呼吸科经典病例——肺放线菌病

2017-11-19 MedSci MedSci原创

放线菌常寄生于人体口腔黏膜、牙龈、扁桃体、结肠等处,平时相安无事,当机体抵抗力下降时可通过口腔分泌物入侵呼吸道,从而导致肺部实质病变。放线菌病因发病率低,故易被误诊,需注意。病史:患者为一55岁女性,47岁时曾行右肺中叶切除术,术后病理诊断为肺结核,术后三联抗结核治疗3个月,有2型糖尿病史4年长期服药治疗,具体不详。 者6年前开始无诱因间断出现咳嗽、咳痰、痰中带血丝,偶有低热



放线菌常寄生于人体口腔黏膜、牙龈、扁桃体、结肠等处,平时相安无事,当机体抵抗力下降时可通过口腔分泌物入侵呼吸道,从而导致肺部实质病变。放线菌病因发病率低,故易被误诊,需注意。

病史:

患者为一55岁女性,47岁时曾行右肺中叶切除术,术后病理诊断为肺结核,术后三联抗结核治疗3个月,有2型糖尿病史4年长期服药治疗,具体不详。

者6年前开始无诱因间断出现咳嗽、咳痰、痰中带血丝,偶有低热,给予"抗生素"治疗2周左右症状可缓解,每年发病1~2次。

20天前再次出现发热、咳嗽及咳痰,体温高达39 ℃,伴轻度呼吸困难。门诊查外周血白细胞计数为14.2×10^9/L ,中性粒细胞百分率为0.85,血红蛋白为156 g/L,血小板为240×10^9/L, ESR为18 mm/1h,C反应蛋白为57 mg/L。

胸部CT平扫示右肺门肿块,直径约4.5 cm,考虑肺癌或肺脓肿可能性大(图1,图2)。给予"盐酸莫西沙星"0.4 g/d静脉滴注,7天后体温降至正常,14 天后复查胸部CT示右肺门肿物明显缩小(图3),为进一步诊治而入我院。


查体:

患者自动体位,精神萎靡,神志清楚、查体合作,皮肤黏膜未见黄染及出血点,浅表淋巴结未及肿大。头颈无异常。胸廓无畸形。左肺呼吸音清,右肺可闻及局限性干啰音,心律齐,无杂音。腹平软,无压痛,肝脾肋下未及。脊柱四肢未见异常。

辅助检查:

支气管镜检查示:右肺中叶和下叶黏膜充血水肿,管腔狭窄(图4)

支气管镜内超声:在右肺中下叶间嵴外可探及直径为1.97 cm的软组织肿块(图5)

透壁肺活检病理:可见炎性肉芽组织及坏死渗出,细菌菌团形成,未见肿瘤细胞

治疗1个月后复查胸部CT: 右下肺病灶进一步吸收(图6)

2个月后查胸部CT 示:右下肺近肺门处肿物及斑片状渗出影(图7)

支气管镜复查:右肺中叶支气管被黄色颗粒样物完全阻塞(图8)

活检病理:革兰染色示为硫磺颗粒,周围可见直径为1 μm、呈放射状生长的菌丝,革兰和六胺银染色阳性(图9,图10)

复检第1次透壁肺活检病理:可见同种形态致病菌(图11)


外院专科鉴定:放线菌

其他:多次痰涂片抗酸染色均阴性、痰培养、PPD试验、结核抗体、支原体、衣原体及军团菌抗体均阴性、血清CA19-9 87.6 U/ml 正常值<37 U/ml、过碘酸雪夫染色、抗酸及弱抗酸染色均阴性

简要解析:


肺放线菌病是由放线菌感染引起的一种慢性化脓性肺部疾病,发病率较低,临床医生对该病认识不足,易将其误诊为肺真菌病、肺结核、肺脓肿及肺癌等。即使高度怀疑本病的患者,也很难取得微生物学证据。本例患者在病程伊始也被误诊为肺癌和肺脓肿。

