<link rel="stylesheet" href="https://studioyszimg.yxj.org.cn/css/video-js.min.css?v=1"><link rel="stylesheet" href="https://studioyszimg.yxj.org.cn/article/css/base.css?v=5"><link rel="stylesheet" href="https://studioyszimg.yxj.org.cn/article/css/index.css?v=35"><link rel="stylesheet" href="https://ysz-web.yxj.org.cn/live/dist/static/base/index.css?ysz_v=2.0"><script src="https://studioyszimg.yxj.org.cn/js/dsbridge.js?v=13" type="text/javascript"></script><script src="https://ysz-web.yxj.org.cn/dsBridge/main.js?v=26" type="text/javascript"></script><script src="https://ysz-web.yxj.org.cn/live/dist/static/base/fun.js?ysz_v=3" type="text/javascript"></script><script src="https://ysz-web.yxj.org.cn/live/dist/static/js/nativeToWeb.js?v=1" type="text/javascript"></script><div id="ysz-header" style="margin:0;overflow:hidden;"><h1 style="font-size:24px;line-height:1.8;color:#333333;word-wrap:break-word;">气短、咳嗽,肺间质性改变,这种结核太少见</h1><h2 style="font-size:16px;color:#999999;word-wrap:break-word;"><em style="font-style:normal;margin-right:10px;color:#7f7f7f;display:inline-block;">2022-05-16</em><em style="font-style:normal;margin-right:10px;color:#7f7f7f;display:inline-block;">原创:离床医学</em></h2></div><p style="text-align: justify;"><span style="color: rgb(215, 0, 15);"><strong><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px;">病例汇报</span></strong></span></p><p><br/></p><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">患者,男,81岁。***年6月14日入院。</span></p><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);"><br/></span></p><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">主诉:活动后气短伴咳嗽、咯痰2个月余。</span></p><p><br/></p><p style="text-align: justify;"><strong><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">现病史:</span></strong></p><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);"><br/></span></p><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">2个月前,无明显诱因出现活动后胸闷、气短,伴咳嗽、咯少量黏白痰,无发热、盗汗,无咯血,无胸痛。</span></p><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);"><br/></span></p><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">半个月前,上述症状加重,活动耐量明显下降,平地行走即感明显气短。</span></p><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);"><br/></span></p><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">近2个月食欲差,体重下降约10kg,就诊于某三甲医院,考虑“双肺炎”,先后予阿莫西林-舒巴坦、美罗培南抗感染,上述症状无明显缓解,遂就诊于我院。</span></p><p><br/></p><p style="text-align: justify;"><strong><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">既往史:</span></strong></p><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);"><br/></span></p><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">30年前曾因“胃溃疡”行胃大部切除术,</span><span style="color: rgb(0, 0, 0); font-size: 16px;">吸烟史60年,约20支/d。</span></p><p style="text-align: justify;"><span style="color: rgb(0, 0, 0); font-size: 16px;"><br/></span></p><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">饮酒史30余年,白酒50ml/d。</span></p><p style="text-align: justify;"><span style="color: rgb(0, 0, 0); font-size: 16px;"><br/></span></p><p style="text-align: justify;"><span style="color: rgb(0, 0, 0); font-size: 16px;">否认结核病史或结核患者接触史。</span><br/></p><p><br/></p><p style="text-align: justify;"><strong><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">体格检查:</span></strong></p><p style="text-align: justify;"><span style="color: rgb(0, 0, 0); font-size: 16px;"><br/></span></p><p style="text-align: justify;"><span style="color: rgb(0, 0, 0); font-size: 16px;">T 36.6℃,P 72次/min,R 20次/min,BP 130/80mmHg,BMI 20.26。</span><br/></p><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);"><br/></span></p><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">神志清楚,全身浅表淋巴结未触及,双肺呼吸音粗,双下肺可闻及爆裂音,心率72次/min,律齐,各瓣膜区未闻及杂音,腹软,无压痛,下腹可见陈旧手术瘢痕,肝脾肋下未触及。