血行播散型肺结核临床分析

目的分析血行播散型肺结核临床特点。方法对2003～2006年收治的34例血行播散型肺结核临床特点作回顾性分析。结果（1）血行播散型肺结核以青壮年居多，老年患者渐有增多的趋势。（2）85．3％在出现临床症状后〉1月确诊。（3）全身症状明显（发热67．6％），呼吸道症状以咳嗽、咳痰居多。（4）痰涂片找核酸杆菌阳性率23．5％，50％PPD试验阴性，35．3％末梢血白细胞不正常，5．8％肝功障碍。（5）52．9％并发肺外结核，20．6％合并非结核性疾病。（6）早期、联合、规律、全程、适量抗结核治疗，对并发症及合并病治疗，97．1％的病例临床治愈。结论血行散播型肺结核是重症肺结核之一，症状重，并发症、合并症多。经有效抗结核治疗，对症治疗不同并发症及合并症，获得了满意的疗效。     

血行播散性肺结核362例临床分析

目的分析血行播散性肺结核临床特点。方法回顾分析鞍山市千山医院1998—2007年住院患者362例血行播散性肺结核患者临床特点、治疗、预后等。结果以青壮年为多,占62.0％,老年患者有上升趋势,占21.0％。临床症状发热占86.1％,呼吸道症状以咳嗽、乏力、气促、盗汗、胸痛等症状居多,伴有结脑者有头痛、恶心、呕吐等。临床确诊时间：30d以内占50.3％,少数病人至4个月以上确诊。痰菌阳性率37.8％。PPD试验阳性反应58.6％,血清抗结核抗体阳性44.8％。急性血行播散性肺结核68.5％,亚急性和慢性血行播散性肺结核31.5％。胸部X线典型粟粒性肺结核阴影占68.5％,并发肺外结核占40.0％。非结核并发症占68.2％。经联合抗结核治疗同时治疗并发症。除结脑脑疝死亡2例外,余者均好转。结论血行播散性肺结核症状严重,常合并其他脏器结核病,必须给予高效、敏感抗结核药治疗,并对肺外结核病、并发症亦予以积极治疗,并辅以营养与支持疗法,能获得满意疗效。     

艾滋病合并肺结核24例分析

目的探讨艾滋病合并肺结核的临床特点及治疗。方法对24例艾滋病合并肺结核进行回顾性分析。结果两病并发率由1998年的0．05％上升至2002年的0．73％。HIV感染途径为静脉吸毒(77．1％)及性途径(22．9％)；临床表现有发热(91．7％)，咳嗽(91．7％)，咳痰(79．2％)，明显消瘦(79．2％)，淋巴结肿大(54．7％)；胸部X线表现以继发性肺结核为主(66．7％)；合并病毒性肝炎50％，痰菌阳性率41．7％，PPD试验阳性率16．7％，14例抗结核治疗(3HRZE／9HRE)治愈或完成疗程，抗结核药物不良反应发生率为79．2％。结论艾滋病合并肺结核常发病急、症状重、PPD试验阳性率低、抗结核药物治疗不良反应多，应加强艾滋病高发区及高危人群肺结核患者并发艾滋病的警惕性。     

继发型肺结核患者短程化疗致肝功能损害的临床分析

目的 了解继发型肺结核患者短程化疗引起肝功能损害情况。方法对我院2005年12月至2006年12月215例继发型肺结核患者在抗结核药物治疗中出现的肝损害情况进行临床分析。结果（1）继发型肺结核患者抗结核治疗前肝功能正常者184例，占85．6％；异常31例，占14．4％。治疗后肝功能正常者151例，占70．2％；异常64例，占29．8％。（2）抗结核治疗后出现肝功能异常时间：72．7％患者发生于治疗2周内，90．9％患者发生于治疗第1个月内。结论继发型肺结核患者抗癌治疗中易出现肝功能损害，加强护肝治疗，能保证肺结核病人化疗方案完成。     

