肺结核住院患者并发肺外结核状况及其与性别和年龄相关性的多中心研究

目的 探讨住院肺结核患者并发肺外结核的发生情况及其与性别、年龄的关系。方法 采用观察性研究方法,由参加过统一培训的调查员从医院信息管理系统(HIS系统)收集2011年1月1日至2017年12月31日我国15省21家医疗机构360187例住院肺结核患者的性别、年龄,以及结核病灶累及部位等信息,比较分析肺结核患者并发肺外结核的发生情况及其与性别、年龄的关系。 结果 360187例肺结核患者中,男238910例(66.33%),女121277(33.67%),年龄中位数(四分位数) [M(Q₁,Q₃)]为47(28,62)岁;42987例(11.93%)并发肺外结核,并发率依次为结核性脑膜炎[2.72%(9809例)]、颈部淋巴结结核[1.93%(6966例)]、结核性腹膜炎[1.59%(5733例)]、结核性心包炎[0.94% (3399例)]、肠结核[0.94%(3380例)]等。男性肺结核患者并发结核性脑膜炎、颈部淋巴结结核、结核性腹膜炎、结核性心包炎、结核性多浆膜炎、腰椎结核、胸椎结核、胸壁结核的并发率分别为2.44%(5829例)、1.44%(3429例)、1.41%(3376例)、0.90%(2138例)、0.75%(1791例)、0.67%(1604例)、0.64%(1522例)、0.60%(1438例),均明显低于女性[分别为3.28% (3980例)、2.92% (3537例)、1.94% (2357例)、1.04% (1261例)、0.90% (1093例)、0.79% (960例)、0.76% (924例)、0.66% (805例)](χ ²=215.235,930.541,144.480,18.061,23.272,16.442,18.585,4.976;P值均<0.05)。不同年龄组(1~岁组至≥65岁组)肺结核患者并发结核性脑膜炎、颈部淋巴结结核、结核性腹膜炎、肠结核、结核性心包炎、结核性多浆膜炎、腰椎结核、胸椎结核、胸壁结核、咽喉结核的并发率差异均有统计学意义(χ ²=3870.549,2939.502,1830.620,673.372,115.428,319.078,52.512,19.308,439.177,136.619;P值均<0.05)。除胸椎结核的并发率未呈现出随年龄变化的趋势($\chi^{2}_{趋势}$=0.814, P=0.367),结核性心包炎呈现出随年龄增长而增高的趋势 ($\chi^{2}_{趋势}$=62.087,P<0.001)外,其他肺外结核的发生率均呈现出随年龄增长而降低的趋势 (P值均<0.001)。多因素logistic回归分析结果显示,肺结核并发肺外结核患者的风险女性高于男性[OR(95%CI)=1.325(1.297~1.353)];其他各年龄组风险均高于≥65岁年龄组[1~岁组、15~岁组、25~岁组、35~岁组、45~岁组、55~岁组的OR(95%CI)值分别为:4.995(4.655~5.360)、2.481(2.397~2.568)、2.053(1.982~2.126)、1.683(1.619~1.749)、1.276(1.228~1.326)、1.109(1.067~1.153)];在控制了性别的影响后,肺结核并发肺外结核患者的风险随年龄的增长而降低[OR(95%CI)=0.817(0.812~0.821)]。结论 肺结核患者可并发结核性脑膜炎、颈部淋巴结结核、结核性腹膜炎、结核性心包炎和肠结核等多种肺外结核;且并发肺外结核的风险女性高于男性,并呈现出随年龄的增长而降低的趋势。     

基于CT分型方法的儿童肺结核临床特征分析

目的 分析儿童肺结核CT特征的临床特点。方法 回顾性分析首都医科大学附属北京儿童医院2006年7月至2014年12月经临床诊断并确诊为肺结核的734例患儿的临床资料(包括年龄、性别、临床表现,疫苗接种史、接触史及实验室检查等),基于CT分型对其CT特征、临床特点进行分析。结果 734例患儿中159例(21.7%)为经病原学检测确诊;CT分型中原发性肺结核和气管、支气管结核最多见(365例,50.4%),并发2种及以上类型者次之(199例,27.3%);3岁以下婴幼儿以原发性肺结核和气管、支气管结核多见(189例,26.1%), 7~14岁青春期儿童以结核性胸膜炎多见(94例,13.0%);并发肺外结核患者以结核性脑膜炎(109例,34.5%)及肺外播散累及2个及以上器官或组织者(103例,32.6%)最多见。192例(26.2%)患儿并发其他疾病或患有基础疾病。结论 不同年龄阶段患儿的肺结核CT分型不同,且常并发肺外结核;儿童肺结核CT表现有其自身特点及年龄分布特点。     

