肺炎支原体快速鉴定培养法对成人支原体肺炎早期诊断价值的研究

目的探讨咽拭子肺炎支原体（MP）快速鉴定培养法对成人社区获得性肺炎支原体肺炎的早期诊断价值。方法应用肺炎支原体快速鉴定培养基对住院的105例社区获得性肺炎（CAP）患者的咽拭子标本进行肺炎支原体快速鉴定培养。同时对所有病例于发病后7~14 d检测血清MP-IgM抗体。结果 105例住院CAP患者咽拭子MP快速鉴定培养,阳性23例,阳性率21.9%。MP-IgM抗体检测阳性19例,阳性率18.1%。MP-IgM抗体检测阳性的19例患者MP快速培养均为阳性。结论咽拭子肺炎支原体快速鉴定培养法可以实现肺炎支原体肺炎的早期诊断,及时正确治疗。     

Serial antinuclear antibodies titre in pleural and pericardial fluid.

The antinuclear antibodies (ANA) test has been a cornerstone of the evaluation of connective tissue disease. The aim of this study was to investigate the diagnostic value of the ANA test in pleural or pericardial effusions of unknown causes. Over a 3-yr period, a total of 126 pleural fluid and 30 pericardial fluid samples were analysed. ANA tests were performed using a commercially available kit. The ANA kit used an indirect immunofluorescent antibody method with a human epithelial (HEP-2) cell line as substrate. Patients with high fluid ANA titre (>1:160) received a second aspiration 2 weeks after the initial aspiration if diagnosis was not confirmed. ANA results were positive in 39 pleural and 10 pericardial fluid samples. All but one of the effusions with positive ANA testing were exudative. Eleven pleural or pericardial effusions due to active systematic lupus erythematosus were identified and all had high ANA titres (1:160) with various staining patterns. Thirty-eight of 145 patients (26%) with effusions of nonlupus aetiologies had positive ANA testing in pleural or pericardial fluid. Thirteen of these 38 patients had high ANA titre. Malignant or paramalignant effusions constituted 11 of the 13 samples. In conclusion, although a negative antinuclear antibodies test makes a diagnosis of lupus serositis unlikely, high antinuclear antibodies titres in pleural or pericardial fluid are not diagnostic of lupus serositis even when as high as 1:5,120. An unexplained high antinuclear antibodies titre in pleural or pericardial effusion warrants search for malignancy.     

Comparison of intuitive versus systematic strategies for aetiological diagnosis of pericardial effusion

In an attempt to elucidate better the various aetiologies of pericardial effusion, we developed a diagnostic protocol that incorporated a battery of systematic tests including blood cultures, throat swab cultures and serological tests for various infectious agents and estimation of serum antinuclear antibodies and serum thyroid-stimulating hormone. Over a 2-y period ending May 2000, we evaluated prospectively and diagnostic usefulness of our strategy in a cohort (n = 136) of patients with pericardial effusion treated at Hospital Timone (HT), Marseille. We compared our findings with those observed in a retrospectively (May 1998-May 2000) drawn cohort (n = 127) of patients treated at Hospital Louis Pradel (HLP), Lyon and in which the laboratory investigation towards establishing an aetiological diagnosis was undertaken intuitively. Overall, the aetiologies were obvious clinically in 18% of cases. In other cases, specific aetiologies (27.3% vs 3.9%; p < 0.001), including treatable conditions (11.1% vs 2.4%; p < 0.001) were identified significantly more frequently in the HT cohort compared to the HLP cohort. The diagnosis strategy we propose may be helpful in elucidating the aetiological diagnosis of pericardial effusion when a cause is not obvious clinically.     

