About tuberculosis

Tuberculosis is a chronic infectious disease caused by Mycobacterium tuberculosis, which can involve many organs of the whole body, but tuberculosis is the most common. It can spread to the whole body for a long time and get sick when the body's resistance drops. The pathological features of this disease are tuberculous nodules and caseous necrosis, which are easy to form cavities. Although the incidence rate has dropped significantly in the past two or three decades, it is still one of the common and frequent chronic infectious diseases.

Clinically, it is mostly a chronic process, and a few of them can have an acute onset. There are often systemic symptoms such as low fever and fatigue, and respiratory manifestations such as cough and hemoptysis.

Mycobacterium tuberculosis has strong resistance, and can survive for more than 5 times in humid places, but it can be killed by exposure to the hot sun for 2 hours, exposure to 5- 12% lysol for 2- 12 hours, exposure to 70% alcohol for 2 minutes, or boiling 1 minute. The simplest sterilization method is to spit on paper and burn it directly.

Tuberculosis is mainly transmitted through respiratory tract. The main source of infection is the sputum of tuberculosis patients who excrete bacteria.

clinical picture

Typical pulmonary tuberculosis has a slow onset and a long course of disease. There may be contact history of tuberculosis, diabetes, silicosis, long-term use of glucocorticoids, immunosuppressants, etc. However, most patients have mild lesions and often have no obvious symptoms.

Fever is the most common symptom of tuberculosis, and most of them are long-term low fever. The symptoms of systemic poisoning are low fever in the afternoon, accompanied by fatigue, night sweats, loss of appetite, irregular menstruation, irritability, palpitation, flushing on cheeks, weight loss, etc. When lung lesions spread rapidly, high fever may occur, and women may have menstrual disorder or amenorrhea.

There is usually a dry cough or only a small amount of mucus. When accompanied by secondary infection, phlegm is mucinous or purulent. About13 patients have different degrees of hemoptysis. When the inflammation spreads to parietal pleura, there is a tingling sensation in the chest wall, which is dull pain or needle-like pain, accompanied by aggravation of breathing and cough. Chronic severe pulmonary tuberculosis, respiratory dysfunction, dyspnea. When there is high fever or extensive destruction of lung tissue, the pleura thickens with shortness of breath.

Typing:

Type I (primary tuberculosis) refers to the clinical symptoms caused by primary tuberculosis infection, including primary syndrome and intrathoracic lymph node tuberculosis. Most of them happen to children, but also to adults who come to town for the first time in remote mountainous areas and rural areas. Symptoms are mostly mild and transient, including mild fever, cough, anorexia, night sweats, erythema nodosum or herpetic conjunctivitis, and some people have no symptoms. X-ray shows lymphangitis and hilar lymphadenopathy (dumbbell image). Primary exudative lesions are mostly located in the lower part of the upper lobe and the middle and upper part of the lower lobe, and the lesions can be absorbed or calcified by themselves.

Type ⅱ (hematogenous disseminated pulmonary tuberculosis) includes acute and subacute or chronic types, which are mostly developed from primary pulmonary tuberculosis, but adults are more likely to see secondary pulmonary tuberculosis or extrapulmonary tuberculosis protruding into blood vessels. There are many symptoms such as high fever, chills, general malaise, emaciation and gastrointestinal dysfunction. X-ray examination of disseminated pulmonary tuberculosis in benign blood showed that the two lung fields were small punctate shadows with equal size and equal density, which were evenly distributed from the apex of lung to the bottom of lung. Chronic or subacute type is characterized by nodular shadows, with different old and new lungs, uneven distribution and different sizes, mostly located in the upper and middle lung fields.

Type ⅲ (infiltrative pulmonary tuberculosis) is the most common type of secondary pulmonary tuberculosis, which is mainly caused by internal heat recurrence, decreased body resistance and exogenous reinfection, and decreased body resistance and exogenous reinfection. Lesions are often located in the upper lung field, with different degrees of exudation, infiltration and/or caseous lesions, which can form cavities. This type also includes two special types: caseous pneumonia and tuberculoma.