疑难肺部阴影临床与病理分析

目的 分析CT引导下经皮肺穿刺活检诊断的疑难肺部阴影患者临床资料,提高临床与病理诊断相关性。方法 选择2021年5月至2022年8月我院呼吸与危重症医学科行CT引导下经皮肺穿刺活检诊断的疑难肺部阴影患者25例,对临床资料、肺恶性肿瘤和肺结核进行分析。结果 疑难肺部阴影活检结果中,肺恶性肿瘤和肺结核23例(92.0%)。肺恶性肿瘤13例(56.5%),其中腺癌9例(69.2%)、鳞癌2例(15.4%)、小细胞癌和腺样囊性癌各1例(7.6%);肺结核10例(43.4%),其中肉芽肿性病变9例(36%)、慢性炎+坏死+多核巨细胞1例(4%)。2例(8.0%)为慢性炎伴碳末沉积。肺恶性肿瘤和肺结核在性别、年龄、基础病、病程、病变部位、病灶大小和影像学高危征象及结核菌素试验(PPD)、结核菌感染T细胞斑点实验(T-SPOT)、全自动医用PCR分析系统(Gene-Xpert)、结核菌聚合酶链式反应(TB-PCR)、结核菌核糖核酸(TB-RNA)和结核抗体等结核相关参考指标进行分析,无统计学差异(P>0.05)。两者在肺部肿瘤标志物,癌胚抗原(CEA)、鳞状细胞癌相关抗原(SCC)、胃泌素释放...     

Immune thrombocytopenic purpura induced by intestinal tuberculosis in a liver transplant recipient

A variety of clinical manifestations are associated directly or indirectly with tuberculosis. Among them, haematological abnormalities can be found in both the pulmonary and extrapulmonary forms of the disease. We report a case of immune thrombocytopenic purpura (ITP) associated with intestinal tuberculosis in a liver transplant recipient. The initial management of thrombocytopenia, with steroids and intravenous immunoglobulin, was not successful, and the lack of tuberculosis symptoms hampered a proper diagnostic evaluation. After the diagnosis of intestinal tuberculosis and the initiation of specific treatment, a progressive increase in the platelet count was observed. The mechanism of ITP associated with tuberculosis has not yet been well elucidated, but this condition should be considered in cases of ITP that are unresponsive to steroids and intravenous immunoglobulin, especially in immunocompromised patients and those from endemic areas.     

全血检测特异性抗结核抗体对结核病快速诊断价值的研究

目的了解全血检测特异性抗结核抗体(LAM-IgG)对结核病快速诊断的价值.方法采受试者手指血20μL用金标试剂盒直接检测LAM-IgG.结果 125例涂阳肺结核抗体阳性检出率为92.0%;267例涂阴肺结核抗体阳性检出率为78.3%;94例陈旧性肺结核抗体阳性检出率为 75.5%;36例肺外结核抗体阳性检出率为83.3%;315例非结核抗体阳性检出率为47.6%.本试验灵敏度为82.7%(324/392),特异度为52.4%(165/315).结论全血快速检测抗结核抗体较血清检测更方便,灵敏度高,但特异度较低,不能作为涂阴肺结核的最终诊断,此项检查可作为涂阴肺结核的辅助诊断和结核可疑者的筛选手段以及肺外结核的诊断指标之一.     

血清抗脂阿拉伯甘露糖及38kD抗体检测对涂阴肺结核及肺外结核诊断价值

目的　评估血清抗脂阿拉伯甘露糖及38kDa抗体 (LAM38kD IgG)检测对涂阴肺结核和肺外结核的诊断价值。方法 采用斑点免疫金渗滤法 (dotimmunogoldfiltrationassay，DIGFA)检测57例涂阴肺结核，52例肺外结核，32例涂阳肺结核，29例肺癌患者及33例正常人血清中LAM38kD IgG。 结果 涂阴肺结核组LAM38kD IgG阳性率为73.7%，其中痰结核菌涂 (-)培 (+)组为84 .6%，涂 (-)培 (-)组为70 .5%。肺外结核组阳性率为71.2%，涂 (+)肺结核组阳性率93.8%，肺癌组假阳性率31%，健康组假阳性率9.1%。结论 血清LAM38kD IgG检测对涂阴肺结核和肺外结核有一定的辅助诊断价值。     

Should pulmonary tuberculosis be an AIDS-defining diagnosis in patients infected with HIV?

