隐源性机化性肺炎误诊16例临床分析
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摘要
目的探讨隐源性机化性肺炎(cryptogenic organizing pneumonia,COP)的临床特点、治疗方法、误诊原因及防范措施。方法对曾误诊为社区获得性肺炎(community acquired pneumonia,CAP)的16例COP的临床资料进行回顾性分析。结果本组误诊率为61. 5%。以咳嗽伴呼吸困难及乏力就诊3例,咳嗽伴发热就诊3例,咳嗽、发热伴乏力就诊3例,单纯发热、单纯咳嗽及单纯胸痛就诊各2例,咳嗽伴胸痛及乏力就诊1例。9例肺部可闻及湿啰音,1例肺部可闻及Velcro啰音。实验室检查以血白细胞、中性粒细胞及C反应蛋白升高为主。胸部CT检查以斑片、实变及磨玻璃影为主。就诊初期皆误诊为CAP。误诊时间4~25(12. 0±5. 6)d。按误诊疾病给予相应治疗效果不佳。后均经病理检查确诊COP。给予糖皮质激素治疗,除1例失访外,余15例均预后良好。结论 COP临床表现和胸部CT检查缺乏特异性,易误诊。认真病史询问、仔细鉴别诊断和及时进行相关检查可减少或避免COP误诊误治。
Objective This study aims to explore the clinical characteristics,the treatment,causes of misdiagnosis and preventive measures of the cryptogenic organizing pneumonia(COP). Methods We conducted a retrospective analysis of the clinical data of 16 cases COP which had been misdiagnosed as community acquired pneumonia(CAP). Results The misdiagnosis rate was 61. 5% in this group. There were 3 COP patients who presented to our hospital for cough associated with dyspnea and fatigue,3 for cough associated with fever,3 for cough associated with fever and fatigue,2 for fever,2 for cough,2 for chest pain and 1 for cough associated with chest pain and fatigue. Moist rales were heard in 9 cases and velcro rales were heard in one. The laboratory tests results showed that the numbers of white blood cells and neutrophils as well as c-reactive protein were increased significantly in these patients. The chest CT scan revealed exudation at different patches and solid shadow. At initial visit to our hospital,they were all misdiagnosed as CAP,and the duration of misdiagnosis was 4-25(12. 0 ± 5. 6) d. Because of the misdiagnosis,the corresponding treatment effect was far from satisfactory. When COP was confirmed by pathological examination,they were treated with glucocorticoid. The prognosis of the remaining 15 patients was good except 1 who was lost to follow-up. Conclusion COP is more likely to be misdiagnosed by chest CT scan due to lack of specificity of clinical characteristics. Careful inquiry of medical history and differential diagnosis as well as prompt examination can reduce or avoid the misdiagnosis and treatment of COP.
Objective This study aims to explore the clinical characteristics,the treatment,causes of misdiagnosis and preventive measures of the cryptogenic organizing pneumonia(COP). Methods We conducted a retrospective analysis of the clinical data of 16 cases COP which had been misdiagnosed as community acquired pneumonia(CAP). Results The misdiagnosis rate was 61. 5% in this group. There were 3 COP patients who presented to our hospital for cough associated with dyspnea and fatigue,3 for cough associated with fever,3 for cough associated with fever and fatigue,2 for fever,2 for cough,2 for chest pain and 1 for cough associated with chest pain and fatigue. Moist rales were heard in 9 cases and velcro rales were heard in one. The laboratory tests results showed that the numbers of white blood cells and neutrophils as well as c-reactive protein were increased significantly in these patients. The chest CT scan revealed exudation at different patches and solid shadow. At initial visit to our hospital,they were all misdiagnosed as CAP,and the duration of misdiagnosis was 4-25(12. 0 ± 5. 6) d. Because of the misdiagnosis,the corresponding treatment effect was far from satisfactory. When COP was confirmed by pathological examination,they were treated with glucocorticoid. The prognosis of the remaining 15 patients was good except 1 who was lost to follow-up. Conclusion COP is more likely to be misdiagnosed by chest CT scan due to lack of specificity of clinical characteristics. Careful inquiry of medical history and differential diagnosis as well as prompt examination can reduce or avoid the misdiagnosis and treatment of COP.
引文
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[2]Epler G R,Colby T V,Mc Loud T C,et al.Bronchiolitis obliterans organizing pneumonia[J].N Engl J Med,1985,312(3):152-158.
