Pneumonia in Immunocompromised Children: Role of Viral and

Pneumonia in Immunocompromised Children: Role of Viral and

35
4
Pneumonia in Immunocompromised
Children: Role of Viral and
Bacterial Pathogens
®“¡√’ ∏’√µ°ÿ≈æ‘»“≈
Viral pneumonia
Cytomegalovirus (CMV) pneumonia
CMV ‡ªìπ herpesvirus ™π‘¥Àπ÷ßË ´÷ßË ¡—°®– infect
‡¥Á°·√°‡°‘¥ À√◊Õ‡¥Á°‚µ∑’Ë¡’¿“«–¿Ÿ¡‘§ÿâ¡°—π∫°æ√àÕß
°“√µ‘¥‡™◊ÕÈ π’∑È “√°¡—°‰¥â√∫— ‡™◊ÕÈ √–À«à“ß°“√§≈Õ¥ ‰¥â√∫—
‡™◊ÕÈ ®“°πÈ”π¡¡“√¥“ À√◊Õ‡™◊ÕÈ „ππÈ”≈“¬ πÕ°®“°π’È Õ“®
‰¥â√∫— ‡™◊ÕÈ ®“°°“√‰¥â√∫— ‡≈◊Õ¥ (‡™◊ÕÈ Õ¬Ÿ„à π infected white
cells) ºŸªâ «É ¬∑’‰Ë ¥â√∫— ‡™◊ÕÈ π’ÕÈ “®®–‰¡à· ¥ßÕ“°“√ (asymptomatic) ·µà‡¡◊ËÕÕ¬Ÿà„π ¿“«–¿Ÿ¡‘§ÿâ¡°—π≈¥≈ß ®–· ¥ß
Õ“°“√‡°‘¥¢÷πÈ ‰¥â (reactivation) ‚¥¬ªí®®—¬‡ ’¬Ë ß ”§—≠„π
°“√‡°‘¥Õ“°“√ ‰¥â·°à AIDS, congenital immunodeficiencies, °“√‡ª≈’ˬπ∂à“¬Õ«—¬«–‚¥¬‡©æ“–‰µ ·≈–
‰¢°√–¥Ÿ°
Õ“°“√∑“ߧ≈‘π‘°
ºŸâªÉ«¬∑’Ë¡’°“√µ‘¥‡™◊ÈÕ CMV pneumonia ®–¡’
Õ“°“√‰¢â ·≈–ÀÕ∫ ‡™àπ‡¥’¬«°—∫ªÕ¥Õ—°‡ ∫®“°‡™◊ÕÈ Õ◊πË Ê
·µà®–æ∫§«“¡º‘¥ª°µ‘¢ÕßÕ«—¬«–Õ◊πË Ê √à«¡¥â«¬ ‡™àπ µ—∫
¡â“¡‚µ retinitis ¿“æ√—ß ’∑√«ßÕ°®–æ∫≈—°…≥– diffuse
reticulonodular infiltration à«π alveolar pattern ®–
æ∫πâÕ¬°«à“1 ºŸªâ «É ¬ immunocompromise À“°¡’Õ“°“√
· ¥ß¢Õß CMV pneumonia ®–¡’Õ—µ√“µ“¬§àÕπ¢â“ß
Ÿß∂÷ß√âÕ¬≈– 85-902
°“√«‘π‘®©—¬
‡π◊ËÕß®“° CMV “¡“√∂µ√«®æ∫‰¥â„π‡ ¡À–,
pharynx, ‡≈◊Õ¥ ªí “«– √«¡∑—Èßµ√«®À“ CMV antibody ‰¥â„πºŸâªÉ«¬∑’ˉ¡à· ¥ßÕ“°“√ °“√µ√«® PCR for
CMV „Àâª√–‚¬™πå„π°√≥’∑æ’Ë ∫º≈≈∫ ‡π◊ÕË ß®“°¡’ negative predictive value §àÕπ¢â“ß Ÿß ·µà¡’§à“ positive
predictive value ‡æ’¬ß√âÕ¬≈– 611 ∑”„Àâ°“√«‘π‘®©—¬
