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          2例特殊結核滲出-縮窄性心包炎患者的診治體會并文獻復習

          時間:2018-03-26 18:01 來源:當代醫學 作者:錢孟佼,彭旭光,苗蔚,王璟,李俊,王思博,王忠銀,歐海波

          2例特殊結核滲出-縮窄性心包炎患者的診治體會并文獻復習

          錢孟佼,彭旭光,苗蔚,王璟,李俊,王思博,王忠銀,歐海波

          (紅河州第一人民醫院心胸外科 云南  蒙自市 661199

          通訊作者:彭旭光,E-mail: wanjj08@126.com

          摘要:目的  報道特殊的結核滲出-縮窄性心包炎患者的診斷及臨床干預過程,分析該病的流行病學、臨床癥狀及影像學表現,總結其診斷和治療進展,以期提高臨床醫生對這類少見、特殊疾病的鑒別診斷及治療能力。方法 回顧性分析本院20162017年收治的2例特殊結核滲出-縮窄性心包炎患者的臨床表現、診療經過及影像學分析,比較治療前后患者心超多普勒血流動力學的變化。結果 1例行心包開窗引流及心包活檢,獲取病理學及金黃色葡萄球菌感染的細菌學證據,及時選用萬古霉素和抗結核治療;另1例存在醫源性損傷,行心包剝脫并取出引流導管,獲取病理學證據后抗結核治療;2例患者舒張早期左室腔內充盈指標均較前下降,病情好轉后出院。結論 結核滲出-縮窄性心包炎是肺外結核的一種嚴重形式,死亡率高、相對少見,不易與單純心包積液鑒別;心包開窗引流及活檢可能有一定的早期診斷和治療價值,而心包穿刺的安全性有待進一步評估;舒張早期左室腔內充盈指標等變化可能反映了心包限制性運動變化的改善情況。

          關鍵詞:結核;滲出-縮窄性心包炎;心臟損傷 

          The Report of 2 Special Cases for Tuberculous Effusive-Constrictive Pericarditis and Review of the Literature

          Qian Mengjiao, Peng Xuguang, Miao Wei, Wang Jing, Li Jun, Wang Sibo, Wang Zhongyin, Ou Haibo

          Division of Cardiothoracic Surgery, First Hospital of Honghe Prefecture, Mengzi,Yunnan,661199, China   

          Abstract: Objective The diagnosis and clinical intervention of special tuberculosis effusion constrictive pericarditis were reported. With summarizing new progress of diagnosis and treatment, analysing the epidemiology, clinical symptoms and radiological manifestations of the disease, in order to improve the ability of clincian's differential diagnosis and treatment. Methods A retrospective analysis was performed 2 cases of tuberculous exudative constrictive pericarditis in our hospital from 2016-2017, the clinical manifestations, diagnosis and treatment and imaging analysis were included. The changes of cardiac Doppler hemodynamics were compared during perioperative period. Results  With pericardial window drainage and pericardial biopsy, 1 cases which had gotten pathological and bacteriological evidence of Staphylococcus aureus infection, had timely accepted vancomycin and anti TB treatment; With iatrogenic injury, the other case which had been treated by emergency pericardial stripping and removed drainage catheter, had accepted anti tuberculosis treatment after operation with pathological evidence; For the two patients, the early diastolic filling indexes in the left ventricular cavity were all lower than those before treatment. Conclusion Tuberculous effusion constrictive pericarditis is a severe form of tuberculosis and not easily differentiated, the mortality rate is high, relatively rare; pericardial drainage and biopsy may have certain value in the early diagnosis and treatment, and the safety of the pericardium puncture need further evaluation; the changes of early diastolic filling indexes in left ventricular cavity may reflect the improvement of pericardial restricted motion.