Between 1983 and 1989, we cared for 56 patients with tuberculosis and human immunodeficiency virus (HIV) infection. In 37 patients (66%), tuberculosis occurred before any other AIDS-defining disease (group 1); in 10 (18%) it occurred during the same month as another AIDS-defining disease (group 2); and in 9 (16%), after the diagnosis of AIDS (group 3). Tuberculosis was entirely pulmonary in 14 patients (25%), entirely extrapulmonary in 9 (16%), and both pulmonary and extrapulmonary in 33 (59%). The frequency of extrapulmonary involvement was similar in patients from group 1 and from groups 2 and 3 (combined): 76% versus 74%. Needle biopsy of the liver revealed hepatic involvement in 18 patients (32%). The mean CD4 lymphocyte count was 232/mm3 when tuberculosis was entirely pulmonary, and 243/mm3 when extrapulmonary disease was present (difference not significant). In group 1, the onset of both pulmonary and extrapulmonary tuberculosis occurred at the same stage of HIV infection, 12 and 10 months, respectively, before any other AIDS-defining disease. Treatment, planned to last 1 year, was highly effective, despite frequent side-effects. Among the 32 patients who completed treatment, relapse of tuberculosis occurred in 2 (6%) with a mean follow-up of 16 months (0-53 months) after completion. Our results suggest that pulmonary tuberculosis should be included in the criteria for diagnosis of AIDS.     

41例儿童复治敏感结核病患者临床特征分析

为了解复治结核病患儿临床特征,笔者选取2015年1月至2021年6月上海市公共卫生临床中心结核科收治的41例复治药物敏感结核病患儿为研究对象,分析其基础特征(性别、年龄)、临床诊断及分类、复治原因、肺结核胸部CT表现、治疗与预后等临床资料。结果发现,41例患儿中,肺结核占58.5%(24/41),肺外结核占41.5%(17/41)。肺外结核中,淋巴结结核占41.2%(7/17),结核性脑膜炎占29.4%(5/17)。因不合理或不规律用药、复发、治疗失败而复治的患儿分别占58.5%(24/41)、31.7%(13/41)、9.8%(4/41),而在前者中有18例(75.0%)因药物不良反应所致。24例有胸部CT检查的肺结核患儿中,12例(50.0%)表现为单侧肺非空洞病灶、9例(37.5%)为双肺病灶,2例(8.3%)为单侧胸腔积液和胸膜增厚,1例(4.2%)表现为空洞。23例(56.1%)复治患儿使用了3H-R-Z-E/9~15H-R-E或3H-R-Z/9~15H-R-E(H:异烟肼;R:利福平;Z:吡嗪酰胺;E:乙胺丁醇)治疗方案,余18例(43.9%)使用了非规范治疗方案。经随访,35例(85.4%)患儿成功完成治疗且治愈;2例(4.8%)患儿仍在服药,病情稳定;4例(9.8%)失访。由此可见,复治药物敏感结核病患儿以肺结核、因不合理或不规律用药致复治者为主,胸部CT表现以单侧肺非空洞病灶者多见,总体预后良好。但应注意患儿的随访,尤其是对初治中有药物不良反应者。     

Extrapulmonary tuberculosis in the United States

From 1963 to 1986, the number of reported cases of pulmonary tuberculosis in the United States declined an average of 5.0% annually, and the number of cases of extrapulmonary tuberculosis declined an average of 0.9% annually over the same period. In 1986, 17.5% of all cases of tuberculosis were extrapulmonary. Of pulmonary cases, 63.0% occurred among racial ethnic minorities and the foreign-born, whereas of extrapulmonary cases, the respective proportion was 71.2%. After adjustment for other variables, the proportion of extrapulmonary tuberculosis among all patients with tuberculosis by age was found to be largest in children and generally to decrease with increasing age, larger among black, Asian, and American Indian than among non-Hispanic white patients, larger among female than among male patients, and larger among the foreign-born than among patients born in the United States. The smaller decline in extrapulmonary tuberculosis over the years may be partially due to changes in the demographic characteristics of patients with tuberculosis. Considerable differences in susceptibility to different sites of extrapulmonary tuberculosis by age, race/ethnicity, sex, and country of origin were found. The reasons for these differences remain largely unexplained.     