CMV infection ∑”‰¥â§àÕπ¢â“߬“° °“√„Àâ definite
diagnosis §◊Õ °“√µ√«®æ∫ CMV inclusion „π lung
tissue ®“°°“√∑” lung biopsy3
°“√√—°…“
¬—߉¡à¡’¬“µâ“π‰«√— ®”‡æ“– µàÕ°“√µ‘¥‡™◊ÈÕ CMV
·µàæ∫«à“°“√„Àâ ganciclovir ‰¥âº≈„πºŸâªÉ«¬ CMV
retinitis à«πªÕ¥Õ—°‡ ∫¬—߉¡à¡’º≈∑’Ë™—¥‡®π ¡’√“¬ß“π
°“√»÷°…“æ∫«à“°“√„Àâ CMV-IVIG (intravenous immunoglobulin) √à«¡°—∫ ganciclovir √—°…“ CMV pneumonia „πºŸâªÉ«¬∑’Ë∑” bone marrow transplantation
‰¥âº≈¥’1,4
Varicella-zoster virus pneumonia
Varicella-zoster virus ‡ªìπ DNA virus „π°≈ÿà¡
herpesvirus °“√µ‘¥‡™◊ÈÕ¡“®“° airborne droplets
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Current Concepts in Pediatric Critical Care
ºà“π∑“߇¥‘πÀ“¬„® À√◊Õ conjunctiva ‡™◊ÕÈ ®–≈ÿ°≈“¡‡¢â“
°√–· ‡≈◊Õ¥·≈–·æ√à°√–®“¬‰ª¬—ßÕ«—¬«–¿“¬„π ·≈–
· ¥ßÕÕ°∑’˺‘«Àπ—߇ªìπµÿà¡πÈ” „πºŸâªÉ«¬ª°µ‘ ‚√§π’È®–¡’
Õ“°“√‰¡à√ÿπ·√ß ·µà„πºŸâªÉ«¬ immunocompromise
®–‡°‘¥ dissemination ‰¥â Ÿß ·≈–„π®”π«ππ’ȇ°‘¥ªÕ¥
Õ—°‡ ∫‰¥â√Õâ ¬≈– 85 ‚¥¬Õ—µ√“µ“¬°Á ߟ ¡“°‡™àπ‡¥’¬«°—π1
Õ“°“√∑“ߧ≈‘π‘°
Õ“°“√®–¡’≈—°…≥–‡™àπ‡¥’¬«°—∫°“√µ‘¥‡™◊ÈÕÕ◊ËπÊ
§◊Õ‰¢â ߟ ‰Õ ÀÕ∫ ºŸªâ «É ¬∑’¡Ë µ’ ¡àÿ πÈ”∫πº‘«Àπ—ß®”π«π¡“°
À√◊Õ¡’‰¢â ߟ ≈Õ¬ À√◊Õ¡’Õ“°“√ª«¥∑âÕß ª«¥À≈—ß√à«¡¥â«¬
®–¡’§«“¡‡ ’ˬ߄π°“√‡°‘¥ dissemination ·≈–ªÕ¥
Õ—°‡ ∫ Ÿß°«à“ ·≈–ºŸâªÉ«¬‡À≈à“π’È¡—°®–¡’°“√µ‘¥‡™◊ÈÕ
S.aureus ·∑√°´âÕπ‰¥â∫àÕ¬ 3
°“√«‘π‘®©—¬
¿“æ√—ß ’∑√«ßÕ° ®–æ∫≈—°…≥– bilateral diffuse
infiltration ´÷ËßÀ“°æ∫√à«¡°—∫¡’ vesicle ∑’˺‘«Àπ—ß °Á®–
™à«¬„π°“√«‘π‘®©—¬
°“√√—°…“
Acyclovir ‡ªìπ drug of choice ´÷Ëߧ«√®–√’∫„Àâ
°“√√—°…“‚¥¬‡√Á«∑’Ë ÿ¥ À“°„À⬓µ—Èß·µà¬—߉¡à¡’ lung
involvement ®–ªÑÕß°—π°“√‡°‘¥¿“«–ªÕ¥Õ—°‡ ∫‰¥â¥’
„π°√≥’‡°‘¥ªÕ¥Õ—°‡ ∫·≈â« °“√√—°…“‚¥¬°“√„À⬓
