矽肺合并机化性肺炎119例临床诊断与治疗
Clinically diagnosing and treating 119 cases of silicosis with organizing pneumonia
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摘要:
背景 矽肺与机化性肺炎合并发生罕见报道，临床医生对其认识不足，经常导致漏诊及误诊。
目的 探讨矽肺合并机化性肺炎的临床、影像及病理特点。
方法 回顾性分析2012年3月至2018年1月间经福建医科大学附属泉州第一医院确诊的119例矽肺合并机化性肺炎患者的临床资料，对其临床表现、实验室检查、影像学检查、病理学检查、治疗及预后进行综合分析。
结果 119例患者中，男性116例，女性3例；平均年龄（48.7±8.8）岁。患者均为石材加工工人，平均粉尘接触史为（30.0±7.1）年。最常见的症状分别为咳嗽（95.8%）、咳痰（87.4%）、发热（71.4%）、气喘（66.4%），最常见的体征为湿性啰音（60.5%）。实验室检查结果为血沉加快（66.6±26.6）mm/h、血C-反应蛋白升高（110.8±73.0）mg/L、血神经元特异性烯醇化酶升高（中位数为28.19 μg/L）、氧合状况差（氧合指数中位数为214 mmHg）。全部患者均可见典型的矽肺影像学表现。此外，CT表现为多发片状、斑片状渗出实变影，以双侧性及下叶分布为主，并沿支气管分布。病理活检的阳性率为78.4%。病理学表现为细支气管间隔增宽并纤维化，细支气管及肺泡腔内见成纤维细胞增生性栓子，栓子内可见粉尘沉积，Masson染色示机化结缔组织呈蓝色。119例患者均给予全身糖皮质激素治疗，治疗后1个月进行疗效评价：98例患者病情明显好转，占82.3%；19例患者部分好转，占16.0%；2例患者病情进行性加重、死亡，占1.7%。经4~74个月（中位数为14个月）随访，35例患者总共出现85例次复发，复发患者再次给予糖皮质激素治疗仍然有效。
结论 矽肺合并机化性肺炎缺乏特异性表现，易误诊为肺部感染性疾病，确诊需综合临床、影像、病理进行分析。糖皮质激素治疗对其疗效好，但易复发。
Abstract:Background The incidences of silicosis co-occurring with organizing pneumonia are rarely reported and ofen misdiagnosed due to insufcient understanding by clinicians.
Objective This article aims to explore the clinical, radiological, and pathological features of silicosis complicated with organizing pneumonia.
Methods The clinical manifestations, laboratory tests, radiological images, pathological features, treatment, and prognosis were retrospectvely analyzed in 119 silicosis with organizing pneumonia cases from March 2012 to January 2018 in First Hospital of Quanzhou Afliated to Fujian Medical University.
Results There were 119 patients including 116 males and 3 females with a mean age of (48.7±8.8) years. All patents were stonecuters with a mean occupatonal silicon dioxide partcles exposure history of (30.0±7.1) years. The main clinical manifestatons were cough (95.8%), sputum production (87.4%), fever (71.4%), dyspnea (66.4%), and moist rales (60.5%). The results of laboratory tests showed elevaton of erythrocyte sedimentaton rate(66.6±26.6) mm/h, serum level of C-reactve protein(110.8±73.0) mg/L, and neuron-specifc enolase (median, 28.19 μg/L), as well as moderate or severe hypoxemia (median oxygenaton index, 214 mmHg). All patents showed typical radiological images of silicosis. The results of CT scans showed multple patchy alveolar opacites, usually bilateral and in lower lobe, with bronchial distribution. The positive rate of lung biopsy was 78.4%. Histologically, widened bronchial septa and pulmonary intersttal fbrosis were noted in all patents; polypoid growth of granulaton tssues with silicon dioxide partcles depositon were presented within small airways and alveolar spaces; with Masson staining, organizing fbers were found blue. All patents received glucocortcoid therapy, and the therapeutc effects were evaluated 1 month afer the treatment:98 patents (82.3%) achieved a complete response, 19 patents (16.0%) achieved a partal response, and 2 patents (1.7%) died of progressive aggravaton. Moreover, 35 patents experienced 85 relapses over a follow-up of 4-74 months (median, 14 months), and dramatc response to resumed therapy was observed in the relapse cases.
Conclusion Silicosis complicated with organizing pneumonia has no specifc manifestatons, and is ofen misdiagnosed as infectous pneumonia, requiring comprehensive diagnosis based on the clinico-radiologic-pathologic features. Glucocortcoid treatment is effectve, though some patents have relapses.
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