兒童結(jié)核病課件

兒童結(jié)核病結(jié)核病兒童結(jié)核病IntheworldTBkills2million

peopleeachyearAbout

8million

peoplebecomesickwithTBeachyearBetween2001and2020,nearlyonebillionpeoplewillbenewlyinfected,200millionpeoplewillgetsick,35million

people

willdiefromTB--Ifpresenttrendscontinue.-----WHOIntroduction兒童結(jié)核病Onethirdofworld’spopulation,2billionpeople,areinfectedwithM.Tuberculosis.TBInfectionratesarehighestinSoutheastAsia,China,India,Africa,andLatinAmerica.------------16th

NelsonTextbookofPediatrics

Introduction兒童結(jié)核病InChinaMorethan330millionpeopleinfectedwithTBMorethan6millionpeoplebecomesickwithTBTBinfectionrateinchildrenis9.6%Introduction▲▲▲兒童結(jié)核病March24WorldTBDay世界結(jié)核病日Introduction兒童結(jié)核病WorldTBDay

24March2001

"DOTS-TBcureforAll"

"DOTS:untraitementantituberculeuxpourtous"兒童結(jié)核病StopTB,FightPoverty.WorldTBDay

2002兒童結(jié)核病兒童結(jié)核病WorldTBDay,March24,2004兒童結(jié)核病TBisachronic

contagiousdisease,causedbytuberclebacilli.PrimarypulmonarytuberculosisisthemostcaseofTBinchildren.Definition兒童結(jié)核病Etiology

病因兒童結(jié)核病Mycobacteriumtuberculosis/結(jié)核桿菌Acid-Fastbacillus,AFB(RobertKoch,1882)

抗酸染色為紅色---抗酸桿菌M.tuberculosis(人型結(jié)核桿菌)&M.bovis（牛型結(jié)核桿菌）aretwomainspeciescausingtuberculosisinhuman.兒童結(jié)核病兒童結(jié)核病兒童結(jié)核病Transmission

TBcandevelopafterinhalingdropletssprayedintotheairfromacoughorsneezebysomeoneinfectedwithM.tuberculosis.(主要傳播途徑為呼吸道)

Transmissionthroughgastrointestinaltractanddirectskincontactisuncommon.（經(jīng)消化道、皮膚和胎盤少見）兒童結(jié)核病

Infants&childrenaremostfrequentlyinfectedbyanadultmemberwhoisanopenactiveTBpatientofthehousehold.

常見的傳播源為家庭成員、密切接觸的親屬、保姆、鄰居，尤其是哺乳期母親患開放型肺結(jié)核。Transmission兒童結(jié)核病anopenactiveTBpatientTransmission兒童結(jié)核病Pathogenesis

發(fā)病機(jī)制兒童結(jié)核病Acid-Fastbacillus進(jìn)入體內(nèi)（胞內(nèi)寄生）致敏T淋巴細(xì)胞（細(xì)胞免疫，4~8周）釋放cytokines/lymphokines激活macrophages吞噬和殺滅結(jié)核桿菌Pathogenesis兒童結(jié)核病ImmunityResponseAllergy同一細(xì)胞免疫免疫過程中的兩種不同表現(xiàn)Pathogenesis兒童結(jié)核病InheritancefactorsPathogenesis兒童結(jié)核病Diagnosis

診斷兒童結(jié)核病DiagnosisSex:female＞maleAge:＜5yrs兒童結(jié)核病Diagnosis-----CaseHistoryToxicsymptomsoftuberculousinfection/

結(jié)核中毒癥狀Historyofcontactwithpulmonarypatients/

結(jié)核接觸史HistoryofBCGvaccination/

卡介苗接種史Historyofotherinfectionillness/

既往病史

兒童結(jié)核病Toxicsymptomsoftuberculousinfection

mildfever/低熱

nightsweat/盜汗

fatigue/乏力

poorappetite/食欲減退

weightloss/消瘦Diagnosis-----CaseHistory兒童結(jié)核病Historyofcontactwithpulmonarypatients

esp.contactwithanopenactivepulmonarytuberculosispatient

Diagnosis-----CaseHistory兒童結(jié)核病

HistoryofBCGvaccinationDiagnosis-----CaseHistory

HistoryofBCGvaccinationCheckthescarofBCG/卡痕兒童結(jié)核病PastillnesshistoryDiagnosis-----CaseHistory

TBmeasles/麻疹

chickenpox/水痘

etc.兒童結(jié)核病因病而異Diagnosis---symptom&sign兒童結(jié)核病EtiologydiagnosisCulture&/orsmearofsamplesfortuberclebacilli

gastricwashingorinducedsputum

結(jié)核菌檢查（查痰液、胃液等）Diagnosis-----AssistedExamination

兒童結(jié)核病兒童結(jié)核病Pathologydiagnosis

LymphNodespunctureTissueBiopsyFibrobronchoscopeDiagnosis------AssistExamination

兒童結(jié)核病

結(jié)核性肉芽腫結(jié)核特征性病變：中央為干酪樣壞死，周圍為增生的上皮樣細(xì)胞，其內(nèi)散在Langerhans巨細(xì)胞。兒童結(jié)核病

