恶性胸膜间皮瘤误诊为结核性胸膜炎17例原因分析

目的 探索恶性胸膜间皮瘤(malignant pleural mesothelioma,MPM) 的临床特点,分析其与结核性胸膜炎(tuberculous pleural effusion,TPE)的临床差异,以减少误诊。方法 回顾性分析盘锦市传染病医院2010—2017年收治的 17例 MPM 误诊为TPE的患者临床资料,以了解误诊原因及提出避免措施。结果 本组MPM患者以男性(70.6%,12/17)、>40岁者(70.6%,12/17)多见,仅1例患者明确有石棉接触史;右侧(52.9%,9/17)多于左侧(35.3%,6/17);临床表现以胸痛(82.4%,14/17)最多见,发热(17.6%,3/17)较少见;误诊时间6d至18个月,平均(80.6±132.6)d。初诊时17例胸腔积液脱落细胞、抗酸杆菌检查均为阴性,结核菌素皮肤试验(PPD试验)阳性8例(47.1%),其中强阳性2例;血T-SPOT.TB阳性6例(35.3%)。胸腔积液生化检测:胸腔积液均为渗出性,11例(64.7%)为黄色,白细胞(WBC)计数以淋巴细胞为主(50%~86%),计数为1300~7500×10⁶/L(正常值<100×10⁶/L);乳酸脱氢酶(LDH)[280~1520U/L(正常值<200U/L),平均(439.76±301.82)U/L]均升高,腺苷脱氨酶(ADA)升高6例(35.3%)[32~56U/L(正常值4~24U/L),平均(26.76±11.96)U/L];血癌胚抗原(CEA)均未见升高,胸腔积液CEA升高2例(11.8%)[分别达8.6μg/L和9.2μg/L(正常值≤5μg/L)];CT检查均有胸膜增厚,11例(64.7%)胸膜增厚超过1cm。最终17例患者均经过组织病理检查确诊,其中胸腔穿刺胸膜活检确诊7例、胸腔镜取组织活检确诊9例、开胸手术病理检查确诊1例;病理检查结果多为MPM上皮样型11例(64.7%)。 结论 MPM的临床表现、实验室检查、早期CT表现同TPE患者相比较缺乏特异性,易误诊为TPE;确诊需依靠组织病理活检或手术病理检查。

Analysis of reasons on misdiagnosing as tuberculous pleurisy in 17 cases with malignant pleural mesothelioma

Objective In order to reduce misdiagnosis of patients with malignant pleural mesothelioma (MPM), to explore the clinical characteristics of MPM and analyze the differences between MPM and tuberculous pleural effusion (TPE).Methods The clinical information and data were collected from 17 patients with MPM who hospitalized at Panjin Infectious Disease Hospital in 2010-2017 and were misdiagnosed as TPE. A retrospectively analyzed was conducted to understand the causes of misdiagnosis and to provide preventive suggestions.Results Most of the enrolled patients with MPM were male (70.6%, 12/17), aged more than 40 years old (70.6%, 12/17) and only 1 patient was determined to have a history exposing to asbestos; patients whose lesions located on the right side of lung (52.9%, 9/17) were more common than those whose lesions located on the left side (35.3%, 6/17); the most common symptom was chest pain (82.4%, 14/17) while fever was rare (17.6%, 3/17). The misdiagnosis time was from 6 days to 18 months with average of (80.6±132.6) days. At the first visit to the hospital, the results of exfoliated cells examination and acid fast bacilli examination in the 17 cases with pleural effusion were negative; the tuberculin test (PPD test) results were positive in 8 cases (47.1%) and among them, 2 cases were strongly positive; the blood T-SPOT.TB test results were positive in 6 cases (35.3%). The biochemical examination results of pleural effusion were as follows: the pleural effusion was exudative, and the color was yellow in 11 cases (64.7%); the proportion of lymphocyte was the highest (50% to 86%) in white blood cells (WBC) and it was counted as 1300-7500×10⁶/L (normal value <100×10⁶/L). The following indicators were all increased: the value of lactate dehydrogenase (LDH) was 280-1 520 U/L (normal value <200 U/L) and the average value was ((439.76±301.82) U/L), adenosine deaminase (ADA) increased in 6 cases (35.3%) (32-56 U/L (normal value was 4-24 U/L), with average of ((26.76±11.96) U/L). The carcinoembryonic antigen (CEA) blood test results were normal in all cases while CEA in pleural effusion increased in 2 cases (11.8%) (one was 8.6 μg/L, the other was 9.2 μg/L (normal value ≤5 μg/L). All cases were found to have pleural thickening by CT scan, and pleural thickening was found to exceed 1 cm in 11 cases (64.7%). Finally, the diagnosis of all 17 cases were confirmed by pathological examinations, including 7 cases were confirmed by thoracentesis and pleural biopsy, 9 cases were confirmed by thoracoscopic biopsy, and 1 case was confirmed by thoracotomy biopsy. The pathological findings were epithelioid-type MPM (11 cases, 64.7%). Conclusion Due to lack of specificity on clinical manifestations, laboratory tests and early CT features in MPM patients comparing with those in TPE patients, so they are easily misdiagnosed as TPE. To confirm the diagnosis of MPM, pathological biopsy or surgical biopsy methods are needed.