tuberculosis in the elderly
Introduction
Introduction to tuberculosis in the elderly Tuberculosis is a chronic infectious disease caused by Mycobacterium tuberculosis that can invade many organs and is most common in the form of pulmonary tuberculosis (pulrnonary tuberculosis). Excreted patients are an important source of infection. Human infection with tuberculosis does not necessarily occur, and when the resistance is reduced or the cell-mediated allergic reaction is increased, it may cause clinical disease. The basic pathological features of the disease are exudation, caseous necrosis and other proliferative tissue reactions, which can form voids. If diagnosed in time and treated reasonably, most of them will be cured. The most common surgical method for surgical treatment of pulmonary tuberculosis is still pneumonectomy, which is an effective means of eliminating chronic infectious diseases, preventing recurrence and treating various serious complications. basic knowledge The proportion of illness: 0.002% Susceptible people: the elderly Mode of infection: respiratory transmission Complications: bronchiectasis, empyema, pneumothorax, pulmonary aspergillosis, chronic pulmonary heart disease
Cause
Causes of tuberculosis in the elderly
(1) Causes of the disease
The decline in immune function and decline in the elderly is negatively correlated with aging. For example, the positive rate of tuberculin reaction is 80% at 60 years old, 70% at 70 years old, 50% at 80 years old, 30% at 90 years old, and immune function declines. The endogenous re-ignition and exogenous re-staining have increased the incidence, resulting in an increasing trend of senile tuberculosis.
Tuberculosis that has not been diagnosed and treated in a timely manner, as well as a high rate of tuberculosis and sputum in the elderly, has become an important source of infection in society.
(two) pathogenesis
The specific mechanism is unknown.
Prevention
Elderly tuberculosis prevention
If there are clinical conditions that increase the risk of tuberculosis, such as pneumoconiosis, malnutrition, chronic renal failure, diabetes, long-term use of a large number of hormones and other immunosuppressive agents, certain blood diseases (such as leukemia and lymphoma) and other malignant tumors, etc. OT test positive; or a recent history of exposure to tuberculosis, OT test turned to yang; or HIV infection or AIDS, formerly untreated tuberculosis, may be given preventive chemotherapy as appropriate, daily oral isoniazid 300mg, course of treatment 6 to 12 months, can reduce the incidence of tuberculosis or recurrence rate, but should closely monitor the side effects of isoniazid.
Complication
Elderly tuberculosis complications Complications, bronchiectasis, pneumothorax, pulmonary aspergillosis, chronic pulmonary heart disease
Complicated with bronchiectasis, empyema, pneumothorax, pulmonary aspergillosis, chronic pulmonary heart disease.
Symptom
Symptoms of tuberculosis in the elderly Common symptoms Weakness, weakness, hemoptysis, small bronchial mucosal edema, sputum, negative hypoxemia, tuberculosis, poor appetite, poor appetite
The diagnosis of senile tuberculosis is often delayed, even at autopsy. The US Centers for Disease Control (CDC) reported 86,292 cases of tuberculosis from 1985 to 1988. Only 26% of the elderly patients over 65 years of age were diagnosed. 60%, the primary cause of delay in diagnosis is the lack of understanding and due diligence of doctors for tuberculosis, without considering the possibility of the disease, so it is not checked accordingly. In addition, the clinical manifestations of senile tuberculosis are often atypical and important for misdiagnosis. The reason is reported in the literature: 67.2% of the elderly tuberculosis is concealed, about 1/4 of the elderly tuberculosis is asymptomatic, easy to miss diagnosis, symptomatic is not typical, no specificity for diagnosis, plus cognitive defects of the elderly, neglect Seek medical treatment or not accurately provide relevant medical history. Older people are often accompanied by chronic cardiopulmonary diseases, malignant tumors or other immunosuppressive diseases, thereby concealing the symptoms of tuberculosis or blaming the symptoms of tuberculosis, such as fever, weight loss, chronic cough The typical symptoms of these tuberculosis are often considered to be chronic bronchitis and senile changes. Xu Yingjie et al compared 613 elderly lungs. Clinical manifestations of tuberculosis and 210 cases of young tuberculosis, found that cough, cough, shortness of breath, hemoptysis, loss of appetite in the elderly, young people with chest pain, blood stasis, fever, night sweats, 797 cases of elderly tuberculosis research report, the elderly The order of symptoms of tuberculosis is: cough 67%, hemoptysis 33%, chest pain 30%, shortness of breath 27.7%, fever 25.4%, indicating that the most common symptoms of senile tuberculosis and the earliest symptoms are cough, where the elderly cough lasts for more than 2 weeks, A chest X-ray should be performed.
