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*This article is only for medical professionals' reference.
What should I do if I have recurrent lung infections? Case profile: Patient Ji Mou, male, 73 years old, retired.
Chief complaint: Intermittent cough and sputum with fever for more than 2 years.
History of present illness: In March 2017, the patient developed paroxysmal cough, yellow pus sputum, accompanied by chills and fever, with a maximum body temperature of 39°C.
Thereafter, he has cough and fever symptoms every year, 2-3 times a year, every time This time lasts for at least 1 month, and can be relieved by anti-infective treatment.
CT results of the outside hospital on August 14, 2017, the right lung showed postoperative changes with cyst-like structure.
I was hospitalized in a Shanghai hospital on February 4, 2019.
The blood test showed that the neutrophils were 93%, and the IgM of influenza A was positive.
Chest CT showed pneumonia, and after right upper lung resection, the right thoracic cavity contained air-liquid sac.
On February 4, 2019, the CT results of the outer hospital showed scattered exudation in both lungs.
Liquid Ping was seen in the right lung sac cavity.
The patients were treated with piperacillin and tazobactam for anti-infection and mucosulfan for 14 days.
The symptoms were improved compared with the previous one.
.
On March 26, 2019, the patient reappeared with symptoms of cough, sputum expectoration and fever.
Re-examination of the chest showed that the two pneumonias had progressed more than before, and the right thoracic cavity was filled with air and fluid cysts.
He was treated with cefoperazone and sulbactam and etimicin for anti-infective treatment, and the fever symptoms improved.
Re-examination of chest CT in April 2019 showed partial absorption of lung lesions.
So he was discharged.
CT results on March 26, 2019 (left); CT results on April 6, 2019 (right): The lung effusion was absorbed slightly than before.
After discharge, the patient's cough and sputum symptoms were still obvious, and the cough was more pronounced when lying down.
Obviously, there are more sputum, mostly purulent sputum.
Thought 1: The patient has repeated lung infections, is it really only as simple as infection? The patient came to our hospital for further diagnosis and treatment.
Past history: 7 years of "diabetes", oral dapagliflozin and glimepiride treatment; 20 years of "hypertension" history, oral felodipine sustained-release tablets treatment.
History of surgical trauma: He underwent right upper lung resection and lymph node dissection in February 2017.
The postoperative pathology was invasive adenocarcinoma, L858R (+), and no chemotherapy or radiotherapy was performed after the operation.
Allergy history: Allergy history of "sulfa drugs" and "Houttuynia cordata", but no special medical history.
Physical examination after admission: body temperature 36.
1℃, heart rate 88 beats/min, breathing 20 beats/min, blood pressure 99/65 mmHg.
Consciousness, good spirits, no deformity of the chest, dullness on percussion of both lower lungs, reduced breath sounds on both lungs on auscultation, no dry and wet rales in both lungs.
The heart rate was 88 beats/min, the rhythm was uniform, and no pathological murmur was heard.
The abdomen is flat and soft, the liver and spleen are not under the ribs, there is no percussion pain in the liver and kidney area, and there is no edema in both lower limbs.
Nervous system examinations were unremarkable.
Auxiliary examination after admission: Blood routine: red blood cells 4.
7X1012/L; hemoglobin 147 g/L; neutrophil ratio 83.
1%; white blood cells 8.
92X109/L; C-reactive protein 95.
4 mg/L; cryptococcal capsular antigen qualitative test: Negative; "9 respiratory pathogens": negative; D-dimer: 0.
48 mg/L; sputum smear for acid-fast bacilli: negative; sputum smear for fungi: negative; sputum smear for bacteria: negative; liver and kidney The function is in the normal range.
Admission diagnosis: community-acquired pneumonia, non-severe; postoperative primary bronchial lung cancer (right upper lung adenocarcinoma, pT2N0M0, stage I, PS 1 point) type 2 diabetes; hypertension.
