胸腔镜辅助小切口在结核性毁损肺叶切除术中的应用

目的探讨胸腔镜辅助小切口在结核性毁损肺叶切除术中的经验及疗效。方法回顾性分析了2007年1月至2012年12月采用胸腔镜辅助小切口施行结核性毁损肺叶切除术治疗的67例患者的临床资料。其中男38例,女29例;年龄26~68岁,平均（43．0±5．3）岁;病史2～17年,平均（6．0±2．4）年。重点对患者术中情况、术后并发症处理,以及治疗转归进行总结。结果全组患者无围术期死亡,67例患者均经一次手术治愈。1例患者术后7h出现偏瘫症状,经过检查考虑为脑血管痉挛,重症加强护理病房（ICU）严密观察12h后症状逐渐消失;9例出现不同程度的心律失常,均经对症处理治愈;7例发生迁延性肺漏气,经过继续胸腔闭式引流后治愈;6例切口愈合不良,4例经过换药护理治愈,2例换药过程中发现有脓液及干酪样物质,经过敞开彻底清理后逐渐愈合。2例患者偶有血丝痰,经过胸部CT扫描及纤维支气管镜检查,均未发现异常,仍在随访中;1例行右肺上叶切除术患者,术后13个月劳累后再次出现咳嗽、咯痰症状,痰抗酸杆菌培养检测到结核分枝杆菌,胸部CT扫描显示系中叶术前稳定病灶复燃,经过调整化疗方案治疗6个月后痰菌阴转,胸部CT扫描显示中叶病变硬化、趋于稳定好转状态,目前仍在密切随访中。结论胸腔镜辅助小切口行结核性毁损肺叶切除术,在确保疗效的前提下,较好地平衡了微创、效率和安全性,在结核性毁损肺的外科治疗中是可选择的一种较为合理的手术方式。     

肾移植后结核病的诊断和治疗

目的总结肾移植后结核病的诊断和治疗。方法对7例肾移植后结核病患者的诊断和治疗进行回顾性分析。结果男5例，女2例，年龄21-53岁，肾移植后距结核病的发病时间为6个月-7年。结核中毒症状6例。X线胸片改变：双肺上野云絮状阴影、密度不均4例，双肺粟粒状改变1例。腹部CT移植肾脓肿样改变1例。细菌学检查：痰抗酸杆菌阳性5例，胸腔积液离心沉淀直涂阳性1例，其中1例痰抗酸杆菌培养阳性，菌型为人型。PPD皮试阳性5例，抗结核抗体阳性4例。治疗包括继续抗排斥反应治疗及抗结核化疗。方案为3HRZ／6HR，对1例肾移植后失功能合并Ⅱ型肺结核及结脑患者，加大激素，加用链霉素，每周2次血液透析，6例患者治愈，1例切除移植肾后切口1年不愈合。结论只要肾功能正常，HRZ抗结核有效，即使发生移植后失功能，或切除移植肾并血液透析，可加用链霉素，疗效良好，为再次肾移植创造机会。     

肺结核合并结核性肛周脓肿38例临床分析

目的探讨肺结核合并结核性肛周脓肿患者的临床特点,以便早发现,提高疗效。方法对我院收治38例肺结核合并结核性肛周脓肿患者与40例单纯肺结核患者的临床资料进行对比分析总结。结果肺结核合并结核性肛周脓肿患者多发于中年男性,多以肛周脓肿,疼痛或大便带血为主诉就诊,呼吸系统症状表现不明显,结核中毒症状明显,实验室检查阳性率较高。结论建议对肛周感染性疾病患者应常规行胸部X线片检查,并行脓液及分泌物培养或涂片检查,提高对本病的诊断,防止漏诊或误诊。     

