Shafer R W, Kim D S, Weiss J P, Quale J M
Department of Medicine, State University of New York-Health Sciences Center, Brooklyn.
Medicine (Baltimore). 1991 Nov;70(6):384-97. doi: 10.1097/00005792-199111000-00004.
The annual number of cases of culture-proven extrapulmonary tuberculosis (TB) at our hospital increased from 47 cases in 1983 to 113 cases in 1988. At least 43% (199) of 464 consecutive patients with extrapulmonary TB during this 6-year period were infected with the human immunodeficiency virus (HIV); since HIV serologic testing was not performed routinely the true HIV prevalence is likely to be higher. Of the HIV-infected patients, 59% were intravenous drug users, 31% were Haitian, 3% were homosexual males, 1% were perinatally-infected infants, and 6% did not have a known risk factor for HIV infection. Ninety-eight percent of the HIV-infected patients were black (84%) or hispanic (14%). The HIV-infected patients were more likely than the control patients to have either disseminated, genitourinary, intra-abdominal, mediastinal, or concurrent pulmonary TB. Fever was nearly universal among the HIV-infected patients, but was absent in about one-third of the control patients. Among untreated HIV-infected patients, disease progression was rapid and nearly always fatal. Among HIV-infected patients who received treatment, the response to therapy, as judged by hospital survival and time to defervescence, was similar to that of the control patients. Despite the extensive tuberculous dissemination among the HIV-infected patients, the diagnosis of TB was difficult and often delayed. In addition to the decrease in tuberculin reactivity and the atypical chest radiograph patterns, there was a need to consider other HIV-related infections in the differential diagnosis. Although sputum specimens grew M. tuberculosis in greater than 90% of the HIV-infected patients in whom they were obtained, sputum AFB stains were positive in less than 50%. Blood and urine specimen cultures were positive in 56% and 77% of the HIV-infected patients in whom these specimens were obtained, but did not provide a means of early diagnosis. Cerebrospinal fluid and pleural fluid were abnormal in nearly all patients with involvement of these sites but were rarely AFB-positive and were, therefore, only suggestive of TB. Procedures such as biopsies and aspirates of peripheral lymph nodes, visceral lymph nodes, liver, and bone marrow provided the highest immediate diagnostic yields with rates between 50% and 90%. These procedures must be considered early in the course of illness in HIV-infected patients with suspected extrapulmonary TB due to the rapidly progressive nature of this often fatal but usually treatable infection.
我院经培养证实的肺外结核病年病例数从1983年的47例增至1988年的113例。在这6年期间，464例连续性肺外结核患者中至少43%（199例）感染了人类免疫缺陷病毒（HIV）；由于未常规进行HIV血清学检测，实际的HIV感染率可能更高。在感染HIV的患者中，59%为静脉吸毒者，31%为海地人，3%为男同性恋者，1%为围产期感染的婴儿，6%没有已知的HIV感染危险因素。98%的HIV感染患者为黑人（84%）或西班牙裔（14%）。与对照患者相比，HIV感染患者更易发生播散性、泌尿生殖系统、腹腔内、纵隔或合并肺结核。发热在HIV感染患者中几乎普遍存在，但约三分之一的对照患者无发热症状。在未接受治疗的HIV感染患者中，疾病进展迅速且几乎总是致命的。在接受治疗的HIV感染患者中，根据住院生存率和退热时间判断，其对治疗的反应与对照患者相似。尽管HIV感染患者中结核广泛播散，但结核病的诊断困难且常被延误。除了结核菌素反应性降低和胸部X线表现不典型外，在鉴别诊断中还需要考虑其他与HIV相关的感染。虽然在超过90%的获得痰液标本的HIV感染患者中痰培养出结核分枝杆菌，但痰抗酸染色阳性率不到50%。在获得血液和尿液标本的HIV感染患者中，血培养和尿培养阳性率分别为56%和77%，但它们并非早期诊断的手段。几乎所有累及这些部位的患者脑脊液和胸腔积液均异常，但很少抗酸染色阳性，因此仅提示结核病。诸如外周淋巴结、内脏淋巴结、肝脏和骨髓活检及抽吸等检查的即时诊断阳性率最高，在50%至90%之间。由于这种通常致命但通常可治疗的感染具有快速进展的特点，对于怀疑肺外结核的HIV感染患者，在病程早期就必须考虑进行这些检查。
