目的 探讨成年血行播散性肺结核并发颅内结核的临床及头颅MRI表现特征,以减少漏诊与误诊.方法 收集2015年2月至2019年7月首都医科大学附属北京胸科医院临床确诊的53例成年血行播散性肺结核并发颅内结核患者的临床资料,纳入资料完整的48例患者作为研究对象,所有患者均进行了结核病相关实验室检查(包括脑脊液检测)、头颅MR平扫及增强扫描检查,分析评价患者的临床及头颅MRI表现特征.结果 48例患者中,24例(50.0％)存在结核中毒症状和呼吸系统症状,36例(75.0％)出现发热、头痛,29例(60.4％)具有神经系统症状和体征;胸部CT平扫均可见两肺弥漫性粟粒状影;脑脊液常规和生化检查异常者45例(93.8％),其中蛋白升高43例(89.6％),葡萄糖含量降低38例(79.2％),氯化物降低37例(77.1％);所有患者均行腰椎穿刺术检查,颅内压增高[＞180 mm H2O(1 mm H2O=0.0098 kPa)]者31例(64.6％).48例患者行头颅MR增强扫描,8例(16.7％)未发现明确结核病灶,40例有脑实质和(或)脑膜结核病变,分别为单纯脑膜结核9例(18.8％)、单纯脑实质结核19例(39.6％)、混合型颅内结核12例(25.0％);而48例行头颅MR平扫的患者仅35例显示颅内结核病灶,除8例增强MR未显示的患者外,仍有5例未发现结核病灶.25例患者抗结核药物治疗3个月后进行了头颅MR复查,其中11例较前好转,7例较前加重,5例出现部分病灶好转和部分病灶加重,2例未见变化.结论 血行播散性肺结核并发颅内结核患者临床多见发热、头痛、神经系统症状和体征、脑脊液常规和生化检查指标异常、颅内压增高.MR头颅扫捕对该病的发现率较高,尤以MR增强扫描更为明显,是发现和诊断颅内结核的重要技术.

目的 了解《WS 288-2017肺结核诊断》标准(以下简称“新标准”)实施后肺结核诊断情况,提高登记治疗的肺结核患者病原学阳性率,以及对病原学阴性肺结核患者的诊断质量.方法 以自愿接受评估为原则,青海、甘肃、新疆、贵州、湖北、广西、山东、辽宁8个省(自治区)接受现场评估,每个省1家地市级、3家县级结核病定点医疗机构.评估内容:查阅“新标准”实施前1年(2017年)、实施后1年(2018年)当地肺结核登记资料,以及结核病影像学诊断、结核病实验室相关检测情况;查阅病原学阴性肺结核病案,每个现场、每个年度从发现第一例患者开始采用整群抽样方法各查阅50例;查阅实验室登记本、留存痰涂片,累计查阅病原学阴性肺结核患者病案3532例,实验室留存痰涂片3260份.计数资料的比较采用x2检验,以P＜0.05为差异有统计学意义.结果 “新标准”实施后各评估现场强化了病原学检测力度,分枝杆菌分子生物学检测率由实施前的18.2％(6/33)提高到60.0％(15/25),差异有统计学意义(x2=9.035,P=0.003);分枝杆菌分离培养率由93.9％(31/33)提高到96.0％(24/25),差异无统计学意义(x2=0.061,P=0.804).实验室检测质量评估发现,2017年度痰标本不合格率为40.1％(384/957),2018年度为40.0％(922/2303),差异无统计学意义(x2=0.000,P=0.993).“新标准”实施后,评估地区登记肺结核患者病原学阳性率从21.6％(4806/22 258)提高到24.7％(4026/16 300),差异有统计学意义(x2=51.200,P=0.000);结核抗原抗体检测率从36.5％(871/2389)提高到37.3％(426/1143),差异无统计学意义(x2=0.186,P=0.667);结核抗原抗体检测阳性率从25.7％(224/871)提高到41.3％(176/426),差异有统计学意义(x2=31.900,P=0.000);结核菌素试验检测率从23.0％(549/2389)提高到47.2％(539/1143),阳性率由57.9％(318/549)提高到73.3％(395/539),差异均有统计学意义(x2值分别为210.900、27.730,P值均=0.000);γ干扰素释放试验检测率由2.3％(54/2389)提高到17.2％(197/1143),差异有统计学意义(x2=260.400,p=0.000).符合肺结核临床诊断要素的患者从23.8％(569/2389)提高到48.1％(550/1143),差异有统计学意义(x2=209.800,P=0.000).结论 “新标准”贯彻实施后提高了登记肺结核患者的病原学阳性率,改进了病原学阴性肺结核诊断质量.

