Childhood Tuberculosis 檀卫平 中山二院 Tan-weiping
Definition <ul><li>Tuberculosis is caused by Mycobacterium tuberculosis ,  isolated by Robert Koch in 1882 ,  M.bovis(seld...
Epidemiology <ul><li>19th century, 25% deaths by TB   </li></ul><ul><li>1940s, effective medicines </li></ul><ul><li>Annua...
Epidemiology <ul><li>The morbidity / mortality of tuberculosis are high in developing countries (southeast asia,China,Indi...
Epidemiology <ul><li>TB adults exposure </li></ul><ul><li>Immunocompromise </li></ul><ul><li>malnutrition </li></ul><ul><l...
Risk factors <ul><li>Socioeconomic status </li></ul><ul><li>Over-crowding </li></ul><ul><li>Poor nutrition </li></ul><ul><...
Etiology <ul><li>Tubercle bacillus: </li></ul><ul><li>aerobic,   grows  slowly </li></ul><ul><li>non-Motile,non-spore-form...
Dr. Robert Koch  discovered the tuberculosis bacilli in 1882  He received the  Nobel Prize in physiology or medicine  in 1...
<ul><li>Tuberculosis is transmitted by  airborne droplet  nuclei(containing tubercle bacilli ) </li></ul><ul><li>prolonged...
<ul><li>Many droplet nuclei are capable of floating in environment for  several hours </li></ul><ul><li>Large  particles  ...
The transmission is determined <ul><li>The probability of contact with  active — not latent — TB </li></ul><ul><li>intimac...
Pathogenesis <ul><li>tubercle bacillus  </li></ul>Human immunity
Pathogenesis <ul><li>90% infected with  Mycobacterium tuberculosis   asymptomatic,  latent TB infection   10% progress to ...
Pathogenesis <ul><li>mycobacteria -> pulmonary alveoli -> replicate within   macrophages  ->   picked up by  dendritic cel...
Human Immunity /hypersensitivity  after TB infection <ul><li>Specific immunity after infected or  given  BCG  vaccine </li...
Two types of cells are essential in the formation of TB <ul><li>Macrophages: directly phagocytize TB and processing and pr...
T lymphocytes(CD4+) <ul><li>Many lymphokines are involved in tuberculosis, the interplay of these cytokines determine the ...
<ul><li>Genetic factors ( HLA-BW35) play a key role in innate non-immune resistance  to  infection with M. Tuberculosis  <...
Basic pathologic changes <ul><li>infiltration -> hyperplasia( granuloma) ,   ulceration  or  calcification  in different s...
A characteristic tubercle at low magnification ( A ) and in detail ( B ) central caseation surrounded by epithelioid and m...
Progression of tuberculosis <ul><li>Absorption </li></ul><ul><li>Fibrosis </li></ul><ul><li>Calcification </li></ul><ul><l...
Five common clinical patterns <ul><li>1.  Primary pulmonary tuberculosis  (Primary Complex and </li></ul><ul><li>Bronchial...
Diagnosis <ul><li>History and Clinical Manifestations   </li></ul><ul><li>Tuberculin testing </li></ul><ul><li>Lab examina...
History /Clinical Manifestations <ul><li>systemic signs : fever,  weight loss, fatigue,  night sweats, wasting,coughing up...
Tuberculin skin test <ul><li>a skin test to determine past or present infection with the tuberculosis bacterium; based on ...
Result is read by measuring the diameter of induration 48-72hrs <ul><li>Induration <5mm negative </li></ul><ul><li>Indurat...
<ul><li>Tuberculin testing </li></ul><ul><li>A positive tuberculin test is of great use in children,  with limited diagnos...
Clinical Significance <ul><li>Positive  </li></ul><ul><li>Negative </li></ul>
Positive Reaction :  indicates TB exposure <ul><li>BCG Vaccination </li></ul><ul><li>Children and adolescents(++) exposed ...
