一例侵袭性肺真菌感染合并气管纵隔瘘救治及文献复习

Management of Invasive Pulmonary Fungal Infection Complicated by Tracheobronchial-Mediastinal Fistula: A Case Report and Literature Review

摘要: 目的：探讨侵袭性曲霉合并毛霉感染导致气管–支气管纵隔瘘的临床特征、诊断要点及综合治疗策略。方法：分析1例侵袭性曲霉合并毛霉感染患者的临床资料，包括影像学表现、支气管镜特征、病原学检测结果及治疗过程，并结合相关文献进行分析。结果：患者以咳嗽、咳痰及呼吸困难起病，胸部CT提示肺部感染伴气道结构异常及纵隔内异常气体影；支气管镜检查见气道黏膜广泛坏死，气道壁多处连续性中断，可见多个瘘口，提示气管–支气管纵隔瘘形成，并伴严重气道狭窄。病理及微生物学检查证实曲霉合并毛霉感染。经系统抗真菌治疗联合支气管镜介入(气道支架置入及局部处理)后，肺部炎症一度好转，但气道结构破坏持续存在，支架多次移位。治疗过程中患者出现类似免疫重建炎症反应，经糖皮质激素干预后症状缓解。结论：侵袭性曲霉合并毛霉感染可导致气道壁严重破坏并形成气管–支气管纵隔瘘，是一种少见但危重的临床表现。支气管镜检查在诊断中具有关键作用。治疗需采取系统抗真菌治疗与气道介入相结合的综合策略，并在治疗过程中警惕免疫炎症反应的发生。

Abstract: Objective: To explore the clinical characteristics, diagnostic features, and comprehensive treatment strategies of tracheobronchial mediastinal fistula caused by invasive Aspergillus combined with mucormycosis. Methods: The clinical data of a patient with invasive Aspergillus combined with mucormycosis were retrospectively analyzed, including imaging findings, bronchoscopic features, etiological results, and treatment course, and relevant literature was reviewed. Results: The patient presented with cough, sputum production, and dyspnea. Chest CT showed pulmonary infection with abnormal airway structure and mediastinal gas shadows. Bronchoscopy revealed extensive mucosal necrosis, discontinuity of the airway wall, and multiple fistula openings, suggesting the formation of tracheobronchial mediastinal fistula with severe airway stenosis. Pathological and microbiological examinations confirmed Aspergillus and Mucor co-infection. After systemic antifungal therapy combined with bronchoscopic airway intervention (stent implantation and local treatment), pulmonary inflammation was partially improved; however, airway structural damage persisted and stent displacement occurred repeatedly. During treatment, the patient developed a transient inflammatory exacerbation suggestive of an immune reconstitution-like response, which was alleviated after corticosteroid therapy. Conclusion: Invasive Aspergillus combined with mucormycosis can lead to severe airway destruction and tracheobronchial mediastinal fistula, which is a rare but critical clinical condition. Bronchoscopy plays a key role in diagnosis. Comprehensive treatment combining systemic antifungal therapy and airway intervention is required, and inflammatory reactions during treatment should be closely monitored.