造血干細(xì)胞移植相關(guān)肺部并發(fā)癥課件

1、造血干細(xì)胞移植相關(guān)肺部并發(fā)癥造血干細(xì)胞移植相關(guān)肺部并發(fā)癥造血干細(xì)胞移植相關(guān)肺部并發(fā)癥Company Logooverview22021/1/12通過(guò)閱讀報(bào)刊，我們能增長(zhǎng)見(jiàn)識(shí)，擴(kuò)大自己的知識(shí)面。造血干細(xì)胞移植相關(guān)肺部并發(fā)癥造血干細(xì)胞移植相關(guān)肺部并發(fā)癥造血Company Logooverview4. GVHD1. 預(yù)處理：FLU、CY、ATG、TBI2.植入3.免疫抑制：CsA/FK-506、激素、MMF、雷帕霉素Auto-SCT & Allo-SCT2021/1/122Company Logooverview4. GVHD1. InfectionsPhases of opportunistic

2、infections among allogeneic hematopoietic cell transplant recipientsCompany Logo2021/1/123InfectionsPhases of opportunisPre-engraftment中性粒細(xì)胞及淋巴細(xì)胞缺乏、粘膜炎、粘膜屏障破壞、吞咽困難、誤吸常見(jiàn)病原菌：細(xì)菌：E coli.、銅綠假單胞菌、鏈球菌病毒：流感病毒A/B、副流感病毒(PIV3)、RSV、h MPV真菌：念珠菌、曲菌427Allo-SCT， 1月內(nèi)肺部感染，4%細(xì)菌性，9%真菌性，2%病毒性11.Aguilar-Guisado M, Jimnez

3、-Jambrina M, Espigado I, et al. Pneumonia in allogeneic stem cell transplantation recipients: a multicenter prospective study. Clin Transplant 2011; 25:E629.Company Logo2021/1/124Pre-engraftment中性粒細(xì)胞及淋巴細(xì)胞缺乏、粘膜曲霉菌Company Logo2021/1/125曲霉菌Company Logo2021/1/125曲霉菌Company Logo2021/1/126曲霉菌Company Logo2

4、021/1/126Company Logo2021/1/127Company Logo2021/1/127念珠菌肺炎1.28Y/M,AML,移植后2.23Y/M AML3.25y/M M1a4.45y/MFranquet T, et al. Pulmonary candidiasis after hematopoietic stem cell transplantation: thin-section CT findings. Radiology 2005; 236:332.Company Logo2021/1/128念珠菌肺炎1.28Y/M,AML,移植后Company LoCompany

5、Logo肺水腫pulmonary edema心源性治療原發(fā)?。篊TX、蒽環(huán)類(lèi)、胸部放療補(bǔ)液VOD肺水腫非心源性肺炎植入綜合征超急性-GVHD2021/1/129Company Logo肺水腫pulmonary edema肺水腫-ButterflyCompany Logo2021/1/1210肺水腫-ButterflyCompany Logo2021植入綜合征Auto-SCT中7-10%，Allo-SCT較少發(fā)生NEU#上升,7-11天發(fā)熱、皮疹、體重增加、低氧、非心源性肺水腫、腹瀉Company Logo2021/1/1211植入綜合征Auto-SCT中7-10%，Allo-SCT較少 A.

6、d0正常CXR, B. d +7,皮疹, d +11CXR間質(zhì)性肺水腫，T升高, 用激素治療后好轉(zhuǎn)。Chest Radiographic Features of Engraftment Syndrome.Ravenel, James; Scalzetti, Ernest; Zamkoff, Kenneth Journal of Thoracic Imaging. 15(1):56-60, January 2000Company Logo2021/1/1212 A. d0正常CXR, B. d +7,皮疹, d +11植入綜合征：肺小葉間隔增厚.心源性肺水腫：中心性分布，血管擴(kuò)張2021/1/1

7、213植入綜合征：肺小葉間隔增厚.心源性肺水腫：中心性分布，血管擴(kuò)植入前Company Logo2021/1/1214植入前Company Logo2021/1/1214植入后-感染3周至3月，細(xì)胞及體液免疫缺陷3月后，cGVHD及治療細(xì)菌：肺炎鏈球菌、流感嗜血桿菌、軍團(tuán)菌、諾卡菌、放線菌；（第1年）分枝桿菌：TB及NTM,Allo-SCT后，1-3%,香港5.5%（10/183）.IV型超敏反應(yīng)抑制PPD病毒：CMV，呼吸道病毒（流感V、副流感、RSV、腺V、人偏肺V），HHV-6;真菌：曲菌、其他侵襲性真菌、PCP；寄生蟲(chóng)：弓形蟲(chóng)Ip MS, Yuen KY, Woo PC, et al.