Negative Reaction <ul><li>Never exposed to TB </li></ul><ul><li>Within 4-8wks of primary infectin </li></ul><ul><li>False ...
PPD reaction of natural TB infection  and BCG vaccination <ul><li>Natural  infection </li></ul><ul><li>stronge </li></ul><...
Laboratory examinations <ul><li>Sputum examination  acid-fast staining </li></ul><ul><li>----LED microscopes </li></ul><ul...
Isolation of  M. tuberculosis   <ul><li>automatic radiometric methods: such as BACTEC—1-3wks </li></ul>
Chest radiography <ul><li>Chest X-ray: most important method to detect TB  </li></ul><ul><li>Characteristics ,area, degree...
bronchoscopy <ul><li>Endobrochial tuberculosis  </li></ul><ul><li>tuberculous tracheobronchial lymphadenitis  </li></ul>
Puncture of peripherial LN <ul><li>Tubercle </li></ul><ul><li>caseous necrosis </li></ul>
Table 39-1     -- The Stages of Tuberculosis in Children  The Stages of Tuberculosis in Children   Three or four One One N...
Treatment <ul><li>Common therapy :  </li></ul><ul><li>Nutrition 、 Rest </li></ul><ul><li>Ventilation </li></ul><ul><li>Iso...
Chemotherapy <ul><li>goal :  Kill TB  </li></ul><ul><li>Limit TB from  spreading </li></ul><ul><li>principles :   </li></u...
Classification of antitubercular drug <ul><li>bactericidal </li></ul><ul><li>( 1 ) complete  bactericidal : </li></ul><ul>...
<ul><li>medicines  are  classified as  first-line  and  second-line  agents </li></ul><ul><li>First-line essential  antitu...
<ul><li>First-line medicines include   </li></ul><ul><li>Isoniazid,  rifampin, </li></ul><ul><li>pyrazinamide,streptomycin...
Isoniazid (INH)  first-line drug <ul><li>Isoniazid is a principal agent used to treat TB </li></ul><ul><li>It is universal...
Advantages <ul><li>Inexpensive </li></ul><ul><li>Readily synthesized </li></ul><ul><li>Availabe worldwide </li></ul><ul><l...
Dosage <ul><li>Tuberculosis organization have recommended  </li></ul><ul><li>5 mg/kg daily  for both groups </li></ul><ul>...
Adverse effects <ul><li>The two most important adverse effects of  isoniazid  therapy  are  hepatotoxicity </li></ul><ul><...
Rifampin (RFP)   first-line drug <ul><li>It is also considered the most important and potent  antituberculous agent </li><...
Chemotherapy Regimens <ul><li>Standard regimen : </li></ul><ul><li>asymptomatic primary infection </li></ul><ul><li>INH 、 ...
Two Stage Therapy <ul><li>Active primary TB 、 Disseminated TB 、  TB meningitis </li></ul><ul><li>Enforcement stage : 3-4  ...
Short-term Therapy DOTS (Directly Observed Treatment Short-course)   <ul><li>2 or 3  drugs  killing  of  organisms  + 1 dr...
Prevention <ul><li>Prevention of Tuberculosis : Vaccination </li></ul><ul><li>BCG Vaccination can obtain immunity acquired...
Prevention <ul><li>Finding patients earlier </li></ul><ul><li>Treatment and management of patients  </li></ul><ul><li>Prev...
Prophylatic chemotherapy <ul><li>Intimate contact with family members suffering active TB </li></ul><ul><li><3y infant PPD...
<ul><li>Regimen: </li></ul><ul><li>INH : 10mg/kg.d , 6-9m </li></ul>
Tuberculous meningitis
Pathogenesis <ul><li>Spreading through bloodstream </li></ul><ul><li>Rupture of TB lesion->bacteria enter choroids plexuse...
Clinical Manifestation <ul><li>The 1st Stage:  1-2wks </li></ul><ul><li>change of character:irritability, </li></ul><ul><l...
