脊柱結(jié)核的微生物學(xué)診斷課件

MicrobiologicaldiagnosisofspinaltuberculosisInternationalOrthopaedics(SICOT)(2012)脊柱結(jié)核的微生物學(xué)診斷AbstractPurpose

Thepurposeofthisstudywastoreviewtheclinicalfeaturesanddiagnosisofspinaltuberculosiscasesreportedintheliterature.Methods

AmedicalliteraturesearchintheMedlinePubmeddatabasewasundertakentoreviewtuberculosisspinalinfectionandextra-pulmonarytuberculosisdiagnosisimprovement.摘要目的：本研究的目的是回顧文獻(xiàn)已報(bào)道的脊柱結(jié)核病例的臨床特點(diǎn)及診斷。方法：在MEDLINEPubMed數(shù)據(jù)庫(kù)中進(jìn)行了醫(yī)學(xué)文獻(xiàn)檢索以便研究脊柱結(jié)核感染及肺外結(jié)核病診斷的改進(jìn)。Weintroducedthefollowingsearchitemsandbooleanoperators:"spinalinfection","spinaltuberculosisinfection","microbiologicaldiagnosisofspinaltuberculosis"and"spinaltuberculosisPCR."Singlecasesorserieswithoutmicrobiologicaldiagnosiswererejected.ManuscriptlanguagewasrestrictedtoSpanish,French,andEnglishversions.我們引用了以下的搜索項(xiàng)目和布爾運(yùn)算符：“脊柱感染”，“脊柱結(jié)核感染”，“脊柱結(jié)核的微生物學(xué)診斷”和“脊柱結(jié)核聚合酶鏈反應(yīng)?！蔽唇?jīng)微生物學(xué)診斷的單病例或系列研究被拒絕納入。手稿語(yǔ)言僅限于西班牙語(yǔ)，法語(yǔ)和英語(yǔ)版本。Pulmonarylocationcanbecomeapublichealthproblem.Previouslytreatedpatientsforothertuberculosislocations,incompletetreatments,orpooradherencecanchangetheM.tuberculosissensitivitypattern.Drugresistancetestbecomesamajorneedinthemicrobiologylaboratory.PCRdiagnostictechniquesadvancethediagnosisandincreasethesensitivityandspecificityrate.肺部結(jié)核病灶可以成為一個(gè)公共健康問(wèn)題。先前治療的其他部位結(jié)核病灶，不完全治療或依從性差的患者可以改變結(jié)核分枝桿菌的敏感性。耐藥性試驗(yàn)成為微生物學(xué)實(shí)驗(yàn)室中的主要需求。聚合酶鏈反應(yīng)診斷技術(shù)的進(jìn)展，提高了診斷的敏感性和特異性。IntroductionTheprincipalinfectioncausingdeathintheworldistuberculosis(TB).ItisestimatedtwobillionpeopleareinfectedwithTB,whocandevelopTBdisease[1].Theriskofdevelopingthediseasedependsonthepatient(hostcharacteristics)andthegeographicalprecedencebecauseofthedifferentincidenceofTBineachcountry.