Thinking 2: Is the diagnosis of community-acquired pneumonia established? Are there other diseases possible? Due to the prolonged course of the patient's disease, and the poor effect of active anti-infective treatment, the condition is prolonged and even worsened, so we consider it may be refractory pneumonia.
So why is this patient’s lung infection so difficult to treat? First, let's analyze the causes of refractory pneumonia.
Patient factors, pathogenic bacteria factors, treatment plan factors, subjective factors, underlying diseases, insufficient coverage of bacterial resistance, non-infectious diseases, immunosuppression, complex multiple infections, insufficient treatment, difficulty in drainage, atypical pathogenic bacteria, insufficient drug concentration, and this patient has repeated lungs Infection, the scope of the disease is not wide, but the symptoms are obvious, especially the patient has a history of lung cancer, there is a cavity in the right lung after the operation, and there is diabetes, and the immune function is poor.
Consider the following reasons for refractory pneumonia: Reason 1: The structure of the lung changes after surgery, and bacteria are easy to grow; Reason 2: There is a mixed special pathogen infection; or repeated use of antibiotics has produced drug-resistant bacteria; Reason 3: Recurrence of lung cancer.
It is not surprising that the patient left a residual cavity after the right lung surgery, but two years after the operation, why does the cyst wall of the residual cavity thicken? Why is there a liquid level change? This should consider the internal infection of the residual cavity, and the liquid level indicates that the residual cavity is connected to the outside world.
On follow-up medical history, the patient had more sputum when lying on the left side.
These signs strongly suggested that the patient had a bronchopleural fistula.
The following question is how to confirm the above assertion? After the patient was admitted to the hospital, puncture and drainage of the pulmonary cyst was arranged to drain the purulent fluid.
After repeated flushing through the drainage tube, the drainage fluid gradually becomes clearer.
However, during the washing process, the patient complained of discomfort in the pharynx and felt salty taste.
This further suggests the possibility of bronchopleural fistula.
Bronchoscopy showed the surgical stump of the right upper lung bronchus, but it was not clear whether it was a fistula.
After injecting Meilan through the cystic drainage tube, Meilan can be seen in the opening of the bronchial stump, confirming that this is the fistula of the bronchopleural fistula.
Thinking 3: What is the cause of bronchopleural fistula? Bronchopleural fistula refers to the fistula formed by the communication between the alveoli, bronchi at various levels and the pleural cavity.
There are many reasons for this.
At present, the more common causes are infection after surgery, necrotic erosion, causing adjacent lung tissue to penetrate the bronchus, or lung lesions directly invade the thoracic cavity or rupture to the pleural cavity to form a fistula. Clinical manifestations may include symptoms such as cough and sputum.
Symptoms may be related to body position.
The contralateral position can aggravate the cough symptoms.
The method of diagnosis is to inject a small amount of methylene blue fluid into the affected side's chest cavity.
Blue sputum can be seen after a while .
The main purpose of treatment is to close the fistula, which can be treated by surgical operation or endoscopic intervention.
After adequately controlling the infection of the residual cavity, this patient underwent bronchopleural fistula repair twice under general anesthesia through bronchoscopy.
During the operation, the fistula was repaired with cinnamyl alcohol and bioprotein glue, and finally the fistula was successfully sealed.
Lung infections did not occur frequently during follow-up.
Summary: This patient was treated in an outside hospital several times after the operation, and was treated with anti-infective treatment alone, but the bronchopleural fistula was not found in time, which caused the lung infection to persist.
Bronchopleural fistula is closely related to pneumonectomy.
It is reported in the literature that its incidence is between 1%-8.
5%.
It is one of the serious postoperative complications, with a fatality rate of 25.
0%-79.
2%.
Professor Zhang Xin's bronchopleural fistula is not uncommon, and it often occurs in ruptured bronchial stumps, purulent infections and tumor necrosis in lung surgery.
The existence of the fistula is easy to cause pleural cavity infection, and the infection makes it difficult to heal the fistula, which is a cause and effect for each other, and it is not healed.
