内科胸腔镜活检在结核性胸膜炎诊断中的临床价值

Clinical value of pleural biopsy using medical thoracoscopy in diagnosis of tuberculous pleurisy

目的探讨内科胸腔镜活检在结核性胸膜炎诊断中的临床价值。方法回顾性分析2014年4月至2017年4月首都医科大学附属北京胸科医院收治的55例因胸腔积液疑似结核性胸膜炎患者的临床资料，并对胸腔镜活检组织行常规石蜡包埋、切片、HE染色镜下观察组织学形态后，考虑为结核性胸膜炎的36例患者，行抗酸染色查找抗酸杆菌，及荧光定量聚合酶链式反应（fluorescent quantitative polymerase chain reaction，FQ-PCR）技术检测结核分枝杆菌DNA对考虑为恶性胸膜肿瘤的19例患者采用免疫组织化学方法进行诊断及鉴别诊断。结果55例患者中，最终病理明确诊断为结核性胸膜炎36例（65．5％）。胸腔镜下表现为胸膜增厚23例（63．9％）；胸膜表面上分布大小不等灰白结节7例（19．4％）；粟粒样结节12例（33．3％）；纤维渗出、粘连及充血26例（72．2％）。病理组织学表现为朗汉斯（Langhans）巨细胞构成的肉芽肿27例（75．O％），肉芽肿中心可见坏死15例（41．7％）；仅见炎性渗出病变6例（16．7％）；仅见坏死3例（8．3％）。36例结核性胸膜炎患者中，32例检测了胸腔积液中腺苷脱氨酶（ADA）的含量，其中ADA≥40U／L者18例（56．2％）。抗酸染色查到抗酸杆菌11例（30．6％），FQ-PCR技术检测结核分枝杆菌DNA阳性25例（69．4％）。其余19例通过活检一病理学检查分别诊断为肺腺癌转移9例（16．4％），间皮瘤8例（14．5％），鳞状细胞癌转移1例（1．8％），肾集合管癌转移1例（I．8％）。结论内科胸腔镜检查及活检一病理学诊断在结核性胸膜炎诊断及鉴别诊断中具有重要价值。

Objective To investigate the clinical value of pleural biopsy using medical thoracoscopy in diagno- sis of tuberculous pleurisy. Methods The clinical data were analyzed retrospectively in 55 patients with suspected tuberculous pleural effusions and histological morphology was examined for forraalin-fixed, paraffin-embedded pleu- ral tissues stained by hematoxylin and eosin （HE）. Acid-fast bacilli and fluorescent quantitative polymerase chain reaction （FQ-PCR） were performed in 36 patients with suspected tuberculous pleurisy and immunohistochemistry was performed to diagnose and differentiate diagnosis in 19 patients with suspected malignant pleurisy. Results Of 55 cases with pleural effusions, 36 （65.5 -） patients were diagnosed with tuberculous pleurisy by pleural biopsy. The appearances of tuberculous pleurisy showed pleural thickening in 23 （63.9 %） cases, different size of pleural nodules in 7 （19.4-） cases, diffuse military nodules in 12 （33.3-） cases, fibrinous exudate, hyperemic or pleural adhesion in 26 （72.2%） cases under thoracoscopy. The pathological features of tuberculous pleurisy showed that granulomas containing langhans giant cell in 27 （75.0%） cases, caseous necrosis in 15 （41.7%） cases, only fibroinflammatory exudation in 6 （16.7%） cases, and only caseous necrosis in 3 （8. 3%） cases. Of 32 cases with tuberculous pleurisy detected with ADA, 18 cases （56. 2%） showed ADA level over than 40 U/L. Acid-fast bacilli was positive in 11 （30.6%） cases. Mycobacterium tuberculosis DNA was detected in 25 （69.40%） pleural tissue samples by FQ-PCR.