結(jié)核總論（英文版）

General

Tuberculosis

in

Children

TuberculosisinChildrenTuberculosisMeningitisPulmonaryTuberculosisGeneral

TuberculosisinChildren

DiagolosisPPDBCGPreventivechemotherapyClinicalmanifestationsDiagnosisClinicalmanifestationsDifferentialdiagnosisEmphases3WhatisTuberculosis?Tuberculosis/Mycobacteriumtuberculosis

(shortforTBorMTB)

"AspecificdiseasecausedbyinfectionwithMycobacteriumtuberculosis,whichcanaffectalmostanytissueororganofthebody,themostcommonsiteofthediseasebeingthelungs."6Epidemiology2012:7EpidemiologyBRICS(2013):

Basicfactofpediatric

TBAglobalTBemergency-byWHOin1993relativelyneglectedpediatricTBdevelopinglife-threateningformsofTBdisease

mostTBcasesareseeninchildren＜5or＞10yearsofageTheincidenceofpediatricTB：6%50,000,in2011EtiologyThescientificnamefortheTBmicrobeisMycobacteriumtuberculosis(MTB)10MycobacteriumtuberculosisTheacid-fastcharacteristicAerobic,slow-growingAveryhardybacillus,butcannottolerateheatHumansaretheonlyknownreservoirsMycobacteriumtuberculosis1882–RobertKoch

HowisTBtransmitted?TBistransmittedthroughtheairTBbacteriaarecoughedupfromthelungsofaninfectedpersonintotheairOncetheTBbacteriaareinhaled,theypushtheirwayintothelungsChildrenarelesslikelytospreadTBbacteriatoothers.anopenactiveTBpatientTransmission14RiskfactorsfortheacquisitionTheenvironmentandthefeaturesoftheindexcaseTheprobabilityofcontactwithacaseofTBTheintimacyanddurationofthatcontactThedegreeofinfectiousenessofcaseThedevelopmentofTBdiseasedependsoninherentimmunologicstatusofthehost.NotallpersonsexposedtoTBbecomeinfected!TransitionsinChildhoodTuberculosis

Notinfected(50-70%)

Infected(30-50%)

Diseased(10-30%)Within2years(50%)Lifelong(50%)LatentTB(70-90%)Neverdevelopactivedisease(90%)ContactwithsmearpositiveindexcaseNotallpersonsinfectedbyTBsufferfromTBdisease!TBInfectionvs.TBDiseaseTBinfection:TBgermsstayinyourlungs,buttheydonotmultiplyormakeyousick.YoucannotpassTBgermstoothersTBdisease:TBgermsstayinyourlungsormovetootherpartsofyourbody,multiply,andmakeyousickYoucanpasstheTBgermstootherpeople17LatentTBvs.ActiveTBLatentTB(LTBI)(Goal=preventfutureactivedisease)1.TBinfection2.Nodisease3.Notsick4.NotinfectiousActiveTB(Goal=treattocure,preventtransmission)1.TBInfectionwhichhasprogressedtoTBDisease2.Sick(usually)3.Infectiousifpulmonary(usually)4.Notinfectiousifnotpulmonary(usually)Human

Immunity

to

TBThenaturalimmunityofhumantoTBisnonspecificAfterinfectedorgivenBCGvaccine:obtainspecificimmunityCell-mediatedimmunity:MacrophagesTlymphocytesPathologicchangesInfiltration,Hyperplasia,Necrosis，CalcificationThesechangeshappenindifferentstageoftuberculosiswhenhostdefenseisdestroyedandthereismuchmorebacteria,caseousnecrosiswillexist

whenhostdefenseispredominantandthereislessbacteria,

perhapshyperplasiaandcalcificationwillhappenPathology:caseousnecrosis:Pathology:TuberculousnodulesLanghan'giantcellTheresultsoftheTBinfection:AbsorptionFibrosisCalcificationDeteriorationordisseminationPathology:23TBmayaffectanytissueofthebody:RespiratorysystemCentralnervoussystemSkinandsofttissueLymphnodesBonesandjointsIntraabdominalstructuresincludingPeritoneumKidneysAdrenalglandsPathology:24TuberculinSkinTest(TST):PurifiedProteinDerivative

Apositivetuberculintestalthoughitisofgreatuseinchildren,butithaslimiteddiagnosticsignificanceinolderagegroups.(PPD):Itmeasuresthebody’simmuneresponsetoTB

Resut

Scleromadiameter

—<5mm+5~9mm

++10~19mm+++≥20mm++++Scleroma,Blister,localnecrosisPPD:Averagediameter=(transversediameter+longitudinaldiameter)/2

Positive

:?AfterBCG-weakpositive?PatientwithTB?AfterinfectedwithTB?Positiveinyoungchild-highrisk?Strongpositive-activeTBdisease?Negativeintopositiveorfrom<10mminto>10mmandgrowth>6mm?Technicalerror?Induration5mmormoreinHIV+PPD:Resultsanalysis

