肺结核与肺癌并存25例的诊断及外科治疗

目的探讨肺结核与肺癌并存的临床特点、诊断及手术治疗方法。方法对25例肺结核并存肺癌患者的临床和实验室资料进行综合分析。结果患者多为老年，多有肺结核病史，有咳嗽、咯血、胸痛等表现。肺癌漏诊率高，手术治疗效果好。结论肺结核并存肺癌时，易发生漏诊，有条件时应手术治疗。     

Surgical treatment of nontuberculous mycobacterial lung disease

While the prevalence of pulmonary tuberculosis has been decreasing, the prevalence of nontuberculous mycobacterial lung disease has been increasing. Unlike tuberculosis, nontuberculous mycobacterial disease is not communicable. However, their indolent nature may result in extensive parenchymal destruction, causing respiratory failure and vulnerability to airway infection. Nontuberculous mycobacterial lung disease, therefore, has been becoming a significant health problem. According to the 2007 American Thoracic Society/Infectious Diseases Society of America statement on nontuberculous mycobacterial diseases, the primary treatment is a multidrug treatment regimen. However, its efficacy is less than satisfactory for Mycobacterium avium complex lung disease, which is the most common type of nontuberculous mycobacterial lung diseases, and for Mycobacterium abscessus lung disease, which is notoriously resistant to chemotherapeutic drugs. The statement, therefore, has proposed a multidisciplinary treatment approach for these types of nontuberculous mycobacterial lung diseases: a combination of multidrug treatment regimen and adjuvant resectional surgery. This review covers the rationale, indication, procedure, and outcome of surgical treatment of nontuberculous mycobacterial lung disease. The rationale of surgery is to prevent disease progressing by removing the areas of lung most affected, harboring the largest amounts of mycobacteria. The indications for surgery include a poor response to drug therapy, the development of macrolide-resistant disease, or the presence of a significant disease-related complication such as hemoptysis. The surgical procedures of choice are various types of pulmonary resections, including wedge resection, segmentectomy, lobectomy, or pneumonectomy. The reported series have achieved favorable treatment outcomes in surgically treated patients with acceptable morbidity and mortality rates.     

Lung cancer accompanied by active pulmonary tuberculosis

We report 2 patients with lung cancer accompanied by active pulmonary tuberculosis. Case1 was a 82-year-old woman with stage I A bronchioloalveolar carcinoma and tuberculosis in right upper lobe. Right upper lobectomy was performed after the histological diagnosis of lung cancer by intraoperative frozen section. Case2 was a 69-year-old man with papillary adenocarcinoma in right lower lobe and tuberculosis in bilateral upper lobe. Partial resection in right lower lobe was performed for diagnosis of lung cancer. Smear-positive tuberculosis was diagnosed by sputum examination after the operation. Post-operative anti-tuberculosis chemotherapy was added in both patients.     