新型冠状病毒肺炎(简称“新冠肺炎”;按照WHO命名其英文缩写为“COVID-19”)是一种具有很强传染性的肺部炎症病变.作者从武汉肺科医院2020年1月20-30日确诊的COVID-19患者采取整群抽取法抽取了核酸检测阳性的185例进行统计分析,并将COVID-19的发现与命名、核酸检测、临床表现、CT表现特点与诊断价值等进行综合分析.185例COVID-19确诊患者中发热157例(84.9％),以中低型发热为主,39.0℃以上高热仅8例(4.3％);乏力、两下肢关节酸、胀、痛感患者58例(31.4％);不同程度的间断咳嗽、少痰、胸闷不适者142例(76.8％).在同期整群COVID-19疑似患者364例中,核酸检查阳性185例(50.8％).CT扫描主要表现为肺部多发斑片状、片状、大片状多形态的磨玻璃样密度影及间质改变,分布于两肺下叶及两肺外带为多,病灶内增粗的肺血管纹理明显、病灶进展较快等.依据CT扫描特点,在185例中以CT首诊第一诊断意见为COVID-19患者161例(87.0％的准确率).因此,CT检查对COVID-19的诊断具有重要的实用价值,同时在评价肺部病变的严重程度、治疗过程中的动态变化,以及康复期患者的随访观察中均发挥了不可替代的作用.

目的 探讨肺结核患者肺部局灶性磨玻璃样(focal ground-glass opacity,fGGO)病灶的CT特征,以提高对肺结核少见征象的认识.方法 收集2009 2019年北京胸科医院确诊的11例具有fGGO病灶的肺结核患者(肺结核组,11个fGGO病灶),其中7例经临床综合诊断、3例经手术组织标本病理检查证实、1例经皮肺穿刺活检病理证实.同期按照1∶4比例选取经我院手术病理证实的44例具有fGGO病灶的肺癌患者(肺癌组,44个fGGO病灶).分析两组患者fGGO病灶的CT扫描特征.结果 肺结核组和肺癌组患者fGGO病灶分布在上叶[分别为63.6％(7/11)和65.9％ (29/44)]、中叶[分别为9.1％ (1/11)和11.4％(5/44)]、下叶[分别为27.3％(3/11)和22.7％(10/44)]的差异无统计学意义(x2=2.608,P=0.106).肺结核组fCGO病灶呈圆或椭圆形[36.4％(4/11)]、边缘与肺交界面清晰[9.1％(1/11)]、有分叶[0.0％(0/11)]的比例均明显低于肺癌组[77.3％(34/44)、93.2％(41/44)、43.2％(19/44)](x2=5.114,P=0.024;x2 =29.974,P=0.000;x2 =5.473,P=0.019).肺结核组fGGO病灶内部密度均匀[9.1％(1/11)]、有支气管影或空泡[0.0％(0/11)]、出现增粗或扭曲血管影[0.0％(0/11)]的比率均明显低于肺癌组[分别为54.5％(24/44)、38.6％(17/44)、77.3％ (34/44)](x2=7.333,P=0.007;x2 =4.475,P=0.034;x2=19.108,P=0.000),而多发结节样病灶[90.9％(10/11)]的比率高于肺癌组[0.0％(0/44)] (x2=42.969,P=0.000).结论 肺结核fGGO病灶分布与肺癌无特异性差别;依据fGGO边缘模糊、无分叶、无胸膜凹陷征、病灶内部密度不均匀、无支气管影或空泡、无增粗或扭曲血管影、多发簇状分布结节样病灶的CT表现,在与肺癌鉴别诊断时有一定的参考价值.

提高结核病的影像学诊断水平,是防止漏诊、过诊和误诊的重要手段,尤其是对病原学检测阴性的肺结核患者.由于我国病原学检测阴性肺结核约占所有肺结核患者的50％左右或更高,因此,除痰结核分枝杆菌检查以外,影像学检查仍然发挥着无可替代的作用[1-2].