The onset of this case is relatively insidious, and the cyst cavity is relatively far from the bronchial surgical stump.
Therefore, despite the manifestations of repeated lung infections, pneumonia and bronchopleural fistula have not been linked for two years.
In fact, comparing the series of CT of patients, it is quite obvious that the cyst wall changes from thin to thick, and the fluid in the cyst cavity changes from scratch to some extent, which is different from the usual residual cavity in surgery; After asking the medical history to know the relationship between sputum and body position, the clinical diagnosis of bronchopleural fistula can basically be established; follow-up puncture and bronchoscopy only further confirm the diagnosis of empyema and fistula.
Because of the existence of empyema, the source of infection, the bacteria spread from the fistula to other lung lobes, resulting in repeated pneumonia in different parts.
In terms of treatment, it is a more effective treatment to control the infection of the cyst and then block the intersection.
Expert profile Professor Zhang Xin, Chief Physician, Doctor of Medicine, Deputy Director of Respiratory Department of Zhongshan Hospital Affiliated to Fudan University, Director of Department of Pulmonary Tumor and Respiratory Intervention, Member of Intervention Group of Respiratory Branch of Chinese Medical Association, Committee of Pulmonary Tumor Specialty of Chinese Medical Education Association Member of the Standing Committee, Executive Director of the Asia-Pacific Society of Medical Bioimmunology, Deputy Chairman of the Shanghai Anti-Cancer Association Respiratory Tumor Intervention Special Committee, Deputy Chairman of the Shanghai Anti-Cancer Association Lung Cancer Molecular Targeting and Immunotherapy Special Committee, and Editorial Board Member .
Engaged in the diagnosis and treatment of respiratory and lung cancer for 27 years.
He has successively engaged in research work including lung cancer gene diagnosis and gene therapy, combined application of targeted and chemotherapy, lung cancer liquid biopsy, magnetic navigation-guided lung biopsy, etc.
, and participated in a number of international clinical trials as a branch PI test.
Participated in the compilation of 6 monographs including "Practical Internal Medicine", and published more than 30 papers.
What should I do if I have recurrent lung infections? Case profile: Patient Ji Mou, male, 73 years old, retired.
Chief complaint: Intermittent cough and sputum with fever for more than 2 years.
History of present illness: In March 2017, the patient developed paroxysmal cough, yellow pus sputum, accompanied by chills and fever, with a maximum body temperature of 39°C.
Thereafter, he has cough and fever symptoms every year, 2-3 times a year, every time This time lasts for at least 1 month, and can be relieved by anti-infective treatment.
CT results of the outside hospital on August 14, 2017, the right lung showed postoperative changes with cyst-like structure.
I was hospitalized in a Shanghai hospital on February 4, 2019.
The blood test showed that the neutrophils were 93%, and the IgM of influenza A was positive.
Chest CT showed pneumonia, and after right upper lung resection, the right thoracic cavity contained air-liquid sac.
On February 4, 2019, the CT results of the outer hospital showed scattered exudation in both lungs.
Liquid Ping was seen in the right lung sac cavity.
The patients were treated with piperacillin and tazobactam for anti-infection and mucosulfan for 14 days.
The symptoms were improved compared with the previous one.
.
On March 26, 2019, the patient reappeared with symptoms of cough, sputum expectoration and fever.
Re-examination of the chest showed that the two pneumonias had progressed more than before, and the right thoracic cavity was filled with air and fluid cysts.
He was treated with cefoperazone and sulbactam and etimicin for anti-infective treatment, and the fever symptoms improved.
Re-examination of chest CT in April 2019 showed partial absorption of lung lesions.
So he was discharged.
CT results on March 26, 2019 (left); CT results on April 6, 2019 (right): The lung effusion was absorbed slightly than before.
After discharge, the patient's cough and sputum symptoms were still obvious, and the cough was more pronounced when lying down.
Obviously, there are more sputum, mostly purulent sputum.
Thought 1: The patient has repeated lung infections, is it really only as simple as infection? The patient came to our hospital for further diagnosis and treatment.
