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Диагностика и лечение хронического легочного аспергиллеза: клинические рекомендации Европейского респираторного общества и Европейского общества клинической микробиологии и инфекционных заболеваний

https://doi.org/10.18093/0869-0189-2016-2-6-665-7679

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Аннотация

Хронический легочный аспергиллез (ХЛА) – нечастое и труднодиагностируемое легочное заболевание, осложняющее многие другие респираторные заболевания. В настоящее время в Европе насчитывается около 240 тыс. больных ХЛА. Наиболее распространенной формой ХЛА является кавитарный ХЛА (ХКЛА) (с формированием полостей), который при отсутствии лечения может трансформироваться в хронический фиброзирующий ХЛА. К менее частым проявлениям ХЛА относятся аспергиллезные узлы и одиночная аспергиллема. Все перечисленные изменения встречаются у иммунонекомпрометированных пациентов с различными заболеваниями легких. Подострый инвазивный легочный аспергиллез (ранее называвшийся хроническим некротизирующим легочным аспергиллезом) – это быстропрогрессирующая (< 3 мес.) инфекция, обычно диагностируемая у больных с умеренным иммунодефицитом, которая должна лечиться как инвазивный аспергиллез. Диагностика и ведение больных ХЛА ранее рассматривалось в единичных клинических рекомендациях. В связи с этим была созвана группа экспертов для разработки клинических, рентгенологических и микробиологических рекомендаций. При диагностике ХЛА требуется сочетание следующих признаков: одна или несколько полостей с грибковым конгломератом внутри или без такового либо узлы при лучевом обследовании легких; прямое подтверждение аспергиллезной инфекции (путем микроскопии или посева биопсийного материала) или иммунологическая реакция на Aspergillus spp. при исключении альтернативного диагноза. Все признаки должны наблюдаться в течение ≥ 3 мес. Уровень антител к Aspergillus (преципитины) повышен у > 90 % больных. В случае технической возможности рекомендуется хирургическое удаление аспергиллемы, желательно методом видеоассистированной торакоскопии. При ХКЛА рекомендуется длительная пероральная противогрибковая терапия для улучшения состояния в целом и устранения респираторных симптомов, прекращения кровохарканья и предотвращения прогрессирования заболевания. Рекомендуется тщательное мониторирование сывороточной концентрации азола, лекарственного взаимодействия и возможных токсических эффектов. Кровохарканье и легочное кровотечение можно устранить с помощью транексамовой кислоты и эмболизации бронхиальных артерий, реже – с помощью хирургической резекции легкого. Кровохарканье может служить признаком неэффективности лечения и / или резистентности к противогрибковым препаратам. Больные с одиночным аспергиллезным узлом нуждаются в противогрибковой терапии только при невозможности резекции, а при множественных аспергиллезных узлах противогрибковая терапия может дать существенный терапевтический эффект. Такие больные нуждаются в тщательном наблюдении.

Об авторах

D. W. Denning

Россия


J. Cadranel

Россия


C. Beigelman;Aubry

Россия


F. Ader

Россия


A. Chakrabarti

Россия


S. Blot

Россия


A. J. Ullmann

Россия


G. Dimopoulos

Россия


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Для цитирования:


Denning D.W., Cadranel J., Beigelman;Aubry C., Ader F., Chakrabarti A., Blot S., Ullmann A.J., Dimopoulos G. Диагностика и лечение хронического легочного аспергиллеза: клинические рекомендации Европейского респираторного общества и Европейского общества клинической микробиологии и инфекционных заболеваний.  Пульмонология. 2016;26(6):657-679. https://doi.org/10.18093/0869-0189-2016-2-6-665-7679

For citation:


Denning, D.W., Cadranel J., Beigelman-Aubry C., Ader F., Chakrabarti A., Blot S., Ullmann A.J., Dimopoulos G. Diagnosis and treatment of chronic pulmonary aspergillosis: clinical guidelines of European Society for Clinical Microbiology and Infectious Diseases and European Respiratory Society. Russian Pulmonology. 2016;26(6):657-679. (In Russ.) https://doi.org/10.18093/0869-0189-2016-2-6-665-7679

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