肺放线菌病的确诊依赖于病理学或微生物学,在咳出物涂片找到典型"硫磺颗粒"或在肺活检组织内找到放线菌即可诊断。外科手术和支气管镜检查是重要的活检手段。支气管镜下常表现为黄色颗粒样物阻塞管腔(如本例患者),该物质即为"硫磺颗粒",色黄质硬,核心由菌丝缠结而成,菌丝向四周放射状排列,因此得名放线菌。放线菌菌丝直径约1 μm,细长无分支,革兰和六胺银染色阳性,过碘酸雪夫染色及抗酸、弱抗酸染色阴性,借此可与奴卡菌、真菌、结核菌等鉴别。由于放线菌可为正常人口腔内的定植菌,因此痰培养阳性不能确诊。

肺放线菌病可形成肺脓肿并产生"硫磺颗粒",病灶内血供极差,且常伴有局部支气管引流不畅,因此治疗需选用敏感的抗生素足量、长疗程治疗,疗程至少6~12个月。青霉素类、四环素类、大环内酯类抗生素大多有效,而硝基咪唑类、氨基糖甙类和喹诺酮类一般无效。文献报道,放线菌对新型氟喹诺酮类药物盐酸莫西沙星敏感,本患者应用盐酸莫西沙星初始治疗有效也证实了上述观点,但由于疗程较短而致复发。药物疗效不佳或不能耐受者可行外科手术切除病灶。

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  4. [GetPortalCommentsPageByObjectIdResponse(id=2083619, encodeId=931c208361998, content=<a href='/topic/show?id=ecb05e4399a' target=_blank style='color:#2F92EE;'>#放线菌#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=37, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=57439, encryptionId=ecb05e4399a, topicName=放线菌)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=a12645, createdName=docwu2019, createdTime=Thu Dec 21 09:18:00 CST 2017, time=2017-12-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=262700, encodeId=395f262e00e6, content=学习学习学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=64, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/jW482SpianMayicTRbRZ5RzR8ylhYfiaoAUx2BsaYHVia1IKhG3Cg8CT84rBrn6iaVRkyAibJxBcLEXabOQ5p19vWgDe34ib5ErxNgx/0, createdBy=8a701629084, createdName=jihuaijun1112, createdTime=Mon Nov 20 01:11:01 CST 2017, time=2017-11-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=262655, encodeId=5b5d2626556d, content=不错的文章值得推荐!, beContent=null, objectType=article, channel=null, level=null, likeNumber=71, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160914/IMG57D82E721DB581755.jpg, createdBy=4fc81933929, createdName=明天会更好!, createdTime=Sun Nov 19 23:11:35 CST 2017, time=2017-11-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=262654, encodeId=00372626541f, content=不错的文章值得推荐!, beContent=null, objectType=article, channel=null, level=null, likeNumber=71, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160914/IMG57D82E721DB581755.jpg, createdBy=4fc81933929, createdName=明天会更好!, createdTime=Sun Nov 19 23:11:26 CST 2017, time=2017-11-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=262653, encodeId=a1db26265361, content=不错的文章值得推荐!, beContent=null, objectType=article, channel=null, level=null, likeNumber=70, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160914/IMG57D82E721DB581755.jpg, createdBy=4fc81933929, createdName=明天会更好!, createdTime=Sun Nov 19 23:11:18 CST 2017, time=2017-11-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=262651, encodeId=89742626517a, content=值得学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=57, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20231215/ac08b4d4cecf4bd3b9af86e00dcbca38/f6b6a60efd854ff191eb5c611ec7dd12.jpg, createdBy=8afb2071832, createdName=15938038573红旗飘飘, createdTime=Sun Nov 19 23:00:10 CST 2017, time=2017-11-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=262633, encodeId=cb4726263391, content=不错的文章值得推荐., beContent=null, objectType=article, channel=null, level=null, likeNumber=22, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=eff51996281, createdName=1e1b8538m79(暂无匿称), createdTime=Sun Nov 19 21:26:24 CST 2017, time=2017-11-19, status=1, ipAttribution=)]
    2017-11-19 明天会更好!

