肺诺卡菌病误诊为慢性阻塞性肺疾病合并肺结核的原因剖析

Causes of Misdiagnosis of Nocardia Infection as Chronic Obstructive Pulmonary Disease Combined with Tuberculosis

目的探讨肺诺卡菌病的临床特点及误诊原因,提高诊断水平及治愈率。方法回顾性分析2016年3月—2022年1月收治的肺诺卡菌病被误诊为慢性阻塞性肺疾病合并肺结核22例的临床资料。结果本组22例主因反复咳嗽、咳黄白色痰和发热就诊,其中闻及肺部呼气相哮鸣音17例,体质量减轻、食欲缺乏3例,全身皮肤斑丘疹伴皮肤脓肿1例,咯血2例。18例有基础疾病,其中糖尿病多见,有11例,支气管扩张7例。本组均误诊为慢性阻塞性肺疾病合并肺结核,误诊时间为3个月~4年。给予对症治疗后效果欠佳,后通过痰液、支气管肺泡灌洗液培养及宏基因二代测序技术检测确诊为肺诺卡菌病。采取复方磺胺甲唑片为基础的联合用药方案治疗后,18例好转出院(好转率82%),2例出院失联,预后不明,2例死亡。结论肺诺卡菌病临床表现缺乏特异性,容易误诊,应提高医务人员对该病的认识,避免延误治疗时机,提高治愈率。

Objective To investigate the clinical characteristics of pulmonary nocardiosis and the causes of misdiagnosis,so as to improve the diagnosis and cure rate.Methods Clinical data of 22 patients suffering from pulmonary nocardiosis misdiagnosed as chronic obstructive pulmonary disease(COPD)combined with tuberculosis from Match 2016 to January 2022 were analyzed retrospectively.Results In this study,22 patients presented with repeated cough,yellow-white sputum and fever,including 17 cases of expiratory wheezing in the lungs,3 cases of reduced body weight and lack of appetite,1 case of systemic skin maculopapules with skin abscess,and 2 cases of hemoptysis.Of them,18 patients had underlying diseases,including diabetes mellitus(n=11)and bronchiectasis(n=7).All patients were misdiagnosed as COPD combined with pulmonary tuberculosis,and the duration of misdiagnosis was 3 months to 4 years.After symptomatic treatment,the result was far from satisfactory,and the patient was diagnosed as pulmonary nocardiosis by sputum,bronchoalveolar lavage fluid culture and metagenomic next-generation sequencing technology.After compound sulfamethoxazole tablet-based combination regimen,18 patients were discharged with improvement(improvement rate of 82%),2 patients were discharged and lost to follow-up,with unknown prognosis,and 2 patients died.Conclusion The clinical manifestations of pulmonary nocardiosis are lack of specificity and more likely to be misdiagnosed.It is necessary to improve the medical staff’s understanding of the disease,avoid delaying the treatment and improve the cure rate.