T细胞斑点试验在肺结核诊断和疗效评价中的意义

目的探讨基于γ-干扰素释放的T细胞斑点试验（T—SPOT．TB）对诊断肺结核及评价抗结核疗效的意义。方法采用T—SPOT．TB检测55例活动性肺结核患者、14例肺部病变非肺结核患者和12名健康体检者外周血特异性T细胞释放IFNγ的斑点形成细胞数（SFC）,并对20例痰菌及T—SPOT．TB均阳性的活动性肺结核患者在治疗前、治疗第2个月末和第6个月末分别行T—SPOT．TB检测。多组间的比较采用多个独立样本Kruskal—WallisH检验,组间两两比较采用Mann—WhitneyU检验,治疗前后SFC数值差异比较采用Wilcoxon符号秩检验。结果肺结核组T—SPOT．TB阳性率（85．5％,47／55）显著高于肺部疾病组（2／14）和健康对照组（1／12）（X^2=40．926,P〈0．05）。肺结核组T—SPOT．TB的早期分泌抗原（ESAT-6）孔（A孔）和培养滤过蛋白（CFP-10）孔（B孔）SFC分别为70．00（27．00～125．00）和80．00（17．00～180．00）,显著高于肺部疾病组和键康对照组,差异具有统计学意义（,=35．376和30．485,P值均〈0．05）。T—SPOT．TB诊断菌阳和菌阴肺结核的敏感度、特异度、阳性预测值和阴性预测值分别为88．6％和80．0％,88．5％和88．5％,91．2％和84．2％,85．0％和85．2％,差异无统计学意义（P〉0．05）。痰菌及T—SPOT．TB均阳性的20例活动性肺结核患者治疗前测试孔A和孔B的SFC分别为75．50（41．25～116．25）和56．25（105．00～225．00）,治疗2个月的测试孔A和孔B的SFC分别为41．0（18．00～68．75）和72．50（42．25～158．75）,较治疗前下降（z=-3．213和-3．622,P值均〈0．05）;治疗6个月末,测试孔A和B的SFC分别为25．00（5．75—52．25）和55．00（6．25～122．50）,较治疗前明显下降（Z=-3．921和-3．923,P〈0．05）,较治疗2个月时下降差异也有统计学意义（Z=-3．926和-3．884,P〈0．05）。结论T—SPOT．TB对诊断结核分枝杆菌感染及监测抗结核治疗疗效上有重要意义,且对痰菌阴性肺结核具有重要的诊断价值。     

Chronic pulmonary function impairment caused by initial and recurrent pulmonary tuberculosis following treatment

BACKGROUND: A study was undertaken to establish the chronic effect of initial and recurrent treated pulmonary tuberculosis on impairment of lung function. METHODS: A total of 27 660 black South African gold miners who had reliable pulmonary function tests from January 1995 to August 1996 were retrospectively followed for the incidence of pulmonary tuberculosis to 1970. The lung function measurements in 1995-6 were related to the number of previous episodes of tuberculosis and to the time that had lapsed from the diagnosis of the last episode of tuberculosis to the lung function test. Miners without tuberculosis or pneumoconiosis served as a comparison group. RESULTS: There were 2137 miners who had one episode of tuberculosis, 366 who had two, and 96 who had three or more episodes. The average time between the diagnosis of the last episode of tuberculosis and the lung function test was 4.6 years (range one month to 31 years). The loss of lung function was highest within six months of the diagnosis of tuberculosis and stabilised after 12 months when the loss was considered to be chronic. The estimated average chronic deficit in forced expiratory volume in one second (FEV(1)) after one, two, and three or more episodes of tuberculosis was 153 ml, 326 ml, and 410 ml, respectively. The corresponding deficits for forced vital capacity (FVC) were 96 ml, 286 ml, and 345 ml. The loss of function due to tuberculosis was not biased by the presence of HIV as HIV positive and HIV negative subjects had similar losses. The percentage of subjects with chronic airflow impairment (FEV(1) <80% predicted) was 18.4% in those with one episode, 27.1% in those with two, and 35.2% in those with three or more episodes of tuberculosis. CONCLUSIONS: Tuberculosis can cause chronic impairment of lung function which increases incrementally with the number of episodes of tuberculosis. Clearly, prevention of tuberculosis and its effect on lung function is important and can be achieved by early detection and by reduction of the risk of tuberculosis through intervention on risk factors such as HIV, silica dust exposure, silicosis, and socioeconomic factors.     

