摘要： 目的 探讨以肉芽组织和肉芽肿为特征的脑结核病的病理学特征及鉴别诊断。方法 回顾分析1 例以肉芽组织和肉芽肿为特征的脑结核病患者的临床表现和组织学特征，并复习相关文献。结果 男性患者，12 岁。临床表现为咳嗽、咳痰、肌肉疼痛和发热。MRI 检查显示左侧额颞叶脑膜及顶枕叶、右侧顶叶呈低密度影，左侧小脑半球结节样低密度影。胸部及脊柱CT 检查胸骨柄及其体部上段“虫蚀”样骨质破坏，前方软组织肿胀；L2 椎体局灶性骨质破坏，椎旁软组织稍肿胀。右侧顶叶立体定向穿刺活检术、胸壁肿物活检术及胸壁窦道切除术后组织形态学观察，右侧顶叶穿刺组织呈边界较清的增生结节，主要由增生的纤维母细胞、泡沫细胞和新生毛细血管组成，伴淋巴细胞、少量浆细胞和中性粒细胞浸润；胸壁肿物、胸骨及软组织则以中性粒细胞浸润为主的化脓性炎性反应为主，伴极少数多核巨细胞浸润。抗酸染色可见右侧顶叶、胸壁及胸骨大量抗酸杆菌生长。结论 以肉芽组织和肉芽肿为特征的结核病组织学形态不典型，有时以化脓性炎性改变为主。对于临床表现不典型者，仍应考虑结核病的可能并及时行抗酸染色，以免漏诊和误诊。

关键词: 结核, 脑膜, 肉芽肿, 肉芽组织, 免疫组织化学, 诊断, 鉴别

Abstract: Objective To investigate the clinicopathological features and differential diagnosis of cerebral tuberculosis with features of granulation tissue and granuloma. Methods The clinical and morphological features were studied in one case of cerebral tuberculosis, with review of literature. Results A 12-year-old boy presented with 2-month history of cough, expectoration, pain of muscle and fever. His brain magnetic resonance imaging (MRI) revealed multiple low-density shadows in the meninges on the left frontal temporal and parieto-occipital lobes, and right parieto-occipital lobes, 2 mm to 7 mm in diameter. Nodular low-density shadows were detected in the left cerebellar hemisphere. Chest computed tomography (CT) showed "moth-eaten" bone destruction of the manubrium of sternum and the upper sternum, and soft tissue swelling. Spine CT showed bone destruction of the second lumbar vertebra, and paravertebral soft tissue swelling. The patient was given stereotactic operation with the guide of MRI at right parietal lobes. Chest wall mass biopsy was performed, and 3 months later, the chest wall sinus was excised. Microscopically, low magnification showed a nodule with clear boundary at right parietal lobes, high magnification displayed nodule composed of fibroblasts, foam cells, newborn capillaries with lymphocytes, plasmocytes and neutrophils. Purulent inflammation with a few multinucleated giant cells could be seen in thoracic wall mass, sternum and soft tissue. A large number of positive bacilli could be seen in the right parietal lobes and thoracic wall by acid-fast staining. Conclusion The morphology of cerebral tuberculosis with features of granulation tissue and granuloma may be atypical, and sometimes present with suppurative inflammation. When clinicial manifestation is also atypical, acid-fast staining should be done to avoid misdiagnosis.

Key words: Tuberculosis, meningeal, Granuloma, Granulation tissue, Immunohistochemistry, Diagnosis, differential