涂阳肺结核患者家庭密切接触者筛查研究

目的了解涂阳肺结核患者家庭密切接触者中活动性肺结核的检出率及有关的影响因素。方法采用多阶段分层整群抽样的方法,对4省(市)8个县(区)2008年登记的涂阳肺结核患者及其家庭密切接触者进行按照规定程序进行调查分析。结果涂阳肺结核患者家庭密切接触者中活动性肺结核患者检出率为2.7%,涂阳肺结核患者检出率为0.6%。家庭密切接触者的年龄、文化程度、与涂阳肺结核患者的关系以及是否与患者居住同一房间等因素为主要影响因素。结论涂阳肺结核家庭密切接触者调查是早期发现活动性肺结核患者的有效手段,对涂阳肺结核密切接触者应及时进行结核病筛查和和随访观察。     

A study of case findings in pulmonary tuberculosis patients

The incidence of tuberculosis patients increased again recently and many outbreaks of pulmonary tuberculosis (PTB) patients were reported. The purpose of this study is to investigate the present situation of the delay in case finding of PTB patients. 1) Of 236 PTB patients who were admitted to our hospital for treatment in 1997, 118 patients, who were detected by their symptomatic visits, were enrolled in to this study. 50 percentile patient's delay was 21.0 days, and 50 percentile doctor's delay was 7.2 days. 50 percentile total delay was 42.0 days, which was longer than about 28 days obtained by summing up the 50 percentile patient's delay and doctor's delay. The number of cases detected within 28 days was only 39 cases (33.1%). Doctor's delay was mainly attributable to the performing the examination. Regarding the relationship between the period of total delay and sputum smear positive rate, the positive rate was less than 50% when total delay was less than 4 weeks, and came to more than 60% when the delay exceeded 4 weeks. 2) Of 236 PTB patients admitted to our hospital for treatment in 1997, 49 patients had been treated at medical institutions for other diseases. The majority of the cases were diagnosed as PTB in the routine examination, but early case findings was not made, with 9.5 weeks on an average and 50 percentile total delay was 5.5 weeks. The duration of doctor's delay in undergoing examination directly related to PTB diagnosis was accountable for doctor's delay. 3) The case finding of far-advanced cavitary PTB (bI3) patients was studied. Eighty-four patients were detected by symptomatic visits, 10 patients were detected during medical treatments of other disease, and 1 patients was detected by accident. The duration of patient's delay was 5.5 months on an average, while doctor's delay was 0.3 month on an average. The bI3 patients included many social and economical weak people. The body status on admission of bI3 patients were very severe. Twenty percentile of bI3 patients died of PTB, and 14 cases of 19 dead cases died within 1 month from admission. 4) The duration of case finding of tracheobronchial tuberculosis patients was studied. 50 percentile patient's delay was 14 days, while 50 percentile doctor's delay was 145 days. The delay in examination was considered accountable for doctor's delay, with 12 cases (57%) which were treated as bronchial asthma and 6 cases (29%) in which the sputum examination for tuberculosis bacilli was not performed after the detection of chest abnormal shadows on chest X-rays. 5) The present situation of case findings in Japan was studied. Patient's delay did not improve in recent years, while doctor's delay was improve in 2000, after Declaration of State of Emergency concerning tuberculosis. 6) As the countermeasures against patient's delay, it appears necessary to continue enlightenment on PTB, and selective detection by health examination for high risk groups is necessary. As the countermeasures against doctor's delay, it appears important to recommend to all doctors to pay attention to the patients with cough and sputum and undergo sputum examination.     

