结核重症监护室中胞内分枝杆菌肺病与脓肿分枝杆菌肺病的临床特征比较分析

Comparison of clinical features of pulmonary infections with Mycobacterium intracellulare and Mycobacterium abscessus in tuberculosis intensive care unit

目的分析结核重症监护室（ICU）中胞内分枝杆菌肺病与脓肿分枝杆菌肺病患者的临床特征，为临床诊治提供依据。方法回顾性分析2012年1月至2017年5月杭州市红十字会结核ICU收治的非结核分枝杆菌肺病（NTM）患者74例的临床资料。其中脓肿分枝杆菌肺病患者54例，胞内分枝杆菌肺病患者16例，鸟分枝杆菌和堪萨斯分枝杆菌肺病患者各2例。对胞内分枝杆菌及脓肿分枝杆菌肺病复合群感染重症患者的临床特征、影像学表现、治疗与预后等情况进行分析。采用SPSS21．0软件对数据进行分析。采用Graph Pad PrismV5．01进行生存曲线分析。结果74例NTM肺病患者中，脓肿分枝杆菌感染率为72．87％（54／74），胞内分枝杆菌的感染率为21．62％（16／74）。胞内分枝杆菌肺病患者的年龄和入住ICU时间明显低于脓肿分枝杆菌肺病患者（t=-2．729和-6．150，P〈0．05或〈0．01），但两组性别分布、APACHEII评分比较，差异均无统计学意义（P值均〉0．05）。在基础疾病方面，胞内分枝杆菌肺病患者慢性阻塞性肺疾病（COPD）的比例明显低于脓肿分枝杆菌肺病患者（x2=3．902，P〈0．05），而支气管扩张比例明显多于脓肿分枝杆菌肺病患者（x2=23．888，P〈0．01）。在合并症方面，脓肿分枝杆菌肺病患者合并脑卒中后遗症、帕金森症等中枢神经系统疾病（x2=14．872，P〈0．01）及糖尿病（x2=3．902，P〈0．05）的比例显著高于胞内分枝杆菌肺病患者，而合并咯血的比例明显低于胞内分枝杆菌肺病患者（x2=9．717，P〈0．01）。胞内分枝杆菌肺病患者入住ICU主要原因为呼吸衰竭（93．75％）和感染性休克（6．25％），而脓肿分枝杆菌肺病患者为呼吸衰竭（90．74％）、心衰竭（11．11％）和肾衰竭（1．85％），两组患者入住ICU原因比较，差异均无统计学意义（P值均〉0．05）。胞内分枝杆菌肺病组患者在机械通气前分离出NTM的比例明显高于脓肿分枝杆菌肺病组患者（x2=30．366，P〈0．01）。在影像学方面，胞内分枝杆菌肺病组支气管扩张比例明显高于脓肿分枝杆菌肺病组（x2=23．888，P〈0．01）。两组患者28d病死率比较，差异无统计学意义（x2=3．244，P〉0．05），而胞内分枝杆菌肺病组患者120d内生存率明显高于脓肿分枝杆菌肺病组患者（x2=12．780，P〈0．01）。结论当重症患者痰抗酸染色阳性时，须考虑NTM肺病可能。对于长期机械通气的重症患者须首先考虑脓肿分枝杆菌感染。

Objective To compare the clinical features of pulmonary infections with Mycobacterium intraceUulare and Mycobacterium abscessus in the tuberculosis intensive care unit （ICU）. Methods Clinical data of 74 patients with non-tuberculous mycobacterial pulmonary infection （NTM） admitted in tuberculosis ICU of Hangzhou Red Cross Hospital from January 2012 to May 2017 were retrospectively analyzed. There were 54 patients infected with Mycobacterial abscesses, 16 patients with Mycobacterial intracellular, 2 patients with Mycobacterium avium and 2 patients with Mycobacterium kansasii. The clinical features, imaging manifestations, treatment and prognosis of patients with Mycobacterial intraceUular and Mycobacterial abscesses lung infections were compared. SPSS 21. 0 software was used for statistical analysis. Survival curve analysis was performed using GraphPad Prism V5.01. Results Among 74 patients with NTM lung disease, the infection rate of Mycobacteriura abscessus was 72.87 % （54/74）, and the infection rate of Mycobacterium iatraceUular was 21. 62% （16/74）. The age of patients with Mycobacterium intracellularis pulmonary disease was younger and the length of ICU stay was shorter than those of patients with Mycobacterium abscessus （t = - 2. 729 and - 6. 150, P 〈 0.05 or 〈 0.01 ）. There was no significant difference in the gender distribution and APACHE Ⅱ scores between the two groups （both P 〉 0.05）. The proportion of patients with chronic obstructive pulmonary disease （ COPD ） in Mycobacterium intracellularis group was significantly lower and the proportion of patients with bronchiectasis was significantly higher than those in Mycobacterial abscesses group （X2 = 3. 902, P 〈0.05 ; X2 = 23. 888, P 〈 0.01 ）. The proportion of patients complicated with stroke sequelae, Parkiason＇s disease and other central nervous system diseases （X2 = 14. 872, P 〈 0.01 ） and diabetes （X2 = 3. 902, P 〈 0.05 ） in Mycobacterial abscess group was significantly higher, and that of hemoptysis was significantly lower （X2 = 9. 717, P 〈 0.01 ） than those in Mycobacterium intracellularis group. Respiratory failure （93.75%） and septic shock （6.25%） were the main reasons of ICU admission for patients with Mycobacterium intracellularis lung disease; while respiratory failure （90. 74% ）, heart failure （11.11% ） and renal failure （1.85%） were main reasons of ICU admission for patients with Mycobacterial abscesses; there were no significant differences in the causes of ICU admission between the two groups （ all P 〉 0.05 ）. The proportion of NTM isolated from patients with Mycobacterial intracellular lung disease, prior to mechanical ventilation was significantly higher than that of patients with Mycobacterial abscess （X2 = 30.366, P 〈 0. 01 ）. In imaging, the proportion of bronchiectasis in Mycobacterium intracellularis lung disease group was significantly higher than that in Mycobacterial abscesses lung disease group （X2 = 23. 888, P 〈 0.01 ）. There was no significant difference in the 28-day mortality rate between the two groups （X2 = 3. 244, P 〉 0.05 ）, while the survival rate in patients with Mycobacterium intracelhdaris lung disease within 120 days was significantly higher than that in patients with Mycobacterial abscesses lung disease （X2 = 12. 780, P 〈 0.01 ）. Conclusion When critically ill patients are positive for acid-fast staining, the ICU physician should consider the possibility of NTM lung disease. For severe patients with long-term mechanical ventilation, Mycobacterium abscessus infection should be considered first.