初治与复治耐多药肺结核患者的CT表现分析

doi:10.3969/j.issn.1000-6621.2020.01.010

摘要/Abstract

摘要：

目的探讨初治与复治耐多药肺结核患者的CT表现。方法搜集2016年1月至2019年1月重庆市公共卫生医疗救治中心经药物敏感性试验确诊的186例耐多药肺结核患者,其中初治患者80例,作为初治组;复治患者106例,作为复治组。对比两组患者病变范围、病灶形态(树芽征、腺泡结节、斑片状影、大片状影、条索状影、钙化影)、空洞数量及形态、空洞壁、支气管扩张等CT表现,对CT表现等计数资料进行统计学分析,采用χ ²检验,以P<0.05为差异有统计学意义。结果复治组肺毁损者占20.8%(22/106)、病灶范围≥3叶者占 90.6%(96/106)、病灶位于中叶及舌段者占85.8%(91/106),以及出现索条状影者占54.7%(58/106)、钙化灶者占27.4%(29/106)、支气管扩张者占77.4%(82/106),与初治组比较 [分别为6.2%(5/80)、71.2%(57/80)、72.5%(58/80)、23.8%(19/80)、10.0%(8/80)、31.2%(25/80)],差异均有统计学意义(χ ²值分别为7.730、11.656、5.098、18.021、8.621、39.670,P值均<0.05)。复治组发生胸廓塌陷者占21.7%(23/106)、纵隔移位者占35.8%(38/106)、胸膜增厚者占78.3%(83/106),与初治组比较 [分别为5.0%(4/80)、7.5%(6/80)、53.8%(43/80)],差异均有统计学意义(χ ²值分别为8.943、20.288、12.576,P值均<0.05)。复治组患者空洞发生率为83.0%(88/106)、空洞≥3个者占59.4%(63/106)、厚壁空洞者占70.8%(75/106)、薄壁空洞者占40.6%(43/106)、虫蚀样空洞者占40.6%(43/106)、空洞呈簇聚集者占40.6%(43/106)、空洞内壁不光滑者占20.8%(22/106),与初治组比较 [分别为56.2%(45/80)、23.8%(19/80)、51.2%(41/80)、12.5%(10/80)、16.2%(13/80)、16.2%(13/80)、7.5%(6/80)],差异有统计学意义(χ ²值分别为16.034、23.551、7.390、17.626、12.810、12.810、6.264,P值均<0.05)。结论复治耐多药肺结核患者病变范围,肺毁损、多发空洞且呈簇聚集、干酪性肺炎伴虫蚀样空洞及静脉曲张型支气管扩张等CT表现与初治组比较更严重。

关键词: 结核,抗多种药物性, 再治疗, 体层摄影术,X线计算机, 诊断相关患者组, 诊断显像, 对比研究

Abstract:

Objective To investigate the CT findings in patients with initial and retreated multidrug-resistant tuberculosis. Methods A total of 186 patients with multidrug-resistant tuberculosis diagnosed by drug susceptibility testing in Chongqing Public Health Medical Treatment Center from January 2016 to January 2019 were collected, including 80 newly treated patients as initial treatment group and 106 retreated patients as retreatment group. The lesion size, lesion morphology (tree in bud, acinar node, speckle shadow, large shadow, strip shadow, calcification shadow), the number and shape of cavity, the shape of cavity wall, bronchiectasis and other CT findings were compared between the two groups. The CT findings were statistically analyzed by χ ² test, and the difference was statistically significant (P<0.05). Results In the retreatment group (106 cases), there were destroyed lungs in 22 cases (20.8%,22/106), lesion size more than 3 lobes in 96 cases (90.6%,96/106), lesions located in the middle lobe and tongue segment in 91 cases (85.8%, 91/106), strip shadow in 58 cases (54.7%,58/106), calcification shadow in 29 cases (27.4%,29/106) and bronchiectasis in 82 cases (77.4%, 82/106), respectively, when compared for those (6.2% (5/106), 71.2% (57/80), 72.5% (58/80), 23.8% (19/80), 10.0% (8/80), 31.2% (25/80)) in initial group with the significant differences statistically (χ ² values were 7.730, 11.656, 5.098, 18.021, 8.621, 39.670, Ps<0.05). In the retreatment group (106 cases), Chest collapse occurred in 23 cases (21.7%, 23/106), mediastinal displacement in 38 cases (35.8%,38/106), pleural thickening in 83 cases (78.3%,83/106), when compared for those (5.0% (4/80), 7.5% (6/80), 53.8% (43/80)) in the initial treatment group with the significant difference statistically (χ ² values were 8.943, 20.288, 12.576, Ps<0.05). The incidence of cavity was 83.0% (88/106), the number of cavity more three in 63 cases (59.4%,63/106), thicken-wall cavity in 75 cases (70.8%, 75/106), thin-wall cavity in 43 cases (40.6%,43/106), moth-eaten cavity in 43 cases (40.6%,43/106), cluster cavity in 43 cases (40.6%,43/106) and cavity with rough inner wall in 22 cases (20.8%,22/106), when compared for those (56.2% (45/80),23.8% (19/80),51.2% (41/80),12.5% (10/80),16.2% (13/80),16.2% (13/80) and 7.5% (6/80)) in initial group with the significant difference statistically (χ ² value were 16.034,23.551,7.390,17.626,12.810,12.810 and 6.264, Ps<0.05). Conclusion The CT findings of retreated MDR-TB patients are more serious than those of the initial treatment group, such as wide lesion, destroyed lungs, multiple cavities and cluster aggregation, caseous pneumonia with moth-eaten cavity and varicose bronchiectasis.

