结核病流行背景下胸内结节病与结核病临床鉴别与处置专家共识

doi:10.19982/j.issn.1000-6621.20220361

摘要/Abstract

摘要：

胸内结节病与结核病均以上皮样肉芽肿为常见病理学特征,两种疾病的影像学特征均表现为多样性,且临床表现具有一定的相似性,容易造成误诊和误治。特别是在结核病流行地区,建立规范的鉴别处置流程具有必要性。为此,中国防痨协会多学科诊疗分会、《中国防痨杂志》编辑委员会和中华医学会放射学分会临床多学科合作工作组联合组织全国多学科专家,在结合临床经验和总结国内外研究结果的基础上,研究制定了《结核病流行背景下胸内结节病与结核病临床鉴别与处置专家共识》。该共识从临床表现、影像学特征、支气管镜检查、病理学诊断与病原学检查等多方面对两种疾病的鉴别进行分类阐述,提出采用多学科合作诊疗模式解决两病鉴别难题,并给出了具体流程和步骤。同时,确定了结节病患者中筛查结核分枝杆菌潜伏感染的目标人群,并就结核分枝杆菌潜伏感染的处置与管理给出了推荐意见,旨在精准施治,改善患者预后。

关键词: 结节病, 结核, 肺, 诊断, 鉴别, 总结性报告(主题)

Abstract:

Common pathological features of both intrathoracic sarcoidosis and pulmonary tuberculosis are epithelioid granulomas, and the clinical manifestations of the two diseases are similar to some extent, which may lead to misdiagnosis and mistreatment. It is necessary to establish standardized identification and management procedures for the two diseases, especially in tuberculosis endemic areas. Therefore, the Multidisciplinary Diagnosis and Treatment Committee of the Chinese Antituberculosis Association, Editorial Board of Chinese Journal of Antituberculosis and Clinical Multidisciplinary Cooperation Working Group of the Radiology Branch of the Chinese Medical Association organized multidisciplinary experts to develop an Expert consensus on clinical differential diagnosis and treatment of intrathoracic sarcoidosis and pulmonary tuberculosis under the background of tuberculosis epidemic after combining clinical experiences and summarizing worldwide research results. The consensus provides the differentiation of the two diseases in terms of clinical manifestations, imaging characteristics, bronchoscopy, pathological and etiological examinations. It also proposes a specific framework of confirming the diagnosis of challenging cases through multidisciplinary cooperation with specific procedures and steps. Meanwhile, target population for the screening of potential tuberculosis infection amongst sarcoidosis patients are determined. Additionally, recommendations are given on the treatment and management of latent tuberculosis infection, so as to provide accurate treatment and improve the prognosis of patients.

Key words: Sarcoidosis, Tuberculosis, pulmonary, Diagnosis, differential, Consensus development conferences as topic

中图分类号:

中国防痨协会多学科诊疗分会, 《中国防痨杂志》编辑委员会, 中华医学会放射学分会临床多学科合作工作组. 结核病流行背景下胸内结节病与结核病临床鉴别与处置专家共识[J]. 中国防痨杂志, 2022, 44(12): 1227-1241. doi: 10.19982/j.issn.1000-6621.20220361

Multidisciplinary Diagnosis and Treatment Committee of the Chinese Anti-tuberculosis Association, Editorial Board of Chinese Journal of Antituberculosis, Clinical Multidisciplinary Cooperation Working Group of the Radiology Branch of the Chinese Medical Association. Expert consensus on clinical differential diagnosis and treatment of intrathoracic sarcoidosis and pulmonary tuberculosis under the background of tuberculosis epidemic[J]. Chinese Journal of Antituberculosis, 2022, 44(12): 1227-1241. doi: 10.19982/j.issn.1000-6621.20220361

