抗结核药物引起的艰难梭状芽胞杆菌相关性腹泻一例并文献复习

doi:10.3969/j.issn.1000-6621.2020.03.021

摘要/Abstract

摘要：

抗生素的使用是发生艰难梭状芽胞杆菌相关性腹泻的危险因素,而其中抗结核药物的使用则很少被报道与之相关。作者报告了1例与抗结核药物治疗相关的艰难梭状芽胞杆菌相关性腹泻患者,并搜集相关文献进行复习。患者为女性,32岁,罹患肺结核已行抗结核药物治疗9个月。因腹痛、腹泻入院治疗,通过艰难梭状芽胞杆菌毒素及谷氨酸脱氢酶检测呈阳性确诊。在停用抗结核药物,以及接受万古霉素和双歧杆菌乳杆菌三联活菌片(金双歧)治疗9d后症状缓解。作者通过复习相关文献,讨论了艰难梭状芽胞杆菌相关性腹泻的发病机制、临床表现、诊断和治疗方法,提醒临床医生了解结核病治疗过程中的罕见并发症,尽早确诊并采取必要的干预措施。

关键词: 结核, 肺, 抗结核药, 芽孢杆菌, 腹泻, 总结性报告(主题)

Abstract:

Antimicrobial agent exposure is a risk factor for Clostridium difficile-associated diarrhea (CDAD), whereas the use of anti-tuberculous (anti-TB) drugs is rarely associated with it. This article reports a case of CDAD associated with anti-TB drugs, and reviews relevant literatures. A 32-year-old woman with pulmonary tuberculosis who had been treated with anti-TB agents for 9 months was admitted for abdominal pain and diarrhea. The test results of Clostridium difficile toxin and glutamate dehydrogenase (GHD) were both positive. Symptoms were relieved after anti-TB drugs were discontinued and treatment with vancomycin and bifidobacterium was given for 9 days. By reviewing literatures, the authors have discussed the pathogenesis, clinical manifestations, diagnosis and treatment of CDAD, in order to remind clinicians to understand the rare complications in the process of tuberculosis treatment, and to avoid pseudomembranous colitis (PMC) and other serious intestinal diseases by early diagnosis and intervention.

Key words: Tuberculosis, pulmonary, Antitubercular agents, Brevibacillus, Diarrhea, Consensus development conferences as topic

王静,张蒙,贺建清. 抗结核药物引起的艰难梭状芽胞杆菌相关性腹泻一例并文献复习[J]. 中国防痨杂志, 2020, 42(3): 293-296. doi: 10.3969/j.issn.1000-6621.2020.03.021

WANG Jing,ZHANG Meng,HE Jian-qing. Clostridium difficile-associated diarrhea caused by anti-tuberculosis drugs: a case report and literature review[J]. Chinese Journal of Antituberculosis, 2020, 42(3): 293-296. doi: 10.3969/j.issn.1000-6621.2020.03.021

