結(jié)核病總論英文

1、我國結(jié)核病的疫情狀況,WHO 93年宣布“全球結(jié)核病緊急狀態(tài)”，98年又重申遏制結(jié)核病的行動刻不容緩。全球現(xiàn)有結(jié)核病人2000萬，其中95％在發(fā)展中國家，每年還會新發(fā)生800-1000萬肺結(jié)核病，其中75％的病人年齡在15－50歲。如不控制，今后10年還將有9000萬人發(fā)病。中國是全球22個結(jié)核病高負(fù)擔(dān)國家之一，結(jié)核病人數(shù)位居世界第二位，僅次于印度.據(jù)調(diào)查全國三分之一的人口已感染了結(jié)核菌；受感染人數(shù)超過4億,受結(jié)核感染人群中有10

2、％的人發(fā)生結(jié)核病,1,,tuberculosis,factor of tuberculosis incidence rising ：HIV spread.TB strain occur drug resistance .fluid population increasing.Management TB patient not perfect、prevention and cure not efficiency.Pover

3、ty、population increasing.,2,etiology,Mycobacterium 、 Acid fastness、G+、aerobe。Growth torpidity , culture need 4-6 weeks.Typing : human type 、 bovine type 、 Bird type、mouse type 、 main human type。way of infection：re

4、spiration tract、digestive track、skin or placenta.,3,Epidemiology,1 infection sources：open pulmonary tuberculosis2 route of transmission: by respiration way or digestion tract.3 susceptible population,4,Epidemiology,Th

5、e factors lead Children ill with TBContact TB amounts and toxicity.power of resistance .hereditary factor .,5,pathogenesy,bacterial number、toxicity、immunization conditionCell-mediated immune reaction:macrophage

6、 swallow TB→antigen presentation Th and macrophage→IL12→CD+4→TH1-IF-γ→to promote mononuclear cell; to gather、activation、proliferation and differentiation→to produce alexin and oxidase 、 digestive enzyme→to kill TB,6,path

7、ogenesy,IF-reinforcement CD+8 、NK cells activity to phagocytosis TB. meanwhile to lead histoclasiadelayed allergy : T cell media，macrophage to be effector cell，to kill reinfection TB and cause cheesy necrosis or hole

8、 formationAfter Infection TB : primary disease（5%），Secondary disease （5%）, not to fall ill all live(90%),7,diagnose,Objectiveto discover focal 。Definite disease character、size whether or not deliver bacterium。,8,diag

9、nose,1 historyTB toxic symptomto contact TB patientBCG vaccinationacute infection:measles，pertussisSupersensitivity erythema nodosum、exanthematous conjunctivitis。,9,diagnose,2 ：OT test agent：1/2000 or 1/10000 PPD

10、dose：0.1ML（OT 5U）（or 1U）。position：left forearm palmaris below 1/3Infuse intracutaneous form 6-10mm hillock。48~72hr observation reaction。,10,diagnosis,reaction<5mm(-)≧5mm(+)10-19mm(++)≧20mm(+++)Super reaction

11、:induration、vesic 、 local ulceration (++++)。,11,diagnosis,significancepositive reactionAfter BCG vaccinationOlder children positive reaction indicate to be ever infected with TB before。Infant never BCG vaccination in

12、dicate new infection recent。Strong positive reaction indicate there is activeness TB.。from（-）to（+）、from 10mm ,or increase >6mm by activeness TB.。,12,diagnosis,negative reactionnever infection TB first Infect TB

13、during 4-8 weeks false negative reaction，immune function to be pressed down。Wrong with test or PPD ineffective,13,diagnosis,BCG Vaccination and natural infection positive reaction condition,14,diagnosis,3 ： laborato

14、ry examination（1）find TB specimen：sputum、gastric juice、C.S.F、serous cavity liquid.method：smear、 fluorescent staining、BACTEC system：culture for 2 weeks，test mycobacteria metabolism production，to distinguish TB and a

15、typical .mycobacteria.L tubercle bacterium：mutation TB，form、construction、acid-fast staining different from common TB。Easy passing placenta，therapeutic inefficacy。,15,diagnosis,（2）immunology and molecular biology test

16、ELISA（酶聯(lián)免疫吸附試驗(yàn)）ELIEP（酶聯(lián)免疫電泳技術(shù)）DNA探針PCR （聚合酶鏈?zhǔn)椒磻?yīng)）線條DNA探針雜交試驗(yàn)ESR (血沉)。,16,diagnosis,4 ： chest X-RAYTo definite focus of infection position 、extent、category、activity condition。To evaluate and follow up therapeutic

17、efficacy 。CT more clear to find the focus、 extent and spread condition。5：bronchofiberscopy check：to definite Endotracheal membrane TB and tuberculosis of trachebronchial lymph nodes。6：lymph node puncture smear or

18、lymphaden biopsy to diagnosis。,17,,tuberculotherapy,general treatmentnutrition、to take a rest。 avoiding to contact infection disease 。Primarily TB treatment in out-patient clinic and regularity return visit 。Repo

19、rt epidemic situation。,18,tuberculotherapy,Treatmen targetTo kill Bacillus tuberculosis in focusto prevent disseminate。therapeutic principleearly treatmentReasonable dosageCombine medicineRegularity take drugt

20、o insist on whole courseSegmenting treatment.,19,tuberculotherapy,Anti-tuberculosis drugsWhole germicide：in acid and alkali，exterior and interior of cell can kill germ。(INH RFP)Half germicide：in acid or alkali envir

