Study On Etiology And Clinical Characteristics Of Patients With Recurrent Lung Disease After Lung Structural Damage Caused By Tuberculosis

BackgroundTuberculosis is an ancient disease,but so far it has still been a major public health problem in the world.Although cure rate for pulmonary tuberculosis is over 85%now,many studies have shown that most patients had been delayed before consulting and diagnosis.So many patients would encounter irreversible pathological damage in the progress of occurrence,development and treatment of tuberculosis.The residual lesion images would present permanently even if the patient with pulmonary tuberculosis had been cured.The patient,of which pulmonary tuberculosis was cured but more than one lung segment were damaged,was not uncommon example in the clinic.On the one hand,the patient’s first awareness may be the recurrence of tuberculosis when he is suffering the symptoms of cough and sputum once again;on the other hand,the clinician is likely to habitually consider the patient to be a case with pulmonary tuberculosis because he had suspicious symptoms of tuberculosis such as cough and sputum,image of residual lesions caused by tuberculosis,coupled with a history of tuberculosis.It was not uncommon that we came across this kind of patient of misdiagnosis and mistreatment in clinical work.Unfortunately,there were not much research on this so far,not to mention an in-depth understanding.As to the concept of lung structure damage involved over one lung segment was not accepted except for tuberculosis destroyed lung（TDL）in the field of tuberculosis,we intend to descriptively study its etiology and clinical characteristics,which may be peripheral but helpful to comprehensive understanding on the subject.Objectives1.To comprehensively explore the factors of the occurrence and development of pulmonary disease for patient with lung structural damage caused by tuberculosis.2.To obtain improving grasp on the clinical characteristics of this kind of patients.MethodsThree hundreds and five patients with lung structural damage（Chest CT showed at least one damaged lung segment）after cured pulmonary tuberculosis,who were hospitalized in Guangzhou Chest Hospital due to cough and sputum from January 2018to December 2018,were registered.The data,including etiology,immune status,nutritional status,basic disease,tuberculosis history,symptoms and signs,inflammatory characteristics,lung function testing,flexible fiberoptic bronchoscope,CT image and other information were collected from Picture Archiving and Communication System（PACS）,Electronic Medical Record System,Laboratory Information System(LIS]and Tuerculosis Biobank Information System.Then the above data were analyzed statistically in descriptive index including frequency distribution,percent composition,quartile,mean,standard deviation and statistical inference were performed by chi-square test,analysis of variance and rank-sum test.Results1.Disease diagnosis and characteristics of gender and age.There were 148 cases with pulmonary infection,88 cases with pulmonary tuberculosis,40 cases with pulmonary aspergillosis and 29 cases with non-tuberculous mycobacterial lung disease（NTM lung disease）among 305 patients.Their percentage composition were 48.52%,28.85%,13.11%and 9.51%respectively.Incidence in male were much more than that in female.The elder between 50-70 year old had a high incidence in male while it was sporadic at various ages in female.2.The effect on the occurrence of these diseases from tuberculosis history and others basic diseases.The longer the history of tuberculosis,the greater the probability of suffering from these four lung diseases;the more times of the history of tuberculosis,the higher the incidence of pulmonary tuberculosis,pulmonary aspergillosis and NTM lung disease.These diseases（for example bronchiectasis,hypertension,diabetes,chronic obstructive pulmonary disease）had great effect on the occurrence of these diseases.3.Evaluation of integrated immune status and nutritional status.Their immunity were lower than that of healthy in general because the counts of CD4+T lymphocytes were under normal in nearly 50%of patients and that of CD8+T lymphocytes were under normal from 14%to 34%of patients in various diseases.Their nutritional status is also poor because A/G were under normal in above 50%of patients.4.Logistic regression analysis of four diseasesThe pulmonary infection group was set as the control group.Compared with the control group,the incidence of pulmonary tuberculosis was related to the basic bronchiectasis and the decrease of albumin.Compared with the pulmonary infection