</span></p><section><br/></section><ul class="custom_macula list-paddingleft-1" style="list-style-type: macula;"><li class="list-macula list-macula-paddingleft"><p><strong><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">外院6月3日</span></strong></p></li></ul><section style="text-align: justify;"></section><section><br/></section><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">血常规:WBC 7.89×10<sup>9</sup>L,N 0.827。</span></section><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);"><br/></span></p><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">PCT&lt;0.05 ng/mL。</span></p><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);"><br/></span></p><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">血气分析(未吸氧):pH 7.49,PaCO,31.5 mmHg,PaO<sub>2</sub>74 mmHg。</span></section><section><br/></section><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">肺CT:双肺近胸膜处分布大片状、斑片状密度增高影及网格影,密度不均匀,边界尚清,部分病灶呈磨玻璃样改变,部分病灶内可见支气管充气征及点状钙化,见图1。</span></section><section><br/></section><section style="text-align: center;"><img class="rich_pages wxw-img" src="https://studioyszimg.yxj.org.cn/0A00007C017C0CE0689EFE02173C9BCE.jpg" alt="图片" style="margin: 0px; padding: 0px; outline: 0px; vertical-align: bottom; box-sizing: border-box ; overflow-wrap: break-word ; width: 481px ; visibility: visible ;"/></section><section><br/></section><ul class="custom_macula list-paddingleft-1" style="list-style-type: macula;"><li class="list-macula list-macula-paddingleft"><p><strong><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">抗感染后6月12日</span></strong></p></li></ul><section style="text-align: justify;"></section><section><br/></section><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">血常规:WBC 9.74×10<sup>9</sup>/L,N 0.895。</span></section><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);"><br/></span></p><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">3次痰结核分枝杆菌PCR均阴性,浓缩后未查到抗酸杆菌。</span></p><section><br/></section><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">复查肺CT上述病灶较前进展,见图2。<br/></span></section><section><br/></section><section style="text-align: center;"><img class="rich_pages wxw-img" src="https://studioyszimg.yxj.org.cn/0A00007C017C0CE06B953BC26A5D090E.jpg" alt="图片" style="margin: 0px; padding: 0px; outline: 0px; vertical-align: bottom; box-sizing: border-box ; overflow-wrap: break-word ; width: 481px ; visibility: visible ;"/></section><section><br/></section><ul class="custom_macula list-paddingleft-1" style="list-style-type: macula;"><li class="list-macula list-macula-paddingleft"><p><strong><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">入院后</span></strong></p></li></ul><section style="text-align: justify;"></section><section><br/></section><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">血常规:WBC8.02×10/L,N 0.746。</span></section><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);"><br/></span></p><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">PCT 0.06 ng/mL。</span></p><p style="text-align: justify;"><span style="color: rgb(0, 0, 0); font-size: 16px;"><br/></span></p><p style="text-align: justify;"><span style="color: rgb(0, 0, 0); font-size: 16px;">血气分析:pH7.44,PaCO<sub>2</sub>为35.5 mmHg,PaO<sub>2</sub>为67 mmHg,SaO<sub>2</sub>为93%。</span><br/></p><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);"><br/></span></p><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">BNP 50.17 pg/mL。</span></p><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);"><br/></span></p><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">IgG 11.1 g/L,IgA 1.7 g/L,IgM 0.35 g/L,IgE 39.3 gL。</span></p><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);"><br/></span></p><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">白蛋白33.5 g/L,球蛋白28.1 g/L。</span></p><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);"><br/></span></p><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">心电图:正常。