Negative:?NotinfectedwithTB?EarlystageofinfectedwithTB(4-8ws)?Intercurrentdiseasesorviralvaccines?Corticosteroidsandimmunosuppressiveagents?Cellularimmunedeficiencydisease?Severemalnutrition?Overwhelmingtuberculosisinfection?FaultytechniqueorimpotenttestingmaterialPPD:ResultsanalysisClinicalmanifestationofTBLatentinfectionhavenosymptom:detectedontuberculintestPatientwithprogressivediseasepresentwith:fever,cough,pneumonia,paininchest,poorappetite,lossofweight,weaknessandfatiguePatientwithTBofthelymphnodes:enlargementoftheglandsleadingtoswellinginneckorcoughPatientswithTBoftheintestine:diarrheaorconstipation,paininaabdomenandmalabsorptionTBofthebrainmaypresentwith:Fever,headache,vomiting,lossofappetite,seizuresorcoma,andhydrocephalusRarelyTBmayaffectbonesandjoints:mayleadparalysis

ClinicalmanifestationofTBDiagnosisofpediatricTBDiagnosisdependson:1.CarefulhistoryHistoryofTBcontactHistoryofvaccinationTBtoxemia：fever,poorappetite,lossofweight,weaknessandfatigueHistoryofcontagionDiagnosisdependson:

2.TBexamination:smearorculturesputum,gastricjuice,cerebrospinalfluid

BacteriologicalConfirmation

-golden

standard333.ThepresenceofthreeormoreofthefollowingshouldstronglysuggestadiagnosisofTB:ChronicsymptomssuggestiveofTBPhysicalsignshighlyofsuggestiveofTBApositivetuberculinskintestChestX-raysuggestiveofTBDiagnosisdependson:

PrimarytuberculosisChestX-rayofTBTuberculosisofbronchiallymphnodesChestX-rayofTB4.OthercluessuggestadiagnosisofTB:PCRELISA

BiopsyErythrocytesedimentationrate(ESR)ESRisoftenelevateDiagnosisdependson:

Appropriate

PrincipleCombinedDifferent-stageFull-termedEarlyRegularTreatmentTreatmentMostTBiscurable,but…Fourormoredrugsrequiredforthesimplestregimen6-9ormoremonthsoftreatmentrequiredPersonmustbeisolateduntilnon-infectiousSideeffectsandtoxicitycommonmedicalandpsychosocialconditionscomplicatetherapyThefirst-lineanti-TBagentsthatformthecoreoftreatmentregimensinclude:Isoniazid(INH)Rifampin(RFP)Ethambutol(EMB)Pyrazinamide(PZA)Streptomycin(SM)TreatmentDRUGRECOMMENDEDDAILYDOSAGE(DOSERANGE),mg/kgIsoniazide(H)5(4–6)Rifampicin(R)10(8–12)Pirazinamide(Z)25(20–30)Ethambutol(E)15(15–20)Streptomycin(S)15(12–18)TreatmentTreatmentPhasesoftreatment:Theintensivephaseusuallycoversthefirst2monthsoftreatment.Duringthisphase,mostofthebacilliwillbekilled.Thecontinuationphase

usuallylasts4-6months,dependingonthetreatmentregimen.Thisphaseisintendedtoeliminatetheremainingdormantbacilli.Thesedormantbacillidecreaseconstantlyastreatmentintakeprogresses.IntensivePhaseContinuationPhaseIsoniazid

RifampinPyrazinamide

Streptomycin2monthsIsoniazid

Rifampin4monthsTreatment:Short-coursechemotherapyPulmonarytuberculosisIntensivePhaseContinuationPhaseIsoniazid

RifampinPyrazinamide

Streptomycin3-4monthsIsoniazid

Rifampin9-12monthsTreatment:Long-coursechemotherapyTuberculosismeningitis

Prevention

vaccination:weakenedMycobacteriumTBintradermalinjection-1stdosegivenatbirth-2nddose3or4yearsprotectsagainstsevereformsofTB(TBMeningitis,miliaryTB)redswollenfesterburstscabbyPreventivechemotherapyTreat&cureadultswithsmearpositiveTBPreventivetreatment:

1.Closecontact2.<3ys,noBCG,PPD+3.PPD:—to+4.PPD+，TBtoxemia5.PPD+，contagion(HIV+TB)6.PPD+,patientswithdiabetesorimmunesuppression7.childrenorteenagers:PPD>15mm

INH5mg/kg

6msor

INH+RFP5mg/kg3msPreventionGoodlivinghabitsIndoorairventilationDon'tgotothedenselypopulatedplaceTBpatientswearingmasks:espcough,sneeze

PreventionNospittingEnoughsleepStrengthennutritionAppropriateexerciseTobeinagoodmood

49LatentTBinfection:10%TBcontactNosyptomsandsignsNormalCXRPPD+NoBCGreaction

PreventivechemotherapyINH5mg/kg

6ms