《Tuberculosi结核》ppt课件

1、 Childhood Tuberculosis 檀卫平 中山二院DefinitionnTuberculosis is caused by Mycobacterium tuberculosis , isolated by Robert Koch in 1882 , M.bovis(seldom)nmainly involves the lungs, but may spread to other organs nconsumption 肺痨Epidemiologyn19th century, 25% deaths by TB n1940s, effective medicinesnAnnuall

2、y, 8 million become ill with tuberculosis, 2 million people dienThe morbidity / mortality are high in developing countriesnChina has the worlds second largest tuberculosis epidemic (after India) nincidences rates 113 per 100,000 in ChinaEpidemiologynAge:60% Infant -5yrnMale:female-1:1 (adults male p

3、redominate)nTB adults exposuren2yr,HIV coinfection, immunocompromise, malnutritionnHIV/AIDS,ndrug-resistantEtiologyDr. Robert Koch discovered the tuberculosis bacilliin 1882 He received the Nobel Prize in physiology or medicine in 1905 for this discovery The transmission is determinedPathogenesisHum

4、an immunityPathogenesisn90% infected with Mycobacterium tuberculosis asymptomatic, latent TB infection 10% progress to TB disease nif untreated, the death rate for these active TB cases is more than 50% Pathogenesisnmycobacteriapulmonary alveolireplicate within macrophages picked up by dendritic cel

5、ls transport to local LN spread through bloodstream to other tissues/organs secondary TB lesionsnprimary site of infection :upper part of the lower lobe, or lower part of the upper lobe of lungnsecondary TB lesions: apex of the upper lobes , peripheral lymph nodes, kidneys, brain, and bone Human Imm

6、unity /hypersensitivity after TB infectionTwo types of cells are essential in the formation of TBT lymphocytes(CD4+)Basic pathologic changesA characteristic tubercle at low magnification (A) and in detail (B) central caseation surrounded by epithelioid and multinucleated giant cells(C) mycobacteria

7、with acid-fast stains (D). Progression of tuberculosisAbsorptionFibrosisCalcificationDeterioration: enlargement of infected aeras and appear newer infiltrated regions or spreading.Five common clinical patterns DiagnosisnHistory and Clinical Manifestations nTuberculin testingnLab examinationnX-raynbr

8、onchoscopynPuncture of adenopathy History /Clinical Manifestations Tuberculin skin testva skin test to determine past or present infection with the tuberculosis bacterium; based on hypersensitivity of the skin to tuberculinvMethod of test protein purified derivative PPD 0.1ml intradermal injectionvS

9、ite: internal side of medium-distal 1/3 left forearmv 6 - 10mmvResult: 48-72hrs, transversev diameterv Result is read by measuring the diameter of induration 48-72hrsnInduration 20mm (+)n A positive tuberculin skin test indicates n tuberculous infection, with or without disease Tuberculin testing A

10、positive tuberculin test is of great use in children, with limited d i a g n o s t i c significance in adults Clinical SignificancenPositive nNegativePositive Reaction: indicates TB exposurenBCG VaccinationnChildren and adolescents(+) exposed to TBnInfant3yrs (+) recent infectionn(+) Active TB infec

11、tinn(-) (+) ，or Induration10mm, 6mm recent infectionNegative ReactionnNever exposed to TBnWithin 4-8wks of primary infectinnFalse negative:compromised immunitynTechnique failure or PPD invalidatedPPD reaction of natural TB infection and BCG vaccinationNatural infectionstronge Induration 10-15mm deep

12、 red、regular margin、 hard pigmentationLong duration 7-10dLess change BCG vaccinationweak Induration 5-9mm light red、 unregular margin、softShort duration:2-3dBecome weak gradually,disappear3-5y Laboratory examinations Chest radiographynEndobrochial tuberculosis ntuberculous tracheobronchial lymphaden

13、itis Puncture of peripherial LNnTuberclencaseous necrosisTreatmentnCommon therapy: nNutrition、RestnVentilationn Isolationn n Chemotherapyngoal : Kill TB n Limit TB from spreadingnprinciples: n earlier, appropriatenCombination, Full coursenregularly and Staged.Classification of antitubercular drugn i

14、ntracellular TB Isoniazid (INH) first-line drugAdvantagesDosageAdverse effects Rifampin (RFP) first-line drugChemotherapy RegimensnStandard regimen：n asymptomatic primary infectionn INH、RFP and/orEMBn 9-12 monthsTwo Stage TherapynActive primary TB、Disseminated TB、 TB meningitisnEnforcement stage :3-

15、4 bactericidal，3-4mnConsolidation stage :2 drug，12-18mShort-term TherapyDOTS (Directly Observed Treatment Short-course) PreventionPrevention of Tuberculosis :VaccinationBCG Vaccination can obtain immunity acquired for tubercle bacillus. one of the most important tuberculosis preventionVaccination ta

16、rget: infants children and youngster of tuberculin negative (vaccination is of course of no use in tuberculin-positive persons)PreventionuFinding patients earlieruTreatment and management of patients uPrevention with medicinesuThe systemic organization of preventionProphylatic chemotherapynIntimate

17、contact with family members suffering active TBn3y infant PPD test(+) without BCG viccinationnPPD test (-) (+) recentlynPPD test(+) accompanied by Tb toxic symptomsnPPD test(+) ，suffered measles,whooping coughnPPD test(+) and need long term steroid therapynRegimen:n INH：10mg/kg.d，6-9m Tuberculous me

18、ningitisPathogenesisClinical ManifestationnThe 1st Stage: 1-2wksn change of character:irritability,n Tb toxic symptomn Headachesvomiting、n drowsinessThe 2nd Stage 1-2wksnMeningeal irritation stagenIncreased ICP: Headaches,vomiting, drowsiness, seizure, nuchal rigidity, back pain, Kerning sign, Brudz

19、inski sign.nCranial Nerve palsy nEncephalitis:disorentation,movement disorders, speech impaiment, papilledema The 3rd StagenComa stage 1-3wksn coma, hemiplegia, paraplegia, convulsion consumption, abnormal metabolise of electrolyten hypertenion, decerebrate posturen brain herniadeathDiagnosisnMedica

20、l history nClinical manifestationnCSF examinationn-ray checknor scanningnTuberculin testDifferentiation diagnosisnMeningococcal MeningitisnViral Meningitisncryptococcal meningitis nCerebral tumorTreatmentnGeneral therapynAnti-tuberculous therapynDecreasing intracranial pressurencorticosteroidsnAnti-

21、symptomatic therapynFollow -upAnti-tuberculous therapy、The initial stage :m、The 2nd stage、mLatent infection of tuberculosisnA patient is infected with Mycobacterium tuberculosis, but does not have active disease nPatients with latent tuberculosis are not infectiousnThe main risk is that approximately 10% of these patients will go on to develop active tuberculosis at a later stage of their lifenThe identification and treatment of people with latent TB is an important part of controlling this disease. Miliary tuberculosis in an infant whose uncle also had