acyclovir ¢π“¥¢Õ߬“ 30 ¡°./°°./«—π ·∫àß IV infusion ∑ÿ° 8 ™—Ë«‚¡ß ‡ªìπ‡«≈“ 7-10 «—π À√◊ÕÕ¬à“ßπâÕ¬
2 «—πÀ≈—ß®“°‰¡à¡’º◊Ëπ„À¡à‡°‘¥¢÷Èπ5-6
„πºŸªâ «É ¬ immunocompromise À“°‰¥â√∫— ª√–«—µ‘
°“√µ‘¥‡™◊ÕÈ varicella-zoster §«√√’∫„Àâ varicella-zoster
immunoglobulin ¿“¬„π 3 «—πÀ≈—ß°“√ —¡º— ‡™◊ÈÕ‡æ◊ËÕ
ªÑÕß°—πÀ√◊Õ≈¥§«“¡√ÿπ·√ߢÕß°“√‡°‘¥‚√§7
Respiratory syncytial virus (RSV) pneumonia
RSV ‡ªì𠓇Àµÿ¢Õß nonfatal infection „π‡¥Á°
‡≈Á° ·µà„π immunocompromised host Õ“®∑”„Àâ
‡°‘¥°“√µ‘¥‡™◊ÈÕ√ÿπ·√߉¥â ‚¥¬‡©æ“–ºŸâªÉ«¬∑’Ë¡’§«“¡º‘¥
ª°µ‘¢Õß T lymphocyte ∑”„À⇰‘¥ªÕ¥Õ—°‡ ∫√ÿπ·√ß
À√◊Õ giant cell pneumonia ‚¥¬‡©æ“–ºŸªâ «É ¬∑’¡Ë ’ graftversus-host reaction ·≈–®–¡’ virus shedding Õ¬Ÿà
‡ªìπ‡«≈“π“π3
Õ“°“√∑“ߧ≈‘π‘°
Õ“°“√®–‡À¡◊Õπ°—∫ªÕ¥Õ—°‡ ∫®“°‡™◊ÈÕÕ◊ËπÊ ∑’Ë
‡°‘¥®“°‰«√— §◊Õ ‰¢â ‰Õ ÀÕ∫ µ√«®æ∫ wheezing ‰¥â
°“√«‘π‘®©—¬
RSV isolation ®“° nasal wash µâÕß„™â‡«≈“
π“π„π°“√‡æ“–‡™◊ÈÕ °“√∑” immunofluorescent antibody technique ‡æ◊ÕË µ√«®À“ viral antigen À√◊Õ ELISA
·≈– RIA °Á®–™à«¬°“√«‘π‘®©—¬‰¥â√«¥‡√Á«¢÷Èπ „πªí®®ÿ∫—π
°“√„™â RT-PCR ®–™à«¬„π°“√«‘π®‘ ©—¬„π√«¥‡√Á« ¿“¬„π
24 ™—Ë«‚¡ß ·µà¬—߉¡à “¡“√∂∑”‰¥â‚¥¬∑—Ë«‰ª
°“√√—°…“
Ribavirin ‡ªìπ°“√√—°…“®”‡æ“– ·µàµâÕß∫√‘À“√
‚¥¬«‘∏’°“√ Ÿ¥æàπ ´÷Ëßæ∫¡’ teratogenic effect „π µ√’
µ—Èߧ√√¿å‰¥â ·≈–¬“π’Ȭ—߉¡à¡’„™â„πª√–‡∑»‰∑¬
°“√ªÑÕß°—π
°“√„Àâ RSV-IVIG or Palivizumab ‡æ◊ËÕªÑÕß°—π
°“√‡°‘¥‚√§„πºŸªâ «É ¬ immunocompromised ¬—߉¡à¡°’ “√
·π–π”™—¥‡®π ·µà„π∫“ß·ÀàßÕ“®®–¡’°“√·π–π”„Àâ„™â
„π™à«ß‡«≈“∑’Ë¡’°“√√–∫“¥¢Õß RSV8
Adenovirus pneumonia
Adenovirus ‡ªìπ DNA virus ´÷Ëßæ∫‡ªìπ community-acquired lower respiratory tract infection