[3]American Thoracic Society,European Respiratory Society.American Thoracic Society/European Respiratory Society International Multidisciplinary Consensus Classification of the Idiopathic Interstitial Pneumonias.This joint statement of the American Thoracic Society(ATS),and the European Respiratory Society(ERS)was adopted by the ATS board of directors,June 2001 and by the ERS Executive Committee,June 2001[J].Am J Respir Crit Care Med,2002,165(2):277-304.
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[5]李红敏,张倩倩,钱伟军.隐源性机化性肺炎20例的高分辨率CT影像表现[J].实用医学影像杂志,2018,19(1):73-75.
[6]魏淑珍,朱思红,李素娟,等.隐源性机化性肺炎及继发性机化性肺炎的临床特征及影像特点分析[J].国际呼吸杂志,2018,38(3):192-196.
[7]Yilmaz S,Akinci Ozyurek B,Erdogan Y,et al.Retrospective evaluation of patients with organizing pneumonia:is cryptogenic organizing pneumonia different from secondary organizing pneumonia?[J].Tuberk Toraks,2017,65(1):1-8.
[8]Nakahara Y,Oonishi Y,Takiguchi J,et al.Nontuberculous mycobacterial lung disease accompanied by organizing pneumonia[J].Intern Med,2015,54(8):945-951.
[9]Narasimhaiah D H,Chakravorty I,Swamy R,et al.Organising pneumonia presenting as acute life threatening pulmonary haemorrhage[J].BMJ Case Rep,2011(8):2011.
[10]Cottin V,Cordier J.Cryptogenic organizing pneumonia[J].Semin Respir Crit Care Med,2012,33(5):462-475.
[11]Travis W D,Costabel U,Hansell D M,et al.An official American Thoracic Society/European Respiratory Society statement:Update of the international multidisciplinary classification of the idiopathic interstitial pneumonias[J].Am J Respir Crit Care Med,2013,188(6):733-748.
[12]高泽林,张晓斌.隐源性机化性肺炎临床诊治23例[J].陕西医学杂志,2013,42(3):328-329.
[13]Cordier J F.Organising pneumonia[J].Thorax,2000,55(4):318-328.
[14]Mehrian P,Shahnazi M,Dahaj A A,et al.The spectrum of presentations of cryptogenic organizing pneumonia in high resolutioncomputed tomography[J].Pol J Radiol,2014,79(4):456-460.
[15]Chung M P,Nam B D,Lee K S,et al.Serial chest CT in cryptogenic organizing pneumonia:Evolutional changes and prognostic determinants[J].Respirology,2018,23(3):325-330.
[16]Niksarlioglu E Y,Ozkan G Z,Bakan N D,et al.Cryptogenic organizing pneumonia:clinical and radiological features,treatment outcomes of 17 patients,and review of the literature[J].Turk J Med Sci,2016,46(6):1712-1718.
[17]Drakopanagiotakis F,Paschalaki K,Abu Hijleh M,et al.Cryptogenic and secondary organizing pneumonia:clinical presentation,radiographic findings,treatment response,and prognosis[J].Chest,2011,139(4):893-900.
[18]李艳利,韩锋锋.隐源性机化性肺炎的发病机制及治疗进展[J].临床肺科杂志,2014,19(9):1701-1704.
[19]Cordier J F.Cryptogenic organising pneumonia[J].Eur Respir J,2006,28(2):422-446.
[20]Shitenberg D,Fruchter O,Fridel L,et al.Successful rituximab therapy in steroid-resistant,cryptogenic organizing pneumonia:a case series[J].Respiration,2015,90(2):155-159.
[21]Cai M,Bonella F,Dai H,et al.Macrolides inhibit cytokine production by alveolar macrophages in bronchiolitis obliterans organizing pneumonia[J].Immunobiology,2013,218(6):930-937.
[22]梅周芳,钱凌,都勇,等.隐源性机化性肺炎反复误诊为社区获得性肺炎[J].临床误诊误治,2015,28(7):12-15.
[23]郭海英,包婺平,周新.隐源性机化性肺炎误诊社区获得性肺炎24例并文献复习[J].诊断学理论与实践,2013,12(2):166-169.
[2]Epler G R,Colby T V,Mc Loud T C,et al.Bronchiolitis obliterans organizing pneumonia[J].N Engl J Med,1985,312(3):152-158.
