我国部分地区病原学检测阴性肺结核诊断质量现状分析

Analysis of diagnostic quality of pulmonary tuberculosis with negative etiology in some areas of China

目的分析我国病原学检测阴性肺结核的诊断现状,为完善和改进病原学检测阴性肺结核的诊断策略提供科学依据。方法依据各省自愿的原则,收集山东、青海、甘肃和辽宁4个省的8个县(区)结核病定点医疗机构2017年6月1日至2018年5月31日登记报告并完成治疗的1761例病原学检测阴性肺结核患者,现场复核患者的病案资料、胸部影像学检查(包括X线摄影、数字X线摄影、CT)和实验室检查结果。通过分析病原学检测阴性肺结核患者接受病原学检查、肺结核实验室检查及影像学检查情况,了解其诊断现状。结果1761例患者中,有2.3%(40/1761)的患者未开展痰涂片检查,4.9%(87/1761)的患者仅开展了1次或2次痰涂片检查。开展痰培养和分子生物学检测的患者分别占27.1%(478/1761)和24.5%(431/1761)。进行结核菌素皮肤试验(40.2%,708/1761)、γ干扰素释放试验(34.8%,612/1761)和结核抗体检测(44.5%,784/1761)的患者均未超过50%。53.5%(942/1761)的患者仅依靠胸部影像学检查进行诊断,未开展任何实验室检查及诊断性治疗;16.8%(296/1761)的患者胸部影像学检查存储图片质量不合格,存在的问题主要有影像模糊、摄影时曝光电压不合适、存储图片保存不当造成损坏等。经复核诊断,9.7%(170/1761)的患者为误诊或过诊。在过诊和误诊的患者中,88.3%(150/170)为陈旧性肺结核,其余11.7%(20/170)为肺部或胸部炎症、肿瘤和其他病变。结论县(区)级结核病定点医疗机构对初诊患者查痰的规范性有待提高,需加强对患者病原学检查的力度,提高肺结核与炎症和肿瘤的鉴别能力;规范对病原学检测阴性肺结核的诊断流程。

Objective To analyze the status of diagnosis of pulmonary tuberculosis with negative etiology testing results in China,and to provide scientific basis for improving the diagnosis strategy of etiology negative tuberculosis. Methods According to the voluntary principle of each province,1761 TB patients with negative etiology testing results were collected from 8 designated TB medical institutions in Shandong,Qinghai,Gansu and Liaoning Provinces registered from June 1,2017 to May 31,2018.The medical records,chest films including X-ray photography,digital X-ray photography,CT and laboratory examination results of the patients were reviewed to analyze the diagnosis status in receiving etiological examination,laboratory auxiliary examination and imaging examination. Results Among the 1761 patients,2.3%(40/1761)of the patients did not carry out sputum smear,4.9%(87/1761)of the patients only carried out sputum smear one or two times.Patients received sputum culture and molecular biology test accounted for 27.1%(478/1761)and 24.5%(431/1761),respectively.Only40.2%(708/1761)of patients underwent tuberculin skin test,34.8%(612/1761)of interferon gamma release test and 44.5%(784/1761)of tuberculosis antibody test.53.5%(942/1761)of the cases only relied on chest X-ray for diagnosis without any auxiliary laboratory examinations.16.8%(296/1761)of the chest radiographs were unqualified,and the main problems were blurred image,inappropriate voltage,damage caused by improper preservation,etc.After reviewed by experts,9.7%(170/1761)of them were misdiagnosed or over diagnosed.Among them,88.3%(150/170)were inactive tuberculosis,the remaining 11.7%(20/170)were inflammation,tumor and other diseases. Conclusion The standardization of sputum examination for newly diagnosed patients in county tuberculosis designated medical institutions needs to be improved,and the efforts of etiological examination of patients and the ability of distinguishing tuberculosis from inflammation and tumor need to be improved;and the diagnostic process of tuberculosis with negative etiology detection should be standardized.