„π§πª°µ‘ ·µà„π immunocompromised host ¡—°®–
‡°‘¥‡ªìπ nosocomial infection ‚¥¬‰¥â√—∫‡™◊ÈÕ¡“®“°
∫ÿ§≈“°√ ·≈–∑”„À⇰‘¥°“√µ‘¥‡™◊ÈÕ√ÿπ·√ß∑’Ë¡’Õ—µ√“µ“¬
Ÿß1
Õ“°“√∑“ߧ≈‘π‘°
ºŸâªÉ«¬®–¡’Õ“°“√‡™àπ‡¥’¬«°—∫ªÕ¥Õ—°‡ ∫®“°
“‡ÀµÿÕ◊Ëπ §◊Õ ‰¢â ‰Õ ÀÕ∫ ‚¥¬‡°‘¥‡ªìπ progressive
necrotizing bronchitis À√◊Õ bronchiolitis obliteran
Pneumonia in Immunocompromised Children: Role of Viral and Bacterial Pathogens, ®“¡√’ ∏’√µ°ÿ≈æ‘»“≈
¿“æ√—ß ’∑√«ßÕ° ®–æ∫≈—°…≥– diffuse infiltration
°“√«‘π‘®©—¬
°“√„Àâ°“√«‘π‘®©—¬∑’Ë·πàπÕπ §◊Õ °“√æ∫ adenoviral inclusion ®“°°“√∑” lung biopsy À√◊Õµ√«®
æ∫‡™◊ÈÕ®“° viral culture ´÷Ë߉¡à “¡“√∂∑”‰¥â‚¥¬∑—Ë«‰ª
°“√µ√«®À“ titer °Á„™â‡«≈“π“π ¥—ßπ—πÈ à«π„À≠à„À⧥‘ ∂÷ß
‡™◊ÈÕπ’È„π°√≥’∑’˺ŸâªÉ«¬¡’ progressive pneumonia ∑’ˉ¡à
µÕ∫ πÕßµàÕ°“√√—°…“∑’‡Ë À¡“– ¡√à«¡°—∫¡’Õ“°“√§«“¡
º‘¥ª°µ‘¢Õ߉µ·≈–µ—∫√à«¡¥â«¬ ·≈–‡°‘¥‚√§¢÷πÈ „π™à«ß∑’¡Ë ’
°“√√–∫“¥¢Õ߇™◊ÈÕπ’È„π™ÿ¡™ππ—ÈπÊ1
°“√√—°…“
¬—߉¡à¡¬’ “µâ“π‰«√— ®”‡æ“– °“√√—°…“®÷߇ªìπ°“√
√—°…“µ“¡Õ“°“√ ·≈–√—°…“·∫∫ª√–§—∫ª√–§Õß ∑’ Ë ”§—≠
§◊Õ°“√ªÑÕß°—π°“√µ‘¥‡™◊ÕÈ ®“°∫ÿ§≈“°√¢Õß ∂“π欓∫“≈
À√◊Õ∫ÿ§§≈„°≈♑¥
Bacterial pneumonia
Bacterial pneumonia ‡ªìπ°“√Õ—°‡ ∫¢Õߪե
∑’ˇ°‘¥®“°‡™◊ÈÕ·∫§∑’‡√’¬ ‚¥¬∑—Ë«‰ª¡—°®–∫Õ°‡™◊ÈÕ∑’ˇªìπ
“‡Àµÿ∑’Ë·∑â®√‘߉¥â¬“° °“√«‘π‘®©—¬‡™◊ÈÕ∑’ˇªì𠓇Àµÿ¡—°
Õ“»—¬Õÿ∫µ— °‘ “√≥å°“√µ‘¥‡™◊ÕÈ „π·µà≈–°≈ÿ¡à Õ“¬ÿ À√◊Õ ¿“«–
¢ÕߺŸâªÉ«¬‡ªì𠔧—≠ ‡™àπ „πºŸâªÉ«¬‡¥Á°∑—Ë«‰ª‡™◊ÈÕ·∫§∑’‡√’¬∑’‡Ë ªì𠓇Àµÿ ”§—≠„π∑ÿ°°≈ÿ¡à Õ“¬ÿ §◊Õ S. pneumoniae ¬°‡«âπ„π‡¥Á°·√°‡°‘¥; ‡¥Á°·√°‡°‘¥®–æ∫‡™◊ÕÈ group
B Streptococcus ·≈– gram-negative enteric bacilli
∫“ß™π‘¥; „π‡¥Á°«—¬°àÕπ‡√’¬π®–æ∫‡™◊ÈÕ H. influenzae
