Tuberculosis:
Tuberculosis, also known as "consumption", can be regarded as one of the oldest diseases in the world. Researchers found traces of mycobacterium tuberculosis in Egyptian mummies 4,500 years ago. Tuberculosis is a chronic and slow-onset infectious disease, which occurs in young people. The incubation period is 4 ~ 8 weeks. 80% of them occur in the lungs, and other parts (cervical lymph, meninges, peritoneum, intestines, skin and bones) can also be infected. Respiratory transmission between people is the main mode of transmission of this disease. The source of infection is tuberculosis patients who are exposed to bacteria. With environmental pollution and the spread of AIDS, the incidence of tuberculosis is getting higher and higher. Except for a few cases of rapid onset, it is mostly a chronic process in clinic. There are often systemic symptoms such as low fever and fatigue, and respiratory manifestations such as cough and hemoptysis.
clinical picture
1. Symptoms
There is a history of close contact with tuberculosis, and the onset can be urgent or slow, mostly low fever (afternoon), night sweats, fatigue, anorexia, emaciation, and menstrual disorders in women. Respiratory symptoms include cough, expectoration, hemoptysis, chest pain, chest tightness or dyspnea.
2. Symbols
Pulmonary signs vary according to the severity and scope of the disease. It is difficult to find positive signs in early and small-scale pulmonary tuberculosis. Patients with a wide range of lesions have vocalization, aggravated tremor, low alveolar respiration and moist rales. Advanced tuberculosis forms fibrosis, and local contraction causes pleural collapse and mediastinal displacement. At the early stage of tuberculous pleurisy, there is pleural fricative sound. When a large amount of pleural effusion is formed, the chest wall is full, and the percussion is cloudy, twitching and breathing sounds are reduced or disappeared.
3. Classification and staging of pulmonary tuberculosis
(1) Classification of pulmonary tuberculosis
① Primary pulmonary tuberculosis (type Ⅰ)
The primary syndrome of pulmonary exudation, lymphangitis and dumbbell-shaped changes of hilar lymph nodes is common in children, or only manifested as hilar and mediastinal lymph nodes enlargement.
② disseminated pulmonary tuberculosis (type Ⅱ)
Include acute miliary tuberculosis and chronic or subacute hematogenous tuberculosis. Acute miliary pulmonary tuberculosis: the miliary size of both lungs is scattered in shadows, with the same size, same density and uniform distribution, which can be integrated with the progress of the disease; Chronic or subacute hematogenous disseminated pulmonary tuberculosis: Nodules and cords with different sizes, different old and new lesions, uneven distribution, blurred or sharp edges appear in both lungs.
③ Secondary pulmonary tuberculosis (type Ⅲ)
This type includes many changes, such as hyperplasia, infiltration, caseation or cavity. X-rays are often cloudy or flaky infiltration shadows with blurred edges (exudation) or nodular, cord-like (hyperplasia) lesions, large consolidation or spherical lesions (caseous-visible cavities) or calcification; Mostly in the upper part of both lungs, but also on one side, a large number of fibers proliferate, in which cavities are formed in the form of broken cotton wool, lung tissue contracts, hilum lifts, and hilum shadows are "weeping willow-like changes, pleural hypertrophy, thoracic collapse and local compensatory emphysema".
④ tuberculous pleurisy (type Ⅳ)
A small amount of pleural effusion on the affected side is shallow costal diaphragm angle, and the effusion above moderate level is density shadow with arc upper edge.
(2) Staging
① Progressive stage
During the follow-up, the newly discovered active pulmonary tuberculosis showed more and more lesions, enlarged cavities or cavities, positive sputum test, fever and other clinical symptoms.
② improvement period
During the follow-up, the focus absorption improved, the cavity narrowed or disappeared, the sputum bacteria turned negative, and the clinical symptoms improved.
③ stable period
The cavity disappeared, the focus was stable, and the sputum bacteria continued to turn negative (1 month 1 time) for more than 6 months; Or the cavity still exists, and the sputum bacteria turn negative continuously 1 year or more.
diagnose
Diagnosis can be made according to the etiology, clinical manifestations and laboratory examination.
differential diagnosis
1. Primary syndrome
It should be differentiated from lymphoma, intrathoracic sarcoidosis, central lung cancer and metastatic cancer.
2. Acute hematogenous disseminated pulmonary tuberculosis
It should be differentiated from typhoid fever, meningitis, septicemia, pneumoconiosis, alveolar cell carcinoma and hemosiderosis.
3. Infiltrative tuberculosis
It should be differentiated from benign lung diseases such as pneumonia, lung abscess, pulmonary mycosis, lung cancer, metastatic lung cancer and pulmonary cyst.
treat cordially
1. drug therapy
The main function of drug therapy is to shorten the infection period and reduce the mortality, infection rate and prevalence rate. For each specific patient, it is the main measure to achieve clinical and biological cure. Rational treatment refers to the principle of early, combined, appropriate, regular and full-course use of sensitive drugs for active pulmonary tuberculosis.
