目的  总结行角膜移植的真菌性角膜炎病例的临床特点，分析不同致病真菌感染角膜组织的共性、特异性，为临床上真菌性角膜炎的预防、诊断、治疗提供有效线索。

方法  收集48例2012年1月~2017年12月就诊于北医三院眼科中心的行角膜移植手术的真菌性角膜感染患者的临床资料，收集不同菌属的致病真菌导致的角膜感染患者的一般资料，进行裂隙灯检查、角膜共聚焦显微镜检查、角膜刮片、病理组织学检查及真菌培养，归纳总结角膜真菌感染病例的临床特点，比较不同菌属导致的角膜真菌感染的异同。

结果  48例患者中，男女比例为1.82：1，50~59岁年龄段人数最多为21例（43.75%），农民感染占总人数的50%，发病高峰季节为秋季，最常见诱因为眼部外伤。导致真菌性角膜感染的常见致病真菌为镰刀菌（48.78%）、曲霉菌（12.20%）及酵母菌（12.20%）。到角膜移植前，各菌属导致的角膜真菌感染的病灶大小、病变深度、前房反应及病变总评分无明显差异。较丝状真菌感染而言，酵母菌有病程时间短、角膜刮片阳性率高的特点。角膜病理组织中，真菌菌丝均可呈平行、斜行、垂直方向生长，镰刀菌周围炎性细胞浸润较少，曲霉菌周围伴炎性细胞浸润，酵母菌往往被炎性细胞密集包围。

结论  各菌属在致病诱因、病理组织学改变等临床特点中有各自特点。经历了复杂的临床环境之后，临床致病真菌体现出不同于实验室标准菌株在实验动物角膜上的生物学行为表现，这些差异需要进一步的研究证实。

 

三种角膜致病真菌体外生长特性初探

目的  通过体外培养方法比较角膜临床分离真菌与标准菌株生长特性的异同，研究真菌致病的关键点。

方法  选取镰刀菌、曲霉菌、酵母菌临床致病菌株各2株，以相应菌属的标准菌株作为对照，制成孢子悬液。配制液态和固态形式的三种培养基：综合PDA培养基、YG培养基、YPD培养基和沙氏培养基。将镰刀菌和曲霉菌的临床菌株和标准菌株分别接种于综合PDA、YG和沙氏的固态、液态培养基上，在29℃下培养96小时，分别于10个时间点测定液态培养基上的吸光度，绘制生长曲线，并在固态培养基上观察记录真菌生长发育情况。 将酵母菌的临床菌株和标准菌株分别接种于YPD和沙氏的固态、液态培养基上，在29℃下培养72小时，分别于10个时间点测定液态培养基上的吸光度，绘制生长曲线，并在固态培养基上观察记录真菌生长发育情况。

结果  同一菌属的临床分离真菌与标准菌在同一培养基上体现出不同的生长特性。固体同种培养基上，镰刀菌临床分离菌菌落颜色比标准菌深；曲霉菌临床分离菌菌落范围、菌落有色范围比标准菌大，菌落颜色出现时间比标准菌早；热带假丝酵母临床分离菌菌落范围比标准菌大，白色假丝酵母临床分离菌与标准菌差异不明显。液体同种培养基上，临床分离菌株在营养丰富的培养基上与标准菌株生长曲线差异较小，在营养相对单一的沙氏培养基上，差异明显。不同培养基比较而言，YG为镰刀菌最适培养基，综合PDA为烟曲霉最适培养基，YPD为酵母菌最适培养基。沙氏培养基上，真菌生长相对较差，但最能体现临床分离菌和标准菌的差异。

结论  临床分离真菌在体外培养的条件下，体现出不同于标准菌株的生长特性，营养条件较差时表现出更强的环境适应能力。造成这些差异的原因可能与临床分离菌的临床经历有关。

 