Type Ⅳ (chronic fibrocavitary pulmonary tuberculosis) is a chronic type of secondary pulmonary tuberculosis, which is mostly caused by untimely detection of various pulmonary tuberculosis, irregular treatment and prolonged illness. Fibrous cavity exists for a long time, often accompanied by extensive disseminated bronchopathy and obvious pleural thickening. The destruction of lung tissue is often obvious, accompanied by the obvious proliferation of sun and moon fiber tissue, which causes the contraction of lung tissue in the affected area and the traction and displacement of mediastinum and hilum. Compensatory emphysema often occurs in adjacent lung tissues, and may eventually be complicated with cor pulmonale and respiratory failure. X-ray examination showed extensive fibrosis, thick-walled cavities and lesions spreading along the bronchus.

Type ⅴ (tuberculous pleurisy)

treat cordially

Anti-tuberculosis chemotherapy plays a decisive role in the control of tuberculosis, and reasonable chemotherapy can sterilize and heal all the lesions. Traditional rest and nutrition play an auxiliary role.

Treatment principle: For active pulmonary tuberculosis, we must adhere to the principle of early, combined, regular, adequate and full-course medication.

Commonly used anti-tuberculosis drugs

Isoniazid (h, INH), rifampicin (r, RFP), streptomycin (s, SM), pyrazinamide (z, PZA), ethambutol (e, EMB), aminosalicylic acid (p, PAS), kanamycin (k, KM), thiosemicarbazone (t, tb65433). CPM), violomycin (VM), ethionine (13 14Th) and protien (132 1Th), rifampicin (RFD), rifapentine (DL, 473) and amikacin (AM).

Short-term chemotherapy

The combination of INH, RFP and more than two fungicides has strong sterilization and disinfection effect, and the course of treatment is 6-9 months. INH, RFP, PZA and SM are the main drugs for short-term chemotherapy.

Symptomatic treatment

Physical cooling can be used in high fever; Cough and phlegm; A small amount of hemoptysis, such as blood in sputum, does not need special treatment. If necessary, a small amount of sedatives and cough suppressants can be used. However, antitussive drugs should be used with caution for the elderly, infirm and pulmonary insufficiency, so as not to inhibit cough reflex and respiratory center, so that blood clots cannot be coughed up and suffocation occurs. ; Irregular mild chest pain does not require treatment. Analgesics can be used appropriately when chest pain is obvious.

Surgical therapy

It has been used less. Surgical indications are: the thick-walled cavity has not been closed for a long time after chemotherapy, and bacteria are still excreted; It is difficult to distinguish tuberculoma with a diameter of more than 3 cm from lung cancer. Long-term discharge of bacteria or secondary bronchiectasis hemoptysis; Tuberculous empyema and/or bronchopleural fistula were ineffective after medical treatment, accompanied by ipsilateral active pulmonary tuberculosis.

Surgical contraindications are: active tuberculosis of bronchial mucosa, which is not within the scope of resection; General condition is poor or heart, lung, liver and kidney function are obviously impaired; The contralateral lung lesion is unstable.

What is the classification of tuberculosis in China at present?

After the founding of New China, China used the "Top Ten Classification of Tuberculosis" formulated by the Soviet Union for a long time, but it was found that this classification was not suitable at the end of 1950s. At the National Conference on Tuberculosis Prevention and Control held in Liuzhou from 65438 to 0978, the Classification of Tuberculosis in China was formulated, which was widely used in the whole country and could meet the needs of clinical work of tuberculosis prevention and control. Now introduce the following:

1. Tuberculosis Tuberculosis is divided into five types:

Primary pulmonary tuberculosis (type I): Primary pulmonary tuberculosis is a clinical disease caused by primary tuberculosis infection. Including primary syndrome and intrathoracic lymph node tuberculosis. When complicated with lymphadenobronchial fistula; If lymph node enlargement is obvious, but there are only a few disseminated lesions in the lungs, it still belongs to this type.

