多种诊断技术在全身播散性结核病诊治中的联合应用

Combined Application of Enzyme-linked Immunospot Assay,Positron Emission Tomography,and Gene Chip Assay in the Diagnosis of A Case of Chronic Disseminated Tuberculosis

目的探讨结核特异的γ干扰素释放分析T-SPOT.TB、CT联合正电子发射断层显像(PET/CT)和基因芯片分析在诊断播散性结核病中的应用,探讨播散性结核病的诊治要点。方法分析北京协和医院感染科收治的1例慢性全身播散性结核病患者的临床诊治情况,以及其T-SPOT.TB、PET/CT和基因芯片分析的结果。结果患者临床符合慢性结核病表现,外周血T-SPOT.TB检测显示结核特异性抗原即6kD早期分泌靶向抗原和10kD培养滤过蛋白肽段库刺激后释放γ干扰素的T细胞分别为:3908和3400斑点形成细胞(SFCs)/106外周血单个核细胞(PBMCs)。全身PET/CT检查显示全身多发放射性摄取增高病变,累及双肺、淋巴结和骨骼,行淋巴结、肺部、右髂后上嵴活检,病理显示为肉芽肿病变。组织培养为分枝杆菌,基因芯片分析确定为结核分枝杆菌,对利福平和异烟肼敏感。抗结核治疗后患者症状缓解,体温正常,治疗10周后T-SPOT.TB检测显示6kD早期分泌靶向抗原和10kD培养滤过蛋白肽段库刺激后释放γ干扰素的T细胞分别为:1528SFCs/106PBMCs、1460SFCs/106PBMCs,较治疗前显著下降。结论播散性结核病的及时诊断有赖于对该病的充分了解和重视。T-SPOT.TB、PET/CT和基因芯片技术的合理应用有助于播散性结核病的诊治。

Objective To highlight the clinical features and diagnosis of chronic disseminated tuberculosis, with emphasizing the usefulness of several recently available diagnostic technologies in this setting. Method We presented a case of chronic disseminated tuberculosis diagnosed with the combined application of interferon-gamma release assay T-SPOT. TB, is F-fluorodeoxyglucose （FDG） -positron emission tomography （PET） , and gene chip assay. Results A 53-year-old gentleman who had chronic cough for 7 years and fever for 2 weeks was referred to our hospital for further evaluation, is F-FDG-PET/CT scan showed increased FDG uptake in multiple lesions involving bilateral lungs, supraclavicular, mediastinal and intro-abdominal lymph nodes and bones, mimicking metastatic malignancy. T-SPOT. TB assay revealed significant responses [ early secreting antigen target 6 （ESAT-6） ： 3 908 spot forming cells （SFCs） /10^6 peripheral blood mononuclear cells （PBMCs）, culture filtrate protein （CFP-10） ： 3 400 SFCs/10^6 PBMCs]. Subsequent biopsy of supraclavicular lymph node, lung, and ilium revealed granulomas, while culture of the obtained tissue yeilded mycobaeteria. Gene chip testing identified M. tuberculosis sensitive to isoniazid and rifampin. After 10 weeks of treatment for tuberculosis, the patient＇s condition was improved and a second T-SPOT. TB assay showed significantly reduced responses （ESAT-6：1 528 SFCs/10^6 PBMCs; CFP-10：1 460 SFCs/10^6 PBMCs）. Conclusions Timely diagnosis of chronic disseminated tuberculosis requires high index of suspicion. T-SPOT. TB assay, PET/CT, and gene chip assay may provide valuable information that facilitates further diagnostic procedures and treatment decision.