吉林省某市寄宿制中学一起结核病暴发疫情调查分析

目的通过对某寄宿制中学一起结核病暴发的流行病学调查,分析学校结核病防治工作中存在的问题,为全省学校结核病防控工作提供指导和依据。方法采用问卷调查法,对所有密切接触者胸透检查,有异常阴影者进行X线摄片和痰涂片检查。结果共查出肺结核病患者9例,其中涂阳患者1例、涂阴患者8例,发病率0.28%;9例患者情绪稳定、病情明显好转,其中车某已于2013年6月7日出院,继续院外督导化疗。结论专科医院传染病报告卡质量不佳,师生结核病防治知识缺乏,学校因病缺课登记管理制度不健全,是导致结核病暴发的主要原因。     

补习学校肺结核暴发的特征及原因调查

目的 2013年4-7月某高考补习学校多名学生陆续被诊断为活动性肺结核。方法采用肺结核可疑症状调查、胸部影像学、结核菌素(PPD)试验、痰涂片检查等对全体师生和被诊断学生的家庭密切接触者进行筛查;收集病例的社会人口学资料进行横断面分析。结果首例患者发病后约2个月才明确诊断,随后该班级45人中有10名学生先后被诊断为活动性肺结核,罹患率22.2%。肺结核病例除与首发病例有密切接触之外,与性别、年龄、户籍等无明显关联。结论这是一起典型的学校班级内感染的结核病暴发,具有发病水平较高、季节性和聚集性等特征。本次暴发原因主要是学校结核病防控意识欠缺、综合医疗机构迟报、漏报、转诊不及时等因素共同造成的。     

Diagnostic value of repeated sputum examinations in pulmonary tuberculosis: how many sputum specimens are adequate?

The aim of this study was to assess the value of examining multiple sputum specimens in the diagnosis of pulmonary tuberculosis (PTB). We analyzed sputum smear and culture results of patients diagnosed with culture-proven PTB during 2002. In 1027 patients, the diagnosis was established by detection of Mycobacterium tuberculosis bacilli in sputum samples. The number of sputum specimens submitted to laboratory was one in 634 cases, two in 167 cases, three in 186 cases and more than three in 48 cases. 760 (74%) cases had positive smear examination result. The first sputum smear examination was positive in 82.3% of smear positive cases. Either the first or the second sputum was diagnostic in 94.9% of these cases. Smear examination of third sputum revealed 4.2% additional diagnostic yield. In 863 (84%) cases, culture examination of the first sputum was positive. The second and the third sputum culture examinations revealed additional diagnostic yield of 11% and 4.5%, respectively. Percent 95 of culture-proven cases were diagnosed with the first two sputum cultures. In conclusion the majority of PTB cases can be diagnosed with the examination of two sputum specimens. Three or more sputum specimens submitted obtain a small additional diagnostic yield.     

A study of patient's and doctor's delay in patients with pulmonary tuberculosis discovered by visiting doctors with symptoms in particular on doctor's delay

Epidemiological trend of tuberculosis in Japan has reversed recently. The incidence of pulmonary tuberculosis (PTB) patients has increased again in Japan, and many outbreaks of PTB including nosocomial outbreaks in health-care facilities have been reported. The purpose of this study is to investigate patient's delay (interval between onset of the disease and first visit to a doctor) and doctor's delay (interval between first visit to a doctor and diagnosis as TB) in patients with PTB discovered by visiting doctors with symptoms, and especially, to investigate causes of doctor's delay in details. Of 236 PTB patients who were admitted to our hospital for treatment in 1997, 118 patients (85 males, 33 females) who were detected by their symptomatic visits were enrolled in to this study. 97 were initial treatment cases and the others were re-treatment cases. Among 34 initial treatment cases who were first seen at a general hospital and diagnosed as PTB by a close medical checkup after admission to our hospital, the 50 percentile of patient's delay was 17.0 days, and the 80 percentile was 36.4 days. The 50 percentile doctor's delay was 19.6 days, and the 80 percentile was 64.2 days. The average hospital stay was 16.2 days, the 50 percentile hospital stay was 7.8 days, and 80 percentile hospital stay was 23.5 days. On the sputum test for acid fast bacilli (AFB) performed on admission to our hospital, 26(76%) out of 34 cases were positive for tubercle bacilli, with 18 cases were positive for smear and 8 cases positive for culture. Therefore, risk of nosocomial infection was suspected. Doctor's delay had been attributed mainly to insufficient medical checkup. Among 25 initial treatment cases in whom doctor's delay as more than 4 weeks, 11 cases (44%) showed delay in chest X-ray examination and 8 cases (32%) ordered no sputum examination in spite of recognition of abnormal shadows on chest X-ray. On the sputum test for AFB on admission to our hospital, 22 (88%) out of 25 cases were positive for tubercle bacilli. Therefore, it is assumed that the delay in the adequate medical checkup was accountable for the doctor's delay. Shortening of the doctor's delay could be possible if hospitals perform the sputum examination for AFB and chest X-ray examinations properly for patients with respiratory symptoms.     