结核病治疗过程中血清腺苷酸脱氨酶动态监测

有文献报告结核病患者血清中腺苷酸脱氨酶(ＳＡＤＡ)活性增高,经3个月治疗后测定,其浓度下降,提示ＳＡＤＡ测定可能有助于疗效判定,但有关治疗全程中ＳＡＤＡ动态变化的研究尚未见报道。作者在6个月抗结核治疗过程中动态监测了ＳＡＤＡ浓度的变化。方法　25(男17、女8)例结核病患者,平均年龄319(17～64)岁,既往身体健康,ＨＩＶ血清学阴性,其中肺结核8例,肺结核伴结核性胸膜炎1例,均从痰中找到抗酸杆菌。另外结核性胸膜炎6例,2例胸水中找到抗酸杆菌,其余4例诊断依据临床、胸水生化、细胞学、病理学及抗结核治疗有效。所有患者均无肺外结核。…     

抗结核药物致大疱性表皮松解型药疹一例

患者,男性,54岁。2011年12月4日因“咳嗽、咯痰2月余”在当地就诊,行胸部CT检查见右肺上叶病变,内可见空洞,痰中查到抗酸杆菌2+（1～9条抗酸杆菌/10视野）,诊断为“肺结核”,遂应用2HRZE/4HR方案抗结核治疗。2012年1月20日开始出现全身皮肤起红斑、丘疹,伴瘙痒,至当地胸科医院住院治疗,考虑为药疹,予以停用抗结核药物并给予葡萄糖酸钙、糖皮质激素等药物（具体药物名称及剂量不详）抗过敏治疗,效果不佳。2012年2月8日患者无明显诱因出现发热,最高体温达39℃,全身皮肤仍潮红、肿胀,并出现松弛性水疱、大疱,部分表皮剥脱,遂至山东大学齐鲁医院皮肤科就诊,考虑诊断为大疱性表皮松解型药疹、肺结核,建议至我院治疗。2012年2月9日门诊以“大疱性表皮松解型药疹、肺结核”收住入院。     

骨髓结核的诊断和治疗

目的探讨骨髓结核的诊断和治疗。方法对１９９０～１９９７年２４１０例行骨髓活组织检查（活检）病例中诊断为骨髓结核的１１例的临床及病理资料作回顾性分析。结果高热、乏力、消瘦、贫血１１例，腹胀、腹痛４例，腹水３例，肝脾肿大５例。１１例均无骨关节的局部症状与体征。痰涂片抗酸杆菌均阴性，肝功能受损９例，检查的６例血沉均升高，为３０～１６８ｍｍ／１ｈ。胸片示血行播散型肺结核４例，７例胸片未见结核病变。病理检查１１例发现结核性肉芽肿，６例发现干酪样坏死，３例肉芽肿组织抗酸染色查到抗酸杆菌。１０例除有骨髓结核外，尚伴有一种或多种其他部位的结核病变。８例经联合抗结核化疗好转出院，３例死亡。结论骨髓结核是血行播散型结核在骨髓的病变，临床表现缺乏特异性。对长期高热待诊的病例，应考虑血行播散型结核的可能，除了寻找常见的肺部病变外，必要时可考虑行骨髓活检。骨髓结核一经诊断，应立即行联合抗结核化疗     

利福喷汀致发热1例

患者，男，39岁，胸痛8d，咳嗽2d，来本院就诊。经X线胸片等相关检查，初步诊断为左侧结核性胸膜炎。给予力克菲蒺、吡嗪酰胺、乙胺丁醇、利福喷汀等抗结核药物治疗。患者在院外121服治疗6d后，不见好转，又增添了胸闷、发热等症状，来我院住院治疗。经彩超、CT、血常规等进一步检查，均支持原诊断，继续服用原抗结核药4联方案加激素治疗，辅以抽胸液。     

