肝移植术后结核病的诊断与治疗

Diagnosis and treatment of tuberculosis infection after liver transplantation

目的探讨肝移植术后结核病患者的临床特点、诊断和治疗方法及临床疗效。方法回顾性研究2003年10月至2011年12月在中山大学附属第三医院肝移植中心接受随访的336例肝移植术后患者，经临床诊断为肝移植术后肺结核共3例。其中男性2例，女性1例，年龄36-59岁，平均年龄47岁。手术方式均采用同种异体改良背驮式原位肝移植术。患者均签署知情同意书，并符合医学伦理学规定。术后常规使用他克莫司为主的免疫抑制方案。收集3例患者的临床资料，并结合文献总结肝移植术后结核病的临床特点、诊治经过和临床疗效。结果肝移植术后肺结核的发生率为0．9％（3／336）。3例患者术前均无结核病史，发病时间分别为肝移植术后43d、19个月和27个月，平均15.8个月。临床表现不典型，2例有发热，其中1例伴有咳嗽和咳痰，1例伴有盗汗和消瘦；第3例无明显症状但结核菌素纯蛋白衍生物（PPD）试验阳性。1例伤口分泌物找到可疑抗酸杆菌。3例胸部影像学检查均有肺部浸润性改变。3例均临床诊断为浸润性肺结核，1例可疑合并“腹腔结核感染”。出现症状到明确诊断的时间分别为7、7和395d，平均136d。接受抗结核治疗后，1例治愈，1例病情已缓解，1例未愈。结论肝移植术后结核病的临床表现不典型，易被延误诊断，抗结核治疗疗效满意，治疗期间应注意防治肝损害和排斥反应。

Objective To investigate the clinical features, diagnosis, treatment and therapeutic efficacy of Mycobacterium tuberculosis （TB） infection in liver transplant recipients. Methods Among 336 liver transplant recipients who were followed up in the Third Affiliated Hospital of Sun Yat-sen University from October 2003 to December 2011, 3 recipients were diagnosed as TB infection after liver transplantation（LT）. Two of them were male and one was female, aged 36-59 years old with the mean age of 47 years old. The three recipients underwent improved piggy-back orthotopic liver transplantation. Local ethical committee approval had been received and that the informed consent of all participating subjects was obtained. They received Tacrolimus-based immunosuppressive therapy. The clinical features, diagnosis, treatment and therapeutic efficacy were collected and analyzed and the relevant literatures were reviewed. Results The incidence of TB infection after LT in our center was 0.9% （3/336）. Three patients developed TB 43 d, 19 months and 27 months after LT （15.8 month mean time） with atypical clinical manifestations.Two of them suffered from fever, one developed cough and sputum, one had night sweats and weight loss and the third patient had no obvious symptoms except positive purified protein derivative （PPD） test. Mycobacterium tuberculosis was isolated from wound in one patient. All the 3 patients were diagnosed as infiltrative pulmonary tuberculosis, among them one with combined abdominal TB. The time elapsed between onset of symptoms and diagnosis was 7, 7 and 395 d respectively （mean： 136 d）. After receiving anti-TB treatment, 1 case was cured, 1 was relieved and 1 was not cured. Conclusions Tuberculosis after LT has atypical clinical manifestations and is easily misdiagnosed or delayedly diagnosed. It can be well cured by anti-TB treatment with close monitoring of liver damage and graft rejection.