Older tuberculous pleurisy is mostly secondary, 80% with pulmonary tuberculosis, and blood pleural effusion accounts for 11.4%. It must be differentiated from lung cancer pleural metastasis. When pleural fluid examination is negative for tuberculosis and cancer cells, pleural biopsy should be performed. Strive for early diagnosis.
Miliary tuberculosis and other extrapulmonary tuberculosis are more common in young people than in young people, and the rate of misdiagnosis is high. Extrapulmonary tuberculosis often has hidden symptoms and no specificity, such as loss of appetite, weakness, weakness, etc., often considered as other chronic diseases or aging. Caused by, and about 1/3 of the miliary tuberculosis chest X-ray film can show normal, the elderly can have no typical signs of tuberculous meningitis or peritonitis, in addition, the elderly are often accompanied by other diseases, there are reports in the literature The number of elderly tuberculosis patients with non-tuberculosis was as high as 82.8%, which was significantly higher than that of the middle-aged group (44.4%) and the young group (28.6%). Among them, respiratory diseases were the most common, accounting for 45.0%, followed by cardiovascular disease 14.4%. 8.5%, senile pulmonary tuberculosis with respiratory diseases, diabetes, due to the lack of typical manifestations of primary diseases, and more visits to general hospitals, the general physician lacks high vigilance against tuberculosis without corresponding examination of tuberculosis, resulting in senile tuberculosis Long-term delay diagnosis, or missed diagnosis and misdiagnosis, the literature reports that the rate of misdiagnosis of elderly tuberculosis due to combined non-tuberculosis is as high as 19% 80%.
Examine
Examination of tuberculosis in the elderly
First, tuberculosis test
It is the most specific method for the diagnosis of tuberculosis. The tuberculosis is the main basis for the diagnosis of tuberculosis. The smear acid-fast staining microscopy is quick and simple. It is rare in China for atypical mycobacteria, so acid-fast bacilli are positive and tuberculosis is diagnosed. Basically, the positive rate of direct thick smear is better than that of thin smear. It is widely used at present. Fluorescence microscopy is suitable for rapid examination of a large number of specimens. No sputum or children will not cough. Use early morning gastric wash to find tuberculosis. Adults can also be examined by fiberoptic bronchoscopy or by finding tubercle bacillus from their sputum. The sputum positive indicates that the lesion is open and infectious, and if the amount of bacteria is high (more than 100,000 per ml) Direct smear is easy to be positive, which is a source of social infection, and the amount of sputum is less (less than 10,000 per ml).
The culture method is more precise. In addition to understanding the growth and reproduction ability of tuberculosis, it can be used for drug sensitivity test and bacterial type identification. The growth of tuberculosis is slow. It takes 4-8 weeks to report the use of modified Roche medium. Although it is time-consuming, it is accurate and reliable, and its specificity is high. If the smear is negative or the diagnosis is doubtful, the culture is especially important. The culture strain is further used for drug sensitivity measurement, which can provide reference for treatment, especially for re-treatment.
The specimens were amplified in vitro by polymerase chain reaction (PCR) method, and the DNA containing microtuberculosis was amplified and detected by electrophoresis. One tuberculosis contains about 1fg of DNA, and 40 tuberculosis can have positive results. The method does not need to be pre-cultured in vitro, has strong specificity, can be reported in 2 days, is fast, simple, and can identify the type of bacteria. The disadvantage is that false positive or false negative may occur.