超声引导下抽吸冲洗加药物注入术治疗胸壁结核性脓肿的价值

目的 探讨实时超声引导下抽吸冲洗加药物注入术在胸壁结核性脓肿治疗中的应用价值。 方法 回顾性分析2011年12月至2016年12月浙江省中西医结合医院40例经GeneXpert MTB/RIF检测诊断为胸壁结核性脓肿初治患者的资料,所有患者在采取标准H-R-Z-E口服抗结核药治疗基础上应用随机数字表法分为2组:对照组20例,口服抗结核药治疗基础上超声引导下对胸壁结核性脓肿行脓液抽吸、生理盐水冲洗,直至冲洗液清亮;观察组20例,口服抗结核药治疗的基础上采取超声引导下对胸壁结核性脓肿行脓液抽吸、生理盐水冲洗,并按抽出脓液容积的1/3~1/2量注入抗结核药与糖皮质激素(异烟肼注射液,2ml/支,100mg/支;地塞米松注射液,1ml/支,2mg/支),每周2次。比较两组患者病变的治疗总有效率。结果 2组患者治疗期以12个月为限,观察组总有效率为95.0%(19/20),高于对照组的45.0%(9/20),差异有统计学意义(χ ²=9.643,P=0.002)。 结论 在标准H-R-Z-E口服抗结核药物治疗的基础上,行实时超声引导下抗结核药物注入术治疗胸壁结核性脓肿,是一种临床效果可靠的微创介入治疗方法。     

利福平致严重眩晕及平衡失调1例报告

患者女,35岁。因咯血3h于2009年12月8日急诊入院。入院后查痰抗酸杆菌（＋＋）,结合CT检查,诊断：继发型肺结核并咯血。给予HRZE方案抗结核治疗,未再咯血。用药2周后出现眩晕,视物旋转,不敢睁眼,平衡失调,与转头及体位无明显关系。无耳鸣、恶心、呕吐,无肢体麻木。     

耐多药结核性脑膜炎4例临床疗效分析并文献复习

摘要：目的 探讨耐多药结核性脑膜炎的治疗方法、方案的组合、疗程并进行疗效判断。方法 回顾广州市胸科医院近年收治的4例脑脊液培养有耐多药抗酸杆菌生长的结核性脑膜炎患者状况,进行临床疗效分析并文献复习。 结果 经个体化的抗结核治疗方案,联合鞘内注射异烟肼等措施,其中2例患者治愈停药。另2例患者因出现严重并发症或药物不良反应、救治无效而死亡。 结论 耐多药结核性脑膜炎病情重、进展快、病死率高。目前,临床尚无统一的治疗方案。     

Tuberculosis of the lacrimal gland

A case of tuberculous dacryoadenitis with abscess formation resolving completely with anti-tuberculous chemotherapy is presented. The growth of acid-fast bacilli in culture from the pus is noteworthy.     

A case of pulmonary tuberculosis complicated with subcutaneous phaeohyphomycosis

A 78-year-old male was admitted to our hospital because of fever, sputum and cough. Chest X-ray showed infiltrative shadows in the right lung field. Smears of his sputum were positive for acid-fast bacilli. We found multiple subcutaneous abscesses on the right distal forearm. Microscopic examination of skin biopsy specimens revealed granulation tissues with the proliferation of epitheloid cells with the scattering infiltrations of neurophils, giant cells and histiocytic cells. The examination of the PAS stained specimen revealed fungal elements and a black fungus, Exophiala jeanselmei, was isolated by the cultures of pus from the abscess. He was diagnosed as pulmonary tuberculosis complicated with subcutaneous phaeohyphomycosis caused by Exophiala jeanselmei and was successfully treated with anti-tuberculosis drugs and anti-fungal agent, 5-fluorocytosine.     

A case of pulmonary tuberculosis complicated with tuberculosis of bilateral cervical lymph nodes and exacerbated pericostal abscess

A 23-year-old man was admitted to our hospital because of cough and sputum in April 2001. A chest roentgenogram revealed infiltrative shadow with cavity formation in the bilateral lung fields. He was treated with sensitive antituberculous drugs. After starting the antituberculous therapy with INH, RFP, EB and PZA, bilateral cervical lymphadenopathy developed. Three months later, pericostal abscess appeared in the left anterior chest wall. Microscopic examination of the specimen obtained by needle aspiration biopsy disclosed positive for acid-fast bacilli. Smears of the pus showed acidfast bacilli identified as Mycobacterium tuberculosis by DNA-DNA PCR method. He developed tuberculous bilateral cervical lymphadenopathy and pericostal abscess during the course of antituberculosis chemotherapy. Drug sensitivity test revealed that tubercle bacilli in this case were sensitive. One year after the administration of chemotherapy, cervical lymphadenopathy and pericostal abscess were improved. Both masses were discontinuous with pulmonary tuberculosis and the possibility of lymphogenous spread of organism was speculated as its etiology. We assumed that both masses were due to paradoxical response to the antituberculosis chemotherapy.     

