肺结核英文讲稿.ppt
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肺结核英文讲稿.ppt
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PulmonaryTuberculosis,ProfessorXiangdongZhou(周向东),TutorofPh.DPostgraduateRespiratorydepartmentofthesecondaffiliatedhospitaloftheChongqinguniversityofmedicalsciences,Introduction,TuberclebacillusTuberculosisepidemiologyKochandtuberculosis,Epidemiology,Oneoftheleadinginfectiousdiseasekillers.OnethirdoftheworldspopulationiscurrentlyinfectedwithTB.Eeverysecondanotherpersonisnewlyinfectedwithtuberculosisaroundtheworld.Eachyearanestimated8millionpeopledevelopclinicaldisease.Eachyear1.87millionpeopledieofTB.,Theincidenceoftuberculosishasdeclineddramaticallyindevelopedcountriesduetoimprovednutrition,housing,effectivedrugs,vaccines.Itremainsasaprobleminpoorercountries(about80%oftheworld)itsoverallincidenceisincreasingworldwidebecauseoftheenhancedsusceptibilityofAIDSpatientsandtheappearanceofdrugresistantstrains.,KochandTuberculosis,RobertKoch(Germany)isolatedthetuberclebacillusin1882andestablishedTBasinfectiousdisease.Kochwasoneofthefirstpeopletoenvisageavaccineforthecontroloftuberculosis,whodiscoveredtheetiologicagentoftuberculosis.,KochisnowknownasTheFatherofBacteriologyHewaspresentedwiththeNobelPrizeinPhysiologyorMedicinein1905forhisinvestigationsanddiscoveriesinrelationtotuberculosis.Ontherightthereisonepageofhis“etiologyoftuberculosis”,Definition,PulmonaryTuberculosis:
1)AcontagiousbacterialinfectioncausedbyM.tuberculosis(TB).2)Thelungsareprimarilyinvolved,buttheinfectioncanspreadtootherorgans.3)Itischaracterizedbythedevelopmentofgranulartumors(nodes)intheinfectedtissues.4)ThepatientswithTBoftenhavethefollowingsymptoms:
tuberculoustoxemia,cough,coughupbloodorbloodsputumetal.,TheTBlesionoftenlocatesatposteriororapicalsegmentoftheupperlobeorthesuperiorsegmentofthelowerlobe,especiallyattheapexoflungjustasthepicturepointsout.,Thereisdiffusesmallgranulomasandnecrosis,ThemacroscopiclesionofTB,Etiologyandpathogenesis,PathogenesisRiskfactorsTransmission,Pathogenesis,InfectionAerosolizeddroplets(varibleorganisms)inhaledperson(susceptible)tuberculosis1.Organismsmacrophagesdie2.Persistandmultiplywidespreadlymphaticandhematogenousdissemination(noeffectiveimmuneresponse)primarytuberculosis(usuallyasymptomatic),3.MycobacteriawalledoffgranulomatousInflammation4.Uncommonlyinadequateimmuneresponseprogressiveprimarytuberculosispulmonaryandconstitutionalsymptoms.5.Afewremainingviableintissuespersistforyearsreactivationmayoccur(whenhostsdefensebecomeimpaired)Person-to-persontransmissionreactivation(one-third),6.Atypicalpresentationsincreased:
ElderlypatientsHIVinfectionNursingpersonsExtrapulmonarytuberculosiscommon,bilateralupperinfiltrates,Diffusebilateralpneumonicinfiltratesonchestradiograph,Riskfactors,1.Immigration(frompartsoftheworldwithahighprevalenceofdrug-resistanttuberculosis)2.Closeandprolongedcontactwithindividualswithdrug-resistanttuberculosis3.Unsuccessfulprevioustherapy4.StrainsofMtuberculosisresistanttooneormorefirst-lineantituberculousdrugs(increasingfrequency),Resistancetooneormoreantituberculosisdrugshasbeenfoundin17%oftuberculosispatientsintheChinaOutbreaksofmultidrug-resistanttuberculosisinhospitalshighmortalityrates5.AIDSincreasedriskofdevelopingtuberculosis,Transmission,TBmainlyspreadthroughtheairfromonepersontoanotherThebacteriaareputintotheairwhenapersonwithTBofthelungscoughsorsneezes.Peoplenearbymaybreatheinthesebacteriaandbecomeinfected.TBmayspreadthroughgastrointestinaltract,Clinicalfindings,SymptomsSignLaboratoryFindingsImaging,Symptoms,1.Constitutionalsymptoms:
fatigue,weightloss,anorexia,low-gradefever,nightsweats2.Pulmonarysymptoms:
drycough,bloodsputumorlaterproductiveofpurulentsputum,ornosymptoms.,Sign,Normal,chronicallyill,weightloss,mayrevealposttussiveapicalrales.,LaboratoryFindings,1.RecoveryofMtuberculosis:
Acid-fastbacillistainDNAprobeCulturesAradiometricculturesystem(BACTEC):
1-2weeks(nuclide)Threeconsecutivemorningsputum.Sputuminduction:
patientswhocannotvoluntarilyproducesatisfactoryspecimens.Sputumspecimens:
concentrated-digested-asascreeningmethod.,2.Demonstrationofonsputumsmear:
doesnotconfirmtuberculosis,sincesaprophyticnontuberculousmycobacteriamaycolonizetheairwaysorcausepulmonarydisease.3.Fibreopticbronchoscopy:
ExpectoratedsputumspecimensBronchialwashingsTransbronchiallungbiopsies4.Mtuberculosis-bloodcultured,Mycobacteriumtuberculosis,5.Pleuralfluidcultures:
Mtuberculosisarepositiveinlessthan25%.6.Needlebiopsyofthepleura:
patientswithpleuraleffusionscausedbyMtuberculosis.7.Susceptibilitytesting:
thefirstisolateofMtuberculosis(whenatreatmentisfailing).8.Restrictionfragmentlengthpolymorphismanalysis(DNAFinger-printing):
identifyrelatedstrainsofM.tuberculosisandchainsofTBtransmission.,Imaging,Primarytuberculosis:
Smallhomogeneousinfiltrates(usuallyintheupperlobe)HilarandparatracheallymphnodeenlargementSegmentalatelectasis.Pleuraleffusionmaybepresent,Primarytuberculosis,Reactivationtuberculosis,Variousradiographicmanifestations:
fibrocavity-nodules-infiltratesTheusuallocation:
apicalorposteriorsegmentsoftheupperlobes;superiorsegmentsofthelowerlobes.Lowerlungtuberculosisendobronchialtuberculosispneumonialungcancer,Infiltrativetuberculosis,Anterior-,Lateral-,Caseousnecrosis,chronicfibrosiscavitarytuberculosis,Extensivedestruction:
widespreadcavitation,fibrosisscars,Acutehematogenousspreading/miliarytuberculosis,thebilateral,diffusesmallgranulomasoftencontainnumerousmycobacterium,Miliarytuberculosis,pleuraltuberculosis,Pleuraleffusionoftenappearsinpleuraltuberculosis.presenceoffluidbetweenthevisceralandparietalpleura.Itcanbeseenwhen300mloffluidispresentonachestradiograph.,Specialexamination,TuberculinskintestidentifiesindividualswhohavebeeninfectedatsometimewithMtuberculosis,butdoesnotdistinguishbetweencurrentandpastinfection.PPDtest:
0.1mLofstandardpurifiedprotein(5TU)isinjectedintradermallyonthevolarsurfaceoftheforearm.Thetransversewidth(inmillimeters)oftheindurationattheskintestsiteshouldberecordedafter48-72hours.,ThepeoplewiththefollowingconditionsshouldhavePPDtest:
1.Peoplewhohavehadcloseday-to-daycontactwithsomeonewhohasactiveTBdisease.(afamilymember,friend,orco-worker)2.PeoplewhohassymptomsofTB,suchas:
acoughthathangson,fever,weightloss,nightsweats,constanttiredness,lossofappetite.3.PeoplewhohaveloweredimmunitysuchasHIVinfectionorcertainmedicalconditions.4.PeoplewhoneedtogiveBCGvaccine.,PPDtest(induration),Thestandardofjudgement,48-72hskinnodediameter:
1.Negativereactiondoesnotruleoutthediagnosisoftuberculosis.2.False-positivereactionsareduetoinfectionwithnontuberculousmycobacteria.3.False-negativereactionsoccur:
Concurrentinfection,malnutrition,oldage,immunologicorlymphoreticulardisorders,corticosteroidtherapy,chronicrenalfailure,virusvaccinationsorinfections,fulminanttuberculosis,impropertestingtechnique.,4.PatientswithAIDSarecommonlyanergic.5.Boostingoftheskintestreactionbyserialtestingmaycauseafalseimpressionofconversion:
Reason:
antigenicchallengeoftheinitialskintest-restore-dormantmycobacterialsensitivityThisboostingphenomenonmayincreasethereactionsizeonasubsequenttuberculintest.Atwo-steptestingproceduremayidentifyaboostedtuberculinreaction.,Iftheinitialtestisnegative,itmayberepeatedaweeklater.Thesecondtestisnegative:
theperson-uninfectedoranergic.Thesecondtestispositive:
mostlikely-boostedreaction(thiseffectmaypersistforatleast1year)Interpretationofananergyskintestshouldbejudgedlikelytobeanergicforanyreason(likeBCG).,EssentialsofDiagnosis,Historyandclinicalsymptoms:
fatigue,weightloss,fever,nightsweats,cough,orbloodsputumPulmonaryinfiltratesonchestradiograph,mostoftenapical.Positivetuberculinskintestreaction(mostcases).Acid-fastbacillionsmearofsputumorsputumculturepositiveforMycobactenumtuberculosis.,Clinicalclassification,PrimarytuberculosisHematogenousspreadingtuberculosisSecondarytuberculosis:
-infiltrativepulmonarytuberculosis-chronicfibro-cavipulmonarytuberculosisPleuraltuberculosis,Physician:
PatientsClinicalsymptomsDrugtoxicityRadiographicandbacteriologicfindingsSerumbilirubinandhepaticenzymesUreanitrogenandcreatinineCompletebloodcount(CBC)Afailureofradiographicimprovementwithin3monthssuggestsanotherdiagnosis,.,Case,ZhouPingisa42yearoldmalewithapasthistoryofactivetuberculosisthatwastreatedatanotherinstitution.Henowpresentswithafourweekhistoryofcough,feverandweightloss.Hedeniesanyotherimportantcomplaintanddoesnotrememberthedetailsofhistreatment,althoughhereportsthathewascompliantduringthe6monthsoftherapy.,Histemperatureis38.2.Hehasevidenceofconsolidationofhisrightchestonphysicalexam.Achestradiographshowsarightupperlungcavitywithsurroundinginfiltrates.OneofhisthreesputumsamplesispositiveforrareAFB.1.Whatimportantpieceofinformationshouldhavebeenobtainedearlyinhishospitalization.Discusstheimportanceofobtainingasmuchinformationaspossibleaboutpriortuberculosis,treatmentandcompliance.,testing.,Atmorningroundsitisdecidedthatitisverylikelythatthepatienthastuberculosis,andempirictherapyisstartedwithINH,RIF,EMB,andPZA.2.Giventhedifferentialdiagnosisandappropriateempirictreatment.1)Discusstheimportanc
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