Second, imaging examination
Chest X-ray examination can find the location of the lesions in the lungs, the extent, the presence or absence of cavities or voids, the thickness of the cave wall, etc., the X-ray has different permeability to various types of tuberculosis lesions, and the pathological properties of tuberculosis can be estimated by X-ray examination. And early detection of tuberculosis, as well as judging the development of the disease and treatment effects, can help determine the treatment plan, it must be pointed out that the lung lesions caused by different causes may present similar X-ray images, so it is not easy to rely solely on X-ray examination Determine the diagnosis of tuberculosis.
X-ray film combined with fluoroscopy can improve the accuracy of diagnosis, and can find ribs, mediastinum, diaphragm or small lesions covered by the heart, and can observe the dynamics of heart, lung and diaphragm.
Common X-ray findings of tuberculosis include: intensive lesions of fibrous calcification, characterized by high density, clear-edged spots, infiltrative lesions of nodules or nodules, manifested as cloud-like shadow cheese-like lesions with lighter density and blurred edges. It is characterized by high density, different shades, and voids with a circular boundary. The tuberculosis lesions are usually in the upper part of the lung, unilateral or bilateral, and have a long time, and there are many different types of lesions mixed with the lungs. Inside broadcast signs.
Exudative or exudative proliferative lesions, caseous pneumonia, cheese-like lesions, and cavities (except for purifying cavities) on X-ray films, suggesting proliferative lesions of active lesions and tight cheese induration Foci and fibrosis foci are all inactive lesions. Tuberculosis can still be found in the sputum of active lesions. Because tuberculosis is mostly mixed, it should be considered as activity when it does not reach complete proliferation or fiber calcification. Sex.
Chest CT examination is helpful for finding small or insidious lesions, understanding the extent of lesions and identifying lung lesions.
Third, tuberculin (abbreviation) test
Old tuberculin (OT) is a metabolite of tuberculosis. It is made from tuberculosis bacteria grown in liquid culture. It mainly contains tuberculosis protein. The OT antigen is impure and may cause non-specific reactions. 1,2000 OT dilution solution 0.1ml (5IU) can be used for intradermal injection on the left forearm flexion side, and the skin induration diameter is measured after 48-72 hours, if less than 5mm is negative, 5~9mm is weakly positive (prompt tuberculosis Bacteria or Mycobacterium tuberculosis infection, 10 ~ 19mm is a positive reaction, more than 20mm or local occurrence of blisters and necrosis is a strong positive reaction.
Purified protein derivative (PPD) is purified from the extracted tubercle protein from the old knot filtrate. It is purely pure and does not produce non-specific reactions. PPD&mdash&mdashRT23, which is commonly used in the world, has replaced OT. PPD (PPD-C) made from tuberculosis and BCG-PPD from BCG have good purity and have been widely used in clinical diagnosis. Intradermal injection of 0.1ml (5IU) induration average diameter &ge5mm is positive. In addition to causing local skin reactions, the prime test may cause systemic reactions. Clinical diagnosis usually uses 5 IU. If there is no reaction, 5 IU can be used after one week (the effect of enhancing the production of sputum). If it is still negative, the TB infection can be roughly excluded. .
Diagnosis
Diagnosis and diagnosis of pulmonary tuberculosis in the elderly
Should be highly alert to the elderly tuberculosis, when the elderly cough, cough, hemoptysis, or fever, night sweats, weight loss, fatigue, weight loss, anorexia and other respiratory or non-respiratory symptoms should be considered the possibility of tuberculosis and corresponding Examination, laboratory examination, anemia, white blood cell count reduction, hypoproteinemia and erythrocyte sedimentation rate are seen in most elderly tuberculosis patients, and hypoxemia is more common in elderly tuberculosis, such as suspected senile tuberculosis, after routine, non-injury Sexual examinations are not yet diagnosed, and when lung cancer cannot be ruled out, a biopsy should be sought.
When suspected extrapulmonary tuberculosis, appropriate specimens should be taken as an early pathogen to confirm tuberculous pleurisy, diagnosis of tuberculous meningitis, for the diagnosis of disseminated tuberculosis, sometimes liver, bone marrow or lymph node biopsy, and check the fundus to see if there is Choroidal tuberculous nodules, suspected genitourinary tuberculosis, can be taken every day for the first time in the morning for smear acid-fast staining and tuberculosis culture.