The 2nd Stage 1-2wks <ul><li>Meningeal irritation stage </li></ul><ul><li>Increased ICP:   Headaches,vomiting, drowsiness,...
The 3rd Stage <ul><li>Coma stage  1-3wks </li></ul><ul><li>coma,  hemiplegia, paraplegia, convulsion  consumption, abnorma...
Diagnosis <ul><li>Medical history  </li></ul><ul><li>Clinical manifestation </li></ul><ul><li>CSF examination </li></ul><u...
Differentiation diagnosis <ul><li>Meningococcal Meningitis </li></ul><ul><li>Viral Meningitis </li></ul><ul><li>cryptococc...
Treatment <ul><li>General  therapy </li></ul><ul><li>Anti-tuberculous therapy </li></ul><ul><li>Decreasing intracranial pr...
Anti-tuberculous therapy <ul><li>1、 The initial stage : </li></ul><ul><li>  3-4 m </li></ul><ul><li>  INH、RFP、PZA、SM </li>...
Latent infection of tuberculosis <ul><li>A patient is infected with  Mycobacterium tuberculosis , but does not have active...
Miliary tuberculosis in an infant whose uncle also had tuberculosis. There is adenopathy in addition to the millet seed–li...
 
A posteroanterior (A) and lateral (B) chest radiograph of a child with hilar adenopathy caused by Mycobacterium tuberculos...
Hilar and mediastinal adenopathy and a partial segmental lesion in a child with tuberculosis
Lobar pneumonia with bowing of the horizontal fissure in a child with tuberculosis. a secondary bacterial pneumonia may ha...
Tuberculous pleural effusion in a teenage girl. The pleural biopsy had caseating granulomas
 
A magnetic resonance image of tuberculoma in a child with culture-positive tuberculous meningitis. The child's presenting ...
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9 tuberculosis tanweiping

  1. 1. Childhood Tuberculosis 檀卫平 中山二院 Tan-weiping
  2. 2. Definition <ul><li>Tuberculosis is caused by Mycobacterium tuberculosis , isolated by Robert Koch in 1882 , M.bovis(seldom) </li></ul><ul><li>mainly involves the lungs, but may spread to other organs </li></ul><ul><li>consumption (肺痨) </li></ul>
  3. 3. Epidemiology <ul><li>19th century, 25% deaths by TB </li></ul><ul><li>1940s, effective medicines </li></ul><ul><li>Annually, 8 million become ill with tuberculosis, 2 million people die </li></ul><ul><li>China has the world's second largest tuberculosis epidemic (after India ), 1.3 million new cases every year </li></ul><ul><li>Work migrants &quot;floating&quot; peasants migrant population:100 million </li></ul><ul><li>incidences rates 113 per 100,000 in China </li></ul>
  4. 4. Epidemiology <ul><li>The morbidity / mortality of tuberculosis are high in developing countries (southeast asia,China,India,Africa,latin america) </li></ul><ul><li>Age:60% Infant - <5yr </li></ul><ul><li>Favored age:5-14yr </li></ul><ul><li>Male:female-1:1(adults male predominate) </li></ul>
  5. 5. Epidemiology <ul><li>TB adults exposure </li></ul><ul><li>Immunocompromise </li></ul><ul><li>malnutrition </li></ul><ul><li>HIV/AIDS infection </li></ul><ul><li>Poverty,immigration </li></ul><ul><li>irregular treatment breeds : drug-resistant tuberculosis </li></ul>
  6. 6. Risk factors <ul><li>Socioeconomic status </li></ul><ul><li>Over-crowding </li></ul><ul><li>Poor nutrition </li></ul><ul><li>Inadequate health care </li></ul><ul><li>HIV infection </li></ul><ul><li>Drug abuse </li></ul>
  7. 7. Etiology <ul><li>Tubercle bacillus: </li></ul><ul><li>aerobic, grows slowly </li></ul><ul><li>non-Motile,non-spore-forming, highlipid content </li></ul><ul><li>acid-fast , weak Gram(+) </li></ul><ul><li>Sensitive to heat/sunlight tolerate in humid or dry or cold. withstand weak disinfectants and survive in a dry state for weeks . </li></ul>
