我國結(jié)核病的疫情狀況,WHO93年宣布“全球結(jié)核病緊急狀態(tài)”，98年又重申遏制結(jié)核病的行動刻不容緩。全球現(xiàn)有結(jié)核病人2000萬，其中95在發(fā)展中國家，每年還會新發(fā)生800-1000萬肺結(jié)核病，其中75的病人年齡在1550歲。如不控制，今后10年還將有9000萬人發(fā)病。中國是全球22個結(jié)核病高負(fù)擔(dān)國家之一，結(jié)核病人數(shù)位居世界第二位，僅次于印度.據(jù)調(diào)查全國三分之一的人口已感染了結(jié)核菌；受感染人數(shù)超過4億,受結(jié)核感染人群中有10的人發(fā)生結(jié)核病,1,tuberculosis,factoroftuberculosisincidencerising：HIVspread.TBstrainoccurdrugresistance.fluidpopulationincreasing.ManagementTBpatientnotperfect、preventionandcurenotefficiency.Poverty、populationincreasing.,2,etiology,Mycobacterium、Acidfastness、G+、aerobe。Growthtorpidity,cultureneed4-6weeks.Typing:humantype、bovinetype、Birdtype、mousetype、mainhumantype。wayofinfection：respirationtract、digestivetrack、skinorplacenta.,3,Epidemiology,1infectionsources：openpulmonarytuberculosis2routeoftransmission:byrespirationwayordigestiontract.3susceptiblepopulation,4,Epidemiology,ThefactorsleadChildrenillwithTBContactTBamountsandtoxicity.powerofresistance.hereditaryfactor.,5,pathogenesy,bacterialnumber、toxicity、immunizationconditionCell-mediatedimmunereaction:macrophageswallowTBantigenpresentationThandmacrophageIL12CD+4TH1-IF-topromotemononuclearcell;togather、activation、proliferationanddifferentiationtoproducealexinandoxidase、digestiveenzymetokillTB,6,pathogenesy,IF-reinforcementCD+8、NKcellsactivitytophagocytosisTB.meanwhiletoleadhistoclasiadelayedallergy:Tcellmedia，macrophagetobeeffectorcell，tokillreinfectionTBandcausecheesynecrosisorholeformationAfterInfectionTB:primarydisease（5%），Secondarydisease（5%）,nottofallillalllive(90%),7,diagnose,Objectivetodiscoverfocal。Definitediseasecharacter、sizewhetherornotdeliverbacterium。,8,diagnose,1historyTBtoxicsymptomtocontactTBpatientBCGvaccinationacuteinfection:measles，pertussisSupersensitivityerythemanodosum、exanthematousconjunctivitis。,9,diagnose,2：OTtestagent：1/2000or1/10000PPDdose：0.1ML（OT5U）（or1U）。position：leftforearmpalmarisbelow1/3Infuseintracutaneousform6-10mmhillock。4872hrobservationreaction。,10,diagnosis,reaction6mmbyactivenessTB.。,12,diagnosis,negativereactionneverinfectionTBfirstInfectTBduring4-8weeksfalsenegativereaction，immunefunctiontobepresseddown。WrongwithtestorPPDineffective,13,diagnosis,BCGVaccinationandnaturalinfectionpositivereactioncondition,14,diagnosis,3：laboratoryexamination（1）findTBspecimen：sputum、gastricjuice、C.S.F、serouscavityliquid.method：smear、fluorescentstaining、BACTECsystem：culturefor2weeks，testmycobacteriametabolismproduction，todistinguishTBandatypical.mycobacteria.Ltuberclebacterium：mutationTB，form、construction、acid-faststainingdifferentfromcommonTB。Easypassingplacenta，therapeuticinefficacy。,15,diagnosis,（2）immunologyandmolecularbiologytestELISA（酶聯(lián)免疫吸附試驗）ELIEP（酶聯(lián)免疫電泳技術(shù)）DNA探針PCR（聚合酶鏈?zhǔn)椒磻?yīng)）線條DNA探針雜交試驗ESR(血沉)。,16,diagnosis,4：chestX-RAYTodefinitefocusofinfectionposition、extent、category、activitycondition。Toevaluateandfollowuptherapeuticefficacy。