腸結核併發中空臟器穿孔之病例報告及文獻回顧

Intestinal Tuberculosis Complicated with Hollow Organ Perforation: A Case Report and Review the Literature

楊國鑫(Kuo-Hsin Yang) ； 王鴻源(Horng-Yuan Wang) ； 蔡樹榮(Shu-Jung Tsai)

《內科學誌》 25卷3期 (2014/06) Pp. 206-214

https://doi.org/10.6314/JIMT.2014.25(3).11

摘要

結核病（mycobacterium tuberculosis）在台灣仍舊是最嚴重的傳染疾病之一；雖然結核菌在全台的發生率已經逐年下降，但每年仍有許多新個案產生。結核病又分肺內結核及肺外結核。肺外結核的早期症狀不明顯也不典型，常常發現肺外結核的時候都已經出現併發症了，處理起來比起肺內結核困難得多。腸結核（intestinal tuberculosis）屬於肺外結核的一種，病人比較容易會以腹痛、發燒、體重減輕來表現。我們這次是要報告一名腸結核的病患，一開始是腸胃不適，後來伴隨慢性腹瀉合併體重減輕，在門診持續追蹤一年，後來因為發燒到急診就診，照了胸部X光後疑似有肺部結核菌感染，開始治療後第三天又併發中空臟器穿孔（hollow organ perforation）。穿孔處的檢體證實有肉芽腫性發炎合併乾酪性壞死（granulomatous inflammation with caseous necrosis），而且結核菌的聚合酶連鎖反應（polymerase chain reaction）為陽性，病患的痰液後來也培養出結核菌，確認是腸結核合併肺結核。病人經過五週的住院治療後順利出院。我們回顧文獻探討此類複雜病況的策略，包括如何評估症狀及相關疾病的鑑別診斷。對於結核病盛行的地區，若是有無法解釋的症狀，都應該把結核病放入鑑別診斷，以便提早確診提早治療；此外，開始治療腸結核時，除了小心藥物的副作用外，腸道相關的併發症也要注意。

關鍵字

肺外結核（Extrapulmonary tuberculosis） ； 腸結核（Intestinal tuberculosis） ； 中空臟器穿孔（Hollow organ perforation）

並列摘要

Mycobacterium tuberculosis remains a serious infectious disease and despite a gradual decrease in its incidence, several new cases annually occur in Taiwan. M. tuberculosis infection includes both intrapulmonary and extrapulmonary manifestations. Early cases of extrapulmonary tuberculosis are nonspecific and easily confused with other diseases, and are typically observed in the late stage of the disease, with serious complication. Here we report a 47-year-old man initially presenting with abdominal discomfort, followed by chronic diarrhea and weight loss. His symptoms failed to improve with supportive care during follow-up. One year later, he visited the emergency department with low grade fever, and pulmonary tuberculosis was suspected based on chest radiography. On day three of admission he developed ileal perforation after taking anti-tuberculosis medication. Pathology of both ruptured bowel and peripheral lymph nodes showed granulomatous inflammation with caseous necrosis. Polymerase chain reaction for tuberculosis was positive and his sputum cultures showed M. tuberculosis growth. The final diagnosis was intestinal tuberculosis with pulmonary tuberculosis, complicated with hollow organ perforation. He was discharged after hospitalization for five weeks. In this report, we review articles and highlight the treatment strategy for this complicated disease. We hope that physicians will be aware of this extrapulmonary presentation of tuberculosis in epidemic areas, and will not neglect patients with intestinal tuberculosis and hollow organ perforation.