Tuberculous pleurisy -: A study of 254 patients
Tuberculous pleurisy -: A study of 254 patients
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DOI：
10.1001/archinte.158.18.2017
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发表时间：
1998-10-12
影响因子：
--
通讯作者：
Pose, A
中科院分区：
文献类型：
--
作者：
Valdés, L;Alvarez, D;Pose, A
目的：确定结核性胸腔积液发生的年龄、胸腔积液的放射学和生化特征、各种诊断试验的敏感性以及结合临床、放射学和分析数据进行诊断的实用性。方法：我们研究了1989年1月1日至6月30日期间确诊为结核性胸腔积液的254例患者的病史，1997年，在西班牙的一所大学医院在一个地区的结核病高发率。结果：平均（+/-SD）的患者年龄为34.1 +/- 18.1岁，62.2%的年龄小于35岁。55.9%的患者积液位于右侧，42.5%的患者积液位于左侧，1.6%的患者积液位于两侧。在81.5%的患者中，不到三分之二的半侧胸廓受到影响。在18.9%的患者中检测到相关的肺部病变，其中14.6%表现出空洞。在93.3%的渗出液中，50%以上的白细胞是淋巴细胞，并且几乎所有的渗出液都具有渗出液的生物学特征（98.8%的渗出液具有高总蛋白含量，94.9%的渗出液具有高胆固醇水平，82.3%的渗出液具有高乳酸脱氢酶水平）。除1例积液（99.6%）外，所有积液的腺苷脱氨酶（ADA）浓度均高于47 U/L，96.8%（123/127）的积液具有高ADA水平，89%（73/82）的积液具有高干扰素γ水平。腺苷脱氨酶2占总ADA活性的72.2% +/- 12.5%（平均值+/- SD）。总ADA活性与ADA（r = 0.83）和干扰素γ（r = 0.30）水平显著相关。明确诊断是基于79.8%的患者胸膜活检组织样本中干酪样肉芽肿的观察、11.7%的患者活检培养结果以及其余8.5%的患者胸腔积液培养结果。结核菌素皮试结果呈阳性，只有66.5%的patients.Conclusions：在这些患者中，淋巴细胞丰富的渗出性胸腔积液发生，平均而言，在一个年轻的年龄，没有偏好的权利或左侧，通常影响不超过三分之二的半胸，并普遍不伴有肺浸润。高ADA浓度是一个高度敏感的诊断体征，由ADA浓度升高引起。胸膜活检最敏感的标准是干酪样肉芽肿的观察，活检材料的培养进一步增加了整体的敏感性。阴性皮肤试验结果不能保证积液是非结核性的。这一点，再加上患者的平均年龄低和相关肺部病变的发生率低，表明结核性胸腔积液是该地区结核病的主要形式。
Objectives: To determine the age at which tuberculous pleural effusions occur, the radiological and biochemical characteristics of the effusions, the sensitivities of the various diagnostic tests, and the utility of combining clinical, radiological, and analytic data in diagnosis.Methods: We studied the case histories of 254 patients in whom tuberculous pleural effusions were diagnosed with certainty between January 1, 1989, and June 30, 1997, in a Spanish university hospital in a region with a high incidence of tuberculosis.Results: The mean (+/-SD) age of the patients was 34.1 +/- 18.1 years, and 62.2% were younger than 35 years. The effusion was on the right side in 55.9% of patients, on the left side in 42.5% of patients, and on both sides in 1.6% of patients. In 81.5% of patients, less than two thirds of the hemithorax was affected. Associated pulmonary lesions were detected in 18.9% of patients, of whom 14.6% exhibited cavitation. In 93.3% of the effusions, more than 50% of leukocytes were lymphocytes, and almost all had the biologic characteristics of exudates (98.8% had high total protein contents, 94.9% had high cholesterol levels, and 82.3% had high lactate dehydrogenase levels). All but 1 effusion (99.6%) had an adenosine deaminase (ADA) concentration higher than 47 U/L, 96.8% (123/127) of the effusions had high ADA, levels, and 89% (73/82) of the effusions had high interferon gamma levels. Adenosine deaminase 2 contributed 72.2% +/- 12.5% (mean +/- SD) of total ADA activity. Total ADA activity was significantly correlated with ADA, (r = 0.83) and with interferon gamma (r = 0.30) levels. Definitive diagnosis was based on the observation of caseous granulomas in pleural biopsy tissue samples in 79.8% of patients, on the results of biopsy cultures in 11.7% of patients, and on pleural effusion cultures in the remaining 8.5% of patients. Results of the tuberculin skin test were positive in only 66.5% of patients.Conclusions: In these patients, lymphocyte-rich exudative pleural effusions occurred, on average, at a young age, with no preference for either the right or the left side; normally affected no more than two thirds of the hemithorax; and were generally unaccompanied by pulmonary infiltrates. High ADA concentration was a highly sensitive diagnostic sign and was caused by a rise in ADA, concentration. The most sensitive criterion based on pleural biopsy was the observation of caseous granulomas, and culture of biopsy material further increased overall sensitivity. Negative skin test results were no guarantee of the effusion being nontuberculous. This, together with the low mean age of the patients and the low frequency of associated pulmonary lesions, suggests that tuberculous pleural effusion is a primary form of tuberculosis in this region.