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

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.

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