目的 探讨胸部CT扫描显示簇状微结节样病灶对肺结核的诊断与鉴别诊断价值.方法 回顾性分析2016年1月至2019年8月北京胸科医院行CT扫描表现为簇状微结节样病灶并诊断明确的患者74例.其中70例患者经临床或实验室检查诊断为活动性肺结核,2例诊断为非特异性炎症,2例诊断为结节病.本研究重点分析其中70例诊断为肺结核患者的CT扫描特征,包括簇状微结节样病灶的分布部位、分布方式、形态特征,以及并存的肺内其他形态病变的CT征象.结果 70例肺结核患者胸部CT扫描显示,簇状微结节样病灶分布于双肺上叶尖后段49例(70.0％),多发者49例(70.0％).CT表现为均匀样、晕征样、反晕征样、混合存在等4种表现形式,分别占47.1％(33/70)、25.7％(18/70)、18.6％(13/70)及8.6％(6/70).病灶内结节大小均匀29例(41.4％),大小不等、有融合41例(58.6％).肺内簇状微结节样病灶之外,伴有其他肺野并存病灶表现为1种形态(实变、空洞、结节样病灶、纤维条索状病灶四种形态之一)者10例(14.3％),2种形态者15例(21.4％),3种形态者16例(22.9％),4种形态者6例(8.6％);纵隔和(或)肺门淋巴结肿大者14例(20.0％),胸腔积液9例(12.9％).2例结节病和2例非特异性炎症也表现为簇状微结节样病灶,与肺结核的影像特征近似.结论 CT扫描表现为簇状微结节样病灶,无论是单发局限性或是多发性分布,均应首先考虑是继发性肺结核的一种较常见的不典型表现形式,值得重视.

目的 分析CT引导下经皮肺穿刺活检术诊断菌阴肺结核时取材部位的病灶形态、密度与诊断阳性率的关系,以提高菌阴肺结核的诊断准确率.方法 搜集首都医科大学附属北京胸科医院2017年1-12月收治的103例经穿刺活检病理证实或临床试验性治疗确诊的菌阴肺结核患者,回顾性分析经CT引导下穿刺活检时各类病灶CT征象与诊断阳性率之间的关系.统计学处理采用IBM SPSS 24.0软件,计数资料的比较采用x2检验,以P＜0.05为差异有统计学意义.结果 (1)病变形态:磨玻璃样影穿刺活检阳性率33.33％ (1/3).结节、实变、空洞、团块病灶穿刺活检阳性率分别为91.67％(33/36)、94.74％(18/19)、100.00％(21/21)、75.00％(18/24),该4种形态病灶穿刺活检阳性率差异有统计学意义(x2=8.918,P=0.030);两两比较,结节组与实变组、空洞组、团块组比较(x2=0.174,P=0.677;x2=1.847,P=0.174;x2=3.137,P=0.077),实变组与空洞组、团块组比较(x2=1.134,P=0.287;x2=3.031,P=0.082),空洞组与团块组比较(x2=8.058,P=0.014).差异无统计学意义.(2)病变密度:纵隔窗不可测量组3例,病灶穿刺活检阳性率33.33％(1/3).0～20 HU无强化组、＞20 HU无强化或强化不明显组、＞20 HU且强化明显组的穿刺活检阳性率分别为96.88％(31/32)、94.34％(50/53)、60.00％(9/15),差异有统计学意义(x2=17.790,P=0.000).该3种密度病灶穿刺阳性率两两比较,0～20 HU无强化与＞20HU且强化明显组比较,差异有统计学意义(x2=10.956,P=0.001).＞20 HU无强化或强化不明显组与＞20HU且强化明显组比较,差异有统计学意义(x2=12.005,P=0.001).0～20HU无强化与＞20 HU无强化或强化不明显组比较差异无统计学意义(x2 =0.286,P=0.593).(3)病理检测:HE染色阳性33例、抗酸染色阳性87例、TB-DNA检测阳性91例,HE染色阳性率32.04％(33/103)、抗酸染色阳性率84.47％(87/103)、TB-DNA检测阳性率88.35％(91/103)比较,差异有统计学意义(x2=94.084,P=0.001).结论 CT引导下经皮肺穿刺活检术对菌阴肺结核诊断具有重要价值,正确选择取材病灶的形态、密度进行穿刺能够提高穿刺活检的阳性率.

