1、肺結核合併愛滋病治療台北榮民總醫院 感染科國立陽明大學愛滋病預防及研究中心王永衛 醫師TAIWAN0.08%(0.03-0.14)Worldwide Adult Prevalence of HIV InfectionHIV-infected Persons Total:18386(in 2009)AIDS:5811 Deaths:2418 On ART 5000(33%)1,000,000-1,200,000 HIV-infected individuals in USA,2007,57%on ARTSynovate Healthcare U.S.HIV Monitor Q2,2007;Cen
2、ters for Disease Control and Prevention(CDC):http:/www.cdc.gov;Taiwan Center for Disease Control(2009 report)目前愛滋病毒感染存活人數目前愛滋病毒感染存活人數:4000萬萬人人每年新感染每年新感染HIV人數人數:500萬萬人人每年愛滋病患死亡人數每年愛滋病患死亡人數:300萬萬人人12001100100090080070060050040030020010001:5121:2561:1281:641:321:161.81.41.20WeeksYears036912345678910111
3、2CD4 T Cells/mm3Plasma Viremia TiterPrimaryinfectionPossible acute HIV syndromeWide dissemination of virusSeeding of lymphoid organsClinical latencyDeathOpportunisticdiseasesConstitutionalsymptoms()()Natural History of HIV Infection結核病結核病 三千年歷史的古老疾病三千年歷史的古老疾病埃及時代埃及時代西元前西元前 3700-1000年年誰是肺結核病人誰是肺結核病人?
4、魯迅魯迅李叔同李叔同林徽音林徽音林黛玉林黛玉身邊隨時都有機會接觸病人，與其排斥逃身邊隨時都有機會接觸病人，與其排斥逃避，不如主動關懷，幫助病人好好治療。避，不如主動關懷，幫助病人好好治療。Robert Koch結核病防治o全球每年約有全球每年約有300300萬人死於結核病，約萬人死於結核病，約300300萬人死於愛滋病，其中愛滋病人死萬人死於愛滋病，其中愛滋病人死於結核病約佔於結核病約佔1/31/3。o全球約有全球約有1/3 1/3 人口已受結核菌感染，人口已受結核菌感染，每年約有每年約有 800 800 萬人新發生結核病，其萬人新發生結核病，其中台灣約佔中台灣約佔 15,00015,000
5、人。人。何謂結核病（何謂結核病（TB tuberculosis）？）？p慢性傳染性疾病慢性傳染性疾病p由結核分枝桿菌（結核桿菌）所引起的由結核分枝桿菌（結核桿菌）所引起的p由飛沫（空氣）傳染由飛沫（空氣）傳染p病情進展緩慢，早期症狀不明顯病情進展緩慢，早期症狀不明顯p人體之任何器官都可能得結核病，以肺部居多人體之任何器官都可能得結核病，以肺部居多認識結核桿菌（認識結核桿菌（tubercle bacillus）p嗜氧菌、抗酸菌，喜潮濕、陰暗處嗜氧菌、抗酸菌，喜潮濕、陰暗處p長約長約1 10m微米微米，寬約，寬約0.20.6 m，生長期約，生長期約 48 週週p最適宜之生存溫度是最適宜之生存溫度是
6、37p怕熱、怕火，怕熱、怕火，100，5分鐘；分鐘；65，15分分鐘即可殺菌鐘即可殺菌p怕陽光；紫外線照射迅速死亡怕陽光；紫外線照射迅速死亡認識結核桿菌（認識結核桿菌（tubercle bacillus）典型分枝桿菌典型分枝桿菌非典型分枝桿菌非典型分枝桿菌人型結核桿菌人型結核桿菌鳥型、牛型分枝桿菌鳥型、牛型分枝桿菌具傳染性具傳染性不具傳染性不具傳染性菌落粗糙菌落粗糙菌落較散，平滑菌落較散，平滑HIV prevalence in adults,and TB notification rates,for Kisumu,Kenya Nat Rev Immunol 2005;5:819-26.TB-H
7、IV co-infection in Taiwano HIV帶原者中有5.6%曾罹患結核病o 2006年確診結核病與HIV資料庫進行勾稽nHIV(+)/TB 的比率為 0.71%（112人）nPrevalence of HIV in adult TB patients(1549yrs)is 2.03%in 2006Clinical manifestation in AIDS with disseminated mycobacterial infection in NTUHo S/SDTB(22)DMAC(15)o Fever21(95.5)14(93.3)o Night sweating15(
8、68.2)4(26.7)o BW loss10(45.5)11(73.3)o Diarrhea 5(22.7)7(46.7)o LNP15(68.2)1(6.7)o Hepatosplenomegaly 3(13.3)6(40)o Splenomegaly 2(9.1)7(46.7)AIDS 1998;12:1301-7CXR findingTB in HIV infected patientsoCD4200CD4 200Upper lobes involvementLower lobe pneumoniaCavity Hilar or mediastinal LNPMiliary TBNor