group,the pulmonary aspergillosis group showed that COPD,basic bronchiectasis diseases and the decrease of total protein were the related factors.NTM lung disease was compared with the lung infection group,indicating that the decrease of albumin was the related factor of the pathogenesis.5.General analysis of symptoms and signs of patients.Patients generally had cough and sputum symptoms,of which nearly 1/3 of lung infections have above 50ml sputum per day.The above 30%of patients had hemoptysis of less than 100 ml per day and hemoptysis occurred in 95%of 40 patients with pulmonary aspergillosis.The fever occurred in 20%of patients and high fever above39℃occurred only in patients with lung infection.The rales were be heard in about35%of patients and their anatomical site lied in the posterior segment+anterior segment of the left upper lobe in about half of patients.Compared with pulmonary infection group and tuberculosis group,there were significant differences in hemoptysis symptoms and lung rales of pulmonary aspergillosis group（P<0.0083）.6.Analysis of the main index of infection detection,blood gas analysis,lung function detection.From white blood cell count,neutrophil ratio,C-reactive protein,procalcitonin,the patients above the normal reference interval accounted for 28.85%,47.21%,58.65%and 46.94%in the detected patients,respectively.The 4 types of patients all had comparable signs of infection,but the differences between the rates of various cases had statistical significance.There was a significant difference in the ratio of neutrophils between the aspergillosis group and the tuberculosis group（P<0.0083）.Compared with tuberculosis group,there was a significant difference in the proportion of CRP increase in NTM group（P<0.0083）.The abnormal rates of oxygen saturation（O₂SAT）,oxygen partial pressure（PO₂）,alveolar arterial oxygen partial pressure difference（Aa DO₂）and carbon dioxide partial pressure（PCO₂）were 3.99%,39.13%,80.80%,and 66.67%,respectively.These data implied that most of patients often had aerobic insufficiency,carbon dioxide retention,etc.The quantitative analysis of blood gas showed that there were different oxygenation disorders in these patients with lung involvement.Of 61patients who had pulmonary function examination,FEV1/FVC<70%accounted for60.56%.Compared between the pulmonary infection group and the aspergillosis group,the difference between FEV1 and FEV1/FVC was statistically significant（P<0.0083）.7.Bronchial examinationThe four types of bronchial stenosis of hyperemic edema type,granulation proliferative type,scar stenosis type,and softened wall type were observed.Bronchial stenosisare occurred in 57.5%patients with pulmonary aspergillosis and 77.5%patients with tuberculosis.The proportion of stenosis of from moderate to severe was relatively high in patients with tuberculosis while that of stenosis of from mild to moderate was more common in patients with pulmonary aspergillosis.The most of anatomical site of stenosis lied in the posterior segment+anterior segment of the left upper lobe in patients with pulmonary aspergillosis.8.CT image examinationThe main image included increased density imaging,calcification,pulmonary bulla,tracheal deviation,thick-walled cavity,pleural effusion,crescent sign,etc.And they accounted for 75.74%（231/305）,45.90%（140/305）,43.28%（132/305）,41.31%（126/305）,9.18%（28/305）and 3.28%（10/305）of all patients.CT images of various diseases such as cavitation,increased density,calcification,pulmonary bullae,pleural effusion,and tracheal migration had their own characteristics in general,but crescent signs occurred in 90%of patients with pulmonary aspergillosis.The difference between pulmonary infection group and tuberculosis group was statistically significant（P<0.0083）.Conclusions1.The current lung disease after lung structural damage caused by tuberculosis can be caused by a variety of pathogens such as Mycobacterium tuberculosis,non-tuberculous mycobacteria,respiratory pathogens and fungi.Bronchiectasis,COPD,albumin and total protein are the influencing factors of different causes.2.These patients with lung structural damage（Chest CT showed at least one damaged lung segment）after cured pulmonary tuberculosis may have different degrees of fever,lung rales,insufficient oxygen supply,carbon dioxide retention,oxygenation disorders,obstructive ventilation disorders,bronchial stenosis,signs and pathological conditions.From CT image,main image include dcavitation,increased density,calcification,pulmonary alveoli,pleural effusion,and tracheal deviation,but each has its own characteristics.It is essential to comprehensively think and consider.