病例:这可不是肺结核,弄错了可就麻烦了!

2018-06-04 MedSci MedSci原创

肺结核临床表现多样,故与其临床表现接近的肺部疾病有很多,但因肺结核比较常见,故很多较为罕见且类似肺结核的疾病容易被诊断为肺结核,误诊了的话治疗起来可就南辕北辙了!


肺结核临床表现多样,故与其临床表现接近的肺部疾病有很多,但因肺结核比较常见,故很多较为罕见且类似肺结核的疾病容易被诊断为肺结核,误诊了的话治疗起来可就南辕北辙了!

去年10月12日,科室收进来一个“咳喘2 月余”的患者。该患者既往10 年间咳喘反复发作,曾诊断为结核和支气管哮喘,并抗结核治疗。2个月前无明显诱因出现咳嗽,咳黄脓痰,1周后出现反复气喘、胸闷,间断发热,热峰39.2 ℃。从上述看肺部感染的可能性很大。

当时患者在当地医院就诊,查辅助检查如下:

血常规示:WBC 16.56 ×10^9 /L↑ ,NE% 43.2 %↓,EO 5.66 ×10^9/L↑ ;

肿瘤指标:癌胚抗原(CEA) 22.23 ng/ml↑ ,CA125 64.94U/ml↑ ,CY199 108.2 U/ml↑。

胸片示左中下肺高密度片状影;肺功能示重度阻塞性通气障碍;

纤支镜示右肺上叶尖支口向心性狭窄,左肺下叶外后支口弥漫性肿胀。



当地医院诊断为肺部感染,可能为肺结核复发,予以抗结核治疗,但是症状无明显好转。

后为求进一步治疗转来我院,入院前3天出现左下胸痛,间断咯血。

入院查体神清、精神萎,两肺呼吸音粗,两下肺闻及哮鸣音和散在湿啰音,余无特殊。

入院后考虑结核可能性较大,但是为何外院抗结核治疗无效呢?难度是肺部肿瘤?还是存在其他肺部疾病?根据这个线索,进行了相关的检查,首先要确定是否存在结核。故行如下检查:

检查结核菌素试验(PPD)5U 皮试阴性,ES R 55 mm/h ,总IgE 1500 IU/ml ,血TB-Ab(+),抗结核LAM(6KD 、38KD)抗体、肺炎支原体抗体和血清血管紧张素转化酶(SACE)、抗中性粒细胞胞浆抗体(ANCA)、多项风湿抗体均阴性,CEA 57.6ng/ml ,半乳甘露聚糖(GM)试验无异常,多次痰培养、痰涂片找抗酸杆菌均无异常。

胸部C T示右上肺点片状模糊影伴点状钙化,局部类圆形透亮影,右中下肺片状高密度影,左下肺不规则病灶。多次痰病理片见上皮细胞、炎细胞、嗜酸性粒细胞,未见肿瘤细胞。



初步的检查未能明确结核的诊断,也未能给出其他线索,只能用尝试性予以抗炎及止咳化痰、平喘等对症治疗,3天后咳喘症状有所好转。

但治疗1 周后复查胸部CT 病灶未有吸收。为明确肺部病灶性质,只能行经皮肺穿刺术,病理见炎细胞,类上皮细胞,多核巨细胞。



根据穿刺结果结合患者病史,考虑为哮喘型肺嗜酸性粒细胞增多症,病因待查。予甲强龙40 mg ,伊曲康唑200 mg 治疗4 天后咳喘症状明显好转。

复查血常规示WBC 12.3 ×10^9/ L ,N E :79 %,EO :0 ;肝肾功能无异常;总IgE 800 IU/ml 。胸部CT 示左下肺病灶较前吸收。患者病情好转故予以出院。



出院后门诊随诊,偶有咳嗽咳痰,无气喘,激素量逐渐减至10 mg维持,并加入吸入激素。复查血常规及肿瘤标志物均降至正常。肺部CT示斑块影较前明显吸收。



出院6月后复查胸部CT 病灶较前明显吸收,见两肺中央性支气管扩张。

复查肺功能示第1 秒用力呼气容积(FEV1 %)预计值为50 %,FEV1/FVC 为63 %,中度阻塞性通气功能障碍。结合患者病史及检查结果,确诊为变应性支气管肺曲霉病(ABPA)。