Key words: Tuberculosis,multidrug-resistant, Retreatment, Tomography,X-Ray computed, Diagnosis-related groups, Diagnostic imaging, Comparative study

杨佳,吕圣秀,唐光孝,舒伟强,王惠秋,杨长萍,刘雪艳,李春华. 初治与复治耐多药肺结核患者的CT表现分析[J]. 中国防痨杂志, 2020, 42(1): 38-43. doi: 10.3969/j.issn.1000-6621.2020.01.010

YANG Jia,LYU Sheng-xiu,TANG Guang-xiao,SHU Wei-qiang,WANG Hui-qiu,YANG Chang-ping,LIU Xue-yan,LI Chun-hua. Analysis of CT findings in patients with initial and retreated multidrug-resistant tuberculosis[J]. Chinese Journal of Antituberculosis, 2020, 42(1): 38-43. doi: 10.3969/j.issn.1000-6621.2020.01.010

图/表 8

图1

图2

图3

图4

图5

图6

表1

表2

参考文献 24

[1]	World Health Organization. Global tuberculosis report 2019. Geneva: World Health Organization, 2019. doi: 10.9745/GHSP-D-19-00210 URL pmid: 31852741
[2]	Seung KJ, Keshavjee S, Rich ML . Multidrug-Resistant Tuberculosis and Extensively Drug-Resistant Tuberculosis. Cold Spring Harb Perspect Med, 2015,5(9):a017863. doi: 10.1101/cshperspect.a017863 URL pmid: 25918181
[3]	王毅翔, Chung MJ, Skrahin A, 等. 与耐多药肺结核相关的放射学征象的文献分析. 新发传染病电子杂志, 2018,3(4):244-253.
[4]	World Health Organization. Guidelines for the programmatic management of drug-resistant tuberculosis. 2011 update. Geneva: World Health Organization,2011[EB/OL]. [2011-11-18]..
[5]	中华人民共和国国家卫生和计划生育委员会. WS 288—2017 肺结核诊断. 2017 -11-09.
[6]	World Health Organization/IUATLD. Global Project on Anti-tuberculosis Drug Resistance Surve illance. Anti-tuberculosis drug resistance in the world. Third report. Geneva: World Health Organization, 2004: 343. doi: 10.1086/430786 URL pmid: 16032561
[7]	Piubello A, Aït-Khaled N, Caminero JA , et al. Field guide for the management of drug-resistant tuberculosis. Paris:International Union Against Tuberculosis and Lung Disease, 2018. doi: 10.1016/j.jinf.2019.03.006 URL pmid: 30849440
[8]	余卫业, 谭卫国, 陆普选 . 耐药肺结核的分类、分型及影像学表现. 新发传染病电子杂志, 2019,4(1):42-47.
[9]	Chuchottaworn C, Thanachartwet V, Sangsayunh P , et al. Risk Factors for Multidrug-Resistant Tuberculosis among Patients with Pulmonary Tuberculosis at the Central Chest Institute of Thailand. PLoS One, 2015,10(10):e0139986. doi: 10.1371/journal.pone.0139986 URL pmid: 26444421
[10]	Li D, He W, Chen B , et al. Primary multidrug-resistant tuberculosis versus drug-sensitive tuberculosis in non-HIV-infected patients:Comparisons of CT findings. PLoS One, 2017,12(6):e0176354. doi: 10.1371/journal.pone.0176354 URL pmid: 28586348
[11]	Perrin FM, Woodward N, Phillips PP , et al. Radiological cavitation, sputum mycobacterial load and treatment response in pulmonary tuberculosis. Int J Tuberc Lung Dis, 2010,14(12):1596-1602. URL pmid: 21144246