A study on family infection of tuberculosis

The guideline for contacts examination and chemoprophylaxis for tuberculosis was revised in 1993. Secondary cases and chemoprophylaxis cases found by the contacts examination of family members were analyzed in Sapporo City. The average age of index cases and of secondary cases has become higher. Many secondary cases were found among spouse of the index case and children of male index case. Chemoprophylaxis cases were found mostly among children of male or female index cases and grandchildren of male index cases. The results of family contacts examination carried out during the period from 1994 to 1999 were compared with those from 1987 to 1992. The incidence of family infection of tuberculosis and the number of newly infected persons and of secondary cases have decreased in the latter period. The time interval from the registration of the index case to the detection of secondary cases has become shorter, and the ratio of sputum smear positive cases among secondary cases has also decreased. Male to female ratio of the index cases was 2:1, that of secondary cases was 3:5, and that of children indicated chemoprophylaxis was 4:5. All secondary cases found by the contacts examination carried out within 6 months after the previous examination were sputum smear negative for tubercle bacilli, and there were a few smear positive cases among secondary cases who were found by the examination with longer interval with the previous examination. Such cases with longer interval from the last periodic examination was found often among younger cases below 40 years of age. Most smear negative tuberculosis cases were found by the family contacts examination, while most smear positive cases were found by symptomatic visit to doctors.     

一起校园肺结核疫情的流行病学调查分析

目的 对一起校园肺结核疫情进行调查和分析,发现学校结核病疫情处置工作中的难点和不足,为完善学校结核病控制策略提供思路和建议。方法 采用描述性流行病学方法,对2020年10月至2021年6月一起学校结核病疫情进行流行病学调查和分析。同时采用结核菌素皮肤试验(tuberculin skin test, TST)和胸部X线摄片(简称“胸片”)开展肺结核筛查和密切接触者调查。结果 在确诊1例痰涂片阳性肺结核病例之后,共开展4次密切接触者筛查并陆续确诊4例活动性结核病病例。其中,针对指示病例的54名密切接触者(学生47名,教职工7名)开展首次调查时,调查对象的胸片均未见异常,学生的TST强阳性率为4.44%(2/45),教职员工为1/7。本次疫情TST强阳性且排除活动性结核病的学生无人接受预防性治疗。与首次筛查相比,后续筛查中与指示病例同宿舍的学生TST阳转率为6/8、同小组学习的学生TST阳转率为4/5、经常性共同就餐的学生TST阳转率为3/3。此外,后续筛查中发现的4例肺结核新发患者均为随访过程中的TST阳转者。结论 本次学校肺结核疫情的流行病学调查分析提示,密切接触者调查和处置工作需要进一步加强,对新近感染的追踪应成为随访密切接触者的重要内容,预防性治疗对象的界定应更加明确并应提高预防干预的覆盖率。     

A clinical study in the collagen disease patients developed pulmonary tuberculosis during corticosteroid administration

