흉막 결핵의 진단에 있어서 흉수 검체양에 따른 중합효소연쇄반응 검사의 민감도 = Sensitivity of Polymerase Chain Reaction for Pleural Tuberculosis according to the Amount of Pleural Effusion Specimens

국문 초록 (Abstract)

연구배경: 결핵성 흉막염의 진단에 있어서 흉수에 대한 중합효소연쇄반응 검사는 매우 낮은 민감도를 보였으며, 이는 흉수 내의 결핵균의 수가 적은 데에 기인하는 것으로 추정된다. 이번 연구에서는 흉수의 검체양을 증가시켰을 때 결핵성 흉수에 대한 중합효소연쇄반응 검사의 민감도가 향상되는지를 알아보고자 하였다. 방법: 결핵성 흉막염에 대한 감별 진단이 필요하였던 53명의 환자에 대하여 전향적인 연구를 시행하였다. 각각의 환자로부터 얻은 흉수를 10 ml, 25 ml, 50 ml로 양을 달리 하여 결핵균에 대한중합효소연쇄반응 검사를 시행하였으며, Cobas Amplicor MTB (Roche Diagnostic Systems)를 이용하였다. 결핵성 흉막염은 흉수에서 결핵균이 배양된 경우, 흉막 생검에서 결핵이 진단된 경우, 가래에서 결핵균이 배양된 경우 및 기타 원인이 배제된 상태에서 임상적으로 결핵성 흉수가 의심되며 항결핵제 투약으로 흉수가 호전된 경우를 포함하였다. 결과: 53명의 환자 중 26명이 결핵성 흉막염으로 진단되었다. 흉수에 대한 항산균 바름질, 결핵균 배양, 아데노신 디아미나아제 측정 및 흉막 생검의 민감도는 각각 3.8%, 15.4%, 88.5%, 84.6%이었다. 10 ml, 25 ml, 50 ml의 흉수를 이용한 결핵균 중합효소연쇄반응 검사는 각각 3명(11.5%), 4명(15.4%), 3명(11.5%)에서 양성이었으며, 통계적으로 유의한 차이를 보이지 않았다(p>0.05, symmetry exact 검사). 결론: 결핵균의 수가 극히 적을 것으로 예상되는 흉수 등의 검사물에 대해서는 결핵균 중합효소연쇄반응 검사의 임상적 유용성이 극히 제한적이며, 검사물의 양을 증가시키더라도 민감도는 향상되지 않는다.

다국어 초록 (Multilingual Abstract)

Background: For the diagnosis of pleural tuberculosis, polymerase chain reaction (PCR) of pleural effusion specimens has shown very low sensitivity, which might be due to the small number of bacilli in the samples. The purpose of this investigation is to determine whether the sensitivity of PCR testing can be improved when increasing the amount of pleural effusion specimens. Methods: We prospectively analyzed pleural effusion specimens obtained from 53 patients for whom the exclusion of the possibility of tuberculous pleural effusion was necessary. We performed Mycobacterium tuberculosis PCR testing using the Cobas Amplicor MTB test (Roche Diagnostic Systems) with three different amounts (10ml, 25ml, and 50ml) of pleural effusion specimen in each patient. Pleural tuberculosis was defined as having one of the following: culture-positive pleural fluid sample, histopathologic finding consistent with tuberculosis on pleural biopsy, culture-positive sputum specimen, and/or positive response to anti-tuberculous medication without other possible causes of pleural effusion. Results: Of the 53 patients, 26 received the diagnosis of pleural tuberculosis. The sensitivities of AFB smearing, Mycobacterium tuberculosis culture of pleural effusion specimen, pleural biopsy, and measurement of ADA were 3.8%, 15.4%, 84.6%, and 88.5%, respectively. The results of PCR testing were positive for 3 (11.5%), 4 (15.4%), and 3 (11.5%) of the 26 patients when using 10ml, 25ml, and 50ml of pleural effusion specimens, respectively. These results did not show a statistically significant difference in the sensitivity of PCR testing when increasing the amount of pleural effusion samples (p>0.05, symmetry exact test). Conclusion: For specimens such as pleural effusion, in which the bacillary load is very low, the clinical utility of PCR testing seems highly limited with the kits designed for the diagnosis of pulmonary tuberculosis. An increased amount of pleural effusion sample does not improve the sensitivity of PCR testing. (Tuberc Respir Dis 2007; 62: 184-191)