应用免疫抑制剂并发肺结核41例临床分析

目的 提高对应用免疫抑制剂治疗中并发肺结核的认识及诊疗水平。方法回顾性选择分析了41例患者应用免疫抑制剂治疗后并发肺结核的临床特征。结果 41例肺结核患者占本院同期确诊为初治肺结核的2．2％，男14例，女27例，均有免疫抑制剂应用史。多为3个月～4年内发现肺结核(80．5％)。临床症状以发热为主(87．8％)。痰液、胸液、脑脊液或支气管灌洗液的涂片结核分枝杆菌涂片或培养阳性者23例(56．1％)，经纤支镜活检或淋巴结活检病理证实6例(14．6％)，临床结合X线胸片诊断12例(29．3％)。治疗疗程多为9～12个月。34例完成全疗程，7例未完成治疗者中5例为严重的肝功能损害或胃肠反应重而停药，有2例死于全身衰竭。结论 对长期使用免疫抑制剂，免疫防御机制功能低下者，定期作临床随访检查，及时发现和早期治疗结核病尤其重要。     

恶性肿瘤合并结核病33例分析

目的探讨恶性肿瘤患者中结核病的发病情况及临床特点，提高其早期确诊率。方法对我院1991年1月-2007年12月33例合并结核病的恶性肿瘤患者临床资料进行回顾性分析和总结。结果33例患者占同期我院诊断恶性肿瘤患者总数的1．61‰，其中实体瘤合并结核病患者31／33例，占同期实体瘤患者的1．6‰，血液系统恶性肿瘤2／33例，占8．1‰。结核部位：肺结核30例（90．9％），浆膜腔结核3例（9．1％）。发热23例（69．7％），咳嗽19例（57．6％），消瘦乏力28例（84．8％）。检出抗酸杆菌5例（15．2％），菌阴肺结核25例（75．8％），病理确诊3例（9．1％）。接受一线抗结核药物治疗的患者25例，22例有效（88．0％），无因结核病死亡的病例；5／25例患者抗结核治疗的同时进行肿瘤治疗，结核病亦得到有效控制。对恶性肿瘤行综合治疗后近期疗效尚好，总有效率为（22／33）66．7％。结论结核病在本院恶性肿瘤患者中较常见，有吸烟史的中老年男性结核病人为合并恶性肿瘤的高危人群，其临床表现无特异性，消瘦乏力及发热是最常见症状；菌阴肺结核占多数，肺部为最常见受累部位；一线抗结核药物治疗有效。     

412例初治菌阴肺结核临床分析

目的探讨菌阴肺结核临床特点和相关诊断方法。方法对2004年6月-2006年2月间诊断初治菌阴肺结核412例进行总结分析，对其临床表现、X线特征等动态观察，治疗前及治疗2、5、6个月末各查痰涂片3张，治疗前痰菌培养1次，同时进行结合抗体及PPD检测。结果菌阴肺结核临床症状以咳嗽咳痰、乏力、盗汗为主，但症状轻微，另11．4％无任何症状在体检时发现。常规剂量全程抗结核治疗后，临床症状改善及X线吸收好转率达到98．3％。结论菌阴肺结核临床症状轻微，X线胸片是诊断菌阴肺结核重要手段之一。结合相关实验室检查并排除其他疾病而综合判定，6个月方案对菌阴病人是可取的，91．5％病例病灶有较明显吸收。     

17例肺支气管囊肿长期误诊肺结核原因分析

目的：通过对肺支气管囊肿（pulmonary bronchogenic cyst,PBC)长期误诊为肺结核的原因分析，提出二种疾病的鉴别诊断能力，方法：对17例经手术病理证实的PBC长期误诊肺结核原因进行回顾性分析。结果：长期误诊肺结核的PBC患者占同期手术治疗的PBC的43．6％（17／39）。主要症状：咳嗽、咳痰、咯血、胸痛、低热和乏力，X线表现形态多样，球形病变10例，部分有卫星灶及钙化灶，空洞或溶解等，在片密度不均匀阴影5例，一侧毁损肺1例，叶间裂积液1例。所有病人均查痰结核菌阴性，正规抗结核治疗后复咳痰、咯血、发热11例（64．7％）,无效6例（35．3％），结论：误诊原因是对不典型的PBC缺乏认识。痰结核菌阴性而临床症状和X线表现与肺结核相似、经正规抗结核治疗后仍反复发作或无效的病人，应考虑到PBC。     