图/表 2

图1~4

表1

参考文献 25

[1]	Surawicz CM, Brandt LJ, Binion DG , et al. Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections. Am J Gastroenterol, 2013,108(4):478-498.
[2]	Loo VG, Poirier L, Miller MA , et al. A predominantly clonal multi-institutional outbreak of Clostridium difficile-associated diarrhea with high morbidity and mortality. N Engl J Med, 2005,353(23):2442-2449.
[3]	Bartlett JG, Chang TW, Gurwith M , et al. Antibiotic-associated pseudomembranous colitis due to toxin-producing clostridia. N Engl J Med, 1978,298(10):531-534.
[4]	Hunt JJ, Ballard JD . Variations in virulence and molecular biology among emerging strains of Clostridium difficile. Microbiol Mol Biol Rev, 2013,77(4):567-581.
[5]	Lessa FC, Gould CV, McDonald LC . Current status of Clostridium difficile infection epidemiology. Clin Infect Dis, 2012,55 Suppl 2: S65-70.
[6]	Moriarty HJ, Scobie BA . Pseudomembranous colitis in a patient on rifampicin and ethambutol. N Z Med J, 1980,91(658):294-295.
[7]	Klaui H, Leuenberger P . Pseudomembranous colitis due to rifampicin. Lancet, 1981,2(8258):1294.
[8]	Park JY, Kim JS, Jeung SJ , et al. A case of pseudomembranous colitis associated with rifampin. Korean J Intern Med, 2004,19(4):261-265.
[9]	Sun YX, Zhao YT, Teng LL , et al. Clostridium difficile infection associated with antituberculous agents in a patient with tuberculous pericarditis. Intern Med, 2013,52(13):1495-1497.
[10]	Nakajima A, Yajima S, Shirakura T , et al. Rifampicin-associated pseudomembranous colitis. J Gastroenterol, 2000,35(4):299-303.
[11]	Chen TC, Lu PL, Lin WR , et al. Rifampin-associated pseudomembranous colitis. Am J Med Sci, 2009,338(2):156-158.
[12]	Choi JM, Kim HH, Park SJ , et al. Development of pseu-domembranous colitis four months after initiation of rifampicin. Case Rep Gastroenterol, 2011,5(1):45-51.
[13]	Yim SY, Koo JS, Kim YJ , et al. Rifampin-induced pseu-domembranous colitis with rectosigmoid sparing. Clin Endosc, 2011,44(2):137-139.
[14]	Akbar DH, Al-Shehri HZ, Al-Huzali AM , et al. A case of rifampicin induced pseudomembraneous colitis. Saudi Med J, 2003,24(12):1391-1393.
[15]	Kim JH, Park JH . A case of rifampicin associated Pseu-domembranous colitis. Korean J Gastroenterol, 2004,43(6):376-379.
[16]	Choi YJ, Kim HG, Choi YA , et al. A case of pseudomembranous colitis associated with rifampicin therapy in a patient with rectal cancer and gastrointestinal tuberculosis. Korean J Gastroenterol, 2009,53(1):53-56.
[17]	Byrd RP Jr, Roy TM, Ossorio MA , et al. Delayed onset of pseudomembranous colitis after rifampin therapy. South Med J, 1997,90(6):644-646.
[18]	Fournier G, Orgiazzi J, Lenoir B , et al. Pseudomembranous colitis probably due to rifampicin. Lancet, 1980,1(8159):101.
[19]	Lee YM, Huh KC, Yoon SM , et al. Incidence and clinical outcomes of Clostridium difficile infection after treatment with tuberculosis medication. Gut Liver, 2016,10(2):250-254.
[20]	Gerding DN, Johnson S, Peterson LR , et al. Clostridium difficile-associated diarrhea and colitis. Infect Control Hosp Epidemiol, 1995, 16(8): 459-477.
[21]	Hull MW, Beck PL . Clostridium difficile-associated colitis. Can Fam Physician, 2004, 50: 1536-1540, 1543-1545.
[22]	Bignardi GE . Risk factors for Clostridium difficile infection. J Hosp Infect, 1998,40(1):1-15.
[23]	Howell MD, Novack V, Grgurich P , et al. Iatrogenic gastric acid suppression and the risk of nosocomial Clostridium difficile infection. Arch Intern Med, 2010,170(9):784-790.
[24]	George RH . Pseudomembranous colitis probably due to rifampicin. Lancet, 1980,1(8181):1304.
[25]	Brunton LL, Hilal-Dandan R, Knollmann BC . The pharmacological basis of therapeutics. 13th ed. New York: McGraw-Hill, 2018.

第一作者及参考文献	性别	年龄 (岁)	结核部位或类型	并发症	抗结核药物	潜伏期 (d)	大便Cd 毒素	大便Cd 培养	肠镜	是否停用利福平	治疗用药
Moriarty^[6]	男	57	肾	无	H-R-E	42	未提及	阴性	阳性	是	无
Klaui^[7]	女	64	血行播散性	无	H-R-E	26	未提及	阳性	未查	是	万古霉素
Park^[8]	男	90	肺	无	H-R-Z-E	30	阴性	阴性	阳性	是	甲硝唑
Sun^[9]	女	63	心包	无	H-R-Z-E	120	阳性	未提及	未查	是	甲硝唑、乳酸菌
Nakajima^[10]	女	49	肺、胸膜	自身免疫性肝炎	H-R-E	67	未提及	阴性	阳性	是	乳酸菌
Chen^[11]	女	28	肺	无	H-R-Z-E	126	未提及	未提及	阳性	是	无
Choi^[12]	男	74	肺	无	H-R-Z-E	120	未提及	未提及	阳性	是	甲硝唑
Yim^[13]	男	81	肺	无	H-R-Z-E	30	阳性	阴性	阳性	是	甲硝唑
Akbar^[14]	女	43	腹腔淋巴结	无	H-R-Z-E	90	未提及	未提及	阳性	否	甲硝唑
Kim^[15]	女	50	肺	糖尿病	H-R-Z-E	55	未提及	未提及	阳性	是	甲硝唑
Choi^[16]	女	65	肠道	直肠癌、高血压、糖尿病	H-R-Z-E	60	阳性	未提及	阳性	是	甲硝唑
Byrd^[17]	男	60	肺	无	H-R-E	120	阳性	阳性	阳性	是	甲硝唑
Fournier^[18]	女	59	血行播散性	无	H-R-E	20	未提及	未提及	阳性	是	万古霉素