对贝达喹啉、异烟肼、利福平、乙胺丁醇和吡嗪酰胺耐药的初治肺结核合并糖尿病一例

A Case of Newly Diagnosed Pulmonary Tuberculosis with Diabetes Mellitus Resistant to Bedaquiline, Isoniazid, Rifampicin, Ethambutol, and Pyrazinamide

摘要: 目的：异烟肼、利福平、乙胺丁醇和吡嗪酰胺是治疗结核病的一线药物，而贝达喹啉是治疗耐多药结核病的关键药物。贝达喹啉耐药性的出现对结核病治疗效果构成严重威胁，但其在初治肺结核患者中的报道仍较为罕见。此外，糖尿病是结核病的重要共病，二者可相互影响、相互作用。方法：收集并整理1例因“慢性咳嗽、胸部不适”就诊的患者的基本信息、病史、实验室检查、影像学资料(胸部CT平扫)以及诊疗经过，进行综合分析。结果：该患者以慢性咳嗽、胸部不适为主诉，近半年体重下降约7.5 kg，其胸部CT平扫提示“双肺多发感染灶，肺结核可能”，痰液检测确诊为利福平耐药肺结核。进一步基因检测证实该菌株对异烟肼、利福平、乙胺丁醇、吡嗪酰胺及贝达喹啉均耐药。实验室检查发现患者空腹血糖为14.87 mmol/L，糖化血红蛋白(HbA1c)为10.8%，诊断为2型糖尿病。经个体化抗结核方案(丙硫异烟胺、氯法齐明、环丝氨酸、利奈唑胺和左氧氟沙星)联合胰岛素控制血糖治疗后，患者症状改善，顺利出院。本案例提示，应警惕初治肺结核患者出现广泛耐药的可能性，并强调快速分子药物敏感性检测在早期诊断中的重要性。此外，本文也探讨了糖尿病与结核病耐药之间的潜在关联。

Abstract: Objective: Isoniazid, rifampicin, ethambutol, and pyrazinamide are first-line drugs for treating tuberculosis, while bedaquiline is a key medication for multidrug-resistant tuberculosis. The emergence of bedaquiline resistance poses a serious threat to tuberculosis treatment outcomes, yet its occurrence remains relatively rare among treatment-naive pulmonary tuberculosis patients. Furthermore, diabetes is a significant comorbid condition in tuberculosis, with both conditions capable of influencing and interacting with each other. Method: Collect and organize the basic information, medical history, laboratory tests, imaging data (plain chest CT scan), and clinical course of one patient presenting with “chronic cough and chest discomfort,” then conduct a comprehensive analysis. Results: The patient presented with chronic cough and chest discomfort as chief complaints, accompanied by weight loss of approximately 7.5 kg over the past six months. A plain chest CT scan revealed “multiple infectious foci in both lungs, suggestive of pulmonary tuberculosis.” Sputum testing confirmed the diagnosis as rifampicin-resistant pulmonary tuberculosis. Further genetic testing confirmed the strain’s resistance to isoniazid, rifampicin, ethambutol, pyrazinamide, and bedaquiline. Laboratory tests revealed a fasting blood glucose level of 14.87 mmol/L and a glycated hemoglobin (HbA1c) of 10.8%, leading to a diagnosis of type 2 diabetes mellitus. Following treatment with an individualized anti-tuberculosis regimen (pyrazinamide, clofazimine, cycloserine, linezolid, and levofloxacin) combined with insulin for glycemic control, the patient’s symptoms improved, and he was successfully discharged. This case highlights the need for vigilance regarding the potential for extensive drug resistance in treatment-naive pulmonary tuberculosis patients and underscores the importance of rapid molecular drug susceptibility testing in early diagnosis. Furthermore, this report explores the potential association between diabetes and tuberculosis drug resistance.