外科实习医师.ppt

Extrapulmonary Tuberculosis 外科實習醫師 Ri 林耿立 91-7-29 Tuberculosis An ancient infection Tubercle bacillus discovered in 1882 WHO: 8,000,000 active cases in 1990 Developing countries (95%) Developed countries: HIV infection Tuberculosis Pathogenesis Chronic necrotizing bacterial infection Tubercle bacilli: Mycobacterium tuberculosis (MTB) Optimal growth: PO2—140mmHg Hematogenous dissemination and lymphatic spread Modified form of tuberculosis (AIDS) Tuberculosis Clinical stages Stage 1: Onset (macrophage inhalation) Stage 2: Symbiosis Stage 3: Early caseous necrosis Stage 4a 4b: Interplay of cell-mediated immunity and tissue-damaging delayed-type hypersensitivity Stage 5: Liquefaction and cavity formation Extrapulmonary Tuberculosis Proportion in all TB in USA : 7% (1963) to 18% (1987) to 20% (now) Increase maybe due to HIV infection More in minorities and foreign-borns Lymphatic TB (30%) Pleural TB (24%) Bone and joint TB (10%) Genitourinary TB (9%) Miliary TB (8%) Meningeal TB (6%) (New York, 1995) Tuberculosis Lymphadenitis (1) Most common form of EPTB Peak age: children shift to 20-40 y/o High risk: Asians, female (2x to male), HIV Hilar, paratracheal and neck lymphnodes Self-limited (90%), a little with pulmonary calcification Tuberculosis Lymphadenitis (2) Differential Diagnosis Nontuberculous mycobacteria (young age, unilateral and normal CXR) Virus or fungus infection Neoplasm Tuberculin skin test, history and CXR Total excision biopsy and culture Tuberculosis Lymphadenitis (3) Treatment Anti-tuberculous chemotherapy for 6 months course (1st line: pyrazinamide, isoniazid, rifampin, streptomycin) Surgical intervention (drainage and incision aren’t suggested) Bone and joint Tuberculosis (1) Pott’s disease Increasing since 1980s 13-25%: HIV positive in several trials Location: lumbar spine (29.5%) thoracic spine (20.5%) knee (13.2%) hip (8.2%) soft tissue or muscle