The study subjects consisted of 14 pulmonary tuberculosis (PTB) patients with collagen disease. They are under corticosteroid treatment and the mean age is 56.4 years. The length of time from the development of collagen disease to the development of PTB averaged 4.1 years. The breakdown of collagen disease are SLE (6 patients), MCTD (3 patients), PN (2 patients), and PSS, PM, Sjogren syndrome (1 case, each). Thirteen cases were bacilli positive by the sputum examination on admission to our hospital. Chest X-ray findings on admission revealed cavitation in 3 cases and non-cavitation in 11 cases, of which 5 cases had miliary tuberculosis. Corticosteroid preparation had been administered to all of the 14 cases for more than one year. The mean dose of corticosteroid preparation administered when PTB developed was 13.9 mg (prednisolone) and it was more than 20 mg in 8 cases. The median duration from the start of the respiratory symptoms to diagnosis was 39.2 days. The delay in the discovery exceeding 1 month were seen in 9 cases. In the cases of collagen disease, when the disease course extends over a long period of time, and even when the dose of corticosteroid preparations are decreased, there is a need to be note on the risk of developing PTB. There are many non-cavitary cases with sputum smear positive. The fact suggested that an appropriate diagnosis is need so that the discovery of PTB should not be delayed.     

Bronchiolo-alveolar cell carcinoma arising after active pulmonary tuberculosis' report of two cases]

We report on two patients diagnosed as having active pulmonary tuberculosis who later developed lung cancer. In both cases, the lung cancer was detected during the treatment of pulmonary tuberculosis. Both patients were initially considered to be experiencing exacerbation of pulmonary tuberculosis. Case 1 was seen in a 74-year-old man. His chest roentgenogram revealed microscopic cavitary lesions with infiltration into both lung fields. His sputum tested positive for acid-fast bacilli. Although he was treated with isoniazid (INH), rifampicin (RFP), ethambutol (EB) and pyrazinamide (PZA), his general condition deteriorated, and the infiltrative shadows in the lung fields had expanded on subsequent chest radiography. Transbronchial lung biopsy (TBLB) yielded findings compatible with a diagnosis of bronchiolo-alveolar cell carcinoma. Case 2 occurred in a 52-year-old man. His chest radiograph revealed cavitary lesions with infiltration into both lung fields. His sputum also tested positive for acidfast bacilli. Despite medication with INH, RFP, EB and PZA, the infiltrative shadow in his chest radiograph increased in size. Bronchiolo-alveolar cell carcinoma was confirmed after examination of the sputum cytology. Case 1 was diagnosed as lung cancer 10 months after being admission to the hospital, and Case 2, seven months after hospitalization. Recent discussion concerning the simultaneous occurrence of pulmonary tuberculosis and bronchogenic carcinoma suggests a high frequency of coexistence of the two diseases. However, the coexistence of active tuberculosis with bronchiolo-alveolar cell carcinoma, as in our cases, is rare.     

一起特殊群体肺结核暴发的调查分析

目的了解在押人员结核病暴发疫情的流行病学特征。方法采用结核菌素试验、胸透、痰菌检查以及流行病学调查。结果查出肺结核7例,罹患率达11.1%,其中肺结核涂阳3例、涂阴4例。结论引起本次疫情的原因复杂,可能与新羁押人员未进行体检、首发病例未得到及时的治疗以及在押人员集居等多种因素有关。     

江苏无锡市农村地区提高传染性肺结核病人发现水平的探讨

目的　探讨农村地区如何提高传染性肺结核病人发现率。方法 在乡镇卫生院设立结防门诊和查痰点,采取发放经费、转诊病人、加强痰检质控、督导检查等干预措施,提高涂阳病人发现率。结果 5年来共发放23.70万元结防经费。涂阳、新发涂阳登记率逐年上升,乡镇卫生院检出涂阳病人数大幅度升高,登记涂阳病人卫生院平均报告率为62.7%。结论 乡镇卫生院是农村地区结核病预防和控制工作中的一支重要力量,在提高结核病例发现水平中可发挥重要作用。     

Prospective study of a new serological test (ASSURE TB Rapid Test) for the diagnosis of pulmonary tuberculosis.