Past history: 7 years of "diabetes", oral dapagliflozin and glimepiride treatment; 20 years of "hypertension" history, oral felodipine sustained-release tablets treatment.
History of surgical trauma: He underwent right upper lung resection and lymph node dissection in February 2017.
The postoperative pathology was invasive adenocarcinoma, L858R (+), and no chemotherapy or radiotherapy was performed after the operation.
Allergy history: Allergy history of "sulfa drugs" and "Houttuynia cordata", but no special medical history.
Physical examination after admission: body temperature 36.
1℃, heart rate 88 beats/min, breathing 20 beats/min, blood pressure 99/65 mmHg.
Consciousness, good spirits, no deformity of the chest, dullness on percussion of both lower lungs, reduced breath sounds on both lungs on auscultation, no dry and wet rales in both lungs.
The heart rate was 88 beats/min, the rhythm was uniform, and no pathological murmur was heard.
The abdomen is flat and soft, the liver and spleen are not under the ribs, there is no percussion pain in the liver and kidney area, and there is no edema in both lower limbs.
Nervous system examinations were unremarkable.
Auxiliary examination after admission: Blood routine: red blood cells 4.
7X1012/L; hemoglobin 147 g/L; neutrophil ratio 83.
1%; white blood cells 8.
92X109/L; C-reactive protein 95.
4 mg/L; cryptococcal capsular antigen qualitative test: Negative; "9 respiratory pathogens": negative; D-dimer: 0.
48 mg/L; sputum smear for acid-fast bacilli: negative; sputum smear for fungi: negative; sputum smear for bacteria: negative; liver and kidney The function is in the normal range.
Admission diagnosis: community-acquired pneumonia, non-severe; postoperative primary bronchial lung cancer (right upper lung adenocarcinoma, pT2N0M0, stage I, PS 1 point) type 2 diabetes; hypertension.
Thinking 2: Is the diagnosis of community-acquired pneumonia established? Are there other diseases possible? Due to the prolonged course of the patient's disease, and the poor effect of active anti-infective treatment, the condition is prolonged and even worsened, so we consider it may be refractory pneumonia.
So why is this patient’s lung infection so difficult to treat? First, let's analyze the causes of refractory pneumonia.
Patient factors, pathogenic bacteria factors, treatment plan factors, subjective factors, underlying diseases, insufficient coverage of bacterial resistance, non-infectious diseases, immunosuppression, complex multiple infections, insufficient treatment, difficulty in drainage, atypical pathogenic bacteria, insufficient drug concentration, and this patient has repeated lungs Infection, the scope of the disease is not wide, but the symptoms are obvious, especially the patient has a history of lung cancer, there is a cavity in the right lung after the operation, and there is diabetes, and the immune function is poor.
Consider the following reasons for refractory pneumonia: Reason 1: The structure of the lung changes after surgery, and bacteria are easy to grow; Reason 2: There is a mixed special pathogen infection; or repeated use of antibiotics has produced drug-resistant bacteria; Reason 3: Recurrence of lung cancer.
It is not surprising that the patient left a residual cavity after the right lung surgery, but two years after the operation, why does the cyst wall of the residual cavity thicken? Why is there a liquid level change? This should consider the internal infection of the residual cavity, and the liquid level indicates that the residual cavity is connected to the outside world.
On follow-up medical history, the patient had more sputum when lying on the left side.
These signs strongly suggested that the patient had a bronchopleural fistula.
The following question is how to confirm the above assertion? After the patient was admitted to the hospital, puncture and drainage of the pulmonary cyst was arranged to drain the purulent fluid.
After repeated flushing through the drainage tube, the drainage fluid gradually becomes clearer.
However, during the washing process, the patient complained of discomfort in the pharynx and felt salty taste.
This further suggests the possibility of bronchopleural fistula.
Bronchoscopy showed the surgical stump of the right upper lung bronchus, but it was not clear whether it was a fistula.
