三例肺结核误诊为肺泡蛋白沉积症的诊治分析

Three cases of pulmonary tuberculosis misdiagnosed as pulmonary alveolar proteinosis

目的报告3例误诊为肺泡蛋白沉积症的肺结核病例,结合文献复习,以提高临床医师对该两种疾病的鉴别诊断水平。方法整理3例影像学表现与肺泡蛋白沉积症有相似性但最终通过病理确诊的肺结核患者的临床资料,结合相关文献进行复习。结果3例患者均为男性,慢性病程,均无肺结核典型临床表现,CT影像学均表现为弥漫性磨玻璃影、小叶间隔增厚、呈“铺路石样”表现,初诊均考虑“肺泡蛋白沉积症”,后经支气管镜肺泡灌洗液找到抗酸杆菌或肺活检组织确诊。复习8例影像学类似的国内外文献报道,1例为肺结核误诊为“肺泡蛋白沉积症”,3例为肺泡蛋白沉积症合并肺结核,4例为肺结核继发肺泡蛋白沉积症,发现患者大多有肺结核的全身或呼吸道症状,CT影像以双肺弥漫性磨玻璃影伴小叶间隔增厚为主,3例患者CT还可见聚集性小结节影,大部分患者经抗结核治疗后好转,仅1例患者死亡。结论不典型肺结核影像学表现多种多样,表现为类似“肺泡蛋白沉积症”时,容易误诊,临床应提高对该种影像学特点的肺结核的认识。

Objective Three cases of pulmonary tuberculosis misdiagnosed as pulmonary alveolar proteinosis were reported and analyzed in combination with literatures,so as to improve the ability of differential diagnosis of these two diseases.Methods The clinical data of 3 cases of pulmonary tuberculosis patients which were diagnosed by pathology whose imaging manifestations were similar to those of pulmonary alveolar proteinosis were collected and reviewed in combination with relevant literature.Results All the 3 patients were male,with a chronic course,no typical clinical manifestations of pulmonary tuberculosis,CT imaging showed diffuse glass grinding shadow,thickened pulmonary lobular septa,showed"Crazy-paving pattern".ALL the three patients were considered as"pulmonary alveolar proteinosis"initially,and finally confirmed by lung biopsy or acid-resistant bacilli found by bronchoalveolar lavage.Reviewing 8 literature reports with similar imaging findings,1 case was misdiagnosed as pulmonary alveolar proteinosis,3 cases were pulmonary alveolar proteinosis combined with pulmonary tuberculosis,and 4 cases were secondary pulmonary alveolar proteinosis.It was found that most patients had systemic or respiratory symptoms of pulmonary tuberculosis.CT images mainly showed diffuse ground glass shadows in bilateral lungs with thickening of lobular septa,and 3 patients also showed clustered small nodulars.Most patients improved after anti-tuberculosis treatment,with only one patient dying.Conclusions The imaging manifestations of atypical pulmonary tuberculosis are various,which are easy to be misdiagnosed when they are similar to"pulmonary alveolar proteinosis".Clinicians should raise their awareness of tuberculosis with this imaging characteristic.