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.1tuberculosis factor of tuberculosis incidence rising：HIV spread.TB strain occ
2、ur drug resistance.fluid population increasing.Management TB patient not perfect、prevention and cure not efficiency.Poverty、population increasing.2etiology Mycobacterium、Acid fastness、G+、aerobe。Growth torpidity,culture need 4-6 weeks.Typing:human type、bovine type、Bird type、mouse type、main human type
3、。way of infection：respiration tract、digestive track、skin or placenta.3Epidemiology 1 infection sources：open pulmonary tuberculosis 2 route of transmission:by respiration way or digestion tract.3 susceptible population.4Epidemiology The factors lead Children ill with TB Contact TB amounts and toxicit
4、y.power of resistance.hereditary factor.5pathogenesybacterial number、toxicity、immunization condition Cell-mediated immune reaction:macrophage swallow TBantigen presentation Th and macrophageIL12CD+4TH1-IF-to promote mononuclear cell;to gather、activation、proliferation and differentiationto produce al
5、exin and oxidase、digestive enzymeto kill TB.6pathogenesy IF-reinforcement CD+8、NK cells activity to phagocytosis TB.meanwhile to lead histoclasia delayed allergy:T cell media，macrophage to be effector cell，to kill reinfection TB and cause cheesy necrosis or hole formation After Infection TB:primary
6、disease（5%），Secondary disease（5%）,not to fall ill all live(90%).7 diagnose Objective to discover focal。Definite disease character、size whether or not deliver bacterium。.8diagnose 1 history TB toxic symptom to contact TB patient BCG vaccination acute infection:measles，pertussis Supersensitivity eryth
7、ema nodosum、exanthematous conjunctivitis。.9diagnose 2：OT test agent：1/2000 or 1/10000 PPD dose：0.1ML（OT 5U）（or 1U）。position：left forearm palmaris below 1/3 Infuse intracutaneous form 6-10mm hillock。4872hr observation reaction。.10diagnosis reaction 5mm(-)5mm(+)10-19mm(+)20mm(+)Super reaction:indurati
8、on、vesic、local ulceration(+)。.11diagnosis significance positive reaction After BCG vaccination Older 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（+
9、）、from 10mm,or increase 6mm by activeness TB.。.12diagnosis negative reaction never infection TB first Infect TB during 4-8 weeks false negative reaction，immune function to be pressed down。Wrong with test or PPD ineffective.13diagnosis BCG Vaccination and natural infection positive reaction condition
10、.14diagnosis3：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、constr
11、uction、acid-fast staining different from common TB。Easy passing placenta，therapeutic inefficacy。.15diagnosis（2）immunology and molecular biology test ELISA（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)。.16diagnosis4：chest X-RAY To definite focus of infection position、extent、category、a
12、ctivity 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
13、tuberculotherapygeneral treatment nutrition、to take a rest。avoiding to contact infection disease。Primarily TB treatment in out-patient clinic and regularity return visit。Report epidemic situation。.18tuberculotherapyTreatmen target To kill Bacillus tuberculosis in focus to prevent disseminate。therape
14、utic principle early treatment Reasonable dosage Combine medicine Regularity take drug to insist on whole course Segmenting treatment.19tuberculotherapy Anti-tuberculosis drugs Whole germicide：in acid and alkali，exterior and interior of cell can kill germ。(INH RFP)Half germicide：in acid or alkali en
15、vironment kill cell interior or exterior TB，SM/PZA bacteriostatic：EMB（ethambutol)ETH(ethionamide).20tuberculotherapy new antituberculosis to Anti drug resistant Rifamate(contain INH 150mg RFP300mg)Rifater(INH,RFP PZA)old drug derivant：Rifapentine New chemicals：Dipasic，to delay resistant INH drug sta
16、ndard treatment：refer to asymptomatic primarily pulmonary tuberculosis usage：INH+RFPEMB course of treatment 912 month.21化疗方案 Two stage therapy refer to：activeness primarily pulmonary TB:acute miliary tuberculosis;brain TB;intensification therapy：（purpose）Combination 34 germicide drugs Longer 34mo、sh
17、orter 2mo。continue treatment stage Combination two drugs to keep therapeutic effect for 1218mo.(longer rang)or 4mo.(Short-rang)。.22化疗方案 short-range therapy WHO important strategy to cure tuberculosis mechanism of action is fast kill organism inner cell or out cell。To sputum bacterium(-)，recovery fas
18、t，recurrence less。2HRZ/4HR、2SHRZ/4HR、2EHRZ/4HR.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。.24Tuberculosis preventionto control source of infection：smear(+)patientPervasion BCG vaccination：t
19、o have an inoculation age is neonate.contraindicationcellular immunity deficiencyacute infectious disease convalescence stageRegion eczema or general skin diseaseOT（+）.25Tuberculosis preventionDrug prevention indication:1 Close to contact open pulmonary tuberculosis in family 2 lower 3 years infant
20、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 prevention Approach 1:INH 10mg/kg course of treatment 69mo.Approach 2:INH+RFP(10mg/kg
21、)course 3 mo.27原发性肺结核（primary pulmonary tuberculosis)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).28primary pulmonary tuberculosis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.29primary pulmonary tuberculosis 支气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
22、或全身性粟粒性结核病）.30primary pulmonary tuberculosis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。.31primary pulmonary tuberculosis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（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。.34primary pulmonary tuberculosis张。.35 conclusionEpidemiologyDiagnosisOT testtherapeutic principle.36
