一例血行播散性结核病患者的临床诊治过程分析  

Analysis on clinical diagnosis and treatment of one patient with hematogenous disseminated tuberculosis

作　　者：赵雪瑶 韩利军 秦桂香 孙力 

机构地区：[1]长春市传染病医院结核性脑膜炎诊断与治疗中心,130000

出　　处：《中国防痨杂志》2017年第6期648-653,共6页Chinese Journal of Antituberculosis

摘　　要：笔者收集整理了1例血行播散性结核病（DTB）患者的临床资料，通过对该患者临床诊治过程的分析讨论，希望增强临床医生对于DTB的重视与认识，提高诊断与治疗能力。该患者以发热、咳嗽3个月，活动后气促、头痛、双耳听力下降、双下肢水肿5d、双肺弥漫粟粒状结节影待查（血行播散性肺结核可能性大）入住长春市传染病医院结核性脑膜炎诊断与治疗中心，人院后综合患者实验室检查，行腰椎穿刺术、头颅MR增强扫描，发现颅内病灶，考虑诊断血行播散性肺结核、结核性脑膜炎（脑内结核球型）、肝功能异常，白细胞（WBC）减少症，血小板（PLT）减少症，胰腺肿大原因待查，根据肝功能情况及血液系统改变情况，给予抗结核、抗感染、保肝及支持对症治疗，患者病情无好转。自行出院后于多家医院就诊治疗（停用全部抗结核药物，仅给予激素治疗），肺部病变、血液系统改变较前好转，但颅内病灶较前加重，经颅内病变组织活检术后病理证实为结核病。综合患者前期实验室检查，考虑肝脏、胰腺、脾脏改变不除外播散性结核病可能，最终诊断为血行播散性结核病，给予积极抗结核、激素及支持对症治疗，但患者病情重，症状未见好转，经检查证实患者并发免疫功能低下疾病，经多次调整治疗方案无效后，最终死亡。The clinical data of one patient with hematogenous disseminated pulmonary tuberculosis （DTB） was collected. Through the analysis and discussion, we hope to enhance the clinicians＇ attention and understanding to the hematogenous disseminated tuberculosis and improve their abilities on diagnosis and treatment of DTB. The patient was permitted to stay at the Center for Tuberculosis Meningitis Diagnosis and Treatment of Changchun Infectious Disease Hospital because he had fever and cough for 3 months, and with shortness of breath after movements, headache, binaural hearing loss, edema of both lower limbs for 5 days, lung shadows （highly suspected as hematogenous disseminated tuberculosis）. After admission, the patient was given the lumbar puncture and head MRI enhanced scan examinations and the intracranial lesions were found. Combined with the comprehensive laboratory tests, the patient was considered to have hematogenous disseminated tuberculosis, tuberculous meningitis （brain tuberculoma）, abnormal liver function, leukopenia, hrombocytopenia, pancreatic enlargement but reasons need to be investigated. According to the liver function condition and the changes in the blood system, the patient received the anti-TB treatment, anti-infective therapy, liver protection and symptomatic support treatment. The patient＇s condition did not improve.After discharge from our hospital, the patient visited several other hospitals for seeking further treatment （anti-TB drugs were stopped and only with hormone therapy）. The lung lesions and the changes in blood system got better than before, but the intracranial lesions were worse. The brain biopsy was done and TB was confirmed by the pathology examination. According to all the preoperative examination results and considering the changes of liver, pancreas and spleen, the patient was finally diagnosed as hematogenous disseminated tuberculosis. The patient received anti-TB treatment again and with the hormones and symptomatic support treatments. However, the patie

关 键 词：结核 肺 血行播散性结核病 转诊和会诊 结果与过程评价(卫生保健) 

分 类 号：R52[医药卫生—内科学]