Isolated gastric tuberculosis of the cardia

BACKGROUND: Isolated gastric tuberculosis is extremely rare, especially in the subcardiac region, where the low pH, high motility and absence of lymphoid tissue result in an unfavourable environment for the development of tuberculous lesions. METHODS AND RESULTS: Here we present a case of isolated gastric tuberculosis in the gastric cardia with no evidence of pulmonary involvement. Our patient was a young man with vague gastrointestinal symptoms and no previous history of tuberculosis. His condition was first detected on upper endoscopy as a raised subcardiac ulcer similar in appearance to a submucosal tumour. An endoscopic forceps biopsy showed the presence of caseating granulomata and acid-fast bacilli. The lesion resolved completely with 12 months of oral anti-tuberculosis therapy. CONCLUSIONS: This case illustrates the need for a high index of suspicion in order to diagnose this rare condition, as it can present in patients with no particular risk factors or symptoms. Once diagnosed, a complete cure can often be achieved with a course of oral anti-tuberculosis medication, with surgery being reserved for severely symptomatic or refractory lesions.     

Tuberculous brain abscess–Case eport

In spite of recent advances in understanding of disease, tuberculosis still remains a major health problem, particularly in developing countries. Central nervous system tuberculosis may present as commonly encountered tuberculous meningitis or tuberculous mass lesions and rare tuberculous brain abscess (TBA). We report a case of tuberculous brain abscess in a patient of chronic liver disease with pulmonary hypertension and HCV infection. A 48 years old male presented with headache and abnormal behavior. There was no history of fever, vomiting, loss of consciousness, seizures, trauma and loss of weight and appetite. On examination patient was conscious but confused. No sensory-motor deficit was revealed on neurological examination. Chest x ray showed no abnormality. Mantoux test was positive. Magnetic resonance imaging of brain showed large, well defined marginally enhancing focal mass lesion in left frontal lobe. Evacuation of brain abscess done and frank creamy pus was aspirated and was sent for gram staining, Ziehl Neelsen staining, fungal smear and culture for both pyogenic and Mycobacterium tuberculosis. Gram staining revealed no microorganisms. No growth of pyogenic organisms obtained. No fungal hypha was seen. Ziehl Neelsen staining was positive for acid fast bacilli and growth of Mycobacterium tuberculosis was obtained. Patient was put on anti tubercular treatment. Patient responded well and discharged in satisfactory condition.     

Case of miliary tuberculosis with esophageal perforation and a tracheal inflammatory polyp secondary to mediastinal lymphadenitis causing massive hematemesis and hemosputum

A 62-year-old man with a history of left nephrectomy due to tuberculosis was referred to our hospital, because chest radiography showed diffuse miliary shadows in the bilateral lung fields, and acid-fast bacilli were detected from his hemosputum after steroid therapy for fever of unknown origin. Chest computed tomography showed mediastinal lymph node enlargement with partial calcification of these lymph nodes together with the presence of air. He was diagnosed with miliary tuberculosis and tuberculous mediastinal lymphadenitis and anti-tuberculosis drug therapy was started. Massive hematemesis occurred 11 days after the start of the treatment. Although gastroendoscopy was performed, the bleeding point could not be identified. The patient's symptoms improved after conservative therapy. Repeat gastroendoscopy showed a submucosal nodule with laceration of the esophageal mucosa, 30 days after admission for the examination of melena and progression of anemia. The episodes occurred because of esophageal perforation secondary to tuberculous mediastinal lymphadenitis. Bronchoscopic examination for hemosputum showed an inflammatory polypoid lesion in the left tracheal wall. These symptoms improved with anti-tuberculosis drug therapy. In our case, mediastinal lymphadenitis progressed to miliary tuberculosis because of endogenous reactivation. We report a rare case of esophageal perforation with a tracheal inflammatory polyp secondary to tuberculous mediastinal lymphadenitis. In cases of tuberculous mediastinal lymphadenitis, if hematemesis or hemosputum is observed, an endoscopic examination should be performed.     

