大叶性干酪性肺炎78例临床分析

Clinical Study on 78 Patients with Caseous Lobar Pneumonia

目的探讨大叶性干酪性肺炎的诊断与治疗方法。方法对我院近8年来收治的78例大叶性干酪性肺炎进行回顾分析。结果发病以青少年及50岁以上人群多见,多急性起病,发热症状较突出,血白细胞增多多见,痰菌阳性率较高,但PPD阳性率偏低,发病部位以上叶尖后段多发,多伴有空洞、含气支气管征及卫星播散病灶,病灶内钙化者少见。正规四联(HREZ或HRSZ)抗结核化疗后第1个月痰菌阴转10例(20.4%);治疗第2个月痰菌阴转者28例(57.1%);治疗第3个月阴转者7例(14.3%);3个月以上阴转2例(6.1%);治疗3个月肺内病灶吸收好转4 7例(6 1.4%);明显吸收好转2 3例(2 9.9%);无变化7例(9.1%)。全疗程结束后空洞闭合2 5例(6 5.8%);空洞未闭合者,综合临床及痰菌认定为净化性空洞者11例(28.9%)。结论干酪性肺炎临床与影像表现易与肺炎等肺部感染性疾病相混淆,综合医院要加强痰抗酸杆菌检查,必要时要行试验性抗结核治疗,正规的抗结核化疗加上适当的免疫支持治疗后效果好,具体疗程要根据空洞闭合、痰菌阴转及合并症的情况而定。

Objective To study the diagnosis and the treatment of caseous lobar pneumonia.Methods A clinical analysis was conducted in 78 inpatients with caseous lobar pneumonia in the recent eight years.Results Caseous lobar pneumonia was more prevalent in the teenagers and in the people over 50 years than in the other population.The onset of the disease was fast.Most patients showed systemic symptoms,predominantly with fever.The count of peripheral white blood cells usually increased.The positive rate of acid-fast staining by sputum smear was high,though the positive rate of purified protein derivative（PPD） skin test was low.The lesions were often located in apical and posterior segments of bilateral upper lobes,frequently complicated with cavitations,air bronchogram and bronchial dissemination and rarely with calcified foci.All the patients received systematic antitubercular chemotherapy regiment（HREZ or HRSZ）.The sputum negative conversion was shown in 10 cases（20.4%） at the end of the first month,in 28 cases（57.1%） at the end of the second month,in 7 cases（14.3%） at the end of the third month,in 2 cases（6.1%） after three months.Three months later,47 cases（61.4%） displayed absorption of pulmonary lesions,23 cases（29.9%） displayed obvious absorption,while 7 cases（9.1%） had no change.At the end of treatment,cavities closed up in 25 cases（65.8%）,and 11 cases were considered as open healing of tuberculous cavity（diagnosed by clinical feature and sputum smear despite cavities were still there）.Conclusion Depending on clinical feature and imaging analysis,caseous lobar pneumonia is often misdiagnosed as common pulmonary infectious diseases（e.g.pneumonia）.Acid-fast staining by sputum smear must be strengthened at general hospital.Testing antitubercular treatment is recommended when necessary.With regular therapy and auxiliary immunotherapy,the curative effects can be satisfactory,though the course of the treatment varies according to the absorption of the focus,the sputum negative conversion and the complications.