  8. 8. Dr. Robert Koch discovered the tuberculosis bacilli in 1882 He received the Nobel Prize in physiology or medicine in 1905 for this discovery
  9. 9. <ul><li>Tuberculosis is transmitted by airborne droplet nuclei(containing tubercle bacilli ) </li></ul><ul><li>prolonged, frequent, or intense contact </li></ul><ul><li>cough, sneeze, speak, or spit </li></ul>
  10. 10. <ul><li>Many droplet nuclei are capable of floating in environment for several hours </li></ul><ul><li>Large particles may be inhaled by person </li></ul><ul><li>breathing the same air and impact on the </li></ul><ul><li>trachea or wall of the upper airway </li></ul>
  11. 11. The transmission is determined <ul><li>The probability of contact with active — not latent — TB </li></ul><ul><li>intimacy and duration of contact </li></ul><ul><li>effectiveness of ventilation </li></ul><ul><li>number s and virulence of the M. tuberculosis strain in infectious droplets </li></ul>
  12. 12. Pathogenesis <ul><li>tubercle bacillus </li></ul>Human immunity
  13. 13. Pathogenesis <ul><li>90% infected with Mycobacterium tuberculosis asymptomatic, latent TB infection 10% progress to TB disease </li></ul><ul><li>if untreated, the death rate for these active TB cases is more than 50% </li></ul>
  14. 14. Pathogenesis <ul><li>mycobacteria -> pulmonary alveoli -> replicate within macrophages -> picked up by dendritic cells -> transport to local LN -> spread through bloodstream to other tissues/organs -> secondary TB lesions </li></ul><ul><li>primary site of infection : upper part of the lower lobe, or lower part of the upper lobe of lung </li></ul><ul><li>secondary TB lesions: apex of the upper lobes , peripheral lymph nodes, kidneys, brain, and bone </li></ul>
  15. 15. Human Immunity /hypersensitivity after TB infection <ul><li>Specific immunity after infected or given BCG vaccine </li></ul><ul><li>Cell-mediate immunity develops within 4-8 weeks after infected with bacillus </li></ul><ul><li>Many immunologic cells: Macrophages, T/B lymphocytes, fibroblasts involved </li></ul>
  16. 16. Two types of cells are essential in the formation of TB <ul><li>Macrophages: directly phagocytize TB and processing and presenting antigens to T lymphocyte </li></ul><ul><li>T lymphocytes(CD4+): induce protection through the production of lymphokines </li></ul>
  17. 17. T lymphocytes(CD4+) <ul><li>Many lymphokines are involved in tuberculosis, the interplay of these cytokines determine the hosts response for example </li></ul><ul><li>IL-1 is related to fever </li></ul><ul><li>IL-6 is related to hyperglobulinemia </li></ul><ul><li>TNF is related to the killing of mycobacteria formation of granulomas </li></ul><ul><li>other cytokines including IL-4,IL-5,IL-10 can promote humoral immunity </li></ul>
  18. 18. <ul><li>Genetic factors ( HLA-BW35) play a key role in innate non-immune resistance to infection with M. Tuberculosis </li></ul><ul><li>These genes may have a role in determining susceptibility to tuberculosis </li></ul>
  19. 19. Basic pathologic changes <ul><li>infiltration -> hyperplasia( granuloma) , ulceration or calcification in different stage </li></ul><ul><li>host defense < bacterias, caseating ulceration( caseous necrosis ) -> fibrosis </li></ul><ul><li>host defense > bacteria, granuloma calcification </li></ul>
  20. 20. A characteristic tubercle at low magnification ( A ) and in detail ( B ) central caseation surrounded by epithelioid and multinucleated giant cells(C) mycobacteria with acid-fast stains ( D ).
