时间:2018-03-26 18:01 来源:当代医学 作者:钱孟佼,彭旭光,苗蔚,王璟,李俊,王思博,王忠银,欧海波
2例特殊结核渗出-缩窄性心包炎患者的诊治体会并文献复习
钱孟佼,彭旭光,苗蔚,王璟,李俊,王思博,王忠银,欧海波
(红河州第一人民医院心胸外科
云南 蒙自市 661199)
通讯作者:彭旭光,E-mail: wanjj08@126.com
摘要:目的 报道特殊的结核渗出-缩窄性心包炎患者的诊断及临床干预过程,分析该病的流行病学、临床症状及影像学表现,总结其诊断和治疗进展,以期提高临床医生对这类少见、特殊疾病的鉴别诊断及治疗能力。方法 回顾性分析本院2016~2017年收治的2例特殊结核渗出-缩窄性心包炎患者的临床表现、诊疗经过及影像学分析,比较治疗前后患者心超多普勒血流动力学的变化。结果 1例行心包开窗引流及心包活检,获取病理学及金黄色葡萄球菌感染的细菌学证据,及时选用万古霉素和抗结核治疗;另1例存在医源性损伤,行心包剥脱并取出引流导管,获取病理学证据后抗结核治疗;2例患者舒张早期左室腔内充盈指标均较前下降,病情好转后出院。结论 结核渗出-缩窄性心包炎是肺外结核的一种严重形式,死亡率高、相对少见,不易与单纯心包积液鉴别;心包开窗引流及活检可能有一定的早期诊断和治疗价值,而心包穿刺的安全性有待进一步评估;舒张早期左室腔内充盈指标等变化可能反映了心包限制性运动变化的改善情况。
关键词:结核;渗出-缩窄性心包炎;心脏损伤
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
渗出-缩窄性心包炎(Effusive-constrictive pericarditis, ECP)是一种相对少见的心包疾病,心包腔积液、压力增高,合并心包增厚缩窄[1-2];仅占心包积液的1.2%,在亚洲许多发展中国家,病因以结核多见[3-4],目前国内文献对其报道不多,多以右心功能不全、低热、盗汗等表现为主[5-8]。我们对收治的2例特殊结核性ECP的影像学特点、病理生理学变化及治疗方式的选择进行分析,总结如下。
1 资料与方法
1.1 临床研究
2例病例为本院2016年1月~2017年6月确诊的结核ECP患者, 均通过心包病检确诊。
1.2 方法 回顾性分析患者的性别、年龄、临床表现、诊治经过以及CT、超声脉冲多普勒血流监测等检查结果和转归情况。
2 结果
2.1 基本资料
2.1.1病例1:患者男性,47岁,既往:否认“结核、肝炎”等传染病史,居住地有肺结核散发;以“发热、咳嗽2个月,胸痛、下肢水肿4天”入院。查体:心率86次/分,血压91/65mmHg, 无颈静脉怒张;双肺呼吸音稍粗,可闻及散在湿啰音;心律齐,未闻及杂音及心包摩擦音;右肋缘下
图1壁层心包广泛性增厚(最厚径
Figure 1 The thickening pericardial pericardium
(the thickest diameter of the pericardium is 5.98mm, the pericardial
effusion is 18.36mm)
图2双肺弥散粟粒状高密度影,考虑血行播散型肺结核
Figure 2 Double lung diffuse miliary high density shadow,
considering hematogenous pulmonary tuberculosis
2.1.2 病例2:患者女性,52 岁,既往:糖尿病史多年,年幼时曾患“肺结核”;因“咳嗽、咳痰半月伴发热、腹胀、尿少、浮肿1周”入院。外院超声示大量心包积液并肝淤血、少-中等量腹腔积液,在B超引导下行深静脉置管心包穿刺引流,但引流不通畅,负压回抽引流液呈暗血性并混有血凝块,遂转入我院。入院查体:血压90/60 mmHg,中心静脉压力(central venous pressure,CVP)25mmHg,颈静脉怒张,心率120~130 次/分,心音低钝,律齐,未及杂音及心包摩擦音,右肋缘下2~3cm触及肝脏增大,双下肢轻度浮肿。超声心动图示:各心腔无增大,未见室壁运动障碍(EF61%),心包腔内见条形无回声液性暗区,最宽约
图3脏层心包增厚直径为
Figure 3 The thickness
of the visceral pericardium is 4.71mm, the pericardial pericardium is 2.89mm,
and the pericardial effusion is 24.88mm
图4右室心肌内存留的深静脉导管(白色箭头所示)
Figure 4 The deep vein
catheter in the right ventricular myocardium (white arrow)
图5术中所见脏层心包增厚挛缩,深静脉导管穿入心包腔内(黑箭头所示)
Figure 5 The visceral pericardium had become thickened
contracture, the deep venous catheter had located in the pericardial cavity
