tuberculosis
Introduction
Introduction to tuberculosis Tuberculosis is a chronic infectious disease caused by Mycobacterium tuberculosis, which can invade many organs. Pulmonary tuberculosis is the most common form of pulmonary tuberculosis (pulrnonary tuberculosis), and it is an important source of infection. Humans are mainly infected by inhalation of bacterial droplets (the tuberculosis patients cough and sneeze). Tuberculosis invading the respiratory tract is engulfed by alveolar macrophages. basic knowledge The proportion of illness: 0.12% Susceptible people: no special people Mode of infection: droplet spread Complications: pneumothorax, bronchiectasis, empyema, chronic pulmonary heart disease
Cause
Causes of tuberculosis
Mycobacterium tuberculosis belongs to the actinomycetes, mycobacteria of the mycobacteria family, and is a pathogenic acid-fast bacteria. Mainly divided into human, cattle, birds, mice and other types. People who are pathogenic to humans are mainly human bacteria, and bovine bacteria are rarely infected. The resistance of tuberculosis to drugs can be formed by the development of congenital drug-resistant bacteria in the flora, or it can be quickly developed due to the use of an anti-tuberculosis drug alone in the human body. bacteria. Drug-resistant bacteria can cause treatment difficulties and affect the efficacy.
Prevention
Tuberculosis prevention
1. Vaccination with BCG Vaccines should be vaccinated in uninfected persons such as neonates, enlisted recruits and new students with negative serotonin test, young workers in new TB medical units, and adolescents undergoing kidney transplantation.
2. Chemoprevention The selective chemoprevention of infected persons is as follows:
(1) Close contacts of patients with bacteriucin, such as children with positive serotonin test (no BCG), strong positive adolescents.
(2) The children and adolescents were tested positively, and the adult sputum test was strongly positive.
(3) Inactive pulmonary tuberculosis is one of the following: 1 long-term large amount of glucocorticoids, immunosuppressive agents, cytotoxic drugs; 2 radiation therapy; 3 before and after gastrectomy; 4 new soldiers, new students' syndrome test Strong positive; 5 tuberculosis and HIV double infection, AIDS patients with positive test; 6 kidney transplant recipients with tuberculosis, or inactive tuberculosis; 7 diabetes with inactive tuberculosis; 8 positive test Patients with silicosis (silicosis).
For chemoprevention, the isoniazid adult is 0.3g/d, the child is 6-8mg/(ks·d), and the treatment lasts for 6 months.
3. Elimination of infectious sources Sputum smear positive (Shangyang) tuberculosis is the main source of infection, eliminating the source of infection is the fundamental countermeasure to control tuberculosis. The initial treatment of smear-positive pulmonary tuberculosis and re-treatment of smear-positive pulmonary tuberculosis is the main target of chemotherapy.
Complication
Tuberculosis complications Complications, pneumothorax, bronchiectasis, empyema, chronic pulmonary heart disease
1, pneumothorax
When the lung cavity and cheese-like lesions are close to the pleural area, it can cause tuberculous pus. Miliary tuberculosis can cause bilateral spontaneous pneumothorax.
2. Endobronchial stenosis
Caused by endobronchial lesions.
3, bronchiectasis
Repeated progression and fibrosis of tuberculosis lesions, resulting in the destruction of the normal structure of the bronchus in the lungs, can cause secondary bronchiectasis, often repeated hemoptysis. Often located in the upper lobe, called dry branch expansion. Can cause fatal hemoptysis.
4, empyema
The pleural effusion of exudative pleurisy, if not treated in time, can be gradually cheeseified or even purulent, becoming tuberculous empyema. It is the result of the progression of cardiovascular and cavitary lung tuberculosis infection, often occurring after pneumothorax, accompanied by failure and loss of resistance to infection.
5, pulmonary aspergillosis
Common in tuberculosis. Hemoptysis is the leading cause of death in this disease.
6, chronic pulmonary heart disease
Severe tuberculosis causes extensive destruction of lung tissue. Chronic fibrovascular tuberculosis or one-sided lung damage, complicated by emphysema, bullous bullae, can cause spontaneous pneumothorax, can also lead to chronic heart disease, and even cardiopulmonary failure.