Sero-reactivity of two different antigenic protein fractions of M.tb H37Ra excretory-secretory antigen in pulmonary and extra-pulmonary tuberculosis

Excretory-secretory proteins of Mycobacterium tuberculosis H37Ra, have been of diagnostic interest in pulmonary (PTB) and extrapulmonary tuberculosis (EPTB). Two different excretory-secretory antigenic proteins of M.tbH37Ra viz., EST-DE1 (a 6% TCA soluble and DEAE anion exchange purified antigen) and ESAS-7 (50% ammonium sulphate solubilized and SDS-PAGE fractionated antigen) were studied in stick-indirect penicillinase ELISA for detecting tuberculous IgG antibodies in serum samples of pulmonary as well as extrapulmonary tuberculosis (tuberculous lymphadenopathy (TBLN), tuberculous meningitis (TBM), bone & joint tuberculosis (B&J TB), abdominal tuberculosis (Abd. TB) patients. The ESAS-7 antigen has shown comparatively better seroreactivity (90%) than that of EST-DE1 antigen in pulmonary tuberculosis cases. The overall specificity of 93.2% using ESAS-7 antigen was also found better compared to 86.4% obtained using EST-DE1 antigen. Further, in extra pulmonary tuberculosis group, using ESAS-7 antigen 84% (21/25) of histopathologically confirmed TBLN cases and 90% (9/10) clinically diagnosed and ATT responded TBM cases showed positive reaction for tuberculous IgG antibody. The per cent positivity using EST-DE1 antigen was however comparatively low in TBLN and TBM cases, (76% and 80% respectively). In histopathologically proven bone and joint tuberculosis and abdominal tuberculosis cases EST-DE1 antigen showed better sensitivity of 75% and 83.3% respectively in IgG antibody detection compared to that of ESAS-7 antigen (50% and 66% respectively). From the present study, it can be envisaged that ESAS-7 antigenic fraction has a good potential in the diagnosis of pulmonary and certain extra-pulmonary tuberculosis infection (TBLN & TBM) whereas EST-DE1 was found to be better in detecting specific antibodies in bone & joint and abdominal tuberculosis.     

四川地区346例耐药肺结核患者临床特征分析

目的了解四川地区346例耐多药(MDR-TB)和泛耐药(XDR-TB)肺结核患者的临床特征以及可能与耐药发生有关的因素。方法回顾分析成都市公共卫生临床医疗中心2016年1月~2017年6月收治的346例耐药肺结核患者以及2370例药物敏感肺结核患者的临床资料,通过比较分析二组的差异,探讨耐药肺结核患者的患病特点以及可能影响耐药发生的因素。结果耐药肺结核发病人群以男性为主,占70.52%(244/346),且各年龄组男性均多于女性;青壮年居多,占81.79%(283/346),老年和18岁以下患者占比分别为13.58%(47/346)和4.62%(16/346)。性别和年龄分布情况与药物敏感肺结核无明显差异。耐药患者中少数民族患者占比接近五分之一;初、复治病例分别占23.70%(82/346)和76.30%(264/346)。在86例使用过喹诺酮类药物的耐药患者中73.26%(63/86)的病例对此类药物耐药。主要临床症状与药物敏感肺结核患者无明显差异。耐药患者中并发肺组织外结核者占65.32%(226/346),与药物敏感肺结核组(72.57%,1720/2370)相比无明显差异。耐药患者胸部影像改变中,空洞、支气管扩张和肺叶毁损分别占75.72%(262/346),23.12%(80/346)和19.08%(66/346),均高于药物敏感肺结核组;病变累及范围分布与药物敏感肺结核组无差别。主要合并症中,合并HIV感染者18例,糖尿病53例,慢性肺部疾患者17例,与药物敏感组相比无明显差异。耐药结核分枝杆菌检出标本最常见者为痰液(82.08%,284/346)和支气管肺泡灌洗液(28.90%,100/346),其他多种组织均有检出。通过Xpert MTB/RIF检测方法,检出利福平突变阳性者82.56%(142/172);北京博奥晶芯分枝杆菌+耐药检测方法检出利福平耐药者90.65%(97/107)。结论耐药结核病在各年龄段人群均可发生,男性高于女性。主要表现与药物敏感肺结核患者无明显差异。复治患者是耐药结核病发病的高危人群,但初始耐药不少见。喹诺酮类药物的不规范使用可能与继发耐药有关。耐药患者肺外结核发生率与药物敏感肺结核患者无明显差异。其肺部影像改变较之药物敏感肺结核患者有更多的空洞、支气管扩张和肺叶毁损。快速分子生物学方法阳性率高,快捷有效。     

