不典型肺结节病的CT表现误诊分析

Misdiagnosis Analysis of Atypical Pulmonary Sarcoidosis Based on CT Manifestations

目的分析肺结节病误诊的不典型CT表现,提高对肺结节病的CT诊断水平。方法选取2012年1月—2015年8月首都医科大学附属北京朝阳医院24例CT误诊,后经病理证实,符合临床诊断标准并进行治疗的肺结节病患者为研究对象,回顾性分析24例患者的临床表现、实验室检查资料及CT影像学资料。结果 24例肺结节病患者中,23例(95.8%)表现为不同程度肺部症状(咳嗽、咳痰,胸闷、气促,胸痛);8例(33.3%)同时伴全身非特异性症状(发热、乏力,体质量下降);4例(16.7%)伴有肺外表现(皮肤结节性红斑,双髋关节痛,神经性耳聋);1例(4.2%)无明显临床症状。红细胞沉降率升高率为47.6%(10/21);C反应蛋白升高率为52.3%(11/21);结核菌素试验(PPD)阳性率为1/9;支气管肺泡灌洗液(BALF)CD_4/CD_8比值升高率为8/18。CT表现:淋巴结增大不典型表现12例(50.0%),其中纵隔伴单侧肺门淋巴结增大5例(20.8%),单纯纵隔淋巴结增大5例(20.8%),淋巴结未见增大2例(8.3%);淋巴结融合8例(33.3%)。肺内不典型表现:磨玻璃密度影10例(41.7%),粟粒样结节影7例(29.2%),索条网状阴影6例(25.0%),类似树芽征表现5例(20.8%),结节及团块影4例(16.7%);胸膜病变10例(41.7%),其中增厚、钙化及胸腔积液2例(8.3%)。CT误诊的疾病包括:肺结核5例(20.8%)、淋巴瘤4例(16.7%)、肺间质纤维化4例(16.7%)、肺部感染3例(12.6%)、纵隔占位2例(8.3%)、肺转移瘤2例(8.3%)、肺癌2例(8.3%)、间质性肺炎2例(8.3%)。结论肺结节病的不典型CT表现较多,不具有特征性,充分认识肺结节病的不典型CT表现并结合临床综合分析,对疾病的诊断及治疗有重要的指导意义。

Objective To analyze the atypical CT manifestations of misdiagnosed pulmonary sarcoidosis,and improve the diagnosis level of CT on pulmonary sarcoidosis. Methods From January 2012 to August 2015,24 cases of pulmonary sarcoidosis misdiagnosed by CT,then confirmed by pathology,met the clinical diagnostic criteria and accepted treatment were selected as subjects in Beijing Chaoyang Hospital, Affiliated to Capital Medical University. The clinic manifestations, the laboratory data and CT characteristics of the 24 cases were retrospectively analyzed. Results In 24 pulmonary sarcoidosis cases,23（ 95. 8%） presented different respiratory symptoms（ cough,expectoration,chest tightness,dyspnea and pectoralgia）; 8（ 33. 3%） complicated with the systemic nonspecific symptoms（ fever,weakness,loss of the weight） simultaneously; 4（ 16. 7%） complicated with the extra-pulmonary manifestations（ cutaneous erythema nodosum,pain of bilateral hip,nervous deafness）; 1（ 4. 2%） was asymptomatic. The erythrocyte sedimentation rate elevated in 47. 6%（ 10/21） of cases,and C reaction protein elevated in 52. 3%（ 11/21） of cases,the positive rate of tuberculin test（ PPD） was 1/9,ratio of CD4/CD8 in bronchoalveolar lavage fluid（ BALF） increased in 8/18. CT findings： in 12 cases（ 50. 0%） of atypical manifestations of lymph node enlargement,mediastinal and unilateral hilar lymph node enlargement in 5 cases（ 20. 8%）, mediastinal lymph node enlargement alone in 5 cases（ 20. 8%）,no lymph node enlargement in 2 cases（ 8. 3%）; lymph node fusion in 8 cases（ 33. 3%）. The atypical pulmonary manifestations： ground glass density in 10 cases（ 41. 7%）,miliary nodules in 7 cases（ 29. 2%）,linear reticular opacities in 6 cases（ 25. 0%）,tree-in-bud opacities in 5 cases（ 20. 8%）,nodule and mass opacities in 4 cases（ 16. 7%）. Pleural lesions in 10 cases（ 41. 7%）,including pleural thickening,calcification and pleural fluid in 2 cases（ 8. 3%）. The misdiagnosed diseases on CT included 5 cases（ 20. 8%） of tuberculosis,4 cases（ 16. 7%） of lymphoma,4 cases（ 16. 7%） of pulmonary interstitial fibrosis,3 cases（ 12. 5%） of pulmonary infection,2 cases（ 8. 3%） of mediastinal mass,2 cases（ 8. 3%） of pulmonary metastases,2 cases（ 8. 3%） of lung cancer, and 2 cases（ 8. 3%） of interstitial pneumonia. Conclusion The atypical manifestations of pulmonary sarcoidosis at CT are diversified and nonspecific.It is of great significance for the diagnosis and treatment of pulmonary sarcoidosis to fully understand the atypical CT manifestations of the disease and combine with the clinical comprehensive analysis.