结核病总论英文-课件

我国结核病的疫情状况WHO 93年宣布“全球结核病紧急状态”，98年又重申遏制结核病的行动刻不容缓。全球现有结核病人2000万，其中95在发展中国家，每年还会新发生800-1000万肺结核病，其中75的病人年龄在1550岁。如不控制，今后10年还将有9000万人发病。中国是全球22个结核病高负担国家之一，结核病人数位居世界第二位，仅次于印度.据调查全国三分之一的人口已感染了结核菌；受感染人数超过4亿,受结核感染人群中有10的人发生结核病.1我国结核病的疫情状况WHO 93年宣布“全球结核病紧急状态”tuberculosisfactor of tuberculosis incidence rising：HIV spread.TB strain occur drug resistance.fluid population increasing.Management TB patient not perfect、prevention and cure not efficiency.Poverty、population increasing.2tuberculosisfactor of tuberculetiologyMycobacterium、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：respiration tract、digestive track、skin or placenta.3etiologyMycobacterium、Acid fEpidemiology1 infection sources：open pulmonary tuberculosis2 route of transmission:by respiration way or digestion tract.3 susceptible population.4Epidemiology1 infection sourcEpidemiologyThe factors lead Children ill with TBContact TB amounts and toxicity.power of resistance.hereditary factor.5EpidemiologyThe factors leadpathogenesybacterial number、toxicity、immunization conditionCell-mediated immune reaction:macrophage swallow TBantigen presentation Th and macrophageIL12CD+4TH1-IF-to promote mononuclear cell;to gather、activation、proliferation and differentiationto produce alexin and oxidase、digestive enzymeto kill TB.6pathogenesybacterial number、topathogenesyIF-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 formationAfter Infection TB:primary disease（5%），Secondary disease（5%）,not to fall ill all live(90%).7pathogenesyIF-reinforcement CD diagnoseObjectiveto discover focal。Definite disease character、size whether or not deliver bacterium。.8 diagnoseObjective.8diagnose1 historyTB toxic symptomto contact TB patientBCG vaccinationacute infection:measles，pertussisSupersensitivity erythema nodosum、exanthematous conjunctivitis。.9diagnose1 history.9diagnose2：OT test agent：1/2000 or 1/10000 PPDdose：0.1ML（OT 5U）（or 1U）。position：left forearm palmaris below 1/3Infuse intracutaneous form 6-10mm hillock。4872hr observation reaction。.10diagnose2：OT test.10diagnosisreaction5mm(-)5mm(+)10-19mm(+)20mm(+)Super reaction:induration、vesic、local ulceration(+)。.11diagnosisreaction.11diagnosissignificancepositive reactionAfter BCG vaccinationOlder children positive reaction indicate to be ever infected with TB before。Infant never BCG vaccination indicate new infection recent。Strong positive reaction indicate there is activeness TB.。from（-）to（+）、from 10mm,or increase 6mm by activeness TB.。.12diagnosissignificance.12diagnosisnegative reactionnever infection TB first Infect TB during 4-8 weeks false negative reaction，immune function to be pressed down。Wrong with test or PPD ineffective.13diagnosisnegative reaction.13diagnosisBCG Vaccination and natural infection positive reaction condition.14diagnosisBCG Vaccination and ndiagnosis3：laboratory 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 atypical.mycobacteria.L tubercle bacterium：mutation TB，form、construction、acid-fast staining different from common TB。Easy passing placenta，therapeutic inefficacy。.15diagnosis3：laboratory examindiagnosis（2）immunology and molecular biology testELISA（酶联免疫吸附试验）ELIEP（酶联免疫电泳技术）DNA探针PCR（聚合酶链式反应）线条DNA探针杂交试验ESR(血沉)。.16diagnosis（2）immunology and moldiagnosis4：chest X-RAYTo definite focus of infection position、extent、category、activity condition。To evaluate and follow up therapeutic 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 lymphaden biopsy to diagnosis。.17diagnosis4：chest X-RAY.17tuberculotherapygeneral treatmentnutrition、to take a rest。avoiding to contact infection disease。Primarily TB treatment in out-patient clinic and regularity return visit。Report epidemic situation。.18tuberculotherapygeneral treatmtuberculotherapyTreatmen targetTo kill Bacillus tuberculosis in focusto prevent disseminate。