摘要
耐药结核病是由耐药结核分枝杆菌所引起的结核病,是目前威胁人类健康的主要呼吸道传染病。在全球范围内,2017年WHO报告了160 684例耐多药结核病和利福平耐药结核病(MDR/RR-TB),接受治疗的有139 114例。约有47%的耐药结核病来自印度(24%)、中国(13%)和俄罗斯(10%)。同时,约有23万例耐多药/利福平耐药患者死亡。为了有效地规范耐药肺结核的预防、诊断和治疗,临床上依据实验室细菌学及耐药产生的原因等对结核分枝杆菌耐药分为新发耐药结核和复治耐药结核两大类;依据耐药数量和种类分为单耐药、多耐药、耐多药、广泛耐药和利福平耐药五型。本文主要就利福平耐药、耐多药和广泛耐药肺结核的影像表现进行描述,并附典型病例的胸片和CT图片,三种耐药肺结核分别具有一些影像学特点,主要表现为肺内多发性厚壁空洞、大小不等的结节影、斑片状实变影、纤维条索状影及部分表现为淋巴结肿大和胸腔积液。病变累及范围广泛、迁延时间长并可出现毁损肺。掌握耐药肺结核的发病率、病死率、临床分类及分型,了解主要类型耐药肺结核的影像学表现特点,有利于指导临床诊断、治疗和疗效评价,降低其发病率和病死率。
Drug-resistant tuberculosis, a TB caused by Mycobacterium tuberculosis, is a major respiratory infection that currently threatens human health. Globally, WHO reported 160,684 cases of MDR/RR-TB in 2017, with 139,114 cases receiving treatment. About 47% of drug-resistant TB patients come from India(24%), China(13%) and Russia(10%). At the same time, about 230,000 MDR/RR-TB patients died. In order to effectively standardize the prevention, diagnosis and treatment of drugresistant tuberculosis, it has been divided into two categories, new drug-resistant TB and previously treated drug-resistant TB, according to the laboratory bacteriology and the cause of drug resistance. While based on the degree of drug resistance, the categories could also be single-drug resistance, multidrug resistance, poly-drug resistance, extensively drug resistance and rifampicin resistance. In this paper, the imaging manifestations of rifampicin resistance, multidrug resistance and XDR-TB were described with representative images of CT and X-rays. Three kinds of drug-resistant pulmonary tuberculosis have some imaging characteristics, mainly manifested as multiple thick wall voids in the lungs, different sizes of the nodule shadow, patchy real changes, fiber stripe shadow, lymph node enlargement and pleural effusion. The lesions involved a wide range areas and long extended time which can cause damaged lungs. Keeping track of the incidence, fatality rate and clinical classification as well as understanding the imaging features of the main types of drug-resistant pulmonary tuberculosis is helpful to guide the clinical diagnosis, treatment and evaluation of curative effect, and to reduce the incidence and fatality rate.
引文
[1]Corbett EL,Marston B,Churchyard GJ.Tuberculosis in subsaharan africa:opportunities,challenges,and change in the era of antiretroviral treatment[J].Lancet,2006,367(9514):926-937.
[2]中华医学会放射分会传染病放射学专业委员会.肺结核分级诊断影像学诊断专家共识[J].新发传染病电子杂志,2018,3(2):118-127.
[3]唐神结,许绍发,李亮主编.耐药结核病学[M].北京:人民卫生出版社,2014:18-26.
[4]World Health Organization.Global tuberculosis report2018[EB/OL].[2018-09-18].https://www.who.int/tb/publications/global_report/en/.
[5]World Health Organization.Global tuberculosis report2017[EB/OL].[2017-10-15].http://apps.who.int/medicinedocs/en/m/abstract/Js23360en/.
[6]王胜芬,赵冰,宋媛媛,等.我国耐药结核病的危险因素--2007年全国结核病耐药基线调查资料分析[J].中国防痨杂志,2013,35(4):221-226.
[7]全国结核病流行病学抽样调查技术指导组.2000年全国结核病流行病学抽样调查报告[J].中国防痨杂志,2002,24(2):3-46.
[8]沈欣,宋沈超,雷世光.耐药结核病流行现状及防控对策[J].职业与健康,2017,33(4):566-568.
[9]成诗明.我国耐多药结核病防治现状与建议[J].中国热带医学,2017,17(3):213-215.
[10]WHO/IUATLD.Global Project on Anti-tuberculosis Drug Resistance Surve illance.Anti-tuberculosis drug resistancein the world.Thirdreport[R].Geneva:WHO,2004:343.
[11]Piubello A,A?t-Khaled N,Caminero JA,et al.Field Guidefor the Management of Drug-Resistant Tuberculosis[J].Pearson Schweiz Ag,2018,63(3):307-319.
[12]Van D A,Salim A H,Rigouts L,et al.Evaluation of tuberculosis control by periodic or routine susceptibility testing in previously treated cases[J].International Journal of Tuberculosis&Lung Disease the Official Journal of the International Union Against Tuberculosis&Lung Disease,2001,5(4):329-338..
[13]Van Rie A,Warren R,Richardson M,et al.Classification of drug-resistance tuberculosis in an epidemic area[J].Lancet,2000,356(9223):22-25.
[14]Falzon D,Jaramillo E,Schünemann H J,et al.WHOguidelines for the programmatic management of drugresistant tuberculosis:2011 update[J].European Respiratory Journal,2011,38(3):516-528.
[15]张志学,任国英,谭宇才,等.耐单药利福霉素肺结核的CT表现[J].中国医药指南,2015,13(25):64-65.
[16]陈根铭,成官迅,朱少乾,等.初治单耐药肺结核的CT影像学研究[J].新发传染病电子杂志,2018,3(2):111-114.
[17]高德杰,王束玫,邱丽华.86例耐多药肺结核患者胸部影像分析[J].临床肺科杂志,2012,17(7):1265-1266.
[18]李春华,吕圣秀,王惠秋,等.耐多药肺结核患者的CT表现及其与CD4细胞的关系[J].中国防痨杂志,2017,39(6):597-603.
[19]Kiyan E,Killicaslan Z,Gurgon M,et al.Clinical and radiographic features of pulmonary tuberculosis in nonAIDS immu-nocompromised patients[J].Int J Tubere Lung Dis,2003,7(8):764-770.
[20]孙华,唐神结,顾瑾,等.广泛耐药肺结核的胸部CT特点[J].中国防痨杂志,2011,33(2):123-125.
[21]Jeong YJ,Lee KS.Pulmonary tuberculosis:up-to-date imaging and management[J].Am J Roentgenol,2008,191(3):834-844.
[22]王毅翔,Myung Jin Chung,Aliaksandr Skrahin,等.与耐多药肺结核相关的放射学征象的文献分析[J].新发传染病电子杂志,2018,3(3):244-253.
[23]罗道宝,刘岩,杨芳玲,等.耐药结核分枝杆菌肺结核的影像分析[J].中国误诊学杂志,2007,7(5):989-990.