引言結(jié)核病(TB)是世界上導(dǎo)致死亡的主要傳染病。據(jù)估計(jì)有20億人感染了結(jié)核菌，并發(fā)展成結(jié)核病。結(jié)核病的發(fā)病風(fēng)險(xiǎn)取決于病人（宿主特點(diǎn)）和地理位置，因?yàn)樵诿總€(gè)國(guó)家的結(jié)核病有不同的發(fā)病率。InastudymadeintheUnitedKingdom,theriskinthewhitepopulationincreaseswithagefrom0.8to10.9/100,000,whereas,theriskinpeoplefromtheIndiansubcontinentincreaseswithagefrom28.7to405.7/100,000;thus,theyrealisedthatanyoneofanyethnicgrouphasanincreasedriskof10–20times,butthisreducesafterfiveyearsintheUnitedKingdom[2].在英國(guó)進(jìn)行的一項(xiàng)研究顯示，白種人口的結(jié)核病發(fā)病風(fēng)險(xiǎn)隨著年齡的增大而增高，從0.8到10.9/10萬(wàn)；然而，在來(lái)自印度次大陸（主要在喜馬拉雅山以南直到印度洋一帶，包括印度、巴基斯坦、孟加拉等國(guó)家）等地區(qū)的人群中結(jié)核病的發(fā)病風(fēng)險(xiǎn)隨著年齡增高從28.7到405.7/10萬(wàn)。因此，他們認(rèn)識(shí)到，任何民族的每個(gè)人都有10-20倍的風(fēng)險(xiǎn)增加，但這風(fēng)險(xiǎn)在英國(guó)5年后就降低。Extrapulmonarytuberculosisaffects15–20%ofpatientswithTB.Themostcommonarepleuralandlymphaticdisease.SkeletalTBoccursin10%ofextrapulmonarymanifestations,ofwhichspinalTBaccountsforapproximately50%.ThisgivesanincidenceofbetweenoneandtwopercentforosteoarticularTBandhalftoonepercentforspinalTB[1,3].Mostpostoperativeinfectionsfollowingspinesurgeryarecausedbybacterialorganisms.結(jié)核病患者中肺外結(jié)核占有15–20%，最常見(jiàn)的是胸膜和淋巴管疾病。骨結(jié)核的發(fā)生率在肺外結(jié)核中占10%，而其中脊柱結(jié)核約占50%。這表明，骨關(guān)節(jié)結(jié)核的發(fā)生率為1-2%，其中脊柱結(jié)核的發(fā)生率約占一半。脊柱外科手術(shù)后的大多數(shù)術(shù)后感染是由細(xì)菌感染引起的。SpinalTBaccountsforonetothreepercentofallTBinfections[6].Spinaltuberculosisisthemostcommonandthemostseriousformoftuberculosislesionsintheskeleton.Atotalof101countriesreportednotificationsofnewcasesofextrapulmonaryTB(thesecountriesaccountedfor50%oftotalnotificationsofextrapulmonaryTB).Therewere195,002malecasesand180,310femalecases,givingamale:femaleratioof1:1.脊柱結(jié)核占所有結(jié)核感染的1-3%，脊柱結(jié)核是骨結(jié)核中最常見(jiàn)、最嚴(yán)重的一種形式。共有101個(gè)國(guó)家報(bào)道了肺外結(jié)核新發(fā)病例的通知（這些國(guó)家占肺外結(jié)核總通知的50％）。男性195002例，女性180310例，男：女比例為1:1。Theincidenceofpatientswithspinalinfectionhasbeenreportedtohaveincreased[7].Thisisprobablyaresultofanagingpopulation,easyaccesstobetterdiagnosticmethodsincludingmagneticresonanceimaging(MRI)andanincreaseintheprevalenceofimmunocompromisedhosts[8].Mostrecentstudieshighlighttheirappearanceinelderlypatients(meanageof50–60years)withaclearpredominanceofmales[9].發(fā)生脊柱感染的患者的報(bào)道逐漸增多，這可能是由于人口老齡化、易于獲得更好的診斷方法，如磁共振成像（MRI）和免疫功能低下患者的患病率增加等有關(guān)。最近的研究表明，在老年患者（平均年齡為50?60歲）具有明顯的優(yōu)勢(shì)。