內(nèi)科學(xué)教學(xué)課件：Pulmonary Tuberculosis

PulmonaryTuberculosis

FifthNationalTuberculosisepidemiologicalsurveyresults（March2011）AtpresentthenumberofannualincidenceoftuberculosisinChinaisabout1.3million,accountingfor14.3%ofglobalincidence,amongtheworldisNo.2Nowtheannualrateofdescendingisabout9%WorldTuberculosisDay(24th,March)GeneralConsiderationsTuberculosisisachronicinfection

lifelongdurationCausedbyMycobacteriumtuberculosisItwasisolatedbyRobertKochin1882Themorbidityandmortalityoftuberculosisarehighindevelopingcountriesconfinedtothelungsinmostpatients,about80-90percentmayspreadtoalmostanypartofthebodyEtiologyThetuberclebacillus(M.Tuberculosis)isaerobic,non-motile,non-spore-forming,highinlipidcontents,andacidandalcohol-fastItgrowsslowlyItcan’ttolerateheat.(60℃-30,85℃-5,95℃-1)Itcanliveinhumidordryorcoldsurroundings.epidemiologyThesourcesofinfectionTherouteofspreadPeoplesofeasilyaffectedTuberculosisistransmittedbyairbornedropletnuclei(containingtuberclebacilli)ManydropletnucleiarecapableoffloatingintheimmediateenvironmentforseveralhoursParticlesmaybeinhaledbyapersonbreathingthesameairandimpactonthetracheaorwalloftheupperairwayThetransmissionisdeterminedTheprobabilityofcontactwithacaseofTBTheintimacyanddurationofcontactThedegreeofinfectiousnessofcaseThesharedenvironmentofthecontactPathogenesistuberclebacillusHumanimmunityPhagocytosisperiodCellmediatedimmunity(CMI)Delaytypehypersensitivity(DTH)Tlymphocytes(CD4+):SymbioticperiodLiquefactionandPropagationperiodHumanImmunityafterinfectedtuberclebacillusandtuberculinhypersensitivityThenaturalimmunityofhumantoTBisnonspecificAfterinfectedorgivenBCGvaccine,humanwillobtainspecificimmunityTheimmunityoftuberclebacillusiscell-mediatedimmunitybasicpathologicchangesIncludinginfiltration,hyperplasia,caseousnecrosisorcalcification.ThesechangeshappenindifferentstageoftuberculosisWhenhostdefenseisdestroyedandthereismuchmorebacterias,caseatingulcerationwillexistwhenhostdefenseispredominantandthereislessbacteria,perhapshyperplasiaandcalcificationwillhappenTheresultofthetuberculosisafterinfectionAbsorption,FibrosisCalcificationDeterioration:enlargementofinfectedareasandappearnewerinfiltratedregionsorspreadingTherearefivecommonclinicalpatternsoftuberculosisPrimarypulmonarytuberculosis(PrimaryComplexandBronchialLymphnoidTuberculosis)MilliaryTuberculosis(acute,subacuteandchronichematogenouspulmonarytuberculosissecondarypulmonarytuberculosis

InfiltrativepulmonarytuberculosisChronicfibrocavenouspulmonarytuberculosisTuberculouspleuritisExtrapulmonarytuberculosisclinicalpatternsofpulmonarytuberculosisClinicalManifestations

systemicsigns:Mostpatientspresentascasesofpulmonarytuberculosiswithfever,weightloss,anorexia,fatigue,nightsweatswasting.

respiratorysigns:CoughHemoptysischestpaintachypeneaectPhysicalsigns:nonspecific.

LaboratoryandphysicalexaminationsPathogenexamination:Sputumexamination

PCRtesttodetectTBTBantibodytestingChestradiographyTuberculintestingbronchoscopy

Sputumexamination

directsmearsputumcultureDirectsmearexaminationisonlypositivewhenlargenumbersofbacillibegintobeexcretedAnegativesmearbynomeansexcludestuberculosisParticularlyifthenegativesarefrequentlyrepeated

PCRtesttodetectTB

(1)

shadowsmainlyintheupperzone(2)patchyornodularshadows(3)thepresenceofacavityorcavities,althoughthese,ofcourse,canalsooccurinlungabscess,carcinoma,etc(4)thepresenceofcalcification.althoughacarcinomaorpneumoniamayoccurinanareasofthelungwherethereiscalcificationduetotuberculosis(5)bilateralshadows,especiallyiftheseareintheupperzones(6)thepersistenceoftheabnormalshadowswithoutalterationinanx-rayrepeatedafterseveralweeks

thishelpstoexcludeadiagnosisofpneumoniaorotheracuteinfectionChestradiographyPrimarycomplexMilliaryTuberculosis

acutemilliarytuberculosissecondarypulmonarytuberculosisinfiltrateTuberculoma

Chronicfibro-cavitarypulmonarytuberculosiscavityTuberculouseffusion

TuberculinskintestApositivetuberculintestalthoughitisofgreatuseinchildren,butithaslimiteddiagnosticsignificanceinolderagegroupsMainSignificance:Epidemiologicalsurvey,detectsomenewpositivepeoples,assistantdiagnosisHowtojudgetheresult?