原发性肺隐球菌病的外科治疗

目的 探讨原发性肺隐球菌病的临床特点、诊断与治疗。方法 回顾分析1996年-2004年解放军总医院胸外科收治的11例原发性肺隐球菌病患者的临床资料。结果 64％（7／11）的患者有全身或呼吸道症状。全部患者胸部X线片及胸部CT检查误诊为肺癌、肺炎或结核。3例行^18氟脱氧葡萄糖-正电子发射体层显像（FDG—PET）检查,均表现为高代谢病灶。全部患者抗炎与抗结核治疗后病变无变化。术前仅2例行超声引导下穿刺病理检查明确诊断,口服抗真菌药物治疗后病灶不能完全吸收。所有患者病变均手术切除,术后仅1例多发病变患者行抗真菌治疗。术后随访9～130个月（中位时间32个月）,均无复发。结论 原发性肺部隐球菌病的临床症状、化验检查、影像学表现均无特异性,病理检查为确诊的依据,治疗采用局部切除为宜,切除彻底术后可不行抗真菌治疗。     

Anthracofibrosis or Anthracostenosis

Anthracofibrosis is a bronchial stenosis due to local mucosal fibrosis that also presents anthracotic pigment in the mucosa. The cause has not been well clarified, although there is a frequent association with tuberculosis and the exposure to smoke from biofuel or biomass combustion. It is an entity that has not been reported in Spain, although the influx of people from rural areas of developing countries or rural areas of our own country should make us contemplate this entity in the differential diagnosis of our patients.We present 3 cases detected in Spain (2 of them natives) diagnosed by bronchoscopy and bronchial biopsy, which are techniques necessary to confirm the diagnosis. There is no specific treatment, except for tuberculostatic treatment in cases with coexisting tuberculosis.     

Multiple osseous involvements in a case of disseminated cryptococcosis

Osseous involvement occurs in 5–10% of patients with disseminated cryptococcosis. We are reporting an unusual case of disseminated cryptococcosis involving the sternum and lumbar vertebra with the formation of psoas abscess with pulmonary tuberculosis. The patient presented with fever for 3 months. A diagnosis of pulmonary tuberculosis was made on thoracic contrast-enhanced computerized tomography and she was put on antituberculosis treatment. She was immunocompetent with negative human immunodeficiency virus. She conceived subsequently and had complaints of backache and swelling over the sternum. Magnetic resonance imaging showed destruction of L5 vertebra with psoas abscess. Vertebral cryptococcosis may mimic tuberculosis and malignancy. She had a bad obstetric history and experienced five, first-trimester spontaneous abortions in each successive year since 2001. This pregnancy again resulted in spontaneous abortion. Cryptococcus neoformans was isolated from two different sites: pus-involving the sternum and ultrasound-guided psoas abscess aspirate. Serum latex agglutination test for cryptococcal capsular polysaccharide antigen was positive. The diagnosis of cryptococcosis was delayed because the patient was diagnosed as a case of pulmonary tuberculosis, wherein clinical signs, symptoms and radiological findings in both the conditions are similar. Amphotericin B was started but she developed varicella infection and expired due to cardiac failure.     

A rare case of human pulmonary dirofilariasis with a growing pulmonary nodule after migrating infiltration shadows,mimicking primary lung carcinoma

IntroductionPulmonary dirofilariasis is a rare pulmonary parasitic infection by the nematode Dirofilaria immitis. It is characterized by an asymptomatic pulmonary nodule usually seen on chest X-ray. The differential diagnosis of pulmonary dirofilariasis includes other pulmonary diseases, primary lung carcinoma and metastatic lung tumor.Case presentationPulmonary dirofilariasis was diagnosed in a woman who presented with interstitial pneumonia. Growth of the pulmonary nodule was detected subsequent to hemoptysis. The histological diagnosis was made based on a wedge resection performed under video-associated thoracic surgery (VATS).ConclusionPulmonary dirofilariasis often varies in its clinical course. The diagnosis is best made using wedge resection under VATS.     

