关节结核延误诊断的原因分析

摘要/Abstract

摘要： 目的探讨关节结核的临床特点,以提高其诊疗水平。方法对2013年2月至2016年2月收治的关节结核109例的临床资料进行回顾性分析。结果本组关节结核患者85.32%(93/109)为中青年, 50.46%(55/109)合并肺结核,病灶以膝41.28%（45/109）、踝14.68%（16/109）、髋12.84%（14/109）居多。临床主要表现为局部疼痛和活动受限,首诊误诊率74.31%(81/109)。本组根据症状体征,结合实验室各项化验检查、影像学检查、是否合并身体其他部位结核、脓肿穿刺、实验室检查、手术活检及诊断性抗结核治疗是否有效的综合手段最终明确诊断。最终通过全身抗结核药物及局部换药治愈16例,手术治愈66例,治愈率100%。结论关节结核早期临床表现隐匿、实验室检查的不确定性、影像学检查的局限性以及临床医师对该症状的认识不足,是延误诊断的主要原因。临床早期综合检查和必要的诊断性治疗是目前关节结核诊疗的基本方法。

关键词: 结核, 关节, 诊断

Abstract: Objective To explore the clinical characteristic of joint tuberculosis patients in order to improve the diagnosis of the joint tuberculosis. Methods The clinical data of 109 joint tuberculosis patients admitted to Shenzhen the third people's hospital of orthopedics for treatment were collected and retrospectively analyzed. Results The joint tuberculosis frequently urred in young and middle aged adults in this group (85.32%, 93/109)); 55 cases (50.46%, 55/109)were secondary to tuberculosis; the lesions were found mainly in knee 41.28%（45/109）cases, ankle14.68%(16/109) cases and hip 12.84%（14/109）cases . The major clinical manifestations were local pain and limited activity. The initial misdiagnosis rate of joint tuberculosis patients was 74.31%(81/109). The joint tuberculosis was confirmed relying on the symptoms and signs, laboratory tests, imaging examination, other involvement of tuberculosis, abscess puncture, laboratory examination, surgical biopsy and efficiency of diagnostic anti-tuberculosis treatment. Finally, 16 cases were cured by anti-tuberculosis drugs and 66 cases were cured by surgery, with the cure rate of 100%. Conclusion Non-obvious early clinical manifestation, nondeterminacy of laboratory examination, limitation of imaging examination are the main reasons of misdiagnosis for joint tuberculosis. Comprehensive utilization of various tuberculosis specialized examination and the diagnostic anti-tuberculosis treatment are still the basic method for the diagnosis and treatment of joint tuberculosis.

Key words: Tuberculosis, Joint, Diagnosis

马克, 刘金柱, 刘晶, 周振中. 关节结核延误诊断的原因分析[J]. 新发传染病电子杂志, 2017, 2(3): 172-174.

MA Ke, LIU Jin-zhu, LIU Jing, ZHOU Zhen-zhong. Cause analysis for delayed diagnosis of joint tuberculosis[J]. Electronic Journal of Emerging Infectious Diseases, 2017, 2(3): 172-174.

参考文献

[1] Marshall, M J, Holt I, et al. The number of tartrate-resistantacedata-positive osteoclasts on neonatal mouse parietal bones is decreased when prostaglandin synthesis is inhibited and increased in response to prostaglandin E2, parathyroid hormone, and 1,25Dihydroxyvitamin D3. Calcif[J]. Tissue Int, 2005, 56(11): 240-245.
[2] Tuli S M.General principles of osteoarticular tuberculosis[J]. Clinical Orthop Relat Res, 2002, 398(398):11-19.
[3] Watts HG, Lifeso RM.Tuberculosis of bones and joints[J]. J Bone Joint Surg Am, 1996, 78(2): 288-298.
[4] Shams F, Asnis D, Lombardi C, et al.A report of two cases of tuberculous Arthritis of the ankle[J]. J Foot Ankle Surg, 2009, 48(4): 452-456.
[5] Ul-Haq MI, Buckley JR.Tuberculosis of the right distal fibula bone case repot: an unusual T. B. Case[J]. Foot (Edinb), 2012, 22(1): 53-54.
[6] Goldblatt M, Cremin BJ.Osteo-articular tuberculosis: its presentation in Coloured races[J]. Clin Radiol, 1978, 29(6): 669-677.
[7] Christoph Gradmann.Robert Koch and the white death: from tuberculosis to tuberculin[J]. Microbes and Infection, 2006: 294-301.
[8] Medvei VC.Imaginary conversations from the history of medicine: Robert Koch and Wilhelm Conrad Rontgen[J]. J R Soc Med, 1992, 85(6): 355-356.
[9] 赵武斌.脊椎结核早期治疗首诊误诊率,复治率分析[J].中国实用医药,2012,7(19):104一105.
[10] 曹仕鹏,蒋芝,傅满姣.脊柱结核延误诊断及治疗困难原因分析[J].临床误诊误治,2015,28(12):1-4.
[11] 葛文涛, 徐向阳. 足踝部结核诊断与治疗[J]. 国际骨科学杂志,2013,34(4):256-262.
[12] 骨关节结核临床诊断与治疗进展及其规范化专题研讨会学术委员会.正确理解和认识骨与关节结核诊疗的若干问题[J].中国防痨杂志,2013,35(5) :384 392.
[13] 张登才,刘斌,张丽华,等抗酸染色在结核病病理诊断中的价值[J]. 中国防痨杂志,2014,36(4):274-278.
[14] 张贺秋,赵雁林.现代结核病诊断技术[M].北京:人民卫生出版社,2013:47-120.
[15] Dhillon MS, Tuli SM.Osteoarticular tuberculosis of the foot and ankle[J]. Foot Ankle Int, 2001, 22(8): 679-686.
[16] 秦世炳. 重视肺外结核病并规范骨关节结核的临床诊治[J].中国防瘩杂志,2014,36(8) :655-658.
[17] 马玙,朱莉贞,潘毓萱.结核病[M].北京:人民卫生出版社,2009:295-307.
[18] 秦世炳,程宏,董伟杰,等.胸椎结核不同部位脓肿的形态分析[J]. 中华感染杂志,2004, 14(10):1128-1130.
[19] XIAO Wei, JIN Ge le. Advances in Diagnosis and Treatment of Spinal Tuberculosis Medical Recapitulate[J]. Medical Recapitulate, 2012, 18(14):2222-2222.