Long R, Guzman R, Greenberg H, Safneck J, Hershfield E
Department of Medicine, University of Manitoba, Winnipeg, Canada.
Chest. 1999 Feb;115(2):522-31. doi: 10.1378/chest.115.2.522.
To define the epidemiology, pathogenesis, pathology, presentation, and management of tuberculous mycotic aneurysm of the aorta (TBAA) in the therapeutic era, we reviewed all of the cases reported in the English language literature from 1945 to the present. To the 39 cases in the published literature, we add two cases of our own. Although it is exceedingly rare, the prevalence of this lesion has remained relatively constant. In 75% of the cases, TBAA appeared to result from erosion of the aortic wall by a contiguous focus; 25% from direct seeding of the aortic intima or of the adventitia or media (via the vasa vasorum). Most of the aneurysms were saccular (90%) and false (88%). The thoracic and abdominal aortas were affected with equal frequency. The mean (+/- SD) age of the patients was 50+/-16 years. Twenty-two were men, and 19 were women. In 63% of the cases, tuberculosis (TB) was diagnosed at presentation. Disseminated TB was present in 46% of the cases. One or more of three clinical scenarios suggested TBAA: persistent pain, major bleeding, and a palpable or radiographically visible para-aortic mass, especially if it is expanding or pulsatile. In turn, each of these findings suggested a complication of TBAA that may be an indication for surgical intervention. Among the patients who were offered both medical and surgical treatment, 20 of 23 (87%) survived. Among those who were offered only one form of treatment or were offered no treatment at all there were no survivors. Both in situ reconstruction with a prosthetic graft, and extra-anatomic bypass appeared to offer excellent results, provided that an effective regimen of antituberculous drugs was delivered postoperatively. We offer our conclusions: (1) symptomatic TBAA is a rare but uniformly fatal lesion if not diagnosed promptly, (2) in the context of active TB, and especially miliary TB, TBAA should be suspected whenever one or more of the three clinical scenarios are present, and (3) combined medical and surgical therapy appears to offer the best chance of a cure.
为明确治疗时代主动脉结核性真菌性动脉瘤（TBAA）的流行病学、发病机制、病理学、临床表现及治疗方法，我们回顾了1945年至今英文文献中报道的所有病例。在已发表文献中的39例病例基础上，我们补充了自己的2例病例。尽管这种病变极为罕见，但其患病率一直相对稳定。在75%的病例中，TBAA似乎是由邻近病灶侵蚀主动脉壁所致；25%是由于主动脉内膜、外膜或中膜（通过滋养血管）直接播散引起。大多数动脉瘤为囊状（90%）且为假性（88%）。胸主动脉和腹主动脉受累频率相同。患者的平均（±标准差）年龄为50±16岁。22例为男性，19例为女性。63%的病例在就诊时被诊断为结核病（TB）。46%的病例存在播散性TB。三种临床情况中的一种或多种提示TBAA：持续性疼痛、大出血以及可触及或影像学可见的主动脉旁肿块，特别是如果肿块在扩大或有搏动。反过来，这些发现中的每一项都提示了TBAA的一种并发症，这可能是手术干预的指征。在接受药物和手术治疗的患者中，23例中有20例（87%）存活。在仅接受一种治疗形式或根本未接受治疗的患者中，无一例存活。只要术后给予有效的抗结核药物治疗方案，使用人工血管进行原位重建和解剖外旁路手术似乎都能取得良好效果。我们得出以下结论：（1）有症状的TBAA是一种罕见但如果不及时诊断则一致致命的病变；（2）在活动性TB，尤其是粟粒性TB的情况下，只要出现三种临床情况中的一种或多种，就应怀疑TBAA；（3）联合药物和手术治疗似乎提供了最佳的治愈机会。