8、 Risk factors for pulmonary tuberculosis in bone marrow transplant recipients. Am J Respir Crit Care Med 1998; 158:1173.Company Logo2021/1/1215植入后-感染3周至3月，細(xì)胞及體液免疫缺陷CompanyCompany Logo植入后-感染分枝桿菌細(xì)菌真菌病毒寄生蟲(chóng)感染肺炎鏈球菌、流感嗜血桿菌軍團(tuán)菌、諾卡菌、放線菌TB、NTM弓形蟲(chóng)曲菌、PCP、其他CMV，呼吸道病毒（流感V、副流感V、RSV、腺V、人偏肺V）HHV-6原因：3周至3月細(xì)胞及體液免疫缺陷，3

9、月后cGVHD及治療2021/1/1216Company Logo植入后-感染分枝桿菌細(xì)菌真菌病毒D+66諾卡菌D+55綠膿桿菌Company Logo2021/1/1217D+66諾卡菌D+55綠膿桿菌Company Logo202CMVCompany Logo2021/1/1218CMVCompany Logo2021/1/1218E L Gasparetto.etal Cytomegalovirus pneumonia after bone marrowtransplantation: high resolution CT findings. The British Journal of

10、 Radiology, 77 (2004), 724727 ,Company Logo2021/1/1219E L Gasparetto.etal Cytomegal流感及副流感病毒有季節(jié)性，淋巴細(xì)胞減少常見(jiàn)，植入前較植入后更常見(jiàn)副流感病毒：潛伏期1-4天，Company Logo2021/1/1220流感及副流感病毒有季節(jié)性，淋巴細(xì)胞減少常見(jiàn)，植入前較植入后更真菌曲霉菌，d+100，高齡、GVHD、GC、NEU#PCPCompany Logo2021/1/1221真菌曲霉菌，d+100，高齡、GVHD、GC、NEU#CoTB2021/1/1222TB2021/1/12222021/1/122

11、32021/1/1223特發(fā)性肺炎綜合征-idiopathic pneumonia syndrome10% 4月內(nèi)（中位D19始）定義：- 廣泛性肺泡損傷 影像學(xué)多葉受累+肺炎癥狀體征+肺功能異常P(A-a)O2,PaO2.- 相隔2-14天，2次BAL或肺活檢無(wú)感染證據(jù)- 無(wú)自身抗體升高病理機(jī)制尚不清楚發(fā)病率與預(yù)處理方案有關(guān)，1100患者，清髓IPS 8%，非清髓2%大劑量放療、CTX、BUFukuda T, Hackman RC, Guthrie KA, et al. Risks and outcomes of idiopathic pneumonia syndrome after non

12、myeloablative and conventional conditioning regimens for allogeneic hematopoietic stem cell transplantation. Blood 2003; 102:2777.Company Logo2021/1/1224特發(fā)性肺炎綜合征-idiopathic pneumonIPS表現(xiàn)：呼吸困難、低氧、干咳診斷：BAL、肺活檢治療:糖皮質(zhì)激素 1mg/kg (30天死亡率約75%)發(fā)現(xiàn)BAL中某些細(xì)胞因子IL-6、IL-8、TNF-a升高伊那西普或英夫利昔，28天生存率73-88%，1年生存率20-30%。Co

13、mpany Logo2021/1/1225IPS表現(xiàn)：呼吸困難、低氧、干咳Company Logo20胸膜下或氣管旁GGO病理：肺泡、肺泡間隔、氣管壁淋巴細(xì)胞浸潤(rùn)Tanaka N, Kunihiro Y, Yujiri T, et al. High-resolution computed tomography of chest complications in patients treated with hematopoietic stem cell transplantation. Jpn J Radiol 2011; 29:229.Company Logo2021/1/1226胸膜下或氣管