Diagnosis and management of pericardial effusion

Pericardial effusion is a common finding in everyday clinical practice.The first challenge to the clinician is to try to establish an etiologic diagnosis.Sometimes,the pericardial effusion can be easily related to a known underlying disease,such as acute myocardial infarction, cardiac surgery,end-stage renal disease or widespread metastatic neoplasm.When no obvious cause is apparent,some clinical findings can be useful to establish a diagnosis of probability.The presence of acute inflammatory signs(chest pain,fever,pericardial friction rub) is predictive for acute idiopathic pericarditis irrespective of the size of the effusion or the presence or absence of tamponade.Severe effusion with absence of inflammatory signs and absence of tamponade is predictive for chronic idiopathic pericardial effusion,and tamponade without inflammatory signs for neoplastic pericardial effusion.Epidemiologic considerations are very important,as in developed countries acute idiopathic pericarditis and idiopathic pericardial effusion are the most common etiologies,but in some underdeveloped geographic areas tuberculous pericarditis is the leading cause of pericardial effusion.The second point is the evaluation of the hemodynamic compromise caused by pericardial fluid.Cardiac tamponade is not an"all or none"phenomenon,but a syndrome with a continuum of severity ranging from an asymptomatic elevationof intrapericardial pressure detectable only through hemodynamic methods to a clinical tamponade recognized by the presence of dyspnea,tachycardia,jugular venous distension,pulsus paradoxus and in the more severe cases arterial hypotension and shock.In the middle,echocardiographic tamponade is recognized by the presence of cardiac chamber collapses and characteristic alterations in respiratory variations of mitral and tricuspid flow.Medical treatment of pericardial effusion is mainly dictated by the presence of inflammatory signs and by the underlying disease if present.Pericardial drainage is mandatory when clinical tamponade is present.In the absence of clinical tamponade,examination of the pericardial fluid is indicated when there is a clinical suspicion of purulent pericarditis and in patients with underlying neoplasia.Patients with chronic massive idiopathic pericardial effusion should also be submitted to pericardial drainage because of the risk of developing unexpected tamponade.The selection of the pericardial drainage procedure depends on the etiology of the effusion.Simple pericardiocentesis is usually sufficient in patients with acute idiopathic or viral pericarditis.Purulent pericarditis should be drained surgically,usually through subxiphoid pericardiotomy. Neoplastic pericardial effusion constitutes a more difficult challenge because reaccumulation of pericardial fluid is a concern.The therapeutic possibilities include extended indwelling pericardial catheter,percutaneous pericardiostomy and intrapericardial instillation of antineoplastic and sclerosing agents.Massive chronic idiopathic pericardial effusions do not respond to medical treatment and tend to recur after pericardiocentesis, so wide anterior pericardiectomy is finally necessary in many cases.     

A systematic diagnostic approach to primary acute pericardial disease. The Barcelona experience

Acute pericarditis and cardiac tamponade without a definite cause at the time of the initial hospital evaluation are defined as primary acute pericardial disease. In immunologically competent patients from the Western World, most cases (more than 80%) are idiopathic. However, severe specific diseases may be present in the remaining cases, the clinical features often providing insufficient clues to the etiologic diagnosis. A systematic approach to these patients is therefore needed. It is relevant to this approach that pericardiocentesis and pericardial biopsy have a much higher diagnostic yield when performed in patients with cardiac tamponade than when they are performed for purely diagnostic purposes. Strategies to increase this yield might be devised on the basis of noninvasive findings.     

纤维心包镜在中大量心包积液病因诊断中的应用

目的观察纤维心包镜在中大量心包积液诊断中的作用。方法对188例中大量心包积液病因不明患者进行剑突下心包开窗术及纤维心包镜检查,明确心包积液病因及镜下表现。结果癌性心包炎90例,心包积液多为血性,符合镜下特征51例,临床病因诊断符合率56.7%;非特异性心包炎67例,诊断符合率56.7%;结核性心包炎22例,诊断符合率63.6%;化脓性心包炎8例,诊断符合率100%。术中曾出现心率减慢、血压偏低7例,气胸6例,腹膜损伤3例,偶发室性期前收缩30例,减压性肺水肿6例,经相应治疗或自行缓解。结论纤维心包镜对中大量心包积液的病因诊断有较大的实用价值。     

Direct invasion of the central nervous system by Mycoplasma pneumoniae: a report of two cases

We studied two patients with involvement of the central nervous system (CNS) associated with Mycoplasma pneumoniae. One patient had encephalitis and acute cerebellar ataxia, whereas the second had a mixed picture of encephalitic reaction superimposed on a disseminated malignancy of unknown origin. Specific IgM antibodies to M. pneumoniae were detected in the patients' sera but not in their cerebrospinal fluid. M. pneumoniae was repeatedly isolated by cultures from throat swabs and cerebrospinal fluid samples from both patients. Our patients add to previous reports suggesting that CNS involvement may result from direct invasion of the CNS by the pathogen.     

