CAJ | 학술논문

目的探讨鸟分枝杆菌复合群(MAC)肺病的诊断及治疗,为提高该病的临床诊治水平提供依据. 方法分析我院诊治的经诱导痰培养结合临床确诊为MAC肺病合并慢性肾脏病4期的1例老年患者临床资料,并复习国内外相关文献. 结果 80岁重度营养不良老年男性患者1例,进行性体质量下降伴乏力、盗汗,体质量仅43～44 kg,胸部CT表现为双肺多发小结节、小斑片影、磨玻璃影,PET/CT表现为代谢活性增高的结节及斑片影,约4年病史.经支气管镜检查肺泡灌洗液(BALF)培养阴性,经高渗盐水诱导咳痰,痰培养鉴定为MAC.患者肾小球滤过率(GFR)左肾9.0ml/min,右肾18.8 ml/min,选择治疗药物困难,常规的抗结核药物低度-高度耐药,加用莫西沙星治疗肾功能不全加重而停用,选用阿奇霉素0.25 g/d、3次/周,利福喷汀0.3 g/d、2次/周,乙胺丁醇0.375 g/d、3次/周治疗,联合母牛分枝杆菌疫苗(微卡)免疫治疗病情趋于稳定. 结论 PET/CT 鉴别肺结核及MAC肺病无意义；合并严重肾功能不全的低体质量的老年MAC肺病患者,治疗困难,应采取个体化治疗,积极改善患者营养状态,并辅以增强免疫治疗；同时应在密切观察不良反应的情况下慎重选择抗MAC药物,可以取得较为满意的临床效果.
목적 탐토조분지간균복합군(MAC)폐병적진단급치료,위제고해병적림상진치수평제공의거. 방법 분석아원진치적경유도담배양결합림상학진위MAC폐병합병만성신장병4기적1례노년환자림상자료,병복습국내외상관문헌. 결과 80세중도영양불량노년남성환자1례,진행성체질량하강반핍력、도한,체질량부43～44 kg,흉부CT표현위쌍폐다발소결절、소반편영、마파리영,PET/CT표현위대사활성증고적결절급반편영,약4년병사.경지기관경검사폐포관세액(BALF)배양음성,경고삼염수유도해담,담배양감정위MAC.환자신소구려과솔(GFR)좌신9.0ml/min,우신18.8 ml/min,선택치료약물곤난,상규적항결핵약물저도-고도내약,가용막서사성치료신공능불전가중이정용,선용아기매소0.25 g/d、3차/주,리복분정0.3 g/d、2차/주,을알정순0.375 g/d、3차/주치료,연합모우분지간균역묘(미잡)면역치료병정추우은정. 결론 PET/CT 감별폐결핵급MAC폐병무의의；합병엄중신공능불전적저체질량적노년MAC폐병환자,치료곤난,응채취개체화치료,적겁개선환자영양상태,병보이증강면역치료；동시응재밀절관찰불량반응적정황하신중선택항MAC약물,가이취득교위만의적림상효과.
Objective To study the diagnosis and treatment of Mycobacterium avium complex lung disease with severe renal insufficiency,and to provide a basis for improving the clinical diagnosis and treatment of MAC lung disease with severe renal insufficiency.Methods Clinical data of an elderly patient with MAC lung disease confirmed by induced sputum culture and complicated with chronic kidney disease (CKD 4) was reported.The related literatures at home and abroad were reviewed.Results A male patient aged 80 years with poor nutrition was suffering from progressive weight loss,exhaustion and night sweats.His weight was only 43-44 Kg.Chest CT showed that multiple small nodules,small spot pieces of shadow and ground glass shadows in bilateral lung tissues.PET/CT indicated that spot pieces and nodules with metabolic activity in high performance.Bronchoalveolar lavage fluid (BALF) inspection was negative.MAC was identified by induced sputum culture through high permeability brine induced sputum.It was difficult to choose drugs for the treatment of MAC lung disease due to his poor kidney function [GFR of left kidney:9.0 ml /min,GFR of right kidney:18.8 ml/min].Conventional anti-mycobacterium drugs showed a low to high resistance to MAC.Moxifloxacin was discontinued for renal insufficiency.His condition was stable after choosing trimodality therapy including azithromycin 0.25 g/d tiw,rifapentine 0.3 g/d biw,ethambutol 0.375 g /d tiw and the joining immunotherapy.Conclusions PET/ CT is not useful in identifying tuberculosis and MAC lung disease.The treatment of MAC lung disease is difficult in elderly patients with severe renal insufficiency and low weight.Individual therapy combined with immunotherapy and improving the nutrition state is a good choice for the treatment of MAC lung disease in elderly patients with severe renal insufficiency.The anti-MAC drugs should be carefully selected and the adverse reactions should be closely observed in order to obtain the satisfactory clinical results.