第118课 病例分析（003）-肺结核（Tuberculosis ）

男，56岁，近1个月消瘦，咳嗽伴痰中带血，无发热。血象检查白细胞正常，血糖正常。既往身体健康。CT如下图

CT影像所见（CT imaging can see） ：

左肺上叶尖后段呈肺段分布的大片实变影像，其内有多数无壁空洞及支气管树影，空洞内壁光滑，病灶边缘模糊，周边有多发斑点状增殖灶。主-肺动脉窗见数个淋巴结影。胸膜未见异常。

on the left lung tip after a period of consolidation of the lung segment distribution of large images, which have no wall cavity and bronchial trees, most empty inside sleek, focal edge blur, periphery have multiple punctate proliferation. Lord - pulmonary window to see a number of lymph nodes. Pleural did not see abnormalities.

观点分析（View analysis）：

观点一：左上叶尖后段病变，成片团状，其内见空洞，空洞内壁尚光滑，周边有渗出性改变，病灶内还可见充气支气管，只是走行较硬，根据部位病灶特点首先考虑结核，肺癌次之。

Idea 1: top left tip of the lesions, group that slices, which see empty, empty wall is smooth, with exudative change, still visible inside the lesions air bronchus, just go hard, first consider tuberculosis based on the characteristics of parts of the lesions, lung cancer.

观点二：左上肺团块状病变，其内见不规则空洞和空腔（蜂房征），见含气支气管征，但支气管壁增厚且僵硬，纵隔淋巴结肿大，病变局部胸壁受侵，加上临床病史，首先考虑肺癌，尤其是肺泡癌，需鉴别于其他肿瘤性病变，如淋巴瘤。

Idea 2: top left lung mass lesion, which see irregular hole and cavity (hives), including air bronchogram, but bronchial wall thickening and stiff, mediastinal lymph node enlargement, local lesion chest wall invaded, combined with clinical history, first consider lung cancer, especially the alveolar carcinoma, to differentiate from other tumor pathological changes, such as lymphoma.

观点三：左肺上叶后壁空洞，紧靠胸膜，与胸膜分界不清，其内并见结节。纵隔内见肿大淋巴结。诊断意见：1、考虑周围型肺癌可能性大。2、空洞性肺结核不排除。

Point three: left upper lobe after the wall hole, close to the pleura, and pleural boundary is not clear, see them and nodules. Within the mediastinum see swollen lymph nodes. Diagnosis: 1, consider the possibility of lung cancer. 2, empty sexual tuberculosis has not ruled out.

最后诊断：肺结核。镜下见结核结节，中心见朗格汉斯细胞，周围有大量的淋巴细胞，类上皮细胞。

The final diagnosis: tuberculosis. Microscopically, the tuberculous nodules, see langerhans cell center, surrounded by a large number of lymphocytes, epithelioid cells.

手术所见：左上叶见块状物，但下叶探查无异常发现，胸膜有部分粘连，但是左上叶易分离，术中快速切片病理报告危结核，顺利进行部分肺叶切除，并做肺门纵隔淋巴结清扫。术后切开病变肺组织，见肿块有空洞，空洞周围是肉芽组织，有部分肺组织内可以挤出黄色液体和奶酪样物质。

Surgery can see: see upper left lobe blobs, but no abnormal findings, the lower lobe detection pleural adhesions of some, but left Ye Yi separation, intraoperative rapid biopsy pathology report latent tuberculosis, smoothly part lobectomy, and do the lung mediastinal lymph node cleaning. Postoperative incision lesions, lung tissue see mass is empty, empty is surrounded by granulation tissue, a portion of the lung tissues can squeeze out yellow liquid and cheese kind material.

疾病的诊断鉴别（The diagnosis of the disease to identify）：

这个病例因为有些影像学表现比较像恶性病变，如空洞的内部局部有突起，在诊断时较为困难，所以我们在实际工作中分歧较大，主要为肺癌和结核两种意见。

This case because some imaging findings are more like a malignant lesions, such as hollow internal local processes, at the time of diagnosis is difficult, so we in the practical work of the differences between the larger, mainly for lung cancer and tuberculosis two opinions.

本例影像学表现有2个特点（Imaging findings in this case has two characteristics）：

1、表现为左肺上叶尖后段的大片实变影，其内有多个无壁空洞及支气管树影，空洞初看好像似有壁结节，但仔细从整体上看空洞内壁绝大部分是光滑的，考虑结核主要依据这点；

1, the show is on the left lung tip in the back of the large area of consolidation, which have no wall cavity and multiple bronchial trees, empty at first glance seem like a wall nodule, but most careful overall hole wall is smooth, consider tuberculosis main basis;

2、病灶边缘模糊，周边有多发增殖灶，因此诊断上应该把结核放在首位。

2, focal edge blur, periphery have multiple focal proliferation, therefore should give top priority to TB diagnosis.

本例误诊为肺癌的原因可能是:考虑患者年龄较大，较大空洞内缘见壁结节，其实肺结核未坏死的纤维索条及血管影亦可在空洞内形成壁结节，如果能认识到病灶主体并非肿块而是大块实变，肿块内多发虫蚀样空洞以及周边有多发增殖灶、病变部位在结核的好发部位——上叶尖后段这个特点，就能得出较正确的诊断。

In this case the reason may be misdiagnosed as lung cancer: considering the older patients, bigger hole to see around the inner wall nodule, tuberculosis is not actually necrosis of fiber cable and vessels can be within the cavity wall nodule formation, if you can recognize the focal subject not bump but large pieces of consolidation, tumors in multiple worm hole corrosion sample multiple focal proliferation, lesion area and surrounding on tuberculosis good location - tip after the period of this characteristic, can obtain a correct diagnosis.

随着结核病发病率的增加，结核病的发病越来越不典型，影像表现亦不典型，如果在诊断中过分依赖某单一征象而忽略对影像的全面分析是误诊的主要原因。

With the increase of incidence of tuberculosis (TB), the incidence of tuberculosis (TB) less typical, is not a typical image performance, if too dependent on a single sign in the diagnosis and ignores the comprehensive analysis of the image are the main reasons of misdiagnosis.

本期试题：继发性肺结核的好发部位是？

A．上叶前段

B．上叶尖后段

C．中叶（舌段）

D．下叶前基底段

E．双叶各肺段