胸膜活检阳性率的主要相关因素

分析了92例胸膜活检资料,认为其阳性率与下述因素有关:疾病种类、病例选择、活检器械、取材方法及技术、重复检查、临床医师与病理医师的配合。     

Local production and localization of transforming growth factor-beta in tuberculous pleurisy.

Transforming growth factor-beta (TGF-beta) is one of the cytokines which play an immunosuppressive role in an inflammatory process. To investigate the local production of TGF-beta, we evaluated the levels of TGF-beta in tuberculous pleural effusions (TBPE) and non-tuberculous benign pleural effusions (non-TBPE) by the growth inhibition assay with Mv1Lu mink lung epithelial cells. The mean level of TGF-beta in TBPE (46.1 +/- 31.5 pM; mean +/- s.d.) was higher than in non-TBPE (21.7 +/- 12.3 pM) (P < 0.05). Although the level of interferon-gamma (IFN-gamma) in TBPE measured by ELISA was significantly higher than in non-TBPE, there was no significant difference in the levels of tumour necrosis factor-alpha (TNF-alpha) measured by ELISA between these two groups. Moreover, to elucidate localization of TGF-beta in tuberculous pleurisy, immunohistochemical studies of pleura, using the rabbit polyclonal antibody Ab39 against latent TGF-beta 1 binding protein (LTBP) were performed. Results revealed that LTBP was localized in immature fibrotic areas where infiltrations of T lymphocytes and macrophages were absent. Importantly, the major sources of LTBP in these areas were thought to be mesothelial cells and fibroblasts. LTBP was not found in granulomas and mature fibrotic areas. Our data suggest that TGF-beta in tuberculous pleurisy may play important roles for regression of granulomatous inflammation and pleural fibrosis for tissue repair.     

The value of pleural fluid anti-A60 IgM in BCG-vaccinated tuberculous pleurisy patients

Objectives   To determine if detection of IgM and IgG antibodies against mycobacterial antigen A60, together with the Mantoux tuberculin skin test (TST), could be used in the diagnosis of tuberculous pleurisy (TP) in BCG-vaccinated cases.
Methods   We investigated 125 BCG-vaccinated patients with pleural effusion. Of these, 88 had TP and 37 had non-tuberculous pleurisy (NTP). TST and anti-A60 IgM and IgG measurements by ELISA were performed in the sera and pleural effusions of both groups.
Results   Cut-off values, in optical density, for serum anti-A60 IgM, pleural fluid anti-A60 IgM, serum anti-A60 IgG and pleural fluid anti-A60 IgG were defined as 0.624, 0.614, 0.464, and 0.613, respectively. TP patients had higher IgG and IgM levels in the serum ( P  < 0.001 and P  < 0.05, respectively) and pleural effusion ( P  < 0.001 and P  < 0.001, respectively). Regardless of the diagnosis, IgG and IgM levels were higher in the sera ( P  < 0.001 and P  < 0.05, respectively) and pleural effusions ( P  < 0.001 and P  < 0.001, respectively) of TST-positive cases, and serum and pleural fluid IgM levels were higher ( P  < 0.001 and P  < 0.001, respectively) in the TST-positive TP cases. Sensitivity and specificity of TST were 65% and 68%, respectively. As a single parameter, pleural fluid anti-A60 IgM had the highest sensitivity (77%) and specificity (94%) in patients with negative TST.
Conclusion   We suggest that in populations where tuberculosis prevalence is high and BCG vaccination is common, pleural fluid anti-A60 IgM can facilitate the diagnosis of TP.     

Cytokines and fibrinolytic enzymes in tuberculous and parapneumonic effusions

Tuberculous (TB) pleurisy and parapneumonic effusion (PPE) are common causes of pleural fibrosis. The mechanisms underlying fibrin deposition may be different since involved inflammatory cells are distinct. In this study, we measured various cytokines and fibrinolytic enzymes and compared the differences between the two effusions. PPE was further divided into noncomplicated PPE and complicated PPE/empyema subgroups. Tumor necrosis factor (TNF)-alpha, interleukin (IL)-1beta, IL-6, IL-8, macrophage inflammatory protein (MIP)-1beta, monocyte chemoattractant protein (MCP)-1, plasminogen activator inhibitor type 1 (PAI-1) and tissue type plasminogen activator (tPA) were measured using enzyme-linked immunosorbent assays. Significantly higher values of PAI-1, PAI-1/tPA ratio, IL-1beta, IL-8 and MIP-1beta and significantly lower values of TNF-alpha, IL-6 and MCP-1 were observed in PPE/empyema than in TB effusions. Compared to noncomplicated PPE, complicated PPE/empyema had significantly higher levels of TNF-alpha, IL-1beta, IL-8 and MIP-1beta. TB pleurisy patients who had higher effusion levels of TNF-alpha, IL-1beta and IL-8 were predisposing to residual pleural thickening. The underlying mechanisms of fibrin formation and deposition between the two effusions studied (PPE/empyema and TB pleurisy) could not be fully explained by the results of the present study. More studies are needed to explore this further.     