Mycobacteriumtuberculosisisthemostcommonorganismamongtheseareas.Accuratediagnosisisessentialinordertoeffectivelyeradicatetheinfectingorganisms.SubsequentmanagementofthediagnosedinfectionremainscontroversialwiththeNationalTuberculosisControlProgrammes[11].結(jié)核分枝桿菌是在這些地區(qū)中最常見(jiàn)的病原體。準(zhǔn)確的診斷是必要的，以有效地根除感染生物體。已經(jīng)診斷的感染性疾病的后期治療在國(guó)家結(jié)核病控制方案中仍有爭(zhēng)議。Tuberculosishasapropensitytospreadalongsofttissueplanes,particularlyanteriorlyundertheanteriorlongitudinalligament,involvingmultiplevertebrae,intimegivingtheso-called“aneurysmalsyndrome”(scallopingoftheanteriorvertebralmargins)[12].Tuberculosisdemonstratesavarietyofclinicalandradiologicalfindingsandshowsaknownpropensityfordisseminationfromitsprimarysite;therefore,itcanmimicanumberofdisorders.結(jié)核病具有沿軟組織平面?zhèn)鞑サ膬A向，特別是在前縱韌帶前下方，累及多個(gè)椎體，在此給予所謂的“動(dòng)脈瘤樣綜合征”（椎體前緣的扇形結(jié)構(gòu)）。結(jié)核病表現(xiàn)了各種臨床和影像學(xué)檢查結(jié)果，并顯示出一個(gè)已知的傾向：從它的病灶部位往外播散;因此，它可以相似許多病癥。Tubercularspinalepiduralabscessisusuallysecondarytotubercularspondylitis,butmayrarelydevelopbyhaematogenousspreadfromanyprimaryfocus[13].Thesymptomsoftuberculousboneandjointinfectionsarenonspecific,andtheclinicalcourseisoftenindolent,usuallyleadingtosignificantdelaysindiagnosisandresultantboneorjointdestruction.About50%ofthepatientswithboneandjointtuberculosishavechestradiographssuggestiveoftuberculousinfection,furtherobscuringthediagnosis[14].結(jié)核性脊椎硬膜外膿腫常繼發(fā)于結(jié)核性脊椎炎，但可能很少?gòu)钠渌l(fā)病灶通過(guò)血源性傳播途徑發(fā)展而來(lái)。骨與關(guān)節(jié)結(jié)核性感染的癥狀是非特異性的，其臨床病理過(guò)程往往是惰性的，通常導(dǎo)致診斷的顯著延誤和由此產(chǎn)生骨或關(guān)節(jié)的破壞。約50%的骨與關(guān)節(jié)結(jié)核患者胸片提示有結(jié)核性感染，從而進(jìn)一步模糊診斷。Differentiationbetweenpyogenicspondylodiscitis(PS)andtuberculousspondylodiscitis(TS)isessentialtodecideontheappropriatetherapeuticregimen.Theaimofthisstudywastocomparethecharacteristicsofthetwoformsofspondylodiscitis.TSwasfrequentlyassociatedwithactivetuberculosisofotherorgans(0%inPSvs.31.9%inTS),andlongerdiagnosticdelay(47.6daysinPSvs.106.3daysinTS)[15].區(qū)分化膿性椎間盤炎(PS)和結(jié)核性椎間盤炎(TS)之間的差異對(duì)決定適當(dāng)?shù)闹委煼桨付允侵陵P(guān)重要的。本研究的目的是比較這兩種炎性病變的特點(diǎn)。TS常伴有其他器官的活動(dòng)性結(jié)核病(PS為0％，TS為31.9％)，和較長(zhǎng)的診斷延遲時(shí)間(PS為47.6天，TS為106.3天)。Theclinicalnon-specificityofmycoticaneurysmorinfectivespondylitismakesdiagnosisintheaffectedpatientschallenging.Althoughneurologicaldeficitwasstatisticallysignificantinpatientswithspontaneousinfectivespondylitiswithmycoticaneurysm,thisuniqueclinicalcharacteristicwasalwaysnotedinlatestagesofinfectivespondylitis[16].