结核性脑膜炎100例临床分析

目的探讨成人结核性脑膜炎的临床特点、脑脊液改变、影像学特点、诊治方法及其转归。方法回顾性分析1982年1月至2003年12月间在北京协和医院确诊或临床诊断为结核性脑膜炎的100例住院患者的临床资料。结果100例结核性脑膜炎患者中,男性49例,女性51例;年龄（31±11）岁。70％为慢性病程（11．1±9．2）周。13例确诊病例,脑脊液结核杆菌培养阳性,或开颅脑活检病理证实为结核性肉芽肿或粟粒样结核;87例为临床诊断病例。临床表现以发热（97％）,头痛（92％）、意识障碍（71％）和脑膜刺激征多见（77％）,44例伴颅神经损害,以动眼神经和外展神经受损为主。35例X线胸片有活动性肺结核表现,肺外活动性结核12例,陈旧性肺结核18例。腰穿示颅内压增高者占86％,脑脊液呈非化脓性改变,白细胞增高以淋巴细胞为主,蛋白质明显增高,葡萄糖显著下降。52例患者头颅影像学有异常发现,脑室扩张、交通性脑积水和脑梗死最常见。全部病例均接受抗结核治疗,9例行侧脑室外引流术。81例患者病情好转,4例因合并开放性肺结核转结核病院治疗,8例自动出院,死亡7例。结论慢性脑膜炎若伴发肺结核或肺外结核者应高度疑诊结核性,鉴别诊断和诊断性抗结核治疗有效有助诊断。脑脊液涂片和（或）培养抗酸杆菌／结核分枝杆菌阳性,以及脑活检为诊断的金标准。早期诊断、早期治疗是改善本病预后的关键。     

72例鼻咽结核的临床分析

目的 探讨鼻咽结核的诊断与治疗。方法 对72例经活检病理证实的鼻咽结核进行回顾性分析。结果 72例患者中男性31例，女性41例，男女比例为1：1．32，平均年龄为30．7岁；鼻咽结核以局部症状为特征，颈淋巴结肿大发生率为79．2％（57／72）；鼻咽结核在临床上误诊率较高；抗结核治疗9～12个月治愈，随访1～5年，未见复发。结论 近年来鼻咽结核有增加的趋势，尤以原发性病例居多。鼻咽镜活检可确诊，规则抗结核治疗可治愈。     

安徽省非结防机构网络报告肺结核病人转诊到位前的诊疗情况调查分析

目的了解安徽省医疗机构结核病人诊疗情况和转诊工作,为今后制定相关政策提供依据。方法根据地理结构,选择萧县、定远县、肥西县、贵池区等4个县（区）开展此项工作,能基本上反映出安徽省的情况。对2008年4月1日至9月30日期间非结防机构网络报告的并到专科门诊就诊的所有肺结核病人逐个进行《非结防机构网络报告肺结核病人转诊到位前的诊疗情况个案调查表》问卷调查。结果83.4%的肺结核病人有症状时,首选综合医院和乡镇卫生院;有90.8%的病人进行了转诊;在其他医疗机构诊疗人均花费1422元;仅有14.9%的做过痰涂片检查;调查对象身体正常时人均年收入5056元,患病后年收入为2479元。 结论医疗机构对结核病病人的转诊较好,但病人在转诊前诊疗的花费较大,可能会影响病人进一步接受规范治疗的依从性。     

Antithyroid drug-induced agranulocytosis: special reference to normal white blood cell count agranulocytosis.