图/表 8

表1

结核病流行背景下胸内结节病与结核病临床鉴别与处置推荐意见一致性

序号	推荐意见	一致性评分 (分, $x ˉ$ ±s)	变异系数 (%)
1	结节病是一种可累及全身多器官的肉芽肿性疾病,当与结核病鉴别困难时,应积极寻找胸外器官受累证据,提高诊断效率	9.88±0.64	6.48
2	应采用高分辨率CT和增强CT对胸内病变进行系统评价,并结合动态CT随访,提出倾向性诊断	9.46±1.22	12.90
3	支气管镜检查应常规用于胸内结节病和菌阴肺结核鉴别,应重视支气管黏膜活检技术的普及和应用。根据病变特点选择经支气管镜肺活检和淋巴结针吸活检用于肺组织和纵隔/肺门淋巴结病变诊断	9.92±0.40	4.07
4	支气管肺泡灌洗液结核分枝杆菌分子生物学检测或培养应作为结节病与结核病鉴别的常规手段;支气管肺泡灌洗液中的CD4⁺/CD8⁺T细胞比值对两者鉴别可能具有价值,诊断尚需结合临床	9.54±0.85	8.90
5	病理科医师对于肉芽肿病变,在病理报告时应详细描述肉芽肿形态、分布特征及伴随病变,并提出倾向性意见	9.79±0.62	6.31
6	病理报告的肉芽肿病变,建议常规做特殊染色寻找结核分枝杆菌,对需要与结核病鉴别的活检及手术标本应进行分枝杆菌培养和菌种鉴定	9.87±0.64	6.48
7	结节病与结核病鉴别时,建议将分子生物学技术用于组织学标本结核分枝杆菌检测,但不能替代分枝杆菌培养作为诊断金标准,阳性结果需结合临床表现综合考虑	9.75±0.67	6.86
8	应采用结核科和呼吸科共同主导的多学科合作模式,开展结节病与结核病鉴别诊断、处置和随访工作	9.75±0.79	8.06
9	经多学科联合会诊或完善相关检查后仍难区分胸内结节病与肺结核时,经权衡利弊和知情同意后,建议选择诊断性抗结核治疗	9.00±1.24	13.75
10	应对结节病患者中的结核发病高风险人群进行结核分枝杆菌潜伏感染筛查,包括接受肿瘤坏死因子拮抗剂、长期接受糖皮质激素和(或)其他免疫抑制剂治疗者,肺结核密切接触者,HIV感染者,血液透析和器官移植的结节病患者	9.38±1.55	16.56
11	建议对结节病高风险人群中的结核分枝杆菌潜伏感染者采用异烟肼联合利福喷丁(利福平)的方案进行预防性抗结核治疗	9.13±1.30	14.23

表1

图1~9

表2

图10~21

表3

表4

图22~25

图26

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不确定性征象	结节病可能	结核病可能
微结节簇集征	占9.9%,中上肺分布为主,团簇状,微结节排列不规则,伴中轴间质和间隔间质不规则增厚	占2.6%,中上肺分布为主,单发或多发团簇状,微结节排列规则,不伴或伴轻度间隔间质增厚
星系征	占7.3%~27%,结节聚集融合成大结节,边界不清,周围伴淋巴管周分布微结节,淋巴结肿大常见,空洞极少见	占1.9%~9.3%,结节融合形成局灶性实变,可坏死形成空洞,伴发树芽征或小叶中心结节,淋巴结肿大少见
反晕征	占5.3%,晕环呈结节表现,常伴肺内淋巴管周分布结节和(或)肺门淋巴结肿大	占3.6%~13.9%,晕环呈结节表现,常伴发树芽征或小叶中心结节,一般不伴淋巴结肿大
空洞	占2.2%~6.8%,大小不一,薄壁空洞多见,较大空洞见分隔带;厚壁空洞见于活动期,随着病情好转,洞壁变薄	占19.6%,空洞形态多样,常见引流支气管征,伴发树芽征
斑块与肿块	占12%~25%,多发或双侧分布,形态不规则,边界不清,伴发淋巴管周分布结节	占15.9%,球形病变,边界清,伴卫星结节,呈小叶中心分布
实变	占12%,多为结节融合所致,密度多不均匀,伴或不伴支气管充气征	占69.6%,渗出性肺实变,节段性分布,密度均匀,可进展成干酪性肺实变
淋巴结坏死或强化不均匀	占5.9%,个别淋巴结局灶性坏死或强化不均,偶可见环形强化,淋巴结边界清晰,不融合	78.1%的淋巴结呈低密度或环形强化;淋巴结结外浸润、融合,边界不清,侵蚀支气管壁形成支气管淋巴瘘

支持特征	不支持特征
沿淋巴道分布	缺乏淋巴道分布特征
显微镜下肉芽肿位于肺间质	显微镜下肺泡腔内肉芽肿
肉芽肿排列紧密,大小相对一致,融而不合	肺泡腔机化,肉芽肿松散,大小不一,融合
非坏死性(偶有点灶坏死)	大片坏死
结节周边纤维组织增生	较多炎症细胞浸润
炎细胞少	淋巴滤泡形成
常见包涵体	抗酸染色阳性和(或)培养阳性

支持特征	不支持特征
沿气道分布或随机分布	沿淋巴道周围分布
显微镜下肉芽肿位于肺泡腔内及间质	显微镜下肉芽肿仅见于肺间质
肉芽肿排列紧密或松散、大小不一,融合
干酪样坏死
较多淋巴细胞浸润
肺泡腔内浆液性、纤维素渗出
抗酸染色阳性和(或)培养阳性