Symptom
Symptoms of tuberculosis Common symptoms Wet Luoyin hemoptysis with cough and sputum, septicemia, low fever, extraintestinal tuberculosis, nasal tuberculosis, middle lobe, fibrous lesions, massive hemoptysis
1. Pay attention to 1 whether there is fever, night sweats, loss of appetite, weight loss, cough, cough, blood stasis or hemoptysis, chest pain, difficulty breathing and other symptoms. Female patients have menstrual disorders or amenorrhea. 2 ask about the length of the disease, onset time, X-ray lesions, sputum examination, diagnosis, treatment medication and program, treatment, efficacy, drug side effects.
2. Physical examination should pay attention to whether the superficial lymph nodes are swollen or not, and there is no BCG scar on the left upper arm. Whether there is abnormality in the chest, other systems have signs of tuberculosis complications.
3. Tuberculosis classification Pulmonary tuberculosis is divided into five large: primary tuberculosis (type 1); hematogenous disseminated tuberculosis (type II); invasive tuberculosis (type III); chronic fibrovascular tuberculosis (type IV); tuberculosis Pleuritis (V type). The activity and outcome of tuberculosis: divided into three phases, namely, the progress period, the improvement period, and the stabilization period.
Examine
Tuberculosis examination
Laboratory examination
Routine tests such as blood, urine, stool, erythrocyte sedimentation rate, liver and kidney function were routinely checked once during admission. Abnormalities were reviewed, and 1 time was reviewed at discharge; liver and kidney function were reviewed once a month. The TB tuberculosis was admitted to the hospital three times in a row, and the smear method was acid-stained and microscopically examined, and at least once a month. In the necessary unconventional examinations, the tuberculosis culture, strain identification and drug sensitivity test are performed. Those with negative tuberculosis can be tested for polymerase chain reaction (PCR) and anti-tuberculosis antibodies. Those suspected of having secondary infections should be tested for common bacteria, fungi, anaerobic bacteria and drug susceptibility.
2. Chest X-ray examination
Patients admitted to the hospital should have a recent posterior position of the chest (within 1 week), and if necessary, a lateral position, a anterior arch position, and a tomographic photograph. The chest radiograph was taken every 2 months during treatment and at the time of discharge. Chest is performed once a month or as necessary. Thoracic CT examinations are performed as needed.
3. Other inspections
Tuberculin test according to the condition, fiberoptic bronchoscopy and bronchoalveolar lavage fluid examination, fiberoptic bronchoscopy or percutaneous lung biopsy, thoracoscopy, mediastinoscopy, lung function, blood gas analysis, electrocardiogram, ophthalmoscope, laryngoscope, etc. an examination.
Diagnosis
Diagnosis and diagnosis of pulmonary tuberculosis
diagnosis
Medical history
1. Ask about the history of exposure or previous history of pleurisy, anal fistula, cervical lymphadenopathy, diabetes, and BCG contact.
2. There are symptoms of tuberculosis, such as low fever, general malaise, fatigue, night sweats, loss of appetite, flushing of cheeks, etc. Miliary tuberculosis and caseous pneumonia are often associated with high fever, some may be associated with joint pain, and women may have menstrual disorders.
3. Early dry cough, when the cavity is formed, the sputum is mucopurulent or purulent, hemoptysis, chest pain, and severe breathing difficulties.
Differential diagnosis
The clinical and X-ray findings of tuberculosis are often similar to many non-tuberculous lung diseases. It is easy to be misdiagnosed. It is necessary to emphasize the comprehensive analysis based on medical history, relevant laboratory data, X-ray films, etc. The necessary fashion needs to be observed dynamically and carefully identified.
First, lung cancer
Central type of lung cancer often has blood in the sputum, with shadows near the hilar, similar to hilar lymph node tuberculosis. Peripheral lung cancer can be spherical, lobulated, and need to be differentiated from tuberculosis. Lung cancer is more common in tobacco over 40 years old. Men often have no obvious toxic symptoms, more irritating cough, chest pain and progressive weight loss. X-ray chest radiograph shows satellite lesions around the tuberculosis ball, calcification, and the edge of the cancer lesion often has notch, burr, chest CT scan It is often helpful to identify the two. In the central type of lung cancer, the CT findings of the bronchial soft tissue density are attached to one side to thicken the bronchial wall, the contour of the mass is irregular, the lung segment and the lobes of the lung are irregularly narrow, and the mediastinal lymph nodes are enlarged. Combined with tubercle bacillus, exfoliated cell examination and fiberoptic bronchoscopy and biopsy, etc., can often identify in time, lung cancer and tuberculosis coexist, also need to pay attention to find that it is difficult to completely eliminate lung cancer in clinical, combined with specific circumstances, if necessary Consider a thoracotomy to avoid delays in treatment.