21、onment kill cell interior or exterior TB，SM /PZAbacteriostatic：EMB（ethambutol) ETH(ethionamide),20,tuberculotherapy,new antituberculosis to Anti drug resistant Rifamate(contain INH 150mg RFP300mg)Rifater(INH,RFP PZA)

22、 old drug derivant：RifapentineNew chemicals：Dipasic，to delay resistant INH drugstandard treatment：refer to asymptomatic primarily pulmonary tuberculosisusage：INH+RFP±EMBcourse of treatment 9~12 month.,21,化療

23、方案,Two stage therapyrefer to：activeness primarily pulmonary TB: acute miliary tuberculosis;brain TB;intensification therapy：（purpose）Combination 3~4 germicide drugsLonger 3~4mo、shorter 2mo。continue treatment stageC

24、ombination two drugs to keep therapeutic effect for 12~18mo.(longer rang)or 4mo. (Short-rang) 。,22,化療方案,short-range therapyWHO important strategy to cure tuberculosis mechanism of action is fast kill organism inner ce

25、ll or out cell。To sputum bacterium(-)，recovery fast ，recurrence less。2HRZ/4HR、2SHRZ/4HR、2EHRZ/4HR,23,,antituberculosis drugs,medicine dose adverse reaction INH 10~20 多發(fā)性神經(jīng)炎，肝損害RFP 10~15

26、 可逆性肝損害，消化道癥狀。尿紅色。PZA 20-30 肝損害，高尿酸血癥。SM 15~20 聽神經(jīng)損害,腎損害。EMB 15~20 球后視神經(jīng)炎。,24,Tuberculosis prevention,to control source of infection：smear(+) patientPervasion BCG vaccination：to have a

27、n inoculation age is neonate.contraindicationcellular immunity deficiencyacute infectious disease convalescence stageRegion eczema or general skin diseaseOT（+）,25,,Tuberculosis prevention,Drug prevention indicatio

28、n:1 Close to contact open pulmonary tuberculosis in family 2 lower 3 years infant have not innoculation BCG; but OT（+）3 OT from（-）to （+）recently4 OT(+) with toxic symptom5 OT（+）and recently ill with measles or pe

29、rtussis6 OT（+）need long-term to take corticosteroids or immunodepressant,26,,Tuberculosis prevention,Approach 1 : INH 10mg/kg course of treatment 6~9mo.Approach 2 : INH+RFP(10mg/kg) course 3 mo.,27,原發(fā)性肺結(jié)核（primary pu

30、lmonary tuberculosis),首次侵入肺部發(fā)生的原發(fā)感染原發(fā)綜合癥（primary complex)原發(fā)病灶+局部病變淋巴結(jié)+淋巴管支氣管淋巴結(jié)結(jié)核(胸腔內(nèi)腫大淋巴結(jié)結(jié)核),28,primary pulmonary tuberculosis,病理部位:右側(cè)肺上葉底部、下葉上部基本病變：滲出（炎癥細(xì)胞 單核細(xì)胞 纖維蛋白）、增殖（結(jié)核結(jié)節(jié) 結(jié)核肉芽腫）、壞死（干酪樣壞死）。炎癥特征：上皮樣細(xì)胞結(jié)節(jié)、langerh

31、ans細(xì)胞浸潤,29,primary pulmonary tuberculosis,病理轉(zhuǎn)歸吸收好轉(zhuǎn)進(jìn)展擴(kuò)大出現(xiàn)空洞支氣管內(nèi)膜結(jié)核或干酪性肺結(jié)核腫大淋巴結(jié)壓迫造成肺不張或阻塞性肺氣腫結(jié)核性胸膜炎惡化：血行播散（肺或全身性粟粒性結(jié)核?。?30,primary pulmonary tuberculosis,臨床表現(xiàn)結(jié)核中毒癥狀過敏癥狀（眼皰疹性結(jié)膜炎、皮膚結(jié)節(jié)性紅斑，多發(fā)性一過性關(guān)節(jié)炎壓迫癥狀：類百日咳樣痙攣性咳嗽，喘鳴

32、、聲嘶、頸靜脈怒張體征：一般無體征、可有周圍淋巴節(jié)腫大，肺部叩診濁音，呼吸音減低，或有濕羅音。,31,,primary pulmonary tuberculosis,診斷和鑒別診斷病史（三史）臨床表現(xiàn)結(jié)核菌素試驗(yàn)X-線檢查（胸正側(cè)位片原發(fā)綜合癥支氣管淋巴結(jié)結(jié)核（炎癥型、結(jié)節(jié)型、微小型纖維支氣管鏡檢查（1管腔狹窄、2炎癥、肉芽腫或潰瘍3腔內(nèi)腫塊3支氣管瘺，孔口火山樣突起，干酪樣物實(shí)驗(yàn)室檢查,32,,治療,無癥狀原發(fā)型肺結(jié)

33、核標(biāo)準(zhǔn)療法用法：INH+RFP±EMB療程9~12個月活動性原發(fā)型肺結(jié)核短程療法2HRZ/4HR,33,結(jié)核活動參考指標(biāo),OT試驗(yàn)≧20mm<3歲尤其<1歲未接種卡介苗而OT（+）者發(fā)熱及其它結(jié)核中毒癥狀者排出物找到結(jié)核菌X-線顯示活動性原發(fā)性肺結(jié)核不明原因ESR升高支氣管鏡發(fā)現(xiàn)有明顯結(jié)核病變。,34,,primary pulmonary tuberculosis,鑒別診斷氣道異物腫瘤各種