胸膜活组织检查诊断儿童结核性胸膜炎的临床价值分析

Clinical value of pleural biopsy in the diagnosis of children with tuberculous pleurisy

目的 探讨胸膜活组织检查在儿童结核性胸膜炎中的诊断价值.方法 根据中华医学会2006年颁布的儿童肺结核临床诊断标准,选取重庆医科大学附属儿童医院2007年1月至2013年1月最终被诊断为结核性胸膜炎且具有胸膜活组织检查资料的51例患儿为研究对象,回顾性分析患儿临床症状、病史特点、实验室检查、影像学特征、胸腔穿刺液及胸膜活组织检查结果,评估胸膜活组织检查的检出率以及术前诊断的误诊率.结果 （1）51例结核性胸膜炎患儿中,男35例,女16例,年龄（9.7±3.5）岁;常见临床症状有发热（82％）、咳嗽（71％）、胸痛（23％）、乏力（10％）及气促（10％）等.14例患儿有结核感染中毒症状（27％）;39例患儿有明确卡介苗接种史（76％）;6例患儿有明确结核接触史（12％）.（2）结核菌素试验、血清结核抗体测定、结核分枝杆菌DNA荧光定量PCR检测、痰/胃液涂片找抗酸杆菌、胸腔穿刺液涂片找抗酸杆菌或结核培养的阳性率分别为61％（20/33）、6％（3/46）、0（0/12）、4％（1/27）及22％（7/32）.（3）影像学检查证实有胸腔积液50例,形成包裹或有包裹趋势28例（55％）,纤维分隔12例（23％）.其他征象还包括胸膜增厚（53％）,肺门、纵隔等部位淋巴结肿大（14％）及钙化灶（10％）.（4）行胸腔穿刺术31例,均为渗出液,90％（28/31）病例以单核细胞分类为主.（5）51例均行胸膜活组织检查,40例镜下见典型结核病理改变,即干酪样坏死、肉芽肿结构形成、郎格汉巨细胞及淋巴细胞等炎细胞浸润;7例患儿未见干酪样坏死,呈现炎性肉芽肿,仍判定为结核性胸膜炎;余4例未见结核特征性表现.47例经胸膜活组织检查确诊的结核性胸膜炎患儿中,术前诊断即为结核性胸膜炎15例（32％）、化脓性胸膜炎24例（51％）、胸腔积液原因待查8例（17％）.结核性胸膜炎的胸膜活组织检查检出率为92％（47/51）,术前诊断的误诊率为68％（32/47）.结论 胸膜活组织检查对儿童结核性胸膜炎具有重要诊断价值.

Objective To explore the value of pleural biopsy in the diagnosis of tuberculous pleurisy in children.Method Fifty-one cases with tuberculous pleurisy,whose diagnosis was established according to the clinical diagnostic criteria of the child pulmonary tuberculosis formulated by the Chinese Medical Association （CMA） in 2006,after pleural biopsy hospitalized in Children＇s Hospital of Chongqing Medical University from Jan.1,2007 to Jan.1,2013 were enrolled into this study.Clinical symptoms,history traits,laboratory examination,imaging tests,pleural fluid characteristics and the results of pleural biopsy were retrospectively analyzed.Medical records of the cases who were diagnosed with tuberculous pleurisy by histological examination were reviewed to assess tuberculosis detection rate of pleural biopsy and to get the percentage of cases with a preoperative diagnosis inconsistent with the final diagnosis.Result There were 35 boys and 16 girls,and the mean age was（9.7 ± 3.5）years.The common symptoms included fever（82％）,cough（71％）,chest pain（23％）,weakness（10％）and shortness of breath （10％） ; 27％ （14/51） children had shown tuberculosis toxic symptoms; 76％ （39/51） patients had BCG vaccination history;12％ （6/51） cases had a history of contact with tuberculosis patients.The positive rates of the tuberculin skin test,serum tuberculosis antibody detection,detection of Mycobacterium tuberculosis DNA by polymerase chain reaction,acid-fast bacillus test of sputum （or gastric juice） smear,acid-fast bacilli （AFB） smear and culture of pleural effusion were respectively 61％ （20/33）,6％ （3/46）,0（0/12）,4％ （1/27）,22％ （7/32）.Pleural effusion was found by using imaging tests in 50 cases,among whom 28 cases （55％）with encapsulated effusion,and the multilocular cysts separated by fibrous tissue in 12 patients （23 ％）.Other features included pleural thickening（53％）,hilar and mediastinal lymph-nodes enlargement （14％）and white nodules of calcification（10％）.Thoracocentesis was performed in 31 cases,and pleural effusion obtained from which were exudative.The cell count,mainly mononuclear cells,increased in 28 patients（90％）.Among the 51 children investigated,47 （92％） were histologically diagnosed to be tuberculous pleurisy.The typical pathologic changes of tuberculosis （caseous necrosis,granulomas,Langhans＇ giant cells and inflammatory cell infiltration） were observed in 40 cases,granulomatous inflammation without caseous necrosis were the main manifestations in 7 other patients.The pathological changes of the remaining 4 cases were not consistent with the pathological characteristics of tuberculosis.All 47 cases were given a preoperative diagnosis of tuberculous pleurisy （32％）,purulent pleurisy （51％） and pleural effusion of unknown origin （17％） respectively before pleural biopsy.Therefore,the tuberculosis detection rate of pleural biopsy was 92％,and the preoperative misdiagnosis rate was 68％.Conclusion Pleural biopsy was of great diagnostic value for children with tuberculous pleurisy.