超声支气管镜下穿刺活检对成人纵隔淋巴结结核的早期诊断价值（附87例临床报告）

Value of endobronchial ultrasound-guided transbronchial needle aspiration in early diagnosis of mediastinal tuberculous lymphadenopathy

目的 探讨超声支气管镜下穿刺活检（EBUS-TBNA）对于纵隔淋巴结结核的早期诊断价值。方法 选取上海市肺科医院2010年1月至2012年12月期间，影像学及临床诊断为纵隔淋巴结结核但气管镜检查无异常的患者共87例；其中男51例，女36例，年龄21～70岁，平均（48.5±11.5）岁。所有患者行EBUS-TBNA，标本送检病理、抗酸杆菌涂片、培养和体外聚合酶链反应检测，根据检测结果进行诊断性治疗并随访3个月，治疗无效者进行纵隔镜检查，最终统计EBUS-TBNA在纵隔淋巴结结核诊断中的诊断率。应用统计软件SPSS 13.0进行数据分析和计算。 结果 66例患者通过EBUS-TBNA直接确诊结核病，1例确诊为非结核分枝杆菌（NTM）感染（菌型鉴定为鸟-胞内分枝杆菌，MAC）；5例确诊肺癌，2例确诊结节病，13例未得到任何阳性证据；13例中6例通过诊断性抗结核治疗确诊结核病，7例行纵隔镜检查，其中3例确诊淋巴瘤，3例肺癌，1例结核病。因此87例患者中最终确诊结核病73例，其中通过EBUS-TBNA确诊66例（90.41%，66/73）。经过EBUS-TBNA确诊结核病的66例中21例（31.82%，21/66）为结核分枝杆菌涂片和（或）培养阳性（3例结核分枝杆菌药敏试验提示耐药）；40例（60.61%，40/66）结核分枝杆菌聚合酶链反应检测阳性，38例（57.58%，38/66）病理检测结果为干酪样坏死或者结核性肉芽肿。 结论 EBUS-TBNA在纵隔淋巴结结核特别是耐药纵隔淋巴结结核的早期诊断上可能具有一定的价值。

Objective To investigate the value of endobronchial ultrasound-guided transbronchial needle aspiration （EBUS-TBNA） in early diagnosis of patients with mediastinal tuberculous lymphadenopathy. Methods Eighty-seven patients, who were considered to have mediastinal tuberculous lymphadenopathy based on clinical indications and imaging, but with normal fiber bronchoscope examination results, were recruited in Shanghai Pulmonary Hospital from Jan 2010 to Dec 2012. All enrolled patients underwent EBUS-TBNA, and then samples obtained by EBUS-TBNA were performed pathological examination, smear, culture and PCR, drug susceptibility testing （DST） was performed for all patients with culture-positive. Patients who had negative results with all above mentioned examinations, a standardized diagnostic chemotherapy with 4 first-line anti-TB drugs was given for 3 months; if no improvement on imaging during 3 months, mediastinoscopy was carried out. Software SPSS 13.0 was used for data analysis. Results Sixty-six patients were diagnosed with TB using the samples obtained by EBUS-TBNA： pathological findings were consistent with TB in 38 patients （57.58%, 38/66）, microbiological investigations yielded a positive culture of TB and/or positive smear in 21 patients （31.82%, 21/66; identified 3 drug-resistant cases）, as well as a positive PCR in 40 patients （60.61%, 40/66）; 1 patients was identified as non-tuberculosis mycobacteria （NTM）; 5 patients were diagnosed with cancer; 2 patients were diagnosed with sarcoidosis. Thirteen patients did not have a specific diagnosis following EBUS-TBNA： 7 patients underwent mediastinoscopy and TB was confirmed in one, lymphoma was confirmed in 3 and cancer was confirmed in 3; 6 patients who responded to empirical anti-TB treatment were diagnosed with TB. A total of 73 patients were diagnosed as TB in this research and 66 of them （90.41%, 66/73） were diagnosed by EBUS-TBNA. Conclusion EBUS-TBNA may be useful in early diagnosis of mediastinal tuberculous lymphadenopathy, especially to drug-resistant TB. The use of PCR can be helpful for the diagnosis of TB.