Characteristics of Clinical and Radiological Manifestations in Empiric Antibiotic-Delayed Diagnosis of Pulmonary Tuberculosis

肺結核延遲診斷會增加發病率及疾病的散播。近年有文獻報告因社區型肺炎而使用經驗性抗生素治療，不論使用何種抗生素，會造成肺結核延遲診斷。本研究探討在肺結核病盛行地區是否有相同情況，並探討不同臨床表現與放射線影像的型態對肺結核病患一開始經驗性抗生素選擇使用所造成的影響。我們回顧403位經由微生物學或組織切片確定診斷為肺結核的病人之病歷記錄，分析其包括臨床表徵，抗生素使用情況及放射線影像型態。另外，我們依照抗生素使用情況，將病人分成三組，分別為接受fluoroquinolone類抗生素（FQ group），接受非fluoroquinolone類抗生素（AB group），及沒有使用任何抗生素（No antibiotic group）。結果403位病人中，在肺結核診斷之前，有83位（20.6%）接受fluoroquinolone類抗生素，有129位（32%）接受非fluoroquinolone類抗生素。而從病人初至門診到臨床醫師開立結核檢查的中位期間在FQgroup, AB group 及 Control group三組分別為2天，2天，0天，有顯著的差異（p＜0.05）。在使用FQ類及non-FQ類抗生素的病人中有較多病人存有原在性疾病（underlying disease）分別是（65.1% and 79.8% vs 37.2%）及低白蛋白血症（hypoalbuminemia）分別是（63.9% and 55.8% vs 26.2%）。另外，使用抗生組（FQ類及non-FQ類）相對於無使用抗生素組有較高比例抗酸性染色呈現陽性（69.9% and 52.7% vs 49.7%）。對於403位肺結核病人中，在放射線影像型態及病變分佈方面，有接受抗生素者（不論是使用FQ類或non-FQ類）與沒有使用抗生素者有顯著的不同。這些差異包括肺泡實質化型態（37.3% vs. 21.9%），多發性肺葉浸潤（50.9% vs. 39.8%）及肺下部侵犯（55.2% vs. 31.9%）。因此，特殊的影像型態及分布包括肺泡實質化型態，多發性肺葉浸潤及肺下部侵犯容易造成肺結核診斷的誤判。所以，臨床醫師在診斷社區型肺炎並給予經驗性抗生素治療的同時，必須將肺結核列入鑑別診斷；尤其是在遇到本研究論文中所提及的特殊放射線影像型態及病變分佈的情況時。（胸腔醫學 2012；27：71－80）

關鍵字

特殊放射線影像型態；社區型肺炎；延遲性診斷；肺結核； Fluroquinolone

並列摘要

Background: Delays in the diagnosis of pulmonary tuberculosis (TB) may result in increased patient morbidity and further spread of the disease. Recent published reports suggest that antibiotic treatment might be associated with the delayed diagnosis of TB. The aim of this study was to evaluate the impact of clinical and radiological manifestations in the delayed diagnosis of TB among different antibiotic classes in an endemic TB area.Methods: Patients with culture or tissue biopsy-confirmed TB diagnosed between January 2005 and December 2006 were included and their medical records reviewed and analyzed. Results: Eighty-three of the 403 patients (20.6%) received a fluoroquinolone (FQ group) and 129 (32%) received non-FQ antibiotics (AB group) before the diagnosis of TB. The median duration from initial visit to ordering a TB study was longer in the FQ and AB groups than in the control group (2 and 2 vs. 0 days). More patients in the FQ and AB groups had underlying disease (65.1% and 79.8% vs. 37.2%, respectively), hypoalbuminemia (63.9% and 55.8% vs. 26.2%, respectively) and a positive acid-fast bacilli (AFB) sputum smear (69.9% and 52.7% vs. 49.7%). Specific radiologic patterns and distribution among patients receiving antibiotics, regardless of class, were significantly different from those among patients without antibiotics, and included alveolar consolidation (37.3% vs. 21.9%), multiple lobe infiltrations (50.9% vs. 39.8%) and lower lung involvement (55.2% vs. 31.9%).Conclusion: Patients who received empiric antibiotics before the diagnosis of TB had a higher percentage of underlying diseases, hypoalbuminemia and positive AFB sputum smears. Antibiotic treatment irrespective of class for presumed CAP delayed the diagnosis of pulmonary TB, and the delay was similar regardless of which antibiotic class had been prescribed. The specific radiologic pattern of alveolar consolidation and atypical distribution with multiple lobes and lower lung involvement contributed to masking the underlying pulmonary TB. Clinicians should consider pulmonary TB in their differential diagnosis when prescribing antibiotics for the treatment of CAP, particularly when encountering the specific radiologic features and distribution reported in this study. (Thorac Med 2012; 27: 71-80)

並列關鍵字

radiological manifestations ； community acquired-pneumonia ； fluoroquinolone ； delayed diagnosis ； pulmonary tuberculosis

國際替代計量

Characteristics of Clinical and Radiological Manifestations in Empiric Antibiotic-Delayed Diagnosis of Pulmonary Tuberculosis

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