真菌性動(dòng)脈瘤或感染性脊柱炎的臨床非特異性使受累患者的診斷具有挑戰(zhàn)性。雖然神經(jīng)功能缺損在患有自發(fā)感染脊柱炎及真菌性動(dòng)脈瘤的患者中有統(tǒng)計(jì)學(xué)意義，但這種獨(dú)特的臨床特征往往是在感染性脊柱炎的晚期才能發(fā)現(xiàn)。Ineithercase,painfulsymptomsofpatientscanberelievedwithmedicaltreatment.Ifthereisatuberculosishistory(inthepatientorafamilymember),nightsweatsandweightloss,detailedMRIinvestigationsfocusingonthelesionarenecessaryforanearlydiagnosisandallowmedicaltherapy.Thediagnosisofspinaltuberculosis(ST)isdifficultanditcommonlypresentsatanadvancedstage.Themanagementandfollow-upiscomplicatedbyalackofguidanceontheappropriateuseandinterpretationofspinalmagneticresonancestudies(MR)[5].在這兩種情況下，患者的疼痛癥狀可經(jīng)內(nèi)科治療得以緩解。如果有結(jié)核病史(在病人或一個(gè)家庭成員)，盜汗和體重減輕，以病灶為中心的詳細(xì)的MRI檢查對(duì)早期診斷和行藥物治療而言是必須的。脊柱結(jié)核（ST）的診斷是很困難的，它通常呈現(xiàn)在晚期階段。治療和隨訪是復(fù)雜的，因?yàn)槿狈顾璐殴舱?MR)研究的正確使用指導(dǎo)和解釋Themicrobiologicaldiagnosisisaprobleminsomepartsoftheworld.Forexample,inthebusiestclinicsinCapeTown,upto46%ofpulmonaryTBcasesarenotconfirmedbacteriologically,andSouthAfricahasoneofthehighestrateoftuberculosisinfection[1].Positivecultureswerereportedinonly27(62%)of47patientswithtuberculousspondylitis[18].Nevertheless,manyspinaltuberculosiscasesarediagnosedaftertheprogressivedegenerativeprocess.Thesecasesmustbetreatedsurgically[19].世界上有些地區(qū)，微生物學(xué)診斷是一個(gè)問(wèn)題。例如，在開(kāi)普敦最繁忙的一個(gè)診所，將近有46%的肺結(jié)核病人沒(méi)有經(jīng)過(guò)細(xì)菌學(xué)確診，而南非有最高的結(jié)核感染率。研究報(bào)道47例結(jié)核性脊柱炎患者中，只有27例（62%）培養(yǎng)結(jié)果陽(yáng)性。然而，許多脊柱結(jié)核病例在進(jìn)行性退變期后才得以診斷，這些病例必須手行術(shù)治療。TherecentdemonstrationthatnucleicacidamplificationtechniquesarerapidandsensitivehasmodifiedstrategiesforthedetectionofMycobacteriumtuberculosis.Sincetheapplicationofthepolymerasechainreaction(PCR)inthediagnosisofTB,diagnosticprotocolsusingvaryingmethodsofDNApurificationanddifferentM.tuberculosistargetsequenceshavebeenevaluated[23,24].近期的研究表明，快速、靈敏的核酸擴(kuò)增技術(shù)對(duì)結(jié)核分枝桿菌的檢測(cè)有了新的改進(jìn)策略。由于聚合酶鏈反應(yīng)(PCR)在結(jié)核病診斷中的應(yīng)用，采用不同的DNA純化方法和不同結(jié)核病目標(biāo)序列的診斷方法進(jìn)行了評(píng)價(jià)。Earlydiagnosisfollowedbypropermedicationisessentialtopreventbothmorbidityandmortality.PCRisagoodoptionfortherapiddiagnosisoftuberculosis[22].Althoughtheconventionaltechniqueofdirectsmearexaminationischeapandeasytoperform,itslowsensitivityisamajordrawback.Ontheotherhand,themolecular-baseddiagnosisbyPCRtechniqueisfasterandmoresensitive[25].Serologicaltestsarefrequentlyusedindevelopingcountries,butalotofworkisyettobedonetoconsiderthemoptimal[26].