结核性胸膜炎的临床特征及诊断技术分析

Analysis of Clinical Features and Diagnostic techniques in Tuberculous Pleurisy

目的了解结核性胸膜炎的临床特征，分析该疾病的诊断和鉴别诊断技术。方法回顾性分析首都医科大学附属北京胸科医院2015年1月1日至2016年12月31日经临床诊断的486例活动性结核性胸膜炎患者的临床和实验室资料，其中男353例，女133例，年龄14-98岁（中位年龄36岁）。结果486例患者中，结核性渗出性胸膜炎约占93．6％（455／486），结核性脓胸占6．4％（31／486）；结核性渗出性胸膜炎最多见于18-44岁青年组，占55．3％（269／486）。89．5％（435／486）的患者表现为单侧胸腔积液，64．4％（313/486）并发肺结核：结核性胸膜炎最常见的临床症状依次是唼嗽、发热和呼吸困难，分别占65．4％（318／486）、65．0％（316／486）和54．9％（267/486）。结核性渗出性胸膜炎患者中，红细胞沉降率增怏者占72．9％（310／425）；有52．7％（240／455（的患者通过X线胸部摄影检查能够发现肺部病变，CT检查发现肺部病变的比率为64．0％（291／455）。临床常用的诊断方法中阳性率最高的为胸腔积液和外周血γ-干扰素释放试验（IGRA），分别为94．2％（163／173）和89．2％（362／406）；其次为胸腔积液腺苷脱氨酶（ADA），240U／L的阳性率为72．6％（321／442）；胸腔积液和血清抗结核抗体阳性率分别为32．8％（86／262）和37．8％（138／365）；胸腔积液xpertMTB／RIF阳性率为15．4％（38/246）。结论结核性胸膜炎以青年男性、单侧渗出性淋巴细胞胸腔积液为主，且多并发同侧或双侧肺结核，胸腔积液IGRAs阳性率最高，ADA≥40U／L有一定的诊断提示意义。但仍需结合临床和实验室多种资料进行综合诊断。

Objective To summarize the clinical features of tuberculous pleurisy, in order to diagnose and differentiate diagnosis from other pleural diseases. Methods The clinical and laboratory data were analyzed retrospectively in 486 patients with active tuberculous pleurisy diagnosed with composite reference standard in Beijing Chest Hospital, Capital Medical University during Jan. 1, 2015 to Dec, 31, 2016, There were 353 Males and 133 Females with median age 36 years old （arranged from 14 to 98）. Results Of 486 patients, tuberculous pleurisy accounted for 93.6% （455/486） and tuberculous empyema accounted for 6.4% （31/486）. Exudative tuberculous pleurisy mostly occurred in youth aged from 18 to 44 year olds, accounting for 55.3% （269/486）. There were 89.5% （435/486） presented with unilateral pleural effusion and 64.4% （313/486） complicated with pulmonary tuberculosis. The most common clinical symptoms of tuberculous pleurisy were cough, fever, and dyspnea, accounting for 65.4% （318/486）, 65.0% （316/486） and 54. 9% （267/486）, respectively. Of 425 cases with exudative tuberculous pleurisy, erythrocyte sedimentation rate （ESR） increased in 310 （72.9%, 310/425） cases. Lung lesions could be detected by X-ray chest radiography in 52.7% （240/455） patients, but higher rate detected by CT with 64.0% （2.91/455）. Among the clinical diagnostic detection tests, the positive rates of IGRA detected in pleural effusion and plasma were 94.2% （163/173） and 89.2% （362/406）, followed by ADA （72.6%, 321/442 ） in pleural effusion, antibodies （37.8%, 138/365 in sera and 32.8%, 86/262 in pleural effusions）. However, the positive rate of Xpert MTB/RIF was the lowest with 15.4% （38/246）. Conclusion Tuberculous pleurisy is more common in young men with unilateral exudative pleural effusion of lymphocyte predominance and pulmonary tuberculosis complication. The positive rate of IGRAs in pleural effusion is the highest, which has certain diagnostic value, as well ADA≥40 U/L, It needs comprehensive diagnosis with a variety of data in the practice.