OBJECTIVE: To prospectively compare a rapid tuberculosis serological test, ASSURE TB Rapid Test, with traditional smear and culture methods for the diagnosis of pulmonary tuberculosis (PTB). DESIGN: All consecutive in-patients aged > or = 18 years suspected of having active PTB and admitted between June 2001 and March 2003 were tested with three sputum samples for smear and culture of Mycobacterium tuberculosis and serology (done within 3 days). RESULTS: Of 238 patients initially enrolled (male: female 2.5:1, mean age 56.6 years), the final analysis included 216 patients. For the final diagnosis of PTB, the sensitivity and specificity of the serological test were respectively 60.2% (95%CI 50.5-69.1) and 82.3% (95%CI 74.2-88.2) compared to 53.4% (95%CI 43.8-62.7) and 98.2% (95%CI 93.8-99.5) for the smear test. A combination of smear and serology provided an increased sensitivity of 74.8% (95%CI 65.6-82.2), but a lower specificity of 80.5% (95%CI 72.3-86.8). CONCLUSION: The new serological test showed a moderate increase in sensitivity but a decrease in specificity compared to smear examination. The combination (smear + serology) test further increased the sensitivity while maintaining a moderate specificity.     

Four cases of simultaneous discovery of familial tuberculous infection

Index case is a 17-year-old boy who was admitted to our hospital with pleurisy and a minimal pulmonary lesion, and tubercle bacilli were recovered from pleural fluid. A diagnosis of primary tuberculosis was made based on the onset by pleurisy and the existence of hilar and mediastinal lymph node swelling. On the same day, a 76-year-old man, grandfather of the index case was admitted for precise examination of suspected extensive pneumonia. Tubercle bacilli were also isolated from the pus of infected bulla obtained by puncture. Neither of these two cases, however, seemed to be the source of the familial tuberculous infection because of such sudden onset of the disease as pleurisy and pneumonia. Two months later, a 46-year-old man, father of the index case was examined at our hospital. He was considered to be the source of the familial infection because he was diagnosed as tuberculosis with positive smear and a thick wall cavity (3.2 cm in diameter) on the left apex, and abnormal shadow was detected on his chest X-ray already two years ago. The fourth case was a mother of the index case, and wife of the third case, whose chest radiography revealed an infiltrative shadow on the right apex by a family contacts examination. Though tubercle bacilli were not isolated from her sputum, pulmonary lesions considered to be tuberculosis due to their typical location and nature, a positive PPD skin test, and the response to antituberculous drugs.     

Clinical analysis of pulmonary tuberculosis found by mass screening medical examination

Five hundred twenty-one patients with pulmonary tuberculosis were diagnosed in our three affiliated hospitals during past 10 years. Among them, 43 cases (22 men and 21 women; mean age 54.8 years) who were detected by active case-finding were clinically evaluated. Most of them were detected in an annual mass screening examination, but seven cases were found by contacts examination which was performed on subjects who were contacted with newly diagnosed patients with pulmonary tuberculosis. Fifteen of them were socially jobless on admission. Eighteen cases (41.9%) had underlying diseases, and gastrointestinal diseases and diabetes mellitus were most frequently observed. The final diagnosis was confirmed through bronchoscopic specimens in 18 cases in which Mycobacterium tuberculosis could not be detected from the sputum. Regarding radiological findings according to the criteria of the Japanese Society of Tuberculosis, most cases had unilateral distribution, and were classified as type III (active, non-cavitary) for characteristics and 1 (minimal) for the extent of lesions. Treatment using combination therapy with four drugs including pyrazinamide was performed for over half of these cases and subsequently the clinical efficacy was good except in one case who died due to worsening of the underlying disease. Anti-tuberculous drugs were generally administered to cases suspected of having pulmonary tuberculosis on chest X-ray. However, early diagnosis using bronchoscopy and early treatment seems to be useful, when Mycobacterium tuberculosis is not detected in the sputum.     