First report on clinical features of Mycoplasma pneumoniae infections in Vietnamese children

Mycoplasma pneumoniae is a common cause of community-acquired pneumonia (CAP) in children, but there has been no clinical report on M. pneumoniae infections in Vietnamese children. We investigated the clinical features of M. pneumoniae infection when the pathogen was detected in the respiratory tract in hospitalized children aged 1-15 years due to lower respiratory tract infections or CAP in Vietnamese children. Throat swabs from 47 patients (18.6%) of 252 patients with a clinical diagnosis of CAP were PCR positive (male, 34; female, 13), and 21 throat swabs (8.3%) showed culture positive for M. pneumoniae. The M. pneumoniae pathogen could be detected by PCR and/or culture in 52 patients (male, 36; female, 16). The major clinical signs in the 52 patients were fever (>38 degrees C) in 100%, pharyngitis in 100%, tachypnea in 94%, dry cough in 86.5%, and rough breathing in 83% of patients. The average term of illness prior to hospitalization was 7.5+/-4.1 days, and the average number of hospitalized days was 7.9+/-3.5 days. Beta-lactam group antibiotics, which were ineffective against M. pneumoniae infection, were used in 37 cases (71%).     

Tuberculous pericardial effusion--mediastinal lymph glands: the cause and clue to the etiology

BACKGROUND: Tuberculous pericardial effusion is most often due to the spread of tuberculosis from the mediastinal lymph glands; however, no attempt has yet been made to study these glands. We studied the mediastinal glands in proven tuberculous pericardial effusion patients and hypothesized that the findings may be of use in the etiological diagnosis of pericardial effusion. METHODS AND RESULTS: We studied 45 patients with large pericardial effusion or tamponade. All underwent chest computed tomographic studies that were reviewed by radiologists blinded to the diagnosis. Of these 45 patients, 27 had tuberculosis and 18 had viral or idiopathic effusion. Pericardial biopsy was done in 25/27 and tuberculin skin test in 22/27 patients with tuberculosis, and all received specific treatment. In patients with tuberculosis the skin test measured 17+/-3.3 mm. All 27 had mediastinal lymph glands > or = 10 mm in size. The mean size of the mediastinal glands was 19.5+/-8.6 mm and the mean number was 2.5+/-1.2. The aortopulmonary glands were the most frequently enlarged (63%), and hilar the least often (14.8%). The glands showed a hypodense center in 52% of the patients. On follow-up of 15.8+/-10.4 months, glands were not seen in 80.9%, and were smaller in size in 19%; none had a hypodense center. Marked lymphadenopathy was not seen in any patient with viral/idiopathic pericardial effusion. Two had glands < or = 5 mm in size. CONCLUSIONS: Only patients with tuberculosis had substantial mediastinal lymph gland enlargement and not those with viral or idiopathic pericardial effusion. Such glands disappeared or regressed on treatment. In the appropriate clinical context, marked nonhilar mediastinal lymphadenopathy on chest computed tomographic studies along with a strongly positive tuberculin skin test could be of value in the noninvasive diagnosis of pericardial effusion due to tuberculosis.     

Leistungsknick, Thoraxschmerz und Polyserositis bei einem 35-jährigen Patienten mit antikonvulsiver Therapie

We report on a rare case of a late-onset drug-induced lupus erythematosus. A 35 year old male patient complained about dyspnea, chest pain and reduced physical activity for three months. His medical history consisted of epilepsy treated with carbamazepine for 20 years. After diagnosis of a large pericardial effusion and percardiocentesis (1200 ml) the diagnosis of viral perimyocarditis was suspected. Under antiphlogistic treatment the symptoms vanished initially. Four weeks later the pericardial effusion recurred and a livedo reticularis became evident. A structural or infectious heart disease, in particular viral myocarditis, was ruled out invasively. Serologic testing revealed antinuclear antibodies and antibodies against histones without presence of antibody against ds-DNA, thereby confirming the diagnosis of carbamazepine-induced lupus erythematodes. After discontinuation of carbamazepine and immunosuppressive medication the patient recovered completely.     