胸膜纤维板剥脱术在慢性结核性脓胸中的应用效果及安全性分析

目的探讨胸膜纤维板剥脱术在慢性结核性脓胸中的应用效果及安全性。方法选取本院2008年7月～2013年12月手术救治的58例慢性结核性脓胸患者作为研究对象,所有患者术前均给予抗结核及抗感染治疗,以胸膜纤维板剥脱术作为手术方式,术后持续治疗,增强呼吸功能锻炼,有效促使肺不张。结果58例慢性结核性脓胸患者手术均顺利完成,术中出血量为（700±45）ml。经胸膜纤维板剥脱术治疗后,患者脓腔消失,病情改善较佳．无死亡病例;术后未发生肺漏气、肺不张、感染、出血等并发症。病情完全改善者50例（86．2％）,病情好转者6例（10．3％）．脓胸复发者2例（3．5％）。结论胸膜纤维板剥脱术治疗慢性结核性脓胸患者的效果显著,可有效改善患者的肺功能,与抗结核等相关治疗相结合,可降低复发率,提高患者的生存质量。     

大鼠角叉菜胶胸膜炎渗出白细胞磷脂酶D活性的变化

目的　观察在整体炎症过程中炎症白细胞磷脂酶D(PLD)活性的变化和炎症的关系。方法　采用大鼠角叉菜胶胸膜炎模型 ,以渗出液量和细胞数及渗出液中髓过氧化物酶活性 (中性粒细胞脱颗粒指标 )作为炎症程度。用酶偶联比色法测定白细胞PLD活性。结果　正常大鼠外周血白细胞PLD活性极低 ,为 ( 0 14± 0 0 3) μmol·g-1·min-1。致炎后各时间点胸膜腔渗出白细胞的PLD活性明显升高 ,分别可达 40～ 6 0倍 ,并在 3h达峰值 ,明显早于炎症高峰 ( 12h)。不同剂量 ( 5 0 0 μg和 10 0 0 μg)角叉菜胶可引起致炎 12h明显不同程度的炎症 ,但渗出白细胞PLD活性两者差别不大。低剂量吲哚美辛 ( 2mg·kg-1,ip)和地塞米松 ( 0 1mg·kg-1,ip)均明显抑制致炎 6h大鼠胸膜腔的渗出 ,但渗出白细胞PLD活性与对照组相比差别无显著性。结论　大鼠角叉菜胶性胸膜炎白细胞PLD活性显著升高 ,提示PLD活性升高在该炎症模型中是原发性表现 ,低剂量吲哚美辛和地塞米松的抗炎机制与PLD无关     

脑脊液腺苷脱氨酶联合实时荧光定量聚合酶链反应在老年结核性脑膜炎诊断中的应用

目的探讨脑脊液腺苷脱氨酶(ADA)联合试时荧光定量聚合酶链反应(PCR)技术在老年结核性脑膜炎(结脑)诊断中的意义。方法以我院近7年来收治的老年结脑107例为研究对象,随机分为对照组和试验组,对照组检测脑脊液常规、生化,试验组在此基础上利用酶比色法测定脑脊液ADA活性,利用实时荧光定量PCR技术检测脑脊液结核分枝杆菌DNA。结果联合上述2项指标老年结脑的早期确诊率试验组(38.5%)明显高于对照组(14.5%),差异有统计学意义(P<0.01)。中期确诊率试验组(67.3%)亦明显高于对照组(43.6%),差异有统计学意义(P<0.05或<0.01)。结论脑脊液中ADA活性检测及脑脊液结核分枝杆菌DNA测定可明显提高老年结脑早中期确诊率。     

结核性渗出性胸膜炎患者胸膜增厚对肺功能的影响

目的探讨不同程度的胸膜增厚对结核性渗出性胸膜炎(结胸)患者肺功能的影响。方法通过胸部B超及CT检查观察测量胸膜增厚的程度,对患者进行常规通气肺功能、脉冲振荡肺功能(IOS)测定。110例患者根据胸膜增厚程度分为2组,比较2组患者肺活量(VC)、最大自主通气量(MVV)、共振频率(Fres)、周边弹性阻力(X5)等指标。结果随胸膜增厚程度的增加VC、MVV明显降低,Fres逐渐增大、X5负向增大,组间比较差异有统计学意义(P<0.01)。结论轻度胸膜增厚对肺功能影响较小,中重度胸膜增厚对肺功能影响明显。     

Cerebrospinal fluid indices in cryptococcal and tuberculous meningitis: the spider web coagulum and its diagnostic significance

The differentiation between a chronic cryptococcal meningitis and a chronic tuberculous meningitis may cause problems for the clinician only if standard microbiological methods are not applied to the diagnosis of both infections. In a male non-AIDS patient (50 y), 11 years after a suggested diagnosis of "tuberculous meningitis", meningoencephalitis with hydrocephalus was diagnosed and treated accordingly without success. Mycobacterium tuberculosis was never found. Because fibrin fibres of a spider web coagulum in the CSF resembled Aspergillus mycelium, the patient was then treated with amphotericin B + flucytosine. Finally, a mycological examination led to the true diagnosis: (1) In the CSF, resembling Aspergillus hyphae were found to be spider web coagulum fibres. (2) Cryptococcal meningoencephalitis based on the detection of Cryptococcus neoformans in CSF and its antigen in serum and CSF. - At post-mortem, cryptococcal meningoencephalitis was established as cause of death. Residual signs of tuberculosis could not be detected in the brain and the meninges. Common clinical similarities of cryptococcal and tuberculous meningitis and the possibility of a double infection are discussed. A comparison of the presence of Cr. neoformans in the meninges of non-AIDS and AIDS patients is made. The formation of spider web coagulum in the CSF is discussed. Proposals for the diagnosis, therapy and prophylaxis of cryptococcal meningitis are made.