六例非典型多发性骨关节结核误诊的临床分析

Clinical analysis of six misdiagnosis cases with atypical multifocal osteoarticular tuberculosis

目的探讨非典型多发性骨关节结核的有效诊断方法，为及时准确的诊断该病提供经验。方法回顾性分析兰州大学第一医院2007年1月至2013年12月收治的6例曾被误诊为骨髓瘤（2例）或转移癌（4例）的非典型多发性骨关节结核患者的胸部x线摄片、CT、MRI和正电子发射计算机体层摄影（PET）CT检查资料。6例患者年龄17-62岁，中位年龄31岁；男4例，女2例。对结核病累及椎体的数量和分布情况、椎体改变情况（骨质破坏的方式）、病变椎体的椎间隙改变情况和病理活检进行分析，并对抗结核药物治疗效果进行随访。结果6例患者胸部x线摄片显示双肺均未见结核病灶；CT、MRI检查显示1例患者枢椎和颈7椎体骨质破坏，脊髓受压变形；其余5例患者CT扫描显示有多灶溶解性骨质破坏区位于椎体中央，椎体周边骨质及椎间隙正常，脊髓未受压迫。2例患者有附件受累，其中1例伴有胸10椎体、左侧横突、腰1椎体、右侧第8肋骨及左侧第9肋骨溶解性骨质破坏区；另1例PETCT检查显示在腰椎、骶椎的椎体，以及左侧髂骨和左侧髋臼上有多个高代谢活性的病灶。6例患者最终进行活检病理切片检查，均诊断为结核性肉芽肿，抗酸染色阳性。6例患者口服异烟肼、利福平、吡嗪酰胺和盐酸乙胺丁醇进行抗结核药物治疗6个月，后改为只口服异烟肼和利福平继续治疗18个月，抗结核药物治疗后病情均好转，随访28-74个月未见复发。结论病理学诊断仍然是非典型多发性骨关节结核确诊的重要手段。

Objective To explore effective diagnostic method, in help to providing experience for accurate and timely diagnosis of atypical multifocal osteoarticular tuberculosis. Methods Xray, CT, MRI and positron emission computed tomography （PET/CT） of six atypical multifocal osteoarticular tuberculosis patients （aged 17-62 years with median age of 31 years; 4 males and 2 females）, who had been misdiagnosed as multiple myeloma （2 cases） or metastatic cancer （4 cases）, from First Hospital of Lanzhou University between January 2007 and December 2013 were retrospectively analyzed. Numbers of vertebral body involved by tuberculosis, distribution, changes of vertebra body （bone destruction） and intervertebral space of the involved vertebra body, pathological changes by spinal biopsy and follow-up of anti-tuberculosis treatment were analysis. Results X-ray showed no pulmonary tuberculosis in the six cases; CT and MRI showed that one patient had bone destruction in the axis and the 7th cervical vertebra, and cord compression; while the other five were found by CT scan that they had multiple destruction of bone in the center of vertebral body, but marginal bone of vertebral body, intervertebral space and cord were normal. Of the 5 cases, one patient had destruction of bone in the 10th thoracic vertebral body, left transverse process, the first lumbar, the 8th rib on right and the 9th rib on left; and another case examined by PET-CT had multiple lesions of high metabolic activity in lumbar vertebrae bodies, sacral vertebrae bodies, the left ilium and left acetabulum. All the 6 cases were finally treated with biopsy pathology slice and diagnosed as tubercu- losis granuloma with positive acid fast stain. After taking oral isoniazid, rifampicin, pyrazinamide and ethambutol for 6 months, and then treated with only oral isoniazid and rifampicin for 18 months, state of all the six patients were imprived and there was no recurrence during 28 74 month follow up. Conclusion Histopathologic examination is still important for the diagnosis of atypical multifocal osteoarticular tuberculosis.