‡ªì𠓇Àµÿ ”§—≠; ‡™◊ÈÕ group A Streptococcus ®–
‡ªì𠓇Àµÿ¢Õߪե՗°‡ ∫„π‡¥Á°∑’¡Ë °’ “√µ‘¥‡™◊ÕÈ ‰«√— ∫“ß
™π‘¥Õ¬Ÿ°à Õà 𠇙àπ measles, influenza À√◊Õ chickenpox
ºŸªâ «É ¬‡¥Á°∑’¡Ë ¿’ “«–¿Ÿ¡§‘ ¡ÿâ °—π∫°æ√àÕßÀ√◊Õ‡ªìπ‚√§
¡–‡√Áß ‡™◊ÈÕ·∫§∑’‡√’¬∑’ˇªì𠓇Àµÿ¢Õߪե՗°‡ ∫ °Á®–
æ∫‡™◊ÕÈ ∑’‡Ë ªì𠓇Àµÿ‰¥â‡™àπ‡¥’¬«°—∫‡¥Á°∑—«Ë ‰ª ·µàÕ“®®–
æ∫ “‡Àµÿ®“°‡™◊ÕÈ ·∫§∑’‡√’¬∫“ß™π‘¥‡æ‘¡Ë ¢÷πÈ µ“¡ ¿“«–
¢Õß√–∫∫¿Ÿ¡‘§ÿâ¡°—π∑’˺‘¥ª°µ‘‰ª µ“¡µ“√“ß∑’Ë 1
Õ“°“√∑“ߧ≈‘π‘°
37
Õ“°“√¢Õߪե՗°‡ ∫®“°‡™◊ÈÕ·∫§∑’‡√’¬ ®–¡’
≈—°…≥–‡™àπ‡¥’¬«°—∫ªÕ¥Õ—°‡ ∫∑—«Ë ‰ª ´÷ßË ¡—°‰¡à¡≈’ °— …≥–
‡©æ“– °“√«‘π®‘ ©—¬·¬°‡™◊ÕÈ ∑’‡Ë ªì𠓇Àµÿ «à π„À≠à ¡—°®–
‡ªìπ°“√·¬°‡™◊ÈÕ‡ªìπ°≈ÿà¡ ‡™àπ ·∫§∑’‡√’¬ ‰«√— ‡™◊ÈÕ√“
‚ª√‚µ´—« (PCP) À√◊Õ mycobacterium ‡æ◊ÕË °“√„Àâ°“√
√—°…“¡“°°«à“ ´÷ËßÕ“®¡’·π«∑“ß ¥—ßπ’È
Early localized pulmonary infiltration
ºŸªâ «É ¬∑’¡Ë §’ «“¡º‘¥ª°µ‘¢Õߪե‡©æ“–∑’µË ß—È ·µà‡√‘¡Ë
µâπ ¡—°®–‡ªì𠓇Àµÿ®“°·∫§∑’‡√’¬ ‡™àπ gram negative
bacilli: Klebsiella species, Pseudomonas species
À√◊Õ Enterobacteriaceae Õ◊Ëπ ´÷Ëß„π°≈ÿà¡π’È ‚¥¬‡©æ“–
ºŸªâ «É ¬∑’¡Ë ’ febrile neutropenia Õ“®®–¬—߉¡à®”‡ªìπµâÕß„™â
invasive technique „π°“√µ√«®À“‡™◊ÈÕ∑’Ë·πàπÕπ ¡—°
·π–π”„Àâ‡√‘¡Ë °“√√—°…“¥â«¬ broad spectrum antibiotics
∑’§Ë √Õ∫§≈ÿ¡‡™◊ÕÈ ∑—ßÈ gram positive ·≈– gram negative
·≈â« —߇°µÕ“°“√ 2-3 «—π À“°ºŸâªÉ«¬¥’¢÷Èπ°Á„Àâ°“√
√—°…“µàÕ®π§√∫ 2-3 —ª¥“Àå À“°‰¡àµÕ∫ πÕßµàÕ
°“√√—°…“À√◊Õ∑√ÿ¥≈ß¿“¬„π 72 ™—«Ë ‚¡ß ®÷ߧ«√æ‘®“√≥“
investigation ‡æ‘¡Ë ‡µ‘¡ ‡™àπ broncho-alveolar lavage9
Refractory localized pulmonary infiltration
ºŸâªÉ«¬∑’Ë¡’ persistence pulmonary infiltration
‡°‘π°«à“ 72 ™—Ë«‚¡ßÀ≈—߉¥â√—∫°“√√—°…“·≈â« Õ“®¡’
