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胸部X光正常或輕微變化,痰結核菌培養陽性之肺結核
【一般內科主任 吳盈勳醫師】

胸部X光正常或輕微變化,痰結核菌培養陽性之肺結核  常有病人因久咳不癒(大於三週)至本院門診求診,胸部X光多數呈現正常,或之前有過纖維化、鈣化現象。基於咳三週快驗痰之原則,加驗痰液耐酸性抹片及培養三套,其中部分病人抹片結果陽性或培養結果陽性,再加做PCR檢查呈陽性反應後,而給予確診為肺結核,通報並且投藥治療。一般病人尚能接受醫療處置,少數病人基於對結核病的排斥,或認識不清而無病識感,拒絕接受治療,造成醫護人員、公共衛生人員、關懷員的困擾,本文就胸部X光正常,但痰結核菌培養陽性之肺結核,做進一步之探討。

  肺結核之診斷包含臨床症狀、胸部X光、驗痰等三方面結果綜合後判斷,一般而言,多數肺結核病人其胸部X光有異常現象,但有少數病人(1~10%)其胸部X光呈現正常,若無加驗痰液檢查,可能就導致病況之惡化,尤其是長期咳嗽或有結核病接觸病史者,診斷時必須多加注意。

一、臨床症狀

  臨床症狀的詢問,除了病人的咳嗽、發燒、倦怠、食慾外,應考慮是否有結核病接觸史,或之前是否有肺結核病史、治療情形如何。

二、胸部X光

  胸部X光是最簡單方便且有價值的檢查,但單一的胸部X光檢查不能推論肺結核是否具有活動性,應把病人先前的舊胸部X光片做一比較,一般胸部X光呈現纖維化結節,或鈣化病灶,並認為是陳舊性無活動性肺結核,但近來的文獻報告仍有5%的胸部X光鈣化、纖維化病灶是活動性肺結核,這也是肺結核延遲診斷的原因之一。

三、驗痰

  痰液耐酸性抹片檢查方便而快速,若再加上PCR檢查,可早期判斷是否為肺結核並且及早治療。當然目前痰結核菌培養仍是標準診斷,但耗費時間太久,約1~2個月,另外還必須要排除實驗室的偽陽性。

  Dr. Pepper於2008年IJTLD期刊(International Journal of Tuberculosis and Lung Disease,簡稱IJTLD)發表601個病人胸部X光正常,但其中有53個(9%)痰結核菌培養陽性的病人,其中22%是人類免疫缺乏病毒(HIV)陽性病人,另外5%無人類免疫缺乏病毒。其他的文獻也有證實HIV陽性病人的肺結核約有11%的正常胸部X光表現。Dr. Harries於1998年的IJTLD期刊,發表79個病人談抹片陰性,胸部X光正常,或者輕度異常懷疑是肺結核的病人。經過三個月追蹤其胸部X光及細菌學變化,其中16個結核菌培養陽性,有7個病人胸部X光惡化,另外41個結核菌培養陰性病人,13個胸部X光惡化,包括1位耐酸性抹片實驗室結果轉成陽性。所以對於痰結核菌陽性的病人應及早治療,以避免病情之惡化。以及Dr. Mirciniuk於1999年Chest期刊談到正常胸部X光之肺結核早期診斷,有518個病人痰結核菌培養陽性,其中有25個胸部X光正常,25個病人當中有23個在就診時有症狀地咳嗽超過一個月或發燒超過一週。與肺結核病人接觸後的皮膚測試變化,11個病人有與傳染性肺結核病人的接觸史。以不同年代的發生率而言,從1988年到1989年的0.7%,1990年到1991年的3.5%至1996到1997年的10%,篩檢率逐年地增加。其原因除了HIV病人增加、新移民增加外,近來的實驗室技術進步也是功不可沒。

  結核菌培養陽性,胸部X光正常的病人臨床上也非少數,且為了排除僞陽性的發生,本院目前建議進一部做胸部電腦斷層掃描、支氣管鏡檢查,希望在可用的檢查方法下,確定病灶的位置,尤其是有傳染性肺結核接觸史、長期咳嗽或抵抗力低下的病人,給予更積極的檢查,以期早日確立診斷,給予治療,避免結核菌的傳播。


Tuberculosis with normal or minimal change of Chest Radiograph, culture-positive for Mycobacterium tuberculosis