Pericardial windows or pericardiocentesis for pericardial effusions

The hospital records of 20 patients admitted to Parkland Memorial Hospital in Dallas with pericardial effusion during the four-year period of 1966 to 1969, and who underwent pericardiocentesis and percutaneous open pericardial windows, were reviewed. The etiologies of the effusions were as follows: purulent pericarditis (5), hypertensive and ischemic heart disease with congestive heart failure (4), and chronic idiopathic effusion (4). Specific etiologic diagnoses were made from the pericardial biopsy in only two cases (10 per cent), while 13 (65 per cent) had at least one serious complication in the postoperative period with eight (40 per cent) developing secondary infection. Twenty-one patients underwent pericardiocenteses without complications and four etiologic diagnoses (20 per cent) were made. Suggestions for indications for these procedures are presented.     

The classification of pericardial disease in the age of modern medicine

The spectrum of pericardial diseases comprises pericarditis, pericardial neoplasms, cysts, and congenital defects. Due to the insufficient diagnostic value of standard, noninvasive diagnostic techniques, many cases remained etiologically unclear, and were therefore classified as idiopathic. A major improvement in the classification of pericardial disease is its clear distinction between the two most frequent forms of idiopathic pericarditis: viral infection and autoreactive pericarditis. This classification has major therapeutic consequences. In autoreactive forms, systemic and intrapericardial corticosteroid treatment has a favorable effect; its application in viral forms is contraindicated. The new classification of pericardial diseases synthesizes the achievements of modern imaging with molecular biology and immunology. Systematic implementation of new techniques of pericardial fluid analyses, pericardioscopy and pericardial biopsy, and the application of molecular biology and immunology techniques have opened new windows to the pericardial diseases, permitting early specific diagnosis, and creating foundations for etiologic treatment in many cases.     

Diagnostic utility of the polymerase chain reaction for the diagnosis of Mycoplasma pneumoniae in elderly patients with community-acquired pneumonia

Mycoplasma pneumoniae is a common cause of community-acquired pneumonia (CAP) in children and young adults, but limited information about its prevalence in the elderly is available. The polymerase chain reaction (PCR) with primers targeting the cytadhesine P1 gene and the 16S rRNA gene was analyzed for detecting M. pneumoniae in throat washings of 84 patients, aged 60-96 years, with clinical diagnosis of CAP, from September 2002 through August 2004, in Santiago, Chile. PCR results were compared with serology performed by indirect immunofluorescence (IFI). Specimens from 11 of 84 patients (13.1%) were positive for M. pneumoniae by any test. The IFI test was positive in 8 (72.7%) patients and PCR in 7 (63.6%) cases. The acute phase sera allowed diagnosis of M. pneumoniae in 5 of 11 patients (45.4%), 4 of them showing an IgM response. PCR was negative in 4 patients with positive serology and 3 patients were positive only by PCR. The two PCR primers showed 100% correlation, and a similar sensitivity; no inhibitory specimens for PCR were detected. In conclusion, M. pneumoniae should be considered as a potential etiologic agent of CAP in the elderly. Its detection must be performed by a combination of PCR and serology.     

Clinical clues to the causes of large pericardial effusions

PURPOSE: To examine whether the size of the effusion, the presence of tamponade, and inflammatory signs are useful in determining the causes of moderate or severe pericardial effusions.SUBJECTS AND METHODS: All echocardiograms performed at a general hospital between January 1990 and April 1996 were screened for pericardial effusion. Patients with moderate (echo-free space of 10 to 20 mm during diastole) or severe (echo-free space >20 mm) effusions were studied. RESULTS: We identified 322 patients (166 [52%] men, mean [+/- SD] age 56 +/- 17 years [range 15 to 88 years]), 132 (41%) with moderate and 190 (59%) with severe pericardial effusion. The most frequent etiologic diagnoses were acute idiopathic pericarditis (n = 66 [20%]), iatrogenic effusions (n = 50 [16%]), cancer (n = 43 [13%]), and chronic idiopathic pericardial effusion (n = 29 [9%]). In 192 (60%) of the patients, the cause of the effusion was a known medical condition. In the 130 other patients, inflammatory signs were associated with acute idiopathic pericarditis (likelihood ratio = 5. 4, P < 0.001), severe effusions without inflammatory signs or tamponade were associated with chronic idiopathic pericardial effusion (likelihood ratio = 20, P < 0.001), and tamponade without inflammatory signs was associated with malignant effusions (likelihood ratio = 2.9, P < 0.01).CONCLUSIONS: In many patients, pericardial effusions are due to a known underlying disease or condition. In patients without underlying diseases, inflammatory signs, the size of effusion, and the presence or absence of cardiac tamponade can be helpful in establishing cause.     