CTmorecleartofindthefocus、extentandspreadcondition。5：bronchofiberscopycheck：todefiniteEndotrachealmembraneTBandtuberculosisoftrachebronchiallymphnodes。6：lymphnodepuncturesmearorlymphadenbiopsytodiagnosis。,17,tuberculotherapy,generaltreatmentnutrition、totakearest。avoidingtocontactinfectiondisease。PrimarilyTBtreatmentinout-patientclinicandregularityreturnvisit。Reportepidemicsituation。,18,tuberculotherapy,TreatmentargetTokillBacillustuberculosisinfocustopreventdisseminate。therapeuticprincipleearlytreatmentReasonabledosageCombinemedicineRegularitytakedrugtoinsistonwholecourseSegmentingtreatment.,19,tuberculotherapy,Anti-tuberculosisdrugsWholegermicide：inacidandalkali，exteriorandinteriorofcellcankillgerm。(INHRFP)Halfgermicide：inacidoralkalienvironmentkillcellinteriororexteriorTB，SM/PZAbacteriostatic：EMB（ethambutol)ETH(ethionamide),20,tuberculotherapy,newantituberculosistoAntidrugresistantRifamate(containINH150mgRFP300mg)Rifater(INH,RFPPZA)olddrugderivant：RifapentineNewchemicals：Dipasic，todelayresistantINHdrugstandardtreatment：refertoasymptomaticprimarilypulmonarytuberculosisusage：INH+RFPEMBcourseoftreatment912month.,21,化療方案,Twostagetherapyreferto：activenessprimarilypulmonaryTB:acutemiliarytuberculosis;brainTB;intensificationtherapy：（purpose）Combination34germicidedrugsLonger34mo、shorter2mo。continuetreatmentstageCombinationtwodrugstokeeptherapeuticeffectfor1218mo.(longerrang)or4mo.(Short-rang)。,22,化療方案,short-rangetherapyWHOimportantstrategytocuretuberculosismechanismofactionisfastkillorganisminnercelloroutcell。Tosputumbacterium(-)，recoveryfast，recurrenceless。2HRZ/4HR、2SHRZ/4HR、2EHRZ/4HR,23,antituberculosisdrugs,medicinedoseadversereactionINH1020多發(fā)性神經(jīng)炎，肝損害RFP1015可逆性肝損害，消化道癥狀。尿紅色。PZA20-30肝損害，高尿酸血癥。SM1520聽神經(jīng)損害,腎損害。EMB1520球后視神經(jīng)炎。,24,Tuberculosisprevention,tocontrolsourceofinfection：smear(+)patientPervasionBCGvaccination：tohaveaninoculationageisneonate.contraindicationcellularimmunitydeficiencyacuteinfectiousdiseaseconvalescencestageRegioneczemaorgeneralskindiseaseOT（+）,25,Tuberculosisprevention,Drugpreventionindication:1Closetocontactopenpulmonarytuberculosisinfamily2lower3yearsinfanthavenotinnoculationBCG;butOT（+）3OTfrom（-）to（+）recently4OT(+)withtoxicsymptom5OT（+）andrecentlyillwithmeaslesorpertussis6OT（+）needlong-termtotakecorticosteroidsorimmunodepressant,26,Tuberculosisprevention,Approach1:INH10mg/kgcourseoftreatment69mo.Approach2:INH+RFP(10mg/kg)course3mo.,27,原發(fā)性肺結(jié)核（primarypulmonarytuberculosis),首次侵入肺部發(fā)生的原發(fā)感染原發(fā)綜合癥（primarycomplex)原發(fā)病灶+局部病變淋巴結(jié)+淋巴管支氣管淋巴結(jié)結(jié)核(胸腔內(nèi)腫大淋巴結(jié)結(jié)核),28,primarypulmonarytuberculosis,病理部位:右側(cè)肺上葉底部、下葉上部基本病變：滲出（炎癥細(xì)胞單核細(xì)胞纖維蛋白）、增殖（結(jié)核結(jié)節(jié)結(jié)核肉芽腫）、壞死（干酪樣壞死）。炎癥特征：上皮樣細(xì)胞結(jié)節(jié)、langerhans細(xì)胞浸潤,29,primarypulmonarytuberculosis,病理轉(zhuǎn)歸吸收好轉(zhuǎn)進(jìn)展擴(kuò)大出現(xiàn)空洞支氣管內(nèi)膜結(jié)核或干酪性肺結(jié)核腫大