[The clinical analysis of chronic obstructive pulmonary disease patients complicated with nontuberculous mycobacterial pulmonary disease].

Objectives: Long-term use of inhaled corticosteroids (ICS) was reported as a risk factor for patients with chronic obstructive pulmonary disease (COPD) complicated with nontuberculous mycobacterial lung disease (NTM-LD). But it was not reported often in China. Methods: We conducted a retrospective analysis of patients who were diagnosed with COPD and NTM-LD in our department from January 1(st) 2017 to December 31(th) 2018. Results: This study consisted of 10 male and 5 female patients with a mean age of (66±7) years. The detailed clinical data and radiological images were reviewed systemically. There were 4 current smokers (26.7%) and 6 past smokers (40%). All cases were current ICS users, with a mean duration of (27.3±9.7) months, ranging from 3 months to 61 months. Among them, 8 cases (53.3%) used inhaled fluticasone and 7 cases (46.7%) used inhaled budesonide. Aggravated coughing (15 cases, 100%), expectoration (15 cases, 100%) and dyspnea (10 cases, 66.7%) were the common clinical manifestations, although fever was only reported in 4 cases (26.7%). All cases showed normal white blood cell count and lymphocyte count, and some of them (7 cases, 46.7%) showed elevated erythrocyte sedimentation rate and C-reactive protein. Most of them (14 cases, 93.3%) had normal TB-SPOT results. Multiple focal bronchiectasis (9 cases, 60%) and significant emphysema (12 cases, 80%) were the common manifestations of basic high-resolution CT (HRCT) prior NTM infection. The occurrence of bronchiectasis (15 cases, 100%), "tree in bud" sign (12 cases, 80%) and tiny cavities (8 cases, 53.3%) were the common HRCT abnormalities for the NTM-LD cases. According to the 2007's NTM-LD diagnosis criteria, most of them (13 cases, 86.7%) were diagnosed with positive sputum samples at least twice, and 2 cases were diagnosed with positive CT-directed bronchial alveolar lavage fluid. NTM-PCR analysis was performed routinely for the isolated NTM samples to identify the NTM species. Mycobacterium avium complex (MAC) was the most common NTM species (8 cases, 53.3%). After treatment with proposed anti-NTM strategies, most cases improved (9 cases, 60%), and some of them (4 cases, 26.7%) were cured and a few cases (2 cases, 13.3%) relapsed. Conclusions: When COPD patients treated with ICS showed aggravated cough, expectation and/or dyspnea, and new occurrence of bronchiectasis and/or "tree in bud" sign in the recent HRCT, the differential diagnosis of NTM-LD should be considered. Respiratory samples should be arranged for NTM cultures and PCR analysis as soon as possible. Earlier antimicrobial strategies according to the identified NTM species would improve the clinical outcomes.目的： 分析长期吸入糖皮质激素（激素）的慢性阻塞性肺疾病（慢阻肺）患者继发非结核分枝杆菌肺病的临床特点。 方法： 回顾性分析2017年1月至2018年12月在我院诊治的慢阻肺并发非结核分枝杆菌肺病患者的临床-影像学资料。共纳入有完整的临床-肺功能-胸部HRCT资料（基线及感染非结核分枝杆菌后）的慢阻肺患者15例，男10例，女5例，年龄平均（66±7）岁。 结果： 15例中仍吸烟者4例，已戒烟既往有吸烟史6例，5例无吸烟史。所有患者均正在使用吸入激素，其中氟替卡松8例，布地奈德7例；疗程3~61个月，平均（27±10）个月。咳嗽、咯痰增加（15/15）及呼吸困难加重（10/15）是常见的临床表现，但发热并不常见（4/15）。所有患者外周血白细胞及淋巴细胞计数均正常，部分ESR及C反应蛋白升高（7/15），绝大部分患者（14/15）外周血结核感染T细胞斑点试验正常。多数患者基线胸部HRCT有不同程度和形式的肺结构破坏，其中多灶性支气管扩张9例，明显肺气肿12例。发生非结核分枝杆菌感染后，胸部HRCT以新发支气管扩张（15/15）、"树芽征"（12/15）及小空洞影（8/15）多见。大部分经痰培养明确病原（13/15），仅2例经BALF培养明确诊断（2/15）。非结核分枝杆菌的菌种以鸟/胞内分枝杆菌为主（8/15）。结合菌种鉴定结果给予针对性抗感染治疗后，大部分好转（9/15），部分治愈（4/15），少数复发（2/15）。 结论： 长期吸入激素治疗的慢阻肺患者若出现咳嗽、咯痰及呼吸困难加重，但发热并不明显、复查胸部CT提示新发支气管扩张、"树芽征"时，需要排查结核或非结核分枝杆菌感染的可能，及时送检痰结核菌培养、菌种鉴定或DNA测序等，以尽早明确诊断、针对性抗感染治疗，改善患者的预后。.