内科学教学课件：Pulmonary Tuberculosis

Pulmonary TuberculosisFifth National Tuberculosis epidemiological Fifth National Tuberculosis epidemiological survey resultssurvey results（March 2011March 2011）oAt present the number of annual incidence of tuberculosis in China is about 1.3 million,accounting for 14.3%of global incidence,among the world is No.2oNow the annual rate of descending is about 9%oWorld Tuberculosis Day(24th,March)General ConsiderationsTuberculosis is a chronic infection lifelong durationCaused by Mycobacterium tuberculosis It was isolated by Robert Koch in 1882The morbidity and mortality of tuberculosis are high in developing countriesEtiologyThe tubercle bacillus(M.Tuberculosis)is aerobic,non-motile,non-spore-forming,high in lipid contents,and acid and alcohol-fastIt grows slowlyIt cant tolerate heat.(60-30,85-5,95 -1)It can live in humid or dry or cold surroundings.epidemiologyThe sources of infection The route of spreadPeoples of easily affectedMany droplet nuclei are capable of floating in the immediate environment for several hoursParticles may be inhaled by a person breathing the same air and impact on the trachea or wall of the upper airwayThe transmission is determinedThe probability of contact with a case of TBThe intimacy and duration of contactThe degree of infectiousness of caseThe shared environment of the contactPathogenesisHuman immunityPhagocytosis periodCell mediated immunity(CMI)Delay type hypersensitivity(DTH)Symbiotic periodLiquefaction and Propagation periodHuman Immunity after infected tubercle bacillus and tuberculin hypersensitivityThe natural immunity of human to TB is nonspecific After infected or given BCG vaccine,human will obtain specific immunityThe immunity of tubercle bacillus is cell-mediated immunity basic pathologic changesIncluding infiltration,hyperplasia,caseous necrosis or calcification.These changes happen in different stage of tuberculosisWhen host defense is destroyed and there is much more bacterias,caseating ulcerationwill existwhen host defense is predominant and there is less bacteria,perhaps hyperplasia and calcification will happenThe result of the tuberculosis after infectionAbsorption,FibrosisCalcificationDeterioration:enlargement of infected areas and appear newer infiltrated regions or spreadingThere are five common clinical patterns of tuberculosisPrimary pulmonary tuberculosis(Primary Complex and Bronchial Lymphnoid Tuberculosis)Milliary Tuberculosis(acute,subacute and chronic hematogenous pulmonary tuberculosis secondary pulmonary tuberculosis Infiltrative pulmonary tuberculosisChronic fibrocavenous pulmonary tuberculosis Tuberculous pleuritisExtrapulmonary tuberculosisclinical patterns of pulmonary tuberculosisClinical ManifestationsLaboratory and physical examinationsPathogen examination:Sputum examination PCR test to detect TBTB antibody testingChest radiographyTuberculin testingbronchoscopy p PCR test to detect TBPrimary complex acute milliary tuberculosissecondary pulmonary tuberculosisinfiltrateTuberculomaChronic fibro-cavitary pulmonary tuberculosiscavityTuberculous effusion :Epidemiological survey,detect some new positive peoples,assistant diagnosisBronchoscopy examinationEndobronchial tuberculosis How to judge the activity of pulmonary tuberculosisClinical signsSputum examinationX ray examinationHow to write the diagnosis correctly?uGenerally,we write the diagnosis according to the site of TB,clinical patterns,the result of sputum examination and the history of chemotherapy.uUpper Right secondary pulmonary tuberculosis,smear(-),retreatment Differential Diagnosis Bronchiectasis chronic cough,sputum production and hemoptysis.HRCT scan to distinguish them.Cavitary lung abscess Acute bacterial pneumonias complicationsnPneumothoraxnBronchiectasisnEmpyemanExtrapulmonary expansionnHemoptysisnChronic pulmonary heart diseaseTherapyChemotherapySurgical therapy Support therapy The principles of antituberculous chemotherapy earlier combinationadequate amount dosage regularly and full durationsTreatment Isoniazid(INH)o Advantages and DosageAdverse effects Rifampin(RFP)Dosage Pyrazinamide(PZA)o Dosage Ethambutal(EMB)The metabolic state of tubercle bacilli A groups:INH RFPB groups:PZAC groups:RFPD groupschemotherapyTo initial patients:TB positive:short-term chemotherapy 2HRZS(E)/4HR,the duration lasts 6 monthsTB negative:2HRZ/4HR To retreatment patients:3HRZSE/5HRZ,the duration lasts 6-12 months.chemotherapyTo MDR-TB:MDR-TB means that resistant to both INH and rifampin.We can select five kinds of antituberculosis drugs in the stage of intensive.These drugs include aminoglycosides(amikacin,kanamycin,capremycin),cycloserine,EMB,quinolones(levofloxacin,ofloxacin),PZA,ethionamide.In the stage of consecutive,we can select three kinds of drugs,including ethionamide,quinolones and EMB.The whole therapy lasts at least 18 months.cavityTuberculomaempyemasevere hemoptysis,ects.PreventionBCG vaccineDOTS strategy:Treatment and management of patients Prevention with medicinesPreventionBCG Vaccination can obtain immunity acquired for tubercle bacillus.It is one of the most important tuberculosis preventionVaccination target:infants children and youngster of tuberculin negativeManagement of severe hemoptysisuGeneral measures:eliminate patients anxiety,rest in beduMaintain the airwaysuUse of medicines of hemostatic,antitussive,ects.uSupportive measures:keep electrolytes and acid-base balance.uElectric bronchoscopy:investigating the site and cause of hemoptysis.uBronchial artery thrombosisuSurgery THANKSCase report患者,男性,65岁。主诉：干咳三个月伴乏力、消瘦一月余现病史：患者自三个月前开始无明显诱因下出现咳嗽，主要为干咳，亦无痰血、胸痛、呼吸困难等其他症状，当时未予以注意。自近一月以来，自觉明显乏力，并出现体重减轻，咳嗽仍以干咳为主，亦无其他呼吸系统症状。遂今日来就诊。自发病以来胃纳尚可，二便正常,近一月来夜间盗汗明显。既往史：有糖尿病史5年，无肺结核和肝炎等传染病病史。实验室检查血常规：正常PPD试验：+痰涂片找抗酸杆菌：阴性胸片讨 论诊断鉴别诊断治疗