14、旁GGOCompany Logo2021/1/1彌漫性肺泡出血-Diffuse alveolar hemorrhage發(fā)病率80%Company Logo2021/1/1227彌漫性肺泡出血-Diffuse alveolar he閉塞性細(xì)支氣管炎-Bronchiolitis obliterans BONIH共識(shí)認(rèn)為BO是cGVHD唯一的肺部表現(xiàn)發(fā)病率210%,無(wú)GVHD者25.5%，GVHD14%死亡率13%-23%危險(xiǎn)因素：cGVHD，ABO血型不合，高齡，PBSCT，某些病毒感染Ditschkowski M, Elmaagacli AH, etal.Bronchiolitis oblite

15、rans after allogeneic hematopoietic SCT: further insight-new perspectives?Bone Marrow Transplant. 2013 Sep;48(9):1224-9. Epub 2013 Feb 252021/1/1228閉塞性細(xì)支氣管炎-Bronchiolitis oblite閉塞性細(xì)支氣管炎-Bronchiolitis obliterans BO左：H-E染色顯示細(xì)支氣管和支氣管周?chē)w維化、單核炎癥細(xì)胞浸潤(rùn)。右：彈性組織染色細(xì)支氣管的彈性層和受壓管腔馬賽克征2021/1/1229閉塞性細(xì)支氣管炎-Bronchioli

16、tis oblite機(jī)化性肺炎Organizing pneumonia特發(fā)或與肺部放療、GVHD、CMV感染有關(guān)邊界不清的間質(zhì)浸潤(rùn)與GGO診斷：病理治療：激素Company Logo2021/1/1230機(jī)化性肺炎Organizing pneumonia特發(fā)或與惡性疾病HCT后原發(fā)病復(fù)發(fā)、繼發(fā)淋巴組織增殖性疾病PTLD:免疫抑制EBV特異的細(xì)胞毒性T細(xì)胞缺乏Scarsbrook AF, Warakaulle DR, Dattani M, Traill Z. Post-transplantation lymphoproliferative disorder: the spectrum of im

17、aging appearances. Clin Radiol 2005; 60:47.Company Logo2021/1/1231惡性疾病HCT后原發(fā)病復(fù)發(fā)、繼發(fā)淋巴組織增殖性疾病Compa肺泡蛋白沉積病-Pulmonary alveolar proteinosis PAP“蝙蝠翼”樣陰影，鋪路石樣改變，肺泡內(nèi)充填脂蛋白樣物質(zhì)Company Logo2021/1/1232肺泡蛋白沉積病-Pulmonary alveolar 肺溶血性栓塞- Pulmonary cytolytic thromb PCT病因不明，d70d400a/c GVHD? 未成年人常見(jiàn)發(fā)熱、咳嗽、呼吸困難CXR正常，HRC

18、T: 外周小結(jié)節(jié)病理：中小肺靜脈內(nèi)嗜堿性物質(zhì)(細(xì)胞破裂碎片)栓塞，網(wǎng)羅有單個(gè)核細(xì)胞肺出血性梗死激素可能有效Company Logo2021/1/1233肺溶血性栓塞- Pulmonary cytolytic tPCT胸膜下小結(jié)節(jié)嗜堿性栓子、網(wǎng)羅單個(gè)核細(xì)胞2021/1/1234PCT2021/1/1234肺靜脈閉塞癥-Pulmonary veno-occlusive disease PVODd+100呼吸困難、DLCO、限制性通氣功能受損肺動(dòng)脈高壓、影像學(xué)肺水腫證據(jù)、PAWP正常Company Logo2021/1/1235肺靜脈閉塞癥-Pulmonary veno-occlu肺靜脈閉塞癥-Pulmonary veno-occlusive disease PVOD間質(zhì)細(xì)線() 、片狀磨玻璃影 (). 動(dòng)脈增粗(), 靜脈直徑正常( ).2021/1/1236肺靜脈閉塞癥-Pulmonary veno-occl藥物毒性和放射性肺炎肺毒性的化療藥物,如 BU，CTX，BCNU，西羅莫司.放射治療及TBI急性放射性肺炎 412周晚期放射性肺炎 612月2021/1/1237藥物毒性和放射性肺炎肺毒性的化療藥物,如 BU，CTX，B結(jié)締組織病HCT后31個(gè)月硬皮病、PM、SS、ANCA相關(guān)血管炎清髓、GVHDN