目的 回顾性分析硬化性肺细胞瘤(pulmonary sclerosing pneumocytoma,PSP)的CT表现,以提高对PSP患者CT诊断的正确率.方法 收集2012-2017年在首都医科大学附属北京胸科医院经手术病理证实的33例PSP患者,均行CT平扫,29例同时行CT增强扫描,分析其CT扫描征象.结果 PSP在CT图像上常表现为单发(30例,90.9％),软组织密度结节(20例,60.6％);大多数呈类圆形(30例,90.9％),边缘光整(27例,81.8％);周围型(22例,66.7％)多见;CT增强扫描呈不均匀强化(19例,65.5％)者多见;大多数病灶呈明显强化(26例,89.7％),且大多数患者延时扫描呈持续性强化(26例,78.8％);病变常伴血管贴边征(21例,72.4％),很少伴有淋巴结肿大(3例,9.1％);病灶内部可出现钙化(10例,30.3％)、囊变(5例,15.2％),可伴有尾征(5例,15.2％),晕征(8例,24.2％),空气新月征(5例,15.2％),其中4例(12.1％)可见空气新月征和晕征同时存在.结论 PSPCT扫描常表现为单发类圆形软组织密度结节,增强扫描多表现为明显强化及延时扫描持续性强化,并有一些特征性的伴随征象,结合患者年龄及性别,可提高CT诊断的正确率.

目的 探讨非结核分枝杆菌肺病和活动性继发性肺结核的高分辨率CT(HRCT)表现异同性.方法 回顾性分析2012年1月至2017年12月首都医科大学附属北京胸科医院住院并经临床及实验室检查确诊为非结核分枝杆菌肺病患者74例(NTM肺病组)和初治活动性继发性肺结核患者100例(肺结核组)的HRCT表现,比较两组病变分布及HRCT表现.采用SPSS 17.0软件进行统计学分析,计数资料采用x2检验,以P＜0.05为差异有统计学意义.结果 两组患者CT分型比较,NTM肺病组结节-支气管扩张型(51.4％,38/74)多于肺结核组(14.0％,14/100),两组比较差异有统计学意义(x2=28.316,P=0.000);肺结核组结节-肿块型(21.0％,21/100)多于NTM肺病组(8.1％,6/74),差异有统计学意义(x2=5.392,P=0.020).肺结核组病变分布优势部位位于上叶者(82.0％,82/100)明显多于NTM肺病组(59.5％,44/74),差异有统计学意义(x2=10.817,P=0.001);NTM肺病组优势部位位于中叶和(或)舌叶者(16.2％,12/74)较肺结核组(5.0％,5/100)患者多见,差异有统计学意义(x2=6.069,P=0.014).比较HRCT表现,肺结核组支气管扩张的发生率(61.0％,61/100)较NTM肺病组(93.2％,69/74)低,差异有统计学意义(x2=23.403,P=0.000);且NTM肺病组支气管扩张分布优势部位位于中叶和(或)舌叶者(39.1％,27/69)多于肺结核组(13.1％,8/61),差异有统计学意义(x2=11.138,P=0.001);而肺结核组分布优势部位位于上叶者(70.5％,43/61)多于NTM肺病组(39.1％,27/69),差异有统计学意义(x2=12.813,P=0.000);肺结核组实变影(86.0％,86/100)较NTM肺病组(67.6％,50/74)多,差异有统计学意义(x2=8.465,P=0.004).NTM肺病组空洞位于肺周边邻近胸膜增厚者(95.1％,39/41)较肺结核组(61.8％,42/68)多,差异有统计学意义(x2=14.909,P=0.000).NTM肺病组中结节＜1 cm者(88.5％,54/61)较肺结核组(54.9％,50/91)多见,差异有统计学意义(x2=19.059,P=0.000);肺结核组中多种大小不等的结节混合存在者(31.9％,29/91)较NTM肺病组(8.2％,5/61)多见,差异有统计学意义(x2=11.784,P=0.001).肺结核组并发胸腔积液(34.0％,34/100)较NTM肺病组(20.3％,15/74)多见,差异有统计学意义(x2=3.963,P=0.047).结论 NTM肺病和肺结核HRCT表现有一定的相似性及相异性.CT分型、支气管扩张的分布及优势部位、实变的发生率、结节的大小对鉴别诊断有意义,紧密结合临床有助于诊断.

肺结核一直是临床诊断与鉴别的重点,随着多排螺旋CT容积扫描和薄层重建等技术的广泛应用,不仅能够清楚显示肺结核的各种不同影像表现形式,而且借助增强扫描等,还能够从血供和代谢方面显示病变的病理生理特点.这样不仅使肺结核的影像理论基础不断地得到丰富,而且部分不典型和少见的影像表现形式也逐渐被认识与理解.尤其是借助于CT引导下的肺部病灶穿刺活检技术,使得部分疑难病例得到进一步证实,极大的提高了肺结核的临床诊断水平.

