以社区获得性肺炎为表现的肺结核的临床特点

目的分析肺结核以社区获得性肺炎为主要表现的特点，提高不典型肺结核诊断水平。方法对本院2000年1月至2006年6月收治的39例首诊为社区获得性肺炎最后诊断为肺结核病例的主要临床参数归纳整理并进行统计分析。结果高热79．49％（31／39），中度发热7．69％（3／39），低热7．69％（3／39），体温正常5．13％（2／39），发热者以午后和夜间为主者71．79％（28／39），不规则发热23．08％（9／39）；痰涂阳性10例，阴性29例；胸片：尖后段12例（30．77％），前段5例（12．82％），中叶或舌叶2例（5．13％），下叶背段15例（38．46％）．基底段8例（20．51％）。斑片影19例（48．72％），多形态影12例（30．77％），团块影8例（20．51％），其中空洞2例（5．13％）。β内酰胺联合阿奇霉素改善4例、无改善2例、加重18例；影像加重83．3％（20／24）、改进8．33％（2／24）。氟喹诺酮类改善12例、加重2例；影像无变化57．89％（11／19）、加重42．11％（8／19）。抗结核1周体温正常21例，2周体温正常18例。1周复查胸片吸收8例、2周后吸收25例，抗结核1。2个月吸收6例，其中胸膜增厚2例。结论以肺炎为表现的不典型肺结核诊断困难，午后或夜间发热，结核好发部位，抗感染效果不佳需要警惕肺结核诊断，影像学尤其螺旋CT检查有利于结核的早期诊断。可疑结核慎用氟喹诺酮，可用β内酰胺和大环内酯类诊断性治疗。

Clinical Features of Pulmonary Tuberculosis Manifested as Community Acquired Pneumonia

Objective To analyze the clinical features of pulmonary tuberculosis manifested as community acquired pneumonia and improve diagnosis rate of atypical lung tuberculosis. Methods 39 cases whose primary diagnosis was community acquired pneumonia and final diagnosis as lung tuberculosis were collected in the 3rd affiliated hospital of Sun Yat-sen University from January 2000 to June 2006. The main clinical data were arranged then analyzed statistically. Results 79.49%（31/39） cases had high fever, 7.69%（3/39） had moderate fever, 7.69% （3/39） had low fever and 2 patients＇ temperature was normal. 71.79%（28/39） cases had fever mainly at afternoon and night; the other 23.08%（9/39） bad irregular fever. 10 patients＇ sputum smear samples were positive and the other 29 were negative. Chest X-rays showed that the lesion sites were in sequence of 12 （30.77%） at apicoposterior segment, 5 （12.82%） at anterior segment, 2 （5.13%） at middle lobe or lingual segment, 15（38.46%） at posterior segment of lower lobe, 8 （20.51%） at basal segment of lower lobe. 19 （48.72%） cases had sign with patching opacities, 12 （30.77%） with muhi-fonnation opacities, 8 （20.51% ） with mass opacities, 2 （5.13%） with cavity in X-rays. The results after treated with β-lactam antibiotics combined with azithromycin were： 4 cases turn out better and 2 without changes, 18 even worse, 83.3% （20/24） cases exacerbated and 8.33%（2/24） ameliorated in imageology; when treated with fluoroquinolones ： 12 cases improved and 2 aggravated, 57.89% （ 11 / 19 ） cases didn＇ t change and 42.11% （8/19） exacerbated in imageology; when treated with anti-tuberculosis therapy：21 patients had normal temperature after one week, and the other 18 had normal temperature after two weeks. 8 cases＇ and 25 cases＇lesion showed in X- ray disappeared after one week and two weeks, respectively. The last 6 patients＇ lesions were absorbed after one to two months, 2 of them ended with pleural thickening. Conclusion It is difficult to diagnose atypical tuberculosis presented as pneumonia. We should pay more attention when come across patients who have fever at afternoon and night, whose lesion site locate at predilection site of lung tuberculosis and who have no response to anti-infective therapy. Imaging examinations, especially spiral computed tomography, are beneficial to early diagnosis of lung tuberculosis. Fluoroquinolones should be deliberatively used to treat suspicious pulmonary tuberculosis. β-lactam combined with macrolides antibiotics may be considered to be one of the first choice of treatments .