罕见原发性肝结核1例和国内22例的临床及病理分析

Clinical and pathological analysis of 1 case of rare primary liver tuberculosis and 22 cases in China

目的总结原发性肝结核的临床特征,探讨其早期诊断方法及合理的治疗方案。方法回顾性分析复旦大学华山医院感染科收治的1例罕见原发性肝结核病理确诊病例的临床表现、治疗和转归,并以"原发性肝结核"为关键词检索万方和中国期刊全文数据库(1984年1月至2020年1月)。结果1例原发性肝结核患者主要表现为午后发热,行胸部CT提示未见明显异常,肝脏MRI及全身PET-CT均提示肝肿瘤,行B超引导下肝穿活检提示肝结核,予规范抗结核治疗后疗效显著。共检索到国内发表的有关原发性肝结核的论文15篇,符合病理确诊标准的22例。其中实验室检查:AFP正常21例,PPD阳性10例,血T-SPOT阳性1例。影像学检查:腹部B超22例,上腹部CT 15例,增强肝脏MRI 4例及全身PET-CT 2例全部误诊;病理结果提示为干酪样坏死、凝固性坏死、上皮样肉芽组织结节、朗格汉氏细胞及淋巴细胞浸润,抗酸染色阳性仅2例;采用规范抗结核治疗,疗效显著。结论原发性肝结核诊断困难,误诊率高,其临床表现及影像学检查无特异性,PPD试验或血T-SPOT强阳性及AFP阴性对诊断及鉴别诊断有重要意义,对疑诊病例积极进行早期B超引导下肝穿活检并作抗酸染色,可早期确诊,且规范抗结核治疗后疗效显著。

Objective To summarize the clinical characteristics of primary liver tuberculosis,and explore its early diagnosis methods and reasonable treatment plans.Methods To report the clinical manifestations,treatment and outcome of a rare pathologically confirmed case of primary liver tuberculosis admitted to the Department of Infectious Diseases of Huashan Hospital,Fudan University,and searched Wanfang database and Chinese Journal full-text database with"primary tuberculosis"as the key word(January 1984 to January 2020).Results The main manifestations of primary liver tuberculosis in this case were afternoon fever,chest CT showed no obvious abnormality,liver MRI and systemic PET-CT showed liver tumor,liver biopsy under B guidance showed liver tuberculosis,and the effect of standardized anti-tuberculosis treatment was significant.A total of 15 papers on primary liver tuberculosis were found in China,and 22 cases met the criteria of pathological diagnosis.Laboratory examination:21 cases of normal AFP;10 cases of PPD positive,1 case of blood T-SPOT positive.Imaging examination:22 cases of abdominal B-ultrasound,15 cases of upper abdominal CT,4 cases of enhanced liver MRI,and 2 cases of whole body PET-CT All misdiagnosed;path ological results suggest that cheeselike necrosis,coagul ative necrosis,epithelial gran ul ar tissue nodules,Lang ham cells and lymph ocytes infiltration,only positive 2 acid staining;this group has standardized anti-tuberculosis treatment,with remarkable efficacy.Conclusion Primary liver tuberculosis diagnosis is difficult,high misdiagnosis rate,and its clinical performance and imaging examination are not specific.PPD test or blood T-SPOT positive and AFP negative are of great significance to diagnosis and differential diagnosis,and actively performed liver biopsy under B ultrasound guidance and anti-acid staining,which can be confirmed in the early stage,standardized anti-tuberculosis treatment was highly effective.