Objective To investigate and analyze the characteristics of CT imaging in pulmonary tuberculosis patients with fungal infection.Methods We analyzed retrospectively characteristics of CT imaging in 112 cases with pulmonary tuberculosis complicated with fungal infection confirmed by pathology, bacteriology and clinical data.According to the species of fungal infections, they were divided into three groups of Aspergillus (61 cases), Candida (48 cases) and Cryptococcus (3 cases).The features of CT imaging were compared among three groups.Results The incidence rates in patients with pulmonary tuberculosis complicated with fungal infection were 54.4% (61/112) in the Aspergillus group, 42.9% (48/112) in Candida group and 2.7% (3/112) in Cryptococcus group.When compared Aspergillus group with Candida group, the differences in clinical symptoms including cough, expectoration, fever, blood streaked sputum and chest pain were no significant statistically (P>0.05 for each).The features of CT imaging showed patchy in 96 cases (85.7%), nodule in 95 cases (84.8%), cavity in 93 cases (83.0%), tree-in-bud in 74 cases (66.1%) and ground glass opacity in 60 cases (53.6%).There was a wide range of lobe involvement of pulmonary infection in the Candida group and Aspergillus group, and more than 3 lobes involvement (98.0%,47/48) in the Aspergillus group were significantly higher than those in the Candida group (80.3%, 49/61), and the difference was statistically significant (χ2=7.91,P=0.005).The incidence rates of patchy (93.4%,57/61), cavity (93.4%,57/61) and ground glass opacity (63.9%,39/61) in the Aspergillus group were higher than those (77.1%,37/48;72.9%,35/48;39.6%,19/48) in the Candida group.However, the CT imaging with tree-in-bud (79.2%,38/48), and segmental or lobar consolidation (39.6%,19/48) in the Candida group were more common than those (59.0%,36/61;3.3%,2/61) in the Aspergillus group.All differences for all features of CT imaging were significant statistically (χ2=6.06,P=0.014;χ2=8.60,P=0.003;χ2=6.40,P=0.011;χ2=5.00,P=0.025;χ2=22.76,P=0.000).There were 93.4% (57/61) cases showed signs of aspergilloma, especially typical signs in 37 cases.There were only 3 cases with Cryptococcus showed nodules located under pleura and there was cavity with smooth inner wall in one case.Conclusion There are some features of CT imaging in pulmonary tuberculosis complicated with fungal infection.It is diagnostic value to diagnose for fungal infection according to characteristics of CT scan.

Objective To investigate CT imaging features and clinicopathological analysis of patients with pulmonary tuberculosis coexisting with primary lung cancer.Methods Seventy-one patients with lung cancer coexisting with pulmonary tuberculosis were collected in Beijing Chest Hospital Affiliated to Capital Medical University from March 1, 2011 to December 31, 2016.Pulmonary tuberculosis was comprehensively diagnosed by sputum smear or sputum culture, CT scanning, laboratory examination, and clinical treatment of dynamic observation.Lung cancer was confirmed through the sputum cancer cells, bronchoscopy or CT guided percutaneous needle biopsy, thoracoscopy, and surgical pathology.CT imaging features and pathological types were observed and analyzed.Results Of the 71 cases, there were 45 cases of non-active pulmonary tuberculosis and 26 cases of active pulmonary tuberculosis.In the coexisten lung cancer, there were 32 cases of adenocarcinoma, 31 cases of squamous cell carcinoma, and 8 cases of small-cell lung cancer.The proportion of squamous cell carcinoma (50%, 13/26) in patients with active pulmonary tuberculosis was higher than that of adenocarcinoma (38.5%, 10/26) and small-cell lung cancer (11.5%, 3/26).The proportion of adenocarcinoma (48.9%, 22/45) in patients with non-active pulmonary tuberculosis was higher than that in squamous cell carcinoma (40.0%, 18/45) and small-cell lung cancer (11.1%, 5/45).However, there was no significant difference between the two groups of patients with different pathological types of lung cancer (χ2=0.20, P=0.904).The cases of lung cancer and pulmonary tuberculosis in the same side accounted for 74.6% (53/71), significantly higher than that in different sides (25.4% (18/71), χ2=34.51, P<0.01).Of the total 71 patients, 56.3% (40/71) lesions located in the same lobe, significantly higher than that in different lobes of ipsilateral lung (18.3% (13/71), χ2=27.51, P<0.01), and that in different pulmonary sides (25.4% (18/71), χ2=16.69, P<0.01).According to the location of lung cancer, 24 (33.8%) patients were diagnosed with central lung cancer (including 8 (33.3%) small-cell carcinomas, 1 (4.2%) adenocarcinoma, and 15 (62.5%) squamous cell carcinomas according to pathological type) and 47 (66.2%) patients with peripheral lung cancer (including 31 (66.0%) adenocarcinomas and 16 (34.0%) squamous cell carcinomas).The distribution of pathological types between central lung cancer and peripheral lung cancer was significantly different (χ2=32.07, P<0.01).Of the 47 patients with peripheral lung cancer, 37 (78.7%) lesions located under the pleura.Three cases of lung cancer were found in the dynamic observation of pulmonary tuberculosis, of which, 2 cases were adenocarcinomas and 1 case was squamous cell carcinoma.Conclusion Different pathological types of lung cancer coexisting with pulmonary tuberculosis have specific CT imaging characteristics.Most lesions of pulmonary tuberculosis and lung cancer locate in the same pulmonary side and same lobe.Squamous cell carcinoma and small-cell lung cancer account for the majority of central lung cancer, while adenocarcinoma accounts for the majority of peripheral lung cancer.

