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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”，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,tuberculosis,factor of tuberculosis incidence rising：HIV spread.TB strain oc
2、cur drug resistance.fluid population increasing.Management TB patient not perfect、prevention and cure not efficiency.Poverty、population increasing.,2,etiology,Mycobacterium、Acid fastness、G+、aerobe。Growth torpidity,culture need 4-6 weeks.Typing:human type、bovine type、Bird type、mouse type、main human t
3、ype。way of infection：respiration tract、digestive track、skin or placenta.,3,Epidemiology,1 infection sources：open pulmonary tuberculosis2 route of transmission:by respiration way or digestion tract.3 susceptible population,4,Epidemiology,The factors lead Children ill with TBContact TB amounts and tox
4、icity.power of resistance.hereditary factor.,5,pathogenesy,bacterial 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 prod
5、uce alexin and oxidase、digestive enzymeto kill TB,6,pathogenesy,IF-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:pri
6、mary disease（5%），Secondary disease（5%）,not to fall ill all live(90%),7,diagnose,Objectiveto discover focal。Definite disease character、size whether or not deliver bacterium。,8,diagnose,1 historyTB toxic symptomto contact TB patientBCG vaccinationacute infection:measles，pertussisSupersensitivity eryth
7、ema nodosum、exanthematous conjunctivitis。,9,diagnose,2：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。,10,diagnosis,reaction5mm(-)5mm(+)10-19mm(+)20mm(+)Super reaction:induratio
8、n、vesic、local ulceration(+)。,11,diagnosis,significancepositive 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（+）、f
9、rom 10mm,or increase 6mm by activeness TB.。,12,diagnosis,negative 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,13,diagnosis,BCG Vaccination and natural infection positive reaction condition,1
10、4,diagnosis,3：laboratory examination（1）find TB specimen：sputum、gastric juice、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
11、、acid-fast staining different from common TB。Easy passing placenta，therapeutic inefficacy。,15,diagnosis,（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)。,16,diagnosis,4：chest X-RAYTo definite focus of infection position、extent、category、activit
12、y 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。,17,tuber
13、culotherapy,general treatmentnutrition、to take a rest。avoiding to contact infection disease。Primarily TB treatment in out-patient clinic and regularity return visit。Report epidemic situation。,18,tuberculotherapy,Treatmen targetTo kill Bacillus tuberculosis in focusto prevent disseminate。therapeutic
14、principleearly treatmentReasonable dosageCombine medicineRegularity take drugto insist on whole courseSegmenting treatment.,19,tuberculotherapy,Anti-tuberculosis drugsWhole germicide：in acid and alkali，exterior and interior of cell can kill germ。(INH RFP)Half germicide：in acid or alkali environment
15、kill cell interior or exterior TB，SM/PZAbacteriostatic：EMB（ethambutol)ETH(ethionamide),20,tuberculotherapy,new 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 treatm
16、ent：refer to asymptomatic primarily pulmonary tuberculosisusage：INH+RFPEMBcourse of treatment 912 month.,21,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。cont
17、inue treatment stageCombination two drugs to keep therapeutic effect for 1218mo.(longer rang)or 4mo.(Short-rang)。,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 le
18、ss。2HRZ/4HR、2SHRZ/4HR、2EHRZ/4HR,23,antituberculosis drugs,medicine 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。,24,Tuberculosis prevention,to control source of infection：smear(+)patientPervasion BCG vaccination：to have an i
19、noculation age is neonate.contraindicationcellular immunity deficiencyacute infectious disease convalescence stageRegion eczema or general skin diseaseOT（+）,25,Tuberculosis prevention,Drug prevention indication:1 Close to contact open pulmonary tuberculosis in family 2 lower 3 years infant have not
20、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,26,Tuberculosis prevention,Approach 1:INH 10mg/kg course of treatment 69mo.Approach 2:INH+RFP(10mg/kg)course
21、3 mo.,27,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,primary pulmonary tuberculosis,病理部位:右侧肺上叶底部、下叶上部基本病变：渗出（炎症细胞 单核细胞 纤维蛋白）、增殖（结核结节 结核肉芽肿）、坏死（干酪样坏死）。炎症特征：上皮样细胞结节、langerhans细胞浸润,29,primary pulmonary tuberculosis,病理转归吸收好转进展扩大出现空洞支气
22、管内膜结核或干酪性肺结核肿大淋巴结压迫造成肺不张或阻塞性肺气肿结核性胸膜炎恶化：血行播散（肺或全身性粟粒性结核病）,30,primary pulmonary tuberculosis,临床表现结核中毒症状过敏症状（眼疱疹性结膜炎、皮肤结节性红斑，多发性一过性关节炎压迫症状：类百日咳样痉挛性咳嗽，喘鸣、声嘶、颈静脉怒张体征：一般无体征、可有周围淋巴节肿大，肺部叩诊浊音，呼吸音减低，或有湿罗音。,31,primary pulmonary tuberculosis,诊断和鉴别诊断病史（三史）临床表现结核菌素试验X-线检查（胸正侧位片原发综合症支气管淋巴结结核（炎症型、结节型、微小型纤维支气管镜检查（
23、1管腔狭窄、2炎症、肉芽肿或溃疡3腔内肿块3支气管瘘，孔口火山样突起，干酪样物实验室检查,32,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,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,primary pulmonary tuberculosis,鉴别诊断气道异物肿瘤各种肺炎，支气管扩张。,35,conclusion,EpidemiologyDiagnosisOT testtherapeutic principle,36,