After injecting Meilan through the cystic drainage tube, Meilan can be seen in the opening of the bronchial stump, confirming that this is the fistula of the bronchopleural fistula.
Thinking 3: What is the cause of bronchopleural fistula? Bronchopleural fistula refers to the fistula formed by the communication between the alveoli, bronchi at various levels and the pleural cavity.
There are many reasons for this.
At present, the more common causes are infection after surgery, necrotic erosion, causing adjacent lung tissue to penetrate the bronchus, or lung lesions directly invade the thoracic cavity or rupture to the pleural cavity to form a fistula. Clinical manifestations may include symptoms such as cough and sputum.
Symptoms may be related to body position.
The contralateral position can aggravate the cough symptoms.
The method of diagnosis is to inject a small amount of methylene blue fluid into the affected side's chest cavity.
Blue sputum can be seen after a while .
The main purpose of treatment is to close the fistula, which can be treated by surgical operation or endoscopic intervention.
After adequately controlling the infection of the residual cavity, this patient underwent bronchopleural fistula repair twice under general anesthesia through bronchoscopy.
During the operation, the fistula was repaired with cinnamyl alcohol and bioprotein glue, and finally the fistula was successfully sealed.
Lung infections did not occur frequently during follow-up.
Summary: This patient was treated in an outside hospital several times after the operation, and was treated with anti-infective treatment alone, but the bronchopleural fistula was not found in time, which caused the lung infection to persist.
Bronchopleural fistula is closely related to pneumonectomy.
It is reported in the literature that its incidence is between 1%-8.
5%.
It is one of the serious postoperative complications, with a fatality rate of 25.
0%-79.
2%.
Professor Zhang Xin's bronchopleural fistula is not uncommon, and it often occurs in ruptured bronchial stumps, purulent infections and tumor necrosis in lung surgery.
The existence of the fistula is easy to cause pleural cavity infection, and the infection makes it difficult to heal the fistula, which is a cause and effect for each other, and it is not healed.
The onset of this case is relatively insidious, and the cyst cavity is relatively far from the bronchial surgical stump.
Therefore, despite the manifestations of repeated lung infections, pneumonia and bronchopleural fistula have not been linked for two years.
In fact, comparing the series of CT of patients, it is quite obvious that the cyst wall changes from thin to thick, and the fluid in the cyst cavity changes from scratch to some extent, which is different from the usual residual cavity in surgery; After asking the medical history to know the relationship between sputum and body position, the clinical diagnosis of bronchopleural fistula can basically be established; follow-up puncture and bronchoscopy only further confirm the diagnosis of empyema and fistula.
Because of the existence of empyema, the source of infection, the bacteria spread from the fistula to other lung lobes, resulting in repeated pneumonia in different parts.
In terms of treatment, it is a more effective treatment to control the infection of the cyst and then block the intersection.
Expert profile Professor Zhang Xin, Chief Physician, Doctor of Medicine, Deputy Director of Respiratory Department of Zhongshan Hospital Affiliated to Fudan University, Director of Department of Pulmonary Tumor and Respiratory Intervention, Member of Intervention Group of Respiratory Branch of Chinese Medical Association, Committee of Pulmonary Tumor Specialty of Chinese Medical Education Association Member of the Standing Committee, Executive Director of the Asia-Pacific Society of Medical Bioimmunology, Deputy Chairman of the Shanghai Anti-Cancer Association Respiratory Tumor Intervention Special Committee, Deputy Chairman of the Shanghai Anti-Cancer Association Lung Cancer Molecular Targeting and Immunotherapy Special Committee, and Editorial Board Member .
Engaged in the diagnosis and treatment of respiratory and lung cancer for 27 years.
He has successively engaged in research work including lung cancer gene diagnosis and gene therapy, combined application of targeted and chemotherapy, lung cancer liquid biopsy, magnetic navigation-guided lung biopsy, etc.
, and participated in a number of international clinical trials as a branch PI test.
Participated in the compilation of 6 monographs including "Practical Internal Medicine", and published more than 30 papers.