Detection of Mycobacterium tuberculosis complex by nested polymerase chain reaction in pulmonary and extrapulmonary specimens ,

OBJECTIVE:

To compare the performance of nested polymerase chain reaction (NPCR) with that of cultures in the detection of the Mycobacterium tuberculosis complex in pulmonary and extrapulmonary specimens.

METHODS:

We analyzed 20 and 78 pulmonary and extrapulmonary specimens, respectively, of 67 hospitalized patients suspected of having tuberculosis. An automated microbial system was used for the identification of Mycobacterium spp. cultures, and M. tuberculosis IS6110 was used as the target sequence in the NPCR. The kappa statistic was used in order to assess the level of agreement among the results.

RESULTS:

Among the 67 patients, 6 and 5, respectively, were diagnosed with pulmonary and extrapulmonary tuberculosis, and the NPCR was positive in all of the cases. Among the 98 clinical specimens, smear microscopy, culture, and NPCR were positive in 6.00%, 8.16%, and 13.26%, respectively. Comparing the results of NPCR with those of cultures (the gold standard), we found that NPCR had a sensitivity and specificity of 100% and 83%, respectively, in pulmonary specimens, compared with 83% and 96%, respectively, in extrapulmonary specimens, with good concordance between the tests (kappa, 0.50 and 0.6867, respectively).

CONCLUSIONS:

Although NPCR proved to be a very useful tool for the detection of M. tuberculosis complex, clinical, epidemiological, and other laboratory data should also be considered in the diagnosis and treatment of pulmonary and extrapulmonary tuberculosis.     

Der tuberkulöse Pleuraerguss

Approximately one third of the world’s population is infected with Mycobacterium tuberculosis and among communicable diseases tuberculosis is the second leading cause of death. The most common type of tuberculosis is pulmonary tuberculosis. Among the extrapulmonary manifestations, tuberculous pleuritis ranks second only after lymphatic tuberculosis. Tuberculous pleuritis is most commonly a disease with acute onset which is self-limiting in the majority of cases. A large proportion of patients though develop some form of active tuberculosis after a latency period. Therefore the correct diagnosis and the initiation of treatment are of the utmost importance. The easiest way to establish the diagnosis of tuberculous pleuritis is to demonstrate an elevated ADA (adenosine deaminase) in a lymphocytic effusion. Should pleural fluid analysis be nondiagnostic, the diagnosis of tuberculous pleuritis can be established with percutaneous closed needle biopsy in over 80% of cases. All patients with an undiagnosed pleural effusion after closed needle biopsy require thoracoscopy with selected biopsies taken under direct vision. The diagnostic yield of thoracoscopy is close to 100% in tuberculous pleuritis.     

结核抗体lgG/lgM检测在肺结核和肺外结核中的诊断价值

目的 探讨异种血清抗体检测技术在结核病诊断中的应用价值。方法 采用IgG/IgM抗体试剂盒分别检测102例结核病患者(包括73例肺结核和29例肺外结核)、223例其他肺部疾病患者和100例对照者结核感染情况,以临床诊断为标准评价该方法的敏感度和特异性,同时分别与痰菌培养及痰涂片平行检验的结果作比较,统计学分析采用χ²检验。结果 结核抗体IgG/IgM检测结核病患者的敏感度为74.51%、特异度为91.64%。结核抗体IgG/IgM检测肺结核和肺外结核的敏感度分别为82.19%、55.17%,肺内和肺外结核的敏感度差异有统计学意义(P＜0.05),结核抗体lgG/IgM检测结核患者阳性检出率明显高于痰培养法和痰涂片法(P<0.05)。102例结核病患者年龄段分组分析,少年组和老年组检出率分别为58.33%、36%,远低于青年组和中年组的96.15%和89.74%。不同年龄组间进行卡方比较分析显示,P＜0.05,差异有统计学意义。425例标本中,共发现8例非结核分枝杆菌,其中6例胞内分枝杆菌, 2例脓肿分枝杆菌,lgG/lgM抗体检测均为阴性。结论 IgG/IgM血清抗体检测肺内、外结核具有快速方便、经济和较高的敏感度,适合用于临床结核筛查。     

Evaluation of a commercial ligase chain reaction assay for the diagnosis of pulmonary and extra-pulmonary tuberculosis.