참고문헌 (Reference)

1 "Transmission of Mycobacterium tuberculosis from patients smear- negative for acid-fast bacilli" 353 : 444-449, 1999

2 "The clinical utility of polymerase chain reaction for the diagnosis of pleural tuberculosis" 41 : 660-666, 2005

3 "Rapid diagnosis of tuberculosis in various biopsy and body fluid specimens by the AMPLICOR Mycobacterium tuberculosis polymerase chain reaction test" 113 : 1190-1194, 1998

4 "Rapid diagnosis of pleural tuberculosis by polymerase chain reaction" 152 : 1977-1981, 1995

5 "Pleural fluid and peripheral blood lymphocyte function in tuberculosis" 932-3,

6 "Operative and pathologic findings in twenty-four patients with syndrome of idiopathic pleurisy with effusion" 473-502, amrevtuberc1955;71

7 "Molecular genetic methods for diagnosis and antibiotic resistance detection of mycobacteria from clinical specimens" 112 : 728-752, 2004

8 "Methods of enzyme analysis" Academic Press; 1983

9 "Laboratory Services in Tuberculosis Control" Geneva, Switzerland: World Health Organization 1998

10 "Issues in the management of contacts of patients with active pulmonary tuberculosis" 88 : 197-201, 1997

11 "From the Food and Drug Administration" 275 : 585-, 1996

12 "From the Centers for Disease Control and Prevention" 284 : 826-, 2000

13 "Four-year experience of use of the Cobas Amplicor system for rapid detection of Mycobacterium tuberculosis complex in respiratory and nonrespiratory specimens in Greece" 22 : 349-356, 2003

14 "Evaluation of polymerase chain reaction, adenosine deaminase, and interferon-gamma in pleural fluid for the differential diagnosis of pleural tuberculosis" 118 : 1355-1364, 2000

15 "Evaluation of polymerase chain reaction for detection of Mycobacterium tuberculosis in pleural fluid" 119 : 1737-1741, 2001

16 "Differential diagnosis of tuberculous pleurisy by measurement of cytokine concentrations in pleural effusion" 78 : 29-34, 1997

17 "Diagnostic value of an amplification method (Gen-Probe) compared with that of culture for diagnosis of tuberculosis" 33 : 2699-2703, 1995

18 "Diagnostic standards and classification of tuberculosis in adults and children" 161 : 1376-1395, 2000

19 "Diagnostic performance of amplified Mycobacterium tuberculosis direct test with cerebrospinal fluid, other nonrespiratory, and respiratory specimens" 34 : 834-841, 1996

20 "Diagnosis of tuberculosis by Amplicor Mycobacterium tuberculosis test: a multicenter study" 33 : 3106-3110, 1995

21 "Diagnosis of extrapulmonary tuberculosis by Gen-Probe amplified Mycobacterium tuberculosis direct test" 34 : 2275-2279, 1996

22 "Detection of mycobacterial DNA in pleural fluid from patients with tuberculous pleurisy by means of the polymerase chain reaction comparison of two protocols" 265-9, thorax1992;47

23 "Detection of Mycobacterium tuberculosis in paraffin-embedded pleural biopsy specimens by commercial ribosomal RNA and DNA amplification kits" 118 : 648-655, 2000

24 "Detection of Mycobacterium tuberculosis in clinical samples by using polymerase chain reaction and a nonradioactive detection system" Schuitema AR 2567-75, jclinmicrobiol1992;30

25 "Clinical evaluation of the automated COBAS AMPLICOR MTB assay for testing respiratory and nonrespiratory specimens" 36 : 2853-2860, 1998

26 "Accuracy and utility of commercially available amplification and serologic tests for the diagnosis of minimal pulmonary tuberculosis" 162 : 1323-1329, 2000

27 "A comparative study of the polymerase chain reaction and conventional procedures for the diagnosis of tuberculous pleural effusion" Maartens G 262-7,

28 "A clinician's guide to tuberculosis" Lippincott Williams & Wilkins 2000