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  5. [GetPortalCommentsPageByObjectIdResponse(id=2083619, encodeId=931c208361998, content=<a href='/topic/show?id=ecb05e4399a' target=_blank style='color:#2F92EE;'>#放线菌#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=37, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=57439, encryptionId=ecb05e4399a, topicName=放线菌)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=a12645, createdName=docwu2019, createdTime=Thu Dec 21 09:18:00 CST 2017, time=2017-12-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=262700, encodeId=395f262e00e6, content=学习学习学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=64, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/jW482SpianMayicTRbRZ5RzR8ylhYfiaoAUx2BsaYHVia1IKhG3Cg8CT84rBrn6iaVRkyAibJxBcLEXabOQ5p19vWgDe34ib5ErxNgx/0, createdBy=8a701629084, createdName=jihuaijun1112, createdTime=Mon Nov 20 01:11:01 CST 2017, time=2017-11-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=262655, encodeId=5b5d2626556d, content=不错的文章值得推荐!, beContent=null, objectType=article, channel=null, level=null, likeNumber=71, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160914/IMG57D82E721DB581755.jpg, createdBy=4fc81933929, createdName=明天会更好!, createdTime=Sun Nov 19 23:11:35 CST 2017, time=2017-11-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=262654, encodeId=00372626541f, content=不错的文章值得推荐!, beContent=null, objectType=article, channel=null, level=null, likeNumber=71, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160914/IMG57D82E721DB581755.jpg, createdBy=4fc81933929, createdName=明天会更好!, createdTime=Sun Nov 19 23:11:26 CST 2017, time=2017-11-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=262653, encodeId=a1db26265361, content=不错的文章值得推荐!, beContent=null, objectType=article, channel=null, level=null, likeNumber=70, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160914/IMG57D82E721DB581755.jpg, createdBy=4fc81933929, createdName=明天会更好!, createdTime=Sun Nov 19 23:11:18 CST 2017, time=2017-11-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=262651, encodeId=89742626517a, content=值得学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=57, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20231215/ac08b4d4cecf4bd3b9af86e00dcbca38/f6b6a60efd854ff191eb5c611ec7dd12.jpg, createdBy=8afb2071832, createdName=15938038573红旗飘飘, createdTime=Sun Nov 19 23:00:10 CST 2017, time=2017-11-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=262633, encodeId=cb4726263391, content=不错的文章值得推荐., beContent=null, objectType=article, channel=null, level=null, likeNumber=22, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=eff51996281, createdName=1e1b8538m79(暂无匿称), createdTime=Sun Nov 19 21:26:24 CST 2017, time=2017-11-19, status=1, ipAttribution=)]
    2017-11-19 明天会更好!

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  6. [GetPortalCommentsPageByObjectIdResponse(id=2083619, encodeId=931c208361998, content=<a href='/topic/show?id=ecb05e4399a' target=_blank style='color:#2F92EE;'>#放线菌#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=37, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=57439, encryptionId=ecb05e4399a, topicName=放线菌)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=a12645, createdName=docwu2019, createdTime=Thu Dec 21 09:18:00 CST 2017, time=2017-12-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=262700, encodeId=395f262e00e6, content=学习学习学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=64, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/jW482SpianMayicTRbRZ5RzR8ylhYfiaoAUx2BsaYHVia1IKhG3Cg8CT84rBrn6iaVRkyAibJxBcLEXabOQ5p19vWgDe34ib5ErxNgx/0, createdBy=8a701629084, createdName=jihuaijun1112, createdTime=Mon Nov 20 01:11:01 CST 2017, time=2017-11-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=262655, encodeId=5b5d2626556d, content=不错的文章值得推荐!, beContent=null, objectType=article, channel=null, level=null, likeNumber=71, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160914/IMG57D82E721DB581755.jpg, createdBy=4fc81933929, createdName=明天会更好!, createdTime=Sun Nov 19 23:11:35 CST 2017, time=2017-11-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=262654, encodeId=00372626541f, content=不错的文章值得推荐!, beContent=null, objectType=article, channel=null, level=null, likeNumber=71, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160914/IMG57D82E721DB581755.jpg, createdBy=4fc81933929, createdName=明天会更好!, createdTime=Sun Nov 19 23:11:26 CST 2017, time=2017-11-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=262653, encodeId=a1db26265361, content=不错的文章值得推荐!, beContent=null, objectType=article, channel=null, level=null, likeNumber=70, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160914/IMG57D82E721DB581755.jpg, createdBy=4fc81933929, createdName=明天会更好!, createdTime=Sun Nov 19 23:11:18 CST 2017, time=2017-11-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=262651, encodeId=89742626517a, content=值得学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=57, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20231215/ac08b4d4cecf4bd3b9af86e00dcbca38/f6b6a60efd854ff191eb5c611ec7dd12.jpg, createdBy=8afb2071832, createdName=15938038573红旗飘飘, createdTime=Sun Nov 19 23:00:10 CST 2017, time=2017-11-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=262633, encodeId=cb4726263391, content=不错的文章值得推荐., beContent=null, objectType=article, channel=null, level=null, likeNumber=22, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=eff51996281, createdName=1e1b8538m79(暂无匿称), createdTime=Sun Nov 19 21:26:24 CST 2017, time=2017-11-19, status=1, ipAttribution=)]
    2017-11-19 15938038573红旗飘飘