Chest Hospital, DOH / Dr. Wu, Jui-Ming

Many patients require the outpatient services due to having cough for a long time (over 3 weeks). Most of them have the normal chest radiograph (CXR) or have the manifestations of the fibrosis or calcification in the past. Base on the principle that we have to examine the sputum (acid-fast smear and culture 3 sets) if someone have cough more than three weeks, if some patients’ smear are positive or culture positive, we need one more PCR examination to confirm. Only having done these examinations, we can make the diagnosis for pulmonary tuberculosis (TB) and then inform the national organization. Although most of patients can accept this medical procedure, some patients still refuse this kind of treatment and have no insight. These behaviors perplex the care-providers, public health practitioners and observers. Our article emphasizes the topic about some pulmonary tuberculosis patients with normal chest radiography but culture positive.

To diagnose the illness as pulmonary tuberculosis, we have to integrate three clinical examinations: clinical symptoms, chest radiograph and sputum examination. Generally speaking, the majority has abnormal finding on chest radiograph, but there still are some patients (1~10%) having normal chest radiograph. If we did not add sputum examination to confirm, this omission may worsen this disease. Most important of all, we have to pay more attention on the patient who have coughed for a long time or have the contact history to pulmonary tuberculosis.

1.Clinical symptom

Besides asking the patient whether he had the symptom of cough, fever, fatigue or poor appetite, we have to consider the possibilities that patients have the contact history of TB, or the history of TB, and how is the curative effect in the past.

2.Chest Radiograph

Chest radiograph is the simplest and valuable examination, but we can not infer the activity of Mycobacterium tuberculosis just according to one time of examination. We have to compare with the past radiograph to make a proper inference. Generally speaking, most of the chest radiography manifests fibrotic nodule or calcified focus, and it was regarded as old inactive pulmonary tuberculosis. However, recent study reports 5 % of CXR calcification and fibrotic foci are active pulmonary tuberculosis, moreover, it also stands the reason why we miss the diagnosis easily.

3.Smear examination

Acid-fast smear is convenient and rapid. If we add the PCR examination, we could find out the possibility of the pulmonary tuberculosis in the early stage and treat it timely. Certainly, culture for Mycobacterium tuberculosis still is the standard examination, but it takes too much time (about 1~2 months) and have to exclude the false-positive in lab.

On 2008, Dr. Pepper published an article at IJTLD (International Journal of Tuberculosis and Lung Disease). Of 601 study patients with normal chest radiograph, there are 53 persons (9%) having culture-positive sputum, 22 percentages have HIV positive and the other 5 percent persons have HIV negative. Other articles also confirm that pulmonary tuberculosis patients with HIV positive are almost 11% having normal chest radiograph. In IJTLD 1998, Dr. Harries published an article that among 79 patients with negative smears and normal CXR, or someone who is minimally suspected of tuberculosis, followed up over 3 months with repeat sputum smears and chest radiography. In his study, of 16 persons were culture-positive for Mycobacterium tuberculosis, 7 persons developed a TB-CXR. Of 41 cultures-negative patients, 13 persons developed a TB-CXR, including one patient who became sputum smear positive. Therefore, to prevent the aggravation of this disease, we have to remedy the culture-positive patients as soon as possible. Furthermore, in Chest 1999, Dr. Mirciniuk described the early diagnosis of pulmonary tuberculosis when the chest radiograph (CXR) is normal. Identified from a review of 518 conservative patients with culture-positive pulmonary TB, there are 25 persons having normal CXR, but 23 of the 25 patients were symptomatic at the time of diagnosis, with cough over 1 month or fever over 1 week. Skin-test conversions after contacting with the infectious TB, 11 patients were identified because of contact tracing from cases of infectious pulmonary TB. According to the incidence on different years, the incidence 0.7% (1988 to 1989) and 3.5% (1990 to 1991) were increased to 10% (1996 to 1997). Although the incidence of the HIV infection or the population of the immigrant has increased, we can not ignore the progress of the lab technique.

The population of the patient with culture-positive and normal chest radiograph is not the less. Moreover, to exclude the occurrence of the false positive, our hospital suggests taking further examination (computed tomography and bronchoscope). Our hospital looks forward to locate the accurate nidus with proper examination, especially for someone who has contact history with pulmonary TB, long-time cough or weak resistance. To prevent the spread of Mycobacterium tuberculosis, we have to examine this kind of patient actively and make a proper diagnosis for treatment.

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