Gallium-67 as a diagnostic tool in the evaluation of peripheral pulmonary lesions

le Roux, B. T., and Houlder, A. E. (1974).Thorax, 29, 355-358. Gallium-67 as a diagnostic tool in the evaluation of peripheral pulmonary lesions. While Gallium-67 shows a high affinity for primary pulmonary tumours, benign pulmonary lesions also concentrate the isotope. In 50 consecutive patients in whom the diagnosis of pulmonary carcinoma was not achieved by other means, the exhibition of ⁶⁷Ga showed a positive scan in 36, of whom three, on histological evidence, certainly did not have a pulmonary carcinoma, and in three others radiographic diminution in the extent of the peripheral pulmonary lesion makes most unlikely the diagnosis of carcinoma. In seven of 14 patients in whom the scan was negative it was judged necessary to undertake surgical management. Scanning with ⁶⁷Ga may modify the extent of surgical resection in some with a negative scan but does not establish the diagnosis of carcinoma in those with a positive scan, is unsafe as a screening test on which to base the decision on the need for referral to a thoracic surgeon, and in particular does not distinguish between the three common causes of `chronic lung abscess'—chronic destructive pneumonia, cavitated carcinoma, and tuberculosis with cavitation and without tubercle bacilli in the sputum.     

The diagnosis and treatment of bronchial carcinoids]

The results of diagnosis and treatment of bronchial carcinoids in 37 patients are discussed. Establishment of the diagnosis is difficult because the clinico-radiological pictures of these tumours are similar to those of unspecific diseases of the lungs as well as tuberculosis. Twenty-six patients received antituberculotic treatment for a long period of time (2 to 5.5 years). Bronchoscopy with biopsy revealed the true cause of the disease in all of the 37 patients, in 9 of them coexistence of bronchial carcinoid and tuberculosis of the lung was found. Eight operations for pulmonectomy, 4 for bilobectomy, and 25 for lobectomy were performed. The volume of the surgical intervention was determined by the location of the bronchial carcinoids and extent of the secondary changes in the pulmonary tissue. Retrospective analysis showed that in timely diagnosis of bronchial carcinoids treatment of some of the patients could be limited to reconstructive-plastic operations with preservation of the whole lung or part of it.     

Pulmonary Infections in Intestinal Transplant Recipients With Preexisting Pulmonary Nodules

BackgroundPulmonary nodules in asymptomatic patients could represent latent pulmonary infections. Intestinal transplant (ITx) recipients with preexisting lung nodules might be at higher risk for pulmonary infections. However, data is scarce.MethodsThis retrospective study included adult patients who underwent ITx from May 2016 to May 2020. Chest computed tomography scans performed within 12 months before ITx were obtained to evaluate for preexisting pulmonary nodules. Screening for endemic mycoses, Aspergillus, Cryptococcus, and latent tuberculosis infection performed within 12 months before ITx was obtained. We assessed for worsening pulmonary nodules, and fungal and mycobacterial infections during the first year post-transplant. Survival and graft loss at 1-year post-transplant was also assessed.ResultsForty-four patients underwent ITx. Thirty-one had preexisting lung nodules. No invasive fungi were recorded in the pretransplant period and one individual had latent tuberculosis infection. In the post-transplant period, one individual developed probable invasive aspergillosis and had worsening nodular opacities, whereas one had disseminated histoplasmosis with stable lung nodules in chest computed tomography. No mycobacterial infections were documented. The cohort survival was 84% at 12 months after transplant.ConclusionPreexisting pulmonary nodules were common in the cohort (71%), yet latent and active pulmonary infections were rare. Appearance of new or worsening pulmonary nodules does not appear to directly correlate with pulmonary infections in the post-transplant period. Routine chest computed tomography is not recommended in the pretransplant period, but follow-up is favored in patients with confirmed nodular opacities. Clinical monitoring is essential.     