(1) Early treatment
Once found and diagnosed, drug treatment will be given immediately;
(2) Joint use
According to the condition and the characteristics of anti-tuberculosis drugs, two or more drugs are used in combination to enhance and ensure the curative effect;
(3) Appropriate amount
Different doses are prescribed according to different conditions and different individuals;
(4) Law
Patients must adhere to the treatment regularly in strict accordance with the' medication method' stipulated in the treatment plan, and must not change the plan at will or stop taking drugs at will for no reason, or stop taking drugs at will;
(5) the whole journey
It means that patients must adhere to the complete course of treatment according to the course set by the plan, and the short course of treatment is usually 6 ~ 9 months. Generally speaking, the newly treated patients are treated according to the above principles, the curative effect is as high as 98%, and the recurrence rate is lower than 2%.
2. Surgical therapy
Surgery is rarely used in the treatment of tuberculosis. When it is difficult to distinguish tuberculoma larger than 3 cm from lung cancer, unilateral fibrous thick-walled cavity can be re-treated, and long-term medical treatment fails to turn sputum bacteria negative, or unilateral damaged lung with bronchiectasis has lost its function and has repeated hemoptysis or secondary infection, so lobectomy or pneumonectomy can be used. When the medical treatment of tuberculous empyema and/or bronchopleural fistula is ineffective and accompanied by ipsilateral active pulmonary tuberculosis, lobectomy-pleurectomy should be performed.
Contraindications for surgical treatment
Active tuberculosis of bronchial mucosa, but not within the scope of resection, generally poor or with obvious heart, lung, liver and renal insufficiency. Surgery should be considered only when medical treatment fails. Patients should be given anti-tuberculosis drugs before and after operation without exception. At the 65438-0993 National Symposium on Surgical Indications for Pulmonary Tuberculosis and Lung Cancer in Thoracic Surgery, the following surgical indications for pulmonary tuberculosis were put forward:
(1) surgical indications for cavitary pulmonary tuberculosis
① After the initial treatment and retreatment of anti-tuberculosis drugs (about 18 months), the cavity has no obvious change or increase, and sputum bacteria are positive, especially in cases of drug resistance of mycobacterium tuberculosis;
(2) If there is repeated hemoptysis and secondary infection (including fungal infection), etc. , drug treatment is invalid;
③ Cancerous cavities cannot be ruled out;
(4) Atypical mycobacteria, the effect of lung cavity chemotherapy is not good or high.
(2) indications for tuberculoma surgery
① Patients with pulmonary tuberculosis received regular antituberculosis treatment 18 months, with sputum positive and hemoptysis;
② Tuberculoma cannot exclude lung cancer;
(3) Nodule diameter > 3 cm, routine chemotherapy has no change, which is a relative surgical indication.
(3) Indications of lung injury surgery
After regular anti-tuberculosis treatment, there are still bacterial excretion, hemoptysis and secondary infection.
(4) Indications of hilar mediastinal lymphadenopathy
① After regular antituberculosis treatment, the focus increased;
② Severe dyspnea caused by compression of trachea and bronchus;
③ atelectasis and caseous pneumonia caused by tracheal and bronchial puncture, but medical treatment was ineffective;
④ Mediastinal tumor cannot be ruled out.
(5) Indications of emergency operation for massive hemoptysis
①24-hour cough blood volume > 600 ml, which is ineffective after medical treatment;
② The bleeding site is clear;
③ Cardiopulmonary function and general conditions permit;
(4) Repeated massive hemoptysis accompanied by asphyxia, aura of asphyxia, hypotension and shock.
(6) Indications of spontaneous pneumothorax surgery
① Multiple episodes of pneumothorax (more than 2 ~ 3 times);
② Closed thoracic drainage continued to leak for more than 2 weeks;
③ Patients with hydropneumothorax with early signs of infection;
④ Patients with hemopneumothorax with unexpanded lungs after closed thoracic drainage;
⑤ Pneumothorax with obvious pulmonary bullae;
⑥ Patients with a history of pneumothorax on one side and the opposite side should be operated as soon as possible.
Extended reading:
World tuberculosis day
1At the end of 1995, the World Health Organization (WHO) designated March 24th every year as the World Tuberculosis Day to commemorate the discovery of tuberculosis pathogens published by microbiologist Robert Koho to a group of Berlin doctors in 1882. In order to remind the public to deepen their understanding of tuberculosis.
Classification of tuberculosis
China's current tuberculosis classification standard (WS196-200 1) formulated by the Ministry of Health in 2001. The standard divides tuberculosis into five categories: primary tuberculosis, disseminated tuberculosis, secondary tuberculosis, tuberculous pleurisy and other extrapulmonary tuberculosis.