(the black arrowhead)
2.2 临床结果
2.2.1 病例1 治疗2周后结核中毒症状控制,复查超声心动图:心包积液明显减少, E值,E/A值较治疗前下降(表1);出院继续抗结核治疗,定期随访半年:病情稳定,心包积液无增加,双肺结核病灶较前吸收,心包厚度无变化及钙化斑。
2.2.2 病例2 腹腔积液消失,复查超声心动图示:少量心包腔积液,舒张早期左室腔内充盈指标下降,且在不同的呼吸时相,指标变化不明显(表1),2周后出院。
表1 2例患者治疗前后的超声多普勒血流动力学监测变化
Table 1 The changes of ultrasonic Doppler hemodynamic
monitoring in 2 patients
病例 |
|
脉冲多普勒血流监测(cm/s) |
E/A比值 |
|
E值 |
A值 |
|||
病例1 |
术前 |
88 |
33 |
2.6 |
出院 |
73 |
42 |
1.7 |
|
病例2 |
术前 |
82 |
35 |
2.3 |
出院 |
70 |
44 |
1.5 |
3讨论
在我国云南的部分边远少数民族聚居区,结核仍是威胁人民健康的主要因素,结核性心包炎(tuberculosis pericarditis, TBP)是肺外结核的一种严重表现形式,死亡率高达17%~40%[3];我国TBP 占心包疾病的21.3%~35.8% [10],分为3种形式:心包积液(80%),缩窄性心包炎(5%),ECP (15%)[2]; 80%以上的TBP为血性心包积液[3],而一些恶性肿瘤和创伤的晚期效应也可引起心包血性积液,故对其病因的早期诊断就非常有必要。
Hancock最早描述了ECP的特点,该病少见、文献报道不多,曾认为是亚急性缩窄性心包炎的亚型[11-12]。但目前认为ECP有可能是结核性心包炎进展至心包缩窄的过渡阶段[13],它包括了单纯心包积液型及缩窄型的临床特点:即使引流了心包积液,缩窄引起的血流动力学改变仍然存在[6-8]。所以在诊治初期,有部分患者可被误诊为单纯的心包积液。第1例患者,起病缓慢,心包填塞症状不明显,但心导管检查表现为特征性的“平方根征”,CT示双肺散在粟粒状结核病灶、心包积液及壁层心包增厚;脉冲多普勒血流监测随呼吸时相变化的限制性图形,仍考虑结核渗出-缩窄性心包炎的可能性很大。同时B超发现心包腔内蜂窝状无回声,考虑心包腔内分隔较多,故选择心包开窗引流及部分切除活检的治疗方式。
虽然,心导管检查及心包穿刺在ECP的早期诊断上有一定帮助,但就安全性来说,仍有争论[14]。临床上普遍开展了超声定位下中心静脉导管心包穿刺引流技术[15],但其在结核性心包积液中的诊治价值及与传统心包开窗引流术的效果评价,还未见文献报道。第2例患者,在院外行心包穿刺造成医源性心肌损伤,存在心包填塞,故急诊开胸探查及心包剥脱;可以看出心包穿刺即使是超声引导,由于操作失误或经验不足,仍可带来严重、甚至是灾难性的后果;对于此类患者,壁层心包增厚、挛缩,心包腔分隔包裹积液,纤维素沉积,如果暂不考虑直接行心包剥脱术,传统心包开窗引流方式不失为一个好的选择,在术中可直接行心包部分活检,以增加其确诊的阳性率,开窗引流方式在结核性心包炎上的诊断价值确实值得我们的再思考。
有报道认为非侵袭性的影像学检查对ECP的诊断帮助不大[16], 因为脏层心包增厚不能达到可察觉的程度,我们这2例患者组织病理学上的发现与Talreja所报道的病例相类似[17],CT测量:壁层心包增厚>
甚至有报道:诊断心包缩窄,超声比心导管检查要更好[18],可这2例患者超声上除了心包积液及室间隔运动异常外,未探及心包腔塌陷、双房增大、左心室舒张期充盈突然中止等缩窄性心包炎的征象[8]。但2例患者舒张早期的左室腔内充盈指标(E值、E/A值)及是否随呼吸时相的改变,在治疗前后均出现了变化,使得我们推测脉冲多普勒的限制图形在ECP的术前诊断上可能会有一定帮助,但我们的临床例数少,尚不能完全说明这些指标的特异性及敏感性,可也为我们在今后的工作中提供一些参考。
结核性ECP的治疗方式有药物治疗、心包穿刺或心包开窗引流、心包剥脱等。单纯药物治疗包括:抗结核药物、类固醇激素及白介素-1b受体拮抗剂(anakinra)[19],主要针对早期血流动力学平稳的患者,部分患者治疗后缓解[20]。但心包缩窄的病理生理过程才是我们关注的重点,因为到了缩窄晚期,由于不可逆转的心肌损伤可致严重心力衰竭,这时手术反而增加患者死亡风险[7]。复习文献发现,在HIV流行地区,感染HIV的患者有90%合并心包结核[3]、且占AIDS患者直接死因的40%[13],说明结核性心包炎与机体免疫功能之间的微妙关系;我们的第1例患者出现了罕见的金黄色葡萄球菌性败血症并结核渗出-缩窄性心包炎,推测与机体免疫功能紊乱也有关联;因此,早期诊断及早期心包剥脱手术是这类患者良好预后的关键[7-8,21],且早期手术难度要小的多。故提高广大临床医师对这类少见疾病的理论水平认识及如何精准、快速地早期诊断,是我们今后的研究方向及工作重点。
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