  21. 21. Progression of tuberculosis <ul><li>Absorption </li></ul><ul><li>Fibrosis </li></ul><ul><li>Calcification </li></ul><ul><li>Deterioration: enlargement of infected aeras and appear newer infiltrated regions or spreading. </li></ul>
  22. 22. Five common clinical patterns <ul><li>1. Primary pulmonary tuberculosis (Primary Complex and </li></ul><ul><li>Bronchial Lymphnode-Tuberculosis) </li></ul><ul><li>2. Milliary Tuberculosis (acute, subacute and chronic hematogenous pulmonary tuberculosis) </li></ul><ul><li>3. secondary pulmonary tuberculosis </li></ul><ul><li>Infiltrative pulmonary tuberculosis </li></ul><ul><li>Chronic fibrocavenous pulmonary tuberculosis </li></ul><ul><li>4.Tuberculous pleuritis </li></ul><ul><li>5.Extrapulmonary tuberculosis </li></ul>
  23. 23. Diagnosis <ul><li>History and Clinical Manifestations </li></ul><ul><li>Tuberculin testing </li></ul><ul><li>Lab examination </li></ul><ul><li>X-r ay </li></ul><ul><li>bronchoscopy </li></ul><ul><li>Puncture of adenopathy </li></ul>
  24. 24. History /Clinical Manifestations <ul><li>systemic signs : fever, weight loss, fatigue, night sweats, wasting,coughing up blood, </li></ul><ul><li>Chest pain. </li></ul><ul><li>TB Contaction : adults in family </li></ul><ul><li>History of BCG Vaccination </li></ul><ul><li>Acute infectious disease recently : measles,whooping cough </li></ul><ul><li>Allergy to TB : erythema nodosum 、 herpetic conjunctivitis </li></ul>
  25. 25. Tuberculin skin test <ul><li>a skin test to determine past or present infection with the tuberculosis bacterium; based on hypersensitivity of the skin to tuberculin </li></ul><ul><li>Method of test protein purified derivative PPD 0.1ml intradermal injection </li></ul><ul><li>Site : internal side of medium-distal 1/3 left forearm </li></ul><ul><li>6 - 10mm </li></ul><ul><li>Result : 48-72hrs, transverse </li></ul><ul><li>diameter </li></ul>
  26. 26. Result is read by measuring the diameter of induration 48-72hrs <ul><li>Induration <5mm negative </li></ul><ul><li>Induration 5-9mm(+) </li></ul><ul><li>Induration 10-19mm(++) </li></ul><ul><li>Induration 》 20mm (+++) </li></ul><ul><li>A positive tuberculin skin test indicates </li></ul><ul><li>tuberculous infection, with or without disease </li></ul>
  27. 27. <ul><li>Tuberculin testing </li></ul><ul><li>A positive tuberculin test is of great use in children, with limited diagnostic significance in adults </li></ul>
  28. 28. Clinical Significance <ul><li>Positive </li></ul><ul><li>Negative </li></ul>
  29. 29. Positive Reaction : indicates TB exposure <ul><li>BCG Vaccination </li></ul><ul><li>Children and adolescents(++) exposed to TB </li></ul><ul><li>Infant﹤3yrs (++) recent infection </li></ul><ul><li>(+++) Active TB infectin </li></ul><ul><li>(-) -> (+) , or Induration<10mm ->>10mm, ↑>6mm recent infection </li></ul>
  30. 30. Negative Reaction <ul><li>Never exposed to TB </li></ul><ul><li>Within 4-8wks of primary infectin </li></ul><ul><li>False negative:compromised immunity </li></ul><ul><li>Technique failure or PPD invalidated </li></ul>
