2025 年第 4 期 第 20 卷

入住重症监护病房血行播散性结核病患者的临床特点及预后分析

Analysis of the clinical characteristics and prognosis of patients with hematogenous disseminated tuberculosis admitted to intensive care unit

作者：刘嘉傅满姣贝承丽陈红梅

英文作者：Liu Jia Fu Manjiao Bei Chengli Chen Hongmei

单位：南华大学附属长沙中心医院湖南省长沙市中心医院结核重症监护室，长沙410011

英文单位：Tuberculosis Intensive Care Unit Changsha Central Hospital Affiliated to the University of South China Changsha Central Hospital Hunan Province Changsha 410011 China

关键词：血行播散性结核病；宏基因组二代测序；结核菌血症

英文关键词：Hematogenousdisseminatedtuberculosis;Metagenomicnextgenerationsequencing;Tuberculemia

• 摘要：

• 目的 探讨入住重症监护病房（ICU）的血行播散性结核病（HDTB）患者的临床特点及预后，提高临床医师对该病的认识。方法 回顾性分析2019年6月至2023年6月湖南省长沙市中心医院结核ICU收治的重症结核病患者130例，根据是否存在血行播散和病灶受累情况分为HDTB组（42例）和局部结核病组（88例），比较2组患者的临床特点和预后。结果 HDTB组患者合并基础疾病、自身免疫性疾病的比例高于局部结核病组，而咳嗽、咳痰的比例明显低于局部结核病组（均P<0.05）。HDTB组患者入ICU时的白细胞计数、血红蛋白、白蛋白水平均低于局部结核病组，降钙素原、C反应蛋白水平及肝、肾功能不全的比例均高于局部结核病组（均P＜0.05）。HDTB组血行播散性肺结核的比例明显高于局部结核病组，而浸润性肺结核的比例低于局部结核病组［54.8%（23/42）比9.5%（8/84）、21.4%（9/42）比54.8%（46/84）］（均P＜0.05），2组空洞性肺结核的比例比较差异无统计学意义（P＞0.05）。HDTB组痰抗酸杆菌阳性率明显低于局部结核病组（P＜0.05）。HDTB组患者多器官功能障碍综合征、脓毒症及抗结核药物不良反应的发生率明显高于局部结核病组，入住ICU时间和总住院时间均长于局部结核病组（均P<0.05）。HDTB组27例（64.3%）患者经治疗病情好转顺利转出ICU，15例（35.7%）患者院内死亡；局部结核病组74例（84.1%）好转出ICU，14例（15.9%）患者院内死亡，HDTB组院内死亡率明显高于局部结核病组（P＜0.05）。结论 HDTB多发生于有免疫受损基础疾病患者，临床表现以全身症状为主，缺乏特异性，肺部影像以血行播散性肺结核为主，痰抗酸杆菌阳性率低，合并感染更严重，多器官功能障碍综合征、脓毒症发生率高，抗结核过程中容易出现药物不良反应，住院时间长，死亡率高。

• Objective To investigate the clinical characteristics and prognosis of patients with hematogenous disseminated tuberculosis (HDTB) admitted to intensive care unit (ICU), and to improve clinicians′ understanding of the disease. Methods A total of 130 patients with severe tuberculosis admitted to the tuberculosis ICU of Changsha Central Hospital, Hunan Province from June 2019 to June 2023 were retrospectively analyzed.According to the presence or absence of hematogenous spread and lesion involvement, the patients were divided into HDTB group (42 cases) and local tuberculosis group (88 cases). The clinical characteristics and prognosis of the two groups were compared. Results The proportions of underlying diseases and autoimmune diseases in the HDTB group were higher than those in the local tuberculosis group, while the proportions of cough and expectoration were significantly lower than those in the local tuberculosis group(all P<0.05). The white blood cell count, hemoglobin and albumin levels of the HDTB group were lower than those of the local tuberculosis group, and the procalcitonin and C-reactive protein levels and the proportions of liver and renal insufficiency were higher than those of the local tuberculosis group(all P<0.05). The proportion of hematogenous disseminated tuberculosis in the HDTB group was significantly higher than that in the local tuberculosis group, while the proportion of invasive tuberculosis was lower than that in the local tuberculosis group［54.8%(23/42) vs 9.5%(8/84), 21.4%(9/42) vs 54.8%(46/84)］(both P<0.05). There was no significant difference in the proportion of cavitary tuberculosis between the two groups(P>0.05). The positive rate of acid-fast bacilli in HDTB group was significantly lower than that in local tuberculosis group(P<0.05). The incidences of multiple organ dysfunction syndrome, sepsis and adverse reactions to anti tuberculosis drugs in the HDTB group were significantly higher than those in the local tuberculosis group, and the length of ICU stay and total hospital stay were longer than those in the local tuberculosis group (all P<0.05). Totally 27 patients (64.3%) in HDTB group were successfully transferred out of ICU after treatment, and 15 patients (35.7%) died in hospital. In the local tuberculosis group, 74 patients (84.1%) were discharged from ICU and 14 patients (15.9%) died in hospital. The mortality rate in the HDTB group was significantly higher than that in the local tuberculosis group (P<0.05). Conclusion HDTB mostly occurs in patients with immunocompromised underlying diseases. The clinical manifestations of HDTB are mainly systemic symptoms, such as lack of specificity, pulmonary imaging is mainly hematogenous disseminated tuberculosis, the positive rate of acid-fast bacilli in sputum is low, the co-infection is more serious, the incidence of multiple organ dysfunction syndrome and sepsis is high, the adverse drug reactions in the process of anti-tuberculosis is easy to occur, the length of hospital stay is long, and the mortality is high.