内科精品课件：06肺结核

1、2021年2月7日星期日,1,肺结核,pulmonary tuberculosis 协和医院呼吸内科 刘红菊,2,世界人口的1/3感染过结核 现有病人2000万 每年新发病人900万 每年死亡300万 If you breathe you are at risk,疫情水平及趋势,3,New TB cases of 9,000,000 per year: 36% in India and China,5,发展中国家疫情严重 95%结核病人 98%结核死亡 中国为高流行国家 高感染率:0.72%,5.5亿受染 高患病率:367/10万 高耐药率:初始耐药18.6%,继发耐药46.5% 中青年多：7

2、5%在1550岁 死亡人数多、递降率低、地区差大 执行DOTs项目的患病率低,6,发病上升的原因,管理不善 MDR-TB 贫富差距 HIV 人口增加,老年化 移民加剧,肺痨,7,结核菌重要的生物学特性,分支杆菌 染色具有抗酸性 对外界抵抗力强 分型,by cattle,by cattle,by cattle,Mycobacterium is also carried by birds(Avian). Mycobacterium is also carried cattles(Bovine,Acid-Fast (Kinyoun) Stain of Mycobacterium,NOTE: cord

3、 growth (serpentine arrangement) of virulent strains,Eight Week Growth of Mycobacterium tuberculosis on Lowenstein-Jensen Agar,Mycobacterium Tuberculosis Stained with Fluorescent Dye,13,14,脂质,蛋白质,多糖类,组织坏死,结核结节,过敏反应,免疫反应,结核菌的不同成分与机体的反应,15,在人群中的转播,传染源: 继发肺结核患者 传播途径: 呼吸道,消化道,皮肤 易感人群: 高危人群 影响传染性的因素 化疗对传

4、染性的影响: 数量下降,毒力减低,16,高危人群,儿童, 老年人 妇女 育儿、家务、孕产及经济 免疫抑制剂使用者 慢性病患者 HIV感染者：TB是唯一与HIV相关的空气传播的机会性感染 山区和农村居民,17,结核病的发生与发展,原发感染 原发综合征 继发性结核 内源性复发 外源性重染 继发性肺结核 慢性发病 快速发病,18,免疫与变态反应,非特异免疫：自然免疫力 特异性免疫：BCG或感染 Koch现象: 免疫和变态反应,TB,巨噬细胞 吞噬,T细胞 致敏,淋巴因子,巨噬细胞 聚积,19,20,结核病的病理,基本病变 渗出性 增生性 变质性 转归,恶化,液化，空洞,好转,吸收 纤维化，钙化,21

5、,结核的病理学镜下特征,22,pathology,结核肉芽肿,23,郎罕巨细胞,24,干 酪 样 坏 死,25,临床表现,结核中毒症状 各系统症状 结核性风湿病,SYMPTOMS,Perpetual Cough Fever Chest pain Hemoptysis Chills Night sweats Loss of appetite Fatigue Swollen glands, lymph node Weight loss Pain while breathing(pleura,Healthy person Initial infection controlled by immune

6、system Bacilli remain confined in tubercles for years The inactive stage of the disease may be symptom-free, the individual may experience a flu-like illness. Fatigue,SYMPTOMS,SYMPTOMS,Unhealthy personBacilli overwhelm immune systemBacilli break out of tubercles in alveoli and spread through bloodst

7、ream Within the active stage of the disease, there might be a slight fever, night sweats, weight loss, fatigue,29,诊 断,30,诊断方法,病史、症状及体征 包括诊断治疗过程、接触史等 X线检查：诊断的重要方法 痰菌检查：确诊的主要方法 结核菌素试验 纤支镜等,31,实验室检查(1,结核菌检查,32,影像学检查,病灶多位于上叶尖后段及下叶背段 密度不均、变化慢 易形成空洞和播散 病灶常呈多形性改变,33,34,实验室检查(2,Skin test Urine 在公共医疗机构应用痰涂片检

8、查以发现患者 至少对所有涂阳病人给予标准短程化疗 有规律、不间断地提供所有基本化疗药物 应有监测及评估系统,Directly-Observed Treatment with Short course (DOTS,95,结核化疗,恰当的用药方案：正确的联合用药、正确的剂量、正确的疗程 确保规律用药：直接督导短程化疗(DOTS) 预防和监测不良反应的发生 监测疗效:随访痰涂片以明确痰菌是否转阴,National tuberculosis control program,96,考核疗效指标,痰菌 X线结合临床和痰菌,97,卡介苗接种,预防性化疗,98,胸腔积液,99,胸水循环机制,100,101,病

9、因和发病机制,胸膜毛细血管静水压增高 胶体渗透压降低 胸膜通透性增加 淋巴管引流受阻 损伤,102,临床表现,症状 呼吸困难, 胸痛, 咳嗽 体征,103,检查,胸水常规 生化 细胞学 瘤标 培养 X线检查 超声波 活检 胸腔镜 支气管镜,104,105,106,107,漏出液 渗出液 脓液 结核 非结核 恶性 非恶性,胸水,108,渗出液和漏出液重要鉴别点,Light标准:渗出液 胸水蛋白/血蛋白 0.5 胸水LDH/血LDH 0.6 胸水LDH血LDH上限的2/3 胸水胆固醇1.56mmol/L 胸水/血胆红素0.6 血-胸水白蛋白差12g/L,109,常见胸水的鉴别诊断,胸腔积液形成的新

10、机制。中华内科杂志 第38卷 第12期 Vol.38 No.12 1999,110,结核性胸膜炎的治疗,一般治疗 抽胸水 抗结核 激素 复张后肺水肿/心衰 胸膜反应 0.1% 肾上腺素0.5 ml,111,类肺炎性胸腔积液的治疗,抗感染 中等量积液 抽胸水 pH7.2 闭式引流,112,脓胸的治疗,控制感染 引流 冲洗 促进肺复张 一般治疗,113,恶性胸水的治疗,原发病的化放疗 局部治疗 抽胸水 引流 化学性胸膜固定术 化疗药 粘连剂 免疫调节剂 胸-腹分流术, 胸膜切除术,谢谢,THANK YOU for attending,Case 1 miliary tuberculosis,typi

11、cally affects the upper zones of the lung,Case 1,Investigation Blood-R normal ESR 53 U and E normal Liver Function Test albumen 31 CRP 40 Induced sputum smear negative,Case 1,Progress Clinical diagnosis of TB 4 drug treatment Clinical improvement TB culture positive at week 3 fully sensitive (week 5

12、) Modified anti TB drug regime in light of lab results,Case 1,What about HIV testing? who to test? Strong association between HIV and TB Universal testing or selective testing? What about testing for vitamin D? Vitamin D has role in activating macrophages to destroy mycobacteria Vitamin D deficiency

13、 in ethnic populations in UK often low,Case 1,Cured after standard 6 months therapy,non pulmonary TB disease,This is an example of tuberculosis of the skin it is normally referred to as Warty T.B. and someone will only contract this type of tuberculosis if they have had prior exposure to tuberculosi

14、s,Physical Symptoms,What will happen if treatment delayed? gibbus formation (acute angulation of spine with or without neurological damage,The physical appearance Potts disease of spine - gibbus,25 male African. Expanding non painful lesion in neck - Cervical lymph node TB progressing to abscess (be

15、ware deep extension collar stud abscess,TB node in neck with deep extension,35 female African systemically well - hand and foot lesions present for 6 months MTB grown on biopsy by plastic surgeons (HIV neg,Astute radiologist should enable the appropriate further investigation,Often associated with delay in diagnosis any chronic discharging lesion must be considered possibly TB,Renal tuberculosis (may have