485例非结核分枝杆菌病的误诊分析

Misdiagnosis Analysis of 485 Cases of Domestic Nontuberculous Mycobacterial Disease

目的提高对非结核分枝杆菌(NTM)病的认识,减少误诊,提高临床诊治水平。方法对2003年10月至2021年1月在国内发表的确诊为非结核分枝杆菌病的485例患者的临床资料进行二次分析,总结其临床特点。结果NTM肺病(472例,97.3%)最常见,其余可见皮肤、关节、角膜、脑等部位NTM感染。所有患者在确诊前均被误诊,NTM肺病最易被误诊为肺结核(447例,94.7%),NTM皮肤病最易被误诊为孢子丝菌病(4例,44.44%)。主要症状为咳嗽(366例,77.5%)、咳痰(360例,76.3%)、咯血(218例,46.2%)、气促(111例,23.5%)。在NTM肺病中,影像学提示双肺(72.3%)受累多见,病灶表现以斑片影(232例,48.4%)、支气管扩张(146例,30.5%)、空洞(124例,25.9%)为主。支气管扩张主要见于右肺中叶或左肺舌叶(100例,75.3%);空洞以薄壁空洞为主(104例,83.9%),上肺最多见(71例,57.3%),其次以右肺中叶或左肺舌叶多见(30例,24.2%),均靠近胸膜;而肺不张、胸腔积液、钙化灶、淋巴结肿大少见。主要致病菌为脓肿分枝杆菌(29.4%)、鸟分枝杆菌(24.2%)、胞内分枝杆菌(18.1%)、龟分枝杆菌(13.4%)。NTM对一线、二线抗结核药高度耐药,治疗主要选择大环内酯类为核心,并联合4~5种药物组成治疗方案,治疗时间长,治愈率低。结论NTM病临床表现不典型、影像学无特异性、检测手段受限,且医生对该病认识不足,易被误诊、漏诊。NTM对抗结核药高度耐药,治疗难度大,治愈率低。

Objective To improve the understanding of nontuberculous mycobacteria(NTM)disease,reduce misdiagnosis and improve clinical diagnosis and treatment.Methods The clinical data of 485 patients diagnosed with non-tuberculous mycobacteriosis published in China from October 2003 to January 2021 were analyzed and their clinical characteristics were summarized.Results NTM lung disease(472 cases,97.3%)was the most common,and NTM infections were also seen in the skin,joints,cornea,and brain.All patients were misdiagnosed before the diagnosis.NTM lung disease was most likely to be misdiagnosed as tuberculosis(447 cases,94.7%);NTM skin disease was most likely to be misdiagnosed as sporotrichosis(4 cases,44.44%).The main symptoms were cough(366 cases,77.5%),expectoration(360 cases,76.3%),hemoptysis(218 cases,46.2%),and shortness of breath(111 cases,23.5%).In NTM lung disease,imaging revealed that both lungs(72.3%)were more commonly affected,and the lesions were characterized by patchy shadows(232 cases,48.4%),bronchiectasis(146 cases,30.5%),and cavities(124 cases,25.9%)Mainly.Bronchiectasis was mainly seen in the right middle lobe or the left lingual lobe(100 cases,75.3%);cavities were mainly thin-walled cavities(104 cases,83.9%),and the upper lung was the most common area(71 cases,57.3%),followed be the right middle lobe or the left lingual lobe(30 cases,24.2%),all close to the pleura,while atelectasis,pleural effusion,calcification,and lymphadenopathy were rare.The main pathogens were Mycobacterium abscessus(29.4%),Mycobacterium avium(24.2%),Mycobacterium intracellular(18.1%),and Mycobacterium chelone(13.4%).NTM was highly resistant to first-line and second-line anti-tuberculosis drugs.The treatment mainly relied on macrolides as the core dose,combined with 4~5 drugs to form a treatment plan.The treatment time was long but the cure rate was low.Conclusion NTM disease has atypical clinical manifestations,non-specific imaging,limited detection methods,and lack of understanding of the disease by doctors.As a result of which,it is easy to be misdiagnosed and missed.NTM is highly resistant to anti-tuberculosis drugs,which makes it difficult to be treated and has a low cure rate.