          Key words: Tuberculosis; Exudative constrictive pericarditis; Heart injury

              滲出-縮窄性心包炎(Effusive-constrictive pericarditis, ECP)是一種相對少見的心包疾病,心包腔積液、壓力增高,合并心包增厚縮窄[1-2];僅占心包積液的1.2%,在亞洲許多發展中國家,病因以結核多見[3-4],目前國內文獻對其報道不多,多以右心功能不全、低熱、盜汗等表現為主[5-8]。我們對收治的2例特殊結核性ECP的影像學特點、病理生理學變化及治療方式的選擇進行分析,總結如下。

          1 資料與方法

          1.1 臨床研究 2例病例為本院20161月~20176月確診的結核ECP患者, 均通過心包病檢確診。

          1.2 方法 回顧性分析患者的性別、年齡、臨床表現、診治經過以及CT、超聲脈沖多普勒血流監測等檢查結果和轉歸情況。

          2 結果

          2.1 基本資料

          2.1.1病例1患者男性,47歲,既往:否認“結核、肝炎”等傳染病史,居住地有肺結核散發;以“發熱、咳嗽2個月,胸痛、下肢水腫4天”入院。查體:心率86/分,血壓91/65mmHg, 無頸靜脈怒張;雙肺呼吸音稍粗,可聞及散在濕啰音;心律齊,未聞及雜音及心包摩擦音;右肋緣下1cm可觸及增大肝臟,雙踝部凹陷性水腫。實驗室檢查:降鈣素原3.57ng/ml, N-端腦利鈉肽前體(N-terminal fragment of pro-B-type natriuretic peptide,BNP543.00pg/ml;CT示:雙肺彌散斑點片狀高密度影,縱隔內多發大小不等淋巴結,考慮血行播散型肺結核;壁層心包廣泛增厚伴大量積液(圖1、圖2)。超聲心動圖:左房輕度擴大,左室側壁運動減弱(EF58%),左右室內徑與室壁厚度正常,室間隔運動異常、舒張早期呈 “反跳”運動,心包腔內見蜂窩狀無回聲,最寬為30mm, 以左右室側壁及心尖為甚;脈沖多普勒血流:左室舒張早期容積(early diastolic velocity,E)、左房充盈容積(atrial filling velocity, A)及E/A比值均升高, 并可隨呼吸時相變化(波動范圍≥26%)(表1)。心導管檢查:左右心室舒張末期壓力增加、均等(15 mmHg);波形表現為“平方根征”[9]?紤]患者為血行播散型肺結核合并結核性心包炎,遂行心包開窗引流及心包部分切除活檢,術中見壁層心包明顯增厚,纖維素樣滲出物附著臟層心包表面,淡紅色漿液被囊性分隔包裹;病檢示:上皮樣結節性肉芽腫性炎伴干酪樣壞死;心包積液及全血細菌培養:金黃色葡萄球菌感染;積液中腺苷脫氨酶(adenosine deaminase,ADA156U/L;術后據藥敏選用萬古霉素、抗結核及糖皮質激素治療,尿激酶20U間斷沖洗心包腔。


          1壁層心包廣泛性增厚(最厚徑5.98mm,心包腔積液厚度18.36mm

          Figure 1 The thickening pericardial pericardium

          (the thickest diameter of the pericardium is 5.98mm, the pericardial effusion is 18.36mm)


          2雙肺彌散粟粒狀高密度影,考慮血行播散型肺結核

          Figure 2 Double lung diffuse miliary high density shadow, considering hematogenous pulmonary tuberculosis

