40例耐药肺结核并发非结核分枝杆菌肺病的诊治

Diagnosis and treatment of 40 cases with drug-resistant pulmonary tuberculosis complicated by non-tuberculous mycobacterial pulmonary disease

目的通过分析耐药肺结核并发非结核分枝杆菌（NTM）肺病患者的临床特征，探讨其诊治策略。方法从2008年1月至2014年12月所有收治入院的2765例耐药肺结核患者中筛查出并发NTM肺病的患者40例，记录其全程的治疗情况，对其耐药类型、并发症、影像学特征、治疗特点、转归及预后进行总结和分析。结果40例患者占所有耐药肺结核的1.4％，其中初始耐药患者11例，获得性耐药患者29例，耐多药肺结核（MDR-PTB）患者32例；并发肺部基础疾病患者37例（92．5％），其中支气管扩张最常见（37例）；影像学特征为肺部病灶广泛、常伴右肺中叶及左肺舌叶的支气管扩张，常伴空洞者25例（62．50o），产生毁损肺者13例（32．5％）；治愈及痰菌阴转者仅15例（37．5％）。给予姑息治疗患者长期排菌但病灶稳定者17例（42．5％），病灶进展痰菌阳性者3例，失访4例，大咯血死亡1例。结论具有毁损肺及支气管扩张的耐药肺结核在治疗中应警惕并发NTM肺病可能，具有空洞及支气管扩张的NTM肺病者疗效不佳时，应充分注意是否并发耐药肺结核，两病并发时患者痰菌阴转率低、治疗难度大，姑息治疗应得到充分重视。

Objective To explore the strategy on diagnosis and treatment of drug resistant pulmonary tuber-culosis （DR-PTB） and complicated with non-tuberuclous mycobacterial （NTM） pulmonary disease through analysis of the clinical characteristics of 40 cases with DR-PTB complicated by NTM pulmonary disease. Methods It was a retrospective study. A total of 2765 cases with drug-resistant PTB who hospitalized at Shanghai Pulmonary Hospital from January 2008 to December 2014 were screened and confirmed if they had NTM pulmonary disease or not. The related information of the patients who were found to have DR-PTB and complicated by NTM pulmonary disease were collected and analyzed, including the type of drug-resistant, complications, the features of image, treatment and treatment outcomes, ect. Results Totally, 40 cases with DR-PTB complicated with NTM pulmonary disease were diagnosed, accounting for 1.4% of all DR-PTB cases. Among 40 cases, 11 cases were initial drug-resistant PTB, 29 cases were acquired DR-PTB and 32 cases were MDR-PTB; 92.5% of them had pulmonary underlying diseases and bronchiectasis was the most common disease （37 cases） ; the features of image of those patients included disseminated lung lesions, and complicated by right middle lobe and left lingular lobe bronchieetasis or cavity （25 cases, 62.5%）, lung segment or lobe destruction （13 cases, 32.5%） ; only 15 cases （37.5%） were cured with bacteriological conversion, while 17 cases （42.5%） received palliative treatment and in the stable situation but sputum positive, 3 cases became worse with sputum positive, 4 cases defaulted and 1 case died of severe hemoptysis. Conclusion Patients with DR-PTB should be alerted to have co-infection of NTM if they had lung destruction or bronchiectasis, while the patients with NTM pulmonary diseases should be alerted to have co-infection of DR-PTB if they had poor outcomes of treatment, cavity and extensive bronchiectasis. The patients with both DR-PTB and NTM pulmonary disease are usually difficult to be cured with low sputum conversion rate. In this case, palliative treatment can be considered and paid more attention.