 11-06 chest CT: local real ity of the upper loitering of the right lung with mild inflation, swelling of the right lung door and vertical lymph nodes, inflammation surrounding the local bronchodiexpansion of the two lungs; III, clinical analysis Medical history characteristics: patients middle-aged men, both after pneumonia bronchodilating history, mainly manifested as repeated yellow pus and chest pain; The pulmonary door and the lymph nodes are slightly swollen, and the treatment of anti-infection drugs such as left oxyfluoracin and azithromycin in the outer hospital is not good After the admission to check blood eosinophils mild rise, inflammatory markers and IgE significantly increased, blood culture and sputum bacteria, fungal culture are negative; Consider the following diseases possible: lung cancer with obstructive pneumonia: patients middle-aged men, have a history of smoking, chest CT shows the right upper lung real ity part is not open, lung door and vertical lymph nodes swelling, bronchoscopy examination also found the right lung upper abdominal ventrline cavity narrow and Mucosal congestion edema, combined with tumor markers see CEA, CYFRA21-1 mild increase, need to consider central lung cancer with blocking pneumonia, but bronchoscopy and lung puncture biopsy have not seen clear evidence of the tumor, if necessary, can again bronchoscopy biopsy to be clear chronic pulmonary abscess/necrosis pneumonia: often due to oral bacteria inhaled into the lungs caused by purulent inflammation, mostly mixed infections, pulmonary tissue after death liquefaction can often form a hole, if acute pulmonary abscess treatment is not good, can gradually turn into chronic pulmonary abscess or necrosis pneumonia The patient's chronic disease course, repeated yellow pus cough, repeatedly check the inflammatory markers significantly increased, chest CT performance in the right lung upper leaf large change, even if the bed see part of the low density stove, the use of left oxyfluorasin treatment part effective; pulmonary curite disease: patients have a history of bronchodilatal disease, chest CT prompt lesions are located in a good part of the right lung leaf ventilation, a blocking pneumonia performance, there is repeated yellow pus cough, conventional anti-infection treatment lesions no obvious absorption, blood etoicemia cells and immunoglobulin E significantly increased, to be considered Mixed pulmonary psoriasis (variant bronchopulmonary psycosis combined with chronic necrotized pulmonary metamorphosis) may further improve the trijoint examination of crankum, if necessary, again bronchoscopy examination or CT-guided lung puncture, irrigation fluid delivery NGS examination to clarify non-infectious diseases: the patient's working environment has a history of sulfur hexafluoride, transformer oil exposure, whether there is a long-term inhalation leading to liposome pneumonia, electtrifying pneumonia and other possibilities; There is no obvious fever in the patient's course, chest CT with a large area of real change and lung door and vertical lymph node swelling greatly demonstrated, both the former hospital lung puncture and bronchoscopy biopsy results are not clearly related basis, and the lesions only affect the upper right lung lobe, so the probability is less 4, further examination, diagnosis and treatment process and treatment response 2018-11-08 bronchoscopy examination and the front of the upper right lung biopsy (TBLB), the mirror see trachea and left and right bronchial tube cavity smooth, mucous membrane smooth, no new organisms; 2018-11-08 Consider combining bacterial infections without exception, to merobinan 1g q8h anti-infection treatment; 2018-11-09 Preliminary pathological return: a large number of inflammatory cells and lesions necrosis in the alveoli tissue; 2018-11-09 Tri-Joint Inspection: GM Test s.25ug/L; Smoky mold IgG Antibodies s.500AU/mL; smoky mold IgM antibodies s.31 25AU/mL; 2018-11-12 Specific IgE Test Results: Tobacco-specific IgE 19KIU/L (Level 4, very high); 2018-11-13 Bronary irrigation lotion delivery mNGS results: a small amount of aflatoxin nucleic acid sequence was detected 2018-11-14 Consider the possibility of variable bronchopulmonary pneumocomylysis (ABPA) combining chronic pulmonary mycomylycosis disease, to be treated with meth40mg qd, combined with Volicazole 200mg q12h antimycilla therapy; 2018-11-18 Coughing a large amount of dark red (illustrated); 2018-11-19 Follow-up IgE 4941 IU/mL, hsCRP 0.4mg/L, ESR 22mm/H; significantly lower than the previous effect; 2018-11-20 Review chest CT: Upper