背景:杜拉血症是由杜拉氏杆菌引起的人畜共患疾病,一种影响人类和小型野生动物的高毒性细菌。它通过与受感染的动物直接接触或通过受污染的土壤间接传播,水或节肢动物叮咬(例如蜱)。图拉血症的原发性胸部表现很少见,因此,对临床医生的诊断挑战。
方法:我们报告了2020年10月至2022年2月在巴伐利亚州的一家肺部疾病诊所诊断出的6例仅胸部受累的图拉血症病例。
结果:所有患者在农村地区生活或活动,四个人报告了最近的蜱咬伤。所有患者均出现胸部淋巴结肿大和肺肿瘤或合并;所有患者均接受支气管镜检查,淋巴结EBUS-TBNA检查,还有三次肺活检.5例患者表现为支气管粘膜的炎性改变。主要组织学表现为坏死性上皮样肉芽肿,粒细胞浸润明显。所有病例均通过血清学阳性鉴定,5通过PCR(这里鉴定F.t.ssp.Holarctica)也来自活检。作为一线治疗,口服环丙沙星(5/6);在2/6例中,给予喹诺酮-利福平的组合。
结论:肺tularia血症可在蜱叮咬后发生,无胸腔外表现。在出现胸部淋巴结肿大和肺部合并以及暴露于户外活动增加的患者中,塔拉贫血应包括在诊断途径中。组织学上,中性粒细胞-粒细胞浸润的存在可能有助于将图拉血症与其他肉芽肿性感染区分开来,如肺结核。喹诺酮-利福平而不是静脉内庆大霉素的组合减少了两名患者的住院时间。
BACKGROUND: Tularaemia is a zoonotic disease caused by Francisella tularensis, a highly virulent bacterium that affects humans and small wild animals. It is transmitted through direct contact with infected animals or indirectly through contaminated soil, water or arthropod bites (e.g. ticks). Primary thoracic manifestations of
tularaemia are infrequent and, therefore, a diagnostic challenge for clinicians.
METHODS: We report six
tularaemia cases with exclusively thoracic involvement diagnosed in a clinic for pulmonary diseases in Bavaria between 10/2020 and 02/2022.
RESULTS: All patients lived or were active in rural areas, four reported a recent tick bite. All patients presented with thoracic lymphadenopathy and pulmonary tumours or consolidations; all underwent bronchoscopy with EBUS-TBNA of lymph nodes, three lung biopsies as well. Five patients showed inflammatory changes in the endobronchial mucosa. The main histological findings were necrotic epithelioid granulomas with remarkable granulocyte infiltration. All cases were identified by positive serology, five by PCR (here identification of F.t. ssp. Holarctica) from biopsy as well. As first-line therapy, oral ciprofloxacin was given (5/6); in 2/6 cases, a combination of quinolone-rifampicin was given.
CONCLUSIONS: Pulmonary
tularaemia may occur after tick bites and without extrathoracic manifestations. In patients who present with thoracic lymphadenopathy and pulmonary consolidations and who are exposed to increased outdoor activities, tularaemia should be included in the diagnostic pathway. Histologically, the presence of neutrophil-granulocyte infiltrations might help to distinguish
tularaemia from other granulomatous infections, e.g. tuberculosis. The combination of quinolone-rifampicin rather than i.v. gentamicin reduced length of hospital stay in two patients.