Areactionoflessthan5mmisconsiderednegative5-9mmisconsideredpositive(+)10-19mmisconsideredpositive(++)morethan20mmorwithBlisterisconsideredpositive(+++)

BronchoscopyexaminationEndobronchialtuberculosis

Diagnosis

Accordingtothehistory,clinicalsigns,chestX-rayandsomeotherexaminations,wecandiagnoseTBPatientswithpositivesputumexamination(ClinicalsignsandXrayfeatures)PatientswithnegativesputumexaminationClinicalsignsandXrayfeatures,excludeothernontuberculosisdisease,positivePPDtestandeffectiveofdiagnosticantituberculosistherapy

HowtojudgetheactivityofpulmonarytuberculosisClinicalsignsSputumexaminationX–rayexaminationHowtowritethediagnosiscorrectly?Generally,wewritethediagnosisaccordingtothesiteofTB,clinicalpatterns,theresultofsputumexaminationandthehistoryofchemotherapy.UpperRightsecondarypulmonarytuberculosis,smear(-),retreatment

DifferentialDiagnosis

Bronchiectasis

chroniccough,sputumproductionandhemoptysis.HRCTscantodistinguishthem.CavitarylungabscessTheSiteofcavitaryClinicalsignsLaboratoryexaminationsTheoutcomeofantibiotictherapyAcutebacterialpneumoniasmayresemblefloridtuberculosisinallparticularsexceptforthesputumexaminationandresponsetoantimicrobialdrugsLungcancer

DifferentialDiagnosis

:lungcancercomplicationsPneumothoraxBronchiectasisEmpyemaExtrapulmonaryexpansionHemoptysisChronicpulmonaryheartdiseaseTherapyChemotherapySurgicaltherapySupporttherapyTheprinciplesofantituberculouschemotherapyearlier

combinationadequateamountdosageregularlyandfulldurationsTreatmentThecriticalissueinTBcontrolisadoptingtheDOTS(1995)(DirectlyObservedTreatment,Short-coursetherapy);DOTSStrategyisrecommendedbytheWHOTBProgram.

Isoniazid(INH)

IsoniazidisaprincipalagentusedtotreattuberculosisItisuniversallyacceptedforinitialtreatmentNowconsideredthebestantituberculousdrugItshouldbeincludedinallTBtreatmentregimensunlesstheorganismisresistantAdvantagesandDosageInexpensiveHighlyselectiveformycobacteriaWelltolerated(aboutonly5%ofpatientsexhibitingadverseeffects)4-8mg/kgdailyforbothgroupsa300mgdailyoraldoseisadoptedAdverseeffectsThetwomostimportantadverseeffectsofisoniazidtherapy:hepatotoxicityperipheralneuropathy

Rifampin(RFP)

ItisalsoconsideredthemostimportantandpotentantituberculosisagentLikeisoniaziditisbactericidalandhighlyeffectiveIthasbothintracellularandextracellularanti-bacterialactivity

Dosage

450-600mgdailyortwiceweeklyAdverseeffectsgastrointestinalupsethepatitis

Pyrazinamide(PZA)

PyrazinamideisamajororalagentusedagainstmycobacteriaItisanimportantbactericidaldrugusedinshort-coursetherapyfortuberculosisThedrugisusedtokillintracellulartuberclebacillusItisdistributedthroughoutthebody,excellentinCSFDosage

15to30mg/KgAdverseeffect

Atthehighdosages,hepatotoxityisaprominentsideeffectStreptomycin(SM)

ItisfrequentlyusedindevelopingcountryforitslowercostItisadministeredonlyparenterally,intramuscularorintravenousDosageTheusualadultdoseis0.5-1.0g(10to15mg/kg)dailyorfivetimesweeklyThedosagemustbeloweredandthefrequencyofadministrationreducedtoonlytwoorthreetimesperweekinmostpatientsoverfiftyyearsoldandinanypatientwithrenalimpairmentAdverseeffectsOtotoxityRenaltoxicity

Ethambutal(EMB)

ItisusedmostoftentoprotectagainsttheemergencyofdrugresistanceOraladministrationThedosageisusually25mg/KgItwilldistributesthroughoutthebodyexceptCSFRetrobulbaropticneuritisisthemostseriousadverseeffectThemetabolicstateoftuberclebacilli

Agroups:INHRFPBgroups:PZACgroups:RFPDgroupschemotherapyToinitialpatients:TBpositive:short-termchemotherapy2HRZS(E)/4HR,thedurationlasts6monthsTBnegative:2HRZ/4HRToretreatmentpatients:3HRZSE/5HRZ,thedurationlasts6-12months.chemotherapyToMDR-TB:MDR-TBmeansthatresistanttobothINHandrifampin.Wecanselectfivekindsofantituberculosisdrugsinthestageofintensive.Thesedrugsincludeaminoglycosides(amikacin,kanamycin,capremycin),cycloserine,EMB,quinolones(levofloxacin,ofloxacin),PZA,ethionamide.Inthestageofconsecutive,wecanselectthreekindsofd