Mert A, Bilir M, Tabak F, Ozaras R, Ozturk R, Senturk H, Aki H, Seyhan N, Karayel T, Aktuglu Y
Department of Clinical Bacteriology and Infectious Diseases, Cerrahpasa Medical Faculty, University of Istanbul, Istanbul, Turkey.
Respirology. 2001 Sep;6(3):217-24. doi: 10.1046/j.1440-1843.2001.00328.x.
The aim of the study was to determine the clinical, radiographic and laboratory characteristics, diagnostic methods, and prognostic variables in patients with miliary tuberculosis (TB).
The records of 38 patients (15 male, 23 female; mean age 41 years, range 16-76 years) with miliary TB from 1978 to 1998 were analyzed. Patients were evaluated also as to whether they presented with a fever of unknown origin (FUO). Criteria for the diagnosis of miliary TB were (i) miliary pattern on chest X-ray or (ii) biopsy or autopsy evidence of miliary organ involvement. Paraffin-embedded tissues with granulomata (n = 15) were re-evaluated for the presence of Mycobacterium tuberculosis DNA by polymerase chain reaction (PCR).
Predisposing conditions were present in 24% of the patients. The findings were fever, weakness, night sweats, anorexia/weight loss (100% for each), hepatomegaly (37%), splenomegaly (32%), choroidal tubercles (13%), neck stiffness (11%), altered mental status (8%), anaemia (76%), leukopenia (26%), thrombocytopenia (16%), lymphopenia (76%), pancytopenia (8%) and hypertransaminasemia (55%). Eighteen patients (47%) met the criteria for a FUO. Miliary infiltrates were found on chest X-rays of 32 of 38 cases (84%). In six cases without miliary infiltrates, the diagnosis was made by laparotomy in four cases, and autopsy in two cases. Tuberculin skin test was positive in 32% of cases. Acid-fast bacilli were demonstrated in 37% (16/43), and cultures for M. tuberculosis were positive in 90% (9/10) of tested specimens (predominantly sputum and bronchial lavage). Granulomas were found in 85% (11/13) of lung, 100% (15/15) of liver, and 56% (9/16) of bone marrow tissue specimens. Acid-fast bacilli staining was negative in all (0/21), while PCR was positive in 47% (7/15) of specimens with granulomata. Mortality was 18%. Stepwise logistic regression identified male sex (P = 0.005), non-typical miliary pattern (P = 0.015), altered mental status (P = 0.002) and failure to treat for TB (P = 0.00001) as independent predictors of mortality.
Miliary infiltrates on chest X-ray or FUO should raise the possibility of miliary TB. Therapy should be administered urgently to prevent an otherwise fatal outcome.
本研究旨在确定粟粒型肺结核（TB）患者的临床、影像学和实验室特征、诊断方法及预后变量。
分析了1978年至1998年间38例粟粒型肺结核患者（男15例，女23例；平均年龄41岁，范围16 - 76岁）的病历。还对患者是否表现为不明原因发热（FUO）进行了评估。粟粒型肺结核的诊断标准为：（i）胸部X线显示粟粒样改变；或（ii）活检或尸检有粟粒样器官受累的证据。对15例有肉芽肿的石蜡包埋组织通过聚合酶链反应（PCR）重新评估是否存在结核分枝杆菌DNA。
24%的患者存在易感因素。表现为发热、虚弱、盗汗、厌食/体重减轻（各占100%）、肝肿大（37%）、脾肿大（32%）、脉络膜结核结节（13%）、颈部僵硬（11%）、精神状态改变（8%）、贫血（76%）、白细胞减少（26%）、血小板减少（16%）、淋巴细胞减少（76%）、全血细胞减少（8%）和转氨酶升高（55%）。18例患者（47%）符合不明原因发热的标准。38例患者中32例（84%）胸部X线显示粟粒样浸润。6例无粟粒样浸润的患者中，4例通过剖腹手术确诊，2例通过尸检确诊。结核菌素皮肤试验32%的病例呈阳性。37%（16/43）的病例发现抗酸杆菌，结核分枝杆菌培养90%（9/10）的检测标本（主要是痰液和支气管灌洗）呈阳性。85%（11/13）的肺组织标本、100%（15/15）的肝组织标本和56%（9/16）的骨髓组织标本中发现肉芽肿。所有标本（0/21）抗酸杆菌染色均为阴性，而PCR在47%（7/15）有肉芽肿的标本中呈阳性。死亡率为18%。逐步逻辑回归分析确定男性（P = 0.005）、非典型粟粒样改变（P = 0.015）、精神状态改变（P = 0.002）和未接受抗结核治疗（P = 0.00001）是死亡的独立预测因素。
胸部X线显示粟粒样浸润或不明原因发热应提高粟粒型肺结核的可能性。应紧急给予治疗以防止出现致命后果。