Hematogenous disseminated pulmonary tuberculosis (code: Type II): Hematogenous disseminated pulmonary tuberculosis includes acute hematogenous disseminated microtuberculosis (acute miliary pulmonary tuberculosis) and subacute and chronic hematogenous disseminated pulmonary tuberculosis.

Infiltrating tuberculosis (type ⅲ): Infiltrating tuberculosis is the main type of secondary tuberculosis. There are exudation, infiltration and/or varying degrees of caseous lesions in the lungs, and cavities can also be seen. In addition, caseous pneumonia and tuberculoma also belong to this type.

Chronic fibrocavitary pulmonary tuberculosis (type ⅳ): Chronic fibrocavitary pulmonary tuberculosis is a chronic type of secondary pulmonary tuberculosis. It is often accompanied by widespread bronchopathy and obvious pleural thickening. The destruction of lung tissue is often obvious, accompanied by obvious fibrous tissue hyperplasia, which causes the contraction of lung tissue in the affected area and the traction and displacement of mediastinum and hilum, and the adjacent lung tissue often presents compensatory emphysema.

Tuberculous pleurisy (type ⅴ): Tuberculous pleurisy has been clinically excluded from pleurisy caused by other reasons, including tuberculous empyema.

2. Lesion range and location The lesion range is described by upper, middle and lower lung fields on the left and right. Upper lung field: the inner end of the lower edge of the second anterior rib is above the horizontal plane. Middle lung field: below the upper lung field and above the level of the inner end of the lower edge of the fourth anterior rib. Lower lung field. Under the middle lung field. The lesion on the right side is recorded above the horizontal line, the lesion on the left side is recorded below the horizontal line, and no lesion on one side is indicated by "(-)".

3. Sputum bacterial examination

Sputum examination is the main index for diagnosis and evaluation of curative effect. Sputum bacteria positive, indicated by (+); The feminine is indicated by (-). The method of sputum examination must be indicated, which is expressed by coating (thick coating), collecting (collecting bacteria) or cultivating (cultivating). If you draw (+), it means that tuberculosis is found on the smear; Set (-) indicates that Mycobacterium tuberculosis has not been found by bacteria collection method; Culture (-) means that mycobacterium tuberculosis has not been isolated by culture. Sputum bacteria turned clear for 3 consecutive months; At least once a month, based on the negative smear or bacterial collection method (culture if possible). When the patient has no sputum or no sputum at the end, it should be marked as "no sputum" or "not checked".

4. Activity and prognosis

When judging the patient's activity and changing to another woman, it can be decided by combining the patient's clinical manifestations, lung lesions, cavities and sputum bacteria.

Progressive period: any of the following circumstances is a progressive period.

① Newly discovered active lesions;

② The pathological changes are more serious and more than before;

③ New cavity or enlarged cavity;

④ Sputum bacteria were positive.

Improvement period: any of the following circumstances is the improvement period.

① The lesion was better than before absorption;

② The cavity is closed or narrowed;

③ Sputum bacteria turned negative (from Yang to Yin).

Stable phase: the lesion is inactive, the cavity is closed, and the sputum bacteria continue to turn negative (at least 1 time per month) for more than 6 months. If the cavity still exists, sputum bacteria must be negative for more than one year.

Activity judgment: both the progressive stage and the improvement stage of pulmonary tuberculosis are active, that is, patients who need treatment and management, "that is, register and manage Group I (infectious) and Group II (non-infectious). The stable patients are inactive pulmonary tuberculosis, which belongs to the patients who have been initially cured but still need to be observed, that is, the registration management class III. After 2 years' observation, the patients in the stable period are still inactive, and the sputum bacteria are still negative (bacterial collection or culture should be adopted as far as possible), which is regarded as a clinical cure and the registration is cancelled. If there is still a cavity, it must be observed for more than 3 years before the registration can be cancelled (note: this point is no longer applicable to the short-term chemotherapy era). If the activity or prognosis cannot be determined due to various reasons or lack of comparative data at the time of initial diagnosis and treatment, it can be recorded as "undetermined activity". Generally speaking, active tuberculosis is still the best treatment.

