肺結(jié)核tuberculosis解析

1、Tuberculosis,The 2nd Xiangya Hospital, CSU,Nov. 2, 2010,病因清楚----結(jié)核桿菌,治 有辦法----抗結(jié)核藥物,防 有措施----BCG,講授內(nèi)容 兩類結(jié)核病 潛伏結(jié)核感染 原發(fā)性肺結(jié)核 兒童結(jié)核病的臨床表現(xiàn) 輔助診斷方法 結(jié)核病的治療,由結(jié)核菌感染引起的結(jié)核菌素試驗(yàn)陽(yáng)性（除 外卡介苗接種后反應(yīng)），X線胸片或臨床無(wú)

2、 活動(dòng)性結(jié)核病證據(jù)者，稱為潛伏結(jié)核感染,有結(jié)核感染的依據(jù)，但沒(méi)有明確的結(jié)核病灶,潛伏結(jié)核感染,Latent Tuberculosis Infection,Children with asymptomatic tuberculous infection,reactive tuberculin skin test normal chest radiograph normal physical examination,Primary

3、pulmonary tuberculosis is the major type of pulmonary tuberculosis developed in children during initial infection,原發(fā)型肺結(jié)核是指結(jié)核菌初次侵入肺部后發(fā)生的原發(fā)感染,原發(fā)型肺結(jié)核是小兒肺結(jié)核的主要類型，占兒童各型肺結(jié)核總數(shù)的85.3%,原發(fā)型肺結(jié)核,Primary Pulmonary Tuberculosis,The man

4、ifestation of TB in children are variable Onset of TB, chronic & hiding Asymptom cases 80% Upper respiratory tract infection Toxic symptoms of tuberculous infection Malnutrition,臨床表現(xiàn)---manifestation,,,The manife

5、station of TB in children are variable Hypersensitivity erythema nodosum/皮膚結(jié)節(jié)性紅斑 phlyctenular conjunctivitis /皰疹性眼結(jié)膜炎 arthritis /關(guān)節(jié)炎 On occasion, the onset of TB, abrupt Lung symptoms asthmati

6、c breathing, cough, etc.,臨床表現(xiàn)---manifestation,,Diagnosis,Case History/Physical Examination Etiology diagnosis Pathology diagnosis Immunology examination Chest X-ray examination Fibrobronchoscope examination,Case Hi

7、story,Toxic symptoms of tuberculous infection 結(jié)核中毒癥狀History of contact with pulmonary patients 結(jié)核接觸史History of BCG vaccination

8、 卡介苗接種史History of other infection illness 既往病史,,Case History,,Toxic symptoms of tuberculous infection mild fever / 低熱 night sweat / 盜

9、汗 fatigue / 乏力 poor appetite / 食欲減退 weight loss / 消瘦,Case History,,History of contact with pulmonary patients open active pulmonary TB patient,Case History,,History of BCG vaccination,

10、History of BCG vaccination Check the scar of BCG / 卡痕,Case History,,Past illness history,TB measles / 麻疹 chickenpox / 水痘 etc.,Superficial lymph node swell Lung signs 多無(wú)明顯體征 叩診可為濁音

11、 聽(tīng)診呼吸音減低 聽(tīng)診少許濕羅音,PE---Signs,,Etiology diagnosisCulture &/or smear of samples for tubercle bacilli gastric washing or induced sputum 結(jié)核菌檢查 （查痰液、胃液等）,Diagnosis,,Diagn

12、osis,,,Diagnosis,,Pathology diagnosis Lymph Nodes puncture Tissue Biopsy Fibrobronchoscope,Diagnosis,,結(jié)核性肉芽腫,結(jié)核特征性病變：中央為干酪樣壞死，周圍為增生的上皮樣細(xì)胞，其內(nèi)散在Langerhans巨細(xì)胞,,Diagnosis,,Immunological diagnosi

13、s Tuberculin Skin Test (PPD or OT test)/ 結(jié)核菌素試驗(yàn) ELISA（PPD-IgM、IgG）,結(jié)核菌素接種后，多長(zhǎng)時(shí)間觀察結(jié)果？接觸結(jié)核后，多長(zhǎng)時(shí)間結(jié)素試驗(yàn)出現(xiàn)反應(yīng)？,Diagnosis,,Chest Roentgenography (Chest X-ray),,Diagnosis,Chest

14、X-ray,Primary Complex (原發(fā)綜合征) primary focus at the site of implantation/原發(fā)病灶 tuberculous lymphangitis/淋巴管炎 regional tuberculous lymphadenopathy/淋巴結(jié)炎 呈典型“啞鈴狀雙極影”,,Diagnosis,Chest X-ray,,,原

15、發(fā)綜合征：?jiǎn)♀彔铍p極影,,Diagnosis,Chest X-ray,Tuberculosis of Tracheobronchial Lymphonodus 支氣管淋巴結(jié)結(jié)核,表現(xiàn)為：肺門(mén)影增濃,,Diagnosis,Chest X-ray,,,Tuberculosis of Tracheobronchial Lymphonodus,Diagnosis,,Bio-Molecular Technique PCR

16、, Polymerase Chain Reaction Southern Blot Northern Blot,無(wú)細(xì)菌培養(yǎng)條件下小兒肺結(jié)核的診斷標(biāo)準(zhǔn),①有與成人結(jié)核、尤其開(kāi)放結(jié)核接觸史； ②持續(xù)兩周以上的咳嗽，抗生素治療無(wú)效； ③結(jié)素試驗(yàn)陽(yáng)性：無(wú)卡介苗接種史者>10mm 有卡介苗接種史者>15mm④符合肺結(jié)核診斷的X線征象；⑤抗結(jié)核治療有

17、效（兩個(gè)月后體重增加10%以上， 癥狀好轉(zhuǎn)）。 --------具有以上兩點(diǎn)或兩點(diǎn)以上條件,（供參考）,,Treatment 治 療,DOTS Directly Observed Treatment, Short-course直接督導(dǎo)下的短程化療,DOTS for primary pulmonary tuberculosis2HRZ/4HR or 9

18、HR,結(jié)核感染治療（推薦） 3個(gè)月INH+RFP 2個(gè)月INH+RFP+EMB,最壞的治療是單一用藥標(biāo)準(zhǔn)化療方案：2HRZ/4HR推薦日劑量頓服提倡直接督導(dǎo)下服藥（DOTS）,原發(fā)性肺結(jié)核治療的注意點(diǎn),,結(jié)核病的早期診斷最為重要結(jié)核病的規(guī)范化治療非常重要,TB is a chronic contagious disease caused by tubercle bacilli.,Thank you !