“‡Àµÿ®“°‡™◊ÈÕÕ◊Ë𠇙àπ L. pneumophila, P. carinii,
Mycoplasma pneumoniae, fungus À√◊Õ gram negative bacilli ∑’Ë resistance Ÿß °Á§«√æ‘®“√≥“ investigation ‡™àπ °“√∑” BAL À“°‰¡à “¡“√∂∑”‰¥â °Á
æ‘®“√≥“ª√—∫‡ª≈’¬Ë 𬓵â“π®ÿ≈™’æ ‡™àπ Co-trimoxazole
√à«¡°—∫ erythromycin ·≈– extended spectrum §√Õ∫
§≈ÿ¡ gram negative bacilli9
Nodular, Cavitary and lung abscess lesion
ºŸâªÉ«¬∑’Ëæ∫ infiltration ‡ªìπ™π‘¥ nodule ¡—°æ∫
„πºŸâªÉ«¬‡¥Á°∑’ˇªìπ‚√§¡–‡√Áß ‡™◊ÈÕ∑’ˇªì𠓇Àµÿ¡—°‡ªìπ
fungus ·≈– Nocardia ·µàÀ“°æ∫‡ªìπ cavity À√◊Õ
abscess „À⧑¥∂÷߇™◊ÈÕ Aspergillus species „πºŸâªÉ«¬
AIDS ‡™◊ÈÕ PCP ·≈– Mycobacteria °Á∑”„À⇰‘¥ cavi-
38
Current Concepts in Pediatric Critical Care
µ“√“ß∑’Ë 1 Typical Pulmonary pathogens associated with immune disorder10
Immune disorder
Neutropenia
Chronic
Neutrophil function
disorder
Acute
Prolonged, hospitalized
patients
Agamma/hypogammaglobulinemia
Congenital T cell
disorders
AIDS
Bacteria
H. influenzae,
S. pneumoniae,
S. aureus, Klebsiella
Gram-negative organisms, Including
Pseudomonas
H. influenzae,
S. pneumoniae
Pseudomonas
Ligionella, Nocardia,
Listeria, M. tuberculosis, Salmonella
M. tuberculosis,
M. avium-intracellulare
Virulent encapsulated
(e.g. S.pneumoniae)
S. aureus, Listeria,
M. tuberculosis
Complement
deficiencies
Immunosuppressive
therapy (e.g., renal,
liver, lung transplant)
Bone marrow transplant
Pseudomonas,
Early
gram-negative
S. aureus, S. pneumoiae
Late
Typical pulmonary pathogen
Virus
Fungus
Protozoa/others
Candida sp.,
Aspergillus sp.,
Mucor, Fusaria
Aspergillus sp.
PCP
Candida sp.