  31. 31. PPD reaction of natural TB infection and BCG vaccination <ul><li>Natural infection </li></ul><ul><li>stronge </li></ul><ul><li>Induration >10-15mm </li></ul><ul><li>deep red 、 regular margin 、 hard </li></ul><ul><li>pigmentation </li></ul><ul><li>Long duration > 7-10d </li></ul><ul><li>Less change </li></ul><ul><li>BCG vaccination </li></ul><ul><li>weak </li></ul><ul><li>Induration 5-9mm </li></ul><ul><li>light red 、 unregular margin 、 soft </li></ul><ul><li>Short duration:2-3d </li></ul><ul><li>Become weak gradually,disappear3-5y </li></ul>
  32. 32. Laboratory examinations <ul><li>Sputum examination acid-fast staining </li></ul><ul><li>----LED microscopes </li></ul><ul><li>DNA-based diagnosis :PCR test TB </li></ul><ul><li>antibody testing </li></ul><ul><li>ESR </li></ul><ul><li>Blood Routine </li></ul>
  33. 33. Isolation of M. tuberculosis <ul><li>automatic radiometric methods: such as BACTEC—1-3wks </li></ul>
  34. 34. Chest radiography <ul><li>Chest X-ray: most important method to detect TB </li></ul><ul><li>Characteristics ,area, degree of activity or progress </li></ul><ul><li>Differentiation with other disease </li></ul><ul><li>Follow the effectivity of therapy </li></ul>
  35. 35. bronchoscopy <ul><li>Endobrochial tuberculosis </li></ul><ul><li>tuberculous tracheobronchial lymphadenitis </li></ul>
  36. 36. Puncture of peripherial LN <ul><li>Tubercle </li></ul><ul><li>caseous necrosis </li></ul>
  37. 37. Table 39-1    -- The Stages of Tuberculosis in Children The Stages of Tuberculosis in Children Three or four One One Number of drugs Always Always If <5 years old Treatment Usually abnormal Usually normal Normal Chest radiograph Usually abnormal Normal Normal Physical examination Positive (90%) Positive Negative Skin test Disease Infection Exposure STAGE  
  38. 38. Treatment <ul><li>Common therapy : </li></ul><ul><li>Nutrition 、 Rest </li></ul><ul><li>Ventilation </li></ul><ul><li>Isolation </li></ul>
  39. 39. Chemotherapy <ul><li>goal : Kill TB </li></ul><ul><li>Limit TB from spreading </li></ul><ul><li>principles : </li></ul><ul><li>earlier, appropriate </li></ul><ul><li>Combination, Full course </li></ul><ul><li>regularly and Staged . </li></ul>
  40. 40. Classification of antitubercular drug <ul><li>bactericidal </li></ul><ul><li>( 1 ) complete bactericidal : </li></ul><ul><li>INH 、 RFP </li></ul><ul><li>( 2 ) semi- bactericidal : </li></ul><ul><li>SM : alkaline, fast propagation, </li></ul><ul><li>intracellular TB </li></ul><ul><li>( Pyrazinamide) PZA : Acidic 、 slow growth </li></ul><ul><li>intracellular TB </li></ul>
  41. 41. <ul><li>medicines are classified as first-line and second-line agents </li></ul><ul><li>First-line essential antituberculous agents are the most effective and are necessary components of </li></ul><ul><li>any short-course therapeutic regimen </li></ul>
  42. 42. <ul><li>First-line medicines include </li></ul><ul><li>Isoniazid, rifampin, </li></ul><ul><li>pyrazinamide,streptomycine </li></ul><ul><li>Second-line medicines include </li></ul><ul><li>ethambutal, para-amino-salicylic acid, </li></ul><ul><li>kanamycin, amikacin and ects. </li></ul><ul><li>Newer antituberculous drugs </li></ul><ul><li>rifapentine, rifabutin quinolones </li></ul>
  43. 43. Isoniazid (INH) first-line drug <ul><li>Isoniazid is a principal agent used to treat TB </li></ul><ul><li>It is universally accepted for initial treatment </li></ul><ul><li>Now considered the best anti-TB drug </li></ul><ul><li>It should be included in all TB treatment regimens unless the organism is resistant </li></ul>