SETTING: Egas Moniz Hospital, Lisbon, Portugal. OBJECTIVE: To evaluate the Ligase Chain Reaction (LCx) Mycobacterium tuberculosis Assay for the direct detection of M. tuberculosis complex in respiratory specimens after smear observation, and its suitability for non-respiratory clinical specimens. DESIGN: Analysis of 156 specimens collected from 123 patients with pulmonary tuberculosis and/or extrapulmonary involvement. RESULTS: Among 93 pulmonary secretions and 63 extra-pulmonary samples and after resolution of discrepancies based on clinical and laboratory findings, two pulmonary samples from a patient with a diagnosis of sarcoidosis, four samples of cerebrospinal and one of seminal fluid were considered as false positives. Two tissue biopsy samples, one pericardial effusion and one pulmonary secretion from patients strongly suspected of having tuberculosis were considered as false negatives for the assay, without inhibition of amplification. All specimens yielding M. avium on culture were LCx negative. CONCLUSION: The LCx Mycobacterium tuberculosis Assay was found to be useful for the rapid identification of M. tuberculosis complex in all types of specimens. It revealed a high specificity both in pulmonary and extrapulmonary products, and a sensitivity of 97% for the pulmonary secretions and of 75% for the extra-pulmonary specimens, independently of the bacilloscopy results.     

泌尿系统结核29例临床分析

目的总结泌尿系统结核的临床特点。方法回顾性分析1998年12月31日—2008年12月31日在中山大学附属第二医院住院的泌尿系统结核患者的临床资料。记录患者的一般情况、既往病史、临床表现、实验室检查、影像学检查及诊断和误诊情况。结果10年间共收集泌尿系统结核患者29例,肾脏受累者24例（占82．8％）,输尿管受累者11例（占37．9％）,膀胱受累者3例（占10．3％）。合并肺结核9例,泌尿系统以外的肺外结核5例,存在免疫功能受损者10例。常见临床特征包括膀胱刺激征18例（占62．1％）,腰痛17例（占58．6％）,白细胞尿14例（占48．3％）及血尿14例（占48．3％）。经病理学检查确诊22例,经病原学检查确诊5例,经诊断性治疗确诊2例。初次就诊至确诊的时间中位数为4个月（0～10年）。结论对于存在肺结核及其他部位肺外结核的成年患者,出现一般抗感染治疗无反应的慢性膀胱炎或无菌性脓尿时,应高度怀疑泌尿系统结核的可能。宜及早行静脉肾盂造影（IVP）或电子计算机断层扫描（CT）检查,反复尿沉渣涂片抗酸染色、结核菌培养、结核菌聚合酶链反应（PCR）检查有助于泌尿系统结核的早期诊断。     

35例小肠间质瘤诊治分析

背景:小肠间质瘤的发病率低,临床症状不典型且缺乏简便有效的检查方法,术前确诊较为困难。目的:了解小肠间质瘤的临床表现,探讨如何提高小肠间质瘤的术前诊断率和合理的手术方式,以提高其诊治水平。方法:回顾性分析1993年4月～2004年6月仁济医院收治的35例小肠间质瘤的临床表现、诊治经过、病理学特点和预后,所有病例均经手术和病理证实。结果:脐周隐痛、消化道出血、贫血、腹部肿块和小肠梗阻是本组小肠间质瘤最常见的临床表现。小肠间质瘤多好发于十二指肠和空肠;80.0%的良性小肠间质瘤瘤体直径<5cm,93.3%的恶性小肠间质瘤瘤体直径>5cm;小肠间质瘤以肠腔外生长为主,良、恶性间质瘤在生长方式上无显著差异。空肠、回肠间质瘤的术前诊断率显著低于十二指肠间质瘤(P<0.01)。胃镜、增强螺旋CT和数字减影血管造影(DSA)对小肠间质瘤检出率较高。30例恶性间质瘤中20例(66.7%)行小肠肿瘤根治术,8例(26.7%)行小肠肿瘤减瘤荷手术,2例(6.7%)行姑息性手术。30例恶性间质瘤切除标本中9例有局部淋巴结转移,5例出现远处转移。结论:合理应用辅助检查方法可提高小肠间质瘤的术前确诊率,术中对间质瘤的良、恶性判断有困难者应行根治性切除术。     