A prospective study of community-acquired pneumonia in Hong Kong.

A prospective study of community-acquired pneumonia in Hong Kong was carried out between January and December, 1988. Ninety adults (57 male) with a mean age of 57.3 years were admitted to the Prince of Wales Hospital with community-acquired pneumonia. The etiologic diagnosis of pneumonia was made in 37 cases (41 percent). Pneumococcal infection was diagnosed in 11 patients (12 percent). The same number of patients had pulmonary tuberculosis presenting as acute pneumonia. It could not be differentiated from other causes of pneumonia on clinical and radiologic grounds, although pleural effusion and upper lobe involvement were more common in patients with tuberculosis. Chlamydia species were identified in five patients (6 percent) and Mycoplasma pneumoniae was identified in three patients (3 percent). There was no case of Legionnaires' disease. The etiologic agent could not be identified in 59 percent of cases. The low incidence of etiologic diagnosis of community-acquired pneumonia was probably related to the widespread use of antibiotics in private practice. Tuberculosis is an important cause of community-acquired pneumonia in Hong Kong and this diagnosis should be considered in patients who fail to respond to first-line antibiotics.     

Mycoplasma pneumoniae and Legionella pneumophila in community-acquired lower respiratory tract infections among hospitalized children: diagnosis by real time PCR

Mycoplasma pneumoniae and Legionella pneumophila are increasingly recognized as important agents of community-acquired lower respiratory tract infections (LRTI). Mycoplasma pneumoniae has been also recognized as a cause of nosocomial infections. The aim of this study was to investigate the role of real time polymerase chain reaction (PCR) for the rapid diagnosis of these infections among hospitalized children with community-acquired LRTI. During 2001, 65 children were prospectively studied. Microbiological investigation consisted of capillary PCR with a LightCycler for M. pneumoniae and L. pneumophila in induced sputum or throat swab specimens, IgM enzyme immunoassay for M. pneumoniae and immunofluorescence for L. pneumophila in paired sera. Serology testing showed acute M. pneumoniae infection in 18 (27.5%) patients and L. pneumophila in 1 (1.5%). M. pneumoniae was also detected in sputum specimen by capillary PCR in 9 (50%) serologically diagnosed cases, including 4 (22%) with non-diagnostic IgM levels in the acute phase. Capillary PCR and IgM enzyme immunoassay diagnosed together 15 (83%) M. pneumoniae cases in the acute phase. It is concluded that M. pneumoniae is an important cause of LRTI necessitating hospitalization among children in Greece. Capillary PCR in sputum may diagnose M. pneumoniae LRTI in the acute setting and direct therapy and isolation of patients.     

Videosurgical pleuro-pericardial windows in oncology

Fifteen consecutive patients with recurrent pericardial effusion associated with confirmed neoplastic disease (N = 11) or with a triad of symptoms: weight loss, anorexia, tiredness (N = 4), underwent videosurgery through a pleuro-pericardial window. The mean age was 58 years (37-77 years). The average procedure and assisted ventilation times were 56.5 min (40-110 min) and 86 min (70-140 min) respectively. Three patients experienced cardiac arrhythmias which regressed. The patients were discharged home on the 5th day (3-11 days). In contrast to needle biopsy which only provided a diagnosis in 3 cases, the histopathological findings were diagnostic in all cases: 12 malignant and 3 benign pericardial effusions with correction of the presumed clinical diagnosis in the latter 3 cases. The average follow-up was 10 months (7 days-3.5 years). There was no operative mortality. Global survival at 1 year was 66%, death being generally caused by a complication of the malignant disease. There were no deaths in the 3 patients with benign pericardial effusions, underlying the necessity of an accurate etiologic diagnosis before assuming malignant pericardial invasion. There were no recurrences of the pericardial effusion and the ventilatory status of these patients was adapted for everyday activities. In patients with malignant disease, the construction of a pleuro-pericardial window by videosurgery is a satisfactory approach. It provides etiologic diagnosis and is well tolerated by patients in poor general condition with no operative deaths, low morbidity and definite improvement in the patients' comfort.     

