儿童全身播散性结核病5例临床分析

Clinical analysis of 5 children with disseminated tuberculosis

目的探讨儿童全身播散性结核病的临床特点、误诊原因及诊治要点。方法收集北京儿童医院2010年7月至2014年9月收治的5例全身播散性结核患儿，分析其临床特点和诊治经过。结果5例患儿中男2例，女3例，年龄3岁至11岁3个月，病程14～91d。5例免疫功能均未见异常。起病均急骤，高热，3例伴咳嗽，1例伴腹痛。1例无明显伴随症状，炎症指标升高，外院曾误诊为细菌性肺炎、真菌性肺炎、恶性肿瘤等。2例有结核接触史．3例卡介苗瘢痕（卡疤）阴性。病变累及多脏器系统，包括肺、支气管、胸膜、外周淋巴结、腹膜、腹腔淋巴结、肝、脾、肠、脑膜、脑实质、脑血管、骨骼等，其中肺结核5例，支气管结核1例，结核性胸膜炎1例，腹腔结核4例（其中肝结核1例、脾结核2例、肠结核4例、腹腔淋巴结结核4例、结核性腹膜炎2例），结核性脑膜炎4例，脊柱结核1例，外周淋巴结结核1例。5例患儿抗痨治疗效果好，预后良好。结论儿童全身播散性结核病属重症结核病，起病急骤，炎症指标高，临床表现复杂多样，多脏器受累，临床诊断困难。完善辅助检查，特别是旧结核菌素（PPD）试验、多部位影像学检查、病原学检查，并积极鉴别诊断及临床疗效观察等，对明确诊断有重要作用。

Objective To explore the clinical characteristics, the reasons of misdiagnosis and the main points of diagnosis and treatment of disseminated tuberculosis in children. Methods The clinical data of 5 children with disseminated tuberculosis from July 2010 to September 2014 in our hospital were collected retrospectively and the clinical characteristics and diagnosis and treatment were analyzed. Results The 5 children （2 boys and 3 girls） were from 3 years to ll years and 3 months and the disease course ranged from 14d to 91d. All the cases were with normal immune function and abrupt onset, high fever and high inflammatory markers, 3 cases with cough, 1 case with abdominal pain, and 1 case with no symptoms ; 2 patients had a history of exposure to tuberculosis, while 3 cases were with negative BCG scar. The 5 cases had been misdiagnosed as bacterial pneumonia, fungal pneumonia, malignant tumor outside our hospital. Multiple organs were involved, including lung, bronchus, pleura, peripheral lymph nodes, peritoneum, abdominal lymph nodes, liver, spleen, intestine, meninges, brain parenehyma, cerebral vessels, and bones, etc. Among these cases, there was pulmonary tuberculosis in 5, endohronchial tuberculosis in 1, tuberculous pleuritis in 1, abdominal tuberculosis in 4 （hepatic tuberculosis in 1, splenic tuberculosis in 2, intestinal tuberculosis in 4, abdominal lymph node tuberculosis in 4, tuberculous peritonitis in 2）, tuberculous meningitis in 4, spinal tuberculosis in 1 and peripheral lymph node tuberculosis in 1. The 5 cases were cured by using anti-tuberculosis treatment and had good prognosis. Conclusion Disseminated tuberculosis in children is severe and usually with abrupt onset, high inflammatory markers, diverse and complex clinical manifestations and muhi-organ involvement, so the clinical diagnosis is difficult. Comprehensive laboratory examination, especially the PPD test, multiple position imaging, etiological examination, and the positive differential diagnosis and observation of clinical curative effect all play an important role in diagnosis.