关键词: 结核, 药物疗法, 利福平,不良反应, 小肠结肠炎, 伪膜性, 疾病特征

Abstract:

Objective: To report the clinical diagnosis and treatment process of 6 patients with pseudomembranous colitis (PMC) caused by anti-tuberculosis drugs, and to analyze the pathogenic mechanism, clinical characteristics, treatment, and prognosis in combination with literature. Methods: Six cases of diarrhea after anti-tuberculosis treatment confirmed as PMC by colonoscopy examination were reported from May 2022 to March 2024 at Beijing Chest Hospital Affiliated to Capital Medical University. Clinical information (including clinical onset, stool shape, and related accompanying symptoms), laboratory examination results (including stool routine examination, stool culture), endoscopic examination, pathological examination results, final diagnosis, treatment process, and prognosis were analyzed. Six articles and 99 patients with PMC after using anti-tuberculosis drugs were retrieved through searching studies published from January 1990 to May 2020 in the PubMed database using “tuberculosis+Clostridium difficile” and “tuberculosis+pseudomembranous colitis” as search terms, and the Wanfang database using “tuberculosis+pseudomembranous colitis” and “tuberculosis+pseudomembranous colitis” as search terms. The characteristics of patients in this group were summarized and literature review was conducted for selected patients. Results: Among the 6 patients, 5 had pulmonary tuberculosis and 1 had Mycobacterial avium disease. All cases occurred diarrhea, abdominal pain and bloating after anti-tuberculosis treatment containing rifampicin and ethambutol for about 2-30 days. Clostridium difficile examination in stool was negative. Colonoscopy examination showed a yellow white pseudomembrane covered with the colon mucosa. Pathological biopsy showed acute and chronic inflammation of mucosal tissue. After discontinuing rifampicin, using vancomycin (0.25 g/time, 4 times/day, orally) for anti infection, regulating gut microbiota, and fluid replacement to treat shock for 3-5 days, the symptoms significantly improved. When the symptoms disappeared and anti tuberculosis drugs were taken again, 2 cases experienced diarrhea symptoms again. Among the 99 patients involved in the literature, there were 97 cases of pulmonary tuberculosis, 1 case of bone tuberculosis, and 1 case of tuberculous meningitis. All cases experienced varying degrees of diarrhea and abdominal pain within 9-120 days of using anti-tuberculosis drugs such as isoniazid, rifampicin, and pyrazinamide. Mucosal congestion and edema with white pseudomembranous features were observed under colonoscopy, and all cases were confirmed after colonoscopy and fecal examination. 29 patients were positive for Clostridium difficile toxin examination and were given vancomycin for anti-infection treatment (including 10 patients who used metronidazole) and probiotics to regulate intestinal microbiota. Symptoms improved for all cases,including 3 recurrent patients. Conclusion: It is necessary to be alert to the occurrence of PMC in patients who use rifamycin for a long time, especially for elderly tuberculosis patients who use glucocorticoids and have abnormal immune function. When a false membrane in the intestine is observed under colonoscopy, and the intervention measures such as discontinuing rifampicin, using vancomycin and/or metronidazole for anti infection, or supplementing with intestinal microbiota regulating agents have good effects, PMC can be clinically diagnosed.

Key words: Tuberculosis, Drug therapy, Rifampicin, adverse effects, Enterocolitis, pseudomembranous, Disease attributes