早期診斷及適當(dāng)?shù)乃幬镏委熓潜夭豢缮俚?，以防止發(fā)病率和死亡率。聚合酶鏈反應(yīng)(PCR)是結(jié)核病快速診斷的一種很好的選擇，雖然直接涂片檢查的常規(guī)技術(shù)是價(jià)格低并易于執(zhí)行，但它的低靈敏度是一個(gè)主要的缺點(diǎn)。另一方面，分子診斷技術(shù)更快速、更靈敏，在發(fā)展中國(guó)家，經(jīng)常使用血清學(xué)檢查，但許多工作有待完成，以考慮它們?yōu)樽罴逊椒?。MethodsAmedicalliteraturesearchinPubMedMedlinedatabasewasundertakentoreviewspinaltuberculosisinfectionandextra-pulmonarytuberculosisdiagnosisimprovement.Ononehand,weselectedstudiestoreviewthelengthofsymptomsbeforediagnosis,concomitantpulmonaryTB,successoftreatment,microbiologicaldiagnosis,asZiehl-Neelsenstainingresultsandresistantstrains.方法在MEDLINEPubMed數(shù)據(jù)庫(kù)中進(jìn)行了醫(yī)學(xué)文獻(xiàn)檢索以便研究脊柱結(jié)核感染及肺外結(jié)核病診斷的改進(jìn)。一方面，我們選擇了相關(guān)文獻(xiàn)以復(fù)習(xí)診斷前癥狀持續(xù)時(shí)間、伴有肺結(jié)核、治療成果、微生物學(xué)診斷及抗酸染色結(jié)果和耐藥菌株等內(nèi)容。Ontheotherhand,wechosestudiesaboutthesensitivityofmolecularbiologytechniquesforthediagnosisofspinalTB.Weintroducethefollowingsearchandbooleanoperatorsitems:"spinaltuberculosisinfection","microbiologicaldiagnosisofspinaltuberculosis"and"spinaltuberculosisPCR".Nopublicationdaterestrictionwasapplied.ManuscriptlanguagerestrictionwastoEnglish,French,andSpanishversions.另一方面，我們選擇了用于脊柱結(jié)核診斷的分子生物學(xué)技術(shù)之敏感性的相關(guān)文獻(xiàn)。我們引用了以下的搜索項(xiàng)目和布爾運(yùn)算符：“脊柱感染”，“脊柱結(jié)核感染”，“脊柱結(jié)核的微生物學(xué)診斷”和“脊柱結(jié)核聚合酶鏈反應(yīng)”。沒(méi)有設(shè)置發(fā)布日期限制。手稿語(yǔ)言僅限于英語(yǔ)、法語(yǔ)和西班牙語(yǔ)版本。Inclusioncriteriaofstudies:Datafromcaseseriesstudiesormeta-analysisthatprovidedspinalTBcasesdiagnosedbymicrobiologicaltests.Studiesthatprovideddataonthemicrobiologicaldiagnosisofspinaltuberculosis.Exclusioncriteria:Studiesperformedonlyinthepaediatricpopulation.Itemswithuniquecasesorcasereports.研究納入標(biāo)準(zhǔn)：①病例系列研究或薈萃分析的數(shù)據(jù)，其能提供通過(guò)微生物學(xué)檢查診斷的脊柱結(jié)核病例。②能提供脊柱結(jié)核微生物學(xué)診斷數(shù)據(jù)的研究。排除標(biāo)準(zhǔn)：①僅在兒童人群中進(jìn)行的研究。②具有獨(dú)特病例或病例報(bào)告的項(xiàng)目。Itisrelevantthat20–40%ofpatientshaveactivetuberculosisatothersites,sothediagnosiscanbeperformedonclinicalspecimensassputum,urine,orlymphnodeaspirate[9]andwealsobelievethatitisimportanttocheckthatnoothermicroorganismsareimplicated[16].TheTBdiagnosis,andspecificallyspinalTB,shouldbebasedonclinicalandserologicaltesting(Mantouxtest,I,IFN-γ,whicharemorespecificforM.tuberculosisthanPPD,becausetheyappearinM.tuberculosisgenes,butarenotpresentinBCGstrainsprovidedforvaccination)[2].相關(guān)的20–40%患者有其他部位的活動(dòng)性結(jié)核病，因此對(duì)臨床標(biāo)本如痰液、尿液和淋巴結(jié)穿刺等進(jìn)行診斷。