讨论

变应性支气管肺曲菌病(ABPA)是机体对烟曲菌产生超敏反应的一种过敏性肺疾病,常发生于支气管哮喘和肺囊性纤维化的患者。本病的主要特点是中央型支气管扩张。患者会咳出褐色黏液痰栓,而罕见咯血。据报道,31%~69%的患者中会出现棕黑色黏液痰栓。听诊时15%的患者能听到粗湿啰音。

ABPA患者的治疗方案包括:糖皮质激素抗炎和抗真菌药降低真菌负担从而减少气道内真菌定植。伊曲康唑与糖皮质激素联用能够减少激素用量,降低25%以上的血清总IgE,但并没有显着地提高肺功能。Omalizumab是重组IgE人单克隆抗体,能够有效阻止IgE和效应细胞上高低亲和力的受体结合,已成功治疗激素依

赖性ABPA的儿童患者。

本例确诊依据:

(1) 患者中年女性,因“咳喘2月余”入院。既往诊断为结核和哮喘,但据患者描述抗痨治疗后症状未完全好转,仍反复发作。

(2) 入院结核抗体、PPD试验均阴性,多次痰涂片和培养找结核杆菌均阴性。

(3) 患者CEA增高,但痰和肺穿病理均未见肿瘤细胞。

(4)患者反复发作哮喘,肺部听诊可闻及哮鸣音和湿啰音,入院前后多次血常规嗜酸性粒细胞增多,总IgE显着增高,胸部CT示两肺多发斑块影,痰病理见嗜酸性粒细胞,规范治疗后患者肺部病灶吸收,出现中央型支扩。

本例的特点之一,患者痰和肺穿刺病理均不支持肿瘤,但患者CEA较正常值高10倍,经激素和抗真菌治疗后CEA降至正常。Yanagitani等报道1例哮喘患者兼有嗜酸性粒细胞增多性细支气管炎和鼻窦炎,同时血清CEA增高,未找到肿瘤依据,口服激素治疗后血清CEA下降。

本例的特点之二,患者确诊为ABPA,GM试验却为阴性。GM是曲菌细胞壁的多糖成分,在曲菌在组织中生长的早期释放入循环。故现广泛应用于曲菌感染的早期诊断。越来越多的研究显示不同研究机构之间,GM试验的灵敏度和特异度差异过大,报道出的灵敏度有高达100%,也有低至17%的,且假阳性、假阴性率较高,故需谨慎分析试验结果。

本例患者GM试验只做过一次,不能排除试验假阴性,且被误诊多年,已进入曲菌的慢性感染期,影像学提示支气管内大量的嵌塞和渗出物,亦有可能曲菌被分泌过多的炎性渗出包绕,GM抗原未能进入循环。

本例特点之三,影像学中央型支扩显现在激素和抗真菌治疗有效后。虽然中央型支扩在ABPA患者中较常见,有学者发现95%的患者会出现中央型支扩,但仍有5%的患者未出现,而代之以黏液栓塞、指套征、树芽征等。本例患者的胸部CT自发病以来到激素治疗前均显示两肺多发片状影,而ABPA典型的中央型支扩则出现在激素治疗3个月后。我们考虑为误诊时间长,病灶处小气道内曲菌定植产生大量渗出长期积累阻塞支气管,待激素和抗真菌药起效后渗出逐渐减少,逐渐显露出扩张的支气管。

本病例的不足之处在于,入院前虽做了纤支镜检查,未查灌洗液涂片和培养,未镜下取组织病理检查。虽做过多次痰培养,均未培养真菌。患者确诊后采用激素联合伊曲康唑治疗,取得显着效果,肿瘤指标CEA亦下降至正常。在激素小剂量维持后改吸入激素,符合文献报道推荐吸入激素减少口服激素的副作用。随访至今,肺部病灶明显吸收,运动耐受性也明显提高,嗜酸性粒细胞维持在正常水平。

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    学习学习学习

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    2018-06-04 医生无国界

    厉害

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    2018-06-04 131****1460

    学习了受益匪浅

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