体外培养营养环境对角膜致病真菌影响的研究

目的  通过体外培养方法比较角膜临床分离真菌与标准菌株在不同营养条件下生物学特性的异同，探索真菌致病的可能。

方法  配制5种不同葡萄糖、蛋白质浓度的培养基，包括液体和固体两种形式。将临床分离茄病镰刀菌、烟曲霉、白色假丝酵母、热带假丝酵母分别接种于不同的培养基上，相应菌种的标准菌作为对照，29℃培养96小时，分别在不同时间点测定液态培养基上的吸光度，绘制生长曲线，并在固态培养基上进行形态学观察。

结果  贫氮培养基上，各菌株生长均十分缓慢。较标准菌株而言，茄病镰刀菌和烟曲霉的临床分离菌在固体培养基上菌落形成更明显，孢子产生更早、更多。当培养基中蛋白质浓度不变，糖浓度变化时，茄病镰刀菌和烟曲霉的临床分离菌株体现出对环境变化更强的感知能力和适应能力，而热带假丝酵母和白色假丝酵母无论标准菌还是临床分离菌株，均体现出良好的对糖浓度变化的感知能力；当培养基中糖浓度接近糖尿病人房水糖浓度时，各菌属的临床分离真菌会表现出生长速度快、繁殖能力强等生长特点。

结论  氮源是真菌生长的十分重要的营养元素；当氮源缺乏时，角膜临床分离真菌较标准菌而言具有更好的生长能力和繁殖能力；当氮源充足时，角膜临床分离真菌具有更强的感知外界糖浓度变化的能力。

Object To summarize and analyze the clinical characteristics of cases of fungal keratitis, which causing by different species. Effective clues for the prevention, diagnosis and treatment of corneal fungal infection could be provided.

Methods A retrospective study of patients with keratitis referred to Peking University Third Hospital was conducted during the period from January 2012 to December 2017. 48 cases who underwent keratoplasty were screened out. The clinical information, including a detailed history, predisposing factors, symptoms, signs, treatment and systemic diseases, was collected and analyzed. Confocal microscopy, cornea scraping, pathological section examination and culture had been done.

Results In the 48 cases, the male to female ratio was 1.82:1. The 50-59 age group had the most cases (21 cases, 43.75%). Famer counted 50%. Trauma was the most common predisposing risk factor. The most common fungal species causing corneal fugal infection is Fusarium (48.78%), Aspergillus (12.20%) and Candida (12.20%). There were no obvious differences about lesion size, lesion depth, anterior chamber response and total lesion score among different species. Compared with the filamentous fungi, Candida had the features of shorter course and higher positive rate of cornea scraping. Pathologically, the fungi could have various growth forms with inflammatory cells infiltrating. There were few inflammatory cells besides Fusarium, some inflammatory cells with Aspergillus, but lots of inflammatory cells surrounding Candida.

Conclusions A series of biological changes might have been happened to the clinical fungal strains after infecting the eyes and experiencing the complex clinical environment, which should be approved by more researches.

 

Growth Characteristics of Clinical Corneal Isolates of Fusarium, Aspergillus and Candida

Object To analyze the growth characteristics of the clinical isolates of Fusarium, Aspergillus and Candida compared to standard strains in vitro.

Methods Comparing with the standard strains, 2 Fusarium clinical isolates, 2 Aspergillus clinical isolates and 2 Candida clinical isolates were selected and inoculated in different nutrient media, including solid media and liquid media. On the solid media we observed the colony morphology, while in the liquid media the optical density (OD) was recorded to generate growth curves for each fungus and medium. The filamentous fungi, including clinical isolates and standard strains, were inoculated in sabourauds agar medium (SDA), yeast extract medium (YG) and potato dextrose agar medium (PDA). Candida, including clinical isolates and standard strain, were inoculated in SDA medium and yeast extract peptone dextrose medium (YPD).