Effect of nucleic acid amplification for Mycobacterium tuberculosis on clinical decision making in suspected extrapulmonary tuberculosis

BACKGROUND: Laboratory-based studies have suggested the nucleic acid amplification test (NAAT) for Mycobacterium tuberculosis may be useful in diagnosing extrapulmonary tuberculosis. We sought to determine how clinicians in one hospital used results of the NAAT in clinical decision making in cases of suspected extrapulmonary tuberculosis. METHODS: We performed a retrospective analysis of all patients who underwent the NAAT on at least one nonsputum sample, excluding cerebrospinal fluid, from 1999 to 2001 in one large urban hospital. For these patients, we reviewed the hospital course, with particular attention to date of the NAAT and its influence on days treated with antituberculous medications and days to final diagnosis. RESULTS: Thirty-five patients with suspected tuberculosis who had undergone the NAAT on extrapulmonary specimens were identified. From three patients, NAAT results were nondiagnostic because of inhibitors, and they were excluded from the analysis, leaving 32 patients. Tuberculosis was ultimately diagnosed in 14 of these 32 patients. NAAT findings were positive in specimens from 12 of 14 patients with extrapulmonary tuberculosis and in 0 of 18 cases in which tuberculosis was excluded (sensitivity, 86%; specificity, 100%; positive predictive value, 100%; negative predictive value, 90%). In only 2 of 19 patients treated with antituberculous medications was the NAAT result used to determine the onset or discontinuation of therapy. In no instance was a negative NAAT result used by clinicians as definitive evidence that a patient did not have extrapulmonary tuberculosis; in all but one case, patients were continued on antituberculous therapy until final culture results were available. CONCLUSIONS: The NAAT proved to be a sensitive and specific test for detection of M tuberculosis in extrapulmonary specimens but did not weigh heavily in clinical decision making at our hospital. Judicious use of these tests may improve the accuracy and speed of diagnosis of extrapulmonary tuberculosis, while helping to eliminate unnecessary antituberculous treatment in patients without tuberculosis.     

Principles of differential diagnosis of diffuse lesions of the lungs]

Intricate questions related to the differential diagnosis of diverse diffuse pulmonary disorders are analysed in more than 1500 patients. Among them 1100 patients had sarcoidosis, 284 alveolitis of different etiology (including 62 patients with fibrotic alveolitis of autoimmune genesis), 45 rare pulmonary diseases, 5 carcinomatosis and 40 disseminated tuberculosis. 70% of the patients were hospitalized for pulmonary tuberculosis. Each disease had its typical diagnostic algorithm. In most cases (86-98%) the diagnosis was morphologically evidenced by intrapulmonary transbronchial biopsy. The cytogram of bronchoalveolar washout was examined. Immunologic methods and immunodiagnosis were used to specify the patients' immune status. Considerable attention was given to external respiratory function. The diagnosis of disseminated tuberculosis was verified by bacteriologic examinations and tuberculin diagnosis.     

Extrapulmonary tuberculosis in the northeastern suburbs of Paris: 141 cases

Background: Big cities were particularly affected by tuberculosis in the 1990s. Methods: We studied 141 cases of extrapulmonary tuberculosis in patients not infected by HIV in the northeastern suburbs of Paris. Results: A total of 84 men and 57 women were included in the study. Their average age at diagnosis was 42.2 years. Some 73.6% of the patients were foreign-born. A total of 182 sites were identified in 141 patients. There was an association with pulmonary tuberculosis in 38 cases. The sites were: lymph node (48.9%), pleural (25.5%), skeletal (22.7%), genitourinary (5.7%), and meninges (5%). Unfavorable social conditions were frequently observed. The average duration of treatment was 10 months. Twenty-four adverse drug effects were noted. Sixty-eight strains of Mycobacterium tuberculosis were isolated. Five cases of primary resistance to at least one antituberculous drug and only one case of multidrug resistance were observed. Some 95.7% of the 93 patients who were not lost to follow up were cured. Conclusion: Independently of HIV infection, extrapulmonary tuberculosis is still present, particularly in the suburbs of big cities, where social conditions are poor. The significant number of patients lost to follow-up demands that measures be adapted for the therapeutic management of these patients.