ImmunologicalExamination

TuberculinSkinTest(PPDorOTtest)/

結(jié)核菌素試驗(yàn)

ELISA（PPD-IgM、IgG）Diagnosis------AssistExamination

結(jié)核菌素接種后，多長(zhǎng)時(shí)間觀察結(jié)果？接觸結(jié)核后，多長(zhǎng)時(shí)間結(jié)素試驗(yàn)出現(xiàn)反應(yīng)？?jī)和Y(jié)核病Bio-MolecularTechnique

PCR,PolymeraseChainReaction

SouthernBlot

NorthernBlotDiagnosis------AssistExamination

兒童結(jié)核病ChestRoentgenography(ChestX-ray)Diagnosis------AssistExamination

兒童結(jié)核病結(jié)核病的早期診斷最為重要

TBisachroniccontagiousdiseasecausedbytuberclebacilli.

PrimarypulmonarytuberculosisisthemostcaseofTBinchildren.兒童結(jié)核病原發(fā)型肺結(jié)核PrimaryPulmonaryTuberculosis兒童結(jié)核病

Primarypulmonarytuberculosis

isthemajortypeofpulmonarytuberculosisdevelopedinchildrenduringinitialinfection.（原發(fā)型肺結(jié)核是指結(jié)核菌初次侵入肺部后發(fā)生的原發(fā)感染，是小兒肺結(jié)核的主要類型，占兒童各型肺結(jié)核總數(shù)的85.3%。）Definition兒童結(jié)核病

Basicpathologicalchanges

Exudation/滲出

Proliferation(tuberculoustubercle,tuberculousgranuloma)

增殖（結(jié)核結(jié)節(jié)、結(jié)核性肉芽腫）

Necrosis(caseation)/壞死（干酪性壞死）

Outcomeofpathologicalchanges

FullyRecover(Calcification/Absorption/Fibrosis)ProgressionWorsenPathology兒童結(jié)核病特征性病理改變：上皮樣細(xì)胞結(jié)節(jié)、Langerhans細(xì)胞浸潤(rùn)Pathology兒童結(jié)核病ThemanifestationofTBinchildrenarevariable.OnsetofTB,chronic&hiding/起病常隱匿

Asymptomcases80%UpperrespiratorytractinfectionToxicsymptomsoftuberculousinfectionMalnutritionManifestation兒童結(jié)核病ThemanifestationofTBinchildrenarevariable.Hypersensitivityerythemanodosum/皮膚結(jié)節(jié)性紅斑

phlyctenularconjunctivitis/皰疹性眼結(jié)膜炎

arthritis

/關(guān)節(jié)炎

Onoccasion,theonsetofTB,abruptLungsymptomsasthmaticbreathing,cough,etc.Manifestation兒童結(jié)核病

Superficiallymphnodeswell

Lungsigns

多無(wú)明顯體征叩診可為濁音聽診呼吸音減低聽診少許濕羅音Signs兒童結(jié)核病Diagnosis

HistoryManifestationsPhysicalexamination

Immunologyexamination

tuberculinskintest/ELISA/etc.

ChestX-ray

examinationFibrobronchoscopeexamination兒童結(jié)核病

ChestX-ray

PrimaryComplex(原發(fā)綜合征)

primaryfocusatthesiteofimplantation/原發(fā)病灶

tuberculouslymphangitis/淋巴管炎

regionaltuberculouslymphadenopathy/淋巴結(jié)炎

呈典型“啞鈴狀雙極影”Diagnosis兒童結(jié)核病原發(fā)綜合征：?jiǎn)♀彔铍p極影兒童結(jié)核病

ChestX-ray

TuberculosisofTracheobronchialLymphonodus

支氣管淋巴結(jié)結(jié)核Diagnosis表現(xiàn)為：肺門影增濃兒童結(jié)核病TuberculosisofTracheobronchialLymphonodus兒童結(jié)核病無(wú)細(xì)菌培養(yǎng)條件下小兒肺結(jié)核的診斷標(biāo)準(zhǔn)①有與成人結(jié)核、尤其開放結(jié)核接觸史；②持續(xù)兩周以上的咳嗽，抗生素治療無(wú)效；③結(jié)素試驗(yàn)陽(yáng)性：無(wú)卡介苗接種史者>10mm

有卡介苗接種史者>15mm④符合肺結(jié)核診斷的X線征象；⑤抗結(jié)核治療有效（兩個(gè)月后體重增加10%以上，癥狀好轉(zhuǎn)）。--------具有以上兩點(diǎn)或兩點(diǎn)以上條件（供參考）兒童結(jié)核病判斷小兒結(jié)核病具有活動(dòng)性的參考指標(biāo)①結(jié)素試驗(yàn)≥20mm；②<3歲、尤<1歲未種卡介苗結(jié)素試驗(yàn)陽(yáng)性；③有發(fā)熱及其他結(jié)核中毒癥狀；④找到結(jié)核