Asimos A W, Ehrhardt J
Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC 28232-2861, USA.
Am J Emerg Med. 1996 Jul;14(4):359-63. doi: 10.1016/S0735-6757(96)90049-2.
Although the presence of typical postprimary or "reactivation" pattern tuberculosis (TB) on chest radiograph (CXR) strongly suggests TB infection in adults, the sensitivity of this finding, particularly in severely immunosuppressed human immunodeficiency virus (HIV) patients, is unclear. To investigate this issue, HIV status, CD4 counts, and CXR findings of all adult patients with culture-proven TB admitted to a tertiary-care hospital over a 2-year period were retrospectively studied. CXRs were classified as typical for postprimary TB if they showed upper lobe opacities with or without cavitation. No attempt was made to correlate the actual clinical phase of TB infection (primary versus postprimary) with CXR patterns, largely because differentiating primary from postprimary TB in HIV patients is difficult due to high anergy rates and inability to skin-test-convert. Of 46 patients who had chest radiographs and medical records documenting HIV status available for review, 23 were HIV-seropositive and 23 were HIV-seronegative. Of 22 HIV-seropositive patients whose CD4 counts were available, 18 (82%) had CD4 counts of < 200 cells/microL. Only 2 of these 18 (11%) had CXRs showing a typical postprimary TB pattern, whereas all 4 (100%) patients with CD4 counts of > 200 cells/microL and 18 of 23 (78%) non-HIV patients had CXRs typical for postprimary TB (P < .005). It was concluded that HIV-seropositive patients with TB and CD4 counts of < 200 cells/microL frequently present with chest radiographs atypical for postprimary TB, including normal CXRs. Typical postprimary TB CXR findings are not sensitive for diagnosing pulmonary TB in this population.
虽然胸部X光片（CXR）上出现典型的原发性后或“再激活”型肺结核（TB）强烈提示成人存在结核感染，但这一发现的敏感性，尤其是在严重免疫抑制的人类免疫缺陷病毒（HIV）患者中，尚不清楚。为了研究这个问题，我们回顾性研究了一家三级医院在两年期间收治的所有经培养证实患有结核病的成年患者的HIV状态、CD4细胞计数和胸部X光片结果。如果胸部X光片显示上叶有混浊影且伴有或不伴有空洞，则将其分类为原发性后结核的典型表现。我们没有尝试将结核感染的实际临床阶段（原发性与原发性后）与胸部X光片模式相关联，主要是因为由于无反应率高且无法通过皮肤试验转化，在HIV患者中区分原发性结核和原发性后结核很困难。在46例有胸部X光片和记录HIV状态的病历可供审查的患者中，23例为HIV血清阳性，23例为HIV血清阴性。在22例可获得CD4细胞计数的HIV血清阳性患者中，18例（82%）的CD4细胞计数<200个/微升。这18例患者中只有2例（11%）的胸部X光片显示典型的原发性后结核模式，而所有4例（100%）CD4细胞计数>200个/微升的患者和23例非HIV患者中的18例（78%）有原发性后结核的典型胸部X光片表现（P<.005）。研究得出结论，患有结核病且CD4细胞计数<200个/微升的HIV血清阳性患者的胸部X光片常表现为非原发性后结核的典型表现，包括胸部X光片正常。典型的原发性后结核胸部X光片表现对于诊断该人群的肺结核并不敏感。
