27例血行播散型结核病临床分析

Retrospective analysis of 27 cases of disseminated tuberculosis

目的 通过对 2 7例血行播散型结核病临床资料的分析 ,提高对该病的认识。方法 回顾性分析 1961～ 2 0 0 0年我院收治的尸检证实的 2 7例血行播散型结核病的临床资料。结果 本组患者临床表现多不典型 ,呼吸道症状隐匿 ,以发热为主要表现 ,部分患者可有肝、脾肿大 ,皮疹 ,血三系减低。胸部影像学以浸润性改变为主 ,空洞少见 ,粟粒性结节影出现较晚。结核菌素试验多阴性。病原学检测阳性率低。尸检证实 ,急性血行播散型结核病 2 2例 (包括无反应性结核 3例 ) ,慢性血行播散型结核病 5例。均合并活动性肺结核 ,肺外病变主要累及肝、脾、肾、淋巴结等部位。生前误诊 12例 ,误诊率为 44 4%。 12例中有 11例 (92 % )因伴发或疑为结缔组织病、血液系统疾病或肿瘤而误诊。2 7例患者中 17例 (63 % )长期应用激素或反复化疗导致结核病播散。结论 临床医师应加强对结核病的警惕性 ,特别是有结核病史、免疫缺陷 (包括长期使用激素或化疗 )病史或合并营养不良的患者。出现长期发热和 (或 )有多系统损害、原发病经正规治疗无缓解时 ,应警惕耐多药结核的可能。应严格掌握糖皮质激素使用的适应证 ,未确诊前不能盲目应用糖皮质激素 。

ObjectiveTo analyze the clinical characteristics and treatment of hematogenous disseminated tuberculosis. MethodsTwenty seven cases of hematogenous disseminated tuberculosis diagnosed by autopsy from 1961 to 2000 were retrospectively analyzed. ResultsAmong these patients the disease was acute in 22 cases (including 3 non-reactive) and chronic in 5.Twenty cases (74%) were misdiagnosed before death, most of which were due to concomitant with or misdiagnosed as connective tissue disease, hematological disease or tumor. 63% of the cases had long-term use of corticosteriods or repeated chemotherapy. Most cases showed atypical clinical manifestations and chest X-ray lesions . The positive rate of tuberculin skin test and sputum for smear were low. Autopsy showed that all cases had active lung tuberculosis and the major extra-pulmonary organs involved were liver, spleen and lymph nodes. Conclusion Unaware of the risk for tuberculosis among immune compromised patients was the main reason for misdiagnosis and corticosteriod abuse was common. Physician should be alert to the occurrence of hematogenous disseminated tuberculosis, especially in immune compromised patients with long-term fever and systemic injury. Direct smear and cultural examination as well as newer diagnostic approaches with sputum and tissue may be useful for a rapid and correct diagnosis.