A case of pulmonary tuberculosis with acute renal failure caused by readministration of rifampicin

We report a case of pulmonary tuberculosis with acute renal failure caused by readministration of Rifampicin (RFP). A 73 year-old man was admitted to a certain hospital complaining with dyspnea on exertion. As his sputum smear was positive for acid-fast bacilli, he was transferred to our hospital for the isolation and treatment. He was diagnosed as lung tuberculosis and was administrated RFP, Isoniazid (INH) and Ethambutol (EB). On the 20th day after the initiation of treatment, the administration of drugs were suspended, because of liver dysfunction. After recovery of liver dysfunction, we have readministered antituberculous drugs, starting with EB, then INH, and finally RFP. On the 22nd day after the readministration of RFP, acute renal failure was observed. All medications were suspended and we started treatment with hydration and furosemide. His renal function recovered after 7 weeks. Histopathological examination of the kidney revealed interstitial infiltration and tubular nephritis. According to the histopathological examination and the clinical course, we concluded acute renal failure was induced by the readministration of RFP. This case suggests that we have to pay attention to renal side effect of RFP in the course of readministration.     

痰与支气管肺泡灌洗液结核分枝杆菌FQ-PCR检测对涂阴肺结核诊断价值的比较

目的 探讨呼吸道痰标本和支气管肺泡灌洗液(BALF)Mtb-DNA检测对涂阴肺结核的诊断价值。方法 选择福州肺科医院2009年7月至2009年12月胸部影像学疑为肺结核但至少3份痰涂片镜检Mtb阴性,或胸部影像学无法排除肺结核需进一步检查的患者共51例,所有入选患者初诊根据临床症状、体征、胸部影像学结果分为疑似结核组（24例）和待排结核组（27例）。均行抗结核抗体、红细胞沉降率检测及PPD试验,应用实时荧光定量聚合酶链反应（FQ-PCR）定性及定量检测两组患者痰和BALF中的Mtb-DNA。结果 疑似结核组和待排结核组各有22例和2例确诊肺结核,确诊的24例中痰FQ-PCR敏感度为45.8%（11/24）,特异度为96.3%（26/27）,Youden指数42.1%;BALF FQ-PCR的敏感度为75.0%（18/24）,特异度96.3%（26/27）,Youden指数71.3%。结论 FQ-PCR检测BALF Mtb较痰更为敏感,对影像学疑诊但痰涂片阴性的结核患者有很高的实用价值,尤其适用于无痰的患者。     

Predictors of delayed sputum smear conversion among pulmonary tuberculosis patients in Kota Kinabalu,Malaysia: A retrospective cohort study

Smear-positive pulmonary tuberculosis (SPPTB) is the major contributor to the spread of tuberculosis (TB) infection, and it creates high morbidity and mortality worldwide. The objective of this study was to determine the predictors of delayed sputum smear conversion at the end of the intensive phase of TB treatment in Kota Kinabalu, Malaysia.This retrospective study was conducted utilising data of SPPTB patients treated in 5 TB treatment centres located in Kota Kinabalu, Malaysia from 2013 to 2018. Pulmonary TB (PTB) patients included in the study were those who had at least completed the intensive phase of anti-TB treatment with sputum smear results at the end of the 2nd month of treatment. The factors associated with delayed sputum smear conversion were analyzed using multiple logistic regression analysis. Predictors of sputum smear conversion at the end of intensive phase were evaluated.A total of 2641 patients from the 2013 to 2018 periods were included in this study. One hundred eighty nine (7.2%) patients were identified as having delayed sputum smear conversion at the end of the intensive phase treatment. Factors of moderate (advanced odd ratio [aOR]: 1.7) and advanced (aOR: 2.7) chest X-ray findings at diagnosis, age range of >60 (aOR: 2.1), year of enrolment 2016 (aOR: 2.8), 2017 (aOR: 3.9), and 2018 (aOR: 2.8), smokers (aOR: 1.5), no directly observed treatment short-course (DOTS) supervisor (aOR: 6.9), non-Malaysian citizens (aOR: 1.5), and suburban home locations (aOR: 1.6) were associated with delayed sputum smear conversion at the end of the intensive phase of the treatment.To improve sputum smear conversion success rate, the early detection of PTB cases has to be fine-tuned so as to reduce late or severe case presentation during diagnosis. Efforts must also be in place to encourage PTB patients to quit smoking. The percentage of patients assigned with DOTS supervisors should be increased while at the same time ensuring that vulnerable groups such as those residing in suburban localities, the elderly and migrant TB patients are provided with proper follow-up treatment and management.     