5. Recording procedure The classification of tuberculosis can be recorded according to the following procedures. Type, lesion range and cavity, sputum examination, activity and prognosis of pulmonary tuberculosis. Acute or chronic caseous pneumonia should be indicated in brackets after disseminated pulmonary tuberculosis, and brackets should be indicated after the type. If there is extrapulmonary tuberculosis or (and) important complications, it can be attached at the end. For example: infiltrative pulmonary tuberculosis (IPTB), last 0 attacks/(-) attacks (+), advanced stage.

What are the characteristics of Mycobacterium tuberculosis?

Mycobacterium tuberculosis is slender, slightly curved, with blunt and round ends, and often arranged in a branching manner. Mycobacterium tuberculosis is not easy to be decolored by acid decolorant after being dyed by aniline, so it is also called acid-fast bacilli. The growth is slow, and the division and reproduction cycle is about 14 ~ 22 hours. It is an aerobic bacterium, which is not easy to be killed by anti-tuberculosis drugs and becomes the source of recurrence in the future.

Mycobacterium tuberculosis can be divided into four types: human type, cattle type, horse type and mouse type. The people who cause diseases to people are mainly human-type, followed by cattle-type, and few people are infected with horse-type, which has not been reported in China at present. Mycobacterium bovis is mainly caused by poor management and disinfection of milk and drinking dairy products from sick cows. Due to the change of people's dietary hygiene habits, it is rare at present.

Mycobacterium tuberculosis has strong resistance and can survive for half a year in dark and humid places indoors. Died in direct sunlight for 2 hours; Ultraviolet irradiation 10 ~ 20 minutes can kill mycobacterium tuberculosis; Dampness and heat are very destructive to it, and it can be killed at 65℃ for 30 minutes, 70℃ 10 minutes, 80℃ for 5 minutes, and boiled in water 1 minute. Dry heat at 100℃ often takes more than 20 minutes to kill, so dry heat sterilization needs higher temperature and longer time. Mycobacterium tuberculosis has strong resistance to acid, alkali and alcohol. It is safe to sterilize sputum with 5% carbolic acid or 20% bleaching powder, and it must be treated for 24 hours. Contact with 5% ~ 12% lysol water for 2 ~ 12 hours and 70% alcohol for 2 minutes can kill mycobacterium tuberculosis.

Mycobacterium tuberculosis has strong drug resistance and needs long-term use of anti-tuberculosis drugs. Drug-resistant strains are easy to appear when drugs are used irregularly or alone or in insufficient doses. Therefore, it is particularly important to pay attention to clinical medication, and it must be sufficient, combined with medication, and the course of treatment should be sufficient to avoid repeated diseases.

How many kinds of tuberculin are there? What is the difference?

Tuberculin is a biological product, which is used to assist in the diagnosis of tuberculosis infection. It is made from the culture filtrate of mycobacterium tuberculosis, and the effective component is tuberculosis protein contained in mycobacterium tuberculosis. There are four kinds of tuberculin here.

(1) old tuberculin: originally made from Coriolis glycerol broth medium. Because the method is old and used for a long time, in order to distinguish it from the later tuberculin, it is called old tuberculin, which is represented by (ot).

(2) Pure protein derivative (PPD): Mycobacterium tuberculosis was cultured in Sutong's culture medium, sterilized and ultrafiltered, then the protein was precipitated with trichloroacetic acid, and then the trichloroacetic acid was removed with ether to purify the tuberculosis protein. Freeze-dried products have been supplied in China, with stable properties and clear reaction, and the positive rate is slightly higher than that of old tuberculin (OT), which can replace old tuberculin (OT).

(3) Replacing tuberculin with dead BCG: 50 mg of BCG per ml was placed in a water bath at 60℃ for 65438 0 hours. The tuberculin reaction caused by it is generally mild.