Background According to the World Health Organization, China is one of 22 countries with serious tuberculosis (TB) infections and one of the 27 countries with serious multidrug-resistant TB strains. Despite the decline of tuberculosis in the overall population, healthcare workers (HCWs) are still at a high risk of infection. Compared with high-income countries, the TB prevalence among HCWs is higher in low- and middle-income countries. Low-dose computed tomography (LDCT) is becoming more popular due to its superior sensitivity and lower radiation dose. However, there have been no reports about active pulmonary tuberculosis (PTB) among HCWs as assessed with LDCT. The purposes of this study were to examine PTB statuses in HCWs in hospitals specializing in TB treatment and explore the significance of the application of LDCT to these workers. Methods This study retrospectively analysed the physical examination data of healthcare workers in the Beijing Chest Hospital from September 2012 to December 2015. Low-dose lung CT examinations were performed in all cases. The comparisons between active and inactive PTB according to the CT findings were made using the Pearson chi-square test or the Fisher’s exact test. Comparisons between the incidences of active PTB in high-risk areas and non-high-risk areas were performed using the Pearson chi-square test. Analyses of active PTB were performed according to different ages, numbers of years on the job, and the risks of the working areas. Active PTB as diagnosed by the LDCT examinations alone was compared with the final comprehensive diagnoses, and the sensitivity and positive predictive value were calculated. Results A total of 1 012 participants were included in this study. During the 4-year period of medical examinations, active PTB was found in 19 cases, and inactive PTB was found in 109 cases. The prevalence of active PTB in the participants was 1.24%, 0.67%, 0.81%, and 0.53% for years 2012 to 2015. The corresponding incidences of active PTB among the tuberculosis hospital participants were 0.86%, 0.41%, 0.54%, and 0.26%. Most HCWs with active TB (78.9%, 15/19) worked in the high-risk areas of the hospital. There was a significant difference in the incidences of active PTB between the HCWs who worked in the high-risk and non-high-risk areas (odds ratio [ OR ], 14.415; 95% confidence interval ( CI ): 4.733 – 43.896). Comparisons of the CT signs between the active and inactive groups via chi-square tests revealed that the tree-in-bud, cavity, fibrous shadow, and calcification signs exhibited significant differences ( P = 0.000, 0.021, 0.001, and 0.024, respectively). Tree-in-bud and cavity opacities suggest active pulmonary tuberculosis, whereas fibrous shadow and calcification opacities are the main features of inactive pulmonary tuberculosis. Comparison with the final comprehensive diagnoses revealed that the sensitivity and positive predictive value of the diagnoses of active PTB based on LDCT alone were 100% and 86.4%, respectively. Conclusions Healthcare workers in tuberculosis hospitals are a high-risk group for active PTB. Yearly LDCT examinations of such high-risk groups are feasible and necessary.

菌阴肺结核临床特征较少,有时仅表现为肺部阴影.其中孤立的肉芽肿结节、不规则肿块样影、段性及大叶性实变、多发性结节、弥漫的雪花状影,以及是否并发免疫功能低下等问题均是影像诊断的难点;此外,结节病Ⅲ期与粟粒性肺结核的鉴别、肺结核与肺癌等恶性病变并存等均为影像学鉴别诊断的棘手问题.分析与把握其基本影像学特征是确定肺结核诊断的前提,重视CT引导下经皮肺穿刺活检并结合临床症状与征象进行综合分析仍然是确定诊断的重要方法.

