支气管镜检查在疑诊肺结核痰菌阴性患者中的诊断价值

摘要

目的 分析支气管镜检查对临床怀疑肺结核而痰涂片结核菌阴性患者的诊断价值.方法 回顾性分析459例于2010年6月-2015年5月临床和影像学怀疑肺结核但痰涂片阴性的患者.所有患者连续3d痰涂片阴性或者无痰者均接受电子支气管镜检查,包括刷检、支气管肺泡灌洗(BAL)和经支气管肺活检,标本分别进行涂片抗酸染色、结核菌培养或组织病理检查.结果 459例临床怀疑肺结核痰菌阴性患者,经支气管镜检查可以明确诊断者378例,占82.4％.378例支气管镜确诊病例中,肺结核238例(占63.0％),其他诊断包括支气管肺癌、非特异性炎症、机化性肺炎、肺部真菌感染、间质性肺炎、结节病和非结核分枝杆菌感染.在支气管镜确诊的病例中,涂片(毛刷和/或BAL液)阳性156例,诊断灵敏度57.95％;BAL液培养阳性213例,诊断灵敏度79.78％;病理活检阳性152例,诊断灵敏度56.93％.支气管镜综合技术(涂片+培养+活检)的灵敏度、特异度、阳性预测值和阴性预测值分别为91.01％、97.46％、97.98％和88.89％.结论 对临床表现和影像学怀疑肺结核而痰涂片结核菌阴性的患者,支气管镜检查对肺结核的诊断具有良好的临床价值,可作为常规检查加以推广.%Objective To examine the value of bronchoscopy in the diagnosis of sputum-negative pulmonary tuberculosis in a general hospital.Methods A retrospective study was conducted for the 459 patients treated in a general hospital from June 2010 to May 2015.All the patients had symptoms and radiographic changes suggestive of pulmonary tuberculosis but smearnegative.All patients were subjected to bronchoscopy,including brushing,bronchoalveolar lavage (BAL) and transbronchial biopsy (TBB).The bronchoscopic specimens were submitted for direct smear and acid-fast stain,Mycobacterium tuberculosis culture or histopathological assay,respectively.Results The diagnosis was confirmed by bronchoscopy in 378 (82.4％) of the 459 patients.Of the 378 patients whose diagnosis was confirmed,pulmonary tuberculosis was identified in 238 patients (63.0％).Other diagnoses included bronchogenic carcinoma,non-specific inflammation,organizing pneumonia,pulmonary fungal infection,interstitial pneumonia,sarcoidosis,nontuberculous mycobacterial infection.Of the patients with confirmed diagnosis by bronchoscopy,the sensitivity for diagnosis was 57.95％ by direct smear and acid-fast stain of brushing or BALF,79.78％ by culture of BALF,and 56.93％ by histopathological assay of TBB specimens.The integrated method by combining smear and stain,culture and histopathological assay of TBB specimens could improve the sensitivity,specificity,positive predictive value,and negative predictive value to 91.01％,97.46％,97.98％ and 88.89％.Conclusions For the patients whose clinical manifestations and imaging changes are suggestive of pulmonary tuberculosis but smear-negative,bronchoscopy is a valuable method for the diagnosis,which should be adopted as a routine test in clinical practice.