继发性肺结核和成人支原体肺炎的临床诊断与鉴别诊断

目的 通过比较继发性肺结核和成人支原体肺炎的临床资料，为两种疾病的鉴别诊断提供依据。 方法 收集解放军第三〇九医院2008年1月至2010年12月的部分（排除病案资料不全者）继发性肺结核患者67例和成人支原体肺炎患者32例，从临床表现、影像学资料和治疗效果等方面进行回顾性研究比较。 结果 与继发性肺结核患者相比：（1）成人支原体肺炎患者起病急者（＜1 d）较多（占87. 5%，28/32；继发性肺结核占7.5%，5/67）（χ²=62.3898，P＜0.01）；呼吸道症状［鼻塞流涕（占68.8%，22/32；继发性肺结核占3.0%，2/67）、头痛（占28.1%，9/32；继发性肺结核占6.0%，4/67）、咽痛（占50.0%，16/32；继发性肺结核占4.5%，3/67）］明显者较多（χ²=51.1830，χ²=9.2565，χ²=30.8682，P值均＜0.01）；多数患者肺部可闻及湿性啰音（占53.1%，17/32；继发性肺结核占13.4%，9/67）（χ²=17.6145，P＜0.01）。（2）成人支原体肺炎多数患者影像学表现为磨玻璃样影（占71.9%，23/32；继发性肺结核0例）（χ²=62.7398，P＜0.01），以两肺中下野多见（占70.0%，14/20；继发性肺结核占34.2%，13/38）（χ²=9.5139，P<0.01），病灶呈游走性者较多（占9.4%，3/32；继发性肺结核0例）（χ²=5.9103，P<0.05）；抗感染治疗后（阿奇霉素或红霉素）多数患者肺内病灶多在2周内消散吸收（占53.1%，17/32；继发性肺结核0例）（χ²=42.8718，P<0.01）。（3）支原体肺炎红细胞冷凝集试验多呈阳性（占71.9%，23/32；继发性肺结核0例；χ²=62.8571，P<0.01）；肺炎支原体抗体IgM也多呈阳性（占81.3%，26/32；继发性肺结核占1.5%，1/67；χ²=67.5228，P<0.01）。 结论 继发性肺结核和成人支原体肺炎鉴别诊断应详细分析病史，注意影像学病灶特征，试验性治疗和多次血清学检查有助于鉴别诊断。

Clinical diagnosis and differential diagnosis of secondary pulmonary tuberculosis and adult mycoplasma pneumonia

Objective To compare the clinical data of secondary pulmonary tuberculosis and adult mycoplasmal pneumonia and to lay foundation for the differential diagnosis for the 2 diseases.Methods Sixty-seven cases and 32 cases of the 2 diseases were collected in our hospital from 2008 to 2010,and the clinical performance,X-ray information,laboratory examination and therapy of the patients were retrospectively analyzed.Results(1)The course of most adult mycoplasmal pneumonia patients was usually shoter(87.5%,28/32)than secondary pulmonary tuberculosis patients(7.5%,5/67)(χ2=62.3898,P<0.01),and symptoms of respiration[runny nose(68.8%,22/32),headache(28.1%,9/32),sore throat(50.0%,16/32)] were more common than those of patients with secondary pulmonary tuberculosis(3.0%(2/67),6.0%(4/67),4.5%(3/67))(χ2=51.1830,χ2=9.2565,χ2=30.8682,All P<0.01).The sign of rale was found more in mycoplasmal pneumonia patients(53.1%,17/32)than that in secondary pulmonary tuberculosis patients(13.4%,9/67)(χ2=17.6145,P<0.01).(2)The most common CT finding of adult mycoplasmal pneumonia were ground glass opacity and consolidation(71.9%,23/32),with none of secondary pulmonary tuberculosis patients(χ2=62.7398,P<0.01).Most of the ground glass opacity and consolidation showed tendency of lobular distribution and involving the lower lobes(70.0%,14/20)in patients with mycoplasmal pneumonia,while secondary pulmonary tuberculosis patients was 34.2%(13/38)(χ2=9.5139,P<0.01).In some patients with mycoplasmal pneumonia,the focus was wandering(9.4%,3/32),while secondary pulmonary tuberculosis patients was not found(χ2=5.9103,P<0.05).The lesions was absorbed after treatment with azithromycin or erythrocin in 4 weeks(53.1%,17/32)in mycoplasmal pneumonia,but that could not be seen in secondary pulmonary tuberculosis patients(χ2=42.8718,P<0.01).(3)Serum cold agglutination test and antibody of mycoplasma pneumoniae were different between adult mycoplasma pneumonia secondary pulmonary tuberculosis(71.9%(23/32) vs.0,χ2=62.8571,P<0.01;81.3%(26/32)vs.1.5%(1/67),χ2=67.5228,P<0.01).Conclusion It is helpful to identify the diagnosis between secondary pulmonary tuberculosis and adult mycoplasma pneumonia if taking medical history carefully,noticing focus characters on imaging,given empirical treatment and multiple serology and bacteriology examination.