结核性胸膜炎并发胸膜结核瘤的影响因素探讨

摘要

目的 探讨结核性胸膜炎并发胸膜结核瘤的危险因素.方法 选取2014年3月至2016年3月同济大学附属上海市肺科医院结核科连续收治的诊断为初治结核性胸膜炎的415例患者作为研究对象.收集研究对象入院时胸腔积液的细胞分类,腺苷脱氨酶(ADA)、蛋白、葡萄糖、乳酸脱氢酶(LDH)水平,以及胸部CT扫描特征;记录随访疗程中是否出现胸膜结核瘤,以及胸膜结核瘤发生的部位、个数,治疗方案是否调整、如何调整,是否发生药物不良反应,方案调整原因;记录所有研究对象的实际疗程、胸膜结核瘤吸收变化的情况及最后的治疗转归情况.所有研究对象均随访到疗程结束.结果 415例患者中,并发胸膜结核瘤者209例(50.4％),中位年龄为29(23～39)岁,较未并发者的中位年龄[38(26～57)岁]低,差异有统计学意义(Z=5.00,P＜0.05).并发胸膜结核瘤患者中使用非标化方案治疗者占42.6％ (89/209),高于未并发者的29.6％(61/206),差异有统计学意义(x2=7.56,P=0.006).初治标准方案由于药物不良反应而调整药物者发生胸膜结核瘤的比率(32.5％,62/1 91)高于未并发者(21.2％,33/156),差异具有统计学意义(x2=4.97,P=0.030);并发胸膜结核瘤后给予变更原方案强化治疗者98例,疗程结束时有90例胸膜结核瘤病灶显著吸收(91.8％);治疗方案未变更者104例,在疗程结束时有89例胸膜结核瘤病灶显著吸收(85.6％),两者相比,差异无统计学意义(x2=1.39,P＞0.05).结论 年龄较轻及治疗中使用非标准方案可能是结核性胸膜炎并发胸膜结核瘤的影响因素.结核性胸膜炎患者并发胸膜结核瘤后,继续给予原强化方案治疗,疗程适当延长,可使大多数胸膜结核瘤获得明显吸收.%Objective To discuss the risk factors for tuberculous pleurisy complicated with pleural tuberculoma.Methods A total of 415 patients with the diagnosis of tuberculous pleurisy were enrolled in the tuberculosis department in Shanghai Pulmonary Hospital of Tonyji University School of Medicine from March 2014 to March 2016.The cell classification of pleural effusion,levels of adenosine deaminase (ADA),protein,glucose,and lactate dehydrogenase (LDH),and chest CT scan findings were collected from the subjects.It was recorded whether the presence of pleural tuberculoma during treatment,the location and number of pleural tuberculoma,whether the treatment plan was adjusted and how to adjust,whether adverse drug reactions occurred or not,and the reasons for the adjustment of the regimen.The actual course of treatment,the absorption status of pleural tuberculoma and the final outcome were recorded.All subjects were followed up until end of treatment.Results Of the 415 cases,pleural tuberculoma was found in 209 (50.4％) cases.The median age of patients with pleural tuberculoma (29(23-39) years) was lower than that of patients without pleural tuberculoma (38 (26-57) years);the difference was statistically significant (Z=5.00,P＜0.05).The proportion of patients treated with non-standardized regimen in patients with pleural tuberculoma was higher (42.6％ (89/209)) than that in patients without pleural tuberculoma (29.6％ (61/206));the difference was statistically significant (x2 =7.56,P =0.006).Among the patients with adjusted regimen due to adverse reaction after initial standard regimen treatment,the rate of patients complicated by pleural tuberculoma was higher (32.5％,62/191) than that (21.2％,33/156) of patients not complicated by pleural tuberculoma;the difference was statistically significant (x2 =4.97,P =0.030).After the occurrence of pleural tuberculoma,98 cases had got intensified treatment,90 cases of whom were significantly absorbed (91.8％)at the end of the course.Among 104 cases with no change in the regimen,89 cases had got tuberculoma completely absorbed (85.6％);there was no significant difference between the two groups (x2 =1.39,P＞ 0.05).Conclusion Younger age and nonstandard regimen in treatment may be the risk factors for tuberculous pleurisy complicated with pleural tuberculoma.After occurrence of pleural tuberculoma,the pleural tuberculoma in most cases will be able to be significantly absorbed by continued original intensive regimen and appropriately prolonged course.