          2.1.2 病例2患者女性,52 歲,既往:糖尿病史多年,年幼時曾患“肺結核”;因“咳嗽、咳痰半月伴發熱、腹脹、尿少、浮腫1周”入院。外院超聲示大量心包積液并肝淤血、少-中等量腹腔積液,在B超引導下行深靜脈置管心包穿刺引流,但引流不通暢,負壓回抽引流液呈暗血性并混有血凝塊,遂轉入我院。入院查體:血壓90/60 mmHg,中心靜脈壓力(central venous pressure,CVP25mmHg,頸靜脈怒張,心率120130 /分,心音低鈍,律齊,未及雜音及心包摩擦音,右肋緣下23cm觸及肝臟增大,雙下肢輕度浮腫。超聲心動圖示:各心腔無增大,未見室壁運動障礙(EF61%),心包腔內見條形無回聲液性暗區,最寬約18mm;脈沖多普勒血流:E值、E/A比值等反映舒張早期左室腔內充盈指標均明顯升高(表1) 。行胸部CT示:雙肺散在結核灶,部分纖維化;心包穿刺術后,壁心包增厚并大量積液?紤]深靜脈置管誤穿入右心室心肌內(圖3、圖4),存在醫源性損傷;遂急診開胸手術取出置管、右室傷口縫扎,術中探查:大量纖維素樣滲出物附著臟層心包表面,壁層心包增厚、攣縮,呈灰白色、纖維化,心包腔呈大小不等囊狀分隔,積液呈淡血性(圖5);向兩側切除壁層心包至膈神經旁,清除約100ml淡血性心包積液,心室搏動仍然受限;除心底部外,切除其余病變臟層心包,松解上下腔靜脈入口處纖維環,心室搏動明顯改善;CVP降至1712mmHg;病檢示:心包組織出血變性壞死、纖維增生,膠原化透明樣變伴慢性肉芽腫性炎, 無急性炎性細胞及鈣化;實驗室檢查:心包積液中ADA113U/L;術后予抗結核及激素治療,控制血糖。


          3臟層心包增厚直徑為4.71mm,壁層心包增厚直徑為2.89mm,積液厚度24.88mm

          Figure 3 The thickness of the visceral pericardium is 4.71mm, the pericardial pericardium is 2.89mm, and the pericardial effusion is 24.88mm


          4右室心肌內存留的深靜脈導管(白色箭頭所示)

          Figure 4 The deep vein catheter in the right ventricular myocardium (white arrow)


          5術中所見臟層心包增厚攣縮,深靜脈導管穿入心包腔內(黑箭頭所示)

          Figure 5 The visceral pericardium had become thickened contracture, the deep venous catheter had located in the pericardial cavity (the black arrowhead)

          2.2 臨床結果

          2.2.1 病例1  治療2周后結核中毒癥狀控制,復查超聲心動圖:心包積液明顯減少, E,E/A值較治療前下降(表1);出院繼續抗結核治療,定期隨訪半年:病情穩定,心包積液無增加,雙肺結核病灶較前吸收,心包厚度無變化及鈣化斑。

          2.2.2 病例2 腹腔積液消失,復查超聲心動圖示:少量心包腔積液,舒張早期左室腔內充盈指標下降,且在不同的呼吸時相,指標變化不明顯(表1),2周后出院。

          1  2例患者治療前后的超聲多普勒血流動力學監測變化

          Table 1 The changes of ultrasonic Doppler hemodynamic monitoring in 2 patients

          病例

           

          脈沖多普勒血流監測(cm/s

          E/A比值

          E

          A

          病例1

          術前

          88

          33

          2.6

          出院

          73

          42

          1.7

          病例2

          術前

          82

          35

          2.3

          出院

          70

          44

          1.5

          3討論

              在我國云南的部分邊遠少數民族聚居區,結核仍是威脅人民健康的主要因素,結核性心包炎(tuberculosis pericarditis, TBP)是肺外結核的一種嚴重表現形式,死亡率高達17%40%[3];我國TBP 占心包疾病的21.3%35.8% [10],分為3種形式:心包積液(80%),縮窄性心包炎(5%),ECP 15%[2]; 80%以上的TBP為血性心包積液[3],而一些惡性腫瘤和創傷的晚期效應也可引起心包血性積液,故對其病因的早期診斷就非常有必要。

              Hancock最早描述了ECP的特點,該病少見、文獻報道不多,曾認為是亞急性縮窄性心包炎的亞型[11-12]。但目前認為ECP有可能是結核性心包炎進展至心包縮窄的過渡階段[13],它包括了單純心包積液型及縮窄型的臨床特點:即使引流了心包積液,縮窄引起的血流動力學改變仍然存在[6-8]。所以在診治初期,有部分患者可被誤診為單純的心包積液。第1例患者,起病緩慢,心包填塞癥狀不明顯,但心導管檢查表現為特征性的“平方根征”,CT示雙肺散在粟粒狀結核病灶、心包積液及壁層心包增厚;脈沖多普勒血流監測隨呼吸時相變化的限制性圖形,仍考慮結核滲出-縮窄性心包炎的可能性很大。同時B超發現心包腔內蜂窩狀無回聲,考慮心包腔內分隔較多,故選擇心包開窗引流及部分切除活檢的治療方式。