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  7. [GetPortalCommentsPageByObjectIdResponse(id=2083619, encodeId=931c208361998, content=<a href='/topic/show?id=ecb05e4399a' target=_blank style='color:#2F92EE;'>#放线菌#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=37, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=57439, encryptionId=ecb05e4399a, topicName=放线菌)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=a12645, createdName=docwu2019, createdTime=Thu Dec 21 09:18:00 CST 2017, time=2017-12-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=262700, encodeId=395f262e00e6, content=学习学习学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=64, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/jW482SpianMayicTRbRZ5RzR8ylhYfiaoAUx2BsaYHVia1IKhG3Cg8CT84rBrn6iaVRkyAibJxBcLEXabOQ5p19vWgDe34ib5ErxNgx/0, createdBy=8a701629084, createdName=jihuaijun1112, createdTime=Mon Nov 20 01:11:01 CST 2017, time=2017-11-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=262655, encodeId=5b5d2626556d, content=不错的文章值得推荐!, beContent=null, objectType=article, channel=null, level=null, likeNumber=71, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160914/IMG57D82E721DB581755.jpg, createdBy=4fc81933929, createdName=明天会更好!, createdTime=Sun Nov 19 23:11:35 CST 2017, time=2017-11-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=262654, encodeId=00372626541f, content=不错的文章值得推荐!, beContent=null, objectType=article, channel=null, level=null, likeNumber=71, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160914/IMG57D82E721DB581755.jpg, createdBy=4fc81933929, createdName=明天会更好!, createdTime=Sun Nov 19 23:11:26 CST 2017, time=2017-11-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=262653, encodeId=a1db26265361, content=不错的文章值得推荐!, beContent=null, objectType=article, channel=null, level=null, likeNumber=70, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160914/IMG57D82E721DB581755.jpg, createdBy=4fc81933929, createdName=明天会更好!, createdTime=Sun Nov 19 23:11:18 CST 2017, time=2017-11-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=262651, encodeId=89742626517a, content=值得学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=57, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20231215/ac08b4d4cecf4bd3b9af86e00dcbca38/f6b6a60efd854ff191eb5c611ec7dd12.jpg, createdBy=8afb2071832, createdName=15938038573红旗飘飘, createdTime=Sun Nov 19 23:00:10 CST 2017, time=2017-11-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=262633, encodeId=cb4726263391, content=不错的文章值得推荐., beContent=null, objectType=article, channel=null, level=null, likeNumber=22, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=eff51996281, createdName=1e1b8538m79(暂无匿称), createdTime=Sun Nov 19 21:26:24 CST 2017, time=2017-11-19, status=1, ipAttribution=)]
    2017-11-19 1e1b8538m79(暂无匿称)

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