Tuberculous mastitis: a disease not to be forgotten.

OBJECTIVE: To present our experience with tuberculous mastitis to increase the awareness of surgeons, pathologists and radiologists about this rare disease. PATIENTS AND METHODS: Records of nine patients with tuberculous mastitis were retrospectively reviewed. RESULTS: Tuberculous mastitis was seen in 0.6% of our patients with surgically treated mammary disease. There were eight females (mean age 32.9 years) and one male. All female patients were parous, two were lactating and one was pregnant. A unilateral breast mass mimicking breast cancer and breast abscess were the presenting feature in seven and two patients, respectively. Two patients had previous pulmonary tuberculosis. Radiological findings were not specific. Fine needle aspiration was performed for seven patients, and excisional biopsy for all patients. The final diagnosis was based on demonstration of acid-fast bacilli in biopsy specimens in two patients, and histopathology aided by polymerase chain reaction in the remaining seven patients. Mastectomy was performed for one patient due to severe breast destruction. All patients had satisfactory results on antituberculosis treatment. CONCLUSION: Tuberculous mastitis is a rare entity in patients with mammary disease. A high index of suspicion is the cornerstone for diagnosis. Conservative surgery and anti-tuberculosis drugs seem to be adequate treatment.     

Case report of tuberculous retropharyngeal abscess

We report a case of tuberculous retropharyngeal abscess. The case reported was an 89 year old female. She visited our hospital with a complaint of swelling in the neck, a feeling of choking and a feeling of dysphagia. With a test puncture to the neck tumor, acid-fast stained bacilli were detected from punctured pus and the patient was hospitalized immediately due to a suspicion of tuberculous retropharyngeal abscess. As present illnesses, mucosal retraction and protrusion were found in the area from the right pharyngeal back to the oral cavity. Palpation revealed soft tumors of a ping-pong ball size without tenderness nor febrile sensation in the right submandibular region and left supraclavicular fossa in the neck. In the cervical contrast enhanced CT images, an abscess was found in the hypopharyngeal posterior gap and was shown as LDA (low density area) surrounded by strongly contrasting walls. The tumor was divided horizontally at the second cervical vertebra and shown strongly at the left cervical region as it goes downward, and in the region from the 6th cervical vertebra to the second thoracic vertebra, vertebral body destruction and numerous small abscesses in the vertebral anterior gap were found. Chest images revealed infiltration (r III 2) in the right lung, but the sputum smear was negative (-) for tubercle bacilli. As the abscess punctured fluid was TB-PCR (+), she was diagnosed as tuberculous retropharyngeal abscess, and a treatment was started with HRS (combination of isoniazid, rifampicin and streptomycin). Due to elevated feeling of suffocation and feeling of dysphagia during hospitalization, CT-guided cervical abscess puncture (using a 21G puncture needle) was performed twice to drain 100 ml and 80 ml pus. Subsequently, since the symptoms have improved and retention of abscesses was not found, the patient was discharged from the hospital. After the treatment for 9 months, no recurrence was reported.     

Lupus vulgaris in a pediatric patient: a clinicohistopathological diagnosis

Lupus vulgaris is the most common form of cutaneous tuberculosis which usually occurs in patients previously sensitized to Mycobacterium tuberculosis. We present a case of a 10-year-old boy who was diagnosed as lupus vulgaris clinically and histopathologically. He had well demarcated, irregularly bordered, pink, infiltrated plaques on his left cheek showing apple-jelly appearance on diascopy. The histopathological examination showed tuberculoid granulomas with Langhans type giant cells. The Mantoux reactivity was in normal limits, and no acid-fast bacilli was found in the lesion, either by direct stained smears or by culture. The lesions showed marked improvement on anti-tuberculosis treatment. We want to emphasize that histopathological examination has diagnostic value in lupus vulgaris in correlation with clinical appearance, when direct analysis or culture is negative.