Second, pneumonia
Typical pneumococcal pneumonia is indistinguishable from invasive pulmonary tuberculosis, and infiltrating pulmonary tuberculosis, which progresses faster, expands into the entire lobe, forming caseous pneumonia, which is easily misdiagnosed as pneumococcal pneumonia. The former has a rapid onset, high fever, chills, chest pain. With urgency, cough and rust, sputum X-ray signs are often limited to one leaf, antibiotic treatment is effective, caseous pneumonia is more symptoms of tuberculosis, slow onset, cough yellow mucus, X-ray signs are located in the upper right lobe It can affect the tip of the right upper lobe, and the posterior segment is cloud-like, with uneven density. It can appear as a worm-like cavity. It is effective for anti-tuberculosis treatment, and it is easy to find tuberculosis.
Symptoms of inflammation on the X-ray with mild cough, hypothermia mycoplasma pneumonia, viral pneumonia or hypersensitivity pneumonitis (eosinophilic pulmonary infiltrates), similar to early invasive pulmonary tuberculosis, for such cases that are difficult to identify at one time, Should not be eager to anti-tuberculosis treatment, mycoplasmal pneumonia usually in a short period of time (2 to 3 weeks) can easily dispel the allergic pneumonia in the lung infiltration shadow is often migratory, blood eosinophilia.
Third, lung abscess
Lung abscess cavity is more common in the lower lobe of the lung. The inflammation around the abscess is more serious. There is often a fluid level in the cavity. The tuberculosis cavity occurs mostly in the upper lobe of the lung. The cavity wall is thin, and there are few liquid levels in the hole. Lung abscess is more acute, high fever, a lot of purulent sputum, no tuberculosis in the sputum, but there are many other bacteria, the total number of white blood cells and neutrophils, antibiotic treatment is effective, chronic fibrovascular tuberculosis combined with infection Confused with chronic lung abscess, the latter is negative for tuberculosis.
Fourth, bronchiectasis
Chronic cough, sputum and repeated hemoptysis need to be differentiated from chronic fibroblastic tuberculosis, but bronchiectasis is negative for tuberculosis, no abnormalities in X-ray chest radiographs or only local lung texture thickening or curling shadows, CT Help to confirm the diagnosis.
Fifth, chronic bronchitis
The symptoms of chronic bronchitis in the elderly are similar to those of chronic fibrovascular tuberculosis. In recent years, the incidence of tuberculosis in the elderly has increased. It is necessary to carefully identify the two, and timely X-ray examination can help to confirm the diagnosis.
Sixth, other febrile diseases
Various types of tuberculosis often have different types of fever, so tuberculosis is often one of the main causes of clinical fever. Unexplained typhoid fever, sepsis, leukemia, mediastinal lymphoma and sarcoidosis are similar to tuberculosis. Typhoid fever has high fever and blood. Decreased white blood cell count and liver and spleen in clinical manifestations, easy to be confused with acute miliary tuberculosis, but typhoid fever type is often missed fever, relatively slow pulse, skin rose rash, serum typhoid agglutination test positive, blood, fecal typhoid culture positive Septicemia onset, chills and relaxation heat, white blood cells and neutrophils, often have recent skin infections, history of squeezing or urinary tract, history of biliary tract infection, common skin defects, near the course of the disease Migratory lesions or septic shock, blood or bone marrow culture can be found in pathogenic bacteria, acute miliary tuberculosis has fever, hepatosplenomegaly, specific X-ray manifestations appear several weeks after onset, occasionally bloody leukemia-like reactions or monocytes Abnormal increase, need to be differentiated from leukemia, the latter has obvious bleeding tendency, bone marrow smear and dynamic X-ray chest radiograph follow-up can help establish diagnosis, adult Tracheal lymphadenopathy often manifests as fever and hilar lymphadenopathy, and should be differentiated from sarcoidosis, mediastinal lymphoma, tuberculosis patients with positive test, anti-tuberculosis treatment and lymphoma development, often liver and spleen and superficial Lymph node enlargement, diagnosis often depends on biopsy, sarcoidosis usually does not fever, hilar lymphadenopathy is mostly bilateral, nodules test negative, glucocorticoid therapy is effective, if necessary, biopsy should be performed to confirm the diagnosis.
The above mentioned are only a few major common diseases. In the specific identification, it is necessary to comprehensively grasp and analyze the diagnosis basis of the tuberculosis that patients have, and should be familiar with the characteristics of such easily confused diseases. Sexuality must be carefully observed and strictly contrasted and judged.