  44. 44. Advantages <ul><li>Inexpensive </li></ul><ul><li>Readily synthesized </li></ul><ul><li>Availabe worldwide </li></ul><ul><li>Highly selective for mycobacteria </li></ul><ul><li>Well tolerated(about only 5% of </li></ul><ul><li>patients exhibiting adverse effects ) </li></ul>
  45. 45. Dosage <ul><li>Tuberculosis organization have recommended </li></ul><ul><li>5 mg/kg daily for both groups </li></ul><ul><li>Generally, 300mg daily oral dose is adopted </li></ul>
  46. 46. Adverse effects <ul><li>The two most important adverse effects of isoniazid therapy are hepatotoxicity </li></ul><ul><li>peripheral neuropathy </li></ul><ul><li>We must measure liver enzymes before </li></ul><ul><li>administrating and during treatment </li></ul><ul><li>periods(usually monthly measure) </li></ul><ul><li>If the liver enzymes level is higher than </li></ul><ul><li>normal,the drug must be discontinued </li></ul>
  47. 47. Rifampin (RFP) first-line drug <ul><li>It is also considered the most important and potent antituberculous agent </li></ul><ul><li>Like isoniazid it is bactericidal and highly effective </li></ul><ul><li>Unlike isoniazid, it is also effective against most other mycobacteria as well as other organisms </li></ul>
  48. 48. Chemotherapy Regimens <ul><li>Standard regimen : </li></ul><ul><li>asymptomatic primary infection </li></ul><ul><li>INH 、 RFP and/ ( or ) EMB </li></ul><ul><li>9-12 months </li></ul>
  49. 49. Two Stage Therapy <ul><li>Active primary TB 、 Disseminated TB 、 TB meningitis </li></ul><ul><li>Enforcement stage : 3-4 bactericidal , 3-4m </li></ul><ul><li>Consolidation stage : 2 drug , 12-18m </li></ul>
  50. 50. Short-term Therapy DOTS (Directly Observed Treatment Short-course) <ul><li>2 or 3 drugs killing of organisms + 1 drug restraint of organisms </li></ul><ul><li>Mild/moderate with small infiltrates and thin wall cavities : </li></ul><ul><li>INH+RFP+SM(EMB) (PZA) 2 M or </li></ul><ul><li>INH+RFP 4 -7 M </li></ul><ul><li>extensive /severe, large areas of caseation or thick-walled cavities are identified: </li></ul><ul><li>INH+RFP+SM+EMB(PZA) 2 M or </li></ul><ul><li>INH+RFP 4 -7 M </li></ul>
  51. 51. Prevention <ul><li>Prevention of Tuberculosis : Vaccination </li></ul><ul><li>BCG Vaccination can obtain immunity acquired for tubercle bacillus. one of the most important tuberculosis prevention </li></ul><ul><li>Vaccination target: infants children and youngster of tuberculin negative (vaccination is of course of no use in tuberculin-positive persons) </li></ul>
  52. 52. Prevention <ul><li>Finding patients earlier </li></ul><ul><li>Treatment and management of patients </li></ul><ul><li>Prevention with medicines </li></ul><ul><li>The systemic organization of prevention </li></ul>
  53. 53. Prophylatic chemotherapy <ul><li>Intimate contact with family members suffering active TB </li></ul><ul><li><3y infant PPD test(++) without BCG viccination </li></ul><ul><li>PPD test (-) -> (+) recently </li></ul><ul><li>PPD test(++) accompanied by Tb toxic symptoms </li></ul><ul><li>PPD test(++) , suffered measles,whooping cough </li></ul><ul><li>PPD test(++) and need long term steroid therapy </li></ul>
  54. 54. <ul><li>Regimen: </li></ul><ul><li>INH : 10mg/kg.d , 6-9m </li></ul>
  55. 55. Tuberculous meningitis