Right Lung Ct 2018-11-21 The pathological end result of the right upper pulmonary tissue (2018-11-08 tracheoscopy sampling): a large number of inflammatory cells and foer necrosis in the alveoli tissue; 2018-11-21 to discontinue merobinan, change oral Vulcanazola 0.2g q12h s medlojol 28mg qd discharged from the hospital, the clinic is ordered to follow up regularly Follow-up after discharge 2018-12-19 Follow-up EOS: 0.02 x 10 x 9, CRP: 2.4mg/L, ESR: 29mm/H, IgE:206 2 IU/mL; follow-up chest CT see the upper right lung leaf lesions were significantly absorbed before; due to liver dysfunction: ALT/AST: 116/28 U/L, discontinuation of voloricazole; hormone gradually regular lysage reduction 2018-03-13 Follow-up EOS: 0.02 x 10 x 9, CRP: 0.3mg/L, ESR: 22mm/H, IgE:512 IU/mL, significantly lower than before; 2019-07-08 Follow-up EOS: 0.01 x 10 x 9, CRP: 1.2mg/L, ESR:32mm/H, IgE:288 IU/mL; Follow-up chest CT: Right lung upper leaf expansion infection, compared to 3-13 tablets basically similar, left upper pulmonary tongue and right middle and lower pulmonary partial partial Deactivate Mejolo chest CT 5, final diagnosis and diagnosis basis Final diagnosis: variant bronchial pulmonary colitinol disease (ABPA) diagnosis basis: Patients in middle-aged men, mainly manifested as repeated yellow pus with chest pain, inflammation markers rise, chest CT prompted the right lung upper lobe with mild deficient, anti-infection treatment effect is not good; Triple test prompted the significant increase of flucoric mold IgG, specific IgE check-out tobacco-cranked mold-specific IgE 4 level, irrigation liquid NGS examination prompted detection of the crankmold sequence;Six, experience and experience of crankmold is widely present in nature, the most common pathogenic bacteria are tobacco-cranked mold and black crankmold, other such as aflatoxin, soil mold, etc can also lead to human infection Pulmonary mycomycin disease mainly consists of chronic pulmonary colitis (chronic pulmonary aspergillosis, CPA), variable bronchiopulmonary pulmonary psycomyolindisease (all bronchocury aspergillosis, ABPA) and invasive pulmonary colitis (pulmonary aspergillosis, IPA) Chronic pulmonary mycomycin disease can be divided into quicillon altnosis, monomycinomycin, chronic hollow pulmonary psycosic disease, chronic fibrosis pulmonary psymey, and chronic necrotizing pulmonary crostomy Pulmonary psycosisis is associated with the patient's immune state and the toxicity of quercetal mold Different types of multiple are present alone, but the same patient can also have two or more types at the same time clinical characteristics of ABPA include recurrent wheezing, chronic coughing and sputum, coughing out a slime sputum with branches usually have diagnostic value, a few patients can have hemorrhage; Laboratory test abnormalities usually include elevated blood eophilic granulocytes, elevated serum total IgE, and immunoassays of citadowne-specific IgE and IgG antibodies (cone triamcine) have good judgmental value For coughing sputum smears often can see more eosinophils, sputum culture can detect the growth of citamy Central bronchial dilation is a common feature of ABPA patients, mainly affecting the upper and middle lobes of the lungs, often visible sputum insertcause of the "toothpaste-like shadow" or bronchial wall thickening caused by the "finger ingenuity", can also be secondary obstructive pneumonia and pulmonary insacist This case of patients lung imaging performance is not typical, considering the patient before yellow pus obvious, there is a bronchodilating base, there may be a combined bacterial infection, so after admission we used melopinan treatment, followed by the patient's fluometform-specific IgE significantly increased, the use of glucocortichormone treatment coughed out more viscosum, review the chest CT hint lesions obviousabsorption, so support the diagnosis of ABPA treatment of Patients with ABPA is designed to control the onset of acute inflammation and reduce sexual lung injury The effects of systemic glucocorticoids and anti-corbyn drugs vary depending on the degree of disease activity Anti-curic therapy may help reduce the number of seizures and reduce the dose of glucocorticoids Patients with acute or recurrent ABPA can be combined with glucocorticoids and iquorcozole, according to IDSA's 2016 guidelines for the treatment of courmia Since in some patients, vulcanazola is better tolerated and absorbed well, it is also possible to choose Volikazole as an alternative to Iqucona Wang Mengran, Jin Wenxuan, Ma Yuyan Source: SIFIC Infection Officer Micro.