儿童结核性胸膜炎的临床特点

Clinical features of pediatric tuberculous pleurisy

目的总结儿童结核性胸膜炎的临床表现及检查特点，提高对结核性胸膜炎的早期认识。方法选择2006年8月至2014年9月于首都医科大学附属北京儿童医院呼吸二科病房诊治的结核性胸膜炎患儿113例作为研究对象，并选择同期住院的肺炎支原体肺炎并胸膜炎患儿113例作为对照组。比较2组基本情况、临床表现、胸水及影像学特点等，应用SPSS16．0软件统计分析2组间的差异。结果结核性胸膜炎组和对照组伴咳嗽症状患儿的比例分别为47．79％（54／113例）、99．12％（112／113例），差异有统计学意义（X2=76．33，P〈0．01），剧咳患儿的比例分别为3．70％（2／54例）、97．32％（109／112例），差异有统计学意义（X2=144．10，P〈0．01）；病程分别为15．00（10．00，30．00）d、10．00（8．00，14．50）d，差异有统计学意义（X2=8668．00，P〈0．01）。结核性胸膜炎组低热、中等热、高热、超高热患儿的比例分别为8．65％（9／104例）、47．12％（49／104例）、44．23％（46／104例）、0，对照组低热、中等热、高热、超高热患儿的比例分别为0．90％（1／111例）、18．92％（21／111例）、79．28％（88／111例）、0．90％（1／111例），2组比较差异有统计学意义（形=9064．00，P〈0．01）。结核性胸膜炎组和对照组中单侧胸腔积液患儿的比例分别为94．69％（107／113例）、71．68％（81／113例），差异有统计学意义（X2=21．39，P〈0．01）。结核性胸膜炎组、对照组患儿胸水单核细胞分别为0．89（0．76，0．93）和0．60（0．30，0．78）（W=888．50，P〈0．01），蛋白水平分别为51．00（47．35，54．20）g／L、42．10（37．85，46．15）g/L（W=842．50，P〈0．01），乳酸脱氢酶（LDH）水平分别为553．50（358．00，749．25）U／L、1189．10（670．95，1820．00）U／L（W=2186．00，P〈0．01），2组比较差异均有统计学意义。影像学特点除了均伴有胸腔积液外，2组均以高密度影为主要特点，结核性胸膜炎组和对照组肺不张比例分别为77．88％（88／113例）、4．42％（5／113例）（X2=125．90，P〈0．01），肺实变比例分别为4．42％（5／113例）、72．57％（82／113例）（X2=110．80，P〈0．01），2组间差异均有统计学意义。结核性胸膜炎组痰结核杆菌培养阳性率仅为1．77％（2／113例），其他病原学检查均为阴性。结论对于单侧胸腔积液的患儿，起病仅有发热（中高热），呼吸道症状不明显或呼吸道症状与影像学病变程度不成正比的，胸水单核细胞〉0．70，影像学提示压缩性肺不张，应考虑结核性胸膜炎的可能，需进一步追问有无结核易感因素，行结核菌素试验检查，有利于结核性胸膜炎的早期诊断。

Objective To sum up the clinical manifestations and laboratory features for the diagnosis of pe- diatric tuberculous pleurisy, and to improve the recognition of this disease in early stage. Methods A retrospective study of 113 children diagnosed as tuberculous pleurisy from August 2006 to September 2014 in the Second Department of Respiratory Medicine, Beijing Children＇s Hospital Affiliated to Capital Medical University was conducted. Meanwhile, another 113 cases of children with mycoplasma pneumoniae pneumonia complicated with pleurisy were selected as con- trol group. The general information, clinical symptoms, pleural effusion and imaging features between 2 groups were ana- lyzed and compared by using SPSS 16.0 statistical software. Results The proportion of patients with cough in tubercu- lous pleurisy group and control group was 47.79% （54/113 cases） and 99.12% （ 112/113 cases） （X2 =76.33 ,P 〈 0. O1 ） respectively,and the proportion with severe cough was 3.70% （2/54 cases） and 97.32% （109/112 cases） （X2 = 144.10,P 〈 0.01 ）, while the disease duration was 15.00 （ 10.00,30.00 ） days and 10.00 （ 8.00,14.50 ） days （ W = 8 668.00 ,P 〈0.01 ） ,respectively,and all the differences between 2 groups were significant. The proportion of pa- tients with low fever,moderate fever,high fever and hyper fever was 8.65% （9/104 cases） ,47.12% （49/104 cases）, 44.23% （46/104 cases） and 0, respectively in tuberculous pleurisy group, while the proportion was 0.90% （ 1/111 cases） ,18.92% （21/111 cases） ,79.28% （88/111 cases） and 0.90% （ 1/111 cases） respectively in control group, and the difference between 2 groups was significant （ W = 9 064.00, P 〈 0.01 ）. The unilateral effusion ratio in tubercu- lous pleurisy group and the control group was 94. 69% （107/113 cases） and 71.68% （81/113 cases）, respectively （X2 =21.39,P 〈0.01 ）. The monocyte ratio was higher in tuberculous pleurisy group [0.89（0.76,0.93） ] than that in the controLgroup [0.60（0.30,0.78 ） ] （ W = 888.50,P 〈 0.01 ） and the level of protein in 2 groups was [51.00 （47.35,54.20） g/L ] and [ 42.10 （ 37.85,46.15 ） g/L ], respectively （ W = 842.50, P 〈 0.01 ）. The level of lactate dehydrogenase （LDH） in tuberculous pleurisy group [ 553.50 （ 358.00,749.25 ） U/L ] was lower than that in the control group[ 1 189.10 （670.95,1 820.00） U/L] （ W = 2 186.00, P 〈0. 01 ）, and the differences were significant between 2 groups. In addition to pleural effusion, the high density was the main feature of imaging examination in 2 groups. The proportion of patients with atelectasis was 77.88% （88/113 cases） and 4.42% （5/113 cases） （X2 = 125.90,P 〈 0.01 ）, while the proportion of patients with consolidation was 4.42% （ 5/113 cases） and 72.57 % （ 82/ 113 cases） ,respectively （X2 = 110.80, P 〈 0.01 ）. All the differences between 2 groups were significant. The sputum culture -positive rate of mycobacterium tuberculosis was only 1.77% （2/113 cases） and the other pathogen examina- tions were negative in tuberculous pleurisy group. Conclusions For patients with unilateral pleural effusion, when the onset only has fever （ moderate - high fever）, and respiratory symptoms are not clear or symptoms are not proportional to radiographic severity, or when high monocytes proportion （ 〉 0.70） in pleural effusion and radiographic evidence of com- pression atelectasis are observed, tuberculous pleurisy should be considered and further questioning of the predisposing factors, purified protein derivative test should be taken so as to diagnose the tuberculous pleurisy at early stage.