  56. 56. Pathogenesis <ul><li>Spreading through bloodstream </li></ul><ul><li>Rupture of TB lesion->bacteria enter choroids plexuses -> CSF </li></ul><ul><li>Extension from nearby organ infected with TB </li></ul>
  57. 57. Clinical Manifestation <ul><li>The 1st Stage: 1-2wks </li></ul><ul><li>change of character:irritability, </li></ul><ul><li>Tb toxic symptom </li></ul><ul><li>Headaches ( vomiting 、 </li></ul><ul><li>drowsiness ) </li></ul>
  58. 58. The 2nd Stage 1-2wks <ul><li>Meningeal irritation stage </li></ul><ul><li>Increased ICP: Headaches,vomiting, drowsiness, seizure, nuchal rigidity, back pain, Kerning sign, Brudzinski sign. </li></ul><ul><li>Cranial Nerve palsy </li></ul><ul><li>Encephalitis:disorentation,movement disorders, speech impaiment, papilledema </li></ul>
  59. 59. The 3rd Stage <ul><li>Coma stage 1-3wks </li></ul><ul><li>coma, hemiplegia, paraplegia, convulsion consumption, abnormal metabolise of electrolyte </li></ul><ul><li>hypertenion, decerebrate posture </li></ul><ul><li>brain hernia->death </li></ul>
  60. 60. Diagnosis <ul><li>Medical history </li></ul><ul><li>Clinical manifestation </li></ul><ul><li>CSF examination </li></ul><ul><li>X -ray check </li></ul><ul><li>CT or MRI scanning </li></ul><ul><li>Tuberculin test </li></ul>
  61. 61. Differentiation diagnosis <ul><li>Meningococcal Meningitis </li></ul><ul><li>Viral Meningitis </li></ul><ul><li>cryptococcal meningitis </li></ul><ul><li>Cerebral tumor </li></ul>
  62. 62. Treatment <ul><li>General therapy </li></ul><ul><li>Anti-tuberculous therapy </li></ul><ul><li>Decreasing intracranial pressure </li></ul><ul><li>corticosteroids </li></ul><ul><li>Anti-symptomatic therapy </li></ul><ul><li>Follow -up </li></ul>
  63. 63. Anti-tuberculous therapy <ul><li>1、 The initial stage : </li></ul><ul><li>  3-4 m </li></ul><ul><li>  INH、RFP、PZA、SM </li></ul><ul><li>2、 The 2nd stage </li></ul><ul><li>  INH、RFP </li></ul><ul><li>  12 m </li></ul>
  64. 64. Latent infection of tuberculosis <ul><li>A patient is infected with Mycobacterium tuberculosis , but does not have active disease </li></ul><ul><li>Patients with latent tuberculosis are not infectious </li></ul><ul><li>The main risk is that approximately 10% of these patients will go on to develop active tuberculosis at a later stage of their life </li></ul><ul><li>The identification and treatment of people with latent TB is an important part of controlling this disease. </li></ul>
  65. 65. Miliary tuberculosis in an infant whose uncle also had tuberculosis. There is adenopathy in addition to the millet seed–like lesions
  66. 67. A posteroanterior (A) and lateral (B) chest radiograph of a child with hilar adenopathy caused by Mycobacterium tuberculosis.
  67. 68. Hilar and mediastinal adenopathy and a partial segmental lesion in a child with tuberculosis
  68. 69. Lobar pneumonia with bowing of the horizontal fissure in a child with tuberculosis. a secondary bacterial pneumonia may have been present
  69. 70. Tuberculous pleural effusion in a teenage girl. The pleural biopsy had caseating granulomas
  70. 72. A magnetic resonance image of tuberculoma in a child with culture-positive tuberculous meningitis. The child's presenting signs and symptoms included fever, altered mental status, and hemiparesis
  71. 73. Thank you

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