This retrospective study was aimed at revealing the incidence of normal white blood cell (WBC) count agranulocytosis in patients treated with antithyroid drugs (ATDs). From January 1975 to December 2001, 109 patients (0.35%) presented with ATD-induced agranulocytosis at our clinic. In 18 patients (16.5%), the WBC count exceeded 3.0 x 10(9)/L at the onset of agranulocytosis. Ten showed a downward trend in WBC count (3.0-3.9 x 10(9)/L) after the initiation of ATDs. Four had symptoms of infection. In the remaining 4 patients, routine WBC and granulocyte count monitoring detected an agranulocytosis. During the first 3 months of ATD treatment, 3347 patients (10.9%) had WBC count 3.0-3.9 x 10(9)/L even once with no symptom and normal granulocyte count and 26672 patients had WBC count >or= 4.0 x 10(9)/L with no symptom and normal granulocyte count. When agranulocytosis was found, twelve patients with normal WBC count agranulocytosis (0.36%) had WBC count 3.0-3.9 x 10(9)/L with no symptom, whereas only 2 patients with agranulocytosis (0.008%) had WBC count >or= 4.0 x 10(9)/L with no symptom. In conclusion, clinicians should take normal WBC count agranulocytosis into consideration at least during the first 3 months of antithyroid drug therapy, especially when WBC count is 3.0-3.9 x 10(9)/L.     

Association of white blood cell count with metabolic syndrome in patients undergoing peritoneal dialysis

Metabolic syndrome is associated with an increased risk of diabetes and cardiovascular disease. Although some data suggest that the prevalence of metabolic syndrome is higher in patients undergoing peritoneal dialysis (PD), the factors related to this increased risk are not well elucidated. We therefore examined whether peripheral white blood cell (WBC) count is correlated with the risk of metabolic syndrome in nondiabetic PD patients. We enrolled 104 nondiabetic PD patients without current infections or chronic inflammatory diseases. Complete blood cell count, anthropometry, blood pressure, fasting glucose, insulin, and lipid profiles were measured. Metabolic syndrome was defined in accordance with the National Cholesterol Education Program (Adult Treatment Panel III) criteria. Metabolic syndrome was present in 49 patients (47.1%). Patients with metabolic syndrome had a higher WBC count and high-sensitivity C-reactive protein level. As the number of metabolic syndrome components increased, WBC count increased significantly. White blood cell count was significantly positively correlated with body mass index, insulin, homeostasis model assessment of insulin resistance, and triglyceride and negatively correlated with high-density lipoprotein cholesterol. The risk of metabolic syndrome increased significantly with a higher WBC count, resulting in an adjusted odds ratio of 1.65 (per 10³/μL increase, P = .002). These findings demonstrate that metabolic syndrome is prevalent among nondiabetic PD patients and that WBC count is strongly associated with metabolic syndrome and its components.     

Causes of death of patients with tuberculosis

The authors analyzed 310 case histories of patients who had died from tuberculosis. The factors predisposing to death were shown to be poor social being, bad habits, severe tuberculosis, and concomitant diseases. Among them there were prevalent fibrocavernous or disseminated tuberculosis that was complicated by the development of caseous pneumonia in every four patients. The main causes of death were progressive tuberculosis (52.7%), cardiopulmonary failure (26.9%). Generalized tuberculosis was responsible for death in 6% of the patients.     

结核性大叶性肺炎的临床研究

目的　分析结核性大叶性肺炎的临床特点。方法　对本院2 0 0 2年3月至2 0 0 4年3月所收治的1 5例结核性大叶性肺炎的临床特点进行综合分析。结果　①起病急骤,②全身症状明显,病灶变化快,部位不典型,咳嗽、咳痰,肺实变体征及肺部湿罗音,似大叶性肺炎。③白细胞正常,或减少:胸片及CT片有大片或肺叶分布的渗出性病变。④痰菌阳性率高。⑤多种抗生素治疗无效,抗痨治疗后效果显著。结论　随着不典型肺结核的不断增加,早期诊断和及时治疗至关重要。强化抗结核治疗能获得满意疗效。     