Human immunodeficiency virus-associated pericardial effusion: report of 40 cases and review of the literature

BACKGROUND: Human immunodeficiency virus (HIV)-associated pericardial effusion is common. We present its clinical features, cause, and prognosis on the basis of a review of 40 cases at a single public hospital. METHODS: A retrospective study was conducted of 122 patients with pericardial effusion (of which 40 were HIV associated) admitted to Queens Hospital Center from January 1988 to April 1997. A review of the literature is also presented. RESULTS: Forty patients with HIV-associated pericardial effusion represent 33% of the 122 patients with pericardial effusion admitted during that period. The most common symptom of the 40 patients was dyspnea (75%). Echocardiogram detected small effusions in 18 (45%), moderate effusions in 10 (25%), and large effusions in 12 (30%). Sixteen (40%) patients had cardiac tamponade, in 15 of whom pericardiocentesis or pericardiostomy was performed. Causes of cardiac tamponade were Mycobacterium species in 3 (19%), Streptococcus pneumoniae in 1 (6%), Staphylococcus aureus in 1 (6%), Kaposi's sarcoma in 1 (6%), and unknown in 10 (63%). In comparison, causes of cardiac tamponade in 74 cases of acquired immunodeficiency syndrome in the literature were 45% idiopathic, 20% mycobacteria, 19% bacteria, 7% lymphoma, 5% Kaposi's sarcoma, 3% viruses, and 1% fungus. Thirteen of the 40 patients were lost to follow-up. Among the other 27, 11 (41%) were alive at 3 months and 5 (19%) at 1 year. Ten of the 27 patients had cardiac tamponade, of whom 5 (50%) were alive at 3 months and 3 (30%) at 1 year. CONCLUSIONS: HIV-associated pericardial effusion is the most common type of pericardial effusion in our inner city hospital. Causes are diverse. The development of pericardial effusion predicts a poor prognosis in HIV infection.     

Pericardial effusion in the elderly: A different disease?

INTRODUCTION AND OBJECTIVES: The aim of the present study was to assess possible differences in etiologic spectrum and clinical course of pericardial effusion in elderly patients, as has been previously suggested, and therefore determine whether clinical, management should be based on patient age. METHODS: All echocardiograms performed in our hospital from 1990 to 1996 were screened for pericardial effusion, and those with moderate or large effusions were selected. Patients under 66 years of age were included in group I, and those above 65 years were assigned to group II. RESULTS: We selected 322 patients with moderate (122) or with large (200) effusions. 221 patients being included in group I (aged 15-65, mean 47) and 101 in group II (aged 66-88, mean 72.5). Effusion was large in 60% of group I and in 66% of group II (p = NS), and tamponade occurred in 36% and 38.6%, respectively (p = NS). Specific pericardial infections (tuberculous and purulent pericarditis) were more frequent in group I (5.9 versus 0.9%; p < 0.05). No significant differences were found in incidence of idiopathic (33 vs 38%) or neoplastic (14.4 vs 10.8%) etiologies. During follow-up (96% of the patients, median time of 11 months, range 1-58 months) the mortality (24 vs 30%) and evolution to cardiac constriction (4 vs 2%) were similar in the two groups, but persistence of effusion was more common in group II (6.3 vs 14%; p < 0.05). CONCLUSIONS: Our study suggests that etiology, clinical course and prognosis of moderate and large pericardial effusion are, in general, similar in elderly and younger patients. Thus, management should be similar in the different age groups, and no etiologic form of pericardial disease should be ruled out because of patient's age when considering the differential diagnosis.