我們也認(rèn)為，重要的是要檢出沒(méi)有其他微生物感染。結(jié)核病的診斷，特別是脊柱結(jié)核的診斷應(yīng)根據(jù)臨床和血清學(xué)檢測(cè)（結(jié)核菌素試驗(yàn)，I，IFN-γ等對(duì)結(jié)核分枝桿菌而言比PPD試驗(yàn)更有特異性，因?yàn)樗鼈兂霈F(xiàn)在結(jié)核分枝桿菌基因中，但不存在于疫苗接種用的BCG菌株中）。OneofthemainchallengesinthemicrobiologicaldiagnosisofTBhasalwaysbeenthetimeforcultureofM.tuberculosis.Microbiologicaldiagnosisisimportantasitprovidesaetiologyandthefoundationforadequateantibiotictreatment.Newtechniquesprovidepulmonaryandextrapulmonarytuberculosisdiagnosis.Aetiologyandearlydiagnosismustbeensuredtocommencepromptandspecifictreatment.結(jié)核病微生物學(xué)診斷的主要挑戰(zhàn)之一，一直就是培養(yǎng)結(jié)核分枝桿菌所需要的時(shí)間。微生物學(xué)診斷是重要的，因?yàn)樗鼤?huì)提供病因和足夠的抗生素治療基礎(chǔ)。新技術(shù)能夠診斷肺結(jié)核及肺外結(jié)核，必須保證找出病因和早期診斷以便開(kāi)始及時(shí)和具體的治療。PCRisverysuccessfulfortherapiddiagnosisofseveralinfectiousdiseases.AchievingthistestforTBdiagnosisisamajortarget.Thiswillallowanearlydiagnosis,earliertargetedtreatmentandpreventionofthespreadofthedisease,andinthecaseofTB,apublichealthproblem.EventodaythesetestsarenotroutinelyusedforTBmanagement,yetmanytestsofthistypeareperformedinmanypartsoftheworld,asinIndia,withmorethan1.5milliontests[26].PCR是在幾種感染性疾病的快速診斷中非常成功的，實(shí)現(xiàn)結(jié)核病診斷的這種試驗(yàn)是一個(gè)主要目標(biāo)。這將允許有早期診斷、早期靶向治療和預(yù)防疾病的傳播，就如公共健康問(wèn)題的結(jié)核病等。到今天，這些測(cè)試并不常規(guī)用于結(jié)核病的治療，但這種類型的測(cè)試是已在世界許多地方進(jìn)行，如在印度，有超過(guò)150萬(wàn)的測(cè)試。ImagingtestssuchasCTandMRIareveryusefulinspinalTBdiagnosis.DescribedbyPolleyetal.[1],mayalsohelptodeterminedifferentlocationsinthespine,asinmanypatientsthereisnosinglelocusbutseveral.Itisalsoimportanttomonitordiseaseprogressionandtreatment[8].Providingorthopaedicphysiciansthemicrobiologicaldiagnosisremainsachallenge.Thedelayinthemicrobiologicalresultsinthisdiseasedelaysthediagnosisand,therefore,thetreatment.Eventoday,mostlaboratoriesdonothavePCRtechniquestofacilitatethediagnosis,asseeninthestudiesanalysed[31,32].影像學(xué)檢查如CT和MRI是在脊柱結(jié)核的診斷中非常有用的。Polley等人描述，影像學(xué)檢查也能有助于確定脊柱病灶的不同位置，因?yàn)樵谠S多患者中病灶為多節(jié)段的，而不是單個(gè)的。監(jiān)測(cè)疾病進(jìn)展和治療也很重要。提供骨科醫(yī)師微生物學(xué)診斷仍然是一個(gè)挑戰(zhàn)。疾病微生物學(xué)結(jié)果的延遲將會(huì)耽誤疾病的診斷，甚至治療。據(jù)研究分析可知，如今大多數(shù)實(shí)驗(yàn)室沒(méi)有具備聚合酶鏈反應(yīng)技術(shù)以方便診斷。Nowadays,TBtreatmentbasedonPCRtechniquesisincreasinglycommon,evenwhenculturesorstainingresultsarenegative(cultureisstillconsideredthegoldstandardtest).PCRsensitivitysometimesimprovescultureandstaining;therefore,weconsiderPCRasaveryusefultool.However,theFDAonlyrecommendsrespiratoryspecimensfo