</span></p><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);"><br/></span></p><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">心脏超声:三尖瓣轻度返流,主动脉瓣轻度钙化,静息状态下左室整体收缩功能正常,左室排血分数(LVEF)54%。</span></p><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);"><br/></span></p><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">肝肾功能、血糖、电解质、凝血像、尿粪常规等:未见明显异常。</span></p><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);"><br/></span></p><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">患者无痰,故未能完成相应痰检。</span></section><section><br/></section><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">入院时病情分析:</span></p><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);"><br/></span></p><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">患者亚急性起病,以活动后气短为主要表现,低氧血症,无明显感染中毒征象,肺CT提示双肺广泛肺间质改变,故首先考虑特发性间质性肺炎、结缔组织病相关性肺疾病可能,但需与细支气管肺泡癌、肺结核及其他非典型病原体肺炎相鉴别,故治疗上给予吸氧、N-乙酰半胱氨酸抗纤维化、异丙托溴胺+特布他林雾化降低气道高反应等治疗,未予抗感染治疗。</span></section><section><br/></section><table width="676"><tbody style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box !important; overflow-wrap: break-word !important;"><tr style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box !important; overflow-wrap: break-word !important;" class="firstRow"><td valign="top" style="margin: 0px; outline: 0px; word-break: break-all; border-color: rgb(0, 82, 255); max-width: 100%; overflow-wrap: break-word !important; box-sizing: border-box !important;"><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">特发性间质性肺炎、结缔组织病相关性肺疾病、细支气管肺泡癌、肺水肿、急性呼吸窘迫综合征(ARDS)以及外源性过敏性肺泡炎等?</span></section></td></tr></tbody></table><section><br/></section><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">同时完善检查结果回报:</span></p><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);"><br/></span></p><ul class="custom_macula list-paddingleft-1" style="list-style-type: macula;"><li class="list-macula list-macula-paddingleft" style=""><p><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">肺炎支原体抗体1:40:阴性</span></p></li><li class="list-macula list-macula-paddingleft" style=""><p><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">抗嗜肺军团菌IgM抗体:阴性。</span></p></li><li class="list-macula list-macula-paddingleft" style=""><p><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">抗肺炎衣原体IgM抗体:阴性。</span></p></li><li class="list-macula list-macula-paddingleft" style=""><p><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">1,3-B-D葡聚糖定量:&lt;10pg/mL。</span></p></li><li class="list-macula list-macula-paddingleft" style=""><p><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">曲霉半乳甘露聚糖检测:0.476。</span></p></li></ul><section style="text-align: left;"></section><section style="text-align: left;"></section><section style="text-align: left;"></section><section style="text-align: left;"></section><section style="text-align: left;"></section><section><br/></section><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">免疫指标:ANA1 : 100(+),线粒体M2抗体(+++)。</span></p><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);"><br/></span></p><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">结合患者无皮疹、关节肿痛、眼口干等不适表现,考虑结缔组织病相关肺疾病依据不足;<br/></span></section><section><br/></section><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">血CEA 7.5 ng/mL, CA 12 595.87 U/mL,细胞角蛋白19片段4.64 ng/mL。</span></section><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);"><br/></span></p><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">CRP:123 mg/L。</span></p><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);"><br/></span></p><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">血沉:35 mm/h ;</span></p><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);"><br/></span></p><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">血结核菌抗体:弱阳性,需进-步行纤维支气管镜除外肿瘤和结核。