Park Joung Ha, Choe Jooae, Bae Moonsuk, Choi Sungim, Jung Kyung Hwa, Kim Min Jae, Chong Yong Pil, Lee Sang-Oh, Choi Sang-Ho, Kim Yang Soo, Woo Jun Hee, Jo Kyung-Wook, Shim Tae Sun, Kim Mi Young, Kim Sung-Han
Departments of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
Departments of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
Open Forum Infect Dis. 2019 Jan 17;6(2):ofz002. doi: 10.1093/ofid/ofz002. eCollection 2019 Feb.
Pauci-bacillary pulmonary tuberculosis (TB) can be delayed to diagnose and start anti-TB therapy, especially in immunocompromised patients. We therefore evaluated the clinical and radiologic features of these delayed cases.
Immunocompromised adult patients with pauci-bacillary pulmonary TB were retrospectively enrolled in a tertiary hospital in an intermediate-TB burden country over a 5-year period. We defined "missed TB" or "not-missed TB" patients as those who started anti-TB therapy after or before positive mycobacterial culture results, respectively.
Of 258 patients, 134 (52%) were classified in the missed TB group, and 124 (48%) in the not-missed TB group. Positive results of molecular tests including MTB polymerase chain reaction and/or Xpert TB/RIF were only obtained in the not-missed TB group (54/106, 54%). The median diagnostic delay in the missed TB group was longer than in the other group (30 vs 6 days; < .001). In the missed TB group, the most common working diagnoses were pneumonia (46, 34%) and lung metastasis of malignancy (40, 30%). Typical radiologic findings for TB, such as upper lobe predominance and centrilobular nodules with tree-in-bud appearance, were less common in the missed TB group than in the other group. Old age (odds ratio [OR], 1.03), solid organ transplant (OR, 3.46), solid tumor (OR, 3.83), and hematologic malignancy (OR, 4.04) were independently associated with missed TB.
Care is needed to differentiate pauci-bacillary TB, especially in immunocompromised patients with the mentioned risk factors, even without the usual radiologic features of TB. Additional rapid diagnostic tests to rule out pauci-bacillary TB are urgently needed.
少菌型肺结核（TB）的诊断及抗结核治疗可能会延迟，尤其是在免疫功能低下的患者中。因此，我们评估了这些延迟病例的临床和影像学特征。
回顾性纳入一个结核病负担中等国家的一家三级医院5年间收治的免疫功能低下的少菌型肺结核成年患者。我们将“漏诊TB”或“未漏诊TB”患者分别定义为在分枝杆菌培养结果呈阳性后或之前开始抗结核治疗的患者。
258例患者中，134例（52%）被归类为漏诊TB组，124例（48%）为未漏诊TB组。仅在未漏诊TB组中获得了包括MTB聚合酶链反应和/或Xpert TB/RIF在内的分子检测阳性结果（54/106，54%）。漏诊TB组的中位诊断延迟时间长于另一组（30天对6天；P<0.001）。在漏诊TB组中，最常见的初步诊断是肺炎（46例，34%）和恶性肿瘤肺转移（40例，30%）。TB的典型影像学表现，如肺上叶为主及伴有树芽征的小叶中心结节，在漏诊TB组中比在另一组中少见。高龄（比值比[OR]，1.03）、实体器官移植（OR，3.46）、实体瘤（OR，3.83）和血液系统恶性肿瘤（OR，4.04）与漏诊TB独立相关。
需要注意鉴别少菌型TB，尤其是在具有上述危险因素的免疫功能低下患者中，即使没有TB常见的影像学特征。迫切需要额外的快速诊断试验以排除少菌型TB。