Tuberculosis in lung transplant recipients

BACKGROUND: Post-lung transplant infection is one of the leading causes of morbidity and mortality. The cause and incidence are similar in many series; however, infections such as Mycobacterium tuberculosis are influenced by the epidemiologic situation. The authors present a prospective and observational study to define the incidence, clinical presentation, and course of tuberculosis in a cohort of lung transplant patients at a single center in Spain. METHODS: Between 1990 and 2002, cutaneous delayed-type hypersensitivity testing and pathologic and microbiologic study of explanted lungs were conducted in 187 lung transplant patients. Serial bronchoscopies with transbronchial biopsy and bronchioalveolar lavage were performed during follow-up. The diagnosis of tuberculosis was established only when M. tuberculosis was identified in any sample or when histopathologic study was conclusive. RESULTS: Forty-eight patients were classified as anergic (25.6%) and 61 (32.6%) were classified as having a positive tuberculin skin test. Of the 109 patients, 95 received latent tuberculosis infection prophylaxis. Tuberculosis was diagnosed in 12 patients (6.41%); in six of them, diagnosis was determined from the explanted lungs. The remainder were diagnosed during follow-up. Fever and dyspnea were the most common symptoms. Chest radiographic findings presented an alveolar pattern. All patients responded well to antituberculous therapy; no deaths were attributable to tuberculosis. CONCLUSIONS: In the authors' experience, tuberculosis is not rare in lung transplant patients and can be managed successfully with antituberculous therapy without rifampin. A systematic protocol for diagnosing tuberculosis of the explanted lung is useful for reducing tuberculous complications of the implanted lung.     

Concurrent pulmonary tuberculosis and primary carcinoma

The relationship between chronic pulmonary tuberculosis and primary carcinoma is a purely circumstantial or fortuitous coexistence. Over a period of 14 years, 5,532 new cases of pulmonary tuberculosis and 1,218 new cases of primary malignancy of the lungs were admitted to the Missouri State Sanatorium. This report reviews 54 cases of concurrent disease and discusses the attendant difficulties in their diagnosis and treatment. Eighty-three per cent of the cases reviewed were found to be inoperable or non-resectable, indicating the urgent need for early detection. A close surveillance of patients with chronic pulmonary disease, especially those with tuberculosis and histoplasmosis, could improve the outcome of these concurrent lung diseases.     

Endobronchial Topical Amphotericin B Instillation for Pulmonary Chromomycosis After Lung Transplantation: A Case Report

We report a very rare case of pulmonary chromomycosis caused by Scedosporium prolificans that developed after lung transplantation and was successfully treated with endobronchial topical amphotericin B instillation. The subject was a woman in her 50s with a history of bilateral lobar lung transplantation from living donors for idiopathic pulmonary hypertension. Eight years after the lung transplantation, chest radiography X-ray and computed tomography showed an abnormal shadow in the right lung. Bronchoscopic findings showed obstruction by a fungal component at the laterobasal bronchus B9. She was diagnosed with pulmonary chromomycosis after S. prolificans was detected in the bronchial aspirate. Systemic antifungal treatment with itraconazole was ineffective. Therefore, we administered topical amphotericin B weekly via endobronchial instillation and replaced oral itraconazole with voriconazole. The endobronchial procedure was safe and tolerable. Bronchial obstruction improved after three 3 instillations. We continued topical amphotericin B instillation once every 3 months for 2 years, and the abnormal shadow nearly disappeared. This case report describes infection by S. prolificans, which rarely becomes an etiologic agent in lung transplant patients, and shows that endobronchial topical amphotericin B instillation is a therapeutic option when systemic antifungal treatment is ineffective.     

Hyperlucent lung. Pathophysiology and surgical management

Thirteen patients with a diagnosis of “hyperlucent lung”, 9 women and 4 men ranging in age from 19 to 68, are reviewed. Four patients had congenital absence of the pulmonary artery, and 9 had what we believe should be termed acquired hypoperfusion of a lung.In patients with acquired hypoperfusion, the pathophysiology is determined by recurrent pulmonary infection with resultant decrease in lung volume and function, decreased pulmonary artery flow, and increased bronchial circulation. Recurrent infection may lead to severe hemoptysis. Pulmonary resection was carried out in 1 of those with congenital absence of the pulmonary artery and in 5 with acquired lesions.     