therapeutic principleearly treatmentReasonable dosageCombine medicineRegularity take drugto insist on whole courseSegmenting treatment.19tuberculotherapyTreatmen targtuberculotherapyAnti-tuberculosis drugsWhole germicide：in acid and alkali，exterior and interior of cell can kill germ。(INH RFP)Half germicide：in acid or alkali environment kill cell interior or exterior TB，SM/PZAbacteriostatic：EMB（ethambutol)ETH(ethionamide).20tuberculotherapyAnti-tuberculotuberculotherapynew antituberculosis to Anti drug resistant Rifamate(contain INH 150mg RFP300mg)Rifater(INH,RFP PZA)old drug derivant：RifapentineNew chemicals：Dipasic，to delay resistant INH drugstandard treatment：refer to asymptomatic primarily pulmonary tuberculosisusage：INH+RFPEMBcourse of treatment 912 month.21tuberculotherapynew antituberc化疗方案Two stage therapyrefer to：activeness primarily pulmonary TB:acute miliary tuberculosis;brain TB;intensification therapy：（purpose）Combination 34 germicide drugsLonger 34mo、shorter 2mo。continue treatment stageCombination two drugs to keep therapeutic effect for 1218mo.(longer rang)or 4mo.(Short-rang)。.22化疗方案Two stage therapy.22化疗方案short-range therapyWHO important strategy to cure tuberculosis mechanism of action is fast kill organism inner cell or out cell。To sputum bacterium(-)，recovery fast，recurrence less。2HRZ/4HR、2SHRZ/4HR、2EHRZ/4HR.23化疗方案short-range therapy.23antituberculosis drugsmedicine dose adverse reaction INH 1020 多发性神经炎，肝损害RFP 1015 可逆性肝损害，消化道症状。尿红色。PZA 20-30 肝损害，高尿酸血症。SM 1520 听神经损害,肾损害。EMB 1520 球后视神经炎。.24antituberculosis drugsmedicineTuberculosis preventionto control source of infection：smear(+)patientPervasion BCG vaccination：to have an inoculation age is neonate.contraindicationcellular immunity deficiencyacute infectious disease convalescence stageRegion eczema or general skin diseaseOT（+）.25Tuberculosis preventionto contTuberculosis preventionDrug prevention indication: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 pertussis6 OT（+）need long-term to take corticosteroids or immunodepressant.26Tuberculosis preventionDrug pTuberculosis prevention Approach 1:INH 10mg/kg course of treatment 69mo.Approach 2:INH+RFP(10mg/kg)course 3 mo.27Tuberculosis prevention Approa原发性肺结核（primary pulmonary tuberculosis)首次侵入肺部发生的原发感染原发综合症（primary complex)原发病灶+局部病变淋巴结+淋巴管支气管淋巴结结核(胸腔内肿大淋巴结结核).28原发性肺结核（primary pulmonary tuberprimary pulmonary tuberculosis病理部部位位:右右侧侧肺肺上上叶叶底底部部、下下叶叶上上部部基基本本病病变变：渗渗出出（炎炎症症细细胞胞 单单核核细细胞胞 纤纤维维蛋蛋白白）、增增殖殖（结结核核结结节节 结结核核肉肉芽芽肿肿）、坏坏死死（干干酪酪样样坏坏死死）。炎炎症症特特征征：上上皮皮样样细细胞胞结结节节、l la an ng ge er rh ha an ns s细细胞胞浸浸润润.29primary pulmonary tuberculosisprimary pulmonary tuberculosis病理转归吸吸收收好好转转进进展展 扩扩大大出出现现空空洞洞 支支气气管管内内膜膜结结核核或或干干酪酪性性肺肺结结核核 肿肿大大淋淋巴巴结结压压迫迫造造成成肺肺不不张张或或阻阻塞塞性性肺肺气气肿肿 结结核核性性胸胸膜膜炎炎恶恶化化：血血行行播播散散（肺肺或或全全身身性性粟粟粒粒性性结结核核病病）.30primary pulmonary tuberculosisprimary pulmonary tuberculosis临临床床表表现现结结核核中中毒毒症症状状过过敏敏症症状状（眼眼疱疱疹疹性性结结膜膜炎炎、皮皮肤肤结结节节性性红红斑斑，多多发发性性一一过过性性关关节节炎炎压压迫迫症症状状：类类百百日日咳咳样样痉痉挛挛性性咳咳嗽嗽，喘喘鸣鸣、声声嘶嘶、颈颈静静脉脉怒怒张张体体征征：一一般般无无体体征征、可可有有周周围围淋淋巴巴节节肿肿大大，肺肺部部叩叩诊诊浊浊音音，呼呼吸吸音音减减低低，或或有有湿湿罗罗音音。.31primary pulmonary tuberculosisprimary pulmonary tuberculosis诊诊断断和和鉴鉴别别诊诊断断病病史史（三三史史）临临床床表表现现结结核核菌菌素素试试验验X X-线线检检查查（胸胸正正侧侧位位片片 原原发发综综合合症症 支支气气管管淋淋巴巴结结结结核核（炎炎症症型型、结结节节型型、微微小小型型 纤纤维维支支气气管管镜镜检检查查（1 1管管腔腔狭狭窄窄、2 2炎炎症症、肉肉芽芽肿肿或或溃溃疡疡3 3腔腔内内肿肿块块3 3支支气气管管瘘瘘，孔孔口口火火山山样样突突起起，干干酪酪样样物物实实验验室室检检查查.32primary pulmonary tuberculosis治疗无症状原发型肺结核标准疗法用法：INH+RFPEMB疗程912个月活动性原发型肺结核短程疗法2HRZ/4HR.33治疗无症状原发型肺结核标准疗法用法：INH+RFPEMB结核活动参考指标OT试验20mm3岁尤其1岁未接种卡介苗而OT（+）者发热及其它结核中毒症状者排出物找到结核菌X-线显示活动性原发性肺结核不明原因ESR升高支气管镜发现有明显结核病变。.34结核活动参考指标OT试验20mm3岁尤其1岁未接种卡primary pulmonary tuberculosis鉴鉴别别诊诊断断 气气道道异异物物 肿肿瘤瘤 各各种种肺肺炎炎，支支气气管管扩扩张张。.35primary pulmonary tuberculosis conclusionEpidemiologyDiagnosisOT testtherapeutic principle.36 conclusionEpidemiology.36