目的 分析肺内多发空洞病变的CT影像表现,探讨其特点与鉴别要点.方法 收集2012年1月至2015年12月期间CT影像表现为肺内多发空洞病变39例共计130个空洞,其中继发性肺结核17例,肺内多发转移癌13例,肺隐球菌病6例,肺脓肿3例;男25例,女14例,年龄16～73岁,中位年龄41岁.分析病灶内空洞的形态、密度及周围病灶影像特点.全部患者均行胸部CT平扫及增强扫描.计数资料采用x2检验,P＜0.05为差异有统计学意义.结果 (1)空洞形态特点:肺结核空洞55个,以裂隙状及新月形多见,占69.1％(38/55);洞壁厚薄不匀,内壁规则51个(92.7％,51/55),空洞外壁大部分清楚35个(63.6％,35/55),39个可见引流支气管影(70.9％,39/55),增强扫描洞壁多无明显强化;肺转移癌空洞44个,以厚壁(75.0％)多见,内壁不规则30个(68.2％,30/44),洞壁强化明显39个(88.6％,39/44);肺隐球菌病空洞20个,多为厚壁(95.0％,19/20),内壁轻度不规整16个(80.0％,16/20),周围多伴有磨玻璃状片影;肺脓肿空洞11个,全部为厚壁,内壁规则10个(10/11),外壁模糊10个(10/11),伴有液平9个(9/11),全部出现周围渗出性阴影(11/11),洞壁强化明显(11/11).肺结核与肺转移癌空洞内壁规则状况差异有统计学意义(x2=40.218,P=0.000);肺结核与肺转移癌空洞洞壁强化程度差异有统计学意义(x2=76.517,P=0.000).(2)伴随病变影像征象:肺结核空洞的伴随病变主要是微小结节及树芽征,分别占60.0％(33/55)和30.9％(17/55);肺转移癌的多发空洞周围主要为斑片及磨玻璃状影,分别占2.3％(1/44)和31.8％(14/44).肺结核与肺转移癌伴随空洞出现微小结节的比率两者差异有统计学意义(x2=39.600,P=0.000),出现实变斑片状影的比率两者差异无统计学意义(x2=1.274,P=0.259),出现磨玻璃状密度影的比率两者差异有统计学意义(x2=20.382,P=0.000),出现树芽征的比率两者差异有统计学意义(x2=16.420,P=0.000).肺隐球菌病的空洞周围主要为磨玻璃状影(85.0％,17/20),而肺脓肿空洞周围主要为炎性浸润的片状阴影(100％,11/11),这两种征象与肺转移癌空洞组明显不同(x2值分别为15.571、49.271,P值均=0.000).结论 肺部空洞病变的内外壁状况、强化程度及周围伴随病变等CT表现具有一定特征性,进行综合分析,有助于对肺部多发性空洞性病变的诊断与鉴别.

目的 探讨表现为孤立结节的原发性肺隐球菌病(primary pulmonary cryptococcosis,PPC)的CT特征.方法 搜集2011年3月至2015年9月在首都医科大学附属北京胸科医院就诊,经病理确诊、表现为孤立结节的原发性肺隐球菌病患者21例(PPC组),对患者的CT平扫及增强CT图像进行回顾性分析,患者免疫功能均正常.搜集同时期经病理及临床综合诊断确诊、影像表现为肺内孤立结节的肺结核球及周围型肺癌各30例,分别为结核球组和肺癌组,分别观察3组结节及其周围病灶的CT特征并进行比较分析,计数资料采用卡方检验,以P＜0.05为差异有统计学意义.结果 PPC组病灶分布多位于下叶(66.7％,14/21)及外带(80.9％,17/21),与结核球组(30.0％,9/30和53.3％,16/30)及肺癌组(36.7％,11/30和40.0％,12/30)比较,差异均有统计学意义(x2=6.708,P=0.010和x2=4.449,P=0.035;x2=4.126,P=0.042和x2=8.446,P=0.004);PPC组病变边缘模糊者(81.0％,17/21)明显多于结核球组(16.7％,5/30)及肺癌组(13.3％,4/30)(x2=20.812,P=0.000和x2=23.319,P=0.000).PPC组病变边缘可出现长毛刺或索条影,以及与胸膜之间的多条状牵拉改变,与周围型肺癌的“幕状或兔耳状”的胸膜凹陷征有所不同;PPC组邻近胸膜增厚者(57.1％,12/21)明显多于结核球组(16.7％,5/30)及肺癌组(0.0％,0/30)(x2=9.107,P=0.003;x2=19.354,P=0.000);晕征在PPC组周围病灶中占比(70.6％,12/17)较高,明显高于结核球组(3.8％,1/26)及肺癌组(20.0％,1/5)(x2=21.708,P=0.000;x2 =4.090,P=0.043);增强CT扫描,PPC结节[76.2％(16/21)]呈轻度不均匀强化,有别于结核球的无强化或包膜强化,以及肺癌的明显强化.结论 表现为肺内孤立结节的PPC,多位于下叶胸膜下,边缘模糊,伴支气管气象、空泡征及晕征,邻近胸膜多有增厚,增强扫描呈轻度强化伴斑片状低密度区;当出现这些征象时,应考虑PPC的可能性.