[3]American Thoracic Society,European Respiratory Society.American Thoracic Society/European Respiratory Society International Multidisciplinary Consensus Classification of the Idiopathic Interstitial Pneumonias.This joint statement of the American Thoracic Society(ATS),and the European Respiratory Society(ERS)was adopted by the ATS board of directors,June 2001 and by the ERS Executive Committee,June 2001[J].Am J Respir Crit Care Med,2002,165(2):277-304.
[4]Musher D M,Thorner A R.Community-acquired pneumonia[J].N Engl J Med,2014,371(17):1619-1628
[5]李红敏,张倩倩,钱伟军.隐源性机化性肺炎20例的高分辨率CT影像表现[J].实用医学影像杂志,2018,19(1):73-75.
[6]魏淑珍,朱思红,李素娟,等.隐源性机化性肺炎及继发性机化性肺炎的临床特征及影像特点分析[J].国际呼吸杂志,2018,38(3):192-196.
[7]Yilmaz S,Akinci Ozyurek B,Erdogan Y,et al.Retrospective evaluation of patients with organizing pneumonia:is cryptogenic organizing pneumonia different from secondary organizing pneumonia?[J].Tuberk Toraks,2017,65(1):1-8.
[8]Nakahara Y,Oonishi Y,Takiguchi J,et al.Nontuberculous mycobacterial lung disease accompanied by organizing pneumonia[J].Intern Med,2015,54(8):945-951.
[9]Narasimhaiah D H,Chakravorty I,Swamy R,et al.Organising pneumonia presenting as acute life threatening pulmonary haemorrhage[J].BMJ Case Rep,2011(8):2011.
[10]Cottin V,Cordier J.Cryptogenic organizing pneumonia[J].Semin Respir Crit Care Med,2012,33(5):462-475.
[11]Travis W D,Costabel U,Hansell D M,et al.An official American Thoracic Society/European Respiratory Society statement:Update of the international multidisciplinary classification of the idiopathic interstitial pneumonias[J].Am J Respir Crit Care Med,2013,188(6):733-748.
[12]高泽林,张晓斌.隐源性机化性肺炎临床诊治23例[J].陕西医学杂志,2013,42(3):328-329.
[13]Cordier J F.Organising pneumonia[J].Thorax,2000,55(4):318-328.
[14]Mehrian P,Shahnazi M,Dahaj A A,et al.The spectrum of presentations of cryptogenic organizing pneumonia in high resolutioncomputed tomography[J].Pol J Radiol,2014,79(4):456-460.
[15]Chung M P,Nam B D,Lee K S,et al.Serial chest CT in cryptogenic organizing pneumonia:Evolutional changes and prognostic determinants[J].Respirology,2018,23(3):325-330.
[16]Niksarlioglu E Y,Ozkan G Z,Bakan N D,et al.Cryptogenic organizing pneumonia:clinical and radiological features,treatment outcomes of 17 patients,and review of the literature[J].Turk J Med Sci,2016,46(6):1712-1718.
[17]Drakopanagiotakis F,Paschalaki K,Abu Hijleh M,et al.Cryptogenic and secondary organizing pneumonia:clinical presentation,radiographic findings,treatment response,and prognosis[J].Chest,2011,139(4):893-900.
[18]李艳利,韩锋锋.隐源性机化性肺炎的发病机制及治疗进展[J].临床肺科杂志,2014,19(9):1701-1704.
[19]Cordier J F.Cryptogenic organising pneumonia[J].Eur Respir J,2006,28(2):422-446.
[20]Shitenberg D,Fruchter O,Fridel L,et al.Successful rituximab therapy in steroid-resistant,cryptogenic organizing pneumonia:a case series[J].Respiration,2015,90(2):155-159.
[21]Cai M,Bonella F,Dai H,et al.Macrolides inhibit cytokine production by alveolar macrophages in bronchiolitis obliterans organizing pneumonia[J].Immunobiology,2013,218(6):930-937.
[22]梅周芳,钱凌,都勇,等.隐源性机化性肺炎反复误诊为社区获得性肺炎[J].临床误诊误治,2015,28(7):12-15.
[23]郭海英,包婺平,周新.隐源性机化性肺炎误诊社区获得性肺炎24例并文献复习[J].诊断学理论与实践,2013,12(2):166-169.
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