Results The growth characteristics of clinical isolates were different from the standard strain of same species in the same medium. On the solid media, the color of Fusarium clinical isolates colonies was darker than the standard strain. The diameter and density of the Aspergillus clinical colonies was greater than the standard one, so was the diameter of conidiation zone. The colony of Candida tropicalis clinical isolate was bigger than the standard strain, but as for Candida albicans, the clinical isolate was similar to the standard one. In liquid media, the growth curves of clinical isolates were similar to the standard ones in nutritious media, while in the simple composition media (SDA) the differences were obvious. YG medium was the most suitable for Fusarium, PDA most suitable for Aspergillus and YPD most suitable for Candida.

Conclusions Compared with standard stains, the clinical isolates had higher adaptive capacity to poorer nutrition condition. In the simple composition medium, the differences between clinical isolates and standard strains would be obvious.

 

Study of the Effect of Nutrient Environment on the Biological Characteristics of Fungal Corneal Clinical Isolates

Object The biological characteristics of fungal corneal clinical isolate growing in different nutrition conditions in vitro were studied in order to find out the key point of pathogenicity.

Methods Five kinds of media with different glucose and peptone concentrations were prepared as the liquid and solid form. The clinical isolates were as followed, 2 Fusarium solani strains, 1 Aspergillus fumigatus strain, 1 Candida albicans strain and 1 Candida tropicalis strain. Clinical corneal isolates and the standard strains were inoculated in the solid and liquid medium. They were all incubated at 29℃ for 96h and observed at defined time points. The optical density was recorded to generate the growth curves in liquid media, while on the solid media, the colonies were observed morphologically.

Results The clinical isolates of Fusarium solani and Aspregillus fumigatus showed stronger reproductive capacity in the abominable nutritional condition. But for the Candida albicans and Candida tropicalis, both standard strains and clinical isolates could sense the changes of the environment sensitively. What’s more, when the glucose concentration in the medium was similar to the aqueous glucose concentration in diabetic patients, the clinical isolates would show the biological features of quicker growth rate and stronger reproductive capacity.

Conclusions Nitrogen source is a very important nutrient element for fungus growth. In the different nutrient condition the clinical isolates showed stronger environmental adaptability and could sense the changes of the environment more sensitively.

第一章 文献综述 1
1.1 眼部主要病原真菌的种类 1
1.1.1 主要病原真菌的分类 1
1.1.2 眼部常见病原真菌的分类 2
1.2 眼部主要病原真菌的地域分布 3
1.3 眼部真菌感染的常见病原菌生物学特点 3
1.3.1 镰刀菌 3
1.3.2 曲霉菌 6
1.3.3 念珠菌 9
第二章 角膜常见致病真菌感染的临床特点 13
2.1 材料与方法 13
2.1.1 材料 13
2.1.2 方法 14
2.1.3 统计学处理 17
2.2 结果 17
2.2.1 患者一般情况 17
2.2.3 临床诊断方法比较 19
2.2.4 致病菌属及不同菌属真菌性角膜炎病变特点 19
2.2.5 特征菌株临床资料总结 21
2.3 讨论 28
2.4 小结 30
第三章 三种角膜致病真菌体外生长特性初探 31
3.1 材料和方法 31
3.1.1 材料 31
3.1.2 方法 33
3.1.3 统计学处理 42
3.2 结果 42
3.2.1 镰刀菌 42
3.2.2 曲霉菌 48
3.2.3 酵母菌 52
3.3 讨论 58
3.3.1 镰刀菌 59
3.3.2 曲霉菌 60
3.3.3 酵母菌 61
3.4 小结 62
第四章 体外培养营养环境对角膜致病真菌影响的研究 63
4.1 材料和方法 63
4.1.1 材料 63
4.1.2 方法 65
4.1.3 统计学处理 72
4.2 结果 72
4.2.1 镰刀菌 72
4.2.2 曲霉菌 80
4.2.3 酵母菌 86
4.3 讨论 93
4.3.1 氮源对眼部分离真菌生长的影响 93
4.3.2 葡萄糖对眼部分离真菌生长的影响 94
4.4 小结 96
第五章 结论及展望 97
参考文献 99
致谢 105
北京大学学位论文原创性声明和使用授权说明 107
个人简历、在学期间发表的学术论文与研究成果 108

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