综合医院住院肺结核诊断现状分析

目的了解分析综合医院住院活动性肺结核患者的诊断现状。方法对2002年1月1日—2006年5月31日北京大学人民医院控感科登记的以“肺结核”为主要诊断出院的患者住院病历进行调查并进行回顾性分析,不包括陈旧性肺结核及结核性胸腔积液。结果共统计分析患者74例,其中呼吸内科报告最多,共53例(71.6%),其次为胸外科,共13例(17.6%)。有典型结核中毒症状者仅31例(41.9%),红细胞沉降率明显增快患者者占54.1%,PPD试验阳性仅54.1%。查痰率64.9%,涂阳率54.2%。患者入院至确诊时间平均为13.15 d,≤14 d者48例(64.9%),>14d者26例(35.1%)。确诊方法主要为痰抗酸杆菌阳性(共26例,占35.1%)。经各种活检确诊共27例(36.7%),其中纤维支气管镜下活检诊断8例(10.9%),经开胸肺活检确诊17例(23.0%),经肺穿刺活检确诊1例(1.4%),淋巴结活检确诊1例(1.4%),除纤维支气管镜下活检阳性率88.9%外,其余方式活检阳性率均为100%。临床诊断20例(27.0%)。结论综合医院呼吸内科处于结核病防治的第一线,目前北京大学人民医院对大部分肺结核患者在住院2周之内确诊。主要诊断方法仍为痰找抗酸杆菌阳性,但相当一部分患者通过各种方式的活检确诊。今后应进一步提高痰菌检查率和阳性率。对于诊断不清的病例应及时进行纤维支气管镜检查(包括镜下活检),必要时行肺穿刺甚至开胸肺活检。     

How many sputum specimens are necessary to diagnose pulmonary tuberculosis?

The definitive diagnosis of pulmonary tuberculosis (PTB) relies on identifying or culturing Mycobacterium tuberculosis from respiratory specimens. National guidelines have recommended obtaining 3 sputum specimens from patients with suspected tuberculosis, but there has been little data on the number of specimens actually needed to support a diagnosis. We retrospectively reviewed all patients diagnosed with PTB at a public inner-city hospital and assessed the sensitivity of the acid-fast bacilli (AFB) smear and the number of smears needed to establish the diagnosis. Between January 1, 1997 and October 1, 2000, 425 patients were diagnosed with culture-proven PTB. Acid-fast bacilli (AFB) smears and cultures were performed on 951 respiratory specimens from 425 patients. The overall sensitivity of a positive AFB smear increased from 67% with 1 sputum collected to 71% and 72%, respectively, with the second and third specimens. The sensitivity of smears from 239 HIV-negative patients was 75%, 79%, and 80% with 1, 2, and 3 smears, respectively, collected compared with 57%, 61%, and 62%, respectively, for 142 HIV-positive patients. In summary, 2 respiratory specimens proved adequate in establishing a diagnosis of tuberculosis, and the third specimen added little additional diagnostic value.