</span></section><section><br/></section><ul class="custom_macula list-paddingleft-1" style="list-style-type: macula;"><li class="list-macula list-macula-paddingleft"><p style="text-align: justify;"><strong><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">6月16日</span></strong></p></li></ul><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);"><br/></span></p><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">行纤维支气管镜检查,术后患者出现发热,体温最高达38.5℃。</span></section><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);"><br/></span></p><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">复查:</span></p><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);"><br/></span></p><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">血常规: WBC 8.09X 10/L,N 0.851。</span></p><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);"><br/></span></p><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">血气分析(FiO<sub>2</sub> 29%):pH 7.52,PaCO<sub>2</sub>为29.8 mmHg,PaO<sub>2</sub>为102 mmHg,SaO<sub>2</sub> 为97.8%。</span></p><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);"><br/></span></p><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">结合纤支镜下见大量黏稠黄色分泌物,考虑继发细菌感染可能,给予美洛西林-舒巴坦(3.75g/次,静滴,2次/d)抗感染。</span></section><section><br/></section><ul class="custom_macula list-paddingleft-1" style="list-style-type: macula;"><li class="list-macula list-macula-paddingleft"><p><strong><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">6月18日</span></strong></p></li></ul><section style="text-align: justify;"></section><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);"><br/></span></p><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">纤维支气管镜结果回报(图3):</span></p><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);"><br/></span></p><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">镜下见双侧支气管黏膜纵行、充血,有大量黏稠黄色分泌物,以左上固有支为著。左上固有支黏膜肿胀、不平,管嵴增宽,管口变形、扭曲,于该处行支气管黏膜活检提示炎症伴上皮样肉芽肿(图4)。</span></section><section><br/></section><section style="text-align: center;"><img class="rich_pages wxw-img" src="https://studioyszimg.yxj.org.cn/0A00007C017C0CE06E2215805D6EB82B.jpg" alt="图片" style="margin: 0px; padding: 0px; outline: 0px; vertical-align: bottom; box-sizing: border-box ; overflow-wrap: break-word ; width: 491px ; visibility: visible ;"/></section><section><br/></section><section style="text-align: center;"><img class="rich_pages wxw-img" src="https://studioyszimg.yxj.org.cn/0A00007C017C0CE070AE913759BAF27E.jpg" alt="图片" style="margin: 0px; padding: 0px; outline: 0px; vertical-align: bottom; box-sizing: border-box ; overflow-wrap: break-word ; width: 491px ; visibility: visible ;"/></section><section><br/></section><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">肺泡灌洗液行TB-PCR (+),浓缩后查到抗酸杆菌(+++)。</span></section><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);"><br/></span></p><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">支气管刷片+肺泡灌洗液病理:均未找到肿瘤细胞。</span></p><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);"><br/></span></p><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">分泌物一般细菌+真菌涂片:未查到细菌,未见真菌丝,未见假菌丝,未查到酵母样菌。</span></p><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);"><br/></span></p><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">分泌物培养:无细菌生长。</span></p><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);"><br/></span></p><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">分泌物真菌培养:未见真菌生长。</span></section><section><br/></section><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">修订诊断为肺结核。(又是多变的结核,大妖精!)</span></p><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);"><br/></span></p><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">故转入结核病院治疗,于结核病院住院期间共行3次痰结核菌涂片抗酸杆菌(+++~++++), 复查血常规: WBC 7.03X10/L,N 0.817。</span></section><section><br/></section><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">诊断为继发性肺结核(浸润型)双肺,痰涂片(+)初治,结核性胸膜炎双侧,初治,继发肺内感染。