Ikeda T, Ikeda N, Kurasawa T, Sato A, Nakatani K, Inoue T
National Minami-Kyoto Hospital, Japan.
Kekkaku. 1996 Nov;71(11):619-23.
We report a case of tuberculous infection of emphysematous bulla, who is a 71-years-old male and ex-smoker. He had no past-history and had been treated for chronic obstructive pulmonary disease. At the periodical consultation on Sept 28 '95, abnormal shadow was found in left middle lung field on plain chest X-ray without any exacerbation of symptoms. Nearly alllaboratory tests on admission were within normal limit, except of slight elevation of inflammatory markers and slight hypoxemia. The Mantoux's skin test was positive. Roentogenologically, the air-fluid level was detected in the bulla of superior segment of left lower lobe. By percutaneous thoracentesis of the bulla under fluoloscopy and ultrasonic echo-guide, the fluid in the bulla was obtained. The fluid was exudate, the activities of ADA and LDH were elevated, but neutrophils were more dominant than lymphocytes in the fluid. The MTD test was positive, which amplifies rRNA of Mycobacterium tuberculosis (MTB), and MTB were cultered after four weeks from the fluid. However, MTB was not cultured from sputum and bronchial washing of left S6 via bronchoscope. After the administration of RFP, INH and EB, the fluid gradually disappeared with reduction of the size of bulla. We discussed the usefulness of the examination of the fluid in the bulla, especially the measurement of the activity of ADA and the MTD test for the confirmation of diagnosis as tuberculosis.
我们报告一例肺气肿性肺大泡结核感染病例，患者为一名71岁男性，有吸烟史。他既往无其他病史，一直在接受慢性阻塞性肺疾病的治疗。在1995年9月28日的定期会诊中，胸部X线平片显示左中肺野有异常阴影，但症状无任何加重。入院时几乎所有实验室检查结果均在正常范围内，仅有炎症指标轻度升高和轻度低氧血症。结核菌素皮肤试验呈阳性。影像学检查发现左下叶上段肺大泡内有气液平面。在荧光透视和超声引导下对肺大泡进行经皮穿刺，获取了肺大泡内的液体。该液体为渗出液，腺苷脱氨酶（ADA）和乳酸脱氢酶（LDH）活性升高，但液体中中性粒细胞比淋巴细胞更占优势。结核分枝杆菌核酸扩增试验（MTD）呈阳性，该试验可扩增结核分枝杆菌（MTB）的核糖体RNA，从液体中培养4周后培养出了MTB。然而，通过支气管镜对左肺S6段痰液和支气管灌洗物进行培养，未培养出MTB。给予利福平（RFP）、异烟肼（INH）和乙胺丁醇（EB）治疗后，液体逐渐消失，肺大泡体积缩小。我们讨论了对肺大泡内液体检查的实用性，特别是ADA活性测定和MTD试验对确诊结核病的作用。