[12]	Ong CW, Elkington PT, Friedland JS . Tuberculosis, pulmonary cavitation, and matrix metalloproteinases. Am J Respir Crit Care Med, 2014,190(1):9-18. doi: 10.1164/rccm.201311-2106PP URL pmid: 24713029
[13]	李利佳, 王迪, 刘倩颖 , 等. 320层CT双入口灌注技术观察复治涂阳肺结核患者病灶灌注特点. 中国防痨杂志, 2016,38(5):349-353. doi: 10.3969/j.issn.1000-6621.2016.05.005 URL
[14]	李成海, 周新华, 吕岩 , 等. 不同耐药类型及药物敏感肺结核患者的CT征象分析. 中国防痨杂志, 2018,40(7):707-712.
[15]	Wáng YXJ, Chung MJ, Skrahin A , et al. Radiological signs associated with pulmonary multi-drug resistant tuberculosis:an analysis of published evidences. Quant Imaging Med Surg, 2018,8(2):161-173. doi: 10.21037/qims.2018.03.06 URL pmid: 29675357
[16]	Gomez JE, McKinney JD . M.tuberculosis persistence,latency, and drug tolerance. Tuberculosis (Edinb), 2004,84(1/2):29-44. doi: 10.1016/j.tube.2003.08.003 URL pmid: 14670344
[17]	Connolly LE, Edelstein PH, Ramakrishnan L . Why is long-term therapy required to cure tuberculosis? PLoS Med, 2007,4(3):e120. doi: 10.1371/journal.pmed.0040120 URL pmid: 17388672
[18]	Hunter RL . Tuberculosis as a three-act play: A new paradigm for the pathogenesis of pulmonary tuberculosis. Tuberculosis (Edinb), 2016,97:8-17. doi: 10.1016/j.tube.2015.11.010 URL pmid: 26980490
[19]	Belton M, Brilha S, Manavaki R , et al. Hypoxia and tissue destruction in pulmonary TB. Thorax, 2016,71(12):1145-1153. doi: 10.1136/thoraxjnl-2015-207402 URL pmid: 27245780
[20]	Volkman HE, Pozos TC, Zheng J , et al. Tuberculous granuloma induction via interaction of a bacterial secreted protein with host epithelium. Science, 2010,327(5964):466-469. doi: 10.1126/science.1179663 URL pmid: 20007864
[21]	Elkington P, Shiomi T, Breen R , et al. MMP-1 drives immunopathology in human tuberculosis and transgenic mice. J Clin Invest, 2011,121(5):1827-1833. doi: 10.1172/JCI45666 URL
[22]	Walker NF, Clark SO, Oni T , et al. Doxycycline and HIV infection suppress tuberculosis-induced matrix metalloprotei-nases. Am J Respir Crit Care Med, 2012,185(9):989-997. doi: 10.1164/rccm.201110-1769OC URL pmid: 22345579
[23]	Baumann MH, Nolan R, Petrini M , et al. Pleural tuberculosis in the United States: incidence and drug resistance. Chest, 2007,131(4):1125-1132. doi: 10.1378/chest.06-2352 URL pmid: 17426219
[24]	Jeon K, Choi WI, An JS , et al. Paradoxical response in HIV-negative patients with pleural tuberculosis: a retrospective multicentre study. Int J Tuberc Lung Dis, 2012,16(6):846-851. doi: 10.5588/ijtld.11.0642 URL pmid: 22507441