Jimborean Gabriela, Nemeş Roxana Maria, Postolache Paraschiva, Milutin Doina, Ianoşi Edith Simona
Pneumologia. 2016 Jul-Sep;65(3):146-9.
Pulmonary tuberculosis can be confirmed by positive bacteriology of sputum, bronchial aspirate or by biopsies (microscopy and/ or culture) or by histopathological examination highlighting specific tuberculous granulomas. When microscopy is repeatedly negative during noninvasive methods, lung biopsy by thoracoscopy is needed for confirmation and differential diagnosis.
A 40-year-old female patient (nonsmoker, diabetic, with previous exposure to chemicals) was admitted to the hospital for weight loss, dry cough, loss of appetite, pallor, and fatigue. Chest-X-ray and thoracic CT revealed multiple irregular macronodules with various shapes, randomly spread across the lungs. Bacteriology for acid fast bacilli (AFB) from six spontaneous sputum was negative. Bronchoscopy showed an acute bronchitis. Bronchial aspirate was negative for tumor cells and AFB. Several biopsies from bronchial wall showed unspecific changes. The molecular biology tests for specific nucleic acids detection (Polymerase Chain Reaction) or positron-emission-tomography (to differentiate benign nodules from malign ones) were not accessible. Multiple biopsies from lung parenchyma and pleura were obtained using thoracoscopy. Histopathology revealed multiple specific tuberculous granulomas. The complex antituberculous treatment (9 months) has led to the total cure of the disease and resorption of the nodules. The patient’s last visit (after 2 years) showed no clinical/imagistic or bacteriologic relapse of the disease.
Tuberculosis may present in the form of multiple macronodules spread randomly across the lung parenchyma. Thoracoscopy coupled with multiple large lung biopsies are recommended for diagnosis of multinodular lung lesions, especially when common bacteriology/cytology from bronchoscopic aspiration failed to achieve diagnosis. Histological exam from thoracoscopic biopsies allows differential diagnosis between entities that have macronodular features: tuberculosis, primitive lung cancer, lymphomas, metastatic disease or invasive fungal disease.
肺结核可通过痰液、支气管吸出物的细菌学阳性结果，或活检（显微镜检查和/或培养），或通过突出特定结核性肉芽肿的组织病理学检查来确诊。当无创检查方法中显微镜检查反复呈阴性时，需要通过胸腔镜进行肺活检以确诊和鉴别诊断。
一名40岁女性患者（不吸烟、患有糖尿病、既往接触过化学品）因体重减轻、干咳、食欲不振、面色苍白和疲劳入院。胸部X线和胸部CT显示肺部有多个形状各异的不规则大结节，随机分布于两肺。六次自发痰液的抗酸杆菌（AFB）细菌学检查均为阴性。支气管镜检查显示为急性支气管炎。支气管吸出物未发现肿瘤细胞和AFB。支气管壁的多次活检显示为非特异性改变。无法进行特定核酸检测的分子生物学试验（聚合酶链反应）或正电子发射断层扫描（以区分良性结节和恶性结节）。通过胸腔镜从肺实质和胸膜获取了多次活检组织。组织病理学显示有多个特异性结核性肉芽肿。复杂的抗结核治疗（9个月）使疾病完全治愈，结节吸收。患者最后一次就诊（2年后）显示疾病无临床/影像学或细菌学复发。
肺结核可能表现为随机分布于肺实质的多个大结节。对于多结节性肺病变的诊断，建议采用胸腔镜检查并进行多次大的肺活检，尤其是当支气管镜吸出物的常规细菌学/细胞学检查未能确诊时。胸腔镜活检的组织学检查有助于对具有大结节特征的疾病进行鉴别诊断：肺结核、原发性肺癌、淋巴瘤、转移性疾病或侵袭性真菌病。
