兒童結核病結核病兒童結核病IntheworldTBkills2million

peopleeachyearAbout

8million

peoplebecomesickwithTBeachyearBetween2001and2020,nearlyonebillionpeoplewillbenewlyinfected,200millionpeoplewillgetsick,35million

people

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

NelsonTextbookofPediatrics

Introduction兒童結核病InChinaMorethan330millionpeopleinfectedwithTBMorethan6millionpeoplebecomesickwithTBTBinfectionrateinchildrenis9.6%Introduction▲▲▲兒童結核病March24WorldTBDay世界結核病日Introduction兒童結核病WorldTBDay

24March2001

"DOTS-TBcureforAll"

"DOTS:untraitementantituberculeuxpourtous"兒童結核病StopTB,FightPoverty.WorldTBDay

2002兒童結核病兒童結核病WorldTBDay,March24,2004兒童結核病TBisachronic

contagiousdisease,causedbytuberclebacilli.PrimarypulmonarytuberculosisisthemostcaseofTBinchildren.Definition兒童結核病Etiology

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

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

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

Transmissionthroughgastrointestinaltractanddirectskincontactisuncommon.（經消化道、皮膚和胎盤少見）兒童結核病

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核。Transmission兒童結核病anopenactiveTBpatientTransmission兒童結核病Pathogenesis

發病機制兒童結核病Acid-Fastbacillus進入體內（胞內寄生）致敏T淋巴細胞（細胞免疫，4~8周）釋放cytokines/lymphokines激活macrophages吞噬和殺滅結核桿菌Pathogenesis兒童結核病ImmunityResponseAllergy同一細胞免疫免疫過程中的兩種不同表現Pathogenesis兒童結核病InheritancefactorsPathogenesis兒童結核病Diagnosis

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

結核中毒癥狀Historyofcontactwithpulmonarypatients/

結核接觸史HistoryofBCGvaccination/

卡介苗接種史Historyofotherinfectionillness/

既往病史

兒童結核病Toxicsymptomsoftuberculousinfection

mildfever/低熱

nightsweat/盜汗

fatigue/乏力

poorappetite/食欲減退

weightloss/消瘦Diagnosis-----CaseHistory兒童結核病Historyofcontactwithpulmonarypatients

esp.contactwithanopenactivepulmonarytuberculosispatient

Diagnosis-----CaseHistory兒童結核病

HistoryofBCGvaccinationDiagnosis-----CaseHistory

HistoryofBCGvaccinationCheckthescarofBCG/卡痕兒童結核病PastillnesshistoryDiagnosis-----CaseHistory

TBmeasles/麻疹

chickenpox/水痘

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

gastricwashingorinducedsputum

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

兒童結核病兒童結核病Pathologydiagnosis

LymphNodespunctureTissueBiopsyFibrobronchoscopeDiagnosis------AssistExamination

兒童結核病

結核性肉芽腫結核特征性病變：中央為干酪樣壞死，周圍為增生的上皮樣細胞，其內散在Langerhans巨細胞。兒童結核病

ImmunologicalExamination

TuberculinSkinTest(PPDorOTtest)/

結核菌素試驗

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

結核菌素接種后，多長時間觀察結果？接觸結核后，多長時間結素試驗出現反應？兒童結核病Bio-MolecularTechnique

PCR,PolymeraseChainReaction

SouthernBlot

NorthernBlotDiagnosis------AssistExamination

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

兒童結核病結核病的早期診斷最為重要

TBisachroniccontagiousdiseasecausedbytuberclebacilli.

PrimarypulmonarytuberculosisisthemostcaseofTBinchildren.兒童結核病原發型肺結核PrimaryPulmonaryTuberculosis兒童結核病

Primarypulmonarytuberculosis

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

Basicpathologicalchanges

Exudation/滲出

Proliferation(tuberculoustubercle,tuberculousgranuloma)

增殖（結核結節、結核性肉芽腫）

Necrosis(caseation)/壞死（干酪性壞死）

Outcomeofpathologicalchanges

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

Asymptomcases80%UpperrespiratorytractinfectionToxicsymptomsoftuberculousinfectionMalnutritionManifestation兒童結核病ThemanifestationofTBinchildrenarevariable.Hypersensitivityerythemanodosum/皮膚結節性紅斑

phlyctenularconjunctivitis/皰疹性眼結膜炎

arthritis

/關節炎

Onoccasion,theonsetofTB,abruptLungsymptomsasthmaticbreathing,cough,etc.Manifestation兒童結核病

Superficiallymphnodeswell

Lungsigns

多無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兒童結核病Diagnosis

HistoryManifestationsPhysicalexamination

Immunologyexamination

tuberculinskintest/ELISA/etc.

ChestX-ray

examinationFibrobronchoscopeexamination兒童結核病

ChestX-ray

PrimaryComplex(原發綜合征)

primaryfocusatthesiteofimplantation/原發病灶

tuberculouslymphangitis/淋巴管炎

regionaltuberculouslymphadenopathy/淋巴結炎

呈典型“啞鈴狀雙極影”Diagnosis兒童結核病原發綜合征：啞鈴狀雙極影兒童結核病

ChestX-ray

TuberculosisofTracheobronchialLymphonodus

支氣管淋巴結結核Diagnosis表現為：肺門影增濃兒童結核病TuberculosisofTracheobronchialLymphonodus兒童結核病無細菌培養條件下小兒肺結核的診斷標準①有與成人結核、尤其開放結核接觸史；②持續兩周以上的咳嗽，抗生素治療無效；③結素試驗陽性：無卡介苗接種史者>10mm

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