Cryptococcus, PCP
Cryptococcus, PCP
CMV, VZV, HSV, Toxoplasmosis
EBV,
adenovirus
CMV
Toxoplasmosis
Aspergillus, Mucor,
Histoplasmosis,
Cryptococcus, PCP
CMV, VZV, HSV Toxoplasmosis
Candida sp.,
HSV
Aspergillus, PCP
CMV, EBV, VZV Toxoplasmosis
CMV = cytomegalovirus, VZV = varicella zoster, HSV = herpes simplex virus, EBV = Epstein-Barr virus
tary lesion 䴉10
Late-onset localized pulmonary infiltration
ºŸâªÉ«¬∑’Ëæ∫¡’ pulmonary infiltration „π√–¬–∑’Ë¡’
persistent neutropenia À√◊Õ„π√–¬– recovery ¢Õß
¿“«– neutropenia Õ“®‡°‘¥®“° unrecognized À√◊Õ
radiographically inapparent pulmonary infiltration
∑’Ë¡’Õ¬Ÿà‡¥‘¡ „À⠗߇°µÕ“°“√ºŸâªÉ«¬‡ªìπÀ≈—° À“°Õ“°“√
ºŸªâ «É ¬Õ¬Ÿ„à π‡°≥±å¥’ „Àâ ß— ‡°µÕ“°“√µàÕÕ¬à“ß„°≈♥‘ ‚¥¬
¬—߉¡àµâÕ߇ª≈’ˬπ·ª≈ß°“√√—°…“ ·µàÀ“° pulmonary
infiltration π—Èπæ∫¡“°¢÷Èπ√à«¡°—∫°“√„Àâ°“√√—°…“¥â«¬
¬“µâ“π®ÿ≈™’æ ·≈–Õ“°“√ºŸªâ «É ¬¬—߉¡à¥¢’ π÷È Õ“®®–¡’ “‡Àµÿ
¡“®“° invasive mycoses À√◊Õ ·∫§∑’‡√’¬∑’¥Ë ÕÈ◊ ¬“‰«√— À√◊Õ‚ª√‚µ´—« „π°√≥’π’È §«√æ‘®“√≥“ investigation ‡æ‘¡Ë
Pneumonia in Immunocompromised Children: Role of Viral and Bacterial Pathogens, ®“¡√’ ∏’√µ°ÿ≈æ‘»“≈
‡µ‘¡ ‡™àπ CT scan of the chest À√◊Õ broncoscopy
with BAL À“°ºŸªâ «É ¬Õ¬Ÿ„à π¿“«–∑’‰Ë ¡à “¡“√∂∑”°“√µ√«®
‡æ‘¡Ë ‡µ‘¡‰¥âÀ√◊Õ¡’¢Õâ Àâ“¡ °Á§«√æ‘®“√≥“‡æ‘¡Ë ¬“√—°…“‡™◊ÕÈ
√“ ‡™àπ Amphotericine B √à«¡‰ª¥â«¬9
Diffuse pulmonary infiltration
‡™◊ÈÕ∑’ˇªì𠓇Àµÿ¢Õß diffuse pulmonary infiltration ¢÷Èπ°—∫ ¿“«–¢ÕߺŸâªÉ«¬9 ‡™àπ
- ºŸªâ «É ¬∑’¡Ë ¿’ “«– neutropenia ‡™◊ÕÈ ∑’‡Ë ªì𠓇Àµÿ
à«π„À≠à‰¥â·°à P. carinii, CMV, L. pnumophila À√◊Õ
M. pneumoniae à«ππâÕ¬‡°‘¥®“° mycobacteria, varicella-zoster, influenza A, RSV ·≈– Candida species
- ºŸªâ «É ¬∑’‰Ë ¥â√∫— corticosteroids ‡™◊ÕÈ ∑’‡Ë ªì𠓇Àµÿ
à«π„À≠à ‰¥â·°à tuberculosis, histoplasmosis À√◊Õ
cryptococcosis
39
- ºŸâªÉ«¬ HIV, bone marriow or solid organ transplant, severe combined immunodeficiency
∑’Ë ‰¡à¡¿’ “«– neutropenia ‡™◊ÕÈ à«π„À≠à ‰¥â·°à P. carinii,
CMV, mycobacteria ºŸâªÉ«¬∑’Ë¡’ adequate neutrophil
¡—°®–æ∫‡™◊ÈÕ√“‡ªì𠓇ÀµÿπâÕ¬
Õ¬à“߉√°Áµ“¡ °“√‡°‘¥ diffuse pulmonary
infiltration „πºŸâªÉ«¬‡À≈à“π’È Õ“®¡’ “‡Àµÿ¡“®“° noninfectious cause ‰¥â ‡™àπ radiation pnuemonitis, chemotherapy, À√◊Õ lymphoid interstitial pneumonitis
¥—ßπ—Èπ À“°‡ªìπ‰ª‰¥â §«√∑”°“√µ√«®‡æ‘Ë¡‡µ‘¡ ‡æ◊ËÕ
„Àâ°“√ «‘π‘®©—¬∑’Ë·πàπÕπ ·µàÀ“°‰¡à “¡“√∂∑”‰¥â °Á
§«√„Àâ em-pirical antibiotics ¢÷Èπ°—∫≈—°…≥–¢Õß infiltration ¥â«¬
‡Õ° “√Õâ“ßÕ‘ß
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