目的 比较分析超声引导下胸膜穿刺获取的病理组织及胸腔积液标本在疑似结核性胸膜炎中的诊断价值.方法 搜集2016年1月至2018年5月在西安市胸科医院初次就诊的298例疑似结核性胸膜炎患者,其中临床确诊结核性胸膜炎患者112例,非结核性胸膜炎患者186例.所有患者均通过超声引导下胸膜穿刺获取病理组织和胸腔积液标本,对活检组织进行病理学切片检查(简称“病理检查”),胸腔积液分别进行结核分枝杆菌培养(浓缩集菌法,采用液体培养BACTEC MGIT 960操作系统,简称“MGIT 960培养”)、全自动医用PCR分析系统(GeneXpert MTB/RIF,简称“GeneXpert检测”)和抗酸杆菌染色涂片检查(简称“涂片检查”).上述各种方法以临床确诊患者为参考标准,得出各自的诊断敏感度、特异度、阳性预测值、阴性预测值、约登指数,以评价各种检测方法诊断结核性胸膜炎的效能.结果 病理检查、MGIT 960培养、GeneXpert检测、涂片检查以临床确诊结果为参考标准的诊断敏感度分别为41.96％(47/112)、73.21％(82/112)、58.93％(66/112)和2.68％(3/112);特异度分别为99.46％(185/186)、100.00％(186/186)、100.00％(186/186)、100.00％(186/186);约登指数分别为0.41、0.73、0.59、0.02.结论 超声引导下胸膜穿刺获取标本采用各种技术与方法进行检测,结果证明胸腔积液标本采用浓缩集菌法进行MGIT 960培养相对其他检测技术与方法具有较好的敏感度、特异度,约登指数最高,具有良好的临床诊断结核性胸膜炎的价值.

Objective To observe the effect of intrathoracic injection of urokinase on the separation of fibrous septa in the pleural effusion of patients with tuberculous pleurisy treated by ultrasound, and to explore the time rule and optimal drainage time node of fibrin strip separation in urokinase-dissolved pleural effusion. Methods A total of 147 patients with tuberculous pleurisy and pleural effusion with fiber strips influencing the drainage were selected. According to the full drainage volume on the day, 48 cases were divided into group A (fully diverted flow≤500 ml), 63 cases in group B (fully diverted flow 500~800 ml), and 36 cases in group C (fully diverted flow≥800 ml). All of them were injected with 200,000 units of urokinase. Then we analyzed the images under the guidance of ultrasound at the time points of before injection, and 0.5 h, 1.0 h, 1.5 h, 2.0 h, 2.5 h and 3.0 h after injection. The changes of the number of fibrous septa in pleural effusion at different time points were analyzed. Results After drug injection, the number of pleural effusion fibers in the 147 patients was compared at different time points, and there was a statistically difference (F=34.989, P=0.000). There was a statistical difference between before injection and 1.0 h after injection (t=6.274, P=0.000). There was a statistical difference between 0.5 h and 1.0 h after injection (t=3.300, P=0.001). There was no statistical difference between 1.0 h and 1.5 h, 2.0 h, 2.5 h, 3.0 h after injection (P>0.05). There were statistical differences between 1.0 h after injection in group A, B and C, and 0.5 h before injection and 0.5 h after injection (pre-drug comparison: t=-6.020, -4.331, 8.554; compared with 0.5 h after injection: t=-3.338, 2.613, 5.216; all P 0.05). Conclusion After injection of 200,000 units of urokinase, the fastest dissolution rate of fibrous septa in pleural effusion achieved with the first hour, and the dissolution effect was not obvious at 1.5 h after injection. Ultrasound is an effective method to observe the changes of fibrous septa dissolution in thoracic cavity in real time, and is worthy of clinical application. Key words: Ultrasonography; Tuberculous pleurisy; Septate fiber; Urokinase; Pleural effusion

目的 探讨胸腔内注入尿激酶对结核性胸腔积液胸水化验结果的影响.方法 选取2016-03～2017-04陕西省康复医院呼吸科确诊的包裹性结核性胸膜炎患者105例,随机分为实验组(注射尿激酶)52例,对照组(未注射尿激酶)53例.实验组超声引导下置管术后随即注入尿激酶20万单位,20 mL盐水稀释,3h后收集胸水标本300 mL,送化验室进行胸水生化与肿瘤系列检测,对照组超声引导下置管术后随即留取胸水标本300 mL,送检.将化验检查结果进行统计学t检验分析,P＜0.05表示差异有统计学意义.结果 两组中神经元特异性烯醇化酶(NSE)指标经分析有统计学意义(P＜0.05),其余指标无统计学意义.结论 胸腔内注射尿激酶后对胸水生化与肿瘤系列化验室检查中NSE指标有一定影响,对其他化验室指标无明显影响.

结核性脑膜炎(tuberculous meningitis,TBM)常累及脑实质及脑血管,患者死亡率高达45％,是成人特别是幼儿结核病致死的主要原因[1-3].TBM临床症状以颅内压增高、脑实质损伤为主,患者易出现严重脑膜刺激症状,病情严重者可出现嗜睡、昏迷、瘫痪,甚至死亡,病死率、致残率极高[4].