Based on basic imaging characteristics of pulmonary tuberculosis,more attention should be paid in diagnosis and differential diagnosis of atypical pulmonary tuberculosis,drug-resistant tuberculosis,tuberculosis in poor immunity patients,and coexisting tuberculosis of other diseases.Furthermore,it is important to take a reasonable application and evaluation of new technology in imaging diagnosis.Thus,it is still an important method to confirm the diagnosis of pulmonary tuberculosis by using the combination of imaging features with clinical comprehensive analysis.

目的 探讨血行播散性肺结核并发颅内结核患者的临床及影像学特点,减少误诊与漏诊.方法 搜集自2008年3月至2015年6月在河南省胸科医院临床确诊的血行播散性肺结核并发颅内结核患者28例,对患者的临床及影像学资料进行回顾性分析.所有患者均进行脑脊液的实验室诊断、CT平扫及MR增强扫描检查,分析胸部CT、头颅CT平扫及MR增强扫描的影像学特点,并重点评价MR增强扫描在颅内结核诊断中的重要性.结果 28例血行播散性肺结核并发颅内结核患者临床表现为高热、盗汗、乏力、纳差、咳嗽等,并同时伴有癫痫发作,或头痛、视物模糊、呕吐,或意识改变,或脑膜刺激征阳性等症状和体征,其中脑脊液实验室检查异常20例(71.4％).胸部CT平扫均可见两肺弥漫粟粒影,26例(92.9％)表现为病灶大小、密度和分布“三均匀”状态.头颅CT平扫仅4例可见异常,1例基底池脑膜增厚并发脑腔积液;2例脑实质多发低密度斑片及结节病灶,其中1例并发脑腔积液;1例右叶脑沟局限性轻度不均匀狭窄.28例患者行头颅MR增强扫描:5例(17.9％)显示单纯基底池及侧裂池脑膜的条状及结节状强化;12例(42.3％)显示为单纯脑实质病变,其中8例呈现为直径2～5mm的弥漫性粟粒结节,4例为脑结核瘤;11例(39.3％)混合型,为脑膜增厚及脑实质病变并存,其中2例并发脑腔积液.8例脑脊液实验室检查正常者,CT平扫虽未见异常,但头颅MR增强扫描检查均显示有脑实质弥漫性粟粒结节病灶.结论 血行播散性肺结核往往并发颅内结核,CT平扫容易漏诊,MR增强扫描是发现和诊断颅内结核的关键技术.

目的 探讨急性血行播散性肺结核早期应用糖皮质激素辅助治疗的临床疗效观察.方法 2010年3月至2013年5月首都医科大学附属北京胸科医院急诊科收治的72例急性血行播散性肺结核患者,按病历号设立随机种子,建立伪随机函数,随机分为治疗组(36例)和对照组(36例),两组均给予标准抗结核方案治疗[3 HR(L2)ZE/6～9HR(L2)E],治疗组在强化期应用泼尼松治疗4周.本研究采用SPSS 13.0统计学软件,临床症状改善时间采用t检验;胸片改善有效率及药物性肝损伤发生率采用x2检验,以P＜0.05为差异有统计学意义.结果 发热症状好转时间在治疗组和对照组分别为(2.5±0.5)d和(7.5±0.5)d,差异有统计学意义(t=-42.43,P＜0.01);4周后两组胸片的有效率分别为86.1％(31/36)和58.3％(21/36),差异有统计学意义(x2=6.92,P＜0.01);药物性肝损伤发生率分别为5.6％(2/36)和27.8％(10/36),差异有统计学意义(x2=6.40,P＜0.05).结论 急性血行播散性肺结核早期抗结核治疗的同时辅助应用糖皮质激素有助于临床症状改善和胸片病变的吸收好转,并能够降低药物性肝损伤的发生率.