(4) Pure protein derivatives of BCG or other mycotoxins: made from the culture filtrate of BCG or other mycobacteria. It is rarely used for the diagnosis of tuberculosis in clinic.

What are the detection methods of tuberculin?

The test methods of tuberculin include intradermal injection, intradermal scratching, intradermal plaster and so on. Intradermal injection is the most commonly used method in clinic.

(1) intradermal injection: clinically, as in the penicillin skin test, 0. 1/0 old tuberculin diluent (1: 1000 or 1: 2000) was injected into the lower palm of the left forearm. If serious active pulmonary tuberculosis is suspected, 1∶ 10000 diluent should be used to prevent local overreaction and possible focal reaction. 48 ~ 72 hours after injection, negative patients tried again with higher concentration until diluted to 1: 100.

(2) Skin scratch method: Drop 65,438+0 drops of old tuberculin stock solution at the same position above, and then cut the epidermis with sterile needle, with scratches less than 5 mm If there are two or more scratches, the distance between scratches should be 65,438+0 cm, depending on the degree of lymphatic exudation, but do not bleed. If you see the results within 48-72 hours, the redness along the line will reach more than 3 mm This method has a low positive rate and is not commonly used.

(3) Application test method: A certain amount of tuberculin or pure protein derivative (PPD) was soaked in the cloth of 1cm2, coated on the palm of forearm 1/3, covered and fixed with plastic film, and the cloth was removed after 48 hours. After 48 hours, the results showed that there were 3-4 papules or blisters on the positive part, which were mainly used for infants.

How to evaluate the test results of old tuberculin (OT)?

Tuberculin test is used to determine whether there is allergic reaction in the body, and it is one of the auxiliary diagnostic methods of tuberculosis.

Whether the result of tuberculin test is "positive" or "negative" needs careful analysis when judging the result.

The true positive reaction of tuberculin test occurs within 48 ~ 72 hours, and there must be local induration besides infrared emission, and its average diameter must exceed 0.5 cm. The degree of positive reaction indicates the degree of allergic reaction, so it can reflect whether there is tuberculosis infection and its activity, which is of certain value for diagnosis. Positive criteria are as follows:

(1) "+":redness and induration, with a diameter of 5 ~ 9mm.

(2) "++":red, induration, diameter 10 ~ 19mm.

(3) "++":redness and induration, with a diameter greater than 20 mm..

(4) "++":In addition to redness and swelling, there are systemic symptoms, such as herpes or necrosis or fever.

Clinically, negative reaction (-or+), positive reaction (+or++) and strong positive reaction (++or++) are used to judge the degree.

Positive reaction can only explain three situations: ① there was tuberculosis infection (natural infection) and it has been cured; ② Currently in the active stage of tuberculosis; ③ BCG vaccination was successful. When the tuberculin test is positive, we should consider whether there is the influence of BCG and old tuberculosis infection, but we can judge it according to the reaction degree. For example, when active tuberculosis is progressing, under normal circumstances, the allergic reaction of the body is strong, so the tuberculin reaction is strong and lasting, and the younger the age, the greater the significance. A cured or quiescent tuberculosis infection will not cause a strong positive reaction. If children under 3 years old, especially 1 year old, are not vaccinated with BCG, but are positive, they should be treated as active tuberculosis.

The tuberculin test is negative, which usually means that there is no tuberculosis infection, but this is not entirely the case. For example, in some diseases, the allergic reaction of the body to tuberculosis may be weakened or temporarily disappeared: ① Acute infectious diseases: measles, whooping cough, scarlet fever and after hepatitis 1 ~ 2 months. ② Weakness, severe malnutrition, severe dehydration or edema. ③ Severe tuberculosis infection: such as tuberculous meningitis, miliary tuberculosis and caseous pneumonia. ④ Moderate use of adrenocortical hormone and immunosuppressant.

In a word, the reaction of tuberculin test is very complicated and influenced by many factors. Therefore, careful analysis and judgment are needed, and correct estimation is helpful to make a correct diagnosis in clinic.

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