成人血行播散性肺结核202例临床及影像分析

Analysis on 202 Adult Patients with Hematogenous Pulmonary Tuberculosis

目的通过对血行播散性肺结核临床资料的分析，提高对该病的认识。方法回顾性分析1998～2008年收治的成人血行播散性肺结核202例的临床资料、影像学特点、误诊情况及治疗反应。结果①中青年患者占80．2％，近年来老年患者有增加趋势占19．8％。②痰涂片查抗酸杆菌（AFB）阳性率为20．7％；31例AFB阴性患者中35．5％纤维支气管镜检抗酸杆菌阳性。③12．9％X线胸片早期表现为肺间质磨玻璃样改变，51．5％表现为大小、密度、分布均匀的栗粒结节。④胸部高分辨CT显示55．0％急性血行播散型表现双肺弥漫分布的大小、密度均匀的粟粒结节；另48例亚急性和慢性血行播散性肺结核表现以上中肺野为主的3～7mm大小、密度及分布不均匀的结节。46．8％的肺野内可见斑片、结节、纤维条索状影；43．1％伴纵膈和／或肺门淋巴结肿大。⑤20例活组织检查60％病理阳性。⑥44．6％合并肺外结核，常见于脑膜、浆膜腔、淋巴结、脑、肝、脾、骨等。⑦42．1％入院前被误诊为其它疾病。⑧除8例外其余患者抗结核治疗后体温在3d到12周内降至正常。⑨79．7％在抗结核治疗2个月后胸片显示病灶不同程度吸收。结论痰涂片、HRCT、纤维支气管镜及器官组织活检是早期诊断的关键。关键词结核，肺／诊断放射摄影术。

Objective To understand further hematogenous puhnonary tuberculosis with analysis on its clinical characteristics. Methods We analyzed retrospectively the clinical data, image characters, misdiagnosis and therapeutic response among 202 adult cases with hemotogenous pulmonary tuberculosis hospitalized from 1998 to 2008. Results （1）The young and the midele aged patients accounted for 80.2%, but the elderly patients have increased recently.（2）The rate of sputum smear positive was only 20.7%. However, the rate of AFB positive was 35.5% by fiberoptic bronchoscopy in 31 patients with sputum smear negative.（3）Patients with ground-glass opacity in chest X-rays accounted for 12.9% at the earlier stage. 51.5% cases manifested uniform military nodules in size, density and distribution in the chest X-rays.（4）Chest HRCT showed that 55.0% patients with acute hematogeonus pulmonary tuberculosis had military nodules in the lungs and 45% patients with subactue and chronic hematogenous pulmonary tuberculosis had inconsistent nodules which distributed in the upper and middle zones. 46.8% patients with hematogenous pulmonary tuberculosis had patchy,nodular and fiberoptic shadow,and 43.1% had hilar and mediastinal lymph node enlargement. （5） 12 of 20 cases receiving biopsy had pathological positive result. （6）44.6% patients were complicated with extra-pulmonary tuberculosis such as meningitis, oromeningitis, tuberculous lymphadenitis, brain tuberculoma tuberculosis of liver, tuberculosis of spleen, bone tuberculosis and so on.（7）42.1% cases were misdiagnosed before hospitalization.（8）The temperature of all patients except 8 returned to normal from 3 days to 12 weeks after given anti-tuberculosis chemotherapy.~The lesions of 79.7% cases had various degree absorption in chest X-rays after 2 months therapy. Conclusion Sputum smear, chest HRCT, fiberoptic bronchoscopy and biopsy are the key methods of early diagnosis.