              雖然,心導管檢查及心包穿刺在ECP的早期診斷上有一定幫助,但就安全性來說,仍有爭論[14]。臨床上普遍開展了超聲定位下中心靜脈導管心包穿刺引流技術[15],但其在結核性心包積液中的診治價值及與傳統心包開窗引流術的效果評價,還未見文獻報道。第2例患者,在院外行心包穿刺造成醫源性心肌損傷,存在心包填塞,故急診開胸探查及心包剝脫;可以看出心包穿刺即使是超聲引導,由于操作失誤或經驗不足,仍可帶來嚴重、甚至是災難性的后果;對于此類患者,壁層心包增厚、攣縮,心包腔分隔包裹積液,纖維素沉積,如果暫不考慮直接行心包剝脫術,傳統心包開窗引流方式不失為一個好的選擇,在術中可直接行心包部分活檢,以增加其確診的陽性率,開窗引流方式在結核性心包炎上的診斷價值確實值得我們的再思考。

              有報道認為非侵襲性的影像學檢查對ECP的診斷幫助不大[16], 因為臟層心包增厚不能達到可察覺的程度,我們這2例患者組織病理學上的發現與Talreja所報道的病例相類似[17],CT測量:壁層心包增厚>5mm,而臟層心包未見增厚(正常心包厚度≤3mm[18]),但術中仍發現臟層心包有不同程度增厚, 纖維素樣滲出物附著表面,限制心室收縮;心包病檢發現纖維化、肉芽腫性炎和干酪樣壞死等結核慢性炎性表現;提示我們在影像學上不一定要觀察到心包腔塌陷、心包融合、攣縮、鈣化,才是心包縮窄的征象[3]。

              甚至有報道:診斷心包縮窄,超聲比心導管檢查要更好[18],可這2例患者超聲上除了心包積液及室間隔運動異常外,未探及心包腔塌陷、雙房增大、左心室舒張期充盈突然中止等縮窄性心包炎的征象[8]。但2例患者舒張早期的左室腔內充盈指標(E值、E/A值)及是否隨呼吸時相的改變,在治療前后均出現了變化,使得我們推測脈沖多普勒的限制圖形在ECP的術前診斷上可能會有一定幫助,但我們的臨床例數少,尚不能完全說明這些指標的特異性及敏感性,可也為我們在今后的工作中提供一些參考。

              結核性ECP的治療方式有藥物治療、心包穿刺或心包開窗引流、心包剝脫等。單純藥物治療包括:抗結核藥物、類固醇激素及白介素-1b受體拮抗劑(anakinra[19],主要針對早期血流動力學平穩的患者,部分患者治療后緩解[20]。但心包縮窄的病理生理過程才是我們關注的重點,因為到了縮窄晚期,由于不可逆轉的心肌損傷可致嚴重心力衰竭,這時手術反而增加患者死亡風險[7]。復習文獻發現,在HIV流行地區,感染HIV的患者有90%合并心包結核[3]、且占AIDS患者直接死因的40%[13],說明結核性心包炎與機體免疫功能之間的微妙關系;我們的第1例患者出現了罕見的金黃色葡萄球菌性敗血癥并結核滲出-縮窄性心包炎,推測與機體免疫功能紊亂也有關聯;因此,早期診斷及早期心包剝脫手術是這類患者良好預后的關鍵[7-8,21],且早期手術難度要小的多。故提高廣大臨床醫師對這類少見疾病的理論水平認識及如何精準、快速地早期診斷,是我們今后的研究方向及工作重點。

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          [7] Suita C, Shiraishi I, Tanaka T, et al. Severe heart failure due to subacute effusive-constrictive pericarditis in a child[J]. Pediatr Cardiol, 2005,26(1):101-103.

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