9、maloNormal CXR8-20%28 Y/O MSMProductive cough for 1 months,BW lossCD4 38 HIV virus load 460000Sputum AFS(-),Lung biopsy:granulomatous inflammation,Caseous necrosis,Multinuclear giant cell2006040420060928TBTB empyemaPulmonary TB with TB lymphadenitis42 y/o MSMIntermittent fever,night sweating for 2 m
10、onthsCD4 215 CD8 1175 HIV virus load 486000LN aspirate AFS(+)Sputum TB culture:MTBExtra-pulmonary tuberculosisPJP and TB38 y/o MSMDOE for 2 weeks,BW loss 11 KgCD4 64 CD8 345 HIV virus load 67300 WBC 2840,Sputum TB culture:MTB,Blood culture:Salmonella choleraesuis 2006020720060214Diagnosis HIV infect
11、ion with TBoSpecimenMicroscopy%Culture%oSputum40-6774-95oBronchoscopyBronchoalveolar larvage 7-2052-89Transbronchial biopsy10-3942-85oUrine2245-77oBlood26-64oLymph nodes37-9040-95oBone marrow18-5225-67oCSF0-27oPleural specimenPleural fluid3-6Pleural biopsy52-55Textbook of AIDS Medicine 1999;Chapter1
12、6Comparison of HIV Disease Progression in TBTC Study 23 vs.CPCRA 019/ACTG 222Years of enrollmentBaseline CD4 cell countUse of HAART during TB treatmentDeath within 1 year of start of TB therapyDeath or new OI within 1 year of start of TB therapy TBTC 231999-20029080%4.5%15.7%CPCRA/ACTG1993-199586020
13、%38.9%Overlapping Side Effect Profiles of First-lineAntituberculosis Drugs and Antiretroviral DrugsSide effectPossible causesAntituberculosis drugsAntiretroviral drugsSkin rashNausea,vomitingHepatitisLeukopenia,anemiaPZA,RIF,INHPZA,RIF,RBT,INHPZA,RIF,RBT,INHRBT,RIFNVP,EFZ,ABCZDV,RTV,AMP,IDVNVP,PIs,I
14、mmunereconstitutionZDVIRS response to pathogens o Mycobacterium tuberculosis(TB)o Mycobacterium avium complex(MAC)o Cytomegalovirus(CMV),o Cryptococcuso Pneumocystiso Toxoplasmao Hepatitis Bo Varicella zoster virus.Clinical Diseases and NTM in HumansoClinical DiseaseNTMoPulmonaryMACM.kansasiiM.chelo
15、naeM.xenopioLymphadenitisMACM.scrofulaceumoCutaneousM.marinumM.fortuitumM.chelonaeM.ulceransoDisseminatedMACM.genovenseM.kansasiiM.chelonaeM.haemophilumM.malmoenseTextbook of AIDS Medicine 1999Mycobacteriual species causing Disseminated NTM infection in AIDS patientso Species Number(%)o MAC1906(96.1
16、)o M.kansasii 57(2.9)o M.gordonae 11(0.6)o M.fortuitum 5(0.3)o M.chelonae 5(0.3)Am Rev Respir Dis 1989;139:4-7Clinical Syndromes of Disseminated MAC in AIDSo GeneralizedFeverFatigueWeight lossPancytopeniao GastrointestinalChronic diarrheaAbdominal painChronic malnutritionPeriportal LNPExtrabiliary obstructive jaundiceMAC pneumonia