</span></section><section><br/></section><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">给予异烟肼(300mg,口服,qd)、利福平(0.3g,口服,qd)、乙胺丁醇(0.5g, 口服,qd)抗结核治疗同时先后联合头孢他啶(2g/次,静滴,tid),美洛西林-舒巴坦(2.5 g/次,静滴,tid)及亚胺培南-西司他丁(1 g/次,静滴,bid)抗感染。</span></section><section><br/></section><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">期间患者仍发热,体温最高达39℃,且呼吸困难进行性加重,出现</span><span style="color: rgb(0, 0, 0); font-size: 16px;">I型呼吸衰竭(pH7.54,PaCO<sub>2</sub>为30mmHg, PaO<sub>2</sub>为40mmHg),WBC持续升高(WBC 15.56X10<sup>9</sup>/L),N 0.905, PLT明显减少(PLT 42X10<sup>9</sup>/L),肝功能损害(丙氨酸转氨酶310 U/L,天冬氨酸转氨酶188 U/L),最终多器官功能衰竭,临床死亡。</span></p><section><br/></section><section style="text-align: justify;"><span style="color: rgb(215, 0, 15);"><strong><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px;">不典型肺结核</span></strong></span></section><section><br/></section><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">肺结核主要沿支气管播散,胸部CT的表现为沿着支气管束分布的小结节影及斑片影,此为典型改变。</span></section><section><br/></section><section style="text-align: center;"><img class="rich_pages wxw-img" src="https://studioyszimg.yxj.org.cn/0A00007C017C0CE072F3FA4524E1830B.jpg" alt="图片" style="margin: 0px; padding: 0px; outline: 0px; vertical-align: bottom; box-sizing: border-box ; overflow-wrap: break-word ; width: 328px ; visibility: visible ;"/></section><section><br/></section><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">有一类不典型肺结核,其以肺间质改变为主要表现。</span></section><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);"><br/></span></p><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">好发于年轻人,且大多无免疫功能缺陷。少数见于合并糖尿病、COPD等基础疾病的老年患者,影像学可表现为不典型的肺结核,其可能与宿主的免疫失调有关。</span></p><p style="text-align: justify;"><span style="color: rgb(0, 0, 0); font-size: 16px;"><br/></span></p><p style="text-align: justify;"><span style="color: rgb(0, 0, 0); font-size: 16px;">吸烟是COPD最主要的高危因素,其导致的慢性气道炎症,可能使COPD患者更易合并这种特殊类型的肺结核。</span><br/></p><section><br/></section><section style="text-align: justify;"><strong><span style="font-size: 16px; line-height: 28px; color: rgb(215, 0, 15);">发生机制</span></strong></section><section><br/></section><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">有学者认为,肺间质改变的机制可能为大量的结核分枝杆菌沿呼吸道蔓延,侵犯肺组织,引起炎性反应,形成间质性改变。</span></p><p style="text-align: justify;"><span style="color: rgb(0, 0, 0); font-size: 16px;"><br/></span></p><p style="text-align: justify;"><span style="color: rgb(0, 0, 0); font-size: 16px;">研究表明,44%粟粒型肺结核中可表现出小叶内间质异常,因发生粟粒型肺结核时,结核分枝杆菌容易引起肺血管和淋巴管的通透性增加,可导致肺泡炎,也可形成间质改变,部分病理结果也表明,肺间质改变出现在34%继发性活动性肺结核中,并引起小叶间隔增厚等。</span><br/></p><section><br/></section><section style="text-align: justify;"><strong><span style="font-size: 16px; line-height: 28px; color: rgb(215, 0, 15);">CT特点</span></strong></section><section><br/></section><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">通常结核分枝杆菌易侵犯血运相对较差和通气不畅的两肺尖、后段和叶背段,曾有多项统计以肺间质改变为主的继发性肺结核发生于上肺者占65%以上,故其好发部位也符合此规律;</span></p><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);"><br/></span></p><p><br/></p><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">病灶主要位于肺野外围或沿支气管束分布,呈片状或磨玻璃样密度增高影,形态不一,上肺病灶有明显的融合倾向,以片状肺实变最为常见,而下肺病灶多为弥漫分布的小片状影,病变区与正常肺组织的分界相对清楚。</span></section><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">但也有研究结果显示,老年肺结核病灶与年轻人相比,易发生于下肺。</span></section><section><br/></section><p style="text-align: justify;"><span style="color: rgb(215, 0, 15);"><strong><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px;">实例</span></strong></span></p><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);"><br/></span></p><section style="text-align: center;"><img class="rich_pages wxw-img" src="https://studioyszimg.yxj.org.cn/0A00007C017C0CE07507AD1A739CEA44.jpg" alt="图片" style="margin: 0px; padding: 0px; outline: 0px; vertical-align: bottom; box-sizing: border-box ; overflow-wrap: break-word ; width: 677px ; visibility: visible ;"/></section><section style="text-align: center;"><img class="rich_pages wxw-img" src="https://studioyszimg.yxj.org.cn/0A00007C017C0CE07774324524A61AC7.jpg" alt="图片" style="margin: 0px; padding: 0px; outline: 0px; vertical-align: bottom; box-sizing: border-box ; overflow-wrap: break-word ; width: 677px ; visibility: visible ;"/></section><section style="text-align: center;"><img class="rich_pages wxw-img" src="https://studioyszimg.yxj.org.cn/0A00007C017C0CE079B4891C5B975E1A.jpg" alt="图片" style="margin: 0px; padding: 0px; outline: 0px; vertical-align: bottom; width: 661px; box-sizing: border-box ; overflow-wrap: break-word ; visibility: visible ;"/></section><section><br/></section><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">多篇文献显示,网格样改变、小叶间隔增厚、微结节、树芽征、磨玻璃影等是活动性间质型肺结核的胸部CT主要表现。</span></section><section><br/></section><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">其病理基础如下:</span></section><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);"><br/></span></p><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">在结核炎症早期,以渗出为主要病变,胸部CT显示斑片状及磨玻璃样密度影。</span></p><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);"><br/></span></p><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">结核分枝杆菌沿支气管播散,引起肉芽肿性炎症,导致细支气管及肺泡管内干酪样物质充填,胸部CT显示树芽征。</span></p><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);"><br/></span></p><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">随着疾病进展,结核菌沿着肺泡间质蔓延,造成肺泡壁、肺泡间隔和外周间质上形成干酪样结节,影响淋巴回流,导致小叶内间质增厚。</span></p><section><br/></section><section style="text-align: justify;"><strong><span style="font-size: 16px; line-height: 28px; color: rgb(215, 0, 15);">临床警惕</span></strong></section><section><br/></section><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">由于以肺间质改变为主的活动性肺结核缺乏普通肺结核典型的临床症状,如发热、盗汗、咳嗽、咯痰、咯血等,且多以呼吸困难为主要表现;结合胸部CT以双肺弥漫性病变为表现继发性活动性肺结核,临床诊断较为困难,容易漏诊、误诊。</span></p><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);"><br/></span></p><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">因此,对于病程短、呼吸困难进行性加重、胸部CT提示双肺弥漫间质性改变的患者,临床思维不能仅仅局限于间质性肺炎,应排除肺结核。<br/></span></section><section><br/></section><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">经纤维支气管镜检查及CT引导下肺活检取得病原学和病理学依据是诊断的关键。</span></p><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);"><br/></span></p><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">对于那些经纤维支气管镜检查及CT引导下肺活检仍不能诊断者,可考虑胸腔镜肺活检,甚至外科开胸肺活检。</span></section><!--auditorInfo--><div class="footer"><div class="item"><p class="ysz-ueditor-references-label" >参考文献 <span>共3篇<i></i></span></p><div class="ysz-ueditor-references-content textLine2" lang="en"><p>[1]<span class="appskip" data-appskip="yxjysz" data-appskipobj="{&quot;type&quot;:18,&quot;id&quot;:0,&quot;title&quot;:&quot;&quot;,&quot;url&quot;:&quot;https://kns.cnki.net/kcms/detail/detail.aspx?dbcode=CJFD&amp;dbname=CJFDLAST2017&amp;filename=KGHL201703018&amp;uniplatform=NZKPT&amp;v=zlLvwWs4ZdZ7mkHDr%25mmd2FaWd51Uc%25mmd2FSKwi2sriGTNxefdezPubMJLGIdl7mE4cvCUc9e&quot;}">刘佳,高丽丽,王贺丽,等. 以肺间质改变为主的重症肺结核1例[J]. 中国感染与化疗杂志,2017,17(3):326-329.</span> <br/>[2]<span class="appskip" data-appskip="yxjysz" data-appskipobj="{&quot;type&quot;:18,&quot;id&quot;:0,&quot;title&quot;:&quot;&quot;,&quot;url&quot;:&quot;https://xueshu.baidu.com/usercenter/paper/show?paperid=dd2d5796904706b8a800c727894140fc&amp;site=xueshu_se&quot;}">吕岩,周新华. 肺结核影像学诊断进展[J]. 临床荟萃,2016,31(10):1067-1071.</span> <br/>[3]<span class="appskip" data-appskip="yxjysz" data-appskipobj="{&quot;type&quot;:18,&quot;id&quot;:0,&quot;title&quot;:&quot;&quot;,&quot;url&quot;:&quot;https://xueshu.baidu.com/usercenter/paper/show?paperid=faecc98fcd4e1335b00e441fcb6bf5dd&amp;site=xueshu_se&quot;}">刘连荣,张雪君,程湘. 肺间质改变为主的继发性肺结核的CT表现[J]. 实用放射学杂志,2014,30(2):219-222.</span> </p></div></div>

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