Diffuse pulmonary infiltrates after bone marrow transplantation: the role of open lung biopsy

Background

Diffuse pulmonary infiltrates is the major complication and cause of mortality after bone marrow transplantation. We analyzed the etiologies and prognostic factors in bone marrow recipients with diffuse pulmonary infiltrates and assessed the role of open lung biopsy in managing this complication.

Methods

Medical records of patients with diffuse pulmonary infiltrates after bone marrow transplantation were reviewed. Possible prognostic factors were analyzed by multivariate logistic regression.

Results

Sixty-eight (20%) of 341 bone marrow recipients had diffuse pulmonary infiltrates and 34 died. Thirty-five underwent open lung biopsy, resulting in therapeutic changes in 22 (63%) and clinical improvement in 16 (46%). The leading diagnoses were idiopathic interstitial pneumonitis (40%) and cytomegalovirus pneumonitis (20%). Cytomegalovirus pneumonitis caused radiographically observable interstitial infiltrates exclusively and was frequently associated with hepatitis. Idiopathic interstitial pneumonitis resulted in either diffuse ground-glass opacity or interstitial infiltrates. Three (9%) patients had miliary tuberculosis. Respiratory failure (p < 0.001) and acute graft-versus-host disease (p = 0.016) were the poor prognostic factors.

Conclusions

Among bone marrow recipients, we found diffuse pulmonary infiltrates in 20% and a mortality rate of 50%. Idiopathic interstitial pneumonitis and cytomegalovirus pneumonitis were the most common causes and should be suspected in patients with diffuse interstitial infiltrates. In endemic areas, miliary tuberculosis should be suspected in bone marrow recipients with diffuse reticulonodular lesions. Respiratory failure and acute graft-versus-host disease were poor prognostic factors. By establishing a correct diagnosis, open lung biopsy led to treatment changes in about two-thirds of these patients.     

Simultaneous Bilateral Spontaneous Pneumothorax Report of 12 Cases and Review of the Literature

Simultaneous bilateral spontaneous pneumothorax (SBSP) is a very rare condition, mainly seen in patients with underlying lung disease. Up to now, there are 65 patients who have been published.

Twelve consecutive patients who presented with SBSP as definitive diagnosis were recruited for this study. They represented 1 % of all patients with spontaneous pneumothorax. All patients had immediate bilateral chest tubes on admission. Five of the 12 patients (42%) had no underlying lung disease. In 7 patients, SBSP was secondary to pulmonary metastases, histiocytosis X, undefined interstitial pulmonary disease, tuberculosis, pneumonia and chronic obstructive pulmonary disease.

None of the patients died during hospitalization. Eleven patients were treated with chemical pleurodesis, whereas thoracotomy and pleurectomy were necessary in 7 patients. Reexpansion of the lungs was achieved in all patients. Immediate bilateral chest tube insertion and pleurodesis are of major importance in the treatment of SBSP although a subset of patients needed surgical pleurectomy. Combination of these treatments provides successful and uneventful treatment of the disease.     

肺移植经验与教训（附3例报告）

作者总结近２年中４家医院合作完成３例单肺移植的经验教训,１例左肺,２例右肺。受体为弥漫性肺纤维化、慢性阻塞性肺病并肺癌和结核性毁损肺。术前均有不同程度的肺部感染,术后死于严重感染,分别生存９、４８及４３天。作者报告并讨论了供受体选择,手术技术、术后管理,尤其是感染和免疫排斥反应的监测、鉴别及处理等关键性问题,强调ＨＬＡ配型及经支气管镜活检对肺移植成功的重要性。详细地介绍了供受体实用手术技术,具体的免疫抑制方案及主要影响长期生存的原因等经验与教训。指出排斥与感染是近期死亡的主要原因,也是今后需重点解决的难题。