TB-SA基因检测在结核病诊断的临床应用研究

目的　研究结核分枝杆菌特异性基因(Tuberculosis-Specific AntigenTB-SA)在结核病诊断中的应用价值。方法 选择2004年4—9月期间在成都市结核病防治院的住院结核病患者371例。其中肺结核307例;肺外结核64例(结核性胸膜炎47例、结核性腹膜炎7例、结核性脑膜炎10例);非结核病的呼吸系统疾病患者61例(肺炎4例、肺癌9例,急性支气管炎7例、慢性支气管炎14例、哮喘10例,COPD12例、肺间质纤维化1例、支气管扩张3例、矽肺1例);同时选择无结核疾患健康志愿者40例,全部选例均知情同意。入选肺结核病例和健康选择痰液、肺外结核病例选择胸腔积液、腹腔积液、脑脊液等标本进行抗酸杆菌浓缩集菌,结核杆菌培养和TB-SA基因扩增(PCR)。结果 307例肺结核患者中PCR检测TB-SA阳性259例,敏感性为84.4%(259/307);细菌学培养阳性193例,敏感性62.9%(193/307);痰浓缩集菌镜检阳性95例,敏感性30.9%(95/307)。64例肺外结核患者中,TB-SA阳性35例;敏感性54.7%(35/64);核杆菌培养阳性5例,敏感性7.8%(5/64)。61例非结核呼吸系统病患者中,TB-SA阳性2例,特异性96.7%(59/61)痰涂片无阳性病例。40例健康志愿者,TB-SA及痰涂片均无阳性出现,特异性达100%(40/40)。结论 TB-SA基因检测的特异性及敏感性都取得了满意的效果。操作也较为简单。     

Application and problems of quantiFERON TB-2G for tuberculosis control programs--(2) clinical use of quantiFERON TB-2G

BACKGROUND: QuantiFERON TB-2nd Generation (QFT) is an accurate tool for detecting tuberculosis infection regardless of past history of BCG vaccination. In Japan, QFT test was recognized for diagnostic tool on April 2005, and adopted officially on January 2006. Tuberculosis Society issued Guideline for using QFT-2G on May 2006. PURPOSE: This article describe the usefulness and remarks in clinical use on diagnosis and system for detection of tuberculosis infection among staff in NHO Tokyo Hospital that has 100 beds for tuberculosis. METHOD: (1) QFT test for 403 definite diagnosed tuberculosis patient before tuberculosis treatment or within 7 days chemotherapy in NHO Tokyo Hospital. Seventy-four patients have immunosuppressive diseases such as diabetes mellitus, malignant disease, using corticosteroid or immunosuppressor and HIV+ including overlap diseases. QFT result was analyzed by immunosuppressive diseases and by age for 329 patients who have no immunosuppressive diseases. (2) For control of tuberculosis infection of staff, QFT test is used in 3 situation. One is baseline QFT for staff who are shifted to tuberculosis ward from non-tuberculosis ward and new employee, 2nd is following up for staff who work at tuberculosis ward, and 3rd is contact investigation for staff who work at non-tuberculosis ward. Tuberculin skin testing and baseline QFT were done for 92 staff on April 2006, 2 were shifted to tuberculosis ward from non-tuberculosis ward and 90 were new employee. RESULT: (1) Among 403 definite diagnosed tuberculosis patient before tuberculosis treatment or within 7 days chemotherapy, QFT positive rate was 78.7%. Among 74 patients who have immunosuppressive diseases such as diabetes mellitus, malignant disease, using corticosteroid or immunosuppressor and HIV+ including overlap diseases, QFT positive rate was 58-70%. Among 329 patients who have no immunosuppressive diseases, QFT positive rate was 88-89% in thirties and forties, 69% in sixties and 63% in nineties. QFT-2G test for 134 previously treated tuberculosis cases who are not suffered from active tuberculosis, 49 cases (37%) were positive, 27 cases (20%) were intermediate and 58 cases (43%) were negative. Instructive three cases were reviewed. Suspicion of tuberculosis relapse with QFT negative case was M. avium-intracellulare disease. Suspicion of M. avium-intracellulare disease rather than tuberculosis by X-ray and CT with QFT positive case was tuberculosis. A case with small nodule on CT with QFT positive was adenocarcinoma. (2) Tuberculin Skin Testing and baseline QFT for 92 staff, 4 were QFT positive. Compared with Tuberculin Skin Testing more than 29 mm in erythema, QFT positive rate was 9% and more than 9 mm in induration, QFT positive rate was 7%. By following up QFT test for staff working at tuberculosis ward, 2 staff, one nurse and one helper, were diagnosed tuberculosis infection. As to contact investigation, one nurse was diagnosed tuberculosis infection. CONCLUSION: Although QFT is a very excellent tool for detecting tuberculosis infection, on clinical diagnosis, it is important to mind that QFT depends on clinical condition especially immunosuppressive diseases, aging and past infection. We cannot diagnose or exclude active tuberculosis by QFT result. This is a useful assistant tool on clinical diagnosis.     

Rapid detection and successful treatment of esophageal perforation after radiofrequency ablation of atrial fibrillation: lessons from five cases

Introduction: The aim of the study was to identify criteria for rapid recognition and successful treatment of esophageal perforation after radiofrequency ablation for atrial fibrillation (AF).
Methods and Results: Esophageal perforation occurred in five patients after intraoperative (n = 4) or percutaneous (n = 1) AF ablation. Patients presented with high fever (n = 3) or severe chest/epigastric pain (n = 2) 8–28 days after ablation. WBC count was elevated at presentation in all patients (15,460 ± 2,910/μL), CRP showed a delayed rise. Thoracic CT detected free air in all. Neurologic complications occurred in three cases (60%) with a delay of 5–40 hours after first symptoms. Only one (20%) developed neurologic complications within the first 24 hours. Two patients (40%) died before surgery could be performed. In both, time from symptom onset to diagnosis was significant (24 and 36 hours). Three patients (60%) underwent esophageal resection and survived. In two of them, treatment was rapid with time from symptoms to surgery of 24 hours; they had favorable outcome. In the third surviving patient, surgery was late (5 days after first symptoms); permanent neurologic residues remained.
Conclusion: The leading symptom of esophageal perforation is high fever or severe chest/epigastric pain. Fever is not necessarily present. Leukocytosis is the earliest and most sensitive laboratory marker, thoracic CT the most valuable diagnostic examination. The dramatic neurologic complications occur with a delay of at least a few hours after first symptoms. Immediate surgery may prevent neurologic complications and could possibly result in a high survival rate without residues. Delay of treatment seems to have devastating results.     

Effect of statins and white blood cell count on mortality in patients with ischemic left ventricular dysfunction undergoing percutaneous coronary intervention

BACKGROUND: While morbidity and mortality were shown to be increased in the setting of an elevated white blood cell (WBC) count for patients with acute coronary syndrome, the impact of statin therapy on mortality for patients with an elevated WBC count is unknown in high-risk patients with coronary artery disease. HYPOTHESIS: The goal of this study was to determine whether statin therapy improved survival in patients with elevated WBC count undergoing percutaneous coronary intervention (PCI) with preexisting left ventricular (LV) dysfunction, a population at high risk for adverse outcomes. METHODS: We retrospectively evaluated consecutive patient procedures performed at our institution from 1996 through 1999. Patients had a technically adequate angiographic left ventriculogram with a calculated ejection fraction (EF) < or = 50%. Patients with prior coronary artery bypass graft were excluded. Mortality data were retrieved using the U.S. Social Security Death Index. Follow-up ranged from 3.5 to 6.5 years. Means are provided with +/- standard deviation, and p values < 0.05 were considered significant. RESULTS: Of the study population of 238 patients (average EF 39 +/- 9.8%, mean age 57.5 +/- 12 years, 68% men) 61% underwent PCI for a recent myocardial infarction, 68% received stents, and 65% were discharged on statins. Mean WBC count was 9,000 +/- 3,100 cells/mm3, with 28% of patients having a WBC > or = 10,000 cells/mm3. During follow-up, 27% of our population died. Patients with a WBC > or = 10,000 had worse survival than patients with WBC < 10,000 (1-year survival: 86 vs. 96%, p < 0.05; 3-year survival: 79 vs. 89%, p < 0.05). Survival was significantly improved in patients on statin therapy regardless of WBC count, but the greatest benefit tended to be in patients with WBC > or = 10,000 (WBC > or = 10,000; odds ratio [OR] 5.14, 95% confidence interval [CI] 1.44-19.0, WBC < 10,000; OR 2.79,95% CI 1.13-7.1). Proportional hazard regression analysis demonstrated that both statin therapy and WBC count predicted mortality. CONCLUSION: Patients undergoing PCI with LV dysfunction discharged on statins had improved survival regardless of WBC count, with a trend for greater improvement in patients with elevated WBC counts. In addition, WBC count predicts mortality in this high-risk population with LV dysfunction undergoing PCI.